THE I J ^ J IS - AMERICAN PRACTICE OF MEDICINE; I BEING A TREATISE ON THE CHARACTER, CAUSES, SYMPTOMS, MORBID APPEARANCES, AND TREATMENT ■OF THE DISEASES OF MEN, WOMEN, AND CHILDREN, OF ALL CLIMATES, ON VEGETABLE OR BOTANICAL PRINCIPLES: AS TA0GHT AT GE&e 3&eforme& JBetofcal (Kollerjes fntjje JHntteti States: CONTAINING ALSO A TREATISE ON MATERIA MEDICA AND PHARMACY, OR THE VARIOUS ARTICLES PRESCRIBED, THEIR DESCRIPTION, HISTORY, PROPERTIES, PKEPAUATION, AND USES J WITH AN APPENDIX, ON THE CHOLERA, ETC. ILLUSTRATED BY NUMEROUS PLATES AND CASES. THE WHOLE PRECEDED BY PRACTICAL RULES FOR THE PREVENTION OF DISEASE AND THE PRESERVATION OF HEALTH. BY W RFACH, M.D. • *» President of the Reformed Medical Society, and Founder of the Reformed Medical Colleges of the United States; Licentiate of the Medical Society of the State of New York ; Member of the Medical Society of the City and County of New York; Professor of Materia Medica, Pharmacy, Theory and Practice of Physic and Surgery in the New-York Reformed Medical College, and Principal Physician and Surgeon of the United States Infirmary. IN THREE VOLUMES............VOL. II. NEW YORK: ^fcUyb B E T T S & A N S r I C E, OPPOSITE ST. PAUL'3 CHURCH. M DCCC XXXUI. 3 a^s* 1933 v. 2 Entered according to the Act of Congress, in the year 1832, by W. BEACH, M.D. in the Clerk's office of the District Court of the United States, for the Southern District of New York. PART IV. SURGICAL DISEASES. CHAPTER L CONNEXION BETWEEN PHYSIO AND SURGERY. It has been, and still is, customary to make a distinction between physic and surgery, committing the two branches to different sets of men. But this distinction is not well founded, or expedient, since it is impossible to decide where either branch begins or ends. A lecturer in St. Bartholomew's Hospital, in London, has the following judicious remarks upon this subject. Surgery, says he, is one division of that science and art which have disease for their object. This science, considered generally, embraces the physical history of man. It investigates the construction of the human body, and its living actions; it inquires into the purposes executed by each part, and into the general results of their combined exertions. It observes the human organization under all the various modifications impressed on it by surrounding influences of all kinds; and it draws from these sources the rules for preserving health and removing disease. The practical application of these rules constitutes the art of healing, or rather of treating disease (for in many cases we are unable to heal, and do not even attempt it); while the assemblage of facts and reasonings on which these practical proceedings are grounded, makes up the science of medicine. The boundaries of surgery have not hitherto been, and perhaps cannot be, very clearly defined; and the line of demarcation between it and physic is by no means easily traced. Considering the distinc- tion between them to be a mere matter of arbitrary usage, I employ the word surgery in its common acceptation: understanding it to include, 1st. injuries of all kinds; 2nd, the greater part of external and local 6 Connexion between complaints; 3dly, such internal affections as produce changes recog- nisable externally: for example, alterations of figure, colour, or consistence; 4thly, all cases requiring external topical treatment, operations, or manual proceedings of any kind. Such is the catalogue of subjects embraced in the surgical books of Mr. S. Cooper, in his Dictionary and First Lines; also in the treatise of Boyer and Delpech. The title adopted by the latter, Traite des maladies reputees chirur- gicales, (treatise on the diseases, reputed or considered surgical,) shows that the distinction is not better understood in France than in England. It must be confessed that the boundary just indicated, is obscure and uncertain. Hence, as in the case of contiguous governments with undefined possessions, disputes have arisen respecting the right to certain portions of territory. Injuries, operations, external local com- plaints, and manual proceedings, are undisputed possessions of surgery. But external and internal diseases cannot be clearly'divided. Here physic and surgery join. This is the border-territory between the two provinces, and has accordingly been the scene of some bitter feuds, which even now are hardly completely tranquillized. As it is thus difficult to establish the distinction, we are not surprised in finding, that in the great majority of instances, physic and surgery are both practised by one set of persons; probably nineteen-twentieths of disease are under their care, and hence they are properly called general practitioners. On the other hand, in cities, and some large towns, they are exercised by two distinct classes of persons, whose education differs widely in important points—they are taught by distinct teachers, in separate courses of instruction; and their regula- tion is entrusted by law to two distinct bodies, the College of Physicians and Surgeons. Viewing these apparent contradictions, we are naturally led to inquire more narrowly in what the distinction between physic and surgery consists; whether in the nature of the disease allotted to each, or in the mode of treatment; whether there is any essential difference in the mode of learning them ? whether it is well- founded ? whether it tends to the advantage of the public, or merely to the benefit of the physicians and surgeons 1 Nothing like the modern distinction was made by the ancients; there is no trace of it in the Greek, Roman, or Arabian writers. Certain branches of practice were followed separately in Egypt, where the diseases of the eyes, of the teeth, and even of some internal parts, were attended to exclusively by particular classes of practitioners; and some such distinctions existed in Rome: but Hippocrates, Galen, Celsus, and the other medical writers of antiquity, treat indifferently of the nature and management of fevers, injuries, external and internal disorders, and operations. In speaking of treatment, Celsus considers it under three divisions, the same which we still adopt; viz. diet, &c, remedies, chirurgical or manual proceedings. But the idea of split- ting medicine into two parts, and of teaching them differently, seems never to have been entertained by this elegant and philosophic writer, nor by those other great founders and promoters of medical science and practice, whose names and works are still regarded with deference and respect. Physic and Surgery. 7 In the long night of barbarism and ignorance, which intervened between the downfall of the Roman Empire and the revival of letters in the West of Europe, learning and science were confined to the members of the ecclesiastical profession, to whom we are indebted for preserving those imperfect remains of ancient literature and arts which we still possess. The exercise of medicine harmonized very well with the immediate objects of their holy calling. After the council of Tours, held in 1163, had declared that the church abhors the shedding of blood, (ecclesia abhorret a sanguine), priests and monks were obliged to desist from all curative proceedings that involved loss of blood. These were taken up by barbers, attendants on baths,-itinerants, and mountebanks. In course of time surgery, which then consisted merely of bleeding, tooth-drawing, and a few other simple processes, became, with the art of the barber, the occupation of a class of men, who were legally incorporated in this and other countries, under the title of barber-surgeons. The separation of surgery, or one branch of treat- ment, from that medical knowledge which is the indispensable guide to the time and mode of its application, and its association with the heart of the barber, long outlived the circumstances which produced them. In England it lasted till the middle of the last century, when the Company of Barber-Surgeons was legally extinguished, in the reign of George II. The union of the two callings still exists in many parts of Europe. In order to judge whether there is any-well-grounded difference between physic and surgery, it is necessary to advert shortly to the nature of medical science and practice generally. The numerous individual organs, which make up the human body, although various in structure and office, are all intimately connected and mutually dependent. They 9re merely subordinate parts of one great machine, and they all concur, each in its own way, in produc- ing one general result, the life of the individual. All the leading arrangements are calculated to give a character of unity to the organization and the living actions of our frame. There is a common source of nutrition for the whole body; a single centre of circulation; a common place of union for all sensations and volitions—for nervous energy of whatever kind. The various organs are not only intimately connected by the share which they severally take in executing associated and mutually dependent functions, they act and re-act on each other, often very powerfully, by those mysterious, or at least hitherto imperfectly known influences, which we call sympathies. Hence the expression of Hippocrates, in relation to the human body, is perfectly correct:—Labor unus; consentienta omnia. (One exertion; all parts concurring.) You could form no adequate notion of any organ, or system of organs, if you insulated it from the rest of the body, any more than you could estimate the use of action of any single wheel or lever detached from a watch or a steam-engine. As the animal machine, although complicated in structure, is single, and as its living motions, although numerous and intricate, form one indivisible scries, so a similar connexion runs through those changes of structure and functions which constitute disease: hence there is one anatomy and physiology, and there can be only one pathology. If we r 8 Connexion between wish to" know any portion of the body, we must not only carefully examine the part itself, but survey the relations of structure and function which binds it to the rest; and if we investigate any class of diseases, we must consider, not only the local symptoms, but also the disturbance which the diseased organs may excite in other parts of the frame, and the influence which other parts may exert over the seat of disease. It must be the first business of the medical student to learn the structure of the body and its living actions; that is, to study man in the state of health. These are the objects of the two sciences, which are denominated anatomy and physiology. He then proceeds to the observation of diseases; he watches the circumstances under which they arise; he follows their progress and termination; he explores the organic changes which they produce, and learns to connect these changes with their appropriate external signs or symptoms; deriving from these comparisons the means of distinguishing the exact seat of disease, and predicting its course and event. These matters form the subjects of morbid or pathological anatomy, and pathology. He is now prepared to employ the external agencies, the outward or inward remedies, or the operative proceedings, which may be necessary fox removing disease and restoring health. When disease is studied in this manner, in reference to the whole body, it constitutes the science of general pathology; as a similar investigation, directed to any single organ, is the pathology of that part. The real question respecting the distinction of physic and surgery is this:—after surveying the whole field of disease in the way just mentioned, can you find out any portions insulated from the rest 1 Any division not connected with other parts, and which can be understood with reference to them? Can you separate this entire subject of disease into two independent halves, requiring different modes of study and practice ? Certainly not. The entire structure and functions are universally and intimately con- nected. No part is independent. The causes of natural functions, and of those deviations which constitute disease, are often found, not in the part itself, but in the state of other associated parts or functions, as in gouty inflammation of the toe; paralysis of the finger; influence of the head on the system in idiopathic fever; in sympathetic fever from injury: and the means of cure are seldom to be applied to the very part diseased. Again, although individual organs are numerous, the elements of organic structure are few. The various proportions in which they are combined make the difference, as the various combinations of a few letters produce the infinite variety of words. The basis of nearly all parts consists of the cellular, vascular, absorbent and nervous structures. Hence, pathological principles are the same for all parts, and, conse- quently, treatment must be similar throughout. When diseases are arranged in any form, you may strike a line through, so as to divide the mass into two halves, give them different names, and call them dis- tinct branches of science, but they will resemble each other in all essential points: the causes, origin, course, and treatment of the diseases comprehended under each, will be the same. If you must have a division, separate the two sides of the body, or the upper and lower PART IV. SURGICAL DISEASES. • Physic and Surgery. 9 hakes. This will at least be clear and intelligible. To assert that surgery and physic are essentially distinct, is to say that there are two kinds of pathology that the external and internal parts are to be treated on different principles, it would be as rational to say, that there are two kinds of physiology, one for the outside, another for the inside of the body. When you know the component tissue, or the organic elements of our frame, are the same throughout, can you suppose that the posi- tion of a part in the body can alter the nature and treatment of the disease ? It may cause differences in the mode of proceeding : thus you cannot act locally on internal parts ; it may make the pathological investigation of one organ more difficult or easy than that of .another ; but it cannot alter essential principles. Inflammation, for instance, is the same kind of disturbance, whether in an internal or external part, and we treat it exactly on the same principles, whether it be in the eye, breast, or testicle, in the heart, lungs, or liver. The principles of pa- thology, therefore, are general; they are the same for all parts of the medical art. They result from our knowledge of health and disease generally,and must, therefore, be common to the physician and surgeon. Hence we may truly say,with Mr. Abernethy, that surgery and physic considered as objects of scientific investigation, are one and indivisible. We may go further, and assert that no branch of medicine, however limited, can be thoroughly understood except by him who has care- fully studied the structure and actions of the whole frame, and then extended his view over the whole field of medical science. By those who are inclined to defend the existing distinctions between physic and surgery, various views have been taken of it; but none of them will bear examination. Internal diseases have been assigned to the former—external to the latter. Unfortunately for this notion, nature has connected the outside and inside so closely, that we can hardly say where one ends and the other begins. She has decreed that both shall obey the same pathological laws, and has subjected them to such powerful, mutual influences, that we cannot stir a step in investigating the diseases of either, without reference to the other. How deep would the domain of surgery extend, according to this view?—half an inch or an inch? The entrance of the various mucous membranes, presents a series of puzzling cases; and the dis- tribution of diseases in these situations, between the two branches of the profession is quite capricious. How far is the surgeon to be trusted ? He is allowed to take care of the mouth: where is he to stop ?—at the entrance of the fauces, in the pharynx, or in the oesopha- gus? Inflammation and ulceration of the throat from syphilis belong to the surgeon:—catarrhal affection of the same membrane to the physician. Polypus and ulceration of the nasal membrane are surgi- cal—coryza is medical. The affections of the bones and joints have been given to the surgeon ; yet they can hardly be called external parts. In hernia and aneurism there is external tumour; but it is produced by displacement or disease of organs that are quite internal. When we look to the nature and cause of disease, the absurdity of the distinction now under consideration is still more apparent, and the inseparable connexion between the interior and exterior of our frame more obvious. Internal causes produce external diseases, as we sec 10 Connexion between in erysipelas, carbuncle, nettle rash, gout, redema; while external agencies affect internal parts, as in catarrhal rheumatic affections, in various inflammations of the chest and abdomen. In all these affections, our great reliance is on the external treatment; external and local means are comparatively unimportant. The eyes have been entrusted to the surgeon as external parts; yet the organ is the most complicated in the body; and many of its com- ponent tissues are highly organised, so that its affections are very much diversified, and require a greater insight into pathology and therapeutics.than those of any other single part. The eye, with its appendages, not only contains mucous, serous, and fibrous membranes, muscular, glandular, and nervous parts, but also several peculiar tissues. It not only exhibits the various affections of these produced by common disease, but it suffers from gout and rheumatism, from small-pox, measles, scarlatina, and chronic cutaneous eruptions; from scrofula, syphilis, and cancer. If, therefore, an organ so complex in its structure, and liable to such a number and variety of diseases, can be safely entrusted to the care of the surgeon, I am at a loss to know why there should be any dis- tinction, grounded on the nature of the affections, between the surgeon and physician. It is in vain, then, to establish separate professorships of external and internal pathology; and to teach them as separate sciences, and to expect that they shall be practised separately. Lecturers and writers cannot make the distinction; and thus we find the same dis- eases, in many instances, considered by the teachers of physic and surgery, comprehended in the writings of both; illustrated by both on the same principles, and treated by the same means. Some have proposed to assign local diseases to the surgeon, and general ones to the physician. It may be questioned whether there are any local or general diseases in the strict sense of the terms; at all events, there are very few in which the cause has been applied to the part itself, and the influence of the disease, as well as of the treatment, does not go beyond it; while, on the other hand, there are hardly any in which all parts of the frame are affected. When a part of little consequence in the animal economy is slightly diseased, no sensible effect may be produced beyond the part itself: if, on the contrary, an important organ is actively disordered, many other parts feel the influence ; and hence arise what are called general affections. Even in fever, we can clearly trace the general disturbance to a local origin, in ninety-nine cases out a hundred; so that the very existence of fever, as a general affection, has been questioned. The difference, therefore, between what we call local and general diseases, is merely in degree, not in kind: it is a difference of more or less. If we were to arrange diseases in one column, beginning with the most local, and ending with the most general, we should fill up the interval with others forming an insensible transition between the two extremes. Where could we draw the line across, to divide surgery and physic, on a scale thus constructed ? Reverting to the nature and extent of the duties which originally constituted the occupation of the surgeon, and looking to the etymo- Physic and Surgery. 11 logical import of the term, which is manual operation, ft has been contended that surgery should embrace those cases only in which operations or other manual aid are required. Thus it has been repre- sented, that the province of surgeons is to administer to external ailments; and that among their duties is included the important negative one of prescribing no internal remedy whatever. Such notions are worthy of the ignorance to which the unnatural separa- tion of surgery and physic owes its origin, and of the dark period in which it occurred. Thus this important professional distinction would rest, not on any essential difference in the causes or nature of diseases, or in the principles or treatment, but on the accidental and often varying circumstances of the means employed for their cure. What are we to do with the numerous cases, such as serious inflam- mations, affections of the head, various gouty and rheumatic diseases, in which change of diet and internal remedies are necessary, in con- junction with topical applications. . If it is meant to confine surgeons to operations and manual pro- ceedings, and thus to reduce surgery to a mere mechanical department of the healing art, I must enter my strongest protest against the arrangement. I should feel degraded in exercising this kind of bar- ber surgery, and I should be a little inclined to attempt touching it. If our profession were reduced to this, it would no longer be necessary for us to study its scientific principles. We might spare ourselves the toil and trouble of learning anatomy, physiology, pathology, and therapeutics; and we might well resign into the hands of our old associates, the barbers, the contemptible remnant to which surgery would then be reduced. k: CHAPTER II. SYMPATHY. The doctrine of sympathy should be well understood by the practitioner. All the body is sympathetically connected together, and dependent, the one part upon the rest, constituting a general sympathy. But sometimes we find particular parts more intimately dependent upon each other than upon the rest of the body, constituting a particular sympathy. Action cannot be greatly increased in any one organ, without being diminished in some other; but certain parts are more apt to be affected by the derangement of particular organs than others. , It may be thought that this position of action being diminished in one organ, by its increase, either in the rest or in some other part, is contradicted by the existence of general diseases or actions affecting the whole system. But in them we find, in the first place, that there is always some part more affected than the rest. This local affection is sometimes the first symptom, and affects the constitution in a secondary way, either by the irritation which it produces, or by an extension of the specific action. At other times the local affection is coeval with the general disease, and is called sympathetic. It is observed, in the second place, that as there is some part which is always more affected than the rest, so also is there some organ which has its action, in consequence of this, diminished lower than that of the rest of the system, and most commonly lower than its natural standard. From the extensive sympathy of the stomach with almost every part of the body, we find that this most frequently suffers, and has its action diminished in every disease, whether general or local, provided that the diseased action arises to any considerable degree. There are also other organs which may, in like manner, suffer from their association or connection with others which become diseased. Thus, for instance we see, in the general disease called puerperal fever, that the action of the breasts is diminished by the increased inflammatory action of the uterus. In consequence of this balance of action, or general connection of the system, a sudden pain, consequent to violent action of any particular part, will so weaken the rest as to produce fainting, and occasionally death. But this dependence appears more evidently in what may be called the smaller systems of the body, or those parts tvhich seem to be more intimately connected with each other than ihey are with the general system. Of this kind is the connection of 'he breasts with the uterus of the female; of the urethra with the '.esticles of the male; of the stomach with the liver; and of the ntestines with the stomach, and of this again with the brain; of the Hie extremity of the bone with the other; and of the body of the nuscle with its insertion ; of the skin with the part below it. Sympathy. 13 These smaller systems, or circles, shall be treated regularly; but first it may be proper to observe, that these are not only intimately connected with themselves, but also with the general system, a universal sympathy being thus established. That there is a very intimate connection between the breasts and uterus has been long known; but it has not been very satisfactorily explained. Fallopius, and all the other authors, declare plainly that the sympathy is produced by an anastomosis of vessels; Bartholin adding that the child being born, the blood no longer goes to the uterus, but is directed to the breasts and changed into milk. But none of all those who talk of this derivation, assign any reasonable cause which may produce it. In pregnancy, and at the menstrual periods, the uterus is active; but, when the child is delivered, the action of the uterus subsides, while the breasts in their turn become active, and secrete milk. If, at this time, we should again produce action in the uterus, we diminish that of the breasts, and destroy the secretion of milk, as is well illustrated by the case of inflammation of the uterus, which is incident to lying-in women. When the uterus, at the cessation of the menses, ceases to be active or to secrete, we often find that the breasts have an action excited in them, becoming slowly inflamed, and assuming a cancerous disposition. The uterus and breasts seem to be a set of glands balancing each other in the system, one only being naturally active, or secreting properly, at a time; and accord- ingly we seldom, if ever, find that when the uterus yjelds the menstrual discharge, the milk is secreted in perfection, during the continuance of this discharge, nor do we ever find them both inflamed at the same time. The uterus has not only this connection with the breasts, but it has also a very particular sympathy with the stomach, which again sympathizes with the brain; and thus we see how a disorder of the uterus may induce an extensive series of affections, each dependent on the other. The organs of generation in the male, form likewise^ little system, in which all the parts exhibit this sympathy with each other. They likewise give us a very good instance of the association of action, or sympathy, in the common acceptation of that word. Sympathy is divided into, first, the sympathy of equilibrium, in which one part is weakened by the increased action of another; and, secondly, the sympathy of association, in which two parts act together at the same time. The sympathy of association is produced suddenly, and for a short time. The sympathy of equilibrium is produced more slowly, and continues to operate for a much longer time. It is curious enough, that most, or at least many, of those organs, which seem to be connected by the sympathy of equilibrium, exhibit likewise more or less of the sympathy of association, when under the circumstances in which this can take place. The sympathy of equilibrium is seen in the effects of inflammation of the end of the urethra on the testicle; which often diminishes itsaction, and produces a very disagreeable sensation of dulness, or, if this inflara- 14 Sympathy mation be suddenly diminished, the action of the testicle is as suddenly increased, and swelling takes place. The same in the connection of the urethra with the^ladder and prostrate gland, as is mentioned in all the dissertations on gonorrhoea. These parts likewise affect the stomach greatly, increased action in them weakening that organ much. This is seen in the effects of swelled testicle, or excessive venery, or inflamed bladder, and in a stone; all which weaken the stomach, and produce dyspepsia. The same remark applies to the kidney; vomiting and flatulence being produced by inflammation of the kidnies. There is also an evident sympathy between the stomach and lower tract of intestines ; which two portions may be said in general to balance each other in the abdomen. When the action of the intestines is increased in diarrhoea, the stomach is often weakened, and the patient tormented with nausea. This will be cured, not so easily by medicines taken into the stomach, as by anodyne clysters, which will abate the action of the intestines. When the intestines are inflamed, as in strangulated hernia, vomiting is a never-failing attendant. When again the stomach is inflamed, the intestines are affected, and obstinate costiveness takes place ; even in hysterical affections of the stomach, the intestines are often deranged. Injections frequently rej^eve these affections of the stomach, by their action on the .intestines. The liver and stomach are also connected with one another. When the liver is inflamed, or has its action increased, the stomach is weakened, and dyspeptic symptoms take place. When the stomach is weakened, as, for instance^ by intoxication, then the action of the liver is increased, and a greater quantity than usual of bile is secreted. The same takes place in warm climates, where the stomach is much debilitated. ;If the liver has its action thus frequently increased, it assumes a species of inflammation, or becomes, as it is called, schiirhus. This is exemplified in the habitual dram-drinkers, and in those who stay long in warm countries, and use freedoms with the stomach. The liver likewise sympathizes with the brain; for when this organ is injured, its action much impaired, as in compression, inflammation and sup- puration have been often known to take place in the liver. Besides this connection of the stomach with the liver, it is also very intimately dependent on the brain, being weakened when the action of the brain is increased; as we see in an inflammation of that organ. The brain again is affected with pain when the stomach is weakened by intoxication or other causes; and this pain will be often relieved by slowly renewing the action of the stomach by such stimuli as are natural to it, such as small quantities of soup frequently repeatc e. A slight increase of action in the stomach, at least if not of a morbid kind, affects the brain so as to produce sleep, diminishing its action. This we see in the effects of a full meal, mid even of a draught of warm water. The stomach likewise sympathizes with the throat, squeam- ishness and anorexia being often produced by inflammation of the tonsils. This inflammation is frequently t.battd ly restoring or increasing the action of the stomach. Hence the throat, in slight Sympathy. 15 inflammation, is frequently easier after dinner; hence, likewise, the effects of emetics in cynanche. The extremities of bones and muscles also sympathize in the same manner. When one end of a bone is inflamed, the action of the other is lessened, and pain is produced ; for a painful sensation may result both from increased and diminished action. When the tendon of a muscle is inflamed, the body of that muscle often is pained, and vice versa. Lastly, the external skin sympathizes with the parts below it. If it be inflamed, as in erysipelas, the parts immediately beneath are weakened, or have their natural action diminished. If this inflamma- tion affect the face, or scalp, then the brain is injured; and head-ache, stupor, or delirium supervene. If it attack the skin of the abdomen, then the abdominal viscera are affected, and we have vomiting and purging, or obstinate costiveness, according to circumstances. This is illustrated by the disease of children, which is called by the women the bowel hive, in which the skin is inflamed from some morbid matter within. If the internal parts be inflamed, the action of the surface is dimi- nished, and, by increasing this action, we can lessen or remove the disease below ; as we see daily proved by the good effects of external stimulants. When the stomach, intestines, or kidney have been vpfy irritable, a sanapism has been known to act like a charm. The utility of counter irritants in diseases of the lungs, the liver, and the joints, is to be explained on the same principle. In these cases we find that they do little good unless they be somewhat painful. It is a well established fact, that when any particular action disap- pears suddenly from a part, it will often speedily affect that organ which sympathizes most with the part that was originally diseased. This is best seen in the inflammatory action, which, as practical writers have well observed, occasionally disappears quickly from the part first affected, and then shows itself in some other. From the united testimony of all these facts, Mr. Burns, of Glasgow, maintains the doctrine just delivered, and proposes to introduce it into pathological reasonings. In the whole of the animal economy, we discover marks of the wisdom of the Creator, but perhaps in no part of it more than in this, of the existence of the sympathy of equilibrum; for, if a large part of the system were to have its action much increased, and all the other parts to continue acting in the same proportionate degree as formerly, the whole must be soon exhausted ; (for increased action would require for its suppoit an increased quantity of energy.) But upon this principle, when action is much increased in one part, it is to a certain degree diminished in some other, the general sum or degree of action in the body is thus less than it otherwise would be, and consequently the system suffers less. CHAPTER I. INFLAMMATION. Description. A disease characterized by heat, pain, redness, attended with more or less of tumefaction and fever. Inflammation is divided into two species, viz. phlegmonous and erysipelatous. Besides this division, inflammation is either acute or chronic, local or general, simple or complicated with other diseases. Causes. The occasional and exciting causes of inflammation are very nu- merous: they, however, may generally be classed under external violence, produced either by mechanical or chemical irritation, changes of temperature, suppressed perspiration, and stimulating foods. Fever often seems to be a remote cause; the inflammation thus produced is generally considered as critical. Spontaneous inflammation sometimes occurs when no perceptible cause can be assigned for its production. Scrofula and syphilis may be considered as exciting causes of inflam- mation. With regard to the proximate cause, it has been the subject of much dispute. Galen considered phlegmon to be produced by a superabun- dance of the humor sanguineus. Boerhaave referred the proximate cause to: an obstruction in the small vessels, occasioned by a lentor of the blood. Cullen and others attributed it rather to an affection of the vessels than a change of the fluids. The proximate cause, at the present period, is generally considered to be a morbid dilitation, and increased action of such arteries as lead and are distributed to the inflamed part. Fevers often seem to become the remote causes of local inflammation. In other instances, inflammation appears to arise spontaneously, or, as I should rather say, without any perceptible exciting cause. The principle, on which the application of cold to a part becomes the remote cause of inflammation, is not decidedly known. " No subject (says a distinguished professor) is more deserving of your study, than the effects which are produced in the human body by the operation of cold applied to its surface; but the subject is, at the same time, exceedingly extensive, complicated, and difficult. These effects differ according to the degree in which the cold is applied, the state of the system, the part of the body to which it is applied, and the mode of its application. So diversified, indeed, are these effects, that it requires no mean confidence in theoretical reasoning to believe, that the operation of cold in producing them is explicable upon any single general principle."—{See Thompson on Inflammation, p. 58.) Inflammation. 17 And in the preceding page he observes: " The operation of cold upon the human body affords the best example which I can suggest to you, of the production of inflammation from the operation of a power acting upon a part at a distance from that in which the inflammation takes place. The instances formerly mentioned of inflammation of the throat, chest, or belly, from the application of cold to the feet, are daily occurrences in these climates, of which it is impossible for us, in the present state of our knowledge of the animal economy, to give any thing like a satisfactory explanation. "In some instances, cold, or a diminution of temperature, seems to act more directly upon the parts with which it comes into contact. We have examples of this in the inflammation of the mucous mem- branes of the nose, fauces, trachea, and bronchise, from the inhalation of cold air; and in the production of rheumatic inflammation from the accidental exposure of some part or other of the body to cold. The application of cold, in the instance I have mentioned, seems to have somewhat of a directly exciting effect; and perhaps the same remark is still more applicable to the local effects of cold in the pro- duction of the inflammation accompanying the state which is usually denominated frost-bite. Touching a solid body, as a piece of metal, the temperature of which has been greatly reduced, produces a sen- sation like that of burning, and may be followed, like the application of fire, by a blister."—:(Op. cit.) Numerous opinions have been entertained respecting the proximate cause of inflammation; but almost every theory has been built upon the supposition of some kind of obstruction in the inflamed part. But the proximate, or immediately exciting cause of inflammation is, usually, the irritation or action of a stimulus or foreign agent, which has been retained in the circulation by a suppression of per- spiration, and this is thrown with an accumulated quantity of blood to different parts or organs, and produces irritation and inflammation; or, in other words, it arises from retained perspirable matter, mixed with the circulating mass, which retreats from the surface to the centre, or is driven in an undue or unequal quantity to the part, which becomes inflamed. The balance is lost in the circulation, and there is an irregular distribution of morbid or vitiated blood, occasioned princi- pally by cold. Symptoms. 1. Phlegmonous inflammation is known by its bright red colour, tension, heat, and a circumscribed, throbbing, painful tumefaction of the part; tending to suppuration. Phlegmon is generally used to denote an inflammatory tumour, situated in the skin or cellular mem- brane. When the same disease affects the viscera, it is usually called phlegmonous inflammation. 2. Erysipelatous inflammation is considered as an inflammation of a dull red colour, vanishing upon pressure, spreading unequally, with a burning pain, the tumour scarcely perceptible, ending in vesicles, or desquamation. This species of inflammation admits of a division into erythema, when there is merely an affection of the skin, with very little of the whole system; and erysipelas, when there is general affection of the system. 18 Inflammation. The fever attending erysipelatous inflammation is generally synochus or typhus, excepting when it affects very vigorous habits, and then it may be inflammatory. The fever attending phlegmonous inflammation is almost always such. Persons in the prime of life, and in full vigour with a plethoric habit of body, are most liable to the attacks of a phlegmonous inflammation; whereas those advanced in years, and those of a weak habit of body, irritable, and lean, are most apt to be attacked with erysipelatous inflammation. Phlegmonous inflammation terminates in resolution, suppuration, gangrene, and schirrhus, or induration. Resolution is known to be about to take place when the symptoms gradually abate: suppura- tion docs not readily yield to proper remedies, the throbbing increases, the tumour points externally, and rigors come on. Gangrene is about to take place when the pain abates, the pulse sinks, and cold perspirations come on. Schirrhus, or induration, is known by the inflammation continuing a longer time than usual; the tumefaction continues, and a considerable hardness remains. This kind of tumour gives little or no pain, and, when it takes place, it is usually the sequel of inflammation affecting glandular parts. It sometimes, however, is accompanied with lancinating pains, ulcerates, and becomes cancerous. Erythematous inflammation terminates in resolution, suppuration, or gangrene. The symptoms of inflammation are accounted for in the following way:— Redness. This is manifestly owing to the increased quantity of blood in the inflamed part. More blood must necessarily be contained there, because the vessels which previously conveyed this fluid are preterna- turally distended, and the small vessels, which naturally contained only lymph, are now so enlarged as to be capable of receiving red blood. " I froze (says Mr. Hunter) the ear of a rabbit, and thawed it again : this occasioned a considerable inflammation, an increased heat, and thickening of the part. This rabbit was killed when the ear was in the height of inflammation, and the head being injected, the two ears were removed and dried. The uninflamed ear dried clear and transparent, the vessels were distinctly seen ramifying through its substance; but the inflamed ear dried thicker and more opaque, and its arteries were considerably larger." Many have supposed that the redness of common inflamation is partly occasioned by the generation of new vessels. This doctrine, however, seems very questionable. When coagulated lymph is extravasated upon the surface of a wound, or an inflamed membrane, unquestionably it often becomes vascular, in other words, furnished with new vessels. But in the extravasated lymph of a phlegmonous tumour, we have no evidence that there is any formation of new vessels. Were the lymph to be rendered organized and vascular, the swelling and redness would probably be more permanent. Swelling. This effect arises from several causes: 1. The increased quantity of blood in the vessels. 2. The effusion of coagulating lymph, and Inflammation. 19 serum, and deposition of new matter. 3. The interruption of absorp- tion particularly noticed by Soemmering.—{De Morb. Vas. Absorb.) Pain. This is observed to be the greatest during the diastole of the arteries. The affection is probably owing to the unnatural state of the nerves, and not to mere dissension, as many have asserted. Were the latter cause a real one, the pain would always be proportioned to it. " Parts, which in the sound state have little or no sensibility (as Dr. Thompson remarks,) become exquisitely sensible in the inflamed. That this is the case with tendon, ligament, cartilage, bone and membrane, seems to be fully established by Dr. Whytt in the very instructive controversy carried on between him and Haller, respecting the sensibility and irritability of the different parts of man and other animals. Heat. The augmented heat of inflammation may be conceived to arise from the increased velocity of the circulation in the part affected. More blood is transmitted into the minute arteries; the capacity of a greater quantity of this fluid for heat is of course there necessarily diminished, and more caloric is extracted. * Buffy coat. Blood taken from a person labouring under active inflammation, exhibits a yellowish white crust on the surface; this is denominated the buffy coriaceous, or inflammatory coat. This consists of a layer of coagulable lymph, almost destitute of red particles. Blood, in this state, is often termed sizy. The colouring part of the blood is its heaviest constituent; and, as the blood of a person labouring under inflammation is longer coagulating than healthy blood, it is supposed that the red particles have an opportunity to descend to a consider- able depth from the surface before they become entangled.-! The buffy coat of blood is generally the best criterion of inflammation; there are a few anomalous constitutions in which this state of blood is always found; but these are rare. Terminations or Consequences of Inflammation. The terminations of inflammation are resolution,—adhesion,—effu- sion,—schirrhus,—suppuration,—gangrene. Of Resolution.—By resolution is meant a gradual subsidence, or going off, of all the inflammatory symptoms ; the state and texture of the part remaining entire. Of Adhesion.—Adhesion is when coagulable lymph has been thrown out from the orifices of the inflamed vessels ; and by its agglu- tinating qualities has cemented as it were membranes, or other conti- guous parts, together. When adhesion is completed, vessels shoot from the opposite sur- c 20 Inflammation. faces, through the coagulable lymph, and anastomose, so as to com- pletely organize the lymph, and form it into cellular membrane. Of Effusion.— This termination is peculiar to cavities lined with smooth diaphanous membranes; the fluid effused is various, and depends upon the nature of the inflammation, the strength of the structure of the part. It may possess all the intermediate degrees or properties between serum, coagulable lymph, and pus. Of Schirrhus.—Schirrhus, or induration, is when the inflammation leaves the part hard and swollen. It is a termination of inflammation more peculiar to glandular parts. Of Suppuration and Abscess. ■ Symptoms.—Suppuration is the process of the formation of pus.— Its accession is marked by rigors, if the inflammation be considerable ; dull heavy weight of the affected part, by the pain becoming more lan- cinating, and accompanied with a peculiar throbbing of the neighbor- ing arteries, fluctuation; by the swelling becoming gradually more elevated above the surface of the surrounding cuticle, acquiring a soft- ness to the feel, and showing a tendency to point in one particular place. If the process be suffered to go on without interruption, the integuments become more and more thin, and change to a whitish or yellowish color; they at length lose their firmness, give way, and pus is discharged at the opening. PROGNOSIS: The prognosis in inflammation will be drawn from the violence of the symptoms, and from the seat of the inflammation. Favourable.—The pain, heat, redness, and other inflammatory symptoms gradually diminishing, and at length altogether ceasing (see the Terminations of Inflammation);—or the swelling becoming more circumscribed; prominent in the centre ; soft and fluctuating (see Suppuration); the constitution at the same time being a little affected. Unfavorable.—Violent fever with delirium; the inflammatory ap- pearances suddenly ceasing, followed by the formation of blisters, dis- charging a thin ichorous matter; the part becoming of a livid colour, and losing its sensibility. See Mortification, COMMON TREATMENT. Bleeding, Blistering, fyc. Effects of Bleeding.—By reference to the lectures of Sir Astley Cooper, it will be seen that he has some allusion to the effect of the loss of blood in inflammation. If, says he, you adopt a system of free depletion, nature will not be equal to the restoration of the injured parts, and the most dis- astrous consequences follow the indiscriminate employment of blood- letting. There is not a greater error than this in the practice of surgery. A stout man was admitted into Guy's Hospital, having a simple fr.icturc of the tibia, with considerable contusion of the surrounding Inflammation. 21 parts ; a day or two after his admission, he had severe constitutional irritation, and acute pain, with spasmodic action of tho muscles near the seat of injury. To relieve these symptoms, the dresser was di- rected to take some blood from the arm of the patient, which he did ; but thinking it proper that faintness should be produced, as a proof of its effect upon the constitution, and forgetting that the patient was in a recumbent position, he abstracted so large a quantity of blood,$that all power of restoration was completely annihilated, and the man died. The first effect noticed is a diminution in the force and rapidity of the circulation, which is manifested by the pulse becoming slower and softer. By and by the motion of the heart is so much weakened, that it no longer propels the blood with sufficient force to support the func- tions of the brain. The individual becomes pale—he complains of weakness and nausea, which sometimes proceeds to vomiting, but more frequently, the. functions of the brain becoming more and more completely suspended, he loses all power of sensation and voluntary motion—he is no longer able to stand or sit—there are frequently slight tremors of the muscles, and in some rare cases violent convulsive contractions of them—he makes some deep inspirations and expirations —looks wildly about him, and falls into a state closely resembling death, which is named Syncope. Syncope occurs most readily when the patient is in an erect posture, and a very large quantity of blood may be withdrawn without inducing it if he lies horizontally. The most effectual method of recovering one from this state is consequently to lay him on his back. The quantity of blood which must be abstracted to induce syncope in ordinary circumstances is extremely variable. Sometimes several pounds may be withdrawn before its symptoms appear, and at other times a few ounces are sufficient for the purpose; the patient's mental alarm has a considerable share in producing the effect, but in general sixteen or twenty ounces are required. When the patient is very weak, or very largely depleted, the syn- cope cither passes directly into death, or is succeeded by an intermediate state, named Sinking. In this condition the pulse is small, feeble, and intermittent; the countenance is deadly pale, and bedewed with clammy moisture : the extremities are cold, and the patient has a dis- tressing sensation of weakness. He lies in a dozing state ; and when roused from it takes some time to recollect his situation, often at first expressing himself incoherently. His breathing is uneasy, being per- formed with dilatation of the nostrils, and is frequently attended with slight crepitation, or mucous rattle in the chest. This state, after continuing for hours, or it may be even for days, terminates in death, which is usually preceded by hiccup and vomiting. When the quantity of blood abstracted is not too great, in proportion to the strength of the patient, there is a recovery or reaction of the system. After an ordinary syncope, the symptoms go off in the inverse order of their approach; and when the patient has completely regained his faculties, it is generally observed that the actions which wero suspended are performed with a slight degree of excitement. This is most observable with regard to the pulse, which is rather more sharp and frequent for sometime afterwards than it was before, pro- vided the patient did not labour under any febrile disturbance. 22 Inflammation. This excess of reaction is observed to be proportioned in degree to the strength of the patient and the quantity of blood withdrawn, provided it is not so large as at once to induce sinking or death. Ex- cessive reaction closely simulates the symptoms of inflammatory fever. The pulse is extremely frequent, and has a peculiar jarring or jerking sort of character—the respiration is hurried—the face is flushed—the eyes are red and suffused—the patient complains of intense head- ache, and distracting noises in his ears—and when blood is drawn, it exhibits the buffy coat, though hardly the cupped surface which is seen during inflammation The local symptoms of inflammation are not wanting ; and the brain, with its membranes, is the part which, out of all proportion, most frequently suffers ; but the viscera of the thorax and abdomen are not exempt from risk. This curious state, for pointing out which we are much indebted to Dr. Marshall Hall, may be induced either by one or two very large bleed- ings, or by a great number of small ones, causing a continued drain on the system for days, weeks, or months; and accordingly, as it occurs in one or other of these ways, the symptoms vary in the degree of their violence or acuteness. It may terminate in fatal effusion on the brain, or some other important organ, in sinking, or in a return to health. Bleeding, as might be expected, though it affords temporary relief, always increases the evil, either by making the state of excite- ment more quickly terminate in sinking, or by increasing the violence of its symptoms. Restoring the secretions, perfect rest both of body and mind, poultices, cooling applications, gentle opiates, and the gra- dual operation of time, ought to be trusted to as the means of relief. The discrimination between the symptoms of excessive reaction and those of inflammation, is of the utmost importance in practice; and the following observations as to the circumstances which modify the effects of hemorrhage are deserving of much attention. In young subjects, that is to say children and infants, the power of reaction is feeble, and the risk of sinking consequentlygreat. In adult subjects who are weak from age or any other cause, there is also small power of reaction ; but their danger of sinking is not merely in the. first instance, and continues for a much longer time after- wards, as the restoration to health is slow and imperfect. In the healthy and robust individual there is always excessive reac- tion, unless the bleeding be so small as not to affect the system suffici- ently, or so profuse as to cause sinking or death in the first instance. Pain, fear, and the exhaustion produced by protracted fever, or the discharge of matter, increase the risk of sinking. REFORMED PRACTICE. Indications of Cure.—The most desirable object in treating inflam" mation of every kind, is to cause it to terminate in resolution, or to subside and disappear without suppuration, or leaving any change of the structure or actions of the part affected. The most obvious indi- cation then, in the first instance, is to remove the cause, which has excited the inflammation, should it still continue. But when this Inflammation. 23 cannot be done, the process for removing it is generally more tedious and difficult, requiring the use of both internal and external appli- cations. Removal of exciting causes.—In all cases, the first circumstance to be attended to is the removal of allsuch exciting causes as may happen to present themselves. If the irritation of a splinter were to excite phlegmo- nous inflammation, who would not of his own accord directly take away the extraneous body ? In wounds, foreign substances frequently excite inflammation, and ought to be taken away as speedily as possible; splin- tered pieces of bone often give rise to the affection, and require removal; the head of a bone, being out of its place, may press and inflame the part onwhich it lies; and who does not immediately see the propriety of putting it back into its natural situation ? These and other similar exciting causes may often be detected and removed at once, and this is doing a great deal towards the cure and even the prevention of inflammation. However, many of the exciting causes of this affection are only of momentary application ; yet, though their action is thus short, the process of inflammation must follow, as a kind of salutary operation, without which, the injured organization and tone of the parts, still remaining, could not be rectified again. Hence, besides taking away the remote cause, whenever this can be done, it is proper to moderate,by other means, the increased action of the larger arteries, and lessen the velocity of the blood's motion towards the inflamed part. Purgatives.—It must be kept in view that the only correct method, or mode of reducing inflammation, is to restore the secretions and ex- cretions of the different organs, and by opening the different outlets of the system, we diminish arterial or febrile excitement. Purgatives, for this purpose, are to be administered. They lessen the quantity of the circulating mass, and thus, by their depletive effect, lessen inflam- mation. Those of a refrigerant kind are, among others, very service- able ; such as the following: Take- Alexandria Senna leaves, {bruised), Manna, Cream of Tartar,—of each half an ounce, Fennel Seed, bruised, one drachm, or a tea spoon full. To the senna and manna add a pint of boiling water, simmer it till there is half a pint of the liquor; strain, sweeten, and add the cream of tartar. Of this, let the patient take a wine-glass every hour, till it purges. It lessens inflammation both by its cathartic and diuretic pro- perties. Perspiration.—Another most important means of subduing inflam- mation is, by restoring or exciting a preternatural action of the skin or capillary system. When this is deranged, inflammation is always increased, but is immediately diminished when its functions are re- stored. A person who has a hot and dry state of the skin, feeling ex- cessively heated, will be immediately relieved and become cool as soon as you produce free perspiration. The medicines to be employed for this, must depend on circumstances. If the patient is able to sit up, the vapour bath will bring on free perspiration in fifteen or twenty mi- nutes. It is only necessary to place him over a tub, containing a 34 Inflammation. decoction of bitter herbs, with a blanket around him to retain the steam. He should also drink diuretic infusions or teas made of spear- mint or catnip, and the feet should also be bathed. Where there is local irritation* or inflammation, the parts should be first fomented, or steamed, with a decoction of bitter herbs. They lessen pain and inflammation by removing the tension of the parts, as well as by excitng perspiration. If the heat is very excessive, cooling or refrigerant lotions may be applied, such as a solution of borax and acetate or sugar of lead. ■• The following mixture I have found useful in Erysipelatous In- flammation : Take- Acetate of Lead,—one drachm, Of Spring or Rain-water,—a porter bottle. Let linen cloths be dipped in the solution and applied to the parts, •and when dry to be renewed. Poultices and Cataplasms.—Of all the applications to remove local inflammation, there is none which has ever been discovered or used, which will bear any comparison in point of utility or efficacy, with the Slippery elm bark, (Ulmus Fulva). It has a specific action, that no other article possesses with which I am acquainted. I have tried every other kind, such as bread and milk, linseed, &c, and I find, compared to this, that they dwindle into insignificance. It is the most soothing, softening, relaxing and refrigerant, and acts the most speedily of any other production ; and it is the most universal in its application, being suitable for every species of inflammation. It usually changes the appearance of the inflamed part from a high degree of redness to per- fect whiteness, at the same time that it diminishes the swelling, and lessens irritation and inflammation ; and it is the only article that will seldom or never disappoint the practitioner in its effects. Even where other kinds of poultices are indicated, this, in combination, forms a most valuable auxiliary, such as a decoction of certain roots, yeast, ley, Sfc. If inflammation can be terminated by resolution, this indication is answered by it, and, on the other hand, if suppuration be necessary to bring about a healthy action, it is favored by this poultice. It also pre- vents mortification. I never knew a case occur after its use. Method of Using it.—The superfine flour of the Elm Bark should be mixed with water, or milk, and brought to the consistence of a poultice; about a large table-spoon full of the powder is sufficient for a pint of liquid. In some cases, particularly erysipelatous inflam- mation, I have found milk better than water to mix with it. Some- times, or in obstinate cases of inflammation, where suppuration pro- proceeds slowly, the bark may be mixed with weak ley, and applied. This makes an excellent poultice, especially for white swellings, felons, inflammation of the breast, &c. I sometimes mix it with beer, or ale] and occasionally a decoction of catnip, wild indigo root, and such other agents as the peculiar character or stage of the inflammation may require. The poultice made of the powder of linseed, or flaxseed, pulverized, forms a very good one in many cases. Indeed, in inflammation attend! Inflammation. 25 ing carbuncle7l have found this poultice, combined with an equal part of slippery elm, preferablo to any other. It has the propoity of very much facilitating suppuration. As much hot water is to be put into a basin as the size of the poultice requires, and then the linseed powder and elm is to be gradually mixed with it till the mass is of the proper consistence. A small quantity of sweet oil may be added to keep it longer soft and moist. Fomentations are only to be considered as temporary applications, while poultices.are permanent ones. As regards the temperature of poultices, tin their application to inflamed parts, no definite direction can be laid down. As a general rule, however, I have always found that they answer best applied warm or tepid. Applied cold, sometimes a more immediate or tempo- rary benefit may follow, but the sedative effect of the cold, after a time, seems to prove injurious; but the only sure criterion is the feeling and comfort of the patient. Poultices should never be suffered to get dry and hard, but should often be renewed or changed, and they will keep moist much longer, if the muslin or linen on which they are laid, be first moistened. Anodynes combined with sudorifics contribute much to diminish irri- tability, and thus lessen inflammation. When the patient is wakeful, restless, and in pain, the disease is exasperated or increased. An anodyne, particularly when it is com- bined with a diaphoretic, has the effect to remove these symptoms; pain and inflammation are lessened by the narcotic and sudorific pro- perties of such a combination. The diaphoretic poxoders answer this purpose well; they should be given, particularly at night, and may be given also at other times, if occasion requires, to be accompanied with the use of diluent drinks. Rest.—In the treatment of inflammation, it is indispensably neces- sary that rest be enjoined upon the patient. Exercise, by increasing the action of the heart and arteries, increases the inflammation. Did.—The diet used has a tendency to increase, or lessen the inflammation. Stimulating kinds of food and liquids should be avoided and that of a cooling nature substituted. I have sometimes leeched and cupped for local inflammation ; but where the parts are very irritated and inflamed, it has a tendency to exa.-perate it, and generally no great benefit is derived from either, though there may be cases in which they may prove serviceable. Blood-letting should be carefully avoided; it so far weakens the action of the heart and arteries, that they are incapable of propelling a .sufficient quantity of blood to the parts inflamed, to effect a restora- tion. Excessive reaction may be moderated, by the means already mentioned. CHAPTER If. MORTIFICATION. uescnpiiu,t. We understand by the term mortification, a loss of vitality in any part or portion of the body. It has been divided into, first, humid, inflam- matory, or acute; and, second, into dry or chronic. It is also divided into' two other species, the one preceded by inflammation, the other without it. In inflammations that are to terminate in mortification, there is a diminution of power joined to an increased action; this becomes a cause of mortification, by destroying the balance of power and action, which ought to exist in every part. There are, however, cases of mortification that do not arise wholly from that as a cause ; of this kind are the carbuncle, and the slough, formed in the small-pox pus- tule. Healthy phlegmonous inflammation seldom ends in mortification, though it does so when very vehement and extensive. Erysipelatous inflammation isobserved most frequently to terminate in gangrene; and -whenever phlegmon is in any degree conjoined with an erysipelatous affection, which it not unfrequently is, it seems thereby to acquire the same tendency, being more difficult to bring to resolution, or suppura- tion, than the true phlegmon, and more apt to run into a mortified state. , Causes. The "external causes of mortification which are manifest, and act mechanically or chemically, are burns, excessive cold, the application of caustics, the presence of any ichorous, urinary, or fecal matter effused in the cellular substance, violent contusions, such as are pro- duced by gun-shot wounds, or bad fractures; the strangulation of a part, as in cases of hernia, or when polypi or other tumours are tied, a high degree of inflammation; and, lastly, every thing that has the power of stopping the circulation and nervous energy in parts.— .(Lassus, Pathologic Chir. t. I, p. 34, 35J Inflammation is one of the most frequent occasional causes of mor- tification. Causes which impede the circulation of the part affected, will occa- sion mortification, as is exemplified in strangulated hernia, tied polypi, or a limb being deprived of circulation from a dislocated joint. Preventing the entrance of arterial blood into a limb, is also another eause. Paralysis, conjoined with pressure, old age, and ossification of the arteries, may produce mortification ; also cold, particularly if fol- lowed by the sudden application of warmth; and likewise excessive heat applied U) a part. I Mortification. 27 The symptoms of mortification that take place after inflammation, ere various, but generally as follows : the pain and sympathetic fever suddenly diminish, the part affected becomes soft, and of a livid colour, losing at the same time more or less of its sensibility. When any part of the body loses all motion, sensibility, and natural heat, and becomes of a brown hvid or black colour, it is said to be affected with sphacelus. When the part becomes a cold, black, fibroug, senseless substance, it is termed a slough. As long as any sensibility, motion, and warmth continue, the state of the disorder is said to be gangrene. 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 mortification, termed sphacelus. When gangrene takes place, the patient is usually troubled with a kind of hiccough: the constitution always suffers an immediate dejection, the countenance assumes a wild cadaverous look, the pulse becomes small, rapid, and sometimes irregular; cold perspirations come on, and the patient is often affected with diarrhoea and delirium. Though long continuance in the same posture is one cause of mortifi- cationyet incidental circumstances are frequently combined with it, and have great influence over the disorder. These are, great debility, the same state of the system as exists in typhus fever, impure air, unclean bed- ding, &c. Some fevers have a greater tendency than others to pro- duce gangrene, as is the case with scarlatina. In slight cases of this disorder, the most horrible effects will sometimes arise from gan- grene. The tonsils will slough to a great extent; parts of the Eusta- chian tube, and even the tympanum will separate, and large portions of bone exfoliate. There is dangerous sloughing frequently brought on in measles by the application of large blisters to the chest of chil- dren, and their disposition to sloughing, occasioned by the use of mer- cury, or by whatever tends to weaken the constitution. There are some causes which produce death in a part at once, by the violence of their operation. A very powerful blow on any portion of the body may destroy its vitality in this sudden manner. Lightning, strong concentrated acids, and gun-shot violence, sometimes act in a similar way. When a ball enters parts with great force and rapidity, many of the fibres which are in its track are frequently killed at once, and must be thrown off in the form of sloughs, before the wound can granulate and heal. Cold is often another cause of mortification, and, when parts which have been frozen or frost-bitten arc suddenly warmed, they are parti- cularly apt to slough. In Baron Larrey's publication there is some interesting observations on the gangrene from cold. He acquaints us, that after the battle of Eylau, one of the most grievous events to which the French soldiers were exposed, was the freezing of their feet, toes, noses, and ears; few of the vanguard escaped the affliction. In some, the mortification was confined to the surface of the integuments of the toes or heels; in some, the skin mortified more deeply, and to a greater or less extent; while in others, the whole of the toes or foot was destroyed.—{See Program- ma quofrigoris acrioris in corpore humano effectut ezpendit. Haller. Ditp. adMorb. Lips. 17T5.) D 2$ Mortification. Dr. Jajnes enumerates the following circumstances, as capable of in- fluencing, in a very great degree, the disposition of inflammation to ter- minate in mortification. 1. The powers of the part in which the inflammation occurs, being naturally weak, as in fibrous membranes, the scrotum, &c. 2. The remote supply of blood or nervous energy, as in the lower extremities. 3. Obstruction to the return of blood. 4. To the supply of blood. 6. Disease in the heart or vessels. 6. Debility from age, habits of life, disorder of the digestive organs, or fever. 7. Poor living, foul air, improper food, scurvy, &c. 8. Im- pairment of organization from external injury. 9. Of the nervous power by poisons. 10. Undue excitement of weakened parts. 11. Depress- ing remedies. 12. Pressure and tension. 13. Excessive violence of inflammatory action. 14. Peculiar disposition in the constitution.— {Jame$ on Inflammation, p. 102.) Healthy phlegmonous inflammation seldom ends in mortification, except when it is unusually violent and extensive. Of all the inflammatory complaints to which the system b liable, phlegmonous erysipelas is observed most frequently to terminate in gangrene. Symptoms. Gangrene, or mortification, then is a partial death, or the death of one part of the body, while the other parts are alive: it is produced either by excess of inflammatory action, where the powers are natural, or by a less degree of inflammatory action, where the powers of the part are feeble. In mortification, or gangrene, the arteries, enfeebled by excessive action, or incapable, from any cause, of carrying on circulation, are deprived of their vitality, the blood coagulates in them, and the death of the part is produced. The symptoms of gangrene differ according to the manner in which it is produced. Authors have generally distinguished mortification into two stages; the first or incipient one they name gangrene; the second or latter Btage, that is, when the part has become quite cold, black, fibrous, inca- pable of moving, and destitute of all feeling, circulation, and life, is termed sphacelus. When gangrene is the result of high and active inflammation, the pain attending its production is exeedingly severe; the inflammation is very extensive ; there is usually a blush to a considerable extent; and there is generally, though not always, a considerable degree of swelling. Under these circumstances, the secretion from any sore which may exist, ceases; for the skin no longer perspires. The surface of the skin becomes of a dark colour ; it is said to become purple, but it is rather of a brownish tinge. The cuticle is raised; a vesication i3 pro- duced, and when this breaks, it is found to contain a bloody serum. When the serum is discharged, the skin assumes the gangrenous appearance, and becomes perfectly insensible. The vesications ex- tend to parts beyond the ulceration. The constitution suffers considerable derangement from gangrene; Mortification. £3 there is a high degree of irritative fever—quick, very imaU, and thready pulse; generally irregular—usually delirium, and it is also attended with vomiting and hiccough. Hiccough is the characteristic sign of gangrene, situated in what- ever part of the body it may be. The fact is, that when gangrenfl arises from a diseased state of the constitution, the stomach is extremely deranged, and this derangement of the stomach is followed by a spas- modic contraction of the diaphragm, producing hiccough. Hiccough may be arrested for a time, either by cold water, or a slight stimulant. We have just related the symptoms when gangrene is the result of excessive action; we will therefore proceed to speak of it when it is the effect of a low degree of inflammation; as from cold, or any other- analogous cause. When a great degree of cold has been applied to any part for a con- siderable time, the part will become benumbed; that is, its nervous powers will be diminished; and when it is thus enfeebled, it will be unable to bear a very slight degree of supervening inflammation, so that gangrene will be produced. When you receive cases of this kind, be cautious that heat is not too suddenly applied ; for even the common heat of the bed, frequently occasions inflammation, which is extremely liable to proceed to gan- grene, in consequence of the diminished nervous influence of the part. When gangrene is the result of either circumstance we have men- tioned, the process of separation soon takes place, and it is one of the most curious operations of nature, in the human body. Under its influence, even large members are destroyed, without any danger from hemorrhage, or the smallest jeopardy to life. When the process of separation takes place, the first appearance we observe is a white fine; at this white line, the cuticle is raised, and in a day or two separates, leaving a chasm between it, produced by tho absorption of the hving skin in contact with the dead:—the next part that begins to separate, is the cellular tissue immediately under the skin; afterwards the muscles nearly opposite the edge of the skin. Tendons, like the cellular tissue, do not separate opposite the skin, but at a considerable distance from the part at which the sloughing takes place; for tendons are incapable of resisting the inflammation. The nerves separate in the same manner as the muscles; the arteries and veins become as it were hermetically sealed with coagulum, and also suffer in the general destruction; and lastly, the bones themselves ex- foliate, and the limb is completely removed. Since the white line alluded to, is the barrier which nature sets up between the dead and the living parts, it is anxiously looked for by tho surgeon, as it becomes a criterion of the cessation of mor- tification. The elevation of the cuticle at the white line, is a vesi- cation which forms a line of circumvallation around the gangrene. The living skin taken up by the absorbents is carried into the constitu- tion ; the absorbent vessels act on the living parts, but not on the dead ; nor n the dead skin absorbed after the time when granulations have formed, but it becomes loose, and ceases to be attached to the surrounding parts; the chasm formed by the absorbent vessels afford- ing a.n opportunity for separation. Gangrene proceeds to much greater 30 Mortification. extent in the oellular tissue, than in the surrounding skin, because the cellular membrane is a part of weaker living powers; it is for this reason that a sloughing disposition in sores extending to the cellular membrane is so dangerous. Wherever skin separates, the muscles give way; a line of separation is formed, and the living portion of muscle is taken from the dead. Bones are very slow in the process of exfoliation; hence they are often taken away, when the process of separation is in other respects complete. During the progress of mortification, nature has provided against hemorrhage, on the destruction of the blood-vessels, so that even the larger arteries are cut through without any bleeding, or danger of the patient's life. This happens in the following manner:—The blood in the vessels of the dead part becomes coagulated ; the coagulum, however, does not confine itself to the dead part, but extends to the living vessels which join it, and is, in this manner, glued to the inner side of the artery, so that the vessels are, as it were, hermetically sealed. The same thing takes place in veins, the coagulum adhering to the inner side of the living vein, so that no blood can escape. The arteries are not only sealed at the part through which nature cuts it, but at a consider ahle distance above it, in order to provide against the danger which would otherwise arise from a separation of the coagulum. Gangrene is frequently the effect of a debilitated state of constitution: whatever, in short, weakens the general health much, dispqses it to the production of gangrene; for the body, when thus debilitated, cannot bear any excess of action. It is also sometimes depending on an impeded circulation, whether arising from cold, from pressure, or from a want of natural strength in the circulation, so that the parts are not nourished in their accustomed manner. It may be stated as a general principle, that gangrene generally arises from inflammation, and is occasionally the consequence of disease unaccompanied with inflammation, by which the circulation is consi- derably impeded.—{Cooper.) PROGNOSIS. Mortification i9 always to be esteemed the worst termination of inflammation. The circumstances which lead to a prognosis of a favorable event, are—youth and strength of constitution,—the ge- neral system little affected by the local disease,—the pulse continuing full,—there being little irritation; a disposition to a separation of the sound from the diseased parts ; marked by a white line, somewhat elevated, distinctly bounding the latter, about which an oozing of a serous fluid is observed. Indications.—'To prevent the extension of the mortification, and to promote a separation of the dead parts from the living. When mortification is acute, and seems to depend on the violence of inflammation, the first indication is to moderate the inordinate action of the sanguiferous system, by the prudent employment of such means as are proper for counteracting inflammation. In short, relief is to be sought in the antiphlogistic regimen, which consists in the employment of purgatives, diaphoretics, and diluents, and in Mortifieafion. m abstinence from all vegetable or animal substances, which have a ten- dency to excite, or to augment the febrile action. This regimen must be pursued as long as inflammatory fever continues. It is only in cases in which the fever from the first assumes a typhoid character, or where the mortification takes place without the previous occurence of fever, that any deviation from the antiphlogistic regimen can be allowed. While genuine inflammatory fever and local inflammation are co-existent with mortification, antiphlogistic means are undoubt- edly useful; but great caution is requisite since, in cases of humid gangrene, as it is termed, the inflammatory state very soon changes into one in which the great feature is prostration of strength. t A very essential and important indication to be fulfilled as soon as the symptoms announcing the existence of the inflammatory state, appear to abate, and the patient begins to be debilitated. This indication is to prevent excessive weakness by the suitable employment of cordials,, and particularly of tonics. These same means also contribute to place the system in a proper state for freeing itself from the mortified parts, or in other words for detaching them. For inflammation is the prepara- tory step which nature takes to accomplish the separation of mortified parts from the living ones, and this salutary inflammation cannot take place if the energies of life be too much depressed. Treatment. When inflammation has been properly treated, it will seldom, or never, terminate in mortification. But when called to treat it, our object should be to arrest and prevent any further extension of it by means both local and constitutional. If it be connected with, or dependent on inflammation, means must be taken to subdue that inflammation. If debility of the system has been a predisposing cause, it must be remedied by a more wholesome regimen, and the strength of the patient must be supported by stimulants, such as wine and a nutritious diet. Tonics also should be administered, and the wine bitters may be taken, and occasionally v. glass of yeast. Local Applications.—When blisters, or visicles, appear upon the part showing a disposition to gangrene, or when sloughingiactually takes pli.ee, the following poultice will separate the living from the dead parts, and put a speedy check to it. Take yeasi, a sufficient quantity ; stir in slippery elm bark, to form a poultice of the proper consistence. Apply tepid, and often reiiow. This will correct the factor of the parts, and assist the powers of nature to separate the mortified from the living flesh. I have not known this application to fail in a single instance. It is now customary to amputate a limb in cases of mortification; but with what propriety, I am unable to decide, as it is very easily arrested by very simple means; and where it cannot be, I have no evidence that the knifcjjwould save the life of the patient. If a proper c( use of treatment will not cure, there will be suoh a faulty state of the constitution, or in the ulcer or wound itself, that should amputa- tion be performed, the stump will slough, or the patient will sink from hritation, or the direct consequence of the operation. It does appear to mc passing strange, that surgeons should direct us to Wi.it till mortification has stopped, before we amputate. We 3-2 Mortification. are directed to remove a hmb fo* mortification, and at the same time, we are directed not to do it, until this very mortification is arrested, or until a line of demarcation is formed, or a separation takes place be- tween the dead and living parts ! I Now, I ask, how can this doctrine be reconciled with reason, com- mon sense, philosophy, or correct principles of surgery. It does appear most absurd to me, however it may appear to others, and this absurd- ity and inconsistency, is more^ strikingly exemplified in practice, or at the bed-side of the patient. I shall here subjoin the remarks of Cooper, on gangrene, who, though a great advocate for the knife, is not quite so partial for ampu- tation as some of his cotemporaries. He remarks as follows, on the propriety of amputation in gangrene: Propriety of Amputating.—As to the propriety of amputation in these cases, says he, there is sometimes no occasion for ampu- tation in gangrene when the sloughing process is proceeding favorably, as you have an opportunity of seeing, in a man in the other Hospital, in whom nature has performed the operation her- self, without any assistance; if the surgeon will be content to wait a short time, and the patient be so disposed, you will find that the parts will separate without an operation. Nature adopts the very plan in her amputations which the surgeon pursues; the skin separates the longest, the muscles next, and then the tendons, together with the bones, which are left considerably-shorter than the other parts, as you may observe from the specimen on the table; the bones become co- vered by the skin, and the muscles surround the extremity of the bone. The cases in which you are required to perform the operation of amputation are those in which the patient is unable to sustain the constitutional derangement produced by the process of separation; but when the constitution is strong, the patient will bear the process required to separate the limb. You have an opportunity of seeing in the other Hospital at present, in the case to which I have so often alluded, separation taking place above the centre of the leg ; there is no absolute necessity to amputate under such circumstances, and you can give the patient a chance of his life without resorting to it. In constitutional gangrene, as a general principle, do not amputate till the sloughing process has commenced, and healthy granulations are to be seen on the sore; for if an operation be performed, the stump will assume the same appearance and become gangrenous. It is curious to see how the loss of a slight quantity of blood will destroy life in these cases. When I was a dresser at these Hospitals, during my apprenticeship, there was a case of sloughing opposite to the calf of the leg; Mr. Cline, my old master, on going round the wards, said to the dresser, that the projecting ends of the bone had better be re- moved ; there were some granulations between the bones, which, in sawing, the dresser did not observe, and he cut through them; a slight hemorrhage ensued, and in the same night the patient died. There was a case, in the other Hospital, in which tho operation of amputa- tion was performed; gangrene existed on one foot, a slight gangreno on the nose, and on the other foot • the leg was amputated • but the gangrene spread on the nose and foot, which before the operation, vers only slightly affected. Amputation, then, thould newr bepe*/Limed Mortification. 21 till tho constitution be in an improved state, and healthy granulations have appeared. With regard to its treatment, continues Cooper, a poultice composed of port wine and oatmeal, or stale beer grounds, will be found the best local application; and the internal remedies should consist of opium, combined with ammonia. You must not expect that these cases will generally recover. I have known, however, a single toe, all of them, and even a portion of the foot, slough, and yet the patient do well. In these cases you must not amputate; whether there be healthy granulations or not, do not amputate ; for as surely as you do, mortification of the stump will supervene, and death quickly ensue. During the sloughing process, says he, the nitric acid may be employed, in the proportion of fifty drops to a pint of water. Amputation, says a distinguished professor, was long regarded as one of the most effectual means which could be employed to prevent the extension of gangrene. This practice, however, has not received the sanction of experience: on the contrary, it has been generally found, wherever it has been practised, in either acute or chronic gan- grene, to accelerate muca the progress of the disease; and in this way to Last on the death of the patient. The parts which were divided in amputation, though at a distance from a spreading gangrene and from sphacelus, were found speedily to assume the appearance of the affection for which the operation had been performed. According to Richter, there is never any certainty that we are amputating in living parts. Mortification rapidly ascends along the cellular substance surrounding the large blood-vessels, and is fre- quently much more extensive internally than external appearances would lead one to suppose. The adjacent surface, still apparently alive, is often so affected that it must inevitably slough, though at present it may not actually have sphacelated. The surgeon imagines that amputation is performed on living parts, but soon afterward dis- covers that he has been dividing those which are dead. The opera- tion, he observes, can do no good, while the mortification is in a spreading state, and it may do considerable mischief. The disorder continues to extend, because its cause still operates, and this is not removable by amputation. If the operation be now injudiciously undertaken, the sphacelus invades the wound, and is the more cer- tainly mortal, as the stance has been farther weakened by amputation and its consequences. Many mortifications, especially those which arise from external causes, very often spontaneously stop and separate. But the place where this will happen can never be foreseen. By amputating in this circumstance we run the risk of disturbing nature in her salutary work, and rendering the disorder fatal. When the toes are to all appearance, perfectly mortified, and seem so loose as to be capable of being easily taken away, it is in general thought right to remove them. But however loose they may seem, if they be violently twisted off, or the parts by which they hang be divided, a very considerable degree of pain will most commonly attend such operation, which therefore had much better be avoided; for Mr. Pott has seen this very pain thus produced bring on fresh mischief, 34 Mortification. and that or* the gangrenous kind. If the patient does well, these parts will certainly drop off; if he does not, no good can arise from remov- ing them. The application of a ley poultice has proved a sovereign remedy in mortification. It is not only well calculated to prevent, but cure it when it has taken place. After having been applied a short time, it has often separated and detached large portions of mortified flesh, and brought about a healthy action. The elm bark should be mixed in leeched weak ley, and applied tepid. A case now occurs to me, where this poultice arrested the disease, Beated on or near the breast of a female, and detached such a portion of dead flesh, that the opening left was as large as a common sized teacup. Another case occurs to me, where a young man was to have had his leg amputated, but before his surgeon or the physician came, the above poultice was applied, which arrested it, and he recovered. Dr. Ferris, who was noted for a successful method of treating mor- tification, made use of the following poultice: Scraped Carrots, Spikenard Root, bruised. Boil till soft; stir in a small quantity of Indian or oat-meal, and apply warm. I have used this poultice but little, and therefore can- not speak with much certainty of its effects ; but in one very difficult and critical case of inflammation, bordering on gangrene, it changed the character of it, and was attended with a good effect. In all cases of mortification, every thing which heats, irritates, or adds to the patient's sufferings, appears, in general, to augment tho disorder and increase the rapidity of its progress On the other hand, every thing which tends to calm, assuage, and relax, frequently re- tards the progress of mortification, if it produce no greater good. The pain also, which is a constant mark of too much irritation, con- tributes of itself to increase such irritation, and in this double point of view, we cannot do better in the majority of cases, than endeavour to appease it by the judicious and liberal use of anodynes. When the inflammatory stage evidently prevails, this medicine may be conjoined with antiphlogistic or cooling remedies. The feet and surface should be often bathed, as this operation contributes much to the cure, by its positive good effects upon the system. The observations of Pott on the local treatment of these cases, are of great practical importance: " I have found (says he) more advantage from frequently soaking the foot and ankle in warm milk, than from any spirituous or aromatic fomentations whatever; that is, I have found the one more capable of alleviating the pain which such patients almost always feel, than the other; which circumstance I regard as a very material one. Pain is always an evil, but in this particular case, I look upon it as being singularly so. Whatever heats, irritates, stimulates, or gives uneasiness, appears to me always to increase the disorder, and to add to the rapidity of its progress; and, on the contrary, I have always found that whatever tended merely to calm, to appease, and to relax, at least retarded the mischief, if it did no more." Mortification. S5 It is customary to facilitate with a cutting instrument, the morti- fied parts before the process is completed by the efforts of nature. This practice is very injurious, and ought to be strongly reprobated, causing unnecessary pain and creating considerable risk. When assistance is given, no irritation should be excited. I shall conclude this chapter on Mortification, by quoting the remarks of Dr. Cuming, on the use of nitre, and abuse of bark, in mortification. " After our attempts at resolution have proved unsuccessful, our next endeavours are, 1st. To produce a separation of the dead from the living parts. 2nd. To prevent absorption of putrid virus during the putrefactive process. 3rd. To cicatrize the wound and support the strength of the patient. In order to produce a separation of the dead from the living parts suppuration is requisite, which we effect by fomentations and poultices. Large quantities of bark in substance have hitherto been administered, from an erroneous notion that this drug had a peculiar and specific effect in arresting the progress of, and curing the sphacelus, which I shall soon prove to .be an opinion founded upon error, and supported merely from arbitrary custom and prejudice. The part should be well washed at each dressing, which must be renewed at least four times in the twenty-four hours; for, notwithstanding the utmost cleanliness, in a warm season of the year, or in a tropical clime, the faetor and stench issuing from it is intolerable. A portion of the mortified part is cut away at every dressing, as much as can be removed, after which Bark and spirit- uous medicaments have been spread upon the surface of the poul- tice or sprinkled over the part, and yet strange to tell all these means have not been sufficient to prevent the effects of absorption, or to destroy the faetor, which Kali Nitratum or Nitre most undubitably does, and which I have styled a sovereign remedy. Though there is no possibility of causing a spontaneous separation to take place without the aid of warmth, there is reason to suppose that it has always added to the malignity of the disorder, by the well known property which it possesses of exciting fermentation, and which neces- sarily keeps up and augments the putrefactive process ; indeed much philosophical sapience is not requisite to convince any one of the truth of this: therefore as Nitre counteracts the effects of heat as far as it is conducive to putrefaction, by rendering the dead mass unsus- ceptible of its baneful influence, and by correcting it and entirely subduing it when it has has already taken place, the fomentations and poultices can now be most advantageously employed. The ~separation will be accelerated by a generous stimulating diet, consisting of strong beef soups and jellies, a moderate allowance of generousport wine, good mild ale or porter should be drank, and the patient's spirits kept up by the mo* positive assurances of a happy termination to his sufferings; for which purpose the company and cheerful conversation of his friends and acquaintances, will now be very conducive. Bark given in substance and in the quantities recommended by men whose practice and experience in such cases, one would suppose were not greater than their penetrat ion, I know from the most correct and sure observation, to be productive of ths B 86 Mortification. most calamitous consequences, which I shall soon particularize. When the appetite is good, a nutritious and easily digested diet, will, without the aid of medicine, answer every purpose. The decoction of Bark, agreeably acidulated with the Elixir of Vitriol, may be advantageously employed. How often do medical men, through a blind and slavish acquiescence to imperious custom, defeat the salutary, though slow and sure operations of nature? The second indication for .the prevention of the absorption of virus, during the putrefactive process, is fulfilled by cleanliness from frequent ablution, and sprinkling finely pulverized Nitre over the part which should be scarified either) superficially or deeply, according to the judgment of the surgeon, or depth of the disease. And here I must remark, that the evil so much dreaded formerly, of wounding the parts underneath possessed of vitality, and thereby exciting absorption with all its train of calamitous consequences, need now no longer be feared, as I^itre neutralizes and renders innoxious the deadly poison." The third indication, for cicatrizing or healing the wound, and supporting the strength of the patient, is answered by a full diet and such modes of dressing as are found to be most effectual. The first time I had recourse to Nitre, as a remedy for Sphacelus, (which may justly be termed a sovereign one) was whilst I was sur- geon of his majesty's ship St. George; it was applied to a man's foot, which was wounded with a cannon-shot in an -action off Cadiz; a mortification took place soon after the accident, owing to the irritation of splinters or spicula impacted in the tendinous and nervous parts (so small as not to be discovered at first) and the destruction of the soft parts. The usual remedies were had recourse to, such as washing the mortified parts with Spt. Terebinthines, Vini, &c, vinegar and fomentations of bark, but without perceiving the smallest benefit resulting from their application. The faetor emanating from the wound which was black and cadaverous, was not at all corrected, nor was any separation of the sphacelated parts perceptible ; on the contrary the disease was spreading all over the foot. In this dilemma revolving in my mind the various antiseptics which the materia medica afforded, I luckily thought of Nitre, and began to use it very finely pulverized in large quantities, sprinkling it all over the wound, covering it so perfectly as to make some degree of pressure without soiling my fingers, for the purpose of promoting its union with the mor- tified parts ; the wound was dressed three times a day, as the climate was warm, and the danger from absorption consequently great. In the course of twelve hours the disagreeable stench issuing from the wound, which before was so extremely offensive as to make the nurses sick, was now quite gone, the extent of the mortification was soon discovered by a line of separation surrounding the wound. Here the beneficial effects of Nitre were very evident, both as far as related to its antiseptic, as well as stimulant power; the former in subduing putrefaction, the latter by restoring energy and activity to the hving sub-latent parts, sufficient to enable them to throw off the cause. It may seem unnecessary to mention that as much of the parts as could be removed by the assistance of the scissors and forceps were taken away at each dressing, and the wound well washed sometimes with vinegar, and at other times with decoction of the bark. Mortifiiaiion. *7 By perseverance and strict attention to the above remedies, particu- larly the Nitre (though the patient was reduced to the lowest ebb of human misery which was sufficiently evinced by symptoms the most distressing and alarming, such as yellowness of the skin, a black furred tongue, tetanus, and some degree of locked jaw, extreme debili- ty, quick and fluttering pulse,) he was restored to health contrary to the expectations of all who saw him. I found in this case, as I have done in many others, the exhibition of bark in substance do great mischief, though not given to near the extent recommended by medical writers. One would imagine these authors were afraid of deviating from the paths of their predecessors, when they are found slavishly subscribing to their rules, whilst the conviction of their own experience should convince them of the folly and even criminality of recommending medicines, which cannot boast of that consequence or efficacy, which they have laboured to bestow upon them. It generally happens, as it did in this instance, that though the patient previously to its administration, may have some appetite, it soon fails, and the space of a few hours entirely deprives him of all inclination to eat, his fever increases, and he loaths every thing offered to him in the shape of food. This is not the worst consequence, the medicine at length proves so nauseating and disgusting, that the stomach, as if conscious of the violence done to it, arms itself with the resolution of rejecting this inhospitable and noxious tenant. Such is the method employed by the vis medicatrix naturae (if there be such a power) to rid herself of matter so heterogeneous and offensive to this delicate organ, the pri- mum mobile of the system. Nor can it be wondered at, that this should happen, when you reflect on the indigestible nature of bark, however finely it may be pulverized. The human stomach is not like that of the Ostrich, it will not digest iron; and it does not require much penetration to discover, that the digestives faculties of this noble organ, are greatly impaired by disease. Then how can it be supposed that a substance which with the great- est propriety may be termed foreign, should not prove injurious, when other things, mild and congenial to it in a healthy state, are now offensive % It is not my wish to have wrong inferences deduced from these observations, I have said enough to convince that I am inimical to the exhibition of bark in substance, yet I would not have it imagin- ed that it cannot'be employed with advantage in any form; indeed I think far otherwise, for I am persuaded that it is of great service when given in decoction, for then you can augment or diminish its strength without clogging up the stomach with a heterogeneous mass of indi- gestible matter ; an advantage which will appear to every unpreju- diced mind, of the greatest importance, as far as relates to the welfare of the patient and success of the surgeon, whose anxiety must ever be commensurate with the danger and difficulty of the case. During the peace subsequent to the treaty of Amiens, whilst I was in practice, I had the care of two very bad cases of Sphacelus, which I treated in the manner already mentioned, with the same success, and the same corroborating proofs of the amazing efficacy of Nitre. The 38 Mortification. first cause was that of a female who had an ulcer on one of her legs, which, from want of medical aid and other comforts, degenerated into a state of sphacelus. The other was the worst, and occupied a space of nine inches on the external part of the forearm and hand, the integu- ments, fascia, and part of the muscles were completely destroyed, as well as the extensor medii digniti tendon, and though the mortification was so very extensive, the repeated application of powdered Nitre pre- vented the mass of humours from being corrupted by the absorption of putrid viris. It appeared very evident at every dressing, that it had perfect com- mand over this disease, by entirely subduing the cadaverous factor which always exhales from mortified parts. It is worthy of remark that the patient's stomach was very little affected, he was enabled to take in a sufficient quantity of nutriment, which would not have been the case, if absorption had taken place, or his stomach had been loaded with huge doses of bark. He took Decoct. Cinchonas and was allowed strong beef soup, with a liberal quantity of port wine and mild ale. I the other day in a conversation with a physician in London of great eminence, respecting the administration of bark in cases of spha- celus, was happy to find his sentiments exactly in unison with my own; and he was, through fatal experience, thoroughly convinced of the folly of the fashionable practice of throwing in large quantities of bark in substance. For he was visiting a patient affected with morti- fication in conjunction with a surgeon, who was of opinion that too much of this drug could not be given, though the patient's appetite was already destroyed by its effects and those of the disease ; yet my friend though he representedto his coadjutors, his opinion of the impro- priety of continuing the bark in substance, remained passive, not wish- ing to stem the torrent of popular prejudice, or take the power out of the surgeon's hands, when he conceived the case to be more closely affianced to surgery, than physic. I need hardly remark that the case terminated fatally. My patient's complaint arose from a small pimple on his hand, which became so troublesome that he was induced to apply to a famous empiric, whose skill was so perfectly baffled in this case, that he was constrained to acknowledge from the black, blistered, swelled, and frightful appearance which the patient's hand and arm exhibited, that the case required more of the acumen chirurgicum than he could boast of, and recommended his poor suffering deluded patient to apply for further advice, as mortification had already taken place. Nor was it surprising considering the treatment which had been adopted, white lily root, and a variety of acrid substances were applied to assuage a most active inflammation. It has lately been ascertained that the nitrous acid gas possesses the power of destroying contagion, on which account government supplies the navy with materials and utensils necessary for the pur- pose of fumigation. It has often happened that malignant ulcers exposed to the action of the fumes have been converted into a mild state, and easily cured, yet having a knowledge of these circumstances, I must confess that I was not induced to use this remedy from any analogical inference striking my mind ; but from the simple idea after a fruitless struggle to subdue Mortification. 39 the faetor issuing from a sphacelous foot, that as Nitre was found to preserve animal substances from putrefaction, it might also arrest its progress when commenced ; and such has been invariably the result, in cases which have come under my care. Some of my medical brethren in the navy have lately informed me, that they experienced the same salutary effects from its use in cases that occurred at naval hospitals, which I shall forbear to particularize, and shall content myself by noticing a part of Mr. Simpson's letter of Skipton, in the fourth num- ber of the 13th vol., page 324 of the Medical Journal." " Gentlemen,—I am induced to request you will allow me, through the medium of your widely extended and truly valuable publication, to return my sincere'thanks to Mr. Cuming, for his recommendation of nitre, Medical and Physical Journal for April and December 1804, in cases of sphacelus. I have recently had a case of that description, where every effort to relieve the patient proved fruitless ; until I resolved upon the application of nitre, in which I was seconded by my very respectable and ingenious naval friend Mr. Birtwhistle of thus place. Having frequently experienced very good effects from the external application of crude sal ammoniac finely powdered in similar cases, and having previously formed........of Mr. Cuming from his style of* writing which I have repeatedly seen in your Journal, I was led to resolve upon giving a fair trial to nitre. I am happy in having it in my power to say the effect was favourable beyond my most san- guine expectation. It would be superfluous to trouble you with the minutiae of the case, suffice it to say the whole class of stimulants and antiseptics were tried internally and externally ; notwithstanding, the putrid diathesis increased daily until arrested by this " sovereign remedy." I shall conclude with joining Mr. Cuming in most strenuously recommending this invaluable medicine to the public, as one which I flatter myself will ultimately prove deserving their confidence and attention." C. Simpson. CH APTER1I t or wounds. Description. By a wound is meant a recent solution of the continuity of the animal solid, from external violence. 1. Incised. "* 2. Laceratell. „ . 3. Contused. Species, < 4 Punctured> 5 Poisoned. 6. Gun-shot. Wounds in general are subject to a great deal of variety, both in their nature and external appearance. The differences depend, in a great measure, on the nature of the injured parts, the manner in which the wound has happened, and its extent. Wounds of fleshy parts are exceedingly different from those of ten- dinous ones, both in regard to their appearance, and nature, and the degree of danger. There is also an essential difference, between such as are made with a sharp cutting instrument, and others, in which the fibres, besides being divided, have suffered considerable contusion and laceration. A wound, made with a narrow-pointed instrument, is also of a very different nature from one that has an ample orifice. The degree of danger attending every wound, depends very much on some of the following circumstances. The extent of the injury; the additional violence, which the fibres of the. part have suffered, besides their division; the nature of the blood-vessels, or nerves, which happen to be cut; the nature of the wounded part, in respect to its general power of healing favourably, or not; whether the operations of the system at large, and life itself, can be well supported, or not, while the functions of the wounded part are disturbed, interrupted, or suspended, by the accident; the age of the patient; the constitution; and the opportunities, which there may be of receiving proper aid, and assist- ance of every kind. Progress of Spontaneous Union. By the first intention.—When the edges have separated only to a certain distance, or still remain in opposition, a portion of blood is thrown out from the incised orifices of the arteries, by which the chasm is filled. The lips of the wound become tumid and painful, a slight inflammation ensues, under which vessels shoot into the inorganized coagulum; this soon becomes endued with life, and thus a complete union is effected. Of Wounds. 41 ' By Suppuration.—When, however, from the nature of the part, or from other causes, the edges have retracted to a considerable extent, this species of union is prevented from taking place, suppuration super- venes, pus is formed ; granulations arise, and, increasing, fill up the cavity ; and, having attained the surface, healing commences, pro- cesses of skin shoot from the surrounding edges, and extending, at length completely enclose the newly-formed parts. PROGNOSIS. The prognosis will chiefly depend upon the situation (see wounds of the different parts of the body), and the extent of the wound. Unfavourable circumstances are—great irritability of constitution ; the constitution of the patient impaired by age, or inebriety; debility, however induced ; the division of large arteries, or of numerous absorb- ent vessels; the firm texture of the part favouring a considerable retraction of the edges ; the presence of certain extraneous bodies, which cannot be readily removed ; too great inflammation, when spha- celus is likely to ensue ; deficient inflammation, when the progress of union is retarded, or entirely suspended. Incised Wounds. A wound inflicted by a cutting instrument; and in which there is a simple division of the part, without any, or, any considerable loss of substance. The usual and immediate consequences are,—a greater or less retraction of the divided parts according to the texture of the particular portion of the body which is the seat of the accident; and a discharge of blood proportioned in quantities to the size of the injured vessels. Contused and Lacerated Wounds. Lacerated wounds are those, in which the fibres, instead of being divided by a cutting instrument, have been torn asunder by some vio- lence, capable of overcoming their force of adhesion. The edges of such wounds, instead of being straight and regular, are jagged and unequal. The term contused is applied to those wounds, which are occasioned by some blunt instrument, or surface, which has violently struck a part of the body. These two species of wounds greatly resemble each other, and as they require nearly the same kind of treatment, writers usually treat of them together. Lacerated and contused wounds differ from simple incised ones in appearing, at first view, much less alarming than the latter, while, in reality, they are more dangerous. In simple cut wounds, the retrac- tion of the parts, and the hemorrhage, are generally much more considerable, than in lacerated wounds of the same size. However, notwithstanding these circumstances, they commonly admit of being healed with by far the greatest ease. It is even proper to remark, that lacerated and contused wounds are scarcely ever attended with any serious effusion of blood, even though some large blood-vessels may be 42 Of Wounds. injured. This circumstance often leads inexperienced practitioners to commit great mistakes, by inducing them to promise too much in the prognosis, which they make. Surgeons, versed in practice, however, do not allow themselves to be deceived by the absence of hemorrhage, and, in proportion as there is little bleeding, they apprehend that the violence done to the fibres and vessels has been considerable. Whole limbs have frequently been torn from the body, without any hemorr- hage of consequence taking place. Punctured Wounds. A punctured wound signifies one, that is made with a narrow- pointed instrument, the external orifice of the injury being small and contracted, instead of being of a size proportionate to its depth. A wound, produced by the thrust of a sword, or bayonet, affords us an example of a punctured wound. Wounds of this description are, in general, more dangerous than incised ones, notwithstanding the latter have the appearance of being by far the most extensive. The greatest degree of danger, in cases of punctured wounds, always depends on the additional injury, and rough violence, which the fibres have suffered, besides being divided. Some of the disagreeable consequences apt to follow, are also to be imputed to the frequent great depth, to which punctured wounds are liable to extend, in consequence of which circumstance, important parts and organs are often injured. These cases are likewise less easy of cure, owing to the difficulty of extracting any extraneous substances, which may happen to be lodged in the wound. All punctured wounds, and stabs, are at the same time dangerous, inasmuch as they are particu- larly liable to be followed by a great deal of inflammation, fever, deep- seated abscesses, sinuses, &c. Gun-shot Wounds. Gun-shot wounds receive their name from the manner in which they are produced, being generally caused by hard, obtuse, 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 shells, or the violence with which pieces of stones from ramparts, or splinters of wood on board of ship, are driven.about. Gun-shot wounds are the most considerable of the contused kind ; and what is to be said of them will apply, more or less, to all contused wounds, according to the degree of contusion. They are particularly characterized by what the French surgeons are fond of calling a disorganization of their surface. The excessive con- tusion and violence observable in gun-shot wounds depend upon the rapidity with which the bodies occasioning them are propelled. The parts touched by the ball are frequently converted into a blackish slough, the colour of which made our ancestors suppose, that bodies projected by gunpowder became heated, and actually burned the flesh with which they came into contact. But reason and experience have now proved, that whatever may be the rapidity of a projectile, it never acquires in its passage any perceptible heat. Indeed, a modern Of Wounds. 43 writer asserts, that such a degree of heat as would be requisite to make a ball burn parts in its passage, would readily melt it.—(Ri- eherand, Nosographie Chir. t. 1, p. 217, edit. I.) In general, gun- shot wounds do not bleed much, unless large blood-vessels be injured; their circumference is often livid; and the shock that attends their infliction, or the injury done to the nerves, may occasion in the limb or part a kind of torpor, sometimes extending itself to the whole system. Poisoned Wounds. These are wounds inflicted by poisoned instruments; by the bites of rabid animals ; or by the bite or sting of certain reptiles and insects. The effect of wounds of this kind are various ; some prove immedi- ately fatal; some produce purple or livid eruptions on the body, and a putrid state of the fluids ; some cause lethargy, but almost all cause pain, swelling, inflammation or ulceration. TREATMENT. To put a stop to the bleeding. To remove any extraneous bodies that may be present. To effect an union by the first inten- tion or, if that be impracticable, to promote suppuration. Incised Wounds* Generally, a wound which is made with a sharp cutting instrument, is attended with the least danger of any other, as it heals by what is termed, the first intention, or, in other words, without suppuration, except, however, it is in the immediate neighborhood of some great blood-vessels, or vital organ. The fibres, or parts, have only been simply divided, having neither suffered contusion or laceration; consequently they are less likely to inflame severely, or to suppurate or slough, and, properly treated, it unites again in a very expeditious manner. In a recent simple incised wound, there are three objects which the physician should endeavour to accomplish without the least delay. The first, and that which requires his immediate interference, is the bleeding, which must be checked. The second is the removal of all extraneous matter from the surface of the wound. The third is the reunion of the opposite sides of the injury. The first thing to be done, in the treatment of a simple incised wound, is carefully to examine it. Some are in the habit of giving every wound a most superficial attention, and then putting a bandage around it, when it may be in a most cntical and dangerous state; when there may be extraneous substances in it, or where there is an effusion of blood in the cellular substance. Such practice cannot be too much deprecated. Every wound must be carefully and deliba- rately examined before any dressings are applied. Indications of Cure, J _ 44 Of Wounds. When the divided vessels are not above a certain size, the bleeding soon spontaneously ceases, and no surgical measures need be taken on this particular account. When the wounded vessels are even somewhat larger, and their situation is favourable for compression with a bandage, it is often advisable to close the wound and apply com- presses and a roller, rather than have recourse to ligatures, which always create a certain degree of irritation and suppuration. Tying the bleeding vessels may be occasionally, perhaps, the only safe mode of proceeding. When the artery is of considerable size, and its mouth can be readily seen, the most proper instrument for taking hold of it is a pair of forceps. In applying the ligature, the surgeon must take care to pull its ends in such a manner that the noose will not rise above the mouth of the vessel, and for the purpose of altering the direction of the force employed in tightening the ligature, the ends of the thumbs are generally made use of. The tenaculum is commonly employed for taking up arteries, which are not large and distinct. Where bleeding is profuse, recourse may be had to a ligature, placed around the limb, and drawn tight or twisted with a stick, until the blood ceases to flow and until the wound can be dressed. I have never yet, in all ni}r practice, had a single case, in which it has been necessary to tie an artery. The hemorrhage or bleeding, in most cases, will spontaneously cease, after a short time, by the formation of a clot or coagulum. But should a case occur where it becomes necessary to tie an artery, the ligature made use of may be strong thread or silk. The lips of the wound should be opened, and the blood washed away or absorbed by a cloth or sponge, to give an opportu- nity to see the end of the-artery from which the blood issues, and, having ascertained it, the end is to be taken hold of with a pair of tweezers, forceps, or tenaculum, and drawn a little out, when the liga- ture must be passed around it, and drawn and tied very tight, and the ligature should be cut off before the wound is closed * This method is * An hemorrhage, says a writer, may be stopped by simple pressure with the finger, compress, or bandage, if the wound be slight, or the hemorrhage trifling ; but when a considerable artery has been divided, and the effusion of blood is copious, by the appli- cation of the tourniquet, in situations where its use is admissible, and by afterwards securing the divided vessel with a ligature. In the application of the tourniquet, a small linen compress or cushion is to be placed over the course of the bleeding vessel, in the most eligible situation above the wound (see Amputation, where the proper positions for its application are pointed out), and secured by means of a roller passed two or three times around the limb. The instru- ment is now applied with its handle in a position opposite to the compress upon the vessel, and rendered firm by the strap to which il £ affixed; after which, by turning the handle, and thereby tightening the compress, the hemorrhage will be restrained. The next object is to secure the bleeding vessel; for which purpose two modes are practised: 1. by means of the tenaculum; 2. by means of the crooked needle. The former is now generally preferred. Tu coats ( ligature, composed of threads proportioned in number to"the"size of the artery, previous* Is waxed, and loosely slipped over the instrument in the manner of a rina, is to be drawn by an assistant over its point, until it encircle the extremity of the vessel ■ when its ends are to be gradually, yet firmly dr.iwn, so that the sides of the latter may be effectual y compressed. It is then to be secured by a second knot, and the ends being cut oil at a propei distance, are to be suffered to hang from the wound \J^^HT'!t^X^e dTh °*. thc.wot™$ or ^m the artery having retracted bfyond the reach of the tenaculum, there ia a necessity for u8ing the crooked needle ; Of Wounds. 45 only to be practised in the most urgent cases, or where other means fail. I have read an account of a surgeon in Berlin, or some part of Europe, who, in amputating a leg, never takes up a single arteiy. This fact shows the wonderful provision of nature in arresting he- morrhage. If the bleeding is so great as to prevent an accurate inspection of the wound, so that the vessel cannot be perceived, pressure must be made upon the trunk of the main artery, which supplies the parts with blood. It may be made with the finger, ligature, or tourniquet, which, after the wound has been cleansed, may be loosened in order to disco- ver the bleeding vessel. In the worst species of wounds to which I have been called, I have found the following treatment sufficient to stop the bleeding. I first ascertain the situation of the vessel from whence the blood issues.—Then 1 take a pledget of lint, roll it up into a little ball, and press it directly upon the mouth of the artery, (I mean where there is profuse hemorrhage,) afterwards apply lint and small compresses to secure permanent pressure upon the artery, after which the dressings are to be applied. In general, a piece of linen folded thick, of a suitable size, and laid directly over the wound, and a bandage applied, is quite sufficient to stop the hemorrhage. Occasionally, I have applied styptic powders to contract the end of the vessel, produce coagulum, and thus arrest it. For this purpose, the red, or styptic powders, are employed, a pre- paration which is extremely astringent. Cold, and lead water, by their astringent and refrigerant effect, are useful; the lint and com" presses may be wet with them. We have made use of a styptic powder here, which a celebrated German physician, in New Jersey, has been for many years in the habit of successfully using. It is a plant pulverized, very astringent and styptic in its qualities, but I am unable, at present, to obtain the correct name of it, as the physician can only give some vulgar name. I hope soon, however, to obtain the botanical character of the plant; it is unquestionably the best vegetable pro- duction known of the kind. The bleeding having been suppressed, the next object is to remove any extraneous matter, such as dirt, bits of glass, clots of blood, &c, which may remain in the wound. Were this circumstance neglected, the plan of uniting the opposite sides of the cut by the adhesive inflam- mation, or by what is more frequently termed, union by the first inten- tion, wouJd in general be frustrated. As soon as attention has been paid to the foregoing indications, the practitioner must put the lips of the wound in contact, and take mea- sures for keeping them in this state .until they have grown firmly together. The sides of incised wounds are kept in a state of apposition, by means of an adhesive plaster, a proper position, the pressure of a roller, and, in a few particular instances, by the employment of sutures. With respect to sutures, as they create pain, irritation, and some this armed with a proportionate ligature is to he introduced at about a quarter of an inch from the situation of the vessel, to be carried under it, and brought cut at the same distance on the opposite side ; and this being repeated, a knot is to be made as above directed. 46 Of Wounds. degree of suppuration, they ought never to be employed when the parts can be kept in contact without them. However, certain cases may require them, and it is admitted by many, that in wounds of the ears, eyelids, nose, and lips, it is proper to use them. To keep the surfaces of divided parts in contact, without sutures, and at the same time to admit of dressings, I have used, with great advantage and success, a very simple invention, or contrivance, which I have denominated the Improved Adhesive, or Uniting Plaster. The following plate gives a representation of this admirable contri- vance, or plaster. It is made by taking four pieces of linen, of suitable size, and spread- ing each thinly over with adhesive plaster. They are then, or before they are spread, doubled, or one lightly placed above the other, to pre- vent immediate adhesion or close contact, after which the ends are brought within the distance of about an inch of each other, and stitched together in the following manner. A stitch is first to be taken in the upper piece; the needle must then be carried across, and a stitch passed through the lower one ; then cross again and pass through the upper piece, and so alternately to the end. It must be applied in the follow- ing manner. The edges of the wound must be brought together, or in contact, and a plaster laid over it at right angles. The two under pieces, or strips, must be made to stick on or adhere to the skin, a short distance from the lips of the wound, in order to give sufficient room for the external dressing. After these adhere firmly, let the upper ones be gradually extended, which, as a matter of course, draws together the lower ones, and with them, the edges of the wound, and when drawn closely together, they likewise must be fastened or made to adhere to those immediately underneath, by which it will be perceived that the parts are brought closely together, permanently secured, and leaving room for dressings without any stitchings or sutures whatever, and to which, certainly, there are great and insuperably Of Wounds. 47 objections. They prove a source of irritation and inflammation, so that it often becomes necessary to remove them. Besides, matter and blood collects underneath, which prove very injurious, rendering it often requisite to remove them ; but by this improved bandage, these objections are obviated. There is an interspace left between the strips of plaster, by which means the matter can be discharged in case of suppuration, and the wound very conveniently dressed. After the bandage, or plaster, has been thus applied, a pledget of lint may be dipped in spirits, and applied over the wound, then a plaster of the black, or healing salve, is to be applied, over the whole ; then, if the nature of the wound call for it, a bandage or roller should be used. In this manner the fresh cut surfaces are brought into contact; and to preserve them quietly in this state, is the next great aim which the surgeon should have in view. The wounded part should be laid in the posture which was found the most favourable for approximating the sides of the cut, at the time of applying the dressings, and the patient should be directed to keep the part in a perfectly quiet state. When attention is paid to these circumstances, it often happens that the two opposite surfaces of the wound grow together again in the course of forty-eight hours, without any degree of suppuration. The process by which this desirable event is accomplished is known by the name of union by the first intention. Besides the advantage of the cure being effected in this way with the greatest expedition possible, there is still another thing much in favour of constantly promoting this me- thod of healing wounds, which is, that the scar is much less than after any other mode of treatment, and the part is covered with original skin, which is always much stronger than any which can be formed as a substitute for it. It is wonderful with what celerity union by the first intention takes place under favourable circumstances. In the course of three days, a large wound is frequently healed. The wound should be dressed occasionally, but in the commence- ment, the dressings may remain from one to three days, according to the feelings of the patient, and other circumstances. I have sometimes given it a superficial examination in one day ; at other times, not till after the expiration of three days. No definite rule can be laid down upon this subject; it must be left to the good sense and judgment of the practitioner. It is sometimes the case, that from some cause or other, more or less suppuration will follow, which will very much retard the healing pro- cess. When this is the case; when inflammation takes place, the salve or external plaster must be removed, and a poultice of the slippery elm bark applied, and after the inflammation has subsided, the salve or plaster to be again applied. Should fungus, or what is termed " proud flesh," arise and prevent the wound from healing, it may be sprinkled with a little pulverized blood-root. If this is insufficient to remove it, a few grains of the vegetable caustic must be daily applied. Contused or Lacerated Wounds. In many wounds which are not attended with contusion, when we either know or suspect that extraneous bodies have been introduced 48 Of Wounds. into the wound, union by the first intention should not be attempted, but they should be allowed to suppurate, in order that the extraneous matter may be expelled. Wounds which are attended with laceration, although free from contusion, cannot always be united by the first intention; because it must frequently be impossible to bring the external parts or skin so much in contact, as to prevent that inflammation which is naturally produced by exposure. But even in cases of simple lace- ration, where the external influence is but slight, or can be prevented, we find that union by the first intention often takes place ; the blood which fills up the interstices of the lacerated parts, having prevented the stimulus in them, and also suppuration, may afterwards be absorbed. Many of the remarks on the treatment of simple and incised, are applicable to lacerated wounds. There is not, however, much difficulty about bleeding or hemorrhage, there very seldom being much present; but the same attention must be paid to the removal of extraneous sub- stances from the wound, after which the parts must be brought in contact, or as closely together as possible, and if the bandage above mentioned, cannot be continually applied, the parts may be kept toge- ther by narrow strips of adhesive plaster; afterwards a pledget of lint, wet in spirits, may be applied, and if there is little or no inflammation present, the black plaster, or healing salve, should be spread thin upon a piece of linen, and applied, not only over the wound, but to some distance on the adjacent parts or around it. Should swelling or inflam- mation take place, this plaster must be immediately removed, and a poultice of the slippery elm barkis to be applied until they subside, when the salve or plaster may be again used. Attention should be paid to the constitution, and such medicine and diet prescribed as will serve to allay irritation. The bowels must be kept open, perspiration promoted, and a cooling regimen recommended. Punctured Wounds. Wounds of this description are in general infinitely more dangerous than cuts, notwithstanding the latter have the appearance of being by far the most extensive. In cases of stabs, the greatest degree of danger always depends on the injury and rough violence which the fibres have suffered, in addition to their mere division. Many of the disagreeable consequences are also to be imputed to the considerable depth to which these wounds extend, whereby important parts and organs are frequently injured. Sometimes the treatment is rendered perplexing by the difficulty of removing extraneous substances, as, for instance, a piece of the weapon which has been left in the wound. Lastly, experience proves that punctured wounds and stabs are par- ticularly liable to be followed by a great deal of inflammation, fever, deep-seated abscesses, sinuses, &c. A strange notion seems to pervade the writings of many systema- , tic authors, that all the danger and disagreeable consequences of punctured wounds depend entirely upon the narrowness of their orifices, so that suitable applications cannot be introduced to their bottom. Hence, it is absurdly recommended to dilate the opening of every stab, with the view, as is generally added, of converting the Of Wounds. 49 accident into a simple incised wound. Some of these writers are advocates for making the dilatation with a cutting instrument, while others, with more propriety, propose to enlarge the opening with tents. Certain authors regard a punctured wound as a recent sinus, and, in order to make the inner surfaces unite, they recommend exciting a degree of inflammation in them, either by means of setons or in- jections. If the notion were true, that an important punctured wound, such as the stab of a bayonet, could be actually changed into a wound partaking of the mild nature of an incision, by the mere enlarge- ment of its orifice, the corresponding practice would certainly be highly commendable, however painful. But the fact is otherwise: the rough violence done to the fibres of the body by the generality of stabs is little likely to be suddenly removed by an enlargement of the wound. Nor can the distance to which a punctured wound frequently penetrates, and the number and nature of the parts in- jured by it, be at all altered by such a proceeding. These, which are the grand causes of danger, and of the collections of matter that often take place in the cases under consideration, must exist, whether the mouth and canal of the wound be enlarged or not. The times when incisions are proper is, when there are foreign bodies to be re- moved, abscesses to be opened, or sinuses to be divided. To make painful incisions sooner than they can answer any end, is both inju- dicious and hurtful. They are sometimes rendered quite unnecessary, by the union of the wound throughout its whole extent without any suppuration at all. Making a free incision in the early stage of these cases undoubtedly seems a reasonable method of preventing the formation of sinuses, by preventing the formation of matter; and were sinuses an inevitable consequence of all punctured wounds, for which no incisions had been practised at the moment of their occurrence, it would undoubted- ly be unpardonable to omit them. Fair, however, as this reason may appear, it is only superficially plausible, and a small degree of reflec- tion soon discovers its want of real solidity. Under what circum- stances do sinuses form ? Do they not form only where there is some causes existing to prevent the healing of an abscess ? This cause may either be the indirect way in which the abscess communicates with the external opening, so that the pus cannot readily escape; or it may be the presence of some foreign body or carious bone; or, lastly, it may be an indisposition of the inner surface of the abscess to form granulations, arising from its long duration, but removable by laying the cyst completely open to the influence of the air. Thus it becomes manifest, that the occurrence of suppuration in punctured wounds is followed by sinuses only when the surgeon neglects to procure a free issue for the matter after its accumulation, or when he neglects to remove any extraneous bodies. But as dilating the wound at first can only tend to augment the inflammation and render the suppuration more extensive, it ought never to be practised in these cases, except for the direct object of giving free exit to matter already collected, and of being able to remove extraneous bodies palpably 50 Of Wounds. lodged. It is an erroneous idea to suppose the narrowness of punc- tured wounds so principal a cause of the bad symptoms with which they are often attended, that the treatment ought invariably to aim at its removal. Recent punctured wounds have absurdly had the same plan of treatment applied to them as old and callous fistulae. Setons and stimulating injections, which, in the latter cases, sometimes act beneficially, by exciting such inflammation as is productive of the effusion of coagulating lymph, and of the granulating process, never prove serviceable when the indication is to moderate an inflammation which is too apt to rise to an improper height. The counter-opening that must be formed in adopting the use of a seton is also an objec- tion. However, what good can possibly arise from a seton in these cases ? Will it promote the discharge of foreign bodies, if any are present 1 By occupying the external openings of the wound, will it not be more likely to prevent it? In fact, will it not itself act with all the inconveniences and irritation of an extraneous substance in the world ? Is it a likely means of diminishing the immoderate pain, swelling, and extensive suppuration so often attending punctured wounds ? It will undoubtedly prevent the external openings from healing too soon; but cannot this object be effected in a better way? If the surgeon observe to insinuate a piece of lint into the sinus, and pass a probe through its tack once a day, the danger of its closing too soon will be removed. The practice of enlarging punctured wounds by incisions, and of introducing setons, is often forbidden by the particular situation of these injuries. In the first stage of a punctured wound, the indication is to guard against the attack of violent inflammation. In short, the antiphlo- gistic plan is to be followed. As no man can pronounce whether such a wound will unite or not, and as no harm can result from the attempt, the orifice ought to be closed, and covered with simple dressings. Sometimes, under this treatment, the surgeon is agreeably surprised to find the consequent inflammation mild, and the wound speedily united by the first intention. " Numerous are the examples of wounds, which penetrate the large cavities, being healed by the first intention, that is, without any suppuration. Even wounds of the chest itself, with injury of the lungs (continues an experienced mili- litary surgeon and professor), ought to be united by the first intention." —{Assilina, in Manuale di Chirurgia, parte seconda, p. 13.) More fre- quently, however, in cases of deep stabs, the pain is intolerable; and the inflammatory symptoms run so high as to leave no hope of avoiding suppuration. In this condition, an emollient poultice is the best local application; and when the matter is formed, the treatment is like that of abscesses in general. , If the situation of the parts will admit of it, let the wound be daily immersed in hot ley; after which apply a poultice of it, (ley) by stir- ring in the elm bark, and applying it warm, and often renewing it. The sinus, or opening, should be often injected with soap and water, and other detergent liquids, such as the tincture of Blood-root, Gum, Of Wounds. 61 Myrrh, &c. A tent, with u few grains of the vegetable caustic, may likewise be introduced to keep the wound open ; when the swell- ing, pain, and inflammation have subsided, apply the black, or healing salve. This treatment is peculiarly applicable to wounds occasioned by old or rusty nails, which are very dangerous, often giving rise to the lock-jaw. Gun-shot Wounds. Gun-shot wounds, as before stated, are solutions of continuity effected by substances impelled from fire-arms. They are generally punctured as to their form, and always contused as to their surface. They are consequently apt to occasion extensive inflammation, and sloughing of the parts more immediately concerned. The orifice by which a ball enters is small, round, depressed, and livid; that by which it escapes larger, more elongated, and rather everted at its edges. These appearances vary with the velocity of the ball, the entrance being most, and the exit least distinctly characterized when it is greatest, and vice versa. The wound, when first received, occa- sions a numb sort of sensation, but before long becomes acutely pain- ful. It bleeds less than an incised wound in the same situation would do. When of any considerable extent, it invariably causes, immedi- ately on its infliction, an extreme degree of mental alarm, despond- ency and prostration of strength. This constitutional effect is proportioned to the importance of the injury, tho weakness of the patient, and his apprehension of danger. The bad consequences of gun-shot wounds were formerly ascribed to the poisonous agency of the gunpowder; and upon this belief was founded the cruel practice of scarifying or excising the wounded surfaces, and dressing them with scalding oils. Pare introduced a milder practice, which he was led to, in the first instance, by necessity, and was afterwards confirmed in by experience and reasoning on the subject. He used merely unctuous applications, and with such success, that his example was soon generally followed. The treat- ment of gun-shot wounds, though so far improved, still continued unnecessarily severe, since the scarification, which was formerly preferred to remove the poison, still remained in use, to prevent tension and inflammation from the fistulous shape of the wound. John Hunter exploded this system of dilatation, as it was called, by showing that it did not prevent the effects in question, and was per- formed soon enough if delayed until they actually appeared. The best application at first is a pledget of lint placed on the wound, a cooling wash, and a poultice. Should inflammation supervene, fomentations, and poultices, become proper; when the sloughs are detached, pressure with the usual cooling lotions, must be carefully employed, as there are apt to be extensive sinuses; and if these have not a sufficient opening, it ought to be afforded by tents, &c. When the ball, or any other foreign matter introduced into the wound, is not carried through, but remains, it ought to be removed, if this can be done without any serious cutting or searching ; for such extraneous substances often acquire a fibrous cyst, and cause no dis- agreeable symptoms. The finger is the best probe for detecting the o 52 Of Wounds. ball or other foreign body ; and when farther search is requisite to find it, the nature of the tissues concerned ought to be carefully considered, since the direction of its course is much affected by those of dense, and unyielding structure, as the bones, fasciae, and even the skin. The velocity of the ball, and the position of the body when it entered, ought also to be taken into account. The forceps is the best instrument to extract it when it is practicable. It is recommended to dilate all gun-shot wounds; but this practice is attended with very little benefit, but on the contrary, with much mis- chief, except the ball is within reach, and can be felt, and it becomes necessary to remove it. Poisoned Wounds. Of the bites of rabid animals.—After the expiration of a shorter or longer time, sometimes not until many months after the accident, the part becomes painful; wandering pains are felt over the body ; great restlessness ; heaviness; disturbed sleep, and frightful dreams ; sudden starting3 or spasms ; sighing; anxiety, and love for solitude. These symptoms daily increase, pains begin to shoot from the wounded part up to the throat, occasioning a straightness and sensation of choking; an aversion is felt-to the swallowing of water or other liquids, which at length arises to such a degree, that the moment any thing in a fluid form is brought in contact with the patient's lip, it occasions him to start back with dread and horror; and the attempt at deglutition is accompanied with a convulsive paroxysm. A vomiting of bilious mat- ter is an early symptom; an intense hot fever ensues, with dryness and roughness of the tongue, hoarseness of the voice, and the discharge of a viscid saliva from the mouth, which the patient is constantly' spit- ing out; together with spasms of the genital and urinary organs, in consequence of which the evacuations are forcibly ejected. There is extreme anxiety, and irritability sometimes so excessive, that the smallest impression made upon the body, by the perching of a fly or other cause, fails not to induce the most terrible convulsions. In some instances delirium arises, and closes the tragic scene; but generally the judgment is retained until the pulse becomes tremulous and irregu- lar, convulsions then arise, and nature is, at length, totally exhausted. Of the bite of the viper.—Acute pain and considerable swelling of the part, which soon becomes red, and afterwards livid; disposition to fainting; or an actual syncope; small rapid, sometimes interrupted, pulse; great nausea ; bilious convulsive vomitings; cold sweats ; the skin becomes yellow ; convulsions ; death. Of the bite of the rattle-snake.—Nausea; a full, strong, agitated pulse; swelling of the whole body; the eyes much diffused with blood ; sometimes copious bloody sweats ; and often hemorrhage from the eyes, nose, and ears. The teeth chatter, and the pains and groans of the sufferer indicate his approaching dissolution. From some facts recorded by Sir Everard Home, and observations made on the operation of the poisons of the black-spotted snake of St. Lucia, the cobra di Capello, and the rattle-snake, it appears, that, " the effects of the bite of a snake, vary according to the intensity of the poison. When the poison is very active, the local irritation is so sud. Of Wound*. 53 den and so violent, and its effects on the general system are so great, that death soon takes place. When the body is afterwards inspected, the only alteration of structure met with is in the parts close to the bite, where the cellular membrane is completely destroyed, and the neighbouring muscles very considerably inflamed. When the poison is less intense, the shock to the general system does not prove fatal: It brings on a slight degree of delirium, and the pain in the part bitten is very severe ; in about half an hour, swelling takes place from an effusion of serum in the cellular membrane, which continues to in- crease, with greater or less rapidity, for about twelve hours, extending during that period into the neighbourhood of the bite. The blood ceases to flow in the small vessels of the swollen parts; the 6kin over them becomes quite cold ; the action of the heart is so weak that the pulse is scarcely perceptible, and the stomach is so irritable that nothing is retained by it. In aboufc sixty hours, these symptoms go off; inflammation and suppuration takes place in the injured parts; and when the abscess formed is very great, it proves fatal. When the bite has been in the finger, that part has immediately mortified. When death has taken place under such circumstances, the absorbent vessels and their glands have undergone no change similar to the effects of morbid poisons, nor has any part lost its natural appearance, except those immediately connected with the abscess. In those patients who recover with difficulty from the bite, the symptoms produced by it go off more readily and more completely than those produced by a mor- bid poison, which has been received into the system.—{Sir E. Home, Case of a Man xoho died in consequence of the bite of a rattlesnake, in Phil. Trans., 1S10.) The bite of the adder is attended with symptoms of a similar nature but they are much less violent; neither does it often prove fatal. Of smaller reptiles, and of insects.—These in general produce local inflammation only ; which, however, is often very severe: in some instances the bite is productive of the same consequences as punctured wounds; inducing inflammation of the absorbents, and convulsions from their effect upon the nerves. The effects of the bite of musquittos, are small tumors, attended with so high a degree of itching and inflammation, that the patient cannot refrain from scratching ; by a frequent repetition of which he not uncommonly occasions them to ulcerate. The Chigre is a kind of small sand-flea, which proves very trouble- some in the West Indies, by insinuating itself into the soft and tender parts of the fingers and toes more usually than into other parts of the body, particularly under the nails, where it continues to increase in size, causing no farther pain than a disagreeable itching and heat. In process of time, however, a small bag or bladder is formed, in which are deposited thousands of nits or ova, that become so many young chiirres, and if not speedily extracted, create running ulcers. Some people have lost their limbs by amputation, nay, even their fives, by having neglected to root out these vermin in proper time. The moment, therefore, that an itching, redness, and heat, more than usual, are perceived in any part affected with a chigre, it will be advisable to extract it. This is usually done with a sharp-pointed 54 Of Wounds. needle by some dexterous negro, who picks out the insect, and if a cyst is formed, endeavours to take out this whole also ; for by breaking it, troublesome ulcers are sometimes formed. The cavity is then usually filled up with tobacco-ashes or snuff. In very inveterate cases, where from neglect either the hands or feet are much beset with chigres, it may be necessary, after the extraction of the several cysts, to wash the parts with a strong decoction of tobacco, or a solution of the vegetable caustic. TREATMENT OP POISONED WOUNDS. !1. To prevent the absorption of the poison. 2. To counteract its destructive effects when already introduced into the system. 1st. As soon as a person has been bitten by any kind of a snake which is poisonous, as a rattle snake or adder, a cup should be applied to the part as soon as possible, and, after it has drawn awhile, use the scarifi- cators, and apply the cups again, and thus drawing out as much fluid as can be done. The efficacy of cupping in poisoned wounds has been well tested, in experiments made upon animals which had been bitten; it was proved that those to which the cups were applied experienced no bad effects of the poison, while the others soon died. This operation prevents the absorption of the virus, or poison. 2nd. As soon as the wound has been cupped, apply the vegetable caustic, and let it be repeated twice a day. 3rd. Make a strong decoction of the common plantain, and wash the wound with it: after which mix it with the slippery elm bark, add freely of sweet oil, and apply it constantly, or as long as there is any swelling or inflammation. This has proved very effectual in poisoned wounds. The plantain has been found a certain antidote against the bites of different animals. I have read an account of a battle fought between a toad and a snake, in which the former, whenever he was bitten, repaired immedi- ately to a little distance and ate the leaves of the plantain, after which he returned and renewed the conflict. The person who witnessed the scene, after a short time, plucked up the root, and when the animal was deprived of it he immediately died, thus demonstrating the power of the plant. This production forms the basis of & receipt for the cure of poisoned wounds, which was long and successfully used by a negro named Caesar, residing in one of the Southern states ; and his master gave him his liberty, on conditions of publishing it. It may be drank internally, and applied externally. 4th. An ounce of Olive oil must be taken by the patient every day, and the cupping repeated. It is now customary to cut out the part wounded; but this is cruel and unnecessary A singular case of poisoned wound, from the bite of a rattle-snake, occurred some years since, under the observation of Dr. S. T. Barstow, of Wilkesbarre, Pennsylvania, and in some respects is perfectly ano- malous. OJ Wounds. 50 A lady, in the fourth or fifth month of hef pregnansy, was bitten by a rattle-snake, but under the treatment she at length recovered from the symptoms usually consequent upon such wounds. At thexfull period of gestation, she was safely delivered of a fine, healthy-looking child ; but immediately on its being applied to the breast and allowing it to suck, the child assumed the peculiar hues of the rattle-snake, swelled exceedingly, and soon died. She then procured a puppy to relieve her breast, which died in two days of the same symptoms. A lamb was then tried ; and in succession, one puppy and three lambs Bhared the same fate. Another puppy was then procured, which escaped with its life, but exhibited some of the symptoms which had been fatal to its predecessors. The lady remained all this time with- out any symptom of the disease, and had as rapid a convalescence from parturition as is usually observed. The poison seems to havebeeji excreted by the process of lactation ; for the second year afterward she had another child, and though she applied it to her breasts, not without fearful forebodings, yet no evil consequences resulted. The obscurity in which the action of poisons on the human consti- tution is involved, is in nowise lessened when we consider that testi- mony of the most satisfactory sort shows that hydrophobia may be generated by heat, and that the disease may sometimes occur sponta- neously. According to M. Unaniel, in 1807, in the village of Sea, forty-two persons died, after having been bitten by mad dogs; and on the north coast, hydrophobia occurred in several individuals without bite.—(See Journal des Progres, quoted in North Am. Med. and Surg. Journ. vol. 6.) The causes which may induce spontaneous hydropho- bia are violent emotions of the mind, sorrow, fear, rage, fright, the want of food, &c. Drs. Hosack and Francis enjoyed a singular opportunity of witnessing a case of hydrophobia, arising in a young man, aged thirteen years, independent of the bite of a rabid animal. He had been severely treated by his guardian or overseer for some imaginary offence ; the want of food and clothing at an inclement season of the year could alone be looked upon as the exciting cause of his complaint. The symptoms of his disorder throughout were similar to those arising from madness induced by the bite of a rabid animal.—(JV. Y. Med. and Phys. Journal, vol. 2.) A curious paper on the various means em- ployed for the cure of hydrophobia by Dr. Mease, may be seen in the Philadelphia Medical Museum. 56 Of Wounds. WOUNDS OCCURRING IN PARTICULAR PARTS OF THE BODY. Wounds of the throat.—Superficial wounds of the throat require the same treatment as others, but they are often very deep from attempts to commit suicide. In this case, the first thing that demands atten- tion is the hemorrhage which is often profuse: the bleeding vessels in this case, if possible, should be secured by a ligature; although I have seen a copious hemorrhage spontaneously cease without tying it, and without compression. When the carotid artery is cut, it is generally fatal, but not always when the jugulars are divided. After the bleeding has ceased or has been stopped, the divided parts must be brought together and secured the same as other wounds. It is customary with some to use stitches or sutures, but they excite ir- ritation, or inflammation, and when the patient coughs, or upon any motion of these parts, the stitches are torn through. Sometimes the trachea, or wind-pipe, and oesophagus are cut through. When this accident occurs, the most that is necessary to be done, is the same treatment as before recommended, or application of the ordinary dressings. Wounds penetrating cavities.—The thorax and abdomen are some- times penetrated, and dangerous consequences result if any of the viscera contained in thess cavities are injured. Wounds of the Thorax.—The thorax is sometimes penetrated suffi- cient to penetrate the cavity of the pleura, and the admission of air, produces an immediate collapse of the lungs, and respiration is per- formed with great difficulty. When this accident occurs, the wound must be closed, a plaster and bandage applied over it, and rest and a cooling regimen enjoined. Should inflammation arise, the parts must be poulticed, and it must be placed between two pieces of muslin to prevent any portion of it from entering the cavity of the chest. Wounds penetrating the Abdomen.—Wounds occurring in these parts are often very dangerous, arising from the danger of peritoneal in- flammation. If the wound is superficial, let it be dressed the same as others, and the treatment both external and internal instituted, as it is calculated to prevent inflammation. If the wound penetrate the cavity of the abdomen, and let out the intestines, after removing the extraneous substances, they must be returned, parts brought together, and secured, and cooling lotions, and poultices applied. Tepid ap- plications are, in general preferable, as those that are cool are apt to pro- duce a chill, and subsequently fever. In general, in all cases of wounds of the abdomen, it is an excellent rule never to be officious about ab- scesses which may take place, nor to exhibit partiality to such experi- ments as have been devised for learning preciselywhat bowel is wound. ed. It is quite time enough tointerfere when the urgency of the symp- toms confirms any suspicions which may be entertained. A great deal of harm is frequently done by handling and disturbing the wounded parts more than is necessary, and it is well known, that wounds at first attended with alarming symptoms frequently have a favourable termination. Swords, balls, and other weapons some- times pass completely through the body without the patient suffering afterwards any threatening symptom, or indeed any effect which^ Of Wounds. 57 abstractly considered, would authorize the inference that the viscera had been at all injured. Severe inflammations may not end in suppuration, and when pus is formed it is sometimes absorbed again. Nothing, then, indicates the necessity for the discharge of purulent matter in the abdomen, unless the fluctuation and situation of the abscess be very distinct, and the quantity and pressure of the matter clearly productive of inconveniences. Under these circum- stances, the surgeon should make a cautious puncture with a lancet. i lately saw a case in which a very aged female had a considerable portion of the abdomen torn open, the intestines thrown externally, by the horn of a cow. By judicious treatment, although there was inflammation of the peritoneum and the most extensive suppuration, when I last heard from her she was nearly, or quite well. In such cases there is much con- stitutional disturbance, which must be removed by a strict anti-phlo- gistic, or cooling course of treatment. Wounds of the Intestines. Sometimes the intestines are wounded, or partially divided. When this happens, we must rely more upon the recourses of nature than art. Adhesive inflammation may arise, and agglutinate, the divided in- testine together. 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 open- ing in the skin, are the common symptoms attending a wound of this kind. When the wound is situated in the protruded portion, it is obvious to the surgeon's eye ; but when it affects a part of the intes- tinal canal within the abdomen, the nature of the case can be known only by a consideration of other symptoms. In addition to such as I have already described, there are some others which ordinarily ac- company wounds of the bowels; as, for instance, oppression about the precordia, acute or griping pain in the belly, cold sweats, syncope, &c. But unless the wounded intestine protrude, 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 simple penetrating wound of the belly, unattended with a wound of any of the viscera. Large wounds of the small intestines, particularly of the duodenum and jejunum, are attended with acute fever, anxiety,'paleness of the countenance, syncope, cold perspirations, a small, intermitting, tremulous pulse, and they fre- quently prove fatal. Injuries of the small intestines are also more often than those of the large ones followvd by extravasation. A total division of the upper part of the intestinal canal, towards the pylorus, will deprive the body of the nourishment requisite for its sup- port. If the chyle escape from the wound, the patient will die of a slow marasmus; and if it become extravasated, it will be likely to excite such irritation as will prove fatal. The escape of excrement or of fetid air from the wound, indicates an injury of one of the large intestines. In these cases, the symptoms are generally milder, and tin' pnssagc of the intestinal contonts outwards, through the 58 Of Wounds. wound, more easy, on account of the bowel being lees moveable. For the same reason, the wounded intestine more readily contracts an adhesion to the adjacent parts.—{Callisen, Syst. Chirurgice Hodierna, t. I, p. 717.) From repeated experience, we learn that most of the viscera of the abdomen may be wounded without any very serious or fatal con- sequences, and this affords wounderful proof of the resources and powers of nature, in providing against danger and death. 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 sewing 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 after- wards manifested, by the discharge of blood per anum, and extrava- sation of intestinal matter, &c, it would be impossible to get at the injured part of the bowel, not only because its exact situation is un- known, but more particularly on account 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 intestine out of the cavity of the abdomen, and hand- ling and disturbing the adjacent viscera. Nothing would be more likely than such proceedings to (render the accident, which might originally be curable, unavoidably fatal. I entirely agree 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 universal pressure, which pre- vents great effusion 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 symptoms, a few days after the accident, show the nature of the case, a suture can be of no use -whatever, as the adhesive inflammation has already fixed the part in its situation, and the space in which the extravasation lies is com- pletely separated from the general cavity of the abdomenr by the surrounding adhesions. When the bowel does not protrude, and the opening in it is situated closely behind the wound in the peritoneum, a suture is not requsite; 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 oc- cupies 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 Of Wounds. 69 or two at length render it impossible Tor the bowel to shift its situation. Things, however, are very far different when the wounded part of the bowel happens to protrude. No enlargement of the outer wound is requisite to enable the practitioner to adopt the suture; there is no dis^ turbance of 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 suture in the case of a wounded and protruded 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 the view of confining the injured bowel near the external wound, so that in the event of an extra- vasation, the effused matter may find its way outwards. Other writers wish to remove the possibility of extravasation, by applying numerous stitches, and attach little importance to the plan of using the ligature, 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 evi* dently 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. Notwithstanding I have carefully read all the arguments adduced by Travers, in favour of stitching a divided bowel at as many points as possible, I still remain unconvinced of the advantage of such practice, for reasons already suggested. If a case were to present itself to me, in which a bowel, partly cut through, protruded, I should apply only a single suture, made with a small sewing-needle and a piece of fine silk. If the bowel were completely cut across, I should have no objection to attach its ends together by means of two or three stitches of the same kind. I coincide with Mr. Travels, respecting the advantage of cut- ting off the ends of the ligature, instead of leaving them in the 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 position, they must be objectionable as extraneous substances. [Cooper.] As confirming some of the foregoing observations, I would refer to the valuable writings of Scarpa and those of Dr. Hennen. "The old practitioners (says Dr. Hennen,) were very much averse from leaving any thing to nature in cases of abdominal injuries, although their universal employment of sutures ought to have con- vinced them how much she could bear with impunity ; for there can be very little doubt that their uniform performance of the operation of gastroraphe was at least superfluous, if not positively hurtful. In the course of a very extensive practice, two cases only have come under my notice, where it was required to a wounded intestine, though fre- quently it may be needed for injuries to the parietes."—{On Military Surgery, ed. 2, p. 411.) R 60 Of Wounds. As Dr. Hennon observes, in tne treatment of wounds of the abdo- men, the violence of symptoms is to be combated more by general means than by any of the mechanical aids of surgery. The search for extraneous bodies, unless superficially situated, or they can be felt with a probe, is entirely out of the question. " Enlargement or con- traction of the wound, as the case may require, for returning protruded intestine, securing the intestine itself, and promoting the adhesion of the parts, is all that the surgeon must do in the way of operation ; and even in this the less he interferes the better."—{On Military Surgery, ed. 2, p. 401.) The principal indication is to prevent a dangerous degree of inflam- mation. Hence the antiphlogistic treatment is highly indispensable. Wounds of the small intestines are attended with more dangerous symptoms than those of the large ones. All flatulent, stimulating, and solid food is to be prohibited. The bowels are to be daily emptied with clysters, by which means no matter will be suffered to accumulate in the intestinal canal, so as to create irritation and distension. When excrementitious matter is dischaged from the outer wound, it is highly necessary to clean and dress the part very frequently. Gen- tle pressure should also be made with the fingers, at the circumference of the wound, at each time of appljing the dressings, for the purpose of promoting the escape of any extravasated matter. For the same reason the patient should always lie, if convenient, in a posture that will render the external opening depending. 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 generally undergoes a diminution in its diameter at the place where the wound was situated. When this contraction is considera- ble, the patient occasionally experiences colic pains at the part, especi- ally after eating such food as tends to produce flatulence. As these pains usually go entirely off after a certain time, and no inconvenience whatsoever remains, the intestine may possibly regain its wonted capacity again. A more considerable constriction of the above sort has been known to occasion a fatal miserere. Even the intestine itself has been known to burst in this situation, after its contents had accu- mulated behind the contracted part. Patients, who have recovered from wounds in the intestines, should ever afterwTard be particularly careful not to swallow any hard substances, or indigestible flatulent food. Wounds of the Joints.—In all wounds of the joints, it is proper to place the limb in such a posture as to favor the approximation of the sides of the wound, and absolute rest must be enjoined. In every other respect they must be treated as other wounds. When there is a dis- charge of synovia, or joint water, it may sometimes be necessary to sprinkle styptic powders upon the wound, to prevent its escape; but as the wound heals, the discharge usually lessens. I attended one case where the knee was wounded with a" scythe, and where there was a discharge both of pus and of the synovial fluid. The application of the elm poultice, and black plaster, reduced Of Wounds. 61 the swelling and inflammation; the wound rapidly healed, and he soon recovered. Wounds of the Tendons.—It requires sometimes nice discrimination to detect wounds of the tendons, as they are usually complicated with ulcers. There is a discharge from the sore, of matter or pus, and also of a clear fluid resembling joint water. In such cases, instead of excit- ing a preternatural discharge, as we do in common ulcers, we must reverse our treatment, and make use of such applications as will check this discharge. I attended a young man, nearly fifteen years ago, who received a wound of the leg by a cart passing over it, and which was attended by a physician, or surgeon, of New Brunswick, who stated that it would be a year or two before he could recover, and that a portion of bone must first be sawed off. He was brought to me, a distance of thirty miles, exhibiting, when he arrived, very unfavorable symptoms. He had become very pale and much reduced. Upon an examination of his sore, which was upon the leg, it appeared to assume the appear- ance or character of a common ulcer, and for such I prescribed. I applied medicine to make it discharge more freely, with a view to bring about a healthy action; but this discharge was attended with a very serious effect; it reduced him in twelve hours surprisingly, and I could not account for it; but upon a more minute examination, I dis- covered two kinds of matter or fluids issuing from the ulcer; one kind was pus, the other was such as issues from a common ganglion, from which I perceived that my treatment was diametrically the reverse from what it ought to have been. I therefore reversed it, and injected in with a small syringe, an astringent preparation, made by adding a few grains of the styptic powder to a strong decoction of the Persimon bark, which immediately checked the discharge and so changed the character of the ulcer, that the patient was soon able to walk, and he entirely recovered, to the great disappointment and mortification of his former physician. When he first came he was unable to walk, I think, even with crutches. Such is the proper treatment of various kinds of wounds, and no matter in what part of the body they are received, the practitioner in treating them is to be governed by the same principles with such va- riations, as particular and peculiar cases may require. In wounds of the integuments of the head, the hair must be care- fully shaved off with a razor, extraneous substances removed, the divided parts replaced in contact, and secured either by the improved adhesive or uniting plaster, or narrow strips of the same. No matter how extensive the wound is, the separate scalp or integuments must be replaced. In cases where nearly half the scalp has been torn off, and covered with dirt and splinters of wood, the parts have been cleansed and replaced, and the wound has healed. CHAPTER IV. INJURIES OF THE HEAD. Ah. injuries of the head are more dangerous than any other kind, in consequence of the effect they produce upon the brain and ner- vous system. From the variety of parts of which the scalp is composed, from their structure, connexions, and uses, injuries done to it by external violence become of much more consequence than the same kind of ills can prove, when inflicted on the common integuments of the rest of the body. One principal reason of the danger in these cases de- pends upon the free communication between the vessels of the peri- cranium and those of the dura mater, through the diploe of the skull; for when inflammation is kindled in the former membnme, it may ex- tend itself to the latter. According to Sir Astley Cooper, there are three modes in which wounds of the scalp may induce fatal conse- quences. 1st, by producing what is called an erysipelatous inflam- mation on the head ; 2dly, by producing extensive suppuration under the tendon of the occipito-frontalis muscle; 3dly, by rendering a simple fracture"compound by means of the trephine, so as to cause more extensive inflammation of the dura mater. The nervous system is composed of the cerebrum, cerebellum, and medulla oblongata, which principally supply the organs of sense and their appendages with nerves, and of the medulla spinalis, with the nerves of volition and sensation proceeding from it. But there is a second system of nerves in the body, called the grand sympathetic, which is distributed to the heart, and to the viscera of the abdomen : it communicates with most of the nerves of the brain, and with those of the spinal marrow : it forms by its branches a large ganglion, or several ganglia, called the semilunar, situated behind the stomach ; and a plexus proceeds from this, which distributes branches to the greater part of the abdominal viscera. The eighth pair of nerves of the brain forms a large communica- tion with the ganglion behind the stomach. If an injury happens to the head, the functions of volition and sen- sation are diminished ; the stomach is disordered through the medium of the par vagum ; and from the general communication between the grand sympathetic nerve, and those of the brain and spinal marrow, the functions of the heart and of the abdominal viscera become af- fected. The powers of the mind are also diminished ; the memory IS lost; the judgment is enfeebled : thus sensation, volition, the in- voluntary actions, and the powers of the mind, are diminished or sus, pended- The time at which inflammation of the brain supervenes, after the injury has been received, is generally about a week, rarely less than Of Wounds. 63 that time ; and this it was that led me to say, on another occasion, that inflammation of the brain was more slow in its occurrence than that of most other organs. It often happens that inflammation of the brain does not come on till a fortnight or even three weeks after the injury. Every surgeon who has written on the subject puts his read- er on his guard about the distance of time that complaint supervenes after the accident he tells you the patient is not safe till two or three weeks afterwards. If you read the works of Mr. Pott on the injuries of the head, you will find the circumstance mentioned ; and in the work of Mr. Dease, of Dublin, it is distinctly stated, that inflamma- tion of the brain is occasionally postponed to three or four weeks af- ter the accident occurs, and even then the patient is not safe. [Cooper.] " A blow on the scalp," says Dorsey, " occasions an ecchymosis, in which blood forming the tumour remains fluid, and the surrounding scalp feels unusually hard and elevated, and conveys to the fingers a sensation resembling that of depressed bone. Mr. Pott describes this accident particularly, with a view to caution young practitioners against opening the tumour under an expectation of finding depressed bone. The proper treatment consists in promoting the absorption of the extravasated blood by cold applications, and ii" these are unsuc- cessful, a small puncture may be made with a sharp lancet and the fluid pressed out. If suppuration take place, the abscess must be treated in the usual manner. It is prudent in all injuries of the scalp to enjoin a low diet, and prescribe a purge." SECTION I. Wounds of the Scalp or Integuments. Dangerous.—Wounds of the scalp are not devoid of danger ; and slight injuries of that part have destroyed life. Incised wounds are certainly less liable to produce deleterious effects than the lacerated or contused ; although I knew a lady, of high consequence in the country, die from the removal of an encysted tumour in the scalp. Cause of danger.—The cause of the danger attending such wounds is the free communication by blood-vessels between the scalp and dura matter; as the vessels of the pericranium freely anastomose with those of the dura mater through the diploe of the skull, and, therefore, inflammation lighted up in the one, is readily extending its influence to the other. There cannot be, therefore, a more absurd and injudicious practice than that of wantonly making incisions through the scalp, to ascertain the exact extent of the injury which the bone may have received, when there are no symptoms to justify such a procedure; because such incisions produce new dangers to the patient, as well as add to that which the injury would itself pro- duce. If, therefore, I am called to a case of injury of the head, in which there is apparent depression of the skull, yet there are no symptoms of injury of the brain, 1 would not render that fracture compound by making an incision through the scalp; and even if 64 Of Wounds. there were symptoms of injury of the brain, I would try the effect of free depletion, before I made an incision, as the loss of blood some- times occasions the entire removal of the symptoms. But if there were already a wound in the scalp, and my finger passed down to a depressed portion of bone, I would immediately use an elevator to raise it, which may be generally done in children without difficulty, and in the adult would saw off a portion of bone to admit the ele- vator. [Cooper.] Wounds in the soft parts of the head must be treated the same as other kinds of wounds. (See Chapter on this subject.) The hair should be shaved off with a razor a considerable distance round the wound, after which the blood may be removed with a sponge or piece of linen, and all foreign substances; the divided edges brought in contact, and secured by means of the improved or uniting plaster, or narrow slips of the same. Over these dressings a plaster of the black or healing salve may be applied ; and it is necessary, previously, to apply a little lint to the wound. The dressings may be secured by a bandage or night-cap. section ir. Concussion of the Brain. Mr. Abernethy has removed a good deal of the perplexity of this subject, by dividing concussion into three stages. In fact, without discriminating them, the various descriptions of the symptoms, as given by different writers, cannot be at all reconciled. "The first is, that state of insensibility and derangement of bodily powers which immediately succeeds the accident. While it lasts, the patient scarcely feels any injury that may be inflicted on him. His breathing is difficult, but in general without stertor; his pulse inter- mits, and his extremities are cold. But such a state cannot last long ; it goes off gradually, and is succeeded by another, which I consider as the second stage of concussion. In this, the pulse and respiration become better, and though not regularly performed, are sufficient to maintain life, and to diffuse warmth over the extreme parts of the body. The feeling of the patient is now so far restored, that he is sensible if his skin be pinched ; but he lies stupid and inattentive to slight exter- nal impressions. As the effects of concussion diminish, he becomes capable of replyirg to questions put to him in a loud tone of voice, especially when they refer to his chief suffering at the time, as pain in the head, &c; otherwise he answers incoherently, and as if his attention was occupied by something else. As long as the stupor remains, the inflammation of the brain seems to be moderate ; but as the former abates, the latter seldom fails to increase ; and this consti- tutes the third stage, which is the most important of the series of effects proceeding from concussion. These several stages vary considerably in their degree and dura- tion ; but more or less of each will be found to take place in every instance where the brain has been violently shaken. Whether they bear any certain proportion to each other or not, I do not know. In- Of Wounds. 65 deed, this will depend upon such a variety of circumstances in the constitution, the injury, and the after-treatment, that it must be difficult to determine. In most cases of concussion, the patient vomits after the accident. According to Mr. Brodie, sickness and vomiting are generally early symptoms, and seldom continue after the patient has recovered from the first shock of the accident.—{Med. Chir. Trans, vol. xiv. p. 339.) In the beginning, a torpor exists in the intestinal canal, and consider- able difficulty in procuring an evacuation ; but afterward the feces are sometimes involuntarily discharged, and the bladder becomes dis- tended, so as to require the catheter ; but after a time, the urine also comes away involuntarily. There is sometimes bleeding at the nose, and a part of the blood which drops in the throat is vomited up. The pupils of the eyes are generally natural; but if changed, both are a little dilated, or sometimes only one. The state of the pupils, how- ever, is differently represented by different writers, and my expe- rience has taught me that it is subject to much variety. In that stage in which the sensibility of the patient is impaired, but not annihilated, " the pupils contract on exposure to light, and are sometimes more contracted than under ordinary circumstances."—{Brodie, vol. cit. p. 338.) According to Sir Astley Cooper, the pulse, although natural when the patient is undisturbed, scarcely ever fails to be quickened by any exertion made by the patient: and the carotids sometimes pulsate with great force; but the latter symptom is generally not noticed till after a few hours. The state of the pulse is very different, according to the stage of the disorder. In severe cases, the pulse is at first intermitting, irregular, feeble, perhaps scarcely perceptible, and the patient in a condition approaching that of syncope. Such maybe his situation for several hours after the accident. When concussion proves fatal, the cause of death is imputed by Mr. Brodie to this disturbance of the action of the heart. " In general, when the patient has lain for some time in the state which has been described, a re- action of the circulating system takes place, and the pulse beats with greater strength in proportion as the failure of it was greater in the first instance. But where the shock has been unusually severe, there is no such reaction. The pulse becomes more and more feeble, more irregular and intermittent; the extremities grow cold, and at last, the action of the heart being altogether suspended, the patient expires. In some cases, even after reaction has begun to take place, it seems as if the constitution were unequal to the effort: there is another failure of the circulation, the result of which is the same as if the patient had never rallied from the beginning."—{Brodie, in Med. Chir. Trans, vol. xiv. p. 341.) The mind, as Sir Astley Cooper remarks, is variously affected, according to the degree of injury which the patient has sustained. In some cases, there is a total loss of mental power ; in others, the patient is capable, though with difficulty, of being roused to make a rational answer, but immediately sinks again into coma. Sometimes the memory is lost; while in other instances, it is only partially impaired. A total forgetfulness of any foreign language is a common effect of concussion. It frequently happens that the pa- tient, when roused, will be perfectly sensible, and answer questions 66 Of Wounds. rationally; but if left undisturbed, the mind appears to be occupied by some particular circumstance, (often an incoherent one,) of which he is constantly talking. Patients recollect nothing about the mode in which their accidents took place. If the injury has been occa- sioned by a fall from a horse, they can only remember mounting and riding to some distance, but not that the animal ran away or threw them; nor, however perfectly they may recover in other respects, do they ever have any recollection of the kind of accident. The change produced by injuries of the brain is remarked to be somewhat similar to the effects of age ; the patient loses impressions of a recent date, and is sensible of those which he received in his earlier years. But, as Sir Astley correctly explains, the degree of injury sustained by the brain varies considerably in different cases. Some patients are only stunned, or deprived of sense for a moment; others recover in a few hours ; some remain in a great degree insensible for fifteen or twenty days. Some recover entirely; others have afterward an imperfect memory. A partial loss of sense will be produced in the function of one eye, or deafness in one ear ; and so of volition, the squinting caused by an injury of the brain being sometimes permanent. In some cases a degree of fatuity; in some, great irritability; in others, vertigo, and tendency to severe headache from the slightest excitement, will remain. In one example seen by Sir Astley Cooper, a remarkable irritability of the stomach and disposition to vomit were the permanent consequences of a concussion of the brain. In parti- cular instances, the faculty of readily uttering the proper words for expressing ideas is lost and never regained, and wrong terms are used. Often the judgment remains enfeebled.—{Lectures, vol. i. p. 254, &c.) Many of the observations in the foregoing statement coin- cide with the accounts given of the subject in the writings of Bichat and Desault. The following passage, extracted from a writer who has already been of material assistance in this article, cannot be too deeply im- pressed on the memory of every practitioner. " To distinguish between an extravasation and commotion by the symptoms only, is frequently a very difficult matter, sometimes an impossible one. The similarity of the effects in some cases, and the very small space of time which may intervene between the going off of the one, and the accession of the other, render this a very nice exercise of the judgment. The first stunning or deprivation of sense, whether total or partial, may be from either, and no man can tell from which; but when theso first symptoms have been removed, or have spontaneously disappeared, if such patient is again oppressed with drowsiness or stupidity, or a total or a partial loss of sense, it then becomes most probable, that the first complaints were from com- motion, and that the latter are from extravasation; and the greater the distance of time between the two, the greater is the probability, not only that an extravasation is the cause, but that the extravasation is of the limpid kind, made gradatim, and within the brain." The causes of the symptoms of injury to the brain are two : 1st. Concussion ; 2d. Pressure, which may be the result of extravasa- Injuries of the Head. 67 tion of blood, of depression of bone, or of matter produced by inflam- mation on the brain. Cooper thus remarks on Symptoms of Concussion.—When you ap- proach the bedside of the patient who has a concussion of the brain, you rind him in what you would suppose a sweetly tranquil sleep : his breathing is easy, and not quicker or slower than natural : his pulse is beating with steadiness, and with its usual velocity, and you would be disposed to say, do not disturb him, but let him sleep on. But if you attempt to rouse him, he is with difficulty excited ; if he be spoken to, he mutters, and returns an incoherent answer, and you then discover that he is comatose. Upon inquiry it is found, that he has received a severe blow upon his head, that immediately after he was senseless, and unable to stand, and that he had since vomited. At first a torpor exists in the intestinal canal, and considerable diffi- culty in procuring an evacuation, but afterwards the faeces are invo- luntarily discharged : in a few hours the bladder is distended, from the accumulation of urine, which demands the introduction of a ca- theter for its removal; but after some time the urine also passes involuntarily. There is sometimes, in these cases, bleeding at the nose, and from the blood trickling into the throat and stomach, blood is vomited ; the pupils of the eyes are generally natural; but if changed, both are a little dilated, or sometimes one only. The state of the pulse is cu- rious. Although when the patient is undisturbed it is natural, it scarcely ever fails to be quickened, if the patient is capable of making any effort to rise, and exerts himself for that purpose. The carotid arteries sometimes beat, under an exertion, with a force dispropor- tioned to the other arteries of the body; but generally this symptom is not observed until after a few hours. Mind.—The mind is variously affected, according to the degree of injury whieh the patient has sustained. In some cases there is a total loss of mental power ; in others, the patient is capable, though with difficulty, of being roused to make a rational answer, but again sinks immediately into coma. Sometimes the memory is lost, at others only partially impaired. SECTION III. Compression of the Brain. Compression of the brain may be produced by blood extravasated within the cranium, or by a portion of the skull being beat in below its natural level. 1st. Compression from Effused Blood.—Blood may be extravasated between the skull and dura mater : beneath the pia mater ; into the ventricles ; or into the substance of the brain. The symptoms in all these cases are similar. It has always been an object of interest, among surgeons, to designate the symptoms which attend compres- sion of the brain, and to discriminate them from those arising from concussion ; and although no subject has been more carefully in- vestigated than this, yet amidst the multiplicity of observations which Vol. II. I 66 Injuries of the Head. are to be found in surgical writings, no accurately distinctive symptoms have ever been pointed out; and this furnishes an argu- ment in favour of the opinion, that in concussion there is extravasation. Le Pran, long ago observed, that " in concussion small vessels may be ruptured, and thereby occasion extravasation in several places." The loss of sense, speech and voluntary motion, which attend severe concussion, is alike common after extravasations of blood, and de- pression of the blood. Mr. Abernethy observes, on this subject, that " if we judge of the symptoms of compression from what occurs in cases of apoplexy, or from cases of the rupture of the middle artery of the dura mater, we must be of opinion that pressure on the brain occasions insensibility partially, or generally, and in a degree propor- tionate to its quantity." " In extreme cases, the insensibility is mani- fested by every circumstance. The pupil of the eye is dilated, and cannot be made to contract, even by a strong light. The respiration is slow and stertorious, and the pulse proportionally slow and labouring. There is no vomiting which would indicate sensibility of stomach. The limbs are relaxed, as in a person just dead. No struggles take place ; no signs of sensation appear during the operation; but on. the pressure being removed, sensation and intelligence are immediately restored. In concussion, the insensible state is of short duration, and during its con- tinuance the body is generally cold, and the pulse feeble and inter- mitting. Afterwards the skin is hotter than usual; the pulse and respiration more frequent; the former often intermits, and the latter has not the stertor of apoplexy. (But the absence of stertor must not be relied on as a proof that there is no compression, for Morgagni relates dissections of apoplectic persons, where the effusion was con- siderable, yet no stertor had occurred; and in some cases where it took place only in a very slight degree.) The pupil of the eye is not dilated, but rather contracted. The countenance expresses pain and uneasiness, and vomiting occasionally takes place. The state of the patient is like that of a heavy and uncomfortable sleep ; yet, being roused, signs even of intelligence appear." These remarks of Mr. Abernethy contain the best contrast of the symptoms resulting from concussion and compression which are to be found; but in some cases they are insufficient to afford an accurate diagnosis. In many instances, however, the symptoms indicating extravasa- tion are very clearly marked : of a great number of cases which I have met with in books and in practice, I shall relate the prominent circumstances of one, to illustrate this observation. Compression of the Brain from Depressed Bone.—Fractures of the skull, as they are produced in a variety of ways, must differ very ma- terially in their nature and extent. The numerous divisions of the ancients, founded upon these circumstances, are, however, of little im- portance. The chief differences now regarded, are the degrees of pressure and irritation. Fissures or cracks in the skull, unattended by a depression of one of the fragments, are not dangerous, and very readily heal without un- pleasant symptoms ; but must occasion all the symptoms which are produced by pressure from an effused fluid : accordingly, we find that Injuries of the Head. 69 patients thus circumstanced are generally affected with the same apo- plectic symptoms,—a complete or partial loss of sense, speech and voluntary motion—stertorious breathing, followed by vomiting, ver- tigo, haemorrhage from the cars, nose, mouth, &c. Now these symp- toms often occur without a fractured skull, as has already been re- marked ; and, on the other hand, many cases of fractured skull, even where the bone is considerably depressed, are unaccompanied by them. " I once saw a woman," says Dorsey, " who had been as- saulted by a lunatic, and struck forcibly with an iron bar : I found her skull fractured near the junction of the parietal bones, a depres- sion existed, which in one part was full half an inch below the na- tural level, and yet none of the usual symptoms of compressed brain occurred, and the fracture healed up without any dressings except a superficial pledget." Similar cases are recorded. Fractures of the skull, although they occasionally produce no un- pleasant symptoms, are, notwithstanding, accompanied with many dan- gers. In addition to the evils to be dreaded from pressure upon the brain, the irritation occasioned by the mechanical action of the sharp and irregular edges of the bone upon the dura mater and brain is to be feared. The constant pulsation of the vessels upon the brain, which produces motion under the fracture, augment considerably the irritation in consequence of which the dura mater sometimes ulcer- ates. In many cases of fracture of the skull, the dura mater is pierced and the brain wounded by the body which caused the accident, or by a fragment of the bone being forced through these parts. In some instances, portions of the substance of the brain escapes through the fracture at the time of the accident. In sabre wounds, slices of brain, together with considerable portions of the skull, are sometimes re- moved. Inflammation of the Brain and its Membranes.—Mr. Abernethy very judiciously remarks, that, "in the generality of cases of injury done to the head, the symptoms of concussion, compression, and inflamma- tion, are so combined as to appear inexplicable. It is only by an at- tention to those rare cases, in which the symptoms of each appear distinctly, that we are likely to increase our knowledge of their spe- cific effects." Inflammation of the brain and its contents, is a con- sequence of different species of violence to which it is subject, and therefore its symptoms will be more or less blended with those result- ing directly from the accident, as stupor, &c. The dura mater, the pia mater, and the whole substance of the brain, is liable to inflammation. Mr. Abernethy remarks—" If the inflammation be violent and general, the patient will be irrational and disturbed, having his mind strongly affected by wrong ideas, and endeavouring to act in conse- quence of them. If the inflammation be moderate, and affect the surface only, he will be irrational, uneasy, restless, and perhaps en- deavour to get out of bed, but without the violence of mania. Should a moderate inflammation be blended with the effect of concussion, he will have less appearance of irrationality, will lie pretty quiet, and inattentive to slight impressions. 70 Injuries of tlie Head. Some variety will occur, probably, in the symptoms of different pa- tients ; but in all there will be more or less derangement of the powers, both mental and corporeal, depending upon the degree of in- flammation, &c. The symptoms which chiefly characterize the com. plaint, are those of an increase of sensibility ; the pupils of the eyes are contracted, the patient often withdraws his arm on being touched, and his pulse and tongue denote general as well as local inflammation. Suppuration takes place when the remedies are unsuccessful in ar- resting the progress of the inflammation; and when this happens, the symptoms of compressed brain are repeated, and a deep coma or lethargy comes on. The pus or matter in this case is very often situ- ated directly under the skull, but sometimes under the dura mater— at other times an abscess is found in the brain. Although inflammation of the brain generally occurs in a fewda3's after the accident which causes it, yet in some cases, a week, or even a month will elapse before its commencement. Common Treatment. Bleeding, blistering, mercurial purges, trephining or trepanning. I have little or no confidence in general blood-letting. It produ- ces injury by the debility which it occasions ; and, besides, it prevents the restorative process. Other means are much better to mitigate the violence of arterial action, or excessive inflammation. As regards the trephine, I have still less confidence in it. From all the information I can obtain respecting its effects, I think it has killed ten where it has cured one, and I am not at all surprised that Desault, in the last years of his practice, should abandon the use of this in- strument altogether, in consequence of the fatal effects which follow- ed its use. Formerly it was very fashionable to trephine for even trivial injuries of the head ; but for some years past, surgeons have become less partial to the operation, from the notorious bad effects which have followed the operation ; but it is still, I regret to say, too much practised. We are directed to trephine, to remove depressed pieces of bone, in order to relieve compression of the brain ; but in doing this, we make a compound fracture, and which is more mis- chievous in its effects than the wound for which the operation is per- formed. It is very evident to all who are in the least acquainted with injuries of the head, that patients do well in very bad cases of compression without elevating the bone ; that they recover and do well, when this very operation, under similar circumstances, proves fatal; and it can readily be accounted for: two severe wounds of the head are much more likely to kill a person than one. It is hardly possible to bore a hole in a person's skull down to the dura mater, or its vicinity, and not produce a dangerous wound. But when this is done in addition to a previous serious injury, what beside can we expect but lamentable consequences. It is hardly possible that irritation, inflammation or suppuration will not supervene. In compression from a depressed bone, we may apply the old maxim : " of the two evils, choose the least." If the pressure on the Injuries of the Head. 71 brain be an evil, and if the operation is still greater, would not com- mon sense dictate to us the propriety of pursuing that course of treatment which, we know by experience, is attended with the least danger. Another objection to the use of the trephine is, that it is often extremely difficult to discriminate between concuss ion and compres- sion of the brain. Hence, there is no sure criterion for performing the operation. Says Sir Astley Cooper, "The old practice used tobe,the moment an injury of the brain was suspected, and the least depression of the bone appeared, to make an incision info the scalp. This is putting the patient to considerable hazard ; for the simple fracture would, by the incision, be rendered compound. In simple fracture, then, when it is attended with symptoms of injury of the brain, deplete before you trephine ; and when it is unattended with such symptoms, deplete merely, and do not divide the scalp, &c. If the fracture be compound, the treatment must be very different; because a compound fracture is very generally followed by inflammation of the brain ; and it will be of little use to trephine, when inflammation is once produced. If ' the inflammation come on, the patient will generally die, whether you trephine or not;" and it is added, that the operation will even be likely to increase the inflammation, which has been excited by a depressed portion of the skull. " The rule," says Sir Astley, " which I always follow, is this : when I am called to a compound fracture with depression, which is exposed to view, whether symptoms of injured brain exist or not, I generally use an elevator, and very rarely the trephine. I put the elevator under the bone, raise it, and if it has been comminuted, remove the small portions of bone."—{Lectures, Sfc. vol. i. p. 304. 308.) Of the propriety of using the elevator in such cases, and also of taking away loose fragments, there cannot be a doubt. 2d. The operation is recommended for the purpose of giving exit to extravasated blood, or collections of pus or matter. But I would ask, how are we to know when either of these fluids are collected, and in what part of the brain they are located, whether between the skull and dura mater, or the ventricles, or on the pia mater, or under this membrane, on the surface, in the substance or cavities of the brain? How, then, I ask, can the trephine be used with any propriety, or the least prospect of success? It is impossible to tell in what part of the cranium or skull to bore the hole, or to make the perforation. But even should we be so fortunate as to make it in the right place, and remove the extravasated fluid, it can only, at best, afford partial relief; and there is ten times more danger to be apprehended from the additional wound, and subsequent inflammation, than from any collec- tion of blood or matter, for which the operation is performed. These, by proper treatment, will be removed by the absorbent vessels. " The case of extravasation between the cranium and dura mater," says Samuel Cooper, "is almost the only one which admits of relief from trephining. Mr. Abernethy informs us, that in the cases which he has seen of blood extravasated between the dura and pia mater, on a division of the former membrane being made for its discharge, only the serous part of it could be evacuated ; for the coagulum was spread 72 Injuries of the Head. over the hemisphere of the brain, and had descended as low as pos- sible towards its inferior part, so that very little relief was obtained by the operation."—(Surgical Works, vol. ii. p. 46.) This statement is confirmed by that of Bichat, and the practice inculcated agrees with what Sir Astley Cooper also directs. Therefore, it appears evident that it is improper to use the trephine with a view to remove any extravasated fluid. I, therefore, cannot see the benefit resulting from this operation, which is held out by many surgeons; neither have I any evidence that it has ever been of any service, although occasionally there may have been cases in which it has proved useful; but they are so sel- dom, .and it is so uniformly attended with injurious or fatal effects, that I think, in almost, if not in every instance, it ought to be dispensed with. Should any instrument be used to enable the practitioner to remove pieces of bone, or to elevate any portion that is depressed, the instru- ment invented, or recommended by Hey, is preferable to the trephine. The inventor remarks, that " the purposes for which any portion of the cranium is removed are, to enable surgeons to extract broken fragments of bone, to elevate what is depressed, and to afford a pro- per issue to blood or matter that is or may be confined, &c. " When a broken fragment of bone is driven beneath the sound contiguous part of the cranium, it frequently happens that the extrac- tion cannot be executed without removing some of the unbroken part, under which the fragment is depressed. This might generally be effected with very little loss of sound bone, if a narrow portion of that which lies over the broken fragment could be removed. But such a portion cannot be removed with the trephine. This instrument can only saw out a circular piece. And, as in executing this, the central pin of the saw must be placed upon the uninjured bone, it is evident that a portion of the sound bone, greater than half the area of the trephine, must be removed at every operation. When the broken and depressed fragment is large, a repeated application of the tre- phine is often necessary, and a great destruction of sound bone must be the consequence. " When the injury consists merely of a fissure with depression, a small enlargement of the fissure would enable the surgeon to introduce the point of the elevator, so as to raise the depressed bone. But a small enlargement of the fissure cannot be made with the trephine. When it is necessary to apply the elevator to different parts of the depressed bone, a great deal of the sound cranium must be removed, where a very narrow aperture would have been sufficient. " The same reasoning will apply to the case of openings made for the purpose of giving a discharge to extravasated blood or matter. " if a saw could be contrived which might be worked with safety in a straight or gently curvilinear direction, it would be a great acqui- sition to the practical surgeon. Such a saw I can now with confidence recommend, after a trial of twenty years, during which time I have rarely used the trephine in fractures of the skull. Its use has been adopted by my colleagues at the General Infirmary in Leeds; and will be adopted, I hope, by every surgeon who has once made trial Injuries of the Head. 73 of it." Mr. Hey next informs us, that the instrument was first shown- to him by Dr. Cockell, of Pontefract; but that there is a saw formed on the same principle in Scultetus's Armamentarium Chirurgicum. In order further to illustrate my views on this subject, I shall quote some remarks by Dr. Samuel Cooper, and others. If, then, it be asked, in what does concussion consist? the answer is, that if it be slight, it is merely a disturbance of the circulation in the brain; if violent, the brain is lacerated. A knowledge of this leads to a judicious treatment of the injury, as laceration of the brain is frequently followed by extravasation : and concussion in the com- mencement, may be compression in its result. Reformed Practice. " Watch your patient," says Sir Astley, " with the greatest possible anxiety ; visit him at least three times a-day ; and if you find any hard- nessof the pulse supervening, after the first copious bleeding, take away a tea-cupful of blood ; but do not go on bleeding him largely, for you would by this means reduce the strength of the patient too much, and prevent the reparative process of nature. It is necessary that there should be a slight degree of inflammation, for without this the repara- tive process cannot proceed, or the patient ultimately recover ; but it will be your duty to keep this inflammation within due bounds. I shall mention a case in which fatal consequences ensued from the error committed by the surgeon in bleeding his patient to such ex- cess, that the slight degree of inflammation necessary for adhesion was removed, and the restorative process of nature consequently prevented. " In these Lectures, gentlemen, I feel it to be my duty to describe to you surgery as it is, and not in the glowing colours in which it is painted to you in books. I am most anxious that you should omit nothing which may contribute to increase your professional skill, and onuble yoo to afford the greatest possible degree of relief to the suf- ferings of humanity; but those who blazon forth our profession as one which is attended with undeviating success, are only deceiving you. You must hear the untoward cases of your profession, as well as those of which the issue is favourable, in order to form a correct judgment in your minds of what surgery really is. It is for these rea- sons, that I shall never hesitate, " coute qui coute" to detail to you, and perhaps to the public, those cases which have terminated unfa- vourably. I have a duty to perform, and I shall never shrink from the discharge of it. It is by detailing to you the unfavourable as well as the favourable cases, that I can alone perform that duty; for it is by such a course alone that I can point out to you the rocks w hich you are to avoid, as well as the haven in which you are to endeavour to an- chor. The case to which I last alluded, was one of concussion, accompanied with slight laceration of the brain, which occurred in the other hospital. The gentleman, under whose care the patient was, thought it right to bleed him, and that he could not bleed him too largely. He accordingly bled not only from day to day, but twice a day. The consequence of this mode of treatment was, that the pa- tient became perfectly pale, was in a state of considerable dejection,. 74 Injuries of the Head. not of the mind, but of the powers of the body, and died, without any symptoms of inflammation of the brain, ten days after the injury* On examination of the head, it was found that there was a slight la- ceration of the brain, with some degree of extravasation of blood ;• but that not the slightest attempt had been made by nature to heal the wound. You are aware that the brain heals, like any other organ, by the process of adhesion; but, in this case, the quantity of blood taken from the patient was so large, that the slight inflammation ne- cessary to the adhesive process was removed, and the powers of re- storation consequently prevented. " You are to use bleeding as a means of preventing inflammation ; but you are not to resort to it as a matter of course, the moment you are called to a patient under concussion. A man falls from his horse, and the instant he is raised from the ground some surgeon thinks it necessary to use the lancet. This conduct is quite irrational; for, suppose the pulse could scarcely be felt at the wrist, and the surgeon were in such a case asked why he proceeded to bleed, what would his answer be ? The probability is, that he could make no reply ; or he would perhaps say, that he bled because the accident had determined a great quantity of blood to the brain. It is not with this view that we bleed in concussion, but in order to prevent inflammation. I have seen patients, who would have died if a large quantity of blood had been taken away at the time of the accident. Thus, in the case al- ready described, when I first saw it the pulse was scarcely per- ceptible. I took a little blood from the arm, and the patient was im- mediately seized with convulsions, like an epileptic fit, which I thought would have proved fatal. I closed the arm, and I would not upon any account have taken more blood from him at that moment." Trephining for after symptoms.—For the symptoms remaining after concussion, the trephine used to be employed ; but it now becomes a question, whether it ever ought to be resorted to in these cases 1 What will trephining do? Probably great harm, by disturbing the brain; and, if not, no good can possibly result from it. Now for the proofs : first, that it does no good. Gentlemen, I never lecture to you but from the recollection of some case that has occurred to me, from which I form my opinion. In a former part of this lecture, I men- tioned to you a case of great irritability of the stomach, produced by concussion, the effect of a blow on the forehead, which happened at Yarmouth, in Norfolk. Mr. W. Cooper, formerly surgeon of Guy's Hospital, visited this gentleman, and prevailed upon him to suffer the trephine to be applied upon the part of the forehead on which the blow was received; and, when the bone had been removed, the dura mater was sound, and no relief whatever arose from the operation : a direct proof that it is useless. Dr. Farre informed me, that he knew a person who was subject to epileptic fits after concussion of the brain. The operation of trephining was performed, and he died soon afterwards. Forty years ago, trephining used to be the plan generally adopted with the patients admitted into the London hospitals ; many were submitted to the operation; inflammation of the membranes of the brain supervened, and nearly all died; recovery being very rare. Injuries of the Head. 75 But do our patients now die from the effects of concussion? No ; by depiction we rarely lose a patient. After the expiration of my apprenticeship at these hospitals, I went over to Paris, to see the practice of Desault, at the Hotel de Dieu ; and 1 found that scarcely ever, under any circumstances, did he trephine ; and he was more successful than the English surgeons. Trephining in concussion is now completely abandoned. The Treatment of Fractures of the Skull is as follows : when there is fracture, unaccompanied with symptoms of injured brain, you will not trephine ; but you must, by the application of adhesive plaster, endeavour to heal the wound in the scalp as quickly as possible. Let your constitutional treatment be that of depletion. This plan re- moves symptoms of concussion, and even extravasation, which ac- company these fractures ; and often a few hours will show you that the application of the trephine, which you at first might have thought indispensable, is rendered unnecessary. It is wrong, therefore, to de" cide hastily in these accidents ; for irreparable mischief might arise from your making an incision, and converting a fracture which was simple into one that is compound. Wait, then, for a time before you operate in such cases, for the purpose of seeing what effects may be produced by bleeding and purgatives. It not unfrequently happens, in these hospitals, upon persons being brought in who have received injuries of the head, that the dresser in attendance will bleed them immediately after their admission, and send for the surgeon ; before whose arrival the good effects of the loss of blood are apparent, and the symptoms of concussion, and even of extravasation, have lessen- ed, so as to lead to a different view of the case. This shows how nc cessary it is that you should not be precipitate. If you act prudently, therefore, in these accidents, you will try bleeding and purgatives be- fore you operate; and the depletion will prove of the greatest possi- ble advantage in preventing inflammation : from which arises a prin' cipal danger. Apparent Depression.—After blows have been received upon the head, it often happens that, upon examining the scalp, there appears to be depression of bone to a great extent, when, in reality, there is none. Let me put you on your guard here in this respect. A person receives a blow on the scalp : the parts immediately surrounding the spot where the blow was received swell from the extravasation of blood; but at the part on which the blow directly fell, the cellular membrane, having been condensed by the injury, will not receive the extravasated blood ; thus the surrounding parts are considerably high- er than the middle ; and the character of the contusion is certainly calculated to deceive those who are unacquainted with the nature of these accidents. I have several times seen these appearances; but the first case which I recollect of it in my own practice was that of a child brought into Guy's, who had received a severe blow on the head from a brickbat. All present were prepared for the operation, fully expecting that I should apply the trephine ; for they felt convin- ced that there was considerable depression of bone ; and when I sta- ted that I should not operate, they exclaimed, " Good God! I wonder what can be his reason." This child, after having been freely bled Vol. II. K 76 Injuries of the Head. and purged, in two or three days recovered, and the appearance of depression vanished. I have been often sent for by my dressers to these cases, and have been requested to bring my instruments with me ; but upon examina- tion have found that there was no depression of bone, and that the un- even appearance of the scalp was produced by the cause before men- tioned. It also very often happens in fracture of the cranium, that consi- derable depression of bone will happen from the external table of the skull being driven into the diploe, without producing the slightest inju- ry to the internal table : do not, therefore, be precipitate in your diag- nosis, nor hastily determine upon performing an operation which you might afterwards have reason to repent. Suppose you are called to a patient who has had a severe blow on the head, and on examining the skull you find a portion of bone considera- bly depressed. You may still find this man capable of giving a his- tory of the accident, and his mind is not at all affected. On the other hand, you may be called to a person who has a fracture of the skull with depression, and who has lost the powers of his mind. If the frac- ture be simple, and there is no wound in the scalp, and no symptom of injury to the brain, it would be wrong to make an incision into the part, and perform the operation of trephining ; for, by making such an in- cision, you add greatly to the danger of the patient, as you may make what was before a simple, a compound fracture, and consequently greatly increase the danger of inflammation, which rarely follows fracture with depression, where the fracture is simple, but is a very frequent consequence of a compound fracture, which is produced by making an incision in the scalp. Never make an incision, therefore, when you can avoid it, or merely because there is a fracture with depression, if there be no symptoms of injury to the brain. Even if there be symptoms of injury to the brain, and the fracture be simple, do not immediately trepan. Take away blood, and purge your patient freely, and see how far the symptoms may be the result of concus- sion of the brain, and not of depression. If the symptoms do not yield to depletion, then, and not till then, perform the operation of tre- phining. I was called to a lady who had fallen against a projection in a wall, in walking across her parlour. The os frontis was driven in, but there were no symptoms of compression of the brain. I bled her, and guarded cautiously against inflammation, but there was no neces- sity for elevating the portion of the bone. This lady never had any symptoms of injury to the brain, and she recovered by depletion alone. The old practice used to be, the moment an injury to the brain was suspected, and the least depression of the bone appeared, to make an incision into the scalp. This is putting the patient to considerable hazard ; for the simple fracture would, by the incision, be rendered compound. The rule, therefore, which I always follow is this : W hen I am called to a compound fracture, with depression which is exposed to view, whether symptoms of injured brain exist or not, I generally use an ele- vator, and very rarely the trephine. I put this instrument under the Injuries of the Head. 77 bone, raise it, and if it has been comminuted, remove the small portions of bone. The elevation of the bone is not followed by any mischief; but if you do not raise it, and inflammation follows, it will be too late to attempt to save the life of the patient. Mischief of Depression not immediate.—The mischief of depression is not, however, always immediate ; the patient sometimes recovers from the first symptoms, but is thrown by any hurried circulation, at a subsequent period, into a new train of effects, which still require sur- gical assistance ; and it is upon that account, if there were a wound, and I felt much depression, that I would immediately elevate the bone ; but if no wound, I would wait the production of symptoms. Danger of the Operation.—Some surgeons assert that it is a trifling operation, and not difficult to perform. But they would deceive you. It is one of the most dangerous operations in surgery. Whilst per- forming it, there is but a thin web between the instrument and the brain ; cut through this, and the destruction of life will generally be the consequence. Mr. Hunter thought that when the dura mater was wounded, the person scarcely ever recovered. [Cooper.] " It is a high source of gratification to be able to record," says Dr. Reed, " that, in this country, the trephine is now much more seldom used than formerly. But a few years ago, on a man being stunned by a blow or a fall, to any considerable extent, almost any neighbouring physician would apply the trephine without hesitation, and the facility with which this operation can be performed, offers no small tempta- tion to the mere operator, especially as there is seldom any risk of life, and always a gain in reputation among the multitude. It is now very generally viewed, as it ought to be, as a dernier resort in such cases; and the use of it is not countenanced, unless the symptoms of compression by depressed bone, or extravasated blood, are altogether unequivocal." " I have seen scores of persons, who would formerly have been tre- phined, without even a " trial by jury," recovered from coma, paraly- sis, and convulsions, justly attributable to compression on the brain, by very large and copious bleedings, aided by cathartics and stimula- ting frictions and cataplasms to the extremities. " In the year 1819,1 assisted Dr. Henry Wm. Ducachet, then a prac- titioner in the city of Baltimore, in the performance of this operation on a woman who had received several blows on the head with an axe from a brutal husband. VV7e could discover no depression of bone, and yet thecoma, stertor, hemiplegia, and other evidences of compression, resisted all our depletion, and on the third day after the violence, we de- termined to apply the trephine, being sustained by judicious counsel in our opinion, that there must be extensive extravasation of blood beneath the cranium. On removing the circular piece of bone, with the largest crown of the instrument, a coagulum was found extending over the left hemisphere of the brain, exterior to the dura mater. This being removed, and only a mitigation of the symptoms following, the obvious distension of the dura mater itself, pointed out the exist- ence of still more extended mischief. We therefore divided the dura mater with a probe-pointed bistoury, for the space of half an inch, when coagulated blood to an immense extent forced itself through the opening. After washing out the cavity by warm water thrown in 78 Injuries of the Head. with the syringe, we were delighted to find the entire removal of the symptoms instantaneously result. Our patient spoke for the first time, asked for water, seemed as though awoke from an ordinary sleep ; the stertor ceased, the dilatation of the pupil and hemiplegia were re- moved, and the most sanguine hopes were entertained of her re- covery. " I shall never forget the painful acutencss of our disappointment, when in a few hours we found all these dangerous symptoms return in a still more aggravated form, discovering to us the mortifying truth, that though the operation had succeeded* yet our patient would die ; for although we had removed the coagula, we could not stop the bleeding vessel." Having, I think, very clearly shown the little benefit, as well as the positive injury, resulting from the use of the trephine, I shall now lay down such treatment as I have found remarkably successful in every injury of the head, concussion, compression, extravasation, inflamma- tion, &c; and I have to observe, that I have never had occasion to use this or any other instrument. The indications of cure, in almost every injury of the head, are nearly alike ; and it may be said that the greatest danger arises from an untimely interference of art; from the officiousness of the practi- tioner, in doing too much ; by intercepting the healthy effort of nature, instituted to effect a cure. Our principal object should be, in every injury of the head, whether concussion, compression or extravasation, to prevent excessive inflammation, and if already estab- lished, to moderate it. In the first place, when called to an accident of this nature, we should endeavour to ascertain, by careful examination, the situation, nature and extent of the injury. When this cannot be done by su- perficial examination, it may be necessary to shave the hair from a portion of the head, or in that part which appears to be the seat of the iijury, by which an opportunity will be afforded to discover it. An inflammatory spot, or small tumour, often appears over the part, or by the uneasiness expressed by the patient upon pressure, or by his frequently lifting his hand, and applying it to a particular portion of the head. This is of practical importance, as it is necessary to know whether a wound has been made or not, either in the integu- ments or bone. Should we discover any laceration, or wound, which requires dressing, the same treatment must be adopted as has been recommended in the commencement of this chapter. In the next place, the irritation or pain demands our attention, and almost every bystander will cry out, " bleed the person, bleed the person;" and that too when, perhaps, he is in a state of asphyxia, or when he is motionless and senseless. In every case, I believe, to which I have ever been called, this has been the language of the populace, or bystanders ; and if the practitioner is not possessed of much deci- sion of character, he will comply with their request, and he may kill the person by taking even a small quantity of blood before reaction takes place. If he is bled at all, it should not be under two hours after the accident; and even then, I cannot believe that it has any decisive good effect; except, perhaps, that it may afford temporary Injuries of the Head. 79 relief; but, on the contrary, it is often productive of positive injury. I have tried it, and therefore consider myself a competent judge. And the reasons have already been assigned in another part of this work. Local bloodletting, however, particularly by cupping, I have occa- sionally found beneficial; probably from the counter irritant effect which it produces. 1st. Opiates.—df the patient is in great pain or distress, administer an anodyne; and one combined with a diaphoretic is preferable, such as the diaphoretic powders. A pill made of the gum opium is very good. I have never seen any bad effects follow the use of opiates, as some have intimated, but they have been attended with the best effects. Anodynes appear to prevent an undue Row of blood to the injured part, by lessening the irritability and commotion of the system. They may be repeated as occasion requires. 2d. Purgatives.—Purgatives are exceedingly valuable in every injury of the head. And whoever reflects a moment upon the con- nexion between the stomach and the brain will realize their utility. They are beneficial by lessening the quantity of the circulating fluid in the system, or, in other words, by their depletive effects. They may be given every day or two, according to the urgency of the symptoms, or according to circumstances. Our common purgatives may be given, and occasionally changed for senna, manna and cream of tartar. 3d. Perspiration.—It is always necessary, either to prevent or reduce inflammation, to keep the skin moist, and therefore diaphore- tic or sudorific medicines must bo given to fulfil this indication. If the diaphoretic powders which are given are not sufficient for this purpose, give the sudorific drops. At the same time let the surface be frequently bathed with tepid ley.water. This contributes much to allay constitutional disturbance, or sympathetic fever, as well as to the comfort of the patient. Cooling or refrigerant Lotions.—In all Injuries of the Head, there is a determination of blood to it, causing a preternatural degree of heat or inflammation. To reduce this, surgeons recommend cold or ice water; and although some benefit may be derived from their applica- tion, they, in general, are followed by some injury resulting from the sedative effects of the cold. I have found the following application preferable to any other, applied cool, but not cold. Take equal parts of spirits, rain water and vinegar, to which add a little fine salt. Let linen or muslin be wet with this liquid and applied to the head, over which tie a handkerchief, or nightcap. Fomentations.—After this has been applied awhile, let it be removed, and the following used, panic ilarly if the patient does not improve as much as is desirable. Take hops and wormwood, equal parts ; simmer in vinegar until they are soft, or the strength is extracted; then enclose in flannel, and apply to the head ; to be occasionally renewed. This fomentation affords essential benefit, by its anodyne and refrige- rant effecis. Poultices.—\\ hen any particular part of the head has been wound- ed, after the hair has been removed, apply a slippery elm poultice. I 80 Injuries of the Head. have seen wounds of the scalp assume a perfectly white and healthy appearance, only in six hours after applying this poultice. It seems almost impossible for inflammation to exist on any part where it is applied. In one or two cases I applied it over the whole head with decided benefit. But when it is applied, the whole hair must be first shaved from the head. Counter Irritation.—Mustard plasters applied to the nape of the neck, or between the shoulders, will often relieve the head. I have applied blisters,' but I think the mustard is better, as it produces the same effect as the blister, without any of the subsequent effects which arise from it. The mustard should be mixed with an equal quantity of Indian meal, and moistened with vinegar. They should also be applied to the feet. Bathing the Feet.—Among all the means used to prevent inflam- mation, and allay irritation, there are none better, however simple it may be, than immersing the feet in warm ley.water, two or three times a day. The patient, when restless and wakeful, will often fall asleep immediately after this operation. The manner in which it proves beneficial, is by equalizing the circulation. After a person has received an injury of the head, the extremities become cold, while the head becomes unusually hot. The reason is obvious : the blood retreats from these parts, and flows in an undue quantity to the brain. Immersing the feet in the warm water recalls the blood from the upper to the lower extremities, and the balance of the circulation is thereby restored. Emetics.—I have seldom given emetics in any stage of injuries of the head, as they have appeared to me rather calculated to injure than benefit the patient. But when the acute stage of inflammation feas subsided, and the brain still appears affected, and it assumes something of a chronic character, as is sometimes the case, gentle emetics may prove serviceable. But on the first attack of the injury, they ought to be prohibited. Cupping.—I have found some advantage from the operation of cupping. The benefit is derived not from the quantity of blood ab- stracted, but from its counter irritating effects. 1 recollect one case where a person fell from a building, more than twenty feet, and struck the fore part of the head upon the ground, which rendered him sense- less, and produced enormous swelling of the eyes, and adjacent parts. Means were taken to reduce the inflammation, which partially suc- ceeded ; but, in consequence of the concussion and extravasation which followed, he was senseless and delirious for two or three weeks. Soon after the accident, it required several men to confine him in bed ; but after having been cupped, these urgent symptoms were relieved, and the patient recovered. I have successfully treated severe injuries of the head, without resorting to the use of cups; but I have found that the application of three or four of them, where not more than half a gill of blood was taken, has been attended with a better effect than when a quart has been drawn from the arm. Leeches.—When there has been a severe contusion about the eyes, I have occasionally applied leeches; and I think with some little Injuries of the Head. 81 benefit: but from the haemorrhage that follows, and the inflammation proceeding from the bites, I am not very friendly to the operation. If it should be deemed requisite to apply them, I would observe, for the benefit of those unacquainted with the fact, that American leeches are equal to any that are imported. Neither cupping nor leeching possesses half the power in removing inflammation, swelling, extrava- sation, &c, as the slippery elm bark poultice. No matter how black the part is rendered by the contusion, this poultice soon removes it. Rest or Quietude.—The patient must be kept from noise as much as possible, as this aggravates all the symptoms. The above treatment I have found uniformly efficacious and success- ful, in all injuries of the head, within the reach of physic or surgery; in concussion, compression and extravasation. Wfiat then, says an objector, do you never trephine, to elevate or remove the bone, in any case whatever? In answer to this, I have to observe, that in all my practice, and I have had my share in differ- ent kinds of injuries of the head, I have had no occasion to resort to it in a single instance. I have had the very worst cases that could occur, and have succeeded beyond my expectations, by pursuing only the treatment here laid down. And it consists in a reliance more fully upon the sanative powers of nature than art. When the bone has been depressed, and even very serious symp- toms have appeared from such compression, I have rather chosen to trust to the restorative powers of nature, than the danger and uncer- tainty of the trephine ; which, as far as my observation, experience as well as history proves, has almost uniformly proved fatal. There is not near the danger to be apprehended from any pressure that a broken bone may make upon the skull, which arises from the addi- tional injury of a compound fracture occasioned by the trephine. The chance of recovery is certainly much greater, in all cases that I have seen or heard of, without, than by an operation. If there be splinters of bone, they should of course be removed; and if the depressed portion of bone can be raised without causing too much irritation, it would be justifiable to do it; and, possibly, cases may occur where Hey's saw could be used with impunity and advantage. But I have never seen any such case ; and I believe there are very few instances where any instrument ought to be resorted to. I might detail numerous cases to illustrate these sentiments, and there are enough on record, of the same nature, to prove that there is no necessity for trephining, in even compression of the brain. A case occurs to me, which I attended some time ago, in which a large portion of the os frontis was driven in upon the brain, by a stone, causing loss of sense, dilatation of the pupil of the eye, convulsions, &c, and having all the symptoms for which trophining is recommended ; and yet the patient recovered by tlie treatment here laid down. The bone still remains depressed, but still without injury. Some time ago, a woman was struck, by her husband, with an iron instrument, which produced an extensive fissure in the skull, with 82 Injuries of the Head. great depression of the bones, notwithstanding whicn, the patient did well. Another case occurs to me, in which a person fell from a con- siderable height, upon a stone, and which wounded the head in a most dangerous manner. The wound bled for several hours, and delirium and inflammation succeeded; but, by pursuing the treat- ment which I recommend, he recovered. A grocer, of this city, a short time since, was thrown from his cart, and so exceedingly injured, that it seemed impossible for him to live but a short time. There were several wounds of the scalp, contusionr concussion, extravasation, if not compression. Yet this man has so nearly recovered, that he feels only some chronic affection of the brain. A man was thrown from a building, which wounded his head in such a manner that his life, for some time, was despaired of. The contusion, concussion and inflammation were excessive, and which resulted, no doubt, from extravasation of blood or pus ; and yet the man, under the same treatment, recovered. A vast number of cases might be mentioned, and given in detail, if the limits of this work would permit. I will relate a few more, recorded by Mr. Abernethy. Cases of Fracture of the Cranium with Depression, which terminated favourably, although no operation was performed. CASE I. A woman, about 40 years of age, was admitted into the hospital for a wound on her head. About a week before she applied for ad- vice, her husband had knocked her down with a brass candlestick. She was stunned by the blow, and lay for some time senseless; but, on recovering, she felt no other inconvenience than the soreness oc- casioned by the wounded integuments. She had suffered some slight indisposition since the accident. On examining the head, the right parietal bone was found denuded about two inches in extent; a fracture of the same length was also to be felt, and the bone on one side of the fracture was depressed about the eighth of an inch. She remained in the hospital a fortnight, without any bad symptom occurring, and was then, at her own de- sire, discharged, although the wound was not perfectly healed. CASE II. A boy, about twelve years old, received a kick from a horse in Smithfield, which stunned him, and he was immediately brought to the hospital. The integuments of the forehead were divided by the injury, and the lower part of the os frontis, and superciliary ridge of the frontal bone, depressed at least a quarter of an inch below its origi- nal level, the depressed portion measuring about an inch and a half in length. Injuries of the Head. 83 It is obvious that the bone could not be thus depressed without a fracture of some part of the basis of the skull occurring at the same time, on which account the case might be considered as more danger- ous. In less than two hours he had recovered from the immediate effect of the blow, being at that time perfectly sensible. Fourteen ounces of blood were taken from his arm, his bowels were emptied by a purge, and saline medicines, with antimonials, were directed to be given. He went on tolerably well for two days, at the end of which time, evident symptoms of considerable irritation of the brain took place. He now complained of pain in his head, slept little, and, when dozing, often started, or was convulsed in a slight degree. To remove these symptoms, he was bled twice, took opening medicines occasionally, was kept quiet, and without light, and was allowed only a spare diet. By continuing this plan for about three weeks, he per- fectly recovered. CASE III. A man, between thirty and forty years of age, received a blow on the forehead from a brick thrown at him, by which the frontal bone was fractured about half an inch above the orbit; the fracture mea- sured two inches in length, and the upper portion of the bone was depressed about the eighth of an inch. He was not even stunned by the blow, and walked to the hospital without assistance, complaining only of soreness in the wounded integuments. Sixteen ounces of blood were immediately taken from his arm ; he was confined (much against his inclination) to a scanty and liquid diet, and was purged every second day. This patient did not experience any illness, and the wound soon healed. CASE IV. A boy, about thirteen years old, had a fracture, with depression of* part of the temporal and parietal bones. By similar treatment, he also escaped without any material ill consequences ; but, in this case, part of the injured bone exfoliated. case v. • A girl, thirteen years old, had a considerable fracture, with de- pression of the left parietal bone. She was not brought to the hos- pital until ten days after the accident. When admitted, she was fe- verish, had pain in her head, and the little sleep she got was very much disturbed ; hut, by the use of bleeding, with antiphlogistic medi- cines and regimen, she soon got perfectly well. The cases above related are not offered to notice on account of any striking peculiarity attending them, but merely to show that such are not unfrequent, as they all occurred within the course of a year. From amongst a great number of similar cases, I shall select the two following, as the symptoms attending them were more violent than ordinary. Vol. II. L 84 Injuries of the Head. CASE VI. A lad, seventeen years of age, had his head pressed between a cart- wheel and a post, by which accident the scalp on both sides was turn- ed downwards, so as to expose the lower half of the parietal bones, the squamous part of the temporal, and also part of the frontal and occipital bones, about a quarter of the cranium being thus completely denuded. The periosteum was in several places stript off from the skull, the scalp much bruised, and the posterior and inferior angle of the left parietal bone was beaten in. The visible part of the de- pressed portion was an inch in length, and more than an eighth of an inch below the level of the cranium ; but the fracture extended along the squamous part of the temporal bone towards the basis of the skull: it could not, however, be traced, as the temporal muscle had not been removed from that part by the injury. The scalp, being cleansed, was replaced, retained in its situation by slips of sticking plaster, and a slight pressure by bandage was applied. The boy was perfectly sen- sible, his pulse regular, and not quickened. He had bled consider- ably from the temporal artery, which had been divided by the acci- dent : eight ounces of blood were, however, taken from his arm, and some purging medicine was administered next morning, which pro- cured three or four stools. The next day, {Friday,) bis pulse beat nearly 120 in a minute ; his skin was hot and dry, and he complained of pain in his forehead. Twelve ounces of blood were taken away, and four grains of pulvis antimonialis ordered to be given three times a-day. On Saturday, the former symptoms still continued, and were rather increased. The antimonial powder made him sick, or at least increased his disposition to be so. Fourteen ounces more of blood were taken from him ; the vibratory feel of his pulse not being alter- ed until that quantity was taken away: the blood, on standing, ap- peared very buffy. His skin, notwithstanding all this, still remained extremely dry : some antimonial wine was given, which produced vomiting. On Sunday, his pulse was evidently lowered by the evacu- ations he had undergone, but it was still quick, and sufficiently strong. The pain of the head remained as before. Having a sufficient num- ber of stools, and the sickness still continuing, the antimonial powder was omitted. He was bled, however, in the vena saphena, and his feet and legs were afterwards immersed in warm water; during which, he, for the first time, perspired copiously. A blister was also applied to his neck. The scalp united, with only a trifling suppuration over the fractured part of the bone ; and to this ready union, the lowering plan, by preventing inflammation, seems very materially to have con- tributed. The matter collected over the fracture was discharged by a puncture, and the boy got well. CASE MI. A lad, eighteen years of age, had the squamous part of the temporal bone beaten in. The fracture ran horizontally, about a quarter of an inch above the zygoma, and could be distinctly traced with the finger, introduced through the i^ni sc. lp .;nd temporal muscle, for two inches. The upper part ol'tln hone was depressed about one eighth of an inch, and it wa:. impo^ibk- to uqa^.e below the fracture in order to elevate Injuries of the Head. 85 the depressed portion. The lad had recovered from the immediate stunning occasioned by the injury ; nor was there any symptom that indicated material derangement of the functions of the brain from the pressure which it sustained. He was bled largely, and took a purging medicine, and was moderately well on the following day. On the second morning he was again purged, and when I saw him at noon, nothing materially wrong appeared; but when I came to the hospital at eight in the evening, I found he had gradually become delirious, and that he then could scarcely be kept in bed. His skin was hot, and his pulse frequent and strong. These symptoms could be attribu- ted to nothing but inflammation of the brain ; he was therefore im- mediately and largely bled. He now became quiet and manageable, but the next morning his replies to all questions were incoherent, his pulse frequent, his skin hot, and his tongue dry. The bleeding and purging were repeated, and at night a blister was applied to his neck. On the following morning he was sleeping and feeble, but his answers were rational; as the frequency and fulness of his pulse increased in the evening, he was again bled. The inflammation of the brain was now subdued, and the patient gradually recovered. The wound healed without any exfoliation of bone, and when he was discharged from the hospital there was not the most trivial circumstance which could in- duce us to suspect that the brain had sustained any injury from the accident. Ilissleep was sound and undisturbed, and the sudden motion of his head in any direction occasioned no giddiness or inconvenience. It appears very clearly, I think, from these cases, as well as from a great number of others to be found in books, that a slight de- gree of pressure does not derange the functions of the brain, for a limited time after its application. That it does not do so at first is very obvious; as persons are often perfectly sensible, and free from, headach and giddiness immediately after the injury. Whether it may not produce such an effect at some remote period, is not so easily determined, since this cannot be ascertained but by a continued ac- quaintance with the persons who had received the injuries. All, however, whom I have had an opportunity of knowing for any length of time after the accident, continued as well as if nothing of the kind had ever happened to them. In Mr. Hill's Cases in Surgery, two in- stances of this sort are related ; and Mr. Hill knew both°the patients for many years afterwards, yet did not perceive any inconvenience to arise. It deserves to be mentioned, too, that one of the patients was a sailor, and, therefore, probably led a life of irregularity as well as of exertion. The result of cases of this kind, which 1 have met with in authors, does not lead to the apprehension of any future mis- chief; nor is it easy to conceive that tho pressure, which caused no ill effects at a time when the contents of the cranium filled its cavity completely, should afterwards prove injurious when they have adapt- ed themselves to its altered size and shape. Severe illness, indeed, does often intervene between the receipt of the injury and the time of its recovery ; and many surgeons might be inclined to attribute this to pressure; but it equally occurs where the depressed portion is elevated ; several instances of which I shall have occasion to relate, and many others are to be met with in authors. This is a circum. 86 Injuries of the Head. stance which nothing but very extensive experience can show in a true light. If, for instance, a surgeon who was prepossessed with the opinion that elevation of the bone is necessary, in every instance of depressed cranium, should have acted upon this opinion in the first, third, fourth and fifth cases, and afterwards have employed proper evacuations, his patients might, perhaps, have had no bad symptoms, and he would naturally have attributed their well-doing to the mode of treatment which he had pursued : yet these cases did equally well without an operation. If the same surgeon had been witness to the disturbance which arose in the second, sixth and seventh cases, he would, without doubt, have attributed them to the continuance of pres- sure made by the bone ; yet these cases also did well by medical treatment only : and when the symptoms which come on thus are of the inflammatory kind, they may generally be removed by the same means. Many cases also are to be met with in books, and some are related in the subsequent part of this Essay, where not only great but even fatal mischief ensued, notwithstanding the brain had been re- lieved from pressure at an early period. Another surgeon, preju- diced against the use of the trephine, might, with equal injustice, consider the mischief, which ensues in certain cases, as entirely ow. ing to the operation. The degree of pressure which the brain can sustain, without great injury to the system, may probably vary according to the disposition of that organ to be affected by it, the suddonness of its application, and the direction in which it is made ; and although it must be very difficult to obtain any precise knowledge on this subject, yet there is great reason to believe that the brain can bear more pressure with- out injury to it, than was formerly supposed. The first of these cir- cumstances seems evident, for in some persons a slight pressure pro. duces severe symptoms, whilst, in others, a much greater degree is borne without inconvenience. We can rarely judge of the effects of pressure when any part of the cranium is beaten in by a blow; for, in that case, the shock generally occasions stupefaction. Internal haemorrhages, perhaps, afford us the best criterion whereby to deter- mine the effects cf pressure on the brain. Tho eighth case will serve as an illustration of this remark, where it appears that a considerable haemorrhage must have taken place before it deprived the patient of his faculties; for he walked home, undressed himself and went to bed, after the trunk of the middle artery of the dura mater had been rup- tured. In cases of apoplexy, also, the haemorrhage is generally very large before it produces those consequences which destroy life. The authorities quoted by Morgagni, as well as his own observa- tions, show that people may recover from apoplexy even after a con- siderable effusion of blood has taken place. Volume IX. page 161, of the London Medical Journal, contains observations on recent depressions of the skull to the same effect. Several cases are reported which were successfully treated, better without than by an operation. One general principle, says a writer, I would inculcate, which is, " that injuries of the head, apparently trifling, should never be neglected; and, on the other hand, those which appear most dangerous and alarm- ing should never be despaired of." Injuries of the Head. 87 Of the Consequence of Injuries to the Brain. Of Fungus and Hernia Cerebri.—The fungus is simply an exube- rant protrusion of granulations beyond the level of the cranium, ari- sing usually from the surface of the dura mater, or from the cut edges of the bone granulating luxuriantly. Hernia cerebri is a tumour formed by the pressure of blood, which has been extravasated into the substance of the brain, owing to a dis- eased state of its vessels induced by one of the foregoing causes. The effused fluid, if the skull were entire, would in all probability, in- duce apoplexy ; but when a deficiency of bone exists, so as to allow it to expand, it presses the surface of the brain and its meninges, through the vacant space, and there forms a tumour, which continues to increase in size, until the superficial stratum of brain becomes so distended as to give way; when blood oozes eut and forms a co- agulum. Treatment* Of the Fungus.:—Moderate pressure ; the constant application of dry lint; sprinkling the excrescence with pulverized blood root. Of the Hernia.—All pressure should be carefully avoided, and no- thing in general need be done but daily to apply simple dressings; when the coagulum may soon drop off, and the tumour waste away. Ligatures and styptics chould be avoided. Should the haemorrhage be so great as to threaten danger, the co- agulum should be removed, the bleeding vessel exposed, and some diluted vegetable astringent may be applied with success to stop the bleeding. CHAPTER V. FRACTURES. Fracture is a division of bone into two or more fragments; gene- rally occasioned by external violence. Species.__1. Simple:—where the bone has been divided, and the integuments remain unimpaired. 2. Compound :—where there is a corresponding wound in the soft parts, by which the fractured extremity of the bone becomes exposed. Again, fractures are divided : 1st. Transverse, which are such as take place directly across the bone ; 2d. Oblique, when they deviate from a perpendicular direction; 3d. Longitudinal, when a fracture runs parallel with the axis of the bone, which seldom or never happens ; and some add a fourth kind, Comminutivc, when a bone is broken into several pieces, or crushed into fragments. Fractures complicated with violent contusion of the soft parts, or with a wound, rendering them compound, are much more dangerous than others free from such accidents. The bad symptoms which render compound fractures so dangerous, are of many kinds : haemorr- hage, violent and extensive inflammation of the limb, with extreme pain,'delirium and fever; large abscesses, gangrene, &c. Fractures of the leg are generally more serious than similar injuries of the uppeT extremity. The wound of a large artery may add considerably to the danger of a fracture. Causes. Predisposing.— Certain diseases of the bone ; as abscess, friability or white swelling, <.Vc. Exciting.—External violence. Symptoms. Some of the symptoms of fractures are equivocal. The pain and inability to move the limb, commonly enumerated, may arise from a mere bruise, a dislocation, or other cause. The crepitus or grating; the separation and inequalities of the ends of the fracture, when the bone is superficial; the change in the form of the limb; and the shortening of it; are circumstances communicating the most certain information ; and the crepitus, in particular, is the principal symptom to be depended upon, though occasionally attendant on dislocations. The signs of fractures, however, are so exceedingly various, accord. ing to the bones which are the subject of injury, that it cannot be said, that there is any one which is invariably present and characteristically confined to them. The writers of systems of surgery usually notice Fractures. 89 loss of motion in the injured limb, deformity, swelling, tension, pain, &c, as forming the general diagnosis of fractures. The crepitus, or the grating sensation, or noise occasioned by the ends of a fracture, when they are moved and rubbed against each other, is one of the most positive symptoms of the existence of such an accident. Treatment of Fractures in general. Tn the treatment of fractures in general, there are three indications to be fulfilled. First, to replace or reduce the fractured or broken bones into their original or natural situation. Second, to secure and keep them in this situation. Third, to prevent excessive inflammation and pain. 1st. Examination of Fractures.—When called to an accident of this kind, it will be first necessary carefully to examine, and ascertain whe- ther the bone or limb is fractured; and bypassing the finger or thumb along thecourse of the bones, the fracture can generally be felt. There is an unevenness or roughness communicated ; a depression; and upon rotating or turning the fractured limb, a grating noise is heard, or a jar felt. Besides, there is an inability to raise or move the limb ; and it is usually shorter than the opposite one. Having ascertained the nature of the accident; the next step will be to remove the patient to his residence, or the place where he is permanently to remain ; and if he is to be removed to any distance, the bones may be tempo- rarily secured by splints. Having arrived, or been carried to the destined place, preparations must next be made for reduction and dressing. If splints have not already been provided, they should now be made, of a proper width and length, according to the part which requires their application ; and they must be properly covered. Next, bandages must be prepared. Muslin will answer, but those made of linen are preferable. They should be made three or four inches wide, and several yards in length, and rolled up for use. Having made the necessary preparations, the patient must be placed on a bed or mattress, and gradual extension and counter extension should be made, provided one bone ride another, or is not already in coapta- tion. It is quite erroneous to suppose that force, or much extension is necessary in reducing all fractures. In most that I have attended, the end of the bones have been in contact with each other, or nearly so, so that very little force has been necessary to be employed. The physician, or surgeon, should take hold of the lower limb, if the frac- ture be upon a limb, while an assistant grasps or holds the upper portion of it; and upon slight extension, examination should be made to ascertain whether the fractured bones are in a straight or direct line with each other ; and, also, whether the ends of the bones are even, or in no respect depressed one below the other, as these are the distinguishing marks, or the criterion which will enable us to judge whether they are brought properly together, or in coaptation. " It is true, that when swelling has come on, it is impossible always to decide by the touch, in what degree we have accomplished our object; we are obliged to judge by the relative position of the joints 90 Fractures. above and below the fracture, and the general aspect of the limb. I have often desisted from my unavailing efforts to reduce a fractured limb to a right position, the spasms that were excited being so violent as to threaten a protrusion of the bones through the skin, and yet have afterwards found no difficulty in bringing the bones into a very satisfactory position. In many cases, also, it has appeared to me that the coaptation has been affected by the action of the muscles them. selves ; for when on the subsequent day, I had removed the splint, I have felt so well satisfied with the general position, that I have done nothing more, and each succeeding day found less cause for inter- ference. In these cases, upon the subsidence of the swelling, scarcely any irregularity could be perceived in the outline of the bone." The bones being properly adjusted, the bandage will be put round the limb, commencing below and rising upwards, or from the inferior extremity, and continuing it to the top, a suitable distance above and below the place of fracture. After covering the limb, let the bandage be still held, and splints, as many as are necessary, be placed around it, to give security, and let these be held by an assistant. The roller must then be continued over the splints, until they are sufficiently compressed to keep the bones in their proper places, or in coaptation* I sometimes fold a piece of linen, a number of times, the width of the splints, to place them upon, in order to prevent too much, or undue pressure. When this has been accomplished, tape or narrow strips of linen may be tied around, in two or three places, to render the dressings and the fractured bones still more secure. The bandages must not be put on too tight, as the swelling that always follows will excite too much pain, by impeding the circulation. The limb may now be placed upon a pillow, a little flexed or bent, and kept in an easy and quiet position. A-decoction, made by boiling wormwood and hops in vinegar, may be applied to prevent and diminish excessive inflammation ; and after this application has been continued awhile, it may be discontinued, and equal parts of rain water, spirits and vinegar be substituted. After the parts have been wet with the liquid, a cloth should be laid over, to prevent too much evaporation. All that art can do towards the reunion of a fractured bone, is to lay it perfectly straight, in its original situation, and to secure it so ; to keep it easy, and moderate excessive inflammation. All tight bandages are injurious. It is in this way that excess of art does mischief. Indeed, fractures may be successfully treated without either the use of splints or bandages. Instead of the roller mentioned, the following bandage may be applied, which, in some respects answers a better purpose. It is made by taking a piece of American muslin, somewhat wider than is sufficient to extend round the limb, and cutting it down each side, to the distance of about half the diame- ter of it, in strips of about an inch in width, and then applying it similar to the eighteen, or many tailed bandage. This admits of the part being examined without changing the position of the parts ; and is more particularly applicable to compound fractures. It is not necessary often, to remove the dressings to examine the fracture, provided we have no just grounds to suppose there is any displace- Fractures. 91 ment. It is sufficient to remove them occasionally, or as often as the bandages become loose, from a subsidence of the swelling, or other causes. As a general rule, once a week is sufficient, except we have some doubt on our minds respecting the bones being in con- tact, or in their proper places. The patient should lay in a horizon. tal position as much as possible ; and should twitchings of the tendons occur, or much pain, an anodyne may be given, and particularly at bedtime. I have taken from different writers, some Temarks upon the treat- ment of fractures in general, which may either throw some additional light upon the subject, or further illustrate the foregoing treatment. In general, the remarks are judicious, and consonant with my own views. Of the Means for keeping Fractures reduced. After the bones have been put into their natural situation, time alone would complete their cure, were there not in the muscles a continual propensity to displace the ends of the fracture again. In cases of fracture the muscles are often affected with involuntary spas- modic action, by which the broken part would certainly be displaced, were no measures taken to maintain the extremities of the broken bone in contact. Besides, the patient, in easing himself, coughing, sneezing, &c, must unavoidably subject the limb to a degree of motion, by which the coaptation would be altogether destroyed. Hence, the necessity of employing means for fixing the broken limb so effectually that it may continue perfectly motionless during the whole time requisite for the union of the fracture. This second indi- cation is sometimes troublesome and difficult, and, as Boyer observes, it is in this part of the treatment that the surgeon has an opportunity of evincing his skill. The means employed for the fulfilment of this indication are, an advantageous position, quietude, bandages, splints, and various kinds of apparatus. In the treatment of all fractures, the position of the part, and indeed of the whole body, is a thing of material importance. Whenever the case is a fracture of the lower extremities, the patient should lie strictly in bed until the callus is completely formed. It is likewise an advantage not to have the bed much more than a yard wide, because the surgeon and assistants can then more conveniently get at any part of the limb. Feather-beds are a great deal too soft and yielding : a horse-hair mattress is far preferable. Boyer, indeed, is so im- pressed with the utility of letting the patient lie upon a surface which will not sink, that he recommends two mattresses to be used, and a board to be laid under the upper one from the hip to beyond the patient's foot.—{TraitsdesMai. Chir. vol. iii. p. 39.) The most favourable position for a fractured limb is that in which all the muscles passing over the fracture, and extending either to the lower fragment or to that part of the limb which is articulated with it, are equally relaxed. The. injured limb should also have firm support at every point, and its position ought to be regulated so that not only this object be carefully fulfilled, but at the same time the chance of Vol. II. M 92 Fractures. displacement from the action of the muscles, or the weight of the body, or part itself, may be diminished as much as possible. The natural, or rather the most easy position of the limb, is that which is usually chosen by a person who reposes himself or who is sleeping; for then all motion is suspended, and every part assumes that posture which is most congenial to it. In this condition, the limbs are not extended, nor yet entirely bent; but only in a moderate state of flexion. Hence, Boyer remarks, that a half-bent position of the limbs is that which is most natural, and that in which all the muscles enjoy an equal degree of relaxation, and, consequently, that it is, generally speaking, the best for fractures. This posture, which was recommended by Hippocrates and Galen, has been highly ex- tolled by Pott, who appears to have exaggerated its advantages. Considered in a general way, it is without contradiction preferable to every other position of the limb ; but its employment should be liable to exceptions, as will be noticed in treating of particular fractures.— (See Boyer, Traite des Mai. Chir. t. viii. p. 40.) In whatever position a broken limb is placed, (says this writer,) it should bear throughout its whole length equally and perpendicularly upon the surface on which it lies, and not be only partially supported. When, for example, only the extremities of a fractured limb rest upon the bed, the weight of the limb itself will make it bend in the situation of the fracture. The limb will also be rendered crooked, if the bro- ken part be supported, while the extremities of the limb (especially the inferior) sink lower by their own weight. The displacement of the fracture is not the only inconvenience arising from the limb being laid upon a surface where it is not every where equally supported. The parts which do bear on this surface experience a painful degree of pressure, which, if long continued, is apt to produce inflammation, and even sloughing, of the integunien'.s. Thus, in fractures of the leg, gangrene of the heel has sometimes arisen entirely from this cause. Such inconveniences may be prevented by laying a fractured limb on a surface of corresponding form ; that is to say, on a surface which is depressed where the limb has projections, and rises where it presents depressions. The surface should not be so hard as to annoy the patient; yet it ought to be sufficiently firm not to yield to the weight of the limb and apparatus. According to Boyer, the best pillows for the support of broken limbs are slutted with chaff of oats, a substance which he describes as far preferable to feathers, because it more readily admits of being pushed from the place where the limb is prominent to another situation where the member presents a depres- sion or hollow ; and ii. has the advantages of being less heating than feathers and less apt to spoil. In whatever position fractured limbs r.ro placed, they ought to be k^pt perfectly quiet during the whole thr.c requisite for the union. If the broken bone be moved while the callus is forming, the surfaces of the fracture rub against each other, and the process is disturbed; and, indeed, sometimes b\ repeatedly moving the limb, the consoli- dation of fractures is entirely prevented, or, at least, rendered very slow and difficult. In order to maintain tl.e limb in the right position, and in a state of Fractures. 93 quietude, and to preserve the fragments in proper contact with respect to each other, the surgeon is to caution the patient to avoid moving at all more than can be helped ; and every cause likely to subject the limb to any kind of shock or concussion is to be removed. But, in particular, it will be necessary to apply a retentive apparatus, usually consisting of some application to the skin itself, bandages, splints, tapes, straps and buckles, soft pads, &c—(See Boyer, Traite* des Mai. Chir. t. iii. p. 42.) L'pon the subject of the dressings,'bandages, &c. which ought to be applied to fractures, no surgeon has written better than Mr. Pott. " The intention (says he) in applying any kind of external medi- cine to a broken limb is, or ought to be, to repress inflammation, to disperse extravasated blood, to keep the skin lax, moist and perspir- able, and at the same time to afford some, though a very small degree of restraint or confinement to the fracture, but not to bind or press; and it should also be calculated as much as possible to prevent itch- ing, an herpetic eruption, or an erysipelatous efflorescence. " This lies very easy, repels inflammation, is not adherent, comes off clean, and very seldom, if ever, irritates, or causes either herpes or erysipelas. But let the form and composition of the application made to the limb bo what it may, one thing is clear, viz., that it should be put on in such manner, as that it may be renewed and shifted as often as may be necessary, without moving the limb in any manner: it being certain, that when once a broken thigh or leg has been properly put to rights, and has been deposited properly on the pillow, it ought not ever to be lifted up or moved from it again without necessity, until the fracture is perfectly united ; and it is true that such neces- sity will not very often occur." Such application having been made as the surgeon thinks right, the next thing to be done is to put on a proper bandage. That for- merly used was what is commonly called a roller. This was of differ- ent lengths, according to the surgeon's choice, or as it was used in the form of one, two or more pieces. " By such kind of bandage three intentions are aimed at, and said to be accomplished, viz. to confine the fracture, to repress or prevent a flux of humours, and to regulate the callus ; (see Duverney;) but who- ever will reflect seriously on this matter, will soon be convinced, that although some sort of bandage is necessary in every simple fracture, as well for preserving some degree of steadiness to the limb, as for the retention of the applications, yet none nor either of these three ends can be answered merely, or even principally, by bandage of any kind whatever: and, therefore, if this should be found to be true, that is, if it should appear, that whatever kind ofdeligation be made use of, it cannot be a principal, but only an accessory kind of assistance, and that in a small degree, and very little to be depended upon, it will follow, that such kind of bandage as is most difficult to be' applied with justness and exactitude, such as is soonest relaxed and out of order, such 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 which is moro easily applied, less g4 Fractures. liable to be out of order, and which can be adjusted without moving the limb, &c. " The best and most useful bandage for a simple fracture of the leg or thigh is what is commonly known by the name of the eighteen. tailed bandage, or rather, one made on {he same principle, but with a little difference in the disposition of the pieces. The common me- thod is to make it so that the parts which are to surround the limb make a right angle with that which runs lengthwise under it; instead of which, if they are tacked on so as to make an acute angle, they will fold over each other in an oblique direction, and thereby sit more neatly and more securely, as the parts will thereby have more connexion with, and more dependence on, each other. In com. pound fractures, as they are called, every body sees and acknowledges the utility of this kind of bandage preferably to the roller, and for very obvious and convincing reasons, but particularly because it does not become necessary to lift up and disturb the limb every time it is dressed, or every time the bandage loosens. " The pain attending motion in a compound fracture, the circumstance of the wound, and the greater degree of instability of parts thereby produced, are certainly very good reasons for dressing such wound with a bandage which does not render motion necessary ; but I Bhould be glad to know what can make it necessary, or right, or eligible, to move a limb in the caee of simple fracture? what benefit can be proposed by it ? what utility can be drawn from it ? When a broken bone has been well set, and the limb well placed, what pos- sible advantage can arise from moving it ? Surelyr none ; but, on the contrary, pain and probable mischief. Is it not the one great inten- tion to procure unition ? Can moving the limb every two or three days contribute to such intention ? must it not, on the contrary, ob- struct and retard it ? Is not perfect quietude as necessary towards the union of the bone in a simple as in a compound fracture? It is true, that in the one there is a wound which requires to be dress- ed, and the motion of the limb may in general be attended with ra. ther more pain than in the other ; but does motion in the simple frac, ture give ease, or procure more expeditious union ? " Every benefit then which can be supposed to be obtained from the common bandage or roller, is equally attainable from the use of that which I have just mentioned, with one additional, and, to the pa, tient, most invaluable advantage, viz. that of never finding it neces, sary to have his leg or thigh once, during the cure, removed from the pillow on which it has been properly deposited."—{Pott's Remarks on Fractures, fyc.) In France, a universal preference is given to Scultetus's bandage in every instance where we employ the eighteen-tailed one, from which it chiefly differs in being composed of separate pieces admitting of removal, so that when a part of the bandage is soiled it can be taken away without disturbing the whole of the dressings. The clean pieces are first stitched to those which are about to be removed, and then they are drawn under the part. In cases of compound frac ture, where the bandage is soiled with the discharge in a very short time, and must be often removed, certainly Scultetus's bandage is the Fractures. 05 best, particularly as it possesses all the recommendations peculiar to that of the eighteen-tailed kind.—{Boyer, Traite* des Mai. Chir. t. iii. p. 46.) With respect to the general objects and uses of bandages, in cases of fracture, I ought to notice one design of them, which is strongly inculcated in the modern French schools ; namely„that of " benumbing the irritability of the muscles," by the compression resulting from their regular and even application to the whole of the member. "The parts of the general apparatus for a simple fracture, which come next in order, (observes Mr. Pott,) are the splints," which are unquestionably the most efficient of all the applications made to a broken limb with a view of keeping the ends of the fracture steady and in a proper state of contact. Without them the surgeon would in vain endeavour to maintain the reduction. " Splints," says Pott, " are generally made of pasteboard, wood, or some resisting kind of stuff, and are ordered to be applied lengthwise on the broken limb ; in some cases three, in others four ; for the more steady and. quiet detention of the fracture. " That splints, properly made aud judiciously applied, are very ser- viceable, is beyond all doubt; but their utility depends much on their size, and the manner in which they are applied. "The true and proper use of splints is to preserve steadiness in the whole limb, without compressing the fracture at all. By the former they become very assistant to the curative intention ; by the latter they are very capable of causing pain and other inconveniences; at the same time that they cannot, in the nature of things, contribute to the steadiness of the limb."—{See Remarks on Fractures and Disloca- tions, in Pott's Chirurgical Works, vol. i. p. 298, &c. edit. 1808.) Assalini strongly disapproves of the employment of all tight band- ages, and of covering the whole of a broken limb with splints. He was called to a gentleman of rank at Paris, who had broken the knee-pan transversely. He laid the limb upon a concave splint, the shape of which was adapted to the under surface of a part of the leg aud thigh. No bandage was used ; merely two leather straps, which crossed upon the knee, and included the fractured bone. A perfect bony union wis thus easily effected. Assalini afterward extended the use of a concave splint, applied under the limb, to fractures of the leg and thigh. In the first of these cases, however, only the thigh is received in the hollow splint, and from this, two branches, or lateral splints, go along the leg. The apparatus has also a kind of sole for the support of the foot. As this simple contrivance is fastened with a very few straps, and no plasters or bandages arc used, the surgeon has constantly a view of the whole front of the limb, and of the frac- tured part of it, which Assalini thinks a great advantage. In com- pound fractures, he puts no other dressings on the wound, but linen compresses, which are kept continually wet with cold water.—{Ma- nualc di Chirunya, parte prima, 1812.) In oblique fr.iotures of the thigh, and sometimeffeven in those of the leg, the difficulty of accomplishing, by the ordinary means, a cure free from deformity, and especially without a shortening of the limb, has led to the idea of employing continual extension. This expres- 96 Fractures. sion implies the operation of a bandage, or machine, which continu- ally draws the fragments of the broken bone in contrary directions, at the same time that it restrains them from gliding over each other, and maintains them in contact during the whole time necessary for their union. In England, this practice has long been relinquished. It appears to have been chased away by the dazzling theory of relax- ing every muscle in such manner as to render it incapable of displacing an oblique fracture ; a theory with which the surgeons of this coun- try were but too much blinded, by the persuasive eloquence of the late Mr. Pott. Desault saw at once, however, every inconsistency in the doctrine of the possibility of relaxing the muscles so as to in- capacitate entirely the whole set connected with a broken thigh ; and he never ceased to inculcate in his school, that in such a case, I he as- sistance of a mechanical apparatus applied to the limb was the main thing by which the shortening of the limb was to be prevented. When we consider the treatment of fractured thighs, we shall find that the principle of continual but moderate extension has had, in France, advocates of great talent and eminence, though it is a met hod to which many surgeons appear to entertain strong objections.—{Cooper.) Means for preventing and rcm;n\..ig the unfavourable Symptoms liable to arise from Fracture*. After having reduced the fracture, applied a suitable apparatus for maintaining the reduction, and put the part in an advantageous po- sition, the practitioner is to attend to the indication in the treatment, viz. the prevention and removal of any unfavourable symptoms. Costiveness is to be averted by die use of clysters and mild aperient medicines. It must be confessed, that in fractures of the lower ex- tremity, the disturbance of the limb, caused by the patient's being obliged to move himself after having taken a purgative, is seriously objectionable ; but perhaps in all, and certainly in some habits, a neglect to open the bowels soon after the accident, would have still more pernicious consequences. In order, however, to lessen the dis- turbance, a bed-pan should be carefully introduced under the patient. One great convenience of a fracture bed, the cost of which is mode- rate, is to enable the patient to void his fteces, without the slightest change of po.uiion or disturbance ; an object effected by the simple contrivance of a little kind of trap, opening under the bed, out of which a small portion of the mattress admits of being withdrawn, and a tin receptacle is placed, for the reception of what is voided from the bowels and bladder. When a fracture is well set, tho position of tho part right, and the bandage and splints neither too tight nor too slack, the less the bro- ken bone is moved, and the less the apparatus and dressings are dis- turbed, the better. Sometimes, however, the practitioner is obliged to take off the splints, and undo the bandage, in order to ascertain that the ends of the fracture lie in even contact. Were he to leave the splints on the part, ten days, or a fortnight, without ever being sure of this important point, he might find, when too late for altera- tion, that the fracture was in a state of displacement, and the limh Fractures. 87 seriously deformed. Hence, a strong reason for employing the eighteen-tailed bandage, which admits of being opened without dis- turbing the limb, or even without lifting it from the surface upon which it has been deposited. In fractures of the lower extremities, particularly of the legs, it sometimes happens, the first two or three nights after the reduction, that the limb is affected with convulsive spasms and cramps, which make the patient start in his sleep, and displace the ends of the bone, which must be again reduced. When the callus has acquired some firmness, the patient should still keep the part or limb quiet, until the union is perfectly consolida- ted. And in fractures of the lower extremity, even after the union has proceeded so far that the splints admit of being left off, the patient ought not to venture to get out of bed, or bear upon the limb, till seve- ral more days have elapsed. All fractures, however simple and well treated they may be, are constantly followed by weakness and stiffness of the limb. These un- pleasant consequences are the greater, the more violently the limb lias been contused, the nearer the fracture is to a joint, and the long- er the part has remained motionless and without exercise. The stiff- ness always affects the inferior joint of the broken bone much more than the superior. For the relief of these effects of fractures, it is customary to employ friction, liniments, emollient relaxing applica- tions, washes, and bathing; but sometimes, notwithstanding such remedies, the membrane does not quickly recover its strength, but continues stiirand weak for a year, or even a longer time. The most effectual plans for the prevention of this state, should therefore be re- sorted to early. These consist in making the joints nearest the frac- ture execute slight motions, as soon as the union is sufficiently ad- vanced not to be in danger of interruption from this practice. A great deal of caution, however, is necessary in moving the part, and it is safer for the surgeon to superintend the business himself, than lease it to the patient or others. One of the best proceedings, also, for the hindrance of much weakness and stiffness in the limb, after a fracture, is to discontinue the splints and tight bandages immediately the state of the callus will allow. The manner in which their pressure retards the circulation, and prevents the action of the muscles, is one of the principal causes of the stillness of the limb ; and, consequently, the sooner they can be safely left off, the sooner will the patient regain the free use of the limb. In France, the chief division of fractures is into simple and compli. cated; which last includes, among many varieties, the cases which we name compound. We shall here briefly notice a i'cw of the com- plications, and the particular treatment which they require. Fractures (says Boyer) are always attended with a certain degree of contusion, which is constantly more severe in cases where the vio- lence has acted directly on the situation of the fracture. But such contusion can only be regarded as a complication of the accident, when it exists in so violent a degree as to demand a different treat- numt from that which is employed in simple fractures. In this circumstance, the splints and bandage should be applied ra- 98 Fractures. ther slackly, and the latter ought to be'wet with some resolvent lotion. The next day, the splints and bandage should be opened; a thing highly necessary to be observed, for where it has been neglected, the limb has been known to mortify, in consequence of the swelling ha- ving rendered the bandage too tight.—{Boyer, Traite" des Mai. Chir. t. iii. p. 63, 64.) In cases where the contusion is severe, but unattended with a wound of the integuments, the tension and swelling may be so intense, that the cuticle is detached, forming vesicles filled with yellowish se- rum. These vesicles may deceive an inexperienced surgeon, and lead him to imagine that the limb is threatened, or actually affected with gangrene. They ought to be punctured, and covered with pledgets of simple ointment. Here the practitioner may apply emol- lient poultices under the apparatus. SECTION I. Treatment of Compound Fractures. In the treatment of compound fractures we are to be governed by the same general principles as in simple fractures. The wound is to be cleared of all extraneous substances, such as splinters of bone, dirt, &c; and they should be removed with all possible gentleness, without pain, violence or laceration ; for if the parts surrounding the fracture be further injured, inflammation will be the consequence, and prove very injurious. There is no necessity of exciting any additional pain by probing, or any harsh means whatever. 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 to each other, as the nature of the case will admit, and thereby to produce as perfect and as speedy union as pos- sible. The wound being cleared from any loose pieces of bone, or other substances, the next thing to be done is to apply the dressing. The wound must be treated the same as any other. The edges must be gently brought in contact as nearly as possible, and then two or three strips of adhesive plaster applied to secure them, and thus afford an opportunity to heal without suppuration. Over this lint should be placed, and then the black or healing salve. " The dressing necessary in a compound fracture is of two kinds, 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, extraneous bodies, or fragments of bone, and this in such a manner, and by such means, as shall give the least possible pain or fatigue, shall neither irritate by its qualities, nor oppress by its quantity, nor by any means contribute to the detention or lodgment of what ought to be discharged. By the latter our aim should be the pre- vention or removal of inflammation, in order, if the habit be good and all other circumstances fortunate, that the wound may be healed by what surgeons call the first intention, that is without suppuration or Fractures. 99 abscess; or, that not being practicable, that gangrene and mortifica- tion, or even very large suppuration, may be prevented, and such a moderate and kindly degree of it established as may best serve the purpose of a cure. The first, therefore, or the dressing for the wound, can consist of nothing better, or indeed so good, as soft lint, laid on so lightly as just to absorb the matter, but neither to distend the wound, nor be the smallest impediment or obstruction to the discharge. 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 ointment. The times of dressing must be determined by the nature of the case ; if the dis- charge be small or moderate, once in twenty.four hours will be suf. ficient; but if it be large, more frequent dressing will be necessary, as well to prevent offence as to remedy the inconveniences arising - from a great discharge of an irritating sharp sanies. " When from neglect, from length of time passed without assistance, from misconduct or drunkenness in the patient, from awkwardness and unhandiness in the assistants, or from any other cause, a tension has taken possession of the limb, and it is become tumid, swollen and painful, a warm poultice is the most proper application that can be made ; immediate union is impossible, and every thing which can tend towards relaxing the tense, swollen and irritable state of the parts concerned, must necessarily be right. But when the parts are not in this state, the intention seems to be very different. To relax swol- len parts, and to appease pain and irritation by such relaxation, is one thing; to prevent inflammatory 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 mo- derate degree of it is all that is required. The poultice, therefore, al- though it be the best application that can be made use of in the one case, is not so proper in the other, as applications of a more discutient kind, such as mixtures of spirit, vinegar and water, with fomentations, and medicines of this class. By these, inflammation may sometimes be kept off, and a cure accomplished, without large collections or dis- charges of matter. " Compound fractures in general require to be dressed every day; and the wounded parts not admitting the smallest degree of motion without great pain, perfect quietude becomes as necessary as frequent dressing." If the common bandage or roller is used, care must be taken, in covering the limb, to leave a space sufficiently large, over the wound, conveniently to dress it. In compound fractures, however, it is best to apply such a bandage as prevents the necessity of changing the position of the limb when it is dressed or Unbandaged. A piece of linen, sufficient exactly to go round and fit the leg, may first be applied, and every part covered except the wound. On this the necessary splints should be placed, underneath being compresses to prevent too much pressure. The splints may be secured by the same kind of bandage as is spoken of under the head of simple fractures, or the whole of the splints or dressings (the wound excepted) may be entirely covered by narrow strips of linen, placed adjoining, or in Vol. II. N 100 Fractures. contact with, or overlap each other, and tied sufficiently tight, but not so as to render the patient uncomfortable. The eighteen or many tailed bandage also answers a very good purpose. The points to be aimed at are, the even position of the broken parts of the bone, and such disposition of the muscles surrounding them, as is most suitable to their wounded, lacerated state, as shall be least likely to irritate them, by keeping them on the stretch, or to produce high inflammation, and at best large suppuration. These cases, require at first the most rigid observance of the re- frigerant regimen; pain is to be appeased, and rest obtained, by anodynes ; inflammation is to be prevented or removed by fomenta- tions of tansy and hops, and aperient medicines. And during the first state or stages, the treatment of the limb must be calculated either for the prevention of inflammatory tumefaction by discutients; or, such tumour and tension having already taken possession of the limb, warm fomentation, and relaxing and emollient medicines, are required. If these, according to the particular exigence of the case, prove successful, the consequence is, either a quiet easy wound, which either heals by the first intention or suppurates very moderately, and gives little or no trouble, or a wound attended at first with consider- able inflammation, and that producing large suppuration, with great discharge and troublesome formation and lodgement of matter. If, on the other hand, our attempts do not succeed, the consequence may be gangrene and mortification. These are the three general events or terminations of a compound fracture, and according to these must our conduct be regulated. In the first instance, there is nothing to do but to avoid doing mis- chief, either by 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 limb, and to take care that the dressing applied to the wound proves no impediment. In the second stage, that of formation and lodgement of matter, in consequence of large suppuration, all a physician's judgment will sometimes be required in the treatment both of the patient and his injured limb. Every body who is acquainted with surgery knows (says Pott) that, in the case of bad compound fracture, attended with large sup. puration, it sometimes happens, even under the best and most judi- cious treatment, that the discharge becomes too great for the patient to sustain ; and that, after all the fatigue, pain and discipline which he has undergone, it becomes necessary to compound for life by the loss of the limb.* This, I say, does sometimes happen, under the best and most rational treatment; but I am convinced that it also ia now and then the consequence of pursuing the reducing, the antiphlo- gistic, or cooling, and the relaxing 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 com- * When symptoms of gangrene appear, the yest poultice may be applied. Fractures. 101 plaint at an end, and all inflammatory tumour and hardness gone, and his patient rather languid than feverish, that his pulse is rather weak and low than hard and full, that his appetite begins to fail, and that he is inclined to sweat or purge without assignable cause, and this in consequence of a large discharge of matter from a limb which has suffered great inflammation, but which is now become rather soft and flabby than hard and tumid ; that he will, in such circumstances, set about the support of his patient, and the strengthening of the diseased limb, totis viribus; in which I am from experience satisfied he may often be successful, where it may not be generally expected that he would. The time necessary for the reunion of a bone is somewhat uncer- tain ; it depends upon many circumstances, such as age, habits of the patient, treatment, &c. In young, the bone unites much sooner than in old subjects ; as soon, sometimes, as ten days. It may be said, however, in general, that from twenty to sixty days are required for bones to unite. A callus, or hard substance, forms in and around the fracture, which becomes more difficult to break than other parts of the bone. A short time after a bone is broken, osseous matter is deposited by the vessels, which forms a callus, and unites it. This shows a wonder- ful provision of nature, to cure such accidents ; and so powerful and effectual is this principle, that it proves effectual under the most dis- advantageous circumstances. A bone will unite even without bandages, splints, or any other application, either internal or external, and that too when it is subject to a considerable degree of motion. I lately had an opportunity of seeing this proved, or exemplified, in a case of a dog, which broke its leg. I daily saw it opposite my office, and thought of applying splints and bandages, but neglected it from some cause. The poor animal kept constantly in motion, and the limb, also, with more or less pressure upon the ground. After a short time, the bone united, and the dog walked as well as ever ; leaving, however, the limb a little crooked, or deformed. A cow also broke its leg; and, as an experiment, it was set, and bark taken from a tree and applied to the fractured limb, and firmly bound on. It united very handsomely, and the cow was as useful as formerly. A fact of practical importance should be drawn from this: instead of killing valuable animals when a bone is broken, they may be in this manner saved, and rendered as valuable as ever. When the requisite time for a broken bone to become firmly united has elapsed, it is proper to examine carefully and cautiously the place of the fracture, in order to learn whether the callus has acquired a suitable degree of strength. If the bone should be found to bend in the least at the injured part, the callus is not sufficiently strong, and the limb should be immediately put up in the apparatus again, with a view of preventing a new fracture, or, at all events, deformity. For the same reason, the patient should not be allowed to make uso of his limb as soon as the fracture has united. In fractures of the lower extremity, he ought to use crutches, and only let the weight of the trunk by degrees bear upon the injured limb. From neglect of this precaution the callus has been known to be absorbed, the limb to 102 Fractures. be shortened, and the patient become a cripple. An accidental slip may also produce the fracture again ; for the callus, so far from being firmer than the rest of the bone, is at first considerably weaker. I have often been astonished to see the treatment practised by dif- ferent persons in cases of fracture. There is no uniformity among them, and the majority appear to be governed by no principles what- ever. One practitioner extends and binds down a limb in the most absurd manner, and thus tortures his patient; while another uses DesauWs long splint, which is another species of torture. Another confines the limb in a box, with little or noother treatment. A physi- cian in New-Jersey practised this method till the wround suppurated, and became filled with maggots or worms; and it is proverbial, that in some hospitals in Europe, patients with fractures are sure to come out cripples. A case of this kind of treatment occurred in this city, a few years ago, the circumstances of which I will briefly relate. A ph5'sician, of this city, was upset in his gig, and his leg became so entangled as to fracture the tibia and fibula just above the ancle. It was a com- pound fracture. Two or three physicians were called, who examined it, one of whom, a noted hospital surgeon, proceeded, after the pa- tient was taken home, to treat it, I cannot say to reduce or dress it, as this he did not attempt to do. He left him in the same situation in which he was placed in the house where he was first taken after the accident. A wide splint each side of his leg had there been temporarily applied, and these were continued without any attempt to reduce the fracture ; nor did this surgeon scarcely attempt to give it a superficial examination. It appears that he adopted a new fashion, which has lately been introduced into some parts of this country, for the treat- ment of fractures, viz. to do nothing, at least, under ten days, and then to put on an apparatus to make gradual and permanent extension. This patient not being mine, or not having been called to him in the capacity of a physician, I had no right to interfere ; besides, the attending surgeon manifested much jealousy and hostility at my pre- sence. I, however, took the liberty, in the presence of the bystanders, and two or three of the physicians, to show the true nature of the accident, and thus expose the man's ignorance. I placed one finger upon the upper portion of the fractured or broken bone, and one upon the lower, and then pointed out the wide separation there was betwixt them, or the great distance they were apart; and, strange as it may ap. pear, this man was left in this condition for a length of time, and it was by mere accident that he discovered that the fracture had never been reduced. This, the physician or patient afterwards communicated to me himself; and stated that he had found it necessary to make an incision in the wound, to let out the pus or matter which had collected. Now, is it not passing strange, that some of our most noted sur- geons are guilty of such mal-practice 1 From many accounts that I have heard, of a similar kind, I am confident, that there is no branch of surgery so badly managed as fractures. I witnessed a case in New -Jersey, many years ago, where a person received a compound fracture of the femur, or thigh bone, which proved fatal for the want of proper treatment. Fractures. 103 The surgeon had received the first medical education in Philadel- phia, and he seemed to possess sufficient knowledge to reduce the fracture; but being unable to subdue the inflammation, the person died. There is no branch of surgery that is more simple or more easy to treat than fractures or dislocations. I have had my share of such practice in them, and I should really feel mortified and ashamed, if a single case that I ever treated could be exhibited, in which there was any deformity or bad management. 1 have never yet attended one, no matter what bone of the system has been fractured, but that has been properly set, secured, and sue- cessfully treated. No lameness, deformity, or inequality in the bones remaining, nor the least mark or symptom, that could ever lead a person to suspect there had ever been a fracture ; and this has been accomplished by the simple treatment here laid down, and which, every person, I was about to say, possessed of common sense, can easily put in practice. I have omitted to state that, as soon as the swelling and inflammation have subsided, the tincture of capsicum should be applied to the parts, and in a short time after an adhesive or strengthening plaster. Much benefit is invariably produced by these applications. Particular Fractures. I have thus given the general rules by which we are to be governed in the treatment of fractures in general; arfd if they are kept in view, they are sufficient to enable us scientifically and successfully, to treat particular fractures, or every species or variety of them. I shall, however, briefly notice fractures occurring in various parts of the body, in order, if possible, to throw more light upon the subject, or still further to illustrate it. SECTION n. Fracture of the Nose, or Ossa Nasi. These bones, from their situation, are much exposed to fractures. The fragments are sometimes not deranged; but most frequently they are depressed. In order to replace them, the surgeon must pass a female catheter, a ring-handled forceps, or any such instrument, into the nostrils, and, using it as a lever, push the fragments outwards; while, with the index finger of the left hand, he prevents them from being pushed out too far. SECTION lit. Fractures of tlie Lower Jaw. This bone is sometimes fractured near the chin ; but seldom so as to produce a division of the symphisis. In other instances, the frac- ture occurs near the angles of the jaw, that is to sav, between the 104 Fractures. insertion of the masseter and the root of the coronoid process. The bone may also be broken in two places at the same time; in which event, the middle portion is extremely difficult to keep right, because many of the muscles which draw the lower jaw downwards are at- tached to that part. The condyles and coronoid processes are also sometimes broken ; the former the most frequently. Fractures of the lower jaw may be either perpendicular to its basis, oblique or longitudinal. Of the latter, examples have been known, in which a portion of the alveolar process, with the teeth in it, was de- tached from the rest of the bone. The soft parts are generally contused and wounded. Treatment. The fracture, or broken bone, should be raised, and its end brought in contact with the other; after which a compress is to be laid over it, and on this, a piece of pasteboard, previously wet, the better to adapt it to the shape of the jaw; and when this has been applied, the whole is to be secured by a proper bandage. The patient must be directed to keep still, and to talk none. The nourishment must be liquids. I attended, some time ago, a very bad fracture of the jaw, which occurred in a female, in consequence of a blow from a ruffian, and which did remarkably well by this treatment. SECTION IV. Fracture of the Clavicle, or Collar Bone. The clavicle is perhaps as often broken as any bone of the body. Its exposed situation at the upper part of the trunk, its long slender shape, and its being covered only by the common integuments, expose it to frequent accidents. The fracture commonly occurs near the middle of the bone, as it is here most prominent; it is also occasionally broken near the sternal and humeral extremities. When fractured by the falling upon it of a heavy body, the nerves of the arm become paralyzed by the contu- sion. In general, the fragments are displaced, unless it is broken near the shoulder, in which case its firm connexion by ligaments with the scapula prevent the displacement. The external fragment, or that nearest the shoulder, is drawn downwards by the weight of the arm, and the action of those fibres of the deltoid muscle, which are inserted into it, and also by the pectoralis major, which, when it is depressed, draws it forwards or inwards towards the sternum, so that the sternal portion is always found riding over the humeral; the arm of the affected side falls upon the breast, and the patient is unable to rotate the humerus, so that it is impossible for him to raise his hand upon his head. He leans to the fractured side ; and the altitude is so remarkable, that the celebrated Desault, it is said, was never deceived in deciding, from this circumstance alone, the existence of the fracture. Fractures. 105 Crepitation, or a grating sensation, may easily be produced by mov- ing the arm; and the finger passed over the clavicle readily detects the place of fracture. This accident in itself is not dangerous, but becomes so when ac- companied with great contusion or laceration of the neighbouring soft parts. The treatment of this fracture has been the source of much diffi- culty among surgeons ; a vast variety of machinery has been contrived for keeping the fragments together ; and a surgeon of great celebrity, Mr. Pelletan, surgeon in chief to the kiotel Dieu, has renounced all applications, and trusts to rest in a horizontal posture as the only remedy. Treatment. The treatment for this accident, pursued both in Europe and Ameri. ca, seems to me to be really useless, injurious, absurd, and even ridiculous. The very appearance of a person who has been bandaged up, according to the popular practice, is sufficient to convince any reasonable person that it must be productive of bad consequences. The poor patient is obliged to submit to be enveloped in so much bandage, and that of such a tight and oppressive nature, that it is worse to him than the injury. The objections to it must certainly be apparent to every one. When applied in the most skilful manner, it is inade- quate to fulfil the necessary indications. Its complexity, its liability to be deranged, and the pressure it makes upon the breast and other parts, impeding respiration, &c, are exceedingly objectionable. In- deed, it is much better to do nothing at all with this fracture, than to apply the ordinary dressings. The treatment of it is exceedingly simple and easy. First, make a cushion of hair, woollen or cotton, long enough to extend from the axil- la, or the arm-pit, nearly to the elbow ; about three inches thick, and of a suitable width. A narrow bandage which may be folded and stuffed with cotton to prevent irritation, must be attached or fastened to the corners of the base, which are placed upwards. They must cross the back and breast, and over the shoulder of the opposite arm ; they are to be tied on the back, or in front, and it may be further secured, and kept under the axilla by additional strips of linen passed over the acromion process and tied, and if necessary others maybe tied around the arm and fastened to the cushion. In applying this cushion or compress, or dressing this fracture, there is no necessity for using much force, extension, or thrusting the shoulder backwards. It is sufficient gently to elevate the upper arm and shoulder, then place underneath and as far up into the axilla, or arm-pit, the cushion; after which let it be secured as directed above. This being done, spread a piece of the sticking salve, or plaster, on a stiff piece of leather, and let it be applied directly over the fracture. This has a considerable tendency to prevent any displacement of the bones. After it has been thus dressed, let a silk handkerchief be placed around the neck, the arm be placed in it, and kept across the abdomen, and hi this condition worn until the bone is united ; in every other respect to be treated the same as other fractures. The patient should keep 106 Fractures. very quiet. This course of treatment will be found invariably suc- cessful, without that inconvenience and torture which accompanies tho common practice. section v. Fractures of the Sternum. The sternum, or breast bone, is not frequently broken, and the reason of this fact is imputed to the position of this bone, resting, as it were, upon the cartilages of the ribs, and also in some measure to spongy texture. When the accident does occur, it is from the direct application of external violence to the injured part; and hence the fracture is always accompanied with great contusion, or even a wound of the integuments, and more or less injury of the chest. As Boyer remarks, the sternum, in consequence of the elasticity of the cartila- ges of the ribs, may be readily propelled backwards by pressure in this direction ; and the result is an actual change in the form, and a real diminution of the chest. Now, since this cavity is always accu- rately filled by its contents, these alterations cannot happen in a con- siderable and sudden manner, without a risk of the thoracic viscera be- ing contused, and even ruptured. Thus, when the sternum has been fractured by violent blows on the chest, the heart and lungs have been found severely contused, and sometimes lacerated ; and there will always be greater danger of such mischief, when the fracture is at- tended with depression of one or more of the fragments. In some cases, a large quantity of blood is effused in the cellular membrane of the anterior mediastinum ; and, in others, the accident is followed by inflammation and suppuration in the same situation, and necrosis of the broken part of the bone. Since the lungs are also liable to be ruptured by the same force which causes the fracture, or wounded by the depressed pieces of bone, emphysema, or collection of matter, may become another complication, as we see exemplified in a case related by Flajani.—{Collezione d''Osservaz, Sfc. di Chir. t. iii. p. 214, 8vo. Roma, 1802.) A fracture of the sternum is rendered obvious by the inequalities perceptible when the surface of the bone is examined with the fin- gers ; by a depression or elevation of the broken pieces ; a crepitus, and an unusual moveableness of the injured part in respiration. In many cases, the fracture may be seen, the soft parts being torn or otherwise wounded. The breathing is difficult, and mostly accom- panied with cough, spitting of blood, palpitations, and inability to lie on the back. According to the observations of Petit and Baldinger, several of these latter symptoms may continue, with less intensity, along while after the fracture is cured.—{Leveille, Nouvelle Doctrine Chir. t. ii. p. 243.) Fractures of the sternum, when mere solutions of continuity, only require common treatment, viz. a piece of plaster to the situation of Fractures. w the injury, a roller round the chest, quietude, and alow regimen, with a view of preventing what may be considered as the most dangerous consequence, inflammation of the parts within the cheat. section VI. Fractures of the Ribs. These generally happen near the greatest convexity of the bones, several of which are often broken together. The first, rib, being pro- tected by the clavicle, and the lower ribs, being very flexible, are less liable to be fractured than the middle ones. When the spicula of a fractured rib is beaten inwards, it may lace- rate the pleura, wound the lungs, and cause the dangerous train of symptoms. A pointed extremity of the rib, projecting inwards, may also cause an extravasation of blood; or by its irritation produce inflammation in the chest. A fracture which is not at all displaced is very difficult to detect, particularly in fat subjects ; and, no doubt, is very frequent- ly never discovered. The surgeon should place his hand on the part where the patient seems to experience a pricking pain in the motions of respiration, or where the violence has been applied. The patient should then be requested to cough, in which action the ribs must necessarily undergo a sudden motion, by which a crepitus will often be rendered perceptible. All the best practitioners, however, are in the habit of adopting the same treatment, when there is rea- son to suspect a rib to be fractured, as if this were actually known to be the case by the occurrence of a crepitus, or the projection of one end of the fracture ; which, indeed, in the instances which are dis- placed, makes the nature of the accident sufficiently plain. A broken rib cannot be displaced either in the direction of the di' ameter of the bone, or in that of its length. The ribs, being fixed posteriorly to the spine, and anteriorly to the sternum, cannot become shortened. Nor can one of the broken pieces become higher or low- er than the other, because the same muscles are attached to both fragments, and keep them at an equal distance from the neighbouring ribs. The only possible displacement is either outwards or inwards. Simple fractures of the ribs, free from urgent symptoms, require very simple treatment. The grand object is to keep the broken bones as motionless as possible. For this purpose, after a piece of plaster has been applied to the side, and over it proper compresses, a broad linen roller is to be firmly put round the chest, so as to impede the motion of the ribs, and compel the patient to perform respiration chief- ly by the descent and elevation of the diaphragm. A scapulary will prevent the bandage from slipping downwards. When the fractured part is depressed inwards, the compresses should be placed on the anterior am! posterior part of the bone. As a roller is apt to become slack, many surgeons, with good reason, prefer a piece of strong linen, large enough to surround tho chest, and laced so as to compress the ribs in the due degree.—{Boyer.) Vol. II. O 108 Fractures. SECTION VII. Fractures of the Thigh. A fracture of the thigh bone, or os femoris, is liable to take place at every point, from its condyles to its very head ; but it is at the middle third of this extent, that fractures mostly occur. The frac ture is sometimes transverse, but more frequently oblique. Accord- ing to the common method, the latter direction of the injury makes a serious difference in the difficulty of curing the case without future deformity or lameness. Sometimes the fracture is comminuted, the bone being broken in more places than one ; and sometimes the case is attended with a wound, communicating w ith the fracture, and ma- king it what is termed compound. As Petit remarks, however, the thigh-bone is less seldom broken into several pieces than other bones more superficially situated. A fractured thigh is attended with the following symptoms : a local acute pain at the instant of the accident; a sudden inability to move the limb ; a preternatural mobility of one portion of the bone ; some- times a very distinct crepitus, when the two ends of the fracture are pressed against each other ; deformity in regard to the length, thick- ness, and direction of the limb. The latter change, viz. the deformity, ought to be accurately understood; for, having a continual tendency to recur, especially in oblique fractures, our chief trouble in the treat- ment is to prevent it. As now treated, almost all fractures of the thigh are attended with deformity. When this is considered in relation to length, it appears that, in oblique fractures, the broken limb is always shorter than the opposite one ; a circumstance denoting that the ends of the fracture ride over each other. We may also easily convince ourselves, by examination, that the deformity is owing to the lower end of the frac- ture having ascended above the upper one, which remains stationary. Besides the action of muscles, there is another cause of displace- ment. However firm the bed may he on which the patient is laid, the buttocks, more prominent than the rest of the body, soon form a depression in the bedding, and thence follows an inclination in the plane on which the trunk lies, which, gliding from above downwards, pushes before it the upper end of the fracture, and makes it ride over the lower one. The muscles, irritated by the points of bone, increase their contraction, and draw upwards 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. Transverse fractures are less liable to be displaced in the longitudi- nal direction of the bone, because, when once in contact, the ends of the fracture form a mutual resistance to each other; the lower end, drawn upwards by the muscles, meets with resistance from the upper one, which, being itself inclined downwards by the weight of the trunk, pushes the former before it, and thus both retain their position in i elation to each other. The deformity of a fractured thigh, in the transverse direction, always accompanies that which is longitudinal; but sometimes it N, so far from exciting any additional inflammation, it absolutely removes it. It should be recollected, that the article must be kept from the air, as ex- posure to it destroys its active properties. This will be found a power. ful auxiliary in the cure of ulcers; but there are some which require even different applications to remove them ; and after using this, or dressing them in this manner, for a number of days or weeks, should the ulcer become stationary, apply the following plaster : Take white-oak bark, a proper quantity, bruise or grind it; add urine, a sufficient quantity to cover it ; lei it stand two or three days, and then boil it till it becomes of the consistence of thin molasses; add to every five pounds of this, one pound of honey, and one pound of gum turpentine, which has been melted and strained ; let the whole be simmered a short time over the fire, to incorporate or mix it. Let this be placed upon a piece of linen, and applied once a day, in place of the black or healing salve ; and should fung.is or proud flesh ap- pear in the ulcer, after using it a few days, add oue drachm of white vitriol, pulverized, to every ounce of the extract. This preparation alone has cured many very obstinate ulcers, even where they assumed a cancerous character. Should it excite any pain, or top much in- flammation, it may be applied during the day, and a poultice at night; and this is applicable to the other dressings. In certain cases, the will indigo saive, or plaster, answers a better purpose than any other application. Take wild indigo, the baik from the roots, 1 bushel; boil till the strength is out; then sirain, boil and skim ; add fresh butter 10 lbs., beeswax 3 lbs., matton tallow 1 1-2 lbs. ; simmer till the water has evaporated, or is out; then strain and skim again. The blue flag roots, is sometimes added. To be applied once or twice a day, the same as the preceding plaster. Ulcers. 149 In treating ulcer9 in general, the practitioner will find it advanta- geous to be acquainted with the effects of a great many external ap- plications ; for very few cases will continue to heal beyond a certain time, without some alteration in the treatment. The necessity of changing the applications, after they have been continued for a certain time, is strikingly illustrated by the fact, that leaving off a powerful application, and employing one which at first would have had no effect, often does a great deal of service. When the change is made to a medicine of powers equal to those of the previous one, the benefit will be more lasting than in the preceding circumstance. The following combination forms an excellent plaster in invete- rate cases of ulcers, where other means fail: Take extract .of blood root, inspissated juice of poke-berry, extract of yellow dock, equal parts, mix, spread upon a piece of linen, and apply the same as the other plasters. There is one application which I have been in the habit of using for many years, as the dernier resort, or as the last alternative, and which has proved a remedy, in conjunction with the treatment first recommended for ulcers, when all other means have failed. It is seldom, however, necessary to resort to it; and, being a mineral pre- paration, although used externally, is not so desirable as vegetable agents. I allude to the mineral caustic, one of the most powerful and active preparations that we make use of. A few grains sprinkled upon an ulcer, corrodes either the healthy or unhealthy parts. It is best to commence by using a very small quantity first, about once or twice a week, only sufficient to produce a preternatural or greater discharge of matter from the ulcer, for this is the only rational indi- cation in curing it. Nature makes a great effort to remove the mor- bid, or diseased action, by establishing a drain, or issue, upon the very part diseased, and all the physician can do, or ought to do, is to aid her salutary efforts, by making an issue directly upon the ulcer, in order to remove the offending cause. The healing process is exclu- sively the business of nature ; and therefore this and other applications should be occasionally applied, to keep up this preternatural discharge, until the exciting cause of the disease is removed, or a healthy action brought about. After such discharge has been kept up a reasonable time, the ap- plications may be discontinued, and the simple dressing used alone, such as the black, or healing salve, and lint. This is necessary, to give an opportunity for the healing process to take place, as an ulcer cannot always heal, or fill up, while under the influence of corrosive or irritating agents. The greatest caution and circumspection must be used in applying the mineral caustic. There is no danger arising from absorption of it into the system ; but if too great a quantity of it is applied, it causes much pain and inflammation. It usually acts with considerable violence for six or twelve hours, after which it sub- sides ; and if much is used, an eschar is formed, which requires the elm bark and yest to separate it ; but in general it is best to apply only a few grains, or such a quantity as will not form an eschar, but merely keep up a little greater discharge than has ordinarily been, before any thing was applied to the sore. 150 Ulcers. The late Dr. Ferris, a root, or botanical doctor, states, that the shrub maple, or cavern wood, applied to ulcers, in the form of decoction, is an infallible remedy ; but I have never used it, not having been able to ascertain its true botanical character. I lately saw a most inveterate ulcer cured, by a botanic physician, of the name of Galloway, by applying a strong decoction, made of the chestnut leaves, several times a day. In what are termed fever sores, and which are exceedingly obsti- nate, and are usually attended with considerable swelling, I have fomented, or steamed the part, once or twice a week, over bitter herbs, such as tansy, wormwood, horehound and catnip, and have occa- sionally applied cups around the sore, and on the leg. In some ulcers, which have baffled the skill of all physicians, I have found the application of ,an ointment made to them, of the fol, lowing plant, prove a sovereign remedy : Take sweet, or Seneca clover, bruise and simmer it, with fresh lard, until the strength is extracted ; then strain, spread upon linen, and apply it. One of the worst cases that I ever beheld was cured by this simple application alone; it seemed to exert a specific effect, different from any other article. As regards the frequency of dressing ulcers, this must depend on circumstances: such as the fetor arising from them, the discharge, &c. As a general rule, they should be dressed morning and night. This treatment is applicable to all kinds of ulcers, except such as are termed sinous, or where there is one or more openings, or orifices, communicating with the ulcer to the adjacent parts. It is necessary, in ulcers of this kind, daily to inject into the orifices some stimulating liquid. A solution of the vegetable caustic is excel- lent, as it destroys unhealthy granulations, without producing inflam- mation. A drachm, or teaspoonful, of the powders may be dissolved in a teacupful, or eight ounces, of a strong decoction of the wild indigo, or, as a substitute, water. If this should prove insufficient properly to cleanse and heal them, inject in a decoction made by boiling blood root, sumac bark and the bark of bitter swat. Soap suds (soap and water) is also very good for this purpose, and also tincture of gum myrrh. I have been in the hi bit, occasionally, of dissolving ten grains of the mineral caustic in eight ounces of water, and inject- ing this once a day, in order to keep these sinous ulcers open. It is sometimes necessary to introduce teuts into them, made of the ravel- lings of linen, twisted hard, or shortpieces of twine drawn through the black salve, or beeswax; and where they prove insufficient to keep the orifice of the ulcer open, they may be rolled in the vegetable caustic, and, should this prove insufficient, a few grains of the mineral caustic. A vast number of applications have been recommended for the cure of ulcers : but I have seen very little good result from any of them, except those which I have recommended. Tight bandaging has been highly extolled, and is now practised by many; but I have very little confidence in it, except as an aux- iliary. Ulcers. 151 General or Constitutional Treatment. In slight, or healthy ulcers, it is not necessary to resort to much, if any, internal medicines ; but where they are protracted, and assume an obstinate, or inveterate character, without attention to constitutional treatment, all local applications will seldom be sufficient. The gene- ral secretions of the system must be attended to. Purgatives, consisting of our common physic or mandrake, should be given as often as once a week. The skin must be kept moist, and an alterative course pursued. Ulcers often depend upon some morbid taint of the system, and it therefore becomes necessary to remove the cause before the effect will cease. I have found no preparation so valuable, in correcting sin impure state of the blood, as the alterative syrup. It should be t.iken regularly, and should he continued until the ulcer has healed. The following medicine, or beer, may be taken at the same time, with advantage :—take sassafras root, black alder, burdock root, wild cherry tree bark, q. s.; cut or bruise' them ; add sufficient water to make a strong decoction, sweetened with honey, or molasses ; then add sufficient yest to ferment it. Drink freely through the day. Regimen. No ardent spirits must be drank, and the diet must be light and nutritious. Too much exercise must be avoided ; the more quiet the patient keeps, the more favourable will it prove. This is the course of treatment which I have found to exceed any other; and it has proved a sovereign remedy in every species of ulcer, without reference to the length of time it has existed, age or habit, even where they have been abandoned as incurable by our most popular surgeons, and where amputation has been proposed. I have deemed it unnecessary to treat the different species of ulcere under distinct heads, as almost every kind requires a similar course. Where any difference is required, it has been pointed out. The bone is often affected in some description of sores, which calls for a different course to be puisued, and which will be given under the head of necrosis. Scrofulous, venereal and cancerous ulcers will be treated under their respective heads. CHAPTER VIII. Necrosis—Caries—{Diseased Bones.) The bones of the body, as well as the soft parts, are liable to be attended with inflammation, ulceration and exfoliation. They are composed of arteries, veins, absorbent vessels, nerves, and a cellular texture; they are endued with vitality; they are nourished; they grow, waste, are repaired, and undergo various mutations, according to the age of the individual; and they are subject to diseases analo- gous to those of the soft parts. To the phosphate of lime, which is more or less abundantly distributed in their texture, they owe all their solidity ; and perhaps it is to the same earthy substance, that the difference in their vital properties, and in their diseases, from those of the rest of the body, is to be referred. In fact, this particular organization and inferior vitality of the bones are generally supposed to account for the small number, peculiar character, and generally slow progress of their diseases. It is customary for writers to make a distinction between necrosis and caries ; but I can see no good reason for this distinction, as they may, with propriety, be said to be one and the same complaint. The appearances to be observed, depend more upon the stage of the disease, than upon any other cause. The treatment, also, is very similar. The following is the distinction made by writers : In necrosis, the bone is entirely deprived of life; in caries, the vital principle exists, but a morbid action is going on, whereby the texture of the bone is altered, and rendered softer and lighter than natural. But, though these disorders are thus far different from each other, they frequently occur together in the same part; and the term seems proper only to express a difference in the stage of the complaint. The tibia, femur, lower jaw, clavicle, humerus, fibula, radius, and ulna, are the bones most frequently affected with necrosis. Except- ing the lower jaw and scapula, the process of regeneration has only been noticed in the cylindrical bones. From twelve to eighteen years of age is the time of life most subject to necrosis. Necrosis of the lower jaw, however, seldom occurs before the age of thirty. No climate, age, sex, mode of life nor condition, (says Weidmann,) is exempt from this disorder. Childhood and puberty, however, are the periods most liable to it. The same thing may be said of persons who labour hard, and are much exposed to external injuries. Every bone of the human body is subject to necrosis; but those which are superficial, and enter into the formation of the extremities, are more frequently affected than others whose situation is deeper. Necrosis less commonly attacks the spongy substance of the bones, because, this being endued with a higher degree of vascularity and life, sup- / Necrosis—Caries—{Diseased Bones.) 153 puration is most apt to occur. Necrosis, on the contrary, is oftener seen in the compact substance, where the vital principle is less ener- getic, and more readily extinguished. As a modern writer has re- marked, a very slight injury will frequently occasion an extensive exfoliation from the surface of the cylinder of a long bone; but a musket-ball may pass through the cellular structure of an epiphysis, or lodge in its substance, without giving rise to necrosis—suppurative inflammation being much more likely to occur than the latter affec tion.—{Bell, on Diseases of tlve Bones, *a greater, or preternatural discharge from it. It is not sufficient to create inflammation alone, for this is insufficient to heal the sore, ThMiscased parts must be first re- 190 Fistula. moved, before it can be placed in a state for healing ; in other words, we must remove the offending cause before a cure can be effected. The first of these objects (the act of keeping open the fistula) may be accomplished by introducing a suitable sized tent, made of the ravel- lings of linen, or thread ; or a piece of twine will answer. It should be made small, or pointed, at one end, similar to a probe, and drawn through beeswax, or some plaster of a proper consistence, in order to stiffen it; and then it is to be introduced as far up the sinus as possi- ble, and a very small portion left out; after which, a little lint should be placed on the end of it, and a plaster of the black salve applied. On this a compress should be placed, and secured by the bandage, as before mentioned. The tents should be gradually enlarged, to fill the opening. Generally, when they are first introduced, they are required to be exceedingly'small, and can be introduced only a very short distance; but the orifice becomes more open, and, in a short time, larger ones can be used, and they will penetrate to the whole depth of the ulcer: nor will they excite any pain, as many might suppose ; for the matter soon renders them soft after their introduc- tion. It is not sufficient to introduce these tents without any applica- tion upon them. It is necessary to make use of some stimulating agents; and, for this purpose, I employ, with decided benefit, an alkali, or preparation of potash. Let ley, made from hickory ashes, be boiled down until it is perfectly dry ; then let it be removed from the vessel, pulverized, and kept from the air. A few grains of this must be put upon the tent every time it is introduced, which should be morning and night. It soon alters the nature of the discharge, rendering it more healthy, the fistula less irritable, and the inflamma- tory state of the system is subdued. It excites sharp pain for a few minutes; but, instead of operating like common caustics, causing greater inflammation, it removes it. The carbonate of potash will answer the purpose, but I think does not act so kindly as the preparation just mentioned. In the next place, the syringe must be resorted to, to aid in curing the complaint; and we may commence by injecting into the sinus a solution of the article just named. About one drachm of the alkali may be dissolvefl in eight ounces of rain-water, and injected once a day, and the strength of it gradually increased, as the patient can bear it. Weak ley answers very well. The strength of it can be gradually increased, as may be required : but there is no danger of using it very concent -for the cure is expedited in proportion to its strength. But w* : st be governed by the feelings of the patient; for they will not permit its being used too strong, as it might cause too much pain. This liquid should be injected once or twice a day. Soon after a fistulous abscess breaks, the parts arc too irritable to bear the use of the syringe. A little time should be allowed for the soreness 4o subside; and I often commepce with the use of injections consisting of Castile soap and water. Once a day, let the following decoction be injected : Take Blood-root—(sanguinaria Canadensis,) Root of wild hellebore—(veratrum piride,) Root of wild, or Indian turnip—(arum tryphillum,) Fistula. 191 Bruise, and make a strong, concentrated dtcoction, by boiling several hours. Let this be injected in the same manner. This course must be pursued as long as the fistula continues to grow better; although, such is tho insidious nature of the complaint, that, after the painful symptoms have subsided, the patient is unable to decide whether he is improving or not, although the callous, or hardened edges of the fistula are daily diminishing. The best and only sure criterion to ascertain whether the morbid or diseased organization has been removed, is the quantity of matter discharged when no dressings are applied; and therefore, when the fistula becomes pitted, or depressed around the edges, and the hardness in a measure gone, a trial may be made to heal it, by omitting the use of the tents and the syringe. The plaster, or salve, should only be applied. This will enable the practitioner to decide whether the discharge arises from the fistula itself, or whether it arises from the stimulating properties of the agents or medicine made use of. For J may say, in a word, that the principle of cure depends upon the act of making, and keeping up, a permanent issue, or drain, upon the fistula, until the morbid nature of it is so destroyed, that the edges of the sinus agglutinate and heal. In general, however, after these applications have been used a sufficient length of time, the discharge of matter will gradually diminish, and the fistula will close, in spite of the stimu- lus arising from the dressings. Sometimes there is a fistulous abscess, which does not appear externally, but opens into the rectum. In operating for this, surgeons recommend an artificial sinus, or opening, to be made, to enable them to operate. I attended one case where this operation was performed twioe, with only injury to the patient. I afterwards treated him according to the principles here laid down, and effected a radical euro. When a ca^e of this kind presents, the anus or rectum must be opened or distended with the fingers, and drawn out as far as possible, and held in this situation at short time, which will, in most cases, bring the orifice in sight; and, when so, let the same dressings be applied as before recommended. In general, I roll up a small piece of lint, and introduce it into the sinus with a probe. When the opening cannot be seen, its situation may be ascertained by either the finger or probe, and then inject a solution of the alkali, and apply it on lint. It will occasion no injury to the sound parts, but will act with considerable power upon the fungus aud spongy flesh of such an ulcer; for in general, when thus situated, they are soft, having but little callus. It often is the case, that such sinuses extend into an abscess situated superficially. And, when this course does not effect a cure, my method is, to bend a silver probe, pass it up the sinus, and press the end of it outward, or externally, and the end of the probe may be felt upon the finger, or the integuments may be seen to rise when it is pressed upon. Tho probe being thus in the opening, and felt, or seen externally, a counter opening may be made, either by a probe itself, or by cutting down upon it with a lancet, and thus converting it into an ordinary fistula, which must be treated in the same manner as othe.s. V.ain : it is sometimes the case, that an abscess forms near the * 192 Fistula. rectum, and finds its way externally, without penetrating it. % This, by surgeons, is termed an incomplete fistula; but I have to remark, in relation to it, that this is a veiy wrong name, as it constitutes a perfect fistula in every respect; and although it does not communicate immediately with the rectum, (which I have almost always found to be the case,) yet, in a very short time, it invariably works its way through. Indeed, it sometimes has been a matter of doubt to me, whether a case of this kind ever occurs; for it is one of the characteristic symptoms of the disease for the sinus to penetrate some cavity or canal. I The treatment for a fistula in this state (should it happen) is the same as any other. It is always best to wait, before dressing the fistula, till there has been an evacuation from the bowels, provided this generally takes place daily, and in the morning, as the applications are sometimes disturbed by the passages. The parts should first always be well washed and cleansed with soap and water, to which a little spirit has been added. It is better for the practitioner to attend personally to the dressings, if practicable, as this will faciUtate the cure. But, in more than half the cases which have been attended, I have been unable, from a mul- tiplicity of business, to do it, and have therefore committed it to the wife, husband, or a friend ; and, although a cure is invariably made, yet it is often much more protracted. A person well experienced in the treatment can cure it in half the time which will be required for any one who must first be instructed, and then act only under the supervision of the physician. In making objections to my practice, some have asked, how can my application be made to a fistula when it runs very crooked or obliquely, or perhaps passes off laterally into the flesh ? In answer to which, I have to observe, that I know not that any such case occurs. At any rate, I have never yet seen a fistula in which I could not introduce the medicine to the very extent or bottom of it, either by the use of the syringe, or by some of the other means recommended. But, should this not be the case, if the applications do not penetrate to the bottom, provided a cure is performed, the modus operandi of the agents employed is of little moment. It is sufficient for us to know that they have the desired effect. Should, from any cause, the disease become stationary, or should it "not improve as fast as desirable, a few grains of the mineral caustic may be applied two or three times a week, and the following plaster used : take the Inspissated juice of the poke-berry—(phytolacca decandra,) Extract of blood-root—(sanguinaria Canadensis,) equal parts; mix or incorporate well together. Spread on linen, and apply night' and morning, instead of the plaster first mentioned. These last dressings will excite a pretty free or copious discharge from the fistula; and, when the powder is applied to the tent, it excites considerable pain for six or twelve hours, after which, it begins to dis- charge very freely, and, in a few days, very much alters the character of the ulcer. In using this, it sometimes becomes necessary to apply Fistula. 193 the dippery-elm bark poultice, to remove.^the inflammation which it creates; and it should be used at any time, in the course of the disease, when there are inflammatory symptoms arising from any cause whatever. It is necessary to administer internal, as well as external applica- tions. A purgative should be given once a week, and, in addition, an alterative course pursued, to remove any morbid taint that may exist or give rise to the complaint; for this purpose, nothing is better than the alterative syrup, which the patient may take three or four times a day, as directed under that head. I have occasionally taken another method to expedite the cure. Where the patient is very anxious to have the ulcer healed in the shortest space of lime, I have pursued the following course. After the dressings already mentioned have been applied a sufficient length of time to promote a free discharge, and the callous edges have been thus broken down, or measurably destroyed, and after it has become enlarged, and the connexion between it and the rectum rendered small which follows this treatment; in order sooner to bring the divided edges of the fistula in contact, or to promote the healing of it more readily, I take a probe, bend it, and introduce the blunt edge through the sinus into the rectum; and after dipping the little finger in sweet oil, let it be slowly passed into the anus until it comes in contact with the end. Let it be held a few minutes in this situation, to relax tho muscles, which it does most extensively and almost in- credibly ; then push gently upon the probe with one hand while pressure is made upon the end of the probe with the other, which is within the anus ; bend it at the same time that the end is brought externally, or out of the rectum ; which, when done, tie or fasten to the end of it a piece of silk or thread, or put it through the eye. The probe then should be drawn back, in the same manner in which it was introduced, taking care as it is returned, that it be a little rebent, in order that it may easily return. This operation brings the silk or thread through the sinus and the rectum as a matter of course. Sometimes it can be passed through in a very few minutes ; at others, it requires a longer period, and is somewhat tedious, but can always be effected by a little perseverance. The ends of the ligature should now be tied and a little tightened, after which let the black plaster be applied with a compress and band- age to secure it. I have tried various ways to introduce the ligature by means of certain instruments, wires, &c, but I have always suc- ceeded best with a probe. A gold wire may be passed through, in- stead of silk or thread, but I know not that it has any advantages over it. Tho ligature, of whatever kind it is, should be a little tightened in order to accomplish the object designed ; which is to make one com- mon opening of the sinus with the intestinum rectum. The advantages of this will be readily perceived. First, it creates, or establishes, a permanent drain on the seat of the disease ; second, it excites adhesive inflammation, and has a tendency-to agglutinate or heal the fistula; and, third, laying the fistula entirely open with the rectum, it. heals more readily than in a state of sinus, by admitting 194 Fistula. healthy granulations to sh6ot up from the bottom of the sore, without any obstruction from pus or any other cause. According, then, to this method of practice, the ligatures are to be tightened, or twisted, from time to time, by means of a small piece of metal or wood, to which it should be tied in the centre ; or it is sufficient to twist the ligature as much as the patient can bear, and secure it by applying the black plaster. It produces some inflammation, and the discharge is considerably increased. This process compresses the part of the rectum usually divided by the bistoury, so as to occasion ulceration and an absorptiop of the part. In this way the sinus gradually heals above the ligature, and oy the time the parts are divided, or ulcerated through, if the callus has been previously destroyed by proper treatment, the cure is nearly, or quite completed. It is very necessary to introduce lint into the part divided, to prevent them, if possible, from uniting, or healing, too soon, lest some portion of the disease should remain. I have, in one or two instances, divided the parts with a bistoury ; for, after the fistula has been treated as laid down, such is the enlarge- ment of the opening, with the removal of the diseased parts, that very little pain is produced by simply dividing it. But I prefer the other method ; first, because the parts do not unite so readily as they do after an incised wound ; second, because the patient almost invariably shudders at the thought of using a knife ; and, lastly, the ligature con- tributes far more to eradicate the disease by the adhesive inflam- mation and ulceration which it produces, and which is not effected by simply dividing it with the bistoury. Let not the advocates for the knife say, from this statement, that this treatment resembles theirs, because it does not scarcely in the least respect, inasmuch as simply dividing the parts is the least distinguish- ing feature in the improvement; nor do we recommend,this, as abso- lutely necessary. I formerly cured the disease without any such practice, and now only advise recourse to be had to it, as before inti- mated, where it becomes necessary to eradicate the disease in the shortest space of time, or where it assumes an unusually obstinate character. A fistula in ano is certainly one of the most obstinate, the most loathsome, and the most serious diseases that afflicts the human body ; and, in consequence of its inveterate nature, it requires considerable t^me to effect a permanent cure, especially when the disease has be- come deeply seated. No definite time can be given in which it can be cured. In some cases it can be effected in a few weeks ; others will require a number of months. But where the treatment here laid down is strictly pursued, it will infallibly cure the disease. I have thus given the description, causes, symptoms, with tha com- mon and reformed treatment offistula in ano; and I must now submit it (as I do the treatment of other complaints) to those who have honesty and candour sufficient to appreciate, or test, the practice which I have recommended ; and I hope they will ascertain, by experience, the comparative merits of both the old and reformed, or improved method: hoping that prejudice will not so far blind the eyes of the Fistula. 195 practitioner as to prevent him from givft% the treatment of this, or any other disease, a fair and impartial trial. We have experience and facts for our superstructure; and we, therefore, solicit any one to overthrow it if possible, by fair and honourable means. My mode of treating the fistula in ano, in particular, has exeited much attention, and has induced some physicians, who have had the most indubitable evidence of its efficacy and superiority, to request md to publish it to the world. I have done so, not only as regards this, but other diseases ; and I, for the merits of the same, must appeal for a decision to an enlight* ened, a candid and impartial public. As considerable pains and exertions were taken, some years ago, by one of our most distinguished merchants, to extend the benefits of our improved method of treating fistula to other parts, and as he was defeated in his philanthropic designs by the envy and jealousy mani- fested by the most egregious misrepresentations, falsehood and ca- lumny, I shall now give some statement of the facts, by way of illus- tration. Fifteen years ago, when I resided about sixty miles from this place, 1 attended a gentleman from this city, who was afflicted with a fistula in ano, (for which a surgical operation was proposed as tho only remedy,) and I succeeded in effecting a cure. On his return to New-York, he communicated the fact to another citizen, a man of considerable note and standing in society, by the name of A. L. De- grove, who had been, for many years, a collector of the fourth ward of this city, and who stated, that if I would come to New-York, and cure him, he would pay me very liberally. I accordingly came, com- menced the treatment of his complaint, and soon removed it. Ac cording to his promise, he gave me a check upon the bank for a handsome sum of money ; and about the same time, in gratitude for the services rendered, presented me with a liberal donation. Nor was this all; so anxious was he for his fellow men afflicted with this loathsome and distressing disease, to have the same benefits extended to them, that he went in every direction of the city to solicit those having the disease to apply to me for medical aid. Being a man of considerable influence, he induced almost every one to apply ; and in consequence of having treated these success- fully, my reputation and practice became established; and that, too, in the face of much opposition from the selfish, the illiberal and preju- diced portion of the faculty. Mr. A. G. Thompson, one of the most wealthy and respectable merchants or auctioneers of this city, having ascertained the merits of our practice in this and some other com. plaints^ expressed an anxiety that its benefits should be extended to others ; and that I should meet with a suitable remuneration for the discoveries and improvements made in the healing art. As he had very little hope that our government, or any body of men, would bestow their patronage for any improvement of the kind; and entertaining an exalted opinion of the character of Alexander, the late Emperou of Russia, in patronizing every thing useful, or calculated to benefit mankind, he applied to Mr. Bogart, then Vice Vol. II. 2 A 196 Fistula. Consul of Russia, and reqlested him to call personally upon some of the persons whom I had cured, and obtain their certificates. Accord- ingly, I introduced him to many of the persons whom I had cured ; whereupon their certificates were procured, and the Consul attached the Russian seal to them. These were forwarded, with a letter from Mr. Thompson, to the Emperor Alexander, giving a brief history of the treatment. In a few months an answer was received from the Rus- sian court, directed to Mr. Poletica, the Russian Minister, then at the city of Washington, stating, that if I would repair to Russia, I should be rewarded according to deserved merit. This information was com- municated to Mr. Thompson, from Mr. Poletica, through Mr. Lomo- nosoff, the Russian Consul General at Philadelphia. While calculations were making to undertake this expedition, with a view to introduce this practice in Europe, intelligence of the fact, or the transaction, was communicated to Dr. David Hosack, or some in- quiries made of him respecting the improvement ; and although he professed great friendship for me at the time, having attended his lee- tures when Professor of the Theory and Practice in the University of the state of New-York; yet, in consequence of his prejudices or mis- 'representation, the expedition was broken up, and I have been under the necessity of suffering the consequences of such injustice and cruel conduct ever since. But it now affords me great pleasure to have this opportunity to lay these facts before the public, and I hope eventually before Nicholas, the present Emperor of Russia. Ten years had elapsed before I ascertained the reason that we were defeated in our attempts to introduce this practice in Europe. The circumstances were communicated to me, during my last visit to Phil- adelphia, through Mr. Lomonosoff. In concluding this chapter on fistula, I shall depart from my usual method, and briefly report a few cases, to illustrate the principles laid down. The limits of this work will not permit me to give them in detail. CASE I. Mr. Henry Crocheron, merchant, recently residing at the corner of Whitehall and Front streets, was attacked with a fistula, termed by sur- geons occult, in which the fistulous abscess burst into the rectum, from which issued constantly a sanious matter. He applied to a surgeon of this city, Dr. M***, or F*;::, who made an artificial sinus at the verge of the anus up to the ulcer; or his attempts were to effect this. He then cut down in the usual manner, and afterwards dressed it with lint. After trying a length of time to heal it, he could not succeed, and performed another severe operation without any benefit. In this situation I was called to him, and such was the difficulty attending the disease,'that I was unable precisely to discover its state, situation, or extent. The orifice extended some distance up the rectum; so far that I could not discover its course ; but from the quantity.of the discharge, and other symptoms, it was evident that there was much mischief taking place in the deep seated parts. I commenced the treatment by applying the alkaline powder on lint. I Fistula. 197 pushed it up with the probe, until I was satisfied that it reached the sore, from the pain which it created. I also injected a solution of the same article as before mentioned. It gradually mended, and in a few months he was well, and has remained so a dozen years. CASE II. Mr. Anthony Graves, then residing at the corner of Oak and Collia- rine streets, was attacked with a fistula which was exceedingly pain- ful, and which confined him to his bed. Great swelling, inflamma- tion, and abscess succeeded, which left the part in a very diseased state. There were two or three sinuses. Two surgeons called, and told him that there was no other alternative, but to have it extirpated by the knife. A gentleman whom I had cured, hearing of his situa- tion, called, and recommended him to have the disease cured without an operation. But, such was the confidence that he had in his physi- cian, that he found it almost impossible to induce him to have re- course to any other mode of treatment. Upon his offering, however, to pay the bill in case I did not succeed in effecting a cure, he finally consented that I should attend him. I commenced the treatment by subduing the inflammatory symp. toms ; and then, by applying the other medicine recommended, the ulcer soon healed, and he became sound in three or four months. The gratitude shown by this family ever since, has, to me, been a source of great satisfaction. In addition to having been liberally compensated for my services, I have repeatedly received donations; and so grateful has been this family, that they have presented the person who recommended me with one or more handsome presents. CASE III. Mr. William Gallaudet, now merchant in New-Rochelle, had been for some time labouring under a fistula in ano, for which a surgical operation had been performed, by Dr. N. Smith, but he was only rendered worse by it. He applied to me, in a very deplorable condi- tion. A fistulous ulcer extended far up the rectum, for which an operation had been performed, and upon examination another was found, which had been entirely overlooked by his physician. He was very much reduced and emaciated when I first saw him, and his general health had suffered exceedingly. There was a constant dis- charge from the fistula, and no prospect of his recovery without a change of treatment. I applied the usual dressings, which acted fa- vourably and soon produced an amendment. Hef daily grew better in every respect, and in a few months he was able to resume his business, and he has been perfectly sound for many years!*' CASE IV. Captain Lyon, master and owner of one of the ships which sails between this, New-Orleans and France, applied to me a few years 198 Fistula. ago to be treated for the fistula in ane. The parts for some distance around the anus, were extensively diseased, and he had had it for a length of time. He had applied to one or more surgeons, who told him there was no other method of curing him than submitting to an opera- tion by the knife. I commenced by treating him with the usual appli- cations, and after the sinuses were opened, the parts were found in a very diseased state. The medicine, however, soon brought them into a healthy condition, and in a few months he was perfectly cured. In one of his voyages to France, he afterwards informed me, that he went to Paris, and showed the parts, which had been the seat of the fistula, to one of the oldest and most popular surgeons in the city, Who said to him, " You have no fistula there ;" in other words, you are perfectly free of it. I think he had three or four different open. ings, or sinuses, one or two of which extended two inches up the rectum. CASE v. Mr. Jacob Anthony, cashier or teller in the United States Bank, had been afflicted some time with a fistula. Dr. V----B——, his family physician, recommended him to sub- mit to our course of treatment. He applied, and upon examination I found that the fistulous sinus was extensive, and penetrated in a very crooked direction, which rendered the cure more difficult. There was much callus attending it, and a constant discharge. Our usual dressings w ere applied, and although he was attended for a consider- able length of time, a permanent cure was effected, and he has been well for many years. CASE VI. Captain Gregory was recommended to submit to our course of treat- ment, for a very obstinate fistula, for which he had been labouring for some time, by Dr. Conger, his family physician, who had seen the effect of our practice on a friend of his, whom I had cured of the same complaint. WThen I saw the patient, I found the disease had commit- ted, very great ravages. The integuments had been destroyed from ■the verge of the anus to the perineum, and which had left a large, flabb)7, fistulous abscess, and which was connected with a great cavity underneath. The usual course of treatment was pursued, which en- tirely cured him. After the cure had been performed, I conversed with the physician who recommended him, Dr.Conger, and he gave the following opinion of the course of treatment, in comparing it w ith the common or old method. "Your mode of treating the fistula," said he, "is the most scientific." CASE VII. Mr. Meyers, who then resided in Water-street, near Catharine, had applied to Dr. Mi, of this city, a noted operative surgeon, who per- formed a most severe operation without any benefit, afterwards ap. Fistula. 199 plied to us for the treatment of his complaint. One or two orifices extended very far up into the rectum, cilous edges, great discharge, &c. From its extent and different ramifications, we found it very difficult to treat; but we finally eradicated it, and he has been well for many years. A few hours ago, a lady, recommended by the same gentleman, called with her daughter, afflicted with a fistula, and requested me to treat it, stating that she had applied to several practitioners, but none had cured it. CASE VIII. Captain Knapp, who owns and sails a vessel from this place, was confined a length of time to his bed with a fistula. I was called to see him, and found that he was afflicted with an ordinary fistula in ano. I gave him my view of his disease, and our mode of practice, and he seemed inclined to submit to it; but, being attended by his brother- in-law, Dr. F., and Dr. M., professors of surgery in the medical school of this city, he concluded first to ask their advice, whether there was any other method of curing the disease than an operation by the knife. Upon their next visit, he asked their opinion, and they told him that it was impossible for the disease to be cured without an operation, and he therefore submitted to one, which was very formida- ble, and which, together with the subsequent treatment, reduced him very low, and confined him to the house for many months. I heard no more from this man from the time I was first called, till nearly a year had expired, when he called upon me, and gave a state- ment, of the course which had been pursued by these physicians. I examined his fistula, and found that he had been extensively cut; the wound being several inches long, and gaping widely, with indurated edges, a free discharge of pus or matter. I applied our mildest dressings to the wound and fistulous ulcer, which improved their condition, and after a few months it healed ; and during the whole time he was enabled to attend to his ordinary busi- ness. He regretted exceedingly that he had not applied at first. He said that it had cost him, taking into account the bills of his physi- cian, board and loss of time, about a thousand dollars, and after all, only made worse. CASE IX. Mr. Mahlon Day, bookseller, residing in Pearl-street, near Frank- fort, was attacked with a fistula in ano, attended with all the ordinary symptoms. He applied to the late Dr. Kissam, a noted operative surgeon, who immediately performed a surgical operation. He after- wards dresstJdTit with lint, in the usual manner; but it did not heal; and the reason of which is explained in this chapter, under the head of " common treatment." Some time after this, he requested me to attend him. 1^ pursued with him the usual course of treatment, viz. established a preternatu- ral discharge upon the disease, which soon brought about a healthy * 200 Fistula. state, and completely eradicated it, and he has been well for many years. In company with him the other day, he voluntarily offered to give me a certificate of the cure, but believing them to be of very little service, I declined receiving it. case x. Mr. Mather, ink manufacturer, rrow residing at the corner of Greene and Prince streets, was attacked with pain, swelling and in- flammation near the rectum, which continued to increase until he was Srown into the most excruciating agony. It was exceedingly irrita- e, became enormously large, and, after a length of time, suppuration took place, but left a very large abscess with two openings, one or both communicating with the rectum, and which were both very ex- tensive. He applied to a physician or surgeon, who, as a matter of course, proposed an operation ; but, understanding that some had been cured without one, he concluded to make trial of the same process, and accordingly placed himself under our care. I pursued the usual course in treating it; and although I found it exceedingly obstinate from the induration, with the crooked direction in which the sinuses extended, as well as their great depth, after a few months was per- fectly cured, and has been sound for many years. After the cure was performed, I requested one of our most noted operative surgeons to examine it, which he did ; and, under an im- pression that he had been cured by a surgical operation with the knife, he exultingly exclaimed, " that is cured, and handsomely done ; who performed the operation ?" or words to that effect. Had this sur- geon known that it had been cured by any different method than that laid down by authors or practitioners, he would not, I presume, so readily have given his testimony in favour of the method pursued to effect it. CASE XI. Mr. Clarke, a wholesale grocer, store at the corner of Roosevelt and Front streets, had been a long time afflicted with a fistula in ano. He had submitted to one or two surgical operations, without having been cured. I attended him, and treated his disease as usual, which en- tirely removed it; and he has remained well for ten years. CASE XII. Mr. George Peterson, then leather inspector of this city, had been for some time labouring under a'fistula, for which he was told there was no other remedy but the knife. The sinus, as usual, communi- cated with the rectum, with hardness, pain, inflammation, discharge, &c. My usual course permanently cured him, and he has remained well for many years. # CASE XIII. Mr. Emmons, grocer, residing at the corner of Hester and Ludlow streets, was attacked with a fistula, and called upon a surgeon of this • Fistula. 201 city, who told him that he must submit to a surgical operation to have it removed. He afterwards applied at our institution, and the ordinary course of treatment entirely cured him. case xiv. Mr. Allen, a mason by trade, now residing at the, corner of the Bowery and Grand-street, had*t>een, for a length of time, labouring under a fistula. It was very painful, swelled and inflamed, and there was a constant discharge from it. He was treated in the ordinary manner, and cured, and has remained well for a number of years. CASE XV. Mr. Lewis, now residing in Fulton-street, opposite the Fulton mar- ket, had been afflicted with the fistula for some time,1 and had extended some distance towards the spine, communicating with the rectum, a considerable distance above the sphincter ani. Its situation was such, that it seemed almost impossible to use the medicine in such a manner as was necessary to remove it; but, by applying it very far up the rectum, where the sinus apparently communicated with it, the fistula. began to improve, and eventually healed. CASE XVI. Mr. Murdoch, collector of the 13th ward, was attacked with a fistulous abscess, which his family physician was unable to cure. After submitting to our course of treatment, he soon began to mend; and the fistula, as far as I now know, is sound. CASE XVII. Mr. Kline, of this city, an habitual drunkard, applied to me to be treated for a fistula. In consequence of his intemperate habits, it seemed that the disease could not be cured. But after a few months he entirely recovered. CASE XVIII. A merchant from Columbia county, near Hudson, placed himself under my oharge, for the treatment of the same disease, and the course pursued entirely eradicated it. I have seen him frequently since, and have ascertained that he remains well. CASE XIX. An elderly man, name not recollected, applied to our office some time ago, afflicted with this complaint, who stated that he had been operated upon five times, and yet was not cured. We treated him as usual, and in the course of a fow months he recovered. t 202 Fistula. CASB XX. Mrs. Nash, of this city, had a fistula in ano, for which she supposed there was no remedy without the knife. In six weeks after submitthig to our course of treatment, the fistula was sound. *• CASE XXI. Mr.----, name not in our possession, wheelwright by trade, then living in Crosby-street, had a most inveterate fistula ; the pain, swell- ing and inflammation were very great. The same course of treat- ment as laid down in this work restored htm to health in a few months, and he has remained so eight or ten years. CASE XXII. - Mr. Peter Graham, of this city, applied to us with a fistula in ano, attended with considerable discharge, callosity or hardness, and the sinus extended up to the rectum. He applied to Dr. M----, a noted .surgeon of this city, and two other physicians, who were unable to cure it, and who proposed a surgical operation. We treated it in the usual manner, and in a short time it healed. The patient is now be- fore me, who states, that it has not broken out or reappeared since, a term of four years; and he further states, that he feels confident that it never will. CASE XXIII. Mr. Pray, shoe dealer, of this city, was attacked with a fistula in ano, which impaired his general health, and affected one side and leg so extensively, that he was rendered very lame. The discharge was profuse and fetid, the abscess large, and it burrowed very deep into the surrounding cellular substance. It had existed for a length of time, and continually grew worse. His only hope of a cure was by a surgical operation ; but, from seeing some who had been cured with- out the knife, he placed himself under our care, and in a few months all the unfavourable symptoms subsided, the fistula healed, and it has remained well for many years. Fistula in the Perineum. 203 Fistula in the Perineum. Description. By this disease, we understand an abscess which terminates in a fistulous sinus into the perineum, and penetrates the urethra, which carries the water off from the bladder. Causes. The disease may be occasioned by false passages made by means of the catheter, or it may be occasioned by strictures in the urethra* which retains or greatly obstructs the discharge of urine, and inflam- mation and ulceration takes place behind the strictured part, which terminates in an opening or sinus externally, or in the perineum. The same circumstance also results in some cases from accidental injuries to the perineum, which terminates in ulceration, causing a fistulous opening. Symptoms. This species of fistula commences with great pain, swelling, and inflammation in the perineum, often by the urine becoming extrava- sated into the cellular texture in the vicinity of the urethra. Suppura- tion and sloughing now follow, and there is left a fistulous opening, or ulcer, through which the urine discharges. It often happens, says Bell, that in these diseases of the perineum, the urine obtaining a free discharge by the fistulous opening, the original stricture is more and more contracted, and a considerable part of the canal is totally obli- terated. The parts around and in the sinus are sometimes as tough and as hard as ligament; and the orifice is sometimes very small, and, if not cured, will remain opening during life. In the integuments of the perineum and scrotum, there are abscesses and sinuses running in various directions, and they are knotty, hard and irregular, with one or more outlets for the urine. Common Treatment. An operation by the knife. A longitudinal incision is made down through the fistula into the urethra. Others recommend that the whole diseased or fistulous flesh be cut out or extirpated. Reformed Practice. The treatment of this Species of fistula is nearly the same as the fistula in ano. A leading indication is to remove the stricture, and thereby give a free passage for the urine to flow through its natural channel. This will be effected by daily introducing a bougie \ at the same time applying the dressings to the ulcer as recommended under the head of fistula in ano. If there is inflammation, poultices must be applied to reduce it. After which, the callus or indurated intcgu* ments must be broken down in order to heal it; to effect which, apply the discutient ointment, the black plaster, as before mentioned, with tents rolled or charged with the stimulating powders, injections, dec* Vol. II. 2B 204 Fistula Lachrymalis. A case occurs to me now, which I cured many years ago, for which an operation had been performed by Dr. M----, of this city. Tha v edges of the ulcer were exceedingly hard, extending a considerable distance around it, and every time the urine was voided, a portion went naturally through the urethra, and the other portion ran a stream through the fistulous opening. He stated that when the operation was performed by the knife, be- fore I commenced with him, the most horrid sensations were produced by it. To use his own expressions, he said, it appeared to him that all his entrails were torn out. Fistula Lachrymalis. The tears secreted by the lachrymal gland, after lubricating the eye, are taken up by the puncta lachrymalia, and conveyed to the lachrymal sac, whence they pass through the ductus ad nasum into the nose. This ductus ad nasum, however, is liable, like all other canals in the body, to stricture. Whenever, in consequence of a stric- ture in this duct, the course of the tears into the nose is interrupted, they accumulate in the sac, which becomes tumid,* and upon being pressed they regurgitate and flow partly over the cheek and partly through the nasal duct. The tumour is situated on one side of the root of the nose, below the inner canthus of the eye. The tears are constantly overflowing the eye ; because, the sac being full, the puncta can receive no more. To the disease in this state, the term fistula is improperly applied. The patient experiences but little in- convenience from it, except a constant watery eye ; no pain and in- flammation exist. Eventually, however, the stricture becomes com- plete, the sac inflames and suppurates, and now a fistulous sore is formed, which discharges tears, mixed with mucus and pus. It is generally accompanied with inflammation of the eye, and often with caries of the os unguis. The puncta, in this stage, are often obstruct- ed, and no tears find their way into the sac, but all which are secreted pass over the eyelids. Common Practice. A variety of instruments and operations have been recommended for the removal of this troublesome complaint, but none of them seems yet to have been found effectual. The general practice among surgeons is now to perforate the os unguis, and then to introduce a nail headed style or silver tube. When the perforation is completed, air passes out of the nose through the wound, and blood flows through it into the nostril. Ware's plan was to introduce the style or silver tube through the duct, and continue it for a great,length of time. This process is much more rational, less painful, and more effectual than the other. "Unfortunately," says Cooper, " for the scheme of making an ar- tificial passage, nature was generally so busy, that she completely frustrated the aim of the surgeon, by gradually filling up the new aperture again. Hence, some practitioners were not content with Fistula Lachrymalis. 206 drilling a hole through the os unguis, but actually removed a portion of this bone ; either with the forceps proposed by Lamorier in 1729, (sec Me'm. de VAcad. des Sciences,) or with cutting instruments, among which the most celebrated is the sharp-edged kind of cannula, devised by Hunter. While this was being applied, however, it was necessary to support the os unguis with something passed up the nose, and a piece of horn was found to answer very well. Instead of these methods, Scarpa prefers destroying a portion of the os unguis with the actual cautery passed through a cannula ; a practice long ago banished from good surgery, and most justly condemned by Richter. " I do not feel it necessary to enter very particularly into the details of these methods of forming an artificial passage between the la- chrymal sac and nostril. I have never seen a case in which I should have deemed such practice advisable ; and that the necessity for it must be rare, sometimes it cannot be returned without difficulty. The disease occurs in persons of all ages ; but it is most common in infants and elderly subjects. Such examples as are com- bined with thickening and relaxation of the inner coat of the rectum, internal haemorrhoids, or other tumours, are sometimes attended with a copious discharge from the anus, and from the prolapsed bowel, of a serous and mucous fluid, mixed with blood. Causes. The disease may originate from various causes : 1. From circumstances tending to relax and weaken the parts which retain the rectum or its inner membrane in its situation. 2. From various kinds of irritation and pressure on the bowel itself, having the effect of increasing the powers by which it is liable to be forced outwards. 3. From any disease or irritation in the adjacent parts, and affecting the rectum sympathetically. Hence, a prolapsus ani may be caused by long habitual crying, and great exertions of the voice ; violent coughing ; sitting long at stool; hard dry faeces, and much straining to void them ; obstinate diarrhoea in infants, kept up by dentition ; dysentery ; chronic tenesmus ; va- rious diseases of the rectum itself; the abuse of aloetic medicines and emollient clysters ; haemorrhoids ; excrescences and thickenings of the inner membrane of the rectum ; difficulty of making water ; the efforts of parturition ; the stone in the bladder ; paralysis of the sphincter and levatores ani; and prolapsus vaginae. Considering the degree of the disease, and the occasional close- ness of the stricture, the symptoms are sometimes mild, the rectum Ptolapsus Ani, or falling down of the Bowel. 219 generally bearing pressure, exposure to the air; and other kinds of irritation, better than any other bowel. But the urgency and danger of a prolapsus ani are greater when the swelling is large, recent and conjoined with violent pain, inflammation and febrile symptoms. When complicated with strangulation, the consequences may be a stoppage of the faeces, severe pain, swelling inflammation, and even gangrene within the cavity of the abdomen. In short, all the evils may arise which attend strangulated hernia. The prognosis, there- fore, varies according to the different degree, species, cause and com- plication of the disease. The recent, small, movable prolapsus ani, the cause of which admits of being at once removed, may be effectu- ally and radically cured. It should always be recollected, however, that when once the rectum has been affected with prolapsus, a ten- dency to protrusion from any slight occasional cause generally re- mains. The habitual prolapsus, which has existed for years, and comes on whenever the patient goes to stool, is the case which is most difficult of relief. Treatment. The treatment of prolapsus ani embraces three principal indica- tions : 1. The speedy reduction of the prolapsed part. 2. The retention of the reduced bowel. 3. The removal and avoidance of the causes by which the disease is induced. In general, when the case is recent, and the tumour not of immode- rate size, the reduction may be accomplished with tolerable ease, by putting the patient in a suitable posture, with the buttocks raised and the thorax depressed, and by making gentle and skilful pressure either with the palm of the hand or fingers ; but from the inflammation and swelling, this cannot always be done, and it will not do to press too hard, or exert too much force, for fear of irritation. No further attempts must be made at reduction, until means have been made use of to reduce the inflammation. Astringent washes may first be tried, if the pain and swelling be not too great. Take White-oak bark, Sumach, Witch-hazel, Hemlock bark ; Bruise, and make a strong decoction of these barks, and to every pint add a teaspoonful of pulverized borax. Let the parts be fre- quently washed with it; soon after, apply the white ointment, as di- rected under the head of " piles." After these have been applied, should it still continue irreducible, apply the slippery-elm bark poultice, to be secured by the T bandage, as recommended under the head of " fistula." This will soon lessen the inflammation, so that the intestine can be reduced. If it proceed from a relaxed state of the bowels, medicines must be given for that complaint. The diet should be such as to keep the Vol. II. 2D 220 Prolapsus Ani, or falling down of the Bowel. bowels in a soluble state, as rye or brown bread, " mush or hasty pudding and molasses." After the protruded intestine has been replaced, let the white oint- ment be continued for some time, until the tone of the parts is re- stored. I have attended some deplorable cases of this complaint, particu- larly in infants, where the anus had been protruded for many weeks, and which had extended several inches, with great swelling, inflam- mation and ulceration, and yet recovery followed, by pursuing these means. In one case, it was necessary to poultice a month before thft swelling was sufficiently reduced to return the intestine. CHAPTER XV. whitb swelling—(Hydarthus.) The white swelling is a peculiarly common and exceedingly terrible disease. The varieties of white swelling are numerous, and might usefully receive particular appellations. Systematic writers havo generally been content with a distinction into two kinds, viz., rheu- matic and scrofulous. The last species of the disease they also distinguish into such tumours as primarily affect the bones, and then the ligaments and soft parts, and into other cases, in which the ligaments and soft parts become diseased before there is any morbid affection of the bones. The propriety of using the term rheumatic is very questionable. The knee, ankle, wrist and elbow, are the joints most subject to white swellings. As the name of the disease implies, the skin is not at all altered in colour. In some instances, the swelling yields, in a certain degree, to pressure; but it never pits, and is almost always sufficiently firm to make an uninformed examiner believe that the bones contribute to the tumour. The pain is sometimes vehement from the very first; in other instances, there is hardly the least pain in the beginning of the disease. In the majority of scrofulous white- swellings, let the pain be trivial or violent, it is particularly situated in one part of the joint, viz., either the centre of the articulation, or the head of the tibia, supposing the knee affected. Sometimes the pain continues without interruption; sometimes there are intermis- sions ; and in other instances the pain recurs at regular times, so as to have been called, by some writers, periodical. Almost all authors describe the patient as suffering more uneasiness in the diseased part when he is warm, and particularly when he is in this condition in bed. At the commencement of the disease, in the majority of instances, the swelling is very inconsiderable, or there is even no visible en- largement whatever. In the little depressions, naturally situated on each side of the patella, a fulness first shows itself, and gradually spreads all over the affected joint. The patient, unable to bear the weight of his body on the disordered joint, in consequence of the great increase of pain thus created, gets into the habit of only touching the ground with his toes; and the knee, being generally kept a little bent in this manner, soon loses the capa- city of becoming extended again. When white swellings have lasted a while, the knee is almost always found in a permanent state of flexion. In scrofulous cases of this kind, pain constantly precedes any appearance of swelling; but the interval between the two symp- toms differs very much in different subjects. The morbid joint, in the course of time, acquires a vast magnitude. Still the integuments retain their natural colour, and remain unaffect- 222 White Swelling—(Hydarthus.) ed. The enlargement of the articulation, however, always seems greater than it really is, in consequence of the emaciation of the limb, both above and below the disease. An appearance of blue, distended veins, and a shining smoothness, are the only alterations to be noticed in the skin covering the enlarged joint. The shining smoothness seems attributable to the distention, which obliterates the natural furrows and wrinkles of the skin. When the joint is thus swollen, the integuments cannot be pinched up into a fold, as they could in the state of health, and even in the beginning of the disease. As the disease of the articulation advances, collections of matter form about the part, and at length burst. The ulcerated openings sometimes heal up; but such abscesses are generally followed by other collections, which pursue the same course. In some cases, these abscesses form a few months after the first affection of the joint; on other occasions, several years elapse, and no suppuration of this kind makes its appearance. Such terrible local mischief must necessarily produce constitutional disturbance. The patient's health becomes gradually impaired; he loses both his appetite and natural rest and sleep; his pulse is small and frequent, and obstinate, debilitating diarrhoea and profuse noc- turnal sweats ensue. Such complaints are sooner or later followed by dissolution, unless the constitution be relieved in time, by the amendment of the diseased part. In different patients, however, the course of the disease, and its effects upon the system, vary very much in relation to the rapidity with which they occur. Rheumatic white swellings are generally considered distinct diseases from the scrofulous distemper of large joints. In the first, the pain is said never to occur without being attended with swelling. Scrofu- lous white-swellings, on the other hand, are always preceded by a pain, which is particularly confined to one point of the articulation. In rheumatic cases, the pain is more general, and diffused over the whole joint. With respect to the particular causes of all such white swellings as come within the class of rheumatic ones, cold is the exciting cause. External irritation, either by exposure to camp or cold, or by the application of violence, is often concerned in bringing on the disease; but very frequently no cause of this kind can be assigned for the complaint. As for scrofulous white swellings, there can be no doubt that they are under the influence of a particular kind of constitution, termed a scrofulous, or strumous habit. In this sort of temperament, every cause capable of exciting inflammation, or any morbid and irritable state of a large joint, may bring such disorder as may end in the severe disease of which we are now speaking. In a man of a sound constitution, an irritation of the kind alluded to might only induce common, healthy inflammation of the affected joint. In scrofulous habits, it also seems probable that the irritation of a joint is much more easily produced than in other constitutions; and no one can doubt that, when once excfted in scrofulous habits, White Swelling—(Hydarthus.) 229 it is much more dangerous and difficult of removal than in other patients. Tho pathology or nature of this complaint is thus given by an experienced practitioner: "There are not, probably," says he, "many disorders, to which the human body is liable, which prove either of worse consequences to patients, or that are less understood by practitioners, than white swellings of the joints; insomuch, that whenever the disease is tho- roughly formed, it is in general considered as incurable. " This ought certainly to be a very strong inducement with every practitioner, for carrying his researches with respect to it as far as possible. " The term white swelling has commonly been applied to such en- largements of the joints as are not attended with external inflamma- tion or discolouration of the skin and common teguments ; the only symptoms, which at first commonly take place, being a greater or less degree of swelling, with a deep-seated pain. In the progress of the disease, indeed, the whole surrounding parts come to be so much affected, that inflammation is at last communicated to the skin itself; and, when this terminates in abscesses and consequent ulcerations, it is not at all uncommon to find a great many openings surrounding the whole joints that are so diseased. " Though there are, by different writers, several detached observa- tions upon this complaint, yet no regular account has ever been given of if, farther than what may be met with in general dissertations on diseases of the bones, which have always been considered as the principal seat of such disorders." Different Species of White Swellings. There seem evidently to be two different species of white swellings, distinct from one another; and, as the one is of a mnch milder nature than the other, it would seem to be a matter of importance, so to characterize the different varieties, that the one may be easily and certainly distinguished from the other. In this, however, as in many other diseases, the complaint has fre- quently been of considerable standing before practitioners are called in : so that although, if seen from the beginning, and through all its different stages, it might generally be easily enough known of what particular nature the disorder in reality is; yet, when it is far advanc- ed, and when an exact history of the symptoms cannot be obtained from patients themselves, it is often impossible to make any accurate or certain distinction ; the symptoms of both species being, in the latter stages of the disease, commonly very similar. When this, however, is not the case, and a practitioner is called in before the symptoms have made any great progress, he may com- monly, with a little attention, form almost a certain judgment of the nature of the complaint. And, as I have had many opportunities of seeing every species of the disorder, in all its stages, I propose, first, to give as exact an account as possible of the rise and progress of the 224 White Swelling—(Hydarthus.) different symptoms in each species ; then to mention the several ap- pearances of the joints, which in each of them are observed on dissec- tion, with the most common exciting and predisposing causes of the disorder; and, lastly, I shall enumerate the different remedies that I have used for it, with their several effects. Swellings of this nature, it may be remarked, occur in every joint of the body; but much more frequently in the large than in the smaller joints : thus, at least, twice as many are met with in the hip, knee and ankle joints, as in all the rest of the body besides. Rheumatic Species of White Swelling. Symptoms. The first, and what may be considered as the most simple, species of the disease, begins with an acute pain, which seems to be diffused over the whole joint, and frequently even extends along such muscles as are connected with it. There is, from the begiiSwng, a uniform swelling of the whole surrounding teguments, which in different pa- tients is in very different degrees ; but it is always so considerable as to occasion an evident difference in point of size between the diseased and sound joint of the opposite side. A considerable tension generally prevails; but there is seldom, in this period of the disorder, any ex- ternal d 3colouration. The patient, from the commencement of the disease, suffers much pain from the motion of the joint; and always finding it easiest in a relaxed posture, keeps it accordingly constantly bent; which generally, in every situation, but more especially in the knee, produces a stiffness or kind of rigidity in all the flexor tendons of the limb. This rigidity of the tendons has by many been considered as an original symptom of the disorder ; but when duly attended to, it will always be found to be rather a consequence of the disease, and to have arisen from the above-mentioned cause. In consequence, too, of the total want of motion, which from this circumstance is always produced, such joints in a very short time generally become quite stiff and immovable, and seem frequently to be in a state of complete and real anchyloses, or stiff. If the disorder, either by nature or by the effects of proper reme- dies, is not now carried off, the swelling, which originally was not perhaps very considerable, begins gradually to augment, and goes on till it sometimes increases to twice, or even thrice the natural size of the part. The cuticular veins become turgid and varicose ; the limb below the swelling decays considerably in its fleshy muscular substance, at the same time that it frequently acquires an equality in point of thick- ness, by becoming cedematous ; the pain turns more intolerable, espe- cially when the patient is warm in bed, or otherwise heated ; and abscesses form in different parts of the swelling, and run in all differ- ent directions, whilst at the same time they frequently do not appear to communicate with one another. In all these abscesses, a fluctuation of a fluid, upon pressure, is generally evident, as is the case in every collection of matter not very White Swelling—(Hydarthus.) 225 deep seated; but, independently of the fluctuation, all such swellings afford a very peculiar elastic feel; yielding to pressure, at the same time that they do not, like oedematous swellings, retain the mark, but instantly rise again as soon as the pressure is removed. These different collections, either upon breaking of themselves, or on being laid open, discharge considerable quantities of matter, which at first is generally purulent, and of a pretty good consistence : it soon, however, degenerates into a thin foetid ill-digested sanies; and has never, at least in proportion to the quantity discharged, any remark- able influence in reducing the size of the swellings, which still retain nearly their former dimensions. If the orifices from which such matters flow are not by art kept open, they very soon heal up; and new collections, forming in different parts, again break out and heal as before. So that, in long continued disorders of this kind, the whole surrounding teguments are often entirely covered with scars that remain after such ulcers. Long before the disorder has arrived at this state, the patient's health has generally suffered considerably; first, from the violence of the pain, which is often so great as to take away entirely both sleep and appetite ; and then, from the absorption of matter into the system, which always takes place in some degree from its first forma- tion in the different abscesses ; but which, indeed, never appears so evidently, till the several collections either burst of themselves or are by incision laid open ; when a quick pulse, night sweats, and a weak- ening diarrhoea, always certainly occur; and generally, at last, carry off the patient, if a cure of the disorder be not otherwise effected. These are the several symptoms of this species of white swelling, in all its different stages. Distinction. The only preternatural affection observed on laying open the swell- ings, is, .a considerable morbid thickness of the surrounding liga- ments, without any disease of the joint whatever ; the bones and car- tilages always remaining perfectly sound, and the synovial fluid in a natural condition both as to quantity and consistence. This thickening of the ligaments, though in general it appears in a greater or less degree, according as the complaint has been of longer or shorter duration, yet we do not find that it always does so; for in some recent instances, the ligaments have appeared more diseased than in others, where the disorder had continued longer. In the former, indeed, the symptoms were always found to have been very violent. In the more advanced stages of the disorder, when abscesses have formed in different parts ; when the pain has been long very violent, with great addition of swelling ; on laying open the parts, the thicken- ing of the ligaments is then found to be more considerable, and is generally, if not always, attended with an effusion, into the surround- ing cellular substance, of a thick glairy matter, which appears to be the cause of that elastic feel peculiar to such swellings, formerly taken notice of in the description. The different abscesses or collections of matter are found to run in 226 White Swelling—(Hydarthus.) various directions through this glairy albuminous congestion, without, however, seeming to mix with it. In some few instances, again, to- gether with collections of pus, a great many small hydatids are observ. ed; and in the farther progress of the disorder, all these together form such a confused mass of different matters and substances, that it is almost impossible, by dissection, to procure a more distinct view of them, than what presents itself on their first being laid open. Even all these appearances exist, without any affection of the bones of the joint; which, together with the surrounding cartilages, upon cutting through the capsular ligaments, remain perfectly sound. When, however, by a very long continuance of the complaint, these ligaments come to be corroded by the different collections of matter, the cartilages, and, in consequence, the bones, are very soon brought to suffer; the latter becoming carious, as soon as the former, by the acrimony of the matter, have been abraded. The tendons of the flexor muscles, which are always, in this disease, as was already mentioned, very stiff and much contracted, do not, upon dissection, exhibit any evidently morbid appearances, either with respect to hardness or enlargement. Of the Symptoms of the more Inveterate or Scrofulous Species of White Swelling. In this species of the disease, the pain is generally more acute than in the other; and, instead of being diffused, it is more confined to a particular spot, most frequently to the very middle of the joint. In some instances, the patients say, they could cover the whole pained part with a small piece. The swelling is at first commonly very inconsiderable ; insomuch that, on some occasions, even when the pain has been very violent, little difference, in point of size, could be observed between the dis- eased joint and the opposite sound one. In this, as in the other species of the disease, the least degree of motion always gives very great pain: so that the joint being here too constantly kept in a bent position, stiffness and rigidity of the tendons come likewise soon to be produced. As the disorder advances, the pain turns more violent, and the swelling becomes more considerable, with an evident enlargement of the ends of such bones as compose the joints. In process of time, the tumour acquires that elastic feel formerly taken notice of, varicose veins appear over its surface, and collections of matter occur in different parts of it. These, upon bursting or being laid open, discharge considerable quantities sometimes of a purulent like matter, but most frequently of a thin foetid sanies; and if a probe be introduced, and can be passed to the bottom of the sores, the bones are found carious, and pieces of them are often discharged at the openings. On the farther continuance of the disorder, the constitution comes here likewise to suffer as in the first species of the disease ; and a diarrhoea, with night sweats, commencing, the patient, though naturally White Swelling—(Hydarthus.) 227 perhaps of the fullest habit, is reduced by loss of flesh to the most extreme weakness. Appearances observed on Dissection, in the Scrofulous Species of White Swelling. When such joints are dissected, either after death, or after ampu- tation of the member in the first stages of the disorder, the soft parts seem to be very little affected : but in all, even the slightest, there was constantly observed an enlargement, either of the whole ends of the bones, or of their epiphyses ; frequently of those on one side of the joint only; in others, again, the bones on both sides have been af- fected. This enlargement sometimes occurs without any other evident dis- ease ; but in general, and always in a more advanced state of the complaint, the soft spongy parts of such bones are found to be dissolv- ed into a thin, fluid, foetid matter; and that too, in some cases, with- out the cartilages which surround them seeming to be affected. In process of time, however, the cartilages come likewise to be dissolved ; and then the different matters, namely, the dissolved bones and softer parts, mixed all together, exhibit, when such swellings are laid open, a still more confused collection than is generally observed, even in the worse stages of the other species of the disorder. Although it was remarked, that in the early periods of the complaint, the surrounding soft parts do not always appear to be much affected ; yet, in its farther progress, they likewise are generally brought to suffer. The ligaments become thickened, and the contiguous cellular membrane filled with that viscid glairy kind of matter we mentioned when speaking of the other species of the disorder. Causes. Having thus given a particular account of the different appearances generally observed in both species of white swelling, we come now, in course, to the consideration of the different causes which-tend to produce them; and, to go on in the same order with the descriptions that have been given, we shall first enumerate those that are particu- larly connected with that which we termed the first, or rheumatic species of the disorder. All such strains may be mentioned as causes, as particularly affect the ligaments of the joints, so as to produce inflammation ; likewise bruises, luxations of the bones, and, in short, every derangement which can in any degree be attended with that effect. A rheumatic disposition may here, too, be taken notice of, as a prin- cipal cause of this species of white swelling ; for, in every rheumatic affection, the parts most liable to be attacked are the ligaments of tho joints, and other deep-seated membranes. The disorders occurring most frequently in the large joints, especially in the knee, is a strong argument, too, for .supposing that the rheumatic disposition has a con- siderable influence in its production; for it is well known that rheu- matism, in its most evident form, does really more frequently attack the larger joints, than any of the smaller: and, in fact, we find this Vol. II. 2 E 228 White Swelling—(Hydarthus.) species of white swelling occurs more frequently in young, pletho- ric people, in whom the rheumatic diathesis or predisposition most frequently prevails, than it ever does in those of an opposite tem- perament. That it is the ligaments of the joints only which are first affected in this disorder, is, from the history of the dissections, rendered evident; these, in the first stages of the complaint, being almost the only parts that are found diseased. The effusions into the cellular membrane, of that thick, glairy matter we have taken notice of, are probably occasioned by an exudation from the vessels of those ligaments that have been originally inflamed, as it is known that such parts never furnish a proper fluid for the formation of purulent matter. In the course of the disease, indeed, abscesses containing real pus do always appear, but never till inflammation has been communicated to the surrounding parts, which more readily afford a fluid proper for this purpose. I would, therefore, upon the whole, conclude, that this species of white swelling is at first always occasioned by an inflammatory, or rheumatic affection of the ligaments of such joints as it attacks, from whatever cause such inflammation may originally have proceeded. The other species of the disorder, from all the symptoms enumera- ted, and from the different appearances on dissection, seems to be an affection of the bones ; the surrounding soft parts coming only to suffer in the progress of the disease, from their connexion with and vicinity to these. This species of white swelling very seldom occurs as the conse- quence of any external accident. It generally begins without the patient's being in the least able to account for it. From the effects usually produced on the bones which it attacks, it would appear to be a species of the real spina ventosa, and which, again, is very probably a disease of the same nature in the bones, that scrofula is of the soft parts. Indeed, the appearances of the two disorders, after making allowances for their different situations, are exceedingly similar; they both begin with considerable enlargements or swellings of the parts they invade, which afterwards, in both too, generally end in evident ulcerations; and they both likewise frequently occur in the same person, and at the same time. It is likewise observed, that this species of white swelling is gene- rally either attended with other evident symptoms of scrofula subsist- ing at the time, or that the patient, in an earlier period of life, has been subject to that disease ; or, what is nearly the same, that he is descended from scrofulous parents, and, consequently, most probably has the see^.s of that disease lurking in his constitution. From all these circumstances, it may, I think, with probability, be concluded, that this species of white swelling is commonly, if not always, of a scrofulous nature : and as it has already been shown, that the other species of the disorder is to be considered as an inflamma- tory, or what we have termed a rheumatic, affection ; and, a thorough distinction of the two different species being, in the treatment, a matter of some importance, it will not here be improper to give a short enumeration of the several diagnostic, or most characteristic symp- toms of each. Wliite Swelling—(Hydarthus.) 229 Discrimination. The pain in the white swellingfrom a rheumatic disposition is always, as was formerly remarked, from the beginning, diffused over the whole joint, and on some occasions extends even a considerable way along the muscles that are attached to it: whereas, in the other species of the disorder, the pain is not only always at first, but sometimes, even when the complaint has been of considerable standing, confined to a very small, circumscribed space. In the former, the swelling is always confined to the soft parts, and is, from the beginning, exceedingly evident: but in the latter there is seldom, for some .time, any perceptible swelling; and, when it does more sensibly appear, the bones are found to be the parts chiefly affected—-the surrounding teguments coming only to suffer on the further progress of the disease. These are the chief local differences of the two species of this disorder; but some assistance in the distinction may likewise be ob- tained from considering the general habit of the patient, and the manner in which the complaint may seem to have been produced. Thus, when such swellings occur in young, strong, plethoric people, and especially in those who have formerly been subject to rheumatism, whether they have been the immediate consequences of external accidents or not, they will most probably always prove to be of the mildest, or rheumatic species of the disorder. Whereas, when swellings of this nature appear in such patients as are otherwise evidently of scrofulous dispositions—where, together with a fine skin and delicate complexion, there are either, on exami- nation, found to be hardened glands in the neck, armpits, or inguina, or it is discovered that the patient may be liable to such complaints from inheritance—when either any or all of these circumstances oc- cur, and if the disorder has begun in the manner formerly described, without any evident external cause, we need be under very little doubt in concluding it to be of a scrofulous nature.—(Bell on Ulcers, p. 274.) Treatment of White Swelling. Common Treatment. Blisters, setons, issues, mercury, amputation, &c. That the reader may have an opportunity of knowing the efficacy of the present practice, I here subjoin the report of B. C. Brodie. From a work called " Morisonia," page 310. Of Tumours, White Swellings, and Diseases of the Joints. " 1 have now before me the work of B. C. Brodie, F. R. S., Professor of Anatomy and Surgery to the Royal College of Surgeons, and Sur- geon to St. George's Hospital, on Diseases of the Joints ; and from the cases stated, a more unsuccessful practitioner never presented himself before the public. One would think this learned and dex- terous surgeon considered it only the patient's wish to have his limbs 230 White Swelling—(Hydarthus.) torn off, or to die a wretched, lingering death. What have his re- searches benefited the world, by his cutting up, dissecting joints, or giving plates of diseased, carious bones ? When once you have im- bibed a true knowledge of disease and of the human body, don't you see the futility of this practice ? and has not experience proved to you the quackery and perniciousness of such medical practice ? With- out entering into this author's mode of treatment, I shall merely lay before the reader the cases stated, and allow him to form his own opinion from them." Case 1. A man with a diseased knee died in two months after ad- mission. 2. A young man, leg amputated after eight months' confinement. 3. A middle-aged man, diseased liver, and swelling of knee : died in two months. 4. A man, forty-seven years of age, after being four months in the hospital, dismissed nearly as well as when he entered. 5. A young lad, after a month, was dismissed as cured. 6. A middle-aged man, after five months' residence in a hospital, was dismissed only better than when he was admitted ; and fifteen months after, he was still a disabled man, not capable of any exertion. 7. A young gentleman, thirteen years of age, treated from July to November, when he was seized with a variety of disorders and died. 8. A man, forty years of age, was treated for months ; dismissed, though not cured : returned again worse than ever. He does not say how it ended. 9. An aged woman was treated a month, and dismissed as cured. 10. A gentleman, of forty-five years, under treatment from 1817 to 1822. At fast, having got vinum colchici, he recovered. 11. A gentleman recovered from vinum colchici. 12. A young lady, felt pain in the thigh and knee ; was put to bed, and fever coming on, died in a week. 13. A middle-aged man, complained of pain in the shoulder; was seized with fever, and died. 14. A diseased knee, sent for examination. 15. A young woman, after five months in the hospital, had her leg amputated. 16. A young man, after two months in the hospital, shared the same fate. 17. A young man, after ten months in the hospital, lost his leg. 18. A boy, of six years, after twelve months in the hospital, leg amputated. 19. A lad, after two years going to and from the hospital, leg am- putated. 20. A young man, leg amputated. 21. An old man, leg amputated. 22. A boy, eleven years, died. 23. A boy, twelve years, died. 24. A middle-aged man, died. 25. A case of examination in a dissecting-room. 26. A boy, ten years, treated from April to October, and died. White Swelling—(Hydarthus.) 231 27. A girl, of seven years, treated four months, and died. 28. A man, treated three months, and died. 29. A young man, treated five months, and died. 80. A young woman, treated three months, and died. 31. A young man, treated four months, and died. 32. A lad, treated three months, and lost his leg. 33. A young woman, treated three months, and lost her leg. 34. A middle-aged woman, treated four months, and lost her leg. 35. A middle-aged man, treated four months, and died. 36. A middle-aged woman, was admitted, and died. 37. A young woman, treated more than a year, recovered a little the use of her knee. " In all, this volume contains sixty-five cases, all terminating in the same unsatisfactory way ; and it is certain that, even in the most fa- vourable cases, not one of them approaches to a radical, perfect cure ; and that if the patients who did not die could be called together and examined, they would declare that their pain and infirmities are far from gone. It is perfectly unnecessary to go through the various treatments, conjectures, and false doctrines set forth in the work— leeching, bleeding, blisters on the part, incisions, cutting out, embro- cations, and a variety of fatiguing nostrums without meaning, and at last amputation;—such are the means of cure recommended. Deluded people ! your lives and comfort sacrificed, by this barbarous science, surgery." Reformed Practice. The numerous cripples that are daily seen, and the amputations that are performed for this complaint, show that the treatment ordi- narily pursued for it is not only ineffectual and injudicious, but ex- ceedingly pernicious and dangerous. And it affords me much pleasure to give a course of treatment which I know by experience to be a most valuable remedy. If the practitioner is called to a case of white swelling in the com- mencement, or in the stage of irritation or inflammation, his first object will be to remove it by resolution, or by such applications and treat- ment as will prevent the second or suppurative stage of the disease ; and this may often be done, provided a very prompt and energetic course be instituted. To fulfil this indication, make use of the fol- lowing fomentation or process of steaming : Take Catnip, (nepeta cataria,) Hearts of mullen, (verbascum nigrum,) Wormwood, (absynthium vulgare,) May-weed, (anthemis cotula,) Two double handfuls of each ; boil them in six quarts of water, to- gether with a pint of soft soap, a sufficient time to obtain the strength of the herbs. Put the part affected over the steam, and cover it closely with a blanket for fifteen or twenty minutes. Immediately after steaming, take a liquid and bathe the disease, made as follows : 232 White Swelling—{Hydarthus.) Take half a gill of spirits, Half an ounce of campltor, A large table spoonful of laudanum, The marrow of three hogs jaws, or, as a substitute, lard or sweet oil. Simmer together on embers. Rub or bathe the swelling, more par- ticularly downwards. The same course to be daily repeated ; and shoukf it not remove the complaint, then apply one of our common strengthening plasters. To aid in redueing the swelling and inflammation, an ointment made by simmering the cicuta leaves in spirits and lard, may be applied three or four times a day, and alternated with the use of the stramonium ointment, made in the same manner. This treatment, with frictions during the day, has been attended with an excellent effect, even without the use of any other medicine. It cured one lady in this city, for which other physicians could not render the least aid or benefit. If it cannot be discussed or dispersed, apply the following poultice: Take of Dandelion roots, (leontodon taraxalum,) Hearts of mullen, (verbascum nigcum,) Catnip leaves and flowers, (liepet. cataria,) Of each, a handful. Bruise or pound the same in a mortar pafter which, boil in sweet milk, until the strength is extracted; then stir in sufficient of the slippery-elm bark, (ulmus fulva,) to make a poultice of the proper consistence ; apply to the parts, tepid or blood warm. Steam or foment, as above directed, in the evening ; and imme- diately after, apply the cataplasm or poultice, which must be kept on during the whole time, or until the swelling suppurates, there is a free discharge of matter, and the inflammation is measurably subsided. After the swelling thus breaks or discharges, apply the following salve: Take the bark of the rocrt of the wild indigo, (podolyria tinctoria,) a bushel; boil till the strength is extracted ; then strain, and again boil and skim. When most of the watery portion of the liquid has evaporated, add fresh butter ten pounds, beeswax three pounds, mutton tallow one pound and a half; simmer till all the water has evaporated; then again strain and skim ; pour into a jar and cover ; it is then fit for use. This forms a beautiful, fragrant and golden coloured salve, which is detergent and healing in its properties. Let it be spread upon a piece of linen or muslin, and laid upon the ulcer ; to be renewed morning and evening. In white swelling, fungus or proud flesh is more apt to arise thap in other ulcers. This arises, probably, from the seat of the disease being probably in the periosteum, and particular attention must be paid to prevent its growth, and to remove it whe:; it is formed. For this purpose, applications very mild may fiist be made, such as the fine powder of blood-root. If this does not remove it, sprinkle a few grains of the vegetable caustic upon it. Should it still remain af- ter these applications, Ferris' plaster must be applied, to which a small quantity of sulphate of zinc, or white vitriol, has been added, in pro- portion of half a drachm or a drachm, pulverized, to an ounce of the plaster, to be well mixed or incorporated together. It should be White Swelling—(Hydarthus.) 233 spread thin, upon a soft piece of leather or linen, and applied to the Bore ; and it may extend a little around the margin or edges of the ulcer. It may be kept on constantly, if the patient does not complain too much ; otherwise let it be occasionally applied, or a sufficient length of time to fulfil the indication required. It has a peculiar ef- fect upon the ulcer, destroying the fungous flesh without exciting in- flammation, by producing a preternatural or greater discharge, which contributes powerfully to heal it. The strength must be regulated according to the feelings of the patient; and it ought to occasion very little if any pain. I have ordered this plaster to be used constantly until the sore was healed, and when it excited any or too much pain or inflammation, have removed it, and substituted the black salve or plaster, and which agrees exceedingly well with the complaint. In some cases it answers a better purpose than the yellow salce above mentioned, and therefore both may be tried and used alternately ; the one that produces the best effects may be constantly applied. Owing to temperament, or idiosyncrasy, what will cure one will exasperate the complaint of another; in consequence of which, we find it advantageous to possess numerous medicinal agents. Sinuses or Openings.—It is often the case that there are little open- ings or sinuses communicating from the surface of the ulcer down to the bone, or into the adjacent parts. When they appear, they should be kept open as long as possible. If they show a disposition to heal, let tents be introduced, on which is put some stimulating article. If they excite too much irritation, let them be removed, and a little lint occasionally crowded in with a probe. Where the parts are not too irritable, stimulating liquids may be injected into the ulcer, such as soapsuds, (Castile soap and soft water,) weak ley, a decoction of wild indigo, &c. I have, generally, however, found the patient unwilling or unable to bear the use of the syringe. Contraction of the Sinews, or Tendons.—In addition to steaming the parts when the limb is contracted, bathe with the following oil. Take Oil of sassafras, " wormwood, " turpentine, Neals-foot oil, Gum camphor, equal parts ; Mix ; rub or bathe the sinews with this oil, or mixture, thoroughly, twice a day, near the fire. Callus.—In almost all cases of white swelling, there is an enlarge- ment, or callus, about the joints; and this often remains after The ulcers have healed, and throws the leg into a state of semiflexion, or such contraction, that the patient cannot touch it to the floor, or ground. To obviate this, in addition to what has been recommended, the above oil should be applied, and friction or rubbing the part three or four times a duy, for half an hour each time ; after which, let a strengthening plaster be applied to the parts. Internal Treatment.—The general health must be attended to. The pale and unhealthy appearance of the countenance of children afflict- ed with white swelling, shows that there i0 a scrofulous or morbid 234 White Swelling—(Hydarthus.) taint of the system; and, therefore, it is of primary importance, while we apply proper local applications, that we improve the condition of the general health. To this end, let a purgative be given, once or twice a week; let the alterative syrup be daily exhibited, according to the age and strength of the patient. The following syrup is also excellent, and which may be used part of the time. Take Yellow dock-root, (rumex crispus,) Sitter-sweet, bark of the root, (solanum dulcamara,) A pound of each; cut or bruise; add a sufficient quantity of water; then boil till the strength is extracted, and simmer till there is two quarts ; add four pounds of loaf sugar. To a child five or six years old, a wine glassful may be given, morning, noon and night. When the pain is very severe, and prevents sleep, let an anodyne be given. This treatment I have found invariably successful where the disease has not proceeded too far, or where the constitution has not been too much undermined. I have successfully treated patients labouring under white swelling, nearly in every stage of the complaint, when all other means have been tried in vain, and wherever the above treatment has been pur- sued, it has been attended Vith the same salutary effects ; and I, therefore, consider it one of the most valuable improvements in medi- cine or surgery. When the patient is labouring under the most excruciating pain, one single process of steaming, or fomenting, in the manner described, usually operates as a charm in allaying pain and inflammation. A part of this treatment, it is stated, came from one of the aborigines of this country, particularly the application of steam to the disease, in the manner here laid down. The other part of it I made use of before I came in possession of the remedy. A brief history of the method of obtaining the information, I will here give, as communicated to me. A person in New-Jersey, travelling in the western states, put up at a tavern in company with an Indian chief, or a number of Indians. They soon heard the groans of a boy, in an adjoining apartment, when one of the Indians inquired into the cause of it. He was told that he was afflicted with a white swelling, which, I think, was stated, had been given up as incurable. The Indian immediately said, if they would follow his directions, he could relieve, or cure him. To this they most cheerfully assented, and the prescriptions soon mitigated the pain, and subsequently proved a sovereign remedy. The woman mentioned above, who was present at the time, obtained the remedy; and such confidence had she in its virtues, after her return home, that she began to use it with great success among her neighbours, not only for white swellings, but for felons, inflammation, &c. Several of my friends spoke in the highest terms of the treat- ment pursued by this woman, and gave the most unequivocal proof and evidence of its efficacy. I did not, however, place much confi- dence in the treatment, from the circumstance that I had so often been deceived in different kinds of nostrums. Besides, the course that I had pursued, in the treatment of white swellings, had generally White Swelling—(Hydarthus.) 235 been successful; and I, therefore, was less anxious to purchase the proposed remedy. After a number of years, the person (Mrs. Moore) concluded to remove a great distance to the west; and a gentleman, a neighbour of hers, who had often witnessed its good effects, being unwilling that it should be lost, purchased the same almost exclusively for my use, and from whom I obtained the recipe; and, upon a fair trial of the course pursued, I find it quite an improvement on my former method. This improvement consists, principally, if not wholly, in the direct application of the steam of stimulating and aromatic herbs, or medicinal plants, with the addition of a part of the ingredients recommended for the poultice. It is impossible for a practitioner truly to appreciate the immediate and sovereign effect of the fomentation made use of, or rather, the effect of the steam or heat, arising from the combination, except they make a trial of it. I have seen the languishing sufferer, nearly worn out with excruciating pain, so suddenly relieved, the transition or change so great, that the patient suspected that a dangerous or fatal dose of opium had been administered. It not only has an astonishing effect upon the parts immediately diseased, but a correspondent, or sympathetic one upon the whole system, and I have found it equally applicable and beneficial in case of felons, inflammations, and other painful diseases. A patient has just called, who has been in great distress with a whitlow or felon, and who had tried a number of applications without much benefit, and to whom I recommended the process of steaming, a day or two ago; but he neglected to do so, apparently from the sup- position that it was too simple to afford any relief, but after repeating to him the necessity of resorting to it, he steamed his hand thoroughly, by throwing the decoction, with the herbs, into a small vessel, placing his hand over it, and retaining the steam by a blanket. He states, that it gave immediate relief, deadening or removing the pain, and pro- ducing a free discharge of matter, and also lessening the swelling or inflammation. I will here give the original formula, or mode of treatment, as I received it. There, probably, has been some alteration from the first that was given. By comparing this, with the treatment I have laid down, the variation made will be seen. 1st. Steaming or Fomentation. Take for the sweat, two double-handfuls of catnip; The same quantity of hearts of mullens; The same quantity of double tansy; The same quantity of wormwood; The same quantity of may-weed; Boil them in six quarts of water, together with a pint of soft soap, a sufficient time to get the strength from the herbs. Put the part affected over the steam, and cover the part closely with a blanket, for fifteen or twenty minutes. Immediately after steaming, take a liquid, and bathe the part affect. ed, made of half a gill of spirits, half an ounce of camphor, a large Vol. II. 2 F 236 While Swelling—(Hydarthus.) table spoonful of laudanum, the marrow of three hogs' jaws, simmered together on embers; apply the liquid, and rub the swelling down- wards. Then apply a poultice, made of one handful of dandelion roots, one handful of the hearts of mullen, the same quantity of catnip. Boil them in sweet milk, and thicken with wheat flour. Steam in the evening, and poultice every morning and evening, until the swelling breaks. After the swelling breaks, apply a salve, made of one handful of English clover, a lump of rosin as large as a walnut, half a pound of sheep's tallow, one handful of bitter-sweet berries; stew slow on embers. Apply the salve twice every day. Take an equal quantity of red precipitate and loaf sugar, with a small lump of charcoal, and powder them, to cleanse the sore of proud flesh. If the sinews should be contracted, take a pint bottle, fill it half full of sweet oil, then fill it with camomile flowers. Let it hang in the sun for three days, taking it in every evening. Rub the sinews with it, twice every day, hard, and heat it in with a hot iron* CHAPTER XVI. venereal disease—{Lues Venerea—Syphilis.) Description. This is a most loathsome affection, which extends to every part of the system, and is occasioned by a specific poison, conveyed by con- tagion or actual contact. It acts both locally and constitutionally. History. About the year 1494, or 1495, the venereal disease is said to have made its first appearance in Europe. Some writers believe that it originally broke out at the siege of Naples ; but most of them suppose that, as Columbus returned from his first expedition to the West Indies, on March 13th, 1493, his followers brought the disorder with them from the new to the old world. Other authors, however, among whom are Mr. Beckett, (Phil. Trans, vols. xxx. and xxxi.) Mr. B. Bell and Dr. Swediaur, maintain the opinion, that the venereal disease was well known upon the old continent, and that it prevailed among the Jews, Greeks and Romans, and their descendants, long before the discovery of America. Another doctrine, not entirely destitute of ingenious arguments, and even containing many valuable truths, is, that the venereal disease, as it is considered in modern times, has no real existence as a distinct affection, arising from any particular virus, but is a name given to an assemblage of disorders of different kinds, to which the human race have always been subjected, from time immemorial.—(See a tract entitled, "Sur la Non-existence de la Ma- ladie Ve'ne'rienne," 8vo. Paris, 1811.) One writer of high reputation believes, that, though syphilis was brought to Europe by the followers of Columbus, there existed, previously to that event, throughout the old continent, venereal disorders, both local and constitutional, which strongly resembled the newly-imported disease, and were for more than three centuries confounded with it.—(12. Carmichael on Venereal Diseases, p. 33. 8vo. London, 1825, 2d ed.) Mr. Bacot has bestowed great pains on an examination of all the passages in old works, affording any ground for the opinion, that syphilis existed in ancient times. He finds in them allusions to many local complaints of tho genitals, warts, discharges, ulcers, pustules, &c, sometimes clearly ascribed to impure coition, but no distinct reference to any constitu- tional symptoms. " Surely," says he, " I may be allowed to say, that, if there is any historical fact that can be said to be proved, it is that of the origin of syphilis being referable to the latter years of the fifteenth century; for I cannot understand otherwise, why, at that precise period, we all at once hear of ulcers on the parts of generation 238 Venereal Disease—(Lues Venerea—Syphilis.) in both sexes, followed speedily by excruciating nocturnal pains, by corroding ulcers over the whole body, by affections of the throat and nose, and very frequently by death—when not one word that can be construed into any similar affection is to be met with distinctly stated by any writer before that period."—(J. Bacot, in Med. Gazette, vol. ii. p. 100.) But, while thjs writer will not admit the truth of the exist- ence of the venereal disease in times of antiquity, he allows that a disorder resembling gonorrhoea has been known from the remotest periods of history. Although many considerations lead me to coincide with Hunter, Sprengel, Pearson and Bacot, in rejecting the common history of syphilis, as fabulous—I mean that account which refers its origin to America, or the French army in Italy—it does not appear to me that any utility would be likely to result from agitating this question in modern times ; because, if ft be true, as the most candid and intelli- gent surgeons of the present day generally acknowledge, that they cannot precisely define what the venereal disease is, nor always point out the exact circumstances in which it differs from some other anomalous complaints, even when the cases are before their eyes, how can such discrimination be attempted from a mere review of old descriptions, not accompanied with the advantage of a view of the living patients themselves? But, as far as the nature of the venereal disease has been unravelled, and it is allowable to judge from such comparisons, I may be permitted to remark, that, in degree of severity, acutcness of symptoms, rapidity of propagation, and extent and quick- ness of fatality, no forms of disease, however conjectured to be vene- real, bear the least resemblance to the destructive malady with which the army before Naples was afflicted, at the close of the fifteenth century ; nor will any ignorance of the uses of mercury, as will be presently noticed, explain differences so strongly marked. With reference to the contagious disorder which scourged a great part of Europe, at the close of the fifteenth century, there is a decree of the parliament of Paris, dated 1496, in which the disease is mentioned to have been then prevalent in that city two years ; consequently, it was known there in 1494 : yet the conquest of Naples, by Charles VIII., was not effected till 1495. It is clear, therefore, that the disease hero alluded to could not have been derived from America. It appears to have been communicated from one person to another by the mere touch, residence in the same chamber, &c.: and, in fact, unless some other mode of propagation, besides coition, be supposed, its extension throughout Europe in two years would imply a depravity of manners quite extraordinary, and beyond all credibility. Another fact is, that, whatever the disorder might be, it was not of long continuance ; and Guieciardini, the historian, who wrote a few years after its breaking ouf, assures us, that it had already become much milder, and under- gone, of itself, a change into kinds different from the first. Dr. Steward supposes that this disease originated in the camp of Israel, as may be inferred by reading the fifth chapter of Numbers. No doubt it was first inflicted upon mankind, as a curse, in conse- quence of departing from moral rectitude, or the law of God. Venereal Disease—(Lues Venerea—Syphilis.) 239 Causes. The venereal disease is supposed to arise from a specific morbid poison, which, whon applied to the human body, has the power of propagating or multiplying itself, and is capable of acting both locally and constitutionally. Mr. Hunter was of opinion, that the effects produced by the poison arise from its peculiar, or specific irritation, joined with the aptness of the living principle to be irritated by such a cause, and the parts so irritated acting accordingly. Hence he considered that the vene- real virus irritated the living parts in a manner peculiar to itself, and produced an inflammation peculiar to that irritation, from which a matter is produced, peculiar to the inflammation. The venereal poison is capable of affecting the human body in two different ways: locally, that is, in those parts only to which it is first applied ; and constitutionally, that is, in consequence of its absorption. In whatever manner the venereal disease was first produced, it began, says Mr. Hunter, in the human race, as no other animal seems capable of being affected by it. He conceives, also, that the parts of generation were those first affected; for if the disease had taken place on any other part, it would not have gone farther than the person in whom it first arose. On the contrary, if the disease, in the first instance of its formation, be presumed to have attacked the parts of generation, where the only natural connexion takes place between one human being and another, except that between tho mother and child, it was in the most favourable situation for being propagated ; and Mr. Hunter infers, also, that the first effects of the disease must have been local, in consequence of the fact, now well established, that none of the constitutional effects are communicable to other persons; that is to say, infectious. Thus, the numberless cases of the venereal disease, afflicting generation after generation, and observable in all the known parts of the world, are supposed to be originally derived from the amours of some unfortunate individual, in whom the poison was first formed, from causes beyond the reach of human investigation. Every modern speculation about the origin of the distemper promises but little in- struction or success; because the question relates to a disease, the diagnosis of which is still very unsettled, and the complete definition of which has hitherto baffled men of the greatest genius and experience. According to Mr. Hunter, the venereal poison is commonly in the form of pus, or some other secretion. In most cases, it excites an in- flammation, which (to use the same author's language,) is attended with a specific mode of action, different from all other actions attending inflammation, and accounting for the specific qualities in the matter. 1st. Gonorrhoea. Symptoms. Gonorrhoea is a discharge resembling pus or matter from the urethra, with heat of urine, &c, after impure coition, to which often succeeds 240 Venereal Disease—(Lues Venerea—Syphilis.) a discharge of mucus from the urethra, with little or nodysury, called a gleet. This disease is also called Fluor albus malignus. Blennor- rhagia, by Swediaur. In English, a clap, from the old French word clapises, which were public shops, kept and inhabited by single pros- titutes, and generally confined to a particular quarter of the town, as is even now the case in several of the great towns in Italy. In Ger- many, the disease is named tripper, from dripping ; and in French, chaudpisse, from the heat and scalding in making water. No certain rule can be laid down with regard to the time that a clap will take before it makes its appearance, after infection has been con- veyed. With some persons it will show itself in the course of three or four days, while with others there will not be the least appearance of it before the expiration of some weeks. It most usually is perceptible, however, in the space of from six to fourteen days, and in a male, be- gins with an uneasiness about the parts of generation, such as an itching in the glans penis, and a soreness and tingling sensation along the whole course of the urethra; soon after which, the person per- ceives an appearance of whitish matter at its orifice, and also some degree of pungency upon making water. In the course of a few days, the discharge of matter will increase considerably ; will assume, most probably, a greenish or yellowish hue, and will become thinner, and lose its adhesiveness ; the parts will also be occupied with some degree of redness and inflammation, in consequence of which the glans will put on the appearance of a ripe cherry, the stream of urine will be smaller than usual, owing to the canal being made narrower by the inflamed state of the internal membrane, and a considerable degree of pain and scalding heat will be experienced on every attempt to make water. Where the inflammation prevails in a very high degree, it prevents the extension of the urethra, on the taking place of any erection, so that the penis is, at that time, curved downwards, with great pain, which is much increased if attempted to be raised towards the belly ; and the stimulus occasions it often to be erected, particularly when the patient is warm in bed, and so deprives him of sleep, producing, in some cases, an involuntary emission of semen. In consequence of the inflammation, it sometimes happens that, at the time of making water, owing to the rupture of some small blood vessel, a slight haemorrhage ensues, and a small quantity of blood is voided. In consequence of inflammation, the prepuce likewise be- comes often so swelled at the end, that it cannot, be drawn back, which symptom is called a phimosis ; or, that being drawn behind the glans, it cannot be returned, which is known by the name of paraphi- mosis. Now and then, from the same cause, little hard swellings arise on the lower surface of the penis, along the course of the urethra, and these perhaps suppurate and form into fistulous sores. The adjacent parts sympathizing with those already affected, the bladder becomes irritable, and incapable of retaining the urine for any length of time, which gives the patient a frequent inclination to make water, and he feels an uneasiness about the scrotum, perinaeum and fundament. Moreover, the glands of the groins grow indurated and enlarged, or perhaps the testicles become swelled and inflamed, Venereal Disease—(Lues Venerea—Syphilis.) 241 in consequence of which he experiences excruciating pains, extending from the scat of the complaint up into the small of the back, he gets hot and restless, and a small symptomatic fever arises. Where the parts are not occupied by much inflammation, few or none of the last mentioned symptoms will arise, and only a discharge with a slight heat or scalding in making water will prevail. If a gonorrhoea be neither irritated by any irregularity of the pa- tient, nor prolonged by the want of timely and proper assistance, then, in the course of about a fortnight or three weeks, the discharge, from having been thin and discoloured at first, will become thick, white, and of a ropy consistence ; and from having gradually begun to di- minish in quantity, will at last cease entirely, together with every in- flammatory symptom whatever ; whereas, on the contrary, if the patient has led a life of intemperance and sensuality, has partaken freely of the bottle and high-seasoned meats, and has, at the same time, neglected to pursue the necessary means, it may then continue for many weeks or months ; and, on going off, may leave a weakness or gleet behind it, besides being accompanied with the risk of giving rise to a constitutional affection, especially if there has been a neglect of proper cleanliness ; for where venereal matter has been suffered to lodge between the prepuce and glans penis for any time, so as to have occasioned either excoriation or ulceration, there will always be danger of its having been absorbed. Another risk, arising from the long continuance of a gonorrhoea, especially if it has been attended with inflammatory symptoms, or has been of frequent recurrence, is the taking place of one or more strictures in the urethra. These are sure to occasion a considerable degree of difficulty, as well as pain, in making water, and, instead of its being discharged in a free and uninterrupted stream, it splits into two, or perhaps is voided drop by drop. Such affections become, from neglect, of a most serious and dangerous nature, as they not unfre- quently block up the urethra, so as to induce a total suppression of urine. Where the gonorrhoea has been of long standing, warty excres- cences are likewise apt to arise about the parts of generation, owing to the matter falling and lodging thereoji; and they not unfrequently prove both numerous and troublesome. Having noticed every symptom whicn usually attends on gonorrhoea in the male sex, it will only be necessary to observe, that the same heat and soreness in making water, and the same discharge of dis- coloured mucus, together with a slight pain in walking, and an uneasi- ness in sitting, take place in females, as in the former ; but as the parts in women which are most apt to be affected by the venereal poison, are less complex in their nature, and fewer in number, than in men, so of course the former are not liable to many of the symptoms which the latter are ; and, from the urinary canal being much shorter, and of a more simple form, in them than in men, they are seldom, if ever, incommoded by the taking place of strictures. With women, it indeed often happens, that all the symptoms of a gonorrhoea are so very slight, they experience no other incouvenience than the discharge, except, perhaps, immediately after menstruation, at 242 Venereal Disease—{hues Venerea—Syphilis.) which period it is no uncommon occurrence for them to perceive some degree of aggravation in the symptoms. Women of a relaxed habit, and such as have had frequent miscar- riages, are apt to be afflicted with a disease known by the name of fluor albus, which it is often difficult to distinguish from gonorrhoea virulenta, as the matter discharged in both is, in many cases, of the same colour and consistence. The surest way of forming a just con- elusion, in instances of this nature, will be to draw it from an accurate investigation, both of the symptoms which are present and those which have preceded the discharge ; as likewise from the concurring cir- cumstances, such as the character and mode of life of the person, and the probability there may be of her having had venereal infection conveyed to her by any connexion in which she may be engaged. Not long ago, it was generally supposed that gonorrhoea depended always upon ulcers in the urethra, producing a discharge of purulent matter ; and such ulcers do, indeed, occur, in consequence of a high degree of inflammation and suppuration ; but many dissections of persons who have died while labouring under a gonorrhoea, have clearly shown that the disease may, and often does, exist without any ulceration in the urethra, so that the discharge which appears is usual- ly of a vitiated mucus, thrown out from the mucous follicles of the urethra. On opening this canal, in recent cases, it usually appears red and inflamed; its mucous glands are somewhat enlarged, and its cavity is filled with matter to within a small distance from its extremity. Where the disease has been of long continuance, its surface all along, even to the bladder, is generally found pale and relaxed, without any erosion. 2d. Chancre. From absorption of the venereal poison, little eruptions, scabs and ulcers arise on different parts of the head of the penis. It begins usually with an itching in the part. A small pimple, full of matter, generally arises, without much hardness, or apparent inflammation or swelling. The itching is gradually changed into pain, and is con- verted into an ulcer. Its base is hard, and the edges a little promi- ncnt. When it begins on thg fraenum, or near it, that part is very commonly destroyed, or a hole is made in it by ulceration. When the disease is more advanced, inflammation is apt to take place. When the pain is severe, Mr. Hunter remarks, there is a strong disposition to irritation. Chancres also, sometimes, soon begin to slough, there being a strong tendency to mortification. Here he probably adverts to what are now usually called phagedenic sores, and frequently believed to differ from the truly venereal chancre. It is also observed by Hunter, that when there is a considerable loss of substance, either from sloughing or ulceration, a profuse bleed- ing is no uncommon circumstance, more especially when the ulcer is on the glands. The adhesive inflammation does not appear to take place sufficiently to unite the veins of this part of the penis, so as to prevent their cavity from being exposed, and the blood escapes from the corpus spongiosum urethrae. The ulcers or sloughs often extend Venereal Disease—(Lues Venerea—SyphUis.) 248 as deeply as the corpus cavernosum penis* and similar bleedings are the consequence. With respect to chancres in women* the labia and nymphae, like the glans penis in men, are subject to ulceration, and the ulcerations are generally more numerous in females than males, in consequence of the surface on which the sores are liable to form being much larger. As Hunter observes, chancres are occasionally situated on the edge of the labia ; sometimes on the outside of these parts; and even on the perinaeum. When the sores are formed on the inside of the labia or nymphae, they can never dry or scab ; but when they are externally situated, the matter may dry on them, and produce a scab, just as happens with respect to chancres situated on the scrotum or body of the penis. The venereal matter from these sores is apt to run down the peri- naeum to the anus, and excoriate the parts, especially about the anus, where tho skin is thin, and where chancres may be thus occasioned. Chancres have been noticed in the vagina; but Mr. Hunter sus- pected that they were not original ones, but that they had spread to this situation from the inside of the labia. Before any of the virus has been taken up by the absorbents and conveyed into the circulation, a chancre is entirely a local affection. From the Hunterian doctrines, however, it would appear, that absorp- tion must generally soon follow the occurrence of the sore; and all the modern opinions concerning the nature of ulceration itself,would lead to the same inference. Some persons appear much more susceptible of the effects of the venereal disease than other individuals. It is re- marked by Hunter, that the interval between the application of tho poison, and its effects upon the parts, is uncertain; but that, on the whole, a chancre is longer in appearing than a gonorrhoea. However, the nature of the parts affected make some difference. When a chancre occurs on the fraenum or at the termination of the prepuce in the glans, the disease in general comes on earlier; these parts being more easily affected than either the glans penis, common skin of this organ, or the scrotum. He adds, that in some cases in which both the glans and prepuce were contaminated from the same application of the poison, the chancre made its appearance earlier on the latter part. Hunter knew of some instances in which chancres appeared twenty- four hours after the application of the matter; and others, in which an interval of seven weeks, and even two months, elapsed, between the time of contamination and that when the chancre commenced. However, here, as in almost all other statements about this perplexing subject, we never know with certainty that the writer has sufficient grounds for the assumed fact, that it is only one kind of poison which is spoken of.—(Thomas.) 3d. Bubo. When the venereal poison is suffered to take its natural course, the absorbents take it up, and it becomes located in the glandular system, and the first part usually attacked, is the inguinal gland, or the groin. Between a local and constitutional affection, there often arises a kind Vol. II. ' 2 G 244 Venereal Disease—(Lues Venerea—Syphilis.) of intermediate state; and that, in consequence of an absorption of venereal matter from some surface to which it has been applied, the glands situated nearest to the parts thus affected are apt to become indurated, swelled and inflamed, and so to give rise to a bubo ; and the parts of generation usually coming first in contact with the matter, so the glands in tho groins are the most general seat of this particular symptom. In most cases the syphilitic virus is absorbed from a chan- cre or ulcer in the urethra ; but instances have occurred where a bubo has arisen without either gonorrhoea, or any kind of ulceration, and the matter appears to have been absorbed without any evident erosion of the skin or of the mucous membrane. A bubo comes on with a pain in the groin, accompanied with some degree of hardness and swelling, and is at first about the size of a kidney-bean, but continuing to increase, it at length becomes as large as an egg, occasions the person to experience some difficulty in walk- ing, and is attended with a pulsation and throbbing in the tumour, and a great redness of the skin. In some cases, the suppuration is quickly completed ; in others, it goes on very slow ; and in others again, the inflammatory appearances go off without any formation of pus. In a few instances the glands have been known to become scirrhous. As many other swellings in the groin, such as a rupture, aneurism, ■ lumbar abscess and scirrhous affection of the glands may be mistaken for a bubo, it will always be advisable, in doubtful cases, to inquire whether or not the patient has lately been afflicted either with a gonor- rhoea or chancre ; and whether or not he has lately laboured under any other complaint that might have given rise to the swelling. It may likewise be advisable to attend to the progress which the tumour has made. By a due consideration and investigation of these circum- stances, we cannot fail to form a just conclusion as to the real nature of the disease. The following are the characteristics of a venereal bubo: the swelling is usually confined to one gland; the colour of the skin where inflammation prevails is of a florid red ; the pain is very acute ; the progress from inflammation to suppuration and ulceration is generally very rapid ; the suppuration is large in proportion to the size of the gland ; and there is only one abscess. A bubo is never attended with danger where the inflamed gland proceeds on regularly to suppuration ; but in particular cases it ac- quires an indolence after coming to a certain length, arising from a scrofulous taint; or, by being combined with erysipelas, it termi- nates in a phagedenic ulceration, and occasions a great loss of sub- stance. This termination is, however, more frequently met with in hospitals than in private practice, and may partly be attributed to the contaminated state of the air of the wards wherein syphilitic patients are lodged. The many inconveniences that ensue from allowing a venereal bubo to suppurate, should induce the practitioner to exert his utmost en- deavours to prevent it from proceeding to such a state, and to occasion its speedy resolution or dispersion, if possible. Venereal Disease—(Lues Venerea—Syphilis.) 245 4th. Constitutional Disease—(Lues Venerea.) A constitutional taint is the third form under which it has been mentioned that the syphilitic poison is apt to show itself, and which always arises in consequence of the matter being absorbed, and car- ried into the circulating mass of fluids. The absorption of it may, however, take place in three ways:— 1st, It may be carried into the circulation without producing any evident local effect on the part to which it was at first applied : 2dly, It may take place in consequence of some local affection, such as either gonorrhoea, chancre, or bubo : and, 3dly, It may ensue from an application of the matter to a common sore or wound, similar to what happens in inoculating for the small- pox. The most general way, however, in which a constitutional taint is produced, is by an absorption of the matter, either from a chancre or bubo. When syphilitic matter gets into the system, some symptoms of it may often be observed in the course of six or eight weeks, or probably sooner ; but in some cases it will continue in the circulating mass of fluids for a few months before any visible effects are produced. The system being completely contaminated, it then occasions many local effects in different parts of the body, and shows itself under a variety of shapes, many of which put on the appearance of a distinct disease. We may presume that this variety depends wholly on the difference of constitution, the different kinds of parts affected, and the different state these parts were in at the time the matter or poison was applied. The first symptoms usually show themselves on the skin, and in the mouth and throat. When the matter is secreted principally in the skin, reddish and brownish spots appear here and there on its surface, and eruptions of a copper colour are dispersed over different parts of the body, on the top of which there soon forms a thick scurf or scale. This scurf falls off after a short time, and is succeeded by another; and the same happening several times, and at length casting off deep, an ulcer is formed, which discharges an acrid fetid matter. When the poison is secreted in the glands of the throat and mouth, the tongue will often be affected, so as to occasion a thickness of speech: and the tonsils, palate and uvula will become ulcerated, so as to produce a soreness and difficulty in swallowing, and likewise a hoarseness in the voice. The tonsils are more usually affected with syphilitic ulceration than the uvula or velum palati, though the affection may spread to these from the tonsils. The ulcer of the latter is an excavation, as if a piece was scooped out; the sore has an uneven, jagged, foul appear- ance, with an erysipelatous redness on a hard, elevated, defined border ; the ulcer is commonly covered with a whitish or brown slough ; it is progressive, and, like the rest of the syphilitic symptoms, it is not curable by the powers of the constitution. Generally there is not much pain nor much enlargement attendant on this form of the 246 Venereal Disease—(Lues Venerea—Syphilis.) disease ; in other respects tho sensations do not materially differ from those produced by ulceration of the throat proceeding from other causes. If tho disease affects the eyes, obstinate inflammation and some- times ulceration, will also attack these organs. The matter sometimes falls on deep-seated parts, such as tho ten- dons, ligaments and periosteum, and occasions hard, painful swellings to arise, known by the name of nodes. When the disease is suffered to proceed, and is not counteracted by proper remedies, the patient will, in the course of time, be afflicted with severe pains, but more particularly in the night-time ; his coun- tenance will become sallow; his hair will fall off; he will lose his appetite, strength and flesh ; his rest will be much disturbed by night, and a small fever of a hectic kind will arise. The ulcers in the mouth and throat being likewise suffered to spread, and to occasion a caries of the bones of the palate, an opening will be made from the mouth to the nose ; and, the cartilages and bones of the nose being at length corroded away, this will sink to a level with the face. It now and then occurs that primary symptoms followed by second- ary ones present themselves, all closely imitating syphilis in its pri- mary and secondary stages, and yet are not venoreal. Symptoms resembling the secondary appearances of syphilis occur also without any preceding primary symptom, and turn out not to be venereal. In some of the cases, the symptoms go off, and the patient gets well without any remedy : in others, common alteratives have subdued the complaint. These complaints resembling the venereal disease, have been called by the name of cachexia syphiloidea, or pseudo-syphilis. Hunter* has remarked, that undescribed diseases, resembling the venereal one, were numerous ; and Abernethyf has drawn the atten- tion of medical men by his remarks on diseases resembling syphilis. Some constitutions will bear up for a considerable time against the disease, while others again will soon sink under the general weakness and irritation produced by it. If the disorder is recent, and the con- stitution not impaired by other diseases, a perfect cure may easily be effected ; but where it is of long standing, and accompanied with the symptoms of irritation which have been mentioned, the cure will prove tedious, and in many cases uncertain, as the constitution and strength of the patient may not admit of his going through a course of medicine sufficient to destroy the poison. Dissection. The general appearances to be observed on dissections of those who die of lues, are caries of the bones, but more particularly those of the cranium, often communicating ulceration to the brain itself; together with enlargements and indurations of the lymphatic glands, scirrhus of several of the organs, particularly the liver and lungs, and exostosis of many of the hartlesf bones. See his Treatise on the Venereal Disease, r See his Surgical Obporrations Venereal Disease—(Lues Venerea—Syphilis.) Common Treatment. Mercury is almost exclusively relied on by physicians, in all its different stages, and it was formerly the practice to salivate most profusely for this disease ; so much so, that the supposed remedy was much worse than the complaint itself, with all its horrors ; but modern practitioners prescribe mercury in such a manner, that its effects are not so extensive and mischievous upon the system; although they frequently salivate, and cause a shocking state of the system, yet, in general, they withhold this mineral before these serious symptoms make their appearance. At any rate, this is the avowed design in prescribing it by the more judicious part of the faculty; but, so un- manageable, so uncontrollable and uncertain is the operation of mer- cury, in different habits, that there is no reliance to be placed upon its effects. The physician cannot rely with any degree of certainty upon fulfilling one single indication- Owing to temperament, and the peculiar state of the system, the physician is often sadly disappointed, or most egregiously mistaken, when he gives it. Oftentimes a single dose will cause a free salivation, and produce a universal derangement of the system, and the pre- scriber has the mortification to hear the anathemas of the patient hurled against him at every visit. And what else can he expect from such a deadly poison, from such a disease creating agent. The use of this metal, says Dr. Chapman, however cautiously administered, sometimes acts as a poison. When I was an articled student at St. Bartholomew's Hospital, says Dr. Cooper, most of the venereal patients in that establishment were seen with their ulcerated tongues hanging out of their mouths ; their faces prodigiously swelled; and their saliva flowing out in streams. The wards were not sufficiently ventilated, and the stench was so great that the places well deserved the appellation of foul. Yet, notwithstanding mercury was thus pushed, (as the favourite ex- pression was,) it was then common to sec many patients suffer the most dreadful mutilations, in consequence of sloughing ulcers of tho penis ; many unfortunate individuals, whose noses and palates were lost; and others who were afflicted with nodes and dreadful phage- denic sores. Setting aside the unpleasant and injurious effects to which mercury subjects the venereal patient, there are other considerations of para- mount importance for entirely dispensing with it; which is principally the fact that no preparation of mercury whatever, according to the ex- perience and observation that 1 have had, (and it has not been very limited,) has any power directly or indirectly, of curing the disease in any stage of it; but, on the contrary, often exasperates, protracts the cure, and brings on the mercurial disease, which is much worse than any form of syphilis. It is frequently, itself, a source of cutaneous diseases, sore throats, and symptoms which, without its baneful influ- ence, would never have occurred. Is it not a startling fact, that this has never been discovered, with all the boasted learning and improvement of physicians ? All their S48 Venereal Disease—{Lues Venerea—Syphilis.) talents have been engaged to ascertain whether the venereal disease can be cured without mercury, whereas they have never yet learned, it appears, that it never was cured with it. When Doctor Alexander H. Stevens first commenced his surgical course in the University of the State of New-York, I attended his lectures ; and I recollect that he remarked, when speaking of the treatment of venereal disease, as follows : said he, " Gentlemen, I know not what to say to you on the use of mercury in the venereal disease ; the whole medical world has been upset within a few years." He then went on to state the experiments which had been tried in Europe, in the military hospitals,which went to establish the fact, that in an equal number of venereal patients treated with and without mercury, those recovered the most speedily who did not submit to a course of mercury, and were treated merely by cleanliness, rest and absti- nence, with the most simple and mild dressings. Further to illustrate or corroborate what I have here stated, I shall give some observations and experiments made by British practition- ers. Dr. Fergusson assures us that, in Portugal, the disease, in its pri- mary state among the natives, is curable without mercury, and by simple topical .reatment; that the antisyphilitic woods, combined with sudorifics, are an adequate remedy for constitutional symptoms; and that th virulence of the disease has there been so much miti- gated, that, after running a certain course (commonly a mild one) through the respective orders of parts, according to the known laws of its progress, it exhausts itself and ceases spontaneously.—(See Med. and Chir. Trans, vol. iv. p. 2—5.) In the third edition of the First Lines of the Practice of Surgery, it was sufficiently proved, from se- veral conclusions drawn from the writing of Mr. Pearson, (Obs. on the Effects of various Articles in the Cure of Lues Venerea,) that vene- real sores might be benefited, and even healed, under the use of seve- ral inert insignificant medicines. And the possibility of curing chancres and other venereal complaints without mercury, was long since remarked by Dr. Clutterbuck, who thence very justly inferred, that the healing of a sore without this remedy, was no test that it was not venereal.—(See Remarks on the Opinions of the late John Hunter, 1799.) But although the whole history of the venereal disease, and of the various articles of the materia medica, if carefully reflected upon, must have led to the same conclusion, the truth was never placed in such a view as to command the general belief of all the most expe- rienced surgeons in this and other countries of Europe. I do not mean to say that the truth was not seen and remarked by several of the older Writers ; for, that it was so, any man can convince himself by referring to several works quoted. But it is to be understood, all in- decision could never be renounced as long as prejudices interfered with the only rational plan which could be adopted, with a view of bringing the question to a final settlement; I mean experiments on a large and impartial scale, open to the observation of numerous judges, yet under such control as insured the rigorous trial of the practice. Nor could such investigation be so well made by any class of prac- Venereal Disease—(Lues Venerea—Syphilis.) 249 Irtioners as the army surgeons, whose patients are numerous, obliged to follow strictly the treatment prescribed, without any power of go- ing from hospital to hospital, or from one surgeon to another, as ca- price may dictate, or of eluding the observation of the medical attend- ants after a seeming recovery. And here I must take the opportunity of stating, that as far as my judgment extends, the most important and cautious document yet extant, on the two questions of the possi- bility and expediency of curing the venereal disease without mercury, is the paper of Mr. Rose. At the time when Mr. Rose published his observations, he had tried the non-mercurial treatment in the Cold- stream regiment of Guards, during a year and three quarters, and had thus succeeded in curing all tlve ulcers on the parts of generation, which he met with in that period, together with the constitutional symptoms to which they gave rise. " I may not be warranted in asserting (says this gentleman) that many of ,these were venereal; but undoubtedly a considerable number of them had all the appearances of primary sores, produced by the venereal virus, and arose under circumstances where there had been at least a possibility of that virus having been applied. Admitting that there is nothing so characteristic in a chancre as to furnish incontrovertible proof of its nature, it will yet be allowed, that there are many symptoms common to such soref, although not entirely peculiar to them, and whenever these are met with, tn>.r. re strong grounds to suspect that they are the effects of tho, fcypiuhtic virus. In a sore, for instance, appearing shortly after suspicious connexion, where there is loss of substance, a want of disposition to granulate and an indurated margin and base, there is certainly a pro- bability of that poison being present. Among a number of cases of such a description, taken indiscriminately, the probability of some being venereal is materially increased, and must at last approach nearly to a certainty. On this principle, some of the sores here re- ferred to must have been venereal. They were also seen by differ- ent surgeons, on whose judgment I would rely, who agreed in consi- dering many of them as well-marked cases of true chancre.—(Rose, in Med. Chir. Trans, vol. viii. p. 357, &c.) The men thus treated were examined almost every week for a considerable time after their apparent cure, " both that the first approach of constitutional symp- toms might be observed, and that any deception from an underhand use of mercury might be guarded against."—(p. 359.) Sixty cases of ulcers on the penis were also cured by Dease in the York Hospi- tal, by means of simple dressings, the only general remedy being occasional purgatives. The practice was likewise extensively tried by Whymper aud Good, surgeons of the Guards, with the same kind of success. In Mr. Rose's practice, all idea of specific remedies was entirely laid aside. The patients were usually confined to their beds, and such local applications were employed as the appearances of the sores seemed to indicate. Aperient medicines, bark, vitriolic acid, and occasionally sarsaparilla, were administered. —(p. 363.) " Upon an average, (says Mr. Rose,) one out of every three of the sores thus treated, was followed by some form or other of constitutional affection : this was in most instances mild, and sometimes so slight that it would have escaped notice, if it had not been carefully sought for. The 260 Venereal Disease—(Lues Venerea-^Syphilis.) constitutional symptoms were evidently not such as could be regarded as venereal, if we give credit to the commonly received ideas on tho subject. Caries of the bones, and some of the least equivocal symp- toms, did not occur. In no instance was there that uniform progress, with unrelenting fury, from one order of symptoms and parts affected to another, which is considered as an essential characteristic of true syphilis."—(Med. Chir. Trans, vol. viii. p. 422.) The constitutional symptoms also yielded, without the aid of mercury; and frequently primary sores, corresponding to what had been called the true chancre, with indurated base, were cured in this manner,yet were followed by no secondary symptoms. We are also informed, that " several cases occurred of a cluster of ill-conditioned sores over the whole inner surface of the prepuce : and behind the corona glandis; and also of a circle of small irritable sores, situated on the thickened and con. traded ring at the extreme margin of the prepuce. These occasion. ally produced buboes." None of the sores of this description, met with by Mr. Rose, were followed by any constitutional affection.—(Vol. cit. p. 370.) He bears testimony to the ill effects of mercury and stimulants in cases of phagedenic ulcers, and confirms a not uncommon opinion, that they are seldom followed by secondary symptoms, which opinion should be qualified with the condition mentioned by Mr. Guthrie, (Med. Chir. Trans, vol. viii. p. 565.) that no mercury be given. Lastly, as I have already stated, Mr. Rose observed, that most of the cases of papular eruptions followed ulcers, which were not very deep, and healed without much difficulty.—(p. 399.) The fact of the possibility of curing every kind of ulcer on the ge. nitals without mercury, has been fully confirmed by the statements of Mr. Guthrie, (Med. Chir. Trans, vol. viii. p. 558. 576.) Dr. J. Thomson, (Edin. Med. and Surg. Journ. for January, 1818,) Dr. Hennen, (Op. cit. Nos. 54 and 55, and Principles of Military Surgery, 2ded.,) Mr. Bacot, (On Syphilis, p. 26, &c.,)and many other careful observers. Respecting the comparative quickness of the cures of chancres, or reputed chancres, without the aid of mercury, much disagreement prevails in the different reports, even those collected by the same in- dividuals, whose statements must therefore be deemed perfectly im- partial, though inconclusive.—(See Hennen's Military Surgery, 2d ed. p. 536, &c.) Some of Mr. Rose's best marked cases of chancre, that is to say, such as were distinguished by the indurated base and circumference, healed in a very short time. But even respecting these, or any other kinds of chancre, no regularity on this point can be found. Mr. Guthrie observes, if the " ulcers were not without any marked appearance, and did not amend in the first fortnight or three weeks, they generally remained for five or seven weeks longer; and the only difference in this respect between them and the raised ulcer of the prepuce was, that this often remained for a longer period, and that ulcers, possessing the true character of chancre, required in general a still longer period for their cure, that is, from six, eight, to ten, and in one case, even twenty-six weeks, healing up and ulcera- ting again on a hardened base. Those that required the greatest length of time had nothing particular in their appearance that would Venereal Disease—{Lues Venerea—Syphilis.) 251 lead us to distinguish them from others of the same kind which were healed in a shorter time."—(Med. Chir. Trans, vol. viii. p. 558.) In relation to the question before us, one of the most important do- cuments which I have met with, is an official circular, signed by Sir James M'Grigor and Sir Wm. Franklin, from which it appears that in 1940 cases of primary venereal ulcerations on the penis, cured without mercury, between December, 1816, and December, 1818, (including not only the more simple sores, but also a regular propor- tion of those with the most marked characters of syphilitic chancre,) the average period taken up by the treatment, when bubo did not exist, was twenty-one days; with bubo, forty-five days.—(See Hennen's Military Surgery, 2d. ed. p. 545.) And it farther appears, that, during the period above specified, 2827 chancres, a more considerable pro- portion of which were probably Hunterian chancres, were treated with mercury, and that the average period required for the cure, when there was no bubo, was thirty-three days ; with bubo, fifty. As far, therefore, as a judgment can be formed from this official estimate, and no calculation is ever likely to be furnished on a larger or more impartial scale, the evidence tends to prove, that primary sores may generally be cured rather sooner without than with the administration of mercury, only by cleanliness, diet and rest. [From the London Medical Gazette.] On the Application of Mercury to Venereal Complaints. By S. D. Bkoughton. Usually, a mine of prejudice has been ready to explode when any anti-mercurial doctrines have been broached; and, in attempting to disturb theories sanctioned by age, and rendered orthodox from an- cestorial experience, the curse of modern heresy often attaches itself to the avower of that which many regard rather in the light of rash innovation than improvement. I will not here dwell upon the often-told tale of the origin and progress of lues venerea, and the blessing conferred upon suffering humanity by the introduction of a supposed specific check to its rava- ges, in the form of mercury. Both bane and antidote have gone hand in hand together, during more than three centuries; nor is it my purpose to repeat the several well-known efforts made, from time to time, to lay the offspring of impurity, by the substitution of milder measures than such as are afforded by extensive and long-continued mercurial applications. These efforts have, indeed, generally fallen in time into disrepute, and the old remedy has been fondly and per- tinaciously adhered to ; the public has been taught to distrust the one, and to consider caution, safety and security, as the sure recommenda- tion of the other. I cannot glance at these successive efforts without offering a remark, (with which, 1 believe, well-informed, experienced and judicious prac- titioners will generally coincide,) that Mr. Rose's late introduction of an anti-mercurial treatment (though some, perhaps, may consider it as a failure) is one of the greatest improvements in modern surgery, Vol. II. 2 H 25J Venereal Disease—(Lues Venerea—Syphilis.) has made the most general impression, and has imparted the most useful direction to practice, of which the pathology of the presen t century can boast. I also consider Mr. Rose's doctrines to be further valuable, upon the ground that they do not inculcate the necessity of hunting after one specific remedy as a substitute for a discarded specific; but that they tend, on the contrary, to lessen the estimation so long cherished, of a dogmatical practice, introducing in its place a pathological theory and remedial measures, built on a far more rational foundation. These doctrines have guided my practice some years, «and expe- rience has taught me not to distrust their truth, safety and value. I have not allowed myself to be scared, by imaginary dangers and terrors, into the adoption of an ancient dogma, too often followed upon the ground merely of suspicion and probabilities, when the alter- native was the use of a powerful mineral—at the best, more or less a positive evil—the ultimate mischief of which, past and present his- tory show to have been, and still is daily being, confounded with the effects of venereal poison, sometimes extending beyond calculation the chance of recovery, from its destructive ravages upon the con- stitution. I aver that mercurial saturation tends to the destruction of mucous membranes, the removal, by morbid absorption, of soft parts, and the disorganization of the osseous substance.*. The mind\ itself has suf- fered, the constitution received a baneful impression, and pulmonary consumption^: has not unfrequently terminated the patient's earthly career, when the system has undergone mercurial saturation ; while the wretched victim of imbecility or imprudent rashness has been commonly reported (with ill-timed levity) to have died of " the breeches fever." Is it not better that we should "------rather bear those ills we have, Than fly to others that we know not of?" I do not, however, contend for the entire abolition of mercury in venereal complaints; like the abolition of slavery, it must be done with care and caution, from regard both to the moral and physical constitution. * A young gentleman went through a full course of mercury; symptoms of phthisis pulmonalis followed repeated inflammatory attacks of the chest, and several deep holes were formed in the forehead, in the manner called corona vene- ris, but more properly should be corona mercurii. This patient did not die; but Ins head is marked, his constitution debilitated, and he is liable to sore throat and acute catarrhal affections, and has been obliged to pass much time in the south of Europe, to the detriment of his professional advancement in his own country. t The brother of a fellow-student of the author, constitutionally strumous, went through a full course of mercury, and in a few weeks he was placed in a private mad-house. t A respectable unmarried tradesman in the city, 30 years of age, went through a full mercurial course. Impaired digestion, irregular bowels, symptoms of phthi- sis pulmonalis and diarrhcea followed. He was removed to the seaside, and there died of hydrothorax, &c. A young nobleman used mercury to a very considerable extent. Consumptive symptoms, &c. ensued. He was sent to the south of Europe, and there died. Venereal Disease—(Lues Venerea—Syphilis.) 253 Though " custom be the plague of wise men, and the idol of fools," the deep-rooted prejudices which it implants require gradual steps to eradicate them ; and there may occur certain cases, wherein a judi- cious application of mercury will be serviceable and inoffensive. But Mr. Rose's mass of evidence has shown how easily we may wean ourselves of the practice, and that the suspension of the mercurial plan is a bugbear, the fear of which has intimidated too much, and been carried unnecessarily far. At the same time, it appears to me, that the adoption of mercurial remedies is more frequently the act of temerity than is its rejection—at least as it is frequently applied. And I trust it is not extravagant to believe, that Mercury is often more to blame than Venus, or that the destroying sword of the god does more execution than the insidious blandishments of the goddess. These remarks have been elicited, not only from having repeatedly observed the safety of an anti-mercurial practice, but also the fre- quent terrible consequences of the contrary method ; consequences which, I do not hesitate to declare, sometimes far, very far, exceed what it is possible to conceive from the progressive steps of venereal taint in the constitution. Then is mercury so mild and safe a remedy in its action that it may be indiscriminately used in all cases of sus- picious sexual intercourse ? Independently of otherwise removing the complaint possibly, even if suspicion be justly formed, is no time to be allowed to give the disease fair play, and declare its nature and character ? Is no account to be taken of the many little constitutional and local circumstances which aggravate an excoriation, ulcer or bubo, or produce some cutaneous eruption, easily removed by a little pa- tient care and judicious treatment, without saturating the system with mercurial ointment and pills ? Yet such is a very common practice, especially with general practitioners; so that amongst high and low, rich and poor, a sufficient course of mercury is generally recommended to the patient; and he must get out of the scrape as well as he can— if matters go wrong, by aid of sarsaparilla, the seaside, mild climate, die. &c. Then, sometimes, it is thought, the poison lurks in his bones, or his throat (perhaps extensively ulcerated) shows that he has not had a sufficient quantity to destroy the venom, and therefore a little more mercury will do for him, (and quickly, too, in a scrofulous habit,) when Nice or Naples will, probably, set him to rights again, and restore his constitution ; and if it does, he may esteem himself very lucky to return with a sound skin and whole bones, &c. Now these are not imaginary cases, and, were it necessary, which it is not, a multitude of instances might be cited in proof, many of which have passed under my personal observation. Many cases might be shown to have done very well without mercury; -many in which this remedy was totally unnecessary, though not, perhaps, in- jurious to the health ; and many in which the abuse of mercury has produced distressing and protracted mischief, and, in some instances, ultimate dissolution, from a train of "superinduced disorders. On the other hand, few, I believe, if any cases, can be authenti. cated, in which the venereal disease, (as it is termed,) when left to it. self, has produced any such consequences as those to which I have alluded above, without the aid of mercury. 254 Venereal Disease—(Lues Venerea—Syphilis.) The common cant is to attribute cases which get well without mer cury, to what is called pseudo-syphilis, a term which is perfectly gratuitous. Those whose prejudices are invincible, believe that all cases healed without mercury cannot have been venereal. With the example of Portugal before us, and some other countries, and the long trial which Mr. Rose gave the anti-mercurial system, I conceive such inferences to be wholly unwarranted. I have taken about three hundred and fifty recorded cases of ulcers of the penis, admitted and treated in the re- gimental hospital of the 2d liife Guards, one hundred and fifteen of which appear to have used mercury in different forms and proportions, and for different periods of time ; so that about two hundred and thirty- five cases of primary symptoms, following sexual intercourse, have been healed by other means than mercurial remedies, as well as many not in the list. The number of secondary cases of symptoms following the prima. ry venereal disorder during the same period, amounts to about twenty- two, out of three hundred and fifty. And, upon following up the nar- ratives of these, it appeals that the majority were generally simple cases of lichen, which got well without mercury, and in.no long time. The greater part of those cases which were protracted, and attended with ulcers of the throat, pains of the limbs, nodes, &c, were origin- ally treated with mercury in the hospital, and the rest showed that mercury had been clandestinely procured at some period or other during the progress of the complaints. The simple cases of lichen, &c, were chiefly found amongst the men not treated with mercury, while the most protracted and troublesome cases occurred with those who had been fully subjected to its operation.* Since the use of mercurial saturation has been suspended, no cases have occurred to throw any distrust upon the propriety of the practioe ; and the few cases of se- condaij symptoms were generally mild and trifling, compared with those which followed mercurial treatment, and readily yielded without mercury. , I do not pretend to enter upon any nice discriminations of practice, or to draw a line between cases requiring and cases not requiring mercu- ry,nor to describe such as mercury will aggravate. Indeed, I am aware of no satisfactory rules to guide the practitioner in this respect, but those which he himself derives from a sound judgment and experience. I wish merely to assist in establishing the fact, that venereal sores admit of treatment without mercury and without cause of alarm ; the secondary evils of mercury being usually far more destructive than those which arise from venereal taint, and that the one case is often mistaken for the other. Consequently, it appears to me, that there is more security in omitting to push a mercurial course, than in adopting it; that comparatively few cases occur requiring mercury ; that the perils of mercury are sometimes manifold and terrible ; that at all times it entails more or less personal inconvenience and annoyance, and frequently leads to a train of ultimate symptoms, from which er * And 6uch I have always found to be the case elsewhere Venereal Disease—(Lues Venerea—Syphilis.) ronnous inferences are made, and a useless, if not mischievous prac- tice adopted, the effects of which cannot be foreseen, and their limits no man can calculate upon. In my dispensary practice I have had frequent occasion to observe the great danger of pushing a course of mercury, when the patient is not under the surgeon's control as to diet, temperature, &c. An_ error, made in the treatment of sores on the penis with persons going about, and exposed to sudden changes of temperature, to cold winds, or wet, is too often irretrievable. The labouring classes in London, perhaps not living on the best diet, nor possessing sound constitutions, exhibit frightful examples of the imprudent use of mercury ; the ef- fects of which, from some cause or other best known to themselves, there are practitioners, (chiefly in private practice,) who are constant- ly disposed to attribute to syphilitic action and deficient mercurial saturation. This propensity,.indeed, I remember once to have heard very satisfactorily accounted for in a medical debating society, by a candid avowal, that if the anti-mercurial mania continued to spread, " it would be ruin to the apothecaries and general practitioners." There- fore, the inference drawn from this liberal sentiment was, that it is better to be on the safe side, and not to hazard the adoption of modern heretical opinions, against the " wisdom and experience of our an- cestors."* My attQption has been particularly drawn to the subject of this pa- per lately, from the circumstances of the following cases affording a tolerable sample of the effects which the blessing handed down to us by our forefathers is capable of producing. [Here follow several cases illustrating these views.] The above six cases are selected from a stock containing many similar; but it is not so much my object to accumulate examples of the points to which I have referred, as to illustrate some of my posi- tions. Instances of the above description have often fallen under my notice in hospital and dispensary practice, and some could be produced from among private patients; and such are, doubtless, to be found in the records of oases which must occur to the remembrance of other practitioners. I am induced to believe, both from the fore- going facts and observations, and those which are put forth by Dr. Thompson, of Edinhjirgh, Dr. Ferguson, (late inspector general of the Portuguese army,) Mr. Guthrie, and others— 1. That all the forms in which venereal complaints present them- selves are to be removed without the aid of mercury; and this is more especially and remarkably the case in regard to the secondary symptoms of the disease. 2. That mercury has formerly been, and frequently is still, used in an unnecessary, indiscreet and highly dangerous manner. 3. That mercury, judiciously and alleratively used, is not only an excellent, but perhaps the best remedy jn many venereal complaints ; * It is, however, to be hoped, that the gentleman who avowed this motive was as much in joke as tho wag who declared that the first standing toast at the College of Physicians1 dinners, was always " a slow /ever,'1'' with three times three ! 256 Venereal Disease—(Lues Venerea—Syphilis.) nevertheless, a tithe of the quantity anciently administered is gene- rally sufficient, and more than sufficient, probably, to eradicate the primary symptoms ; while, again, a tithe of that tithe, or a centime, has been found competent to eradicate the secondary stage of the disease.* 4. That mercury is very far from being a certain preventive of the secondary train of symptoms, in any form or quantity. 5. That mercury, when pushed far, induces ulceration of the mucous secreting surfaces, more especially of the inner palate, throat and fauces, as well as affections of the bones, so exactly resembling those ascribed to true syphilis, that the most experienced surgeon cannot detect any difference. In the hands of the members of the old school, mercury, in fact, creates its own work, by establishing diseases which have too often been confounded with venereal poison, and thereby led to a most dangerous and destructive practice. 6. That the train of symptoms following mercurial treatment has been found more severe and difficult to remove, than that which follows primary venereal sores not treated with mercury; and that repeated relapses into secondary symptoms are removed with increased facility every time they occur, (as if the disease wore itself out,) in cases wherein no mercury has been given. 7. That mercury tends to undermine the healthy state of the con- stitution, to establish, in some instances, and in others to • aggravate, constitutional diseases, to increase constitutional irritability;'to excite inflammation and ulceration in, and to destroy the mucous textures of, the body, to promote morbid absorption and removal of the fatty, fibrinous and osseous substances of the system, and to induce synovial, albuminous and serous accumulations in the respective cavities lined with the membranes producing such secretions. 8. That the extent and injury to the soft and bony parts of the system, arising from the action of mercury, is far more dreadful than any primary or secondary effects of venereal poison. 9. That mercury never was a specific against the venereal poison ; for relapses were'constantly occurring during its fullest operation; nor possessed any virtue in the cure of the disease; and that the creed so long believed in, (to the ruin of the health of multitudes, through mercurial salivation,) of its indispensibility towards the cure, and the destruction of the patient if omitted, is utterly false and ground- less ; facts which can admit of immediate, every-day demonstration, in the many thousands of the healthiest British soldiers, who have been easily, effectually and permanently cured of every stage of the venereal disease, without ever having taken one particle of mercury. The bigoted adherence to a belief so false, and so universal, in which the wisest and most philosophic of our profession blindly par- * Vide Abernethy on his imaginary pseudo-syphilis, who cured so many of the worst cases of the disease with so little mercury, that he actually distrusted the work of his own hands, and therefore summoned the trustiest of his brethren of the old school, to vouch for the impossibility of the diseases so treated being truly syphilitic. Venereal Disease—(Lues Venerea—Syphilis.) 257 ucipated, will be quoted by after ages as a national reproach ;* and, as it has indeed already done, will, it is to be feared, go far in des- troying our confidence in all medical dogmata, or any doctrines, whatever. 10. That mercury is wholly inadmissible in cases of sloughing sores of the penis, wherein there is preceding high inflammation and tumefaction of the parts affected, attended with fever ; as it aggravates the local symptoms, and increases continual irritation ; and that mer- cury is inadequate to the cure in such cases, specific contagion being superseded by violent infiammatory action, which is too rapid in its course to be overtaken by the accumulative power of mercury, or by any remedies but those which act immediately and directly npon the symptoms of danger, f [From the Journal dee Progres des Sciences et Institutions Medicales.] Non-mercurial Treatment of Syphilis. (Communicated by M. Gan- ther.) Dr. Fricke, of Hamburg, after a long series of experiments, made in the general hospital of that place, has at length published the re- sults of his observations on the non-mercurial treatment of this disease. The regulations of that hospital particularly adapt it for observations of this nature ;, the venereal patients are long subjected to the ex- amination of the physician, and he is consequently enabled to ascertain with correctness. In support of this method of treatment, it may be alleged, 1st, that the primary symptoms were more speedily cured, than by the employment of mercury ; 2d, the unpleasant consequences sometimes occasioned by that mineral were avoided, and, 3d, the ci- catrices or scars presented generally a better aspect. Reformed Practice. 1. Gonorrhoea. Having shown the inutility, and in some degree the injury of mer- cury, or the common practice, in the venereal disease, I shall now lay down such a course of treatment as I have found speedily to remove the disease ; and, in justice to the efforts of nature, I must add, that gonorrhoea, as well as other venereal affections, are sometimes spon- taneously cured, and very generally by a simple and mild treatment, such as cleanliness, simple dressings, diet and regulation of the se- cretions. At the same time, by the use of more active means, the disorder may be sooner eradicated. * This time has already arrived, and this bigoted adherence to a belief so false in the use of mercury I now quote, and pronounce with thousands of others, " a national reproach." t It his occurred to the author to notice two distinct examples of destruction of the penis—in one case entirely, and in the other reducing it to a short stump—fol- lowing the application of mercury, to sloughing sores on the penis, consequent to inflammation and fever. 258 Venereal Disease—(Lues Venerea—Syphilis.) The practitioner is usually called to prescribe first for gonorrhoea. There is swelling, inflammation and pain of the parts, with heat and scalding, and difficulty of making water, from which symptoms the indications are clearly inferred, which is promptly to subdue the in- flammatory symptoms ; to effect which, the following mixture will be found very effectual: Take Spirits of nitre, (spts. nhvdulc.,) 1 oz. Spirits of turpentine, (ol terebinth,) £ oz. Oil of almonds, (ol amygdalis,) 1 oz. Balsam of copaiva, (bals. copaivae,) £ oz. Mix, and add half a scruple of gum camphor. Dose, a small teaspoonful three or four times a day, to be given in half a wineglassful of the mu- cilage of gum Arabic, and to be accompanied with the use of spearmint tea. These drops generally mitigate the symptoms in a few hours, and entirely remove them in a few days. When the heat and scalding of the water have subsided, should there remain any discharge or gleet from the urethra, a refrigerant and gently stimulating injection may be introduced. A strong decoc- tion of the blood-root or sanguinaria Canadensis may be injected three times a day ; two or three small syringes full each time. Should not this diminish the discharge, and act favourably., introduce the follow- ing liquid : Take eight grains of white vitriol, pulverized, Sixteen grains of borax, pulverized ; Add eight ounces of rain or soft water. To be used in the same man- ner ; and if there is much swelling or inflammation, wet a piece of linen or muslin in the liquid, and apply to the parts. I have not, how- ever, found very great benefit from injections ; besides, if given too strong, they are apt to be followed by suppression of urine or disease of the testicle. It will be necessary, also, from the commencement of the complaint, occasionally to give a purgative ; and I have a particular choice in this class of medicines, there being a great difference in the action or properties of them. Every kind of cathartic appears to have some peculiar effect upon the system, acting more especially upon certain parts or organs. I formerly employed, in this complaint, our common purgative, the base of which is jalap, and with it I succeeded very well; but, as far as my observation goes, I have found the podophyllum peliatum much better, although its operation is not quite so pleasant. I have sometimes thought that it appears to have a specific effect in the venereal disease ; whether in consequence of acting more gene- rally upon all the secretions or not, I am unable to decide. I also find that those who have used it, speak highly of its virtues. It may be given as follows : Take mandrake or May-apple, (podophyllum peltatum,) 2 parts, Cream of tartar, (supertras potassae,) 1 part, Spearmint, (mentha sativa,) 1 part ; Pulverize each article separately, then mix. Of this give thirty or forty grains, or an ordinary sized teaspoonful. The best method of taking it, is to put the powder into a teacup, with a small piece of loaf sugar : add a gill of boiling water, and, when cool, let it be taken. Venereal Disease—(Lues Venerea—Syphilis.) When it operates, give oatmeal or indianmeal gruel. It proves a very cleansing or detergent cathartic,evacuating the whole alimentary canal, and acting in a greater or less degree upon all the secretions and excretions. This preparation may be repeated every two or three days, or according to circumstances, the stage, severity of the disease, &c. This is sufficient to remove the symptoms of gonorrhoea. Occa- sionally, as under every kind of treatment, a troublesome gleet is left, unaccompanied with any other symptoms. Should this be the case, the same means must be continued until it is removed ; and should it prove very obstinate and protracted, recourse must be had to the same treatment as is recommended for a general taint of the system, or a constitutional affection. The patient must resort to tepid bathing, country air and a restorative diet. He must make use of a spare diet, when there is inflammation, and abstain from all spiritous and fermented liquors. I have omitted to mention, that in case a chordee attend the complaint, the patient should take an anodyne at bedtime, and bathe the parts with the marshmallow ointment; and should the skin of the prepuce retract, and become very much inflamed or swell- ed, a poultice must be applied. Should a swelling of the testicle come on, it must be bathed with the stramonium ointment, and if the inflammation be very considerable, the leaves may be simmered with vinegar, and applied as before stated. «. Chancres. The second local form under which the syphilitic poison has been mentioned to show itself, is that of a chancre : this is distinguished by a want of disposition to heal, a thickened base, and circumscribed inflammation, with other characteristic marks already noticed. The parts most apt to be affected with these ulcerations in men, are the prepuce, the frsenum, at the orifice of the urethra, and in the angle between the glans and body of the penis ; and in women, about the labia, nymphre, and clitoris ; but in some instances they have ex- tended Into the vagina, and even so far up as the os uteri. Syphilitic matter, by being applied to other parts of the body covered with a mucous membrane, such as the lips, nostrils, &c. may give rise to chancres there also ; but, being most usually applied to the organs of generation, in consequence of an intercourse between the sexes, these are generally the seat of such ulcers. A chancre makes its appearance either with a slight inflammation, which afterwards ulcerates ; or there arises a small pimple or pustule filled with a transparent fluid, which soon breaks and forms into a spreading ulcer. The period at which it makes its appearance after infection is very various, being most commonly in five or six days, but in some cases not till after the expiration of as many weeks. As there is always a risk that an absorption of matter may take place from a chancre, and possibly very speedily, it will not only be necessary to attend to the ulcer, but likewise to secure the constitu- Vol. II. 21 260 Venereal Disease—(Lues Venerea—Syphilis.) tion by a use of such remedies as are well known to possess the power of counteracting the syphilitic poison. The treatment of chancre must be very similar to that of an ordi- nary ulcer. The inflammation must first be reduced, by applying the elm bark poultice, also the marshmallow ointment on a pledget of lint. When the inflammation has subsided, apply the black salve, and if the ulcer does not heal under this dressing, let it daily be sprinkled with the powdered blood-root, and subsequently, if it does not heal, with a mild mineral caustic. No irritation is excited by this powder, but it changes the character of the sore usually in twenty-four hours, caus- ing it rapidly to heal. Every time the sore is dressed, it should be well cleansed with a mixture of Castile soap, soft water and spirits, and any collection of matter in the contiguous parts must be removed with the same. < I formerly was in the habit of using a wash made by adding about ten grains of the corrosive sublimate to ten ounces of borax water, and it makes a very cooling and astringent wash for venereal ulcers, without any danger of its being absorbed ; but more recently, I have almost entirely dispensed with it, and used the applications mentioned above, in preference. Chancres are often attended with that stage of the disease, called phymosis or paraphymosis, which renders it difficult to make any applications to the ulcers. When this occurs, poultices and cooling lotions must be applied, and other means to remove the inflammation, before any thing ^can be done to the chancres. Sometimes it is necessary to apply them a number of days before the swelling subsides, but there is no necessity of dividing the prepuce as surgeons recommend, as it only requires a little time to accomplish that for which the operation is recommended. In addition to these local applications, it will be necessary to attend to the constitution. The mandrake must be given as a purgative; and in addition, the following decoction is a good alterative, although I have repeatedly cured the complaint without using it. Take blood-root, (sanguinaria Canadensis ;) Bark of the root of sumach, (rhus glabrum ;) Root of blue flag, (iris versicol;) Bruise the roots, and make a strong decoction. Let the patient drink freely. This makes a very purifying or alterative decoction, and some botanical physicians rely almost exclusively upon the blue flag for the cure of the venereal disease, while others rely almost exclu- sively upon the mandrake. Dr. Elisha Smith, who has written a work entitled the Botanic Physician, highly extols the use of the flag-root, in the following lan- guage : "This root," says he, " possesses great medicinal power, and, from a long experience of its use, I am convinced that it is equally as effi- cacious as mercury in all the diseases in which, in the common prac- tice, it is supposed mercury is indicated. It serves as an alterative and sialagogue, in small continued doses, as a powerful drastic purge, a stimulant, a vermifuge, a diuretic, errhine, &c. It is a complete substitute for that mineral, for any of its purposes ; and, being a vege- table, I consider it far preferable; because, after its operation and Venereal Disease—(Lues Venerea—Syphilis.) 261 effects, it passes off, and leaves the 9ystem free ; whereas, mercury fastens upon the bones and solids, and remains like a corroding and •eating canker, rendering vast numbers feeble and debilitated for life. Such is the difference between these two articles of medicine ; and it would be a happy event for mankind, if physieians would, for once, devest themselves of their blind prejudices in favour of the mineral, and consent, at least, to make a trial of this vegetable substitute. Their humanity should be a sufficient inducement for this. The plea that the vegetable kingdom contains no equivalent to mercury, is no longer tenable. Then why should not physicians discard the use of it at once, when it is universally acknowledged and felt that in the aggre- gate it has proved a curse, a destroyer to the human race ?" Under this treatment, should the chancres decrease very slowly, or in any respect become stationary, in addition to what has been recommended, the ulcer, or ulcers, may be sprinkled with a few grains of the mineral caustic, and afterwards poulticed. This treatment is not only applicable to chancres, or ulcers, which appear upon the penis, but likewise to every species of venereal ulcerj in whatever part of the body they^may appear. Bubo. When the poison becomes absorbed, and affects the inguinal glands, particularly as before stated, it is termed a bubo, and our first object should be to discuss or disperse it; to effect which, apply the discutient ointment, three or four times a day, rubbing it well in before the fire; after which, a poultice may be made, by simmering the cicuta leaves in water, and when soft, the slippery-elm bark to be stirred in, to form a poultice, and it may be used constantly, but the night is the most convenient time. The patient should be pretty freely purg- ed. Should this attempt to discuss the venereal tumour or bubo fail, and should the swelling and inflammation increase, suppuration will probably succeed, and it must be promoted by applying the fol- lowing poultice. Take the root of wild carrot, (daucus sylvestris;) bruise, and simmer in milk, then stir in the elm bark, and apply to the part, to be secured by proper bandages. When symptoms of suppuration appear, which will be known by the subsidence of pain and inflammation, with softness and fluctuation of the bubo, a small opening may be made to let out the matter, or it may be left a short time, to open spontaneously. After it has dis- charged freely, the poultice may be laid aside, and the black plaster or salve substituted. It should be washed with a little soap water and spirits, and if it does not heal kindly, to be treated as any other ulcer. Constitutional Affection—Lues Venerea. If, from neglect or improper treatment, or peculiar temperament, or any other cause, the venereal poison is suffered to be absorbed and taken into the circulating mass, and thus contaminate and affect the whole system, our treatment must be varied, and adapted to this melan- choly stage of the complaint. 262 Venereal Disease—(Lues Venerea—Syphilis.) It is customary, not only in the preceding stages of the disease, but likewise in this, to administer mercury, but there is no evidence of any good arising from it, but, as before stated, much mischief. The following statement of Doctor Hennen, shows still further the propriety of treating the venereal disease, even in the worst stage of it, without mercury, and also the ill effects arising from its use. Carious affections of the bones, which are so common in persons treated by long mercurial courses, proceed, not from the disease, but from the remedy rapidly and irregularly thrown in while periostitis exists : and he has not seen a single case of carious bone in the mili. tary hospitals since the non-mercurial treatment was adopted, except where mercury had formerly been used.—(On Military Surgery, 2d. ed. p. 505, 506.) Nor will the results of modern experience and inquiries, made on a very extensive and impartial scale, allow us to consider the venereal disease as regularly and unavoidably leading to any secondary symp- toms, even though no medicine at all be employed for their preven- tion. This is fully exemplified in the official reports of the army hospitals. The particulars of 5000 cases, spoken of by Sir James M'Grigor and Sir W. Franklin, lead to the opinion, that "the fre- quency or rarity of secondary symptoms would seem to depend on circumstances not yet sufficiently understood or explained, although the following fact would tend to the belief, that either the constitutions of the men, or the mode of conducting the treatment without mercury, are the causes that possess the greatest influence in their production. In one regiment, four secondary cases out of twenty-four, treated without mercury, supervened." In another regiment, sixty.eight ca- ses were treated without mercury, all bearing marks of the true vene- real disease, (and twenty-eight of them especially selected for their decided characters of chancre,) yet no secondary symptoms of any kind had taken place fifteen months after the treatment had ceased. Therefore, the investigations made in the military hospitals of Eu- rope, without any other evidence, show conclusively that this disease can be curedVithout'a particle of mercury ; and in Spain, and in the the south of France, they likewise treat it without this poison. When called to a patient labouring under this form of the venereal disease, the object should be to eradicate the syphilitic poison from the system ; and this must be effected by attending to the secretions of the system. It must be driven from it, the same as any other mor- bid affection. The patient should take the same purgative as before recommend- ed, viz. the compound powder of mandrake, once or twice a week, or according to circumstances. He will also commence and continue the use of the following concentrated vegetable syrup : Take sarsaparilla, (smilax sarsaparilla,) 6 lbs., cut or split fine ; Bark from the sassafras root, (laurus sassafras,) 2 lbs. ; Guaicum shavings, (guaie. officinal,) 3 lbs. ; Elder flowers, (sambucus niger,) 2 lbs. ; Add a sufficient quantity of soft boiling water, or a little more than to cover the articles ; then let them stand on embers, or near a fire, twenty-four hours, properly to digest or steep, after which commence Venereal Disease—(Lues Venerea—Syphilis.) 263 boiling. In two or three hours pour off the decoction into an earthen vessel, again cover with water, boil the same length of time, and thus continue to add water, and boil five or six times, or until all the strength of the articles are extracted ; after which remove them, and after straining the different boilings or the decoctions, let them be put together and again boiled until there are but sixteen porter bottles ; then add twenty-five pounds of loaf or white sugar ; again boil, to form a syrup. In order to clarify it, the whites of three or four eggs may be beat up and mixed with a pint of milk, and added to it, and, boiled a short time ; the scum should be removed as it rises to the surface. It should now be passed through flannel, made in the form of a cone, and it is then fit for use. A wineglassful should be taken three times a day, before eating. During the use of it, the patient may take a strong decoction of the best Honduras sarsaparilla. I have tried every preparation used by modern physicians, with most of the nostrums now so highly extolled, such as Swaim's Panacea, and other preparations, and after repeated and comparative trials for years, I find that the above syrup by far exceeds the whole of them. If there is any chance of recovery for the patient, or the disease is within the control of medicines, with proper agents accompanying it, this syrup will prove effectual. It requires to be given a length of time, in certain cases, before it has the desired effect. I know not the modus operandi, or how it acts on the system, nor is this of much consequence. The effect of it is enough for us to know, but it appears pretty evident that it must change the secretions, or eliminate the morbific matter by the skin, kidneys, bowels or intestines, although it has very little sensible effect upon any of these organs. In very obstinate cases, fifteen or twenty bottles should be taken. The surface should be daily bathed in weak ley water, and an in- fusion may be also alternately given with that of sarsaparilla, made of the roots or seed of burdock, blood-root, sumach and blue flag com- bined. When there are sores in different parts of the body, as there usually are when there is a general taint of the system, apply the following wash three times a day : Take muriate of gold, (murias auri,) eight grains ; Rain water, four ounces : mix. If it is practicable, let lint be dipped in this liquor and applied to the ulcer, after which the black salve. Where there is much inflam- mation, apply the marsh mallow ointment. When the ulcers are situated in the throat or nose, the liquid should be applied repeatedly, by a piece of sponge fastened to a wire or stick. Should the ulcers be very intractable and unyielding, they must be occasionally touched with the mineral caustic; the same as other ulcers. This course, with me, has been invariably successful, even in those desperate cases .where they have been abandoned, or given up, as incurable, by hospital surgeons and others. But much time and'pa- tience is often required to effect a cure in the worst variety of the complaint. 1 264 Venereal Disease—(Lues Venerea—Syphilis.) This treatment is also very beneficial in mercurial affections, which are usually connected with the venereal disease. In concluding this chapter on the venereal disease, I have to remark, that there is one diagnostic symptom, which will enable the prac- titioner always to detect the real character of the venereal ulcer. It is the peculiar fetid effluvia, or stench, which arises from it. It is always of a most loathsome and sickening nature, and essentially different from that arising from any, and every other complaint. CHAPTER XVII. SCROFULA, OR KING'S EVIL. Description. The scrofula was so called, as is supposed, in consequence of swine being subject to this disease ; and it is vulgarly called tho " King's Evil," from the custom of submitting patients to the royal touch. The disorder consists in hard indolent tumours of the conglobate glands in various parts of the body ; but particularly in the neck, behind the ears, and under the chin, which, after a time, suppurate and degen- erate into ulcers, from which, instead of pus, a white curdled matter, somewhat resembling the coagulum of milk, is generally discharged. The first appearance of the disease is most usually between the third and seventh year of the child's age, but it may arise at any pe- riod between these and the age of puberty, after which it seldom makes its first attack. It most commonly affects children of a lax habit, with a smooth, soft and fine skin, fair hair, rosy cheeks, and a delicate complexion ; but it is occasionally met with in those of a dark one. It likewise is apt to attack such children as show a disposition to the rickets, and marked by a protuberant forehead, enlarged joints and a tumid abdomen. The glandular system appears to be almost entirely, if not exclu- sively, the seat of the disease ; and in almost every instance it is located in the conglobate glands of the neck. Writers, from their representation, make out almost every morbid taint of the system to consist of the scrofula. The hip disease, white swelling, chronic ophthalmia, and every morbid affection of the system, by them is pronounced " scrofulous." The term is entirely too ex- tensive, at any rate, for practical purposes. A physician of this city was called to a boy, who had a white swell- ing in the knee, and, upon being asked what it was, he said it was a scrofulous affection ; on which the mother asked him if he meant the king's evil, when he replied in the affirmative ! ! It is very probabh^hat the proximate causes of almost all diseases are alike, but the diversity or variety of character which they present, depends upon the peculiar tissues or organs dieased. For instance, if the exciting cause of scrofula were to attack the joints, it would pro- duce a specific complaint, entirely different from that which arises from the application of the same to the conglobate glands of the neck or other parts. ft has been supposed by many that tho scrofula is hereditary, but we have no evidence of this, as it often appears in families whose predecessors, as far as they can be traced, have never had a vestige of it. Children born of scrofulous parents are not invariablv affected 266 Scrofula. with scrofulous diseases ; and sometimes one child has some strumous affection, while the parents and all the rest of the family have no appearance of scrofulous habits. Scrofula is not communicable from one person to another : neither can it be conveyed into the system by inoculation. The opinion, also, that scrofulous nurses may infect children, seems quite destitute of foundation.—(See White, p. 26, dec.) Pinel and Alibert have purposely kept scrofulous and healthy chil- dren together in the same ward, without any of the latter receiving the complaint. Hebreard could not communicate the disease to dogs by inoculation. And G. T. Kortum, whose valuable work contains every thing known about scrofula at the period when it was written, tried in vain to impart the distemper to a child, by rubbing its neck every day with the pus discharged from scrofulous ulcers. Lepelle- tier, desirous of ascertaining the correctness of such experiments, has of late repeated them : he has made Guinea-pigs swallow scrofu- lous matter; and he has injected it into the veins, and applied it to wounds; but in no instance was there even a temporary appearance of the disease being communicated. The same author also mixed scrofulous with vaccine matter, and inoculated with it; yet he never found the vaccine vesicle, thus produced, deviate in the least from its regular course. Lastly, Lepelletier inoculated himself with pus dis- charged from scrofulous sores, as well as with the serum collected under the cuticle of a strumous patient after the application of a blis- ter ; but he remained free from every scrofulous ailment.—(See Diet. des Sciences Med. t. 1. p. 294.) Goodlad inoculated himself several times with the discharge from scrofulous sores and abscesses, and the result was, that the disease could not be thus transmitted. According to White, scrofula prevails more extensively in tempe- rate latitudes, than in very hot or very cold climates. It is also more frequent in some parts of Europe than others. At all periods it seems to have been a very common complaint. From history, we learn that it was denominated the king's evil in the time of Edward the Confes- sor, who is supposed to have been the first that attempted to cure it by the royal touch. From a register kept in the royal chapel, we find that Charles II. touched 92,107 persons in a certain number of years; and this equally bigoted and useless practice was not discontinued till a recent period, when kings were found to be, as well as their poorest subjects, totally destitute of all supernatural power. Scrofula prevails most in those climates where the atmosphere is cold and humid, where the seasons are variable, and the weather un- steady. From latitude 45° to eOS is the principal climate of this dis- ease. A long continuance of inclement weather may increase any predisposition to scrofula ; and in persons already much predisposed to it, any uncommon, though temporary exposure to wet and cold, is sometimes an exciting cause of an immediate attack. Besides cli- mate and exposure to moist air and atmospherical vicissitudes, every other circumstance which weakens the constitution and impairs the general strength of the system, predisposes to scrofula; thus, breathing impure tainted air, unfit for respiration, and living upon food of an un- wholesome and indigestible nature, which does not a fib id proper Scrofula. 267 nourishment to the body, favours an attack of scrofula, by reducing the strength of the system, and making the person weakly. The neglect of due personal cleanliness, and of salutary exercise, indo- lence, inactivity, the want of warm clothing, confinement in cold, damp habitations, dec, may all be regarded as so many exciting causes, and satisfactorily account for the prevalence of the disease among chil- dren employed in large manufactories. The influence of climate, says Gregory, is immense, and may be estimated by the following facts. In the East and West Indies, scro- fula is hardly known ; but when the natives of either are brought into this or any European country, they suffer from it severely. The prevalence of scrofula is directly proportioned to the coldness, or, more properly, to the variableness of the climate. Scrofulous affec- tions are principally met with in all countries during the winter months. They rapidly improve, or disappear altogether, on the ap- proach of summer ; and this effect of warm weather upon scrofulous ulcers, is important in diagnosis as well as in practice. Among the causes of scrofula, the close, confined air of a town appears to merit especial mention. The'complaint is infinitely more common among the inhabitants of a town, than among those of a corresponding class of society breathing the pure air of the country. It is notorious, that the population of our large manufacturing towns, pent up during the day, are, of all others, most afflicted with it. Certain modes of life contribute also in no small degree to the developement of scrofula ; confined habitations, want of cleanliness, sedentary occupations, ir- regular habits, but, above all, deficient or unwholesome diet. They concur in reducing the tone of the system below that healthy standard, which is the surest preservative, not only against the attacks of scro- fula, but of every other disorder. The extensive influence of debili- tating causes, lastly, is demonstrated by the prevalence of scrofulous affections subsequent to small-pox, measles, hooping cough, and other diseases which most unequivocally impair the energies of the constitution. Of late years, attempts have been made to connect the scrofulous state, in a peculiar manner, with primary derangement of the digestive functions, but no sufficient reasons have been adduced in support of this opinion. It appears to me to be founded on very imperfect views of the mutual influence of the different parts of the animal economy upon each other.—(Gregory's Practice, p. 512.) Symptoms. Among the earliest, tke most frequent, and most characteristic symptoms of the disease, are swellings of the absorbent glands, parti- cularly those of the neck. Such tumours sometimes continue for a long time, neither advancing nor receding, unattended by pain or any constitutional disturbance. Sometimes they subside sponta- neously, but more frequently suppuration of an imperfect kind gradually takes place in them, followed by open ulceration. The ulcers heal slowly, leaving ragged and unsightly scars, and are succeeded by other tumours, which run a similar course. In this manner the disease is often kept up for a series of years, until at length, the constitution Vol. II. 2K 268 Scrofula. strengthening, either throws it off, or it appears under some of its more severe and dangerous forms. An opinion has been entertained, that 'in scrofula a morbid matter is generated which has a specific influence on the lymphatic system. What the circumstances, however, are, which in a scrofulous habit render the lymphatic system so peculiarly liable to inflammation, we know not. Scrofula affects other structures, and in all cases the in- flammation which is excited has the same general character. It is of a chronic, languid kind. The scrofulous abscess is distinguished by its jagged and uneven sides. The pus which it contains, instead of having a bland, uniform, cream-like appearance, is thin, or ichorous, and mixed with curdy flakes. The ulcer by which it is succeeded has a smooth, obtuse, and overlapping margin. The surface of the sore is of a light red colour, and the granulations are flabby and in- distinct. For a great length of time, in spite of every care, it remains indolent, neither increasing nor diminishing in size. The attacks of scrofula, says a writer, seem much affected or in- fluenced by the periods of the seasons. They begin usually some time in the winter and spring, and often disappear, or are greatly amended, in summer and autumn. The first appearance of the dis- order is commonly in that of small oval or spherical tumours under the skin, unattended by any pain or discoloration. These appear in general upon the sides of the neck, below the ear, or under the chin ; but in some cases other parts are affected. After some length of time, the tumours become larger and more fixed, the skin which covers them acquires a purple or livid colour, and, being much inflamed, they at last suppurate and break into little holes, from which at first a matter somewhat puriform oozes out; but this changes by degrees into a kind of viscid serous discharge, much intermixed with small pieces of a white substance, resembling the curd of milk. The tumours subside gradually, while the ulcers at the same time open more, and spread unequally in various directions. After a while some of the ulcers heal; but other tumours quickly form in different parts of the body, and proceed on in the same slow manner as the for- mer ones to suppuration. In this way the disease goes on for some years, and, appearing at last to have exhausted itself, all the ulcers heal up, without being succeeded by any fresh swellings ; but leaving behind them ugly puckerings of the skin, and scars of considerable extent. This is the most mild form under which scrofula ever ap- pears.—(Thomas.) Scrofulous inflammation (as Burns observes) is marked by a soft swelling of the affected part, which very frequently isone of the lym- phatic glands. The covering or coat of the gland becomes slightly thickened, and its substance more porous and dougfiy. The swelling increases, and the doughy feel changes by degrees into that of elas- ticity, or fluctuation, 'and a firm, circumscribed, hardened margin, can be felt round the base of the tumour. The skin is slightly red. If, at this time, an incision or puncture be made, either no matter or very little is evacuated ; the lips of the wound inflame and open, dis- playing a sloughy-looking substance within; and between this and Scrofula^ 369 the skin a probe can often be introduced for some way all round. If, however, the disease should have advanced farther, then there is very little elasticity in the tumour; it is quite soft, rather flaccid, and fluctuates freely ; the skin becomes of a light purple colour, and small veins may be seen ramifying on its surface* Some time after these appearances, the skin becomes thinner at one particular part, and here it is also generally rendered of a darker colour. It afterward bursts, and discharges a thin fluid, like Whey, mixed with a curdy matter, or thick white flocculi. The redness of the skin still conti- nues ; but the aperture enlarges as the tumour subsides, and thus a scrofulous ulcer is produced. The margins of this kind of sore are generally smooth, obtuse, and overlap the ulcer; they are of a purple colour, and rather hard and tumid. The surface of the sore is of a light-red colour; the granulations are flabby and indistinct; and the aspect is of a peculiar kind, which, says Burns, cannot be described* The discharge is thin, slightly ropy, and copious, with curdy flakes. The pain is inconsiderable. When this ulcer has continued for some time, it either begins slowly to heal, or, as more frequently happens^ the discharge diminishes and becomes thicker. An elevated scab is next formed, of a dirty white or yellowish colour. This continues on the part a good while; and when it falls off, leaves the place covered with a small purple cicatrix or scar. Burns adds, that the preceding description corresponds to the mild scrofula, or the struma mansueta of the old writers. Sometimes, especially if a bone be diseased below the ulcer, the sore has a more fiery appearance, the surface is dark- coloured, the margins soft, elevated, and inflamed, and sometimes retorted. The discharge is watery, the pain very considerable, and the surrounding skin inflamed. This has been called the struma ma- ligna. Such overacting scrofulous sores are most frequently met with over the smaller joints, particularly those of the toes. Some- times a scrofulous abscess, after it has burst, forms a sinus; the mouth of which ulcerates, and assumes the specific scrofulous ap- pearance, while the track of the sinus still continues to emit a dis; charge. Scrofulous swellings are often disposed to subside in winter, and recur on the approach of summer ; but this is not an invariable law. Glandular enlargements are very apt to become smaller, in a short time, in one place, while other glandular swellings originate with equal suddenness, somewhere in the vicinity of the former ones. Ulcers also very often heal upon the appearance of the disease in other parts.—(Burns' Dissertations on Inflammation, vol. ii. 1800.) The glandular swellings which occur in syphilis, says Dr. Thom- son, are of a more acute character than those which proceed from scrofula. They arise from the absorption of a specific poison ; and they do not, like those of scrofula, admit of a spontaneous cure ; a belief, however, now known not to be exactly correct.—(See Vene- real Disease.) Chronic swellings of the lymphatic absorbent glands occur also in carcinoma or cancer ; but these manifest little or no dis- position to suppuration : they succeed most frequently to carcinoma- tous indurations, or ulcers existing in the neighbourhood of the glands affected ; and they are accompanied in their progress and growth by a peculiar lancinating pain.—(On Inflammvtion, p. 135.) 270 Scrofula. Common Treatment. There is nothing very definite in the treatment of this disease, laid down by physicians. It is considered by them incurable, and very little is done for it. Mercury by some is given, but with a decided injurious effect. " For the cure of scrofula," says Cullen, " we have not yet learned any practice that is certainly or even generally successful. The remedy which seems to be the most successful, and which our prac- titioners especially trust to, or employ, is the use of mineral waters. But, he adds, in very many instances of the use of these waters, I have not been well satisfied that they had shortened the duration of the disease more than had often happened when no such remedy had been employed. With regard to the choice of the mineral waters most fit for the purpose, I cannot, with any confidence, give an opin- ion. Almost all kinds of mineral waters, whether chalybeate, sulphu- reous or saline, have been employed for the cure of scrofula, and seemingly with equal success and reputation ; a circumstance which leads me to think, that if they are ever successful, it is the elementary water that is the chief part of the remedy. Of late, sea water has been especially recommended, and employed; but after numerous trials, I cannot yet discover its superior efficacy."—(First Lines of Physic, vol. iv.) On the subject of mineral waters, Dr. Thomson very properly remarks, that they are now usually employed as pur- gative and tonic remedies, and not as specifics. In employing them, it is often difficult to distinguish between the effects which they in reality produce, and those which are to be attributed to the slow ope- ration of time, the season of the year, change of situation, alteration in the mode of life, or exercise in the open air.—(Lectures on Inflamma- tion, &c. p. 195.) Reformed Practice. There are four particular states of this disease, which must be kept in view in treating it: 1st. A state of inflammation. 2d. A state of abscess or ulcer. 3d. A state of tumour or scirrhus. 4th. A state of constitutional affection. 1st. A State of Inflammation. When the disease attacks a person with pain, swelling and inflam- mation, the following poultice must be applied : Take the wild or Indian turnip, (arum tryphyllum ;) if green or fresh, let it be bruised, a little rain or soft water added, and sufficient pulverized slippery-elm bark mixed with it, to form a poultice of a proper consistence. Let it be applied cold, and continued till it begins to be dry ; then renew it. It often is necessary to apply three or four a day, according to the inflammation present. Let this be continued until the swelling subsides, either by or with- out suppuration ; but it is very difficult to disperse scrofulous swellings, Scrofula. 271 attended with much pain and inflammation. I have found the above poultice preferable to any other ; but where the disease is very ob- stinate, a change is sometimes beneficial, and, besides, a substitute may be necessary. 1 then apply a poultice, made of the yellow or narrow-leaved dock, made by bruising or pulverizing the root, simmer- ing it in milk, and then adding a sufficiency of the elm bark to form a poultice, to be applied the same as the one preceding. 2d. State of Abscess or Ulcer. When the swelling or the abscess breaks, or suppuration takes place, our next object will be to bring the ulcer into a healthy state and heal it. As before stated, these ulcers assume a very indolent and invete- rate character, and therefore require altogether a different treatment from that usually pursued to cure them. And I am happy in being able to give, what I have found, a sovereign remedy. We must be governed in our applications, in some degree, by the state of the ulcer. If it be well opened, and no orifice is connected with it, let the following dressings be applied : 1st. Thoroughly cleanse the ulcer with soap, water and spirits, after which, apply to the ulcer a little lint, and over this, the follow- ing salve or plaster: Take bayberry tallow, one part; White turpentine, two parts ; Mix and melt over a slow fire ; then strain, spread upon a piece of linen, and apply to the ulcer. In some seasons and latitudes, a little sweet oil is necessary to make the plaster of the right consistence. Let this dressing be continued through the day. During the night use the following poultice : Take the bark of the root of bayberry, (myrica cerifera,) a suffi- cient quantity. Bruise or pulverize; then add rain or soft water, and simmer until it is soft ; after which stir in sufficient Indian meal, to form a poultice, and continue during the night, and it may be used during the day, provided there is any pain or inflammatory symp- toms present. The original poultice was directed to be made in this manner. But I find that it is a considerable improvement to substitute the elm bark instead of the Indian meal, as it makes a better poultice. I have found, by experience, the bayberry to be one of the most extraordinary remedies in'.the scrofula, particularly in a state of ulcer, of any other article, either in the animal, vegetable or mineral king- dom ; and I have thought, if there was a specific, in any complaint, it is this very plant or shrub. I have never yet known it to fail in a single instance, in all my practice, in the most advanced and worst stages of the complaint, and when they have been treated, without any benefit, by our most popular physicians and surgeons. I have hitherto spoken of scrofula in a state of ulcer. I shall now give directions for the treatment of it, in a state of ulcer connected with a sinus or orifice. By a close examination, often a small opening will be seen, pene- trating deeply into the integuments, or cellular substance, even to the bone, denuding the periosteum, and from this issues either a thin or 2T2 Scrofula. thick matter. When such an opening is found or discovered, it should be kept open, and freely discharging, by the use of tents drawn through beeswax or adhesive plaster, and then rolled in the vegetable caustic, and introduced as far into the sinus as possible. In addition to this, the sinus must be injected with a proper sized syringe, morning and night, with a strong concentrated decoction of the bayberry bark. The black salve may occasionally be substituted for the plaster first mentioned. When the bone is diseased, which may be ascertained by the gra- ting sensation which is communicated when probed, a few grains of the vegetable caustic must be introduced to the bottom of the sinus, and a solution of the same daily injected. 3d. State of Tumour or Scirrhus. This variety or species of scrofula is very frequent. Hard, indo- lent, inert and indurated tumours appear in the glands of the neck, which often continue a long time very stationary ; at other times they slowly increase. Sometimes they are very painful, at other times they give none at all; but sooner or later, if they are not dispersed, they degenerate into a malignant and scrofulous ulcer. In the treatment of these tumours, our first attempt should be to disperse or discuss them, to effect which, apply the following ointment. Take the poke or skoke root, finely scraped or pulverized, any quan- tity. Simmer in spirits till the roots are soft ; cover with fresh butter or lard ; then simmer until the strength is extracted. Strain, and to every four ounces of the ointment, add half an ounce of Venice turpen. tine, and let it be well mixed or incorporated. Rub the tumour with this ointment, three or four times a day, half an hour each time it is used. Then apply a plaster of the inspissated juice of the poke-berrry, to be spread on a soft piece of leather, and occasionally renewed. Continue these dressings a sufficient length of time to ascertain whether the tumour decreases, and if so continue them ; but if they are not diminished, but on the contrary grow larger, then use the discutient ointment in the same manner, and, after having anointed the parts with it, apply our common strengthening plaster* These applications will in general discuss these tumours, even when very large, if aided by proper internal medicine. 1 recollect, however, having one case, on the neck of a young lady of this city, of very long standing, so large and so indolent, as not only to baffle the skill of several physicians, but likewise my own. In this case, I made a little roll of adhesive plaster, the thickness of a quill, formed a ring about the size of the tumour, placed it over it, and then covered the inner part, or the part encircled, with the mineral caustic, wet with a few drops of water, and over the whole I placed the black plaster. This was suffered to remain on twenty-four hours, which enveloped a considerable portion of the tumour in an eschar. I then applied a poultice made of yest and the elm bark, which separated the part, destroyed, and in this manner removed the scrofulous tumour.. The young woman has been well many years. Scrofula. 27S I am not, however, very partial to this method, as it excites con- siderable pain, and requires very skilful management. But it is (seldom, if ever required, if the means 1 have recommended be pro- perly applied, and persevered in a suitable length of time. When all means fail to discuss the tumor, mild dressings must be applied, until there are symptomsof inflammation, or suppuration, and then it must be poulticed as before directed. Constitutional Affection. It appears that there is generally a scrofulous diathesis, or state of the system, which may be known by a peculiar haggard and pale countenance, flabby muscles, and small tumours appearing in the glands, in different parts of the body, attended with a considerable de- gree of debility, with more or less derangement of the digestive organs. When such symptoms present, give the following decoction : Take yellow dock-root; Bark of the bitter-sweet; Of each a pound ; bruise ; add a sufficient quantity of water, and boil till all the strength is extracted down to two quarts. Strain ; add four pounds of sugar. Then boil a few minutes to form a syrup. Of this, give from half a wineglassful to a wineglassful, three or four times a day, to a child five or six years old. As a change, give the alterative syrup part of the time. Both are exceedingly well calculated to eradicate a scrofulous, or any other taint of the system. In addition to this, the patient should take a purgative at least once a week. If any small tumours are perceived, in any part of the body, let the discutient ointment be applied to them three or four times a day. By pursuing this treatment, I have succeeded in curing the most formidable cases of scrofula on record ; one of which I here repre- eent by the annexed figure. 274 Scrofula. The subject of the disease was a coloured man, then residing in Trenton, N. J. The swelling and inflammation were prodigious, and several physicians, who were first called, appeared to consider the case entirely hopeless. One of them observed, that whoever cured the disease should be pronounced " King of Doctors." It was first poulticed with the green root of Indian turnip, (arum triphyllurn,) until suppuration followed, with fifteen different apertures, or orifices, through which the pus or matter discharged. I now injected the alka- line liquid, and it issued through every one of them. Tents were used to prevent the ulcers from healing ; a plaster was kept upon the swell- ing, and it was in other respects treated in the usual manner. It im- proved daily, till it healed perfectly sound, leaving but very small scars immediately over the sinuses or apertures. May not the bayberry (the principal article used in the cure of this complaint) derive some of its medicinal effects from the muriate of soda, which it imbibes from the salt water, near where it grows ; or upon some peculiar organization arising from it ? It is somewhat remarkable, that the bayberry should only grow near the seacoast, or salt water; which it is known often exerts some beneficial effect on the patient by bathing with it. Regimen. The patient should be confined to a nutritious diet, principally milk. He should bathe once a week in salt water, and, if it is convenient, should live near it, in the country. CHAPTER XVIII. INFLAMMATION OF THE EYE--(Ophthalmia.) Description. By the term ophthalmia, we understand inflammation, either pri- mary, or symptomatic, of the membranes of the eye, its superficial, or deep-seated parts, muscles, ■■ . - • 'V'-.r v th • --.'nroi:-.. V:v '■].? r>r? ' r ■">•" a tViS1: 332 Aneurism—(Aneurisma.) theory ; since observation shows that there is only one form of the disease, or that caused by a rupture of the proper coats of the artery, and an effusion of the arterial blood into the cellular sheath which surrounds the ruptured artery."—(See Treatise on Aneurism, by A. Scarpa, transl. by J. H. Wishart, Edin. 1808.) Such were the inferences made by Scarpa, in 1804, one of the most distinguished anatomists and surgeons of the present day upon the con- tinent. It has been already stated, that, great as this authority is, several eminent modern surgeons, as Richerand, Boyer, Dubois, Dupuytren, Sabatier, Breschet, &c, did not yield to it, but still contended that in some aneurisms the coats of the artery were dilated. These profes- sors in France coincided with what has been usually taught upon this subject in the surgical schools of Great Britain. Every lecturer here has been accustomed to describe the distinctions of aneurisms into true and false, or into some cases which are accompanied with dilata- tion, and into others which are attended with rupture of the arterial coats. A few years ago, Mr. Hodgson, of Birmingham, published a valuable treatise on aneurism, in which work he differs from Scarpa, and joins those surgical writers who believe in the occasional dilata- tion of the coats of the arteries.—(S. Cooper.) Partial as well as general dilatation (says Hodgson) frequently pre- cedes the formation of aneurism in the arteries of the extremities. A gentleman had a large aneurism in the thigh, which had undergone a spontaneous cure. Upon examining the limb after death, the popliteal artery was found to be thickened and covered with calcareous matter. A small pouch, which would have contained the seed of an orange, originated from the side of this artery. This little sac was evidently formed by a dilatation of the coats of the vessel. A man died from the sloughing of an aneurism in the ham; in the femoral artery there was a small aneurism about as large as a walnut. The external coat was dissected from the surface of the tumour to a considerable extent. The internal and middle coats were evidently dilated, and contributed to the formation of the sac. In many instances the most fatal accidents have happened, in con- sequence of incisions having been made in aneurisms, which were mistaken for abscesses because there was no pulsation. Vesalius was consulted about a tumour of the back, which he pronounced to be an aneurism. Soon afterward an imprudent practitioner made an open- ing in the swelling, and the patient bled to death in a very short time. Ruysch relates that a friend of his opened a tumour near the heel, not supposed to be an aneurism, and the greatest difficulty was experienced in suppressing the haemorrhage. De Haen speaks of a patient, who died in consequence of an opening which had been made in a similar swelling at the knee, although Boerhaave had given his advice against the performance of such an operation. Palfin, Schlitting, Warner, and others, have recorded mistakes of the same kind. (Sabatier, t. iii. p. 167.) Notwithstanding a pulsation is one of the most prominent symptoms of an aneurism, it is not to be inferred, that every swelling which pul- sates is unquestionably of this description. Whenever an ancurismal sac of immoderate size beats violently and Aneurism—(Aneurisma.) 333 f'H a long while against the bones, as the sternum, ribs, clavicle, and vertebra?, they are in the end invariably destroyed, so that the aneu- rismal sac elevates the integuments of the thorax, or back, and pulsates immediately under the skin. Scarpa, with the best modern writers, attributes the effects to absorption in consequence of the pressure. Aneurisms are common in the aorta, and they are particularly often met with in the popliteal artery. The vessels which are nextte 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, fore-arm 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 aneurisms, the smaller arteries seem to be more immediately concerned in the formation of one peculiar aneurismal disease, now well known by the name of the aneurism by anastomosis. Causes. The causes of aneurisms operate either by weakening the arterial parieties 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, frequent mercurial courses, fits of anger, rough exercise, exortions in lifting heavy burdens, &c. In certain persons aneurisms appear to depend upon a particular organic disposition. Richerand affirms, that out of twelve popliteal aneurisms which he had seen in hospital or private practice, ten were caused by a violent extension of the leg. In many instances it is difficult to assign any cause for the commence- ment of the disease. Among the circumstances which predispose to aneurisms, however, the large size of the vessels may undoubtedly be reckoned. Those trunks which are near the heart are said to have much thinner parietes, in relation to the magnitude of the column of blood with which they are filled, than the arteries of smaller diameter; and since the lateral pressure of this fluid against the sides of the arteries is in a ratio to the magnitude of these vessels, it follows that aneurism must be much more frequent in the trunks near the heart than in such as are remote from the source of the circulation.— (Richerand, Nosogr. Chir. t. iv. p. 72. 2d. ed.) The whole arterial system is liable to aneurism ; but, says Pelletan, experience proves that the internal arteries are much more frequently affected than those which are external.—(Clinique Chir. t. i. p. 54.) The curvatures of the arteries are another 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 cross and the origin of this large artery, and is the more considerable the older the person is: Monro even thought that one half of the old persons have an aneurism at the beginning of the aorta. And with respect to aneurisms in gene- ral, which are preceded by calcareous depositions, thickening, and disease of the coats of the vessel, they are most frequently met with 334 Aneurism—(Aneurisma.) in persons of advanced age. Aneurisms from wounds are of course often seen in individuals of every age. In old people the coats of the arteries are subject to a disease which renders them incapable of making due resistance to the liberal impulse of the blood. It was observed by Morgagni, that popliteal aneurisms occur with particular frequency in postilions and coachmen, whose employments oblige them to sit a good deal with their knees bent. In France, the men who clean out the dissecting rooms and procure dead bodies for anatomists, are said, almost all of them, to die with aneurismal dis- eases. Richerand remarks, that he never knew any of these persons who were not addicted to drinking, and he comments on the debility which their intemperance and disgusting business together must tend to produce.—(Nosogr. Chir. t. iv. p. 74. 2d. edit.) It may be pro-. duced by wounds, contusions, debility, &c. Symptoms. The symptoms of a circumscribed true aneurism are as follows: the first sensation which the patient perceives, is an extraordinary throbbing in some particular situations, and on paying a little more attention, he discovers there a small pulsating tumour which disap- pears when compressed, but returns again as soon as the pressure is removed. The colour of the skin is not changed. The tumour now continues gradually to increase until it attains a very great size. There is beating, throbbing and pain. In proportion as it becomes larger, the pulsations are less distinct, or become weaker, sometimes they are entirely lost when the disease acquires a great magnitude. The diminution of the pulsation has been ascribed to the coats of the artery losing their dilatable and elastic quality in proportion as they are distended and indurated, and, consequently, the aneurismal sac being no longer capable of an alternate diastole and systole from the action of the heart. The fact is also imputed to the coagulated blood deposited on the inner surface of the sac, particularly in large aneurisms, in which the motion of some of the blood is always inter- rupted. Immediately such coagulated blood lodges in the sac, pres- sure can only produce a partial disappearance of the swelling. This deposition of lamellated coagulum in the aneurismal snc is a circum- stance of considerable importance ; for it has been well explained by Hodgson, that it is the mode by which the spontaneous cure of the disease is in most instances effected. " One of the circumstances which, in the most early stage, generally attend the formation of aneurism, (says this author,) is the establishment of that process which is the basis of its future cure. The blood, which enters the sac soon after its formation, generally leaves upon its internal surface a stratum of coagulum, and successive depositions of the fibrous part of the blood gradually diminish the cavity of the tumour. At length the sac becomes entirely filled with this substance, and the deposition of it generally continues in the artery which supplies the disease, forming a firm plug of coagulum, which extends on both sides of the sac to the next important ramifications that are given off from the ar- tery. The circulation through the vessel is thus prevented, the bloo^ Aneurism—(Ancurima.) 335 is conveyed by collateral channels, and another process is instituted, whereby the bulk of the tumour is removed, &c. As the tumour grows larger, the communication of blood into the artery, beyond the tumour, is lessened ; hence, in this state, the pulse below the swelling becomes weak and small, and the limb fre- quently cold and swelled. The pressure of the tumour on the adja- cent parts may also produce a variety of symptoms, such as inflam- mation, ulceration, absorption of bone, &e. In the advanced stage of an aneurism, the skin is found extremely thin, and confounded, as it were, with the aneurismal sac. The ca- vities of the cellular substance near the disease, are either filled with serum or totally obliterated by adhesion. The adjacent muscles, whether they lie oVerthe aneurism or to one side of it, are stretched, displaced, dwindled, and sometimes confounded with other parts. It is the same with the large nervous cords situated at the circumference of the tumour: they are pushed out of their natural situation, dimi- nished in size, sometimes adherent to the outside of the sac, and so changed as scarcely to admit of being known again. Lastly, the cartilages and the bones themselves are not exempt from the mischief which the aneurismal swelling produces in all the surrounding parts : they are gradually destroyed, and at length not the least trace of their substance remains, just in the same way as the bones of the cranium are destroyed by fungous tumours of the dura mater. Even the car- tilages of the larynx and rings of the trachea are sometimes destroyed ; this tube is pierced, and the blood escapes into it, or the aneurism bursts into the oesophagus.—(Boyer.) While an aneurism is small and recent, it does not generally cause much pain, nor seriously impede the functions of the limb. But when it has increased, several complications are produced. Thus, the drag- ging of the saphenal nerve, by femoral aneurisms, frequently occa- sions acute pain in the course of this nerve as far as the great toe. The distention of the sciatic nerve, by the popliteal aneurism, some- times brings on intolerable pain, which extends to all the parts to which this nerve is distributed, and which can hardly ever be appeased by the topical use of opiate applications. The compression of the veins and lymphatics gives rise to swelling, numbness and coldness of the limb. And, finally, the long continued pressure of the aneu- rism on the neighbouring bones, causes their destruction.—(Boyer, t. ii. p. 105.) In true aneurism, the coats of the artery are not always in the same state, the kind of changes observed depending upon the progress of the tumour. In the early stage of the disease, either the whole cylinder of the vessel, or only a part of its circumference, is dilated ; but this period is generally of short duration, especially in arteries of middling size, because their middle coat is capable of less resistance than that of the larger arteries, like the aorta, where this coat is yel- lowish, firm, and very elastic. As Breschet remarks, this difference of resistance in the middle coat of the aorta and the branches given off from it, accounts for the rarity of true aneurisms cither in the small arteries or those of middling size, and their greater frequency in the principal trunk of the arterial system. 336 Aneurism—(Ancurisma.) At length, in consequence of the increasing distention, some of the coats of the artery possessing the least elasticity give way, and these are found to be the internal and middle coats, while the external one still makes resistance and continues to be more and more dilated by the lateral impulse of the blood. The second stage of true aneurism is that which is mostly met with ; that in which the tumour increases more rapidly, and therefore begins to excite greater attention. The disease, when it has attained this form, is in point of fact no longer a true aneurism, but a case which Monro distinguished by the name of the consecutive or external mixed false aneurism. In this stage the patient's life is endangered, and death often brought on by the rupture of the tumour. Examina- tions of the dead subject, under these circumstances, have frequently led to mistaken notions ; and doubtless if various swellings of this kind had not been found in different degrees or stages in the same in- dividual, one might be disposed to join Scarpa in the belief, that no aneurism consists of a dilatation of all the arterial coats.—(Brescket, Fr. trans, of Mr. Hodgson's work, p. 128, 129.) The false aneurism is always attended with at least a rupture, or giving way of the inner coat of the vessel, and usually with a breach in both this and the muscular coat, the outer elastic tumour forming the pouch in which the blood collects. But after the swelling has attained a certain size, this coat also bursts, and then the blood either becomes diffused, or a large circumscribed space is formed for it by the condensation of the surrounding cellular membrane. False aneu- risms, when produced by a wound or puncture, are of course, from the first, attended with a division of all the coats of the vessel. This form of the disease is often seen at the bend of the arm, where the artery is exposed to injury in venesection or bleeding. In this circumstance, as soon as the puncture is made, the blood gushes out with unusual force, and in a bright scarlet, irregular, interrupted current; flowing out, however, in an even and less rapid stream when pressure is ap- plied higher up than the wound. These last are the most decisive marks of the artery being opened ; for blood may issue from a vein with great rapidity, and in a broken current, when the vessel is turgid and situated immediately over the artery, which imparts its motion to it. The surgeon endeavours precipitately to stop the hemorrhage by pressure, and in general a diffused false aneurism is the result. The external wound in the skin is closed, so that the blood cannot escape ; but this does not hinder it from passing into the cellular substance. The swelling thus produced is uneven, often knotty, and extends up- wards and downwards along the track of the vessel. The skin is also usually of a dark purple colour. Its size increases as long as the internal haemorrhage continues, and if this should proceed beyond certain bounds, mortification of the limb ensues. Such is the diffused false aneurism from a wound. The circumscribed false aneurism, from a wound or puncture, arises in the following manner. When proper pressure has been made in the first instance, so as to suppress the haemorrhage, but the bandage has afterward been removed too soon, or before the artery has healed, the blood passes through the unclosed wound, or that which it has Aneurism—( Aneurisma.) 337 burst open again, into the cellular substance. As this has now be- come agglutinated by the preceding pressure, the blood cannot diffuse itself into its cells, and consequently a mass of it collects in the vi- cinity of the aperture of the artery, and distends the cellular substance into the form of a sac. Sometimes, though not often, the circum- scribed false aneurism originates immediately after the opening is made in the artery. This chiefly happens when the aperture in the vessel is exceedingly small, and consequently when the hemorrhage takes place so slowly that the blood, which is first effused, coagulates, and prevents the entrance of that which follows into the cavities of the cellular substance, and of course its diffusion. False aneurisms, pro- ceeding from the rupture of the inner coats of an artery, are always at first circumscribed by the resistance of the outer tunic. The circumscribed false aneurism consists of a sac composed of the external coat of the artery; or, in case this has given way, it is com- posed of an artificial pouch, formed among whatever parts happen to be in the vicinity of the burst artery. This cavity is filled with blood, and situated close to the artery, with which it has a communication. Hence, in false aneurisms, a throbbing is always perceptible, and is more manifest the smaller such tumours are. The larger the sac be- comes, the less elastic it is, and the greater is the quantity of laminated coagula in it; so that in very large aneurisms of this kind, the pulsa- tion is sometimes wholly lost. The tumour is at first small, and on compression entirely disap- pears ; but returns as soon as this is removed. It also diminishes when the artery above it is compressed ; but resumes its wonted mag- nitude immediately such pressure is discontinued. When there is coagulated blood in the sac, pressure is no longer capable of produ- cing a total disappearance of the tumour, which is now hard. The swelling is not painful, and the integuments are not changed in colour. It continually increases in size, and at length attains a prodigious magnitude. The.following are generally enumerated as the discriminating dif- ferences between circumscribed true and false aneurisms : the true aneurism readily yields to pressure, and as readily recurs on its re- moval ; the false one yields very gradually, and returns in the same way ; and as it contains coagula, it cannot be reduced in the same degree by compression as an aneurism formed by a dilatation of the arterial coats, where such strata of coagulated blood are usually ab- sent. Frequently a hissing sound is audible when the blood gushes into the sac. The pulsation of the false aneurism is always more feeble, and as the tumour enlarges, is sooner lost than that of the true one, which throbs after it has acquired a considerable volume.—(See Richter's Anfangsgr. b. i. Discrimination. Aneurismal tumours may be known by the pulsation being per- ceptible over every part; whereas, in tumours which derive their pul- sation from being situated over an artery, it is only to be felt in the direction of the vessel. 338 Am urism—(Aneurisma.) Also, if the aneurism be recent, by pressing your finger on the af tery which leads to the aneurism, you will empty the aneurismal bag ; but if the aneurism be of long duration, and the pulsation is but slight, place yourself by the side of the patient, observe carefully the size of the swelling, and by pressing your finger on the artery above, you will see the aneurism sink down as you make the pressure, though the sac will not entirely empty itself; and upon raising your hand sud- denly, you will observe a jet of blood rush into the aneurismal sac, and raise it to its former height. The following are the principal or the most formidable aneurisms : Aneurism of the Heart. An aneurism of the heart consists of a bag formed out of the parie- tes of that organ, and in this bag an opening is formed, as in aneurisms which take place in arteries. In these unhappy cases, the only course you can adopt, is to enjoin quietude, with mild and moderate diet.—(Cooper.) Aneurisms of the Aorta. Aneurisms of the aorta, are diseases of by no means unfrequent occurrence ; and are, indeed, most truly to be dreaded, both by the surgeon and the patient. No affliction, in fact, can be more deplorable ; for, the sufferings which they occasion hardly ever admit of palliation, and the instances of recovery are so very few, that no consolatory expectations can be indulged of avoiding the fatal end to which the disease naturally hastens. Aneurisms of the aorta vary in their situation; sometimes arising in one part, in other instances, at another ; more frequently, however, at the arch of the aorta.—(Cooper.) Popliteal Aneurism. Popliteal aneurism, as its name implies, is situated in the popliteal space of the ham ; it is the most common external one, and is charac- terized by the symptoms lately drawn in illustration of external aneurisms. Femoral Aneurisms. It is not an uncommon occurrence to meet with an aneurism of the femoral artery, just below Poupart's ligament. Axillary Aneurisms. There may happen cases of aneurism iii the axilla. Carotid Aneurisms. Aneurisms of the carotid artery may undergo a spontaneous cure, without any senous consequences to the br^'o Aneurism—(Aneurisma. J 339 t Common Treatment. The method now adopted in the treatment of aneurism, is to make an incision down to the artery, passing a ligature round, tying it, and then closing the lips of the wound. This is done to prevent the en- trance of blood into the aneurismal sac. But from the effect of this operation, and from the various reports which have been detailed by those who have performed it, (I mean honest reports, for many I have found have been false,) I am led to doubt the propriety, or the utility of the operation. I find, by strict inquiry, that more cases even on record have been cured without an operation, or cured spontaneously by the natural efforts of the system, without the least medicine what- ever, than have been cured by a surgical operation, or tying the ar- tery. A large proportion of the cases where an operation has been performed, have proved fatal. Occasionally one has been reported which has proved successful. But even such, I find, has often been followed by the most serious, injurious, or fatal effects, such as morti- fication of the leg, scirrhous enlargement, stiffness, and permanent lameness. Were I to give an account of the number of cases that have proved fatal by a surgical operation, the catalogue would indeed be frightful. My objections to the operation are as follow : 1st. The consequences arising from-irritation or pain. In some habits, and in some aneurisms, such a degree of pain or irri- tation is produced that the patient is carried off at the time, or shortly afterwards. In this city, some time ago, a woman died in about twen- ty-four hours after an operation for a femoral aneurism ; and nume- rous others might be mentioned. 2d. The second objection is the danger arising from haemorrhage. The impetus of blood is so great after an artery has been tied, that sometimes hemorrhage or bleeding takes place, and proves fatal. 3d. Mortification of the Limb.—If hemorrhage does not imme- diately arise from the act of tying the artery, as soon as the ligature or ligatures cut through it, mortification often takes place, and carries off the patient. 4th. After the operation has been performed of tying the artery, even if no such effects follow as above mentioned, in consequence of the anastomosing branches not being sufficient to supply the limb with blood below the aneurismal tumour, or in consequence of the want of a due circulation, the temperature of the limb is diminished or re- duced, mortification and sloughing takes place, and the limb or life of the patient is endangered or lost. This happened in this city in the case of a Mr. Parcells, who was operated upon for femoral aneurism by Dr. M----. 5th. Callus and stiffness of the limb. Where an aneurism is situated upon any of the extremities, if the circulation is cut off by tying the artery for an aneurismal tumour, the whole limb frequently becomes not only oedematous and exceed- ingly swelled, but it likewise becomes stiff, indurated, and so perma- nently enlarged, that the use of it is entirely lost, and amputation Vol. II. 2 T • 340 Aneurism—(Aneurisma.) is proposed as the only remedy. This occurred in the case of Rich- ard White, of Brooklyn, who was operated upon for a popliteal aneu- rism ; and such deplorable consequences resulted from it, that ampu- tation was proposed as the only alternative. I objected to this operation, (for which I received a liberal share of abuse,) and after about nine months, succeeded so far in reducing the enlargement, and removing the stiffness of the limb, that he was enabled to walk without crutches, and he now attends to his ordinary business. 6th. I object to the operation, because it does not even in all cases prevent the blood from passing into the aneurismal sac, by which the pulsations and the tumour still continue in a greater or less degree. 7th. I object to the operation again, because nature alone effects more cures than are effected or performed by the operation. 8th. I object to it, because I have succeeded in curing it where an operation has been proposed as the only alternative to save life, and where a fatal event was predicted without such operation being performed, by a most distinguished operator of this city. 9th. I object to it, because the operation is not only uncertain in the event, but because it is excruciatingly painful, particularly under cer- tain circumstances. 10th, and lastly. Because the operation may be resorted to, as an ex- periment, when all other means fail, or as the last alternative. According to Scarpa, the circumstances chiefly preventive of suc- cess, especially in the popliteal and femoral aneurisms, are the follow- ing : Rigidity, atony, or disorganization of the principal anastomoses, between the superior and inferior arteries of the ham and leg ; some- times depending on an advanced age, or on it together with the large size of the aneurism, which by long continued pressure has caused a great change in the neighbouring parts; or sometimes on steatoma- tous, ulcerated, earthy, cartilaginous disorganization of the proper coats of the artery, not confined to the seat of the rupture, but extend. ing a great way above and below the aneurism, and also to the princi- pal popliteal recurrent arteries, tibial arteries, and, occasionally, to portions of the whole track of the superficial femoral artery. Some- times the pressure of a large aneurism renders the thigh-bone carious. In such circumstances, the ligature is apt to fail in closing the trunk of the artery; and, if it should succeed, the state of the anastomosing vessels will not admit of a sufficient quantity of blood being conveyed into the lower part of the limb. Hence, when the patient is much advanced in life, languid and sickly ; when the internal coat of the ar- tery is rigid, and incapable 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 oedematous, Scarpa considers the operation contra-indi- cated. I will now give a few cases that, are before me, that have proved fatal in consequence of the operation. Aneurism—(Aneurisma.) 341 Cake 1st. Aneurism of the Carotid Artery, related by Sir Astley Cooper. The first case is that of Mary Edwards, aged 44. The swelling occupied two thirds of the right side of the neck, pulsated very strong- ly, and the integument at the most prominent part of the tumour ap- peared very thin. It had existed six months previous to the operation, which was performed as follows:—On November 1,1805, I made an incision, two inches long, on the inner edge of the sterno mastoid muscle, from the inferior part of the tumour to the clavicle, which laid bare the omo and sterno-hyoideus muscles, which being drawn aside towards the trachea, exposed the jugular vein. The motion of this vein produced the only difficulty in the operation ; as, under the different states of breathing, it sometimes presented itself to the knife tense and distended, and then as suddenly collapsed. Passing my finger into the wound, to confine that vein, I made an incision upon the carotid artery, and having laid it bare, I separated it from the par vagum, and introduced a curved anuerismal needle under it, taking care to exclude the recurrent nerve on the one hand, and the par va- gum on the other. The two threads were then tied about half an inch asunder, being the greatest distance to which they could be se- parated : on account of the short space, I did not divide the artery. As soon as the threads were tied, all pulsation in the tumour ceased, and the wound was superficially dressed. Immediately after the operation she was seized with a severe fit of coughing, which continued half an hour, when she became more tranquil, and slept six hours during the following night. She con- tinued in a favourable state until the eighth, when it was observed that her left arm and leg were paralytic : she was restless, but had not any pain in the head. 9th. Could not'swallow solids, and felt oc- casional pricking pain in the wound. 11th. Power of motion of the left arm returned, and she appeared going on favourably. 12th. The two ligatures came away with the intervening portion of artery. She went on well until the 17th, the tumour reducing, and the wound healing; when the wound again opened, the tumour increased and was painful; she had a violent cough, great difficulty in swallowing, and a high degree of constitutional irritation. From this time she gradually got worse, and died on the 21st. CASE II. Mr. Travers, in an operation which he performed for a popliteal aneu- rism in a sailor, in Nov. 1813. A double ligature was passed under the femoral artery. The ligatures were tied with loops or slip knots, about a quarter of an inch of the vessel being left undivided between them. All that now remained of the pulsation in the tumour was a slight undulatory motion. Nearly six hours having elapsed from the application of the ligatures, the wound was carefully opened, and the ligatures untied and removed without the slightest disturbance of the vessel. In less than half a minute afterward the artery became dis- tended with blood, and the pulsations in the tumour were as strong as 342 A neurism—( Aneurisma.) they had been before the operation. Mr. Hutchison then applied two fresh ligatures ; hemorrhage afterwards came on ; amputation was performed, and the patient died.—(See Practical Obs. in Surgery, p. 102.) CASE III. The following cases were mentioned by Sir Astley Cooper. A man underwent the operation for aneurism ; the femoral artery was tied ; the pulsation ceased ; and the patient in a little while was supposed to be cured of the aneurism, and discharged. Upon his return to la- bour, however, a swelling arose in the ham, without pulsation. The swelling subsided in consequence of rest: but afterward, while the man was at work, the swelling returned with great pain. At length, as Sir Astley conceived that there was no prospect of the limb be- coming useful again, it was amputated. Upon an examination of the parts, he found that the femoral artery, below the place of the ligature, had been conveying blood. It does now and then happen (says he) that a blood-vessel will arise from the artery close above the ligature, and pass into the artery immediately below it, by which means the circulation is produced. Sir Astley then referred to a specimen in the hospital museum, where this fact is illustrated in the brachial ar- tery.—(See Lancet, vol. i. p. 298.) CASE IV. Another example of the operation is reported in vol. xii. of the Lancet. The carotid was tied above the aneurism by Mr. Lambert, and Mr. Callaway, March 1st, 1827. On the third day, the tumour seemed much consolidated, and reduced in size. On the 10th day, there was some bleeding from the wound ; but it was suppressed by the application of a compress wet with cold water ; and in a few days, the swelling had entirely disappeared, and all that could be felt of it on pressing the finger deeply down, was a small hard tumour, having a very faint undulatory thrill. Unfortunately,1 this patient, also a fe- male, fell a victim to hemorrhage on the 1st of May, in consequence of ulceration extending. CASE v. Another instance, in which the internal iliac artery was tied, was some time ago communicated to the public. The operation was per- formed by Mr. Atkinson, of York, on account of a gluteal aneurism. The following are a few of the particulars, as related by this gentle- man :—Thomas Cost, aged 20, presented himself at the York County Hospital, April 29th, 181J. He was a tall, strong, active bargeman, not corpulent, but very muscular. He was enduring great pain from a large, renitent, pulsating tumour, situated under the gluteus of the right side ; an obvious aneurism. It had existed about nine months, and was the consequence of a blow from a stone. In a consultation with Dr. Lanson and Dr. Wake, the necessity of the operation was determined upon, and it was performed on the 12th of May, without any material difficulty or interruption. The artery being then tied, the pulsation of the swelling entirely ceased. Aneurism—(Aneurisma.) 343 The patient went on tolerably well for some time after the opera- •ion ; the pulse never exceeded 130, and after a time sunk to 85 or 90. He became exhausted, however, partly by the discharge, and partly by hemorrhage, and died on the 31st of May, about nineteen days after the operation. CASE VI. Dr. Jeffrey, of Glasgow, was consulted in a case where the gluteal artery had been wounded. He urged the propriety of tying the ves- sel where it had been injured. This sensible advice was at first re- jected, and when the friends at last consented, the operation was too late, as, while preparation was making for it, the tumour burst, and the patient expired in a few moments. CASE VII. Thenden also mentions an instance in which the gluteal artery was wounded in the dilatation of a gun-shot wound, and the patient lost his life.—(See Scarpa on Aneurism, p. 407. 2d. edit.) CASE VIII. Professor Gibson had occasion to put a ligature round the iliac, in an example of gun-shot wound. " The patient lived fifteen days after the operation, and then died from peritoneal inflammation, and from ulceration of the artery. The circulation in the limb of the in- jured side was re-established about the seventh day after the artery was tied." Axillary Aneurisms. Aneurisms occasionally take place in the axilla, and make it neces- sary to tie the subclavian artery. A question here naturally present- ing itself is, whether the surgeon should attempt the operation in an early period of the disease, or wait till circumstances are urgent; the aneurism large and far advanced; the arm oedematous and insupport- ably painful, from the stretching of the axillary plexus of vessels ; the patient worn out by suffering and loss of rest; and the tumour in danger of bursting? In all cases of aneurisms, unquestionably, there is a certain chance of the disease getting well spontaneously; 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 patient, while living, gave of his case, and by the obliteration of the artery, found on inspection after death. CASE IX. Mr. Hunter's second operation for internal aneurism, was on a trooper. Instead of using several ligatures, which were found hurt- ful, he tied the artery and vein with a single strong one ; but un- luckily the experiment was made of dressing the wound from the bot- tom, instead of attempting to unite it at once ; and the event was, that the man died of hemorrhage. 344 Aneurism—(Aneurisma.) case x. The operation of tying the artery below the tumour was repeated by Sir A. Cooper, not for an aneurism of the femoral artery in the groin, but for an aneurism of the external iliac, where tying the artery above the swelling was impracticable. The femoral ar- tery was therefore tied immediately below Poupart's ligament, be- tween the origins of the epigastric and the profunda. The pulsations of the tumour continued ; but the progress of the disease was checked. After a time, indeed, the swelling decreased, and this in so consi- derable a manner, that hopes began to be entertained that perhaps the external iliac artery might soon admit of being tied above the disease. The ligatures came away without any unfavourable occurrence, and when the wound was healed, the patient was sent into the country for the benefit of the change of air. Afterward, however, the tumour gave way; an extravasation of blood took place in the abdomen and cellular membrane of the pelvis, and the patient died. case XI. December 10, 1826, Mr. Wardrpp attempted a similar operation for the cure of a carotid aneurism in another woman, aged 57. Some reduction of the throbbing, and other relief, are stated to have en- sued ; but the patient died of a complication of complaints on the 23d of the following March, 1827. " Up to the day of her death, a tu- mour remained in her neck of about the bulk of an almond, which pulsated strongly, felt very thin in its coats, and its contents could be readily squeezed out of it, but returned rapidly, when the pressure was removed."—(p. 33.) In the dissection, it deserves notice, that the carotid was found completely pervious, and that no cicatrix nor other appearance, enabled Mr. Bennet to ascertain the precise point to which the ligature had been applied.—(p. 35.) CASE XII. Mr. C. Bell met with a case in which the femoral artery divided below the profunda into two equal branches, the most superficial of which was alone noticed and tied in the operation. The patient died of constitutional disturbance, arising from inflammation in the whole course of the sartorious. CASE XIII. Mr. Vincent tied the carotid trunk for an aneurism. A single ligature was applied ; the pulsation in the tumour did not entirely cease, at first, when the artery was tied, but it did so two days afterward; and the swelling was rapidly diminishing. The li- gature came away about three weeks after the operation, and there was every hope of a cure ; but, between the fourth and fifth week, a considerable swelling occurred between the wound and the jaw, im- peding deglutition, but not the breathing. This state was followed by febrile symptoms, increased difficulty of swallowing, an attack of coughing, and impeded respiration. In the hope of affording relief, an incision was made in the tumour, from which a small quantity of pus and coagulum issued; but it was in vain, for the patient was dying. Aneurism—(Aneurisma.) 345 CASE XIV. John Townly, a tailor, aged thirty-two, addicted to excessive in- toxication, of an unhealthy and peculiarly anxious countenance, was admitted into St. Bartholomew's hospital on Tuesday, the 2d of No- vember, 1809, on account of an aneurism in the right axilla. Imme- diately the artery was tied, the pulsation of the swelling ceased; the arm of the same side continued to be freely supplied with blood, and was even rather warmer than the opposite arm. The opera- tion, which was severe from the length of time it took up, was, after a time, followed by considerable indisposition. The patient died about five days after its performance. After the artery had been tied, the oedema of the arm and the aneurismal tumour partly subsi- ded ; and, on examination after death, nothing but the vessel was found included in the ligature. CASE xv. In Dr. Colles's first case, the artery was tied before it reached the scaleni muscles, as the tumour, which was in the right subclavian ar- tery, extended from the sternal origin of the sterno mastoid muscle along the clavicle, a little beyond the arch of that bone, and rose near- ly two inches ahove it, in a conical form, the apex of the cone being situated at the outer edge of the foregoing muscle. After a tedious dissection, it was found that only a quarter of an inch of the artery was sound, and on this portion the ligature was placed. Great difficulty was encountered in passing it round the artery, and the pleura was supposed to have been slightly wounded. Before tightening the liga- ture the breathing became laborious, and the patient complained of oppression about the heart. These symptoms, indeed, were so violent, that it was judged prudent not immediately to tighten the ligature. On the fourth day, however, the artery was constricted, when the pulse at the wrist ceased, the patient not seeming to suffer much from what had been done. The patient then went on pretty well till the ninth day, when he was seized with a sense of strangling, and pain about his heart, and, becoming delirious, died nine hours after the be- ginning of this attack. On dissection, the aorta was found diseased, and the disease extended into the subclavian artery. In another instance, Dr. Colles tied this vessel at the point where it emerges from between the scaleni muscles, without any particular difficulty. The operation, however, was soon followed by a train of severe symptoms, delirium and mortification, and the patient died on the fifth day.—(See Edin. Med. and Surg. Journ. January, 1815.) With respect to tying the subclavian artery on the tracheal side of the scalenus, we have seen, that it was performed by Dr. Colles, and the event was fatal. Descriptions of the operation may be found in Mr. Hodgson's work, p. 382. CASE XVI. Mr. Aberngthy was under the necessity of tying the trunk of the carotid, in a case of extensive lacerated wound of the neck, where the 346 Aneurism—(Aneurisma.) internal carotid and the chief branches of the external carotid were wounded. The patient at first went on well: but in the night he be- came delirious, and convulsed, and died about thirty hours after the ligature was applied. This case fell under my own notice, and the inference which I drew was, that the man died more from the great quantity of blood which he lost, and the severe mischief done to the parts in the neck, than from any effect of the ligature of the artery on the brain. CASE XVII. In another instance in which the common carotid was tied, on ac count of a wound of the external carotid by a musket ball, complica- ted with fracture of the condyle and coracoid process of the lower jaw, every thing went on favourably until the 7th day after the opera- tion. Neither the intellectual faculties nor the functions of the or- gans of sense had been at all disturbed. But at that period, stupor, confusion of ideas, restlesness, a small unsteady pulse, discolouration of the face, and loss of strength came on, followed in the evening by a violent paryoxysm of fever. On the eighth day three copious he- morrhages took place from the whole surface of the wound, and on the ninth the man died.—(See Journ. General de Med. 8fc. par Se- dillot.) CASE XVIII. Scarpa mentions one unfortunate patient who was killed by a knife being plunged in a carotid aneurism, on the supposition that the case was an abscess. CASE XIX. Deschamps tied the femoral artery below an inguinal aneurism; but the progress of the disease, instead of being checked, seemed to be accelerated by the experiment. The operator was obliged, as a last resource, 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 afterward. case xx. Dr Mott operated upon a person, on the 11th of June, 1818, in the New-York hospital, for a subclavian aneurism. On the twenty-third day, hemorrhage came on from the wound : it was stopped by the introduction of lint, and the employment of pressure. About twenty- four ounces of blood were lost, whereby the patient was so depressed that the pulse was no longer distinguishable. On the twenty-fourth day, in the evening, he lost four ounces more blood; on account of his restlessness and the painful state of his arm, two grains of opium were administered to him. After one or more returns of bleeding, he died on the twenty-sixth day. CASE XXI. The arteria innominata was tied by Graefe, in the hospital at Ber- lin, on the 5th of March 1622, on account of a subclavian aneurism. The carotid was exposed and traced down to the innominata, to which a ligature was applied by means of a blunt tenaculum constructed for the purpose, the vessel being tied at most about an inch from the cur- vature of the aorta, and two inches from the heart. As soon as the Aneurism—(Aneurisma.) 347 ligature was tightened, the pulsation of the arteries of the right arm, right carotid, and right temporal artery ceased ; at the same instant the throbbing of the aneurism stopped, and the tumour became flaccid. The constriction of the cord produced no disturbance of any function. The patient went on so well for several weeks afterward, that no doubt was entertained of his recovery. However, when the wound was nearly healed, hemorrhage came on, and though it was suppress- ed, and hope began to be again indulged, the bleeding recurred, and the patient died on the sixty-seventh day.—(See Journ. der Chirurgie, von C. F. Graefe, and Ph. v. Walther, b. 3. p. 596, &c, b. 4. p. 587.) The example in which the carotid was tied by Dr. Fricke, in the hospital at Hamburgh, for the cure of ^diseased parotid, is reported in the Lancet, No. 182. Some diminution of the swelling, and in- creased power of swallowing, followed ; but suppuration took place, and the case ended fatally. The limits of this work will not permit me to insert more cases which have proved fatal. Nearly all these were selected from Cooper's Surgical Dictionary. I might, were it necessary, give a sufficient number to constitute a volume. Some might wish us to insert some cases in which an operation has proved successful, but these, in the first place, are very scarce, or difficult to find, and in the next place, when any such do occur, they are so emblazoned abroad, that others are induced to perform the operation so frequently that much injury is the consequence of it. Of the Spontaneous Cure and General Treatment of Aneurisms. The obliteration of the sac in consequence of a deposition of co- agulum in its cavity, as Hodgson has well described, is the mode by which the spontaneous cure of aneurism is in most instances effected. The blood soon deposites upon the inner surface of the sac a stratum of coagulum ; and successive depositions of the fibrous part of the blood by degrees lessen the cavity of the tumour. At length, the sac becomes entirely filled with this substance, and the deposition of it generally continues in the artery on both sides of the sac as far as the giving off of the next large branches. The circulation through the vessel is thus prevented ; the blood is conveyed by collateral chan- nels ; and another process is instituted, whereby the bulk of the tu- mour is removed.—(On the Diseases of Arteries, &c. p. 114.) Such desirable increase of the coagulated blood in the sac is indicated by the tumour becoming more solid, and its pulsation weak or ceasing altogether. Another mode, in which the disease is spontaneously cured, hap- pens as follows : an aneurism is sometimes deeply attacked with in- flammation and gangrene ; a dense, compact, bloody coagulum is formed within the vessel, shutting up its canal, and completely inter- rupting the course of the blood into the sac. Hence, the ensuing sphacelation and the bursting of the integuments and aneurismal sac are never accompanied by a fatal haemorrhage ; and the patient is cured of the gangrene and aneurism, if he has strength sufficient to Vol. II. 2 U 348 Aneurism—{Aneurisma.) bear the derangement of the health necessarily attendant on so con- siderable an attack of inflammation and gangrene. When a patient dies of hemorrhage, after the mortification of an aneurism, it is because only a portion of the integuments and sac has sloughed, without the root of the aneurism, and especially the arterial trunk, being similarly affected. For cases illustrative of this state- ment, refer to Hodgson on Diseases of Arteries, p. 103, &c. A third way, in which an aneurism may be spontaneously cured, is by the tumour compressing ^the artery above, so as to produce adhe- sion of its sides, and obliteration of its cavity. This mode of cure must be uncommon : it has been adverted to by Sir E. Home, Scarpa, Dr. John Thomson and others; but some facts, tending to prove it, have been collected by Mr. Hodgson, and are published in his useful work.—(See p. 107, &c.) The treatment of aneurism (says Mr. Hodgson) consists in the ob- literation of the cavity of the artery communicating with the sac, so that the ingress of the blood into the latter is either entirely prevented, or the stream which passes through it is supplied only by anastomos- ing branches, and consequently the force of the circulation is so much diminished, that the increase of the tumour is prevented, and the de- position of coagulum is promoted. By the absorption of its contents, and the gradual contraction of the sac, the cure is ultimately accom- plished. The blood is conveyed to the parts, which it is destined to supply, by collateral vessels, some of which, being gradually enlarged, constitute permanent channels for the circulation. The obliteration of the artery is effected by the excitement of such a degree of inflam- mation in its coats as shall produce adhesion, of its sides. I will now mention a few spontaneous cures of aneurism, by way of contrast. CASE I. Patients should know that this disease, says Cooper, sometimes un- dergoes a spontaneous cure, for it is a great consolation for them to know this. I have known many examples of this change in aneu- rism, and will relate one of the most striking : George Bowie was admitted into Guy's hospital, with an aneurism in the groin. When the aneurism had acquired considerable magnitude, as he was sitting by the fire in his ward, he suddenly felt a snap in the swelling; his leg and thigh became immediately swollen and useless, and the pa- tients assisted him into bed. The pulsation in the swelling continued for four days, and then ceased; the swelling of the limb gradually subsided, and four months afterwards he was able to walk, with scarcely any lameness: I met him one day in the square of the hos- pital, and, asking him how he was, he said, " Sir, I am pretty well of my old complaint, but I have got something alive in my inside ;" and upon applying my hand to his abdomen, I found a pulsating tumour. He died from the bursting of this aneurism into the abdomen. I ex- amined him, and we have the parts preserved in the museum of St. Tfcomas's hospital. The aneurism of the thigh had burst under the fascia lata, and the accumulated blood pressed the aneurism on the femoral artery, so as to interrupt the circulation. Both the iliac and Atveurism—(Aneurisma.) 349 upper part of the femoral artery were obliterated, and the blood found its course by the internal iliac vessels. I have seen spontaneous cures of aneurism produced without any circumstance which would readily explain the cause : one case with Sir William Blizard, at Walworth; a case of popliteal aneurism; and another of popliteal aneurism in Guy's hospital. Mr. Ford has published cases of this description; and Dr. BaiUie has met with similar instances. I once saw, in Guy's hospital, a man who had an aneurism in the thigh, which had existed several years; which still retained its pulsation, but had ceased to increase, although it had not diminished: this man died of some other disease; and, upon ex- amination, I found it to be aneurism produced by the general dilatation of the coats of the artery. CASE II. From a foreign periodical, entitled, Medical Facts and Observations. By George Wilkinson, Surgeon. A tall, muscular man, about fifty years of age, was unfortunate enough to have the artery wounded in the opening of the basilic vein, in June, 1788. After a very large quantity of blood had escaped per saltum, a considerable degree of pressure was made on the ori- fice, and the blood was staid. There was an ecchymosis that ex- tended from the shoulder to the wrist. A tumour, which had a strong pulsation in it, immediately began to be formed, and continued to in- crease till it equalled the size of a common cricket ball, and the limb at the same time grew (to use his own words) painfully lifeless. It had been told him that nothing but an operation could give a chance of preserving his arm ; but as he had formerly lived near Petworth, and had been a patient of mine, he chose to show me the case before he came to a determination concerning it. When I saw him, it was about six months after the accident had happened, and I received from him the above account. On examination, I found the tumour very nearly as he had described it, somewhat less indeed than a cricket ball, but hard, and with a strong pulsation in it. The arm was shrunk and cold, and the wrist entirely pulseless. The patient having repeatedly assured me that the tumour had been somewhat larger, and the pulsation still stronger, I did not hesitate to dissuade him from the operation, at least for the present. I recommended the constant use of the flesh brush only to the whole arm, and desired to see him regularly every fortnight. Within a few weeks the arm grew a little warm; in about three months I could perceive a tremulous kind of motion at the wrist; the tumour very gradually diminished in size, its pulsation grew weaker, and the motion at the wrist stronger in the same proportion ; the hardness of the tumour likewise increased as the tumour itself be- came less, so that when it was diminished to the size of a small apple, it was perfectly incompressible: indeed in this situation it was so long stationary, that I began to doubt whether it would ever vary from it; but within the last eight or nine months even this extreme hardness has gradually abated, and the decrease gone on, till the tu- 350 Aneurism—(Aneurisma.) mour is become no larger than a full-sized hazel-nut, and not harder than a steatoma. The pulse too is now as strong in that arm as in the other; the arm itself is as large, and the power of using it, un- less on very laborious occasions, (which he is cautioned to avoid,) nearly equal. It is too evident to admit of any doubt that the circulation is prin- cipally carried on in its usual course through the artery, and not through the capillary and anastomosing branches of it. This case may perhaps be thought to add some little weight to two of the conclusions drawn by Mr. Ford in his excellent paper on the same subject, " that nature is capable of effecting the cure of aneu- risms solely by her own efforts, and that the cure by nature is a per- manent one :" but although I am unable to form a satisfactory idea of the manner in which nature has so completely effected the cure in the present instance, I still hope the case may not be altogether unworthy of regard; for I confess myself of Mr. Watson's opinion, that the history of the disease is not complete, and that every aneurismal tumour will be found to have its peculiarities, and of course may afford useful information. CASE III. Aneurism cured by Valsalva's method. [Translated from the Quebec Medical Journal, No. 5, for 1827.] Miss Antouard, aged 18 years, enjoying good health, on the 18th of June, 1825, received a stab with a dagger, which wounded the left carotid artery below the superior extremity of the sternum, the in- strument having been directed inwards and downwards. A very large quantity of blood was immediately diffused in the cellular tissue of the lateral and anterior part of the neck. She swooned away on the spot. The fourth day afterwards, this mass of blood was almost entirely ab- sorbed, but an aneurismal tumour made its appearance at the border of the sternum. Dr. Souchier saw the patient a month after the ac cident, and the tumour was then as large as the lady's two fists. The pulsations were nearly equal throughout every part of the tumour ex- cepting opposite the orifice of the artery. The tumour caused no other inconvenience than that which resulted from its weight, which gave rise to a continual headach. Dr. Souchier, finding it highly imprudent to have recourse to an operation, owing to the heat of the season, and especially on a tumour situated so deep under the sternum, therefore he determined to put in practice the following principles : 1. To diminish the quantity of the blood, and consequently its stimulating action on the heart; thus diminishing its projectile force, checking the rapidity with which the blood escaped through the orifice of the artery, and causing a continual vibration of the walls of the tumour, which was an obstacle to the coagulation of the blood within the tumour. 2. To second this effect, by general and local bleeding, by the use of cold, by pressure, and, most of all, by digitalis. The force of the circulation being thus diminished, a coagulation would take place, and perhaps a complete cure. Aneurism—(Aneurisma.) 351 Miss Antouard willingly submitted to this treatment, and he pre- scribed, 1st. Rice water acidulated with lemon juice, and an infusion of mallows. This was all the drink and nourishment he allowed. 2d. Frictions over the abdomen and inside of the thighs morning and evening, with eight grains of fol. digitalis, previously pulverized, and macerated twenty-four hours in a sufficient quantity of saliva. 3d. The application of twelve leeches every day close to the tumour ; and af- terwards, to procure a greater discharge from their bites, by means of emollient fomentations. The tumour was also to be covered with bandages dipped in a cold solution of acetate of lead, renewed fre- quently, so that their temperature should always be below that of the skin. 4th. To augment the pressure on the tumour with the bottom of a tumbler, held by the hand of an assistant. 5th. Lastly, absolute rest and silence. Aug. 2, 1825. Fourth day of treatment. The pulsations of the tumour are more central. Aug. 12. The volume of the tumour diminished to three fifths of its original size. Aug. 18. The tumour is no longer visible ; the pulsations, never- theless, discernible ; the skin thickened over the tumour ; pulse fifty. Dr. Souchier revisited his patient fifteen days after. It required an expert hand to distinguish in what place the artery was cicatrized, there being but a very small elevation on the artery. The pulses for- ty-eight, extreme hunger, and the remedies have become disagreeable, some of which are suspended, and she is permitted a little fruit and a piece of chicken, besides her ordinary diet. The digitalis is reduced to twelve grains per day ; compression, silence and moderate exercise are prescribed. The catamenia returned at the expiration of twenty days after their cessation, and in greater abundance than at the first time. A month after, no trace of a tumour could be discovered. The young lady, by degrees, took a little more exercise and nourishment, without experiencing any inconvenience, and finally ceased using any remedies. In last December and January, she felt neither pain nor inconvenience about the part where the tumour was situated ; and the union of the sides of the artery was regarded as complete. CASE IV. Petit mentions that the advocate Vieillard had an aneurism at the bifurcation of the right carotid, for the cure of which he was or- dered a very spare diet, and directed to avoid all violent exercise. Three months afterward the tumour had evidently diminished ; and at last it was converted into a small, hard, oblong knot, without any pul- sation. The patient having died of apoplexy seven years afterward, the right carotid was found closed up and obliterated from its bifurca- tion, as low down as the right subclavian artery.—(Acad, des Sciences de Paris, an. 1765.) Haller dissected a woman whose left carotid was impervious.—{Opuscula Pathol, obs. 19. tab. 1.) An example . of the total closure of both carotids in consequence of ossification, is stated by Koberwein, to be recorded by Jadelot. 352 Aneurism—(Aneurisma^) CASE v. Whenever the ulcerated, lacerated, or wounded artery, says Cooper, is accurately compressed against a hard body like the bones, it ceases to pour blood into the surrounding cellular sheath, because its sides, being kept in firm contact, for a certain extent above and be- low the breach of continuity, become united by the adhesive inflam- mation, and converted into a solid ligamentous cylinder. Molinelli, Guattani and White, have given examples and plates illustrative of this fact. When aneurisms get well spontaneously, the same fact is ob- served after death, as Valsalva, Ford, &c. have demonstrated. I have myself seen, in St. Bartholomew's hospital, an instance in which a man had had a spontaneous cure of an aneurism in the left axilla, but afterward died of hemorrhage from another aneurismal swelling under the right clavicle : the artery on the left side was found com- pletely impervious. My friend Dr. Albert had under his care, in the York hospital, Chelsea, a dragoon, who recovered spontaneously of a very large aneurism of the external iliac artery : the tumour sloughed, discharged about two quarts of coagulated blood, and then granulated and finally healed up. Paoli relates a similar termination of a popliteal aneurism. Moinichen and Guattani relate other exam- ples. Hunter found the femoral artery quite impervious and oblite- rated 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 describes the spontaneous cure of an aneurism at the bifurcation of the right carotid : the subject having afterward died of apoplexy, the 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 patieht, in whom a sponta- neous cure of a popliteal aneurism was just beginning: he found a very hard bloody thrombus, which extended for three finger-breadth6 within the tube of the artery above the sac, and was so firm as to re- sist injection, and make it pass into the collateral branches. CASE VI. Popliteal aneurisms, as well as other external tumours of the same nature, stand the best chance of a spontaneous cure, when any cause induces a general, violent and deep inflammation all over the swelling ; for then the communication between the sac and the artery is likely to become closed w ith coagulating lymph, and the pulsation of the tu- mour to be suddenly and permanently stopped. If in this state the disease sloughs, and the patient's constitution holds out, the coagulated blood in the sac and the sloughs are gradually detached, leaving a deep ulcer, which ultimately heals. An example, in which a popliteal aneurism was cured by such a process, is related in the Trans, for the Improvement of Med. and Chirurgical Knowledge, vol. ii. p. 268. CASE VII. A celebrated case, says Cooper, completely established the im- portant fact, that simply taking off the force of the circulation is suf- ficient to cure an aneurism, as the tumour is afterward diminished and removed by the action of the absorbent vessels. Aneurism—(Aneurisma.) 353 In order to confirm the same fact, Sir E. Home related a case of femoral aneurism which got well without an operation, but on a similar principle to what occurs when the artery is tied. A trial of pressure had been made without avail. The tumour became very large, and such inflammation took place in the sac and integuments that mortifi- cation was impending : no pulsation could now be felt in the tumour, or the artery above it. The correct inference of Sir E. Home was, that a coagulum, which we know always occurs in an artery previously to mortification, seemingly to prevent bleeding, had formed in this in- stance, and in conjunction with the effusion of coagulable lymph about the root of the aneurism, had kept the blood from entering the sac. case vm. Pelletan also cured a large axillary aneurism, which was deemed beyond the reach of operative surgery. On the thirteenth day, the patient was reduced to a degree of weakness which alarmed many of the observers. From that time, all pulsation in the tumour ceased. The contents were gradually 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 of the obliteration of the axillary artery, and the limb only receiving blood through the branches of the subclavian artery. additional cases. Pelletan records the cure of one popliteal aneurism by compression and absolute repose during eleven months, (t. i. p. 115.) Boyer re- lates two instances. (TraitC des Mai. Chir. t. ii. p. 204.) One is mentioned by Richerand. (Diet, des Sciences Med. t. ii. p. 96.) The practice of Dubois is said to have furnished several examples of the same success ; (vol. cit. p. 97.) and a case, in which Dupuytren ef- fected a cure by compressing the femoral artery by means of an in- strument applied just above the place where the vessel perforates the tendon of the triceps muscle, is detailed by Breschet.—(Fr. trans, of Mr. Hodgson's work, t. i. p. 249, &c.) Two cases of aneurism are reported by a surgeon in Baltimore, which were cured by the efforts of nature alone, the particulars of which I am unable now to give. Mr. H----, a methodist minister, of New Jersey, called upon me Borne years ago, with an aneurism of the carotid artery. He was not disposed at that time to have any thing done for it, and although the tumour was large, the pulsations great, accompanied with very unfa- vourable symptoms, which threatened the most imminent danger, still it gradually grew better, and I believe he is now well. There are cases of this kind, or spontaneous cures of aneurism, to fill a volume ; but it is unnecessary to insert any more. 1 think it must appear evident, that, even admitting that medical treatment avails nothing in the disease, that more reliance is to be placed upon the powers of nature alone, or that more cures are performed by it, than by a surgical operation, or tying the artery above the tumour. If, then, the evidence preponderates against the operation for aneu- rism, and in favour of the efforts of nature alone, how much more does 354 Aneurism—(Aneurisma.) it preponderate against it, when we take into consideration the addi- tional prospect of a cure by aiding her salutary efforts ? The balance appears to me to be in favour of dispensing with the knife, when I take into view, the danger and uncertainty of the operation, and the great probability of curing the disease by the combined aid of nature and art. I shall now give the treatment which I pursue in cases of aneurism. Although the resources of nature are very great in curing all com- plaints, I wish it not to be understood that art is incapable of aiding her salutary efforts. It is our duty carefully to watch her progress, and, when her struggles are ineffectual, to assist her. And this is particularly applicable to aneurisms of all kinds. The first attempt should be to cure the disease by compression. This has succeeded in some instances, particularly when the tumour is small and compres- sible ; but when very large, I have found it to aggravate the symp- toms. Pressure may be applied in any convenient manner. When an aneurism is upon a limb, a piece of lead, bone, ivory, or wood, may be covered with linen, and laid directly over the artery above the tumour, and secured by a bandage, to be compressed as much as the feelings of the patient will permit. The tourniquet may be used for this purpose, or any other suitable contrivance, which will operate without retarding the return of blood through the veins. This will sometimes effect a cure, by exciting adhesive inflamma- tion in the walls of the aneurismal sac, by which it will be removed. Or it may be cured by the coagulum, which is produced in conse- quence of such pressure. In order that pressure may succeed, the coats of the vessel at the place where it is made must be sufficiently free from disease to be susceptible of the adhesive inflammation. When the arterial coats around the root of the aneurism are much diseased, Scarpa considers them as insusceptible of the adhesive inflammation, although com- pressed together in the most scientific manner, and even when tied with a ligature, which only acts by making circular pressure on the vessel. During this process, a suitable course of regimen must be pursued, and such medicine taken as is calculated to prevent inflammation. Another method has been practised in some cases with success, the credit of which has been given to Valsalva, and one interesting cure is detailed in this chapter, which proved successful by follow- ing his directions. It consists in moderating the force of the circula- tion by low diet, bleeding, laxative medicines and opiates. A num- ber of successful cases, treated in this way, are also on record. Aneu- risms within the thorax and abdomen, acknowledged to be without the reach of operative surgery, have been cured by this treatment, or rather, perhaps, by the efforts of nature. When, by these or similar means, the tumour continues to enlarge and grow worse, it is then that we must rely almost exclusively upon the resources of nature, and a vigorous antiphlogistic course of treat- ment. It is upon this principle or treatment that we must depend for the cure. 1st. The patient must be freely purged, and to be repeated two or Aneurism—(Aneurisma.) 355 three times a week. The common physic, combined with a little cream of tartar, is the best preparation to give. 2d. Sudorifics.—As there is much inflammation usually attending the complaint in its most aggravated form, moderate perspiration will be necessary, to lessen the heat and pain, or to moderate the violence of arte rial action. An opiate maybe combined with a sudorific or diaphoretic, for which give the diaphoretic powders. But where the pain becomes excruciating, as is the case in some species of aneu- risms, it becomes necessary to give powerful anodynes. An opium pill, containing three or four grains, is scarcely sufficient to mitigate the pain. The black drop is a good preparation of opium, and it must be given in doses according to the urgency of the symptoms. Local applications.—The tumour may be bathed with the discutient ointment two or three times a day, after which apply the following : Take wormwood and hops; Simmer in vinegar; apply cool over the swelling, and often renew. If it be a femoral aneurism, and the limb is very much swelled, let it be fomented with the same. The feet should also be bathed in warm ley-water, once or twice a day. If it be cold, which is often the case for want of circulation, let it be steamed over bitter herbs, and let frictions be applied with the hand occasionally. While these applications prove beneficial, let them be continued. But, if there is no improvement in the aneurismal tumour, apply a poultice made of the slippery-elm bark and weak ley. At the same time, administer from twenty to twenty-five drops of the tincture of digitalis, four or five times a day, in any kind of tea. Let the patient take freely of infusions, or teas, of mint, catnip and other diluent drinks. They aid very much in reducing inflammation by their diuretic and diaphoretic properties. I have applied cups over the aneurismal tumour and in its vicinity, where the pain, swelling, and inflammation has been very great, and I think with some advantage. As regards general blood-letting, I have no evidence that it possesses any control over the disease. Where it is necessary to give opiates to allay the irritation, it may be !necessary to give injections or clysters to evacuate the bowels. Position.—The patient must be kept in a recumbent and quiet po- sition, and if it is on an extremity, the limb must be a little flexed, turned outwards, and made to rest upon a pillow. Diet.—Nothing stimulating must be taken internally, as regards food or liquids. The diet must be spare, and principally vegetable. In short, all the ordinary means for subduing inflammation must be promptly and rigidly adhered to; for I conceive that art, in this dis- ease, can do very little besides. Our reliance, in other respects, must be upon the resources, or powers of the system. After this course has been continued for some time, there will often be an audible snap or report, sometimes almost as loud as a pistol, (to use the expression of a patient,) when instantaneously the beating and pain will cease, the swelling and inflammation subside, and gra- dually diminish, until there is nothing left except a cartilaginous tumour directly over the artery, which becomes, no doubt, obliterated. Vol. II. 2 W 356 Aneurism—(Aneurisma.) Now it is a very interesting inquiry, to know in what manner a cure is thus effected. It appears to me, that after inflammation has existed a certain length of time, the external coat of the artery, or rather the cellular sheath of it, which forms a portioh of the aneurismal sac. ulcerates, or is ruptured from the impetus of the blood, which is then diffused into the cellular substance, and subsequently taken up by the absorbents, while, at the same time, coagulated blood is formed in the tumour, and finally obliterates its cavity; the circulation being carried on below the tumour, by the anastomosing branches, or the lateral blood-vessels, as in amputation. Should this theory be correct, the idea would occur to us that, in imitation of nature, we might expedite the cure, by rupturing the artery with a probe, or passing a seton through it, on the same prin- ciple that a ganglion is destroyed by bursting its sac. I, however, leave this for the reflection of others. I have thus given my treatment for different species of aneurism, and I conceive that there is less danger in pursuing it, and a greater probability of effecting a cure, than by a surgical operation, or tying the artery. I will not, however, say that such operation should never be performed, although 1 am led to doubt the propriety of it, both from experience and observation; and should the ordinary treatment be found preferable to this, I trust that I shall have the magnanimity to acknowledge and adopt it. I wish to advance nothing that will not bear me out by facts. I must, therefore, leave the subject to be in- vestigated and tested by those who have candour and honesty enough to do it. In concluding thischapter, I will relate an interesting case of fe- moral aneurism, which will serve to illustrate the principle of treat- ment here laid down. Mrs. Grant, aged about forty, then residing, in Reed-street, in this city, was attacked with a throbbing and beating sensation in the thigh, just below the groin, and over the femoral artery. It gradually in- creased for several weeks, until the tumour became very great, and the whole leg exceedingly swollen and enlarged. The pulsations were very great, and the tumour almost lost in the surrounding parts; extremely hard, and excruciatingly painful. The whole thigh, from the groin to the knee, and particularly the upper portion of it, assumed a very morbid and diseased state. The circulation was carried on very feebly below the tumour, which rendered it very cold. She was now confined to the bed, and such was the pain attending it, that she took an ounce of laudanum during each night to procure relief. I was called to attend her soon after its commencement, and so formidable was it, that there appeared to be very little chance or prospect of recovery. It appeared, too, that if an operation was performed, and the artery tied, it must inevitably prove fatal, and I had not much confidence that any thing that I could prescribe would prove effectual; I was, therefore, at a loss to know what course to pursue. I took a physician, or surgeon, to examine the limb, who immediately pro- posed an amputation, to save the patient's life. About this time, one of the neighbours requested Dr. Mott, of this city, to examine the dis- ease, who, upon finding it an aneurism, immediately proposed an Aneurism—(Aneurisma.) 357 operation, without which, he said, she could not live. To this, the woman objected, and said, "the knife shou-ld never enter her flesh," let the consequences be what they might. Taking every thing into consideration, the objections of the patient, and the danger and uncertainty of the operation, I concluded that it would be more prudent and safe to rely upon nature, aided by suitable means, than to rely upon such operation. It appeared to me that the chance of her recovery would be greater, and I therefore concluded to abandon it, and wait the result. But when Dr. Mott found that both myself and the patient were not disposed to take his advice, so anx- ious was he to try the experiment of tying the artery, that he employed another surgeon, and one or two private citizens, one of whom was a minister of the gospel, to wait upon the patient, and to inform her that except she submitted to the operation, it would certainly kill her. She replied, that she was getting better under the prescriptions of her present physician, and that she should not discharge him. Accord- ingly, after this, I was permitted to treat the case without further in- terference or molestation. My applications were the same as before mentioned, with the addi- tion that, a part of the time I applied the leaves of stramonium the whole length of the leg, to assist in reducing the swelling and inflam- mation. 1 also applied a tourniquet above the tumour over the femo- ral artery, with directions that it should be tightened in case the tu- mour should burst, as I feared it would, from the great swelling and enlargement, together with the excessive pain and inflammation. The tumour continued slightly to im- prove for some time, when one night she felt and heard a sudden snap or report in the leg, from which time all the symp- toms subsided, and she continued to im- prove, till, two or three weeks after- wards, there was nothing left of the aneurismal tumour but a little hardness, or, apparently, a cartilaginous tumour, immediately over the femoral artery, and which appeared to be the centre of the swelling. Her leg, for some time, was weak, but the strength gradually returned, and she was soon able to walk as well as ever. She has been per- fectly sound for nearly fifteen years, and I have several times exhibited the patient to our school, whon lecturing upon this subject. I herewith annex a plate, or figure, representing the appearance of the aneu- rism when I first commenced the treat- ment of it. About two years after the patient recovered, two surgeons called upon her to know whether she conti- nued well, and what means 1 employed to effect the cure. CHAPTER XXIV. rw pture—( Hernia.) Description. Hernia, or rupture, is the protrusion of any viscus from its proper cavity. It has obtained various names from its situation, as the ingui- nal, when it occurs in the groin ; the scrotal, when it occurs in the scrotum ; the/ewioraZ, when it is situated under the crural arch, or Poupart's ligament; umbilical, when it occurs in the abdomen, or um- bilical region ; ventral, when it is situated in some other part of the parietes of the abdomen—most frequently in the linea alba, but some- times in the linea semilunaris—a very rare complaint; hernia conge. nita, formed by a protrusion through the abdominal ring into the tunica vaginalis testis, and can only happen in the cases where this cavity remains continuous with the general cavity of the abdomen. The protruded viscera are in contact with the testicle, the hernial sac be- ing the tunica vaginalis. There are some instances of the bladder and stomach escaping from their cavities, and forming hernial tumours. If a portion of intestine forms it, it is called enterocele hernia intes- tinalis, or gut rupture ; if a piece of omentum only, epiplocele hernia omentalis, or caul rupture ; and if both intestine and omentum contribute mutually to the formation of the tumour, it is called enter o-epiplocele, or compound rupture. If the piece of gut or caul descends no lower than the groin, it is said to be incomplete, and is called bubonocele; if the scrotum be oc- cupied by either of them, the rupture is said to be complete, and bears the name af oscheocele. When the protruded bowels lie quietly in the sac, and admit of be- ing readily put back into the abdomen, the case is termed a reducible hernia ; and when they suffer no constriction, yet cannot be put back, owing to adhesions, or their large size, in relation to the aperture through which they have to pass, the hernia is termed irreducible. An incarcerated, or strangulated hernia, signifies one which not only cannot be reduced, or without great difficulty, and the consequence is, often, that the contents of the intestine cannot be expelled, and in- flammation takes place, and brings on alarming and fatal conse- quences, if relief be not speedily obtained. It is a prevalent idea, that the contents of the abdomen are protruded through some ruptured viscus or part; but this is a mistaken notion, as it arises from dilata- tion, not rupture. Both the scrotal and femoral hernia pass out from the abdomen by Openings which are natural to every human body ; as well those who have not ruptures, as those who have. The former, that is, the scrotal, descend by means of an aperture in the tendon of the external oblique muscle, near the groin, designed for the passage of the spermatic vessels in men, and the ligamenta uteri in won.en ; Rupture—(Hernia.) 359 and the latter made by Pourpart's, or Fallopius' ligament, at the upper part of the thigh, along with the great crural vein and artery. Causes. The cause* of hernia are, debility of any'particular part of the pari- etes of the abdomen, whether natural or the consequence of morbid affections, and violent efforts by which the muscles of the abdomen are made to contract forcibly upon their contents; lifting heavy weights, jumping, running, violent coughing, parturition, vomiting, straining at stool, and many other analogous exertions of the muscles : these are the occasional causes of hernia. The causes of hernia are either predisposing or exciting. Among the former, writers mention a preternaturally large size of the open- ings, at which the bowels are liable to protrude ; a weakness and re- laxation of the margins of these apertures ; a preternatural laxity of the peritoneum; an unusually long mesentery, or omentum, &c. With regard to the abdominal ring, the transverse tendinous fibres which naturally cross and strengthen its upper and outer part, are much weaker in some subjects than others. No idea seems more prevalent in books, than that taking a good deal of oil with our food, is conducive to the formation of hernial diseases. Some of the al- leged predisposing causes may justly excite skepticism ; but several circumstances tend to prove, that a natural deficiency of resistance, in any part of the parieties of the abdomen, promotes the occurrence of hernia. Hence, persons who have had the peritoneum wounded are very liable to the present disease ; (Richerand, Nosogr. Chir. t. iii. p. 317. Schmucker, Vermischte Chir. Schriften, b. i. p. 197.) and men are much more liable than women to inguinal hernia, evidently from the larger size of the abdominal ring; while, in women, as there is a larger space for the protrusion of the viscera, below Poupart's ligament, they are more exposed than men to femoral hernia. With regard to the exciting causes, our knowledge is involved in less doubt. The grand cause of this kind is the powerful action of the ab- dominal muscles and diaphragm on the viscera. In feats of agility, such as jumping, &c. the pressure which the contents of the abdomen must often encounter, sufficiently accounts for their protruding at any part, where the abdominal parieties do not make adequate resistance. The same consideration explains why hernia very often takes place in lifting and carrying heavy weights, running, vomiting, straining at stool, parturition, &c. and in people who inhabit mountainous coun- tries. The diminution of the capacity of the abdomen, by the action of the abdominal muscles and diaphragm, in many occasional exertions, must take place in every body, by reason of the common habits and necessities of life. But, as only a certain number of persons meet with the disease, it is fair to infer, that either the exciting causes must operate with greater force in them, than in the generality of people, or else that their abdominal parieties haVfe not been capable of the ordinary degree of resistance. Many patients, who meet with her- nia in making violent efforts and exertions, may be in the former 360 Rupture—(Her,nia.) circumstance ; while others, whose viscera protrude from such trivial things as coughing, sneezing, crying, the fi/^ei .. \:-\ cumbeni po-■■■:■> :y. ■. : : .-j.rM-r.-eu v,v. :. o'hr • •;:s*ai. ..m'j .>M.. ' ir-g position. Suppression and Retention of Urine. 381 Where there is inflammation, accompanied by inordinate irritation at the neck of the bladder, all straining to'expel the urine should be avoided, and the organ be emptied every six hours, by introducing the elastic gum catheter, and afterwards washing it out with a little tepid water, injected through the catheter by means of a gum-bottle properly fitted thereto. By so doing we shall soothe the irritability of the parts, by substituting tepid water for the acrid urine. In the healthy state of the parts connected with the bladder, the surface is not susceptible of the stimulus from the urine, or in only due degree ; but when inflammation occupies these parts, the acrid urine becomes a continual source of excitement. Besides, by thus injecting the bladder, the ropy mucus and purulent secretion, when there is any, are washed away, and that sort of tenesmus vesicae caused by their presence, is much relieved. In every instance of suppressed urine, whether arising from stric ture, gravel, inflammation, an enlarged state of the prostate gland, or spasm, opiates will prove highly serviceable, and ought therefore to be administered not only by the mouth along with diuretics of a mild or bland nature every four hours, but likewise in clysters repeated frequently. The liquor potassae, in doses of from twenty to thirty drops, joined with tincture of opium, the patient drinking freely of mu- cilaginous liquors, such as linseed tea, parsley, elm bark, or barley water, in which a little gum Arabic has been dissolved, is a very useful remedy in all cases of irritation at the neck of the bladder. Injecting sweet oil, or even warm milk and water, frequently up the urethra, will often afford relief, especially if the suppression has been occasioned by a small piece of gravel which has stuck in the canal. Injecting tepid water into the bladder itself in similar cases by the apparatus before mentioned, will also afford great relief in such cases. In both ischuria and dysuria, arising from gravel or a stone in the bladder, besides adopting this step, we should have recourse to the means advised expressly under these heads. Where the patient is frequently troubled with strangury, he should take the urinary decoction, diuretic drops, infusions of spearmint, slippery-elm, flaxseed, &c. I have been called to patients when they have nearly lost their sen- ses from the excruciating pain arising from a retention of urine, and after putting this practice in execution, they have experienced almost instantaneous relief. The transition from acute suffering to relief, has been truly surprising to all who have witnessed it; and the feel- ings of the patient can be more easily conceived than described. On one occasion, a person with spasmodic stricture, had retained his urine so long, that the flesh above the pubis had turned black. Several attempts had been made to introduce the catheter, but all were unsuccessful. Medicine was given, warm bath and injections used, when the catheter most easily entered the bladder and evacuated its contents. I have been called when the patient has been groaning and scream- ing from distress by severe agony, and in a short time the suffer. ings have been removed, aud that, too, without the introduction 382 Suppression and Retention of Urine. pf the catheter. And, as for puncturing the bladder above the pubis, or by the rectum, I consider it cruel and unnecessary. The following case is translated from a late work published in Canada, and which may be of practical importance. A case of Retention of Urine from Stricture of the Urethra, related by M. Amussat.—(Quebec Med. Jour. 1827. No. V. p. 60.) A man, aged seventy years, of a plethoric constitution, thirty years previous, had had three attacks of gonorrhoea, and ever since has had considerable difficulty in discharging his urine, not being able to eject more than one or two ounces at a time. At 8 o'clock, P, M., he made an effort to void hiis urine, without success, which caused him most excruciating pain. His pulses were agitated, face flushed, his abdo- men distended, the lower part much tumefied; the subcutaneous ab- dominal veins distended, and a partial priapism. His efforts to void his urine were extremely painful and fruitless. The following day, at 10 o'clock, A. M,, M. Amussat introduced a bougie, which was ar- rested hy the bulb of the urethra, and brought a trifling quantity of blood. The urine had now been retained for fourteen hours, though he was accustomed to pass it as much as twelve or sixteen times every night. The obstruction was such, that there seemed to remain no other alternative than either to forcibly introduce the catheter, or to puncture the bladder. M. Amussat finally had recourse to a me- thod which completely succeeded without putting his patient to the pain of either of the other operations. He injected gradually, but with force, warm water into the urethra, which, in dilating the orifice of the stricture, freed the urethra from the thickened mucus which was an additional obstruction. As soon as the injected liquid had reached the urine, the patient cried out he was cured, and the flow of urine returned, as heretofore. At two efforts he voided about two pints of muddy urine. Since, he has had no retention, and continues in good health. If this method is confirmed by experience, of which I have no doubt, U will be of great valuo in the treatment of strictures. CHAPTER XXVII. GRAVEL and stone. SECTION I. GRAVEL. Description. By the term gravel, we understand a collection of sand, or small particles of stone, collected in some part of the body, in the kidneys, ureters, or the bladder. Causes. There is, no doubt, contained in our food and our drink, the agents which form the gravel and stone. There is a sufficient quantity of sand, either in a native state, or combined with other substances, to produce or to form calculous affections. 4When the system is healthy, these ingredients are carried of by the proper secretions of the sys- tem. But, when there is debility of any organ, especially the kid- neys, they become incapable of expelling such sandy concretions, and consequently they lodge in the kidneys, ureters, or bladder. In general, these minute portions of gravel pass off, without oc- casioning much disturbance or disease. But, if there be an excess of uric or any other acid, a chemical union takes place, and these particles of stone are united, or combined together, and there is a constant apposition, until they become considerably large, or a stone is formed. This stone, or stones, may be deposited uVthe kidneys or ureters, and give rise to inflammation of these organs; or, it may pass down into the bladder, and, if not discharged, constitute all the symptoms of stone. "The causes," says Gibson, "ofthe formation of urinary calculi, although frequent attempts have been made to investigate them, have never yet been unravelled. We know, indeed, little beyond this, that the disease prevails in certain countries and districts, more than in others; and that, in some climates, especially very warm ones, it does not exist. Throughout the United States, which embrace a very extensive tract 'of country, fugitive cases may be every where seen ; but, upon the whole, the complaint must be considered by no means common, if we except some portions of the western country, especially Kentucky, Alabama and Tennessee, where it is exceedingly frequent, and usually attributed to the use of lime-stone water. All substances, containing azote, furnish matter for the formation of uric acid,* into which it is readily transformed, and tends to the pro- * See Dr. Magendie's Physiological and Medical Researches into the Causes of GraveL 384 Gravel. duction of gravel. The use of animal food and other analogous ali- ments, tends to diminish the quantity of urine, at the same time that it increases the proportion of uric acid ; whereas, a vegetable diet has the contrary effect. Those who are in the decline of life, and who have been much en- gaged in sedentary employments, as likewise those who are much afflicted with the gout, are in general very subject to nephritic com- plaints ; but, it is a matter of notoriety, that the period of life from infancy to about fifteen years, is most subject to the formation of cal- culi in"the bladder, and that the children of the poor are afflicted in a greater proportion than those of the opulent. From the difference in the structure of the urinary passages in the sexes, men are much more liable to them than women. In warm climates, we seldom meet with instances of calculous concretions forming of any size, either in the kidneys or bladder, as the particles of sand deposited from the urine, usually pass off before they can adhere together, owing to the re- laxed state of the parts ; but in cold ones, they are found frequently of considerable magnitude. Excess of urea is not unfrequently met with, especially in children and persons depositing the phosphates. In these cases, the urine is generally pale, but sometimes high-coloured, like porter and water mixed. When recently voided, it reddens litmus paper, and is for the most part free from sediment. It is stated that a long use of fermented liquors, and of wines abounding with tartar, may possibly, in some constitutions, prove oc- casional causes of the gravel and stone. Intemperance, by producing debility, may occasion gravel. Symptoms. Where urea is in excess, there is usually a frequent and almost irresistible desire of voiding the urine; but this does not arise from a fulness of the bladder ; for, in general, only a small quantity is voided at one time, but, from the frequency, the total quantity voided in a given time not being greater than natural. In cold weather the quantity is augmented, and it is also increased by all causes producing mental agitation. There is often a sense of weight, or dull pain in the back, and an occasional irritation about the neck of the bladder, which now and then extends along the urethra. The pulse, however, is not affected, and the tongue is clean: there is no remarkable thirst, nor are the functions of the stomach and bowels much deranged. A fit of the gravel is attended with a fixed pain in the loins, numb- ness of the thigh on the side affected, nausea and vomiting, and not unfrequently with a slight suppression of urine. As the irritating matter removes from the kidney down into the ureter, it sometimes produces such acute pain as to occasion Huntings and convulsive fits. The symptoms often resemble those of nephritis, or inflammation of the kidneys; but the deposition of reddish-brown sand, or very fine powder of the same colour, in the urine On becoming cold, will de- monstrate the difference. • When gravel has once formed in the pelvis of the kidney, or Gravel. 385 elsewhere, it continues to increase, by receiving on its surface new layers of uric acid successively precipitated ; of which we may be convinced by cutting the concretions transversely, which enables us to perceive that they are almost entirely composed of concentric layers. One of the principal diagnostic symptoms of calculus in the kidney is the dark appearance of the urine, as if it were mixed with coffee grounds, evidently depending on broken down particles of blood, proceeding from the obscure but continued irritation of the kidney. When this occurs in conjunction with a dull, heavy pain in tho loins, there can be very little doubt .of the presence of calculus in the kid- ney. In mere inflammation of this organ, when no calculus is pre- sent, the urine does not put on the above appearance. The symptoms which attend on a stone in the bladder are, a fre- quent inclination to make water, which flows in a small quantity, is often suddenly interrupted, and is voided towards the end with pain in the glans penis. The patient, moreover, cannot bear any kind of rough motion ; neither can he make use of any severe exercise, with- out enduring great torture, and perhaps bringing on either a discharge of bloody urine, or some degree of temporary suppression. With these symptoms he experiences pain in the neck of the bladder, tenes- mus, itching and uneasiness in the anus, frequent nausea, and some- times a numbness of one or both thighs, with a retraction of one of the testes. The long-continued irritation of the coats of the bladder by the stone, produces a considerable thickening in their substance, but principally in the muscular coat, the packets of its fibres becoming large, and incapable of that dilatation which they formerly possessed: their irritability, however, increases, so that they are excited to con- tract upon a few drops of urine, and thus, by pressing the stone against the part, already too sensible to pain, an almost constant state of suf- fering is kept up. The bladder in time becomes more diseased, the inner coat constantly inflamed, and sometimes ulcerated : all the un- favourable constitutional symptoms increase, and unless the stone is removed, the patient's sufferings are only ended by death. Disordered affections of the prostate gland are those which, with- out proper attention, are most likely to be confounded with stone in the bladder. One mark of distinction which the practitioner will do well to attend to is, that in the prostate affection, the pain expe- rienced in making water will be always in the commencement of mic turition, while, on the contrary, it is most usually during the passage of the urine, or when the bladder is nearly emptied, that pains and obstructions are perceived in cases of calculus. Another important diagnostic of stone is, that the irritation which it induces does not so much affect the general health as. the same degree of local disturb- ance from other causes.—(Thomas.) Tie at men!. 38(3 Gravel. which are the seat of the affection, and, second, by administering stimulating diuretics. If we are called to treat a fit of the graveL the most speedy way of giving relief will be to administer an opiate, the black drop, or an opium pill; the doses to be in proportion to the urgency of the symptoms. This medicine will so far diminish the sensibility of the parts, and at the same time take off the tension or relax them, that the spasms or fit will be allayed. There is usually very severe pain across the kidneys, proceeding from the irritation of the calculus. When this symptom occurs, fomentations will be found very useful. Hops and wormwood, simmered in vinegar, must be re- peatedly applied, and it will be found of great service to throw the pa- tient into a free perspiration; to effect which, let the feet be bathed, and a strong infusion of spearmint tea be given; this plant has a ten- dency to allay the vomiting, to produce perspiration, and at the same time promotes a discharge of urine; and, should it be necessary, the Vapour bath may be used. If there is a Strangury, or difficulty of passing the water, the spirits of mint may be freely given, combined with the spirits of nitre. The spirits of mint is made by pounding or bruising the green plant (spearmint) to a pulp or soft mass, then adding sufficient of the first runnings from the still of Holland gin, to make a satu- rated tincture. The watery portion will so far dilute the gin, that it may be taken without the addition of any menstruum. This is to be given as often, and as much as the patient can bear. No fear need be apprehended of inflammation arising from the stimulating properties of this medicine. There is no other preparation with which I am ac- qainted, so exceedingly efficacious in producing the discharge of urine, as the above, in retention from any cause. I was lately called to a case where two physicians exerted their skill in vain, in case of a re- tention of urine from gravel and calculi, and after giving this prepara- tion, or a similar one, all the symptoms of the complaint subsided in a very short space of time. Having none of the medicine then prepared, I went into the garden, and broke off a quantity of the tops of the plant, bruised it, and put it into a quart bottle, and then filled it up with best Holland gin. Of this I directed the woman to take about a wineglassful, (whether with the addition of the spirits of nitre, or otherwise, I cannot now say,) as often as the stomach would bear. The effect of the medicine was almost immediate. Although she was exceedingly reduced from pain, arising from a long retention of urine, but a very short time elapsed before she was better. Nor was she, like too many in this day, ungrateful for the benefit received. In addition to the commendation bestowed, when I pre- sented my bill, she most promptly produced a bag of silver, and evinced, by her manner and feelings, a disposition to pay double the amount. But, alas, where we find one patient of this description, we find five, even after we have cured them of some desperate dis- ease, who, instead of manifesting gratitude for the favour conferred, refuse to pay, and probably will even censure. Where the case is desperate, it may be necessary to use the warm bath, to produce sufficient relaxation to afford relief. The patient Gravel and Stone. 387 should take mucilaginous and diluent drinks: such as slippery-elm, parsley, &c. Physic should also be given, and, in some cases, emol- lient injections will be required. After the urgent symptoms have been removed, and the ordinary symptoms of gravel exist, a teaspoonful of the diuretic drops should be given, two or three times a day, in a tumbler of wild carrot tea ; and, at the same time, let the person drink the following decoction. Take marshmallows, three ounces; Queen of the meadow, (spiraea ulmaria,) three ounces; Add four quarts of water; boil to one ; then add two ounces of gum Arabic, and half an ounce of nitre, (nitras potassae.) The dose is a teacupful, four or five times a day. It may be sweetened with honey. If nausea and vomiting attend the complaint, give the solution of the bicarbonate of potash or scdaeratus. This also has a tendency not only to allay the vomiting, but also to remove the calculous affection. Many persons have found great benefit from the use of Haerlem oil, but most that is now sold is counterfeit or spurious. I am acquainted with but one place, in New York, where it can be obtained pure, (Van Antwerp & Co.) I know not exactly the component parts of this medicine, but believe it to be principally the product of the pine, tar and balsam of sulphur. SECTION II. Stone. Symptoms. The symptoms of a stone in the bladder are, a sort of itching along the penis, particularly at the extremity of the glans; and hence the patient often acquires the habit of pulling the prepuce, which becomes very much elongated ; frequent propensities to make water, and go to stool; great pain in voiding the urine, and difficulty of retaining it, and often of keeping the faeces from being discharged at the same time : the stream of urine is liable to stbp suddenly, while flowing in a full current, although the bladder is not empty, so that the fluid is expelled by fits as it were ; the pain is greatest towards the end of, and just after the evacuation ; there is a dull pain about the neck of the bladder, together with a sense of weight or pressure at the lower part of the pelvis : and a large quantity of mucus is mixed with the urine ; and sometimes the latter is tinged with blood, especially after exercise.—(Sharp, Earle, Sabatier.) Frequently (says Deschamps) a patient will have a stone in his bladder a long while without the occurrence being indicated by the symptoms. (See Case in Howship on Complaints affecting the Secretion and Excretion of the Urine, p. 125.) Most commonly, however, the presence of the stone is announced by pain in the kidneys, more especially in adults and old persons ; children scarcely ever suffering in this way, because in them the stone is hardly detained in the kid- neys and ureters at all, but descends immediately into the bladder. It seldom happens that calculous patients void blood with their urine before the symptoms usually caused by the stone have taken place. Vol. 11. 3 A 388 Stone. It is not till after the foreign body has descended into the bladder, acquired some size, and presented itself at the orifice of that viscus, that pain is occasioned, particularly when the surface of the stone is unequal. The patient then experiences frequent inclination to make water, attended with pain. The jolting of a carriage, riding on horseback, and much walking, render the pain more acute. The urine appears bloody, and its course is frequently interrupted, and sabulous matter, and particles of stone, are sometimes discharged with it. The want to make water becomes more frequent and more insupportable. The bladder is irritated and inflames, its parietes become thickened and indurated, and its diameter is lessened. A viscid, more or less tenacious matter is observed in greater or less quantity in the urine, and is precipitated to the bottom of the vessel. The urine becomes black and putrid, and exhales an intolerable alka- lescent smell, which is perceived at the very moment of the evacua- tion, and is much stronger a little while afterward. The patient can no longer use any exercise without all his complaints being redoubled. Whenever he takes much exercise the urine becomes bloody; the pain about the hypochondria, which was dull in the beginning, grows more and more acute; the ureters and kidneys participate in the irritation with the bladder; they inflame and suppurate, and very soon the urine brings away with it purulent matter. The fever in- creases, and changes into one of a slow type ; the patient loses his sleep and appetite, becomes emaciated and exhausted ; and death at length puts a period to his misery. (See Traite Historique et Dogma- tique de VOperation de la Taille, par J. F. L. Deschamps, t. i. p. 163. Paris, 1796.) It is acknowledged by the most experienced surgeons, that the symptoms of a stone in the bladder are exceedingly equivocal, and may be produced by several other disorders. " Pain in making water, and not being able to discharge the urine without the faeces, are common consequences of irritation of parts about the neck of the bladder, from a diseased prostate gland, and other causes. The urine stopping in a full stream is frequently caused by a stone altering its situation so as to obstruct the passage ; but the same thing may hap- pen from a tumour or fungus in the bladder. I have seen an instance of this, where a tumour, hanging by a small pedicle, would sometimes cause obstruction, and by altering the posture would retire and give a free passage. The dull pain at the neck of the bladder, and the sensation of pressure on the rectum, are frequently owing to the weight of the stone, &c; but these may proceed from a diseased en- largement of the prostate gland. Children generally, and grown persons frequently, are subject to a prolapsus ani, from the irritation of a stone in the bladder; but it will likewise be produced by any irritation in those parts."—(Earle.) The rest of the symptoms are equally fallacious; a schirrous enlargement of the os tincae and disease of the kidneys may occasion a copious quantity of mucus in the urine, with pain, irritation, &c. " The least fallible sign," says Sir James Earle, " which I have remarked, is the patient making the first por- tion of urine with ease, and complaining of great pain coming on when the last drops are expelled. This may readily be accounted for, from Stone. 389 the bladder being at first defended from contact with the stone by the urine, and at last being pressed naked against it. But to put the matter out of all doubt, and actually to prove the existence of a stone in the bladder, we must have recourse to the operation of sounding." A stone in the ureter or kidneys, or an inflammation in the bladder from any other cause, will sometimes produce the same effects : but if the patient cannot urinate, except in a certain posture, it is almost a sure sign that the orifice of the bladder is obstructed by a stone. If he finds ease by pressing against the perinaeum with his fingers, or sitting with that part upon a hard body, there is little doubt the ease is procured by taking off the weight of the stone ; or, lastly, if, with the other symptoms, he thinks he can feel it roll in his bladder, it is hardly possible to be mistaken ; however, the only sure judgment is to be formed from searching. An enlarged prostate gland is attended with symptoms resembling those of a stone in the bladder; but with this difference, that the mo- tion of a coach, or horse, does not increase the grievances when the prostate is affected, while it does so in an intolerable degree in cases of stone. It atso generally happens, that the fits of the stone come on at intervals : whereas the pain from a diseased prostate is neither so unequal nor so acute.—(Sharp, in Critical Inquiry, p. 165. 4th. edit.) Though, from a consideration of all the circumstances abovo related, the surgeon may form a probable opinion of there being a stone in the bladder, yet he must never presume to deliver a positive one, nor ever be so rash as to undertake lithotomy, without having greater reasons for being certain that there is a stone to be extracted. Indeed, all prudent surgeons, for centuries past, have laid it down as an invariable maxim, never to deliver a decisive judgment, nor undertake lithotomy, without having previously introduced a metallic instrument, called a sound, into the bladder, and plainly felt the stone.—(Cooper.) I know of at least seven cases, and at two of them I was present, where the patients were subjected to all the torture and perils of this operation, without there being any calculi in their bladders. The maxim, therefore, cannot be too strictly enforced, that the operation ought never to be attempted, unless the stone can be distinctly felt with the sound or staff. In one of the examples, of which I was a spectator, not only the symptoms, but the feel which the sound itself communicated when in the bladder, made the surgeons imagine that there was a calculus, or some extraneous body in this organ. Most of the above cases, I understand, recovered, which may be considered fortunate ; because, when the stone cannot be found, the disappointed operator is apt to persist in roughly introducing his fingers and a variety of instruments, so long, in the hope of catching what cannot be got hold of, that inflammation of the bladder and peritoneum is more likely to follow, than when a stone is actually present, soon taken out, and the patient kept only a short time upon the operating table.—(Cooper.) In a valuable practical work, is recorded an instance, in which what is called a horny cartilaginous state of the bladder made the sound communicate a sensation like that arising from the instrument actually 390 Stone. touching a stone, and the surgeon attempted lithotomy. This patient unfortunately died in twenty-four hours.—(See Desault's Parisian Chir. Journal, vol ii. p. 125.) However, were the symptoms most unequivocal, there is one cir- cumstance which would always render it satisfactory to touch the stone with an instrument, just before the operation, I mean the pos- sibility of a stone being actually in the bladder to-day, and not to-mor- row. Stones are occasionally forced, by the violent contractions of the bladder, during fits of the complaint, between the fasciculi of the muscular coat of this viscus, together with a portion of the mem- branous lining of the part, so as to become what is termed encysted. Or, as there is reason to believe, the cyst is sometimes produced first, and the calculus is formed in it, as a kind of effect of the existence of the separate pouch. The opening into the cyst is frequently very narrow, so that the stone is much bigger than such orifice, in conse- quence of which, it is impossible to lay hold of the extraneous body with the forceps, and the operation would necessarily become fruitless. —(Sharp's Critical Inquiry, p. 228. 4th. edit.) Treatment. A great variety of means have been recommended for the removal of this most formidable disease. The ingenuity of physicians has been much puzzled to find out some agents that would have the power to dissolve the stone ; and although some may possess considerable virtue, it is pretty evident, that as yet there has been discovered no specific. Lime-water, alkalies and various diuretic articles have been extolled, but all have proved unavailing. Various liquids have been injected into the bladder, in order to dissolve the stone, but none, I believe, has been attended with much benefit. It would appear that all internal medicines prove ineffectual, in consequence of their acting only by sympathy, and therefore not proving sufficiently powerful, or if they enter the circulation, they still prove insufficient. The most reasonable theory given of the formation and cure of the gravel and stone, where it is effected, is given by Dr. Perry. He states, that all that internal medicine can do, is to prevent any future apposition of the stony concretions, by exciting a healthy action of the urinary organs, and then depending entirely upon the power of the urine alone to dissolve the stone ; and, in all probability, it is in this way that medicine, when taken internally, proves efficacious in the disease. In this manner, unquestionably, many persons have been cured of stone in a very aggravated form, and the medicine given has acquired the character of a solvent. Some years ago, I was called forty or fifty miles from this city, to see a lady labouring under a fistula. On my passage there, a gentle- man stated to me that he had been for a length of time afflicted with a stone in the bladder, and that he had been entirely cured of it by taking a tea of a simple plant, which was the wild carrot (dancus syl- vestris.) He voided forty-seven large pieces of stone, part of which he exhibited to me, and the other pieces, he said, were in the hands of Stone. 391 a physician in the city of New-York. He made a strong decoction of the top or seeds of the plant, and drank it freely and very warm, and continued the use of it a length of time. He stated also, that he had found that when the stone produced a retention of the urine, he avoided the difficulty by laying upon his back or in a recumbent po- sition, by which the stone was thrown to the posterior part of the body, and he was enabled to make water by turning on one, or the other side. The course which has been recommended in the preceding com- plaint, the gravel, should be first thoroughly tried in this disease, and if this should not prove effectual, I should recommend the patient to submit to the use of the instrument called the lithontriptor, em- ployed for crushing the stone in the bladder, by which the horrible and dangerous operation of lithotomy, or cutting open the bladder, is rendered unnecessary. According to some accounts, it was invented by M. Le Roy d'Etioles, but first brought into much notice by the exertions of Dr. Civiale, of Paris. It is not for me to enter into the dispute concerning the degree of merit which may belong in this subject to each of these gentlemen, or to Baron Hourteloup, who has warmly defended the priority of M. Le Roy's claim, at the same time that he has himself contributed very much to the perfection of the instruments and the success of the practice. The lithontriptor consists of a straight silver catheter of considerable diameter, and enclosing another of steel, the lower extremity of which consists of three branches, calculated to grasp the stone, on withdrawing the steel catheter a short way within the outer one, when they become approximated. The cavity of the inner catheter is capable of admitting a steel rod, to which may be af- fixed, at the surgeon's option, a simple quadrangular drill, or a straw- berry-shaped file, or a trephine. By means of a spring the latter part of the apparatus is pressed evenly inwards, and it is made to re- volve with velocity through the medium of a bow, after the manner of a common hand-drill. Chausier and Percy were requested by the Royal Academy of Medicine at Paris, to examine the merits of this new invention, and to draw up a report on the subject. " This re- port (as a respectable journal states) speaks in very strong terms of the success which the reporters witnessed in repeated trials by the inventor; and there can be no doubt, from the distinct and precise evidence adduced by them, that none of the means previously sug- gested for the same purpose can compete with the instrument now proposed. The first case in which the reporters witnessed its appli- cation, was that of a man thirty-two years old, who had a mulberry calculus of considerable size. The experiment was made in presence of Chaussier, Percy, Larrey, and several other surgeons of eminence. The instrument having been introduced, and the stone caught at the first attempt, ' at every stroke of the bow those present heard a crackling sound, which announced both the hardness of the stone and the rapidity of its demolition.' The operation was continued, at occasional intervals, for forty minutes, during which the patient com- plained rather of uneasiness than of decided pain. The instrument was then withdrawn, and the patient immediately discharged with his 392 Stone. urine a quantity of powdery detritus, which was supposed to form a third part of the stone. The operation was renewed eleven days af- terward, in presence of the same persons, and of Magendie and Serres ; and again, a third time, ten days afterward. The quantity of powdery matter then discharged, appeared to be equivalent to the size of the stone, and no calculus could be afterward discovered in the bladder by the most careful sounding. The second case was that of a man affected with a calculus, of which the nucleus was a kidney- bean. The urethra had been previously dilated by the successive introduction of sounds of larger and larger diameters. The sound caused in this instance was dull and obscure. The bladder being irritable and disposed to contract, the operation was continued for a shorter period than in the former case, and was resumed every third day. Four operations removed the whole of the stone, the patient being sounded after the fourth by one of the most dexterous lithoto- mists in Paris. The stone in this case came off in sundry particles, and little fragments loosely agglutinated by a viscous animal matter. At the third operation, the forceps caught and brought away the bean, deprived of its epidermis; and at the next, the crust came away with the remaining fragments of the stone. In the third case, the stone was of the size of a pigeon's egg, and moderately hard. After three operations, the cure, at the period of the delivery of the report, was considered as nearly completed. Nothing unusual occurred in this case, except that, on one occasion, the operator failed in catching hold of the stone. The plan is evidently inadmissible when the stone is too large to be seized with the forceps, when it is adherent, encysted, or formed on a nucleus of a metallic or bony nature."—(See Arch. Gin. de Med., May, 1824, and Edinb. Med. and Surg. Journ., Jan. 1825.) This invention, certainly, is a great desideratum, and a very im- portant one ; for the idea of undergoing a surgical operation by the knife for a stone, is most appalling, and by most persons is dreaded more than the disease itself. The objections to the operation are certainly very serious. About one fourth, it may be computed, die of it, and often the bladder is opened and no stone found; and even if one or more is taken out, the same causes still remaining in the system, are very liable to reproduce the complaint. From the success which has attended this ingenious invention, by those who well understand it, I confidently hope that this dreadful operation will hereafter be dispensed with. I speak with confidence on this subject, because I have had an op- portunity of witnessing and learning the treatment and operation, as practised by an ingenious French surgeon. Of thirty patients operated upon by M. Civiale, since the month of April of the year just mentioned, twenty-five have been cured, and the remainder were still under treatment when the memoir was pub- lished. Among the former, was a lad seven years of age, in whom the operation was attended with great difficulty, by reason of the im- perfect developement of the parts, and the irritability of the patient; every obstacle, however, was surmounted; the stone, of the size of an almond, and composed of oxalate of lime, was perforated, and ex- tracted in three sittings often minutes each.—(Cooper.) Stone. 393 The author asserts that the reproduction of the calculi, is not more frequent after lithotrity, than the common operation of lithotomy ; and if the reverse should appear to be the case, it arises, according to him, from the fatality attending the latter, which must of course diminish the number of relapses. A priori, we might suppose they would oc cur more frequently after lithotrity, in consequence of some small fragments being left in the bladder, which would thus serve as nuclei to fresh formations ; but this is in a great measure obviated by the construction of the instruments, which affords great facility of ex- tracting small bodies. In proof of which, M. Civiale states, that he has removed pieces of straw, and other substances equally minute, which had served as nuclei.—(Nouv. Biblioth. Med.) Should this instrument, and the means recommended, fail of per- forming a cure, I cannot conscientiously recommend the operation of lithotomy as practised in this day. There is one, however, that might, under some circumstances, be justifiable, and which I consider to be altogether preferable to that now adopted. It is the ancient method practised by Celsus, being safe, more simple, altogether less painful, and more certain, and may even be performed on children without causing great irritation or much hazard ; and we have the best au- thority for stating, that nothing but the simplicity and the success at- tending it, in the hands of every one who thought proper to make use of the method, induced surgeons to abandon it, and to substitute in its place the common operation of lithotomy. Interest, and new and complicated inventions, then, were the cause of its falling into disuse. I will now describe this method, as practised by the ancients. Apparatus Minor Cutting on the Gripe, or Celsus' Method. The most ancient kind of lithotomy was that practised upwards of two thousand years ago by Ammonius, at Alexandria, in the time of Herophilus and Erasistratus, and by Meges at Rome, during the reign of Augustus ; and, being described by Celsus, is named Lilhotomia Celsiani. As the stone, fixed by the pressure of the fingers in the anus, was cut directly upon, it has been called cutting on the gripe, a knife and a hook being the only instrument used. The appellation of the less apparatus was given to it by Marianus, in order to dis- tinguish it from a method which he described, called the apparatus major, from the many instruments employed. The operation was done in the following way. The rectum was emptied by a clyster, a few hours previously; and, immediately before cutting, the patient was desired to walk about his chamber, to bring the stone down to the neck of the bladder; he was then placed in the lap of an assistant, or secured in the manner now practised in the lateral operation. The surgeon then introduced the fore and middle fingers of his left hand, well oiled, into the anus; while he pressed with the palm of his right hand on the lower part of the abdomen, above the pubes, in order to promote the descent of the stone. With the fingers the calculus was next griped, pushed forwards towards the neck of the bladder, and made to protrude and form a tumour on the left side of the perinoeum. The operator then took a scalpel and made 394 Stone. a lunated incision through the skin and cellular substance, directly on the stone near the anus, down to the neck of the bladder, with tho horns towards the hip. Then, in the deeper and narrower part of the wound, a second transverse incision was made on the stone into the neck of the bladder itself, till the flowing out of the urine showed that the incision exceeded in some degree the size of the stone. The calculus, being strongly pressed upon with the fingers, next started out of itself> or was extracted with a hook for the purpose.—(Celsus, lib. 7. cap. 26. J. Bell's Principles, vol. ii. p. 42. Allan on Litho- tomy, p. 10.) The objections to cutting on the gripe are, the impossibility of always dividing the same parts; for those which are cut will vary according to the degree of force employed in making the stone project in the perinaeum. When little exertion is made, if the incision be begun just behind the scrotum, the urethra may be altogether detached from the prostate ; if the stone be much pushed out, the bladder may be entered beyond the prostate, and both the vesiculae seminales and vasa deferentia inevitably suffer. Lastly, if the parts are just suffi. ciently protruded, the neck of the bladder will be cut, through the substance of the prostate gland.—(Allan on Lithotomy. Burns, in Edinb. Surg. Journal, No. XIII. J. Bell, vol. ii. p. 59.) The preceding dangers were known to Fabricius Hildanus, who attempted to obviate them by cutting on a staff introduced through the urethra into the bladder. He began his incision in the perinaeum, about half an inch on the side of the raphe: and he continued the cut, inclining the knife, as he proceeded, towards the hip. He con- tinued to divide the parts till he reached the staff, after which he enlarged the wound to such an extent as permitted him easily with a .. hook to extract the stone, which he had previously brought into the neck of the bladder by pressure with the fingers in the rectum.— (Burns.) In this way Mr. C. Bel) has operated with success.—(J. Bell.) The apparatus minor, as practised by Fabricius, with the aid of a staff, is certainly a very simple operation on children, and some judi- cious surgeons doubt the propriety of its present neglected state. You cut, says an eminent writer, upon the stone, and make of course with perfect security an incision exactly proportioned to its size. There is no difficult nor dangerous dissection : no gorget nor other dangerous instrument thrust into the bladder, with the risk of its pass- ing between that and the rectum ; you are performing expressly the lateral incision of Raw and Cheselden, in the most simple and favour- able way. The prisca simplicitas inslrumentorum seems to have been deserted for the sake of inventing more ingenious and complicated operations.—(J. Bell.) Celsus has delivered one memorable precept in his description of lithotomy, ut plaga paulo major qudm calculus sit; and he seems to have known very well that there was more danger in lacerating than cutting the parts. The simplicity of the apparatus minor, however, formerly embold- ened every quack to undertake it; and as this was followed by the evils and blunders unavoidably originating from ignorance, at the same Gravel and Stone. 395 lime that it diminished the emolument of regular practitioners, the v operation fell into disrepute.—(See Heister.) It was longer practised, however, than all the other methods, having been continued to the Commencement of the 16th century ; and it was performed at Bor- deaqx, Paris, and other places in France, on patients of all ages, by Raoux, even as late as 150 years ago. Frere Jaques occasionally had recourse to it; and it was successfully executed by Heister.— (Part 2. chap. 140.) A modern author recommends it always to be preferred, on boys under fourteen.—(Allan, p. 12.) Enlargement of the Prostate Gland. Symptoms. Sense of weight and bearing down in the perineum ; frequent in- clination to make water, with difficulty and pain in voiding it; great costiveness ; the evacuation of faeces is attended with much pain, and is in general accompanied with a discharge of urine ; micturition and dysuria increase, and at length a total suppression takes place. Diagnosis. The urine and faeces discharged at the same time ; the patient, in making water, is observed to kneel and separate his legs from each other, in order to effect a relaxation of the muscles ; an examination per rectum, when a large irregular tumour will be discovered in the situation of the prostate gland. Treatment. Recourse should be had to all those means which allay irritation in the urinary organs. The internal use of opium, cicuta ; the occa. eional or constant use of a catheter.—(See Gravel and Stone.) Vol. 11. 3B CHAPTER XXVIII. AMPUTATION. "It is an excellent observation, founded on the purest humanity, and justified by the toundett professional principles, that to save one limb is infinitely more honourable to the surgeon, than to have performed numerous amputations, however successful." I introduce the subject of amputation here, not to give the method of performing it, but to make some remarks upon the propriety or impropriety of it in many diseases. " From the earliest periods," says Gibson, " the question of the propriety or impropriety of amputation, in certain diseases and inju- ries, has been agitated with warmth and even acrimony ; some con- tending that the operation was scarcely ever necessary under any circumstances ; others, that patients were often suffered to die for the want of it. Unfortunately, these points are almost as unsettled at the present day, as at any former period."—(Gibson's Surgery.) It certainly must be admitted, that the act of performing amputa- tion is proof of the surgeon's ignorance ; for, if he possesses skill or knowledge of the healing art, he would be enabled to cure the disease for which he amputates. " The amputation of a limb," says Pott, " is an operation terrible to bear, horrid to see, and must leave the person on whom it has been performed, in a mutilated and imperfect state." When we reflect how often this operation is performed, either through the desire of obtaining notoriety, ignorance or other causes,! it is enough to produce a strong feeling of indignation in the mind of every feeling person. In every direction, there are cases in which amputation has been proposed, which have been cured by very simple means, or perhaps the efforts of nature alone ; thus showing conclusively, that practi- tioners in this day labour under a most lamentable error. A case occurred in New-Jersey, where a man injured his leg, and where a physician decided that it must be amputated ; and after it was cured by another physician, he felt so indignant at the first, who wished to deprive him of it unnecessarily, that he could scarcely re- train, when he saw him, from " kicking" him with it. Let us briefly examine into the reasons given for amputation, and refer to the diseases for which it is performed. And, first—Compound Fractures, particularly of the ankle joint. It has been thought necessary to amputate almost in every case for this accident. A noted surgeon of this city was always in the habit of it. But, to show that it is unnecessary to amputate in such cases, even without tho benefit of any reformed system of medicine, I shall quote some remarks and cases, as recorded by Sir Astley Cooper, in a work of his, on dislocations and fractures of the joints. Amputation. 397 Speaking of compound dislocations of the ankle, he says, " is ampu- tation required ?" The first question which arises upon this subject, is the following : Is Amputation generally necessary in Compound Dislocations of the Ankle ? My answer is, certainly not. Thirty years ago, it was the practice to amputate limbs for this accident, and the operation was then thought absolutely necessary for the preservation of life, by some of our best surgeons ; but so many limbs have been saved of late years, indeed I may so say, so great a majority of these cases exist, that such advice would now be considered not only injudicious, but cruel. I shall now proceed to state the cases which have induced me to say that amputation, as a general rule, is improper. case r. I was, many years since, going into the country with a friend of mine, and we met with a surgeon on our journey, who put this ques- tion : " How do you act in compound dislocations of the ankle joint ?" I do not recollect the reply, but he proceeded to say, "I have had a case of compound dislocation of the ankle joint under my care, in which I told the patient he must lose his limb. Not approving this advice, his friends sent for another surgeon, who said he thought he could save it; the patient placed himself under his care, and the man is recovering." About thirty years ago I received from Mr. Lynn, of Woodbridge, now Dr. Lynn, of Bury, St. Edmunds, the astragalus of a man broken into two pieces, which he had taken from a dislocated ankle joint, His letter is as follows : CASE II. Dear Sir:—J. York, aged thirty-two years, being pursued by some bailiffs, jumped from the height of several feet to avoid them. The tibia, and a part of the astragalus protruded at the inner ankle. I immediately returned the parts into their natural situation. Suppura- tion ensued ; and in Ave weeks a portion of the astragalus separated, and another piece a week afterwards, which, when joined, formed the ball of that bone. In three months the joint was filled with granula- tions. It soon afterwards healed, and the man recovered with a good use of the limb. case iti. (Communicated by Dr. Battley.) A person threw himself from a window and produced a compound dislocation of the ankle joint. The tibia was thrown on the inner side of the foot, and when the finger was passed into the wound, the astragalus was discovered to be shattered in a number of pieces. A neighbouring surgeon was sent for, who, on viewing the case, pro- posed an immediate amputation, which was not acceded to. Mr. 399 Amputation, Cooper and myself were requested to take charge of the case. The loose and unconnected portions of the bone were removed, and the tibia was replaced. The parts were ordered to be kept cool by fre- quent applications of evaporating lotions. Suppuration continued, but after four or five months, filled up, and the joint healed at the end of nine months, but the ankle was stiff. In two years he could walk with- out the aid of a stick, and at the end of three or four years was near- ly as well as at any former period of his life. CASE IV. Compound Dislocation of tlve Tibia, inward. Mr. Knowles, a farmer, was thrown from his chaise, against the hinder wheel of a wagon, and dislocated the tibia inward, and fractur- ed both the tibia and fibula. Mr. Richards, who was called, reduced the dislocation, and endeavoured to heal the wound by adhesion. When I saw Mr. Knowles, which was ten days after the accident, the wound wore a favourable aspect. The discharge was abundant, but not in a degree to excite alarm, and all I had to do was to praise the judgment which led to the preservation of the limb. The wound per- fectly healed, and the patient walks without the use of a stick. CASE V. Compound Dislocation of the Tibia outwards. Elizabeth Chisnel, received a compound dislocation of the ankle joint outwards. The wound communicated with the joint, which was situated upon the outer part of the leg, and was about four inches in extent, through which the fibula projected two inches. The liga- ments connecting the malleolus externus and the astragalus were lacerated. From the inclination of the sole of the foot inwards, the whole surface of the joint was so displaced as to allow two fingers to pass readily across. The tibia was fractured. The parts were re- turned to their original situation, straps of adhesive plaster applied, and the leg splintered. The parts discharged freely, and in two months the wounds were almost healed. During the progress of the cure, there was not much constitutional disturbance. CASE VI. Compound Dislocation of the Tibia inward. Mr. George Caruthers received a compound dislocation of the ankle joint inwards, with fracture of the tibia, the end of which pro- jected through the integuments of the inner ankle, two or three inches, and the b'one was tightly embraced by the skin. A considerable por- tion of the bone*afterwards came away, when the sore immediately healed, and he is now in better health than he was before the ac- cident. Mr. Somerville relates the following cases. Two patients were re- ceived in the Stafford Infirmary, with compound dislocation of the ankle-joint. They were both dislocated inwards, and were both dis- Amputation. 399 charged cured ; tho one at the end of the fifth, the other not till the end of the seventh week. CASE VII. (Communicated by Dr. Scarr.) Compound Dislocation of the Tibia outwards. John Plumb, in descending upon a ladder, with a sack of oats upon his shoulders, received a compound dislocation of the tibia outwards. The tibia and fibula had penetrated through the integuments at the outer ankle, and were lying on the outside of the foot. The articula- tory surface of the astragalus had penetrated through the integuments of the inner ankle, the foot nearly reversed, the bottom of the foot being placed where the side of the' foot was naturally situated. The bones and integuments were replaced, and cooling lotions applied. Abscesses took place, and after five-and-twenty weeks, the man was convalescent, union of the articulatory surfaces took place, the wounds healed, and the patient became able to walk. He could not bear to work much on his foot till about twelve months after the accident, from which time he has been constantly labouring. CASE VIII. (Communicated by Dr. Abbott.) Compound Dislocation of the Tibia inwards. Mr. Robert Cutting, near seventy years of age, corpulent, intern- perate and subject to gout from his youth, in a dispute in a state of in- toxication, was thrown violently to the ground, and suffered a com- pound dislocation of the tibia at the ankle-joint. The end of it was forced through the integuments nearly four inches, and the wound was large. In the struggle to stand erect, he rested his weight upon the end of the bone, which was covered with sand and dirt. The cavity of the articulating surface of the joint was filled with blood and sand, the fibula fractured, and the foot completely turned outwards. He was now carried several miles in a cart, and it was five hours before surgical assistance was rendered, in the middle of a cold night. A case so formidable, a large wound, the connecting ligaments lacerated, the surface of the articulating parts long exposed and much injured, led me to conclude that it would be impossible to save the limb, in a constitution so disordered. However, no persuasion could prevail with a mind obstinate and inflexible ; he would not submit to amputation. The surfaces were as carefully and expeditiously as possible made clean with warm water; the reduction was easily accomplished ; the lacerated parts propcrlv placed, and the edges of the wound brought nearly in apposition, without stitches or adhesive^plaster. 1 he limb was laid upon a proper-sized thin board, so as to take the form of the leer, with an opening to receive the outer ankle. Refrigerant lotions were applied, and the system properly attended to. After ten weeks, he was taken from his bed, and the wound was healed. At the end of five months, he was allowed to go upon crutches, and, to please himself, the patient plunged bis foot and ankle into the paunch of an ox. In twelve months, he could walk without a stick. 400 Amputation. CASE IX. (Communicated by Dr. Ransom.) A female, of a scrofulous habit, fell from a high stool, and caused a compound dislocation of the ankle-joint. The foot was dislocated, the external malleolus was fractured, a lacerated wound extended half round the joint, and laying the cavity of the joint so open as freely to admit the finger, and through it the synovial fluid escaped. The pa- tient recovered. case x. (Communicated by Dr. Chandler.) Compound Dislocation of the Tibia inwards, and Fracture of the Thigh. A bricklayer fell from a height of from between thirty and forty feet, and received a fracture of the thigh, a considerable contusion and laceration of the left ankle-joint, accompanied with a dislocation of the bones inward, the tibia resting upon the inner side of the astra- galus. The fibula was broken, and the ligaments lacerated. The question arose on the propriety of amputation, but I ventured to give him a chance of saving the limb. Evaporating lotions were applied, and a cooling course enjoined. Considerable inflammation followed, with the symptoms of gangrene, but they soon disappeared, and the patient gradually improved until the tenth week. In fourteen weeks he was discharged well. I treated another case of the compound dislocation of the ankle, which was also cured. Remarks. (Communicated by Dr. Stephen S. Hammick.) The result of my observations has been, that in cases of compound dislocations of the ankle-joint, there is not only a chance of saving the limb, but that limb being useful. The following case shows that, under the most unfavourable circum- stances, these injuries are not destructive to life in sound constitutions. I was called, five weeks after the accident, to reduce a dislocation of the ankle, as he had reduced the fracture of the fibula. I saw the patient, but the fractured fibula was so firmly united, that a reduction could not be attempted. The compound dislocation gradually got well, and no bad symptoms arose. 28 Park Street, Bristol, October 20th, 1818. My Dear Sir:—During the twenty-two years I have been surgeon to the Bristol Infirmary, and I believe during my apprenticeship there, making in all nearly thirty years, it has been our invariable practice to endeavour to save the limb in cases of compound dislocation of the ankle, unless where the chance was annihilated by some concomitant injuries or circumstances : but as a general rule, it was always adhered to, which it would not have been, unless the great majority of cases had done well. We save the limb in private practice almost inva- riably, unless in very bad cases indeed. R. SMITH. Amputation. 401 Dr. Fisk communicates the following case. A man fell from a lad- der, and dislocated the tibia inwards, the bone protruding through the integuments. The man recovered, and has a very useful limb. CASE XI. (Communicated by Dr. Maddox.) A man was thrown from a horse, and dislocated his ankle. The end of the bone protruded through a large, lacerated and contused wound, and which was broken four inches above the joint; ligaments torn. The patient, in three months, recovered the use of the joint, and from this time experienced no inconvenience from the accident. Two other cases communicated by the same. Two cases of dislocation occurred in boys, by falls from horses. In both cases the ankle was broke, and the bones protruded through the flesh. Both recovered. CASE XII. (Communicated by Dr. Ormond.) A lad, thirteen years old, got his foot entangled in machinery, and caused a bad compound dislocation of the tibia and fibula. The bones protruded four or five inches through the integuments, which were dreadfully lacerated. The wound extended from the ankle nearly to the knee ; the bones of the foot were very loose, being torn from their connecting ligaments. It seemed impossible to save the limb, and 1 was about to amputate, but deferred it. In fifteen weeks after he re- ceived the injury, he was able to walk to the factory without crutches. I was about to proceed to detail thirty or forty cases more of the same nature, many of which were much worse than any of the pre- ceding, but the limits of this work will not permit. Those who wish further information on this subject, may refer to Sir Astley Cooper's work on Dislocations and Fractures of the Joints. A volume might be filled with cases of accidents occurring in other parts of the system, where amputation is commonly practised, and which have been cured without it by very mild means. I trust, however, that I have already exhibited proof enough to satisfy every judicious person, that amputation is very rarely or seldom necessary, in the worst cases of compound fracture. 2d. Mortification.—I know of no disease in which amputation is ren- dered more unnecessary, than for mortification ; and that according to the very principles now laid down in surgery. It is admitted, that if a limb, in a state of gangrene, be cut off, that the stump will par- take of the same character, and thus prove fatal: and therefore it is now recommended never to amputate, until a line of demarcation is formed between the living and the dead part, or, in other words, until the disease is arrested. Then, according to this theory and practice, there is no propriety in removing a limb until the disease gets well or begins to grow better, for which the limb is removed. Any attempt to refute a doctrine so palpably absurd, is rather imposing upon the good sense of the reader. It carries its own refutation on the very face of it. 403 Amputation. I know of no complaint that can be more successfully treated, than mortification ; and amputating for it, was it in reality a remedy, would be useless and cruel. I shall, therefore, not dwell upon this subject, but leave it for all sober minded persons to decide how far my state- ment or views coincide with correct principles of the healing art. 3d. While Swellings.—Limbs are now removed for white swellings, but with what propriety, I cannot see. Although it is an obstinate complaint, yet it is a curable one, as I have demonstrated in numerous instances, ever since I commenced the practice of medicine. I have found a sovereign remedy for this most afflicting complaint, for which little else but blisters are recommended, (and which may truly be said to be the oppropria medicorum.) An interesting child, afflicted with this complaint, the other day was led from one of the wards of the hospital into the amputating theatre, writhing in agony in anticipation of the dreadful calamity about td come upon him, while a set (shall I not say) of human butchers were eagerly waiting to display their adroitness in using the amputating knife. His leg was removed for a common white swelling, which I should only have required the period of three months effectually to have removed. Let this case be contrasted with one that recently occurred in a lady of this city, labouring under the same disease. She was told that her leg must be amputated for it; but by the application of ve. getable agents alone, the inflammation, pain and swelling subsided, and she has now the use of it, and can walk as well as ever. And, did the limits of this work permit, a vast number of similar cases might be adduced, to corroborate these principles. 4th. Necrosis, or Diseased Bone.—Amputation is recommended and practised for necrosis, or diseases of the bone ; but this arises, as in other cases, in consequence of the ignorance of the surgeon. If he Understood his business, or was a skilful physician, he would be able to treat this disease successfully, without ever resorting to amputation. I have never yet seen a case in which I deemed it necessary ; and I do not believe that it is justifiable in any case whatever ; and of this, every practitioner who has had much experience in surgery, must be fully aware. The efforts of nature in expelling dead or diseased bones, is truly astonishing ; and whoever is acquainted with her salu- tary and powerful efforts, if he possesses only a moderate share of medi- cal skill, would never think of using the knife in affections of this kind. 5th. Cancer. —Amputation is now performed for cancerous diseases, particularly for the fungus haematodes. But it is well known, and generally acknowledged, that after the patient undergoes an operation for any of these complaints, it returns with greater violence than ever. The cancerous humour, or virus, is so extensive and so inter- woven with the adjacent parts, or the vessels concerned in the produc- tion of the disease, that only a portion can be removed. So far from even affording relief, it usually aggravates the disease. A writer remarks, that " when this disease shows itself only exter- nally, internal organs are mostly at the same time similarly affected." The very nature of this complaint is sufficient to prove that th« knife is no remedv for it. Amputation. 403 6th. Ulcers.—Surgeons perform amputation for inveterate ulcers, which certainly evinces great ignorance and cruelty, for it requires but a small share of medical knowledge to cure the Worst species of ulcers. But some surgeons, even if they had skill to cure them, Would much rather have the name of cutting off a limb, than saving it by any treatment whatever. Again and again we have been called to obstinate ulcers, where amputation has been proposed as the only remedy, and we have succeeded in effecting a cure. I have never yet seen one which has required amputation, nor do I believe that any ever occur which require it. I have thus briefly treated of the various diseases for which ampu- tation is usually performed, and I think I have shown that few, if any, call for it. I grant, that if the practitioner have no other resources than such as are laid down in surgical works for the removal of the various diseases for which amputation is performed, that it might be often necessary. But inasmuch as the treatment pointed out in this work is sufficient to cure these diseases, it should be dispensed with, at any rate, with very few exceptions. Poor must be the resources of that surgeon who has not sufficient skill to prevent the necessity of amputation. How much more credit- able would it be to him to save a limb, than ever so handsomely to amputate it. In concluding this chapter, I shall again quote the remarks inserted in Gibson's Surgery, on bony tumours. In Dr. Gibson, on bony tumours, page 136-7, is the following, to the same import: " Whoever attends a European Infirmary, will be struck with the diversity and multiplicity of operations performed upon the most trivial occasions. Will it be credited, when I say that the illustrious founder of American surgery, during a practice both hospital and pri- vate, of thirty years, and more extended than that of any other indi- vidual of our country, has hardly ever had occasion to resort to ampu- tation ? It may be asked what became of his patients ? I answer, they have been cured by general and local means. Doctor, said a surgeon of Pennsylvania hospital, to a distinguished practitioner of a neighbouring city, what would be done in your town with such a leg ? We should cut it off, was his reply. We can cure it here without, re- joined the other. • In a certain London hospital,' says Dr. Gregory, ' a patient was under the care of the physicians, on account of a very bad leg, which baffled their skill, and appeared to them almost hope- less ; they therefore requested a consultation of the surgeons, to ex- amine the leg and to decide what should be done with it. "The surgeons accordingly met, examined it, consulted about it, and resolved nemine contradicente, that the leg could not be saved, and ought to be cut off. They cut it off without delay. But, strange to tell, the physicians, at their next visit, on examining the patient, found, to their great astonish- ment, the supposed hopeless leg as fast to his body as ever it had been. "' The puzzle was soon explained. It happened that the man had two legs, both of them very bad ; o»e the physicians thought they could save, the other they despaired of. There being but right and wrong, it was not very marvellous that the consultation took the wrong. Both Vol. II. 3 C 404 Amputation. physicians and surgeons, I believe, were a little disconcerted at that quid pro quo ; and as it was thought rather a strong measure to cut off both of the man's legs, they exerted themselves to the utmost and saved the leg which should have been cut off; so that, after all, the poor man was but one leg out of pocket. "'As I was not an eye-witness of this edifying transaction, it is proper to give some notion of the genealogy of the story, which is very short and simple. I have it from a reverend clergyman, who had it from one of the physicians concerned, and who is now one of the most eminent of his profession in London. I know both the clergyman and the physician intimately ; I know them both to be men of veracity and men of sense ; and I have no doubt the facts were just as I have stated them.' " These remarks may appear, perhaps, irrelative, but I am satisfied of their importance, and shall be gratified if they tend to check the disposition, so prevalent among surgeons, to use the knife; or con- tribute, in a single instance, to alleviate pain or remove diseases by milder or more appropriate means." Even supposing that amputation ever was required, the practice of doing it immediately should be deprecated. The act of performing the very painful operation of cutting off a limb immediately after a severe injury, is sufficient of itself to produce the most serious conse- quences, besides depriving the patient of any chance of saving his limb. All the pretexts for immediate amputation, can never convince me of the propriety of such a course. It has often been the case that an operation has been immediately proposed, and when for some reasons it has been deferred a few hours, such a change has taken place as has induced the surgeon to abandon it and the patient has recovered. Two conclusions, then, are to be drawn from the preceding remarks. 1st. That the diseases for which amputation is performed may be cured without resorting to it. 2d. Should it become necessary ever to amputate, a dangerous, if not fatal error, is practised, by performing such operation prematurely. In concluding this chapter, I would now ask—for what disease is amputation necessary ? CHAPTER XXIX. Dropsy of the Scrotum and Spermatic Cord—(Hydrocele.) Hydrocele is an accumulation of water within the cavity of the tunica vaginalis of the testis, of the spermatic cord, or in the cellular membrane of the scrotum. SECTION I. Dropsy of the Scrotum—(Hydrocele.) Symptoms. An accumulation of a fluid is first perceived to commence at the bot- tom of the scrotum, which gradually increasing, the latter becomes enlarged and distended ; a distinct fluctuation is generally to be dis- tinguished ; the tumour acquires a pyramidal shape ; there is no pain nor discolouration of the integuments; and, upon viewing the parts near to a strong light, a transparency is observable. Diagnosis. It is distinguished from other diseases by its shape, which is con- stantly pyramidal, except where the patient has had a hernia, or where the disease has been taken for hernia, and a truss has been worn, when it acquires an oblong shape ;—by its transparency; yet this criterion is rendered fallacious when the investing membranes have previously undergone inflammation, in which case they become thickened and impermeable to light;—by the fluctuation of the con- tained fluid; by the tumour having first commenced at the bottom of the scrotum. From Hernia.—By the tumour not dilating when the patient coughs ; by the tumour in the one disease commencing at the top of the scro- turn, in the other at the bottom ; by the facility of returning the pro- truded intestine, in reducible hernia, into the abdomen. From Disease of the Testicle.—By the want of discolouration and hardness, and the absence of that irregularity to the touch possessed by scirrhus. From Hematocele.—By the colour and shape of the tumour, and by that disease suddenly coming on, and being usually the consequence of accident. From Anasarca of the Scrotum.—By the one being elastic to the feel, the other oedematous; the one pyramidal, the other irregularly shaped. Treatment. At the commencement of the disease, and when a small quantity of fluid only is collected, attempts may be made to disperse it by in- ternal and external applications. When it occurs in children, which is often the case, it may readily be cured by proper treatment, without ever evacuating the water by the trocar or lancet. It is usually con* 406 Dropsy of the Scrotum—(Hydrocele.) nected with anasarca, or a general dropsical affection; and we must begin the treatment in the same manner as we do for general dropsy, by administering hydragogues and diuretics. Let the parts be fomented or steamed, by placing the patient over a suitable-sized vessel, in which is put a strong decoction of bitter herbs; the heat or steam to be retained in the usual manner, by means of a blanket. Immediately after, let the herbs be enclosed in muslin or linen, and applied warm to the scrotum, to be repeated two or three times a day. This treatment should be applied not only to children, but to adults, as in some cases it may remove the disease without fur- ther applications. But, when it has become large, it usually requires a different course to effect a radical cure. The water may first be drawn off in the following manner: Let the patient be seated in a chair, when the practitioner will grasp a portion of the tumour at its anterior and inferior part, between his thumb and finger; then with a lancet make a small puncture or inci- sion, by which the contents of the scrotum will be discharged. Some use a trocar, but there is no necessity for it; a simple puncture is suffi- cient. As soon as the water has been discharged, a tent must be in. troduced into the orifice, sufficiently stiff; (and to the largest end there should be a piece of silk thread tied, to keep it from entirely entering the sac,) and another should be introduced in the course of twelve hours, in order to keep the wound from healing, as a radical cure de- pends in a considerable degree upon this circumstance. Should there be any difficulty attending it, in consequence of the wound healing too fast, a mild escharotic must be applied to each tent, before it is introduced, to enlarge it, or keep it open. As soon as the water has been evacuated, every day afterwards Castile soap and wa- ter, to which a small quantity of the tincture of gum myrrh has been added, must be injected into the scrotum by a syringe, with a long pipe. It should be strong enough to excite a little pain. After this, a plaster of the black salve is to be applied, and the dressing secured by a suspen- sory bandage ; and, should any inflammation follow, let a poultice be applied. The hydrocele may also be cured by introducing a seton into the scrotum, and turning or drawing it a little every day, and using injec tions as above mentioned. This complaint, in all stages, is the most easily managed of any in surgery; at least I have found it so, having always cured it without any difficulty. But, at the same time, it is, like other diseases, easily controlled only when it is known how properly to treat it. It may be said of every department of the healing art, that it is simple when un- derstood. But it is often extremely difficult to obtain this simple know- ledge. It can only be acquired by honesty, perseverance, experience and great research, especially when there is so much rubbish to clear away. Sometimes the hydrocele is connected with an indurated state of the testicle, and which Pott called the hydro-sarcocele. After the wa- ter has been evacuated, by examining the testicle with a probe, it will be found hard and insensible. The cure consists in keeping the ori- fice open, and injecting occasionally stimulating liquids, sufficiently strong to excite a slight degree of inflammation. Dropsy of the Scrotum—{Hydrocele.) 407 Some time ago I attended a gentleman in this city, who was first attacked with a collection of water in the scrotum, which continued to increase until the swelling or tumour became enor- mous. I think it had continued for one or two years. It was not transparent, but still its appearance indicated the existence of more or less water. He had applied to several practitioners, but so formidable had it become, that all except one were afraid to undertake it. This surgeon proposed such a severe operation, that the patient was deterred from having it performed. When I commenced the treatment, I was doubtful what the event might be, but I concluded to undertake it, and hazard the result. I first punctured the tumour in the lower portion of it, about half an inch from the septum, or middle portion. After making a puncture with a lancet, I attempted to introduce a trocar, but the water flowed so freely, that I found it quite unnecessary. After having evacuated thirty or forty ounces of serous fluid, I injected, with a small syringe, a weak solution of corrosive sublimate, which caused some inflamma- tion, but it subsided in a few days. I-then introduced a long tent, over which I placed a piece of lint, then a plaster of the black salve. The whole dressings were then secured by a suspensory bandage. In this manner it was dressed once or twice a day, (the injection ex- cepted.) The patient was now very feeble, and confined to his bed; and although there was a great diminution of the tumour, yet, from the solution made use of, or injected into the scrotum, there was con- siderable pain and inflammation. I next applied a poultice, which 6oon reduced the inflammation, but still the patient did not recover; and, as the disease had become stationary, and assumed a very obsti- nate and dangerous character, I requested a surgeon to examine the disease with me. He did so, and, after introducing his probe, and finding a scirrhous state of the testicle, he gave it as his opinion, that castration was necessary to effect a cure. I could not, however, agree with the gentleman, but communicated his opinion to the pa- tient, who was totally unwilling to submit to the operation. I there- fore continued my treatment, with very little variation. I applied poultices and discutient ointments, until pus or matter collected, when, after being discharged, the hardness, swelling and inflammation soon subsided, and the man grew better very fast, and in a few weeks en- tirely recovered. Pott, speaking of this disease, thus remarks : " An indurated or scirrhous testicle has, indeed, very frequently, a quantity of fluid lodged in its vaginal coat, which is a circumstance not to be wondered at; the diseased state of the gland being sufficient to account for the non-execution of the absorbent faculty, and, con- sequently, for the collection of the water. But, although part of this mixed tumour is undoubtedly owing to a fluid, and such fluid as is lodged within the vaginal coat, yet it is a very different disease from the true, simple hydrocele, and ought not to be confounded with it; one of these marks of the latter being the natural, soft, healthy state of the testicle, and the characteristic of the former being its diseased and indurated enlargement." 408 Dropsy of the Scrotum, drc.—{Hydrocele.) " We are, by most of the writers on this subject, advised, in operating for the radical cure of an hydrocele, to regard carefully the state and condition of the testicle; and, if we find it enlarged, hardened, pu- trid, fungous, or any other way really diseased, to remove it imme- diately." "The testicle is first diseased, and the faculty of equal regular ab- sorption thereby interrupted ; by which means a quantity of fluid is accumulated, and that mixed appearance produced, which is not im- properly called hydro-sarcocele. But in this case, the extravasation of water is really the consequence of the morbid state of the gland; and (being still mere lymph) neither is, nor can be, the cause of it." " Those who choose it, may call this a species of hydrocele ; and the literal sense of the word will certainly vindicate them, but they will by that means run the risk of confounding together two things extremely unlike to each other, and which require very different treat- ment : I mean the true, simple hydrocele, in which the testicle is soft and sound, (only perhaps a little more lax, and larger than ordi- nary,) and the hydro-sarcocele, in which the testicle is not only en- larged, but hardened, and not in a sound or healthy state ; the former of these will permit such treatment with perfect safety, but in the other may bring the patient both into a state of pain and hazard." SECTION II. Hydrocele of the Spermatic Cord Is of two kinds: the first is described as an oedematous affection, extending to more or less of the cellular substance round the sperma- tic vessels, and sometimes named the diffused hydrocele of the cord; the second form of the disease is that in which the fluid is collected in a particular cavity or cyst, which has no communication with the cavities of the common cellular substance of the cord. This case is denominated, accordingly, the encysted hydrocele of the cord. The cellular substance, situated behind the bag of the peritoneum, sur- rounds the spermatic vessels, passes with them through the inguinal ring, and accompanies them to their insertion in the testicle. Hydrocele of the spermatic cord, says Cooper, may be defined as a collection of water, which takes place in the tunica vaginalis, be- tween the testicle and abdominal ring. " Sometimes the fluid extends above the ring, giving rise to the idea of its being inguinal hernia ; but you may judge of the nature of the tumour by its blue and semi-transparent appearance, by its being entirely unattended with pain, and by its not running into the abdo- men, like inguinal hernia." It is distinguished from hydrocele of the tunica vaginalis testis, by be- ing situated above the testicle ; which, when the tumour is not large, may be distinctly felt below. From Anasarca of the Spermatic Cord.—By the smoothness, elas- Scirrhus of the Testicle. 409 tioity and fluctuation of the one tumour, and the oedematous feel of the other. It is often with great difficulty distinguished from hernia.—(See Hernia.) Treatment. The treatment for this variety of the complaint must be very similar to that recommended for a collection of water in the scrotum. The water must first be evacuated, after which a little soap and water in- jected, a tent introduced, and a plaster applied. The common method is, simply to let out the water, and let the wound heal immediately; the consequence of which is, that the water soon collects again, and the disease is worse than ever, and all for the want of using the precaution which is obviously indicated from the very nature of the complaint. A German physician in this city requested me to aid him, or ac- company him to perform an operation for a hydrocele of the spermatic cord, which had previously been done by another surgeon ; but, as he had let the puncture heal, it became necessary again to evacuate the water. The tumour was punctured, and the water drawn off in the usual manner ; but, no tent being introduced to keep the orifice open, as a matter of course, it soon closed ; and, although I have not heard from the patient since, I have no doubt that it was necessary soon to renew the operation. I intimated to the surgeon the propriety of keeping it open, but he did not choose to depart from established principles, whether right or wrong. Like Dr. Sangrado, when told by Gil Bias that almost all his patients died under his prescriptions, he replied, "Never mind, Gil Bias, we have written a book, and therefore perish the clergy, perish the nobility, perish the people, but let us stick to its principles." SECTION III. Scirrhus of the Testicle. Symptoms. An enlargement is first observed in the body of the testicle, which becomes preternaturally hard, and gradually increases in size. An acute, intermitting, lancinating pain ensues ; the colour of the inte- guments becomes livid; the surface assumes an irregular knotty ap. pearance ; and often adhesions take place of the skin, forming inden- tations which much resemble cicatrices. Ulceration supervenes ; the edges of the ulcer become livid, sore, hard and retorted; fungous excrescences sp%ut forth; and if timely means are not employed to prevent the extension of the disease, the spermatic cord partakes of the affection, becoming hard and knotty. Emaciation and hectic fe- ver ensue. 410 Scirrhus of the Testicle—Varicocele and Cirsocele. Diagnosis. From Hernia Humoralis.—The one is an acute, the other a chronic disease; the one enlarging gradually, the other suddenly. In the one the pain is intermittent, pungent, lancinating ; in the other con. stant. In hernia humoralis the surface of the testicle is smooth, and of the usual colour of inflammation; in scirrhus it is livid, irregular, or knotty. From Hydrocele.—By the transparency of the tumour in that dis- ease ; and other marks already mentioned.—(See Hydrocele.)} Treatment. It is recommended to remove the testicle, but this operation, I be- lieve, is never attended with any success. Sir Astley Cooper, when speaking of this disease, thus remarks : " The operation of castration for this disease is, however, extremely unsuccessful, for it rarely happens that the complaint does not return after the removal of the scirrhous testicle. The same course must be pursued for scirrhus of the testicle, as for scirrhus of any other part. SECTION IV. Varicocele and Cirsocele. 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 wasting of the testicle, which now and then follows, it may truly be called a disease. It is frequently mistaken for a descent of a small portion of omentum. The uneasi- ness which it occasions is a dull kind of pain in the back, generally relieved by suspension of the scrotum. It has been fancied to resem- ble a collection of earth-worms ; but whoever has an idea of a varicose vessel, will not stand in need of an illustration by comparison. It is most frequently confined to that part of the spermatic process, which is below the opening in the abdominal tendon ; and the vessels gene- rally become rather larger as they approach the testis. In general the testicle is perfectly unconcerned in, and unaffected by, this disease 5 but it sometimes happens, that it makes its appear- ance very suddenly, and with acute pain, requiring rest and ease; and sometimes, after such symptoms have been removed, Mr. Pott has seen the testicle so wasted as hardly to be discernible. He has also observed the same effect from the injudicious application of a truss to a true cirsocele ; the vessels, by means of the pressure, be- came enlarged to a prodigious size, but the testicle shrunk to almost nothing.—(Pott's Works, vol. ii.) Morgagni has remarked, that the disease is mon# frequent in the left than in the right spermatic cord ; a circumstance which he refers to the left spermatic vein terminating in the renal.—{De Sedibus et Caus. Morb. epist. xliii. art. 34.) Varicocele and Cirsocele—Hcematocele. 411 Cirsocele is, more frequently than any other disorder, mistaken for an omental hernia. As Sir Astley Cooper remarks, when large, it dilates upon coughing; and it swells in an erect, and retires in a re- cumbent posture of the body. There is only one sure method of dis- tinguishing the two complaints : place the patient in a horizontal pos- ture, and empty the swelling by pressure upon the scrotum ; then put the fingers firmly upon the upper part of the abdominal ring, and desire the patient, to rise : if it is a hernia, the tumour cannot re-ap- pear, as long as the pressure is continued at the ring; but if a cirso- cele, the swelling returns with increased size, on account of the re- turn of blood into the abdomen being prevented by the pressure.—(A. Cooper on Inguinal Hernia.) Treatment. In general the disease occasions very little inconvenience, and the patient seldom applies for medical aid ; but, sometimes the distention becomes very great, and the patient suffers inconvenience from it; a severe pain in the back and loins. The treatment consists in applying fomentations, refrigerant or cooling washes, occasional purgatives, and a suspensory bandage. eECTION vk Hematocele Is a tumour formed by an extravasation of blood in the tunica vagi- nalis of the testicle, or of the spermatic cord ; in the body of the tes- ticle itself, or in the cellular membrane of the scrotum. Cause. Mechanical injury ; puncture ; a rupture of vessels after the sud- den removal of the water in the operation for hydrocele ; a relaxed state of the vessels themselves. Diagnosis. The sudden appearance of the tumour ; when arising from external injury, the effect immediately following the cause; the livid disco- louration of the scrotum ; the swelling increasing from the bottom. Treatment. Upon the first appearance of the tumour, astringents may be em- ployed to effect an absorption of the fluid ; should these be unsuccess- ful, recourse must be had to the same treatment as for hydrocele ; after which, should an oozing of blood continue, tonics and astringents may be employed both internally and topically. Vol. II. 3D 412 Inflammation of the Testicle. SECTION vi. Inflammation of the Testicle. Symptoms. Pain and enlargement of the epididymis of the affected testicle ; shooting pains along the course of the spermatic cord. The body of the testicle next becomes affected ; it swells, becomes hard and pain- ful ; the scrotum becomes much enlarged and inflamed; there is a distressing pain in the loins; the system at length becomes affected with fever, quick, hard pulse, nausea and vomiting. Causes. Inflammation of the testicle maybe induced by any of the common causes of inflammation, but is most frequently produced by irritation of the urethra, by the matter of gonorrhoea ; the improper use of in. jections, or incautious introduction of a bougie. It often follows a suppression of the gonorrhceal discharge from cold : sitting on wet grass is a frequent cause. Inflammation of the testicle and epididymis do not occur from go- norrhcea alone; but are a frequent result of the introduction of a bougie. This complaint, from an error of pathology, used to be called her- nia humoralis, in consequence of a belief that it arose from a fluxion of humours to the testicle. Inflammation of the testicle generally shows itself from within ten to fourteen days after the gonorrhceal discharge. The first symptom is a sensation of a drop of urine in the perinaeum; at this time, the inflammation is proceeding down the urethra, and, before it reaches the testicle, affects the prostate, veru montanum, vasa deferentia, proceeds up the cord to the abdominal ring, then at- tacks the epididymis, and finally the testicle itself. While the inflammation is confined to the epididymis, the patient feels little or no pain; but when it has passed to the body of the tes- tide, then there will be felt excessive pain, in consequence of the un- yielding nature of the tunica albuginea. The scrotum is sometimes reddened, arising from the degree of violence which characterizes the inflammation. The pain does not, generally speaking, corres- pond to the course of the inflammation just now described.—(Cooper.) Treatment. The patient should be put upon a spare regimen, should remain in a recumbent posture, with the part suspended by means of the bag- truss, employed for irreducible hernia. If the inflammatory symptoms run high, subdue it by the ordinary means- by fomentations, refrigerant washes, poultices, &c. The treatment laii.down for inflammation in general, must be ap- phed in this disease!'" Suppuration must be prevented, if possible, by the use of discutient applications. Felon, or Whitlow—(Paronychia.) 413 The testicle must be bathed two or three times a day, with the stramonium ointment, and after a short time, let it be changed for the discutient ointment. It should also be fomented or steamed over bitter herbs once a day, and continued as long as there is any pain, swelling, or inflammation. A plaster may also be applied. Should the disease still progress, and threaten to suppurate, ap- ply the cicuta poultice. Simmer the plant in water till it is soft, then stir in a little of the slippery-elm bark, sufficient to make it of a proper consistence. This should be applied to the testicle, and kept on by a proper bandage. After suppuration has taken place, or an abscess formed, and the matter evacuated, the orifice, or orifices, must be kept open by means of tents. Injections must also be used, the same as for any sinous ulcer. I, in general, use the alkaline liquid, made strong enough to ex- cite considerable pain for a few minutes, and alternate it with the use of tho mild solution of the sublimate, in proportion of four grains to eight ounces of water; the black plaster, or salve, to be applied as usual. A purgative should be given once or twice a week, and the general health renovated by the exhibition of alterative medicines. In this manner I have cured some of the worst diseases of inflamed and diseased testicles, where other surgeons have been unable to sue ceed, and where castration has been proposed as the only alternative. CHAPTER XXX. felon, or whitlow—(Paronychia.) A whitlow is an inflammation at the end of one of the fingers or thumb, exceedingly painful, and very much disposed to suppurate. The toes are also sometimes the seat of the disease. Writers usually divide whitlows into four kinds. In the first or mildest, a vesicle filled with matter commonly arises near the root or side of the nail, after a superficial inflammation of trivial extent. The matter is situated immediately under the cuticle. Sometimes the abscess takes place under the nail, in which case the pain is severe, and not unfrequently shoots upwards as far the external condyle. The second kind' of whitlow is chiefly situated in the cellular sub- stance under the cutis, and for the most part occurs at the very end of the finger. In this case the inflammatory symptoms, especially the pain, are far more violent than in other common inflammations of not greater extent. However, although the pain is thus severe, it does not in general extend far from the part affected. Writers usually im. 414 Felon, or Whitlow—-(Paronychia.) pute the violence of the pain, and the considerable degree of inflam- mation attending the complaint, to the hard and unyielding nature of the skin on the finger. To the same cause they also ascribe the dif- ficulty of perceiving any fluctuation, after matter is formed; and the slowness with which the pus makes its way outwards. The third kind of whitlow is distinguishable from the others by the following circumstances. With the most excruciating pain, there is little swelling in the affected finger, but a vast deal in the hand, parti- cularly about the wrist, and over the whole fore-arm. The pain ex- tends to the hand, wrist, elbow, and even the shoulder. When suppu- ration takes place, a fluctuation can never be felt in the finger, though it may often be distinctly perceived in the hand, at the wrist, or even somewhere in the fore-arm. The case is frequently accompanied with considerable fever. The disease is seated in the tendons and their sheaths, and the power of moving the fingers, and even the whole hand, is lost. Authors describe the fourth kind of whitlow, as arising principally from an inflammation of the periosteum. The case is attended with one peculiarity, which is, that however violent the pain may be, it never extends to the hand and fore-arm, nor is there any external swell- ing of the affected finger. Suppuration generally follows very soon, the usual consequence of which is a caries, or rather a necrosis of the subjacent finger-bones. Whitlows commonly begin on the inside of the fingers; but they do occasionally commence on the back of these parts, and even on that of the hand. Though pain about the wrist is usually the effect of in- flan, nation in the finger, Acrel mentions a case in which the disorder was altogether confined to the hand itself.—(Vorfalle, b. ii. p. 191.) Treatment. It is customary, in treating felons, to make a deep incision even down to the periosteum, but I have found this practice in most cases, to make the complaint worse, as much pain and inflammation follows. Some apply blisters, which also prove injurious, while others recom- mend a bread and milk poultice, all of which treatment I have found to be useless or injurious. In treating this complaint successfully, in whatever variety it may present itself, our object should be, if possible, to remove it, by reso- lution, or without the formation of pus or matter; and if we are not able to accomplish this, to make' use of such applications as will fa- vour suppuration. The patient should be directed to immerse the finger in strong ley, as hot and as long as he can bear it; after which mix the elm- bark with the liquid, and apply it. If this fails to afford relief, the whole hand must be effectually steamed over a decoction of herbs, consisting of catnip, wormwood, horehound, tansy and hops. A handful of each should be boiled down until the strength is extracted, then a small quantity of soft soap must be added, and then the whole thrown into a small vessel, the hand placed over it, and the steam retained by means of a blanket, or piece of flannel, as directed for severe! Felon, or Wliitlow—(Paronychia.) 415 other diseases. The steaming should be continued fifteen or twenty minutes, or as long as the patient can bear, and if there is not suffi- cient heat to produce perspiration, let a hot brick or stone be thrown into the decoction. This process should be repeated every time it becomes painful. The same herbs and decoction may be preserved, as they answer the purpose as well as those that are fresh. In almost every case, no matter how severe the sufferings of the patient are from the complaint, this operation alone will mitigate them, and af- ford the most sudden relief. I have ordered it when the patient has been in acute distress, but he has delayed putting it into practice, under a supposition that it would afford no benefit, when a continuance of the sufferings has forced him to employ it, and the process has been followed by the happiest effects. After this has been attended to, the poultice should be still conti- nued, and if it does not afford relief, or if it does not appear to agree with the complaint, then substitute the following: Take the Indianturnip, (arum triphyllum ;) Blue flag, (iris versicolor ;) let them be well pounded or bruised; simmer in water until they are soft; then add a sufficient quantity of the pulverized slippery-elm bark, to form a poultice of the proper consistence. Where the disease is deep-seated, and protracted, I have some- times found it necessary to apply two or three different kinds of poul- tices. I have occasionally used equal parts of linseed and slippery-elm, simmered awhile in milk and applied ; but the first kind is, in most cases, sufficient. After it has been treated in this manner awhile, a small white spot will appear in the centre of the swelling, indicating the formation of matter. When this symptom appears, the exit of the matter may be fa- voured by slowly and cautiously introducing a large needle or probe, directly through this point or place, from which the matter appears about to issue. By rolling the probe backwards and forwards, or by giving it a drill-like motion, and making a little pressure, and conti- nuing it for some time, it can be introduced even down to the perios- teum without exciting much pain ; but if matter or pus has sufficiently formed, it is unnecessary to introduce it so far. If it cannot be ac- complished at one operation, it must be repeated. Where there has been any difficulty in making the opening, I have occasionally touch- ed the end of the needle or probe with the mineral caustic, but this is very seldom necessary. Even after there is a considerable discharge of matter, it may be proper to introduce the probe, to prevent the orifice from closing. Fungous flesh will often shoot from the open- ing. This must be removed and kept down by a little of the vegetable caustic or potash. Some species of felons are exceedingly painful, and protracted, pro- ducing a necrosis or destruction of the bone. I have been called to cases where the whole thumb or finger has been in a state of ulcera- tion, and the bone partially or wholly destroyed, and where the flesh of the patient has wasted away 100 pounds, in a short space of time 416 Hare-Lip—(Labia Leporina.) from excessive irritation. When such a form of the complaint pre- sents, in addition to the means already prescribed, the vegetable caus- tic must be applied, and the ulcer enlarged as much as possible, to obtain access to the diseased bone ; and when the bone is sufficiently loose, it must be removed by a pair of forceps. When this has been removed, or when inflammatory symptoms sub- side, simple dressings are suflicient to complete the cure. The ulcer may be dressed with a little lint, and the black or healing salve applied. When there is any constitutional disturbance, suitable medicine should be given. If the patient is unable to sleep at night, let him take an anodyne. After the felon has healed up, sometimes the sinews are contracted, impeding the motion of the joint. For this let the part be daily rub- bed with a relaxing ointment or oil. In this manner, I have invariably succeeded in curing the worst and every species of felons, and in all stages of them, and often, when the complaint has been exceedingly aggravated by the common prac- tice, particularly in laying it open. Perhaps, in certain cases, it might be deemed justifiable to make a small puncture with the lancet to let out the matter, but it ought never to be done until there is certain evidence that matter has formed. I, however, prefer the method which I have laid down, having found it more successful. CHAPTER XXXI. hare-lip—(Labia Leporina.^ This is a deformity which consists in a fissure, or perpendicular division of one or both lips. The term has arisen from the fancied resemblance of the part to the upper lip of a hare. Occasionally the fissure is more or less oblique. In general, it is directly below the septum of the nose ; but sometimes it corresponds to one of the nostrils. The two portions of the lip are generally movable, and not adherent to the alveolary process ; in less common cases they are closely attached to the fore part of the jaw. Children are frequently born with this kind of mal-formation, which is called a natural hare-lip, while that which is produced by a wound, is named accidental. Sometimes the portion of the lip which ought to be united have a considerable interspace between them ; while in other instances they are not much apart. The cleft is occasionally double, a little lobe or small portion of the lip being situated between the two fissures. The fissure commonly affects only the lip itself, and usually the upper one. In many cases, however, it extends along the bones and Hare-Lip—(Labia Leporina.) 417 ■oft parts forming the palate, even as far as the uvula ; and sometimes those bones are entirely wanting. In a few instances, the jaw not only is imperfectly ossified in front, so that a cleft presents itself there, but one side of it projects forwards, and is at the same time inclined too much outwards, drawing with it the corresponding part of the palate, and the septum nasi, so that a very unsightly distortion of the nostril and nose is produced. A hare-lip, in its least degree, occasions considerable deformity; and when more marked, it frequently hinders infants from sucking, and makes it indispensable to nourish them by other means. When the lower lip alone is affected, which is rare as a mal-formation, the child can neither retain its saliva, nor learn to speak, except with the greatest impediment. The constant escape of the saliva, besides being an annoyance, is found to be detrimental to the health ; for its loss impairs the digestive functions, the patient becomes emaciated, and even death would sometimes ensue, if the incessant discharge of so necessary a fluid in the animal economy were not prevented. Thus, a lady, who was in this state, consulted Tronchin, who imme- diately saw the cause of her indisposition, and recommended the fis- sure in the lip to be united ; the operation was done, and the dyspeptic symptoms then ceased. And when the fissure pervades the palate, the patient not only articulates very imperfectly, but cannot masticate nor swallow, except with great difficulty, on account of the food readily getting up into the nose. An early removal of the deformity must obviously be very de- sirable. A rational objection to early operations, is the liability of infants to convulsions after operations, and this has induced many to postpone the cure of the hare-lip till the child is about two years old. This custom is also sanctioned by Sir Astley Cooper, who mentions, in his lectures, several instances, which have either been communicated to him by others, or have occurred in his own practice, where operations for the cure of hare-lips, in very young infants, have had a fatal termination, in consequence of an attack of convulsions or diarrhcea. The period when dentition is completed, or the age of two years, he therefore sets down as the most advantageous for the operation, and if parents urge its being done earlier, he very properly advises the surgeon to let them be duly apprized of the risk, so that in the event of the child being cut off, he may not incur blame for having operated at a disad- vantageous period^of life.—(See Lancet, vol. iii. p. 108.) Common Treatment. The common treatment consists in cutting each side of the cleft, then bringing the edges together and keeping them united by passing pins through the lip, or by stitches. The objections to the pins are, 1st. the irritation and inflammation they occasion ; 2d. the failures which occur from the pins being torn out by the child, or catching in the nurse's clothes. The objections to stitches or sutures, are equally great. 1st. the pain and irritation ; 2d. the extensive scar which is left where they have been inserted, as they soon cut through the lip, and leave an unsightly scar through the whole track. 418 Hare-Lip—(Labia Leporina.) I saw a case, a few days ago, the child of Mr. Valentine, in Mul- berry-street, on which the interrupted suture was used by Dr. M—-; and although the fissure united, an extensive cicatrix was left as far as the stitches extended. Reformed Practice. In the operation, the grand object is to make as smooth and even a cut as possible, in order that it may more certainly unite by the first intention, and of such a shape that the scar may form only one narrow line. The edges of the fissure should, therefore, be cut off with scis- sors or a sharp knife. If the knife is used, the best plan is, either to place any flat instrument, such as a piece of horn, wood or pasteboard, underneath one portion of the lip, and then, holding the part stretched and supported on it, to cut away the whole of the callous edge ; or else to hold the part with a pair of forceps, the under blade of which is much broader than the upper one : the first serves to support the lip, the other contributes also to this effect, and, at the same time, serves as a sort of ruler for guiding the knife in an accurately straight line. When the forceps are preferred, the surgeon must of course leave on the side of the upper blade just as much of the edge of the fissure as is to be removed, so that it can be Cut off with one sweep of the knife. This is to be done on each side of the cleft, observing the rule, to make the new wound in straight lines, because the sides of it can never be made to correspond without this caution. For instance, if the hare-lip had an uneven shape, the incision of the edges must be continued in straight lines till they meet, in the manner here repre- sented : A In short, the two incisions are to be perfectly straight, and are to meet at angle above, in order that the whole track of the wound may be brought together, and united by the first intention. After the edges of the fissure have been thus cut smooth, they are to be brought evenly together, each part perfectly corresponding, after which the improved uniting plaster is to be applied, as directed under the head of incised wounds. The lower plasters must be placed close to the edges of the incised fissure, and the upper ones drawn suffi- ciently to bring them closely together. Two or three narrow strips of adhesive plaster may be also placed over it. This will keep the edges of the fissure in contact, and they will speedily unite by the first intention, and without ever causing convulsions or any untoward or unpleasant effects. Besides, in pursuing this improved method, the operation may be performed at almost any age, or, at any rate, much earlier than is recommended in the ordinary operation. But the most suitable time to do it is when the child is a year old. A person who has never seen the application of this improved plas- ter, cannot form a correct idea of the excellent indications which it fulfils, besides obviating the danger, pain, inconvenience, the inflam- mation, ulceration and failure consequent on the use of pins or the interrupted suture. It is necessary to administer an anodyne to the child one hour be- fore the operation ; and if the lip adheres to the jaw, to separate it with a lancet. If there is a double hare-lip, it must be treated in the same manner. CHAPTER XXXIL POLYPUS. A polypus is a fleshy excrescence, of various density and Colduf, originating from the lining membrane of a canal, or cavity, as the nose, vagina, rec\um, &c. The nostrils are the most frequent situation of this complaint. It commences as a small pendulous tumour, Void of pain, accompanied with watering of the eyes, sneezing, and the usual symptoms Of ca- tarrh. The colour of these tumours is generally of a pale red. They commonly commence from the ossa spongiosa ; but occasionally from all the parts concerned in forming the Cavity of the nostril. They produce, at first, no other effects than have been noticed, but as they enlarge, the defluxion from the eyes increases, sneezing is frequent, and the tone of the voice is much altered. The weather has a great influence on the patient: in dry weather the tumour appears to diminish, and it increases in damp and cold weather. Augmenting gradually in size, it at length obstructs the passage of air through the nostril, and in this stage produces a very unpleasant nasal tone of the voice. The polypus assumes gra- dually the shape of the nose, being formed in it as in a mould. It becomes visible at the anterior nostril, and at the fauces behind, where it may be seen situated over the soft palate, and sometimes hanging down behind the uvula. In this state great inconvenience is expe- rienced, the eyes are constantly suffused with tears, from the obstruc tion to the ductus ad nasum. In some instances ulceration takes place, and a fetid matter is discharged, attended with great inflammation and severe pain. In some cases, however, it is remarkable that the tumour acquires a great size, and the patient suffers no pain. From the nose being stopped, patients generally sleep with the mouth open, and inconve- nience is sustained from the dryness of the mouth and throat. Hear- ing is often injured, probably from pressure against the eustachian tube. In swallowing, some difficulty is experienced from the weight of the tumour, which presses against the velum pendulum palath The ap- pearance of the face becomes changed, from one nostril being wide! than the other, the root of the nose appears swelled, and violent head- aches come on ; the bones eventually become carious and ulcerated i a foul fetid sanies, mixed with blood, is discharged; haemorrhage sometimes ensues, the teeth fall out, and a fungus shoots through the sockets. The symptoms, in some cases, increase, and exhaust the patient's strength ; frequent bleedings, and an incessant discharge of matter takes place, and during the last stage of the disease, stupor and coma come on, and eventually death. SuCh are sometimes the dreadful effects of a disease, at first trifling, and to all appearance of very little consequence. The causes of this complaint are not well understood. Some have Vol. II. 3 E 420 Ranula. supposed picking, or violently blowing the nose, to have produced it, but for this there is no foundation. Several species of nasal polypi are described by authors, one of which is said to be of a malignant nature, disposed to end in cancer. This, however, I believe, is extremely rare ; the most common are a fleshy, ted, vascular polypus, and a pale, tough, firm polypus, neither of which is of a cancerous nature. Treatment. I have succeeded in curing this disease, when it has not become too large, by directing the patient to use the following, as a sternutatory or snuff: Take Bayberry bark, Blood-root, Calomel; equal parts. Pulverize and mix. This must be snuffed up the nose frequently through the day. If the polypus is too large to admit it, it may be introduced by tying a strip of linen to a probe, wetting it, then dipping in the powder, and touching the tumour with it: to be often repeat- ed. Where the tumour is quite large, and this method does not prove effectual, it may be necessary to introduce a pair of forceps, and seize the tumour as far up as possible, and compress so hard as to disorganize it, or by turning the forceps to twist it off, and afterwards apply the powder to prevent a regrowth. I have never had occasion to do this except in one instance, and this was in the last stage of the complaint. Many practitioners are in the habit of introducing a liga- ture round the polypus, by means of a double canula. But, whether taken out in this manner or by the forceps, it is very apt to appear again, except some escharotic be applied to the source or origin of it. The above powder generally turns the polypus black, when it will either disappear by a discharge, or drop off. The powder must be continued for some time after it is apparently well. CHAPTER XXXIII. Ranula Is a little inflammatory or indolent tumour, situated under the tongue, by the side of the ranular artery, on either side of the fra;- num. It is of greater or less size ; sometimes acquiring such magni- tude as to impede the motions of the tongue, obstruct the speech, and. in children, who are equally subject to the affection as adults, prevent the action of sucking. Its contents are various: generallv a fluid Salt Rheum, Tetter—(Herpes Psoriasis.) 421 resembling saliva ; sometimes a glairy matter like that found in the cells of swelled joints; and then a fatty or carious substance. Its cause is supposed to be an obstruction of the salivary ducts, arising from either cold, inflammation, calculary concretions, dec. It is at- tended with little or no pain. In some cases, it long remains in an indolent state ; in others, it soon acquires a considerable size, spon- taneously bursts, and leaves an ulcer extremely difficult to heal. Treatment. The usual applications to this disease are powerful astringents and escharotic applications. If this should fail, pass a seton through the tumour, which will radically cure it. CHAPTER XXXIV. »alt rheum, tetter—(Herpes. Psoriasis.) This is a troublesome, inveterate eruption, appearing on different parts of the body, usually the hands. Very small eruptions or vesicles appear, which break and discharge a thin, ichorous or corrosive fluid, that causes a very great degree of irritation or itching. Afterwards scabs often form upon the part affected, which, though they be rubbed off, or dry away, will after awhile re-appear. It is attended with more or less inflammation and swelling, and such is the degree of itching sometimes attending it, that the patient is obliged to scratch continually to obtain the least relief. The whole hands, or parts, sometimes become excoriated, stiff and almost im- movable. It appears to be located principally underneath the skin, although, from its disappearing in one part, and then appearing in another, it is evident that the disease is located in the vascular system, or the blood. It appears to be occasioned by a retention of morbid humours, which are thrown to the surface, and which the system seems unable entirely to expel. The disease appears to be very similar to the different species of herpes, as described by some authors. Four kinds are enumerated, as follows : 1. Herpes Farinosus, or what may be termed the dry tetter, is the most simple of all the species. It appears indiscriminately in differ- ent parts of the body, but most commonly on the face, neck, arms and wrists, in pretty broad spots and small pimples. These are generally very itchy, though not otherwise troublesome ; and, after continuing a certain time, they at last fall off in the form of a white powder, similar to fine bran, leaving the skin below perfectly sound; and 422 Salt Rheum, Tetter—(Herpes Psoriasis.) again returning in the form of a red efflorescence, they fall off, and are renewed as before. 2. Herpes Pustulosus. This species appears in the form of pustules, which originally are separate and distinct, but which afterwards run together in clusters. At first, they seemed to contain nothing but a thin watery serum, which afterward turns yellow, and, exuding oyer the whole surface of the part affected, it at last dries into a thick crust, or scab; when this falls off, the skin below frequently appears entire, with only a slight degree of redness on its surface ; but on some occasions, when the matter has probably been more acrid, upon the scab falling off, the skin is found slightly excoriated. Eruptions of this kind appear most frequently on the face, behind the ears, and on other parts of the head ; and they occur most commonly in chil- dren. 3. Herpes Miliaris—the miliary tetter. This breaks out indis. criminately over the whole body ; but more frequently about the loins, breast, perinaeum, scrotum and inguina, than in other parts. It gene. rally appears in clusters, though sometimes in distinct rings, or circles, of very minute pimples, the resemblance of which to the millet seed has given rise to the denomination of the species. The pimples are at first, though small, perfectly separate, and contain nothing but a clear lymph, which, in the course of this disease, is excreted upon the surface, and there forms into small distinct scales ; these, at last, fall off, and leave a considerable degree of inflammation below, and still continues to exude fresh matter, which likewise forms into cakes, and so falls off as before. The itching, in this species of complaint, is always very troublesome ; and the matter discharged from the pimples is so tough and viscid, that every thing applied to the part adheres, so as to occasion much trouble and uneasiness on its being removed. 4. Herpes Exedens, the eating and corroding tetter, (so called from its destroying or corroding the parts which it attacks,) appears com. monly, at first, in the form of several small painful ulcerations, all collected into larger spots, of different sizes and of various figures, with always more or Jess of an erysipelatous inflammation. These ulcers discharge large quantities of a thin, sharp, serous matter, which sometimes forms into small crusts, that in a short time fall off; but most frequently the discharge is so thin and acrid as to spread along the neighbouring parts, where it soon produces the same kind of sores. Though these ulcers do not, in general proceed farther than the cutis vera, yet sometimes the discharge is so very penetrating and corrosive as to destroy the skin, cellular substance, and, on some occasions, even the muscles themselves. It is this species that should be termed the depascent or phagedenic ulcer, from the great destruc tion of parts which it frequently occasions. Treatment. A thousand different remedies are recommended for this complaint, but none can be relied upon as capable of removing it. Hence, U may be considered very difficult entirely to cure ; although in many oases which have been exceedingly obstinate, we have successfully Salt Rheum, Tetter—(Herpes Psoriasis.) 423 treated. The treatment may be commenced by applying the follow- ing wash : Take Litharge, one drachm ; Vinegar, eight ounces ; Mix, and wash the parts whenever the itching is troublesome. After this has been applied a short time, anoint with the following : Take White turpentine, half a pound ; Indian turnip, (arum triphyllum,) one ounce ; Common plantain leaves, (plantago major,) two ounces ; Leaves of white lily, (lilium candidum,) two ounces ; Olive oil, one ounce ; Fresh butter, half a pound ; Beeswax, two ounces ; » Bruise the leaves and roots, and simmer them in an earthen vessel, in equal parts of spirits and rain water, and closely covered, and, when nearly cold, add two drachms of yellow ochre pulverized. This forms a very handsome and efficacious ointment, and which I do not recollect ever to have applied without benefit. After using this wash and ointment for a reasonable length of time, if it shouldjjnot cure, with the aid of such internal medicines as I shall hereafter mention, let them be omitted, and let the following wash or tincture be applied: Take of Celandine, (chelidonium major,) one drachm ; Irish whiskey, or good spirits, eight ounces ; Add the celandine to the spirits, and digest a few days to extract the strength. Wash often with this tincture. After which, apply the following ointment or salve : Take sweet oil, and add gradually sufficient red lead, pulverized, to convert or change it into a salve, or ointment, of a proper consistence to spread, which is effected by placing the mixture over a fire, and rimmering it until a decomposition takes place, or until it becomes dark, and acquires a proper consistence for use. Let it be spread thin upon a piece of linen, and applied over the parts affected. If the complaint is attended with any inflammation, it must be first subdued by a poultice made of the slippery-elm bark and fresh milk, which will soon allay it, as well as the itching. An excellent ointment for the tetter, or salt rheum, is made by mixing half an ounce of the sulphur vivum, (native sulphur) with two ounces of fresh butter, and applying it two or three times a day. Internally, the patient should take such medicines as are calculated to purify the blood: as the alterative syrup, and an infusion of black alder bark, Virginia speedwell, and yellow-dock. An excellent beer or diet drink, possessing alterative properties, is made by boiling in a suitable quantity of water, the following articles : Take the root of sassafras, (laurus sassafras ;) Burdock, (arctium lappa;) Black alder, (prinos verticillatus ;) Wild cherry-tree, (prunus Virginiana ;) Of this, let a strong decoction be made, then sweeten with molasses or honey, and when about blood-warm, add a sufficient quantity of yest to ferment it. The patient should take freely of this beer. The 424 Salt Rheum, Tetter—(Herpes Psoriasis.) perspiration should be promoted, and the bowels kept open. The hands should never be immersed in water, as this is sure to exasperate the complaint, and prevent a cure, nor should the patient eat any greasy or sour victuals. This treatment will either cure, or essen- tially benefit the patient. Before I commenced the practice of medicine, when I resided in the state of New-Jersey, I became acquainted with an elderly lady who had suffered exceedingly by this complaint; and she had inci- dentally found a medicine that had entirely eradicated it. Her hands were so swelled, inflamed and excoriated, that she was unable to close them or the fingers, and the medicine cured the complaint. I solicited the family to communicate it to me, for five or six months, before they consented. And it was finally disclosed on conditions of secrecy; but, as I consider the welfare of my fellow men paramount to any promise of this nature, I shall communicate the remedy or preparation used, and leave the reader to judge what merit it possesses. It is a poisonous article, as is elsewhere stated, and I have never used it, except as the last alternative, or when every other means failed : Take corrosive sublimate, one scruple ; Venice turpentine, two drachms ; Fresh butter, two ounces ; Rub the whole in a mortar until it is well mixed ; then apply a small quantity morning and night, after which, let the patient be directed to wear a soft pair of gloves. While this ointment is used, the following wash is to be applied; Take corrosive sublimate, half a scruple ; Best French brandy, eight ounces ; Mix. Wash the hands with this liquid before the ointment is applied. These are not the original receipts or formulas, as I have found it necessary to vary or alter them. This has cured some very obstinate cases of this disease, although it will sometimes fail. A case occurs to me now, where a lady applied to me from a great distance to be attended with an herpetic affection, which covered the whole body. Every night large quantities of scales came off, and the complaint was attended with a great deal of pain, itching and distress. I tried various medicines without much benefit; and, at last, I con- cluded to make use of the sublimate, in the following form : Corrosive sublimate, two drachms ; Best French brandy, two quarts ; Mix. I directed the patient to wash the whole body with this, two or three times a day, or as often as the disease became troublesome. Fearing, however, some ill consequences from the application of such a large quantity of this preparation, I directed the patient to commence by first using a little, and gradually increasing it. She found that it benefited her, and, therefore, washed the body as fearlessly as though it had been water. It constantly grew better, until it eradicated every vestige of the complaint; and, notwithstanding exposures, no bad consequences followed the use of it. In some eruptions, assuming an anomalous character, and particu- larly those appearing on the face, body, and extremities of infants and Chilblain—( Pernio.) 425 children, as well as adults, I have found the application of the stramo- nium ointment a very valuable remedy. In some species of this disorder, where other means fail, the yellow dock, the stramonium and the discutient ointments, may be used alter- nately ; for such a protean type does the salt rheum, or herpes, some- times assume, that a variety of medicines become necessary to eradi- cate every species of it. The sulphur bath is highly recommended, and I have used it, but I am not prepared to speak decisively of its merits. It is said, however, to have performed cures. CHAPTER XXXV. chilblain.—(Pernio.) Chilblains are painful, inflammatory swellings, of a deep purple or leaden colour, to which the fingers, toes, heels, and other extreme parts of the body are.subject, on being exposed to a severe degree of cold. The pain is not constant, but rather pungent and shooting at particular times, and an insupportable itching attends. In some in- stances the skin remains entire, but in others it breaks and dischargee a thin fluid. When the degree of cold has been very great, or the application long continued, the parts affected are apt to mortify or slough off, leaving a foul, ill-conditioned ulcer behind. Children and old people are more liable to be troubled with chil- blains than those of a middle age ; and such as are of a scrofulous habit are remarked to suffer severely from them. The best mode of preventing these affections is to avoid, with much care, any exposure to wet or cold ; wherefore, those who are subject to them should be cautious, on the approach of winter, to keep warmly clothed. Treatment. If the parts have recently been frozen, or frost-bitten, the fire must not be approached ; but the cold gradually abstracted. The affected parts may first be immersed in snow, or cold water, which will remove the frost; after which, let brisk friction be used, and a little cam- phorated spirits be applied. If there be much pain or inflammation, apply an elm-bark poultice ; after which, a cooling and soothing oint- ment, and, lastly, the black or healing salve. CHAPTER XXXVI TIC DOULOUREUX. This term is used to signify a disorder, the most prominent charac- ter of which consists in severe attacks of pain, affecting the nerves of the face ; most frequently the filaments of that branch of the fifth pair which comes out of the infra-orbitary foramen : but sometimes the other branches of the fifth pair, and occasionally the numerous fila- ments of the portio dura of the auditory nerve, which are distributed upon the face. The complaint is not continual, but occurs in violent paroxysms, which vary in duration in different instances. In the frontal neuralgia, the pain usually begins in the situation of the supra-orbitary foramen, extending at first along the branches and ramifications of the frontal nerve, distributed to the soft parts upon the cranium, and afterward shooting in the direction of the trunk of the nerve towards the bottom of the orbit. In a more advanced stage, the conjunctiva and all the surface of the eye participate in the effects of the disorder, and become affected with chronic inflammation, which is described as a particular species of ophthalmy. At length the pain passes beyond the distribution of the branches of the frontal nerve, and affects all the corresponding side of the face and head. It seems as if it extended itself to the facial, sub-orbitary, maxillary, and even to the temporal and occipital nerves, through the communications naturally existing between the filaments of all those organs of sensa- tion. Each paroxysm produces a spasmodic contraction of the eye- lids, and a copious effusion of tears. The sub-orbitary neuralgia is first felt about the sub-orbitary fora- men. The seat is probably in the nerve of this name, and the pain extends to the lower eyelid, the inner canthus of the eye, the muscles about the zygoma, the buccinator, cheek in general, ala of the nose, and the upper lip. At a later period, the pain appears to extend backwards to the trunk of the nerve, and those branches which are given off in its passage through the sub-orbitary canal. Hence, pains are then experienced in the upper teeth, the zygomatic, fossa, the palate, tongue, and within the cavity of the nose. As the disorder advances, it may extend, like other neuralgiae of the face, to all the same side of the head. During the paroxysms, when the disease is fully formed, an abundant salivation usually takes place. In general, the attendant toothach deceives the practitioner, #who, in the belief that the pain arises from another cause, uselessly extract several of the teeth. The tic douloureux of the lower jaw, or maxillary neuralgia, is usu- ally first felt about the situation of the anterior orifice of the canalis mentalis, and it extends to the lower lip, chin, neck, teeth and temple. This form of the complaint is more uncommon than the preceding ; Tic Douloureux. 427 but after it has prevailed some time, is equally remarkable for its in- tensity. With respect to the neuralgia of the facial nerve or portio dura of the auditory nerve, it is a case which very soon cannot easily be dis- tinguished from the other species of tic douloureux. The pains at an carry period are no longer continued to the passage of the principal branches of this nerve between the parotid gland and ramus of the jaw. The numerous communications of the portio dura with the rest of the nerves of the face seem to facilitate the extension of the dis- ease, so that the agony is soon felt over the whole side of the head. The original source of the disorder can only be detected by attentively considering the progress of the complaint in all its stages.—(See Del- pech, Traits des Maladies repuUes Chirurgicales, t. iii. sect. 7. p. 214, dec.) Tic douloureux may be known from rheumatism by the paroxysm being excited by the slightest touch, by the shortness of its duration, and the extreme violence of the pain. In acute rheumatism, also, there is fever, with redness, heat, and generally some degree of swell- ing; and in chronic rheumatism the pain is obtuse, long continued, and often increased at night; none of which symptoms characterize tic douloureux. It may easily be distinguished from hemicrania by the pain exactly following the course of the branches of the affected nerve. It is known from the tooth-ach by the comparative shortness of the paroxysm ; the quickness of their succession ; the intervals of entire ease ; the darting of the pain in the track of the particular nerve affected ; the more superficial and lancinating kind of pain ; and the convulsive twitchings which sometimes accompany the complaint. The causes of tic douloureux may be said to be in general unknown ; but there are a few instances recorded, which appear to be the con- sequence of external violence, wounds, contusions, &c. It is men- tioned in one of the journals, that distant irritations, especially of the splanchnic nerves, often produce this disease, and that Sir H. Halford has met with cases where the discharge of portions of diseased bone, even from a distant part, has cured the complaint.—(Med. Chir. Re- view, No. 9. vol. iii.) The difficulty of placing implicit reliance oh such observations depends on the fact, that disorders frequently exist together in different parts, without having any kind of connexion with each othei^ and terminate quite as independently. A modern writer has related a very curious instance of a resem. bling disease in the arm, where the affection proceeded from the lodgment of a small bit of bullet in the radial nerve.—(Denmark, in Med. Chir. Trans, vol. iv. p. 48.) Dr. Parry attributed the pain to increased Vascularity or determination of blood (perhaps amounting to inflammation) to tho neurilema or vascular membranous envelope of the nerves affected.—(Elements of Pathology and Therapeutics.) Hosack has published among his medical essays some observations on tic douloureux, in which he contends that neuralgia is not a local affection or disease of a particular nerve, and to be removed by the division of such nerve; but a disease dependent upon the whole sys. Vol. II. 3 F 423 Tic Douloureux.—Tumours. tem and only to be counteracted by remedies addressed to the pecu- liar state or condition of the constitution.—(Reese.) Treatment. This is a difficult disease to cure, but can generally be mitigated, and, after occurring occasionally, will disappear altogether. The treatment consists, 1st, in cleansing the stomach and bowels ; 2d, in giving tone to the system, by the exhibition of strengthening medi- cines; 3d, in administering anodynes, such as opium, stramonium, the restorative bitters, alsoscullcap tea, extract or tiucture of henbane, &c, may be given. CHAPTER XXXVII. TUMOURS. Of Sarcomatous Tumours. These are vascular tumours, arising from a morbid growth of skin. They generally begin with a small warty projection, which soon be- comes pendulous, and sometimes, though not often, enlarges to a con- siderable size. As the tumour increases, and becomes weighty, it draws the skin from the neighbouring parts, and a pedicle is thus formed. In advanced life, it becomes smooth, livid, and in some in- stances has degenerated into cancer. Of this species are navoi mater ni, or original marks, which are small excrescences, sometimes hardly arising above the cuticle, at others considerably protuberant; they are firm, fleshy and very vascular, consisting solely of a congeries of vessels. Smaller tumours of the sarcomatous kind are denominated warts: these are usually confined to the hands and fingers, and pudenda, where they are often situated in great number, and follow as a con- sequence of the venereal disease, though not themselves partaking of the venereal taint. Corns are small tumours of a horny nature, situated db the feet and toes : they consist in a diseased state of the cuticle, produced by pressure. Diagnosis. Sarcomatous tumours are distinguished from all others by the hard- ness of their texture; by their great vascularity; by the absence of pain and inflammation. Of Steatomatous Tumours. These consist in a morbid growth of the adipose membrane : their Encysted Tumours. 429 first appearance is usually a small excrescence, soft and oedematous ; this gradually increasing, often attains an enormous size. They are free from pain and inflammation, and discolouration of the cuticle, and occasion inconvenience to the patient only by their bulk; some- times, however, after they have become extremely large, inflamma- tion and ulceration take place. They are soft to the touch, feeling not unlike the omentum contained within a hernial sac. Diagnosis. The characteristic marks are, the softness of their texture; their great bulk; the absence of pain and inflammation. Of Encysted Tumours. The true encysted tumour is a collection of matter contained within a cyst, formed by adhesions in the cellular membrane. From the nature of its contents, it has obtained different appellations, as athe- romatous, mehceratous, &c. Its seat is the cellular membrane of any part of the body, its size usually that of an egg, and it seldom or never increases to a great bulk. It begins with a distinctly circum- scribed swelling, hard to the feel, and unattended by pain. It gra- dually gets larger and larger, until some slight inflammation comes on, when it becomes in a small degree painful, and a fluctuation is soon afterwards distinctly perceived. As it slowly enlarges, the vessels of the integuments become varicose, and in some instances, though not often, slightly livid. Diagnosis. It is distinguished from common abscess by the extreme slowness of its progress to maturation, and by the absence of pain and inflam- mation. Treatment. Tumours may be removed, particularly when they are pendulous, by passing a silk or linen thread around the base, and then fastening it to a short piece of metal or wood, and drawing it daily tight enough to stop tire* circulation. Tumours of great magnitude may be taken off in this manner, and there is an advantage in removing them in this way, in consequence of no haemorrhage attending the operation. Besides, the patient has less dread of it than excision by the knife. I removed a very large sarcomatous or fleshy tumour, of fourteen years' standing, in this manner, from the shoulder of a lady in this city, which was preserved in a jar of turpentine, and exhibited a length of time in Scudder's museum, as a curiosity; and I have found very little difficulty in removing every kind of tumour, without re- sorting to the knife. Another method 1 have successfully practised, which consists in applying the caustic potash over a small portion of the most promi- nent part of the tumour, until a deep eschar is formed, and afterwards 430 Encysted Tumours. applying slippery-elm bark and yest, to promote suppuration. After a few days, sloughing will commence, and the contents of the tumour will be discharged. I once removed a tumour so large from the face of a person, that the boys were in the habit of running after him, to examine it, as a matter of curiosity. The following is the method of applying the caustic : Take a stick or roll of the caustic potash, and enclose it in a piece of paper, all except the end, to prevent injury to the fingers ; then, after having wet the most prominent part of the tumour, gently touch or rub it in a circular form, about the size of a twenty-five cent piece, or accord. ing to the size of the tumour, to be continued until the skin turns brown or dark, which is usually in about five or ten minutes. As the caus- tic dissolves, it runs down and excoriates the parts. This should be absorbed by cotton or linen. The pain is severe for a short time only, and no more is experienced until the eschar separates. A poultice of the elm bark and yest must now be kept on, to favour the process of sloughing, or a detachment oT the disorganized parts ; which, when done, gives vent to the internal portion or substance of the tumour. I have taken out a very large tumour, by applying only a few grains of the mineral caustic on the most dependent part of it. The method of applying it is as follows: Make a small roll of any hard plaster, about half the size of a goose-quill; form it into a little ring, of the size you intend to make your opening, and place this upon the tumour; wet the mineral caustic with a few drops of water, and apply it within the ring, and a sufficient quantity to cover it; over this, place a suitable plaster, to retain it; after it has remained on for twelve or twenty-four hours, it will penetrate the tumour to a considerable depth, which will form an eschar, and will penetrate to a considerable depth, and which must be removed by a poultice, made as before di- rected, when the contents of the tumour will be discharged. In this manner it is removed, without destroying but a very little portion of the skin. I think it is better to remove tumours in this manner, than it is by the knife ; because, 1st. In using the knife, it is necessary to dissect the whole tumour, which is very painful. 2d. There is sometimes dan- ger of haemorrhage. 3d. The tumour is more apt to recur after ex- cision, than when it is taken out by this method, particularly where the contiguous parts are diseased. Some kinds of sarcomatous tumours adhere so slightly to trfd swelling, or the connexion is so slight, that it is only necessary to separate it from the skin, to remove it. All that is required to detach the disease, or the tumour, is to remove the skin, and the little vascular connex- ions. Hence, this process very easily removes them. It has occurred to me, that some tumours might be removed with greater facility, by drawing a roll of the caustic potash around the bottom or base of the tumour, until an eschar was formed, or until the skin was cut through or destroyed ; which, if the tumour was not one solid mass of organized matter, would be separated. Having suc- ceeded so well in removing all kinds of tumours by the method pro- posed above, I have never attempted this experiment. Encysted Tumours. 431 I see an account in the Baltimore paper, of one or two large tumours removed merely by puncturing them in one or two places, and then exciting a discharge by injecting a stimulating liquid. In passing the street some time ago, my curiosity was attracted by a tumour of considerable magnitude, which was situated on the cheek of a negro. I examined it, and made some inquiries respecting it. I found that about one half of the tumour had been removed, which, he informed me, had been effected by rubbing upon it, two or three times a day, the juice of milk-weed, or the milky fluid which issues from the plant; and, from the change that had been produced, I have a favourable opinion of this juice in some kinds of tumours. There is a species of tumour which, it appears, the knife, caustic, ligature, or any thing else, has not been sufficient always to remove : I mean the bony, callous, or esteo-sarcomatous tumour. Amputation has been performed for this, and various other means tried, but with- out effect, although I cured one which appeared upon the side of a gentleman, who, in consequence of its inveterate character, came to me a distance of sixty miles, to have it treated. I applied the sas- safras oil, and camphor, and cupped it often, then a discutient or sweating plaster, which, after about six months, entirely dispersed it. I have repeatedly seen the patient since, who is perfectly well. A gentleman from the eastward informs me, that a bony tumour ap- peared upon some part of an ox belonging to his father, and which he entirely removed, by applying the phytolacca decandria, or the com- mon poke or scoke root. From analogy, we may infer, that this plant, which possesses great discutient properties, would cure tumours of a similar nature, appearing on the human body. A gentleman called at the office the other day, who had had a wen upon his cheek for eighteen or twenty years, which one of my students removed by the preceding treatment; and another student has removed one since, which had been upon the face for many years, by one ap- plication of the caustic potash, which enveloped the whole in an eschar, and removed it in a solid mass. From the success we have invariably had, in removing different kinds of tumours, in the manner here laid down, I am induced to be- lieve that the knife is very seldom required. Method qffreating an Abdominal Tumour, supposed to contain Hydatids. A man, about thirty-four years of age, was recently admitted at the Hotel Dieu, who, for the last eighteen months, had complained of tumour in the situation of the liver, which increased very gradually, but at present occupies the whole of the right hypochondrium. At- tentive examination showed, that it is connected with the liver. It is perfectly free from pain, even when pressed upon ; has not produced any derangement of the healthy functions of the part, and gives rise to no other inconvenience than that of preventing the man from pursuing his usual avocations. He has had advice from many differ- ent medical men, and has tried a great variety of internal and external remedies, to no purpose. It so happens, that M. Recarnier, about a year ago, treated a tumour somewhat similar to this, which proved to 432 Bronchocele. contain hydatids; and, as the means he then employed were perfectly successful, he determined to adopt them on the present occasion. The tumour in the present instance is, however, much larger than the former one ; and, although some thought they could perceive that sort of crepitation which hydatids cause when pressed against each other, yet the diagnosis is by no means very clear. However, M. Recarnier proceeded, as in the former case, to puncture the tumour with a very fine trocar, in order to ascertain the nature of its con. tents. The fluid which flowed out, as had been anticipated, was lim- pid and colourless, and did not coagulate by heat. After having ex- tracted a small quantity of this fluid, the puncture was carefully closed and healed ; and a week after, when the tumour was again distended to its former size, the caustic potash was applied, so as to form an open- ing into the cavity of the cyst. In the former case, this method an- swered admirably, as great numbers of hydatids were extracted. A sufficient quantity of water was then injected^ to fill the space they had occupied, in order to avoid the introduction of the air; the exter. nal wound was dressed in the usual manner, and the patient recovered rapidly. The object in applying caustic, rather than making an open- ing by incision, is to produce adhesions between the cyst and parietes of the abdomen, so as to form an uninterrupted canal from the tumour to the external parts.—(Lon. Med. Gaz.) CHAPTER XXXIX. BRONCHOCELE. A tumour on the fore part of the neck, formed by an enlargement of the thyroid gland. The progress of the swelling is extremely gra- dual, and in general the skin long retains its natural appearance. It is at first soft, but as it advances in size, it acquires a great degree of hardness; the skin becomes of a brownish or copper colour, and the veins of the integuments are varicose. The face is subject to fre- quent flushing; the patient complains of frequent head-achs, and likewise of pains shooting through the body of the tumour. It is often accompanied with hysteric affections. Causes. The inhabitants of Derbyshire, and other mountainous parts of Europe, and those of the Alps and adjacent mountains on the conti- nent, are peculiarly subject to this disorder. Among the latter, it is known by the name of goitre, and its origin is ascribed to the use of snow-water. It is considered a scrofulous affection of the gland. Common Boil—(Furunculus.) 438 Treatment. An ointment made of the roots of poke may first be applied, and if this does not discuss it, apply the discutient ointment. If this fails* make an issue upon the tumour with the caustic potash, and then poultice it with yest and elm-bark, to promote a discharge. The juice of milk-weed, from its specific effects in removing wens, might also remove this kind of tumour. In other respects, let it be treated the same as scrofulous tumours, both internal and external. Dr. S. Bell, a graduate of our school, has recently cured a diffi. cult case of bronchocele by pursuing this kind of treatment. The discutient ointment, united with an ointment made of the poke root, contributed much towards the cure. CHAPTER XL. common boil—(Furunculus.) This disease is so well known that it needs not much description, and although very common, is extremely tedious and painful. A hard, circumscribed, exquisitely painful phlegmonous tumour, generally appearing under the figure of a cone, the base of which is consider- ably below the surface of the surrounding skin.—Upon the most pro- minent part of the boil, there is commonly a whitish or livid pustule, exquisitely sensible to the touch, and immediately beneath this is the seat of the abscess. The matter is generally slow in forming, and is seldom found to exist in considerable quantity. Treatment. When in a state of inflammation let it be poulticed, with a mixture of equal parts of linseed and slippery-elm bark, boiled for a short time in rain water or milk. If the pain be very great, steam it over bitter herbs. After it suppurates and breaks, and when the inflammation has subsided, apply the black or healing salve. CHAPTER XLI. ENLARGEMENTS OF THE TONSILS. Enlargements of the tonsils may be of two kinds : 1. The common abscess occurring in cynanche tonsillaris, or in- flammatory sore throat. 2. A chronic swelling, generally the consequence of previous in- flammation of the gland in a scrofulous habit. They often become so large as to impede both respiration and de- glutition. Treatment. Occasionally give a purgative and also an emetic ; after which, ex- cite perspiration by the ordinary means recommended. If the child is of a suitable age, let it frequently inhale the steam of bitter herbs. When the swelling is very great, bathe it with equal parts of sassa- fras and olive oils, to which add a little gum camphor. After- wards apply over the tonsils equal parts of hops and wormwood, sim- mered in vinegar. When the inflammation has in a measure subsided, apply the discutient ointment on a batt of cotton, to be kept constantly bound on the throat, over the seat of the swelling. The tonsils, if practicable, should be frequently touched with common ley, by means of a piece of sponge or muslin, fastened to a probe or a piece of stick. The feet should frequently be bathed, and exposure to wet and cold should be avoided. It is customary to remove the tonsils when they become enlarged with the knife or ligature, but this is very painful, and not devoid of danger, and if possible should never be resorted to. If these means be persevered in, they will effect a cure without either of these ope- rations. CHAPTER XLII. GANGLION. A hard tumour, movable on the tendons, called " weeping sinew." Ganglions, upon the tendons, are enclosed in the same cellular membrane which forms their vagina, to facilitate their motion. They Deafness; 435 occupy their station also on the annular ligaments and capsulae mu. cosee, through which they pass. These tumours, although indolent, being yet very troublesome by pressing on the tendons, it becomes needful to remove them. This may in common be effected by excit- ing the absorbents, the best way of doing which is by pressure ; for this, when applied to a degree just beyond the point of ease, calls forth their activity to remove, when it is removable, the pressing sub- stance, and that substance is the ganglion. I need scarcely add, that the pressure must be uniform and long continued. Another method of cure is, to give repeated and hard blows with a hammer; for this, by bruising, disturbs the organic structure of the part, and thereby, according to a beautiful law of the animal economy, excites the absorbents into action for the purpose of conveying it away. When the ganglion, by neglect, has been suffered to enlarge itself, it may be vain to attempt its resolution in these ways. Nothing then remains but to remove it. Treatment. I have removed this complaint in the following manner: make a small puncture into the tumour with a lancet, which will evacuate a fluid of a transparent appearance ; then, with a suitable syringe, inject a stimulating liquid ; after which introduce a tent and apply a plaster. Let it be kept open as long as possible. It may also be removed in the same manner which is recommended for the removal of other tumours. Let it be touched with the caustic potass until an eschar is formed, and then employ the yest and elm poultice to separate it. CHAPTER XLIII. DEAFNESS Is most commonly owing to a relaxation of the tympanum; accu- mulation of wax ; or paralysis of the auditory nerves. Treatment. Hot stimulating oils applied by means of wool; drop in the ear the balsam of copaiva, then inject soapsuds daily. If this fail, try elec- tricity, and keep up a discharge behind the ear by means of an issUe Extraneous Bodies in the -Ear. These may often be extracted by means of a small forceps, or by Vol. II 3G 436 Ague, or Pain in the Face and Jaw. svrinein* the ear with tepid water. Should these means be unsuc- ZZfu\ they may be suffered to remain with impunity if they do not produce pain, as in a short time they will be forced out with the accu- mulating wax. Insects may be killed by filling the ear with spirits, or any other fluid, and afterwards be removed by injections of warm water. CHAPTER XLIV. AGUE, OR PAIN IN THE FACE AND JAW. The jaws, teeth and face frequently become swollen and painful, proceeding from cold, which is termed by some, ague in the face. It is a very distressing complaint- Treatment. 1st. Steam the jaws or face over bitter herbs. 2d. If the swelling bo very great, apply a ley poultice. 3d. Bathe the parts with sassafras oil. 4th. Dip a piece of cotton or lint in the tincture of red pepper, (cap- sicum,) made warm, and place it between the lip and the jaw. A free discharge of saliva follows, which usually affords immediate relief. Toothache. Pursue the same course. If it fail to cure, dip a piece of lint in the oil of cloves, and press it into the tooth affected. If this fail, apply the oil of capsicum in the same manner. And if all these means fail, the nerve may be destroyed, by putting into the decayed tooth, a few drops of nitric acid. Great care must be observed to keep it from touching or getting into the mouth. If the patient is unwilling to have the tooth drawn, and the pain is very great, an anodyne may be taken. By cleaning the teeth, two or three times a week, or even once a week, with a powder composed of equal parts of levigated charcoal and prepared chalk, it will both preserve and prevent them from aching. CHAPTER XLV. INVERTED TOE NAIL. A disease frequently occurs in the great toe, productive of much inconvenience and distress; an inversion of the nail, generally of the great toe, which grows in upon the flesh, usually in consequence of wearing a tight shoe. This complaint is attended with severe pain and inflammation ; sometimes with ulceration. A fungus arises in many cases, which is extremely sensible, and gives great pain when touched, so that the patient is completely incapacitated from walking. The nail, in many cases, becomes completely imbedded in the flesh, and in others, a thick skin forms over the greater part of it. Distressing spasms oc- casionally result. Treatment. The foot must be well bathed in very warm ley water at least once a day, and immediately after, the slippery-elm bark poultice must be applied. This will diminish excessive inflammation, and render the patient more comfortable. But, in order to effect a radical cure, it will be. necessary, immediately after the foot has been immersed in the ley water for twenty or thirty minutes, to press down as far as pos- sible, without exciting too much pain, pledgets of lint between the nail and the flesh, until they are brought upon a level with the contiguous parts ; and after this has been done, if the inflammation has measura- bly subsided, let a plaster of the black salve be applied immediately over, and a narrow bandage again bound over this, in order to secure the dressings. I find it best to apply sufficient lint to elevate it above the nail and flesh, that the plaster and bandage may continually produce such a degree of pressure, as to separate the flesh from the nail. Where there is great soreness, the lint may be dipped in a little marshmallow ointment, and if there is much fungus or proud flesh shooting up from the ulcer, apply a few grains of the vegetable caustic. After continuing this treatment a few days, an opening will be made down to the bottom of the projecting nail, except it be unusually deep; and the act of bathing the part will so soften the nail, that the portion which is the source of irritation, can easily be removed, which may be done in different ways. I have been in the habit of raising the nail with a small pair of tweezers, and then cutting it off with a penknife. Previous to this, however, it is desirable not only to open the parts well, but actually to introduce the lint underneath the point of the nail which penetrates the flesh ; and the hour that this is done, the patient feels compare. lively well, as the pain and inflammation suddenly subsides. This 438 Inverted Toe Nail. not only affords great relief, but enables the practitioner to cut off the nail without creating much pain. Sometimes I cut off a little at every dressing; at other times, nearly the whole. The nail must be removed upon a line level with the nail of the op- posite foot on the same side, and afterwards the lint and plaster must be k«ypt on until the ulcer has healed. In following this method, I have never yet failed, in a single instance, of effecting a cure ; nor have I ever known a case, after it has been thus cured, again to return. One lady, I now recollect who applied to me, a distance of forty or fifty miles from this city, who was suffering under a very severe case of inverted toe nail. It was very painful, and she was unable to walk ; but, after pursuing the foregoing treatment a few weeks, she was cured, and has remained well for many years. Another case occurs to me, which strikingly exemplifies the differ. ence between this practice and that usually pursued. A woman, of this city, had been for many years labouring under this disease, in a most aggravated form. She was in the hospital some length of time, but the surgeons there were unable to cure it. She suffered so much, that she requested them, and subsequently myself and another sur- geon, to amputate the leg or the offending members. It is impossible for me to describe the deplorable state into which this woman was thrown by the complaint. The seat of the disease was in the great toe of each foot, and so deep had the nails penetrated into the flesh, that the pain, swelling, inflammation and ulceration, were excessive, extending to the feet and legs, and which affected the constitution, and rendered her not only a cripple, but completely miserable. I was called to attend her in connexion with a noted surgeon of this city. He commenced the treatment of one toe, and I commenced the treatment of the other; and while I pursued the plan already laid down, he passed a pair of forceps underneath one corner of the nail, and suddenly tore the whole of it off, in the act of which the woman fainted, and was thrown info convulsions. Although the nail was thus entirely removed, so far from curing her, it only aggravated the complaint:' whereas, the toe which I treat- ed, and on which no such operation was performed, became perfectly well, and has remained so for years; and it is now my impression that it was, in the commencement, much worse than the other; thus clearly evincing the difference between the two modes of treatment. CHAPTER XLVI. CORNS AND WARTS. Corns are too well known to need any description, and although attended with no danger, they are exceedingly troublesome and pain- ful. They are usually occasioned by wearing shoes that are too tight or small. Treatment. As prevention is better than cure, persons should be careful to wear such shoes as sit easy, and produce no pressure or irritation. But when this precaution has not been attended to, and he becomes af- flicted with them, the following treatment will be found very effectual. Bathe the feet, or foot, in warm ley water every day ; after which ap- ply the black salve or plaster. I know not that I have ever recom- mended this without its having the desired effect. Dr. Seely informs me that he has always cured corns by bathing the part in warm water and paring or shaving the corn with a razor, and then covering it with an alkaline powder called kali praparatum. This, he says, entirely destroys them. I presume that the vegetable caustic would be still better, as it is more active. Warts. A very popular remedy for warts, in the country, is the juice of milk-weed and the juice of celandine. If neither of these should remove them, they may be touched with some kind of caustic. CHAPTER XLVII. FOREIGN SUBSTANCES IN THE OSSOPnAGUS AND TRACHEA, OR WINDPIPE, Substances sometimes become lodged in some portion of the ceso- phagus or throat, and, by pressing upon the trachea or windpipe, im- pede respiration, such as fish bones, copper coins, &c. When I attended the lectures of Dr. Stevens on surgery, I recollect he exhibited a preparation, in which a pair of clasps bad destroyed the child by one entering the trachea, and the other the oesophagus, and which might easily have been removed, said the professor, had the situation of it been known at the time. From thin circumstance, 440 Foreign Substances in tlie (Esophagus, §r. we may infer what ought to be done when first called to an accident of this nature. The tongue should be pressed down, and the finger introduced as far as possible, which will often enable a person to ex- tract it, even though it may not be seen. I removed a fish bone from the throat of a person the other day, in this manner, in a few moments. If a fish bone, or pin, or needle, can be seen in the posterior part of the throat, it may be seized by a pair of tweezers and extracted. An emetic, by the spasmodic affection which it produces, often dis- lodges any substances of this kind. If these means fail, a small piece of sponge may be fastened to a piece of whalebone or wire, and, after having immersed it in water, it is to be slowly and cautiously introduced into the throat, in a spiral like manner. Dr. Perkins, one of the graduates of our school, in- formed me, a few months since, that, by this simple instrument, he removed a fish bone from the oesophagus of a patient. Some use a probang, and force down the substance ; but there is danger of driving some agents, such as needles, into the integuments, and thus causing serious if not fatal consequences. A lady, in this city, lost her life by this means, a few years ago. A physician in Canada obtained great celebrity, a few years ago, by a simple but ingenious contrivance, with which he extracted a sub- stance in the oesophagus of a person. It consisted simply in tying a small piece of sponge to a piece of silk, and" causing the person to swallow it ; after which, to drink warm tea, and after waiting a short , time for the sponge to expand by the absorption of the liquid, the end of the strings was seized and cautiously drawn until the sponge came up, and with it the substance. This may be practised in some cases. The late Dr. Nathan Smith, of New-Haven, professor of surgery in the medical institution of Yale College, invented a very excellent instrument to extract coins from the oesophagus. " I have twice been called upon," says he, " to remove coins from the throats of children. In both instances they had descended to near the inferior extremity of the oesophagus, where the passage is a little narrowed, just before entering the stomach. Of course, they were entirely beyond the reach of forceps, or any instrument which might be employed to grasp and thus withdraw them. " The instrument which the exigencies of the case suggested, and with which I succeeded, was unlike anything which I have known to be employed for a similar purpose. A very few words will be suffi- cient to give an idea of it. " The shaft of the instrument is a rod of whalebone, twenty inches in length, and of the size of a small quill. Half an inch from one extremity there are attached, at acute angles, like the barbs of an ar- row, two wings of silver, an inch and a quarter in length, a quarter of an inch wide, and so thin as to be very elastic and flexible. The ex- tremity, which stands off from the instrument, is convoluted so as to render it blunt, and is a little curved inward toward the shaft of the instrument. The two wings are pinned to the shaft of the instrument, and may be continued over its extremity, which should terminate with a bead or obtuse point. "From the position of the oesophagus between the trachea and Rickets—(Rachitis.) 441 spine, the faces of the coin present forward and back. When the in- strument is thrust down the oesophagus, avoiding the glottis, as may be done without difficulty, and presenting the barbs one forward and the other back, it will pass either behind or before the coin, and the barb will spring beyond it, and catch it between itself and the shaft, when it may be very easily withdrawn. The manner in which the shaft is embraced by the oesophagus above, prevents its slipping off laterally. In both the cases alluded to, I accomplished the extraction of the coin without any difficulty, and at the first trial. In the second case, after I had once raised the coin into the mouth, the child instantly swal- lowed it again, though I had almost seized it with my fingers. It returned to the same place, and I again withdrew it at the first trial. " The barbs are made so thin, that should they catch in any of the follicles of the eesophagus, they would be everted sooner than rupture the membrane." Sometimes substances get into the trachea, or windpipe, and prove serious or fatal. When this happens, an emetic may first be given, and if this fails, and the substance still continues, it may be ne- cessary to make an opening into the trachea. This has sometimes succeeded when other means have failed. A longitudinal or horizon- tal incision is made just below the thyroid cartilage, which constitutes the prominence in the throat. CHAPTER XLVIII. rickets—(Rachitis.) This is a peculiar disease, produced by debility of the vascular sys- tem, and is commonly called rickets. Rachitis first manifests itself in disease of the mesenteric glands; the abdomen is increased in size, the head is considerably enlarged, and out of proportion to the rest of the body, so that the disease is often mistaken for hydrocephalus. The chin is expanded, the sides of the jaws are brought together, and the whole of the features are altered, so that, in general, by merely looking at the face of a patient, you infer from it the nature of the complaint. In rachitis, an alteration takes place in the form of the spine, which has a double curvature above and below, like the italic 5; and the other parts of the body are consequently affected by the distortion. Tnder these circumstances, nature endeavqurs still to preserve the 442 Rickets—(Rachitis.) perpendicular line of the body, by producing a second curve as soon as one begins, and the equilibrium is maintained, though there is a con- siderable variation in the form of the spine. The scapula is also considerably projected: but pressure on the shoulder, with a view of remedying this defect, is a most absurd and unscientific practice ; it may give pain, but can do no possible good. The spine, in these ca- ses, has given way in two directions, and the ribs on one side are more curved than on the other. This incurvation of the ribs occasions the alteration in the form on the scapula. The anterior part of the chest is extremely projected ; the sternum is sometimes sunk between the cartilages of the ribs, and sometimes advances so as to form what is called a chicken breast. In addition to the parts already mentioned as influenced by rachitis, the bones of the extremities all undergo a curvature. When this disease has continued for any length of time, absorption of some of the bones takes place, and nothing but the cartilage re- mains ; such are the miserable changes to which rickety children are subject. The cause of all these changes is a great deficiency in the powers of the circulation, in consequence of which the bones lose their phos- phate of lime, and become spongy at the extremities, and the joints, therefore, are exceedingly enlarged. The ossific matter binds down the cartilages, so as to prevent their expansion, hence arises a dimi- nution of the ossific deposit, which leads the alteration in the form of the bones. Treatment. With respect to the treatment of these cases, you will observe the Same general principles which I laid down for scrofula. The joints or parts affected, may be bathed with equal parts of the sassafras and olive oil, to which a little gum camphor has been added. Afterwards a strengthening plaster may be applied. The alterative syrup should be freely given, and continued a length of time. The bowels must be kept regular, and bathing in a tepid salt water bath, will also aid in the cute. I have found that a syrup, made of comfrey, shoke-weed and Solomon's sice, very serviceable in this complaint. Some time ago, I cured two very bad cases of rickets by pursuing this method. Friction on the parts is also useful. CHAPTER XLIX. dow worm, or scald head—(Tinea'Capitis.) This disease consists in a chronic inflammation of the skin of the head, productive of a secretion of matter, peculiar in its nature, and capable of propagating the complaint, if applied to the scalp of a healthy subject. At first the eruption is confined, probably, to only a small portion of the head ; but by degrees its acrimony is extended to the neighbouring parts, and at length the whole of the scalp is eroded, and beset with a scabby eruption. Dr. Willan has substituted the term porrigo for that of tinea, as being less objectionable, and considers this genus as consisting of several varieties. Children are principally affected with it, particularly those of the poor; hence it may arise from uncleanliness, from the want of a due proportion of wholesome nutritive food, and possibly from bad nursing. At any rate, these will very much aggravate the disease. In many instances it is propagated by contagion, either by using a comb imbued with the matter from the head of a person labouring under it, or by putting on his hat or cap. Treatment. It is recommended to cut off the hair, and apply a tar plaster over the head, and in some cases it may be beneficial, but I prefer a mode of treatment somewhat different. The head, or the part affected, should be fust well washed with soap and water, and then the follow- ing ointment applied : Take Venice turpentine, one ounce { Sulphur vivum, two drachms { Fresh butter or lard, one ounce ; Stir the whole in a mortar until it is well mixed. Let ihis be rubbed upon the affected parts three or four times a day. Give the child cream of tartar and sulphur, mixed in molasses, suf- ficient to act lightly upon the bowels. " From some recent experience," says Thatcher, " I am confi- dent that we have a domestic plant, easily procured, which will set- dom fail to cure this troublesome and loathsome disease, if properly applied. The plant I refer to is the kalmia, or laurel, of which we have two species in our woods and swamps ; the broad-leafed laurel, or winter-green, and the narrow-leafed laurel, well known by the name of lamb-kill, from its fatal effects among sheep. The last spe- cies is said to be the most active. Take the leaves of laurel or lamb- kill, at any season of the year, boil them till the water is strongly im- pregnated with their virtues, and then wash the scabby parts about the head twice in a day, until a perfect cure is effected. It will excite considerable smarting, but if it cannot be borne it may be made weaker. Another method of using this remedy is to reduce the dried loaves to a fine powder, and make an ointment by mixing it with hog's Vol. II. 3 H 444 Ringworm, or Impetigo. lard to which some of the powdered root of our swamp hellebore may be added, if desired. This remedy ought, in my opinion, to be preferred, as it is far more neat and cleanly than either the sulphur or tar ointment, and unquestionably of equal efficacy." CHAPTER L. RINGWORM, OR IMPETIGO. This is a cutaneous disease, chiefly occupying the scalp, but some- times other parts of the body, and arises most frequently from coming much in contact, or using the same comb, cap or hat, with those al- ready affected by it; but in some habits there seems a predisposition to it. It is a disorder more frequently met with in warm climates than in cold ones, is of a very contagious nature, and in inveterate cases is sometimes very difficult to eradicate. It shows itself in small red pimples, which break out in a circular form, and contain a thin acrid fluid. When the body is heated by exercise these itch intolerably, and upon being scratched, discharge their contents, which, by falling on the neighbouring parts, spread the disease to a considerable degree. The original size of the circle formed by the pimples is usually about that of a sixpenny piece ; but in process of time it will become, by neglect, as large as the palm of the hand. In some cases the disease is so universal that the habit becomes tainted; the skin puts on a leprous appearance, is much disfigured with blotches, and the unhappy patient enjoys not a moment's ease, from the intolerable itching and painful excoriations. Where the disease is not of an inveterate nature, it may easily be removed, by washing the parts affected with some kind of restringent lotion. Treatment. Wash the ringworm with the following lotion : Take litharge, two drachms ; Vinegar, eight ounces; Mix; apply it three or four times a day. After which anoint it with the yellow dock ointment. Should this fail to remove the complaint, treat it the same as tetter, or salt rheum. CHAPTER LI. PSORA, OR THE ITCH. The itch is evidently confined to the skin, and rarely affects the general system, however great its irritation. It arises most usually from infection, communicated by coming into immediate contact with the body of a person already affected, or by wearing the same clothes, or lying in the same bed-linen that he has done; but it is sometimes produced by unwholesome food, bad air, and a neglect of cleanliness. The itch shows itself in small pimples about the fingers, wrists, hams and waist, which, after a short time, become so many pustules, and are attended with such an itching as to occasion a constant desire to scratch. When they break, the acrid fluid which they contained falls on the neighbouring parts, and thereby spreads the disease over almost the whole body, if proper remedies are not used to check its progress. Where the pustules are very large, and attended with much inflammation, they are apt to run into boils. The animalculae which are seen in the pustules are the effect, not the cause of them : as all other stagnating fluids abound with microscopic animals. Treatment. Give internally, the following: Take flour of sulphur, two parts ; Cream of tartar, one part; Mix. Of this powder, to an adult, give a teaspoonful, in molasses, morning and night. The following ointment to be used externally: Take sulphur vivum, (native sulphur,) half an ounce, pulverized; Lard, two ounces; Melt the lard, and stir in this powder until it is cold. Let the parts be bathed two or three times a day with this ointment. This treatment will cure this loathsome disease in a few days, with- out the necessity of even changing the clothes, or producing any of- fensive effluvia. CHAPTER LII. COLLECTIONS OF MATTER IN THE ANTRUM, OF HIGHMORE, Symptoms. Pain extending upwards to the eyes, nose, and ears ; swelling and redness of the integuments over the part; frequently on a sudden, and especially upon rising from bed, a discharge of matter issues from the nose, which affords a relief to the symptoms, until the cavity becomes again distended. Treatment. Evacuating the matter by means of a puncture made through the alveolus, with a probe, or sharp-pointed instrument; and after the contents of the cavity have thus been emptied, preventing the sides of the opening from closing, by means of a tent; and occasionally injecting tincture of myrrh, or some astringent fluid. Generally after matter has formed, it will find an exit, or it may be evacuated by a probe, without extracting the molar tooth, as some re, commend. CHAPTER LIII. PSOAS AND LUMBER ABSCESSES. By these terms are understood chronic collections of matter, which form in the cellular substance of the loins, behind the perito- naeum, and descend in the course of the psoas muscle. If the disease forms on the side of the vertebrae, instead of the fore part, it is termed a lumber abscess, instead of psoas. The origin of psoas abscess is not, in general, attended with any symptoms of acute pain and inflammation, nor with any febrile dis- turbance of the constitution. Previous to the appearance of any other symptom, the patient long feels an unaccountable sense of weakness across the loins, accompa- nied by an obtuse, yet distressing pain; but this, so far from leading to a suspicion of the nature of the disease, is usually regarded as rheumatic. The matter is formed slowly, and imperceptibly, and occasions, at first, no manifest swelling, nor fluctuation. When the matter has collected, it spreads until it reaches the ori- Psoas and Lumber Abscesses. 447 gin of the psoas muscle, which passes into ulceration, and forms a bag, surrounded by a complete ring. The abscess proceeds as far as the tendon of the muscle, by Poupart's ligament, and its further progress is restrained by the tendon ; when it passes under Poupart's ligament, between the femoral vein and the symphysis pubis, it has generally attained considerable magnitude. While the abscess is attended with no external tumour, the discri- mination is always difficult. Upon the first appearance of the tumour beneath Poupart's liga- ment, it possesses so many of the characteristics of hernia: but the marks, which distinguish it, are the pain in the loins, and the great constitutional derangement which the patient suffers in the progress of the complaint. The outward swelling, at length occurring, may take place in va- rious situations, and assume different appearances. The swelling, when in the groin, sometimes insinuates itself be- neath the femoral fascia. In other instances, it descends as far as the knee, where it forms a prominent swelling. Sometimes it makes its way downwards into the pelvis, and occasions a swelling in the neighbourhood of the anus. Sometimes it tends towards the loins and sacrum, giving rise to a swelling exactly in the place where ab- scesses often make their appearance, in the disease of the hip-joint. In a few instances, the matter causes a swelling in the vicinity of the vertebrae : and, less frequently still, it makes its way through the ab- dominal muscles, and produces a tumour at some part of the abdomen. Causes. -The causes of a psoas abscess are frequently involved in great ob- scurity. It is supposed, sometimes, to arise from injury done to the back and loins, by severe twists, blows, &c. : at other times, to proceed from sudden exposure to cold after severe exercise, particularly in scrofulous habits. Treatment. If there be inflammation and pain, steam the part, and afterwards apply the slippery-elm poultice. Continue this treatment until the abscess breaks ; and after the matter is evacuated, let it be kept open and the discharge of matter facilitated. After a few days, inject in Castile soap and water, and subsequently liquids more stimulating, such as weak ley, tincture of gum myrrh, &c. They promote the adhesive process in the interior of the abscess, glue its sides together, promote a healthy secretion and the healing process. The black salve may be applied to the ulcer. There being usually much constitutional disturbance, particularly after it suppurates, such as debility, loss of appetite, &c. it will be necessary to give such medicines as will counteract these symptoms. CHAPTER LIV. SPRAINS. A sprain is an injury occurring to the ligaments or tendons sur- rounding a joint, which are either forcibly stretched or lacerated. It usually happens from the sudden extension of the joint in a direction which the muscles are unprepared for; in the same manner as when a dislocation is produced, only that the violence is not sufficient to oc- casion a displacement of the bones. The most common situations of these accidents are, either at the wrist or ankle, arising from sudden falls, by which the joints are un- expectedly and forcibly bent. These injuries are attended with considerable pain at the time of the accident, and the part soon becomes swollen and tender; the for- mer symptom arises from the effusion of blood in the first instance, out of the lacerated blood-vessels, and becomes subsequently much increased from inflammation ; the tenderness and pain are generally in proportion to the tumefaction. At first the surface of the skin presents its natural appearance, but after a short time, as the effused blood coagulates, it becomes much discoloured. When inflammation has been set up, and given rise to the effusion of fibrin, a sensation of crepitus is felt on examining the injured part. This might, by an ignorant surgeon, be mistaken for the crepitus of fractured bone ; but it never gives that distinct feel which occurs from the rubbing of one portion of broken bone upon another. Immediately after the receipt of the injury, the ordinary motions of the joints can be readily performed. However, as the swelling takes place, these motions become much impeded, and ultimately cannot be performed without producing acute pain, and increasing the mischief. Treatment. The best application to a recent sprain, is wormwood and hops sim- mered in vinegar, to be often renewed. If the inflammation is very great, let a poultice be applied. After the irritation, swelling, &c, has subsided, apply a strengthening plaster sufficiently large to cover the sprain. Camphorated spirits is sometimes serviceable, and opo- deldoc, which consists of alcohol, soap and camphor. Where sprains are obstinate and protracted, I have applied our green or rheumatic oil, with excellent effect. It is made as follows : Take oil of wormwood, Oil of sassafras, Oil of hemlock, Oil of red cedar, Burns and Scalds. 440 Oil or spirits of turpentine, Olive oil, Gum camphor, Equal parts. Mix, and bathe the sprain two or three times a day. Some have recommended cold water, tp be poured from a height upon a sprain, and in some cases this may have proved serviceable ; but injury sometimes follows the practice, from the sedative effect of the cold. After the aboye has been used, apply a strengthening plaster. CHAPTER LV. BURNS AND SCALDS. Burns are usually divided into three kinds: 1st. Into such as pro- duce an inflammation of the cutaneous texture, but an inflammation which, if it be not improperly treated, almost always manifests a ten- dency to resolution. 2d. Into those which occasion the separation of the cuticle, and produce suppuration on the surface of the skin. 3d. Into others in which the vitality and organization of a greater or less portion of the skin are either immediately or subsequently destroyed, and a soft slough or hard eschar produced.—(See Thomson on In- flammation, p. 565, 586.) Suppuration is not always an unavoidable consequence of the vesi- cations in burns ; but it is a common and a troublesome one. " In severe cases, it may take place by the second or third day ; often not till a later period. It often occurs without any appearance of ulcer- ation ; continues for a longer or shorter time, and is at last stopped by the formation of new skin. In other instances, small ulcerations appear on the surface or edges of the burn. These, spreading, form extensive sores, which are, in general, long in healing, even where the granulations which form upon them have a healthy appearance.— (Op. cit. p. 595.) Burns present different appearances, according to the degree of violence with which the causes producing them have operated, and according to the kind of cause of which they are the effect. Burns which only irritate the surface of the skin, are essentially different from those which destroy it; and these latter have a very different aspect from what others present which have attacked parts more deeply situated, such as the muscles, tendons,, ligaments, &c. Scalds, which are the effect of heated fluids, do not exactly re- semble burns, occasioned by the direct contact of very hot metal- lic bodies, or some combustible substance on fire. As fluids are not capable of acquiring so high a temperature as many solids, scalds are generally lf.s.s violent than burns in the injury which they pro- 450 Burns and Scalds. duce; but, in consequence of liquids often flowing about with grea* rapidity* and being suddenly thrown in large quantities over the pa- tient, scalds are frequently dangerous on account of their extent. It is worthy of remark, that the danger of the effects of fire is not less proportioned to the size, than the degree and depth of the injury. A burn that is so violent as to kill parts at once, may not be in the least dangerous, if not extensive ; while a scald, which perhaps only raises the cuticle, may prove fatal, if very large. The degree of danger, however, is to be rated from a consideration both of the size and vio- lence of the injury. The worst burns which occur in practice, arise from explosions of gunpowder or inflammable gases, from persons' dresses catching fire, and from the boiling over of hot fluids in labo- ratories, manufactories, & lumber merchant, Brooklyn, had an ulcer upon the face, which was pronounced a cancer by a physician of this city. Our applications removed it, and he has now been well for several years. Venereal Disease. Case 147. William Graham, Forsyth-street, applied at the infirm- ary, affected with the venereal disease, of seven years' standing. The symptoms were general emaciation and debility ; part of the time hectic fever. The disease had contaminated the whole system, and had nearly ruined the constitution. Ulcers of a very virulent and ir- ritable character existed in various parts of the body; copious dis- charges of fetid matter, and all the ordinary symptoms of the worst species of lues venerea. He had applied to numerous physicians without benefit. Most of the medicine he received from all, was mercury in some form or another, which caused the mercurial rheu- matisrn. The treatment pursued under the head of venereal disease, after some length of time, effected a cure. Necrosis. Case 148. George Hewlet applied at the infirmary, afflicted with an ulcer below the hip-joint. It extended to the bone, which also be- 502 Illustrations. came affected. It commenced with ordinary inflammation, being at- tended with very excruciating pains for a length of time ; and it finally suppurated, and continued to discharge a large quantity of matter for the space of three years. The physicians to whom he applied could afford him no relief. The course pursued at the infirmary separated the diseased bone, and he has now been well about two years. Case 149. Mr. Henry Lewis, from Columbia county, state of New- York, was attacked with an inflammation of the leg, which, after con- tinuing for some length of time, suppurated, and discharged large quantities of sanious matter, or pus. There were numerous sinous openings in the leg, extending to the bone, causing a decay of it. Most of the tibia, or front-bone, was rotten, or in a state of decay. We applied medicines to open the sinuses, and to make one common com- munication, one with the other; after which the applications were used to separate the diseased portion of the bone, when, after about six months from the time we commenced, it healed up. A number of pieces of bone were extracted. A surgeon of this city, Dr. M----, proposed an operation, by the knife. Necrosis—Venereal Disease. Case 150. A woman, aged about thirty years, applied for assistance, at the infirmary, with the whole fluids completely contaminated with the venereal poison. One or more openings had been made through the skull, by the effect of the complaint. The lower jaw-bone was carious from one angle to the other. Numerous sinuses or openings to the bone. It had been many years standing, and could not be cured by the various medicines which she had used. Medicines were given internally, to eradicate the taint of the system, and such applied externally, as separated the diseased bone, which, together with a little manual effort, after a period of about six months, removed the whole maxillary, or jaw-bone. O.-seous matter had previously been deposited about the alveolar processes, by which the teeth still were retained. It began rapidly to heal, and when we last saw her, it was nearly closed up ; and, as far as we know, she is now well. The jaw-bone, after extraction, appeared very much diseased, but still retained considerable firmness and strength. Bilious Remittent Fever. Case 151. Mr. R----, Delancey-street, was attacked with a bilious remittent fever; great prostration of strength ; tongue coated ; nau- sea ; severe headach; great degree of heat through the whole sys- tem ; little or no remission of symptoms, together with the ordinary characters of bilious remittent. The treatment pursued soon arrested the fever, and he daily grew better, till his health was completely es- tablished. The rapidity with which he amended, was the subject of remark by all his friends- Illustrations. 503 Consumption—Phthisis Pulmonalis.) Case 152. Mrs. Miller, aged about thirty years, residing in Suffolk- etreet.was taken with a severe cold, which lasted for six or nine months. After the inflammation subsided, suppuration followed. She expec- torated, or raised large quantities of thick matter or pus, which con- tinued during most of the time of the complaint; more or less pain in the chest; night sweats ; continued to waste away, until most of her flesh was gone ; countenance pale ; cough excessive ; great debility, and every symptom of approaching dissolution. Soon after she commenced taking the medicines, a mitigation of all the symptoms followed, and in the course of three or four months, she was perfectly well, and has remained so ever since. We have named the disease the consumption. Some may prefer to give it another name ; but names, being arbitrary, will not alter the complexion of the disease. Case 153. Mrs. Griffin, a relative of the lady above mentioned, was afflicted in a similar manner, though the symptoms were not so vio- lent. Cough, wasting of the system, hectic fever, expectoration of matter, great debility. A similar course of treatment restored her to health in two or three months. Venereal Disease. Case 154. Mr. Farmer, grocer, of this city, residing in Broome. street, in company with some others, employed some of the Oneida Indians, to sail to Europe, for the purpose of exhibiting the war dance and some other Indian customs or practices. One of the company, named Samuel, on his arrival here, was found to be in a deplorable condition, with secondary symptoms of the syphilis, or venereal dis- ease. It had extended throughout the whole system, with deep seated and most extensive ulcers, which emitted such a fetid smell, that it rendered it almost impossible to dress them. It was with great diffi- culty that he could walk. This man began to recover from the day the medicine was administered to him, and in the course of three weeks he was perfectly cured. Chronic Inflammation of the Kidneys. Case 155. Mrs. Sturges, from Lansingburgh, in this state, applied at the infirmary, with the chronic inflammation of the kidneys. Symp- toms—constant pain in the small of the back, which had been for years ; urine very turbid, and unequal in quantity, in connexion with rheumatic pains ; great debility; indigestion ; fever; irritability of the nervous system. She had been treated by steam doctors, and phy- sicians of the old school, with little or no benefit. She continued for some months in the city, during which time she daily grew better ; and, as far as we know, is now well. 504 Illustrations. Scrofula. Case 156. Joseph Denton, then residing in the city of New-York, now in Brookhaven, Long Island, was attacked with a scrofulous tumour upon the neck. It increased, and finally suppurated, leaving an obstinate scrofulous ulcer. He could find no relief till he sub- mitted to our treatment; when the tumour began to subside, the dis- charge to lessen and become healthy ; and the ulcer healed in about three months from the commencement. He has been well for a num- ber of years. Case 157. The child of Mr. W. Morris, then auctioneer, in this city, had the scrofula for a length of time. The neck was inflamed; great heat, pain, and finally ulceration took place. It assumed a very formidable character. The treatment pursued at the infirmary ef- fected a radical cure. White Swelling. Case 158. A child, about six years of age, was attacked with a white swelling, which caused the most intolerable pain. The knee and hip were excessively swelled, and the child confined to his bed; and he was rapidly wasting away. The physician who attended him was unable to afford the least relief. He was placed under the care of one of our students, who soon succeeded in mitigating the pain, reducing the swelling, and thus preventing suppuration. His health was so impaired, that he was unable to sleep for nights in succession. The course pursued removed the complaint. He was subsequently attacked in the other leg, in the same manner, and the same course of treatment removed it. Case 159. Joseph Denton, the person before mentioned, was seized with a severe pain in the knee, followed by great swelling and inflam- mation, which prevented him from labour for a great length of time. The disease assumed such a character, that it was feared that it would be necessary to resort to amputation. The usual remedies were ap- plied ; the symptoms abated, and in the course of two months he re- covered. Dyspepsia. Case 160. Mr. Conklin Davis, of Brookhaven, Long Island, was afflicted with the dyspepsia, for a number of years. Stomach and liver diseased ; great debility ; food not digested. The whole sys- tem became much impaired, and continually getting worse. He could find no relief from physicians, or any other source, until he applied at the infirmary. The remedies removed the complaint, after some length of time. I have since seen the person, who states, that he en- joys tolerable health. Illustrations. 505 Case 161. Mr. T. Atwater, of Williamsburg, Long Island, was af- flicted with indigestion, for a great length of time ; pain and swelling of the stomach, particularly after eating ; general debility, dec. ; dis- ordered state of the bowels. Soon after he applied for relief, he grew better ; and, in a short time, the symptoms subsided. Chronic Dysentery. Case 162. Mr. S----, of this city, had been labouring under the chronic dysentery, for more than a year. His bowels were constant- ly in a morbid or unhealthy state. The remedies prescribed for him effected a cure. Fistula. Case 163. Mr. Washington Lewis, Chatham-square, had been afflicted with a fistula for a great length of time. It commenced with great pain, inflammation and swelling, and finally suppurated, and continued to discharge matter freely for more than a year. It extended up the bowel, or rectum, about two inches ; hard callous edges, &c. A surgeon of this city attempted to extirpate it with the knife, by making extensive incisions. After submitting to the treatment usually pursued in this complaint, it healed up, and he was restored to health. [For twenty-two other cases of this complaint, see Fistula.] Obstinate case of Intermittent Fever. Case 164. Mr. James Conklin, of this city, was taken with the in- termittent fever, in Bushwick, Long Island, where it extensively pre- vailed. The physicians there gave him large quantities of mercury, salts, bark, &c, without effecting a cure ; the disease had nearly destroyed his health. Dropsy of the whole system succeeded. In this condition he was placed under our care, and we soon prescribed medicines which brought about a healthy state of the system, and he is now well. Dropsy. Case 165. The same person, Mr. James Conklin, was taken with a dropsy of the whole system : his face became very much bloated, and abdomen enormously swelled, so much so that his clothes could not be buttoned. He was unable to perform any manual labour, and his system was fast sinking, attended also with a troublesome cough. This was brought on by the use of mercury, for the fever and ague, &c. So obstinate was the disease that it was feared he never would recover. After attending, however, to our prescriptions, the water in enormous quantities was discharged, the swelling of the body sub- sided ; and in a few weeks not a vestige of the disease remained. He has been perfectly well for a length of time. 506 Illustrations. Cancer. From the New-York Evening Post. Case 166. Mr. Coleman—As you have ever manifested a disposition to publish any fact that might be useful to the afflicted, I take the liberty of requesting you, through the medium of your paper, to make known the following case. About one year ago, I discovered a tumour in my left breast, which gradually increased till it ulcerated. The pain attending it was darting and lancinating, producing sensations similar to needles, or some sharp pointed instruments piercing the flesh. Feeling alarmed at these symptoms, I applied to Dr. Richard Kissam, who pronounced it a cancer, and advised me to submit to an operation. In consequence, however, of hearing, a few days after- wards, that Dr. Beach had been successful in curing this disease with- out the knife, I relinquished the idea of such an operation, and plaeed myself under his care. His first application mitigated the pain, and in the space of two months I had the satisfaction of finding myself perfectly well. The gratitude I feel on the occasion, prompts me to make the circumstance thus publicly known, not only in justice to the physician, who was the instrument, in the hands of Providence, of rescuing me from the jaws of death ; but also for the benefit of all those who are labouring under this most distressing malady. In con- trasting my case with that of a lady from the country, who, a few weeks since, died under an operation for a similar disease, (performed by two surgeons of this city,) I feel emotions of gratitude more easily felt than described—and therefore, out of sympathy for all who are afflicted with cancers, I do most earnestly recommend Dr. Beach's mode of treatment, and request, that in the cause of humanity, other editors will have the goodness to give the above statement a few in- sertions. ELIZABETH MICHAELS. New-York, March 11, 1822. Necrosis. Case 167. Mr. Douglas had been afflicted with a diseased leg, in which the bone had become carious, or diseased, for eighteen months. He could find no benefit from any other source, until he applied at the infirmary; when, by submitting to the treatment prescribed, he was entirely cured. Dropsy of the Chest. Case 168. Mrs. Washburn, residing then in First-street, was seiz- ed with pain at the lower portion of the breast-bone ; difficulty of breathing ; fulness and tightness of the chest; diminution of urine ; which was very high-coloured, and all other symptoms of dropsy in the chest. It afflicted her so much, that, for a portion of the time, she was confined to her bed. The medicines which we prescribed, in a few weeks, effected a perfect cure. Illustrations, 607 Apoplexy. Case 170. Mr. Paul aged about 70, residing in Forsyth street, had been subjectto tttacks of apoplexy, for considerable time, they increas- ed upon him, ui til he was seized with one so severely, that the imme- diate extinction of life was threatened. The physician who was call- ed to him prop' sed bleeding. We did not bleed him, but used means to equalize the irculation, which gave immediate relief. His senses re- turned, and strength, he gradually grew better, until he recovered, and has remained so for a great length of time. I have this day seen him and he is as wed as ever. Had the usual depletive course been follow- ed, he would in all human probability been now in his grave. Fever sore or Ulcer. Case 171. Mrs. Paul, Forsyth-street, had been afflicted for many years with a fever sore, with a constant discharge, great swelling and inflammation, &c, the humours from the ulcer often receding, and settling upon some inward organ, and causing great distress. A great number of physicians were applied to in vain, after which we were called to attend her. Our prescriptions were attended with a happy effect, swelling and inflammation subsided; the discharge ceas- * ing, and the ulcer (very extensive) nearly healed. Fistula. Case 172. Mv Tomes, wood inspector, residing in Crosby-street, was attacked with a fistula, great pain, inflammation, &c, and all the symptoms of that formidable disease. He was attended by two phy- sicians, who were unable to cure him. After this we were called; our treatment affected a cure without any surgical operation by the knife. Debility, Fluor Albus, tyc. Case 173. Mrs. Miller, Laurens-street, had been a long time afflict- ed with fluor albus, general debility, &c. She was unable to find re- lief from any of the prescriptions of her physicians. In the course of a few weeks, by adhering to our prescriptions, she was enabled to re- sume her ordinary business. Chronic Dysentery. Case 174. Mr. Rehorn, in Allen-street, had been afflicted with the chronic dysentery for a year, our treatment cured him. * Chronic inflammation of the Liver. Case 175. Mrs. Pessenger, Norfolk-street, had been a long time af- flicted with a chronic inflammation of the liver; pain in the side and shoulder, disordered state of the stomach, general debility, &c. She was unable to find relief from physicians, or from any source. After submitting to our treatment for a short time, the symptoms subsided, and as far as we know, the patient is now well. Vol- II. 3 Q 503 Illustrations. Inflammation of the Bowels. Case 176. Mr. Taber, 158 Stanton-street, was seized violently with the bilious colic. His physician bled, blistered, and salivated him ; all of which only exasperated the complaint. Nothing passed the bowels for days; constant retching and vomiting, excruciating pain, the bowels finally became enormously swelled; he had been in this condition for about ten days, when his life was almost despaired of. Under these discouraging circumstances we were called to treat him. We gave him such physic as soon produced a free evacuation from the bowels, which lessened the swelling, pain, &c, and arrested the disease. From this time he grew better, and recovered in about a week. Intermittent Fever. Case 177. Mr. Brewster, residing at the corner of Moore and Water streets, had become very low, and much reduced by intermittent fever. He was at times delirious, and his disease had become so seated, that it was feared he would not survive. In a few weeks our prescriptions cured him. Remittant Fever. Case 178. The son of Mrs. Burkhill, then residing in Hester-street, was seized with the remittent fever; great nausea, pain of the head and other parts, pulse quick, skin dry, delirium and great prostration of strength. A vegetable course of treatment soon restored him to health. His life was once before threatened with bleeding from the nose. In an hour our applications suppressed it. Dyspepsia. rnse 179. The daughter of Mrs. Burkhill, then residing in Park Place, became so low and emaciated with dyspepsia, that her recovery seemed doubtful. Our usual course of treatment gave immediate re hef. Her mother now states that she is indebted for her life to our medicines. The ordinary means were used. Piles. Case 180. Mrs. Delamater of this city was severely afflicted with the piles. A few prescriptions removed the complaint. Inflammatory Rheumatism. Case 181. Mr. Caleb Fordham, Madison-street, was confined to his .bed for severa months with inflammatory rheumatism, attended with pat pain and inflammation of the joints, which prevented him almost from moving the limb. The treatment gradually eradicated the dis, ease from the system, and he now walks and attends to his ordinary Illustrations. 509 Various Diseases. Case 182. Five or six different cases occurred in the family of Mr. Gibbs, plane maker, in the Bowery, all of which were speedily curedby a vegetable course of treatment. Remittent Fever. Case 182. A young man boarding at the house of Mr. Hunt, in Broome-street, was violently seized with remittent fever, pain, &c. He was restored to health in a few days. Another member of the family was violently afflicted with colic, fe- ver, Sec. He also was soon cured. Case 183. Five or six different diseases were cured in a family of P. Hickock, in Ludlow-street. Case 184. A number of diseases were cured in the family of Mr. Noah Hanford, Suffolk-street, as usual, without bleeding or mercury. Bilious Colic. Case 185. Mr. Hadley, 104 Allen-street, was so suddenly and pow- erfully seized with bilious colic, that his life seemed in imminent dan- ger. Our medicines afforded immediate relief, and in a few days he was well. Scurvy, Swelling, Tetter, fyc. Case 186. The daughter of Mr. Henry, Williamsburgh, Long Island, had been for a long time afflicted with a swelling of the lower lip, which became very much enlarged, the colour changed, and it was attended with very obstinate symptoms. The family physicians and others to whom he applied were unable to cure it. Our medicines effected a cure. Case 187. A number of desperate diseases were cured in the fami- ly of Mr. NeWcomb, in Broome-street. Inflammation of the Eye. Case 188. Mrs. Parcells, Elizabeth-street, was suddenly seized with severe inflammation of the eyes. Our applications soon reduced it. Case 189. Several inveterate cases occurred in the family of Mr. Charles Sweezey, corner of Grand and Mangin streets, which were cured by the usual course of treatment. Ischuria or suppression of Urine. Case 190. Mr. Jqhn Fleming, 397 Bowery, was seized with an in- 510 Illustrations. flammation of the bladder, kidney, &c. Total suppression of urine, swelling over the region of the abdomen, fever and pain so great that delirium succeeded. His life seemed in imminent danger; his attend- ing physician being unable to afford him any relief. After submitting to our treatment, he was relieved in an hour. He continued to mend until he entirely recovered. Pleurisy and Fever. Case 191. The daughter of Mr. John Fleming, 397 Bowery, was Attacked with inflammation of the pleura, great fever, &c. Great pain, and confined to the bed for a great length of time. The usual course was .taken to reduce the inflammation, which effected a cure. Pleurisy. Case 192. The wife of Mr. John Fleming, 397 Bowery, was severe- ly attacked with pleurisy; acute pain in the side, cough, fever, &c. Instead of following the course pursued by ordinary physicians, medi- cines were given to promote perspiration, fomentations were applied to the side, purgatives were administered which afforded immediate re- lief, and she was soon cured. Nervous Debility. Case 193. Mrs. Ludlum, 223 Thompson-street, was reduced very low by nervous debility. The family physician was unable to render her any benefit; our prescriptions cured her. Case 194. Mr. Porter, 218 Essex-street, had been afflicted with an obstinate disease of the face for a long time, and could find no relief until he used our medicines, which cured him. Dyspepsia, Palpitation, fyc. Case 195. Mrs. Neal, 232 Stanton-street, was taken with a severe palpitation of the heart, which proved very painful and obstinatef the stomach was very much disordered; great emaciation., fever, debility, &c. Two physicians pronounced her case hopeless. Our treatment cured her of this complaint. Case 196. Several cases occurred in the family of Mr. A. W. Youle, Water-street. All were cured by our treatment. Inflammation of the Eye. The wife of Mr. Townsend, Water-street, was taken with inflam- mation of the eyes, which were cured in a few days. Contusion. Case 198. Mr. Babbit, corner of Essex and Stanton street, received a severe and dangerous contusion on the side. Without bleeding he recovered. Illustrations. 511 v Case 199. Mrs. Babbit, corner of Essex and Stanton streets, had some anomalous disease. Our prescriptions soon relieved or cured her. Contusion. Case 200. Mr. S. Rust, Eldridge-street, fell through the scuttle door from an upper story, and received a severe and dangerous con- tusion and wound. Our treatment afforded immediate relief, and ef' fected a cure. Liver Disease. Case 201. M. Shade, then residing at 631 Water-street, had been for a long time afflicted with a chronic disease of the liver. Our pre- scriptions soon cured her. Since that time we have also cured her of the bilious colic. Stricture and inflammation of the Bladder, fyc. Case 202. Mr. Tice, Avenue D, was seized with an inflammation of the bladder, which produced great pain, and total suppression of urine. Our prescriptions soon relieved him. Inflammation of the Bladder, suppression of the Urine, Sf-c. Case 203. The wife of Mr. Rayner, 62 Avenue D, was taken with an inflammation of the bladder, which produced a total suppression of urine. Her agony was so great that her cries could be heard in an adjoining apartment. In twenty minutes our treatment afforded re- lief, returned the water, and in a short time cured her. Fever. Case 204. A child of Mr. Raymond, 8 Mangin-street, was seized so bad with a fever, that his life was despaired of. The course we pur- sued cured it in a short time. Contusion. Case 205. Mr. John Newcomb, 343 Third-street, fell from a scaffold in a ship yard, fractured the clavicle, and received a severe contusion of the hip, which prevented him from using it for many weeks; great swelling, pain and inflammation, which confined him to his bed. His family physician was unable to afford him any relief. Our treatment soon cured him. Fracture and Contusion. Case 206. Mr. Rider of Fourth-street, fell from a scaffold in a ship yard, fractured the clavicle, and severely bruised his side. One phy- sician attempted to reduce the fracture, and stated that it was properly done. Another was called who stated that it was not reduced: the consequence was that both were dismissed. We were then called and commenced treating it, and he speedily recovered. 512 Illustrations. Hip Disease, Ulcer, 4-c. Case 207. The son of Mr. Williamson of Williamsburg, Long Island, was attacked with a tumour between the hip and the knee, which was cut out by a surgeon of this city. Ulcerations followed, which appear- ed to extend to the joint. A large opening or orifice formed about twelve inches long, which penetrated deep into the flesh, and from it was a copious discharge of pus and matter. The joint appeared dis- eased, which rendered him a cripple for many months. Under the treatment of a number of physicians he constantly grew worse. In this condition we were callled to attend him, and he began rapidly to re- cover ; he threw aside his crutches, can now walk, and is perfectly well. Schirrhous tumour of the Breast. Case 208. Mrs. Yates, 23 Division-stteet, was taken with an inflam- mation and tumour of the breast. The applications removed the tu- mour, and she is now well. Epilepsy. Case 209. Mr. Snyder of Kingston, (N. Y.) was subject to the epi- lepsy for a great length of time. Fits frequently occurred, and no re- lief could be obtained. He applied to us, and our prescription cared him. Fits. Case 210. The son of Mr. T. Benjamin, 352 Fifth-street, was seized with convulsions or fits. Our treatment cured him. Case 211. Two or three cases were cured at Mrs. Campbell's, 101 Nassau-street. Several cases of disease in the same family were cured. Cancer. Case 212. The daughter of Mr. Van Nostrand, Brooklyn, Long Is- land, was taken with an ulcer upon the nose, which continued to cor- rode the parts, and destroyed a considerable portion of one nostril. It had progressed until it appeared to be incurable ; a number of physi- ing unable to afford any relief. Our treatment eradicated it. Measles. Case 213. A child of Mr. Dick, Grand-street, was given up as hope- less with the measles. Our treatment effected a cure. Pulmonary Disease. Case 214. Mr- Hoyt, of Danbury, Connecticut, was reduced exceed- ing low with a cough, flesh and strength wasted away, fever, great quantities of matter daily expectorated, and so deep seated was the disease, that he was pronounced by all who knew him in a decline. None of the physicians to whom he applied could afford him any re- rlief. Under these circumstances he applied to us. The medicines Illustrations. 513 which we gave him, he states, soon produced a crisis in the disorder. When we last saw him he was nearly well. White Swelling. Case 215. The child of Mrs. Williamson, 200 Norfh-street, was ta- ken with a pain, inflammation, and swelling of the hip. Ulceration finally succeeded, which proved to be the white swelling or hip disease. There was an orifice or opening, which extended to the bone. She was unable to find relief from any source, until she submitted to our treatment, which cured her. She was a long time a cripple, but now walks, and has been well for a dozen years. Syphilis, Ulcer, fyc. Case 216. Mrs. Smith, Rivington-street, had been afflicted for two or three years with an ulcer in the throat, which a number of physi- cians were unable to cure. Our prescription effected a cure. Dysentery. Case 217. The child of Mrs. Holmes, 42 Forsyth-street, was taken so severe that its life was despaired of. The worst and most unfavour- able and the last stage of dysentery. Two physicians attended her, under whose treatment she grew worse. In this condition, in the advanced stage of the disease, we were called, and our medicine al- most immediately arrested the disease and cured her. One of the at- tending physicians witnessed the effect of our medicine, and expressed his admiration of it. Spasms or Cramps. Case 218. We were called to see a woman affected with cramp, and gastric spasms, vomiting, pain, contraction of the tendons, &c. The physician who was called could not relieve her. He was unable to prescribe any thing to allay the vomiting, irritation, Sec. The first dose we gave her mitigated all the symptoms, and in a few days she was well. Hydrothoraz. Case 219. Mrs. Kimball, of this city, was afflicted with a dropsy of the chest. Our prescriptions cured her in a short time. We also cu- red her of another inveterate disease. Fever. Case 220. Mrs. Christie, residing in Christie-street, called us to see her daughter, who was in the last stage of remittent fever, and al- though the case seemed almost hopeless, our treatment broke the fe- ver, and she speedily recovered. St. Anthony's Fire. Cass 221. Mrs. L., Stanton-street, received a check of perspiration, which caused the St. Anthony's Fire. It caused such a swelling in the face, as made her totally or partially blind for some time; 614 Illustrations. great pain, heat, Sec, succeeded by ulceration. Our medicine redo* ced the inflammation, removed the swelling, and soon cured her. St Anthony's Fire. Case 222. A young woman applied to us with the St. Anthony's Fire in both legs, great pain, heat, itching, inflammation, &c. She had been confined to her room, without being able to walk for many months. A noted surgeon of this city, Dr. C, had attended her a long time, without rendering her any service. Our prescriptions cured her. Dropsy in the Chest. Case 223. Mr. Richardson, grocer, then residing in Eldridge-street, was afflicted with a dropsy in the chest, pain, fulness, and stricture of the chest, shortness of breath, diminution of urine, &c. The medi- cines prescribed for him affected a cure. Cancer. Case 224. Mr. Adams, of this city, had an ulcer upon the lip, which continued to corrode and destroy the flesh for a length of time. Ap- plications were applied which cur^l him. Case 225. Mr. M'Bride, cartman, of this city, had been afflicted many years with a tumour of the breast, which was pronounced a cancer. Cured. Curvature of the Spine, Tumour, d*c. Case 226. A child of Mr. R., Greenwich Village, was attacked with a disease of the spine. A hard tumour formed by the side of it, which prevented the child from rising or walking. Our treatment cured it. Ulcer. Case 227. Mrs. Smith, 261 Rivington-street, had an ulcer in the throat, of seven months standing; had applied to twelve physicians in vain; was given up as incurable. Our prescriptions effected a perfect cure. Dropsy in the Chest. Case 228. Mrs. Walker, in Orchard-street, was afflicted with dropsy in the chest, cured. Callous Tumour. Case 229. Mary Bleeker, had been troubled for a considerable time with a hard callous tumour on the side. Discutient. applications re- moved it without cutting. Scrofula. Case J. Q. Underhill, had been for some time afflicted with a scro- fulous tumour on the neck or under the chin, applied to different phy- sicians without any benefit. After submitting to our treatment he was cured. Illustrations. 515 White Swelling, Ulcer, fyc. Case 231. The child of Mr. Ross was taken with inflammation in the leg, which terminated in suppuration, and extensively diseased the whole knee, covering it with ulcers, hardness, swelling, &c. Un- der the treatment of a noted surgeon of this city, it constantly grew worse. Under our treatment it healed up. • ' Dropsy of the Chest. Case 232. Mrs. L., Centre-street, near Grand, was seriously affected with a dropsy of the chest, pain, difficulty of breathing, diminution of urine, &c. Cured. Pulmonary Disease. Case 233. The son of Mrs. Burling, had all the symptoms of con- sumption, cough, pain in the breast, &c. Cured. Pleurisy. Case 234. Miss Dunlavy, Attorney-street, was so severely attacked with pleurisy, that it appeared that she could not survive but a short time. The physician who was first called could afford her no relief. Immediate relief was given, and she was soon cured. Croup. Case 235. The child of Mrs. Griffith, in Essex-street, was in the last stage of croup. The physicians who attended him, pronounced him to he incurable and dying. They frequently called in and asked if he was not yet dead. At this time we were called to see him, and al- though the case seemed entirely hopeless, the child being nearly gone, from the accumulation of mucus in the bronchial vessels and lungs, a few drops of medicine was administered, which caused him to raise the mucus, and relieved the oppression, from which moment he gradu- ally grew better, until he recovered. Rickets. Case 236. The child of Mr. Washington Lewis, Auctioneer, Chat- ham-square, was attacked with a scrofulous affection, which termina- ted in the rickets. He was unable to walk, and very feeble, his joints were enlarged, and the disease seemed almost incurable from its obsti- nate character. Internal and external means were used to produce a healthy state of the system, by which the child was restored to health* and has for a length of time continued well. Pulmonary Disease. Case 237. Mr. William Cook, of this city, was attacked with in- flammation of the lungs, which continued for a length of time, and then suppuration took place. He continued to raise for-many months, large quantities of pus or matter, not less than half a pint each day; pain in the breast, fever and night sweats, continual wasting of the whole body, excessive debility, and almost constant cough. Every Vol. II! 3 R 516 Illustrations. symptom of confirmed phthisis or consumption. The remedies pre- cribed cured him. Pulmonary Complaint. Case 238. Mrs. Wicks, of this city, was attacked with an inflamma- tion of the pleura and lungs, which continued for about a year; fever during most of the time, continual pain in the chest, cough during most of the night, expectoration of large quantities of purulent matter; part of the time she was confined to her bed. Cured. Scrofula. Case 239. Caroline Benedict, of Flushing, Long Island, was attack- ed with a scrofulous disease in the neck, breast, and right arm, attend- ed with great inflammation and pain. After some length of time it suppurated and discharged freely, but for some reason was afterward twice lanced, The ulcers assumed a very unhealthy appearance, and they extended over a large portion of the neck, breast and side, caus- ing a general taint and disease of the whole system. All the physi- cians to whom she applied were unable to cure her. After she had been in this condition for about four years, she applied for relief to our institution; a change was speedily effected in the ulcers, and general system. She was restored to health, and has continued so for many years. Ulcer and Cutaneous Eruption. Case 240. Mr. Samuel Walker, then residing 507 Washington- street, had been afflicted for six months with salt rheum, and an herpetic ulcer on the face. The parts became very much enlarged, very irritable and inflamed, so much so, that he had not shaved him- self for four months. It was attended with itching, burning, and the most unpleasant symptoms. A noted physician, Dr. H., of Boston, had attended him, without affording him any benefit* *In this situation he was placed under our care, and in twelve days he was cured. I saw him the other day, and he informed me thathe had no return of the complaint since, it having been more than a year. Syphilis. Case 241. Levi M'Alister, then residing at 132 Elizabeth-street, had been labouring under the lues venerea, for eighteen months. Most extensive and formidable ulcers covered a portion of the body, from which issued great quantities of matter, so offensive that it was ex- tremely unpleasant to dress them. During the continuance of the disease, he was unable to attend his business. He had been attended by three physicians without deriving any benefit. He was in the New- York Hospital for eighteen months, but the surgeons were unable to cure him. When he was nearly ruined by the disease, we began to prescribe for him. In a few days he was better, and in a few months he was cured. Illustrations. 517 Scrofula. Case 242. A child, a few days since, was brought to the office, aged about twelve months. The symptoms were excessive, inflammation of the parotid glands of the neck, fever, hardness of the parts, swelling so great that the neck was thrown upon one side, much inflammation, the neck enormously enlarged. So aggravated was the complaint, that it appeared incurable. Medicines were applied to promote suppu- ration, which was finally effected. The contents of the abscess were discharged, and the ulcer healed. Scrofulous Tumour. Case 243. A hard indolen tumour, about the size of an egg, attack- ed a child of Mr. Carpenter, of this city. It had remained in this con- dition for some months. Discutient applications were applied, which shortly cured it. Inflammation of the Lungs, {Pneumonia.) Case 244. A child of Mr. Bloomer, of this city, was so severely af- flicted with inflammation of the lungs, that little or no hopes were en- tertained of its recovery. The usual course of treatment restored it to health. St Anthony's Fire, {Erysipelas,) Mortification, fyc. Case 245. Mr. R. L., Orchard-street, was taken with erysipelatious inflammation of the arm, which became enormously swelled and in- flamed. Suppuration followed, and mortification commenced, and de- stroyed the greater part of the arm. It was attended with excruciating pain, itching, &c. The case was so desperate that it seemed almost hopeless, but immediately after the application of our medicines, the disease assumed a more healthy aspect. The dead flesh separated, the swelling and inflammation subsided, and in six weeks the arm was well. Bilious Remittent Fever. Case 246. We were called to visit a young man residing with Mr. Eustice in Orchard-street, attacked with bilious remittent fever, tongue furred, nausea, headache, great prostration of strength, skin dry, thirst and fever great, &c. Means were taken to restore all the se- cretions and excretions of the body, which effected a cure in a few days. A number of others were cured in the same house, affected with various diseases, by pursuing a vegetable course of treatment. GENERAL DEBILITY. Case 247. Mrs. Lee, Greenwich street, had been declining in health for a great length of time, flesh wasted, strength gone, restless- ness, fever, digestion impaired, with general debility of the whole sys- tem. She could find no relief from the ordinary prescriptions. A ve- getable course of treatment restored her to health in a few weeks. 61S Illustrations. Pulmonary Disease. Case 248. Mrs. Provost, 11 Clinton-street, was seized with pneu- monia, or inflammation of the lungs, which lasted for several months, and terminated in suppuration. It was attended with a very deep seat- ed cough, with a copious discharge of matter, hectic fever, night sweats, great emaciation, with all the symptoms of consumption. The course pursued at the infirmary cured the disease. A number of others in the same family were cured without mercury or bleeding. Ague and Tumours of the Breast. Case 249. Mrs. Hadley, Stanton-street, was taken with an inflam- mation of the breast, which became very hard and swollen, and attend- ed with very excruciating pain, fever, and great debility. Cured. Sckirrhous Tumour of the Breast. Case 250. Miss Tilton, of' Shrewsbury, New-Jersey, had a large echirrhous tumour of the breast, which continued to increase for near- ly a year. It was attended with darting and shooting pains, great soreness and distress. Was cured in about six months, without a sur- gical operation. A neighbour of hers, had her breast extirpated by the knife for a similar disease, which proved fatal during the time. Cancer. Case 251. Mrs. Holdridge had a schurhous tumour, which was pro- nounced a cancer, and which her physician was unable to cure. She applied to u^, and the disease was removed. She waa afterward af- flicted with inflammation of the lungs, pleura, cramp, &c, and other complaints, which were all cured. Ulcer. Case 252. Mr. Stewart, corner of Seventh and Lewis-street, was taken with an inflammation of the leg, which was swelled twice as large as the other. From the knee to the ancle it became hard and ulcerated. Several pounds of flesh separated from the calf of the leg. He was either confined to the room, or went upon crutches for near a year. The discharge from it was very copious and fetid, and several phy- sicians treated it without benefit. Among the rest was a professor of the medical school, New-York, who decided that the leg must be am- putated. In this situation we were called to treat it, and although we found it very obstinate, after a length of time, succeededin effecting a cure. The man walks well without crutches. Aneurism, Ulcer, Swelling, fyc. Case 253. Richard White, of Brooklyn, L. I., had an aneurismal tumour in the ham of the leg, (popliteal aneurism.) A surgeon of this city tied the artery above the tumour. This operation, however, was attended with the most serious consequences. The principal sinew of the leg became contracted, ulceration followed, and the leg swelled to ei least four times the size of the other. He had been a perfect cripple Illustrations 519 for a year ; could not even raise his leg from the floor without assist- ance. Dr. M., in consultation with a number of other physicians de- cided that it must be amputated, and a day was appointed to perform it. Under these discourageing circumstances we were called to treat him, and although his case seemed almost hopeless, the treatment soon produced an alteration, and lessened the diameter of it about two inch- es in a very short time, as we found by measurement. It mended slowly for about a year, when he djppensed with his crutches, and be* gan to walk as usual. He is now attending to his ordinary business. Every persuasion was used by the surgeons to induce him to have it amputated. Inflammation and Ulcer. Case 254. A little girl, corner of Anthony and Elm streets, was at- tacked with inflammation and ulcer upon the ancle. One of the pro- fessors of the medical school in this city ordered it to be amputated immediately. A few simple dressings cured it. Inflammation of the Lungs, {Pneumonia.) Case 255. A child of Mr. William Marks, printer of this city, aged about one year, was attacked with inflammation of the lungs and croup, so severely, that its life was "despaired of. Cured. Case 256. A child of Mr. N. Cort was attacked with an inflamma- tion of the lungs so severely, that it was given up as incurable. Symptoms, swelling of the throat and neck, great fever, &c. Cured. Also, eight or ten other cases of inveterate diseases, all cured by a vegetable mode of treatment Fever Pneumonia, fyc. Case 257. The child of Mr. S. Rust, (inventor of patent printing presses) in Eldridge-street, was attacked with fever and inflammation of the lungs so severely that his life was despaired of.t This case was likewise cured. Different members of the family were attacked with ten or fifteen other diseases, all of which were cured without mercury or bleeding. The recoveries were rapid, and no effects of the poison left in the system. Ulcer and general taint of the System. Case 258. Mrs. Lewis, 246 Fulton-street, had been labouring for many years under morbid or scrofulous taint of the system, which finally appeared in the form of an ulcer in the arm. She was soon relieved or cufed by the treatment. Swelling and Inflammation. Case 259. A young lady at Mrs. Bogardus's 23 Division-street, was attacked with a swellingand inflammation of the face, which became so great that she was scarcely able to open her mouth or articulate, and it appeared dangerous. By proper applications, suppuration took place, and she was cured. 520 Illustrations. Case 260. Mrs. P. Gallagher, 105 Chapel-street, was at different times affected with serious complaints. She could find no relief ex- cept by our prescriptions. She is now well. Chronic affection of the Chest, Debility, fyc. Case 261. Mr. Miller, 142 Norfolk-street, was afflicted with pain in the breast and side, with general debility, which prevented him from attending to his business for about a year. Our medicines afforded re- lief, and as far as we know is now well. Nervous Disease. Case 262. Miss Demarest, Brooklyn, was subject for many years to a nervous affection, which for many years seemed to threaten her life. She could find no relief from any treatment or any prescription, until she applied to our institution. Our treatment arrested the disease and soon afforded relief. Fracture of the Thigh. Case 263. A child of Mrs. Hutchinson, 161 Stanton-street, fractured the thigh about midway. A physician was called, who only placed a roller or bandage around it, after which we were called to treat it. Upon examination we found that it had not been reduced. We brought the bones in coaptation, secured them by our improved double inclined plane or splint, the bones knit in the usual time, and the boy walks so well that no one could even suspect the accident. Fracture of the Tibia and Fibula, {lower-leg.) An elderly woman in the lower part of the same house, fractured the tibia and fibula. It was treated in the usual manner. Means used to reduce the inflammation ; and to kefep the bones in contact, &c, by which she speedily recovered. Fracture of the Femur or Thigh Bone. Case 264. Mrs. M., 21 Pell-street, fractured the femur, which had been previously diseased by a scrofulous affection. The ends of the bone were brought together and secured by the improved inclined plane, usual means to subdue inflammation made use of. She speedi- ly recovered, and was enabled to walk as well as ever. Case 265. I was called to treat Mr. Rice, Eldridge-street, who fell and fractured the femur. The improved inclined plain was applied, rest, enjoined; inflammation was reduced, and the patient rapidly re- covered. Case 266. A child at the foot of Rivington-street, was run over by a cart, which fractured the femur. The physician who was called appli- ed splints and a bandage, and when we were called, we changed the treatment. We applied our bandage, splints, and improved inclined Illustrations. 521 plane as recommended; reduced the inflammation, and the boy rapidly recovered. Fracture of the Leg. Case 267. A journeyman of Mr. Samuel Rust, Eldridge-street, broke both bones of the leg, (tibia and fibula.) The usual treatment was pursued, the bones knit, and the patient recovered. Fracture of the Femur with the Capsular Ligament. Case 268. Mrs. Mott, residing in Mott-street, near Hester, in going down stairs slipped and fractured the thigh bone, near or within the joint. Two experienced surgeons saw the case, and stated that the fracture was within the capsular ligament, and that she would be a cripple for life. We used means to subdue the swelling and inflam- mation, &c. She can now walk, though not as well as formerly, and the foot of the fractured leg turns considerably outward* Case 269. Mrs. Chase 18 Stanton-street, was confined to her bed a length of time, with great inflammation, and swelling of the whole leg. It was excessively painful, and so much impaired her general health, that her recovery seemed very doubtful. Her former physician she stated, had only injured her. By submitting to our treatment, she recovered. Small Pox. Case 270. The son of Mrs. Holmes, Forsyth-street, was seized so bad with the small pox, that he became delirious, fever and pain vio- lent. Medicines were given to throw the eruptions to the surface, and when they appeared, he was relieved. In a very short time he was well and enabled to return to his business. Incipient Apoplexy. Case 271. Mr. Campbell, 24 Stone-street, was taken suddenly with a determination of blood to the head, senses gone, coldness of the extremities, &c. We used warm and stimulating applications, which recalled the blood to the surface of the body ; these means afforded re- lief, and soon effected a cure. He has been well for several years, whereas, under the treatment of his former physicjan he had a frequent return of the complaint, and was often bled for it. Case 272. I was requested by Mr. Lane, to visit one of his children, aged sixteen months. He informed me that it had been unwell nearly three months, during which time Dr.----, had regularly attended it, without affording any relief. He said he was fully convinced that the child had the consumption, that medicine would be of no benefit to it, and that in calling me, he was actuated more by a sense of duty, than a hope of saving the life of his child. From what I could learn, from the present symptoms, and a history of the case, the child was evidently labouring under a severe attack of morasmus, (or infantile remittent fever,) and that much aggravated by 522 Illustrations. improper treatment. Digestion appeared perfectly at a stand, the food passed off without undergoing any change, but what would naturally result from its exposure to heat and moisture. The fceces altogether void of their natural smell and appearance, the appetite entirely gone. Emaciation had gone on so rapidly that there was not sufficient strength left, for the child to turn itself in bed; the cheeks had fallen in, the eyes were glassy and sunk in their sockets, the skin was re- markably pale, except when reddened by the flush of hectic fever. Under these discouraging symptoms I deemed it an almost hopeless case, but feeling anxious to test the efficacy of the reformed practice, I commenced a course of treatment, and in four weeks it produced an as- tonishing change in the patient. His flesh became clear and natural, the cheeks were more full and less pale, the appetite was improved, and in fact every bad symptom was subdued: Three months from the time I commenced treating it, I found the child in the enjoyment of better health than it had ever before experienced. Case 273. This was a female aged nine years, labouring under acute dysentery, in its most aggravated form. The patient had been confined between three and four days, and consequently very much exhausted. Prompt and energetic treatment restored her to health in a few days. Case 274. This was a case of enteritis, in its most severe form. The patient was aged three years, and had been generally healthy, (except at nine months old it had the small pox.) The symptoms were too plainly marked to mistake the disease. The pulse was quick, hard, and resisting, the tongue white, a streak of black down the middle, se- vere pain in the umbilical region, sickness of the stomach, and vomit- ing, the bowels costive, great restlessness and tossing of the arms. Two physicians were requested to visit it, and both pronounced the case a hopeless one, yet the reformed treatment proved victorious, and the child was completely cured without the use of the lancet. Case 275. This was a child aged eighteen months, exhibiting all the symptoms of pneumonia, or inflammation of the lungs. Respira- tion was extremely difficult, and an almost incessant cough, mucus accumulated so rapidly in the trachea, as to greatly endanger the life of the patient, expectoration was suspended, and the patient was thrown into epileptic fits. Tihe abdomen was much distended and tense ; the tonsils were enormously swollen, and great determination of blood to the head. This case was also cured without bleeding. Chronic Diarrhoea. Cas"e 276. The patient was a married lady, about thirty-six years of age, she had been confined about two weeks, and was so much redu- ced, as not to be able to sit up in bed. The fourth day after she com- menced taking medicine, she was able to leave her bed without assist- ance, and in one week more was perfectly cured. Case 277. Were children of Mr. These children were se- Illustrations. 523 verely afflicted with apthai or thrush. Their mouths and tongues were completely covered with the eruptions, and the breath so foeted that it was extremely disagreeable to remain near them. They were all cured in a few days. During the month of October, I attended about twenty-five other cases, and with universal success. SAMUEL M. OLDEN. Student of Medicine. Another student, S. B. Merrill, attended during his residence at the institution, several hundred patients, many of which were afflicted with diseases of the most virulent character, and the same success attended his practice. The other students of the " Medical School," connected with the infirmary, have attended several thousand cases with the same inva- riable and universal success. Hydrocephalus. Case 278. A child of Mrs.----, No. 170 Rivington-street, between four and five years old. Symptoms, fever, restlessness, nausea and vomiting, bowels relaxed, stools of a dark colour, and very offensive, pulse quick, pupil of the eye very much dilated, intolerance of light, tongue furred, appetite impaired, skin dry, pain in the head, and ex- tremely hot, she would throw her head back and shriek or cry out without, any perceptible cause, lethargy, Sec. She had been ill and rapidly growing worse, for about four days, when I was called. She was when I first saw her in almost a hopeless condition, so bad indeed that her life was despaired of, and her mother and friends imagined her dying; but the following treatment cured her, and she is to the best of my knowledge now perfectly well. I commenced with purga- tives, the neutralizing physic to regulate the bowels, afterwards the bilious physic, cooling washes to the head, put the feet in warm ley water, and bathed the surface, gave the sudorific tincture, but it did not agree with her, I then gave, to keep up a gentle diaphoresis, the amaranthus. This treatment was repeated for about five or six days, when I gave the digitalis and spearmint, and finished with restorative cordial, which performed a perfect cure. Ibid. Stricture of the Uretka. Case 279. Thomas Parker, 147 Christie-street, affected with a bad stricture of the uretha, the bladder very much distended, no urine voided for several days, the operation of puncturing the bladder was proposed to the patient by several physicians, in consultation, but they were refused, and immediate application made at the Infirmary ; a phy- sician attended, who commenced treating it on the reformed system, and in a short time he obtained relief, and was discharged cured. Inflammation of the Eye. Case 280. Margaret Wade, was seized with a severe pain in the es, great swelling and inflammation, after a while she became blind, Vol II. 3 S .524 Riustrations. she then applied to the eye infirmary. The attending physician prescri- bed seven weeks without any good effect, the pain was so great at this time as to cause delirium ; she was then placed under our charge ; the first application produced relief, and all the symptoms gradually subsi- ded ; in ten days her sight was restored, and in two weeks she was en- nabled to walk the streets, and attend .to her usual business, Case 2S1. Thomas and Elizabeth Taylor, aged seven and five years, were placed in the New-York AlmsHouse, and were shortly seized with sore eyes, so swelled and inflamed, constantly discharging matter, that they became blind, and continued so for two months, suffering with extreme pain; they were obliged to lay on their faces continually, to avoid the light; even in this position, if the windows were opened it would cause the most excruciating agony. All the treatment of the physicians afforded no relief; so deplorable was their condition, that the superintendant advised the mother to remove them; accordingly they were placed in our infirmary. Under our treatment the swelling gradually subsided, the discharge soon ceased, and in a short time they could see as well as ever. Opthalmia. Case 282. Henry Ogden Seavy, aged five years, was brought to the infirmary from the Alms House, by Alderman Whiting. The com- plaint was opthalmia. It was pronounced by one of the physicians, (a member of the board of Aldermen,) to be a " deep seated case." The tunica conjunctivia, or external coat of the eye was much infla- med, purulent matter was constantly discharging from the eyes, the lids of the eyes were also inflamed and swollen, as well as the sur- rounding integuments. The head also was affected with a preterna- tural degree of heat. He was received at evening, and before an op- portunity offered of giving relief, all the symptoms were much in- creased ; the upper lids projecting so far over the lower, that they could not be opened. Cooling lotions, and other means were now ap- plied to his eyes, and about 12 o'clock the next day his eyes were open- ed, and the applications through the day checked in a considerable de- gree the purulent discharge. In the morning, after having applied emohent applications through the night, the swelling was rather less, and the eyes were opened several hours earlier than the preceding morning, though they had been much aggravated by crying, still no very visible change for the better had taken place. The whole system seemed to participate in the virulence of the disease, proving beyond a doubt that the fluids were contaminated. An alterative course of treatment was now rigidly adhered to, with a view to excite a healthy action ; soon as the constitution was fairly brought under the influence of medicine,^ very visible and striking change took place. The boy recovered from that apathy and depression of spirits and became cheer- ful and sprightly, the swelling, inflammation, and discharge gradually subsided, and in a short time he became as well as ever. Illustrations. 525 Gastric Spasms and Convulsions. Case 283. John Smith, aged twenty-six, residing in Ludlow-street, No. 11, was seized suddenly with violent gastric, spasms and convul- sions of the whole body, caused by drinking cold water to excess. The convulsions were so great that it took six men to hold him. A com- mon practitioner was called, who immediately bled the patient, and prescribed some other medicines, under the use of which he was evi- dently failing fast. His friends being very much alarmed, sent to the United States Infirmary for a physician, who found the man to all ap- pearance dying, his pulse was hardly perceptible at the wrist, the ex- tremities cold, and life almost extinct. The treatment was immedi- ately changed, which produced the most immediate salutary effect. He soon began to show signs of returning life, and in three hours the symptoms were all allayed, so that in a few days he was enabled to return to his usual avocation. Scrofula. Case 284. Mrs. Sniffin of Ludlow-street, requested attendance from the Infirmary, for her son, aged four years and a half. Found the boy with symptoms as follows : a variety of glandular swellings, tumours on the neck, a large tumour on the front of the right shoulder, near the arm pit, also one on the back part of the left shoulder, near the same place, the size of a hen's egg, painful and much inflamed. A large abscess formed, broke and discharged a large quantity of icho- rous matter, mixed with curdy flaks. The right leg he was unable to straighten, the knee largely swelled, much inflamed, and very painful. Tumour on the back part, in which suppuration took place. The left leg was also much enlarged about the knee, painful, with symptoms of white swelling. A part of the abdomen above the left groin, the big- ness of a saucer, was indurated or hardened, and projected in form of a tumour. Violent pain in the right side, and shoulder. Constipation of the bowels, loss of appetite, suppression of urine, cough, hectic fe- ver, and night sweats. He was perfectly cured in seven weeks. Case 285. Mr. Cline, residing in Catherine-street, had a long time been afflicted with a deep seated cough, pronounced consumption, had been attended by two physicians, and abandoned the case as incurable, the treatment pursued completely restored his health. Case 286. Mr. Outwater of New-Jersey, reduced to a low and dan- gerous state by an attack of bilious remittent fever, which had degene- rated into the typhus; his physicians were administering to him Dover's powder, combined with mercury. Stomach, liver, and whole systeti in a morbid and diseased state, reduced so low, that his recovery was considered doubtful; after the first portion of medicine was given, he grew better, and from that time he recovered rapidly, and in two or three weeks he became wwil. 526 Illustrations. Case 287. Mr. Coles Tompkins, was seized last summer with the bilious remittent fever, under the attendance of two or three physicians, he constantly grew worse; in this situation we were called to prescribe, and our treatment soon cured him. Case 288. A child of Mr. Avery, broke its arm immediately above the condyle of its elbow, the upper bone nearly protruded through the integuments, the usual dressings were applied, with the angular splint, and in two weeks the child could use its arm. Case 289. Mr.----, had a fleshy tumour on the leg, which grew until it became very large, the usual applications removed it. Case 290. Mrs. Hozier, of Williamsburg, L. I. had been a long time afflicted with fever cough, debility, hectic fever, and night sweats, and considered incurable by her attending physician, who pronounced her disease the consumption. She had been bled, blistered, and taken mercury without any beneficial effect. After changing the treatment, and prescribing vegetable agents, she began to improve ; and at the present time she is free of all the former symptoms, and has resumed her usual business. Treatment: The treatment in one particular differed from that laid down under the head of pulmonary consumption. 1st. The pulmo- nary balsam was given. 2d. Tincture of foxglove, to lessen arterial excitement. 3d. Elixir of vitriol to aid in checking night sweats. 4th. A syrup made of liverwort, and the rock polypod, and given alter- nately with the other. 5th. A pill was given composed of the yellow pine turpentine, as it exudes from the tree, containing about three grains each. 6th. For drink, equal parts of milk, warm from the cow, and hot water drank freely. Fistula. Case 291. Mr. Washington Lewis, Chatham-square, was attacked with a fistula, excruciating pain, great swelling and inflammation. An abscess formed near the rectum, which was extensive, and through w.hl£h issued great quantities of pus or matter. He was confined to his bed or room for months, during which time he was attended by two other physicians, or surgeons of this city. A very formidable opera- tion was performed, two or three times in succession without effecting a cure. Under these circumstances he applied to the infirmary, and submitted to our treatment, when he began to grow better, and after a tew months the fistula was healed, and he now enjoys excellent Rlustrations. 527 AFFIDAVITS OF MEDICAL CASES* John Wright, being duly sworn, deposeth and saith, that, in the year 1826, while residing in Sandy Hill, Washington county, state of New-York, I was seized with a very excruciating pain, and great in- flammation in my eyes. I was attended by a great number of physi- cians, in all, not less than twenty or thirty, during a period of four years. Some pursued one course of treatment, and some another. I was bled several times, had my eyes scarrified, took large quantities of salts, was salivated until my teeth were loose, and my tongue very much swollen, and my general health very much impaired. I was re- peatedly blistered, cupped, leeched, and had a seaton introduced in my neck. Part of the four years, while submitting to this course of treat- ment, I was partially or totally blind. My pain and sufferings were very exquisite throughout my whole head, temples, and eyes; the heat, swelling, and pain were so excessive, that I was obliged to keep the parts continually wet with cold water; to obtain the least mitigation of the symptoms ; such, indeed was my distress, that my life became a burden to me. During a part of this period, I was attended by some of the most noted physicians in the city o( New-York. They continu- ed to attend me, until they appeared to abandon my case as hopeless. The last physician, seeing that his treatment was of no use, recom- mended me to apply to Dr. Beach, remarking at the same time, that he would help me if any physician could. At this time, when all hopes had nearly failed, I placed myself under his care, and found, be- fore much time elapsed, a change for the better. My pain, and all the unfavourable symptoms, in less than a week began to subside. In three weeks I could, distinguish objects, in two months I was enabled 'to leave my house and. walk the streets without any one to lead me. The discharge from the eyes, and the opacity or film, gradually ceased and disappeared; and they continued to grow more healthy, until in a few months from the time I placed myself under his treatment, I was enabled to commence business, which I have continued ever since; four or five years having passed without my being able to perform any kind whatever, or even to walk without being led. JOHN WRIGHT. Subscribed and sworn before me, this 7th day of June, 1S31. Ebenezer Whiting, Commissioner of Deeds. Henry Weed, being duly sworn, deposeth and saith, that about the beginning of March last, my wife Margaret, was seized with a severe pain in both her eyes, ;great swelling and inflammation succeeded, till in a short time, total blindness was the consequence. I then placed her under the care of Dr. Delafield, of the Eye Infirmary, who made various applications and prescriptions for some weeks, without any benefit; but on the contrary was continually growing worse. The pain was so severe that she became delirious. I then applied to Dr. Beach, who commenced a different course of treatment. His first ap- plications produced relief, and all the symptoms gradually subsided, • Tbr^ affllaviw were t&ksn atth* re^a*1 of AUterman Vfhi'.mg, for a particular ofc fo«t 528 Illustrations. until she was free from pain. In the course of one week or ten days she could discern objects. In three weeks she was enabled to leave her bed and walk the streets, and soon after resumed her usual busi- ness. HENRY WEED. Sworn before me, this 3d day of June, 1831. Ebenezer Whiting, Commissioner of Deeds. Denis Hanan, being duly sworn, deposeth and saith, that about five or six months ago, my child, aged seventeen or eighteen months, was severely afflicted with pain, swelling, and inflammation of its eyes. Shortly after, I applied at the Eye Infirmary, corner of Broadway and Grand-street, and placed it under the treatment of the physicians of that institution, for about six weeks. The child's eyes however did not mend, but the symptoms still continued, until I feared that irreco- verable blindness would follow. I then applied to Dr. Beach, and pla- ced the child under his treatment. I soon perceived a great improve- ment, which continued till the child recovered its sight. DENIS HANAN. Sworn before me this, this 3d day of June, 1831. Ebenezer Whiting, Commissioner of Deeds. Elizabeth Taylor, deposeth and saith, that in the year 1829, two of my children, Elizabeth, aged seven, and Thomas, aged five, were placed in the New-York Alms House. The boy had not remained there more than two wreeks, before he became infected with sore eyes. His eyes were so swollen and inflamed, that he became blind, and continued so for the space of two months, during which term he suf- fered the most excruciating pain ; his agony and distress were very great; he constantly lay upon his face, and even in this position, if the window was opened, he screamed violently. He remained in this situ- ation for two months; all the treatment of the attending physicians af- fording no relief. After my daughter Elizabeth had been in the Alms House for two months, she was seized with the same complaint in her eyes. Her situ- ation had become so deplorable in consequence of the disease, that her nose was lanced to discharge the matter. She remained blind or dis- eased for the space of six months, and so bad had these children be- come that Mr. Burtis, the superintendant, advised me to remove them, stating that he was fearful that they never would get well. I took them home, and then sent for Dr. Beach. At this time they were both blind. • Their eyes were exceedingly swollen, greatly inflamed, and matter continually running from them ; the least light produced the greatest distress. They were obliged to lay upon their faces the greatest part of the time. In about one week after this, my third child took the complaint, and also became blind. The prescriptions and treatment of Dr. Beach, was now adhered to. in a short time {observed some change, the swelling and inflammation decreased, the discharge lessened, and before long they could all see. they continued to improve under the treatment, rill :n about two Illustrations. 529 months, or a less time, they were cured as well as ever, with the ex- ception of weakness. They now appear as well as ever. Another child, boarding with me, also caught the disease at the same time. The mother removed it, and placed it under the care of another physician, and the disease still remains, it having been afflicted for the space of one year. ELIZABETH TAYLOR. Sworn before me, this 6th day of July, 1831. Ebenezer Whiting, Commissioner of Deeds. William G. Boggs, deposeth and saith, that about the first of Octo- ber last I was seized with an inflammation of the eyes, great pain, swel- ling, loss of sight, and discharge of matter. I applied to two physicians who decided that the case was a very obstinate one, and would require a course of mercury, to relieve it, which would take several months. I then applied to Dr. Beach from recommendation, which I received from others, one of whom especially stated, that he had suffered from inflammation of the eyes for two years ; had been treated at the Eye Infirmary for some time, had his eyes scraped or cut without benefit; and after having submitted to the treatment of Dr. Beach, had received the use of his sight; having been prevented from attending to any business for two years. Dr. Beach, when I first applied to him, stated that my case was ob- stinate, but that he could relieve them. I submitted to his treatment, and in seven weeks I again commenced my usual occupation. WM. G. BOGGS, Printer, Office of the Com. Advertiser. Jacob Cooper is a brother-in-law to Wm. G. Boggs, and was seized with the same complaint, which operated in the same manner, or was attended with the same symptoms. I applied to Dr. Beach, and by at- tending to his prescriptions, I received my sight in four weeks. JACOB COOPER, Office of the Com. Advertiser. Mrs. Lucinda Whaley, No. 55 Suffolk-street, deposeth and saith, that Martha Ann Smith, aged nine years, was received into my house, from the Alms House, about four weeks ago, where she had been se- verely afflicted with the prevailing complaint in that institution. When I first took her in charge, the following were her symptoms; her eyes were red, extremely painful, and attended with much swelling during the night, so much matter discharged from the eyes that they became glued together, and could not be opened in the morning, until after two hours washing. Great pain in the head, with an entire inability to bear the light of day. Soon after I received her, fearing that she would lose her sight altogether, I took her to Dr. Beach, who had previously given me great relief when my own eyes were inflamed, he gave me some medicine both to be applied internally and externally, I immediately commenced administering according to his directions, and the next day her eyes were better, the treatment was continued, and in a few days her eyes had undergone a great change. It is now 530 Rlustrations. about three weeks since Dr. Beach commenced his treatment, the child is not necessitated to'wear any shade over her eyes. No speck is left on either eye, and in short, she may be considered as well as ever, save her eyes are a little weak. LUCINDA WHALEY. Sworn before me, this 2d day of July, 1831. Ebenezer Whiting, Commissioner of Deeds. Cholera. Case 298. During my appointment by the Board of Health of this city, there were treatments to over one thousand cases of Cholera, eith- er in the premonitory or confirmed state of the disease. In the first stage of the disease every case was successful, in the second stage the great proportion was cured, and nearly all, except the most malignant cases, and those to which we were called too late. LEONTODON TARAXACUM. COMMON DANDELION. FRONTISPIECE it-.»* APPENDIX, CONTAINING A TREATISE ON THE INDIAN OR SPASMODIC CHOLERA, AS IT OCCURRED AND WAS TREATED IN THE CITY OF NEWYORK, IN THE SUMMER OF 1832, AT THE TENTH WARD MEDICAL STATION, UNDER THE APPOINTMENT AND SANCTION OF THE BOARD OF HEALTH AND CORPORATION. ALSO: A TREATISE ON THE DISEASES OF WOMEN AND CHILDREN. / MALIGNANT, OR SPASMODIC CHOLERA. " This pestilence {says the London Quarterly Review) has, in the short space of fourteen years, desolated the fairest portions of the globe, and swept off at least Fifty Millions of our race. It has mustered every variety of climate, surmounted every natural barrier, and conquered every people. It has not, like the simoom, blasted life, and then passed away : the Cholera, like the small pox or plague, takes root in the soil which it has once possessed." DESCRIPTION. This disease, which has committed such terrible ravages in the old world, has found its way across the Atlantic, and has prevailed to a most alarming extent throughout the continent of America; it has proved one of the most mortal of any other that has visited the human family ;* and although it is in the mouth of every person, the pathology, or nature of it, seems to be very little better understood than it was when it first made its appearance; among the numerous physicians who have been called to treat it, no two of them entertain similar views, or treat it in the same manner. For fifteen years past it has been traversing the globe, spreading over vast districts of country, and cutting down great numbers of its inhabitants; crossing seas and oceans, and travelling by land at all seasons of the year, prevailing alike in the heal of summer, and cold of winter, being subject to no known laws, although usually cold weather destroys it. Sometimes its victim is struck as it were with a thunderbolt, and almost immediately expires. In most cases, how- ever, it manifests itself in its mode of attack more like other diseases. Wherever it comes, it is terrible indeed ; it fills the inhabitants with terror and dismay; " the very sight of the external expression of the unutterable agonies of its victims, appals the strongest nerves;" even physicians, whose feelings, by their profession, are steeled against undue emotions, confess themselves unmanned, and their whole frame to be chilled with horror, when they stand over their suffering pa- tients, feeling as if their own sympathy would inevitably draw them * I have consulted the following authors: Winslow on ChMera Dr. Wm. Ste- phens, Do. Dr. AshM Green, Do. Bruussiiis, Do. Yates. Do. Bell, & Contlee, Do. Leury, Do. O. N. Binaghi, Do. New-York, Cholera Hospital Report. 4 APPENDIX. into the same convulsions, and to the same fate. They say, " We never saw disease on this wise. It is new—it is strange—it makes us wish we were not physicians." Here man finds-himself inclined to fly from the distress of his fellow when he stands most in need of his assistance, stricken with horror at the frightful phenomenon before him. Such are some of the features and effects of this disease which has at length fixed itself on our continent, appearing equally as de- structive here as it has been in the old world. The generic appellative Cholera, is radically derived from a Greek word, which signifies bile. The title was appropriated in conse- quence of one of the most prominent symptoms being either a re- dundant flow of bile into the intestines, accompanied with evacua- tions of a bilious fluid characterizing Bilious Cholera, or a total ab- sence of bile in the intestines, with evacuations of a watery fluid, characterizing Spasmodic Cholera. These symptoms are so com- pletely opposed to each other in the quality of the fluid discharged, that attending to them alone will, in general, preclude the possibility of confounding the two species. The characteristic symptoms of this complaint, are, purging, vomit- ing, cramps of the lower extremities, choleric decomposition of fea- tures, profound alteration of the voice, absence or extreme feebleness of the pul«e, great thirst, non-secretion of urine, general prostration, coldness and discoloration to a greater or less extent of the surface, integrity of the intellectual faculties. HISTORY. Since the Black Plague, says a writer, slaughtered one fourth of the inhabitants of Europe, in the fourteenth century, no pestilence has ravaged the world to such a frightful extent, and with such unap- peasable ferocity, as Spasmodic Cholera. In the short period of fifteen years, it has ransacked Eastern Asia, the Islands of the Afri- can Sea, Persia, Arabia, Mesopotamia, Syria, Russia, and Poland. It has traversed the Grand Duchy of Posen and Gallicia, it has visit- ed Prussia, and Germany. Wherever it has yet appeared, it has sel- * Vr1?"5 Asiatishe Cholera in Russland in den Jahren 1829, 1830, and 1831. Von Dr. J. R. Lichtenstadt, &c. Berlin. 1831. 2.—Die Cholera Morbus; ihre Verbreitung, ihre Zuffalle, &c. Von Dr. Schrn- urrer, &c. 1831. . 3.—Rapport au Ccneeil Superieur de Sante Sur le Cholera Morbus Pestilentiel. Par Alex. Moreau de Jonnes, &c. Paris. 1831. 4.—Memoire sur un Nouveau Tratement du Cholera Morbus, et des Affections Typhoides, &c. Par H. F. Ranque, &c. Paris. 1831. i -5' m 1S£TZ °f lte EPideinic Spasmodic Cholera of Russia, &c ; by Bissit Haw- kins, M. D. &c. London. 1831. 183TCh°lera 5 ^ NatUrC' °aUSeS' and Treatment> &c- By C. Searle. London. • 7'~"fuapeTS "JPH'T? t0 the disease calIed Cholera Spasmodica in India, now prevail- Hnnn, ™K,n%^ £Ur0PM ?rin*?d b? authority of the Lords of His Majesty's Most Honourable Privy Council. London. 1831 TuruTTri83ai° dellC Varie SpCCie di Ch°Iera Morbus: DiMichele Buniva, M. D. CHOLERA. 5 dom destroyed fewer than one-third of the diseased; in general it is fatal in proportion of one half; and not unfrequently three-fifths, two- thirds, and even six-sevenths of the infected have perished. Little respect has been hitherto paid to any country which it has'invaded, whether insular or continental; whether distinguished for its salu- brious or pestilential character. It has traversed the burning sands of Arabia as rapidly as the banks of the Euphrates; Caucasus and Mount Ararat, in common with the jungly marshes which are periodi- cally bathed in the waters of the Ganges; and although the number of the healthy whom it has infected, and the number of the infected whom it has destroyed, considerably vary with the density, health, and habits of the population, the Tartar and the Turk, the Indian Na- bob and the Persian Prince, have indiscriminately suffered. It is, therefore, most desirable that something precise and authentic should be more generally known of the character and causes, rise and progress, symptoms and treatment, of a scourge so extensive in its range, and so mortal in its influence, that it may appear how far the means of checking its further progress lie within the exercise of human skill; and the treatment found best adapted for its cure, may be fully under- stood. Some such information it is our present object to convey, and no source of intelligence which lay within our reach has been ne- glected. Cholera is a disease which has been long known and fully describ- ed by many authors ; but until about the middle of the seventeenth century, neither its prevalence nor fatality was such as to invest it with the character which it now wears. As it usually appeared dur- ing the heat of summer and the fruit season, it was very generally ascribed to an elevated temperature and the immoderate use of fruit; but although it was occasionally violent, its ordinary features were by no means alarming. Sydenham says that it appeared in an epidemic form in England during the summers of 1669 and 1676, and that its symptoms were so severe, as to " frighten the bystanders, and kill the patient in twenty-four hours." According to Le Begue de Presle, it prevailed in 1762 in Bengal, and caried off 30,000 negroes and S00 Europeans. Dr. Paisley mentions it as being at Madras, in 1774; in 1775 it seems to have invaded the Mauritius ; and in 1781, a di- vision of Bengal troops were attacked by it so fiercely at Ganjam, that 5,000 were admitted into the hospital during the first day, and by the end of the third, the half of the entire corps were ill. Men, previously in perfect health, instantly dropped dead upon the ground, and few survived the first hour, who did not ultimately recover. In 1780, during a festival at Hurdwar, it destroyed 20,000 people; and in the records of Madras it is stated to have raged at Arcot, in 1787, as an epidemic. It is, therefore, erroneous to maintain, that this pestilence made its first entree into notice in 1817; for with the exception that the eva- cuations are described as " mostly" bilious, in the Cholera of Arcot, whereas in the present epidemic they are " always" watery, the symptoms of both affections are precisely the same. Trallian divides Cholera into the bilious diarrhoea, the bilious Cholera, and the Chole- 6 APPENDIX. ra without bile; and as Dr. Johnson observes that this disease assumes every degree of violence from the mort de chien, in which nothing but phlegm is ejected, to an ordinary Cholera, in which the ejections are principally composed of bile, it is not unreasonable to infer that the Cholera of 1817 is only an aggravated form of a disease which had ex- isted previously. The Brahmins have long since described a malady which they call Vishuchi; and the Japanese a similar affection which they call Senki; both of which have a very striking resemblance to Spasmodic Cholera ; and certain it is that Sydenham, whose accuracy of observation is well known, never alludes, in his description of the severe form of Cholera which he witnessed, to the existence of bile in the evacuations, merely calling them " pravi humores," or bad humors.* * Cholera. [Noticed by Curtis, in 1782.] From this period, up to the year 1787, and perhaps even to 1790, the Cholera would appear to have existed epidemically, in various parts of India. Curtis states, that the fleet, in which he served, joined Sir Ed- ward Huges's squadron at Madras, in the beginning of 1782; in May of that year, his ship, the Seahorse, arrived at Trincomalee, and he says, " The mort de chien, or cramp, I was also informed by the attending surgeon, had been very frequent and fatal among the seamen, both at the hospital and in some of the ships, particularly in the Hero and Superb." The Seahorse had no case of the disease till the 2lst of June, when between that day and the 25th they had eight cases. " In every one of the eight cases the symptoms were so much alike, both in order and in degree, that a description of any one would answer almost equally well for every other. Any difference that took place was in the suddenness of the attack, or the rapidity with which the symptoms succeeded each other. In all of them the dis- ease began with a watery purging, attended with some tenesmus, but with little or no griping. This always came on some time in the night, or early toward morning, and continued some hours before any spasms were felt; and slight affections of this kind being very common in the country, the patients seldom mentioned them till they began to be more severe, and extended to the legs or thighs. This purging soon brought on great weakness, coldness of the extremities, and a remarkable paleness, sinking and lividity of the whole countenance. Some at this period had some nausea, and retching to vomit, but brought up nothing bilious. In a short time the spasms be- gan to affect the muscles of the. thighs, abdomen, and thorax, and lastly they passed to those oi the arms, hands and fingers; but I never saw, then or afterward, those of the neck, face, or back, at all affected. The rapidity with which these spasms suc- ceed the first attack, and their severity, especially as affecting the muscles of the tho- rax and abdomen, denoted in general the degree of danger in the case. The affec- tion is not, as in tetanus, confined to a single muscle, or to a certain class of muscles only. Neither does it, as in the spasmus clonicus, move and agitate the members. It is a fixed cramp in the belly of the muscles, which is gathered up into a hard knot, with excruciating pain. In a minute or two this relaxes, is again renewed, or the af- fection passes to others, leaving the miserable sufferer hardly an interval of ease: and, lastlv, it passes from one set to another; from those of the inferior extremity to those on the upper parts, leaving the former free. The patients complain much of the pain of these cramps ; think they obtain some relief from friction of the parts, and cry to their companions to rub them hard. As the disease proceeded, the countenance became more and more pale, wan, and dejected; the eyes became sunk, hollow, and surround- ed with a livid circle. The pulse became more feeble, and sometimes sank so much as not to befell at the wrist in. two or three hours after the spasms came on. But so long as it could be felt, it was but little altered in frequency. If the spasms happened to intermit, it would sometimes rise a little, and the countenance assume a better look. The tongue was generally white, and more or less furred toward the root; the pa- tients had all great thirst, or rather a strong desire for cold drinks ; but there was no head-ache or affection of the sensorium commurce throughout. " The coldness of the extremities, which was perceptible from the very first, conti- nued to increase, and spread over the whole body, but with nomoisture in the skin till the severity of the pain and spasms forced out a clammy sweat, which soon became profuse. The hands now began to put on a striking and peculiar appearance. The CHOLERA. 7 But however this may be ultimately settled, a very malignant form of this disease suddenly appeared on the 28th of August, 1817, at Jessore, a town situated about one hundred miles north-east of Cal- cutta. From twenty to thirty died daily, and although the inhabi- tants became at length terrified, and deserted their habitations, 6,000 perished in the short space of a few weeks. It rapidly spread through the neighbouring country to Dacca, Patna, Dinnapore, and Nuddea. In September, it reached Calcutta, and since that time the metropolis of British India has been regularly invaded by it during every suc- ceeding season. In November, when the English army were pre- paring to go out to battle with the Hindostan chiefs, it attacked its central division, and in ten days destroyed 764 officers, and 8,500 men. From Calcutta it travelled westward to Bahar, and from Bahar northward to Benares, Lucknow, Cawnpore, and Delhi. It then di- rected its course southward to Agra, Hussingabad, and Nagpore. From Nagpore it again struck off in a south-west direction to Aurun- gabad, then to Panwell and Poonah; and by the second week in Sep- tember, 1818, it took up its residence in Bombay, on the western, coast of the Indian Peninsula. Notwithstanding this rapid journey from Jessore to Bombay, it was equally active in its movements along the Coromandel coast, in reaching Madras; for, while it was shooting northward from Jessore to Dacca, it was at the same time penetrating southward to Chita- gong. By the 20th of March, it had entered Ganjam, it reached nails of the fingers became livid, and bent inward: the skin of the palms became white, bleached, and wrinkled up into folds, as if long soaked in cold water ; the effect, no doubt, of the profuse cold sweat, which is one of the most pernicious and fa- tal symptoms of the disease, both from the effect it has in such a climate, of exhausting the strength, and in abstracting heal from the system. In some of the present cases, and in many others after this, we had recoveries from the severest degrees of spasmo- dic affection; even where the pulse had been for hours completely lost at the wrist, and the body perfectly cold; but never of any who had these profuse cold clammy sweats, and where the hands had put on this appearance. " All this while the purging continued frequent, and exhibited nothing but a thin watery matter or mucus. In many, the stomach became at last so irritable, that no- thing could be got to rest upon it; but every thing that was drank was spouted out im- mediately ; without straining or retching. The countenance and extremities became livid, the pulsations of the heart more quick, frequent, and feeble; the breathing be- gan to become laborious and panting; and, in fine, the whole powers of life fell under such a great and speedy collapse, as to be soon beyond the power of recovery. In this progression, the patient remained from three to five or six hours from the accession of the spasms; seldom longer. These began at last to abate, but with more internal op- pression, great jactitation, panting and gasping for breath, from the diminished action of the respiratory organs; for there were no marks of oppression or effusion on the lungs ; and the motion of the heart, so long as it could be felt, became more and more quick and irregular, till death came at last to the relief of the miserable sufferer. Some- time before that event took place, the spasms gradually abating, left the sufferers en- tirely, and so much possession of their faculties did they retain, that they would con- tinue to talk sensibly to their messmates to the last moment of their life, even when the whole body had become perfectly cold, and all pulsation of the heart had ceased for a long time to be distinguishable. "About the middle of July, 1782, I entered on duty at Madras hospital. Here, again, I had occasion to see many more cases of the mort de chien. It was frequent in the fleet in the month of August, and beginning of September, the season at which the land wind prevails on this part of the coast. We had some cases in the hospital in the end of October, and in November after the monsoon, but few in comparison." 8 APPENDIX. Aska in April, in May it was at Vizianagram, at Mazulipatam in Ju- ly, and on the 8th of October, 1818, it had entered Madras, about a month after its appearance at Bombay. Now, when it is considered that during the winter months the cold had rendered it inactive, it will appear that this pestilence traversed the whole Peninsula of India, or about 66,000 square leagues in less than a year. It is not our intention to enumerate and describe the various irrup- tions which Cholera has made from that period to the present time in British India; suffice it to say, that with the exception of the winter seasons, it has unceasingly preyed upon their Eastern settlements. Toward the close of each November, it only hybernates to rest, that on the approach of spring it may burst forth afresh to repeat its inju- ries ; and, although it has thus swept, with the besom of destruction, its towns and its rivers upward of fourteen times, it still finds fresh victims for the slaughter, and it still betrays a poison as malignant as ever. Even the inferior animals are said not to be exempt from its influence. On its first appearance, a great number of cattle died in the most extraordinary-manner, in the grand army of India. During the October of 1827, many of the dogs in the streets of Calcutta were attacked with Cholera symptoms and killed. Mr. Chalmer observes, that in the towns near the hills, where the epidemic was so fatal, a disease occurred among the cattle, which kept pace with, and often exceeded in mortality that of the human species. Ac- cording to Dr. Ranken, goats and camels died of it in Rajputana: and it would appear that at Vercelli, in Italy, the same phenomena sometimes occur, when the ordinary Cholera is more than usually se- vere. Mr. Searle examined some ducks, which he was convinced died of the Cholera, and he found in their stomach and bowels the same appearances which are discovered in the human subject after death. A few months after its first appearance at Jessore, and while it was travelling through the northern provinces, it began to ravage along the eastern shore of the Gulf of Bengal; and in 1819 it reached the kingdom of Arracan. From Arracan it extended itself into Siam, and after destroying 40,000 in Banku, the capital of that kingdom, it passed into the Peninsula of Malacca. In October, it en- tered the Islands of Sumatra, and Penang; Java and Borneo after- ward suffered; Canton was attacked in 1820, and at Pekin its mor- tality was so frightful that the government were obliged to have the dead interred at their own expense. From China it passed to the Philippine and Spice Islands. Thus, in little more than two years did it traverse a space in Eastern Asia, which, from north to south, is not less than 1,300, and from west to east about 1,000 leagues in dia- meter. Two months after Cholera entered Madras, it travelled along the eastern shore of the Peninsula, through Arcot to Palamcottah, from whence it traversed the strait, and entering the province of Jaffna, which is opposite to Palamcottah, it penetrated into the capital of Cey- lon, which is situated in the very centre of the island. About the same period, the Mauritius was attacked; and on the 14th of Janua- CHOLERA. 9 fy, 1820, it appeared at the town of St. Denis, in the Isle of Bourbon, which is only forty leagues south-west of the Mauritius. In July, 1821, it betrayed itseii ut Muscat, on the southern extremity of the Arabian Peninsula. The neighbouring islands of Ormus and Kishme, in the mouth of the Persian Gulf, were shortly afterward infected : by August it had ascended along the eastern coast of Arabia, as far as the island of Bahrein); and not long after, it entered Bassorah, on the northern extreir tty of the Persian Gulf. Opposite the little island of Ormus, is the po/t of Bender-Abassi, in Persia, the principal sea- port town in which the Persians conduct commerce with British India. The Cholera broke out here with so much violence, that the bazaars were closed, and th» deud left unburied. Those who escaped its first onset, abandoned their houses, and sought for safety in flight. Shiraz, which is about 100 leagues north-west of Bender-Abassi, manifested symptoms of the pestilence in September, and during the first nine days, 4,500 persons jerished. Yerd afterward suffered, and by the time the disease had reached Ispahan, the cold season had so far advanced that its severity wss much lessened, and it soon wholly disappeared. On the recommencement of spring, however, it developed itself afresh, and spreadiig from Ispahan, where it had wintered, round the contiguous Persian provinces, it visited in succession, Kermanshah, Cashan, Khom, Casbin and Tauris, following, as it invariably did, whether in Asia or Europe, the great commercial lines of national in- tercourse. At Tauris, 4,800 perished in the short space of twenty- five days, when it left the town, and travelled on through Khaz, Eri- van, and Kars, to Erzeroum on the southern shore of the Black Sea. The prince royal cf Persia had driven the Turkish army into this town, in the month of July; but immediately after his victory, Cho- lera broke out with such devastating fury among the Persian forces, that from thirty to forty died daily, and the soldiers became so dispi- rited that they precipitately retreated, and left the prince with his mi- nisters to sign an armistice at Khoe. Before the disease quitted Bassorah, in 1821, from 15,000 to 18,000 of its inhabitants were destroyed; and so dreadful was the havoc which it made in the surrounding country, that Dr. Meunier says the third of the population fell before it. At Bagdad it was so prevalent that a Persian army, which was marching against the town, were compelled to withdraw, but were pursued by the pestilence, and among the other losses which it sustained, their commander fell. In the spring of 1822, it appeared between the Tigris and Euphrates; in July it attacked Mosul, which is about sixty leagues north of Bagdad, and then travelling more westward, it passed through Merdine, Diar- bekir, Orfa, Biri, and Antab, on its way to Aleppo, in Syria, which it reached in November. During the winter, as usual, it lay dormant, but in the spring of 1823 it revived, and visited Latakia, Antioch, Tortosa, Tripoli, and other towns on the borders of the Mediterranean sea. By the end of July it had advanced in the direction of Sarkin, Arsous, Khankaramout, and the Gulf of Alexandretta ; and passing over the high mountains of Beylam, it entered the towns of Adena and Tarsous. In 1824 it appeared at Tiberias in Judea. 10 APPENDIX. Thus have Arabia, Persia, Mesopotamia, and Syria, been overrun by Cholera in little more than two years; traversing every species of country, from the arid deserts of Irac-Arabia, to the succulent banks of the Euphrates, and depopulating almost every village in its path, with a pertinacious obstinacy which human skill was seldom able to overcome. It will be seen that the disease, during this journey, took two distinct routes through these countries, which it prosecuted with equal energy. By the one it penetrated Arabia, attacked Bassorah, ascended the Euphrates, ravaged Mesopotamia, and finally appeared in Syria, where it committed frightful havoc among the towns skirting the Mediterranean sea. By the other it travelled through the very centre of Persia, until, in 1823, it reached the shores of the Caspian. Early in September, 1823, it entered Astracan, a large and popu- lous town seated on the northern shore of the Caspian, at the mouth of the Volga. The Russian fleet were first infected, but 216 persons were all who fell ill, and of these 144 died. As soon as it became known to the Russian government that Astracan was invaded, they despatched a medical commission, composed of six physicians, to in- vestigate its character ; a physician was sent into Persia with the same view; a Board of Health was established at Petersburg, and every exertion was made to prevent its extension farther north. How far such preventive measures were connected with the result, it may be difficult to decide; but certain it is, that the disease got no farther in that direction that year than Astracan, and did not again appear in Russia until toward the close of 1828, when it unexpectedly entered the town of Orenburg, as is supposed by some through the caravans which came from Upper Asia, and by others, through the Kirghis- Cossacks, who neighbour Orenburg, and are said to have been infect- ed by the disease. As the cold season commenced shortly after its appearance, the mortality which it occasioned was not great until the spring of 1829, when it raged with great severity, both in the town and neighbourhood, and entered the forts of Rassyphaya and Isetzk. On the 31st of July, 1830, it again appeared in Astracan ; by the 10th of August, 1,229 were ill, of whom 433 died ; and by the 27th, no fewer than 4,043 within the town, and 21,268 throughout the province of which it is the capital, perished. After committing this unprecedented destruction, it pursued a north-west course along the banks of the Volga, making tributary to its power the populous towns of SaratofT, Penza, Samara, and Kazan. Kazan it reached on the 5th of September, and on the 26th of the same month its symptoms were first detected in Moscow. The town was immediately divided into forty-seven compartments, which were separated from each other by a cordon sanitaire ; ten temporary hospitals were erected, and Count Zakrewski, the Minister of Interior, was appointed by the Emperor to superintend these protective arrangements. The Emperor Nicholas himself visited the town when the disease was at its height, and when he left to go to Twer, by submitting to a quarantine of eight days, he gave an example of obedience to the sanatory laws. During the first ten days of October, 747 died; from the 10th to the 20th, 958 CHOLERA. 11 perished; and from the 20th to the 31st, 1,284 sunk under the disease. At first the mortality was as great as nine-tenths ; it afterward dimi- nished to seven-eights, five-sixths, three-fourths, one-half, and ulti- mately to one-third. During even the winter months, which had been hitherto a complete specific against its progress, when all the rivers were covered with ice, it carried on its works of death ; but the num- ber who were infected gradually decreased, and the mortality propor- tionally diminished. Having now travelled so far north, it was almost universally expect- ed that the Cholera would have soon reached Petersburg, and from thence have extended to the shores of the Baltic ; but the capital, at this time escaped, and the disease, taking an almost opposite direction, accompanied the Russians into Poland. During the revolution of July, in 1830, a body of troops were ordered out of the province of Koursk, in the country of the Cossacks, which was then infected, to march against the Poles. These troops, in their passage through Po- dolia, and Volhynia, took with them the disease along their entire line of march. The towns of Astrog, Zaslaf, and Luck were infected; and a few leagues from this latter place the disease passed the Bug, and entered Poland. Lublin was attacked toward the end of March, 1831; by the first of April, the hospitals of Siedlec were filled with Russians laboring under the malady ; ten days afterward it was disco- vered among the wounded at Praga, which is separated trom Warsaw only by the Vistula; and on the 14th it entered the capital of Poland. According to the Central Committee of Health, from 100 to 150 died during the first week, out of every 1,000 sick ; and according to the Berlin Gazette, during thirteen days, ending on the 5th of May, there had been between the town and the camp, 2,580 sick, of whom 1,110 died, and 1,278 still remained under treatment. On the 8th of May, Ostrolenka, Lomza, Szczuczzyn, Drohicyzn, Pultusk, Makow, Nesielskal, and Plousk, were ill; on the 24th it appeared at Polangen ; on the 25th at Riga, and by the 28th, it had reached Dantzic, in Prus- sia, Brody and Lemberg in Austria. On the 26th of June, the dis- ease entered Petersburg; early in August, it appears to have invaded Hungary, and by the beginning of September, it had entered Germa- ny, and Vienna. In this hurried and imperfect outline of the geographical progress of Cholera, we have intentionally avoided to interfere with the narra- tive, by making any observations on its identity in different localities ; on the peculiarity of its habits in following the great thoroughfares of human intercourse ; on its strikingly progressive mode of travelling, and on the probable causes by which it was influenced in its selection of the course it had taken. That the Eastern and Russian Cholera are substantially the same disease, every circumstance with which we are acquainted tends to prove. Those, who have witnessed them both, as Drs. Russel, Schn- urrer and Riecke, do not hesitate to assert their identity ; and whether we consider their symptoms, their mortality, their facility of propaga- tion, their mode of travelling, their habitudes during life, or their pa- thology after death, all demonstrate them to depend on the same mor- J2 APPENDIX. bid causes, and to consist in the same diseased action. Their outset is equally instantaneous and alarming ; their progress is equally rapid and masterless; their termination is equally fatal and appalling. In November of 1831, it was transported from the continent to Sunderland, in England, and from thence it spread to London, Edin- burgh, Dublin, and many other places in the United Kingdoms. On the 30th of March, 1832, 66 cases of Cholera were reported to have occurred in Paris, the capital of France. From that time the disease increased with the most appalling rapidity. April 6th, 370 new cases were reported: 7th 509; Sth to the same hour on the 9th 1020, and from the 10th to the next morning 1300. From Paris the disease spread rapidly in every direction, and in a few weeks made its way into 17 departments of that kingdom. In Paris, not less than 15,000 of the inhabitants were swept off by this disease, and it has revisited many of those places again and commit- ted great mortality. . " Scarcely, says a writer, had the Cholera made its appearance in Pa- ris, before news arrived from all the towns and villages in the neigh- bourhood, to the distance of 200 miles, of the same disease among them; and when it did break out, it was like a sudden and over- whelming flood which swept off hundreds of persons in every situa- tion in life, and in all parts of that extensive city—persons who could have communicated with each other in no other manner than by breathing the air common to all. In the short space of one month more people were cut off by Cholera in Paris, than by the plague of London." The Malignant Cholera first made its appearance upon this conti- nent at Quebec, on the 8th of June, 1832 ; previous to its introduc- tion, there were some remarkable features in the season. It was no- ticed in Canada that an easterly wind prevailed with an intermission of five days only, from the 1st of May to the 10th of June, which in all probability brought the choleric atmosphere from Europe to this country; although the first cases were among emigrants, the situa- tion and state of whom readily accounted for the appearance of the disease in the minds of many. They were in a filthy and crowded condition, and it is stated they were of the lowest description; besides, the Board of Health states that the disease broke out in a low, un- cleanly, and ill ventilated part of the city, crowded with the popula- tion of those emigrants. So prevalent and mortal was this complaint, that in two weeks there were one thousand deaths! previous to its appearance here, dis- eases, as well as the season, assumed a peculiar character; the wea- ther was unusually cold, and the influenza very prevalent, and proved fatal to many. During the winter the scarlet fever prevailed, and proved very mortal; bowel complaints also appeared, such as common cholera morbus and dysentery in the very depth of winter, many of which terminated fatally. The season was throughout very sickly, and the mortality by other diseases great. In the Montreal Herald, fcr June 9, it is stated that the interments from January 1st to June 6th, amounted to 554 for one CHOLERA. 13 parish only. During the whole winter and spring all diseases mani- fested the greatest irregularity, and in April infantile diarrhcea was quite common. There was also sickness of an unusual character in the interior of Canada; for in the Canadian of July 16, there is an account, by a " voyageur," of a disease which appeared among the Indians of Schomonchouan, 100 leagues from the sea, which exhibited all the appearances of Cholera. It was attended with vomiting, diar- rhcea, and cramps, producing entire prostration in four hours. It was treated with uniform success, by a decoction of equal parts of bark, of white birch and the larch fir, given frequently in small doses. At New London, in Connecticut, a disease prevailed in the early part of the spring, which was quite analogous to Cholera in all its principal phenomena, although it was considered at the time to bear a close af- finity to spotted fever, a disease well known in that state. A mode of treatment very analogous to that most approved by experience in cases of Malignant Cholera was also found to be highly successful. It is also stated by Dr. Elwood, of Rochester, N. Y.,* that cases of pneumonia in the winter assumed a typhoid form, so that depletion was not admissible, and in which the patients sunk with rapidity —a circumstance which he has rarely observed during a residence of fif- teen years in that place. Diarrhcea was very prevalent in Rochester and its vicinity from the first of June, that is, for six weeks previous to the appearance of the first case of Cholera. It next appeared at Montreal, and for the following facts we are in- debted to a report by Dr. Robert Nelson, Health Commissioner of that city. "With the month of June diarrhcea showed itself as a common or predominant symptom in every form of disease, and about the first of June there was one case of severe Cholera. But on Saturday the 9th, the malignant Cholera made its appearance as an epidemic. On the evening of that day a passenger was landed from the Voyageur steamboat, sick with Cholera, who died the same evening. It is stat- ed by Dr. Nelson, that during the same night several native inhabi- tants in various parts of the city, remote from the port and from each other, and having no communication with the port or place of landing, sickened, and most, if not all of them, died during twenty-four hours. On Sunday, the 10th, another emigrant from the same boat died. From this time it continued to spread, and soon prevailed universally. In two weeks eight hundred persons had died of it. It continued its progress from one place to another, along the river and lakes, " soon outstripping the emigrants," and early in July had reached Detroit. Without having shown itself at any intermediate spot between Ca- nada and New-York, it appeared in this city about.the last of June. The first known case of Cholera in New-York is that of Mr. Fitzge- rald, an Irish emigrant, who arrived at Quebec in the autumn of 1831. He resided at Albany from September to May, and on the 3d of May took the first floor of a house in Cherry-street near James-street. He was by trade a tailor, and a steady and temperate man. His wife was also a neat housekeeper, so that in this case neither of the most com- mon causes of Cholera, viz. dirt and intemperance, were present. * In Montreal and Quebec, it is stated that about one tenth of the population was ■Wept away by it. 14 APPENDIX. On Monday, June 25, after spending the day at Brooklyn, he re- turned late in the evening, and was taken sick in the night, but was seen by no physician until Tuesday. In a few days he was convales- cent. Early on Tuesday morning two of his children were attacked with the disease, who both died on Wednesday, the 27th. They were seen by many physicians, who considered their symptoms to be those of Spasmodic Cholera. On Thursday, after eating some sour strawberries, the mother was attacked with Cholera, at 12 M. and died on Friday, the 29ih. On the same day an Irishman named O'Neil, was seized with ma- lignant Cholera, and died the next day. He lived in Greenwich, at least two miles from the first cases, and died at the Medical Mansion in Greenwich. He was very intemperate, had been drunk all the week, and had fallen, while intoxicated, into the North River. On Saturday morning, June 30, a man who lodged with Mr. Han- nasy, at No. 15 James-slip, was seized with the disease, and died on Sunday rsorning. He was a temperate man, and was not known to have had any communication with the family in Cherry-street. Ano- ther lodger in the same house sickened and died on Sunday. The keeper of the house and several others were subsequently taken sick and died, either there, or at places to which they were removed. They were all intemperate, were drunk at the time, and the house was most disgustingly filthy. On Monday cases occurred in Water- street near James-street, and on Wednesday, July 4, it had shown itself at various places upon the opposite side of the city. From this time cases continued to multiply daily, and all efforts to trace these cases to any foreign source had thus far been wholly unsuccessful. It subsequently appeared at Albany, and in the New-York state prison, at Sing-Sing, and in many towns throughout the country. It has extended to Philadelphia, Baltimore, Cincinnati, Louisville, New-Orleans, and other places ; in the last mentioned place, two or three hundred have perished in a day; many to whom interment could not be afforded were thrown into the water. The habits of the people, and the locality of the place, caused unquestionably this great morta- lity. It took many off in the space of two hours without any premo- nitory symptoms, and it is very remarkable that the yellow fever pre- vailed there at the same time. CAUSES. 1st. Remote Cause. Whatever diminishes the tone of the system, operates as a remote, or predisposing cause of the Cholera, such as the depressing passions, great fatigue, change of air, derangement of the digestive organs, intemperance, drunkenness and excess in eating, sudden transitions from heat to cold, exposure to the night air, licen- tiousness, and in short, every deviation from universal temperance; but perhaps nothing sooner produces an attack of Cholera than the use of crude fruit and vegetables of every description, as well as every article that readily yields an acid by fermentation. Low and damp situations, either*as regards the quarter of the city, CHOLERA. 15 or the part of the house occupied, local filth and dirt, either of premi- ses or persons. Those who are subject to diarrhcea are very liable to an attack of Cholera. Licentiousness and debauchery are great pre- disposing causes of the complaint. Debility occasioned by watching over persons sick with the disease, often brings on an attack. Breath- ing stagnated, or unventilated air, also powerfully predisposes to the complaint, and residing in low, damp situations, such as cellars. Alderman Palmer of this city, who visited much among the Cholera during the late epidemic, states, that three-fourths of those who were attacked with the disease, resided in cellar kitchens, and houses situ- ated back from the street, where there was very little circulation of air, and most of the cases which we treated at the 10th ward Medical Station inhabited similar places and situations, while those who resi- ded in large and airy houses were nearly exempt from the disease Marsh effluvia, or the air arising from low, marshy places, contri- butes much to the production of this disease. Hence it would some- times suddenly spread from a city even to country places, and towns where the intermittent fever is usually prevalent. This has usually been the case in every part where it has prevailed. But of all the predisposing causes, intemperance, and drunkenness are unquestionably the greatest. It seems, as it were, to have been sent as a special scourge to this unfortunate class of men, and this is readily accounted for, from the morbid state of the liver and stomach which ardent spirits produce. It appears to render these organs alto- gether incapable of resisting the poison of this contagion; hence the victim sinks immediately under it. Testimony, to the like effect, has been borne with wonderful unani- mity, by all the writers on Cholera, not only in India, but in China, Persia, Russia, Poland, Germany, and England. The disease was most widely disseminated, and most deadly in its effects, among the serfs of Russia, who live in the extremest filth, and in habits of beastly intemperance. The houses in which the disease occurred in Moscow, were inhabited by a class of persons extremely poor, habitually filthy, and addicted to intemperance, and who lived in low and damp houses, and in cellars. Many of the chambers only nine feet square, were occupied each by thirty individuals. Every where in Europe, say the best authorities on the subject, the poor, the ill fed, and the ill clothed, and the intemperate, have been the greatest sufferers. The Russian physicians have also adverted to the agency of bad and indigestible food, in the production of Cholera in that country. This is distinctly admitted in the precautionary instructions issued by the Russian and Austrian governments, and by the medical boards in Berlin and Hamburgh, respecting the articles to be shunned as food— they are unripe and watery fruits, beer, hydromel, sour soup, mush- rooms, cucumbers, and melons, sallad, and spoiled fish, and greasy food generally. The sale of cucumbers and watermellons, which were peculiarly abundant in the fall of 1829, was prohibited by the magistrates at Orenberg. In every place in the United States where the Cholera visited, the 18 APPENDIX- mortality among the intemperate and the drunkards was truly appaW ling Although thev were the first to trifle with the complaint, they were its first'and most suie victims; and it is a remarkable fact in the history of this epidemic, that those who disbelieved in its preva- lence, and even ridiculed its approach, were the first and most strik- ing examples of its fatality. But while we have to state the dreadful ravages among this class of men, truth constrains us to state, that it attacked manv that were strictly temperate in every respect. But this peculiar feature of the complaint, seemed to be more marked in some places than in others. _ Similar causes have been assigned for the disease also in Europe, It has been stated on good authority, that in ninety cases in a hundred, in St. Petersburg, the common victims to Cholera were the irregular, the dissipated, those with broken constitutions, and impaired health, the badly fed, the badly clothed, and those who indulge in intoxicat- ing liquors. In London, the places where the Cholera raged were the haunts of poverty, wretchedness, and vice, and its victims were the half fa- mished and intemperate inhabitants of these situations. These con- stituted the fuel which the all pervading flame selected' as the victims of its rage; and wherever they were located in numbers, there the disease prevailed. In Paris, however, it prevailed among all classes, the rich as well as the poor. Among other causes which might be mentioned, are first, certain agents taken for medicine, such as calomel or mercury, any of the neutral salts, rancid caster oil, bleeding, and most of the medicines ordinarily prescribed. Drastic purgatives of any kind have been found to bring on the complaint. " We may add to these agencies," says a physician of this city, their crowded, close, and unventilated habitations, which have consti- tuted a confined and locally infected district, in which the prevailing epidemic exerted a greater activity, and carried off many victims. This has been witnessed at 450 Cherry-street, where fifteen who died of Cholera were taken from one alley ; and in Stagg's Row, in De- lancy-street, where forty-three others fell victims to the disease. Intermediate cause. We have now spoken of the remote, or pre- disposing cause of the complaint. I shall next speak of the interme- diate cause or causes, and which, to me, appears to consist in the agen- cy or influence of a deleterious gas or effluvia mixed with the atmos- phere, and this extends over whole districts of country, showing its effects just in proportion as it finds materials to feed upon. In country places where the air is generally pure, and where there is little or no marsh miasmata, this deleterious state of the atmosphere manifested itself by generating only the premonitory symptoms of cholera, such as nausea at the stomach, derangement of the bowels, &c.; but in those places where there is a large population, filth, un- ventilated apartments, and other predisposing causes, the Malignant Cholera becomes developed in all its features. Hence it appears that when the epidemic visits the country, the inhabitants as well as in the CHOLERA. 17 city breathe the pestilential air alike, and nothing is wanting but some exciting cause to develope its character, and which so fully exists in all our dense populous cities, for which reason it usually prevails in them almost exclusively. " If the state of the atmosphere over the world, at any one time, is equally vitiated by some unknown cause, its effects will first appear in places where that state of air is most powerfully aided by local vitiations, as in cities or marshy grounds." In other places, the exciting causes do not exist, or are not sufficient to bring on an attack of the complaint. The intermediate cause, then, of cholera, is a malaria, or a poisonous gas or gas'ses floating in the atmosphere, inhaled by the lungs mixing with the blood, and contami- nating it with a specific poison. Proximate cause. The proximate cause of this disease consists in an effusion of this poison which has been secreted from the blood through tire* medium of the liver, and is thrown upon the stomach and intestines,iphich by its poisonous quality causes an irritation and in- flammation of the mucous membrane of the alimentary canal; and which is proved by dissection. That the immediate or proximate cause is a poison admits of no doubt; but of the nature of it, we are not prepared to state precisely. It may be a peculiar acid somewhat similar to that which causes the common cholera morbus, but more deleterious or powerful. It appears to lodge in the gall bladder, the structure of which is such that it remains in it for some time with im- punity, seldom or never causing the complaint, except there be a pre- ternatural effusion of it by some of the secretions becoming closed, or by relaxation or debility occasioned by fatigue, drunkenness, or some other predisposing cause. Thus, if I mistake not the contents of the stomach and intestines, will immediately turn the tincture of litmus red, which appears to show the existence of an acid. Be this as it may, we are confident that a most deadly poison is thrown into the stomach and intestines which produces all the symptoms of the disease. This may be proved conclusively by analogy. Certain kinds offish, when eaten, produce almost the same symptoms as the spasmodic cholera, one kind of which, the yellow bill sprat, possesses a poisonous virus almost incre- dible, and has, in several instances, been known to destroy life by ex- citing dreadful convulsions. The Conger eel, and the large white land crabs that feed upon the leaves of the machineel tree, are poisonous, and produce violent Cholera. Certain and rapid death is almost sure to ensue from eating the yellowbill sprat; but from a use of most other kinds of poisonous fish, the* person is seized, after a few hours, with languor, heaviness, and faintness, succeeded by great restlessness, flushings in the face, giddiness in the head, cardialgia, nausea, griping pains in the bowels, and a severe vomiting and purging. Under the supposition that the poisonous quality of the fish before noticed is occasioned by their feeding on the moss which grows on copperas banks, a late writer on the subject tells us, that in the treat- ment of such cases during his residence in the West Indies, his object 3 18 APPENDIX. was to decompose the poison; to effect which, he almost entirely de- pended on alkalies in simple solution with water. Here then says a " physician, we have a disease whose symptoms not only, but whose effects prove to a moral certainty the existence of a highly deleterious and morbid secretion in the first passages of the alimentary canal—that this morbid matter is of an acrid and viscous nature, producing a painful, griping, and spasmodic action in the in- testines, and, in proportion to its intensity, calls into sympathetic ac- tion the muscles of the abdomen and of the extremities. This secre- tion is sometimes so acrid, and of so poisonous a nature, that its effects on the system bear a strong analogy to the effects of arsenic. Physi- cians have often mistaken the symptoms of poison by arsenic for cho- lera morbus; and I distinctly recollect that in the first case of poison by arsenic to which I was called, unsuspicious of the cause, I thought it a case of Cholera, and I sat by the bedside of the patient several minutes before the suspicion of poison entered my mind."^ It was this strong analogy in the respective symptoms of Cholera and mineral poison that undoubtedly excited the suspicions of the people of Paris that their waters and liquors had been poisoned with arsenic. Some considering the blood as the natural principal, and general stimulus of the organic fibre, and consequently as the principal cause and effect of all the vital movements, have attributed the morbid pro- cess to the want of oxygenation in the blood, which thereby losing its faculty of natural stimulus, produces, like narcotic poisons, that which is called asphyxia of the heart; and they therefore propose the use of oxygen as a remedy. SYMPTOMS. FIRST, OR INCIPIENT STAGE. " The. intestinal irritation, which I have distinguished as the first stage of Cholera, has been usually regarded in no higher light than a premonitory symptom ; and to this neglect is to be attributed the little success which has attended the treatment of the disease. It is true, the London central board of health laid it down as a certain precursor n™^ T6 l,he TSt Public announcement of the fact, call- mfd3 ti 7G ^^ Wlth diarrh(Ea t0 have immediate recourse to udnotZ 5T1" ,ButbeiQS only regarded as a premonitory sign, effect on ZZ^I fyT°m °f the true Cholera/npro^Ja little France in sTf , lhe'PeoPle' When the Cholem made its ap- SLthp,! f nd'/he caae,8 of diarrhoea were separately no- and subslnn^?nS SGnt *°m the loca* ^ the central board of health, afterward\Zltl 7™/h°g,etheT Struck out- Whether they were toudlv dlZt 65 ?nder the Seneral head of "*** Cholela" or diseal aDoeSIdt' 'T0' SayJ but little' from that tim* ^ the SE2EL °nd°n' was ^ uP°n this object." sever^ S^Xl ft* 'T^ °f the b™eIs' rao'e « les9 tient. It aS heeviuaHn ™* C,0nst1ittttionai disP°^<>n of the pa- ^t nrst tne evacuations are deeply tinged with bile, but gradu- CHOLERA. 19 ally the faeces undergo a very marked change, become colourless, and very much resemble thin gruel or rice water. The diarrhcea is noticed as a common preliminary symptom, though for a long time presenting no peculiar character distinguishing it from the complaint denominated simple diarrhcea; yet the dejections are in many instances from an early period more fluid, whiter, and less feculent than they usually are in that disease ; and generally, toward the advance of the true choleric symptoms, these evacuations assume the peculiar rice water character. In some instances, during this stage of the complaint, there are slight indications of the symptoms which are to follow : nausea, pro- ceeding even to vomiting, and slight trembling of the muscular fibres in various parts of the body, attended with loss of appetite, dejection of spirits, general debility, and giddiness. There are cases noticed, in which this diarrhcea was not observed as a precursor of the second and more alarming stage. In others it has commenced at night, and before morning the disease in its most aggravated form has prostrated all the vital powers of the unfortunate sufferer. But these exceptions are not sufficiently numerous to inva- lidate the rule; and I lay it down as a settled position, that the gene- rality of cases are preceded by a relaxed state of the bowels. The im- portance of this observation will appear, when I notice*the proper sanative measures to be adopted for the prevention and cure of the disease. " The best writers on Cholera Asphyxia, generally agTee that it is invariably preceded by the following symptoms : "The patient complains of lassitude and a partial uneasiness in the region of the stomach, accompanied with some slight evacuations from the bowels, insufficient however to excite his attention or alarm. As these symtoms increase, and the evacuations become more frequent, from two to twelve times a day, accompanied with increased griping, his countenance becomes sharp and dark, of which he seems to be perfectly unconscious. Occasional nausea sometimes appears at this period. These symptoms generally continue, varying in severity, from one to ten days before the second stage supervenes. The eva- cuations at first are of a dark brown or blackish hue. As the loose- ness continues, they become of a less natural appearance, until they assume the consistence and aspect of dirty water. Some headache, cramp of the fingers, toes, and abdomen, slight giddiness, and singing in the ears, accompany these symptoms. Sometimes a costiveness of two or three days' duration supervenes, which is immediately suc- ceeded by a return of the diarrhcea, and in a few hours after by a col- lapse of the whole system, with nausea and vomiting."* • The epidemic had a peculiar effect upon almost erery individual, and proved most conclusively that th re existed an impure and pestilential state of the atmosphere. Most of the citizens were affected with diarrhcea, or a derangement of the digestive organs. It h;id a peculiar effect also upon my own system. It appeared that the blood became charged with the poisonous effluvia, but for the want of some exciting or pre- disposing cause, the disease was not brought fully into action, but was carried off by the excretions. Notwithstanding which, in consequence of certain kinds of diet once or twice indulged in, such as beans, peas, &c, very strong premonitory symptoms mani- 20 APPENDIX. This stage, continuing for a longer or shorter duration, is suddenly terminated by the accession of symptoms of a more alarming charac- ter, usually denominated the proper Cholera, but which I consider as the second stage of the disease. SECOND, OR CONFIRMED STAGE. The diarrhoea, which had perhaps scarcely been noticed by the pa- tient, becomes suddenly more severe, the evacuation thinner, and more colourless. The stomach, which up to this moment has remained un- disturbed, or but little affected, now becomes very irritable, and throws off first its contents, mixed with food, and at length, like the evacua- tions from the bowels, colourless and of watery consistence. At the same time, the strength of the patient becomes as suddenly depressed, which is indicated not so much by his feelings, a!s by the lowness and almost imperceptible pulsation of the heart and arteries. The urine is suppressed, the voice weak and hoarse, the respirations few, the breath chilled, and the tongue shrunk and of icy coldness, attended with great thirst, the skin cold and covered with a cold and clammy moisture; the countenance is shrunk, the eyes glassy and sunk in their orbits, and the features pinched, and exhibiting the most painful and anxious expression. The muscles in various parts of the body are now affected with cramps, rather than spasms. They are drawn up in knots, and their fibres are seen trembling under the skin. The muscles principally affected are those of the extremities, the calves of the legs, the flexors of the fingers, and the abdominal muscles; but there are twitches of the muscular fibres and tendons in every part of the body. These cramps have been described by patients them- selves, as uncomfortable rather than painful; and the generality of the cases I have seen have not appeared to suffer much from this cause. In this stage there is little or no livid hue to be noticed. There may be a darker circle under the eye, and the nails may be a little dis- coloured. I have given the symptoms of this stage of the Cholera in the order in which they usually occur. Some may occasionally be absent, or more or less aggravated; but generally all are to be found occurring simultaneously. fested themselves. On one occasion after eating beans for dinner, nausea, retching and some vomiting supervened, with great debility; and which was removed only by \£$TL%Xf the complaints of children are accompanied with evident signs of acidity, such as flatulency, griping pains, and stools of a green colour. The child so affected becomes restless, cries much, and draws up its legs forcibly to its body, is troubled with sour belchings, vomiting or purging, and not unfrequently becomes convulsed. New born infants until they are about three months old are apt to be affected with much distress from flatulence, or wind, or some of the causes mentioned. An infusion or tea made of the flowers or leaves of catnip will always afford relief; sometimes a few fennel seeds may be added, and a little gin. If the pain be very great, and prevents the infant from sleeping, one or two hops may be added, and the tea sweetened with loaf sugar : a few spoonfuls of it may be given. It answers a much better purpose than paregoric, or any other pre- paration of opium; affording relief without producing costiveness, nausea, or any other unpleasant symptom. Sometimes however, it may become necessary to give some preparation of opium, such as paregoric, or syrup of poppy. To remove offending matter, it will be sometimes necessary to give the infant about two grains of sal seratus and rhubarb, mixed in a little peppermint water, or tea and water with loaf sugar. The medicine at the same time that it occasions a gentle operation of the bowels, will tend to correct the acidity, by which means it not only removes the disease, but obviates its cause. If necessary, it should be repeated the succeeding day, being far preferable to prepared chalk and such other medicines, which, although they correct the acidity, are apt to lodge in the bowels, and occasion costiveness. A costive habit is, indeed of itself, a frequent cause of flatulency and griping pains in infants, and when it occurs ought to be obviated, by administering the above medicine. If not found sufficiently active, htteen or twenty drops of the compound tincture of senna may be added. When the griping pains are very acute, warmth may also be applied herbs" t0 stomach and bowels, by fomenting them with bitter In infants who are brought up by the hand, it will be necessary to EL ! e5J attention t0 tbeir food, and carefuUy to observe what seems to agree best with them. Such infants are very apt to be trou- DISEASES OF WOMEN AND CHILDREN. 69 th f1™*1- ^"lity and flatulency in their stomach and bowels, and therefore it ought to be prepared fresh once or twice a day, and to have a few fennel seeds inclosed in a small bag, boiled up in whatever fa- rinaceous substances are given to them as food. Where pap, arrow root, or the like productions do not seem to agree, the crumbs of bread mashed very fine in a little chicken broth or weak beef tea may be substituted occasionally. GALLING AND EXCORIATION. Young children are very apt to become excoriated in particular parts of the body, particularly about the groins, and wrinkles of the neck, behind the ears, and under the arms, such places being kept much moistened by urine or sweat. These complaints prove very troublesome to children, and are, in some measure, owing to a want of due cleanliness in the mother or nurse. To prevent them, and likewise to remove them when they do occur, it will be necessary to wash the parts well with cold water once or twice a day, to change the linen often, and keep the child per- fectly clean and sweet. After the child is washed and dried, the parts affected may be sprinkled with a little fine elm bark. Where the ex- coriation or galling is considerable, the parts, after having been wash- ed with cold water, may be wetted with a linen rag moistened in equal parts of rectified spirit and common water, and then be dressed with fine lint spread with elder ointment. OF A LOOSENESS OR PURGING. This complaint, as well as the former, very often arises in children from the introduction of unwholesome food into the stomach, as well as the sudden disappearance of some cutaneous eruption of a critical nature ; and infants who have been recently deprived of the breast are sometimes greatly disordered in their bowels by frequent watery stools, attended with gripes, and occasionally by convulsions. When this happens, restoring the child to the breast of its former nurse, or that of another, should not be neglected as the first necessary step to be taken. A little of the neutralizing physic or mixture will soon remove this complaint. TEETHING OR DENTATION. Ahbuthnot states that above a tenth part of infants die in teeth- ing, by symptoms proceeding from the irritation of the tender nervous parts of the jaws, occasioning inflammation, fever, convulsions, gan- grenes, &c. These symptoms are in a great measure owing to the great delicacy and exquisite sensibility of the nervous system at this time of life, which is too often increased by an effeminate education. Hence it comes to pass that children who are delicately brought up, always suffer most in teething, and often fall by convulsive dis- orders. 70 APPENDIX. About the sixth or seventh month the teeth generally begin to make their appearance; first, the incisors, or fore-teeth; next, the canini, or dog teeth; and, lastly, the molares, or grinders. About the seventh year there comes a new set; and about the twentieth, the two inner grinders, called dentes sapientia, the teeth of wisdom. Children about the time of cutting their teeth, slaver much, and have generally a looseness. When the teething is difficult, especially when the dog teeth begin to make their way through the gums, the child has startings in his sleep, tumours of the gums, watch- ings, gripes, green stools, the thrush, fever, difficult breathing, and convulsions. Difficult teething requires nearly the same treatment as an inflam- matory disease. If the body be bound, it must be opened either by emollient clysters or gentle purgatives ; as senna and manna, rhubarb, &c. The food should be light, and in small quantity; the drink plen- tiful, but weak and diluting, as infusions of balm, catnip flowers, &c.; to which about a third or fourth part of milk may be added. Sydenham says, that in fevers occasioned by teething, he never found any remedy so effectual as two, three, or four drops of spirits of hartshorn in a spoonful of simple water, or other convenient vehicle, given every four hours. When children are cutting their teeth* a small strengthening plaster may be placed between their shoulders. This generally eases the tickling cough which attends teething, and is by no means a useless application. When the teeth are cut with difficulty, it ought to be kept on during the whole time of teething. It may be enlarged as occasion requires, and ought to be renewed at least once a fortnight. Several things have been recommended for rubbing the gums, as oils, mucilages, &c.; but from these not much is to be expected. If any thing of this kind is to be used, we would recommend a little fine honey, which may be rubbed on with the finger three or four times a-day. Children are generally at this time disposed to chew whatever they get into their hands. For this reason they ought never to be without somewhat that will yield a little to the pressure of their gums. With regard to cutting the gums, we have seldom known it of any great benefit. In obstinate cases, however, it ought to be tried. It may be performed by a penknife or lancet In order to render the teething less difficult, parents ought to take care that their children's food be light and wholesome, and that their nerves be braced by sufficient exercise. Infants, during dentition, are subject to sudden attacks of spasm about the windpipe, producing a temporary feeling of suffocation, with a crowing sound; but there is no hoarse cough. It is apt to take place suddenly at night, or when crying. It is cured by giving a combination of tincture of blood root and lobelia, and by using laxa- tives. The tepid bath is also useful. The gum may be cut; and if there be any tendency to a return, particularly if the child be hot, and the pulse quick, the eye heavy, and the face unusually pale, or flushed, DISEASES OF WOMEN AND CHILDREN. 71 purgatives should be given, the feet bathed, and garlic applied to them. BOWEL COMPLAINTS GENERALLY. A great proportion of infants are cut off before they are a year old, from bowel complaints, particularly in populous cities ; and most of them arise from an unnatural, and I was about to say wicked practice, of such vast numbers of persons crowding together in small, filthy, and confined apartments or houses. In this city there are instances where a dozen families occupy one tenement, and in Europe it is no doubt much worse. This alone is sufficient to account for most of the bowel and other complaints of infant children; but when we add to this the great quantities of trash or green fruit they eat, can we wonder that so many are sent to an untimely grave. Children are always sickly in the fruit season, which may be thus accounted for : two-thirds of the fruit which comes to market in this country is really unripe; and children, not being in a condition to judge for themselves, eat whatever they can lay their hands upon, which often proves little better than a poison to their tender bowels. Servants, and others who have the care of children, should be strictly forbidden to give them any fruit without the knowledge of their parents. In all these complaints it must be recollected that prevention is bet- ter than cure. Their diet must be attended to, and it should consist principally of milk, and at a suitable age it must be boiled with a little flower. No fruit should be given except it is fresh and ripe. Their apartments, persons, and clothing must be kept perfectly clean, and it is of the highest importance that they be placed in pure air, and if pos- sible in the country. As soon as the bowels become disordered, the neutralizing cordial or mixture must be given, as directed under the head of that prepara- tion. This medicine will almost immediately remove the acidity of the stomach, pain in the bowels, change the appearance of the passa- ges, and, in a word, cure the complaint. Sometimes it may be necessary to give an infusion or tea of rasp- berry leaves, bene plant, fyc. Foment also the bowels with bitter herbs. APHTHJE, THRUSH, OR CANKER. Infants and children are often affected with little sore spots or erup- tions about the mouth, and it usually extends from the stomach to the end of the bowels, giving rise to many painful and unpleasant symp- toms. This complaint arises from a morbid state of the stomach, and it must be treated by giving a gentle neutralizing physic, such as the medicine mentioned above. The mouth may be often washed with a decoction of sage and hyssop, sweetened with honey, and a little fine borax may bemadded. CONVULSIONS. When fits or convulsions arise from teething or any other cause, the 72 APPENDIX. feet must be immediately bathed in warm ley water, and an anodyne must be administered, such as the syrup of poppy or paregoric. Garlic should be bruised and applied to the stomach, and if there be heat of the head, spirits, rain water, and vinegar may be applied. These means must be repeated as often as fits occur: in obstinate ca- ses it may be necessary to use a warm bath. SORENESS, oft EXCORIATION OF THE NAVEL STRING OR UMBILICAL CORD. About the time the umbilical cord separates, there is sometimes sore- ness and inflammation; for such symptoms, sprinkle with a powder of slippery elm bark, and apply the black salve. RUPTURE, (HERNIA.) Sometimes from crying or other causes, infants are afflicted with ruptures; when this happens the earliest attention is required. The infant or child should be placed in a recumbent position, or on its back. Then press the tumour or protruded part back, make a compress of linen, which has been previously wet in a decoction of oak bark, apply it over the rupture, and secure it by a bandage. If this fails to keep it in its proper situation apply a truss. TONGUE TIED, OR DIVISION OF THE FRENUM LINGUJB. Sometimes the frenum of the tongue is so contracted, that the child cannot nurse or suck. When this occurs, and only then, there must be a very slight incision made with a pair of scissors or lancet. The cut must be very small and superficial, lest a blood vessel be wounded. If the child can nurse, this practice must never be resorted to. In almost every case this is an imaginary complaint; and when parents or a parent insists upon its being done, from a mistaken notion, the back of the lancet may be used, and this will satisfy them. IMPERFORATED VAGINA. Sometimes a thin membrane forms across the mouth of the vagina, which partially or wholly closes it. This is very easily divided by a lancet or a pair of scissors. CLUB, CROOKED, OR DEFORMED FEET. When children are bom with this deformity, an intelligent person informs me, that a certain practitioner is always in the habit of imme- diately turning them at birth into a right position, and securing them with proper splints and bandages. This he says, always obviates the deformity. CHOAKING. Infants often become choaked by getting various substances into their mouth and throat. When this accident occurs, let the child be placed upon the lap of the mother or nurse, and its head turned down- DISEASES OF WOMEN AND CHILDREN. 73 ward, while it is gently struck a few times on the back between the shoulders ; if this does not immediately remove it, let the fore finger be introduced and extract it; should this fail, give a mild emetic. VENERIAL DISEASE OF INFANTS. It is now common in this corrupt age for infants to be born with the venereal disease, received in consequence of the licentious conduct of the parent or nurse, giving rise to ulcers in some parts of the body. I have known some children almost a mass of corruption from the vene- real disease communicated in this manner. The poison instead of af- fecting the mother during pregnancy, is communicated to the infant. When such a complaint occurs, the medicine must principally be given to the mother, instead of the child. The alterative syrup must be ad- ministered, and such other medicines as recommended under the head of the venerial disease. Who can calculate the magnitude of the vices of such men who thus entail such a loathsome and horrid disease upon their offspring. Why are crimes which dwindle into insignificance, compared with this, punished, while this is passed over without any penalty ? I have sometimes thought from the prevalence of this vice, that half of the diseases of women and children were produced by it. Besides the miseries inflicted upon innocent children, what domestic broils and difficulties are the consequences. The reader would be astonished if he knew how many young: men are ruined by visiting houses of ill fame. It either brings thousands to an untimely grave, or cripples, or diseases them for life ; and the only method to put down this disgraceful and destructive vice, is for the municipal authorities of every county wholly to exterminate every house of the kind, by employing officers who instead of countenancing or visiting them, as is now the case, will faithfully and rigidly perform their duty. Not only so, every female who has the least regard to virtue or morals, should resolve never to associate or show the least favour to any young man, who is known or suspected of keeping com- pany with prostitutes. Nor should any person guilty of this vice be treated with respect until he reforms. Let him be viewed in the same light as a thief or a robber, and then we may expect to see a refor- mation. The odium must be stamped with public disgrace and infamy. The Jews, by their laws, were, in certain cases, forbid to have any manner of commerce with the diseased ; and, to this all wise legisla- tors ought to have a special regard. In some countries diseased per- sons have actually been forbid to marry. This is an evil of a compli- cated kind, a natural deformity, and a political mischief; and there- fore requires a public consideration. ON THE MANAGEMENT OF CHILDREN. It is during infancy that the foundation of a good or bad constitution is generally laid ; it is therefore of importance that parents should be 74 APPENDIX. well acquainted with the various causes which may injure the health of their offspring. # " It appears from the annual registers of the dead, says a writer, that almost one half of the children born in Great Britain die under twelve years of age. To many, indeed, this may appear a natural evil; but on due examination it will be found one of our own crea- ting. Were the death of infants a natural evil, other animals would be as liable to die young as man; but this we find is by no means the case." It may seem strange that man, notwithstanding his superior reason, should fall so short of other animals in the management of his young; but our surprise will soon cease, if we consider that brutes; guided by instinct, never err in this respect; while man, trusting solely to art, is seldom right. Were a catalogue of those infants who perish annually by art alone, exhibited to public view, it would astonish most people. If parents are above taking care of their children, others must be employed for that purpose; these will always endeavour to recom- mend themselves by the appearance of extraordinary skill and ad- dress. By this means such a number of unnecessary and destructive articles have been introduced into the diet, clothing, &c, of infants, that it is no wonder so many of them perish. It must be admitted, that most of the complaints, peculiar to infancy and childhood, are owing to the mismanagement, or ignorance of the mother or the nurse. First, as regards diet, or sustenance. Many are in the habit of pouring down various liquids and mixtures made of rich substances, and so much sweetened that the tender organs of digestion are impaired, and acidity and bowel diseases follow. Sugar, molasses, and every other "article of this nature, should be avoided. No food, except the milk of the mother should be given, except absolutely ne- cessary. Nature has designed this liquid exclusively for the nourish- ment of the infant, and indeed, we may say for children. There is another precaution to be observed, which is, " never to put an infant to a wet nurse if it can possibly be avoided." Such persons are generally strangers, and they often communicate the most loath- some and fatal diseases. Besides, their milk is often rendered un- wholesome by age, or other causes. This is a very unnatural practice. Nothing can be more preposterous than a mother who thinks it be- low her to take care of her own child, or who is so ignorant as not to know what is proper to be done for it. If we search nature through- out, we cannot find a parallel to this. Every other animal is the nurse of its own offspring, and they thrive accordingly. Were the brutes to bring up their young by proxy, they would share the same fate with those of the human species. We mean not, however, to impose it as a task upon every mother to suckle her own child. This, whatever speculative writers may allege, is in some cases impracticable, and would inevitably prove destructive' both to the mother and child. Women of delicate'constitutions, sub- IecJ l? hysteric fits, or other nervous affections, make very bad nurses; and these complaints are now so common, that it is rare to find a wo- DISEASES OF WOMEN AND CHILDREN. 75 man of fashion free from them; such women, therefore, supposing them willing, are often unable to suckle their own children. Almost every mother would be in a condition to give suck, did mankind live agreeably to nature ; but whoever considers how far many mothers deviate from her dictates, will not be surprised to find some of them unable to perform that necessary office. Mothers who do not eat a sufficient quantity of solid food, nor enjoy the bepefit of free air and exercise, can neither have wholesome juices themselves, nor afford proper nourishment to an infant. Hence children who are suckled by delicate women, either die young, or continue weak and sickly all their lives. When we say that mothers are not always in a condition to suckle their own children, we would not be understood as discouraging that practice. Every mother who can, ought certainly to perform so ten- der and agreeable an office. But suppose it tq be out of her power, she may, nevertheless, be of great service to her child. The business of nursing is by no means confined to the giving suck. To a woman who abounds with milk, this is the easiest part of it. Numberless other offices are necessary for a child, which the,mother ought at least to see done. [Buchan.] " A mother who abandons the fruit of her womb, says Buchan, as soon as it is born, to the sole care of an hireling, hardly deserves that name. A child, by being brought up under the mother's eye, not only secures her affection, but may reap all the advantages of a parent's care, though it be suckled by another. How can a mother be better employed than in superintending the nursery? This is at once the most delightful and important office ; yet the most trivial business or insipid amusements are often preferred to it! A strong proof both of the bad taste and wrong education of modern females. " It is indeed to be regretted that more care is not bestowed in teach- ing the proper management of children to those whom nature has de- signed for mothers. This, instead of being made the principal, is sel- dom considered as any part of female education. Is it any wonder, when females so educated, come to be mothers, that they should be quite ignorant of the duties belonging to that character? However strange it may appear, it is certainly true, that many mothers, and those of fashion too, are as ignorant, when they have brought a child into the world, of what is to be done for it, as the infant itself. Indeed the most ignorant of the sex are generally reckoned most knowing in the business of nursing. Hence, sensible people become the dupes of ignorance and superstition; and the nursing of children, instead of being conducted by reason, is the result of whim and caprice. " Many advantages, says a writer, would arise to society, as well as individuals, from mothers suckling their own children. It would pre- vent the temptation which poor women are laid under of abandoning their children to suckle those of the rich for the sake of gain; by which means society loses many of its most useful members, and mothers become in some sense the murderers of their own offspring. I am sure I speak within the truth when I say, that not one in twenty qf those children live who are thus abandoned by their mothers. For this 76 APPENDIX. reason no mother should be allowed to suckle another's child till her own is either dead or fit to be weaned. A regulation of this kind would save many lives among the poorer sort, and could do no hurt to the rich, as most women who make good nurses are able to suckle •two children in succession upon the same milk." Tacitu3, the celebrated Roman historian, complains greatly of the degeneracy of the Roman ladies in his time with regard to the care of their offspring. He says, that in former times the greatest women in Rome used to account it their chief glory to keep the house and attend their children; but that now the young infant was committed to the sole care of some Grecian wench, or other menial servant. We are afraid, wherever luxury and effeminacy prevail, there will be too much ground for this complaint. Again, infants and children are often injured by improper clothing. It is customary for some nurses to wrap them in such a quantity, as to injure their health; moderation in this respect, should be observed, due regard being paid to that which is sufficient to render them com- fortable. Another very reprehensible custom is to pour down some nauseous drug, such as paregoric, Godfrey's cordial, or some other articles, every time the child begins to cry, or is fretful, by which it becomes habitu- ated to the use of opium, and makes it necessary to increase the dose in order to produce the same effect. Another injurious practice is to give frequently worm lozenges, (the basis of which is calomel or mercury,) upon any attack of illness, un- der the impression that the disorder is occasioned by worms. By this imprudent course both the health and life of the child is endangered. Therefore those who wish to bring up their children in a healthy con- dition, must avoid these evils, and be content to follow the simple path of nature, and common sense. Few things tend more to the destruction of children than drenching them with drugs. That medicine may be sometimes necessary for children, I do not deny; but that it hurts them ten times for once it does them good, I will venture to assert. A nurse or mother, the mo- ment her child seems to ail any thing, runs immediately to the apothe- cary, who throws in his powders, pills, and potions, till the poor infant is poisoned; when the child might have been restored to perfect health, by a change of diet, air, exercise, clothing, or some very easy and simple regulation. Care must be taken to keep the bowels regular, which may be effect- ed in most cases by the milk of the mother alone. Most of the com- plaints in children arise from) flatulence or wind; to remove which, S1™ common catnip or fennel seed tea, and let them drink it freely. When children complain of pain in the stomach and bowels, give a moderate dose of vegetable physic; senna and manna is very good, and after the operation of physic, let the diet be attended to. Green iUUuUSt be avoided' and whatever is hard of digestion. The feet should be often bathed in warm water, the bowels must be fomented with bitter herbs, and it is also necessary to give the child sufficient exercise m the open air. Nothing is more injurious to the health of DISEASES OF WOMEN AND CHILDREN. 77 children than the confined and impure air of great cities. The most rigid attention must be paid to cleanliness. By pursuing this course, disease will be avoided, and health promoted. EXERCISE OF CHILDREN. Of all the causes which conspire to render the life of man short and miserable, none has greater influence than the want of proper exercise : healthy parents, wholesome food, and proper clothing, will avail little, where exercise is neglected. Sufficient exercise will make up for se- veral defects in nursing: but nothing can supply the want of it. It is absolutely necessary to the health, the growth, and the strength of children. The desire of exercise is coeval with life itself. Were this princi- {)le attended to, many diseases might be prevented. But while indo- ence and sedentary employments prevent two-thirds of mankind from either taking sufficient exercise themselves, or giving it to their chil- dren, what have we to expect but disease and deformity among their offspring ? The rickets, so destructive to thildren, and other com- plaints are cured by it. Arguments to show the importance of exercise might be drawn from every part of the animal economy ; without exercise the circulation of the blood cannot be properly carried on, nor the different secretions duly performed ; without exercise, the fluids cannot be properly prepared, nor the solids rendered strong or firm. The action of the heart, the motion of the lungs, and all the vital functions, are greatly assisted by exercise. But to point out the manner in which these effects are pro- duced, would lead us farther into the economy of the human body than most of those for whom this treatise is intended, would be able to fol- low. We shall therefore only add, that when exercise is neglected, none of the animal functions can be duly performed ; and when this is the case, the whole constitution must go to wreck. A good constitution ought certainly to be our first object in the ma- nagement of children. It lays a foundation for their being useful and happy in life ; and whoever neglects it, not only fails in his duty to his offspring, but to society. I have been told that in China, where the police is the best in the world, all the children are employed in the easier part of gardening and husbandry ; as weeding, gathering stones off the land, and such kind of exercise. ON THE FOOD OF CHILDREN. Nature, says Buchan, not only points out the food proper for an in- fant, but actually prepares it. This, however, is not sufficient to pre- vent some who think themselves wiser than nature from attempting to bring up their children without her provision. Nothing can show the disposition which mankind have to depart from nature more than their endeavouring to bring up children without the breast. The mother's milk, or that of a healthy nurse, is unquestionably the best food for an infant. Neither art nor nature can afford a proper substitute for it. 78 APPENDIX. Children may seem to thrive for a few months without the breast; but when teething, the small pox, and other diseases incident to childhood come on, they generally perish. A child, soon after the birth, shows an inclination to suck; and there is no reason why it should not be gratified. It is true, the mother's milk does not always come immediately after the birth; but this is the way to bring it; besides, the first milk that the child can squeeze out of the breast answers trie purpose of cleansing better than all the drugs in the apothecary's shop, and at the same time prevent inflammations of the breast, fevers, and other diseases incident to mothers. If the mother or nurse has enough of milk, the child will need little or no food for the third or fourth month. It will then be proper to give it once or twice a-day, a little of some food that is easy of diges- tion. This will ease the mother, will accustom the child by degrees to take food, and will render the weaning both less difficult and less dangerous. All great and sudden transitions are to be avoided in nursing. For this purpose, the food of children ought not only to be simple, but to resemble, as nearly as possible, the properties of milk. Indeed, milk itself should make a principal part of their food, not only before they are weaned but for some time after. Next to milk, we would recommend good light bread. Bread may be given to a child as soon as it shows an inclination to chew; and it may at all times be allowed as much plain bread as it will eat. The very chewing of bread will promote the cutting of the teeth, and the discharge of saliva, while, by mixing with the nurse's milk in the sto- mach, it will afford an excellent nourishment. Children discover an early inclination to chew whatever is put into their hands. Parents observe the inclination, but generally mistake the object. Instead of giving the child something which may at once exercise its gums and afford it nourishment, they commonly put into its hands a piece of hard metal, or impenetrable substance. A crust of bread is the best gum-stick. It not only answers the purpose better than any thing else, but has the additional properties of nourishing the child, and car- rying the saliva down into the stomach, which is too valuable a liquor to be lost. Bread, besides being used dry, may be many ways prepared into food for children. One of the best methods is to boil it in water, af- terward pouring the water off, and mixing with the bread a proper quantity of new milk unboiled. Milk is both more wholesome and nourishing this way than boiled, and is less apt to occasion costive- ness. For a child farther advanced, bread may be mixed in veal or chicken broth, made into puddings. Bread is proper food for children at all times, provided it be plain, made of wholesome grain, and well fermented; but when enriched with fruits, sugars, or such things, it becomes very unwholesome. , It is soon enough to allow children animal food when they have got teeth to eat it. They should never taste it till after they are weaned, and even then they ought to use it sparingly. Indeed, when children live wholly on vegetable food, it is apt to sour on their stomachs; but, DISEASES OF WOMEN AND CHILEREN. 79 on the other hand, too much flesh heats the body, and occasions fevers and other inflammatory diseases. This plainly points out a due mix- ture of animal and vegetable food as most proper for children. THE INJURIOUS EFFECTS OF UNWHOLESOME AIR UPON CHILDREN. F.r'w things says an experienced physician, prove more destructive to children than confined or unwholesome air. Impure air is render- ed so extremely pernicious, that it becomes a poison to infants. Want of wholesome air is likewise destructive to many of the chil- dren born in great towns. There the poorer sort of inhabitants live in low, dirty, confined houses, to which the fresh air has scarcely any access. Though grown people, who are hardy and robust, may live in such situations, yet they generally prove fatal to their offspring, few of whom arrive at maturity, and those who do are weak and de- formed. As such people are not in a condition to carry their children abroad into the open air, we must lay our account with losing the greater part of them. But the rich have not this excuse. It is their business to see that their children be daily carried abroad, and that they be kept in the open air for a sufficient time. This will always succeed better if the mother goes along with them. Servants are often negligent in these matters, and allow a child to sit or lie on the damp ground, instead of leading or carrying it about. The mother surely needs air as well as her children ; and how 'can she be better employed them in attending them ? A very bad custom prevails, of making children sleep in small apartments, or crowding two or three beds into one chamber. In- stead of this, the nursery ought always to be the largest and best aired room in the house. When children are confined in small apart- ments, the air not only becomes unwholesome, but the heat relaxes their solids, renders them delicate, and disposes them to colds and ma- ny other disorders. Nor is the custom of wrapping them too close in cradles less pernicious. One would think that nurses were afraid lest children should suffer by breathing free air, as many of them actually cover the child's face while asleep, and others wrap a covering over the whole cradle, by which means the child is forced to breathe the same air over and over all the time it sleeps. [Buchan.] CLOTHING OF CHILDREN, AND CLEANLINESS. It is too common a practice with nurses and mothers to swathe very young children with flannel bandages and stays, the consequences of which are, that they either become very susceptible to the im- pressions made by the external air when they are left off, or deformity takes place. The best rule that can be observed with respect to the dressing of a child, is that it be encumbered with no more clothes than are necessa- ry to keep it warm, in every instance proportioning these to the tem- perature of the atmosphere, the season of the year and climate ; that they sit easy and sufficiently loose on its body, so as not to compress and confine any part of it; that they are composed of articles that are 80 APPENDIX. lieht soft, and warm, being at the same time simple and without com- plication and that they be changed frequently, or as often as they hap- pen to be wetted by the urine of the child. Wet clothes not only fret and gall the tender skin of infants, but also give them a strong un- pleasant smell, and not unfrequently occasion eruptive disorders; whereas cleanliness in the clothing of an infant, together with proper ablutions with tepid or cold water, and frictions with the hand over every part of the body after it has been thus purified, each day previ- ous to dressing it, will greatly tend to preserve it in good health. In every part of the dress of an infant, as well as in the application of its napkins, tape should be substituted instead of pins. NURSES. Parents who are obliged to employ nurses should be very particular in employing such as are free from any complaint, unquestionable re- ferences as to character should be given. Her milk should not be old, and she should be clean, her person and dress prudent and careful, and her nursing should be under the immediate control or superintendance of the mother or parents. All diseases of women and children not noticed in the preceding chapters will be found under the appropriate heads; such as rickets, worms, dropsy in the head, croup, &c. NOTES CHOLERA Note 1. Annual bill of mortality.—We have obtained a sight of the annu- al bill of mortality for New-York, during the year 1832, which was presented to the Common Council on Monday evening, January 21st, 1833, and is now in the process of publication, from which we derive the following particulars : The whole number of deaths during the year, as will be seen be- low, was ten thousand three hundred and fifty-nine; being three thousand nine hundred and ninety-six more than ever occurred in the city before, in any one year. This extraordinary increase of mortali- ty is mainly attributable to the ravages of Malignant Cholera, which carried off no less than three thousand five hundred and fifteen indi- viduals, all in the months of July, August, September, and October. Of the whole number, (10,359) there died of Abscess, . . . ••......5 81 10 8 6 29 15 3 72 5 55 3 3515 93 7 1 1415 501 2 16 1 104 3 Apoplexy, Asphyxia, Asthma, Bilious dysentery, , Burned or scalded, Cancer, Caries, Casualty, Catarrh, Childbed, Chlorosis, Cholera, Cholera morbus, Cholic, Compression of the brain Consumption, Convulsions, Contusion, Cramp in the stomach, Diabetes, Diarrhoea, Drinking cold water, 11 g2 APPENDIX. Dropsy, Dropsy in the chest, Dropsy in the head, Drowned, Dysentery, . Dyspepsia, . Epilepsy, Erysipelas, . Fever, . Bilious fever, Bilious remittent, Hectic, Inflammatory, Intermittent, Puerpal, Remittent, Scarlet, Typhus, Flux infantile, Fracture, Frozen, Gout, Gravel, Hemorrhage,. Hemoptysis, . Hiyes or croup, Hysteria, Jaundice, Inflammation of the bowels, Inflammation in the brain, Inflammation in the chest, Inflammation in the liver, Inflammation in the stomach, Influenza, : : Insanity, : : Intemperance, : filled or murdered, Lock jaw, : : Lumber abscess, : Marasmus, : : Measles, : : Mortification, : Nervous disease, : OJd age, : : Palsy, : : Peripneumony, : pleurisy, : : Pneumonia typhodes, Quinsy, : Rheumatism, 130 43 344 65 130 8 11 13 80 31 8 3 3 7 5 27 221 84 334 2 5 2 2 10 6 179 2 14 196 99 77 44 30 33 4 119 3 3 2 177 290 23 2 154 36 234 22 57 2 7 NOTES. 83 Rupture, : : Schirrus of the liver, Scrofula or king's evil, Small pox, : Sore throat, : Spasm, : Spina bifida, Sprue, : Still-born, : Stranguary, : Sudden death, Suicide, : Syphilis, : Tabes mesenterica, Teething, : Tumour, : Vomiting blood, Ulcer, : Unknown, : Whooping cough, Worms, : Inflammation of the bladder, 7 37 17 89 22 13 5 32 384 1 2 29 4 24 110 5 1 1 132 63 41 4 Total, 10,359. The number of deaths in January was 564; February, 735; March, 545; April, 478; May, 515; June, 410 ; July, 2,467,—of which by Cholera, 1,797; August, 2,206—of which by Cholera, 1,202; Septem- ber, 1,064—of which by Cholera, 451; October, 586—of which by Cholera, 63 ; November, 400 ; December, 389. Total, 10,359. Of the age of one year or under, there died 1,922 ; between one and two years, 830; between two and five years, 965; five and ten years, 450; ten and twenty, 433 ; twenty and thirty, 1,397; thirty and forty, 1,617; forty and fifty, 1,142; fifty and sixty, 705; sixty and seventy, 489; seventy and eighty, 273; eighty and ninety, 109; ninety and a hundred, 25; over a hundred, 2. Total, 10,359. It will be observed that the proportion of deaths in middle age is unusually large: the Cholera having selected the greater part of its victims from that description of persons. » Of the whole, number deceased, 3,200 were men, 2,694 women, 2,463 boys, and 2,092 girls. Total males, 5,663; females, 4,696. Excess of males, 967. Proportion of deaths to the whole population, rating it at 220,000, 1 in 21 1-4. In 1KJ1, rating the population at 210,000, 1 in 34 1-2. The number of deaths in 1831 was 6,353 : in 1830, 5,537 : in 1829, 4,094; in 1828, 5,181: in 1827, the same ; in 1826, 4,973. Note 2. Sm—I request permission through your extensively circulated pa- per* to convey to the public my opinion as. to the nature, and my su«- 84 APPENDIX. cessful practice in the cure of cholera morbus, for more than thirty years, with uniform success. The disease is introduced by causes too well known, and shows it- self at first by violent pains from the stricture of the gall duct, and is afterward kept up by the irritability of the bowels, brought on by the excoriation of the internal coat, from the acrid or scalding nature of the bile when first expelled the gall bag. This irritation keeps up the dis- ease till nature recovers or sinks. 1 never use calomel, because I have a more certain, safe, and speedy remedy, that produces an almost instantaneous relief; calomel relieves by inducing a more copious secretion of means to defend the membrane from excessive irritation, where it succeeds : whilst the remedy I re- commend, affords a tone of firmness to the membrane, a smoothness of surface that defends it from the action of the bile, and removes exces- sive irritation; by vdrich means the disease goes off as soon as the gall bladder is emptrcd of its excessive irritative contents, which is very soon accomplished, as from three to five or six doses complete the cure. The following is one of the proofs of my assertion. I was surgeon of the Dolphin in the year 1825, between the 17th and 26th of July in that year ; I had two hundred and sixty-four cases of cholera morbus, from which, with the exception of sixteen being kept under treatment for three days, four patients demanding attention for four days, and three for five days, every patient Was restored with- in the space of fifty hours : one who had been previously ill, demand- ed longer attention. I persuaded the chief mate to take a dose of the remedy before the healthy remaining part of the ship's company to induce them to fol- low his example; they all complied, and to the best of my recollection not one of them had occasion to trouble me from illness. The remedy I gave was—one drachm of nitrous acid, (not nitric, that has foiled me,) one ounce of peppermint water or camphor mix- ture, and forty drops of tincture of opium. A fourth part every three or four hours in a cupful of thin gruel. The body should be covered with a succession of hot clothes dry; bottles of hot water to the feet, if they can be obtained; constant and small sippings of finely strained gruel, or sago, or tapioca; no spirit, no wine, no fermented liquors till quite restored. I am your obedient humble servant, THOMAS HOPE, Surgeon. Note 3. It is remarkable, that even now, January 21st, 1833, bowel com- plaints are very prevalent, particularly the cholera morbus; and which very much resembles the Spasmodic Cholera, showing evidently, that the atmosphere is charged with the poison, and that nothing is want- ing but some exciting cause to bring it into action. I have just this moment been to visit a patient who has had a very severe attack of the complaint, vomiting and purging, the discharges consisting of a fluid resembling " dirty rice water." INDEX TO VOLUME II. Abscess, Amaurosis, Abscess of the eye, Anthrax, Ague in the breast, face, Animation, suspended, 20 291 295 310 315 436 452 by hanging, 452 by drown- ing, . 452 Amputation, .. . . 396, 465 Antrum, collections of matter in,. 446 Abscess, lumbar, . . . 446 Aneurism, . . . '331 of the heart, . . 338 aorta, . . 338 popliteal, • . .338 femoral, . . . 338 axillary, . . .338 carotid, . . .338 B Bites of rabid animals, viper, rattlesnake, adder, Brain, concussion of, . compression of, Bones, diseases of, Bronchotomy, Bronchocele, Boil, Burns and scalds, Bubo, C Connexion between physic and surgery, . • Concussion of the brain, Compression of the brain, . from effused blood, 52 52 52 52 64 67 152 474 432 433 449 243 bone, Cancer, and scirrhus, . Carcinoma, Compound dislocations, Carbuncle, Caries, Cold, exposure to intense, Canine madness, Castration, Cupping, . Cataract, . 5 64 67 67 . 68 164,178 . 164 164, 178 . 127 . 310 . 152 . 452 . 455 . 472 . 475 . 289 Chilblain, Corns, Circocele, Chancre, D Dropsy of the eye, scrotum, spermatic cord, Dislocations, .... of the humerus, or shoulder, . lower jaw, fore-arm, radius, wrist, . thumb, . thigh-bone, or hip, . knee-pan, ankle, . Deafness,..... Dow-worm, . Page 425 439 410 242 298 , 405 , 408 . 119 131 129 133 135 136 136 137 142 141 435 443 Eye, inflammation of, . . . 275 dropsy of, . . . . 298 fungus of, . 296 abscess of, . . . 295 tumours of, . . • 297 protrusion of, 298 Erysipelas, .... 325 Extraneous substances in the ear, 435 Enlargement of the prostate gland, 395 F Fungus heematodes, of the eye, testicle, . Fistula, perineum, lacrymalis, * in ano, . plate of, bandage for, . illustrations of, Fractures in general, . particular, of the nose, . lower jaw, clavicle, or collar bone, sternum, humerur, or uppa arm, ribs, . 178 179 179 182 203 204 182 184 188 196 89 103 103 103 104 106 115 107 IV INDEX. Fractures of the feiriur, or thigh- bone, within the capsular liga- ment, fore-aim and leg, remarks on, by Count Lasallec, Femoral hernia, . Felon, Furunculus, Face, pain in, Foreign bodies in the throat, Falling down of the bowel, G Gases, poisonous, Ganglion, . Gonorrhoea, Gravel, Gun-shot wounds, H Head, injuries of, Hordeolum,, Hydrophobia, Hernia, femoral, . Hematocele, varicocele Hare-lip, Herpes, Hydrocele, . Hydarthus, Haemorrhoids, Page 108 110 117 I Inflammation, of the testicle breast, eye, Injuries of the head, . Illustrations, Inverted toe nail, Impetigo, . Itch, King's evil, Locked-jaw, Leeches, Lues venerea, K M 117 . 467 . 413 . 433 . 436 . 439 . 218 . 460 . 434 . 239 . 383 . 42 . 62 . 296 . 455 . 358 . 467 . 411 . 410 . 416 . 421 . 405 . 221 . 208 . 16 . 412 . 315 . 275 . 62 . 479 . 437 . 444 . 445 . 265 . 300 . 475 237, 245 Necrosis, Neuralgia, O Mortification, Mammary abscess, Mastodynia, Madness, canine, Mineral poisons, . Means for keeping fractures re duccd, .... to prevent bad conse quences of fractures, Method of treatinjr a hydatid tu mour, .... Mercury, in venereal complaints, 26 315 315 455 456 91 96 431 251 Opacity of the cornea, Ophthalmia, chronic, . tarsi, Operative surgery, Operation in cataract, of couching, for aneurism, fistula in ano, femoral hernia, of castration, trepanning, for enlarged tonsils, Opening the wind-pipe, Plaster, uniting, . Plate of, . Pulleys, remarks on Pterygium, Poisons, tests for, Poison vine, Poisonous gases, Paracentesis, Paronychia, Polypus, Psoriasis, Pernio, Pain in the face, Psora, Prostate gland, diseases of, Piles, . Prolapsis ani, R Ranula, Rickets, Ring-worm, Rupture, Retention of urine, S Sympathy, Suppuration, Scirrhus, Scrofula, figure of a case, Staphyloma, Stye, . St. Anthony's fire, Suffocation, Scarification, Salt-rhcum, Scald head, Sprains, Scalds and burns, Strictures, . Suppression of urine, Stone, Scirrhus of the tenuis. Syphilis. INDEX. T Page V Tumours and warts of the eye, . 297 Varicocele, ...'.. sarcomatous, . 428 Venereal disease, steatomatous, . 428 W encysted, . 429 Wounds,..... Tetanus, .... . 301 incised, Tests for poisons, . 458 lacerated, . Tapping, .... . 471 contused, Trepanning, . 473 punctured, Tonsils, enlarged, . . 434,474 gun-shot, Tongue-tied, . 474 poisoned, Treatment of compound fractures, 98 of the intestines, Testicle, inflammation of, . . 412 in particular parts, Tic-doloureux, . . 426 penetrating cavities, Toe-nail, inverted, . 437 of the thorax, Toothache,.... . 436 joints, Tinea capitas, . 443 of tendons, . Testicle, scirrhus of, . . 409 of the scalp, . U White-swelling, . . . . Ulcer of the eye, . 295 Whitlow,..... Ulcers, .... . 144 Weeping sinew, (sec ganglion,) Urethra, strictures in, . . 374 Warts,..... Urine, suppression and retention of, 378 Wind-pipe, foreign bodies in, APPE NDIX. Page Falling of the womb, . 65 Lethargy, . Inflammation of the womb, . 66 Headach, . Diseases of children, . . 67 Costiveness, . . . . Still-born infants, 67 Piles,..... Retention of the meconium, 67 Suppression of urine, . Acidities, .... 68 Toothache, . . . . Flatulency, 68 Longings,..... Gripes, .... . 68 Hysterics, . Galling and excoriation, . 69 Swelling and pain in the breast, Looseness, or purging, . 69 Palpitation of the heart, Teething, .... 69 Cramps,..... Bowel complaints, generally, 71 Wakefulness, . Aphthae, thrush, or canker, 71 Fits,...... Convulsions, 71 False pain, . Rupture, .... 72 Abortion, . Tongue-tied, . 72 Labour, . Imperforate vagina, . 72 Delivery, . ' . Club, or deformed feet, 72 Parturition, . . . . Choking, .... 72 Management of labour, Sore nipples, 66 Venereal disease of infants, Atrophy, from suckling, 66 Management of children, . Soreness, or excoriation of th e Exercise of ditto, navel string, .... 72 Food of ditto, . . . ' . Conception, 49 Clothing of ditto, Pregnancy, 49 Cleanliness, . Sickness of the stomach, 50 Nurses,..... Heartburn, 51 CHOLERA. Pago Description, .... 3 History, . . ' • 4 Notes on,.....6 Causes, ..... 14 remote, . .14 intermediate, . . 16 proximate, . . .17 Symptoms, .... 18 First, or the incipient stage, . 18 Second, confirmed stage, . . 20 Third, collapsed stage, . . 21 Fourth, stage of re-action, . . 21 Symptoms of the disease, as they occurred in the New-York hos- pitals, .....22 Premonitory symptoms, . . 23 Essential symptoms, . . .23 Premonitory, do not always occur, 24 Discrimination, .... 25 Prognosis,.....26 Contagion, .... 26 Remarks against contagion, . 26 in favour of contagion, 29 Dissection, . .32 Page Common practice, 32 Reformed practice, . 33 Treatment in the premonitory ' stage, .... 33 Circular, .... 33 Treatment in the confirmed stage, 35 collapsed stage , 38 stage of re-ac tion, . . 39 Convalescence, . . 40 Prevention, . 41 Quarantine regulations, . 41 as regards filth, . 41 habitations, . 41 persons, 41 Reports of a medical commission i 42 Cure of the cholera, . 44 as practised among the In- dians, 45 Stephen Ayres' remedy, 45 Dr. Cokes*, 46 Dr. Robson's, 46 Epidemics, an account of, . 47 Notes on the cholera, 81 ?'■