S
o
5
TO
SY
SIN
RER
.
3322
LES
DRE
BAS

0
0
2
N
LIBRARY VERITAS OF THE
TOE MICHIGAN
III|II|||||||||||IIIIIIIIIIIIIIIIIIIII...
UNIVERSITY OF ME
RIIT11111111111111111111111111in111111111TIMIINI111001Inuillo111111111unnilminin
.
TUERIS
KNINSULAMA
"L'11'.
CINCUMSP
MSPICL
I'II|||||||
een in
is
t
He
||||||||||||||IITA
' MINI ||||IIIIIIIIIIIIIIIIIIIIMML
101111111110111stinttuli11011
l
l|||||||||IIHIUT
10l||||||||||||||||||||||||||||||IIIIIT.
--..
hiiiiiiiinimilitillatulatituttuttuttill
lic

-
MIU MIUHUIMHIIIHDUHMIINIHILIMHLITTRADITHI HIILIHUINSULISELTIEROTTIILIUINIINIT
.
L
.
. .
.
.
..
......
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHNIHIIIIIIIIIIIIIIHIL
The
George E. Wantz
(UM Medicine 1946)
Collection
DHIMILLETTERETRIBILLENNIUMITOMILDIRITTIINTIMITUJUDSTIPERSEDIAL
..
.
...
..
- -
-
.
. .
inwilliini NUNTAMIENTATIE
TOTENTIALITOMr.
.
.
.
.

SERIES
OF
LECTURES,
ON THE MOST
Approved Principles and Practice
OF
MODERN SURGERY :
PRINCIPALLY DERIVED FROM THE LECTURES DELIVERED
BY ASTLEY COOPER, ESQ. F.R. S, &c. &c.
AT THE
UNITED HOSPITALS OF GUY AND ST. THOMAS,
AND IN WHICH WILL BE FOUND
SOME OF THE OPINIONS OF THE MOST CELEBRATED SURGEONS, FROM
THE TIME OF HUNTER, TO THE PRESENT MOMENT:
INTERSPERSED WITH NUMEROUS CASES.
BY CHARLES WILLIAMS JONES.
THE FIRST AMERICAN, FROM THE SECOND LONDON EDITION.
BY CHARLES MINGAY SYDER,
SURGEON
Boston :
PUBLISHED BY CHARLES EWER.
NO. 51, CORNHILL.
1823.
.
:
Taubman / hore
. Bask Room
1823
SERIES OF LECTURES,
&c. &c.
.
IJACOB B. MOORE, PRINTE
Concord, N. H.

TO THE
Students attending the Lectures,
IN THIS

METROPOLIS.
GENTLEMEN,
IT has been my wish, for the last four
years, to see a Work of this description published.
It is presented to you in the familiar form of Lec-
tures : and I trust and believe it will be found to
contain as concise and faithful a view of the most
improved Practice of Surgery, as any work ex-
tant.
I can only assure you, it has been a very
arduous undertaking : that it may prove as useful
to you as a Guide and DIRECTOR, as my Friends
have had the presumption to anticipate, will be ex-
tremely gratifying ; and amply compensate me
for the great length of time devoted exclusively to
this pursuit.
I am, Gentlemen,
With great respect,
Your very obedient Servant,
THE AUTHOR.
London, September, 1818.

TO
ASTLEY COOPER, ESQ. F. R. Si
&c. &c.
SIR,
Much as I regret the appearance of the
FIRST EDITION of this Work in the name of
“ CHARLES WILLIAMS JONES,” formerly a pupil
of your's, it is particularly gratifying to have this
opportunity afforded me of doing justice to your
professional exertions, by publicly acknowledging
that the original ideas of THIS SERIES were deriv-
ed from your Lectures on Surgery, as delivered at
the United Hospitals of Guy and St. Thomas.
With the most unfeigned respect for your
talents, and the sincerest wish that the Profession
may long, very long, possess so valuable a mem-
ber,
I have the honour to subscribe myself,
Your most obedient and
Very humble servant,
CHARLES MINGAY SYDER.
London, June, 1821.
LECTURE I.
I shall commence the series with a few preliminary re-
marks,which will render more intelligible the subjects hereaf-
ter to be discussed. The natural temperature of the blood,
circulating in the body, is 98 degrees of Fahrenheit's ther-
mometer; the pulsations of the heart in a state of health from
60 to 84 degrees in a minute, the medium is 72, which may be
considered the natural standard. The pulsations, with res-
pect to respiration, may be considered nearly as 4 to 1, or
rather 7 pulsations of the heart to 2 respirations in the adult :
in children the pulse is much more frequent, in old age less so;
and the smaller in proportion the animal is, the more frequent
is the circulation : in children the pulse is very quick.* In
the brute creation, as for instance, the horse, we cannot dis-
tinguish above 32 or 37 in a minute ; in the dog, 130. The
pulse becomes much accelerated in fevers : from 72 it has
risen to 120,130,150, and even 160 in a minute, even so quick
that it could not be ascertained, and beyond 200 it would be
impossible to count it ; the lowest pulse ever known was from
13 or 14 to 28 pulsations, observed by Dr. Cholmley and Mr.
Stocker. There are many variations in the pulse denoting the
state of the circulation ; the action of the heart may be di-
minished, increased, or changed ; as a stronger or weaker
pulse than natural, a contracted one, a harder or softer, and
sometimes irregular or intermittent. A temperature from
60 to 64º admits with ease and safety every exertion neces.
sary either to our subsistence or pleasure, hence it may be



* According to Heberden and Blumenbach, in infants at birth, the pulse is 140 ;
first year, 124; second, 110 ; third and fourth, 96 ; seventh, 86 ; at puberty, 80 ;
manhood, or 21 years old, 75; sixty years of age, 60,
LECTURE 1.
termed temperate. The higher degrees up to 70€ are called
warm, and all above that hot. In the inferior range,a few de-
grees below 600 is termed cool, and all below, cold.
The arteries are divided into three orders, the sanguineous,
seriferous, and lymphatics, each set conveying the different
descriptions of fluids from whence their names are taken:
from the minuteness of the vessels, this cannot easily be de-
monstrated, although it is so evident to our senses, as we find
parts of the body that only transmit lymph. This is found to
be the case in the minute ramification of arteries called ex-
halants, and from which that transparent fluid lubricating the
cavity of the thorax, abdomen, &c. is derived, and also the
insensible perspiration.
The blood is an uniform homogeneous fluid; in three or
four minutes after it escapes it begins to coagulate, anda spon-
taneous separation takes place into serum and crassamentum.
The crassamentum is found again to be composed of red
particles and coagulable lymph, and this can be very easily

demonstrated.-
The lymph is of a size-like appearance, and becomes evi-
dent from the red particles subsiding from it.
The blood is then composed of 3 parts, serum, the lightest,
coagulable lymph, or fibrin, next, and the cruror, or red par-
ticles, which are the heaviest of all. Professor Blumenbach
calculates that the quantity of blood in the body is about 120
ounces troy; and allowing his assumption to be correct, that
two ounces are expelled from the left ventricle at each con-
traction, and the pulsations 75 in a minute, it follows that
125lbs. of blood will circulate through the heart every min-
ute, being · more than the whole quantity contained in the
body, and the whole of the blood thus passes through the
heart 75 times in each hour. The system is soon affected
when a vessel or orifice is large, and the animal expires from
sudden exhaustion ; while, if blood were drawn from a small
vessel or orifice, the vessels would be able to accommodate
themselves gradually to the loss, and we see in bleeding at
the nose, the piles,&c., the blood escapes for days successive-
ly, and the quantity lost will be extremely great, and this with-


LECTURE I.
out danger, while the same quantity drawn suddenly from a
large vessel or orifice would prove fatal. Mr. Boyle found
the specific gravity of blood to water to be as 1041 to 1000,
that is, rather less than one-twentieth heavier than water :
Dr. Jurin, 1054 to 1000, being rather more. Water at 32°
is congealed into ice ; even quicksilver becomes solid at a
certain temperature.
The blood coagulates without diminution of temperature ;
if received into a vessel at 969 or 98° equal to its heat, it co-
agulates equally quick; at 40° it does so later than at 98°;
at 100° sooner than at 40°; if stirred continually, it still does
so as well. Rest or air was thought to be the cause; but it
coagulates when not exposed to either. Mr. Hewson laid the
jugular vein of a rabbit bare, and applied two ligatures, at
some distance between which a quantity of blood was inclu-
ded: it was left alone 23 hours, when, on examination, only
of the fluid was coagulated. It coagulates when in a blad-
der or gold-beater's skin. Rest does not produce it; air facil-
itates it. Eight minutes is commonly the time it takes to co-
agulate :-What a wise provision of nature ! When blood es-
capes in violent hemorrhages, the mouths of the vessels be.
come plugged up by the coagulation, and the bleeding pre-
vented ; hence in uterine hemorrhage, or indeed, in any oth-
er kind of excessive bleeding, nothing can be more favoura.
ble than syncope or fainting, which facilitates, or rather gives
an opportunity for this formation. By no means permit or
use stimuli in any shape in these cases, as they occasion in-
creased action, which would remove the coagula from the
mouths of the bleeding vessels, and the hemorrhage would be
renewed; rather let your patient be kept cool, and perfectly
quiet. Common and neutral salts prevent its speedy coagula-
tion. Coagula are found in many parts of the body ; in an-
eurismal tumours,coagulable lymph is effused in large quanti.
ties, and this appears to be gradually forming strata, having
a lamellated appearance, resembling the layers of an onion.
I shall enter more fully on the nature and properties of coag-
ulable lymph as I proceed in the series : it will be here only
necessary further to observe, that it is abundantly deposited



LECTURE 1.

under inflammation, and when there is no outlet, it becomes
organized,and occasionally it is seen to unite the pericardium
to the heart, the pleura to the lungs, &c.; and where there is
an outlet, it peels off as in the bronchia, and is coughed up,
when persons suppose they have brought up part of the lungs.
The late Dr. Cheston, of Gloucester, had a fine specimen of
it. In dysentery and inflammation of the urinary bladder,
such large portions have come away as would very much
surprise an ignorant spectator.
The sizy buffy coat in inflammation of an important organ
seems to proceed from the action of the vessels themselves,ac-
cording to Mr. Hewson : they perform their office with great
force, and the appearance is to be attributed to this strong ac-
tion, as in pneumonia, &c. This is observable in pregnant
women, and as nourishment is to be provided for the fætus, it
only indicates increased action, not disease. In proportion
as the animal is strong, so is coagulation slow, while in the
weak and faint, as we see in patients greatly reduced, previ.
ous to amputation, it coagulates while on the stump immedi-
ately after the operation : so, when the blood is sizy, it does
not coagulate so soon ; it takes half an hour, and sometimes
2,4,6, and even 24 hours before this happens, when great in-
flammation exists : this has been seen in acute rheumatism.
Suppose in pneumonia I take 16 ounces of blood away in 4
cups; in the first the blood will be very sizy, in the second
and third not much so, and in the fourth not at all. Again, if
you draw blood in another person to the same quantity in a
similar way, in the first there shall be no size or buffy coat,
the second and third shall be very sizy, and the fourth shall
be as the first. Some people have great fear of having this
simple operation performed, and fear produces a diminution
in the action of the heart; hence the latter is to be attributed
to this cause ; first, when the puncture is made, and at last,
when the circulation becomes weak. A gentleman had an af-
fection of the chest, and blood-letting being the only relief,
he was bled so often as hardly to tinge or stain a white cloth;
it is therefore apparent the red particles are slower in being
formed than the other component parts of the blood, and al



LECTURE 1.
so that they do not circulate in the minute parts of the body.
I shall digress a little on the effects of stimuli and seda-
tives. Whatever increases the strength and frequency of
action has been called a stimulus ; whatever diminishes it, a
sedative. A stimulus increases the momentum of the pulse;
a sedative diminishes it: whatever would alter the pulse to
hard or intermittent, may be called an irritant.
Stimulants are said to be either common or specific ; com-
mon are what increase every part of the circulation, as wine,
&c., but the greater number are specific, that is, they have a
peculiar effect on some particular part; such a stimulus is
seen in mercury, in squills, and in cantharides; so also in
purgative medicines, as aloes, &c. &c. Some medicines stim-
ulate the arteries alone, and some the absorbents, and those
that produce this effect on the latter generally have a con-
trary one on the former, as digitalis. Arsenic was injected
into the jugular vein of a dog, which died in twenty minutes
from inflammation of the stomach ; so also of muriate of mer-
cury, as will be detailed when treating of poisons.
The effect of stimuli depends on the constitution ; hence
the immense variety in different applications of medicines.
All stimulants are found to lose their effect by repetition ; this
is illustrated by wine and opium. The utmost stimulating
effect of opium is to raise the pulse 15 strokes in a minute,
that of wine 50, and this without an adequate sedative effect,
whereas the sedative operation of opium is considerable.
Sedatives : these diminish the force and frequency of ac-
tion; some obviously in the first instance act as a stimulus, as
opium ; the sedative effects of this and wine bear no propor-
tion; the operation of some sedatives is a direct effect on
the nerves ; this is demonstrated by injections of opium to
the heart or brain ; the same of belladonna to the eye ; one
grain applied, causes such a dilatation of the iris, as totally
to disappear; so of lead applied to the muscles of the eye,
one or a few grains applied causes paralysis; it has no stim-
ulant effect; neither has digitalis.
The effects of heat on the body are universally stimulant.
The natural temperature of the blood, as I have previously



LECTURE 1.
observed, is 98° of Fahrenheit's thermometer in the human
body. A person was put into a vapour bath, heated to
202°, it raised the pulse to 120. In another, whose pulse
was 75, it rose to 164. A third person's pulse, exposed to
the same degree of heat, rose only to 145. Dr. Fordyce went
into a vapour bath of 120°; his pulse rose to 145: going into
a dry heat of 254°, he supported it much better. The effect
of heat in a warm climate produces quicker growth, and pre-
mature old age: the inhabitants arrive at puberty at 11 and
12, and seldom live to 60. In more temperate climates, this
does not happen till from 18 to 21, and life is prolonged from
70 to even an hundred years and upwards. The effect of
heat on the pulse is to produce a quicker and fuller action ;
the external veins dilate, and are seen apparently distended
in the warm bath, which always produces perspiration, and
is a general stimulus; it has great power in exciting the ab-
sorbent vessels, and in weakening the body. In twenty min-
utes, this power extends to the production of syncope : in five
minutes, it only increases the general tone of the vessels. The
hot bath, from 105 to 110°, is productive of uncommon bene-
fit in some scrophulous cases. Violent heat causes blisters
to arise; a more violent still, excoriation and detachment of
the cuticle; still greater, death of the part and mortification :
and of these three stages of burns, the second is the most
dangerous, as I shall explain hereafter, on burns and scalds.
The patient dies of excessive irritation when the cuticle is
removed extensively, in a few hours. Heat, when applied to
the body, generally with moisture, as in a poultice, relieves,
by exciting perspiration of the part, and unloading the capil-
lary vessels ; with the same view, fomentations are used :
and to excite the absorbent vessels, dry heat by friction or
otherwise, tends to the same effect.
Of Cold : its effects are very interesting ; though it does
diminish, yet sometimes it increases the action of the heat.
Of its sedative effects : I made this experiment while in
Edinburgh, which had been done often before; my pulse be-
ing 85, I exposed myself to 18° of Fahrenheit's ; my pulse
became in one hour 76, in two hours 65, then followed sleepi-




LECTURE I.
ness; its ultimate effect is a sleep, and more remotely death.
In this circumstance, the body is robbed of its heat faster
than the organs of respiration can supply it, and when the
heat becomes lost, the circulation ceases. Cold, when par-
tially or particularly applied, causes a difference in the
heat ; the ears and nose, from excessive cold, mortify and
drop off, as was very fatally exemplified in Napoleon's cam-
paign at Moscow. The living part of the body may be fro.
zen, and yet restored to life, as has been proved by experi-
ments made on frogs ; being completely frozen during a
severe winter, they were put on a table before a fire: on
the return of warmth, their sensibility returned ; they soon
began to move, and presently one jumped off. In a case of
strangulated hernia, Mr. Cline and Mr. Sharpe applied pow-
dered ice for upwards of forty hours; the consequence was,
the part was frozen white and hard, heat restored life to the
part, but being too suddenly applied, ultimately caused
sloughing. Though cold in general diminishes the frequen-
cy of the pulse, yet if applied suddenly, it increases it. A
man having a pulse of 60, by plunging into the cold bath,
it rose to 120 ; another person by doing the same, whose
pulse was 90, had it raised to 135. I have repeated the
experiment, that of trying the effect of a partial application
of cold, by plunging my arm in snow ; my pulse, from beat-
ing slowly, became very quick. By the addition of ice to
water, lowering it to 33°, my pulse being 81, was raised to
121 ; at another time, being 87, to 139. It seems to me to
depend on the suddenness of the plunge and the irritability
of the person ; as this effect of cold is irritating, the pulse,
though increased, is a contracted one, and thready. I am
not aware that the tonic effects of cold have ever been sat-
isfactorily explained. A debilitated person shall have a
quick pulse, but weak, with heat too on the skin; the effect
of cold is to bring down the pulse to its natural standard,
and take off the excessive heat ; and it is in this way the
cold bath does good in weakly habits, and in typhoid pa-
tients. It produces a slower and fuller pulse ; it does not
agree with a plethoric habit, as it causes head-ache, from a



LECTURE 1,
determination of blood to the brain. Ice is used as an exa
ternal application in hernia, and has been strongly recom-
mended by Sir James Earle, in burns with the best effect;
but I must refer you to the subject itself : do not use it if
the cuticle be removed; it has been most strongly objected
to. Artificial ice may be made with equal parts of nitre
and sal ammoniac, mixed. Cold is applied occasionally by
means of evaporation ; æther is the best to a warm sur-
face, and has relieved in a few hours, as on the temples in
severe attacks of the head-ache, &c. Cold applications are
had recourse to for removing inflammation, in some cases
with good effect. The liquor. acet. plumb. dil. c. spir. vin.
rec. is an excellent application ; it has this double effect,
that of cold, and the sedative effect of the lead ; and is very
effectual in removing inflammation : few clothes should be
put over inflamed limbs. That cold poultices retard the
formation of matter, and warm encourage it, must be con-
sidered only ideal; heat is so quickly imparted from the
body, that unless it is repeated every ten minutes, nearly
the same effect is produced from both.
It is deemed expedient that a short digression on Constitu-
tional Irritation should still precede the subject of Inftam-
mation, which most authors have immediately commenced
their works with.
Irritation is a subject on the knowledge and comprehen-
sion of which our surgical treatment will depend ; by it is
meant an unnatural stimulus. If a stimulus be natural to
the body, as in taking food, the irritation is confined to one
part. Irritation may be either considered local or general;
the effects are produced by the nervous influence, as when
a nerve is wounded, it communicates the injury to remote
parts. There is an universal connexion of one part of the
body with another, but more particularly so in some parts
than in others ; and this is denominated sympathy; by which
is meant one part being affected in consequence of injury
done to another at a distance from it; although sufficiently
obvious, yet this principle is doubted by some. It must hap-
pen by the general communication of the nervous agency ;




LECTURE I.
the most common and natural is the sympathy of the uterus
and breasts. Coughing is an act of sympathy, the effect of
irritation in the larynx ; sneezing is an act of the same
kind. Other instances might be adduced; but my object
now will be to treat of diseased sympathy, which is of two
kinds.
Theone is called the sensation; the other is termed the
action of the part. Examples of the first kind : When an ob-
tuse pain is felt in the loins, from a diseased testicle. In
inflammation or disease of the hip joint, pain is felt through
the whole course of the sciatic nerve, from the knee to the
foot ; and this often proves a source of mistake to the sur-
geon, when consulted by a person who complains of pain in
the knee. The leg should be examined up to the hip joint,
to ascertain if it proceed from sympathy. The length of
the limb is apparently increased. A stone in the bladder
causes pain in the extremity of the penis. A disease of the
prostate gland, causes pain at the basis of the sacrum, and
not unfrequently in both thighs. A disease of the stomach
will produce pain in the left shoulder. A disease of the
liver a sympathetic affection in the right shoulder. A dis-
eased testicle pain in the loins. An affection of the mesen-
teric glands of the rectum produces an itching at the nose.
Examples of the second kind, or sympathetic, diseased action.
Diseases in the urethra very frequently produce inflamma-
tion of the testicles, sometimes of one, at other times of both.
The glands in the groin are often affected with sympa.
thetic hubo, in consequence of gonorrhæal inflammation,
which disappears as soon as the cause subsides or is remov-
ed. Hiccup and convulsive action of the diaphragm is a
symptom of a mortification. But of all organs to which
these effects are produced, none are more frequently affect-
ed than the stomach. For instance, if a blow be received
on the head, causing injury to the brain, vomiting is the
first and almost constant symptom. Vomiting is produced
when the testes are injured, or the intestines hurt, wounded,
or strangulated ; it will often arise from the inere introduc-




10
LECTURE 1.

tion of a bougie, when it is attended with faintness; or from
a gall stone passing the biliary duct ; or calculi passing
through the ureters into the urinary bladder, &c. An obtuse
pain in any part may occasion vomiting ; but an injury to
the stomach itself will be attended with fatal effects. A man
walking through Fleet-street quarrelled with a woman; an-
other female came up, and gave him a blow on the region
of the stomach, which caused almost instantaneous death.
Upon dissection, to trace the cause of his expiring so sud-
denly, no disease could be perceived. A man belonging to
the India House, while lifting a weight, which he was al-
most incapable of doing, was accidentally struck by another
while in the act of extension, and he fell down ; no life was
perceived in him, and attempts to restore animation were
ineffectual; on being opened, there was hardly any appear-
ance deviating from the natural, except a small part oppo-
site to where he received the blow, which appeared red.
When the stomach receives a blow suddenly, the diaphragm
becomes incapable of respiration; and when inspiration is
thus impeded, nature cannot perform her functions, and
death is the result. Some substances introduced into the
stomach, such as oysters, muscles, &c., will, by a sympathy
between it and the skin, produce eruptions on the skin. It
is by irritation, that corrosive sublimate and arsenic cause
effects on the stomach which cure cutaneous affections.
Fainting is caused by local irritation, respiration being for
the moment suspended. A violent shivering once or twice
in twenty-four hours, is often the result of a stricture in the
urethra, and is best relieved by opium. Shivering is also
caused by the formation of matter, and occasionally by the
introduction of a bougie. Paralysis of the lower extremities
sometimes occurs in children from irritation in the bowels,
and it sometimes proceeds from teething, which will also oc-
casion in them convulsions. A rash may be brought out on
the skin by teething, and by costiveness, in apparently
healthy children. A suppression of urine has followed the
amputation of a limb; and the practitioner is sometimes



LECTURE I.
obliged to desist in the extirpation of the female breast, from
the sickness caused by it. Scalds, burns, &c. though occa-
sioning slight local injury, are frequently followed by bad
effects. Compound fractures also are often attended with
but slight local effects; but in the morning succeeding the
accident, great constitutional injury will be evinced, which
has been known to mislead the physician, who conceived
them to be typhoid. Irritation in the stomach is followed
by loss of appetite, vomiting, &c. ; the bowels being at first
costive, but generally concluding with diarrhæa; the secre-
tion of bile is lessened, consequently the fæces are of a bad,
unhealthy colour. Vegetable poisons, such as tobacco, in-
troduced into the intestines, produce great relaxation, de-
bility, syncope, &c. Pressure on the brain will stop the
motion of the heart to a great degree ; but on the cause being
removed, it again re-acts. The symptoms of constitutional
irritation are pains in the head, back, and loins; the pulse
being quick, hard, and generally full, next, contracted and
thready : when the irritation is great, irregular, and often
intermittent, tongue furred; if the irritation be slight, white;
if considerable, yellow ; if so great as to terminate in mor-
tification, brown, the stomach rejecting its contents, bowels
costive, urine high coloured, and when the irritation is
ceasing, it deposits a sediment. The effect on the skin is
generally cold chills, succeeded by heat and profuse sweat-
ing: if slight, once in (wenty-four hours ; if great, twice,
and so on. The symptoms produced by contused wounds,
from their effects causing considerable irritation, are often
mistaken for fever. The first effects of the accident are
pain in the head, back, and loins, tongue white and furred ;
afterwards brown, and in proportion to its quickness in be-
coming brown, the violence of the irritation is to be esti-
mated; the mouth dry, appetite lost, and sometimes sick-
ness ensues ; costiveness, which, if the irritation be of any
continuance, changes into purging ; pulse preternaturally
hard, though not full; the arteries not dilating : when the
irritation becomes more violent, the pulse becomes irregu-





12
LECTURE 1.
lar and interrupted, (intermission of pulse in old people not
to be considered dangerous of itself, without other concur-
ring symptoms,) and sometimes there is a sensation of jerk.
ing; respiration quick and laborious; urine discharged in
small quantity and highly coloured; the skin dry, and the pa.
tient restless ; delirium and subsultus tendinum often succeed.
The degree of irritation depends on four principal circum-
stances : on the size of the wound; on the part injured ; on
the ease with which it can be restored ; and on the consti-
tution of the patient.
The violence of the symptoms in a great measure depends
(when the parts are not vitally important) on the irritability
or susceptibility of the constitution, and as the latter will be
able to resist the influence of irritation, so will it be regula-
ted, for a slight injury occasions violent effects in some per-
sons, while in others they are trilling.
Case. A man who lived intemperately, was bled by the
late Mr. Saunders, two days after he was taken ill; on the
fifth, the arm was inflamed above and below the elbow, and
pus was discharged from the wound ; his pulse was 120,with
delirium. Opium was used both internally and externally,
combined with other medicines ; on the 6th day,his pulse was
110; on the 7th, he was purged, and his delirium became less
violent ; a poultice of bread and water was applied to the
arm with opium ; the 8th day, the pulse was 120, the edges
of the wound covered with a brown substance, and having a
fleshy feel ; the arm discharged a bloody serum; and on the
9th, notwithstanding every assistance that art could devise,
he died. On dissection, the skin was found mortified round
the arm, the cellular membrane inflamed and suppurated,
but the vein which had been opened was uninjured.
Case. An instance contrary to this, of considerable injury
without fatal effects, was seen in the person of a brewer's ser-
vant, who was run over by a dray; his elbow joint was open-
ed, the bones fractured, and the artery separated from the
bone. As he would not consent to an operation, although
strongly advised to do so, the wound was closed, it soon
healed, and he recovered.



LECTURE I.
13
To relieve constitutional irritation, when excessive, or
arising from the injury of any vital organ: 1st, take away
blood, in proportion to the strength and plethoric disposition
of your patient.
2dly. Restore the secretions of the liver, kidneys, skin,
and intestines.
In children give calomel and antimonials, for nineteen dis-
eases in twenty in them are inflammatory, and this is the best
medicine to restore perspiration, &c.; bathe the feet in warm
water : by these means you take off the momentum of the
blood, and give a healthy action to the secreting organs.
In adults it will be better to give calomel at night and sa-
line purges the following morning.
3dly. Lessen the nervous irritability by opium, combined
with some sudorific.
And, 4thly, Guide your patient's diet and regimen.
The influence of some passions of the mind, as grief, anger,
fear, &c., are evident to us all; and their influence, on dis-
eases, being increased, must be observed with peculiar care
and attention by the practitioner. Their effects are almost
incredible. Grief disturbs the stomach, and is a depressing
passion : it lowers the pulse, and particularly affects those
organs whose actions are languid, such as the liver,frequently
producing in it obstructions and disease. Anger has an irri-
tating effect, quickens the pulse, but renders it thready: it re-
tards the cure of disease in general, of inflammation in par-
ticular, rendering ulcers ill-conditioned and sloughy. Fear
augments the quantity of urine, and has the most extraordin-
ary effect of all ; from it diseases, not otherwise attended
with immediate danger, prove fatal. Instances of this might
be enumerated in fractures of the leg, cancers of the breast,
stone in the bladder, in which patients have died from ex-
cess of fear alone; it is a most depressing passion, and low-
ers the pulse till it altogether ceases. The passions being a
part of the mind, and of the animal functions, powerfully
affect the organic or vital functions under disease.



LECTURE IT.

ON INFLAMMATION.
WHEN inflammation occurs externally, it is denoted by four
marks or signs; these are redness on the part, pain, swelling,
and increased heat. It is defined by Mr. Hunter to be a pro-
cess occasioning, in a given time, and from one immediate
cause, the following local effects, viz. pain, swelling and red-
ness.
The redness is owing to a great quantity of the red globu-
les being determined to the part, and distending the vessels
which before admitted only the transparent particles. This
is often remarkable in the tunica conjunctiva of the eye.
The swelling in a tumour, proceeds from the dilatation of
the vessels from the effusion of coagulable lymph into the in-
terstices of the cellular substance.
The cause of pain is supposed to arise from the distention
of the blood vessels of the nerves, and thus making pressure
on them. A part inflamed is infinitely more susceptible of
pain than the same part when in a state of health. An en-
cysted tumour has been removed from a lady with scarcely
any pain being expressed, while the mere opening of an ab-
scess,where the integuments were inflamed, has caused appar-
ent tortures; therefore it would at all times be desirable in
• LECTURE II.
amputation to cut, if possible, above all inflammation, for if a
cut be made into an inflamed part, independent of the ex-
cruciating pain given, the stump will scarcely ever do so well.
This is remarkable in hydrocele ; when uninflamed, the
injection produces a slight adhesive inflammation ; but if it
were previously inflamed, the case would be altered ; and if
precisely the same injection were made use of, the inflam-
mation would extend to the suppurative process.
The heat of inflamed parts has been and remains a matter
of question. Hunter denied the existence of it, and made
several experiments to support his arguments. He introduc-
ed a thermometer into the rectum of a dog, and found it
stood at 101 ; he then injected a solution of muriate of mer-
cury, by which a violent inflammation was produced; on ap-
plying the thermometer, there was no increase of heat.
He likewise introduced it into the vagina of an ass: it
was then 100; on producing inflammation, it fell to 99; after
a short time, it rose again to 100, but there was not any fur.
ther increase.
These experiments, however ingenious they may be thought,
are by no means satisfactory. On the surface of the body
increased heat is found to arise from inflammation : a blister
raises the thermometer to 94, while the parts around are on-
ly 90.
That increased heat really exists externally is now univer-
sally admitted : Hunter has allowed that the temporary en-
largement of the diameters of vessels always happens when-
ever there is any process going on requiring an extraordina-
ry supply of blood. He also states that the colouring mat-
ter of the blood, the red particles, is its heaviest part, and
does even acquire an increase in bulk in inflammation. Now
in inflammation,the vessels of the part are certainly enlarged;
they allow the red particles to circulate through them, which
before, in a natural and healthy state, contained only the
transparent; this, combined with the increased velocity of
the circulation, will be sufficient to account reasonably for
the excess of animal heat, by the greater portion of caloric



LECTURE 11.
which is given off, causing the variation in the temperature,
and hence it approximates nearer to the heat of blood, ac-
cording to the extent and violence of the inflammation.
Inflammation has four results or terminations :
1st. Adhesion, from coagulable lymph being thrown out in
the cells, and the parts becoming glued together, or incasing
the extraneous substance, which was the original source of
mischief, and all the symptoms existing gradually disappear-
ing. This process, or stage, by some, is termed adhesive in-
flammation, by others, resolution, and is the most favourable
of each.
2dly. Suppuration, or a secretion of matter in the centre :
from the continuance of the inflammation, the action of the
blood vessels becomes changed, and pus is formed.
3dly. Ulceration, which eventually, by continued pres-
sure, excites absorption of the surrounding parts, thereby al-
lowing the escape of the extraneous body ; this is termed ul-
cerative or absorbent inflammation.
4thly. Mortification or gangrene, in which process the
parts losing their vitality become dead, and separate from
the living, by the suppurative process taking place for their
removal.
Inflammation produces different effects in different parts of
the body. In the skin it generally extends a considerable
way; besides the cuticle is raised, as in blisters, containing
underneath serum, and very seldom producing pus ; this is
called the Erysipelatous Inflammation. In this affection
there is generally constitutional irritation, subsequent to its
origin, accompanied by shivering, acceleration of the pulse,
depression of spirits, prostration of strength, &c. &c. Ac-
cording to Mr. Hunter, this is a cutaneous inflammation,
which now and then spreads over a considerable extent of
surface very rapidly, without extending generally to the cel-
lular membrane underneath.
It differs from local or common inflammation, which is of a
deep red, by being of a scarlet colour, tinged with yellow,
being also more diffused, and not so elevated or circumscriba


LECTURE II.
17
ed, disappearing in one situation and attacking another, the
colour of the cuticle having a glossy smooth appearance ; it
is accompanied with a burning itching pain in the part ; fre-
quently ending in resolution, but seldom in suppuration.
Inflammation of the arteries also is very extensive, even
going to the heart itself. This has been frequently observed
in patients who have died from constitutional irritation, after
an operation, where a ligature has been made on an artery.
Case. A man in St. Thomas's Hospital, after the operation
before mentioned, had a violent inflammation in the artery,
which ran on to suppuration. The symptoms attending it
were, first, a sense of cold, with rigidity of the joints similar
to rheumatism ; delirium came on; pulse, 130. After death,
the inflammation was discovered running along the internal
coat of the artery as far as the heart itself. The cure in
such cases must consist in venesection and other evacuating
remedies. The inflammation is always found to be in the in-
ner coat only.
In the veins its progress is slower than in the arteries; and
when it reaches the valves, these generally adhere, and glue-
ing the sides of the veins together, often prevent any further
extension of the mischief; but if this fortunate result be not
effected, abscesses form in the veins from the continuance of
the inflammation, and pus mixed with blood has been seen in
the heart.
In the absorbents inflammation may be distinguished by
red lines under the skin, feeling like cords, and frequently
terminating at the first absorbent gland.
Inflammation of the membranes of large cavities is very
extensive, beginning at a point and rapidly spreading, and if
recoveries take place it is from adhesion ; as the pleura to
the lungs, the pericardium to the heart, and the peritoneum
to the intestines, &c. &c.
In inflammation of the bones, the pain is obtuse and scarce-
ly to be borne, the constitution suffering more irritation than
from the most acute pain.




LECTURE II.

Case. A woman had her leg amputated below the knee,
an inflammation took place in the bone, which caused such
an excess of the most excruciating pain, as induced her to
submit readily to a second amputation above the knee for its
removal. When it continues in bones, its effects are exosto-
sis, in consequence of cartilaginous and bony matter being
effused.
In the muscles it produces spasms, as in fractures; the pa-
tients are restless for two or three nights, from the effects
caused in the inflamed muscles.
Tendons, when inflamed, slough to a great extent, and the
reason of this seems to be, the weaker part or action of the
living powers in them being diminished ; thus, if an abscess
form in the finger, and the tendon becomes exposed, it will
slough through the whole extent of the abscess.
The nerves are very rarely inflamed ; when it happens,
the pain is constant and violently severe, increased on the
least motion, and may be known by the tremor of the mus-
cles below it.
Inflammation in glands, if general, stops their functions,
but if partial, their functions continue. In the affection of
the liver no bile is secreted.
In the viscera it affects their different functions; thus, in
the stomach, there is a violent pain and vomiting, constipa-
tion, tremor, and ultimately hiccup. In inflammation of the
viscera, the pulse is generally quick and small; this has de-
terred many surgeons from venesection in these conplaints ;
but without it, in my opinion, there will be but a very little
chance of saving the patient's life ; but it must not be done
sparingly, unless in very feeble and debilitated habits; we
generally find the pulse rise in proportion to the extent of
the bleeding.
We should likewise make use of local applications ; such
as cupping, leeches, blisters, &c. The warm bath is highly
useful also.
In inflammation of the lungs, there is great difficulty in
breathing, pain in the side and head, pulse slow, labouring,


LECTURE II.
19
and full. On dissection, we generally observe the cellular
substance distended with grumous blood, and a serous fluid
and coagulable lymph in the cavity of the thorax.
In inflammation of the heart, the pulse is peculiar, feeling
double its natural diameter, and very hard; if it be on the
internal surface of the pericardium, the pulse is fluttering.
In inflammation of the brain, there is great pain in the
head, redness of the eyes, delirium, pulse full and hard, and
an extraordinary pulsation observable in the carotid arteries,
which you should always take notice of. Here arteriotomy,
or opening the jugular vein, gives relief sooner than bleed-
ing in the arm.



( 20 )
LECTURE III.
INFLAMMATION CONTINUED.
INFLAMMATION is divided into two kinds, the common and
the specific.
By the first is meant that before described, as regularly
producing adhesion, &c. &c.
In the specific, the action of the vessels is peculiarly
changed, and the effects different.
In the common kind, the action is only increased.
In the specific, it is changed.
The common, is called the healthy inflammation, being the
means which nature makes use of for the restoration of lost
parts. As for example, an artery is divided ; here, without
inflammation, death must inevitably ensue : ligatures might
be applied, but these would be thrown off and separated in
from 10 to 14 days; but when this happens, nature makes
the necessary provision, inflammation ensues, the internal
coats of the vessel throw out or deposit coagulable lymph,
and its sides become glued together; and the same effect
takes place in every part of the body.
If the constitution be bad, the inflammation is slow, and it
is called chronic: thus, when the coats of the eye are divided
in the operation for cataract, if healthy, the wound unites in


LECTURE IN.
21
two or three days ; if unhealthy, it frequently runs on for a
month, or many weeks, being kept up by local and general
debility, and the habit of body of the patient.
Specific inflammation is of two kinds :
The first arises from the peculiarity of the constitution, by
the simple change of the action of vessels.
The second is from the effects of poison.
Of the first kind is gout, which is an inflammatory action
in the joints and tendons, and an earthy or chalky matter is
secreted. This depends on the peculiarity of the person's
constitution, which causes that particular and peculiar action
of the vessels, which in common inflammation would produce
pus. Cancer is another of a similar kind, produced, owing
to some peculiarity in the constitution which we are ignorant
of, and is generally most frequent about the cessation of the
menses in women. A blow, however, may so disorganize
the structure of parts, as to produce it in some constitutions,
which shows that it does not depend upon any specific poi-
son, but is the result of a peculiar action, throwing out a car-
tilaginous substance, instead of coagulable lymph, and some-
times a portior of earthy matter in it: it likewise exists of-
ten in the uterus. Fungus hematodes is also the effect of a
peculiar action of the vessels ; it begins by a small blue tu-
mour, which after a short tiine bursts, and a soft fungus grows
rapidly, the lymph effused is soft and pulpy, and the vessels
shooting into it grow luxuriantly, having no resistance oppo-
sed to them; but cancer grows slowly, the substance effused
being hard, and with difficulty penetrable.
Specific inflammation, as the result of poison, is by no
means unfrequent; as the venereal, small-pox, cow-pock,
rubéola, scarlatina, and hooping-cough : the matter produced
in these is of a specific kind, and capable of communicating
a similar disease. Thus, in chancre, the ulcerative process is
peculiar, true pus being rarely if ever secreted ; it is a thin,
acrid, sanious fluid: indeed, when true pus is discharged, it
is a mark that the disease is overcome and the part is return-



22
LECTURE 111,
ing to a healthy and natural state. The edges of a chan.
cre are very different from those of a common wound, being
thicker and particularly jagged, and easily distinguished at
first sight; in this case, the process of inflammation is not
performed.
Scrophulous inflammation comes nearest to the common;
but in this case the ulcerative process is slow, and the mat-
ter composed of curds and serum, with the edges of the
wound turned to each other. It is generally the result of an
original debility, and thinness of the coats of the arteries
and absorbents.
We must attend carefully to the varieties of inflammation,
and thus vary the remedies, and study to endeavour to allay
the predisposing causes, &c.
When inflammation is spontaneous (if ever so), it is the ef-
fect of a singular or peculiar weakness, and if once set up,
extends rapidly. We are, however, to distinguish carefully
between the various kinds of debility.
There is one species which arises from stimuli, as any con-
siderable evacuations, and these are the very subjects we
would choose to perform operations on.
There is another species of debility, arising in consequence
of excess of excitement, that is, broken down by intemper-
ance; these last will never do well under operations, and
most generally die, either from compound fractures or other
causes.
• In debility, arising from fevers, the parts of the body pres-
sed upon inflame and slough occasionally to a great extent.
Blisters have been seen often, in cases of scarlatina and
measles, to extend to gangrene: and in children, the same
effects are produced now and then from excoriation, arising
from their urine. When the parts become gangrenous, calo-
mel and lime water, forming the black wash, is a very bene-
ficial application ; exhibiting Peruvian bark internally, and
allowing a generous diet, seldom fail to restore the parts to a
healthy appearance.
The original cause of inflammation seems to be, any part
of the body put into an unnatural posture or state, when an



ON
LECTURE III.
23
effort is made in a surrounding part to rectify it,which causes
inflammation ; thus, if any part be divided, inflammation is
excited in the neighbouring parts, and the wound becomes
healed; and if any extraneous substance be by any means
introduced into the body, an inflammatory action becomes
excited, the result of which is, suppuration, by which process
the offending substance is expelled. Inflammation arising
without any evident cause, is the effect of distention of the
vessels of the part ; thus cold, suddenly applied after heat,
produces inflammation of a deep seated kind. Rheumatism,
and sometimes an effusion of coagulable lymph, or an ab-
scess, which is often extensive, will form, if there be consti-
tutional debility. External violence, from mechanical or
chemical means, application of irritating substances, &c.,
are common causes of inflammation. There can be howev-
er but one general cause of inflammation, that is, parts put
into an unnatural state.
The proximate cause of inflammation is a matter of dis-
pute. Dr. Cullen's doctrine of spasm of the extreme ves-
sels, is considered not at all conclusive. Boerhaave's opin-
ion of an obstruction in the smaller vessels from the thick-
ness and lentor of the blood, is disapproved of. He admits
the vessels are dilated, and allows the mischievous red glob-
ules to enter, which he conceived produced permanent con-
striction. If you examine transparent parts with a good
microscope, and to do this, take the web of a frog's foot, you
will find that it apparently contains no red blood; but if you
excite inflammation by pricking it with a sharp instrument,in
a few minutes you will see red particles of blood enter into
the vessels,at some little distance from the part injured ; they
are pushed forward by little and little, till they approach the
ramification of the veins, which they immediately enter, and
become directly conspicuous, though before they were mere-
ly visible : but they are now distended by the vessels be-
hind propelling the blood forcibly into them.
There does not appear to be any evident action in the ves.
sels in the part itself, on the blood which they receive : they



4
LECTURE 111.
dilate and open to receive it, but the action would appear to
be in the surrounding paits-a kind of sympathetic action ;
and if this be an important fact, it extends to the sensorium
and heart itself, and causes the constitution to sympathize in
severe injuries.
I cannot give you a better idea of this, than by showing
you what happens in the eye, when an offending matter gets
into the tunica conjunctiva; the lachrymal gland immediately
sympathizes, and a flow of tears rushes over the eye to ex-
pel the offending substance ; did this run through tubes, it
would be exactly similar to what takes place in inflammation.
The action of the neighbouring vessels is increased, and the
blood rushes to the injured part: this increased action you
may observe in a whitlow on the finger; if you feel the ar-
tery in the finger, you will find it much increased in its ac-
tion from that of the corresponding fingers; and sometimes
this increased action extends throughout the whole limb.
How a spasm in the extreme arteries, supporting an in-
creased action in the course, as Cullen remarks, can be con-
sidered as the proximate cause of inflammation in all cases
not arising from the application of direct stimuli, must be ar-
gued on this principle : that when glandular structures are
inflamed, they cease to secrete as usual; but this is only
when they are generally, not partially inflamed ; as in the
latter case their secretions become augmented rather than
diminished.
Hunter says inflammation is to be considered merely as a
disturbed state of parts,requiring a new salutary action to re-
instate them in their original position: it ought,strictly speak-
ing, not to be deemed a disease, but as a salutary operation.
Again, he says, it is to be considered as an increased action
of the vessels of the part, an increase or distention beyond
their original size and diameter; it is not a relaxation, but
merely temporary dilatation, and a necessary operation per-
formed by nature.
To render this intricate subject as intelligible as can be, it
will be necessary to enumerate a few of the preceding re-
marks.




LECTURE III.
25
We are not to consider arteries as tubes formed merely on
mechanical principles, to transmit a certain fluid: their mus-
cularity, their elasticity and vital powers being so well
known,ought to induce us to give them more important offices;
and whatever theory may be hereafter introduced, this ought
to be borne in mind; they are temporarily and visibly en-
larged in an inflamed part, and that an increase in the cir-
culation of the part is also manifest. How many go thus far
and halt, perfectly satisfied; but I should imagine, that let
the cause of inflammation be what it may, the first and pri-
mary cause of all, must be on the organs of sensation-the
nerves of the part; and hence I should say, that the ultimate
proximate cause of inflammation, as far as it can be traced,
would be, that the sensibility of the part affected becomes in-
creased, that it would appear, if I may be allowed to ex-
press myself, as if first susceptible of the injury, and from
the intimate connexion of the nerves with each other, they
call on their immediate neighbours for assistance ; that the
command they possess over the circulation, produces a wil-
ling compliance, and if the damage sustained be great, is
transmitted to the sensorium : nature, ever on the alert, sets
about the re-establishment. Hence, if the part be easily re-
paired, the constitution suffers no interruption in its accus-
tomed functions; but if the part be of vital importance, or
the person of an extremely irritable habit, the general frame
suffers in proportion to the violence of the injury. When the
cause is removed, the nerves gradually resume their wonted
powers, the arteries their natural diameters, the circulation its
healthy standard, and the integuments their usual tempera-
ture : in fact, the tout ensemble, their respective healthy avo-
cations.
ON THE TREATMENT OF INFLAMMATION.
INFLAMMATION being a local affection, in most cases, it will
give way to local measures, such as the application of leech-
es, cupping, &c. &c.; but when any vital organ is the seat




26
LECTURE III.
of it, the constitution thereby suffering and the life being
endangered, we must not rely upon local means alone.
In inflammation of the lungs, when difficulty of breathing
comes on, and the person's constitution is rather delicate, the
taking away a small quantity of blood will be attended with
more advantage, than where the contrary plan is followed :
ahout five or six ounces will commonly answer, and this may
be repeated according to the urgency of the symptoms.
Syncope is considered a favourable circumstance in vene-
section, as proving that the evacuation has acted powerfully
on the system. It has been the practice, and I think too
very properly, where we have evident marks of high inflam-
matory action prevailing, of making a large orifice in the
vein; two reasons seem to guide this determination, the one,
that it will take off the determination of the blood to what-
ever vital organ is affected, much quicker than if the orifice
were small; the other, by no means an immaterial one, that
the circulation becomes so sensibly affected, as to induce
syncope ; the earlier it is practised, and the more suddenly
the evacuation the better.
There is an evident advantage in drawing blood as near as
possible to the seat of inflammation : for instance, if there
be high action going on in the brain, opening the temporal
artery, or jugular vein,should he had recourse to for this rea-
son, that the impetuosity of the blood to the part is much di-
minished in consequence of the neighbouring vessels being
considerably lessened in their diameter, and the great dis-
tention taken off.
The indications necessary to be observed in repeating
blood-letting are, when the blood drawn is sizy, the pulse
still remaining hard, and above the natural standard; but
there is one objection to the former inference, namely, in
pregnant women, and also in some irritable constitutions, in
whom, when blood is drawn, there is generally a siziness
observable. It also depends upon a quantity of serum in
the blood evacuated : if there be a larger quantity or por-
tion, with respect to the constituent parts, than usual, it will
be improper to repeat the operation.




LECTURE III.
27
A pulse from 76 to 100, with tenseness in the artery, indi-
cates bleeding; but from 100 to 120 not so, as it rather indi-
cates debility, though in the intlammatory state of some im-
portant organs, the pulse is often thus; and therefore to re-
lieve any urgent symptoms, it will be proper to have recourse
to blood-letting, especially when we find (which is often the
ease) the pulse gets much fuller after a small quantity has
been drawn : but if, on the contrary, we observe the pa-
tient's pulse weakened in the pulsatory motion; (a more cer-
tain sign, however, is when the blood is taken away by cup-
ping, and the pulse at the time, instead of being slower and
fuller, becomes rather quickened) then we are immediately
to desist. When any secreting surfaces are the subject of
inflammation, and more particularly those of joints, it will
be our aim to prevent its extending to the suppurative pro-
cess ; here we must use local and general bleeding, though it
should occasion debility in the system.
Purging is considered one of the most effectual remedies
in inflammation, for three reasons, the first is, by discharging
the fæces, and taking off the irritation produced in the in-
testinal canal ; secondly, by restoring the secretions of the
alimentary tube : and lastly, by deriving blood from the
surfaces inflamed to the intestines.
For children, calomel with rhubarb to be given every
fourth night, if the disease be acute ; but if not, every sixth
night, as mercury, given too often, may be attended with bad
effects. For adults, calomel with cathartic extract, in pro-
portion of a grain and a half of the former, and five grains
of the latter, has been considered as very beneficial when
given at proper intervals, that is, repeated according to the
acuteness of the disease; but if it should not be found suffi-
ciently active as a purgative, it will be better to give, the
following morning, the magnesiæ sulphas, or oleum ricini.
It is very necessary to be particularly careful in exhibiting
the mercurial, especially in scrophulous cases, and in vene-
real ones combined with the latter affection, when the com-
plaint will be more aggravated than relieved. One of the



28
LECTURE 11.
principal practitioners in town employs mild purgatives, of
the saline kind-Glauber's, Epsom, or Rochelle salts. Dras-
tic purgatives are to be avoided, of whatever kind, as they
produce very considerable irritation in the constitution.
Another mode of lessening inflammatory action is by per-
spiration, by which the edges of the crassamentum being
drawn towards each other,and forming a kind of cup, drains
the system of its redundancy, and drives the blood to the
surface of the body. Reciprocal affections also take place
in the kidneys, by an increase of the urinary discharges.
The ho: bath is often attended with considerable benefit,
and there are other remedies to be given according to cir-
cumstances, such as large quantities of diluent drinks, blad-
ders of warm water applied to the extremities, and lastly
antimonials ; they relieve the oppressive dryness of the
skin, and tend to lessen the increased action of the affected
part.
The remedies just mentioned are intended for acute in-
flammation. Chronic inflammation requires somewhat of a
different treatment ; when an organ has laboured long under
an inflammation, so as to threaten its entire derangement or
dissolution, the hydarg. muriat. with or without the Peruvi-
an bark, according as circumstances may direct, which may
or may not favour the exhibition of the latter medicine, has
been found beneficial and serviceable to a great degree.
Case.—A striking instance of this is recollected, which
occurred in Guy's hospital, in the case of a woman who had
a chronic inflammation of the eyes, to such an extent as to
have produced an opacity of the cornea : the common rem-
edies were persisted in, but in vain ; when, after taking the
above medicine, the opacity of the cornea began gradually
to diminish, and in a few days the inflammation subsided.
The mercurial, in this instance, was combined with a decoc-
tion of sarsaparilla.
In tabes mesenterica, chronic affections, and in scrophula,
it answers very well, provided it does not act on the system
as a mercurial.


LECTURE III.
29
Some of the remedies for topical inflammation have been
before alluded to, as cupping, leeches, &c.; but it will be
necessary to observe, that there are other remedies equally
proper ; these are cold applications, which are of an astrin-
gent or sedative nature, and which, by abstracting heat, les-
sen the action of the blood vessels, and act as powerful
agents on the nervous system ; but there are certain limita-
tions to be observed with respect to their use; it would be
highly improper to have recourse to them too frequently, or
in too violent a degree, as instances have been known, when
so applied, they have produced the worst consequences, by
freezing the parts, and consequently effecting a morbid ac-
tion, owing to a lax and torpid circulation. Mr. Samuel
Sharp has related a case of this kind, when, from ice being
applied to the groin in a strangulated hernia, such a morbid
state was induced as to occasion the whole of the scrotum to
slough off ; but this may be prevented, in similar cases, by
enclosing the ice in a bladder.
Evaporating means have been resorted to, on account of
their action in extracting heat from the body, by effecting a
continual evaporation from the part inflamed, for which pur-
pose the spir.vin. rect. 3j., liquor. acet. plumb. dilut. vel aq.
puræ 3v. ſt. lotio. have been recommended. There are oth-
er lotions which act in a very different manner, by being
immediate agents on the nerves, thereby diminishing their
energy ; but these are apt to occasion mischief when too
powerful, or long persevered in: as for instance in a case of
ophthalmia, where preparations of lead, (liquor. acet.plumb.)
were used for some time, and produced paralysis of the
eyes. Another case is recollected, when the same prepara-
tion was once used through mistake undiluted, in a case of
hernia humoralis, where it occasioned a mortification of the
scrotum ; thus clearly proving that these kinds of sedatives
act immediately on the parts themselves, and are of no ad-
vantage in deep-seated inflammations.
Heat, combined with moisture, namely, flannels wrung out
of warm water, or the pediluvium, answers well, by produc-



LECTURE III.
ing perspiration, unloading the excretory ducts, and thereby
freeing the system of its redundancy: it is on these princi-
ples that oiled silk and soap cerate act.
If inflammation should not be got rid of and subdued by
the methods mentioned, then, as has been before said, it will
be proper to have recourse again to leeches, cupping, and
scarifications : the latter are found of great service in in-
flammation of the scrotum, done by means of a lancet.
In inflammatory affections of any of the internal viscera,
blisters may be used to induce a counter-action ; liniment
ammon. 3j. antimon. tartar. 3ij. well rubbed in is very ser-
viceable; this liniment brings out eruptions very similar to
the variolous.
In joints diseased with scrophula, or indurations remain-
ing in them, the result of an inflammatory action, these lat-
ter mentioned remedies are particularly useful, and more so
when assisted by internal medicines, such as calomel given
every fourth night, &c.; if the enlargement should not yield,
and the joints are stiff, friction must then be used, and per-
severed in for a length of time; but the use of it is improp-
er when there is inflammation existing.
It is by friction Mr. Grosvenor, of Oxford, has acquired
so much celebrity; thus, one hand is rubbed up, and the
other down the limb at the same time ; and continued for
half an hour or longer every day,
The above are the principal remedies for local and con-
stitutional inflammation, and are to be employed with judg.
ment according to the existing circumstances; as it is im-
possible to lay down rules in a particular way, they must be
general ones, and the surgeon must avail himself of those
most applicable to the case of his patient: lastly, it may be
proper to observe, that in most instances, rest and support
will prove advantageous, the antiphlogistic regimen must be
observed, and attention paid to the patient's diet; avoiding
those causes that would agitate or disturb him, &c.



( 31 )
LECTURE IV.

ON ADHESIVE AND SUPPURATIVE INFLAM-
MATION.
INFLAMMATION has the effect of changing the blood into three
parts, serum, crassamentum, and coagulable lymph, which is
different from that in a state of health.
If you put a portion of blood, just drawn, into rectified
spirits of wine, you will perceive it harden on the surface;
but it does not harden on the under part, which is composed
of red particles, and which are easily separated. The buf-
fy appearance is not only found when the system is affected,
or if blood be drawn from an inflamed part, but it will have
this appearance, though there be no constitutional affection
present, as has already been remarked.
In consequence of coagulable lymph becoming attenuated,
it is capable, in inflammation, of being poured out from ex-
treme vessels, and inflammation is then taking place when
this lymph is effused for the purpose of glueing parts togeth-
er: we are all of us aware, that if a piece of lint be laid
over a wound after this process has taken place, it will, so
adhere as only to be separated by violence.
Such surfaces as take on this kind of inflammation, are
the peritoneum, pleura, &c. &c. and immediately on the
commencement, the adhesive process takes place,coagulable


32
LECTURE IV.
lymph is effused, and connects the membranes to their at-
taching surfaces.
The cellular membrane is very liable to this species of
inflammation. On cutting into a tumour, when the process
has commenced, you will certainly find a mass of coagula-
ble lymph by attending closely to the appearances, for when
first effused it is yellow, and has the consistence of jelly :
observe the appearances under the cuticle, raised by a blis-
ter; when effused it takes on a peculiar arrangement; on its
first appearance you will discover its vascularity, and the
parts in contact with its surface begin to shoot out vessels,
they become more and more elongated, until they at last
shoot entirely into its substance; hence then it is evident
that coagulable lymph owes its vascularity to neighbouring
vessels.
The uses of this lymph are several; in the first place, it
serves to confine pus in the cavity of an abscess: an abscess
is capable of producing great destruction, if not prevented
by the effusion of this lymph. One case may be related :--
it was that of a man much debilitated, who had a tumour on
the neck, which, forming an abscess, extended even to the
loins, whereas had coagulable lymph been effused, this great
extension would have been avoided; the patients, in these
cases, are to be considered in imminent danger, though not
at first generally so.
The second use it serves, is in dividing a cavity into several
parts, so that if inflammation come on in any one part, and
pus form, by this process taking place, and glueing the sides
of this cavity together, the inflammation is prevented from
spreading farther.
Thirdly, in case of any extraneous body, such as, for ex-
ample, a musket or pistol ball being received into any part of
the body, this lymph, by forming a cyst, encases this extra-
neous body, and the parts around it are not stimulated to do
any further injury ; and cases where extraneous substances
have so remained in the body for a length of time, without
any very manifest inconvenience, will be detailed in the
course of these lectures.



LECTURE IV.
33


Fourthly, to unite parts together which have been divided,
and which is considered as the most essential of its uses. A
very wrong opinion has prevailed, that extravasation of
blood produces what is called the first intention, which is
now evident can only be answered by coagulable lymph;
for example, in the operation for the hare-lip, it has been in-
variably observed that the less the loss of blood the better.
For the accomplishment of the union of parts, it is abso-
lutely necessary that inflammation should first come on, and
during its early progress the lymph is thrown out, which an-
swers every purpose required.
There are two modes of union, the one already mentioned,
namely adhesion, the other by granulations; if there be
any exception to this, it is where the hæmorrhage is stopped
by a coagulum or clot of blood; but here ultimately the
union is effected by the medium of lymph, which causes an
adhesion of the clot to the inside and orifice of the artery,
and to the surrounding parts ; and, in bad habits, the increase
or recurrence of hæmorrhage is from a deficiency of this
action, and after the ligature operates, the ends not being
glued together, nor the clot of blood to the sides of the ar-
tery, it is carried away by the force of the blood.
No operation, not even the simplest, could be effected with
safety, without the adhesive process ; for after the opera-
tion of venesection, if it were not for this mode of union, the
vein would inflame, and the inflammation extending along its
coats, through the valves, even to the heart itself, would ne-
cessarily prove fatal. Many other cases could be mentioned
illustrative of this subject, such as tapping in ascites, and in
the operation for strangulated hernia, where, if the peritone-
um and intestines did not adhere, death would be the result;
amputations might also be alluded to; and with respect to
this latter operation, there is one question I would wish to
put to you, that is, why is it found so necessary to save so
much of the skin or integuments ? To this it may be answer-
ed, that it is for the purpose of glueing or connecting it with
the ends of the muscles : and from thence proceeds the ne-




34
LECTURE IV.


cessity of cleaning the stump of any foreign body, tending
to prevent that desired process, and perhaps it may not be
amiss to mention a circunstance which occasionally happens
to unskilful practitioners; the impropriety of removing the
dressings a few days after the operation has taken place is
here alluded to, in order to see how the limb appears, but it
must be evident to every thinking man, this is extremely
wrong, as it tends precisely to destroy thai mode which na-
ture has intended for the restoration of the parts. It is only
warranted in those cases where, from the excess of pain the
patient complains of in the amputated part, you have reason
to suspect there is matter confined, and even in such a case
it would be preferable, merely to slip through the adhesive
plaster, in order to give vent to the confined matter, without
removing all the dressings.
• The saine adhesive process takes place in the hard as well
as in the soft parts of the body, the bones for instance, only
that in them, a gelatine is secreted, and in the soft parts lymph
is deposited to cover the edges of the fractured bones, either
simple or compound: with the exception that, in the latter
accident, this process is hindered from being completed by
the formation of pus and granulations.
One more proof in favour of the adhesive process will be
adduced, namely, in the improved method for the radical cure
of hydrocele, for which we are indebted to Sir James Earle ;
by the effect of an injection, inflammation is produced, and
the sides of the vaginal tunic are glued together, so that the
whole cavity or bag previously existing, becomes oblitera-
ted; we here see that even disease can be cured hy the beau-
tiful and admirable process of nature, in itself very simple,
which shews the wisdom of our great Creator in a striking
degree.


ON SUPPURATIVE INFLAMMATION.
- When inflammation passes the limits of adhesion, pus is
formed ; the symptoms are, the parts affected become more
prominent, the tumour being harder on its sides than in its
centre, attended with a throbbing pain, and a suffused red-
LECTURE IV.
35
ness over its surface ; this redness generally denotes inflam-
generally perceptible in its centre, which becomes the most
elevated part, and appears whitish and soft to the feel. The
consti!ution now, in its turn, is affected, the patient is seized
with shiverings, which are more or less violent, according to
a combination of circumstances, the pain, before acute, be-
comes of a dull kind.—These are the general symptoms, but
there will be always some little variety according to the

Although Hunter remarks no suppuration ever takes place
without being preceded by inflammation, and no pus is ever
formed but in consequence of it, yet there are some particu-
lar structures which arrive to the formation of pus, without
previous adhesive inflammation ; in mucous membranes, for
example, where, on any stimulus being applied, immediately
pus begins to form. We may observe this in the urethra, when
a bougie has been introduced, in an irritable habit of body.
Also in the trachea and in the lachrymal duct; and this
is a very wise provision of nature, for if those parts took on
the adhesive instead of the suppurative process, in most ca.
ses it would be attended with fatal effects.
.
In croup, lymph is produced instead of pus; and fistula
lachrymalis is a consequence of an obstruction in the duc-
tus ad nasum.
If we are asked why mucous surfaces pour out pus, and
vaporous surfaces, coagulable lymph, it may be answered,
that the extreme vessels in exhalant services are more mi-
nute, and will not readily admit pus through them, although
they allow of coagulable lymph; whereas, in mucous sur-
faces, the vessels are larger, and pus readily finds its way.
When suppurative inflaınmation takes place in a wound,
it is always preceded by the adhesive process. Granula-
tion is a mode of union where the adhesive process tails ;
for instance, if a part be wounded by any sharp instrument,
and lymph is not thrown out sufficiently for its union, then
suppuration commences, and the wound is healed by granu-
lation.


36
LECTURE IV.
;

OF THE NATURE OF MATTER AND ITS MODE OF FORMATION,
If we attentively examine the nature of pus, we shall find
it composed of serum and white particles similar in form to
the red globules of the blood; the usual mode of discovering
the difference between pus and mucus is by art, and it has
been found that pus cannot be coagulated by the gastric
juice, and this was attempted from its being thought to have
some similarity to milk ; the fluid part of pus can be made
to coagulate in a solution of sal ammoniac, and this effect can-
not be produced on any other secretion or animal fluid.
Hunter also remarks, that pus is constituted, as I have al-
ready stated, of serum and white globules, and is more or
less healthy in proportion as the white globules predominate.
The specific gravity, of pus and blood are nearly similar:
it must consequently be much heavier than water, in which
fluid it sinks, and occasions an uniformly troubled whitish
tinge, while mucus poats and communicates to the water
something in the resemblance of stringy or fibrous portions
floating in it. Pus has a sweetish taste, which is remarka-
ble as well as its smell.
It was supposed, till of late years, that pus was formed by
the destruction of solids ; but this opinion is now very gen-
erally exploded: we have several striking examples to the
contrary, as in the urethra, where its membranes are rather
thickened than otherwise by it; in this case formerly it was
contended that the matter discharged in gonorrhæa must be
caused by an ulcer in the internal passage. The lachrymal
duct also, and many similar structures, such as the peritone-
um, pleura, and pericardium; which are always found con-
siderably thickened after the formation of matter. Dr. Hun-
ter first noticed that the dissolution of parts of the body was
not essential to the formation of pus: a subject died of em-
pyema, and in the dissection, this fact became apparent;
the matter, although the quantity was very considerable, ap-
peared to be formed from the fluids, and not the solids, as no
breach of continuity, or dissolution of structure could be
observable.



LECTURE IV.
37
The formation of pus is from the neighbouring vessels,
and will be proved by this experiment :-After a sufficient
quantity of fluid is raised under the cuticle, by the applica-
tion of a blister, remove the latter, make an opening in the
cuticle, and apply a bit of glass to the secreted fluid, and
you will find it, after remaining a short time, similar in ap-
pearance to pus, directly proving that it is produced from
the mouths of the vessels, and not from the solids.
Pure pus has not the power of irritating the surfaces in
contact, being quite a bland fluid : but this is only so when
it is in an healthy state, and unchanged; for as soon as any
irritating cause has acted on it, or the vessels rather that se-
crete it, so as to excite a total change in regard to its texture,
then the surfaces no longer secrete a mild bland fluid, but
what is already effused becomes ichorous, exciting irritation
in the adjacent parts; such is the case in bones when expo-
sed, where true pus is seldom or ever formed, of which doc-
trine we have a simple, but sufficiently illustrative example,
in the instance of a nail growing into the skin—the parts be-
come irritated, and instead of secreting pus, are discharging
an ichorous matter; as soon as true pus is formed on any
sore, inflammation immediately ceases; this latter process is
absolutely required for the production of the former, but of
no longer utility when formed : for if inflammation continue,
or is resumed, it prevents any further secretion. On a part
being irritated by any poisonous matter, it directly becomes
inflamed, and in it a poison similar to that which was appli-
ed, is produced, and if this morbid matter be introduced
into the system by absorption, so as to effect the con-
stitution generally, it then brings on fever by its irritation,
and generates similar poison throughout the system at large.
We have examples of this in syphilis, small-pox, &c. &c.;
in these cases the constitution takes on a particular action,
which is continued as long as the cause is applied.
The uses of suppuration are two-fold, and are important;
1st, by its covering granulations, and keeping them in a moist
state, otherwise no sore could be possibly healed; for if a.





38
LECTURE IV.

sore be exposed to the action of the atmosphere, it soon be-
comes incrusted, and under which matter is confined, which
keeps the granulations perfectly moist, so that nature here
performs her part without the aid of surgery ; the second
use it has, is by its pressure on parts so as to cause them to
be absorbed, and by that means rid the body of extraneous
substances; in this it acts similar to ulcerated parts.
OF ULCERATION.
Ulceration is the absorption of any natural formed parts
or solids of the body, but differing from simple absorption
in this, that the latter takes up minute substances in contact
with the vessels. Ulceration is commonly accompanied by
matter, but this is not essential to it, as it often occurs with-
out. It is the result of two circumstances :-
Inflammation, with pressure : but inflammatory action is
not of itself the immediate cause of it, but only when attend-
ed with pressure.
In aneurism of the aorta, where no matter is formed, the
parts in contact with the aneurismal sac, such as parts of the
ribs, and the sternum, will become absorbed merely hy the
mechanical pressure of the sac, producing increased action
in the absorbent vessels of those parts ; in fungous tumours
of the dura mater, the bone will be absorbed without any
collection of matter.
Ulceration has a tendency to the surface more generally
than to the internal parts of the body, as is seen in cases of
diseased thigh-bones ; or it may be better illustrated in those
cases of matter forming behind the sternum, close to the
pleura, where, instead of ulcerating that membrane, it ab-
sorbs the sternum. A case of this kind occurred in Guy's
Hospital, during my attendance. In the formation of matter
also in the abdominal muscles, instead of forcing its way in-
to the viscera, it most commonly finds an outlet on the sur.
face of the body.
The same thing is seen happening also with respect to
bones, where matter makes its way to that part of the bone



LECTURE IV.
39
IS way
most exposed; these examples shew the admirable wisdom
of the Divine Architect, for, were it otherwise, the conse-
quences would be generally prejudicial; and which is ac-
counted for by Hunter thus: although a tumour makes equal
pressure in every direction around, it will make its way ex-
ternally, because interstitial absorption only happens in that
direction. Slight pressure from without, Hunter remarks,
will even produce a thickening of parts, and hence he in-
fers, there even appears to be a corresponding backwardness
to admit disease: both these facts are shewn in the case of
fistula lachrymalis, for though the collected matter is nearest
the cavity of the nose, still it makes its way externally, and
the Schneiderian membrane becomes thickened,so as to prove
a barrier against its progress inwardly. He gives five causes
for ulcerative absorption, pressure, irritation of stimulating
substances, weakness, inutility of parts, and death of them.
It takes place readier in the cellular and adipose substance,
than in muscular, tendinous, ligamentous, and nervous sub-
stances, or blood-vessels. A cicatrix, or newly-formed skin,
is sooner acted on, than the originally formed cutis ; thus, if
an inflammation take place in a patient's leg, that had been
previously affected with ulceration, the ulcer will break out
much sooner than if the disease had not existed prior to this
last inflammation.
The progress of ulceration takes place much quicker than
that of restoration, as parts may be so affected as to be de-
stroyed in two or three days, which for their restoration
would require twice as many weeks.
Ulceration, although a diseased process, yet it is not with-
out its advantages to the body and animal economy, by dis-
charging extraneous bodies from the system ; as, for instance,
a ball; a ligature upon an artery is disengaged in the same
manner; sloughing parts are also similarly removed; parts
having weak circulating or living powers, are readily acted
upon by absorption, and we more frequently see ulcers in
the legs than in other situations.




'LECTURE IV.
When the body has been long accustomed to the discharge
of matter, it is absolutely necessary in stopping this, to sub-
stitute other evacuations in its room, or the change will pro-
duce apoplexy, or a peripneumonia ; these consequences
are seen on healing old ulcers of the legs. Surgeons were
formerly in the habit of making issues in other places, but
purgatives persevered in for some time are now deemed pref-
erable, and sufficient for every purpose.
OF ABSCESSES.
An abscess means a collection of matter in a cyst. In
cellular textures, prior to the formation of matter, coagula-
ble lymph is effused, forming a kind of wall or cyst, by
means of which the further increase of the disease is pre-
vented and arrested. In the middle of this wall you will ob-
serve a partition and a small quantity of matter, which is
poured into the coagulable lymph, so that by its pressure it
produces the absorption of parts. This process goes on in
a regular manner, and matter is still secreted, and the pro-
cess of absorption continues as long as matter is poured out,
till at last, with the assistance of the pressure, the whole is
taken up.
The dangers attending abscesses are several. The 1st is,
when they are very large and present a vast extent of sur-
face. 2dly. When seated in an organ essential to life, the
brain or heart for instance, where the lodgment of a very
small quantity of matter would prove fatal; but other organs,
such as the lungs and the liver, although very important,
do not appear to sympathize with the constitution so much;
abscesses in them will be suffered to exist to a great extent.
3dly. When not seated in parts important to life, yet by
their pressure on any essential organs, render the case very
different. Matter, for example, seated behind the pharynx,
so as to press on the trachea, will destroy life. There is
one case on record, however, of this kind, which ended fa-
vourably, free vent having been given to the confined mat-
ter, by an opening into the sac, which relieved the patient

LECTURE IV.
41
from the most imminent danger. 4thly. When matter be-
gins from a bone extending to the surface of the body; and
this is the great cause why lumbar abscesses are attended
with danger, as bones require to exfoliate before granula.
tion, so that from the length of time induced by this process:
which is very tedious, patients seldom recover. .
TREATMENT OF ABSCESSES.
When an abscess is formed accidentally, poultices and foc
mentations are all that is requisite. But in a constitution
much worn down by debility, and in indolent abscesses, it
would be proper to have recourse to stimulating remedies, in
order to excite the system to action, and giving also at the
same time tonics with a generous diet.
In opening abscesses, the lancet is the best instrument, and
is much preferable to the using of caustic; but after having
made an opening, should the abscess not discharge freely,
then introduce a probe (the point of which being dipped in
nitrous acid) into the orifice. If the abscess be very exten-
sive, the best method after an opening has been made, is
to apply around it a roller, only taking care to leave an op-
ening sufficiently large to give vent to the matter; by this
plan the sides will generally unite.
It is necessary to be thoroughly acquainted with the time
necessary for opening an abscess, as a great deal depends
on it. There are some that require an early opening; those,
namely, that are situated under the fascia or ligamentary ex-
pansion and thickened cutis, the palm of the hand and sole
of the foot; and the opening made into them should be very
free, as there is no risk in so doing, and it prevents their un-
necessary extension.
Abscesses also near bones should be prematurely opened,
and those that are near organs important to the functions of
the animal economy, such as are under the pericranium, in
the eye, the thorax, and abdomen, and also in joints, require
this plan. Hunter says, generally a collection of matter

LECTURE Iy.
should be allowed to break of itself: but it is now consider-
ed bad practice to allow an abscess to do so, although the
confinement of its contents can do no injury; an opening
should therefore be made when there is a conical tapering
to a certain point, with evident Auctuation, indicating where
nature would, if left to herself, fix upon for the precise spot:
but it must not be understood that a premature opening is
recommended, except in selected cases.
ON HECTIC FEVER.
It is found (but this depends more or less on the irritabili-
ty of the patient's constitution,) that the system is affected
with hectic fever to a considerable degree, according to the
extent of the abscess, which comes on sometimes iwice a
day. Till of late years an opinion prevailed, (and it is even
now maintained by some) that hectic fever was caused by
absorption of matter; but this opinion is certainly wrong.
In proof of this assumption, it is found that hectic fever pre-
vails where there has been no formation of matter.
Case. An instance of this is recollected which occurred
some time since in this city; where a girl was admitted into
an hospital for an affection of her knee, accompanied with
pain, yet no appearanee could be perceived of any collec-
tion of matter. Hectic fever came on twice a day, and so
redur ed her constitution, that amputation was resolved on,
conceiving there might be matter formed internally, which
could not before be detected. But on examination, the limb
was discovered to have nothing of this sort: the only ap-
pearance of disease was in the epiphises of the os femoris,
which were much inflamed.
This case distinctly set the question at rest, and proved
that hectic fever is capable of existing without absorption of
matter. Since that time many other proofs might be addu-
ced, that hectic fever often exists previous to the formation
of matter. A small ulcer in the lungs may bring on hectic
symptoms, while a very large one in the leg will produce no

LECTURE IV.
43
such effect : these are certain and incontrovertible evidences
of what has been advanced. The hectic fever is simply
this : it arises from sympathy induced on the system by the
irritation of some part or parts; or in other words, it is that
general disordered state, the immediate effect of irritation.
There are three stages of it, the cold, the hot, and the sweat-
ing fits; the patient is alternately seized with chilliness, which
is succeeded by flushes of heat and copious perspirations ;
the pulse is small but frequent, with an unnatural moisture
of the skin, indicative of debility; urine pale, and rather
copious, depositing a sediment; tongue dry and parched ;
with indigestion, vomiting, and diarrhæa.
This fever, as has been previously remarked, depends on
local irritation: we must first diminish or remove the cause
before it can be expected to cease; do that, and it ultimately
will vanish. Hunter says, when an incurable disease in an
extremity is removed by amputation (such as a scrophulous
affection of the joints where the suppurative process has
been tediously prolonged) the hectic fever immediately be-
gins to abate. 6 I have known,” says John Hunter, “ a hec-
tic pulse at 120, sink to 90 in a few hours, upon the removal
of the cause. I have known persons sleep soundly the first
night without any opiate, who had not slept tolerably for
weeks before. I have known cold sweats stop immediately,
as well as those called colliquative. I have known a purg-
ing stop as suddenly on the removal of the hectic cause,
and the urine drop its sediment.”
The practice in these cases is plain enough : but where
our patients are reduced to the lowest state of debility by
some incurable local disease, as in lumbar and psoas absces-
ses, &c. &c. this plan cannot be pursued; we must there-
fore endeavour to support the person's strength, and invigor-
ate his vital powers, both by the aid of medicine and diet,
by the most powerful tonics on the one hand, as bark, acids,
&c. &c. and by nourishing and nutritious food on the other,
combined with cordials and aromatics. Sleep may be pro-
cured and pain alleviated by narcotics, as opium, cicuta, &c.


LECTURE IV.
Resuming the subject of abscesses, we are not to be sur-
prised to find inflammation come on in a few days after an
abscess has been opened, as this is commonly the case. It was
generally believed that the admission of air was the cause
of it; but this we are certain is incorrect; and to prove it,
these experiments were made some time since; a trocar was
passed through the skin of a dog, and then inflated with air,
yet no appearance of inflammation followed; openings were
also made into the chest and abdomen of the same animal,
and with the like result. Also it is found, that if the lungs
are wounded by any sharp instrument, the air immediately
escapes from the bronchial cells into the cellular membrane,
puffing it up, as was the case in the experiments made on the
dog; and yet after the air has been absorbed, no traces of
inflammation could be discovered. The cause of it then is
truly this; the dividing of the vessels, which, exciting irri-
tation, produces a change in the parts so acted on. Fomen-
tations and poultices may be continued after an opening has
been made, until the granulations nearly fill up the cavity,
when the more simple the dressings are the better.
ON UNION BY GRANULATION.
Granulations are those substances which arise from wound-
ed or other injured surfaces, as in suppurating wounds or
surfaces of ulcers. Their formation is after this manner ;
wben an abscess is opened, coagulable lymph is deposited,
which lines the internal surface of the abscess; after a few
hours, this lymph becomes vascular; and after the expira-
tion of five or six days (but this depends on the age, consti-
tution, &c.) the whole surface lining the abscess is found to
become highly so; the vessels open on the external part or
the coagulable lymph, and their termination is in its middle,
or internal surface; from the orifices of these vessels, after
a little time has elapsed, is deposited another layer of lymph,
and thus layer after layer are successively formed, till at
last the whole cavity of the abscess is filled up.

LECTURE IV.
45
The difference existing between this mode of union and by
adhesion is this : that in the latter the vessels do not shoot
forth from their orifices; and in the former the vessels throw
out pus at the same time that coagulable lymph is effused.
Granulations are entirely new substances formed from se-
creted matter; they are extremely vascular, from the vari-
ous arteries passing in radiated forms on their surfaces; and
it is principally owing to this circumstance that they appear
so red, which is their colour when healthy ; when livid, or
of a pale red, it denotes the languid circulation in the part,
and they are considered by no means of a healthy disposi-
tion. Their surfaces are generally approaching to a point,
and termed convex, and the smaller and more numerous
such points are, the more health they indicate.
With respect to absorbents, few can be discovered in their
new structure, so that fresh formed granulations have bad
absorbent surfaces. But this is not the case with old sores
or ulcers, which readily take up any mercurial preparation
that may be applied.
On looking at granulations, they appear tender and en-
dowed with great sensibility ; this is the case, indeed, with
regard to the skin, but it is not so in the other parts of the
body; the bones for example; where iſ granulations form
after exfoliation has taken place, we find little if any sensi-
bility adherent in them.
To illustrate this, suppose a blow has been received, or a
wound inflicted on some part of the cranium, and the integ-
uments do not unite by the adhesive process, consequently
this method by granulation ensues; but previous to this, a
thin plate of bone is exfoliated. On touching the granula-
tions, there will be no pain excited ; and cases have been
known where it has not created the least uneasiness, even by
pressure.
The want of sensibility also is applicable to tendons and
fascia, except when inflammation is present, which alters
the case very materially.


LECTURE 17.
There remains one very important observation to be made
on the subject; which is, that granulations applied to each
other will readily unite ; this is certainly very useful to be
known, and is of great service to the practitioner. After
amputation, if the adhesive process should not succeed, by
bringing the granulations on one side to those of the other
side of the skin, they may be made readily to unite; but
one caution is here necessary to be observed, namely, that
care should be taken that the union thus effected is not par-
tial, as here a sinus would be formed extremely trouble-
some to get rid of.
OF CICATRIZATION.
When granulations arise even with the surface of the sur-
rounding parts, or a little above them, then the process of ci-
catrization commences, which effects a covering over the
whole extent of the sore; or in other words, skin is formed
which spreads over the entire surface of it; this process de-
pends in a great measure upon the inosculations of the gran-
ulations which form on the edges of the skin. There is a
gradual and uniform contraction from the sides to the centre
of a wound,during the healing of it ; the progress of the gran-
ulations is from the sides, not the centre of a wound ; and thus,
if it be a concave one, this fact is indisputable, as the skin be-
comes puckered or drawn inwardly to a centrical point. In a
transverse wound, the edges recede by their natural elas-
ticity, but during the healing process, they are again approx.
imated, from the contraction of the granulations; and hence it
is, that as they contract, the skin becomes gradually elon-
gated, till the progress of cicatrization is complete. As soon
as a sore begins to cicatrize, the surrounding skin becomes
smooth, and has that whitish cast so frequently observed,
with a similar coloured substance,which Hunter conjectured
to be the new forming cuticle. It would appear that new
skin is derived mostly from elongations of the old ; but this

LECTURE IV.
is not always the case, as new skin is seen formed in detach-
ed portions in the centre of some sores, quite uncounected
with the surrounding skin. Now whether this is a new sur.
face formed by the granulations, or a change that they un-
dergo, remains to be ascertained. New formed cutis is less
yielding, less elastic and moveable, also thinner and more
tender than the original, although in course of time it recov-
ers more flexibility, is less attached, and becomes firmer and
more dense ; it has a smooth general surface, without the in-
dentations of the original, and the living principle is less ac-
tive, as it is sooner absorbed than the old.
The cicatrix forms an entirely new cuticle over the sore,
and which is very expeditiously done ; but not quite so soon
with respect to the rete mucosum, as instances have shewn
with regard to negroes. In the filling up of the parts, it is
the general opinion, that the substance restored is similar to
that which was lost: this is certainly true as respecting most
parts of the body; it is known very well that skin can be re-
produced. The cellular membrane also generally acquires
its original texture, though at first it is somewhat condensed.
Tendons are also readily re-produced; their production sel-
dom takes longer than a fortnight or three weeks; but there
are some ohjections, however, to be advanced against this
opinion above quoted.
The muscles are not properly re-produced ( and here I am
aware that I differ from most writers ), but it has been care-
fully observed the mode of union in them, after a wound
had been inflicted, and a complete union taken place, was
different; on examining their structure, it has always been
found that the connecting substance was tendinous and not
muscular.
The ribs also, if their cartilages are wounded, do not unite
again by their original structure, but by bone. But a gentle-
man, very eminent in practice, has discovered, that this is
not the case as far as regards young subjects, in whom car-
tilage is commonly produced,

48
LECTURE IV.
Skin, newly formed, has a redder and more florid aspect
than an original formed cutis ; the reason is, on account of
the full distention of the vessels, so that a cicatrix, that is
large at first, afterwards lessens, in consequence of the ves-
sels becoming greatly diminished in their diameter.
There is one circumstance to be kept in view in the forma-
tion of skin :-a wound which is long and narrow will soon-
er unite than one that has a circular form; the reason here
is obvious ; every cicatrix is healed from the vessels of the
edges, so that a long one must be united much sooner than a
circular one, on account of the vessels in the latter having a
further extent to pass to the centre.

( 49 )
LECTURE V.
ON ULCERS.
An ulcer is a granulated surface secreting pus: when healthy
the granulations have a forid appearance, and the skin form-
ing the edge of the sore is approximating to the surface of
the sore: here granulations are no impediment to its restora-
tion. Every wound must become an ulcer, which does not
unite by adhesion. Healthy ulcers secrete pus which is
white and thick, and not adhering to the surface.
The only treatment required is, first to apply lint to the
surface, which will come off after a few days, and when re.
moved, granulations will be discovered under it, and a quan-
tity of pus will be also secreted at the same time, and deposi-
ted on the surface of the sore. Poultices must then be applied,
as they materially assist the rising of the granulations by
their gentle stimulus, and are of greater utility than simple
dressings of any ointment. In a few days more they rise as
high as the edges of the skin; then lint must be applied, and
some unctuous substance on the edges, the simpler the better,
as that composed only of wax and oil; but be careful the lint
does not touch the edges, as it would greatly impede the heal-
ing of the parts, by preventing the shooting of granulations to
the skin. A formation of a scab from the evaporation going
on, on the surface, will be best prevented by the poultice.
This is the treatment required when an ulcer is in an heal-
thy state.
LECTURE V.

IMPEDIMENTS TO THE HEALING PROCESS.

Mr. Home on the healthy ulcer, tells us, that some super-
ficial ones will not be so disposed to heal when kept moist
and unexposed to the atmosphere, as when they become dry
and covered with a scab; and it will also be proper here to
remark, in his work on this subject, that he discountenances
the employment of poultices. The subject will now be re-
sumed.
The 1st impediment is, when granulations arise above the
edges of the skin, and are too luxuriant, forming what is com-
monly called fungus flesh; here bandages are proper, and ev-
en a thin sheet of lead applied will be found useful: but if
this plan do not arrest their further progress, it will be neces-
sary to have recourse to caustic applications, as the lunar
caustic, which should only be applied round the edges; any
further extension of the caustic is unnecessary; afterwards
cover the part with dry lint.
The 2d obstacle to healing is, when the granulations are too
languid, and have a glossy aspect : the coagulable lymph de-
posited is not rendered vascular, which gives them that semi-
transparent appearance; it marks a languid constitution, and
want of energy in the vascular system, so that the action is
greater than the person is able to support; these granula-
tions grow with greater rapidity than in the healthy ulcer ;
they are larger, and do not possess that firmness in texture.
It will be here necessary to improve the constitution by ton-
ics, such as bark and steel, and allow a generous diet. Stim-
ulating ointments will be required to rouse the parts to action,
and the best will be found to be the red nitrate of quicksil-
ver, from 5 to 10 grs. mixed with an ounce of lard: vitriolic
lotions may also be used : two grains of the zinci sulphas to
an ounce of water, or the diluted nitric acid, in the propor-
tion of two drops to an ounce of water ; a tight roller should
also be applied, as increasing the vigour of the circulation,
and also giving due support, and is effectual in producing a
determination of blood to the parts; and Mr. Home here
very justly remarks that ulcers which heal while the patient



LECTURE V.
51
is walking about, are not so apt to recur as those which heal
while at perfect rest.
3dly, An inflamed state of the parts, which will prove an
impediment to the healing process :-here poultices and fo-
mentations may be recommended, rest should be enjoined,
and the bowels kept open. Ein
4thly, Irritable ulcers, according to Mr. Home, are thus
designated: “The margin of the surrounding skin being jag-
ged, and terminating in an edge, which is sharp and under-
mined, the bottom being made up of concavities of different
sizes, with no distinct appearance of granulations, hut a whit-
ish spongy substance covered with a thin ichorous discharge;
the surface readily bleeds, and is painful. Ulcers which
occur on the malleolus externus, on the ligament of the pa-
tella, and the anterior surfaces of the tibia, are generally of
this kind;" and Mr. Home conceives that the periosteum is
the seat of this ulcer.
The treatment most generally pursued consists in the ap-
plication of steam, or vapour from warm water, or with a
small quantity of vinegar or spirits added to it; fomentations
of poppy heads, of hemlock, or of opium, are very service-
able; a decoction of the poppy heads, and of the recent hem-
lock dried, if it can be procured, are to be employed. A
striking instance of the good effects of dried hemlock made
into a decoction, in these irritable ulcers, the author saw in
the person of an invalided officer of rank in the country.
The hemlock was collected in the summer, and carefully
dried, and the old veteran did not feel satisfied unless he had
an ample stock regularly in the house by him. It is but fair
to remark, this occasionally failed in procuring him accustom-
ed relief, and then he was obliged to have recourse to a wa-
tery solution of opium. A decoction of wormwood or camo-
mile is recommended by Mr. Home. Poultices made of
marshmallows, or linseed, are useful; but that so frequently
used in town, the carrot poultice, seems to agree as well as
either; but it is sometimes preferred to mix linseed with it, in
the proportion of one part of the latter to five of the former :



52-
LECTURE V.

a change in the applications will be very advantageous in
some cases; and the principle of this occurrence is compar-
ed with that by which change of air even to a less salubri-
ous one, often improves the health. It is advisable that a
heavy poultice should not lie on the ulcer, but the ulcer rath-
er on it. Mr. Home remarks on this subject, that carbon
powdered has been found useful. Ointments are not proper
applications; and when warmth has been found hurtful,cream
has proved very serviceable ; bandages are of course to be
avoided.
5th, Indolent ulcers are the very reverse of those previous-
ly alluded to; " the edges of the surrounding skin are thick,
prominent, smooth, and rounded; the surface of the granula-
tions is smooth and glossy; the pus is thin and watery, being
imperfectly formed, and coagulable lymph in flakes appear
blended together. The lymph consists of flakes which can-
not be easily separated from the surface of the ulcer : the
bottom of the ulcer forms quite a level, or nearly so; and
Mr. Home remarks, the general aspect conveys an idea that
a portion of the skin and parts underneath, has been for some
time removed, without the exposed surface having begun any
new action to fill up the cavity.”
The principal part of the ulcers which are seen in the hos-
pitals are of this kind, although in appearance they vary
somewhat from the above characteristic. A healthy,weak,or
irritable ulcer, unless healed in a certain time, degenerates in-
to an indolent one, although we see some few exceptions, as
there are irritable ulcers which never change their nature.
Indolent sores, form unhealthy granulations, which become
again suddenly absorbed, and this event is promoted by
changes in the weather, anxiety, fatigue, &c.
Treatment.
Mr. Abernethy has remarked,that,generally speaking,who-
ever could apply a roller or a bandage the most perfectly and
securely around a limb,would cure these ulcers the best; and
the profession is under singular obligations to Mr. Thomas
Baynton, of Bristol, for the very excellent treatise which he



LECTURE V.
53
has published on this disease, which further elucidates the
subject. The treatment consists in strapping the wound with
adhesive plaster, and applying a bandage from the foot to the
knee (if the ulcers are situated, as we so often find them, be-
tween the knee and ancle) to give due support to the circula-
tion. Adhesive plaster is to be applied round the limb, cov-
ering the sore both above and below; this is to be so done as
to approximate the sides of the ulcer as near as possible:
soft compresses are to be then laid on, and afterwards a rol-
ler applied. The excess of inflammation is to be moderated
by keeping the bandages moist with spring water; or a very
diluted solution of the acetate of lead, if considerable:-wa-
ter generally will be found sufficient; and then there is no
necessity to confine the patient; he may use moderate exer-
cise. It may be proper in some cases to apply poultices at
the commencement, till the granulations arise to some height;
then stimulating them with a solution of lunar caustic, or the
nitrous acid diluted, giving due support to the circulation, by
means of a roller applied to the same extent as before allu.
ded to; but the preceding plan is always preferable, and
will be found more universally successful.
An indolent ulcer is sometimes attended with a varicose
state of the vena saphena, and this is found more trouble-
some to heal than the preceding, and is more likely to recur
afterwards. Compression, by means of a common roller, is
the most approved mode of treating this state, extending from
the foot to the knee, and an horizontal posture. Mr. Home
states cases where this has failed; and has practised an op-
eration, that of securing the vein as it passes over the knee
joint; he does not divide, but merely tye the vessel : but this
plan has but few advocates, if any, at this moment, on ac-
count of the very serious effects that have been known to re-
sult from its adoption.
6th. When a sore is sloughy, and has a black aspect, it is
another impediment to the healing process. The treatment
in this case is simple; use a strong solution of nitrous acid,
from 50 to 60 drops to two pints of water. Poultices of stale




54
LECTURE

beer, or wine lees, or what is known as crop of beer, which
is the remains in the cask after the clear beer has been drawn
off, mixed with oatmeal, will be very proper: and in some
cases, a table spoonful of yeast added will be an improve-
ment to restore it to a healthy surface.
7th. In consequence of sinuses: the mode of treatment,
when they are deeply seated is, to inject the hydr. muriat.
in the proportion of 2 grs. to % j. of aquæ : it should be used
thus strong to excite inflammation, and produce adhesion of
the sides. Tinctura lyttæ has been also used to bring on the
same effect. A caustic bougie may be also introduced. If
the sinuses have two openings, it will be best to make an in-
cision between them both, and to introduce proper applica-
tions. A sinus in the rectum (fistula in ano) is not to be cured
in this way, and rarely by injection. The reason is, that on
the motion or contraction of the gut, the sides of the sinus
separate; here a cut must be made through the rectum, the
whole length of the sinus.
8th. The next obstacle opposed to the healing of ulcers is,
a suppression of the menstrual discharge ; when this hap-
pens, it is seldom found an ulcer will be at all disposed to
heal, and will continue in this state so long as the cause re-
mains. In cases of this nature it is necessary to give stimu-
lants, to excite them to an healthy action, and the best med-
icine to answer this purpose is Dr. Griffith's mixtúre, compo-
sed of myrrh, steel, zinc,&c. and to the sore the best appli-
cation will be mercurial ointment, or the liq. calcis: but these
local applications will avail little, without we are successful
at the same time in restoring the natural vigour of the consti-
tution. Indurations are often observed in those who have
obstructed menses in their lower extremities. arta
9th. Sores are very subject to a fungus state, the effect of
extraneous bodies irritating the granulations, commonly at-
tended with bloody serum instead of pus, being of an offen-
sive nature. Nails growing into the skin often produce fun-
gus, by the great irritation they cause ; it was usually the
custom to destroy this excrescence by means of caustic; but


LECTURE V.
55
the treatment is evidently improper, as the fungus was always
found to grow again; which is not surprising, as long as the
cause existed, namely, the irritation produced by the nail,
which ought to be cut out in the following manner: put the
foot or hand into warm water ; suffer it to remain for some
time, then scrape the nail through with a piece of glass, put
a piece of lint under it, for the purpose of raising it, which
being done, cut it off. There is another method, which is, to
pass a pair of scissars about one eighth of an inch in length
under it, so as to slit it up; but this latter mode, although
quicker, is attended with a great deal of pain. Sores of this
description, although apparently so trifling, have been seen to
produce such a disordered state of the parts, as to cause the
necessity of dissecting into the skin, and also the gland which
secretes the nail; but previous to this it will be better to try
the liq. calcis, or ung. hydrarg. nitr.
10th. Sores often occur in the lower extremities from dis-
eased viscera, and are generally accompanied with anasarca;
--here it is proper to attend to the state of the viscera, as no
cure will take place before they are restored to their proper
functions. When attended with anasarca, calomel united
with squills, and about half a grain of gamboge, will be
found very efficacious; also the cathartic extract; at the
same time giving digitalis with the bark, twice a day, as ton-
ics are highly proper at the time evacuants are employed.
Bandages are here to be applied.
**
11th. Sores are also found in the lower extremities, with
disquamation of the cuticle, and skin abraded: under the
cuticle is found a small quantity of serum, owing to a lax
circulation of the parts. There are two remedies proper for
this disease: the liq. calcis, with hydr. muriat, in the pro-
portion of one grain of the latter to an ounce of the former;
dip linen in this wash and lay it upon the sore, over which
apply a piece of oil silk, which prevents the linen from being
too suddenly dried ; upon the oil silk apply a roller, which
should extend over all the limb. If the parts are irritated
with the above wash, apply the nitrate of mercury united
with lard.





56
LECTURE V.

12th. There are other impediments to healing, such as a
white and callous state of the edges of the sores : in this
case apply the ung. hydrarg. and if this should not succeed,
it will then be useful to scarify the edges with a lancet. Blis-
tering ointments have also their uses as stimulants. When
the edges turn inwards, it has been observed that this state
is a general attendant on scrophulous sores; apply this wash
to the ulcers twice a day-argent. nitrat. 3ss. liq. calcis 3j.
M. and afterwards the liq. calcis alone, as a constant lotion,
at the same time strengthen the habit with tonics. It is gen-
erally the mark of cancerous sores when the edges turn out-
wards. Sometimes we observe a species of sores not very
common, which are attended with a great deal of pain, and
yet little or no inflammation present; these are best treated
by the diluted nitrous acid, giving at the same time the de-
coction of sarsaparilla, applying the adhesive strapping on
Mr. Baynton's plan, so as gently to stimulate them to pro-
duce granulations, and also to cause the skin to elongate
over the sore by the cicatrizing process. This variety may
come with much propriety under the general designation of
indolent ulcers. The plan adopted in most hospitals in town
in indolent ulcers, is to foment and poultice at first, and after
granulations have formed, to apply the adhesive plaster, rol-
ler, &c. as already stated. b a it oites
Ulcers, with a specific action, will be noticed elsewhere in
the course of this work, such as scrophulous, venereal, can-
cerous, &c. &c. &c. c
o
sebON GANGRENE, OR MORTIFICATION. THIS
By gangrene or mortification is meant the death or loss of
any particular parts of the body of their vital principle,
while the others are perfectly sound. Authors give a dis-
tinct definition to the term gangrene and mortification; but
this is of very little practical utility. By gangrene they
mean to designate that stage commencing with the loss of the
vital energy of the part, till it becomes quite insensible, cold,
and of a dark discolouration : when they apply the other
term mortification. It is the result of two states or condi-


LECTURE V.
tions of parts : 1st. of high inflammation; secondly of cold.
When of the former, the parts are red and painful, and on a
sudden the patient becomes easier, the redness disappears,
and vesication succeeds, the skin becomes insensible, and of
a dry brown livid colour ; within these vesications there is
contained a bloody serum; the pulse is quick, small, and in-
termitting; shiverings, followed by cold perspirations, come
on; diarrhea, often delirium and hiccup: the patient's spir-
its become dejected, and his countenance assumes a wild ca-
daverous look.
A different state ensues when the mortification arises from
cold; the parts are at first benumbed, and on the exposure
to heat are afflicted with redness and pain ; the parts are de-
stroyed not by a constant, but by a weakly and frequent in-
flammation. One species of inflammation has been seen
where there is a medium between high inflammatory action
and excessive cold, and wherein the patient feels but little
pain; this was first noticed by Percival Pott, Surgeon of Bar-
tholomew's Hospital. It most frequently happens to men of
a gouty diathesis, who have enjoyed themselves in their
youth, and are considerably advanced in life ; it commences
at the extremities of the toes, and gradually advances to the
foot, ankle, and now and then to the leg, unpreceded by any
visible inflammation; there are instances adduced by Mr.
Pott, where it has occasioned very little pain; in others, dur-
ing the night, they suffer greatly from the toes to the ankle.
The cuticle becomes separated on the spot where it begins,
and a darkish red appearance becomes apparent underneath;
its progress is mostly slow, but when it becomes unusually
accelerated, the patient suffers in proportion. It is by no
means confined alone to the male sex, or those in years, but
when it attacks youth, it is rapid in its progress, and may,
with propriety, be referred to exposure to cold. A remarka.
ble case the author saw in Mary Jenkins, aged 13, brought
on from losing her way in the snow. The five toes, to the
second phalanx of each, mortified and sloughed; she lost her



58
LECTURE V.

voice and recollection, which was not restored under a week
from the time she was discovered; she ultimately did well.
Some parts mortify sooner than others; in the extremities
for instance, owing to a due want of circulation, and a pro-
per degree of warmth necessary for the maintenance of that
vigour in the parts. The difference of heat in the calf of
the leg and foot has been known to be so much, that the for.
mer exceeded the temperature of the latter by 20 degrees of
the thermometer. A very curious process takes place in the
removal of dead parts, and is as follows :- Around the dead
substance, in about two days, there is observable a white pro-
minent line; this appearance is owing to a raised cuticle, un-
der which there is serum: if you look 24 hours hence, at.
tentively, the skir, under this line will be absorbed; this pro-
cess passes very soon through the skin, a chasm becomes
formed between the dead and the living parts by the absorp-
tion of the latter; the process continues i extending, till at
length all are taken up except the bone. The process of ab-
sorption, in these cases, will be found to be much favoured by
the application of nitrous acid: the inside of a bone will re-
quire two or three years to exfoliate; this is to be attributed
to a languidness in the constitution.
In mortification, when the parts are separated by nature,
'a very curious and important circumstance occurs, which is,
that the arteries, though completely eaten through, discharge
no blood, and this is prevented by coagulation in the large
arteries, to some little distance from the seat of the mortifi-
cation.
The predisposing cause of mortification is principally de-
bility; a languid habit is often observable to take place after
great weakness has been induced on the system, by the se-
vere attack of small pox, measles, scarlet fever, &c. Sores
also are remarked to slough from the use of mercury exciting
salivation, so as to produce the same effect, viz. debility; al-
so after considerable hæmorrhage; numerous other instances
might be adduced, as any interruption to the circulation ; as
in hernia, &c.; ossification of the arteries; old age; pres-

LECTURE V.
59

sure, by long continued lying in the same posture ; but this
may be referred at once to debility, erysipelas, and severe
injuries, as gun-shot wounds, bruises, &c. &c. Climate, spe-
cific diseases; as fluxes, &c. may be also enumerated.
It will be necessary to give a caution here, in amputating
the limbs of those persons whose disposition of body is fa-
vourable for the formation of gangrene, to take care that
they do not loše much blood, as the very worst effects have
been known to result from such loss. Inflammation is the
proximate cause of mortification; if there be any exception
to this, it is in hydro-thorax, but very rare even in this case.
Frost bitten parts do not die without previous inflammation.
Treatment.
It consists, in the first place, of local evacuations, such as
leeches to the part, scarifying, &c. and to strengthen the hab-
it by a generous diet, and tonic medicines; if the patient
have been accustomed to take wine, or spirits of any kind,
it will be advisable to allow him them in a moderate degree,
so as not to heat him too much ; apply spirituous lotions, as
spirits of wine and the liquor ammoniæ acet. and camphor
combined; turpentine also, in some instances, may be ap-
plied warm: relieving the parts by perspiration is proper,
for which purpose the stale beer or wine lees poultices are
useful; but they should not be used before fomentations and
emollient cataplasms have been applied, as the latter are
preferable, owing to the inflammatory state of the parts.
Hunter advises that all the applications made use of should
be cold; but it would be more prudent to consult the feelings
of your patient, and warm applications are occasionally seen
to sooth and afford ease, where cold would not be produc-
tive of the same result. Opium alone, given in small doses,
to ease the excessive pain suffered, will occasionally be pre-
ferable to its combination with the bark; but be careful, pre-
vious to its being administered, to open the bowels gently;
these are the means used to arrest the progress of the dis-
ease.
If mortification have already begun, apply stimulating
60
LECTURE V.

poultices, as those already mentioned, stale beer, wine lees,
&c.; but the most advantageous poultice that the author has
witnessed, and which has been employed from Hunter's time
to the present moment, with uniform success, is crop of beer
united with oatmeal, and a spoonful of yeast added to it, and
applied cool, and renewed at least twice daily, by it, the pro-
gress of the mortification becomes checked, a separation
from the living parts effected, and a secretion of healthy mat-
ter produced. At the same time give decoction of bark in-
ternally, either combined with ammonia or opium, in small
doses. If a diarrhoea be induced, unite the bark and opium
with the aromatic confection; this has been found to check
it: but if it should be prolonged, give the mistura cretæ with
opium. If the patient he delirious, apply a large blister on
the nape of his neck, and internally give the camphorated
mixture, with musk. Bark, in mortification, is combined
with other medicines, by some, as the sulphuric acid, by oth-
ers it is altogether omitted, and ammonia, opium, or musk,
substituted ; in some patients, bark certainly will disagree
and prove prejudicial, under any form ; while in others it
will be of the most decided advantage. Ward's paste is
sometimes made use of with great success; it is composed
of the following ingredients, made into an electuary:-Piper.
Nigr. 3ij. pulv. emul. camp. sem. fænicul. in pulv. āā 3ss.
Mellis Anglic. q. s. ut form. electuar. 3j. bis terve in die su-
mendus. This has been found very useful in sloughy and
ill-conditioned sores of a scrofulous nature.
& Allow the patient a generous diet, and introduce aromatics
in it; porter, good beer, wine or brandy may be given.
On the subject of Amputation.
It is certainly not right to operate till after the complete se-
paration of the dead from the contiguous parts, that is, until
a line of separation becomes evident, and this is one point
among the few on which surgeons are unanimous; because,
if you amputate before, you will still have the seeds of the
disease in the system: but if mortification be the effect of a
wound, or a division of an artery, then you may operate, as



LECTURE V.
here there will have been no predisponent cause to gangrene;
also when ulcers are very large and extensive, it may be done
with advantage. Parts will often, as has been before obser-
ved, separate without amputation ; but if we have reason to
suspect that the stump will be very long and tedious, or that
it would exhaust the patient in the efforts to repair so exten-
sive an injury, it will be preferable to take off the limb; if
the mortification have been considerable, the cure would at
least prove troublesome, the stump of a bad form, and ulti-
mately of little utility to the patient. With respect to giving
opium, I have omitted one circumstance, it will be better to
give it before, than after gangrene has taken place. Morti-
fication is often the result of an ossification of arteries; in old
people it cannot be cured by any means that we are acquain-
ted with. Mortification commonly attacks the toes and ex-
tremities of tall people, for reasons easily explained, such as
a degree of torpor in the circulation of those parts, owing to
the great distance from the heart, by which the blood is not
sufficiently propelled into them. It now and then is seen to
proceed from the most trifling causes imaginable. It has been
known to come on from cutting a nail to the quick (the nail
of the toe is meant.) A gentleman had, unluckily, cut his
nail in this manner; mortification ensued: on examining the
course of the arteries, they were found ossified, and it was
not difficult to foretel that he would not survive three weeks;
which was the case, for he died in a fortnight afterwards.
Mortification has been known to proceed from an opening
made into a tumour on the great toe. The treatment in these
cases consists in the use of fomentations; stimulating poul
tices; opium internally; wrapping the feet and legs in flan-
nel or wool; applying bottles of hot water to the feet, &c. &c.



( 62 )

LECTURE VI.

OF THE FURUNCULUS, OR BOIL.
A BOIL is a circumscribed, painful, inflammatory swelling, of
considerable hardness to the feel, very prominent, and of a
dark red colour. Boils are not generally of any considera-
ble size; a cyst is formed in the cellular structure for the re-
ception of the matter, which is generally tedious in its forma-
tion : except where large, or when several exist at the same
time, they do not affect the constitution. They mostly occur
in young people, and are thought to be a salutary operation
of nature. In their treatment, the object we ought to have
principally in view is to facilitate the suppurative process, by
every means in our power: poultices of an emollient nature
are to be employed, and an opening made into the most prom-
inent part (which approaches when the process is nearly
complete to that of a cone,) an early opening is not recom-
mended. The matter is of a thicker consistence than we
find formed in abscesses; it ought to be squeezed out, as the
whole of it will not readily flow itself. If the boil be large,
and very painful, it will be advisable to have recourse to opi-
um: if the patient be much debilitated, bark and the sulphu-
ric acid may be given; mild purgatives are to be employed.

LECTURE VIS
63
ON THE CARBUNCLE.
A carbuncle is an abscess in which the cellular structure
takes on a sloughy state; it differs not from a common pro-
cess in its containing matter. The first appearance it as-
sumes is similar to a boil, and of a bluish colour, raising a lit-
tle above the skin, having within it commonly a bloody se-
rum. It can be distinguished from other swellings by pres-
sure, which causes a discharge in several parts of its surface;
it occurs mostly in old people, and in those accustomed to a
debauched life, as tending in a great degree to debilitate and
undermine the constitution. In England we see it preceded
and accompanied by typhoid symptoms; abroad it marks
the plague and other malignant disorders. Richerand tells
us, in some provinces of France there is a particular species
of this malignant boil. Carbuncles are occasionally seen
very.extensive, and the danger is proportionable to the extent
and seat of the disease: sometimes, when on the neck, they
are to be considered in a favourable point of view, at other
times not so, and this will be favourable or not, according to
the concurring circumstances. When in the rectuni, the
prognosis is unfavourable. As these malignant boils so easi-
ly take on a gangrenoús or mortified disposition: the same
treatment here will be necessary as in those affections. Warm
fomentations (the warmer in reason the better) are to be made
use of; emollient poultices will also be proper. Stimulants
also, as turpentine or the mercurial plaster, &c. may be of
advantage. Incisions should be made, which will relieve the
skin greatly, by taking off the sloughy substance; but mak-
ing openings in the very beginning of the disease, with any
other view, than that of taking off the distention of the skin,
would be improper. When an opening is made, which ought
to be done early, squeeze as much of the contents out as you
possibly can, without occasioning considerable pain; the
constitutional treatment will consist in the exhibition of bark,
aromatic confection, opium, &c. as recommended for morti-
fication; allowing a generous and nourishing diet. Porter,
wine, &c. -




LECTURE VI.
ON BURNS AND SCALDS.
Burns may be divided into three states or conditions:
The 1st. consists in a simple vesication, in which the cuticle
remains unbroken.
The 2d. where the cuticle is extensively separated from
the surface of the skin, so that the papillæ of the extremities
of nerves are exposed, which is most frequently the case,
from the application of fire.
The 3d. in which the life of the cutis vera is gone, and
where the process of suppuration is absolutely necessary.
The danger of the first state is but little, provided the vesi.
cations are not disturbed, however extensive they may be, al-
though on this subject there has been a severe controversy:
in this state, the Liquor. plumb, acet. dil. et spirit. vin. should
be frequently applied cold ; the chief object is to keep the
blister from breaking, as a considerable discharge would
come on : otherwise no great irritation, and consequently no
attendant danger arise. The spirit. vin. and acet., also a
camphorated lotion, as liq. plumb. acet. 3ss. spirit. camphoræ
3 ss. aq. distill. tbss. ft. lotio, may be applied with the same
view.
The danger attending on the second, or that state in which
the cutis is bare and exposed, is greater than in the prece-
ding, owing to the increased sensibility of the parts, and it is
no uncommon thing for death to take place soon after such
an accident, when extensive, in consequence of the system
receiving such a violent and immediate shock; in this case
you will find the pulse quick and small, and the patient fre-
quently chilly, perhaps every quarter of an hour : so that he
ultimately falls a victim to the first impression. It is some-
what curious, and at the same time worthy of remark, that
children sometimes die of injuries apparently of a trivial na-
ture: an instance of this occurred some time ago, in the case
of a child, who died from a trifling scald on the nates, the
same evening of the day the accident happened. Burns pro-
duced by hydrogen gas differ in their nature from those aris-
ing from other causes, and require a different treatment: in
LECTURE VI.
65

the one case a stimulus is necessary, in the other not. This
was ascertained some time ago, in one of the hospitals in this
metropolis, from the following circumstance :-A young gen-
tleman, who came from the North of England, and had seen
a variety of burns and scalds, in which the turpentine (at
that time so much talked of) had been used indiscriminately,
and which he averred with success; advised it for a patient
in the hospital in which he was a dresser ; but the fatal ef-
fects of it were very soon obvious; besides this, it is neces-
sary to observe, that should the patient survive the accident,
still it is likely that death will take place, from secondary ir-
ritation. The practice usually followed is to administer opi-
um and wine, and to apply lime water and milk, for the pur-
pose of lessening the degree of irritability present, and also
preventing the increased discharge, which would subsequent-
ly take place from the use of the stimulants. The old appli-
cation, the liq. calcis, with oil, is still frequently used. Where
granulations have arisen, as they will, extensively, in a few
days, the following lotion is to be applied :-R. Zinci sulph.
gr. vj. aq. fontanæ 3iv. M. ft. lotio. ; this will, in a short time,
produce a new cuticle, even over an extensive surface.
With respect to the third state, though there is no immedi-
ate danger, yet there is a remote one, for the skin being de-
stroyed, separates and forms an eschar, which must natural-
ly debilitate the living powers, by calling on them beyond
their natural capacity. It is in this state that we find so
much benefit derived from the application of the ol. tere-
binth. first recommended by Dr. Keates; this stimulates the
parts, and promotes a quick restoration of them, and it is in
those burns where the cutis is destroyed, that it has been used
with such manifest advantage and decided success. The au-
thor might instance the extensive iron-works at Cyfartha,
Pendarren, Douglass, Tredegar, Sirhowey, Beaufort, Nanty-
glow, and Llanelly, in proof of this assertion ; and it is only
in those cases where it has been used indiscriminately, that
it has afforded any other than a satisfactory result; in some
cases it is combined with linseed oil, in others used alone, in

66
LECTURE VI.
the first instance, and afterwards united with yellow basili-
con for the subsequent dressings.
In the species before alluded to (the second) it has been
already shown that turpentine will be more injurious than
otherwise; and in children, if the life of the skin remain un-
injured, it is an application of great severity. A case occur-
red in Guy's Hospital, where the skin was uninjured, which
afforded a very good opportunity of judging of its effects. A
man was scalded nearly the same in both legs; the white wash
was applied to the one leg, and the turpentine to the other-
in the former a new cuticle was soon formed : in the latter a
sore was produced which was very irritable. A ridiculous
objection has been made to what appeared a very convinc-
ing proof of the relative benefit of each application ; that if
two remedies be made use of at the same time, one counter-
acts the other : but here let one question be asked. Is it
not very possible, in case of two buboes, by fomentations, &c.
to bring one to suppurate, while, by an opposite mode of
treatment, we disperse the other ?-Still there can be no
doubt as to the truth of those cases mentioned by the dres-
ser, of the efficacy of turpentine in the North of England;
but burns, produced by hydrogen gas, are not attended with
consequences so serious as others. Mr. Hey, of Leeds, re-
commends the use of turpentine : but it should not be ap.
plied when there is simple vesication, or in the second spe-
cies, but only when the skin is destroyed.
It will be necessary to distinguish each species as here
laid down, and the remedies will be found, by experience,
to be those mostly successful; it will now be proper to state
in as brief a manner as possible, what other applications and
treatment have been advised by authors. Paré, Haldanus,
and many others, think no injury will arise from puncturing
the vesicles, which they countenance ; but the author re-
collects a case, in practice, which directly bears on this
point. Mrs. Baskerville scalded her left foot rather exten-
sively; the vesicles were punctured, and the fluid discharg-
ed; but whether there was some peculiarity in her disposi-
LECTURE VI.
67
tion and habit of body, or to whatever cause it may be at-
tributed, so as to leave the puncturing the vesicles totally out
of the question, a mortification ensued, and was restrained
with difficulty: this case was tediously prolonged, but she
perfectly recovered in the course of some time. Now what
will Paré and others say, if the medical practitioner (a house
pupil of John Hunter's, and a man as capable of practising
as any provincial surgeon in the kingdom) attributed the
principal mischief originally to the bad practice of punctur-
ing the vesicles, which he most decidedly disapproved of.
Sir James Earle recommends ice, or the coldest water, made
of a solution of sal ammoniac and saltpetre, to be applied
either by means of linen, or that old favourite of the public,
in these cases, scraped raw potatoes. Mr. Cleghorn, of Ed-
inburgh, extols vinegar in burns and scalds, to be applied a
little warmed ; and it must be allowed, that the fact of Hun-
ter's deeming a communication to this effect, from Mr. Cleg-
horn, of sufficient importance to be published in the Medical
Facts and Observations, contributed, not a little, to raise the
estimation of this remedy; the vinegar to be applied till the
pain ceases, then a poultice, and afterwards powdered chalk.
It is not a little curious, that two remedies, diametrically op-
posite to each other, should have attracted public attention,
nearly at the same time. Sir James Earle's, of ice, &c.;
and Dr. Kentish's stimulating applications; and I too well
recollect Mr. Abernethy's remarks on tetanus, ever to be for-
gotten’; they were to this effect :—that if the warm bath be
şerviceable in tetanus, the cold one, reasoning à priori, can-
not be so, although authors would endeavour to reconcile us
to those contradictions ; if the cold bath be beneficial, on the
same principle the warm bath cannot be advantageous. The
author would think, unless right and wrong are synonymous,
applications so different cannot universally be useful, unless
burns and scalds are found to vary very much from what
are generally seen, both as to their different states and ex-
tent of the violence. But we must endeavour to draw a
line of distinction at all events. Cold applications, it must




LECTURE VI.
be allowed, are not advisable in every kind of burns and
scalds, neither are stimulating ones ; hence let us see if we
cannot tempt these two authors of Iceland and of Guinea to
approach each other. Dr. Kentish advises the parts to be
bathed with the rectified spirits of wine, with or without
camphor; then the oleum terebinthinæ with the ung. resin.
flav. on lint, on the burns; in the second application, lauda-
num or proof spirits may be substituted : and the ointment
to be mixed with camphorated oil instead of turpentine, or
the ung: liquor. acet. plumb., or lapis calaminaris ; he then
advises powdered chalk to be applied. The first dressings
should remain on twenty-four hours.
Very great deformity now and then occurs from the gran-
ulations on the chin, adhering to those of the breast : of the
thigh, to the abdomen : of the fore-arm, to the upper, &c.
&c. : in the former the under lip is drawn down, and the
saliva, by trickling over the breast, is apt to excoriate it;
here, by putting your finger behind the portion of skin, you
can divide it, and then apply adhesive plaster ; but should
the union be complete, then the operation will be useless, of
which several instances could be mentioned. We should, in
the first instance, endeavour to prevent its taking place, by
interposing some body between, as the deformity is some-
times excessive, and the loss of character certain ; the best
thing we can do is to apply adhesive plaster over the granu-
lations, and upon this a soft cushion. The same treatment
and attention is required for the thigh and fore-arm; it is of
no advantage to divide the skin between the arm and fore-
arm, the deformity will exist. Sir James Earle has men-
tioned a case where the chin was united to the breast, on
which he operated with benefit.
D
a biodh ann

( 69 )
*
LECTURE VII.
ON WOUNDS.
Wounds are divided into four kinds: the incised, or those
which are occasioned by some cutting instrument; the lace-
rated, or those which are caused by parts being violently
torn asunder ; the contused, or that species arising from a
blow happening to a part, by which the vitality of that part
is destroyed; fourthly, and lastly, the punctured, or those
made by a sharp pointed instrument: of all the varieties of
wounds, these are most to be dreaded, on account both of
their more immediate as well as remote effects; from this de-
scription of wounds arise the locked jaw, &c. &c.
OF THE INCISED WOUND.
The direct effect of this species of wounds, is, besides the
separation of the parts, the immediate discharge of a quan-
tity of blood, greater or less, according to the magnitude of
the vessels divided. The more remote effect is that of in.
flammation, and in the course of a very few hours the wound
becomes covered with a gluey matter; the first object re-
quired is to put a stop to hæmorrhage, and this should al-
ways be done by means of pressure, if it be possible. "It is
always better to avoid applying ligatures if they can be

70
LECTURE VII.
done without, and in general, pressure, made for the space
of five minutes, will be sufficient to stop the bleeding, more
particularly if assisted by a dossil of lint on the wound.
This suppression of hæmorrhage arises from the coagula-
tion of blood around the extremities of the divided vessels,
as well as in the mouths themselves. Then the subsequent
inflammation, which always supervenes, is taken advantage
of; in order to facilitate a cure of the wound, the edges are
brought together by means of adhesive plaster, and adhe-
sion takes place, which glues the edges fast together; in ob-
serving the process of nature in healing wounds, the opin-
ion that was formerly entertained of the bond of union, as this
process was then termed, between the divided parts, is en-
tirely exploded ; no wound is united by the blood alone; it
was then thought that a coagula of blood was the uniting
medium, but there is only one example of the healing of
wounds, in which it happens that a clot of blood acts as an
auxiliary to the healing process, and this is in the division
of arteries. If a ligature be applied upon an artery, there is
a clot of blood immediately formed within this artery, just
above the ligature, but it does not become the immediate
bond of union : inflammation takes place on the inner mem-
brane of the vessel ; coagulable lymph is poured out, and
the part ultimately becomes organized by the elongation of
the original vessels. But setting aside this one solitary exam-
ple, we shall not find a parallel one, in which the blood forms
the uniting bond. If a muscle or a tendon be divided with a
sharp instrument, the re-union first ensues by the effusion of
coagulable lymph into the cavity of the wound, and also when-
ever we are anxious to produce union by adhesive inflamma-
tion.
The first necessary step must be to clear away all the sur-
rounding blood, and that between the lips of the wound, and
unless this is done, it will prevent the adhesion, by being in-
capable of being rendered vascular ; after this the parts are
to be brought together neatly and closely by the adhesive
straps, and supported by proper bandages.
LECTURE VII.

In the course of a few days, coagulable lymph having
been thrown out, vessels may be traced into this newly formed
substance, and these are found to proceed from the divided
vessels, as well as from the surrounding cellular membrane.
I have seen the tendo achilles of a dog which had been di-
vided purposely, ten days before, at the end of which time
the dog was killed, and the process examined ; there was
about an inch of newly formed tendon, and this was render-
ed vascular, according to the above-mentioned manner: to
produce this, an increased action is set up in the surround-
ing parts.
It is found that the newly formed part mostly takes on the
same structure as the parts to which it is immediately united.
Supposing that it is skin only that is divided, inflammation
takes place, coagulable lymph is effused, and this becoming
organized from the surrounding skin, by means of an exten-
sion of its vessels, a similar substance becomes replaced; the
cuticle also is reproduced, and in the course of time the rete
mucosum is also renewed, though a considerable time will
elapse previous to its complete restoration. If cellular mem-
brane, newly formed, exactly resemble that which previous-
ly existed, being reticulated; the cells in the first instance
are filled with lymph which causes it to appear denser; but
this is soon removed by the absorbent vessels. A similar pro-
cess is going on when tendons are divided, as well as when
injuries happen to the bones. Thus from these examples it is
evident that the body is possessed of a power of reproduc-
ing a structure like in every respect to that which had been
destroyed. To this however there are some exceptions, as
has been mentioned, with respect to cartilages, as bone is
reproduced, resulting from an increased action in the neigh-
bouring vessels: but if an experiment be made in any
young animal, bone is not produced, but cartilage, so that
the peculiarity in some degree depends upon the age. A
second exception is when muscles are divided, they are
united by a tendinous substance. A third is with regard to
glands ; these are not restored to their perfect state by


92
LECTURE VII.
means of a simple effusion of lymph, they will be found to
have arteries, veins, nerves, and absorbent vessels, but no
excretory duct, as the original gland had.
It will be found that this union by adhesion will take
place between soft parts and bone ; inflammation produces
a severing of the parts, as the periosteum from the tibia, be-
tween which an effusion of lymph is produced, and by being
endowed with vitality connects the two parts firmly togeth-
er. This is often perceived in injuries done to the scalp, as
well as the tibia, if the parts are applied together when
found separated. This process will take place both in flat
and in cylindrical bones ; as this is the case the obsolete
practice of cutting away a portion of the scalp in fractures
of the cranium, is done away with ; and formerly, if the
periosteum were separated from the tibia, it was the prac-
tice to cut it off, which occasioned tedious exfoliations :
whereas, had it been laid down, it would have united in a
short time, and prevented the necessity at all for so tedious
a process.
With respect to this union, it will be found not to hold
good in an attempt to unite the articulating cartilages and
the cellular membrane, or common integuments : one of
these is laid bare, as in removing a finger, and the integu-
ments are brought over it, as in the common amputation of
a large extremity, they never become united to the carti-
lage, from a cavity being left, in which a fluid is secreted,
which causes a' tumour in the extremity of the stump ;
therefore as this is now well known to happen, surgeons ge-
nerally pare off the articulating cartilage, until the bones
bleed, from which surface granulations arise, which will be
sufficiently vascular to unite by the adhesive inflammation.
We are not to be deterred from attempting union by this
process, even though the parts are much separated ; for if
they remain attached by a very small piece of integument
alone, they will often unite, though apparently no chance of
it existed. A case might be adduced, which occurred in a
near relation of Mr. Astley Cooper's :-A boy playing with
LECTURE VII.
a dog, enraged him, when the animal seized the lad by the
nose, and nearly bit it off ; it hung down by a small portion
of the cartilaginous septum : the parts being immediately
brought together, in the regular situation, so good an union
took place, that the scar is scarcely perceptible, and no de-
formity is apparent.
When Tippoo Saib, or Hyder Ali, took any English or Se-
poys in the Mysorean wars, it was their general custom to
cut off their noses, by which they were able to know them
again when taken, then they invariably were put to death.
In these cases, the native surgeons were in the habit of cut-
ting a triangular piece of integuments from the forehead,
twisting it half round, but not entirely separating it, and
bringing it in such a manner as to form a nose ; the edges of
the old wound on the face were pared off, and the edges of
the skin brought down were inserted into the face; the form
of the nose was supported by parchment, or any other con-
venient substance stuffed in each nostril, until it gained pow-
er to support itself : in the course of some days the integu-
ments thus brought down will unite, and the nose appear a
very good substitute for the old one. The scar on the fore-
head will remain long a mark; but in time it will not be
much perceived. In about 24 days after the operation the
part which remained whole and twisted round may be re-
moved at the root of the artificial nose, which clearly proves
that inosculation must have ensued between the vessels of
the nose and those of the cheek. This operation has been
successfully performed in the west end of the town very late-
ly.
In animals it has been found by experiments that parts
which have been entirely separated, and even transplanted
to another animal of a different gender, will unite and be-
come supplied with blood vessels from their new possessor.
Some analogical experiments of Hunter led him to take up
the fanciful opinion, that he could convert a hen into a cock,
by taking out the testes of the latter and inserting them into
the abdomen of the former. This he actually tried, and



10
74
LECTURE VII.

though he did not succeed to the extent of his wishes, yet in-
flammation taking place, the new substance introduced was
supplied with blood from the hen, and remained united there;
yet nothing further was observed with respect to the change
in the sex. The tooth of an animal just extracted was in-
serted into the comb of a cock, and this being bound on,
united, and remained firmly attached and adherent, being
supplied with vessels from that appendage.
Mr. Lucas of Guy's hospital, has a preparation in which
the spur of a cock being inserted into his comb, it not only
united to this, but even to the bone of the cranium. With
respect to similar analogical experiments on man, they have
not been carried to a sufficient extent; yet Hunter ascertain-
ed that a sound tooth taken from the alveolar process of one
person might be transplanted into that of another, and unite.
Garengeot mentions a case nearly similar to some of those
which have latterly been published, of parts of the body be-
ing entirely removed, afterwards replaced, and uniting. He
says, a soldier's nose was bit off completely, but on being di-
rectly restored to its original situation, it became united. A
marvellous case has been told of a man having his nose com-
pletely removed, which fell into the gutter, the removed part
wiped clean, replaced and all did well. Few have gone the
length of this case. They will do pretty well for our credi-
bility where they extend only to all-but separated, as innu-
merable instances could be adduced of such cases uniting
well; but when they are carried further, in the present state.
of our knowledge, they only stagger our belief in the truth
of the asserted and attested cases.
Case.—A tailor's wife holding a piece of wood for her hus.
band to cut through with a sharp cleaver, unluckily by his
aiming a very straight forward blow, nearly, that is, “all-
but," separated his wife's second finger of the left hand: she
came under the author's care, who suggested the propriety
of attempting an union: she caught eagerly at the proposal,
and this was deemed a very fair case to see the extent union

LECTURE VII.
75
but were held together by a small piece of integument only:
in a month the finger was healed.

The mode of retaining parts in contact with each other
when divided, are two, viz. the application of adhesive plas-
ter, and using sutures. When the first is made use of, it
should be applied in the form of slips across the wound, tak-
ing care to leave interstices between each for the escape of
any matter which may be secreted, or blood which might be
effused; for if this be not done, these acting as extraneous sub-
stances, will force the lips of the wound asunder, and thus
render the suppurative process and granulations necessary
to heal it. The exceptions to the use of adhesive plaster to
every case of incised wound are but few. In the eye-lids,
cheeks, and lips, sutures must be used, on account of the
great mobility of these parts ; also in the scrotum, after ex-
tirpation of the testicle, &c. In wounds that are triangular,
a suture had better be placed at the raised angle. When
the muscles have been divided transversely, it is in general
only necessary that the position of the limb should be attend-
ed to, as if it be placed in that posture by which the divid-
ed muscles can be relaxed, the edges of the wound will read-
ily approximate ; and if a suture through a muscle should be
incautiously or erroneously applied, it will occasion inflam-
mation and violent spasms.
Ligatures should never be applied upon small arteries
that are divided in incised wounds of parts, for by so doing
a greater surface is left to be filled up by granulations, which
might have been healed by the adhesive process. The ap-
plication of a roller moderately tight upon a stump or wound,
will generally be sufficient to suppress the hæmorrhage, even
from the second rate arteries, and must remain on 24 hours.
However, below the knee, when a leg is amputated, all the
vessels of any importance must be tied, as pressure cannot
act upon those between the bones, or contiguous to them.
There is a circumstance all surgeons that consider the wel-


76
LECTURE VII.

fare of their patients should avoid, namely, an idle curiosity
of opening the wound or stump too soon; the time that
wounds ought to be allowed to remain unopened will be from
three days to seven or eight, according to the extent and na-
ture of the wound. After the operation for amputation,
some are curious and desirous to see how the healing pro-
cess goes on; in this it will often happen that the adhesive
inflammation will give way, and the parts recede, by which
suppuration must ensue before the wound can possibly heal.
The straps should not be removed under seven days; inter-
vals must always be left between them, that any discharge
taking place may have an opportunity of escaping. If there
be pain or great inflammation after the amputation, it may
be mostly removed by the application of cold water to the
stump; if an oozing of blood ensues, by which the rollers
and bandages are rendered stiff and uncomfortable, it will
be advisable to remove them, but the straps must remain. If
a number of lymphatics are divided, the effusion of this fu-
id will retard the union of the wound.


an
O2
CONTUSED WOUNDS.
A contused wound is occasioned by the collision of a
blunt instrument or surface against a part of the body; un-
der these circumstances, it would be absurd to attempt union
by the adhesive process. These wounds are not merely le-
sions of continuity, but are accompanied with such force
and violence done to the substance of the part, that suppu-
ration and sloughing generally ensue, if the force applied
have been sufficient to destroy the vitality of the part. In
the course of a few hours inflammation comes on, and the
absorbents take up the living substance immediately in
contact with the dead part, and by this means it is separated
from the other. The treatment is to be quite different from
that of incised wounds :-carefully remove any extraneous
bodies; use leeches, fomentations and poultices. It is also
requisite, if the injury be extensive, to support the constitu-
tion under the process. After the bowels have been opened,

LECTURE VI.
opium and antimony are the best internal medicines : in
some wounds of this description, the bark is found liable to
irritate the stomach : hence in these cases it would be bet-
ter to omit it.
S
9

LACERATED WOUNDS.
Lacerated wounds are different from the other species, as
the hæmorrhage from them is much less. Sometimes whole
limbs will be torn off with little or no blood being lost. Che.
selden has related a case which came in St. Thomas’s Hos-
pital, where the arm and scapula were torn off without any
hæmorrhage. These wounds are often dangerous, on ac-
count of their containing extraneous substances ; and they
are more liable to be succeeded by tetanus than either of
the two before mentioned.
Treatment.—After washing the wound very clean, and re-
moving all extraneous bodies, it may be right to apply adhe-
sive plaster to bring the edges of the wound together, or as
near so as possible, to prevent nature from having so large a
cavity to fill up as she otherwise would have by granula-
tions ; afterwards apply emollient poultices. Leeches may
be necessary, and sometimes the lancet is required, if the
irritation be great. Opium, &c. must be employed in these
cases, the action of the bowels being previously regulated,


( 78 )
LECTURE VIII.

ON PUNCTURED WOUNDS.
When wounds of this description are produced by any
sharp pointed instrument, the effects resulting from them are
three-fold: they excite inflammation of the absorbent vessels,
they may wound the fascia, and they may destroy life by in-
ducing tetanus. With respect to the first species, namely,
that by which inflammation of the absorbent vessels is excited.
The symptoms attendant upon a wound of this kind are as
follows: red lines are seen extending from the wound to the
next absorbent gland in the course of these vessels; on feel-
ing them they are found to be hard and knotted where the
valves are placed. The contiguous glands are enlarged;
sometimes matter is formed in the vessels or glands, occur-
ring in the latter ; and this also more frequently happens in
wounds of the leg and foot than in those incident to the arm,
on account of the vessels being larger in the part, and the
circulation in the blood vessels more languid.
! When suppuration takes place in the absorbents, from the
inflammation consequent upon a punctured wound, the consti-
tutional affection and irritation runs extremely high. These
wounds are accidents frequently affecting medical men, who
are in the habit of opening or dissecting bodies. A pupil in
one of the hospitals in this city in sewing up a body, punc-
LECTURE VIII.
79
tured his finger about ten o'clock in the day: at nine the
same evening, inflammation came on in the part, and became
very considerable; on the ensuing day the local and consti-
tutional symptoms were very severe; in the evening delirium
came on,and he died 37 hours after the accident. It is generally
thought that the putrid matter was the cause of these violent
symptoms, it being inoculated under the skin by the instru.
ments used; but the body was quite fresh, and had been dead
but a short time. From this case, and many others which
have occurred, and which are seen every season, where no
matter of the above kind could possibly have been introduc-
ed, it is evident that the severity of the symptoms depends
upon the constitution of the patient, for these appearances
will arise from pricking the finger or hand with scissars or
needles, which could not have putrid matter upon them when
entering the skin. Treatment.-Cut a piece of lunar caustic
into a pointed shape like a point of a black lead pencil, and
introduce this into the wound, and cauterize the whole inter-
nal surface of it. When this is done, very severe symptoms
are prevented from coming on. If this should not have been
done in the first instance, from fear of occasioning unneces-
sary pain, or too great confidence in yourselves to be mate-
rially alarmed about such an injury, at least dilate the wound;
should inflammation and pain have arisen, leeches and
fomentations must be applied. The antiphlogistic regimen
adopted to its full extent; calomel accompanied or succeed-
ed by saline medicines ; opium and antimony must be given
at the discretion of the surgeon. From imagining that a
putrid diathesis existed, many surgeons were in the habit
formerly of giving wine, bark, &c. to correct it, and never
allowed the symptoms resulted from inflammation; the conse-
quence was, that many died under this plan of treatment.
Mr. Astley Cooper, in dissecting, some years ago, punc-
tured his finger; he had very severe symptoms resulting from
it: he did not confide in his own knowledge, fearful he might
not be so able to judge of the treatment necessary for him-
self, so satisfactory, as if well and prescribing for another;





80
LECTURE VIII.
a medical practitioner was sent for, who recommended wine,
&c. and Mr. Cooper had the resolution to submit to it for a
very short time, but sufficiently long to find it only exasper-
ated the disease: on adopting the antiphlogistic regimen, he
got better, though it was a long while before he became per-
fectly recovered, which change of air materially con-
tributed to.
If the puncture be deep, the nitric acid may be used, as the
caustic will scarcely reach the bottom of it; these wounds
have been converted by some surgeons into simple incised
wounds, by boldly laying them open ; but unless the wounds
are deep, it is better practice to use the caustic liberally, as
it will ever be attended with a prevention of the symptoms.
Although many have attempted to account for the pheno-
mena, attendant upon these apparently trivial wounds, yet a
great deal very unsatisfactory and inconclusive has been ad-
vanced; every thing depends on the form of the wound;
when a sharp-pointed instrument perforates the body, the
cells of the cellular membrane are exposed, and the termin-
ation of the absorbent vessels into these cavities : hence they
become inflamed, and a progressive inflammation is set up in
these vessels, until they reach the next gland; but when an
incised wound occurs, blood is effused into the cavity, or
coagulable lymph, by which the extremities of the vessels,
of the absorbents, are covered, and thus are prevented from
removing into an inflamed state.
The second species of this description of wounds, are those
which penetrate the fascia of any part of the body; danger-
ous symptoms will here take place, frequently from the mat-
ter effused being confined by a tensé covering, and unable
to make its way out.
Case.—A botanist, in getting over a gate, ran a nail into
his thigh, penetrating the fascia; the inflammation was great,
a day or two after the accident, and the constitutional symp-
toms were also considerable: there was a swelling around
the wound, fomentations and poultices were used, without
any benefit, for some time; it then became necessary to
LECTURE VIII.
81

make an incision down to the fascia, which was laid open, and
which gave discharge to a large quantity of matter, when
immediately the very urgent symptoms, before existing, were
relieved. This is to be the mode of treatment in every
case of this kind, and the incision must be made free, and
to penetrate the fascia completely, otherwise the diseased
symptoms will not abate. Mr. Jones applied to the author
under the following circumstances :–His son, a lad 12 years
old, had, in going into the cellar with his shoes off, trod on a
nail or spike, which had entered in the hollow of his foot;
he was in great pain, very much disturbed, and had no rest
since the accident; the wound was immediately dilated,
fomented and poulticed. Opium was administered with saline
medicines, to procure ease'; very little relief was obtained
during the two succeeding days: when the leg was again
examined, it then became evident there was a collection of
matter confined under the theca, which the first dilation of
the wound had not reached ; a free and liberal opening was
made now, by me, through it, by which a large collection of
matter was evacuated; the boy was much reduced during his
short confinement. He now became easy, slept well, and
by the use of tonics and a generous diet, soon recovered. i
Mr. Price's servant met with a similar injury in the palm
of the hand, and as he was not seen by me, in the first in-
stance, fomentations and poultices were used ; ultimate re-
lief, however, was not obtained till a free opening was made
through the aponeurosis, when every untoward symptom
disappeared. ar to
the name

The third species of punctured wounds are those where
nerves are affected; when these occur, tetanus is produced.
Though tetanus is not always arising from injuries of the
nerves alone, as it will frequently be induced when wounds
of tendons have occurred of a slight nature, either in the
hands or feet, but mostly in the feet; this may be consider-
ed rather a medical disease, and comes with greater propri-
etor 11 c t B

82
LECTURE VIII.
ety under the province of the physician, yet, as it is a con-
sequence of wounds, it is right to notice it here.
It is divided into trismus and tetanus : trismus when confin-
ed to the muscles of the jaw and throat only; tetanus when
the whole body becomes more or less affected: and this last
species when the body is bent forwards, is called emprosthoto-
nos : when bent backwards, opisthotonos. It commences
with general uneasiness and restlessness; the suppurative
discharge from the wound suddenly diminishes, and at length
totally ceases ; the surface becomes puffy and dried; at first
red, afterwards marbled. This phenomenon is accompani-
ed with acute pains, which are increased by exposure to the
atmospheric air, and by the slightest touch of external bod-
ies. The pain continues to extend till the whole limb is af-
fected; the wounded parts inflame; the muscles are seized
with convulsive twitchings, accompanied or preceded by vi-
olent cramps ; a stiffness is felt about the neck, similar to
that brought on by cold: the jaw becomes fixed ; the mus-
cles of the back are then affected, which produces opistho-
tonos; the muscles of the limbs next; then those of the ab-
domen; these are hard, but the body is not bent equally
forward by the spasms in them : the limbs get stiff, and the
countenance has a peculiar smile on it, termed the risus sar-
donicus ; the last muscles becoming affected are the dia-
phragm and intercostals. The pulse is extremely quick pre-
vious to death, but it has never discovered intermission in it,
which would indicate spasm of the heart; cold perspirations
pervade the body. The muscular irritation extends rapidly;
deglutition becomes difficult, and in a short time impossible,
on account of the forcible constriction of the pharynx and
æsophagus. Although occasionally delirious, the functions
of the brain however remain uninjured to the last moment
of existence, so that the unhappy patient sees himself dying.
When tetanus is general, all the muscles are affected at once:
the limbs becoine straight and immovable. The opisthoto-
nos happens more rarely than the emprosthotonos, and it
LECTURE VIII.
83

has been observed to be more speedily fatal. By the for-
cible extension of the vertebræ of the neck forcing back
the head, a compression on the spinal marrow is produced,
and a permanent constriction of the larynx and pharynx.
The immediate causes of death may be imputed to the pres-
sure on the abdominal viscera, the derangement which the
organs of respiration experience, to the stricture of the
heart, and eventually to the congestion of the brain; and
these appearances are confirmed by dissection.
- The disease is divided into two species; the acute and
chronic : the former proves so rapidly fatal, that little op-
portunity is afforded for the exhibition of medicines, and
what has been given and done has mostly failed in arresting
its progress. The latter has often been relieved, and has
sometimes got well spontaneously. D. J. Larrey tells us,
• Experience shows that tetanus left to nature is in all cases
fatal;" the surgeon then ought to have recourse without a
moment's delay to such means as the disease indicates, to re-
move the causes of irritation, and re-establish the suppressed
excretions. In the former, opium, camphor, musk, castor,
&c. and venesection, tepid bath, &c. have been often tried,
and as often failed. In these cases, indeed, no reliance can
be placed on such medicines ; and with respect to opium,
though apparently it has sometimes proved its beneficial ef-
fects, yet it frequently has been given to a great extent with-
out any service being derived from its use. Mr. Stocker, of
Guy's Hospital, gave an ounce of the tincture of opium at a
dose without its producing any sensible effect; the man di-
ed. On the medical treatment little can be said that would
promise success; I shall therefore select two passages from
D. J. Larrey's excellent work, which is more expressive on
this subject than any other that I have perused. “Would
it not be better to remove at once the wounded limb by am-
putation the moment the symptoms of tetanus appear, than
to wait for the resources of nature ; and of the very uncer-
tain remedies we possess for the cure, which so rarely takes

84
LECTURE VIII.
place ?? The unexampled success he met with ought to en-
courage its adoption.
E
a st
In the chronic species, more has been attributed to medi-
cines than they deserve. Persons in these cases will often
recover without a grain of physic. The cold bath has, we
are told, been used with advantage, so also has the warm. I
must here, from the testimony that has been adduced, favour
the cold bath. Relief has been afforded by the administra-
tion of large doses of steel, in the form of the tinctura ferri
muriat. and ferri sulph., as well as from the free use of opi-
um, and other antispasmodics, in this species. there
Trismus will be induced from slight injuries, or from cold
alone ; but it is not dangerous ; the electric aura will fre.
quently remove it, and will be found to have more influence
than any other application, or medicine, in its removal ; it
must, however, be applied merely in the form of aura, as it
will only exasperate the affection, if it be given in the form
of sparks or shocks,
D
o ber
30
is s WOUNDS OF ARTERIES.
When arteries are wounded, they may generally be dis-
covered to be injured very readily, by the blood being of a
florid red colour, or by its escaping per saltum; syncope
will be produced, which will have the effect of arresting the
progress of the blood to the wounded vessel, and consequent-
ly put a stop to the hæmorrhage, for the time being, at least;
this affords an opportunity for the vessel to contract in diam-
eter, and also to be closed by the formation of a coagula of
blood in the mouth of the vessel, therefore, during this state
of the system, a salutary effort of Nature is going forward,
and ought to be encouraged, and not, as is usually the case,
prevented by the administration of stimulants, &c. The
manner in which the hæmorrhage is suppressed is as fol-
lows :—when syncope is induced, the artery contracts, not
exactly at the extremity, but above it, as far as the first an-
astamosing branch ; this will resist the flow of blood from
LECTURE VIII.
85
the heart; the second circumstance assisting this, is the re-
traction of the artery; its drawing itself within its sheath,
and blood which will become in a coagulated state is accu-
mulated round its extremity : and this will satisfactorily ac-
count for the stoppage of the bleeding, when the artery has
been completely divided, which resists every application when
only partially so. The third principal circumstance is the
sealing up of the end of the vessel by a clot formed within
it, that is, formed within the cavity of the sheath, and pro-
jecting a very little way into the mouth of the vessel; this
principally suppresses the hæmorrhage, by its external pres-
sure. These three circumstances always occur when an ar-
tery is divided by means of a sharp cutting instrument.is
But when an artery is torn asunder, the mode of bleeding
being stayed, is rather different. Arteries, in these cases,
seldom bleed any. The cellular membrane here is twisted
around the vessel, and acts in the same manner as a ligature.
A man had his thigh torn off by the recoiling of a cable in a
Margate hoy; he was taken into an hospital, and the stump
was amputated; the end of the artery had exactly the above-
mentioned appearance. He recovered, for no bleeding hap-
pened at the time of the accident; this, however, is not al-
ways the case, for sometimes arteries are torn off, leaving the
mouths open and completely exposed ; in these cases the
texture of the vessel is destroyed by the extending power
made use of, and this may be proved by experiment on the
dead subject, for if an artery be very much lengthened, its
circular form is altered, and it will collapse in a similar man-
ner to a vein. Contused wounds of arteries do not shew
themselves as very dangerous until some time after the ac-
cident has been received, namely, at the period when the
sloughs separate. A person received a contused wound from
a fall on the neck, nothing particular occurred at the time,
and the man appeared going on well, but on the sloughing
off of the bruised parts, a portion of the carotid artery came
away along with them, and the man died instantaneously,from



86
LECTURE VIII.
the effect of the hæmorrhage. Punctured wounds of arteries
produce every appearance of aneurism, and require the same
operation.
Arteries have three coats: the external, which is white,
dense, and very elastic; the middle or thickest, composed of
muscular fibres, arranged in a circular form; and the internal,
which is extremely thin and smooth, possessing, considering
its delicate structure, considerable elasticity and firmness, in
a longitudinal direction, but weak, and easily torn in the
circular. We have ample proof of its vascularity, and it has
been inferred that it is by no means destitute of sensibility.
Arteries are connected with their sheaths, by means of »fine
cellular structure: thus, when divided, they are capable of
contraction as far as the first anastamosing branch, and
retraction within their sheaths; they possess a similar struc-
ture to other parts of the body, being supplied with arteries,
veins,nerves, and absorbents ; hence they are as susceptible of
change as other parts of the body, and as able when injured,
to repair that injury, by a similar process, by the adhesive
inflammation.
When pressure cannot be employed or trusted to suppress
hæmorrhage, ligatures become necessary. But for the im-
mediate and suddenly arresting the profuse flow of blood,
the application of a tourniquet will be required; it cannot,
with safety, be continued long, and its extent of operation is
confined to the limbs. Every surgeon ought to understand
the form and method of applying this instrument; if on the
lower extremity, the best place will be about one-third the
length of the thigh downwards, as the artery will be here
passing close to the bone, and consequently easily compress-
ed. If the upper extremity, ahout 2-5ths downwards, on the
inner side of the biceps muscle. Temporary pressure may
be made in the groin, on the femoral artery, by means of a
key or something of the kind, and under the clavicle on the
axillary artery also.
From Dr. Jones' truly valuable work on hæmorrhage, the
intentions of applying ligatures are these: To cut through
LECTURE VIII.
S7

AD
the internal and middle coats of the artery, and to bring the
wounded surfaces into apposition, thus allowing of the forma-
tion of a coagulum of blood within the artery, exciting inflam-
mation, and causing an effusion of lymph, which glues the
clot to the sides of the vessel; the using and applying liga-
tures, so as to divide the two coats, seems to be the desirable
end to which we should be directed ; as when applied to an
unwounded artery, a complete obliteration of the canal will
be effected; hence broad flat ligatures, as used formerly, are
objected to. The ligature ought to be round, firm, and not
too thick, and applied as circular as possible, and drawn
round the vessel with sufficient tightness, then apply a knot ;
always tie a large artery as separately and distinctly from sur-
rounding parts as possible ; and Dr. Jones coincides in opinion
with Mr. Abernethy, that it is the safest and best to use two
ligatures and to divide the artery between them, in cases espe-
cially of aneurism; and when large arteries are divided, this
plan ought to be pursued ; ligatures usually separate from the
largest artery in about a fortnight, from those of less size, in
six or seven days. Never use force to detach them, but gen.
tle efforts may be attempted, at each dressing after the above
period has elapsed.
When an artery is divided, or becomes impervious, blood
is supplied to the limb, thus deprived of its nourishment by
the principal trunk, by means of the enlargement of the col-
lateral or anastamosing branches. When the accident hap-
pens in the carotid artery, the jugular vein must necessarily
be divided.

OF SECURING THE ARTERIES.
The carotid artery may be tied without disturbance to the
functions of the brain. Hebenstreit mentions a successful
case of this vessel being tied, wounded in removing a can-
cerous tumour. Mr. Abernethy secured this artery, in a
large lacerated wound on the neck; but his patient died.
This experienced surgeon recommends the incision to be

88
LECTURE VIII.
made on that side of it next the trachea, where no impor-
tant parts are exposed to injury, carefully avoiding the par
vagum in the ligature.
The subclavian artery has never been tied above the cla-
vicle; but Mr. Keate had a case in which he successfully put
a ligature upon this vessel, under the bone; but it would be
much better to make the incision above it, on account of the
artery being more superficial in this situation : below, a great
déal of care is requisite to avoid the subclavian vein and
cephalic vein, and the thickness of the pectoral muscle will
add to the difficulty of applying the ligature. ne vened
The axillary artery has been successfully tied by Mr. Hall,
of Cheshire, wounded with a scythe. Mr. White, of Man-
chester, details an unsuccessful instance; but on dissection,
three of the nerves were found included in the ligature. It
is very seldom necessary to secure this vessel from a wound
in it, as it is seldom seen injured ; in cases of amputation, at
the shoulder-joint, it has been repeatedly operated on; it is
rather a difficult thing to do this, from its being surrounded
by the axillary plexus of nerves, from which it must be very
carefully separated. bart baixant bobbedmi
The brachial artery is closely accompanied by the median
nerve; this artery has been frequently injured in bleeding
from the arm. When this is the case two ligatures will be
required, otherwise hæmorrhage will occur, in consequence
of the blood being returned into the lower part of the wound-
ed artery, through the medium of anastamosing vessels. stay
Note.-The operations for each of these arteries will be
found detailed under the article Aneurism. buss i Boileraqo
The ulnar artery must be distinguished from the cubital
nerve accompanying it ; the vessels must be taken up with a
tenaculum ; the situation may be readily found by bending
the arm and hand, when the tendon of the flexor carpi
ulnaris will come into view; the artery may be found on the
inner side of it; the nerve, however, is between it and the
tendon : two ligatures are required on this vessel, one above,
and the other below the wound.
LECTURE VIII.
89

The radial artery is more frequently wounded than any
other artery in the body, on account of its superficial situa-
pi radialis ; if two ligatures are not applied, it is liable to
form a tumour of an aneurismal kind, from its anastamosing
with the rami from the ulnar artery; it should be taken up
with a tenaculum, for though no nerves are present here, yet
the tendons being numerous and small, may be accidentally
included in the ligature. When this vessel is divided, where
it passes down between the thumb and fore-finger, on the
extremity, and it must be tied ; as the other end is apt to be
retracted among the tendons, it is recommended to tie the
vessel on the fore-part of the wrist, where the pulse is felt.
The femoral artery is occasionally divided; it must be tied
under the edge of the Sartorious muscle, as in the operation
which will be detailed hereafter for popliteal aneurism;
avoiding the anterior crural nerve, and the femoral vein.
To tie the popliteal artery, accurate knowledge and great
presence of mind is required, as the vessel lies so very deeply
imbedded in the muscles, the sciatic nerve must not be taken
up instead of the artery. Mr. Cline saw a case of aneurism
where the nerve was taken up instead of this vessel, and in-
cluded in the lower ligature, the consequence of which was
the death of the patient speedily. The nerve is much more
superficially seated, and is on the outside. The popliteal
vein is between the two.
When the posterior tibial artery is wounded high up, the
operation is attended with a great deal of difficulty. An incis-
ion must be made four inches in length: this will lay bare the
gastrocnemii muscle, the fibres of which must be divided
transversely, in order that they may retract and allow of
more space for the surgeon to find the vessel ; they should
only be cut across, on the inner side, as the artery is situated
here; the posterior tibial nerve must be avoided. A person
who did not well understand the anatomy of the parts, would
12

90
LECTURE VIII.
be deterred from operating, and be inclined to use lint and
sponge, but which ought to be reprobated, as in two instan-
ces of this kind, where these were employed, mortification
ensued from the high degree of inflammation induced by their
renaining in the wound. When the artery is wounded low-
er down, it may easily be found just behind the malleolus
internus, In wounds of the interosseal artery, Mr. Hey, of
Leeds, recommends a portion of the fibula to be sawed off;
but it is not, except in very rare cases indeed, in the least
degree necessary, as the vessel may always be found by
making an incision close to the inner side of the bone where
it lies.
The anterior tibial artery, in like manner to the posterior,
is very difficult of access, when requiring to be tied at its
ſupper extremity, but when lower down it is easily discovered.
In a case published by Mr. White, this vessel was wounded
high up, and he used sponge with success; and this mode of
treatment would be advisable, as the difficulty of tying it is
great: when wounded on the foot, it is very evident to the
feel, and ought to be secured.
WWW


LECTURE IX.
E ON WOUNDS OF VEINS.
The largest vein that can be found on the external surface
of the body may be wounded without any serious conse-
quences resulting from it. The axillary vein is sometimes
injured during an operation for the extirpation of the lymph-
atic glands in the axilla, yet the hæmorrhage, from this large
vessel, may be easily restrained by the application of a dossil
of lint to the mouth of the bleeding vein. The femoral vein,
close to Poupart's ligament, has been seen to be completely
divided by a gun-shot without any immediate bad effects,
though from the nature of the wound, the patient ultimately
died. Although it may be said that generally no important
consequences will follow the division of a large vein, yet, if
inflammation take place in the vessel, dangerous symptoms
will arise, though the divided vessel be only of the second or
third class in point of magnitude. The truth of this remark
is amply proved by numerous examples. In the simple
operation of bleeding, patients have died from the inflam-
mation which has been induced in the vein, and which was
formerly attributed to the puncture, either of a nerve or a
tendon.
The symptoms, denoting an accession of this inflammation,
are a large or broad chord, felt under the skin both above



92
LECTURE İX.
and below the wound, in the vein : this is different from the
hard line perceptible to the touch, when an absorbent ves-
sel is inflamed, as in this latter case the tumefied vessel is not
larger than a pack-thread, while in an inflamed vein it is as
large as the little finger: when this symptom exists in a vein,
matter is formed within it; this is contained in a cyst, and
sometimes bursts externally, making its way through the
coats of the tumour: or the coats of the tumour give way,
and the matter becomes mixed with the venous blood. This
circumstance of inflammation and suppuration in a vein, after
bleeding, is more commonly occurring in animals than in the
human species. It was from these that Hunter first discov-
ered the cause to arise from inflammation, which was form-
erly placed to the account of an injured tendon or nerve.
The causes of the affection are these :—the size of the wound;
from its not being carefully closed, and from the patient not
being possessed of a healthy stamina. The treatment of these
cases will be the same, in the first instance, as used for inflam-
mation, and if not subdued, then by fomentations and poultices
applied to the part itself, and evaporating lotions to the other
parts of the vein and arm, as the spir. vin. camph., &c. When
inflammation happens in a vein, Hunter judiciously advises us
to apply pressure on the vessel above the seat of the injury,
so as to prevent its extention, and confine it within certain
limits, thus facilitating an adhesion of the sides. Mr. Aberne-
thy remarks, in some cases it will be actually necessary to
completely divide the vessel, with this intention, to arrest
the progress of the inflammation; Mr. Samuel Cooper ob-
serves, 6 Might it not be better to put a ligature upon the
suppurating vein above the affected part ?” The answer
clearly is, “ certainly not ;” and the following remarks will
explain this subject.
A ligature on a vein is a much more dangerous operation
than what surgeons in general are aware of. It has fre-
quently been made use of to cure varices in the veins of the
lower extremities more particularly, and some few years ago
LECTURE IX.
93

it was put often in practice, but at the present time it is
strongly reprobated, on account of the fatal consequences
which have resulted in a number of cases; in three or four
which the author has in his recollection, the vena saphena
major was tied to effect the cure of ulcers and varices of the
legs, without any mischievous consequences; but other cas-
es have been witnessed, in which the patients died. It was
then thought the mere division of this vessel would be suffi-
cient, as it was very rightly conjectured, the ligature produ-
.ced the bad symptoms; this was often done with success,
but two cases happened nearly at the same time, which ter-
minated fatally. On the whole, it is strongly recommended,
not to operate in either way, if it be not, in consultation, held
be entirely blasted by an unfortunate case of this descrip-
tion; and if any thing further be required to forbid this
practice, it is, that there has not occurred one case where
the disease was cured by its adoption (setting the fatality of
it out of the question) unless a bandage was worn constantly
afterwards, and as this bandage alone will always relieve,
if not entirely cure, which it does frequently, it is much bet-
ter to use a roller and evaporating lotions, accompanied with
a purgative medicine occasionally. Numberless cases yield
to this mode of treatment; but even if it do not succeed, it
is by no means prudent to resort to the above operation,
which ought to be strongly deprecated. Das
tentang marino consente do Con
WOUNDS OF THE NERVES,
When a nerve is divided, the effect is a destruction of the
nerve was distributed, and a partial loss of involuntary mo-
tion in that part; the power of arterial action is not destroy-
ed, though it is most certainly weakened. Nerves, when di-
vided, will unite again, so as to carry on the actions of the
nerve. A small nerve will require from ten to twelve weeks,

94
LECTURE IX.
a large one from four to six months. The sciatic nerve was
divided in a fracture, when six months elapsed before the
patient could use his limb in the least. Electricity assisted
very much this case. The brave Kosciusko had his sciatic
nerve cut across in a battle in Poland, by a sabre: many
months after, he came to England, and was obliged to be
carried from one room to another. When union takes place,
it is effected by means of the formation of ganglion; but if
the extremities are very distant, union happens through the
mediuni of a narrow nervous substance. If nerves are only
partially divided, from their state of extension and tense-
ness, they will occasion excessive pain, and it will be advisa-
ble to make a complete division of the vessel, when it can be
50 ascertained. The only treatment it is possible to adopt,
will be to place the ends of the nerves as nearly in apposi-
tion and contact as possible ; the rest of the cure must be
left to Nature.
WOUNDS OF TENDONS.
These wounds arise from two causes :—from cutting in-
struments, and from the action of the muscles. The tendo
achilles appears to be mostly divided, and the treatment, in
this case, may be extended to the division of tendons in oth-
er parts of the body: pay attention to the relative situation
of the incised muscle, with respect to its flexion and exten-
sion. The heel of the patient must be raised, and the foot
extended as much as possible; in order to secure the foot in
this position, a piece of adhesive plaster must be bound cir-
cularly round the calf of the leg, but previous to the appli-
cation of this, a broad piece must be applied from the sole of
the foot, over the heel, to the calf, at its posterior part; the
circular piece is then to be put on, with the intention of se-
curing and rendering the longitudinal piece firmer in its situ-
ation; it is, therefore, to be secured above it. The slightest
dressing must be applied to the wound, if there be any, and
not the least pressure made upon it. However, if there ex-
LECTURE IX.
95

02
ists much inflammation, leeches and fomentations must be
had recourse to, to abate it, previous to the use of the plas-
ters: great care must be taken to avoid pressure upon the
ends of the tendon, otherwise it would be glued to the poste-
rior part of the tibia and muscles, and thus prevent its mo-
tion in a great degree. The patient is to be confined to his
bed four or five days, at the expiration of which time he may
get up, but must immediately have a high heeled shoe put
on, to prevent the rupture of the newly formed tendon, which
would certainly take place, with very little exertion, if this
were not done--he may be allowed to walk a little. The
shoe should be one inch and a half high at the heel at least,
and must be worn four or five weeks, gradually taking it
down to its level.
Mr. Hunter ruptured his tendo achilles in dancing, and was
supposed to be the first who improved on the old method of
treating this accident, it being the practice formerly to stitch
the ends of the tendons together. From his observation and
experience, and what he reaped from others, particularly in
the case of the Duke of Queensberry, he has completely es-
tablished his mode of treatment as the best. Dr. Alexan-
der Monro, of Edinburgh, met with this accident—he was
confined five months by the treatment employed, which is
more complicated than what is now practised.
There is a partial rupture either in the tendon or some of
the fibres of the gastrocnemei muscle occasionally occur-
ring, always ensuing from muscular exertions: at the time it
happens the patient has a sensation of being struck on the
part with a stone, he becomes lame, and a hollow may be
perceived where the fibres have given way; there is a slight
ecchymosis from extravasation of blood in the part: if it be
neglected, the patient will be lamie for the remainder of life.
July 9th, 1815, Col. Williams, of the 2d Garrison Battal-
ion, met with this accident from a very trifling cause: making
rather a longer extension in his walking to hear the news
brought by the mail of the victories of the Duke of Welling-
ton, he put his foot on a round stone and slipped. The au-

96
LECTURE IX.
thor adopted the following plan: he pressed the muscle
down, and applied a roller to retain it in that situation; his
stocking was put on, and a cabinet-maker in the town imme-
diately made, under his inspection, of splints, a permanent
apparatus to retain his leg and foot immovable, and in an ex-
tended posture; it was fixed on the foot and on the calf of
the leg, and answered every intention perfectly, making not
the least pressure on the ruptured tendon--an evaporating
lotion was occasionally applied,—this was continued on for
a week, but he was not confined at all to his bed; a high
heel shoe was then substituted, and by being careful in his
steps he was enabled to bustle about stoutly; the heel was
gradually depressed, and he recovered with scarcely any
lameness.
On the 23d of January, 1816, the Colonel completely rup-
tured the tendon; the same means were again employed, and
with the same success ;—he was however advised to contin-
ue the use of the high heel shoe longer before it was dimin-
ished. The lameness gradually lessened, and he found
much benefit from putting his leg under a water spout every
morning, which seemed to strengthen it very much.
Whether partially or completely divided, the same inten-
tions are to be kept in view.
WOUNDS OF THE ABDOMEN.
These may be divided into two kinds, namely, those which
penetrate the parietes of the abdomen, without injuring any
viscus; and those which enter the cavity, and wound some
one or more of the contained viscera. It is singular that
very large wounds have been made into this cavity, without
wounding any of these parts : this is arising from their elud-
ing the blows, in consequence of their great mobility and
lubricity. A curious case, illustrative of this fact, was seen
in a lady who divided the abdominal muscles and peritoneum
LECTURE IX.
97
from the ensiform cartilage to the symphysis pubis, with a
razor, without injuring in the least degree the intestines. In
these cases, where none of the viscera are wounded, which
may be known almost always by the attendant symptoms,
the gastroraphe must be adopted as soon as possible, which
means the sewing up of the wound, in order to shut up the
cavity; then apply adhesive plaster, and a proper bandage
to support the parts in contact: in some cases the common
interrupted suture will be best, if the wound be not very ex-
tensive. The antiphlogistic regimen must be adopted. Bleed-
ing, purging, &c. must be had recourse to in order to obvi.
ate any undue degree of inflammation which will come on.
In the second case, where some viscus, as the stomach, is
wounded, there are, immediately after, faintings, vomiting of
blood, and the contents of this organ; as well also as some
of it being discharged from the wound, paleness, cold sweats,
pulse scarcely perceptible, &c. In some few cases, where
the wounds have been small, the patients have recovered :
here nothing must be taken by the mouth for a week; let the
patient have strong nutritive glysters administered to support
him, with opium; at the end of the week he may take a lit-
tle jelly ; in ten days a little broth, &c.; and so on at the
discretion of the practitioner. It will be necessary to bleed
largely, and an attempt must be made to effect union by the
adhesive inflammation.
If a surgeon be called to a wound in the intestines, and
the gut does not protrude, nothing local can be done; we
are not warranted to enlarge the opening : opium must be
administered and large bleedings had recourse to ; and al-
though the pulse will be feeble and weak, yet the antiphlo-
gistic regimen must be strictly adhered to :—but should the
intestine protrude, the nature of the injury will be very ob-
vious; and if the wound be only a very small one it may be
returned, as in all probability it will unite by the adhesive
process; but if not large, yet sufficient to let the fæces escape, it
may be closed by the application of a ligature around the
orifice, cutting the ends of the thread close off. In an oper-



13

98
LECTURE IX.
ation for strangulated hernia, performed at Guy's Hospital,
Mr. Astley Cooper found the intestine wounded, and the
small opening he included in a ligature, and the man did very
well. Mr. Travers says, that a ligature applied round a
portion of intestine acts in a similar manner to one applied
on an artery ; the inner coats become divided, the external
(the peritoneal) remains entire: from the interior coagulable
lymph becomes deposited, and an union effected.
Mr. John Bell recommends one stitch only, and the liga-
ture to be attached with the gut to the external wound. Mr.
Travers tells us, that the absolute contact of the everted sur-
faces of a divided intestine, in their entire circumference, is
requisite to secure the animal from the danger of abdomin-
al effusion-and that wounds amounting to a direct division
of the canal are irreparable, and invariably fatal.
Dr. Smith, of Philadelphia, tried Mr. John Bell's plan on
dogs; but in both instances they died from extravasation of
fæces in the abdomen. Mr. Travers made the same experi-
ment on four dogs, and he allowed the intestine to retract in-
to the abdomen. Mr. Travers made one experiment with
three stitches, cut the threads away, and returned the gut,
being in all five cases, which were fatal: thus Dr. Smith
and himself seem, as far as inferences can be drawn from
the brute creation, to controvert Mr. John Bell's plan.
Longitudinal wounds must evidently be easier repaired
than transverse, and the cause Mr. Travers assigns is that
they maintain a state of approximation by their longitudin-
al fibres resisting the action of the circular.
From what Mr. Travers bas premised, he advises stitch-
ing a bowel at as many points as possible ; now from the fol-
lowing experiments this does not at all seem necessary. Mr.
Astley Cooper repeated an experiment made by Duvergers,
in which he had succeeded, on a dog—the interrupted su-
ture was used. The trachea of a calf was included in the
gut, and three stitches were employed to bring the divided
intestine into contact ; on the fifteenth day he killed the dog,
and found the union complete. Mr. Cooper made another
LECTURE IX.
99

similar one, omitting the trachea of the calf, and the animal
did well. Dr. Thompson divided the small intestine of a
dog, and used five stitches-he cut the ends of the ligatures
off, and returned the gut; the wound externally was secur-
ed with one stitch-and he also succeeded. Dr. Thompson
repeated the experiment, and in six weeks he killed the dog,
when it became apparent that the ligatures employed would
make their way into the intestine, and be evacuated with the
fæces ; cutting the ends of the ligatures off was originally
recommended by Mr. Benjamin Bell. Thus we have five
experiments in opposition to Mr. Travers's assumption, exclu-
sive of those made by Dr. Smith, who employed four stitches
with equal success.
Thus it would appear, that, unless there is a complete divi-
sion of the tube, from three to four sutures are all that is ne-
cessary, and in the latter case probably it would be advisable
to make as many as five: one fact is clear, the ends are to be
cut off close to the intestine—that I believe is universally
agreed on:-it would appear, that inflammation is much more
violent and unrestrainable when the small intestines are
wounded than the large. It has been recommended by some
speculative surgeons, to introduce one end of the gut into the
other, when divided; if these gentlemen had attended more
to experiment, and less to theory and some fanciful notions of
their own, they would have been convinced of the impossi-
bility of effecting such an absurdity. In all these wounds,
the apparent debility, weakness of pulse, and coldness of the
extremities, would deter many from using depletion; but if
not done, the patient inevitably sinks.



WOUNDS OF THE LIVER, &c.
Wounds of the liver, when small, as those made with a pen-
knife, may be recovered from, but if larger they are fatal :
the patient is seized with vomiting, great pain, &c. A rup-
ture of the liver, from blows or carts going over the body,

100
LECTURE IX.
is universally fatal. A wound of the spleen is ever fatal; and
it is rather singular, that this viscus may be entirely removed
without detriment, yet the smallest wound will inevitably oc-
casion death. There is a case recorded by a surgeon, who
found a wound made by a sabre in the person's side, and the
spleen hanging out; the surgeon cut it off, closed the wound,
and the man recovered. Mr. Coleman and several others
have removed the spleen in dogs with impunity. A man re-
sisting a press-gang received a wound in the spleen, only half
an inch in length, from a dirk; a great hæmorrhage follow-
ed, and the patient died from the extravasation of blood act-
ing as an extraneous substance, by which the peritoneum be-
came highly inflamed. A woman died from a ruptured
spleen, occasioned by a blow from an ox's foot ; a part of it
was found broken off. In the expedition to Walcheren ma-
ny died from intermittents, and the spleen was found to be
enlarged and diseased in them. Wounds of the kidneys, in
some few cases, have been recovered from, but the reverse
generally happens,
( 101 )
LECTURE X.

ON WOUNDS OF THE CHEST.
These are divided, in a similar manner to those occurring in
the abdomen, into two kinds : viz. those that penetrate the
parietes alone, without injuring any of the contained parts;
and those that wound some of the viscera. When a wound
of considerable size is inflicted, coming under the first species
of the above-mentioned classes, the following symptoms are
evident : when the patient inspires, the viscera recede from
the wound, and we are able to see into the cavity of the
chest : when in the act of expiration, that portion of the
lung opposite the external wound is protruded, so as to be-
come quite visible. There is also a considerable quantity of
air rushing out at the time, so that an appearance is produced
that would lead us to expect, reasoning à priori from this
symptom, that the lungs were perforated; whereas, in fact,
it is occasioned by the wound extending through the pleura
costalis. The treatment of this species of wound is very
simple, and consists in approximating the lips of the wound,
by means of sutures, in order that they may be kept in con-
tact ; between the stitches slips of adhesive plaster must be
applied. In the case of a boy who fell from a tree upon a
stake, though the wound thus produced was a ragged one,



102
LECTURE X.
yet it united by adhesion. It is very requisite to apply su-
tures, on account of the variation in the size of the chest, re-
sulting from respiration.
When wounds of the chest are accompanied by injury
done to the contained parts, the most decided treatment is
necessary; if the lungs are wounded, the circumstance is
known by the patient's coughing up frothy blood, at the same
time there is considerable hæmorrhage from the external
wound, and if the wound be made with a sharp instrument,
this is often in great quantities ; the patient has extreme dif-
ficulty in breathing, and more especially if the external
wound be small: emphysema is also produced by the es-
cape of air from the bronchial cells into the cellular mem-
brane covering the chest.
The treatment required must be guided by the space of
time that has elapsed since the accident was received, for
these wounds are attended with danger of three kinds after
the accident; first, from the quantity of blood lost; second-
ly, from inflammation of the lung on that side of the chest ;
and, thirdly, from suppuration, or hydro-thorax; as matter
sometimes forms at a distant period after the accident, as
well as an effusion of water takes place. With respect to
the first, it is necessary to stop this, by taking away a large
quantity of blood from the arm suddenly, as this bleeding
must be carried so far as to produce syncope, when the hæ-
morrhage from the wound will cease, and then the edges of
the wound may be brought into contact by sutures and ad-
hesive plasters, previously cleaning away any coagula which
may have been formed between the edges of the wound.
Secondly: If inflammation arise, and the patient be suffer-
ing considerable pain between the scapulæ, as well as in the
head, it is right to repeat the bleeding, and this must be done
very freely : those are most likely to recover who have been
depleted copiously, and many have been seen to die for want
of this boldness of practice: the most perfect rest must be
observed, and the antiphlogistic regimen strictly enjoined ;
every thing given should be cool.

LECTURE X.
103
The bleedings have been carried by some able practition-
ers to a great extent in these wounds—it is what is principal-
ly to be relied on for the recovery of the patient. In em-
physema the air soon becomes absorbed, and it is seldom ne-
cessary to make small punctures in the cellular structure for
its discharge, unless the collection is very great.
If extravasation of blood into the cavity of the chest, from
the wound in the lungs or intercostal arteries, happen, as it
very frequently does, the difficulties are increased and the
danger of the patient's dying from suffocation imminent,
many advise the endeavouring to evacuate the effused blood
--others prefer leaving it to be absorbed : the compression
on the lung must be great, yet the danger of making fruit-
less efforts partially to get rid of it is still more serious, be-
sides occasioning very probably a renewal of the hæmor-
rhage; it would be all very well if the blood remained in a
fluid state, in which case it might, by dilating the wound, be
got rid of, combined with posture.
The third danger is that in which, in spite of our efforts,
the inflammation goes on to suppuration, and the effusion of
a fluid ; under these circumstances the symptoms arise at a
distant period. An example of this kind occurred some
years ago in Guy's Hospital; a man attempting to arrest
another was stabbed between the shoulders with a penknife,
which wounded the lung: the wound healed, and it was
thought that he was recovering, but symptoms, evincing the
existence of some fluid in the cavity of the chest, made their
appearance-he went into the country, and soon after his re-
turn to town he died. On examination it was found, that a
coagulur had formed in the cavity of the pleura, and it was
supposed that this coagulum, not becoming vascular, acted as
an extraneous body, and produced inflammation and its ulti-
mate consequences. This being the case, we should be on
our guard in giving our prognosis of the safety or danger of
these patients.

104
LECTURE X.
WOUNDS OF THE PERICARDIUM AND HEART.
· These wounds are but rarely seen in practice. Some time
ago, a soldier on duty had a bayonet plunged into the right
auricle, and what is surprising, the man lived forty-eight
hours after the accident. On examination it was found, that
a coagulum had formed, and completely filled up the wound;
but on the man's first going to stool, a second hæmorrhage
took place, and he was found dead, sitting on the chair. The
late Mr. Saunders saw a case where the man, who was the
subject of this accident, received a stroke with a sickle upon
the chest, between the sixth and seventh rib, rather nearer
the sternum than the nipple; the man in the first instance did
not appear to suffer much from the wound, and it was closed
and went on well—but in a short time symptoms of hydrops
pericardium came on, and he died. On examination after
death, a clot was found in the pericardium, which was alone
wounded, and the whole internal surface of this membrane
was inflamed.-Wounds of the heart always prove fatal, and
it is generally supposed immediately, but this is not uniform-
ly the case. Patients have lived under these circumstances
several hours, but the wounds of course have been but small.
If the heart have been ruptured, it is impossible to preserve
life, even a few minutes : this accident sometimes happens in
old age, absorption of the substance of this organ taking
place near the coronary valves : King George the Second
died from this cause.
Wounds of the aorta and vena cava prove more suddenly
fatal than those injuring the heart.
WOUNDS OF THE THROAT.
These wounds require in their treatment a great deal of
anatomical knowledge, as well as prompt decision. Consid-
ering the distance from the chin to the sternum as nine inch-
es, when the chin is extended, we are led to class wounds hap-
pening to those parts into three kinds. In the first three in-

LECTURE X.
105
ches from the chin, downwards, may be comprised almost all
those wounds occasioned by persons attempting self-destruc-
tion : it is seldom that the esophagus is wounded here, and
for one case where such an accident happens, may be seen
thirty cases of wounds of the pharynx. Wounds above the
os hyöides penetrate into the mouth. The incision made by
persons attempting to destroy themselves is generally too
high up to wound the carotid arteries. The most frequent
vessels divided in wounds of the throat are the branches of
the external carotid—the external maxillary, the lingual, and
thyroideal, and it will be necessary to secure these. When
the main trunk, the carotid, is divided, it must be secured as
recommended on the subject of wounds of arteries, and the
simplest plan is that of Mr. Abernethy, when there will be
no danger of wounding the internal jugular vein, or the par
vagum. The treatment is to bring the chin as much as pos-
sible to the chest, in order to secure the edges of the wound
perfectly together, and the head should be retained in this
position by bandages properly adapted: the wound should
be brought into as narrow a compass as can be done, by su-
stures and adhesive plaster.
Wounds of the second kind may include three inches, the
upper part of the larynx, the cricoid and thyroid cartilages;
the wound seldom goes beyond the posterior part of the tra-
chea, or injures the æsophagus—in this case the air escapes
from the wound, but fluids may be swallowed without their
passing through it. If the thyroid cartilage be divided to
any great extent, a suture is to be passed through the peri-
condrium, bringing the edges into contact. It sometimes
happens, that several cuts are made, and the cartilages are
divided in more places than one : here attempts must still be
made to unite them by the adhesive process, though in these
cases the cartilages have been known to exfoliate. It is bet-
ter to use sutures in every description of wounds in the throat.
When a wound happens between the thyroid cartilage and
the os hyöides it is attended with great danger, and it was
formerly deemed invariably fatal; but a case occurred to
14

106
LECTURE RUK
X.
Mr. Astley Cooper, which proved that this was erroneous :
the death of the patient is occasioned by the fluids and food
taken into the mouth making their way into the larynx, on
account of the separation of the epiglottis from the trachea—it
would be advisable, to prevent this happening, to convey
nourishment into the stomach by means of a tube introduced
into the passage to the æsophagus.
The third species of wound takes place in those parts be-
tween the sternum and three inches up the trachea: this will
include, on the fore part, the trachea; on the back part, the
æsophagus; and on the lateral parts, the carotid arteries. A
wound of the trachea is not of itself mortal. If the esopha-
gus be wounded with the carotid artery, it must be done by
a sharp instrument of a pointed kind. A transverse wound,
by which this tube is injured, must inevitably include the ar-
teries. Wounds of the trachea alone are easily known by
the cartilages separating from each other, and by the air
rushing out in the act of expiration.
The treatment is to make use of three sutures through the
pericondrium, one anteriorly and two latterly; it is rarely
an instance is seen of the csophagus being wounded; these
latter wounds are fatal either from the fluids taken in, pas-
sing through into the cellular membrane, and thus producing
violent inflammation, or when the æsophagus is healing, a
contraction of its diameter being the result, and the patient
is starved to death. Bougies might be used with advantage
if introduced previous to the contraction extending to any
considerable degree. The only fair chance we give patients
thus wounded is by introducing a long tube into the æsopha-
gus, and administering the requisite nourishment through it:
in other respects it should be attempted to heal the wound
by the adhesive process. When the carotid artery, or in-
ternal jugular vein is divided, the patients mostly die before
any professional assistance can be rendered. session
Mr. Astley Cooper has clearly demonstrated on the hu-
man subject the practicability of securing this artery with-
out any great and immediate derangement in the functions of

LECTURE X.
107
the brain ; and it would be’advisable in this instance to se-
cure the internal jugular vein by ligature, as pressure alone
cannot be trusted to; and the danger we run by applying a
ligature would be infinitely less than the hæmorrhage that
would ensue, from neglecting its adoption. The most trou-
blesome occurrence we meet with is a convulsive cough, which
greatly distresses the patient, and to relieve it, opium, given
in mucilage of gum-arabic, will be proper. The sutures in
none of these cases should penetrate through the lining of
the trachea or larynx, otherwise the irritation will be mate-
rially aggravated. The larynx is found to be more sensible
of irritation than the continuance of the tube, the trachea.
There is generally great hoarseness and weakness, and occa-
sionally complete loss of the voice, from division of the
nerves. Bleeding must be had recourse to, to mitigate the
severity of inflammation, and the antiphlogistic plan strictly
adhered to. The patients should be kept as quiet as possi-
ble,
Toute to
Sie einen
WOUNDS OF THE JOINTS.
Wounds made into the cavities of large joints are the most
dangerous of those affecting the body almost in any instance,
on account of a very large surface becoming exposed, though
the external wound be very small. If union do not take
place by adhesion, inflammation to an alarming extent, and
consequent suppuration, almost uniformly ensue, from the
nature of the parts composing a joint: for it is not only the
great extent of surface that becomes exposed to inflamma-
tion for the purpose of uniting, but the inner parts of a joint
when inflamed are incapable of readily uniting by the adhe
sive, and mostly proceed to the suppurative process: and
this goes on until the extremities of the bones exfoliate and
granulations arise from their surface. This being the case
the most violent symptoms arise subsequent to a wound of a
joint. When a wound is first inflicted, the synovia escapes,

108
LECTURE X.
LEO
and this circumstance is the criterion by which we judge
whether the instrument has entered the cavity : if the lips of
the wound are neatly and carefully brought together, and
they adhere, no further extension of the mischief is to be ap-
prehended; but if allowed to be left open, the discharge of
the lubricating fluid will prevent union, and inflammation will
most certainly ensue upon the whole internal surface, and a
great quantity of matter will be formed which does not dis-
charge itself directly out of the joint, but burrows itself both
above and below the wound, and several openings are fre-
quently formed for the evacuation of the pus : the constitu-
tional irritation will be extreme, and if the patient be not
very strong, it will be necessary to amputate the limb; but
if his stamina be good, the patient may probably escape with
anchylosis.
Treatment. It is required, in the first instance, to bring the
edges of the wound together with adhesive plaster, and if
this cannot be readily done, sutures may be employed,
though with great caution, lest the capsular ligament should
be included: for if this occur, unfavourable symptoms will
arise. In the last case seen, although suppuration had com-
menced, the joint did not suffer materially, for the opening
was closed up with the adhesive plaster, and the inflamma-
tion in the joint being very great, a saturnine poultice was
applied all over the knee : under the plaster a portion of co-
agulable lymph formed, and which was, perhaps, rendered
more firm by the action of the lead. Union by this means
was effected, and the fluid effused in the cavity of the joint
was ultimately absorbed; so that even when inflammation
has come on, it is better to attempt union by adhesion. In
cases of this kind, we are to depend much upon opium, and
this may be given in as large quantities as the constitution
will bear without injury. Other topical means, besides the
poultice, may be used, as leeches, &c.; and the antiphlogis-
tic regimen raust be here persevered in.
When granulations have taken place in a joint, anchylosis
will ensue, and it will be found to be of three kinds : First,
BPS

LECTURE X.
109
when there are granulations between the ends of the bones
and where the ligament is attached, adhesive matter is thrown
out, (but is to be considered a very rare occurrence) which
becomes vascular; for when inflammation has taken place, it
seldom ceases before exfoliation ensues. Under the preced-
ing circumstances a little motion of the joint will be pre-
served, but if the cartilage covering the ends of the bones
be absorbed, then bony matter is thrown out, and motion
completely destroyed. Second kind, is that which arises
from the bone being altered in its shape at the diseased ends,
by little spiculæ of bone arising from the extremities, and
thus motion is prevented: but by passive motion of the limb,
united by friction, we can produce absorption of these, and
restore in some degree the motion of the joint. The third
kind is that in which anchylosis is formed by bony granula-
tion, and the joint becomes fixed.
WOUNDS OF THE BRAIN.
The brain is every where surrounded with bone, therefore
well defended from injuries. Sometimes, however, the bones
are fractured, and a portion of the brain removed either by
sharp instruments entering the skull, or by pieces of depress-
ed bone. It may be supposed that these wounds would be
immediately fatal, but they often do not affect the powers of
the mind or body, and are dangerous only from inflammation
supervening, and the shooting out of fungus. A man had a
portion of the os frontis driven in on the cerebrum; part of
the brain escaped from the wound, to the quantity of a tea-
spoonful, with the pia mater on it; the wound healed with-
out any bad symptoms, and the depression remained with-
out any serious consequences arising from it. A boy like-
wise received a blow from a boat hook, which drove the
right parietal bone in upon the brain: the brain was seen
pulsating with a hole in it; he had a slight hemiplegia of the

110
LECTURE X.
left side, the wound healed without any untoward symptoms,
and the paralytic parts recovered their usual powers.
Whenever a depression takes place, if the displaced bone
be removed, no disagreeable symptoms ensue; it is imflam-
mation alone that occasions the death of the patient; when
this is feared, large quantities of blood may be taken: after
the inflammatory stage, a fungus shoots out from the brain ;
this is found to be the substance of the brain, granulating in
a luxuriant state; as much as three or four ounces has been
seen to be discharged this way: if, however, it continue any
time, hemiplegia ensues, and the patient dies. If the wound
be not very large, a piece of the fungus may be cut off even
with the bone, then a piece of dry lint should be placed on
it, and constant pressure kept up by a bandage; this treat-
ment has often succeeded. Granulations from the dura mater
shoot over the fungus and form a cicatrix,

( 111 )
als LECTURE XI. -
-*©©****
ON GUN-SHOT WOUNDS.
das de
Any substance that enters the body with a degree of velocity
occasions the same consequence as a gun-shot wound, as from
the blowing up of a rock, &c. These wounds differ from
incised in this, that from the contusion received, they most
commonly terminate in a sinus; they are of two kinds, that
in which the ball has passed through, and that when it still
remains lodged in the body. When a surgeon is called to
an accident of this nature, from the smallness of the aperture,
he is led to doubt the possibility of a ball having entered the
body : but this appearance depends upon its being received
either point blank, or in a slanting direction, also on the size
of the ball: it, however, generally enters at right angles.
The wound has a black aspect around its edges, like an eschar
produced by a caustic. In the course of a few hours inflam-
mation supervenes to a much greater degree than that follow-
ing an incised wound; this is shewn by the swelling not being
confined to the part, but supposing the leg to be wounded,
extending along from the knee even to the thigh.
The first discharge of the wound is of a jelly-like appear-
ance, being composed of coagulable lymph. This has been
known to have been removed from day to day by an expe-
rienced French surgeon, who was not aware that he was
counteracting Nature's first efforts towards a cure. This

112
LECTURE XI.
lymph adheres, and is now and then vascular. After con-
tinuing four or five days, a slow and gradual process of sup-
puration comes on, which is not complete until from the 10th
to the 14th day; so that this takes a much longer time than
in an incised wound, especially if any tendinous structure
have been injured. The eschar must necessarily separate
before suppuration is complete, which accounts for the slow-
ness of this last process.
If a ball have passed out opposite to where it entered, it
is to be treated as a contused wound ; very little hæmor-
rhage commonly comes on, as will be hereafter explained.
Hunter considered these wounds to differ in no respect from
those of contusion; and the same treatment will be applica-
ble. The best application will be, a poultice of bread and
milk to the wound and evaporating lotion to the leg, as soon
as the skin becomes inflamed. The reason for applying
thus early a poultice is, that it is an object to bring about a
separation as soon as possible. After a few hours, and pri-
or to any danger that may arise from a second hæmorrhage,
poultices and fomentations are advantageous, from their di-
minishing inflammation; we may also do good by topical
blood-letting, as leeches, which are easily procured in this
city, but not so on actual service in the army. This would
induce me to take notice of the practice of a surgeon in the
army on foreign service, who had a number of gun-shot
wounds under his care: it was freely to dilate the wound,
and suffer it to slough, with a view of affording an opportu-
nity for the discharge of any irritating body. Now this in-
discriminate dilation Hunter decidedly objected to: and it
is evident that the only way in which it can do good, is by
unloading the vessels, and for this purpose scarifying the
part will answer every purpose, and is one of the best means
to be made use of when the limb becomes extensively inflam-
ed and swollen. By its adoption, united with the above
means, the appearances have been found to subside the fol-
lowing day or two; and another good effect scarifying has,
is that the eschars separate more quickly.
LECTURÉ XI.
113
It is but fair to mention there are numerous instances of
the success of dilating wounds ; this practice was adopted in
many cases that occurred in the engagement between the
Swiss and Parisians on the 10th of August, 1792. A prac-
tice that gives ease,and tends to check inflammation is wrap-
ping the whole limb in cloths wet with the liquor. acet. plumb.
dil. especially in warm weather. As to the constitutional
treatment, large doses of opium with antimonials will be
found beneficial when the patient becomes restless. Bleed-
ing, if the powers of the constitution are not good, and the
contusion extensive, will be improper ; but in general it will
be right to bleed plentifully, and if after the first bleeding
the pulse becomes full, a second bleeding may be resorted to,
especially if the wound be near any vital organ. It should,
however, not be carried to any imprudent excess, as tetanus
is a likely consequence of these wounds, and the great weak-
ness induced would render the living powers unfit to sustain
the discharge from wounds of this nature. The Peruvian
bark is of great advantage to be judiciously administered.
We should purge sparingly, as it is often difficult to check it.
Anxious to ascertain whether a person suffered much pain
or not at the time of receiving a gun-shot wound, numerous
inquiries have been made, from which I have learnt, that un-
less the ball struck against a hone, the person was not in the
least sensible of his having received an injury; but if a bone
were struck, the sensation of a strong shock was communica-
ted to every part of the body; and this was seen to be the
case in a duel fought by a Captain Lewis : he was severely
wounded in the legs, and fell as if he had been struck by
a forge hammer.
Having got rid of the inflammation by the adoption of the
means recommended, and given due support to our patient by
rather a liberal and generous diet, combined with tonics, the
healing of the sinus will be our next endeavour; and this
sometimes takes a long time, from the inability of stimulating
the centre of the wound. Under these cases it is proper to
introduce a little of the hydrarg. muriat. dissolved in water,



15

114
LECTURE XI.
the tinctura lyttæ, &c., so as to excite healthy granulations ;
or a bougie smeared with the hydrarg. nitr. rubr., so as to
stimulate the inner surface of the sinus. Some advise setons,
but they do more harm than good, by laying the foundation
of an abscess. If, notwithstanding these means, we do not
yet succeed, and the sinus remains of considerable depth,
the best plan will be to make an opening into the middle of
it, so as to form two cavities, whereby union will be effected.
In cases where the ball is lodged in the body,a greater de-
gree of consideration is required, and one might naturally in-
fer,that the first step to be taken would be the extraction of it,
or in fact, of any extraneous body that might have been intro-
duced, as pieces of iron, splinters of wood, &c. This prac-
tice will be perfectly right when it can be easily felt, and
there is no danger of wounding any vessels. If it have pas-
sed with great velocity, so as not to be near the wound, nor
yet to be felt on the opposite side, supposing it to be in parts
not essential to life, the best method is to introduce a flexible
metallic bougie, which yielding easily to pressure, acquaints
the surgeon with the extent of the wound, without at the same
time incurring any risk. Another instrument advised for this
purpose, is the elastic gum bougie. The common silver probe
is extremely improper. When, however, the ball is lodged
in the cavity of the chest or abdomen, it is an unwise step to
attempt any thing of this kind, as it will in all probability add
to the danger. There are several reasons why it is frequent-
ly wrong to search after the ball; one is, that it sometimes
becomes encysted in coagulable lymph, and remains so for
life, being enveloped by a substance which prevents its act-
ing any longer as an extraneous body, except it be in the vi-
cinity of a large nerve. Another reason is, that Nature fre-
quently forms an outlet for the ball in the production of an
abscess; and the best and principal one is, that from the
tortuous and indirect line which the ball is liable to take, it
is rendered almost impossible to attempt any thing of the
kind with a prospect of success. Several cases have been
krown where Nature has formed an opening for the passage
LECTURE XI.
115

of a ball at some distance from the part it entered, two of
which will be sufficient for the present purpose.-Case I. A
boy who had been guilty of robbing his master, determined
to put a period to his existence, and for that purpose loaded
a musket and fixed the muzzle opposite the scrobiculis cor-
dis, which he supposed to be opposite the heart: the ball
had entered at the scrobiculis cordis ; his shirt caught fire,
and he was a good deal burnt. Some opening medicine was
directed him, but no blood came away by stool, which was
much in his favour. On examining again four days after, a
red line was discovered on the skin, extending some way,
and on carefully passing the finger along that part, the ball
was found lodged above two inches from the spine, having
passed through the rib. Case II. A young lad was acciden-
tally shot at Walworth by some volunteers while firing at a
target. It appeared as if the ball had passed under the scap-
ula. In about nine months he felt a kind of knob in the
arm; and on feeling it, no doubt could be entertained that
it was the ball which had worked its way thence. A long
incision was made near the deltoid muscle, and it was ex-
tracted. From these cases it will then appear, that if a ball
can be easily taken out, it should be done ; but if not, it is
better to allow it to take its course, as Nature is found very
kind in her operations ; and lead causes less irritation than
any other substance in the body.
An ARTERY divided by a gun-shot wound does not bleed
as in other injuries, and the reason is, that a fringe of cellu-
lar membrane is formed at its end, and within this a coagu-
lum forms, whereby the hæmorrhage is stopped; but though
there is no immediate danger, yet a distant one may be ap-
prehended, so that it would be extremely unwise in a sur-
geon to state with confidence his opinion that no bleeding
will come on, although the wound be ever so slight. An offi-
cer, who had been shot through the leg, appeared to be do-
ing so well as to be directed by his surgeon to walk about,
and without the tourniquet, and from the increased exertion
hæmorrhage came on, which proved fatal before any one

116
LECTURE XI.

could assist him. In case an artery is wounded and a liga-
ture is necessary, remember to put it on much farther up than
you would in other divisions, or you will not prevent subse-
quent bleeding during the sloughing process. Although a
small artery will not bleed so readily as when divided with
a knife, yet an hæmorrhage may occur sufficient to destroy
life; if the artery be partially divided, it bleeds as freely as
if made in any other way. It is on the separation of the
eschar that a secondary hæmorrhage is to be apprehended,
and although they may not have been originally divided, yet
they may suffer so much contusion and violence as to slough
with other parts. The eschar may not affect the whole of
the coats of an artery, but they become weakened and give
way at its separation. When a ligature is made, it should
be passed at least an inch above the wound, so as to allow
space for the sloughing process. The division of a vein
sometimes requires surgical assistance; here it will be ne-
cessary to tie it above the wound. As this, however, cannot
be done to the auxiliary vein, a piece of lint may be intro-
duced to compress it. It will be advisable, when a gun-shot
has passed near an artery, to apply a tourniquet loosely on
the leg, so as to be immediately applied if necessary. Gun-
shot wounds of the chest are common, though wounds of the
lungs do not so frequently happen; for the chest, being sur-
rounded with bone, presents a firm resistance to a bullet,
which enters the skin and becomes turned off, following the
course of the ribs without penetrating the chest.
The first symptom of a wounded lung, is coughing with
bloody expectoration, difficulty of breathing, and the patient
always lies on the wounded side, great pain, small, contracted,
irregular pulse, pallid countenance and cold extremities, with
emphysema on the external surface of the chest: the blood
that is brought up is mixed with a quantity of air,which makes
it appear frothy. Hunter considered the wounds less fatal
than when made with a cutting instrument; and this in all
probability may be attributable to their bleeding less, and
consequently the danger of extravasation is diminished,

LECTURE XI.
117

Wounds of the lungs are not always fatal. A farmer in a ren-
counter with some smugglers, received a ball which pierced
his scapula, and came out at the nipple, and he recovered.
M. Sabatier relates a case of an officer wounded in the chest :
the ball entered where the cartilage and bone of the seventh
rib unite, and in coming out at the angle of this bone, frac-
tured it in two places; the splinters of bone were removed,
and a piece of his coat; several splinters were afterwards in
the progress of the treatment extracted, and one from the
substance of the lungs. In thirty days he was bled exactly
thirty times, and although he had to contend against the ir-
ritation of the splinters, the introduction of a seton, &c., he
recovered. A bullet may lodge in the lungs without being at-
tended with fatal consequences. In the dissection of a man,
a bullet was found in the lung, a cyst had been formed round
it, and he had suffered no inconvenience from it during life.
I have remarked that gun-shot wounds are less dangerous
than those from a bayonet, or a similar instrument, owing to
the hæmorrhage being less from one than the other. When
patients die of these wounds, it is from their not healing by
adhesion; but after the inflammatory stage, suppuration en-
sues, which exhausts them. Although it is well known that
a ball may pass through the lungs, and a recovery take place,
yet it is stated by a gentleman of considerable experience as
an army surgeon, that phthisis pulmonalis most frequently
comes on. Morgagni mentions an instance of a ball being
found encysted in the lungs, but he did not know any thing
of the history of the case, as it happened in the course of
dissection. Wounds of the chest are often confounded, or
rather complicated with those of the abdomen; that is, a
ball enters the chest and pierces the abdominal viscera : one
instance of this has been seen; they are uniformly fatal.
The treatment of gun-shot wounds in the lungs, will be
precisely with the same intentions as those of more simple
wounds. Copious bleedings in the beginning; they relieve
the patient, and lessen the danger of hæmorrhage, and also
inilammation. If the inflammatory symptoms run high, they



118
LECTURE XI.

must be repeated at the discretion of the surgeon. Opium,
to keep the patient quiet, should be freely given ; it dimin-
ishes the irritability and cough. Every thing taken should
be cool; low regimen and perfect quiet observed. Dry lint
may be laid on the surface of the wound, so as to check the
discharge, which occasions an extravasation in the cavity of
the thorax. When extravasation has taken place, an incis-
ion should be made into the chest, thus: the patient must
be laid in a recumbent posture, leaning rather to the affected
side. The integuments are to be drawn up with one hand,so
that when replaced in their original situation, the opening in
them may not be opposed to that made underneath through
the intercostal muscle and pleura. An incision is to be made
between two of the ribs through the integuments : at what-
ever point is fixed on, it must be made near to the superior
edge of the lowermost rib of the two, so as to avoid the inter-
costal artery, which runs on the lower edge of each rib. The
muscle is to be divided and the pleura exposed, into which
a small opening is to be made, a canula introduced, and by
the patient's inclining more on this side, the matter evacuat-
ed; the wound must be healed by adhesion. The usual
place, either for hydro-thorax or when matter is collected, is
between the sixth and seventh rib, midway between the
sternum and spine.
In gun-shot wounds tents were formerly introduced, but
they are very improper, and now universally abandoned, as
they act as extraneous bodies, and aggravate the mischief.
Experiments have been made of throwing quicksilver into
the lungs, from which we know that extraneous bodies may
remain there sometimes without producing fatal effects.
Gun-shot wounds of the heart are immediately fatal, in
most instances; but Mr. Astley Cooper had a case sent him
from Mr. Furze, a surgeon, at Plymouth, in which it did not
happen so.—Case. A soldier was wounded at Corunna, the
ball it was found had entered the chest, but there were no
particular symptoms, except high inflammation : he survived
fifteen days after the accident, and was then examined. It



LECTURE XI.
119
was found that the left side of the thorax contained two
quarts of sanious fluid, and the pericardium considerably
thickened: the ball was found lodged in the right auricle,
having passed through the root of the ventricle at the root of
the tricuspid valve. This may at first sight appear extraor-
dinary, and one thing is certainly so, and which I am at a
loss to account for, viz. that the effusion of blood did not
produce death sooner.

GUN-SHOT WOUNDS OF THE ABDOMEN.
These are for the most part fatal. In the case of a wound
in the stomach, inflicted on a gentleman, he only survived
forty-eight hours. In another, where the intestine was the
subject of injury, in the instance of Mr. Blight, who was
murdered by Patch some years ago, the former only lived
seventeen hours: the intestine was inverted, and presented
a rose appearance. A slanting or indirect wound of the ab-
domen is now and then recovered from, of which a case
occurred at Haslar Hospital; the ball had pierced the peri-
toneum and portion of the intestine in contact-granulations
formed, and he did well. There is another species of wound-
ed intestine, which has been known to be recovered from.-
Case. Captain Hanley, of the 3d regiment of Foot Guards,
at the battle of Aboukir, under the gallant Nelson, received
a shot through the pelvis, on one side, and it came out on
the outer side of the femoral artery, and fell into his panta-
loons. The ball weighed upwards of three ounces : a glys-
ter was thrown up a short time after, but the rectum being
wounded, it came through the wound; the latter however
soon closed; he recovered, and was some time ago in good
health : the wound took place below the reflected portion of
peritoneum. Wounds of the abdomen are rare in compari-
son to those of the chest, and this proceeds from the direc-
tion troops are taught to fire being more elevated. Those
who have had opportunities when abroad, after engagements,
of seeing a vast number of gun-shot wounds, have assured
me, that not one of them was in the abdomen, but a great



120
LECTURE XI.
many in the chest. When the small intestines are wounded,
no fæces are discharged; there is a feeble quick pulse, de-
jected countenance, vomiting, with extreme pain and tension
in the abdomen: if the large intestines are wounded, it is
known by the stools being bloody, and the fæces are dis-
charged at the wound as well as at the rectum ; these latter
are not so dangerous as wounds of the small; in some cases
the same treatment will be advisable as in mortified strangu-
lated hernia, when reduced, if the wound be confined to one
only. Copious bleedings are proper, fomentations, &c. to
produce separation-no cathartics are to be given—such
diet should be allowed as produces little or no fever, and
milk for this purpose will answer best.
GUN-SHOT WOUNDS OF THE BRAIN.
Injuries of the skull or cranium, from this cause, are to be
treated the same as produced from any other : if there be a
depression of the bone, with a corresponding wound in the
brain, you are to remove the depressed portion of bone, &c.
Symptoms of compression seldom come on, granulations or
adhesions take place, and the patient recovers. There is,
however, a greater degree of danger from a gun shot wound
of this kind than from a common accident, for in it there is
an eschar to separate, which is an increased process of dan-
ger : but if the bone be depressed, it should be raised as if
proceeding from any other accident. Examples have been
seen often of balls lodging in the head, without any inconven-
ience; and from these taking a direction as if they had en-
tered the brain, they have generally been supposed to have
lodged in the skull, but on dissection they have commonly
been found in the ethmoid, sphenoid, or frontal sinuses. A
case occurred where, from the bursting of a gun, part of
the breech entered the os frontis, the inner diploé of which
was broken, and the pulsatory motion of the brain observed :
after a time a suppuration took place, the piece of iron was
discharged, and the patient recovered. In this case it must
LECTURE XI.
121

have been lodged in the frontal, and perhaps part of the
sphenoidal sinus, and this without producing pressure on the
brain. In another case, where a nobleman attempted to de-
stroy himself by firing a pistol a little anterior to the ear, he
recovered from the immediate symptoms, and after two years
a discharge took place in the nostril, and continued some
time; ulceration then came on in the roof of the mouth, the
palatine artery was divided by the process, and in restraining
the hæmorrhage the ball was felt, which afterwards was dis-
charged through the palatine portion of the superior maxil-
lary bone. A ball may be lodged in the brain without any
fatal symptoms or mischief ensuing : it first occasions coma,
but soon goes off. Desault mentions a case of it in his me-
moirs. A case was seen at Guernsey, of a ball lodging for a
length of time in the ethmoid cells. And among other sur-
prizing cases of these wounds, was seen that of a man who
had the ramrod of a pistol pass into his forehead and out at
the occiput, without death ensuing.

ON COMPOUND FRACTURES OCCASIONED BY GUN-SHOT WOUNDS.
A compound fracture by a ball is the worst kind of frac-
ture that we have to treat, because the bone is broken into a
number of pieces, besides the laceration of the integuments,
which will be disposed to slough. When bones are much
splintered, an incision should be made, and every small par-
ticle with the greatest care removed—the two extremities
are then to be brought into contact, and will unite, though
the limb may be shortened.
This injury, of all others, requires dilatation, as the incision
will prevent the formation of an abscess :-by this method
being accurately. pursued, the amputation of the limb might
be prevented. If a ball wound a small joint, the patient will
generally die from extent of inflammation, and if the bone be
splintered there is no chance of saving the limb: in the knee
or ankle there need be no hesitation in operating. It was
tried with success to save the limb, when the elbow joint was
16
122
LECTURE XI.

splintered in the hospital at Toulon. If the person be intox-
icated during such an accident, and the operation be per-
formed immediately in this state, there is little chance of
recovery ; Dr. Babington mentions, that out of twenty-four
operations on board of ship, during the last war, only two
recovered thus situated. It would therefore be right, if pos-
sible, to wait till the patient got over the inflammatory and
the commencement of the suppurative stage, which may be
done in every injury but that of the knee joint and ankle,
where it would be right to amputate immediately. Amputa-
tion performed in health is similar to removing a branch of
a tree in summer when it is in full foliage ; it affects the
health of the tree much more than when removed in winter ;
so in man an operation will succeed infinitely better when
the constitution has been gradually brought from a plethoric
to a lower state. This treatment refers only to the lower
extremities. Operations on the upper are not so fatal. A
wound in the arm may require immediate amputation, and
the patient will generally do well: the larger the part remov-
ed, the greater the danger, i. e. amputation above the knee is
more dangerous than below it.
After the battle of Fontenay, the Royal Academy of Sur-
gery, in 1756, adjudged to Faure the prize in cases of gun-
shot wounds, where amputation was necessary, for assigning
the most proper time to operate. Faure tells us, that after
this battle, out of three hundred amputations,thirty only were
followed with success. His plan was to delay its perform-
ance till the first effects had subsided from the injury. Our
celebrated countryman, Hunter, coincided in this opinion,-
we must either operate previous to the inflammatory symp-
toms, or wait till after the suppurative process has commenc-
ed; these are the only two periods at which it would be
prudent to adopt such an operation,—and I think the infer-
ence is clear, that if a limb cannot be preserved, the sooner
the better it is adopted : why suffer the patient to run the
risk of sinking from the effects of the injury? The violent
coinmotion in the system attendant on the attempts at its res-
LECTURE XI.
123
toration must be great, the constitutional suffering excessive,
the dangers of mortification and death staring us in the face;
---by its speedy adoption, we convert an extensive contused
wound, with fracture, into a simple incised one, and I should
consider it a wilful neglect on the part of the surgeon if he
hesitated.
The celebrated D. J. Larrey has written a valuable work
in three octavo volumes, wherein this subject is introduced,
and this long debated question, in my opinion, very satisfac-
torily decided that operating before the appearance of the
primary symptoms is by far the most safe and successful;
and although Faure was supported by so great an authority
as John Hunter, I trust none will be found so illiberal as to be
obstinately destitute of conviction of error. D. J. Larrey, by
his speedy operating, saved three-fourths of his patients, of
which several had lost two limbs.
On primitive amputation, he says, “when a limb, which has
received a gun-shot wound, cannot be preserved, it must be
amputated immediately; the first twenty-four hours are the
only hours of calm which nature enjoys. Secondly, the dan-
ger of a long continuance in the hospitals is less, by convert-
ing it into a wound capable of a speedy cure. Thirdly, when
the patients are obliged to be abandoned, and the operation is
performed, the dressings may remain several days on with
benefit to them.” D. J. Larrey enumerates eight cases, in
which immediate amputation will be necessary. First, a
limb carried away by a shot, splinter, or shell. Secondly,
when a body propelled by gunpowder strikes a limb, in such
a manner that the bones are crushed, the soft parts greatly-
contused, lacerated, and carried away to some depth. Third-
ly, if the same body should carry away a great portion of
the soft parts, and the principal vessels of a limb, as the thigh,
for instance, without fracturing the bone. Fourthly, if a
grape-shot of a large size strikes the thick part of a limb,
crushes the bone, cuts and lacerates the muscles, and des-
troys the great nerves, leaving the principal artery unhurt.
Fifthly, if a spent ball, leaping along the ground, should
strike obliquely a limb, without producing any solution of


124
LECTURE XI.

continuity in the skin, as often happens, the parts which make
resistance to its action, such as the bones, muscles, tendons,
aponeuroses, and vessels, may be ruptured and torn.-Note.
Should, on a careful examination, the vessels and bone be
spared, and the muscles are the only parts injured, amputa-
tion will not be necessary; and although M. Lamartiniere
and D. J. Larrey recommend an incision, to give exit to the
effused blood, it should not, in the author's opinion, be adop-
ted unless the extravasation was very considerable. Sixthly,
when a piece of a shell, a splinter, or a ball has fractured
the articular extremities, especially those forming the joint
of the foot or knee, and the ligaments have been ruptured
or lacerated, or if a foreign body were lodged in the thick
part of the articular extremities, or wedged in the joint.
Seventhly, if a large grape shot, a small cannon ball, or a
piece of shell, have denuded in passing through the thick
part of a limb, a great surface of bone, without fracturing it.
And, eightbly, when one of the great articulating joints, as
the elbow, has been laid open to a great extent, by a cutting
weapon, and an effusion of blood into the joint. ota
Faure considered that the operation performed from the
fifteenth to the twentieth day appeared less dangerous than
at the first instant, by which time he thought the commetion
produced by the violence dissipated. Experience has now
fully demonstrated the impropriety of Faure's practice. It
is the primitive symptoms that are to be most feared in gun-
shot wounds: of those who suffered immediate amputation,
in the naval service, after the battle on the 1st of June, 1794,
very few died ;-out of sixty carried to the Naval Hospital
at Brest, only two died of tetanus, although several had both
arms amputated, the rest were cured. D. J. Larrey observes,
on consecutive amputation, that extensive mortification, where
nature has traced out its limits, convulsions of the wounded
limb, diseased or excessive suppuration, and bad unhealthy
state of the stump, may require its performance. 164
I have already remarked, that incisions for the extraction
of foreign bodies, as wadding, pieces of linen, &c. as well as
to remove splinters of fractured bones, are required;—they


LECTURE XI.
125

produce more mischief than a bullet, for being in pieces, they
cause a number of small abscesses ; large substances may
remain without however exciting inflammation : a piece of
iron was lodged between the flexor tendons of the thigh ; it
was so near the intercostal artery that an incision could not
safely be made ;-it remained without any mischief, only in-
terrupting the action of the muscles. When a ball excites
inflammation it will come out with the pus. When a ball
can be found, it may be removed with a slender pair of for-
ceps. When abscesses form, from the entrance of any ex-
traneous bodies, a large opening should be made for their
discharge. Wounds from small balls are not often danger.
ous; they will sometimes remain in the body, and at other
times work out of themselves. When amputation is requisite
in common accidents, it is especially so in gun-shot wounds;
--the bones are more splintered, and the wound much more
contused; we find exceptions to every general rule that could
be laid down. Dr. Babington had a case of compound frac-
ture of the knee, from a gun-shot, in which the patient re-
covered; but I mention this, however, more as an extraordi-
nary case than for imitation ; although fortunate, the prac-
tice was decidedly wrong. The treatment must be assisted
by rollers and proper bandages, as the eighteen-tailed ban-
dages, pads, and splints, &c. Never use any oily or unctuous
dressings, as some authors have recommended.
- Burns, proceeding from gunpowder, appear alarming to
those who are unaccustomed to see them, from their black ap-
pearance. Cloths wet with the liquor. acet. plumb. dil, should
be applied; all oily substances should be avoided, as being
improper ; they induce ulceration : the blackness generally
remains : care should be taken to prevent sound parts from
coming into contact with the burned, which might give rise
to an union between them. A case was seen where the fore
arm, from being kept too much bent, had adhered to the up-
per: when these burns are deep they occasion much fever.
A man in Guy's Hospital died from the inflammatory symp-
toms that ensued after a burn. Poultices, to moderate these
symptoms, are the best applications in all deep burns.


( 126 )

LECTURE XII.
i
s
. ON POISONS.
A Poison may be defined to be any substance which, howe
ever minute and small, is capable of producing deleterious
effects upon the animal machine. It originates from four dif-
ferent sources, and may therefore be divided into as many
different kinds: viz. animal, vegetable, mineral, and morbid,
and with respect to the last, it is necessary to distinguish be-
tween those occasioned by the human and the brute creation ;
some add a fifth, viz. gaseous. Animal poisons are the stings
of various insects, reptiles, rabid animals, &c. Vegetable,
such as opium, cicutæ, hyoscyamus, aconite, &c. Mineral,
as arsenic, sublimate, (the muriate of mercury), lead, zinc,
&c. Morbid are numerous, as small-pox, measles, plague,
venereal virus, marsh, miasmata, angina, scarlatina, vaccine
virus, hooping cough, itch, &c. Some of these morbid pois-
ons act locally, as itch, hooping-cough, and syphilis, but the
most are constitutional. The itch appears in three days.
Syphilis from the third to the seventh day. It will be found,
in tracing the action of poisons, that they operate in three
ways—first, upon the nervous system, exciting considerable
irritation; the sedative effect is rather doubtful: others act
on the blood-vessels producing inflammation, which destroys
the life of the part, as arsenic: and there are some which
LECTURE XII.
127
act in both ways. It appears that opium does this,-it in-
flames the coats of the stomach, and also affects the nervous
system, so as to bring on convulsions. Zinc, as a mineral
poison, almost immediately acts, which is not the case with
respect to morbid poisons. Most of the latter, however, have
a particular rate: as, for instance, the small pox, which in the
natural way appears about the fourteenth, but the inoculated
on the eighth or ninth day. A variation will be observed
according to the disposition of the constitution, but this will
hold good as a general rule : so also with respect to the vac-
cine. As to scarlatina it commonly happens on the seventh
or eighth day, though I have known it protracted to the seven-
teenth or even to the twenty-first. Rubeola on the ninth day
after infection is received.
To make myself better understood ; from the time the con-
stitution becomes indisposed the small-pox eruption appears
from the third to the fifth day; that of rubeola on the fourth
or fifth day; and scarlatina anginosa between the second and
fourth day inclusively. Some act by abrasion of the surface,
as in measles; affecting the cuticle of the eye or trachea.
Many are absorbed before they produce their effects, as the
small-pox, &c. ; it may be absorbed if taken into the stomach
on bread, but is slower in producing its effects; the quantity
of virus does not appear of consequence in producing the dis-
ease, and many are of opinion that the disease is milder if
the matter be diluted. Some are extremely remote in their


miasmata, that though it produces ague in some very rapid
and quick, yet in others it is found not to happen so.
Case.—A lady who had been absent at a watering-place
with her family, about a month after her return was seized
with an intermittent, some time afterwards her servant was
confined with a similar disease, and the children successively:
side, where the disease was prevalent. It has been also re-
marked, that a person who comes to London, from the aguish
country, if ill at all, is affected with some intermittent com-

128
LECTURE XII.
plaint. But the poison that is the most gradual of any in
its effects, is the saliva of a rabid animal.
Dr. Babington has recorded a case in the Medical Re-
searches, of a gentleman who was seized with hydrophobia,
in a day less than twelve months after the bite of a cat.
You will find that the action of vegetable and mineral poi-
sons depends upon the quantity introduced into the system,
as it is known when administering them in small doses, they
act as remedies ; but this will not hold good with regard to
morbid poisons, as the minutest particle inserted will pro-
duce the original disease, which may be frequently seen in
the small-pox. Dr. Fordyce, however, thought by dilution
its powers were weakened, but I have not had sufficient
proofs adduced to submit implicitly to this opinion, although
it appears very rational. Some poisons require a suscepti-
bility or predisposition in the constitution for their action :
in the small-pox this is certain though not so in syphilis : this
is not readily explained, for though the predisposition be de-
stroyed, yet we can trace no obvious explanatory cause. There
are several examples on record of persons having had the
small-pox twice; in general, however, the predisposition is
lost by having the disease once :-hence we hear of some
few solitary cases of the inefficacy of the cow-pock, as a pre-
ventive against variola ; it may be attributed to a similar
cause, and ought not, with justness and fairness, to militate
against the general advantages we derive from so'inestimable
a discovery, which has immortalized the name of Jenner. By
frequent repetition of lues venerea, the body gradually bè.
comes less susceptible of it. Very few diseases can be in-
oculated. The small-pox, cow-pock, chicken-pox, measles,
&c. may be produced thus, but some are not rendered milder
by its adoption, as for instance the measles.-
A man was employed in the neighborhood of Yarmouth to
kill wasps, because he was never known to have felt the least
inconvenience from their sting: some time after this happen-
ed he was met accidentally, and it occasioned some little sur-
prise, to hear him say, that he had latterly suffered extreme-

LECTURE XII.
· 129
ly from the sting of these insects; and, on inquiring the rea-
son, discovered that he had been afflicted with an ague some
time before, which had produced a total change in his con-
stitution, and rendered him as susceptible as another person.
A case came under my own observation, in the person of
Mrs. Francis, who had been stúng on the arm below the el-
bow by a wasp; her arm swelled up to the axilla, to an ama-
zing size in the course of a short time. I attributed it to her
extreme irritability; a strong poultice was applied to the
wound, and cloths kept constantly wet applied around the
arm, with the liquor. acet. plumb. dil. vinegar and water in
equal quantities : and it was deemed necessary to bleed,
purge, and give opium.
The sting of insects, in this country, seldom requires much
attention ; oil, opium, and volatile alkali, as the spir. ammon.
succin., are the principal remedies ;-some apply vinegar, le-
mon juice, spir. vin. camph. spir. corn. cer., &c.; others re-
commend employing only an alkali to neutralize the poison,
extracting the sting by incision, &c.
* The bite of a viper is productive of great inflammation,
and constitutional irritation, with an appearance of ecchymo-
sis, but is rarely fatal. The poison of these animals is found
in capsules, or bags, at the root of two moveable fangs in the
upper jaw: it is by compression of these bags that it escapes
along the grooves in the fangs into the part bitten. A com-
panion of mine, in attempting to kill a viper, was bitten; he
immediately sucked the wound, but the part soon became
painful, the arm considerably swollen, and attended with
some degree of fever, and he lost the power of articulation;
with respect to this circumstance, I cannot determine whether
it arose from the tongue or arm, though it did not appear to be
in consequence of the former, as it was not swollen. He ul-
timately recovered by the use of oil and poultices. There
are several other instances: one case is recollected where
the part was removed, but still the arm swelled a good deal,
and it was some time before the patient recovered. This poi-
son seems to operate chiefly on the nervous system. To see,
17

130
LECTURE XII.
in some measure, how it acts, a rabbit was taken and a viper
bit its ear; after a short time was found a great determina-
tion of blood to the part, which soon became thickened, and
the animal died. The whole surface of the cellular mem-
brane appeared as if injected with venous blood, hence the
tumefaction and livid spots which appear in these cases. Fon-
tana attributes the danger in proportion to the size of the
animal: in children it is more fatal than in adults. It seems
also that the bite of a rattlesnake produces similar effects.
Treatment.
If the wound be inflicted on the finger or hand, a tight lig.
ature is to be applied above the part, to arrest the progress
of the fluid. Mr. Astley Cooper was led to adopt this plan,
which it seems was countenanced by Fontana, from its hav-
ing been practised on himself with success. Whilst lectur-
ing on comparative anatomy, a viper accidentally bit him; a
ligature was immediately applied by Mr. Fox above the
wound: there was a slight ecchymosis the following day on
the back of the hand, but no constitutional irritation. If it
happens to a limb, a roller is to be put on, by which the op-
eration of the poison is confined to the part, and absorption
impeded. Excision is to be adopted in cases where this can-
not effectually be employed, and your patient has fortitude to
submit; or cauterizing the part with the kali purum, should
he demur; or inserting the pulv. lyttæ in powder. Constitu-
tionally the eau de luce is a great favourite, which some em-
ploy externally also. Olive oil has been equally celebrated,
employed in the same manner, inwardly and outwardly. Dr.
Mead advises emetics.
Mr. Ireland, Surgeon to the 4th Battalion of the 60th Re.
giment, formerly a pupil of Mr. Chevalier’s, has inserted a
very interesting account of the varieties of serpents in the
West-India Islands, in the second volume of the Medico-Chi-
rurgical Transactions, and four cases which were cured by
the administration of arsenic, originally noticed in Russell's
History of Indian Serpents, from facts communicated by Mr.
Duffin and Ramsay, of the efficacy of the celebrated Tan-
So

LECTURE XII.
131
jore pill, in which this was a principal ingredient. Dr. Fowa
ler's solution of arsenic was employed, containing one grain
of arsenic in two drachms of liquid. R. liquor. arsenic.
3ij., tinct. opii. gtt. x. aq. menth. pip. 3 isso, this medicine to
be given during the slight act of effervescence, which 3ss. of
lime or lemon juice would occasion. The medicine was con-
tinued every half hour for eight times successively, using this
liniment, R. ol. terebinth. liquor. ammon. āā. 3 ss., ol. olivar.
3 iss. When purging commenced the arsenical solution was
discontinued, and a purgative glyster given twice. The la-
cerated edges of the wound were immediately removed.
os
en
ON HYDROPHOBIA.
A person bitten by a rabid animal is commonly affected
about a month after the accident, but this varies very con-
siderably in some cases, even so remote as eighteen or nine-
teen months; while others are affected so early as the eigh-
teenth day. The first symptoms are a chilliness and indis-
position to take food, attended with thirst, pyrexia, &c.; and
on attempting to drink, the patient experiences the greatest
horrors, though for some time he conceives the idea of swal-
lowing a fluid without fear, but after repeated efforts is disap-
pointed: he draws deep inspirations, and such anxiety is
apparent in his countenance as even to excite pity in the mind
of the spectator; his hand is at the same time convulsed, and
the fluid spilt: after a time, in consequence of the spasmodic
action of the muscles concerned in deglutition, he is equally
incapable of digesting either solids or fluids. Ptyalism suc-
ceeds, and if any saliva happens to touch the patient, he ex-
periences great: uneasiness ; just before death convulsions
come on, so that in a few minutes he is in a state of epilepsy;
but this only happens in young people, as adults are gradual-
ly exhausted by irritation. A person labouring under this
disease has been ridiculously said to bark. I have never
known an instance where the patient has attempted to bite

132
LECTURE XII.
others; he will, however, in case he knows what his com-
plaint is, advise the by-standers to be aware; but this arises
from impressions previously made on the mind. The cause
of the disease appears to be excessive irritability, for any
kind of stimulus is known to produce a degree of horror and
shuddering. It is curious to see a patient go into the bath;
before he sees it, it appears to affect his mind but little, but
as soon as he comes near he suddenly starts back; as, how-
ever, the resolution is seldom gone, he jumps in, but on touch-
ing the fluid convulsions are excited; the ruffling of the wa-
ter is often enough to occasion these.
A very marked case of hydrophobia occurred at Guy's
Hospital. The patient, a young healthy man, attributed the
pain he felt in his right arm, hand, and shoulder, to rheuma-
tism, being unconscious of the injury , he had received; a
gradual feeling of uneasiness, loss of appetite, oppression
from wind in his stomach, and a sense of stricture in the
esophagus, succeeded to the pain in his arm. The symp-
toms which followed were those generally described: he liv-
ed only eleven hours after his admission into the hospital.
His agitation was extreme, his countenance anxious: when
spoken to, his sentences were interrupted: his thirst was ur-
gent, but the spasm brought on by deglutition gave him a
dread of liquids. Under the effort to drink, two people with
difficulty held him in his bed: his skin was cool and natural
to the touch, but exquisitely sensible to the impression of
air, even the breath of a by-stander: he complained of ex-
treme heat, pulse intermitting; saliva viscid, and excreted
with vehemence: latterly he swallowed easily. He vomi-
ted up much grumous matter, and was perfectly sensible
within a short period of dissolution. In the ninth volume of
the London Medical Journal, we find a similar case. Fran-
cis Stannier died in November, 1787, with every symptom of
hydrophobia, although he was equally unconscious that it
was occasioned by the bite of a rabid animal.
The wound occasioned by the bite heals very kindly, and
apparently healthy, in the first instance; when the symp

LECTURE XII.
133
toms of hydrophobia come on, the cicatrix inflames, swells,
and appears puffy, with a slight discharge. Two appearan-
ces present themselves on dissection. Inflammation of the
pharynx, opposite the mouth, of the erysipelatous kind, and
an inflammation of the stomach, yet not to that degree as to
account for any particular symptoms: these are effects, not
causes of the disease.
The saliva of a mad dog has been inoculated, but I never
heard of its having taken effect, although Mr. Lawrence has
related one case of this kind.
Treatment.
The first thing to be done is to ascertain, with a tent probe,
to what depth the teeth of the animal have passed; then ap-
ply the kali purum, so as effectually to destroy the parts a-
round the wound, beyond which we suppose the poison not
to have insinuated itself; and as it would appear, from all
the cases on record, that absorption is slow, and the consti-
tution does not become immediately affected, but rather re-
motely, we may hope for success from its adoption, more
particularly if done soon after the injury has been received.
The lunar caustic may be also applied, and I have the au-
thority of Mr. Cline for asserting, that in several cases which
came under his care, it was amply sufficient : it must be us-
ed liberally. Many prefer extirpating the bitten part com-
pletely, and I see not the least objection to its adoption ; and
probably it would be preferable, less tedious, not so painful,
and sooner healed; and I must confess, were a case to come
under my own care, I should have no hesitation in removing
the wounded part, even if situated among structures that
would suffer by the necessary incision.
A young nobleman fell a victim to hydrophobia when caus-
tic had been applied, but I attribute it principally to its not
being effectually used, that is, so liberally as to cause a
sloughing of the whole extent of the wound. With respect
to medicine, all the celebrated specifics of different writers
deserve only contempt; and it is only in those cases where

134
LECTURE XII.
probably hydrophobia would not, and where it did not make
its appearance, that they have been so greatly extolled as
preventives. Sea-bathing is of little service; though com-
formable to the opinions that are prevalent of its efficacy by
the generality of mankind, it may be given a trial.
ON VEGETABLE Poisons.-All of these produce nearly the
same effect: viz. giddiness, confusion of sight, wildness of
the eyes, palpitations, stupor, vomitings, convulsions, &c. I
have never known a person destroy himself with cicuta,
though from its resemblance to the leaf of carrots, parsley,
and other plants, it has often accidentally produced very dis-
tressing symptoms, and in some cases, I believe, a fatal ter-
mination. When it occasions deleterious effects, it causes
pain in the head, giddiness, loss of sight, convulsions, stupor,
death. On dissection, the stomach does not appear inflamed
or altered, so that it can only be detected by its presence or
smell. If injected into the arteries, it puts a stop to all mo-
tion of the body : applied to a limb, it destroys its sensibility.
It has been much recommended in cancer, but it has seldom,
if ever, been seen to effect a cure; it affords a temporary re-
lief. In some scrophulous and venereal ulcers it relieves
pain, and diminishes their irritability. I have successfully
used it in acute rheumatism, combined with the antimonial
powder. Its operation in an irritable bladder is doubtful.
I do not recollect tobacco taken by the mouth in sufficient
quantity to prove fatal, but it now and then does by the bow-
els. If injected into the intestinal canal, it produces a very
quick irregular pulse, universal paleness, cold sweats, great
debility, and death. In hernia it has thus proved fatal, even
3j. in 3 viij. aquæ : it quickens the pulse, but lessens its
strength; it therefore is not a stimulant. As to its being in-
jurious externally applied, the following case will sufficiently
shew.—A child with tinea capitis, had the expressed juice of
tobacco applied to its head. A short time after his mother
missed him, and on going out, found him returning to the
house, pale and nearly incapable of helping himself, and on
going up stairs, he involuntarily voided his fæces : he soon

LECTURE XII.
135
became comatose, and died in three hours. On examina-
tion of the brain there was only found a slight effusion oppo-
site the diseased part.
Opium produces, in addition to the symptoms mentioned,
sleep, with apoplectic sterta, total insensibility of the eyes,
the pupils of which do not contract when the strongest light
is applied : large quantities, however, have been taken with
impunity, but innumerable instances are on record when it
has proved fatal; and the effects, during the whole time, are
coma, with apoplectic sterta, succeeded by convulsions and
death. On dissection, the stomach is found invariably infla-
med, and coagulable lymph effused between the coats. The
first effect of this drug seenis to be stimulant; the second,
sedative. In one case the pulse rose at first from 76 to 86,
and then sunk to 65: from this circumstance the conclusion
may be drawn, that it should never be given in active inflam-
mation alone, or at least till previous evacuations are had re-
course to: its operation is thought to be directly on the
nerves, suspending their irritability.
TREATMENT OF VEGETABLE Poisons.—If called to a per-
son during the first stage, when the narcotic has not been
long taken, give a large dose of the sulphate of zinc alone,
say from fifteen to thirty grains: or the tartarized antimony
from ij. to iij. grains combined with it. Endeavor to make
him swallow warm water plentifully: to facilitate the opera-
tion of the emetic, and to counteract the effects of the poison,
it should be strongly acidulated with lemon juice or vinegar.
Having thus attained your object, if the patient should be
comatose, as is generally the case, make him walk about the
room supported. He will appear to have no fear of death,
and only wishes for sleep, but keep him in constant motion
notwithstanding; and by no means indulge him in this pro-
pensity ; and if not acceded to willingly, exercise must be
enforced. If incapable of standing, he must be continually
roused, and his body rubbed with warm salt and stimulating
applications. Diffusive stimuli may be given, as the ammo-
niæ in considerable doses ; and when the vital energy is rap-

136
LECTURE XII.
idly sinking, endeavour to rouse it to action by powerful
stimulants, as brandy, &c. To take off the accumulation of
blood in the brain, and prevent effusion or extravasation, it
will be right to open the jugular vein in some urgent cases;
but this practice requires much discrimination. A blister
may be applied to the nape of the neck, and mustard cata-
plasms to the hands and soles of the feet. Flour of mustard,
united with warm water, is not only a good stimulant, but it
also possesses emetic properties. The sulphate of copper
is sometimes used instead of zinc. Query:-As tartarized
antimony is known to act almost immediately as an emetic
if injected into the median vein, and equally as effectual as
if swallowed, might it not be advisable to adopt this plan
when the patient is insensible ? or when there is an almost
insurmountable difficulty in getting down a sufficient quantity
of an emetic solution to operate expeditiously? or when got
down, the action is deferred, or altogether lost, from the tor-
pidity of the stomach ?
Among vegetable poisons may be enumerated, besides
those already stated, the small agaric, or champignon, mis-
taken for mushrooms, laurel-water, nightshade, foxglove, &c.
Foxglove operates generally by lowering the pulse in a few
minutes, without any increased action of the pulse previous-
ly; it has the same effect in health ; the pulse becomes irreg-
ular as well as slow..
I have read lately of several instances of oxalic acid being
mistaken for Epsom salts, consequently taken, and terminat-
ing fatally : chalk and water given soon after it has been
swallowed may be considered an antidote for this poison, as
it decomposes the acid in the stomach, and produces oxalate
of lime.
Vegetable poisons ãct only, or principally, on the nervous
system. The American poison, used by the Indians for their
arrows, is similar in appearance to cicuta. To shew its
effect the following experiment was made on a rabbit: a
slight incision was made with a lancet, and about one-six-
teenth part of a grain of the poison was inserted ; in about

LECTURE XII.
137
five minutes the animal began to drop its ears, then became
convulsed, and in two minutes more died. The poison seem-
ed to operate rather gradually, the voluntary powers first
ceased, then the involuntary, and lastly the heart. Even-if
the principal nerves are divided the effect is produced.
ON MINERAL POISONS.
The oxymuriate of mercury, when swallowed, acts immedi-
ately on the stomach, producing in it excessive pains, at-
tended with vomiting and purging, heat in the throat and
extreme thirst, restlessness, slight convulsions and great debil-
ity : it seems to occasion death by the irritability produced.
If called upon to examine the body after death, be careful
that you leave nothing undone on your part for the purpose
of ascertaining whether it is occasioned by poison or not,
and if so, of what nature, as your evidence will have great
weight in a court of justice. Adopt this plan: make a liga-
ture around the duodenum and oesophagus, then take out the
stomach, pour its contents into a vessel, wash the stomach
out as clean as possible, retaining the water in a bason ; then
cut it open. If this poison have been taken, the stomach
will have the appearance of red velvet, that is, generally inflam-
ed : this poison not only universally inflames the stomach, but
also the small intestines. I am aware, that it is stated from
experiments lately made, that small quantities do not pro-
duce this effect, but I do not believe this to be the case. I
should not remain satisfied in my own mind unless a ligature
was also made on the lowest extremity of the ilium; and the
contents of the small intestines, as well as their appearance,
ought to undergo the strictest scrutiny. The fluid is next to
be examined : a portion of it is to be put into a tube, evapor-
ated, and the remains sublimed with heated charcoal, which
will give running mercury. To another portion add an
alkali, and a brown powder will be precipitated; pour off the
clear fluid, sublime, and mercury will be discovered. Oxy-
muriate of mercury may be precipitated by the carbonated
fixed alkalies, and by lime water in the form of an orange,
18

138
LECTURE XII.
or orange yellow coloured deposit. The muriate of tin is
countenanced by Dr. Bostock, of Liverpool..
When arsenic has been taken, it produces the same symp-
toms as the before-mentioned poison in the first instance: the
abdomen is distended, the extremities cold, evacuations both
by vomiting and by stools of an offensive odour, hiccups, &c.
In addition, persons frequently die with twitching and strong
convulsions. In the examination of the body, the same cau-
tious proceeding is requisite : the powder of arsenic often
adheres to the stomach, so as to require it to be scraped off.
Arsenic inflames a good deal, but in Patches, being a sub-
stance not so soluble as the oxymuriate of mercury; this
serves as a mark of distinction.
Put the liquor for inspection into a bason, add warm water
to it; then a little dry powdered charcoal, and also potash
well dried; and a yellow precipitate will be afforded : put it
into a glass tube over a lamp, and a regulus, or ring of metallic
arsenic will be found on the glass on the surface of the powder;
no other metal has been found to rise from a precipitate in the
same manner : this is the most absolute proof of it. The flux
used in the fusion of metals will answer the purpose, as it con-
tains potash. By this method, Dr. Marcet operated with one
tenth of a grain, and the presence of metallic arsenic was
abundantly shewn by the regulus which was formed.
Mr. Hume's test is this : pour boiling water on the suspect-
ed fluid, and filter through paper: dissolve the nitrate of sil-
ver (lunar caustic) in from nine to ten times its weight of dis-
tilled water ; then gradually add a solution of ammonia, and
a precipitate will be formed : continue to add the solution of
ammonia till the fluid again becomes nearly transparent :
procure a strip of glass, dip it into this last solution, and
apply it to the first liquor supposed to contain arsenic. If a
bright yellow immediately appears, it may fairly be con-
cluded arsenic is contained, as the arsenic is thus combined
with silver.
Bergman's test is this : a solution of vegetable alkali, as the
potass. carbon., is to be added to the suspected liquor (united
LECTURE XII.
139

with boiling water and filtered). Let it stand an hour or two;
then pour upon it a solution of the sulphate of copper, and if ar-
senic be contained, the copper will be converted into a beau-
tiful pale green precipitate, which is Scheele’s green pigment.
Note. This deposit may be imitated by an infusion of
onions, united with the carbonate of potash and sulphate of
copper, which would produce an exactly similar precipitate.
Other tests may be enumerated. If a few grains of arsenic
can be obtained from the stomach, and they are thrown on
a red-hot iron, you will perceive a smell like garlic : if they
are placed between two plates of copper, and exposed to an
intense heat, the copper will be found whitened.
Treatment. -
The object to be kept in view, is to evacuate the poison as
speedily as possible ; and a powerful emetic of the tartarized
antimony, or the sulphate of zinc, must be immediately admin-
istered: get the patient to drink plentifully of niucilaginous
and gelatinous drinks, to sheath the stomach as much as
possible. I have great doubts whether we can succeed in
preventing the influence of either the sublimate or arsenic;
although with respect to the oxymuriate, good may be done
chemically by giving an alkali, as it decomposes it. If this
cannot be directly procured, give soap and water, or chalk.
Alkaline salts are found to lessen the destructive effects of
these powerful minerals; such as the potass. sub-carb. or the
potass. sulphuret. If a decomposition can be fortunately ef-
fected, it will be extremely desirable. Orfila says, the al-
bumen, or white of egg, is the most powerful and efficacious
antidote for the oxymuriate. Should success attend our ef-
forts, the subsequent inflammation must be kept under by
copious bleedings, blisters, and the oleum ricini as a purgative.
It is a curious fact, that if arsenic or the oxymuriate of
mercury be injected into the jugular vein, they act on the
stomach, and produce inflammation of it, and intestines, as
if introduced at once into that organ: a solution of the lat-
ter was injected into the jugular vein of a dog; vomiting soon
came on, and death : the stomach and also the intestines
were inflamed. Afterwards a similar experiment was made


140
LECTURE XII.
with arsenic, with nearly the same result. If injected into
the arteries, all the living powers are speedily destroyed,
and violent contractions of the muscles are produced, which
render them white.
It should be recollected, a solution of the stomach appa-
rently occurring from inflammation, and gangrene, is not in-
discriminately to be considered in that light, and this caution
is particularly necessary when called in to inspect the body
of a person who suddenly expired. John Hunter first noti-
ced this circumstance; a more accurate observer probably
never existed : he found that the gastric juice alone was ca-
pable of dissolving the coats of the stomach after death.
This was found the case in those who suddenly were depri-
ved of life in the full enjoyment of health and vigour, and in
those who died from long and protracted disease. Neither
on the other hand should it be hastily inferred a person did
not die from poison where its presence could not be detected,
as the metallic poison might be so evacuated by vomiting and
purging, as to leave no trace of its actual existence by chem-
ical analysis.
Lead appears to act spasmodically on the stomach and
bowels. On opening a man who had taken a considerable
quantity, the intestines were found burst, and the cellular
membrane inflamed with air. The spasmodic action some-
times goes to that extent as to rupture the blood vessels in the
stomach, occasioning an excessive hæmorrhage. A little sul-
phuric acid will detect the presence of lead, which is precip-
itated in the form of a white powder. The potass. sulphu-
ret. or lime, precipitates it of a blackish colour.
Copper, when taken, may be detected by the beautiful
blue colour produced in its solution by pure ammonia. If
alarming symptoms are occasioned by eating food dressed in
a copper vessel badly tinned, charcoal will be found of great
service. If verdigris have been taken, emetics, and then al-
kali, must be resorted to, and from the chemical action which
saccharine matter has on verdigris, rendering it insoluble in
water, sugar may be given.

( 141 A
)
LECTURE XIII.
n
ON INJURIES OF THE HEAD.
I
I SHALL commence this subject with superficial injuries. On
account of the occipito-frontalis muscle, (which has its origin
from the transverse protuberating ridge of the os occipitis to
the basis of the mastoid process of the temporal bone) spread-
ing into a very broad tendon, which covers the upper and
lateral parts of the head, and extending to the integuments
of the eyebrows, and even to the dorsum of the nose, and its
adhering to the skin of the head, and being attached to the
bone only by a loose cellular structure, forms a considerable
interstitial cavity, and owing to this peculiar structure is seen
so frequently to arise from a puncture in this part or wound,
an erysipelatous inflammation ; this may, perhaps, be ascrib-
ed to the injury done to the cellular membrane: the parts
become red and inflamed, and if not properly treated in the
first instance, suppuration commences, and numerous absces-
ses form under the tendon, and sloughing will ensue from por-
tions of the tendon becoming dead : the reason appears to
be that a tendon is very slow going into an inflamed state, but
when it does, is very subject to mortify. I have seen from a
blow on the head, which a person received, and from the
stunning effect of which he recovered, matter form under

142
LECTURE XIII.
PE
this tendon, and make its way under the eyelids, so as to en-
large them so much as to prevent the person from seeing : the
matter had a communication with the abscess by means
of the cellular membrane. Master Edw. Davies came to me
with a simple wound on the forehead, and adhesive straps
were applied. In the course of a week he was sent to me
again; the wound had almost shut; both his eyes were near-
ly closed; a collection of matter was evidently the cause;
the wound was enlarged considerably, and a poultice order-
ed to be applied; and this is the treatment to be pursued.
The incision must be a free one.
The temporalis is covered by a particular fascia or apon-
eurosis, which is attached to the cranium and zygomatic arch;
it is a dense tendinous structure. Inflammation will occasion-
ally take place in the cellular membrane, between this fascia
and muscle, which will continue until the formation of matter,
which is very liable to make its way under the zygomatic
arch, and burst into the mouth. Sometimes inflammation will
proceed so far as to set up an ulcerative process, which affects
the bones, and large portions of those diseased will come
away. The coronoid process has been known to exfoliate
from it. The symptoms are a slight tumefaction in
the temple, great pain in the lower jaw, so as to prevent
the patient's eating; the redness is not always apparent,
so do not be deceived by this. If inflammation be
considerable, blood should be taken away in a general way,
and locally; the bowels are to be kept open, and if the inflam-
mation still continues, bleed from the temporal artery. If
matter form, a free incision should be made through the apon-
eurosis, so as to allow of a sufficient outlet for it to escape.
ON INJURIES OF THE CRANIUM, &c.
The general symptoms consequent to an injury of the cra-
nium are loss of sense and volition: the parts below become
paralytic (paraphlegia,) sometimes on one side only (hemi-
phlegia :) both pupils much dilated (occasionally but one, but

LECTURE XIII.
143
this happens where the brain is affected only on one side, or
more that side than the other:) bleeding at the nose, and
sometimes of the ears also: the breathing takes on that kind
of sterta which accompanies apoplexy, pulse slow and labo-
rious, and often intermittent; and this often, when the least
exertion is made, will be quicker, and take on an irregularity.
The stomach becomes affected: in fact, an instance, I believe,
was never known, of an injury done to the brain, without this
organ being more or less affected by vomiting. Sometimes
blood is thrown up; but this should not excite any alarm, as
to its proceeding from internal hæmorrhage, as in this case
it passes from the nose into the throat. Costiveness also is
an attendant symptom: there are other minor symptoms
which do not merit a particular attention in this general de-
scription.
The injuries of the brain are commonly divided into two
states or classes: concussion and compression : the latter be-
ing the effect either of extravasation of blood, of effusion of
serum, pressure of bone, or formation of matter :-others
add, loss of some part of the substance; and, lastly, inflam-
mation from an injury.
ON CONCUSSION.
The symptoms of concussion resemble very much those of
intoxication, so much so, that if a surgeon should be called to
a patient (who in consequence of having fallen down, from
excessive drinking, and yet received no injury,) he may be
led to suppose that the symptoms indicate concussion of the
brain: the first question, therefore, should be directed to as-
certain the state of the patient before he fell—he appears
possessed, as it were, with sound sleep, a kind of slight deli-
rium, and sometimes coma; his voluntary motions, as well
as his senses, are lost apparently, but he breathes without
any kind of restriction : his pulse rather slow than other-
wise, but on rousing him, or on the least exertion on his part,
the difficulty of breathing, with an increased motion of the

144
LECTURE XIII.
pulse, comes on immediately. Vomiting, in this affection, is
generally a striking and attendant symptom: his mental pow-
ers are considerably diminished, but commonly are retained
in a small degree. His natural wants, or calls of nature, will
cause him to those desires, as if they were implanted in him
by instinct; he will get out of his bed, void his urine, but
when got into bed again, all that can be done, to rouse him,
and make him sensible of any thing, will be ineffectual and
vain. A striking instance of this I heard mentioned, in a
gentleman who had unfortunately met with this injury; no
answer could be got to any questions put to him at his bed-
side, but it was observed, after the attendants had left the
room (having narrowly watched for that purpose,) that he
got out of bed to pass bis urine, after which he again laid
down, and immediately on approaching his bed-side, not an
answer in any shape whatever could be obtained: this proves,
evidently, that they attend to the calls of nature merely from
habit, which is so strongly fixed in them, as not at all to be
done away with, though all other motion and sense seems to
be quite obliterated. If the concussion should not have been
violent, yet sufficient to stun the person, accompanied by gid-
diness, noise in the ears, loss of memory, and stupefaction,
and these symptoms go off, it may be concluded, that no very
serious injury has happened to the brain, further than the
immediate shock: the patient should be requested to live ab-
stemiously for some time, and by no means to indulge in any
diet that would be likely to hurry the circulation, as inflam-
mation will be very apt to follow. The patient is to be bled,
and purgative medicines administered—every trace of the
symptoms will, in all probability, go off in five or six days,
, but if they continue beyond that period, it may be concluded,
inflammation has taken place, and the necessary measures
decidedly pursued; and when inflammation is thus complica-
ted, the nature of the injury is more obscure. No patient is
safe from the effects of concussion, till fourteen days after the
accident. Mr. David Watkins, a farmer, met with this inju-
ry in returning from market, and he was intoxicated at the

LECTURE XIlI.
145
time; I concluded, at first, the symptoms were merely those
of drinking to excess; however, as a neighbor stated, he fell
on his head: as a measure of precaution, I only gave him a
purgative medicine, as it was late at night, and the following
morning, early, I again saw him, when the symptoms were
more decided, and I pursued the usual means, as will be here-
after detailed :-being the father of a large family, whose
anxiety on his account was great, induced me to pay him the
very greatest attention, but it was several months before he
recovered notwithstanding. In the case of a surgeon's mate,
mentioned by Sir Everard Home, the effects of such an in-
jury were protracted to a much more remote period: at the
end of six months he was in a great measure recovered, but
wanted the power of walking straight, and had lost his mem-
ory: his complete recovery did not happen till the end of
twelve months. This depends entirely upon the nature and
extent of the injury.
To distinguish concussion of the brain from other injuries
of that important organ, it will merely be necessary to state
the symptoms, particularly marking this injury, and this will
lead to the distinguishing it from others : many of these I
have before mentioned, but some of them accompany other
injuries of the head. A blow on the head often produces
symptoms not before existing. The respiration, as I have
observed above, is free, unless some exertion is used. The
symptoms come on immediately after the accident : the pulse
at the time pretty regular, soon becomes quicker and fuller:
simple concussion causes another action of the brain, by
which its functions are deranged, and the action of its ves-
sels is increased : but this does not last a great-while, as the
brain sets about immediately to restore the injury which it
has received ; and which, if the blow inflicted is not violent,
it soon effects: the pupil of the eye will be observed immo-
veable; the extremities cold, and the muscles of the limbs
are not relaxed, as in the state of compression.
In the treatment of concussion we are generally led to the
same method as that of inflammation, and it should always
19

146
LECTURE XIH.
be considered in that light. As vomiting comes on common-
ly in this affection, many practitioners, when this is not the
case, endeavour to excite by medicines that effect: perhaps
there may be some degree of propensity in it as endeavour.
ing to fulfil the intentions of nature; but I have never had
an opportunity of deciding this point, as in every case I have
met with, vomiting has come on naturally. There are two
objects to be kept in view in the treatment of concussion: the
first is, to prevent an extravasation of blood in the brain, when
it has been lacerated; and, secondly, to guard against in-
flammatory action. The first purpose, as well as the last,
will be attained by venesection ; but there should be particu-
lar care not to draw blood directly after the injury has been
received, as at that period it would tend to weaken the living
powers too much, which are already in a feeble state, from
the violent nature of the shock: many instances have prov-
ed fatal, from this observation not being properly attended to;
it is therefore necessary to wait until the pulse indicates bleed-
ing, by its fulness or quickness ; it has already been men-
tioned, it is regular at first. The danger that arises is from
existing inflammation, which should be prevented by all pos-
sible means; and as soon as we are warranted to bleed, by
the state of the pulse, &c. to do so. In case the patient is
of a plethoric habit, the quantity drawn should be pretty
large; but this will, in a great measure, depend on the pa-
tient, and the violence of the symptoms: the strongest and
best indicative I know, is a strong pulsation of the carotid
artery. The pulse must be watched with attention, and it
will be better to take away a small quantity at first, in some
cases, and frequently repeated; the contrary practice has
been seen to be attended with fatal effects, as tending to low-
er the constitution to a great degree. In my opinion, the
nearer the part affected that the blood is drawn the better: 1
should advise opening the temporal artery or jugular vein, in
preference to bleeding at the arm. The bowels are to be
carefully attended to; small doses of calomel at night, with
the magnes. sulph. given the next morning, will be found

LECTURE XIII.
147
WO
useful in evacuating the intestinal tube, which ought to be
kept in a general state of irritation. Mr. Abernethy, I have
reason to believe, concurs in this plan of treatment, but he
recommends purgatives of a more drastic kind. Sudorifics
and antimonials are also to be given for the purpose of reliev-
ing the body of its redundancy, and exciting the different
excreting ducts to action. Opium, if combined with antimo-
ny, requires a degree of nicety in the administration of it;
alone it is improper. The local treatment to be observed
consists in the application of a blister to the head, after a few
days has elapsed, which is attended with very good effects,
and ought not to be omitted. If there be any wound on the
scalp, it will be right to apply stimulants to it, in order to
produce a quick formation of matter. Blisters operate by
taking off the determination of blood to the brain, effecting
what is termed a retrovulsion or counteraction. All stimula-
ting substances, with respect to diet, &c. should be carefully
avoided: the food should be as light as possible, such as pa-
nada, water-gruel, &c. The patient should be kept free from
all noise and conversation, and even from the stimulus of
light: after recovering from the most urgent symptoms, ma-
ny are liable to paralytic affections, strabismus, fatuity, and
other nervous diseases, so that the recovery is imperfect :
electricity, in these cases, will be found very beneficial. In
concussion, I have never witnessed, or read detailed, any
great benefit from the use of the trephine, nor can I recollect
any case where it has been successful.
Remarks.— Is the liver affected to that extent Desault
would persuade us, in concussion ? Is it found inflamed and
suppurated in those who die from this accident? Would not
the plan of an eminent surgeon, in the Prussian service, of
the name of Schmucker, be worthy of adoption externally:
it is, a lotion applied to the head, of spring water, vinegar, ni-
· tre, and sal-ammoniac; and would not this be manifestly in-
creased in effect by a large blister on the nape of the neck,
kept open with savine cerate?

148
LECTURE XIII.
ON COMPRESSION.
The symptoms of compression differ from those of concus.
sion in this, that we find in the former that apoplectic sterta,
which accompanies it always in a great degree, and also at-
tended from the first instant with extreme slowness, oppres-
siveness, and irregularity of pulse : the loss of sense and
voluntary motion is not immediate, as in concussion; it comes
on gradually: the limbs are pliant, from the relaxation of
the muscles: the pupils of the eye are much dilated.
When the brain of a living animal is compressed, by the
finger, for example, it excites immediately an uneasy sensa-
tion, from which the animal endeavours to extricate itself:
on pressing harder, the animal becomes irritated: on still fur-
ther pressure, the pulse gets exceedingly slow: on withdrawa
ing the finger, a severe giddiness follows. From this experi-
ment may be seen what effect compression of the brain has
upon the human species,
Compression is commonly the result of three causes: the
first is extravasation of blood, or serum; the second depres-
sion of bone ; and, lastly, the formation of matter. When,
from extravasation, the symptoms come on gradually, and
according to the quickness that the fluid should have been
effused. After a blow has been received, the result of which
is extravasation, it is found, on opening the cranium, that the
extravasated fluid may be situated in three places: on the du-
ra mater, on the pia mater, and in the substance of the brain
itself. In the treatment of this accident, viz. from extravasa-
tion, our principal objects must be to guard against inflam-
mation, and promote absorption : the symptoms may not be
so violent in the first instance, so that the patient recovers
from the first attack, and may continue, perhaps, tolerably
well for two or three days; but this seeming recovery must
not put the surgeon off his guard, and prevent his using ac-
tive depletion, as the patient otherwise will sink under the
compression caused by the effused blood: blood-letting I con-
sider as the best and shortest step to take, and must not be
done with a sparing hand, unless it is directly contra-indicated.

LECTURE XIII.
149
With respect to the use of the trephine, in two states of
this injury, it will be improper; first, when the effused fluid
is on the pia mater; and, secondly, when in the brain itself:
it will only be found beneficial when situated between the du-
ra mater and the skull itself; and it is evident, that the use of
the trephine is of very little use in the two first states, as it is
impossible, after the opening has been made, to discharge the
contained fluid without the greatest hazard.
Previous to trephining, supposing it were proper, we should
bleed freely, and take care to evacuate the bowels ; if the
symptoms continue undiminished, we should not hesitate
about the operation, as the risk in its performance is not
equal to its neglect, and will be the only chance of preserv-
ing life. Look carefully at every part of the skull, and make
pressure around it with the finger; if by doing so any pain
or uneasiness is excited in a particular part, there the tre-
pine should be applied. It has been the practice to operate
on any part that has been bruised, but I think with a degree
of hazard, as it is often found that blood is extravasated, on
the opposite side of the head; after having made the open-
|ing with a scalpel, if we should not find the pericranium
detached from the skull (which will be the case if there is any
fluid between the dura matter and the cranium), I do not con-
ceive we are warranted in proceeding any further, except in
one instance, which is, if a blow have been received on the
lower part of the parietal bone, just where the artery en-
ters; and if the symptoms should be violent, in this case I
would advise trephining, as in dissection of these cases a fluid
extravasated between the dura matral artery and bone, from
the vessel yielding to the violence of the blow, is commonly
observed.
The operation of trephining is very generally given up,
except in cases of fractures; but it may be proper under two
circumstances in a limited way, namely, from extravasation
and depression; and in some cases it requires the greatest
judgment to distinguish as to its propriety or not.

150
LECTURE XIII.
ON FRACTURES OF THE CRANIUM,
These are to be considered in the same light as other frac-
tures, when unaccompanied with extravasation or depression.
It is no uncommon thing to see patients brought into the Lon-
don hospitals with simple fractures, which do very well. I
saw an instance where a man was brought in with a fracture
of the cranium, attended with symptoms rather violent: he
was immediately bled freely on his admission, and by the
time the surgeon arrived, under whose care he was taken in,
he was greatly relieved, and in a short time after quite recov-
ered his sensibility :-this single case (and I might adduce
many others) sufficiently shews the use of depletion, before
we proceed to the use of the trephine ; for instance, had the
operation been directly performed, in the above case, the
worst effects might have resulted. A fracture of the cranium
is not to be considered dangerous, when neither extravasa-
tion or depression is present. When the basis of the skull
is fractured from a high fall, from the whole pressure of the
body resting upon that part, on opening the brain and tear-
ing up the dura matter, extravasated blood is commonly
observed; this kind of fracture must inevitably prove fatal,
nor can it be discovered till after death. A fracture some-
times occurs in the orbitar process of the os frontis: an in-
stance of this was seen sometime ago; a child had been play-
ing with a pair of scissars in her hand, upon which she fell
and the point perforated the orbitar process of the os frontis :
inflammation soon came on, which shortly proved fatal: on
examining the brain there was evident marks of an extensive
action in the vessels by the great redness present. We should
trephine in cases of fracture with depression, accompanied
by symptoms of extravasation. There may be depression
without affecting the brain, so as to produce symptoms of
depression, but this is a rare circumstance. Mr. Home men-
tions a case of a colonel in the army, who had a portion of
the parietal bone so depressed, that half a pigeon's egg
might be laid in the place, yet he is not sensible of any in-

LECTURE XIII.
151
jury, unless he drinks too much wine, which deprives him of
speech. I recollect a somewhat similar case, in one of the
commanders of the Prince Regent's yacht.
Treatment.
If there should be a fracture with depression, and no marks
of injury to the brain, we should not trepine ; but if, on the
contrary, there are evident marks of injury, in case they do
not subside in the course of a few hours, after the depleting
plan has been pursued, the operation will be sufficiently war-
ranted : but there will be no necessity if the fracture be a
simple one, unless urgent symptoms exist. A slight degree
of pressure does not derange the functions of the brain—yet
a simple fracture may require trephining, when evident
symptoms of extravasation exist. In compound fractures,
with depression, it will be proper to trephine, whether there
are any existing symptoms or not; on this principle, that it
is required to prevent succeeding inflammation. Many la-
bouring under evident marks of compression have been
known to have remained so for some months, and recover af-
ter the cause had been removed. An instance of this occur-
red in a sailor, who had fallen from the yard-arm of a ship;
he was carried into the hospital at Gibraltar, but not recov-
ering there, his friends brought him home: a surgeon was
consulted, and on examining him, he was satisfied there was
some pressure existing, which had produced and continued
those symptoms of compression under which he had labour-
ed for six months before: he was trephined, and the result
was favourable.
. This case evidently shews, that there will be beneficial ef-
fects even from the late use of the trephine; and I only mean
to shew, that iſ the operation should not have been perform-
ed in the beginning, yet it will prove advantageous when the
cause has long existed. We should recollect, when the tre-
phine is proper, to operate before inflammation comes on, as
afterwards it would only hasten the death of the patient,
Two boys were brought into an hospital, with fractures of

152
LECTURE XIII.
UNGUS
ERE
VOR
the os frontis, with symptoms of compression: one had ac-
tive inflammation, and in this state he was trephined; he sur-
vived but a short time subsequently: on dissection, very
great vascularity and distention of the vessels of the brain
were apparent. The other boy was trephined, previous to
any inflammation, and he did well. Fractures, with depres-
sion, sometimes injure the brain, and are in general fatal :-
but instances have been known to the contrary. A man was
brought into St. Thomas's Hospital with a fracture of the os
frontis, accompanied with depression, and part of the bone
pressing through the pia mater : it was elevated to its proper
place, and the man recovered: this case merely shews, that
what in general may be considered as desperate cases, some-
times are known to do well, so that there may be always a
glimmering hope entertained.
Fungus CEREBRI, OR ENCEPHALOCELE.—Wounds of the brain
are commonly followed by fungus : the treatment of it is of
the utmost importance, for if left alone, or improperly man-
aged, the consequence would be fatal: sloughing would come
on, so as to cause inflammation, the result of which will be
suppuration of the brain. This fungus is formed of coagu-
lable lymph on its surface, and brain at its root, and is insen-
sible, owing to its little vascularity, and growth being too rap-
id to allow of its being organized. The treatment is simple ;
if it projects through the bone, cut it off by means of a silk
ligature tied round its base, or it may be pared off with a
knife; then apply a piece of lint, over it a strap of adhesive
plaster, then bind a proper bandage over the whole.
From violent blows on the head, a portion of bone will
sometimes be forced into the substance of the brain, produ-
cing epilepsy, and its result. A case of this kind, which ter-
minated favourably, occurred to Mr. Foster, one of the sur-
geons to Guy's Hospital. A man was brought in with a con-
siderable fracture, with depression ; violent epileptic fits
came on, and the prognosis was very unpromising. Mr. Fos-
ter having raised the depressed bones, discovered that a small
portion of it, not larger than a thorn, hąd pierced the sub-
LECTURE XIII.
153

stance of the brain ; the man on the removal of it speedily
recovered. In case a part of the brain has been lost, from
the severity of the accident, if that portion lost is not greater
in extent than that of the fractured bone, I should not tre-
phine.
ON THE FORMATION OF MATTER WITHIN THE SKULL.
In injuries of the brain, many days and sometimes weeks
will elapse before inflammation supervenes: and it is general-
ly the case, that the progress of it is much slower in this or-
gan, than in other parts of the body; when it happens, the
first sensation is, an acute pain in the head, with a cessation
of discharge from the wound ; and the wound, which before
presented an healthy aspect, assumes a livid and glossy ap-
pearance: on feeling carefully around its edges, the parts, as
in anasarca, yield to the finger on pressure, and will have a
very flabby feel. This is owing to a quantity of extravasated
serum : the flabbiness of the skin is not merely confined to
the edges of the wound, but extends a great way over the
scalp. The patient's countenance is much flushed, and on ob-
serving the eye, the tunica conjunctiva will be very red and
vascular. There may be many alterations in the symptoms,
in the course of twenty-four hours: at one time the patient
will have a depressed countenance, and to all appearance in a
dying state, but on visiting him an hour afterwards, perhaps
quite the reverse will be found. Vomiting commonly takes
place, but the most certain mark of the formation of matter
going on, is the patient being seized with violent shiverings,
which often remit similar to those of an intermittent fever.
The sooner relief is had recourse to, the more likely is it to be
attended with success. The seat of the matter is similar to
what takes place in extravasation, namely, in three places :
first, between the dura mater and the skull; secondly, on the
pia mater ; and, lastly, in the brain itself. When situated on
the dura mater, the only and quickest relief is by means of
the trephine; the matter escapes after a little while through

ILION
20
154
LECTURE XIII.

the bone. The perforator alone is occasionally used with suc-
cess. This latter instrument is proper when the skull is very
thin, as in very old, or infantine subjects: here the saw would
be likely to wound the dura mater, which must always be cau-
tiously avoided. I wish I could say, that the operation for
the discharge of matter, when seated between the dura mater
and skull, was always attended with success, or even in the
majority of instances; but I am sorry to state, from what I
have seen, that I believe there are but few that survive: and
there is still less chance when matter is on the pia mater, much
less in the brain itself; for if an opening be made through the
dura mater, the probability is, that the patient will die from
inflammation.


THE OPERATION OF TREPHINING.
The instruments required are few : a knife with a double
edge ; two crowns, with perforators, one smaller than the
other; an elevator, a probe and brush.
The parts that should be avoided, if possible, in the opera-
tion, and which ought to be well known, are these : a line
drawn from the nose to the ridge of the os occipitis, on ac-
count of the frontal and longitudinal sinuses, and the falsi-
form process of the dura mater. Avoid the lower edges of
the parietal bones, which are anterior to the ear, and nearly
at its superior part, as at the anterior and inferior angle, the
foramen for the dura matral artery lies ; not but the hæ-
morrhage might be stopped, and consequently, if an opera-
tion be required on that part, it certainly may be done; but
if it can be avoided, so much the better.
When called to a fracture with depression (supposing the
symptoms warrant an operation), the first thing to be done is,
to make a longitudinal incision, which should be about two
inches in length, so as effectually to expose the whole extent
of the fracture; but the length of the incision must depend,
in a great measure, upon circumstances ; then raising the per-
icranium in the same direction, apply the trephine in the man-

LECTURE XIII.
155
ner I shall hereafter describe. It will be better practice
to make a crucial incision, and remember to make it chiefly
on the sound portion of the bone, I mean that which is near
the fracture, but remaining in its situation; or about two-thirds
on the sound bone, and one-third on the depressed portion :
having made the crucial incision, and having raised the per-
icranium in the same direction, taking care not to raise more
of the latter than is absolutely necessary, as exfoliation will
be more likely to take place, the trephine is to be applied,
pushing down the pin in it, which then becomes a perforator,
and work on till a complete circle is made, and the saw re-
mains in its place, without the aid of the pin, which is then to
be withdrawn. It has been remarked by some authors, that
the operation ought to be proceeded in till a bloody discharge
from the diploé ; but if this were to be attended to indiscrim-
inately, it would lead us often into great and fatal errors; for
instance, in old and very young subjects there is no diploé;
the pressure of the saw must be made very even, and if the
bone have yielded in one part before another, the saw must
be worked on that part which has not given way. As soon
as it is found, by sounding with a probe, (which should be done
frequently), that the bone is loose at any one part, pass in the
elevator at that part, and disengage the piece of bone.
I think, from what I have seen, that it is advantageous to
have a small circle, and to take care that it is of an equal
depth; to be certain of which it must often be examined with
a probe. The operation of trephining should not be done in
a hurry, as the probability will be greater of wounding the
dura mater : the surgeon ought to be very cool and steady.
When the portion of bone is removed, if we are looking for
extravasation of blood, we shall find it escape immediately,
if there be any present, but if none be perceived to escape,
we are not warranted to proceed any further, according to
the opinions of some of our best operating surgeons, although
I have my doubts of the propriety of this practice. If the
operation be performed with the view of elevating a depres-
sed portion of bone, the treatment required after it has been



156
LECTURE XIII.

effected is very simple : bring the edges of the wound to-
gether, and lay some lint over the part, and in the course of
a day or two a poultice ought to be applied, and the subse.
quent treatment will be that of a common wound.
I must observe, when we are certain, from the symptoms,
that there is matter under the dura mater, in such a case, I
say, it may be proper to make a cautious puncture with a lan-
cet, as the risk will not be greater, and the patient certainly
will have a better chance for his life. The sensation of fluc-
tuation, often apparent to the feel, is apt to lead many into
error, as after an opening has been made, no fluid could be
discovered, and this has happened in several instances; there-
fore particular attention is required to the concurring cir-
cumstances, before we make a puncture.
The scalp is often affected with erysipelas after an injury
of the head, and which inflammation extends to the face, ow-
ing to an injury done to the tendon of the occipitofrontalis
muscle. In this case, it will be proper to make several open-
ings, and apply bandages all around the head, except at those
parts opened, from which there must be a discharge kept up.
When matter forms under the tendon of the temporalis, it is
advantageous to make a longitudinal incision early.


(157)

LECTURE XIV.

TT
ON HYDROCELE.
By hydrocele,derived from the Greek üdwp, water, and xnán,
a tumour, is meant a collection of water in the vaginal coat of
the testes; the cyst in which the fluid is contained will be
better explained by the following anatomical description.
The testicles are situated obliquely upwards, hanging loose-
ly in the tunica vaginalis, the left being lower than the right.
Within the scrotum is situated a bag, formed by the peritone-
um, assuming the appearance of a bladder nearly empty, and
taking the name of tunica vaginalis, and this membrane is
reflected over the testicle, as the pericardium is oyer the heart.
The testicle consequently has three coats: first, and the out-
ermost, is the tunica vaginalis reflexa; secondly, the tunica
vaginalis propria; and the third, the tunica albuginea. The
epididymis is situated at the upper and outer side of the tes-
ticle, and by this circumstance the right can be distinguished
from the left. Between the tunica vaginalis propria, and re-
flexa, is naturally contained a vapour, which, when condens-
ed and collected in any considerable quantity, forins the
common hydrocele.
- The signs marking an hydrocele, are, first a tumour will be
observed in the lower part of the scrotum, and can be easily
pressed from one extremity of it to the other : it gradually



158
LECTURE XIV.
ascends from below upwards, as the swelling increases in bulk
and size; it becomes light and elastic, and affording resist-
ance to the hand on pressure; it extends over the anterior
part of the scrotum, and is of a pyramidal shape, somewhat
resembling a large pear: the upper part, or base, is consider-
ably smaller than the lower: it is unattended with pain in
general, and it is sometime before the patient discovers it,
and then accidentally, and this proceeds from the before-
mentioned circumstance, namely, want of pain, and also of
its little weight: but if there be any inflammation present,
then, of course, it will be painful. When it gets very large,
the patient commonly feels a painful sensation in the loins of
the diseased side, also occasionally at the spinous processes
of the ilium. An hydrocele thus formed is generally trans-
parent, which may be detected by exposing it to a candle :
but there are circumstances which prevent this transparency
sometimes from being discovered, by merely holding it to the
light of a candle ; recourse must be had to other means ; hav-
ing previously darkened the room, grasp the tumour at its
lower part, so as to squeeze the fluid anteriorily, then putting
a lighted candle, at its anterior surface, the transparency will
be visible.
The scrotum in this disease is undiscoloured, and the size
of its vessels very little enlarged: the scrotum also slips over
the vaginal coat or tunic, which circumstance adds much to
the knowledge of the disease. On applying the fingers, a
fluctuation will be discovered from one extremity to the
other; whereas, when other fluids are contained, the fluctua-
tions are confined to one spot; and this, with that of its little
weight, will add much towards distinguishing it from other
affections of these parts :—there are certain varieties that an
hydrocele assumes, and which, if the surgeon be not proper.
ly acquainted with them, may lead to great errors. It is
sometimes a double tumour, one in the scrotum, the other
above the abdominal ring, in consequence of its distention
above the ring giving it a double appearance. An hydrocele
is not always transparent, that is, the fluid which it contains :


LECTURE XIV.
159
either this may arise from the state of the fluid, or a thick-
ness of the tunic, in consequence of the long existence of the
disease; so that when it is cut open, it does not fall down
upon the testes as usual, but remains fixed, having the ap-
pearance of cartilage. It has sometimes been found ossified,
but this rarely. One instance only has been seen, and with-
in this ossified tunic it was discovered, that the water contain-
ed a mucilaginous substance. The vaginal coat has occa-


a partial adhesion taking place after inflammation.
The spermatic chord sometimes passes entirely through
the cyst ; in this case the trocar should be passed rather on
the outer side of it. The nature of the fluid varies à good
deal, and it is no uncommon thing to find it bloody: if this be
found the case, after the operation has been performed, the
injection made use of should be much weaker than usual, by
about one-third; the reason is, the result of an inflammatory
process, and if a strong injection were made use of, it would run
the risk of exciting too great action and irritation of the parts,
which would most probably terminate in suppuration. In-

fluid in the vaginal tunic, of a yellowish colour, resembling
pus, sometimes so viscid as to be ropy. Cartilaginous sub-
stances are also occasionally found loose within this tunic.
There are several diseases with which an hydrocele may
be confounded :—in the first place, with hernia. A careful
inquiry should be made into the history of the case, and take
particular care to be informed of its origin, &c., whether the
tumour began from below, and extended upwards, or vice
versa. Again, direct the patient to cough; if it be hydrocele,
there will be no dilatation; but if hernia, there will. However,
there are some exceptions to this as a general rule, which I
shall hereafter notice. Another test of hydrocele, I may
observe, is the distinctness with which the spermatic chord
may be felt, which is not the case with inguinal hernia.
The exceptions that I alluded to, with respect to the dila-
Yation of hydrocele, by coughing, are these : first, when a hy.


160
LECTURE XIV.
drocele is so extensive as to pass between the abdominal
rings, this will dilate by coughing: also when the fluid, which
is rarely the case, passes from the vaginal tunic into the ab-
domen :—but those just mentioned, if properly attended to,
will not deceive, as they are perfectly transparent, and may
be instanced as exceptions. It is proper to be thoroughly
acquainted with the disease before operating, as otherwise
fatal effects may ensue from wounding the testis. An hydro-
cele may be distinguished from an inflamed testicle, by the
scrotum in the latter being red, and having a general blush
on the surface; the vessels also of the testis are much more
enlarged and numerous, besides, in squeezing the testicle
gently with the hand, it will excite a considerable degree of
pain. There are some diseases of a pulpy kind, liable, with-
out some little attention, to be confounded with hydrocele, but
may be easily distinguished by the feel, for if the fluctua-
tion be in a general state, it will be an hydrocele; and other-
wise, if is confined in a fixed spot: besides, the form of it is
different from any hydrocele, by being very flat. There is
another disease which is often likely to be mistaken, that in
which the tunica vaginalis contains blood, termed hematocele.
This commonly is the result of a blow : the tumour, in its
first formation, is sudden, of a solid texture, and of a pyra.
midal shape.
The discriminating marks are these : on elevating the tu-
mour, it will be found of great weight, not transparent, and
on inquiry into the case, it commonly will be found to have
proceeded from a blow, or a similar accident. As it is, how-
ever, in some degree liable to be confounded with an hydro-
cele, and also with that state of diseased testicle termed
schirrus, it is right, to be certain, previous to the operation,
to make an incision with a lancet, as from this small opening,
its contents can be readily known, and no bad effect will re-
sult from it; whereas several fatal instances have happened
from not strictly attending and acceding to this mode; the
operation having, without any previous opening with a lancet,


LECTURE XIV.
161
been performed, by introducing the trocar, supposing it to
be hydrocele.
The cause of hydrocele is an increased action in the ves-
sels of the tunica vaginalis testis: this is proved by injection,
when its vessels are found red and much enlarged, and in
cutting open the tunic, a general blush is suffused over its
surface ; it has not this colour when injected in a healthy
state. The absorbent vessels are, also, in a diseased state,

times that in health. Diminished absorption has, therefore,
nothing to do with the formation of the disease; and the real
cause of it is, that of the secretion, owing to an increased ac-
tion of the vessels, exceeding that of absorption.
The treatment is either palliative or radical ; by the former
only temporary relief is afforded, by the latter an endeavour
is made to produce an union of the coats of the tunica vagin-
alis, by means of the adhesive inflammation. If the constitu-
tion be irritable, and the patient naturally timid, the palliative
will be found the most proper in these cases, as if the radical
cure were to be attempted, the result might be very unfay-
ourable,from too much irritation being caused in a constitution
susceptible of it.
The mode of performing the pallative operation, is thus :-
grasp the lower part of the tumour firmly with your left hand,
squeezing it anteriorly, then feel for the testicle in the lower
part, which will be easily discovered by the degree of pain
excited, then laying hold of the scrotum, pass a small trocar
obliquely upwards, at its anterior and inferior part, by no

wounded : withdraw the trocar, leaving the canula, and when
the fluid is evacuated through it, it may be removed ; merely
apply a bit of lint to the part, and over this a slip of adhesive
plaster. Some prefer dividing the integuments first with a
lancet, and then using the trocar, but that is unnecessary
here. To prevent ensuing inflammation, have the parts wash-
ed with a lotion, composed of liquor. ammon. acet., or the
ammon, muriat, dissolved in vinegar. The water will per-
21

162
LECTURE XIV.
haps require to be drawn off, in the above manner, two or
three times a year. Sometimes, however, a spontaneous
cure takes place.
The water has been known to have been evacuated, and
the tunic be completely filled again, a week after the opera-
tion ; but this only occurs when the patient has a general ten-
dency to dropsy, and should be treated accordingly; and I
should make it a rule, whenever this tendency prevailed, to
correct it before I proceeded to the radical cure. Even the
palliative method of operating, although apparently so sim-
ple, has been known to have been attended with serious con-
sequences, arising from constitutional irritation, caused by
improper subsequent treatment, or want of care, such as un-
dergoing fatigue soon after the operation, making use of spir-
ituous liquors too liberally, or by high-seasoned food; all
which, for some time, the patient should be enjoined strictly
to avoid. Two fatal instances have been seen, where a mor-
tification came on, after a great deal of fatigue, &c. An hy.
drocele sometimes bursts of itself, but will fill again : a blow
received will occasion it, and perhaps, instead of being filled
again with the same fluid, blood will take its place ; so that
knowing that a blow has been received, a practitioner would
often be deceived if he expected a discharge of water on the
introduction of the trocar; if any doubt exits, an incision
should be previously made, as already stated.
It would appear, no age is exempt from this disease, and
in the majority of instances in young subjects previous to
the age of eight or ten years, subjects to hydrocele, the mere
application of stimulant lotions to the tumour will disperse it,
by lessening the action of the secreting vessels, and restoring
the balance between them and the absorbents. The best ap-
plication for this purpose, is a single drachm of ammon. mu-
riat., dissolved in about four ounces of the liquor. ammon.
acet. : linen, dipped in this solution, should be kept constantly
wetted and applied to the part. There is no disease in which
practitioners, both ancient and modern, have differed so much
as to the treatment of the radical cure ; each perhaps had his
LECTURE XIV.
163

particular favourite remedy, and which he did not like to give
up for any new one brought forward. With some, after an
opening had been made, it was customary to put in a tent, for
the purpose of keeping the cavity distended until the adhe-
sive inflammation took place; but this was not at all attended
with success, as the tunica vaginalis fell into folds, so that on-
ly a partial adhesion took place, consequently the water was
capable of continuing to increase between these folds. An-
other mode of treatment, and one strongly rerommended by
Mr. Pott, which of course influenced many others, was by
seton ; but this had evidently great disadvantages, on account
of the violent irritation produced by it. There is only one
state in which any kind of ligature is proper, and that is in
very young subjects. Here many prefer the passing a small
ligature to that of using the trocar, as from the small quantity
of contained fluid, the latter instrument would be in great dan-
ger of wounding the testicle.
The method by ligature is this: pass a curved needle with
the ligature through the integuments rather transversely, but
sufficiently deep to pass through the upper part of the tunica
vaginalis, and then left there; the time that it is to remain
should be commonly eight or ten days. Another favourite
mode was by caustic, and strongly supported by the late Mr.
Else ; but this is now generally exploded, as it was impossi-
ble to know when the tunic was burnt by it, so that very of-
ten only partial adhesions took place. The present treat-
ment is a good deal more simplified, and the cure attended
with much more certainty of success.
There are two modes only whereby the radical cure is to
be accomplished. The first is by incision : the method is as
follows: embrace the tumour with the left hand, then begin.
ning the incision from the upper part, continue it downwards
about three-fourthş, leaving the tunic partially adhering in
some parts ; it then becomes neccessary to introduce some
extraneous body to excite some degree of inflamniatory ac-
tion, for which purpose a small quantity of flour may be
kised, and to be rubbed gently against the tunic.


164
LECTURE XIV.
The cure in this manner is not accomplished by means of
adhesion, but by granulations, which fill up the whole of the
cavity. There is one advantage attending this method of op-
erating, and that is, that we are better acquainted with the
state of the testicle ; but there is evidently, on the other hand,
one great objection against it, on account of the violent irri-
tation and inflammation produced by it, and its being not-
withstanding sometimes unsuccessful: therefore it becomes
necessary to have a milder substitute, and this has been am-
ply attained by the means proposed by Sir James Earle,and
which certainly do him great credit ; and although many
lay claim to the priority of this treatment, it signifies not a
straw what was done formerly,it was principally through Sir
James Earle that this treatment was so generally adopted by
the profession. When Dr. Harvey discovered the circula-
tion of blood, what was endeavoured to be done ? Why, that
it was no discovery at all, that it was known the Lord knows
how many centuries before! When Dr. Jenner proposed
the vaccine, many searched all the old manuscripts and pub-
lications to see if they could trace any hint that might be
swelled out into something similar; so with respect to other
discoveries. But this species of illiberality is truly con-
temptible, and ought to be banished from every generous
mind. What ought to be looked to is this, who is it, that is
the means of directing the public attention to such a remedy
or treatment, which probably had been obsolete or never
known at all? And any manifest improvement made, devi-
ating from the regular routine of practice, is equally, in my
opinion, as original, as if no hints ever previously existed.-
What I have alluded to is the operation by INJECTION, which
is not only the most simple, but the most certain method of
obtaining the wished for success.
Before I proceed to detail the operation, it will be right to
make a few observations. If the hydrocele be not trans-
parent, as sometimes happens to be the case, it will be prop-
er in the first case to make a small puncture with a lancet in
the tunica vaginalis; by this means, the exact nature of the
LECTURE XIV.
165
disease will be better known, and if it should prove to be any
other disease than that of hydrocele, this siinple plan, inva-
riably adopted when there is the least doubt whatever, will
avoid many unpleasant consequences; in fact, as I have al-
ready stated, when this précaution has not been attended to,
the most fatal effects have resulted from its neglect.
The instruments necessary for the operation, are a small
and a large trocar; the former is preferable in the greater
number of cases, and the latter should not be used unless the
scrotum is a good deal thickened. The canula should be
made so as to fit perfectly to the trocar, as otherwise the in-
jection will not be thrown into the tunica vaginalis, but into
the cellular membrane: an elastic bottle, capable of contain-
ing about four ounces of fluid, and having a stop-cock to it, is
useful for this purpose. The solution most commonly made
use of, is one drachm of the zinc. sulph., formerly vitr. alb.,
to aq. rosæ lbj., and this is considered preferable either to
wine and water, used by Sir James Earle in the proportion of
two-thirds of wine to one of water, or brandy and water used
by others, as the precise strength of the two latter cannot
be always exactly ascertained. When, however, Sir James's
injection is used, I should think equal parts would not be too
strong ; and if brandy, and good, one part of it to five of wa-
ter. The strength of the injection, however, must always de-
pend upon the irritability of the patient's constitution. Hav-
ing divided the integuments with a lancet, proceed exactly
with the introduction of the trocar, as advised for the palli-
ative treatment ; and when the fluid is evacuated, throw in
the injection into the tunica vaginalis. The time common-
ly allowed for it to remain, is from three to five minutes, ac-
cording to the degree of pain excited, moving the scrotum
from side to side, for the purpose of producing an equal irri-
tation ; when withdrawn, lint and adhesive plaster is all that
is necessary. In introducing the trocar, care should be taken
not to do it in a hurry, nor plunge it in suddenly, but keeping
it obliquely upwards, and gently rolling the hand : the best
part for making the puncture, is about two-thirds of the tu-




166
LECTURE XIV.
mour downwards, remembering to let the trocar pass suffi-
eiently deep into the tunic. When the water is evacuated,
take hold of the scrotum, and the part of the vaginal tunic
which is around the point of the canula, and then throw in
your injection.
The first symptom that the patient feels, is a pain in the re-
gion of the kidneys, in the thigh also of the diseased side, in
the groin, and at the neck of the bladder. The symptoms
are so common, that the patient may be previously acquain-
ted with them. The time that the injection is to remain has
already been mentioned, but it will be necessary to observe,
that if the patient should not be affected within the course of
five or six minutes, it would be advisable to leave a small
portion of the injection within the tunic, or in preference, let
it exceed the time mentioned. A gradual degree of pain ex-
cited, will prove more certain of a cure than when inflamma-
tion is at first violent, as partial adhesions in the latter in-
stance commonly take place. The first mark of cure is a
redness of the scrotum, observable in about twenty-four
hours. In forty-eight hours the scrotum will be as large as it
was previous to the operation ; but in elevating it, the weight
will be much greater. This arises from the effusion of co-
agulable lymph, and if pressure be made at this time on any
part of it, there will be a feeling in it, as in anasarca. The
swelling in the course of a week diminishes, and in a fort-
night will be still further reduced, if not entirely removed:
but this must depend upon the degree of absorption.
Even this operation, as simple as it may appear to be, yet is
not without its danger, of which three cases could be instan-
ced: one was an old man who had the operation performed
on him in Guy's Hospital ; about two years after, he was a-
gain admitted, and it was done by a dresser, and in a proper
manner, as he concluded; but during the operation, the pa-
tient appeared in excruciating pain; to relieve which, the
dresser removed the elastic bottle, but was much surprised not
to see any fluid return with it, neither was he able even by
pressure to get out any of the injection, it having passed into
LECTURE XIV.
167
the cellular membrane, owing to the canula not properly fitting
the trocar, and the more he pressed, the more the injection
passed towards the abdomen; the consequence was excessive
inflammation, succeeded by mortification, which carried him
off. If any surgeon should be thus circumstanced, I
would advise the immediate enlargement of the orifice, and
the injection of a large quantity of water, so as to dilute the
first solution used, in order to take off in some measure its
stimulating effect. But, in fact, this case proving fatal, was
chiefly to be attributed to the dresser. There is danger en-
suing from the injection when the tunica vaginalis communi-
cates with the abdomen, and I would advise it by no means
to be used where this exists, as it commonly does in young
persons, as they may be treated in a much better way, which
I shall notice : but if it be done at all, which I would not
think at any time prudent, pressure must be made on the
mouth of the tunic with an assistant's fingers, or otherwise
peritoneal inflammation would take place: on which account,
I should certainly prefer letting the disease alone, and treat
the cure as hernia, that is, by putting on a truss on the mouth
of the tunic, which will in the course of a few months close
the communication by means of adhesion; and after the
opening has been closed, the disease then becomes more sim-
ple, and may be treated by injection, if the patient be an
adult, except its being also complicated with a tendency to
dropsy, the symptoms of which it will be by all means de-
sirable previously to remove. In young people I should not,
from what I have seen, advise the injection, but merely make
use of the stimulating applications already mentioned, or any
others of a similar nature, and which will most commonly
succeed. It has been objected to the operation by injection,
that the state of the testicle cannot be accurately known ;
but this is easily answered, for if I were certain that the tes-
ticle was enlarged, this circumstance would be an additional
inducement for its adoption, as many instances are known
where the enlargement has very greatly diminished. *




168
LECTURE XIV.
Instances have sometimes been seen of an hydrocele of
the spermatic chord, and it is often liable to be confounded
with the inguinal hernia, on account of its similarity in
some of its leading symptoms; for when the patient is de-
sired to cough, a dilatation, as in hernia, will be perceived ;
also on the patient's lying down, the tumour will disappear,
and vice versa. Here it would be prudent to wait, and not
hurry to operate, as the disease, although at first intricate,
yet in the course of two or three years, or probably less,
will be easily distinguished ; it then gets very large and
transparent, a circumstance which will set its nature in a
elear point of view, and enable it to be distinguished from
hernia.
Cysts occasionally are found on the external parts of the
body: if transparent, which may be known by placing the
patient in a dark room, and holding a lighted candle to the
tumour, may be safely injected with success, of which ma-
ny instances could be stated, but which would only en large
this work, without being productive of utility.
( 169 )
LECTURE XV.

DGSONA
ON ANEURISM.
By aneurism, derived from the Greek QvEvgvvo, to di-
late, is meant a pulsating tumour in the situation of an arte-
ry, and proceeding in consequence of the coats of the arte.
ry giving way and yielding to the process of absorption. It
is commonly divided into three states with respect to its
symptoms. On examination, in the first instance, a small
tumour will be discovered, having a strong pulsation, the
skin undiscoloured, and generally unattended with pain : on
compressing the part above the tumour, the sac most com-
monly can be emptied of its contents; and this arises from
the circulation of blood in the artery being stopped in its
course towards the sac. In the second state, the tumour is
solid, and of a firmer texture, and attended with a degree
of shooting pain ; the parts below very often become vede-
matous, and are heavy, cold and pulseless. If the tumour
be compressed above, although the sac yields a little, yet it
will still remain prominent. There is a throbbing pain felt
in consequence of the blood rushing from the orifice of the
artery to the aneurismal sac, and an unaccountable sensa-
tion of weight, pain and numbness through the limb; the
circulation below the tumour is weak and feeble, and the
limb is deprived of a portion of its heat, until the anastomos-


22

170
LECTURE XV.
ing branches enlarge, and allow an increased portion of
blood to flow through them. On dissecting, the artery be-
low is found to be considerably smaller than above the tu-
mour. In the third stage, the skin becomes discoloured,
having a reddish brown cast, the cuticle separates from the
surface, and a desquamation takes place; under this there
are commonly ulcerations,
The portion of skin so discoloured loses its vitality, and
forms an eschar; the process by which an aneurism bursts,
is by sloughing: a small quantity of blood is at first thrown
out, and the eschar proceeds to separate further and further,
till at last, from repeated hæmorrhages, the patient is ex-
hausted: it rarely occurs, that it bursts so suddenly as to oc-
casion immediate death. When sudden hæmorrhage has
taken place, it is possible to protract the patient's life for a
few days, by the application of a piece of lint to the part,
over this, adhesive plaster, and properly secured hy band-
age : it does not always break externally, it having been
known to break under the skin, producing ecchymosis, and
ultimately death from mortification.
The seats of aneurism are various, and the symptoms are
more or less violent and dangerous, according to the situa-
tion. When in the cavity of the chest, the following ap-
pearances present themselves: if above the heart, in the
curvature of the aorta, it contracts adhesions to the peri-
cardium, and bursting into this membrane, proves fatal, and
in this seat of the disease there are few symptoms of aneu-
rism apparent; the patient in moving quick, or making any
exertions, is affected with difficult respiration, and has an
uneasy sensation in the scrobiculis cordis ; these symptoms
are often found in patients labouring under dyspepsia, so
that there is scarcely any distinguishing mark of the dis-
ease.
The next seat is between the heart and the curvature of
the aorta, but this is not very common ; if it forms beyond
the curvature, or what is then called the ascending aorta, it
will prove fatal by its pressure upon the trachea and ceso.
LT
LECTURE XV.
171
phagus, preventing ultimately the admission of air, as well
as the power of deglutition, and this often before it has ad-
vanced very materially in size. When seated in the cavity
of the abdomen, if above the superior or lesser curvature of
the stomach, it occasions the rejection of every thing swal-
lowed; if it forms in the beginning of the mesenteric arte-
ry, here its pressure is below the stomach, and the functions
of the intestinal canal are not impeded; the situation and
pulsation may be felt by placing the patient in a horizontal
position, with his shoulders elevated, and making pressure
with one hand on the abdomen. Aneurisms are sometimes
seated in the abdomen, in the posterior part of the aorta,
and pressing internally and latterly towards the spine and
loins ; here an aneurism may be easily mistaken for an ab-
scess; an instance of this occurred in St. Thomas's Hospi-
tal, when the surgeon, taking it for an abscess, made an open-
ing into it with a lancet, and immediately there was a sani-
ous and bloody discharge : he being aware of his error,
stopped the hæmorrhage directly with lint, bandage, &c. :
other similar mistakes may be recorded. Aneurisms also
occasionally form in the ischiatic notch, or under the gluteus
maximus muscle.
When aneurisin occurs in the limbs, its situation is most
frequently opposite the joints, and the reason is, that in con-
sequence of the frequent flexion and use of them, the blood
is more likely to be interrupted in its course. Hence, on
this principle, it is, that popliteal aneurism ensues so fre-
quently. Next to this, the inguinal is the most common.-
Aneurism of the carotids is not so commonly seen, and when
it occurs, it is generally from pressure ; thus it is that por-
ters are so liable to it. That of the axillary artery, oppo-
site the os humeri, generally proceeds from the same cause.
Subclavian aneurism is rare, but very few examples have
been seen, and their origin has not been so satisfactorily
traced ; hence it may be justly said, it is seldom seen in
these arteries. Instances have occurred of the internal pu-
dendal artery, the posterior aural, and occipital arteries be-
ing subject to aneurism.




172
LECTURE XV.
In some persons, there appears to be a disposition to aneu-
rism in different parts of the body, so that an operation in
them is seldom attended with success, as the disease is lia-
ble to form in another part of the body.
- With respect to the prognosis to be drawn in regard to the
different situations of aneurism, they are most favourable
when seated opposite to joints, still less so in the thigh, but
the most unfavourable of all when in the aorta ; the reason
is, that the former most frequently proceed from mechanic-
al causes, and not, as in the latter, (though this is not al-
ways the case) from any previous disposition in the body,
from imperfect structure, to the formation of them; but
however favourable the prognosis might be, aneurisms are
by no means to be neglected, as they are always to be con-
sidered dangerous from whatever cause they may arise.
Their ModE OF FORMATION.—The appearances that
aneurism presents before the parts yield, are these : the
coats of the artery are much thickened, of a yellowish hue,
and opake, as if they had been subject to an inflammatory
action from an injury, or disease, by which they become
weakened ; the thickness, with its opacity, is owing to the
lymph thrown out; the part is commonly tender to the
touch, and easily broken down by pressure. After this, a
process of absorption commences opposite to where the
opake spot is, coagulable lymph is effused, and the circulat-
ing blood pushes this before it. Hence, the sac in aneurism
is formed by the facial sheath on its outside, and by the co-
agulable lymph on its inside. As it increases in size, the
sheath becomes absorbed, the coagulable lymph soon yields,
and the aneurism forms a sac with whatever is next in con-
tact, till it reaches the skin, and through which it ultimately
bursts ; hence it would appear, that aneurism is not the result
of the yielding of the coats of an artery, but from the absorp-
tion. If the artery be seated near a bone, it would appear
that the whole circumference of the tube is not equally ab-
sorbed, and the expansion of the tumour is confined more to
one side; in other cases, the expansion is more uniform.
LECTURE XV.
173
Professor Scarpa, who has made some very valuable obser-
vations on this disease, and from the great opportunities which
he had of prosecuting the subject, and his minute and accu-
rate dissections, states, that in every case of true aneurism,
(and to these only I confine my present writing) the rupture
of the proper coats of the artery was clearly evident. A
very prevalent opinion existed, that every tumour of this
description was actually occasioned by the dilatation of the
coats of the artery; but from accurate observations, this has
been found erroneous. Others thought that the two inner
coats only were ruptured, and the external, conjointly with
the sheath, formed the sac or pouch. Aneurisms appear to
arise from any sudden exertion, violent shock or contusion,
so that the arterial parietes are weakened and disorganized;
or by increasing the lateral impulse of the fluid against the
sides of the vessel ; but I deem these to be both essential to
their formation. Aneurisms most commonly occur between
the ages of thirty and forty; rarely in the young, or very old
subjects : most frequently in irritable habits, and those who
are addicted to debauchery and dissipation ; they mostly in-
crease gradually, and enlarge where the least resistance is
opposed.
To distinguish this disease from others, it is necessary to
attend to the following discriminating remarks : when a tu-
mour is seated over an artery, and the pulsation is as strong
as that of aneurism, it becomes then highly necessary to be
positive with respect to the nature of the disease, and for this
purpose the tumour is to be elevated as much as possible; if
it be an aneurism, the parts so raised continue to pulsate, and
vice versa. However, there is another better and more dis-
criminating mode than this ; suppose, for example, the pul-
sating tumour is situated on the thigh, in the course of the
femoral artery, make strong pressure in the groin, on
the artery of that side, to interrupt the flow of blood in-
to that part ; the aneurismal tumour, if it be one, will be im-
mediately emptied, and sink down, and on removing the
pressure, it will again suddenly regain its former size :
whereas, if it be not an aneurism, the tumour will by no



174
LECTURE XV,

means be diminished. The artery sometimes lies anterior
to the tumour; when this happens, feel only for the sides of
the tumour; and if there be any pulsation, it may safely be
concluded to be an aneurism, and vice versa, for in the latter
case the pulsation will only be found in the direction of the
artery.
Aneurisms, as far as I can trace, occur less frequently in
women than in men. They sometimes, though but very rare.
ly, undergo a spontaneous cure, of which two instances could
be stated ; and where an operation may be deemed improper
from certain existing circumstances, it may be agreeable and
advisable to let the patient know this; but otherwise it would
be highly improper to inform him of it, as prejudicing his
mind against an operation from which alone he can derive
any benefit. It is possible, that if the aneurism be of that na-
ture as to prevent an operation from its situation, still the pa-
tient's life may be considerably prolonged by a «strict atten-
tion to a spare diet, as milk,broth, and acidulated drinks,&c.,
the occasional use of digitalis ; in applying repellent lotions
to the tumour, as ice, or vinegar and water: bleedings should
be largely and repeatedly had recourse to: recommended
by Valsalva, and successfully adopted at the Hotel Dieu, Pa-
ris, by Pellatan; avoiding every stimulus or exertion, and
observing perfect quiet and rest.
If the tumour be so small, and can be compressed, it will
be prudent to have recourse to pressure by means of a pad,
composed of somewhat yielding materials, accurately secured
on the seat of the tumour, (having previous to its application
emptied the sac of its contents,) and support it firmly in this
situation by means of a bandage, properly applied; if this
should prove unsuccessful, it will be necessary to operate.
Of the old Method of performing the Operation.
Supposing the aneurism to be popliteal, the old method was
thus : a tourniquet was to be applied in the same direction as
in amputation, an incision was to be made into the ham from
the upper to the lower part of the tumour, which was com-



LECTURĒ XV.
175
pletely to be exposed ; the clot of blood which the aneurism
contained, was removed from the sac, and the orifice of the
artery, being marked by momentarily loosening the tourni-
quet, it was again to be fixed, a probe was passed into the up-
per orifice of the artery, and an incision being made on each
side of it, a needle and ligature was passed about an inch on
each side of the vessel, and firmly tied, and the tourniquet
again slackened. the place where the blood flowed from the
lower orifice was marked, and an incision and ligature made
on it as above: the blood in the tumour was generally of a
venous colour.
This operation was seldom attended with success, so little so,
as to deter surgeons very often from performing it; several un-
pleasant circumstances resulting from its adoption, as violent
inflammation being brought on from such an immense cavity
being exposed (as it appears from subsequent experience un-
necessarily), and independently of this, the chances were,
that an exfoliation of bone would take place, so as to pro-
duce a stiffness in the limb: these disagreeable circumstan-
ces attending the old method of operating, induced the late
John Hunter to make trial of a new mode, which I consider
undoubtedly quite original : notwithstanding the priority of
this, as well as every other improvement, has been contested
by succeeding writers, as being known by the most ancient
surgeons from some obscure passage that had sunk into ob-
livion many centuries before their day. The French jealousy
is more pardonable, when the foibles of that nation are con-
sidered, and I take this opportunity of stating my belief, that
the greatest blemish in D. J. Larrey's work, is his unwar-
rantable boasting, that the French surgical practice was so
pre-eminently superior to the English : as this does not ap-
parently to me exist, I think it might have been omitted. I
believe it will be allowed by all those who had the honour of
knowing John Hunter, that he entertained no great predilec-
tion for the ancient writings, neither was he at all aware that
any similar plan had been previously adopted: from manu-
scripts I have by me, it would appear to be the result of nu-


176
LECTURE XV.
merous experiments made by him, from reflections on this
subject, to ascertain the probability of a substitute for the
old mode, but which, with all due deference for his great abil.
ities, he states hirnself, with his usual characteristic candour,
he was led, originally, merely by accident to pursue. He
performed the operation at various times, and with great suc.
cess, and it was deservedly considered as one of the greatest
improvements made by him in surgery.
The first operation was done on a coachman, in St.George's
Hospital, in the month of December, 1785 ; a broad double
ligature was used, and with an eyed probe put under the ves-
sel, it was then cut and made two separate ones—they were
tied, but with that force only as merely to bring the sides of
the vessel together; two other ligatures were similarly ap-
plied on the vessel lower down, and these were tied ; the lig-
atures were left hanging out of the wound, and union attemp-
ted by adhesion : on the fourth day, the wound was healed,
except where the ligatures remained : on the ninth, a tourni-
quet was applied, as a considerable discharge of blood took
place from the ligatures ulcerating through the artery: on
the fifteenth, some of them came away, and also matter; the
wound healed, and some time afterwards the remainder of
the ligatures formed abscesses and were discharged, the tu-
mour gradually became less, until it was entirely removed :
he died in rather more than two years afterwards, when an
opportunity was afforded of dissecting the diseased part; the
femoral artery was imperforate from the arteria profunda
down to the ligatures, and an ossification had taken place for
nearly two inches_below the ligatures, the vessel was open
till it came to the sac, when it was again closed ;—the lower
opening from the sac was completely obliterated. In the
second case, an attempt was made to heal the wound by gran-
ulations, but this was not successful; hence he determined to
make use of but one ligature, and unite the wound by adhe-
sion.
This practice was much more preferable than the old.
inethod, for two obvious reasons, independent of its simplici-


LECTURE XV.
177
ty ; first, the artery where the incision is now made,was not,
or if any, very little diseased ; and secondly, its easy access.
A broad ligature was at first made use of, and continued for
some time, on the supposition that the parts would not be so
liable to ulcerate ; but on dissection, the reverse of this was
observed. The principle by which an artery heals, after
the application of a ligature, has been ably and ingeniously
explained by Dr. Jones, in his admirable work on hæmor-
rhage, the result of a numerous series of experiments on ani-
mals. He says, thạt for an artery to unite, it is absolutely
necessary that its internal and middle should be ruptured,and
this is only to be accomplished by a round and very firm lige
ature, drawn moderately tight on the vessel ; the inner coats
become united by adhesion before the process of ulceration
separates the ligature round the outer coat: a broad ligature
he found not to have this desirable effect. Dr. Jones proceeds
further to observe, that the ligature may be taken away af-
ter the rapture, and division of the inner coats has been ef-
fected, and yet the artery will unite by the adhesive imflam-
mation, glueing its sides together: this, in my humble opin-
ion, is a most important fact ascertained, and tends greatly to
simplify the operation for aneurism, as no impediment what-
ever would impede the healing the wound immediately. Mr.
Abernethy made an improvement in this operation, which
has been very successful: it is, applying two ligatures on the
artery, about an inch asunder, and dividing the vessel be-
tween both. I think it but fair, however, to state, that many
cases have done well without this division ; but future expe-
rience will prove the advantages of both more fully. In case
no hæmorrhage follows, which I conceive would depend ma-
terially on the proper use and application of the ligature,
one only will do. Dr. Jones's plan may be sufficient, as it ef-
fects every intention that could be desired, a permanent in-
terruption of the flow of blood to the tumour.
The operation for popliteal aneurism, as practised now, is
commonly attended with success, and I recollect only two ca-
ses where it failed: in the one, from mortification, in conse-

23

178
LECTURE XV.
quence of an ossification of the arteries ; in the other, from
violent constitutional irritation.
It will be proper, previous to its adoption, to prepare the
patient in some measure for it. In case he is of a full pletho-
ric habit, the taking away blood will be beneficial; if not so,
at all events it will be right to open his bowels with some
brisk purgative. Place the patient in an horizontal position,
on a table three feet high; his legs are to be kept in a relax-
ed state, that is, his knees bent, and his heels brought towards
the other leg, so as to form an angle with the body; the rea-
son for this position is obvious: if the limb were extended,
the Sartorius muscle would completely exclude the possibili-
ty of easily getting at the artery ; the surgeon is to be seat-
ed on the left side of his patient in an elevated chair ;-there
are four incisions necessary: the first is to be made on the
anterior and inner part of the thigh, beginning one-third
downwards from the spinous process of the ilium to the knee,
and continuing it in the direction of the femoral artery four
inches in length, which would completely expose the inner
edge at the Sartorius muscle. The surgeon is then to press
his finger into the opening, and cutting along the edge of the
muscle, to draw it outwards, which will then expose the fasci-
al sheath, enveloping the femoral artery, vein and branch of
the crural nerve. The next incision is to be carefully made
about an inch in length, through this sheath, which covers
the femoral vessels. com
The exact anatomical derivation of this fascia, as origi-
nally made manifest by Mr. Astley Cooper, will be explain-.
ed when treating on femoral hernia. The artery will be
found exterior to the vein, and a septum between them,
which must be separated ; the vein is on the inside, the ar-
tery in the middle, and the nerve to the outside of the arte-
ry. It will, in this stage, be proper to lay aside the scal-
pel for the present, and take a director, which must be


LECTURE XV.
179
moved gently from side to side till it is easily insinuated under
the artery; then withdrawing it, pass a flattened probe under
the vessel with two ligatures, secure the uppermost immedi-
ately, then separate the artery below from the cellular mem-
brane, connecting it to the sheath, in order to secure the
seeond ligature, about one inch asunder from the upper-
most; the artery, thus secured, is to be lifted up, and divid-
ed midway between the two ligatures with a probe-pointed bis-
toury; as soon as this is done, the parts are to be brought to-
gether by means of adhesive plaster; care should of course be
taken by no means to include the nerve in the ligatures, which
will be directly known by the degree of pain excited, and
which extends up to the crural nerve; it will be known also
from the numbness that ultimately takes place in the limb.
The limb must be kept moderately warm, and which may be
done by a woollen stocking drawn over it. It may be
prudent to take away blood after the operation, but this will
depend upon circumstances, which must be left entirely to
the discretion of the operator; the bowels are to be kept
gently open. The ligatures commonly separate and come
away, from the twelfth, to the thirteenth or fourteenth day ;
they are sometimes protracted to even the twentieth ; at all
events, do not mention any stated time to the patient, as
should he be deceived, it might make him restless and uneasy,
The securing the femoral artery, as detailed above, will be
also applicable to aneurisms in the anterior and posterior ti-
bial arteries, of which some few instances have been seen;
the reason is, that the anastomosis is so free between these
three, that there would still be a communication with the
aneurismal sac if either the tibial arteries were secured,
and would not answer except the interruption was com-
plete; therefore the femoral artery being the principal medi-
um through which the sac constantly receives its supply of
blood, the cutting off this communication must naturally be
more preferable, and likely to be attended with the desired
success.


180
LECTURE XV.
OF FEMORAL ANEURISM HIGH UP,
The sac commences below Poupart's ligamert, between
the arteria profunda, and the edge of the above ligament.
The pulsation is commonly very strong ;-the ligament just
mentioned, forms a boundary above the aneurism, and the
artery superior to this is sound; hence there becomes a ne-
cessity for securing the external iliac artery.
The first person who performed the operation for taking
up this artery, and to whom the profession is much indebted,
although the operation, as might be expected, was capable
of improvement, yet was deserving of great merit, as the
operation was new and certainly original ;--it is to Mr.
John Abernethy, of St. Bartholomew's Hospital, that I al-
lude, and it must be extremely grateful to his feelings, to
have found it so very successful; the judgment and bold-
ness which prompted him to the trial, and the ease and sim-
plicity with which he secured the vessel, were so many
proofs of his discernment and anatomical knowledge ; our
neighbours were incredulous, and they doubted and hesitat-
ed, disbelieving what has since been so repeatedly demon-
strated practicable. In the first case, one ligature was used,
and no division made : in the two succeeding, two ligatures,
were employed, and the artery divided. Mr. Freer, of
Birminglam, and Mr. Tomlinson, used but one ligature, and
no division, and both were successful. Mr. Astley Cooper
has since repeatedly and successfully operated on this ves-
sel, in some cases even where the aneurismal sac was in
a sloughy state, and having an eschar formed on it, which
I perfectly recollect witnessing, where, if it had not been
speedily adopted, the patients would inevitably have soon
died. Some few unsuccessful instances have occurred, and
one I remember, which happened to Mr. Cooper, where a
ligature was applied below Poupart’s ligament, between it and
the arteria profunda: in fourteen days after, the man died of
hæmorrhage, from which it would appear, that if a ligature
be made near a considerable branch, as was the case in this

LECTURE XV.
181
instance, it prevents adhesion taking place, in consequence
of the flow of blood washing away the adhesive matter.
THE MODE OF OPERATING.
Mr. Abernethy operates thus :-an incision, three inches
in length, is to be made through the integuments of the abdo-
men, commencing a little above Poupart's ligament, and ex-
tending it upwards ; it is to be rather exceeding half an
inch to the outer side of the abdominal ring, to avoid, by
so doing, the epigastric artery ; thus the fascia, or aponeu-
rosis of the external oblique is exposed—this is to be divid-
ed in a similar direction-hence comes into view the inter-
nal oblique—the finger is now to be introduced below the
inferior margin of it and the transversalis, which are to be
divided with a crooked bistoury, to the extent of an inch and
a half: two fingers are to be introduced beneath the perito-
neum, which are carried upwards by the side of the psoas
muscle, so as to touch the artery about two inches above
Poupart's ligament ; the pulsations of the artery make it
easily distinguishable: a slight incision is obliged to be made
on each side, to detach it from its fascia, so as to allow one
finger to be inserted under it: with an eyed probe two liga-
tures were conveyed under it, one was secured upwards, as
high as the artery was detached, the other some distance
lower down, and the vessel divided midway between each:
the wound to be attempted to be united by adhesion.
Mr. Astley Cooper operates somewhat differently : he rea
commends the incision to be made above the abdominal ring,
in a semilunar form (thus deviating from the custom of mak-
ing it parallel with the direction of the artery,) carrying it
in the direction of Poupart's ligament, which will serve as a
guide, within an inch and a half of the spine of the ilium ;
this will expose the tendon of the obliquus externus : then
carry the knife above the ligament, so as to expose the ob-
liquus internus ; laying aside the knife for the present, the

182
LECTURE XV.
fingers are to be passed beneath the spermatic chord, and
under it is the situation of the artery: it is very necessary
to separate distinctly the artery from the surrounding sub-
stance, which runs on the inner side of the former : the best
method is by means of a director, which by moving it a lit-
tle from side to side may easily be insinuated under the ar-
tory, which is then to be secured in the same manner as de-
scribed in the operation for popliteal aneurism.
Case.—A robust Swede, thirty-five years of age, was ad-
mitted into St. Bartholomew's Hospital, in February, 1809,
with an aneurism of the femoral artery, immediately below
Poupart's ligament. The external iliac artery was tied by
Mr. Abernethy; two broad ligatures were applied very
tightly to the vessel, but it was not divided; both came away
on the tenth day, and the wound healed soon afterwards.-
The tumour, which at the time of the operation was as
large as a lemon, became absorbed.
Case.—The subject of an aneurism, operated on in June,
1808, by securing the external iliac artery, by Mr. Astley
Cooper, has been perfectly successful; he walked with con-
siderable ease, with the aid of a stick, and accomplished a
walk of three quarters of a mile at one time, at the end of
less than six months. He made no complaint of coldness
in the limb. The event of this case is the more gratifying,
as the man did not see Mr. Cooper until the tumour, which
was very large, was actually livid ; and the operation could
not have been postponed without considerable risk: in
proof, it may be added, on the sixth day following, the sac
burst, and discharged its contents.
SECURING THE CAROTID ARTERY.—It is necessary here to
observe, that an aneurism of the arch of the aorta, may and
has been mistaken for a carotid aneurism. Allan Burns has
stated, that this was first remarked by Mr. Astley Cooper,
the appearance it assumes being somewhat similar. I do
not remember, as far as my recollection serves me, of the
carotid artery being successfully tied till June, 1808, by
Mr. Astley Cooper. The patient was a man aged fifty : he
LECTURE XV.
183
came into Guy's Hospital with a carotid aneurism, occasion-
ing throbbing in the brain, and great pain on one side of the
head, giddiness, hoarseness, cough, slight difficulty of breath-
ing, sickness, &c. The swelling appeared to be near the
acute angle made by the bifurcation of the common carotid,
on the left side, under the angle of the jaw. The operation
was attended with perfect success.
This case is highly valuable, inasmuch as it is hitherto
the only one which, as far as I know, the credit and charac-
ter of the operation is supported—1 mean its character in a
medical sense.
The practicability of the safe application and removal
of the ligature, was put beyond doubt by the event of his
first operation for the disease, some time previously, on Fri-
day, November 1st, 1805, on Mary Edwards, aged 44. The
aneurism was seated on the right carotid artery. On the
twelfth the ligatures came away—on the twenty-first she di-
ed, and on dissection the aneurismal sac was found increas-
ed in size, highly inflamed, and containing a quantity of pus.
Humphries, whose occupation was that of a porter, the sub-
ject of the former operation, resided afterwards in Labour-
in-Vain Court, Old Fish Street; he was quite well, and re-
turned to his usual employment. The fascial and temporal
arteries of the corresponding side had no susceptible pulsa-
tion ; on the opposite side, the temporal artery was larger
than usual. The tumour totally disappeared ; his intellect
was perfect, his nervous system unaffected, and the very se-
vere pain which he endured upon the same side of the head,
previous to the operation, he has never experienced since ;
a hoarseness which he had prior, continued, though it was
not then so much as it had been. Mr. Benjamin Travers
tied the carotid artery in a woman, who laboured under an
aneurism by anastomosis in the left orbit, by which the eye
had been protruded from its socket, accompanied by dis-
tracting head-achs: two small round ligatures were applied,
but the artery was not divided; they separated on the
twenty-first and twenty-second day, without hæmorrhage, or 1


184
LECTURE XV.
any alteration in the functions of the brain, and the tumour
was absorbed : the effect of the ligatures, upon the artery,
coincided with Mr. Cooper's successful operation.
These two operations put the practicability of the opera-
tion being performed with success beyond the shadow of a
doubt, and to render success more certain, it would be ad-
visable to adopt it early, before the tumour has increased to
any considerable size, so as to affect the æsophagus or tra-
chea.
MODE OF OPERATING.—An incision is to be made opposite
the centre of the thyroid cartilage, to within one inch of the
clavicle, on the inner side of the stemo-cleido-mastoideus;
having exposed this muscle, turn the margin of it aside, and
then the omo hyoideus comes into view, crossing the sheath
of the vessels, and also the descendens noni: in separating
the stemo-cleido-mastoideus from the omo hyoideus, the jugu-
lar vein is seen; the vacillating motion of this vessel, which
is increased in respiration (so that without care it will be lia-
ble to be wounded), presents the greatest difficulty in the op-
eration—a finger is to be introduced into the wound, to keep
the vein out of the way, under which lies the carotid artery,
It is of the greatest consequence, not to injure or inelude the
par vagum, which is situated immediately between the vein
and artery, a little to the outer side of the latter, as such a
mistake would prove fatal, and also the recurrent nerve,
which is attached to the artery; a blunt iron probe used to
convey a double ligature under the artery: the lower one
was first secured, the artery was then detached about an
inch in length, and the upper ligature applied : in the unsuc-
cessful case, the artery was left undivided ; in the successful
one, it was cut through, mid-way between the two ligatures :
the wound is to be closed with adhesive plaster.
An opinion formerly prevailed, that the tying of the caro-
tid artery was always succeeded by stupor, sleepiness, &c.;
but this requires very little to refute it, as the fallacy of such
opinions has been demonstrated. When both carotids are
tied, the circulation must be carried on by means of the sci-

LECTURE XV.
185
perior and inferior thyroideal and vertebral arteries: I have
never heard this attempted on the human subject.
In operating for aneurism on the sealp, supposing it to be
in the posterior aural artery, it is generally necessary to tie
the artery, passing into the sac, as well as that leading out
of it on account of the free anastomosis.
SECURING THE SUBCLAVIAN ARTERY.-In a true aneurism
of the axillary artery, that is, a very well marked one, where..
in the clavicle is much elevated, the operation is very diffi-
cult ; but under the common circumstances of aneurism,
where the clavicle is in its situation, it is by no means so: it
here becomes necessary to tie the subclavian artery; and to
do so, an incision is to be made, beginning about an inch and
a half from the sternal end, and continue it to the same dis-
tance from the scapular end of the clavicle, so as to make
the middle of this bone the centre of your incision : the inter-
nal jugular vein will be discovered in the middle of this cut,
and underneath, the axillary plexus of nerves, lying above
the artery, which will be found emerging from the chest, be-
tween the scaleni muscles. There is considerable difficulty
in the passage of a ligature under the artery, and in separa-
ting it from the nerves; and many very ingenious instruments
have been invented for this purpose ; à curved eye-probe
probably may do as well as any. Great care must be tak-
en to avoid including any of the cervical nerves; and if
the operation is done on the left side, be aware not to wound
or include the thoracic duct, as it would soon prove fatal.-
One ligature, properly applied, appears to be sufficient, and
there will be no necessity to divide the vessel.
. To secure the axillary artery below the clavicle, the fol-
lowing operation is necessary, which has been performed
successfully by Mr. Keate. The tumour had burst, and the
artery was compressed against the first ribman incision was
made obliquely downwards, below the clavicle, the fibres of
the pectoral muscle were divided, and when he came to the
24

186
LECTURE XV.
artery he passed a curve blunt-pointed silver needle, doubly
armed, as he thought, under the artery, and tied two of the
ends ; as the artery still pulsated below the ligature, anoth-
er was passed more deeply, higher up, nearer to the clavicle,
and tied. Mr. Charles Bell, in his System of Operative Sur-
gery, details a more easy method, but very similar : the in-
cision is to commence about an inch from the sternal end of
the clavicle, in a direction towards the acromion, the direc-
tion to be a little downwards, from a line parallel to the clav-
icle—here the fibres of the pectoral muscle are exposed,
which are to be divided : underneath is some cellular sub-
stance, which is to be carefully elevated with a pair of for-
ceps and cut; this will bring into view the subclavian vein,
and cephalic vein uniting with it ; under the subclavian vein
and a little backwards, more under the clavicle, the artery
may be felt and tied. Another method is this : an incision,
to the extent of three inches, is to be made below the clavi-
cle, over the space between the deltoid and pectoral muscles,
which will expose the axillary vein, situated anterior to the
artery, and which latter vessel is lying among the cervical
nerves : great care must be taken not to wound the vein, or
include a nerve in the ligature ; having passed a ligature un-
der the artery, detach it completely from the nerves—one
ligature will be here only necessary, and no division re-
quired.
SECURING THE BRACHIAL ARTERY.—A varicose or venous
aneurism, a circumscribed or diffused aneurism, may be thus
distinguished : the first is generally the result of bleeding
with a lancet, by which a tumour is formed, from the effu-
sion of blood into the adjacent vein : it is denoted by a kind
of tremulous motion in the vein, and by a peculiar hissing
sound; the swelling will not be less by compressing the vein
below; but if pressure be made on the artery, it will al.
most entirely disappear. I saw a married woman, who had
been thus injured by a country operator ; à tumour had form-
ed, which alarmed her a good deal; it had, however, by con-
stant pressure, at the time I saw it last, almost disappeared.

LECTURE XV.
189
A circumscribed or diffused aneurism is from a wound of
an artery only, by which the blood is effused into the cellu-
lar membrane; it has also been named a false aneurism : it
happens thus:--I shall say,for instance, the brachial artery is
wounded and the wound being small, an attempt is made by
pressure to close it ; but not being applied in such a way as
totally to obstruct the escape of blood, an effusion takes
place into the adjoining cellular membrane.
This last disease may require the brachial artery to be se-
cured in a similar manner to that of an aneurism forming
from absorption of the coats of the artery: the vessel is very
readily found on the inner edge of the biceps, the artery is
accompanied by the median vein and nerve, and care must
be taken not to secure either in the ligature ; one ligature is
sufficient, and no division necessary: merely securing the
vessel above, or at some little distance from the tumour, will
be amply sufficient.
In an aneurism of the ulñar artery, high up, it will be ne-
cessary to secure the brachial; if at the wrist, probably
opening the sac, and inaking a ligature on the ulnar artery
above and below, would be most proper.

( 188 )
LECTURE XVI.
ON CATARACT.
CATARACT is derived from xatacadow, to confound, or
disturb, because the sense of vision is confounded, if not
destroyed: it means an opacity of the crystalline lens, that
obscures the sight. There are two kinds of cataract, the
one termed the crystalline, the other the capsular ; the for-
mer when the humour alone is affected, the latter when its
capsule is: these are often found both to be combined in the
same subject. At the commencement, the patient complains
of an indistinctness in vision, as if a cloud hung over
his eyes, or the objects were enveloped in a mist; he
observes a body floating before him: this latter symp-
tom sometimes occurs when there is no cataract, as in an
affection of the optic nerve, but it may be distinguished from
this disease by these circumstances ; when the nerve is affect-
ed, several bodies are observed floating before the eyes, but
not fixed, so that they continually appear to be in motion ;
whereas, in cataract, it is only a single body, and stationary:
as the disorder advances, objects become very indistinct in
a glaring light, from the contraction of the pupil; but in the
shade, from the enlargement and dilatation of the pupil, they
become more obvious: as it continues to increase, although ul-
LECTURE XVI.
189
timately vision is perfectly obscured from discerning objects,
the rays of light are not altogether prevented from passing
to the retina, so that if a hand be placed between the patient's
eye, and a candle, he will be able to know that there is a
something before him, though he cannot describe what it is.
When on trial this is found not to be the case, it may fairly
be suspected to be complicated with gutta serena. In the
progress of the disease, previous to its being so matured, the
imperfect vision, if I may so term it, is more or less accord-
ing to the strong or weak action of the rays of light, as I have
above remarked, and it is on this account that the vision, par-
tially obscured as it is, yet is rendered better in the evening,
the rays of light then proceeding from that luminous body,
the sun, being much weaker, and consequently the pupil is
more dilated.
A cataract appears as a speck or spot in the lens, through,
the pupil in the first instance becoming gradually enlarged,
till the whole of it appears through the aperture to be of a
whitish colour, as vision becomes insensibly lessened and
diminished, but is not altogether obscured. Occasionally it
is found of a greyish cast, and at other times remarkably
white, and apparently opaque, resembling a pearl, or the eye
of a fish boiled. The crystalline humour, when converted
into a cataract, is most commonly white, but not invariably
so, as it is sometimes of a yellow,and also of a reddish brown
colour, which latter appearance renders the disease obscure.
In adults it is mostly, but not always, of a solid texture
throughout: it has occasionally been found in a fluid state,
at other times a mixture of both, and when removed in the
operation the fluid part escapes first : the distinguishing marks,
whether it is solid or fluid, are, that when the latter happens,
it is of a perfect uniform colour, and when the former, it has
a radiated and streaky appearance; there is considerable ad-
vantage in knowing this, because the respective operations
for each are different. It is very rare, indeed, that the crys-
talline lens has been seen ossified, and I recollect to have
heard mentioned of but one instance having been so seen.




190
LECTURE XVI.
f
If the lens be hard and opaque, it is termed a firm hard cat-
aract, if fluid, a milky cataract, and if of the consistence of
jelley, a soft cataract. The capsule itself is sometimes opaque,
as well as the lens; to distinguish it, it is only necessary to
observe attentively the close connexion between the pupil
and the cataract, the iris resting on the latter: sometimes the
capsule adheres to the edges of the iris, and in this case the
operation is very unsuccessful: an easy way of knowing
when this has taken place, is by introducing a small portion
of the extract of belladonna (deadly nightshade), with a cam-
el hair brush on the eye, over which it very soon spreads, if
there are no adhesions, and the pupil is perfectly distinct,
which will be known by its motion being free and prompt;
it will be observed very much dilated, in consequence of the
contraction of the iris.
The cataract is sometimes loose and floating in the eye, and
having an opacity; in this case it would appear, that the tuni.
ca transversalis, the connecting membrane between the crys.
talline and vitreous humours, becomes absorbed, and in the
operation here it will be necessary to make use of a scoop. I
had some years ago a very excellent opportunity of witnessing
the progress of this disease from its infancy, in Mrs. Basker.
ville, the lady whose case I have introduced on the subject
of burns and scalds : she had a cataract in both eyes: 1 re-
collect her sight as perfect as any person's, and I remeniber
the gradual loss of vision, which she attributed to her anxi-
ety in getting some very fine and delicate needle-work com-
pleted, and which she thought tended to weaken her sight
very much. At her request, I very often examined her eyes,
and was satisfied in my mind there was every probability of
success to be expected from an operation. I strongly advis-
ed her to undertake the journey to town, and place herself
under Mr. Wathen Phipps. She did so; le couched her,
and she recovered her sight, which she retains to the present
moment.
The cause giving rise to the formation of cataract is not
well understood : it has generally been supposed to originate
LECTURE XVI.
191
from an inflammatory action of the parts, but this is not al-
ways the case ; I do not mean to affirm it is never so, for the
contrary is well known; there is no marked sign of the
presence of inflammation at the commencement of the dis-
ease, and seldom any pain accompanying it. It appears no
age is exempt from cataract, as it is seen in children and in
old age ; but the most prevalent age is in the decline of life,
that is, after forty. If it suddenly forms from a severe inju-
ry, it recovers its transparency without any operation being
necessary.

Treatment.
Mr. Ware, who has had extensive practice, and written on
this subject, advises the application of ether to the eye, to
the extent of a drop or two, once or twice daily, in the in-
cipient state, rubbing occasionally the eye, over the lid, with
the point of the finger, having a mercurial liniment on it:
the hydrargyri muriatus in small doses has been found very
serviceable, and also the submuriate ; electricity has been
recommended.

THE
OperatION FOR THE CATARACT.
The operation is commonly divided into two kinds, but
properly speaking, there are three. The first is by extrac-
tion, or removal of the crystalline lens, by a semicircular in-
cision being made through the transparent cornea : the sec-
ond is that of couching or depression of the lens into the vi-
treous humour: the third is by puncturing the capsule of the
crystalline humour, so as to allow of the discharge of the
lens into the anterior chamber of the eye.
MODE by ExtraCTION.—It is necessary to keep in mind,
that there is much danger to be apprehended from the ensu-
ing inflammation, and therefore the patient must be prepar-
ed, in some degree, by purgative medicines, and even by
bleeding, if the patient be of a robust and plethoric habit.
But the best method that I am acquainted with, and that
adopted by the most celebrated occulists, for preparing the


192
LECTURE XVI.
1
patient for the operation, and from which he will derive con-
siderable benefit, is this ; to draw a probe, a few days pre-
vious to the operation, across the eye, over the cornea, and
to repeat this plan twice daily ; this will, at first, from its ir-
ritation, excite, as might naturally be expected, considerable
pain, which will gradually diminish after a few days' use :
it will have this effect--the patient will be less liable, after
the operation, to excessive constitutional irritation, from his
having been thus habituated gradually to an irritant. The
light for operating must not be too strong, and it should fall
obliquely on the eye, not direct. In fixing the patient, care
must be taken that the light does not fall on that part of the
eye where the knife is to be directed, and let the chair,which
should be a low one, be placed with a degree of obliquity to-
wards the window. The oculist is to be seated on a high chair,
rather on one side of the patient, so as to rest his foot upon
the side of the patient's chair, with his arm resting upon his
knee, and his hand on the patient's temple. The patient's
head is to be supported by a pillow. The assistant is to
place himself behind the patient's chair, having a handker-
chief to cover the sound eye in his hand, and with the other
he is to press the eyelid against the orbit firmly, taking great
care that the lid does not slip, which would totally prevent
the operation, therefore his fingers should be very dry. The
necessary instruments are, a lancet-shaped knife, of a wedge
form, gradually diminishing from the handle to the point ;
this is nearly in the shape of Wenzel's knife; the length is
an inch and a half, and a quarter of an inch at its widest
place, gradually tapering to a point. Mr. Ware's knife is
less spear-pointed, increasing in thickness from the point to
the handle, and this former he maintains will prevent the dis-
charge of the aqueous humour, before the puncture is com-
pleted, when there will be less danger of wounding the iris.
A tenaculum will be required, to scratch the capsule of the
lens; a silver scoop, to exact the solid parts, if any; a pair
of delicate forceps, for taking away any part of the capsu-
lar membrane. A speculem was also formerly used to fix
LECTURÉ XVI.
193
the eye, but its use has been long discontinued. Wenzel and
Ware both coincide in this respect; the pressure occasioned
by all these contrivances, for fixing the eye, is a serious ob-
jection, as it is very apt to cause a sudden protrusion, and
consequently loss of a great part of the vitreous humour. It
will be right to observe, in some children Mr. Ware has been
obliged to use these mechanical instruments; what he used
was merely an oval ring. The only method, and which was
long kept a profound secret, of fixing the eye, is with the
fore finger placed in the inner canthus. The operator is to
take the knife in his right hand, if the left eye is to be op-
erated on ; and in the left hand, if the right eye ; holding it
like a pen in writing, his hand resting on the outer side of
the eye, with the little finger on the edge of the orbit, sepa-
rated from the others : the knife is to be passed into the eye,
an hair's breadth anterior to the junction of the transparent
cornea with the opaque, or, as Wenzel says, at the upper and
outer part of the cornea, a quarter of a line distant from the
sclerotica, in such a direction that it may pass obliquely from
above downwards, parallel to the plane of the iris. Wenzel
does not commence till the eye is perfectly quiet, and turned
towards the outward angle, but avoids all pressure on the
eye-ball. To this Mr. Ware very justly, in my opinion, dis-
sents; he recommends the operator to fix the eye with the
fore and middle finger of the left hand, placed upon the tuni-
ca conjunctiva, just below, on the inside of the cornea, while
an assistant places his finger in apposition, on the inside and
above the cornea. Mr. Weare advises the knife to enter the
outside of the cornea, a little above its transverse diameter,
and at the same distance from its connection with the sclero-
tica, as Wenzel and others approve of; the knife is to be
pushed on slowly and steadily, in a straight direction, with
its blade parallel to the iris, till it pierces the cornea at the in-
ner angle of the eye, opposite to that which it first entered ; all
pressure is to be removed; the aqueous humour will now be
evacuated, and the eye becomes placid, and the knife is to



194
LECTURE XVI.

cut its way out by pressing it downwards, making a semicir.
cular division of the cornea at the lower part of the eye.
In Wenzel's mode of operating, to shew his dexterity, rath-
er than with any other motive, when the knife got opposite
to the pupil, he inclined it backwards, and thus punctured the
lens; but Mr. Ware very properly objects to this, for the
danger of wounding the iris is very great. The obliquity of
the incision countenanced by Wenzel, who was an extreme-
ly expert oculist, is not followed by any of our best Eng.
lish operators ; they think the advantages which he states are
not of that importance as to warrant imitating it :-neither,
is it prudent to attempt the wounding of the capsule at the
same time: it is thought better and equally as effectually
done with a tenaculum, with the back turned towards the hu-
mour in the first place, then afterwards turning its point to-
wards it, the capsule is to be scratched with it, and by using
gentle pressure on the eye, the lens immediately escapes.
• The only parts divided in this operation are the transpa-
rent cornea, and the capsule of the lens, which allows the
lens to escape, as well as the aqueous humour. When the op-
eration is finished, if the iris projects below the flap, which
is made by the knife in the cornea, passing a scoop under it,
will succeed in getting it into its place : if there are any sol-
id portions of the lens remaining, they are to be removed
with a scoop. The eyelids are to be closed immediately,
by which the edges of the flap are brought into contact,then
apply a piece of lint, dipped in the liq. acet. plumb. dil., or
weak brandy and water, and, according to Mr. Ware, a
pledget of spermaceti ointment over it, and over this a roller,
which should, in the first instance, be applied rather loosely :
the patient is to be put to bed with his head somewhat ele-
vated, and he is to be particularly cautioned against opening
his eyelids. All kinds of stimuli are to be avoided, there-
fore the room should be darkened, and light entirely exclu-
ded, and the less conversation the better ; and he should, if
possible, avoid going for some time to stool, hence the neces-
sily of opening the bowels previously. His diet is to be of


LECTURE XVI.
195
a light nature, and in fact the antiphlogistic plan strictly ad-
hered to. If inflammation be at first violent, it will be right
to apply leeches, and if it should not abate soon, it will then
be proper to bleed freely from the arm, or, what is still bet-
ter, to open the jugular vein or temporal artery. The pa-
tient should lie continually on his back, after the operation
has been performed, as in this position the humours are not
so liable to escape. The eye is often opaque afterwards,
from the great imflammation which ensues ; hence when this
exists recourse must be had to vene-sectio, to moderate its
violence. Pus likewise occasionally forms. The operation


instance, to the state of the optic nerve ; should it be diseas-
ed, the operation will be utterly useless.
DIFFICULTIES TO BE ENCOUNTERED.—When the iris is con-
vex, considerable danger is run in completing the section of
the cornea, of entangling and wounding it with the edge of
the knife ; and Mr. Ware.considered Wenzel made a very
important practical remark, to avoid this difficulty, which
was in rubbing the cornea gently downwards with the fin-
ger. The incision for cataract should not be too small, nor
terminate opposite the pupil, otherwise a cicatrix would form
here, which would obstruct the sight afterwards. Care should
be taken, that the knife did not slip between the lamina of
the cornea only, but went sufficiently deep to pass through it :
neither should the instrument be carried so far as to run a.
risk, on the opposite side, of wounding the iris at its junction
with the sclerotica. I think decidedly with Mr. Ware, that
the cornea never ought, in any case, to be punctured in the
first instance, and Wenzel allows this so far to be valid when
the pupil is much contracted. The anterior part of the cor-
nea should be rubbed gently, to detach any opaque part
that might remain of the lens. When these bodies are pre-
vented being easily separated, from adhesions or any other
cause, they are to be broken down with the tenaculum. In
operating, be very careful not to use any unnecessary pres-
sure, so as to force the vitreous humour to escape ; what re-


196
LECTUŘE XVI.

quisite pressure is employed must be seasonably removed,
when the knife has pierced the cornea opposite to where it
entered. The lens should be punctured in the centre, not in
the circumference. The whole of the cataract should, if
possible, be removed. If the capsule be opaque, Mr. Ware
advises, that a fine pointed instrument should be introduced
carefully under the flap and through the pupil; the lens is
then to be punctured in a circular direction, as near the rim
of the pupil as the instrument can safely be applied without
injuring the iris ; when detached, it may be removed with a
small delicate pair of forceps.
ON AN ARTIFICIAL PUPIL.
It may be necessary to attempt the formation of an arti-
ficial pupil, from the closure of it permanently after the oper-
ation, I have previously described in detail: and also from
the following one, that of depression ;-during the process of
restoration, the pupil occasionally is found to become so con-
tracted, that it is nearly completely shut, so as to obstruct vis.
ion altogether. Whatever cause. may remotely, or immedi-
ately,occasion this deformity, whether from excessive inflam-
mation of the coats of the eye, or of the iris itself, an opera-
tion becomes indispensable,having previously attempted, con-
stitutionally and locally, by the application of belladonna,
ineffectually to produce an enlargement; and the first person
who ventured to adopt a plan for its removal, was Cheselden,
one of the surgeons formerly at St. Thomas's Hospital ;-
he did this with a couching needle, having a sharp cutting
edge on the one side only ;-he introduced it through the
sclerotica, at a very little distance from the cornea, into the
interior of the eye, and which he made to enter the iris at
the outer angle; he then forced gradually the point of the
instrument through the anterior chamber of the aqueous hu-
mour to the other extremity of the iris nearest the nose, he
turned the edge of the needle backwards, and in withdraw-
ing it, made a transverse section of the iris :-it appears,


LECTURE XVI.
197
that the contractile powers of this membrane, made the open-
ing, which was but small, considerably larger, and the opera-
tion was eminently successful. Professor Scarpa, in his val-
uable work, recommends a straight slender couching needle
to be introduced through the sclerotica, at the outer or ex-
ternal edge, at the distance of two lines from the cornea,and
then to be pushed to the upper and inner edge of the iris ;-
it is made to perforate the inner edge of this membrane at its
upper part, and a portion of the edge of the membrane is to
be detached by its means from the ciliary ligaments by re-
peated exertions, till a considerable aperture is made, and
this detached membrane is then to be left in the aqueous hu-
mour to be finally absorbed : at the conclusion, he seems to
think it might be done more effectually with a curved needle.
Other authors have written on this subject, from which it
would appear, that whatever method tends most to facilitate
and simplify the detaching a circular portion of the iris, would
be the most preferable : I have detailed briefly these two, in
order to shew the intention to be kept in view. Some sur-
geons are unfavourable to the formation of artificial pupils,
but I think success in some few cases would fully warrant
such attempts.


ON COUCHING.
By couching, is understood a depression of the crystalline
lens, either to one side or to the bottom of the eye, removing
it from its axis. The operation is not only very easy, but
simple. There are three kinds of needles that have been
used for performing it, one of which is a very old one, and
rarely used, if at all, at the present day, being larger than is
necessary, and more productive of inflammation ; its point is
in the form of a spear.
The celebrated Mr. Sharpe made a great improvement on
this, in having it a little curved at its ends ; in other respects
it is similar to the former. But Mr. Hey, a very clever and
198
LECTURE XVI.

ingenious surgeon at Leeds, and author of very excellent
practical observations, has introduced one of a much better
form than either of the above, and which, on account of its
shape and small size, is attended with but slight inflamma-
tion, and may be introduced repeatedly; it is about an inch
in length, small, pointed at the end, very light, and has two
shoulders to it, and in some degree spear-pointed ;—but the
spear is very short. The only instruments that may be gen-
erally seen in use, is this and Professor Scarpa’s needle, which
is curved a little at the point, but is much too long.

The Operation is to be thus performed.
Place the patient in a chair before a window, in order to
have as strong a light as possible; in this, it differs from the
operation of extraction : some, however, use the same pre-
cautions here as in extraction, but they appear to be un-
necessary. The surgeon is to be seated in an elevated
chair, or what is still better, to stand before the patient ;-
the sound eye is to be closed, and covered with a handker-
chief by an assistant, who is also to support the patient's
head on the back of the chair;—the patient is to be request-
ed to turn his eye rather towards his nose, and the operator,
with his one hand, is to fix it momentarily steady :-he is
then to introduce the needle through the sclerotic coat, one
line below the transverse diameter of the eye, and one-six-
teenth part of an inch (some recommend a distance of two
lines or more) behind the junction of the transparent cornea
with the opaque, and it is to be passed as if directed to the
centre of the eye, inclining it downwards in the first instance.
Having reached the ciliary processes, which are carefully
to be avoided, the handle is to be brought upwards and down-
wards, so that the point of the needle, which passes under
the pupil, may be easily observable through it ;—the needle
is to be moved gently upwards and backwards upon the crys-
talline lens, if the operator's object be to depress it to the
bottom of the eye, or on the side, if his intention be to cause


LECTURE XVI.
199
its removal in that direction: the former is far preferable, as
the lens will not be so likely to recover its situation again.
The object to be kept in view, is to lacerate the inner sur-
face of the lens, so that it may escape into the vitreous hu-
mour: many deem it essential to the success of the opera-
tion, that the anterior layer of the capsule should be also
lacerated, as the absorption of the lens will be much facili-
tated.
There are several advantages attending this operation ;-
one is, the ease with which it is done : another is, that if the
lens should happen to be in a fluid state, it will immediately
escape on puncturing the capsule; therefore it is preferable
to be performed in children, as the lens is seldom found sol.
id in them ; also if it should not succeed in the first instance,
yet on account of the simplicity and ease with which it is
done, it may be often repeated; whereas in the mode by
extraction, if a cure be not accomplished in the first instance,
the eye will be inevitably lost. Mr. Hey, as well as other
professional gentlemen, are of opinion, that the operation by
couching, is by far the best ; however, there are objections
to it. In the first place, the cataract is liable to rise again
into its former place, and patients do not like to submit to re-
peated operations, thinking that the surgeon does not know
what he is about. Secondly, it gives no relief in a capsular
cataract:-it may be lacerated in the operation, and the
rays of light may pass for a short time perhaps, but it will
be soon obstructed by the broken pieces of the capsule, ri-
sing again, and, without they are absorbed, which is not very
commonly the case, the disease will return again to its full
extent. And lastly, it is unsuccessful when the capsule ad-
heres to the iris.
I would advise those gentlemen who wish to get credit for
skill as occulists, to commence practice with the extraction
of the cataract; but those, on the contrary, who are likely
to have but few operations, perhaps that of couching may
answer their ends better, as it is so simple, and easy, requir-
ing only a inoderate share of attention for its performance.



200
LECTURE XVI.
On breaking down the Cataract ; or, as termed by Dr. Farre,
an Operation on the Capsule.
This operation is also very simple, and one which does
not expose the patient to a repetition, as that of couching
does. It is to the late Mr. Saunders the profession is in-
debted for this mode, which he adopted and practised with
very great success. I can only assert, if it be generally at-
tended with the happy results I have witnessed, I should
certainly give it the preference to couching. It appears,
from Mr. Saunders's success, that out of sixty persons, fifty-
two recovered their sight.
The operation consists either in introducing the needle
anterior to, and in front of the iris ; or posterior, that is, be
hind that membrane ;—the pupil is to be dilated with a so-
lution of the extract of belladonna, which will effect its en-
largement in from half an hour to an hour ;—the patient be-
ing placed in a convenient posture, and the precautions be-
fore expressed being attended to. When he performed
this operation on young children, he was obliged to be aided
by several assistants to keep the child steady, and he made
use of an elevator, invented by Pelleir, which he inserted
under the upper eye-lid, while one of the assistants depressed
the lower ;-by the moderate pressure instantly applied with
the elevator, the eye was stationary. The needle here used
was very slender, with a cutting edge from the shoulders to
its point : I think Mr. Hey's needle will do equally well, or
Professor Scarpa’s, if shortened in length. It is to be intro-
duced either through the cornea near its junction with the
sclerotica in the anterior operation, or through the sclerotica
a little behind the iris in the posterior ; the point of
the needle is to be directed to the centre of the dilated
pupil, so as to puncture the middle of the capsule of the
crystalline lens, and to lacerate a central portion of it
equal to the size of the pupil in a natural state: if the lens
were opaque, he used to rupture its texture with the needle:



LECTURE XVI.
201
but if a fuid cataract, wounding the capsule was all he aimed
at ;--if capsular, he did so with more freedom : thus the lens
will escape into the anterior chamber of the aqueous humour :
the parts of the lens will be afterwards observed floating in
this humour; if fluid, it will render it turbid ; but in a short
time,these appearances will be entirely removed by absorp-
tion. One operation will frequently accomplish a cure. Mr.
Saunders has been obliged to perform it five successive times
in some few cases, but it should never be repeated under an
interval of a fortnight at least : the inflammation is to be kept
under by local, and even general bleeding, if required. Mr.
Saunders seldom performed the posterior operation : his prac-
tice is far preferable either to Mr. Ware or to Mr. Gibson.
This operation may be performed both on infants and adults
with success, but the ages in which he met with most suc-
cess, were from eighteen moriths to four years, in those who
were the subjects of congenital cataract.


The advocates for couching, in preference to extraction,
are numerous : I have detailed what appear to be the most
favorable modes of operating. To enter into a discussion of
the advantages of one operation in preference to another,
would only be involving myself in an endless controversy.
I have the very best authorities for recommending extrac-
tion ; but I beg leave to observe, let others do as I have done,
think for themselves, and not be biassed by any illiberal
prejudices ;-writers of very great eminence support depres-
sion.

ON THE USE OF BELLADONNA.
Deadly night-shade, as made into an extract according to
the Pharmacopoeia of the London College, is a violent nar-
cotic poison: it is only on account of the peculiar or specific
virtue of this plant, that I introduce it in this place, as notice
\ will be hereafter taken of it among vegetable poisons. One
26
202
LECTURE XVI.
grain, dissolved in water, and applied either into the eye be-
tween the eye-lids, or on the eye-brows, causes a remarka-
ble dilatation of the pupil, and the late Mr. Saunders made
use of it with this intention : it discovers whether there are
any adhesions of the iris with the capsule of the lens. Af-
ter the operation for congenital cataract, Mr. Saunders ap-
plied it externally, so as to keep the pupil dilated till the in-
flammatory process had subsided ; by which plan he prevent-
ed the edge of the iris from forming adhesions with the mar-
gin of the lacerated capsule : it may be also very advan-
tion of extraction in the early part of the process, so as to
cause dilatation to its natural circumference.

This is a disease in which the natural course of the tears
is obstructed, in consequence of a stricture, or closure in
the membrane lining the ductus ad nasum : in whatever
state it is found, whether there is a sinus or not, yet it takes
this name. There are three states of the disease : the first
is a simple enlargement of the lachrymal sac, denoted by a
tumour on the internal canthus,which, if large and distended,
extends one-third above the tendon of the orbicularis muscle;
the skin over the tumour is undiscoloured, and scarcely any
pain felt ; when the patient is exposed to the cold or wind,
the tears flow down over the cheeks. If the further progress
of the disease be not arrested, then the second state is form-
ed, inflammation takes place, the tumour becomes red and
painful, and the eyelids much swollen : on pressing the tu-
mour, instead of a jelly-like matter, a mucus first presents,
then pus is discharged mixed with tears. The third state is
the true fistula lachrymalis : when the inner part of the sac
becomes inflamed, suppuration takes place from the irritation
of the tears, and an abscess forms, not directly opposite the
sac itself, but below it :-at length the ulcerative process
forms a fistulous orifice a little below the inner corner of the

LECTURE XVI.
203
eye, about half an inch from the lachrymal sac; a fungous
projection of the orifice now takes place, for which caustics
have often been used with but little success, and only attend-
ing with temporary relief, and not to be removed effectually
without an operation. When the ulcerative orifice, or open-
ing, is thus established in the inner canthus of the eye, the
tears will pass that way, and prevent its healing ; occasion-
ally the os unguis gets carious from this affection, and the
other eye becomes weak and inflamed; hence the tears
pass as usual through the puncta lachrymalia into the lach-
rymal sac, they are prevented, from the obstruction, taking
the usual course into the nose, the sac becomes distended,
inflamed, suppurates and ulcerates, so that no prospect of
cure can be expected till the obstruction into the nose, the
primary cause, is removed by an operation.
The original cause of the affection is various; by some it
is thought to proceed from a common cataract, by others
from catarrhal affections in scrophulous habits,occurring more
generally in children than in adults : next to these the vener-
eal disease may be reckoned, and in this latter case the fistu-
la lachrymalis cannot be expected to be used before the spe-
cific poison glueing the parts together, is got rid of, and it
has been known, though rarely, that the use of mercury in
these cases has effectually cured both diseases. A pustule of
the small-pox has been observed to have occasioned an ob-
struction in the duct, and not unfrequently this is the case.
Professor Scarpa thinks that it originates from a yellow vis-
cid matter, secreted by the lining of the eyelids, and from
the meibomian glands, which accumulates in the sac.
The treatment of the first state of the complaint consists in
passing the tube of a fine silver syringe into one of the puncta
lachrymalia, so as to press against the other and close it, then
let a single injection be thrown in, the more simple the better,
as warm water; but if inflammation be present,a weak solution
of acetate of lead will be proper; if the obstruction be not very
considerable, or the ductus ad nasum only partially closed, so
that the tears are able still, though not to the usual extent, to


204
LECTURE XVI.

pass into the nose, this plan will be sufficient, as a free passage
will thus be restored. The introduction of quicksilver will be
found highly beneficial proposed by Sir W. Blizard to be done
through a tube. It is to be observed, some little force may be
used prudently to restore the passage. I have merely con-
sidered the obstruction in the simplest manner: should it be
deemed to arise,according to Scarpa,from an altered secretion
of the eyelids and meibomian glands, it will be right to employ
applications to correct this morbid disposition, and a collyri-
um composed of the sulphate of zinc, dissolved in rose water,
above oss. of the former to tss. of the latter, will be requi-
site: if an ointment should be preferred, the ung. hydr. nitr.
united with lard, or Janin's ophthalmic ointment, about one
part of it to three of lead, applied with a camel-hair pencil
on the edge of the eyelids. In the second stage, where in-
flammation has extended to the formation of an abscess, which
has not burst, it will require an operation, which consists in
opening the sac, and giving vent to the contents; then pass a
probe into the ductus ad nasum to force the stricture, and
then put in a pin, or style, to keep it open. Mr. Ware was
the first person who performed the operation, which is as
follows: having felt for the ridge of the orbit, about one-
eighth of an inch behind it, on the lower edge of the eye, is
situated the lachrymal sac; then carry a probe.pointed bis-
toury, or a phymosis knife, with the point, immediately into
the sac ; then the probe is to be used with a little degree of
bearing and force, so as to overcome the stricture; and to
ascertain whether it has passed into the nose or not, pass a
director under the inferior turbinated bone, you touch the
probe, then withdraw the probe, and introduce a style, with
a flattened head to it,into the passage, the head of it is to rest
upon the inner cânthus of the eye; to be certain, however,
then, that the passage is clear, it will be right to direct the
patient to blow his nose, and if it be so, a bloody matter will
be found on the handkerchief. If there come on much inflam-
mation, direct the patient to keep on a poultice for a few days.



LECTURE XVI.
205
As to how long the style ought to remain in the ductus ad
nasum, must depend upon this circumstance—as long as any
matter, or purulent discharge is kept up, or even capable of
being squeezed out on pressure, so long it ought to remain, and
sometimes it is necessary to let it stay for the space of three
months longer. The end of the style gets flattened, and pro-
duces but little inconvenience or deformity; it should be
withdrawn frequently, and warm water injected through the
passage. Mr. Ware has thought, generally speaking, sia
weeks to be long enough to allow the style to remain, but the
practitioner must be guided entirely by circumstances in this
respect.
If, from the long existence of the disease, the nasal duct be
perfectly obstructed, either from ossification or any other
cause, then it becomes necessary to have recourse to the fol-
lowing operation : a larger opening must be made in the sac,
then pass the point of a knife through the os unguis obliquely
outwards, and turn it a little around, so as to break through
the bone and form a circular orifice; then withdraw the knife
and pass a probe into the nose, introduce a style as previ-
ously advised, and let it remain till the orifice, thus artificial-
ly formed through the os unguis, is completely established
and fistulous.



( 206 )


LECTURE XVII.

ON THE OPERATION FOR THE REMOVAL OF
THE EYE.
An operation for removing the important organ of vision be-
comes necessary in cancerous affections, and also in that
particular disease, the fungus hæmatodes. A true cancer of
the eye is a very rare occurrence, and the instances on re-
cord are very few. I recollect to have heard of but one well
defined case, and in this subject it did not disease the eye it-
self, but had its origin in the lachrymal gland, and destroy-
ed life by the great irritation produced in the system by the
affection of the brain. We read of the eyeball becoming
gradually enlarged, and presenting that irregular scirrhous
state this disease assumes in other parts of the body, the
structure of the eye becomes completely disorganized and
changed, and vision becomes lost : this malignant and la-
mentable disease at length ulcerates, and proves fatal by its
extension along the optic nerve to the brain, or the constant
irritation it occasions previous to its affecting that part : it is
accompanied with those burning lancinating pains peculiar
to this complaint. Authors have defined three states of can-
cer, two of which may be fairly classed among other affec-

LECTURE XVII.
207
tions, brought to assume the appearance of this disease by
improper applications.
Fungus hæmatodes begins with the appearance of mucus
at the bottom of the eye, presenting a bluish purple aspect
from the reflection of the rays of light through it ; that
which was before of a light colour is now mixed with bloody
spots, the eye soon becomes swollen, and the tunica conjunc-
tiva appears tinged with blood of a purple venous colour :
at length the tumour protrudes through the opaque cornea,
and when much enlarged, a good deal of it commonly
sloughs, and the ultimate consequences are, that a luxuriant
fungus arises ; this extends through the foramina, resting on
the brain. The patient immediately becomes blind, and is
seized with a considerable degree of coma, and the scene is
soon closed with all the symptoms of compressed brain. A
woman labouring under this fatal disease, was lately seen.
The origin of the affection is evidently in the tendinous
structure, seldom affecting the glands. Mr. Wardrop, who
has written on this subject, says, that it originates in the ner-
vous structure ; but I affirm, that the disease first makes its
appearance in the sclerotic coat, and that the retina, as well
as the optic nerve and choroid coat, are only subsequently
affected by the communication from the sclerotica, or tendi-
nous coat of the eye. It is observed, that this disease is very
frequent in the tendinous expansion of the fore arm, an ex
ample of which I have within the last day or two seen; and
also in the fascia lata of the thigh, and that the disease is
communicated from thence to other parts. If the eye be to
be removed at all, it should be done in the earliest stages of
the disease, and I am sorry to state, that the operation for it
is one of the most unsuccessful in surgery.

Operation.
Push a curved needle through the eye, for the purpose of
fixing it, then with a double-edged knife divide the inner
canthus, and pass it down around the eye till it is separated
from the orbit: having proceeded as far as the optic nerve,
208
LECTURE XVII.
divide it with a small straight knife, and also those muscles
that may be necessary--some use a curved knife. The he-
morrhage is commonly slight, and ceases in the course of
five minutes. The parts are then to be brought as near to-
gether as possible, and poultices must be applied if the pain
be considerable.

ON POLYPI IN THE NOSE.
There are three different kinds of polypus; the first looks
like jelly in the nose; it is coagulable lymph contained in a
bladder, in general of a pyriform shape, hanging by a thin
pedicle or neck, very moveable, and so little vascular as only
here and there to be streaked with blood. The only incon- ·
venience that it is attended with, is the prevention of a due
degree of respiration during sleep; but when there is a poly-
pus in both nostrils, the inconvenience is far greater, and
much increased in wet weather.
- REMOVAL.--The usual manner of removing it was by means
of a forceps, but this was very unsuccessful, as the whole of
it could very seldom be removed; the plan now adopted, in
my opinion, is far preferable; it is thus : pass a pair of probe
pointed scissars up the nose till you have reached the root of
the polypus, then opening them, divide it at that part, and di-
rect the patient to blow his nose, upon which it immediately
escapes : but sometimes the polypus is so very large, that it
is impossible to effect its removal in the above manner, and
in this case proceed with the scissars in the same manner to
divide it at its neck ; then pass one finger into the mouth to
the back part of the nostril, and hook it down from above
the velum pendulum palati.
The second species of polypus is of the hydatid kind; it
can be distinguished from the last by the discharge of a thin
watery fluid produced on pressure, and its again forming. It
has been thought, that a weak solution of arsenic, or subli-
mate of mercury, applied to it, would be beneficial, and ef-
fect a cure.


LECTURE XVI.
209
The third kind of polypus is the most alarming of all; it is
the malignant or cancerous ; it hangs from the pituitary mem-
brane—its base is very broad: it presents that hard scir-
rhous appearance in its early stages, similar to carcinoma in
other parts. The disease is perfectly incurable, and all rem-
edies that are employed should be only of the palliative kind,
and merely to afford temporary relief and comfort, as very
little can be done in these cases.
General remarks.—It is from mucous membranes polypi
are found to grow generally: the nose, uterus, vagina, rec-
tum, and the meatus auditorius externus, are where they
are most frequently met with: the fleshy polypus of authors
may be classed under the first description. Some mistake
the hydatid polypus, and consider it a prolapsus of the
Schneiderian membrane; others term it the vesicular poly-
pus; but these may be considered as so many varieties when
they exist : no description can be laid down of a disease,
but what there will be found some variety in practice. Mr.
John Bell thinks that there are never originally any malig-
nant polypi existing in the nose ; he attributes their assum-
ing this character to the irritation from the distention of the
swelling in its confinement in so close a passage ; and if this
be the case,which I think very probable, I see no reason why
in the early stages they might not be removed with perfect
safety.


ON DROPSY OF THE ABDOMEN,
This disease is of two kinds, the ovarial and the perito-
neal ; the former called the encysted, the latter ascites. The
peritoneum is a membrane lining the whole cavity of the ab-
domen, and naturally exhales a fluid for moistening the vis-
cera, and preventing friction, &c. Various causes may pro-
duce a morbid increase of this secretion, such as the enlarge-
ment of the liver, spleen, &c.; any circumstance producing
a torpid circulation ; also a scrophulous affection of the me-
senteric glands; too liberal a use of spirituous liquors, as
27
210
LECTURE XVII.

well as anxiety of mind, may be also ranked among its oth-
er causes.
The encysted dropsy often occurs in people of a good con-
stitution, and in this respect differs from ascites, which is
commonly the effect of a worn out constitution ; also in the
ovarial dropsy, it may commence very early in life, and yet
the patient may live to a good old age ; but the contrary is
perceived to take place in ascites.
Dropsy of the ovary is of two kinds ; in the first, the fluctua-
tion sometimes is not very distinct. Before an operation is un-
dertaken, the fluctuation should be distinctly ascertained,and
unless complicated with ascites,the second kind,the swelling is
either on one side the abdomen or the other : the water is at
first collected in a number of cysts or bags, which do not
adhere in the first instance, although adhesions between them
take place subsequently. There would be great risk in ope-
rating in the early stages of this disease, and no benefit could
possibly accrue, as if one of the cysts was opened, still oth-
ers would remain ; and the chances are, that peritoneal in-
flammation would take place, and the operation is only war-
ranted when the quantity of Auid is pretty large. The quan-
tity of water in ovarial dropsy is commonly from thirty to
thirty-five pints, and cases have occurred where it exceeded
ninety-seven ; it varies also very much both in its consistence
and colour, sometimes being yellow, at others ropy, and oc-
casionally purulent: if thick at first, tapping will make it
thinner, and vice versa. What is above stated is applicable
to ascites or peritoneal dropsy, the distinguishing marks of
which I shall now state : a swelling in the abdominal cavity,
with a sense of tightness all over the belly, so that the pa-
tient's clothes gradually get too tight, and require enlarging ;
the breathing difficult and laborious, especially when in a
recumbent posture, or in bed; a fluctuation may be dis-
tinctly felt by one hand being placed on one side the pa-
tient's abdomen, when it is struck forcibly on the opposite
side with the other; besides there are many other concur-
rent symptoms, such as thirst, heat of the skin, scarcity of
urine, &c.




LECTURE XVII.
211
PARACENTESIS ABDOMINIS.
The same method of operating is required in the ovarial
dropsy as in ascites ; I shall therefore merely describe the
mode as performed in the latter. The trocar is the instru-
ment generally in use; but when the integuments are thin, I
should give preference to the lancet. Having placed the pa-
tient in an horizontal posture, with the head a little elevated,
a flannel roller is to be applied on the upper part of the abdo-
men, and gradually drawn tighter as the water is drawn off,
in order to support the patient by moderate pressure during
the evacuation, as such a quantity of fluid being so sudden-
ly drawn off would occasion fainting, &c.; then pass a tro-
car or lancet in the linea alba, from one inch to two or three
below the navel, as on one side of that line there will be
some danger of wounding the epigastric artery: if it be the
trocar that is used, and a sudden stop of the discharge hap-
pens when withdrawn, pass a blunt probe through the canu-
la, in order to discharge any thing that may obstruct the
free passage of the fluid through the tube. I think myself
that the lancet is the most preferable instrument, and I have
known instances where it has been used that the patients
would by no means submit to the introduction of the trocar in
a future operation ; besides there is some risk attending thelat-
ter, for the end of the canula has been known when the pa-
tient coughed, to lacerate the mesentery, by first rubbing
against the peritoneum, and the result proved fatal, high in-
flammation having come on. A gentleman at Chichester,pro-
posed some years ago, to cure dropsy by leaving an ivory
canula in the abdomen for some time, and he related some
cases where it succeeded : I shall offer no remark on the
subject. The quantity of fluid contained in this disease, is
very great, and during my apprenticeship, Mrs. Davies had
evacuated at seven different operations, with a short interval
between each, a large pailful each time: she died soon after
the last, from debility. This case convinced me to what an
extent it will accumulate, as well as the time it took, after
212
LECTURE XVII.
each operation, to re-produce the effects of the disease to its
former extent, and as far as I recollect, the intervals gradu-
ally lessened. When the operation is finished, apply merely
a piece of dry lint on the wound made, and support it by ad-
hesive plaster, and bind round the abdomen a flannel band-
age.


ON THE HARE-LIP.
Hare-lip takes its name from its resemblance to the fissure
in a hare's lip: it most commonly occurs in children, being
born with this malformation in one or both lips. The fissure
mostly happens in the upper lip, and often extends back to
the roof of the mouth, and to the soft palate : it is sometimes
double, (i. e.) taking place on each side the lip, a portion of
the latter remaining between the fissures ; occasionally the
space intervening is considerable, but mostly they are not
far apart; whenever it occurs,it occasions very great deformi-
ty, and can only be remediable by an operation.
The time proper, and most likely for the operation to be
attended with success, is after the age of two years ; prior 10
this, it is conceived, that there is great risk of the child's los-
ing its life; in fact many instances have been witnessed when
children have been carried off by convulsions at an earlier
age, which ought to put the surgeon on his guard. The op-
eration, it must be admitted, has certainly been performed
in children very young, and with complete success; but as
it has proved fatal in several cases, I conceive it will be suffi-
cient to defer attempting it at an earlier period than I have a-
bove stated as it is nearly certain of being attended with a cure
of the malformation when children have attained two years of
age, their system at that period being more capable of re-
sisting any constitutional irritation that may be excited.


Mode of operating.
The chief object the surgeon lras in view, is to form an
acute angle in -removing the edges of the fissure by two

LECTURE XVII.
213
smooth and even incisions meeting at a point at the upper
part, so as to produce an entire new surface on each side,
in such a manner, that when closed together the whole can
be approximated neatly without an intervening space; and
with this view pass a double edged cataract knife through
the upper part of the lip, continuing the incision down to
the bottom, parallel to the fissure on one side; then the knife
must be carried in the same manner on the other side; make
two interrupted sutures; the first midway between the nose
and under edge of the lip, passing the needle before and
behind, and taking care that it gets completely through
the edges of the lip into the mouth; the second suture
· is to be made through the middle of the red part of the lip,
quite through to the opposite side, otherwise there will be a
small fissure still remaining; then tie both ligatures, and the
edges will be nicely and exactly brought into contact, so as
to be united by adhesion.
Two silver pins, with steel points, were formerly used,
passed nearly through the edges of the wound, and a thread
carried around them in the form of a figure of eight; but
from their producing generally a considerable degree of irri-
tation, they are now very commonly laid by. If during the op-
eration any considerable hæmorrhage (for there will always
be some) arise, it will be right to carry the needle and
ligature near the bleeding vessel; this will be much better
than applying a ligature around the vessel, for if it be done,
the union will be incomplete: the bleeding almost invariably
ceases when the edges of the wound are accurately brought
into contact. If the hare-lip be double, (i. e.) if there are
two fissures present, the operation is to be performed in the
above manner, only in this respect, that it is only to be
operation till that fissure is quite healed, when the same op-
eration may be performed on the one remaining. A portion
of the jaw occasionally projects between the fissures; and
sometimes a tooth. When this latter happens, and it presses
on the jaw, it may be removed ; even the removal of a piece
214
LECTURE XVII.

The period at which the ligatures are to be taken away,
will be from the fourth to the fifth day in adults, and in chil-
dren, from the fifth to the sixth: but this must depend upon
circumstances, for if it be perceived the process of ulcera-
tion is commencing, it will be right to take them away on
the fifth day, and if at that time the lip have yielded at all,
it will be right to apply a narrow and long slip of adhesive
plaster across it to the cheeks, so as to allow a relaxation
during the crying of the child.
If the child be tedious and fretful, the administration of a
small quantity of the syr. papav. alb. will answer the pur-
pose of quieting it.
I never saw the hare-lip, or fissure in the under lip, but a
cancerous affection to which it is liable requires the same op-
eration as that kind which I have described for an hare-lip:
according to the extent of the division, the length of the in-
cision toward the chin is to be made: the knife is to be car-
ried from the upper part of the lip in an oblique direction to-
wards the chin on one side the diseased part, and the same
incision is to be made on the opposite side, so as to cut out a
complete angular piece, and the parts are to be brought to-
gether by three sutures : without the divisions are accurate-
ly made so as to form a complete angle, the parts cannot be
brought closely together.
When an hare-lip is complicated with a fissure in the roof
of the mouth, a piece of sponge, joined by means of silk to a
silver plate, will be found beneficial ; the plate of silver must
be made exactly adapted to the arch of the palate; the sponge
is to be introduced into the fissure, and the plate attached to
it is to remain in the roof of the mouth : the sponge being
dry when inserted, absorbs moisture from the surrounding
parts, and becomes so enlarged as to retain its position and
the silver plate attached to it. But when the fissure extends
to the soft palate, and is confined solely to the uvula and vel-
um pendulum palati, there is no instrument can be used so
as to remedy this defect, although a silver plate extending
along the bony parts has been attempted in various shapes.




( 215 )
LECTURE XVIII.
1993
y
faces
ON PUNCTURING THE BLADDER.
A
Н
!
There are three ways proposed to puncture the bladder in
cases of retention of urine-first, per rectum. When the
bladder is excessively distended, by an examination per
anum, it will be found protruding downwards and occupying
the proper situation of the rectum at its extremity, and is im-
mediately felt on the introduction of the finger. The tumour
is very tender, and a fluctuation always perceptible, so that
there can seldom be a doubt with respect to the nature of
the case. As soon as the bladder is found projecting on
the rectum, a surgeon, void of anatomical knowledge, would
not hesitate to puncture it. The peritoneum is reflected in
that manner' as to give ample space for allowing the bladder
to be opened, so as to be in no danger of wounding the
above membrane. The vasæ deferentiæ leave an opening
of a triangular form behind the prostate, in the centre of
which the trocar is to be introduced.b a
216
LECTURE XVIII.

The operation is a very simple one, and may be thus per-
formed : having a trocar of considerable length, about four
inches, and a canula three, and somewhat curved (al-
though a straight one will answer the purpose ) it is to be
carried up to the superior part of the bladder, having previ-
pusly passed the fore finger of the left hand into the anus to
serve as a director, then lowering the handle, and elevating
the point through the axis of the pelvis, as if it were intend-
ed to come out at the abdominal muscles, it enters the blad-
der; the trocar is then to be withdrawn, and the urine evac-
uated through the canula. This necessary operation would
always be had recourse to, if it were not for the inconven-
iences resulting from it : a very material one is, that the
urine distilling through the canula, (or when this is with-
drawn, which must be done ), it passes in contact with the
rectum, and produces a considerable degree of irritation and
thickening of its internal coat; besides there is a constant
inclination of voiding the fæces, together with an extreme
tenderness of the gut. With respect to the danger of wound-
ing the vesiculæ seminales, or the vasæ deferentiæ, this will
be avoided by passing the instrument at least an inch and an
half up the rectum, as they would most certainly be injur-
ed if it were not carried sufficiently high up.
2. Above the pubis :—When therefore a surgeon is called in
to a patient labouring under retention of urine, and having a
considerable degree of swelling and fluctuation perceptible
above the os pubis, he would not hesitate about puncturing
the bladder if every other means previously resorted to had
quite failed: the manner of this operation I shall now de-
tail. When the bladder is empty, and in a relaxed state,
then the peritoneum is reflected in such a manner as to be
in contact with the rectus muscle, and consequently in the
direction of the pubis ; but when distended, the reflection
is at some distance from the latter, and not liable to be
wounded by the trocar : first feel for the symphisis pubis,
then make an incision with a lance or scalpel through the
integuments, about an inch in length, in the direction of the



LECTURE XVIII.
217
linea alba, immediately above the symphisis, then with a
straight trocar and canula, (both rather short) although ma-
ny prefer a curved one, pass it so as to correspond with the
axis of the bladder into this viscus, that is, obliquely down-
wards and backwards ; be careful of the direction, as the
trocar might otherwise pass between the bladder and pubis.
This simple operation has been objected to by experienced
practitioners for two reasons ; first, because an ulceration
of the bladder takes place in consequence of the canula be-
ing left in: and the second is, that the urine is liable to be ex-
travasated into the cellular membrane, between the abdomi-
nal muscles and bladder : both of these objections may be
easily refuted. To counteract the first, an elastic gum ca-
theter might be introduced, which will answer as well as the
canula, and from the use of which no inconvenience will
arise. The second objection is conceived to be fallacious,
and I have heard a medical gentleman of some celebrity re-
late three cases where no extravasation happened. The
elastic gum catheter may be worn for some time without
causing any ill effects. Mr. Sharp, Mr. Abernethy, and Mr.
Astley Cooper are favourable to this operation : Sir Everard
Home and Mr. Hey of Leeds, as well as others, think the
operation per rectum preferable. I should be disposed, in
case of diseased prostate, where the catheter could not be
passed, though such instances are very rare, as in the praca
tice of one of our most popular surgeons, a case never oc-
curred of a disease of that gland where it could not be in-
troduced, to tap above the pubis.
In cases of diseased prostate, the operation per perineum,
would be highly dangerous : it is similar in many respects
to that of lithotomy. The patient is to be bound in the
same manner, an incision, an inch and an half in length, is
to be made in perineo, so as to lay bare the bulb of the pe-
nis; having done this introduce one finger, and it will be
found resting on the prostate gland, which is to be pushed a
little to the right side of the patient, and the trocar is to be
carried by it in a direct line backwards into the side of the



28
218
LECTURE XVIII.

bladder nearly at the base of the prostate. This operation
will be much facilitated by introducing at the time one fin-
ger into the rectum. It requires a perfect anatomical know-
ledge for the proper execution of it. The trocar and canu-
la must be of a convenient length.
Having now stated the usual methods practised in punc-
turing the bladder, I shall briefly enumerate the causes that
would dictate the necessity of either operation.
ON ISCHURIA, OR RETENTION OF URINE.
The distinction between suppression and retention of urine
is this : the former means a defect in the secretion of the
kidneys; the latter when secreted, an inability of expell-
ing it.
Those advanced in life, are most frequently the subjects
of this affection. The bladder holds about one pint and a
half of urine without inconvenience ; but when that quantity
becomes considerably augmented, an urgent desire is felt of
evacuating it; and if this cannot be attained, the bladder in
time loses its contractile power, and becomes paralytic; still,
for a time, as the bladder becomes more and more dilated,
efforts are made to obtain relief by its discharge, till the
distention can proceed no further : and it would evidently
become lacerated did it not derive support from the uniform
pressure of the contiguous parts. When the retention has
continued for three or four days, the neck of the bladder ex-
pands, and urine escapes, but this should not mislead the
surgeon : it may continue to dribble away till the eighth or
tenth day, or till the bladder sloughs ; not only the patient
but his friends are led to believe the imminent danger has
ceased, from the time the urine escapes; but this is most de-
ceptive, and here let me caution the young surgeon not to be
so blind and credulous. The continued distention causes an
universal inflammation of the abdomen, and the symptoms
of incipient mortification are here mistaken for relief. The
pressure of the abdominal parietes prevents a laceration,


LECTURE XVIII.
219
and the opening found on dissection is caused by mortifica,
tion. Occasionally, even from the commencement, the urine
is not altogether retained, but it escapes in trifling quantities
without manifest relief, and in these cases the disease is lia-
ble to be mistaken for a stranguary...
The hard, circumscribed, and rather prominent tumour in
the hypogastrium, immediately above the symphisis pubis,
combined with other circumstances, will always detect the
disease.
The causes of this affection are numerous ;-paralysis of
the bladder, resulting from neglecting the calls of nature af-
ter drinking to excess : concussion of the medulla spinalis :
inflammation of the neck of the bladder : extraneous bodies
in the bladder. In pregnant women, from pressure by the
gravid uterus : enlargement of the prostate gland; and
strictures in the urethra.


Treatment.

When called in to a patient labouring under a retention of
urine, prior to the performance of an operation, it will be
right to have recourse to other means, and the first and most
obvious will be the introduction of the catheter ; but if this
should not be practicable at first, I should bleed, and emerge
the patient in the tepid bath, and administer opium, &c. If,
however, after the lapse of several hours, these remedies
should not succeed, and no probability remaining of passing
the catheter, the operation above the pubis would be advisa-
ble : but if a stricture existed, I should proceed to operate
thus, which would be a material deviation from either of the
three previously detailed, as it would consist in making an
opening into the urethra: in fact, excepting the case of di-
seased prostate, already alluded to, I should never think of
puncturing the bladder in cases of stricture; my only ob-
ject would be, to cut beyond the stricture, so as entirely to
free the latter. As soon, therefore, as I should perceive the
urethra to be considerably swollen and enlarged, I should
direct the patient to make a violent effort to void his urine ;

220
LECTURE XVIII.
at this very juncture, place your finger upon the perineum,
and the tumour and fluctuation will be very evident, and
here the incision is to commence: another similar exertion,
as just stated, is to be then made, and the tumour being again
distinctly felt, there will be no difficulty in proceeding with
the further necessary incision, going on, as it were, mechanic-
ally. Another method, and one very easy, is to pass a staff
into the urethra, as far as the stricture (for it will go no fur-
ther ), then cut down and lay it bare, then divide the stric-
ture in the direction of the groove of the staff, carrying the
knife towards the arch of the pubis. By these methods it is
possible to relieve the stricture, which cannot otherwise hap-
pen : those arising from accidents, as in falling, are more ea-
sily cured than when caused by gonorrhæa, &c. It is at-
tended with this advantage, that if it should not succeed, yet
recourse may be immediately had to the trocar and canula.




( 221 )
LECTURE XIX.

ON THE STRUCTURE OF CALCULI.
The different kinds of structure that the various calculi as-
sume, ought to be well known, as well as their external ap-
pearances : this will depend, a great deal, on the mode of
living, and the nature of the nucleus, &c. Calculi are com-
monly laminated, connected together by means of a few cal-
culous fibres, not quite so much laminated as the others. In
the centre is the nucleus, which is variously formed, some-
times from mucus, at other times from a coagula of blood or
from extraneous substances getting into the bladder,as needles
for example, and even pieces of a bougie broken off. Calculi
are also different in their colour from each other, not only
in the whole, but also varying in their parts. Their compo-
sition is also differing. The size generally extracted is from
two to three ounces. The largest that I have heard of ex-
tracted weighed four ounces and an half; but there is no
judging of their weight from their size, as a stone of four ounc-
es may not be as large in bulk as one of an ounce and a
half, as it depends upon the nature of the component parts.
There is one, which is preserved in Trinity College, Cam-
bridge, and was taken as far back as the reign of Charles
the Second ; its weight is thirty-three ounces, three drachms,
and thirty-six grains : but the largest that has ever been




222
LECTURE XIX.
known, in the human subject, was in a case reported in the
Philosophical Transactions for 1809, by Sir James Earle.
The subject was Sir J. Ogleby, who had long been labour-
ing under symptoms of stone in the bladder : an operation
was performed on him, at his particular request, by Mr. Cline;
but on account of the size of the calculus, it was found im-
possible to extract it whole, and an attempt was made to
break it; this was not attended with the desired success, as
only a few fragments were taken away: he did not long sur-
vive the operation, and after death his body was examined;
a stone of an immense size was found in the bladder; it
weighed forty-four ounces, apothecaries' weight: its form
was elliptical; its long axis of circumference sixteen inches,
its short diameter four and a half, its long diameter five and
a half, and its short axis of circumference fourteen inches.
It entirely filled the bladder and even distended it; it com-
pletely occupied the cavity of the pelvis, projecting beyond
and resting on the pubes. The pelvis of the kidneys was
much enlarged, as well as the ureters, which appeared to
be the receptacle of the urine. On analyzing the stone, it
consisted of phosphate of ammonia and magnesia, with phos-
phate of lime, united with an unusually large portion of ani-
mal matter. He had, in addition to the usual symptoms of
stone, a paralytic affection of the lower extremities. The
greatest number of calculi seen, extracted at one time, was
twenty-two. Dr. Catling has seen twenty-five : they were
about the size of a waistcoat button. Mr. Cooper has ex-
tracted thirty-seven at one time, of the size of marbles: in
another person nine of some size.


ON THE CHEMICAL COMPOSITION OF CALCULI.
Urinary calculi are divided into four species :-1st. Those
calculi are most common which are formed from the uric
acid, the colour similar to wood, and the appearance when
cut into resembles the trunk of the branch of a tree; these
are called the uric acid concretion, and are soluble in alkalies
LECTURE XIX.
223
and acids. Lithic, or uric acid, is a composition of carbon,
nitrogen, hydrogen and oxygen : it is that sediment in the
urine which appears in the form of small red crystals very
frequently observed to be deposited. The 2d are those
formed from phosphate of ammonia and magnesia, having a
whitish grey appearance, and often transparent crystals on
the fusible calculi. Note—I would observe respecting this

ed in the bladder, of the latter being in a diseased state, and
that its formation is more from diseased mucus than from the
urine. When, therefore, small portions of this calculus pass
by urine, which may be easily known by analyzing them,
the patient may be assured with confidence of the utility of
the operation : there is commonly a quantity of coagulable
lymph coming off at the same time with the portions of stone.
-- The 3d kind is the mulberry calculus, consisting of oxalate
and prosphate of lime; so named from its resemblance to the
mulberry stone.—The 4th and last are termed the bone-earth
calculi, composed of the prosphate of lime.
A gentleman, whose name I do not at this moment recol-

tions, from which it appears he has analyzed 150 calculi;
and has given their component parts, shewing at the same,
time the forms in which they mostly occur, viz. : 16 of urid
acid : 45 of uric acid and a small quantity of phosphate : 66
of large quantities of ammonia and magnesia, and a small
quantity of uric acid: 12 of phosphate of lime : 5 of uric
acid with phosphate and a nucleus of prosphate of lime : and
6 of the mulberry calculi, or oxalate of lime.
In the third volume of the Med. Chirurg. Transactions will
be found the following minute analysis of urine by Benzelin:
-Water 933.00; urea 30.10; sulphate of potass 3.71; sul-
phate of soda 3.16 ; phosphate of soda 2.94; muriate of soda
4.45; phosphate of ammonia 1.65; muriate of ammonia 1.50;
free lactic acid ; lactate of ammonia ; animal matter soluble
in alcohol, and usually accompanying the lactates; animal

224
LECTURE XIX.
matter insoluble in alcohol; urea not separable from the pre-
ceding 17.14; earthy phosphates with a trace of fluate of
lime 1.00; uric acid 1.00; mucus of the bladder 0.32; silex
0.03=1000.00.
MEDICAL TREATMENT.
* Some calculi are acted upon by alkalies, others by acids.
From the experiments of Fourcroy and Vauquelin, a weak
solution of potass, or soda, gradually dissolves calculi com-
posed of uric acid and the urate of ammonia. Weakly di-
luted muriatic, or nitric acid, readily dissolves those formed
of the prosphate of lime and the ammoniaco-magnesian phos-
phate. Diluted nitric acid will nearly dissolve those com-
posed of the oxalate of lime. Fourcroy tells us that the
caustic alkali alone is capable of dissolving almost every in-
gredient in the composition of calculi, and hence, no remedy
• in calculous affections is more universally employed than
lime-water as a solvent. I believe a Mrs. Steevens had no
less a sum than 50001. from parliament for a nostrum, of
which this was the principal ingredient, united so as to form
a soap.
From the above experiments, it is evident that the different
varieties of calculi can be dissolved out of the body, or they
might even in the bladder be soluble, if that organ would re.
ceive these medicines passively, and not inflame and suppu-
rate on their introduction : even in that case, there would
be a trifling difficulty to surmount, which is, that the precise
nature of the calculus could not be readily ascertained.--
From these circumstances it has been attempted by various
authors, who have written expressly for the purpose, to
prove that they are of no kind of utility in cases of stone ;
in this they argue chemically (knowing the changes they
must necessarily undergo before they arrive at the bladder),
but not 'philosophically. I will allow, that as far as the
idea has prevailed of their power of dissolving calculi, it is

LECTURE XIX.
225
at least ingenious ; but independent of this they are of mate-
rial benefit in practice : first, in mitigating pain ; and second-
ly, as excellent preparations for the operation of lithotomy.
The good effects of one the preparations of soda could
not have been more manifest than in a naval commander,
who before he had recourse to this medicine was in constant
pain and anguish, and although he had continued its use but
a little while, he got perfectly easy, and remained so, al-
though the stone was easily felt in the bladder. The dose
he took was two drachms in twenty-four hours of the sub-
carbonate of soda, dissolved in a quart of water ; and I
think the way it must have acted was by acting on the
nervous powers, and consequently diminishing the irritabili-
ty of the constitution, which, of course, would afford materi-
al relief.-Query. Has this medicine any specific effect on
the nerves, as it is found to be eminently serviceable in tic
doloreux and other affections, in affording ease ?
In some of Mrs. Steevens's cases, it would appear from Dr.
W. Hunter, and others, that the calculi were not actually dis-
solved, but rather incased in a cyst, as they are often found,
and were not capable of irritating the bladder as formerly ;
and they might be compared in these instances to a ball,or any
other extraneous body, which is known to remain for years
in the body, perfectly inactive, when lymph becomes effused
so as to form a complete covering. Aërated soda water may
be given—the aërated kali.—The liquor. potassæ is attended
with similar good effects, especially when the bladder is irri-
table; it is better to combine it with opium. Acids, such as
the sulphuric or muriatic, may be also found beneficial. In
some cases they have but little effect, as has been satisfacto-
rily proved, where they have not only been administered by
the mouth, but also in a very weak state by injection. The
greatest benefit that has been found to arise from injection
of any medicine into the bladder was the tincture opii : uva
ursi has been much spoken of. A decoction of the garden
leek is used, and also the root carefully dried in an oven, and
powdered. It is in those cases where the bladder is very
29

226
LECTURE XIX.
irritable, accompanied by a diseased secretion, that most
surgeons decline operating.
ON THE SITUATIONS AND SYMPTOMS OF CALCULI.
Urinary calculi have been found in five different situations ;
first, in the kidneys; secondly, in the ureters; thirdly, in
the bladder ; fourthly, in the urethra ; and fifthly, in the
prostate gland, arising in two several ways, either by pass-
ing from the bladder,or originally formed in the gland itself.
When in the kidney, it is known by pain in the loins oppo-
site to the kidney affected ; this is increased by pressure or
bending the body, as in stooping, &c.; but if the stone be
not large there is a peculiar sensation felt as if something
were rubbing in the loins of the affected side, occasioning
a considerable degree of uneasiness. When any considera-
ble exertion, or exercise, is used, exacerbations of pain come
on in consequence of the existence of inflammation, attend-
ed with profuse sweating, nausea, and frequent vomiting. A
benumbed sensation is extending from the kidney across the
abdomen to the umbilicus: there is also a paleness or sal-
lowness in the countenance. If the pain be excessive, it
extends to the opposite loin. The urine is rather diminish-
ed in quantity, and there is often observable during the vio-
lent pains, not only a difficulty in making water, but a good
deal of blood discharged and mixed with it: this bloody ap-
pearance, however, is known to take place after violent ex-
ercise on horseback, independent of calculi. A calculus in
the kidney will sometimes cause suppuration of the latter.
The abscess has been described, as pointing towards the
loins, and that the stone might be easily felt; for the pur-
pose of extracting it, an opening has been advised to be made.
Inflammation will sometimes produce an adhesion between the
kidney and the colon, in consequence of which during the
suppurative stage, a communication takes place between the
two, and the stone will be voided by the rectum. When cal-
culi form in the kidney, their situation is most frequently in
the infundibula. In cases, therefore, where they have long
existed in the viscus, they commonly take on the form of the

LECTURE XIX.
227
pelvis and infundibulum. Their texture is laminated, and is
a substance mostly made up of uric acid.
The circumstance of calculi forming in the ureters is, com-
paratively speaking, rare. I have heard of but three instan-
ces of it in the dead subject: in the living there are many
characterizing marks of the existence of the disease. The
symptoms are, pain felt in the hip, thigh, and leg of the affect-
ed side immediately on the existence or entrance of the stone :
as it gets lower, the thigh becomes painful along the course
of the anterior crural nerve, which is united to the nerve go-
ing to the ureter by the spermatic plexus: as the stone de-
scends still further, pain and contraction of the spermatic
chord takes place from a spasmodic contraction of the cre-
master muscle, which draws up the testicle to the abdomin-
al ring. In addition to these, a tingling sensation will be
experienced at the end of the penis; in fact, I believe there
are very few cases occurring where stone is present in which
this does not happen: the urine is sometimes retained, pro-
ducing ischuria, or when discharged, it is either accompani-
ed with blood, mucus, or pus. It mostly (if not too large)
descends into the bladder. Many instances have been
known where it has remained in the ureter at its lower part.
The best treatment in these cases will be to put the patient
in a warm bath, and give doses of opium repeatedly, espe-
cially if the pain and irritation be violent. The patient
should drink freely of soda water, and the state of the bow-
els will require particular attention, and castor oil will be
found very advantageous, also warm clysters, as they act as
fomentations to the part.
As soon as the stone has passed into the bladder, the symp-
toms are nearly the same as when originally formed in it.
The first thing the patient feels is an excessive smarting sen-
sation about an inch in the urethra, opposite the frænum ;
this is very unlike what a person experiences from slight
causes; the pain is exquisite, so as to be compared to a red
hot iron instrument applied to it, and the patients will de-
clare, after they have undergone an operation for the ex-

228
LECTURE XIX.
traction of stone, that the pain excited by the latter is by
no means equal the former : there is seldom any uneasiness
felt in the bladder itself, and it is only when the disease has
long existed, that it takes place there and above the pubis.-
The pain is much increased on any agitation of the body, as
in stepping from one place to another suddenly. When the
bladder is in an irritable state, change of posture will add to
it, and even the riding in a carriage is not easily borne, much
less riding on horseback. There will be a bearing down of
the rectum if the pain be great, so much so that the patient
is unable to void his urine without at the same time going to
stool. The urine is in most cases perfectly limpid, but in
quantity less : after exercise, blood is commonly mixed with
it; this appearance goes off by the patient's remaining at rest:
during the discharge of urine, the pains are increased more
and more as the evacuation draws to a conclusion, and still
more so after the whole is passed, from the bladder contracting
on the stone. This circumstance will tend in a great measure
to distinguish a stone in the bladder from an irritable state of
it: for we find in the latter case the very contrary happens,
viz: the sooner the water is discharged, so in proportion
will relief be found. During the passing of the urine, there
is often an interruption to its flowing regularly, and it stops
of a sudden. It is discharged also when in as relaxed a pos-
ture as possible, and this is principally effected by relaxing
the abdominal muscles : therefore it is, these patients are
found bending their bodies forward, resting upon their arms,
&c. so that when a surgeon has once seen a patient in this
situation, he cannot hesitate a moment about the nature of
the disease, when the other symptoms are also present. In
the advanced stages of the disease the urine becomes of a
ropy purulent appearance, indicating a diseased state of the
mucous membrane lining the bladder. A spasmodic con-
traction of the abdominal muscles is now taking place, at-
tended with violent rigours, succeeded by heat, and profuse
sweating, similar to paroxysms in an intermittent fever. The
bladder of one who long has been the subject of calculus is
LECTURE XIX.
229
much contracted in its dimensions, and less capable of re-
taining its proper quantity of urine: this state of the bladder,
even if it were satisfactorily ascertained previous to the op-
eration, yet ought by no means to prevent its being perform-
ed, as many cases of this kind turn out extremely well:
the only thing to be observed is a more particular care in
passing the gorget, or whatever other instrument is used,
as it is somewhat more difficult to operate. When the irri-
tability is great, inflammation and suppuration of the inter-
nal coat is the most probable result; the ureters and kidneys
participate in the irritation, the patient loses his rest and
appetite, and becomes einaciated and exhausted, and death
finally closes the scene..

* It would appear that the most frequent and indeed princi-
pal proximate cause of the formation of calculi, is an excess
or superabundance of uric acid, which becomes deposited
from a peculiar disposition of the fluids. It is also thought,
that the tartar contained in wine may be the cause of calcu-
lous matter occasionally ; so also may be enumerated water,
if it contain sulphate and carbonate of lime in excess.—
Some assign hereditary predisposition—sedentary employ.
ments, as well as the long and free use of spirits, as tending
to these formations. The particles of calculous matter are
easier evacuated in warm climates, from the relaxed state of
the passages, than in the colder, so that these concretions are
seldom found there of that magnitude seen in our own or
colder regions. The most frequent period of life for these
formations is from infancy to fifteen or sixteen years; and
children are the most frequent subjects of operation in the
London hospitals, and it appears from attentive observation,
that the lower classes of society are more frequently afflicted
than the more wealthy, and this evidently may be attributed
to the dissimilitude in the purity of the solids and fluids they
take. It requires only a moment's consideration to solve the
question, Why calculi of some size are more frequent in the
male than in the female? It is on account of the greater diffi-

230
LECTURE XIX,
culty in getting rid of them when formed, from the length and
narrowness of the urethra.
ON THE PROPRIETY OF LITHOTOMY AT CERTAIN AGES.
When the presence of stone has been satisfactorily as-
certained by sounding, the operation is not to be determined
on immediately,without the person's age and constitution has
been taken into consideration ; a neglect of which many op-
erators have been, and are, guilty of. It does not appear
that there is any objection to lithotomy in persons advanced
in life, if their constitution be in every other respect unbro-
ken ; as it has been done with success even at the advanced
age of eighty, and frequently between seventy and eighty.--
The most favourable age is certainly the middle period of life.
It is better not to perform it in children under the age of two
years, as they are not able to undergo the operation with
that degree of safety, as when a few years older. It has once
been attended with success in a child only one year and nine
months old : however, I should not recommend it as a favour-
able period, and, indeed have a great objection to its being
done so early, as convulsions, from an unavoidable constitu-
tional irritation, are likely to ensue, accompanied also with
coma, &c. which carries them off. It is also requisite to at-
tend to the state of the viscera, for if there be any diseased
action going on in any one organ, either remotely or imme-
diately essential to life, I would decline operating, as it will
not, by any means, be prudent to do so. This remark not
only holds good in early and advanced age, but also in adults,
as when it has been done in these cases, it was seldom, if ev-
er, the patients did well: it is, therefore, for these reasons,in-
dispensably necessary that the constitution should be perfect-
ly restored to its healthy actions before it is attempted.
Sometimes from a stone in the bladder the kidney is en-
larged in some ; in others, it wastes in its substance from ul-
ceration : if then the patient complains of severe pains in
the loins and a discharge of matter with the urine, after the .

LECTURE XIX.
231
presence of stone has been ascertained in the bladder, it
will be advisable to delay the operation: a similar appear-
ance is presented when there is a diseased prostate, but un-
accompanied with the acute pains in the loins characterizing
the other. It will be equally improper to operate when there
is an ulcerative state of the bladder, which is known by the
excessive pain sounding produces, and a discharge of blood
mixed with the pus.
Necessary Precautions.
Those who intend to perform lithotomy should be furnish-
ed with a case containing every requisite instrument, as well
as the proper bandages. There are different kinds of sounds
used ; they are not to be introduced indiscriminately, but
large in proportion to the size of the patient, as without at-
tention to this caution, mistakes and affirmations might be
made of the existence of a stone, when in reality there is
not actually one present. It is also right to sound the pa-
tient in an erect, as well as in a recumbent posture, for this
reason ; if there should be a diseased prostate, the instru-
ment, in an erect, slips over the gland into the bladder, and
the stone cannot be felt, being situated behind the prostate,
in the hollow between it and the rectum ; but it is easily felt
in a recumbent state of the body: it should likewise be
known by examination when the bladder is full, as well as
when in an empty state. These points are of great impor-
tance to the surgeon, as his character so much depends upon
an accurate knowledge of the presence of a stone in the blad-
der. Having perfectly satisfied yourself with regard to a
stone being present, and there are no objections with respect
to the health of the patient, so as to militate against the per.
formance of the operation for its removal, a few preparatory
steps are required, and if the patient be of a full plethoric
habit, bleeding the day previous to that fixed on for ope-
rating, will be right, to a moderate extent, and also the ad-
ministration of purgative medicines. This mode of prepara-
tion is particularly necessary about the middle period of life,
and it is owing principally to its adoption that the operation

232
LECTURE XIX.
succeeds in the hospitals. But the best step of the kind
which may be had recourse to, is that of sounding the pa-
tient very often, even every other day for some time: this
frequent irritation accustoms the patient to a considerable
stimulant, and he will bear the operation with less uneasiness
and pain than would otherwise happen; and also by this
means the surgeon gets more complete depth in the cut by
passing the sound. The morning it is to be performed, it
will be right previously to evacuate the rectum by means of
a glyster, as it might otherwise be so distended as to be cut
with a knife, and the patient should be directed to retain
his urine for some hours.
The old Operation.
* It is set down by surgeons, as an invariable rule, never to
operate for lithotomy unless the stone can plainly be felt,
and struck against immediately previous to its performance.
The vibrating sensation of the sound against the stone, may
be distinguishable by the ear as well as by the feel. I have
seen it postponed by Mr. Henry Cline, and others, on this
account; although the calculus could be readily felt a short
time before, yet on introducing the staff on the morning the
operation was contemplated, it could not be detected. Some-
times the stone is protruded through the fasciculi of the
muscular fibres, forning a kind of bag by the lining of the
bladder and hence the reason it cannot be felt. If the subject
be an adult, he is to be laid on a table about three feet high;
there are three bandages required,one on both sides for tying
the ancles and wrists of each side firmly together, by means
of a noose formed in a piece of each bandage; the thighs
are then to be separated, and the other bandage is to be ap-
plied so as to secure the knees towards the neck, drawing
the thighs up to the abdomen ; the nates of the patient be-
ing made to project a little over the edge of the table, the
surgeon is to be seated in a chair before, and rather to the
patient's right side ; and before he makes his incision into
the membranous parts of the urethra, a staff, with a groove
in it of a proportionable size, and a little more bent than the

LECTURE XIX.
233
sound, is to be introduced, the groove being on its convex
part for the purpose of receiving the beak of the gorget; a
double-bladed knife is then necessary for the purpose of cut-
ting into the membranous part of the urethra. With this in-
strument there is an advantage over those in use formerly, as
the opening can be made either large or small, or if it be
found convenient, the groove in the staff must be laid bare,
and the beak of the gorget is to be introduced into it: the
staff is then to be taken from the assistant, and drawing it
gradually towards him, he is to push the gorget forwards in
an horizontal direction until it has entered the bladder, which
is immediately known by the escape of urine and the per-
cussion of one instrument against another. The staff is now
to be withdrawn, and a pair of forceps introduced along the
groove of the gorget; move them about till the stone is
struck against, when the blades are to be opened cautiously,
and the stone grasped at the least diameter, which will be
known by the expansion of the handles of the forceps; it
must then be extracted under the arch of the pubes, inclin-
ing it rather downwards. If the stone be too large to pass
the angle formed by the rami of the ischia, a strong forceps,
contrived for the purpose, must be passed up so as to break it
into pieces.
The gorget has been mostly in use till latterly, and some
considerable improvements have been made in its shape, and
the last of all by Mr. Cline, who was for years considered
the best lithotomist in England, and used no other instrument
than this in finishing the operation. Not only Sir W. Bliz-
ard, but more lately Mr. Astley Cooper, has made an altera-
tion in this respect, and substituted a knife, which, as well
as I can judge, is not only more simple, but far preferable
to the gorget, as the latter is apt to divide the internal puden-
dal artery, which, however, in old people, does not produce
any great hæmorrhage,and is very generally stopped without
much difficulty: it is as well notwithstanding to avoid doing
S0. It is from other disadvantages that the knife has obtain-
ed the preference, and which, as far as I have been able to
30

234
LECTURE XIX.
learn, has been attended with great success, the fatal cases
being but one in twenty. The greatest superiority it possess-
es over the gorget, is, that it is by no means so liable to
slip between the bladder and rectum; a circumstance which
would be fatal to a professional character. The knife I last
saw Mr. Cooper use, was exactly similar to a probe-pointed
bistoury, with this difference, that there is a beak at its end,
and in using it, it should be passed along the groove in the
staff into the bladder, and then make the cut as it is drawn
out again, so as to allow of the stone being extracted.
New method of Operating.
Having properly secured the patient, as already describe
ed, on a table of convenient height, the surgeon seated, and
the staff introduced, which must incline a little to the left side,
so as to rest upon the stone; it must be kept in this position
by means of an assistant: feel for the symphysis pubis, and
'make the incision an inch below, and opposite the arch of
the pubis; and as it would be perfectly unnecessary, it
it should not be too near the scrotum, but rather on the left
side of the raphe, as inflammation would most likely take
place, which would end in mortification and sloughing of
the parts; the incision is to terminate in a line near the mid-
dle of the anus, between it and the tuberosity of the ischium,
having been carried in an oblique direction downwards and
outwards ; this exposes the bulb of the penis, which is cov.
ered by the accelerator urinæ muscle. The next incision
will be through that muscle, when the bulb will lie bare;
continue it, a little below, and on one side of the bulb or
rather betwixt the bulb and the crus penis—then with one
finger of your left hand, press the bulb towards the right
side of the patient—then divide the transversalis perinei, the
transversalis alter, and also the artery which goes to supply
the bulb, which is a branch of the internal pudendal; the divis-
ion of it is readily known by the stream of blood flowing out;
then feel for the staff, which is laid bare in the membranous
part of the urethra, and with the fore finger of the left hand;
LECTURE XIX.
235

carry it up to the groove in the staff—now take the latter in
your own hand, and bring it forwards, so as to rest it against
the arch of the pubes; by this means the knife will readily
slip along the groove into the bladder, keeping the staff in
der, which is to be done by drawing out the knife, and this
divides the prostate latterly, when the staff is to be with-
drawn. Having passed in the forceps, and laid hold of the
stone, it is not to be extracted with violence, but rather wait
a moment until the muscles are a little relaxed, and if any
resistance be found in the beginning, turn the forceps round,
and by gently moving it about until the stone is laid hold of
this do not succeed, introduce it a second time : if the ston
be of a soft texture, a scoop must be used. On the 18th Jan-
uary, 1810, Mr. Cooper operated thus, and extracted thirty-..
seven calculi, of a tolerable size, from a gentleman. When
the stone is very large, Mr. Henry Earle has constructed an
instrument for breaking it in the bladder.
Subsequent Treatment.
The legs of the patient are to be bound together by pass-
ing a bandage around the thighs; the simpler the dressings
to the wound the better : he is then to be laid in bed, and a
dose of opium given. If the internal pudendal artery have
been divided, it may, in general, be stopped by pressure; but
should it still bleed copiously, it will be right to introduce a
piece of firm sponge,perforated through its centre with a canu-
, la, by the expanding nature of which,when it imbibes moisture,
the hæmorrhage will be stopped.
Peritoneal inflammation is the cause of death in most cases
from this operation; and hence, if the abdomen become
swelled, tender, and painful, bleeding must be had recourse
to, both locally as well as generally; fomentations may be
used, immersion in the warm bath—a blister will be advisa-
ble if the pain and tenderness continue: doses of castor oil,
or emollient glysters, should also be administered.
236
LECTURE XIX.

ON LITHOTOMY IN FEMALES.
Women are much less liable to calculi than men, and the
reason appears to be, that from the short, and almost straight
course of the urethra, they are more apt to be carried off by
urine.
The first symptom of stone in the bladder, is a burning
heat felt at the extremity of the meatus urinarius; also an
excessive bearing down of the uterus, with frequent inclina-
tion to go to stool : in other respects the symptoms are siini-
lar to men. Women will sometimes pass calculi of great mag-
nitude, even in some instances so large as from two and a
half to four ounces. I remember once a very singular case
related, where a large stone in its passage through the mea.
tus, stopped half way, and forced a cavity for itself, one
half in the meatus and the other in the vagina, and the sur-
geon who operated was under the necessity of introducing
his finger per vagina to extract the stone, and on examina-
tion it was found to be nearly of an equal size in the mea-
tus and vagina ; that is, it was half in one and half in the
other. As impositions often occur, it is necessary to be on
our guard. Several cases could be detailed bearing on
this point. In one, on examination, a pebble was ex-
tracted : in another, a young woman was admitted into St.
Thomas's Hospital, having, as it was supposed, a retention
of urine; the deception was carried on for some time, and
at last it was agreed that an operation should be performed;
accordingly she was brought into the theatre for that pur-
pose, and bound as usual. On Mr. Cline’s introducing the
sound, he thought that he perceived something between the
stone and the bladder, and having examined again, he was
further convinced of it : on this he introduced his finger per
vagina, and extracted successively nine pieces of coal.-
These are merely detailed to put operators on their guard.
Women with diseased ovaria are most prone to these kind
of impositions.
LECTURE XIX.
237
It has been mentioned by different authors, that the mea-
tus urinarius is capable of being so mechanically dilated, as
to give free access to the bladder, for the purpose of extract-
ing the stone, without having recourse to the knife : this is
done by means of a sponge tent. It was indeed some time
ago noticed by writers on this subject, but was never carried
into execution, till a Mr. Thomas had recourse to the method
in a lady, who had, some way or other, contrived to intro-
duce an instrument used for the ears into her bladder--af-
ter a sponge tent had been suffered to remain for a few
hours, the urethra was so dilated as to admit of an easy
extraction. By continuing the dilatation in this manner
still further, a very large stone might be extracted. It is
from the dilatable nature of the meatus, which allows calcu-
li of considerable size to pass, that the operation in them is
much less frequently required than in men. Various other
means have been employed to dilate the passage, as gentian
root, the gut of different animals, and eel skin. When a
portion of gut is used, it is to be introduced into the meatus
in a collapsed state, then gradually enlarging it with warm
water, it may be withdrawn. Many contrivances have
been proposed besides, but as they are intended to act on
the same principle, it will be unnecessary to state them,
There are chjections started to the employment of these
means, but I think very unjustly ; such as the length of time
sacrificed, being insufferably tedious and painful to the pa-
tient: and the incontinence of urine occasioned by the re-
quisite distention. With respect to the first objection, it is
found in practice not to hold good, generally speaking ; and
as to the second, the operation for lithotomy would be much
more likely to produce it. .

Operation.
Having properly secured the patient by bandages, the
male sound is to be introduced into the bladder—some use
a straight staff, or one nearly so ; the groove of the staff is
to be turned downwards and outwards obliquely, towards
238
LECTURE XIX.

the left side, in which direction the incision is to be made
and not horizontally, as being too near the arch of the pu-
bes; then pass a probe-pointed bistoury, or gorget, along the
groove in the staff into the bladder, taking the staff in the
left hand to serve as a guide; these instruments are imme-
diately to be withdrawn, and you are presently capable of
feeling the stone : introduce a pair of forceps rather curved
-the reason for the curve is, that the stone is mostly situ-
ated on the upper part of the vagina, behind the meatus.
In passing the forceps, depress them at the part where the
handles unite, as much as possible with one finger, as this
will greatly facilitate the stone being raised from under the
pubis : if there be any difficulty found in extracting it, pass
one finger up the vagina, and tilt it into the bladder, and
then it will easily come away.
Incontinence of urine often takes place subsequent to the
operation ; to remedy which, Mr. Hey of Leeds has propos-
ed a very ingenious method, and one which he has practised
with success. The principle of it is to introduce a substance
into the vagina, for the purpose of pressing upon the cut
wound after the operation, in order to produce an adhesive
inflammation of the sides, and render the meatus urinarius
of its original size ; this is to be attempted as soon as the
healing process has begun; the woman is directed to draw
it out when she wants to void urine. It has been thought
very highly of in the profession.
STONE IN THE PROSTATE GLAND.
There are two kinds of calculi found; one originally
formed in it, the other passing from the bladder and lodging
in the urethra within the prostate. The calculi generally
found are small, and their composition appears to be chiefly
phosphate of lime : they are situated between the follicles
of the prostate, several of them emitting from a bag, which
is easily felt per rectum.
LECTURE XIX.
239

IN THE URETHRA.-Calculi are found situated in three
different situations in this canal: but chiefly in the membra-
nous part, at the place where the bulb of the penis commenc-
es, and which, by being so narrow, is often entirely choked
up by them. When called to a patient labouring under the
symptoms of stone in this part, and which will readily be
ascertained by introducing a catheter, which would natural-
ly be resorted to in the first instance, for the purpose of re.
lieving the patient of a retention of urine : if a stone be
discovered in the urethra, be careful not to pass the cathe-
ter any further, for fear of pushing it back into the bladder :
the best plan will be to pass the largest size bougie as far as
the stone, suffering it to remain there until such time as the
patient becomes distressed on account of the bladder being
greatly distended with urine, and is under the necessity of
trying to void it, to relieve himself: at this time withdraw
the hougie, and direct the patient to pass his urine immedi-
ately, and the chances are that the stone is discharged at
the same time ; but if it be too large to allow of this being
accomplished, the operation must then be directly resorted
to, which is similar, at first, to that already described for li-
thotomy, with this precaution, that the finger must be intro-
duced, at the time of operating, by the rectum, otherwise
the stone will certainly be forced into the bladder, and thus
render the operation an extremely difficult one.
When a calculus is situated opposite the scrotum, and an
operation is thought advisable, it would be improper to make
an incision into the scrotum for the purpose, as those parts
are so liable to subsequent inflammation and sloughing.
The manner then in which the extraction is to be accom-
plished, is by first pushing the stone a little behind the scro-
tum, and then making the incision upon it into the urethra,
taking care that the external opening is sufficiently large, as
a great deal of trouble will otherwise be occasioned after-
wards; and not only here, but in the first instance, there
will be a great impediment, if not altogether frustrate the
performance of the operation satisfactorily. There is a tu-

240
LECTURE XIX.
ture objection against opening through the scrotum, which
is, that after this is done, there is almost an impossibility of
withdrawing the stone ; but by the other mode it will be
very easily accomplished, if the external opening be made
to a proper extent, taking care that the incision is continued
quite down to the stone, which may be extracted by laying
open the corpus spongiosum.
( 241 )
LECTURE XX.

NO
ON DISEASES OF THE TESTICLE.
31
THERE are four diseases which the testes are liable to, and
which require the operation for their removal. The first is
of the hydatid kind, where cysts are formed in the substance
of the testes; it mostly occurs to people from the age of
thirty or forty to forty-five, seldom exceeding that pe-
riod. An enlargement first takes place in the external part
of the epidydimis—the continuation of it is downwards :
its progress is slow and gradual, and at last affects the
whole substance of the testicle, and then extends to the vas
deferens ; but never, as far as I can ascertain, so as to di-
sease the spermatic chord, which is free from it, its vessels
being only a little enlarged, and consequently it does not
extend to the abdomen. This disease is unlike all others to
which the testes are liable, and the patient is not subject to
any future danger after an operation, from extension.
- On examining the scrotum after the removal of the testis,
the veins are observed to be in a varicose state, distinguish-
ing it from the affections of the testis; and on cutting through
the scrotum, the veins of the tunica vaginalis will be found
to exceed in size those of the former. The scrotum is not
at all inflamed, having no redness or blush on its surface :
there is a greater determination of blood to the testis than
in an healthy state, and therefore the chance of hæmor-
31

242
LECTURE XX.
rhage, after an operation, is greater than in other diseased
testes. A fluctuation is always perceptible---and this, with
many other similar symptoms, may lead, without cause, to
the supposition, that the disease is hydrocele : but the
distinguishing marks are these—in an hydatid testi-
cle, the fluctuation is confined to one part on applying
the fingers, and is not communicated to the feel gen-
erally, as in hydrocele, when on striking or pressing it in
any part the fluctuation is felt at a distant spot. Besides, in
the hydatid testicle it yields like dough, or similar to anasar-
ca. When there is a doubt, however, by applying a lighted
candle it will not be observed to be transparent. Its weight
also is much greater than that of hydrocele, and of a more
solid texture. The form is not pyramidal, as that of the
testes is much preserved, and a distinction can evidently be
discovered between the latter and the epidydimis. To re-
move all doubt on the subject, it will be right, previous to
the performance of any operation, to make a puncture with
a lancet, and if no fluid escape, then there will be no hesita-
tion as to its nature ; and it may be right here just to ob-
serve, to prevent the injury of a person's character with re-
spect to a false opinion delivered as to the nature of the di-
sease, that when a professional man is asked by the patient
respecting a complaint of this kind, where any difficulty ex.
ists of ascertaining it, to give him an indirect answer; and I
should always make it a rule to puncture with a lancet before
I would castrate any disease of the testicle, as since there
will be every probability of its removal, this small opening
cannot injure it, and yet it may sometimes prove of great
advantage. I remember a case related during my attend-
ance in town, where a surgeon of skill in his profession had
removed the testicle, and on examining it afterwards, found
that there was rather an obscure hydrocele in the vaginal
tunic; so that here the testicle was unnecessarily extirpat-
ed, and might have been prevented by only attending to
the preceding precaution.
The operation for removing the hydatid testicle becomes
necessary from its great size, though the disease has not ex-

LECTURE XX.
tended to the abdomen : on examining it after extirpation,
a number of bags or cysts are found on the side of the tes-
tis of various sizes, and the state of the fluid is always very
different, sometimes of a yellowish colour and ropy, at oth-
er times inflammation has gone on to suppuration ; the coats
of the cysts are extremely vascular.
The second disease of the testes that I shall remark, is the
scirrhous ; this is very rare, and the examples of it, in an
extensive practice, have been very few. It begins in the
body of the testicle, and the edges are much more hardened
than in the centre, the whole composed of coagulable lymph
It gradually and slowly proceeds through the body of the
testicle, and extends to the epidydimis throughout its whole
course ; the spermatic chord becomes hardened, and the
disease extends along its course till a swelling is produced in
the loins. This disease, being slow in its formation and
progress, may be prevented from extension, by an opera-
be known by the strong hard feel it assumes when affected ;
and this, in a great measure, distinguishes it from other dis-
eases. In every case that has come to my knowledge, it
was complicated with hydrocele ; and when the water was
drawn off, the testis presented a marbly feel : it occurs in
old people after the virile powers are lost, generally about
fifty years of age. There is great danger in operating when
the spermatic chord is affected, from inflammation extending
into the abdomen, besides the liability of its being, at the
time, in communication with the glands in the loins. On
cutting open a scirrhous testicle, its appearance is uniformly
white, being full of coagulable lymph, perfectly solid : bony
matter is sometimes found within a cartilaginous substance.
The third disease, that I now come to, is what, till a few
years ago, was called the pulpy testicle, of a cancerous na-
ture : Mr. Wardrop, Mr. Hey, and others who have writ-
ten on this subject, have described it under the name of
fungus hæmatodes. It begins at the external part of the
epidydimis, at that part where it is applied to the testis ; or,
Se
244
LECTURE XX.

anatomically speaking, in the ræti, near the vasa efferentia.
In the first place, coagulable lymph is thrown out, mixed
with blood, in the tubuli semeniferi, perfectly distinct from
the body of the testicle. The disease soon makes its progress
through the body of the latter, owing to the rapid absorp.
tion taking place in this disease more than that of scirrhus,
the substance being applied to the mouths of the absorbents
from its softer texture. Wardrop describes its progress as
slow, with no severe pain attending it-no inequality or
hardness is perceptible—no change in the scrotum : as the
disease increases, it gets soft and elastic, and has that pulpy
feel, from whence the name originally was taken. This
mass, it would appear, is composed of lymph, pervaded by
a great number of vessels, differing from other similar de
posits in this respect, that it is much softer, and less capable
of resisting the impetus of blood. It is a most mistaken
notion to imagine, that it is an unorganized mass, for it is
the contrary. The equal surface and deceptive feel of fluc-
tuation which it presents in the more advanced state, has
misled a surgeon to imagine it to be hydrocele, and it was
punctured with a trocar ; but in fungus hæmatodes, the tes-
ticle gradually enlarges, then the spermatic chord, and by
the disease extending along it, the inguinal glands, which
acquire an immense size. On examining the spermatic
chord, several tumours are found around it of the same
structure as that of the diseased testis–so even of the inguinal
glands, and of the absorbents, even to the thoracic duct,
which has become obstructed in the more advanced stages
of the disease, and a pulpy medullary substance thrown
out on its forming a tumour. It has been supposed, that
from the rapid progress of the disease when once formed,
it is impossible to operate with any rational prospect of suc-
cess ; but this is not altogether true, as in the very early
stages of the disease, it may be attempted. This melancholy
disease occurs more frequently, it is said, in young subjects
than those more advanced in life. I presume I have said
already sufficient to convince the profession, that on the very





LECTURE XX.
245
early performance of the operations, rests the probability
of cure ; and I should consider it hopeless if deferred till
the spermatic chord was affected along its course—should
this be the case, and the inguinal glands also, the less the
surgeon does the better, for death is inevitable.
The fourth disease of the testis, is that of a scrofulous
affection in the anterior of this organ ; a person who has re-
ceived a blow on this part may be liable to it, if his system
be so disposed already from subsequent inflammation, ex-
tending to the labuli, and instead of lyinph, curd-like matter
mixed with pus has been found on dissection: a consider-
able enlargement takes place in the testicle and epidydimis ;
and as the disease is slow, and does not 'extend by absorp-
tion, an operation will be attended with success.
There is another disease liable to affect the testes, and
which requires an operation, although not for the entire
removal of the testicle : it is that of a fungus projecting from
it. Castration here is not necessary, as exposing the patient
to unnecessary danger and deprivation. All that is requisite
to be done is, to make an incision down on each side of it
in the scrotum, and divide the fungus at its neck : then bring
the scrotum together by aligature, and apply a poultice, &c.
to subdue the excess of inflammation. There was a case
some time ago at Guy's Hospital, where the surgeon remov-
ed the testicle completely, and the consequence was fatal.
ON CASTRATION.
Shave the hair off the pubis ; make an incision from the
upper part of the abdominal ring, and continue it down to
the bottom of the scrotum : by extending the incision to the
lower part of the scrotum, matter is prevented from accu-
mulating there during the cure : then, if a puncture have
not been previously made with a lancet, (which ought, in the
först instance, cautiously to be done) cut through the tunica
vaginalis, and observe if there be any water or fluid con-

246
LECTURE XX.
tained : having done so, lay bare the spermatic chord per-
fectly at the ring : if the chord be hardened, expose it about
an inch higher in the oblique canal: as soon as this is done,
direct an assistant to take hold of the chord between his
finger and thumb, keeping it steady, then divide it, and
drawing the chord to you, detach the cellular membrane
behind it, which is easily removed: then take up the sper-
matic artery and that of the vas deferens with a tenaculum,
and secure them by ligature. The external pudendal ar.
tery, and also some other small branches which enlarge un-
der disease, will perhaps require securing. Surgeons for.
merly used to pass a ligature around the whole chord very
tight, but this has now very justly been laid aside, as it was
altogether unnecessary, and gave such excessive pain. The
testicle is easily detached. After the operation is over, the
edges of the wound are to be brought together. Some use
sutures ; but adhesive plaster will mostly be sufficient, aided
by compresses and a T bandage :-if there be much inflam-
mation, the saturnine lotion must be constantly applied.
The artery of the septum, as well as smaller branches that
become enlarged by disease, require securing, otherwise
hæmorrhage would come on.
The testicle sometimes becomes amazingly enlarged, even
to the weight of several pounds ; here it will be obvious an
elliptical portion of the scrotum must be cut out, and this
must vary in extent according to the size of the whole.
ON CHIMNEY SWEEPER’S CANCER.
This disease is denominated the soot-wart. It appears
first in that form on the inferior part of the scrotum, and
extends until an ulcer of some size forms under the crust,
which becomes ragged, with the edges elevated, hard and
scirrhous : then it takes on the nature of the true cancer,
having in the centre a fungous kind of excrescence, the
surface freely bleeding. It is not confined alone to the

LECTURE XX.
247
scrotum, but the membranes lining the testis, as well as the
testicle itself, become ultimately affected by it, and also the
inguinal gland, and it continues its progress until some of
the viscera get diseased. The cause is derived from the
lodgment of soot in the rugæ or folds of the scrotum, and it
is confined to chimney sweepers ; so that it is brought on
them by their occupation, and from the want of sufficient
cleanliness. Mr. Pott remarks, it is not only rapid in its
progress, painful in all its attacks, but most certainly de-
structive in its effects. It is seldom, if ever, seen under
the age of puberty.
The treatment consists in the early extirpation of the dis-
ease before the habit is tainted : if the testicle be affected
already, the operation will be too late. The operation con-
sists in carefully dissecting that part of the scrotum out
where the disease has commenced its ravages, and the sub-
sequent treatment will be to effect union by adhesion of the
wound.
ON TIC DOULOUREUX.
Tic Douloureux is a peculiar affection of some particular
nerves distributed to the face. The ophthalmic, a branch
of the fifth pair, is often the seat of it—the portio dura of
the seventh pair, not unfrequently ; and this is the very
worst situation of the disease, as admitting of no relief as
far as I have heard : but the most common seat of tic doul-
oureux, as it is named by the French authors, is in the sub-
orbitar nerve. This disease is attended with pain so exces-
sive as scarcely to be borne with ; and even persons pos-
sessing great vigour of mind cannot refrain from expressing
the constant anguish under which they labour. The pain
which they complain of is similar to an electrical shock,
causing the patient to start : it is brought on by the most
trifling cause, such as jolting in a carriage, or taking of food.
Prior to the disease being well understood, it was the
custom of practitioners to extract several teeth ; but this was

248
LECTURE XX.
found never to give the least relief, and the only method of
affording ease and effecting a cure has been thought to be
by dividing the nerve : the radial, the sciatic, and also the
tibial nerve have been known to be affected with this dis-
ease, and also an instance has occurred where the lingual
nerves and the gland were affected. One of our best sur-
geons thinks medicine has but little influence in eradicating
it, and the only thing of the sort which this gentleman has
seen of service was a copious application of a solution of
arsenic combined with potash. Practitioners had formerly
recourse to salivating the patient, and a few cases are relat-
ed where it succeeded : but as far as I have been able to
ascertain, there has been no good effects resulting from the
use of mercury. Mr. Abernethy considers it to proceed
from a derangement in the digestive organs, and he has seen
the carbonate of soda of very material service in this afflic-
tion : probably it neutralizes the acidity in the stomach:
great attention should be paid to regimen, exercise, change
of air, &c. to effect permanent relief. The carbonate of
soda should be swallowed a little at a time. Mr. Abernethy
had drank “just as much wine as would do him good,” and
in the night was troubled with heart-burn ; he recollected
having some of the carbonate of soda in the room, and dis-
solved, possibly, as much as two scruples or more in water,
which he drank ; but to the last day of his existence he will
remember the consequences ; his stomach was distended
amazingly, as if he had been blown up ; he was not reliev-
ed till the disengaged gas, which had so enlarged his stomach,
gradually escaped.
Mode of Operating.
The method of dividing the nerve, should it be determin-
ed on, is thus ; supposing it to be the sub-orbitar, feel for
the under edge of the orbit, and half an inch below and
opposite to the middle of it is situated the foramen, through
which the nerve passes, then carry into this foramen the
point of a sharp-pointed bistoury or phymosis knife down

LECTURE XX.
249
the bone under the nerve, then lifting up the point of the
knife, in drawing it out, the nerve is completely divided ;
to be certain of which, however, inquire whether the patient
feels a numbness or not on the side of the nose and upper
lip; if so, then we may be assured it is effectually done;
but if, on the contrary, he does not, then it may be neces-
sary to divide another small twig arising from it—a trifling
hæmorrhage commonly takes place. The ophthalmic branch
is to be divided thus : this nerve passes near the inner ex-
tremity of the upper eyebrow-the knife is to be directed
for the upper and inner edge of the orbit, and in withdraw.
ing it, the division is effected. If the inferior labial nerve,
the bistoury must be passed on the inner side of the mouth
between the gum and the teeth. Alum dissolved and taken
into the mouth will afford in this case some degree of relief.
In a case where the anterior tibial nerve was affected, caus-
tic was used with complete success, not by dividing the
nerve, but irritation produced on the skin. When the por-
tio dura of the seventh pair of nerves is the seat of this dis-
ease, the operation is of no avail, as the branches are so
numerous on the face ; but for the preceding situations it is
sometimes successful, although in the majority of instances
I think it is not so ; and I have known the pain recur before
the numbness had ceased, which commonly takes place in
about three months. Tic douloureux seldom occurs in
infants.
Sisters
ON AURA EPILEPTICA.
The singular affection, which has obtained the above
name, is very similar to the preceding disease. It is com-
monly supposed to have its origin in the particular nerve of
a part, but from what I have seen, and especially from the
history of a case which occurred in Guy's Hospital, I am
of opinion that it has its origin in the brain. The person
who at that time laboured under this complaint was about
32

950
LECTURE XX.
twenty-four years of age : a peculiar kind of tingling sen-
sation came on generally in the evening in thể thumb, which
extended up the arm along the course of the radial nerve,
until it reached the shoulder, when a violent epileptic fit
immediately took place, which commonly lasted above half
an hour. After it was over, the patient appeared as well as
ever, and his appetite equally good. It was conceived, that
by dividing the radial nerve at the part where he felt the
first sensation, that the complaint would have been eradi-
cated ; and accordingly five-eighths of an inch was dissect-
ed off ; but it was not attended with any degree of success ;
and what is very singular, he felt the same sensation in his
thumb as before: having, therefore, given it a fair trial, and
not attained the wished for success, the conclusion was
drawn that its origin was in the brain, and not in the par-
ticular nerve, and there would, in any future case, be a
doubt of the propriety of any operation : the only method
that could be rationally adopted, would consist in regularity
in diet, exercise, change of air, &c. and the exhibition of
the carbonate of soda.
Mr. Abernethy removed half an inch in length of the nerve
going to the ring finger of the left hand, in the case of a
lady afflicted with tic douloureux in the integuments under
and near the inner edge of the nail of her finger. The
skin, &c. recovered its sensibility in three months in a great
measure, but relief was not afforded to the extent anticipat-
ed. The part had been previously cauterized.
er
oor d
ie

( 251 1
)
LECTURE XXI.
ON DISEASES OF THE BREAST.
The breast is subject to a variety of tumours, and not con-
fined, as was formerly supposed, to one, i. e. scirrhus; which
I think the most frequent of all.
The first that I shall commence my description with is
that of the hydatid kind, where there are a number of little
bags or cysts formed. The first appearance that it presents,
is a tumour on the part, occurring in people apparently of
good health ; unlike that of cancer, in the constitution being
but little affected : it is about the size of a pea, and yielding
on pressure, but elastic and returning to its former size,when
that pressure is removed : in this state there is but little or
no pain ; it begins often in one part of the breast, and at
another at some distance, so that the intermediate space is
not diseased ; but this does not long continue, as the whole
substance of the breast soon partakes of it: suppuration next
ensues, and a great deal of pain is now felt, and if the in-
flammation have long existed the tumour will burst, and a
glairy fluid, or inspissated mucus, mixed with a small quan-
tity of matter, will be discharged. A cyst thus opening
remains in a sinuous state, and a fluid is constantly secret-
ed: then another cyst inflames and terminates as above,
and so on, from one to another : if the case were to be left
to itself, it would take some time before a complete sinus of

252
LECTURE XXI.
the whole took place. No ulceration is found in the parts
around. It is confined entirely to the glandular substance
of the breast ;-the axilla is never found affected, which
shows that there is no absorption taking place.
Treatment.
When there is only a single tumour formed, and that very
gent lotions, as in hydrocele, so as to produce adhesive in-
flammation, and an union of the sides of the cyst : but when
the cysts are numerous, we must have recourse to the re-
moval of the breast.
The second disease is A SCIRRHOUS STATE OF THE BREAST.
It most frequently commences with a small sanious discharge
from the nipple : if it be situated at some distance from the
nipple, the patient feels great uneasiness in moving the arm
backwards, so as to put the pectoral muscle on the stretch.
The distinguishing marks of this disease, are its stony
hardness to the feel; and its being perfectly circumscribed,
so that the surgeon can distinctly feel its whole extent and
limits unconnected with the other parts. It is at first very
cle, or to the integuments ; the pain in this disease is not
constant, but attacks the patient all of a sudden, and with
great violence, so much so, that he compares it to a hot iron
but extends along the axillary plexus of nerves : as the tu-
mour increases in size it adheres to the skin, which may be
known by the latter being puckered, having the appearance
of a cicatrix. The cellular membrane sometimes partakes
of the disease, and here the whole breast from the first in-
stant feels of a stony hardness : from which it would appear
that a cancer extends beyond the glandular parts. The
glands in the axilla soon become enlarged. On opening the
part, four or five have been commonly discovered much
increased in size, although not one could be felt externally.
The glands also above the clavicle, just at the point where

LECTURE XXI.
253
the subclavian and jugular vein unite, are commonly dis-
eased. The next course the disease takes is to the inter-
costal muscles, and below the cartilages of the ribs. In
true scirrhus, inflammation is attempted, but it does not last
long ; a purple part around the tumour is formed, which
bursts, and granulations are seen springing up, but differ-
ent from those of other parts, as they are uniformly irregu-
lar: in some places deep depressions are seen, in others,
projections like fungus shoot out from the rest. In this
state of the disease, the pain is not only more constant, but
more severe ; although it is not very tender to the touch,
and the application of the necessary dressings to the part
excites but little sensibility.
A very characteristic mark of this complaint, and one
which serves to discriminate between it and other affections
of the breast, is, a white inverted edge around the wound,
which is of extreme hardness, owing to coagulable lymph
being effused : there is frequent hæmorrhage, and from it
the patient always experiences a degree of relief. The dis-
case is very slow in its first stage, and in the ulcerative
process, so that a patient may exist many years with no
open cancer ; this, however slight, is some consolation for
patients to know, when there is no chance of affording re-
lief by an operation. When about to destroy life, it does
so by its effects on the arm ; the glands being enlarged, by
their pressure on the blood vessels, prevent the free return
of blood ; a great tumefaction therefore takes place, and
commonly an erysipelatous inflammation : if in this state
of the disease a puncture be made, the fluid discharged will
presently coagulate. The tumefaction, together with the
frequent hæmorrhage, soon destroys the patient by produc-
ing great prostration of strength. In true cancer the disease
is much slower in its progress than when it does not assume
its regular form.
A cartilaginous substance is most commonly found, on
dissection, within the breast, very rarely any earthy mat-
ter. The disease mostly occurs in advanced periods of life,

254
LECTURE XXI.
very scldom under thirty-five years of age ; mostly from
forty to fifty ; and it has been seen to occur above the age
of seventy. When a tumour, apparently of a cancerous
nature, takes place before the age of thirty-five, suspicions
may rationally be entertained whether it is a cancer or not;
as, generally speaking, it is rarely malignant before that
period. The operation has been frequently performed, 1 am
sorry to state, when no such disease actually existed. It is
at that period when the menses cease (which is considered
critical to women) that cancer most often occurs. It is also
found to take place in particular families. Blows are to be
reckoned among its principal causes, and it mostly happens
in constitutions predisposed to the disease from particular
irritability of fibre, which affects this disposition : for I wquld
allege, that where this peculiarity of constitution did not
exist, and the patient healthy, scirrhus would not be the
result of a blow : so it is with scrophula, and I believe that
if a person enjoying good health in every respect, were to
be inoculated with the poison of cancer (if there be any
such) it might be done with perfect safety. A case, how-
ever, has been related, which, without attending to the
description carefully, would lead to a disbelief of the preced-
ing remark. In this case, it is said, that a young woman
having drank out of a cup in which the matter of cancer
had been accidentally put, had a cancerous breast some
years afterwards. I must confess I am not inclined to credit
the assertion.
Unmarried women, and those who have never borne
children, are more the subjects of cancer than those who
have had a family and suckled each at the breast : for it is
necessary that the breast, as well as other secreting organs,
should, at its proper period, perform the necessary functions
it was originally destined for ; if then this be suppressed, the
constitution becomes more liable to take on a predisposition
to disease, which a trivial circumstance might afterwards
call into action. Ladies of the haut-ton will not relish this
principle much, I imagine : but if they were to abandon

LECTURE XXI.
255
the erroneous opinions of interested accoucheurs on this
subject, however grateful to the gratification of their amuse-
ments unrestrained by maternal ties, their offspring would
be more likely to thrive, and they would be amply reward-
ed by being rarely the subject of this lamentable disease..
The operation for the removal of the breast is one of the
simplest in surgery. First, make a semi-lunar incision
above the tumour, between it and the axilla, quite down to
the pectoral muscle, in doing which the mammary vessels
sent off for the nourishment of the breast, are necessarily
divided ; then direct the assistant to make pressure with his
finger on those two vessels, which will allow the operator to
proceed with more precision. The next incision is to be
made in the same semi-circular form below the tumour, so
that the two points of each may meet. Many practitioners
advise saving as much skin as possible ; but there is a degree
of care required here, lest any diseased portion be left be-
hind, which would render the operation entirely nugatory ;
therefore, if any portion of skin be found adhering to the
cancerous parts, it is better to remove it, and trust to the
vacancy thus occasioned being filled up by granulations.
Let both the incisions be carried down to the pectoral mus-
ele, and dissect out the tumour close to the latter, so as to
lay it completely bare, removing even the fascial covering,
for if this be not minutely attended to, there will be a very
great probability of the disease returning, or, I may say
with more propriety, remaining.
It is not always to be expected that this simple operation
will be successful, for it sometimes happens from certain
affections of the mind, that the patient does not long survive
it, especially when it is connected with any visceral disease;
and I should invariably make it a rule not to operate when
this could be ascertained to be the case. The glands in the
axilla, if enlarged, are now to be cautiously removed, to-
gether with the intervening substance, as the leaving the
latter would be the future cause of a similar disease being
produced. I am, however, of opinion, that when the glands

256
LECTURE XXI.
in the axilla are diseased, that the operation is useless, as I
never saw it in these cases attended with any benefit, and
therefore I should advise, in case they are found on exami-
ination much enlarged, not to operate. After the breast is
removed, look carefully for the vessels; if the tumour be
small, mere pressure will do, but if large, then it will be
necessary to secure them by ligatures, in order to prevent
present or future hæmorrhage, which, if it should occur,
would effectually prevent the adhesive process. The sides
of the wound are to be brought into contact with adhesive
plaster, covering it with lint and a bandage.
Another disease which the breast is the subject of, and it
is said even more frequent than scirrhus, is the pulpy tumour,
known by the name of FUNGUS HÆMATODES. In dissecting
this tumour after removal, it is discovered that there is more
disease in its substance than in scirrhus. The first appear.
ance that it presents is a small cluster, swelling like a sponge
distended with a quantity of fluid, yielding on pressure, but
returning again to its former size. When this is removed,
it possesses great vascularity, so that the vessels cannot be
entirely emptied on pressure, although the tumour may be
a little diminished. It is almost altogether unattended with
any pain, is extremely moveable, much more so than that
of scirrhus, and perfectly detached from the surrounding
parts. It has not that marbly hardness scirrhus has, and
this, with the want of pain, distinguishes it from the latter.
This tumour grows from that tendinous substance which
connects the parts of the breast together, and not unfre-
quently from the fascial covering of the pectoral muscle.
This, like scirrhus, has an imperfect suppuration going on,
but the progress of it is different ; first, in its being larger,
and forming a cyst which contains a large quantity of fluid ;
this, when discharged, has the appearance of whey mixed
with pure matter. In this respect it is something similar to
the hydatid breast, but it does not in this disease admit of
any relief from injection. It is more rapid in its progress
than true cancer, spreading, from absorption, to the glands
LECTURE XXI.
257
in the axilla, which are generally considerably larger than
in cancer.
How far the operation may be proper, when this enlarge-
ment of gland has taken place, is yet to be determined; but
I think the operation in these cases would be quite useless.
It is necessary in the removal of the breast in this disease,
to prevent a recurrence of it, to take particular care that
the whole of the breast is removed, and even parts at some
distance from it: the aponeurosis of the pectoral muscle is
to be also taken away. The great debility and prostration
of strength caused by this disease is to be attributed to the
quantity of fluid constantly discharged, and hence often by
removing the disease the patient recovers, although in an
exhausted state, which will require time and great care to
surmount. From the vessels being much larger in fungus
hæmatodes than in true scirrhus, it necessarily follows that
the hæmorrhage is greater, and more vessels require to be
secured after operating,
some
There are several other diseases to which the breasts are
liable, but one that I shall particularly dwell on, as it has
often been erroneously mistaken for cancer, and is an affec-
tion generally curable. It is what I would term an IRRITA-
BLE TUMOUR. It often occurs in florid young women of san-
guine temperaments, most frequently before marriage, and
in those who have not had any children from the age of
seventeen to twenty-one, when the passions are strong, and
call for desires that are not satisfied.
The discriminating marks between this disease and
scirrhus are two-fold; first,' its exact limits cannot be ob-
served, i. e. where the tumour ends and the glandular sub-
stance begins, as can be known in scirrhus ; and, secondly,
an extreme tenderness to the touch, even from the slightest
pressure, and this not only for the moment, but is prolonged
for hours afterwards; yet there are no marks of external
inflammation, no redness of the skin, &c. This disease is
capable of being remedied, but from the want of knowledge
of the case, it is often unnecessarily the subject of removal.


33

258
LECTURE XXI.
As this affection originates at, or soon after puberty, the
remedy I should recommend, and one which has been known
several times to be attended with complete success, is Dr.
Griffith's mixture. À stirnulating plaster should be made
use of, such as the empl. lytharg. comp., the empl. ammon.
comp., or even the empl. saponis. The breast is to be kept
warm by means of flannel, fur, or by a bladder of warm
water occasionally renewed. Change of temperature aggra-
vates the disease.
It is from the cure of this complaint that certain prac-
titioners, some professed quacks as well as others, have
arrogated to themselves the skill and credit of having cured
cancerous affections ; but practitioners of credit and repec-
tability ought not to be cajoled by such puffers ; as there is
actually no remedy yet found out capable of eradicating
the latter disease. In opening the breast, after removal of
an irritable tumour, the common appearance it presents is
a little thickening of the glandular substance, owing to the
arrangement and nature of the coagulable lymph effused.
( 259 )

base LECTURE XXII.

MU
N AMPUTATION.
Previous to performing this operation, a tourniquet is to be
properly applied, so as to make sufficient pressure on the
principal artery : if the lower extremity be to be removed,
it should he secured one-third the thigh downwards, as the
artery passes here close to the bone, and can be readily
compressed ; if the upper extremity, it should be put on
two-fifths downwards on the upper edge of the biceps muscle.
FINGERS OR TOES.-- The same method is applicable to
either. If the second or third joint of the former requires to
be amputated, let an assistant, with a piece of tape, separate
the fingers, so as to leave enough of room ; then make a
circular incision beyond the joint, and a cut on each side as
far as the joint, for the purpose of forming two flaps, which
are to be raised ; then turning the finger on one side, divide
the tendons and lateral ligaments on the inner and lateral
parts, and pass the knife into the joint and separate it ; the
flaps are then to be brought together, and retained with
adhesive plaster.
The first joint is rather more difficult, and this consists in
the situation ; for it should be recollected it is from the
knuckle about the one-eighth part of an inch. There are
two lateral or angular incisions to be made, and supposing
it is the fore-finger, the first is to be on the outside and

260
LECTURE XXII.
carried to the back of the joint, the other in a similar direc.
tion cutting between the fingers, so that both incisions may
meet, forming a kind of triangle ; the extensor and two
flexor tendons are next to be divided down to the joint, then
depress the finger, cut the ligament open and separate the
finger; the parts are to be brought together with adhesive
plaster.
Observe. It is seldom requisite to secure any artery ; but
should the bleeding be profuse, a ligature may be applied...
Tarsal Bones.—It is often required either from a mor.
tification of the toes, caused by being frost bitten, or disease,
to remove these parts. I should think it far preferable to
amputate the tarsal bones, to taking off the limb below the
knee, for several reasons: the patient not only suffers less
constitutional irritation, but has a greater advantage in the
use of his leg. A circular incision is to be niade about the
middle of the foot, and two lateral ones, forming two flaps,
exactly similar ; these are to be raised, and turned back.
It is requisite that the tendons and muscles should be divid-
ed quite down to the bones, especially at the bottom of the
foot, which are large, and seated very deep : the bones are
then to be sawed through. There are three arteries to be
secured by ligatures—the anterior tibial, and two plantar
arteries : the edges of the wound are to be brought together
with adhesive strapping
Below THE KNEE.—Amputation may be done by means
of a flap, or what is undoubtedly preferable, the circular
operation, as there are many objections to the former mode,
which is now generally abandoned by the profession : the
constitutional irritation is more considerable, and if any
subsequent hæmorrhage should take place, the difficulty of
finding the artery will be great; besides, taking down the
flap after adhesion has once commenced, will be attended
with evident inconvenience, and it will be almost impossi- :
ble a second time to procure union by the adhesive process. »
Another disadvantage attending it is, if any portion of bone
exfoliates, which often is the case in robust people after ac-
LECTURE XXII.
261

cidents, there is great difficulty in the removal of it. The
one advantage, however, experienced from its adoption, is
that a cork leg will fit with more ease and comfort, conse-
quently it is generally preferred by people of fortune. In
the inajority of instances this cannot be effected, as the
greater bulk of patients are not able, on pecuniary accounts,
to be thus accommodated with artificial legs : I, therefore,
would never advise this mode of operating, excepting in
cases, where from disease, or other causes, little integu-
ment would be saved otherwise. It may be done thus :
having secured the artery with the tourniquet, push a catlin
under, and through the muscles, posteriorly to the fibula,
bringing it out at the opposite side; then measure the quan-
tity of integument necessary to cover the stump, and cut
downwards close to the bone, by a longitudinal incision, as
far as is requisite for the purpose : let this be intersected by
a semi-circular incision. A semi-lunar incision must then be
made on the opposite side, which must depend upon the
want of integument, as to the extent it should be raised.
The interosseal ligament is now to be divided with the cat-
lin, and then the bones are to be sawed through with the
convexity downwards. There are three arteries to be tak-
en up : the anterior and posterior tibial, and the peroneal.
The integuments are then to be brought together with ad-
hesive plaster.
The circular operation is to be thus done : ascertain the
quantity of integuments necessary, which will depend upon
this circumstance-if the limb be wasted from disease, two
inches will be enough; but if after an accident amputation
be necessary, never less than three or four inches. Make
a circular incision six inches below the knee joint, so as to
cut througli the integuments and fascia at the first stroke of
the knife, taking care not to touch the muscles ; then dissect
the integuments back from two or four inches, and retain
them in that posture while the muscles are cut through by a
similar circular incision, close to the retracted skin ; then
with a catlin divide the interosseal ligament, and saw the

262
LECTURE XXII.
bones through about four inches below the patella : while
this is doing, an assistant must hold the limb in a straight
line with the thigh, otherwise the bones will be liable to be
splintered. The same arteries require securing, and the
same after treatment as in the flap operation. Observe.-In
these operations it will be best to saw both bones through
at the same time.
ABOVE THE KNEE.--Compressing the artery properly, and
the limb being supported by an assistant, a circular incision
should be made immediately above the knee joint, or as near
to it as possible, so as not to cut into the latter : if the dis-
ease requiring the operation be scrophula, the incision must
be made higher up, as the collection of matter pushes the
tendon of the rectus muscle higher up. Generally from two
to three inches above the patella is the proper place to com-
mence making a complete division of the integuments and
fascia, which adheres to the tendons of the rectus and
triceps : the integuments can then easily be retracted or
drawn back three inches in length, which is enough to be
saved. The muscles, &c. are then to be cut through by an-
other circular incision down to the bone, which is to be saw-
ed through. The only artery of consequence is the femoral;
some small branches will occasionally be required to be
secured besides. A roller must be applied for the purpose
of keeping down the muscles, and preventing their retrac-
tion, otherwise the bone will be apt to project. The in-
teguments are to be united by strapping. It is usual both
here and below the knee to cover the adhesive plaster with
a pledget of soft tow or lint, to be retained by linen, or a
laced stocking. It is also customary to give an opiate when
the patient has been put to bed. The tourniquet must be left
loose about the limb.
REMARKS, AT THE HIP JOINT.—It would be extreme mad-
ness, it is thought, to attempt this operation : I am not
aware it has been performed but a very few times, and these
patients did not survive more than twenty-four hours after-
wards. It can only be warrantable in one particular case ;
LECTURE XXII.
263

when a shot has shattered the head of the bone, and the
patient is of a thin and spare habit : but in a diseased state
of the parts, as in scrophula, for instance, it would be of no
utility, as the acetabulum is also affected, and cannot be
come at, as in amputation at the shoulder joint, where the
cavity of the os humeri can be exposed.'
Below THE HIP JOINT.—If attempted here, the femoral
artery must of course be taken up; there can be no doubt
as to sufficient nourishment being afforded to the stump. An
incision must be made, so as to find the artery just as it
emerges from under Poupart's ligament, pass a broad liga-
ture under it, and tie it loosely, so as to secure it for the
moment ; let an assistant hold the ligature : then make two
semi-circular incisions, so as to form two flaps, one above,
the other below; raise them sufficient to allow the bone to
be sawed through. The profunda circumflexa and ischiatic
arteries are to be secured, the ligature then is to be remov-
ed from the femoral, and another ligature on Dr. Jones' plan
is to be substituted. The integuments are to be brought to-
gether in a similar manner to what I have previously de-
scribed. Sinif m etode into
AT THE HIP JOINT.— The operation here is nearly the same
as below it—the femoral artery must be in the first instance
secured ; the other arteries had better be taken up as the
operator proceeds in forming the two flaps, which are to be
carried further up, and instead of sawing through the bone,
cut through the capsular ligament and ligamentum teres, and
remove the bone from the socket.
AT THE WRIST JOINT.—It is a great object, when it can
possibly be done, to amputate at the wrist joint, as the
operation is very simple, and the symptoms of irritation
much less than when it is done below the elbow. First, feel
for the styloid process of the radius, and one inch below
cărry a circular incision around the wrist, then dissect the
integuments back to the styloid process, at which part, by
turning the hand to the opposite side, the opening should
be made into the joint, and the operation is easily effected.

264
LECTURE XXII.
It is particularly necessary, in this case, to save sufficient
integuments to cover the joint, as no union by granulation
will take place if the cartilage be exposed, unless it is pre-
viously absorbed, which would be a long and tedious pro-
cess, and the certainty of ultimate success would be uncer-
tain. Three arteries are to be secured, the radial, the
ulnar, and interosseal, now become the external interosseal.
THE FORE-ARM.—The operation here should be avoided as
much as possible ; I would much rather always amputate
above the elbow, for the stump of the fore-arm is useless,
and it is besides much more dangerous to do it, on account
of the great number of tendons which must necessarily be
divided, and which will suppurate and slough through the
whole extent of the arm. This almost always happens, and
instances have been seen of death occurring from it ; if the
fore-arm be to be removed, it is desirable to do it, as near
the elbow as possible, because here the cut is made through
more muscular parts. It is very similar to the operation
below the knee-a circular incision through the integuments,
which are to be drawn up sufficient to cover the stump,
another cut through the muscles, then use the catlin to sever
those parts between the bones, and in sawing turn the hand
upwards, stand on the outer side, and saw both bones
through at once : four arteries require ligatures, the radial,
ulnar, and two interosseal.
The operation at the arm is exactly similar to the thigh,
the structure of the parts being much alike. If very high
up, the artery cannot be compressed with the pad of the
tourniquet ; it then must be firmly pressed on as it passes
over the first rib by an assistant—the principal artery is the
brachial, but small branches will now and then require
ligatures. Some knowing ones made a whole sheet of this
operation ; after a circular incision is made, the biceps is
to be divided, then the muscles in front of the arm bending
the elbow, then straightening it, the triceps may be cut
through, next the brachialis internus, &c. ; all this is very
amusing, no doubt, but I have too much respect for the

LECTURE XXII.
265
junior members of the profession, to desire they will retain
more of this detail than they can rationally digest, which
puzzled me at first to know what it meant. ,
SHOULDER JOINT.—This operation, it is found, may be
done with great safety, even when there is considerable en-
largement of the limb, as from exostosis, &c. It may be
performed in two ways. First, cut down and secure the
axillary artery, which will be found concealed by the nerves
of the brachial plexus, some of which it will be found im-
possible to avoid dividing without very great care is taken,
then make a flap of the deltoid muscle, cutting it upwards
until the head of the os humeri is exposed, forming the an-
gles of the flap above, so as to make it of a semi-circular
form, and if the circumflex arteries bleed freely, they must
be immediately secured; then carry the incision round the
under part of the limb until the bone is here again exposed,
incline the bone upwards and backwards, and a cut can
easily be made into the joint at the under part, and dividing
the capsular ligament, the head of the bone is easily dis-
located from the glenoid cavity of the scapula, then bring-
ing down the flap which forms a cushion over the joint, it is
to be retained in that situation by adhesive strapping.
One objection to this mode of operating, is that the flap
does not unite to the glenoid cavity ; this latter being a se-
creting surface, and covered with cartilage, the secretion
accumulates, and sinuses are formed from ensuing inflam-
mation ; to counteract this objection, the cartilage of the
glenoid cavity must be scraped off ; thus the secretion will
he prevented, and granulations will arise, which will unite
with the flap.
SECOND MODE.—If there be any enlargement of the os
humeri or other cause, that a flap cannot be made of the
deltoid muscle, a double flap may thus be formed-secure
the artery as before, then make an incision obliquely at the
anterior and upper part of the arm, carrying it down to the
axilla, so as to form a flap, then make another incision on
the opposite side, exactly similar, commencing at the upper
34

266
LECTURE XXII,
point of the first incision, and meeting it below; the head
of the os humeri being exposed, turn the arm backwards,
easily separated ; the cartilage must be cut off from the
glenoid cavity, the arteries must be secured by ligatures, as
in the other operation, then bring the flaps together. This,
I conceive, makes a much neater stump, and one which will
possess more living powers than the single flap, and I have
understood two surgeons of eminence intend adopting this
plan; besides the circumflex, the superior scapular artery,
which is large, will require a ligature, and also various
communicating branches.
I think in both these operations it will be better not to
secure the axillary artery in the first instance by ligature :
pressure properly made on the artery as it crosses the first
rib will be sufficient to restrain hæmorrhage till the operation
is complete, when it may be secured with the others.
Remarks. When ligatures remain a great while, they
should be drawn tight every day, by means of a small piece
of wood or bougie twisted round their ends.-I have again
to observe, that the first dressing after amputation should
not be removed under a week. In gun-shot wounds, where
the head of the os humeri is shattered, Baron Larrey, and
other military surgeons, have succeeded in removing the
splintered portions of bone, and rendering amputation at
the shoulder joint unnecessary ; the arm must be afterwards
supported in a sling, so as to keep the end of the humerus
as far upward as can be done.
y som sa ost
TO
105 er binte sotadi
e to mesto in
po
( 267 )
LECTURE XXIII.

Best als bis zumal & ses cama st
903 STEVE
t
ardio ON HERNIA. DO
HERNIA is a disease of a most important nature, on account
of its frequency, and of the very great and imminent danger
to which the person afflicted with it is liable : it has been
improperly termed a rupture. Hernia means the protru-
sion of some viscus from its proper cavity, by which a
tumour is formed, sometimes internally only, but mostly
externally. :-according to the acceptation of the term, it
might with propriety be applied to any swelling produced
by the dislodgment of parts from the boundaries within
which in a state of health they are contained : those only
are applicable to surgical treatment in which the tumour is
perceptible. It is a disease to which every human being is
subject at every period of life, and from a great variety
of causes.
The situations of these tumours are as various as their
contents. There are as many as twelve different species,
which have obtained their names from their situation ; as the
bubonocele or inguinal, when the sac and its contents extend
only to the groin : oscheocele or scrotal, when in the scro-
tum : crural or femoral, when below Poupart's ligament in
the thigh (this is most frequent in women) : the exomphalos
or umbilical, at the navel : the ventral, when the protrusion
has taken place at the linea alba or linea semilunaris : the


268
LECTURE XX11.
ee
pudendal, when descending between the vagina and the
ramus of the ischium, forming an oblong tumour in the labi-
um : the vaginal, when it protrudes in the space between
the uterus and rectum. The perineal between the bladder
and rectum in men, between the vagina and rectum in
women. The thyroideal, or hernia foraminis ovalis, when it
protrudes through the obturator ligament, descending be-
tween the obturator muscles. The cystocele, when the uri-
nary bladder is included. The ischiatic, (which is very
rare) when at the ischiatic notch. The phrenic, when pro-
truding through the diaphragm : and the mesenteric and
mesocolic, when through the mesentery, or mesocolon. ilmu
If the contents of the hernial sac are only intestine, it is
called enterocele, or intestinal hernia : if omentum only,
epiplocele, or omental; and if both, entero-epiplocele, or
compound hernia : with respect to its other contents, the
names are derived from the contained viscus; if the stomach,
gastrocele ; if the liver, hepatocele ; if the urinary bladder,
cystocele, &c. The contents may be distinguished from
each other by a careful examination : if omentum only,
there is an irregularity in the feel, and the tumour is com-
monly of an oblong shape ; if intestine, it forms a more
smooth, round, and elastic substance, and appears as if dis-
tended with air, which it is. When both omentum and in-
testine are included, the same rounded form presents itself,
as if intestine only ; but by examining more minutely, the
irregularity of the omentum is perceived. Thus, so far, the
contents may be known ; the other parts occasionally oc-
curring in hernia are not so easily to be discriminated ; if a
portion of the urinary bladder, the feel is denser, and by the
account of the patient an opinion may be formed. In the
morning when he rises he finds the tumour very large,
which is the contrary to the others ; and at night it will be
scarcely perceptible. This is easily accounted for. The
patient has a considerable quantity of urine collected in his
bladder in the morning, hence the distention, while previous

LECTURE XXIII.
269
to his going to rest the urine is evacuated ; and thus, the
cause of the diminution is obvious.
OF INGUINAL HERNIA.
This species of hernia has been divided into four different
kinds ; the most frequent of which is the oblique, which takes
the course of the spermatic chord. The second, by no
means unfrequent, though less so than the oblique, is that
which passes directly through the abdominal ring, and hence
called the direct hernia. The third is the hernia congenita,
where the intestine, or omentum, is in contact with the tes-
tis within the tunica vaginalis. The fourth and last, is that
in which a cyst is formed within the tunic itself, when the
contents are either intestine or omentum.
By considering each, individually, more correct ideas
will be entertained on this subject; and it is of importance
to the student to preface it with an anatomical description
of the structure of these parts, without which it is impos-
sible to understand the ensuing details, and I may observe,
it is to Mr. Astley Cooper the profession at large is indebted
for the very able and accurate exposition of the anatomy
of hernia. tot
When the integuments are removed, the lower part of the
abdomen is covered on the fore part by a tendinous expan-
sion, and on the side by muscular fibres, which are derived
from five pair of muscles : as this expansion ascends it be-
comes narrower: in it, at the lower part, are two holes, or
openings, called the abdominal rings, formed in the male
for the transmission of the spermatic chords, and the round
ligaments in the female. These rings, or openings, are made
up of two columns of tendon, the upper column passing into
the symphisis—the lower, into the tuberosity of the pubis ;
and these columns are joined by transverse fibres, and are
of an elliptical, or, as some think, triangular shape. These
I shall call the external abdominal rings.

270
LECTURE XXIII.
Midway between the pubis and ensiform cartilage is a
hole, or opening, called the umbilicus, or navel, formed for
the passage of the umbilical chord, which is composed of
two arteries and one vein. The arteries and vein are
never found to perforate the peritoneum, as has been
supposed, as it is as compact as in any other situa-
tion : the arteries pass upwards from the bladder, while
the vein passes between the tendinous expansion and the
peritoneum to the liver. The white line which is seen ex-
tending from the pubis to the ensiform cartilage is the linea
alba : on each side is the linea semilunaris, which begins at
the cartilage of the seventh rib, and is continued on each
side just above the body of the pubis. The lines extending
in a transverse direction are called the linea transversalis.
The external abdominal ring appears merely to be formed
by the splitting of the fibres of the external oblique. Mr.
Pott considered that the chord took its course behind the
ring directly into the abdomen. Albinus has shown in his
plates that the chord took an oblique course.
The abdominal ring is shut up, and well protected by the
tendons of the external oblique and transversalis muscles-
and behind them, by that of the rectus: and to effect this
still the more effectually, there is a fascia which passes up
behind these tendons ; from the deficiency of which, no
person could stand upright without the hazard of the pro-
trusion of some of the abdominal contents through the in-
terstices, and this forms the only partition between the
peritoneum and the external abdominal ring. I shall now
describe its origin.
Poupart's ligament, or crural arch, is a doubling of the
external oblique, and is extending or stretched from the
spine of the ilium to the tuberosity of the pubis : this liga-
ment splits into three distinct portions or fascia ; two pass
upwards and one downwards—the portions it sends upwards
would be supposed at first to be peritoneum. The first is
the fascia transversalis—one small portion of which passés
downwards under Poupart's ligament to form the anterior

LECTURE XXIII.
271
part of the sheath of the femoral vessels ; the other part passes
behind the transversalis muscle, and forms a lining to it all
the way up : now in this fascia is an aperture or opening,
situated midway between the spine of the ilium and crus of
the pubis, which is easily discovered by the little resistance
opposed to the fingers, and this aperture is the internal ab-
dominal ring through which the spermatic chord is observed
to emerge from the abdomen, passing in an oblique course,
in a kind of canal, under the edge of the internal oblique
and transversalis, and the obliquity is downwards and for-
wards, from one inch and a half to two inches previous to
its arrival at the external opening. jos seankie
The second fascia, is the fascia iliaca, which passes over
the muscles of that name : this shuts up the space under-
neath Poupart's ligament, while the fascia transversalis pre-
vents the viscera from getting underneath the transversalis
muscle. The portion it sends downwards is the fascia lata
of the thigh, the inner part of which comes from the pubis :
a part of this fascia is derived from the gluteus maximus
muscle ; there is a passage for the femoral vessels under
Poupart's ligament or crural arch, the interstices of which
are filled up with fatty substance, and lymphatic glands :
this, and the external abdominal ring, are the only two
natural openings through which the femoral and inguinal
hernia protrudes : this will be more accurately described
when I shall treat of femoral hernia. The lower portion of
the obliquus ascendens internus passes through the abdominal
ring with the spermatic vessels, and then forms the cremaster
muscle.
In the description of hernia, it is requisite to understand
perfectly the nature of the herniai sac. In hernia there is a
smooth polished membrane in which the protruded parts
are contained ; this is denominated the sac, and is nothing
more than an elongation of the peritoneum. In some parts
of the cavity of the abdomen this membrane is more loose-
ly attached than in others, and this is perceived to be the

272
LECTURE XXIII.
case at the lower part of the abdomen. It was, a few years
ago, thought impossible for the peritoneum to admit of such
a degree of distention as to surround tumours containing
such large portions of the viscera as are sometimes pushed
out ; but it is now found that the peritoneum has the power
of extension to a very great extent, and will accommodate
itself to the degree of elongation necessary : the hernial
tumour has been seen so extremely extended as to reach
the knees of the patient, and in this sac of peritoneum were
contained almost all the viscera of the abdomen. I knew
two gentlemen, the one an archdeacon, the other a publican,
who had enormous hernial protrusions, although not to the
extent I have heard mentioned by gentlemen, and particu-
larly by Mr. Cline, sen. All the living parts are found
capable of increasing in size, according to the emergency
of the case required—and this is the case with the peritone-
um. When the sac first protrudes, it is loosely attached, and
is capable of being returned; but when hernia has existed
for some time, and is become more extended, the external
surface is found to adhere to the contiguous parts, so that to
return the sac with the contents, is a thing wholly imprac-
ticable, unless in a very incipient state, as the adhesions
are such as not to admit of its being done. In consequence
of this sac, or elongation of the peritoneum being protruded
through the abdominal ring, it is liable to undergo some
changes—it is found to be more dense, and unyielding in its
structure ; sometimes it is found narrower at one part than
at another, and this is mostly found at the part where it is
protruded from the abdomen ; this is denominated the ori-
fice, or mouth of the sac—other parts of the sac are liable
to become contracted, and possess considerable density:
these contractions are occasionally found to arise from the
pressure of trusses on the pubes, which compresses the
part so forcibly as to cause it to become thickened and con-
tracted : there may form three or four of these, and fre-
quently when the operation for hernia is performed, it is
necessary to dilate them one after the other: another cir-
LECTURE XXIII.
273

cumstance that is frequently found in an hernial sac, is
transverse membranous bands, which are a considerable
impediment to the reduction ; these bands are extending
from one side of the sac to the other; they are formed from
the existence of inflammation for some time, by which
coagulable lymph is continued to be effused till the sides of
the sac are united, and by extension might be elorgated, and
form these bands. There is a possibility of there existing
more than one hernial sac at a time : Mr. Cline, sen. acci-
Pentally found an instance, some years ago, of this kind.
He found the two sacs formed on the same side, so that
more than one protrusion might have happened, constitut-
ing a kind of double hernia—it is a very rare instance, and
seldom occurring.
In the formation of hernia, they are mostly coming on in
a very gradual and insensible manner : but occasionally
they are found to be produced suddenly. Hernia are very
properly divided into three different and distinct states :
the reducible, or when the contents are easily replaced in the
abdomen, suffering no constriction ; irreducible, when the
contents cannot be returned, from their size, and the small-
ness of the aperture, yet suffer no impediment in their func-
tions, the intestinal canal not being interrupted ; and stran-
gulated, or incarcerated, where there is constriction, and
cannot be replaced.
fen
OF OBLIQUE INGUINAL HERNIA. c
This species commences midway between the spine of the
ilium and symphysis pubis. The first appearance of the
tumour is over the iliac artery, where it will be found pulsat-
ing. A small portion of the peritoneum first protrudes over
the spermatic chord, forming the sac ; on the inside is the
epigastric artery. As it descends it is confined by the
oblique muscle, so that it turns downwards and outwards.
After passing about two inches, it emerges through the
abdominal ring. In its course above the ring, it has the
35

* 274
LECTURE XXIII.
tendon of the obliquus externus before it, the spermatic
chord behind, and posterior to this again, the tendons of the
internal oblique and transversalis. When it gets through
the abdominal ring into the scrotum, it ridiculously has the
name of scrotal hernia. The protruded parts have three
coverings : the first is the aponeurosis of the external
oblique muscle ; next to this, is the cremaster, which is very
dense if the hernia has been long down; and then the her-
nial sac itself appears, which is the thinnest of the three.
A knowledge of the existence of these coats, is of the very
first importance ; for, without it, a practitioner may, with
great caution, in dissecting fibre by fibre, chance to do no
injury, yet he spends a great deal of unnecessary time in
the operation. In the scrotum, the sac is situated anterior
to the chord, which is behind-below are the testes—on the
inner, or pubic side of the mouth of the sac, is placed the
epigastric artery.
: Diagnosis.—Hernia is known from other tumours near
the ring, by its dilating hy coughing ; by its descending in
the erect, and returning in the horizontal posture : besides,
if intestine be present, it returns with a guggling noise.
Hernia most frequently appears on the right side, at least in
the proportion of sixty or seventy cases out of an hundred,
according to Mr. Astley Cooper. Hernia sometimes ad-
vances, as I have previously remarked, to an enormous
size, even to reach as far as the knee : here the parts are
so thin, that the motions of the intestines can be perceived :
this, I may observe, is most common in umbilical hernia.
Inguinal hernia is sometimes liable to be confounded with
hydrocele, for in this latter disease, it now and then hap-
pens, that the water reaches as high up as to form a double
tumour, that above of a rounded, that below of a pyramidal
shape. The tumour, as in hernia, dilates by coughing. Do
not decide too hastily; examine it with attention, and a
transparency will be discovered. Varicocele, or an enlarge-
ment of the spermatic veins, is still more likely to be mis-
taken ; as this dilates, by coughing, from the return of the
S
NONE
LECTURE XXIII.
275

blood : also if the patient is directed to lie down, the tumour
will disappear like hernia, but returns in an erect posture.
To distinguish it, let the patient be placed in an horizontal
position, then by lifting up the testes, empty the veins into
the abdomen ; after this is done, place your finger on the
abdominal ring, direct the patient to rise, and if it be hernia,
no descent will take place; but if varicocele, the scrotum
will soon be filled as before. Inguinal hernia is also apt to
be confounded with an hydrocele of the spermatic chord.
This disease, when it takes place between the ring and ab-
domen, protrudes, and can be nearly pushed into the abdo-
minal cavity ; but although a small tumour should still re-
main, no man would operate for hydrocele, except it was
transparent. There are, besides what I have enumerated,
cases of a complicated nature, as hernia combined with
hydrocele : the chord is now and then split into two portions
upon the hernia, the vas deferens being on one side, and
the spermatic artery and vein on the other. On this account
it will be right, in operating, to be cautious in avoiding any
vessels, by cutting at all on one side, as the slightest devia-
tion from the centre of the tumour might prove fatal.
Causes.—Any disease which occasions an enlargement of
the viscera, so as to increase their pressure on the parietes.
Obesity and pregnancy may also be ranked as causes, but a
more frequent one is that which affects the abdominal parie-
tes in old age. Any cause acting too powerfully on the ab-
dominal muscles will induce pressure on the viscera on those
parts which may be naturally weaker than the rest, as at
the navel, abdominal ring, &c. and force a protrusion—such
aš jumping, riding, lifting heavy weights, blows, kicks, &c.
especially, after a severe illness. Those who have had
strictures are liable to hernia.—Want of strength, and defi-
ciency in the abdominal parietes ; warmth of climate, by
relaxing the body, and much exercise, may be reckoned
causes. Many think, but it is not generally credited, that
those who live on oleaginous substances are more subject to
hernia. It is more frequent in France than in this country,
276
LECTURE XXIII.

which may be attributed to the nature of the climate...
Though it has been asserted that one in nine have hernia,
yet it is thought one in fifteen is more likely to be nearer the
point. In old people hernia is generally discovered, and if
an allowance is made for women and children, the propor.
tion will be as above stated. was abou t

Treatment of reducible Hernia.
It is absolutely necessary for a person, the moment he
discovers a hernia, to have a truss applied ; even though
the tumour may be but small, and occasion no great incon-
venience, and easily returnable, for the danger is propor-
tionably greater. To measure a person so as to have him
accurately fitted, all that is required is to carry a string
round the pelvis, just above the abdominal ring. Trusses
are made of an elastic substance, generally of steel, so con-
structed as to keep up constant pressure, sufficient to resist
the action of the muscles, and so formed as to allow of the
patient's going about his business as usual. In applying a
truss, be careful to let the pad rest midway between the
spine of the ilium and crus of the pubis over the iliac arte-
ry, so as to reach as far as the abdominal ring, and not di-
rectly upon it, as is usually done. The truss-maker should
be instructed to make the neck of the truss short. In case
the hernia is very large, the pad is to be placed at right an-
gles, so as to have a perpendicular bearing from the ring
upwards. The reason of this is, that owing to the size of
the hernia, both rings, that is, the internal aperture and ex-
ternal, are brought nearly into a straight line. There is one
very material objection to Salmon's patent truss, which is, that
the patient cannot wear it at night,which is absolutely necessa-
ry to attain a cure. To effect a cure, a truss must be worn sev-
eral years: from pressure an obliteration of the mouth of the
sack happens, and hydrocele sometimes occurs afterwards,
which may be treated in the usual manner. A well con-


LECTURE XXIII.
277
structed truss, properly applied, so as to keep up an uniform
pressure for a long continuance, will cause the internal part
of the sac to be thrown into folds, in consequence of the
contraction of the cremaster muscle, which is occasioned by
the pressure, so that ultimately a thickening of the mem-
brane is produced, which occasionally is found to be com-
pletely united, so as to effect a permanent cure.
se commande tot agenten
da bodo povet sout of its 2 18 100
og moderno se sme da se taomsa git
se p
resents
JERATC) Da
2004
t e de a contar con la
ta soto
kong i-
1
test breason of 22413
en blonde bois un nesasta
asso tant
e coste
the start out o n annet
( 278 )

Gak LECTURE XXIV.

IRREDUCIBLE HERNIA.
Or this species there are two kinds, one in which there is no
inflammation, the other attended with strangulation. It may
originate from four causes :-First, from an enlargement of
the omentum, and a thickening of it by growth and pressure,
and from its being considerably loaded with adeps, for now
and then the omentum is of that size that it is impossible to
return it. Secondly, from an adhesion of the intestine, or
omentum, within the sac. Thirdly, in consequence of mem-
branous bands formed from inflammation across the hernial
sac: and lastly, from the omentum enveloping the intestine
in such a manner as to prevent its return ; under these cir-
cumstances the former, not the latter, adheres.
An irreducible hernia is very frequently caused by the
neglect of the patient to pay due attention to himself ;-he
allows the hernia to be down, perhaps, all day, and like-
wise at night, and frequently they neglect the truss entirely,
hence the sac gradually enlarges by the weight of the tu-
mour, more of the abdominal viscera continue to be protru-
ded, and at last it becomes so very large as to be totally im-
possible to replace the contents. It will be soon found,
from the patient's account, whether ever he has been able to
reduce it or not. oknot

LECTURE XXIV.
279
After hernia has continued irreducible for some time, it
gets to an amazing size ; it is also at times accompanied
with hydrocele. A bursting of the intestine in these cases,
from a blow or a fall, was witnessed in a man in Guy's Hospi-
tal some time ago, and a person is not only exposed to this
danger, but also to that equally serious-strangulation. An
omental hernia, when it has long been irreducible, now and
then gets scirrhous and carcinomatous, and proves destruc-
tive to life by going into a state of ulceration.
Treatment.
When called to a patient, provided the hernia is not stran-
gulated, and has not long been irreducible, it may after some
few efforts be returned, although at the first attempt it does
not appear easy to be accomplished. Ice applied in a blad-
der to the scrotum has had the effect of diminishing the tu-
mour in the course of twenty-four hours, and in the space of
two days more it has been perfectly returned. So that Mr.
Astley Cooper was led to advance an opinion in his valua-
ble work on this subjeet, that though hernia is irreducible by
the taxis, yet it may be sometimes accomplished by the ap-
plication of cold, if there should be no existing inflammation.
It is recommended by authors to put the patient on a poor
spare diet, in order to produce an absorption of the omental
adeps: but the difficulty here is to get patients to submit to
it long enough-also giving purgative medicines, &c. to fa-
cilitate this object. If success should not attend the long
continued application of cold, apply a laced truss on the
scrotum, as this will by its pressure excite absorption; and
should this point not be gained, still it will, as long as it is
worn, prevent further growth: but supposing the contents of
the sac to be omentum, the patient's feelings must be consult-
ed in the application of the truss, as to the degree of pres-
sure that can be borne. The truss sbould be a spring one,
and made light, and a few hours after it is applied it should
be examined. A reducible hernia may by inattention be
rendered irreducible, or from the formation of adhesions.
280
LECTURE XXIV.

STRANGULATION.
If part of the intestinal canal form the tumour, and be-
come obstructed by a stricture upon the prolapsed parts, or
a stoppage of the circulation, when a portion of omentum
alone forms the swelling, the patient may be considered in
very imminent danger; but it is not so great, nor attended
by so alarming and speedy a termination if omentum only is
included, as that organ is not so immediately necessary to
life as the other parts are.
The symptoms of a strangulated hernia, are pains in the
diaphragm, causing a sensation as if a tight cord were put
around the chest at that part : a constant rejection of wind
from the stomach—and the patient, under this circumstance,
is anxious to pass it downwards, but finds it impossible.
When, however, it does take place, it is an event to be par-
ticularly attended to, denoting that strangulation is past;
and the first favorable symptom, after an operation, is a cessa-
tion of it; incessant vomiting, with constipation. This lat-
ter, however, depends upon whether it is omental or intesti-
nal hernia ; for if the latter, though it be small, there will
be no stools ; but in the former case, evacuations not unfre-
quently take place. Also this further remark will be right
with respect to constipation. In case the hernia has gone
on to mortification, an immediate discharge per rectum
takes place, which, instead of being favourable, is quite the
contrary. The pulse, at first quick and hard, after some
time becomes quick and small, having a thready ſeel similar
to that in enteritis. As soon as mortification has commenc-
ed, it becomes intermittent and irregular, and the general
opinion is, that the artery is broader in its diameter ; but
the increased diameter, if so, is no certain sign of mortifica-
tion having taken place. Hiccup is by no means, as was
formerly supposed, a sign of mortification, and no surgeon,
at this present day, would conceive, that this symptom alone
is a barrier to the operation. I have reduced a strangulated
LECTURE XXIV.
281

scrotal hernia, where hiccup had existed for a considerable
time, in the case of Howel Jenkins, and he recovered as.
soon as could be expected, without any difficulty.
As to the changes which the tumour undergoes, it is, at
first, very tense, as if inflated ; this, however, is not so con-
spicuous when the omentum is down. Next a redness is ob-
servable on the surface, and the finger leaves an impression,
as in anasarcous swelling, in consequence of an effusion of
serum. As soon as mortification has taken place, it is indi-
cated by the inflammation on the skin taking on a purplish
hue, and this is so generally the case, that I heard Mr. Ast-
ley Cooper say, that he felt himself justified in stating, that
spots will be found on the intestine ; of which, he had seen
an instance, in a woman who came under his care some lit-
tle time previously. Sometimes an emphysematous feel at-
tends this inflammation; and this is occasionally occurring,
in consequence of the intestine yielding. If the mortifica.
tion is suffered to take its course, sloughing of the scrotum
and intestine is the result, by which the fæces are evacuated
at the wound. It is seldom patients are strong enough to
get through this process, nineteen in twenty dying before:
nature, however, sometimes succeeds, but the instances are
very few.
Vomiting continues from time to time, and at last becomes
so frequent as to cause an inversion of the peristaltic mo-
țion of the intestines, and it is said that the fæces are ejected;
but this is impossible to take place, as the valve, situated
between the small and large intestines prevents it. What is
vomited is generally of a greenish cast, produced by the
quantity of bile thrown up with it. When the symptoms of
strangulation have existed for some time, the tumour is
more tender to the touch, and the abdomen becomes tense
and painful. I should rather consider hiccup as a symptom
preceding the approach of mortification, than of its actual ex-
istence. The pulse at length intermits ;—the patient is all
along exceedingly restless, and appears extremely anxious
and distressed : and from the constant varying of his posi-
36
282
LECTURE XXIV.

tion, to endeavour to procure relief, becomes very much ex-
hausted. The pulse continues intermittent, and the tumour
is less painful, which is generally a certain sign of the actual
existence of mortification, and the sickness also is less fre-
quent : here a surgeon may be misled: the sudden abate-
ment of the vomiting ;-pulse soft ;-skin cool,—with
scarcely any pain upon examining the tumour,—and the pa-
tient's stating his being a great deal better, and compara-
tively easy, are very deceptive, and might be erroneously
attributed to a total cessation of the strangulation, by those
who have had but little experience. A patient has been
known, under such circumstances, to be declared out of
danger, and in five hours he died: however, in general their
death is not so rapid ; but in twenty-four hours they inevita-
bly expire. If inquiry is made into the state of the case,
the danger will be soon apparent ; but if the abdomen, as
well as the tumour, is soft and not painful, with no vomiting,
&c. it may fairly be concluded there is an abatement of the
symptoms of strangulation, and the patient out of danger.
On dissection of those who have died of strangulated
hernia, if omentum is down, it will be found, as soon as the
sac is opened, a little discoloured; but not so much so as
would naturally be expected from the pressure of the stric-
ture: it takes on the character which the intestine has when
strangulated, and has a crispy feel. If intestine, it is found
of a reddish purple colour, with spots of extravasated blood
on its surface: it is also covered with a portion of coagula-
ble lymph, which can be easily pulled off ; but, take care
not to mistake this for the mortified part. On the inner side
of the sac, is a similar appearance, through the adhesive
process having here commenced. The quantity of water
or fluid within the sac, depends a great deal upon its con-
tents, whether intestinal or omental-being considerable in
the former case, and vice versa in the latter : the looseness
of the intestine, and length of the strangulation, have also
much to do with it.

LECTURE XXIV.
283
There are three different situations in which stricture may
be found. The first I shall notice, is that at the abdominal
ring : this is not so frequent, and is mostly found in old and
large hernia : it is formed by the margins of this aperture.
A more common seat of stricture, is about one inch and a
half from the external opening, in the direction I have pre-
viously remarked, of the course of the canal upwards and
outwards. The reason that it here occurs so frequently, is
owing to the common practice of wearing trusses for a time,
and then leaving them off, so that the orifice of the sac be-
comes contracted. The stricture is produced by the tendon
of the tranversalis on the inner side, and the muscular part
of it on the outer; by its fibres running across the neck of
the hernial sac, so as to produce a gradual compression ; and
by the fascia transversalis, the semi-circular border of which
passes under the sac. A third seat is within the sac itself,
occasioned by membranous bands, or chords entangling the
intestine, and great care is requisite, in operating, to divide
them without injuring the bowel. nr



ko
Treatment.
Tanto rimai
When called to a patient labouring under strangulation,
the first, and primary object, is to replace the parts in their
natural situation, as medicine will avoid nothing. To at-
tain this end, what is to be attempted is the taxis, which
means efforts properly applied to reduce and return the pro-
lapsed parts with the hand. It is to be performed thus :
place the patient in a recumbent posture, with his shoulder
and knees considerably elevated, and the thighs bent to the
trunk, so as to relax as much as possible the abdominal
muscles and fascia of the thigh ; then, supposing the tumour
to be on the left side, embrace it with the right hand, while,
with the finger and thumb of the left hand above the ring,
move them gradually from side to side, kneading in a man-
her the tumour, and at the same time making steady pres.
sure with the right hand : it is not to be expected that it will
284
LECTURE XXIV.

go up suddenly, but in a gradual manner: the direction of
the surgeon's efforts must be in the course of the canal, that
is, upwards and outwards : these efforts may be continued
from a quarter to half an hour. It is observed by Mr.
Lawrence, in his treatise on this disease, that sometimes it
is attended with success to draw the tumour downwards. In
the taxis, much force should not be used, as the intestine
may be burst, of which several instances are on record:
Though there is no doubt success cannot follow, in the ma.
jority of cases, without the taxis repeatedly tried, yet it is
not always equally proper to attempt it directly, without
first having recourse to other means. I will suppose, for in-
stance, a strong young man has a strangulated hernia of a
sudden, in consequence of lifting a heavy weight, and on
approaching his bedside he is found in much pain ; here the
taxis ought not to be had immediate recourse to ; blood
should be as expeditiously drawn as possible, and cold ap-
plications made use of: by these means an easy return will
be accomplished. In cases where the patient complains of
much pain, surgeons have been under the necessity of aban-
doning the taxis and bleeding freely, when they have been
surprized at its having gone up without the least difficulty. It
is to the temporary weakness and syncope, which the sudden
loss of blood induces, that may be attributed the peculiarly
favorable facility of reduction ; but on the subject of bleed-
ing, there are many of our best writers advocates for and
against its adoption. In old people the taxis can be used,
and continued with more freedom. In case manual efforts
are not attended with the desired success, take away from
twenty to twenty-two ounces of blood ; this evacuation Trst
only facilitates reduction, but lessens subsequent irrita-
tion, if the operation is required. If these means should
be unsuccessful, make an infusion of tobacco, 3j. to tbj.
of water, throw up one half, and increase this, if found
insufficient, by using the remainder: it is attended with
great risk to throw up the whole at once, as will be
illustrated by the following case. A young girl, some



LECTURE XXIV.
285
years ago, was admitted into Guy's Hospital, and had the
whole quantity thrown up at once ; alarming symptoms
came on, and Mr. Astley Cooper was sent for; but when
le came, she had vomited a great deal, and the hernia was
returned, but such excessive fainting followed, as to occa-
sion a speedy dissolution. Less quantities have been known
to produce this lamentable effect. What I allude to, is a
decoction or infusion for about ten minutes; others employ
the smoke, and very ingenious apparatus have been invented
for this purpose: I think the first is by far preferable. To-
bacco has a relaxing and depressing influence on the body
universally, lowering the pulse, inducing nausea, sickness,
cold sweats and syncope, and under slight pressure the her-
nia becomes reduced. I have heard Mr. Cooper say, it was
à most unpardonable neglect in the practitioner, not to use
tobacco in strangulated hernia, and which ought to be im-
pressed on the mind of every surgeon.
Powdered ice, in a bladder, must be applied to the tu-
*mour ; if this cannot be procured, the powdered muriate of
ammonia and nitre, 3j. to Tbss. of water ; this will produce
a degree of cold equal to 20°: it must be frequently chang-
ed, as it soon acquires the temperature of the body by the
abstraction of its heat : even rags, dipped in spirit and wa.
ter, will suffice occasionally. Cold applications have this
effect : they cause a corrugation of the whole scrotum and
the cremaster muscle, which thus act on the bowel, or pro-
lapsed contents, and by its pressure, the tumour becomes
lessened, and ultimately reduced.
As to the warm bath, from what I can judge, I do not
conceive it to be equally efficacious with the cold applica-
*tion and tobacco enema: I have seen it frequently used at
Guy's Hospital, and when syncope is brought on, it will be
serviceable. The advantage of cold applications over warm,
is, that heat gives no relief if it do not assist in reducing the
strangulation pretty quickly ; whereas, if cold is used, if it
do not gain the point desired, it will arrest the progress of
inflammation. Fomentations should never be used, unless


286
LECTURE xxiv.

there is slow inflammation going on, and no direct symp-
toms of strangulation. Mr. Hey is an advocate for opiates,
given in large doses, after bleeding, in some athletic persons,
and purgatives he has found of great utility in those cases
where the intestine has retired, and the omentum only re-
mains strangulated ; he also countenances the warm bath:
in many instances where it has been used, reduction has
been accomplished—but I leave these subjects, as I find
them, without any comment. I have only to observe,
in strangulated hernia the greatest danger is, useless delay,
and reposing confidence in remedies or treatment to an un-
pardonable extension of time a rapid disease must be com-
batted by decisive practice. Apply the taxis; if young and
plethoric, bleed: if the warm bath be ready, emerge the
patient in it ; if not, apply ice to the tumour, and a tobacco
enema is to be injected. What Mr. Lawrence very prop-
erly says, is this, if the surgeon is not called in till some
progress has been made, the tobacco enema is to be used,
and the topical application of cold : if what Mr. Pott re-
marks be correct, that the operation, when performed in
time, was only fatal once in fifty times, I have only to ob-
serve, how culpably negligent I have seen surgeons, as
their success is by no means so flattering, and why ? from
its being protracted to too great a length ; as Mr. Hey of
Leeds states, when he first got in practice, from dilatory
practice he lost three patients in five; afterwards he waited,
when called in, only two hours, and tried bleeding and the
tobacco enema, and in nine cases he lost only two ; he says
he has since performed the operation, when his work went
to the press, thirty-five times, and he has often had occasion
to lament that he performed too late, but never that it was
done too soon. Hernia strangulated has been seen to prove
fatal in the short space of twenty-four hours. Mr. Astley
Cooper tells us there is scarcely any period of the symp-
toms which forbids the operation ; but pain on pressing of
the abdomen, and tension, he believes, call for its immediate
adoption. Mr. Lawrence says, when the rupture becomes

LECTURE XXIV.
287
painful, and a sufficient or moderate pressure cannot be en-
dured, the operation is immediately necessary.
20.
Operation

As soon as the time is fixed for performing the operation,
which will be determined entirely by the judgment of the
practitioner and the existing state of things, such as extreme
tenderness of the abdomen, indicating peritoneal inflamma-
tion, or other symptoms not so alarming, yet rapidly in-
creasing: at all events as little time should be lost as pru-
dence would dictate, for on the speedy, and I may remark
early execution of it, will depend all future chance of suc-
cess ; in fact, I firmly believe, the generality of failures may
in a great measure be ascribed to its being resorted to too
late : at the same time I am of opinion, that prior to using
such measures or means as I have previously mentioned, the
operation should not be attempted, as there is a chance, that.
from the process of inflammation in the abdominal cavity, the
patient dies : hence the old practice of a radical cure has
been abandoned, for this reason, that though the inflamma-
tion was not present at first, yet it was induced in the opera-
tion : therefore let the patient be well reduced, as in this
case the result will be more favourable. There is however
one exception to this, viz. in old people, where the loss of
much blood would be unnecessary, as in them there is a less
disposition to inflammation than in the young and plethoric.
the patient's consent to the performance of the operation ; it
is better to tell him candidly, that every prudent and advisa-
ble attempt has been made to return the contents of the sac,
but it has been rendered fruitless by a string confining it
across, and that if he will only suffer this to be cut through,
it will be very possible to succeed: it is extremely injudi-
cious to cause any alarm in his mind. In old people, success
may at last attend repeated attempts by the taxis, but in
young subjects these only aggravate materially the com-
a
288
LECTURE XXIV.

plaint; besides the danger in old people is proportionably
less, and may be adduced as another cause for extended de-
lay ; but supposing the patient's consent is gained, and every
thing ready, the operation is to be performed in the follow-
ing manner: place the patient upon a table three feet high,
with his legs hanging over and resting on a chair; the ope-
rator is to stand between the thighs; the parts are to be
shaved, and the hair carefully wiped away, for if any should
remain, and fall into the sac, great irritation would be pro-
duced. The surgeon, embracing the tumour in his left
haad, is to make an incision from one inch to one inch and a
half of the spinous process of the pubis, commencing from
the upper part of the abdominal ring, and extending it
through the integuments to the lower part of the tumour, the
centre of the latter being the direction for the incision ; by
doing which the external pudic artery will be divided—it
must be immediately tied, if it bleeds freely-in general there
is no necessity for a ligature ; this lays the aponeurosis of the
external oblique, which forms a dense and distinct covering,
bare. The operator is next to make a small opening into
this fascia in its middle, into which a director is to be intro-
eluced, so as to dilate it upwards (not of equal length with
the first) to within an inch of the abdominal ring; this ex-
poses the second covering of the sac, the cremaster muscle,
which is to be divided precisely in the same cautious man.
ner : not the least difficulty will be experienced in separat-
ing it from the parts underneath, as the connecting medium
merely consists of loose cellular substance. The cremaster
will be found as dense as at the first, if the disease has long
existed, and the best way to make an opening into it, is to
nip it up between the fingers, and then introduce the point
of the instrument carefully. Covered as these parts are by
blood-vessels, it must evidently be an operation rather diffi-
cult; but keeping in mind the above coverings, it will be
made much easier. The next part of the operation, is to
divide the sac ; for this purpose nip it up between the finger
and thumb, in order to clear it from the intestine, and then


LECTURE XXIV.
289
make a tolerable sized opening for the director ; this divise
ion is to extend to the inferior part of the sac and upwards
to within an inch of the abdominal ring : keeping the knife
in an horizontal direction, the water immediately escapes.
Another mode, is to embrace the tumour behind, and press
the fluid forwards, so as to feel a fluctuation, thus preventing
any injury being done to the intestine in dividing the sac.
As soon as the sac is opened, the intestine and omentum are
discovered, the latter enveloping the former, and the intes-
tine occupying the upper and back part. In making the
first incision, nothing impedes the operation more than the
division of the external pudendal artery, as I have above re-
marked, in cutting through the integuments : to ensure fu-
ture success, it is preferable to secure it immediately.
After the operator has observed in what direction the
omentum runs, he is to endeavor to ascertain the seat of the
stricture by the introduction of his finger between the omen-
tum and hernial sac upwards ; if it is at the abdominal ring,
he is to introduce a director, or what is still better if it can
be done, the finger into the neck of the sac within the aper.
ture of the ring, and guide a blunt probe-pointed bistoury on
the groove, in the direction the stricture is to be divided, di-
rectly upwards, or, as some say, upwards and outwards, Mr.
Astley Cooper adopts, and recommends the cut to be direct-
ly upwards; and the peculiarity in his plan is this : he di-
vides the sac to within an inch of the abdominal ring, the fine
ger of the operator is to be introduced into the sac, and when
the stricture is felt, a probe-pointed bistoury is to be con-
veyed over the front of the sac into the ring, between the sac
and the ring, and the ring only he advises to be divided di-
rectly upwards in the centre of the middle of the sac, suffi-
cient to allow of the protruded parts being returned into the
abdomen : others advise dividing the hernial sac with the
stricture as far as it extends. Cutting directly upwards will not
endanger the epigastric artery even in those less frequent
hernia where the sac protrudes on the inner side of this ves-
sel : the only danger in fact that arises from either mode of

37
90
LECTURE XXIV.

dividing the stricture, is incurring some risk of wounding the
intestine,
Supposing the stricture to be near the internal ring, then
the bistoury is to be passed up to the part within the sac,
as countenanced by Mr. Lawrence, and according to
Mr. Cooper between the front of the sac and the ab-
dominal ring till it arrives under the stricture formed by
the lower edge of the transversalis and obliquus inter-
nus; the edge of the instrument is then to be turned
forwards, and the stricture divided upwards—this is the
difference, Mr. Cooper does not cut the sac, Mr. Law-
rence does. The bistoury, according to Mr. Lawrence, is
either to be introduced on the finger, with the blade turned
towards it, or on a director, and divided upwards and out-
wards. Mr. Cooper here introduces his finger into the her-
nial sac, and the bistoury between the front of the sac and
abdominal ring, carried on the flat side, then turn it to cut,
and change it to the flat side in withdrawing it. It becomes
a consideration when the stricture exists at the inner open-
ing, where the cut to divide it can be made, on account of
the epigastric artery, as it sometimes deviates from its or
dinary course,and is found on the outer side of the sac; here,
if the incision is made towards the spinous process of the
ilium, the chances are that the artery is divided ; and the
same accident may happen, supposing the artery to be on
the inner side, and the cut is made in that direction. There
is one general rule to be adopted, which is to take the mid-
dle course, and divide directly upwards, as there is no in-
stance adduced of the artery passing over the sac. Though
some are of opinion, that the division of the epigastric artery
is of no serious consequence, yet I conceive such gentlemen
to be devoid of that necessary ingredient, common sense.
Several divisions of this vessel have occurred, one of which
has been related by Mr. Lawrence, and two by Mr. Astley
Cooper : in Mr. Lawrence's case, the surgeon, 'not content
with having divided the stricture, made another cut on the
inner side of the sac, and wounded the artery: it immedi-


LECTURE XXIV.
291
ately retracted, and the patient soon died from the hæmor-
rhage. In another case, in a woman, she lived but a short
time ; but in the third, though the patient recovered from
the accident for a while, the hæmorrhage being with difficul-
ty stopped, yet the excessive loss of blood produced a drop-
sy.
Die
I do not myself see the necessity, in any operation for
hernia, to run such a risk by cutting inwards, even if the ar-
tery ran on the other side.
Having divided the stricture, if there be still an incapa-
bility of returning the intestine, the operator must look for
à membranous band, which is easily seen by pulling down
the gut, and carefully dividing it.
The state of the prolapsed parts is to be then examined,
and prior to dividing the stricture, I should not conceive it
proper to do so, as no correct judgment can be formed
while there is an obstacle to the free return of blood. If
the intestine be mortified, it will have several purple spots on
its surface, which assume a chocolate colour previous to the
removal of the stricture : on putting the finger on the mor-
tified part, sometimes only coagulable lymph will be found;
but in case you cannot peel this off, do not return it, but
adopt the following treatment: if a small portion of the cy-
linder be diseased, a ligature is to be passed through the at-
tached mesentery, at right angles with the intestine, and
then through the hernial sac ; by which means the intestine
becomes confined to the aperture, adhesions form, and an ar-
tificial anus is produced ; the opening has closed in some few
instances after a time, and the fæces have resumed their nat-
ural course: but when the whole cylinder is mortified, the dis-
eased part should be cut away, the divided ends brought to-
gether, and united by four ligatures inserted at proper or
equal distances around the intestine, cutting the ends of the
Aligatures close off. But it would appear, from the experience
of others, that the practice they adopt, is this—first divide the
stricture so as entirely to remove the cause of strangulation;
and secondly, make an opening into the intestine, so as to



292
LECTURE XXIV.
communicate with the abdomen: if the stricture only is
divided, the constipation, hiccup, and vomiting continue ;
but if the intestine is opened, these symptoms, in the course
of a few hours, are relieved. I may further observe, that
in case of there being much intestine down, and only one
gangrenous spot, an opening ought to be made here, and a
corresponding one in the integuments, for the fæces to pass,
and not attempt to return the gut, as this will be glued for a
time, and the fæces discharged by the opening. But sup-
posing it did not adhere, and that there was a large spot
mortified, still from the valuable documents I have by me, I
should be disposed to recommend the adoption of a similar
practice, leaving the intestine undisturbed, as several instan
ces are known where patients have died when the gut has
been returned. A difficulty arises when the intestine ad-
heres to the mouth of the sac, which is not easily got rid of;
and it frequently happens that a patient dies from this cause
after the operation : if the adhesions are short, they may
be separated with the finger, otherwise with the knife : but
if, after all, in pulling down the intestine, further adhesions
are still found higher up, though it is attended with some
risk in exposing so much intestine-still as no fæces will pass
if the intestine is returned into the abdomen in folds, there
will be a necessity of dividing the whole of the stricture. Mr.
Lawrence objects to the practice of using sutures to bring
the ends of the canal together. The stricture must be di-
vided, but the progress of the cure should not be left entire-
ly to nature: where the intestine has not already burst, the
fæces should be evacuated by an opening into the mortified
part. If there be a great deal of omentum down, diseased,
thickened and indurated, it will be right to cut it away, as
large quantities may be removed with impunity. If hæmor-
rhage of any consequence should ensue, fine ligatures should
be used; otherwise mere laceration of the vessels with a
pair of forceps, will suffice. The removal of omentum does
not add to the danger. It will be right not to re-
turn the remainder into the abdomen, but let it ad-


LECTURE XXIV,
293
here to the mouth of the sac, by which, future descents are
rendered less liable to happen. Should the portion of omen-
tum be not large, but considerably hardened, still it will be
improper to return it, as the scirrhous state of it will most
probably irritate the peritoneum ; when mortified, it should
also be removed, though Mr. Hey has recommended a liga-
ture to be put on, in order, as he infers, to produce slough-
ing: but if you do this around the sphacelated part, it is of
no use, as no ulceration will be effected, and if it is applied
on the living portion, you reproduce stricture, and conse.
quently render the operation nugatory. In a patient under
Mr. Chandler's care, it was found that the man was at first
materially relieved, but after a ligature had been put on, on
the above principle, symptoms of strangulation appeared,
which proved fatal in eight days. It is very different from
tying a single artery, and I may here add, that in a case
where no ligature was applied, and the mortified portion was
left to slough off of itself, a great deal of time was required
for the accomplishment of this process : the subject was a
woman. Inflammation came on after the operation, the
omentum appeared at the wound, and gradually became re-
moved, and it was from six to seven weeks before she recov-
ered. The fact is, that unless the powers of the constitution
are very strong and vigorous, there is a probability of your
patient's becoming exhausted.
i The operation being now detailed, with the necessary ob-
servations that ought to guide you in its performance, the
integuments are to be brought together by ligature and ad-
hesive plaster, and a recumbent posture must be strictly en-
joined, for fear of another descent of the gut, which actual.
ly occurred in a patient of Mr. Cline's in his attempting to
remove to the night-stool : it was, however, soon returned.
Opiuin used to be given, to allay irritation ; but, in my
opinion, from what I have observed in the practice of the
London hospitals, medicine is attended with little advantage.
Purgative medicines ought not to be directly administered,
as the bowels are generally lax at first : if, however, it be

294
LECTURE XXIV.
deemed necessary to procure alvine evacuations, it should
be attempted by means of a glyster, as medicines given by
the mouth are apt to excite vomiting.
Some immediately set to work after the operation is per-
formed, to procure evacuations from the bowels by means of
castor oil, common salts, &c. until every doubt has ceased of
inflammation of the bowels and peritoneum. Keep your
patient on the antiphlogistic plan strictly : if inflammation
takes place, endeavour to subdue it by general and local
bleeding, fomentations, immersion in the warm bath, glys-
ters, &c. The practice requisite must be prompt and de-
cided. When you rationally conclude the danger is over,
it will be prudent to reverse the treatment. The bark may
be ordered, combined with wine, porter, cordials, and, in
fact, altogether a generous diet. Some give a saline medi-
cine with opium, to allay sickness, and should too profuse a
diarrhæa come on, aromatics, or the confect. aromat, with
opium, will be useful.
A truss should be put on during the healing of the wound,
for the purpose of glueing the sides of the sac together, and
this has been effected in several instances, so completely
that hernia never afterwards descended; at all events, the
danger of a future descent is lessened, should perfect success
not attend its application.
The following case, detailed by Mr. Astley Cooper, will
shew the inutility of taking the sac away. He attended,
with Mr. Holt, a woman, on whom he was called to operate
for female hernia, and it struck bim, that it would be a fa-
vourable opportunity to see how the case would succeed by
dissecting away the whole sac, which was accordingly done :
some little time after, on directing her to stand erect, the
hernia appeared as large as before, and shortly another
portion of peritoneum descended.


( 295 )
LECTURE X X V.

e
n
teman
sa
Ghe
OF LARGE INGUINAL HERNIAS.
In very large and irreducible hernia, the belly becomes di-
minished, after some time the muscles sink in, and there is
but little room for the return of the prolapsed parts, suppos-
ing it were to be attempted. When strangulation exists, the
usual method of operating is not adopted ; Mr. Cooper, Dr.
Monro, and others, here follow Petit, which consists in di-
viding the abdominal ring without opening the sac, on ac-
count of the admission of air into the peritoneal cavity being
thus prevented : but when the stricture is placed at the up-
per part of the sac, the division of the ring can be of no ser-
vice, and consequently ought only to be performed when
the rupture is of great size, and the sac not adhering to the
intestine. The operation is performed in the following man-
ner : a small opening is to be made into the tendinous cov-
ering of the sac three-fourths of an inch below the abdomin-
al ring: then a director is to be introduced into the ring,
and a probe-pointed bistoury carried along it, with 'which
the ring is divided : the tumour is then to be embraced, and
the parts returned into the abdomen : this operation has
been done several times, both by Mr. Cooper and others,
and generally speaking, successfully,

296
LECTURE XXV.
SMALL HERNIA NOT PROTRUDING THROUGH THE RING,
Hernia is now and then so small as not to pass through
the external ring, yet becomes strangulated, and a little tu-
mour observable, which, with concomitant symptoms, leads
the surgeon to the seat of the disease. Here an incision
must be made upon the tendon of the external oblique, par-
allel to the course of the canal, or course of the spermatic
chord, and having laid bare the sac, cut it open; you will
then ascertain the seat of the stricture to be at the upper part
of the canal, or internal ring, which is to be divided up-
wards and outwards. As the hernia is oblique, the artery
will be found on the inner side: but should any doubt arise,
by all means cut upwards. ver
t oon
OF DIRECT INGUINAL HERNIA.
W
In dissecting a man at Chelsea Hospital many years ago,
Mr. Cline, sen. states, in his valuable Lectures on Hernia,
that he found the epigastric artery to be seated on the outer
side of the hernia, a thing of course which surprised him, as
being a circumstance thought extremely rare at that time,
though from minute investigation since, many other similar
cases have been discovered. It is of the utmost importance
to distinguish this species from the common, or oblique her-
nia, as otherwise, in dividing the stricture outwards, still re.
commended by some surgeons,a great risk would be incurred
of cutting through the epigastric artery. The diagnostic
marks are, that here the spermatic chord is always on the
outer side of the sac, instead of being on the inner, as in the
oblique hernia ; of course the sac is situated between the
chord and the symphysis pubis : in this species there is
generally no distinct tumour above the abdominal ring ; but
this last is not so certain, for though the hernia may be af
first oblique, yet, after a time, from the approximation of
both openings, the obliquity is in some measure lost, and
less perceptible.

LECTURE XXV.
297
When called to a patient under this kind of rupture, and
it is easily returnable, apply the direct truss, the pad being
at right angles with the spring, for this reason, that as in
the oblique hernia you want to press upon the whole ingui-
nal canal, here the pressure is only required rather above
the abdominal ring. When strangulation exists, be not too
hasty in concluding the gut is returned after efforts have
been made to this end, as it often lies concealed in the ten-
don of the transversalis muscle. In every instance that has
come under Mr. Astley Cooper's cognizance, he states, the
stricture has been in the tendon of the transversalis, and all
that is necessary is, after the integuments, &c. have been
divided, to pass a director into the abdominal ring and cut
directly upwards, though it may be equally safe to make
the incision inwards ; but the other, as a general rule, should
rather be adopted, because, being attended with no risk, it
is not worth while to deviate in the least.
INGUINAL HERNIA is not so frequent in the female as in
the male : when in the former it constantly takes the course
of the ligamentum rotundum, anterior to the iliac artery,
and behind the tendon of the oblique, and appears at the
ring in them : it is rarely of considerable size; the largest
I have ever seen was in Guy's Hospital, and the attention
of students some years ago, was directed to the case by Mr.
Cooper; it reached half way down to the knee, and it had
an opening at the anterior part, which discharged feculent
matter. This hernia in the reducible state requires the same
kind of truss as in the male ; in the irreducible, a bag truss ;
and when strangulated, a similar operation to that described
for the male. There is, however, some kind of difference
as to the coverings of the hernia. The tumour appears in
the labium, and in dividing the integuments to the most de-
pending part, you will expose the covering given off by the
external oblique ; after its division the sac directly comes
in view, as there is no cremaster nauscle, so that more cau-
* tion is requisite here. In cutting open the sac, it is prefer-
able to do so at the lower part, as there is commonly much
38

298
LECTURE XXV.
water found there. The stricture is mostly found at the
upper opening between the pubis and ilium. The finger can
be readily introduced three quarters of an inch into the sac
without entering the abdomen; after it has passed up to the
mouth, carry upon it a probe-pointed bistoury, and dilate
the stricture towards the ilium ; but if any doubt should
exist, do it upwards. Should any fear arise with respect to
the intestine being entangled, it would be advisable to divide
the tendon of the external oblique up to the mouth of the
sac, which will expose the stricture ; but this should be
avoided if possible, as future inconvenience is likely to arise.
The truss to be worn after the operation is the same as that
in the male.
HERNIA CONGENITA.
I am not aware that this species of hernia was at all satis-
factorily explained till the time of Dr. and Mr. Hunter, in
1762, and 1764. It is founded upon the descent of the
testes, which generally takes place between the seventh and
eighth month, from the abdomen into the scrotum : it is in
consequence of the tunica vaginalis not being closed prior
to birth, that this kind of hernia takes place; a portion of
the intestine gets down from the efforts of the child in cry.
ing; the omentum rarely reaches so far: here the tunica
vaginalis is the hernial sac. In the descent of the testicle,
a portion of peritoneum is carried before it into the scro-
tum, which receives the name of the tunica vaginalis re-
flexa; independent of that peritoneal investment it originally
had while seated in the loins, which is called the tunica
vaginalis propria. It must appear evident, that the com-
munication with the abdomen remains open, and does not
become closed as is mostly the case before, or at all events,
soon after birth, so that this cavity remains unobliterated.
It does not so frequently occur on the right as on the left
side. It is not always observable at or soon after birth.
Whenever it happens at a remote period of life, it must be

LECTURE XXV.
299
in consequence of some great exertion, and also from the
cicatrix, by which the original opening was shut up, being
naturally weak. The time it generally is discovered is some
months after birth. Mr. Hey saw a case in a young man
sixteen years of age, whose right testicle had descended but
a short time previous to his being subject to this disease.
Mr. Lawrence details a case of an infant, of the tender
age of fourteen months, having a strangulated bubonocele,
so that we are not, in every case of rupture in early life, to
conclude it to be congenital, although, generally speaking,
we should be correct. This species takes the course of the
spermatic chord, with the epigastric artery on the inner
side. The diagnostic marks are more difficult to be defined
in this, than in the other species of hernia, from its being
so deeply buried. On attempting to grasp the tumour, it
has the feel of a thickened chord ; and the testicle is so in-
volved as to be very indistinct, and generally somewhat
wasted, so as to lead the surgeon to suppose some disease
of the chord existed. It has been mistaken for inguinal
hernia, and the operation performed.
In the reducible state, it requires the oblique truss. In the
irreducible, the same treatment is proper as has been already
noticed ; but it is somewhat different when strangulated, as
the surgeon has not the same power of reducing it as in the
other species. The stricture is generally at the upper open-
ing, and rarely at the abdominal ring, for this reason, that
the parts, from the long application of a truss, become so
much thickened as to prevent its occurring in the last stated
situation.
In operating, the cut is not to be made so low as the testes,
and it is necessary to have a sufficient portion of the tunica
vaginalis to cover the testes ; but it should, at the same time,
be recollected, that the incision must be carried downwards,
rather more than an inch from the abdominal ring. After
the stricture is divided, which is to be cautiously done with
a bistoury, carrying a finger or director to serve as a guide,
return the contents.
son os e mesmo

300
LECTURE XXV.
There is another species of hernia lately discovered by
Mr. Hey, of Leeds, which is called the ENCYS TED : in which
there is a complete cyst within the vaginal tunic, forming
the hernial sac. The manner in which it occurs is this :-
the tunica vaginalis, instead of being closed at its orifice per-
fectly, adhesions form across it, shutting up the ring : these
adhesions become elongated by the pressure of the intestine,
and a pouch is formed, which, by continual pressure, be-
comes so extended as to reach as far as the testis itself.
When a hernia of this kind becomes strangulated, it renders
the operation more complicated and difficult : the only pecu-
liarity is the additional covering.
ditional covering.

tot
året
med e
bedste to restoring så

( 301 )
LECTURE XXVI.
ON FEMORAL HERNIA.
ca
It is necessary that the anatomical structure of the parts
concerned in this species should be well known, and this
anatomists have considered somewhat difficult to make in-
telligible and understood.
Fron Poupart's ligament two portions of fascia pass up-
wards, the fascia transversalis and iliaca : and one down-
wards, the fascia lata, which is given off from the greater
part of the ligament, and covers the thigh. The inner part
of this fascia forms a thin edge, which Mr. Hey has called
the femoral ligament, and which he wrongfully supposes to
be the cause of stricture.
Another portion of fascia coming from the pubis, unites a
short distance downwards from Poupart's ligament with the
inner edge of the fascia lata, under the vena saphena major,
and thus a space or opening is left between the junction of
the two portions and Poupart's ligament, which is named the
falsiform, or lunated edge of the fascia lata : through this
opening the vein issues forth ;—the absorbent vessels also
pass here, and terminate in the groin; and it is through this
opening that the femoral hernia descends and becomes situ-
ated over, not under the fascia lata.
In cutting through the fascia lata, half an inch below the
falsiform process, a second portion of fascia will be found to
be given off from the back part of Poupart's ligament, which

302
LECTURE XXVI.
forms the sheath of the femoral vessels ; and it is into this
sheath that the hernia descends. The anterior crural nerve
forms the boundary of the sheath on the outer side, and the
triceps and pectineus muscles on the inner. On cutting
open the sheath, the femoral artery, vein, and a branch of a
nerve will be found : the sheath is continued down the thigh,
and in the operation for aneurism, it must be carefully open-
ed to detach the vein and nerve from the artery. The
sheath communicates with the abdomen, which may readily
be ascertained by introducing one finger.
The sheath lies about half an inch behind the fascia lata,
and is the proper covering of the sac; from a want of a
knowledge of this circumstance, femoral hernia has been
returned into the abdomen strangulated, the surgeon having
supposed the stricture to be divided.
The hernia first descends between the border of Gimber-
nat's ligament (which is nothing more than the lower edge
of Pouparts, and which turns from the pubis backwards),
the femoral artery on the inner side, and the vein on the
outer. It begins to elongate after it has got about half an
inch from Poupart's ligament, and forms a kind of pouch.
At the upper part of the sheath there are various openings
for absorbent vessels, which render it rather weaker there.
As soon as the sac has passed through the opening in, or
rather formed by the fascia lata, as previously described,
it becomes turned over it, the orifice of the sac being below,
the body above ; thus it turns upwards and backwards.
After it has pushed forwards and turned upwards upon the
tendon of the oblique, it is covered by an aponeurosis as in
inguinal hernia, which may be termed the superficial fascia.
On cutting through the integuments, this aponeurosis is ex-
posed, which being next divided, the crural sheath comes
into view; between this and the bernial sac is a quantity of
tum ; divide the sheath, turn this fat aside, and the sac is
brought into sight; on its division the contents come into
view, and the orifice of the sac will be found embraced by

LECTURE XXVI.
303
the sheath. The seat of stricture is sometimes deeper, but
less frequent than the former ; Mr. Hey supposed from one
quarter to half an inch below the falsiform process : there
is an opening which is formed by the passage of the hernia
in the crural sheath, and this is the seat of it, the division
of which renders the prolapsed parts easily returnable.
Should this division not succeed, carry one finger behind
Poupart's ligament, and its posterior edge will be found to
be the seat, which is turned back upon the pubis, called
Gimbernat's ligament. S
o bien o DIAGNOSIS. :
at worst
A psoas abscess has the same seat as femoral hernia ; it
comes down on the inner side of the femoral vein, between
it and the pubis: it also dilates by coughing, and though in
the recumbent posture it is not completely returnable, yet
in some degree it is so: it may be distinguished from hernia
by its being accompanied with considerable pain in the loins,
and the impossibility of returning it all into the abdomen :
besides, should any doubt exist, wait a little while, when,
from the considerable enlargement of the abscess, its nature
will be obvious. With a bubo, femoral hernia is liable to be
confounded ; and a patient in one of the London hospitals,
actually was poulticed by a surgeon, who imagined the tu-
mour to be a bubo; the operation for hernia was subse-
quently performed. In another case, an opening was made
through mistake, and the patient had an artificial anus. On
the other hand, I have read of a truss having been applied
on a bubo, which is equally as ridiculous.
Treatmen.
If the hernia be reducible, the oblique truss ought to be ap-
plied, which frequently succeeds in preventing future de-
scents. If very large, the same kind of truss as ordered for
direct inguinal hernia. Femoral hernia is seldom cured by
wearing a truss, however ingeniously constructed, owing to

304
LECTURE XXVI.
the variation of position in Poupart's ligament, being some-
times increased, at others lessened in its diameter, in conse-
quence of the powerful action of muscles.
If the hernia be irreducible, and the content consists of
omentum only, an oblique truss will answer with the altera.
tion of having a kind of cap, so as to make slight pressure,
and at the same time defend the hernia: the pad is to be put
on after a time: by this arrangement the hernia will be
much diminished from the absorption of omentum, though a
portion will still remain in the sheath; that part pushed for-
ward through the falsiform process, and lying on the outer
side of the fascia lata, will be nearly removed; in some cases
entirely so.
When strangulation takes place, the treatment will be very
nearly the same as described for inguinal hernia ; but the
employment of the taxis, in the first instance, varies a little.
It is to be performed thus :-Standing over the patient, put
two fingers upon the tumour and press downwards in a direct
line, by which the prolapsed parts are pushed into the fem.
oral sheath; then pressing upwards, they are returned into
the abdomen. If success be attempted by kneading it up-
wards at first, the surgeon only forces the tumour over the
ligament, and hence it will be further from the opening into
the abdomen than at first; for femoral hernia takes, instead
of a direct (as many imagine), a curved course; the upper
part being under, and the lower part over, Poupart's ligą.
ment. If the taxis fail, all the other means must be had re-
course to, except the application of ice, which is not equally
beneficial here as in inguinal hernia ; because, in the scro-
tum it produces a regular contraction; but here is no portion
of skin so arranged around the hernia as to allow of any pres-
sure. The tobacco glyster must not be forgotten, and if pru-
dent means, continued sufficiently long, fail of affording re-
lief, the operation is the dernier resort.

LECTURE XXVI.
305
Operation.
A cut is to be made one inch and a half long, at right an-
gles with Poupart's ligament, as far as the middle of the an-
terior part of the tumour; a transverse incision is then to be
made at right angles with this, and the two corners of integu-
ble portion of tumour, otherwise, from its depth,and especial-
ly in a fat subject, the operation will be extremely difficult; a
thin covering then comes in view, which is the aponeurosis
of the external oblique, or fascia superficialis ; a small open-
ing is to be made through it, into which a director is to be
passed, and by carrying a probe-pointed bistoury along
the groove, this covering is to be divided. The crural
sheath, or fascia propria, is then exposed, which is to be
cut through in the same cautious manner; then instead of
taking hold of the sac with a pair of forceps as usual, nip it
up between the finger and thumb, in order to separate it
from the intestine. The knife is then to be carried horizon.
introduction of the director, along which the probe-pointed
bistoury is to be passed, so as to dilate the sac completely.
The greatest caution is here required in opening the sac, as
the intestine is in close contact with its inner surface. Hav-
ing proceeded thus far, and turned the gut on one side, in-
troduce one finger in a gradual manner, and the usual seat
of stricture being found, the flat side of the bistoury is to be
carried upon the finger into the orifice of the sheath, and
with a very slight movement the stricture is to be divided
as far as Poupart's ligament, so as to allow of the hernia
being reduced ; in doing of which the knife is not to be
passed into the abdomen at all.
Mr. Hey recommends cutting directly upwards, which is
certainly a safer practice than the usual one of dividing the
stricture upwards and inwards, even when there is a variety,
which I shall hereafter notice. But supposing the stricture
not to be in the above direction, feel for the orifice with a
39

306
LECTURE XXVI.
director, and then carrying the finger quite into the abdo-
men, it will be found behind Poupart's ligament. The knife
is to be carried behind its posterior border, with its edge
uppermost, and the stricture is to be divided upwards and
inwards, letting the umbilicus be the line for the incision.
The operator must carry his finger one inch and a half into
the crural sheath, before he reaches the tendon of Poupart's
ligament. The incision should not, upon any consideration,
be made towards the pubis, for the danger here is so great,
and comparatively speaking, so trifling when in the other
direction, that no man who feels for his patient would, for a
moment, think of doing so. The operator is under the
necessity of pushing his finger very deep into the sac, and
although care would be taken, of course, to avoid the intes-
tine, still, as the knife is passed in a concealed way under
the intestine and omentum, the former is very liable to be
wounded. I recollect a case mentioned of a woman, who
had the gut cut into in three different places, by which the
fæces were discharged into the abdomen, and she did not
survive six hours.
The following case will shew the absolute necessity of
perfectly understanding the anatomy of the parts concerned
in femoral hernia, as well as the morbid anatomy of those :
parts. The case is detailed by Mr. Cooper. A woman had
the operation performed by a surgeon ; she experienced no
relief whatever from it ;-on consultation, there could be no
doubt the formidable symptoms arose from violent inflam-
mation. The woman died soon afterwards, and on examin-
ing the body it was discovered that the covering of the sac
was gone ; on looking further, the sac was found pushed
into the abdomen unopened, so that the stricture still existed.
The intestine was mortified. The fascia propria was also
pushed back, but it had been opened.
There is not the least risk of either wounding the epigas-
tric artery or vein, unless the cut is made outwards, which
no man in his senses would think of doing. This artery
passes on the outside, but at an extreme distance from the

LECTURE XXVI.
307
mouth of the sac. Preparations are apt to give a wrong
idea of its situation. It is only by making an extensive in-
cision towards the spine of the ilium that it could be wound-
ed, and in doing of which a risk would be incurred of wound-
ing the femoral vein. The spermatic chord is quite out of
the reach of the knife, and it scarcely requires notice, as
femoral hernia is most common in females, where no chord
exists, and in males it crosses over the anterior part of the
sac, at such a distance, and so far behind Poupart's liga-
ment, as to be entirely out of the way; supposing, however,
the orifice of the sac to be so large as to lead to a fear of
doing so, pass a director under Poupart's ligament and
divide the ligament; but this, I believe, never will be found
necessary.
There is a variety now and then seen in femoral hernia,
where the obturator artery passes over the sac, but were
this more frequent than it is, still I conceive it ought not to
be an obstacle to the present mode of operating; as the stric-
ture is commonly in the crural sheath ; but even if it were
at the posterior edge of Poupart's ligament, still no risk
would be run of wounding this artery, unless the knife was
carried far into the abdomen.
There is a circumstance occurring in femoral hernia which
every surgeon ought to be aware of, that previous to the
division of the stricture, a pulsation cannot be felt, either in
the obturator or epigastric arteries, these being situated
above.
- With respect to a preparation sent to London formerly by
Dr. Barclay, for the purpose of having a drawing made, in
which the obturator artery passed over the sac, Mr. Cooper
has dissected many cases, and never found this to be the
case ; but if it should, the stricture ought to be divided as
usual.
The subsequent treatment will be similar to inguinal
hernia.

308
LECTURE XXVI.
UMBILICAL HERNIA.
This species is to be classed next in frequency to inguinal,
and if the numerous instances of its existence in children are
taken into account, I think it is equally as often met with in
practice.
The umbilicus, or navel, was originally an opening into
the fætus, through which the umbilical vein and arteries
passed. After birth the vessels degenerate into ligaments
in the abdomen, and the opening is closed, like a ring, in
the middle of the linea alba ; the tendinous fibres are very
firmly connected together in this place, yet they occasion-
ally give way, and furnish an outlet for the abdominal vis-
cera, which constitutes the umbilical rupture, or hernia. It
is to be recollected, that this hernia does not consist in the
rupture of any part to allow the viscera to protrude. The
tendinous fibres lose their strength, and constant pressure
causes them to be elongated, or to separate from each oth-
er; when this happens, the peritoneum always goes before
the protruding viscus, and forms the hernial sac. This
rupture now and then runs through families, owing to sev-
eral causes : first, original malformation, which may either
arise from a deficiency of muscular or tendinous structure,
of which I have heard cases of such, and seen one ; or
secondly, when the umbilicus was at first particularly large,
and the opening of course in proportion : but from the funis
diminishing in size, greater space is left; or thirdly, an
accumulation of adeps in the omentum or mesentery, which
is not unfrequent in females, from their greater disposition
to its formation than males ; or fourthly, and lastly, from
utero-gestation, by which the viscera are thrust into a very
small space,
Umbilical hernia sometimes attain an enormous size. I
recollect a case where the peristaltic motion of the bowels
could plainly be seen ; it hung down to a considerable ex-
tent, was smooth, and scolloped like a melon.



LECTURE XXVI.
309
Treatment.
In the reducible state in infancy, after the contents are
returned into the abdomen, apply to the part the flat side
of an ivory ball, which has been cut into two parts ; or a
piece of cork over this adhesive plaster, and a belt to con-
fine the whole, having two straps to pass between the thighs
and one over the shoulders to prevent its slipping. When,
from a deficiency of muscles, the integuments are thin, it is
advised to cut a piece away and bring the parts together by
suture. There are cases detailed, one by Dr. Hamilton,
one by Mr. Blizard, and others by surgeons whose names
I do not recollect, in which the practice proved successful :
a very favourable opinion is entertained of it by the pro-
fession.
In the adult, the best plan, if the hernia be small, will be
to apply an ivory ball, as in infancy, after the contents are
returned. A mere pad of wool, put on, and confined by a
girth, has succeeded ; but this pre-supposes a cavity, into
which the hernia sinks. The hernia now and then projects
here : a circular truss, like that in inguinal hernia, is prop-
er : but the greatest difficulty is in women, when the abdo-
men is considerably enlarged ; here a girth is to be put
around the body, having a pad in the middle to cover the
hernia ; at its inferior part is to be a shorter band, which
passes under the pendulous part of the belly : the upper one
goes round the back, and is buckled.
When the hernia is irreducible, and of considerable size,
a cap, made of copper, and lined with leather, should be
put on the tumour, with a bandage under it, and a belt over
the shoulders, otherwise ulceration will take place.
It is not unfrequent to find a strangulation through an
orifice in the sac forming a pouch, so that a part of the con-
tents can be returned, and yet the symptoms of strangula-
tion still exist.
When the operation (which is rather simple) is necessary,
it may be done thus : make a transverse incision across the
E

310
LECTURE XXVI.
middle part of the tumour, and carry another from this to
the lower part, so as to form two flaps ; then open the sac
carefully, and having found the seat of stricture, divide it
above and below, as there is no danger of wounding any
vessel: return the contents, and bring the flaps down, so
that the process of adhesion may take place. In case the
hernia is very large, and has long been irreducible, cut down
upon the upper part of the tumour, which lays bare the
linea alba above the aperture, into the abdomen ; having
exposed it and the sac, introduce a probe-pointed bistoury
between the two ; but do not cut into the sac, only, as in
large inguinal hernia, divide the tendon of the external
oblique muscle.
VENTRAL HERNIA.
This is very nearly the same as the umbilical, only that
it occurs in the linea alba, linea semilunaris, &c. An artery
and vein frequently pass through these tendons, but do not
completely occupy the opening, which, from malformation,
allows the passage of the hernia. The linea alba has been
seen deficient from the umbilicus to some distance.
Treatment.
A very broad belt is to be bound round the body, after
the contents are returned, and constantly worn. The opera-
tion has been performed, although very rarely. In operat-
ing, supposing the hernia to be at the lower part of the linea
semilunaris, divide upwards, as the epigastric artery lies
contiguous. With respect to the other varieties in situation,
no particular observations will be required.
PUDENDAL HERNIA.
The hernial sac protrudes on the inner branch of the is-
chium ; it occurs very rarely. Mr. Cooper saw a case
LECTURE XXVI.
311
strangulated; it appeared at the labium ; he reduced it, and
in doing so, he found that his finger had passed up to the
vagina to the pelvis ; a sponge was ordered to be applied.
A gentleman, whose name I do not remember, relates a case
where the bladder occupied the part.

PERINEAL HERNIA, &c.
A case of this kind was discovered in one of the dissecting
rooms. A tumour was observed between the bladder and
rectum ; it nearly reached the apex of the prostate, and on
examination, it proved to be an hernial sac, containing a
portion of intestine.
The vagina is sometimes pushed forward by hernia, situ-
ated between it and the rectum : a case of this kind occurred
at Guy's Hospital, in a girl : when she stood upright, the
tumour appeared on the outside of the labia, but was easily
returned in an horizontal posture by pressure on the upper
part of the vagina. A pessary was ordered to be worn.
This species of hernia now and then causes suppression of
urine.
The existence of hernia at the foramen ovale, cannot be
ascertained in the living subject, consequently no operation
can be performed. It is always very small.
Hernia at the ischiatic notch descends and rests upon the
sciatic nerve, between this and the obturator and gluteal ar-
teries ; the latter being above, and the pyriformis muscle
below : if it should happen to be very large, it may be ope-
rated on; but it very rarely occurs..
I have been shewn two specimens of hernia through the
diaphragm. In hernia of the meso-colon and mesentery, a
separation of the laminæ takes place, forming an aperture
into which the hernial sac protrudes.
( 312 )
LECTURE XXVII.
ON DISLOCATIONS.

VV
02
There are very few accidents so likely to be mistaken, and
their nature properly ascertained, as dislocations, and they
are sometimes found extremely difficult to be reduced, and
have baffled the skill of some surgeons completely. A
slight, sudden force will produce such an injury when the
muscles are unprepared.
THE LOWER Jaw.—This bone is often dislocated, either
from yawning, or a slight blow received on it when the mouth
is open, by which the condyloid processes slip under the zy-
goma ; one only, or both condyles may be thus displaced :
if both, the nature of this accident is very obvious: the
patient cannot shut his mouth, and the under teeth project
much more than the upper forwards; if on one side only,
the mouth is turned to one side. To reduce it, put handker-
chiefs round your thumbs, or thick cloths ; then grasp the
dislocated bone firmly on each side; the condyles are to be
then depressed, and the chin elevated. The thumbs are im-
mediately withdrawn, as they would be in danger of being
wounded unless protected, as I have described, from the
force and violence with which the ends of the bone slip in-
to their places. If it be difficult, take a piece of wood, and
put it between the molares teeth-direct a person to go be-
LECTURE XXVII.
313
hind, and hold the patient's head steady-then put your
hands under his chin, and lift up his jaw as much as you can,
and by means of this lever it is tilted into its place.
CERVICAL VERTEBRÆ.—Dislocations between the first and
second cervical vertebræ, produce instant death; the denti-
form process is broken off: this is the only part liable to such
an accident; all other supposed dislocations are fractures of
the vertebræ,and if lower down in the neck,generally prove
fatal. The consequences of such an accident are paralysis
of the lower extremities, an involuntary passing off of the
fæces, and a retention of urine. The reason of the stools
passing involuntarily, is on account of the nervous influence
which belongs to the sphincter muscle, being suspended by
the pressure which the fractured vertebræ make upon the
spinal marrow, while the nerves of the intestines are in
their functional state, because they have a higher origin.
The vermicular motion of the intestines is carried on while
there is no resistance to oppose the escape at the anus : the
urine is retained, because the nervous energy of the muscu-
lar coat of the bladder is interrupted. The first patient
that came under my care with this accident, was John Hill:
he fell from the top of a cart-load of barley while securing
it with a rope, in the field, on the morning of the 16th Sep-
tember, 1816. His fæces escaped involuntarily, and his
urine was evacuated with a catheter. Until noon on the
18th his breathing was free and natural, when it suddenly
became extremely difficult and laborious till he died, which
happened in about an hour. On the 9th of September,
1817, early in the morning, I was sent for to William Wil-
liams, who had, in returning home late the preceding night
from a harvest dinner, (at which it appeared he had drank
freely) féll off a stone stile, and met with a similar accident,
at least in the symptoms, to John Hill—a tumour was ob-
served on his neck ; his breathing also was not much alter-
ed at the time I saw him. I was sent for at four the follow-
ing morning, as he appeared to experience the greatest diffi-
culty in breathing, which suddenly came on--but before I

40
314
LECTURE XXVII.
arrived, he died. The injury, in both cases, indisputably
happened below the origin of the phrenic nerve, otherwise
their death would have been immediate.
If a fracture happen in the back, the person may survive
a fortnight ; if in the loins three weeks ; the spinal marrow
is generally ruptured. Very little can be done in these
desperate cases ; palliatives are all that can be employed ;
by bleedings, properly conducted ; in the beginning a glys-
ter, and the introduction of the catheter, at stated intervals,
will be right.
CLAWICLE,

A dislocation of this bone, may happen at either extrem-
ity ; when separated from the sternum there is a tumour
susceptible, and the clavicle is either thrown forwards or
backwards. By drawing the scapular extremity backwards,
and making pressure on the sternal extremity, it is easily
reduced.
The scapular end is oftener dislocated than the other ; it
is thrown upwards on the processus acromion : carry your
finger along the spine of the scapula to the acromion, when
you will feel the clavicle : this accident is liable to be mis-
taken for a dislocation of the os humeri. By drawing the
shoulder backwards, and pressing down the end of the
clavicle, it regains its situation. In both these accidents
the arm had better be kept in a sling after the reduction :
but notwithstanding, deformity very often remains.
OS HUMERI.
The shoulder joint is liable to three different kinds of dis-
location ; first, downwards, which is the most common, into
the axilla : in this case the head of the bone is situated be-
tween the glenoid cavity and ribs, and there are four signs
which will denote the nature of this accident: first, the
LECTURE XXVII.
315
shoulder will appear sunk and flat, and a vacancy is plainly
distinguishable under the acromion ; secondly, the elbow
cannot be brought to the side, because the triceps muscle is on
the stretch, which permits this motion ; thirdly, the patient
cannot bring his hand to the top of his head, neither can it
be raised in a line parallel with the acromion; and fourthly,
the feeling the head of the bone in the axilla, which will be
facilitated by casting the elbow as far from the side as pos-
sible ; the lower edge of the pectoral muscle is drawn tight
-the arm is longer than the other.
Having ascertained the nature of the accident, proceed to
the reduction, by placing the patient upon a chair ; put a
towel in the axilla, under the dislocated shoulder, and tie it
tight over the opposite shoulder ; then bending the elbow,
put another towel round the arm, and let two persons extend
this, while iwo others are to hold the other towel firmly.
Now while the head of the bone is pulled out of the axilla
by the towel round the arm, the other acts as a lever in rem
placing the bone. I have seen this dislocation accomplished
over the edge of a door or settle, placing a pad underneath
in the axilla, to prevent injury: I have myself reduced it,
assisted by Mr. Bird, with my heel in the axilla, in the case
of Mr. John Lewis, an iron-monger. I have also effected
this singly : but in the servant of Mr. John Prosser, miller,
I was obliged to use the pullies (having in vain attempted
other methods) with success. Sometimes, after reducing a
dislocation of this kind, the head of the bone will again fall
into the axilla, from the relaxation of the parts ; in such
cases, a pad in the axilla will be useful, and support the
shoulder by placing the arm in a sling.
The easiest node of reduction is with the heel or knee in
the axilla, and extending the arm at the same time ; the
knee is best in women. The principal intention is to fix the
scapula before extension is used. The direction the arm is
to be drawn, is in a right angle from the body, and a little
downwards. The longest time the bone in this accident has
been out and afterwards reduced, is nine weeks and six days.



316
LECTURE XXVII.
- Second, dislocation is forwards : here the head of the bore
lies on the second rib under the pectoral muscle, and under
the clavicle about its middle : to ascertain it, lay your hand
on the clavicle, rotate the arm, and you feel the head of the
bone : the signs are, loss of the elevation of the shoulder,
the hand cannot be put to the head, and the elbow is with
difficulty brought near the side : but still there is more
motion than in the former case ; but the difficulty in reduc-
tion, is greater considerably. The pectoral muscle is here
relaxed: the head of the bone can be distinctly felt under
the clavicle: neither the heel or knee are useful here. The
accident being ascertained, proceed to the reduction, by pro-
viding yourself with a kind of girth, with a slit in the mid-
dle, through which you are to put the arm of the patient;
then buckling and fastening it to a point behind, you thus
confine the scapula while the pullies are in action : if it
were not for this precaution of fixing the scapula, you would
often pull the humerus away, instead of reducing it. You
are now to make an extension of the arm by means of a
napkin with pullies attached, directly outwards on a line
with the side of the body, gradually extending the arm for
five minutes, and then slacken them ; if the reduction be
not effected, put the napkin on as before, and proceed in
the same gradual manner ; for by a long continued exten-
sion, the resisting muscles become tired, and at last allow
of the replacement of the bone. I have never seen this
species of dislocation reduced without the assistance of the
pullies, although very great force had previously been used.
The third dislocation is backwards. It is a rare occur-
rence. The head of the bone is felt under the spine of the,
scapula, resting on the dorsum of that bone. The sign is
the protuberance which the head of the bone occasions in
that situation. To reduce it, the scapula is to be fixed, and
extension made directly outwards.
Dislocations of the os humeri never happen without ex-
tensive rupture of the capsular ligament ; this is never an
impediment in their reduction : the difficulty consists in the
LECTURE XXVII.
317
resistance of the muscles, which should be overcome by
address more than by effort.
OF THE ELBOW

The most common dislocation of this joint is when the
radius and ulna are thrown backwards, which will be per-
ceived by a great protuberance in a situation rather farther
up than the elbow is originally. The coronoid process of
the ulna takes the place of the olecranon ;—the radius lies
backwards on the os humeri : the arm is straight, and the
projection of the olecranon distinguishes it. Feel for the
rotation of the radius, and if it be present, then that bone is
not concerned in the dislocation. The mode of reduction
is this : place yourself in a chair, letting your patient re-
main on the floor; then take hold of his arm, and place
your knee in the bend of his elbow ; then, by gradual ex-
tension, it is reduced. I met with, in my own practice, this
accident twice : once in Thomas Watkins, the parish clerk,
and the other in a Miss Lewis.
When the ulna and radius are out of place, either before
or behind, the same extension is to be made as above de-
scribed : and although they are to one side, as soon as the
arm is bent, and extension made, they will come in their
places; if forwards, which is not at all frequent, a fracture
of the olecranon must inevitably happen.
The lateral dislocations are usually incomplete: if of the
ulna itself, the coronoid process sinks into the cavity destin--
ed to receive the olecranon ; if of the radius, the head of
the bone is separated from the ulna, and thrown on the fore
part of the external condyle : it is known by the arm being
a little bent, but cannot be either bent or straightened far;
the motion is thus : the hand cannot be laid either complete-
ly prone or supine, therefore the motion of flexion and ex-
tension is much diminished. It is with great difficulty re-
duced. The best way is to place the elbow upon your foot
in such a manner that the olecranon shall be fixed from going


318
LECTURE XXVII.
back ; then endeavour to straighten the arm. Some advise
a forcible extension to be made backwards. It may be
proper, in obstinate cases, to bleed, so as to produce syn-
cope ; *use the warm bath, a tobacco glyster, &c. : in some
instances it is incapable of reduction without.
OF THE WRIST.
When it is dislocated, it is either outwards, or, as some say,
backwards, and inward or forward. The injury is very
evident. The transverse or lateral ligament, which passes
from the styloid process of the radius to the scaphoid bone,
is ruptured, by which the hand is distorted. It is only re-
quisite to use simple extension : and after reduction, a splint
is to be applied, bound by a bandage to the palm and wrist.
Note.— There is an injury sometimes taking place at the
wrist joint, which might be mistaken for dislocation : it is a
swelling arising over the wrist joint, generally occasioned
by a person putting out his hand to save himself in falling.
It may be known from a dislocation, by feeling for the sty.
loid process of the radius, and the root of the metacarpal
bone of the thumb, and if they are in a line, it is not a dis-
location : this swelling will sometimes require six or even
twelve months to subside. From the sprain an inflammation
is induced, by which a quantity of coagulable lymph is
deposited among the sheaths of the tendons of the flexor
muscles of the wrist, which, by its bulk and rigidity, sus-
pends their motions. The treatment consists in the applica-
tion of the emplast. hydrarg. c. ammon.; and after this has
been continued for some time, friction may be used, fre-
quently moving the fingers. Another method, which may
be useful by exercising the part, is to have a ball put in the
palm of the hand, which the patient should grasp often ;
and when he is able to do so with a large one, substitute a
smaller one, and diminish its size until he recovers the com-
plete use of the flexor muscles.


LECTURE XXVII.
319
If the thumb or fingers are dislocated, simple extension
will reduce such an injury; and splints, or pasteboard, are
to be applied to retain the position afterwards.
OF THE OS FEMORIS.
There are four different dislocations of the thigh bone.
The most frequent of all, is that which occurs upwards.
There are four signs or circumstances which characterize it,
and distinguish it from the others; and which should be
ascertained.—First, whether one limb is shorter than the
other ; in this accident it generally is about two inches, and
sometimes even so much as three. 2dly. In this species the
knee and foot are thrown over the other leg. 3dly. The
trochanter major is resting very near the anterior superior
spinous processes of the ilium ; and 4thly, the limb is in a
fixed state—the head of the os femoris rests on the dorsum
of the ilium. This accident can only be confounded with a
fracture of the neck of the os femoris ; the limb is shortened
in both cases, but in fracture the limb is turned outward ;-
dislocation happens in young people, fracture in those ad-
vanced in life.
To attempt its reduction, lay the patient on his side; fix
the pelvis by means of a bandage or girth passed betwixt
the thighs, between the spine of the ilium and trochanter
major ; secure it with a handkerchief ;-without attending
to the fixing of the pelvis all efforts to reduce it will prove
abortive. After this is accomplished, fasten another towel
or girth, smaller, round the thigh, above the knee; to this
girth are straps to fix the pullies, which are to be applied,
and make extension in a gradual manner ; the direction of
the situation of the bone being obliquely upwards and back-
wards, the other thigh is not to be crossed by making the
extension at right angles, but it should be made across about
two-thirds or three-fourths the length of the bone down-
wards, and by using this degree of obliquity its reduction




320
LECTURE XXVII.
will be accomplished. Repeat the extension rather than
use any very considerable force, several times, especially
if the bone have been long out. The pullies are not abso-
lutely necessary. Bleeding, previous to the attempt, is use-
ful and mostly required, and if the patient be very muse ular
an injection of tobacco will be found beneficial; also proper
doses of antimon. tartar. to excite nausea, are useful, as they
tend very much to facilitate the necessary exertions.
The second species of dislocation of the thigh is down-
wards, into the foramen ovale. The head of the os femoris,
in this accident, descends into the cavity of the foramen
ovale--the trochanter major is drawn backwards by the
obturator muscle. The appearance of the limb is much
longer than before, one and a half inch or two inches and a
quarter. The knee and foot are turned out, the body drawn
forward, and the patient is incapable of straightening him-
self; this is occasioned by the action of the psoas and ilia-
cus internus muscles,—they pull the spine downwards. This
dislocation is the most easy of reduction. If it have re-
cently happened, secure the pelvis by means of a bandage
round the pubic region; the surgeon is then to go to the out-
side of the limb and push it inwards. Supposing it has been
out for some time, confine the pelvis by means of a strap;
also place a bandage around or across the regio pubis. The
first strap is to be applied between the pelvis and thighs ;
when these are applied, push the bone inwards.
The third species is backwards. In this accident there is
scarcely any difference in length between the one leg and
the other—if any, about half an inch shorter. The knee
and foot are turned inwards, but different in appearance to
that of the dislocation upwards—the foot is turned over the
other, the toe resting against the upper part of the other
foot. When an attempt is made to move it, there is scarce-
ly any motion. The situation of the bone is thus :—the
head of the os femoris is thrown into the ischiatic notch, the
trochanter resting upon the side, or a little behind the
acetabulum. The mode of reduction is best effected with
ane
LECTURE XXVII.
321

the pullies. In the first place, fix the bandage between the
thigh, so as to secure the pelvis, then apply another around
the thighs, and make the extension ; instead of doing this
so low as the knee, the direction is across the middle of the
other thigh, as this gives the head of the bone a direction
immediately towards the acetabulum: if the other thigh is
crossed so low as the knee, the head of the bone is drawn in-
to the foramen ovale, and then it cannot afterwards be mova
ed without extreme difficulty. After the extension has been
made for some time, carry a towel around the thigh, and
insinuate your head and neck into it ; you are then to place
your hands firmly on a table, and elevate the bone as much
as possible. Sometimes the pelvis may be fixed by means
of the bed-post, as Mr. Hey, of Leeds, has recourse to, as
detailed in his work.
The fourth, and last species, is forwards. In this case, the
head of the os femoris is thrown on the body of the pubis ;
the femoral artery and vein are put upon the stretch, and
thrown inwards ; the acetabulum is occupied by the tro-
chanter major ; there is very little difference in the length
of the two legs. The head of the os femoris is distinctly
felt in the situation of bubo : the knee and foot are turned
outwards. In the reduction the pelvis is to be fixed, and a
bandage or girth applied round the thigh, to which the pul-
lies are to be attached. The extension is to be made down.
wards and a little backwards. The patient lying on his
side, after continuing the extension for a short time, in order
to bring the head of the os femoris near the acetabulum, tie
a towel round the upper part of the thigh, and insinuate
your head and neck into it, then raise the head of the bone
upwards over the edge of the acetabulum till it slips into the
socket. If the bone be out for a considerable time, and
there is considerable difficulty, carry a bandage under a
table, on which a person is resting, and by bending the leg
till the heel nearly touches the back part of the thigh, and
the head of the bone is near the acetabulum, endeavour to
tilt it backwards into the socket.
41

322
LECTURE XXVII.
DATE
PATELLA.

The patella may be dislocated, either inwards or outwards,
from sudden falls, or from a peculiar relaxity of the parts.
I have known such an accident to happen, from a very
trifling cause, to a servant girl living in my father's service;
indeed, the great mobility of her joints was not confined to
the knee, but it extended to her wrists and fingers. When
the patella is thrown out of its place, the signs are, the bone
appearing either to one side or the other, and the straight-
ness of the knee. The mode of reduction is very simple ; it
consists in pressing down the outer edge of the patella, by
this means the inner edge is elevated, while the muscles in-
serted into it soon bring it into its former place. Extension
is sometimes necessary first, before pressure is used. It
sometimes happens that there is a laceration of the capsular
ligament, by which the patella is drawn up, as in fracture :
the same means for restoring it to its situation are necessary
as in fracture, and it is afterwards to be retained by proper
bandages. In the dislocation, I have above alluded to, it
occurred outwards, which is the most frequent accident. It
must be retained by a proper bandage, and lotions used of .
vinegar and water, or the liq. acet. p. dil.

TIBIA.
The dislocation of the tibia may be either inwards or out-
wards, or the head of the tibia may be thrown backwards,
behind the condyles; if outwards, the lateral ligament is only
ruptured : if inwards, the external and crucial ligaments are
torn. The reduction is very easy ; simple extension, and
proper direction of the bone, when carried to a certain ex-
tent, is all that is necessary : although rest, at first, will be
right, yet I decidedly object to its continuance beyond a
certain period, nine days or a fortnight, after which gentle
inotion must be allowed, to prevent a stiffness.

LECTURE XXVII.
323
There is a species of dislocation of the knee joint, first
described by that accurate observer, Mr. Hey, in which the
semilunar ligaments were so long as to allow the semilunar
cartilages to get between the condyles ; which causes the
condyles to become placed rather sideways in the joint, and
which has been named an oblique dislocation. The sign is,
the knee bent and cannot be straightened, except the body
also is bent, as the extensor muscles prevent it. The mode
of treatment is, to place the patient on a high seat, and let
the legs hang over; then take the leg and bend it smartly
as far as you can towards the buttocks, by which means the
condyles will slide over the semilunar cartilages.
ANKLE.
The dislocations of the ankle joint are, first, where the
tibia is thrown forwards, on the upper part of the foot.
The mark is, the heel greatly lengthened, and in this acci-
dent the fibula is broken. In the reduction, let one assistant
take hold of the foot, and another the leg, each making ex-
tension ; then the surgeon, with his hand, is to guide the
tibia into its place : during the cure the patient is to lie on
his heel.
The second dislocation of the ankle is inwards, and the
tibia is thrown on the inner side of the astragulus, together
with the fibula fractured just above its base ; also that part
of the tibia which is attached to the fibula at its lower part,
is broken. The mode of reduction will be the same as in
the former case-by extension and directing the bone. The
leg must rest, during the cure, on the malleolus internus.
The third species is outwards : in this case the foot is
turned inwards on its edge, and the malleolus internus is
broken off. The extension must be made as before. The
leg must be put to rest on the malleolus internus, and if found
to be an uneasy posture, it may be changed, and rešted on
324
LECTURE XXVII.
the externus on a pillow, letting the foot hang over :—it will
be some time getting well.
Observations,
After the reduction of each of these, splints are to be used:
any prefer the limb to lie altogether on the outside, not
the inside, in a bent posture, treating it similar to a fracture.
The gastrocnemii, and other strong muscles, must be relaxed
in reducing these dislocations.

COMPOUND DISLOCATION OF THE ANKLE JOINT.

Ketika bilan
A surgeon's character is in great hazard in such a case as
this, and it is a most important point in practice here, as
well as in compound fracture, to endeavour, after the dis-
location has been reduced, by every means to effect an union
by adhesion. Patients have been known to die so early as
the seventh day, from the surgeon's trying to save the limb,
and at other times, where the appearances were quite as
bad and unpromising, the limb has been saved, and the
patient recovered. Now, I will suppose for a moment, in
such a case, the limh was to be amputated, from a convic-
tion, in the surgeon's mind, of its being the best and safest
practice; the patient's friends would, perhaps, say that the
limb had been removed unnecessarily, and if he should, not-
withstanding, chance to die after such an operation, they
would say the surgeon had killed him. On the contrary,
I will suppose he bad tried to save the limb, and the patient
had died; they would be ready to say, the surgeon did not
understand his profession, and that the limb ought to have
been taken off. Now, in such embarrassing accidents, be
guided by the following rules. If the patient be old, am-
putate ;—if an adult of a bad habit of body, amputate ;—but
if an adult of a good constitution, try to save the limb, duly
considering the degree of constitutional irritation and fever :
if it be not great, the limb may be saved, but the joint will

LECTURE XXVII.
325
be anchylosed. If the astragulus be also broken, a better
expectation may be held out ; for in all inflamed joints there
must be an absorption of cartilage, and bony granulations
formed, which will produce great and excessive constitu-
tional irritation, so much so, that death often ensues ; there-
fore, if the cartilaginous surface of the astragulus be broken
off and come away, there will be left only the cartilage at
the lower part of the joint to be absorbed ; and hence, only
half the risk is incurred. In Mr. Gooch and Mr. Hey, we
have advocates for sawing off the lower end of the tibia,
for the above reason : this would seem to be a plausible
plan, but I have never heard of its being successfully done.
I really think removal of the limb, on the whole, would
be preferable in those cases where it might be deemed ad-
visable. The young, and those who are not irritable, of a
thin spare habit of body, are good subjects to endeavour to
save the extremity. If amputation be resolved, I am decid-
edly for its being done immediately: it will be folly to wait
till inflammation commences ; the chances of saving the
limb are few ; adopt, by all means, the decisive and com-
mendable practice of J. M. Larrey; depend on it, more
patients are saved by its speedy performance, than if defer-
red to the suppurative stage ; when done early, very sel-
dom the patient does otherwise than well. If the wound
be contused and extensive, no one will hesitate : here, as in
all other cases where joints are exposed, the synovia escapes.
In a good healthy constitution, notwithstanding, do not be
in haste to operate ; many cases do exceedingly well, and
particularly in country practice, where the air is good.

( 326 )
LECTURE XXVIII.
INTRODUCTORY LECTURE TO GONORRHA
AND SYPHILIS.

1
Syphilis made its first appearance in Europe in 1493 or
1495. Some maintain it was first observed at the siege of
Naples, or that, at all events, the followers of Columbus
brought it from the West Indies ; others consider it of much
earlier origin, and that the Greeks and Romans, nay, even
the Jews, were afflicted with it. It may be reckoned one
of the morbid compound poisons capable of affecting the hu-
man body constitutionally, and communicating to others
the same disease. The poison itself is known but little, but
its effects are very manifest. The virus is always in, or
mixed with pus, which shews that it is secreted by an in-
flamed surface : it always produces a species of inflamma-
tion in those that receive it, which is different from any

specific matter is formed after the continuance of it for some
little time. Infection may remain, and a capability of giv-
ing the disease to others, even when the inflammation has
totally disappeared. In order that this poison should act;
it must be applied in contact with a part in a state of solu-
tion, or mixture, for in vapour it does not give the disease,
differing in this respect from small-pox and other poisons.
The seat of it is well known to be the parts of generation

LECTURE XXVIII.
327
chiefly, from whence it may be concluded those are its
principal residences, and communicated by the act of co-
ition. Its effects on the body are two, local and universal,
or constitutional : the effects locally are immediate, the
universal are consequent.
The cause, both of gonorrhæa and syphilis, were consid-
ered the same, that is, to arise from the same poison,
though the effects were different, from the mode of action ;
the reason of which was said to be, that the economy of the
parts vary, one being a secreting surface, as the urethra, the
other not. It requires only one mode of action to produce
the effect on this canal: when any irritating matter is thrown
upon a secreting surface, nature, to overcome the stimulus,
increases the action of the part, from whence gonorrhæa is
formed : when the same application happens to a cuticular,
or non-secreting part, nature not being here possessed of the
same advantage as in the former, absorbs that part so stimu-
lated, by which the other disease, a chancre, is formed.
The secretion in gonorrhea is not the natural increased, but
one substituted, partaking of the poisonous nature of the
stimulant. Thus, any secreting surface, as the eye-lids, will
have the natural secretion altered and changed, although
the part most readily disposed to receive infection is the ure.
thra.
The poison of syphilis is more readily absorbed from
some parts than from others, as from chancre, sooner than
from an incised wound, for the incised wound must become
of the same nature as the virus before matter is absorbed :
this is seen in the inoculation for the small-pox, where the
variolous matter is not at first absorbed, but remains stimu-
lating till it has produced an ulcer of the same specific ną-
ture with itself before absorption takes place.
Mr. Hunter has, in himself, produced a chancre by mat-
ter from a gonorrhea, and he says, from numberless other
experiments, that he is led to conclude there is no difference :
as he found, indisputably, that the matter from gonorrhea
and chancre were capable of producing the pox. When a

328
LECTURE XXVIII.
secreting surface has set up the inflammatory action, the sea
cretion is always increased, and is at last so much altered as
to become exactly similar to that by which it was produced:
the matter that it first received stimulated, as it were, the
parts to secrete and wash it off; but this does not succeed, as
the irritation still continues, and the consequent inflammation
occasions a continuance of it, and a succession of the for-
mation of the same pus. The virus is not obliged to the pus,
but to the specific inflammation, for the continuance of the
action. Some have asserted that the matter in gonorrhoea
arises from an ulcerated surface ; now, although this might
be found to be the case in a few instances, yet, having ex-
amined many after death without finding any appearance of
ulceration, Mr. Hunter could not but conclude that it is far
from being the case in general ; besides, if it depended on
ulcers, these could not be expected to heal without the use
of mercury, whereas, every one who is at all acquainted
with gonorrhoea, now knows that it can, and ought to be
cured without a grain of this medicine. Gonorrhea differs
very much in the degree of violence of the symptoms in
different constitutions, some being much more affected than
others: when mild it may be called simple; when violent,
complicated : this would not appear to arise from any alter-
ation, or difference, in the specific quality of the matter, but
in the susceptibility of the parts that receive it. A chancre
in some people, will heal up immediately, while a gonorrhoea
in the same person will produce the most violent symptoms.
In some, a venereal ulcer will heal readily, while a slight
wound from any trivial cause whatever, will torment both
surgeon and patient. A case is related by Mr. Hunter, of
a gentleman, who, from running his spur into his leg, had a
very troublesome ulcer, at the same time that chancres were
healing with the greatest readiness: he was almost inclined,
in this case, to apply venereal matter to the ulcer, for he
could not help thinking that it would induce it to heal.
Some diseases are capable of curing themselves; nature not
being able, or disposed to continue the same action beyond
LECTURE XXVIII.
329

a specified time: if this were not the case, there would be
no end to many complaints: this principle is common to
many, hence the conquest in gonorrhæa ; the power of con-
tinuing the action is here gradually diminished, and the cure
effected by a natural decay. This cure in general takes
place in a secreting part, for a chancre will increase as long
as the virus remains unattacked. Mr. Hunter makes it a
doubt whether a gonorrhea would be increased by a com-
munication of the same matter ; for when the matter of go-
norrhea, or chancre, has been applied to a bubo, no re-
tardment in the cure has been noticed, the matter thus ap-
plied being only a renewal of the same kind it in the first in-
stance was amply furnished with. The poisonous gland
and duct of the viper is not stimulated by the fluid it se-
cretes : but if the same be applied to any other part of the
animal, different circumstances will occur. When a part
has been accustomed to a stimulus some time, it gradually
grows insensible of its action ; but if there be any interval,
the part will become almost as sensible as ever. The first
infection of gonorrhea is generally, if not always, the
worst, and it is a well-known fact, that the number of claps
diminished the susceptibility and degree of violence.
Notwithstanding it was considered, that gonorrhea and
chancre arose from the same poison, which I always have
doubted, it would be very difficult for the advocates of the
former to explain to me, if such really were the case, why
the two species do not attend at the same time, for it is
natural to suppose that the one would produce the other,
and although cases are related of a chancre coming on soon
after gonorrhea, and vice versa, yet they are not to me sat-
isfactory. I have known a young gentleman contract a clap
• from one girl, and a chancre from another, two successive
evenings. The one girl was known to have gonorrhea, the
other a chancre. I have heard it endeavoured to be ex-
plained thus, that the presence of one irritation excludes the
other in general; but in this case they were both present,
and distinctly contracted.

42
330
LECTURE XXVIII.
The constitution will not be contaminated from gonorrhea
---from chancre it will : and although the matter of the lat-
ter finds its way, if applied to a common wound, or ulcer,
yet it cannot get into the constitution by the breath, per-
spiration, milk, &c.
Case.—Gonorrhæal matter was inserted in the prepuce,
Sept. 1, 1817, with the point of a lancet, in a similar way to
vaccination ; on the 4th and 5th the part inflamed and sup
purated ; the pustule was opened, the contents squeezed
out, and a poultice applied twice ; the wound was then
dressed in as simple a way as possible; and on the 14th it
was perfectly healed. Nothing further was done than I have
detailed, and yet no secondary syphilis was observed after
six months had elapsed.
What does this case prove? Why, that allowing the mat-
ter to be gonorrhæal, similar to what is mostly seen, (as
there are exceptions to all rules) it was not capable of caus-
ing a venereal affection. If gonorrhæal matter be applied
to a wound or ulcer, will it produce syphilis ? I think not.
If the matter of chancre be applied to a scratch, or wound,
it will cause every symptom of the disease locally and con-


urethra, cause clap ? I think it will produce a discharge.
The effect of any irritating body on a secreting surface
tends to do so; but ulceration would follow; and those
claps that are seen sometimes so inveterate, I imagine to be
of this nature. I have reason to believe a clap may be
caused by connexion with a woman during the continuance
of the catamenia, and I think it might be occasioned by
fluor albus also. Women are sometimes so insensible to
shame as to set no bounds to their depravity, and allow
periods only; and from the want of requisite cleanliness,
these discharges become extremely acrid and offensive.
( 331 )
LECTURE XXIX.

Hoofth

ON GONORRHEA.
This disease arises from the action of a morbid poison on
a secreting surface, and is commonly attended with exten-
sive inflammation. The usual seat of it in men is the ure-
thra ; but it sometimes takes place on the prepuce and glans
penis : in women, the vagina, urethra, labia, clitoris, nym-
phæ, the glans, &c. When it attacks the glans and con-
tiguous parts, it commences principally about the root of
that body, where the cuticle is thinnest ; it occasions sore-
ness and tenderness in the parts, with a secretion of a thin
matter : it is often here so slight as not to be much noticed.
Case.—Mr. B. was connected with a woman in town, and
perceiving a running four days afterwards, consulted Mr.
Hunter, who, on examining him, found the glans excoriat-
ed, and discharging matter, but did not suspect it to be oc-
casioned by impure coitu, till other circumstances set the
case clear. It is seldom extended from thence to the ure-
thra. The most probable way the poison attacks the ure-
thra is this, that it is either translated from the glans to it,
or, at least, from the beginning, or lips of the urethra itself,
along its inner surface. It is not possible to conceive that
the matter could be conveyed far into the urethra in the act
of coition. The case of Colonel B. strongly corroborates
this ; he received infection, and had a bad gonorrhea, from
sitting on a necessary in Germany, and getting a plaster of
gonorrhæal matter (which some person had left there) on his


332
LECTURE XXIX.
penis. When it attacks the urethra it seldom extends far-
Symptoms.
The first symptom a patient experiences is a titillation, or
itching sensation in the urethra, as if a drop of urine remain-
ed in the passage. A small quantity of mucus is discharged
discharge will be found to have taken place ; at first, not at
all purulent, but in a few hours it assumes this character,
having a yellowish appearance, and is composed of a num-
ber of globules very similar in its nature to that of pus, with
the exception of its being poisonous. The discharge soon
changes from a yellow to a greenish colour, and is often
mixed with blood ; when examined on a cloth, it assumes
various hues, the circumference pale, and the centre thick-
er and of a deeper colour, and it is probable that these dif-
ferent tinges depend most commonly upon the extravasation
of a small quantity of blood. The matter has a very pecu-
liar smell, and there is a great tendency to putrefaction, in
consequence of unhealthy inflammation. During a very
high inflammation in the urethra a considerable quantity of
blood has been often lost ; this proceeds from a rupture of
some of the vessels in the passage ; it gives relief at the
time by checking the inflammation. Sometimes a great deal
of coagulable lymph is seen floating in the urine, and this
even after the disease has existed for some time. After the
first irritation felt by the patient, he has a smarting sensa-
tion in voiding his urine, and in a little time this increases to
that degree, accompanied with considerable heat of the
parts, constituting what is termed ardor urinæ : the pain is
sometimes so excessive that the patient dreads the thought
of voiding his urine, and delays it for several hours : it is,
however, much lessened by discharging it guttatim. The
pain felt is owing to a deficiency, or rather, an altered state
of the natural mucus, which is secreted for lubricating the
urethra during the discharge of urine.


LECTURE XXIX.
333
The external appearances are these : the lips of the ure-
thra are observed very red, with a prominent and tense tu-
mefaction, with pain at the frænum : the disease takes two
courses, externally and internally. As it advances, the
whole of the glans penis becomes affected, and is of a florid
red colour ; a deposition of serum takes place, accompanied
with a swelling of the parts, which is productive of phy-
mosis. The absorbents of the dorsum penis become enlarg-
ed, and are easily distinguished by the finger being rubbed
on the surface : the inflammation extends to the root of the
penis, and in bad habits even to the pubis, along the course
of these vessels, terminating occasionally in suppuration.
The glands in the groin are next enlarged, constituting what
is termed a sympathetic bubo, for sympathy, in the strict
meaning of the word, applies to an affection taking place
in a part remote from the seat of the disease. This enlarge-
ment in the groin differs very much from the true venereal
bubo. The gonorrhæal inflammation does not subside here,
but directs its course riore internally, and the patient, flat-
tering himself with the hopes of the disease going off, from
the disappearance of the bubo, begins of a sudden to have a
peculiar uneasy sensation at the neck of the bladder, owing
to the extension of the inflammation along the urethra ;
spasms may soon be anticipated; a great deal of pain is felt
in perineo during walking, below the part first inflamed : the
corpus spongiosum next is affected, adhesions take place in
it, constituting that most troublesome sensation, the chor-
dee, which produces an incurvation of the penis. The la-
cunæ become soon affected, an obstruction takes place in
them, and it frequently happens that an abscess forms,
which bursting, the contents are discharged per urethra : it
generally occurs near the frænum, but there are instances
where they forin near the bulb, and in this situation they
are dangerous, in consequence of the probability of the
contents being effused into the cellular inembrane. When
the inflammation extends along the urethra, opposite to the
acceleratores urinæ, spasmodic contractions are occasioned
every four or five minutes, extending to the perineum, and
334
LECTURE XXIX.
often accompanied with an inflammatory stricture in the
urethra, which is easily known by the flow of urine being
often suddenly interrupted. When the inflammation extends
as far as the membranous part of the urethra, those ducts
which open into it take on the disease, as the vasæ defer-
entiæ, and which, extending along their course to the tes-
ticle, produce hernia humoralis, prior to which, however,
there is considerable pain felt in perineo.

Treatment.
It was formerly the custom to administer mercury in this
complaint, under the idea that it was a similar disease to
syphilis ; but the notion being now completely refuted, this
medicine, even as a purgative, is unnecessary; and it is much
better to depend upon any other medicine to induce this
effect.
In the inflammatory stage, a purgative, composed of six
grains of cathartic extract, should be given every night,
and a powder, composed of the sulphate of magnesia, two
drachms, nitre a scruple, twice daily. The patient should
drink plentifully of barley water, mucilage of gum arabic,
linseed tea, &c. : the best drink I know of is composed of
gum arabic, linseed and nitre, boiled in a quantity of water.
He should live very abstemiously, avoiding fermented or
spirituous liquors, spices, &c. : the best beverage is soda
water. In every stage the bowels must be kept open by
mild laxatives; and if the patient be of a plethoric habit, and
the symptoms run high, general bleeding will be proper.
He might take occasional doses of the aq. kali pur. ; and if
the pain be great, three grains of the extr. cicutæ bis die :
the penis should be emerged frequently in warm water.
The carbonate of potass dissolved in water, half a drachm
for a dose, or the carbonate of soda, which is still prefer-
able, may be occasionally recommended. If there be in-
flammation on the outer surface of the penis, leeches should
be applied, and afterwards warm fomentations, so as to pro-
mote the bleeding ; afterwards a lotion or poultice of the


LECTURE XXIX.
335
liquor. acet. plumb. dil. should be made use of_indeed,
cloths, wetted with this lotion, are recommended by Mr.
Abernethy to be kept to the penis from the commencement.
When these or other means directed to subdue the inflam-
matory action, are successful, attempts must be made to di-
minish the discharge by taking internally the bals. copaiba,
formed into a mixture with mucilage of gum arabic : it will
have the effect of changing the colour of the discharge from
yellow to a whitish coloer, but acts very slightly in dimin-
ishing the quantity of it. By the use of the balsam, the ca-
nal is brought into a better state for the use of injections and
therefore it should be given three or four days previous to
their use. Astringent injections may then be had recourse
to, used weak at first, and increased gradually in strength,
as the sulphuric acid, six drops to four ounces of water; this
is found not to irritate the urethra : having persisted in its
use three or four days, it may be used stronger. The acetate
of zinc, six drops to four ounces of water, may then be sub-
stituted: this should be warmed previous to its being injected.
Injections of lead are not approved of, as they are thought
to occasion permanent strictures. Injections of the muriate
of mercury should only be had recourse to in those patients
who have frequently been affected before with gonorrhæa ;
it must be used very weak; it is a safe injection, but is very
slow in exerting its beneficial effects. A good injection is one
made of calomel two drachms, opium one scruple, mucil-
age of gum arabic four ounces. Injections should be used
three or four times daily, besides morning and evening; and
also if the patient awake in the night. Syringes with long
pipes are improper, being liable to wound the urethra ; they
should be short and accurately smooth, and rounded at the
extremity. At the time of forcing in the injection, the pa-
tient should compress the penis about three inches down, in
order to prevent the passage of the fluid any further down
the urethra. Much benefit may be derived from varying the
injection every two or three days; a lotion composed of a
different medicine should be substituted, by this means the
336
LECTURE XXIX.
cure will be much accomplished : as when only one kind is
made use of, the urethra becomes accustomed to the stimu-
luz, and loses its intended effect ; to overcome this, if it be
much and suddenly increased in strength, it will be very apt
to cause stricture. If the injections, though varied, do not
make a cure when used for some time, it will be prudent to
lay them aside, and a bougie should be introduced dipped in
the following composition : bals. copaib. one drachm, ol. ol-
ivar. opt. three drachms, or smeared with the ung. hydrarg.
nitr. very weak: these are found frequently to succeed where
injections have failed. I would remark, that the great ob-
jection to the bals. copaib. is, that it sometimes occasions
eruptions on the skin.
This is the plan I would lay down; but I cannot in justice
avoid noticing the contents of a paper, by a Mr. Addington
of West Bromwich, to be found in the “ Contributions of
Medical Knowledge,” published by the late Dr. Beddoes of
Bristol. He gave a grain and a half of the oxymuriate of
mercury, dissolved in half an ounce of rectified spirits of
wine, at bed time : for an hour and a half or more, a copious
salivation was produced, and his patient spit a quart. Aperi-
ent salts are to be taken on the day but one afterwards; and
on the evening of that day, the solution, as before, is to be re-
peated, and the salts the succeeding day but one. Three or
four doses thus given, frequently, he assures us, removed a
gonorrhæa ; and he further states, that hundreds were cured
by this plan. Cubebs, which are dried berries resembling
pepper, have lately attracted notice in this complaint; but
until I hear of something more rational on this subject, I shall
suspend my judgment. It is asserted, that these berries have
a specific action on the urethra, and that the irritation they
cause being greater, it overcomes that set up by the gonor-
rhæal virus : thus the symptoms will be materially aggrava-
ted for a time, and when the medicine is discontinued, they
abate and disappear. How far this will prove to be the fact,
time alone will develop ; but in my opinion such expedients
are improper where much inflammation exists, or the patient
is of an irritable habit.



( 337 )
LECTURE XXX.
ON STRICTURES.
The existence of strictures in the urethra, may be known by
the patient frequently experiencing an inclination to void
his urine, which is first noticed in consequence of his being
disturbed during the night more frequently than usual, in
order to discharge the contents of his bladder. The urine
passes out in a spiral direction, and this symptom is present
long before there is any evident diminution in the size of the
stream : the stream itself is next found diminished in vol-
ume, and is frequently forked, or divided into two. It also
often rises up in passing out of the canal at the glans. As
the disease proceeds, the urine will first be expelled in
drops, and then in spasmodic gushes--seldom in a continued
stream. Patients afflicted with this disease, will often apply
for relief on account of an incontinence of urine, which is an
effect of the complaint. Sometimes, though very rarely,
there is a retention of urine ; but this is seldom attendant on
permanent stricture, and when it does occur, there is gen-
erally some other cause superadded besides the stricture.
The urine is mostly of the colour of whey, which denotes
the existence of an inflammatory affection of the mucous
membrane lining the bladder. Persons who have this com-
plaint, have also, in most instances, a gleety discharge,
colouring the linen like semen: if he have been intemperate
43
338
LECTURE XXX.
and irregular in his mode of living, the discharge will be of
an opaque yellow colour, the inflammation being excessive.
Fistule will frequently arise when the disease exists in sev-
eral parts, mostly in the perineum, though sometimes at the
fore-part of the scrotum. When a bad stricture is present,
that part of the urethra, beyond the stricture, becomes en-
larged, while the fore-part is diminished in size and diam-
allows of the extravasation of the contents of the bladder
into the surrounding cellular substance : this, by inducing
inflammation, causes the formation of matter, which general-
ly bursts externally, though not always, allowing the urine
to pass by the same aperture from the bladder. The dis-
ease from stricture, does not confine itself to the urethra
alone. When a stricture has existed for some time, the blad-
der becomes affected and thickened, in consequence of the
continued irritation set up in the urethra, inducing an almost
constant inflammation, and also from the continued action
of the muscular fibres of this viscus, by which they are also
increased in their thickness. When disease of the bladder
is present, it is denoted by an uneasy sensation in the regio
pubis, and a sense of fulness in this part.
On examination after death, the mucous membrane is
found to be thickened and streaked with bloody marks, aris-
ing from inflammation—it is also oedematous. A secretion
of coagulable lymph takes place, which causes the wheyey
appearance in the urine. When this symptom makes its
appearance, the constitution generally becomes affected
with febrile symptoms, similar to an intermittent, consisting
of a more or less severe paroxysm, recurring at uncertain
intervals, now and then preserving regular distances of time
between the fits. When these appearances were present, it
was generally the custom to throw in the cinchona; but this
practice was attended with little or no success. Opium, with
evacuants of different kinds, were found to be effectual
remedies; and few cases occur in which this plan will not
succeed. From the bladder, the ureters and kidneys be-



LECTURE XXX.
339
come diseased : they enlarge, and ulceration takes place in
the ureters, and pelvis of the kidneys. Patients often die
of the ultimate effects of stricture ; hence stricture is found
to be one of the most serious consequences succeeding go-
norrhæa ; and as it may prove very dangerous, and is sel-
dom completely relieved, practitioners ought to be very
cautious not to induce it by the use of injections during the
inflammatory stage.
The appearance of the urethra on dissection, when stric-
ture exists, is a thickening of its coats, and a diminution of
its diameter at the thickened part. It sometimes appears
as if a string had been tied round the outside of the urethra,
and the stricture will extend no further than where inflam-
mation, thus induced, would be supposed to extend : occa-
sionally, though less frequently they are met with, resem-
bling the urethra compressed by a broad riband, the con-
tracted part being some space in length; when this latter is
the case, they are difficult indeed to remove. A stricture is
now and then caused by membranous bands crossing the
urethra. There is also another species, termed the elastic
stricture ; in this, though the common bougie is applied
daily, no progress is obtained, as immediately on its being
withdrawn, the strictured part regains its former tightness.
Caruncles and warts are sometimes situated in the ure-
thra, but the cases are rare; in one specimen the wart grew
from the verumontanum.
Some have imagined that the existence of excrescences in
the urethra was only ideal, and handed down from one prac-
titioner to another as probable. Mr. Hunter, however, saw
two cases of stricture of long standing, in each of which
there was a substance in this canal similar in appearance to
polypi, and he considered them a species of internal warts.
SEAT OF STRICTURE.
This is various ; but the most general situation is where
the original stricture is found about seven inches down the
340
LECTURE XXX.

urethra, or rather less, at that part where the membrancus
portion of the urethra is joined to the corpus spongiosum.
It is seldom the case when the disease has existed for some
space of time, that one stricture alone is found, there are
mostly two or three ; one from three and an half to four
and an half inches, one at five inches, and another at six and
an half or seven inches from the glans. Occasionally there
are several existing. Mr. Hunter has seen from five to six
in the same person. If the patient have had the disease a
long time, the penis is often distorted, and not unfrequently
bent to a right angle, which arises from inflammation in the
corpus spongiosum from the irritation induced by the stric-
ture. Strictures are slow in forming, and are worse in
cold weather.

CAUSE OF STRICTURE.
The primary causes are various ; but the proximate are
always inflammation of the membrane lining the canal. The
most frequent occurrence is inflammation subsequent to go-
norrhæa, whether arising from the violence of the disease
itself, or brought on by the use of injections during the in-
flammatory stage. Riding on horseback during the period
of cure, as well as drinking spirituous liquors, will equally
tend to produce such an effect. Other causes will induce
the disease, independent of any taint whatever, as is proved
by the existence of it in children, though it certainly is a
rare occurrence in them. Mr. Hunter believed, that stric-
tures seldom arose from the venereal disease in any shape,
and he says it will be difficult to open people's eyes on this
subject, there being but few persons now-a-days that have
not, some time or other, had a gonorrhæa!! He founded
his opinion for supposing strictures not a consequence of
gonorrhæa, on these grounds, that the esophagus, rectum,
ductus ad nasum, and parts of the intestines, &c., are occa-
sionally the subject of the same disease ; another reason
was, his having patients with stricture who never had a go-

LECTURE XXX.
341
norrhæa ; and further, a gentleman, a patient of his, suffer-
ed with one, who had not had a gonorrhæa for between
thirty and forty years : again he says the most common seat
of it, is the membranous and bulbous parts of the urethra ;
the principal focus of the gonorrheal inflammation is direct-
ed to the lacunæ ; that, he maintains, is the head-quarters
of it. Strictures, he says, never arise during gororrhæal
inflammation, and patients have come to him labouring un-
der strictures, who never employed any injections, though
these are considered almost the invariable cause by some
surgeons. A bougie is more severe than an injection in its
introduction, and yet they are never blamed.
Strictures are sometimes rendered worse by a small stone
passing along the urethra as far as the diseased part, and
lodging there. Strictures are at times considered the cause
of stones forming in the bladder, and this seems to depend
upon the retention of urine.
TREATMENT OF PERMANENT STRICTURE.
This disease is só very obstinate, that scarcely a single pa-
tient is ultimately cured : those who have been once affected
with it, retain such a disposition to a re-attack of the disease,
that a very slight cause will induce its re-appearance. It
certainly is often relieved, but rarely permanently cured,
though many cases have been published that would lead a
medical man to suppose such an assertion not well founded ;
but long use to the perusal of cases detailed with interested
views, have rendered some surgeons sceptical.
The first step in the effort to cure, is to introduce a bougie,
composed of soft wax, into the urethra, to ascertain the situ-
ation, nature, form and size of the stricture ; and the surgeon
will then be enabled to judge of the kind of bougie required.
The stricture is more commonly situated at the upper part
of the canal. When the particular bougie is determined on,
it must be bent similar to a catheter, and introduced in the
same manner, well oiled. When a bougie can be passed
into the bladder, one of the largest size must be used each
342
LECTURE XXX.
time of passing it, until the canal has regained its original
size: this being done, the patient should be instructed how
to use and pass it himself, and he should be advised to intro-
duce it into the bladder every two or three weeks, otherwise
the stricture will be apt to return as bad as ever. The me-
tallic bougies are not so good as the wax ones ; they give more
pain, and do not adapi themselves to the form of the ure-
thra as well as those made of wax: besides the latter sel-
dom produce hæmorrhage from the canal by passing through
or injuring its coats, as they will bend when impelled against
the sides : such an accident, as injuring the membrane, will
often lay the foundation of future strictures. A catheter
may be introduced into the bladder when a bougie cannot,
and it is always better to attempt the introduction of it, pre-
vious to using the caustic bougie. The catgut bougie is not
a good one, though it may be of use to dilate the strictured
part when the opening is very small. It will be right to in-
crease the size of the bougie, in such cases, almost daily, un-
til the passage is restored. Supposing that neither a bougie
or catheter, however small in size, can be introduced, re-
course must be had to the caustic one. In making use of it,
take one of a good size, as large as the urethra will admit of,
and I think those charged with the nitrate of silver are the
best: the kali purum irritates the urethra more than the for-
mer; besides it dissolves more readily, and will be much
more liable to induce inflammation around the stricture: the
nitrate of silver being less soluble, will have its effects con-
fined more to the strictured part. Prior to using the armed
bougie a common one should be passed, to ascertain exactly
the seat of the disease, and also to dilate the passage; it
should be larger than the caustic one, and the distance on
the latter must be marked, so that it may be known when it
has reached the stricture. The caustic bougie must be pas-
sed as quickly as possible, and then suffered to remain in the
urethra a longer or shorter time, according to the irritability
of the patient, and according to the frequency of using it:
half a minute every other or second day, will be enough at


LECTURE XXX.
343
first, allowing the slough to separate on the intervening days:
it has succeeded in removing the stricture after a few appli-
cations. Several cases could be detailed, proving, beyond
a doubt, its utility. Other instances could be given, where
it produced very distressing symptoms, such as retention of
urine, &c.; to prevent which, it is extremely necessary to be
cautious in the first introduction, the suppression being caus-
ed by the great degree of irritability induced in the urethra.
It has happened that the artery of the bulb has been des-
troyed by its use, and thus an alarming hæmorrhage took
place, and ultimately the formation of a spurious aneurism.
From its having been used improperly or incautiously, false
passages have been made, which are always troublesome,
and not totally unattended with danger. Such are the dis-
advantages of the caustic bougie, which, I may remark, are
principally to be attributed to the mode of applying it; al-
though, on the other hand, I must candidly confess, even in
the hands of the most skilful men, it has frequently failed.--
The cure must be effected either by dilatation of the con-
traction, or destruction of it. To whom is the profession in-
debted for this last plan of treating strictures ? To Mr. Hun-
ter. His ideas were too original to be a copyist. He began
with red precipitate. Sir Everard Home has written a very
excellent work on strictures, advocating the plan of Hunter.
Mr. Whately has favoured the world with a new method of
treating strictures ; it is on the same principle, so that there
is no novelty in this respect; he prefers the kali purum.
ON FISTULA IN PERINEO.
It has its origin from an enlargement of one of the lacu-
næ, in consequence of inflammation, resulting from the ap-
plication of the matter of gonorrhea to that part of the
urethra, in its extension downwards towards the neck of the
bladder, causing a stricture. It is variously situated as well
as formed; being sometimes found in perineo, at other times
further back, forming a communication between the urethra
and rectum. It is most frequently arising from strictures :
344
LECTURE XXX.
the internal membrane inflames and ulcerates, urine readily
extravasates into the loose cellular membrane, not only of
the penis, but also of the scrotum ; hence suppuration soon
commences, and ultimately affects this fistula. Sometimes
a fistula is thus formed very suddenly, but in general
gradually.
The patient observes a very hard and distinct tumour
existing in that part of the urethra opposite to the bulb, not
in general exciting much pain, but causing a good deal im-
mediately the contents of the bladder are evacuated. The
urine being extravasated here, occasions inflammation and
subsequent suppuration. When this takes place very suid-
denly, the life of the patient is in great danger, from the
extravasation of urine into the cellular substance of the
perineum or scrotum ; in such cases the inflammation and
suppuration are violent and extensive, spreading not only
to the scrotum, but to the integuments, at the anterior and
inferior parts of the abdomen. In cases of this nature, it is
right to make an opening into the part as soon as possible.
An attempt to check the formation of matter is only so much
loss of time, as they are never attended with success. Ear-
ly opening of the abscess is highly necessary here, and more
particularly when the urethra bursts suddenly : if it be
neglected, patients will, in all probability, fall a sacrifice.
The mode of operating is thus : pass a catheter as far as
the stricture will allow, then make an incision an inch be-
yond it ; after which pass a staff into the urethra, and cut
directly upon it through the stricture ; by this means, pres
ent relief is not only afforded, but it may effectually relieve
the stricture, introducing an elastic hollow bougie, and suf-
fering it to remain two or three days. The scrotum should
always be opened at different parts by means of incisions,
made sufficiently deep to admit of the urine being evacuated
by means of them, but not so as to endanger the wounding
of the tunica vaginalis : by this method, and by this only,
will sloughing be prevented. The application of a vinegar
poultice to the scrotum, will be found extremely beneficial.



LECTURE XXX.
345
Whether the extravasation is anterior to the scrotum, in it,
or in the perineum, the early opening is always to be
adopted. Having made the necessary incisions, the sur-
geon's next attention must be directed to the stricture, as
while it remains in its original state the fistula can never be
cured. For this purpose practitioners employ the bougie,
and the caustic is far preferable to the common one. It
sometimes happens, that the stricture shall be entirely re-
moved, and yet it is found impracticable to heal the fistula :
under such circumstances, the flexible metallic catheter
should remain in the bladder, and the patient be directed to
lie as much as possible in an horizontal position. The ca-
theter should not be suffered to remain any great length of
time in the bladder, as the urine will act upon the metal so
as to corrode and break it, and instances are on record
when it was requisite to perform an operation for the re-
moval of portions of the catheter thus confined in the blad-
der. It is better, therefore, to suffer it to remain in the
bladder only a certain length of time, then remove it, and
introduce another : three or four days will be the best
space. If the fistula do not beal under this treatment, ap-
plications to the part may be useful, such as a gentle solu-
tion of the hydrarg. muriat. thrown up the fistula by means
of a syringe. A case happened where the abscess burst and
formed a connexion between the urethra and rectum ; here
the plan to be adopted must consist in removing the stric-
ture, and the constant introduction of a catheter, or else an
operation must be attempted similar to lithotomy, at the
commencement, and for a time form a fistula in perineo.
The grand intention to be kept in view in treating fistula in
perineo, is to restore the passage of the urethra ; when this
fails, the sinuses must be laid open.
SPASMODIC STRICTURES.
This species of stricture is rarely found unconnected with
the permanent one. It may be known by its being only of
44
346
LECTURE XXX.
a temporary duration ; it is generally attended with a gleet.
The patient is not conscious of any disease of the kind : feel-
ing a more frequent inclination to void his urine than usual,
and being foiled in the attempt, is the first thing that strikes
his attention ; it is for the most part unattended with pain.
It is caused, when connected with permanent stricture, by
the free use of injections of a stimulating kind, and the plen.
tiful administration of opium : at other times by the frequent
and copious use of spirituous liquors, riding much on horse-
back, &c. At the contracted part a spasmodic action is
induced. Even a difference in the temperature has great
influence in the facility of voiding the urine, hence, a person
going out of a warm room into the street, will not be able
to pass a drop of urine, but on returning, after a little time
has elapsed, he will make water readily.
Treatment.
First attempt to pass a bougie, but in a very gentle and
cautious manner, so as not in the least to irritate the penis :
when it has passed as far as the stricture, do not attempt to
push it beyond this point by any means, but preserve a gen-
tle and uniform pressure for the space of five or ten minutes,
waiting for the absence of the spasm : by these means the
surgeon will generally succeed in passing the bougie into
the bladder. If the patient be desired to force gently, on
withdrawing the bougie, the urine will mostly follow in a
moderate stream. If, however, this treatment fail, antimony,
combined with a very small dose of opium, or administered
alone in small quantities, frequently repeated, so as to in-
duce nausea, should be ordered. Tobacco glysters will also
be found serviceable, so as to produce general relaxation.
Ten drops of the muriated tincture of iron every five or ten
minutes, has been of the most decided benefit, and Mr.
Cline most strongly recommends it in the spasmodic stric-
ture. Mr. Else had a case, which was relieved from time
to time by lime water. Another person was cured by means
of the cold bath, when every thing else had failed. The
author has known a gentleman, who was subject to this



LECTURE XXX.
347
stricture, materially relieved by emerging the penis only in
cold water ; in fact, he could not void his urine for some
time, till he adopted this practice. The warm bath has oc-
casionally been recommended, and considered very useful,
but this practice appears to have been pursued by confound-
ing the spasmodic with the inflammatory stricture.
THE INFLAMMATORY STRICTURE,
Is caused by the extension of gonorrhæal inflammation
towards the bladder. It is accompanied with great irritation
and pain of the accelerator urinæ muscles. This pain will
come on very violent, and continue so for the space of two
or three minutes ; it will then cease for five or six minutes,
when it will again recur with equal violence. This com-
plaint will continue thus to torment the patient some time.
The inflammatory action set up causes a retention of urine.
Stimulating medicines given to act as diuretics in gonorrhoea
are often the cause ; virulent gonorrhæas, as well as the ir-
ritation of strictures, tend to this effect. Cantharides affect
the neck of the bladder by their stimulus, and produce a
strangury.
Treatment.
Bleeding largely from the arm, the application of leeches
to the perineum, and emerging the patient in the hot bath,
or in a vessel invented for this purpose, called the hip-bath,
must be had recourse to; sponging the parts continually with
tepid water will give relief. The mustard poultice applied
to the abdomen is useful, from the rubefacient property it
possesses, and is better than the empl. lyttæ, on account of
its not stimulating the urethra or bladder. A pill composed
of submuriate of mercury, gr. iss. ; powder of opium, gr. j. ;
extract of hemlock, gr. ij.; camphor, gr. iij. ; made into a
bolus, with some conserve, has a very good effect. If these
means fail in affording relief (but they seldom will), the ca-
theter must be cautiously introduced, and the collected
urine evacuated. If this be found impracticable, and there
be evident marks of distention of the bladder, the operation

348
LECTURE XXX.
must be performed without delay. When it has arrived at
the chronic state, small doses of the hydrarg. muriat. with
decoct. sarsaparill. are beneficial. I would remark, it is
better not to attempt the introduction of any instrument, till
the body, at all events, has been a good deal relaxed by the
bleeding, hot bath, &c. This complaint is almost, if not
entirely, confined to irritable habits.
ENLARGEMENT OF THE PROSTATE GLAND.
This is a disease attributable also to gonorrhæa in some
instances. It occurs frequently in elderly people after the
age of sixty. It causes retention of urine, in consequence
of the posterior lobe of the prostate being so enlarged as to
act as a valve upon the urinary canal. The gland becomes
inflamed, and this is mostly succeeded by suppuration. The
prostate of old people is naturally enlarged, particularly
when the urethra has been very much excited. It happens
to be a provision of nature, to prevent an incontinence of
urine, which would otherwise often be the case, as the mus-
cles lose their tone to such a degree as almost to have lost
their powers of action. It is frequently found enlarged in
three different parts. The urethra within it is also so much
dilated, that a surgeon is liable to be deceived in passing the
catheter, supposing he has entered the bladder, when in
fact the instrument remains still in the urethra. The symp-
toms of an enlarged prostate are in many respects similar to
those of the sione; instead, however, of feeling a sharp pain
at the extremity of the penis, it is only a sense of numbness :
great tension in the regio pubis on discharging the urine,
which passes off in sudden gushes, requiring considerable
force to void small quantities of it: there is a sense of weight
in the perineum, and sharp pain in the neck of the bladder
when voiding fæces; next, the patient is incapable of mak-
ing water without going to stool. The desire to evacuate
the urine is greater in a recumbent than in an erect position
of the body. A total retention is the consequence, which is
more particularly distressing in the night, arising from a
great accumulation of urine at this time. When the urine is

LECTURE XXX.
349
drawn off, it is of a chocolate colour and peculiarly foetid.
The reason why a retention is greater in the morning be-
fore the patient rises, than it is at another time, is, that the
third, or posterior lobe of the gland, is at that time acting as
a valve upon the opening into the urethra, in consequence of
the pressure of the accumulated urine behind it.
The existence of the complaint may very generally be
ascertained by an examination of the part per anum.-
Though it is also a disease which may, in most cases, be
considered as peculiar to old persons, yet there are instances
of its having occurred not only in the prime of life, but also
in a boy.
Treatment.
The balsam of copaiva is to be ranked as one of the most
effectual remedies, giving twenty drops thrice daily. The
uva ursi has been much recommended, but it cannot be held
in the same estimation as the preceding medicine. Soda wa-
ter, or in its stead a solution of soda, has been found very
beneficial. The only remedy known to give permanent re-
lief is the hydrarg. muriat. in solution, accompanied by the
sweet spirit of nitre. The hip-bath is useful. In the treat-
ment of diseases of the urethra, not a little depends upon an
accurate knowledge of their symptoms and the anatomy of
the parts. When the urine requires to be drawn off in a case
of enlarged prostate, a catheter is necessary two inches
longer than usual; its extremity should also be enlarged:
it should be passed down to the prostate, then depressing the
handle so as to raise the other end above the posterior en-
largement, will generally prove successful. Having intro-
duced it for two or three days, the prostate will put on a
healthy appearance, and the inflammation will subside, pro-
vided the affection is only recent, and proper attention be paid
to the antiphlogistic plan of treatment, &c. It will be proper
to let an instrument remain in the bladder ; for this purpose
Smith's hollow elastic bougie will be best : but it should not
remain in the bladder long, without being withdrawn and
cleansed-not exceeding five or six days at all events.

( 350 )
LECTURE XXXI.
THE EFFECTS OF GONORRHEA ON THE
BLADDER.
The bladder is occasionally getting into an irritable state,
which mostly proceeds from the use of very powerful injec-
tions during the inflammatory stage of gonorrhea. It some-
times denotes the existence of a stricture in the canal. Now
and then it is attended with the symptoms of stone in the
to discriminate one from the other.
The symptoms of an irritable bladder are, a frequent incli-
nation to void urine in the day time, probably every three
or four minutes, and six or seven times in the course of the
night. As soon as the bladder is a little distended with urine,
there will be a strong propensity to discharge it, and any at-
tempt made to retain and overcome this troublesome desire is
attended with an excruciating pain in the regio pubis. There
is also a considerable quantity of mucus discharged along
with the urine, which is often tinged with blood. The blad-
der occasionally becomes inflamed, and contracts adhesions
habit of body, he is very much curved forward. The pas-
sing of any instrument into the bladder occasions symptoms
the most distressing, nor do the sufferings in this case abate
for a considerable time. It had the effect of exaggerating
the distress so much in a case of this kind in a young gentle-

LECTURE XXXI.
351
man, that most of the subsequent danger was attributed en-
tirely to this cause. The disease, in the first instance, arose
in consequence of his retaining his urine too long, through
motives of delicacy.
The distinguishing character between this complaint and
stone in the bladder, is, that when the bladder is empty, the
patient is so free from pain and uneasiness that he can bear
to leap or put himself into any position, without suffering in-
convenience ; but if he exert himself, however so trifling,
when the bladder is full, he experiences very great pain. -
The sudden stop put to the flow of urine in this complaint, is
not similar in its cause to that which exists when a calculus is
in the bladder, being, in the former case, caused by his own
efforts from the excessive pain he suffers. There is generally
a great deal of tenesmus and bearing down of the rectum in
this complaint. Upon dissection it has been found, that the
mucous membrane of the bladder has been highly inflamed,
and in a fungous state, having a very striking resemblance to
an eye affected with Egyptian ophthalmia: the bladder is
much contracted in size, and does not generally contain more
than two ounces of urine if the disease be much advanced,
nor more than half a pint in its earlier stage.
If this disease arise from a stricture in the urethra, the first
object must be to get rid of it, by means of the caustic bou-
gie : and the use of it, under these circumstances, rather
tends to lessen than increase the irritable state of the blad-
der : but if the disease should remain after the stricture has
been destroyed, and depends upon any other cause, the in-
jection into the bladder of a lotion composed of the tinct.
opii one drachm; mucilag. g. acaciæ one ounce; or the ex-
tract. opii, united with four ounces of mucilage, will be found
to have a good effect : the mode of throwing this into the
bladder, with the greatest facility, is to introduce a hollow
bougie into that viscus, and then with a common syringe
throw it up. When there is no bougie to be obtained to con-
vey the fluid, it must be passed forward after injection with
a syringe, by rubbing down the canal of the urethra, taking

352
LECTURE XXXI.
care that the aperture at the extremity of the penis is closed,
and also that the liquid must be forced along the passage
very gently. This plan has been known to give palliative
relief, when every thing else had failed. Opium introduced
into the rectum in the form of a pill, combined with hemlock,
will also sometimes afford relief; as this can be done with-
out much trouble, it should be adopted in the early stage.---
The liquor of potass with tincture of opium is found to be
of very essential service; but generally speaking, all the
means that can be adopted are only productive of tempora-
ry relief, unless the irritation is subdued in the first instance.
The irritability of the bladder will now and then go on to
suppuration, and this leads to a communication between it
and the rectum : when this happens, it may be ascertained
by a considerable portion of lymph, in pieces about the size
of a shilling, folded up, passing off by the urethra ; also
there will be a quantity of blood mixed with mucus, coming
away. The urine has a very fætid smell, similar to the
fæces; the patient loses his strength; in a short time purging
comes on, which soon terminates his existence. The most
deplorable case the author ever witnessed, was where a com-
munication was formed between the bladder and rectum : it
healed for a short time, and there were great hopes enter-
tained of recovery ; but from some exertion or other, un-
necessarily made, the newly formed substance gave way:
and it soon ended fatally.
Treatment.
Independent of the injection of opium, the patient should
drink plentifully of mucilaginous drink and soda water, es-
pecially in the first stage. When ulceration has occurred,
introduce an elastic catheter into the bladder, so that the
urine may continually dribble away, thus keeping the blad-
der completely empty, which allows the lips or edges of the
ulcer to come into contact, and an opportunity is given them
to unite, which by a contrary plan would be prevented. The

LECTURE XXXI.
353
iwo principles to be held in view, are, to keep the rectum
clear, by the frequent use of cooling laxative glysters; and
the bladder free from urine, hy means of the elastic bougie.
The administration of the bals. copaib., or the aq. kali pur.,
combined with opium, constitutes the medical treatment.
The plan laid down by Dr. Cheston was a powder compos-
ed of the pulv. tragacanth. comp. and the sodæ carbon. taken
several times daily ; and the following mixture, at intervals
between each powder : R. Tinct. benz. comp. 3ij, ; vitel.
ovi, q. s, decoct. hordei, lbss. ; ft. mistura.
The bladder sometimes ulcerates anteriorly, in consequence
of stricture. The plan of treatment to be pursued will be
to destroy the stricture, and when it is accomplished, intro-
duce a hollow bougie into the bladder, so as to allow the
urine to drain off continually. The edges of the wound are
then to be touched occasionally with caustic, in order to
induce union.
There is a PARALYTIC affection, which sometimes, though
rarely, supervenes gonorrhea, and affects the bladder alone.
This disease generally attacks old people. It may be known
by two circumstances; when the bladder is completely dis-
tended with urine, there is not any pain or fever present,
and when a catheter is passed into the bladder in this state,
not a drop will pass off if the patient be in a recumbent
posture, but immediately on his elevating himself, the urine
will flow off in a full stream, owing to the pressure of the
abdominal muscles and viscera, which force the urine down-
wards. A blister sometimes will have a good effect in these
cases. Turpentine glysters, tonic medicines, and cold bath-
ing, will contribute to restoration.
Diseases of the kidneys, which go on to ulceration, gen-
erally end in the death of the patient.
Bleeding from the urethra, during the acute stage of go. .
norrhæa, is generally an alarming circumstance to the
patient, though the result is ultimately beneficial. In order
to check hæmorrhage, pressure made upon various parts
of the canal, for the space of five or ten minutes, will gen-
45

354
LECTURE XXXI.
erally be sufficient. Sometimes it will require that the
whole of the penis should be pressed with a roller, or a T.
bandage, secured on the perineum. The introduction of
bougies, under these circumstances, into the urethra, is the
very worst thing that can be done, as they open the mouths
of the bleeding vessels. It will be right to give purgatives,
such as the sulphate of magnesia in the infusion of roses.
Chordee. This is a very troublesome symptom, though
not an alarming one. The cause of it is an effusion of co-
agulable lymph into the cells of the corpus spongiosum, by
which they are glued together, so as not to allow of disten-
tion by the blood, whilst that side of the penis unaffected is
filled with it; this causes the pain which the patient ex-
periences. Leeches to the penis, fomentations, &c., will
generally relieve; but in order to get temporary ease, a
bottle of cold water held between the thighs, bathing the
parts with cold water, or the saturnine lotion, will be use-
ful. The medicines to be administered internally are calomel
with opium, or cicuta, in full doses. Opium is the one prin-
cipally to be depended on ; but as it is apt to cause costive-
ness, an alterative combined with it, is required.
For the hardness which remains, after the inflammatory
and most urgent symptoms are relieved, the best applica-
tion will be the mercurial ointment with camphor.
There is, sometimes, in gonorrhoea, an inflammation of the
lacune, so as to induce the formation of small tumours about
the size of peas, on the under side of the urethra and corpus
spongiosum ; one of them opposite the frænum often sup-
purates, and the urine will take its course occasionally
through the opening, by which the matter has made its exit
externally. Abscesses have thus formed behind the scro-
tum, and in one of these cases the patient died, whose habit
of body was excessively irritable. In general, as soon as
the existence of matter can be known, they should be open-
ed with the point of a lancet, and if a sinus form, in order
to destroy it, and afford an opportunity of healing, a piece
of the lunar caustic, made very pointed, should be occa;

LECTURE XXXI.
355
sionally introduced into it, taking care to avoid injuring
the urethra.
Not unfrequently there are several glands in the groin
inflamed and enlarged, forming the sympathetic buboes ;
these do not require the exhibition of mercury, as in a ve-
nereal enlargement. They are to be treated as if proceed-
ing from a common inflammatory affection : by leeches, in
some cases, in others, merely the liquor. ammon. acet. ; or
the saturnine wash, applied on the part, and the exhibition
of purgative medicines, will be adequate to their removal:
if mercury be made use of, they will certainly suppurate.
Abscesses will occasionally form along the absorbent ves-
sels on the dorsum penis; no mercury is necessary for their
cure ; they require to be opened early.
ON IMPOTENCE, OR SEMINAL WEAKNESS.
The disease thus named, consists in a discharge of mucus;
or something resembling it, from the urethra after the urine
has been evacuated more particularly ; and at being at
stool, especially if the patient be costive. It is not semen,
as some have supposed, but the fluid contained in the vesi-
culæ seminales: this has been proved by experiments. Old
men are generally the subjects of it, and it is often supposed
to arise from a venereal cause invariably, which cannot be
easily determined, although Mr. Hunter was disposed not
to think so. Patients labouring under this disease, are gen-
erally more affected in mind, being hypochondriacal, than
in body, and suppose the discharge will drain them to death.
It may be observed, that every organ of the human body,
without exception, is made up of different parts, so formed
as to produce a succession of actions and ultimate effects ;
and if any irregularity in these actions take place, it is what
constitutes disease. The parts subservient to generation in
man are two ; one immediate, which is the testes, the other
secondary, which is the penis. It sometimes happens that
the penis is too forward, becoming erect before the testicles

356
LECTURE XXXI.
are subservient ; and on the contrary the testes will throw
out the semen before the penis is erect.
Of the first, or priapism. This is an erection of the penis
without the mind or testes corresponding, and a violent go.
norrhæa will produce it : the sensation is a pain arising
from an inflammation of parts. The spontaneous priapism
is a very dangerous disease, and should be treated with
powerful tonics, &c.; that-arising from an inflammatory
affection, generally gives way to the evacuating treatment,
and the administration of opium.
The second cause is more common than the former, and
what is generally seen in practice. It is an irritability of
the vesiculæ seminales, and perhaps of the vasa deferentia,
which is evinced by this : a man going to be connected with
a woman, the moment his organs come in contact with her's,
an emission takes place, and all inclination ceases. There
are some men, who, by seeing women, or conversing with
them, have emissions. Very slight causes or impressions
on the mind cause these nocturnally. Once a week, or
every ten days, a man in perfect health might be thus
troubled. It arises from general weakness, and is too fre-
quently the result of a depraved imagination and libidinous
ideas. If it were confined to debility, arising from disease,
it would be all very well ; but youth are found to contract
these habits from one another, at public schools and semi-
naries ; excited and allured by momentary pleasure, and
unconscious of the melancholy consequences, the practice
is pursued with unremitted ardour ; it soon becomes habit-
ual, is constantly reiterated, till they at length become, in a
mortifying degree, conscious of their folly and wickedness,
by a ruination both of body and mind. Independent of the
great and innumerable miseries and inconveniences to which
the unhappy individuals are reduced, it becomes moreover
a matter of public concern. It strikes at the very root of
generation itself, and deprives the world of many valuable
members of society, who might have lived a glory to their
country, and a credit to themselves. If youth, from levity

LECTURE XXXI.
357
and inadvertence, and perhaps from a kind of modesty, be
the dupes for the most part, what can be said of those in
more advanced years, who practise it from abandoned, but,
in their own opinion, more politic considerations! In this
wicked age, when there is unbounded communication be-
tween both sexes, and modesty has become a mere nominal
existence, the universal prevalence of this pernicious prac-
tice is truly surprising. If it were confined to the male part
of the creation it would be the less excusable, but I am
truly sorry to declare, that the fair are no less criminal in
this respect, to the great prejudice of their health and na-
tive beauty.
The other causes are, excessive venery, severe evacua-
tions, which cause great debility in the system. In some
persons it may be occasioned by a want of confidence in his
capabilities at the time of connexion.
In the treatment, the profuse and unseasonable discharge
of semen, which occasions a state of great debility, must be
discontinued, or prevented ; and those medicines which
communicate strength and vigour to the system, freely giv-
en, and chiefly depended on, combined with the cold bath,
and local bathings for the re-establishment of health. Mr.
Hunter advised a young man who had an evacuation every
night, and frequently when he walked or rode on horseback,
to take twenty drops of laudanum at bed-time, which afford-
ed relief, when bark and other remedies had failed, and by
continuing its use he perfectly recovered. An elastic yoke,
put on the penis to bind it to the thigh, will be of service, or
a piece of thin metal to retain it in that situation, which will
occasion some pain if erection take place, and awake the
patient. If it arise, as it frequently does in old people, from
an affection of the mind, two instances of which I have
known in men of property and respectability, married to as
fine and handsome women as could be seen, which I attribut-
ed to a consciousness of incapability, as there was a consider-
able disparity in years, make light of their complaint ; but,
at the same timne assure them of a certainty of cure, or at

358
LECTURE XXXI.
least of getting better, and prescribe pills composed of any
inert substance, desiring them to be careful to take one only
at night, and by no means have any connexion with their
wives : and it is seldom that more than half a dozen are
swallowed before a good account is given by the patient of
their surprising efficacy. Mr. Hunter recommended a pa-
tient who was complaining of impotence to sleep with a fe-
male, but forbad him to have any connexion with her for
several nights. In this case the disease being merely a men-
tal affection, he was completely relieved by pursuing the
plan for only a night or two, as nature was found to be
ever vigorous.
One of the testicles may be lost without producing any
very perceptible effect upon the virile powers, though both
of course will entirely destroy it. A curious case illustra-
tive of this, occurred in Guy's Hospital some years ago.
Abscesses of the epididymis, which supervene on inflam-
mation of the testes, will very much, though not entirely,
abolish the power.
INFLAMMATION OF THE TESTES.
Inflammation of the testes, arising from gonorrhea, has
been absurdly termed HERNIA HUMORALIS by most authors;
why, or wherefore, may rationally admit of a volume of
controversy. The symptoms which denote the approach of
this affection, are, a sense of irritation towards the interior
termination of the urethra ; as the gonorrhaal inflammation
proceeds down the canal, and arrives at the perineum, there
is a sensation felt as if a drop or two of urine lay at that
part, which causes the uneasiness felt there ; almost immedi-
ately on the last symptom being perceived, the testicle begins
to be affected : there are shooting pains felt along the course
of the spermatic chord, about the abdominal ring: the in-
flammation passes down to the epididymis, and fixes there :
it is this part that is chiefly affected. When the inflamma-
tion in the epididymis has arisen to a considerable height,
the body of the testes inflames, and becomes much swollen,

LECTURE XXXI.
359
hard to the touch, and very painful on pressure: the pain
extends to the crista of the ilium on that side, and also to
the groin. The structure of the scrotum is redder than usu-
al, and touching it occasions pain ; and if the testicle hang
down and be not supported, it is very much increased.
Sometimes there is much constitutional irritation, but this de-
pends upon the habit of body of the patient.
The disease originates from the inflammation extending
along the vas deferens to the epididymis, along its mucous
membrane. I am not of the general opinion, that it is cau-
sed by a sympathetic affection. Any circumstances occur-
ring to cause irritation at the termination posteriorly of the
urethra, will have the effect of exciting the disease. Thus,
powerful injections, walking to great distances, or riding dur-
ing the inflammatory stage of gonorrhæa ; drinking freely
of vinous or spirituous liquors ; passing a bougie into the
bladder in irritable habits, will induce it, by touching the
orifice of the vesiculæ seminales : strictures independent of
injections, or bougies, will bring it on; therefore this last be-
ing known, if no other cause be evident, ought to raise a
suspicion of its inducing the disease. As this disease is so
liable to happen from gonorrhæa, it will be as well always
to desire patients to support their testicles by means of a
bag-truss, made of silk netting. Even when passing or
using bougies for the cure of strictures, it will be advisable
that patients should keep their testes supported.
Treatment.
It will consist in the suspension of the testicles, the liquor.
ammon. acet. applied by means of linen cloths to the part,
and the administration of purgatives; as calomel with the
cathartic extract, or calomel at night, and the sulphate of
magnesia the following morning. If the inflammation should
not be removed by the perseverance in this method, a leech
or two should be applied to the testes every morning, and
afterwards warm fomentations and a poultice; the patient.
must keep in a recumbent posture. Should these means fail,
and the inflammation still continue violent, general bleeding

360
LECTURE XXXI.
from the arm must be adopted in addition, the number of
leeches increased, and the reclining position strictly attended
to : fomentations must be frequently employed. It will oc-
casionally be requisite to repeat the general bleedings twice
or thrice.
If a hardness should remain in the epididymis after the
inflammation has abated, fomentations of vinegar, as warm
as the patient can bear, will be serviceable : if it should be
obstinate, the mercurial ointment with camphor must be
rubbed on, and small doses of calomel and antimony given
internally, either alone or combined with cicuta. When
the hardness gets into an indolent state, the patient will fre-
quently get tired of these remedies, and a bag, made to fit
the testes, of oiled silk, may be substituted : it acts similar
to a poultice, by inducing a great flow of perspirable mat-
ter; and in effecting the reduction of the enlargement, it will
be far preferable to any plaster, and will be of the most de-
cided service ; indeed, when applied to tumours of an in-
dolent nature in any part of the body, it is of singular ad-
vantage.
Patients will often express some anxiety to know whether
this hardness (which will often - continue during life) will
occasion any diminution in their procreative powers. If the
epididymis on both sides be enlarged and hardened, it will
have the effect of lessening the secretion of semen, though
to what extent has not been satisfactorily explained : if one
side alone be hardened, there will be some difference, but
not to any manifest extent.
Sometimes the induration of the epididymis will proceed
to suppurate and ulcerate, causing sinuses difficult to heal,
on account of the semen being discharged through them;
these sinuses are similar to a wound of the salivary gland,
and equally, if not more difficult to cure. A lotion, com-
posed of six drops of the sulphuric acid to four ounces of
water, applied to the part on linen cloths, and injected into
the wound by means of a syringe, often will be proper. The
sulphate of zinc and copper in solution are good applications.

LECTURE XXXI.
361
When the epididymis has suppurated, the virile power is
much diminished : if both, it is nearly lost. It is only in
scrophulous habits that the epididymis thus suppurates.
Persons who have once had inflamed testicles, are very li-
able to a return of the complaint, on a second attack of go-
norrhæa; therefore when this latter disease is again con-
tracted, it is always much better to cure it by purgatives,
and the antiphlogistic plan, never using injections of any
kind, although the case may be a longer time in being re-
stored than if injections were had recourse to.
EXTERNAL GONORRHCA:
It is a rare occurrence that gonorrhea is seen externally :
the glandulæ odoriferæ, surrounding the corona glandis, is
the seat of it. Phymosis always accompanies the disease,
attended with much inflammation, and great discharge from
under the prepuce, mixed with blood : the glans and prepuce
are considerably swelled. The black wash made of lime
water and calomel, and a small quantity of the tincture of
opium, is the best application ; or the acetate of lead and
opium. These lotions should be injected under the pressure,
as well as applied constantly to the parts by means of linen
cloth: it will generally subside in six or seven days. The
parts must be kept very clean, and a purgative medicine
taken every other morning.
There are some cases of gonorrhea, I am told, which
have the effect of producing an attack of rheumatism, or of
ophthalmia. If injections are used, the symptoms are great-
ly aggravated ; but if the discharge be allowed to be secret-
ed or promoted by the use of emollients, the general disease,
if it may be so called, will be much relieved in its violence.
To effect a cure of this secondary complaint is considered,
by some practitioners, as rather a difficult matter, and the
best niode of treatment they advise, is the use of the warm
bath every day, local fomentations, and the balsam copaiva
exhibited internally ; and, under these circuinstances, sur-
geons, they think, ought never to use any injection, but
46
362
LECTURE XXXÍ.
trust the cure to our old assistant and doctress, dame Nature,
who might be more tedious, but not less effectual.
The author thinks the first complaint originates from the
frequent exposure of some gonorrhæal patients to cold, strip-
ping almost naked to foment, poultice, inject, &c. I know,
at this moment, a gentleman suffering rheumatic pains from
this cause, lately afflicted with the previous affection. I
knew another, a little while ago, with ophthalmia ; and from
whence did it proceed ? Why, most assuredly, from want of
cleanliness, transferring the gonorrhæal matter from the
lower to a more elevated and conspicuous situation ; soap
and water is the best preventive of the last, and a stout
Welch flannel wrapper of the first.
ON GONORRHEA IN THE FEMALE.
It commences its ravages in the female sex with an inflam-
mation of the nymphæ; the next attack is at the os exter-
num, or labia vagina, then the meatus urinarius participates
and becomes one of the principal seats of the disease ; it be-
gins at the orifice, and afterwards extends along the mem-
brane lining it, and the lacunæ, situated in the canal, in-
flame: owing to the shortness of the urethra, in comparison
with that of men, the disease is much sooner communicated
to the bladder than in our own sex. Women suffer exces-
sively in the first stage of gonorrhæa, by a violent bearing
down of the bladder and rectum, more particularly experi-
enced in the former immediately on having discharged the
urine. They are also almost always subject to sympathetic
bubo.
The Treatment
Consists in the exhibition of purgatives of the same kind as
in the male, but rather smaller doses, as the habit of body
in females is much more delicate. Diluent drinks of various
kinds are to be given until the inflammatory stage is over,
when the use of injections, of the same composition as in
the male, but stronger, may be had recourse to : not to be
used as injections are generally recommended, but merely
as a wash, applied by means of folded linen. When the


LECTURE XXXI.
363
discharge is great, and the more interior parts are affected,
it will perhaps be a better plan to introduce a piece of sponge
into the vagina, dipped in the lotion, and allow it to remain
there. One of the best lotions is composed of half a drachm
of alum to a pint of decoction of cinchona or oak bark; it
ought not to be used at the commencement, but rather when
the parts get much relaxed from the continuance of the
disease.
Women, being subject to fluor albus, makes it sometimes
absolutely impossible to distinguish between it and gonor.
rhæa : the appearance of the matter throws no light on the
nature of the disease, the quantity of discharge, as well as
the sight of the parts, being much the same. In forming an
opinion, therefore, it should be taken into consideration,
whether the woman has been connected with a suspicious
man, her character and respectability, and whether she is
capable of communicating the infection to others. It is clear
a woman may labour under this complaint without knowing
it, as it will continue for years in the vagina without extend-
ing further, or wearied out as in men. A man, Mr. Hunter
says, may be connected with a woman, and contract the
disease, even without the woman being diseased, for the
gonorrhæal matter may only have been deposited on the
parts of a woman by the last person connected with her.
Mr. Hunter met with a very remarkable case in a gentle-
man : he was attacked with rigors, slow fever, restlessness,
&c. several weeks before the discharge appeared, and this
case shews that the disease cannot be communicated but by
matter, for he had connexion with his wife before the run-
ning appeared, and was very much afraid he had given the
disease to her : this, however, did not prove to be the case.
Many of the gonorrheas met with by men in practice, Mr.
Hunter thought were occasioned by the fluor albus, which
is sometimes extremely acrid, and by stimulating the parts,
might produce a discharge from the urethra.
Young girls, from two to twelve or fourteen years of age,
are not unfrequently attacked with a discharge from the
364
LECTURE XXXT.
organs of generation, similar in every respect to that result-
ing from the poison of gonorrhoea : it proceeds from the
glands between the prepuce and clitoris, and is of a scroph-
ulous nature, happening only to children that are evidently
of this habit of body, or those belonging to the poor, who
are neglected and dirty. It met with a case which was
strongly suspected to proceed from a different cause by the
parents of the girl, but which I firmly believe had no such
origin, as it gave way to cleanliness, the application of lime
water and calomel, and purgatives occasionally given, which
will be the practice to be pursued in all such cases.
ON GLEET.
This disease, which is extremely difficult to cure, is a
common consequence of gonorrhæa in both sexes. Gleet is
a discharge from the urethra, ceasing to communicate, as
many think, a similar affection, on having connexion with
another : respecting the period when gonorrhea becomes
gleet, and thereby is unable to create infection, much difi-
culty exists ; indeed, it is almost impossible to draw limits
of duration justly. Five months have elapsed between a
man cohabiting with two women, at two different times, and
yet he communicated to the second woman the disease. I
have known a gentleman who took no pains to get rid of a
gonorrhæa, have it as a companion for ten months ; he had
it nine times before, and defied any of the boasted clap
doctors to cure him as expeditiously as nature generally had
previously : in fact, he had paid five pounds to one, and the
same to another, in the first and second attacks, and still
the gonorrhæa was not diminished; the dread of strictures
precluded his ever using injections of any kind.
As to the gleet in women, it is still more difficult to say
when it ceases to be infectious, as a female has clapped a
man though she had previously abstained from coition dur-
ing a period of twelve months; and a case has been met
with where the time has been as long aś two years. A man
has infected his wife, who had a gleet for twelve months,
and was absent from her so long.



LECTURE XXXI.
365
The seat of gleet is the same as gonorrhoea; the discharge
is similar to the white of an egg in appearance, consisting of
globular bodies contained in slimy mucus ; but by intem-
perance, or riding on horseback much, or by venereal ex-
citement, it will be completely changed, becoming yellow
and opaque. It often has its foundation in stricture ; there-
fore, when this exists, the gleet cannot be cured until the
cause of it is removed. It is not peculiar to weak or relaxed
constitutions. The cure consists in effecting a change in the
action of the parts, and this may be attempted in three ways,
constitutionally, locally, or sympathetically: and the pow-
er of medicines, taken internally, may be divided into spe-
cific, strengthening, and astringent. By specific, are meant
such medicines as produce a specific action on the parts ;
these are the balsams, turpentines, cantharides, &c. Strength-
eners are, bark, the salt of steel, sea-bathing, cold-bathing;
&c. Astringents are, the bark in decoction, the sulphate of
zinc, alum, lead, &c. The best general treatment is the ex-
hibition of the bals. copaib, combined with the spir. æther.
nitr. in equal proportions, or the bals. copaib. and the pulv.
cinchon, lancif. made into an electuary. An injection must
be used of the muriate of mercury two grains to a pint of
water. It may be gradually increased in strength, if re-
quired. The pulv. lytte one grain, terebinth. chio. five
grains, ft. pil. omne nocte sumendus, is very useful. Another
good injection is composed of ten grains of ammoniated cop-
per to two ounces of water. An injection much used is made
of the cupri sulph. gr. ij. aqua f3iv. If these injections
should not have the effect of making a cure, they had better
be left off, and a bougie must be used two or three times
daily, dipped in the bals. 'copaib., or in equal parts of it and
oil. This will have considerable influence on the disease.
Some cases will only yield to mercury ; therefore, when
gleet is obstinate, the hydrarg. inuriat. may be given. A
blister applied on the under side of the urethra will now
and then cure, so will electricity, excess in drinking, and
riding on horseback. Rest and quietness must, however,
be attended to in most cases.



( 366 )
LECTURE XXXII.

CHANCRE.
The first sensation that induces a person to suspect his hav-
ing contracted the venereal disease, is an itching of a circum-
scribed kind, felt on the penis; on examining the place a
day or two after the irritation has made its appearance, a
small pimple will be observed projecting, having a white
head, with a quantity of matter in its centre : on the head
being rubbed off, the contents will be seen, which is not pure
pus, but inclining more to that description of matter termed
sanious; it is mixed with blood. A deep cavity will remain,
the edges of which are ragged and thickened around: the
surrounding inflammation is not of a healthy kind, but of a
livid colour, resembling that resulting from venous conges-
tion. The best diagnostic symptom by which chancre may
be distinguished from an inveterate sore, is the deep thick-
ening of the skin and integuments around the ulcer, in this
respect, resembling that which exists after the application
of vaccine, variolous, or other poisons, to the surface of the


LECTURE XXXII.
367
body: by nipping up the skin between the fingers, this hard-
ness will be particularly evident, even to the most inattentive
observer. If a sore be found upon the genitals without show-
ing these symptoms, it will always be found merely an ex-
coriation, and as such may be treated.
The seat of chancre is various : it is found seated upon
the glans, at the corona glandis, or on the prepuce. A com-
mon seat of it is on or at the side of the frænum, which often
goes on to the destruction of the part, unless the constitu-
tion is good, and mercury is freely and early administered.
A part not very common, though occasionally affected with
chancre, is the lips of the urethra, or about a quarter of an
inch down the canal : when this is the situation, more par-
ticularly the latter, it is very liable to be mistaken for
gonorrhea, without the surgeon attentively examines the
different symptoms. The discharge in this case is very un-
like gonorrheal, the former being sanious, and the latter, at
first albuminous, afterwards resembling pure pus : besides,
if the inflammation do not run very high, when the lips of
the urethra are pressed, the thickening is so evident, that no
deception can exist. Sometimes the ulcer may be seen upon
opening the lips of the urethra. Chancre is not unfrequent-
ly met with upon the body of the penis : in this situation it
loses many of its discriminating marks ; it is in the form of
an encrusted sore, covering an ulcer containing matter mixed
with blood; when this is removed, a deep wound is left, not
having the hard edges which chancre has, when seated on
the glans, &c. Now and then the scrotum underneath the
penis is attacked ; in this respect the same effect is produced
on the glands of the groin, as if the prepuce were affected.
Venereal matter differs from gonorrheal : the former,
when applied to a secreting surface, produces inflammation
and ulceration : the latter, when applied in a similar situa-
tion, produces inflammation and a discharge, without excit-
ing ulceration. The former induces the same disease in the
neighbouring glands, the latter does not.
202 Won


368
LECTURE XXXII.
· Treatment.
It is recommended to treat a chancre with caustic, but I
do not approve of this mode : it has two bad effects : it
often induces a disease of the glands of the groin, where no
previous disposition existed, by its irritating quality, and by
the healing up of the sore, it makes the surgeon at a loss to
know the effect which mercury has wrought upon the dis-
ease, through the medium of the constitution. It frequently
has happened, that when the chancre has been healed in a
very short time by means of caustic, the exhibition of mere
cury has not been persisted in, under the idea that the dis-
ease has been eradicated ; but in a short time secondary
symptoms make their appearance, extremely difficult to re-
move; therefore, if the patient be anxious to have the local
disease removed early, caustic may be applied, but mer-
cury must be given as long as if nothing of the kind had been
used. The shortest space of time that this medicine should
be used is three weeks, that its visible effects may be pro-
duced, and perceived on the constitution, which may be
estimated by the discharge of saliva from the mouth, for that
space. The sore will frequently have healed long before
this period has elapsed ; yet, notwithstanding this, a gentle
salivation must be kept up for the above-mentioned time,
or in some cases longer, as all the appearances of hardness
must have gone off, previous to the discontinuance of the
mercury. Indeed, as a general rule, mercury must not be
laid aside under a shorter time than a week at least after the
sore has healed. The best form to administer this medicine
is the mercurial pill, ten grains at night, and five grains in
the morning ; to this may be added three-fourths of a grain
of opium : this will prevent its passing off by the alvine ex-
cretions. With regard to the local applications which it is
requisite to make use of to chancreone of the best is the
black wash (made of lime-water and calomel) if the patient
be not of an irritable habit of body. Calomel sprinkled up-
on the sorë, or calomel mixed up into a soft paste, with


LECTURE XXXII.
368
mucilage of gum arabic, is very beneficial. The hydrarg.
muriat. dissolved in water, or lime-water, will be of service.
The ungt. hydrarg. nitr. is frequently made use of, but any
applications in the form of unguents to venereal sores are not
approved of. When it is necessary to use the red nitrate of
mercury, it will answer best rubbed down with the conserve
of hips ; but lotions applied to chancre are always to be
preferred.
The pursuance of this mode of treatment is only recom-
mended in those cases where the symptoms do not run very
high. In some the pain and inflammation will be very great,
and phymosis will be introduced. There will be a general and
deep redness in the parts, with great discharge from under
the prepuce: when these are the existing symptoms, a con-
tinuance of the use of mercury will only exasperate them: it
should be, immediately after they are observed, left off, and
thus, abstaining from the exhibition of the medicine, is the
great secret of those who practise this branch of the profession
with success. It will be right to abandon the use of mercury for
some space of time, until the inflammatory symptoms are en-
tirely, or, in a very great degree, subsided in the part, more
particularly if there be any appearance of sloughing. A
wash should be used, composed thus, R. liquor. plumb. acet.
3ss.; tinct. opii 3 iij. ; aqua fontanæ 3iv. M.; or the black
wash with opium. Pieces of lint, or linen, wetted with eith-
er, are to be kept constantly applied to the part. A brisk
purgative of calomel and rhubarb may be given, but a con-
tinuance of purging must not be followed, as it will weaken
the patient and increase the tendency to sloughing. If the
inflammation should not subside, a leech or two would be ad-
visable. The black wash with opium may be injected un-
der the prepuce, in order to clear away the discharge, which
is apt to collect there and cause irritation.
· Observe. A chancre, in the very earliest stage, I think,
might be successfully treated with caustic, and render mer-
cury altogether unnecessary : but I must remark, it is seldom,
If ever, patients apply soon enough to render this practice


47
370
LECTURE XXXII.
justifiable. Many practitioners salivate their patients with
mercurial ointment, and never administer this medicine in-
ternally, but from the concealment requisite in these cases, it
could not be adopted without discovery, from the percepti-
ble marks on the linen : the other plan is by far the cleanli-
est, and I would recommend its adoption in private practice.
In the hospitals, friction with ointment is universally pursued.
PHYMOSIS.
A chancre seated on the prepuce during the healing pro-
cess, often causes phymosis, from the contraction of the pre-
puce, as the inflammation abates and subsides. It is to be
relieved by an operation. Sometimes the thickening will go
off, and the phymosis will be spontaneously cured, so that it
is always best to wait a short time, and the penis should be
occasionally soaked in warm water, in order to facilitate this
desirable effect: when it cannot be relieved, pass a director
three-fourths of the way to the corona glandis, along the
dorsum penis, then direct the patient to retract the prepuce
as much as he can, pass a curved bistoury along the director
to its extremity, in which place it must be passed through
the prepuce, and by drawing it out, the skin will be divided
to its edge. In whatever way phymosis is produced, this
will be the mode of operating to remedy it, even when it re-
sults from natural causes in children. A speculum, with a
screw in the centre, so contrived, that when used, it is capa
ble of being enlarged, or diminished in size at pleasure, is
* advised to be introduced within the prepuce in cases of phy
mosis, and the parts are to be gradually dilated, allowing it
to remain until the prepuce can be drawn back over the
glans : this is a very ingenious invention, and will occasion-
ally succeed. Cases of phymosis will sometimes, though
rarely, occur, in which the prepuce has formed numerous
adhesions to the glans throughout its whole internal surface ;
this is mostly resulting from natural formation, and here
the operation will be unattended with success.

LECTURE XXXII.
371
When there is great tightness of the prepuce, and it is with
difficulty drawn back, it will remain back without a possibil-
ity of returning it, and cause the disease which is termed
PARAPHYMOSIS. In proportion to the length of time which
the glans remain in this situation, is the danger of mortifica-
tion. It is in general accompanied with an effusion of se-
rum into the prepuce on the anterior part of it, and behind
this, the skin of the prepuce forms a tight ligature around
the penis, just beyond the corona glandis.
Treatment.
It is too frequently the custom of surgeons to direct the
application of a warm poultice to the part, which is absurd,
and only aggravates the disease. The point of a lancet
should be passed into the prepuce to evacuate the serous flu-
id effused into it: and when this is done, the glans must be
compressed by the fingers of a surgeon, in order to expel
all the blood out of its cells, and when the pressure has been
continued for five minutes, place the thumb at the extremity
of the penis, and surround the prepuce with the other hand;
then press the former back, and at the same time draw the
latter forward. Very few cases occur, which have not ex-
isted longer than fourteen or twenty-one days, in which this
plan fails to succeed. The glans, previous to the final at-
tempt, may be put into cold water, which will assist the
surgeon in his efforts. If this be pursued, I do not believe it
will ever fail : but where it has been of long continuance,
the skin requires to be divided with a lancet, which relieves
the constriction, and it will be best to insert a director under
the part, and cut down through to it.
When paraphymosis has continued some time, sloughing
will not unfrequently take place of a portion of the glans :
in this case the operation of circumcision must be perform-
ed, which consists in cutting off a circular portion of the
prepuce.
Besides these effects of chancre, it sometimes happens,
that the ulcer occasions such excessive irritation, and such a.


372
LECTURE XXXII.
high degree of inflammation, attended with great pain, that
the deplorable situation of the patient requires immediate
relief. In these cases mercury must be laid aside, and a
lotion, composed of the nitric acid, six to eight drops, distilled
water four ounces, will be of great advantage, and more
effectual in removing irritation than any other application
that I know of. The bowels should be cleansed with a
brisk cathartic, and then opium, combined with bark, must
be thrown in. When the symptoms are much abated the spir.
æther. nitr. and the hydrarg. muriat. are to be given : these
are to be given in the proportion of one grain and a half of the
latter to half a drachm or a drachm of the æther : the quantity
at each dose will depend on the capability of retaining it on
the patient's stomach : probably twice or three times will be
often enough in the course of the day. If much mercury
be given, it will have the effect of inducing a return of the
irritable state of the local disease. The ulcer is sometimes
apt to get into an indolent state, in which case the applica-
tion of caustic will be found serviceable : if it still continue
thus, give the bark, and use a wash composed of the nitrate
of silver half a drachm, water an ounce, over which, linen
moistened with the black wash, may be applied, or the ul-
cer may be touched with a probe, every day, dipped in the
nitric acid.
The most destructive cases are those in which sloughing
of the glans or prepuce takes place. When the preprice
sloughs, a portion of the penis also mostly accompanies it ;
indeed cases have been seen where about an inch of the
urethra has thus separated. In these cases, if mercury be
used, it will induce the sloughing disposition to extend to the
contiguous parts. The local applications are several; one
of the best is the black wash, applied as hot as the patient
can bear it. The nitric acid lotion may also be used in the
proportion of two drops of the acid to an ounce of water,
A poultice composed of carrots and linseed, one part of the
former to three of the latter, will have the effect of remov-
ing the slough, and at the same time correcting the disagree-

LECTURE XXXII.
373
able fætor which is present. No application that can be
made use of is superior to half an ounce of yeast, half a
pint of water, made up into a poultice with linseed meal or
oatmeal. Turpentine applications, made hot are advisable.
Another good remedy is conserve of roses, one ounce; tinc-
ture of opiun, and liquor of acetate of lead, of each two
drachms. Fomentations of cicuta and belladonna are ser-
viceable. A solution of opium will be productive of bene-
fit, also the pulverized carbon, or a cataplasm made of it.
The internal medicines from which most advantage will be
derived, are ammonia from five to ten grains, mosch. gr. X.
mucil. g. acacia. q. s. m. ft. bol. ter in die suinendus. Opi-
um has been generally recommended, and with great pro-
priety; it is much better than bark, as the latter will often
have the effect of disordering the stomach and exciting fe-
brile symptoms. Patients have generally a pulse from 120
to 130 in sloughy cases of this description, but opium will
very soon reduce this undue degree of velocity. The decoc-
tion of sarsaparilla is an excellent remedy, and more partic-
ularly where the irritable state of the local and constitution-
al disease has arisen from the injudicious exhibition of mer-
cury. Wine or porter may be allowed, unless they excite
a considerable increase in the pulse, in which case they
must be laid aside. The surgeon, in these cases, sometimes
is called to suppress hæmorrhage from the penis, in conse-
quence of the separation of the slough : here lint, moisten-
ed in spirits of turpentine, and wrapped round the penis,
will be found mostly effectual; but if it fail, the artery must
be taken up. As this sloughing disposition arises from a
high degree of irritation and inflammation, it is a query
whether leeches might be applied with advantage-experi-
ence must determine this point.
It occasionally happens that the urethra sloughs open at
the frænum, and the urine flows out from the opening thus
formed. In this case, an elastic catheter may be introduced
down the urethra, and allowed to remain whilst the edges of
the canal are brought into contact over the instrument; and



374
LECTURE XXXII.
this must be effected as far as possible, and success will com-
monly attend efforts thus made, if one-third of the circum-
ference of the canal be lost; but when more than this is de-
ficient, the chance of success will be proportionably dimin-
ished.
When a chancre is situated at the lips, or just within the
urethra, it will often produce a stricture at the part, which
cannot be cured by common bougies or caustic ones. A piece
of bougie, about two inches in length, must be introduced,
smeared with some unctuous substance: this must be allow-
ed to remain an hour at first, then longer, until it excites sup-
purative inflammation in the part, by which the stricture will
be removed.
CHANCRES IN WOMEN.
These are seated on the inside of the nymphæ and labia,
rarely at the orifice of the vagina : now and then an opening
is formed between the vagina and rectum, for which there
is no cure.
Treatment.
By means of the black wash and mercury; in other res.
pects the same as in the male subject.
VENEREAL WARTS.
These excrescences, which are found arising after chancre
and gonorrhea, although termed venereal, are confidently
asserted not to be so. They are often the production of ir-
ritating applications, which have been made use of during
the continuance of the two mentioned complaints. They are
growths of the cutis, and do not require mercury to remove
them. They are broken and divided on the surface, similar
to warts found in other parts of the body. In asserting that
these warts are not venereal, I would not wish to be under-
stood as including those situated near the anus, particularly
in the female; they are evidently produced by the direct ap-
plication of venereal matter to the parts, and are in effect

LECTURE XXXII.
375
chancres, covered over with an incrustation : they require
mercury to be administered before a cure will be made.
The species of warts previously alluded to are of two
kinds; the one soft, and from which bleeding occasionally
takes place; the other firmer, similar to warts upon the hand,
Those of the first description are easily eradicated by a
regular application of a strong solution of the liquor. plumb.
acet. Poultices will frequently bring away great numbers
of these at once. The black wash, as well as a lotion com-
posed of the hydrarg. muriat. has been applied with advan.
tage. The tinct. ferri muriat. will succeed, so will blisters:
The ung. hydrarg. fort. and the application of a poultice, is
a good plan. When they are obstinate, equal parts of the
powder of savin, acetate of copper, and the red nitrate of
quicksilver, will succeed. A saturnine solution of the hy.
drarg. muriat. is a good irritating wash-it should only be
used once a day.
The other species, those of the firm kind, are said to be
very difficult of removal: but I do not think this is the case.
To destroy the worst kind of warts that are met with upon
the penis, nothing more is necessary than to use a small
quantity of arsenic finely levigated : the warts are to be
sprinkled with it, which is to be allowed to remain on, tak-
ing care to avoid the adjacent parts from touching the ar-
senic by means of lint, applied previously all round. It
destroys the warts by inducing inflammation and suppura-
tion. In the male, this application will seldom, if ever,
fail ; but in the female, from the great number which are
occasionally met with upon the labia, it has. In these it had
better be applied on lint, in the form of ointment, 3j. of ar-
senic to 3j. of lard, every, or every other day, according to
the degree of inflammation produced by it--if great, a poul-
tice ought to be applied. A powder commonly in use for
these excrescences, is one composed of savin, as before de-
tailed, but it is much inferior to arsenic. Warts have been
seen seated on the corona glandis ; these, by pressure, have
found their way through the prepuce, and in course of time,



376
LECTURE XXXII.
the glans has made its way through this opening ; this will
require an operation similar to that of phymosis, or that of
circumcision. Warts in the male seldom or ever become
larger than a walnut, but, in the female sex, they are not
unfrequently seen much larger.
VENEREAL BUBO.
This affection takes place most frequently upon the side
on which the chancre is seated ; but it is not always the
case, for I have known one of the glands in the groin enlarge
when the chancre was situated on the opposite side of the
penis. It is extremely rare to find more than one venereal
bubo on a side: occasionally more than one gland is enlarg-
ed, but it is only in one that the poison exists ; and the oth-
ers enlarge from irritation, not from the application and
communication of venereal matter. One chancre will now
and then (though rarely) occasion a venereal bubo on each
side.
The symptoms are merely those attendant upon inflam-
'mation of a gland from any irritating cause being applied to
the absorbents which enter it, with this exception, that here
there will be an increase of pain in the inflamed part to-
wards evening and at night, and this is the case in almost
every variety of the venereal disease.


Treatment.
Mercurial frictions are to be immediately had recourse to,
and chiefly depended on for the cure. One or two drachms
of the strong mercurial ointment may be rubbed in every
night, and if this be employed in an early stage, generally
speaking, nothing more will be required.
I have here to remark, that in every case, previous to
using mercury, it is most advisable to prescribe an active
purge, and in this case it will have the effect of diminishing
the inflammation, and will induce the absorption of the gland
more readily. If, after these means are had recourse to,

LECTURE XXXII.
377
the pain in the bubo increase, and the cuticle begins to look
red, the mercury must be discontinued, and leeches appli-
ed; afterwards, washing the part with the saturnine lotion
very frequently : these means must be persisted in three or
four days, by which time the probability is, that the inflam-
mation will be reduced, when the use of mercury may be
again resorted to. If, during the inflammatory stage, the
frictions were to be continued, it would only serve to hurry
on the ulcerative process.
When it is found that these efforts are ineffectual, and that
the bubo has commenced the suppurative process, which
will be evinced by a circumscribed redness around the tu-
mour, with an evident fluctuation in it, desist from the use
of the frictions ; the reason of this is, if mercury were still
applied during the suppurative inflammation, it always has
the effect of rendering that inflammatory action unhealthy,
and causes a sloughing ulcer. The case must now be treat-
ed by fomentation and poultice, locally, until the bubo is fit
for opening, and discharges its contents ; and by bark and
wine constitutionally, combined with a generous diet.
I would again observe, the great secret in the treatment
of these cases, consists in never giving mercury during the
inflammatory stage ; as this remark is of consequence, it
deserves to be borne in mind. When it subsides, mercury
may again be employed; as a general rule, I should say,
after the bursting, or opening of a bubo, a week ought to
elapse before it is recommended.
Supposing the diseased gland has suppurated, and still
appears not inclined to discharge its contents, though en-
couragement has been given it by warm applications, it is
requisite it should be opened either by caustic or incision.
I should prefer making a puncture with a lancet to the ex-
tent of half an inch, and if the skin be thick, and the open-
ing likely to close, dip a probe in the nitrous acid, and touch
the edges. When the patient is extremely timid, a drop of
this acid may be put upon the part of the swelling, where
the fluctuation is most distinct : this will, by its corrosive



48
378
LECTURE XXXII.
effect, generally make an opening into the cavity of the ab-.
scess in twenty-four hours after its application.
When matter is formed, and the absorption of the integu-
ments goes on excessively slow, and when, at the same
time, scarcely any redness is present, and the pain has
ceased, except when pressed on, it will be found advan-
tageous to make use of mercury, so as to cause the absorb-
ents to act, which will tend to the promotion of the absorp-
tion of the contained matter (if inconsiderable in quantity),
and its ultimate dispersion. If buboes are indolent, and
have no appearance of discussing or suppurating, use mer-
cury, and apply a blister to the part. If the bubo be large,
two openings ought to be made, one at the superior, the other
at the inferior part of the tumour, which will prevent the
formation of a sinus ; it will be proper to carry a thread
from one opening to the other, to produce an equal irrita-
tion. Sometimes enormous swellings of the glands in the
groin are seen, four inches in a perpendicular, and three in
a transverse direction, in diameter. In these cases, by no
means use mercury, but improve the constitution with bark,
ammonia, &co, and also change of air, as it proceeds from a
scrophulous disposition in the habit of the patient ; OCCA-
sional purgatives ought to be given.
When a bubo has burst, and the ulcer is indolent, that is,
shews no disposition to granulate and cicatrize, apply caus-
tic to the edge of the sore once every twenty-four hours,
and keep it continually moist with the black wash : solu-
tions of the nitric and sulphuric acids are had recourse to
with the most decided advantage. In some subjects, even
desisting from the use of any application, and allowing a
scab to form over the ulcer, will facilitate the formation of
granulations, and the cicatrizing process, more expeditious-
ly than where the surgeon is over-officious.
Erysipelatous inflammation, accompanying bubo, is to be
treated by purgatives, bark, &c.—Mercury would be high-
ly improper.




LECTURE XXXI.
379
Sometimes a sinus will form in spite of the surgeon's
efforts : if superficial, it should be dilated : if deep seated,
and running in such directions as to preclude the possibility
of its being opened without a good deal of danger being in-
curred, injections may be used, composed of the hydr. mu-
riat. gr. ij. aqua 3j. M. or the nitric acid, or the tinctura
lyttæ 3j. to aqua 3j. M.
Some cases are seen, where the healing process cannot be
induced almost in any way that can be devised, and here it
will be advisable to try setons, or laying open the sinus :
in the latter, very great caution must be taken, on account
of the contiguity of the parts, so important and numerous.
The lymphatic glands in the groin take on now and then
a disease of a fungous nature, projecting through the skin.
The treatment will consist in the application of the nitrate
of silver, once in the day, and the black wash, or else make
a number of little points of paste, and dip them in the mu-
riate of mercury in solution, and introduce five or six into
the gland, which will produce a sloughing of the parts in
about four days.
The glands in the groin often continue enlarged, and in
an indolent state after a mercurial course : here blisters
should be used to disperse them.
Buboes, as well as chancres, not unfrequently put on a
sloughing disposition, and will occasionally destroy life.
Several cases have been seen in which the femoral artery
has thus separated : in one, this artery was laid bare all
around, yet the patient recovered as the wound filled up with
granulations. There are many patients that die annually,
in the London hospitals, from sloughing buboes. The treat-
ment is exactly similar to that of chancre similarly diseas-
ed: carrot poultices, foinentations, &c. A sloughing bubo
is often caused from the injudicious use of mercury, and the
surface thus exposed will be very extensive. I have seen
several lamentable cases of this kind. It is to the interposi-
tion of the sheath surrounding the femoral vessels, that many
patients owe their existence.


380
LECTURE XXXII,
BUBOES IN WOMEN.
Two of the situations are different to those in men. When
the chancre is on the labia nymphæ, the venereal matter
will be carried along the round ligament, and the seat of the
bubo will be there, just before it enters the abdominal ring :
when the chancre is more backward, then the bubo will be
situated between the labia and groin, or in the groin itself,
similar to men. What I have remarked on this complaint
in men, as to treatment, will be wholly applicable to the
same in women.
LOCALITY OF BUBOES.
These affections are entirely local, having no more con-
nexion with the constitution than chancres, from which they
arise; some, notwithstanding, have been absurd enough to
consider them in the light of a critical deposit ; but why, if
this were the fact, should the absorbent glands be affected?
and why should not the glands in the neck, and elsewhere,
be affected as readily as those in the groin, or those nearest
the source of absorption? and lastly, if critical, why should
it be necessary to administer mercury?
The difference in the treatment of buboes depends on
this : mercury can only cure the specific disposition of the
inflammation : sometimes there is a great deal of common
phlegmonous inflammation ; at other times, erysipelatous,
and in some the inflammation partakes of the scrophulous
diathesis : the specific requires mercury; the common, bleed-
ing and purging, &c. ; the erysipelatous, bark, &c. ; and the
last, cicuta, sea water poultices, &c. ; abstaining from the
use of mercury in all except the first. Emetics have been
known to cure buboes, even where suppuration has taken
place; they seem to cause a disposition for absorption. A
gentleman went to sea with a suppurating bubo, sea sick-
ness occasioned its entire dispersion. A surgeon ought to
be acquainted with the course of the absorbents ; this ex-
plains why a boil on the buttocks causes a swelling in the



LECTURE XXXII.
381
groin, &c. In some habits, although the venereal disposi-
tion is completely destroyed, yet a bubo will not heal; in
these, hemlock used externally and internally, joined with
bark, is the most effectual remedy ; sarsaparilla, sea bath-
ing, and poultices of sea water, are all serviceable at times;
goldbeaters' water, an application in use at the Lock Hos-
pital, often does service ; lemon juice or oranges is recom-
mended.
SECONDARY SYMPTOMS OF SYPHILIS.
The secondary effects of lues venerea are numerous ; but
of all, that which occurs in the throat is most serious, and
will occasionally prove destructive to the patient. When
the venereal poison is carried into the system, it attacks
three parts more particularly, the throat, cuticle, and bones ;
and nearly all the secondary symptoms may be classed un-
der these three distributions, or heads : there are certain
anomalous symptoms sometimes seen, but they are very rare.
OF THE POISON UPON THE THROAT.-—When in this situation,
the most common parts that it attacks, are the tonsil glands,
appearing in the form and character of chancre as situated
on the penis ; it is a deep sore covered with a white sloughi,
the edges ragged, and the adjacent circumference thicken-
ed; there is also a dark redness around, from venous con-
gestion. The character by which this species of ulcer is to
be known from others is so very well marked, that no per-
son can feel himself at a loss when put to the test of deci-
sion. The pain is slight, except on swallowing, when in a
few cases it is felt running up the Eustachian tube to the
ear; these symptoms are more complained of by the patient
in the evening than in the morning ; the throat constantly
feels husky, but never sore ; and this arises from the quan-
tity of mucus thrown out upon its surface. This disease in
the tonsils is the least dangerous of any of the venereal
affections of the throat : even when the tonsils are totally
destroyed, they occasion no other feeling than dryness in the
throat, more than what previously existed before their loss.


382
LECTURE XXXII.
A second seat of the disease is in the palate, and here,
although it never proves fatal, yet it may be very serious
in its results to the patients, as it will occasionally destroy
the voice, and almost entirely the power of deglutition, by
the destruction of the velum pendulum palati. It commences
by a small speck upon the integuments covering the os pala-
ti, and the ulcer, though small, extends to the bone, which
also is attacked with the ulceration : it mostly begins be-
tween the velum and the bony palate. An opening has been
seen thus formed between the mouth and nose an inch and
a half in length, and one inch in breadth, the velum being
adherent to the posterior part of the fauces. Sometimes the
ulcer is placed in the back of the fauces, behind the velum
pendulum palati. A third seat is in the larynx, and this is
the most dangerous of all; a great many cases have been
seen of this kind : it mostly attacks the sacculi larynxi in
the first place : occasionally the , larynx will exfoliate in
this disease, in which case the patient may recover. The
thyroid cartilage has been found with a large aperture in it,
from the effects of venereal poison. The disease in the
larynx has the following symptoms : hoarseness, cough, and
difficulty of breathing; it is also frequently attended with
pain in the bones and venereal eruptions. As the disease
here may prove of such importance and so very destruc-
tive, immediately on discovering its existence the most
vigorous methods must be pursued, as mercurial fumigations,
and the hydrarg. muriat. internally, &c.; for the other dis-
eases, mercurial frictions may be adopted. If the tonsils be
sloughy, a little borax powdered and sprinkled on them will
relieve : the mel. ærugin. has been found a very good ap-
plication, but is less powerful than the borax and honey.
The nitric acid gargle, or gargle of the hydrarg, muriat.,
has been used with the most decided success. The sores in
the roof of the mouth may be washed with a weak solution
of the acids, which will correct the fætor of the breath, and
of the discharge likewise, and at the same time induce a
more healthy state of the ulcer. When the sore heals, if an


LECTURE XXXII.
383
opening or fissure remains, a false palate must be used : these
are now very ingeniously made. If the openings are ex-
tending far back there is no remedy, as nothing will lie in
contact with the soft palate without irritating it. An ulcer
in the fauces seldom occasions any alteration in the voice,
or difference in the power of deglutition, provided no other
part has been affected. The use of the before-mentioned
remedies will be also proper when the larynx is diseased,
but from the distance that it lies back, it is scarcely possible
to apply any thing to it.


VENEREAL ERUPTIONS.
The character of these differs from that of other diseases
of the skin in many respects. The skin surrounding the erup-
tion is of a copper colour, the sore is covered with a crust,
and on its being rubbed off, a mixture of blood and in per-
fectly formed matter will be found. In addition to these ap-
pearances, there is the same thickening surrounding the ul-
cer in the skin and integuments, which marks a chancre else-
where, and which exists only in venereal sores; hence it is
possible to discriminate this species of cutaneous ulcer from
every other kind to which the surface of the body is liable.
The part upon which the eruptions first make their appear-
ance, is on the scalp, in the form of scabs amongst the hairs;
next the face becomes the seat of the affection, then the
breast, and afterwards other parts, as they are seated more
or less distant from the course of circulation: the palms of
the hands will occasionally become affected with them, with-
out the other parts of the hands or arms participating in the
appearance. The whole of the back has been seen covered
with these eruptions, but mostly between the shoulders.-
Nothing can be judged of them by their size, as they vary
much in this respect; most commonly they are small, but
are occasionally met with as large as a sixpence: when they
are large and numerous, they leave portions of healthy skin
insulated from the other healthy cuticle. There is little or
no pain attendant on venereal eruptions, unless the patient is


384
LECTURE XXXII.
ful at night; also, when the patient has been heated with
exercise, or otherwise so as to perspire, there is itching and
slight pain. Venereal eruptions are the mildest form of the
secondary symptoms, and seldom prove fatal; instances
have been seen where the patient was carried off.
Treatment.
Mercury given internally, and also introduced into the con-
stitution by friction, will be necessary. If the eruptions are
going on to a dangerous extent, the hydrarg. muriat. must be
given dissolved in the spir. vin. rec. as often as three or four
times daily. The best mode of giving it in feeble constitu-
tions and tender bowels, is in small but frequently repeated
doses. I: is the best form of mercury in this species of the
complaint, as it acts most powerfully and immediately on the
stomach; and this action, on account of the intimate sympathy
existing between that organ and different parts of the body, af-
fects the skin more particularly than any other part. If the e-
ruptions become very irritable, the nitric acid may be given
with great advantage: it assists the mercury much by increas-
ing the digestive powers,though it has little effect directly upon
the disease. Some surgeons have asserted its capability of
curing the disease, but I do not assent to this opinion: it is
unquestionably a most powerful auxiliary. With respect to
local treatment, the eruptions always do better if allowed to
remain without being touched by any preparation. The
crust alone should be allowed to cover them; but should they
seem disposed to ulcerate, calomel, united with mucilage,will
be advantageous to dress them with.



PHAGEDENIC ULCER.
This absurd term is applied to that species of ulcer,which
often makes its appearance in consequence of the improper
use of mercury; that is, by the employment of it during the
inflammatory stage of a bubo, or when it is in an irritable
LECTURE XXXII.
385
state. It is nothing more than a very irritable sore, and one
which is thought generally extremely difficult to cure: the
character of it is, the surrounding edge being hollow and
ragged, purple in colour, and the granulations on the surface
white and flabby, being but imperfectly supplied with blood.

The Treatment
Consists in washing the sore once a day with a strong solu-
tion of the nitrate of silver, one drachm to one ounce of wa-
ter; dipping lint in this, and touching the whole extent of the
sore with it, but more particularly the edges ; the black wash
must be applied over this,and a part of the black oxide of mer-
cury, which remains at the bottom of the phial, must be put
on the ulcers, from which they will derive great benefit: this
wash must be kept constantly applied to the sore by means
of lint or linen cloth, and the whole ought to be covered with
a piece of oil skin. If the edges of the sore are very hollow
and ragged, they must be touched with the nitrate of silver :
if this treatment do not succeed, lotions composed of the
vitriolic or nitric acids must be substituted, in the proportion
of four drops to four ounces of water. If the irritation run
very high, opium may be given, and also used as a lotion.-
Bark and the decoction of sarsaparilla must be prescribed,
ammonia, &c.; but more dependence ought to be placed on
the diet and regimen-wine, porter, &c. may be allowed.

VENEREAL OPHTHALMIA.
This may be considered as belonging to the eruptive spe-
cies of the disease, and is mostly attendant on the cutaneous
complaints. The characters are : a much less abhorrence
of light than is experienced when inflammation is resulting
from any other cause ; it is accompanied with nocturnal ex-
acerbations, and becomes worse in the evening : but the best
mark to discriminate the disease, is by a circle of inflam-
mation around the transparent cornea, situated on the tu-
nica conjunctiva, having a white uninflamed space between
49
386
LECTURE XXXII.
it and the lucid cornea. It is often joined or combined with
an inflammation of the iris : as this disease frequently tere
minates in the loss or great defect of the organ of vision in
a very short time, immediately upon its being ascertained
to exist, the most prompt measures must be undertaken, in
order to prevent this danger. The use of mercury has an
extremely quick effect in checking the progress of the dis-
ease. The muriate of mercury in solution must be given
along with the decoction of sarsaparilla. When the symp-
toms are a little abated, but not before, mercurial frictions
may be had recourse to.

VENEREAL DISEASE OF THE BONES.

Many bones of the body are liable to the attack of the
disease, but the nasal bones seem more susceptible than any
others. These are often affected, and the first symptom
which denotes the existence of the disease, is a painful sen-
sation exténding across the bridge of the nose between the
eyes; a tenderness is perceptible here on pressing with the
fingers ; then the skin becomes red, and large scabs, lined
with blood and matter, are discharged from this part on
blowing the nose : afterwards the bones exfoliate. The
greatest part of the vomer has been discharged by the ex-
foliating process. Occasionally the ossa nasi are also de-
stroyed in this manner, in which case the nose falls in, and
permanent deformity remains. Much of the disfiguration
may be prevented by taking away the portions of bone as
they decay. The general treatment is to be the same as in
eruptions, but the local treatment differs : bere a solution of
any mineral acid must be made, and a small quantity must
be snuffed up the hase, by putting the fluid on the hand ;
if this cannot be done, Asyringe must be employed to inject
it up. This will have the offect of correcting the great and
extremely disagreeable fætor, which is always present when
this disease exists in bones, and as the same time the ex-
foliation will be expedited.
LECTURE XXXII.
387
NODES.
A node is a swelling found upon cylindrical bones where
but thinly covered with integuments : they are found on the
malleolus internus, on the middle of the tibia, on the clavi-
cle, ulna, and sternum, &c. : they are very rarely found on
that part of a bone which is thickly covered with muscles
and integuments. The pain attending their formation is
generally obtuse, and more in the evening than in all the
other varieties. Surgeons must be careful in ascertaining
their venereal origin previous to their giving an opinion, as
it very frequently happens that nodes will arise without any
preceding venereal symptoms, and on persons who it is cer-
tain never had syphilis ; in these latter cases, of course, they
are not venereal. At first, the seat of the disease is in the
periosteum, and not in the bone, as some authors have assert-
ed. It is here simple adhesive inflammation, and consists
of an effusion of a glairy albuminous fluid situated between
the periosteum and bone. If the disease continue its progress
unmolested, this matter appears to be absorbed, and good
pus is poured out by the extremities of the arteries into this
cavity, which takes place before the bone is affected. When
this matter is formed, the skin over the swelling becomes
red, and there are evident marks of suppuration. Fluctu-
ation also is apparent ; but this is no rule to judge of the
existence of pus, as this symptom is perceptible when the
glairy fluid exists. The integuments on the surface becom-
ing absorbed, the matter is discharged through the open-
ing, and the bone is found in a diseased state. This is the
progress of the complaint when allowed to remain, and go
through its natural course. Sometimes nodes will make
their appearance of an evening and subside in the morning,
and this will continue several days, until the periosteum be-
comes thickened, and takes on a permanent diseased state,
when it will be found to continue both day and night with-
out any further disappearance, unless reduced by the ap-
plication of mercury.



388
LECTURE XXXII.
Treatment

Mercurial frictions can alone he depended on for the cure
of the disease. The local treatment is very simple. If there
be any great degree of irritation and inflammation, the soap
plaster must be applied on the node. If those symptoms do
not run so high, but are moderate, the empl. litharg. comp.
may be put on.
If the inflammation go on to the production of a fluid,
leeches must be applied, and the liquor. acet. plumb. dil.,
or the liquor. ammon. acet., may be used as a wash, with
the intention of discussing the tumour. A blister may be
put on the part, and very great advantage is derived from
the application of it. If a glairy fluid be formed, and there
is no suppuration, this last being indicated by a redness on
the skin, the surgeon must not attempt on any account to
open the abscess, as the use of mercury will be quite suffi-
cient for the removal of the swelling; for if the swelling be
imprudently opened at this stage of the complaint, the bone
will certainly exfoliate, and the case will be rendered ex-
tremely tedious; but if pus be formed, mercury will never
cause the absorption of it, in which case it will be requisite
to evacuate the contents by means of a small incision.
BONES OF THE CRANIUM.
These are occasionally affected with this complaint-the
disease in these parts is the same, only attended with more
danger. Very large collections of pus have been seen un-
der the cranium, and also several fatal cases of the disease
when in these bones. In general it is the result of bad con-
stitutions, or of the complaint being neglected. When the
venereal disease is situated in the bones, it requires a much
longer course of mercury than in other parts, and in gen-
eral, as the vital principle of any part is less, the more
mercury does it require to eradicate the disease from that
part.
LECTURE XXXII.
389
There are other parts of the body that are occasionally
affected with syphilis ; but they are generally easy of dis-
covery: the testes are sometimes enlarged from it : here a
mercurial course will recover them. Patients will now and
then complain of pain extending down the thighs, legs, arms,
&c. ; when this is the case, it is truly venereal ; but when
they tell the surgeon the pain is seated in the joints, the
disease is rheumatism.
The venereal virus is sometimes taken into the system by
means of inoculation ; in this case the disease is extremely
irritable and inveterate, and also serious to the person who
has it. Practitioners of midwifery are very liable to it, and
several cases could be related of this kind. The constitu-
tional fever runs so high occasionally, that the patient's life
is endangered by its continuance, in which case the symp-
tomatic disease must first be attended to, and then the
primary.
GENERAL REMARKS ON SYPHILIS, AND ON ITS TREATMENT.
From what I have detailed of the venereal disease as to
its various symptoms and appearances, it is evident that on-
ly some parts of the body are liable to be attacked with it,
and these are, comparatively speaking, but very few, the
greater number escaping infection by their being unsus-
ceptible of the complaint : thus the skin, or rather the in-
teguments of the penis, the glands situated in the groin, the
parts contiguous to the throat, the skin generally, the eyes,
and some of the bones, are the only parts of the body
which are liable to the disease. The vital organs, as the
brain, the cavity of the thorax and of the abdomen, the
blood-vessels, the nerves, &c. are never affected with it. It
is a wise provision of nature, that this poison, in its passage
through the lymphatic system to the blood-vessels, only
should affect a single gland, or at most two; were this not
the case, many, if not every patient who contracted the
disease, must perish from the suppuration of the numerous
glands which the virus passes through in its progress to the
thoracic duct.

390
LECTURE XXXII.
;
The symptoms of the venereal disease are divided into two
distinct species, the primary and secondary. Of the first,
chancre and bubo may be enumerated ; but the latter ought
to be ranked as an intermediate description of symptoms.
The secondary are the diseases of the throat, skin, and
bones. Thus then there are, one primary, one intermedi.
ate, and three secondary.
The venereal disease, when classed properly, is simple,
and easily discriminated from any other, though it is in gen-
eral considered as difficult to distinguish it, in all its various
forms. This idea has arisen from persons supposing that
many other parts, besides those enumerated before, are lia-
ble to the disease, which opinion is erroneous; as some
parts of the body only can be attacked with infection, so
some persons appear to be more susceptible than others.-
A person who has been much in the habit of cohabiting with
infected women, will sometimes not imbibe the complaint,
though the females may have several chancres at the time:
and yet if another person do the same, he will immediately
contract the disease. À person of very debauched habits,
will occasionally be found, to whom it is scarcely possible to
give the disorder, though he exposes himself to every variety
of it, and has connexion with the most impure females.
The disposition to gonorrhæa and syphilis appear to he
less, according to the frequency of the person's being attack-
ed with these complaints. A person who has had two or
three attacks of gonorrhæa, will have connexion with a wo-
man who is unwell without her communicating the disease to
him, while if one come to her immediately after, who has not
experienced the complaint, he will carry it away with him.
A surgeon ought carefully to distinguish between gleet and go-
norrhea, for a person slighty affected with the former, on hav-
ing connexion, will find the discharge often increased, which
he will conceive to be gonorrhea, but which in reality is
merely a greater flow of matter, in consequence of the irri-
tation and inflammation attendant on erection, and which




LECTURE XXXII.
301
matter is perfectly incapable of communicating any infec-
tious disease.
The venereal disease has been considered by Mr. Hunter
as merely a local complaint, unattended with any constitu-
tional fever or affection ; but many of the surgeons since his
decease differ with him decidedly in this respect; for the
secondary symptoms are always accompanied with consti.
tutional irritation and fever, which is evinced by the exac-
comes on towards five or six o'clock in the evening, and
abates about the same hour in the morning; and the remain-
der of the day the patient remains in good health as usual.
Even before the appearance of venereal eruptions, febrile
symptoms have been known to occur for the space of sever-
al days: and this has been treated as proceeding from gen-
eral causes until the skin became diseased, which evinced
the nature of the complaint : the increase in the severity of
the symptoms occurring in the evening is now considered to
be constitutional. ca
The matter produced from the secondary ulcer differs very
much from that discharged in chancre, having no power to
communicate the disease when applied upon the skin, or in-
serted under it by inoculation. This discovery was made
(among numberless others) by Mr. Hunter, who made many
experiments, in order to verify the truth of it; and since his
time others have followed his steps, and similar tests have
been made at almost all the hospitals in town, all of which
coincide with those made by him. The matter from a sore
throat not being able to communicate the disease, it will
therefore be impossible to be infected by kissing a person
who has venereal ulcers, as they cannot transmit the disease
to another, and it can only be done by chancre ; thus there
are only chancre and gonorrhæa from which the two diseas-
es can be caught; the matter from the latter is very liable
careful respecting their instrument, &c. Bougies which have
been introduced into the urethra of a person labouring un-
-392
LECTURE XXXII.
der gonorrhæa, will certainly produce the disease if passed
afterwards into that of a person in health. A case of this
kind occurred some time ago—an old man of seventy caught
á severe clap, by having an elastic catheter introduced which
had previously been used on a person who had a gonorrhea.
I have already remarked that it has been ascertained in
the most satisfactory manner, that the matter of gonorrhea,
when inserted beneath the skin of the penis, will not cause
chancre or any other venereal disease: the experiment has
been made so many times besides the case I have inserted,
that not the least doubt exists at the present time of the dif-
ference between the two diseases.
It has been stated by many authors, that the fætus in ute-
ro cannot contract the venereal disease, but I entertain, with
others, a different opinion; from the experience of an emi-
nent surgeon, who has vouched for the fact, I will take upon
myself to assert positively, that it can; that a child can be
contaminated while remaining in utero. Mr. Hunter was of
the former class of writers. I have never seen a child born
with venereal eruption on the skin ; but I have seen them
with the disease existing a fortnight subsequent to the birth
of the infant. They chiefly made their appearance on the
nates, on the soles of the feet, and on the palms of the hands;
the latter being most commonly affected. In these cases,
children require nothing more to cure the disease than the
milk of the mother, if she be taking or using mercury her.
self. I am of opinion, that a woman who has a child in ute-
ro is incapable of being cured of the venereal disease, as
frequently large quantities of mercury have been given, and
continued a long time without destroying the virus ; for al-
though apparently they were cured, every symptom being
completely removed, yet soon after the child had been born,
the disease re-appeared, requiring a complete course of the
medicine to cure it.
It requires a good deal of experience to distinguish in
every case, the venereal disease from others that resemble
it: but when a surgeon has once seen the different varieties,


LECTURE XXXII.
393
(and every young man has a fine opportunity in the wards
of the London hospitals of seeing them,) the diagnostic is
not attended with much difficulty. Persons will frequently
apply for relief, supposing they have caught the disease,when,
in reality, it is merely an excoriation which they take for a
venereal ulcer; here some mercenary wretches, who are a
disgrace to their profession, have an opportunity of gratify.
ing their propensities ; but the conscientious surgeon, who
has integrity and character to maintain, would spurn at such
practices; if it be not accompanied with the surrounding
thickening of the skin, it is the latter, and may be cured
by the spirits of wine with water.
It sometimes happens, that after mercury has been given
for some time, sores will break out upon the penis, and those
have been thought venereal, but are no such ulcers ; being
entirely mercurial, caused by the long continuance of the
medicine : they certainly resemble chancres in some degree,
being ragged and sloughy ; but they have not that circum-
scribed circle of inflammation around them which chancres
have, nor the surrounding thickening : but they have mostly
a good deal of inflammation extending about them. These
ulcerations will soon heal, if they are frequently washed with
warm milk and water, and the parts afterwards covered
with dry lint.
With respect to bubo, if the patient have not had a pre-
ceding chancre, it ought not to be considered as venereal;
on account of the glands in the groin becoming enlarged
trom a great variety of causes, independent of venereal mat-
ter. But now and then, a chancre will spontaneously heal,
in which case, if a bubo be present, the penis must be ex-


degree of hardness remaining which will point out the situ-
ation of it.
If several of the inguinal glands are enlarged, the disease
will scarcely ever be found venereal, but generally either
sympathetic or scrophulous.

50
394
LECTURE XXXL.
With regard to sores in the throat, there are several kinds
which may be confounded with venereal, viz. scrophulous;
those arising from debility, independent of scrophula; and
those which owe their origin to the free use of mercury.
The venereal are resembling chancre in every respect; the
mercurial are similar to phagedenic ulcers, as before des-
cribed : the scrophulous generally begin by an enlargement
of the tonsil glands, and when they are pressed from the
outside, quantities of sanious matter will be forced out of
their follicles.
If a patient have once had a venereal sore throat, after-
wards if he have a chancre, the rubbing in of mercury will
induce a sore throat ; but here the ulcers will not be vene-
real, but similar to those of the mercurial description : and
so much inflammation will attend them, that it will be quite
necessary to desist from the use of medicines, or mercury,
at least for a time.
With respect to venereal eruptions, they differ from all
others in being of a copper colour, and having the circum-
scribed circle around them of inflammation ; but mercury,
if long continued, will cause a cutaneous eruption of the
crusted kind, siinilar to the venereal in every respect; with
the single exception, of wanting the discriminating mark,
the circle of deep coloured inflammation around.
As to the swelling of the bones, they are frequently at-
tacked with a similar disease in appearance to the venereal,
but they are unattended with the nocturnal increase of the
symptoms. The long continued use of mercury will occa-
sionally produce a complaint very like it : but in all these
cases, no preceding venereal symptoms having existed, will
explain their distinction. They are readily relieved by the
application of blisters to the part affected, and by giving the
decoction of sarsaparilla. Women of delicate habit of body,
in whom debilitated symptoms occur, will occasionally have
nodes without their in the least partaking of the venereal :
they may be removed by blisters, or other stimulating ap-
plications, and by giving the mistur. myrrhæ.


LECTURE XXXII.
395
There is a disease, which is occasionally met with in the
nose, which, by many, is confounded with that resulting
from the application of the venereal virus to the constitution,
this is called NOLI ME TANGERE ; at first sight it re-
sembles it, but on accurate examination it will be found to
differ. The best remedy is a solution of the argent. nitr, 3i.
to aqua 3i. The parts are to be bathed once daily with it,
and afterwards the black wash is to be applied, giving at
the same time tonic medicines. In one case, which baffled
every usual means, it yielded to a solution of arsenic appli-
ed to it, taking this medicine internally at the same time.
The venereal disease cannot be cured by the grand spe-
cific, mercury, in some people, who have extremely irritable
habits of body, as very soon after beginning the use of mer.
cury, the constitution will become so much deranged as to
compel the surgeon to desist from its continuance: this may
be owing to debility, and frequently occurs in scrophulous
patients : when this is the case, mercury must be laid aside,
with the exception of a mild preparation, and none will be
found better than Plummer's pill. The decoct. sarsaparil.
may be given at the same time. Some surgeons in exten-
sive practice, who have patients with this irritability of fibre,
have given the hydrarg. muriat. in the decoction with ad-
vantage. Van Swieten's celebrated remedy was composed
of this preparation, and it is supposed De Velno's vegetable
syrup is nothing more than it sweetened with molasses.
Various opinions have been entertained by different wri-
ters, as to the specific action of mercury: as an attack of
fever will suspend the violence or action of the venereal
poison for a time, until that fever is abated, so the use of
mercury is supposed to cure the disease, by inducing a more
powerful action in the system than that caused by venereal
virus : as the disease might return upon the declination of
the newly set up action, it is thought, that during this time,
a more healthy state being produced in the constitution, has
the effect of overpowering the diseased action, and thus the
complaint is removed.


396
LECTURE XXXII.
In administering mercury, this rule should always be
kept in view, namely, that the cure of syphilis does not de-
pend upon the violent action of the medicine, but on the
gentle and long continued use of it, so as to have a slight
effect upon the salivary glands : it is scarcely possible to
point out a definite length of time which this medicine ought
to be given in the several species of the venereal disease,
with the intention of removing it. Very much must depend
on the constitution of the patient; on the inveteracy or mild-
ness of the complaint, and on several other circumstances.
In chancre, it ought not to be given for a shorter time than
three weeks ; in bubo, four weeks ; in the venereal sore
throat, five weeks ; in diseases of the bones, it should be
continued rather longer ; and in venereal rheumatism, eight
weeks. Some persons are so immediately affected with
mercury, that a simple dose of three grains will salivaie;
this is not often seen in men, but frequently in women : and
persons have often been destroyed, even by the moderate
use of this powerful medicine ; which has, in the majority
of the fatal instances, induced a sloughing of the throat and
parts adjacent. Patients will occasionally he met with, in
whom it is impossible to produce a salivation, though mer-
cury is given in very large and long continued doses : hence,
though no perceptible effect is produced, yet, the disease
will be cured as well as if salivation were caused. Mer-
curial frictions, assisted by the warm bath, giving calomel,
hydr. mur. pil. hydrarg., &c. have failed in promoting the
least discharge from the salivary glands. To assist fric-
tions, the feet may be put in warm water : the best form of
mercury is certainly the ointment, and this should always
be used if it can conveniently and without exposure. The
next is the blue pill ; this may be given in pills of five grains
each, combined with one-fourth of a grain of opium ; two
at night and one in the morning. Calomel will affect the
mouth sooner than the above, and the hydrarg. muriat.

not so effectual in removing the disease.
The hydrarg. Co.
LECTURE XXXII.
397
cretæ is a good medicine where tenderness of the abdominal
viscera exists. Confinement, in general, is unnecessary in
the cure of the venereal disease. The
It is said, that mercury pervades the system after being
given for some time in every secretion, in its metallic form ;
but this idea is erroneous, as the most delicate chemical
tests cannot discover it in any which I have heard of exam-
ined, as the saliva; the blood, the urine, &c. Sometimes
mercury will produce such a profuse salivation, that it will
be quite necessary to put a stop, or at least diminish it ; this
may be effected by a weak gargle, composed of two grains
of the nitrate of silver, to four ounces of water; the strength
of it may be increased according to circumstances : a solu-
tion of nitric acid has also been found very good as a gar-
gle; at the time of using these, give purgatives, &c.
The tongue sometimes will be tumefied and protrude out
of the mouth, so that the patient cannot draw it in; here a
piece of gauze, tied round the head and made to press upon
the tongue, will be found to reduce it in twenty-four hours.
When the salivation continues profuse, the patient may be
exposed cautiously to a colder atmosphere. Mercury ought
ever to be given and used with great caution, and wet and
damps must be avoided especially.
There is a disease, which is induced by the use of mer-
cury, and which is occasionally destructive to life; it is
termed the erythema mercuriale: it consists in a desquama-
tion of the cuticle over each of the papillæ of the skin, around
the roots of the hairs ; it takes place also in those parts on
which hairs are not to be found : a circle of inflammation
begins, commonly in the groin, or thigh, or lower parts of
the abdomen ; afterwards it extends to other parts of the
body. In this case, the scrotum is often deeply ulcerated,
and the disease is accompanied with considerable constitu-
tional irritation. The patient generally dies, with an affec-
tion of the organs of respiration, and when these symptoms
make their appearance it is always a fatal sign. The spots
of inflammation on the body become purple before death.


398
LECTURE XXXII.
It mostly arises from the patient having been exposed to cold
and wet while under the influence of mercury : sometimes,
however, it happens from an irritable state of the skin. The
best treatment is to wash the whole body with equal parts of
lime water and milk, giving, at the same time, bark and
sarsaparilla. Country air will much assist in the recovery.
The ungt. hydrarg. nito, or an ointment composed of lard
and the acetate of lead, will be useful. A solution of the
hydrarg, muriat. C. liquor, calc. has also been very bene-
ficiale

inter
rompre
( 399 )
LECTURE X X XIII.
ON SIMPLE FRACTURES.

The existence of fracture is generally easily known, by the
alteration of shape which the limb undergoes; by the mo-
tion of the fractured part, and by the crepitus which may
mostly be felt at the place where the bone is broken : if,
however, one portion of bone be not in contact with the
other, crepitus will not exist, and this sensation is not al-
ways to be depended upon; as it may sometimes be perceiv-
ed when a fracture has not taken place : when a part re-
ceives a blow, intlammation is produced there, by which
coagulable lymph is thrown out: the pressure of this lymph
against the periosteum will induce crepitus when the part is
examined, similar to what is felt when a bone is broken, but
this crepitus never is perceived until inflammation has arisen
in the part, which generally requires three or four days to
produce in a sufficient degree ; therefore, tension, spasm, &c.
will come on, and if the bandages are too tightly applied at
first, it will be necessary to remove them at this period. -
It is generally the plan at the present time, not to apply
any bandage on a fractured limb for four, five, or even six
days ; simple extension must be adopted, when the limb

400
LECTURE XXXIII.
should be placed in an easy position, with the ends of the bone
as perfectly in apposition as possible. The deposition of
the jelly-like substance, which is cartilaginous, and which
commences the process of ossification, never is produced, un-
til the inflammation has subsided : hence, if bandages are
employed in the first instance, they should be put on loosely,
and they must be rendered tighter towards the fifth or sixth
day. From the prejudice which prevails, the practice be-
ing still pursued by surgeons of the old school, it will be
necessary, in order to quiet the patient, to apply bandages
immediately, but do so, as I have previously observed, loose-
ly: the limb would certainly be better without them. ,
When the inflammatory process has subsided, the limb is
as mobile as it was, subsequent to the accident ; but no crep-
itus will be distinguishable at this time (if previously felt,)
the extremities of the bone being covered with a new sub-
stance. After the ninth day in young subjects, the ends of
the bone begin to unite ; but in persons who are more ad-
vanced in years, this does not happen until the tenth or elev-
enth day; and the union is complete in the small bones in
about twenty-one days, but in the large, not until the fifth
or sixth week : this, however, depends much upon the age
and constitution of the patient. In young persons, the dep.
osition is effected much sooner than in those who are ad-
vanced in life.
The process which goes forward to effect the union of
bones in cases of simple fracture, is thus: for the first four
days, blood is effused betweer. the ends of the bones, which
also pervades the cellular membrane: this is ultimately
absorbed, as it has not the least tendency or share in pro-
ducing the union between the ends of the bone ; towards
the fourth day, inflammation commences in the bone, and
this process pours out a jelly-like substance between the
bone and periosteum ; this effusion continues from the fifth
until the tenth day, and constitutes the new callus,which is ex-
actly similar to that substance into which ossific matter is
deposited by the arteries in the foetus, resembling very much

LECTURE XXXIII.
401
cartilage: ossific matter is deposited by the vessels in this
substance in patches, without any regular order being ap-
parent: the earthy matter is found to consist of animal glu-
ten and phosphate of lime. Thus a fracture is united in the
same way that bones are originally formed.
When fractured bones are united in direct apposition, the
jelly-like substance becomes poured out of the mouths of
the vessels in a circular direction around the broken extrem-
ities of the bone, and the ossific matter is deposited in this
cartilaginous substance: but if the fractured ends are not
directly in contact, the cartilage thus formed, does not com-
pletely cover the brokenends, and the parts thus protruding
are taken up by the absorbent vessels.
Callus newly formed, is very vascular, but in a similar
manner to those in a cicatrix, the vessels here become dimin-
ished in their diameter in the course of time. This callus
consists of a solid substance and cancelli. A new perioste-
um is also formed over it, being an elongation or production
of the original periosteum. When two portions of bone
are laying in contact, the periosteum, covering and interven-
ing between them, is taken up by the absorbent vessels. In
the formation of this callus, it sometimes happens, that it is
deposited in a superfluous quantity ; even to such a degree
as to produce an increased size in the bone : this abundance
is arising from a very extensive laceration of the parts, which
induces an undue degree of inflammatory action in the ves-
sels depositing the ossific matter; in order to repress its
growth, in the first instance, endeavour to allay the inflam-
mation by the application of leeches to the circumjacent
parts, and afterwards, when the entire inflammation has sub-
sided, by pressure and the empl. ammon. c. hydrarg. -
When the fractures are oblique, callus is slow in being de-
posited: in all oblique fractures, be very careful to keep the
bones directly in apposition ; the limb should be examined
frequently, and extension ought to be made very often.
It will not unfrequently happen, that no callus will be



51
402
LECTURE XXXIII.

formed; but a substance similar to ligament, of an elastic
nature, will form a union between the bones; when this is
the case, it has been advised by Mr. White of Manchester,
to cut down on the fractured part, and saw off the extremi-
ties of the bone; but this operation is now deprecated, and
it is advised never to perform it: as from the experience of
men, who have had the greatest opportunities for observa-
tion, that it is never successful, that is, the production of
bone in the place of the substance removed by the opera-
tion never takes place. An exfoliating piece of bone inter-
vening between the fractured terminations, will impede the
formation of callus, and thus prevent union; here the be-
fore-mentioned operation might be performed to extricate
the piece.
The only examples of the first kind which I ever heard
of, in which the operation succeeded, were two, but in both
these the constitutions had undergone a complete alteration;
the patients having experienced attacks of typhus fever, sub-
sequent to the operation. Thus people have been exposed
to contagion with the intention of effecting a formation of
callus ; they have been prescribed a mercurial course, which
will not produce the deposition of ossific matter when union
has once been formed by this ligamentous substance.
Sometimes union will not be obtained for a considerable
length of time, but in some cases, this desirable effect has
taken place by a case of leather being made, adapted to the
shape of the limb, and bound upon it very tight. Spasms
will now and then occur, and ultimately destroy life ; large
doses of opium must in these cases be given. A simple frac-
ture is not entirely devoid of danger, as many instances are
known to the contrary. In old people, where the fracture
is near a joint, it most frequently proves fatal. In persons
of bad habit of body, a high degree of inflammation comes
on, and proves destructive to the vital principle. Vesica.
tion will occasionally extend over the whole surface of a
limb, which generally is owing to the fracture being accom-
panied with contusion, more or less.


LECTURE XXXIII.
403
I have heard a great deal said lately, as to the mode of
union, as if it were a new idea, that the cartilage was first
maintain it is no such thing : Mr. Hunter says, “ the union of
bones is much more tedious than the union of soft parts of
the body, because cartilage is to be formed first, then bone.”

TIDIA AND FIBULA.
When the tibia and fihula are fractured, it is very soon
ascertained by running the finger along the bones where
nearest to the surface. When the tibia is broken sepa-
rately, it is generally about five inches from the malleolus
internus ; and when the fibula is broken, it is mostly about
three inches from the malleolus externus : the empl. sapon.
on leather, should be first applied, but not tightly, in order
that room may remain for tension, which always comes on
soon after the accident : over this the eighteen tailed ban-
dage should be secured, having the strap on each side: this
bandage is very much superior to a roller, as if it were put
on too tight, or the limb swelled too much, it may readily be
loosened, and may be removed without moving the limb :
over this, two splints made of wood, copper, or whalebone,
covered by linen, are to be secured. The best position for
the limb is on the side, and the foot should be kept in a line
with the patella.

OS FEMORIS.

Here apply the empl. sapon. the eighteen tailed bandage
outer side of the limb, the next in length on the anterior part
of the thigh, and the shortest on the inner side ; they should
be lined with tow or wool. Two pillows will be required,
one to reach from the buttock to the heel, and a smaller one
to be placed under the knee, which should be raised in er-
der to relax the muscles of the thigh. It is never the case
404
LECTURE XXXIII,
that the femur unites directly in apposition.
The best po-
heel. The thigh bones of children mostly unite very well,
if properly attended to; the many tailed bandage ought not
to be applied in children, as a roller will serve the purpose
of keeping a due degree of pressure upon the bone much
better than the bandage. Fracture boxes, when properly
made, answer very well for adults, but in young subjects
they are seldom fixed suitable to the linıb, and are not so
necessary, as the bones unite much sooner.
CLAVICLE.

When this happens, the sternal extremity of the bone is
found to be higher than the other, on account of the latter
being drawn down by the weight of the arm. To remedy
this, and secure the ends of the bone as nearly in contact
as possible, the stilette bandage being five or six yards in
length, made of linen, must be applied over the shoulders,
and passing on the back in the shape of a figure of eight: a

natural position. This bone seldom unites in an even man-
ner ; and to effect as perfect a union as possible, Dr. Haigh-
ton has invented a bandage having two openings to receive
the shoulders, and a strap and buckle attached to them to
buckle upon the back.

OS HUMERI.
Two rollers and two splints are required. Several turns
of the roller should be made around the fractured part, when
the two splints are to be placed, one on the inner, the other
on the outer side of the arm, and the remainder of the rol-
ler is to be carried around these from the top to the bottom,
in order to secure them on. The splints may be made of
LECTURE XXXII.
405
wood or pasteboard; the latter is the best, and being soaked
in water it will adapt itself to the figure of the arm, and thus
better retain the bone in its position. The arm is to be sup-
ported, but not raised by a sling, and the patient is not to be
confined to his bed, as he does much better without.
RADIUS AND ULNA.
In this case, the same splints and bandages are required
as when the os humeri is fractured : the splints are to be
placed one on the outside and the other on the inside of the
arm, and the arm must rest upon a pillow within a sling.
When the radius alone is fractured, if the treatment of it
be not very judicious, impediments to motion will very often
remain ever after. Here two rollers and two splints are
requisite; but the latter are not to extend beyond the wrist,
as the object principally to be attended to, is to allow of the
arm hanging down, and also to keep the thumb uppermost,
having the palm of the hand applied flat towards the breast.
This position of the limb will prevent the pronator quadra-
tus drawing the lower extremity of the broken bone out of its
apposition with the other portion.


RIBS AND STERNUM.
A fracture of the ribs requires the same treatment as a
fracture of the sternum. A fracture of the ribs often proves
dangerous, particularly when the force occasioning it was
great, and several of them have been broken. If a single
rib be fractured, little pain ensues, and no ill consequences ;
but, if several are in this state, the patient will frequently
fall a victim to the effects caused. He will die from ex-
travasation of blood into the cavity of the chest, occasioned
by the rupture of the intercostal arteries : this will produce
dyspnea, from matter which will form within the chest.


406
LECTURE XXXIII.
On dissection, the matter will be found, and a clot of blood
also floating in it. He may die from the point of the frac-
tured rib puncturing the lungs, and producing emphysema ;
and this appearance will often occur, however, without any
bad consequences ensuing ; but when the lungs are much
lacerated, death ensues from emphysema and inflammation
combined. A case has occurred where the end of a broken
rib punctured the spleen, and occasioned death.
It sometimes happens, that the ribs upon both sides are
fractured, causing great danger. No bandage ought to be
applied in this case, otherwise pressure will be made upon
the lungs, and unpleasant symptoms produced. The chief
dependance will be in perfect quiet, and the antiphlogistic
regimien, using purgatives, bleedings, &c.
When the ribs on one side only are injured, a roller from
seven to eight yards in length, and from four to six inches
in breadth, ought to be made use of. It should be made of
flannel cut from selvage to selvage. It ought to be applied as
tight as possible, and after two or three turns have been
made, a piece of stiff pasteboard should be placed directly
upon the fractured ends, and this will assist greatly in pre-
venting the action of the intercostal muscles, which will be
the great object to be attained. A fracture of the ribs may
be discovered by placing the hand on the painful part, and
when a deep inspiration is made, a sensation of crepitus will
be plainly conveyed to the fingers.



LOWER JAW.
This bone is not unfrequently fractured near the angle or
symphysis by blows received on the opposite side to that on
which the fracture is caused. A sling of wash leather must
be had recourse to, with a hole in the centre to admit the
chin; two tapes attached to the upper part of this must pass
over the forehead, and be made to fasten at the vertex, in
order to keep the jaw from falling down ; and two tapes are
• LECTURE XXX111.
407
to be carried along the course of the jaw to the occiput, to
prevent the bone from falling forward. During the progress
of the cure, the patient should be supported almost entirely
upon liquid, or rather thin food. There has been an in-
strument invented for a fracture of this bone, when near the
symphysis, which answers very well ; but it requires a
different spring if the fracture be at the back part of the
jaw; a patient can eat as usual, after wearing it three weeks.
PATELLA.

The patella, from its situation, is very much exposed to
accidents, and hence it is often seen fractured : it is very
rarely the fractures are longitudinal, being mostly transverse.
The fracture lengthways has been known to occur in a few
instances. When it is broken in the latter direction, it will
unite again through the medium of callus, as the ends of the
bone can be brought sufficiently near for the vessels of the
bone to shoot into the effused - fluid, and deposit an earthy
matter.
When the patella is fractured transversely, the upper
portion is drawn up from the lower by the action of the rec-
tus and vasti muscles, to some distance between one and
six inches. This accident happens most frequently from
falling upon the knee, and occasionally (though much less
often) by the action of the muscles above mentioned alone,
in jumping down stairs, &c. In consequence of the great
separation which ensues, union is hardly ever effected by
bone, but by a ligamentous kind of substance, this being
supplied with vessels from the adjacent ligaments of the
bone or joint. The effect of which is, that the bone being
separated to a much greater distance than what it had been
before, a weakness is produced in the extremity, which is
seldom or ever recovered from, and owing to the weakness,
the opposite is required to exert more force in exercise, and
is often broken a short time afterwards.



408
LECTURE XXX111.

If, by way of experiment, to ascertain the mode of union,
and the advance made in it at different periods, the patella
of a dog be divided : in one week afterwards, the coagulum
of blood which had existed to this time, between the por-
tions of bone, is found to be absorbed, and a deposition of
lymph occupying its place : in two weeks, the union is com-
pleted by the formation of a firm but ligamentous substance,
uniting the separated portions.
Treatment.
In the first instance, the inflanimation must be moderated
by leeches, and a vinegar poultice for four or five days,
when bandages may be put on, but not before the inflam-
matory symptoms have subsided ; there is often tension and
swelling in the parts, so that bandages would be improper
until this time. When a roller is used, a cushion ought to be
placed over the upper portion of bone, and put the roller on
in the form of a figure of eight ; the crossing of the bandage
ought to be in the ham, the lowest portion passing over the
head of the tibia. The bone should not be forcibly pressed
down on the first application, but it must be got lower daily,
and the bandage must be gradually tightened to retain it in
the position it is pressed into. To prevent a stiffness in the
joint, passive motion must be used in four or five weeks after
the accident has happened. The patient may be placed on
a table with his leg hanging down, and he may be allowed to
swing it gently backwards and forwards at first ; the extent
of motion may be increased daily, which will prevent the
stiffness.



FRACTURE OF THE OLECRẠNON.
The treatment of this fracture must resemble that recom-
mended for fracture of the patella. When the arm is bent,
the detached portion will be found from two to two and a
half inches drawn up the arm by the action of the triceps
LECTURE XXXII.
409
extensor cubiti ; but if the arm be extended, the small piece
will be only half an inch distant from the ulna: the arm,
therefore, must be extended, and the portion of bone must be
brought as nearly into contact as possible, by a bandage
properly applied. Passive motion of the arm must be used
in this case likewise.
CERVIX FEMORIS.
This accident almost uniformly happens to old people.
It may be ascertained by the surgeon not being able to feel
a crepitus, and by the limb being shorter, from an inch to
an inch and an half, whilst the foot is turned outwards : this
sufficiently distinguishes it from dislocation. There is pain
experienced at the trochanter major, owing to the psoas and
iliacus internus muscles being put on the stretch. The thigh
bone can be brought forward towards the abdomen, which
cannot be done to any extent when the bone is dislocated.
If this fracture take place within the capsular ligament, the
person must remain lame for life, as the bone will never
unite again, and thus the patient is deprived of all power of
using it. However, if it be not very heavy, in the course of
time, he may be able to walk with the assistance of a stick :
but if this be not the case, he must resort to crutches.
If the fracture have happened on the outside of the capsu-
lar ligament, the bone will unite again, but the existence of a
fracture at this part is a very rare occurrence ; it is thought
not to occur from an accident. In fifty cases of fracture at
the cervix, in two only of these did it occur on the outside
of the joint ; a trifling circumstance will often produce this
formidable fracture, on account of the softening of the bone
at this part, which it universally obtains at an advanced
period of life. Various attempts have been made to cure
patients, by keeping the limb extended for a long time; but
none have succeeded in effecting a union.


52
410
LECTURE XXXIII.
ON COMPOUND FRACTURES.
These differ from simple fractures, in being accompanied
with a wound which communicates with the bone internally,
and with the air externally; so that if the external wound
do not communicate with the extremities of the bone which
is broken, it is not a compound fracture : therefore, large
wounds may be seen with fracture, and yet that fracture
still be a simple one. The process of union is similar to
that which takes place in a case of simple fracture, though
in the latter there is no discharge of matter ; but in the for.
mer there is this appearance-a cartilaginous kind of sub-
stance is deposited in the first instance between the broken
ends of the bone; this is partly taken up by the absorbents,
and ossific matter is replaced in lieu of it; granulations arise
very soon from the surface of this, and matter is thrown out
to protect them from the drying action of the air.
If a surgeon be called to a case of simple compound frac-
ture, he should place a little dry lint over the wound, in or.
der to arrest the flow of blood which may be issuing forth-
a little pressure will easily effect this. When the bleeding
has ceased, he is to make extension of the limb, in order to
bring the ends of the bone into direct apposition with each
other. If there be great resistance to this by the contrac-
tion of the muscles, and twitchings occur in these parts of a
spasmodic kind, he must desist, and the leg being placed
upon a pillow, must be wrapped in an emollient poultice for
four or five days, until the irritation has abated, when ex-
tension may be made without difficulty. But supposing this
degree of resistance is not mei with, extend the limb as far
as is desirable, then bring the edges of the wound into con-
tact as near as possible, and cover it with dry lint: the many
tailed bandage may be employed, and wooden splints,
which, though not so good as pasteboard in simple fracture,
yet are here much better in several points of view. The
position recommended in simple fracture, may be observed
generally in compound, though this must vary according to


LECTURE XXXIII.
411
the situation of the wound. On the outside and on the heel
will be the best positions for the leg, if circumstances will
admit of it ; but if the wound be on the outside, it may be
placed inwards.
It is very desirable to unite the wound in compound frac-
tures if possible by the adhesive process, by which the
fracture is changed into a simple one, capable of being cur-
ed in a fourth part of the time which would be required to
effect it, if the wound were to be filled by granulations.
This being the principal object, it must always be attempt
ed, unless the wound is accompanied with contusion of the
soft parts, so as to communicate with the bone. If there
be contusion, apply a poultice, in order to facilitate a quick
discharge from the wound. If the wound, which consti-
tutes a compound fracture, be caused by the ends of the
bone, or by a sharp instrument, it may mostly be united by
adhesion : adhesive plaster of any description should never
be made use of, but place a piece of lint accurately over the
wound, and when this becomes moist with blood, and dries,
it will effectually prevent the access of air; it should be as-
sisted by compressing the sides of the wound together by
means of a roller. I succeeded some time ago in the case
of William Samuel, a mason, working on an estate of the
Earl of Ashburnham : the compound fracture was of the


hæmorrhage had occurred. When the fracture was re-
duced, I attempted union by adhesion, and although the
DIFFICULTIES MET WITH.

The first difficulty is when the bone is much comminuted
or splintered, as here the danger will be increased ; by à
careful and cautious examination, this will be known; the
pieces thus detached or loose are to be removed, observing
the greatest degree of care, to avoid irritating the wound
412
LECTURE XXXIII.
more than is absolutely necessary. If these portions of bone
are not removed, they will excite excessive pain by irrita-
ting the wound, and will induce a copious discharge until
they are thrown out or separated, either by nature or art.
This being the case, I would advise that the surgeon should
never be backward in dilating the wound when the bone is
splintered, as the particles ought to be taken out. Large
portions of bone should not be taken away if the perioste-
um remain on them, as they will re-unite ; but if this mem-
brane be torn off, they will never again be consolidated with
the bone.
The second difficulty occurs when the surgeon is unable to
reduce the portions of bone which protrude through the op-
ening in the integuments : in this case the practitioner has
two remedies; the one consists in the dilatation of the
wound made, the other in the removal of the piece of bone
with a saw. The first plan is always to be preferred to
the second, and is most strongly recommended, unless the
periosteum is stripped off the exposed piece of bone, in
which case it must be taken off, otherwise it will exfoliate ;
and also it must be removed if the fracture be a very oblique
one,as the chances are against its retaining its vitality,and the
wound required to be made to replace it would be a large one.
The third difficulty is when any considerable artery is di-
vided. I think that reasoning as to this occurrence ought
not to be employed alone, but that experience must serve as
a guide generally. The anterior tibial artery has been di-
vided in a compound fracture, and two ligatures were put
on the vessel, and the man recovered. If the posterior tibial
be divided, it requires amputation to be performed, unless
when the fracture is low down. If the femoral artery he
opened in a compound fracture, amputation must be resorted
to as the only chance of saving life. If the brachial artery
be wounded, it is not necessary to remove the limb; the
surgeon should wait the event, after having secured the ves-
sel. In a case where the arm mortified up to the ligature af-
ter such an accident, amputation succeeded very well ; there-


LECTURE XXXIII.
413
fore, though we delay, no additional danger can ensue, and
a chance is afforded the patient of having his limb saved,
although I must admit the chance is a very hopeless one. If
the radical or ulnar artery were injured, I would not advise
amputation on any account.
Compound fracture occasionally extending into joints :-
When this happens into that of the ankle, the plan of treat-
age and constitution of the patient. These fractures will
the experience I have had, and from what I have been
taught, I think that it might be laid down as a general rule to
amputate almost immediately if the patient be advanced in
life; also if the person be at the meridian of life, yet if he
be of an irritable habit of body, or if his constitution have
been injured by intemperance of any kind, the limb ought
to be taken off. In these cases there has not one to my
knowledge recovered without amputation, and several have
fallen victims to the accident, even though the limb has been
removed. In young subjects, amputation is scarcely ever
required, as they will mostly do well.
The next circumstance which I shall advert to, as consti-
tuting an unfavorable symptom, is the appearance of a high
degree of inflammation on the limb three or four days after
the accident has occured. When the middle of the leg is
the situation of the fracture, the inflammation will sometimes
extend down to the foot, and upwards as high as the knee.
If an effusion accompanies this appearance as high up as the
groin,it generally portends death,and evinces the existence of
a high degree of constitutional debility, in which it will be re-
quisite to administer bark,wine, and a generous diet. Leeches
will be found serviceable applied around the wound, by un-
loading the vessels, and enabling them to regain their origin-
al tone ; after these, fomentations and poultices are to be ap-
plied, the latter of stale beer grounds, wine lees, &c. Lo-
tions also will be useful of the liquor. ammion. acet. and
spir. vin. rect. applied to the inflamed limb, whilst the poul-


414
LECTURE XXXUI,
tice is on the wound. At the same time opium must be giko
en freely, to allay the constitutional irritability, and a gena
tle diaphoresis promoted on the skin, by giving some saline
medicines. These several symptoms mostly take place in
those who have lived rather high.
Sometimes after a fracture, trismus will make its appear-
ance, in which case experience has taught, that the removal
of the cause by amputation of the limb will not induce a
relaxation of spasm. Tetanus is also frequently brought
on by a compound fracture, when apparently not a severe
one.
Amputation is occasionally required for the relief of symp-
toms occasioned by the existence of a portion of the frac-
tured bone in the wound which is become dead, and locked
in by the newly formed bone. Extensive laceration of the
muscles and integuments will now and then require amputa-
tìon; but it ought not to be done even if the laceration be
to a great extent, unless accompanied with contusion.
With respect to the question, whether it is best to ampu.
tate immediately, or wait until the irritable symptoms have
subsided, I have before decided, as far as I am capable of
judging, that D. J. Larrey's practice is the only one to be
pursued, which is, when such an operatian is deemed neces-
sary, to perform it as soon as possible.


( 415 )
LECTURE X X XIV.
ON SCROFULA.

The term scrofula is applied to a disorder of an inflam-
matory nature ; but differing from other inflammatory affec-
tions, in being accompanied with original debility of the
vascular system, and of the vis vitæ. When the different
phenomena are examined which occur in the progress of a
scrofulous malady, it is found that all the stages of inflam-
mation are attempted, but generally are imperfectly fulfilled,
in consequence of a deficiency of energy in the constitu-
tion.
When the adhesive process is going on, it is slow, weak,
and imperfectly accomplished ; when the suppurative, it
does not terminate in the formation of genuine pus, but a
curd-like matter is secreted, consisting of serum and coagu-
lable lymph : the ulcerative process is languid and tedious
in its progress ; and when suppuration takes place in an
absorbent gland, the progress is slow indeed.
Scrofula may be termed a disease incident to youth, and
persons under the age of puberty are most subject to it; al-
though there are exceptions to this rule (and in fact to every

416
LECTURE XXXIV.
general one that can be laid down), yet they are compara-
tively rarely occurring.
Scrofula is a disease having so many leading principles,
that it is well marked. It is considered a specific disease,
having the power of making the adjacent parts sympathize
in the same mode of action ; but parts are not affected in
the course of absorption. It cannot be inoculated. Mr.
Hunter tells us turkies and monkies are liable to this dis-
ease, and he saw white swellings in a young boar; so that it
would not appear to be confined to the human species.
The constitutions most susceptible of the disease, are those
of a delicate and irritable habit, who can neither bear fa-
tigue, heat, or cold, or the action of mercury. Those of a
fair complexion and light hair are more liable than those of
dark: the former do not appear to have much red blood in
them, the circulation being languid: this complexion, when
accompanied with thick lips, is indicative of a scrofulous
diathesis. Mr. Hunter never saw but one black in this coun-
try affected with scrofula.
The parts of the body most disposed to take on this dis-
ease, from apparently the slightest causes, are the lympha-
tic glands in every part of the body, more particularly those
which are superficially seated and most exposed to the
vicissitudes of the weather, &c., as those of the neck and
lungs; the joints, with the soft ends of the bones, and liga-
ments in the hands and feet; the knee, hip, and shoulder
joint, and the vertebræ of the back and loins, &c. The
skin has the least tendency of any part of the body to be
affected.
The first disease of this description which attacks chil-
dren, is an enlargement of the mesenteric glands, termed
tabes mesenterica ; next the absorbent glands of the neck be-
come affected and diseased ; then the joints are attacked
with it about the time of puberty. A person with a scrofu-
lous disposition is liable to phthisis pulmonalis, to psoas and
lumbar abscesses ; enlargement of the testes, &c. In old
age, an increase in the size of the prostate gland has been


LECTURE XXXIV.

said to be owing to scrofula, but there are some who do not
attribute it to that cause. Some of the before detailed coma
plaints may occur in the latter stages of life, but they are
much seldomer met with than at earlier periods.
The distinguishing characters by which the scrofulous
disposition may be known, are various. The skin is always
extremely thin, whether it is light or dark; the complexion
is mostly fair; the hair is often found to be lank and very
fine ; the pupils are dilated in a light, which would cause
their contraction in children of a healthy stamina, and these
children have a great degree of weakness apparent: the
ter surrounding them: the upper lip is thicker than natural;
the extremities of the fingers are enlarged, or chubbed as it
were; also when the fingers are long and thin. Children
that perspire much and have pimples making their appear.
ance on the face. All, or some of these appearances, mark
the scrofulous disposition in the constitution, and by their
presence a surgeon might form his judgment tolerably cor-
rect. Persons of this disposition are either very irritable,
or very indolent: in the first description of people, it is
a much worse disease than in those of the latter. When the
patient is of an indolent disposition and habit of body, it is
with difficulty cured; but in those who are irritable, the
complaint is continually flying from one part to another, and
is severe in its attacks, sometimes destroying life rapidly,
which it seldom does in the indolent class.
Much has been said, and many arguments adduced for
and against the opinion, that the disease is hereditary. Mr.
with respect to the disease, as it cannot with propriety be
termed hereditary, but there is scarcely any doubt but that
the disposition to the disease is transmitted from parents to
their children.
The predisposing causes to the complaint are those (let
them be of whatever kind they may) which induce debility
and a weakened state of the frame. Thus fevers of various
53
418
LECTURE XXXIV.

kinds may excite it, as that attendant on measles, small-pox,
scarlatina, or the mercurial fever. A great advantage is de
rived from the vaccine inoculation in this respect, as it leaves
much less disposition to scrofula than the variolus does, as
it does not excite that degree of fever which the latter mostly
produces. Want of nourishment is a frequent cause of the
disease in large cities, which is assisted very much by the
confined air which children are constantly in the habit of
breathing, and also by a deficiency of a proper quantity of
clothing. The exciting causes are not very obvious in many
instances.
The proximate cause of the disease consists in the original
formation of a weak arterial system, and the powers of this
system are much weaker in children who have a predispo-
sition for scrofula, than those who enjoy health: the blood
having as component parts a less portion of crassamentum
and coagulable lymph: a proof of this is frequently met
with in the dissecting room, for if it be wished to inject a
scrofulous child, the injection will never be found to have
passed into the extreme vessels, owing to the presence of a
quantity of blood in them, which the last effort of life had
not power of propelling as usual into the veins ; giving evi-
dence of the debilitated state of the vascular system. If, in
consequence of the existence of an inflammatory complaint,
blood be drawn from a scrofulous child, on examination it
will be found to possess a smaller portion of crassamentum
than that taken from a healthy child, and this will be also of
a looser texture : but this last is entirely an effect of the
weakened action of the arteries. The process of digestion
will be found not to be so well performed, and this is to be
all attributed to the want of good blood to fulfil the different
offices of the assimilating system : the debility extends also
to the absorbent system, as well as the vascular.
When called upon to treat this disease, a surgeon should
always have in view the original debility of the vessels, and,
as a priinary object, attempt to remedy this as much as is in
his power; and a second consideration is to form a strong
LECTURE XXXIV.
419

and more compact crassamentum. To effect both these in-
tentions, the surgeon has air and exercise, nourishment, and
tonic medicines. All these, judiciously combined, will tend
a great deal towards removing the original defective forma-
tion of the constitution. Practitioners in large towns and
cities have an advantage over those in the country with re-
spect to the first of these, by having it in their power to
send their scrofulous patients into a purer air than that in
which they reside ; but, even in the country, great benefit
is derived from directing the patients to change their place
of residence. It will be of service to all if they live near
the sea. It is almost absolutely necessary that they should
be placed in a warm atmosphere, as they will seldom re.
cover if allowed to remain in a cold, damp air, or situation.
Great attention should be paid to their taking exercise, and
that of a proper kind ; they must only use this whilst they
are free from fatigue ; and immediately upon their feeling
tired, they should desist. They should have their minds
exercised at the same time, and their spirits should be kept
up by playing with other children, and this will prove of
much more service than walking with their parents. They
should have the best nourishment, but this must not be giv-
en so as to excite fever. They must have very little veget-
able food: their diet should almost entirely consist of ani-
mal matter : they should be allowed to eat oftener, not less
frequently, and their food should not be taken in large
quantities at a time. Porter and wine must be given them,
unless the latter excites heat and fever, in which case it
must be laid aside. Different circumstances of the case will
require different medicines. The tinct. cinch. cum tinct.
ferri muriat. has been given with advantage ; but as it heats
and induces fever, the surgeon should have recourse to
other medicines. The tinct. cinch. cum acid. muriat. is most
strongly recommended, 3iss of the latter to 3ij. of the for-
mer ;-a tea-spoonful of it may be given two or three times
a day: it will be found very efficacious as a tonic.
420
LECTURE XXXIV.

When there is extravasation, and it is wished to induce
absorption, the hydrarg. muriat. cum tinct. cinch. will prove
serviceable. Indeed, in every case of this description, much
benefit may be derived from this medicine, particularly in
scrofulous enlargements of the mesenteric glands, and
glands of the neck, indolent enlargement of the joints, or
scrofulous ophthalmia. The quantity of the hydrarg. muriat.
should be small, the one-sixteenth part of a grain twice a
day will be enough. In this proportion it has not the spe-
cific effect of mercury, but acts merely as a tonic. The
mineral solution has been recommended, and certainly has
been given with advantage ; but those I have previously in-
serted, I should invariably give the preference.

ENLARGEMENT OF THE GLANDS.
The reason why the glands in the neck are most frequent-
Jy affected with scrofula, is on account of their being more
exposed to the vicissitudes of the weather : if they are cut
into, when in an indolent state, unattended with redness,
they will be found to contain a substance composed of co-
agulable lymph, imperfectly formed, mixed with a small
quantity of serum, which latter is increased if there be cu-
taneous inflammation to any extent. When the ulcerative
process comes on, the colour of the skin is changed to a
dark red, similar to that around venereal sores, and which
marks debility of the system. Sometimes the whole gland
will slough, but it is seldom that this takes place, as the
powers of the constitution will not admit of it. These glan-
dular enlargements sometimes destroy life ; in some, by the
pressure of the tumour on the larynx ; in others, the ulcere
ative process will surround the jugular vein, and cause an
absorption of its coats, so that the matter will pass into the
blood-vessels. A scrofulous enlargement of the bronchial
glands is sometimes attended with the formation of calcare-
ous matter. Dr. Curry has coughed up some of these con-
cretions.
HA
LECTURE XXXIV.
421
IUC
The treatment must be similar to that of inflammation
arising from any adventitious cause. A purgative of scam-
mony, rhubarb, and calomel, must be given, and this must
be repeated every fourth or sixth day, but not oftener.
Mercury should never be given in scrofulous affections with
the intention of inducing a mercurial effect. Evaporating
lotions should be applied to the enlarged glands, composed
of liquor. acet. plumb. dil. et spir. vin. If the inflammation
under this plan of treatment do not abate, a leech or two
had better be applied.
If suppuration, notwithstanding, should ensue, as soon as
a fluctuation is evident, the abscess must be opened by a
small incision made into the most prominent part of the tu-
mour. If the abscess be large, probably it would be of
more advantage to use a needle and thread as a seton to
evacuate its contents. If the skin be of a purple colour, and
a considerable extent of it is thin and diseased, it had much
better be allowed to break without opening, as in this case
it never heals kindly, and the surgeon may get into discredit
for having meddled with it. A common poultice may be ap-
plied to the part after the swelling has been opened, and af-
terwards a lotion of sulphuric acid upon linen. When the
ulcerative process has commenced, and the ulcer has de-
generated (as most scrofulous sores do) into an indolent one,
the ung. hydrarg. nitr. will be found advantageous, as it will
cause healthy, florid granulations to shoot out. The argent.
nitr. in solution, 3j. to 3j. may be applied once a day.
The black wash, covered with oiled silk, will be useful.
Bathing in tepid salt water, made in the proportion of an
ounce of bay salt to jbj. of water, may be had recourse to,
the heat about 94 degrees. The patient should remain in
the bath about ten minutes, and must not go to bed imme-
diately after using the bath, as perspiration is apt to weaken
him exceedingly if he do. The bath may be used three
times a week.



422
LECTURE XXXIV.
DISEASE OF THE MESENTERIC GLANDS.

The disease here has got the name of Tabes Mesenterica.
It is marked by an increased size of the abdomen, a raven-
ous appetite, and if the stools are examined, matter similar
to chyle will be found in them : this, in fact, is chyle, which
is not taken up by the lacetals, owing to an obstruction in
these glands. The ravenous appetite is owing to a deficien-
cy of nutriment, which the body endeavours to counteract
by stimulating the stomach to increased action, in conse-
quence of which, the demand for food is much greater than
if the system were supplied in a regular manner by absorp-
tion from the intestines. This disease sometimes occasions
ascites. Sometimes ulceration will take place at the navel.
Treatment.
* A purgative must be given occasionally of the pulv. scam-
mon. c. hydrarg. submur.—The hydrarg. muriat. has a great
and powerful effect upon this form of the disease, given in
small doses combined with a tonic. The diet should be
nourishing, and the patient, instead of being curbed in the
indulgence of his appetite, as usually is advised, should be
allowed as much as he can possibly eat, on account that the
system demands this additional supply. A plaster must be
applied to the abdomen: the empl. litharg. will do, but if
there be any pain, the empl. sapon. may be substituted.
Should dropsical accumulations come on, and the collection
of water is so great as to require it, the operation of para-
centesis must be performed as in the adult subject.
DISEASES OF THE JOINTS.
These are generally denominated White Swellings, from
the integuments on the surface preserving their original un-
inflamed colour. Scrofulous diseases of the joints are divi-
ded into three stages, the adhesive, the suppurative, and the
LECTURE XXXIV.
423
ulcerative. Similar to the enlargement of glands, the dis-
ease in these parts is very slow in its progress, remaining
for weeks, and sometimes for months in one stage ; and
when it has arrived at the suppurative, it still evinces the
same degree of languor as when it attacks the glands: when
ulcerations ensue, the wounds are uncommonly slow and te-
dious in healing.
Symptoms.—Scrofulous enlargement of a joint is seldom
attended with much pain at the commencement; the patient
complains of a sense of stiffness in the joint, and on minute
examination at the affected part, the limb will be found
shorter : sometimes, however, it will be found even longer
than its fellow. Occasionally, the limb will be in a slight
degree painful, coming on at intervals ; yet this sympton is
by no means a regular attendant upon the disease, and most-
ly occurs in those persons who are of an irritable disposi-
tion, and most commonly in affections of the hip-joint. In
this state of stiffness and enlargement, with pain at intervals,
the disease continues for years, the patient suffering very
little either locally or constitutionally, further than what I
have described; then, suddenly, and most frequently in the
spring season, the disease takes on a more active state, the
pain becomes violent, the size of the limb much increased,
and a general sympathizing pain and uneasiness pervades
the whole frame, so as to affect the constitution; the rest is
disturbed, and the appetite and strength decrease. From
these symptoms existing, a person would be led to imagine
that matter will be discharged almost immediately ; but this
is rarely the case, as the joint will frequently lessen very
much, and many weeks will elapse previous to the matter
making an outlet, and then two or three inches from the
seat of the disease, having insinuated itself between the
muscles and integuments. Not unfrequently a fluctuation is
perceptible to the touch, resembling an increased secretion
of synovial fluid ; at length inflammation again ensues, and
ulceration commences. If the opening did not take place
at some distance from the cavity of the joint, it must neces-

424
LECTURE XXXIV.
sarily follow that life would be but short, unless amputation
was had recourse to: this being the case, the inflammation
set up in the joint is but partial. When the matter has been
evacuated, it mostly occurs that the urgent symptoms will
abate, and the patient remain in the same state for years,
the ulcers continually discharging: the limb remains useless
until anchylosis supervenes, which is caused either by the
deposition of a gelatinous substance, or an osseous one, or
by a direct communicatton between the extremities of the
bones. When the ulcerative process commences in the joint,
what are termed hectic symptoms come on, and under these
circumstances the life of the patient is at stake, unless the
limb is removed, when it is possible to do so : yet this is by
no means had recourse to so frequently as it formerly was,
even within these few years : indeed the operation is never
resorted to, unless the constitution of the patient suffers so
much that his life is brought into imminent danger by the
hectic fever. When the disease has ran to its greatest
height, it will mostly abate, and in the course of time anchy-
losis terminates the mischief, which preserves the original
limb, instead of compelling the patient to use an artificial
one; which is more advantageous to the patient in every



tated, the disease attacks other joints.
.
APPEARANCE OF THE JOINT ON DISSECTION.
If the limb of a person be dissected who has suffered from
this disease, under the skin there will be found a very large
quantity of fat, and this is found, though the other parts
of the body are very spare : this appearance arises from a
greater determination of blood being made to this part, in
consequence of the irritation and inflammation present. The
ligaments are found very much thickened, which is produ-
ced by the same cause. The membrane, lining the cavity
of the joint, is undergoing the inflammatory process, also
the suppurative and ulcerative; granulations exist on some
LECTURE XXXIV.
425
parts of it, and ulceration going on in others; so that the
principal seat of the disease is in this membrane, and the
ligaments are thickened from it. Next, the cartilaginous
substance covering the extremities of the bones becomes ab-
sorbed ; and lastly, the bones themselves are acted upon by
the absorbent vessels; the inflammatory symptoms present,
stimulating these vessels to an increased action, and not un-
frequently foramina are formed in the bone by the action of
these. It may be remarked here, that when the epiphyses
of the bone separate, they will convey the same sensation
to the feel as iſ a fracture of the cervix of the bone had ta-
ken place, and many clever surgeons have been deceived in
this manner.
Causes. These are generally attributed to some acci.
dent, but commonly they are spontaneous, or arise from such
slight accidents, as would in a healthy constitution pass away
without being productive of any mischief : for instance a
child being compelled to walk a considerable distance; this
will bring on so much inflammation in the membrane lining
the cavity of the joint, that on the succeeding day, the little
patient is rendered unable to move, without causing a great
degree of pain.
Treatmeni.

The first and most essential circumstance to be attended
to, is placing the affected limb in a perfect state of quietude,
and all motion should be strictly prohibited; for, without this
abstinence from exertion of the part is observed, it will be
almost impossible to effect a cure: in fact, it is absolutely ne-
cessary, for if the synovial membrane be pressed upon by
the extremities of the bones, the irritation resulting from
this pressure will be a constant source of inflammation in this
membrane. The next object to be attended to, is the keep-
ing up a constant discharge from the skin lying above the
diseased joint, and this by inducing a regular determination
of blood to the surface, the inflammation going on in the cav-
ity of the joint will be materially lessened by this obstruc-


426
LECTURE XXXIV.
tion of a quantity of blood, which would otherwise be de
termined there. To effect this desirable intention, one of
the best applications will be found in the liniment. ammon.
cum. antimon. tartar. 3j. to 3j. used twice a day, it will pro-
duce an eruption on the part it is applied to, after it has been
used two or three days, similar in appearance to that result-
ing from variolus matter to the constitution : but it will dis-
appear in a few days, unless the liniment is again applied,
which ought to be done. Several eminent practitioners ap-
pear to think very highly of, and strongly recommend, this
plan of treatment, in preference to any other. A vinegar
poultice will produce a similar effect to the liniment: the oc-
casional use of it will effect permanent service. In addition
to either of these plans, purgatives administered once a
week, or every ten days, or as often as they are found ne-
cessary, will be found beneficial, as the pulv. scammon. et
hydrarg, submur. If there exist a great degree of consti-
tutional irritation, saline medicines, with opium, must be giv-
en; but, if this should not be the case, the tinct. cinchona
cum hydrarg. muriat.; vel acid. muriat. or natron united
with the cinchona will be found most serviceable. These
are to be used in incipient states of the disease, often with
the greatest advantage. If the parts are considerably thick-
ened, the latter medicines will be found peculiarly of use.
Great benefit is frequently derived from giving the mistur.
imyrrh. cum ferri, and this is more particularly advanta-
geous in those females who are attacked with the disease
about puberty. If there be a fresh accession of inflamma-
tion threatening suppuration, the application of leeches must
be had recourse to ; more active purgatives administered,
and more frequently; fomentations, or the hot-bath, made
use of every night, of the heat of 95 or 100; blisters ap-
plied and kept open by the ung. sabina ; to effect this latter
purpose it is necessary to peel of the cuticle, otherwise this
effect will not be produced. As blisters are generally very
inconvenient to the patient, and as they likewise produce
- very considerable constitutional irritation, issues may be sub-



LECTURE XXXIV.
427
stituted; but these should not be placed very near the joint,
on account of inflammation, consequent upon the insertion
of them, often extending to the synovial membrane, and thus
being the cause of fresh distress instead of relief, so as to
retard the cure. Many practitioners apply caustic, so as to
cause afterwards a permanent discharge. But, supposing
ulceration has taken place, and the matter has been dis-
charged, the treatment required is still to excite external in-
flammation, though in a less degree: to effect this purpose,
place blisters on the opposite side of the joint to that where
the ulcerative opening exists. Issues may be made use of
with a similar intention, and if the joint be not very much
inflamed, the injection of some fluid into it, will be found of
great service : for this purpose a solution of nitrous acid gtt.
vj. to 3iv. of aqua, will be found useful: this stimulates the
vessels, and assists the formation of granulations, and at the
same time, by its chemical properties, it expedites the pro-
cess of exfoliation.
The disease very generally ends in a more or less degree
of anchylosis. Sometimes the deposit is merely gelatinous,
at others, a deposition of earthy matter takes place. If it be
the first or adhesive kind, as it is termed, there is mostly
some slight degree of motion remaining in the joint, and un-
der these circumstances, a hope may be entertained of its
returning to its former extent. It is by the treatment of such
cases as these, that Mr. Grosvenor, of Oxford, has obtained
such merited reputation. It is by friction he succeeds; one
hand is rubbed up, while the other passes down on the limb,
both are in motion at the same time; this plan ought to be
persevered in for at least half an hour daily. A little chalk
or oil on the palms of the hands will prevent excoriation of
the skin on the joint. If it appears from the degree of in- .
flammation which had taken place, a complete anchylosis
may ensue, it is right to consider what degree of flexion or
extension the limb ought to be placed in, in order to enable
the patient to derive the most efficient services from it, in its
fixed state: if it be allowed to remain straight it will be ex-


428
LECTURE XXXIV.
SC
tremely inconvenient to the patient, for if the disease have
existed in the knee-joint, he will be compelled to take a cir.
cuitous step, and if in the elbow, he will not be enabled to
assist himself with that limb in any way whatever ; therefore,
considering these circumstances, rather a bent position will
be the best.
DISEASE OF THE HIP-JOINT.
There is some degree of variation in the symptoms which
generally attend a scrofulous affection of this, and the other
joints of the body. The hip-joint is rather a frequent seat
of the disease. The surgeon may detect the existence of
this complaint by the following symptoms and appearances ;
at the commencement, the patient will mostly complain of a
great deal of pain on the inside of the knee of the affected
side, though this is not always attendant : on examining the
knee, no appearance of disease is present, and this being the
case, he is immediately led to suspect that the affection is
situated in the hip, and a surgeon knowing this, who hears a
patient complain of considerable pain towards the knee,
will be suspicious of the real cause. The mode of ascer-
taining the disease is this ; desire the patient to raise his
knees alternately to the abdomen, that limb which is affected
will not be completely elevated as the other, and its eleva-
tion will be attended with some degree of pain : the patient
should then rotate his limb, outward or inwards, which on
the diseased side he will not be able to do : then placing the
patient on his feet, a line should be extended from the cleft
in the nates to the spine of the ilium; this being done, it will
be found, that the distance is much greater on the diseased
side than it is on the other : the nates also, on this side, are
more prominent to the eye: the leg also, on that side, is
much larger ; this is in some measure the case, in conse-
quence of effusion into the cavity of the joint, but much of
this appearance will depend upon the situation of the body


LECTURE XXXIV.
429
when examined. After the disease has been present some
time, the affected limb will be found shorter than the other,
arising in consequence of the absorption of the acetabulum
and head of the os femoris : this action of the absorbents
will sometimes go on until an opening is formed between the
cavities of the acetabulum and the pelvis. Cases have oc-
curred where three abscesses have made their way and dis-
charged themselves through the vagina, and yet the patient
has recovered. This has also happened when they have
burst into the rectum : but in the only instance I recollect
detailed, the patient died.


The Treatment.
The application of a perpetual blister, or an issue, is re-
quired in this disease, but I should prefer the latter. The
hip-bath, or a large bladder filled with hot water, and ap-
plied to the adjacent parts for a considerable length of time,
will afford temporary relief, at the same time pursuing the
mode of cure by medicines as before noticed

DISTORTED SPINE.
This was first accurately detailed by Mr. Pott. The dis-
ease of the spine, by which a curvature is formed, arises in
consequence of the absorption of the bodies of the vertebræ,
so that the spinous and articulating processes are left in statu
quo, forming the posterior projection, which mostly takes
place ; unless the absorption goes on more laterally, when
the distortion is in that direction. The degree of projection
will depend on the number of vertebræ affected ; occasion-
ally only one will be diseased: at other times many, and
sometimes as large a number as seven, are affected. It com-
mences in the inter-vertebral substance, extends to the
bodies of the vertebræ, and ultimately destroys them; the
consequence of which is, that pressure is made upon the


430
LECTURE XXXIV.
spinal marrow, which will have the effect of a ligature, and
produce a paralytic affection : but this differs materially
from a common paralysis, as the irritation produces a rigid
contraction of the muscles of the lower extremities, and this
without any absorption of the bones of the spine ; this is
caused by the effusion of coagulable lymph, in consequence
of injuries particularly occurring: if the dorsal vertebræ are
the seat of this disease, the bladder is paralyzed, so that a
retention of urine ensues ; the rectum also loses its power,
and the fæces are expelled by the peristaltic motion of the
intestines alone : if the injury happens to the cervical ver-
tebræ, the arms, either partially or entirely, lose the power
of action. This disease will very frequently continue for
years, gradually taking on an adhesive process, and ulti-
mately getting well, by allowing the adjacent vertebræ to
come in contact with each other.
It is strongly recommended, by surgeon's instrument-
makers, and even by some of the profession, to have an ap-
paratus so fixed as to keep the body of the patient in a natur-
al position until anchylosis is formed. This practice is very
wrong, as it is impossible for anchylosis to take place if the
vertebræ are prevented from coming in contact. This dis-
ease often ends fatally, by proving the cause of psoas ab-
scesses.
Issues, in the treatment of the disease, are to be principal-
ly depended on, with the same precautions as have been
before recommended in the varieties of scrofula. Rest is
at the same time to be advised.


ON PSOAS AND LUMBAR ABSCESSES.
These diseases properly follow that which I have last
described, for they are quite of the same origin ; they are
beginning in the ligaments of the spine, in consequence of
inflammation, or of the scrofulous disposition taking on a
diseased action : matter is effused between the ligaments and
LECTURE XXXIV.
Ć 431
the bone, and this fluid is taking its course in the direction
of the psoas muscle to the upper part of the thigh ; or if the
pus is seated on the lateral parts of the spine, it passes back-
wards by the side of the vertebræ, so as to appear upon the
loins ; but wherever the matter makes its appearance, the
diseases are one and the same. The symptoms are but few:
it commences with a pain in the loins, and which prevails
for four or five months before there is any appearance to
announce the nature of the complaint in a precise manner.
The patient complains of a stiffness in the part, so as to
have a difficulty in stooping. The pain often extends down
to the thigh of the diseased side in the direction of the cru-
ral nerve : but if it is a lumbar abscess, the pain is experi-
enced more in the sciatic nerve. After these symptoms
have continued for a time, a swelling is perceived in the
groin, in the situation of a common bubo. It first appears
on the inner side of the femoral vein, between it and the
pubes, not larger than a walnut : when in this state, it is
very easily mistaken for a femoral hernia, it being exactly
in the situation of this disease, and what still tends further
to mislead, is, that on putting the finger upon it, and desir-
ing the patient to cough, the situation will be precisely the
same as if a portion of intestine were protruded. The dis-
crimination is so difficult sometimes that a surgeon of great
experience has recommended a truss. When it appears at
the groin, it gradually extends downwards under the fascia
lata of the thigh, and by this means is confined, while a
femoral hernia is most invariably tilted back over Poupart's
ligament; and this difference between them is a mark of
distinction : but in addition to this, it will be found never to
disappear when the patient is in a recumbent posture, nor
can it be made to return as in a reducible hernia : but if,
added to these, inquiry is made, if there has been long
continued pain in the loins, it is scarcely possible to mistake
the nature of the disease. Femoral hernia has been open-
ed, on the supposition of its being a psoas abscess. As the
swelling increases, it extends still farther down the thigh,



432
LECTURE XXXIV.
and sometimes as far as one-third of its length, or more
so that a person would scarcely conceive the disorder to
have its origin in the abdomen. After being confined under
the fascia lata for some time, the matter causes the absorp-
tion of it, and appears immediately under the skin, and
here an evident fluctuation will determine the nature of the
complaint, for whilst it remained confined under the fascia
lata, the Auctuation was indistinct. For a short time the
skin that covers the tumour retains it natural colour, but it
changes as the ulcerative process of the integuments comes
on. At length a very small opening is formed, which al-
lows the matter to escape, though not all at once; it is pre-
vented from being completely emptied, by small portions of
coagulable lymph, which are mixed with the matter, and
plug up the opening from time to time : this is a beneficial
effort instituted by nature, as otherwise fatal consequences
would mostly ensue if the cavity were quite emptied at
once. During the time that the abscess is forming, the con-
stitution of the patient suffers but little, and even though a
pint of matter may be collected, he may not have experi-
enced a single rigour : perhaps, he might have perceived a
slight chill, but not so great as to produce any alarm in his
mind, or cause him to relax from his usual occupation; and
yet, this very man, about four days after the matter has
discharged itself, if it be allowed to flow off voluntarily, will
have violent constitutional irritation produced in the form of
severe hectic symptoms, and these will mostly destroy life,
in the course of two or three weeks most probably, though
the length of time will vary according to circumstances.
These abscesses have been known to continue discharging
for years, and this occurs more frequently by far in adults
than in children.
On examination after death, the disease will be found to
have commenced in the ligaments of the spine : they are
found thickened, and the vertebræ absorbed, in consequence
of pressure made upon them. The matter makes its way
between the anterior ligaments of the spine and the bodies




LECTURE XXXIV.
433
of the vertebræ until it reaches the psoas muscle, which,
more regularly giving way to pressure, becomes the con-
ductor of the matter externally, and the principal part of
this muscle becomes absorbed in the centre, so as to form a
tube, and prevents it entering the cavity of the abdomen,
which, if it were to do, would cause the destruction of life
in a very short time. It takes the course of the psoas until
it arrives at its tendon, when it perforates the anterior side
of the muscle close to the tendon of the external oblique,
and then makes its way under the fascia lata. The psoas
abscess does not always make its way by the inner side of
the femoral vein, as it is sometimes found on the outer side
of the artery.
The lumbar abscess does not always originate from the
anterior ligaments of the vertebræ, but now and then from
a lateral ligament under the spinous processes; this species
of the disease is rather more rapid in its progress than that
taking the course of the psoas muscle.


Treatment,
The first thing requisite to be done is the insertion either
of issues or setons directly over the seat of the disease, ft
the purpose of producing external irritation, as well as dis-
charge. When it has made its way into the thigh so that
the abscess may be opened, it may either be dové by tap-
ping, or by a lancet, in the manner so strongV recommend-
ed by Mr. Abernethy. The thin skin, muated directly
over the most prominent part of the mour, is not to be
chosen for the introduction of the insedment, but some part
where the skin be not so much rected by the disease; for
if the opening be made when the skin is very thin, it will
seldom unite as readily as ; desirable. The matter is to be
discharged once in abow ten days or a fortnight : this de-
pends upon the quarity that was at first discharged. Thus,
if a pound and analf be discharged on the first opening, it
must be repeard when half a pound is collected in the cyst,
55
434
LECTURE XXXIV.
and so on, diminishing the proportion, or rather collection,
gradually. The whole contents of the abscess should never
be discharged at one time, but in proportion to its size and
quantity contained, will be the rule to evacuate it, and the
discretion of the surgeon must decide how much will be ad-
visable to take off each time. Sometimes the matter will be
collected in a much shorter time than at others : the dis-
charge still proceeds from the loing, and the surgeon is not
to be discouraged it this continues for years, as it has often
proved the case. A very striking case may now be seen of
the continuance of this disease in the daughter of the assist-
ant to that truly respectable and scientific surgeon, Mr.
Francis, of Bexley.
As the discharge is nothing inore than an effect of a dis-
eased action set up, it is necessary that the complaint in the
spine should be equally attended to as if there were no dis-
charge ; and if the practitioner Jo not succeed in preventing
the discharge from continuing a great length of time, yet he
might be able to prolong life to a great extent, when com-
pared with the rapid fate of those who are allowed to have
the abscesses trusted to nature alone.
The opening made in the abscess should never be made
large and the skin should be drawn aside previous to punc-
turing he cellular membrane or substance interposed, after
having pt.otrated the skin. Pieces of bones have been seen
to exfoliate imm the spine in this disease, and then the pa-


tarded the cure, by keeping up the flow of matter.
The Treatment
Of Lumbar Abscesses will'e exactly the same as Psoas in
every respect. Constitutiona. remedies should be admin-
istered in both cases.
SCROFULOUS OPHTHALM.
This differs from the common species of oxhthalmia in be-
ginning with a small ulcer in the transparent wonea or tu-
LECTURE XXXIV.
435
nica conjunctiva. The opacity that arises from ulceration
will ever remain ; but if it be the effect of scrofulous inflam-
mation, it will go off. These ulcers get irritable, and cause
considerable inflammation on the eye.

Treatment.
Aperient medicines are here requisite every fourth or
sixth day. The hydrarg. muriat. given in the quantity of
one-sixteenth or one-eighteenth part of a grain at a dose is
eminently serviceable : it may be combined with a tonic ; it
should not be given in large doses, otherwise it will affect
the mouth, which must be cautiously guarded against. The
local treatment consists in an application of a solution of the
argent. nitr. made weak. The black wash, witk or without
the tinct. opii, is used according to the degree of pain attend-
ant upon the disease. The vin. opii is used with similar
intentions, but many consider it not so beneficial as the
spirituous, and the late Mr. Saunders coincided for one in
this opinion ; his opportunities of using it having been very
numerous.
LIPPITUDO.
This means a scrofulous inflammation, taking place in the
eye-lids, and most frequently attacking the uppt. The
secretion natural to the parts is changed in its naure, which
glues the eye-lids together during sleep. Tb; eye-lashes
are often separated by ulceration, which attacks the edges
of the eye-lids. The best remedies for thise, are the ung.
hydrarg. nitr., or a solution of the hydra g. muriat. in aqua
calcis. A small blister may be applies to the temples. The
constitutional remedies are the same as have been recom-
mended generally in scrofula.
436
LECTURE XXXIV.
SCROFULOUS TESTES,

Is an affection which generally takes place from the severic
teenth to the twenty-second years of age, but the disease
has been seen in a boy eight or nine years old. It mostly
appears in the form of a tubercle at the anterior part of the
epidydimis, though sometimes it affects the body of the
testes. Dr. Haighton, on dissecting a patient, who died of
this complaint, found the same kind of scrofulous matter in
the vesiculæ seminales, as was contained in the epidydimis.
Of all the scrofulous affections, this most readily yields
to the exhibition of mercury. Calomel, given internally,
and the ung. hydrarg. c. camph. rubbed into the scrotum,
are mostly employed. The disease will often attack both
testes at once, yet very little pain will be produced, al-
though they are very much enlarged. If matter torms in
the testis, the function of it will certainly be destroyed.

ON RACHITIS.
Rickets is generally considered a scrofulous affection, but
it occurs at a period prior to this disease showing itself. It
kone of the earliest diseases which attacks the bones, and
is Dostly accompanied with an enlargement of the mesen-
teric glands; in this way, the due degree of nourishment is
not traışmitted to the system ; which will have the effect of
rendering the constitutional disease much worse than it
would othrwise be. The blood, by the existence of these
enlargements of the glands, is prevented from receiving a
due quantity of osseous matter from the food taken into the
stomach, and th, bones are consequently deficient in their
solid texture : they are rendered so weak as to be unable to
support the weight of the body, and joints are frequently
forming in the middle of cylindrical bones. I have seen a
specimen of a child who ħad two additional joints in each
os humeri, and one in each as femoris. All the natural
LECTURE XXXIV.
437
joints are very much enlarged: the wrist is remarkably so.
The head is also undergoing an alteration in its shape ; it is
much enlarged; the forehead is very prominent, and the
fachial bones distorted in some degree. The head appears
of a square figure, and is flattened at its vertex: In propor-
tion as the head is large are the intellects of the child more
acute. The bones of the cranium not affording the usual
resistance to the growth of the brain, it increases more
rapidly in size than in those who are healthy. The spine

curvations, so as to preserve the perpendicular state of the
and this occasioning a projection of one of the shoulders, the
pelvis is altered in its shape, the pubes approaching each
other, and the sacrum much incurvated; the thigh, the tibia
and fibula, as well as the radius and ulna, are all bent for-
wards. Those who are the subjects of rickets when they

others at the adult age ; and those persons that perform such
great feats of strength are generally distorted, and have been
suffering from rickets in their younger days; the reason of
this is evident; the bones being deprived of their proper
nourishment, and absorption going on in the usual manner,
a spongy texture is formed, in which state, by the action of
the muscles, the bones become more curved than in a healthy
person, and when the patient regains his strength, there is a
greater surface for the deposition of earthy matter.

Treatment.
The object that a surgeon would have principally in view,
is that of affording the body the best nourishment, and of
· giving the arteries an additional power of action. The food
should be stimulating, the meat should be so prepared as to
admit of easy digestion ; the diet should be animal food and
milk ; ale and wine should be allowed ; very little or no
vegetable matter should be permitted. The three circum-
stances to be recommended, are, air, exercise, and a nour-
438
LECTURE XXXIV.
ishing diet. Friction upon the limbs will be of considerable
advantage, in assisting the powers of the circulation by
mechanical aid : it may also be serviceable to bathe the
body in cold salt water twice daily ; the little additional
stimulus the salt gives, will assist in promoting the circula-
tion. The child should be afterwards well rubbed over the
whole surface of the body. It will be right to administer
purgative medicines occasionally, and the strength of the
system must be renovated by the exhibition of tonics and
chalybeates. When patients have, by judicious means,
acquired some additional strength, then, and not till then,
recourse may be had to instruments for the support of the
frame.
Rickets is a disease entirely of children, but there is a
disease attacking adults very much resembling it, termed
Mollites Ossium. It is very seldom met with: the bones are
extremely light and spongy, owing to constant absorption,
and not a due degree of deposition. This cause is not elu-
cidated, nor has the treatment been successful.




( 439)

LECTURE XXXV.
ON TUMOURS.

THE STEATOMATOUS TUMOUR,
Is generally said to be encysted, but it is not so ; the charac-
ter of it is lobulated, consisting of lobes united together by
cellular membrane. The best mode of ascertaining pre-
cisely its nature is to tighten the skin on its surface by pres-
sing the sides of it with the hands, which forces the contents
of it upwards, when the lobulated appearance may be per-
ceived on the surface of the skin :-an obtuse fluctuation
will also be felt, as it is, when composing part of the living
body, of a fluid nature, containing animal oil. It is quite un-
attended with pain, and only inconvenient from its bulk ;-
but when the ulcerative process commences, these tumours
become painful. The size of them is various ; they will ac-
quire, if allowed to grow unmolested, an enormous magni-
tude. One, weighing fourteen pounds ten ounces, has been
removed from the breast : another, fifteen pounds, from the
back ; but the largest ever extirpated, was from the back,
weighing twenty-eight pounds. These excessively large

440
swellings are mostly situated upon the integuments of the
back. Their growth may be retarded by pressure, the effi-
cacy of which is finely illustrated in the slow advance in
size of these tumours, when seated, or originating under the
fascia. A roller, if judiciously applied, will prevent their
gaining any great size for years : if, however, on account of
their bulk they become inconvenient to the patient, it is much
better to remove them. When they are found on the back,
on the shoulders, on the nates, or thighs, the operation will
be attended with little hæmorrhage, as the vessels supplying
them are small. If the swelling be very large, it will be ad-
visable to remove a portion of skin, by making an oval in-
cision, carrying it through the covering, and down to the cel-
lular membrane : a hook must be introduced into the coats
of the cyst, and it must be drawn out as much as possible,
at the time dissecting around it. If the swelling be not very
large, securing the vessels may be delayed until the tumour
is entirely removed; but if it have attained a large size, it
will be found better to tie the arteries, as they are divided in
dissection. It will generally be found that a patient will
suffer very little constitutional irritation after the removal of
a swelling of immense size of this kind, it being situated in
the cellular membrane, and being a growth of the adipose
cells.
A second kind of tumour is the Encysted, which has been
not unfrequently termed Atheroma or Melviris, from its con-
taining a substance resembling curd or honey. It is formed
by the dilatation of a single cell of the cellular membrane,
which has its communication with the other cells obstructed;



gradually enlarges in size. There is very little danger at-
tendant upon an operation in this species of tumour. When
uninflamed, it contains a curd-like substance, but when the
least active inflammation has existed in the vessels entering
the cyst, in most instances a serous fluid will be effused, mix-
ed with flakes of coagulable lymph. If this description of
tumour should undergo the suppurative and ulcerative pro-
LECTURE XXXV.
441
cesses, it generally will not heal, and here caustics must be
had recourse to,in order to remove the cyst. The distinguish-
ing character of this particular swelling, is its being a cir-
cumscribed tumour, arising evidently from the cellular sub-
stance, with well-defined edges, or boundaries. This is not
the case in common abscess, as in this case the swelling is
extended into the adjoining cellular substance, and does not
terminate so abruptly. There is a slight degree of fluctua-
tion perceptible, and it is unattended with pain, unless at the
time that it is approaching suppuration. The vessels enter-
ing it are mostly small in diameter, and it is frequently the
case, that it is lined internally with a cuticle, from which hairs
are produced, but these productions of the cuticle in this
part, are different to those hairs growing on the surface of
the body, on account of their not having any bulbs. In per-
forming an operation, for the removal of a tumour of this
kind, there will seldom be any necessity for removing a por-
tion of the superincumbent integuments, as it never arises to
any great magnitude. If the encysted tumour be the pro-
duce of parts, the removal of which would be attended with
danger, from its vicinity to large blood-vessels, it will be bet-
ter to adopt the plan of opening it, and evacuating its con-
tents : and here some stimulating applications will be requi-
site, in order to induce the cyst to heal. A poultice is to be
applied for the three or four days after an opening, then
dress the inside of the cyst with the ung. hydrarg. nitr. rubr.
This method may be pursued when the swelling is seated on
the face, on account of its producing a less degree of de-
formity than if it were removed by the knife. These cysts,
if very large, may also be treated as an hydrocele, by injec-
tion, zinci sulph. 3j. aquæ rosæ ). M. This application
will induce the adhesive imflammation in the cavity of the
cyst. Some persons appear to have the disposition to form
a great number of these tumours, being generally seated on
the scalp. When on the integuments of the head, the cyst is
found to be very thick.
22 : 56



442
LECTURE XXXV.
ABSORBENT GLANDULAR TUMOURS.
The absorbent glands will not unfrequently become en-
larged, in persons who are apparently healthy in every
respect. Cases have occurred of this kind, where they have
been increased to such a degree as to destroy the patient ;
but this does not often take place. The character of this
swelling is, that it resembles the scrofulous enlargement of
these glands; but in the affection I am now writing on, the
glands affected are rather harder, and have the feel of a
scirrhous tumour. They are very moveable, and not at-
tended with pain. They will continue gradually enlarging
for a number of years, without inducing any unpleasant
effects, but when they inflame, ulcerate, and their contents
are discharged, they will then produce such a degree of
severe constitutional irritation that the patient will not un-
frequently sink under it. The situation which they mostly
occupy is the neck. They should be extirpated previous
to the accession of the inflammatory symptoms. As these
are originally contained in the cellular membrane, when
the glands become enlarged, this is condensed around them,
and forms a cyst. When they suppurate the content is not
pus, but appears similar to rice in texture, contained in a
small bag. Danger exists in attempting the removal of
these tumours, from their connexion with large blood-ves-
sels, when seated about the neck : therefore, a surgeon
ought not to operate, unless the situation which they are
placed in is a favourable one for using the knife, without
endangering adjacent parts of importance. Sometimes they
lie so contiguous to the carotid artery, that this will be laid
bare if they are removed. A case of this kind occurred to
Mr. Hunter, who removed a tumour from the throat, weigh-
ing fifteen pounds, growing from among the arteries in that
part. A surgeon, who had been previously consulted by the
patient, told him, it must be either a madman or a fool who
would attempt its rernoval; but Mr. Hunter was neither,
and the man recovered very well, although the carotid was



LECTURE XXXV.
443
thus completely exposed. In removing a tumour of this
description, cut down as close as possible to the cyst, and
in the dissection, carry the knife directed towards the swell-
ing, lest it is plunged among the vessels ; at the same time
drawing the cyst out as much as possible, by means of a
hook. Each of these tumours has a considerable artery en-
tering it, which supplies blood. When extirpated, they
never return again.

FUNGUS HÆMATODES.
In these Lectures, I have noticed this disease several
times : I shall offer a few further observations on it. It was
not unknown to Mr. Hunter; he describes it under the ap-
pellation of fungated ulcer. Since his time it has been no-
ticed by several writers. It has its commencement in a
pulpy, swelling, often seated among tendons, which would
induce an inexperienced surgeon to suppose it a ganglion.
When it is opened, it contains nothing but grumous blood,
and soon after, a luxuriant fungus will be found to arise
from its internal surface. Within my own knowledge, a
respectable woman applied to a surgeon of some experience,
respecting a small tumour she had on her leg ; he said, You
live too far off, but if you will come and board near me, I
will cure your leg. She did so.' He prematurely, and most
imprudently, punctured it, from which time she dated the
signature of her passport for another, and, I trust, a better
world. A more deplorable case I never witnessed, even
among the wards of the London hospitals, where diseases
are seen of the most malignant description. The fungus
• that arose was of a sponge-like kind, containing among its
interstices a fluid which flowed on a slight degree of pres-
sure being applied : previous to the opening, the integu-
ments covering it, were of the usual colour, a light blue, and
the veins could be seen through them much enlarged. In
this stage of the disease, little pain was experienced; but


444
LECTURE XXXV.
when an opening was made, and the internal surface had
ulcerated, it became very painful, indeed : but this symp-
tom, I have since reason to believe, will depend upon the
situation which the tumour occupies. If this be a part which
is much pressed by tendons, fascia, &e. the pain will be
much more severe than if it were originating from soft parts,
and placed among them. The opening made, certainly
facilitated and expedited the fatal termination much; not
but that I allow, even if it had been left alone, it would have
been possible, without amputation, to remove the disease :
for, after the swelling has continued for a month, sometimes
less, oftener longer, it will ulcerate, and from the opening a
brownish tumour, of a caulitlower kind, will arise, which
will bleed on the slightest degree of force being applied to it ;
indeed, from time to time, it will bleed spontaneously, and
it is a very difficult matter to restrain the hæmorrhage. The
tumour appears to be entirely composed of a congeries of
vessels, and will enlarge rapidly. If some operation be not
performed, the patient will die of exhaustion, in consequence
of repeated hæmorrhages from the tumour. On cutting
open the swelling, it is found to be composed of a cellular
deposition of coagulable lymph, being excessively vascular,
and if this be macerated in water, it will have the appear-
ance of sponge.
The precise nature of the disease is still, in my opinion,
involved in much obscurity. It generally occurs to persons,
who are debilitated either from intemperance of any kind,
or depressing passions of the mind, inducing this weak-
ness,-One theory is this. In consequence of the body be.
ing in an unhealthy state, most of its actions partake of this
affection : thus, if the adhesive inflammation be necessary
to be set up in a part, the lymph which is thrown out by
the increased action of the vessels, is not of an healthy kind,
being loose in texture, &c. ; this being the case, when the
vessels shoot into it, it is incapable of compressing them
sufficiently, and they attain a large size : this process con-
tinues going on until the tumour bursts, when a fungus of



LECTURE XXXV.
445
this description is thrown out at the opening, being some-
what of an aneurismal kind. The circumstance on which
the above theory was founded, was, a patient died of enter-
itis, who had a fungus hæmatodes ; on dissecting the abdo-
men, coagulable lymph was found thrown out, of a much
less firm texture than that which is usually found in healthy
persons, and was similar to a sponge in appearance, the
cells containing grumous blood.
The origin of this disease appears to be in the fascia or
aponeurosis in the first instance, afterwards other parts par-
take of the affection.
Mr. Burns of Glasgow, has given a good description of this
disease ; be terms it spongoid inflammation.
Respecting the capability of the disease being extended
by absorption, some are disposed to think it is, as one case
in particular occurred where the disease formed originally
in the leg ; being extirpated, it re-appeared in the thigh, in
the groin, and on the patient's death, tumours, answering the
description of this, were found in several parts of the lungs ;
these were attributed to absorption ; also, it is observed, al-
most universally, that the disease re-appears after being ap-
parently extirpated, unless the limb is amputated. It is al-
most unnecessary to mention, that if the disease have ad-
vanced to any extent, amputation is the only resource, and
it ought to be done some distance above the diseased part.
I must beg leave to advise the perusal of cases detailed by
Mr. Hey upon this subject. From discussions I have had
on the subject with several practitioners of eminence, I have
reason to think the lunar caustic has removed the disease
in the incipient state. I have used it successfully in one case
of a tumour on the hand, which assumed, externally, the
· appearance of this disease in the very early stage ; and I
have extirpated another tumour that presented a very simi-
lar character.




446
LECTURE XXXV.
ON CUTANEOUS TUMOURS.

These are sometimes met growing from the skin alone,
being an elongation of it ; they are of three kinds. The first,
consists merely of the growth of the skin hanging in folds
without any pendulous tumour. The cellular membrane un-
derneath, in this species of cutaneous tumour, remains un-
affected by the disease. The second species is that where
the cellular membrane grows along with the skin, and they
form pendulous swellings, having small necks ; they com-
mence in the form of a small wart, and may be safely re-
moved without the smallest chance of danger. The third
species, is of a warty kind, and frequently will become can-
cerous. They mostly arise from long continued irritation
on the surface of the body, or from wearing a truss. They
will remain for many years without ulcerating ; therefore,
it is wrong to apply caustic to them, as they, by so doing,
are apt to degenerate into carcinomatous ulcers. They are
frequently extremely vascular ; and if an operation be ne-
cessary, the skin and cellular substance surrounding them,
should be deeply cut out along with them.

OSSIFIC TUMOURS.

These may be subdivided into two kinds ; the first, con-
sists of a deposition of earthy matter between the periosteum
and the substance of the bone. The inode of their produc-
tion is in consequence of inflammation being set up in the
bone and periosteum by some cause or other, when a car-
tilaginous substance is deposited between the membrane and
the bone, which becomes ossified by means of the vessels
going to the bone extending into it : from time to time fresh
depositions take place, which also become converted into
bony matter; the periosteum still serving as a covering to it.
This will go on to a great extent sometimes, and the tumour
will attain a large size; but they are a long time arriving

LECTURE XXXV.
447
at any magnitude. If they are external, they may be re-
moved by a saw. In one case which happened to a sur-
geon, he bored holes into the swelling, with the idea of
promoting absorption, which took place soon afterwards.
The second kind of exostosis is arising from the internal
part of the bone, and originates in consequence of inflamma-
tion of the medullary membrane, producing a callus, which
is thrown out : this, by its pressure on the original bone, in-
duces an absorption of it, gradually extending in every di-
rection, and will completely destroy the whole circumfer-
ence of it. The disease does not stop when arrived at this
point, but fresh deposits of earthy matter following each
other, the tumour will sometimes increase to an enormous
size. As to any remedies in this kind of tumour, they are
never of service ; the sole dependance must be placed on
amputation, which ought to be had recourse to, before the
constitution is injured by the disease.


SEROUS, OR HYDATID TUMOURS.
There are three different species of these. When this
tumour is situated in the liver, it is formed by a great num-
ber of hydatids adhering to the internal surface of one large
one, and these fill up the cavity. Each of these vesicles is
fed by small vessels going into it, as in the larger ones.
They are truly considered, at the present time, as consist-
ing of animals surrounded by a fluid, and this fluid retained
by a cyst. They are most frequently found in the cavity
of the abdomen, on the liver, omentum, &c.; one or two
cases have been met with when they were present between
.the bladder and rectum, in which situation they occasioned
many unpleasant symptoms to both of those parts, by ob-
structing the execution of their functions.
The second species of hydatid tumour is that which is
existing in the form of a stalk, from which several oval tu-
mours will depend: these are most commonly found on the


448
LECTURE XXXV.
placenta, and those hydatid swellings occasionally met with
in the cavity of the nose, growing from the pituitary mem-
brane, partake of the nature of these.
A third species consists in those which are formed in the
cellular membrane. This kind is sometimes met with, ad-
hering to the surface of the ovarium, and when very much
distended, is taken for ovarian dropsy.

BURSAL TUMOURS, OR GANGLIONS.
These tumours consist of collections of serous fluid within
the bursæ mucosæ : they are met with on the different parts
where these numerous bags exist, frequently on the wrist,
on the fibula, and on the tibia, &c. The best mode of treat-
ment is by bursting them by means of a blow given with a
flat hard substance, as a book. When this is smartly appli-
ed, it will generally succeed in rupturing the cyst, which
the fluid is contained in, but if it be impossible to effect it
by this means, apply the empl. ammon. c. hydrarg. with
the assistance of pressure constantly. Much advantage has
been derived from the application of a blister, put on repeat-
edly at short intervals. If, however, the cyst be very thick,
as that upon the side of the patella usually is, a needle and
ligature of silk passed through it, and allowed to remain in
the wound five or seven days, will excite adhesive inflamma-
tion, which will unite the sides of the cyst together.




INDEX.
00447
DEDICATION
INTRODUCTORY LECTURE.
LECTURE I....... Temperature of the Blood, &c., 1.
Effects of Stimuli, 5.
Sedatives, 5.
- Heat, 5.
· Cold, 6.
Constitutional Irritation, 8.
Treatment, 13.
LECTURE II...... On Inflammation, 14.
Results, or Terminations, 16.
LECTURE III.
LECTURE IV. i.
Inflammation continued, 20.
Original Cause, 22.
Proximate do. 23.
Treatment of Inflammation, 25.
On Adhesive Inflammation, 31.
- Suppurative Inflammation, 34.
Of the Nature of Matter, and its Mode of
Formation, 36.
ULCERATION, 38.
ABSCESSES, 40.
Treatment of do. 41.
HECTIC FEVER, 42.
Union by Granulation, 44.
CICATRIZATION, 46.
. On ULCERS, 49.
Impediments to the Healing Process, 50.
Treatment, 52.
Gangrene, or Mortification, 56.
LECTURE V...,
57

450
INDEX.
Treatment, 59.
On the Subject of Amputation, 60.
LECTURE VI.
On the FURUNCULUS or BOIL, 62.
Carbuncle, 63.
On BURNS AND SCALDS, 64.
LECTURE VII. . .
. On WOUNDS, 69.
-- Incised Wounds, ibid.
--- Contused do. 76.
- Lacerated do. 77.
LECTURE VIII. ... On Punctured Wounds, 78.
Trismus, and Tetanus, 81.
--Wounds of Arteries, 84.
- Securing the Arteries, 87.
LECTURE IX. ..... On Wounds of Veins, 91.
- Nerves, 93.
Tendons, 94.
- The ABDOMEN, 96.
LIVER, &c., 99.
LECTURE X. ..... On Wounds of the Chest, 101.
- Pericardium and Heart, 104.
Throat, ibid.
- Joints, 107.
Brain, 109.
LECTURE XI. , ... On Gun-shot Wounds, 111.
– of the Chest, 116.
Abdomen, 119.
Brain, 120.
On compound Fractures occasioned by Gun-
shot Wounds, 121.
LECTURÉ XII. , . . . On Poisons, 126.
Treatment, 130.
HYDROPHOBIA, 131.
Treatment, 133.
On VEGETABLE Poisons, 134.
Treatment, 135.

INDEX.
451
On MINERAL Poisons, 137.
Treatment, 139.
LECTURE XIII. ... On Injuries of the Head, 141.
-Cranium, &c., 142.
Concussion, 143.
- Compression, 148.
- Fractures of the Cranium, 150.
Treatment, 151.
On Formation of Matter within the Skull,153.
- Trephining, 154.
LECTURE XIV. , , , On HYDROCELE, 157.
- The Treatment,Palliative and Radical,161.
- The Cure by Incision, 163.
-- by Injection, 164.
LECTURE XV. .... On Aneurism, 169.
--- Its Mode of Formation, 172.
- The Old Method of Operating, 174,
Mr. Hunter's Improvement, 175.
- The New Mode for Popliteal Aneurism, 178.
- Femoral Aneurism, high up, 180.
- Mr. Abernethy's Mode of Operating, 181.
- Mr. Astley Cooper's Plan, ibid.
--- The successful Operation for securing the
Carotid Artery, by Mr.Astley Cooper,182.
- The Mode of Operating, 184.
- Securing the Subclavian Artery, 185.
-- - Axillary Artery, ibid.
- Mr. Keate’s and Mr. Charles Bell's Opera-
tions, 185, 186.
— Brachial Artery, 186.
LECTURE XVI. ... On CATARACT, 188.
— The Treatment, 191.
- Operation, ibid.
- Mode by Extraction, ibid.
Wenzel and Ware's Method, 193.
On the Difficulties to be encountered, 195.
-- Artificial Pupil, 196.

452
INDEX.
On COUCHING, 197
-- Breaking down the Cataract, or the Ope-
ration on the Capsula, 200.
- The use of Belladonna, 201.
--Fistula Lacrymalis, 202.
- Mr. Ware's Operation, 204.
LECTURE XVII. . . . On the Operation for the Removal of the
- Operation, 207.
On Polypi in the Nose, 208.
General Remarks, 209.
On DROPsy of the ABDOMEN, ibid.
Paracentesis Abdominis, 211.
On the Hare-Lip, Mode of Operating, 212.
LECTURE XVIII. .. On Puncturing the Bladder, 215.
-- Ischuria, or Retention of Urine, 218.
— Treatment, 219.
LECTURE XIX..... On the Structure of Calculi, 221.
Chemical Composition, 222.
Medical Treatment, 224.
Situations and Symptoms of Calcu-
li, 226.
Cause of Formation, 229.
Propriety of Lithotomy at certain
Ages, 230.
Necessary Precautions, 231.
Old Operation, 232.
- New Method of Operating, 234.
Subsequent Treatment, 235.
On Lithotomyin Females, 236.
The Operation, 237.
LECTURE XX..
. On Diseases of the Testicle, 241.
- Castration, 245.
- Chimney Sweeper's Cancer, 246.
- Tic Douloureux, 247.
- The Mode of Operating, 248,
-- Aura Epileptica, 249.

INDEX:
453
UB
LECTURE XXI..... On Diseases of the Breast, 251.
Treatment, 252.
The Operation for its Removal, 255.
Lecture XXII. ... On Amputation, 259,
LECTURE XXIII. .. On Hernia, 267.
-Inguinal Hernia, 269.
Anatomical Structure, 271.
Oblique Inguinal Hernia, 273.
Diagnosis, 274.
Treatment of reducible Hernia, 276.
LECTURE XXIV... On Irreducible Hernia, 278.
Treatment, 279.
Strangulated Hernia, 280.
Treatment, 283,
Operation, 287.
Difference between Mr. Lawrence's and Mr.
Cooper's Mode, 290.
LECTURE XXV. ... On large Inguinal Hernia, 295.
--Small Hernia, not protruding through the
Ring, 296.
- Direct Inguinal Hernia, ibid.
---Hernia Congenita, 298.
-Encysted Hernia, 300,
On Femoral Hernia, 301.
Diagnosis, 303.
Treatment, ibid.
Operation, 305.
Umbilical Hernia, 308.
Treatment, 309.
Ventral Hernia, 310.
Treatment, ibid.
Pudendal Hernia, 310.
Perineal do. 311.
LECTURE XXVII. . . On Dislocations, 312.
Cervical Vertebrae, 313.

454
INDEX
Clavicle, 314.
Os Humeri, ibid.
Elbow, 317.
Wrist, 318.
Os Femoris, 319.
Patella, 322.
Tibia, ibid.
Ankle, 323.
Compound Dislocation of the Ankle Joint, 324.
LECTURE XXVIII. . Introductory to Gonorrhoea and Syphilis, 326.
LECTURE XXIX... On Gonorrhea, 331.
Symptoms when in the Urethra, 332.
Treatment, 334.
LECTURE XXX.. On Strictures, 337.
The Seat of Stricture, 339.
-Cause of do. 340.
Treatment of Permanent Stricture, 341.
On Fistula in Perineo, 343.
Spasmodic Stricture, 345.
Treatment, 346.
Inflammatory Stricture, 347.
Treatment, ibid.
Enlargement of the Prostate Gland, 348.
Treatment, 349.
LECTURE XXXI. ., On the Effects of Gonorrhoea on the Blad-
der, 350.
Treatment, 352.
Paralytic Affections, Bleedings from the Ure-
thra, Chordee, &c. 353.
On Impotence, or Seminal Weakness, 355.
Treatment, 357.
Inflammation of the Testes, 358.
Treatment, 359.
External Gonorrhæa, 361.
On Gonorrhea in the Female, 362.
Treatment, ibid.
On Gleet, 364.

INDEX.
455
LECTURE XXXII. . . On Syphilis, Chancre, 366.
--The Treatment, 368.
Phymosis, Paraphymosis, &c. 370.
Treatment, 371.
Sloughing of the Glans Penis, 372.
Chancres in Women, 374.
Treatment, ibid.
Venereal Warts, ibid.
-Bubo, 376.
Treatment, ibid.
Buboes in Women, 380.
Locality of Buboes, ibid.
Secondary Symptoms of Syphilis, 381.
Poison upon the Throat, ibid.
Venereal Eruptions, 383.
Treatment, 384.
Phagedenic Ulcer, 384.
Treatment, 385.
Venereal Ophthalmia, 385.
--Disease of the Bones, 386.
Nodes, 387.
Treatment, 388.
Bones of the Cranium affected, ibid.
General Remarks on Syphilis and on its
Treatment, 389.
LECTURE XXXIH... On Simple Fractures, 399.
Tibia and Fibula, 403.
Os Femoris, ibid.
Clavicle, 404.
Os Humeri, ibid.
Radius and Ulna, 405.
Ribs and Sternum, ibid.
Lower Jaw, 406.
Patella, 407.
Treatment, 408.
Olecranon, ibid.
Cervix Femoris, 409.
On Compound Fractures, 410.
Difficulties met with, 411.
456
INDEX.
LECTURE XXXIV.. On Scrofula, 415.
Enlargement of the Glands, 420.
Disease of the Mesenteric Glands, 422.
Treatment, ibid.
Disease of the Joints, ibid.
Appearance on Dissection, 424.
Treatment, 425.
Disease of the Hip-Joint, 428.
Treatment, 429.
Distorted Spine, ibid.
Of Psoas and Lumbar Abscesses, 430.
Treatment, 433.
Scrofulous Ophthalmia, 434.
Lippitudo, 435.
Scrofulous Testes, 436.
On Rachitis, ibid
Treatment, 437.



LECTURE XXXV... On Tumours; the Steatomatous Tumour, 439..
Encysted Tumour, 440.
Absorbent Glandular Tumours, 442,
Fungus Haematodes, 443.
Cutaneous Tumours, 446.
Ossific do. 446.
Serous or Hydatid Tumours, 447.
Bursal Tumours, or Ganglions, 448.
The End.