/?D&f2'^^ Lfn Columbia SBitttierjfttp CoUege of ^fjpgitiatijs anb ^urgeong Hitirarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/consultationsonmOOIedr C aN S U L T A T I O N S DISORDERS That require the A5s S I S T A N C E O F S^"" S U R G E R \. By HENRT-FRANCIS LEJDRAN, Matter in Surgery, Senior Diredor of the Royal Academy of Surgery at Paris, Fellow cf the Royal Society of London, formerly Priiicipal Surgeon to the Hotel de la Charite, and .' cnior Confulting Surgeon to His Majefty*s Armies. Tranflated by ALEXANDER R E 1 D, Assistant Surgeon to the Royal Hospital ^r LONDON: Printed for Robert Horsfield in Ludgate-Strut . MDCCLXVI. ^ MP d;SAR HAWKINS, Efq; Serj£Ant-Surgeon to His Majesty 5 AND THOMAS GATAKER, Efq; Surgeon Extraordinary to His Majesty, And Surgeon to Her Majesty's Houshold. GENTLEMEN, TWO Motives have induced me to infcribe to you this Tranfla- tion of the lafl: Work, of one of the moft eminent Surgeons France ever produced. One of them cannot fail of public Approbation ; for to whom could it be dedicated with greater Propriety, than to thofe who are in the fame De- gree of Eftimation in England? A 2 The iv DEDICATION. The other perhaps may not be fo generally approved of, as I muft can- didly acknowledge it is not without an Allay of Self-Intereft ; fince by thus offering you a public and lafting Teftimony of my Senfe of your paft Patronage and Favour, I am not with- out Hopes that you will ftill continue them to, GENTLEMEN, Tour mofi Obliged and mojl Obedient Servant ^ A. R E I D. in Translator to the Reader, 7I/1^R le DranV Works have been fo well -/ rX. received^ and his Reputation as a Surgeon isfo great, that there needs nothing to be f aid in his Favour, He has likewife in his "Preface explained the Nature and Dejig?i of the following Work fo clearly, that to reconi" mend it would be fuperfluous. The 07ily Thing neceffary for me to fay is, that if the Tranf- lation is not erroneous in any jnaterial Fart, it will be a very valuable Additio?i to the reft of his Works that have already ap- peared :in Englifli j and my Motive for at- tempting it ■'was it's being declined by a Gen- tleman whofe Bufinefs would not permit him to fpare the Time neceffary for the Purpofe. Could he- have found Leifure, I am very fenfible Mr Ic Dran woidd have had more yujiice done to his Merits, than it has bee?i in iny Fower to do. However I am in Hopes, that to thofe Gentlefnen who do ?tot un~ derfand Fr ench, this Tran/lafion will be ac- ceptable, as it will fupply them with a Fund of Knowledge and Experience to have Recourfe A3 to vi Tranflator to the Reader. to upon any Emergency. The Cautions given to avoid MiJiakeSj the Methods of treating with Propriety a Number of uncommon Dif- orderSy and of reSfifying and relieving thofe Accidents that have happened in Confequence of an erroneous PraBice^ are of fuch excellent life, that there is no Surgeon but perhaps at one Time or other may avail himfelf of thefe Fruits of fo long Experience and extenfive PraBice. To conclude -, if this meets with a favourable "Reception from the Publick^ and fhould attain to a future Editiony the Tranf- lator ^ by the Ajfiflance of a Gentleman, who was formerly a Pupil of Mr le DranV, will be enabled to add fome interefiing Cafes to- thofe contained in this Volume^ which at pre-' fent is deferred for fome particular Reafons. P Pv E-- [ vii ] The Author's Preface, QEVERAL Authors, both ancient k3 and modern, have given excellent Rules for the Treatment of Chirur^ical Dif- orders : But after having defcribed them according to their different Natures, they have only laid down general Rules for their Treatment, to which the Sagacity alone of the Surgeon may and ought to make Ex- ceptions, or even Additions, as Circum- ftances may require. For Example, fpeak- ing of Fiftula's in Ano^ which are very common Diforders, they agree that it is neceffary to divide the Redum by an Ope- tation, as far as where it has been pene- trated or denuded by the Matter, and fome- times even to take away a Part of it along with the Callofities about it. Neverthelefs Pra(5lice affords us many Inflances ol Fijlu^ Ids in Ano, fome of which want no Ope- ration at all, and of others that are attended with Circumflances that require different Methods of operating. It is the fame in A 4 almoft viii PREFACE. almoft all the Difeafes that require the Af- fiftance of Surgery, and it is Pradtice only that inftrudls and difcovers to us the dif- ferent Species belonging to every kind of Diftemper. From hence we may conclude, that the more Pradice a Man has, the greater his Opportunities are of obferving the Difference of Difeafes, which to ano- ther at firfl: Sight may feem to be the fame, notwithftanding they vary in feveral Cir- cumftances, and confequently require a Di- verfity of Treatment. If Knowledge then can only be acquired by confiderable Pradice, it is certain it can fcarcely be met with but in great Cities, where, proportionably to the Number of Inhabitants, there are more Difeafes than in fmall Towns and Country Villages. It is in Confequence of the different Cir- cumftances I have juft mentioned, that in great Cities, Confultations are frequently held in difficult Cafes, where every Sur- geon that is called in, giving his Opinion according to the beft of his Knowledge, they colledt from the whole what is moft proper to be done for the Diforder they are P R E F A C E. IX are confulted upon. Surgeons in fmall Towns and Country Villages (which is a Misfortune to Mankind) are deprived of this Affiftance. The latter in particular for the moft Part being but in indifferent Cir- cumftances, are not in a Condition to vifit or refide long enough in great Cities to at- tain fufficient Knowledge for pradlifing fo important a Science, with the requiiite Per- fedtion. Neverthelefs they are daily under the Neceffity of deciding the Fate of Men, in Cafes wherein even thofe of the greateft Pradice would perhaps adt with Timidity. Is it the Fault then of thefe Surgeons that they do not always fucceed ? No, it re- quires a Degree of Genius fuperior to that which Nature generally affords. Thefe Confiderations induced his Majefly to eftabliih the Royal Academy of Surgery, where every one might communicate his Obfervations in Pra(5ticej and the fame Modves prevailed with this Academy to publifh it's Memoirs, filled with Obferva- tions and Precepts capable of direding mofl Surgeons. Precepts, which are not the Work of a fingle Perfon, frequently liable to X PREFACE* to Error ; but the joint Work of the ablefl Surgeons in Europe. It was with the fame Intentions, that previous to it's Eftablifh- ment, feveral Praditioners pubUfhed Vo- lumes of Obfervations, in which are de- fcribed the Treatment of a great many Dif- orders, that without departing from gene- ral Rules, have required many particular Attentions. It is with the fame View I alfo publifli thefe Confultations ; befides I think it would be contrary to the Didates of Hu- manity, to fuffer what may be of Service to many Perfons to be lofl in Oblivion. The Queftions are fuppofed to be alked by a Country Surgeon, who is defirous of hav- ing nothing to reproach himfelf with, in the Treatment of any Diforder under his Care. I have particularized as much as poffible every Circumftance attending the Diforders related, together with their Treat- ment. It were to be wiflied, that in all the Con- fultations we receive from the Country, the Account of the Diforder was as exactly de- Icribed j as it is only from ^ perfect Know-^ led^e PRE FACE. xi ledge of every Circumftance that accom- panies a Diforder in it's Beginning and Pro- grefs, and fhall hereafter happen, that we can be able to determine it's Caufe and Na- ture, and in Ihort every Thing which ought to be done for the Cure of it. I have not confined myfelf to a Defcrip- tion of thofe uncommon Diforders, which may be feen only once in our Lives. I have feleded thofe which are' common e- nough, the Care of which has been en- trufted to me many Times, or have pafled under my InfpecSion at Pans and other Places, during a Pradtice of more than fix- ty Years. Confequently thefe Confultations may give Rife to new Idea's in young Sur- geons, and throw fome new Light on the Pradice of Surgery. If I have been fcrupuloufly exa(fl: in de- Icribing trivial Things, in the Method of Treatment, I defire thofe great Mafters of the Art, who are willing to employ any of their Time in reading my Book, not to be offended at it j not. writing for them, whom I do not pretend to teach. But I thought it incumbent on me to do it for the xii PREFACE. the Benefit of others, to whom it might afford Indications of Cure, in Cafes fimilar to thofe I have related, which they might make a proper Ufe of j for there are few Chirurgical Diforders which have not fomc Refemblance to one or other of them. No contemptible Refource for a young Practi- tioner. This Collecftlon I made for the Ser- vice ^f my Pupils, and formed a Hiftory of Obfervations of all the Diforders herein fpecified. I related to them every Particu- lar belonging to each Diforder, and enjoin- ed each of them to return me an Anfwer in Writing feparately. After which I rec- tified their Anfwcrs, explaining to them why it was neceffary to adl in fuch a Man- ner in treating them, preferably to any other. By this Method, they were not only ac- cuftomed to remark every Circumftance which might accompany a Diforder, and to give a very circumftantial Defcription of them 5 but in order to anfwer them, they were obliged to confult Authors, coUedt their Opinions, refled; on them, and deter- mine PREFACE. Xlll mine in Confequence j in {hort, to acquire a Habit of writing and arranging their Ideas in a proper Manner *. I did not think it would be of any Ufe to put the whole in Form of Obfervations, becaufe it would make no Addition to them. It is agreed that to make a good Surgeon, Theory fhould be united to Pradice, and that if Theory is of no Ufe without Prac- tice, Pradice will alfo be very defedive without Theory j neverthelefs it is princi- pally by Pradice that all young Surgeons begin. Thofe who are defirous of attaining to Perfedion, fludy at the fame Time, fol- lowing the great Mafters of the Art for a long while, and making Refledions on all that they fee and underfland. But the greateft Part conceit themfelves fufficiently able, after they have attended an Hofpital for a few Months ; when indeed they are as yet fcarcely capable of perceiving the Differences that occur between one Difor- dcr or Wound, from another of the fame kind, .do'.^72M^9 * Every Pupil may aft in the fame Manner for his la- " ijru£\ion. xiv PREFACE. The Theory which they might acquire by Study, and ferious Refledions, might illumi- nate the Underftanding, (that EytofPo/ypbe^ mm in the Fable, which can diilinguifh fo far ofFj) aod by that Means perfetfl their Practice. On the contrary, too many being but very llightly inftruded, having but a fuperficial Knowledge of Anatomy and the animal Oeconomy, which can only be ob- tained by frequently repeated Diffedtions of dead Bodies ^ Too many I fay, difperfe themfelves all over the Provinces and Vil- lages to pradice and get a Livelihood by the little they know.' ^du-^ov-l The little Theory ' acquired by very few 6f them, aind the want of Pradice, induced me to publifh this CoUedion, where the Symptoms which accompany the moft Part of Chirurgical Pifordcrs are related with exadnefs. "*"' " ' ^ ^ ' \ If thefe Cafes t^^&v^^iiy'^em/'(fertkinly they have not had Opportunities to make the neceffary Refledions for the well under- Itanding of them, and treating th^fn prai perly according to the beft Rules of Art : I have therefore done it for them. There P R E F A G E. XV There can be no young -Surgeon but what is defirous of curing his Patient, either from Humanityj Honour, orlntereft^ and who will not be glad to forefee and pre- vent all the SytViptoms that may accompany the Diforder under his Care. He will be Mc to do this much better, if he can com- pare it with ^n exadt Detail.of a JDifordet refembling itj and may find Expedients which would have efcaped him from want of Pradlice. This is what has induced me to publifh this CoUedion, and 1 hope it will be ufeful to fuch. I have made for fome of my Friends who are neither Phyficians nor Surgeons, an Abridgment of Anatomy in general, ad- apted to the Ufe of ftudious Perfons, who defire to be acquainted with that Science. Being perfuaded that this Compendium may be ufeful for thofe Surgeons I have jufl mentioned, I imagine I fhall do them an effential Service in publifhing it after this CoUedion of Obfervations, knowing that many of them are not in a Situation to learn Anatomy, which can never be ac- quired without frequent Difledlions. The xvi PREFACE. The mod eminent of the Faculty may perhaps remark fome Omiffions or Errors in my Pradice. I am fenfible of it, but it is not for thofe that I write, and befides that every Perfon does not think alike, the fame End is often attained by different Ways. For the reft, this is the fixth and laft Work that I have publifhed, and I think I have now performed my Errand in this World. CON- [ xvii ] CONTENTS. yiN Abfcefs on an exojlofed 7ibia Page i An Abfcefs under the Os Maxillare 4 An Abfcefs under the Os Maxillare 8 An Abfcefs under the yaw-Bone 12 A Fluxion on the lower Jaw 14 Ajifiulous Abfcefs in the Belly i % An Abfcefs near the Verge oj the Anus 22 An Anchylojis of the Knee 26 A Burn on the Arm 3 1 A Burn between the Buttocks 34 A carious ^high-Bone 38 A Caries of the parietal Bone 42 A Gonorrhaa 4j A Cicatrice which prevents the life of the Fingers 47 A PunSfure in the Hand 49 AfraBured Rib j;3 A Blow on the Breafl 59 A Wound on the Foot by a Hatchet 67 A Wound by a Knife in the Loins on the left Sid^ 73 a A Wound xviii CONTENTS. A Wound in the Thigh by a Sword yy A Wound in the Fore- Arm by a Sword 80 A Wound in the Breaft by a Sword, and another in the Arm 8 5 A Wound by a Sword above the Eye -Brow 9 x A Wound in the Breafl by a Sword 93 A Wound by a Pijlol in the Fore- Arm 95 A Wound by a Sabre, making a Flap 98 A Wound in the Fore- Arm by a Sabre i o i A Wound on the Elbow by a Sabre 1 06 A Wound in the Thigh by a Piftol ill A Contufion on the Forehead by a Mujket Shot 11^ A Mujket Shot in the Arm 1 1 9 A Gun-Jhot Wound in the Hand 122 A Mujket Shot in the Arm 125 A Mujket Shot in the Breafl 129 A Mujket Shot in the Breafl 132 A Mujket Shot in the Foot 135 A Mujket Shot on the Sinus Frontalis 137 A Can72on Shot on the Arm and Breafl 1 40 An Ar?n taken off by a Cannon Shot 1 43 Afpraitied Foot 146 A Finger ?iearly cut off 150 A Pain in the Head i^z Pain in making Wafer 155 Ajmall CONTENTS, xix A [mall Stone in the urinary Bladder 1 60 Tain in making Water 165 Tain in making Water 173 An Excoriation on the Spine of the Tibia 1 8 1 An Excoriation on the Spine of the Tibia 183 A fungous Excrefcence in the Orbit 186 A flight Running from the Penis 196 An Exoftofs on the Humerus 198 An encyjied Dropfy 201 A Fijiula in the Joint of the great Toe 2 1 o A Fijiula in the lower Jaw 213 A Fijiula in the Cheek 2 1 ^ A Fijiula in Ano 219 A biind external Fijiula near the Anus 223 A FraSlure of the Thigh-Bone from an in- ternal Caufe 226 A Fijiula in Ano 228 A Fijiula in Perincso 233 A FraElure of the Humerus 240 A Fradiure of the Humerus 244 A Fra5lure of the Femur 246 A FraSlure of the Arm below the Elbow 253 A Fluxion on the Cheek 255 A Fijiula in Ferinceo 259 A Gland upon the Leg 263 a 2 ^^n XX CONTENTS. jdn indurated Gland in the Membrana Adipofa, forming a Tumour on the Side 265 A crooked Knee 268 A Gangrene from an internal Caufe 271 A bandy Leg from the crookednefs of the Bones 276 A Gland in the Breajl 279 A Ganglion on the Hand 28 1 Bleedings in the Mouth 284 i:h€ Piles 288 The Files 293 Bandy Legs 297, Coagulated Milk, after a Child-birth 299. The Ligament of the Patella, divided 302 An Puncyfted Tumour on the Knee 304 A Carcinomatous Tumour on the Knee 307 An Encyjled Tumour on the Head 309. Wens^ or Flejhy Tumours 312. The Nofe cut 3^7 The Nail growing into the Flejb 3 1 9 A Pejfary left in the Vagina 3 23 An imferfeSi Phymofs 326 A Wound on the Mufcle Thenar 329, A SuppreJJion of Urine 331 A Supprefjion of TJrine 336 A SuppreJJion oj JJrine 342 A Wound CONTENTS, xxi A Wound i?i the Hand 346 Tie Tendo AchilUs partly divided 348 A SuppreJJion of Urine 3 50 A SuppreJJion of Urine 352 A FraBure of the Patella 35S l^he Confequence of a bad Labour 3^5 A Diforder arifmgfrom the ceafing of an Hamorrkoidal Flux 373 An Accident in Bleeding 376 A bad Shape 3 So ^he Tendo AchilUs divided 387 Divided Tendons 390 Afwelled Tejlicle 393 A Swelling of the Thigh 39^ A Swelling on the Leg 402 Swelling of the Pudenda 413 A Swelling of the Tejiicles, attended with Impotence 416 A Tumour on the Thigh, occafioned by a Fall 42 1 An indolent Tumour on the Leg, the Confe- quence of a Contujion 426 A Tumour protruding from the Matrix 430 An indolent Tumour between the falfe Ribs and the Os Ilium 433 A Swelling xxii CONTENTS. A Swelling on the Leg 43 7 ji I'umour arifingfrom the Loins 442 jin Ulcer on the T^ongue 447 Hyjierick Convuljive Fits 449 Firfi Letter to Monfieur * ** 455 Second Letter 462 The Emplaft. c Ceruffa^ & DIvinum, not be- ing in the Pharmacopeia Londinenfis, their Compofition taken from he Mery^ is here infertcd. Emp, e Cerujfa, R. CerufT. Venet. Ol. Rofar. ana }fe4. Aq. Fontan. lb ij. aut q. s. Coq. ad coniiftentiam Emp. deinde adde, Cer. Alb. f viij. M, £ Emplaft. Emp. Divinum. R. Litharg. Aur. preparat. Ibjfs. OI. Olivar* ibiij. Aq. Fontan. ibij. Coqiie fimul ad Emp. fpiffitud. deinde permifce Lapid, Magnet, preparat. ib^s. Gum. Ammon. Galban. Opopan. Bdellii ana 5iij. Myrrh. Oliban. Maftich. Virid. ^ris Ariftoloch. rotund ana ^ifs Cer. flav. gviij. Terebinth §iv. M. f, Emp. S. A. ERRATA. Page 7, 1. I, for expels read expel. Ibid. 1. 17, for not read root. ■ Page 21, 1. 7, for Mufcels read Mu/cUs. Page 33, 1. 10, dele the Comma after Linen. Page 51, 1 18, put a Comma after Breadth. Page 53, 1. 12, for Clavicles read Cla'vicle, Page 91, 1. 17, (or punSured ttlid pricked. Page 1 10, 1. 22, for nuould read 'ivzV/. Page 113, I. I, after digeji, add ^«/. Page 131, 1. 20, after abundance of Matter, read thus, Thf xvhole Cellular Memhrant conneSled to theft Parts has been ^if' folved. ' Page 140, 1. 14, dele the / in Bifceps. Page 204, 1. 5, for an Apple, read a large Apple, Page 234, 1. I, iot putrifed, read petrified. Page 276, 1. 20, fpr groiv, read go. Page 341, 1. 13 formate, rczd contrarian. Page 385, 1. 15, for their, read its. Page 4?6, 1. 1 9. for above, read under. CONSULTATIONS On mdft of the DISORDERS That require the Assistance of S U R G E R ISt^^oFTHE ?^. „a ^n Abscess en an exojiofed Tibia. AM A S O N, Forty Years of Age, has had the Tibia exoflofed ever lince he was Eight Years old, at which Time he received feveral Blows on it, and had a large Abfcefs with Caries, from which there came away feve- ral Scales or Exfoliations. He does not re- member any thing that might occafion the Exoftofis, at prefent extending the whole Length of the Tibia, which is twice it's natural Thicknefs. He has never felt any Pain from the Time he was cured, nor even obferved that the Tibia grew larger. B Within . [ 2] Within this Week, a flight Inflammation has appeared on the middle and anterior Part of this exoftofed Tibia; the Patient has applied Cataplafms of Bread and Milk, and now has Recourfe to you , upon exa- mining of it, a Fluctuation is very evident. What are w^e to think of this Difeafe, in it's prefent State before the Tumor is open- ed ? What fhould be done ? The Patient has never had any Commerce with a Wo- man, therefore nothing can be fufpedted on that Account. Answer. Although the Patient does not remember having received any new Blow, it is poflible he may have given himfelf a flight one, and that might be fuflicient to excite the In- flammation, which has terminated in an Abfcefs. It is alfo poflible, that the Exof- tofis of the Tibia having become carious, has occafloned the Putrefadlion and DiflTo- lution of the Periofteum, cfpecially as he felt fo little Pain while the Matter was forming. In [3 ] In the firft Cafe, the Patient may be cured after the Abfcefs is opened j but in the fecond he runs the Hazard of worfe Confequences, becaufe it is very difficult to procure the Exfoliation of an exoftofed Bone, v^hen carious in any Part, except it proceeds from a Venereal Caufe. To know the Nature of the Difeafe, the Abfcefs fhould be opened it's whole Length ; and, if the Bone is found with the Periof- teum on it, the Tumor muft be treated as a limple Abfcefs, which will ealily heal, when opened ildlfully. But if the Bone is found bare, an Exfoliation muft be procured if poffible. Of this there are but little Hopes, on Account of the Exoftofis, and the Ulcer mav become fiftulous : however, the Patient fhould preferve his Leg as long as he can, for Amputation is the laft Reme- dy to have Recourfe to. The Surged n'j Reply. I followed your Advice, the Bone was co- vered, but the Periofteum was bare without B 2 fceming [4] leeming to be altered. The Wound healed in lefs than a Month -, I have advifed the Patient always to wear a Tin Plate between two Stockings, to cover and defend the Ti* bia ; for in it's prefent State, a Wound which might afFedt that Bone, would not eafily be cured on Account of the Exoftofis, and might render Amputation neceflary. j^?2 Abscess mider the Os Maxillare. AM A N who had the third of the Dentes Molares in the lower Jaw decayed, which gave him a great deal of Pain, had it drawn. On examining the extradled Tooth, a Piece of the Socket was found adhering to the Root. There enfued fo confiderable a Fluxion on all that Side of his Cheek and under his Jaw, accompanied with a Fever and violent Pains, that it be- came neceflary to bleed the Patient five or fix Times. This continued for five Days, and at length an Abfcefs formed under the Jaw, behind the Mufculus Membranofus, which [ 5 ] which appeared but imperfe(ftly outwards, on Account of the fwelling of the Throat. In the fixth or feventh Night, the Patient perceived a fmall Difcharge of very fetid Matter from the Socket on the inner Side of the Gum ; he fpit out a Spoonful direft- ly, and there has fince difcharged a fmall Quantity at different Times. Upon preffing on the Outfide under the Jaw with the Fin- ger, one may diftinguifli the Cavity where the Matter was formed, by that Place be- ing fofter than the reft, which continues fwelled and hard ; upon infpecfling the Mouth, the Socket appears ftill fwelled -, and introducing a Probe into it, the Bone is felt bare. Your Advice is defired : Is there not Reafon to fear, that the Os Maxillare will become carious ? x\nd is it not proper to open the Cavity behind the Mufculus Membranofus, to give a more free Difcharge to the Matter ? In fhort. What fhould be done ? B 7 Answer. [6] Answer. It is probable that the Matter coUeded behind the Mufculus Membranofus was formed in the Fat which furrounds the Vef- fels and maxillajy Glands 5 for it is faid it was not plainly difcoyerable on the Outlide, before it made it's Appearance by the Socket. Befides, it came out between the Socket and the Gum. Probably it may be propofed to make an Incifion in the Neck, at the Place where the Cavity is diflinguifbable on the Outlide, to give a more free Difcharge to the Matter, the rather as the Cavity is lower than the PalTage made by the Matter -, be- ing apprehenfive alfo, that it may form Si- nufTes in the Fat, and foul the Os Maxillare. But, from an Acquaintance with the Re- fources of Nature, we learn, that in thefe Cafes, as well as many others, the Motion of the neighbouring Parts, and the elaftic Property of the cellular Membrane which connects them, contrail the whole Circum- ference of the Cavity towards the Place, through which the Matter is evacuated, and expels [7] expels it as foon as it is coUedled. I there- fore think the Incifion unnecefTary, and the more fo, as there is not that Danger of a Caries as is apprehended. The Ufe of the Cataplafms, therefore, muft be continued, to foften the Indurations which are felt about the Cavity, where the Matter comes from, and that the Parts may recover their Elasticity. The fwelling of the Cheek and the Neck will go off, in Proportion as the Matter is difcharged ; juft as we obferve the Inflammation about an Abfcefs does, when it is properly opened and the Matter let out. The Event. The Method prefcribed by the Confulta- tion was followed, and the Patient cured in lefs than ten Days, without any Inciiion being made. B 4. ^fi C 8] jin Abscess under the Os Maxillare. VERY fat Man, thirty-five Years of Age, was attacked in the Night with fo confiderable a Fluxion on his Cheek, that in the Morning he could not open his Jaw ; the Swelling in a Ihort Time extend- ed from his Eye to his Throat, yet the Pa- tient felt very little Pain, only a kind of uneafy Senfation. Notwithftanding the Ufe of emollient and refolvent Cataplafms fre- quently renewed, all the Side of his Face grew confiderably hard. It has continued a Month much in the fame State as at prefent,- except that there feems to be a very deep Flu(5lua- tjon under the Jaw, near the third and fourth of the Denies Molares, and another as doubtful near the Angle of the Jaw. How fhould this Difeafe have been treat- ed at the beginning ? and how ought this Abfcefs to be opened ? Is it a proper Time to open it, the Patient having very little Fever ? Note, He now feels, and has felt very little Paiq. Answer. [9] Answer, The Patient ought to have been bled once, or oftener, in the beginning of the Difeafe, on Account of it's Violence, and his full Habit ; for probably that might have prevented the forming of Matter. It was right to make ufe of emollient Cata- plafms 5 but neverthelefs, I think that when the Matter began to form, maturative Cata- plafms fhould have been ufed to affift Na- ture, The Matter which you think you feel fluctuate, is more likely the Confe- quence of a Putrefadlion of the obftrudled cellular Membrane, than of a Fermentation of the ftagnated Fluids j as he has never had, and has now, but very little Pain. However, this Matter (hould be dif- charged by a proper Operation, provided you are certain of it's Exiftence. The Abfcefs, therefore, muft be opened, and the Extent of the Cavity, containing the Matter, will determine the Direction and Extent of the Incifion ; for when you have made an opening large enough to ad- mit [ lo ] mit your Finger, you muft introduce it into the Wound j and feeling the Extent of the Cavity, you may condud: the Biftoury by it, cither to lengthen the Incifion, dired: it's Courfe, or make a Counter-opening (if neceffary) near the Angle of the Jaw. Be- iides, with the Finger you will be able to diftinguifh the Pulfation of an Artery, which otherwife might be cut -, and is what every Surgeon fhould be attentive to, before he makes a deep Incifion, efpecially in the Neck, becaufe a Haemorrhage there is very difficult to be flopped. ^he Surgeon*^ Account of the Progress of the Disease. I opened the Abfcefs it's whole Extent, and likewife made a Counter-opening near the Angle of the Jaw, to prevent the Mat- ter lodging in a Sinus, which I found there. The Wound went on well j and the Coun- ter-opening, which difcharged a great deal of Matter, was clofed in three Weeks. But the large Wound, the Edges of which are contraded and funk in, without filling up from [ " 3 from the Bottom, threatens to become fiftu- lous. In Proportion as the Wound has di- gefted, all the Hardnefs has in a Manner difTolved, and the Jaw begins to open juft enough to admit the End of the Little Fin- ger. What is to be done to prevent it's be- coming fiflulous ? Answer. As the Jaw can be a little opened, the Teeth on that Side fhould be examined, by ilriking them one after another with a thick Probe. If the Stroke is more fenlibly felt by one than another, that Tooth is certain- ly damaged, though it has never been pain- ful, and confequently fhould be drawn. The Event. The Patient, who is the Subjed: of this Confultation, being come to Paris, I found- ed his Teeth in the Manner propofed, and caufed a flight Senfation in the fartheft Dens Molaris, next the Angle of the Jaw. I therefore had it drawn. The Tooth was not [I2] not carious, only changed in it*s Colour, being yellower than the others. I conclud- ed this was the Caufe of the Difeafe, and fo it proved ; for in about three Days the Motion of the Jaw became quite free, and, in about ten, the Orifice, which had re^ mained fiftulous, was clofed up. An Abscess under the Jaw-bone, YOUNG Lady was attacked with a Fluxion, which gave her very lit- tle Pain, reaching the whole Length of the lower Jaw-bone, and under it. The In- flammation infenfibly increafed, and in a- bout ten or twelve Days an Abfcefs formed under the Jaw-bone. Pultices of Bread and Milk have been applied, and the Ab- fcefs having broke of itfelf, the Patient de- lires to know of you what farther fhould be done. The Surgeon of the Place, to whom fhe applied, has examined all her Teeth on that Side, and finds them very good and white 5 and being informed by the Patient, likewife, 1 13 ] like wife, that fhe has never felt the leaft Pain from them, was fatisfied with making the fmall Orifice that broke of itfelf a little larger, and drelTed the Abfcefs in the moft limple Manner. The Abfcefs does not heal, and the Bottom ©f the Cavity having now continued fix Weeks juft the fame, without filling up, though the Orifice is grown narrower, you are confulted, and afked whether this Fiflula fhould be left to Nature ? Answer. It is very feldom that thefe AbfcefTes arc formed without fome Tooth being con- cerned. The Surgeon was fatisfied with infpeding, but that was not fufficient ; they fhould be flruck one after another with a large Probe, and, if any one of them feels a different Senfation from the others, that Tooth is certainly afFeded, and is the Caufe of the Fluxion 5 confequently it fhould be drawn. Tbe [ 14 ] ^he Surgeon 'i Letter. The Patient being unwilling to part with a good and handfome Tooth, which gave her no Pain, fufFered a Month to elapfe ; in which Time the Orifice under the Jaw was more contradled, but not cured. At length, tired of wearing a great Patch, which fhe was obliged to change twice or thrice a Day, fhe had the Tooth drawn (it was the firft of the Molares next the Den- tes Canini), and there was found at the Root of it a white Excrefcence, of the Size of a Hempfeed. Four Days afterwards the Fiftula was clofed, with the Ufe only of the fimple Emplajirum de Cerujfa, ^Fluxion on the Lower Jaw. A YOUNG Woman, who is very fat, has for fome Time paft had the third of the Dentes Molares of the lower Jaw decayed, without having given her any Pair^ C IS ] Pain 'till now. Within thefe two Days the Cheek is fwelled, and the Inflammation has extended under the Jaw, which is become very hard ; the Patient not being able to open her Mouth, her Teeth are clofed toge- ther. This is accompanied with a Fever, and a great deal of Pain, without the Tooth appearing to be concerned j and (he defires your Advice. Answer. Though the decayed Tooth gives her no Pain at prefent, it is certainly the Caufe of the Fluxion, which probably will terminate in an Abfcefs about the Socket. Perhaps too, the Socket may be injured by the Tooth, the Caries being communicated from one to the other ; the Tooth giving no Pain, is owing probably to it*s not being damaged, and the Nerve there being de- ftroyed by the Putrefadio|i j which Putre- fadion, however flight, has occafioned the Fluxion, that will terminate in an Abfcefs. The Tooth cannot be drawn, becaufe the Jaw cannot be opened -, therefore you muft [i6] muft endeavour to abate the Inflammatioii if poffible, or at leafl prevent it's Increafcji by fpeedy repeated Bleedings in the Arm or Foot, according to the State of the Patient^ and by emollient Cataplafms often renewed. I fay nothing of the Diet, as the Patient cannot open her Mouth ; but it will be proper for her to hold a Spoonful of warm Milk frequently in her Mouth, by way of bathing the Gum, which will fupply the Place of a Cataplafm. If thefe Endeavours do not prevent the forming of an Abfcefs, they will at lead hinder it's being fo large, as it would be, if nothing was done to pre* vent it. Second Consultation on ^^^ Progress of the Disease. The Abfcefs formed, and broke of itfelfj under the decayed Tooth ; the Hole is large enough to admit the End of the little Fin* ger, and there has difcharged the Quantity of a Spoonful of Matter, which fcems to proceed from fome Diftance, and the Teeth continue clofed. What is to be done now? Answer* t i7] Answer* The Ufe of the Cataplafms muft be con- tinued, and the hardnefs will be foftened fo much the fooner, as there is a very free Difcharge for the Matter. Belides this, it will be proper to cover the Orifice with ^mplajlrum Divinum^ in order to retain Ibme of the Matter in the Cavity, and prevent it from mixing with the Cataplafm ; for the Matter having undergone it's laft De- gree of Fermentation, and keeping the Bot- tom of the Wound moift, is a kind of Pap or Pultice, which ferves to increafe the Suppuration. The Cataplafms mufl be ap- plied over the Plaifler. The Jaw will open by Degrees, as the Hardnefs diffolves by the Suppuration, and when it can be opened, the Tooth, which is the Caufe of the Abfcefs, fhould be drawn. Without this the Hole will never be clofed, and the Jaw-bone, where the Complaint is, may likewife be injured. In thefe Cafes, there very feldom is a perceptible Exfoliation j and when the C Tooth Tooth is extraded, mofi commonly the fiftulous Orifice clofes in a few Days. A Fistulous Abscess in the Belly. AW O M A N about thirty-five Years of Age had the Jaundice, and after the Cure, was attacked with ChoHcks and Pains all over the Belly. Some Time after, when the Cholicks were cured by proper Remedies, an Abfcefs formed, about four Fingers Breadth on the right Side above the Navel, which broke of itfelf. A great Quantity of Matter difcharged, and foon after the Orifice clofed, leaving a confide- rable Hardnefs all round it. In a Qiort Time the Abfcefs filled again and broke, after having occafioned violent Pains, which continued 'till the Matter was difcharged. The Orifice clofed again, and broke a third Time. A Probe being then introduced in- to the Sinus, the End of it, about four Fingers Breadth deep, met with a hard Body in the Middle of the Tumour, which feemed [ 19] feemed to be fcbirrhous. What is to be thought of this Difeafe, and what ought to be done ? A N S V/ E R. The Jaundice which preceded the other Symptoms, forms a ftrong Prefumption that the Secretion and Excretion of the Bile has fuffered an Alteration, either from fome Diforder of the Gall-bladder, or of it's Duds, which ferve for the Paffage of the Bile into the Duodenum 5 or, perhaps, from a Diforder of the Liver. The Cho- lick which fucceeded the Jaundice, proba- bly was an hepatic Cholick j and the In- flammation of the Gall-bladder extending all over the Belly, caufed thofe Pains which always accompany it. The Tumour v^hicli in confequence appeared foon after in the Belly, gives Reafon to believe, that the Inflammation of the Gall-bladder has caufed an Adhefion of it to the Peritoneum, and having fuppurated at the Place of it's Adhe- fion (as we fee happen between the Pleura .and the Lungs, which become adherent in C 2 a Pleu- [ 20 ] a Pleurify) the Opening in the Bladder has given Room for either a Stone, or fome Part of the Bile to pafs 5 which has infinu- ated itfelf amongfl the Interftices of the Mufcles of the lower Belly, beneath the Membrana Adipofa, to the Place where the Tumour is formed. This extraneous Subflance has caufed an Inflammation, which has terminated in an Abfcefs ; and the hard Body felt with the End of the Probe is a biliary Stone, either difcharged from the Gall-bladder, or formed by a Concretion of that Bile, continuing fome Time in the Place where it is felt. The Sinus fhould be opened, as far as to the ex- traneous Subftance, and then you may fol- low fuch other Meafures as Circumftances require. *^* In my Obfervations you will find a Difbrder of the like Kind, "'"^ ^^''^^^ Second [ 21] Second Consultation 07t the Progress of the Disease. Upon opening the Sinus I found a Stone as big as a Walnut, bituminous, and of the fame Nature and Colour as thofe we find fometimes in the Gall-bladder. This Stone was fituated upon the Mufcels of the Ab- domen, between them and the Membrana Adipofa J and there was a great Number of Callo(ities formed round it. Having extraded the Stone, I difcovered a Si- nus, which ran between the Sheath of the Mufculi Redi and the Linea Alba, and paffed tranfverfly as far as to the left Side. I opened it the whole Length, and found another fmall Stone at the Bottom, of the fame kind as the large one. How were thefe Stones formed, and how will this Dif- ordcr terminate ? Answer. Two Things occafion the Concretions which are formed in our Bodies : i. The C 3 Quality [ 22 ] Qaality of the Fluids , 2. Their Continu- ance in any Part, contrary to Nature. In the prefent Cafe, if the Gall-bladder, which, from it's Inflammation, adheres to the Peri- tonsum, that lines the Infide of the Muf- cles of the lower Belly 5 I fay, if this has burft (of which I have feen many In-* fiances), and has let any of the Bile efcape as far as the Membrana Adipofa, where it has ftoppedjit's Continuance there muft have been the Occafion of it's petrifying ; and that fo much the fooner, as this Fluid is greafy, fulphureous, and fometimes fo thick, that even in the Gall-bladder itfelf, {which is it's proper Place) it concretes into the Subftance of a Stone. Perhaps alfo the Stone may have cbme out of the Bladder very fmall, and grown bigger in the Tu- -mour. It fhould be drelTed as a fimple Abfcefs, and if the Opening in the Gall- bladder clofes, the Cure will follow in the fame Manner as that of a fimple Abfcefs, when properly drelTed. If the Opening in the Gall-bladder, which has given a PafTage to the Bile, does not clofe (which it feldom does), a fniall Q^iantity of Bile will difcharge from ' [ 23 3 from Time to Time, and in this Cafe the Ulcer may remain fiftulous. Nature alone can clofe the PalTage, Art avails nothing. ^ Abscess near the Verge of the Anus. AM A N forty Years of Age, has had for a Year an Abfcefs near the Verge of the Anus, which broke of itfelf, and clofed again in a Fortnight. Since that Time the Abfcefs has broke three or four Times, and as often clofed. The Breaking has been always preceded by fome Pains, and the Patient at prefent perceives them anew, and tired with fuffering, is delirous of being cured radically. On examining it, a Flu(5tuation of thick Matter is felt under the Skin. What do you think of this Cafe ? How can it be determined, before the opening of it, whether the Inteftine is denuded or not ? In {hort, what is to be done to obtain a perfecfl Cure ? C 4 Answer. [ 24 ] Answer. It is very feldom that an Abfcefs which breaks of itfelf, if it is any thing large, can be cured without the Affiftance of Surgery, becaufe the Opening is fo fmall, that the Matter difcharges with Diffficulty ; and befides, proper Medicines cannot be applied to the Bottom of the Abfcefs. Thofe which form in the Fat near the AnuSj if not fufficiently and fkilfully open- ed, heal more rarely than others, becaufe the Redlum is often found bare, from the Diflblution of the cellular Membrane which covers it, and hence follows a blind exter- nal Fiftula. This is the Cafe of the Patient in Queftion : the Opening has clofed feveral Times -, but not healing from the Bottom of the Abfcefs, there oozes from thence continually a fmall Difcharge, which being coUeded by little and little in the old Cavity, again burfts through the Cicatrice. This is what has happened feveral Times, and always becaufe the firll Abfcefs had de- nuded [ 25 ] nuded the Intefline, to a greater or leffer Extent. If the Inteftine had not been de- nuded at firftj perhaps the Abfcefs might have healed firmly of itfelf ; but it certainly either was, or elfe has become denuded by the Continuance of the Matter every Time it was collected, before a frefh Open- ing of the Cicatrice. The Patient there- fore has a compleat blind external Fiftula, and cannot be cured without an Operation, fuitable to the State of the Dlfeafe, by mak- ing the external Opening larger than the Bottom, dividing the Re(5lum as far as to the Place where it is denuded, and deftroy- ing or taking off the Callofities, if there are any, or at leaft procuring their Diffolution by a good Suppuration. Perhaps it may be neceffary in the Operation to take away a Part of the Re(3:um and the Verge of the Anus. This is what ought to have been done at iirft, when the Abfcefs was formed, if the Inteftine was denuded at that Time ; and we generally find it fo in almoft all the Ab- fceifes formed near the Verge of the Anus, which [ 26] which are very feldom cured without the Operation. \* Read my Treatife of the Operations in Surgery, Chapter of the Fiflula in Ano. An Anchylosis of the Knee. A YOUTH fifteen Years of Age, has had a Diforder in his Knee, ever fince he had a Fall eight Years ago. The Contufion and the Pain would not permit him, for fome Time, to extend his Leg ; and though the firft Symptoms were remo- ved, the Leg became more and more bent, till it formed a right Angle, without any Motion in the Articulation of the Knee. Within thefe fix Months, he has felt Pains which he looked upon as rheumatic j at length the Knee fwelled, and the Tegu- ments became cedematous. The Pain gra- dually increafing, there appeared a Rednefs on the external Part of the Knee, and a few C 27 ] few Days after, a Flucfluation of a thick Matter was felt, four Fingers breadth be- low the Articulation. The Tumour broke and difcharged fome Matter. This occa- lioned the Surgeon to enlarge the Opening about an Inch. It is now four Months, 'that the Ulcer has been dreffed with Injec- tions, thrown up to a fufficient Height un- der the Skin. The Knee is very painful, the Thigh and Leg very much emaciated j the Patient has a flow Fever, with irregular Intermiflions, and a Diarrhoea. The Probe has been introduced four Fingers breadth upwards, but we do not feel the Bone bare ; only a Refiftance of fomething like an Aponeurofis, or Tendon j and the touch- ing of that gives him a great deal of Pain. There is a large Difcharge through the Opening, What do you think of this Dif- order ? and how fliould it be treated ? Answer. ' It feldom happens that fuch an Anchy- lofis of the Knee, in confequence of a Fall^ remains many Years without a Suppuration in [ 28 ] in the Joint -, for the Cartilage between the Femur and the Tibia, moft commonly fuf- fers, and gradually waftes away. I have known this Cartilage fometimes entirely de- ftroyed, and the Ends of the Bones carious. Of this there may be feen many Inflances, in the fecond Volume of my Treatife of Obfervations. In this Cafe, the Inflammation of the in- jured Parts, was the Caufe of the Pain which the Patient took to be rheumatick. It began amongft the Aponeurofes, from ■whence it extended to the Teguments, and made them cedematous. At laft it has ter- minated by fome of thefe Parts putrifying, perhaps even the Capfula of the Joint, to a greater or lefs Degree 5 and this Putre- fadion has produced Matter of a very bad Kind, which was felt under the Finger, and at laft burft through the Skin, to have a free ilTue. As this Tumour, now be- come an Abfcefs, was not a Phlegmon, but the Matter in it produced from the Putre- fadion of fome of the aponeurotic Parts ; it might be formed without a great deal of Pain. The [ 29] The enlarging the Opening which broke of itfelf, was of no Ufe -, and if it was ex- tended ftill farther, it would be to no Pur- pofe, the Difeafe being in the Middle of the Articulation 3 and for the fame Reafon the Injediions are unneceflary. In thefe fort of Cafes the whole Limb waftes, becaufe the Courfe of the Fluids is obftruded, and a Part of the Matter con- ftantly returning into the Circulation, is a Kind of extraneous Body 5 from whence enfue the Fever and Diarrhaea, which al- ways accompany thefe Difeafes. The only Method to be purfucd, is to take off the Leg above the Knee j and this fhould be done before the Diarrhsea and Fever have entirely deftroyed the Patient's Conftitution. The Judgment I give is founded upon a great deal of Ex- perience. I have feen in many Patients, after Amputation, a Caries of greater or lefs Extent, and always accompanied with ei- ther a partial or total Deftrud:ion of the Cartilage. The [ 3° ] T^he Event. Being fent for to this Patient, I perform* ed the Amputation, and found the whole Joint carious. The Fever and Diarrhaea ceafed in two Days, and the Patient was cured in fix Weeks. Reflection. When the Diforder is entirely local, the Patients generally do well ; but where there is a fcrophulous Habit, as I have often feen, you muft endeavour to corred that Habit, after the Operation (fuppofing it to be ab- folutely necelTary, and even preffing j) other- wife the Patient will ,not be cured. A ve- nereal Taint may occalion a limilar Difor- der, but for the mofl Part it arifes from a fcrophulous Habit j and in this laft Cafe we find the Bone enlarged at the Joint. *^* Read my Treatife of Obfervations, Vol II. [31 ] 1/^ Burn on the Arm. AW O M A N fet Fire to her Ruffle, and burnt her Arm all round from the Elbow to the Wrift, but not the Hand. Ink was immediately applied, and the Arm wrapt up in brown Paper and Linen over it. The next Day, a Surgeon having gent- ly removed the Linen and Paper, found a great many large Bladders of Water, fome of which were burft, and the others ftill full. He perceived an Inflammation on the Wrift, alfo on the Arm, and above the El- bow. He fnipped the Bladders, took off all the Cuticle that formed them, and after- wards dreffed the whole with Cerate. The Patient fuffering a great deal of Pain, deiires lo know whether any thing elfe can be done J and how the Sore ihould be dreffed? Answer. In thefe forts of Burns we always find the Flame afFeds fome Places more than others j the Heat having there penetrated through [ 32 ] through the whole Subftance of the Skin. I have even feen the Membrana Adipofa fufFer almoft as much as the Skin. It is only in the Courfe of the Dreffings, that wt difco- ver the Depth of the Burn, which is too often looked upon as only fuperficial. When there are any Bladders, they fhould be fnipped, without removing the Cuticle ; for at the next dreffing, upon the removal of it, we often find another Cuti- cle already formed in fome Places. In thefe Places the Skin has not fuffered much, for in thofe that have, the Skin muft fup- purate, and perhaps may llough away, ac- cording as the Burn has penetrated more or lefs. I am not furprized at the Arm be- ing inflamed above and below the Burn 5 it might have equally extended all round the Arm, and may probably incrcafe, notwith- ilanding one or more Bleedings, which may be necefTary ; and it is pofiible that it will not abate, till the Suppuration comes on ; which may alfo be very confiderable. The 'Emplajirum de Ceriijfa, and the Ce- ratum Galeni, mixed with an equal Part of the Unguentum Nutritunii in my Opinion is what [ 33 ] what will be propereft to drefs with, taking Care to fpread it thin upon the Cloth, and renew it Night and Morning, if it is only to remove the great Quantity of Matter which flows from the Wound. Thefe Dreflings mufl be affiiled by Diet, and fuf- iicient Bleedings, to abate the Inflamma- tion ; and if there fliould be Occaflon, e- mollient Cataplafms muft alfo be applied over the Linen, fpread with the abovemen- tioned Ointments. The Cicatrice of Burns differs from that of other Wounds or Ul- cers ; for, infl:ead of beginning at the Cor- ners or Sides, it often begins in the Middle, and in feveral other Places j becaufe the Skin has not fuffered every where alike, or has not been totally deftroyed, as I before obferved. However, when the Skin is eve- ry where equally damaged, the Cicatrice will begin only at the Sides, as in other Wounds. It is not to be wondered at, that an Ul- cer made by a Burn is fo tender, particu- larly at firfl:. The Skin, we know, is the principal Organ of Senfation, and the ner- vous Papillae which compofe it, are divefled D of [ 34 ] of their Covering when the Cuticle is re- moved. It is upon this Account I have faid, that on the firil Day we fhould be fatisfied with opening the Bladders, and emptying them, without removing the Cu- ticle that covers them. The great Seniibi- lity will not ceafe, until a new Cuticle is formed, which is fometimes effeded in two or three Days, in fome Places j or at leafl until a fufficient Number of flefhy Granu- lations have grown up, to cover the Extre- mities of the nervous Papillae, efpecially if the Subflance of the damaged Skin has fup- purated. A Burn between the Buttocks. MAN who had the Piles, and fuf- fered a great deal of Pain from them, being defirous of Eafe, placed himfelf on a Chair with a Hole in it, over the Steam •of a Bafon of hot Water j where he received this Vapour-bath for half an Hour. He was fometimes obliged to defift, be- caufe [ 35 3 caufe it burnt him, but almoll immedi- ately rcfeated himfelf j for when the Parts became heated, he could bear the Steam much hotter than at firft. At length he went to Bed, and the next Day felt a \^ery fevere Pain in the Scrotum and Perineum, which appeared red, and looked like an Erylipelas. In about three Days, a Num- ber of fmail Bladders appeared like Phlyc- tens, full of reddifh coloured Serum; and on the two Buttocks, within an Inch of the Anus, particularly on the right Side, the Beginning of two Efcars, of a very deep Red, and very little fenlible of the Touch. He has a Fever and a Diarrhsea. What is the Nature of this Diforder ? And how ought it to be treated. Answer. I make no Doubt, but that the exceffive Heat has produced a kind of Mortification on the Skin, and that a Suppuration of thofe Parts is coming on ; which, though not perceptible at prefent, v/ill difcover it- felf in a few Days. D 2 At [ 36 ] At prefent we muft confider how to a- bate the Inflammation of the Parts, where the Mortification is not begun. For this Parpofe he muft have Recourfe to Bleed- ings, and obferve a ftrid Diet, with the Ufe of emollient and refolvent Cataplafms, frequently renewed, that they may not be- come dry. The Diarrhaea and Fever prove, almoft to a Certainty, that there is Matter forming j and thefe Symptoms will not a- bate, but in Proportion as the Inflamma- tion goes off, and the Matter has a free Difcharge. I look upon the abovementioned Blad- ders as gangrenous, and caufed by the burning Heat 5 they muft be fnipped with the Scifl^ars and dreflTed with Storax. The Efcars on the Buttocks, which muft be confidered as a Gangrene begun, are owing to the too hot Steam penetrating deeper there than in other Places, and drying up the radical Moifture. Thefe Places will come to Suppuration, and flough ofl^ in the fame Manner as the Efcars made by a Cau- ftick. To make them feparate more eaflly, they ftiould be fcarified to the Quick, and afterwards C 37 3 afterwards drefTed with a Digeftlve animated with Storax. If the Panniculus Adipofus and the Membrana Ceilularis are alfo ma- cerated in fome Places by the great Heat, and fie wed (as one may fay) by the Vapour-bath, thefe Places will diirolve into Matter, and the Efcars on the But- tocks, when they fall off, will give a free Difcharge to it. If there is any Fludluatlon perceived under the Efcars, they mufl be divided immediately, to give the Matter vent, T^he SaRGEON'i Account of the Event. The Inflammation on the left Buttock of the Patient terminated by Refolution j but at the fame Time a Collection of Matter formed under the Efcar on the right But- tock, and perhaps much farther, which probably was the Occallon of the Fever and Diarrhea. This Matter at laft made it's Appearance on one Side of the Scrotum. Having enlarged the Orifice that broke, I did not think it necelTary to lengthen the Incifion as far as the Bottom of the Abfcefs D 3 whence [ 38 ] whence the Matter came 5 becaufe, when the Patient lay on his Back, the Matter difcharged freely. For foar Days there was a great Difcharge ; it then gradually decreafed, and fince has entirely ceafed 5 upon which the Rednefs that extended on the Scrotum and Skin, as far as the Matter came from, difappeared. The Fever and Diarrhaea went off as foon as the Matter had a free Difcharge. vf CARIOUS Thigh-bone. AM A N thirty Years of Age, to all Appearance in Health, as was his Wife, within thefe two Years obferved a Swelling on the pofterior and lower Parts of the Thigh 5 which, fmce it's firft Appear- ance, has often gone away almoft, and re- turned again. ' The Swelling was pretty broad and long, fomewhat elevated, very little painful, without any Difcolouring of the Skin, and feemed to affed: all the Muf- fles whiph form the lower and back Part of C 39] of the Thigh. This Swelling again made it's Appearance within thefe few Weeks, and at lall terminated in a fenfible Fludua- tion, rather more on the Inlide of the Thigh than the Outfide. It formed with- out Pain, and confequently the Tumour has not the Signs of a Phlegmon. , 1 made an Opening four or five Inches in length, where the Matter was moft per- ceptible ; and the Difcharge was ferous, ajid of a bad Smell. V Upon introducing the Finger to the Bottom of the Cavity where the Matter lodged, I felt the poilerior Part of the Femur bare, unequal, and carious, and the Teguments on the Infide of the Thigh very thin ; but the aponeurotic Ex- panfion of the Fafcia lata was intire, as well as fome Part of the Membranes. On queftioning the Patient of the Manner of JUife he had led, he replied, that he had only had a few Claps, which were cured above ten Years ago. What do you think 'of tills Ahfcefs ? D 4 Answer. [ 4° ] An s w e r. . The alternate Appearances, and Difap* pearances of the Tiimour, it's IndolencCj the few Symptoms attending the forming of the Matter, and the Caries of the Femur, give Reafon to think that this is a venereal Abfcefs. The Tumour being properly opened, the Ulcer fhould be drelled according to it*s different State, and the Manner in which it goes on. The Event only can confirm or difprove, whether the Sufpicion of it's be- ing venereal is well or ill founded; thofe Circumftances therefore muft regulate your future Proceedings. ^he SuRGEON*i Account of the Evi:nt of the Disease, In about fixteen Days after the opening, an Exoftofis appeared on all the interior Part of the Femur, which in a few Days confiderably increafed j being no longer doubtful of the Caufe^ I treated the Patient accordingly. [ 41 ] accordingly. Having prepared him by the ufual Method, and alfo by warm bathing, notwithftanding the Wound in the Thigh, I made ufe of mercurial Fridions ; by the fourth Fridion the Exoflofis began to di- minifli, and by the tenth was entirely gone, Notwithftanding it's Difappearance, how- ever, I continued the Fridions, at longer Intervals, for fix Weeks j being convinced that when the venereal Virus is feated in the Bones, it is much more difficult to fubdue, than when it affeds the Flefh. During this Treatment, the Femur imperceptibly exfoliated, and the Wound was cured in feven Weeks, reckoning from the firft o- pening of the Turnour, Reflection. How many Diforders do we fee, which are not fufpeded to arife from a venereal Virus, that neverthelefs have no other Caufe. This Tumour on the Thigh was of that kind ; the Difappearance of the Ex- oftofis, and the imperceptible Exfoliation of 42 ] of the Bone, after the mercurial Fridlons, are a Proof of it. Thus do we often meet with Cafes where, this Virus has remained concealed many Years, without difcovering itfelf by any Sign 5 and how many Diforders, which appear limple, fail of being cured, becaufc they are complicated with this Virus, which has not difcovered itfelf by any of it's cha- ra(5teriftic Signs. A Caries of the Parietal Bone. ABOUT two Months ago, a Woman received a Blow by a Stick, which gave her a Wound on the lower Part of the right parietal Bone. She dreffed it after her own Manner, and confults you now becaufe it is not cured. There is a Space as broad as the Palm of the Hand, where the Skin is red, fwelled, and alfo oederaatous. In the Middle of this Space there is a Hole you may turn your Finger in ; and, on introdu- cing the ProbCj which may be paffed un- der [ 43 ] der all the difeafed Part, the Bone is felt bare and unequal. Note^ This Woman at firfl had great Pains in her Head, which iafled for three Weeks, but are fince gone off. She has not been bled, nor obferved any Regimen 3 appears to be in Health, and confults you, only becaufe fhe is not cured. What is to be done ? Answer. The Blow which gave the Wound has, without Doubt, lacerated, and at the fame Time contufed the Aponeurolis of the fron- tal Mufcle and the Pericranium ; perhaps alfo feparated the latter from the Bone. The Confequence has been an Inflamma- tion, which has terminated in a Suppura- tion of the Parts. This has occafioned the Bone to become carious, which may alfo probably have been contufed. It therefore is not to be wondered at, if great Pains in the Head fucceeded fuch a Wound. All the Skin which covers the Caries is difeaf- ed, and befides, by it's Continuance there, prevents the Application of proper Reme- dies [ 44 3 Remedies to haften the Exfoliation. This fhould be cut ofF where it is feparated from the Bone, and afterwards the Bone fhould be touched with either the Lapis Infernalis or the mercurial Water, to forward the Exfoliation, the Time of which is uncer- tain. This Application fhould be repeated for feveral Days together, and the Exfolia- tion being made, will be known by the Piece of feparated Bone becoming movable on the Granulations of Fle(h which grow over the found Bone, and, when the Ex- foliation is compleated, the Wound will foon heal. ^he Surgeon'^ Account of the Cure. I followed the Method you diredted, and the Exfoliation was compleated in lefs than a Month. I then obferved, that in the Middle of the exfoliated Bone, which was round, about an Inch and half broad, and almoft every where thin 3 I obferved, I fay, that in the Middle of it, a Place about the Bignefs of my Nail, was as thrck as the two Tables of the Skull. I could then fee the [45 ] the Motion of the Dura Mater, or rather of the Flcfli grown over it, to feparate the Piece of the inner Table, which had pro- bably fuffered. It is furprizing that, as this inner Table was difeafed, there was no Ex- travafation of Blood or Matter between it and the Dura Mater 5 which muft certainly be owing to it's not being contufed : But the Contulion having reached as far as the Diploe> obftrudled the Courfe of Circula- tion between them, and was the Occafion of the Injury done to the inner Table, by depriving it of it's Nutriture. After the Exfoliation of the Bone, the Wound was foon cured. A Gonorrhoea. AM A N had an Affair with a Wo- man of a fufpicious Character, and three Weeks after a Gonorrhoea appeared, accompanied with great Heat, efpecially when he made Water. He has flight Pains in his Tefticles, but there is no Swelling, and [ 46 ] and they feem both to be in their natural State. What are we to think of his Condi^ tion ? Answer. What became of this Virus for three Weeks before it fhewed itfelf by the Run- niiig ? Though not apparent, it certainly was in fome Part of the Body, and the Go- norrhoea, mofV probably, is only a Symp- tom of the Pox, the ufual Signs of which are fufpended by the Running ; for even a very flight Difcharge, either conftant or periodical, is often fufficient to prevent the venereal Virus appearing elfewhere. I am of Opinion, therefore, that a prudent Ufe of mercurial Fridions is the bed Method of treating the Patient, v/ithout which he will not be cured 3 or if the Gonorrhoea fhould feem to be cured, fome Time after other Symptoms of the Pox will appear. But although, from it*s Manner of Ap- pearance, one may be almofl certain that this Gonorrhoea is only a Symptom of the Pox, yet for fome Time it will be fufficient to [47 ] to treat it as a limple Gonorrhoea j and, i£ it does not yield to the ufual Remedies and a proper Regimen, it will be a Proof that the Patient has the Pox -, if contrary to Ex- pecStation it is cured, it is a happy Event ; but you may be affured, if it is only fymp- tomatic, the Pox will Ihew itfelf one Time or other. I have known it lay concealed for near ten Years, the Patient having ne- ver had but one Clap, which was then cur- ed. The Patient affured me, that fince that Time he had been more prudent. See the Consultation on the Caries of the Femur. ^Cicatrice which prevents the Ufe of the Fingers. A CHILD eight Years of Age, in his Infancy had his Hand burnt j his Nurfe dreffed and cured it, but the four Fingers remain bent, and as it were faftened to the Hand by the Cicatrice, ia fuch [+8] fuch Manner that he has very little Ufe o^ his Hand, the Thumb only being at Li- berty. The Skin is a good deal contradled, but the little Finger not quite fo much as the others. Is it not poffible to divide the Cicatrice that prevents the moving of the Fingers, by proper Inciiions, and by that Means facilitate their Extenlion ? A N s v^^ E R* The Cicatrice of the Skin might be di* vided, and perhaps w^ith fome Advantage, if the Fingers were kept extended by a pro- per Bandage, 'till a new one was formed, and alfo for a Month after. But this Ope- ration is not practicable now, as well on Account of the Child's Age, who cannot have Patience enough to undergo an Ope- ration, which will take up fome Time, as becaufe the Skin mofl certainly now is con- nected to the Mufcles and Tendons in the Palm of the Hand. Belides, as it has con- tinued in this State feveral Years, the Ope- ration will not only be dangerous, but alfo ufelefs, as, during this Time, the Fibres of [49] of the Flexor Mufcles have been contraifl- ine, and that Contradion is now fixed. For this Reafon, the Fingers cannot be extended but by too forcible Means, which would be prejudicial to the Flexor Ten- dons, and yet not be effedual 5 fo that at laft they muft be divided, the Confequence of which would be, they could not be bent, and would in that Cafe become ufe- lefs upon many Occafions, v/hen their ne- cefTary Service is wanted, I am therefore of Opinion, that the Hand fliould be left as it is, the Operation being impracticable, and alfo dangerous. ^Puncture i?2 the Hand, LADY, rubbing Pomatum in her Hands to put upon her Hair, felt herfelf pricked by fomething, which ran into her Hand very near the Middle of the Mufculus interolTeus, between the two me- tacarpal Bones which fupport the litde and ring Fingers, She wiped her Hand dire the Cauftick will infinuate itfelf into the Wound as it diflblves, and when the Efcar is formed, it may be divided without Pain or Danger ; you may likewife E 2 feel [ 52 ] feel with your Finger in the divided Efcar for that End of the Extraneous Subftance next the Skin j if you can touch it either with the Finger or a Probe, as I make no Doubt you can, it will be eafily extracted. You muft then endeavour to make the Ef- car fall off, and cure the Wound with Am- ple Dreflings. ^he Event. The extraneous Subftance was a fmall Shiver of Glafs about a Quarter of an Inch long, and near as broad. It was found in- clofed in the Efcar, about a Third of an Inch Deep, and was extracted ealily. The fmall Opening healed in a few Days with- out any Accident. A fraSfured [ 53 ] A fraSfured Rib. AY O U N G Woman, twenty- five Years of Age, pretty fat, received a Kick from a Horfe on her left Side, near upon the Middle of the fixth Rib; (he fainted and was carried to Bed. Being re- covered from her Swoon, (he was feized with a violent Cough and Oppreffion at her Breaft, and fpit up pure Blood. A Sur- geon who was fent for bled her immediate- ly ; a Fever arofe, and in lefs than two Hours there came on an Emphyfema, which extended from the Clavicles to the Groin. On the Place that was ftruck, there was nothing to be feen but a black Mark of fmall Extent, and a very flight Contulion without a Wound. What is the Nature of this Difeafe ? What has occa- lioned the Cough and Spitting of Blood ? How comes fhe to have an Emphyfema, there being no Wound ? And what is to be done to remove all thefe Symptoms ? E 3 Answer, [ 54] Answer. The contufed Part marked with the black Spot, being but of fmall Extent, has certainly been ftruck by only the Edge of the Horfe-fhoe, and the Rib is fradlured. When we want to ftraiten a Hoop, it breaks, but it does not break fmooth, and there is ge- nerally a Splinter, with the Point elevated, left on the Infide, This is pretty often the Cafe with the Ribs, on Account of their Brittlenefs and Form j therefore a Splinter of the Rib has very probably pierced the Pleura, and the external Membrane of the Lungs, whether it adheres or not to the Side that was flruck. From this alone the Oppreffion of the Breaft, the Cough, the Spitting of Blood, the Emphyfema, and the Fever, may be deduced. Confequently there muft be an Irritation and a Cough, proportionable to the Wound of the Lungs ; for the Blood which iflues from the Veffels in this internal Wound cannot remain in the Bronchiae, and mufl iflue out by the Force of the Cough, raifjng it gradually up to the E 55 ] the Larynx. The Air which enters at eve- ry Infpiration, being expelled by Expira- tion, the greateft Part goes out through the Larynx j but fome of it coming from the Wound of the Lungs, pafTes through the Pleura and intercoftal Mufcles, where they are wounded, and afterwards difperfing it- felf amongft the Veficuls of the cellular Membrane of the Mufcles and Fat, neceffa- rily mud caufe an Emphyfema, which is augmenting, and will continue to do fo un- lefs it's Progrefs is flopped. There are three curative Indications to be accomplifhed ; the firil: is to flop the Progrefs of the Emphyfema, as it will cer- tainly difperfe as foon as the Paffage is clof- ed, which furnifl:ies the Air through the Wound of the Lungs and the intercoftal Mufcles } the fecond is to elevate the Mid- dle of the Rib that is depreffed as much as poflible J the third is to abate the other Symptoms. The Fradure of the Rib being the Caufe, it feems neceiTary we fhould confider how to reduce that, by making a Comprefficn on the two Extremities of the Ribs, v/here E 4 they i 56 ] they are articulated to the Sternum and VertebrzE 3 but this is prevented by the Em- phyfema, and will be ftill lefs practicable as that increafes. We muft therefore begin by flopping the Paffage of the Air. To do this, beat up the White of an Egg with a little Water ilrongly impreg- nated with Salt ; dip a fquare Comprefs, three Inches long and two broad, in this Mixture, and fqueeze it out well, that it may dry and harden the fooner. This mull: be placed on the black Spot which covers the Fradlure of the Rib, and fecured by three or four Turns of a Roller as broad as the Comprefs j there is no Danger of binding it too tight, becaufe the Air, being expelled by the Compreffion into the neigh- bouring Veficulas, will foon make it loofe. It is very material to place the Turns of the Roller fo as not to comprefs the Breaft. In four and twenty Hours you mufl make fe- deral Plaits in the Roller, before and be- hind, in Proportion as the Turns of it be- come too loofe, by the Diminution of the Emphyfema 5 managing it in fuch Manner that the Preffure made by the Comprefs may C 57] may be always the fame. There Is no fear of deprefiing the Middle of the Rib too much, becaufe the two next Ribs will not permit it, on Account of the Breadth of the Comprefs, which mufl necefTarily bear up- on them, as foon as the Emphyfema, which Covers them, is difperfed by the Compref- fion. By thefe Means there is great Rea- fbri to believe that the Emphyfema will be entirely diffipated in four and twenty Hours, as I have feen happen in the like Cafe. As foon as that is difperfed, we muft think of failing up the Middle of the Rib ; but this cannot be done by Extenfion and Reduc- tion, as in Fra flanding the Compreffion I made, and con- tinued on the ThrombuSj on the fourth Day there happened a fecond Hemorrhage, which fortunately I flopped with dry Lint. The Swelling of the lower Arm has fince gradually increafed, and now extends above the Elbow. The Fever which was flight is become more violent, and the Patient feels a great Numbnefs all over the lower Arm. The Thrombus continues in the fame State* What ought I to do ? An s w e r. The Return of the Haemorrhage is a cer- tain Proof that there is a confiderable Arte- ry opened in the Bend of the Arm -, and the Thrombus being at the Divifion of the G 2 brachial [8+] brachial Artery, it is there we muft look for the Opening, without which the Hse- morrhage will frequently return, and the Patient die. It will be neceffary therefore, without Delay, to perform the Operation for the Aneurifm} that is, to find out the Opening in the Artery, and make a Liga- ture above and below it. The external Wound where the Sword entered, will then be no more than a fimple Wound, and muft be dreffed accordingly. The Swelling of the lower Arm is ow- ing either to the plugging up of the Wound to ftop the Bleeding, or clfe the Compref- fion made on the Thrombus, and in all Probability will go off after the Operation, which I think abfolutely neceffary. Bleeding, Fomentations, or emollient Cataplafms frequently repeated, and proper Diet, will all contribute to remove it, and to all Appearance the Fever will abate when the Dreffings become eaiier. The Dif- charge from the two Wounds will be bloo- dy a long while, on Account of the coagu- lated Blood which remains in the Interffices of [ 85 ] of the Mufcles; when that ceafes the Wound will foon heal. A Wound in the Breast by a Sword, and another in the Arm. AM AN has juft received two Wounds with a Sword. One penetrated the right Arm in the anterior and middle Part, above the Infertion of the deltoide Mufcle, and ended between the Mufcles, without going through ; the other Wound entered at the Back and on one Side of the Bottom of the Scapula, and the Patient fpits a little Blood. What is to be done to both of thefe Wounds ? Answer. The Wound in the Arm is a fimple Wound, the re-union of which fhould be procured fpeedily. To do this, a large Doffil of Lint fhould be placed on each Side of the Wound, to make a flight PreiTure ; ' G 3 and [ 86] and a little dry Lint on the Orifice, wliich fhould be coveted with a Plaifter to pre- vent it's removing j the whole fuftained by an eafy Bandage. This may be cured in two Days. The Wound at the Back re- quires much more Attention j for the Blood fpit by the Patient is a Proof that the Lungs are wounded. If they adhere to the Pleur- ra, there will be no Extravafation of Blood in the Thorax, but if they do not, proba^ bly there may -, which will be known by the particular Signs of an Extravafation, and there will be a Neceffity of performing the Operation for the Empyema. Whether the Lungs adhere or not, which is difficult to difcover at prefent, their being wounded is fufficient to render it neceffary, that the Wound of the Teguments and Mufcles which cover the Ribs {hould be dilated, to make a Paffage for the Blood and Matter that difcharges from the Bot- tom ; but the intercoftal Mufcles muft not be divided. At the fccond Dreffing, and the following ones, a few Drops of the green Balfam muft be poured into the Wound, for a Wound of the Lungs fel- [ 8? ] dom is eafily cured, on Account of the al- ternate Motion of Dilatation and Contrac- tion, and will fuppurate. As for the ex- ternal Wound, that fhould be drelTed ac- cording to Art, obferving to keep it open till the Wound of the Lungs is cured, which will be known by the Manner in which the Patient breathes, and by the SaJt liva being free from Blood and Maeter. The Incifion which I propofe is fo much the more neceffary, as by that Means an Emphyfema, which might otherwife come on, will be prevented. The moft exad: Regimen muft be obferved, with Bleedings proportioned to the Symptoms that may arife, and other Remedies given according as they are indicated. Second Consultation on the Progress of the Disease. The Method prefcribed in Confultatlon was not followed, and both the Wounds were drelTed by the fecret Method*. That G 4 of * Panfees du Secret. This Exprefiion, I have been in- formed, takes if & Rife from the Method ufed by ihofe Per- [ 88 ] of the Arm was , cured in twenty-four Hours, and the Wound of the Lungs alfo j but within this Week there has come on an Inflammation on the latter, which termi- nated in an Abfcefs, that broke and dif- charged a good deal. It was thought ne- ceffary to inje6t fome vulnerary Water through the Orifice to cleanfe the Wound, and it is obferved that the Injedion made the Patient cough, and Part of it came away with the Spittle. Probably in this Place the Lungs adhere to the Pleura. We defire to know what is meant by dreffing Wounds according to the fecret Method ? Why the Wound of the Arm healed by this Method, and not that of the Lungs, which burft open a Week after ? Laftly, we defire to know how this new Wound fliould be dreffed ? Answer. This fecret Method of Dreffing con- {jfts in fucking a Wound, which cannot be done fons, who dare not apply to a Surgeon to be dreffed, for fear of a Diicovery how they game by their Wpund. C 89 ] done without bringing the Sides of it from the Top to the Bottom nearly into Con- tad; for the Mouth adts hke a Pump. Confequently all the Blood which has flop- ped and coagulated in the Wound, is brought away by this Sudlion, and all the fmall VefTels at it's Circumference are e- qually emptied and in a Manner dry. Is there any Method that could more fpeedily procure a Re-union, than what extrads the extravafated Blood, and brings the Parts together which are divided ? It is on this Account that the Wound of the Arm heal- ed fo foon. (A Wound that has penetrated through a Limb, without opening any con- fiderable VefTel, might heal of itfelf, pro- vided Care was taken before it was fucked, to clofe one of the Orifices exadly, and to keep the Part perfecftly quiet for twenty- four Hours.) The Wound of the Lungs could not heal of itfelf, becaufe at every Refpiration the divided Lips were moved, and at every Expiration a Part of the Air flipped in between the Sides of the Wound, and kept them afunder , in Confe- quence an Inflammation has come on, a Suppu- [ go ] Suppuration is formed the whole Length of the Wound, and Matter coUeded be- tween the Sides. The fmall Opening which broke of itfelf is not fufficient for the Difcharge, it muft be therefore enlarg- ed by an Incilion through the whole Length of the Cavity filled with Matter, and this Wound muft be afterwards dreffed as a fimple Abfcefs, only pouring into it a few Drops of the Green Balfam. No Injection (hould be ufed, for a fingle Drop entering into the Lungs with ever fa little Force, will make the Patient cough, and bring on a new Laceration. It is Na- ture alone that can operate towards curing the Wound of the Lungs, and in order that it fhould not be oppofed in it's Endeavours by an Inflammation, that fhould be pre- vented or abated by one or more Bleedings, as Occafion requires, by an exadt Diet, and other proper Remedies, according to Cir- cumflances. The external Wound will not heal till after that of the Lungs is cured. -^ Wound [91 ] ji Wound by a Sword above the Eye- Brow. AM A N received a Wound yefterday by a Sword above the Eye-brow, the Point of which fcarcely entered a Quar- ter of an Inch, being flopped by the Bone. At the fame Time he felt a Numbnefs all over him, which entirely deprived him of Strength, fo that he fell dovi^n backwards. This in twenty-four Hours has degenerated into a perfed; Palfy all over him. You are afked whether you have ever feen fuch a kind of Diforder ? What is to be thought of it, and what is to be done ? Answer. Without Doubt fome fmall Branch of a Nerve is either punctured or cut, and pro- bably a Branch of the fifth Pair. In 1 744, there was a Man who had his Face ilightly grazed by the Branch of a Tree he was cutting, to whom happened much the fame Thing. Two Hours after, the Side of his Face [ 92 ] Face fwelled, and the Jaw became paraly- tic. The next Day the Palfy extended to the Larynx and the neighbouring Mufcles, in fuch Manner that the Patient died in a few Days, not being able to fwallow. To account for thefe Symptoms, we ought to have a more perfect Knowledge than we have, of the Nature of the Nerves, the Animal Spirits, the Manner in which they are diftributed to every Part of us, the Caufe of their Motion, and the Diforder and Irritation which the Pundure of a An- gle Nerve can communicate to the whole nervous Syftem. Perhaps in this Cafe the Nerve may only be pricked or partly divided ; all the Affiftance that can be given then, is to di- vide the Nerve entirely ; and the Reafon of my propofing it, is, becaufe I look upon this partial Pundture or Cut, in the fame Light as that of a pricked Tendon -, and Experience has taught us, that the moft certain Method of curing the Symptoms which arife from that, is to divide it entire- ly, at the Place where it is wounded, or above it. ./f Wound [93 ] A Wound in the Breast by a Sword. AM AN has juft received a Wound by a Sword in his left Bread. The Entrance of the Wound is about a Quarter of an Inch in Breadth -, the Circumference is neither inflated nor tumified. The Pa- tient has a flight Difliculty of breathing, and does not remember whether the Wound was given obliquely or not. What (hould be done in this Cafe ? Answer. The Wound may have penetrated into the Thorax, and pofiibly may not -, but as there is no Sign of any of the Vifcera being wounded, the firfl: Indication that offers to be fulfilled is the Re- union j the rather, as the flight Oppreflion the Patient complains of, may be occafioned only by the Terror with which he was ftruck, when he felt himfelf wounded : even the flight Pain he feels may be fufficient to caufe it. You mufl: be careful therefore not to probe the Wound, [ 94 S Wound, to examine whether it penetrates or not 5 for even fuppofing that it does pe- netrate, a fpeedy Re-union is beft, whereas the Probe, by difturbing the Sides of the Wound, will retard it. It is fufficient therefore to bring the Lips of the Wound together, cover them with a little Lint, to abforb any Blood that may Difcharge, and to fecure it with a Plaifter and a Roller round the Body, rolled moderately tight, as Infpiration is performed more by the De- preffion of the Diaphragm than the Eleva- tion of the Ribs. The Patient ought to be bled immediately, and poffibly again two Hours after. He muft be confined to a ve- ry ftridt Diet for twenty-four Hours, and be enjoined the moft perfedl Quiet, in Or- der that nothing may diflurb Nature, and retard the Re-union of the Lips of the Wound. A Wound [ 95 ] A Wound by a Pistol in the Fore-Arm. AM A N received a Wound by a Pif- tol, the Ball of which entered the lower and inner Part of the Fore-Arm, a- bove the Mufculus Quadratus, and went out at the upper and outer Part, piercing the Mufculus fupinator longus, two Fin- gers Breadth below the Articulation with the Humerus. Under that Mufcle, near the Place where the Ball went out, the Radius is obferved to be difplaced, the Na- ture of which makes it doubtful, whether it is fra(5tured in its upper Part, or only diflocated. What Operation ought to be performed ? How fhould this Wound be drefled ? And what Prognoftick fhould be made ? Answer. This Wound is fo much the more im- portant, as the Entrance and the Exit of the Ball being fo diflant from one another, makes a hollow Wound the whole Length of the Limb. There [ 96 3 There is no Manner of Doubt, but that the Entrance of the Wound fhould be fuf- ficiently enlarged by an Incifion, that will admit the Finger to examine whether there is any extraneous Subftance remaining, which may be felt and extracted 5 fuch as a Piece of the Shirt or Waiftcoat j and to fet at Liberty the common Membrane of the Mufcles. An Incifion muft alfo be made in the fame Manner where the Ball paffed out, to introduce the Finger into it's PafTage, in order, if it fhould be found ne- celTary, to fet the Membrane ftill more at Liberty. If the Radius is only dillocated, we muft endeavour to reduce it; if it is broke, you muft dilate the Wound in the fame Manner as you have done where the Ball entered, for it is principally here we muft exped: to meet with the Splinters ftruck off iby the Ball. In this Cafe, con- ducting the Point of the Sciflars on the Finger, you muft cut the fmall mufcular membranous Portions which retain the Splinters ; or if they are very large, and pretty ftrongly conne(fted in fome Places to the [97 ] the Bone itfelf, you muft then reduce thefd Pieces of broken Bone. The Wounds being lightly dreffed, the whole muft be covered with an emollient Cataplafm, or CompreiTes dipped in a vul- nerary Lotion, and fuftained by a very loofe Bandage. I fay a very loofe Bandage, be- caufe moft probably the Arm will fwell, and then the Bandage will become too tight. The x^rm muft be put in a Cafe, to prevent the Bone from being difplaccd, and the Cataplafms or Lotions muft be fre- quently renewed. In fach Cafes, or fimilar ones, an In* ilammation is the more to be dreaded, as i£ may extend over all the Fore- arm j in Con* fequence of which, AbfcefTes and Collec- tions of Matter might be formed in miny Places, between the Interftices of the Muf- cles, where they are feparated by the Membrane that covers them ^ thefe Ab- fcefTes or Sinuffes muft be opened as fooa as they are difcovered. It is poffible likewife, that it may be neceffary in a Httle Time to amputate the Arm above the Elbow* This muft be de- ll termined [ 98 ] termined by one Circumftance, which is, if that Joint fliould begin to fwell and be- come eryfipelatous, and this Symptom is plainly feen to increafe j in this Cafe it muft be done without Delay, or elfe you will fee the Difcharge from the Wounds flopped, and the Swelling extend up to the Shoulder. Then it would be too late to do it, or elfe it might be done to no Purpofe. A Wound by a Sabre, making a Flap. AM A N has received a Wound on his Head by a Sabre, which has fepa- rated a Piece of the Teguments about the Size of a Card ; it's Shape is nearly trian- gular, and confifts of the Skin, the Apo- neurofis of the frontal and occipital Muf- cles, and even the Pericranium j for the Bone is quite bare, and in a Manner fcrap- ed. The Accident has juft happened, and the Wound fcarcely done bleeding. This Piece adheres to the reft of the Teguments only by one Side of the Triangle, which was [ 99 ] was cut but half through. The Bone be- ing bare, are there any Hopes of a Re-union of the divided Parts without an Exfoliation ? Answer. It is not always a Role, that a Bone, be- ing laid bare, ought to exfoliate, either per- ceptibly or imperceptibly ; the Cure of Am- putations with the Flap is a Proof of it. Confequently this Wound being recent, ought to be fpeedily re-united 3 befides Na- ture will operate towards the Re-union, by the Juices which iffue from the Bone mix- ing with thofe that ifTue from the Flefh when replaced. All the coagulated Blood in the Wound mufl be firft taken away, the Flap then replaced, and kept there by feveral Slips-'of Sticking-Plaifter, which will form fo many dry Sutures. As the Mufcles here are cut, it will not be pro- per to ufe the Suture with the Needle, which might bring on at leaft a flight Inflammation; and the Skin being kept in it's Place by the dry Sutures, will re- tain the mufcular or aponeurotic Fibres H 2 that [ lOO ] that adhere to it* Thefe Slips of Plaifter ought to be very long, to take hold of the Skin and confequently the mufcular Fibres> for fome Diftance, and they fhould be a lit- tle feparated from one another, that if any Matter fhould ifTue from the Wound, it may be difcharged through the Interflices ; for if it was to remain in the Wound, it would become an extraneous Body, and would obftru6t the Re-union, which we propofe to procure as foon as pofiible. As there mufl be feveral Slips of Plaifter, if one fliould loofen it's Hold by being moift- ened with the Matter, it muft be changed without removing the others. The Patient fhould be bled immediately after, to prevent an Inflammation. I cured a Wound of this kind in three bays, Without any Accident intervening ; confequently the flefhy Parts united with the Bone as well as the Skin at the Cir- cumference. I found in the Burial Place at Worms, an entire Skull of a Man, who had been dead a very long Time. It appeared that a Piece of the parietal BonCj round and full aa Inch [ lOI ] Inch in Diameter, had been feparated by a Stroke of a Sabre. Without Doubt the Patient had been cured of this Wound, and the Surgeon had replaced the Piece of Bone, for the Callus was formed and equally hard the whole Circumference j it was the fame within the Skull as without. There was even on the Infide of the Piece, which had been united by the Callus, three little Scales of Bone, which the Surgeon had not taken Care to remove, and were foldered, as it were, in the Middle of the Piece which was replaced. Several Surgeons have feen this very curious Piece, which was flole from me fome Time after. A Wound in the Fore-Arm by a Sabre. A MAN has juft received a Stroke with a Sabre, which has divided the two Bones of the Arm in the middle Part of it ; the Stroke which was given on the Outfide of the Arm, has left nothing un- woundcd but the flefhy Parts which form th^ H3 [ I02 ] the lefide of the Fore- Arm, fo that the Wrift and lower Part of the Fore- Arm drop, being fupported only by thefe Parts. Being fent for immediately, What ought to be done ? May one hope to preferve the Wrift ? Answer. There is no doubt but we ought, if pof- fible, to procure the Re-union of the di- vided Parts J for the Bones may be united as well as the Flefh. It is very true, that if we Ihould be fo happy as to fucceed^ the Hand will remain clofed, becaufe all the extenfor Mufcles of the Wrift and Fingers are divided, and the flexor Mufcles always tend to contra(5l themfelves, even indepen- dent of that Contradion which is voluntary. But the Hand, though clofed, will be al- ways more ufeful than a Stump without a Hand. . It will be neceffary to examine dired:ly, \vhether there is any Splinter or fmall Piece of Bone feparated from the whole, and on- ly connected by fome of the flefhy Parts ; if { ^^3 ] if there is any diicovered by the Finger, it mufl be extracted by cutting it off from what it adheres to ; the divided Parts mufl then be immediately replaced, and kept there by a flat Splint well lined, placed and fixed on the Infide of the Fore- Arm ; this Splint fhould be long enough to keep the Wrift and Fingers a little forcibly extended,, fo that the mufcular Parts which are divid- ed entirely may touch one another. I do not propofe the Suture with the Needle, becaufe, without the Afliftance of that, the Parts may be kept exactly in Contadt. You fhould begin with wafhing the Wound with warm Wine, to remove all the little Clots ©f Blood which may ftick to the divided Flefli 5 and, if the Wound ftill bleeds, it fhould be wafhed with Alum- Water, to contract the Mouths of all the fmall opened Veffels. When the Wound has done bleeding, the divided Parts mufl be brought exadly together ; and to keep them fo, the abovementioned Splint muft be placed the whole Length of the Infide of the Fore- Arm, as well as on the Infide of the Hand and Fingers. Oiv H 4 the [ 1^4 ] ' the Side ,of the Wound the Lips muft be fuftained by feveral Slips of agglutinative Plaifter, which will make dry Sutures, and they muft be renewed, according as they are loofened by the Matter which difcharg- es from the wounded Flefh. The Arm muft afterwards be placed in a Cafe, in fuch Manner that the Hand may be a little more elevated than the Elbow, and the El- bow upon a Level with the Shoalder, to affifl the Return of the Juices into the Limb. Neither Lotions nor Cataplafms are to be applied to the Arm, becaufe they would only loofen the Plaifters which form the dry Suture ; neither fhould there be any Dreffings applied for fome Days, the fole Objedt of our Attention being the Pofition and Quiet of the Limb, as well as of the dry Sutures; Circumflances may require them to be added hereafter, but the Splint muft not be removed till the Bone Is judg- ed to be perfectly united. Note, that the Bones may be much longer in uniting than the foft Parts. We know by Experience, that the Re-union of a Bone is a longer or Ihorter [ ^OS ] fhorter Time in forming, according to the Age of the Patient. The Inflammation is the only Thing to be dreaded here, and to prevent that, fre- quent and large Bleedings, more or lefs, muft not be fpared, according to Circum- flances and the Strength of the Patient. The Diet likewife is a Thing which de- ferves a great deal of Attention 5 other Re- rnedies that Circumftances may indicate I omit. This Wound may be fome Months in curing, as I have feen in a Trooper, that received fuch a Wound at the Battle of Ou- denard. In propofing the Re-union in this Marv- ker, I am fenfible it will not be perfeded very foon 5 many Points of the Divifion will unite fpeedily, others more flowly, owing to the Difficulty and even the Im- poffibility of bringing them together, and making them meet as exadtly as we could wifh ; but at laft they will all unite, fomc without Suppuration, and others after hav- ing fuppurated, as I have feen them do. A Wound [ io6 ] A Wound on the Elbow by a Sabre. AM A N receives a Stroke by a Sa- bre, which divides the Olecraeon, but does not affedt the Body of the Cubitus or Radius, being given from above down- wards, while the Arm was beet s the Piece of Bone is held by and adheres to the Piece of Flefh. What ought to be done to this Wound ? Answer. Experience teaches, that Bones, when tbey are divided, will often unite as well as Flefh ; it is true their Re-union is flower in effedling, but neverthelefs it is accomplifhed at laft. The firft Indication then that offers here is the Re-union. The Flap muft be replaced and kept there by the dry Sutures, by a uniting Bandage, and by the Polition of the Limb, which fhould be placed and fixed in a State of Ex- tenfion, fo that it cannot bend itfelf nor be bent by any Means. It will be therefore proper [ I07 3 proper to fecure it well in that Pofition. To do this commodioufly, and in fuch a Manner that the Wound may be feen, without removing what keeps it extended, there muft be placed on the Infide of the Arm a Plate of Tin, about a Foot long, bQnt in the Form of a Boat, and wrapped in Linen. The Middle of the Plate muft be placed at the Bending of the Arm (for Want of fuch a Plate fomething equivalent to it muft be ufed, as the Bark of a Tree.) Two other Plates not fo long fhould be placed at the outer Part of the Fore- Arm, that is, one above and the other below the E^lbow J and thefe three Plates in a Man- ner almoft furrounHing the Limb, muft be fecured with a broad Roller moderately tight. The Elbow by this Means being uncovered, you may fee every Day what pafTes. The Wound fhould not be dreifed for three or four Days, but it may be pro- per to change the dry Sutures if they Ihould be loofened by the Difcharge. The Arm muft be kept extended without any Relaxa- tion for thirty or forty Days, either more or lefs, according to the Age of the Patient, becaufe [ io8 ] becaufe the Callus is longer in forming- in old People, on Account of their Bones be- ing drier. The Nature of the Olecranon, which is fpongy, may expedite the Cure. The Fleih may be united in a few Days ; neverthelefs, it may happen that fome Part may not re-unite fo foon. In that Cafe the Wound will fuppurate for a fhort Time and heal afterwards, perhaps not till the Bone is re-united. If an Inflammation fhould happen, it may occaflon Collections of Mat- ter, SinufTes, Abfceffes, and other Acci- dents capable of hindering the fpeedy Re- union ; therefore we muft endeavour to prevent it by every Means that Art can af- ford, without quitting the Extenfion that I have diredled. Second Consultation on the Progress of the Disease. The Perfon who faw the Patient had fil- led the Wound with Lint, and as it ftuck very clofe when your Anfwer was received to the preceding Confultation, he would not remove it. An Inflammation has en- fued. [ I09 ] fued, and you are again confulted, being the fourth Day of the Wound ; the Lint is a little moiftened, and the Wound begins to digeft, even the inner Part of the Flap to which the Olecranon is conned:ed ; the Fore- Arm is fwelled, and alfo the Arm above the Elbow a little. What ihould be done ? Answer. The Lint is an extraneous Body in the Wound and {hould n-ot have been put there. The Wound begins to digeft -, but that is no Reafon to continue dreffing it in the fame Manner ; therefore as foon as the Lint can be removed the Lips of the Wound muft be brought together in fuch Manner that the di- vided Bones may meet and touch one another exadly, for poffibly there may be no Exfo- liation, and the Olecranon may unite aa it is of a fpongy Texture j another Reafon to think that the Olecranon may unite foon to the Cubitus, is the Arm being fixed in a pofture of extenfion, as I have dired:ed. In I "o ] In regard to the foft Parts which fup- purate, it is very certain that by keeping them together, in fuch Manner as to touch. Nature will have lefs to do to unite them, than if they were left afunder, as was done at firft. At the fame Time you muft atten^ tively obferve the Directions I mentioned in the former Confultation. In Confequence of the inflammatory Swelling of the Fore- Arm, there may poffibly be feme Abfcefs formed amongft the Mufcles of that Part, and during the forming of the Matter, the Swelling may increafe, but this mufl make no Alteration in what I have direded for the Wound. As foon as a Fluduation of Matter is perceived, the Abfcefs muft be opened and drefTed according to Art ; then the Swelling will go off, but not before. That the re-union of the Olecranon may be made as foon as poffible, the Arm muft remain for a Time extended without a Poffi- bility of being bent, which would render it ufelefs and even inconvenient ; but the Flexure will return again with proper Affifl:- ance j this coniifts in making ufe of emolli- ent [ill ] ent Fomentations for a Fortnight, not only on the Cicatrice but even all over the Arm to the Shoulder, to permit the extenfor Muf- cles of the Fore-Arm, that are {hortened, to yield to Extenfion, and the Flexors to recover their motion of voluntary contrac- tion, which they have loft the ufe of. After this the bending of the Fore- Arm muft be effe(Sted gradually by fome Degree of Force fuch as the Pain will permit, for it cannot be done without. The tenth of an Inch ob- tained in a Week, in three Months will be- come a ufeful Flexure, the Progrefs of which will certainly augment by. continuing the fame Method. A Wound in the Thi gh by a Pistol. AVERY fat Man of forty Years of Age returning from the Country on Foot about eleven at Night, carried in his Hand a Pocket-Piftol charged with a fmall Piece of Lead j the Piftol went off and the Piece entered into the left Thigh, four Fingers [ 112 ] Fingers breadth above the Knee, between the anterior Part and the Infide. Confe- quently it muft have paffed from above downv^ards, acrofs the Vaftus internus Muf- cle, near the Place where it meets with the three other extenfor Mufcles of the Leg, to form together the Aponeurolis that covers the Rotula. The Patient walked a quarter of a League to get Home, and did not fend for me to drefs him till eight in the Morning. I found the Knee and Thigh fwelled, and very painful. To difcover the Track of the Shot I examined the Wound with a pretty large Probe, that I might not make a falfe PafTage ; it entered obliquely, with Eafe, an Inch and a Half, where it was ftopt by the Mufcles without my being able to follow the Track of the Shot any further ; I have enlarged the Orifice fuffici- ently, as far as into the Mufculus Vaftus internus, but neither my Finger introduced to that Depth, nor the Probe, could dif- cover the Track the Ball had made, fo I dreiTed it up lightly. Bleedings and emolli- ent Cataplafms repeated for fix Days, by de- grees have abated the Inflammation, fo that the ["3] the Wound begins to digeft riot knowing where the Ball is, I dare not, (even follow- ing the oblique PalTage it has taken) make a deeper Incifion in a Place furniflied with Aponeurofes, which in Confequence may Inflame. What is your Opinion ? and what am I to do now ? I would if jpoflible extract this extraneous Body. Answer. From the State of the Wound as you have defcribed it, and the Occafion of it ; I am doubtful it will not heal, but will remain fiflulous at leafl:, if you cannot get out the extraneous Body. The Fear yoti were under of making Incifions in the aponeuro- tic Parts to fearch for it, was well founded, efpeclally as you could not feel it, but I do not doubt but you will fucceed in finding it by a very fimple Method, which has already fucceeded with me, without diflurbing the Wound. You muft inclofe in the Middle of a fmall Doffil of Lint, a little Piece of Cau^ ftick, and place it at the Bottom of the J Wound, Wound, keeping it fixed there by two or three other Doflils, fo that it may not be difplaced, the whole fuflained by a Plaifter, a Comprefs, and a Roller. The Cauftick will dilTolve and infinuate itfelf along the Track of the Ball, where it will make an Efcar as well as on the neighbouring Parts ; this Efcar in the Mufcles will not be fo hard as what the Cauftick makes on the Skin, the Texture of which is very firm, and requires being cut with a Biflory : by this Method you will eafily introduce a Probe to the Bottom, or even the Finger, and feel the Ball by it's Hardnefs. It will then be not difficult to take hold of it with the Forceps without hurting the Mufcles, and making a new Laceration. The Ball being extrad:ed the Efcar will fall off, and the Wound digefl and heal in a little Time. The Surgeon'^ Answer. I followed your Advice, and the next Day, introducing my Finger as far as the Bottom of the Wound, through the Efcar, I felt ["s3 1 felt the Piece of Lead, which lacerating the Periofteum had ftruck the Femur, and was conneded to it's Superficies by feme Inequalities J for it had become of a very ir- regular Figure by the Refiftance of 'the Bone ', it weighed a Dram. The Wound after this digefted, the Bottom filled up without any Exfoliation of the Bone, and the Wound was cicatrized in about twelve Days by the mofl fimple Dr-'sfTings 5 that is to fay, by every Day pouring i^;/a few Drops of the green Balfam, and leaving the reft to Nature. i: A Contusion on the Forehead hy a Musquet-Shot. A MAN received a Mufquet-Shot in the Middle of his Forehead, on one Side of the fagittal Suture, the Ball of v/hich being at the End of it's Courfe, made no Wound, but only a Contufion, and dropped at the wounded Maa's Feet* I 2 At [ii6] At that Inftant he felt a Numbnefs that made him ftagger, but went off immedi-. ately. Your Advice is defired. Is there liothing to fear ? And what fhould be done to the Contulion ? Answer. If the Ball has ftruck hard enough to make a Go.ntufion, and the Commotion is but flight, the Bone may be and moft pro- bably h: fradured. In this Uncertainty a crucial Incifion (hould be made on the Con- tulion, to difcover the Bone. If there is no Fradure, you will have nothing more to do than to wait for the Exfoliation of the Bone, and the Wound will heal. If there is one, the Trepan muft be applied as foon as the Symptoms of an Extravafa- tion begin to appear. It will not be proper to do it fooncr, becaufe the Dura Mater as yet adheres to the Cranium, which can on- ly be feparated from it by the Extra vafation, and it is proper that it fhould be feparated by that. It is uncommon in fuch a Cafe to have the Bone broken in Pieces, but if it was,. [ 1 rr ] was, the Trepan fhould be applied diredly, becaufe the Signs of an Extravafation would come on very foon, whereas in a flight fim- ple Fradiure it is two or three Days before they appear, and often longer. Perhaps you may be furprized that I diredl an Inci- fion to be made when there is no other Symptom yet ; but it happens very often, that the Bone is fraflured with fuch Blows, and I have feen a great many Patients die, where there has been no Sufpicion of any Fradture, becaufe there was no Wound, and the Contufion appeared flight ; there is nothing wonderful in this, for a Ball is a round Body, which ftrikes only in one Point ; and all the Weight of the Ball cen- ters in that Point. I do not fpeak of the Regimen the wounded Perfon is to obferve, of the Bleedings in the Arm or Foot, nor of the Dreffings, which mufl: be accommo- dated to the Circumfliances of the Wound, and the State of the Patient. Although the outer Table of the Bone may not be fractured, perhaps the inner may ; and in that Cafe, in a few Days, Symptoms will come on, in Confequence I 3 of ["8] of the Extravafatlon that wilj happen, there- fore you cannot be too attentive in this Cafe. It is befides poffible, that without any Frac- ture there may be a local Commotion, and that the Dura Mater may have fufFered from it's Adhefion to the Cranium. I have feen it in thefe Cafes and fimilar ones, come to Suppuration and kill the Patient twelve or fifteen Days after the Blow was given i though during the Time, there has not appeared any dangerous Symptom. You cannot therefore be too attentive to the leafl Symptoms that may appear and indicate the Neceflity of trepanning the Patient. *^* See my Observations, Vol. L.,of a Cut with a Sword on the Coronai. Suture. A MUSQJJE'T [ "9 ] A MusQUET Shot in the Arm. AM A N received a Mufquet Shot in his Arm,, the Ball of which entered the Middle and anterior Part, and went out nearly on the oppofite Side. The Entrance is not exadtly round, and where it went out two Holes are feen, nearly about a Finger's Breadth from one another. The Shot was fired pretty nigh, and the Bone does not appear to be broke. What fhould be done ? Answer. As there are two Holes where the Ball pafled out, there is no Doubt but two Bails entered at the fame Time, and parted be- fore they went out. If the Balls entered at the Infide of the Arm, between the Bone and the Veflels, the Entrance mufl be enlarged, dividing only the Skin ; for, by cutting deeper, you may perhaps open the VefTels. It is ufelefs to introduce the Finger at the Entrance to difcover the Track of the Balls, becaufe that is known I 4 by [ 120 ] by the Place they pafs out at. Afterwards the twp Holes where the B^Us pafTed out muft be laid together by an Incifion, fo as to make but one Wound. If they entered on the Outfide, the Finger muft be intro- duced in the fame Manner to the Bottom, to open a free Communication, if poflible, from the Entrance to the Exit, and to feel if one of the Balls has not touched the Bone in it's Paflage, which would oecalion a Contufion of the Periofteum ; for the Se- paration of the two Balls in their Courfe gives Room to fufpect it. The Finger be- ing introduced will likewife difcover wher ther fome Care Ihould not be taken, to a- void a branch of an Artery in making the Jncifion I propofe from one Wound to the other, through the Mufcles and Fat, Af- ter this the Wound will require no more than fimple Dreffings, but, however, me- thodically. Bleeding, a Regimen, and the Pofition of the wounded Part, will effectu- ally prevent the Inflamrnation, after the propofed Incifions are made. It may per- liaps be propofed to pafs a Seton from the ^ntrarice to the Exit of the galls, but it C 121 ] will be ufelefs if the proper Incifions are made, and the Paflagc is opened enough j nay it may be added, that it will only be an extraneous Body in the Wound. The Contulion of the Periofteum (if it has been ftruck) may retard the Cure, and the Bone may poffibly become bare in that Place. Neverthelefs that will require no other Attention, but to drefs the Wound with vulnerary Lotions, that it may not be- come carious, by the Ufe of greafy Medi- cines, which Digeftives are made of. As it is poffible that fome Branch of an Artery, included within the Efcar, may bleed when the Efcar falls off, it will be proper to leave a Turniquet loofe upon the upper Part of the Limb j which muft not be tightened, unlefs it fhould happen to bleed when the Efcar falls off, charging and inftrudling fome Perform in that Cafeto doit, till ^Surgeon arrives. JGvN-. [ »22 ] A Gun-Shot Wound in the Hand. AM A N loading his Mufquet, having put in three Balls, the Powder and Wadding, fixed his Bayonet and then with- drew it ; at that Inftant the Shot was dif- charged. One Ball took off the fecond and third Phalanx of the Thumb, at the Arti- culation with the firft. Another Ball in it's PafTage fradured the metacarpal Bone (which fuflains the Fore-Finger) in it's middle Part. The Space between thefe two Wounds is black, either from the Powder or the Efcar. It is afked what fhould be done to this wounded Man, and how he fhould regulate his Conduct, dur- ing the Courfe of his Cure. Answer. Thefe two Wounds require different Treatment. Two Phalanges of the Thumb are {hot off, and the End of the firff Pha- lanx, or at leaft the Corners -, confe- quently this Wound is to be conlidered in C 123 ] In the fame Light as when Part of the Leg has been taken off by a Cannon-Bail ; that is to fay, the Bone muft be amputated above the Place where the Wound is. The cir- cular Inciiion being made, the End of the Bone muft be fawed off with a fmall Saw, that it may unite to the Flefh i this will make it a fimple Wound, which muft be drefted according to Apt. In regard to the other Wound which Is diftindl from the former, it is neceflary to make an Inciiion at the Place where the Ball entered, and where it went out ; that the SpHnters which are fhivered from the metacarpal Bone may be the more eafily extraded, and to cut off the Ends of the broken Bone with the cutting Forceps ; by this Method we may hope to fave the Fore- Finger. There will be no Occafion to make Sca^ Tifications on the Efcar, becaufe the Inci- fions will be fufficient for the Difcharge from the Part, as it is not very flefhy. It is true the Fore-Finger will have no Mo- tion, as all the Tendons belonging to it are deftroyed ; but if it is kept bent during the Time C '24 ] Time of Cure, which may eafily be done by a Bandage, it may be ufeful afterwards. The Inflammation, if not prevented by proper Attention, may occafion Abfcefles and Colle<5tions of Matter in the Hand, and along the Fore- Arm* Therefore, befides repeated Bleedings, it will be proper to ap- ply Pultices all over the Hand, and make Ufe of vulnerary and refolvent Lotions. A proper Diet muft be obferved, and the wounded Part muft be placed in a conve- nient Pofition, with fuch other Affiftance as may be occafionally required. As foon as the Sloughs are come away, all greafy and digeftive Medicines muft be left off, and only vulnerary Lotions made Ufe of. Spirits of Turpentine alone may be of Ufe to feparate the membranous and tendinous Parts, the Sloughs of which are fometimes a long while falling oiFj but it muft be ufed only to the Sloughs of the tendinous Parts, and pot the reft of the Wound, when it is come to a good Digef- tion, and the Inflammation is gone off. -^MUSQUET [ 125] A MusQUET Shot in the Arm, AN Officer received a Mufquet Shot in the middle and anterior Part of his Arm, the Ball of which did not go through, but is felt under the Skin, pretty nearly on the oppofite Side. The Humerus appears to be fractured. What fhould be done at Prefent, and what are the neccelTary Atten- tions to be obferved during the Courfe of the Treatment. Answer, The Arm being fecured, fo that the {hat- tered Bones may not caufe a new Diforder, by any Motion which the Pain from thence might Occafion, an Incifion muft be imme- diately made on the Ball where it is felt, large enough to extrad: it with Eafe, for it will not be proper to endeavour to extraShot on the Breast. MAN received a Wound by a Mufquet-Ball, which entered the right Side, feven cr eight Fingers Breadth from the Cartilago Xiphoides, and pafTed out fix pr feven Inches Diftance from it's Entrance, towards the lateral and pofterior Part, without entering into the Thorax. The Entrance and Exit of the Ball have been dilated by two Incifions, and fome Days pafTed without any bad Symptoms. But a Fever is now come on, the Lungs are inflamed, and there is a frequent Cough. Bleeding, flrid: Diet, and other proper Remedies, have not at all diminifhed thefe Symptoms 3 they even increafe. What do you think more fhould be done? The whole Courfe of the Wound is fwelled and painful. Answer. [ ^32 I Answer. - ' ■ x^^ ' '- -^ ■-■-- • ■•■ -- ■-'■■' ' -■' 'From the Symptoms that have ^rbf^,' there is Reafon to believe that the Wound is not fo (imple as it appeared at firfl, and I am very fearful that, either the^ fixth ©r'fe-^ venth Rib has been ftruck and brokei^'; ir^ which Gafe the Points of the Bone that are' feparated and drove inwards, either have lacerated the-Pleura, or prick it. This alone is capable of producing all the above Symp- toms, and cauiing a Suppuration in the Thorax. It is not unlikely but you may difcov^r the Place where the Rib has been flruck, either by the Pain from the Preffure of the Finger, or by feeling with it all along the Rib ; fuppofing that to be the Cafe, ijt will be abfolutely neceifary to make an Incifion in that Place, of a fufiicient Extent to dif- cover all the Injury, and at the fame Time to remove any Points or Splinters of Bones that may be there. This will be perform- ing the Operation of the Empyema, that is, making an Opening by which one may K 3 difcovtr [ '34- ] difcover all that has been done by the Shot, and likewife what is the State of the Difor- der in the Thorax. But it is the only Me- thod to prevent the Ekath ^f ■ the Patient, which without this is almoil inevitable. I do not fpeak of the Regimen nor ;of the Dreffings ; the State of the Patient, which I believe to, be fuch as I have mentioned, will indicate both to the Surgeon, who af- ter the Operation I have propofed, muft drefs it; according to Art, and the Circum- flances that occur when he knows the Caufe Qf the Illnefs. • Tbe £^ V E N T. I have been informed that there was no Operation performed, and that the Patient died fome Time after. ^4 MUSQUET- [ »35 ] A Musquet-Shot /« the Foot. AM A N received a Mufquet-Shot itl the Foot, the two Balls of whichj ftriking below the Malleolus externuSj with- out touching itj penetrated through the Tarfus, below it's Articulation with the Leg, and went biit on the oppofite Side, without touching th6 Malleolus internus. What do you thitik of this Wound ? And what ought to be done ? Answer. Several of the tarfal Bones are broke, and their aponeurotic Adheiions are lace- rated. It is impoflible to make an Incifiori in the Teguments to the Bottom of this Wound, on Account of the Contiguity of thefe Bones which touch one another, and ^^fe'^dnneded by aponeurotic Parts ; fronl henice in all probability in a (hort Time fe- veral Symptoms will arife, as an acute Fe- ver, a Tenfion of the whole Foot and Leg. K 4 with [ 136 ] with Swelling, fevere Pain, Convulfions, Inflammations, &c. There is only one Method to be taken to prevent thefe Symptoms, and fave the Patient's Life ; that is, to immediately am- putate the Leg, If the Symptoms begin to appear, particularly the Gonvulfions, the others will foon follow, and will increafe fo faft, that the Succefs of the Operation will become very doubtful. If it could even be done upon the Spot where the Hurt was received, it would be fo much the bettpr ; for in the Removal, the wound- ed Bones will rub more or lefs ^gainft one another, whatever Care may be taken -, and the Extenfion of the aponeurotic Parts which conned: them together, wilLaccele^^' rate the coming on of the Convulfions. For one or two Patients that perhaps Jiave been faved in a parallel or fimilar Cafe without Amputation, fo many others die, becaufe fome have imagined they could fave the Leg, that it may be laid dpwn a^ ^ P-ule never to attempt it, ^ MySQUETr [ ^27 ] y^ M u s QjT et-Shot on the Siiwj^ Frontalis. AM A N received a Mufquet-Shot on the Sinus Frontalis, and the Ball has penetrated into this Sinus, as is eafily perceived with the Finger, befides the Bot- tom of the Sinus feels very unequal. The wounded Man loft his Senfes immediately and fell, but came to himfelf in a quarter of an Hour. What Prognoftic is there to be made according to the different Circum- ftances refulting from the Wound ? and what fhould be done in Confequence of them? A N SW E I^. The Bone having given way to the Shot, it is not to be wondered at, that the Com- motion of the Brain has been fo ili2:ht, not- withftanding the Violence of the Stroke and the Reafon there is to believe that all the Hurt is confined to the wounded Part. J^everthelefs the Ball is not yet found, and it [ »38 ] it is uncertain whether or not it has en- tered into the Cranium by piercing the pofteriour Part of the Sinus. (The late Monf. Markhal^ firll Surgeon to the King, told me as well as many others, that he had feen an Officer wounded in the Forehead with a Mufquet Shot, the Ball of which entered into the Skull and was loft j that neverthelefs he was cured, and dying a Year afterwards, the Ball was found in the Brain near the Sella Turcica.) Suppofing in the Cafe before us the Ball has entered the Skull, the Bottom of the Sinus being pretty thin, the Fracfture is radiated from the Cen- ter 5 and the Pieces ftill adhering to the Dura Mater at their Bafis, have been lifted up and replaced by the Motion of the Brain, but though this may be the Cafe yet never- thelefs the Dura and Pia Ma:ter muft be lacerated. The Surgeon fhould at leaft inform him- felf by feeling whether or not the Bottom of the Sinus remains whole; if it is, he will certainly not be able to difcover the Motion of the Brain, whereas on the con- trary if it is broke, he will. Whether the Ball has entered or not he fhould make an Incifion [ 139 i Incifion of one Kind of other, to difcover the Mifchief and remove the Splinters. If the Bottom of the Sinus is fracftured, and it is impra(fticabie' to remove any of the Pieces, it may perhaps^ be heceiTary immediately to ^pply the Crown of the Trepan, for certain- ly either there is Blood extravafated on the Dura Mater, or there will be foon. If the ,Thing is doubtful, you mu.ft wait till fome Sign of an Extravafation appears. The Wound muft -be afterwards dreffed accord- ing to Art. As the pofterior Part of the Sinus is pretty unequal on that Side of the Cavity, thefe Inequalities may deceive the Surgeon and make him believe there is a Fradure. He {hould be cautious of this Miftake, ^nd the Application of the Finger will inforrri him, by preffing ftrcmg enough with it to make the Pieces of Bones give way a little if they are fradlured, and feeling the Mo- tion of the Brain. All the Circumftances I have mentioned, that is to fay, the different Diforders that may be produced by the Stroke, either in ihp Wound or in the whole Oeconomy of the [ 14° ] the Machine, will regulate the Prognoflic and the Method of drefling, Bleedings in the Arm and Foot, with an exa(ft Regimen, muft not be negled:ed, no more than fuch other Affiftance as the various Diforders produced by the Stroke and the Commotion of the Brain may require. A Cannon-Shot on the Arm and the Breast, AM A N received a Cannon - Shot, which palTed between his Body and Arm, and ftruck them both at the fame Time. The Humerus is not broke, but Part of the flefhy Belly of the Bjfceps Muf- cle fcems to be carried away, without any of the large Veffels being touched, and a Part of the great perioral Mufcle feems likewife to be taken off along with the Skin and Fat which cover it. Thefe two Wounds are of an irregular Figure, that of the Bread is about four or five Inches in Diameter. The whole is full of Sloughs and as it were mafhed, [ i4r ] mafhed, confequently the Contufion is very great. This is accompanied with a great Difficulty of breathing, and a Spitting of Blood, which Symptoms came on in a very ihort Time after the Blow was received. It does not appear that the Ribs are touched. How Ihould this Wound be drefled ? arjd what do you think of it ? Answer. The Laceration, the Efcar, and the Contufion which accompany thefe two Wounds demand a great deal of Atten- tion ; but the whole State of the Body like- wife requires as much, on Account of the general and particular Commotion, which has occafioned the Difficulty of breathing and fpitting of Blood. The Difficulty which the Blood finds in paffing through all the Parts which are loaded with Efcars, re- quires their being fcarified to empty all the neighbouring Parts. At the fecond Dref- fing it will be proper to ufe warm Digef- tives, to preferve the Elaflicity of the Vefi^els, to revive if poffible the Motion of the itag- nated [ 142 3 nated Fluids, and to caufe the E)fcars to fe- parate as foon as poffible v the Dreffings muft be covered all over with refolvent Ca-- taplafms, which muft, be carefully; renewed, to keep up a proper Heat in the P^rt. To prevent the Neceffity of renewing the Dref- fings, every Time theCataplafms are changed they fhould be put between two Pieces of Linen, one of which fhould be very fine, and be placed next the Lint fpread with the Medicine. Though there is neither Frac- ture of the Ribs, nor of the Arm, this Wound is very dangerous, becaufe of the Contufion which extends perhaps to th? Infide of the Thorax, of which the Spit- ting of Blood is a Kind of Proof. Bleed- ings mufl not be negleded, nor a Regimen, with Quiet, and fgch Evacuations as the dif^ ferent Circumftances may require^ which m,uft be proportioned to the Strength of the patient, to the Symptoms that may come on, and the Condition of the Wound. As on the falling off of the Efcar, fome VefTel more or lefs confiderable may happen to bleed, it will be prudent to leave on the upper Part of the Arm a Turniquet, ready to [ H3 ] to be tightened if neceffary. The two Wounds of themfelves require no more than regular Dreffings. If on the fepara- ting of the Efcars, either on the Arm or the Breaft, there fhould happen any Hae- morrhage, it muft be flopped, either by tying the Artery or by fome ftyptic Water, ac- cording to the Flux of Blood from the Veffel. _^ ^ OF -^Hf^ ^ An Arm taken off hy a CANNON-sHbT. AM A N received a Cannon-Shot, which took off his Wrift at the Joint ; confequently the Radius and Cubi- tus had their Extremities broke off. Another Man received a Shot which took off the lower Part of the Fore- Arm, three Fingers breadth above the Joint of thfe Wrift. Another received a Shot which carried off the Fore-Arm, two Fingers breadth below the Articulation with the Hume- rus. In [ 144 j In all ihefe Wounds, as the Mufcles Wef6 very much contufed, and the Bones broken off irregularly, there is no doubt of the Neceffity of amputating them, but where- abouts {hould it be performed ? Answer. In the £rft Patient, as the Bone was ndt fhattered but only it's Corners broke off, there feems to be no Occafion for Amputa- tion. If only the Bone was Hurt, an Ex- foliation might be procured without an Am- putation, but the Mufcles are contufed, feveral Tendons lacerated, and the annular Ligament torn off. Therefore Amputation muft be perfor- med three or four Fingers breadth above the Place where the Limb was taken off j the propereft Place for which muft be de- termined by Infpedion. As to the fecond Patient, the Fore- Arm may alfo be amputated below the Elbow ; becaufe as the Bones are fractured in the middle, there is Reafon to believe the Arti- culation [ 145 ] culation of the upper and lower Arm has not fufFercd much by the Shock. The third Patient's Cafe is different ; the Bone has been ftruck above it's middle Part, and fo near the Articulation with the upper Arm, as to make one conclude, according to the Laws of Motion, that the Shock has been communicated to tne Capfula which fixes and conneds the Bones of the lower Arm to the Humerus. Repeated Experience confirms this Prac- tice. How often has the Articulation been known to inflame, and the Suppuration ftop in Confequence ? which has obliged the Surgeon to amputate above the Articu- lation, or the Patient die in a few Days, being attacked by a Croud of Symptoms, all occafioned by a total Inflammation of the aponeurotic Parts that inveft and con- ned, that Articulation. Swelling and Inflammation being much flower in going off in aponeurotic Parts than in mulcular ones, we cannot be too much on our Guard againft their hap- pening. In [ 146 ] In a fimilar Cafe to the third, where Amputation happens to be performed below the Elbow, becaufe there is Room for it, in Cafe a Swelling of the Articulation fhould Gome on afterwards, there fhould be no Delay in amputating it above the Elbow. A Sprained Foot. WOMAN very fat and very big with Child, within thefe twenty- four Hours received a violent Sprain of her Foot. She immediately rubbed it with Oil and Wine, and afterwards covered it with Cloths dipped in thefe two Liquors. Two Hours after the Accident, the whole Foot fwelled and became very painful. A Fever is come on, and you are confulted next Day J What could produce fo fudden a Tumour and Swelling ? What ought to have been done at fir ft ? And what fliould be done now ? Answer. [ »47 ] Answer. it is impoflible to have (o confiderable a Sprain as this is, without the Capfula of the Joint, the Ligaments and the Tendons which furround it, having fufFered a violent Extenfion ; and this could not be done, without feveral of the aponeurotic FibreSj the fmall Blood-VefTels, and others, being ruptured : The Sw^elling followed in Con- fequence. Befides there could be no Rup- ture of thefe Veffels without an Extravafa- tion of Fluids, according to the Nature of the VefTels from whence they iffue, their Number and Diameter. The Method which ought to have been taken at firft, was to have ftrengthened the Veflels by fome aftringent Application in- flead of the Oil which was applied, which could only relax. It is not yet too late to do this. The bed Defenfative to be made ufe of in the like Cafe, as well as in other confiderable Bruifes, is the White of an Egg beat up with a little Vinegar and a fufficient Quantity of Bole Armenic, in ve- ry fine Powder, mixed together to a pretty thick Confidence, fpread upon Cloth and L a applied [ 148 ] applied to the Limb. In Cafe of Neceffity, the Want of this may be fupplied by pretty thick Comprefles, dipped in Water im- pregnated with Salt and ftrongly prefTed out ; (if the Part is covered with Hair, it fhould be fhaved before this Application.) Thefe Applications as they grow dry will harden and infenfibly comprefs all the Part, which will be produdlive of two good Ef- fedls. By their Hardnefs, in Proportion as they dry, they will fupport the Refiftance of the VefTels, which moil commonly is loftj and the gradual Compreffion made by their drying over the whole Part, will infenfibly diffufe the Blood and Lymph (which are extravafated) to a Diftance from the ruptured Veffels ; in Confequence you will fee in four and twenty Hours the Ec- chymoiis fpreading itfelf over the whole Length of the Limb, both above and below the contufed Part. And what can more expeditioufly produce a Re-union of all the ruptured VefTels, than what will difperfe the Blood, which being once coagulated, becomes an extraneous Body placed exadtly at their Mouths. The Patient fhould after this [ '49 ] this be bled twice or oftener on the Day following. In about twenty-four or thirty-fix Hours, it will be proper to remove the Defenfative, which fhould be grown very ftiff, and fub- flitute fuch Refolvents as are moft capable of warming the Fluids which are infiltrated over the whole Member, in order to haflen the Refolution. Thefe Refolvents fhould be a Decodion of Elder-Flowers, or other Plants of the fame Kind, with which the Part fhould be fomented twice a Day, for fo long a Time as to warm the Part tho- roughly J and Comprefl^es afterwards ihould be dipped in the Decodtion, and applied all over the Part after fomenting it. Embro- cations with Oil of Lilies or Camomile, which are frequently made ufe of, only ferve to flop up the Pores : Aqua Vitae, or a warm aromatic Wine, in fhort all that can accelerate the Refoludon of the extra- vafated Fluids, agree much better with it, and fhould be made ufe of. After fo confiderable a Sprain or Con- tufion, the Patient may be two or three Months before fhe is perfectly cured j that L 3 is [iSol is to fay, before (he will have the free Ufe of her Leg, becaufe the Mufcles of the Thigh, and particularly thofe of the Foot, will have loft their Ufe during the Time of reft, and becaufe there v^rill be a Number of fmall Cicatrices all round the Articulation of the Foot under the Skin, which will contrad: the Parts and obftrudl the Flexion and Extenfion. (The Cicatrices are the Re- union of all the Fibres that have been rup- tured,) It will therefore be infenfibly and in an uncertain Time that the Articulation of the Foot will recover the free Ufe of all it's Motions. Probably it will alfo fwell every Night for fome Time, the Circula-^ tlon as yet not being perfectly reftored. A Finger neat^Iy cut off. COOK holding a pointed Knife with a very fharp Edge, by Acci- dent cut his Fore-Finger almoft off. The Point of the Knife at once penetrated through ihe Infide of the Hand^ the Capfula of the Joint [ 151 ] Joint of that Finger, with the metacarpal Bone that fuftains it j and the Edge being turned towards the Thumb, all the Part between the Edge and the Thumb was di- vided in fuch Manner, that the Finger was held on only by a fmall Part of the Capfula and the Skin on the Side of the Middle- Finger. The Finger hanging in this Man- ner, he came and delired me to cut it oft. What ought to be done on this Occalion ? Answer. As the Finger is not entirely cut off, great Care muft be taken to fave it, and Endeavours fhould be ufed to procure it's Re-union as foon as poffible, although the Capfula is not only wounded but even above half divided. Some dry Sutures will be fufEcIent for that Purpofe, and Nature muft do the reft, affifted by proper Dreffings, and the Part being kept perfedly ftill. The Skin there- fore muft be kept together by the dry Su- tures, and the Finger fixed in it's Place for feveral Days by Pafteboard Splints, the L 4 whole [ 152 1 whole kept^on by a Roller, put on in fuch Manner that the Finger fhoiild be half bent, which is moft commonly it's Pofition. It is true the flexor and extenfor Tendons being both cut, the Finger will have no Motion J but after it is cured, if Care is taken to keep it bent for a Fortnight, it will always remain fo, and it will not only be without Inconvenience, but fometimes of Ufe, and without any Deformity. I have known a Wound of the fame kind perfectly re-united in three Days, by the Care I took to bring the divided Parts ex- adly together, and keeping them confined in the Manner beforementioned. A Pain in the Head. AL A D Y, five and forty Years of Age, has for feveral Years com- plained of almoft continual Pains in her Head, which frequently increafed, and be- cajne fo violent as to occafion Want of Sleep, Fever, and Convulfions -, and alfo made [ IS3 ] made her often irregular in her Menfes. This coinciding with her Time of Life, is the Reafon that they have now entirely ceafed. She has no Remembrance of any Blow, yet upon examining a Place fhe points to, where the Pain has moftly been, we can feel it cedematous, and upon Pref- fure the Pain is augmented. What can be the Caufe of this Diforder ? And how is it to be remedied ? Answer. It is not impoffible but the Time being near when her Menfes were to ceafe, was the Origin of the prefent Diforder 3 mod certainly there is fome local Diforder where it is cedematous, and I conclude from thence that the aponeurotic Expanfion is certainly injured, and very probably the Pericranium alfo in the fame Place. Thefe Complaints cannot be removed, without making either a crucial Incifion, or one of another Form, and laying the Bone bare in the fame Manner as if the Trepan was to be applied. I have in fimilar Cafes often [ '5+ ] often known the Pains go off entirely, as foon as the Wound came to Suppuration, The Bone will afterwards exfoliate either perceptibly or imperceptibly. This Diforder in Time might become very conliderable ; for whatever is difFufed under the Pericranium, or between that and the aponeurotic Expanfion, might fo injure the Parts as to bring on a Putrefac- tion, and in that Cafe the Cranium would certainly become foul. We have often known local Pains occa- fioned by a Caries of the Bone, and in that Cafe, there has probably been a Virus of fome Kind or other, which has been the Caufe of the Caries, If it's Nature and Charader can be difcovered. Endeavours ihould be ufed to correct it, independently . of the local Diforder, other wife it will only increafe. When the Incifion is made, if the Bone is found carious, as it has been fometimes, an Exfoliation muft be procured by fuch Means as are direded by Art, and perhaps there may be Occafion for the Ufe of the Trepan. But the Extent and Depth of the Caries muft determine that. Pain C »ss ] Pain in making Water. A MAN forty Years of Age, about four Years ago, was feized with a Difficulty in making Water, although he wanted very much to do it 5 he took fome diuretic Medicines, and in about three Days the Urine difcharged with great Impetuo- fity, feconded by the. Efforts he continually made. It is proper to obferve that he had often voided Gravel in his Urine, however he voided none at this Time, nor has void- ed any iince. A Month after he felt be- tween the Scrotum and the Anus, near the Neck of the Bladder, a pungent Pain, which hindered him from walking, and his Water appeared bloody every Time he made it. Thefe Pains have gradually in- creafed, and are becorne almoft infupport- able, notwithftanding the Ufe of many Re- medies, as Diuretics, Baths, Bleedings, E- mulfions and others. He continues to make Water with a great deal of Difficulty, lying or (landing; and every Time the Penis fwells and is very hard. His Water, which at at firft was thick, whitifli, and left a white Sediment at the Bottom of the Pot, is how very mucous. The Patient can neither ftir nor walk. What do you think of this Dif- order ? Answer. All thefe Symptoms denote that there is a Stone lodged in the Urethra, between it's Bulb and the Neck of the Bladder, i. The Patient has often voided Gravel, and it is probable there was a fmall Stone engaged in the Neck of the Bladder, which caufed the firft Difficulty in making Water -, this fmall Stone having difengaged itfclf from the Neck of the Bladder, the Urine necef- farily difcharged itfelf with Impetuofityj but if this Stone has lince remained fixed lower down in the membranous Part of the Urethra, fome Angle of it may have made an Excoriation, which occafioned the Blood that came away with the Urine, and may ftill come away at Times. 2. The Stone making the PafTage lefs free, the Patient is obliged to increale his Efforts, and the Irri- tation [ 157 ] tation occafioned by that, is the Caufe of the Swelling and Tenfion of the Penis. 3. The continual Irritation of the Paflage being communicated to the Bladder, the Urine in Courfe becomes uneafy to it. 4. The Symptoms muft neceffarily augment every Day, becaufe what at firft was only a Bit of the Gravel, is now become a Stone, and being enlarged, probably reaches into the Neck of the Bladder, which it partly flops up. Who knows but there may alfo be other Gravel and Stones in the Bladder, as none have come away fince. When a Stone is there, the Urine generally becomes mucous when it is cold, as this is. The introducing of the Catheter will in- form us of the State of the Difeafe, and I make no Doubt but it will meet with a Stone which will obflrudt it's Entrance into the Bladder. The [ ^58 J ^he Surgeon*^ Account of the State of the Disease. I fearched the Patient, and felt a Stone which would not permit the Sound to en- ter into the Bladder, for it lay juft at the Neck. There is no Doubt but it muft be removed by an Operation, as it cannot pafs through the Urethra. What are the Attentions we fhould obferve in perform-* ing it I Answer. The fame Method muft be obferved in extrading it as I have defcribed in my Treatife of Operations, printed in 1742. It will be neceflary likewife after the Stone is extracted to introduce a Staff into the Bladder, to know if there is any other Stone, in order to remove that immediate- ly ; for it would be a melancholy Affair to have the Patient undergo another Operation fome Time after. There [ IS9 ] There is great Reafon to fear the Wound will remain fiftulous, on Account of the Urethra's being dilated by the Stone, in the Place where it lodged, but this ought not to be imputed to the Fault of the Surgeon. A remarkable Example of which is to be feen in my Treatife of Chirurgical Obferva- tions* Suppofing that the Stone fhould have extended into the Neck of the Bladder, as I have known in a limilar Cafe, the Pa- tient may be troubled for a long Time after the Wound is healed with an Inconti- nence of Urine, and it mufl: be left to Na- ture to contrad the Neck of the Bladder, as Art can do nothing ; and the Wound may remain fiftulous if Nature does not clofe it. As the Neck was gradually dilated and con- tinues fo, it muft recover it's Power of Con- traction imperceptibly, confequently the Incontinence of Urine will continue fome Time. Afmall [ i6o ] Afmall Stone in the Urinary Bladder. AM A N between forty and fifty has had flight nephritic Pains for fome Time paft, in which he has voided fome Gravel. About four Days ago he voided with his Urine (not without Pain) two Stones, unequal, and large as a middling Pea 5 to all Appearance there are more in the Bladder, for when he makes Water, by the Time he has^made half a Glafs-full, it ftopsj but his Defire of making Water continues, and he then feels a flight prick- ing at the Neck of the Bladder, as well as at the End of the Penis. In a few Moments he makes Water eafi- ly, and then the Urine ftops again. He fears (with Reafon) that if another fmall Stone fhould grow larger in the Bladder, he fhall be obliged at lafl to be cut, and he has Recourfe to your Advice. Is there any other Method, befides a chi- rurgical Operation, by which this Gravel or fmall Stone may be difcharged, before it's Bulk is increafed. AlSWER. [ i6i 3 An S W E R, He may attempt one, which perhaps will fucceed ; but I cannot promife Suc*- cefS) as the Size of the Stone is unknown. It is true that at prefeiit it does not caufe the fame Pains that one of a middling Size might occafion, by it's Bignefs and Weight at the Neck of the Bladder ; but they may come on, if the Stone grows bigger, as will certainly happen in Time. The two fmall Stones which the Patient has paiTed, would not have come away if they had not been proportioned to the Dia- meter of the Neck of the Bladder, and the Reafon that the other remains is, that pro- bably it is larger. I know therefore of but one Way that can be tried without Danger, and that is to enlarge the Paffage through which it muft pafs to be difcharged. The Neck of the Bladder is always clof- ed by it's Sphinder, and will not permit the Urine to pafs, but only when the Con- traction of all the mufcular Fibres which furround it's Body tend to contrad: it's Ca- M vity^ [ l62 ] vity. At that Time the Urine itfelf diftends the Sides of the Neck, and opens it for a PafTage. ^a data porta^ ruit. If the Urine can in this Manner diftend the Sides of the Bladder, notwithftanding it's Sphinder, perhaps it may be poffible to open and diftend the Neck ftill more than it is. This fhould be attempted by the Ufe of Bougies, well made of Linen or TafFety, waxed and rolled, of the fame Sort as thofe we make ufe of in Diforders of the Urethra contracted by fome Difeafe j and fuch as I have fometimes made ufe of in Suppreflions of Urine, to facilitate the Introdudion of the Catheter. This Me- thod muft be attempted very cautioufly, every Day gradually increafing the Size of the Bougies, that no Harm may be done to the Neck of the Bladder and the Urethra. When you are able to introduce a pretty large Bougie, you muft begin by making the Patient Urine, and then introduce it fa far as that the End muft enter the Bladder ; he (hould afterwards drink three or foiir Glafles of fome diuretic Liquor, as Tea, or any other, in order to fill the Bladder. When [ i63 ] When he feels a great Inclination to make Water, he muft place himfelf on his Knees, his Body a little inclined forwards, fo that the Neck of the Bladder may be placed exadly downwards. By this Pof- ture the fmall Stone muft naturally fall to the Neck of the Bladder. Then with- drawing the Bougie, the Urine will iflue out immediately with Rapidity, and may bring the Stone away with it, as we fee a pretty fcrong Stream carry away the fmall Stones with it in it's Current. The In- creafe of the Size of the Bougies ought to be made, if poflible, without giving any Unealinefs to the Neck of the Bladder and the Urethra. Suppofing a Bougie of a mo- derate Size to have been introduced two or three Days fucceffively, and that the fmall Stone does not come away notwithftanding the prefcribed Diredions, in all probability the Stone (though fmall) is too big for the- Diameter of the Neck of the Bladder. In 1744 I faw this Pradice fucceed in a Patient who was in the like Situation. I introduced Bougies into his Urethra for twelve Days fucceiTively, every Day aug- M 2 menting [ 164 ] meriting the Size. He was obliged to go into the Country, where he continued to introduce them himfelf. On the fifth Day he paffed a fmall Stone, which was of the Size of a very large Pea. The largeft Bou- gies are about a third of an Inch in Diame- ter, at the End which diftends the Neck of the Bladder, doubtlefs the Urethra and Neck of the Bladder gradually yielded to fuch a Dilatation. We have Reafon to be well fatisfied, when, by fo fimple a Method, we are able to fave a Patient from fo dangerous an Ope- ration as that for the Stone. For this, the Stone muft ftill be very fmall, for the Neck of the Bladder will not admit of being dilated beyond a certain Point, which is difficult to determine. Pain [i65 ] Pain in making Water. AM A N five and forty Years old feels very acute Pains at the Time he is making Water. It comes away in a full Stream, fo that there is no Reafon to fuf- ped any Diforder in the Neck of the Blad- der nor the Urethra j and probably there is a Stone in the Bladder, which is the more likely, as the Patient has been cut for the Stone twice in his Life. He has been fearched feveral Times in different Pofi- tions, and with Sounds of different Curva- tures, without finding the Stone j at laf^ one was thought to be felt fo plain, as to leave no Doubt of it's Reality. But it was only for a few Moments, fo that the Sound could not be fixed on the Hardnefs which v/as diflinguifliable. From thence it is in- ferred, that it is very fmall, and changes it's Place by the different Contradlions of the mufcular Fibres of the Bladder. But aflonifhed that fo fmall a Stone caufes fuch continual Pains, and fo acute as they are, the Patient has been queflioned concerning M 3 every [ i66 ] every Thing that has preceded, and this is what he fays. 1. It is more than a Year fince he firll perceived very flight Pains in the Region of the Bladder, at the leaft Effort he made in going to Stool, or making Water. 2. About two Months ago, fitting down one Day, he felt an extream acute Pain on the left Side, and having at the fame Time a great Inclination to make Water, he fuf- fered greatly in making it, and his Urine was tinged with Blood. He fays he has never had the like happen fince. 3. He has ever fince perceived a fixed Pain in thefe Places, and fomething that feems to lie acrofs. 4. He has not thofe frequent Inclinations to make Water, that he experienced when he had the Stone formerly; but he is obliged to lie down on his right Side to make Water^ not being able to do it in any other Pofition, without fuffering the mofl acute Pains. Having no Doubt of his having a Stone, I cut the Patient, but when the Forceps were introduced into the Bladder, I could not [ »67 ] not feel any: However, fearching with the Sound, I felt a fixed Point of a Stone on the left Side, but could neither lay hold of it, nor change it's Situation. I contented myfelf therefore for the prefent with placing a Canula in the Wound, and put the Patient to Bed. The Point of the Stone feems to be about an Inch more or lefs beyond the Neck of the Bladder. What are we to think of this Diforder ? And what ought to be done ? Answer. As the flony Point which is felt in the Bladder cannot change it's Place, and as the Stone, though fmall to Appearance, does not prefent itfelf at the Neck of the Blad- der when the Patient makes Water, it muft be owing to it's being confined in fome Ca- vity. No Doubt but there is one of a greater or lefier Magnitude, which is in- clofed in fome Cell, and according to what the Patient has mentioned of his Pains, and his Manner of making Water, there is Rea- fon to believe it is fituated at the Extremity M 4 of C i68 ] of the left Ureter -, and as it may be at it*s Opening into the Bladder that it is felt with the Staff, being hitherto almoft entirely in^ clofed there, poffibly a fmall Portion of it; may have projeded into the Bladder. Several Things give Reafon to think fo, J. The Immoveablenefs of the ftony Point ; 2. It's Situation j 3. The Pain which the Patient has felt for a Year pail, and which he itill feels in making Water 5 4. The a- cute Pain the Patient Jias felt for a Year in fitting down ; 5. The Blood which was at that Time obferved in the Urine, and could only be occafioned by the End of the Stone, that, forcing it's Way through the narrow Paflage it found at the Opening of the Ure- ter into the Bladder, has lacerated fome of the membranous Fibres in it's Paflage j 6, and laftly, By the Subftance which the Pa- tient feems to feel, placed as it were acrofs, and the Neceffity he is under to lie on the right Side to make Water 3 for that can on- ly happen from the Weight of the Contents of the Abdomen being pufhed by the Con- traftion of the Mufcles, and prefling on the Sides of the Ureter in the Place where the C 169] the Stone is lodged when he lies on his left Side. From all this we may conclude, there is a Stone fixed in the Ureter 3 therefore, without thinking of extracting it at prefent, as the Forceps cannot lay hold of it, we muft endeavour to keep the Paflage open till it can be taken hold of. Probably with the Ufe of emollient Injedions, frequently made into the Bladder, we may relax the Socket which retains it. If at any Time it fhould proje6l farther into the Bladder, it may be taken hold of and extraded. When fuch Symptoms as abovementioned occur^ or fimilar ones, we may always fufpedt there is a Stone lodged in fome Part of the Bladder, though we cannot feel it with the Sound when we fearch the Patient. ^e Surgeon's Account of the Sequel of the Disease. I know well that when the Point of a Stone can be felt, the Wound ought to be kept fufficiently open with a Canula, in Order to throw up Injedions, and remove the [ 17° ] thp Stone when it projects farther into the Bladder, But by Experience we learn, that thefe Sorts of Wounds more than o- thers, contra to remove the fmall Efcars as they are fepa- rated* The Tumour muft be touched a^ gain with the fame Caution, as often as it is neceffary, with two or three Days interval, till the Eyelid has recovered it's natural State ; it will then foon cicatrize. There will then be nothing more to do, than to deftroy the Root of the Excrefcence at the Corner of the Eye. Attempts have been made at other Times to deftroy it by the Lapis infernalis, and it would not have always grown again, could the Cauftic have penetrated to the Root. We muft therefore try a more efficacious Method : The two Eyelids being opened and fecurcd by an affiftant Surgeon, a long and thick fewing Needle, mounted and fixed in a Needle-holder, muft be heated red hot, in a lighted Wax Candle, and puftied boldly and ikilfully into the Middle O of C 19+ ] of the Excrefcence, about a third Part of an Inch deep, and be held there about half a Minute ; then withdrawing the Needle, the Eyelids are to be loofed ; the Burning will certainly make an imperceptible Efcar, and the Heat will be communicated from thence further than where it was touched by the Needle. It is not painful. In two or three Days a little Matter will be dif- charged, which will be loft in the Eyelids without being obferved. A few Days after the cauterizing muft be renewed, and per- haps it will be neceflary to repeat it three or four Times, at the fame Intervals of Time. I make no Doubt but this Method will fucceed in deftroying the Excrefcence to it's Root, as the Burning will extend beyond the Needle, and I think Nature will not produce a new Excrefcence, as the Patient is now regular in her Courfes. ^e Event. Hippocrates fays, that where the beft and moft approved of Medicines do not cure a chirurgical Diforder, it may be cured by a proper [ X95 ] proper Ufe of the Knife ; and that where that is not pradticable, although the Dif- cafe is curable by Surgery, the Ufe of Fire will cure it* By Fire I imagine he means every Thing that burns j that is, either cauftick or a red hot Iron. But it is not pollibie always to confine the Operation of the Cauftick, which by diflblving may fpread farther than was in- tended, though it is not fo with a Cautery. The Method I pradiced for this Difor- der (for the Patient came from Holland to me); this Practice I fay was founded on Hippocrates % Aphorifm, and verified it, for the Excrefcence never returned. For the more firmly eftablifhing the Cure of the Patient, I thought it necelfary to continue the conftant Difcharge by the If- fue, and likewife procure another Evacua- tion by the Ufe of aperient Bolufies. I therefore direded the Patient for fix Months to take every Morning a' Bolus made of fif- teen Grains of Mthiops Mmeraly oi Aqiii-^ la Alba and Diagridium each four Grains, mixed up with the compound Syrup of Succory, which kept the Body open. O 2 I made [ 196 ] I made the Patient continue at Paris for more than eight Months after the Excref- cence was deftroyed, to fee if it would re- turn again, as it had done aft;er the Ufe of the Lapis infemalis. Nothing appeared, nor even two Years after her Return into Holland^ from whence fhe came to Farts to get cured. • This Cure, effeded by the adual Cau- tery, may fuggeft Ideas of Cure in many Cafes, where the AppHcation of the folid Caufticks, which only operate as they dif- folve, are not fafe, or cannot be applied. A Jlight Running from the Penis. AY O U N G Man who had an Affair with a Woman of a fufpicious Cha- radcr, about a Week after found his Shirt marked with fome Drops of a greenifh co- loured Liquor, without any Smarting when he made Water.' This Running lafted for a Week, and then flopped of itfelf. In o- ther Refpe<3:s the young Man feems per- fedly [ 197 ] fedly well. What is your Opinion of this Running ? Answer. This is probably produced by impure Coition, and is a Gonorrhoea negledted 5 or an old Gonorrhoea ill cured, which has returned. It fignifies nothing that the Pa- tient, who believes himfelf cured becaufe the Running has flopped, fays it is only a Strain, froni exerting himfelf too much with the Woman he had Commerce with. I fhall not go from my Opinion j i . Be- caufe we never fee any Running happen to young married Men in Health, who do not fpare themfelves on the wedding Night; 2. Becaufe I have known a great many Perfons, to all Appearance cured of a Clap, who have had the Running return in a lit- tle Time, or elfe Chancres or other Signs of a Pox make their Appearance fome Months after ; I fay therefore that if the Running has been flight, it is becaufe the greateft Part of the Virus has paffed into the Blood, where fooner or later it will O 3 (hew [ 198 ] {hew itfelf, by fome charaderiftic Symp* torn of the Diftemper. As to the reft nothing can be done at prefent, for Half- Proofs are not fufficient to determine that a Man has the Pox s therq (hould be fome pofitive Symptom, or elfe feveral equivocal ones, to decide that it ex^ ifts. An Exostosis on the Humerus. AM A N eighteen Years old, who has never been ill, and feems to be in perfcd: Health, has an Exoftofis on the up^ per and back Part of the Humerus, three Fingers Breadth below the Neck, This Exoftofis, which is raifed an Inch above the Body of the Bone, makes a kind of Horn, having a broad Balis, and rifes to a blunt Point, The Bafis extends over more than half of the Circumference of the Bone. There is no Pain nor Inflammation, It is feven or eight Months fince the Pa- tient fjrft perceived it by Accident. He has [ 199 ] has never had any Commerce with Wo- men, and has always been a fober Man. His Father and Mother have always been and are now very healthy. How (hould this Exoftofis be treated, which is gradual- ly increafing ? Answer. From the Account of the Patient's Con- duft, there can be no Sufpicion of a vene* real Virus in his Blood, at leaft unlefs it comes from his Nurfe, But how comes it to be eighteen Years before it appeared ? There has never been any Sign that could caufe a Sufpicion of a fcorbutic or fcrophu- lous Habit, confequently v/e. muft look wp- on this Exoftofis as a local Diforder. The Texture of the Bones as well as the Flefli is liable to a local Obftrudion. If it is a fcorbutic or fcrophulous Habit beginning to (hew itfelf, till there appears a fufficient Number of charaderiftic Signs, I cannot propofe any Remedy 3 for it is very difficult and would be imprudent to determine how to acft, while we are igno- O 4 rant [ 200 ] rant of the Caufe. Suppofing that this lo- cal Difeafe fhould not give Way to any Thing that ihall hereafter be propofed (for at prefent I propofe nothing) it is it's Pro- grefs mull decide that. As long as thQ Difeafe continues, whether it grows bigger or not, it fhould be borne with Patience, if it does not hinder the Ufe of the Arm and Hand 5 for the Exoflofis cannot extend higher than the Head of the Humerus. If as it grows bigger it fliould obftrud the Ufe of the Arm, and the Patient's Life be in Danger, in Confequence of other Accidents proceeding from the Exoftofis, it will be abfolutely necelTary to ampu- tate the Arm at it's Articulation with the Scapula J but at prefent I think we fhould wait till the Difeafe determines what fhould be done. Perhaps it may be propofed to make a Wound now that fhall lay the Exoflofis bare, and to extirpate it with the Chizel and Mallet ; but I cannot agree to that Ad^ vice for this Reafon. Half of the Circum^ ference, and perhaps half the Thicknefs of the Bone, is included in the Bafis of the Exoftolis 3 i 201 ] Exoftofis ; and there muft be too great a Lofs of the Mufcles which cover it, if it is laid bare. On the other Hand, fuppofing this Wound unattended with Accidents, which is not probable, it will contrad: be- fore the Bone is exfohated. Befides an In- flammation might fucceed the Incifion, ex- tend to the Capfula of the Joint, and evea all over the Shoulder, which would make it impoflible to amputate at the Articulation. Inftead of which, if in Time the Exoftoiis fhould augment fo as to make it necefTary to perform the Amputation, the Succefs will be almoft certain. An Encysted Dropsy. AL A D Y, forty-two Years of Age, who never had her Menfes regu- larlyi has been for thefe three Years un- der a Courfe of Medicines, for that and va- rious other Diforders attributed to Obftrucf- tions in the Vifcera. Lately her Menfes have entirely left her, Since that Time her [ 202 ] her Belly has gradually grown bigger, and a Fluctuation of a confiderable Quantity of a Fluid is perceptible, froni whence it is concluded {he has the Dropfy. Upon be- ing fent for to tap her, and examining her Belly, we feel a Fluduation as we judge of about fifteen or fixteen Pints of Liquor. Neverthelefs the Navel is neither protruded nor funk in, as is ufual in an Afcites. After being informed of every Circum- flance that has happened antecedent to her prefent Situation, we f^nd {he has a good deal of Fever, her Urine is Brick-coloured and fmall in Quantity, {he has frequent Reachings, is much troubled with Wind, and very coftive (never having a Stool with- out the Exhibition of a Clyfter), and that fhe has Pains all over her Belly. What do you think of this Difeafe, and what is pro- per to be done ? Answer, The Diflempor without Doubt Is a Drop- fy, but whether it is an Afcites or an en- cyfled Dropfy cannot be decided yet. The Fluctuation, { 203 ] Fluduation, the fmall Quantity of Urine, and it's Quality, only prove that there is aa Effufion, and equally accompany an Afcites QX an encyfted Dropfy. But the Reachings, the Flatulencies, the Coftivenefs, the Ap- pearance of the Navel, and particularly the Pains all over the Abdomen, give Reafoa to believe that it is rather an encyfted Drop- iy, as thefe Symptoms do not ufually attend an Afcites. In this Uncertainty it will be proper to foUov^r the firfl apparent Indica- tion, and make the Pundure, which will relieve the Patient, and difcover the Nature of the extravafated Fluid. Second Consultation on the Progress of the Disease. Three Weeks ago the Pundure with the Trocar was made, and about twenty Pints of a thick muddy Liquor drawn off, mixed with a fmall Quantity of Blood. This Li- quor was fo foetid, as to be offenfive to the whole Houfe and Neighbourhood. From that Time the Urine has been better co- loured and more plentiful, the Vomitings lefs [ 204 ] lefs frequent, and the Pains more moderate though continual. As foon as the Liquor was evacuated, one could eafily diftinguifh a Tumour in the left iliac Region, of the Size of an Apple ; and as the Belly gradually grew bigger, one might eafily feel a Cyft which was fill- ing, and difcover it's Dimenfions, which could not be done before the Pundlure, be- caufe it then extended all over the Belly, even fo as to include the epigaftric Region. This Cyft is now as full as before the Punc- ture ; the Pains are returned as bad as ever, and the Vomitings ; the Urine is fmall in Quantity and Brick-coloured. What is there further to be done, as the Pun^ure has been of no Service ? Answer. This Difeafe is certainly an encyfted Dropfy, and the Infide of the Cyft being ulcerated, there is a Suppuration. The fimple Puncture therefore will not do for many Reafons. i. The Cyft, which filled again in three Weeks, will fill now in lefs Time, [ 20S ] Time, as is known by Experience, and will be full in a Fortnight or fooner. 2. The Infide of the Cyft being ulcerated, it can- not bear the Extenfion, which is the Caufe of the Pain the Patient complains of. 3. As the Infide of the Cyfl is ulcerated, it will be proper to drefs it with Injedtions, as we do all other deep Ulcers, which can- not be done through the fmall Orifice made by the Trocar. For thefe Reafons it will be neceffary to make an Incifion through the Skin, the Mufcles, and the Cyft, large enough to prevent it's clofing too foon. To do this efFed:ually, a Trocar with a Groove upon it's Canula muft be plunged into the Cyft, and immediately putting a fmall Stop- per into the Canula to prevent the Difcharge of the Water, introduce a blunt-pointed Biftory along the Groove into the Cyft, and make an Incifion through it and the Teguments large enough to admit the Fin- ger ; which being introduced into the Cyft will cover the Point of the Biftory, and guide it in lengthening the Incifion, which muft be at leaft three Fingers Breadth long, becaufe [ 206 ] becaufe as foon as the Fluid is evacuated, k will contra(5t to half it's Size. As foon as the Cyft is emptied, a leaden or a filver Canula, a little curved, and of a proper Length, fhould be introduced into the Wound as far as the Cyft, armed with a Plaifter to prevent it's being loft in the Cavity. The Pundlure preceding the Incilion, fhould be made at a proper Diftance from the fchirrhous Tumour which gave Rife to the Cyft, that is full three Fingers Breadth above it, and the Courfe of the Inciiion muft be from the Tumour. The Bottom of the Cyft afterwards will approach by De- crees towards the Tumour it arofe from, in the fame Manner as the Bottom of the Ma- trix does to the Neck after Delivery. Every Day there will difcharge through the Canula more or lefs of the fame kind of Fluid as came away at firft, according as the Sides of the Cyft draw near one ano- ther, and I do not doubt but in two or three Weeks the Matter will be of another Quality, T© [ 207 ] To affift Nature, two Injedions fhould be thrown up every Morning and Evening, conipofed of Bariey-Water and Honey of Rofes. The firft to cleanfe the Cyft, and confequently fhould be made fo as to be immediately evacuated. Part of the fecond fhould be left, which will eafily come away between the Time of Dreffing ; as foon as there is but a fmall Difchafge of Matter, the Injedions may be left off, and the Cyft will be daily obferved to contradl in Pro- portion to the Quantity of Injedtions made ufe of J but I doubt whether the Sides will adhere to one another, and the Wound en- tirely clofe. You may expedt therefore that it will become fiftulous, and that there will be a continual Difcharge of a few Drops of Matter. ^he Event. r A Patient whofe Cafe was the fame as the abovementioned, after the opening of the Cyft had as bad Symptoms as before, particularly Vomitings, and her Stomach was fo difordered, that for eighteen Days the [ 208 ] the only Thing fhe could retain was about feven or eight Ounces of Spanijh Wine* taken every Day at as many Times, which was her whole Nourifhment. During more than two Years fhe made ufe of a fmall Canula, through which there difcharged about a fmall Spoonful of white Matter every Day; but one Day having taken it out to clean, {he could not intro- duce it again, and the Fiftula clofed in a few Days. Of the many encyfted Drop- lies I have treated in this Manner, this Pa- tient is the only one in whom I have known the Fiftula clofe without opening again. In I759> I opened the Body of a Lady fifty Years old, who had been all her Life very irregular in her Menfes, and who died of feveral Diforders owing to that, of which they could give me no Account. I found two Cyfts filled with a thick bloody Fluid, and as foetid as that of the Patient mention- ed before. Might not thefe proceed from the fame Caufe, though differently fituated ? One was in the right iliac Region near the Ova- rium, conne(3:ed to feveral fchirrhous Tu- mours, [209] tnours, and contained about thirty Ounces of Liquor j the other adhered to the right Kidney, and contained eight Ounces. From this Account I conclude, that the encyfted Dropfy being different from the Afcites, the limple Pund;ure is not fuffici- ent, and it is neceflary to divide the Cyffc along with the Teguments, whenever the interior Part has fuppu rated. It is often only a palliative Cure, as I have feen 5 but by it I have prolonged the Life of feveral. The Perfon for whom this Confultation was held lived twenty Years afterwards. O- thers have died fooner, on Account of fe- veral fchirrhous Tumours, formed on the Menfes ceafing. In mofl of them I found a great deal of Blood and foetid Matter mix- ed with Water which filled the Cyft. Having opened feveral Women who died of this Diforder, who had no other Opera- tion performed than the fimple Pundture, I have found the Cyft filled in the like Manner with a good deal of Blood and gru- mous Matter. P ^Fis- [ 2IO ] yj^FisTULA in the Joint of fhe Great Toe, AM A N has for a long Time had a pretty confiderable Swelling in the Joint of his great Toe, fomewhat red and very little painful. About two Years ago it broke into a fmall Hole, which was pre- ceded by Inflammation and very acute Pain, and fince that Time there has been con- ftantly a fmall Difchafge of Matter. He has drefled it his own Way, and now de- lires your Advice, becaufe the Pain is con- tinual and hinders him from walking. On prefling the Sole of the Foot, between the metatarfal Bone that fuftains this Toe and the next to it, there difcharges a fmall Spoonful of purulent Matter of a bad Smell. The Swelling of the Joint prevents any Motion of the great Toe, which is not big- ger than it Hiould be j but the Top of the Foot is, and likewife oedematous the whole Length of the metatarfal Bone that fuftains it. What do you think of this Diforder ? And what ought to be done ? Answer, i 2" ] Answer. The Length of Time that this painful Swelling has continued, the Inflammation that has preceded the Opening which broke of itfelf, the Time lince that happened, and the Smell of the Matter which is difcharg- ed, altogether are a kind of Proof of the Difeafe being in the Jointj and there is Reafon to believ^e that the Capfula is at length corrupted, and that from thence if- fues the fanious Matter which difcharges through the fmall Hole in the Skin. The Swelling on the Top of the Foot, as well as the Impoffibility of moving the great Toe, flrengthens this Conjedlure -, and the Foetidnefs of the Matter which is difcharo;- ed gives Room to think, that after having rotted away the Capfula, it may have occa- fioned a Caries of the Ends of the two Bones where thev articulate with one ano- ther, that is the metatarfal Bone and the firfl: Phalanx of the Toe. Notwithflanding thefe Appearances, the Joint may perhaps be found, and the Opening may make it P 2 the [ 212 ] the ealler to difcover the State of the Dif- eafe. It fliould be enlarged by an Incifion made by Means of a hollow Probe, intro- duced as far as the metatarfal Bone where the Part is (Edematous. Perhaps the Bones may be found bare and carious, and in that Cafe it will be abfolutely neceflary to am- putate the great Toe at the Joint, fuppofing only the firft Phalanx to be difeafed j or elfe even to take off the half of the meta- tarfal Bone, if it's Extremity is likewife ca- rious. When the firft Incifions direcfted are properly made, if the Bone is found not bare, the ufual necefTary Dreffings will ef- fed the Cure. TToe Surgeon's Account of the Event. I found, on making the Incifion the whole Length of the Cavity of the Patient abovementioned, the Capfula of the Joint bare, but not penetrated 3 confequently the Bone was not bare, notwithftanding the Appearances which had deceived me j and the [ 213 3 the Patient preferving his Toe was cured in a reafonable Time. A Fistula in the Lower Jaw. AM A N within thefe eight Months has had a fiftulous Hole in the low- er Jaw, juft below the Dens Molaris next the Caninus, from whence there difcharges a fmall Quantity of Matter. A Probe in- troduced into the Fiftula is lofl in the Flelh, without difcovering the Bone to be bare. What is your Opinion ? And what is there to be done ? Answer. The Tooth above the Hole is certainly difeafed, that is to fay carious, changed in it's Colour, or has a more painful Senfation than the others when it is flruck, and the Jaw-Bone is injured in Confequence. The Tooth muft be drawn, and in a few Days the Fiftula will be clofed. Frequently if a ? 3 Tooth [214 ] Tooth is found, there is found at it*s Root when it is extraded a fmall Excrefcence, which adheres to it. If the Tooth is not drawn, the Fiftula will not clofe, and per- haps in Time the Jaw-Bone will be injured. If it is not a whole Tooth which has occa- fioned the Fiftula, it may be fome Frag- ment or Root which remains in the Socket after the Tooth has been broke in Pieces, or otherwife has not been perfedly extradl- ed. The flight Injury which the Jaw-Bone has received from the forming of the Ab- fcefs which has degenerated into a Fiftula, will be cured without any perceptible Ex- foliation, if the Teeth on that Side are found and firm in their Sockets. But though they are found, if they are loofe there is great Reafon to fear that the Dif- eafe in the Jaw-Bone has affe that they may have their right at Liberty. A Ga'ugrene from an internal Cause. AM A N feventy-two Years old, who is lufty and feemingly in good Health, within this Fortnight has perceived the fe- cond Toe of his right Foot to be fomewhat fwelled, and a little redder than the others, but not very painful. Within this Week he has perceived an Excoriation between this Toe and the third, which feems to be trifling. However [ 272 ] However being uneafy, he has made me look at it. I find the fmall Ulcer fome- what livid, and the Top of the Foot a little oedematous. The Patient has no Fever, nor does he want Appetite. For this laft Week I have dreiTed the fmall Ulcer with Storax, wrapping the whole Foot up with ComprelTes dipped in Aqua Vitse -, but this has not hindered the Ulcer from growing bigger. The Oedema likewife continues, and feems rather increafed. What do you think of it ? And what fliould I do ? Answer. From the Account you have given me I am ftrongly apprehenfive, that this Ulcer of your Patient, trifling as it appears-, is the Beginning of a Gangrene from an internal Caufe 5 the rather as it has continued a Fortnight, is very little painful, and inftead of growing cleaner and better by your Care, has gradually increafed, and the Oedema on the Top of the Foot is augmented. What makes me fay (o, is, that I have feen feveral of the fame Sort, or like it, few of which T 273 ] which. have been cured, the Ulcer fpread- ing and the Gangrene afcending by Degrees the whole Length of the Limb. In this Cafe it is necelTary, without neg- lecting the Care of the Ulcer, to endeavour 40 corred the Fault of the Juices, which has occafioned it, and will certainly increafe it every Day if not prevented. You ob- -iprye that the Patient has no Fever j I be- lieve it, but permit me to offer you one Refledtion : Every Man's Pulfe is not alike ; therefore one would wiih to be well ac- quainted with the Pulfes of the Patients when we firft fee them, becaufe fome are naturally flow, others very quick j fome have them very flrong, others very weak. Befides the different Alterations that happen in our Fluids are not always known by the Pulfe, and perhaps your Patient may be in this Cafe. This being confidered, I think ^we fhould here be direcfted by Experience. Others befides myfelf have feen, and I have obferved the conftant Ufe of the Bark and Antifcorbutics given four Times a Day, cor- real the Fault of the Fluids difpofed to gan- grene, and the gangrenous Ulcer incline to T heal [ 274 ] heal inftead of fpreading. Neverthelefs I have likewife remarked, that thefe Re- medies have been given unfuccefsfully, and the Gangrene has gradually advanced for fome Months till the Death of the Patient. At prefent vve are unacquaint- ed with more efficacious Remedies for a Gangrene proceeding from an internal Caufej I think therefore he ftiould have Recourfe to them without Delay. You muft continue to drefs it according to it's different Condition, and fuppofing that the Gangrene fhould fpread all over the Toe, and become black, nothing but it*s bad Smell fhould caufe it to be amputated, for that will not prevent the Gangrene from fpreading higher up. To thefe Methods of Treatment I will add one more by which I fucceeded, and which may probably be ufeful in the pre- fent Cafe. A Man forty Years old, was in the fame Situation as your Patient, with this Differ- ence only, that he was very thin. The five Toes fucceffively mortified and gan- grened in twelve or fifteen Days, notwith- flanding [ 275 ] landing he took the Bark with Antlicorbu- tics four Times a Day. The Top of the Foot was very oedematous, which obliged me to make a difagreeable Prognoftic. To aflift thefe Remedies, recal the Heat to the Limb, and re-animate it, I made the whole Leg every Day be fomented for a quarter of an Hour with a Decodion of vulnerary Herbs and Vine Wood-Afhes. The Gan- grene continued to afcend by Degrees and the whole Metatarfus was gangrened as well as the Toes 3 at laft in about three Weeks, I obferved in the Skin, above the Jundion of the five metatarfal Bones with thofe of the Tarfus, a fmall Line where the Suppuration was different from the Pu- trefadtion which fpread all over the Meta- tarfus. This Line became clean, and rea- ched all round the Foot. The Gangrene did not affed: the Tarfus, and in two Months the Metatarfus feparated entirely from the Tarfus. I drelTed the Ulcer ac- cording to Art, and the Patient was fix Months in curing. At length the Cica- trice formed in fuch Manner, that the Pa- T 2 tienS C 276 ] ticnt was able to walk on the Tarfus, which remained entirely whole. To the Attentions which I have propofed for the Patient who is the Subjedt of this Confultation, I think, it will be neceffary to add the above Fomentation, as it will help to re-animate the Fluids which conti- nue their Circulation in the Limb, but whofe progrefTive Motion may be daily growing weaker, by the Lofs of the Elafti- city of the Blood-Veffels. Jl Bandy Leg from the Crookedness of the Bones. AC H I L D of five or fix Years old, having the Tibia and Fibula crook- ed, the Leg being turned from within out- wards, and alfo from the fore Part back- ward, the Foot is diftorted. The Child was ricketty in it's Infancy, and it was hoped that the Deformity would grow off as it grew older j but it ftill continues, although there is no Swelling in any oi the other Joints^ [ '^ll ] Joints, and it is feared it will increafe. What ought to be done to prevent that, and to reftore the Leg to it's proper Form ? Answer. It is abfolutely neceflary that the Child fliould wear two fmall Boots made of plated Steel according to Art. I mention two, although there is only a Fault in one Leg, becaufe the Child walking awry, that is, drawing the left Leg along, and refting only on the well Leg, might turn the Spina Dorfi, as the Loins are weak. Each Boot ihould be furnidied with a fteel Sole fixed in the Shoe, with two Hinges, one on the left Side and tlije other on the right, to facilitate the Flexure of the Foot. There fhould likewife be two Hinges on the Sides of the Knee, and the Boot flioiild reach to the Middle of the Thig-h. The fteel Plates fliould be fo difpofed, as to lightly prefs on thofe Parts of the Bone that protrude, and ihould be properly quilted there, that they may not gall. Though the Inflrument-Makers underftand how to T 3 make [ 278 ] make them, yet it is proper that the Sur- geon fhould give Directions. As the Child grows, or as the Leg comes to it's Shape, other Boots mufl be made ; I have reco- vered many Legs by this Method. I have often made ufe in flight Diflor-. tions, of ftrong leather Boots laced before. Upon thefe Boots there were Sheaths to in- troduce Whalebone Bufks, which prefs up- on the Curvature j and as the Whalebone in a Day's Time would be bent, they were turned every Day. Thefe leather Boots may be of Service in flight Deformities and Diftortions, but they are of no Ufe in Dif- tortions of the Bone of long fl:anding. The Child muft wear the one or other both Night and Day, during two Months or thereabouts, and will foon be ufed to them. There can be no Inconvenience at^ tend them, if Care is taken to well line the Parts that prefs on the Curvature of the Bones. At the Expiration of that Time, it will be fufficient to wear them only in the Day, till the Bones are quite ftrait, ^Glano { 279 ] A Gland in the Brea^st, A LADY five and forty Years old, who has always been regular in her Menfes, for a long Time has been fubje(5t to violent Head-aches, which continue for two or three Days, attended with great Vomitings. Within thefe few Months her Menfes feem as if they were leaving her, for they come more irregularly, and fhe is fubjedt to Fioodings, which though but tri- fling, yet are neverthelefs frequent. Since this has happened her Head-ach has left her, and within thefe few Days fhe has felt a Kernel very deep in her left Breaft, which flie never perceived before. She is fenfible of only a flight Pain when it is touched ^ it has gradually increafed to near the Bignefs of a Chefnut, and there is no other Part fwelled. This Kernel is fi- tuated and feems to lie on the great pectoral Mufcle, a little on one Side of the Nipple, and is moveable. Your Advice is defired. T 4 Answer. 1 280 3 Answer. The critical Period of the Patient is pof- fibly the Caufe of the Swelling in her Breaft, as I have frequently known to happen. Perhaps it may be occafioned by the Hu- mours fettling there which caufed the Head- ach, as the Patient has not been lately troubled with it. Both Caufes require frequent Evacuations by bleeding alternately in the Arm or the Foot, on Account of the Kernel and the Flooding, and by purging to hinder the Humour from falling on the Glands of the Breaft, and by that Method prevent the Increafe of the Swelling. Warm bathing, a prudent Adminiftra- tion of Diflblvents, a moift and fweetning Diet, in fhort every Thing that will abate the Plethora, remove the Obftrudtions, and prevent the too great Acrimony of the Jui- tes, muft be made ufe of as foon as pofli- ble. No Remedy need be applied to the Breaft at prefent, except a Piece of Swan- fkin Flannel to keep the Part conftantly warm. [ 28l ] warm, as the Kernel lies very deep. If it grows larger and more painful, the differ- ent Circumftances will decide what ought to be done, for at prefent I would not pro- pofe any Operation. A Ganglion on the Hand. A YOUNG Lady about eighteen, very regular, has a Ganglion on the Joint of the Wrill, of the Caufe of which ihe is ignorant. It is above a Year fince it began to form, and it is grown half as large as a Walnut. It is fituated on the outer Part of the annu- lar Ligament, is not painful, and on one Side of it there is another fmaller, which feems to adhere to it. It is difagreeable to the Sight, and the Lady is defirous of be- ing cured. What is this Ganglion ? Can 31 be cured without leaving a Scar ? Answer, [ 282 ] Answer. The Ganglion Is a lymphatick Tumour formed by the Rupture of the lymphatick Veflels which nourifh the Tendons and A- poneurofes. This Liquor is difperfed be- tween them and the Membrane that covers them. This is exadly on the annular Li- gament, which is a kind of Aponeurofis. The fluid commonly found in thefe forts of Tumours is as tranfparent as Chryftal, and is rather thicker than Lymph; it is fomewhat like the unboiled White of an Egg, and is not fubje<5l to inflame. To cure a Ganglion, you muft wait till it is big and hard enough, that the Mem- brane that forms the kind of Cyfl: where the Liquor is inclofed may be grown thin by the Extenfion. Holding the Hand then bent, and fixing it fo as the Tumour may not flip, you muft; ftrike the Tumour one or two Strokes with a kind of Mallet, hard enough to break the Cyft and evacuate the Fluid. The Stroke (though given fmartly is not painful. Im- mediately [ 283 ] mediately preffing with the Thumb on the Place where the Stroke is given, that is where the Ganglion was, the Liquor muft be diiFufed all about by moving the Thumb to the right and left, and the Tumour will difperfe. A Comprefs, fuch as is ufed af- ter bleeding, but a little thicker, dipped in fait Water, and fqueezed out that it may the fooner harden, muft be then applied and kept on with feveral Turns of a Rol- ler 5 this Roller may be taken off in two Days. Very often a fmall Ganglion which is near the large one is not brote at the fame Time, becaufe it is not ftruck by the, Mallet J and it is not a proper Time yet to attempt it's Cure, as the Stroke may happen to light on fome neighbouring Part, where* as it would only fall on the Ganglion if ic was large. When the fmall one is grown big enough, it muft be cured like the for- mer. Sometimes it happens that the Cyft of the Ganglion fills again, and appears after it's being feemingly cured j in that Cafe it muft be treated in the fame Manner. But I have never known it fill a fecond Time. Bleedings [ 28+ ] Bleedings in the Mouth, AM A N five and twenty Years old, who is much troubled with the Scurvy, had the third of the Dentes Mola- res in the lower Jaw drawn j and in about two Hours after, finding the Socket conti- nued to bleed, he fent for the Tooth- drawer. To flop the Bleeding, the Tooth-drawer fearched for the Veflel at the Bottom of the Socket ; but doing it with a fharp Fleam, he unfortunately cut the Gum on the Side next the Tongue. He immediately flopped the whole with Lint and fmall ComprefTes, ill fuilained by the upper Teeth. The Pa- tient pafTed the Night in this Manner j but the ComprefTes being difplaced, he fpit a great deal of Blood and Saliva, fo that he is very much weakened, for it amounted to three or four Pints. When the Patient's Mouth was rinfed, the Blood was perceived to ifTue from two Places, On putting the Finger on the O- pening of the Artery which is next the Tongue, [ 285 ] Tongue, it eafily flops, but that cannot be always continued. What Method fhould be taken to flop thefe two Haemorrhages ? Answer. ■V- _ The Artery which fupplies a Tooth may be large enough to furnifli in Time a great Quantity of Blood, when a Tooth is ex- tracted. But this Hasmorrhage, together with the Lofs of a Quantity of Saliva; (for in this Cafe the Patient fwallows none, but is continually fpitting) ; this Lofs I fay muft weaken him, as the Saliva is' a falutary Se- cretion, which, according to the Order of Nature, is continually fwallowed, and pafTes again into the Blood ; it's Lofs therefore is very hurtful. Every Thing that will make an Efcar is not proper to flop the Blood from the Soc- ket of a Tooth, becaufe it cauterifes the Gum, and perhaps may the Socket, extend- ing much farther than the Artery. Where the Blood ilTues only from the Socket, the coagulated Blood mufl be clean- fed with a Probe and a Linen Tent, and then i 386 J then the Cavity muft be filled with Agarick of Oak ', or for Want of it with Lint, light- ly covered with Powder of Rock- Alum. To prevent the Blood from moiftening or difplacing it, it muft be kept on with fmall thick ComprelTes, to fill up the Space to the Surface of the Gum where the Tooth was J and the Teeth of the other Jaw pref- fing upon the ComprelTes for fome Hours, and flopping the Haemorrhage, the Patient will^no longer want to fpit. . But when, as in the prefent Cafe under Confultation, we have ftopt the Bleeding in the Socket in this Manner, the Compref- fion cannot be placed upon the Artery which is opened near the Tongue, and the Pref- fure of the Finger cannot be continued long enough for the Opening of the wounded Artery to contracft itfelf fufficiently to retain the Coagulum formed there ; for the Blood of fcorbutic People does not readily coagu- late. In this Cafe there muft be a little oblong bard Bolfter made to prefs upon both the Arteries together. This Bolfter muft be fixed to a Steel Crefcent made like a Chin- Cloth, [ 28; ] Cloth. This Crefcent miift be placed be- low the under Lip, embracing the Jaw, and faftened by two Straps of Leather which join to one another behind the Neck. When a fimilar Cafe happens to the up- per Jaw, the Crefcent muft be placed un- der the Nofe, upon the upper Lip, and fixed nearly in the fame Manner. The Machine muft remain long enough on the Place, for the Orifice in the Veflel to have Time to contract: itfelf. In a fcorbutic Per- fon it lliould remain a Fortnight or longer. If the Machine is well made, it will not hinder the Motion of the Jaw nor of the Tongue. In all other Cafes where an Ar- tery is opened in any Part of the Mouth, if there is a Difficulty in flopping the Blood, and you cannot apply cauterizing Styptics, the fame kind of Machine muft be ufed. The Event. As foon as the propofcd Bandage was put on, the Patient fpit no more Blood or Sali- va. It was not removed for a Fortnight, by which Time the Patient was cured. This [ 288 ] This Bandage, which ought not to confine the Motions of the Tongue, neither inter- rupts Speech nor Swallowing. The Patient was nourilhed with Spoon- Meat. T^he Piles. AM A N for more than a Year has had a Defcent of the Redum, that is, it's internal Coat is elongated and turned out- wards, making a round Subftance like a Collar two Inches thick. To this Subftance there are connedled fix fchirrhous Piles, each about the Size of a Grape. The Verge of the Anus is very wide, for which Reafon the Patient can replace them with Eafe i but for the fame Reafon the whole comes down eafily, which cannot be pre- vented. The Patient feels no Pain, but the Mafs daily increafing becomes very trouble- fome. Is it poffible to cure this Complaint radically, and what (hould be done to efied: it? Answer. [ 289 ] Answer. In the Account of this Diforder there are feveral Things which deferve a good deal of Attention. The iirft is the Mafs of fchirrhous Piles, which connected to the in- ner Coat of the Inteftine ealily comes out, as the Verge of the Anus is very much di- lated } and the Expuifion of the Fsces, if a little hard, neceffarily puflies them out. The fecond is, that this Mafs of Piles protruded, draw along with them and ex- tend the inner Coat of the Intefline, and confequently the cellular Membrane, which conned:s them to the mufcular Fibres which belong to thefe Parts. The third is the kind of Collar formed by the folding in of the inner Coat, which the Piles pufli before them when they come out ; hence this Subftance furrounds the piles in Form of a Ring. The firfl Thing to be done is to prepare the Patient for the Operation by a llender Diet for feveral Days, and a Purge or two, U that [29° ] that there may be no large Faeces in the in- teftinal Canal. The Piles muft then be cut off one by one at their Root j that is clofe to the inner Coat to which they are connected. Read in ray Treatife of Operations the Method of doing it. In cutting them off, great Care mufl be taken of the Collar, for it is Part of the In- teftine, which is forced out of .its natural Situation. The Piles will bleed but little, and pro- bably the Blood may only ooze, as they are fchirrhous 3 however it fhould be flopped, which may be done by a large Doffil tied, placed upon the Wound, and introduced into the Redum, by returning the Inteftine and Subftance along with it as far as poffi-r ble. This Doffil fhould be dipped in a weak flyptick Water, and fqueezed out. It will be neceffary to tie it that it may be drawn out and not loft in the Intefline. This ftyptick Water will make a flight Efcar where the Piles adhered, which will fall off in a few Days by the Help of Di- geftives, with which it fhould be dreffed every [ ^91 ] every Day, introducing a fmall Doffil into the Intefline* The Suppuration will dimi- ^nifh the Swelling of the inner Coat, which may have been more or lefs, from the Irri- tation it received before the Operation, when the Patient went to Stool. If the Collar does not quite return immediately after the Operation, it will in two or three Dreffings. When the Wounds have difcharged a Week by Help of the Digeftives, it will be fufficient to throw up vulnerary Injedions into the Redum Night and Morning. The inner Coat of the Rectum and the cellular Membrane, which the Piles have ftretched by drawing them out, will reco- ver their natural State by Pegrees. As the preternatural Extenlion was made by little and little, to affifi: Nature, which always endeavours to contrad our Fibres, when they are relaxed, we muft take Care that nothing obflruds it. The beil Method is to make the Patient remain in Bed three Weeks at leaft, for by this horizontal Situ-^ ation, the Intefline will not have it's own Weight to fupport, and the Circulation of the U 2 Fluids [ 292 ] Fluids will be affifted. This horizontal Si- tuation is fo much the more neceffary, as the Verge of the Anus (as before obferved) is very wide and open. The Patient {hould likewife live upon thin Food, that the Faeces may give as little Iiiitation and be difcharged with as little draining as poffible. Morning and Evening an aftringent De- cod;ion fhould be injedled into the Rectum, to contract the Coats of the Inteftine as much as poflible j thefe Injedions will like- wife help to thin the Faeces which may be in the PalTage. Where the Verge of the Anus does not defcend, as it does in this Cafe, the Ufe of Injedions beforementioned, and lying in an horizontal Pofture for three Weeks, are unneceffary 3 as the Redum has not been fubjedt to a preternatural Extenfion. I make no Doubt but if you obferve what I have diredled, the Patient will be fo per- fed:ly cured that the Rectum will never de- fcend as it does now. I fpeak from Expe- rience. The [ 293 ] The Piles. AM A N forty Years old, for a long Time has been troubled with the Piles, which have no periodical Flux of Blood as fome have, but bleed when he has a hard Stool, which excoriates fome of them. They always come down when he goes to Stool, and he is above an Hour be- fore he can put them up again. This In- conveniency, which is daily increafing, has occaiioned him to confult you. If you ex- amine him immediately after giving him a Clyfter to make them come dov/n, you will fee five Piles as large as Cherries, ad- hering by a pretty broad Bafis to the Cir- cumference of the Infide of the Redum, fixed to the inner Coat ; and fix others the Size of Grapes placed between them ; the whole forming a Mafs as big as a Pippin, furrounded with a Ring formed by the In- ner Coat of the Redum. In other Rei'peds the Patient is well, and only defires to be cured of this. What do you think of this U 3 Diforder ? [ 294 ] Diforder ? Is it curable by any Method ? And what is to be done ? Answer, This Diforder is of fo much the more Confequence, as it will every Day inqreafe if it is not cured 5 for when the Piles are protruded, the Verge of the Anus forms a kind of Ligature above them, which makes them fwell more, till they are returned a- gain. All Ointments, Liniments, and In- jedions, are of no Service, and they muft be cut off from their Bafis one after ano- ther. They might be tied, as I have fecn done, in which Cafe there is no Danger of an Hasmorrhage j but befides the exceffive and ' almofl infupportable Pain which the Ligatures occafion, it is poffible that the Inflammation extending up the whole Length of the Redum, may reach the o* ther Inteftines, and produce the fame Symptoms as attend the Strangulation of the Intelliine in a Hernia ; it is therefore better to cut them off one after another. For [ 295 ] For the Manner of doing it, read my Trea- tife of Operations printed in 1751. As moft certainly the Blood will fpring from the Artery that fupplies fome of them, a fmall Comprefs dipped in Rahel's Stvp- tick, and fqueezed out, muft therefore be applied to the Opening of the Arteiy^ and kept on with the Finger for half an H >ur without moving it. Upon thofe where the Blood only oozes, there may be put a pret- ty large Doffil of Lint, dipped in a ftyptick Water not fo ftrong as Rabel's^ and fqueez- ed out 5 and if it is poffible to return the whole together it muft be done, but moft commonly only a Part can be returned. In about half an Hour the whole muft be withdrawn, and only a Doffil tied, dipped in ftyptick Water and moderately fqueezed, introduced into the Rectum along with tlie Mafs which the inner Coat of the Inteftine forms about the Files. Notwithftanding thefe Precautions, he may lofe fome Blood, which may be dif- charged into the Redium ; and I have feen the Qu^antity of three Porringers of Blood evacuated by the Patient an Hour after, in U 4 Conie- [ 296 ] Confequence of Motions which have obli- ged him to go to Stool. In that Cafe the whole Dreffings will loofen and come away at the fame Time ; therefore another Dofiil tied and dipped in ftyptick Water muft be introduced. This will make a few Efcars on the inner Coat of the Inteftine, which will flop the Bleed- ing. At each Dreffing afterwards, a large Doffil tied, and fpread with Digeflive, muft be introduced a good Way up the Anus, to procure a Suppuration that may lefTen the Swelling of the inner Coat, which will fuf- fer a long Time from the Diftenfion occa- fioned by the coming down of the Piles. When the Difcharge is confiderably leffen- ed, there will be nothing neceffary but an Injedion to be thrown up three or four Times a Day. Bandy [ 297 ] Bandy Legs. AG I R L who was ricketty in her In- fancy has attained her twelfth Year; flie is no longer ricketty, and the Joints which were formerly fwelled have reco- vered their natural State, but the Bones of the Legs remain bent, one inwards and the other outwards. Upon feeling of them one may diftinguifh that their Subftance is flat- tened. The Thigh-Bones likewife partake a little of the fame Diforder, being both bent outwards j but the Body and Arms are well fhaped, and the Girl is in good Health. Can this Deformity which makes her lame be remedied ? Answer. The Weaknefs of Childrens Bones may make them bend under the Weight of the Body, and if there is no other Diforder but the Rickets, there may be Hopes that as the Child grows, the Diforder may be re- moved. When [ 298 } When the Child is no longer ricketty, if the Legs are crooked, one may hope to re- medy them by the Ufe of Boots ; but the Crookednefs of the Thigh-Bones cannot be remedied by this Method, and they muft be left to Nature, The Crookednefs of the Bones of the Leg being accompanied with a Flatnefs, makes it fo much more difficult to remedy, as the Point of Preffure made by the Boot will be on the Angle formed by the Bone, which will gall the foft Parts upon it very much : However as the Boot is the only Method to remedy the Bone, it mufl be ufed, obferving the neceflary Pre- caution to have the Place well quilted where the Point of PrelTure is. If the Bones continue flat, they may however be made flrait, and one muft lot»k upon the Flatnefs of the Bones as a con- firmed Rickets, and I never knew any of thofe Bones recover their natural ^Round- nefs. As this Cafe is of that fort, the mofl pro- per internal Remedies for redlifying the nu- tritive Juices mufl be adminiftered. I have known the Ufe of Antifcorbuticks fucceed with [ 299 ] with wearing of Boots. Are we to attri- bute thefe Cures to fuch Medicines ? Or to the continual Ufe of well contrived Boots ? Or to Nature ? Whenever it is thought proper to make ufe of Boots in thefe Cafes, they rnuft be worn in the Night as well as the Day. On Account of the Crookednefs of the Thigh- Bones of this Girl we are confulting about, I doubt whether fhe will be able to make ufe of Boots with any Benefit -, it is the Work of Nature. Coagulated Milk afier Lying-in. AW O M A N who has lain-in about ten or twelve Days, has the right Breaft inflamed -, the Milk runs from the other Breaft, and there is none comes from the difeafed one. She is not a Nurfe, and has made ufe of the common Methods for drying up the Milk. Since the Inflammation of the Breafl, they have applied emollient Cataplafms to it 5 [ 300 ] it ; two Fingers breadth on one Side of the Nipple, there feems to be a Fluduation, the Patient feels a great deal of Pain, and is very feverifh. It is required of you to know how this Tumour, which in all Pro- bability is coming to Suppuration, is to be treated ? To dired: how it fhould be open- ed if it becomes neceflary ? When to do it ? And how to drefs it ? Answer. You muft continue the Ufe of the Cata- plafms till the Matter is formed -, for it is pretty certain it will. Maturatives feem to be indicated, but there is Heat enough in the Part without increafing it, and emollient Cataplafms will do. The Abfcefs muft not be opened till the Matter is formed, and the Skin fo thin as to be ready to break j and the Incifion muft extend no farther than where the Skin is elevated by the Matter. It is poffible and even common enough for Matter to be felt in two Cavities on each Side of the Nipple, communicating with one another by fome Sinus. [ 30I ] Sinus. It will then be necefiary, If the Skin is thin in both Places, to make ano- ther Opening, that the Matter may be free- ly difcharged.. It will be proper to continue the Ufe of the Cataplafms over the Dreffings, which fhould be as eafy as poffible, and not cram- med in J for Lint in fuch Sores is an extra- neous Body, and of no Ufe but to apply the Medicines. The Difcharge may be very great 3 for fometimes we fee the whole Breaft loaded with Milk mixed with Matter, therefore light Dreffings afford it a freer Difcharge. When the Inflammation is gone off, the Cataplafms may be omitted, and the Patient purged feveral Times, to turn the Courfe of the Milk and evacuate it as much as pof- fible. One may indeed affirm that the Wound wjll not heal till the Milk ceafes coming to the Breafts, for which Reafon it may be a long Time curing, perhaps not till the Menfes become quite regular. For the future Dreffings I do not mention any Thing, they muft be determined by the State of the Ulcer. The [ 302 ] T^he Ligament of the Patella divided, MAN walking along, received a Wound of a Sabre, which divided the Ligament of the I atella, and he fell down, without being able to get up again. Are there any Hopes of it's re- uniting ? And how is it to be cured ? Answer. The Ligaments being nearly of the fame Texture with the Tendons, one may like- wife hope they will unite in the fame Man- ner ; and this Wound ilill bleeding, v^e mufl endeavour to procure the Re-union as foon as poffible. To put Nature in a Way of doing this, (for the Union muil be performed by her) the Leg mufl be extended as much as pof- fible, to bring the Part of the Ligament conneded to the Tibia as near as poffible to the Patella ; then bring the Patella, which is drawn upwards by the extenfor Mufcles, near that, and keep them toge- ther ^ [ 3^3 ] ther by the fame kind of Bandage diredled to be ufed in tranfverfe Fradures of the Pa- tella. To this jGiiould be added two Junks, to prevent the Leg from being bent by any Means whatever. In putting on the Ban- dage it muft be placed fo that the Wound may be uncovered, that we may every Day fee what is going on. The Suture of the Ligament in this Cafe is ufelefs, as the Pofition of the Limb and the Bandage are fufficient to keep the two Ends of the Ligament near enough to touch one another. It would even be prejudicial, on Account of the Inflammation it would occafion. But the dry Suture will, be of great Service in uniting the Skin and pre- ferving the nutritive Juices, which fhould agglutinate the Lips of the Wound quite to the "Bottom, in their proper State. Suppofing the Wound to be united> the Bandage and Junks muil be kept on for two Months longer, that the Cicatrice of the Ligament may become fo firm as it may not feparate the firfl Time the Limb is extended j for this Ligament alone is to counterballance by it's Strength that of the four [ 304 ] four external Mufcles of the Leg, which are very ftrong ; and the whole Weight of the Body, which always tends to bending the Leg. I imagine it needlefs to mention Bleed- ing, and fuch a Diet as is always cuftoma- ry in the Treatment of all Wounds, and which mufl be regulated as Circumftances require. An Encysted Tumour on the Knee. AY O U N G Woman twenty Years old, has had for feveral Years a Tu- mour on her Knee, which at the Beginning was very fmall, but is increafed to be half as big as an Orange. It is fituated on the Ligament of the Patella, fixed and indolent, having a large Balis. It is no other Incon- veniency than preventing her from kneel- ing, and giving her Apprehenfions of it's growing bigger. There is a Motion of a thick Fluid felt in it, it may therefore be looked upon as a Meliceris. What Prog- noflick [ 305 3 hoftick can we form of it ? And what fliould be done to cure it ? Answer. As the Tumour is indolent and without any Rednefs of the Skin, the Fluid in the Cyft does not ferment, and therefore the Tumour is not likely to fuppuratej and we may hope to cure it without an Operation. It muft be covered all over with a Plaifter a little larger than the Tumour, made of equal Parts of Diapalma and CerufTa, mix- ed together and fpread pretty thick upon Leather. This muft be kept on with a Roller about four Ells long and four Fin- gers Breadth, with which the Knee muft be rolled pretty tight, to comprefs it to a certain Degree^ As this will be very troublefome to the Ham and the Tendons of the Flexor Muf- cles of the Leg, there muft be fome Wool quilted in Linen applied to the Ham. It will be kept on by the Turns of the Roller, and may be faftened with a Needle and Thread that it may not be difplaced. A X Pafteboard [306] Paftcboard may be put on with this quilted Comprefs to prevent the Bending of the Leg J by this Method the Patient may walk with her Leg extended the whole Time of the Cure, the Plaifter fhould be changed every Week, and the fame Ban- dages replaced. I have cured a great many Tumours of this fort in this manner in a Month or thereaboats. Mofl likely the Fluid that was gradually colle(5led by Degrees, has re- turned into the Courfe of the Circulation, and the Sides of the Cyft adhered to one another. It will be right to purge the Patient two or three Times during the Courfe of the Treatment 5 I have known feveral Tumours of this kind on the Head not very large, that have been cured by nothing elfe but a Compreflion made for fome Time with a Plate of Lead kept on by a Cap. When this kind of Tumour becomes painful, it is owing probably to the Fer- mentation of the Fluid within it, or an In- flammation of the Cyft, which may poffi- bly terminate in a Suppuration. In that ^ Cafe [ 30? ] Cafe a Cure is not to be expe(Sed the fame Way, as abovementioned. A Carcinomatous Tumour on the Knee* AM A N has had for feveral Years a Tumour above half as large as an Orange upon his Knee, and about a Month ago it became painful. A few Days after it broke, and two or three Times has dif- charged a good deal of Blood. There are now feveral Places in it of a lively Red, fome of a Purple, as if difpofed to Gan- grene, and others of a very deep Red. A flefhy Excrefcence, hard, and about the Size of a fmall Nut, comes out of the Hole 5 and in the Cyft which has cmptyed itfelf, there are felt through the Skin feve- ral little Tumours feparate from one ano- ther. The Skin that covers them is flabby, and almofl without feeling. How fhould this Tumour be treated ? And if you think an Operation neceffary. How fhould it be performed ? X 2 Answer. [ 3o8 ] Answer. The Cyft of this Tumour is difeafed, as there are fungous Excrefcences rifing from it, and the different Colours of the Skin fhew that a Gangrene is farther advanced in fome Places than in others j this Gangrene is the Confequence of the Inflammation which is come on, therefore it cannot be cured but by an Operation, which muft not be deferred. A crucial Incilion muft be made in the Skin and the Cyft, and the Corners of them cut off. The reft of the Cyft, which ad- heres to the Aponeurofis of the extenfor Mufcles of the Leg, covers the Patella and it's Ligament, muft be exadtly, dexteroufly, and deliberately diffecfled out. As it is up- on this that the Cyft is formed, and from thence that the Excrefcences fpring, if it was left it might prevent the Cure, confe- quently the Excrefcences will be taken a- way with their Roots. If any fmall Root fhould efcape the Knife, it will be feen at the firft or fecond Dreffing, and muft be entirely [ 3^9 ] entirely deftroyed with the mercurial Wa- ter. It will then become a fimple Wound, which may be cured by the ufual Dreffings. An Inflammation muft be prevented by Bleeding, Diet, emollient Cataplafms over the Dreffings, and other Remedies adapted to Circumftances and Symptoms that may arifc. ^ Encysted Tumour on the Head. AL A D Y between forty and fifty Years of Age, had an encyfted Tu- mour about five Inches in Diameter at the Bottom of the fagittal Suture, which reach- ed over the Lambdoid. A Monk who called himfelf a Surgeon, divided the Tu- mour acrofs it's Diameter, and emptied the Cyft ; then filled it with Lint, and dreffed the Patient for two Months. At length the Lady, tired with fuffering and not be- ing cured, difmified him, and confults you what is proper to be done. There is an X.3 Ulcer [ 3IO ] Ulcer four Inches long and an Inch broad, furrounded with two Lips, each an Inch and an half thick, in the Shape of a Sau- fage, painful and very hard, ulcerated the whole Length of the Side next to one ano- ther, and threatning to become cancerous. What can this Tumour adhere to ? How fhould it be treated ? And what fhould be done to it in it's prefent Condition ? Answer. This Tumour takes it*s Rife from, an4 is formed on the aponeurotic Expanfion made by the Jundion of the frontal and occipital Mufcles, In Proportion as it in^ creafed, the Skin over it extended and yield- ed gradually to the Quantity of Fluid col- leded in the Cyfl, and when the cellular Membrane between the Skin and the Cyft was wafted, the Skin adhered to the Cyft. Several Things have been negled:ed in this Operation. He fhould have entirely extirpated the Tumour, and not have been fatisfied with dividing it only. He ought beiides to have preferv^d fome of the Skiii if C 3X1 3 if poflible, to have covered Part of the Wound. As it is almoft impoffible in ope- rating to extirpate the v^hole Cyfl, and that there always remains fome fmall Part adhe- rent to the Aponeurofis, he ought to have deflroyed that with fome Cauftick, as the mercurial Water. What Skin ou^ht to have been left, would forward the Cure, by having a fmaller Cicatrice to form. The prefent State of the Patient requires another Operation ; the two Lips muft be taken oft to make it an even Wound, pre- ferving as much Skin as poflible. This will make a fmooth Ulcer, which 'mufl be drefled according to different Times and Circumflances. As this Ulcer will be of a long oval Figure, it will be practicable and of Ufe to bring the Sides towards one ano- ther, with Slips of flicking Plaifter, in the Manner of the dry Suture j but this muft not be till the Bottom of the Ulcer is de- terged, for that which digefled after the firfl Operation, is at prefent a foul Ulcer, and requires a good deal of Skill to deterge it. The dry Sutures will be fo much the more ufeful, as the Mufcles here are cuta- X 4 neous. C 312 ] lieous, and will follow the Motion of the Skin, which will fhorten the Cure. WpNs, or Fleshy Tumours. M A N has a Wen upon the Mufcu- lus Gluteus, fix or feven Inches in Diameter, which appears outwardly of ^ globular Form ; it is not painful, but in- convenient from it's Weight, and trouble- fome to the Patient in fitting. Therefore he defires to be cured. Another has on the Middle of his Back a Wen confifling of Fat, and Glands of fuch a Size, that it feems to be larger than a Mafs of Fiefh of twenty or thirty Pounds Weight. It is pendulous, and it's Weight has flretched the Skin in fuch a Manner, that it's Bafis is not above half the Diame- ter of it's Body : The Subflance that forms the Bafis feems to be of the fame Nature as that which forms the Body of the Wen, for they are both full of Inequalities and tumefied Glands. trhe t 313 ] The Body of this Wen is about four Feeg in Circumference, and it's Bafis more than two, Are thefe Wens curable by any O- peration ? Should they be treated in a diffe- rent Manner ? And how fliould they b^ treated ? Answer. I have known Mountebanks undertake the Cure of fuch Diforders, by deftroying the Tumour with Caufticks. They may- have cured fome fmall ones, but a melan- choly Experience has more than once (hewn the Danger of fuch Pradice, for, by the Ufe of Caufticks, they are frequently known to become of a cancerous Nature, the In- flammation to extend along the Skin far be- yond the Bafis of the Tumour, and deftroy the Patients, having put them into fuch a State as not to admit of an Operation to be performed. Befides, the Pain which the Cauftick gives, and muft be often repeated, becomes infupportable and vitiates the Flu- ids. Extirpation by the Knife then is the moft proper, becaufe it is lel5 painful ; the Pain [ 314- J Pain continues but a fhort Time, and the Succefs is more certain. The Operation of thefe two Wens mufl be different, for in that on the Butiock a good Part of the Skin that covers it may be faved, which is not practicable with that on the Back. In regard to that on the Buttock, a cru- cial Incifion muft be made the whole Ex- tent of the Tumour, dividing the Skin and the' Membrana Adipofa as far as the Out- fide of the Cyft ; the four Flaps will then be ealily feparated by the Fingers to the Bottom of the Tumour, afterwards the Cyf> muft be feparated from the Parts it adheres to, a good Part of it may be fepa- rated by the Fingers alone, and what ad- heres too flrongly may be done by the Knife, after which the whole Wen com- prehending the Cyft may be extirpated, by dividing it from every Part it is connected to. The four Flaps will then be too large in Proportion to what they are to cover, a Part therefore muft be cut off, and the Re- mainder applied to the Wound, becaufe Part of the Skin will be agglutinated before the [315 ] the firfl Dreffing is removed, and the reft will gradually unite during the Suppura- tion ; thus by leaving of the Flaps we fave Nature three Parts of her Work, and the Cicatrice is much fooner formed. The Dreffings require nothing particular. The fame Method cannot be taken to cure the Wen on the Back, which muft be cut entirely away at it's Bafis, and as clofe to the Spine as poffible, without endeavour- ing to fave the Skin as in the other. 7'be Surgeon'^ Letter. The laft-mentioned Wen being extirpat- ed as you diredted, weighed thirty Pounds, and left a circular Wound about eight Inches in Diameter, which was cured in fix Weeks by very fimple Dreffings. I fhall now relate to you what I did to expe- dite the Cure of this Wound, which other- wife might perhaps have been three or four Months in curing. I imagine the fame Method may be pradtifed in all Wounds that are round and v^ry large. When [ 3i6 ] When the firft Dreiling was removed, I brought the Lips of the two Sides of the Wound a little towards one another, and kept them fo by Means of Slips of flicking Plaifter, which flicking to the Skin by their Extremities on the two Sides of the Woupd, palTed over the Pledgets fpread with Medi- cines, covered them, and alfo kept them on. At each Dreffing I placed five or fix of thefe Slips of Plaifler, which were nar- row in the Middle, long, and pretty broad at the Ends, to take more hold of the Skin and keep it the better together. By this Method I brought the Wound, which was round at firfl, to be oblong, then long and narrower, and in lefs than a Fortnight it was not more than three Inches wide, to feven in length. In the mean Time, as the Lips grew nearer, the Cica- trice at the Extremities advanced, and the whole was cured in lefs than {even Weeks, I mufl mention here one remarkable and fingular Circumflance which related to this Patient, and which will not do but upon very few Occafions, The [ 3^7 ] The Patient was an old Toper ; I thought it proper according to the regular Method, to confine him to Broths from the firft Day after the Operation. But the next Day but one he became terribly weak, and I was obliged to fupport him with Wine, of which he drank three Bottles every Day, and eat nothing but Bread, ufing no other Drink the Remainder of his Cure. I am fenfible this is not a Method to be followed with every Patient. TJ&^NOSE CUT. AM A N received a Stroke of a Sabre, which cut his Nofe in fuch a Man- ner, that it hangs only by the lower Part of the Bridge and by the Corner of one of the Noftrils. Are there any Hopes of it*s Re-union ? And fuppofing it is thought proper to attempt it. What is the Method that fliould be taken to efFed it ? Answer; [3i8] Answer. There is no Part whatever that is recent-* ly divided by a cutting Inftrument, but if there is any Adhefion to the whole, the Re-union may be attempted, by bringing the Lips of the Wound exaftly together, and keeping them fo, by the dry Suture, by the Suture with a Needle and Thread, or by Bandage. I give the Preference here to the Suture with the Needle and Thread, becaufe the dry Suture is not fo ufefui and efficacious where the Surface is not every where plain and even 5 but it may however be made ufe of here to favour fome of the Stitches of the Suture made with the Nee- dle. The Bones of the Nofe and it's Bridge may be difplaced, which fhould be imme- diately examined into with Attention 5 and if fo they muft be replaced, either by intro- ducing the little Finger up the Noftril, or a Small Stick covered with Linen ; and kept fo for about a Week by a Quill likewife co- vered with Linen, which will give a free FafTage [ 319 ] PafTage to breathe through, and difcharge any Humidities. This being properly done, the neceflary Stitches may be made. In a few Days the Quills may be removed, be- caufe the Bones being united will not be difplaced again. The other neceffai v At- tentions have nothing particular from what is to be obferved in all other Sutures. The Places where the Stitches are made may be fuftained by the dry Suture, if they can be of any Ufe any where. I have known the Nofe unite again exadtly, though it has been held by as little as abovementioned. When the Part is cured, he muft be very careful for fome Time in wiping his Nofe, left he fhould break the Ligature. ^he Nail gt'owing into the Flesh. AM A N who takes Pains in cutting his Toe-Nails, and particularly the Corners, for two Years has had the fol- lowing Complaint : The Flefh on the out- fide of the great Toe clofe to the Nail is fwelled, [ 320 ] fweiled, making a fungous Tumour about a Quarter of an Inch higher than the natu- ral Surface, which covers nearly half of the Nail. From under it there is a Difcharge of a fanious Matter 3 the whole Toe is fweiled and hard, efpecially the firft Pha- lanx; and there is a continual Pain that extends to the Metatarfus, which is oede- matous. How Ihould this Complaint be treated ? Answer. The whole Tumour formed on the Nail by the fweiled and indurated Flefh muft be cut ofF, and then you will find Part of the Nail grown into the Flefli on the Side of it. This Side of the Nail is partly feparated from every Thing, neither adhering to the Flefh under it nor that which covers it 5 confequently it is a foreign Body which muft be taken away, becaufe it will inter- rupt the Cure. The Point of a Pair of Sciflars therefore muft be dexterouily introduced under the Piece of Nail which is feparated from the Flefh, [ 321 ] Flelh) not to cut it acrofs, but lengthways, advancing gradually to the Root and far- ther in one or more Days. If after having^ divided in this Manner all the Piece of Nail which is feparated from the Fle(h, you were to cut it acrofs, there would always be a Gorner remaining j therefore it is ne- ceflary always after cutting the Piece of Nail as far as the Skin, to lift it up, to take faft hold of it with the Forceps, and extract it by tearing it away as one may fay by the Root, To do this well, it {5iould be turn- ed back and lifted up in tearing it oat. A Piece of fcraped Lint fhouid then be put under the reft of the Nail, and dry Lint will be fufficient for the iirft Drefiing on the reft of the Wound. The Dreffings af- terwards when the feparated Piece of Nail is taken quite away, are very (impie, and the Wound will heal in a few Days with common Deficcatives, as dry Lint, and fometimes a litde burnt Alum to prevent fungous Flefh. It will be neceflary till the Wound is cured, and alfo afterwards, to in- troduce a Piece of dry Lint between the ,Nail and the Flefh, which will ferve to Y defend [ 322 ] defend the Flclh from being hurt by the Nail that remains. Sometimes we may defer cutting off the Flefh that covers the Piece of Nail that pricks it, for a Day or two ; but as it is ab- folutely neceflary that it fhould be cut away in the Manner I have mentioned ; to come ^t it the eafier it will be proper to gently in- troduce in that Time a Piece of fcraped Lint between the Fleih and the Nail you want to cut away, and alfo under it. It is painful, and therefore muft be done with Care and by Degrees. To prevent this kind of Complaint, the Corners of the Nails fhould never be cut, elpecially thofe of the great Toe, becaufe it grows fafter at the Place where it is cut than any where elfe ; becaufe it is very dif- ficult not to leave a Corner, and becaufe either the Shoe, or the Toe next it, al- ways preffes the Fleih againft the Corner. It fhould therefore be permitted to grow out a little, cutting the Nail fquare. If by Accident the Nail hurts the Flefh, it will be proper to put a little fcraped Lint under the [ 3^3 ] the Corner of it, which being foft, will preferve the Fieih from being wounded or hurt. ^ Pessary kff in the Vagina. ABOUT eight Months ago a young Woman who lives in the Country, after lying in,, had a Prolapfus Uteri, for which a Peffary was introduced that is ve- ry troublefjme to her. She has a great deal of Uneafinefs in walking, and alfo in fitting, and is defirous of being relieved. Upon introducing the Finger into the Vagina, there is felt fomething like a Bowl, which feems to be above four Fingers breadth in Diameter, but the Thicknefs cannot be certainly known on Account of the Difficulty of introducing the Finger be- tween it and the Side of the Vagina. The Woman who attended her and faw this PeiTary before it was introduced, fays it was about the Size of a Tennis-Bali, made of two large Buttons of Cork, joined Y a End [ 32+ ] End to End, and covered with Wax. En- deavours have been ufed to extradl this Pef- fary, which was introduced with a good deal of DifHcuhy, when fhe had not been delivered above fix Weeks, the Entrance of the Vagina being contraded. This Pef- fary has no Hole in the Middle, as is ufual, according to the Nurfe*s Account. What Method muft be taken to extract it ? Answer. The Peffaries are generally made in the Shape of a round or oval Ring, about half an Inch thick, of Cork, on Account of it*s Lightnefs, and covered with Wax. The Figure of this not allowing of it's be- ing taken hold of like thofe that are open in the Middle, you muft endeavour to break it with proper Forceps, without which you will not be able to extrad: it, on Account of it's Size 5 then you may take out the Pieces, as I have done upon the like Occa- fion. The C 325 ] ^he SuRGEON'i Letter. According to your Advice, I made ufe of the Forceps for extra<5ting the Stone out of the urinary Bladder. The Wax being foftened by the Heat, gave Way to the Forceps, therefore I could extract but very little at a Time ; and extracting it by fuch fmall Pieces, I vi^as about it three Days fuc- ceffively. As this could not be done vi-'ith- out giving Uneafinefs to the Vagina, the Entrance of which was much narrower than the Bottom, I thought it proper to let the Parts lie quiet after fome Attempts, and afterwards to bathe them feveral Times a Day with Wine. The Matrix has nevqr defcended fince, and the Woman has had no Children lince the Extraction of the Peffary. Y3 An [ 326 ] An imperfedi Phymosis. AM A N fifty Years old, has had no Commerce with any Woman but his Wife for thefe thirty Years that he has been married. He never received any In- jury from her, and for fome Time paft has feldom had any Commerce with her ; but the Condition he is in at prefent gives him Caufe to fufpedt her, becaufe he feels a Sorenefs upon the Glans, and a purulent ferous Humour difcharges from under th« Preplice. He could before uncover the Glans when he had a Mind to do it, but cannot at pre- fent, and has a kind of Phimofis. In this Situation he confults you. What do you think of it ? And what ought to be done ? An s we r. It is very poffible that this Patient has cither a Gonorrhoea or Chancres ; but it is alfo poflible that he may not have them notwith- [ 327 ] notwithftanding Appearances. It is eafy to difcover if it is a Gonorrhcea, for the Phi- molis being imperfe(^, the Orifice of the Glans may be eafily feen, and you may ex- amine whether the Matter ifTues from the Urethra, by preffing along the Canal. If it is fo, proper Remedies mufl be given for it ', but you muft likewife cleanfe the Infidc of the Prepuce, by making Injedlions be- tween it and the Glans, to remove the Matter that lodges there, and caufes the In- flammation of that and the Glans. If there are Chancres between them, they may be eafily felt through the Prepuce by the Hardnefs which always accompanies them. They may be behind the Corona, or upon the Glans ; and in that Cafe there will be a Neceffity to divide the Prepuce as far as the Corona, that it may be drefled at the fame Time that proper Medicines are adminif- tered. • But the Misfortune this Patient complains of may proceed from a more innocent Caufe, as he has not known any other Woman but his Wife, who is a fober and healthy Wo- man. Y 4 There [328] There is upon the Corona Glandis a great many febaceous Glands, from \Vhich is fecreted a mucous Liquor in very fmall Quantities. If Care is not taken to wafh the Part, this Liquor will fometimes thick- en to a kind of Greafe, and it is poffible, that, by being heated or fretted, the Parts may be fo irritated as to produce an Inflam- mation ; the Glans will then fwell, the Prepuce will contradt, and a Phymofis en- fue. If the Patient the Confultation is held on, has neither Gonorrhoea nor Chancre, moft probably it is that which occafioned the Complaint, To relieve it, it will be fufficient to wafh it with Wine and Water, or fome deficca- tive Liquor, fuch as Plantane- Water, with a little Saccharum Saturni dilTolved in it, throv/n up with a fmall Syringe between the Prepuce and the Glans, and it will foon be well. The Caufe being removed, che Effeft will ceafe, and the Glans may be uncovered. It will be proper to advife the Patient to wafh the Parts often, to prevent a Return [ 329 3 a Return of the Diforder, which might otherwife happen from the fame Caufe. I have feen it more than once miftaken for a venereal Complaint, and treated as fuch very improperly. A Wound on the Muscle Thenar. A MAN has juft cut himfelf almoft acrofs the whole Mufcle Thenar, the Wound having penetrated nearly to the Bone. The Blood fprings from two Arte- ries, one at the Bottom of the Wound, and the other in the Membrana Adipofa. What fhould be done to this Wound ? Or how ihould it be drefled ? Answer. Although the Blood fprings from two Arteries, this Wound is in the Circum- flance of being fpeedily united by the Su- ture with a Needle and Thread, which is neceffary on Account of the Diredion of the C 330 3 the Wound, and as a Bandage is not fuHi- cient to keep the Lips of the Wound ex- adly together. It is true there are two Arteries opened, which without Doubt arc two Branches of the radial Artery. But we Jcnow that the Finger only, prelTed gently on the Opening of a divided Artery, is fuf- ficient to flop the Bleeding. Therefore the Jundion of the Lips of the Wound will be fufficient to flop the Blood from thefe two fmall Arteries ; and the Lips being clofe to one another, will have the fame EfFe(5l as the Finger prelTed on them. You muft begin by applying the Turni- quet to the Wrift, that the Blood from the radial Artery may not interrupt you in your Work, and that none may remain in the Bottom of the Wound after it is fcwed up. Afterwards the Wound muft be wafhed with warm Wine, to cleanfe away the Clots that are there, and the Blood being flopped, you muft make two Stitches of the interrupted Suture -, when that is made the Turniquet fliould be removed, and a fmall thick Comprefs applied upon the radial Ar- tery near the Wrift, fuftained by three or four [ 331 ] four Turns of a Roller moderately tight, in order to retrain in fome Meafure the Paf- fage of the Blood. You may add to the interrupted Stitches fome dry Sutures to ftrengthen their Hold, and the Thumb muft be bent and fixed fo, as to be kept ftill, in order to haften the Cure. If the Wound was made in fuch a Di- redion, that the bending of the Thumb would bring the Lips exadlly together, I fhould not propofe any Suture. By thefe prefcribed Attentions, I have known a Wound of this kind cured in four Days, notwithftanding the two Arteries were opened, which by this Method did not bleed any more. yf Suppression ^ Urine. AM A N of five and forty, of a ftrong Conftitution, who has never run the Rifque of any venereal Diforder, ob- ferved about four Years ago, that he made • Water [ 332 ] Water with fome Difficulty, and that the Stream of Urine was much fmaller than ufual. This Complaint has gradually in- creafed, and at length he confults you, be- caufe in making Water he feels very great Pain, and for thefe five or fix Days has not made any but by Drops. To find out the Caufe of the Diforder, a Sound has been introduced into the Ure- thra, and pafTed as far as the Proftate or the Neck of the Bladder, but could not be paffcd into the Bladder. Endeavours have been likewife ufed to introduce pretty llifF Bougies, and fome very fmall j but they all flopped at the fame Place as the Sound, and could not be got any farther. The Patient has been bled three Times at fome Hours Diflance, but notwithfland- ing cannot make Water. The Bladder is growing fuller, and it may already be felt prominent above the Os Pubis. He feels great Pain in his Loins, and the Fever is much increafed. It does not appear to be an Inflammation lately come on, as it is above four Years lince the beginning of the Complaint, and it has gra- dually [ 333 ] dually augmented. What Method is. there to be taken ? Answer. The Diforder being of long ftanding, which has gradually increafed, it is plain that this is not an accidental Swelling and Inflammadon of the Neck of the Bladder 5 but according to all Appearance is a fchir- rhous Tumour of the Proftates, or fome other fchirrhous Tumour that contracts the Neck of the Bladder ; confequendy there is no Hopes that a fpeedy Relaxation of the Parts will permit a Paflage for the Urine, nor the Introdudlion of the Catheter j and the Complaint having increafed by Degrees, it is not a Cafe for the Puncture in Perin^o, or above the Os Pubis. It is neceffary therefore to make a free PafTage for the Urine as foon as poffible j and to do this, fuch an Opening muft be made in the Perineum as is made in Litho- tomy, which we call making the But- ton-Hole, without which the Bladder will foon mortify. .''''-^'" It [ 33+ ] - Jt is true that the common Staff which fhould condudt the Knife into the Neck of the Bladder, cannot be introduced any more than the Catheter, and therefore the Knife cannot be diredted further than to the out- fide of the Neck of the Bladder ; but that is fufficient. You muft make ufe of a Staff open at the End, introduce it as far as the Neck of the Bladder, and by the Help of the Groove make an Incifion as near the Neck as poflif ble ; you mufh then flide a pretty long and pointed Bifloury along the Groove, and pierce through the Obflrudlion into the Bladder. As foon as the Urine is obferved to iffuc out, you mufl pufh the Staff into the Blad- der, which will follow the Biftoury with- out Difficulty. The Neck of the Bladder muft be divided with the Proflate, and an Incifion made the whole Length of the Wound, capable of permitting the Intro- dudtion of the Finger, as is done in Litho- tomy. The Finger will eafily diftinguifh the HardnefTes which may be there, and condudt the Knife to cut them in order to 4)ring [ 335 3 bring them to Suppuration. By Help of the Finger or a Gorget, a Canula likewife may be introduced, one End of which muft be in the Bladder, and the other without the Surface of the Wound in Perinso. It muft be left there a pretty long while, that whatever obftruds the Exit of the U- rine may be diflblved and foftened by the Suppuration. In Time this Wound will heal, as that in the Operation for the Stone, and the U- rine will refume it's natural Courfe. - You muft obferve that if the Operation is not performed foon, the Patient will cer- tainly die ', becaufe the Fever and Pain will foon exhauft him, and the Bladder may mortify, as I have feen happen -, nay even burft and empty itfelf into the Pelvis ; an Accident which fhould be prevented, and which actually happened to a Patient, on whom the Operation was not performed ac- cording to my Advice. ^Sup- [ 336] »^ Suppression o/" Urine. A MAN forty Years old, who has had feveral Claps, for fome Years has obferved that the Stream of his Urine has every Day become fmaller. Having drank very freely three Days ago, he v/^s feized in the Night-Time with a Difficulty of making Water, and afterwards with a Suppreffion of Urine, for which he has been bled three Times without receiving any Relief. The Bladder is fo full that it appears prominent above the Os Pubis, and is extended almoft as far as the Navel ; In Confequence the Patient is continually want- ing to make Water, without being able to do it. He has an irregular Pulfe, and vio- lent Pain which reaches as far as the Kid- neys, whofe Pelvis is without Doubt equal- ly diftended by the Urine, as well as the Ureters, which are filled with Urine as the Bladder is. All this denotes that the Urine (hould be difcharged as foon as poffible. I would have introduced the Catheter, but the In- trodudion [ 337 ] trodudion of it into the Urethra becomes proportionably painful the further it pafles, and it cannot be got any further than the Bulb of the Urethra. I have attempted to Introduce Bougies ; but neither the Catgut which commonly enters eafily, nor thofe made of Linen or Taffety waxed and rolled up, can open a PalTage at the Bulb of the Urethra -, perhaps even the Neck of the Bladder is as much contracfted as the Bulb. The Cafe is preffing j for the Bladder is fo diftended, that poffibly it may have already loft it's Power of Contraction, and if not fpeedily emptied may gangrene. What fhould be done to relieve this Patient, and cure him ? Answer. In this Cafe, where there is no Time to be loft, an Operation capable of procuring a free Difcharge of the Urine muft be im- mediately performed. What Operation is the propereft is Matter of Confideration. The Operation called making the Button- Hole might be performed, to introduce a Z . Canula [ 338 ] Canula into the Wound, and caufe a Sup- puration in all that Part of the Urethra from the Bulb to the Neck of the Bladder, and even the Neck itfelf, which perhaps may be alfo difeafed. But as the Inflam- mation of the Neck is recent, and there are Hopes that the Urethra and the Neck of the Bladder may both be perfedly cured, I believe that it will be better to make the Puncture in Perinaso with the Trocar, that the Urine may be evacuated that Way till the Inflammation is gone off. A Trocar about as long as what is made ufe of in Li- thotomy, according to the Patient's Size and Fatnefs, fhould be chofen, to make the Pundure and empty the Bladder. As the Bladder would foon fill again, and it would be neceflary to repeat the Operation in a few Hours, the Canula of the Trocar mufi: be left in the Wound : And left it fhould Hip out, muft be faftened with a Lace, by Means of two Holes in the Shoulder of the Canula, and the Paflage ftopped with a Stopple, which may be removed whea the Patient wants to make Water. As [ 339 3 As the Operation will only remove fome of the Symptoms occalioned by the Reten- tion of Urine, that will not be fufficient j Endeavours therefore mull: be ufed to re- flore the Urethra and the Neck of the Blad- der to their necelTary Diameter for the Paf- fage of the Urine : The Canula of the Tro- car therefore fliould be left in till that is effe iri Proportion as it is emptied, and might flip from it : The Canula will then be found top fhort and of Courfe ufelefs ; therefore by confidering the Diflance between the Skin of the Perinseum and the Bladder, ac- cording to the Size of the Patient, it is eafy to chufc a Trocar long enough to enter at leaft an Inch into the Bladder, without which it will be found too fhort, on Ac- count of the Make of the Bladder, an Ac- cident which fhould be forefeen and pre- vented. Having made the Pundture in a fimilar Cafe to this, I left the Canula in for feven Weeks, without any Accident happening. How fhould it occafion any ? Do not we often after the Operation of the Stone in- troduce a Canula, the End of which goes farther in than an Inch ? Having fucceeded in refloring the Canal to it's Diameter, I then withdrew the Canula. The Wound Jiealed in three Days, Z 3 A Sup- C 342 ] >f Suppression 0/* Urine. AM A N fifty Years old, having fup- ped in Company, and drank a little more than ordinary, is attacked in the Night with a Suppreffion of Urine, and imme- diately has Recourfe to you. NotCy That he had a Clap in his Youth, in the Cure of which he made ufe of drying Injedions. He has been cured a long while, neverthe- lefs he has perceived, that ever fince that Time, the Stream of his Urine was fome- what fmaPer than before. What is there to be done ? Answer, As this new Diftemper is probably occa- sioned by a Phlogofis, or Inflammation of the Neck of the Bladder, the Patient fhould immediately have the Catheter introduced, that the Bladder may not lofe it's Power of Contradion, by the filling and Diflenfion of iti Soon after he fhould be bled twice or thrice [ 343 ] thrice at fome Hours Diftance, to take off the Swelling at the Neck of the Bladder. But, according to the Account of the Patient's Manner of making Water previous to this new Complaint, it is poiEble that the Catheter cannot be pafTed far into the Urethra, as probably it may be become narrower at the Bulb, or the Neck^ or poflibly the Proftate being fwelled and per- haps inflamed, may form an Obftacle to the Introdudtion of the Catheter into the Blad- der. On this Suppolition, the firft Thing to be done, while Endeavours are ufed to abate the Inflammation, mufl: be, if pofllble, to make a Pafl^age for the Catheter, by en- larging the Canal by the Ufe of Bougies capable of dilating it. For this Purpole, thofe made of Catgut feem to be moft proper, becaufe though very fmali they will not foften in the Canal by the Heat of the Part, as thofe do which are made of Taffe- ta or Linen. They will like wife fwell with the Moifliure, which the others will not do, and by this Means increafing their Thick- nefs, will dilate the Fafl^age without Vio- lence or Uneafinefs to the Patient, In fuch Z 4 a [ 344 ] a Cafe as this, it is fometimes a long while before the Bougie can be paffed as far as the Neck of the Bladder ; confequently if it is made of waxed Linen or Taffeta, it will be heated and foftened fo, that it will bend, and not be ftiff enough to open the Paffage to the Neck of the Bladder -, but the Catgut ones are a long Time before they grow foft. Answer. Having been fent for to this Patient, I fucceeded in introducing into the Bladder a very fmall Catgut, ftrait, very fmooth, and rounded off at the End, fuch as are ufed for the third String of a Violin. In about half a quarter of an Hour I withdrew it, fwelled, and then introduced another of the fame Thicknefs as the firfl was when I withdrew it. I afterwards in- troduced a third bigger, and judged upon withdrawing that, I could introduce a very fmall Catheter. I immediately introduced one very carefully, that I might make no falfe Paffage by piercing the internal Coat of ''^ the [ 345 ] the Urethra, which is to be feared In mak- ing ufe of a fmall Catheter. I left the Ca- theter in, after having emptied the Bladder, and put a Stopple into the Catheter. The fecond Time I drew off the Water fronx the Patient, I obferved the Urine to come away brifkly, from whence I judged the Bladder had loft but little of it's Force, Note, This Patient had not loft three Days before he ajfked for Affiftance, as he of the preceding Confultation had done. It were to be wi.lied in Suppreffions of Urine, that the Catheter was always intro- duced foon, becaufe the Bladder only lofes it's Force by it's extraordinary Extenfion. When it has loft that, the Catheter ftiould be left in till it has recovered it : It is only in Cafes of the Palfy of the Bladder, that the Patients are under the hard Neceffity of keeping the Catheter in a long while, and fometimes even during th.eir Life, A Wound [3+6 J A Wound in the Hand. MAN received a Wound on the Back of his Hand by a broad Sword. He drefled it himfelf, and the Wound was cured in a few Days* It is a Month fince the Accident, and now he wants Advice, becaufe he cannot extend the middle and -ring Fingers, which have always continued bent. What do you think of his Condition ? And what is there to be done ? Answer. Without Doubt the extenfor Tendons of thefe two Fingers have been divided, and the Patient not having kept his Fingers and Hand extended, the Ends of both the di- vided Tendons are fo much the farther fe- parated from one another, as the flefhy Part of the Extenfors have retraced the upper Part of them towards the Elbow, at the fame Time that the Flexors have drawn the lower Part of them downwards towards the Joints [ 347 ] Joints of the Fingers. The Ends of thefe Tendons being thus feparated from one an- other, are cicatrifed with the neighbouring cellular Membrane, and all the Space be- tween them which they occupied in their natural State, is filled up by the Cicatrice. Is it proper to cut the Cicatrice and divide the Skin above and below to find the Ends of the Tendons, which are re- traded and feparated to a greater or lefs Diftance, and to unite them by a Suture, as advifed by the Ancients ? Befides the Thing being impoflible on Account of the Cicatrice formed at the Bottom of the Wound, I cannot advife it to be done for feveral good Reafons. i. The upper Part of each Tendon cannot be brought near the other, without Force, becaufe the mufcular Fibres which are contracted will with-hold them j and fuppofing it pofiible to make an exadl Suture, the Fingers might then continue extended without any Flex- ion ; confequently they would remain ufe- lefs and troublefome, as the Fingers are of no Ufe except they can be bent. 2. It would be impoffible to exad:ly cover that Part [ 348 ] Part of the Tendons where the Sutures are made with the Skin, therefore they would fuppurate; and fuppofing they {hould not Hough off, the Cicatrice will be fixed there, and the Fingers remain extended. 3. The Inflammation which might enfue might al- fo produce great Diforders. I therefore advile Things to be left in the Condition they are. It is more fervice- able for the Fingers to continue bent, with- out Power of Extenfion, than ^o be extend- ed without a Power of bending 3 for when they are extended they are of no Ufe. ^he Tendo AcuihLis parffy divided, A MAN has juft received a Wound on the Tendo Achillis by a Scythe 3 but it is not above half cut through. How (hould this Wound be dreffed ? Answer. C 349 ] Answer. ' The dividing the refl of the Tendon muft not be permitted. It is very true that if the Foot is not perfedly extended, and even a Httle forcibly, the Diftenfion which the Fibres that are not cut will fufFer, will bring on bad Confequences. But a little forced Extenfion of the Foot relaxing the Gaftrocnemii and Solaris Mufcles, the ten- dinous Fibres that are not cut will not be diflended, and the Cure of the divided ones will only be the more certain and fpeedy. As to the Dreffings and Treatment, they muft be the fame as if the Tendon was en- tirely divided. There muft be a great deal of Difference made between a large Tendon which is but half divided, and a large or fmall Tendon that is only punctured. In the divided one, tlie nutritious Juices do not ftagnate and corrupt, and even the Blood and Lymph difcharged from the neighbouring Parts that are wounded mix along with them ; but in the fimple Pundture of a fmall or large [ 35° } large Tendon, they ftagnate, corrupt, and irritate -, this is the Reafon that a Pundture occafions more terrible Symptoms than an Incifion does. j4 Suppression of Urine. A CHILD eight or nine Years old, within thefe three Days has had a Suppreffion of Urine. His Belly is much diftended, particularly the Hypogaftrium j he is in violent Pain and very feverifh ; from his Infancy he has been fubjed to a Prolapfus Ani, and every Time he makes Water or goes to Stool, Part of the Redum defcends. The draining of the Child in endeavouring to make Water, has made the Redtum come down more than ever, and it is now down above fix Inches. The Parents being accuftomed to it, are net a»- larmed at this, becaufe they have been ufed to put up the Inteftine, and are only unea- fy about the Suppreffion of Urine ; and it is fdr . that they delire your Advice. The Surgeon t 351 3 Surgeon would have introduced the Cathe- ter, but could not, as it flopped near the Neck of the Bladder. What fhould be done to relieve this Child ? Answer. It is not to be wondered at that the Ca- theter could not enter the Bladder, It's Neck and the Red:um are furrounded by the Fibres of the Levator Ani, and the De- fcent of the Rec^lum has changed the natu- ral Situation of thefe Parts 3 and this is the chief Obftacle to the Introduction of the Catheter. The firft Thing to be done is to reduce the Inteftine, and afterwards keep the Finger in the Anus, which muft be fufficiently wide, without which the Gut will come down again diredly on the firft Efforts to make Water j by doing this, poflibly the Child may make Water, if the Bladder has not loft it's elaftick Power by being too much diftended. If he does not make Water foon, it \>'ill at leaft be pofUble to introduce the Catheter, obferving to have fomebody fupport the Redtum with the Finger, [ 352 ] Finger. The Catheter fhould even be left in the Bladder, and fecured for Fear it fhould come out, and there fhould be Oc- cafion to introduce it again in an Hour's Time ; for in this Cafe the Bladder may be filled again in lefs than an Hour. It will be known by the Manner the Urine comes away in, whether the Bladder has lofl it's Spring by the over Diftenfion. In this lafl Cafe the Catheter mufl be left in the Blad- der as long as it is neceffary, that is to fay till the Bladder has recovered it's Strength, which will be known by the Velocity with which the Urine comes away through the Catheter. ^Suppression 0/ Urine. A MAN forty Years of Age, is fud- denly feized with a Supprefiion of Urine. The more the Bladder fills, the more he endeavours to make Water with- out EfFedl 5 the Pain confiderably increafed, and at length, in about five or fix Hours, he [ 353 ] he makes a few Drops, which gives him Eafe only for a Moment : He makes as much every Inftant ; and as that gives him no Eafe, you are confulted fome Hours af- ter. Pleafe to take Notice, that in about thirty Times he has made fifteen or fixteen Ounces of Urine, and that nevei thelefs he flill fuffers very great Pain. What ought to be done to relieve him ? Answer. Though the Patient makes Water every Inftant, the Bladder is ftill certainly full j it may even be perceived to protuberate, railing the Skin of the Belly above the Os Pubis ; and if you prefs your Hand on it, it increafes the Pain and the Inclination to make Water, which is a Proof of it's Ful- nefs ; therefore what has been made by the Patient is only from the Overflowing; in Confequence this Evacuation docs not take off from the Neceffity of introducing the Catheter as foon as pofiible, for the Kid- neys, their Pelvis, and the Ureters, are as full as the Bladder, A a The C 354- ] The Patient's Age gives no Reafon to fufped a Palfy of the Bladder -, but the long Retention of Urine is the Reafon that it has been over-filled, and therefore in all Pro- bability it has loft fome of it's Power of Contradion, which it will not recover very foon. The Catheter muft be left in and fecured from coming out. It fhould be ftopped with a Stopper of waxed Linen rolled up, which will flop it exadtly, and is not liable to be broke as a Cork is. This Stopper fhould not be taken out, but when the Patient certainly wants to make Water. If it comes away continually, without No- tice, it will be contrary to the Order of Na- ture, which is to have the Bladder alter- nately emptied and filled. The Surgeon'j Answer. More than four Pints of Water were drawn off by the Catheter. It was left in, and in about two Hours three Pints more were drawn off, and then the Catheter was taken out -, when the Patient afterwards wanted to make Water he could not, there- : fore [ 355 3 fore the Catheter was again introduced and left in. In a few Hours the Water appear- ed thick, and being faved, there fettled at the Bottom of the Pot a Quantity of fmall white Spots, which fwim upon flirring of the Water, and afterwards fink to the Bot- tom of the Pot. What is this Subftance ? And what fhould be done to help this Pa- tient ? How comes the Bladder to have loft it's contradile Power ? How fhould it reco- ver it ? And how will it be known when it has ? An s w e r. The Bladder has loft it's contracftile Power from it's mufculous and membra- nous Fibres having fufFered too great an Extenfion, before the firft Time of intro- ducing the Catheter. In Confequence the whole Bladder is hurt, and there are fome Obftrudions formed in it, efpecially in the febaceous Glands which are placed in it's thick Part. Thefe Glands now empty themfelves by a kind of Suppuration, and this fort of Pus A a 2 falls [356] falls into the Bladder by their external Ca- nals, which open into it's Cavity through the inner Membrane. This is w^hat makes the Appearance of all thefe white Spots. The Bladder will not recover it's Strength but by Degrees, according as the Obftruc- tion is a longer or (horter Time in going off. This generally continues twenty, thir- ty, or forty Days, more or lefs, according to the Degree of Diftenfion the Bladder has fuffered. The Catheter (hould only be taken out once a Week to clean it, and muft be in- troduced again as foon as the Patient wants to make Water. I mention cleaning of it, becaufe feme Slime might ftop in it's Ca- vity ; nay fometimes we have even feen the two Eyes at the End of it incrufted over with Gravel, which has prevented the Paf- fage of the Urine. To facilitate the emptying of the Glands into the Bladder, two or three Times a Day, Injedtions of Barley- Water, and a little Honey of Rofes, fhould be made through the Catheter into the Bladder, I do [ 357 ] I do not direft what Quantity {hould be - injected, that muft be regulated by what the Bladder can bear without Pain. Before every Injedlion he {hould empty his Blad- der, and the Injedlion fliould continue in till he wants to make Water. When no more of the white Spots appear in the U- rine, two Spoonfuls of diftilled vulnerary Water fhould be fabftituted in the Room of the Honey of Rofes. It is a Sign the Bladder has recovered it's Power, when a litde Urine is obferved to come away from the Penis on one Side of the Catheter, while it is flopped. The Catheter then may be taken out in about two Days. I fay it is a Sign, for it is not . a certain Rule, as I have feen fome Patients who were in that Cafe, and in whom I have been obliged to replace the Catheter, becaufe they could not make Water with- out that Affiftance. If the Bladder is para- lytic, the Catheter muft remain in as long as the Palfy continues. In this Cafe, for the Conveniency of the Patients, a Catheter fliould be introduced, made in the Form of an S j and then they A a 3 may [ 3S8 ] may get out of Bed and walk about, as this Catheter will flay in without being faf- tened. A Fracture: of the Patella. YOUNG Woman four and twen- ty Years of Age, being upon her Knees, and endeavouring to rife, broke her Kneepan tranverfely, in Confequence of which fiie fell down upon the Ground. Being carried to Bed, without knowing that her Kneepan was broke, a Swelhng came on all over the Knee, which fo exactly con- cealed the Caufe of the Complaint, that the Fradlure was not perceived. Every Thing was done in Confequence of the Swelling and the Pain, which was confider- able, that could contribute to abate them. At laft, in about eight or ten Days, they went off, and the Patient thought herfelf cured. Neverthelefs fhe could not extend her Leg, nor keep it extended without the Foot being fupported, which was attributed to [ 359 ] to the Weaknefs of the Part 3 and this Leg being extended by any Perfon, immediately on their quitting it, returned to it's State of Flexure ; in Confequence the Patient can- not ftand upon it in any Manner. In about three Months after it happened, they difco- vered that the Patella was broke tranfverfe- ly, which is the Reafon (he cannot extend her Leg j it may be felt with the Finger, that the upper Part is feparated an Inch from the lower, and they may be moved crofTways, that is, one may be pufhed to the right and the other to the left, without the upper one being brought nearer to the lower one. The Patient feels no Pain, not even when it is moved any Way, but the Inconveniency remains, and fhe fees her- felf reduced to the Neceffity of paffing her Life either Iving down or fittins:. Is there any Method to remedy this Accident, and reftore her to the free Ufe of her Leg ? Answer. During the three Months that thefe two Parts of the Patella have been feparated, a A a 4. fort [ 360 ] fort of Callus is formed to each of them, - and between them a Cicatrice, and a Union of the two aponeurotic Parts, that, being placed above and below the Patella, fur- round them in their natural State ; the two Parts of the Patella therefore are divided for ever, without a poflibility of being brought together. From the Inftant of the Frac- ture, the Mufcles which drew up the fu- perior Part contradted to a certain Degree, by the Elafticity with which all our Fibres are endued ^ and whatever Contradion ex- traordinary the Patient wants, they cannot efFeduate fufficient to extend the Leg, or keep it fo when it is extended : For that, they muft be capable of double the volun- tary Contradion they were accuftomed to when well J but that they cannot be, as Nature has given them only a certain De- gree of Contradion dependent on our Will. It is only then by procuring an extraor- dinary Contradion to the mufcular Fibres of the Extenfors, which are already con- tradod to a certain Degree, that a Core can be effeded. We mufl: therefore begin by giving, or to fpeak more properly, by cauf- mg [ 36i 3 ifig' ii contrary Diforder to the Leg than what affed:s it at prefent j ading in fuch Manner, that the Leg being once extended, it cannot afterwards be bent by any Means whatever. We know that all our mufcular Fibres are ihortened at our Pleafure, by a Contrac- tion proper to them, and which continues no longer than we pleafe ; but we likewife know, that all our Fibres, mufcular or o- thers, continually tend to fhorten, and that they infenfibly contrad: to a - certain Point determined by Nature, independent of our Will, when nothing oppofes it. Expe- rience proves this -, for if on any Occafion the Fore-Arm is kept bent for fix Weeks or two Months, as we fee fometimes on Account of Fradlures, the biceps and bra- chial Mufcles which bend the Arm, infen- fibly contract themfelves in fuch Manner, that it is impoffible to extend the Fore- Arm» Therefore from this Example the fame Thing is to be done to this Leg, and we muft ad; in fuch Manner as to keep the Leg extended for two or three Months, without ever permitting it to be bent. Du- ring [ 362 ] ring this Time, the extenfor Mufcles, which are already contradied, will contrad: themfelves ftill more by the Elafticity of their Fibres, and it will not be poffible to bend the Leg. It will then be necelTary for the Patient to ufe herfelf for fome Time to walk with her Leg ftrait, without at- tempting to bend it. And even if it was to continue extended in this Manner, it would be more ufeful than when it bends under the Weight of the Body. In about five or fix Months the Patient muft endeavour to bend her Knee, putting the flexor Mufcles into as great a voluntary Contradion as flie can, letting the Body reft on the Limb, endeavouring at the fame Time to extend it, by accufloming the ex- tenfors to a voluntary Ufe, which has been loft ever fince the Fradlure. In this-Man- ner fhe fhould endeavour from Time to Time to reftore the Leg to it's natural Mo- tions, and this will be obtained fooner or later, according to the Perfon's Strength or Alertnefso The zH The Event. Here follows the Fruits of Experience. A Patient to whom I was called fome Years ago, was in the abovementioned Circum- itance for four Months, and then had Re- courfe to me. I treated her in the Man- ner that I have juft advifed, and in about a Year fhe walked as well as if the Patella had never been broke, or the Fradture been reduced j neverthelefs, the two Parts of the fradured Patella remained feparated above an Inch. I have Unce treated in the fame Manner another Patient, who was very fat and indolent, and in the fame Cafe. This Perfon was near two Years in recovering the Ufe of her Leg. There is nothing wonderful in the Patel- la's breaking in getting up, as well as in falling down, on Account of the Weight of the Body, joined to the ftrong Contrac- tion of the four extenfor Mufcles which ad: together. Beiides that, there is a Difpofi- tion in the Patella to this Accident, as ap- pears by the following kind of Proof of it's happening. [364] happening; About thirty Years ago I re- duced the right Patella of a young Woman of twenty Years old, which was broke by fome Means unknown to me. In about a Year after, flie felt fome flight Pains in the other Knee, and in the Morning fhe faid to feveral of her Acquaintance, jOhe felt fome- thing (he could not defcribe, that made her believe the other Kneepan would break as well as the former ; and adually as fhe was walking that Evening in the Garden with the fame young Ladies, her Kneepan broke tranfverfely, which made her fall down. They fent for me, and I reduced it. I found the Knee a litde fwelled, and was not furprized at it, becaufe fhe was in a Convent four Leagues from PariSy and fe- ven or eight Hours had elapfed before my Arrival, The [3^5 ] ^ke Confequefice of a Bad Labour. AL A D Y twenty-two Years of Age, three Years ago had a very bad La- bour, in which, as fhe told me, the Head of the Child continued three Days in the Paffage. It is natural to imagine, that all the neighbouring Parts muft have fuffered greatly by the Compreffion. This occa- fioned a Mortification, which deflroyed the Conformation of the Parts. The Redlum efcaped the Mortification, but the Urethra was deftroyed in fuch Manner, that the Day after the Delivery the Urine was dif- charged through the Vagina. All the mor- tified Part of the Vagina by Degrees fepa- rated, and at length an irregular Cicatrix was formed, which has left only a very narrow and almoft imperceptible PafTage from the Matrix to the Labia Pudendi. Since this Misfortune, her Menfes have come away with great Difficulty, for the fmalleft Clot of Blood formed in the Paf- fage, that is to fay, from the fmall external Opening [ 366 ] Opening as far as the Neck of the UteruSj flops up the PafTage, and the Patient fufFers violent Pains which fhe calls Womb-Co- licks. For more than a whole Year the Urine has come away freely by the fame Hole, the Urethra being deftroyed by the Morti- fication J but gradually by little and little it has come away only by Drops, which has occafioned frequent Pains. At length the Lady fent for her Surgeon to attend her, after which (he has fent you the above Ac- count, with the Surgeon's Relation as fol- lows. Between the Labia Pudendi there is a very irregular Cicatrix, funk in, of the Shape of a Funnel, corrugated in fuch Manner, that it is with much Difficulty one can difcover a fmall Hole at the Bot- tom. Introducing a Probe, you feel a Stone at about three Inches depth, neither the Size nor Nature of which can be difcover- ed, becaufe the Probe cannot be moved in this narrow PafTage. Without Doubt it is this Stone which makes the PalTage of the Urine and the Menfes fo difficult. What is [ 367 ] is to be done to cure this Diforder, or to put the Patient out of Danger of worfe Confequences? Answer. To proceed properly in a Cafe of fuch Difficulty, we muft endeavour to form a right Idea of the unnatural State the Parts are left in by the Cicatrix, formed after the Deftrudlion of the Parts which fuffered in the Labour. It is probable that the Urine ifluing out of the Bladder has taken an oblique Courfe, by which it palTes to the oppofite Part of the Neck of the Womb, in order after- wards to be difcharged through the narrow PalTage that the Cicatrix of the Infide of. the Vagina has left. If there is a Stone, it has come out of the Bladder in Gravel, and fo a calculous Concretion may have formed by the long Retention of fome Drops of Urine, as we fee fometimes under the Prepuce of Chil- dren ; and this Gravel could not be forced away by the Urine, on Account of the nar- rownefs of the Paflage. What ever [ 368 ] Whatever fl^iould be done, it will be im- polTible to reflore the Urethra, which is gone without Recovery. It is alfo as im- poflible to reftore the Vagina to it's former State ; and all that Art can do, is to make the Paflage, preferved by Nature for the Difcharge of the Menfes and Urine, larger, and confequently better. This may be done two Ways, that is, either by an Ope- ration or a limple Dilatation. The Operation confifts in making two Incifions, one to the right and the other to the left, beginning at the lower Part of the fmall Orifice, and carrying it towards the Buttock, as far as the two Tuberofities of the Ifchium. When this is done, the Fin- ger mud be introduced into the Opening, and upon that a llrait blunt- pointed Biftou- ry, to cut the Cicatrix of the Vagina it*s whole Length, to the right and left, avoid- ing the Redum. A Scoop or Forceps may then be introduced as far as the- Stone, to extrad: it. A Canula of a proper Length and Thicknefs muft then be put in and fe- cured in the Vagina, to extend and keep the Sides feparated till a new Cicatrix is formed. .AU C 369 ] All this may be done, but not without Inconveniency. I know by this Method the Stone may be extrafledj but if any Thing, as the Menfes, Pain, or other Ac- cidents, fhould happen, that would prevent the Canula's remaining long enough for the Cicatrix to be perfedly formed, and even forrke confiderable Time after, it is certain the Operation will become ufelefs from the Straitnefs of the Paflage, as the Cicatrix v/ould foon return to it's former State, The fecond Method to be made ufe of in Surgery, is the dilating the whole Paf- fage as far as the Stone ; this there may be Hopes of accomplifhing, by a conftant and long continued Ufe of Bougies made with Catgut, the Thicknels and Number of which may be augmented without Danger, till by the Enlargement they are capable of, they ftretch the Sides of the PalTage through which the Menfes and Urine difcharge. This Method is not painful nor liable to In- conveniencies. Bb Tbs [ 370 ] Event. In Confequence of my Anfwer, the La- dy came to Paris, and having examined her, I found the Relation given to me of her Condition was very light and exa6t. Dilating was the Method I preferred ; I introduced through the fmall Orifice a very fmall Catgut, fuch as the treble String of a Violinj blunted at the End, three Inches long, and greafed with Pomatum. This fwelled with the Moiflure ; but an Inchna- tion to Urine coming on, there was a Ne- ceility of removing it, as it entirely flopped up the Paffage. One of the fame Size was put in Night and Morning, and in about four Days I was able to put in another fomewhat bigger. The repeated Ufe of this and thicker, for I wjsnt on, till at laft I infenfibly arrived at the largell of the Violincello -, this Ufe, I fay, increafed the Dilatation made by the iirfl fo much, that v/hen the largeft could enter eafily, I put in two clofe to one ano- ther, then three, then four. Thus I aug- mented [ 371 ] merited the Number during three Months that I introduced them, till they amounted to fourteen, which together were nearly the Thicknefs of my Finger, and were left in by the Patient Night and Day. Between them I put a fmall leaden Canula, of the Bignefs of one of the fwelled Catguts, that the Want of making Water might not make it neceffary to remove them. Each of thefe was rounded at one End by a File, and a Thread faftened at the other, that they might be the eafier removed. They were eafily introduced when hard and dry, one after the other, and when fwelled were ex- tradied in the fame Manner, but enlarged and foftened. I continued in this Manner the Ufe of the Catgut Strings for three Months, buc was feveral Times interrupted by the Men- fes, Colicks, and other Inconveniencies. Notwithftanding this, the Paffage was made large enough to eafily introduce a fe- male Catheter about one third of an Inch thick. I then fearched with this Catheter for the Stone, which I had touched the firfl B b 2 Day [ 372 3 Day with the Probe, but could not find it again. Apparently being of a foft Tex- ture, it had been crumbled and broke by the freq^uent touching of it with the Cat^ guts, and came away like Sand. In Fadt, we often obferved fome fmall Pieces of Gra- vel on their Surface when they were ex- tracted. The Menfes and Urine difcharge eafily and without giving any Pain. What more could have been done by the Operation? Could it have put the Woman in a Condi- tion to cohabit with her Hufband ? Cer- tainly not, becaufe the Hardnefs of the Ci- catrix would have obftru6ted it. But fup- pofing even that the Thing was poffible, and the Woman was to become pregnant, in what a dangerous Situation would both the Mother and Child be. I advifed the Lady to continue the Ufe of the Catgut, to preferve the Diameter of the Paflage ; and I make no Doubt but (he did, as (he. continued very well, In another Confultation we have feen the great Utility of the Catgut Strings, in keep- ing open for fix Weeks a Wound made in [ 373 ] in the Perinasum, in order to extrad a Stone fixed in the Urethra ; which could not be done with a Canula, without a great deal of Inconveniency and Pain to the Patient, A Disorder arifing from the ceafing of an HiEMORRHOIDAL FlUX. AM A N fifty Years old, had for ma- ny 'Years been fubjed to the Piles, Two Years ago this cudomary Evacuation ceafed, and fix Months after he was trou- bled with a Noife in his Ears, which ter- minated in a Suppuration and Difcharge. Since that, very obftir^ate Tetters have af- feded his Face, and thefe Appearances are alternative with the Noifes in his Ears. sPught this Complaint to be cured ? How i^ould it be treated ? And is there no ill Confequence to be apprehended from the Cure of it ? B b 2 Answer, [ 374 ] Answer. It is the Ceffation of the haemorrhoidal Flux that has occafioned thefe Noifes in the Ears, and thefe Eruptions j for Nature fel- dom chufes to be obftrucfled in her own Ways. As the Noife in the Ears is aher- native with the Eruptions, from the Hu- mour which occafions them changing it*s PlacCj there is Reafon to fear it may fall on the Brain, or fome other internal Part, and bring in much worfe Confequences. Perhaps there may be a Way of prevent- ing it, and curing the prefent Diforderss and it ought to be tried. This is to pro- cure if pofiible a Return of the haemorrhoi- dal Flux, or fupply the Want of it. Na- ture may do this^ without the Help of Art, as fhe has done before ; but Art may alfo invite and excite her to it, or otherwife fup- ply the Defed, as Experience has proved. For this Purpofe it will be neceffary to apply Leeches frequently to the Anus, and when they drop off, the Patient mufl place himfelf in a Chair with a Hole in it, over the C 375 ] the Steam of hot Water in a Bafon. The Leeches draw but little Blood j but, by- Help of the Steam of hot Water, the Ori- fices made by them will in about an Hour's Time bleed about twelve or fifteen Ounces. After which, a Comprefs dipped in Oxy- crate fhould be applied to the Part, and the Blood will flop prefently. This fhould be repeated as often as it is neceffary ; and if the haemorrhoidal Flux was periodical and regular, as the Menfes are in Women, the fame Period fhould be ob- ferved as was cuflomary in the natural Dif- charge. If the hasmorrhoidal Flux fhould return, the Ufe of Leeches will be unnecef- fary. Bleeding in the Foot might fupply the Want of this natural Evacuation, but I have obferved that it does not do fo well as the Application of Leeches in the Manner I have propofed. Nothing fhould be applied to the Erup- tions on the Face, for fear of repelling the Humour and throwing it upon the internal Farts. If the Diforder continues, notwithfland- ing the frequent Repetition of the Evacua- B b 4 tion ■ [ 376 ] tion I have propofed, it will be right to ad- vife the Patient to chew Tobacco, to re-- lieve Nature by a continual Difcharge that Way. An Iflbe in each Leg likewife will be of Service. At the fame Time it will be proper to make the Patient drink a Pint of Whey e- very Morning, or a Decodion of Fumitory and the Roots of Water-Dock; bathing may Hkewife be ufed, and purging fortie- times, to prepare the Patient for a Milk- Diet, in order to amend the bad State of the Blood as much as poffible. An Accident in Bleeding. VERY fat Lady has been bled in the Foot. The Surgeon not finding the Saphena a good Vein, and perceiving a fair one on the Metatarfus, bled her there, which was attended with no more Pain than in another Place. Two Days after, the Lady having removed the Comprefs alid [377] and Bandage, obfcrved a fmall Scab on tlie Orifice, which (he left on. This Scab came off two Days after, and a fmall Difcharge ilTued from the Orifice. ComprefTes dipped in Aqua Vits, Bole Water, and other Applications, have been made ufe of, and repeated for feveral Days, this fmall Wound conftantly difcharging ten or twelve Drops of purulent Matter in twenty-four Hours, without either Pain or Inflammation in the Foot. Three Weeks having palTed in this Manner, the Lady, at length grown impatient, deiires to know from whence arifes fo confiderable a Dif- charge from fo fmall a Wound, and how it may be flopped ? For probably that is what hinders the doling of the Orifice. Answer. So obftinate a Difcharge can only hap- pen from fome lymphatick VefTel, which lying under the Skin has been divided a- crofs at the fame Time the Vein was open- ed ; and as the lymphatick has not united fo foon as the Blood- VeiTel, the Lymph, which [ 378 ] which continues to difcharge, is conftantly appearing at the Orifice in the Skin, and prevents it's clofing. All the Deficcatives that have been applied have been of no Ser- vice, being conftantly wafhed away by the Difcharge of the Lymph : Recourfe there- fore muft be had to another Method. It is a common PracStice in Surgery to flop Haemorrhages with Rabel'^ or fome other ilyptick Water. Thefe Medicines form an Efcar at thf Orifice of the wound- ed Veffel, and extend fomewhat further. This Efcar ftops the Blood, which th^n takes it's Courfe by the collateral Vefi^els -, and upon the falling oiF, we find the Open- ing of the wounded VeiTel either flopped up or clofedi and no Flux of Blood. This may ferve as a Diredtion in this Cafe. As it is impradticable to apply the ftyptick Wa- ter exadly upon the Orifice of the lympha- tic Vefifel, it will be proper to touch the fmall Wound with the Lapis Infernalis, whofe Adion is more confined than the h- quid Cauftics, and continue it on for about half a Minute, that it may form a fufficient Efcar. Afterwards dry Lint muft be ap- plied. C 379 ] plied, and the falling off of the Efcar wait- ed for. This Application of dry Lint mufl be daily repeated, without thinking of haft- ening it's Separation by any greafy Medi« cine. By this Method it will come away ilowly and by Bitsj during which Time the Lymph will take another Courfe, and the Lips of the Orifice will unite gradually, as I know by Experience. It would be wrong to impute this Acci- dent to the Perfon who bled her, for be- fore he pierced the Skin with the Lancet, it was impoffible to know by feeling that there was a lymphatick Veffel under the Skin, immediately clofe to the Side of the Vein, at the Place where he made the Pundure ; as this Veflel would not fwell in Confequence of the Ligature, as the Veins do. w^Bad [ 38o ] '' A Bad Shape. AY U N G Lady ten or twelve Years old, who has always enjoyed good Health, and does now, has her Back-Bone awry, owing to the fifth or fixth Vertebra of the Back projeding from the right Side. On an attentive Examination of the Body, it is obferved that both Sides of the Breaft are not alike. The right is too flat before and projedling behind, forms a Banch, be- caufe the Ribs being too much bent about three Fingers breadth from the Back-Bone, lift up the Shoulder-Blade, whilft on the left Side the Breaft projeds too much, and behind is too flat. It is likewife obferved, that one of the Hips puflies out more than the other. Upon perceiving this, they made the young Lady wear very flifF Whalebone Stays, and alfo inclofed in the Infide of them a Steel Plate, to prefs upon the projeding Shoulder-Blade. What can be the Caufe of this Fault of the Bones ? And do you believe we can remedy it ? Answer. t 381 3 Answer. rTi^c faulty Shape of the Back-Bone and Ribs may arife from four Caufes. The firft is a Fault in the nutritious Juices, which is carried to the Bones, and changes the na- tural Make of them ; this is the true Ric- kets. The fecond is a bad Habit of hold- ing themfelves during their Exercifes which are fome Time in performing, as in learn- ing to write or draw, &c. The third is the wearing of Stays made too ftiff and too tight ; for when a young Perfon finds out a Pofture in which the Whalebone Stays do not give fo much Uneafinefs, they ufe themfelves to that, and by thefe Means give a wrong Turn to the Back-Bone, and very often alfo to the Hips. Whalebone Stays, though ever fo well made to Ap- pearance, have often made young Women awry for that Reafon only. The Spine is alfo obferved to grow crooked from Chil- dren in Diforders of long Continuance, con- jftantly lying on the fame Side, on Account of the Situation of the Bed. When 382 When the Spine has begun to grow crooked, it increafes pretty fad, and moft commonly one of the Hips is elevated, if the Crookednefs of the Spine is from the lower Part and on one Side j for the Ofla Ilia which articulate with the Os Sacrum, cannot avoid following it. This does not proceed from the Hip's growing bigger, but only becaufe it fhews itfelf more pro- jecfling, in Confequence of being elevated by the faulty Turn of the Spine, to which it is articulated and fixed. I have feen others in whom the Spine had a fpiral Turn ^ and in that Cafe one of the Hips, without projecting, has been turned a little before, and the other behind, for one, two, or three Inches, more or lefs, in Proportion to the Turn of the Spine; and always for this Reafon, that the three or four loweft Vertebrae of the Back and the Os Sacrum, which makes Part of the Spine, determines the Pofition of the Hips. If thefe Deformities can be remedied, it is only while the Children are growing; for when they are full grown, nothing more [383] more can be done than fupporting the Bo- dy, and preventing the Increafe of the De- formicy. The only Affiftance Art can afford in all thefe Cafes, is to make them wear a Whale- bone Stay, which may be turned every Day ; for this will mould itfelf upon the faulty Shape of the Child, and take it's Form ; but by turning it, the Whalebone lofes the next Day the bad Shape it had ac- quired the Day before. This Stay fhould be limper on the fore Part, lels fo on the Sides, and pretty fliff at the Back. The Shoulders fhould be kept down with Shoulder-Straps. The Head placed properly fliould be kept fo by a Collar, as the Polition of the Head is of great Confequence to that of the Back-Bone. The flifi Part of the Whalebone Stay being only on the Back, will not confine the Child, but fupports and prevents it from growing crooked behind. The Back of the Stay prefTing againfl the Scapula, will be oppofed to the faulty bending of the Ribs over which it is placed. The Child being obliged to keep itfeif upright without being [ 384 ] being confined, we often find the Ribs and Back-Bone infenfibly recover their natural Shape. I repeat it, that the Stay fliould be worn one Way one Day, and turned the other ; becaufe when the Whalebones are heated they yield to the faulty Shape of the Child, which would make them ufelefs if they were not turned : Inflead of which, the Whalebones which are bent one Day, lofe by a contrary Pofition the next Day the wrong form they had taken. If one of the Hips is turned forwards and the other backwards, which fuppofes the Spine to be a little turned like a twifted Co- lumn, the two Hips mull: be confined. To do this, the Coat-maker fliould length- en and join . together the Skirts of the Whalebone Stay, in fuch Manner that the Hips fhould be in a fort of Cafe. This kind of Cafe fhould be tightened before on that Side that the Hip turns forwards, and loofened behind on the fame Hip which is tightened before. The contrary is to be done on the other Side, This may be done by two fingle Tags, which will faften them to the Bottom of the Stay, one behind and th^ [ 38s ] the other before. The Skirts that are join- ed and inclofe the Hips fhould be ftifF e- iiough to prevent the lower Part of the Whalebone Stay from preffing and making them hollow, that is to fay above the pro- je(5ting Hip at the Waifl. All thefe Attentions are necefTary, till a fufficient Number of offified Fibres are grown capable of counterballancing thofe which have begun to grow crooked, and by that Means remedy the whole. They have often fucceeded to my De- fire j in others fometimes they have only fupported the Child's Waift, fo as to pre- vent their ill Shape growing worfe. One may compare thefe Stays to the Props which the Gardeners fallen to young Trees that grow crooked, which they leave {landing till a fufficient Number of ftrait ligneous Fibres are grown, to counterballance thofe which have acquired a difagreeable Figure. As there is in the Blood of many Chil- dren a ricketty Difpofition, which renders their Juices difficult to offify, this probably is the Caufe of the Joints fvvelling and tlie Rickets, It is proper therefore to endea- C c vour [386] vour at the fame Time to give a greater Fluidity to their Juices. I have remarked, ' that Antifcorbuticks conftantly given, have often done a great deal of good, and fe- conded our Attentions with the Whalebone Stay that I propofed ; at leafl I believed I ought to attribute to them a Part of the Change, which perhaps may have folely been owing to Nature. Children often take irregular and con- flrained Pofitions in their Beds, which are capable of adding to the Deformity of their Shape, and make them lofe in the Night what Advantage is gained by the Whale- bone Stay in the Day, which it will be ve- ry proper to remedy, and even to prevent. This may be done by making them a fort of Whalebone Jumps, but more plia- ble than thofe worn in the Day-Time. It is fufficient that the Back is fliifened, and the Shoulders are well kept down by Shoul- der-Straps. The Child will then be oblig- ed to lie on it's Back -, but as all Children are found Sleepers, it will eafily acquire the CuHom of lying in thefe Jumps ; for Want of which they would lie and fleep in very irregular [ 387 ] irregular Poftures, capable of increafing their Deformity, and by thefe Means ren- dering ufelefs all the Pains that are taken to corredt and reftore their Shape. ^e Tendo Achillis divided, AM AN has juft received a cut of a Sabre, which entirely divided the Tendo Achillis, three Fingers breadth a- bove it*s Adhefion to the Os Calcaneum. The Wound is oblique and flill bleeding : Wc defire to knov7 what ought to be done? Answer. Divided Tendons are re-united by the fame Afliftance of Nature as the Bones and flelhy Parts. Confequently it is neceffary to make ufe immediately of fuch Affiftance as Art indicates, bringing the Ends of the divided Tendons exadily together, and keeping them conftantly in Conta(ft. This will be done, by keeping the Foot in fucl^ C c 2 a State C 388 j a State of Extenfion as it cannot be bent by the Force of the flexor Mufcles, nor any other Means. The following is the beft Method for the Purpofe. A Leather Knee-Piece muft be applied round the Knee and laced, which fhould reach no farther than four Fingers breadth above-Knee, and two below ; to the upper and hind Part of this Knee-Piece, fhould be faftened a ftrong Strap of* Leather about a Foot long. The Foot mufl be kept warm with a Slipper, at the Bottom of which muft be nailed or faftened one End of a fufficient large Plate of Wood or Tin, to extend three or four Inches beyond the great Toe ; and to that End fhould be nail- ed another Strap of Leather about a Foot long, with a Buckle at the End. The Patient being in Bed, his Leg muft be bent a little ; the two Straps muft then be drawn together by the Buckle, till the Foot is ex- tended in fuch Manner, that the two Ends of the Tendon touch one another exactly, and reft in fome Meafure one againft the other. The Lips of the Wound muft then be immediately fecured by dry Sutures, to prevent [389] prevent the Air altering the nutritious Jui- ces which are to form the Re-union. The whole (hould be covered with a Comprefs fuftained by a loofe Bandage. This Manner of keeping the Foot extended permits the Wound to be looked at as often as you pleafe, without being obliged to loo- fen the Straps. An Inflammation fhould be prevented by Bleedings, a proper Regimen, and other Remedies which Circumflances may indi- cate. If the Wound comes to Suppuration, the Foot muft neverthelefs be kept extended ; and it muft be dreiTed with Deficcatives, avoiding all greafy Medicines. The Leg muft not be extended, nor the Foot bent for fix Weeks or two Months, as the Tendons do not unite fo foon as the Mufcles. If the Wound fhould inflame in Spite of the Precautions that are taken, the Wound will be a long Time before it is cured, if not, it will foon be cured ; but if it fhould inflame, neverthelefs the Foot muft ftill be kept extended. C c 3 When [ 39° 3 When a Tendon happens to be only dU vided in Part, it muft be dreffed in the fame Manner, otherwife bad Symptoms may arife, on Account of the irregular Contraction of that Part of the Tendon which is not divided. Divided Tendons. MAN has juft received a Cut of a Sabre above his Hand, which has tranfverfely divided the extenfor Tendons of the fore and middle Fingers j he has re- ceived another on the lower and outer Part of the other Fore- Arm, juft above the an- nular Ligament, which has divided the greateft Part of the Fibres compoling the Mufculus Extenfor Communis, by which Means the Fingers cannot be extended. How is the Re-union to be accompliflied ? Answer, [ 391 3 Answer. Although the two Wounds are fituated in different Places, their Re-union will be accomplifhed by the fame Means. The Ancients ufed the Suture of the Tendons fuccefsfully 5 but Reafon fupported by Ex- perience has demonftrated to us, that it is unneceffary, where a proper Bandage can be applied, that will keep the Ends of the divided Tendons exa(5tly together. Confe- quently the Suture muft not»be ufed here, efpecially as it might occalion an Inflamma- tion of the Part, which would retard the Re- union of the divided Tendons. The Means of accomplifhing the cura- tive Indications for both thefe Wounds, is to place the two Fore-Arms in two Cafes of Wood or Tin. The Bottom of each Cafe {hould be formed of two Pieces joined together by a Hinge, which being lined with little foft Cufhions, or padded, the Fore-Arm mufl be placed in it, fo that the Joint of the Wrift may be a little within the Hinge. The anterior and moveable C c 4 Part [ 392 ] Part of the Cafe muft then be elevated, which will keep the Hand and the Fingers turned back in a kind of forced Extenlion. This Pofition will bring the Ends of the Tendons together, fo as to be in Conta<51:. What could be done more by the Suture ? The Arm fhould be fixed in the Cafe, that the Elbow may be prevented from drawing back -, by this Means the Pofition of the Hand and Fingers cannot be altered. The Lips of the Wound muft then be brought together, and kept fo by Means of dry Suture^. Bleedings, a Regimen, and the Parts being kept ftill, will all contribute to retard or prevent an Inflammation, which might obftrudt the Cure. The Bleedings fhould be in the Foot. It will take up a Month to accomplifli a folid firm Re-union, as the tendinous Parts do not unite fo expeditioufly as the mufcu- lar. ji Swelled [ 393 ] A Swelled Testicle. AM A N forty Years of Age, has a Tefticle enlarged to near four Inches in Length and twelve in Circumferenee. It is indolent and very hard, perfectly round and fmooth, and without any Fluduation within. It is fix Years fince it began to fwell. The Chord of the Veffels is quite free from Complaint, as well as the other Tefticle. Moreover the Patient finds no Inconvenience but from it's Weight and Bulk, for he has never had the leaft Pain. He perceives that he falls away continually, though he was very lufty. What do you think of this Difeafe ? And what muft I do to cure it ? Answer. The Tumour in Queftion is not a Hy- drocele, as there is no Fludluation perceiv- ed J nor is it a Varicocele, as the Chord is in it*s natural State. Neither is it carcino- . matous, as it is indolent and perfedly fmooth. [ 394 ] fmooth. In fuch a Cafe it is neceflary to examine the Patient concerning his former Way of living ; and if he has been accuf- tpmed to loofe Women, we may fufpedl and even affert that his Complaint is vene- realj though there is no other Symptom to determine it , and the rather, as the Patient falls away without any Appearance of a Di- ilemper. The S u R G E o n'5 Reply. According to your Advice, the Patient was treated regularly with mercurial Fric- tions, and I obferved the Tumour diminifh in Proportion to the life of the Mercury, fo that it is now become like the other. I acknowledge I (hould never have fuf- peded the Caufe j but the Completion of the Cure clearly proves, that it was a vene- real Taint which occafioned the Swelling, and that we muft not be determined always by common outward Symptoms, that there is no venereal Virus exifling. Reflection. t 395 ] Reflection. How many odd and uncommon Com- plaints do we fee in Pradlice, occalioned by this Virus, or complicated with it, without any of the ufual known Symptoms where- by it may be difcovered ! A Swelling of the Thigh. AM A N about fifty who had been wild in his younger Days, has been fre- quently troubled ^ith different venereal ^Complaints, and about a Year ago had a Difficulty in making Water, which was cured by the Ufe of Bougies. About fix Months fince he obferved his right Thigh to be fomewhat larger than the other. He ■made the fame Ufe of it as before, as it was not painful, and has walked a great dfeal on it in the Country ; till infenfibly it has grown to near twice its natural thick- 'nefs, Note^ within thefe two Months hfe has [ 396 ] has felt a kind of StifFnefs in it, which has incommoded him in walking. He has ihewn it to me, and I obferved that almoft every where, but particularly on the Out- fide there is a Fludlualion of Fluid, prin- cipally difFufed to the lower Part, where k is the moft painful, and fo coniiderable that it appeared as if the Skin was upon the Point of breaking, as it happens in a very ripe Abfcefs. I made a Pun6ture into it with a Tro- car, and difcharged near four Pounds of a purulent Matter, after which I withdrew the Canula, the Orifice healed and the Thigh in a Week's Time has filled again, confequently it is in the fame State as it was before. Is there any other Thing to be done ? Answer. You muft again difcharge all this extra- vafated Fluid ; but a fimple Pun6lure is not fufficient, for in that Cafe the Thigh will foon be filled again as after the former Punc- ture J an Opening therefore a full Inch in Length [ 397 ] Length muft be made with a Lancet, that it may not clofe up fo foon. When the Matter is evacuated the Wound muft be kept open with a foft Tent of Lint. This will give Room to throw up Injeftions which may pafs into every Part of the Abfcefs, and eafily come away by putting the Thigh into a proper Pofition after the Injedion. The Sides of the Cavity which con- tains the Fluid, that is thofe Parts which the Matter may have loofened, will c prefTed out from the Veficuls Seminales, inftead of difcharging itfelf through the Canal of the Urethra, is thrown back on the Side of the Bladder ; where it lies concealed in fome Cavity formed by the irregular Cicatrice, and from thence is eva- cuated. It is alfo poffible that Part of the Diffi- culty which the Semen has in ilTuing from the Veficulae Seminales, on Account of the Cicatrices which are on the outfide of the Neck of the Bladder, that this Difficulty I fay [ 4^9 ] I fay, is the Caufe of the Swelling of the. Epididymis. Thefe Circumftances did not fliew them- felves till about the eighteenth Year, which is the Time the Semen begins to be fecreted from the Blood ; and they could not be per- ceived fooner. The Swelling of the Epididymes may then be called Spermatoceles, which may grow bigger in Time, and if the Patient continues in this State, he will be incapable of Procreation. There is jrreat Reafon to doubt whether it will be pofiible to remedy this Defed: of Conformation, which interrupts the natural Courfe of the Semen j however v/e ihould endeavour to do it by all pofTible Means. As Cicatrices of long {landing are very hard, we muft endeavour to- fotten them. The moft likely Method of effeding this, will be to make the Patient bathe- himfelf Morning and Evening in a bathing Tub, in which is put a ilrong Decodtion of emollient Herbs, as Mallows, Marflimallows, and others of the fame Kind, putting him afterwards diredly to Bed to dry himfelf. E e 2 At [ 420 ] At the fame Time we muft Endeavour if poffible to enlarge the Canal which leads to the Bladder, in which the Cicatrices are. This muft be done by emollient Bougies introduced every Day and Night as far as the Bladder, taking Care to increafe their Size from Time to Time as much as pofli- ble without injuring the Urethra, and leav- ing them in about an Hour. This Method may either comprefs or efface any Stricture made by the Cicatrice, that interrupts the Courfe of the Semen. If the Ufe of the Bougies happens to bring on a Suppuration in the Urethra, that may be able to relax the firmeft Cicatrices, which may contract: the Urethra in the faulty Part. This Method fliould be perfifted in for five or fix Months j perhaps it may not fuc- ceed, perhaps it may, but there is no other Method to follow. As to internal Remedies there is no Need to recommend any in this Cafe, becaufe they will be ufelefs j nor any Regimen but what tends to the Prefer- vation of Health in general. A Tumour [ 421 ] A Tumour on riv'TniGH occajioned by a Fall. AM A N five and forty Years old, but without any Weaknefs in his Legs, walking along the Street, fomebody put a Stick between his Legs, which threw him 3own, and in falling his left Leg was bent under his Thigh. He was carried Home, and in about two Hours as he complained very much of his Knee, his Surgeon was fent for. He examined the Condition of the whole Limb, but found only a moderate Swelling of the Knee. However three Fin- gers breadth higher, in the fore Part of the Thigh he obferved a circumfcribed Tumour, elevated about an Inch, and four Fingers broad, extending more towards the outer than the inner Side, and very painful to the Touch. The Surgeon defires your Opiiiioa as well in Refpedt to the Nature of the Tumour as what ought to be done to it. E e 3 Answer, [ 42 2 ] Answer. The Patient having fell with his Leg bent under his Thigh, it does not appear that he could poffibly give the fore Part of his Thigh any Blow, that could make fo great a Contuiion as to occafion fuch a Tumour as is perceived, and it is probably formed by one of thefe three Things, njiz, by the entire Patella, if it's Ligament is ruptured by the Effort of the 6xtenfor Muf- cles at the Time of the Fall : by the fupe- riour Part of that Bone if it is fradtured, for in that Cafe it would be retraded by the Effort of the extenfor Mufcles of the Leg j and laftly by a Rupture of the Aponeurolis, formed by the Union of the extenfor Muf- cles ; for in this Cafe the Parts will fwell by their Retradion, and the Inflammation which fuccecds it foon after -, beiides which the Blood and Lymph extravafated from all the ruptured VelTels, will increafe the Bulk of the Tumour. In either Cafe there will be found a more or lefsconllderable Vacuity between the Tumour [ 423 ] Tumour and the Knee. In other Refpedls I can give you no particular Advice, efpe- ciaily as the Nature of the Complaint is not exactly known. It is only by an exadt exa- mination of the Part, that a perfedl Know- ledge can be gained what Mifchief was done at the Time of the Fall. Till I have this particular Account, I can only advife you to keep the Limb in an horizontal Pofture, that is the Leg exadly extended in fuch a Manner that it cannot be bent by any Means whatever ; to cover the injured Parts with a Defenfative, and to bleed the Patient in Order to prevent or Cure the Swelling and Inflammation, which are our great Enemies. The Surgeon'^ Account. By an exad: Examination, I difcovered that the Patella was whole and in it's Place ; but as you obferved I found on preffing with my Finger a Kind of Vacuity or De- preffion between the Patella and the Tu- mour, which in fome Meafure proves to E e A me, [ 4H ] me,, that there is a Rupture of the Apb'- neurofis of the extenfor Mufcles of the Leg, particularly of that Part belonging to the Vaftus externus, for on the Side of the Vaftus internas it appears to me to be whole. I have already fixed the Limb in an hori- zontal Poilure, that is, extended it, and ap- plied over the Tumour a Deferifative, to difperfe the Fluids that may have been ex- travafated. Having taken off the Dreffings about four and twenty Hours after, I found a large Ecchymofis all along the Thigh and Leg. What more is there to be done ? Answer. The Leg muft be continued in the fame , Pofition, and the Patient prevented from any Motion that may occafion a Contrad:ion of the extenfor Mufcles of the Leg, in or- der that all the ruptured Parts may at pre- fent be relaxed, and afterwards brought to- gether and united by the Affiftance of Na- ture, which only can eifed it j for no Ban- dage or Application can do it. It will alfo be proper to fecure the Extenfion of the "^- Limb [ 425 ] Limb, by the Help of two Junks, that no Contradion of the flexor Mufcles, occaiion- ed by any Means, whether convulfive or otherwife, may obftru(ft the Re-union which you are endeavouring to procure. It will be neceffary at prefent, to make xife of Refolvents to affift Nature, for the Limb fhould become black in fome Degree, by the extravafated Blood approaching to- wards the Skin, which will appear firft black and afterwards yellow, but will be afterwards reflored to it's natural Colour by the Difperfion of the extravafated Fluids. During this Time the ruptured Parts will approach one another, which will be perceived by the filling up of the Vacuity and the fwelling of the Part going oiF. .The Patient muft be cured near a Month before he offers to bend his Leg. ■to <• ^n at C 426 ] ^n indolent Tumour on the Leg; the Consequence oJ a Contusion. THREE Weeks ago a Man received a Blow on the outfide of the Leg, which made a violent Contufion two Fin- gers breadth higher than the Malleolus ex- ternus, without making a Wound, or breaking either the Tibia or Fibula, borne Perfon immediately applied Wine and Oil to it, wrapping up the Leg in it. It fwel- led ; and on removing of the fecond DrefT- ing, there appeared a coniiderable Ecchy- mofis, extending from the Ancle up to the Knee. By the Ufe of Refolvents it was gradually difperfed, and the Leg reduced to it's natural Size and Colour -, only on the Place where it was flruck, there remained between the Bone and the Commencement of the Tendo Achillis, above the Skin, a fmall Tumour, in which one can feel with the Finger a Fluctuation, fimilar to what is felt in an Abfcefs jull come to Suppura- tion. There C 427 ] There feems to be about a Spoonful of fome Fluid, lying between the Membrana Adipofa and Membrana Communis Mufcu- lorum J the Skin is not thin, and is of it's natural Colour. The Patient feels no Pain. The Surgeon of the Place is defirous of o- pening the Tumour, afluring him, that as this has not been difperfed as well as the reft of the Contufion on the Leg, this Flu- id will turn to Matter, and occafion an Ab- fcefs. The Patient ftrongly objeds to the opening, and defires your Advice. Answer. There is no violent Contufion, without a Number of the fmall Blood-VelTels beins- ruptured under the Skin, in the Tunica Adipofa and the Membrana Cellularis of the Parts. By thefe Means thefe Fluids are extravafated, and while one Part is eva- cuated, and fpreads amongft the neighbour- ing Veficulse, forming what is called an Ecchymofis ; it is poffible another Part may remain and accumulate in the Place where the Blow was. If proper Repellents had been [ 428 ] been applied at firft, fuftaitied fey a mode- rately tight Bandage^ the Blood might have quitted it's Place, been difFufed as well as the reft the whole Length of the Limb, and quitted the Mouths of the ruptured Veflels, whofe Re-union would have been effeded in a fhort Time. But they were not ufed, and what was done was quite wrong, as the Application of Oil relaxed, inftead of contrading. Hence, in Propor- tion as the Fluids have l)een extravafated, their Quantity has gradually extended the Sides of the Cavity wherein they are extra- vafated, and formed the Cavity which they now fill up. This Blood not being expofed to the Airj cannot be changed fo as to become Pus^^ and for the fame Reafon has retained Part of it's Fluidity ; neverthelefs it is become a ' foreign Body, by it's long Continuance out of the Circulation. If there was a very large Quantity, I think we could not do without evacuating it by opening of the Tumour; but in it's prefent Condition, I think the Cure may be hoped for without^ an Opening. The Application of Refol- :; . ;:. - - vents ■ [ +29 } vents has efFeded nothing, and I think will not do any Thing; but a gentle gradual Preffure may propel the Fluid remaining into the neighbouring Cells, and from thofe into others,, and there the Heat of the Part will certainly procure the entire Difperfion. What remains of the fibrous Part in the Cavity will affimulate and unite with the Sides, in Proportion as they approach toge- ther, as I have feen in many Patients, who were exadly in the fame Cafe, and whom I have preferved from the Operation. .A Comprefs exad:ly of the Size of the Cavity where the Blood is extravafated, and about twice or thrice as thick as what is ufed in bleeding, mull: be folded up, dip- ped in Water well impregnated with Salt. This wrung out that it may the fooner dry, muft be placed on the Tumour, and kept opL,, wjtli . a moderately tight Bandage. In about two Days it muft be moiftened with the fame Water, and repeated every two Days. I dare venture to allure you, that in lefs than a Fortnight the Tumour will difappear with this Drefling only, and wi^^gji^any Oper^|^^|i, _ , A Tumour [ 43° ] A Tumour protruding from the Matrix. WOMAN forty Years of Age, for fome Time has had Fluxes of Blood, and in the Interval of thefe Fluxes fhe has had a confiderable Difcharge of va- rious Colours, which {he imagined to be the Fluor Albus. Some Time after fhe perceived a large flefhy Subftance, about as big as a fmall Apple, protruding from the Matrix. Not being painful, fhe was not anxious about Advice, and the Excrefcence, which is more and more elongated, is increafed in about two Months to the Size of one's Fift, fufpended by a round Stalk about an Inch in Diameter. Upon introducing the Finger into the Vagina, the Stalk is felt with Diffi- culty, on Account of the Body of the Tu- mour reaching to the Os Uteri, from whence it protrudes. Can this Diforder be cured? Answer. [431 ] Answer. The Tumours which arife from the Ma- trix, are but fmall when they firft appear ; but when they have pafTed beyond the Neck, this Neck which is contraded makes a kind of Ligature, which obftruding the Return of the Blood, occafions the Swelling of that Part that has defcended. This is the Caufe of the Fluxes of Blood and the In- creafe of the Tumourj fo much the more, as the Vagina being larger ealily affords Room for it's Bulk, which the Matrix does not when the Tumour is inclofed there, Thefe Tumours are only cured by Ex- tirpation J and in order to avoid any Dan- ger of a Hemorrhage, a Ligature fhould be made as near as poihble to -the Neck of the Matrix. This Ligature, if it is not tight will be ufelefs. It occafions all below it to mortify, by intercepting the Circula- tion, and inflaming that Part of the Pedi- cule that is above it. By this Method, the Pedicule mortifies and feparates higher up, as Experience daily confirms. The [ 432 ] The Excrefcence being feparated, a few Injedions made into the Vagina will be fufficient for the Dreffings. As the Fluxes of Blood in thefe Cafes happen frequently, and are often very con- fiderable, and there are befides many other Accidents which accompany thefe Excref- cences from their Beginning, it is necelTary they {hould be extirpated as foon as it is poffible to tie them. The firfl: Knot may and muft naturally loofen while you are making the fecond. To prevent this great Inconveniency, Mr Levret^ Mafler in Surgery, and a very able Man- Midwife, has invented a very conve- nient Method of making this Ligature. Inftead of a Linen Thread, he makes ufe of a Silver Wire ; by twifting this Wire, he can every Day again tighten the Liga- ture, which might foon after grow too loofe, becaufe it cuts the foft Parts that it inclofes. But by Means of this Silver Wire which remains on, the Ligature may every Day be tightened by twifting of it again. Several of thefe Tumours have been known to have Roots fpringing from various Parts E 433 ] Parts of the internal Surface of the Matrix i thefe indeed happen but feldom, and have nothing to diftinguifh them from others ; but the Patients all die. An indoknt Tumour between the False Ribs and the Os Ilium. AM A N about three Weeks ago, had a foft Tumour, about an Inch and a half broad, appear under the falfe Ribs, between them and the middle of the Os Ilium. In three Weeks this Tumour, which, is perfedly indolent, and without any Change of Colour in the Skin, has in- creafed fo, as to be now half as big as at large Apple. A Fludiuation is plainly diftin- guiflied. Note^ The Patient has had a kind of flow Fever this long Time, and a Year before had a malignant Fever. What is to be thought of this Tumour ? What mull be the Confequence of it ? What curative Indication fhould be propofed ? Should it be opened ? F f Answer, [ 434 ] Answer. This Tumour cannot be a ventral Her- nia, becaufe thefe Tumours difappear on the leaft PrefTure, which is not the Cafe here. It is not a Wen, becaufe they do not grow fo faft. It is not a Phlegmon, becaufe it has neither been accompanied nor preceded by any Shivering, Fever, or Pain. It can be nothing but a Collecftion of Mat- ter, which being formed in fome other Place, has gradually flowed into this, and fettled between the Interftices of the Muf- cles ; the flow Fever that accompanies it is almofl: a fufficient Proof of it. The Pa- tient a Year ago had a malignant Fever, and I imagine that v^'as the firfl Caufe of the Tumour on which you confult me. We know that thefe forts of Fevers pretty frequently, either critically or fymptomati- caily, fettle on fome of the membranous Parts, where the eryfipelatous Inflamma- tion terminates fometimes in the Putrefac- tion of thefe Membranes. By fome of thefe Abfcefles formed in the Limbs which are [ 435 ] are within our Infpecftion, we may judge of thofe that are formed in one of the Ven- ters. From this Putrefadion a fanious Matter difcharges, which gradually and flowly collecting, fpreads amongft the neighbour- ing Parts, and (as one may fay) difleds the Parts, to find out a PalTage for it's Dif- charge. If the Putrefadion happens near a Bone, the Periofteam becomes aifeded, the Bone is laid bare, and becomes carious. On opening of dead Bodies, how many Suppurations are feen formed within one of the three Cavities, which are the Confe- quence of a malignant Fever, and of which there was no external Appearance. Two Circumftances contribute here to make a difadvantageous Prognoflick. i. A Caries, if there is one, whofe Situation, fuppoling it to be certain, we mufl be ig- norant of, as I have frequently feen in thefe forts of Difeafes. 2. The Impoffibility of difcovering where this Matter was iirfl for- med. All this coniidered, I think the opening of the Tumour will be of no Service, and F f 2 perhaps C 436 ] perhaps may be fucceeded by the Death of the Patient, from a Reflux of the purulent Matter. It is what I have obferved in almoft all thefe Cafes, that the Patients have died, and always fooner in Confequence of the opening than otherwife j many Inftances of which may be feen in my Chirurgical Ob- fervatlons, publifhed in 173 1, in the Rue Saint Jacques a VOUvier. There the Rea- fon is given why the Patients generally die by the Reflux of the purulent Matter. I am of Opinion therefore that the Pa- tient will live longer, if the Tumour is not opened, or can be prevented from breaking of itfelf, and entirely difcharging it's Con- tents. If thefe Tumours break of them- felves, or we are obliged to open them to Hum V and Omentnoi. This, Sir! is an aatOt Account of the Diic£&, and of all we obierred at the open* iDg of the Body. What I am gCHog to fay moce to yoOt are only CoDJedores refulcing from all the Qrcomftances that has^e ac- fynpynK*^ the Dileafe from it's Begin ning to tbe End, and hafe £xne Degree of Proba- bffiiT. The canccrons Sac, or Bag, which u'c ibood in the Stomach, made me recollect die litde Animal which the Patient had vonuted up about two Years before, and I remembered at the lame Time what we fee da3y happen to Trees, particularly the Oak and Linden Tree, where feveral Infecls as Flies, Gnats, or other Animals, pierce the Infide of tbe Leaves and depofr.e their Eggs in the cellular Texture of the Leaves be- tween die two Kinds of Membranes which fix and conned their Fibres. It appears that the Caterpillar then wanders gradually, for [ 459 ] iyz he forms Excrcfccnccs of different Sizes in the fcifidc of the Leaves, which ferve for 2 Mttrix to the Embryo there depofited. The Animal is preferred, noorifhcd and grows to a certain Degree, when he appa- rently breaks through his Confinement. I hvrc fecn fereral of thefe Excrefcenccs which were as large as Hazle Nuts. Up- on opening one of thefe into two equal Parts, wkhoQt damaging the Middle, I hare fecn a perfed Fly come oot and fly away. Yoo may fee the fame io Spring. I letum to this caoceroos Tumoar formed ia the Stocnach ; this little Animal which was thrown up eighteen Months before, was it not the original Caufc of it ? This is a Point to be rdbWed. Is it impoflible that a fmall Animal fwaDowed alive in Sallad or wnhoilfx i Vegetables, may have pie rc ed the ioDcr Coat of the Stomach, lod^ idclf in Ac cxihilar Textme, whkh conneds and keeps the Membranes together, and there have depofited k*s Eggs ? S op pofii^ tliiy lo be a Fad; the Animal bang arrivod to its Time of Maturity, like a Child in the Womb, or like die Fly in it's little Tumoar, pierced [ 46o ] pierced through the inner Coat, and getting into the Stomach, might by only the tick- ling of it's Feet in crawling, have oecalioned the vomiting which threw it up. During the Time of it's Growth in the little Matrix (for I look upon the Space it occupied in that Light) a fmall Tumour was formed by the Extenfion of the Coats which enveloped it, that infenfibly increafed, and in Confequence upon the Evacuation of the Animal, there was a Vacuity remaining, into which the Food entered at Meal-times, there continued, became altered, and being as extraneous Bodies, would not permit Nature to bring the Sides of the Cavity together, fo that they might be re-united by a firm Cicatrice. This Vacuity then became ul- cerated. The Ulcer grew bigger, became deeo and cavernous, a Sac formed infenfibly, and the VefTels growing varicous and being fretted, difcharged Blood from Time to Time, as ulcerated Cancers in the Breaft or other Places do. The Ulcer fpread more and more, and made a Hole in the Bottom of the Bag ; then, v/hatever vv-as taken into the Stomachs v/hether [46i] whether Food or Medicines, fell into the Cavity of the Belly, and occalioned thofe violent Pains which for two Days preceded the Death of the Patient. As to the Reflexions which I have added to the Account of the opening of the Body, I do not give them to you as exadly right, and founded on experimental Knowledge, but merely as Conjecftures which have fome Probability. I do not therefore alTert what I fufpedt to be the Caufe of the Cancer in the Stomach as a Certainty, but I have en- deavoured to explain how the Animal might pierce through the inner Coat of the Sto- mach, and in what Manner the Nutriment, diverted from it's proper Courfe, has form- ed the Tumour, which I compared to thofe which the Flies and other Infedisoccaiion un- der the Leaves of Trees. Confequentlylleave to you free Liberty to make what Reflec- tions you pleafe on this Obfervation. I fhall only make one, which perhaps you may have made before me : Which is, that in our Profefllons, even the mofl: fkilful have Reafon to lament, that they have often particular Difeafes under their Care, that even [ 462 ] even fuppoiing they had a thorough Know- ledge of all their Circumftances, muft una- voidably be the Deftrudion of the Patient, in Spite of all the Affiftance of Art, howe- ver well direded or adminiftered. l^he Second Letter. YO U fay, Sir, that you endeavour to get Information of every remarkable Thing that occurs in our Profeffion ; which is a right Method of proceeding. I ima- gine I (hall anfwer your Views, or at lead contribute towards them, by adding to the Account I have juft given you of the Dif- eafe of the late Monf. £***, the Particu- lars of a Cafe, which the late Monf. le GeU" drey firft Surgeon to the King of Spaitty communicated to my late Father ; an exa(5t Account of which I have preferved. I fhall here give you a Copy of it. Word for Word. " The Perfon, Sir, who I informed you *■* had laft Year fwallowed a Fork on Shrove ;* Tuefday^ [ 463 ] <» Tuefdayy difcharged it by the Anus the « fame Year, 171 5, on the 25th ofjime-, « I fend you a Drawing of it inclofed, that i< is, the Spoon and the Fork, this laft co- «« loured black, as you fee. Although thefe « twoPieceswere nearly of the fame Weight « and Size 5 at prefent we find that the « Fork weighs a good deal lefs than the «* Spoon 5 for this laft weighs three Ounces « wanting one Dram, and the Fork weighs « but two Ounces and two Drams, want- « ing a Scruple, and had an Impreffion on <* it for the chief Part of it's Length refem- « bling Shagreen. I imagine that this cx- « traneous Subftance, which was fwallow- « ed when the Perfon was cleaning the «« Root of his Tongue with the End of the f« Sheath, flipped from him at the Inftant, « that rubbing too hard the Infide of the « Mouth, might occafion the Oefophagus « fuddenly to rife up and open j and upon « recovering it's former Situation laid hold «« of the Fork, which by it's own Weight " dropped down into the Stomach, finding " an eafy PalTage by the alimentary Dud:. « It was in his Stomach, that he felt the « firft « [ 4^4 ] *• firft Pains, accompanied by a Weight,' " which he plainly diftinguifhed in that ** Part, that continued for three Weeks or " a Month ; after which he complained of " an Inclination to vomit, and of a very " fenlible Pain in the Stomach, which muft " have been, according to our Judgment, ** about the Time that the Fork prefented " itfelf, at different Times to pafs into the " Duodenum ; which feems to be the " Truth, as the Weight after the firft " Complaint became lefs acute, more in- " ternally, and fomewhat lower down. " During all this Time the Patient was in " terrible Diflrefs, offered up Vows to all ** the Saints, had MalTes faid every where, " and enquired after Phyficians of all kinds, <* to know what would be the Confequence " of the Situation he was in, looking upon " himfelf already as a dead Man. " At length his Pain and Uneafinefs con- " tinued indifcriminately at Times through " all the lower Belly, fometimes provoking ** a Propenfity to vomit, and at others ** Gripings and Inclinations to go to Stool, ** followed by Fai^itings, At lafl there " came C 465 ] came on a fixed and violent Pain In the left iliac Region, which continued for two Months with different Symptoms, pro- ceeding from the Place where the Fork was obftruded, which I judged to be the Ileon. Among thefe Symptorrfs, the moft alarming, were Strings of Blood which appeared in his Stools, and gave me Caufe to apprehend, (and all the reft of the Profeffion who faw it as well as me) that the Prongs of the Fork were enga- ged in the Coats of the Inteftines, and making a PalTage that Way ; but after thefe two Months were paffed, this ex- traneous Subftance changed it's Situa- tion, and for fome Time gav« no more Pain -than what was fupportable, till at length (as I imagine) it flopped in the Caecum j judging fo from the Pain he felt in the greateft Part of the right Ileum, accompanied with the mod melancholy Symptoms, and fuch confi* derable Evacuations of all Sorts of Mat- ter and Blood, without any Medicine being able to ftop them for a Mo- ment ', till the Patient,^ broke down H h ** and [ 466 ] *' and emaciated, with a confiderable Fever, ** and a weak Pulfe, was at the laft Ex- *' tremity, and received the Sacraments and *■ extream Undion ; the Phyficians attend^' " ing him, believing as well as himfelf, that ** he had not above two Hours to live, " They even hurried me away from Padro ** the Royal Palace where I was, two ** Leagues diftant from Madrid, to be " prefent the next Day at the Opening of *' the Body, to fee if it was true that this " Officer had fwallowed the Fork, of *' which there' was no one a Witnefs but ** himfelf } becaufe the greateft Part of " thofe who knew that it was faid, he had " fwallowed a Fork, doubted whether *^ fuch a Thing was poffible. But to *' all Appearance thofe melancholy Symp- *^ toms which preceded, were owing to *' nothing but the Effort Nature made to *' expel this extraneous Body out of the " Cascumj for being arrived at Madrid ihc " next Day, I found the Patient a great deal *^ better, with but very little Pain about the *' right lumbal Region, all the other Symp- " toms being gone off, even the Fever, tho' " his [467 ] ** his Pulfe remained irregular and weak, " The Patient foon recovered his Appe- •' tite, his Fledi, and Corpulency, and " found hiinfeif in his natural State of *' Health, except a few flight wandering *' Pains, which pafled from the right Side of " the Loins to the left. He went abroad, " walked, eat and drank heartily for three *' Months, rejoicing in himfelf, as he " thought the Fork was difiblved, which he ** had been made to believe fcveral Times *' in Order to comfort him, would hap- '* pen. At laft on the 2oih of yune, " he felt violent Pains in the left Groin, " accompanied with Gripings and Eva- " cuations of different Kinds, glairy, bi- " lious and purulent to the Knowledge " of feveral, which continued to the 25th, " when the Patient going to the Clofe-* " ftool, after violent Straining, at length ** voided the above-mentioned Fork, with- " out feeling any, or but little Pain at the ** Time j and would not have known he *« had voided it, if he had not heard it " fall into the Bafin, which made him " call the People to examine what it H h 2 *' could [ 468 ] *' could be 5 when they difcovcred thfi <* Fork, covered with the Excrements <• he had evacuated. This is ^ (liort ** Account of a pretty extraordinary Cafe ** in the Way of our Profeffion, the ** greatcft Benefit of which was to the Per- " fon who was perfedly cured ; but may be " fome Confolation hereafter to any one ** who may have fwallowed any Thing of " the hke Kind. I did neither fee him " fwallow, nor evacuate this extraneous " Subflance ; but as I attended the Patient ** during the whole Time of his Com- *' plaints, which lafted fifteen Months ; I " have Reafon to believe as well as all thofe *' who vifited him, that the Story is true ; " the rather as the Gentleman, whofe ** Name was Don 'John Antonio de Aranda^ ** forty Years of Age, born in Catalonia ** but of Cafiile Parents, and brought up in «* Caftile^ was a Brigadier in the King of ** Spain's Armies, Colonel of the Madrid " Regiment, a good Officer, a brave Man, ** Son and Brother to Perfons in the Ser- ** vice, People of good Underftanding j <♦ and that the moil critical Examiners^ *' could [ 469 3 *' could never difcover any Reafon to be- " lieve him guilty of any Impofition in it. ** This Officer fpoke good French^ having " had the Misfortune to be taken Prifoner " and carried to Langres, where he was " three Years. I do not pretend to ex- " plain from whence the Complaints a- " rofe, which accompanied the different " Obftrudions to the Paffage of the Forkj " as there is no Man of Knowledge in the " Profeffion, but knows that it's EfFeds " on the Inteftines were the Caufe of the " above-mentioned Symptoms more or lefs, " amongft which the Obftrudtion in the " Ileum, and that afterwards in the Cae- ** cum, were the moft confiderable, *' Befides Sir ! it is to you I have addref- " fed this Relation, who are capable of " giving it the moft perfed Explanation. ** I have frequently been concerned " at the miftaken Tendernefs of many Per- " fons, who in their Grief for the death " of Relations to whom they were ftrongly ** attached, have looked upon the Requefl ** I have made to open the Body, as a Vio- *' lence C 47<3 ] " lence to Humanity. Nevcrthelefs it k "only by Diffedtion that we have learn- *' ed the Strudure of the Human Bo- *« dy, which has brought us to a more " perfed Knowledge of thofe Diforders, " that contribute to it*s Deftrudlion. But ** leaving this Matter, it is eafy to judge " how much our Art has been improved " from the Knowledge in general obtained " by opening of dead Bodies. In fome *' Perfons, the nature of the Difeafe has «« been intirely unknown -, fuch as that of ** the late Monf. de 5***, for there was " nothing that could give Occalion to fuf- ** pect what the Caufe was ? The other " very terrible Diforder, the Caufe of which " was known, was cured, I am bold enough " to fay Invita Natura, at leafl as far as " we know, fince the moft experienced, " aflerted that the Patient had nothing *• to hope for ; fuch is the Hiftory of the " Fork fwallowed. Other Diforders which " feem trifling, and to require only a little *' regular living, fometimes acquire all at " once a bad Difpofition, without our being *' able C 4-71 ] " able to dlfcover the Caufe of the Altera-- <' tion. Befides this, our Art will be " much improved by DifTedtions, if ♦* we only gain as much Knowledge as " is poffible, of the Ways which Nature ** has taken and followed, to fecond the Re- " fources of Art, which without her, can " do very litde. I therefore Sir, dcfire you " will lofe no Opportunity of Opening thofe " Bodies, which unfortunately ihall receive " no Benefit from your Skill and Care. J ajn^ ^c, ^c. FINIS. wV ^H COLUMBIA UNIVERSITY This bqjok is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE p C28(e3B)MS0 Le Dran Consultations =CvJ =00 =o iO =o :0 s-