M3L con College of 10fip9iimm anJi ^urgeons( ILihvavy Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofsurgeryfOOcast MANUAL OF SURGERY, FOUNDED UPON THE PRINCIPLES AND PRACTICE LATELY TAUOHT Br SIR ASTLEY COOPER, BART, F.R.S. SEBGEANT-SURGEON TO THE KING, CO'SCi-TIXG SUBGEON TO GUY's HOSPITAL ; JOSEPH HENRY GREEN, ESQ. F.R.S. PROFESSOR OF ANATOMY TO THE ROYAL ACADEMY ^ SURGEON TO, AND LECTURER OIT S^EGERF, ST. Thomas's hospital. THE FOURTH EDITION, COW8IBERAB1.Y ENLARGED, CONTAINING MANY ADDITIONAL NOTE* FROM THE-WRITING8 OF OTHER^DISTINGCISHED SURGEONS, EDITED BY ^ * >» THOMAS CASTLE, RL.S. // r^^.Cum OF qUEEN's COLLEGE, OXFORD J PROFESSOR OF MATERIA MEDICA TO THE ECLECTIC SOCIETY J ETC. ETC, SLontinn : PRINTED FOR E. COX, ST. THOMAs's STREET. 33oston : EE-PUBLISHED BY MUNROE AND FRANCIS, AND JOSEPH H FRANCIS. IN NEW-YORK : CHARLES S. FRANCIS. T,lDCCC^i:.1.TS.. *\\ TO SIR ASTLEY COOPER, BART. F.R.S. SEHJEA.NT-SURGEON TO THE KING, CONSULTING SURGEON TO GUY's HOSPITAL J JOSEPH HENRY GREEN, ESQ. F.R.S. PROFESSOR OF ANATOMY TO THE ROYAL ACADEMY J SURGEON TO, AND LECTURER ON SURGERY, ST. Thomas's hospital ; THE PRESENT VOLUME OF SURGICAL NOTES, CHIEFLY SELECTED FROM THEIR LECTURES, FOR THE USE OF STUDENTS, IS, BY PERMISSION, MOST RESPECTFULLY INSCRIBED, IN PARTIAL TESTIMONY OF THE VALUE OF THEIR INSTRUCTIONS ; AND -WITH THE EARNEST HOPE IT WILL PROVE A CONVENIENT AND USEFUL COMPANION TO THE WARDS ; AND ALSO ASSIST IN THE FURTHER DISSEMINATION OF PRACTICAL LNFORMATION. S% 515' EDITOR'S PREFACE. A VERY prominent object, in the publication of all works, should be, to convey as much useful matter in as concise and convenient a volume as the peculiar nature of the sub- ject will allow. Almost every department of the study of medicine has been presented to the student, both in the elaborate and more restricted form, — the first with a view of furnishing every known circumstance connected with the science, and the second to be the more immediate guide and companion to his studies. In acquiring a knowledge of the theory and practice of surgery, extensive reading is not only beneficial, but abso- lutely necessary, before we can practise with success, or understand the true intention and application of our reme- dies ; yet, for the mere beginner to commence his studies by plodding through volume after volume, forgetting, as he must, in the multiplicity of description, the very facts he is anxious to acquire, is not only overloading the understand- ing ere it can form a judgment for itself, but it is a sad loss of time, and a great source of perplexity and confu- sion. While 'the mmd is young in knowledge, let us re- VI PREFACE. member its powers of comprehension are but weak ; and, since the study of the medical profession generally includes such a variety of subjects, alike extensive and alike wrapt in the mysteries of doubt, rather should we first be taught the ruling principles, and then, when we have derived a per- fect knowledge of the outlines, we may safely venture to drink deeper of the science, and be better prepared to meet the baffling sentiment so universally presented in all medical and surgical works. Although we have advanced thus much upon the part of reading, it is well kno-\vn, that neither the principles nor practice of surgery can be sufficiently impressed upon the mind by that alone. There must be something, far more illustrative, to make a scientific and skilful surgeon ; he must not only read, but he must compare, at the bed-side of the patient, that which he reads, with the peculiar character of attending circumstances. This, and this alone, will make him an accurate observer of nature : he will then be able to judge the value of existing opinions, and not until then can he enter on the stage of his professional life, prepared to perform the various duties of his station. Most students in the country have not the opportunity of pursuing such a course with much advantage ; but, when they arrive at the metropolitan schools, every facility is of- fered, and it only rests with themselves to make a necessary proficiency. The grand source and support of surgical knowledge must ever devolve on the noble institutions which humanity has erected in this and other cities of distinction ; for, without these, the collateral rays, which emanate from private prac- PREFACE. Vll tice, would never have raised the dignity of surgery to the rank it now holds in the opinion of the world. Here we havC; at one and the same time, an assemblage of the disea- ses and accidents to which mortality is heir, and, attached to every institution, a school of instruction for the young and inexperienced, where they may learn to avoid the super- stition and empiricism of our ancestors, and be taught to exercise their profession with honour to themselves, and v,-ith benefit to the public. Although the usual means of cultivating sound surgical knowledge are generally given in these institutions, yet there remains, in my humble opinion, one point in which their utility might be more constantly secured to the pupil. The mere walking from one ward to another, and taking a cursory view of every patient, is not a proper plan to be pursued : they should take with them a pocket companion, and, when they meet with any particular case, they should first make their own observations,and then immediately refer, to know what they have overlooked, or what is unusual to its general character. In this way, they would readily ac- quire accuracy of observation, and soon become tolerable masters of each subject. Notwithstanding the surgical press te-ems with works of every description, I do not know that there is one which will answer the double indication of furnishing the pupil with a general outline of the science, and, at the same time. is sufficiently portable to admit of no material personal in- cumbrance as a companion to the wards. It is under such an impression, that I am endeavouring, in the publication of this volume, to supply that deficiency ; and, as the opin- Vm PREFACE. ions herein contained were for many years delivered at a public liospital,*= and have been occasionally publ'ishedf to the world, the reader must not expect any thing novel, save the manner of re-communication. The lectures, from which I have made my extracts, I was led to select, because they are the result of extensive practice, and the instructions of observing surgeons, — the one highly courted for his skill and universal reputation, the other equally admired for his general knowledge and professional acquirements. The lectures of Sir Astley Cooper^ I would further add, are the result of forty years' experience in St. Thomas's and Guy's Hospitals, and in a large scene of private prac- tice. The only ground, on which I was induced to become editor of this Manual of Surgery^ was the full assurance of the utility and necessity of such a work j and, as the learned lecturers have individually and connectedly given me an honourable permission to re-publish their surgical sentiments, I cannot be considered trespassing on literary property. If a free grant had not been conferred, on the part of the respected gentlemen in question, I would not, on any account, have undertaken the work ; but as they have in this, as in every other professional capacity, proved themselves disinterested well-wishers of surgery, I have availed myself of their generosity, and seek no other remu- neration than their approbation, and the satisfaction of ben- efitting the student. * St. Thomas's Hospital, Borough. I Lancet, Sec. PREFACE. m Thronghout the -u'hole treatise, I have aimed at brevity and clearness of communication, and, wherever it was pos- sible, I have inserted the usual expressions of each lec- turer ; but, thinking that short sentences are best adapted for convenient reference, I have treated each subject in the form of paragraphs with appropriate or occasional notes, and so arranged the peculiarity of type in printing, as to give the whole a marked and impressive appearance ; not how- ever but that one part is as much entitled to minute attention as another. In the present edition, I have endeavoured to remove such points as were objectionable, and to make more perfect other passages, which may have been considered wanting in pro- gressive developement. I have also introduced considerable additional matter, selected from the most popular surgical writings, and more particularly from the truly practical *' Dictionary of Surgery," by Samuel Cooper, esq. a work abounding in interest and utility, and one which every student should use, not only as a book for general reference, but as a valuable compendium of all surgical subjects. My sole object, in the execution of my task, has been di- rected towards the convenience and advantage of the stu- dent, but if he unhappily considers his inquiries have gone sufficiently far, when he understands the contents of the volume in hand, he labours under a very serious and dan- gerous error ; the work is only presented to him to refresh or direct his memory, and" not to complete the grand struc- ture of his surgical understanding : surgery is a science too extensive to be condensed in so small a compass ; it is only possible to give leading points, and he must naturally X PREFACE. look to other sources, before he can conscientiously enter into practice. Although I am desirous, m the present undertaking, of al- leviating the steps to a general knowledge of surgery, let it not be imagined, for one moment, that I am wishing to save the necessary toil and perseverance of greater devotion to the subject, and thereby encouraging idleness in the rising profession ; for, on the contrary, I have pointed out the value of extensive reading, and would have this effort of assistance considered only as intended for their convenience, and as an additional means of ensuring them practical information. It is their duty to recollect that they are hereafter to hold re- sponsible situations in life, and, if they neglect to embrace every opportunity of instruction, they will probably be called upon to equalize the consequences, by a painful reflection of their incompetency to meet the claims upon their public character. I would therefore recommend them earnestly to give their sole time and attention to the true design of their Hospital Education, to search indefatigably after science, and, however difficult or unbounded the prospect may appear before them, they have only to pursue one even path with patient industry, and they will never fail to secure an honourable passport to the ultimate advantages of their pro- fessional studies. T. CASTLE. January 1st, 1831, 38, Bermondsey Square. MANUAL OF SURGERY. PAET I. CONTAINING PRACTICAL NOTES CHIEFLY SELECTED FROM A SERIES OF LECTURES, DELITERED BY SIR ASTLEY COOPER, BART. F. R. S. SEBJEANT-SURGEON TO THE KING, CONSULTING SURGEON TO GTTy's HOSPITAL, &.C. &C. MANUAL OF SURGERY. INTRODUCTION. 1. Surgery is that part of the medical science, which re- lates to the performance of operations for the removal of diseased parts ; and which also shows the use of medicine in cases of local disease, produced by constitutional derange- ment, or vice versa. It would be a very difficult taak to define the exact limits of surgery and pnysic With accidents, tumours, and many other affections of the body, there can be no hesitation as to which province they exclusively belong ; but with regard to erysipelas and a few more, it is almost a matter of per- sonal opinion. 2. Surgery is usually divided into the principles Rui prac- tice. 3. The principles of surgery are learned from observations on the living, when diseased ; by dissection of the dead ; and by experiments upon living animals. Our deductions from these sources ftimish us with the means of know- ing a malady by its symptoms, the alteration of structure in a part which had been diseased, and the various ways by which nature attempts the repa- rative process, both in external and internal parts. 4. In the practice of surgery, many essential qualities are requisite on the part of the surgeon ; as neatness in apply- ing his remedies, gentleness of manner, and self-possession. The quality of self-possession is of the highest importance in surgical operations, for the head must always direct the hand, otherwise the opera- tor is unfit to discover an effectual remedy for the sudden and unforeseen accidents which may occur in his practice. 5. A thorough knowledge of anatomy is absolutely ne- 14 INTRODUCTION. cessary ; it not only firmly impresses on our memory the situation, form and structure of the difierent organs of the body ; it also teaches us how to discriminate disease, and to detect the nature of injuries with more certainty. Morbid anatomy in particular should be attended to. A man who has seen much of morbid preparations, possesses great advan- tages ; but his anatomical knowledge cannot be perfect unless he has seen and assisted in the dissection of the healthy body. In surgical science, hypothesis should be entirely discarded, and sound theory, derived from ac- tual observation and experience, alone encouraged. Observation is a polar star, — hypothesis an ignis fatuus. 6. Physiological knowledge is of the utmost importance to the profession of surgery. This will give you a clear idea of the healthy functions, and thus enable you better to un- derstand the nature of diseased action. 7. The study of medicine is important to the surgeon ; he should be able to prescribe with judgment ; should well understand the great influence of local disease on the con- stitution, as well as the origin of local disorders from consti- tutional derangement. Without such knowledge, a surgeon knows but half his duty, for there are many cases which require a strict medical treatment, and unless the medicines are judiciously administered, the disease will be aggravated rath- er than relieved. 8. Reading and application to your studies will also prove considerable auxiliaries in rendering you well-informed and skilful surgeons. You should read select works on particular diseases ; but I would not recommend to young students those which lay down syste^ns for their guidance. 9. The expenses of your professional education, and the expectations of the public, call upon you to search for true knowledge, that you may, thereby, fulfil your duty toward them, shed honor on the medical profession, and finally, af- ter the necessary toils of life, retire into the bosom of your family honored and respected. 15 IRRITATION. 1. All the actions of the body are excited and sustained by internal and external impressions, which are called stim- ulants. These stimalants may be either natural to the human frame, as blood to the blood-vessels, bile to the intestines, and so ou ; or they may he /"oreign, as medicines and extraneous bodies. 2. Between all the different parts of the human frame, there exist intimate relations, which correspond with each other, and carry on a reciprocal intercourse of actions. The beautiful harmony produced by these concurrent phenomena is called sympathy. Thus impressions not only produce eifects on the part to which they are directly applied, but in consequence of the freedom of communication be- tween the nervous system, parts of the body at a distance from those in which the original mischief exists, become affected by it. 3. Sympathy may exist naturally, as the communication which there is between the uterus and breast ; or it may be the result of injury and disease. 4. When sympathetic action is the result of injury and disease, it becomes the cause of restoration on the one hand; or of destruction on the other. 5. I should therefore say, irritation is an altered action excited in the system by an unnatural impression. Thus sympathetic pain is experienced in the knee and foot from diseased hip, and at the extremity of the penis when there is stone in the bladder j the passage of an urinary calculus through the uretur, occasions retraction of the testicles and pain in the thigh ; disease of the prostate, causes pain on the inside of one or both thighs ; disease of the liver occasions pain in the shoulder ; a diseased testicle, pain in the loins ; and irritation of the intestines, an itching of the nose. 6. The sympathetic effects which we have just mentioned, do not consist of morbid actions of the parts thus affected, but of disordered sensations. Nevertheless, morbid actions 16 IRRITATION. are sometimes excited in parts near to, or at a distance from, those originally affected. Inflammation of the testicles is frequently the consequence of irritation in the urethra ; and swelling of the breast, of a morbid action of the uterus ; but there is no organ so much affected by irritation or sympathetic influ- ence as the stomach, for an obtuse pain in any part of the body will occa- eion sickness. 7. The subject of irritation, consequently, is a very im- portant part of your surgical studies ; it is in fact the chief foundation upon which your practice must be established ; for being, as we have before said, the cause of restoration on the one hand, or of destruction on the other, unless you well understand its great local and constitutional influence, you will be ignorant of the most valuable and unerring guide you can possess. The art of surgeiy, it must be remembered, is exercised on a peculiar ■class of maladies. The diseases which professedly belong to it, are more or less the result of disordered actions ; accidents are for the most part re- lieved by attending only to a moderation or restoration of the sympathetic functions, and of the secretions ; and the success of operations, is also de- pending on the same principle. 8. Irritation, then, is an excited action, necessary, in a certain degree, for the restoration of injuries ; but when too violent, or of a morbid nature, occasioning disease and even destruction of the part. The first part of the paragraph shows, that nothing can be more errone- ous in practice, than to bleed or purge immediately after an injury or an operation, because the skin is hot, pulse quick, and tongue white ; for such a state is necessary for restoration : it is only when action is in dangerous excess, that such remedies are to be resorted to. 9. Irritation is generally communicated through the me- dium of the nerves, of which, there are two grand divisions in the body. The first composed of the brain, spinal mar- row, and their nerves, which naturally convey sensation and volition ; the second, consisting of the grand sympathetic nerve, the centre of which is behind the stomach, in the semilunar ganglion and solar plexus. IRRITATION. 17 The modes of sympathetic communication are various, and with difficulty reducible to any specific law. In some instances, the course of irritation is from the irritated part to the sentient extremity of the nerve, as the pain experienced in the knee and foot from a disease in the hip. In other cases, the course of sympathy is from the atfected part to the origin of the nerve, as in pain in the loins consequent on diseased testicles. Irritation on the nerves of the grand sympathetic, is communicated to the stomach, probably through the medium of the semilunar ganglion ; and to the heart, through the cardiac nerves. 10. Kinds : — Irritation may be of two kinds, local and constitutional ; local, when it affects only particular parts, as with an abscess from a decayed tooth ; and constitutional, when irritative fever is produced by local injury or disease. It is of the greatest importance to ascertain ttie cause of disordered sym- pathetic actions, as the removal of the complaint will depend on this cir- cumstance. If the cause be undiscovered, the effects are likely to continue in spite of every treatment you may pursue. 11. The coTistitutional or general effects of irritation, are not only produced by severe injury, but they are also some- times excited by the most trivial circumstances. A person, on having a bougie passed into the uretha, for the first time, feels faint, becomes sick, looks pale, and unless you prevent it, will fall to the ground. On placing him in the recumbent posture, he soon recovers fais senses; but constitutional irritation frequently comes on, for a short time, in the evening. 12. The symptoms of constitutional irritation following severe injuries, are attended with considerable derangement, the heart, brain, stomach, and other organs participating in the affection. A person receives an injury of the leg, producing compound fracture of one or both bones ; constitutional irritation commences, generally, in twen- ty-four hours ; the patient complains of pain in his loins, extending up the spinal chord, and pain in the head. He then becomes restless, and hia countenance anxious ; the tongue at first is dry and covered with a whitish for, but as the symptoms increase, it becomes yellow, and lastly, coated with a thick brown fur. There is loss of appetite, the stomach becomes irritable, and nausea and vomiting supervene : the secretions are diminish- ed and the stools white. As the severity of the complaint increases, the pulse becomes quick, hard, irregular, and alternately intermittent. The 2 18 IRRITATION. respiration is hurried, intellects deranged, all impressions on the Senses are painful, subsultus tendinum, hiccoughs, vomiting, and tension of the abdo- men come on, the patient sinks into a low muttering delirium and soon ex- pires. 13. From these symptoms we may perceive, that imme- diately upon the receipt of an injury, the usual balance of healthy functions is destroyed, nature becomes alarmed, and directly sets about repairing the damaged parts, by what is termed the restorative process. Accordingly, we find that a strong impression is made on the nervous system; all the secretions are stopped or diminished, to supi)ly the injured part with an increased power to secure its restoration. The various out- lets being closed, the blood collects in larger quantities in the heart, and great blood-vessels ; from thence it is propelled with increased force to the wounded part, and gives rise to some form of inflammation, which either terminates in a cure of the injury, or runs on to a destruction of the mem- ber or of life. 14. The degree of constitutional irritation, resulting from injury, depends on several causes ; these are, the import- ance of the parts injured ; the extent and nature of the in- jury ; the state of constitution, age, and previous habits of the patient. Irritation is greatest in children, and least in aged persons ; the former are very much affected by operations, whilst the latter are very slightly so. 15. Treatment : — The treatment of irritation is very sim- ilar to that required for inflammation. 16. When constitutional irritation arises from a local cause, the remedies must be chiefly directed to the removal of that cause, or to lessen its effects on the constitution ; but, on the contrary, when local disease is either promoted or ag- gravated by constitutional derangement, then your treat- ment must be directed to the disorder of the system, and as that improves, so will the local aff'ection disappear. Constitutional irritation must not be too suddenly subdued nor destroyed, as a certain degree of irritation shows, that nature is endeavouring to ac- complish the restorative process : keep it within bounds, carefully watch its progress, and if necessary check its violence, but do not entirely destroy it. IRRITATION. 19 17. There are two means of reducing irritation: — the first, by restoring to the different organs their various secre- tions, by which the outlets become opened and fever lessen- ed ; — and the second, by allaying the excitement of the ner- vous system. The first indication may be fulfilled by producing a determination to the skin, and the administration of aperients ; but when the irritation is very severe indeed, you should give mercurials to act on the liver, saline aperi- ents on the intestines and kidneys, and antimonials on the skin. The sec- ond indication is answered by giving opium and antimony combined, or cal- omel, antimony, and opium, to act on the skin and liver, as well as on the nervous system. 18. In cases of irritation, bleeding must be resorted to with care, for if it be carried to a great extent, the powers of the constitution will be unequal to the reparation of the injury. 19. "Where there is chronic irritation, the best treatment you can adopt, is to give steadily those medicines which have the greatest chance of overcoming the complaint. My favorite medicine is the oxy-muriate of mercury combined with rhubarb, bark, or sarsaparilla ; Plummer's pill is also a very fair remedy j as also, the blue pill at night, with saline aperients in the morning. INFLABIMATION. 1. Inflammation is the process hy which local injuries are repaired, and it may therefore be considered as the resto- rative principle. By inflammation, however, is genernlly understood, the state of a part, in which it is painful, hotter, redder, and somewhat more turgid, than it nat- urally is ; which symptoms, when present in any considerable degree, or when they affect very sensible parts, are attended with fever, or a general disturbance of the system. 2. There are four signs that commonly attend it j viz. redness, pain, increased heat, and swelling. 3. Redness : — Arises from an increase of the red particles of blood in the part. 20 INFLAMMATION, More blood must necessarily be contained there, because tlie vessels, which previously conveyed the fluid, are preternaturally distended, and the small vessels, which naturally contained only lymph, are now so enlarged as to be capable of leceiving red blood. 4. Fain : — Increased sensibility or pain, is owing to dis- tention of the nerves, by the greater quantity of blood de- termined to them. Parts naturally little sensible, are quite the reverse when in a state of inflammation. Bones, though nearly destitute of sensation in their healthy state, are sometimes extremely sensitive when inflamed. 5. Increased Heat : — This is not yet generally allowed to exist. Though no increase of heat is manifested in internal inflammation, yeft when it occurs on the surface of the body, an alteration sometimes, of sev- eral degrees, takes place. It is said never to exceed the heat of the blood, at the heart. This in health is about 100° Fahr.4 but sometimes in disease it rises to 160° or even 170°.^ 6. Swelling : — Ts owing in a measure to an increased de- termination of blood to the part, and also depends on effusion of the fibrin of the blood, which, in coagulating, deposits serum in the surrounding cellular tissue^ That the extravasation of coagulating lymph has a remarkabFe share ire producing the swelling of inflamed parts is unquestionable ; for it fills up all their interstices, glu«s their wh&le structure together, and consolidates them into one mass. Frequently, when its quantity isconsiderabl*, it is convert- ed into a true cellular, or membranous texture, or assumes more or less, the peculiar qualities of different organs. This is very evident in the bones. By means of such change, also, several loose parts may acquire the external properties of denser organs. Thus, the lungs are sometimes turned into a liver-like substance, and hence calPed hepatized. 7. Kinds : — Inflammation may be either acute or chrome. 8. Acute Inflammation : — Acute inflammation usually goes through its various stages with great rapidity. The adhesive stage is marked by hardness and pain ; the suppurative, by irritative fever, fluctuation, and throbbing or pulsation ; ulceration usually Bucceeds in a short space of time, and the matter is discharged^ CHRONIC INFLAMMATION. 21 9. Chronic Inflammation : — Chronic inflammation is exceed- ingly slow in its progress, and is either the result of acute in- flammation, or owing to a peculiar state of constitution, oc- curring in persons vrho have lived intemperately, or "u-ho hare been depressed by laborious exertions and disappointments. An instance of chronic inflammation succeeding the acute, maybe seen in gonorrhoea. During the first stages of this complaiat, we are obliged to check the action of the vessels of the urethra, but afterwards to excite it by the balsam of copaiba, and slightly stimulating injections. 10. Inflammation may also be either common or specific. 1 1 . Common Inflammation : — Common or healthy inflamma- tion is the kindle look to for the reparation of an injured part. Shortly after an injury, if inflammation of this character is set up, adhe- sive matter is thrown out upon the edges of the wound, by which they become perfectly united. 12. Specific Inflammation: — In specific or unhealthy inflam- mation, the vessels have an entirely diff'erent action to "vrhat happens in the healthy, and thus the fluids and solids which they secrete have a decidedly opposite character. There are two descriptions of specific inflammation : the first is produced by a peculiar condition of the constitution, as in the formation of schirruSj scrofula, gout, &c. and the second, by the application ©f a poison, as in syphilis, &c. The best example of the first kind is scrofula. Persons attacked by this disease, have generally light hair, fair complexion, and a delicate appear- ance : when inflammation occurs, it is slow in its progress, although easily excited ; and at last, ulceration taking place, the discharge consists of curdy matter, or a thin serous fluid, not at all resembling the pus which is formed in healthy inflammation. Gonorrhoea, variola, &c. are good illustrations of the second kind of spe- cific inflammation. Thus, in gonorrhoea, the matter secreted is widely dif- ferent fi-om common healthy matter, having in the first place a much large- quantity of mucus mixed with it ; and, secondly, when applied to a secre- ting surface, is capable of exciting in the part, an action by which similar matter and the same efi"ects can be produced. The matter of small-pox oc- casions the same result, and as far as constitutional effects are concerned, it does not seem material how large or how small a quantity of the poison is applied, the result in each case depending upon the state of the consti- tntion. 22 INFLAJIMATION. 13. Irritahle Inflammation : — In addition to the kinds of in- flammation already mentioned, there is another, -^hich I pro- pose to call the irritable. In this kind, the nerves are more affected than the blood-vessels j consequently the parts labour- ing under its influence, are exceedingly tender to the touch. The eyes, the breasts of young women, the bladder, and the testicles are very disposed to this species of inflammatioa. 14. Causes: — The true jjrozmc^e causes of inflammation, appear to be an increase of action in the vessels of the part, and an increase in the size of the vessels themselves. With regard to the proximate cause, there has been a great diiFerence of opinion. Galen considered phlegmon to be produced by a superabundance of the sanguineous humour. Boerhaave referred the proximate cause to an ob- struction in the small vessels, occasioned by a leiitor of the blood. Cullen and others attributed it rather to an affection of the vessels than a change of the fluids. The question, however, is by no means satisfactorily explained. 15. Exciting : — The exciting causes of inflammation are whatever produces an unnatural state of the parts, calling up- on nature for its reparation,whichshe effects by the process of inflammation, as bruises, pressure, extraneous substances, &c. Mechanical or chemical irritation, changes of temperature, and stimulating foods are also exciting causes. Fever often seems to be a remote cause, the inflammation thus produced is generally considered as critical. Spon- taneous inflammation sometimes occurs when no perceptible cause can be assigned for its production. 16. Inflammation sometimes arises from debility, as is frequently seen in the extremities of old persons, in whom the blood returns to the heart with difficulty. From the weakened power in elderly persons, the arteries are called upon for unusual exertion, and inflammation of the skin succeeds, frequently at- tended with incrustations, and sometimes with a watery secretion into the cellular tissue. In these cases, bleeding must be resorted to with caution. 17. Irritable persons are much more predisposed to inflam- mation than others, and, when it occurs in them, it is of a more dangerous nature than in those who are not irritable. INFLAMMATION. 23 Thus in fevers, when the constitution has been much weakened, the parts on which the body has been resting become inflamed, and quickly mortify. But in fractures, where the system is healthy and strong, although the pa- tient remain many weeks in bed, no such effects are produced. 18. Treatment : — The treatment is either constitutional, local, or both combined. 19. Constitutional Treatment : — When any important organ is injured, or its functions disturbed in consequence of the influence of an injury on the constitution, the treatment must be in\^ariably constitutional. In persons of irritable habit, constitutional treatment is necessary, wheth- er any important partis injured or not ; foi- in these cases, very trivial local damage will speedily affect the entile system. 20. The most powerful remedy for relieving inflammation is the abstraction of blood : its beneficial effects principally result from producing a diminution of nervous power, or syn- cope ; — secondly, by lessening the quantity of blood ; — and lastly, by facilitating the re-establishment of the secreting functions. A hard, wiry, and quick pulse indicates blood-letting ; but quickness of pulse is not in itself a sufficient proof that bleeding is requisite ; but when united with hardness, no additional evidence of its necessity can be wanted. The pulse, however, is not always hard when inflammation attacks impor- tant parts, for when the stomach or intestines are thus affected, the pulse is scaicely perceptible. 21. The indication for a repetition of blood-letting, is said to be a buffy state of the blood ; but your decision must not be governed by this appearance, you must still have a hard pulse. When blood is cupped, it is said to be a proof of strength, and that bleed- ing should be repeated ; but experiments have shown that even a cupped state of the blood, and buffiness conjoined, are not sufficient evidence to warrant the repetition of blood-letting. 22. The quantity of blood which should be drawn, must depend entirely on the severity of the complaint. As the grand object of bleeding in inflammation is to produce syncope, the blool sliouIJ be ab.-tractad rapidly ; therefore tke orifice made into the ves- 24 INFLAMMATION. sel snould be of considerable size ; for if it be allowed to run slowly, the ves- sels have time to accommodate themselves to the diminished volume of circu- lating fluid ; so that the system scarcely receives any shock when blood is abstracted in this gradual manner. The grand object is always to produce faintiDg. 23. When you hare accidents brotight to you, which will require a long time for their recovery, 5'ou must be exceed- ingly careful how you take away blood from the general sys- tem, but must adopt, in these cases, local depletion. There are some cases of inflammation, where bleeding will not afford relief: this more frequently happens in inflammation of the testicle than in any other part. For these affections you must administer the compound jiowder of ipecacuanha, combined with calomel. 24. The second mode of relieving inflammation, is by re- storing the secretion. The most important secretions are those of the liver, intestines, skin, and kidneys ; and when these cease to perform their proper functions, from a shock on the nervous system, irritative fever is the consequence. 25. As it is necessary in inflammation, not only to act upon the intestines, but also to stimulate the liver, the best plan is to give calomel at night, and a saline aperient in the morning. An excellent aperient for adults is one grain of calomel, with four of cath- artic extract ; or two of blue pill, with three of cathartic extract ; castor oil, may also be recommended ; and as another safe opening medicine, you may prescribe infusion of senna with sulphate of magnesia. In children, calomel with rhubarb, scammony or antimony, may be ordered as aperients ; and in addition to these means, the use of injections, and the warm bath, are the best means of restoring the secretions of the digestive organs. 26. The secretion from the skin, may be produced by giv- ing antimonials with calomel ; and that of the kidneys, by the administration of diluents, squills, or acetate of potash. Extensive inflammation will not be overcome by restoring this or that se- cretion, for it cannot be effected but by the complete restoration of them all, 27. Provoking a constant nausea in the stomach, is ano- ther mode of subduing inflammation. INFLAMMATION. 26 For this purpose, the solution of tartar emetic should be giveu in repeated small doses ; it will relieve that oppressive dryness of the skin which accom- panies the fever attendant on severe local inflammation ; diminish the in- creased action of the heart and arteries in general ; tend to restore the se- cretions ; and v/ill be found, more or less, to promote the removal of cos- tiveaess. 28. The remedies employed in chronic inflammation must have a slow and gradual action on the secretions. You cannot take this disease by storm. Calomel and opium ; compound pills of sub-muriate of mercury ; oxymu- riate of mercury, with the decoction of sarsaparilla ; and in children, rhu- barb, with the hydrargyrum cum creta. 29. From what has been said on the treatment of inflam- mation, it appears that, by venaesection, we diminish the quan- tity of circulating fluid, and, assisted by the restoration of the secretions, we prevent the heart from propelling a great quan- tity of blood with violence to any particular part of the body. 30. Local Treatment : — Cold applications will relieve, by ab- stracting heat, by lessening the size of the vessels, and by di- minishing the action of the part, through lessening its ner- vous irritability. A lotion of sp. vini rect. §j. with aquae §v. is the best local remedy. Ice is not recommended in the inflammatory stage, it irritates and sometimes produces gangrene. In applying spirits of wine, let your cloth be very thin, that evaporation may freely take place. 31. In contra-use to cold applications, heat and moisture are very valuable, for the two produce relaxation, open the pores, give rise to perspiration, and thereby remove con- gestion. Fomentations or poultices are the general forms. Leeches are used with the same view as poultices or fomentations ; and also in some cases, puncturing the veins of the part with a lancet. 32. As in the acute inflammation, our object is to diminish, vascular action ; so in the chronic, we endeavour to increase it, by the use of stimulants. « 26 INFLAMMATION. Thus in long-continued discliarges arising from relaxation, we employ Btiraulating lotions, for the purpose of restoring to the vessels their healthy power of contraction. Again, in sluggish indolent ulcers, it is absolutely necessary to excite action. 33. Counter-irritation : — Is a very powerful remedy in in- flammation, and its advantages numerous ; but the chief benefit arises from its drawing ofi" the blood from the neigh- bouring inflamed parts, whereby it checks the course of disease in important organs. Thus a blister at the nape of the neck, if early applied, will arrest an in- flammation of the brain, and so on in other parts of the body. Blisters, is- sues, setons, and ointment of tartarized antimony, are the usual counter- irritants. 34. Counter-irritation, if carried to too great an extent, will aggravate the original disease. 35. Position and rest must be particularly attended to, in the treatment of inflammation. 36. Indurations frequently remain after inflammation has entirely ceased. These are to be got rid of by diminishing the circulation of the part, and producing absorption. Piessure with rollers or strapping, electricity, mercury, and friction, are the usual means resorted to. 37. Effects : — In inflammation, the vessels of the part are in a dilated state, and the surrounding ones have an increased action. 38. The local effects of inflammation, are either adhesion, suppuration, absorption, or gangrene ; the constitutional symp- toms are similar to those of irritation. 39. Inflammation produces different results in different parts 40. When seated in the skin, it usually becomes extensive, because the surface is unbroken. INFLAMIVIATION. 27 Its colour is very florid ; it separates the cuticle in the form of vesica- tions, which usually contain serum, but also in some cases, fibrin 3 a serous effusion is also produced by it into the subjacent cellular tissue 3 in some instances it is preceded by fever, in others follo'wed by it. 41. In che cellular meynbrane, inflammation produces an ef- fusion which obliterates or fills its cells ; if it proceed, it oc- casions suppuration, and produces an abscess. 42. In debDitated irritable constitutions, inflammation destroys the cellular tissue, and produces cc'r^z^ac^e ; but if the inflammation is of a chronic nature, it occasions tumours of various kinds, as the steatomatous or adipose ; or. under peculiar circumstances, those of a malignant nature, as the schirrhous, fungous, &c. 43. Inflammation of fasdcB is generally extensive, from the large surfaces they present. When matter is produced by inflammation of this texture, and is seated under it, great irritative fever succeeds until it is discharged, as,for example, in the palms of the hands, or soles of the feet. 44. When inflammation attacks muscles, it is kno^vn by the spasmodic twitchings which attend it. It is from this cause, in fractures, that patients are restless for the two or three first nights. 45. Tendons are not very susceptible of inflammation, but they sometimes become inflamed to a considerable extent. ■ Punctured wounds of tendons are apt to produce tenatus more than wounds of other parts of the body. Matter formed under tendons, burrows to a great extent, and produces violent irritation. 46. Inflammation in the aisorbent vessels, is marked by red lines on the skin, in the course of these vessels. These form hard knots, from the skin participating in the inflammation. Their glands also become inflamed, and both glands and vessels occasionally suppurate. Absorbents more frequently inflame from common irritation than from the absorption of poison. 47. Arteries are rarely inflamed, excepting after wounds or the application of ligatures. 28 INFLAMMATION. Inflammation of the arteries is, however, sometimes very extensive even going as far as the heart itself. This I have frequently observed in patients who have died from constitutional irritation, after an operation where a ligature has been made on an artery. 48. Veins which are inflamed from -wounds, become like hard and broad cords, and extremely tender to the touch. The process of inflammation in veins is slower than in the arteries ; and when it reaches the valves, these generally adhere, and, glueing the sides of the vein together, often prevent any further mischief. 49. Nerves are very rarely inflamed, but when they are, the pain is excessive, and there is a tingling sensation in the parts to which the nerve is distributed. Wounds of nerves, though extremely painftil at the moment, are followed by little irritation. 50. Ligaments, like tendons, are not very prone to inflam- mation in healthy constitutions : but the synovial membrane which lines them, is highly so ; and the inflammation has a tendency to go on to the suppurative process. In scrofulous persons, the synovial surface becomes inflamed and the liga- ment covering it thickened, so as to produce great enlargement of the joints. 51. Cartilages in joints, ulcerate from inflammation, and often become entirely destroyed. 52. The bones, like other parts of the body, are subject to inflammation ; and when fractured, it is by this process that their union is efliected. Suppuration, ulceration, and mortification also attack the bones, so that this structure,like all other parts of the body, is subject to the different pro- cesses of inflammation. 53. Serous membranes, when inflamed, are remarkably disposed to pass into the adhesive inflammation ; whilst mucous: membranes, on the contrary, generally go into the suppurative state. 29 ADHESIVE INFLAMMATION. 1. Adhesive inflammation is the process by ^"hich divided parts become united. Unless adhesive inflammation take place, not the slightest wound \yould unite, it is therefoie one of the first points of surgery, to endeavour to ob- tain a healthy adhesive inflammation. 2. Serous membranes, as we have already remarked, are particularly disposed to adhesive inflammation, "^'hereas mu- cous surfaces, on the other hand, are generally attended with the suppurative process ; that is, in both cases, if the inflam- matory action does not subside without effecting a change in the parts. This ordination is a most beautiful and wise provision of nature ; for if the serous membranes of cavil ies, such as the pleura and peritoneum, instead of the adhesive, were to receive and support the suppurative inflammation, effusion and death would be the inevitable consequences. Again, were the mucous membranes of the urethra, intestines, and so on, affected with adhe- sive inflammation, instead of the suppurative, the outlets of our bodies would be closed, and death certainly follow. Sometimes, however, where inflammation of a mucous membrane is ex- ceedingly violent, it passes into the adhesive state, glues the parts together, and, unless relieved by an operation, would end in the destruction of life. 3. Adhesive inflammation once set up. either as the result of an accident or otherwise, the fibrin of the blood is effused into the cellular membrane, or on the surface of the wound, by which means, a connecting medium is formed, and the parts become permanently united. Adhesive matter, when effused on a thin membrane, coagulates into a net work, assuming the character of cellular membrane. 4. The length of time which is necessaiy to transpire be- fore the adhesive inflammation commences, is different accor- ding to the structure of the part, a ad the nature of the consti- tution. 30 ADHESIVE INFLAMMATION. In the cavity of the abdomen, the intestines will be glued together in nineteen hours, or thereabouts. On the surfaces of wounds, the process of adhesion takes place still more rapidly. 5. "When adhesive matter has been formed, blood-vessels soon enter it, and within a short time it becomes organized ; the vasa vasorum are elongated by the force of the circula- tion ; they enter the newly-formed substance, and send throughout it minute ramifications. In cutting into adhesive matter, within twenty-four hours after it has been deposited, small bloody spots may be seen, which mark the future situation of the vessels which nourish it 3 but it is not till ten days after it has been formed, that adhesive matter becomes completely organized j for you will find that a fine injection would not enter adhesive matter, sooner than the tenth or eleventh day after its formation. When vessels elongate, they have not the character of arteries 5 in general, they take a serpentine course. 6. The adhesive process is useful in the formation of cysts, in healing wounds, sealing blood-vessels, enclosing pus, and by its dividing cavities into distinct parts, thus fix- ing a boundary to the suppurative process. 7. The effusion of adhesive matter, by unloading the vessels of the part, has the effect of reducing inflammation, so that the process generally terminates as soon as this effect is pro- duced. SUPPURATION. 1. Suppuration is one of the terminations of inflammation ; it consists in the formation of purulent matter from the secre- ting orifices of the blood-vessels, which matter is named pus. Pus is formed in cavities, produced in the body by a process of absorption, as in abscesses ; it is found also as a secreting fluid, on the surfaces of mem- branes, or upon granulating surfaces. 2. The formation of matter is often attended with severe constitutional irritation ; there are rigors succeeded by heat, and if the inflammation be extensive, or seated in any vital SUPPURATION. • 31 organ, the constitutional disturbance will be very severe, and the shivering, which indicates the formation, will also be severe, and followed by a powerful re-action. When pus is easily produced, as upon mucous membranes, there is no rigor whatever. 3. When there is an attempt to produce matter, there is an unusual sensation of uneasiness in the part, together with a blush on the skin. As this continues, the tumour becomes soft in the middle, but remains hard at the sides ; the centre rises, and upon pressure, fluctuation will be evident. In the adhesive inflammation, the pain is an acute thrilling one ; but here it is more dull, and is, likewise, pulsatory or throbbing. 4. The next thing to be observed, after the pointing of the tumour, is an effusion of serum beneath the cuticle, which, separating it from the cutis, it becomes gradually distended, and then bursts, leaving the cutis exposed. Ulceration sometimes takes place on the surface of the skin, whilst the same process is going on internally, so as to facilitate the discharge of the matter : generally speaking, however, the ulcerative process is continued entirely from within. 5. Pus is generally formed, in from seven to fourteen days ; but the time required for this process will very much depend on the constitution of the patient, and the structure of the part in which the inflammation is seated. 6. Some parts more readily run into the adhesive, others into the suppurative inflammation ; the pleura, pericardium, peritoneum,&:c. are subject to the former ; while the urethra, vagina, lachrymal duct, trachea, bronchia, &;c. are liable to the latter : serous surfaces therefore are affected by the ad- hesive inflammation, and mucous surfaces by the suppu- rative. The vessels of serous membranes are too small to permit the transmission of the particles which pus contains ; but when the inflammation becomes excessive or long continued, then the vessels dilate, and purulent matter ia formed, even on seroua surfaces. ■Br^- 32 SUPPURATION. 7. Pus is not a fluid produced by the dissolution of the solids ; it is secreted by the blood-vesselsj but not till they have been acted upon by inflammation. The effects produced by the application of a blister exompHfy this. When the cuticle is raised, first serum and fibrin are thrown out ; remove the cuti- cle, and apply upon the raw skin a piece of glass ; at first no matter is to be seen, but in a few minutes you will observe it collect and adhere to the under side of the glass. Bile, urine, the tears, and in fact all the fluids are secre- ted from the blood, but in each instance the action of the vessels is different. 8. Pus is composed of particles, nearly similar to the blood, only differing in colour, swimming in a fluid resem- bling serum, and coagulating as serum does, when exposed to the influence of heat. Pus, when healthy, is a bland fluid, and will not irritate the parts that pro- duce it J but when it is unhealthy, having mixed with it too large a portion of serum, or when bloody, then it will irritate and occasion excoriation. Healthy pus appears to be composed of the constituent parts of the bloody slightly changed in their character, by inflammation. 9. When pus of a poisonous kind, (the result of specific inflammation) is applied to the surface of the body,it irritates^ occasions inflammation and suppuration, and the newly -formed matter is exactly of the same virulence and poisonous na- ture, as that which produced it. The discharge of gonorrhoea, chancre, vaccine, and variolous matters, are well-known examples. 10. Suppuration answers two very beneficial ends : the first, by forming a convenient covering to granulating sur- faces ; and the second by effecting the escape of extraneous todies. 11. Some wounds are very troublesome, — do what we will, we cannot get them to heal. In these cases, it is advisable to discontinue your dressings, and let their surfaces remain exposed to the air, incrustations or scabs will form ; under these, pus will be secreted, which, by keeping the granulations constantly moist, will often cause ulcers of this kind to heal, when all artificial at- tempts have been completely uneuccessful. ULCERATION OR ABSORPTION. 33 12. Long-accustomed discharges require great caution when healing them ; for, if done too suddenly, hectic or apo- plectic symptoms are very apt to supervene. Quantities of matter, constantly discharging for a considerable period, in- evitably act on the constitution as sources of depletion j and which, if sud- denly discontinued, will naturally produce the symptoms just mentioned. 13. Ancient surgeons, therefore, instituted issues as a counteraction ; but purgative medicines will answer much better, and speedily carry from the system, by a natural channel, any increase of its fluids. 14. Suppuration is best promoted by the application of heat and moisture combined. ULCERATION OR ABSORPTION. 1. Ulceration is the absorption of any part of the body, and the result of previous inflammation. Inflammation has not only an influence on the arteries ; it has also an ef- fect on the absorbent vessels ; there is a natural balance between the action of the arteries and the absorbent vessels. In a state of health, and at the adult period of life, the portion of matter deposited by the arteries, and the portion taken into the system by the absorbent vessels, are, as near as possi- ble, balanced. But if any considerable inordinate absorption of some part of the body takes place, that absorption is called xdceration. 2. Ulceration, therefore, arises from an increased action of the absorbents ; and this generally proceeding from pres- sure united with inflammation. These vessels are thrown into a state of inordinate action, whenever any considerable quantity of blood is thrown upon them ; whereby the natural balance between the arteries and the absorbents is destroyed. 3. Ulceration often occurs without being accompanied by any purulent secretion. 3 J4: ULCERATION OR ABSORPTION. Aneurism is a very good proof that pressure is the cause of ulceration, and that ulceration is not necessarily accompanied with the formation of matter. 4. Formation of matter more frequently happens on ex- posed surfaces of the body, where it is necessary for the pro- tection of sores, by covering the granulations. 5. The constitutional symptoms of ulceration are usually moderate. In general, a degree of fever attends it ; but it is rather of the hectic or chronic kind, than sudden or violent in its attack. The pulse is under 100, and at the same time small ; and the pain is of a gnawing dull nature, as if insects were about the part. 6. The local symptoms present the appearance of the part being worm-eaten ; the surface is rough and very irregular. 7. Ulceration is sometimes extremely rapid, and exten- sively destructive : as much will be destroyed in a few hours, as will require weeks and months to repair. The difficulty of cure must necessarily be proportional to the extent of surface destroyed ; something will depend also on the form of the ulcera- tion, and the kind of surface exposed. 8. The ulcerative process has always a tendency to the nearest external surface of the body. In consequence of this tendency, matter, formed at a depth in the body, finds its way through the integuments, instead of proceeding through the more important parts. 9. This is a law in part depending on the less vitality and greater irritability of those parts which are nearest the sur- face of the body. The external parts are more weakly, with respect to circulation, and more readily absorbed. The external parts are not weakly with regard to the quantity of blood, for they possess a consideiable share of vascularity ; but they are weakly with respect to the living powers : they are more irritable, and more subject to vicissitudes of action, from corresponding changes of temperature, than other parts of the body j have less strength of circulation, and, consequent- ly, give way to ulceration more readily than those parts which are deeper seated, and possess a greater strength of circulation. ULCERATION OR ABSORPTION. 35 10. Parts, at a considerable distance from the source of circulation, are generally more disposed to ulcerate than others situated near to the heart. This accounts, in a measure, for the greater number of ulcers on the lower extremities, than on the arms. 11. Newly -formed parts of the body, such as cicatrices, callus, and all adventitious new matter, like tumours, are more liable to be absorbed than those which have long ex- isted. In Lord Anson's voyage, when the crew of his ship began to suffer from great privations, fatigue, scurvy, &;c. it was remarked, that such men as had had ulcers and broken bones formerly, became again disabled by their old sores breaking out afresh, and the callus of their old fractures being removed by absorption. When the men got fresh vegetables, &.c. on shore, they recovered their health, their bones united, and their sorea healed. 12. The irritablility of a part is proportional to its weak- ness ; and the parts, which are M^eak and irritable, fall most readily into the ulcerative process. When a child labours under symptoms of constitutional derangement in cutting a tooth, why do you lance the gum .'' You cut the gum, not for the purpose of making an immediate passage for the tooth, and procuring imme- diate relief to the child, but, because, when the gum by the adhesive pro- cess heals upon the divided part, a cicatrix is produced by this little opera- tion, which is very readily absorbed ; and the result is, that when the tooth rises, the child cuts it with much less pain and irritation than it otherwise would have done. 13. In those parts which are endued with little vital pow- er, ulceration takes place very readily ; while in those to which the quantity of blood sent is very small, ulceration takes place with difficulty. This is the case with tendons. Tendinous parts possess very little blood ; very few arteries or absorbent vessels are distributed to them. Hence the process of absorption goes on with great difficulty, and tendons will slough to a great extent rather than become absorbed. 14. The circumstance of tardy absorption of tendinous structures must not unfrequently influence our practice. 36 ABSCESSES. Wlien there is an abscess under a fascia, an incision should be made as soon as possible through the covering, to liberate the confined matter ; so with an abscess of the finger, when the constitution suffers because the theca will not give way to the process of ulceration, and the nervous system be- comes irritated by the pressure of confined matter, an early incision should be made to liberate the matter, and give relief to the constitution. The eame practice should be pursued in abscess of the palm of the hand. 15. The ulcerative process is useful to the animal econo- my, in removing extraneous^ bodies from the system ; in the exfoliation of portions of bone, and in separating parts which would otherwise remain in the body for the remainder of life. Thus a ball lodged in the body, and a ligature round an artery, are disen- gaged by the ulcerative process. ABSCESSES. 1. An abscess is a collection of matter in a cyst, produced by inflammation, giving the surrounding parts a tendency to the ulcerative process, so as to lead to their absorption. First, there is an inflammation of the adhesive kind in the cellular tissue, by which the different cells of the cellular membrane become filled with ad- hesive matter. A slight ulcerative process takes place, the inflammation still proceeding, and a little cavity is formed by the process, a space being left for the effusion of pus, the result of the second stage of inflammation. A drop of matter is secreted into the cavity, and as soon as it is poured out, the pressure on the side occasions an increase of the ulcerative process, which adds to the cavity previously formed. More matter is then produced, and the surrounding solids have a tendency to the same process ; it is accu- mulated so as to lead to absorption of the neighbouring parts. 2. In the formation of an abscess, matter does not pro- duce absorption of all the parts around equally. It excavates chiefly on the side towards the skin, and very little in the opposite direction j therefore has no power of eroding. — 1« I ilr' ' -"■ • -^ -^«~fe- ^' • ABSCESSES. 37 3. Abscesses are dangerous according to their size, num- ber, and situation. 4. In large abscesses, neither the danger nor consti- tutional effects arise from the quantity of matter produced, but from the difficulty which nature has in repairing the devastation made by the excavation of the solids, from the pressure of the matter. An abscess may discharge a great quantity of matter, and the constitution may not have scarcely been affected by it , but, very soon after it is opened, the constitution begins to suffer. Very large abscesses sometimes termi- nate favorably, but in a number of cases they destroy life. 5. A great number of small abscesses on the surface of the body, as in small-pox, frequently terminate fatally. Here nature performs the suppurative process ; the pustules die away, and the cuticle is separated from the surface of the body ; but nature has not the power, in many cases, of repairing the destruction of the cutis ; the exposure of the nerves of the skin occasions great constitutional irritation, and the patient dies as if destroyed by a burn or a scald. 6. Abscesses are also dangerous from their being situated in vitally important parts, such as the brain, heart, or lungs j and even though not situated in vital parts, they sometimes become dangerous, by their pressing on them. Abscesses in the perinaeum, or between the prostate gland and the rec- tum, will, by their pressure on the urethra, occasion irritation of that part, and sometimes complete retention. 7. When bones form the boundary of abscesses, they be- come very long and tedious in their progress, and, in some cases, attended with'a considerable share of danger. Thus it is in psoas abscess : in this disease, the matter begins to collect on the fore part of the vertebrae, and proceeds through the hollow of the psoas muscle till it reaches the groin, where it makes its appearance just below Poupart's ligament j extensive discharge supervenes, and not unfre- quently the patient sinks. 8. When abscesses occur between bones and their cover- ings, exfoliation sometimes takes place to an alarming extent. 1^.; 38 ABSCESSES. 9. Abscesses are either acuU or chronic ; the former hav- ing a common course of three weeks ; the latter much slower in their progress. 10. With the acute abscess, the adhesive inflammation first begins ; this is succeeded by the suppurative ; and, last- ly, the ulcerative process comes on ; and it is generally three weeks from its commencement before matter is discharged. 11. The constitutional treatment of acute abscesses should be directed towards the secretion of the bowels, by sulphate of magnesia ; and the nervous system and painful sensations relieved by opium. The best medicine you can give, is three or four table spoonfuls, three times a day, of a mixture, made with six ounces of the solution of acetate of ammonia, one ounce of sulphate of magnesia, and one drachm of the tincture of opium. By this medicine you lessen irritation, and promote the suppurative and ulcerative processes. 12. The local treatment consists in the application of fomentations and poultices, for, by promoting heat and mois- ture, a greater quantity of blood is sent to the part, and a relaxation of the vessel takes place : this expedites the sup- purative process, and, that being done, the ulcerative process takes place with more ease. The kind of poultice to be applied, is of little importance ; linseed or bread poultices are perhaps the best. No stimulating application vi^ould do. 13. In the suppurative stage, prevent evaporation by cov- ering the part with oil-silk ; it preserves the heat and mois- ture, is clean, agreeable to the patient, and most conducive to his comfort. 14. If an acute abscess seems disposed to go through its different stages without any interruption, the best practice is to leave it undisturbed. 15. Acute abscesses, beginning under aponeurotic fasciae, ought to be opened as early as possible ; the earlier the better. ABSCESSES. 39 The moment one drop of matter may be felt to fluctuate, it is advisable to make a ftee opening both as regards the constitution and the part. 16. "Whenever matter can be felt close to bone, it wiH be right to open it, excepting in cases where it may occur from severe courses of mercury, between the cranium and per- icranium. In those cases where a fluid exists, between the pericranium and bone, unattended with any blush, do not open it ; it will be removed by purging, and giving bountifully the decoction of sarsaparilla ; but when matter is formed and there is a hlush, it will not be absorbed j an opening must be made, and exfoliation will often take place. 17. As in acute abscesses we are called upon to diminish the state of excitement in the constitution ; so, on the other hand, in chronic abscesses, we must do all we can to give the constitution additional powers, by allowing the patient a generous diet, and administering ammonia and bark. 18. Stimulating poultices should be applied to the part, and, when the abscesses are of an indolent nature, a stimu- lating plaster will prove serviceable. The best poultices for the purpose are made with yeast and oatmeal, or vinegar and flour, and these wetted with a solution of common salt. The compound galbanum plaster, mercurial plaster with ammoniacum, and soap plaster, are those commonly used ; they excite the parts to action, and gen- erally produce a slight local perspiration. 19. When it is necessary to open an abscess, you should do it early, particularly in exposed parts of the body, as the early discharge of matter is the prevention of scars. Abscesses situated in-the neck, or any exposed part, should be opened before the skin is much affected, and before a blush has appeared ; thus scars will in general be prevented, and the incision should be made trans- versely and not in the axis of the neck. When these tumours have ac- quired the hue of a grape, the veins are dilated, and they, consequently, should never be opened. 20. In common abscesses a small opening is sufficient, but, when the matter is seated beneath a fascia, it should be more free. 40 GRANULATION. After the opening is made, the matter should be pressed out, and the •wound poulticed, or the adhesive process attempted by pressing the sides of the cavity together, and retaining them in that position (leaving a suffi- cient hole for the escape of matter) by strapping j or, if necessary, by the application of bandages. If the edges of the wound should not unite in any part, a little injection of sulphate of zinc or copper may be used. 21. Hectic fever, sometimes attending abscesses, does not arise, as was formerly supposed, from absorption of the mat- ter into the system ; for, till after the abscesses have broken, the constitution is not attacked with it. The formation of matter is usually attended with a slight fever, but not of the hectic kind ; the tongue will be clean, the pulse very little affected, and the patient very slightly deranged ; but after an opening is made into the part, constitutional irriteition comes on ; and life is then endangered. 22. The degree of hectic fever is not at all proportionate to the size of the surface on which the matter is formed. For in extensive sores of the leg, there will be little or no inconvenience ; whilst a sore on the lungs, of the size ofhalf-a-crown, produces hectic fever of the most violent kind. 23. Old surgeons imagined, that the local irritation at- tending the openmg of abscesses, was depending on the ad- mission of air into the cavity, but from my own observations, and the result of many experiments, this is not the case. GRANULATION. 1. A granulation is a newly- formed part, generally red in colour, and having the power of secreting pus ; and is pro- duced by a similar process to adhesion. After opening an abscess, adhesive inflammation is produced in the inter- nal surface of the cavity. A layer of adhesive matter is in this way thrown out, and if the sidos of the abscess are brought together, by passing a roller round it, we may often prevent the future formation of matter ; but if the union by adhesion does not take place, then granulations are formed. GRANULATION. 41 2. The manner in which granulations are formed is as follows :— When an abscess is opened, or when a wound has been produced, if the edges are not brought together, inflam- mation is excited 5 and this inflammation occasions an effu- sion of the fibrin of the blood upon the surface of the wound. This fibrin is poured out in a layer upon the surface, and seon becomes vascular, for blood-vessels, which are elonga- tions of the vasa vasorum of the divided vessels, are forced by the action of the heart into the fibrin as it becomes depos- ited, layer after layer. The difference between the mode of union by adhesion; and by granula- tion, is that, in the latter, vessels shoot to the surface of the layer, which has been thrown out, terminating by open mouths on the surface of the newly-fermed substance, aed secreting pus, at the same time that a layer "Of fibrin is effused. The fibrin which is thrown out, b&sides the purulent secretion from the vessels, forms a second layer, into which the vessels shoot as before. The vessels supporting the first layer are the means of supporting the second layer, where the vessels terminate as before, by open mouths on the substance effused. In this manner, layer after layer k formed, until the cavity becomes filled. 3. Granulations are usually exceedingly sensible, and very vascular, having nerves, arteries, veins,and absorbent vessels. The vessels are principally arteries, which throw a quantity of blood to the surface of the wound, and then secrete pus. There is a vein accompa- nymg each artery, and the fluid, conveyed bj the vessels, is partly converted mto pus, on the surface of the ulcer, and partly returned back to the heart. 4. Granulations which spring from parts endued with great sensibility, such as muscles, are extremely sensitive. Many granulations, such for instance as arise from bones, have no sensi- bility whatever, unless indeed they spring from the cancellated structure, or the bone is in an inflamed condition. 5. Granulations appear to become vascular in the follow- ing manner :— An artery enters at the base of the granula- tion, and is there divided into radiated branches ; from these vessels pus is secreted, and an incrustation is formed, produ- cing a layer of adhesive matter on the surface of the granu- lation. ' 42 CICATRIZATION. 6. Granulations are not good absorbent surfaces in ulcers recently formed, but, if the ulcers have existed for any length of time, the absorbent vessels readily take into the system any substance which may be applied to them. This should caution the use of arsenic and any other poisonous apphca- tion. ^ . . ^ It is not an uncommon practice to inject a solution of a gram or two grains of oxy-muriate of mercury, into sinuses, for the purpose of stimula- ting the vessels. Ifthe sinus has existed for a length of time, the oxy- muriate of mercury is frequently absorbed, and the mouth becomes affected in the same manner as if the mercury had been taken into the system, by rubbing it into the skin, or taking it into the stomach. 7. Opium, when applied to the surface of sores, is very readily absorbed into the system ; and I believe it is often a very useful application. Its effects, when absorbed into the system, are the same as when it is in- troduced into the stomach, which are only to be removed by the ftee admin- istration of active purgatives. 8. Granulations are very readily united to each other, by bringing the edges ot the two granulating surfaces together, so as to produce the adhesive process. A knowledge of this circumstance will save much time, for, instead of waitin.^ for the tedious process of the union of both surfaces, by granulations fillin.^ the cavity, you have only to bring one portion of the granulations m contact with the other, bind them well together with adhesive plaster, and they will be sure to inosculate. CICATRIZATION. 1. Cicatrization is the formation of the new skin over a sore, and is effected by the vessels at the edge of the skin, formmg granulations ; and these granulations uniting with the gran- ulations of the surface of the sore. The granulations, produced from the edge, proceed towards the centre, and tho'se on the edge inosculate with those on the surface of the sore, and are united by the adhesive process. The vessels become elongated from the ed-'e of the sore, and proceed in radii from the circumference to the CICATRIZATION. ■^ centre. Day after day, an addition is thus made to the cicatrix, until, at last, the vessels reach the centre from every part of the circumfereace,when the process of cicatrization is completed. 2. Some surgeons "will say that cicatrization sometimes commences from the centre of the sore, and that the centre of the sore has in itself the power of forming new skin ; but that is not the case, for the new skin in the centre is produ- ced in consequence of the whole of the skin not having been ulcerated away, and gramilations arising from that part of the skin which was left. This only happens in irregularly formed sores, ■v\bere the healing process has gone on to the centre, and then the sore broken out in the circumference. If granulations arise from any portion of skin in the centre, these granu- lations produce new skin, and an insulated portion of skiu is produced, form- ing a part of the cicatrix, ■which is not afterwards ulcerated away. 3. When a cicatrix is formed in the first instance, it is extremely vascular ; but when it has existed for any length of time, the blood-vessels become contracted, and is whiter than the original skin, loses its vascularity, and is endued with less living power than the surrounding parts. 4. The form and situation of a sore ven,' much regulates the readiness with which it is covered in by cicatrization ; so that you may always expect, that a round sore will be longer in healing than a longitudinal one. The reason is, that the vessels have to elongate much less from the edge to the centre, in a longitudinal than in a circular sore. 5. In the formation of cicatrices, the original parts may all be re-produced, except muscle and cartilage. A muscle unites by tendon, and the cartilages of the ribs unite by bone. This, however, will depend in some measure on the age of the person : for, in very young subjects, cartilaginous union will be produced ; but in subjects more advanced in years, the cartilages of the ribs invariably unite by bone. 6. The skin, which is produced in a cicatrix, is true skin, the cuticle is very quickly re-produced, and the rete muco- sum^ after a short period. 44 ULCERS. The cellular membrane is also reproduced, though it has at first the ap- pearance of a solid fibrous mass, which requires some time before it is drawn into the reticular texture, similar to the original membrane. Tendons, bonea and nerves are also re-produced, but there is some little doubt whether nerves assist at all in the restoration of sensation by anastomosis. ULCERS. 1. An ulcer may be defined to be a granulating surface, secreting matter, arising from an inordinate action of the absorbents, produced by previous inflammation. By some writers an ulcer is defined to be a solution of continuity in any of the soft parts of the body, attended with a secretion of pus, or some kind of discharge. 2. Ulcers are usually distingnisbed from each other by the symptoms which they exhibit ; the causes by which they are induced ; and by the parts of the body in which they oc- cur. In treating of ulcers, I shall first describe the appearance of ulcers id what may be termed their healthy state ; T shall then detail the severaJ circumstances which render their care difficult, and proceed to point out the general varieties, and the treatment most likely to prove efficacious, 3. Healthy Ulcers : — "When an ulcer is in a perfect healthy state, the granulations are red and small upon the surface^ rising a little above the edge j the discharge of matter of the appearance of cream ; and the edge of the sore whitish, and nicely adapted to the surface. The florid colour of the healthy granulations, is produced by the blood- vessels having a considerable quantity of arterial blood, and a fi-ee circula- tion. Their being raised above the surface of the sore is necessary, in order that a sore should heal kindly. By the edges of the sore being nicely adapted to the circumference, the granulations, springing from the surround- ing skin, unite with those of the surface. 4. When you open an abscess, or when a wound is pro- duced, which cannot be healed by the adhesive process, you TTLCERS. 45 must encourage the groTrth. of granulations, by the applica- tion of the gentle stimulus of poultices, and when the granu- lations have risen to the surface of the skin, press do-^n the granulations of the edge on those of the surface, either by the application of adhe^dre plaster, or unctuous substances. The more unctuous the substances are, the better j foi the vessels tvilJ have a greater facility in shooting towards the centre, and the granulatious embedded in this unctuous matter will more readily extend along the sur- face of the sore. 5. Such are the principles of treatment applicable to ul- cers in the healthy state ; ve shall now proceed to consider the impediments to the healing process, which frequently occur, and render a different mode of treatment necessary. 6. When there is too prominent a state of the granula- tions (vulgarly called proud flesh) rising considerably above the edge of the skin, they are necessarily prevented from uniting with those of the surface. In order to prevent the continuance of this state of the sore, the common treatment is, to apply dry lint to the centre of the sore, and some unctu- ous substance to the edges. The lint, byit3pressure,prevents the growth of granulations in the centre, while the unctuous substance allows the granulations on the edge to pro- ceed, and inosculate with those on the surface of the sore. The lint should not be applied to the edge of the sore, for, if it is, the granulations will ho prevented from proceeding towards the centre. 7. In those ulcers in which luxuriant granulations shoot up near the edges of the sore, our practice is just reversed ; for instead of applying lint to the centre, we must use a kind of caustic, to destroy the prominent granulations at the edges. The nitrate of silver, and the sulphate of copper, are the common caustic salts in general use. 8. Adhesive plaster is also used to keep down granulations. The common adhesive plaster is, usually, too stimulating for the purpose. A plaster composed of equal parts of the emplastrum thuris compositum and the emplastrum saponis, is better calculated to promote the healing process. %. _™=..^_,...^-:. - ^iS ULCERS. 9. Applications of too stimulating a nature, will some- times excite inflammation and excoriate the skin, so that we are often under the necessity of leaving off the adhesive plaster : it sometimes happens, that the action is so great as to oblige us to apply sheet lead to the surface of the sore. When this is necessary, you may apply a piece of lint covered ^ith the ceralum cetacei 5 over these, a piece of sheet lead, and round the whole, a roller should be passed of about fiye yards in length. 10. Indolent Ulcers .—There is often great difficulty in the cure of ulcers, when they are of a languid condition, and the action too slight. To overcome this unhealthy state of the sore, the application, most com- monly used, is the unguentum hydrargyri nitrico-oxidi ; which occasions a determination of blood to the part, and produces a florid redness in the gra- nulations, instead of the semi-transparent appearance which they assume m the languid state of the sore. 11. The mercurial application produces, however, a white appearance in the edge of the ulcer, arising from the thick- ened state of the cuticle, which prevents the growth of the granulations on the edge. This may be corrected by the application of the unguentum hydrargyri fortius, to the edge of the sore. The oxy-muriate of mercury with l.me water ; and lotions, such as the sulphate of zinc, in the proportion of two grains to one ounce of water ; or the sulphate of copper, in the ratio of one grain to three ounces of water, are frequently applied with the same view. 12 In addition to the means already mentioned for the cure "of indolent ulcers, it will be highly useful to employ some stimulating plaster. The emplastrum galbani compositum is a very good one ; the adhesive plaster will not answer the purpose, the sores are languid, and the object is to increase the action in the part. 13. The constitutional powers of a person afflicted with indolent ulcers are weak, and the circulation generally tardy. You should, therefore, recommend in addition to the local remedies, a generous diet, free exercise, and, in fact, every thing calculated to improve the general health. ULCERS- 47 14. infiavied Ulcers :-^'HeYe you ha\^e a serous discharge from the sore ; a bloody ichor, composed of serum and the red particles of the blood ; a disposition in many cases to slough J the surface covered with a brown incrustation 5 and the skin and surrounding parts highly inflamed. 15. The treatment which is applicable to inflammation in general, will be of service in these cases, where inflammation has been kept up for a long time, to a high degree. 16. Fomentations and poultices must be employed : rest and the recumbent posture be enjoined ; and the general secretions of the body attended to, for without attention to the constitutional treatment, all your local applications will be of very little use. Fomentations will tend to produce a secretion from the part, and poultices, by their soothing quality, to promote tlie growth of granulations : and both will evacuate the matter from the wound. After these applications have been applied, the vessels begin to form, and the sore assumes a better ap- pearance : healthy secretions are thrown out, granulations shoot up, fibrous matter is deposited, and. in a little time, you will have the skin covering the wound. 17. Gangrenous Ulcers : — In ulcers of this kind, the sur- face is perfectly free from any discharge ; the surrounding edges of a livid appearance, with small vesicles or blistered spots on them ; and the patient suflTers much from irritative fever. 18. In the treatment of these cases, you must adopt con- stitutional as well as local remedies. 19. The recumbent posture must first be enjoined, as it is essentially necessary to promote the separation of the dead parts ; a generous diet allowed ; stimulating medicines administered ; and moderate stimulating applications, to promote a slightly increased action on the part ; sometimes however, when the action is excessive, you must, on the contrary, soothe the part, and lessen the stimulating nature of your constitutional treatment. L 40 ULCERS. Thfc most approved constitutional treatment, in these ulcefs, is test and ^nerous diet ; port wine should also be allowed, and spirits may be given to those who have been in the habit of using them. By brandy and opium I have seen these wounds cured ; in fact, they are our sheet anchor, in the tr«atment of gangrenous ulcers. The best medicine to be administered is opium and ammonia ; twenty drops of the tincture of opium, three times a day, with ten grains of the ammonia, in an ounce and a half of camphor mix- ture, and one drachm of compound tincture of cardamons. 20. When there is debility of the part, a slight stimulus should be employed, but when there is excessive action, it is to be avoided. The best application for producing a slight stimulus, and checking gan- grene of the part, is nitric acid : there is none equal to this ; fifty drops of it to a quart of distilled water is the average quantity ; but this, however, may be increased or diminished, just as it may give pain to the part. 21. There is usually much dif&culty in the cure of gan- grenous ulcers, so that you must necessarily have recourse to a great variety of applications ; for after you have tried one, which at the beginning did good, you will, from the wound getting worse under its use, be obliged to change it for another, and so on. The other local remedies, in addition to nitric acid, are, the application of oil-silk to the wound, so as to prevent the smell, arising from the parts, tainting the room: — Nitre, in the proportion of one drachm to a pint of wa- ter, agrees very well with the sore, and has the same effect as nitric acid, though in a diminished degree : — all the combinations of nitric acid appear beneficial. Sulphuric acid is also of use in these cases, six drops of the acid to an ounce of water ; but the muriatic acid is not to be recommended. Poultices made of port wine, porter, dregs of lees, yeast with meal, may all be used ; as also the carrot poultice. 22. Irritable Ulcers : — May be known by the inequality of the granulations, the discharge of bloody pus, and the great tenderness in the part ; so that the patient, when touched in that part, shrinks with excessive sensibility. 23. There is always considerable difficulty in the treat- ment of these sores. The alterative and anodyne plans must be adopted. MB i . I' MJM i Btt.iJ S' MH" '" ' — •- ULCERS. 49 The best local remedy you can apply, is one composed of one drachm of powdered opium, with four drachms each of the uuguentum cetacei and ungTientura hydrargyri mitius. This must be spread on lint, and applied to the part, twice a day. 24. Your internal remedies must not be carried so far as to produce ptyalism, or to affect the constitution severely : they should be given so as to restore the secretions, and to diminish the action of the nervous system. Calomel and opium are the internal medicines on which you are to rely ; a grain and a half of calomel with a grain of opium, morning and evening. Other acids, such as the compound decoction of sarsaparilla, are sometimes used : I do not think much of it myself in these cases ; but afler the use of mercury, it diminishes the irritability of the constitution, and soon soothes the system into peace : with this view, and combined with other remedies, it may be beneficial. 25. Sinuous TJlceration : — Whenever a sore extends to any considerable depth, so that the discharge has to travel through a channel before it arrives at the surface, such an ulceration is called sinuous. The cure of sinuses is rendered difBcult, — first, from matter forming at the bottom, forcing its way through the passage, aud, thereby, disturbing the heal- ing process by breaking down whatever adhesions or granulations form on its sides ; and, secondly, the same interruptions occur from the action of the muscles, when these ulcerations happen in muscular parts, thereby some- times rendering (as in fistula in ano) a division of the muscle necessary. 26. Your object of treatment, in the cure of sinuous ulce- ration must be to promote healthy granulation, either by cut- ting the canal open, and applying stimulants or caustics ; or, if it should not be necessary to excite the part, by stimula- ting injections, such as the Tincture Lyttas ; these will readi- ly produce inflammation ; adhesive matter will be thrown out, and, by taking care to keep the sides of the sinus in con- tact, the parts will permanently coalesce. 27. Ulcers under Nails : — Are sometimes exceedingly dif- ficult to heal, from an irritation caused by a portion of the nail, producing fungus ; but as soon as the projecting part 5 50 ULCERS. of the nail is removed, the fungus will cease to grow, and the ulcer immediately heal. A nail, for example, from pressure or some other cause, shoots into the skin beside it ; a fungus springs up : the surgeon applies caustic and destroys it J in a short time it rises again ; the caustic is repeated, and the fungus disappears ; it speedily, however, returns, and will continue to do so, not- withstanding all his eiForts to the contrary, unless be removes the irritating cause. 28. There are two modes of treating these ulcers ; either the application of a blister ; or introducing a piece of lint under the nail ; the former brings away the cuticle and sometimes the nail along with it ; the latter, however, is more lenient, and a better remedy. Pare down the nail as thin as you can without producing bleeding, then raise it a little, and introduce a small piece of lint: in this way, the irrita- ting cause may generally be removed ; but sometimes it happens, that the sore is so exceedingly irritable, that even lint cannot be lodged on its sur- face without producing increase of inflammation and pain : in such caseSj I would recommend slitting up the nail with a pair of scissors, on that side where the disease exists, and then, with a pair of forceps, turn back, and completely remove the divided portion. The part should be poulticed after the operation. 29. The nail sometimes turns black from a disease of the gland from whence the nail proceeds : such aflfections are not uncommon, and are often thought to be syphilitic ; this opinion, however, is erroneous, "Vou must wash the sore with the black wash, and administer Pfummer's pills : sometimes, in these cases, we are obliged to dissect out the gland that produces the nail. 30. Whitlow : — This is an exceedingly painful swelling, terminating in an abscess by the side of the nail : the matter forms at first under the nail, but, unable to force its way through that horny substance, burrows under it, thus produ- cing excessive pain and irritation. Fungou.s excrescences often arise in these cases, which induce the sur- geon to apply caustic, but this ought never to be done. After fomenting and poulticing the part, remove the loose portion of nail : this will permit the matter to escape, and instantaneous relief is the result. ULCERS. 51 31. Mtmtrual Ulcers : — These are sores peculiar to the female sex, and are depending on amenorrhcea. Their pecu- liar character is, that, once in three weeks or a month, they are covered "v\ith blood j so that they will one day be covered with pus, and probably, on the next, be covered with blood. This state of affairs is the result of a defective menstrual discharge, so that the superabundant quantity of blood, which ought to be voided in the natural way, is thrown back upon the system, and obtains an escape through the ulcer. 32. In these cases, in addition to local applications, you must endeavour to improve the state of the constitution, by restoring the defective secretions. Menstrual ulcers should be well moistened with the black wash, and tlie patient should take about an ounce and a half of the mistura ferri cum myrrha, twice or three times a day ; and five grains of the pilulee hydrargyri sub-muriatus compositae, every night at bed-time. 33. Chronic Carhv.ndes : — An ulcer of the cellular mem- brane, or what is caUed chronic carbuncle, occurs when the health is impaired : — a small swelling forms under the skin, at first red, then turns purple, and ultimately sloughs : a white substance is soon perceived at the bottom of the sore, and as soon as this comes away, healthy granulations will rapidly form, and the wound become healed. 34. As these cases appear to arise from an impaired con- stitution, the general health must be improved and the gran- ulating process incited. The first indication will be answered by the administration of aperients and alteratives ; and, in cases of great debility, by giving ammonia. If any one medicine improves the nert'ous system when deranged, more than another, it is the carbonate of ammonia. Half a drachm of ammonia, with half an ounce of compound tincture of cardamoms, and five ounces and a half of spearmint water, is my usual mixture : 2 table spoonfuls t« o or three times a day. The second indication,or local treatment, must be effected by poultices, or if they wil! not answer, by slight stimulants, as the black wash, or caustic. 35. Superficial Ulceration : — It not unfrequently happens, the skin, in various parts of the body, gets into a state of su- perficial ulceration, and mthout any evident cause. 52 rLCERS. The cure of superficial ulceration is best effected by the local application of either the black wash, the unguentum hydrargyri nitratis, or the un- guentuni zinci-oxydi: and the internal use of the oxy-muriate of mercury, in conjunction with the tincture of bark, more especially when the ulceration is connected with disease of the messenteric glands. 36. Noli me tangere : — This is a disease of the face,which has not yet been correctly described ; the truth is, that it is an ulceration of the glands or follicles of the nose, those small cavities from which you can squeeze sebaceous mat- ter : the ulceration extending deeply, at last even the carti- lages of the nose become destroyed. 37. The plan of treating this disorder will depend upon circumstances, for, if the ulcer is deep, you must use an ar- senical preparation ; but if it is not deep, you may cure it by merely painting the surface of the sore with a solution of the nitrate of silver. The arsenical preparation which I always use, is one ounce of spermaceti ointment, and one drachm each, of oxyde arsenic and flowers of sulphur, well incorporated : — You must spread some of this ointment on lint, lay it on the ulcer, and leave it there for twenty-four hours ; then remove it j a slough will come away ; you dress the ulcer with some simple ointment, and in a short time it will generally heal. 38. Deep ulcers, having a malignant aspect, often remain in the face of old persons without producing any bad conse- quences. The best application is the black wash. 39. Ulcers from Varicose Veins : — These are ulcers most frequently situated in the lower extremities. They are the result of inflammation produced by an impeded venous circu- lation ; and as soon as the inflammation is set up, the sequel is desquamation of the cuticle ; then the whole face of the surface, covering the diseased veins, is formed into a crust, under which a quantity of serum is secreted. A varicose condition of the veins may arise from many causes ; but the more immediate one appears to be, either a thickening of the valves, so that they are incapable of approximating, or a rupture of the valves 3 in either case, the effects will be the same, — the veins being distended and serpentine, and the valves widely separated from each other,— the arteries by their ULCERS. 53 powerful attempts to return the blood to the part, soon excite inflammation ; and ulceration quickly supervenes. 40. In the treatment of these ulcers, the recumbent pos- ture must be strictly enforced. Lint, wetted by the mercu- rial wash, should be laid on the ulcer, oil-silk orer these, and then the limb should be regularly and properly bandaged, beginning at the foot. Opening the veins about twice a week, if necessary, is very safe and effective practice; then applying a bandage, and keeping the parts wet by means of an evaporating lotion. If the punctures, at any time, should not unite, but fret into ulcers, you must apply the black wash. 41. In persons, who have been subject to raricose veins for a length of time, the crust, just alluded to, will come oil, and hemorrhage follow ; but by placing the patient in a re- cumbent posture, applying a bandage, and keeping the parts constantly cooled with the spirit wash or cold water, you will, in all probability, get rid of the disease altogether. It was formerly the practice, when the veins were in a varicose state, to tie and divide them ; but it is a practice replete with danger, therefore let me exhort you never to sanction it. Another overwhelming objection to the operation is, that when it does not prove fatal, its ultimate effects are per- fectly nugatory. 42. Ulcers in Joints : — These arise from an inflammation caused by a deposition of the urate of soda, so that persons will come to you with many joints open from this cause, and the cartilages more or less absorbed. If it is necessary, you must increase the openings through the skin, and remove the urate of soda, that being the exciting cause. 43. Use of Ulcers : — Ulcers are sometimes very beneficial to the general health, for they are frequently formed for the purpose of allowing the discharge of extraneous bodies. When such substances become lodged, therefore, in any part of the human frame, inflammation is excited ; pus become secreted, which pressing to- wards the surface, ulceration takes place, and the extraneous substance is thus afforded an opportunity of escaping. 44. Ulcers frequently occasion exfoliations of bone, to a very considerable extent. Here you can assist nature by ap- 54 GANGRENE. plications which act chemically on the parts ; therefore apply a lotion composed of muriatic acid and water, or nitric acid and water. This wash will dissolve the phosphate of lime, or earthy matter of the bone ; and by removing this inanimate substance, the power of the absorb- ent will be increased, and a quicker separation of the diseased from the healthy parts, be the consequence. 45. Edges : — The process of healing ulcers is occasional- ly very much impeded by a thickened state of the edges, to obviate which, the edges must be adapted to their surfaces. The emplastrum galbani compositum will remove the indurated cuticle, and stimulate the parts to action ; if this, however, should not succeed, you may use the unguentem hydrargyri fortius, or unguentum lyttae ; or you may scarify the edges. 46. The edges of sores are sometimes very much inverted ; for which the usual constitutional medicines are to be given, and nitrate of silver applied to the edges, and the black wash to the surface. 47. Some sores have felt their edges very much everted, and this affection is commonly symptomatic of a cancerous diathesis : the usual method of treatment is to poultice such ulcers, and to attend particularly to the general health, until the edges have resumed a natural and healthy state. The admirable mode recommended, by Mr. Baynton, should be had re- course to, which, by approximating the sides of the wound, and thus facil- itating the process of granulations and cicatrization, will surprisingly con- tribute towards the completion of the cure. GANGRENE. 1 . Gangrene 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. GANGRENE. 55 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. 2. The symptoms of gangrene differ according to the manner in which it is produced. Authors have generally distinguished mortification into two stages j the first or incipient one they name gangrene ; the second or latter stage, that is, when the part has become quite cold, black, fibrous, incapable of moving, and destitute of all feeling, circulation, and life, is tanned sphacelus. 3. When gangrene is the result of high and actire inflam- mation, the pain attending its production is exceedingly se- vere ; the inflammation is very extensive j 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 is produced, and when this breaks, it is found to contain a bloody serum. When the serum is discharg- ed, the skin assumes the gangrenous appearance, and becomes perfectly in- sensible. The vesications extend to parts beyond the ulceration. 4. The constitution sufl'ers considerable derangement from gangrene ; there is a high degree of irritative fever — quick, very small, 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 whatever part of the body it may be. The fact is, that when gangrene arises from a diseased state of the constitution, the stomach is extremely deranged, and this derangement of the stomach is followed by a spasmodic contraction of the diaphragm, producing hiccough. Hiccough may be arrested for a time, either by cold water, or a slight stimulant. 5. We have just related the symptoms when a gangrene is the result of excessive action : we will therefore proceed to speak of it, when it is the efl"ect of a low degree of inflam- mation J as from cold or any other analagous cause. 56 GANGRENE. 6. When a great degree of cold has been applied to any part for a considerable 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 inflamm^ation, so that gangrene will be produced. When you receive cases of this kind, be cautious that heat is not too sud- denly applied ; for even the common heat of the bed, frequently occasions inflammation, which is extremely liable to proceed to gangrene, in conse- quence of the diminished nervous influence of the part. 7. "When gangrene is the result of either circumstance we have mentioned, 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. 8. When the process of separation takes place, the first appearance we observe is a white line ; at this white line the cuticle is raised, and in a day or two separates, leaving a chasm beneath it, produced by the absorption of the living skin in contact with the dead : — the next part, which 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 re- sisting 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 sufler in the general destruction; and, lastly, the bones themselves exfoliate and the limb is completely removed. Since the -white line alluded to, is the barrier which nature set? up be- tween the dead and the living parts, it is anxiously looked for by the sur- geon, as it becomes a criterion of the cessation of mortification. The eleva- tion of the cuticle at the white line, is a vesication which forms a line of circumvalhition around the gangrene. The living skin taken up by the absorbents is carried into the constitution ; the absorbent vessels act on the GANGREXE. 57 living parts, but not on the dead ; nor is 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 affording an opportunity for separation. Gangrene proceeds to much greater extent in the cellular 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. 9. During the progress of mortification, nature has provi- ded against hemorrhage, on the destruction of the blood- vessels, so that even the larger arteries are cut through ^vith- out 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 considerable distance above it, in order to provide against the danger which would otherwise arise from a separation of the coagulum. 10. Gangrene is frequently the effect of a debilitated state of constitution : — whatever, in short, weakens the general health much, disposes 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 cir- culation, 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 unac- companied with inflammation, by which the circulation is considerably impeded. 11. Treatment : — If gangrene is likely to result from inor- 53 G-ANGRENE. dmate action, v/e shoal J endeavour to relieve the part by local abstraction of blood with leeches, and the application of boothing poultices. It vdll be necessary, at the same time, to attend to the general health ; for the best means of pre- venting gangrene are to restore the secretions by calomel, and to diminish irritation by opium ; and, in some cases, by taking away very small quantities of blood. In this metropolis, it is seJdom safe to take blood from the arm of pa- tients, to prevent gangrene _ but in the country, a diifeient practice may be pursued. When you take away blood, however, do not take more than eight or ten ounces, lest the vigour of the circulation, and consequently She nervous powers of the constitution, should bs too much diminished. 12. If gangrene is likely to arise from the application of cold, the treatment must be different ; — in these cases, the action of the parts is feeble, from the diminution of nervous power, and it will be proper to restore it to a healthy state by stimulants of the most gentle kind. For this purpose, the best application is the camphorated spirit of wine, accompa- nied with gentle friction. If you are called to a patient whose feet are benumbed from the effects of cold, you must sit by his bed-side, pour camphorated spirit into your hand, and rub it on his feet with the utmost gentleness, so that the part may not be irritated by violent friction ; when the first effects of the cold are re- moved, it will be proper to apply cold poultices ; for warm applications are to be carefully avoided. When parts are frost-bitten in colder climates, the common practice is to restore the circulation by rubbing them with snow. 13. We have now concluded the means of prevention ; we will therefore now proceed to speak of the treatment, when gangrene has commenced. 14. As soon as gangrene has commenced, it will be neces- sary to apply a gentle stimulus to the parts, with a view of supporting the action of the surrounding parts which are threatened with the destruction of life. Poultices of stale beer grounds with linseed-meal ; spirituous fomenta- tions ; port wine poultices ; turpentine, particularly in sloughing sores, ari- sing from impeded circulation ; yeast, and a composition of vinegar and camphor mixture, have all been beneficial in gangrene. GANGRENE. 59 15. When the dead are separating from the living parts, the epithema pliimbi sitb-acetatis is a very useful application ; during the sloughing process, the nitric acid 5 when the gan- grene stops, and the line of demarcation is drawn, and the sloughing process is commencing, the same acid may be em- ployed in the proportion of fifty drops to a pint of water. The epithema consists of one ounce of the conserve of roses well mixed with two drachms each of the honey of roses, tincture of opium and the solution of sub-acetate of lead. 16. These are the different modes of treatment for the preven- tion of gangrene, and of arresting the sloughing process. We will next proceed to speak of the propriety of amputation. 17. Amputation : — There is no occasion in general for amputation in cases of gangrene, when the sloughing process is going on ; if you will be content to wait a short time, and the patient is disposed also, you will find the parts will separate as well without as with an operation. The cases in which you are called upon to perform the operation, are, when the patient will not be able to sustain the shock to the constitution ; then if gangrene be going on in any part, or through the middle of the leg, by which the power of the constitution will be nearly destroyed, you may have recourse to an operation ; but even here, there will not always be oc- casion for it. Always, if you can, give the patient a chance of his life, without resorting to it. 18. In constitutional gangrene, never amputate till the general health is good, the sloughing process commenced, and healthy granulations are to be seen on the surface 01 the sore j for, if an operation be performed, the parts will as- sume exactly the same appearance as before it. 19. Yv^hen gangrene arises from an accident, ordefective action from pressure on some important vessel, amputation may be performed without the least hesitation. 20. Old persons are very subject to gangrene of the toes and feet, arising from ossification of the smaller arteries ; 60 GANGRENE. which, losing their elasticity, and combined with a debilita- ted action of the heart, give rise to this disease : — It is atten- ded with some degree of fever ; the cheeks are of a florid red colour, and the constitution becomes considerably influenced. The appearances, whieh the part assumes, are these : — at first it is red and painful ; the person, thinking little of the matter, puts upon the affect- ed part a piece of linen ; in a few days the cuticle comes off, and there issues from the surface a sanious discharge ; red streaks are now seen passing from different parts of the foot, up the leg ; and the glands in the groin often undergo considerable inflammation and enlargement ; all the absorbent vessels of the foot becoming inflamed, produce universal redness of the diseased member. Soon after this, the gangrene begins to extend, destroys the whole of the foot, and passes to the upper part of the leg, where it usually stops. 21. This gangrene will not commonly destroy life, if at- tention be paid to the patient. A poultice, composed of port wine and linseed meal, will be found the best local application ; and your internal remedy should consist of opium combined with ammonia. Never amputate, whether they are healthy granu- lations or not, for as surely as you do, mortification of the stump will su- pervene^ ANTHRAX on CARBUNCLE. 1. Carbuncle is a hard and circumscribed inflammatory tubercle like a boil, which sometimes forms on the cheek, neck, or back, and in a few days becomes highly gangrenous. When carbuncle is about to take place in any part, it is generally prece- ded by pain, and at first a swelling of considerable hardness : this is occa- sioned by ths adhesive inflammation ; the surface of the tumour then as- sumes a livid redness and a spongy soft feel ; ■ little ulcers now form on the skin, which, from their number, give it a sieve-like appearance, so nu- merous are the orifices : from these a white discharge passes ; this fluid resembles water and flour mixed together, and a surgeon, who has seen much of carbuncle, knows the nature of the disease immediately on seeing the discharge. When the little openings are all formed into one, the dead cellular membrane begins to escape, for it previously cannot do so, from the emallness of the apertures. ATsTHKAX OE CARBL'-XCLE. 61 2. Carbuncles usually proceed from internal or constitu- tional causes. They are commonly attended with considerable excitement, great prostra- tion of strength, sickness, loathing of food, head-ache, and other symptoms of low febrile impression. In very bad cases, you ■will find all these indica- tions in an aggravated state, accompanied with syncope, extreme anxiety, and sometimes delirium. 3. That carbuncle is connected ^'itli an idiosyncrasy, or some peculiar state of the constitution, is very generally thought, though not satisfactorily substantiated. 4. Carbuncles do not generally prove fatal, but the prog- nosis will depend very much on the size and situation of the tumour. In ordinary situations they usually do well ; but if they are on the neck or head, local derangement is so great, that effusion takes place between the tunica arachnoides and pia mater, and death is the consRcjuence. 5. In the treatment of carbuncle, you must pay particu- lar attention to the secretions, and employ all means calcula- ted to allay undue excitement, and to tranqaillize the system. The bowels should be relieved by a cooling aperient, after a dose of cal- omel : and the tendency to prostration of strength, and typhoid symptoms, combatted by a strictly tonic plan, as bark, ether, nutritious food, and so on. Fresh air is also highly necessary. 6. With respect to local means, do not vainly endeavour to disperse the tumour by refrigerant applications : you can- not succeed. Always have recourse, at once, to emollient poultices and fomentations. Your peculiar treatment must consist, however, in making upon the sur- face of the swelling, at an early period of the disease, a large crucial inci- sion, for the purpose of affording the deadened parts an opportunity of es- caping; then applying the port-wine poultice, and giving the patient such stimulants (ammonia with opium,) as will tend to increase the vigour of the constitution. 62 ERYSIPELAS or ST. ANTHONY'S FIRE. 1. Erysipelas is a peculiar kind of inflammatory state of the skin, characterized by a diffused redness and slightly ele- vated condition of the part, a burning or itching pain, and frequently beset with vesications. When touched with the end of the finger, a white spot is left, which immediately turns red again. The skin has a shining appearance, feels as it were a little thickened, and somewhat less pliable than natural 5 and whether complete vesication have been formed, or not, the cuticle peels off on the decline of the inflammation. 2. Erysipelas may be distinguished from common inflam- mation by the florid redness of the skin, accompanied with vesicles, containing an amber colour secretion under the raised cuticle. I would recommend you, as young men, to be very particular in search- ing out the cases of inflammation and erysipelas which are brought to the hospitals. Examine them separately and collectively j study to know them distinctly : for unless you do, you will probably mistake a simple case of inflamed skin, for erysipelas, employ the depleting system where a contrary indication is required. 3. The constitutional symptoms attending erysipelas are always in proportion to the mildness or severity of the com- plaint. 4. In its mildest form, it is preceded or attended by no material complaints, or merely by a very slight indisposition, languor, loss of appetite, and so on.. These symptoms are of short duration, and abate as soon as the epythema appears, which increases for a couple of days, then remains unchanged about a similar space of time, and afterwards turns yellowish, and gradually fades away, the cuticle at the same time peeling off. During the whole course of the disorder, the fever is slight, the pulse being sometimes only a little disturbed previously to the appearance of the redness. 5. In a more severe degree of the disorder, the patient experiences, for a couple of days before the erysipelas breaks ^^j^^^ ERYSIPELAS OR ST. AJNTHONY's FIRE. 63 out; unusual debilityj heaviness in the limbs, headache, loss of appetite, nausea, actual vomiting, oppression about the stomach, and such like. After two days, generally on the third, the erythema appears, attended with a gentle perspiration, and an increase in the secretion of urine, when the fever, and all other complaints subside. The disease then follows the same course as the first case already described. 6. In the third and most violent degree of erysipelas, "which m.ostly attacks the face, the patient is affected with severe fever, headache, lethargic dro^o'siness, shiverings, vomiting, delirium and so forth. These symptoms do not, as in the foregoing examples, subside upon the breaking out of the erythema on the third day ; but continue with undimin- ished vehemence until the local disorder goes oflF, which usually happens about the eleventh day, attended with copious evacuations from the skin and kidneys. 7. Causes : — As to the causes of erysipelas, I should say they are mostly constitutional ; though not unfrequently local. General irritability of the frame, or a peculiar state of the constitution, manifest the first ; while violent passions, injuries, chemical, aud other external causes, constitute the second class. In fact, whatever renders the body irritable, predisposes to erysipelas, and after a person has once had it, he is very subject to it again. ^ S. Certain parts of the body are sooner affected by ery- sipelas than others . The head seems to be more commonly attacked than any other part ; it often succeeds the most trifling injury to the scalp; and, like carbuncle, when it occurs in this situation, generally destroys life. 9. Erysipelas usually makes its appearance in spring and autumn, but seldom in winter. It is sometimes epidemic, and sometimes contagious. 10. Treatment : — TVith respect to the treatment of this af- fection, that must depend upon the constitution you have to deal with, and whether you are practising in town or in the country. 64 INJURIES OF THE HEAD. In London, the best thing you can do, is, first to give calomel for restoring the secretions of the liver and intestines j then allow a generous diet, and administer the ordinary tonics. You will find, where erysipelas attacks the lower orders of this town, who weaken their constitutions by the excessive use of ardent spirits, that gin may be sometimes advantageously employed as a remedy, at once being the evil and the cure. 11 . Where there is simple erysipelatous inflammation going on to a great ejstent, accompanied with a full plethoric state of the body, then you must pursue a different treatment. Mercurials to act on the liver, aperients on the bowels, and saline medi- cines will be necessary. Bleeding, though sometimes highly necessary, is not always so. The local abstraction of blood, a practice lately advocated with considerable warmth, is, in my opinion, injudicious. INJURIES OF THE HEAD. 1. In considering the nature of injuries to the head, it is necessary to bear the following remarks in recollection, as concerns the nervous system. 2. That the nervous system is composed of the brain, the medulla spinalis, and trvo sets of nerves, one set issuing from the brain, and the other from the medulla spinalis'. Besides which there is the grand sympathetic nerve. 3. That an immediate communication exists between the stomach and brain, by means of the eighth pair of nerves, or parvagum. 4. That the brain is the medium through which the mind is communicated. 5. That the grand syvipathetic nerve is, as it were, a system complete in itself, though bearing a connexion with the brain, 6. And that the nerves are freely distributed to every part of the human frame, and are the means by which oXl vo''. unta- ry and involuntary motions are maintained. CONCUSSION. 65 7. To these remarks I shall add one or two observations on the symptoms which generally present themselves when a patient labours under an injury. 8. When the brain receives an injury, the symptoms sta- ted to be the result of that injury are, general loss of sense and volition, if the injury be considerable ; but if not so se- vere, some portion of sense and volition will remain. When you are called to the bedside of a person thus situated, you will find him to be what is termed comatose ; if you speak sharply to him, he be- comes roused for the moment, mumbles some brief answer to you, and again lies down and relapses into his former sleepy state ; thus you observe par- tial mental faculties and volition still remain. This symptom you should minutely note, as it will greatly assist you in your after diagnosis ; and you should be upon your guard you are not deceived by the person being intoxi- cated. 9. In addition to loss of sense and motion, there is sick- ness ; a laborious pulse, but quick on exertion ; dilated pu- pils ; and sometimes bleeding from the nose, which, when the patient has been kept lying on his back, often occasions vomiting of blood ; the fseces pass off involuntarily, and the urine is retained without power to evacuate. To mention more symptoms, there is often partial paralysis or hemiplegia j occasionally, squinting is produced, the natural direction of one or both eyes becoming changed ; permanent, partial, or total aberration of the mental fa- culties may also be added to the consequences already named. Injuries to the head are very dangerous, and persons usually fall victims to them. CONCUSSION. 1. Concussion is simply a shock which the brain has re- ceived, more or less severe, and attended with laceration or not. 2. The best marked symptoms are, increased motion of the carotids ; an apparent tranquil sleep ; the instantaneous relapse to that state after being roused ; a remarkable ex- citement of the pulse upon using exertion, and the insensi- bility having immediately followed the accident. 6 QQ CONCUSSION. When called to a person whom you find in a state of stupefaction, but not to a great degree, regular pulse, tranquil and regular breathmg, and the accident has existed some hours, you will generally be justified ni pio- nouncing that the injury has been trifling: but when the indivioual has been first seized with vomiting, is incapable of using any muscular power from loss of nervous influence, a total aberration of the mental faculties, ,vith intermittent pulse and breathing ; these will be found the diagnostic symptoms of severe injury, and the case is a dangerous one. 3. The diminution of the operations of the mind is often so great in concussion, even where considerable voluntary motion remains, that you cannot possibly get any other an- swer from your patient, than " eh !" delivered m a gru£f undertone. The extraordinary changes which the memory sometimes undergoes irom the effects of concussion, is worthy of observation, for cases are related in which persons, on recovering, found they had lost all recollection of a lan- guage which they knew previously ; and recent occurrences were not so weU remembered as those of their younger days. 4 It is somewhat curious to observe the graaual change which takes place in the intellectual faculties, as alterations occur in the brain ; and the gradual diminution of ideas which have been more recently acquired, until at length they become totally obliterated. Old persons are observed to be very fond of relating anecdotes of their vouth for<'etting incidents of more recent occurrence ; and the change which takes plac^e in the intellect, from injuries of the brain, is very similar to the effects of age. The patient becomes, as it were, suddenly old ; loses im- pressions of a recent date, and is sensible only of those which he has receiv- ed in his earlier days. 5. With respect to the state of the brain under concussion, when the concussion is not extremely violent, there is merely a change in the circulation, and a corresponding loss of sen- sibility ; but, when the circulation is restored by proper means, the powers of the mind will return with those of the body. On the other hand, if the concussion is severe, there will be laceration, accompanied with extravasation of blood, and the symptoms will be found to ran into those of com- pression. CONCUSSION. 67 Dissection has pointed out, that when the concussion is very violent, a laceration of the brain takes place, accompanied with extravasation of blood, but when it is slight, no appearance can be discovered which indicates any alteration of structure. 6. Treatment : — The great danger "U'e hare to guard a- gainst, in the treatment of concussion, is inflammation of the brain. This must be prevented by taking aT\-ar a very con- siderable quantity of blood, and other reasonable means of reducing any inordinate action which might follows-. By bleeding largely at first, we not only remove existir-g inflammation, but we prevent that which would otherwise occur. This practice, although denied by some, may be carried to excess ; regulate your conduct by the symptoms, observe whether there is any hardness in the pulse, and whether he complains of any pain in the head, if he has still the power of complain- ings watch your patient with the greatest possible anxiety ; visit him at least three times a day, and if you find any hardness of the pulse superven-- ing after the first copious bleeding, take away a tea-cupful of bixiod, but do not go on to bleeding him largelj', for you would by this means reduce the strength of your patient too much, and prevent the reparative process of nature. A necessary degree of inflammation is absolutely necessary, but it must be kept within bounds. 7. You are to use bleeding as a means of preventing in- flammation, and not as a matter of coarse, the moment you are called to a patient under concussion. You will always find the pulse very weak, or scarcely perceptible, at the mo- ment of the injury ; wait till the pulse rises and re-action is indicated, then extract blood. The brain, whf u lacerated, heals like any other organ, by the process of adhesion: it is necessary, therefore, under such circumstances, that there should he a slight degree of inflammation, for, without it, the reparative process cannot go on, and the patient cannot recover. Bear this always in your mind ; do not abstract blool indiscriminately ; use the lancet with caution ; lest you reduce the animal powers too much, and evide a favour- able terminaiion of your cases, 8. Emetics I have seen of considerable use in these ca- ses, but I never order them for three or four hours after the accident, lest there should be extravasation of blood in the brain^ or any tendenc}^ to apoplexy. 68 coNcirssTON. Vomiting acts beneficially in simple cases of concussion, by relieving the stomach of its coatents, as the accident generally happens to peisons in a state of intoxication ; and also by propelling the blood to the brain, and thus restoring the powers of life. 9. With respect to the exhibition of cathartics, the bowels should be kept open by calomel purges, followed by the infu- sion of senna and sulphate of magnesia. The calomel should be given about two hours after the accident ; and it will be useful to give to the patient, at the same time, a quantity of mild fluids to drink, as by this means, a disposition to purging is kept up, counter- irritation is, as it were, produced,, and the blood is drawn from the brain to the intestinal canal. Calomel, with lemon-juice squeezed in water, should also be given. 10. Perspiration on the surface of the body should be ob- tained by antimonials. The pnlvis ipecacuanhee compositus ought not to be used to promote moisture of the skin, on account of the opium it contains, as it confounds the judgment, and prevents your seeing what are the effects of the opium, and what those of the disease. 11. Counter-irritation is of use, but not until other means have been resorted to. The object of blisters is to subdue the inflammation when other means have failed. I have known a patient, with pain in the head, sickness at the stomach, loss of strength, and throbbing of the carotids, who had been oflen relieved by blood-letting, for about two hours only after it was done. A person un- der such circumstances, I have known benefitted by the application of a blister, on the principle not of increasing but subduing action, from an excess of which the ill consequences are to be feared. 12. In addition to the means already named for the treat- ment of concussion, you must pay strict attention to the mind ; excessive anxiety must be prevented ; for if you suf- fer the mind to be disturbed, you do little or nothing towards the recovery. 13. In the treatment of concussion, with children, you cannot always bleed from the arm ; you must therefore open the jugular vein, apply leaches to the temples,, and give ca- lomel with mild drinks, so as to purge them. COMPRESSION. 69 1 J . For the after symptoms of concussion^ as pain in the head or sickness at the stomach, trephining Tvas formerly much employed; but it is a practice full of danger, and of little or no use whatever. Make an incision through the scalp ; put issues in ; wash the head ^vitS spirits of wine and water; use the shower-bath two or three times: and they will be found the best means of giving power to the system, and bring- ing the action of the brain into a healthy state. C03IPRESSI0X. 1. When a person is labouring under compression of the brain, it is known by the breathing being stertorous, the pulse slow, and the pupils dilated : to which may be added the symptom.s of concussion. 2. The causes which produce compression are these three ; extravasation of blood, fracture with depression, and forma- tion of matter within the skull. 3. When the brain is compressed by extravasated blood, the symptoms do not directly occur ; the person at the time of the injury is often stunned, recovers himself, and a short time after falls into a comatose state, and then the apoplectic stertor begins. Extravasation with concussion, renders the case of a different nature ; then the symptoms of concussion come on first, and the apoplectic stertor and other symptoms of compression succeed. 4. The extravasated blood is found in three different pla- ces : first, bet^veen the dura mater andpia mater ; secondly, between the pia mater and brain j and lastly, within the substance of the brain itself. These are the three different situations in which extravasation of the blood is principally formed : but 1 do not find any difference of symptoms prorluced by the different situations ; the compression is produced by the pressure of the blood, and the quantity of blood effused will depend on the size of the vessels of the dura mater that are divided. If there should be any blood resting on th"^ origin of a ner\'e, there will be partial paralysis of the part which the nerve supplies. 70 FRACTURES OF THE SKULL. 5. In the treatment of these cases there is little to be done. If extravasation of blood occurs with fracture, the trephine may be used. You should deplete freely for the purpose of preventing inflammation, and lessen irritation, by enjoining quietude, and opening the bowels. If there is a bruise near the fracture, indicating the spot where the hlood is effused, you may trephine, that is, before symptoms of excitement come on : when they take place, you must deplete only, and not dream of per- forming the operation on any account whatever. FRACTCJRES OF THE SKULL. 1. Fractures of the skull are not of themselves dange- rous, nor are they injurious to the brain, if care be taken to prevent inflammation. The danger is to be apprehended from compression of the brain, extravasation of blood, or ir- ritation in some distant part. Therefore, when called to a case of fracture of the skull, you do not ope- rate, but consider the symptoms that are present, endeavour to ascertain from what they arise, and then regulate your treatment accordingly : if the symptoms are those of concussion, the treatment must be directed to it ; if those of extravasation of blood, and there is not much excitement, it will be necessary to remove a portion of bone ; but if there be fracture only, without any of the symptoms above-mentioned, there will be no occasion to operate. 2. "When a fracture occurs at the base of the skull, it is much more dangerous than at any other part, because ex- travasation of blood is more likely to take place ; or if not, inflammation of the brain, from the violence of the injury received, very often supervenes. Fractures of the base of the brain are produced by falling from a great height on the summit of the head, when all the weight of the body rests on the foramen magnum and cuneiform process of the os occipitis. 3. The cranium may be fractured in very different ways ; but there are two kinds, which require to be noticed on ac- count of their characteristic symptoms. First: if there is a transverse fracture through the foramen magnum, FRACTURES OF THE SKULL. 7l cuneiform process, and part of the temporal bone ; a discbarge of blood into each meatus auditorous takes place, and, when there is no otlier mischief, deafness often remains for life. Secondly : should the skull be fractured over the frontal sinuses, when the fracture is simplej if the nose be blown, the air escapes through the opening in the bone, and, getting into the cellular membrane under the skin, renders the forehead emphysematous. If, on the other hand, the frac- ture is compound, upon blowing the nose, the air rushes through the wound. 4. Fractures of the skull, if unaccompanied with concus- sion or compression, as readily unite as fractures of the bones in any part of the body. \Miea large holes are made through the skull, (as in trephining,) the apertures do not again become filled with ossitic matter, but by a tendi- nous structure formed from the bone and dura mater. When the bones of the skull, in fractures, are widely separated, the interspace will not become filled by bony matter, but remain open. 5. Treatment : — The treatment of fractures of the skull will depend, more or less, on the symptoms which present themselves. 6. In the first place, when there is a simple or compound fracture, unaccompanied with symptoms of injury to the brain, you must not trephine. 7. In these cases, let your treatment be constitutional de- pletion, by means of blood-letting and purgatives j and if there is a wound in the scalp, endeavour to heal it as quickly as possible by the application of adhesive plasters. This plan often removes symptoms of concussion, and even extravasation, which accompany these fractures ; and frequently a few hours will show you that the application of the trephine, which you at first might have thought indispensable, is wholly unnecessary. 8. In the second place, when there is fracture jvith depres- sion, the treatment must differ according as the case is simple or compound. 9. Before speaking of the treatment for fractures with de- pression, there are one or two injuries of the head, which it 72 FRACTURES OF THE SKULL. is necessary should be borne in mind, to direct your diagno- sis on being called to accidents of the kind. Sometimes a person receives a blow on the scalp ; the parts immediately surrounding the spot where the blow was received, will rise (from the ex- travasation of blood) two or three lines higher than the part itself ; for there, the cellular membrane, having been condensed by the injury, will likewise tend to increase the deception ; thus the surrounding parts are considerably higher than the middle, and the external character of the contusion is cer- tainly calculated to deceive. Again, it very often happens in fractures of the cranium, that considera- ble depression of bone will take place, from the external table of the skull being driven into the diploe, and without producing the slightest injury to the internal table ; these fractures, however, can only occur in those of a middle age, ior, in very young, and in very old age, the skull is thin and without diploe. 10. These cases sufficiently show that you ought not to be too precipitate in your diagnosis, nor hastily determine upon performing an operation, which you might afterwards have reason to repent. 11. To return to the subject of fracture with depression, if the fracture is simple, and there is no wound in the scalp, and no symptoms of injury to the brain, you must not trephine. Even if there are symptoms of injury to the brain, and the fracture is simple, do not immediately trephine : take away blood, and purge your patient freely, and see how far the symptoms may be the result of concussion of the brain and not of depression . Inflammation rarely follows a simple fracture with depression, but very often follows a compound fracture ; you must therefore be very cautious of rendering a simple fracture compound by the operation of trephining. 12. When fracture with depression is of the compound nature, you should immediately trephine or elevate the depressed portion of the bone, for, as these cases are usually attended with inflammation, you must not wait till the inflammatory symptoms come on, but at once proceed to remove the cause of depression. If inflammation comes on, the patient will die, whether you operate or WOUNDS OF THE BRAIN. 73 not, and you will be so far from arresting its fatal progress by trephining, that you only will be adding to the danger. 13. Inflammation does not uniTormly follow compound fractures with depression, but it is always advisable to se- cure the life of pur patient by operating. The rule, therefore, which I always follow is this: — When I am called to a fracture, with depression which is exposed to view. 1 generally use an elevator, and very rarely the trephine. I put this under the bone, ruise it up, and if it has been comminuted, remove the small portions of bone. Jf, however, one bone is wedged within the other, I apply the trephine for raising the depr'^ssed portion of the bone. The elevation of the boae is never followed by any mischief j but if you do not raise it, and intianiniation follows, it will be too late to attempt to save the life of the patient. 14. It sometimes happens, in fracture of the skull atten- ded with depression, that a small spicular portion of the bone will project into the brain, so as to produce and support epi- leptic symptoms, but let this be removed, and the symptoms will subside. WOUNDS OF THE BRAIN. 1. Wounds of the brain will often happen without produ- ,ing any interruption to the operations of either the mind or body. But, should the wound be accompanied by compres- sion or concussion, then the particular symptoms, which char- acterize those injuries, will be present. If the wound is a simple incision or laceration, it will prove quite harm- less. Indeed, it frequently occurs that considerable portions of the brain are lost, and yet the mental and bodily functions continue unimpaired- Epileptic fits and hemiplegia certainly sometimes follow those injuries. 2. It occasionally happens, when a portion of brain has been lost, that a piece of the cranium will, by being driven in, occupy its place. If in these eases, no symptoms of compression manifest themselves, you must not elevatrt the depressed bone ; for were you to do so, you would, in all probability, give rise to extravasation, or ivjrease the hazard of in- flammation. 7 74 WOUNDS OF THE BRAIN. 3. The danger, attending injuries of the brain, arises prin- cipally from two causes j the formation of fungus, and from inflammation. 4. Fungus : — When the brain receives a wound, you must commence your curative exertions, by abstracting as large a quantity of blood from the system as the constitution of your patient will bear ; not, however, to such an Extent as to pre- vent the restorative operations of nature. After some days have elapsed, the divided parts begin to unite by means of the adhesive inflammation ; but, if this process cannot effect a cure, granulations form, which at length project through the opening in the skull, and give rise to fungus. 5. When this is the case, the safety of your patient will depend on the treatment you adopt ; for, if you do not repress the growth of the fungus until the dura mater heals over it, there will be violent constitutional irritation, and the life of the patient in jeopardy ; but, on the contrary, if you attend to the condition of the wound, and prevent the fungus from rising, there will be, comparatively speaking,but little danger. Your treatment should be as follows : — Apply to the fungus a piece of lint wetted with liquor calcis, and over this, strapping of adhesive plaster ; when you examine the part on the following day, yon will find the fungus con- siderably diminished : you are then to use a thicker piece of lint, and the strapping as before ; you must pursue this plan until you have succeeded in getting it even with the dura mater, in which position it must be cautiously preserved; when, at last, the dura mater heals over it, and your object is accomplished. 6. Inflammation : — Wounds of the brain are dangerous from the inflammation which supervenes, and which danger is increased, if the dura mater is the part attacked. When inflammation attacks the membranes, symptoms of irritation will be present ; but if the brain itself, they will be those of compression. The ordinary symptoms are, great pain in the head ; the scalp oedema- tons round the external wound ; the edges of the wound have a shining, glossy appearance ; and there is a discharge from the wound itself, com- posed of serum and blood ; sometimes the parts about the wound have a I WOUNDS OF THE BRAIN. 75 sloughy appearance ; the countenance is very much flushed, and the carotid arteries beat with very great force; there are very frequent rigors ; some- times hemiplegia] and the patient very quickly falls into a comatose state. 7. Inflammation of the brain is more slow in its occur- rence after an injury, than inflammation after an injury of another part. It is generally about a week before it comes on J very rarely under that time. It often happens that inflammation of the brain does not come on till a fortnight, or even three weeks after the injury ; you must, therefore, be upon your guard, as your patient is not out of danger until that length of time has elapsed, and sometimes not even then. 8. Treatment : — This is the same as for inflammation gen- erally, with this exception only ; that blood should be drawn from the temporal artery in adults, and the jugular vein in children. In addition to this rule, you , must purge, produce perspiration, and apply blisters to the head. I have seen poultices, containing some stimulating application, of con- siderable use. 9. When inflammation terminates in suppuration, the matter may be situated between the dura mater and skull, pia mater, tunica arachnoides and brain, and, lastly, in the substance of the brain itself. 10. First : — When pus is situated between the dura mater and skull (though this is very seldom the case) trephining for its removal would be attended with complete success ; but the chances of finding it there are against you, as it is generally situated between the pia mater and surface of the brain, for which an operation would be worse than useless. 11. Secondly : — When matter is situated between the pia mater and brain itself, it is diffused over the hemispheres of the brain, so that it will be of no use to operate, as very little will be discharged, there being no communication between one part and another ; for the matter is contained in distinct cells, between the vessels which come from the pia mater to the brain. 76 TREPHINING. 12. Lastly : — Matter may form in various parts of the brain itself, and instead of being attended with symptoms of irritation, they are rather those of compression. TREPHINING. 1. This was formerly an operation requiring several in- struments, but, as it is now performed, three are quite suf- ficient. A knife, with a double edge, in order to scrape off the pericranium ; an elevator ; and a trephine having a crown, and a pin which will allow of being easily moved. 2. Trephining, though by no means so frequently resort- ted to, or so badly conducted, as in former days, is neverthe- less one of considerable danger, and ought not to be perform- ed unless the case absolutely demands it. It is in fact, one of the most dangerous operations in surgery ; whilst per- forming it, there is but a single step, a small net-work between your pa- tient and eternity ; saw through this, and destruction of life will generally be the consequence. 3. This operation must never be performed where a sinus would be laid open, or in any other place where an important part would be exposed to injury. First : — You should never trephine in the course of the longitudinal sinus, or the line that extends from just above the nose, along the top of the head, to the tuberosity of the occiput. Secondly : — Over the frontal sinuses. Thirdly : — Over the anterior inferior angle of the parietal bone, just above the zygoma, on account of the great artery of the dura mater. And lastly : — Behind the ears, on the posterior inferior angle of the same bone, lest you should lay open the great lateral sinus. Fractured portions of these bones may be raised by the elevator ; and I may observe here, that this is the in- strument chiefly used in cases where the fractures are running in the direc- tion of these parts. 4.. In performing this operation, a crucial incision is to be made, and the integuments turned aside ; then cut through the pericranium, and scrape it off ; this done, apply the tre- phine (taking care the pin is moved as soon as a circle is TREPHINING. 77 made, which in young persons will be requisite very early, because the bone is readily sawn through) and take care you do not injure the dura mater. After you have perforated the skull, the elevator should be introduced, to raise the depres- sed bone, and m this way return it to its natural situation. When the operation is finished, the scalp is to be laid down in its natural position, and dressed very slightly with a pledget of any simple bland ointment. When operating on living subjects, you are informed of the progress you are making, by blood issuing from the wound when you reach the diploe ; and when you see the blood, you will know you are hnlf way through : but recollect, ill very young and old persons, there is no diploe ; therefore, very few turns of the saw will do. When you find you have sawn through one part, introduce the elevator, and lift the poition of bone, the parts not cut through, being easily broken ; and the bone may thus be safely removed without wounding the dura mater. 5. When the dura mater is wounded in this operation, the patient very rarely recovers ; but if the dura mater and pia mater are both injured, the danger is less : in the former case there will be excessive inflammation ; whereas, in the latter, a fungus immediately projects and fills up the cavity. 6. If the whole depressed portion of bone cannot be raised, or all the blood or matter cannot be discharged, by making one perforation, the operation must be repeated, and as often as the case may require. Removing large portions of tlie skull, however, should always be avoided if possible, because it may be itself the source of bad and even fatal conse- quences ; but it is certainly less dangerous, than not completely removing the pressure from the surface of the brain. 7. The operation in question, we have observed, is not always necessary j but there are four circumstances when it becomes requisite. 8. First : — When there is extravasation of blood between the dura mater and skull . 9. Secondly : — In compound fracture with depression, unacr-ompanied with sjTnptoms of compression. '^5 Vt'-irv^ M ^$ \ 78 ^ WOUNDS OF THE SCALP. 10. Thirdly : — In simple fractures, with depression and symptoms of compression continuing after depletion. 11. And lastly : — It is sometimes required that an open- ing should be made in the cranium, when there is matter be- tween the dura mater and skull. Now it generally happens in this last case, where there is matter between the dura mater and skull, that there is fracture, and this is an indication that some injury has been done to the brain, when it is also followed bj rigors and other symptoms : still it will be right, in some cases where there is no fracture, and the other symptoms, rigors, &c., are present, to penetrate the bone, to see whether matter is lodged between it and the dura mater j and this is the only case in which it is proper. WOUNDS OF THE SCALP. 1. Simple wounds of the scalp, without injury to the skull, will generally unite, as other wounds, without any pe- culiar constitutional derangement. It may be as well, however, to remark here, that wounds of the head are not unfrequently followed by erysipelas, a circumstance explained by Petit, Desault, and Bichat, by the suppositinn that they often disorder the hepatic functions, and thus produce a state of the constitution favourable to its occurrence. 2. Contused and lacerated wounds of the scalp, though not so easily healed, may, nevertheless, be frequently united without much delay. The flaps, angles, and detached portions of these wounds, provided they are connected with the rest of the scalp at some point or other, ought never to be removed, so as to cause an unnecessary exposure of the cranium ; on the contrary, they ought to be carefully laid down, and, when not too severe- ly contused, they will be found to unite and do well. 3. Wounds of the scalp are not always devoid of danger, for there are two ways in which they occasionally prove de- structive to life ; first, by producing erysipelas ; and second- ?'U?i/^'H^?e "^ INJURIES OF THE SPINE. 79 ly, by producing inflammation of the tendon of the occipito- frontalis. 4. When inflammation attacks the tendon of the occipito frontalis, it extends over the scalp and face, and assumes an erysipelatous character, but it is not true erysipelas. It has not the vesicles which commonly attend erysipelas, but it has a tendency rather to suppuration ; and if the constitution has the strength to produce this suppuration, it takes place between the tendon and the pericra- nium. In this way, a very extensive abscess is often formed, into which we are obliged to make an incision, in order to dischage the matter, which cannot make its way through the tendon. 5. Erysipelas, in cases of wounds of the scalp, has been erroneously imputed to an injury of the aponeurosis of the occipito-frontalis muscle and pericranium ; but it does not, in point of reality, arise from this cause. Whatever may be the precise inducing cause of erysipelas in these cases, your treatment must be the same as is ordinarily recommended for erysipelas generally, with the exception that if there is much inflammatory action about the wound, mild diet, and depleting plan of medicine would be better calcu- lated. 6. Finding, therefore, wounds in the scalp may be atten- ded with considerable hazard, you will be convinced of the impropriety of making incisions in this part, merely for the sake of exploring the nature of an injury. INJURIES OF THE SPINE. 1. Injuries of the spine produce effects similar to those arising from injuries of the head ; the spine being liable to concussion, extravasation, a-nd fracture with depression. 2. Concussion : — Cases of concussion of the spine are not very unfrequent ; and most commonly occur in the lumbar region. A violent blow on the loins will produce paralysis of the lower extremities. The paralj^sis, however, is not 80 INJURIES OF THE SPINE. complete ; the person is unable to support his body, but gen- erally some power of moving his limbs reraains. This paralytic state, arising from a Mow on the loins, is in general easily removed. Yo;.i apply cuppmg glasses to the part, and take away blood from it several times with the scarificator. Jfat the end of a week or ten days, the ])aralytic state stiil continues, you must apply a blister to the loins, and keep it dressed with equal parts of the unguentum lyttte and unguentum BabinsB. The lyttaa being in this way absorbed into the constitution, dimin- ishes the disposition to paralysis, while the counter-irritation also produces good effects. 3. Extravasatim .-—In cases of considerable extravasa- tion, I do not know what can be done, except to bleed in the first instance, in order to prevent further extravasation ; and afterwards to produce absorption, and excite counter-irrilation by the application of blisters. These are cases of too rare occurrence to enable us to lay down any posi- tive principle as to the mode in which they are to be treated. 4. Fracture rvith depression : — Fractures v;ith displacement of the spine, are by no means uncommon accidents. They have been improperly called dislocations ; but dislocations of the spine are extremely rare, and only occur in the cervical vertebra?. They are, in fact, fracture with displacement ; not one vertebra separating from another, but a fracture through the vertebra, and consequent depression of the spinal chord. 5. When fracture with displacement of the spine occurs,, paralysis takes place in the parts of the body below the injury. 6. If it occur in the loins, paralysis of the lower extremi- ties follows ; the power of retaining the faeces, and of expel- ling the urine, is lost. 7. When the injury is in the dorsal vertebrae, there are the same symptoms as I have just mentioned, with this ad- dition, that they are accompanied with considerable inflation of the abdomen. This inflation might lead you, at first, to suppose there was some ru))ture of the intestines ; but after a few hours, when the patient has had free evats* I INJURIES OF THE SPINE. 81 nations, this inflated state of the intestines disappears. The inflation is produced by the great secretion of air into the intestines, in consequence of the diminished powers of the part. 8. When the injun^ occurs in the lower parts of the cer- vical vertebra^, paralysis takes place in the upper as well as the lower extremities, though not in the same degree. There is a numbness of the upper extremities, but seldom to such a degree of paralysis as to deprive the patient of all power, when the injury occurs below the fourth cervical, 9. The time, in which the person dies from these injuries, varies according to the seat of the accident, as being far or distant from the head. If it occur in the loins, the patient will generally die in fiom five to six weeks : — if in the dorsal vertebrae, a muc-h shorter time : — when hets\een the fouifh and seventh cervical vertebrae, in four or five days ; and if the injury is between the second and fourth cervical vertebra, the person dies on the instant, because it is above the origin of the phrenic nerve. 10. With respect to the treatment of fracture, with dis- placement of the spine, nothing hitherto has been effectually done in surgery. The removal of the displaced portion of vertebrae has been attempted, but without success. If you should meet with a case of fracture with displacement, and the urgency of symptoms great, T should recommend the removal of the de- pressed portion of bone; but if the injury is not so severe as to require an operation, your best plan is to place the patient on the fracture bed re- commended by Mr. Amesbury. With this convenient apparatus, your pa- tient may lie on his back, undisturbed for any length of time ; atraji portion of the mattress being left for the passage of the fjeces, as also one allowing local applications to the part affected. Every other necessary attention, as to diet, and so on, must be assiduously given. By pursuing this mode of treatment, the injury, in some instances, may be gradually overcome, and the person ultimately restored to health and vigour. 82 ANEURISM. 1. Aneurism is a pulsating tumour containing blood, and communicating with the interior of an artery. There is one exception to this definition, namely, where aneurism, as it sometimes happens, takes place in the heart. 2. Aneurisms are situated either externally or internally. That is, they are either so situated on the limbs, as that access may be had to them, and the nature of the disease clearly ascertained : or they are so placed in cavities of the body, such as the abdomen, chest, and cranium, as to render the nature of the disease very often extremely doubtful. 3. External Aneurisms : — In external aneurisms, the sjrmp- toms may be divided into the first, second, and third stages. 4. First : — There is a small tumour, pulsating very strong- ly, and as it contains only fluid blood, if you apply your finger to the artery between the aneurism and the heart, you will readily empty the aneurismal bag, by pressure. In this state there is scarcely any pain, and no other alteration in the limb, than some irregularity of circulation, producing spasm in the muscle : and when the patient is going to rest, cramps in the leg, and sudden twitch- ings which prevent him from sleeping. 5. Second : — In this stage we find the blood is beginning to coagulate in the interior of the sac, the coats of which are very materially thickened. At this time, if you press on the artery, you may empty the sac in part; you will see the swelling re-produced when you take off the pressure. You cannot completely empty the bag by pressure, for a considerable de. gree of swelling will still remain. There is some degree of pain below, and the circulation is retarded in consequence of the pressure on the sur- rounding parts. The aneurism becomes a solid swelling instead of a mere bag containing fluid. 6. Third : — AVhen an aneurism reaches its third stage, it has acquired considerable magnitude, and the pulsation is in a ANEURISM. 83 degree lost, or seldom perceired over the whole swelling. A small portion of the blood still remains in a fluid state, but the greater part of it is filled with coagulum. Finally, the aneurismal sac bursts, and the patient sinks from repeated hemorrhage or gangrene. When the third stage has commenced, the swelling gradually increases, and the aneurism becomes of a dark, colour: inflammation of the cuticle eusues, vesication of the cutis to the size of half-a-crown, takes place, and the skin in this part is quite insensible. In a few days an eschar is formed, a small wound takes place, and blood issues from the part ; lint is applied to the wound, and the hemorrhage is stopped ; but as the eschar proceeds, and the size of the wound increases, the hemorrhage returns ; and thus by repeated bleedings, destruction of life is produced. 7. Internal Aneurisms : — The symptoms of these cases will vary according to the seat in which the disease is found ; the digestive organs will be in fault at one time, the urinary at another, according to the part on which the aneurismal tu- mour presses. 8. Causes : — In many instances it is difficult to assign any cause for the commencement of aneurism ; but among the circumstances which predispose to the complaint, the large size of the vessels may undoubtedly be reckoned. Those trunks which are near the heart are said to have much thinner pa- rietes, iu 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 aneurisms must be more frequent in the trunks near the heart, than in such as are remote from the source of the circulation, 9. The curvatures of the arteries are also a presumed predisposing cause of the disease : as also are several other circumstances unnecessary to detail. Acccording to some surgical writers, the causes of aneurisms operate either by weakening the arterial parietes, or by increasing the lateral im- pulse of blood against the sides of these vessels. Thus they are said to be occasioned by violent concussions, the abuse of spirituous drinks, frequent 84 Ai\EURi9M. mercurial i.ourscs, fits of anger, rouyh exercise, exertions in lifting heavy weights, and so on. 10. In some persons, aneurisms appear to depend upon a particular organic disposition. This has been, in a few instances, particularly noticed, for although the generality of persons who are athicted with aneurism, have but one, Sir A. Cooper speaks of a case where there were seven aneurismal tumours, at difi'erent parts. ■ 11. Males are more subject to aneurisms than females, and females more subject to internal aneurisms than external. The age at which aneurism generally occurs is from thirty to fifty; at that age exercise is considerable, and strength less. 12. Formation ; —Every aneurism was formerly supposed to te produced by the dilatation of the coats of the artery ; but this is not always the case, for they are generally the fruit of absorption of the internal coats. First, the artery becomes opaque, and slightly inflamed ; a small yellow spot appears in the part where the aneurism is afterwards formed, and there is a slight efflorescence stirrounding it. The process of absorption after- wards takes place, and thins the coat of the artery so that the texture be- comes like that of a fine web. At tlie same time that tliis takes place, na- ture begins to set up a process of defence, a coat of adhesive matter is thrown out, and thus a covering is produced which shuts up the artery, so as to prevent the immediate escape of the blood. As the coat of the arte- ry becon)es absorbed, the cellular membrane is glued by this matter to the ouier surface of the artery. The surrounding parts then become absorbed, until there is no longer any thing to prevent destructive hemorrhage. 13. Although aneurisms are generally produced by ab- sorption, they are sometimes formed by dilatation, and are now and then the effect of the bursting of an artery. A pointed body introduced into an artery will produce all the appearance* of aneurism, (aneurismal varix) and require the samiC treatment, fn short, however aneurism may be produced, the surgical treatment will be the same. 14. Diagnosis : — Aneurismal tumours may be known by the pulsation being perceptible over every part j whereas, in ANEURISM. 65 tumours which derive their pulsation from being situated over an artery, it is only to be felt in the direction of the vessel. Also, if the aneurism be recent, by pressing your finger on the artery 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 your- self 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 emp- ty itself j and upon raising your hand suddenly, you will observe a jet of blood rush into the aneurismal sac, and raise it to its former height. lo. Some aneurisms are local, and others general ; when they occur in the ham, they are frequently only local ; but when between the groin and ham, or in the middle of the thigh, you very commonly find disease of other arteries. A knowledge of this circumstance should lead you to attend to your pa- tient before you operate, lest he may afterwards sink from internal aneurism. 16. Prognosis: — Your opinion of the probable termination of these cases must vary according to a variety of circum- stances. The disease may generally be considered as ex- ceedingly dangerous ; for, if left to itself it almost always terminates in rupture, and the patient dies of hemorrhage. There are some examples, however, in which a spontaneous cure took place, and aneurismal swellings have been knovvn to lose their pulsation, become hard, smeller, and gradually reduced to an indolent tubercle, which has entirely disappeared. 17. Every aneurism, so situated that it can neither be compressed nor tied above the swelling, is "for the most part incurable. 18. The age, constitution, and state of the patient's health, are also to be considered in the prognosis, for they undoubt- edly make a great difierence in the chance of success after the operation. The operation is not, however, to be set aside on account of the age of the patient, provided the circumstances of the case in other respects appear to demand it ; for it has been performed favourably on patients above sixty j and in one case, by Sir A. Cooper, &s late as eighty-five. 86 ANETJRISM. 19. Spontaneous cure : — The obliteration of the sac, in con- sequence of a disposition of the lamellated coagulum in its cavity, is the mode by which the spontaneous cure of aneu- rism is in most instances effected. In these instances a stratum of coagulum is deposited upon the inner surface of the sac 3 and successive depositions of the fibrous part of the blood, by degrees, lessen the cavity of the tumour. At length, the sac be- comes entirely filled with this substance, and the deposition of it generally continues in the arteries on both sides of the sac, as far as the giving oif of the next large branches. The circulation through the vessel is thus pre- vented j the blood is conveyed by collateral channels ; and another process is instituted, whereby the bulk of the tumour is removed. 20. Sometimes an aneurism is deeply attacked with in- flammation and gangrene ; a dense, compact, bloody coagu- lum is formed within the vessel, shutting up its canal, and completely interrupting the course of the blood into the tumour. 'Hence, in cases of this kind, the ensuing sphacelation and bursting of the integuments and aneurismal sac, are never accompanied by a fatal hemor- rhage : and the patient is cured of the gangrene and aneurism, if he has strength sufficient to bear the attending derangement. 21. Another mode in which the disease is spontaneously cured is, the tumour pressing on the artery above, so as to produce adhesion of its sides, and thus cutting off the supply of blood to the aneurismal sac. Other processes of spontaneous cure are mentioned by different writers : but of too rare an occurrence to require mentioning in the present treatise. 22. General Treatment : — In those cases where a sponta- neous cure cannot be anticipated, and the urgency of the symptoms imperative, you must give your attention to an appropriate medical and surgical plan of treatment. 23. In your medical treatment, do not keep your patients too low, for you wiU thereby render them very irritable; bleeding is occasionally useful : strict attention is to be paid to the regimen,and stimulants of every kind carefully avoided. ANEURISM. 87 24. In your surgical treatment, some say, you must have two objects in view : either to attempt the curative process by the application of pressure on the artery, or aneurismal bag, for very small aneurisms, as of the temporal arteries : or, in cases of larger aneurisms, to cut off the supply of blood, by taking up the nourishing artery. From the cases which Sir A. Cooper has witnessed, the plan of pressure on arteries he believes to be ineffectual, and therefore does not recommend its adoption. 25. The principle, however, on which external aneurisms are usually cured, consists in preventing the entrance of fresh blood into the aneurismal sac. When this is accomplished, the blood, already contained in the sac, is gradually absorbed, the sac itself contracts, the whole tumour diminishes, and, by degrees, the power of using the limb is restored. 26. The stoppage of the influx of blood into the sac may sometimes be fulfilled by the skilful application of pressure, particularly while the aneurism is small, and its contents can be made to recede. There are too few instances of cure by pressure to merit an unreserved reliance on this mode of treatment. If it is adopted, the customary rules for the lessening and moderating of arterial action must also be attended to. 27. As pressure is by no means an effectual cure in these cases, your final remedy must be the operation of tying the artery which supplies the aneurism. We shall first make a few general remarks on operating for aneurism, and afterwards speak of the aneurisms individually as they occur : with the treatment necessary in each case. 28. The general rules to bear in mind in operations for aneurisms are, the manner and direction of your incision ; the application of the ligature ; and the after-treatment of the patient. 29. The direction and extent of the incision must obviously depend on the situation of the artery about to be operated on. 88 ANEURISM OF THE HEART. 30. In the operation of taking up vessels, various sorts, and many modes of applying ligatures, have been, at one time or other, in use ; but on the whole, rest assured, that the best manner of applying them is that now commonly adopted : tie a tight knot v/ith a fine ligature, and then cut one end close to the vessel, and let the other hangout of the wound. If, in the operation, tlie artery has been disturbed much from the sur- rounding cellular membrane, (for an inch or so,) apply two ligatures and divide tlie artery in the centre, and there will then be room for the retrac- tion of the artery ; but if on the contrary, it has not been much disturbed, apply only the single ligature : — Broad ligatures must, on no account, be used, as they are very likely to produce constitutional irritation, and conse- quently cause the parts to suffer for a great length of time. 31. When the operation is completed, you are to bring the integuments close together, by means of adhesive plaster, leaving, however, a small space between each, so that the matter may escape through the interstices : and the other after- treatment must entirely depend on existing circumstances. If the operation performed has interrupted the supply of blood to any limb, you must be particularly careful to preseive warmth, lest gangrene should ensue. 32. The time, at which the ligature separates, is generally from the twelfth to the fourteenth day j but it is variable ac- cording to the kind of ligature used. If early inflammation comes on, the separation will be rapid ; but if there be a broad ligature, and the inflammation indolent, it will be from twenty-five to thirty days. If the ligature should come away without any hemorrhage, do not con- sider your patient safe ; therefore, be on your guard, and let him remain quiet for two or three days afterwards. ANEURISM OF THE HEART. 33. An aneurism of the heart consists of a bag formed out of the parietes 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 quie- tude, with mild and moderate diet. 89 ANEUEISMS OF THE AORTA. 34. Aneurisms of the aorta are disease 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 5 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 avoid- ing the fatal end to wliich the disease naturally hastens. 35. Aneurisms of the aorta vary in their situation ; some- times arising in one part, in other instances, at another ; more frequently, however, at the arch of the aorta. Dr. Hunter was of opinion, that the frequency of the latter cases depend- ed on the forcible manner in which the blood must be driven against the angle of the curvature of the vessel. 36. Ascending Aorta : — Aneurism of the ascending aorta, just at the commencement, where it is covered by the peri- cardium, is not of unfrequent occurrence. 37. Curvature of the Aorta : — Aneurisms in this part are, as we have before mentioned, very frequent. They are to be seen just above the sternum, and are very hable to be mista- ken for aneurism of the subclavian artery . The termination of existence from these cases is very different. Some- times they cause, by their pressure, dyspnoea and suffocation ; sometimes they press behind on the oesophagus, instead of in the front, on the sternum. In some cases, the swelling bursts into the cavity of the chest and the patient drops suddenly down. In other examples, the blood is effused into the trachaea, or bronchia, and the patient, after violent coughings and ejec- tions of blood from the mouth, expires. These are among a variety of ter- minations ; to guard against which nothing more can be done than rest, viiiYi mild and moderate diet. 38. Arteria Innominata : — Aneurisms of this vessel do not, in general, allow of an operation being performed ; there is no room for the ligature. 8 90 ANEURISM OF THE AORTA. Dr. Mott, of America, has put a ligature on this vessel ; and, for a time, the patient appeared to be doing well, but he afterwards died. 39. Descending Aorta : — When the descending aorta is the subject of aneurism, in its course through the posterior medi- astinum, it very often presses on the oesophagus, adhesion of the coat of the sac to the oesophagus takes place, and after- wards an opening between the aneurismal bag and gullet is formed ; the patient vomits a considerable quantity of bloody and soon expires. ft is as well to observe here, that aneurisms of the thoracic aorta are scarcely ever known with certainty, before they have advanced so far as to be attended with an external pulsation, and a tumour that admits of being felt, or even seen. 40. Abdommal Aorta : — Aneurisms are not unfrequent in different parts of the aorta below the diaphragm ; and, accor- ding to their situation, so will the symptoms, more or less, characterize their position. There are two or three instances, which it may be deemed essential to speak of in particular, as the diagnosis in similar cases will thereby be ren- dered more certain. 41. First, when the aneurism is situated above the coeliac artery, a pulsation may be distinctly felt at the scrobiculus cordis : — Secondly, when it is lower down in the cavity of the abdomen, it often bursts into the intestines : — And in the third case, if the tumour presses on the spine, absorption of the vertebrae takes place. In the first case you may know the complaint by the aneurismal tumour pressing on the stomach, producing nausea and vomiting, and the immediate ejection of small quantities of food. In the last case, in addition to what is mentioned in the paragraph, you will also find a large swelling in the loins ; but these tumours have no dis- cernable pulsation, owing to their distance from the aoita. ♦ 42. Aneurisms of the abdominal aorta, like those of the thoracic aorta, are formidable diseases, leaving scarcely a hope of alleviation, much less of a cure. Moderate the force of the circulation by gentle bleeding and low diet ; avoid every thing that has a tendency to heat the body, or quicken the mo- PELVIC, ISCHIATIC, AND GLUTEAL ANEURISM. 91 tfon of the blood ; keep the bowels open with laxative medicine, and les- sen pain by the use of sedatives. 43. Tying the Aorta : — The securing of the abdominal aorta I have once attempted, and, from the promises of success which I have observed after the operation, I should feel my- self authorized to attempt it a second time. In the case I have had an opportunity of giving it a trial, I commenced the incision in the linea alba, two inches above the umbilicus, and carried it to the same distance below, taking care in my descent to avoid the um- bilicus by giving it a semilunar turn or curve. My finger was easily passed do'vn to the artery, and the vessel secured without difficulty. The princi- pal danger does not appear to be from gangrene, nor is any tiling to be ap- prehended as far as regards the carrying on the circulation, for that will be eiFected by anastomosins vessels. The danger in part consists in including the nerves in the ligature (which must be cautiously avoided) but more es- pecially from the irritation produced in the intestines by the ligature, and for that reason, if I was ever called upon to repeat the operation, I would cut the ligature close to the vessel, where it should take its chance, either to become encysted or absorbed. PELVIC, ISCHIATIC, AND GLUTEAL ANEURISMS. 44. Aneurisms sometimes form in the cavity of the pel- vis, in the isch'.atic notch, and under the gluteus maximus muscle. This last circumstance should put you on your guard when you find tumours on the nates. 45. In cases of gluteal aneurism, or in wounds of the gluteal artery, the operation of securing the vessel should be performed. In those cases where the ischiatic portion, or tlie pelvic arteries, are the seat of disease, it has been recommended also to put a ligature, if prac- ticable, on the nourishing vessel. 46. Internal Iliac Artery : — The operation of taking up this artery is one of extraordinary difficulty. It is only necessary for an aneurism of the gluteal artery, just at its commence- ment, so that it cannot be reached under the gluteal muscle. You make an incision on the inner side of the spine of the ilium, by which you cut through the abdominal muscles, and reach the peritoaeum : 92 POPLITEAL ANEITRISM. this you turn to the opposite side, in order that the artery may be reached. In putting your ligature on the vfssel, be particularly careful lest you iu- clude the ureter, which crosses the internal iliac at the bifurcation, and thus cause the destruction of life. The after manEigement is the same as for aneurisms in general. POPLITEAL ANEURISM. 47. Popliteal aneurism, as its name implies, is situated in the popliteal space of the ham ; it is the most common ex- ternal one, and is characterized by the symptoms lately drawn (Par. 6.) in illustration of external aneurisms. Much has been said of the value of compression in some cases of popli- teal aneurism, and the celebrated Scarpa, from his observations on the sub- ject, has laid down certain rules, in which cases it might be used with ad- vantage, and, on the other hand, where it would be injurious. 48. In this country, the aid of compression is scarcely, if ever, resorted to, the operation of tying the nourishing artery being the most effectual mode of treatment. There are various sentiments on the precise spot where the vessel is best secured, for the effect, in respect to the primary indications, which the sur- geon proposes to accomplish, is the same, whether the artery be tied in the ham, a little above the breach in the vessel ; whether the ligature be ap- plied on the inner side of the thigh, in the middle, or at the top of the thigh ; that is to say, the flow of blood through the popliteal artery into the aneurismal sac being thereby intercepted, the obliteration of the cavity will supervene. 49. Femoral Artery ; — For the ciire of popliteal aneurism, this artery was first secured in the middle of the thigh, by BIr. Hunter, and is the operation now generally practised. Operation : — Put the sartorius muscle in action by placing the leg in the tailor's position ; then make an incision three inches in length, rather above the middle of the thigh, in the oblique direction of the muscle, and on its inner edge ; continue it through he integuments and fat, till the bor- der of the muscle is exposed. Observe the direction of the fibres, to as- certain that you have not come upon the vastus, tlien elevate the sartorius, draw it a little outward, which brings the femoral sheath into view ; open this with care by a small incision, and then dilate it, but cutting from with- in, oufwartZ* .• this exposes the artery, wliich has the vein rather behind, PEMOEAL A^'EtJEISM:. 93 and to its inner side. When the artery is secured, you are to bring the in- teguments close together by means of strips of adhesive plaster, leaving a small space between each, for the escape of matter. Xo bandage or rol- ler should be applied ; and as for the position of the limb, it should be plac- ed on a pillow, and on its outer side, occasionally changing it so as to pre- vent pressure in any particular part. It not unfrequently occurs, when there is aneurism of the popliteal artery, there will also be aneurism of the ascending aorta, therefore, in such cases, and in fact, always before operating for any aneurism, examine the patient and see if there is pain and pulsation in any other part, as death may take place by the rupture of an internal aneurism, whilst you are performing it, 50. When the femoral artery has been tied,, the circula- tion has gone on by the arteria profunda ; from this, anasto- mosing vessels are sent off, which communicate with branch- es from the anterior tibial. Owing to the difficulty which is at first given to the circulation of the member, in cold weather, and always if the temperature of the limb sinks after the operation, flannel should be applif-d ; and pressure on the heel carefully avoided, lest gangrene of that part should take place. FEMORAL ANEURISMS. 51. It is not an uncommon occurrence to meet with an aneurism of the femoral artery just below Poupart's ligam^ent. Not many years ago, cases of this description were deemed incurable by any surgical operation ; but it is now proved, that not only the securing the femoral artery above the profunda may be successfully attempted, but even the external iliac artery itself. 52. External Iliac : — The possibility of a cure for aneu- rism of the femoral artery high up, having been established., the tying of the external iliac artery is the operation to which, we must refer. Operation : — Besin the incision a little above the abdominal ring, and extend it, in the shape of a crescent, to the edge of Poupart's ligament, and then continue it to about an inch and a half from the inner spine of the ilium, where it terminates. By this incision T lay bare the tendon of the external oblique muscle ; in the second, I divide this tendon and expose the internal oblique and transver^alis muscles. The ne.xt siep will be to raise the internal oblique aud transversalis muscles from Poupart's liga- 94 ANEURISMS OF THE LEG AND FOOT. ment, by introducing the finger behind them ; which done, you reach the passage of the spermatic cord ; and then behind the pulsation of the iliac vessel. You now draw up the internal oblique, and transversalis muscles with the finger, at the same time elevating the spermatic cord a little, and then carry the finger into the abdomen, behind the peritoneum, and you ascertain the beating of the artery. Having found the artery, I put the aneurismal needle into the opening, and introduce it under the vessel ; clear it a little from the surrounding parts, and take it up, carefully avoid- ing the vein. If the artery should be much exposed (as an inch and a half) two ligatures must be used ; but if a small portion only, the single ligature. When you use two ligatures, you will separate them from each other, drawing one upward, and the other downward, and leaving about three quarters of an inch of the vessel exposed at the extremity of each ligature ; for if this is not done, on dividing the artery, there will be danger of tlie ligatures slipping off. The instrument, with which the artery is usually di- vided, is the probe-pointed bistoury ; when it is done, retraction of the ves- sels immediately takes place. There will he no danger in including the nerve in the ligature, as the anterior crural does not accompany it ; the vein and the artery are included in the sheath, and the nerve is on the ouier side. Lastly, the edges of the wound are to be brought together, and the case treated in the usual way. 53. After the external iliac is tied, the circulation is prin- cipally carried on by the gluteal ; assisted by the ischiatic, the obturator, and the external pubic. The gluteal passes out through the ischiatic notch, comes over the ilium to the groin, and enters the femoral artery a little below Poupart's ligament : The ischiatic arises from the termination of the internal iliac, passes out of the pelvis between the trochanter major, and tuberosity of the ischi- um to the back of the thigh, and sends a few branches to the anterior pro- funda and external circumflex arteries : — The obturator passes out through the obturator foramen and joins the internal circumflex artery : — And the external pubic communicates freely with the internal pubic. ANEURISMS OF THE LEG AND FOOT. 54. Anterior and Posterior Tibial Arteries : — The operation, which has been described for popliteal aneurism, is the one used for aneurisms situated at the upper part of these vessels ; but the operation is not to be performed when the aneurism is near the foot, for, in such cases, you must make an inci- ANEURISMS OF THE SCALP, 95 sion on the sac, and apply a ligature both above and below the aneurism. 55. Aneurisms of the instep and sole of the foot, as ob- served by the celebratea Scarpa, have been found incurable by the ligature on the anterior tibial artery. He thinks, however, that the operation of tying the artery where it passea over the dorsum of the foot might succeed, if aided by compression, applied so as to stop the current through the other main channel : and he seems to ap(>rove of this practice, because the plan of tying the artery above and be- low tiie disease could not be done without extensive incisions in the sole of the foot. a:sEUrisms of the scalp. 56. In these cases, if the aneurismal bag is not very large, you may cut immediately across it ; apply a piece of doubled lint, then a^dhesive plaster, and over the whole a roller. If the swelling is small (not larger than a walnut), you should make a circular incision completely down to the occipito- frontalis tendon. Id this manner, the connection between the blood-vessels and the aneu- rism is destroyed ; and by applying a dossil of lint, and strips of adhesive plaster, you speedily succeed in getting rid of the disease. CAROTID ANEUEISMS. 57. Aneurisms of the carotid artery may not only under- go a spontaneous cure without any serious consequences to the brain ; but the artery itself may be secure by ligature and the patient still do well. Aneurism by anastamo^is, situated in the orbit, antrum, and on other parts of the head, have been cured by the application of a ligature to the common carotid. 58. Carotid Artery : — In the operation of securing this arterv'. it is desirable to make the incision as high as you can ; the upper boundary, therefore, will be the angle of the jaw, and below the omo-hyoideus. 96 AXILLARY ANEURISMS. Make your incision first, then high up, on the inner side of the sterno- cleido-mastoideus, upon drawing aside the edge of which, you will distinct- ly see the omo-hyoideus obliquely crossing the artery. In psssing the liga- ture round the artery, if you raise it a little, you can readily discover whether the par vagum is in contact with it, and thus guard against an ac- cident which might lead to a fatal result. AXILLARY ANEURISMS. 59. There may happen cases of aneurism in the axilla when the operation of securing the subclavian arUry is ren- dered necessary. 60. Various opinions have been entertained whether it is best performed above or below the clavicle. In ordinary in- stances, Sir A. Cooper considers the common mode of secur- ing the vessel above, the most adviseable. The operation is as follows : — The middle of your incision should be op- posite to th'^ external jugular vein, and the centre of the clavicle ; the parts to be exposed are, the omo-hyoideus muscle, crossing obliquely above the clavicle, below the sterno-mostoideus, upon the inner side, and the jugular vein, passing immediately opposite to the centie of the opening. Soon af- ter commencing this operation, you will meet with branches of nerves from the axillary plexus ; you must carefully avoid including these in the ligature, for it would be a fatal error if you were to tie them. The scale- nus anticus being the boundary of the artery on the inner side, you cut down for the purpose of finding its inner edge ; and this you will find a useful guide. 61. After the subclavian has been tied, the circulation is principally supported by the superior scapular. BRACHIAL ANEURISMS, ETC. 62. Aneurismal tumours sometimes occur in the brachial artery, as also in the arteries of the forearm and hand. But as the securing of these vessels are more frequently required for wounds than for aneurisms, the individual operations will be shortly consid- ered 97 ANEUEISMAL VARIX. 1. By arteurismal varix, varicose or venous aneurism, is meant a tumour arising from a preternatural and direct communica- tion, formed between a large vein and a subjacent artery. Thus, in venesection, performed immediately over the artery at the bend of the elbow, if the lancet be carried too deeply, it ma*' trausfix the veia and wound the artery, in which event, the arterial blood, in consequence of the proximity of the two vessels, instead of being effused into the cellular substance, will pass directly into the cavity of the vein, which will bcconae dilated in the form of a varix, and, consequently, constitute a varicoiC aneurimn. 2. "When an aneurismal %"arLs: at the bend of the arm has been thus formed, let me recommend you not to cut down sipon it in order to secure the vessel ; rather tie the brachial artery at the middle of the arm-, and not make aa incision upon the swelling at the middle of the elbow. To put a ligature upon the vessel here, amidst a mass of extravasated blood, is tediousj difficult and dangerous. HYDROCELE. 1. Hydrocele is an accumulation of water in the tunica vaginalis testis, and not between the tunica albuginea and the tunica vaginalis, as was formerly suspected. 2. Hydrocele may be of two kinds : first, of the tunica vaginalis ; and the second^ of the spermatic cord. 3. Tunica Vaginalis ; -The swelling in hydrocele of the tunica vaginalis, at first snows itself at the lower part of the scrotum, and gradually rises till it arrives at the abdominal ring ; is of a pyriform shape ; largest two-thirds of the way dowuTvards ; a little less at the bottom ; and smallest at the ring. 9 98 HYDROCELE. The common formation of hydrocele is unattended with pain, excepting however in those cases, where it has been the result of inflammation ; but generally speaking there is no pain, and the patient accidentally discovers the existence of the swelling, and often not until it has arrived at consid- erable magnitude. Commonly there is no redness of the scrotum and no discoloration. 4. The ordinary situation of the testicle in hydrocele is two-thirds of the way down the tumour, at the posterior part ; but in this respect it sometimes varies. The testicle is sometimes found in the front ; sometimes at the bottom, and at other times attached to both the anterior and posterior surfaces. These varieties are depending upon adhesion from inflammation before the collection of fluid. 5. The diagnostic marks of this disease are, its sense of fluctuation, its transparency, lightness, form, freeness from pain, and the history of the case. Diseased testicle may be easily distinguished from hydrocele, by its weight and flatness, and the pain and sickness which it occasions ; and from hasmatocele or a collection of blood, by the history of the case, and the lat- ter immediately following the receipt of an injory. In very old cases of hydrocele, and in persons who have long resided ire hol climates, the tunica vaginalis is much thickened, so that there occa- sionally is great difficulty in detecting the transparency of the tumour. 6. The contents of hydrocele is usually yellow serum j which gradually rises from the bottom of the tumour till it arrives at the abdominal ring ; but this, however, is not al- ways the case. Sometimes the water of hydrocele forms tvvo swellings, one above the ring, and the other below, thus giving cause for the surgeon to suspect hernia, and although the upper part dilates upon coughing, from the action of the abdominal muscles, its transparency and liglitness will readily distin- guish the complaint. There are also otiier variations in the disposition of the fluid in hydrocele. 7. Co7i!^enital Hydrocele : — In addition to hydrocele of the tunica vaginalis and spermatic cord, there is another variety, called the congenital hydrocele. It is in consequence of a HIDROCELE. 99 communication having from birth existed between the tunica vaginalis and the cavity of the abdomen. When the parts are natural and perfect, there is no opening leading from one to the other, as you know ; but occasionally the natural closure does not take place, and then a fluid may descend from the abdomen, and collect in the tunica vaginalis. 8. Congenital hydrocele may be readily discovered from any other, in consequence of your being enabled, mth ease, to return the vrater into the cavity of the abdomen, by placing the person upon his back, and then elevating the scrotum. In these cases, I would recommend you to have a truss worn over the ring, until you have succeeded (by adhesion of the parts) in destroying the communication ; and if the health is good, the water will become absorbed, and an operation unnecessary. 9. Cause : — The cause of hydrocele appears to depend upon increased secretion, as the vessels are dilated, though there is generally no inflammatory action. Inflammation of the testicle will give rise to hydrocele : for, as the inflam- mation disappears, hydrocele forms. This can generally be removed by exci- ting absorption j for which purpose, give Plummer's pills, and apply to the Bcrotum a lotion composed of the solution of acetate of ammonia, and muriate of ammonia. These means will be found to have considerable influence in hy- drocele which results from inflammation, but in the other sort. they have none. 10. Treatment : — Hydrocele, if left to itself, will often un- dergo spontaneous cure, ; but we are frequently called upon to use a palliative treatment, by drawing the water ofl", and in some cases a radical or curative treatment, by the after- use of stimulating injections or other means. When persons are afraid of the curative treatment, or when it would be at- tended with inconvenience, as also in old persons, the palliative will be deman- ded ; and, insignificant as it may appear, it has been kno^^Ti to cause the des- truction of life ; I would therefore advise, whenever you perform this operation on old persons, to make them keep their beds for a few days after^vards. 11. In performing the operation, a trocar and canula are all that is necessary ; — whether you perform it for the pallia- 100 HYDROCELE. tive or curative treatment, remember that the testicle is usually two-thirds of the way downwards at the posterior part ; introduce the trocar in the fore part obliquely upwards, indeed almost perpendicularly, to avoid wounding the testi- cle ; withdraw the trocar the instant you believe that the canula is within the tunica vaginalis ; and once having the trocar in, take care to keep it there till the operation is con- eluded, by grasping the tumour at the posterior part, so as to keep it tense where the trocar entered. If you wish to accomplish this operation hloodlessly, to prevent internal bleeding, and the formation of haematocele, keep the patient at the time you are doing it, in the erect position. There is no necessity for any after application j on the following day, the wound will be well. 12. The palliative treatment is required to be repeated in proportion to the dropsical tendency existing in the person. In some it will be necessary once a month ; in others, once in three months ; but, generally speaking, the usual time is every six months. 13. The radical cure of hydrocele is effected in three ways : — First, by absorption ; secondly, by adhesion ; and, thirdly, by granulation. When hydrocele is produced in the common way, medicine or local appli- cations have hardly any influence upon it ; and, when it arises from a re- laxed state of the vessels, neither stimulants nor blisters will be of use. 14. In young persons and children you should not always perform the operation ; but endeavour to occasion absorption of the fluid, by suspending the scrotum, and the use of inter- nal and external stimulating remedies. Calomel, scammony, and rhubarb, may be given internally ; and the scro. turn held in a suspensory bag, fastened by a tape round the abdomen, just below the umbilicus, and kept constantly wet by a stimulating lotion of mu- riate of ammonia with the solution of acetate of ammonia. 15. When cases of hydrocele do not yield to absorption, or are too far advanced to attempt it, your next resource is to endeavour a cure by the adhesion of the tunica vaginalis, S^S~' HYDROCELE. 101 and thus prevent the future collection of fluid. This is eflTec- ted ill three ways, either by a seton, incision, or by injection. 16. Setons : — Setons are very rarely used ; but in young persons, whose hydroceles do not give way to the absorbent plan before mentioned, rather than inject, use the seton ; the thread should be allowed to remain for ten or fourteen days, till inflammation and the adhesive process is set up. Operation : — Take a curved needle, armed with thread, and carry it into the tunica vaginalis and scrotum, just at the point where the trocar had been previously introduced, and include two inches above the point, where the nee- dle enters, and bring it out sufficiently long ; inflammation will generally ensue, and adhesion of the tunica vaginalis come on. 37. Incision : — If there is any suspicion of a disease of the testicle, you may use the incision (except in old persons), and, when the opening is made, spnnkle some meal or flour into the wound, to prevent immediate adhesion, and to pro- mote granulation. 18. Injection : — The operation, more generally required for the radical cure of hydrocele, is that of injection. After the water has been drawn off in the usual manner, and the canula still left in, you are to force into the scrotum, by means of an elastic bottle, a stimulating fluid, for the promo- tion of adhesive inflammation. When you inject for hydrocele, you should place the patient in the recum- bent posture. Before you introduce the trocar and canula, make it a rule to squeeze the scotum and tunica vaginalis, so as to make the part where the fluid is most distinct very tense ; then introduce them obliquely in the same manner as in the palliative treatment. Having passed the trocar and canula into the tunica vaginalis, withdraw the trocar, and push the canula alone fearefullv upwards, so as to prevent any injury to the testicles or spermatic cord. You should nip the tunica vaginalis round the canula, to guard against the instrument being diverted, and thus throwing a portion of the fluid into the cellular tissue, thereby leading to the destruction of life. Having taken this precaution, you are gradually to throw up the injection, turn the stop cock, so as to confine it in the tunica vaginalis, and move the scrotum from Bide to side, so that the fluid may reach every part of the surface. It should be suffered to remain in for four or five minutes. 102 HYDROCELE. The elastic bottle should be of a moderate size, and be furnished with a stop cock, and only half the quantity of fluid contained in it should be thrown in at a time, lest the action of the cremaster muscle should force apart of it into the cellular tissue. If this happens, inflammation and sloughing may take place around the part at which the canula is introduced. 19. The fluid used for injection should be of a stimula- ting kind. If you use port wine, the proportion of wine and water should be half and half ; but the best injection you can use is the sulphate of zinc, in the proportion of one drachm to a pint of water, as you can always depend upon the degree of strength. While the injection remains in the tunica vaginalis, the patient will complain of a good deal of pain ; he will first feel as if the testicle were squeezed ; he will then feel the pain running along the course of the sper- matic cord, at the spinous process of the ilium, and at the loins, where the spermatic plexus of nerves arises ; and, lastly, at the neck of the bladder in the course of tlie vas deferens, and little inflammation follows it. 20. The pain from the injection will be greater or less in proportion to the irritability of the patient ; and it may gen- erally be observed, that the degree of subsequent inflamma- tion is in the inverse ratio of the pain sufiered at the time. If little pain is experienced, a considerable degree of inflammation will folLowj while on the contrary, where much pain is felt, it is generally the effect of nervous irritability, and little inflamation follows it. 21. It sometimes happens, in constitutions which have a great disposition to inflammation, that the injection will act so violently as to produce suppuration. When there is danger of this, which you may ascertain by the great pain and redness of the scrotum, make an incision with the lancet into the part, and discharge the contents, and, if the opening is not large, the cure will bo effected by the adhesive process. 22. AVhen the fluid has been suffered to remain in the usual time, withdraw the instrument, and there will be no oc- casion for any application to the part. After a few hours have elapsed, inflammation will probably come on. iiiiiiiif^''''' HERNIA. 103 Let your patient walk about as usual in the course of the day, if he feels but little pain : if much, tell him to lie down, take his dinner tiiut day, and his glass of wine after it, if he has been in the habit of doing so. Should inflammation not come on from your remedies, you must take the part in your hand, and touch it here and there until the patient feels a good deal of pain. Then desire him to take a long walk, and an additional quantity of wine aud water. 23. Spermatic Cord : — Hydrocele of the spermatic cord may be defiaed as a collection of water, which takes place in the tunica vaginalis, between the testicle and abdominal ring. Sometimes the fluid extends above the ring, giving rise to the idea of ita being inguinal hernia ; but you may judge of th(i 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 abdomen, like inguinal hernia. 24. The best mode of treating this disease is to make an incision in the tumour ; introduce your finger into the sac, so as to ascertain that there is no communication with the abdomen, and then introduce a small quantity of flour to pro- mote a slight internal irritation. Injections in this situation would be attended with difficulty and danger ; and in the above manner you may readily effect a cure. HERNIA. 1. Hernia is a generic term, and is used to signify the protrusion of any viscus from its natural cavity 5 as of the abdojnen, chest, &cc. Surgeons generally confine it to protrusions of the viscera from the cav- ity of the abdomen, as they are of the most frequent occurrence, and arise from the bulk of the paits contained in the abdomen, and the relaxation of its parietes. 2. There are a great variety of herniee, according to the parts in which they occur, or according to their contents. 3. Hernise most frequently make their appearance at the groin, the navel, the labium pudendi, and the upper and fore part of the thigh. .Ja 104 HERNIA. Inguinal Hernia is the name when a hernia protrudes at the abdominal ring, and only passes as low as the groin or labium pudendi ; Scrotal Her- nia, if the parts descend into the scrotum ; Ftmoral Hernia, when it takes place below Poupart's ligament ; Un^ilical H: ruin, when the bowels pro- trude at the navel ; Ventral Hernia, when it occurs at any other promiscu- ous part of the front of the abdomen ; Congenital Hernia is altogether a peculiar case, the description of which will be presently given. 4. From the contents of hernise, they are said to be either enterocele, epiplocele, or entero-epiplocele. Enterocele, if a portion of intestine alone forms the contents of the tu- mour; Epiplocele, if a piece of omentum only; Entero-epiplocele, if both intestine and omentum. 5. In addition to the terms already explained as connect- ed with the distinction of herniae, they are likewise said to be reducible, irreducible, and strangulated. Reducible : — WTien the protruded bowels lie quietly in the sac, and admit of being readily put back in the abdomen. Irrcditcible : — When the protruded bowels suffer no constriction, yet can- not be put back, owing to adhesions, or their large size in relation to the aperture, through which thoy have to pass. Strangulated: — Signifies one, which not only cannot be reduced, but suf- fers constriction also ; so that, if a piece of intestine be protruded, the pressure to which it is subjected, stops the passage of its contents towards the anus, excites inflammation of the bowels, and brings on a train of alarm- ing, and often fatal, consequences. 6. Having cursorily gone through the definitions of her- niae, we shall now treat of the causes, the symptoms, and prognosis of hernise ; the treatment of reducible hernise in general ; then of the irreducible ; afterwards of the strangu- lated ; and fi.nally of the individual cases. CAUSES OF HERNIA. 7. The causes of herniae, like those of other complaints, may be either predisposijig or exciting. 8. Predisposing : — The predisposing causes are deficiencies of resistance which some parts of the abdominal parietes are §YMPTOivrS 01* KERNI^. 105 subject to ; resulting either from relaxation, formation, or otherwise. Amongst the principal, we might enumerate, a preternaturally large size of tlie openings, at which the bovs els are likely to protrude; a weakness and relaxation of the margins of these apertures ; a laxity of the peritoneum ; an unusually long mesentery or omentum. 9. Exciting : — There are a numerous train of exciting cau- ses which could be brought forward, but suffice it for the pres- ent treatise to obserA'e a few of the most frequent in occur- rence. The grand exciting cause is the powerful action of the abdominal mus- cles and diaphragm ; to this might be added, accidental blows ; great mus- cular exertion ; pressure from obesity, or the wearing of tight clothes ; pregnancy j any forcible agitation of the body, ai< jumping, violent riding,&:c. SY3IPT03IS OF HERNIA. 10. The common symptom of a hernia, which is reduci- ble, and free from strangulations, is, an indolent tumour at some point of the abdomen, either making its appearance suddenly, or gradually preceded and accompanied by a train of symptoms. The swelling is subject to a change of size, being smaller when the pa- tient lies down on his back, and larger when he stands up and holds his breath. It frequently diminishes when pressed, and grows large again when the pressure is removed. Its size and t'^nderness often increase after a meal, or when the patient is flatulent. Sometimes the functions of the vis- cera seem to suffer little or no interruption ; at other times, in consequence of the unnatural situation of the bowels, many patients with hernia are oc- casionally troubled with colic, consiipation and vomiting. 11. If the case be an enteroceJe. or intestinal hernia, it is generally characterized by the uniformity of its surface ; its elasticity and other symptoms depending on the state of the parts. When the portion of intestine is small, the tumour is small in propor- tion ; but, though small, if the gut be distended with wind, inflamed, or have any decree of stricture made on it, it will he tense, resist the impres- sion of the finger, and give pain on being handled. On the contrary, if 106 PROGNOSIS OF HERNIA. there be no stricture, and the intestines suffer no degree of inflammation, let the prolapsed piece bo of what length it may, and the tumour of what- ever size, the tension will be little, and no pain will attend the handling of it ; upon the patient's coughing, it will feel as if it were blown into ; and, in general, it will be found veiy reducible. A gurgling noise is often made when the bowel is ascending. 12. If the hernia is an epiplocele, or one of the omental kind, the case is equally characterized. The tumour has a more flabby and a more unequal feel ; it is in general perfectly indolent, is more compressible, and if in the scrotum, is more ob- long, and less round, than the swelling occasioned in the same situation by an intestinal hernia ; and, if the quantity be large, and the patient an adult, it is, in some measure, distinguishable by its greater weight. 13, If the case is an entero-epiplocele, the characteristic marks will be less clear, being more or less accompanied with a combination of the symptoms which attend the simple cases. As the smooth slippery surface of the intestine generally makes its reduc- tion easier than that of omentum, Mr. Lawrence is of opinion, that, if a portion of the contents slip up quickly and with noise, leaving behind some- thing which is less easily reduced, the case, in all probability, is an entero- epiplocele. PROGNOSIS OF HERNItE. 14. On the subject of prognosis, Mr. Pott remarks, that the age and constitution of the subject, the date of the dis- ease, its being free, or not free, from stricture or inflamma- tion, the symptoms which accompany it, and the probability or improbability of its being returnable, naturally produce much variety. Sir A. Cooper has observed that the danger of hernia is in proportion to the smallness of its size. If the hernia is large, it is more readily returned into the abdomen ; it is rarely strangulated ; and if strangulated, it is more easily reducible. If, on the contrary, the hernia is very small, the ring through which it passes be- ing extremely narrow, the protrudod parts are very tightly embraced, the hernia is very liable to strangulation, and in this state is rarely reducible. 107 TREATMENT OF HERNTJE 15. The treatment of hernise must necessarily depend on the circumstances of their being reducible, irreducible^ or strangulated. TREATMENT OF REDUCIBLE HERNIA. 16. When you meet with cases of reducible hernise, your treatment must be the immediate return of the tumour, and afterwards use such means as will be likely to prevent a re- currence of the complaint. As soon as the parts are returned, an appropriate truss should be put on and worn without remission. The surgeon should also be careful that equal pressure on the part is secured ; and the patient be desired to keep the parts clean. 17. Although many persons are accustomed to frequent hernise, which are spontaneously or readily reduced in the supine posture, they should be informed, that, by neglect, they are in danger of bringing on such a state of the com- plaint, as may put them into hazard, and perhaps destroy life. It is, therefore, always advisable, for persons subject to reducible hernia to wear a truss ; this, moreover, should be well made, and properly fitted to the mouth of the sac, for as in these cases, the opening in the tendon is usually both large and lax, and the parts having been used to descend through them, if the pad of the truss be not placed right, and there be not a due degree of elasticity in the spring, a piece of intestine will, in some posture, slip down behind it, and render the truss productive of that very kind of mischief it ought to prevent. TREATMENT OF IRREDUCIBLE HERNIA. 18. The most frequent causes, which prevent the ordinary reduction of hernise, may be considered either the largeness of the contents, an alteration made in their form and texture, adhesion of parts and transverse membranous bands within the sac. i08 TREATMENT OF STRANGULATED HERNIA. In addition to these causes, there are occasionally others, but of too un- frequent occurrence to require naming in a Manual of Surgery. 19. With respect to the treatment of irreducible hernice, very little can be said. You must first adopt the gradual steps recommended previous to an ope- ration tor strangulated hernia, and if you fail in returning the tumour, and no unpleasant symptoms attend the case, you can only advise the parts to be worn in a suspensory bandage, to prevent an increase of the malady. TREATMENT OF STRANGULATED HERNIA. 20. The indication of a strangulated hernia is a tumour in the situation of the rupture, attended with pain, not only in the part, but all over the belly ; sickness and inclination to vomit ; suppression of stools, and some degree of fever. If the reduction be delayed, the vomiting becomes more frequent ; all the contents of the stomach, and afterwards those of the bowels, down to the stricture, being rejected. There is a great anxiety and restlessness, with a small, quick, and hard pulse, and cold extremities. After a time, hiccough comes on, the pulse is hardly perceptible, respiration weak, and the whole body covered with a cold clammy sweat. Mortification now takes place, beginning in the protruded viscera, and extending to the containing and neighbouring parts. The patient suddenly becomes easy, the swelling of the belly subsides, and the tumour of the part diminishes, and the skin covering it sometimes changes its natural colour for a livid hue. Whether it keeps or loses its colour, it has an emphysematous feel, or crepitus to the touch. This crepitus is the sure indication of gangrenous mischief within. In this state, the gut goes up spontaneously, or is returned with the small- est degree of pressure ; a discharge is made by stool, and the patient fan- cies himself better. This feeling, however, is of short duration, hiccough and the cold sweats increase, convuisive symptoms come on, and the patient soon expires. 21. The difficulty of returning a hernial tumour may oe owing to several causes ; resulting either from its contents or the state of the parts. 22. The immediate cause of all the bad symptoms, which we have enumerated above, is the stricture made on the pro- K uisc^.M iS ss r' TREATMENT OF STRANGULATED HERNIiE. 109 lapsed part of the gut; by the aperture through which it passes. The removal of such stricture, consequently, is the only thing whi(;h can bring relief j and this object is to be accomplished by returning tlie bowel back into the abdomen, or dividing the parts which form the stricture. 23. As there is no safety, but in returning the intestine into the cavity of the abdomen, you must first use the ordinary remedies for reduction, and if, after a due trial, these fail, your patient must submit to the required operation. The remedies generally employed before an operation is resorted to, are the taxis, bleeding, warm bath, cold applications, and finally the use of to- bacco. 24. Taxis : — the taxis is a particular kind of pressure on the hernia, which is to be performed in the following man- ner : — Embrace the lower part of the hernia in your hand, elevate it gently, and push it towards the abdominal ring ; having done this with one hand, you are to put the finger and thumb of the other on the part just above the ring, and knead it gently by a successive motion of the finger and thumb, until you at last obtain a passage for a small portion of the intestine or omentum through the strict ured part, into the abdomen. When, by this process, you have gradually insinuated a small portion of intestine into the abdomen, it generally happens that the rest will follow, accompanied with a peculiar gurgling noise, and the hernia will consequent- ly be returned. It is of no use to make pressure on the hernia, with a view of emptying the intestines of their contents. 25. The time, in which the hernia is returned by the pro- cess of the taxis, is generally from ten to fifteen minutes. Do not attempt to perform it at once ; proceed gently and gradually, and never press with any considerable force on the lower part of the swelling, lest you burst the intestine. If it does not answer after a fair trial, do not continue to repeat it, for it is not only useless, but often renders all other means, which may be sabsequently employed, unavailing. 110 TREATMENT OF STRANGULATED HERNI-E. It now and then happens, that a person is so extremely sensitive, and resists the employment of the taxis with so much violence, that it will be impossible to persevere for a time, at least, in its use. In these cases, therefore, do not employ the taxis immediately, but advise the applicatioa of ice, which will reduce the irritability of the part, and perhaps render its employment unnecessary. 26. Bleeding : — If the use of the taxis does not succeed, you must then immediately abstract blood in proportion to the age and constitution of the patient. If the person is young and athletic, a considerable quantity should be taken away : if, on the other hand, he is extremely old, you should hesitate in taking away much ; but if he is of the middle age, and not infirm, you should bleed freely until fainting is produced, and then apply the taxis. This course is to be taken, not merely with a view of reducing the hernia, but to prevent peritoneal inflammation after the operation, if the operation should be thought necessary. 27. Warm Bath .-—The warm bath, from 90 to 100", and the patient kept in until fainting is produced, also aflFords an- other more favourable period of employing the taxis. The taxis should be used while be is in the bath ; or he must be taken out and wrapt in flannels, to preserve the faintness, and the remedy em- ployed under such circumstances. 28. Cold Applications : — Cold applications, as ice, are sometimes used with considerable benefit ; and indeed, if you wish to have time to consult on the case, it will retard the progress of inflammation most effectually. Ice or snow should be used when they can be procured : these should be put into a bladder (half filled,) and the part completely enveloped in it; if it is put in linen, there is danger of some escaping, and destroying the life of the parts on which it goes. As a substitute for ice a mixture of about half a table-spoonfial each of muriate of ammonia and nitrate of potash, dissolved in a pint of water, will produce a degree of cold equal to 26** Fahr. ; or a greater degree of cold than this may be obtained by the addi- tion of more of the salts, as low as 20° Fahr. 29. Tobacco : — Next to the operation, tobacco glysters are the most certain means of bringing about the reduction of a strangulated hernia. Besides exciting the action of the intes- tines, they exert a peculiar depressing influence on the whole TREATMENT OF STRANGULATED HERNIA. Ill system, reducing the pulse, and causing nausea and sickness, cold sweats and fainting, under which circumstances the parts often recede spontaneously, or may easily be reduced. The tobacco enema is to be made in the following manner : — Take one drachm of tobacco, and add a pint of boiling water ; let the infusion remain about a quarter of an hour, and then strain. Use only half an ounce, to begin with, for though some persons might bear the whole, and eveu more, yet there are others who cannot bear the least thing. 30. The effects of the tobacco enema, in hernia, depends much upon whether the hernia is situated near muscle or tendon. If it is surrounded by the former, as in umbilical and inguinal, its effects will be considerable ; but if by tendon or bone, as in femoral herma, but slight. 31. The extraordinary violence of the tobacco enema on some constitutions, particularly delicate females, renders it a remedy not without danger ; and, therefore, it requires to be employed with great caution. In cases of this kind, where you are anxious to avail yourself of the re- laxing powers of tobacco, and cannot with safety resort to the enema, you may recommend your patient to smoJce tobacco in the ordinary way. This will be followed by the usual effects of tobacco on the system, and your pa- tient secure from any undue action, as the remedy is always under command. 32. If you should succeed in reducing the hernia, without having recourse to the knife, and if the symptoms of strangu- lation were severe before such reduction, they will not always cease immediately afterwards. As they probably depend on the reduced bowel having b^en iuflamed by the stricture, the body should be kept open, and the diet and regimen should be low and sparing, whilst the least degree of pain and tension remain ; in short, till all complaint is absolutely removed from the abdomen, and the intestines do their office freely, and without trouble. 33. Operation : — If, on the other hand, you fail in your object of reduction, before you submit your patient to the danger of an operation, to recapitulate what I have already said, I would have the taxis employed steadily for ten or fif- 112 TREATMENT OF STRANGULATED HERNIiE. teen minutes ; if this did not answer, I would bleed to syn- cope, and then have the reduction by the hand attempted again ; if this also proved unsuccessful, I should use the tobacco enema, or smoking, and wait a short time ; and then, if necessary, have the operation performed. Do not defer the operation tec long ; but let it be dorte before there is any peritoneal tenderness. In a boy, you should wait but a very short time, af- ter you have used the other means 5 but in an older person, you may stop longer, because the parts are generally more relaxed. 34. Before we enter on the treatment after an operation, it is right a few observations should be made on the treat- ment of the intestine, and of the omentum. 35. Intestine : — Sometimes the intestine adheres to the sac ; if the adhesions be slight, break them down with the finger, or divide them very cautiously with the knife. If they are general and strong, the best plan will be completely to divide the stricture, so as to reduce the strangulation, and leave the intestine in an irreducible state. An irreducible hernia is not dangerous, provided there is no strangulation, 36. When strangulation has gone on to gangrene of the intestine, it will be found of a deep brown or chocolate col- our, covered with a layer of brown coagulated lymph, fetid, and interspersed with purple or leaden-coloured spots, which readily break down under the impression of the finger. In such cases, the following treatment is recommended : — If a small por- tion only of the cylinder is diseased, a ligature is to bo passed through the attached mesentery, at right angles with the intestine, and then thiou^'h the hernial sac ; when, by this means, the intestine becomes confined to the aperture, adhesions form, and an artificial anus is produced. The opening has, however, in some instances, after a time closed ; and the faeces have resumed their natural course ; but when the whole cylinder is mortified, the diseased part should be cut away ; the divided ends brought together, and united by means of four ligatures, inserted around the intestine. 37. Omentum : — =If the quantity of omentum be small, and little changed in character, you must return it into the mouth TREAOIENT OF STRANGULATED HERNI-E. 113 of the hernial sac, so as to seal up the opening ; but when there is much, your treatment must be somewhat different. When there is a great descent of omentum, it is not thin and fine as in its natural state, but the different laj'ers unite and form a solid mass. In such cases, you must remove a large part by the knife, and return the remainder to the mouth of the sac to plug up the opening. After cutting the omentum, numerous vessels will frequently bleed, these should be drawn out with a small pair of forceps, and lacerated. If the vessels continue to bleed, liga- tures should be applied, and care taken that no omentum is included. The ligatures must be left to hang out of the hernial sac, and in three or four days they will separate. 38. "When the omentum adheres to the internal part of the hernial sac, cofisiderable freedom may be used in destroying the adhesions ; but I would not advise the use of the knife ; just tear through those first in front with the finger, and then spread the liberated omentum out, and lastly tear through the adhesions which confine the omentum to the back of the sac. Ligatures must be applied to the bleeding vessels. When the adhesions are torn through, and the vessels secured, the omen- tum must be returned, as before-mentioned. Take care all the vessels are secured, and that hemorrhage has entirely ceased ; else, when the omentum is returned, the warmth will bring on the bleeding. 39. "When the omentum is in a gangrenous state, it will be known by the blood coagulating in the veins. The treat- ment always adopted is to cut away the omentum close to the mouth of the hernial bag, and leave the remainder to plug up the opening ; the vessels must be secured. Omentum in a state of gangrene, has nothing of the blue appearance seen on gangrenous surfaces, nor any of the green spots to be found on the intes- tine in a similar state ] and if the fingers are passed along the surface there is a crispy feel. 40. Treatment after o'perating : — After the operation for strangulated hernia, there are two things from which danger is to be apprehended ; the first, that the intestines may not perform their office, and the faeces not pass in their regulai lO 114 TREATMENT OF STRANGULATED HERNIA. course ; secondly and principally, that peritoneal inflamma tion may come on, and produce the same effects as if gan grene were present , The object consequently should be, as soon as the hernia is returned, to close the wound as completely as possible, by means of sutures, and to em- ploy gentle pressure. But if the hernial sac remains open, the integuments should be brought together by means of sutjres, slight pressure should be made by dossils of lint, and the parts should be supported in a suspensory bandage. 41. The horizontal posture must be strictly ordered ; and; in five or six hours after the operation, give a little sulphate of magnesia, or castor oil ; the more motions your patient has, the better. You must not imagine because your patient has two or three motions in the twenty-four hours after the operation, that he will do well ; for this is generally the case : you must therefore keep up a free discharge from the bowels, or the next day you will find them bound, the abdomen tense, and tender to the touch, and vomiting will come on. He is at this time in the greatest danger ; you must bleed largely and purge him freely by medicines or injections. 42. Hiccup will sometimes take place ; it is not the result of gangrene, but of inflammation of the intestine, or of the peritonaeum . Hiccup, under these circumstances, should be treated by bleeding and purgatives j and these means aided by opium. 43. The operation for strangulated hernia does not pre- vent the future descent of the intestine ; but the application of a truss, early, prevents it from being so large. The patient, as we have already observed, should be kept in bed some time after the operation, and goo tient to lie down, raise the testicles, and empty the veins ; then press firm- ly on the abdominal ring; keep your finger there, and raise the patient from the recumbent posture, and the swelling will return. On the contrary, if it be hernia, the tumour cannot re-appear until the finger is removed. 52. Causes : — The causes of oblique inguinal hernia are the same as with herniae in general. 53. Treatment : — The treatment of these cases must obvi- ously depend on their being reducible, irreducible, or strangulated. 54. Reducible : — After a reduction of the tumour, (which in this case can be readily effected by the patient himself ) the universal mode of preventing its return is the "wearing a truss ; the pad of which, by its constant pressure, when ap- plied to the mouth of the sac, occasions an adhesion to take place between its sides, and thus a cure is obtained. Various kinds of trusses have been invented at different periods ; but the common truss in general answers the purpose extremely well ; it does not require an understrap ; and it has this advantage, that it may be woni in the night as well as during the day. The mode of applying it is merely to place it on the side of the hernia, and biing it round the body j and if you use an understrap, this should be brought between the thighs. 55. A patient should wear his truss at least two years ; hut whether he will, at the end of that time, be perfectly cured, will depend upon his age. A young person is generally cured in that time, but it is advisable to continue the truss for three years. If the person is not young, there is not much hope of effecting a cure by wearing a truss. When a truss has been worn for some time, the 66*601 upon the hernial sac is, that it falls into folds by the action of the cremaster, resembling the appearance of the stomach after death, when it has undergone contraction. Sometimes water forms beneath the adhering part, producing hydrocele of a particular kind. The fluid in this case is clear as water, and has not the common character of serum. 56. Irreducible : — Oblique inguinal hernia becomes irre- ducible from various causes j the most common cause is, the 118 OBLIQUE iNGUmAL HERNIA. adhesion of the omentum or intestine to the interior of the hernial bag. A second cause is the growth of omentum or mesentery, without adlie- sion, from the accumulation of adeps, which renders it impossible to return the liernia. A tliird cause is the foimation of a membranous band, produc- ed by inflammation across the sac, by which the omentum and intestine be- come entangled, and the return of the protruded part is prevented. 57. In irreducible scrotal hernia, advise your patient to wear a simple suspensory bandage, without which he would be exposed to considerable danger, from the possibility of the hernia bursting, if he should receive a blow on the part. A patient with irreducible hernia, is always exposed to considerable dan- ger from blows which he may receive. If the hernia burst, the intestine may be returned into the abdomen ; but the omentum, in general, cannot be returned. If a truss be worn in irreducible hernia, the spring should be very slight, so as to occasion no pain, otherwise there will be danger of strangulation. 58. When oblique inguinal hernia is rendered irreducible by the growth of mesentery or omentum, there is no doubt that a patient may be relieved by abstinence in diet, and by taking such means as are calculated to reduce the bulk. If the hernia is irreducible, in consequence of the formation of a mem- branous bag across the sac, you cannot depend upon any plan to effect its reduction. Long continued application of cold is sometimes used with benefit. 59. In those cases, in which the hernia is very large and irreducible, the best plan is to advise the patient to wear a laced suspensory bag, which, by its pressure on the scrotuir.', will not only prevent the hernia from increasing, but will diminish its size by absorption. In this manner, a bulky hernia may be rendered much less inconvenient to the patient. With respect to wearing a truss in this state of hernia, if the patient should feel any pain, it will not be advisable. 60. Strangulated : — When the hernia is incarcerated or strangulated, the patient first complains of pain about the region of the diaphragm, as if a cord was bound tightly round OBLIQUE EXGUIXAL HER>-IA. 119 the upper part of the stomach ; frequent eructations follow ; vomiting of a bilious, and sometimes of a feculent matter ; obstinate constipation ; quick, hard pulse. The tumour is red, painful, and cedematous ; the abdomen becomes sore and painful to the touch ; a profuse perspiration breaks out over the body ; the pulse becomes small and thready ; troublesome hiccups ; remarkable expression of anxiety in the countenance. These symptoms often undergo a remission, but return afain with in- cr-^iise'i violence ; and if reduction is not speedily effected, a mortification of ti:f intestine takes place, when the patient, after suffering intoli rable pai:i, becomes suddenly easy ; the tumour assumes a purple or leaden col- our, and, from being lensp, and elastic, becomes soft and doughy, and has an emphysematous feel ; tie abdomen becomes more tense ; the hiccup more severe ; the body is covered with a cold clammy sweat ; the eyes have a glassy appearance ; the pulse is irregular, though softer and fuller; the patient is tranquil and sensible to the last, and often expires w ith tl.e delu- sive hope of recovery. 61. The Seat of Stricture : — Is commonly opposite the tendon of the transversalis muscle, which circumstance is often produced in consequence of the thickening of the herni- al sac. from the pressure of a truss. Sometimes the stricture is an inch above the abdominal ring. At others, when the hernia is old and large, at the ring. But when the hernia is recent and very small, the stricture is often two inches above the ring. It is owing to this last circumstance, that the fuger is often lost in ob- lique inguinal hernia, before the stricture can be felt, so far above the ring is it situated. Sometime.^ the finger feels the stricture an inch above the ring, at others an inch and a half, or even two inches ; and in each of these situations, it is very common. The stricture is sometimes found at the neck of the hernial sac, in consequence of a membranous band crossing it at that part. And another cause of stricture arises from a pcriion of intestine being occasionally entangled in a part of the cmientum. 62. Cause ; — The cause of strangulation may te an ad- ditional portion of intestine, though it consists only of a sin- gle volume, bringing down with it a portion of mesentery, which, added to the piece of intestine previously descended, 120 OBLIQUE INGUINAL HERNIA. SO completely occupies the space of the opening as to produce the symptoms of strangulation. It is not sufficient, in giving the cause of strangulation in intestinal ner- nia, to say tliat a portion of intestine has descended into the sac; because it often happens that strangulation is produced, although only a single con- volution ha? descended, and this convolution being elongated, does not oc- cupy any additional space in the mouth of the sac. 63. Treatment : — As there is no safety in these cases, but in returning the intestine into the cavity of the abdomen, it must be your first object, except in one or two cases, hereaf- ter to be mentioned. You would at the onset make use of the taxis in the manner and direc- tion as hinted in the 24th paragraph ; and then pursue the other steps for reduction as related in the 33d paragraph. 64. Operation : — Having used the means, which have been recommended, without success, you will then proceed to the operation. The patient should be placed on a table from two to three feet high, with the legs hanging over the end : the hair having been removed from the pubes, you should commence the incisions from the upper part of the tumour, in whatever situation it may be, and carry it along its middle till to the lower part. There will be no necessity to continue the incision quite to the lower part, if the hernia is large, as then it often happens that there are vessels crossing in that part. By the first incision, you lay bare the fascia of the cord, and in doing this you will divide a small artery, the external pudendal, which crosses directly opposite to the abdominal ring; take your tenaculum, and se- cure the two ends of the bleeding vessel, and then scratch through the fascia of the cord, just below the ring, with considerable care, separating it from the cremaster muscle ; a small opening being made, you introduce a directfir upwards to the abdominal ring, and inferiorly to the lower part of the swel- ling, and divide the fascia more or less, as may be required. The next parts that will be brought into view are the fibres of the cremaster muscle, passing obliqiiely from above, downwards ; this covering is of considerable density, and must be opened with care ; a director is to be introduced under it, in the same manner els for the fascia of the cord, and then it is to be divided ; as soon as this is done, the hernial sac becomes exposed ; it is of a blue appear- ance, and semi-transparent from the fluid it contains. Having laid bare the sac, you pinch it between your fingers, and feel distinctly the intestine and omentum within it ; in rubbing the sac between the fingers, do not use any force, as this is exceedingly dangerous. When you have raised the sac so as OBLIQUE INGTHNAL HERNIA. 121 to separate it from its contents, take the knifo and make a small cut into it, not downwards, but in a lateral direction ; place the instrument horizontally, so as to avoid the danger of wounding the intestine, a danger to which you would he exposed if you cut downwards. As soon as an opening is made, wa- ter generally escapes, if intestine be included in the sac, and there arc no ad- hesions. Having opened the hernial sac, a director is to be introduced as far as the abdominal ring, and then it is to be divided up to that extent ; the director is theu to be carried to the lower part of the sac in the same manner. When both omentum and intestine are in the sac, the omentum will be found before, and intestine behind ; there will also be a small portion of omentum at the upper part. After having opened the hernial sac, the great difficulty com- mences ; you are next to feel for the stricture ; put your little finger into the hernial sac, and ascertain if the stricture is situated at the abdominal ring ; and if so, spread the omentum on the fore part of the intestine, like an apron, so as to cover it entirely ; by this plan, the in- testine is less liable to be wounded, and it adds exceedingly to the secu- rity of the patient ; and then you pass a probe-j>ointed bistoury, guided on the finger, and divide the stricture, not very freely, but to a small ex- tent ; a sliglit motion of the knife will do. The stricture, however^does not generally exist at the external ring, for it is usually situated at the upper part of the hernia, just opposite to the tendon of the transversalis muscle, or else in the hernial sac itself ; and what you have to do is to slit up the abdominal ring, to hook up the abdominal muscles, and draw them upwards towards the abdomen ; then to pull down the heruial sac ; by this means you expose the stricture, and render the operation more safe to the patient. The probe-pointed bistoury is bluut to the extent of a quarter of an inch, sharp for half an inch, and then blunt again, so that you may introduce it on the director and finger, and divide the stricture without fpar of cutting too much. \ou must divide the stricture in the centre, and cut directly u-pxvirds, let the hernia be where it may, and you will be in no danger of wounding tire epigastric artery. The stricture being divi- ded, you next return the intestine before the omentum. You should al- ways, at this stage, introduce a finger, to see whether the parts are fi-eely returned or not, aud are not compressed at the place where the stricture was situated. If there is any air in the intestines projecting above the stricture, bring it down into the lower part, and by this means they will be more easily returned. The intestines should be returned piece-meal to the cavity of the abdomen, and then the omentum should succeed it. 65. After- TrfMtment : — The general remarks on the after- treatment of hernise must be here resorted to and put in practice. 11 122 OBLIQUE INGUINAL HERNIA. 66. Operation for large hernia •- — Herniae of a large size require a very different operation from that we have just gone through. In those cases in which I have operated, I have made an incision to the extent of three inches in the upper part of the hernia, an inch and a half above the abdominal ring, and an inch and a half below it ; having com- pleted this, and laid bare the fascia of the cord, a small opening was made to the extent of about an inch below the abdominal ring, and a director put into it. Having insinuated the director between the fascia of the cord and the cremaster, I passed it under the abdominal ring; and carrying a probe- pointed bistoury upon this director, divided the ring to the extent of an inch. I then put my hands on the side of the tumour, a portion of the in- testine was returned into the cavity of the abdomen, but all the force I could venture to use, oould not return the whole. By dividing the stric- ture, however, the patient was relieved from the symptoms under which he had previously labored. All you have therefore to do is, to bring the edges of the wound together, and let the hernia remain. 67. Small inguinal hernia : — There is a small hernia that occurs above the abdominal ring, and does not emerge through it at all, which is equally dangerous as a hernia of twenty times its magnitude. 68. This is a case which it is difficult to ascertain in the living subject. A patient will come to you with symptoms of strangulated hernise, and you will find a fulness on one side above the abdominal ring, which is not observable on the other ; tenderness upon pressure of the part where the fulness is, and a great disposition to vomit. The operation necessary to be performed is, to make an incision along the course of the inguinal canal, a little obliquely above the abdominal ring, en as to avoid making the opening large. The incision through the integu- ments Jays bare the tendon of the external oblique ; having laid bare this tendon, and made an incision through it, the hernia immediately appears projecting through the edge of the wound. The hernial hag is covered by a tendinous process wh'ch passes from the upper aperture, from which the hernia proceeds. As soon as the hernial sac is laid bare, a little fluid es- capes. You will find the stricture at the orifice. You are to introduce a small director into the orifice, and divide the stricture by making a slit up- wards with a probe-pointed bistoury. DIRECT INGUINAL HERNIA. 123 69. Inguinal hernia in the Female : — Inguinal hernia is of less common occurrence in the female than in the male, in consequence of the smallness of the parts through -vrhich the ligamentum rotundum descends. When this occurs, the hernia is generally small, and takes a similar course to that of inguinal hernia in the male, comparing the ligamentum ro- tundum to the spermatic cord. It begins midway between the spine of the ilium, and the symphisis pubis ; its origin being situated on the e likewise to remark, that the largest arteries of limbs may be torn through without any dangerous hemorrhage occurring. 24. The nervous system frequently suffers severely from lacerated wounds ; and erysipelas is not an unusual effect of laceration, more particularly if it is inflicted on the scalp. Spasms of the limbs and tetanus often follow lacerations of the head. 25. Lacerated wounds are more disposed to inflame than the incised, and they require the same treatment. However, more care is required in the use of cooling lotions, and the ap- plication of leeches ; in quiet, and in the exhibition of opium under the first appearance of spasmodic symptoms. Bleeding should be resorted to with caution. CONTUSED WOUNDS. 26. These injuries differ from the incised and lacerated wounds, it being accompanied with disorganization : blood is extravasated, the cellular tissue is broken down, muscles are bruised, and many parts disorganized. Contused wounds bleed but little, from the organization of the parts being destroyed, and from the extravasation making pressure upon the vessels which are divided. 27. The pain, which accompanies a contused wound, is in an inverse ratio to the cause of the injury. It is generally severe, when the wound is only moderately contused ; and, on the other hand, when there has been so violent a degree of contusion, as at once to destroy the organization of the part, the patient scarcely suf- fers any pain at all. CONTUSED \VOUNDS. 139 28. The changes, "\;v-hich a contused wound must undergo, will depend on the extent of violence by which it was pro- duced, and the constitution of the patient. When the bruised fibres have not been injured above a certain degree, the part suppurates, but such portions of the wound as Lave suffered great- er violence inevitably die, and are cast off in the form of sloughs. Granu- lations are afterwards formed, and the breach of continuity is repaired by the process of cicatrization. 29. The treatment of contused wounds must consist in fa- cilitating the separation of the contused parts, instead of ap- proximation, as in the incised and lacerated wounds. To effect this object, and to expedite the process, fomentation and poul- tices are to be used, which lessen inflammation when too violent, and has- ten the suppurative and ulcerative processes. If the inflammation be still considerable, leeches should be applied ; but bleeding ought not to be had recourse to from the arm. Professor Assalini, however, recommends both general and topical bleeding, and gives the preference to cold applicationa instead of the warm. 30. At the same time that you attend to the local treat- ment of the wound, the internal remedies and regimen should also be adapted to the condition of the patient. The bowels should be kept regular ; but opium should be combined with the medicines given, to effect that object. If the constitution becomes much debilitated, the sulphate of quinine may be given, or ammonia con> bined with opium. A generous diet is also necessary. 31. "When the sloughing, or separating process is com- pleted, the fomentations and poultices are to be abandoned. The parts are then to be approximated by adhesive plaster or a simple dressing be applied to the wound, treating it as a simple ulcer. PUNCTURED WOUNDS. 32. A punctured wound signifies one made with a nar- row-pointed instrument, as by a sword, bayonet, scissors, hooks, points of broken bones, &c. 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. 140 PUNCTURED WOUNDS. 33. Punctured wounds are often highly dangerous ; from the effects which they produce in the parts injured, or on the constitution generally. The effects of punctcred wtiunds depend, however, very much upon the form of the wound, and the state of the constitution. 34. A slight punctured wound, through the skin into the cellular tissue, will be sometimes followed by the absorbent vessels forming red lines, from the wound to the absorbent glands, in which they terminate. Abscesses sometimes form upon the absorbents, in their course to the ax- illa, or to the groin ; and sometimes in the gtands in wliich they terminate ; and in very irritable subjects, death will occasionaily ensue. 35. If a tendinous structure be punctured, alarming symp- toms will sometimes arise, in part from the form of the wound, from the feeble power of the structure, and partly from the confinement of matter beneath the fascia. The form of the wound produces these symptoms, because the parts are rather forcibly separated than actually divided, and consequently the adhe- sive process does not readily succeed. The structure of tendons and fasciae, from their little vascular organization, and difficult restoration, leads to much constitutional effort; and the form of fascia tends to confine the pus when it is secreted. 36. The effects of punctured wounds on the nervous system we shall presently explain in speaking of tetanus 37. The treatment of punctured wounds must, more or less, depend on the extent of the puncture, and the parts injured. 38. The treatment of punctured wounds, with respect to dilating them, is a matter of controversy, but I should recommend the following rules, as most likely to be attended with benefit. As soon as you are called to a case of this kind, extend the puncture to an incision by a lancet ; the surrounding parts should then be pressed to re- move, by the blood which issues, any extraneous matter which may have been introduced. A caustic of nitric acid, nitrate of silver, or caustic of POISONED WOUNDS. 141 potash, should be applied to the wound ; a cold lotion be put over the part to prevent too much action when inflammation begins ; and if the pain and inflammation become considerable, you should apply leeches, and follow them up with fomentations and poultices. 39. With regard to the position of the limb, and the diet of the patient ; the limb should be supported on an inclined plane, so that the blood shall gravitate towards the body j and all stimulating food or drink be carefully avoided. 40. "When a puncture is made into a theca, suppuration is apt to ensue, when an early incision, by allowing the matter to discharge, prevents the serious effects which would other- wise follow. But, if matter does not form, no incision may be required. The treatment, therefore, must consist in endeavouring to prevent suppu- ration, by leeches and evaporating lotions, in the first instance : if matter forms, then open the abscess early, both with a view of making the punc- tured an incised wound and to give a free outlet for the escape of the pus. POISONED WOUNDS. 41. In treating of poisoned wounds, we shall refer the subject of hydrophobia, and the bites of venomous animals, to another part of the work ; and here only speak of poison- ed wounds as occurring from dissection. 42. In dissection, pricks of the hand sometimes occur, frequently causing considerable pain and irritation in the course of the absorbents ; swelling and suppuration of the lymphatic glands of the arm or axilla ; and severe fever and constitutional irritation. In many instances, however, surgeons wound their fingers in dissescting bodies, and no particular ill consequences ensue. The healthy and robust are said to suffer less frequently after such accidents, than persons whose constitutions have been weakened by hard study, excesses, pleasure, or pre- vious disease. 43. The treatment you should have recourse to is imme- diately to cleanse and suck the partj to free it from the viru- 142 GUN-SHOT WOUNDS. lent matter, and then, if necessary, use additional cautions, and attend carefully to your regimen. French surgeons advise the immediate cauterization of the wound with some caustic potash, or liquid muriate of ammonia. In this country, caus- tics are occasionally used, but the more frequent plan is to soak the hand in ■warm water, put on an emollient poultice, and support the arm in a sling. Tonic remedies such as wine, bark, and so on, are prescribed, and great at- tention paid to relieving the bowels. 44. The inflammation, from punctures of the hand in dis- secting, will continue a long time, and be resumed when it seems to be at an end. Attention to the general health, and to the part, must therefore be regard- ed closely for a considerable period aftei the injury. gun-shot wounds. 45. Gun-shot wounds receive their name from the manner in which they are produced, being generally caused by hard, obtuse bodies, projected from cannons, muskets, or some other species of fire-arm. 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. 46. Dr. Hennen observes, the effects of a gun-shot wound differ so materially in different men, and the appearances are so various, according to the nature of the part wounded, and the greater or lesser force with which it has been struck, that no invariable train of symptoms can be laid dowTi as its ne- cessary concomitants. Tf a musket or pistol-ball has struck a fleshy part, without injuring any material blood-vessel, we see a hole, about the size of, or smaller than, the bullet itself, with a more or less discoloured lip, forced inwards ; and, if it has passed through the parts, we find an everted edge, and a more rugged and larger orifice at the point. 47. Gun-shot wounds, from whatever cause, whether from a musket-ball, cannon-ball, or shell, &c, are, in general, con- GUN-SHOT WOUNDS. 143 tused "vroiinds, usually attended with a deadening of a part of the solids, which ultimately sloughs, and thereby prevents union by adhesion. This does not, says Hunter, always take place equally in every gun-shot wound, nor in every part of the same wound ; and the difference commonly arises from the variety in the velocity of the body projected ; for we find in many cases, where the ball has passed with little velocity, which is often the case with bails, ev-eu at their entrance, but more commonly at the part last wounded by the ball, that the wounds are often healed by the first in- tention. 48. Gun-shot wounds, on account of their commonly hav- ing a part killed, do not, in general, inflame so readily as those from other accidents ; and this backm'ardness to inflame V. ill be found in proportion to the quantity of deadened parts. If, however, the ball has fractured some bone, which fracture in the bone has done considerable mischief to the soft; parts, independent of the ball, llien there will be nearly as quick inflammation as in a compound fracture of the same bone, because the deadened part bears no proportion to the lac- eration or wound in general. 49. From the same circumstance, of a part being often deadened, a gun-shot wound is often imperfectly understood at first ; for, in the earliest period, in many cases, it is im- possible to know what parts are injured. It not unfrequently happens, that some viscus, or a part of some viscus, or a part of a large artery, or even a bone, has been killed by the blow, which does not show itself till the slough comes away. 50. Gun-shot wounds may have either one or two aper- tures, according as the ball has lodged, or passed quite through. In some cases, the openings are diametrically opposite each other ; in others they are not so, the direction of the ball being sometimes changed by the resistance, which it meets with from a bone, cartilage, or so on. The circumference of the aperture where the shot enters, is usually depressed ; that of the opening, from which it comes out, elevated. At the entrance there is commonly more contusion than at the exit of the ball. The former , opening is generally narrower; the latter wider and more irregular. -51. T\^e have already hinted at the indefinite nature of gun-shot wounds, but Mr. Hunter attributes many of the va- 144 GUN-SHOT WOUNDS. rieties to arise from the difference in the velocity of the body projected. 52. If the velocity of the ball is small, then the mischief is less. There is not so great a chance of their being compounded with fractures of the bones ; but, if the velocity is sufficient to break the bone it hits, the bone will be much more splintered, than if the velocity had been very con- Biderable. 53. When the velocity is small, the direction of the wound, produced by the ball, will, in common, not be so straight, arising from the easy turn of the ball. If the velocity is great, the direction of the w^ound will be more straight, as the ball more easily overcomes obstructions, and therefore passes on in its first direction. 54. When the velocity is small, the deadened part or slough is always less ; for, with a small velocity, a ball would only seem to divide parts, while, when the velocity is great, the contrary must happen. From this circumstance it is, that the slough is larger at that orifice where the ball enters than where it comes out ; and, if the ball meets with a great deal of resistance in its passage through, there will be very probably no slough at all at its exit. 55. The greater the velocity of the ball, the cleaner it wounds the parts. 56. Gun-shot wounds are attended with less bleeding than most others ; however, some will be attended with hemor- rhage more than others, even in the same part. Bleeding arises from a vessel being cut or broken ; but the freedom of bleeding arises from the manner in which this is done. If the artery is cut directly across, and it is done by a ball passing with a considerable velocity, it will bleed freely ; if bruised, and in some degree torn, then' it will bleed less. When the velocity of the ball is small, the vessels will be principally torn, for they will have time to stretch before the continuity of their parts give way ; but if it is great, they will bleed more freely, because veiooity will make up for want of sharpness. GTTN-SHOT WOUNDS. 145 57. Velocity in the ball makes parts less capable of heal- ing, than when it moves with a small velocity. Therefore, gun-shot wounds in pretty thick parts are, in general, later of healing at the orifice where the ball enters, than at the orifice where it pas- ses out. 58. Having selected thus much, from Hunter, on the va- rieties produced by the velocity of ball ; we will conclude; by a general outline of the treatment for gun-shot wounds. 59. Treatment : — In your treatment, you have two indica- tions to fulfil : — first, to remove any extraneous bodies which may be in the wound ; and secondly, to obviate inflamma- tion, and expedite the formation of pus. 60. Tf the situation of the ball, or any other extraneous body, can be ascertained by examination with the probe, or with the finger, recourse may be had to the forceps in order to extract it ; and if these prove inefiectual, the wound should be dilated. Should the ball have run superficially beneath the integuments, it may be felt by the finger; its course may, sometimes, be detected by a red line in the cuticle extending from the external wound, and in this situation a sim- ple incision will often be sufficient for its extraction. If its situation can- not be readily ascertained, little trouble need be taken upon the occasion, aa numerous instances prove that balls may remain imbedded in the animal solid without producing injurious consequences. 61. It has been customary to" dilate all gun-shot wounds, m which extraneous bodies are still lodged. Mr. Hunter ob- jects to this indiscriminate dilatation, and lays down the fol- lowing rules concerning the propriety of dilating, and the period at which the dilatation ought to be made. If the wound be slight, and extraneous bodies are lodged in it that may increase consequent irritation, it should be immediately dilated; as also where an artery is to be secured ; where there has been a fracture, and it becomes necessary to remove detached pieces of bone ; or where a protru- ded part is to be replaced: — But if the injury is severe, the dilatation should be deferred until the first inflammation is over, as by adding an incised to the contused wound, two sources of irritation would exi.«t instead of one. 13 146 GUN-SKOT WOUNDS. 62. Your second indication is to prevent inflammation, and hasten the suppurative process. This is to be answered both by general and local treatment. A strict antiphlogistic regimen 5 repeated venesections ; cooling purga- tives with tartarized antimony ; saline medicines j opium and antimony ; and other remedies proper for infiammation. Your local means must consist in the application of leeches ; hot fomentations, and, if the inflammation be great, fomentations of poppies and hemlock ; and warm cataplasms. Tur- pentine, and the diluted solution of nitric acid,have also been advantageous- ly employed. 63. After suppuration has taken place, you must support the system, and apply a stimulating lotion to the part. Peruvian bark and the ordinary tonics ; opium in large doses ; and a nour- ishing diet, as the case may require. The diluted solution of nitric acid is most recommended as a local stimulus. 64. Amputation : — Where the injury has been so extensive as to require amputation, much dispute has taken place con- cerning the period proper for performing it. A state of health is by no means the most calculated to endure with suc- cess an important operation, and experience teaches us to waive the per- formance of amputation, till the first inflammation has subsided; unless, from the greatness of the injury, it may be expected to destroy the patient, 65. The circumstances which call for an immediate oper- ation are numerous. Namely, when there is such destruction of the soft parts as to destroy the circulation of the blood; the partial division of an artery when it is imbed- ded and entangled in the fractured and swollen parts, that it cannot be se- cured ; bad fracture^ high up the os femoris, also when the ball has passed through the extremity, fracturing the bones, and lacerating extensively the surrounding parts, the mischief being too great for the limb to recover it- self; and in other instances. 66. When it is determined on to amputate immediately after the infliction of the w^ound, the antiphlogistic system of treatment is highly necessary. It will be advisable to allow a considerable portion of blood to escape from the stump during the operation ; or, which is better, to bleed freelj WOUNDS OF ARTERIES. 117 from the ann, as soon as the pulse indicates that reaction, which, mere cr less, must always follow so violent and so sudden a shock. INDIVIDUAL WOUNDS. 1. Having gone through a cursory description of the na- ture and treatment of incised, punctured, contused, lacerated, poisoned, and gun-shot wounds, "we shall next commence some general observations on wounds of individual parts. WOUNDS OF ARTERIES. 1. Wounds of arteries may be either incised, lacerated, contused, or punctured. 2. Incised : — When an artery is cut or divided, an im- petuous hemorrhage of florid blood takes place, which, if the artery be large, whizzes through the wound. It flows in jets or pulsations. The brain soon ceases to be supplied with blood, and fainting is produc- ed ; sensation and volition become suspended ; and the action of the heart is in a great measure suppressed ; the flow of blood from the wound becomes mach diminished, and sometimes entirely ceases. 3. Your treatment, in cases of this kind, must depend on the vessel being cut in part, entirely through, or much injured. 4. The treatment, when a small artery is divided in an extremity, is to apply a tourniquet to compress the trunk from which it proceeds. This, with gentle pressure on the wound, for a short time, will generally command the hemorrhage, when the edges of the wound may be approxi- mated, and union promoted j leaving on the tourniquet, so as to keep a mod- erate pressure on the trunk. 5. When the artery is large, it is necessary to make an incision in the direction it takes, so as to expose the wound- 148 WOUNDS OF ARTERIES. ed portions, when a ligature must be placed above and below on each portion of the vessel. Tlie ligatures should be small, and one of the ends removed, as first rec- commended by Dr. Vetch, after their application. 6. If an artery is not completely divided, the natural retraction does not take place, and a coagulum is formed with much difficulty. I should, therefore, advise you, in such cases, to completely divide the vessel, when its retraction will engage a coagulum to form around it ; but if the artery is large, a ligature must be applied. 7. Lacerated : — Arteries, when they have been lacerated, bleed comparatively very little. This arises either from the cellular tissue being drawn over the mouth of the vessel, and thereby forming a ligature ; or from the falling together of the side of the artery, so as to render its canal impervious. 8. The most approved treatment is to apply ligatures, if the vessel is large ; otherwise, when the powers of circula- tion are restored, there will be danger of hemorrhage. 9. Punctured : — Punctured wounds of arteries are follow- ed with a tumour, bearing every character, and requiring the same treatment, as aneurism. Thus, the external wound being small, the blood does not readily escape, and therefore coagulates in the cellular tissue, and forms a swelling there, which gradually increases in size as the blood issues from the wound in the artery ; the impetus of the blood causes a pulsation ; and the cellular mem- brane, around the extravasated blood, being condensed, forms a sac, which impedes the evolution of the swelling. The external wound heals, and thus an aneurism is formed. 10. This species of wound of arteries is commonly the result of bleeding at the arm, and produces, as we have just described, an aneurismal swelling, more fully mentioned un- der the denomination of aneurismal variz. 11. Contused : — Gun-shot wounds and severe bruises sometimes destroy the vitality of a portion of an artery, which WOUNDS OF PARTICULAR ARTERIES. 149 is afterwards followed by sloughing, and, if great care is not taken, by fatal hemorrhage. You will find that the slough will not separate until from eiglit to ten days, or more, after the wound has been inflicted ; the slough opens the vessel upon its side, and no retraction ensuing, the bleeding is unrestrained. 12. In these cases, it is required that the patient should be kept at rest until the sloughing process be completed. He must likewise be instructed in the tightening of the tourniquet, which must be applied, and left constantly upon the limb, until all the sloughing has ceased. WOUNDS OF PARTICULAR ARTERIES. 13. Arteries of the Scalp : — Wounds of these arteries re- quire a complete division of the injured vessel, and the ap- plication of pressure. By the first, retraction is permitted, and future bleeding prevented ; by the second, the present hemorrhage is suppressed. 14. Carotid Artery : — The wounds of this artery are usual- ly so speedily fatal, that surgery is rarely able to preserve life. It has been secured for aneurism, under which subject the operation is described. I would also here observe, that the operations enumerated un- der the same head, are, for the abdominal aorta^ inttmal and exlemil iliac arteries, femoral artery, arteries of the scalp, and the subclavian. 15. Axillary Artery : — In taking up the axillary artery. when it is wounded, Scarpa recommends the opening, made to expose the vessel, should be sufficiently extensive ; and that the vessel should be raised from the plexus of nerves before it is secured . In performing this operation, agreeable to Scarpa's directions, an assis- tant must compress the vessel, from above the clavicle, as it passes over the first rib. When the weapon has penetrated from below upward directly in- to the axilla, the surgeon is to make a free dilatation of the wound upon a director, or his finger. This must be done to a sufiicient height to expose a considerable portion of the artery, and the precise situation of the wound in it. When the weapon has pierced obliquely, or from above downwards, 150 WOUNDS OF PARTICULAR ARTERIES. through a portion of the great pectoral muscle, into the axilla, the surgeon is to cut through the lower edge of this muscle, and enlarge the wound, on a directory, or his finger, so as to bring fairly into view the injured part of the artery. The thoracic arteries, divided in the operation, must be imme- diately tied. The clots of blood are then to be removed, and the bottom of the wound cleaned with a sponge, by which means the opening in the axil- lary artery will be more clearly seen. Two ligatures will be required ; one above the wound of the artery, and the other below. 16. Brachial Artery : — In tying the brachial artery, there is only one circumstance to bear in mind, and it is this ; the vessel is accompanied by the median nerve : now, if you should include this in the ligature, it would either destroy the patient's life, or cause paralysis of the limb. Sometimes, in wounds of the brachial artery, the injury may be overcome by a slight bandage, and a thick dossil of lint as a compress. But if aneu- rism forms, the tourniquet should be employed, and if this does not succeed, a ligature must be applied. The direction for the incision is the inner edge of the biceps muscle, and this cut almost immediately lays bare the median nerve. 17. Ulnar Artery : — The wounds of this artery are usual- ly at the lower part of the forearm, where the vessel is situa- ted, between the flexor carpi ulnaris and the flexor profun- dis : it is accompanied by the ulnar nerve, which must be carefully excluded from the ligatures. When this artery is required to be secured, what is the anatomical direc- tion for the incision.'' Why the tendon of the flexor carpi ulnaris ; if you make your cut upon the inner side of this tendon, you will directly perceive the ulnar artery and ulnar nerve. This then is the part where the vessel may be most easily and safely tied. Two ligatures will be required, one above, and the other below, to prevent hemorrhage from the free anastomo- sis with the radial artery. 18. Radial Artery : — This artery is much more frequently wounded than the ulnar, being, in every respect, more ex- posed. In securing the radial artery, let your incision be made on the radial side of the tendon of the flexor carpi radialis, and you will immediately find the artery close to its edge. The application of two ligatures is also necessary. Instead of putting ligatures on these vessels at the wrist, for aneurism, or WOUNDS OF PARTICULAR ARTERIES. 151 wounds of the palmar arch, it has been recommended to employ pressure, by means of cork folded in lint, and bound down by a bandage. Tliis prax;- tice, when used, leads to great inflammation and irritation, and I would ad- vise you against using pressure generally, and more especially as regards the ulnar and radial arteries, as they can be so readily tied. 19. Palmar Arteries : — Wounds of the palmar arteries are very frequent, but generally the hemorrhage may be stop- ped by steady and continued pressure, by means of a com- press and bandage, and by a tourniquet on the brachial ar- tery. Cold applications, and the position of the limb will also materially assist. Should these means fail to arrest the bleeding, and if the openings of the divided vessels cannot be easily found, it will be necessary to secure the ul- nar or radial arteries, or both ; els from the very free communication of these vessels,- the securing of one only, will not, in many eases, prevent fur- ther bleeding. It will be best, however, in wounds of the superficial palmar arch, under such circumstances, first to put a ligature upon the ulnar artery, and then try pressure again, before the radial is taken up; which should not be done unless a troublesome hemorrhage continues. On the contrary, should the deep palmar arch be the seat of injury, and it becomes necessary to secure an artery, the radial should be first tied, and afterwards, provided the bleeding does not stop, the ulnar should be likewise secured. 20. Femoral Artery : — If this vessel is wounded high up in the groin, the finger must be thrust into the wound to stop the bleeding, until a compress can be applied upon the pu- bes, and the artery be secured. 21. If the femoral artery is wounded in the middle of the thigh, a large swelling will sometimes immediately form, and the artery will be deeply situated under a large coagulum. In these cases, a free incision must be made to give the surgeon ample room to proceed in securing the wounded vessel, a tourniquet being first ap- plied. The direction of the incision will be that required in the operation for popliteal aneurism, only it must be more entensive. The coagulum which is then exposed must be scooped out from the wound by the fingers, and the parts be cleanly sponged. The tourniquet is then to be loosened, and the aperture in the vessel will be directly seen, when the tourniquet is to be again tightened, and two ligatures are to be placed on the artery, one above, and the other below the wound, an end of each thread being cut olf j 152 WOUNDS OF PAHTICULAR ARTERIES. the edges of the wound are to be approximated so as to favour the union by adhesion. ^2. Popliteal Artery : — This vessel is so protected by the condyles of the os femoris, and so concealed behind the bone, that it is rarely lacerated. Jn tying the artery in the ham, there is some danger of including the Bciatic nerve, as it is placed above the artery in cutting into the ham, which of course must be carefully avoided : the artery must be drawn from the veitt where the large nerve is placed upon it. 23. Anterior Tibial Artery : — This vessel is rarely woun- ded at the \ipper part of the limb, but frequently at the lower and middle portions ; consequently, it requires to be secured at different parts of its course. 24. The anterior tibial artery passes forward between the bones of the leg, about an inch below the upper head of the fibula. In order to take up the vessel in this situation, a free cut must be made through the fascia, extending between the heads of the tibia and fibula. The incision is then to be continued more deeply at the edge of the pero- naeus longus, following the fascia between this muscle and the origin of the extensor digitorum communis. The artery will be met with on the interos. eeous ligament. 25. Another situation, in which this artery is sometimes required to be secured, is a little above the middle of the leg. The finger is to be passed along the outer side of the spine of the tibia, anr} the breadth of the tibialis anticus muscle is to be ascertained. Along the outer margin of this muscle, an incision is to be made through the integu- ments and fascia, two inches and a half in length. The knife is then to be introduced between the outer margin of the tibialis anticus muscle, and the extensor longus of the great toe. In this space, at the depth of about are inch, the anterior tibial artery is situated. 26. Posterior Tibial Artery : — "Wounds of this vessel are not very frequent, but they sometimes occur, and render op- erations necessary. In wounds of this artery at the upper part of the limb, I should first apply a tourniquet, then place the limb in a bent positionj so as to relax the gas- WOUNDS OF VEINS. 153 troctiemius muscle : this I should raise from its attachment to the tibia, so as to expose the artery and its accompanying nerve, which I should be care- ful to exclude ; I should then put two ligatures on the wounded vessel, and afterwards carefully close the wound and unite it by the first intention. 27. The laying bare the posterior tibial artery behind the malleolus internus is also quite easy. An incision, about two inches long, is to be made between the interna) malleolus, and the tendon Achillis, down to the posterior surface of the tuberosity of the tibia. At this depth, the tendon of the tibialis posticus muscle, and that of the flexor communis digitorum pedis, run, as in a fur- row. Along with these two tendons, but little nearer to the os calcis, the posterior tibial artery descends to the sole of the foot. 28. Plantar Arteries .- — For a wound of either of these ar- teries, I should first try what the application of a bandage, with a compress upon the wound, and tourniquet on the thigh, would efiect. If these mean? failed, I should tie the posterior tibial artery, rather than cut down for the plantar vessel, because of the depth and numerous tendons and nerves in which it is placed. WOUNDS OF VEINS. 1. "Wounds of veins, like those of arteries, are attended with a flow of blood, butj instead of being ejected in jets, the hemorrhage is a continued regular stream. Venous hemorrhage, as Mr. Lawrence obser^'es, is much less formidable than that which proceeds from wounds of arteries. Indeed, under scarcely any circumstances do we entertain much alarm at the flow of blood which takes place from the wound of a vein, and we find, in general, that the nat- ural powers of the constitution are adequate to arrest such hemorrhages. As soon as the flow of blood from a vein is left to itself, coagulum forms in the orifice of the wound in the vessel, and the opening becomes closed. If this does not take place of itself, pressure on the wounded part is found to arrest the bleeding, and to give occasion to the formation of a coagulum within the vessel, which will permanently stop the hemorrhage. 2. In treating wounds of veins, the first grand object is 154 WOUNDS OF THE ABDOMEN. to empty the vessel, as much, as possible, by the position of the limb, and to use the appropriate pressure. The position of the limb should be such aa to allow of the gravitation of the blood to the heart ; in the arm, an inclined plane ; in the leg, the position for a fractured tibia. A roller should be applied from the extreme part of the limb, to the wound, wetted with the liquor plumbi subacetatis dilutus and spirit, so as to approximate the sides of the vein by gentle pres- sure. If necessary, leeches should be freely applied, and, if suppuration takes place, fomentations. WOUNDS OF THE ABDOMEN. 1. Wounds of the abdomen are of three kinds, viz. super- ficial only ; those in which the cavity is opened, but the vis- cera not injured ; and those in which some of the viscera are injured. 2. With respect to the first and second of these, very ex- tensive wounds are often recovered from. This last circumstance arises from the peculiar manner in which the intestines often glide away from the sharpest instruments. 3. The first thing which the surgeon is anxious to know, when he is called to a wound of the belly, is, whether the wound is superficial only, penetrates the cavity of the abdo- men, or whether any of the viscera are injured. The peculiar symptoms of wounds into this cavity are, an immediate universal coldness and paleness, with nausea and faintness. 4. When the wound is narrow, and the viscera do not protrude, it is sometimes a difiicult point to know whether the cavity of the abdomen is penetrated or not. An opinion, however, may be formed, by carefully examining the wound with a finger, or a probe ; by observing, if possible, how much of the weapon is stained with blood ; considering the direction in which it was pushed ; the quantity of blood lost, the state of the pulse, and whether any bile, faeces, or other fluids, escape from the orifice of the wound. WOUNDS OF THE ABDOMEN. 155 5. When the wound is sufficiently large to admit the fin- ger, you may always learn whether the injury extends into the abdomen, because the smooth lining of that cavity, and the contained bowels, may be easily felt. There is one chance of deception you must bear in mind, arising from the possibility of mistaking the inside of the sheath of the rectus muscle for the cavity of the peritoneum 5 and when the examination is made with a probe, particular caution should be used in forming a judgment of the na- ture of the case ; for the parts are so soft and yielding that a very little force will make the instrument pass a considerable way inward. 6. The diagnosis, when a wound is actually made into the cavity of the abdomen, and when any of the viscera are injured, will be commonly attended with symptoms, more or less indicative of the extent of wound inflicted. 7. Treatment : — Where there is only a superficial wound, you should endeavour to procure union, by adhesive plaster and compress alone ; but, if necessary, by the introduction of sutures. 8. When the cavity of the abdomen is penetrated, Sir A. Cooper thinks it best to make interrupted sutures ; the needle should pass through the skin and muscles, but not the peri- tonaeum. If the muscle be not included in the ligature, a hernia is sure afterwards to form ; and, if the threads penetrate the peritonaeum, it adds much to the danger of the abdominal inflammation. Between the sutures, strips of ad- hesive plaster, or of lint dipped in blood, should be applied, and the patient should be freely bled from the arm. If the local inflammation be great, leeches should be employed ; purgatives must be avoided, and food must not be given for several days. 9. When a man is stabbed, or shot, in the belly, and none of the bowels protrude. Dr. Hennen recommends the patient to be kept as quiet as possible, copious and repeated bleeding, anodynes, lowest fluid diet, and light superficial bland dres- sings to the part. In the event of severe pain and swelling of the belly coming on, leeches, fomentations, the warm bath, and emollient poultices will be necessary, and the most rigorous employment of antiphlogistic remedies. 156 WOUNDS OF THE THORAX. 10. I might here pass on to speak of those w^ounds of the abdomen, where some important viscera are injured ; but, as wounds of this cavity, extending to the stomach, intes- tines, and so on, are very rare, I shall not consider them es- sential to the limits of a Manual. It will be as well, however, to remark, that in these cases the danger is much lessened if the wounded portion of the viscus protrudes through the opening in the parietes ; for, if not, they are generally fatal. WOUNDS OF THE THORAX. 1. These are also of three kinds, viz. superficial only ; wounds penetrating the parietes, and wounds of the viscera. The thorax, I would however observe, is subject to all kinds of wounds ; but their importance particularly depends on their depth. Those which do not reach beyond the integuments, do not differ from common wounds, and, when properly treated, are seldom followed by any bad consequences. On the other hand, those which penetrate the cavity of the pleura, even by the slightest opening, may give rise to alarming symptoms. 2. Many plans and modes of procedure have been laid down to ascertain whether the cavity of the pleura is woun- ded or not. For a general rule you might expect, where the cavity is penetrated and the viscera uninjured, extreme anxiety and difficulty of breathing, great ir- ritation in the larynx, cough, sense of suffocation, and so on, but if the vis- cera are wounded, blood will be coughed up, of a florid red colour, frothy and mixed with air ; breathing difficult ; in inspiration, air will be heard to issue from the external wound with a hissing noise, and to rush in with a similar sound during expiration ; emphyseme very generally takes place, first beginning in the cellular membrane of the thorax, and often spreading to a very great extent. 3. Treatment : — In wounds of the parietes only, your ob- ject must be to promote, as much as possible, the adhesive inflammation to close the wound externally. Should the hemorrhage be considerable, it will most likely proceed from a divided Intercostal artery ; you should press your fingei on the orifice of the vessel until the disnosition to bleeding ceases. The wound is afterwards to WOUNDS OF THE THOKAX. 157 be united by suture ; in making which, care is to be taken that the ligature pass tlirough the integuments and muscular substance only, without pene- trating the pleura. 4. The treatment, necessary for wounds of the viscera, may be said to rest entirely in the treatment of wounds of the lungs. When the lungs are injured, the patient labours under all the symptoms we have lately mentioned, as characteristic of wounds to the thoracic vis- cera. 5. Wounds of the lungs prove dangerous in three ways ; viz. from hemorrhage, from inflammation, and from em- physema. 6. If any large branch of the pulmonary artery is woun- ded : if it is injured by a sword or knife, it bleeds very free- ly ; but if by a broken rib, very little, as it will then have the nature of a lacerated wound. In either case, the patient must be bled freely to prevent the continuance of the hemorrhage from the wounded lung, and the opening must not be closed in the parietes until all bleeding from the lungs has ceased, other- wise the blood will remain in the cavity of the chest, and produce irritation and inflammation. 7. The second danger is from inflammation of the lung, and efiusion into the cavity of the pleura. 8. Inflammation of the lungs is to be guarded against by large and repeated bleedings, determined by the dyspnoea and hardness of the pulse. There is but little danger of bleeding too much in one of these cases, as it is an object not only to diminish the force of the circulation, but the quantity of blood in the pulmonary vessels. 9. If efiusion takes place, it is the result of neglected in- flammation, or of having closed the external wound too early. In the one case, it is a purulent secretion ; in the other, a bloody serum. For efiusion into the chest, it is right to perform the operation of para- centesis of the thorax, to draw off the pus or bloody serum which has col- lected in the pleura. 158 WOUNDS OF THE THROAT. 10. Emphysema, the third consequence of wounded lungs, IS less dangerous than the others. It sometimes extends to the face, covering the neck, and also a large part of the trunk. In the treatment, a bandage is to be placed so tight around the chest as to prevent any rattling during a deep inspiration ; the patient is to lie on the wounded side, and punctures may be made into the cellular tissue, where it is much loaded, but not so large as the wound made in bleeding. 11. In all cases of wounds of the chest or lungs, rest is essentially necessary to recovery. WOUNDS OF THE THROAT. 1. Attempts to commit suicide are the usual causes of these injuries, and usually one of the following parts suffer ; the pharynx, the larynx, the trachea, or the oesophagus. The student should here call to mind a recollection of the parts. If the chin be a little elevated, its distance from the sternum is about nine inches. First, — three inches below is the thyroid cartilage, and the space has the muscles of the os hyoides and tongue on the fore part. Second, — in the middle division is the larynx, with the pharynx behind it. Third, — in the lower part is the trachea before, and the cesophagus behind. On the sides of these parts are situated the carotid arteries, which are divided near the OS hyoides. The internal jugular veins are also placed laterally. The pars vaga accompany the carotid arteries, and the great sympathetic nerves are found somewhat nearer the vertebrse. 2. When persons cut their throats, they do not often di- vide the carotid artery,owing to their incision being made high up in the neck, where this vessel has attained a very back- ward situation. When any serious hemorrhage does arise, it is sometimes from the lower branches of the lingual artery, but most frequently from the superior thy- roideal arteries. Such arteries may occasion a fatal bleeding, which, in- deed, would more frequently be the event than it actually is, did not the patient often faint, in which state the bleeding spontaneously ceases, and gives time for the arrival of surgical assistance. WOUNDS OF THE THROAT. 159 3. Wound above the Larynx : — This is the most frequent seat of injury, which is inflicted whilst the chin is elevated. 4. It is characterised by air and blood issuing from the wound, with frightful impetuosity, more especially when the patient coughs. The arteries which bleed freely are the sublingual that pass just above the OS hyoides, on each side of the tongue ; but sometimes the external car- otid arteries are divided, when, from the rapid hemorrhage, death is almost immediate. 5. The wound is commonly, in itself, but little dangerous. When persons die shortly after its infliction, it is frequently from the fever which has led to the commission of the act, if it be not from hemorrhage. 6. In your treatment of a wound above the larynx, posi- tion must be carefully attended to j the lips of the wound kept together by sutures ; and some cooling application be used to the patient's mouth. The first indication ig to be answered by bringing the head down upon the ch^st, and confining it in that position, in order fo prevent a separation of the edges of the wound. The second, by putting three sutures in the in- teguments only, the more eflTectually to guard against any disturbance of the approximated edges, what may, otherwise, from the constant motion of the pa- tient during irritability or delirium, be produced. And the last indication, by keeping the mouth cool and moist, with a portion of lemon dipped in water. 7. Your after-treatment must be directed to the appropri- ate nourishment for the case, and the removal of the sutures. The patient should be chiefly supported by glysters of broth and gruel, to which opium should be added if they quickly return ; and when the fever has subsided, the addition of port wine should be made. When food is given by the mouth, a small quantity of solid matter excites less irritation than fluid: and a small portion of jelly is the best. The sutures should be removed in a week, and adhesive plaster be substituted for them. 8. Wound into the Larynx : — This wound is either into the thyroid or cricroid cartilages, or into the ligament which unites them. A wound confined to the cartilages of the larynx, or to the ligament uniting them, is not dangerous, and by far the greater number of these cases do well. 160 WOUNDS OF THE THROAT. 9. With wounds in this situation, the air rushes through the wound in expiration, and violently in coughing, and is also inspired through it. The person is not able to speak, unless the aperture be closed by pressure j but the food does not pass from it. 10. The treatment of these cases consists in the approxi- mation of the parts by position, and in the application of ad- hesive plaster to retain the edges in contact. When the wound is inflicted with excessive violence, or by a stab, the pha- rynx may be wounded, as it is situated behind the larynx, and then the treat- ment of the wound is to be similar to that of the wound above the larynx. 11. Wound helow the Larynx : — When the wound is inflict- ed within three inches of the sternum, it is more dangerous than in any other situation. The trachea is here on the fore part, the oesophagus behind, and the carotid arteries are situated close to the trachea, more especially the right. The thy- roid gland crosses the upper part of the trachea, and its veins cover the fore part. 12. If the trachea is cut, the air rushes through the wound both in expiration and inspiration. The blood gets into the trachea, and excites a violent coughing, by which a bloody froth is forcibly ejected, but the food or liquids do not pass out through the aperture. The external opening in these cases is generally small, as the wound often arises from a stab) and the consequence is, that the blood does not freely es- cape, but, lodging in the bronchia, adds considerably to the dyspncea. 13. In the treatment of wounds of this kind, the first ob- ject is to stop the bleeding ; and, if the wound is not suffi- ciently large to lead to the easy discovery of the source of the hemorrhage, an incision should be made, in a longitudinal direction, to expose the mouths of the vessels. Tf the trachea be widely opened, pass a needle and ligature through the cellular tissue upon its surface, which, from its firmness, will support the lig- ature, and thus bring the edges of the aperture into cor.tact ; but do not penetrate the trachea itself with the needle. Thus securing the trachea, WOUNDS OF JOINTS. 161 bring the edges of the external wounds together by bending the head, for- ward ; but do not apply adhesive plaster, as it prevents the escape of air and blood in coughing, produces additional difficulty of breathing, and occa- Bions emphj-sema. The ligature upon the cellular covering of the trachea, is to be separated by the ulcerative process, which will generally be effected in a week. 14. When the trachea is deeply cut, the oesophagus is sometimes wounded ; and if the injury be extensiv^e, death will generally ensue ; but a stab into the oesophagus, or a small wound, may be recovered from. After an injury of this kind, the wound into the trachea is to be treated as in the former instance ; by which, the opening into the oesophagus will best approximate : all food, liquid or solid, must be avoided, and the patient supported, as long as nature can bear it, by glysters. 15. In the treatment of these wounds, I object entirely to the introduction of tubes into the pharynx and oesophagus, as worse than useless. In fact, thr-.y are highly injurious, by the cough which they occasion, by their irritating the wound ; and if adhesion or granulation have taken place to close the wound, such tubes tear it open again and destroy the process of restoration. WOUNDS OF JOINTS. 1. By a wound of a joint, surgeons mean a case where the capsular ligament is penetrated or divided. The injury is often attended with a division of the lateral, or other liga- ments, and sometimes also with that of the cartilages and bones. 2. These accidents are but trivial, or very dangerous, ac- cording as the surgeon is directed by proper principles, or is ignorant of the treatment which they require. 3. If the patient has a poultice applied, or if the utmost attention is not paid to the immediate closure of the wound, inflammation of the synovial membrane arises, and suppu- ration ensues. 14 162 WOUNDS OF JOINTS. The most violent constitutional irritation succeeds; shivering, heat, flush- ing, and profuse perspiration ; generally great swelling and excessive pain in the joints. Abscesses form in different parts of the joint, one succeed- ing anotiier, until the strength becomes exhausted. 4. In young and healthy constitutions, these wounds in the largest joints are recovered from ; but in aged and weak persons they destroy life. Recovery from these injuries, when inflammation has followed, is by ad- hesion, so us to destroy the synovial surface ; or else by granulation, when a partial or general ossific anchylosis is the result. 5. All ill effects from wounds of joints may be prevented by care and skilful treatment. When called on to treat a wound of from one to two inches extending in- to the knee-joint, you must, with a fine needle and thread, pass through the skin only, and bring the edge? of the external wound together. Adhesive plaster should not be placed immediately on the aperture, as it is apt to sep- arate and prevent union ; you should therefore dip some lint in blood, put it over the surface of the wound, and place the plaster over it ; then cover the surface of the knee with sofl; linen, dipped into a lotion of the liquor plumbi sub-acetatis and spirit. Afterwards the limb is to have a splint plac- ed behind it to prevent all motions of the injured joint, and to secure per- fect rest. 6. Your after-treatment must be principally directed as the circumstances of the case may require. Purging medicine should be, as much as possible, avoided, and a rigid ab- stinence enforced. In eight days the threads may be cut and drawn away, but the adhesive plaster and lotion should be continued. Three weeks should elapse before the patient be allowed to quit the bed. 7. If inflammation and suppuration should follow a wound into a joint, the ordinary remedies must be employed. If the former, leeches and evaporating lotions should be used, and if the Inflammation run high, the patient should be freely bled from the arm. If the suppurative process be produced, fomentations and poultices are requir- ed locally, and the use of the liquor ammoniae acetatis and opium internally. 8. I would also have you remember, that the fungous granulation, which forms the wound, is not to be disturbed, as it is formed by nature to close the aperture. WOUNDS OF TENDONS. 163 9. "When a limb is stiff from inflammation and adhesion, early motion of the joint is required, and its use may gener- ally be restored. A joint thus circumstanced is not injured but benefitted by motion, \\-hilst, in a chronic or scrofulous inflammation of a joint, rest is more essential to its cure. In this case, therefore, a patient should not only use the limb in common exercise, but he should sit upon a high table, and employ the m.uscles for some length of time at once, in flexing and extending the lirnb. 10. In removing loose cartilages from joints, it is proper first to draw do"UTi the skin to render the aperture after^wards valvular. Operation : — The cartilage is fixed by an assistant, an incision is made over it, after the skin has been drawn an inch to one side, then as soon as the surface of the cartilage is well exposed, it jumps from its situation, the skin is let go, and no direct opening remains communicating with the joint. The after-treatment is the same as in simple incised wounds, only a suture is not required. WOUNDS OF TENDONS. 1. First: — The divisior). of the tendo AchilUs is most fre- quent, and is usually occasioned by a"U"ound from an adze, or from a sithe. In whatever way it has been divided, there is a sudden inability, or at least, an extreme difficulty either of standing or walking. Hence the patient falls down, and cannot get up again : besides these symptoms there is a very palpable depression between the ends of the tendon, which depression is in- creased when the foot is bent 5 and diminished, or even quite removed, when the foot is extended. 2. The principle in the treatment is to approximate the ends of the tendon by raising the heel, extending the foot, and bending the knee ; the external wound (if there is one) is then to be carefully brought together by a small suture, in order that it may be healed by the adhesive inflammation. To effect the object at view, a shoe with a heel one inch and a half in height, is to be placed on the foot of the injured limb, and a strap is to be carried from the heel of the shoe to the calf of the leg, then a roller is to be 164 LACERATED TENDO-ACHILLIS. lightly applied upon the upper part of the leg, to confine the strap and to keep the foot extended. All pressure at the part should be avoided, only an evaporating lotion being placed over it. The patient is to be confined to his bed until the wound be healed, and then he may be allowed to walk a little with a high-heeled shoe ; the heel of which is gradually to be lowered until it is even with the heel of the shoe. Should much inflammation arise during the cure, the limb must be elevat- ed to prevent all gravitation of blood, and leeches should be applied near the wound. 3. Second : — A rupture of the tendon of the extensor muscles of the leg requires nearly the same kind of treatment as a fracture of the patella. However, pressure exactly on the wounded part of the tendon should be avoided, the limb should be kept extended and somewhat raised j a bandage might be put round the thigh, and the antiphlogistic treatment be at first adopted. In the course of two or three weeks, the surgeon should cause the joint to be very gently movedj without any muscular exertion on the part of the patient himself. 4. Third : — If the tendon of the triceps extensor ciibiti be divided, the limb is to be kept straight ; cold applications for a few days, and, if necessary, the antiphlogistic plan adopted. I would here observe, it is only necessary to consider whether the divided tendon, in any case, belongs to a flexor or extensor musclej to know wha4 is to be done ta assist its union. LACERATED TENDQ-ACHILLIS. 1. Many tendons are liable to be lacerated by the violent action of muscles with which they are attached ; but more particularly the tendo Achillis, and may be either complete or partial. The same note, as just delivered, is also applicable in the present case» 2. Complete Laceration : — This accident to the tendo Achillis is produced either by a violent effort of the muscles, as in jumping and dancing, or by an unexpected extension of the tendon. 3. In whatever way the accident may be prodaced, the HEMORRHAGE. 16-5 treatment required will be to extend the foot, and bend the knee to allow the ends of the lacerated tendon to approximate- In this way the tendon soon unites by the adhesive process, and the use of the limb is aftervvurds gradually restored. Some degree of thickening of the tendon for a long time remains, and the patient halts a little in rapid mo- tion. The position of the foot and leg is to l)e maintained in the same way as when the tendon is divided by incision, and an evaporating lotion should be employed. After the union, the same precautions are to be observed with respect to the use of the high-heeled shoe. 4. Partial Laceration : — A partial laceration of the tendo Achillis and gastrocnemius muscle is an accident of very frequent occurrence. A person in running or walking fast, or if his foot slips backward when it has been advanced, sometimes feels as if he had received a severe blow upon the back of the leg, and is immediately unable to walk but with the greatest difficulty, and with the foot extended. The cause of this feeling is a laceration of some fibres of the tendo Achillis, or of the gastrocnemius muscle, where it joins the tendon. There is great tenderness upon pressure on the following day, with some echymosis, which daily increase, until the limb becomes considerably discoloured. The least attempt to bend the foot is accompanied with great pain, and followed by swelling of the leg and ancle. 5. A similar treatment to that recommended for division or laceration of the tendon is requisite for the cure of this injury. When the patient can bend the foot without pain, then the high-heel shoe must be worn, and the heel be gradually lowered as in the previous cases. From three to six weeks are required to eifect a cure. HEMOKRHAGE. 1. Hemorrhage may occur both from arteries and veins j when the former, the blood is of a bright scarlet colour, and gushes from the vessel per saltum, in a very rapid manner j if the latter, it is an even unbroken stream, and is of a dark purple red colour. Mr. Samuel Cooper remarks, it is of great practical use to remember those distinguishing differences, between arterial and venous hemorrhage, because. 166 HEMORRHAGE. though in both cases the oozing of blood may be equal in quantity, yet in the latter instance, the surgeon is often justified in bringing the sides of a wound together, without taking farther means to suppress the bleeding, while it would not be proper to adopt the same conduct, were Ihere an equal dis- charge of arterial blood. 2. Dr.Jones describes arteries to have, in particular, three important capacities, which tend, most materially, to prevent hemorrhage from these vessels. First : — If an artery be divided, the divided parts owing to their elasticity, recede from each other, and the length of the cellular substance, connecting the artery with the sheath, aidmits of its retracting a certain way within the sheath. Second : — When an artery is divided, its truncated extremities contract in a greater or less degree, and the contraction is generally, if not always, I)ermanent. Third : — Arteries are furnished with arteries, veins, absorbents and nerves j a structure, which makes them susceptible of every change to which living parts are subjected in common ; enables them to inflame, and to pour out coagulating lymph, by which the injury is repaired, or the tube permanently closed. 3. Many opinions have, from time to time, been advanced to explain the means by which nature stops arterial hemor- rhage. Dr. Jones attributes the cessation of bleeding to the effusion of blood in the surrounding cellular membrane, and betYtieen the artery and its sheath j but, in particular, the diminished force of the circulation from loss of blood, and the speedy coagulation of this fluid under such circumstances. 4. The suppression of hemorrhage by the natural means is, sometimes, more easily accomplished when an artery is completely divided, than when but merely punctured, or par- tially divided. Completely dividing a wounded artery was practised by the ancients for the stoppage of hemorrhage ; the moderns frequently do the same thing, when bleeding from the temporal artery proves troublesome. 5. If hemorrhage from an artery does not abate from nat- ural causes, surgical aid must, of necessity, be given. As pressure is the most rational means of impeding hemonhage, so it is the most efl"ectual ; and also all the plans, employed for this purpose, are HEMORRHAGE FE03I ULCERS. 167 only modifications of it. The tourniquet, tlie ligature, the application of a roller and compresses, even agaric itself, says Jlr. S. Cooper, only becomes useful in the suppression of hemorrhage, on the principle of pressure. The cautery, caustics, and styptics, which are likewise used to prevent bleeding, act in a different way. 6. Referring the student to more detailed accounts of the nature and application of these means, I shall only add one observation on the proper manner of using pressure. When an artery is the wounded vessel, the pressure should be made on the side towards the heart, the blood flowing from that organ to the wound- ed part. The current of blood in the veins, running in the opposite direc- tion, requires the pressure to be applied to that side of the wound, which ia most remote from the heart. HEMORRHAGE FROM ULCERS. 1. Mr. Abemethy has observ^ed, thai occasionally with ul- cers a sort of increased action is established, which produces a hemorrhagic disposition in the newly-formed vessels of the part ; and that bleeding also occurs from the complete relax- ation, or weakness of the vessels. Various methods have been recommended for the purpose of restraining such hemorrhages ; styptics, pressure, and so on, have been used ; but as to styptics, Mr. Abemethy does not like them ; they are, says he, irritating applications, and frequently do more harm than good. When the hemor- rhage arises from increased action, lessening the temperature of the part will generally succeed, and give at the same time something to act on the bow- els. If ic arise from the second cause, the constitution must be improved generally. TETANUS. 1. Tetanus is a more or less violent and extensive con- traction of the muscles of voluntary motion ; attended with tension and rigidity of the parts affected. It begins generally in the muscles of the jaw, and when it is confined to this part of the body it is called trismus, or, locked jaic ; when all the body 168 TETANUS. is affected and becomes rigid, but retains its ordinary straightness, tlie case is named tetanus. When the muscles at the back of the neck stretch the head backwards, it is called episthotonos. When the body is bent forward, it is called emprosthotonos ; and when the tension is confined to the muscles of one side of the body, it is denominated, pleurosthotojws. 2. Mr. Lawrence recommends the division of tetanus into the idiopathic, or that which is produced from internal causes, and the traumatic being that which is the result of a wound. He observes, the progress of the affection differs in rapidity in different in- stances, and hence it is divided into acute and chronic ; of which division he does not approve. Baron Larrey on the other hand adopts it, adding, that the first is exceedingly dangerous and usually fatal, while the latter, on ac- count of the more gradual progress of the symptoms, affords more opportu- nity of being successfully treated. 3. Setting aside the absolute importance of the division into acute and chronic, we must treat of tetanus as it general- ly presents itself to the notice of the surgeon. 4. Traumatic tetanus derives its origin from the infliction of wounds ; and it is observed to arise more particularly in consequence of wounds of the extremities. It is produced, most commonly, in consequence of contused, lacerated, or punctured wounds j and it has been supposed to arise, more especially, from such wounds as are attended by injury, with division, laceration, or punc- ture of nerves. 5. "Whether injury to the nerves is the origin of tetanus is not yet faithfully authenticated ; but Larrey is disposed to favour this supposition. A partial division of a nerve has often been suspected as a cause ; but as some nerves must be imperfectly cut through in almost every wound, and yet tetanus does not arise, the reality of this cause is doubtful Besides, if it were true, the cure would be easily effected by making the division of the nerve complete, which experience contradicts. Mr. Abernethy suppo Bes it to be a muscular affection. 6. Tetanus will occur in all states or stages of a wound. It may happen when a wound is in an inflamed or sloughing state ; :t TETANUS. 169 may happen when a wound is going on very favourably towards healing, and when liealing is considerably advanced, 7. It is not the immediate consequence of a wound ; it usually comes on some days after the occurrence of the inju- ry, and often a considerable number of days after it, Mr. Lawrence state? from five to fiftecH days as the ordinary limit ; and, if the patient have no affection of this kind for the space of about three weeks after the accident, he considers the case free from ail danger of tetanus. S. Symptoms : — Tetanus, in the first place, shows itself in the muscles of the jaw, and those that are concerned in de- glutition. The patient finds a stiffness in the movement of the jaw ; he experiences an uneasiness in swallowing, and he soon finds that he ha? a difficulty in separating the teeth for the admission of food into the mouth. About the same period, a pain begins to be felt behind the sternum, and this pain ex- tends from the pit of the stomach towards the vertebral column. The mus- cles of the back of the neck begin to be affected by the spasms j subsequent- ly those of the back generally ; then the muscles of the abdomen, and the abdomen becomes as hard as a board ; then the muscles of the limbs, and lastly, those of the face. When the muscles of the face are affected with tetanic spasm, the features are drawn, indnpendently of the will, into a pe- culiar form ; very frequently a kind of grin is produc-ed by their aclion. 9. The affection of the muscles in tetanus does not at first reach to the highest degree of contraction, but the muscles become more and more rigid as the affection proceeds. W^n the disease is in its most violent stage, the flexor muscles of the head and trunk contract so powerfully, that they counterbalance the force of the extensors, and hold those parts in a straight, fixed, immoveable posi- tion. The muscles of the lower extremities become rigid ; and even the arms, which till now were little affected, also partake of the general spasm and stiffness, with the exception of the fingers, which often retain their moveableness to the last. The tongue likewise continues a Ions while en- dued with the power of voluntary motion ; but at length, the violent spasms do not leave it unaffected, and it is then liable to be forcibly propelled be- tween the teeth, where it is sometimes dreadfully lacerated. 10. In the extreme period of the disorder, all the muscles destined for voluntary motion are affected. 15 170 TETANUS. Amongst others, those of the face ) the forehead is also drawn npinto fur* rows; the eyes, sometimes distoi ted, are generally fixed and motionless in their sockets ; the nose is drawn up ; and the cheeks are retracted towards the ears 5 so that the features undergo an extraordinary change. Ultimate- ly the spasms becoming uniyersal, a violent convulsion puts an end to the patii^nt's misery. 11. Wherever the muscular contractions are situated, in cases 01 tetanus, they are always accompanied with the most excruciating pain. The contractions sometimes last, without any manifest remission, to the end of the disorder ; but in almoat all cases, their violence, and the suffer- ings excited by them, undergo periodical diminutions every minute or two- The relaxation, however, is never such as to let the muscles, which expe- rience it, yield to the action of their antagonists ; and it is in nearly all ca- ses followed, in ten or twelve minutes, by a renewal of the previous contrac- tions and suffering. The recurrence of these aggravated spasms frequently happens, without any evident cause ; but it is often determined by efforts which the patient makes to change his posture, speak, swallow, &c. 12. With respect to the state of the other parts of the body^ and of the mind, during tetanus, there is but little change considering the severity of the disorder. In the sanguineous- system we find no particular alteration ; when the patient is labouring under spasms and shaken by convulsions, we naturally expect to find a considerable acceleration of pulse, and we do find it; butir> t!ie intervals the pulse is regular enough, and of the common standard. With regard to the secretions, De Haen has remarked the high colour of the urine, but Mr. Abernethy says he has not found the urine of tetanic pa- tients either high coloured or deficient in quantity. Patients generally per- Bpire freely when they are agitated by the convulsions ; at other times noth- ing particular is observable, either in the secreting or sanguiferous system. The bowels are generally acted upon with great difficulty, and the motions bad. There is no particular agitation of mind, but there is undoubtedly great insensibility in the nervous system with respect to the operation of medicines. 13. Causes : — Tetanus may arise idiopathically, which is, originating from some internal cause ; or it may be trau- matic, that is, produced by a wound. Tetanus occurs, in its idiopathic form, more frequently in hot climates TBTAmjS. 171 than in those which are temperate ; it is quite uncommon in the latter, though very frequent in the former. 14. Notwithstanding the doubts connected •vrith the cause of tetanus, IMr. Abernethy observes, there is one thing which we know, and that is, that the disposition to the disease oc- curs long before the action of the disease takes place. Hence he concludes with cases of traumatic tetanus occurring when the wound is partially healeJ, that, in the painfiil and bad state of the wound, the disturbed state of the nervous system produces disease of the digestive organs, which re-acts on the nervous organs : so that the disorders do. in feet, reciprocally aggravate one another, till at last, there is no longer any local irritation, the tetanic disorder proceeding entirely from the established irritation of the cerebral and visceral functions. 15. JNLr. Abernethy, therefore, is of opinion that the disor- dered state of the digestive organs, established during the ir- ritative state of the wound, is the cause of tetanus. 16. Prognosis : — The more rapidly the symptoms are de- veloped, the greater the danger ; and on the other hand, the more gradual the symptoms are. the greater chance is there of overcoming the disease. It was observed by Hippocrates, that, if the patient survived the fourth day of the disease, there was a much greater chance of his recovery. Dr. i'arry states, that if the pulse do not rise above 100 or 110 by the fourth day, there is a tolerably fair chance of cure. 17. Treatment : — On the treatment of tetanus, very differ- ent opinions have been ventured j but the points, which I shall propose to consider, are, the propriety of amputation ; the efficacy of incisions, cautery, irritants, and of cold affu- sion, the use of bleeding, and internal remedies. 18. Amputation : — The removing a part, by amputation, with the view of relieving tetanic symptoms, is now pretty generally disapproved. Baion Larrey advocates amputation in chronic c^ses -. but it is the opinion of Sir A. Cooper, Mr. Abernethy, Mr. Lawrence, and others, that the prac- tice is injudicious, because there is not suiBcient chance of arresting the progress of the disease. 172 TETANUS. 19. Incisions : — On the subject of making incisions, for the purpose of separating the nerves of the wounded part from the sensorium, Baron Larrey states, that, if resorted to, they should be done before inflammation has come on, for if this has made any progress they would be useless and even dan- gerous. They should comprehend, as much as possible, all the nervous filaments and membranous parts ; but he condemns all incisions into joints, as increas- ing the symptoms of the complaint. 20. Cautery: — On the principle of destroying the parts which are the seat of the local irritation, Larrey also fre- quently applied the actual and potential cautery to the wound. The application of cautery, says he, may be practised with advantage on the first attack of the symptoms, the same precept being observed as in making the incisions. Bleeding, if necessary, and the use of topical em- ollients and anodynes, may follow these applications, though, in general, they have little effect. 21. Irritants : — Blisters, as nearly as possible to the wound, or their application, or that of the ointment of cantharides, to the wound itself, have been recommended. Almost all modern writers have observed, that tetanus is accompanied at its commencement, and in its progress, with an interruption, or total cessation of suppuration in the wound. Hence, the indication to excite this process again, by the use of irritants. 22. Cold A fusion : — The immersion of the patient into cold water has been practised, and, apparently, in a few ca- ses, with benefit. Dr. Wright, of Jamaica, went so far as to pronounce it a cure for tetanus. Dr. Currie, of Liverpool, tried the cold affusion, and it certainly did good ; he relates one case, indeed, in which every body conversant with the history of tetanus must be convinced that the patient would have died but for this remedy. He was plunged into the water, and kept there till he was nearly exhausted : he was, however, got out alive ; a perspiration subsequently came on, the symptoms were mitigated, and eventually he did well. 23. Venesection : — Mr. Lawrence advises blood-letting, TETANUS. 173 more particularly in the early stage : Baron Larrey, Dr. Dickson, and Mr. Gathrie, also favour bleeding. Patients, says Mr. Lawrence, have been bled largely, and, in certain cases, the appearance of the blood drawn has seemed to justify the step. The blood is buffed and cupped ; and this, in conjunction with the state of the pulse, in his opinion, proves that venesection might be considered as an auxiliary remedy, although, if employed alone, it is not capable of accom- plishing the purpose in view. 24. Medicines : — Concerning different medicines much has been written, though very few, apparently, are worthy of a trial. 25. The rigidity of the muscles, and the excessive suffer- ings of patients labouring under tetanus, have led to the free use of opium and other anti-spasmodics. Opium does not produce the same effect on a tetanic patient as it does on a person if he be in health ; so far, therefore, you may give it in large doses. Mr. Abernethy recommends it in small doses, and at such intervals, as to keep up a permanent effect on the system. Dr. Babington has given 180 grains in eleven hours. An ounce of the tincture of opium has been given many times in tetanus, in the course of four and twenty hours. Though opium may sometimes cure idiopathic tetanus, it must not be considered, if employed alone, as a powerful or certain means of relieving the traumatic variety ; in combination with other means it may be useful. Musk, camphor, and ether, in large doses, in fact, all kinds of remedies which have been supposed to have any power over the nerves and muscles, have been em- ployed. 26. Another remedy, said to have frequently effected a cure in tetanus, is mercury ; but it has now fallen into dis- repute. 27. Bark, wine, brandy, and other stimuli have been used, particularly by Dr. Rush, under the idea of tetanus being essentially connected with debility. He particularly advises the liberal use of wine and Peruvian bark ; and when tetanus arises from a wound, he directs the dilatation of it, and dress- ings with oil of turpentine. Considerable success is said to have attend- ed this practice, not only by Dr. Rush, but likewise by Dr. Hosack. Dr. Elliotson appears to have successfully treated two cases of traumatic teta- 174 CALCULI IN THE KIDNEY. nus, with the subcarbonate of iron, in large and frequent doses of from two to four drachms every two liours. 28. If Mr. Abernethy's proposition could be established, the very important conclusion would follow, that, by prevent- ing the disordered state of the digestive organs, you will pre- vent the occurrence of tetanus. 29. Finally, Mr. Lawrence is of opinion, that the three objects of treatment, on which we should place our reliance, are venesection, aperient medicines, and opium. It appears to me, observes this distinguished lecturer, that the most suc- cessful treatment of tetanus has been from venesection, in the early stage, until the symptoms of general fulness of the vascular system are removed; from the employment of active aperient medicines, (in alternation with anti- spasmodics,) from time to time, so as to keep up a continued action on the bowels, and prevent the recurrence of that state of costiveness in which the disease is generally found to commence : and from the free use of opium, for the purpose of mitigating the severity of the spasms. URINARY CALCULI. 1. These are found in four diiferent situations in the uri- nary organs ; viz. in the kidney, ureter, bladder, and urethra. The calculi, which are discovered in the prostrate gland, are not, in gen- eral, of the same kind as those met with in the organs just named. CALCULI IN THE KIDNEY. 1. When a calculus is situated in the kidney, there will be felt considerable pain in the loins, in the vicinity of this organ, and occasionally it will be so very acute, and the part so exquisitely tender, that the afflicted person cannot allow even the slightest pressure over the loins. The urine, blad- der, and sometimes the stomach, also afford characteristic marks of their presence. CALCULI IN THE KIDNEY. 175 When a calculus ia situated in the kidney, it is often accompanied by a numbness of the intestinal tube leading from the kidney to the navel. There •will likewise be felt great pain in the act of stooping, with frequent inclina- tion to make water. The urine is frequently of a dark colour, from being mixed with blood : when this appearance is present, coupled with excru- ciating pain round the loins, it will generally happen that the stone is then in the act of descending, and, in a few days afterwards, you will probably find that it has entered the bladder. There is also frequent vomiting ; and excessi\-B irritability of the bladder. 2. Renal concretions vary considerably in their number, size, and shape. Calculous concretions of large size very often exist in the kidneys, with- out their presence being indicated by any external circumstances, or attend- ed with any symptoms sufficiently unequivocal to constitute a ground for suspecting the importance of their cause. On the other hand, it is very usual for renal calculi, of middling dimensions, to excite serious and alarm- ing complaints. The reason of this difference becomes obvious, when it is recollected, that smallish concretions are readily carried with the urine into the ureter, and become fixed in the narrow portion of the tube. But very large calculi can be contained only in the upper part of this canal, where its parietes ate more yielding, and the space in them more copious. 3. In cases of calculi in the kidney, nature generally makes attempts to discharge them through abscesses formed in the loins ; unless, indeed, they are- small enough to de- scend through the ureter. Calculi often cause an absorption of the kidney ; and v.-hen both kidneys are effected at the same period, or if they successively become destroyed, in either case, death must ensue. 4. Treatment : — But little can be accomplished b}' the med- ical man in these affections ; when the stone, however, is composed of uric acid, the exhibition of potash or soda may be attended with considerable advantage. These medicines will not dissolve a stone when once formed, but I am inclined to believe that they prevent the fiirther deposition of uric acid, and most decidedly lessen thn irritability of the urinary organs ; and, by covering the surface of the calculus with a sort of mortar, it becomes much less an- noying to the patient and much less irritating to the part in which it is con- tained. 176 CALCULI IN THE URETER, 5. If the calculus i& too large to be passed into the blad der, you will be able very readily to feel it by a probe^ through the openings formed by ulceration for its escape y and, in order to prevent the closure of the sinus by granula- tion, you should introduce a sponge tent. With a view of facilitating the escape of the stone, you may dilate the sinus by means of a bistoury ; for there will be no danger in doing it, as the emulgent artery and vein are situated behind the calculus. CALCULI IN THE URETEE, 1. When the stone has descended from the kidney into the ureter, there will be felt great pain at different parts, ac- cording to the sympathy existing between those parts and the course of the ureter. At first there will be great pain at the spine of the iliumy at the anteriec saperior spinous process, in the course of the psoas muscle, and over the surface of the abdomen j as it passes along the ureter, at the time it crosses the lumbar plexus, there will be experienced very great uneasiness in the groins, and in the course of the anterior crural nerve down the thigh ; when it goes over the spermatic plexus, the cremaster will be spasmodieairy con- tracted, and there wilT be felt severe pain in the testicle ; the stomach will likewise be particularly irritable and continually eject its contents ; the skin covered with cold sweats ; and a death-like paleness of the countenance. 2. The pain, experienced in this complaint, is not con- stant, but comes on at intervals ; after continuing some min- utes^ a complete remission occurs ; but after a lapse of ten or fifteen minutes, it returns with as much severity as before. The symptoms, just mentioned, teach you, unequivocally, that a stone ex- ists in the ureter. 3. Treatment : — During the violent paroxysms of suffer- ing, the patient should be bled to syncope, with a view of pre- venting inflammation j opium and potash should be given to diminish pain and lessen irritability ; and the patient may be put into the warm bath. When the patient is in the warm bath, you should set by his side and rub the abdomen in the course of the ureter j for the urine having collected STONE IN THE BLADDER. 177 above the stone, ami its vis a tcrgo being insufficient to push the calculus onward, friction, properly directed, will prove of great service by its me- chanical inlluence on the accumulated fluid, and it will be found agreeable to the i)alicnl ratiier than otherwise. 4. If nature, and the attempts of relief, fail in passing the calculus on, the disease then necessarily terminates in the destruction of life. STONE IN THE BLADDER. 1. Directly the calculus has passed from the ureter into the bladder, the symptoms change. There will be micturition ; pain or a sense of irritation at the extremity of the penis, greatly increased upon making water, to the evacuation of which there is fretjuently a sudden stop, followed by an almost insupportable sense of bearing down ; and at the ejection of the least drop, the pain a- mounts even to torture. 2. The diagnostic symptoms of stone in the bladder are, pain towards the extremity of the penis, opposite to the fra;- num ; discharge of bloody urine ; sudden arrest of the water during the flow of a full stream ; and a frequent disposition to void the urine ; and pain in doing it, particularly in the erect position. The sudden arrest of the flow of urine, is in consecjuencc of oilhor a valve formed in the urethra, or the stone resting against the neck of the; idadder. 3. AVhen a person under this complaint is voiding his urine, he is observed to place himself in a position in which every muscle may be as relaxed as possible ; his knees are bent, his head resting against some object for support, while he draws the prepuce forcibly over the glans penis. The urine is not changed unless there is much irritation in the biaddeF| but if the stone has been of long standing, and there is disease in the blad- der, there will be clots of blood in the urine. Again, in the attempt to pass urine, there is a disposition to void the faeces, as the rectum obeys the in€>- tion of tiie blaihier. 4. In many cases the abdominal muscles are affected with violent spasms. 178 STOKE m THE BLADDER. First, persons are affected with violent spasms of these muscles ; thea have disease of the mucous membrane of the bladder, and frequent shiver* ings. When the mucous membrane of the bladder is affected, the urine will be white ; there will also be flakes of matter in it, and when this is the case, the patient is in a state that would be improper for an operation. 5. When boys are the subject of this disease, there is gen- erally a remarkable elongation of the prepuce. This is singular, and not easily explained, unless it is produced by pres- sure on it when the pain at the extremity of the penis comes on ; for as the pain in this part is an exceedingly distressing symptom, and pressure on the nerve deadens it, it (pressure) is made, and the prepuce thus becomes elon- gated by it. 6. Calculi either pass from the ureter ; or they are form- ed in the bladder around some extraneous body, or around clots of blood, in either case forming a n^ucleus for the stone. 7. The calculi will be composed of the triple phosphate, or of uric acid, according to the degree of irritation which has been kept up ; if it has been considerable, the stone will contain the triple phosphate. Some stones are composed of concentric lamellae, whilst others are not ; in those which are, layer after layer is deposited and adheres, but the la- mellse are composed of much firmer materials than the bond of adhesion which unites them. 8. Calculi in the bladder vary both in number and in size. Their usual weight is from half an ounce to an ounce, more generally under, and there is usually only one at a time ; but I do not imagine the patient is in greater danger in an operation, from a larger number of stones being in the blad- der, or even so much, as when there is only one large or moderate-sized one. It is not the frequency of introducing the forceps for withdrawing calculi from the bladder that is dangerous, but it is the bruising, from pressure, which gives rise to the destructive symptoms. 9. The magnitude of calculi in the bladder is generally in an inverse ratio to their number. STONE IN THE BLADDER. 179 When a great number of calculi are found in the bladder, the circum- stance 1= generally attended with an enlargement of the prostate gland, di- rectly behind which a saculus is formed. In cases of diseased prostate, the bladder can seldom be completely emptied ; and this particular stagnation of the urine ia the sac is supposed to facilitate the production of calculi. 10. The urinary salts, in calculous patients, are not con- tinually precipitated in the same quantities : in some cases, indeed, the process appears to be even suspended for a con- siderable time. Hence a stone of middling size, already formed, may increase, but very slowly ; and it has actually happened, that a calculus, which could be plain- ly felt with a sound, has remained more than ten years in the bladder, and yet, after all this time, been only of a moderate size. 11. The pain which a patient experiences from stone in the bladder is by no means in proportion to its bulk. It is not exactly in the inverse ratio to its magnitude, but still it approaches that inverse ratio. When a stone becomes excessively large, the patient generally loses the power of retaining his urine, and the distillation of urine from the bladder prevents that contraction of it which occasions so much pain to the patient in discharging the last drops of it. 12. Again ; the pain does not so much depend on the form of the stone as on the general irritability of the patient, and especially on the irritability of the bladder. Thus you will sometimes in performing the operation, find a stone exces- sively pointed, where the patient has complained of but trifling symptoms j and, on the other hand, when the stone is perfectly smooth, the patient suf- fers extreme pain : however, rough scones are more likely to give the great- est degree of pain. 13. Variety : — There are four different kinds of calculi, ■when chemically examined. The first is the uric acid, which is common, but not the most common form of calculus. The second is the triple-phosphate, or ammoniaco-magnesian phosphate. The third species is the mulberr)", or oxalate of lime : and the fourth, the cystic. Uric ^cid Calculus : — Is distinguished by concentric lamsTls, and v.'hon ISO LITHOTOMY. cut, has the colour and appearance of wood. It is soluble in alkalies, and alkaline remedies are commonly recommended for this kind of stone. Arrvmordaco-magnesian Calculus : — Is of a greyish white colour, and not BO distinctly laminated as the uric acid. It is not soluble in alkalies, but it is acted upon by the acids, but not in any considerable degree. A quantity of matter resembling mortar, which is in fact, ammoniaco-magnesian phosphate, is generally passed from the bladder, and the urine is highly offensive. Mulberry Calculus: — Consists of oxalate of lime, and is, to a certain de- gree, soluble in acids. It will be proper, therefore, to give, in these cases, muriatic or sulphuric acid; the muriatic is generally preferable. Cystic Oxide Calculus .- — Has the appearance of brown sugar in a state of crystallization; it is not composed of concentric lamellae. 14. Treatment : — Although some little benefit may be de- rived from the use of alkaline remedies, by lessening the irri- tability of the bladder and constitution, the stone will still remain, and surgery will be the only effectual means by which the sufferings of the patient can be removed. Soda, and the usual list of alkalies, may sometimes prove beneficial. The liquor potassae conjoined with opium, has considerable effect in diminishing irritability, and it should be given for some time before the operation for stone. This medicine has a very beneficial effect in children who have stone in the bladder, and pass a large quantity of matter ; it will remove this excessive secretion, and enable you afterwards to perform the opera- tion with success. LITHOTOMY. 15. In speaking of lithotomy, I shall commence by point- ing out the symptoms of the actual presence of stone ; then allude to the diagnosis and prognosis ; point out what should be attended to before the operation ; name the instruments required ; explain the different ways of extracting calculi from the bladder ; and finally make a few cursory observa- tions as connected with the subject at question, 16. Symptoms : — The symptoms, particularly indicating the presence of stone in the bladder,are exceedingly equivocal. There is a sort of itching along the penis, particularly at the extremity of the gland ; frequent propensities to make water, and to go to stool ; great pain in voiding the urine, and difficulty of retaining it, and often of keeping LITHOTOMY. 181 the feces from being discharged at the same time ; the stream of urine is liable to stop suddenly, while flowing in a full current, although the bladder is not empty, so that the fluid is expelled by fits, as it were ; the pain is greatest towards the end of, and just after, the evacuation ; there is a dull pain about the neck of the bladder, together with a sense of weight, or pressure, at the lower part of the pelvis : a large quantity of mucus is mixed with the urine ; and sometimes the later is tinged with blood, especially after exercise. 17. Diagnosis : — The symptoms of stone may be confoun- ded with several disorders connected with the urinary organs ; therefore you should not give a decided opinion founded alone on the indications just mentioned. The least fallible sign, says Sir John Eurle, is the patient making the first portion of urine with ease, and complaining of great pain coming on when the last drops are expelled. This is readily accounted for, from the bladder being at first defended from contact with the stone by the urine, and at last being pressed against it. Your maxim, however, should be never to say there is a stone in the bladder, unless you can distinctly feel it with the sound or staff". 18. Prognosis : — Having ascertained, by sounding, the actual existence of a calculus ; before you operate, you must endeavour to draw your prognosis. 19. The first circumstance to be considered before you operate is, whether the constitution of the patient is in a sound state, or his general health good ; for there is no ope- ration in which attention to these points is more necessary, before it is performed, than that for stone. The person should be in good health at the time, for unless he is, there will be little hopes of success. Those who have been exposed to the vicis- situdes of life and poverty, and have been obliged to labour for their bread, generally bear the operation for stone well, and in those persons the chance of success is generally greater than in the higher ranks of society, and those you usually meet with in private practice. If the constitution be broken by dissipation, debauchery, or other irregUr- larities ; if the patient's strength shall have been impaired by hardship, want, or anxiety; or more especially if he be of a scrofulous diathesis, or shall have indulged in the abuse of spirituous liquors, your prognosis ought at all times to be extremely guarded, for the most part unfavourable, and in aggravated cases, utturly hopeless. * 182 LITHOTOMY. 20. If the disease shall have been of long standing, hav- ing exhausted the strength of the patient by suffering and want of rest, your opinion must be unfavourable. 21. If the bladder is ulcerated, do not perform the opera- tion on any account, for it will not be successful. But es- pecially never submit a patient to the operation of the stone, if there is the slightest affection of the chest, the least diffi- culty of breathing, any signs of asthma, or any irregularity of circulation. Unless the patient is suffering exceedingly from the stone, you should not operate until he is free from every other complaint. 22. Old age is no objection to the operation, for the best time of life fitted for it is about sixty-one or two ; and at this period a great number of cases occur. After this, the danger increases, but, between sixty and sixty-three, more cases recover than at any other period. If a patient is loaded with fat, there is always danger of peritoneal in- flammation. Again, when there is an enlargement of the prostate gland, you should not operate. 23. Children, before they are four years old, are in con- siderable danger from the operation. After four, they ac- quire strength, and the irritability of the constitution is much lessened. Under four years of age, convulsions frequently come on after the opera- tion ; and in three days the children often die, more especially if they have lost much blood at the time of the operation. 24. Diet, 4-c. — The case being fully decided on, great ad- vantage will be derived from putting your patient on vegeta- ble diet for a few days before the operation ; and giving the solution of potash with opium. He should also be sounded frequently. The introduction of the sound, accustoms the bladder to irritation, and when it has been done pretty often before the operation is performed, the patient bears it infinitely better than when he has been operated on without. — ^ :^'*#;- s.^^'k-^^"-&:^jSi»^^^, CANCER OF THE BREAST. 195 be a chance of the return of the disease, therefore, the best plan is to take away the entire glandular structure of the breast. 8. Although the removal of the breast is the plan usually adopted, I have employed a diflferent treatment when there has been a single cyst, with perfect success. If the disease consists of a single cyst, I would recommend you to pierce it with a lancet, the fluid will then escape. Do not close the opening until the adhesive process has commenced, and glued the cyst ; in this way, the disease may be cured. The cure may also be effected by leaving the cyst open for granulation. SCHIRROUS TUMOUR, OR CANCER OF THE BREAST. 1. This is one of the two malignant diseases to which the breast is subject, and is extremely frequent in its occur- rence. The symptoms of this horrible complaint may be conveniently divided into the incipient, the inflammatory, and the suppurative stages. It is supposed by some, that the name of cancer was given to this disease, on account of the appearance of the surrounding veins. I should rather say, it was from the appearances on dissection; for when you dissect a scirrhous tumour,you will see a number of roots proceeding to a considerable distance. 2. The first symptoms of a scirrhous breast are, a hard, circumscribed, and moveable swelling ; little or no pain, and sometimes a discharge of blood from the nipple. The tumour, however, is not always circumscribed, for it sometimes hap- pens that inflammation extends, and the disease is lost in the surrounding parts. The disease continues in the first stage for a long time, for weeks and months, gradually increasing, and at last the second set of symptoms comes on. 3. In the second stage, there is violent darting pain ; a burning sensation in the part ; the patient feels worse a little before menstruation ; enlargement of the tumour, and of the neighbouring glands 5 a puckered appearance of the skin about the nipple, &c. a*§ 196 CANCER OF THE BREAST. In the progress of the complaint, a number of small black spots will be seen in the breast, and these increase as the breast enlarges. Inflammation on the skin and nipple comes on, and the cellular membrane partakes of the character of the disease. 4. The third set of symptoms arise from suppuration go- ing on in the part. The constitution becomes severely affec- ted ; there is a difficulty of breathing, an inability to lie but on one side, pain in the right sidC; and also in the loins. The stomach is deranged, severe spasms at the scrobiculus cordis, and frequent vomitings come on ; at last the patient is worn out from irritation, and expires. Prior to an opening being formed, the skin becomes livid, and the breast is very painful in that part where it opens ; and when the ulcerative state has begun, the glands above the clavicle enlarge, the arm swells just above the elbow, then it extends over the hand, fore arm, and upper arm. There is an interruption to the functions of the absorbent system j the blood is not returned by the veins ; an increased secretion takes place from the termina- tion of the arteries ; fluid is thrown out into the cellular tissue, which, when evacuated, coagulates. It is not true pus whichis generally secreted, but after the adhesive pro- cess has been set up, there is an attempt at the formation of pus, which, if it forms, is not general, being only in some parts, and not in others ; and it is more properly a sanious serum, as it has not the common character of pus. 5. Married women who bear no children, and single women, are more subject to this complaint than those who have large families. It is very probable that the natural change which the breast undergoes in the secretion of milk, has some power of preventing this disease ; but is no security against the complaint, though it lessens the tendency to it. 6. The progress of this complaint is in some persons ex- tremely slow. In general, however, it destroys life in about four years from its commencement. It is from two to three years growing, and from a year and a half to two years in destroying life, after it has arrived at its acme. When suppuration and ulceration have commenced, and the constitution is disordered, it is even then some time before the patient is worn out. 7. Cause : — This disease is frequently the consequence of grief and anxiety : it is also attributed to an accident of some CANCER OF THE BREAST. 197 shape or other to the part ; but this is not the proximate cause of the complaiut. The constitution itself must either partake of, or there must be a specific action in the part. If there is a disposition in the constitution to the production of this dis- easej in any part, some circumstances exciting a peculiar action in it must occur, and then scirrhous inflammation is produced. The disease is made up of a derangement in the constitution, and of a local peculiar action j it is the effect of a specific action in the part, preceded by a disposition in the constitution, to its production. 8. The scirrhous tubercle is said to be fibrous ; but the fibres do not belong to it, they are nothing more than the cellular tissue thickened. 9. Treatment : — AVe have no medicines that can cure this disease ; but if a patient applies to you ^vith scirrhous tuber- cle, and her general health is in a disordered state, you may retard its progress by giving alterative medicines. Fou should never operate unless the patient has undergone a course of medicine. 10. Another view with which medicine is to be given is this : if an operation has been performed, you should alter the state of the constitution by the exhibition of alterative medicines, (Plummer's pill, and compound decoction of sar- saparilla, or soda with rhubarb.) by which means you will improve the general health, and lessen the chance of the disease returning. You may alter the constitution in this complaint, but it is impossible to disperse scirrhous tubercle -when it has formed. Therefore, all we can do by medicine is to change the state of the constitution prior to an operation, BO as to prepare the patient for it ; and when an operation has been formed, we can give alteratives so as to lessen the chance of its returning. 11. As to local treatment, we possess no specific local ap- plication. They can do nothing more than retard, in some slight degree, the progress of the disease. The best applica- tion is the soap cerate ; or, if there is much pain. I would use a drachm of the extract of belladonna rubbed down with an ounce of the soap cerate. 198 CANCER OF THE BREAST. Evaporating lotions, and warm applications should never be used, they do more harm than good ; but the remedy just recommended, diminishes the nervous irritability of the part, and excites a gentle perspiration without auy undue heat. 12. If there is much inflammation, you can apply leeches, though the mode of treatment which I like is, to give those medicines which restore the constitution generally. You may restore the different secretions, by Plummer's pill, and diminish the irritability of the nervous system by carbonate of ammonia. This is the best plan, as far as I know, to keep the patient alive as long as the case will permit. 13. With respect to diet, it must not be too low ; but let your patient take those things which she finds agree with her own feelings, and which do not derange the general health. Wine or spirits must not be taken, or, if wine is al- lowed, it should be mixed with water. Never hurry the constitution, nor give her anything so as to disorder the constitution, but support the strength by animal food. Do not debilitate it then on the one hand, nor stimulate it on the other ; for if you do, it will be the sure way to hasten the progress of the disease. 14. Climate has been supposed to have an effect in pre- venting that state of the constitution which favours the re- turn of the disease, but it has no such influence. 15. Operation : — The operation for the removal of a scir- rhous breast should not be performed if the glands of the axilla generally are enlarged, for it will be sure to return. The operrescribe in the way of med- icine, either the hydrargyrum cum creta, orPlummer's pill, together with some bitter infusion and soda. 11. The radical cure of this complaint is to be effected in two ways • the one by removing the fungoid part ; and the other, by endeavouring to occasion its suppuration by means of pressure. In either case, it is necessary, for the purpose of promoting a favourable issue of your surgical treatment, that you should attend to the state of the patient's constitution, both before and after they are employed. 12. If you have recourse to an operation for the removal of the part, you must make your incision heyond the discol- 202 SIMPLE CHRONIC TUMOUR OF THE BREAST. cured or inflamed parts, for, if you cut into the skin which has become reddened, it will, of course, have taken its pecu- liar morbid action, and the disease will unquestionably still continue to grow in that situation. 13. Much has been said concerning the largeness of the vessels in these tumours ; but if these vessels are large, no danger ought to be apprehended from hemorrhage, as the bleeding can easily be stopped by pressure. Blood-vessels situated in fungoid tumours, have no contractile power j consequently,' when they are cut into, or divided, the bleeding from them will continue for a considerable period, unless pressure is employed. SIMPLE CHRONIC TUMOUR OF THE BREAST. 1. This disease is not of a malignant character, and by no means dangerous to life ; it is generally very young people who are attacked by it, and we seldom see it in persons above thirty years of age. 2. Diagnosis : — The age and healthy appearance of the person in which this state of the breast is found, the lobula- ted feel of the tumour, and its lying more blended with the neighbouring parts, at once characterize it from cancer ; nei- ther will it ever become cancerous, or dangerous to life. 3. The size of the tumour is generally from that of a filbert or walnut to that of a billiard-ball. They may grow larger, and may be attended with pain at the periods of menstrua- tion, but never will prove of serious consequence. If, however, the mind should be rendered wretched, in consequence of such a tumour, an incision will instantly enable you to remove it, and there- by allay all mental irritation ; but as far as the tumour itself is concerned, and as regards the health or safety of the patient, the operation is by no means necessary, or, when necessary, is by no means dangerous. 4. Cause : — I am induced to believe this affection sympa- thetic with the functions of the uterus ; as also, that a com- ADIPOSE TUMOUFlS OF THE BREAST. 203 mou caaie may be traced to the pressure produced by the whalebone and steel busks usually worn in stays. 5. Treatment : — Medical treatment will not hare any influ- ence on these tumours ; you may, however, for the purpose of correcting the state of the constitution, should any thing amiss exist in it, place your patient under a course of medicine. If the digestive functions be disordered, the compound calomel pill may be taken at night, and the infusion of calumba with rhubarb, and the car- bonate of soda twice a day. When the uterine secretion is defective, give small doses of the blue pill and colcynth, with steel medicines. For local applications, I should recommend the emplastrum ammoniaco cum hydrar- gyro, and the iodine ointment. The disease, however, rarely yields till the uterine excitement ceases, or the part is required to furnish its own natural Becretion. ADIPOSE TUMOURS OF THE BREAST 1. Tumours of this kind now and then occur in the breast, as well as in other parts of the body. They are not dange- rous, although sometimes of an enormous size ; and may be removed by the knife with safety. IRRITABLE TUMOUR OF THE BREAST. 1. Like the simple chronic tumour, is very common, and generally occurs between the age of fifteen and twenty-five. It is characterized entirely by its exceeding tenderness, and by the sanguineous temperament of the patient. If you examine the tumour otherwise than with gentleness, she will ex- perience pain for hours, and even days afterwards, so exquisitely tender is this irritable swelling. 2. There is no necessity for alarm in these cases ; the cause of the disease is easily ascertained ; it merely arises from functional derangement in the uterine secretion. 204 CARCINOMA OF THE MALE NIPPLE. Although the tumour is painful in common, yet the tenderness and pain immediately before the i)eriod oi menstruation, are almost incredible: the pain extends from the breast to the arm on the affected side, and down to the fingers' ends, and has been known to affect the sight. 3. Treatment : — There is no visceral disorganization in these cases, and to afford relief you have merely to adopt such measures as are calculated to restore the proper quanti- ty and condition of the uterine secretion. As the uterine discharge increases, the irritation in the breast lessens, and will soon completely disappear. To accomplish this, the best medicine you can give is, an ounce and a half of the mistura ferri composita, two or three times a day ; or from two to five grains of the ferrum ammoniatum, as often. Leeches J would not advise ; neither an operation for removing the tumour. Rather attempt to cure the disease by the plan I have just prescribed. CARCINOMA OF THE MALE NIPPLE. 1. The nipple of men is sometimes affected with cance- rous ulceration, similar to the breasts of women : it begins in the same way, in the form of the scirrhous tubercle j here, however, it is generally in the immediate neighbourhood of the nipple. An incrustation forms on the surface of the nipple ; this drops off, anoth- er succeeds it, and another to that again, until an ulcer is produced, and ultimately the whole nipple is destroyed j then the glands in the axilla, and likewise those above the clavicle, become diseased j and men die from this complaint precisely in the same manner as women do from cancerous breasts. 2. The chance of success from an operation depends upon its being performed before the axillary glands become diseas- ed ; if they are, you must not employ the knife. The same medicine, and the same manner of treatment, as is recommen- ded for cancer of the breast in women, must likewise be resorted to in thesa cases. 205 AREOLA TUMOUR 1. Tumours occasionally exist round the areola of chil- dren. Upon examining the breast, you will find a swelling as large as half-a-crown, just round the areola ; flattened to- wards the outer edge, but convex in the centre, that is, the nipple, which the swelling closely surrounds. They generally occur from seven to twelve years of -age ; boys as well as gitis are subject to the disease ; but I never saw either afflicted with it after the age of puberty, nor anterior to the eige of seven. 2. Your treatment must consist in the application of the emplastrum ammoniaci cum hydrarg}'ro ; and at the same time you are using the plaster, you should give to the patient the eighth of a grain of the oxy-muriate of mercury in one drachm of the tincture of bark, twice a day ; or, if the bowels should be disordered, you may give one drachm of the tinc- ture of rhubarb, as a substitute for the tincture of bark. The plaster that is used should have a hole in its centre, for Ihe reception of the nipple ; about every seven days it should be renewed. This plan, constantly followed, will subdue the disease in about six months. LACTEAL TUMOUR. 1. "Women, shortly after their confinement, are frequently annoyed by these tumours. They are very large, and upon examining them with your hand, you will readily perceive a sense of fluctuation : there is no pain, or any signs of inflam- mation, and the contents of the tumour is purely milk. Your treatment should be to open the sac with a lancet ; and after the milk has been "vacuated, you should introduce into the opening a sponge or cotton tent, this, in a short time, will excite inflammation in the sides of the sac ; adhesive matter will be thrown out, which, glueing the parietes of the sac to each other, will be the means of gradually obliterating the cavi- ty, and thus produce a permanent cure. 2. We have now considered the subject of diseases of the breast ; we will next pass on to speak of retention of urine. 206 RETENTION OF URINE. 1. Retention of urine is an inability, whether partial or total, of expelling, by the natural efforts, the urine contained in the bladder. The characteristic symptoms of this complaint, previous to the introduc- tion of the catheter, is a distention of the bladder, to be perceived by an examination of the hypogastrium, after the patient has discharged all the urine, which he is capable of expelling. 2. Causes : — The most frequent causes of retention of urine are, strictures in the urethra, and enlargement of the prostate gland, in the male ; and retroversion of the uterus, in the female. There are several other causes which give rise to this complaint ; an ac- cumulation of blood in the bladder, stones in the urethra, or pressure of matter between the prostate gland and rectum, will sometimes occasion a necessity for opening the bladder. 3. Treatment : — Every case of retention of urine demands prompt assistance ; but, when the disorder presents itself in its complete form, the mischief of delay is of the most serious nature. If the bladder is allowed to remain preternaturally distended, it not only loses its contractile power, but is quickly attacked with inflammation and sloughing. At length, some point of it bursts, and the urine is extravasated in the cellular membrane of the pelvis ; spreading behind the peritoneum as far up as the loins, and in other directions, into the perineum, scrotum, and thn integuments of the penis, and upper part of the thighs. The in- flammation thus excited is extended to the peritoneum and bowels, and the patient expires. 4. In all cases of retention of urine, your first indication is to procure a discharge of the fluid through the natural passage. This is to be answered, sometimes by means of fomentations, the warm bath, bleeding, opium, and other medicines ; sometimes by the removal of mechanical obstacles to the flow of the urine ; but more frequently by the use of the catheter, than any other means. RETENTION OF UEINE. 207 5. "When all the plans you have used prove ineffectual ; then it becomes necessary to puncture the bladder. 6. Before I speak more particularly of the means, which surgeons recommend for relieving retention of urine by the knife, you should first well understand the introduction of the catheter. No person should ever dream of performing any operation by puncturing the bladder, or in any other way, without first endeavouring to relieve the patient by the introduction of the catheter. 7. In passing the catheter, in common cases, you have only to bear in mind two motions which are necessary to ef- fect your purpose. But in cases of enlargement of the pros- tate gland, there will be some difference in the mode of pas- sing this instrument. First : — When you are called upon to introduce the catheter, place your- self on the right side of the patient, pass it down under the arch of the pubis, perpendicularly, until you reach the membranous parts of the urethra ; and then do not continue to pass the instrument in that direction, for if you do, you will push it towards the rectum instead of entering the bladder ; but, having reached the membranous parts of the urethra, you have only to give your hand a peculiar turn, and it will immediately pass the bladder. Second : — When the prostate is enlarged, the urethra is pushed forward, so as to be doubled on the point of the instrument. You must, in this case, pass the catheter down to the apex of the prostate gland, then carry the instrument towards the abdomen, so as to push the urethra as much as you can towards the perinseum, and then, having brought the urethra into a straight line again, deprsss the point of the instrument, and you will be ena- bled to pass it into the bladder. 8. The operation of puncturing the bladder may be effec- ted in three different ways : above the pubes ; through the rectum ; and through the perinseum. 9. Operation above the Pubes : — The operation of punctur- ing the bladder, above the pubes, is very simple, and is foun- ded in the following anatomical circumstances : in the natu- ral formation of the parts, the peritoneum falls from the inner side of the rectus over the upper part of the bladder, and is reflected backwards to the fundus, leaving a space, filled with cellular tissue, between the pubes and the reflected peritoneum. SOS RETENTION OF URINE. This is the space in which the operation is performed, and all that is re- quired is, to make your incision through the integuments, to the extent of an inch above the pubis. It is best to open the integuments in the first instance, because the trocar will afterwards enter the bladder with more ease, and because, if there should he any extravasation of urine by the side of the instrument, it will more readily escape. The incision should extend as far as the linea alba. With respect to the direction in which the trocar is to be passed, you must not, on any account, direct the point downwards, towards the anus, bnt obliquely from the penis to the back of the pelvis, just towards the basis of the sacrum. The trocar and canula being introduced, the water passes through the canula ; and an elastic gum catheter should be introduc- ed through the canula, and may be left in the bladder, for a great length of time without producing any injurious consequences. 10. Tn the female, it is absolutely necessary this operation should be performed in cases of retention of urine, from retro- versio uteri, and from a cancerous disease affecting the mea- tus urinarius. Operating through the vagina ought never to be performed. 11. Operation through the Eectuvi : — This operation is per- formed in the triangular space, formed by the meeting of the vasa deferentia, constituting the apex ; the sides, from the vasa deferentia, as they diverge in their passage backwards ; and the basis of the triangle, by the peritoneum, as it is re- flected from the posterior part of the bladder to the upper part of the rectum. When you pass your finger into the rectum, you will feel the bladder pro- jecting into it. It is elastic,and yields with difficulty to the pressure of the finger ; you will readily feel the fluctuation. This leads you to the spot where the trocar is to be introduced : the triangular space, above mentioned, is directly presented to the point of the instiument. You introduce your finger about an inch, (never less than half an inch) behind the j)rostate gland, and then upon the upper part of the finger pass the trocar, which may be either curved or straight, to the posterior part of the bladder. When the point of the instrument rests upon the upper part of the rectum and the pos- terior part of the bladder, you pass the trocar into the bladder obliquely wp- VDords and forwards by a slight and sudden motion of the hand. Arr elastic gum catheter is then to he employed. On the whole, however, though an easy operation, there are many objections, and I would not recommend it to be performed. 12. Operation through the Perinccum : — This operation bears INCONTINENCE OF URINE. 209 a great similitude to that for stone. It consists in puncturing the bladder by the side of the prostate gland, and is unatten- ded with any danger of wounding the peritoneum, because it does not reach the anterior part of the bladder. You make an incision in the perinaeum, as in operation for stone, cutting down on the bulb of the penis, and drawing it to the right side. You then carry the knife within the ramus of the ischium till it reaches the prostate gland, which you push to the patient's right side. You then carry the instrument obliquely upwards into the bladder, your finger resting on the prostate gland. 13. We have now gone through the three different operations for puncturing the bladder, and, although there is no great difficulty in either, I affirm that we ought to avoid all these operations, and that puncturing the bladder for stricture in the urethra, or enlargement of the prostate gland, is in gene- ral perfectly unnecessary. In case of accumulation of urine in the bladder, for which many would have recourse to puncturing that organ, I have found opening the urethra, only, a better and safer course. All I do is this, T desire the patient to draw up his legs as if he was going to be operated on for stone ; I then make my incision into the urethra, according to the seat of the stricture, and the re- sult is, that the urine is passed by the perinasum, and the bladder relieved, without being in the slightest degree injured. INCONTINENCE OF URINE. 1. This complaint is quite the reverse of retention of urine, for, as in the latter affection, the urine is continually flowing into the bladder, without the patient having the power to expel it ; so, in incontinence, it flows out, without the patient being able to retain it. According to Desault, children are particularly liable to the disorder 3 adults are less frequently afflicted with it, and persons of advanced years ap- pear to be still less liable to it 2. Causes : — The causes of incontinence of urine, strictly so called, are the reverse of those of a retention. Incontinence may arise from a relaxation or pa.lsy of the sphincter vesicae muscle, induced by debility, the abuse of spirituous liquors, excess in ve- 210 ASCITES, OR PERITONEAL DROPSY. nery, &c. ; from injury produced by calculi ; injury to the parts ; and from the pressure of the uterus in the state of pregnancy. 3. Treat77ient : — This must obviously depend on the cir- cumstances which induced the complaint. If it arises from relaxation or paralysis, tonic medicines internally, and cold applications to the region of the bladder, would be proper: — if the result of irritation, opiates and mucilaginous diluents ; or, if from laceration, pres- sure during pregnancy, and so forth, any reasonable plan of treatment, as the case may indicate. DROPSY. 1. There are two species of dropsy of the abdomen : — the peritoneal or ascites, and the encysted or ovarian, ASCITES, OR PERITONEAL DROPSY. 2. The peritoneal dropsy is an accumulation of water in -the peritoneum. The first symptom, which a person feels who is affected with ascites, ia pain on the abdomen being pressed ; every day this symptom becomes more and more severe ; the body goes on gradually enlarging, until, at length, the person applies for medical assistance^ Upon examination, it will be found that the intestines are floating in a fluid, the abdomen enlarged, (in propor- tion, of course, to the quantity of fluid witliin,) and upon loosening the clothes, applying the hand to each side of the body, and gently using pres- sure with one hand, and slightly tapping the abdomen with the other, or giving the body a gentle sudden jerk, from side to side, fluctuation will be readily perceived. As the disease advances, dyspnoea comes on from pres- sure produced on the diaphragm, which at length becomes a very trouble- some symptom. 3. Diag?iosis : — The difficulty of breathing, and the in- crease of quickness on taking exercise, the inconvenience arising from the slightest pressure by the clothes, and the gradual enlargement of the abdomen, so strongly point out the character of the disease, it is hnrdly possible you can form an incorrect opinion respecting it. 4. The fluid secreted in ascites is serous, but does not contain so much albumen as serum in general. ASCITES, OK. PERITONEAL DROPSY. 211 The quantity of water, usually drawn oiF, is from twenty-five to thirty pints ; but, in this respect, the surgeon will occasionally find a variation. 5. Causes : — The most common cause is disease of the liver ; it is also the result of local irritation, from enlarge ment of the abdominal viscera ; it likewise proceeds from debility arising from fever, and from debilitating courses of mercury, the use of ardent spirits, &c. Diseases of the liver, by impeding the circulation of the blood throuch that organ, by obstructing its free passage, must of necessity occasion a conges- tion of blood in the vessels of the mesentery, stomach, spleen, pancreas and neighbouring parts, and, for the relief of this congestion, nature is under the necessity of effusing, from the filled vessels, the serum which we subse- quently find in the peritoneum. 6. Treatment : — Medical treatment, when judiciously pur- sued, is very often successful in the cure of ascites ; in the use of medicines, however, you must take care to direct their influence against the cause of ascites. . The medicines, which experience has proved to be the most beneficial in dropsy of the abdomen, are calomel and squills : one grain of calomel and three of squills in a pill ; or, two grains of blue pill, combined with three grains of squills ; one of these should be taken every night, or every other night, and in the day you should give a mixture, composed of from seven to ten grains, of carbonate of ammonia, one drachm of nitious .•■■pirit of aether, twenty drops of the tincture of fox-glove, and an ounce and a half of cam- phor mixture. These medicines will often succeed in restoring a person to health, whose constitution may be considered so broken and faulty that it may be deemed impossible for him to regain a sound state of body. 7. If the liver is the defective organ, you should endeav- our to restore its healihy functions, which in general is easily accomplished ; but, when the disease is occasioned by local irritation, arising, for example, from enlargement of the spleen, you will then find great difficulty in performing a cure. If ascites arises from debility, independeist of disor- ganization, it is readily overcome by medical treatment. When the disease has arisen from the irritation caused by ardent spirits, the medicines just recommended must be re- linquished (or the complaint will not disappear) for more active remedies. 212 ENCYSTED OS OVARIAN DROPSY. There are other msdicines which are powerful in producing an absorption of effused water, and carrying it off hy the kidnies and by stool. The most active of these is eluterium; it is, indeed, so active, so severe in its effects, so destructive, that you must never give it to persons of advanced years, nor to those who labour under great debility. In dropsy, however, which occurs in the middle of life, where there is strength to bear its operation, this medicine will be found a most valuable remedy ; but you must be cautious to commence with small doses. 8. When the attempts of medical treatment do not effect a cure, an operation, called paracentesis abdominis, is per- formed, of which we shall hereafter speak. ENCYSTED OR OVARIAN DROPSY. 9. The encysted or ovarian dropsy is a collection of water in the membrane which covers the ovarium. It is entirely local, and a person may be attacked by it who is in perfect health ; indeed the health of the female may be as good when she has this disease, as a man's may be when he has hydro- cele, and the two diseases are somewhat similar. Afler the encysted dropsy has existed for a short time, a small tumour wii! be perceived just above Poupart's ligament, tying upon the brim of the pelvis in the hollow formed by the iliacus internus ; no fluctuation can be perceiv- ed in it at first ; as it increases, it gradually rises as high as the kidney ofthe affected side, it then crosses the abdomen, and fills the opposite side ; it thus forms on one side, grows to a considerable size, then passes to the opposite side, and thus becomes of very considerable magnitude. There is no pain in the progress ofthe complaint, and the principal inconvenience,that arises from it when the tumour is situated in the pelvis, is its pressing upon tho bladder, and interrupting the free flow of urine. 10. The presence of fluid or fluctuation is not so discovera- ble in this species of dropsy as in ascites ; it is necessary to have the abdomen very much distended before it can be per- ceived." There is about the same quantity of water drawn out in ovarian dropsy as in ascites, and, although the swelling may occupy both sides of the abdo- men, you will not find much variation in the quantity. 11. The fluid contained in the cyst of ovarian dropsy dif- fers considerably in different subjects j so that when you op* ENCYSTED OR OVARIAN DROPSY. 213 erate, it is quite uncertain what kind of fluid you will find. Sometimes the cyst is filled with a number of hydatids. In some cases it is serous, in others mucilaginous, and occasionally puru- lent. The fluid is sometimes so thick when mucilaginous, that it will not escape through a common-sized canula, and you are under the necessity of introducing one of larger diameter before you can succeed in drawing it off. 12. The cysts, in which the fluid of an ovarian dropsy is contained, are of two kinds 5 one is formed of the membrane which covers the ovary, and the other from a hydatid which lodges upon that membrane ; the ovary itself being quite unafiiected. 13. Treatment : — I do not consider that medicines will produce any marked diflerence in the quantity of fluid con- tained in the cyst of an ovarian dropsy, because there is a deficiency of absorbents attached to that part. You may, if you think proper, give digitalis and mercury ; they are strong- ly recommended : but I am fully satisfied, after you have tried them, you will agree with me, that they do not possess the least power of decreasing the water of encysted dropsy. Whether medicines are taken 01 not with a view of promoting the absorp- tion of the water, I would advise you, at least, to attend to the fecal dis- charges, 14. When a person consults you, having ovarian dropsy^ you should direct a belt X-o be applied tightly round the abdo- men, for the purpose of producing such a degree of pressure as will diminish the tendency to enlargement. If a person leads a sedentary life, and does not employ pressure, you will soon find that the dropsy v/ill so increase as to require an opeiation ; where- as, if the belt be worn, tapping may be put off almost to an indefinite period. 15. The operation of tapping has occasionally been per- formed with a view of merely relieving the load under which the patient has suffered, when, to the surprise of the surgeon, it has ended in a perfect cure ; but, generally speaking, the vessels more commonly have a disposition to renew the se- cretion of fluid, and the disease again forms. When about to perform this operatioUj^ take care that you may not be mis- 214 PARACENTESIS ABDOMINIS. lcc*C!r^-^--^ §17 FISTULA IN ANO. 1. Fistula in ano is a sinuous ulcer in the neighbourhood of the anus and rectum ; and is a disease in which you will be called upon to operate more frequently, perhaps, than in any other, I (k) not con«iiler it a disease which is very easy to treat 5 it very often Wffles liie skill of the best sorgoons, 2. Fistula in ano is more painful than a common abscess ; the patient has excruciating pain in the evacuation of his faeces, dreadful tenesmus, and very often retention of urine, the pressure of the matter preventing the passage of the sarine through the urethra, 3. Causes ; — The causes of this disease are Yery various 5 such as constipation and relaxation of the bowels 9 distant disease, as of the liver, or derangement of the alimentary ca- nal - sedentary habits ; and more especially diseases of the chest. It is r>ecesfiaTy, therefore, to inquire whether the ])atieiit 1alx)urs miclcr CGu;sh, (iyspntpa, and whether liis constitution is impaired. No operation "will avail without attention to the state of rlistant parts; you may divide the sinus, but if tlie fistuia depends on a disoideied stste of remote parts, the fistula will nevei heal without attention to lire constitutionofthe patient, 4. There is considerable variety in the size and complica- tion of fistulee. Sometinjes the sinus is confined to one side of the gtit ; in others half sur- rounding the gut ; and jn a third, entirely enciriles the intestine, Wlion there is an opening on each side, it is best to perform the operatio.i first on one side and then on the other. The fistula sometimes extends to the nates, and burrows to a great distance behind the gluteal muscles, 5. Fistulse are called blind, when the matter has made its way into the rectum, without making an opening externally • they are extremely difficult to treat. 6. Treatment : — The medical treatment of fistula in ano will depend on their cause : if they arise from costiveness, 19 218 FISTULA IN ANO. give aperients ; if from disease of the liver, give saline pur- ges and calomel ; if they arise from disease of the chest, as hydrothorax. I scarcely know what medicine to recommend, these diseases almost always produce destruction of life. It is of great importance to give such medicines as will bring tlie fistula into a healthy state. With tlils view the balsam of copiaba may be given with great advantage ; if there is much irritation, give soda, which has great efficacy in diminishing the irritability of the rectum. Aromatic medicines should be given, especially the confectio piperis nigri of the London Phar- macopa?ia. 'J'his medicine in a very short time brings the fistula into a heal- ing strtte ; healthy granulations arise from the surface, and the discharge, instead of being serous or bloody, consists of good pus. Sub-muriate of mert^ury, with saline purges, should be occasionally given during the use of aromaticsj vvitli a view of promoting the secretion of the liver and intes- tines. 7. The principle of your surgical treatment consists in the division of the sphinctor ani ; if you do not divide the sphincter, you had better not attempt to treat the patient at all. The operation of dividing the sphincter ani is simple in proportion as you find a ready opening into the rectum. You introduce a small probe-pointed bistouTy into the fistula, pass youi finger up the rectum to meet the instru- ment, and carrying the point downwards, divide the intervening parts. If the fistula is very extensive, you will be under the necessity of putting your finger on the extremity of the intitrurnent, drawing the knife downwards. If the fistula dees not open into the rectum, you must pass the instrument up the sinus until it reaches the extremity ; put your finger into the rectum to meet the knife, place it along the end of the knife, and move the rectum for some little time with your finger nail, and then, cutting through the cellular tissue, bring the point of the instrument into the rentum. A very copious bleeding generally follows the divisioti of the intestine, you most not, therefore, leave your patient, hut endeavour to stop the hemor- rhage by introducing a portion of lint into the wound. No union of the pphincter ani will take place until granulations have arisen at the parts of the wound most distant from the rectum. You should not change the lint for several days, but apply poultices, and merely introduce a probe from day to day, to see that there is no improper adiit-sion. If you were to put fre.sh liut imraedintely, it v/ould excite inflannnation and produce fresh abscesses In the surrounding cellular tissue. On the fourth or fifth day, you may insert a small quantity offresh lint; healthy granulations will arise in about a fort- night, under the treatment I have just mentioned : you may then apply lint dipped in a solution of .sulphate of copper. FISTULA IN ANO. 219 8. A fistula in ano will hardly ever heal of itself, after the operation is performed, without the utmost attention on the part of the surgeon. The sphincter ani is the source of the difficulty in this complaint ; every time the patient has an evacuation, the contraction of the sphincter ani sep- arates one side of the abscess from the other, and thus the process of adhe- sion and inosculation of the granulations is continually destroyed. 9. After the operation, the sore will often assume an indo- lent state, when you think it is upon the point of healing. Injections are often successful. 10. Lastly, fistulas are sometimes cured by the introduc- tion of a ligature, which gradually cuts through the part. A thread is passed through the sinus, brought out by the rec- tum, and tied very tightly. Many persons will not submit to the operation of being cut for fistula, but prefer enduring much greater pain than any occasioned by the operation. la such cases, the introduction of a ligature will sometimes prove successful. DISEASES OF THE TESTICLE. 1. The testicle, like other glandular bodies, is subject to a variety of diseases ; some of which are malignant in their nature, others not so. The afiections of this part, which call for surgical enquiries, are, the hydatid testicle, the scirrhous, the fungoid, the eolarged, and the irritable testicle. HYDATIDS OF THE TESTICLE. 2. Hydatids of the testicle is a disease of no very frequent occurrence, and it affects the young (between the age of sev- enteen and thirty) rather than those who are advanced in years. It is confined entirely to the testicle and epididymis ; and at the first glance bears much the appearance of hydrocele. 3. If begins at the extremity of the epididymis, where it joins the testicle : there is an enlargement of the part which 2S0 SCIHEHUS OP THE TESTICLE. extends through the epididymis towards the vas deferens, and from the epididymus to the body of the testicle. The disease is never attended with pain, unless it acquires a very con- eiderable magnitude. The spermatic cord is a little varicose, but not hard ; the spermatic veins are not larger than usual. There is very little inflam- matory tendency, and the patient can bear the parts to be roughly bandied without pain. 4. This disease is entirely local, and unattended either with constitutional symptoms or danger ; still, hoM^ever, the operation of castration is sometimes required on account of the size to which the complaint arrives ; the patient being unable to conceal the disease, is incapable of going into soci- ety, and will frequently entreat for the removal of the part. It isj]ot on account of the pain that he suffers, or any apprehension that the surgeon need entertain, but on account of the inconvenience to which a patient is exposed, that the operation is usually performed. 5. I am not aware of any instance in which, after the ope- ration, the disease has returned, either in the spermatic cord, or in the other testicle. SCIRRHUS OF THE TESTICLE. 6. True scirrhus of the testicle is a very rare complaint ; it begins in the body of the testicle, with an extremely hard swelling, which may immediately inform the surgeon of the nature of the disease. It feels like a marble body lodged within the scrotum, and it is tuberculated on the surface. It sometimes begins in the centre of the testicle, and gradually extendi until the whole is involved in the disease. The epididymis next becomes the seat of the disease, that portion being first attacked which communicates with the vas deferens. The spermatic cord be(^omes enlarged, and tubercles of various sizes form upon it. After the spermatic cord has become enlarg<;d, a hard tumour forms beneath the emulgent artery, which maybe felt through the abdominal parietcs. Tn true scirrhus, the testicle does not become en- larged to any considerable size. After the swelling in the loins, the thighs become enlarged, and cedemafous on the side of the disease, which arises from the obstruction to absorption ; and the pressure on the veins may also have some influence in producing this effect. FUNGOID DISEASE OF THE TESTICLE. 221 7. Diagnosis : — In hydatids of the testicle, the health is not affected ; but in the present disease, the countenance undergoes a remarkable change ; it is yellow, and sunk, a fixed colour terminates abruptly in the cheek ; the disease is also attended with excruciating pain, which becomes more intolerable as the complaint advances. It is generally from a year and a half to two years before the disease de- stroys the patient. When you cut into a swelling of this kind, you will find it composed of a considerable number of lobes ; and cartilaginous substances, and earthy mat- ter, are frequently deposited in the testicle. 8. Treatment : — After employing the common remedies for the removal of scirrhus, (as recommended under cancer of the breast,) without effect, the safety of the patient de- mands the performance of an operation for the removal of the diseased testicle. 9. 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. This may arise in some measure from the late period at which patients usually apply for relief. If the spermatic cord has not become enlarged, you may, by giving the patient alterative medicines for a length of time, succeed sometimes in preventing the return of the disease after the opera- tion ; it is, however, an operation which is in general, even less successful than that for scirrhous tubejcles of the breast. I have never performed it after the spermatic cord has become enlarged, because I know the disease will be sure to return. FUNGOID DISEASE OF THE TESTICLE. 10. This disease is much more common than the last ; it begins, like true scirrhus, in the body of the testicle ; but, unlike that disease, it almost immediately affects the whole body of the testicle at its first commencement. In a very short time, the epididymis becomes affected ; next the spermatic cord ; and, in the course of a very few weeks, a tumour forms in the loins. The disease is at first unattended with pain ; but when the spermatic cord and the tumour in the loins become of great magnitude, the patient suffers considerably. 222 FUNGOID DISEASE OF THE TESTICLE. 11. The fungoid swelling of the testicle sometimes in- creases to the weight of several pounds j ana usually occurs between the age of seventeen and thirty-five. The appearance of the surface 19 somewhat livid ; the spermatic cord is loaded with biood, and in some parts you may feel a fluctuation, as if there was a cyst within it : it also becomes covered with tubercles of a consider- able size. 12. The tumour has a soft pulpy feel, readily yielding to pressure ; and on the first examination, you might suppose the disease to be hydrocele. It may be distinguished from A?/f titillation in the urethra, as if a drop of urine were contained in it. This directs his attention to the part, and he finds that the lips of the urethra are red, and that there is a slight mucous discharge. Afterwards the urethra begins to be affected with con- siderable heat, and pain is experienced in voiding the uiine, which state is called ardor urinte. The pain increases till it becomes, in many cases, ex- cessively severe ; there is an appearance of threads mixed with the urine, which arises from the adhesive inflammation in the lacunjE of the urethra. The next efl^nct is a considerable diminution in the stream of urine, the swollen state of the urethra contracting the size of the canal. (The urine is often discharged in two, three, or more streams, in consequence of the con- tracted and irregular state of the urethra.) At first the discharge from the urethra is mucous, but after a little time it assumes a purulent appearance, The matter becomes yellow, and if the inflammation is very considerable, green ; and it is often intermixed with blood, so as to give it a sanious ap- pearance. 3. The usual limit of the appearance of gonorrhoea, after connexion, is from four to seven days ; it is seldom under four, and very rarely exceeds seven days. I have known it, however occur within twenty-four hours after -eorraejt- ion : and sometimes a fortnight, or a longer time, will elapse before it ap- pears. 4. The time that gonorrhoeal matter will continue to dis- charge, is quite indefinite. It is said that gonorrhoea will GONOERHGEA. 247 wear itself out ; but it is an assertion which is not to be re- lied upon, for it sometimes continues for so long a time, that even where medicines have been employed, it remains an opprobrium to our art. In no case, ought you to rely on the efforts of nature for its cure 5 for, in general, you may very much expedite it by adopting a judicious method of treatment. 5. Besides the symptoms already enumerated as the ex- ternal effects on the urethra, gonorrhoea takes also an internal course. It does not confine itself to the beginning of the urethra, but extends along the course of that canal, and often produces an erysipelatous inflammation of the glands and freenum, occasioning effusion into the prepuce and phymo- sis. The absorbent vessels on the dorsum penis oflen become enlarged and bard, and produce little abscesses, which go on to suppuration. 6. The glands of the groin are generally sympathetically affected, and, in a first gonorrhoea, seldom fail to become en- larged, and painful. They very rarely go on to the formation of matter, if proper attention is paid on the part of the surgeon. Where the glands of the groin are affected by gonorrhceal matter, sever- al are attacked at the same time ; whereas, in the absorption of the poiaoa of syphilis, a single gland only is enlarged on each side. 7. The other circumstances to be considered, with regard to the internal course of gonorrhoea, are inflammation, strict- ure, chordee, abscesses in the lacunae, &c. Of these we shall hereafter treat. Inflammation, although commencing at the lips of the urethra, Vei^r oflen extends along the course of that canal, so that there will be effu- sion further than the original seat of the inflammation. Irritation and inflammation also takes plice in the corpora spongiosa producing that painful state of the parts, termed chordee, in which the peni« feels as if it were bound down, so as to prevent a complete extension. The penis is sometimes curved, and sometimes turned considerably to one side. Another effect is, an inflammatory state of the muscles of the perinoeum, accompanied with great irritation, and violent spasmodic contractions. 248 GONORKHCEA. 8. Whenever an old man gets a gonorrhosa, it is general- ly accompanied with an enlarged state of the prostate gland ; the bladder becomes affected in consequence of gonorrhceal inflammation ; it becomes highly irritable, and the patient experienf'es a constant inclination to make water. From what we have surmised in regard to the symptoms and results of gonorrhoea, you can very well convince yourself that it produces various effects, not only in its external, but in its internal course. 9. Cause : — The cause of gonorrhoea is undoubtedly inflam- mation of the lacunae of the urethra, and particularly of the lacuna magna, from the previous application of gonorrhoea! matter to the lips of the urethra. The inflammation is of the erysipelatous kind, but there is no appearance of ulceration. If ulcerations were produced, the membrane of the urethra would soon give way. It merely gives rise to a specific secretion from the mouths of the vessels. Ulceration does occasionally take place in the lacunae, but not in the ureth.ra itself. 10. The discharge of gonorrhoea is not unfrequently en- tirely suspended by constitutional causes, but the symptoms will return as soon as the constitutional irritation ceases. A man shall have an abundant discharge from the urethra, considerable pain, and even chordee ; and, if he should get a fever, the discharge dis- appears, the pain ceases, and he will be entirely free from all symptoms of the disease for a period of from seventeen to twenty days ; as soon, however, as he begins to recover from his fever, the discharge of matter will be re- sumed, the pain and chordee will return, and a long time may elapse before the disease will be removed. 11. Treatment .-—You will generally find the cure of gonorrhoea difficult in proportion as the constitution of the patient is disposed to strumous affections. If a patient has pimples on his face, enlargement of the glands of the neck, a thin delicate skin and irritable fibre, you may expect to have great diffi- culty in curing gonorrhoea. 12. The treatment of gonorrhoea is founded on two prin- ciples ; the disease may be either treated simply, by diminish- ing inflammation j or it may be treated by producing a GONORRHOEA. 249 change in the action of the part, by which the disease is re- moved in a short period. Mercury is wholly unnecessary in any form of this disease, and ouglit by no nneans to be used. 13. Your treatment must vary according as the case may be a first clap, or not ; for it seldom happens it can be cured by the same means which may be employed in subsequent attacks. When a patient applies to you for his first clap, there will be generally a great deal of inflan)mation, and I advise you always to purge actively with the sulphate of magnesia and the infusion of senna. You may afterward.s give the sub muriate of mercury, with extract of colocynth, but merely as a purge ; for if it were to act as a mon-urial, I would not give it at all. There is no necessity for giving calomel, unless you wish it to act on the liver, as well a.* on the intestinal canal. Having purged the patient very freely, you will direct him to take plentifully diluent drinks. 14. The diluents, usually recommended in this disease, are very numerous ; but some of them ought not to be used under peculiar circumstances. Two drachms of the carbonate of potash, or the subcarbonate of soda, should be taken in a quart of some diluting drink, in the course of a day : capillaire or tea will answer the purpose very well ; some advise the gum acacia, but whether it does any good or not, T do not know. I have found the liquor calcis a very excellent diluent in this disease. Soda-water is oP ten useful, but it must be ascertained whether it produces irritability of the bladder; for, in some persons, it increases instead of diminishing irritability. ir it increases very much the inclination to make water, it should not be persisted in ; if it does not produce this effect, it is an excellent diluent. 15. Excess of inflammation in gonorrhoea will require your attention and alleviation. The penis should be suffered to hang for a considerable time in warm water, which will relieve the inflammation, and produce nearly all the good effects of a warm bath. When the ardor nrinae, and pain from chordae, is very severe, twenty drops of the liquor potassae, with from three to five grains of conium, in the camphor mixture, may be given wiih considerable benefit. 16. The plan of treatment, already stated, is that which 250 GONORRHCEA. you are to pursue for the first week ; after which period; your remedies must somewhat differ. After that timn, you may apply lint with the liquor plumbi subacetatis dilutus (white wash,) to the part j and at the end of the tenth day, when the inflammation has in a great degree subsided, you may give the balsa- mum copaibae. An ounce of the balsam maybe mixed with an ounce of the mucilage of acacia, and four ounces of the camphor mixture, and a table- epoonful given morning and evening. Having given this mixture for two days, the discharge will be very considerably diminished, and you may then order an injection, and still continue the use of the balsam. 17. Injections ought not to be used in the first instance, but having waited for ten or twelve days, until the inflamma- tion has in a measure subsided, and the extent of discharge di- minished, you may then employ them with benefit and safety. The best injection you can use, is the liquor plumbi subacetatis dilutus: simply at first, and afterwards united with about six grains of the sulphate of zinc to four of the fluid. If, instead of using an injection at the stated time, you suflTer the dis- charge to run on week after week, you will be almost sure to lay the foun- dation of stricture. 18. "We have now gone through the different steps of your treatment for a first attack of gonorrhoea ; but if a pa- tient applies to you for a second or third clap, you will not proceed in the same way, but give him the balsam of copaiba immediately, which will in general put a speedy stop to the discharge. The inflammation of a second clap is comparatively slight, so that the treatment, which is necessary to subdue inflammatory action in a first clap, is in general unnecessary in subsequent claps. AH that is usually required is to give the balsam of copaiba for a week, and then begin with the injec- tion of the liquor plumbi subacetatis dilutus and the sulphate of zinc. 19. Various injections are employed in the treatment of gonorrhcEa : so that if the one you first use does not speedily put a stop to the discharge, it is much better to vary )'^our injection, than to persist in the use of the same, and thereby lay the foundation of stricture. Haifa grain of the sulphate of copper, in an ounce of rose-water, is a pow- GONORRHCEA. 251 erflil injection ; a solution of one grain of oxymuriate of mercury, in twelve ounces of distilled water, makes a very irritating injection. The use of irritating injections must necessarily be regulated by circum- stances ; if they produce much inflammation, you should suspend the use of them ; and if, on the other hand, they excite no paiu at all, you may gradu- ally increase their strength. 20. If these attempts of cure prove ineffectual, I ■would recommend you to begin immediately the use of bougies with injections. The use of bougies will increase the discharge for a time ; but, being com- bined afterwards with the use of an injection of the sulphate of zinc, will generally succeed in effecting a cure. 21. With respect to the number of times the patient should inject, three or four times a day -u-ill be quite sufficient. As to the strength of the injection, it should be increased so as to produce a slight degree of irritation : but it is better to vary the injection, than to in- crease its strength in any great degree. 22. There are other means of curing gonorrhoea, by pro- ducing a change in the action of the urethra, as for instance, by the use of cubebs. Cubeb appears to produce a specific inflammation of its own, on the ure- thra, which has the effect of superseding the gonorrhoeal inflammation. It is a remedy of a most admirable and useful kind, and may be given with advantage even in the inflammatory stages of gonorrhoea, provided the inflammation does not run exc-essively high, [n the early stages when the inflammation is just beginning) it often succeeds in removing the disease in a very short space of time. Although cubebs are so serviceable alone, the greatest advantage may derived from combining its use with that of the bal- Bam of copaiba when the latter is beginning to lose its effect. 23. If Strict attention is paid to the rules Thave laid down for your treatment of gonorrhoea, I think you will find it the most likely course to contribute to the maintenance of your own professional character, and to the welfare of your pa- tient. The subsequent surgical subjects, which we shall now consider, are the consequences of gonorrhiEa. 252 STRICTURES OF THE URETHRA. 1. There are three kinds of stricture of the urethra ; the permanent, the spasmodic, and the inflammatory. 2. Permanent Stricture : — The permanent stricture is the result of a thickening of the urethra from chronic inflamma- tion. An individual having permanent stiicture, first observes a few drops of water remain after the whole seems to have been discharged, then notices a fine spiral or divided stream, and, lastly, discharges his water by drops only. In this last state, for the purpose of facilitating the escape of the urine and preventing its being retained by the lacunae of the urethra, he draws out the penis with considerable force. ^ 3. In cases of stricture, you will find in all stages, that the appearances and nature of the urine will be according to the degree of inflammatory excitement. When the inflammation has extended to the mucous membfane of the bladder, there will be a considerable quantity of mucus with the urine ; the urine, when discharged, is as transparent as usual 5 but, when it has cooled the mucus sinks to the bottom, where it appears ropy, and adheres to the vessel. As the inflammation of the membrane increases, the urine becomes yellow on cooling. When the disease is of a very aggravated nature, the urine will become quite white. If the urine is bloody, it is a proof that the ulcerative process has commenced, and, if not bloody, on the contrary. 4. In that state of stricture when the urine is loaded with pus, the patient has frequent and severe rigors^ or even be- low that state of inflammation. The person will have frequent shivering fits, so that you would suppose he had an intermittent fever, and would probably order him bark. In these cases, however, this medicine has uo eflTect, and you will find opium the remedy. 5. Persons, labouring under stricture, are sometimes se- verely afflicted with piles, and, not unfrequently, direct in- guinal hernia. The last complaint is in consequence of the extreme force that is employ ed to evacuate the urine. StRlCTtJRES OF THE URETHRA. 25^ 6. Seat of Stricticre : — There is no part of the urethra which is not liable to stricture, but most frequently it is found in three situations : first, just at the beginning of the bulb ; secondly, at the membranous part ; and thirdly, in the pros- tate gland itself. A stricture does not always arise from an equal contraction of the urethra all round J for, in some instances the contraction is only on one side. 7. Cause of Permanent Stricture : — The cause of perma- nent stricture of the urethra is inflammation of the chronic kind, and, in ninety-nine cases out of every hundred, it is the result of neglected gonorrhoea. Chronic inflammation occasions a greater determination of blood to the part, and produces a deposition of adhesive matter on the outer side of the urethra ,: the urethra itself becomes thickened, which, together with being pressed upon by the adhesive matter collected in the iiitersticial spaces sur- rounding the urethra, produces the stricture in question. 8. Treatjnent of Permanent Stricture : — There are ttiree principal objects to be attended to : the first of which is, to cure the complaint by dilatation ; the second, by absorption ; and the third, to destroy it altogether. The fiist is effected by mechanical means ; the second, by the influence of medicines ; and the third, by burning it away wjth caustic. 9. The first, or cure by dilatation, is accomplished by means of bougies ,■ from the regular use of which, strictures may be readily cured, and the strictured part of the urethra made to regain its natural size. Bougies are made of either wax, uitgut, or silver ; and they are usually numbered from 1 to 16, according to their dimension, so that the surgeon may, on each occasion, know the size he is using, and the size last used. Catheters are sometimes employed as a substitute for bougies, and answer thr- purpose tolerably well. Catgut bougies are only employed when Iho stricture is particularly small. 10. The wax bougie is the one in general use ; but, for a successful employment of this bougie, there are a few neces- sary points to bear in mind. Never attempt to pass a bougie in its straight state, for, if you do, it will 254 STRICTURES OF THE URETHRA. be obstructed in its passage, whether there be stricture or not ; you should invariably give it, before its introduction, the curve of the catheter. Now, with respect to wax bougies, before introducing them into the ure- thra, you should always warm them by the fire, for the purpose of rendering them soft; when, if they are introduced into the urethra, and pass through the stricture, you will ascertain the distance at which it is situated from tiie orifice, and the form and size of the stricture will be modelled on the bougie. On the following day, you again introduce two bougies, that is, if there be no existing inflammation to prevent it: the first bougie you then use, is to be of the same size as the one with wliich you concluded on the previous day; after this has been withdrawn, you again pass another, a sise larger ; thus using on every occasion two bougies, always beginning with one of the same size as that with which you had concluded on each preceding occasion. 11. Although this is the general practice, T do not alto- gether so well approve of the wax bougie. The bougie I use is made of silver: it is of the form of the catheter, but at the point, and running back for some distance towards the handle, it is conical, and the way F use it is this : — I first pass down, in the manner al- ready described, a wax bougie, for the purpose of ascertaining the size, form, and distance of the stricture. Having obtained a knowledge of these, I then introduce my conical silver bougie, the point of which having entered the stricture, the further it passes, the greater is the dilatation produced, in consequence of the form of the instrument. 12. In endeavouring to pass a bougie, it now and then happens that the urethra is torn through ; and, unless atten- tion is paid to the circumstance, may give rise to a trouble- some extravasation of urine. When you suspect a tear of the urethra, immediately withdraw the in atrument, and desire the patient, if possible, to retain his urine, that it may not irritate the wound, and also to prevent its escaping through the open- ing, and becoming extravasated in the surrounding cellular substance. In this way, you give time for a clot to form over the surface of the wound, a slight degree of inflammation is excited, and it becomes healed by the adhe- sive process, without any further mischief. 13. With respect to burning away strictures with eschar- otics, you must be particularly careful to prevent them get- ting in contact with any other part than where their presence i& absolutely necessary. StElCTTJRES OF THE tJRETHRA. 255 Let me advise you never to use the caustic alkali as a substitute for lunar caustic ; it is much too soluble, and, by running over an extended surface, is calculated to produce a great degree of inflammation. 14. Spasmodic Stricture : — Ari5es either from a contrac- tion of the muscles surrounding the urethra, or from the urethra itself. The spasmodic stricture is usually, T believe, more or less, connected with permanent stricture, and T am of opinion, that the spasms commonly attack the muscular part of the urethra. 15. Spasmodic stricture may arise from various causes, and attacks individuals of all ages. Common accidents will sometimes give rise to it ; even an operation for an aneurism. The complaint usually comes on of a sudden, is unattended v;\ih pain, and the first notice that a patient has of it is, that he experiences a difficulty in voiding his urine. 16. Treatment of Spasmodic Stricture : — This must consist in the introduction of a bougie, and, if necessarj^, other sur- gical and medical means. You should introduce a bougie, letting it steal gently along the urinary pas.sage, and, when it arrives at the strictured part, there let it rest for a short time ; after this, you should gradually push it forward, using only a very slight force, but continuing that force until you have succeeded ia passing the stricture. Let the bougie rest for a minute or two in the stric- tured part, and then withdraw it ; directly that you do so, the person will be enabled freely to pass his urine. If the attempts of introducing a bougie do not answer, other means must then be resorted to ; as calomel and opium ; antimony j tobacco enema ; warm bath and cold bath. 17. Inflammatory Stricture : — This kind of stricture is gen- erally produced by the inflammation of gonorrhcea ; but there is another mode by which it is caused, and that is, the introduction of a bougie. The passing of bougies, although done with care, will sometimes give rise to a violent inflammation of the urethra, 18. Treatrne/it of Inflammatory Stricture : — Under this com- plaint, you must not think of introducing either a bougie or 256 ABSCESSES FROM GONORRHCEAL INFLAMMATION. catheter ; but, by a regular and judicious antiphlogistic treat- ment, you will be able to afford relief. When a person comes to you, having retention of urine, with dreadful pain in the urethra, you should immediately take blood from the arm, in Buch quantities as to produce syncope, administer purgatives, apply leeches to the pp.rinaeum, and put the patient in a warm bath ; you will also, in this complaint, find antimony and opium, in a state of combination, particularly serviceable. 19. The consequences of stricture of the urethra are very numerous. First, in very bad cases, a great dilatation of the urethra behind the stric- ture : — secondly, a considerable thickening of the coats of the bladder: — thirdly, enlargement of the ureters, an effect of there being distended with urine, during the retention common in the advanced stages of stricture ; — fourthly, the kidneys are often diseased, their glandular structure being sometimes entirely destroyed ; — lastly, the prostate gland is frequently en- larged, and abscesses are occasionally formed in it, with fistuiae leading from them to the perinaeum, or parts around, and its natural ducts arc often considerably dilated. ABSCESSES FROM GONORRHCEAL INFLAMMA- TION, &c. 1. Abscesses in the LacuncB : — After the violence of the gonorrhoeal inflammation has subsided, you will frequently find a great number of small abscesses along the urethra. You will frequently feel along the under surface of the urethra, a number of small knotty tumours ; these, in the course of a short time, successively discharge themselves into the urethra, and the swellings tlien subside. Sometimes these swellings break externally to the urctlira, thus forming a double swelling. 2. The most frequent situation of abscesses in the urethra, from gonorrhoea, is the lacuna magna opposite to the frsenum. They likewise form between the lacunee and the scrotum. When you feel an abscess moving about the scrotum, and that abscess occurring after the inflammation attending gonorrhoea, you may be pretty sure that it has been formed in the lacuna?, opposite to the scrotum, and will prove troublesome to the practitioner, and dangerous to the patient ; for in this situation, abscess after abscess will frequently form, until the patient sinks under the long continuance of the severity of the complaint. \ ., ABSCESSES FROJI GONORRHCEAL LNTLA^I^IATIO^'. 257 3. Abscesses in the Perinaum : — The nest situation, in which we find abscesses that are produced from the same cause, is in the perinaeum, giving rise to swellings there, of considerable magnitude. If the mflammation is not checked in its progress, it will gire birth to these abscesses, which, if permitted to remain, will at length, break through the integu- ments, and matter and urine will be discharged through the opening. The passage, leading from the external wound to the internal, is exceed- ingly tortuous, so that upon introdaring a probe, it will not directly enter the urethra; indeed you will find great diSculty in getting jt tjiere, fiom the winding and irregular course of the canal which the matter has formed. The nature of the wound will at once show you that tlie arine may easily become extravasaled into the cellular membrnne of the neighbouring parts. From the pressure vVhicfa these abscesses make upon the urethra, they very frequently give rise to retention of urine. 4. If the inflammation continues to extend, it will be the means of producing abscesses in the follicles of the prostate gland. These likewise will occasion retention of urine, and, upon introducing a catheter to relieve this, it occasionally occurs that the catheter will enter an abscess, and a considerable quantity of matter will pass throogh it before any urine makes its escape ; at length, after the whole of the matter has been evacuated, the cause of the retention having been removed, the nrioe can be freely expelled from the bladder. 5. It occasionally occurs that the two last rarieiies of abscess I have mentioned, by being neglected, have led to the formation of fistula in ano. The true character of the fistula may be learnt by obaerring that a few drops of urine will, at different periods, run frcni it j and' this will cf coarse convince you that it is connected with the bladder. 6. Treatment : — Abscesses of the lacxmae of the urethra, arising from gonorrhoea! inflammation, shonld be continually poulticed until the matter is discharged. After you are satisfied that it has once formed, it is not right to let the ab- scesses break of themselves. When, thereS»re, the hard knot that yon feel 33 . 258 ABSCESSES FROM GONORRHCEAL INFLAMMATION. in the urethra becomes converter! into a fluctuating: tumour, connected with Ihe skin covering it, the sooner you open it tlie better. 7. When the abscesses are situated in the lacunae opposite to the scrotum, the treatment must be exceedingly prompt, for, if it is not, you will endanger the life of your patient. Into these abscesses make early and free incisions ; let your incisions be of considerable size, and a great deal larger externally than internally ; I generally make these incisions in the middle of the septum, at the anterior part of the scrotum. 8. When you are called to cases of abscess in perinaeo, it is necessary that you should be particularly decisive in your management of these complaints, for the purpose of guarding agninst that troublesome and dangerous disease, fistula in perinaeo. If called to a case of abscess in perinaeo, the best plan of treatment that you can pursue is, immediately to introduce a cathexer, mado of elastic g-am ; tliis will relieve the retention, and obviate much irritation ; apply leeches and evaporating lotions to the swelling, and keep the bowels open by cool- ing laxatives. If these means should not succeed in dispelling the tumour, the moment that you can distinctly foei fluctuation, you should make such an opening with the lancet, as will allow the matter to escape, to prevent its burrowing under the skin and producing additional mischief; it will ?ave the patient much pain, and will probably lead to the speedy cure of the disease, whicli might otherwise prove not only protracted, but fatal. Remem- ber you are not only to open the abscess early, but keep introduced in the bladder an elastic gum catheter. 9. In the treatment of abscesses of the lacunae of the urethra and perinaeum, it is of the utmost importance that you should attend to the state of the patient's general health, for these abscesses often form in broken constitutions, and it is impossible to cure them while the system is in a depraved and debilitated state. You should therefore prescribe alterative tonic medicines, nutritive diet, and country air ; attention to the state of the constitution will sometimes cure these abscesses, after every local remedy has failed. 10. Extravasated Urine : — Extravasation of urine, from bursting of the urethra, can never happen without the gross- AFFECTIONS OF THE PROSTATE GLAND. 259 est neglect on the part of either the surgeon or the paiient ; unless, indeed, in the eases of unfortunate sailors, who have been so situated that they were incapable of procuring medi- cal advice. You may see these poor fellows brought into the hospital, in the most lior- rid condition from rupture of the urethra, and the escape of the urine into the cellular membrane of the surrounding parts ; the scrotum is in these cases of a purple cast, and e."5tremely distended ; and when the urine is al- lowed to escape, it will sometimes jirove successful j but, at others, tiie en- tire scrotinn will slough, together witJi a considerable portion of the sur- rounding parts, aad sometimes lead to the death of the patient, 11. Treatment : — This must consist in making an incision for the escape of the urine, and paying attention to the stric- ture, which is the cause of the accident, When you see a case of tliis description, you should immediately make into the scrotum an incision, at least two jnclies in length ; this iucisiou ehouJd he iii a direction ujrmards a.tid backtcards tova.rds the nates. 12. Irritable Urethra : — The irritable state of the urethra, if attended with inflammation, it is of the chronic kind ; and persons suffering under tlie complaint have a freq^uent de- sire to make water. The affection may be readily removed by giving, three times a day, an eighth part of a grain of the oxymuriate of mercury, and a draclun of the aitrous spirit of ether. These should be continued tiw: a little time, aiid the compJainl wiJl disappear. AFFECTIONS OF THE PROSTATE GLAND. 1. There are three species of disease, exclusive of the formation of calculi, by which the prostate gland is affected ; viz. acute inflammation, chronic inflammation or enlarged prostate, and the fungous polypi, 2. Acute Irijfammation of the Prostate Gland ; — This com- plaint is not confined, like the chronic enlargement, to late periods of life, but attacks persons of any age, and generally terminates in suppuration. 260 AFFECTIONS OF THE PROSTATJE GLAND. The mofst prominent symptom which characterizes this complaint is vi- olent pain immediately after discharging the urine, and in this respect, the disease resembles stone. As the inflammation advances, an abscess will be produced in the gland, and retention of urine the consequence. 3. Your treatment, in this case, must consist of blood- letting, and administering mild laxatives,together with antimo- nial medicines. It is also necessary the catheter should be used. You, therefore, pass a common catheter, and about the fourth day you will perceive that matter escapes through it j so that this, coupled with oth- er circumstances, stamps the nature of the complaint. Rigors do not at- tend the formation of this matter. 4. Chronic Inflammation or Enlargement of the Prostate Gland : — This is the consequence of age, and not of disease j and is characterised by a number of symptoms sufficiently particular to distinguish it from stone. In these cases there is sometimes partial retention of urine ; the patient is a long time voiding his urine, which has a particularly powerful smell, arising from its beinir ammoniated in consequence of its long continuance in the bladder. The next symptoms observable are, pain and numbness in the glans penis ; the prepuce not possessing its usual sensibility ; there is a sense of weight and uneasiness in the perinseum, relieved by pressure with the finger ; pain in the back of one or both thighs, in the loins, and at the origin of the sciatic nerve, and course of the ureters ; and the fa;ces are flattened from the pressure which is made upon the rectum by the swollen gland. The urine finally acquires a highly oflTensive ammoniacal smell, and at length becomes white or milky, and, when long retained, brown and even bloody. 5. If the enlargement of the prostate gland continues to proceed for a length of time, it will, in many cases, occasion a complete retention of urine. This may, however, be the effect of retaining more urine in the bladder, and for a longer period, than it ought, or it may be the result of checked perspiration ; but, in either of these cases, exciting a copious perspiration will often afford relief. 6. The prostate gland may increase to an enormous size, laterally, without giving rise to retention of urine ; but the AFFECTIONS OF THE PROSTATE GLAND. 261 enlargement, which occurs posteriorly in the third lobe, fre- quently occasions retention, for the enlargement is situated immediately behind the orilice of the urethra, so that the urine collects behind the swelling, presses it upon the mouth of the urethra, and forms a complete barrier to the passage. From the appearances on dissection after death, as the prostate enlarges, it is pushed forward : in consequence of which, the urethra becomes curv- ed immediately before the apex of the prostate : indeed, the coming forward of the prostate, causes the urethra almost to double upon itself; the curve, thus formed, is at the symphysis pubis, and it is in this situation that the difficulty of passing the catheter in diseased prostate is found. Tracing on the course of the urethra, behind the curved part, that canal is seen much enlarged. The next thing we observe is, that the urethra itself is conside- rably enlarged, that is from an inch and a half to two inches, which increase of length is behind the pubes, and it is owing to this circumstance that you are under the necessity of carrying on the catheter so great a distance after its point has passed the arch of the pubes. We also find the bladder much enlargerl in this disease, as also the ure- ters and the pelvis of the kidneys. 7. "With regard to the cause of retention of urine, in those cases of enlargement of the prostate gland, where the disease exists in the third lobe, it generally arises from the urine having been allowed to remain in the bladder for too long a period ; this collecting in so large a quantity that the swollen lobe is pressed forward against the mouth of the urethra, and thus closes the entrance, to that canal. The enlargement of the prostate laterally, may be readily ascertained by introducing the finger into the rectum ; but the enlargement of the middle lobe cannot be so learnt. In what way then ? Why, by the introduction of a catheter or bougie (and the latter is the best) ; it will be found to stop suddenly ; you are then to introduce a catheter, for the purpose of drawing off the water; the instrument will be resisted in its common course, and you mnst depress the handle a good deal, with a view of tilting its point over the enlarged gland; thus the end of the instrument will be rising per- pendicularly, as it were, behind the pubes. 8. Treatment of Enlarged Prostate : — Your object of treat- ment should be to act upon the gland, by means of small doses of the oxy-muriate of mercury, when the enlargement is the 262 AFFECTIONS OF THE PROSTATE GLAND. only complaint ; but if there is retention, you must relieve this symptom, and afterwards guard against its return. Wlien no urine passes whatever, and when there is great pain at the neck of the bladder, you should take away blood from the arm, apply leech- es to the perinaBum, administer purgatives, and put the patient into a warm bath. If these means should succeed in procuring relief, the best medicine that can afterwards be given for the purpose of preventing a re- turn of the retention, and, at the same time, of lessening the inconvenience which sometimes attends the complaint, is composed of fifteen drops of the liquor putass«e, five drops of the balsamum copaibae, and an ounce and a half of the niistura camphors. This is the best medicine you can use ; it will afford considerable relief, which is all that you can expect, for you must not dream of making a cure. 9. When you are called upon to relieve retention of urine, from enlarged prostate, by the introduction of a catheter, the instrument should be fourteen inches in length, and a quar- ter of an inch in diameter. In consequence of the pressure within, a broad instrument will answer better than a narrow one, for, being bulbous at the end, it will readily ride over the enlargement. When introducing the catheter, you will meet with no difficulty until you reach the curve, which the enlargement of the gland has produced in the urethra; the handle of the instrument is to be here slightly raised, for the purpose of insinuating the point through the curved part. Having pas- sed this, you are then to depress the handle completely between the thighs, so as to occasion the point of the instrument immediately to rise perpen- dicularly above the pubes, in which way, it will readily enter the bladder. 0. In the treatment of enlarged prostate, an elastic gum catheter is sometimes introduced into the bladder, and kept there for a continued relief to the patient. In passing an elastic gum catheter, the removal of the siilette will some- times cause it to enter with ease, when it would not pre- viously pass at all. If it be deemed requisite to leave the catheter in the bladder, I should prefer one of pewter, for it can be curved down before the scrotum, and, by plugging up the end, the patient may move about as he likes, and at any time he wishes, can expel his urine. If a pewter catheter is used, it should be quite new, and ought not to be i PROLAPSUS ANI. 263 worn for a longer period than a fortnight, for the urine acts upon the metal, renders it brittle, and may probably cause the instrument to snap. 11. Fungous Polypi of the Prostate Gland: — The last cir- cumstance connected with the prostate is fungous polypi growing from its base. I am not aware of any treatment that is likely to be successful for the re- moval of this disease : it appears to be entirely out of our reach. PROLAPSUS ANI. 1. This is a complaint in which the rectum protrudes in a greater or less degree at the verge of the anus. It may occur either from mere relaxation of the internal membrane of the hovvel, or from a real displacement and inversion of its upper portion, which presents itself as an external tumour. 2. Causes : — The causes of prolapsus ani may be relaxa- tion of the parts ; irritation of the rectum by the use of alo- etic purgatives ; worms ; hem.orrhoids ; violent exertion for the expulsion of hardened feeces ; and so on. The disease occurs in persons of all ages ; but is most common in infants and elderly subjects. 3. Prognosis: — Considering the degree of the complaint, and the occasional closeness of the stricture, the symptoms are generally mild ; the rectum generally bearing pressure, exposure to the air, and other kinds of irritation, better than any other bowel. The urgency and danger of a prolapsus ani are greatest, when the swel- ling is large, recent, and conjoined with violent pain, inflammation, and fe- brile symi)toms. When complicated with strangulation, the consequences may be a stoppage of the fisces, severe pain, swelling, inflammation, and even gangrene, within thp cavity of the abdomen. 4. Treatment : — This embraces three principal indica- tions ; viz. the speedy reduction of the prolapsed part ; the retention of the reduced bowel ; and the removal and avoid- ance of the causes by which the disease is induced. 264 PKOLAPSIJS ANI. 5. First : — In general, when the case is recent, and the tumoar not of immoderate size,its reduction is readily effected. The patient, being laid upon his back, the finger being covered with apiece of soft linen, oiled, or a cone formed of stiff paper, is to be introduced at the aperture in the prolapsed intestine, when gentle pressure is to be naade until the whole be returned to its original situation, successively pushing back the last protruded portions : — after which a thick compress, so graduated in Bi2e as to adapt itself to the space between the nates, and steeped either in red wine, or in some astringent lotion, as a weak solution of alum, should be bound on the part by means of the T bandage. Should there be much inflammation, fomentations, or the vapour of hot water, should be applied to the parts previous to any attempt at reduction. 6. The second indication may be answered, by rest, and the internal and external administration of tonics, and astrin- gents, more particularly if the disease arises from debility. The reduction having been effected, it is proper to introduce the forefin- ger into the rectum, in order to ascertain, that no interception exists above the anus within the sphincter. The bowel is then to be kept in its place by quietude and the recumbent posture, and if there be a great tendency to relapse, it will be proper to apply to the fundament a piece of sponge, or compresses, supported with the T bandage. The remedies which likewise may be used, are, daily affusions of cold water ^ lotions of a solution of alum, and sulphate of zinc ; glyster of decoction of galls or logwood ; as- tringent injections ; a spirituous infusion of oak-bark with lime-water ; de- coction of oak-bark with alum ; and other tonic and astringent applications. 7. The last indication in the treatment is, the removal, and avoidance, of all such causes as are known to have a tendency to bring on the complaint. In infants, a fresh protrusion of the rectum may sometimes be prevented by making them sit on a high, close stool, w-ith their feet hanging freely down. Every thing tending to cause either diarrhea, or costiveness, should be avoided. 8. "With respect to the still further treatment of prolapsus ani, if the above means fail in effecting a cure, the patient may be relieved by a slight operation. You may make a little incision by the side of the sphincter ani, with a view of producing the adhesive inflammation, so as to glue the rectum to the cellular tissue surrounding it. This cannot, however, be done without danger in certain constitutions. S65 IRRITABLE BLADDER. 1. Daring the last stages of gonorrhoea, it often happens that the patient is annoyed by a frequent desire of voiding his urine, arising from an irritable state of the bladder ^ this symptom at length becomes so urgent, that the inclination occurs so often as every ten minutes or quarter of an hour. The complaint wi.il also proceed from retaining the urine too long. The pain, that the patient feels, is in exact proportion to the quantity of urine contained in the bladder : the greater the quantity, the more severe will be the pain. Sometimes in this complaint, the urine will be mixed with blood ; this appearance is calculated to deceive you, and excite a suspicion of the exis- tence of stone, and induce you to pass a sound, for the purpose of satisfying your doubts : now, in this disease, the introduction of an instrument into the bladder is highiy improper, as it would produce additional irritation. 2. You may readily distinguish this complaint from stone ; for, in irritable bladder, the pain is felt when the bladder is full ; biit in a case of calculus, the pain tortures when noth- ing but the stone remains. Irritable bladder of itself is a dreadful disorder, the patient's life is a burthen to him, he is obliged to keep from society, and linger away his te- dious hours in solitude. 3. Treatment : — Your treatment must be both medical and surgical, for, unless they are combined, you will not avail much ; but your first object should be to keep the bladder in a state of rest 5 nothing can be done without it. To keep the bladder in a state of rest, a short catlieter should he kept in- troduced. A flexible catheter is the one that you are to employ : it should only just enter the bladder, and when sufficient has been introduced, the re- mainder may be cut oil ; it should be tied to a bandage carried between the thighs and round the loins. The instrument thus used will aiford great ease, and keep the bladder at rest by allowing the urine to escape as fast as it streams from the ureters j thus keeping the bladder continually empty In your medical treatment, opium should be given in doses of from one to 23 266 MUCOUS DISEASE OF THE BLADDEK. two grains, with a view of allaying the pain and irritation, and with the same object, five or six grains should be introduced into the rectum in the form of suppository. The liquor potassae with opium or some bitter tinc- ture is also recommended ; castor oil as a purgative ; and after shaving off the hair, a blister should be applied over the region of the pubes: the coun- ter irritation, thus produced, will prove of infinite service. 4. Sometimes irritable bladder goes on to ulceration ; the urine will then be mixed with blood, there will likewise be a discharge of bloody mucus, and the inclination to void the urine will be more frequent, and exceedingly urgent. If the bladder should be ulcerated, you must pursue exactly the same plan of treatment, it is the best that can be adopted : for, by keeping the bladd&i at rest, you afford the sores an opportunity of healing. MUCOUS DISEASE OF THE BLADDER. 5. This disease is known by the discharge from the urethra of an enormous quantity of ropy yellow mucus ; s» thick that it hangs to the sides of the vessel. This mucus is produced from the internal surface of the kidneys, ureters, and bladder. 6. Treatment : — The treatment of this disease, like that for irritable bladder, must also be medical as well as surgi- cal. Introduce a short catheter, as in the last case, and give your patient, one- eighth of a grain of the oxymuriate of mercury, three times a day, and like- wise three times a day you should give one drachm of the nitrous spirit of oether,with an ounce and a half of the camphor mixture : soda-water should be plentifully drunk. But the best remedy that can be given is the balsam of copaiba : no medicine so completely robs the urine of mucus as this. Eight or ten drops, three times a day, will be found quite suflScient: it may be given in conjunction with the medicines before mentioned, or in muci- lage and water. 267 PARALYSIS OF THE BLADDER. 7. Now and then a paralytic state of the bladder takes place. In these cases, the urine will not pass when you in- troduce a catheter, if the patient is in a recumbent posture : but if he stands upright, the pressure of the super-incumbent viscera on the bladder will occasion it to flow in a full stream. The treatment, which I have adopted in paralysis of the bladder, has been blisters to the loins, and the exhibition of a pill twice a day, composed of five grains of the chio turpentine, and a quarter of a grain of powdered cantharides. HEMORRHAGE FROM THE KIDNEYS. 1. It occasionally happens that persons will be troubled by frequent bleedings from the kidneys. In these cases, you must order the recumbent posture to be rigidly adher- ed to, in order to give the vessels an opportunity of closing, and to be con- tinued for some time after this has taken place. The balsamum copaibas should also be prescribed in small doses. The diet low. CHORDEE. 1. A chordee is a painful erection of the penis, during which, it is drawn violently back or to one side. 2. Chordee arises from an inflammatory condition of the pus spongiosum, and the pain is produced by the dilatation of the vessels, from the influx of blood, to cause an erection. When inflammation from gonorrhoea is not confined merely to the sur- face of the urethra, but afiects the corpus spongiosum, it produces in it an extravasation of coagulable lymph, as in the adhesive inflammation, which, uniting the cells together, destroys the power of distention of the corpus spongiosum urethras, and makes it unequal in this respect to the corpora ca- vernosa penis, and therefore a curvature takes place at the time of an erec- tion. 268 HEMORRHAGE OF THE URETHRA. 3. This complaint is exceedingly painful, and is more fre- quent in its occurrence during the night than in the day Your treatment must consist in the application of poultices, fomentations, and leeches. During the night, the penis may be enveloped with linen, wet- ted with the white wash ; evaporating lotions may also be employed. The best medicine you can give is twenty drops of the liquor potassae, three grains of the extractum conii, and ten drachms of the mistura camphorae, three times a day. You may also give a pill every night, composed of a grain of calomel, a grain of opium, and two grains of camphor; this will be found materially to abate the pain, and will be productive of much comfort. 4. Very frequently after the painful erections have disap- peared, there will be a considerable degree of hardness left, but easy of removal. For this purpose you should rub the part with camphorated mercurial ointment, and apply some of the same ointment on silk. 5. Sometimes after a person has had gonorrhoea very se- verely, the dorsum of the penis will become extremely hard, as, upon examination, to feel ossified. This is called chronic chordee. To remove this complaint, you should direct the linimentum hydrargyri to be rubbed on the part night and morning ; or you may order it to be kept covered by a plaster of the ceratum saponis : this acts like a poultice, and when the complaint is recent, will answer the purpose very well ; but when of long standing, you must have recourse to the mercurial liniment, and even this will often fail, owing to the extremely thickened state of the ten- dinous sheath of the dorsum. HEMORRHAGE FROM THE URETHRA. 1. This sometimes occurs from the rupture of a vessel during inflammation ; at other times, and more frequently so, it is caused by the introduction of a catheter or bougie. Treatment : — Press the finger and thumb upon the urethra, deep in the perinseum, and observe if you command the bleeding; if you do not, bring your hand a little nearer towards you : proceeding carefully in this way, you will at last learn the precise spot from whence the blood flows, which INFLAMMATION OF THE TESTICLE. 269 you will generally find to be from that part of the urethra opposite the sym- physis pubis. If you continue to press with your finger and thumb for a quarter of an hour or twenty minutes, the bleeding will cease : but as this would be tedious, and often inconvenient, a compress placed upon the part, and secured by a roller carried round the loins, and brought up between the thighs, will answer equally well, and perhaps better, as it may be worn for an hour or two if deemed necessary. You may give to the patient eome aperient medicine, and, to lessen the disposition to bleeding, you may take blood from the arm. INFLAMMATION OF THE TESTICLE. 1. Inflammation of the testicle and epididymis do not occur from gonorrhoea alone ; but are a frequent result of the in- troduction of a bougie. This complaint, from an error of pathology, used to be called hernia hu- nwralis, in consequence of a belief that it arose from the fluxion of humours to the testicle. 2. Inflammation of the testicle generally shows itself from within ten to fourteen days after the gonorrhoeal 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, aflects the prostate, veru montanum, vasa deferentia, proceeds up the cord to the abdominal ring, then attacks 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 testicle, then there will be felt excessive pain in consequence of the unyielding 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, correspond to the course of the inflammation just now described. 3. Treatment: — This must depend entirely on the violence of the complaint, and whether it will yield to simple reme- dies, or go on to suppuration. First order a suspensory bandage : give the patient two or three calomel and colocynth pills ; and in the morning, a dose of infusion of senna with 270 INFLAMMATION OF THE TESTICLE. sulphate of magnesia. Apply to the testes, a lotion composed of an ounce of spirits of wine and five ounces of water, or muriate of ammonia and wa- ter, and a small quantity of the spirit. These means usually succeed in overcoming the disease ; if they should not, you must take blood from the scrotum,but not by the application of leeches, at least not in private practice, as the mess they make, will probably lead to an exposure of your patient's malady : therefore what I do is this, — 1 direct the patient to stand before me, and, making the skin of the scrotum tense, I open three or four of the veins with the point of the lancet, then by fomenting the scrotum with a little warm water, or directing the patient to stand before the fire, in five or ten minutes you obtain as much blood as is requisite ; and then, by making the patient lie down, the bleeding will immediately cease. The weight of poultices is an objection to their employment ; but fomentations may be pre- scribed with advantage, as they unload the vessels, and act beneficially in the same manner as leeches. At the same time, purgative medicines should be freely given. 4. In some irritable constitutions, even all the remedies which I have named, Avill not be successful ; the pain and in- flammation still continuing, you are under the necessity of employing anodynes ; and it sometimes happens that not- withstanding all we can do, abscesses in the testicle will form. The best form of anodyne is ten grains of the compound powder of ipe- cacuanha with two grains of calomel every night, and sometimes night and morning. If the inflammation goes on to the formation of abscesses, wo must then apply poultices and fomentations, for the purpose of bringing them to a speedy issue. After the discharge of matter, should any sinuses remain, you must inject with a solution of sulphate of copper, in the pro- portion of two grains to an ounce of water ; diluted sulphuric acid is occa- sionally used, but T give the preference to the former. The reason that there is so much difficulty in getting these sinuses to hnal, is that the semen is a fluid which is constantly secreting day and night, consequently the ad- hesive inflammation is interrupted in its progress. 5. There very frequently sprouts out from the sinuses just alluded to, a fungus, though not of a malignant char- acter ; but resembling those shooting from the brain. The treatment consists in paring them off at their roots, and then bringing the edges of the external wound in contact. 271 WASTING OF THE TESTES. 1. This sometimes takes place, and is produced by two causes, absorption and ulceration, and it generally occurs in early age. It is a curious circumstance, that if a boy of fifteen or sixteen gets a go- norrhoea, that it is often succeeded by a wasting of one or both testicles. This effect is not the resuJt of gonorrhoea only ; but any cause, producing inflammation of the testicle, in very young persons, will now and then lead to a similar misfortune. 2. Treatment : — The only course, likely to prevent their entire decay, is probably to employ them, to render them ac- tive, before the whole of the glandular structure has become absorbed. If, however, the inflammation of the testicle has been very severe, that alone is sufiicient to derange the glandular structure in very young persons. I have known both the testicles to waste from the formation of scrofulous abscesses. SYMPATHETIC BUBO. 1. This is usually the result of inflammation of the glands of the penis. The inflammation extends on the outward sur- face of the glands, the absorbents of the dorsum of the penis become enlarged, and, if you rub your finger along the dor- sum, you feel them hardened like a knot or cord, and fre- quently connected with the glands near the pubes. A bubo of this kind rarely suppurates : now and then you will meet with one that suppurates, but only in very irritable constitutions. V/hen the in- flammation extends from the penis to the glands of the groin, these become inflamed also, and enlarged ; and it is not at all surprising for a swelling, after a gonorrhoea, to come on in the groin : a patient under such circum- stances is afraid of bubo, and alarm is excited in his mind of its being syphilitic : you may, however, calm his fears, and tell him that it is a com- mon concomitant of gonorrhoea, and that he need not be uneasy. 2. The distinction between a sympathetic bubo, and one from syphilis, consists in this circumstance : — in general, one 272 GLEET. gland only is enlarged in syphilis ; but, in a s3^mpatliefic bubo, you most frequently find a chain of glands affected. In the gioin, there are two sets of glands, one just above Poupart's ligament, and the other two inches or an inch and a half below it ; the lower is seldom enlarged from sympathy, the upper frequently. 3. Treatmetit : — The plan of treatment in sympathetic bubo is the same as that for inflammation in any other part of the body ; you purge the patient, apply leeches and an evaporating lotion, and advise him to diminish his quantity of exercise. Whether the gland will suppurate or not, depends greatly on the mode of treatment j if mercury be given, it will be hurried into a suppurative pro- cess : therefore it should not be used so as to produce a mercurial action in the system, but connected with aperients it is proper. GLEET. 1. Gleet is a disease very difiicult of cure. It is said to be that stage of gonorrhoea when the discharge ceases to be infectious ; but for my own part, I doubt whether the gonor- rhoeal discharge ever ceases to be infectious ; consequently, I consider, you ought to pronounce that the discharge from gonorrhoea, which terminates in gleet, never loses its power of producing infection. The discharge of gleet is generally transparent at first, afterwards yellow, and if there is much excitement, green. If the excitement is very consider- able, the discharge will be tinged with blood. It is rendered purulent and bloody from excesses of different kinds. 2. The discharge of gleet does not proceed from the vesi- culse seminales, or Cowper's glands, or the prostate, but from the lacunae of the urethra ; and what you hear about seminal weakness is nothing but folly and absurdity j there is no truth at all in it. A discharge now and then comes from the vesiculse seminales, through the urethra: when a person has a costive motion, a drop or two of mucus, or a ropy fluid, proceeds from the vesiculae seminales, and is quite a differ- ent discharge from that called gleet. Sometimes there will be a discharge from a stricture, but it does not produce infection ; and not unfrequently GLEET. 273 you find a discharge from the uretlira, from an abscess of the lacunae, but not of a virile nature. 3. Treatment : — As we have before mentioned, the cure of gleet IS a very difficult thing to accomplish, and you must often make use both of constitutional and local remedies. The constitutional treatment consists in the exhibition of nitric spirits of aether, and the balsam of copaiba j from two to three drachms of the former, a drachm of the latter, in four ounces camphor mixture, combined with an ounce of mucilage, will form the best mixture. A large spoonful of this may be taken three times a day. If this should not succeed, you must give a quarter of a grain of cantharides, (three times a day,) made into a pill, with five grains of the chio turpentine. 4. When the contitutional treatment is unsuccessful, you must have recourse to bougies and injections. A bougie should be passed every other day, according to the irritability of the patient, making use of an injection at tlie same time. Some persons apply to the urethra, the unguentum hydrargyri nitratis ; also the unguentum hydrargyri nitrico-oxydi, which should be diluted : a scruple to an ounce may be used, and gradually increased to a drachm. The best injection is the oxy muriate of mercury, about a quarter of a grain to three ounces of water, to begin with. If it should not, however, be productive of any good, in the proportion of half a grain to an ounce of water; do not use it any stronger, for it is likely to produce considerable irritation. The sulphates of copper and zinc, and the cuprum ammoniatum have also been recommended. 5. Intercourse with women often causes a return or in- crease of gleet. In such cases, it usually gives suspicion of a fresh infection ; but the dif- ference between this and a fresh infection is, that here the return is almost immediately after the connexion. 6. Gleets in women are cured nearly in the same manner as those of men. Turpentines, however, have no specific effect on the vagina ; and the astringent injection used may also be stronger than those intended for male patients. 274 GONORRHCEA, ETC. IN FEMALES. 1. Gonorrhoja in females is rather less violent than in males ; and the seat of the complaint is in Cowper's glands, on each side of the urethra, at the os externum. In gonorrhcBa with females, there is a great degree of surrounding inflam- mation : the orifice of the meatus urinarius, and the lacunse, discharge mat- ter. There is pain in making water, and in some severe cases, it commonly happens that there is considerable irritation of the bladder; of which the shortness of the meatus urinarius is the cause ; the inflammation at the ori- fice extends down the meatus urinarius, to the internal coat of the bladder. The meatus urinarius, Cowper's glands, and the extremity of the vagina, are red, and the carunculae myrtiformes swollen. 2. Treatment : — As to the treatment of gonorrhoea in fe- males, you must depend on diluent drinks, and purgatives, and appease any local inflammation by the use of lotions. We have no medicine which has a specific action over the discharge in females, and the best lotion you can recommend, is the liquor plumbi sub- acetatis dilutus ; a sponge, dipped in this, should be introduced into the va- gina, and be allowed to remain there, though often changed. 3. Pudendal Discharge : — Children from one year old, and even under, up to the age of puberty, are frequently the sub- ject of a purulent discharge from the pudendum, chiefly ori- ginating beneath the preputium clitoridis : the nymphs, orifice of the vagina, and the meatus urinarius, are in an in- flamed state, and pour out a discharge. The bed linen and the rest of the clothes are marked by this discharge, and, from its bearing a strong resemblance to gonorrhceal matter, it has re- peatedly been thought by parents that their child has been injured ; suspi- cion has been excited against some unfortunate person as the offender, and several cases have actually received the punishment of the law for the of- fence of rape, because the medical witnesses were not conscious of the true nature of the affection ; therefore, my young friends, be particularly careful to bear this complaint in mind, and never let it be your's to repent the igno- minious death of an innocent fellow-creature. 4. "When a child labours under this discharge, there is a LUES VENEREA, OK SYPHILIS. 275 heat of the parts, slight inflammation, and this sometimes increases, and goes on to ulceration. Notwithstanding violation has been suspected, from the discharge alone, you must be cautious in admitting the evidence of the child itself 5 for this last paragraph fully shows, that although the parts may be abraded (by ul- ceration) it is no further proof that a rape has been committed. 5. The treatment you must adopt in cases of pudendal discharge is the Kme-"water "vrith calomel, applied to the part : and gire calomel and rhubarb, combined with jalap. LUES VENEREA, OR SYPHILIS. 1. There are two poisons, as I have before mentioned, communicated by venereal intercourse, the one of gonorrhoea, and the other of syphilis. One, the poison of gonorrhoea, which, falling on a mucous surface, pro- duces from that surface, a discharge of matter w-hich is infectious ; the other, the poison of syphilis, which, applied to the skin, or, as far as is at present known, to any surface, produces inflammation and ulceration, form- ing a sore called chancre; which, being received into the glands of the groin, occasions bubo; and, being conveyed into the system, circulates with the blood, produces ulceration on diiferent parts of the body, on the mucous membrane of the throat, the skin, the periosteum, and bones. 2. AVe will first go through the various symptoms or con- sequences of syphilis, and then institute more inquiries on the true nature of the complaint. CHANCRE. 1. The time, at which the eifect of the poison that produ- ces chancre makes its appearance, is uncertain ; the chan- cre, however, generally appears three or four days after con- nexion, and from four to seven days is the average lime. The poison first produces inflammation, then ulceration ; the inflamma- tion is attended by a pimple arising from the surface affected, which is like 276 CHANCRE. a common pimple, excepting that it is of a deeper colour ; instead of being quite florid, it is of a darker hue. The pimple is surrounded by a kind of erysipelatous inflammation ; an ulcer forms in the centre, and then a pit forms in the body of the sore, which is often of considerable magnitude, and extends beneath the skin. The surrounding edges of the sore are hard and ragged, its surface is yellow, and the margin red ; and if you were asked if a sore was a chancre or not, you would answer, I must feel it first, and not decide by merely looking at it. You would then lift up the- part be- tween your fingers, and, if you find a hardness beneath, this would be a very good criterion of its being a syphilitic sore, for it is neither in the ulceration, nor in the yellowness of the surface, nor the ragged edges, but in the colour and hardness of the sore, that the characteristic marks of chancre manifest themselves : from the presence of these, you form an opinion, and are ena- bled to say positively if the sore be a chancre. 2. Chancre assumes very different appearances in differ- ent persons, and also in the same person, under different de- grees of irritation, and according as it is accompanied by more or less of inflammation. So that if you ask me whether it is possible to determine, that a sore on the penis is not chancre, I should tell you, that I believe it impossible for any man positively to say that it is not. 3. We will now speak of the varieties of chancre, and the causes which more frequently produce them. 4. If the poison be applied to a sore, or an excoriation, it produces ultimately a syphilitic action, as is witnessed after- wards in bubo and secondary symptoms ; but it is a long time before the venereal action is excited, and, in these ca- ses, you will find that the sore has neither a surrounding hardness, nor a livid colour. When the chancre is produced by the application of the venereal virus to an excoriation or tear, there is some difficulty in pronouncing its nature ; the sore may have the appearance of being syphilitic, but you must hesitate before you give a positive opinion : it requires time to decide it, and you may say to the patient, that there is considerable doubt as to the nature of the sore : it may be simply an excoriation, or on the other hand, it may be a syphilitic sore : your best plan is, merely to apply some simple application to the part, and wait, if it be syphilis, till secondary symptoms appear, when you must have recourse to mercury for the treatment of the complaint. I cnj^cRE. 277 5. Chancre, situated on the fraenum, is different to -u-hat has been described attacking the other parts. A chancre, in this situation, generally rapidly destroys the part, unless mercury be given early ; it is more irregular in its appearance than chancre in other parts, and does not assume a character similar to those seated on the glans. 6. When a chancre is situated on the prepuce,, it is also characterized by some peculiar symptoms ; and likewise when seated on the corona glandis. If the chancre happens on the edge of the prepuce, a good deal of effusion into the cellular membrane takes place, and ^A?/?fl05-is is produced: when the sore is situated just where the skin doubles over the penis, it is extreme- ly troublesome : there is considerable swelling, also a difficulty in drawing back the skin. In this situation it seldom fails to produce phymosis. If the chancre be on the corona glandis, or between it and the fraenum, you often find it extending deep, and producing sloughing of the part, and even of the glans itself, which is not at all an uncommon result of deep- seated chancre at the corona glandis. 7. Another circumstance, which gives rise to a variety in the appearance of a chancre, is when it ulcerates deeply into the cellular tissue ; a chancre on the surface of the skin is very slightly irritable, but if it passes the skin, and extends into the cellular tissue, it assumes a disposition to ulcerate and slough. A chancre on the skin heals under the use of medicines and external ap- plications ; but, if once it enters beneath the skin, and inflames the cellular tissue, it becomes irritable, sloughs, and is attended with danger, the dan- ger arising when the chancre extends beneath the part on which it began. When chancre is on the surface of the skin, and does not produce deep ulceration, it is a disease slow in its progress, and easy of cure ; but if, on the other hand, it extends deeply into the part, it proceeds with rapidity, and those acquainted with the disease dread it, knowing the extended sloughing which will be produced. 8. Of all the causes of varieties of chancre, one of the most common is the habit and constitution of the patient. The variety is not only produced by the previous mode of living; and the constitution of the patient, but any act of in- 278 CHANCRE. temperance, excess of any kind, or any thing that hurries the circulation, will alter the action of the part. So, if two persons be attacked with chancre, the one not of an irritable habit, and the other being very irritable, you will find in the first that there would be scarcely any inflammation, whilst in the second it would be violent, and of an erysipelatous character j indeed, under' these circumstances, if the patient be not very carefully managed, he will be in considerable danger. So a man with chancre to-day, which has a healthy appearance, shall to- night indulge in some act of debaucliery ; to-morrow he will have a bloody discharge from the sore, inflammation round the edges, and an irritable state of the parts, which you will soon find assuming a sloughing disposition. 9. When a chancre goes on to sloughing, there will be considerable previous inflammation, and a great increase in the frequency of the pulse. The pulse will be generally from 120 to 130 ; the inflammation of the ery- sipelatous kind, extending round the chancre, and, in a short time, the Bloughing process commences, by which the penis is lost. 10. The time, at which a chancre appears after connex- ion, is from four to seven days. If, however, there be gonorrhoea also, it prevents the appearance of chancre so early ; so that if a person is affected with the two poisons, the one delays the appearance of the other. 11. Treatment : — The use of caustic to the part is highly objectionable ; and all that you have to do is to counteract the nature of the venereal virus, by a regular mercurial course of medicine. Order your patient to take five grains of the blue pill, and a quarter of a grain of opium, night and morning j if you exceed this quantity, let him take an additional pill at bed-time. This medicine, continued for three weeks, will be quite sufiicient for the cure of the disease. All that you want to do with mercury is just to keep up a mercurial action on the con- stitution : the patient may pursue his usual avocations ; partake moderately of wine, if so accustomed ; and his diet must be such as will not disorder the bowels, for which reason he should avoid acids and vegetables, but his food may be as usual. 12. In addition to the constitutional treatment of these IRRITATING AND SLOUGHING CHANCRE. 279 cases, I make use of local applications, Tvith the vie-u' of les- sening the irritability of the sore, and to prevent its attack- ing the neighbouring parts. The best application you can use, is the liquor calcis, -with calomel ; the sulphate of copper is too irritating; submuriate of mercury, sprinkled on the sore, is sometimes beneficial, but it is generally too irritating also. The unguentum hydrargyri nitrico-oxydi, I have seen of considerable use after a time ; but it should not be applied at the beginning of the complaint. The unguentum hydrargyri is a bad application, it is too irritating. 13. Sometimes a chancre gets into a very indolent state, and it becomes necessary to use the nitrate of silver, not however "vrith a view to destroy the part, but for the purpose of cleaning the surlace and thickening the edges of the wound. The skia surrounding the part is thin, and by the application of the nitrate of silver, you thicken it, and thus enable it to carry a greater number of vessels to produce cicatrization. 14. When a chancre has healed by your local remedies, you must not discontinue your mercurial course, but con- tinue it for the time I have above stated, to prevent the re- currence of secondar)'' symptoms. It will be proper to heal the sore as quickly as you can, but you must protect the constitution against the effects of the venereal virus, by mercu- rial treatment. IRRITATING AND SLOUGHING CHANCRE. 1. Every now and then a chancre becomes irritable, from causes already pointed out, and there will be considerable attending inflammation. Directly you see a chancre assume an irritable character, you must desist in the use of mercury ; if not, the inflammation will extend. 2. In your treatment, when the chancre has put on the irritable character, lay aside mercury, and have recourse to simple application, such as poppy fomentations and poulti- ces, to lessen the irritation. 280 IRRITATING AND SLOUGHING CHANCRE. After you have purged the patient, give opium combined with the liquor ammoniaB acetatis, or some other saline medicine. In this way you will diminish the irritation j and, when the surrounding injflammation is got rid of, return to the mercury, taking care to discontinue it if the irritability should return. The compound decoction of sarsaparilla may also be given, but not solely relied on. 3. If a person with irritable chancre is guilty of intempe- rance, under bad treatment, or is careless of his health, the sore will slough, and often end in the destruction of the penis. Do not think that it is a rare occurrence for the penis to be destroyed by mercury ; no, a chancre that has remained weeks in a healthy state, shall become irritable, and, by maltreatment, by the injudicious and improper use of mercury, shall siough, and end in the destruction of the penis ; this is not a rare case, and is attributed to the venereal disease, but in reality is an eifect of the improper use of mercury. 4. When you see a sore take on the sloughing appear- ance, the treatment must be changed, and the employment of mercury suspended. What you have to do, is gently to stimulate the part by the nitric acid lotion, in the proportionof thirty to fifty drops of the acid to a quart ^of water. Fomentations and poultices must be sometimes employed, but in general they are not good, they are not sufficiently stimulating j warm spirits of tur- pentine is also sometimes used, and with benefit. You will be obliged to have recourse to a great number of applications, and frequently to change them, before any relief can be obtained. 5. In addition to the local treatment for sloughing chancre, you must support the patient's strength by a nutritious diet ; and give stimulants to assist the efforts of nature, and to in- crease the digestive function and the power of circulation. When the patient is very irritable, opium and the compound decoction of sarsaparilla should be exhibited. When the sloughing extends, ammonia combined with opium, will be found of considerable benefit ; five grains of ammonia, and one grain of opium, three times a day. Musk and ammonia is a very serviceable compound, which has considerable influence in slough- ing chancre. Wine and porter must be allowed ; porter, if the patient is of an irritable constitution, and wine if he is not : they must be given so as to keep up a vigorous action, but not to excite a feverish heat. PHYMOSIS. 281 6. By the means we have now laid down, you will gene- rally put a stop to the sloughing stage of chancre, and es- tablish the patient's health. If the chancre slough early, you should not make use of mercury immedi- ately after the healing process has commenced, but wait for the secondary symptoms. CHANCRES IN WOMEN. 1. Chancres in women are often worse than in men. They attack the external labia, not unfrequently the inside of the nymphaB, and the os externum vaginae. Chancres in women are attended with very little irritation ; but, if they exist in a bad constitution, and extend into the cellular tissue, inflammation and sloughing of the part take place ; and many lives are lost in consequence. 2. The treatment for chancres in women is the same as for males. PHYMOSIS. 1. Phymosis is that state of the prepuce when it is so much constricted as to prevent the glans from being uncov- ered. It sometimes arises from slight inflammation of the cellular tissue, and effusion of serous matter into it ; and it not unfrequently happens that phymosis is the result of chan- cre. Here I will observe, that should you find, during a mercurial treatment, considerable inflammation produced round the chancre, lay aside the use of mercury. 2. Treatment : — The great secret, in the treatment of sy- philis, is knowing when to discontinue the use of mercury ; you should always suspend it when the inflammation is in- creased during its employment ; for, if you persevere in the 34 282 PHYMOSIS. use of mercury, you will only add to the irritation, which will end in the sloughing process, and destruction of the part. If T were to give to a patient, mercury for chancre on the Sunday, and on the following Monday I perceived svcelling and inflammation round the sore, I should immediately lay aside the mercury, give active purges, order poppy fomentations, and the parts to be suspended. The black wash should be applied to the sore, injecting it under the skin, unless it should increase the irritability of the part. After the purges, administer opium in considerable quantities, and, when you have reduced the inflammation, have recourse to the mercury again, but not before. 3. When there is phymosis, together with sloughing of the penis, you must stop your mercurial treatment, order the pa- tient the recumbent posture, and the part to be well supported. In these cases, you must use fomentations and poultices of a slightly stim- ulating kind ; you must support a gentle stimulating action, in order to produce a secretion sufficient to support the power of the part j if you stim- ulate it too much, the part will be destroyed, and if you omit to do it in a slight degree, there will be no separation of the slough. The poultices we generally employ are made with stale beer-grounds : carrot poultices are too stimulating. The medicine we give is five grains of ammonia, with ten of musk, two or three times a day. Forty drops of undiluted nitric acid to a quart of water, is the best lotion you can apply. 4. When phymosis remains after the inflammatory symp- toms have passed away, it becomes necessary to perform an operation for its cure. The operation is exceedingly simple ; it consists in introducing a director beneath the skin, along the glans, till it reaches the corona glandis ; this is the extent to which it should be introduced, so that the point should rest against the inside of the prepuce ; this being done, a sharp-pointed bistoury is to be passed along the director to its extremity, then pushed through the skin opposite to the corona glandis, and drawn out. But when you have done this, you will find that the internal part of the prepuce is not divided as much as the external, which you are obliged to divide a second time. The next thing you do, is to apply a piece of lint round the prepuce, which is to be supported on the penis by tape ; a roller should be applied, so as to make gentle pxessure, for the purpose of preventing a secretion from tlie blood vessels. You let the patient remain as long as he can without making water, in order not to disturb the dressings. When you see him on the following day, PARAPHYMOSIS. 283 you soak the penis in warm water, remove the lint, and draw the prepuce gentl}' over the glaiis. This you should do daily, taking care that the edges of the divided surface do not unite. When the part is quite liealed, a small aperture only is left in the upper part of the prepuce, whicli is of very tri- fling importance. 5. In some cases of phymosis, where the prepuce is natu- rally long, and only a small division of the skin is required to allow of its being drawn back, it is necessary to remove a portion of the prepuce, by circumcision. Operation : — The prepuce is first taken hold of with a nair of forceps, as much of the part being left out, as is judged necessary to be removed. The removal is then accomplished by one sweep of the knife, which, directed by the blades of the forceps, is sure of making the incision in a straight and regular manner. A fine suture is next passed through the edges of the inner aiid outer portions of the skin and the prepuce, so as to keep them together. The only necessary dressings are lint, and over it an excellent poultice. PARAPHYMOSIS. 6. Paraphymosis is a tightness or constriction of the pre- puce from inflammation, so that, after the skin has been pull- ed back, it cannot be again drawn over the glans penis. The skin of the prepuce forming a tight ligature round the penis, just be- hind the corona glandis, strangulates it in the same way as the intestine is strangulated in hernia, 7. Treatment : — The object in your treatment should be to reduce the strangulated part as quickly as possible. The only proper plan to be pursued is this ; you see the penis greatly dis- tended with blood, therefore take hold of the glans between your fingers, and endeavour to empty the vessels by means of gentle pressure. When you have done this for a fexv minutes, you endeavour to reduce it by pushing the glans back, and at the same time, taking hold of the skin of the penis, and drawing it forward. By this plan of treatment you will generally succeed, if you see the case a short time after it has happened. 8. If paraphymosis has existed for some days, it will be wrong to attempt reduction by pressure on the glans. In such cases, jou should divide the strictured part wilh a bistoury. This 284 SLOITGHINGS OF THE URETHRA, ETC. you do by separating the skin on each side, as much as you can from the stricture ; you then insert a director under it, and with a sharp-pointed bistoury divide the stricture, which will allow the skin readily to be drawn over the penis. After the paraphymosis has been reduced, poultices must be applied to the part. SLOUGHINGS OF THE URETHRA, &c. 1. " Sloughing Urethra : — It occasionally happens in syphi- lis, that an opening in the urethra is formed to a considera- ble extent. 2. There are three plans of treatment to be adopted in these cases, according to the circumstances attending the apertures. First: — if the opening is small, a bougie should be passed till there is established a considerable diameter of the urethra, just anterior to the open- ing, to allow the water to pass freely, when the aperture will soon close. Second : — If the opening is large, caustic should be applied round the edges of the aperture, a little nitric acid will do, which produces a slough of the cuticle and cutis ; when the healing process commences, it should be continued once a week till a cicatrix forms, and draws the parts together, and entirely cures the patient. Third : — If the first or second plan of treatment is not available, the next mode is the Talicotian operation, or the bringing a piece of living skin over the aperture. I performed it once, by separating a small piece of skin from the scrotum, and applying its raw surface to the edges of the wound ; this I kept in its situation by three sutures. Adhesive plaster was put over thg whole, and a. gum elastic catheter kept in the urethra. 3. Cicatrized Urethra : — If there is at the mouth of the urethra a cicatrix at all, or the orifice is small, you cannot cure such a stricture in the usual way. You must cut off a piece of bougie, and regularly wear it in the urethra, withdrawing it twice or thrice in the course of a day, to allow the urine to pass off. The object is to excite a suppurative inflammation, and thus remove the stricture ; for when the suppurative process has been excited, the urethra has not the same disposition to contract as before. WARTS. 285 4. Closed Urethra : — Sometimes the extremity of the ureth- ra is closed ; after making water in a stream about the size of a bristle, the opening suddenly closes, and the patient can- not make a drop. If called to such a case, what you do is, not to open the bladder, but you put the point of the lancet into the glans, just at the commencement of the urethra; the urine gushes out by the side of the lancet} and then a bougie requires to be worn, to keep the orifice open. WARTS. 1. Warts were formerly considered as syphilitic, but you are to learn that they are only a local disease, requiring nothing but local means for their cure. It is a common opinion that they are propagated by the blood ; but it is no such thing ; it is by the secretion of matter. 2. Simple local irritation will produce warts. The secre- tion from the glandulse odoriferee, if not cleaned, will give rise to them, or any dirt between the penis and glans. They are also communicated from one person to another. 3. Treatment .-—The plan of treatment you are to adopt must depend upon whether the warts are hard or soft. Soft warts readily bleed and may be easily removed ; the liquor plumbi sub-acetatis ditutus, applied to the surface of them, will remove them : the oxymuriate of mercury will destroy them ; I have used the tinctura ferrimu- riatis, and the black wash and calomel, with good effect. The unguentum hydrargyri fortius destroys them, by producing irritation, inflammation, and sloughing. The hard warts are more difficult to remove : they had better be poulticed first, and then touched with the unguentum arsenicale, which should con- tain a drachm of the osyde of arsenic to an ounce of lard. A few of the warts should be touched with this application in the beginning, and after- wards the whole. It produces inflammation and sloughing of the warts. 4. Sometimes warts will not give way even to these plans of treatment. If they should not, you will then do well to apply the powder of savine and subacitate of copper, which is said to be particularly efficacious. 286 SYPHILITIC BUBO. 1. The venereal poison is taken from the chancre on the penis, to the glands of the groin ; and, in its course, usually irritates one of them. Now and then the matter proceeds through them without producing any irritation, but more frequently it excites inflammation, and the common effects of inflammation, if it is not opposed; that is, if a proper treatment be not pursued, the gland inflames and suppurates. 2. In syphilis it commonly happens that only one gland is affected in either groin ; now and then the contrary takes place ; but, in general, when several glands are enlarged, it is from irritation, and not from the absorption of the venereal virus. When there is only one gland enlarged, and it goes into a suppurating state, it is usually the consequence of the stimulus of the syphilitic virus. Therefore you may conclude, if several glands be enlarged, that it is not the effect of syphilis. 3. The symptoms of a syphilitic bubo are the same as those of common abscess ; with this exception, that there are even- ing exacerbations. A syphilitic bubo may be known from a sympathetic swelling in the groin, by its being in a line with Poupart's ligament; and by the presence or pre- vious existence of a venereal sore on the penis. 4. Treatment : — When you are called on to treat a syphi- litic bubo, you must pursue a mercurial course, as in chan- cre ; and, at the same time you are employing constitutional remedies, local means should not be neglected. The medicine you should give, is five grains of the blue pill, with a quar- ter of a grain of opium, night and morning ; the opium subdues the disposi- tion to an irritable action being set up in the constitution by the mercury; and, when it is given in conjunction with the mercurial pill, j'ou seldom have those direful effects from the syphilitic disease as when the mercury is given alone. If you find the pain in the evening is not subdued, you may give ten grains of the blue pill at night, and five in the morning. For local means I would recommend that evaporating lotions should be applied to the part, a bandage should be put round the waist, and a linen, SYPHILITIC BUBO. 2S7 %x'elted with a lotion, composed of one ounce of spirits of wine to five onnces of water, sliould be kept to the swelling, and fastened to the tape by bandage. 5. It sometimes happens, notwithstanding the means that you employ, the pain, swelling, and the disposition of the gland to suppurate, increase. This will be known by sharp pains darting through the part, and a pulsa- ting feel in it j for when these occur, the suppurative process has generally commenced : you must then apply evaporating lotions and leeches, give ac- tive purges, and omit the blue pill. The best purgative you can give, is, calomel in combination with jalap. When the pain in the part has subsided, you must return to the first treat- ment, which will correct the venereal action. 6. AVhen a bubo acquires a considerable magnitude, it is usually the result of debility, and is very apt to become chron- ic ; when this is the case, you must give up the use of mercury. Never continue mercury when a bubo is large, it will only hurrj- it into a suppurative process ; therefore suspend its use, and endeavour to lessen the size of the swelling and the inflammation by lotions, leeches, and acting on the bowels, in order to promote the secretions, for this should be your grand object in all these cases ; take care, at the same time, to give the kind of nourishment which will best support the system, without exciting any undue excitement. You should also endeavour to promote absorption of the gland by the application of the muriate of ammonia. 7. If the means for preventing the suppurative process do not succeed, suppuration has commenced, and matter can be felt fluctuating ; it will be right to make an opening for its escape. The opening sjiould be small, and ought to be made with the lancet, as soon as any puss can be felt ; by which plan, the surrounding swelling will be lessened, the inflammation diminished, absorption rapidly produced, and then you can return to mercury for effecting the cure. 8. Syphilitic buboes sometimes become very irritable, therefore when you have to treat these cases, immediately discontinue the use of mercury, and have recourse to other means. Tn order to subdue this irritable state of affairs, give opium and the com- pound decoction of sarsaparilla, which have the power of suspending the 288 SLOUGHING BUBO. symptoms of syphilis for a time, but will not cure them. When the state of the swelling will allow, you can return to the use of mercury to complete the cure. SLOUGHING BUBO. 1. If mercury be continued whilst a bubo is suppurating, as sooa as ulceration takes place, the sloughing process will follow, and extend over a considerable portion of the cellular tissue. Destruction of life, in sloughing bubo, takes place from two causes ; from the extent of the sloughing process, and hemorrhage from the opening of the femoral artery. In these cases, you generally see that there is something faulty in the constitution, or that the patient has been injudiciously treated. 2. Your treatment of sloughing bubo must be the same as for sloughing chancre ; entirely devoid of mercury. Exhibit ammonia with opium, and a generous diet, so as to give vigour to the constitution, without exciting any febrile action. The local treatment must princii»ally consist in the application of the nitric acid wash. 3. It sometimes happens when the gland separates, and the sloughing process is going on, that secondary symptoms appear. It is not right to give mercury in consequence of the appearance of se- condary symptoms, but you should order the compound decoction of sarsapa- rilla. When the sloughing process is stopped, and the wound is well, do not give mercury unless the secondary symptoms remain or return. 4. If, after the healing of a suppurating bubo, a ?inus should remain in the groin, you must direct your attention to its cure. This may often be done by an injection of about two grains of the oxy- muriate of mercury to an ounce of water, or the undiluted tincture of lyttse, which will generally bring on adhesive inflammation. If these should not succeed, you must depend on the use of a seton, or laying the sinus open, but this latter mode is very rarely adopted. 5. It occasionally occurs that a gland shall project very much after ulceration, so as to require surgical means for removal. SYPHILITIC AFFECTIONS. 289 Wlien a case like this occurs, when the gland is insulated, and rises abovo the surrounding surface, you get rid of it by means of small troches, made of bread and osymuriate of mercury, which are pointed at the extremity ; these are inserted into the gland, and allowed to remain there twenty-foui hours. Tliis generally brings on a little inflammation, the death of the gland and its separation from th« surrounding part. Sulphate of copper is some- times used. 6. After a bubo has suppurated and ulcerated, it now anc' then assumes the character of what is called a phagedenic ulcer ; the edges of the sore are thin, rugged, loose and irreg- ular, owing to a sloughing state of the cellular n:iembrane beneath it- In these sores, there is an increased number of blood-vessels, over which the skin hangs loosely, and the ragged edges of the wound are ov\ing to a want of action in the part, the blood being retained in it on account of there not being sufficient freedom to carry it into tlie system. 7. The phagedenic bubo arises from the cellular tissue, and it is difficult to give life to it, because it becomes consid- erably excavated and the skin hangs loosely over it. The best treatment you can adopt, is saturated solution of the nitrate of silver; dossils of lint, wetted with this, should he daily applied to the sur- 'face and edges of the wound, and the yellow wash should always be used. Oil-silk should i)e put over the wound, to prevent it getting dry ; for, if it becomes dry, there is great danger of the gangrene spreading. You should give bark and ammonia, in combination with opium, and do all that you can to restore the secietions, for this ought to be the first principle of your treatment. SYPHILITIC AFFECTIONS. 1. The venereal poison, when it passes the absorbent glands in the groin, goes into the system, but, in its course, affects no other glands than these ; it is carried through the thoracic duct to the blood, and when in the blood, it ap- pears to affect but three parts of the body. 2. The three parts of the body, capable of being acted upon by the absorption of venereal virus into the system, are, ^5 290 SYPHILITIC DISEASES OF THE MOUTH AND THROAT. Ihe mucous membrane of the nose and throat, the skin or sur- face of the body, and the bones with their periosteal covering. These three are the only pans liable to the syphilitic action after the virus has entered the blood ; and, with respect to the organs essential to life, these are not capable of having a syphilitic action excited in them ; only in those parts of the body subjected to the influence of external causes, is the syphi- litic action observed; the internal organs are entirely free from it ; the brain, the viscera of the abdomen, and chest, are never affected by it ; eveo the mucous membrane of the interior of the body is not affected by it. SYPHILITIC DISEASES OF THE MOUTH AND THROAT. 1. When the syphilitic action is set up in the mouth, ei- ther the mucous membrane of the floor of the nose, or the roof of the mouth, becomes red and inflamed ; a pimple forms on it, and ulceration ; the bony palate is laid bare, and exfoliates. When the bony palate exfoliates, a commuication is set up through the mauth and nose, fluids return through it, and the voice becomes nasal : there is also a most truly offensive discharge. The tonsil glands become afTected with sores, which have exactly the character of chancre, having rugged edges, a yellow surface, and a livid colour in the surrounding part j a sense of dryness is felt in the throat, which spreads up the eustachian tubes to the ear. 2. When the venereal virus attacks the mouth and throat, it proceeds to the pharynx, and not unfrequently ulcerates completely through it, and the cellular membrane behind, to the vertebra ; but the worst effects of all are produced by its action on the larynx, and, unless immediate attention is paid to it, it will destroy life in a very short period. Attending this last affection, there is also a loss of the voice, so that you are obliged to put your ear to the patient's mouth, he speaks in so low a whisper. This effect of the venereal disease more frequently destroys life than any other. 3. Treatment ; — The treatment required in syphilitic sore throat must depend on the parts under its influence, and the nature of attending circl^mstances. SYPmLITIC DISEASES OF THE MOUTH AND THKOAT. 291 It will be necessary to make use of mercury, if the part is not too irrita- ble, and the sore has no other character than in a healthy person, and does not aifecl the mouth more than is generally done when syphilis appears in any other part of the body- Here, you must endeavour to prevent the dis- ease making those dreadful ravages on the soft palate and superior maxillary bone which require artificial means to close it. 4. Mercurial fomentations are found the most efficient lo- cal means for sores of the palate ; but, if the roof of the mouth itself becomes affected, a little diluted muriatic acid will assist exfoliation, and prevent the aperture from being very large. When an aperture has been produced in the roof of the mouth, [ put a piece of lint into the opening, and the consequence is, that the person does not speak through his nose so much, and is not exposed to the observations of his friends. As soon as the exfoliation has taken place, it will be right to introduce some extraneous substance to fill up the aperture ; and the best instrument I know, is one contrived by ilr. Weiss, of the Strand. 5. When venereal sores exist on the tonsils, local means are not necessary, for a considerable portion of the tonsils may be lost without producing any bad effects ; constitution- al remedies alone are generally employed. With respect to my own treatment, I am always disposed to assist, by local means, the healing of syphilitic sores, wherever they occur. 6. When there is syphilitic disease of the soft palate, nothing can be worn, because any instrument, unless kept near the bone, would excite inflammation. M. Eoux, of La Charite, at Paris, in a case of division of the soft palate, performed an operation, for the purpose of closing the aperture, on the Bame principle as the operation for hare-lip. 7. With respect to venereal affections of the larynx, you' must act immediately on the system by the use of mercury. In my own practice, I use the oxjTnurias hydrargyri, because it is the quickest in its operation. I also make use of mercurial fumigations. Some give the blue pill and opium, but I prefer the oxvmuiiate, on account of its speedy effect. 292 SYPHILIS AFFECTING THE NOSE. 1. The mucous membrane of the nose is liable to be affec- ted by this disease as well as the mucous membrane of the raouth. Ulceration in this part very speedily affects the bones, which afterwards exfoliate, and the patient will be in danger of losing a considerable portion of his nose. 2. The first circumstance, which indicates the existence of the disease, is an incrustation forming in the nose, which, on being removed by the hand, gives rise to a dischorge of blood mixed with purulent matter. In two or three days similar incrustations are formed, and under these, ulceration takes place, which frequently lays bare the bone, and occasions the process of exfoliation. The bones very often separate by exfoliation, long after the syphilitic action has ceased. 3. Treatment : — The treatment of syphilis in the nose is similar to the treatment of it in other parts of the body. The constitutional treatment is precisely the same ; but, in addition to the constitutional treatment, local applications should be employed. Fumigating the part is attended with some advantage ; injecting lotions is also sometimes found to be beneficial. Lotions of diluted nitric or muria- tic acid, may be used with a view of healing the sores, and assisting the process of exfoliation. Fumigations are useful in clearing away the accu- mulated incrustations. Steaming the nose with hot water, assists in separ- ating the incrustations, and affords considerable relief to the patient. We have now gone through the ordinary treatment of this disease ; and if the bones of the nose have not become affected, there will be but little trouble in effecting a cure. 4. Sometimes you will meet with cases in which very considerable difficulties will be encountered, and in which the most horrible deformities will frequently be the result. In general, you are to consider these deformities not of syphilis itself, but of the improper mercurial treatment. The disease usually occurs in the following manner: — apationt uvdprsoes a mercurial treatment, and the sores appear to be cured ; but when the mer- SYPHILITIC ERUPTIONS. 293 cnry ha« been h-fl off for a time, and the person rf^turned to his ordinary em- ployments, h? finds the discharge again appearing in the nose, and, as it be- comes offen-iivp, applies to a medical man. Under such circumstances, it is frequently suiij-osed that he has undergone a treatment which is insufficient for the cure of syphilis, the disease is not yet sufficiently subdued, and he is put under a S'^-'ond course of mercury, and from this erroneous opinion pro- ceeds the .iisea.se in question. The mercury, instead of assisting the exfoli- ation which is sroing on, adds to the inflammation, and produces other and more extensive exfoliations. 5. To prevent the great deformity, -^irhich -^"ill arise in such cases, if an opening be formed through the skin, in the upper part of the nose, a probe should be introduced, to feel for the loose ossa nasi, which should be removed by a pair of forceps. In these cases, the nose will be somewhat altered 5 there wi]] be still some deformity, but not to that horrible extent which ensues, if the skin is allowed to give way in the upper part of the nose. Evaporating lotions should be employed, to prevent ulceration taking place through the skin. SYPHILITIC ERUPTIONS. 1. Syphilitic eruptions are the mildest of the secondary symptoms of the venereal disease, and in general admit of an easy cure. 2. The common character of syphilitic eruptions is, that they are of a copper colour, rising a little above the surface of the skin, and, if they go on to ulceration, form thick in- crustations. Syphilitic eruptions are attended with very little pain 5 an itching, rather than painful sensation, is felt in the part, which increases a little in the evening. 3. There is a greater variety in the character of venereal eruptions than in any other symptoms of the complaint ; not only in appearance, but also in size. In some you will find the eruptions of considerable magnitude, appearing^ as if a (lortiiin of copper skin was laid down upon the surface, but unattend- ed with ulceration. Tn others, you will observe deep ulcerations, with a ragged edge ; in a third, there will be scaly eruptions, covering very large SBT&ces in various parts of the body. 294 SYPHILITIC ERUPTIONS. 4. AVith respect to the parts in which venereal eruptions most frequently appear in the first instance, they are the head, face, and roots of the hair. Incrustations form about the hair of the head, and scabs appear on the forehead, breast, the palms of the hands, and sometimes on the soles of the feet. The palms of the hands are more frequently attacked with venereal erup- tions than other parts of the body, because there is more vigour of circula- tion in these parts ; the parts where the circulation is more feeble, are less liable to be attacked. 5. The treatment of venereal eruptions is very simple ; you must pursue the same constitutional remedies as have been already advised. Give ten grains of the blue pill united with opium, at night, and five in the morning. Five grains of Plummer's pill at night, and half a pint of the compound decoction of sarsaparilla daily, is also recommended. The sar- Baparilla will relieve the symptoms for a time, but the disease will re-appear, and you are never sure that the patient will not return with syphilitic Bymptoms. These medicines must be continued for about two months ; for although the eruption will yield in a short time, unless you continue tho medicine till the syphilitic action is destroyed, the disease will return. 6. Venereal eruptions show ah irritable disposition, as well as other symptoms of the disease, from which the parts will be in danger of sloughing. Whenever this irritable disposition appears, suspend the use of mercury, and give the compound decoction of sarsaparilla alone, in considerable quan- tities. It will be better not to unite the decoction with mercury in any form : if you add any thing, let it be opium and nitric acid. The opium (if it does not disagree with the stomach) has the power of lessening irrita- bility, and the nitric acid has sometimes a specific action on sores of this kind. 7. The local treatment of eruptions will also aid consid- erably in relieving the patient of his troublesome complaint. The best application is mercurial ointment with opium ; an ounce of the ointment, with a drachm of tho extract of opium. This, and the nitric acid lotion, diminish irritability better than any other applications. The epithe- ma composed of the liquor plumbi subacetatis, with the mel ropse and tinctu- ra opii, is often found to be useful. Carrot poultice?, the solution of the SYPHILITIC DISEASES OF THE PERIOSTEUM, ETC. 295 pitrate of silver, and a great variety of applications are employed with the same view. SYPHILITIC DISEASES OF THE PERIOSTEUM AND BONES. 8. The third effect of the syphilitic poison is on the peri- osteum, and on the bones. It first attacks the periosteum, and the bones subsequently become affected. Those bones which are most external, or have the least to cover them, are more subject to syphilitic disease than the deeper-seated ones. The symptoms which attend are as follow: — Some weeks after the chan- cre has healed, the patient experiences in the evening a sensation of pain in the bone, which afterwards becomes the seat of the node. The pain does not immediately produce a swelling ; but, in the course of a few days, a painful swelling appears in the evening, which disappears again on the fol- lowing morning, and leaves no pain. At this time the periosteum only is affected by inflammation ; in a short time, a deposit takes place between it and the surface of the bone; this deposit is, in the first instance, only a serous fluid, but a cartilaginous substance is soon secreted, which is gradu- ally converted into bone, and technically called a node. 9. Treatment : — The treatment of this disease is not dif- ferent from that which is necessary for the other symptoms of syphilis. Give the blue pill united with opium, and simply apply evaporating lo- tions, which will certainly assist in getting rid of inflammation. When the inflammation has ceased, if there is any enlargement of the bone, a stimula- ting plaster, as the emplastrum ammoniaci cum hydrargyro, should be used. 10. Though the treatment of nodes, when attended to early, is very simple, cases sometimes occur in which con- siderable difficulty arises. You will sometimes find a considerable quantity of serous fluid fluctuating between the periosteum and bone, unaccompanied with inflammation and redness of the skin. This may be removed by adding a little to the influence of the mercury. When tire fluctuation, however, is accompanied with an appearance of redness in the skin, and much pain in the part, indicating tlie 296 SYPHILITIC DISEASES OF THE PERIOSTEUM, ETC. presenceof matter, it will be impossible to produce absorption by any means, and the sooner an incision is made do'vn to the bone, the better. The exfe>- liation, which will afterwards take place, will be proportional to the extent of surface laid- bare ; and if you delay making the opening till the extent of irurface affected is very considerable, you will only be adding to the evil, 11. The fiat bones are sometimes the subject of syphilitic action, characterized by the same symptoms as before rela- ted. That which is more commonly afiected than any other is the OS frontis. Tt sometimes happens, when this disease attacks the flat bones, that it f* attended with a very coiiaiderable tumour and fluctuation. No incision should be made under such circumstances. Now and then, indeed, the sup- j)uralive process takes place, and a most serit)us disease is the result. When the skin is inflamed, and matter is formed beneath, it will be right to discharge it. 12. It very often happens, in venereal affections of the cranium, that matter forms on the surface of the bone, and the suppurative process also takes place between the dura mater and the internal part of the skull. The treatment you are to adopt in these cases, is to take out a portion of the exfoliating bone ; and to give immediate relief to the brain, by removing the pressure produced by the matter formed between the dura mater and bone. 13. Whenever you are called to a case, in which exfolia- tion of the bone of the skull is accompanied with symptoms of pressure on the brain, you may infer that matter has formed between the dura mater and bone, and it will be right to apply the trephine. This observation applies not onTy to eases of syphilitic disease, but to all cases of exfoliation of the bones of the skull, accompanied with coma. 14. We have now gone through the consequences of im- pure venereal intercourse ; and as the student, by this time, iias a tolerable knowledge of the results of gonorrhoea and syphilis, we will now pass on to some general remarks of the true character of the latter. 297 GENERAL REMARKS ON SYPHILIS. 1. Syphilis, as v.-e have before observedj is a disease communicated by a peculiarly morbid poison ; the symptoms of which complaint are divided inlo primary and secojidary. 2. Chancre and bubo are the primary symptoms ; sore throat, eruptions, disease of the nose, and nodes, the secon- dary ; and secondary symptoms are the consequences of the absorption of the venereal poison into the system, and its circulation through the blood. The time at which secondary symptoms usually appear, is from eight to sixteen weeks ; sometimes, however, they are protracted, in consequence of the system labouring or suffering under the irritation of another disease, as diarrhoea for example. 3. According to Mr. Hunter, the venereal poison is com- monly in the form of pus or some other secretion. lu most cases it excites an inflammation, which is attended with a specific mode of action, diflFerent from all other actions attending inflammation, and accounting for the specific quality of the matter. 4. The formation of matter, though a general, is not a constant attendant of this disease. For inflammation, produced by the venerea] poison, sometimes does not terminate in suppuration. 5. Venereal poison is very irregular in its effects : and hence, probably, is one cause of a great deal of uncertainty yet prevailing about its distinguishing characters. Thus, as Mr. Hunter mentions, two men sometimes have cnnnection with the same woman, both catch the disease ; but oue may have very severe, the other exceedingly mild, sjmptoms. 6. Mr. Hunter gives it as his opinion, that children could not be affected by syphilis when in utero ; but, from my own observations; they undoubtedly can be, and are. 298 GENERAL REMARKS ON SYPHILIS. Within twenty-four hours after their entrance into the vorld, such chil- dren have the palms of their hands, the soles of their feet, and the nates, covered with copper-coloured eruptions ; and the nails at the same time, generally, be:rin to peel off, and, if care is not taken, the little patient will sink under the effects of the disease. In these cases, you give the mother a quantity of mercury, the influence of which is communicated to the child, through the medium of the milk,aud it becomes cured of the syphilitic disease. 7. A woman during pregnancy cannot be cured of the venereal disease ; you may give mercury, and cause the dis- appearance of the primary symptoms, but, after delivery, the secondary effects are very soon manifested in different parts of the body. 8. To the question, does much inflammation usually at- tend syphilis ? no direct answer can be given ; for the degree of inflammation, vi'hich attends it, is proportioned to the health or irritable state of the patient. In a healthy person, the venereal disease is slow in its progress, and but little inflammation accompanies it ; on the other hand, in the irritable per- son, it is rapid in its progress, and accompanied by considerable inflamma- tory action ; therefore, the differences which characterize the syphilitic dis- ease in various persons, do not asise from any peculiarity of the poison itself, but from the peculiar condition of the person on whom it falls. 9. Mr. Hunter considered syphilis a local disease ; but the evening exacerbations formerly mentioned, fever, sore throat, and copper-coloured eruptions, fully prove that there is a constitutional effect produced by syphilis. 10. "Whether the matter of a secondary venereal ulcer is infectious or not, I cannot possibly say, but, if what I have heard be true, it certainly is capable of propagating the disease. 11. The matter of bubo, as far as experiments have gone, is not infectious ; and for my own part, I think there is but very little difference between the matter of bubo and that of a common abscess. 12. Some persons imagine gonorrhoea and syphilis to be the same disease ; but the experiments which have been in- POLYPI OF THE RECTUM. 299 stituted to illustrate this point, decidedl}' prove the tTvo dis- eases widely diiferent in their true characters. 13 To the question, is chancre curable without the use of mercary ? I should reply, that mercury is not always ne- cessary. Some chancres will certainly not heal without mercury ; and this is more especially the case, when they are deep seated, or of long standing; hut on the other hand, when the sore is slight, superficial, and recent, a wash com- posed of brandy and water, will often cause them to heal without any other application. 14. The modus operandi of mercury has been supposed to be, that of exciting, in the nervous system, a general fever, which overcomes and subdues the syphilitic action ; but it is impossible to mention to a nicety the peculiar action of this specific for syphilis. That mercury cures syphilis is well known ; but though the disease may disappear quickly after using it, remember that it is not cured; you ought to continue it three weeks for a (rhancre ; a month for chancre and bubo ; and in case of secondary symptoms, the patient cannot be safe, unless you continue it for five or six weeks. If it disagrees with the patient, it should either be omitted for a time, or united with other medicines. 15. Is any other medicine but mercury capable of curing syphilis ? This is a question which my own practice enables me to answer, and I strenuously and conscientiously advise you always to give mercury bpth for primary and secondary symptoms, and not trust to any other remedy. The only permanent or successful mode of treating syphilis, is to excite a slight (not violent) mercurial action ; and continuing the mercury for the periods just alluded to : do not produce salivation, for it would rather prove injurious than beneficial. The compound decoction of sarsapacilla, which is so highly spoken of by some, may be used as an auxiliary, but cannot be relied on as a specific. POLYPI OF THE RECTUM. 1. Most mucous surfaces produce polypi, and the rectum among others. Polypi of the rectum generally occur in chil- dren, and very rarely in adults. ^35Sr 300 NASAL POLY?!. The way I would recommend you to remove them, is to draw them down, BO as to bring into view the part of the rectum from which they spring, and when this part is brought into view, to put a ligature round them, and re- move the part below the ligature witli a pair of scissors. NASAL POLYPI. 1. There are four different species of polypi of the nose ; the first and most common, the gelatinous ; the hydatid ; the carcinomatous ; and the fungoid. 2. Gelatinous Nasal Polypi : — Polypi of this description grow from a narrow peduncle, are composed of a very soft substance, resembling jelly, (hence their name,) and are very slightly vascular. A polypus of this kind, is yellow and transparent, very thinly streaked with vessels, which are never sufficient to give it a red appearence. It hangs from the schneiderean membrane by a small peduncle, therefore loose in the nose, and, if you stand opposite the patient, and he draws in and forces out his breath through the nostrils, you will then be able to see it advance, and again retreat, (if not too large) to the posterior nares. It generally has its origin in the middle of the chamber of the nose, between the superior and inferior turbinated bones. 3. Polypi of the nose, of the gelatinous description, often acquire a very considerable magnitude. When this is the case, they extend into the posterior nares, and often hang over the fidge of the velum pendulum palati, so that you can frequently see them at the back of the mouth ; and if they are not quite so large aa to allow of this, they may be distinctly felt on passing back the finger. 4. The remedy for these polypi is extraction by means of forceps ; and you must bear in mind, that, unless the points of the forceps are applied near their basis, you cannot expect to be successful in extracting every part of them ; consequently, they will again form, and the operation be again required. The forceps which you should employ, are long, have small points, the in- sides of which are made rough to prevent their slipping from the peduncle NASAL POLYPI. 801 and thereby losing their hold. The manner of using the forceps is this: pass lip a probe in a direction between the superior and inferior turbinated bones, and foel for, and ascertain tlie precise situation of the peduncle. Having satisfied yourself of the situation of the peduncle, with the probe, then let it remain as a director for the forceps, and having carried the points of the forceps to the peduncle, thus guided by the. probe, seize the peduncle and tear it off by a sudden jerk of the forceps: by adopting this mode, polypi may be effeetually removed. 5. If the person should be very young, and the nose small, you must remove the polypus with a pair of forceps similar to such as are contained in our common pocket instrument cases ; if, however, the polypus should grow^ far back, then you will succeed best with the forceps just named. Sometimes I take away polypi by merely using a pair of probe-pointed scissois. After cutting through the peduncle, if you desire the patient to blow his nose, the air will force it out of the nostril ; but I should fell you that when thus removed, they are more likely to return than when extracted with forceps, because you do not here take away the pituitary membrane, and this is the source from whence these polypi arise. 6. When the polypi extend into the posterior nares, and are very large, so that they can only be felt, but frequently seen, different forceps and a different mode of operation is necessary for their removal. The forceps for such a case should be exceedingly curved. They should be passed to the back of the mouth, then their points or blades are to be carried up the posterior nares, when, having satisfied yourself (in the man- ner lately directed) that you have hold cf the peduncle, you are to break it off by moviog the forceps in a direction downwards and backwards. Another way, when the polypus is large, and when the peduncle grows from the side of the antrum, is to divide it by means of a pair of curved Bcissors, and then with your finger, hook down the polypus at the back of the mouth, from over the velum pendulum palati : in this way it falls into the throat, and produces a sensation of choaking ; retching is the conse- quence, and the polypus will be thrown upon the floor before you. 7. If, after the removal of a gelatinous nasal polypus, you think any portion remains, you should, by means of a probe, 302 NASAL POLYPI. pass up a piece of lint to the spot, to prevent any annoyance from hemorrhage. The lint, previous to its introduction, may be dipped in a solution of alum; indeed, where patients have objected to have this polypus removed by the forceps or scissors, it has been recommended to use injections of alum, and of the oxymuriate of mercury. 8. Hydatid Nasal Polypi : — These are formed by a collec- tion of hydatids, and have the appearance of bags or bladders of water ; with these there is generally a copious serous discharge. They are usually found in young persons. The peduncle of this species resembles the cord formed from the placenta ; it is composed of thin fibres or films, which form the covering of the polypus, and these converge to form and complete the peduncle. 9. The best plan of treatment you can adopt for these cases, is, daily to touch the polypus with the muriate of antimony. This should be carefully done by means of a camel-hair pencil, for a very few times will be sufficient. It acts chemically, and quickly destroys the tumour. 10. Carcinomatous Nasal Polypi : — These have similar symptoms and appearances to scirrhous tumours in other parts of the body, are painful at intervals, ulcerate, and dur- ing this stage occasionally bleed. They are commonly met with in old persons. They are usually attended with severe pain across the forehead, in thp situation of the frontal sinuses ; the passage of the air through the nose becomes obstructed from the size of the swelling ; the tumour also presses upon, and occasionally obliterates the lachrymal sac, preventing the natural course o-f the tears, thus giving rise to the inconvenience and symptoms of fistula lachrymalis. 11. In this complaint, all that you can do will only amount to tranquillizing nature. It is a malignant affection, and will ultimately destroy life. As regards internal remedies, you may give opium in such quantities as shall have the effect of lessening the dreadful pain. Belladonna and opium, also conium, may be applied to the part ; and if the inflammation should be severe, you may apply leeches in the vicinity of the nose, together with evaporating lotions. 8Bt^aiiiia 'iffli'm'llffi''i'' '^fuHi fe' ENLARGED PITUITARY MEMBRANE. 303 10. Fungoid Nasal Polypi : — These are characterized by the general symptoms of fungoid disease in other parts ; and their extensive adhesions preclude the success of their remo- val, either by the forceps, with scissors, or by ligature. In either case, the operation will be useless, and what is still worse, will do injury, by exciting irritation, whereby the disease becomes aggravated. In these cases, I shall, in future, try what effect will be produced by the muriate of antimony. ENLARGED PITUITARY MEMBRANE. 1. This complaint consists of red projections from the nostrils, which are merely an enlargement of the pituitary membrane, and not unfrequently occurs with young children, and, as it bears some resemblance to polypi of the nose, you must be upon your guard. Be assured, when you observe these red projections in the nostrils of young children, that they are not polypi ; the disease is merely an enlarge- ment or thickening of the pituitary membrane. 2. In these cases, there is no necessity for any operation : all you have to do is to touch the projecting parts, by means of a small bougie formed of nitrate of silver : from this ap- plication, they will in a short time turn white, and very soon disappear altogether. ENLARGEMENT QF THE TONSILS. 1. Enlarged tonsils are generally the result of one of the diseases common to children, as the small-pox or measles ; and the inflammation, which produces them, is of the scrofu- lous kind. Children will be brought to you with swellings in their throats, and it will be stated that they have great difficulty of breathing, sleep with their mouths widely distended, the skin, at the same time, being covered with a profuse perspiration. Upon feeling the throat, looking into the mouth, or passing back the finger, it will be readily ascertained that one or both tonsil glands are enlarged. Sometimes the enlarged part is attached to the gland by a distinct small peduncle ; at other times, the base of the swelling is of considerable size. 304 ENLARGEMENT OF THE TONSILS. 2. The treatment, you are to pursue, should be both con- stitutional and local. 3. Constitutional Treatment : — To prevent the growth of these enlargements, and their formation altogether, the best medicine that can be given is the oxymuriate of mercury, combined with the tincture of bark and rhubarb. A very jrood formula is one grain of mercury, in an ounce each of tincture of bark, and tincture of rhubarb. A teaspootiful to be taken in a little white wine, twice or three times a day, according to Ihe age or peculiar state of the patient. By this medicine you will improve the appetite, strengthen the etomach and bowels, and gradually restore the vigour of the constitution. 4. Local Treatment : — The application of the nitrate of sil- ver will often succeed in getting rid of these tumours, as also the sulphate of copper, and even alum ; but the first is the remedy generally selected. In order to apply it, you are to press down the tongue with one finger, then holding the nitrate of silver in its ivory case, between the finger and thumb of the other hand, gently apply it to the surface of the swelling. The application may be repeated, if necessary : where the caustic is appli- ed, the part will soon become white, and scale off. A succession of these, produced by a succession of applications, will often effect a cure. 5. When the tonsils are too large to admit of cure, by the plans already described, or when they resist the proposed method, you must remove them by ligature. It is easily applied, and may be done by first passing it through the eye of a probe, (previously curved for the purpose) then carrying it over the tonsil, bringing it out below, and tie it in front of the diseased gland. Tfyour finger should not be sufficiently long to make the knot, you should then use the tonsil iron, an instrument well adapted to the purpose, and would do much better for performing the operation altogether, than either the probe or finger. If the tumour is not of that form which will admit of a ligature being put on in the way just mentioned, you must then pass the ligature through the centre of the swelling, by means of a needle, and tie it above and below ; your ligature must, of necessity, be double. In this way, you will succeed, as pffoctually as with the other mode, in producing a separation of the en- larged part. !38^-^»^»{a3icgg^aa*ife*?'^^^^^^^^ i 305 HARE-LIP, OR LABIA LEPORINA. 1. Hare-lip is a fissure, or perpendicular division, of one or both lips ; though, occasionally, the fissure is more or less oblique. In general, the division is just below the septum of the nose ; but some- times it corresponds to one of the nostrils. The two portions of the lip are generally moveahle, and not adherent to the alveolary process : in lees common cases, they are closely attached to the forepart of the jaw. 2. Hare-lip is sometimes single, that is, the fissure being only on one side ; sometimes double, a fissure being then on each side ; and occasionally attended with a -^ivant of the teeth in the upper jaw ; also a loss of the pendulum palati and uvula. Sometimes in the double hare-lip, the only thing between the fissures is a small projection of cartilaginous substance, attached to the tip of the nose ; the soft palate, in these cases, is generally wanting, and the turbinated bone exposed. 3. In the operation for the removal of hare-lip, the simple principle is union by adhesion or first intention. The nature of the operation must obviously depend upon its being either a single or double hare lip. Operativn for Single Hare-Lip: — Pare off the edge of the divided lip on each side, by means of a small bistoury: in executing this step of the opera- tion, take care that you cut off enough, for immediately at the margin the parts are callous, and will not readily unite. Having pared off a sufficient quantity of both edges, all that remains is to apply the ligatures, of which two are enough. Introduce one ligature immediately at the edge of the lip, that is, at the lowest part of the divided portions where the red part or line of the lip begins, and the other ligature is to be introduced exactly midway •between the first and the extent of the wound towards the nose. As your object should be to cause the wound to unite as soon a^ possible, anything calculated to retard that effect should be studiously avoided ; and, as wax is known to have a tendency to induce suppuration and ulceration, it should not be rubbed over the ligatuies. Again, the ligatures should not be too delicate, that is, not too thin, — if they are, the lip might be cut through by them. 26 306 HARE-LIP OR LABIA LEPORINA. 4. Having gone through the operation for single hare-lip, we will next speak of the operation for the double hare-lip, and afterwards allude to other circumstances connected with them. Operation for Double Hare-Lip ; — It has been recommended to cut away that portion of skin which exists between the two fissuies. That, hosvever, 13 not the best plan ; indeed, it is a very bad one. Always allow that por- tion of skin to remain, you will find it a great support, and of considerable utility in rendering the oj)eration perfect. Therefore you are to pare the edges of this portion of skin in the same manner as you were directed in the first operation. But you must not, when a hare-lip is double, operate on both sides the same day. You must let one side get well, and then you may operate on the other. 5. When the operation for hare-lip has been performed, and the edges of the lip have been brought together, your best plan is to let the blood remain over the wound ; let it clot there, and not sponge it oS. This will be the best bond of union, and the adhesions which take place under this, seldom give way. Poultices must never be used. 6. In performing these operations, there will sometimes be considerable bleeding from the superior labial artery. There will not be any necessity for applying a distinct ligature to the vessel, because you can easily tie the ligature at the angles of the lip in such a manner as shall compress the artery and stop the bleeding A sep- arate ligature would be highly improper. 7. As regards the time of removing the ligatures, you must be governed by the state in which you find the parts. On the fourth day after the operation, the middle ligature may be removed, and on the fiflh or si.\th, the otlier. If adhesion has ?iot taken place, you must not take away the ligatures on the fourth or fifth day, but you should wait a short time longer. 8. With respect to the age at which you should operate I would advise you never to do so on very young infants but defer it imtil the completion of dentition. Children, when so very young, are not (competent to undergo operations, and you ought not to perform them for hare-lip, unless they have reached the a.ge of two years. After that period they possess some degree of strength, and are much less disposed to irritation and co ivubions. 307 CANCER OF THE LIP. 1. Cancer, occurring in the lip, generally commences with a small crack, which becomes exquisitely painful, and, upon examination, is found to be formed in a small, hard, deep-seated tumour. As the disease advances, the pain becomes more intetise, and is pungent and lancinating ; ulceration ensues, and, if its progress is not timely sus- pended, the life of the patient is endangered by an extension of the disease, first to the glands of the neck, and afterwards to other parts'of the body. 2. Cancer of the lip is of a true scirrhous nature, even at the beginning ; it is hard, has a bleeding surface, everted edges ; and other symptoms indicative of the carcinomatous character. It chiefly afiects the under lip. The disease generally arises fiom the use of a pipe: — The adhesive nature of the clay of which the pipe is made, causes it to adhere to the lip: at length the cuticle becomes torn off, and tlie continued irritation frets the Bore into a true cancerous disease. 3. An operation, for the complete removal of the disease, is the patient's only real hope of succour. Oxyde of arsenic has been employed ; but it very soon produces a rapid dis- ease of the glands, therefore ought to be abandoned. In removing tliis disease with the-knife, you should make an opening in the lip similar to what has been advised in single hare-lip; that is, it should be a triangular portion of the lip, including the disease, entirely cut out: the integuments can be easily approximated, and kept in their proper situa- tion by as many ligatures as the size of the wound shall seem to require : generally speaking, two will be found quite sufficient. The hemorrhage from the inferior labial artery may be stopped in the same manner as was recommended in the hare-lip operation. TIC DOULOUREUX. 1. This is a most dreadfully painful affection of the nerves of the face, but of what nature it is difficult to say. 808 TIC DOULOUREUX. The pain is m general like the pain of electricity — patients will exclaim, " Oh ! I had a shock at that moment." It produces a kind of flittering through the nerves ; its motions are like summer lightning, and the pain cannot be compared to any thing more appropriate than the horrid sensations created by electric shocks. 2. This complaint usually occurs in the nerves of the face, more especially in the filaments of that branch of the fifth pair, which comes out of the infra-orbitary foramen. Sometimes it attacks other nerves. It is not continual, but occurs in vio- lent paroxysms, which vary in duration in diflTerent instances. 3. Of the nature of tic douloureux, nothing, bearing any thing like conviction, can be named. The nerves in this disease are not in an inflamed state, most certainly, fo» under the most horrid suffering they are found of a natural colour: they are not increased, but, on the contrary, are found to be rather diminished. Again, I think the disease to be one of diminished action rather than of in- creased ; and it has been found that stimulating, exciting medicines^ are more beneficial than those of an opposite character. 4. Then, as to the causes of this complaint, we are almost as entirely ignorant. There are a few instances recorded, which appear to be the consequence of external violence, wounds, contusions, and so on. Mr. Abemethy is de- cidedly of opinion that tic douloureux is completely constitutional, arising from general irritability of the nervous system. 5. Treatment : — The best medical treatment you can adopt for cases of tic douloureux is, probably, the adminis- tration of carbonate of iron ; or, if this remedy fails, the use of other tonic and sedative medicines. Stimnfating embrocations, blisters, caustic, issues, fomentations, leeches, friction with mercurial ointment, electricity, opium in large doses, the ar- senical solution, and a variety of antispasmodics, are the principal means which have been tried ; but, for the most part, they only afford paitial and temporary relief. Opium with sulphuric ether; extract of hyoscyamus, valerian, and peroxide of zinc ; belladonna; sulphate of quinine ; arsenious acid ; and extract of stramonium ; have also been recommended, and casea recorded in which they have, severally, been useful. TIC DOULOUREUX. 309 6. If no impression can be made on the complaint by the use of medicines, will the division of the nerve effect a cure? The division of the diseased branch will at least generally succeed in keep- ing off the pain for the space of three Or four months ; about which time it appears that the nerve re-unites, or that its branches anastomoze with each other. In fact it must be confessed, that tlie operation has even failed in aifording relief, much less of effecting a permanent cure. 7. As operations will afford even a temporary relief, you may probably be called upon to divide the trunk of the affec- ted nerve, and even of dissecting out a portion of it, so as to give a chance of entirely cutting off the complaint. But, before having recourse to an operation, you should be sure that the particular nerve, which you are about to expose and divide, is really the principal seat of the disease ; for, when all the nerves of the face generally are affected, or when the branches of the portio dura are especially concern- ed, there is little hope of success. 8. The nerves, which most frequently require the opera- tion, are, the sub-orbitar, the supra-orbitar, and the sub- mental nerves. Sub'Orbitar JVerve .- — Tf it should be deemed requisite to divide the sub- orbitar nerve, it should be done a quarter of an inch below the orbit : the nerve passes out through the foramen, half un inch below, so that you are to divide it midway between the foramen and the ed^'e of the orbit ; if you divide it lower than this, you will leave some branches which will still con- tinue the disease. The proper mode to be adopted for dividing it, is to in- troduce a sharp-pointed bistoury at the distance from the orbit already stated, and, carrying the point of the instrumctit close upon the bone, you hook up the nerve on its edge, then press upon the skin over the edge with your firiger, and, at the same time, withdraw the knife through the opening by which it entered ; in this way, as you take out the knife, the nerve will be divided. You should ask the patient 'f he feels a numbness of the upper lip, and if he should not, your operation will be incomplete. Supra-orbitar JVervc : — When necessary, the supra-orbitar branch is to be divided in a similar manner, by introducing the knife under the integuments of the superciliary ridge, and cutting through the nerve immediately as it emerges from the supra-orbitar foramen, by carrying the point of the knife from the nose outwards. Sub^mental JVerve: — When the sub-mental nerve requires division, you need not make any incision through the integuments, but may perform the operation by placing the knife within the mouth, and directing its point 310 SCROFULA. downwards to the mental foramen, where the nerve passes out, and, by gliding the knife along the bojne at that part, the nerve is eure to be divided. In performing this opeiation, you may direct your knife by ihe bicuspidati teeth, the anterior maxillary foramen being just below them. SCROFULA. 1. Scrofula is a peculiar disease, of an inflammatory char- acter, arising in debilitated constitutions of a peculiar habit. You will find that scrofulous diseases are inflammat«)ry, that tliey undergo all the different processes of inflammation, the adhesive and sufpurativo processes, ulceration, and gangrene ; but gangrene less frequently than any of the others. 2. The inflammation, attending scrofula, diflfers materi- ally from common chronic inflammation ; connected with the latter, there is certain debility, but that debility is the result of intemperance, or change of constitution ; whereas, in scrofulous inflammation, the weakness exists from birth, and the four usual terminations are imperfectly performed. The adhesive matter, secreted in scrofulous affections, instead of being firm, consists of a curd-like matter, easily broken, and very soft'; and this is owing tOjthe blood-vessels not entering it. The suppuration is not of the common kind, it contains curd like matter, and is not truly purulent ; ulcera- tion is slow in its progress ; and granulations are unequal and slow in forming. 3. The age, at which scrofula manifests itself, is during growth ; it is extremely rare for it to occur after. In scrofulous children you will generally find they are characterized by the following symptoms : thin delicate skin ; rosy countenance ; light coloured and fine hair; long eye-lashes; dilated pupils; clubbed fingers; and a thick upper lip. Again, those who are the subjects of scrofulous diseases, often have follicles on different parts of the body, incrustated with inspissated matter. 4. Most parts of the body are subject to this disease ; but some parts do not appear to be so much so, or to be the least aflfected by it. The absorbent glands and joints are most frequently attacked ; the lungs and the brain not unfrequently. The secreting glands are very rarely aflTect- SCROFULA. 311 ed by it, at leaat the liver and kidneys, for the testicles and breasts are ex- ceptions. 5. Scrofula differs in different constitutions ; it may be of an indolent or irritable kind, but more frequently of the first than the second. Soroful;i of the irritable character is a dreadful complaint, for, joint after joint, and various parts of the body become inflamed, whilst in indolent habits, the complaint is sometimes confined to a particular class of ])art3, and the rest are excluded. 6. Scrofula prevails more extensively m temperate lati- tudes than in very hot, or very cold climates. It is also more frequent in some parts of Europe than others ; and, in this country, it has been known to be most prevalent in the counties of Sufiblk and L'lncashire. 7. You will find scrofula considerably influenced by cli- mate, particularly those climates in which the change from cold to heat, and heat to moisture, are most frequent ; and on this account, our own island is favourable to the produc- tion of scrofulous disease. We find cold and moist climates* giving rise to the occnrrence of scrofulous affections, although it is found that those who live in countries where they are exposed to the extremities of heat and cold, are not the subjects of scrofula. It very frequently occurs that children born in warm climates, and su!)3equently brought to this country to be educated, frequonty perish from scrofula. 8. Although we have proof of some climates predisposing to this complaint, and favouring its production more than others, yet the most striking effects are manifested by the changes of the seasons, after scrofula has occurred. Thii^, for instance, ifa child with scrofulous disease be examined in the gprin^, an 1 it has a gland that is inflamed, the complaint will go on, during the spring;, till the summer months, when it will be arrested, and the health of the child improved. *fn this state it will remain till October and No- vember, and then the child will become worse. From this circumstance a surgeon either gains or loses credit in the opinion of the parents, according to the seasons he may first be call-'d upon to administer medical advice. 812 SCROFULA. 9. That scrofula is an hereditary disease appears as clear to me as can be ; and they that deny it cannot have given the subject open and candid investigation. You may prevent scrofula by care, but that some children are originally predisposed to the disease, there cannot be the least doubt; and in such cases, the education and the habits of youth should be so directed as to ward off a complaint, the effects of vhich are so frequently fatal. 10. Although scrofula is an hereditary complaint, there is sometimes a singular intermission in its being developed. Thus, it will occasionally pass over in one generation, and appear again in the next, so that the grandfather and grandson (the first and third genera- tions) shall both be scrofulous, while the intermediate one, which holds the more intimate relation of father and son, and connects the two others to- gether, shall be exempted from any developement of the disease. 11. Scrofula is not communicable from one person to an- other. Neither can it be conveyed into the system by inoculation. The opinion also, that scrofulous nurses may infect children, seems quite destitute of foundation. 12. Causes : — The predisposing cause of scrofula is con- genital, or consists in an original fault of constitution. The exciting causes are those which tend to produce, or rather increase that debility ; such as fever of a specific kind, as measles, scarlet fever, and small-pox. With regard to the state of body in scrofulous children, the blood is less firm, the crasamentum loosely formed, and coagulating weakly; the quanti- ty of serum abundant ; and the solids are feebly formed. 13. Treatment : — The principles on which the treatment of scrofula should be founded are three : First, to make bet- ter blood : Secondly, to strengthen the solids : and Thirdly, to give vigorous action to the circulation. To one or all of these principles, every mode of treatment should be re- ferred. The action of the heart and arteries is naturally feeble, the serum of the blood preponderates, whilst the fibrous portion is deficient in quantity, therefore you must fulfil the indications just alluded to. 14. The two first indications are to be fulfilled by paying SCROFULA. 313 particular attention to the diet. Medicine is a secondary consideration, and certain!}' may be used wiih advantage as an auxiliary. In diet do not allow vegetables ; but let meat be taken in small quaritities and often, for when flie stomach is but little leaded, digestion g-oes on bf tter. Some slight stimulant, as good beer or wine, should be allowed also. Milk lor breakfast I do not approve of. Animal fooonftil of which sl.ould be given twice a day in a glass of the chpmomile infusion. If the bowels are costive, the tincture of riiuharb slwuld be substituted for the tincture of bark. The liquor potassse is also used. Tl.-e medicines whirli I employ, are the steel, with rhubarb and ciiloniel, or the subcarljonate of soda, witJi rhubarb -i.; J calumba. 27 dl4 SCROFTTLOirs AFFECTION'S. 17. A great deal of care should be taken of children ori- ginally formed weakly : you should excite no feverish action on the one hand, nor do any thing to debilitate on the other. Such children should be well clothed, and never exposed to ehanges of temperature. For this purpose they should wear flannel close to the skin j end, in this case, it should be worn also during the night. If the weather be very warm, calico may be substituted for flannel. The great object is to preserve an equal temperature of the skin, and not to produce perspiration, because that would debilitate. It is right to recommend sea-bathing: the bath should be taken about three times a week, at eleven in the morning. The temperature of the bath should be at 94°; the person should remain firom sixteen to twenty minutes in it, and walk afterwards. SCROFULOUS AFFECTIONS. 1. Having given you a general description of scrofula^ we shall now proceed to treat of the several parts attacked hy this disease. GLANDS OF THE NECK. 2. Of the different absorbent glands, those of the neck are most frequently affected by scrofulous disease, owing to their being so much exposed, and consequently so much influ- enced by the changes of the weather and the seasons. Now, when you are consulted in a case of this kind, the symptoms you find are as follows : — In the first place, you learn from the child's mother, that she at first observed a swelling in the neck, which was small, hard, and not painful, nor in any way discoloured, but tender to the touch. Thus the inflammatory process does not go on to the rapid destruction of the part, for the rvvelling will frequently remain in this state of indolence during weeks, months, and sometimes years. 3. It is a general character with these tumours to remain in an indolent state for a length of time ; but owing to acci- dental circumstances, or changes in the weather, or the state of the constitution, the complaint proceeds with great rapidity. If the complaint occurs in a person of irritable habit, it will advance with rapidity; if, on the contrary, the person be of an indolent habit, it will be slow in its progress. SCROFULOUS AFFECTIONS. 315 4. "When suppuration takes place, there is much pus pro- duced ; its formation is characterized by the common symp- toms of suppuration, but in a much milder degree than are usually met with. In these cases, the suppuration is weak and languid, and it is a long time before matter forms. The suppuration is very imperfect, the pus has not the true character of purulent secretion ; it is composed of a curd-like mat- ter, and resembles pus mixed with blood. When suppuration is about taking place, the skin at first has a blush of inflammation on it, then becomes of a livid or purple hue. It frequently happens when the skin is in this state, a long time elapses before it gives way. When the skin, however, bieaks, it generally separates to a consid- erable extent. 5. Treatment : — In the treatment of enlarged scrofulous glands of the neck, you must be regulated according to cir- cumstances. If the complaint be of recent occurrence, you ftiust treat it like a case of common inflammation. You will give rhubarb and calomel internally, and recommend evaporating lotions as local applications. The best lotion you can use, is the liquor plumbi subacetatis, with spirits of wine and water. 6. These glands, however, are apt sometimes, notwith- standing all the means you employ, and all the care that may be taken of the child, to go into the suppurative stages. In this case, you must give rhubarb and carbonate of soda, twice a day, together with a small quantity of the hydrargyrum cum cretd, (one grain,) three or four times in the twenty-four hours. 7. You must next consider what local treatment to em- ploy if the gland suppurates. You find there is a disposition to suppurate, evaporating lotions will not succeed, and therefore must be discontinued. The moment there is the slightest blush on the p^t, and sense of fluctuation, indicating the presence of pus, you should make a small opening with a lancet, as in a common ab- scess ; you should not wait for the skin to assume a livid hue ; for then you will never be able to prevent scars. 8. Scars in the neck ought by all means to be avoided, if possible ; but the reason why they are so frequently met with, the surgeon waits too often, till the skin has become livid, and then makes a puncture. 316 SCROFULOUS AFFECTIONS. Tn this case, he gains nothing by making an opening into the gland ; in fact, if the skin be of a livid colour, I advise you then not to maki; an open- ing j apply poultices, and let nature effect the opening, for the scar will not be so great then, as if you were to make it. 9. When you are about opening these tumours, you must remember first, the time at which you are to make the punc- ture, and the direction in which it is to be made ; and, sec- ondly, do not omit to squeeze out all the solid matter that may be within the gland. The instrument, with which T open these abscesses, is a cataract knife, and T make the incision transversely, and just in the direction of the creases of the neck ; so that when the wound heals, no scar is to be perceived. When the matter is discharged by puncture, apply your finger to the side of the swelling, and squeeze out all the solid matter that may be contained in the gland. If the sac be not carefully emptied of all the solid matter, this substance will keep up considerable irritation, and prevent the healing of the wound ; therefore I wish to press on your attention the necessity of attending to this point. If the wound be indolent afterwards, you had better inject into it a solu- tion of the sulphate of zinc, containing about a scruple of the zinc to a pint of water. Throw a little of this into the wound ; it will soon produce heal- thy granulations, and lessen the discharge if it be copious. 10. With respect to the ulcerative process, there is noth- ing particular to remark ; fomentations, poultices, and the ordinary means, must be had recourse to. Your object, however, should be to prevent ulceration by the rrode of treatment I have laid down, and it is only when it cannot be prevented, that the latter means should be employed. THE MESENTERIC GLANDS. 11. The glands, which are affected with scrofulous dis- ease next in frequency to those of the neck, are the mesen- teric glands. In young persons, they are most commonly affected at the age of six or eight months. The complaint is known by the belly being tumid, and from the tenderness on pressure ; attenuation of the skin, voraciousness of appetite ; the limbs of the child at the same time wasting. The intestines are equally irregular, being sometimes purged, at others costive. In the motions are occasionally observed earthy matter composed of carbouate of lime. SCROFULOUS AFFECTIONS. 317 12. The causes which produce enlargement of the mes- enteric glands arise from disease of the secreting glands of the intestinal canal, such as irritating food, which irritates the mouths of the absorbent vessels of the intestines leading to the mesentery. WitI) re-ipsct to tiiG eflfects of mesenteric diseases, they consist at first in an interruption of the process of absorption. The chyle travels through the absorbents to the mesenteric glands, and, when some of these are enlarged, the chyle is interrupted in its course. 13. Treatment : — In this, yonr main object must be direc- ted to giving highly nutritious food, for, absorption being to a great degree prevented, it is important nothing but what is very nutrient should be given, so that the constitution may be improved and supported. Animal foot is more nutritious than vesetable food, therefore you give it in preference to the last, and prepared so that it may be easily digested. A little arrow-root may be taken, and nutritious broths. When animal food is given, it is desirable to give some wine and water, to stimulate the Btomach to secrete the gastric juice, and to excite the action of tlie intestines. In excitin? the iiitestines, you have a two-fold ohjrct in view : stimulating the absorbents, and producting the peristaltic motion of the intestines. 14. In addition to nutritious food, it is well you should employ some tonic and alterative medicines ; and external applications to the abdomen. The best medicine in this disease, with \vhich I am acquainted, is the oxy- muriate of mercury, given in small doses, and in combination \vith the tinc- ture of hark; one grain of the oxymuriate in two ounces of tincture of bark; or should the bowels be costive, in the same quantity of tincture of rhubarb. The hydrargyrum cum creta and rhubarb, given so els to produce an aperient effect, are good medicines. The osymuriate of mercury should be given with no other view than to improve the secretions from the liver and intestines, and thus produce one stool a day. The abdomen should be covered with a stimu'ating plaster, or frequently rubbed with the hand, in order to pro luce a gentle action m the ptirt and excite the absorbents. 15. Dropsy is sometimes connected with this disease. Then paracentesis should be performed, and the patient gets well. 16. Now and then a mesenteric gland suppurates, opens §18 Scrofulous affections. at the navel, and frequently comnmnicates with the intes- tines, and thus an artificial anus is produced. In these cases where tliere is an artificial anus, a large proportion recover. Poultices should be applied over the opening, and when the inflammation is subdued, strips of adhesive plaster should be applied so as to bring the edges of the wound together, but not until you think all the matter has been discharged from the gland. DISEASES OF THE JOINTS. 17. Scrofulous diseases of joints vary in their character, according to the stage of the complaint. It generally hap- pens, after a child of a strumous habit has walked a consid- erable distance, that it complains of pain in the joint • which is accompanied with a stiffness and inability to move it. Under these circumstances the parent takes alarm, and I may * — A dislocation of a carpal bone is of very rare occurrence, and generally happens from a person, when falling, receiving the weight of the body on the part j and it is also sometimes attended with a fracture. DISLOCATIONS OF THE CARPAL BONES, ETC. 351 In these cases, straps of adhesive plaster should be braced rather tightly about the wrist, to support and strengthen it; and over these you should pass a bandage, which would afford it additional support. Pumping cold water, from a considerable height, is also very useful, and rubbing the parts afterwards with a coarse towel, gives vigour to the circulation, and increases the strength of the joint. Sometimes ganglia are mistaken for dislocations of the carpal bones, but these are easily removed by striking them smartly with the flat surface of a book, and the supposed dislocation immediately disappears. 80. A compoTind dislocation of the carpal bones frequent- ly occurs ; it arises, generally, from the bursting of guns, or the hand being cut in machinery. In these cases, one or two of the carpal bones maybe dissected away, and the patient recovers without losing his hand, and also preserves a consider- able degree of motion in the part. If, however, greater injury be done, am- putation is generally required. 81. Metacarpal Bones : — I have seldom seen the metacar- pal bones dislocated, except as the result of excessive vio- lence. They are so firmly connected with the bones of the carpus, that great force is necessary to separate them, and so much injury is done to the parts that amputation is gen- erally necessary. These cases usually happen from the bursting of guns, or passage of heavy bodies over the hand. If it should happen that the metacarpal bones of the middle and ring fingers require to be removed, you may bring the fore and little fingers so nicely together, as to produce little deformity ; that is, if you can succeed in procuring union by adhesion. 82. Fingers and. Toes : — Dislocation of the fingers and toes are accidents of rare occurrence ; for, in addition to their capsular and lateral ligaments, their articulations are power- fully strengthened by the extensor and flexor tendons. 83. "When dislocation of the fingers takes place, they are more frequently found between the first and second phalan- ges, than between the second and third. A dislocation in this place can be readily ascertained by the projection of the first phalanx backwards, while the head of the second can be felt on the fore part less distinctly. 352 DISLOCATIONS OF THE THUMB. 84. If the finger has not been dislocated many hours, you can easily reduce it ; but if it has been neglected at first, the reduction can only be accomplished by long-continued and steady extension. I would not advise you to divide the ligament of the joint in order to facilitate its reduction ; but recollect that you are to give the joint a slight inclination forwards to relax the flexor muscles. After the reduction, the finger should be rolled with tape, and surrounded and supported with pasteboard, till the lacerated ligaments have united; care being taken to keep the hand and fore-arm in a sling. The dislocations of the toes are rather more diflBcult to reduce than the fingers, as the phalanges are much shorter, and the parts less easily moved, from their being less stiff. 85. A toe or finger is sometimes thrown out of its natural situation by the flexor tendon and theca, or even the palmar fascia becoming contracted. When the thecae are contracted, nothing should be attempted, as no ope- ration will succeed ; but when a thickened band of fascia appears to be the cause of the contraction, it may easily be divided by a pointed bistoury in- troduced through a very small wound in the integument. The finger should be then extended, and kept in this position by a splint. DISLOCATIONS OF THE THUMB. 86. The dislocations of the thumb are four in number, and, on account of the numerous strong muscles inserted about it, they are very difficult to reduce. 87. Metacarpal Bone : — The metacarpal bone is sometimes dislocated from the trapezium ; and it will generally be found that it is thrown inwards between the trapezium and the root of the metacarpal bone of the forefinger. Considerable pain and swelling are produced by this accident, but it may be detected by the protuberance forwaid towards the palm of the hand, by the thumb being bent backwards, and not allowing of its being brought to- wards the little finger. DISLOCATIONS OF THE THUMB. 353 88. With respect to the reduction of this dislocation, if the bone cannot be reduced by simple extension, it is better to leave the case to the degree of recovery which nature will in time produce, than to run any risk of injuring the nerves and blood-vessels by dividing the muscles or ligaments. What I have before said respecting the relaxation of mnscles inserted into a dislocated part, is particularly necessary to be attended to here. You know that the flexor muscles are more strong than the extensors, and you will, therefore, very much facilitate the reduction by giving the thumb a little inclination towards the palm of the hand ; in this manner the flexors may be relaxed, and their resistance diminished. The extension must be steadily continued for a considerable time, as no sudden violence will effect the reduction. 89. A compound dislocation of the metacarpal bone of the thumb is sometimes produced by the bursting of guns ; but, in these cases, you can easily return it to its natural situ- ation ; and, if the flexor tendon should have escaped unhurt, the person may recover useful motion of the part. You should bring the integuments together as nicely as you can, confine them by a suture if necessary, and over this put a piece of lint dipped in blood, which is the best application j if necessary, you must apply a poul- tice, but wheu the bruise has not been considerable, it will heal by the ad- hesive process. 90. First Phalanx : — Tn the simple dislocation of the first phalanx of the thumb, you will find it thrown back npon the metacarpal bone, where it forms a projection ; and the lower part of the metacarpal bone projects inwards, towards the palm of the hand In this case, the thumb may be brought towards the fingers, but the flex- ion and extension, which are performed between the metacarpal bone and the first phalanx, are prevented by the dislocation. 91. In the reduction of this bone, as in the last case, the direction, in which the extension is to be made, must be at- tended to. The thumb should be bent towards the palm, in order to relax the flexor muscles, and the mode of applying 30 354 DISLOCATIONS OF THE THUMB. the extension is that which I would recommend to be gener- ally adopted in dislocations of the toes, thumb, and fingers. In order to relax the parts as much as possible, the hand should be soaked for a considerable time in warm water, a piece of wetted wash leather is to be as closely wrapt round the first phalanx as possible ; a tape, about two yards in length, should be fastened on the leather with a knot which will not slip, such as the sailors call the clove-hitch. An assistant should now firmly press on the metacarpal bone, by putting his middle and first fingers between the fore finger and thumb of the patient, and thus make counter- extension, whilst the surgeon, assisted by others, draws the first phalanx from the metacarpal bone, inclining it, at the same time, a little towards the palm of the hand. 92. If the efforts, made in the way just described, after having been continued fifteen or twenty minutes, do not suc- ceed, then it will be necessary to adopt another plan. In addition to the apparatus already employed, let a strong worsted tape be carried between the metacarpal bone and fore-finger, bend the fore-arm round a bed post, and let the tape be firmly tied over it, so as to prevent the hand yielding when extension is made. To the tape, surrounding the first phalanx, a pulley is to be applied, and extension made, which will generally succeed. 93. With the greatest care and attention, and with the most persevering efforts, you will sometimes fail in reducing this dislocation, where it has been neglected, and much time allowed to intervene between the occurrence of the accident, and your attempts at reduction. Although this may be the case, no division of the parts should be made, as the patient will have, after a time a very useful thumb. 94. In compound dislocation of the first phalanx, if the wound is large, and much difficulty is experienced in the re- duction, I should recommend the removal of the part. I would advise you rather to saw oflf the extremity of the bone, than injure the parts further by the pressure which would be necessary. Lint dipped in blood should be applied to the wound, a roller lightly passed round, and evaporating lotions should be used for several days, until the wound be healed. If passive motion be begun early, a very useful joint will be formed. •nmtmmmmmmm DISLOCATIONS OF THE LOWER JAW. 355 95. Second Fhahnx : — A simple dislocation of the second phalanx is more easily reduced than a displaced first phalanix. It is best reduced by grasping firmly the back of the first phalanx with your fingers, and placing the thumb on the fore part of the dislocated pha- lanx, then bending it on the first as much as you can. In this way you may lift the second over the lower part of the first phalanx, by making your thumb the fulcrum. 96. When there is a compound dislocation of this joint, your treatment must be similar to that for a compound dislo- cation of the first phalanx. In addition to the sawing off the ends of the bone, you should pare the ends of the tendon smoothly with the knife, and, if you then bring them together, they will unite. Passive motion should be begun at the end of a fortnight or three weeks. DISLOCATIONS OF THE LOWER JAW. 97. The lo\rer jaw is subject to two species of dislocation, the complete and the partial. 98. Complete Dislocation ; — When the jaw is completely dislocated, both its condyles are advanced into the space be- tween the surface of the temporal bone, and zygomatic arch. The jaw is knowTi to be completely dislocated, by the mouth being open- ed, and the patient not being able to shut it by any pressure which you may make on the chin. The lower teeth will be found in a line anterior to the upper. You may depress the jaw a little, but to a very inconsiderable extent. The appearance is just that of a person when yawning. The pain, although severe, is not attended with danger. The saliva is very much in- creased in quantity, in consequence of the irritation of the parotid glands, and it dribbles over the mouth. 99. A blow upon the chin, when the mouth is widely opened, will cause this accident. Yawning very deeply will also, sometimes, produce the same efl'ect. 100. Partial Dislocation : — When the lower jaw is partial- ly dislocated, one condyloid process only advances, while the other remains in the articular cavity of the temporal bone. ^5(i DISLOCATIONS OF THE LOWER JAW. In this case, the mouth is not so widely opened as in the complete dislo- cation, but the patient cannot close it, from the condyloid process on one side being advanced under the zygoma ; and presents a very ludicrous ap- pearance of the face, from the twist which is given it. This accident is easily distinguished, by the chin being thrown to the op- posite side of the dislocation, the incisor teeth are advanced upon the upper jaw, but are no longer in a line with the axis of the face. 101. Reduction : — The reduction of these dislocations must depend on circumstances. They are generally reduced, by wrapping a handkerchief around the thumbs J placing them on the coronoid processes, and depressing the jaw, you force it backwards as well as downwards, and the bone suddenly slips into its place. 102. Tn recent cases, this mode will succeed ve-ry well, but it is not the plan I would recommend as a general resource. I should advise you to place some body that will not injure the gums, behind the molar teeth, on each side of the mouth, and for this purpose, I know no better material than two corks, and then raise the chin over them. This practice is very effectual in reducing dislocation, and is less likely to injure the bone or soft parts. I have also used two forks for the same purpose ; having wrapped a towel or handkerchief round the points, I carried their handles into the mouth on each side behind the molar teeth ; they were then held by an assistant, and, drawing the chin towards the upper jaw, the bone was easily and quickly reduced. 103. Imperfect Dislocation : — An imperfect dislocation of the jaw sometimes happens from a relaxation of the liga- ments, something in the same way as that in which the thigh bone is thrown from the semilunar cartilages. The jaw appears to quit the interarticular cartilage of the temporal bone slips before its edge, and fixes the jaw, the mouth being, at the same time, slightly opened. 104. In these cases, the natural efforts generally restore the situation of the parts, but I have seen it continue a length of time ; yet the motion of the jaw, and the power of closing the mouth have returned. iSiiiiftli te i aiiw i DISLOCATIOXS OF THE OS COCCYGIS. 357 You must, in your attempt to return the jaw, press directly downwards: by which you separate the jaw from the temporal bone, and allow the carti- lage to replace itself on the extremity of the condyloid process. A snapping is sometimes heard when the bone is returned to its socket. 105. Young women of a relaxed mnscnlar fibre are gen- erally the subject of this complaint j and, when it has once occurred, the bone is easily displaced again from a slight cause, and therefore the motions of it should be limited. In your treatment, you should endeavour to give a general tone to the constitution, by the exhibition of ammonia and steel, with the warm bath ; a blister before the ear will also contribute to remove the disposition to a re- appearance of the accident. You will best confine the jaw by making a hole in the middle of a broad tape, to receive the chin, and split the ends in two parts, bring one over the top of the head, and the other over the occiput, and the tendency to subse- quent luxation will thereby be prevented. DISLOCATIONS OF THE OS COCCYGIS. 106. Authors mention two kinds of dislocation, to which the OS coccygis is liable ; — the one, inward ; and the other, out- ward. The first is always occasioned by external violence ; the second, by the pressure of the child's head in difficult labours. Pain, difficulty of voiding the fEeces and urine, tenesmus and inflammation, sometimes ending in abscesses, which interest the rectum, are symptoms, said to attend and follow these injuries, 107. The best surgeons now regard all schemes for the re- daction useless, as the bone will spontaneously return to its place. The introduction of the finger within the rectum, and handling of the in- jured parts, are more likely to increase the subsequent inflammation, and produce abscesses, than have any beneficial effect. The wisest plan is to bo content with enjoining quietude, and adopting antiphlogistic measures^. 358 DISLOCATIONS OF THE HIP-JOINT. 108. As far as I have seen, there are but four dislocations of the thigh bone ; viz. upwards, or upon the dorsum of the ilium ; downwards, or into the foramen ovale ; backwards and upwards, or into the ischiatic notch ; and lastly, forwards and upwards, or on the body of the pubis. Another dislocation has been described by some surgeons, namely, down- wards and backwards, but I have never met with a case, and should rather doubt the accuracy of description. 109. First Dislocation : — Of the dislocation upwards, or on the dorsum of the ilium ; this happens more frequently than any other dislocation of the hip-joint. When called to this accident, you must expect to find great extravasa- tion, which will conceal, in some degree, the situation of the parts ; but, by a rotation of the knee inwards, the head of the thigh bone may be felt, and the trochanter major approaches the anterior superior spinous process of the ilium. 110. The characteristics of this dislocation are, a differ- ence in the length of the limb ; a change of position in- wards ; a diminution of motion ; and a flattening of that side by the altered situation of the trochanter major. You will find the toes rest against the tarsus of the opposite foot ; the knee and foot are turned inwards, and the knee is a little advanced upon the other ; the limb is about one inch and a half, or two inches and a half shorter than the other, and this may easily be detected, by comparing the malleoli interni when the foot is at right angles with the leg. If you try to separate the leg from the other, you find you cannot do it, as the abduction of the limb is completely prevented, but you may bend the thigh a little across the other. 111. This accident may be distinguished from fracture of the neck of the thigh bone, within the capsular ligament, with which it is most likely to be confounded, by symptoms which are sufficiently distinct to a person who is commonly attentive. iMMiikriMMidiieiiidiiM^^ DISLOCATION'S OF THE HIP-JOINT. 359 Tn the fracture of the neck, the knee and foot are turned o-utirards, the trochanter is drawn upwards and backwards, resting on the dorsum ilii : but the most striking symptom is this, although the limb may be shortened one or two inches, according to the duration of the accident, yet, by exten- sion, you may restore the natural length of the limb, but the limb is again shortened immediately on your removing the extended force. If, when you have drawn down the bone, you rotate it, you can distinctly feel a crepitus, but this ceases to be felt when the limb is allowed to be again shortened. 112. The dislocation on the dorsum of the ihnm is produ- f'ed by the patient falling -^-hen the knee and foot are turned inwards, or by a blow being received while the limb is in that position. The following plan is to be adopted in attempting to reduce this disloca- tion. Bleed the patient to twelve or twenty ounces, or more if he is a very strong man. Next place him in a warm bath, at 100°, gradually increase it to 110°, until he begins to faint. Whilst he is in the bath, give him one grain of tartarized antimony, until he feels nausea : then wrap him in a blanket, and place him on a table, between two strong posts, into which two staples have been fixed ; or, if you cannot find a convenient place for this, place him on the floor, and screw two rings, at a convenient distance, into the floor. 113. Such is the plan which is usually adopted, but the course which I take is somewhat different. I place the patient on a table, with a blanket on his back ; then a strong girt is passed between his pudendum and thigh, and this is fixed to one of the staples. A wetted linen roller should be applied just above the knee, and on this a leather strap is to be buckled, having two straps with rings at right angles with the circular part. The knee should be slightly bent, not quite at a right angle, and brought across the opposite thigh, a little above the knee. The pullies are to be hooked to the rings on the circular strap, and fixed to the other staple. You should now tighten the pullies, till you see the baudage is on the stretch, and the patient begins to complain of pain ; then wait a little, with the degree of extension you have now made, to give the muscles time to fatigue ; then draw again gently, and, when the patient complains much, stop again, until the muscles yield; and so go on until you find the head of the bone is brought just opposite the acetabulum. Let the same extension be kept up by another person taking the string of the pullies, and theu rotate the l]mb gently and the bone will generally slip into its place. 360 DISLOCATIONS OF THE HIP-JOINT. You must not expect to hear a snap when the bone is returned, as, by using the pullies, the muscles are so much relaxed, that they cannot act with sufficient violence ; and you can, therefore,only tell if it is reduced, by loos- ening the bandages, and comparing the length of the limb If there should be any difficulty in bringing the head of the bone over the edge of the acetabulum, you must pass your hand, or napkin under it, and lift it over the edge of the socket. When the reduction of this dislocation is effi3cted,you should take care in removing the patient to his bed, as from the relaxed state of the muscles, the dislocation would again happen, and that from a cause so trifling that you would not suspect it to have occurred. 114. Second Dislocation : — In the dislocation downwards, or, into the foramen ovale, you must not trust so much to the foot, as a diagnostic mark : the increased length of the limb, the separated knees, the bent position of the body, are such appearances as sufficiently point out the nature of the injury. The dislocated limb, in this case, is two inches longer than the other. By making pressure with the hand on the upper and inner part of the thigh, you can, in thin persons, distinctly feel the head of the thigh bone. There is a flattening of the hip on that side ; the body is bent forwards, owing to the psoas magnus and iliacus internus being put upon the stretch. If you desire the patient to stand upright, you find that the knee is considerably advanced towards the trunk. It is widely separated from the other knee, and it cannot be brought to touch it without much difficulty and pain. The foot is generally turned outwards or inwards, hut the toes point to the ground. It generally happens when the thighs are widely separated from each other, that the ligamentum teres and capsular ligament are torn through, and the head of the bone is situated on the obturator externus muscle, at the inner and back part of the thigh. 115. In this dislocation, if the accident is recent, it is very easily reduced. Place the patient on his back, separate the thighs as widely as possible, and place a girt between the pudendum and upper part of the thigh ; fix the girt to the staple in the wall, then take hold of the ankle of the dislo- cated side, and draw it over the other leg, or, if the thigh be very large, behind the sound limb, and the head of the bone usually slips into the socket. Or the thigh might be secured by a bed-post being received be- tween the pudendum and the upper part of the limb, and the leg be carried inwards, across the other. But the best plan, in general, is to fix the pelvis, by a girt passed round it, and crossed under that which passes round the DISLOCATIONS OF THE HIP- JOINT. 361 thigh, to which the pullies are to be attached, otherwise the pelvis moves in the same direction as the thigh. 116. If the dislocation has existed for three or four weeks, a different plan of reduction must be adopted. In these cases, it is better to place the patient on his sound side, and fix the pelvis by one bandage, and carry another under the dislocated thigh, to which the pullies are to be affixed perpendicularly ; then draw the thigh upwards, and, at the same time, press down the knee and foot, to prevent the lower part of the limb being carried with the thigh, and you thus use the limb as a lever of considerable power. But take care not to advance the leg too much, as the head of the bone would be forced behind the acetabulum into the ischiatic notch, from which it would be extremely dif- ficult to remove it. 117. Third Dislocation : — The dislocation backwards, or into the ischiatic notch, is the most difficult of all the disloca- tions of the thigh to detect, because the length of the limb differs but little, and its position is not so much changed as respects the knee and foot, as in the dislocation upwards. In this dislocation, the head of the bone is placed on the pyriformis mus- cle, between the edge of the upper part of the notch and the sacro-sciatic ligaments. The limb is from half an inch to an inch shorter than the other, but usually not more than half an inch, and the toe rests against the ball of the great toe of the opposite foot. The natural prominence formed by the trochanter major, is lost, but it still remains nearly at right angles with the dorsum, but it has a slight inclination towards the acetabulum. Ex- cept in very thin persons, you cannot feel the head of the bone, and then only by rolling it a little forwards. The knee and foot are turned inwards, ,but less so than in the dislocation upwards ; the knee is only very slightly bent, and therefore is not so much advanced as in that dislocation. The toe touches the ground when the patient is standing, hut not so the heel. Flexion and rotation are in a great degree prevented from the limb being so firmly fixed. 118. This dislocation is produced by the knee being pres- sed inwards whilst bent at right angles with the abdomen, or whilst the trunk is bent forwards on the thigh. 119. The reduction of this dislocation is very difficult, because the head of the bone is placed deep behind the 31 '-■■>'*•'- ^ 111 — ^ i^MM^MiXltrfiiimrll'— '— 362 DISLOCATIONS OF THE HIP- JOINT. acetabulum, and requires to be lifted over its edge, as well as to be drawn towards it. Let the patient be laid on a table, on his side, and a girt passed between the pudendum and inner part of the thigh, to fix the pelvis ; then pass a wetted roller round the knee, and buckle the leather strap over it ; let a napkin be passed under the upper part of the thigh ; next bring the thigh over the middle of the opposite one, and then begin to make your exten- sion with puUies. Whilst the extension is making, an assistant should grasp firmly the napkin at the upper part of the thigh with one hand 5 and, rest- ing the other hand on the pelvis, he should lift the thigh as much as possi- ble towards the acetabulum, so as to get the head of the bone over its edge. I have also directed a round towel to be used for this purpose j this passed beneath the upper part of the thigh, and then carried over the shoulders of an assistant, who then rests both hands on the pelvis, and, by raising his body gently, raises the thigh with it. This dislocation has been reduced, by making extension with the pullies in a right line with the body ; and, at the same time this extension was made, the trochanter major was thrust forwards with the hand. The former method is the most easy, and is that which I generally adopt. 120. Fourth Dislocation : — The dislocation on the pub es is much more readily detected than any other dislocation of the thigh. In this dislocation, the limb is an inch shorter than the other, and the knee and foot are turned outwards, and cannot be rotated inwards : but the most striking mark is, that the head of the thigh bone may be felt upon the pubes, above the level of Poupart's ligament, to the outer side of the femo- ral artery, and feels like a hard ball there, which will readily move on rota- ting or bending the knee. 121. The dislocation in question generally happens in this way : — if a person, while walking, puts his foot into some unexpected hollow, he throws his body suddenly backwards to preserve his equilibrium, and the head of the bone starts forwards on the pubes. To reduce this dislocation, you place the patient on a table, on his side : then carry a girt between the pudendum and the inner part of the thigh, and fix it in a staple, a little before the line of the body. The roller is to be passed around the thigh, and the pullies fixed as in the dislocation up- wards, and the extension is to be made in a line behind the axis of the body, the thigh bone being drawn backwards. After this extension has been con- tinued some time, pass a napkin under the upper part of the thigh, whilst DISLOCATIONS OF THE PATELLA. 363 an assistant, resting one hand on the pelvis, lifts the head of the bone over the pubes and edge of the acetabulum. DISLOCATIONS OF THE PATELLA. 122. The patella may be dislocated in three directions, viz, outwards, inwards, and upwards. 123. First Dislocation : — The patella is most frequently thrown on the external condyle, and produces there a great projection, and the patient is unable to walk. It generally happens in those persons who have a little inclination of the knee inwards : and is most frequently produced by a person felling with his knee turned inwards, and his foot at the same time turned outwards, and the action of the muscles in the attempt made to prevent the fall, draws the patella over the external condyle of the femur. 124. Second Dislocation : — The dislocation on the inner condyle is less frequent, and happens from a blow on the outer side of the patella, received in a fall on some project- ing body . In the reduction of either of these dislocations, you are to place the pa- tient in a recumbent posture, and let the leg be raised by lifting it at the heel, by which you relax the extensor muscles of the thigh in the greatest possible degree ; you then press on that edge of the bone which is furthest from the articulation, and this raises the inner edge of the bone over the condyle of the femur, and it is directly drawn into its proper position by the action of the muscles. Evaporating lotions of spirit and water are to be employed, and afterwards, say in two or three days, bandages should bo applied. 125. Third Dislocation : — In the dislocation of the patella upwards, the ligamentum patellae is torn through, and the pa- tella is drawn on the upper and fore part of the thigh bone. The marks of this accident are at once decisive ; for, besides the easy motion of the patella from side to side, a depression is felt above the tu- bercle of the tibia, from the laceration of the ligament. The patient loses the power of bearing on the limb, and a considerable degree of inflammation Bucceeds. I I I Htfciiii II t" II If 1^ lull iTit urn 111 Ik 364 DISLOCATIONS OF THE TIBIA. 126. The object of your treatment, in this case, is to keep the bone in contact with the ruptured ligament, and to subdue or prevent inflammation by appropriate remedies. First apply leeches, and afterwards evaporating lotions, from four to seven days : then apply a roller round the foot and leg, and keep them com- pletely extended by a splint behind the knee ; then buckle a leather strap above the knee, and to this, let another strap be fastened, which is to be passed under the foot, and buckled to the opposite side of the circular strap. The bone is in this way drawn down to the ruptured ligament, and an union, consequently, takes place. The patient, at the same time, should continue in the sitting posture, so as to relax the extensors of the leg which are in- eerted into the patella. DISLOCATIONS OF THE TIBIA, AT THE KNEE JOINT. 127. The dislocations of the tibia at the knee joint are four, two complete, and two incomplete ; or, inwards, out- wards, forwards, and backwards. As Boyer obserres, complete dislocations of the upper head of the tibia are exceedingly rare, because the articulating surface of the condyles of the femur is so extensive, that the tibia cannot be entirely removed from it, without a prodigious laceration of the ligaments, tendons, and all the rest of the soft parts. 128. First Dislocation : — In the dislocation inwards, the tibia projects on the inner side of the joint, and the condyle of the femur rests on the external semilunar cartilage. 129. ' Second Dislocation : — The tibia is sometimes thrown on the outer side of the joint, the condyle of the femur being placed on the inner semilunar cartilage, and the deformity produced is just as much as in the first dislocation. 130. Third Dislocation : — The tibia is sometimes disloca- ted forrvards ; in which case the tibia is raised, the thigh bone is depressed and thrown rather to one side, sometimes so much so, as to compress the popliteal artery PARTIAL DISLOCATION OF THE FEMUR, ETC. 365 131. Fourth Dislocation : — "When the tibia is dislocated backwards, the limb is shortened, the condyles of the femur project, and there is a depression of the ligaments of the pa- tella, and the leg is bent forwards. 132. deduction : — Each of these dislocations may be redu- ced by simple extension, for, as soon as you remove the sur- faces of the bones from each other, the muscles give them the direction necessary to be restored to their proper situation. The grand object, after the reduction, is to avert inflammation of the knee, and to promote the union of the torn ligaments. With this view a strict antiphlogistic, plan must be adopted, — bleeding, leeches, low diet, opening medicines, and a cool evaporating lotion. The limb should be kept perfectly motionless. As soon as the ligaments have grown together, and the danger of inflammation is over, which will be in about three weeks, the joint should be gently bent and extended every day, in order to prevent stiffness. PARTIAL DISLOCATION OF THE FEMUR, FROM THE SEMILUNAR CARTILAGES. 133. The most frequent cause of this accident is the per- son striking his toe against some projecting body when the foot is everted. He immediately feels pain in the knee, and it cannot be completely extended. I have also known it from a sudden twist inwards, when the foot is turned. The manner in which the accident happens is as follows : — The ligaments uniting the semi-lunar cartilages to the head of the tibia, become relaxed, the cartilages are easily pushed from their situations by the condyles of the femnr, which, therefore, come into contact with the head of the tibia. When the limb is attempted to be extended, the edges of the semi-lunar cartilages prevent it. 134. The mode of restoring the parts, in this accident, to their natural position, is very clear and easy You must bend the limb back, as far as possible, by which you remove the pressure made by the thigh bone, and this enables the cartilage to slip into its place, and the condyles of the femur are again received on the semi- lunar cartilage. 366 DISLOCATIONS OF THE ANKLE JOINT. As the accident is very liable to happen again, the return of it is best prevented by a bandage made vrith a piece of linen having four straps at- tached to it, and these are bound lightly above and below the patella. COMPOUND DISLOCATIONS OF THE KNEE JOINT. 135. I have only seen one example of this kind, which required an immediate amputation ; and it is probable that, in all these cases, unless the wound is very small, so as to allow of its ready closure and adhesion, that a similar prac- tice will be necessary. DISLOCATIONS OF THE ANKLE JOINT. 136. The dislocations, occurring at the ankle joint, are said to be four ; inwards, outwards, forwards, and backwards, but I have never seen one backwards. The ankle joint is well protected by numerous small ligaments j the union oi the fibula, particularly, is so firm to the tibia and tarsel bones, that it generally happens that the bone will rather break, than the ligaments give way. 137. First Dislocation : — The dislocation inwards is the most frequent; and generally happens from a person jumping from a considerable height, or from running violently with the toe turned outwards, the foot being suddenly checked in its motion whilst the body is carried forwards on the foot,and the ligaments on the inner side of the ankle give way. The foot is thrown outwards, and its inner edge rests upon the ground : the internal malleolus projects so much against the integuments as to threaten their laceration. The foot easily rotates on its axis. There is also a depression above the malleolus externus, attended with great pain : and, about three inches above the lower end of the tibula, a cripitus may be felt. 138. The reduction of this dislocation must be followed up by rest and local applications, to prevent inflammatory symptoms. DISLOCATIONS OF THE ANKLE JOINT. 367 To reduce the dislocation, place the patient on a mattress on his injured side, and bend the leg at right angles with the thigh, so as to relax the gastrocnemii ; let an assistant grasp the foot, and gradually draw it in a line with the leg. You should, at the same time, iix the thigh, and press the tibia downwards, to force it on the articulating surface of the astraga- lus. After the reduction, let the limb remain on its outer side in the bent position, with the foot well supported, a many-tailed bandage should be applied, and kept wet with the spirit wash. The patient may leave his bed, and walk on crutches, at the end of five weeks ; friction and passive motion should be used at the end of eight weeks ; and twelve weeks will elapse before he has the perfect motion of the joint. 139. Second Dislocation : — The dislocation outwards is the most dangerous, as it is produced by greater violence, and is attended -with, more laceration of the ligament, and more contusion of the integuments. In this case, the foot is thrown inwards, and its outer edge rests upon the ground. The malleolus projects very much, and forms sucli a decided p)ro- minence, that the nature of the injury cannot be mistaken. The toes and foot are pointed downwards. - 140. In this dislocation, the maleolus intetnus is oblique- ly fractured, and the accident happens from the wheel of a carriage passing over the leg, or by the foot being twisted in jumping or falling. To reduce this dislocation, you place the patient on a mattress, on his back, bend the thigh at right angles with the body, and the leg at right angles with the thigh ; let the foot be held fiimly by one assistant, and the thigh grasped under the ham by another ; then extend the foot in a line with the leg, and press the tibia inwards towards the astragalus. The limb should be laid on its outer side, resting on splints with fool pieces, and a pad should be placed on the fibula, above the outer ankle, ex- tending a little way up the bone, so as to support that part of the leg. The after treatment will be the same as in the former case. Passive motion should be used in six weeks. 141. Third Dislocation : — The dislocation /orwcr^Zs happens from the body falling backward whilst the foot is confined, or from a person jumping from a carriage in rapid motion, with the toe pointed forwards. 368 DISLOCATIONS OF THE ANKLE JOINT. Tn this case, tlie foot ajipears mnch shortened and fixed, and the toes are pointed to the ground. The lower end of the tibia forms a hard swelling on the middle of the tarsus. The heel appears lengthened, and there is a projec- tion before the tendo achillis. The tibia rests on the navicular and internal cuneiform bones, the fibula is broken, and carried forwards at the side of the tibia, and it is fractured about three inches above the malleolus. 142. In this dislocation, your treatment of reduction must be followed up by rest. In reducing this dislocation, you should lay the patient in bed, on his back J an assistant should grasp the thigh at its lower part, and draw it towards the body, whilst another pulls the foot in a line from the leg, and you then push the tibia back, to bring it into its proper place ; attending to the same rule for relaxation of the muscles and the after treatment as in the former dislocation. The patient should afterwards rest the leg on the heel, and you should apply splints on each side of the leg, with foot pieces to support the foot at right angles with the leg. In five weeks you may allow the patient to get up, and use passive motion, as the fibula will by that time have united. 143. Sometimes the dislocation forwards is only partial ; but the treatment is to be the same as in a complete dislocation. In a partial dislocation forwards, the tibia rests half on the os naviculare, and half on the astragalus ; the fibula is broken, and there is not any con- siderable projection of the heel. The toe is pointed downwards, and there is great difficulty in putting the foot flat on the ground. The heel is dravv© up, and the foot is in a great degree immoveable. 144. Compound Dislocations : — Compound dislocations of the ankle joint may take place in the same direction as the simple, and the bones and ligaments suiFer in the same way. Great local inflammation and constitutional disturbance attend these ac- cidents, on account of the wound made into the joint, and the great effort required to repair it. 145. The principle of treatment to be observed, in these dislocations, is to close the wound as completely as possible, to assist nature in the adhesive process by which the wound is to be closed, thus rendering suppuration and granulation less necessary for the union of the opened joint. . iiii«*'iiiitiiM>«a^ahi FRACTURES. 369 The reductioa is to be effected in the same manner as I have before de- scribed in simple dislocation. Apply a little lint dipped in blood to the wound, put on a many-tailed bandage, -which is to be kept -wet with spirits of wine and water, and the lint should rest on the outer side. But in the dislocation outwards, it is best to keep the foot on the heel, with a splint and foot piece on the outer and inner side of the leg. The knee should he slightly bent, and care taken that the foot does not become pointed. FRACTURES. 1. Fracture is a term, used ty surgeons, to express the division of a bone into one or more pieces, from violence. 2. Fractures are either simple or compound ; according as they are accompanied with an external wound, communica- ting with the ends of the bones or other-wase. If the bone is broken in two or more pieces, and there is not an external wound, communicating with the fractured edges of the bone, the fracture ia still called simple ; and, on the other hand, if the bone is bioken in but one place, and there is an outward wound, the accident is called a compound fracture. Large wounds may occur at the same time with fractures, but unless these communicate with the bone, they are not called compound fractures. 3. Fractures are, likewise, said to be complicated, when they are attended with diseases, or accidents, which render the indications in the treatment more numerous, and require the employment of different remedies, or the practice of sun- dry operations, for the accomplishment of the cure. Thus, fractures may be complicated with severe degrees of contusion, wounds of the soft parts, injury of large blood-vessels, a dislocation, or diseases, and particular states of the constitution, as the scurvv-, rickets, lues venerea, pregnancy, &:c. -which are said to retard the formation of callus, and render the cure more backward. 4. The immediate result of a fracture is the escape of ex- travasated blood, which in simple fractures becomes ab- - -f^ MiWiM Itllll^W II iimiiT ■ ''•«»««M«l«Mla 370 I^RACTURES. sorbed ; and the effect, which a fracture produces on the con- stitution, is to set up a violent reaction, so as to bring about a restoration of the injured part. The degree of this effort of the system will very much depend on the man- ner in which the accident is treated ; for if you are careful in the manage- ment of the case, you may procure adhesion of the external wound, and thus reduce the accident to the state of a simple fracture. 5. The mode of union in fractures is ultimately the same, but, in simple fractures, ossific matter is deposited in carti- lage without a suppurative process, and, in the other, with it. If you do not procure union by adhesion, it is brought about by granula- tion, and in the following way : The blood, which is at first poured out io consequence of the division of the vessels of the medullary membrane, and the periosteum, instead of being confined in the surrounding structures, passes off by the external wound; yet it must be remembered that this eflEused blood has no share in producing union of the ends of the bone, as it becomes after a few days entirely absorbed. Next, there is a fluid poured out between the periosteum and the bone, which separates the periosteum firom the surface of the bone for about an inch, or an inch and a half beyond the place where the bone is fractured. This fluid does not cause a laceration of the vessels of the periosteum, but rather an elongation of them. Now here is the difference between the simple and compound fractures, for in the former, the fluid, after accumulating for a day or two, becomes in a great measure taken up by the absorbents, and adhesive matter is poured out in its stead ; but in the latter, a suppurative process is established, and granulations arise from the broken surfaces. In these granulations, carti- lage becomes deposited, and continues to be formed for some time ; the dis- charge of pus gradually dimiuishes, and, in a compound fracture, cartilage continues to be formed until about the twentieth day. It is deposited be- tween the internal surface of the periosteum and the external surface of the bone. At the place where the bones are brought into contact, the peri- osteum becomes absorbed, and cartilage is deposited between them, in which patches of bony matter are formed, and these, when completed, are covered bj an extension of the original periosteum. 6. The cause of non-union in fractures is the want of ap- proximation. If the fractured ends are rot brought into contact, the periosteum is not raised, the cartilage that forms does not cover the extremities of the boaes, and the protruding portions are removed by the absorbents j so that f ^T^'^S' i". T fi - TTTBrnBitii '-""^ FRACTURES. Stl Ihe process of union only goes on in those surfeces of bone which are lying in contact. 7. Compound fractures are mucli slower in their progress of union than simple fractures ; and the union is frequently retarded by exfoliations of bone, which will often take up a tedious time to separate, and keep up considerable constitu- tion irritation. Under the granulations arising from the cancellated structure, cartilage is also found, and about the twelfth day in simple, and from the seventeenth to the twentieth day in compound fracture, there are bony patches deposi- ted in the cartilage ; and it is by the accumulation of these patches that ossific union gradually takes place. From three to nine or twelve months is the grade of time required for the complete union of compound fractures. 8. Causes : — The causes of fractures are divided into predisposing and remote. 9. In the first class are comprehended the situation and functions of the bones, the age of the patients, and their dis- eases. Superficial bones are more easily fractured than those which are covered by a considerable quantity of soft parts. In respect to functions, some bones are more likely to be fractured than others ; thus, the clavicle which serves to keep the shoulder in its proper situation, and support on its arched extremity all the motions of the upper extremity, is particularly subject to be broken. The gradual increase of the phosphate of lime, in the structure of bones, making them brittle in proportion as we advance in years. Lues venerea, arthritis, cancer, rachitis, scurvy,scrofula, and a few other diseases also predispose to fracture. 10. The remote cause of fractures is external force. This may result from falls, blows, &c., or in particular instances, from the violent action of the muscles which are attached to the injured bone ; which, in fact, is always the case with a fractured patella. 11. Symptoms .-—Some of the symptoms of fractures are nearly conclusive ; while, on the other hand, many are very equivocal. - JiaWLfc .Iff" ' 37^ FRACTURES. The pain and inability to move the limb, commonly enumerated, may arise from a mere bruise, a dislocation, or other cause. The crepitus, the separation and inequalities of the ends of the fracture, when the bono ia superficial j the change in the form of the limb ; and the shortening of it ; are circumstances communicating the most certain information. The crtfpi- tus, however, though the principal demonstration of fracture, also occasion- ally attends on dislocation, arising from a change in the quality of the synovia. 12. Prognosis : — The prognosis of fractures varies accord- ing to the kind of bone injured, what part of it is broken, the direction of the breach of continuity, and what other mis- chief complicates the case. Fractures of bones, which have many strong muscles inserted into them, are the more difficult to cure ; a fracture of the middle part of a long bone is less dangerous, than a similar injury near the joint. When a bone ia fractured in several places, the case is more serious, and the difficulty of cure much augmented. But the accident is still worse, when a limb ia fractured in two different places at once ; as, for instance, in the thigh and leg. Oblique fractures are more troublesome, and difficult of cure, than transverse ones, because an oblique surface does not resist the retraction of the lower portion of the broken bone j and, consequently, it is very difficult to keep the ends of the fracture duly applied to each other. Compound and complicated fractures are more troublesome than simple ones. Disease and debility, also, are unfavourable attendants' on fractures 13. Treatment : — The general treatment of fractures em- braces three principal indications. The first is to reduce the pieces of bone into their natural situation. The second is to secure and keep them in this state. And the third is to prevent any unpleasant symptoms likely to arise, and to relieve them when they have come on. 14. First :--The means employed for the production of fractures in general are chiefly three ; viz. extension, counter- extension, and setting. 15. It was formerly recommended to apply the extending force to the lower fragment, and the counter-extension to the upper one. FRACTURES. 373 Such practice, indeed, was advised by Mr. Pott, and is still generally pre- ferred in this country ; but the French surgeons apply the extending force to that part of the limb, which is articulated with the lower fragment, and the counter-extension to that, which is articulated with the upper. 16. It is difficult to lay down rules respecting the precise degree of force which should be used in making extension. This must vary in different cases, according to the species of displace- ment, and the number and power of the muscles of the part. The exten- sion must always be gradual, and should be begun in the direction of the lower fragment, and be continued in that which is natural to the body of the bone. 17. In every case of fracture with displacement, as soon as the necessary extension has been made, you must endea- vour to place the ends of the broken bones in their natural situation : this is termed coaptation or setting. Here the grand means of success is potting the limb into such a position as will relax the most powerful muscles, which oppose the reduction. 18. Secondly : — After the bones have been put into their natural situation, you must adopt such means as will keep the fracture reduced. The means you are here called upon for the fulfilment of this indication, are — an advantageous position ; quietude j bandages} splints; and various kinds of apparatus. 19. Thirdly : — After having reduced the fracture ; appli- ed a suitable apparatus for maintaining the reduction ; and put the part in an advantageous position, you must then at- tend to the third indication, viz. the prevention and removal of any unfavourable symptoms. This indication more immediately comprehends diet, local applications, and the other necessary steps of after treatment. 20. With the exception of a few simple fractures of the upper extremity, it is proper, in all cases, to allow, for the first few days, only very low diet. Broths, tea, and so on. The patient should also be permited to drink aa 374 PRACTURES. often, and as much as he likes, of any cooling acid beverage. The low diet is only to be continued for a few days, unless great inflammation arises. 21. "With respect to external applications, you should carefully avoid using such plasters and ointments as irritate the skin, or create a disagreeable itching ; for they some- times bring on erysipelas. ' The emplastrum saponis is the best for all simple fractures. It is, gen- erally speaking, a good plan, for the first two or three days, to wet the ban- dages with cold water ; for, in this way, the tendency to inflammation and swelling is considerably lessened. You should recollect, however that the bandages shrink when wetted, and may become so tight as to do harm, if not attended to. 22. When the callus has acquired some firmness, the pa- tient should still keep the part or limb quiet, until the union is perfectly consolidated. And, in fractures of the lower extremity, even after the union has pro- ceeded 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 several more days have elapsed. 23. All fractures, however simple and well treated they may be, are constantly followed by weakness and stiffness of the limb. For the prevention of these effects of fractures, passive motion should ba cautiously performed when the union is perfect. You may also employ friction, liniments, emollient relaxing applications, cold washes, and bath- ing ; but, sometimes, notwithstanding these remedies, the member does not quickly recover its strength, but continues stiff* and weak for a year, or even a longer time. COMPOUND FRACTURES. 24. In your treatment of compound fractures under com- mon circumstances, you should reduce the bone as speedily as you can, and then bring the edges of the wound together. This may be very easily done by relaxing the muscles acting upon the limb. Bring them as nearly into apposition as possible, and, if there be slight hemorrhage, do not be searching for a small vessel, but place a little lint over the wound, and by making gentle pressure on it, you may easily MillaBaa^lMlaiMu COMPOUND FRACTURES. 375 suppress the hemorrhage. Next bring the integuments together as neatly as you can, and dip a dossil of lint in the blood, and put it on the surface of the wound. In this "way, the wound unites by the adhesive process, and the union of the bone goes on as in simple fracture, and is cured in one- fourth part of the time which would be required if the wound were allow- ed to be filled by granulations. 25. Such should be the principal object of your treatment under ordinary circumstances, but if the fracture is accom- panied with severe contusion of the soft parts, a somewhat different course must be adopted. You may apply a poultice in these cases, in order to facilitate the dis- charge from the wound, and promote the separation of the parts to be re- moved ; for the parts must slough, and therefore it would be useless to at- tempt to procure union by adhesion. 26. If, in compound fracture, the wound is caused by the ends of the bone or any sharp instrument, you may general- ly succeed in procuring an adhesion as already directed. Do not apply adhesive plaster, as it frequently produces erysipelas on the edge of the wound, but use the lint as before recommended; it is the least irritating application I know of, and appears to approach the nearest of any other to the natural covering of the parts. 27. The subsequent steps of your treatment must consist of the application of bandages, evaporating lotions, and splints. Apply the many-tailed bandage loosely, so that it may give way to the tension that follows, and evaporating lotions over this. Splints should afterwards be put on ; those made of wood are the best, and one should be put on each side of the limb. Do not apply the splints tightly at first, so as to cause pain, but see that they are well padded, and the bones nicely adjusted. 28. It often happens, when a fracture has been thus treat- ed, that in a few days inflammation arises, and a discharge of pus follows. When this is the case, the lint which was at first applied should be part- ly removed, and the matter allowed to discharge. If the matter should be small in quantity, after you have let it out, replace the lint carefully, and 376 COMPOUND FRACTURES. do not apply a poultice, but continue the use of the cold wash. If, on the other hand, the discharge of matter is considerable, or if it is a contused wound, with a tendency to slough, then you should apply fomentations and poultices, and heal the wound by a granulating process. 29. The position of the limb must be the same in com- pound as in simple fracture ; with this exception, that, if the suppurative process should be set up, the wound will require dressing, and therefore it will be necessary to have the limb in a convenient position for that purpose. 30. Constitutional Treatment : — The constitutional treat- ment, required in compound fractures, will be regulated by the force of the symptoms. If the patient be young and plethoric, take blood from the arm sufficient to allay the constitutional suffering, but do not give purgatives, as they very much disturb the patient, and add to the irritation, by the necessity which there is of his being frequently removed. Nothing is so bad in the treat- ment of compound fractures, as the frequent changing of the positions and dressings of the patient : it is a state of rest which is necessary for the re- covery of the parts, and therefore the less they are disturbed the better. Give opium to quiet the irritation, and give also, at the same time, the sa- line mixture, with the liquor antimonii tartarizati, to keep up the secretion of the skin. 31. Difficulties in Treatment : — And first of the difficulty which now and then exists in the reduction of the bone, which occasionally arises from a portion of skin being nipped un- der the projecting extremity of the bone. When you try to extend the limb, you find you cannot bring the skin into its place. If this projecting portion of bone is not large, make an incision through the integuments, and turn them to one side sufficiently to reduce the bone, and afterwards try to unite the parts by the adhesive process. 32. "When you experience any difficulty in the reduction of a fracture which is very oblique, do not divide the integu- ments ; but saw off the sharp projections of bone at the ex- tremities of the fractured portions, and then carefully replace the bone in its proper situation. The muscles will draw the ends of the bone together, even if it be short- COMPOUND FEACTrRES. 377 ened. Do not adopt this practice, however, where there are two bones, and one is not fractured, for if the broken or the sawn surfaces are not brought into contact, no ossific union can take place. 33. Tf the bone in fractures should be very much shattered^ and several pieces be detached and loose, remove them, but with the greatest possible care, so as to avoid irritating the wound more than is absolutely necessar}'. If these portions of bone be not removed, they will produce excessive irritation, and will very much retard the healing of the wound by frequent exfoliations. But, if the pieces be large, do not detach them, for, if they he connected by periosteum, they will again unite ; or if there be one large piece, and the periosteum on it is entire, let it remain. 34. Compound fractures are often attended with himor- rhage from large arteries, which have been wounded by the broken extremities of the bone. It was formerly the practice to amputate in these accidents, whenever any vessel of importance was wounded, under the supposition that the injury could not be repaired, and that gangrene would in all probability happen. But I have seen so many limbs saved, even when the principal artery going to the limb has been torn, that I am induced by experience to adopt a different plan. The introduction of extraneous bodies into wounds, to suppress hemor- rhage, is wrong in compound fracture, as they produce too much irritation, and do not effectually answer the proposed object. It is better, in somo cases, in which you have great difBculty to secure the vessel at the wound, not to be twitching and pulling, and continually irritating the wound, and frequently to no purpose, but to cut do%vn at once on the artery, in its course to the part. 35. Another untoward circumstance to the welfare of compound fractures is, a high degree of inflammation attack- ing the neighbouring part. If the patient's health is good, the inflammation will not extend beyond a few inches around the accident ; but if the patient is irritable, and the injury, for example, be in the leg, the inflammation will extend along the course of the absorbents to the groin, and if there be effusion at the same time accompanying this, it must be considered as an indication of great danger. 33 378 COMPOUND FRACTURES. 36. The symptoms of great inflammatory excitement generally make their appearance in persons who have lived irregularly, either as regards their diet or their habits. Such symptoms must not be treated very actively by depletion ; apply leeches, foaientations also, and poultices to the neighbourhood of the wound. Lotions also of the liquor ammoniae acetatis, with rectified spirits of wine, should be applied to the inflammation on the limb, whilst the poultices are applied to the neighbourhood of the wound. At the same time, opium should be given to allay the constitutional irritability, and a gentle diaphoresis pro- moted on the skin, by giving some saline medicines. Be very cautious about the administration of purgatives, as they disturb the patient very much ; but, if absolutely necessary, give an enema. 37. Another obstacle, met with in the treatment of com- pound fracture, is, an excessive spasmodic action of the muscles. This action is sometimes so violent, as to render all your attempts to overcome it absolutely nugatory. Amputation is at once required in a case of this kind. 38. It is sometimes necessary to amputate from a want of union between the fractured ends of the bones. Non-union, T am inclined to think, is generally the result of fracture oc- curring at the period of parturition. I also believe it is sometimes the re- sult of continuing cold applications for too long a period to the part, thus checking that degree of inflammatory action which is absolutely necessary to bring about a restoration of the parts. 39. If these cases are properly managed, it is not always necessary to amputate ; you may give the patient a chance of saving the limb. The ordinary treatment in these accidents is, to bandage the limb firmly, buckle on a case of firm leather over the limb, and carefully adjust a splint on each side of it, so that no lateral motion may be allowed. If it should happen in the leg, let your patient walk about on crutches, so that by making pressure on the ends of the bone, you may bring on a suflScient de- gree of inflammation to throw out adhesive, and afterwards ossific matter. Mr. Aymesbury's splints will be found very useful in the treatment of these cases. -~- ^ "* ' *' ' ii ' ""' ^ I '^- I ri Miiii l i FRACTURES OF THE NOSE. 379 40. It has been recommended to amputate parts which have been injured by compound fracture, when tetanus makes its appearance. 1 advise you never to amputate in these cases, but to put some of the ex- tract of opium, liquefied by the addition of a little water, into the wound, I have known this succeed when large doses of musk and opium have been taken without producing any effect. 41. To the question, when is the most proper time to op- erate in compound fractures, supposing the operation to be necessary ? I should say, that, all the circumstances before mentioned being taken into account, if it will be necessary to amputate in a few days after the accident, then, the sooner it is done the better. If you amputate at one hour after the accident, the patient will do better than if you leave it twelve hours, for this reason : if you amputate immedi- ately, the constitution has but one shock to sustain, and, in general, rallies much belter than when the amputation is delayed ; but, if you leave it eight or twelve hours, there is a great degree of irritation previously set up. The loss of blood is rather a favourable circumstance than otherwise, to precede an operation. 42. The persons, on whom operations for compound frac- tures succeed the least, are such as are loaded with adipose matter. In these persons, if you leave the limb, the constitutional excitement runa so high, that it generally destroys life, and, if you amputate, they frequently die in twenty-four hours after the operation, from the constitution being un- able to bear the shock which the operation produces. FRACTUEES OF THE NOSE. 43. The bones of the nose, from their situation, are much exposed to fractures. The fragments are sometimes not de- ranged ; but, most frequently, they are depressed. In order to replace them, you must pass a female catheter, a ring-handled fcrceps, or any such instrument, into the nostrils, and, using it as a lever, 3S0 FRACTURES OF THE JAW. pu«h the fragments outwards, while, with the index finger of your left hand, you prevent them from being pushed out too far. In general, they will retain their situation without any farther assistance ; if not, the fractured portion may be supported by the introduction of lint. FRACTURES OF THE JAW. 44. The lower jaw is subject to simple and compoand fractures ; but, whether the one or the other, the displace- ment is readily reduced. By introducing one or both thumbs into the mouth, and by depressing or keeping stationary the posterior part of the bone, at the same time that you elevate or bring forwards the anterior part with the fingers, you can, in gen- eral, replace the fracture with great facility. 45. The retaining it in its situation, and the preventing it from moving, are points not quite so easily accomplished as the replacement. The parts being accurately replaced and kept firm by an assistant, a thick compress of lint should be placed over the seat of the fracture, and a ban- dage applied, by means of which, the jaw may be firmly held upwards and backwards ; and, for this purpose, the most effectual is a bag or purse, to receive the chin, with four strong tapes, or ends, attached to it, the two in- ferior of which are to be tied over the parietal bone, the two superior over the occiput. 46. During the cure, the patient should be kept quiet, and fed upon spoon meat. This diet should be continued till the bone is firmly united, and may be given by means of a small spoon introduced between the teeth. Broths, soups, jellies, tea, and other slops, appear most eligible. 47. Compound fractures of the lower jaw are to be treat- ed on the same principle as similar injuries of other bones. If possible, the external wound should be healed by the first intention; and, when this attempt fails, care must be taken to keep the wound clean by changing the dressings about once in three days, but not oftener, lest the fracture suffer too much disturbance 381 FRACTURES OF THE CLAVICLE. 48. In accidents of this kind, the shoulder is usually drawn forward, and that portion of bone, which is attached to the sternum, projects over the other fractured extremity, and may be distinctly felt by tracing the usual course of the clavicle with the finger. Generally speaking, the fracture of the clavicle is single ; that is, it con- sists of one fracture only. But, in the case of a violent blow, the bone may be broken at more than one place, and there may be great echyraosis of the surrounding parts. 49. It is very easy to reduce a broken clavicle ; but the difficulty rests in retaining the fractured ends in exact appo- sition, so as to produce an union in which there is no defor- mity. What you have to do is this : — The arms and shoulders of the patient are to be firmly drawn backwards by an assistant, when the fractured extremi- ties of the bone immediately come in apposition. The parts are then to be covered with an adhesive plaster, and a bandage is to be applied, to retain them in their reduced situation. That called the stellate is usually employ- ed ; it is a single-headed roller, of moderate breadth, and is applied by making it to pass under the axilla of one side, and over the shoulder of the opposite, describing on the back the figure 8. It should be drawn with con- siderable tightness, and the arm should afterwards be supported with a sling. FRACTURES OF THE STERNUM. 50. A fracture of the sternum is rendered evident by the inequalities perceptible when the surface of the bone is ex- amined with the fingers. It is also characterized by a depression or elevation of the broken pieces ; a crepitus, and an unusual mobility of the injured part in respiration ; by the breathing being difficult, and almost always accompanied with cough, spitting of blood, palpitation, and inability to lie on the back. 51. Fractures of the sternum, when mere solutions of cou- tinuity, only require common treatment. 382 FRACTURES OF THE RIBS. A piece of soap plaster should be applied to the situation of the injury, a roller round the chest, quietude, bleeding, and a low diet, with a view of preventing what may be considered as the most dangerous consequence, in- flammation of the parts within the chest. 52. In cases, attended with great depression of the frac- tured bone, it may become necessary to elevate it. The necessary incisions should be made, in order to raise with an eleva- tor the portions of the bone driven inward, or to extract with forceps any loose splinters, which seem to be similarly circumstanced. However, it is not often necessary to trephine the sternum, either to raise a depressed por- tion of the bone, or to give vent to extravasated fluid. FRACTURES OF THE RIBS. 53. Fractures of the ribs are much more common than those of the sternum. When these take place at the anterior part, or sides of the chest, the acr cident is generally easily recognisable by putting the hand where the vio- lence has been received, or where the patient says there is considerable pain. The movements of the chest produce a sensible grating, or crepitus, and the patient experiences great pain from the motions of the broken ends of the bone in the chest. When, however, the fracture is situated in the lower ribs, and farther back, where the ribs are covered by thick muscles, we often do not succeed in detecting grating or crepitus, although all other circumstances are present which lead us to believe the existence of the fracture. In a doubtful case like this, it is better to adopt the treatment suitable to fracture of the ribs. 54. The fracture of a single rib is by no means an impor- tant occurrence ; for the patient readily recovers on a simple treatment of his case. An adhesive plaster, or the ceratum saponis, should be applied over the part, and the body should then be tightly encircled with a broad bandage. 55. Should the extremity of the fractured rib puncture the lungs, an effusion of air into the cellular membrane wiil take place (called emfhijsemd) ; and sometimes will extend to the scalp, the eyes, and downwards, along the abdomen, to the lower extremities. '••*•-""■*-■ '"^^r itT*T"iiilii>*iAJiii7rin" FRACTURES OF THE SCAPULA. 383 In such cases, small scarifications with the point of a lancet are required, and, if there be symptoms of fever or inflammation, bleeding and other anti- phlogistic regimen. FRACTURES OF THE SCAPULA 56. The scapula is so much covered by muscle, and its connexions with the trunk are of such a kind, as to allow of its yielding under the application of external force, so that fractures are uncommon. Some parts, however, which are placed nearest the surface of the body, and which prLJect particularly, may be broken; the acromion, especially, the inferior angle of the scapula, and, more rarely, the coracoid process, and the neck of the bone. 57. Now, as for the treatment for fracture of the inferior angle of the bone, the acromion and coracoid processes, but little can be said. All that you can do, says Mr. Lawrence, in these cases, is to keep the upper extremity at rest ; for, when that moves, the scapula will move also. And you may, perhaps, in some measure, assist the maintenance in apposi- tion of the broken fragments, and the consolidation of a fracture, by the relaxation (through the peculiar position of the upper extremity) of a par- ticular muscle connected with the broken part of the bone, or by the appli- cation of some local compress. 58. The neck of the scapula is suspected by some to be a frequent accident ; but by Boyer, Lawrence, and others, it is said to be a rare accident. Your treatment, in this case, consists in keeping the head of the os hu- meri outwards, by means of a thick cushion in the axilla, in keeping the glenoid cavity and arm raised with a sling, and in preventing all motion of the arm, by binding it to the trunk with a roller. FRACTURES OF THE HUMERUS. 59. The humerus may be fractured at any point of its length : from the head down to the inferior articular ex tremity. 384 FRACTURES OF THE HUMERUS. 60. Fractures of the Neck : — Are not very easily ascertained, and, from want of attention, have been frequently confound- ed with luxations of that bone. When the neck of the humerus is fractured, a depression is observed at the upper part and external side of the arm, very different from that which accompanies the luxation of the bone downward and inward. In the latter case, a deep depression is found, just below the projection of the acromion, in the natural situation of the head of the humerus j whereas, in fracture of the neck of that bone, the shoulder retains its natural form, the acromion does not project, and the depression is found below the point of the shoulder. 61. In this case, to support the weight of the limb, and keep it firmly fixed to the side, are the most effectual means of maintaining the apposition of the broken bones. Tt may happen, if the situation of the fracture be low, so that you can feel the exact spot ; you may assist the apposition of the fragments, by plac- ing a compress in the axilla, and drawing the upper part of the extremity downwards, inwards, or forwards, or even by applying a compress exter- nally. There are minute points which must be judged of in every particular case. 62. Fracture of the Shaft : — As we have the whole of the body of the humerus immediately under our observation, the existence of fracture is easily ascertained. The head of the bone being grasped with one hand, and the elbow with the other, upon rotating the arm, no motion will be communicated from the lower to the upper portion, and, at the same time, a crepitus will be distin- guishable. 63. The reduction of these cases is very easy, and the maintenance in apposition is readily secured. In other fractures of the kind, it is usual to apply two pieces of soap plas- ter, which together surround the limb, at the situation where the accident has happened. Extension, if necessary, being now made by an assistant, who at once draws the lower portion of the bone downwards, and bends the elbow, the surgeon is to apply a roller round the limb, and three splints. The external splint is to extend from the acromion to the outer condyle, and being lined by a soft pad, the wood cannot hurt by pressure. The in- ternal splint is to reach from the margins of the axilla to a little below the inner condyle, and is to be well guarded with a pad, filled with tow, or any FRACTURES OF THE HUMERUS. ^5 soft material. Mr. S. Cooper recommends four splints ; one on the outside, one on the inside, one on the front, and another on the back of the arm. These are to be carefully fixed in their respective situations, by means of tape. Throughout the treatment, the elbow and whole of the fore-arm are to be quietly and effectually supported in a sling. 64. Fracture of the Condyles ; — The humerus may be bro- ken at its lower part, the fracture extending through the condyle into the joint. When the condyles of the humerus are obliquely broken off, just above the joint, the appeal ances are those of a dislocation of the radius and ulna backwards ; but the nature of the case is evinced by the circumstances of the displacement recurring, as soon as the extension is stopped, and also by the crepitus, generally perceptible, when the fore-arm is rotated upon the humerus. 65. Your principle of treating these cases consists in bend- ing the arm, drawing it forwards so as to reduce the parts, and then applying a roller. The best splint for the purpose is one formed at right angles, the upper portion of it being placed behind the upper arm, and the lower under the fore-arm. A splint should also be applied to the fore part of the upper arm. The splints are to be fixed with straps ; evaporating lotions used ; and the arm kept in a sling. In a fortnight, if the patient be young, and, in three weeks, if he be an adult, passive motion may be gently employed for the purpose of preventing an anchylosis. 66. Compound fractures of the elbow joint generally hap- pen through the internal condyles of the os humeri, and the fracture takes an oblique direction into the joint. 67. In the most severe accidents of this kind, the consti- tution is generally able to support them, if they are judicious- ly managed. In all cases of this accident, the arm should be kept in the bent position ; for, as anchylosis in a greater or less degree will be the consequence, it is attended with much less inconvenience in this position than in any other. Now rather than submit your patient to an amputation, endeavour to heal the wound, 'by bringing the integuments together, and thus make the cafe a simple fracture. If a contrary practice is adopted j if poultices, for ex- 33 386 FRACTURES OF THE ARM AHiD WRIST. ample, are applied, tlie adhesive process is prevented, and suppuration pro- duced, which puts life in danger, or renders amputation necessary. If the bones be very much comminuted and the wound large^ all the de- tached portions of bone should be removed ; but in old people, when much injury is done, there is often not sufficient strength to support the suppura- tive process, and amputation should be recommended. Even if suppuration should take place in these accidents, it will not be absolutely necessary to amputate, unless any thing should afterwards happen. FRACTURES OF THE FORE-ARM. 68. The bones of the fore-arm may be both broken to- gether, or they may be fractured separately. The existence of a fi-acture of these bones may be ascertained in the sam© manner as directed for discovering a fracture of the humerus; or by tracing the course of the bones with the finger along their inferior surface. 69. A similar treatment is also required as in a fracture of the humerus. The splints should be laid, one on the inside, the other on the outside of the arm ; so that both bones may be at once effectually compressed ; that on the inside should be long enough to reach the palm of the hand, by which means the wrist will be kept steady, and the radius will be prevented from rolling. They may be confined either by the application of a bandage, or by tying them with broad tapes or riband. FRACTURES OF THE WRIST JOINT. « 70. A compound fracture extending into the wrist joint is a very serious accident, when the radius is much comminu- ted ; but it is an injury which does very well when the radius is broken without being much shattered. If yon should meet with a case of this kind, it would be proper, when torn pieces of bone can be felt at the extremity of the radius, that the wound should be enlarged for their removal ; and, instead of fomentations and poultices being used, that the wrist should be surrounded by lint dipped in the blood, and a roller loosely applied. The arm should be supported on a splint, so as to keep it perfectly free from motion ; evaporating lotions should be applied, and the limb should not be disturbed unless the patient .-.4MiM£tt FRACTURES OF THE CARPrS, ETC. 387 has S3fTnptoms of a suppurative process, when a small opening should be made in the bandage, to allow of the escape of pus, but still the bandages should be allowed to remain. 71. If there should be much inflammation or constitu- tional irritation, you must have recourse to appropriate mea- sures for reducing it. You should take blood from the arm, and apply leeches occasionally. The bowels should be gently opened, but all active purging avoided. 72. If your attempts of reducing inflammation should prove unavailing, and the suppurative process comes on, and extends up the tendons of the fore-arm, it mil be necessary to amputate. The operation should not be performed where the tendons are loose in the ann, but further up, in the muscular part of it ; you will otherwise have a sloughy irritable stvmip. FRACTURES OF THE CARPUS, ETC. 73. Carpus : — The bones of the carpus, "vrhen broken, are usually crushed, as it were, betveen very heav}^ bodies, or torn by violence ; and are commonly followed by severe and troublesome symptoms. When an attempt is to be made to save the part, the chief indications are to extract splinters of bone, and prevent inflammation, abscesses, and mor- tification. The parts may at first be kept wet with a cold evaporating lo- tion, any wound present being lightly and superficially dressed ; but after- wards, as soon as all tendency to bleeding is over, emollient poultices may be put over the dressings instead of the lotion. The dressings themselves, however, should not be removed for three or four days, all unnecessary dis- turbance of the crushed part being highly injurious. Should abscesses form, early openings should be practised, so as to prevent the matter from ex- tending up the fore-arm. Duly supporting the hand and fore-arm in a sling is of the greatest importance. 74. Metacarpus : — A fracture of a metacarpal bone is gen- erally produced by violence applied directly to the part. Bir. Lawrence ehseives, that fractures of the metacarpal bones of the / 388 FRACTURES OF THE THIGH. fingers or thumbs must be treated by keeping the hand in a state of rest. When the hand is very badly crushed, amputation is indicated. 75. Phalanges : — Fractures of the phalanges of the fingers and thumbs sometimes require attentive treatment. It consists in applying a piece of soap-plaster, rolling the part with tape, covering it in pasteboard, sometimes placing the hand on a flat splint, or finger-board, and always keeping the hand, fore-arm, and elbow, well sup- ported. FRACTURES OF THE THIGH. 76. If the fracture is in the thigh, it should be placed over a doable inclined plane, with a splint on each side ; that on the outside should reach from the trochanter beyond the knee ; and, both in this and the former fracture, you should keep the ball of the great toe in a line with the inner side of the patella. I do not like the extended position of the limb, because the muscles are put upon the stretch, and there is danger of a shortening of the limb ensuing. This was the practice about fifty years ago. A compound fracture of the femur generally does better than a compound fracture of the leg, because the bone is so much surrounded by muscle, that the wound made is much more easily closed, and is not therefore followed by the same degree of suppuration. 77. Of the fracture, which happens at the upper part of the thigh bone, there are three distinct species, very different in their nature and result. First, where it happens through the neck of the bone entirely within the capsular ligament. Secondly, through the neck, at its junction with the trochanter major, by which the trochanter is split, and the upper piece is driven into it. Thirdly, a fracture through the trochanter major, beyond its junction with the cervix. 78. First : — Of the fracture within the ligament, and this is an accident which always happens to persons of advanced years ; young persons never have it ; and it more frequent- ly occurs with women than with men. FEACTUEES OF THE THIGH. oS9 Under this accident, tlie leg is from one to two inches shorter than the other; the foot and knee are ecetted. There is little pain when at rest in the recumbent posture. But, on rotatioD, a pain is felt, from the rouirh end of the bone grating against the synovial membranes lining the capsular ligament. The thigh may be perfectly extended, but flexion is more diffi- cult, and atteuded with pain ; this is increased if the thigh be directed to- wards the puhes, and lessened if carried outwards. A crepitus is also dis- coverable when the limb is drawn down, so a^ to be of the same length as the opposite one, and then rotated, but uot so wheu the patient is lying on his back, with the limb shortened. 79. On the first sight of a patient, then, there are two things that -will particularly strike your attention ; the s?iort- ening of the injured limb, with an eversian of the foot and knee. Now, in the dislocation of the femur upwards, the head and neck of the bone prevent the trochanter from being drawn downwards, whilst the neck of the bone, being shortened by the fracture, readily admits of it, and this is the reason why the limb is inverted in the one, and exerted in the other. The limb has been found inverted in this fracture, but it is a very rare oc- earrence. 80. This fracture rarely happens under fifty years of age, and the dislocation seldom at a more advanced period. But the most common period, at which the fracture occurs, is be- tween fifty and eighty. The slightest cause often produces this fracture, from the bones in old persons having undergone the change peculiar to age ; and the way in which they usually happen is from the person slipping off a pavement, and though it is only thedescent of a few inches, the unexpected shock acting perpendicularly on the cervix, with the advantage of a lever, produces a fractuie. The patient immediately falls, and the accident is, frequently, improperly attributed to this one circumstance. Even turning suddenly round has produced it. 81. The union of this fracture has been the cause of much differetice of opinion. It has been said, that these fractures unite, like fractures in any other part of the body, by bone ; but it is my firm opinion, that fractures of the neck of the thigh bone, of the patella, olecranon, coronoid process of the j-^-^-^-^. 390 FRACTURES OF THE THIGH. ulna, and condyles of the os humeri, unite by ligament, and not by bone. In all the examinations which I have made of transverse fractures of the cervix femoris within the capsule, I have had my opinions confirmed, as I have not met with a single instance in which bony union had taken place. T would not maintain its impossibility, but what I wish to be understood to say is, that, if ever it does happen, it is an extremely rare occurrence, and that I have never yet met with a single case. 82. There are many reasons, which may be assigned for the want of ossific union in the transverse fracture of the cervix within the ligament. 83. The first reason is, the want of the proper apposition of the fractured ends of the bone. It is scarcely possible to preserve the parts in apposition, even for a few hours, and the sliglitest change of position produces an instant contraction of the large and powerful muscles passing from the pelvis to the thigh; so that the ends of the bone become immediately displaced. This is also the case in fractures of the patella, where, notwithstanding all your efforts to prevent the retraction of the muscles, it very seldom happens that you can succeed in supportiug a complete approximation of the bones. 84. The second reason for a want of a bony union is, the want of pressure of one bone on another. Even if the limb were preserved at its proper length, and admitting the capsular ligament not to be torn, this circumstance would operate to pre- vent an ossific union. There is a large quantity of synovial fluid secreted into the joint, this distends the ligament, and entirely prevents the contact of the bones. After a time, this fluid becomes absorbed, but not until the inflammatory process has ceased, and ligamentous matter has been effused into the joint from the surface of the synovial membrane. 85. The third and principal reason of the waut of ossific union is, the almost entire absence of ossific union in the head of the bone, when detached from the cervix. The natural supply of blood, for the neck and head of the bone, is deri- ved from the periosteum ; and when the neck is fractured, and the perios- teum torn through, the means of ossific action are necessarily cut off. FRACTURES OF THE THIGH. S91 deposit of cartillage or. bone, as in other fractures, is produced, but there is a deposition of ligamentous matter covering the surface of the cancellated structure. ' In dissection of these accidents, you find that the cancelli are rendered firm and smooth by friction, as in other banes which rub on each other when their articulating cartilages are absorbed. Portions of bone remain attached by ligament, or are loose and floating in the joint, covered by liga- mentous matter ; butthese do not excite inflammation any more than similar portions which are found in the knee or in the elbow joints. The capsular ligament, and the synovial membrane are very much thickened, from the inflammation which they have undergone, and are therefore very much strengthened. This membrane is sometimes separated from the fractured portions, so as to form a tiiick band passing from the fractured edges of the ■cervix to the bead of the bone. Ligamentous matter passes also from the ■cancellated structure of the head to the neck, thus uniting, by a flexible material, the one broken portion of bone to the other. 86. With respect to the treatment of fracture within the capsule, numerous measures have been adopted for the pur- pose of producing an ossific union, both by myself ahd others, but all to no purpose. Disappointed in the attempt, and finding the patient's health suffer from the necessary confinement, what I now direct to be done is, that a pillow be placed under the limb, throughout the whole length, and another be put under the knee, and the limb be, in this way, extended for ten days or a fortnight until the inflammation has subsided. Then let the patient get out of bed, and sit on a high chair, to prevent being too much bent, afterwards walk, with crutches, bearing gently, at first, on the foot, then increase the pressure more and more, until the ligament becomes thickened, and the power of the muscles increased. Next, let him use a shoe with a high heol, which would very much diminish his lameness. The patient treated in this way walks after a day or two with a crutcfi, then with a stick, and in a few months requires no additional support. But in all cases in which the slightest dmibt may be entertained, whether the fracture be within or without the capsule, it is much better to treat them as if they were external to the capsule, and which fracture will unite by bone. 87. Secondly : — In fractures external to the capsule, and when the neck of the bone is driven into the cancellated structure of the trochanter m.ajor, the leg is from half to three-quarters of an inch shorter than the other ; and they 392 FRACTURES OF THE THIGH. generally happen in the young, and in persons under fifty years of age. The foot and toe are everted, moch pain is fe?t at the hip, and on the mner And upper part of the thigh, and the usual rotundity of the joint is lost; cre- pitus is easily produced by a sliglit motion of the Hmb, and it is not necessa- ry, in this accident, to draw the leg down to feel the crepitns, as the retrac- tion is not so great as in the former accident. There is also usually great extravasation into the surrounding parts, and this swelling is quickly fol- lowed by a great tenderness to the touch, also violent pain is produced upon slight motion of the joint, followed by a high degree of const! tntiona! irritation ; and m^any months elapse before the patient recovers a proper use of the limb. The accident is usually the result of very severe injury. 88. The principle to be attended to in the treatment of this fracture is, the approximation of the bones by pres- SttiC. You must press the trochanter toAvards the acetabuTum, at the same time preserving the length of the limb, by applying a roller around the foot of the injured leg, and binding it firmly to the sound one, thus making the sound limb afford support, and act as a splint to the fractured one. A broad leather strap should be buckled around the pelvis, and include the trochan- ter major, so as to press the fractured portions of bone firmly together ; and the best position, in which you can place the limb, is in a straight direction with the body. I have also, known cases do very well where the patient has been laid on his back on his mattress, and the thigh brought over the double inclined plane, which may be very easily made by three boards, one passing from the tuberosity of the ischium to the foot, and the two others, having a joint in the middle, by which you can increase the elevation of the angle as may be required; over these a pillow should be thrown. A long splint should be then placed on the outer side of the thigh, fastened above with a strong strap around the pelvis, and secured below by another strap aroimd the knee, so as to prevent the knee being moved from its position. Thii must be persevered in for several weeks, and the patient may then be al- lowed to rise from his bed, if the attempt do not give much pain. He must still, however, wear the strap around the pelvis, and he thus recovers, with a useful but shortened limb. 89. Thirdly : — Fractures through the trochanter major are gener£llly oblique, and they may happen without any injury being at the same time done to the neck of the bone. ^ii«ii.M>^^^i*^»»^" " ' -?;^^!^J«S^'? FRACTURES OF THE THIGH. 393 These fractures occur at any period of life, and are marked by the fol- lowing symptoms : the limb is very little, anil sometimes not at all, shorten- ed ; there is a numbness in the foot; the patient cannot turn in bed without assistance, and the attempt is productive of great pain. The trochanter is sometimes drawn forwards towards the ilium, sometimes it falls towards the tuberosity of the ischium, but is generally widely separated from that portion of bone remaining in connexion with the neck. The foot is greatly everted, and the patient cannot sit, as any attempt to do so produces veiy great pain. You can feel a crepitus with great difficulty, if the detached portion of the trochanter he either much fallen, or much drawn forwards. 90. The treatment of this fracture is much the same as that of the former. It unites ver}^ firmly, and the patient re- covers a good use of the limb. You should pass a wide bandage round the pelvis, and keep the limb ex- tended, and the patient in the horizontal position, io the way before pointed out. 91. Sometimes the femur is fractured just beneath the trochanter, and the deformity produced by this accident is very- great, which is caused by the upper end of the bone being drawn upwards by the action of the psoas magnus, and ilia- cus internus. The proper way to treat it is by raising the thigh over an inclined plane, and elevating the trunk to about an angle of 45°. In this manner you bring the ends of the bone in apposition, but you should not attempt to de- press the upper end of the bone, as it only increases the patient's suiferings to no purpose. 92. When you meet with fractures of the condyles of the femur, extending into the joint, you will find great swelling of the joint, a crepitus, and deformity. In these accidents, you should place the limb on a pillow in the extended position, for then the head of the tibia keeps the extremities of the bone in their places. You should apply evaporating lotions, and leechrts ifisecessa- ry, to subduR the inflammation, and then mould a piece of stout pasteboard, moistened, round the knee, and bind it on with a roller. This, when dry, adapts itself equally to the different surfaces, and forms a most excellent splint to retain the fractured extremities of the bone. After five weeks, you should commence passive motion, otherwise, anchylosis will take place. The same observations apply to fractures of the head of the tibia. 394 FRACTURES OF THE PATELLA. 93, If a compound fracture extend into the knee joint, and the opening be large, it will be necessary to amputate j but if the opening be small, try to procure adhesion, and thus make it a simple fracture. FRACTURES OF THE PATELLA. 94. The patella is generally broken transversely, but sometimes longitudinally. It is also subject to compound fracture. 95. Transverse Fracture : — In this accident, the upper part is drawn from the lower by the action of the muscles insert- ed into it, whilst the lower part remains fixed by its liga- ment. The degree of separation depends on the laceration of the ligament. The accident \a at once known by the depression between the two por- tions of bone, into which you may put your fingers, and by the upper part of the bone moving readily on the lower and fore part of the thigh. The power of extending the limb is also lost, and the knee bends forwards from a loss of action in the extensor muscles. Soon after the accident, extrava- sation takes place on the fore part of the joint, and produces a livid ap- pearance, but this is removed by absorption in a few days. There is after- wards considerable effusion from inflammation into the surrounding parts. 96, The union of this fracture is generally by ligament, whether the separation of the bones be great or little j but still the principle, which should guide you in the treatment, is, to make that ligament as short as possible. When called to this accident, you should place the patient on a mattress extend the limb on a well padded splint, which is placed behind the thigh and leg. The patient should be raised as much as he can to the sitting pos- ture, to relax the rectus ; an evaporating lotion of white wash should then be applied, and the heel should also be raised towards the trunk, to bring up the lower portion of the patella, If there should be much inflammation continue for a day or two, leeches should be applied, and evaporating lo' tions continued ; and, when the tension has subsided, you may apply your bandages. The mode generally adopted, is to pass a roller from the foot to the knee, fo prevent the swelling of the leg; then rollers are applied above and be- FRACTURES OF THE PATELLA. 395 low the joint, under which a piece of broad tape is passed on each side, which crosses the rollers at right angles, and, by tying these, the upper portion is brought down toward the lower. But the plan which I like best is this : buckle a leather strap around the thigh, above the fractured por- tion, and from this another strap should be passed beneath the foot, the leg being kept extended and the foot raised ; this strap is brought up on the other side of the knee, and buckled to the circular strap above the knee j a roller should also be applied on the leg. After keeping the limb in this position five weeks, you may begin to use slight passive motion,^ taking great care, however, not to do too much, as you would separate the liga- mentous union that had been formed. You may increase this from day to day, until the limb can be bent perfectly. 97. The smallest distance, at which I have known the patella to unite, is half an inch, and the greatest distance, seven inches ; a moderate distance is one or two inches. Tt sometimes happens, that, from the degree of separation, the patient loses the command over the motions of the leg, and in such cases you must exercise the muscles by letting the patient swing his legs over a table, in order to accommodate the muscles to their new line of action. Unless this be done, or passive motion be used, the patient can never recover the use of the limb. 98. Longitudinal Fracture : — In the longitudinal fracture of the patella, the bone also unites by ligament. T have seen it unite by bone, but it was rather a fissure than a fracture. The treatment will be to apply leeches and evaporating lotion? ; in a few days a roller should be applied, and then a laced cap, with a strap to buckle ahove and below the knee, with a pad on each side of the patella, to bring the parts as nearly as possible in contact. 99. Compound Fractures : — Compound fractures of the pa- tella are very dangerous accidents, frequently proving fatal to life, from the violent degree of constitutional irritation which they occasion. They are generally recovered from by the following treatment : bring the integuments together by a small suture, apply adhesive straps round the knee, evaporating lotions on the fore part, and keep the limb extended by a splint passed beneath. Whenever a joint is laid open, except by a valvular opening, that wound }s difficult to heal, from the flowing of the synovia; but if the integumeqta I '^ 396 FRACTURES OF THE LEG AND FIBULA. be brought together by a suture, the parts beneath often heal by the adhe- sive process. The suture should not be kept in mote than a week. FRACTURES OF THE LEG. 100. Tn fractures of the leg we may have the two bones broken together, or we may have them broken separately. The first is the more frequent accident, and the usual 8ymptoms,by which it is attended, are a change in the direction and shape of the limb, pain, and incapability of walking or bearing upon the limb, mobility of the fractur- ed pieces, and a distinct crepitus. 101. The same cooling wash, or soap plaster, will be proper, in these cases, as in fracture of the femur ; and over one of these the many-tailed bandage. Two splints are then to be applied, the one on the outside, the other on the inside, of the leg. In applying them, care should be taken that the out- side splint be long enough to reach completely from the knee to the toes. The limb may thea be either laid straight out, and still further secured by the application of junks and a foot-board, or it may be laid on its side upon soft pillows, with the knee a little bent. FRACTURE OF THE FIBULA. 102. A fracture of the fibula generally happens from two to three inches above the ankle joint. This accident may occur, either in consequence of some violence directly ofFcred to the fibula, — that is, some blow upon the bone, fracturing it at the point of contact, — or it may happen in consequence of a twist or dislocation of the fool. 103. In fractures of the fibula only, as Mr. Pott observes, the position is not of much consequence ; because, the tibia remaining entire, the figure of the leg is preserved, and ex- tension quite unnecessary. Splints are to be applied, and the limb treated as for a fracture of both bones ; with the exception of a roller, which is to be substituted in the place FRACTURES INTO THE ANKLE-JOINT. 397 of the usual bandage. It should at first be loosely applied, but afterwards gradually tightened and extended to the foot. FRACTURE OF THE TIBIA, 104. The tibia may be broken independently of the fibu- la ; but as, in these cases, there is no material displacement, the common treatment for fracture of bones may be safely adopted. FRACTURES INTO THE ANKLE JOINT. 105. If a compound fracture should extend into the ankle joint, that, of itself, would form no reason why amputation should be performed ; but you should be guided principally by the nature of the injury, by the age, and also by the con- stitution of the patient. 106. If the compound fracture extending into the joint be oblique, it will generally do well, provided care be taken to procure adhesion of the wound. This is best effected by applying lint dipped in blood to the lacerated in- teguments, and allowing it to remain there until it separates spontarjeously. The many-tailed bandage should be applied, and kept wet with a spiritous lotion, composed of spirits of wine and water. A splint should be applied on each side, padded with cushions, so as to preserve the great toe in a line with the patella. Place the leg on its outer side, in the senuflex position, BO as to relax the muscles, and render the patient's position as easy as pos- sible. The position, however, will require to be varied, according to the situation of the wound. 107. In these accidents, if the bone is comminuted, as well as broken into the joint, and if there is bleeding from any large vessel, it will be proper to amputate immediately ; more especially if the person is obliged to work hard for his support, for, after recovery from comminution, the bone will bear but a slight degree of exertion. 398 DISEASES OF BONES. But still, if the constitution be good, and the person is about the middle age, it is right to take away the small pieces of bone, heal the wound by adhesion, and ptoduce anchylosis. DISEASES OF BONES. 1. The diseases of bones which we shall now consider are the following ; viz. inflammation of bones ; periostitis ; suppuration in bones ; caries ; necrosis ; exfoliation of bone : exostosis ; and mollities ossium. INFLAMMATION OF BONES. 2. The same organization, which enables bones to repair the effect of injury, renders them liable to inflammation, and the various changes which are consequent on that process. Inflammation of a bone may arise from external causes, that is, from ac- cidental injury, such as a blow ; or from internal causes, such as a scrofu- lous disposition of the system, or influence exerted over it by the venereal poison. 3. Inflammation of the bone may, as in the soft parts of the body, be either acute or chronic j it may vary consid- erably in different cases. Enlargement from intersticial deposition and ulceration, or caries, pro- ceeds from what we should call chronic inflammation of the bone, whilst suppuration and necrosis are referable to acute inflammation. 4. Persons, labouring under inflammation of the bones, experience a deep-seated, aching pain, extremely distressing to the feelings, and finally affecting the health to so remarka- ble a degree as to induce a speedy emaciation of the body. The part at length swells, and a tumour forms, possessing great hardness ; the skin becomes red and extremely 8ensible,and there is an increase of heat, with other symptoms of inflammation. PERIOSTITIS. 399 5. Treatment : — This must be regnlated by the sta2:e and urgency of the symptoms. During the inflammatory stage of the affection, by antiphlogistic means, by the abstraction of blood from the part, and other measures of the same character; and, when the active period has passed bv, counter-irritation, such as setons, issues, and the application of mosee should be resorted to. PERIOSTITIS. 6. The periosteum, or the fibrous membrane which cov- ers the bone, is equally liable, if not more liable to inflam- mation than the bone itself. As contrasted with inflammation of the osseons structnre, inflammation of the periosteum is much more rapid in its developement j it takes place much quicker; it is seated upon the bone, and is firm to the touch, though possessing a certain degree of elasticity. 7. The symptoms of periostitis are not only locally severe, but the constitution at large participates in the complaint. The pain is considerable ; for, being fibrous, and of a very condensed na- ture, the structure does not easily give way ; and, when the inflammation ijs extensive, considerable sympathetic eSect is produced ou the circulating and digestive systems, and more or less general disturbance ensues. 8. Treatment : — Periostitis must be treated much in the same manner as inflammation of the bone. During the inflammatory period of the affection, you must employ a pretty active local antiphlogistic treatment. You must apply leeches to the part affected, — relieve the pain and tenderness by fomentations and poultices ; or, if these should faiJ, you must employ mercury to such an extent aa to affect the svstem. SUPPUEATIOX IX BONES. 9. Abscesses are sometimes found between the perioste- um and surface of the bone ; at other times within its can- cellated structure ; and occasionally^ but very rarely, between the lamina forminsr the shell of the bone. 400 SUPPURATION IN BONES. 10. First : — When an abscess forms between the perios- teum and surface of the bone, it possesses the common char- acters of the formation of matter. There is severe pain extending along the surface of the bone ; this pain, though severe, is not of an obtuse liind ; it becomes worse at night, and produces an inequality on the surface of the bone. It is a long time, how- ever, before tlie periosteum ulcerates ; the skin presents a circumscribed blush ; you may even feel a fluctuation for a long period before the abscess breaks. 11. When you have ascertained that matter has formed, it should be evacuated as soon as the redness and fluctuation are distinct. The opening should be small, for, if it is left to nature, or a large wound made by the surgeon, the bone is deprived of its supply of blood, the part exfoliates, and gran- ulations afterwards shoot out. As soon as the matter has been discharged, the periosteum should be placed on the bone, as closely as you can, leaving a small opening for the escajie of the matter, and apply, at the same time, straps of adhesive plaster round the opening, to keep the periosteum in contact with the bone, and the probability is that the parts will unite by bone. The treatment to be further pursued is this : if the bone be much expos- ed and die, touch it with an acid that will decompose the phosphate of lime, and the cartilaginous part also; and, for this purpose, the lotion of muriatic acid, commencing with two drops to an ounce of water, or tlie lo- tion of nitric acid in the same proportion, will be found the most useful : I think, however, that the diluted nitric acid is the best ; it induces a healthy state of the bone and of the other parts. 12. Second : — When an abscess forms in the cancellated structure, a peculiar process takes place. The result of the pressure of the abscess is to cause an absorption of the can- cellated structure, and, in this way, the space for the increase of the abscess continues to be enlarged. It is sometimes called Medullary Abscess. At the time that there is an inflammatory action existing in the medulla- ry membrane, there is a corresponding degree of inflammation going on in the periosteum, which causes a bony crust to be deposited on the surface, which materially increases the size and strength of the bone. But, upon that part of the bone least covered by skin and muscles, there is an ulcera- ■ ^ "*''«*-'^-'-' CAKIES. 401 tive process going on, which overcomes the deposit from the periosteum, and thus the matter is evacuated. In this way, it often happens that there is little of the original bone left, but the weight of the body is principally supported by the new shell of bone which is formed. 13. In these cases, if the constitution is so enfeebled that it cannot deposit a sufficient quantity of bony matter exter^ nally, whilst the process of absorption is going on within ; then the coats of the bone become so thin, that the bone ei- ther breaks, or cannot support the superincumbent pressure. The best treatment to be pursued, in this stage of the disease, is to inject the interior of the bone with the muriatic or nitric acid lotions, the latter is preferable, and at the same time insist on the observance of rest. Sup- port the constitution, and avoid all those causes, which would produce irri- tation, either generally or locally. 14. Third : — Abscesses in the shell of the bone require to be treated in the same way, and their process of restora- tion occurs rather quicker than when the abscess is seated more internally. CARIES. 15. Caries is a disease of the bones, supposed to be very analagous to ulceration of the soft parts. The bones, like other parts of the body, are composed of arteries, veins, absorbent vessels, nerves, and a cellular texture. They are endued with vitality ; they are nourished, they grow, waste, are rejiaired, and undergo various mutations, according to the age of the individual, and they are subject to diseases analogous to the soft parts. 16. Bones of a spongy texture are more frequently at- tacked by caries, than such as are compact. Hence, the vertebrae, astragalus, and other bones of the tarsus, — those of the carpus, the sternum, the pelvis, and the heads of long bones are often affected ; and the bones of young persons are unquestionably more fre- quently the seat of caries than those of old subjects. 34 402 NECROSIS. 17. In the most common species of caries, a loose fun- gous flesh grows out of the interstices, formed on the surface of the diseased bone, and bleeds from the slightest causes ; while, in the soft parts, a sinus generally leads down to the caries, and emits a very fetid, dark-coloured sa- nies. Different writers have endeavoured to demonstrate different species of caries ; but tiiere are, at present, so many circumstances, throwing obscuri- ty on preciseneas, that they can only be divided into three kinds, viz. : caries from external causes, caries from an internal local cause without disease, and caries from a general internal cause, or constitutional disease. 18. Treatment : — The indications in the treatment of ca- ries are ; either to produce a change in the action of the diseased portion of bone, whereby it may regain a healthy state ; or to destroy it altogether. The first indication is to be attempted by diet and internal remedies, and the second by the actual and potential cauteries, and cutting instruments. NECROSIS. 19. This disease of the bones is very similar to caries, yet sufficiently distinguishable by its characters. In caries, the nutrition of the bone is only impaired, and an irregular action disunites the elements of the bony structure, which consequently sustains a loss of substance ; but every remaining part is yet alive. In necrosis, on the contrary, the vitality and nutritive functions cease altogeth- er in a certain portion of the bone, the reparation of which then becomes indispensable. 20. The causes of necrosis are not essentially different from those which produce ulcers and gangrene of the soft parts. These may be wounas, contusions, pressure, fractures, comminutions, acrid substances, caustics, extreme degree of heat or cold; or they may exist in constitutional disease. EXFOLIATION OF BOXE. 403 21. The symptoms "vrhich attend necrosis are those of a high inflammatory character. There is a considerable general tumefaction of tlie WiriL ; a firm tumefac- tion with increased heat, throbbing, and violent pain j and when you put the hand to the part and grasp it, you are sensible of a considerable increase in the size of the bone. With these local symptoms, you have very con- ^ iiderablo disturbance of the circulation ; decrease of appetite ; white tongue ; thirst J want of sleep ; and very commonly delirium. 22. Treatment : — "W'e have just seen that both the local and general systems are highly inflammatory; your treat- ment must, consequently, be strictly antiphlogistic. Free abstraction of blood, by leeches, fomentations, and ?uch kind of treatment, may alleviate, in some degree, the sufferings of the patient, but it does not put a stop to the progress of the complaint. The greatest bene- fit we can produce, by surgical treatment, is by making free openings in the early period of the affection, so as to give issue to matter as soon as formed in the neighbourhood of the bones. When a free vent has been ^ven to the matter, we sometimes can bring the disease into a quiet state bj keeping the limb at rest, and by employing counter-irritation. EXFOLIATION OF BONE. 23. By exfoliation of bone is meant the spontaneous sep- aration of one part from the other ; and this roay be external or internal. The process of separation is the game as among soft parts ; — nl'^ern.tion takes place, granulations form between the dead and living bone, and the useless portion thus becomes detached and forced away. 24. External : — T\Tien the periosteum is separated to any extent from the surface of the bone, if it be immediately replaced, it vrill again unite, and no exfoliation will take place ; but if it be allowed to remain detached from the sur- face 'of the bone for twenty-four hours, it will not re-unite, the bone dies, and is ultimately separated. 404 EXOSTOSIS. The dead portion of the bone appears at first white, but it soon becomos black from the hepatized ammonia formed during the putrefactive pro- cess. 25. The separation of the dead from the living portion of the bone, is a tedious process, and is effected by the action of the absorbents on the surfaces of the living bone, removing that part which is in absolute contact with the dead bone j a space is thus formed into which granulations can rise. When these granulations reach the dead bone, they also act on it, and therefore you find the surface rough and uneven, which is in contact with them, whereas the external surface remains perfectly smooth. 26. The object of your treatment, in this case^ should be^ to quicken the process of the granulations a little, and to act chemically on the parts by the use of acids. It is right, if we wish to diminish the size of the exfoliation, to bind it upon the granulations, which will absorb a part of it, according to experi- ments made by Sir William Blizard on this subjects 27. Internal : — Internal exfoliation is also a very singular process, which I have already described to you, when speak- ing of medullary abscess. In the treatment of this disease, as soon as the bones become loosened^ which you may easily know by passing a probe into the wound, what I should advise you to do is this : take away a portion of the new bone, so as to admit of your sawing the old bone into two portions, and then draw them out. EXOSTOSIS. 28. An exostosis is a tumour formed by an exuberant growth of bony matter on the surface of a bone. 29. Exostoses have two different seats j from whence they may be named periosteal and medullary. EXOSTOSIS. 405 By periosteal exostosis, I mean an osseous deposition, seated between the external surface of the bone and the internal surface of the periosteum, and firmly adherent to both ; and medullary exostosis I call a similar formation, originating in the medullary membrane, and cancellated structure of a bone. 30. Exostosis I would also divide into two other general divisions, according to their structure, as being either carti- laginous or fujigous. 31. Cartilaginous : — The cartilaginous exostosis contains only a very small quantity of the phosphate of lime, and grows originally from the inner surface of the periosteum, and spiculse of bone afterwards shoot into it. Where the exostoses are cartilaginous, growing from the periosteum, they cease to increase beyond a certain extent, and usually form at tha insertion of the triceps adductor magnus. You should make an incision through the integuments, cut through the muscle in the direction of its fibres, and having reached the top of the exostosis, you find the knife easily sinks into it, from its being still partly cartilaginous. Then slit down the muscle on each side, and apply the circular saw invented by Mr. Machim, which is worked by a winch in the handle. 32. When the exostosis arises from the cancellated struc- ture of the flat bones, and the diseased surface is not large, you may get rid of it by a different plan. Make an incision through the periosteum covering the tumour, and then separate it further with the knife on each side, and the exostosis will be gradually discharged by the suppurative process. 33. Fungous : — The fungous exostosis is rather a nest of bone enveloping the fungus, than constituting the fungus itself It grows from the medullary membrane. In the treatment of the fnngous exostosis, nothing can be done but to pal- liate ; the growth will proceed, in spite of local and constitutional rem- edies. 406 MOLLITIES OSSIUM. 34. The disease thus named is intended to signify, a morbid softness of the bones, which become preternaturally flexible and incapable of forming a natural support to the soft parts. This state of the bones is the consequence either of the inordinate absorp- tion of the phosphate of lime, from which their natural solidity is derived, or else the matter not being duly secreted into their texture. 35. The mollities ossium is an exceedingly uncommon disease, and its causes are buried in obscurity. It is supposed, however, to depend upon some peculiar state of the con- stitution, and the individuals attacked with it have been remarked to be most about, or rather beyond, the middle period of life, and generally, if not always, women. 36. This disease, when once established, generally goes on to the destruction of the patient. Your indications of treatment should be to alter and invigorate the sys- tem at large, and to palliate such symptoms as are under your control. ON BURNS AND SCALDS. 1. Burns and scalds produce three different effects, vesi- cation, desquamation, and gangrene. 2. First : — If called in when vesications only are produced, there is no danger, although the vesicles be numerous and extensive. The object is to preserve them from bursting, and therefore do not open them on any account, but allow the serum to accumulate in them, until a new cuticle is pro- ON BURNS AND SCALDS. 407 duced ; the serum escapes, and there is no further mis- chief. If you open them, there is a constitutional effort produced, -which is fol- lowed by some considerable inflammation, and sometimes by suppuration, and the sufferings of the patient are very great. All you have to do, is to apply evaporating lotions, as the camphorated spirits of wine, or spirits of wine; and the diluted solution of the acetate of lead, to prevent the disposi- tion there is in the cuticle to break. A little opium should also be given, to allay the irritability. 3. Second : — When the burn is severe enough to produce desquamation, the most violent symptoms arise ; indeed, it is the worst stage of the injury, from leaving the cutis unpro- tected. The si)irits of turpentine is the best application in this form of burn, as the object is to excite a speedy re-action ; and, if you apply evaporating lotions, re-action can never take place. Lime water and the oil, and lime water and milk, have been commonly used ; but the spirits of turpentine is the best application. Where the constitution is irritable, and it gives violent pain, dilute it with oil, or with oil and lime water, and I think it would then form a very good application. Give opium and wine as long as the chilly state continues ; but as soon aa the heat is developed, and the pulse has recovered its power, do not con- tinue it any longer, but employ other means to reduce inflammation when necessary. 4. Third : — The third effect, sometimes produced, is gangrene, or the death of the parts. There is no immediate danger when this takes place, for the constitution does not suffer in the first iuLUance ; but it is to be feared when the sphacelated part begins to separate. The absorbents act briskly, and a great discharge follo-vvs the separation of the part. Fomentations and poultices are most useful in those cases, as the turpen- tine cannot act on the dead surfaces. It is necessary to give wine and opium during the chilly state, as in the former case. The treatment is just the same, indeed, as in a case of common gangrene, and towards the end, when the process of suppuration is commencing, you may give wine and opium, or ammonia, to support the constitution. 408 ON BURNS AND SCALDS. 5. Alter severe burns or scalds, you will often have the most remarkable deformities, and they are usually owing to the natural tendency which there is in the cicatrices to con- tract. The wounds will often heal smoothly, but afterwards become puckered. These contractions are apt especially to occur in the neck, by which the skin is united to the chest ; and, if the arm be the burnt part, the fore-aim becomes united to the upper-arm. The fingers become united to each other, and the thumb is sometimes bent very mucli backwards. 6. Such, indeed, is the deformity in many cases, that you ought to give your attention to prevent them as much as you can. The contraction in the arm may be prevented by passing a splint behind the arm, and keeping the arm extended on it. The same rule should be attended to if there is any danger of the thigh uniting to the abdomen. You should pass a splint behind the thigh, and keep the thigh extended on it, and the contraction will be prevented. With respect to the neck, do what you will, you cannot prevent contractions. 7. In burns or scalds, when the cuticle is removed, and the cutis is in a granulating state, you may produce cuticle over it very easily, by proper treatment. This object is sometimes well accomplished by sprinkling the granulations with the oxyde of zinc. But a lotion of two grains of the sulphate of zinc, to an ounce of the liquor plumbi subacetatis dilutus, appears the best ap- plication to me. Some lint should be dipped in the lotion, and laid on the wound ; over this, some folded linen should be placed, and over the whole a piece uf oiled silk, to prevent evaporation. END OF PART I. 409 MANUAL OF SURGERY. PART 11. CONTAINING PKACTICAI, NOTES CHIEFLY SELECTED FKOM A SERIES OF LECTTJP.es ON DISEASES OF THE EYE. DELfTERKD BT JOSEPH HENRY GREEX, ESQ. F. R. S. PROFESSOR OF ANATOMT TO THE BOTaL ACADEMY, surg£o:t to, and lecturer ox surgery, ST, Thomas's hospital. 35 411 MANUAL OF SURGERY. I DISEASES OF THE EYE A^'D ITS APPENDAGES. SECTION I. I« consequence of the various affections of the eye, I shall first speak of simple inflammation of the tunica conjunc- tiva ; then of its modifications; its consequences, and treat- ment. SECTION II. I shall next speak of simple inflammation of the deeper seated tunics, those of the globe of the eye ; the consequen- ces of such inflammation, and the treatment which it may be proper to adopt. SECTION m. Thirdly, I shall describe the diseases of the humours, and particularly that disease of the crystalline lens which termi- nates in cataract ; and the operations which are necessary for that disease, &:c. SECTION IV. Lastly, I shall speak of the diseases of the appendages of the eye, their treatment, and the operations required for Aeir cure. 412 SECTION I. OF SIMPLE INFLAMMATION OF THE CONJUNCTIVA, ITS MODIFICA- TIONS, CONSEQUENCES, AND TREATMETJT. SIMPLE INFLAMMATION OF THE CONJUNCTIVA. 1. Simple inflammation of the conjunctiva may be divi- ded, like other inflammations, into acute and chronic. 2. Acute Ophthalmia : — The symptoms of the afiection in question do not difier from those of acute inflammation of other parts of the body, except in so far as they are modified by the structure of the part, and by the function of the or- gan. We will first speak of the local appearances, and af- terwards of the constitutional derangements. The first symptom is redness of the part ; which is very remarkable, be- cause the blood naturally conveyed by the vessels to this part is coiourlesa. The vessels become injected with red blood. When the irritation contin- ues, the vessels become still more apparent, and at length, all the interlace- ments and anastomeses of the vessels of the conjunctiva partake of the inflammation, and present almost one uniform appearance of redness. During this time, more or less pain is experienced: at first, as the vessels become filled, an uneasy sensation is felt; this increases, and at length, upon the admission of light, a sharp lancinating pain is experienced ; the patient is under the necessity of keeping the eye closed, and, indeed, has some difficulty in raising it, not only from the pain he suffers, but from the degree of fullness and swelling with which it is accompanied. This pain goes on increasing, and at length the patient complains of a burning heat, and a sensation as if some extraneous body were lodged in the conjunctiva of the lid. At this time, the admission of the least light or air produces such lancinating pain, that the eye is spasmodically closed. The afiection is also attended with a more abundant secretion of tears, which, at the highest stage of excitement, is suddenly diminished, and SIMPLE LN'FLAMMATION OF THE CO^'JUNCTIVA. 413 there is a preternatural dryness of the eyes, producing j)ainful sensations. A considerable degree of swelling takes place, the conjunctiva becomea turgid from the quantity of blood admitted by the vessels, and effusion fol- lows. Although the swelling is pretty equally diffused over the whole sur- face of the conjunctiva, it seems to be the greatest at the transparent cornea, because here the coat is more tightly adherent. The conjunctiva is here elevated in a circular fold, and this appearance is called chemosis. The eyelids are in general more or less swollen. Not only is pain experi- enced in the eye, from the causes I have mentioned, but also a sense of weight and fulness in the globe of the eye, as if the ball were too large for the socket. The neighbouring parts also, the forehead and temples, partake of the pain; there will be a shooting pain to the maxillary bone, or more deeply seated in the head j and these pains are in some instances extremely violent. 3. The local symptoms, as we have already hinted, are attended with considerable constitutional eifects. There will be a greater or less degree of constitutional irritation, great lassitude, prostration of strength, chilness or rigour followed by heats. The skin will often be hot and dry, pulse quick and hard, stomach affected, and ■vomiting produced. The patient will also complain of pain in the back, and, in short, of ail the symptoms which indicate a considerable fever of the sympathetic kind, arising from local irritation. 4. The degree, in which the symptoms of this disease occur, will very much depend on the constitution of the pa- tient. In young and robust persons, there will often be a high degree of local inflammation, without much constitutional irritation ; while, on the other band, in delicate and irritable patients, a much less, nay sometimes a very trifling degree of local inflammation, will be accompanied with violent symptoms of constitutional derangement. 5. The principal causes of this complaint are, the admis- sion of any extraneous body, and variations of temperature, especially if accompanied by intense heat and light, or par- tial exposure to drafts of cold air. It will not be necessary to point out the predisposing causes of this com- plaint, because they do not differ from the predisposing causes of inflamma- tion in any other part of the body. 414 SIMPLE INFLAMMATION OF THE CONJUNCTIVA. 6. Chronic Ophthalmia : — The term chronic, to inflamma- tion of the conjunctiva, is not applied merely with reference to duration of time ; it is not only applied to signify that state of congestion and debility of vascular action produced by the acute stage ; but it is also applied to that state of in- flammation, which, from the commencement, has a charac- ter of atony and debility. As this is the most frequent form in which you will find this inflamma- tion, whether primary or following the acute stage, it is necessary to attend particularly to the symptoms by which it is distinguished, as the mode of treatment is very different from that which is required in acute inflammation. 7. The symptoms of chronic differ from those of acute inflammation of the conjunctiva, rather in degree than ia kind ; so that, after they have existed for some time in the acute stage, you find the disease gradually passing into the chronic stage. The redness will be less intense, the pain which accompanies it less acute, the intolerance of light will be less, the chemosis and swelling will be di- minished, the effusion of tears less considerable, the constitutional irritation will, in a great degree, have subsided, and, in short, all the acute symptoms will be mitigated. There will still, however, remain a considerable degree of irritability in the eye, on exposure to light ; some artificial defence, to exclude the light, will be necessary, and the person will still be incapable of applying the organ to the ordinary purposes of vision. 8. The causes of chronic inflammation, both exciting and predisposing, are very similar to those of acute inflamma- tion ; but there are many causes which tend to produce this inflammation, accompanied with atony and debility in the very onset, which distinguish it from acute inflammation. Chronic inflammation of the conjunctiva is very apt to take place, where the patient has for a long time been labouring under disorder of the diges- tive organs. It is not unfrequently the concomitant of dentition, measles, or small pox ; it sometimes accompanies rheumatism and gout. Frequent intoxication and various other causes may predispose to it. It is also very apt to arise from, ur to be kept up by, exposure to aciid fumes or smoke in particular trades. I T'l "'i JM III' iill ' I SIMPLE INFLAMMATION OF THE CONJUNCTIVA. 415 9. In general, inflammation of the conjunctiva is a very manageable complaint. It passes into chronic inflammft- tion after the acute stage has continued for a certain time, and it not unfrequently subsides of itself. A spontaneous cure must not, however, be depended upon, and we oug:ht on no account to neglect or relax in the proper nwde o^f treatment, from any reliance upon such a cure ; because by simple inflammation of the deeper seated tunics of the globe of the eye, suppuration may be induced, the organ may at length become permanently disorganized, and the sight of the eye irretrievably lost. 10. The consequences of inflammation of this membrane are very similar to those of inflammation in other parts of the body ; namely, eSiision, adhesion, suppuration, ulcera- tion, and mortification. It sometimes terminates in effttsion, the serum or bkrad under the con- junctiva rising in a roll above the cornea. It sometimes produces the adhesive process ; and, when it terminates in this manner, the adhesive matter is deposited under the conjunctiva, which «overs the transparent cornea, and is recognized by a hazy appearance at the part. The adhesion is various, both in extent and quantity ; it is some- times so slight, as only to produce a simple clouded appearance over a cer- tain part of the cornea, which is technically (tailed nebula; it is at other times more considerable in quantity, and produces an appearance of consid- erable opacity in the cornea, which is usually caWed nUmgo or leucoma. The inflammation sometimes proceeds to the suppurative process ; indeedi the tunica conjunctiva appears to be of a nature very analogous to she mu- cous membranes of the body, and, like these, is exceedingly prone to the suppurative stage of inflammation. The sijppuration generally proceeds from the surface of the conjunctiva, as from the surface of any mucous- membrane in a state of inflammation. In other instances, the formation of pus is circumscribed : a deposit of lymph takes place where the conjunctiva covers the cornea, or in its immedisite vicinity, and a little abscess or pustule' arises from the centre. Ulceration is sometimes produced, and this usually occurs in the cornea, in consequence of laying open the pustule just alluded to, probably from tiia denudation or exposure of the cornea. Lastly, sloughing and mortification of the cornea are not uncommon effects of a high degree of suppurative inflammation. 11. Trmtment : — In the treatment of simple inflammation 416 SIMPLE INFLAMMATION OF THE CONJUNCTIVA. of the conjunctiva, it will be necessary to adopt at once, with vigour, antiphlogistic remedies, as the best mode of dimin- ishing the action of the heart and arteries ; and with this view the use of the lancet should be freely resorted to in the commencement. You ought not to be satisfied with taking away a certain quantity of blood, — ag, for instance, eight, ten, or sixteen ounces, — but you should, in this, as in all other cases of acute inflammation, accompanied with hard- ness of the pulse, make a free orifice in a large vein, and take away a quantity of blood, until some manifest effect is produced upon the action of the heart and arteries ; keep your finger on the pulse of the paJient, in order to ascertain how the heart is affected, and carry on the bteeding-eveii to faintness. This may prevent the necessity of again having recourse to the lancet ; or, if it should be necessary to do so, blood may be taken away in much smaller quantifies. Fou will, of course, be guided by the state of the patient's pulse, as the only criterion. 12. When you have diminished the pulse by general bleeding, leeches may be afterwards conveniently applied, and other resources made beneficial. The application of leeches, in the first instance, except in very Targe num- bers, is seldom sufi^icient in acute inffammation ; three or four will scarcely produce any effect upon it. Opening the temporal artery has been recommended, and it is attended with very good effiect. Some practitioners advise the practice of dividing^ the vessels of the part by scarifying the conjunctiva, bat it is a plan I do sot recommend. 13. Great benefit is derived from treatment directed more especially to the body at large ; such as diaphoretic medi- cines ; and the constitutional irritation may be materially abated by keeping up the secretions from the intestines, by altering them and rendering them more healthy. The tartdrized antimony should be used with the first vie'v. The bowels should be freely acted upon, by doses of calomel, combined with jalap, acammony, or cathartic extract, and the effects of these medicines should be kept up, by the exhibition of neutral salts, so as to produce a considera- ble number of watery stools. At the same time, the diet of the patient should be low, and he should be kept in a state of perfect rest and quietude. 14. "When an impression has been produced on the symp- SIMPLE INFLAMMATION OF THE CONJUNCTIVA. 417 toms, by the treatment I have laid down, it wlU then be prop- er to adopt other measures. For instance, where blood has been taken to a considerable extent, the application of a blister to the nape of the neck will be attended with ben- eficial effects. The treatment of the part should also be considered, the head should be raised, and the access of air or light should also be prevent- ed, by keeping the room darkened. Witli respect to local applications, boih warm and cold remedies may be used with benefit, but the choice should depend entirely on the feelings of the patient; if he does not find relief from warm, you should then try the effects of cold applications. 15. Such is the plan of treatment you would adopt in acute inflammation of the conjunctiva ; but when the chronic stage has commenced, you must pursue a different course. The evacuating plan may to a considerable extent be laid aside; the diet, though not stimulating, may be more generous; there will be no ne- cessity for continuing the diaphoretic medicines, as the skin will generally be sufficiently moist; nor will it be necessary to evacuate the bowels so freely, though every attention should be paid to their due action ; alterative medicines will often be found beneficial. 16. The local applications which are used for the chronic inflammation, should be entirely different from those used in the acute. They ought to be moderately astringent and stimulating, as your object now is to excite some degree of action in the vessels, and to get rid of their relaxation and atony, care being taken not to stimulate the parts too much. Various collyria or eye-waters are used for this purpose, all of them mo- derately astringent or stimulating; such as the solution of alum in water, solutions of the sulphate of zinc or the sulphate of copper, or the liquor plumbi subacptatis. These solutions at first should be very much diluted, and afterwards gradually strengthened in proportion to their action ou the part, and the degree of stimulus which may be produced. To judge how far the stimulus may be carried, the criterion is exceed- ingly simple ; if you find that a certain degree of smarting and pain is pio- duced, which soon subsides, and leaves the patient much more easy than before, you may be convinced that the collyrium is beneficial ; if, on the other hand, the patient experiences a great degree of pain, which does not subside speedily, and the vessels become turgid, you may be assured that the collyrium is doing harm, and that the quantity of stimulus ought to be diminished. 418 PURULENT OPHTHALMIA. 17. Among the numerous applications recommended in this complaint, we will speak of those most frequently em- ployed, and the manner of using them. Those commonly employed are, the solution of alum in water, solutions of the sulphate of zinc, or the sulphate of copper ; or the liquor plumbi subacetatis j and the best mode of applying these eye-washes is to inject them by means of a silver or ivory syringe, introduced under the lids every three or four hours. In this vi'ay you may be certain that the solution is diffused over the whole surface of the conjunctiva. An eye-cup will an- swer the purpose very well, if the person after immersing his eye in the cup, has the courage to open it. They will succeed better with the chill off than otherwise. The vinum opii seems to be one of the best stimuli which can be employed in chronic ophthalmia ; it acts as a mild astringent, and, at the same time, by its soothing quality, sheaths the effect of the stim- ulus, so that no pain is produced ; it may be employed in the quantity of one drop, or even of two or three drops, two, three, or four times a day. It will be best to drop it into the inner canthus of the eye, with a camel-hair pencil ; the patient should then shut his eye, and move it about, so that the fluid may be diffused over the whole surface. The patient should wear no bandages, have no other protection than a shade, and, if he can bear a moderate degree of light, it should be freely admitted. In addition to the local treatment we have gone through, you must give those medicines which will act on the morbid state of the constitution. PURULENT OPHTHALMIA. 18. Suppurative inflammation of the conjunctiva is the most severe form of inflammation in that membrane. It is exceedingly acute, very rapid in its progress^ and often very de- Btruetive in its ultimate effects ; consequently requires very active treat- ment. 19. The symptoms of purulent ophthalmia are so mani- fest, that there can be no doubt of the nature of the com- plaint, its prominent character being the formation of a con- siderable quantity of purulent matter. In other respects the symptoms are not very diflferent from those which characteir- ize inflammation generally. The patient at first feels an uneasy sensation about the eyes ; next some degree of pain on the admission of light ; redness, and swelling of the part j PTTRITLENT OPHTHALMTA. 419 eyelids swollen ; conjunctiva, •where it covers the fore part of the globe of the eye, is tumid ; considerable chemosis, and often such turgescence of the upper lid as to prevent the patient from raising it. The lids are often so much tumified as to become everted, so that a sort of roll of the lid is formed. These are the symptoms which precede the discharge of inatter. A fluid first appears, which is not opaque, and has the character of tena- cious mucus; iu the course of twenty-four hours, it assumes the appear- ance of pus. It is thick, yellow, sometimes green, and poured out in considerable quantity. The tunica conjunctiva has the appearance of a villous membrane higly injected. 20. The acute stage of purulent ophthalmia is of very short daration ; it has a tendency to pass rapidly into the atonic stage, in which there is action without power, and congestion of the vessels of the part. At this time, the violence of the acute symptoms is mitigated, but the patient labours under considerable prostration of strength. 21. Purulent ophthalmia has a great tendency also to ter- minate in sloughing. Sometimes the sloughing commences in a small portion, and gradually lamella after lamella is destroyed, until the aperture assumes a funnel-liko shape ; at other times, a slough forms in a considerable portion of cornea at once, and opens into the anterior chamber. 22. Causes : — The causes of purulent ophthalmia are ra- rious : It is often occasioaed by the violent degree of inflam- mation produced by some highly irritating substance ; and it occasionally occurs in new-born infants. In the last case, it is doubtful whether it arises from the first exposure of the eye to the light, or, as is commonly supposed, from the vaginal secre- tions to the eyes of the child on its passage into the world. It generally takes place in the first week or month after the birth of the child, and sel- dom later than three months. 23. Treatment : — The treatment of purulent ophthalmia must obviously very much depend on the stage of the com- plaint. During the first stage, when all the indications of acute inflammation ara present, you must bleed largely from the arm of the patient; topical bleed- 420 PURULENT OPHTHALMIA. ing is out of the question, except with children. All the other antiphlogis- tic remedies, which I before enumerated to you, are to be put in practice in this case. Purgatives should be administered, so as to produce a consid- erable quantity of watery stools ; diaphoretic medicines, and especially the tartarized antimony, in doses of a quarter to half a grain, should be given at such intervals, as to keep the patient in a state of nausea, and topical ap- plications should be employed very much in the same manner as in simple inflammation. During the first stage of the conjplaint, moist warmth, in the form of fomentations and poultices, will be found beneficial j the acute stage, however, is of very short duration, and they are not to be continued beyond that period. 24. The extent, to which the antiphlogistic plan should be carried, must vary according to the violence of the com- plaint, and the constitution of the patient. You must not, in any constitution, be deterred from adopting an active plan of treatment, until you have produced a manifest efllect on the system of the patient, — until the pulse becomes soft, the skin moist, the pain, swel- ling, tension, and throbbing of the eyes considerably abated, the chemosis diminished, and, in fact, all the acute symptoms more or less subdued. When this is the case,the subsequent treatment will in general be very easy. 25. If it should happen that you are not called upon for this complaint until it has arrived at a chronic stage, when the conjunctiva is feebly pouring out pus ; the pulse depres- sed ; the skin cold and clammy ; the countenance sallow ; and when the constitution has materially suffered from the progress of disease, an entirely different plan of treatment will be required. Gently stimulating applications should be employed, by means of a syr- inge, so as to cleanse the conjunctiva, and free it from the |ius which has collected on its surface, and at the same time stimulate the relaxed vessels. In general, it will be necessary to employ tonic remedies, — such as bark, for instance, always attending to the due action of the bowels, without which, tonics would he useless, and even injurious. 26. "Witn respect to the treatment of the sloughing cornea, some nicety will be required. When you have ascer- tained that the sloughing process is commencing, from the hazy or opake appearance of the cornea, the antiphlogistic PURULENT OPHTHALMIA IN INFANTS. 421 must be changed for a gently stimulating and tonic plan of treatment. Weak, astringent collyria should be used, to favour the throwing ofF of the sloughs. Observe tlie process of tlie sloughing from time to tjme ; if there is a firm layer beneath, the patient is going on well ; but, if the sloughing has a flouculent, soft, ash-coloured appearance, in adition to mild stimulants to the part, you should employ tonic remedies, such as bark. 27. The errors in the treatment of purulent ophthalmia may be comprised in two words ; they consist either in con- tinuing the depleting plan too long, or not resorting to it suf- ficiently early. If the antiphlogistic plan be not adopted at a very early stage of the dis- ease, the tonic treatment will afterwards be of no service j and, on the other hand, if you continue the depleting plan too long, you will check the restorative process, and the beneficial effects which nature would otherwise assist in producing. PURULENT OPHTHALMIA IN INFANTS. 28. According to the late Mr. Ware, the principal differ- ence between the purulent ophthalmia in infants, and that in adults, consists in the different states of the conjunctiva. In the former, notwithstanding the quantity of matter, confined within the eye-lids, is often profuse, the inflammation of the conjunctiva is rarely con- siderable, and whenever the cornea becomes impaired, it is rather owing to the lodgment of such matter on it, than to inflammation. But, in ]>urulent ophthalmia of adults, the discharge is always accompanied with a violent inflammation, and generally with a tumefaction of the conjunctiva, by which its membranous appearance is destroyed, and the cornea is made to seem sunk in the eye -ball. 29. In children, purulent ophthalmia is occasionally ac- companied with eruptions on the head, and with marks of a scrofulous constitution. 30. Treatment : — The treatment of these cases must obvi- ously depend on the stage of the complaint, and on the na- ture of the symptoms which present themselves. 422 PURULENT OPHTHALMIA IN INFANTS. 31. If the disease be in its first stage, a simple antiphlo- gistic plan is likely to succeed. The temporal arteries are to be opened, or leeches applied to the temples or neighbourhood of the eye-lids, and a blister put on the nape of the neck. The child should be kept in a cool room, not covered with much clothes, and if no diarrhoea prevail, a little rhubarb or magnesia in syrup of violets should be prescribed. 32. "When the first short inflammatory stage is over, an immense discharge of matter commences to flow from the eyes. Here emollient applications must generally not be used. On the contra- ry, astringents and corroborants are immediately indicated, in order to re- store to the vessels of the conjunctiva and eye-lids Iheir original tone, to rectify the villous and fungous appearance of the lining of the palpebrse, and thus finally to check the morbid secretion of matter. 33. Mr. Ware condemns the use of emollient poultices, as having a tendency to increase the swelling and relaxation of the conjunctiva. If poultices are preferred, he particularly recommends such as possess a tonic or mild astringent property ; as one made of the curds of milk, turned with alum, and an equal part of ungueutum sambucci, or prepared lard. This is to be put on cold, and frequently renewed, without omitting aa aa^ tringent lotion. 34. "When the secreted matter is glutinous, and makes the eyelids so adherent together that they cannot be opened, after being shut for a length of time, you must use remedies to overcome the difficulty. The adhesive matter must be softened with a little fresh butter mixed with warm milk, or by means of any other soft oleaginous liquor, after the poul- tice is taken off, and before using the lotion. 35. If eversion of the eyelids only occurs when the child cries, and then goes off, nothing need be done in addition to the above means. When, however, the eversion is constant, the lotion must be repeated more frequently than in other cases ; the eye-lids put in their natural posi- tion after its use ; and an attendant directed to hold on them, with his fin- ger, for some length of time, a compress dipped in camphor water. 423 GONORRHCEAL OPHTHALMIA. 36. Another, and one of the most violent forms of puru- lent opthalmia, is that which is called gonorrhceal, from its being produced by the application of gonorrhoeal matter to the conjunctiva. This of all others produces the most intense degree of infiammation ; and although it is said upon good autlioiity to be depending on a metastasis of the gonorrhoeal symptoms from the urethra to the conjunctiva, I have never seen a case in which I could entertain the least suspicion that the complaint was produced in that way, and I do not think that there is sufficient evi- dence to establish such an opinioo. 37. Gonorrhoeal ophthalmia Mr. "Welbank supposes to dif- fer in no material point from purulent ophthalmia, excepting that its symptoms, in general, are more violent, and its pro- gress more rapid. Thus, he says, the swelling of the conjunctiva, particularly that covering the globe, the pain of the eye, the intolerance of light, the purulent dis- charge over the cheeks, are all much more vehement than in the purulent eye, produced from other causes. 38. Treatment : — The first indication, is to oppose the in- flammation, and thus resist the destruction of the eye and opacity of the cornea. A copious quantity of blood should be taken away both topically and lo- cally ; mild laxatives should be exhibited, and a blister applied to the nape of the neck or temples. The eyes ought to be often fomented with a decoction of white poppies, and warm milk repeatedly injected beneath the eye-lids. To prevent the palpebrse from becoming agglutinated together du- ring sleep, the spermaceti cerate should be smeared on the margins of the tarsi, every night. 39. "When the heat and pain in the eyes, and febrile symptoms have subsided ; when an abundant discharge of pus has commenced, all topical emollients are to be relin- quished. 424 STRUMOUS OPHTHALMIA. In these states j'ou should employ a collyrium, containing one grain of the oxymuriate of nriercury in ten ounces of rose water. STRUMOUS OPHTHALMIA. 40. Strumous or scrofulous ophthalmia is so called because it is met with in those persons who are of a scrofulous dia- thesis. It occurs in children and not unfrequently in adults. In this affection, the inflammation is of the chronic kind from the com- mencement; the patient cannot bear the least access of light j there is great dif- ficulty of opening the lids, the orbicularis palpebrarum is spasmodically con- tracted, and so difficult is it for the patient to open the eyes, that he can sel- dom do it. The only way,by which this can be done, is fixing the head of the patient, when it is a child, between your knees ; with the forefinger of the one hand to raise the upper lid, and with that of the other to depress the lower, which will give you an opportunity of seeing the eye; but, in doing this, great caution will be required, to prevent eversion of the under lid, or any undue violence to the part. 41. In this complaint, it is of the greatest importance tnat the cornea should be narrowly watched, for, if the inflamma- tion continues for a long time, ulcers are very apt to form on it. Disorganization of the different parts of the eye oilen takes place. The cornea, or rather conjunctiva covering it, becomes covered with an opaque capsule, with vessels shooting over the cornea, so as to give it an herpetic appear.ince ; that is, there will be seen, over the cornea, yellow spots which are deposits of lymph. These open into small ulcers, which are streaked with vessels carrying red blood. The eye becomes very painful, and ex- tremely irritable, and there is often, in this state, intense redness of the con- junctiva. Under these circumstances, similar ulcers form in different parts of the cornea. The formation of these ulcers produces all the symptoms of acute inflammation of the eye, and the organ not unfrequently becomes slowly and gradually disorganized. So long, however, as the cornea continues bright, and of its natural colour, there will be no danger to apprehend from the for- mation of ulcers. 42. Treatment : — Although strumous ophthalmia is of the chronic nature, there is still considerable irritation ; and as PSOROPHTHALMY. 425 the constitution in -u-hich it occurs is of an unhealthy charac- ter, your treatment must be botli general and local. First, constitutional. The mild depleting plan must be first adopted, regulated as far as the con- stitution will bear it ; you must remove the symptoms of irritation, open the bowels freely by calomel purges, repeated more or less frequently, as they improve the secretions. Alterative mercurial medicines should then be giv- en, and, if necessary, they should be combined with rhubarb and magnesia, but not so as to produce watery stools. When the fever becomes diminished, the bowels perform their naturaJ functions, the tongue looks clean, and the skin assumes its healthy feel, you may begin with tonic remedies, and alter the diet, &.c. Aromatic bitter?, combined with alkalies, light and nutritious diet, warm clothing, moderate exercise, sea-bathing, &c. 43. As for the treatment of the part affected, it \rill be right to employ depletion at the onset, and mild astringent applications afterwards. Leeclies should be employed. It will be also proper to apply blisters be- hind the ears, or to the nape of the neck, and blisters in this complaint are no ordinary remedy ; warm and moist applications are beneficial ; the steam of water containing opium will also prove useful. If any of these applica- tions be used at the onset, they must not be long continued ; mild astrin- gent collyria must be had recourse to, and their strength must be regulated by the feelings of the patient. The vinum opii is particularly adapted to the purpose in question. Alteratives are also sometimes necessary. ^OEOPHTHALJIY. 44. Psorophthalmy is an inflommation particularly of that part of the conjunctiva which lines the lids, but it extends sometimes over the whole of the conjunctiva, covering the globe. This complaint is very nearly allied to strumous ophthalmia, because iti§ in general a consequence of it ; it is characterized by the same Intolerance of light, the inflammation is of the chronic kind, and the patient complains of a sensation, as if there was some extraneous bodv in the eye, grit or sand, which gives rise to an effusion of tears. 36 426 PSOROPHTHALMY. At the origin of the disease, there is a glutinous matter secreted on the edge of the lids ; ulcers form, and there is often great difficulty in separa- ting the lids from one another. By this means, matter lodges on the lids, and tends to keep up the irritation of the part ; the redness sometimes ex- tends down tho cheek, and excoriation of the cuticle takes place. There are also numerous other circumstances attending this complaint. 45. This affection of the eye is of difficult management, and is frequently found in persons of a scrofulous diathesis j in children of large towns, who are ill fed and badly clothed, with little attention to cleanliness. It is a complaint very obstinate in its cure ; and if relieved, it generally returns and becomes bad as ever. The affection is not however confined to the lower classes, but the higher and middling ranks of society are sometimes attacked with it, — those who are of the scrofulous diathesis. In schools, also, it will be found ; it fre- quently arises from the irritating matter being applied to the lid, which may be conveyed from one to another, by using the same towel, or in some auch way, 46. Treatment : — The treatment of psorophthalmy does not essentially differ from that of the strumous ; it is an in- flammation without power ; one of the atonic kind. Your remedies must be both constitutional and local. Depletion must not be pursued to any extent. It will be right, when any symptoms of irritation are present, to remove them by the application of leeches, and gently opening the bowels by mild aperients combined with mercurial medicines, such as calomel, the hydrargyrus cum creta, or the blue pill, and in quantities so a^, to give tone to the system. When any fe- brile excitement, that may have existed, is remove^ begin with tonic rem- edies ; that is, when the skin is clean, and the secretions from the bowels are regular in their quantity and quality. The applications to the part should consist of sthnulants, and the best form in which they can he employed is that of ointment. Any of the milder stimulating mercurial ointments will do, and their degree of strength must be regulated by the effect on the eye. The use of the vinum opii will be attended with beneficial results, and the applicatt^ of blisters will have an universally good effect, but they should always be healed immediately, and repeated again if required. 47. The consequences of inflammation of the eye. requiring distinct notice, and which are accompanied with an equal or OPACITY OF THE COR^'EA. 427 less inflammalion of the conjunctiva, and kept up or excited by attendant circumstances, are now to be spoken of. OPACITY OF THE CORNEA. 48. Opacities, or specks of the cornea, may be divided into several kinds or species. Those, which are caused by the altered or more condensed state of the inner lammellar secretion, are denominated by Beer, Macula cornea simplex cbscuratio ; otherwise, nebula ; those depending upon the formation of a pseudo-membrane, are more appropriately termed leucama ; and the third variety, oi that in whicli the lammelte are firmly united with each other, or the conjunctiva, he has termed albugo or cicatrix, 49. Nebula : — Nebula, or simple opacity of the cornea, is recognized by a diffused cloudiness of the whole or part of the cornea ; it has no distinct or circumscribed boundary, but gradually loses itself in the transparent part of the tunic. The opacity appears always greater in its centre, declining steadily to- wards its circumference. It seldom attacks the deeper lametlse, but is seat- ed commonly directly beneath the conjunctiva. The obscurity of the cor- nea is never so great as to conceal the pupil or iris ; and the vision, on this account, is never totally destroyed, but only rendered less clear and dis- tinct. 50. Leticoma : — In this kind, the opacity is more circum- scribed, and of a whitish, chalky, or pearl colour. If it be deeply seated, it will assume a polished or shining lustre ; if more euperficial, or beneath the conjunctiva, the colour is mote dull. In both cases, there is a considerable degree of nebula surrounding the opacity. Where the disease occupies the centre of the cornea, so as to obstruct the entrance of the rays of light into the pupil, the patient is rendered com- pletely blind. Sometimes one half of the pupil only is obscured, and the patient still enjoys very tolerable sight through the diaphanous portion 3 tlie sphere of vision is simply contracted. He will always see better in the twilight, or in an obscure chamber, than in the broad glare of dav, because the pupil, being espauded, permits a greater number of rays to enter the tetiaa. 428 PUSTULES. 51. Albugo : — This species differs no less in form and colour from the two other varieties, than in the cause which produces it ; being always the consequence of a wound or ulcer of the cornea. Its form is infinitely varied. Not iinfreqnently the iris will be found uni- ted with the cornea at the point of the albugo, so that the pupil is consider- ably distorted or drawn from its natural position. The cornea is sometimes seen completely studded over with these cicatrices, so that it has lost in a great measure, or altogether, its transparency and convexity. 52. Opacities or specks of the cornea may always be tra- ced to previous inflammation of the tunic. Those varieties of ophthalmia, which are connected with some peculiar diathesis of system, are most disposed to terminate in this way. Any acci- dental or artificial wound of the cornea will cause a nebulous or leucoma- tous cicatrix. Opacities of the cornea are also often caused by the contact Bf acrid, or strongly corroding substances with the eye. 53. Treatment :^The inflammation in these affections is generally of the chronic kind, and arises from a relaxed state of the vessels, which require stimulating applications in order that they may recover their tone and convey the blood unin- terruptedly. If the vessels be stimulated, the blood will be likely to ftow through the veins ; the absorbents will be excited, and remove the effused lymph. If there is considerable inflammation, it must be removed by active means ; and in these cases it will be proper to deplete. 54. Care must be taken that in the treatment no undue degree of stimulus be employed ; if there should be inflam- mation it will be increased, and the complaint be as bad as ever. By stimulating applications, the cornea will frequently be restored to the same transparency as before the attack. A good stimulus, which may be used, is one with the sulphate of zinc, containing about a grain to an ounce of water, gradually increased in strength. PUSTULES. 55. Pustules are generally seated at the junction of the transparent with the opaque cornea ; but they sometimes oc- FUNGUS 0? THE CONJUXCTIYA. 429 CUT in the cornea itself, or on the conjunctiva covering it or the ball. They are seated in different parts. The appearances they present, at first, are red or yellowish spots arising from a deposit of lymph in those parts, and are slightly elevated. There is considerable turgescence of the vessels around them. If they occur on the cornea, it will be nebulous and opaque ; the vessels around the cornea will be seen distended, carrying red blood, and having a radiated disposition. 56. If the lymph, secreted in this complaint, is not absorb- ed, the pustules break, matter escapes, and ulcers form in their place. Sometimes there is only one of these ulcers, frequently two, one on each side of the cornea, just at the junction of the transparent with the opaque cornea, and occasionally the cornea is encircled by them. They are very difficult to cure, and easily re-produced. 57. Treatment: — As for the treatment \rhich pustules re- quire, if there should be much inflammation, you must de- plete ; but as the inflammation is of the chronic kind, deple- tion must not be pursued to too great an extent at the outset. The system must be invigorated by tonic remedies, and tone given to the vessels of the part. First, apply leeches, not in too large numbers ; evacuate the bowels by mild apr-iients ; and attend to the secretions : blisters will be useful if the sight be affected. When the state of the bowels has been regulated, yoa must begin with tonic remedies, and, as early as possible, with astringent collyria, and the best is the vinum opii. FUNGUS OF THE COXJU^'CTIVA. 58. This appearance of the conjunctiva, is the result of purulent ophthalmia, and occurs in diseased persons. The conjunctiva becomes loose and red, the vessels turgid with blood, and there is a fold of this membrane on the inside of the lids, which produces considerable irregularity on its surface ; a morbid secretion is kept up on the part, and not unfrequentJy eversion of the lids is the result. 430 ENCANTHIS. 59. Treatment : — The treatment of this state of the con- junctiva, consists in the simple excision of the diseased part. Whilst the lids are separated by an assistant, the surgeon raising the pro- jecting portion with a pair of forceps, removes it at a single stroke, with a common lancet shaped knife, or the curved scissors. When there is any tendency in the disease to form anew, the divided surface may be rubbed slightly over with the sulphate of copper or lunar caustic. GRANULATIONS OF THE CONJUNCTIVA. 60. These are nothing more than loose irregularities of this membrane, where it lines the lids. These projections continue to pour out a morbid secretion, which stini'- ulates and irritates the whole eye ; the palpebial conjunctiva becomes al- tered in its texture, and its surface is covered with a fleshy elevation, hav- ing the exact appearance of granulations. These granulations, covering the surface of the conjunctiva lining the lids, are constantly rubbed over the globe of the eye whenever it moves, producing pain and irritation, and keeping up morbid secretion, and, in fact, giving rise to chronic ophthalmia. 61. Treatment: — Granulations of the conjunctiva, if not removed or remedied, produce ultimate blindness. Cases of this complaint are difficult to cure, and the remedies you are to use are caustic applications, and the division of the varicose and enlarged vessels. These may be aided by eetons, issues, blisters, and attention to the general health. ENCANTHIS. 62, This consists in an alteration of the structure of the caruncula lachrymalis, and neighbouring semilunar fold of the conjunctiva. In this complaint, the caruncula is enlarged ; at the commencement it has a granulated appearance, which it loses as it increases, and then becomes similar to a hazel-nut, being ash-coloured, and streaked with varicose ves- sels. This enlargement or excrescence prevents the lids from closing, and allows extraneous matter to enter, which keeps up inflammation of the eye, PTERYGIUM. 431 and it also presses on the puncta lachrymalia, and turns them out of their place; the tears, thus prevented from getting into the lachrymal sac, are effused on the cheek. 63. Treatment : — The best treatment you can adopt for the cure of this complaint, is the entire remoral of the diseased part. The operation should be thus performed: an assistant is to raise the lid ] you then take up the tumour with a pair of forceps, and remove it with a pair of curved scissors with convex edges. 64. When this complaint has not assumed the malignant form, it is alv\-ays remediable by excision. Never operate, however, when the encanihis has become of the malignant kind, and put on the cancerous appearance. This will be known by the dull red colour of the excrescence, its exces- sive hardness, lancinating pains extending to the eye-ball and forehead, par- ticularly when touched, foul ulcers with irregular edges, having all the ap- pearance of cancer in otlier parts of the body. PTERYGIUM. 65. This term is generally applied to a preternatural, red- dish, ash-coloured, triangular little membrane, which most frequently grows from the internal angle of the eye, near the caruncula lachrymalis, and gradually extends over the cor- nea, so as to cause considerable impediment to vision. This disease most frequently originates from the internal angle of the eye, and it was this circumstance which induced the belief, among the older writers, of its being a mere expansion, or growth from the membrana semi- lunaris, or caruncula lachrymalis. It is sometimes seen to proceed from the external canthns, and more rarely from the superior or inferior hemis- pheres of the eye-ball, 66. The disease has been divided into two species, the 'pterygium lenue or membranous pterygium ; and the pterygia um crassum or fleshy pterygium. The disease most commonly appears, and runs its course without the slightest pain. ^2 PTERYGIUM. 67. Membranous Pterygium : — This kind has the appear* ance of a thin film of minute vessels converging towards the cornea. The usual seat of this affection is towards the inner canthus ; that is, with the base at the canthus, and the apex against the cornea. It is always of a triangular shape, and the vessels proceed from the base to the apex. 68. Fleshy Pterygium : — The fleshy pterygium differs from the membranous, and is more vascular. They first appear of a yellowish colour; then the vessels running through them become large, and they have a red appearance, but always retaia their triangular shape. 69. Treatment : — "When a pterygium has proceeded far on the transparent part of the eye, the only treatment to adopt will be the removal of a part of the pterygium. This consists simply in raising the membrane as near as you can to the cornea, and cutting it through whilst suspended. When the pterygia are fleshy, more care must be taken in dividing them ; they must be divided more towards the margin of the cornea, and turned back from the apex to the base. 433 SECTION II. SIMPLE INFLA^IMATION OF THE DEEPEE.-SEATED TUMCS ; THOSE OF THE GLOBE OF THE EYE ; THE CONSEQUENCES OF SrCH I^t- FLAMMATION, XyB THE NECESSARY PLANS OF TFvEATMENT. INFLAMMATION AND ULCERATION OF THE COR- NEA. 1. Inflammation: — At the outset, in inflammation attack- ing the transparent cornea, there is a hazy appearance, the cornea loses its natural lustre, and in a short time there may be discorered, on its surface, vessels carrying red blood, and then the symptoms 'vvill be the same £is those of inflamma- tion in general ; the patient "uill complam of intolerance of light, and also have effusion of tears. 2. If the inflammation of the cornea should continue, m.atter very frequently forms between its lamellae, and the appearance which it then assumes is called omjx or unguis, from its resemblance to a nail ; the matter is to be rery dis- tinctly seen in the transparent part of the eye, and gradually extends tillit occupies one-third or fourth of the cornea. If you place the eye iu profile, you can generally observe yellow spots, ■which are usually seated at the anterior part of the cornea, and, if you em- j'loy gentle pressure with a probe, the fluid may be felt fluctuating within. In the various positions of the head, the matter does not ?hift its situation, but remains in the same spot. By proper treatment, the matter often becomes absorbed ; but it not un- frequently makes its way externally, or an opening is formed internally, and the matter then is effused into the anterior c?iamber of the eye. 3. Wceration : — L'lceration of the cornea is the common consequence of inflammation of the cornea ; but it is very frequently produced by the contact of matter in purulent oph- 37 434 INFLAMMATION, ETC. OF THE CORNEA. thalmia ; or, in fact, any irritating substance, tnechanical of chemical, that may be introduced into the eye. The inflam* mation produces the formation of pus j this breaks and an ulcer is formed. In ulcers of the cornea, you will find the edges rugged, uneven, and ele- vated, the ulcer itself having an ash-coloured appearance, and the patient complaining of great pain ; there will also be a discharge of a good deal of acrid and irritating matter. In general, there will be no difficulty in distin- guishing ulcers of the cornea ; all you have to do, is to put the eye in pro- file, and take a side view of this organ, and you will see the ulcer with the appearances I have described. 4. The situation of ulcers of the cornea varies ; as also do the ulcers vary in their appearance. Very frequently these ulcers are at a superior portion, and affecting only tbe external lamellae ; in other cases, spreading over the whole cornea, and penetrating into the anterior chamber, by which means, the aqneous humour escapes, and the iris is often protruded ; sometimes, even the opening be- comes enlarged, and the crystalline lens and vitreous humour escape. Some ulcers are large and others small, and those which are small, on cicatriza- tion, do not materially obstruct vision, whilst those that are large, when bealed, produce a nebulous appearance, which destroys the power of sight, 5. Treatment : — The treatment required in inflammation of the cornea does not materially differ from that of inflam- mation of the conjunctiva, or any other part of the eye. You must rely upon the efficacy of a strict antiphlogistic plan, and whers the acute inflammation has been subdued on the use of mild astringent col- tym. 6. When ulcers form in any part of the cornea, it Mali be proper to use active means, if they are accompanied with acute inflammation ; but most frequently, they are accompa- nied by chronic ophthalmia, and have a disposition to spread rather than heal. When they are of a spreading disposition, astringent lotions will be of great service ; but of all remedies in ulcers of the cornea, the nitrate of sil- ver is the one on which you are to depend : it is generally used in the state of soliniun, about two grains to an ounce of water ; or it may be better to STAPHYLOMA. 435 begin with a grain to an ounce, regulating the strength in proportion to the degree of irritation it may produce. When ulcers of the cornea are attended with acute inflammation, it will be necessary to employ bleeding, by leeches, before the use of astringents, and at the same time to keep the bowels regular by mild aperients. During the progress of the ulcers, it will be necessary to watch them very closely, and examine them frequently ; but in doing so, great caution must be used lest the eye-lids become everted. 7. "When ulcers of the cornea heal, it is by cicatrization, as in any other part of the body. The specks which are left upon cicatrization, are nothing more than rounded spots of coagulable lymph, aud constitute the albugo we have al- ready described. STAPHYLOMA. 8. Staphyloma is that disease of the eye-ball, in which the cornea loses its natural transparency, rises above the level of the eye, and even projects beyond the eye-lids, in the form of an elongated, whitish, or pearl-coloured tumour, which is sometimes smooth, sometimes uneven, and according to Scarpa, attended with total loss of sight. This disease is justly considered as one of the most serious to which the eye-ball is subject : for, to the total and irremediable loss of sight that it oc- casions, are added, all the evils which necessarily result from the bulk and protuberance of the staphyloma. In such circumstances, the continual ex- posure of the eye-ball to the contact of the air, and particles of matter sus- pended in it, the friction of the eye-lashes, the incessant flux of tears down the adjacent cheek, render the eye painful and inflamed ; the sound one is affected by sympathy, and the diseased one at length ulcerates, together with the lower eye-lid and cheek, on which it presses. 9. Staphyloma appears to proceed principally from puru- lent ophthalmia, or from the small-pox. Scarpa observes, that infants are often attacked with this disease soon af- tei their birth, and mostly in consequence of purulent ophthalmy. It is al- Bo produced by the small-pox, yet never during its eruption, nor during the stage of suppuration, but when the pustules dry, and even after the detach- gaeuit of the variolous scabs. 436 IRITIS. 10. Treatment : — In this complaint, nothing can be done for the restoration of sight ; and the only plan of treatment will be to remove the staphylomatous part, so as to return the eye within the orbit, and permit the use of an artificial eye. The operation is exceedingly simple : the surgeon first passes a needle, with a ligature, through the staphylomatous part, in order to steady the eye, and then, with the other hand, takes the cornea knife, and removes as much of the projecting part as may be necessary ; the operation gives little pain ; it generally happens that the iris adheres to the cornea, and that a portion of it is removed. The crystalline lens escapes, together with a portion of vit- reous humour, and the eye collapses, so that, when the part is healed, an artificial eye may be worn. IRITIS. 11. Inflammation of the iris is a peculiar and specific in- flammation, attended with symptoms which, in some cases, are with difficulty recognized. In looking into the eye, you see the iris changed in colour, or having a brownish hue, or rather a reddish brown colour, (this, however, varies ac- cording to the natural colour of the iris,) from the increased number of ves- sels on its surface carrying red blood. The iris itself is altered in texture, being puckered and thickened. These appearances are soon removed, and deposits of yellow lymph, resembling yellow tubercles, will be seen on the iris, the pupil becomes irregular and altered in shape, and the pupillary mar- gin of the iris thickened and turned back towards the posterior chamber. These are the principal symptoms by which you recognize iritis ; but there are many other marked appearances. 12. Inflammation of the iris often comes on from very slight causes ; it occasionally happens in those who have been under the influence of mercury, and in persons of a scrofulous diathesis. Iritis has, in consequence of its occurring so frequently after syphilis, been classed as a secondary symptom of that complaint j I have, I must say, con- siderable doubt on the subject, for I have never met with it in a person la- bouring, at the same lime, under any other secondary symptoms of syphilis, with eruptions or nodes on the bones ; and also 1 have never met with a 1 IRITIS. 437 case of iritis after syphilis, but where mercury had been previously given, and therefore I cannot say whether the inflammation of the iris was the effect of the mercury, or the original disease for which it was given. 13. Ophthalmitis : — Iritis is not unfrequently accompaniea by inflammation of the tunics of the eye, which may be call- ed ophthalmitis, or deep-seated inflammation of the globe of the eye. In this complaint, the sclerotic appears reddened, the cornea is dull, and the capsule of the lens itself becomes opaque : all these participate in the inflammation. There is a deposition of lymph on the edges of the iris, and there are also adhesions of it in some places to the crystalline lens. The Bclerotic coat, however, is particularly inflamed ; the vessels may be seen carrying the blood in a straight course, whilst those of the conjunctiva are tortuous. There is pain in the eye, intolerance of light ; so that these Bymptoms, together with a turbid state of the humours, are sufficient to in- form one of the presence of inflammation of the sclerotic coat ; the patient also labours, at the same time, under great febrile excitement. 14. The result of this severe form of inflammation, if it be not checked, is efiusion of lymph or matter into the ante- rior chamber of the eye, producing what is technically called Hypopium. In these cases, the matter may be easily observed, and sometimes there is 80 much as to conceal the edges of the pupil and the iris. 15. Treatment : — In the treatment of iritis, you must, of course, adopt all the steps of depletion as in other inflamma- tions of the eye ; but in addition to these, there are also one or two other remedies. There is one remedy above all others, on which you are to rely, and that is mercury ; it must be given so as to affect the constitution, till the gums and mouth are sore, or the saliva begins to flow, which will be the signs of it, and the best form in which you can give mercury is that of calomel ; let it be given internally after the bleeding, in the dose of two to three grains, combined with about a quarter of a grain of opium, so as to prevent its acting on the bowels. In order that the calomel may affect the system, it must be given every four or six hours, till the mouth is sore ; in more chro- nic forms of this complaint, it may be given less frequently. As soon as the •ystem has become affected, you will sec the zone of vessels disappearing, 43S AMAUROSIS. the lymph absorbed, the aqueous humour becoming clear, and the cornea losing its hazy appearance. Other remedies have been recommended, but there is not one on which you can rely, but the exhibition of mercury. Belladona will be found a very useful adjunct in this complaint ; by dilating the pupils, the adhesions are often prevented from forming between the iris and capsule of the crys- talline lens, and when they are formed, it tends to elongate the adhesions. The belladona should be applied, iu the form of extract, around the eye, morning and evening. AMAUROSIS. 16. By amaurosis I mean partial or total loss of vision, arising from paralysis of the optic nerve or retina ; and this is produced by a congestion of the vessels of the part, or mi- nute alteration of its structure. The persons, subjected to this complaint are those who have been in the habit of viewing minute objects, or exposing the eyes to strong light j and those, who are affected with amaurosis, are frequently troubled with false appearances, as flashes of light, or balls of fire before their eyes. 17. The symptoms of this complaint are few, and therefore require to be well known. The pupil is generally dilated and motionless; the iris is nearly im- moveable, and acts very little, and vision is completely destroyed. There is also slight strabismus. There is frequently the sensation as if a cloud were before the eye, which is termed caligo, and there is often a greenish appearance of the humours, which is named glaucoma. This depends on an alteration of the lens, or an alteration in the structure of the vitreoua humour. 18. Causes : — The causes of amaurosis I shall divide into three parts ; those which affect the retina or optic nerve ; those affecting the brain, or that part of it from which the optic nerve arises, the thalami nervorum opticorum ; and, lastly, those affecting the body at large, or some particular organ, and thus sympathetically affecting the eye. First : the structure is sometimes altered by disease or violence, lacera- tion from wounds, blows, the changes from inflammation, pressure from tumours, accumulation of the humours of the eye, paraylsis from exhausted AMAUHOSIS. 439 Sensibility, as by the frequent viewing minute or brilliant objects, too strong light, the use of magnifying or telescopic glasses, or suddenly by a Strong transition from darkness to light, as that of the sun, lightning, &c. Second ; the second class of causes consists of affections of the brain, such are plethora, an increased action, a fulness of the vessels of the brain, and from pressure on the brain from tumours, apoplectic effusion, hydro- cephalus, injuries to the head, &c. Third: the third set are those causes, which, operating through the ner- vous system, depend on some condition of the body at large, or irritation in a distant part. Such are general debility, palsy from lead, irritation in the primae viae from disorder of the biliary secretions, or digestive organs gener- ally, worms, &c 19. Treatment : — Although the prognosis in this disease is unfavorable, yet we are not to give up all hopes of benefit from treatment. It is, however, especially necessary to dis- tinguish those cases which admit of cure or amendment, and to ascertain in these the cause upon which the affection depends. In those cases of amaurosis which are accompanied by, or dependent upon inflammation of the organ, the active antiphlogistic treatment requisite for that condition may relieve the retina. In those cases in which it de- pends upon plethora, congestion or action of vessels in the brain, the appro- priate treatment for such disorder will suit the amaurosis. In cases where the disorder is in theprimse vise, the clearing of the stomach and in- testines, and the restoring of its healthy secretions, will be the indications. Where the amaurosis depends upon debility, the use of bark and other tonics and stimulants will be requsite. In cases which depend upon some paralytic or torpid state of the part, we use stimulants (the liquor ammonise puras, of which the vapours are directed against the eye,) friction on the eyebrows, stimulating liniments, sternutatious powders, blisters, electricity, and in some ca,-es manifest advantage has been derived from a mercurial course. 20. "Whatever may be your plans of treatment for this complaint, you will find that there are many cases incapable of cure, many others which are but slightly benefitted, and that the cases, most likely to be successful, are those de- pending upon some obvious and remediable cause, and those only when incipient. 440 SECTION III. DISEASES OF THE HUMOURS OF THE EYE ; CATARACT ; THE OPERATIONS REQUIRED FOR THAT DISEASE ; FUN&US H^MATODES, ETC. HYDROPHTHALMIA. 1. Hydrophthalmia, or dropsy of the eye, arises in this organ precisely as in the other cavities of the body, and de- pends on some inequality in the condition of the secerning and absorbent vessels. It seldom occurs as a local or independent disease ; more commonly it is the eiFect of a certain weak or cachectic state of the whole system, or it is symptomatic of some other dropsical affection. 2. The disease may arise from an increased accumula- tion of the aqueous or vitreous humours, or both. 3. Dropsy of the Aqueous Humour : — Is known by its protrusion forwards, and by other diagnostic indications. The cornea increases considerably in size ; the anterior chamber is much enlarged ; the iris is sluggish, and becomes of a darker hue ; the patient complains of a sensation of pressure or constriction of the globe ; and by degrees loses his power of vision. When the disease advances to such a state that the eye-ball is considerably protruded beyond the orbit, there will be other symptoms resulting from its exposed situation. 4. Dropsy of the Vitreous Humour : — In this species, the enlargement of the eye takes place chiefly from behind, or in the posterior part of the ball. The iris is arched forward, and brought almost into direct contact with the cornea, bo that the anterior chamber is nearly or completely obliterated. Its colour remains unchanged, but the pupil is rather more contracted thaa in its ordinary state. GLAUCOMA. 441 5. Treatment : — The remedies recommended for this com- plaint are various, of the most opposite kind, and have been tried generally without any good effect. Knowing so little of the true causes of hydrophthalmia, it is difficult to prescribe any systematic course of treatment, or to expect much benefit from any particular mode of cure. Nothing, indeed, can be done to pre- vent the blindness which inevitably follows the more advanced stages of the disease, or to alleviate it when it has actually taken place ; and the ut- most the surgeon can do is to quiet the uneasy sense of distention or con- striction, which the patient feels throughout the orbit) or to arrest the fur- ther progress of the complaint. 6. Where the disease is symptomatic only of a general hydropic state, our remedies should be adapted more to the general than to the local affection. Of these, says Mr. Welbank, perhaps the most efficacious are calomel, cicuta, or the Pulsatilla nigricans. Professor Beer prefers a combination of calomel with digitalis. In addition to these, we may resort to blisters, issues, stimulating and mercurial friction to the eye-brow, &.c. Instead of the astringent or stimulating collyria, so much employed, nothing more should be advised than the covering the eye with a fold or two of warm, dry linen, rubbed over with a little camphor, or some other aromatic sub- stance. 7. If, however, the disease be far advanced, or produces an unpleasant tension in the eye, it will be necessary to draw off the superabundant fluid. The operation of paracentesis is performed with a common lancet, which should be thrust into the cornea a line from its margin, and the fluid evacu- ated by slight pressure upon the eye-ball. The eye should be kept in this state of collapse for days, or even weeks, by lifting the flap daily, and per- mitting the fluid to escape. GLAUCOMA. 8. In this complaint, the vitreous humour becomes al- tered in texture, more dense, and presents a sea-green hue, and the pupil is dilated. 442 CATARACT. Glaucoma is often mistaken for cataract, and a person affected with it is frequently supposed to have a cataract in its incipient stage. On examining tlie eye minutely, this greenish appearance may be observed to be behind the crystalline lens, and posterior to the seat of the cataract; it may, how- ever, be mistaken for many diseases, but has a greater resemblance to cat- aract than any other. 9. Glaucoma is generally the sequela of gouty ophthal- mia, or it may arise spontaneously, and without much pre- vious inflammation. It is always connected, however, with morbid changes in other parts of the body, which may be traced to the same arthritic diathesis. 10. Glaucoma, when fully developed, is incurable. The remedies, upon which most reliance is placed for arresting or con- trolling the disease, are local and general blood-letting, purgatives, blisters to the temples or behind the ears, warm aromatic application to the eyes, &c. CATARACT. 11. By cataract is meant, an opacity of the crystalline lens, or its capsule : the cataract depending on a morbid secretion of the liquor morgagni being very rare. 12. The symptoms of cataract are unequivocal, and may be easily recognised. At first, there is always defect of vision, and the patient sees things as through a mist, and requires a strong light to see them plainly ; this symp- tom changes during the progress of the complaint, the patient being abl» to see better in a moderate than a strong light, and then a speck or opacity in the lens or capsule, may be distinctly observed ; it is jrenerallv in the centre of the pupil, and at the situation of the lens ; this gradually enlarges, and, in proportion as the opacity increases, the sight becomes more dim, and the capability of discerning objects diminishes. These symptoms of cataract differ in the different kinds, and the diagnos- tic marks of each we shall hereafter speak of. 13. There are four kinds of cataract : viz. the hard ar firm ; the milky or fluid cataract ; the soft or caseous j and CATARACT. 443 besides these, there is a fourth kind, the capsalar cataract ; the three first forming in the lens itself, and the last in the capsule. There is also a congenital cataract. 14. Firm or Hard Cataract : — In this kind of cataract, the lens acquires a greater degree of density or firmness than natural ; and, in undergoing this change, it becomes smaller and thinner, and more concentrated. This cataract is to be known by its amber colour and size 5 by the inter- space between the iris and front part of the lens, on account of the leus be- coming thinner ; the motions of the iris are free, there being no adhesions j the vision more or less perfect j and, lastly, by its occurring at an advanced period of life. 15. Fltdd or Milky Cataract .-—This kind of cataract is always more or less fluid, and of unequal density through- out. It is called milky, from its white colour. If you examine the eye of a patient with attention, you will see that it has a flocculent appearance, from specks or streaks consisting of solid parti- cles of the lens, and these will move up or down in the various positions and motions of the head, and be removed out of sight 3 but, on the head be- comins steady, they again appear. Besides these symptoms, the lens be- comes enlarged and globular, and the increase of size is such, that the lens reaches the iris, so that there is no posterior chambei at all. The size and shape of the pupil is altered, the rays of light do not pass into the eye, and the patient can scarcely tell the difference between light and darkness. 16. Soft, or Cascovs Cataract : — This kind of cataract is of the consistence of firm jelly or cheese. It is uniformly opaque, and there is a milky whiteness, as in the fluid cata- ract ; but the spots and streaks sometimes observable in this form never shift their position, as in the other ; the lens also becomes increased in size. In this cataract, the posterior chamber of the eye is obliterated, — there is no interspace betwRcn the fore part of the lens and iris, — the motions of the iris are performed with difficulty, from the size of the lens, and the rays of light are prevented from entering. The patient sometimes cannot dis- tinguish between light and darkness, although they are seldom so blind as this. 444 CATARACT. 17. Membranous or Capsular Cataract : — This form of cataract is not connected with the lens, but the capsule it- self. It usually comes on after an operation, or in conse- quence of it. The membranous cataract is also found in children, when it is called cojp- genital cataract. It does not differ essentially from the other forms of cap- sular cataract, but is called congenital on account of its occurring at a par- ticular period of life, or children being born with it. 18. In membranous cataract, the opacity or affection may exist either in the posterior or anterior layer of the capsule, or combined with that of the lens, and thus produce cataract. In the last case, there is no distinct mark of diagnosis ; but, when the capsule only is affected, you may offer an opinion. If the anterior layer of the capsule is opaque, it has the appearance of being superficial and close to the pupil, and appears rather nebulous. It does not quite lose its trans- parency, but becomes semi-transparent. When the posterior layer is affect- ed, this appearance is deeper, being at a considerable depth, and having more or less of a concave form. There are also strise passing in a radiated direction. Another species of membranous cataract is, when the capsule becomes opaque, and the lens, at the same time, absorbed, and a tough, dense, mem- branous substance is formed, as in congenital cataract. 19. Congenital Cataract : — Children are not unfrequently either born with cataract, or with a disposition to cataract, which speedily makes its appearance. The nature of the cataract may be firm, soft, or fluid ; and it may be lenticu- lar as in the adult. It seems to be hereditary. The appearance of congenital cataract is somewhat different from cata- ract in the adult ; there is an opaque nucleus either at the centre or some part of the circumference, and the rest has an unequal opacity, or streaked reticular appearance, and there is also a remarkable unsteadiness of the globe of the eye. 20. We have now gone through the variety of cataracts, and offered the marks of diagnosis, from which you will see the difficulty of distinguishing one from the other. But it is necessary, as fur as possible, to be acquainted with the appear- CATARACT. 445 aoce each form of cataract presents, as the treatment or operation required must be adapted according to the kind of cataract. 21. Causes of Cataract : — By far the greater mirnber of cases of cataract are produced, as it is called, spontaneously, or under circumstances which are too subtle for our cogni- zance. Sometimes, however, the cause can be fairly discov- ered. Cataract sometimes arises from obvious causes, as injury, violence, in- flammation, or sharp-pointed bodies wounding the capsule of the lens, or the lens itself, and consequently producing opacity of these parts. The opacity arising from this cause often becomes absorbed, and the case under- goes the natural process of cure without requiring an operation. It also runs through families, and appears to be hereditary ; and it is likewise said to arise from other causes. 22. Treatment : — There are certain symptoms accompa- nying cataract, by which you are enabled to form a pretty accurate opinion as to the issue of an operation Various plans of treatment have been adopted for the removal of cataract, but without success ; an operation is only to be depended on. 23. There are four particular circumstances which should lead you to determine as to the success of the operation. First : — Whether the loss of vision has been gradually supervening, and has always been in proportion to the opacity of the lens. Second : — Whether the cataract has been accompanied by chronic oph- thalmia, or any changes have been produced in the eye by it ; if the cataract has been attended by a penetrating paiu in any part of the eye, or orbit, or back of the head, which it will be necessary to inquire about. Third :— Whether the motions of the iris are duly performed, in the dif- ferent variations of the light ; if not, fear may be entertained of the eye be- ing amaurotic. Fourth : — If there is the power of distinguishing between light and dark, or the colour or form of things, or the shade of passing objects. 24. These circumstances should be particularly inquired into ; and if you find the patient has all, or the greater part of them, then you may operate. That is, if the defect of sight has been increasing just in proportion to 446 CATARACT. the increase of the opacity of the lens ; the patient has had no pain in the head ; the motions of the iris are free, and light can be distinguished, you may operate and with the chance of success, as there are no evident reasons against it ; for, by the first circumstance, you see that the vision has been impaired in consequence of the opacity of the lens ; by the second, that there has been no disorganizing inflammation in the eye, or that the brain and ori- gin of the optic nerves have not been affected ; by the third, that the retina is sound ; and by the fourth, if the opacity of the lens be removed, that the retina will be in a state to receive the impression of external objects. 25. When there is cataract, the operation must be regula- ted by taking all the circumstances into consideration. By the figure of the cataract ; whether there are any adhesions of the iris to the capsule of the crystalline lens ; and especially by the patient being able to distinguish objects, and light from darkness. On the whole, the lat- ter is a very favourable symptom, and when present, the operation may be performed. If the case is doubtful, it is better to operate j but previously represent the circumstances to your patient. 26. Another question, with regard to the treatment of cat- aract, is, whether the operation should be performed, if one ire only is affected. eye only is affected. Some recommend the operation when only one eye is affected ; but for my part, the best plan is not to operate, except both are affected ; for if you do it when there is only one eye diseased, the focus will be made different by the operation, and the patient will not be able to use both eyes at the same time. OPEEATIONS FOR CATARACT. 27. The operations for cataract are three in number ; first, depression or couching, by which the cataract is removed from the axis of vision ; second, extraction, which consists in mak- ing an incision through the cornea ; and lastly, the operation for the solution of the cataract. 28. Depression or Couching .•—This mode of operating con- OPERATIONS FOR CATARACT. 447 sists m removing the opaque lens out of the axis of vision by depressing it into the vitreous humour. This is done by a needle, of which there are three different kinds now employed, Hey's, Scarpa's, and Beer's, which last is spear-pointed and nar- row at the neck. The needle is the only instrument required ; some use a speculum, but, excepting in children, this will not be of much use. I give the preference myself to Beer's needle : a surgeon is not so likely to wound the ciliary ligaments or processes with it. 29. Previous to the operation, you should ascertain whether the patient is in good health, the bowels regular, and that all the functions are properly performed. And when you are about operating, the light, and the position of the patient and operator, are extremely important, and ought to be attended to. The light should be clear, distinct, and full, but not vivid, and it should not fall on the centre of the eye of the patient, but laterally, else it would produce a dazzling and unsteadiness of the organ. The patient should be placed on a low seat with a high back, and the head resting against it or the body of an assistant. The operator should be on a high stool, or at least of sufficient height to enable him to put one foot on it, and rest his el- bow on the knee opposite to the eye to be couched. 30. Having gone through the preparatory steps to the op- eration, we will now consider the mode of operating itself. The operator holds the instrument between the thumb and fore-finger; the assistant, passing his fore-finger round the head of the patient, raises the upper lid by a fold of skin, and presses it gently against the sujiercilia- ry ridge ; the patient is now desired to look inwards, towards the nose, and the operator, resting his little finger on the upper part of the chin of the patient, penetrates the sclerotic coat about a line and a half from the juncture of the transparent with the opaque cornea, and a line below the transverse diameter of the eye. In the first place, the needle is introduced here, just where the retina terminates, and the ciliary ligament commen- ces, so that these shall be avoided ; and secondly, for the purpose of not wounding the ciliary artery, as it goes along the middle of the external convexity of the eye-ball, between the sclerotic and choroid coat. In using Beer's needle, it is introduced with the edge laterally, and its surface up- wards and downwards, and directed towards the middle of the globe of the eye. It must be moved slightly between the fingers, (a piece of ivory or brass at the handle, showing the disposition of the cutting edge,) and then 448 OPERATIONS FOR CATARACT. the point carried inwards parallel to the iris, and so as to cover the poste- rior chamber; the instrument will now be visible through the pupil. When this is the case, the operator must raise the needle upwards, and then de- press it downwards and backwards, and a little outwards ; by which means the crystalline lens becomes pushed into the vitreous humour. If the lena should rise from its situation, it must be again depressed ; and when it is safely lodged in the vitreous humour, the needle must be withdrawn. The after-treatment is very simple, and consists in a simple fold of linen moistened in cold water, being applied to the eye. The patient is also to be put in a dark apartment, and narrowly watched, in order to see if any inflammation supervenes : very frequently, none arises. 31. Extraction of Cataract: — This operation is the entire removal of the crystalline lens j and there are several instru- ments required in its performance. First, you will require the cornea knife j Beer's is the one I recommend, the upper edge of which is quite straight, while the lower edge is made straight and oblique; the whole of the lower edge is cutting ; the upper edge is cutting towards the point, and the size is accurately increased from the point towards the handle, so as to fill up the opening, and prevent the escape of the aqueous humour. The next instrument is a pair of curved scissors, in order to enlarge the opening made into the cornea, if it should not be of sufficient size to extract the cataract. A minute curved needle will be required, in order to scratch the capsule of the crystalline lens ; a curette or scoop, to remove any opaque fragments of the lens ; and a pair of minute forceps, of which the best construction is that recommended by Beer, to extract any portions of opaque membrane from the capsule of the lens. These are the principal instruments required. 32. There seems no necessity for prepanng a patient for this operation, beyond taking care that his bowels be duly evacuated, and that he is not labouring under any other com- plaint or morbid afiection, or has not any unusually stimu- lating diet previous to the operation. Let us now consider the operation. The position of the patient should be nearly the same as that in the operation for couching ; he should be placed opposite a window, so as to admit a full, clear, but not too vivid light. It should not be a reflecting light, so that if the sun should happen to shine, a north window should be chosen ; the inner side of the eye to- wards the nose, where the point of the knife is to be carried through, OPERATIONS FOR CATARACT. 449 ehould be well brightened. The patient should be seated in a low chair as in couching. The operator should place himself behind the patient in a chair of sufficient height to enable him to plant his foot conveniently on a stool, and resting his elbow on the knee opposite to the eye to be operated upon, bring his hand towards him. The assistant should then place hia hand behind the patient's head, and with the extremity of the fore-finger gently raise up the lid without making pressure on the globe. The operator then takes the knife in his right hand, if it be the left eye which is to be operated upon, and in his left, if it be the right eye, in the same way as he would take a pencil between his fore-finger and thumb, resting his little finger upon the malar bone. The first thing which the operator then does, is to make what is called the punctuation of the cornea. He introduces the jwint of the instrument at a distance of half a line from the anterior junction of the cornea with the sclerotic coat, and passes it in a direction nearly parallel to the iris, and before it with a little obliquity through the anterior chamber to the oppo- site or nasal side. In making the section of the cornea, the knife should be carried onwards without any downward motion ; and as soon as the section is completed, the lid should be allowed to drop over the fore part of the eye to prevent the escape of a portion of vitreous humour, if there should be any spasm of the part, or any unsteady motion of the patient. The opera- tor waits till the eye is quiet, and then introduces the curved needle with a convesity under the flap of the cornea; and turning the point towards the fore part of the capsule, moves it upwards and downwards and laterally from side to side, making a sort of crucial incision. He then squeezes out the cataract, by making gentle pressure on the globe above and below, un- til the lens is lifted from its bed, and passes through the opening of the cor- nea upon the cheek of the patient. All that then remains to do is to exam- ine whether there are any opaque fragments of the lens left ; if there are, they must be scooped out by the curette ; if not, the upper lid is to be rub- bed over the surface of the conjea. If there is any portion of opaque mem- brane remaining, it must be removed by the forceps, and in this way the operatiou will be completed. 33. Many untoward circumstances frequently interfere with the success of this operation, which, for the sake of clearness, we will speak of in regular order. When any unfortunate circumstance happens, you should be perfectly calm, cool, and deliberate ; close the eye-lid ; consider what is best to be done ; and having made up your mind on that point, proceed with firmness and decision in the operation. 38 450 OPERATIONS FOR CATARACT. 34. First : — The section of the cornea may be too small ; ia which case you will either be unable to dislodge the cata- ract, or so much force will be required for that purpose as is likely to produce serious inflammation, and such a degree of disorganization as will destroy vision. The section through the cornea should be about nine-sixteenths of a line, or one sixteenth more than half a line from its junction with the sclerotica: the point of the instrument is introduced a little below the transverse dia- meter of the eye, on one side, and should come out a little above it on the other. If you find, when you have completed the section of the cornea, that the opening is not large, do not hesitate to use the scissors, in order to make it large enough to admit the passage of the cataract. 35. Second : — The second untoward circumstance,, to which I shall advert, is, the premature escape of the aqueous humour, either from the unsteadiness of the operator, or from some defect in the knife. On the escape of the aqueous humour, the iris loses its support and be- comes prolapsed. When this happens, the way of preventing any mischief will be, not to continue the incision, but to rub the cornea with the point of your finger, by which the prolapsed iris will be stimulated to contract; and, on this being removed out of the way, you may complete the incision. 36. Third : — The third unfortunate circumstance, which .sometimes occurs, is, the loss of a portion of the vitreous humour, arising from some undue pressure on the globe of the eye by the operator or assistant, or from some spasm of the muscles of the eye. It may also occur from other causes. Another way, in which this accident sometimes occurs, is when the nee- dle is injudiciously used too near the circumference of the lens, and the capsule of the vitreous humour is torn through ; so that when you make pressure on the globe, instead of the cataract coming forward, a large por- tion of vitreous humour is protruded. In this case you should not attempt to force out the cataract, but endeavour to entangle it as much as possible go as to prevent the escape of the vitreous humour. The escape of vitreous humour is also sometimes the consequence of the curette being passed through the back layer of the capsule. The curette should never be used OPERATIONS FOR CATARACT. 451 when the pupil is at all obscured; the field of the pupil should be perfectly distinct, when you resort to that instrument. The loss of a small portion of vitreous humour does not essentially interfere with the success of the operation, neither should it prevent you from completing the operation in the best way possible, by removing all the loose fragments of the opaque lens, and the different portions of opaque membrane or capsule. 37. Fourth : — Another unfortunate circumstance, ^vhich may interfere with the success of the operation, is, the intro- duction of the cornea knife between the lamellae of the cor- nea ; the consequence of which will be; that the section of the cornea will bo very small and imperfect. These four are the principal circumstances untowardly to year success. but there are many others of less importance. 38. Afttr-treatment : — With respect to the after-treatment of the operation of extraction of cataract, your object must be, as far as possible, to prevent inflammation. A compress of fine linen or cambric, kept wet with cold water, should be applied to the eyes, or rather to the eye opposite that which has been oper- ated upon. The patient should be carried to bed, placed in the recumbent posture, with his head a little elevated, and the room should be darkened. He should be allowed nothing but barley-water, tea, or watet-gruel, for the first few days ; and if there should be any symptoms of inflammation, such as pain, a sensation as if there was some extraneous body in the eye, accompa- nied with quickness of pulse, a quantity of blood should be immediately taken from the arm. It will be better not to disturb the bandage, nor raise the lid to examine the eye, for at least three days, unless the patient should feel any considerable pain or irritation ; for, in that case, it would be advis- able to ascertain the cause, by examining the eye. The patient should be kept in bed, in the recumbent posture, for five days, and not even suffered to rise for the evacuation of the faeces ; a bed-pan should be used for that pur- pose ; at the end of that time, he may get up to have his bed made. The best way of preventing irritation is carefully to avoid making any undue pressure on the globe of the eye. Great care must be taken in adjusting the bandage, not to depress the lower lid, by which means, the section of the cornea maybe brought over, and the adaption of the cut edges prevented. 39. Solution of the Cataract ; — The third operation is that for procuring solution of the cataract, which is particularly adapted to the cataracts of children, or congenital cataract. 452 OPERATIONS FOR CATARACT. It was formerly deemed advisable to defer the operation for cataract m children, but we are now able to perform one with a hope of success, be- tween the age of eighteen months and four years. But the operation under consideration is not confined to congenital ; it may be employed also in the cataracts of adults, provided they are fluid, soft, or membranoas cataracts. 40. The operation is very simple ; it consists merely in making an opening in the anterior layer of the capsule of the lens, breaking up, more or less, the texture of the cataract, and admitting the aqueous humour, in which the cataract is dissolved, and by this means absorbed. The instrument required is a needle very similar to that employed in the operation for couching; the point, however, is somewhat different j it» shoulders are more cutting. It will be right, before operating, to use bel- ladonna, for the purpose of dilating the pupil, so that the cataract may be distinctly seen. A small quantity of the extract of belladonna, softened to the consistence of cream, may be introduced into the eye, or smeared round the lids. 41. Having prepared your patient in this way for the operation, it will be advisable, while operating, not to at- tempt to do too much at once ; but rather to repeat it fre- quently, than to break up the texture too extensively at once. In operation on the adult, the i)atient should be placed in the same posi- tion as for couching ; children are better placed in the recumbent posture, with the head fixed on a pillow. Sometimes a spcculam is required t& steady the eye ; Pellier's speculum is the best for this purpose. The needle may be introduced either in the same way as in the operation for couching,^ or else through the cornea. In the latter case, there are two modes of op- erating, called the anterior and posterior ; in the former, the needle is in- troduced at the dis-tance of half a line from the junction of the cornea witk the sclerotica, carried parallel to the iris, and turned inwards so as to break up a portion of the capsule of the lens. In the posterior operation, the needle is carried through the posterior chamber, a little behind the iris, and the texture of the capsule is broken up in the same way, so as to admit of the aqueous humour. If the cataract is fluid, it immediately mixes with the aqueous humour, and you will have no more trouble. 42. As to the after-treatment of this operation, your object must be, as in former cases, to prevent inflammation. OPERATIONS FOR ARTIFICIAL PUPIL. 453 43. Having described these different operations, it may be necessary to consider %Thich of them it may be most ex- pedient to adopt. 44. It seems to me, that, in those cases which admit of the operation for solution, — namely, fluid, soft, and most ca- ses of membranous cataract, — that operation is greatly pref- erable to any other. Soft, fluid, and membranous cataracts cannot be depressed ; it is true that the operation for extraction might be performed, but it is to be considered that the operation for solution is much more easy, and that it does very little injury to the part. 45. In firm cataracts, where it is a matter of indifference whether the operation for depression or extraction should be performed, that for extraction, supposing it to be equally well performed, is undoubtedly preferable, because the disease is entirely removed by it. It is not always, however, a matter of indifference, for there are many cases in which it would be extremely imprudent to attempt the operation for extraction, as, for instance, in cases of adhesion of the iris to the cornea, or where the cornea is very flat, and the anterior chamber necessarily small, or in cases of contraction of the pupil, myosis, or arcus sellis, 46. Where there are no contra-indications to deter us from performing the operation for extraction, it is undoubted- ly the most effectual, provided the surgeon has had sufiicient opportunities of acquiring dexterity ; but if he has not been much in the habit of performing the operation, I should rec- ommend as the safer, though less effectual course, the ope- ration for depression. OPERATION FOR ARTIFICIAL PUPIL. 47. Where, from some defect of the cornea or iris, or the pans connected with them, there is no passage for the rays of light, the operation for artificial pupil is required. This 454 FUNGUS HiEMATODES OF THE EYE. consists in making a section, with a cutting needle, through the iris, which, by the elasticity of its fibres, separates its edges, and thus makes a passage for the rays of light. There are three modes of performing this operation. First .- — By a simple incision of the iris, technically called corotomia ; but this operation was seldom resorted to. Secondly .- — where a portion of the iris was cut away, which operation was called corectomia : and thirdly .- — where the iris was turned away from its attachment to the ciliary ligament, technically called coredialysis. FUNGUS HJEMATODES OF THE EYE. 48. This malignant fungus is a disease which soon proves fatal, unless an operation be early performed ; even the chance of success is extremely doubtful. No age appears exempt from it ; but it more frequently attacks the young, and a large portion of the cases occur before twelve years of age. On looking into the eye at the commencement of the complaint, you see opposite to the pupil, and deeply seated, an appearance like a mirror, re- sembling an opacity of the lens, from which it is difficult to distinguish it. If you watch the progress of the disease, you will see that this appearance en- larges into a prominence, proceeding from the bottom of the eye towards the cornea, and as it reaches the lens, you must be the more on your guard, that you do not mistake it for cataract. There is one appearance, however, at this stage, by which you may distinguish the one from the other ; upon the opaque substance, or the retina, of which its covering consists, branches of the arteria centralis retinae may be seen ramifying. The other symptoms are loss of vision, and the iris remaining iihmovable. As the prominence enlarges, the iris becomes protruded, and the cornea distended. The con- junctiva becomes inflamed, the eyelids vascular, and in a diseased state ; and, in process of time, the cornea sloughs, an opening is formed, and a discharge of a ropy mucus first takes place. The fungus does not always protrude through the cornea, but sometimes through the sclerotic, and then it has a purple livid hue, and is covered by the conjunctiva. As it increases in size, it assumes a dark red colour, its surface is unequal and irregular, it bleeds at the slightest touch, the parts slough, and then there is a fetid sanious discharge. 49. Dunng the progress of fungous hsematodes of the CANCER OF THE EYE. 455 eye, the health becomes affected, the countenance puts on a sallow hucj and the patient wastes in flesh. The disease is accompanied, and generally preceded, by disorder of the digestive organs ; the appetite is impaired, and there are present all the other marks of derangement of the general health. When the strength and health are broken up, the disease very soon comes to a termination. The close of the disease is preceded by hectic fever, as is that of most complaints from vhich the general health has suffered much during their progress. In fun- gus of the eye, the rest is completely destroyed, there is an affection of the nervous system ; and in children, convulsions come on, which terminate their existence. 50. Treatment : — The only remedy in this disease is the extirpation of the eye, and this in the early stage, before there is a disposition in the constitution to re-produce the disease. CANCER OF THE EYE. 51. By cancer of the eye is meant, not cancer of the globe of the eye, for it rarely or ever commences in it ; but it be- gins in the appendages and conjunctiva, and then extends to the globe of the eye. Cancer of the eye at the onset, resembles a warty tumour, with an ulcer on its surface, which has exactly the same appearance as ulcers in other parts of the body ; it then extends not only to the globe of the eye, but the palpebral lining, the lachrymal gland, the periosteum of the bones, forming the orbit, and the antrum ; in fact, the globe and its appendages become one mass of disease. 52. No good can be expected in the treatment of this complaint, unless the cancer be early removed by the knife. In the progress of the disease, the general health becomes broken up. EXTIRPATION OF THE EYE. 53. Although this operation appears formidable, and is 456 EXTIRPATION OF THE EYE. SO to the patient, as it is a most painful one, yet it is not dif- ficult of execution. The best mode of performing it is as follows : — The patient is to be placed in the sitting posture, or at any rate, with the head elevated, and in order to steady the eye, or shift its position, if necessary, you are to pass a needle, armed with a ligature, through the fore part of the globe of the eye, by which means you can readily steady it, or move it from one side to the other, [f the lids are contracted, or the eye ball is exceedingly large, it will be necessary to divide the outer angle in order to facilitate the operation. An assistant raises the upper lid, and the operator then introduces a double- edged straight knife through the conjunctiva, and divides the cellular mem- brane as extensively as he can. He next cuts through the oblique muscles : and having done this, he then divides the recti muscles and the optic nerve ; to complete this last step of the operation, a curved knife, adapted for the purpose, is used, and the globe of the eye is thus easily extracted. It sel- dom happens that any hemorrhage takes place which may not be stopped by dossils of lint. The lids are to be brought in apposition, a compress of lint is to be applied over the eye ; inflammation should be guarded against, and the patient should not be neglected; for although inflammation does not fre- quently supervene after the operation, yet it sometimes comes on. extends to the membranes of the brain, and proves fatal. 457 SECTION IV. DISEASES OF THE APPENDAGES OF THE ETE. HORDEOLUM OR STYE. 1. One of the most common affections of the eye-lids is that known by the name of stye or hordeolum, from its re- semblance to a stye or barley-corn. It consists of a small abscess in the lid, and is prodnced by an obstruction in the follicles of Meibomius ; the secretion from the part is altered, be- comes inspissated, lodges in the lid, excites irritation, inflammation, and the process of suppuration ; lastly, the small abscess breaks, and matter is dis- charged. In most instances, the suppuration is confined to a small space, but in oth- ers, it puts on the character of a boil, and sloughing of the cellular mem- brane then takes place. 2. It most frequently happens that hordeolum depends upon something ■wrong in the system, or derangement of the digestive organs, or impaired functions in some part of the body ; and then these states must be attended to, for they produce irritation, and sometimes ulceration of the edges of the eye -lids. 3. It is necessary when styes are attended with inflam- mation and redness, that cold applications, poultices, and fomentations be applied, as in other inflammations ; and, when matter is formed, that the abscess should be opened with a lancet. The best local applications, that can be used, are those of a mild stimula- ting nature, the mercurial ointments, with a little of ■which the edges of the lid should be besmeared every night at bed-time, the parts being previously washed with tepid water. The unguentum hydrargyri nitratis is the one in common use ; but it is in its usual state too stimulating for the eyes, thero- 39 458 TRICHIASIS. ENTROPrUM. fore it must be diluted with some simple ointment. Both the red and wliita precipitate mercurial ointments are used, and the zinc ointment also ; in fact, it is not essential what kind is employed if it be mildly stimulating. if the hordeolum is large and painful from inflammatiou, you should dis- charge the matter with the point of the lancet, and afterwards poultice, or baihe the part with a slight astringent wash, according to circumstances. TRICHIASIS. 4. Trichiasis is that state of the eye-lashes, in which they become altered in growth, and turned inwards on the globe of the eye, irritating the conjunctiva on every motion of the eye. Chronic ophthalmies of long continuance sometimes bring on this com- plaint, in consequence of the skin of the eye-lids being kept, for a long time in a state of distension and cedema, terminating in a considerable relaxation of it. Long-continued puriform discharges from the ciliary glands likewise spoil the shape and consistence of the cartilage of the eye-lids, and there- fore not unfrequently occasions trichiasis. 5. The treatment of these cases should be both local and constitutional. The only means, however, that can be relied on for cure, is to pluck away the eye-lashes, by means of forceps rather broad at the points : some benefit may be derived from applying a piece of adhesive plaster to the lid, which is to be fastejied to the cheek, so that the eyelashes may be kept bent out- wards. ENTROPIUM. 6. Entropium, or inversion of the eyelids, is produced from ulceration of the tarsi, the cicatrices formed by the healing of lippitudinous ulcers which alter the shape of the lids, so that the eye-lashes are turned inwards, irritate the conjunc- tiva, and produce a continual state of irritation of the whole organ. There is a watering of the eye, together with chronic ophthalmia, and in a short time vessels may be seen shooting over the cornea ; nebula and ul- ceration of the cornea supervene, and thus a serious state of irritation of the transparent part of the eye is produced. Ji^jSL, ECTROPirx. 4.59 7. In the treatment of entropium, nothing vriW be of any use except cutting a'WB.y a piece of skin from the affected lid ; for when this is done, the edges of the -wound are brought together by strips of adhesive plaster ; a cicatrix is formed, and the eyelids are then drawn outu-ards. The mode of performing the operation is very simple ; you must lift a por- tion of the skin of the aiFected lid with a pair of forceps that have, towards the poiut, transverse branches, and which are grooved j with this you lay firm hold of the portion of the lid, and all you have to do is, to take a pair of curved scissors, and cut off the projecting portion, as near to the edge of the lid as you can. ECTROPIUM. 8. Ectropium, or eversion of the lids, happens from ul- ceration on their edges ; an altered and vitiated secretion from the follicles of Meibomius, which produces a redness and an altered state of the conjunctiva ; and from cicatri- ces and contractions of the skin of the lids,, v;hich tend to evert them. This complaint is very distressing to the patient ; the eye has DOt its nat- ural covering; irritation, from extraneous bodies getting into it, is produced, and thus a constant state of chronic ophthalmia is kept up. 9. The plan usually adopted for the relief of this com- plaint consists in removing the triangular portion of the lid, just in the same way as the operation for cancer of the lip is performed. This is done by cutting through a piece of the lid, which is raised by a pair of forceps, so that the base shall be towards the edge of the lid, and the apex below, at the union of the two sides, A suture is applied through the incision, the edges of the wound are brought together ; these united, tend to keep the lid in the natural position ; and, in fact, the operation, iu this way, is often successful. Where the disease is brought on by a thickened state of the conjunctiva Jining the lid, you must remove that portion ; if from a cicatrix, it must be divided ; but it will be proper to state that this seldom answers, the divided cicatrix re-contracts, and the disea-^e returns. 460 FISTULA LACHRYMALIS. 10. By this term is understood, all obstructions of the lachrymal passage, preventing the natural flow of the tears and mucus from the eyes to the nose. 11. The most common cause of this complaint is a clo- sure of one of the puncta, and then there is epiphora, or a watering of the eye, together with suffusion of the tears, and the surgeon consequently discovers that one of the puncta is closed. This puncta must be punctured by a small sharp pin, made of gold or sil- ver, which is to be pushed through it to the lachrymal sac ; the obstruction is thus removed, and the epiphora relieved. 12. When the epiphora continues, the eye becomes irri- table, a drooping of the lids comes on, and an altered state of the lachrymal sac is produced, so that the original seat of the complaint is in the ductus ad nasum. The original seat, then, is in the duct leading from the lachrymal sac to the nose, and the tears, instead of finding their way to the nose, flow dowa the cheek. 13. Fistula lachrymalis may be divided into three stages ; first, where there is only simple distension of the lachrymal sac ; secondly, where there is inflammation and suppuration of the sac ; and lastly, where there is a fistulous opening leading from the sac to the cheek. 14. First Stage : — The first symptom in simple distention of the lachrymal sac, which leads the patient to observe any thing amiss with the eye, is, that on reading or exposing it \o the wind, there is a watering of the eye. ::xu: FISTULA LACHRTMALIS. 461 In a short time, this symptom becomes constaat, and then a swelling ap- pears at the inner corner of the eye, arising from the distention of the lachrymal sac, the tears collecting in it. These produce irritation ; mucus and purulent matter is secreted ; but when the sac protrudes, pressure made on it pushes the tears or mucus either through the puncta, over the face, or down the nose. 15. The complaint sometimes remains in this stage for many years, with only little inconyenience, pressure being occasionally made on the sac to empty it. Finally, however, from the pressure of the distended sac, and obstruction of the nasal duct continuing, or some accidental cause, irritation is excited, and the second stage produced. 16. Second Stage : — Inflammation and suppuration of the lachrymal sac are attended by a pufiiness of the inner corner of the eye, redness of the surrounding skin, which becomes swollen and hard, from the effusion of lymph. Suppuration having commenced in the sac, ulceration comes on, and the matter effects an external opening, by which it is dis- charged. Now obstraction, inflammation, and suppuration, do not always take place in the course of the ductus ad nasum, from ordinary causes ; but the progress of the complaint, when arising from ordinary and from specific causes, will be very different. 17. Third Stage : — An opening being thus made from the influence of the second stage, it is rendered permanent or kept open by the flow of pus and tears out of the wound, over the cheek ; and thus a fistulous opening is formed from the sac to the cheek. In this stage of the complaint, the patient is distressed a good deal by fre- quent returns of inflammation and suppuration of the sac. 18. Treatment : — Although various means have been at- tempted in the cure of this complaint, no plan has yet been laid down that has proved successful ; or at least, the benefit, 462 FiSTtJLA LACHRYMALIS. to be deprived from the means and treatment recommended, is, in most cases, very slight. 19. In many cases, little need be done but to evacuate the sac for the purpose of preventing irritation, in those cases where there is simple distention of the sac. One of the causes of this complaint is a vitiated state of the follicles of Meibomius ; when matter is secreted, and the eye-lids are closed together, and irritation is thus produced in the lachrymal sac ; in these cases the lids should be washed with tepid water, and besmeared every night at bed-time with a little of the unguentum hydrargyri nitratis. By this means, and at- tending to the constitution, and removing irritation as it arises, the patient may remain in that state for years. 20. When the obstruction is completed, the distention con- siderable, the attacks of inflammation frequent, and suppura- tion has commenced, another kind of treatment must be adopted. Your object will be to effect a natural passage for the flow of the tears, that is, through the nasal duct, instead of their flowing over the face. Methods have been proposed by Anel, Mr. Travers, and Mr. Wathen ; but the plan laid down by Mr. Ware is the one now generally adopted ; it consists in introducing a nail-headed style into the ductus ad nasum, and let- ting it remain there. The style should be just large enough to allow of the flow of the tears, by the side of it. If no opening has been made from the repeated inflamma- tion, the mode you will adopt to make one is as follows : you direct the pa- tient to be seated, and then standing behind him, you pass your hand round the patient's head, open the lachrymal sac, and then carry a biunt-pointed bistoury inwards and downwards, and divide the obstruction : the instrument with which you make the external opening is a phymosis knife. Having done this, you ascertain whether the passage is free, and then introduce a nail-headed style, about an inch and three-eighths long ; the head of the style is to lay obliquely on the front of the cheek, and a piece of adhesive plaster spread on black silk to be put over it, which will prevent persona from suspecting that there is any thing wrong in the eye. The style requires to be removed once a day for the first week, and to be washed ; sometimes there is a little irritation produced by its introduction, but in general, there is none, and the comfort the patient experiences is very great ; the water ceases to flow over the cheek, the sight becomes stronger, ^li^f^^'r^-r^-r^s::^ FISTULA LACHRYMALIS. 463 the tendency to inflammation is obviated ; and, indeed, so much comfort is experienced that the patient is lotli to dispense with the use of the etyle^ The obstruction frequently returns when the styic is removed. 21. It sometimes happens that, from disease about the bones of the nose, a fistulous opening from the sac to the nose is formed. If you should operate in such a case, you must introduce a sharp-pointed instrument, either a probe or a trochar, through the fore part of the lachry- mal bone into the nose, and the only object which remains is to keep open the perforation by a sponge tent, or nail-headed style j but it becomes rare- ly necessary to perform this operation. END. -^'3i£::^;£:.^-'Q_t:j3!=iiqa;.^^SiX:^::<^ i;ajS3 ^ >'.'»*' V ^--^ INDEX. PAGE Abscesses . . ..... 36 From gonorrhoea! in- flammation . . . 256 Absorption 33 Albugo _ 428 Amaurosis 438 Amputation ... ... 226 Of the Arm .... 235 Finger ... 229 Hand .... 234 Hip Joint . . 236 Lei . ... 282 Shoulder Joint . 2:36 Thigh ... 234 Toes .... 231 Ankle Joint, Fractures of . . 397 Aneurism 82 Axillary 96 Brachial 96 Carotid 95 Femoral 93 Pelvic, Gluteal, &;c. , . 91 Popliteal 92 Aneurism of the Aorta ... 89 Heart 88 Leg aad Foot ..... 94 Scalp 95 Aneurismal Varix 97 Anthrax 60 Ardor Urinee 246 Areola Tumour 205 Artificial Pupil 453 Ascites 210 Bladder, Irritable 265 Mucous disease of . . . 266 Paralysis of 267 Stone in 177 Bones, Diseases of 398 Exfoliation of 403 Inflammation of ... . 398 Suppuration in .... 399 Syphilis of 295 Brain, Wounds of 73 Breast, Diseases of ... . 193 Adipose Tumour of . . . 203 FAG-e Breast, Cancer of . . . 195 Encysted Swelling of . . 193 Irritable Tumour of . . . 203 Simple Tumour of . . . 202 Bubo, Sloughing 288 Sympathetic 271 Syphilitic 286 Bums' and Scalds 406 Carbuncle 60 Caries 401 Carpal Bones, Dislocation of . 350 Carpus, Fractures of . . . 387 Castration 224 Cataract 442 Operations for ... . 446 Chancre 275 Irritable and Sloughing . 279 In Women 281 Chemosis 413 Chordee 267 Chronic Carbuncle 51 Cicatrization 42 Clap, or Gonorrboea .... 246 ClaricJe, Dislocations of . . 340 Fractures of 381 Compression 69 Concussion 65 Conjunctiva, Fungus of . . . 429 Granulations of ... . 430 Simple Chronic Inflam. . 412 Cornea, Inflammation of . . 433 Ulceration of 433 Opacity of 427 Couching 446 Dislocations 339 Compound 335 Dropsy 210 Peritoneal 210 Ovarian or Encysted . . 2!2 Ectropium 459 Elbow, Dislocations of . . . 346 Encanthis 430 Entropium 458 Epiphora . 460 Erysipelas 62 466 INDEX. PAGE Exfhiiation 403 hxomphalos 130 Exostosis 404 Eye, Fungus Hsematodes of . . 454 Cancer of 455 Extirpation of .... . 455 Eye-Lids, Inversion of . . . 458 Eversion of 459 Femur, Dislocations of . . . 365 Partial 365 Fractures of 388 Fibula, Fractures of .... 396 Fingers, Dislocations of . . . 351 Fistula in Ano 217 Fistula Lachrymalis .... 460 Fore-Arm, Fractures of . . . 386 Fractures 369 Compound 374 Fungus Haematodes .... 454 Gangrene 54 Glaucoma . 441 Gieet , . .272 Gonorrhoea 247 In Females 274 Granulation 40 Haemorrhois 238 Haemorrhoidal Excrescences . 241 Hare-Lip . 305 Head, Injuries of 64 Hemorrhage 165 Hernia 103 Irreducible 104 Reducible 104 Strangulated 104 Congenital 125 Crural 128 Direct ]23 Encysted 128 Femoral 128 Inguinal 115 Umbilical 130 Ventral 133 Hernia Humoralis .... 269 Hip, Dislocations of .... 358 Scrofulous Disease of . . 320 Hordeolum or Stye 457 Hornet, Sting of 245 Humerus, Dislocations of . . 341 Fractures of 383 Hydrocele 97 Of the Spermatic Cord . 103 Hydrophobia 242 Hydrophthalmia 440 Hypopium 437 Infants, Purulent Ophthalmia . 421 Inflammation 19 PAGE Inflammation, Adhesive . . 29 Chronic 21 Common 21 Irritable 22 Specific 21 Iritis 4.36 Irritation - 15 Jaw, Fractures of 380 Joints, Scrofulous Diseases of . 318 Kidney, Calculi in .... 174 Hemorrhage from . 267 Knee-Joint, Compound Disl. of 366 Dislocations of .... 366 Lacteal Tumour 205 Lacunae, Abscesses in ... . 256 Leg, Fractures of ... . 396 Leucoma 427 Lip, Cancer of 307 Lithotomy 180 In the Female .... 188 Lock-Jaw 167 Lower Jaw, Dislocations of . 355 Lues Venerea 275 Lumbar Abscess 323 Male Nipple, Carcinoma of . . 204 Medullary Abscess .... 400 Mesenteric Glands, Scrofulous 316 Metacarpal Bones, Dislocat. of 351 Mollities Ossium 406 Mortification 54 Mouth, Syphilis of 290 Nasal Polypi 300 Nebula 427 Neck, Glands of. Scrofulous . 314 Necrosis 402 Nodes 295 Noli me tangere 52 Nose, Fractures of .... 379 Syphilis of .292 Ophthalmia, Acute .... 412 Chronic 414 Purulent 418 Gonorrhoeal 423 Strumous 424 Ophthalmitis 437 Os Coccygis, Dislocations of . 357 Paracentesis Abdominis . . . 214 Thoracis 215 Paraphymosis 283 Patella, Dislocations of . . . 363 Fractures of 394 Perinaeum, Abscesses in . . 257 Periostitis 399 Phymosis 281 Piles 238 Pituitary Membrane, Enlarged 303 INDEX. 467 PAGE Poisong 241 Animal 242 Morbid 245 Prolapsus Ani 263 Prostate Gland, Affections of . 259 Stones in 191 Proud Flesh 45 Psoas Abscess 323 Psorophthalmy 425 Pterygium 431 Pudendal Discharge .... 274 Pustules 428 Rachitis or Rickets .... 325 Rectum, Polypi of 299 Ribs, Dislocations of ... . 339 Fractures of 382 Scalds and Burns 406 Scalp, Wounds of 78 Scapula, Fractures of ... • 383 Scrofula 310 Scrofulous Affections .... 314 Skull, Fractures of ... . 70 Sinuous Ulceration 49 Sphacelus 55 Spine, Dislocations of . . . . 338 Injuries of 79 Sprains 327 St. Anthony's Fire .... 62 Staphyloma 435 Sternum, Fractures of . . . 381 Stumps, Treatment of . . . 237 Submaxillary Duct, Calculi in 192 Suppuration 30 Sympathy 15 Syphilis 275 Remarks on 297 Syphilitic Affections .... 289 Eruptions 293 Tapping or Paracentesis . . . 214 Taxis 109 Tendo-Achilles, Lacerated . . 164 Testicles, Diseases of . . . 219 Fungoid Diseases of . . . ^I Hydatids of 219 Inflammation of ... . 269 Irritable 224 Scirrhus of 220 Simple Chronic Enlargem't 223 Wasting of 271 Tetanus 167 Thigh, Fractures of .... 388 Dislocations of 358 Thumb, Dislocations of . . . 352 Tibia, Dislocations of ... . 364 Fractures of 397 PAGB Tic Douloureux 307 Toes, Dislocations of . . . 351 Tonsils, Enlarged 303 Trephining 76 Trichiasis 458 Trismus 167 Ulcers 44 Gangrenous 47 Inflamed 47 Indolent 4G Irritable 48 Menstrual 51 Phagedenic 289 From Varicose Veins . . 52 In Joints 53 Under Nails 49 Use of 53 Ulceration ........ 33 Sinuous 49 Superficial 51 Ureter, Calculi in 176 Urethra, Hemorrhage from . . 268 Irritable 259 Sloughing, &c 284 Stones in 190 Strictures of 252 Urinary Calculi 174 Utine, Extravasated .... 258 Incontinence of ... . 209 Retention of 206 Venereal Diseases 245 Vertebral Diseases, Scrofulous 322 Vertebrae, Fractures of . . . 336 Viper, Bite of 244 Warts 285 Wasp, Sting of 245 Whitlow 50 Wrist, Dislocations of . . . 349 Fractures of 386 Wounds 134 Contused 138 Gun-shot 142 Incised 134 Lacerated 138 Poisoned 141 Punctured 139 Wounds of Arteries .... 147 Abdomen 154 Joints 161 Tendons 163 Thorax 156 Troat 158 Veins 153 ?■.«*•, -'-Sfce'a^^'w; LIBRARY OF INSTRUCTIVE AMUSEMENT. I. ^is^^ THE SUMMER DAY BOOK. N E W-Y R K: CHARLES S. FRANCIS, 252 BROADWAY. BOSTON: JOSEPH H. FRANCIS, 128 WASHINGTON STREET. 1838. CONTENTS. Agricultural Hymn 326 Alphabet, its Mutation , . 2S5 American Herculaneum 152 American White Oak ......... 270 Ancient Britons 269 Ancient British Churches . 265 Ancient Irish Cup 309 Ancient Mounds in the West 295 Antiquities of Guatimala 266 Artificial Opening in the Stomach . . . . . . 201 Banana 248 Bathing 80 Bed 59 Bird Architecture . .42,301 Bottle-Tit, and Nest ......... 49 Bread 184 Burning Water 310 Camel Fights 332 Camphire Tree . : 115 Cape Tit, a Bird and Nest 48 Caravan of Pilgrims 222 CarnaubaTree 112 Change of Colour . 235 Charcoal, why it takes Fire 130 Cherokee Indians 167 Chesnut Tree 292 Chinese Travelling 199 Citron . 73 City in the Moon 334 Coal 20 Continent, New Ill Cork Tree . . 231 Corvorant, a Bird , , 105 Country News-carrier . 25 Currants . 213 Death-watch .84 ^wrUrJM-fcSi^- VI CONTENTS, Dew, Philosophy of , . . 251 Diseased Thirst 294 Diving Bell, Fatal Experiment ....... 315 Dog-days 76 Dogs, Impolicy of Rearing 61, 78 Dotteril 87 Dow, Lorenzo, the Preacher 173 Dream 223 Educate, what will 1S6 Education in Reign of Henry Vni 129 Education in United States 181 Falsehood 185 Fashionable Ears 334 Fig 132 Flowers and Music 312 Food, Farinaceous 34, 139 Food of Herbivorous Animals 55 Fossils, Animal and Vegetable . . . . . . . 290 Freedom of the Press . 333 Fusing Point of Metals ........ 31 Gas, Exhilarating 324 Georgia, Sketches of 160 Germination of Plants 12 Globe, a Shell 198 Gooseberries 214 Granite Mountain cut into a Statue 275 Grosbeak, Pensile 42 Grosbeak, Sociable . 46 Gypsies 86 Hints on Self-education 193 Hints to Younger Members of Families 98 History, King Arthur 322 Honey, Poisonous 150 Horrors of War 121 ^uman Frame ... 249 Human Height and Weight 88 Human Life, Table of its Probability ...... 101 Ice .... . 284 Inaccuracy , 268 Indian Virtues and Vices 23 Insect Anatomy 154 Italian Sonnet 274 Jenkins, the Self-taught Colored Man 207 July Thoughts 9 CONTENTS. VIl Knowledge, Progress of 147, 203 Lafayette 107 Land Breeze between the Tropics 108 Lemons and Limea 73 Liberty 227 Libraries . . . 147 Longevity 102 Mackerel Fishing 328 Madras and the Monsoons . . 255 Mahogany Tree 210 Mallon Grave Digger . . 239 Mangrove . 313 Maniac 263 Man wants but little 246 Marquis de la Place 54 Maxims . .31, 123, 129, 234, 280 Meetings for Mutual Improvement 247 Mis-education, Story of St. Dunstan 124 Millet . : . 60 Moon 91 Mutations of the Alphabet 285 Mulberries . . 216 New Continent . . . .111 New England 122 New England Manners and Customs 217 New Haven described 195 Newspapers, Origin and History 203 New-Zealand Instruments 165 Oak, Valuable .323 Oranges 71 Paper from Corn Husks . . .53 Pen and Press .......... 278 Per 327 Philosophy and Religion 333 Philosophy of Clouds and Lightning 55 PoiBird 212 Poisonous Honey 150 Portland, Me., its History . . 217 Presence of Mind, an Anecdote 85 Progress of Knowledge 147, 203 Raspberries 214 Religion and Philosophy . . . . . . . . 333 Retirement 280 Rider, Jane C, the Somnambulist 219 VUl CONTENTS. Robin Hood 67 Rock Fish 135 Roman Emperor and Empress . 277 Roman Ruins 247 Ruins of a Roman British Castle li>9 Sailing Matches : ISS Scenes in India 32 Scotch Duns . . . 253 Singular Animals in S. America 279 Snug Salaries 30 Song in Captivity 1 37 Song of an American in Turkey 1 03 Sparrow, Bottle-nested . . 44 Story of Edwin 26 Strawberries 215 Street Education 16 Substances used for Human Food 34, 139 Sugar, does it injure the teeth ? 23, 50 Sun 328 Summer Fruits .... 213 Sweet Potatoe : 325 Taking Honey in Cashmere . - • . •* . . 229 Tattooing 316 Teak Tree .233 Thoughts for July . 9 Thoughts for those who think . . . . ' . . . 119 Tobacco, and Snuflf Taking 306 Tragacanth . . ; 131 Trees, Valuable . . . i ; . . : . .113 Tropical Fruits : . 71 Trolling for Rock Fish 135 Turnstone, or Dotterel . 87 Universal Kingdom 82 Varieties of Human Food -. . . 272 Village of Nobles .......... 334 Water- fowl, Lines to a 153 What is to be done 288 What will educate . . . . . . . . . 166 Winter in Russia -281 Wooden Pavement . 284 Yew Tree 14 Zeno the Philosopher . . . , . . . . 151 Zimmerman's Reflections . . ^ .... 27 i r - ^jj ..-^ ■ n ■i ' — a|r~lt~' 183 THE QIJEEN OF GANDY, '«S*5KBgS»r^ TEE YOUNG MAN'S EVENING BOOK. NEW-YORK: CHARLES S. FRANCIS, 252 BROADWAT. BOSTON: JOSEPH H. FEAXCIS, I2S WASHINGTON STREET, 18 3S. o O l-H O < K "-2r~--r: THE PARLOUR BOOK. NEW-YORK: CHARLES S. FRANCIS, 252 BROADWAY. BOSTON: JOSEPH H. FRANCIS, 128 WASHINGTON STREET. 1839. .~