THE UNIVERSITY 
 
 OF ILLINOIS 
 LIBRARY 
 
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 COMPREHENDING 
 
 all the most interesting improvements, from the earliest 
 
 TIMES DOWN TO THE PRESENT PERIOD ; 
 
 AN ACCOUNT OF THE INSTRUMENTS, REMEDIES, AND APPLICATIONS 
 EMPLOYED IN SURGERY ; 
 
 THE ETYMOLOGY AND SIGNIFICATION OF THF. PRINCIPAL TERMS: 
 
 AND 
 
 Numerous References to Ancient and Modern Works, forming together a “ Catalogue 
 Raisonnee” of Surgical Literature 
 
 WITH 
 
 formerly surgeon to the forces; member of the royal college of surgeons; 
 
 OF THE MEDICAL AND CHIHURGICAL SOCIETY OF LONDON : AND 
 
 , Op THE MEDICAL SOCIETY OF MARSEILLES. 
 
 OF THE COLLEGE OF SURGEONS OF EDINBURGH; PROFESSOR OF ANATOMY AM' 
 PHYSIOLOGY TO THE VERMONT ACADEMY OF MEDICINE; AND 
 LECTURER ON SURGICAL ANATOMY IN NEW-YORK. 
 
 \ variety of original facts and observations 
 
 BY SAMUEL COOPER, 
 
 WITH 
 
 NOTES AND AN APPENDIX. 
 
 BY WILLIAM ANDERSON, 
 
 N two volumes 
 
 YOL. II. 
 
 FROM THE FOURTH LONDON EDITION 
 
 NEW-YORK ; 
 
 PUBLISHED BY COLLINS &■ HANNAY, 230 PEARL-STREET 
 
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 A Dictionary of Practical Surgery : comprehending all the most Interesting Improve 
 il ments, from the earliest times down to the present period ; an Account of the Instru- 
 ments, Remedies, and Applications employed in Surgery ; the Etymology and Signi 
 fication of the Principal Terms ; and Numerous References to Ancient and Modern 
 1 Works, forming together a “ Catalogue Raisonnee” of Surgical Literature ; with a 
 - Variety of Original Facts and Observations, by Samuel Cooper, formerly Surgeon to 
 ci the Forces ; Member of the Royal College of Surgeons ; of the Medical and Chirur- 
 *•' gical Society of London ; and of the Medical Society of Marseilles. With Notes and 
 : an Appendix, by William Anderson, of the College of Surgeons of Edinburgh 
 “ Professor of Anatomy and Physiology to the Vermont Academy of Medicine 
 rc and Lecturer on Surgical Anatomy in New-York.” 
 
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A. 
 
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 THE HORARY OF THE 
 
 DICTIONARY ^ A ° 1933 
 
 ■ , F ILLINOIS; 
 
 OP 
 
 PRACTICAL SURGERY. 
 
 P This murk (*) will signify , that the Word which it precedes is further spoken of in the Apptndix. 
 
 if 
 
 I O ^ 
 
 HER 
 
 Ue'RNTA. (From sgvoc, a branch, from 
 its protruding forward.) Burgeons under- 
 stahd by the term hernia, a tumour, formed 
 by the protrusion of some of the viscera of 
 the abdomen, out of that cavity, into a kind 
 of sac, composed of the portion of perito- 
 neum, which is pushed before them. How- 
 ever, there are certainly cases which will 
 not be comprehended in this definition ; 
 either because the parts are not protruded 
 at all, or have no hernial sac, as the reader 
 will learn in the course of this article. 
 
 “ The brilliant progress which surgery 
 has made in modern times (says Scarpa) is, 
 properly speaking, only the result of patho- 
 logical anatomy, that is to say, of exact 
 comparisons of the natural slate of our or- 
 gans with their different diseases, which may 
 depend upon an alteration of texture, a de- 
 rangement of functions, a solution of con- 
 tinuity, or a change of situation. It is from 
 morbid anatomy, that the most rational 
 curative methods, with which modern sur- 
 gery is enriched, are deduced as so many 
 corollaries ; methods, to which we are also 
 indebted for the perfection of operations. 
 
 “ There are indeed a certain number of 
 surgical operations, for the prompt and sufe 
 execution of which, mere anatomical know- 
 ledge will suffice; but in many others, the 
 surgeon cannot promise himselfsuccess, even 
 though he be well acquainted with ana- 
 tomy, unless he has particularly studied the 
 numerous changes of position, and altera- 
 tions of texture, of w’hich the parts, upon 
 which he is about to operate, are susceptible. 
 If he has not the requisite information upon 
 all these points, false appearances may de- 
 ceive his judgment, and make him commit 
 mistakes, sometimes of a very serious and 
 irreparable kind. 
 
 “ In order to have a convincing proof of 
 this truth, it will be sufficient to take a view 
 of the different species of hernia;, and their 
 numerous complications. Assuredly, no 
 anatomist would believe, that the intestine 
 ccecum, naturally fixed in the right ileum, 
 and the urinary bladder, situated at the bot- 
 tom of the pelvis, could undergo, without 
 being torn, so considerable a displacement 
 as to protrude through the abdominal ring, 
 
 HER 
 
 and descend even into the scrotum ; that the 
 same intestine, the ccecuin, could pass front 
 the right iliac region to the umbilicus, pro- 
 trude at this opening, and form an umbili- 
 cal hernia ; that the right colon could have 
 been found protruded from the abdomen at 
 the left abdominal ring, and the left colon 
 through the right one ; that the liver, spleen, 
 and ovary could sometimes form the con- 
 tents of umbilical, inguinal, and femoral 
 herniae ; that the caecum could engage itself 
 within the colon, and even protrude at the 
 anus ; that the stomach could be forced 
 through the diaphragm, and form a hernia 
 within the chest ; that the omentum, or in- 
 testine, or both these parts together, could 
 sometimes escape from the belly through the 
 foramen ovale, or sacro-ischiatic notch of* 
 the pelvis; that a noose of small intestine, 
 after being engaged in the abdominal ring* 
 or under the femoral arch, could suffer the 
 most violent strangulation, without the 
 course of Ihe intestinal matter being inter- 
 cepted ; lastly, that in certain circum- 
 stances, the intestine and omentum could 
 be in immediate contact with the testicle, 
 within the tunica vaginalis, without the 
 least laceration of this latter membrane. 
 These and several other analogous facts, 
 says Scarpa, are so surprising, that they 
 would yet he regarded as incredible, had 
 they not been proved by numerous obser- 
 vations on individuals affected with hernia : 
 their possibility (repeats this experienced 
 professor) would not even have been sus- 
 pected, either by the anatomist or physiolo- 
 gist.” (see Scarpa, Traitc dcs Hernits, Pref.) 
 
 The parts of the body, where hernia; most 
 frequently make their appearance, are tlm 
 groin, the navel, the labia pudendi, and the 
 upper and forepart of the thigh ; they do 
 also occur at every point of the anterior part 
 of the abdomen ; and there aro several les<r 
 common instances, in which hernial tu- 
 mours present themselves at the foramen 
 ovale ; in the perinaeum ; in the vagina ; at 
 the ischiatic notch, &,c. 
 
 The parts, which, by being thrust forth 
 from the cavity, in which they ought natu- 
 rally to remain, mostly produce hernia?, are 
 either a portion of (ho amentum, or rv jwwY 
 
 95 
 
 O iLSJC* 
 
HERNIA. 
 
 of the intestinal canal, ©r both together. 
 But the stomach, the liver, spleen, uterus, 
 ovaries, bladder, kc. have been known to 
 form the contents of some hernial tumours. 
 
 From these two circumstances of situation 
 and contents, are derived all the ditlerent 
 appellations, by which herniae are distin- 
 guished. If a portion of intestine alone 
 forms the contents of the tumour, the case 
 is called enterocele ; if a piece of omentum 
 only, epiptocele ; and if both intestine and 
 omentum contribute to the formation of the 
 tumour, it is called an entero-epiplocele. 
 When the contents of a hernia protrude at 
 the abdominal ring, but only pass as low as 
 the groin, or labium pudendi, the case re- 
 ceives the name of bubonocele, or inguinal 
 hernia ; but if the parts descend into the 
 scrotum, it is called an oscheocele, or scrotal 
 hernia. The crural, or femoral hernia, is 
 the name given to that w’hich takes place 
 below Poupart’s ligament. W hen the bowels 
 protrude at the navel, the case is named an 
 exomphalos, or umbilical hernia ; and renlral 
 is the epithet given to the swelling, when 
 it occurs at any other promiscuous part of 
 the front of the abdomen. The congenital 
 rupture is a very particular case, in which 
 the protruded viscera are not covered with 
 a common hernial sac of peritoneum, hut 
 are lodged in the cavity of the tunica vagi- 
 nalis, in contact with the testicle, and, as 
 must be obvious, it is not named like herniae 
 in general, from its situation, or contents, 
 but from the circumstance of its existing 
 From the time of birth. 
 
 When the protruded bowels lie quietly in 
 the sac, and admit of being readily put back 
 into the abdomen, the case is termed a re- 
 ducible hernia; and when they sutler no 
 constriction, yet cannot be put back, owing 
 to adhesions, *or their large size in relation 
 to the aperture, through which they have 
 to pass, the hernia is termed irreducible. 
 An incarcerated, or strangulated hernia, sig- 
 nifies one, which not only cannot be re- 
 duced, but suffers constriction ; so that if a 
 piece of intestine be protruded, the pressure 
 to which it is subjected, stops the passage of 
 its contents towards the anus, excites inflam- 
 mation of the bowel, and brings on a train 
 of alarming, and often fatal consequences. 
 
 The eauses of hernia; are either predispo- 
 sing, or exciting. Among the former, wri- 
 ters mention a preternaturally large size of 
 the openings, at which the bowels are liable 
 to protrude ; a weakness and relaxation of 
 the margins of these apertures ; a preterna- 
 tural laxity of the peritoneum; an unusually 
 long mesentery, or omentum, kc. With 
 regard to the abdominal ring, the transverse 
 tendinous fibres, which naturally cross and 
 strengthen its upper and outer part, are 
 much weaker in some subjects than others. 
 No idea seems more prevalent in books, 
 than that taking a good deal of oil with our 
 food, is conducive to the formation ol her- 
 nial diseases. Some of the alleged predis- 
 posing causes, may justly excite scepticism ; 
 but several circumstances tend to prove, 
 that a natural deficiency of resistance, fn any 
 
 part of the parietes of the abdomen, pro- 
 motes the occurrence of hernia. Hence, 
 persons who have had the peritoneum 
 wounded, are very liable to the present dis- 
 ease ; ( llicherand JVosogr. t hir. T. 3 ,p. 317 ; 
 Schmucker, Vermischte Chir. Schriften, B. 1, 
 p. 197,) and men are much more liable than 
 women, to inguinal hernia, owing evidently 
 to the larger size of the abdominal ring; 
 while in women, as there is a larger space 
 for the protrusion of the viscera, below Fou- 
 part’s ligament, they are more exposed than 
 men to femoral hernia;. 
 
 Willi regard to the exciting causes, our 
 knowledge is involved in less doubt. The 
 grand cause of this kind, is the powerful 
 action of the abdominal muscles and dia- 
 phragm on the viscera. In feats of agility, 
 such as jumping, Ik c. the pressure which the 
 contents of the abdomen must often en- 
 counter, sufficiently accounts for their pro- 
 truding at any part, where the abdominal 
 parietes do not make adequate resistance. 
 The same consideration explains, w hy her- 
 niae very often take place in lifting and car- 
 rying heavy weights, running, vomiting, 
 straining at stool, parturition, kc. and in 
 people who inhabit mountainous countries. 
 
 This diminution of the capacity of the 
 abdomen, by the action of the abdominal 
 muscles and diaphragm, in many occasional 
 exertions, must take place in every body by 
 reason of the common habits and necessi- 
 ties of life. But as only a certain number 
 of persons meet with the disease, it is fair 
 to infer, that either the exciting causes 
 must operate with greater force in them, 
 than in the generality of people, or else that 
 their abdominal parietes have not been ca- 
 pable of the ordinary degree of resistance. 
 Many patients, who meet with hernia;, in 
 making violent efforts and exertions, may* 
 be in the former circumstance ; while others 
 whose viscera protrude from such trivial 
 things as coughing, sneezing, crying, kc. 
 must be considered, as being under the 
 influence of some predisposing cause. A 
 gentleman, who has gained great honour by 
 a most valuable treatise on ln rnia, remarks, 
 that “ herniae, which originate in predispo- 
 sition, generally come on gradually, and 
 almost imperceptibly ; w’hile those which 
 are produced by bodily exertions, are form- 
 ed suddenly, and by the immediate action 
 of the exciting cause. The occurrence of 
 the complaint is often indicated, in the first 
 instance, by a fulness, combined with a 
 sense of weakness, about the abdominal 
 ring. The swelling is increased by any ac- 
 tion of the respiratory muscles, and disap- 
 pears on pressure, and in the recumbent po- 
 sition of the body. It gradually finds its 
 way through the tendon of the external ob- 
 lique muscle, into the groin, and afterward 
 into the scrotum. When a hernia takes 
 place suddenly, it is generally attended w ith 
 a sensation of something giving way at tlio 
 part, and with pain.” ( Lawrence on Rup- 
 tures, p. 29, Edit. 3.) 
 
 Upon the subject of the immediate cause 
 of hernia?, it Is observed by Scarpa, that se- 
 
HERNIA. 
 
 5 
 
 veral distinguished modern surgeons, as, for 
 instance, YVarton, ( Adenograph . cap. 11.) 
 Eenevoli, ( Dissertazioni Chirurgische , 1.) 
 Rossius, ( Acta JVat. cur. T. 2, Obs. 178.) 
 Brendel, (de lierniarum natalibus,) and Mor 
 gagni, (de sed. et caus. morb. epist. 43, art. 13,) 
 consider a relaxation and elongation of the 
 mesentery as the principal cause of herniae 
 in general, and of the bubonocele in parti- 
 cular. Hence, say they, the whole mass of 
 intestines, or only a portion of an intestine, 
 descends against the inner orifice of Ihe 
 inguinal ring, presses against this opening, 
 and gradually makes its way out of the 
 abdomen. In examining this pathological 
 point without prejudice, it is incontesta- 
 ble, says Scarpa, that an intestine cannot 
 be moved beyond its natural limits, unless 
 that part of the mesentery, which retains 
 and fixes the bowel in its proper place, be 
 at the same time elongated. But it does not 
 follow from this, that a relaxation of the 
 mesentery must precede the displacement 
 of the intestine. It appears to Scarpa much 
 more probable, that these two events are 
 simultaneous, and depend upon one and the 
 same cause. 
 
 “In the healthy state the abdomen, con- 
 sidered altogether, is submitted to two oppo- 
 site forces, which reciprocally balance each 
 other. One is the pressure of the viscera 
 against the abdominal parietes; the other is 
 the reaction of the same parietes upon the 
 viscera which they contain. If these two 
 forces were in perfect equilibrium in all in- 
 dividuals, and under all the circumstances 
 of life, we should not be in the least subject 
 to hernia?. If, when the equilibrium has 
 been broken, every point of the parietes of 
 the belly were to yield equally to the im- 
 pulse of the viscera, an increase of the vo- 
 lume of the whole abdomen would be the 
 con-equence ; but a true hernia would never 
 happen. The cavity of the abdomen is al- 
 ways completely full. The containing ar.d 
 contained parts react upon, and reciprocally 
 compress one another. It is by the effect 
 of this moderate, but equal and unremitting 
 pressure, that all the viscera mutually sup- 
 port each other. Without it. the ligaments 
 of the liver, those of the spleen, and the 
 various membranous bands of the intestines 
 in general, would only be feeble means for 
 fixing such parts in their respective situa- 
 tions. But there are certain points of the 
 abdominal parietes which naturally present 
 much less resistance than others, and which 
 react with much less power against the pres- 
 sure made from within outwards by the ab 
 dominal viscera. Such is particularly the 
 part which extends from the pubes to the 
 anterior superior spinous process of the ili- 
 um. This relative weakness of some points 
 of the abdominal parietes is very marked in 
 certain individuals, in consequence of a 
 defect of organization. It may also be in- 
 creased by internal or external causes, which 
 are as various as they are numerous. When 
 in one of these cases the pressure made by 
 the viscera is unusually increased, as hap- 
 pens in a violent effort, a defect in the equi- 
 
 librium between the two forces above men- 
 tioned is occasioned ; that is to say, the re- 
 action of the abdominal parietes isno longer 
 proportioned, at least at certain points, 
 to the force of the impulse of the viscera. 
 The conjoined powers of the abdominal 
 muscles, diaphragm, and levator ani, are 
 then directed and concentrated against the 
 most feeble point of the abdomen, towards 
 which they propel the nearest viscus, or that, 
 which from its moveableness, is the most 
 liable to displacement. If such viscus should 
 happen to be the noose of an intestine, it is 
 evident that the power which tends to make 
 it protrude from the belly, must at the same 
 time act upon the corresponding portion of 
 the mesentery ; and the intestine, in passing 
 through the parietes of the abdomen, drags 
 the mesentery after it, and makes this mem- 
 brane yield and become elongated. When 
 the displaced viscera meet with little resis- 
 tance on the part of the parietes of the ab- 
 domen, the hernia is quickly formed, and 
 the elongation of the mesentery occurs with 
 equal celerity. We have an example of 
 this in the inguinal congenital hernia : in 
 this case the intestine is, in some measure, 
 precipitated into a sac previously prepared 
 for its reception. On the contrary, in the 
 ordinary inguinal hernia, a totally different 
 disposition of the parts renders the progress 
 of the disease much slower. In most in- 
 stances, the hernia is not formed immediate- 
 ly the equilibrium between the impulse of 
 the viscera and the reaction of the abdomi- 
 nal parietes is broken. But in the groin, a 
 slight elevation is first observed, in the di- 
 rection from the anterior superior spinous 
 process of the ilium towards the inguinal 
 ring. Some lime afterward, when the intes- 
 tine has made its appearance on the outside 
 of the ring, the enlargement of the hernia, 
 and the elongation of the mesentery, make 
 much more rapid, though always simulta- 
 neous progress. 
 
 “ Numerous practical observations, (says 
 Scarpa) concur in proving, that we must not 
 search for the immediate cause of hernia; in 
 the relaxation of the mesentery but rather 
 in a want of equilibrium between the pres- 
 sure of the viscera and the resistance of one 
 or several points of the abdominal parietes. 
 Indeed hernia; are seen occurring from the 
 slightest causes in infants, in whom the neck 
 of the tunica vaginalis is not speedily oblite- 
 rated, and in individuals, who from being fat, 
 have all on a sudden become extremely thin. 
 Such women ns have had children, arc more 
 subject to the disease than others. Persons 
 also of both sexes, who carry considerable 
 burdens, or who play upon wind instru- 
 ments, or who have suffered a forcible con- 
 tusion of the abdomen, are particularly ex- 
 posed to the disorder, even though there is 
 not the least reason for suspecting in them a 
 relaxation of the mesentery. Vaginal her- 
 nia;, which arise after difficult labours, af- 
 ford another proof of the same truth : their 
 cause is owing to a laxity and weakness of 
 the parietes of the vagina, which, not being 
 capable of making any further resistance to 
 
0 
 
 HERNIA, 
 
 the pl-essure of the viscera, situated in the 
 cavity of the pelvis, at length suffer these 
 parts to protrude. 
 
 “ With respect to the second proposition, 
 that during the formation of a hernia, the 
 combined force of all the abdominal mus- 
 cles is, as it were, directed and concentra- 
 ted against the most feeble point of the pa- 
 rietes, we see a proof of it in a fact that 
 occurs to our observation every day. In 
 order to. convince ourselves of this, we 
 need only notice what happens in indivi- 
 duals afflicted with hernia? : if they cough, 
 or sneeze, or make the slightest effort, they 
 instantly find the size of the swelling in- 
 creased, and hasten to support the part 
 with their hand. During the slightest ef- 
 forts, which render the hernia? larger, it is 
 also indisputable, that the mesentery is elon- 
 gated in the same proportion as the intes- 
 tine protrudes. All the viscera have such 
 a tendency to be displaced and carried to- 
 wards the weakest point of the parietes of 
 the abdomen, that even those, which are 
 naturally the most distant from it, and are 
 the most firmly fixed by the folds of the me- 
 sentery, may in their turn descend into the 
 hernia?. Anatomical knowledge alone would 
 never have led us to have a suspicion of the 
 possibility of these occurrences. Sandifort 
 and Paletta have found, in an umbilical her- 
 nia, the ccecurn, with a portion of the ileum 
 and colon. ( Obs. Pathol, cap. 4, Nova Gu- 
 bernaculi testis Description Mauchart, Cam- 
 per, and Bose, have met with the ccecum in 
 an inguinal hernia of the left side. ( De 
 Hern. Incar c. in Halleri Disput. Chirurg. Torn 
 3. Demonstrat. anat. paiholog. lib. 2, p. 18, 
 Animadvers. de hern, inguin. p. 5.) Lassus has 
 seen the left colon protrude at the right in- 
 guinal ring. ( Medecine Operatoire , T. 1, p. 
 173.) If it be proved by all these facts, that 
 such viscera, as are the most closely united to 
 the great sac of the peritoneum arid neigh- 
 bouring parts, are nevertheless liable to form 
 hernia? ; and if such displacements cannot, 
 happen without a considerable elongation of 
 the membranous bands fixing these bowels, 
 in their natural situation, how can we refuse 
 to admit, that a noose of intestine, pushed 
 by degrees through the inguinal ring, drags 
 along with it the corresponding portion of 
 the mesentery ? In order to explain this 
 event, there is no necessity for supposing a 
 partial relaxation of the mesentery.” ( Traitt 
 Pratique dts Henries, Par A. Scarpa, trad, de 
 l' It alien, p. 37 — 43.) 
 
 The general symptoms of a hernia, which 
 is reducible, and free from strangulation, 
 are an indolent tumour in some point of the 
 abdomen, most frequently descending out of 
 the abdominal ring, or from just below Pou- 
 part’s ligament, or else out of the navel ; but 
 occasionally, from various other situations, 
 as will be presently explained. The swelling 
 often originates suddenly, except in the cir- 
 cumstances above related, arid it is subject 
 to a change of size, being smaller when the 
 patient lies down on his back, and larger 
 when be stands up, or holds his breath, it 
 frequently diminishes when pressed, and 
 
 grows large again when the pressure is renao 
 ved. Its size and tension often increase af- 
 ter a meal, or when the patient is flatulent. 
 In consequence of the unnatural situation 
 of the boweb, many patients with hernia 
 are occasionally troubled with colic, consti- 
 pation, and vomiting. Sometimes, however, 
 the functions of the viscera seem to suffer 
 little or no interruption. 
 
 If the case be an enteroeele, and the por- 
 tion of intestine be small, the tumour is 
 small in proportion ; but, though small, yet, 
 if the gut be distended with wind, inflamed, 
 or have any degree of stricture made on it, 
 it will be tense, resist the impression of the. 
 finger, and give pain upon being handled. 
 On the contrary, if there be no stricture, 
 and the intestine suffer no degree of inflam- 
 mation, let the prolapsed piece be of what 
 length it may, and the tumour of what- 
 ever size, yet the tension will be little, and 
 no pain will attend the handling it; upon 
 the patient’s coughing, it will feel as if it 
 were blown into ; and, in general, it will 
 be found very easily returnable. (Pott.) A 
 guggling noise is often made when the bowel 
 is ascending 
 
 If the hernia be an epiplocele, or one of 
 the omental kind, the tumour has a raora 
 flabby and a more unequal feel ; it is in ge- 
 neral perfectly indolent, is more compressi- 
 ble, and (if in the scrotum) is more oblong, 
 and less round, than the swelling occasion- 
 ed in the same situation by an intestinal 
 hernia ; and, if the quantity be large, and 
 the patient adult, it is in some measure dis- 
 tinguishable by its greater weight. (Pott ) 
 
 If the case be an enter o-epiplocele , that is, 
 one consisting of both intestine and omen- 
 tum, the characteristic marks will be less 
 clear, than in either of the simple cases : but 
 the disease may easily be distinguished from 
 every other one, by any body in the habit 
 of making the examination. ( Pott , P. 28.) 
 
 As the smooth slippery surface of the in- 
 testine generally makes its reduction easier 
 than that of the omentum, we may infer, 
 with Mr. Lawrence, “ that, if a portion of 
 the contents slip up quickly and with noise, 
 leavingbehirid something which is less easily 
 reduced, the case is probably an enlero-epip- 
 locele. (See Treatise on Ruptures , Edit. 3, 
 p. 32.) 
 
 On the subject of prognosis, Mr. Pott re- 
 marks, that the age and constitution of the 
 subject, the date of the disease, its being 
 free, or not free from stricture, or inflamma- 
 tion, the symptoms which attend it, and the 
 probability or improbability of its being re- 
 turnable, necessarily produce much variety. 
 
 If the subject be an infant, the case is not 
 often attended with much difficulty or hazard, 
 the reduction being easy as well as the de- 
 scent ; and though from neglect, or inatten- 
 tion, the bowel may fall down again, yet it 
 is as easily replaced, and mischief seldom 
 produced : Mr. Pott says seldom, because 
 lie lias seen an infant, one year old, die ol’ 
 a strangulated hernia, which had not been 
 down two days, with all the symptoms of 
 mortified intestine. (For other examples of 
 
HERNIA, 
 
 Strangulated hernia in very young infants, 
 refer to Gooch’s Chir. Works, Vol. 2, p 33 ; 
 Lawrence on Ruptures, p. 65, Edit. 3 ; Edinb. 
 Med. and Surgical Journal, Vol. 3, p. 470, 
 *c.) 
 
 “ If the patient be adult, and in the vigour 
 of life, the consequences of neglect, or of 
 maltreatment, are more to be feared than at 
 any other time, for reasons too obvious to 
 need relating. The great and principal mis- 
 chief to be apprehended, in an intestinal 
 hernia, is an inflammation of the gut, and 
 an obstruction to the passage of the aliment 
 and feces through it ; which inflammation 
 and obstruction are generally produced by 
 a stricture made on the intestine. In very 
 old people, the symptoms do not usually 
 make such rapid progress, both on account 
 of the laxity of their frame, and their more 
 languid circulation ; and also that their rup- 
 tures are most frequently of ancient date, 
 and the passage a good deal dilated ; but 
 then, on the other hand, it should also be 
 remembered, that they are by no means ex- 
 empt from inflammatory symptoms ; and 
 that if such should come on, the infirmity of 
 old age is no favourable circumstance in the 
 treatment, which may become necessary. 
 (Pott.) 
 
 If the disease be recent, and the patient 
 young, immediate reduction, and constant 
 care to prevent another protrusion, are the 
 only means whereby it is possible to obtain 
 a perfect cure. 
 
 “ If the disease be of long standing, has 
 been neglected or suffered to be frequently 
 down, and has given little or no trouble, the 
 aperture in the abdominal muscle, and the 
 neck of the hernial sac, may both be pre- 
 sumed to be large ; which circumstances in 
 general render immediate reduction less 
 necessary and less difficult, and also frus- 
 trate all rational expectation of a perfect 
 cure. On the contrary, if the rupture be 
 recent, or, though old, has generally been 
 kept up, its immediate reduction is more ab- 
 solutely necessary, as the risk of stricture is 
 greater from the supposed smallness of the 
 aperture, and narrowness of the sac. If the 
 rupture be very large and ancient, the pa- 
 tient far advanced in life, the intestine not 
 bound by any degree of stricture, but does 
 its office in the scrotum regularly, and no 
 other inconvenience be found to attend 
 it, but what proceeds from its weight, it will 
 in general be better not to attempt reduc- 
 tion, as it will, in these circumstances, most 
 probably prove fruitless, and the handling 
 the parts in the attempt, may so bruise and 
 injure them as to do mischief.” 
 
 With respect to the correctness of the ad- 
 vice here delivered, some doubt may be 
 entertained, because, though it would cer- 
 tainly not be right to protract the attempts 
 at reduction, so as to do mischief, it must 
 be equally wrong to make no trial, whether 
 the hernia is reducible or not; and, if re- 
 ducible, I should say, that it ought to be 
 reduced without delay, and a truss applied. 
 This opinion, however, seems to agree with 
 the injunctions delivered by Pott in another 
 
 place, as will be seen in the next section of 
 this article. 
 
 With regard to the contents of a hernia, 
 Mr. Pott observes, that “ if it be a portion of 
 omentum only, and has been gradually ’ 
 formed, it seldom occasions any bad symp- 
 toms, though its weightwillsometimesrender 
 it very troublesome. But, if it be produced 
 suddenly by effort or violence, that is, if a 
 considerable piece of the caul by accident 
 slip down at once, it will sometimes prQve 
 painful and cause very disagreeable com- 
 plaints ; the connexion between the omen- 
 tum, stomach, duodenum, &c. being such 
 as to render the sudden descent of a large 
 piece of the first sometimes productive of 
 nausea, vomiting, colic, and all the disagreea- 
 ble symptoms arising from the derangement 
 of these viscera. When the piece of caul is 
 engaged in such a degree of stricture as to 
 prevent the circulation of blood through it, 
 it will sometimes, by becoming gangrenous, 
 be the occasion of very bad symptoms and 
 even of death, as I have more than once 
 seen : and thus, as a mere omental hernia, 
 it may sometimes be subject to great hazard. 
 But even though it should never be liable to 
 the just-mentioned evil, that is, though the 
 portion of the caul should remain uninjured 
 in the scrotum, yet it renders the patient 
 constantly liable to hazard from another 
 quarter; it makes it every moment possible 
 for a piece of intestine to slip into the same 
 sac, and thereby add to the case all the 
 trouble and all the danger arising from an 
 intestinal rupture. It is by no means an un- 
 common thing for a piece of gut to be 
 added to a rupture, which had for many 
 years been merely omental, and for that 
 piece to be strangulated, and require imme- 
 diate help 
 
 “ An old omental hernia is often rendered 
 not reducible, more by an alteration made 
 in the state of the prolapsed piece of caul, 
 than by its quantity. It is very common 
 for that part of the omentum, which passes 
 through the neck of the sac, to be compress- 
 ed into a hard, smooth body, and lose all 
 appearance of caul, while what is below in 
 the scrotum is loose and expanded, and en- 
 joys its natural texture ; in this case, reduc- 
 tion is often impossible, from the mere 
 figure of the part ; and I have so often seen 
 this, both in the living and the dead, that I 
 am satisfied, that for one omental rupture, 
 rendered irreducible by adhesions, many 
 more become so from the cause above-men- 
 tioned. 
 
 “In the sac of old omental ruptures that 
 have been long down, and only suspended 
 by a bag truss, it is no very uncommon thing 
 to have a pretty considerable quantity of 
 fluid collected : this, in different states and 
 circumstances of the disease, is of different 
 colour and consistence, and seldom so much 
 in quantity as to occasion any particular at- 
 tention to it ; but, on the other hand, it 
 sometimes is so much in quantity as to be- 
 come an additional disease to the original 
 one. I have more than once been obliged 
 to let it out, in order to remove the incon- 
 
s 
 
 HERNIA. 
 
 venience arising from its weight, and the 
 distention of the scrotum, which I have also 
 seen become gangrenous by the neglect of 
 this operation. 
 
 “If the hernia be of the intestinal kind 
 merely, and the portion of gut be small, 
 the risk is greater, strangulation being more 
 likely to happen in this case, and more 
 productive of mischief, when it has hap- 
 pened : for the smaller the portion of gut is 
 which is engaged, the tighter the tendon 
 binds, and the more hazardous is the con- 
 sequence. I have seen a fatal gangrene, in 
 a bubonocele, which had not been formed 
 forty-eight hours, and in which the piece 
 of intestine was little more than half an 
 inch. 
 
 Another observation made by Pott is, 
 that “ if the hernia be caused by a portion 
 of the intestine ileum only, it is in general 
 more easily reducible, than if a part of the 
 colon has descended with it, which will also 
 require more address and more patience in 
 the attempt. The reduction of a mere in- 
 testinal hernia too ( ceeteris paribus) will al- 
 ways remain more practicable, than that of 
 a mere omental one, after it has attained 
 to a certain size and state, as the part con- 
 tained within the former is liable to less al- 
 teration of form than that within the latter ; 
 which alteration has already been mention- 
 ed as no unfrequent hinderance of the re- 
 turn of an old caul rupture. 
 
 “ Not that the parts within a mere intes- 
 tinal hernia are absolutely exempt from 
 such an alteration as may render their re- 
 turn into the belly impracticable, even 
 where there is no stricture ; for, says Pott, I 
 have seen that part of the mesentery, which 
 has lain long in the neck of the sac of an old 
 rupture, so considerably hardened and thick- 
 ened, as to prove an insuperable obstacle to 
 its reduction.” 
 
 Upon the whole, this author infers, that 
 an intestinal rupture is subject to worse 
 symptoms, and a greater degree of hazard, 
 than an omental one, though the latter is, 
 by no means, so void of either as it was 
 formerly supposed to be ; that bad symp- 
 toms are more likely to attend a recent 
 rupture, than one of ancient date ; that the 
 descent of a very small piece of intestine is 
 more hazardous than that of a larger ; and 
 that the hernia, which consists of gut only, is 
 in general attended with worse circumstan- 
 ces, than that which is made up of both gut 
 and caul. 
 
 Mr. Hey coincides with Pott, in thinking 
 the prognosis more unfavourable when the 
 tumour is small. I think it is not a bad 
 general rule, that the smaller the hernia, 
 the less hope there is of reducing it by the 
 taxis Long-continued efforts to reduce a 
 prolapsed intestine, are most likely to suc- 
 ceed in old and large hernias, when no ad- 
 hesions have taken place.” ( Tract . Observ. 
 in Surgery, p. 203.) 
 
 “The opening (says Mr. Lawrence) 
 through which the parts protude, is narrow- 
 er in some situations than in others ; the 
 progress of the case will therefore he more 
 
 rapid, and the danger of the patient morer 
 urgent. The aperture is generally very 
 small in femoral hernia ; this kind of rup- 
 ture in men, and the bubonocele in women, 
 have a particularly narrow entrance. On 
 the same grounds, femoral, inguinal, and 
 umbilical ruptures are more dangerous thau 
 the ventral, perineal, or vaginal kinds. 
 {Treatise on Ruptures, p. 63, Ed. 3.) 
 
 TREATMENT OF A HERNIA CAPABLE OF EASY 
 
 AND IMMEDIATE REDUCTION, AND NOT 
 
 ATTENDED WITH ANY TROUBLESOME OU 
 
 BAD SYMPTOMS. 
 
 “ This case,” says Mr. Pott, “ is very fre- 
 quently met with in infants and sometimes 
 in adults, and is too often neglected in both. 
 In the former, as the descent seldom hap- 
 pens but when the infant strains to cry, and 
 the gut is either easily put up, or returns svu 
 sponte , as soon as the child becomes quiet, it 
 often is either totally unattended to, or an 
 attempt made to restrain it only by a ban- 
 dage made of cloth, or dimity, and which 
 being ineffectual for such purpose, lays the 
 foundation for future trouble and mischief. 
 
 “ This is, in great measure, owing to a 
 common opinion, that a young infant can- 
 not wear a steel truss ; a generally prevail- 
 ing error, and which ought to be corrected. 
 There is no age at which such truss may 
 not be worn, or ought not be applied ; it is, 
 when well made, and properly put on, not 
 only perfectly safe and easy, but the only 
 kind of bandage that can be depended upon ; 
 and as a radical cure depends greatly on 
 the thinness of the hernial sac, and its being 
 capable of being so compressed as possibly 
 to unite, and thereby entirely close the pas- 
 sage from the belly, it must therefore appear 
 to every one who will give himself the 
 trouble of thinking on the subject, that the 
 fewer times the parts have made a descent, 
 and the smaller and finer the elongation of 
 the peritoneum is, the greater the probabili- 
 ty of such cure must be. 
 
 “ The same method of acting must, for the 
 same reasons, be good in every age in which 
 a radical cure may reasonably be expected ~ r 
 that is, the prolapsed parts cannot be too 
 soon returned, nor too carefully prevented 
 from falling down again, every new descent 
 rendering a cure both more distant and more 
 uncertain. 
 
 “ As soon as the parts are returned, the 
 truss should be immediately put on. and 
 worn without remission, care being taken , 
 especially if the patient be an infant, to keep 
 the parts on which it presses constantly 
 washed, to prevent galling. 
 
 “ It can hardly be necessary to say, that 
 the surgeon should be careful to see that the 
 truss fits, as his success and reputation de- 
 pend on such care. A truss which does not 
 press enough, is worse than none at all, as 
 it occasions los 3 of time and deceives the 
 patient, or his friends ; and one which press- 
 es too much, or on an improper part, gives 
 pain and trouble, by producing an inilarn- 
 
HERNIA. 
 
 9 
 
 mation and swelling of the spermatic chord, 
 and sometimes of the testicle. 
 
 “ In adults, whose ruptures are of long 
 standing, and accustomed to frequent de- 
 scent, the hernial sac is generally firm and 
 thick, and the aperture in the tendon of the 
 abdominal muscle large ; the freedom and 
 ease with which the parts return into the 
 belly when the patient is in a supine posture, 
 dnd the little pain which attends a rupture 
 of this kind, often render the persons who 
 labour under it careless : but all such should 
 be informed that they are in constant dan- 
 ger of such alteration in their complaint, as 
 may put them into great hazard, and perhaps 
 destroy them. The passage from the belly 
 being open, the quantity of intestine in the 
 hernial sac is always liable to be increased, 
 and when down, to be bound by a stricture 
 An inflammation of that portion of the gut 
 which is down, or such obstruction in it as 
 may distend and enlarge it, may at all times 
 produce such complaints as may put the life 
 of the patient into imminent danger; and 
 therefore, notwithstanding this kiud of 
 hernia may have been borne for a great 
 length of time, without having proved either 
 troublesome or hazardous, yet as it is always 
 possible to become so, and that very sud- 
 denly, it can never be prudent or safe to 
 neglect it. 
 
 “ Even though the rupture should be of 
 the omental kind, (which considered ab- 
 stractedly is not subject to that degree or kind 
 of danger to which the intestinal is liable) 
 yet it may be secondarily, or by accident, 
 the cause of all the same mischief *, for 
 while it keeps the mouth of the hernial sac 
 open, it renders the descent of a piece of in- 
 testine always possible, and consequently 
 always likely to produce the mischief which 
 may proceed from thence. 
 
 “ They who labour under a hernia thus 
 circumstanced, that is, whose ruptures have 
 been generally down while they have been 
 in an erect posture, and which liave either 
 gone up of themselves, or have been easily 
 put up in a supine one, should be particularly 
 careful to have their truss well made, and 
 properly fitted ; for the mouth of the. sac, 
 and the opening in the tendon being both 
 large and lax, and the parts having been used 
 to descend through them, if the pad of the 
 truss be not placed right, and there be not a 
 due degree of elasticity in the spring, a piece 
 of intestine will, in some posture, slip down 
 behind it, and render the truss productive of 
 that very kind of mischief which it ought to 
 prevent.” (See Truss.) 
 
 Mr. Pott then comments upon the im- 
 portance of having the parts completely re 
 duced before the truss is applied, and upon 
 the danger that may be incurred by laying 
 such bandagC aside alter it has been worn 
 some time; since the partial closure of the 
 ring, whereby the descent of the gut is ren- 
 dered less easy, will also make the reduction 
 more difficult, if a piece should happen to 
 slip down ; and hence he insists, that a truss 
 u should be long, and unremittingly worn by 
 alt those, whose time of life makes the ex- 
 Vbr„ 11 o 
 
 peofations of a perfect cure reasonable, 
 many of the ruptures of adults being owing 
 to the negligent manner in which children 
 at school are suffered to wear their trusses.” 
 Besides the danger of strangulation, ant’ 
 the loss of all chances of a radical cure, 
 when a reducible hernia is neglected, and al- 
 lowed to remain down, there are other mo- 
 tives for keeping up the tumour with a truss, 
 and preventing its increase of size. “The 
 vast size, to which neglected herniae some- 
 times inertase, not only prohibits all active 
 exertion, but by involving, in the male, the 
 integuments of the penis, incapacitates the 
 subject from the act of copulation, and gives 
 rise to excoriation from the discharge of the 
 urine over the swelling. Probably too, the 
 testis may be affected by the pressure of a 
 very large scrotal hernia. ( Morgagni dt 
 
 Caus. et Sed. Ep. 33, Art. 12 ; Schmurker 
 Vermischte Chir. Sc/iriften, B. 3, p. 195.) 
 Disorders of the intestinal functions invari- 
 ably attend these large ruptures, and in- 
 crease in frequency and violence in propor- 
 tion to the size of the swelling, and age of 
 the patient. All the moveable viscera of the 
 abdomen gradually find their way into the 
 hernial sac, if a rupture be entirely neglect- 
 ed. ( Lawrence on Ruptures, p. <57, Edit. 3. 
 1816.) 
 
 TREATMENT OF IRREDUCIBLE HERNI-ST, FREE 
 FROM INFLAMMATION, AND UNATTENDED 
 WITH TROUBLESOME OR DANGEROUS SYMP- 
 TOMS. 
 
 Mr. Pott, and all the best writers on rup- 
 tures, ascribe the incapacity of reduction, in 
 most cases, either to the largeness of the quan- 
 tity of the contents, an alteration made in their 
 form and texture, or to adhesions, which 
 they have contracted with e^ch other, or 
 their containing bag. 
 
 Mr. Pott was also aware, that ruptures are 
 sometimes rendered difficult to be reduced, 
 by the cttCum being contained in the hernial 
 sac. Of which fact, he was as much con- 
 vinced as the nature of such kind of things 
 would permit ; that is, by observations made 
 both on the living and the dead. This state- 
 ment, which w A3 made by Mr. Pott very 
 many years back, deserves particular notice, 
 because its truth is confirmed by the modern 
 observations of Scarpa, whose very import- 
 ant explanations of the cause of the diffi- 
 culty ot reduction, may be seen in the second 
 vol. of the First Lines of Surgery. 
 
 Air. Pott has adverted to the kind of im- 
 pediment to reduction, produced by (lie 
 thickening of the neck of i he sac, when the 
 hernia is long neglected, and suffered to re- 
 main in the scrotum, without any bandage to 
 support its weight. 
 
 The fame author reckons an alteration 
 produced by time, and constant, though 
 gentle pressure in the form and consistence, 
 or texture of tlm omentum, as no infrequent 
 cause, why neglected omental ruptures be- 
 come irreducible. 
 
 When a portion of omentum “ has b'*en 
 suffered to remain for a great length of time 
 
10 
 
 IlERiMA. 
 
 in tlie scrotum, ^without Laving ever been re- 
 turned into the belly, it often happens, that, 
 although that part of it, which is in the lower 
 part of the hernial sac, preserves its natural 
 soft, adipose, expansile state, yet all that 
 part which passes through what is called the 
 neck of the sac, is, by constant pressure, 
 formed into a hard, firm, incompressible, 
 carnous kind of body, incapable of being 
 expanded, and taking the form of the pass- 
 age in which it is confined, exactly filling 
 that passage, and rendering it impossible to 
 push up the loose part which fills the scro- 
 tum. 
 
 “ The same reason for incapacity of reduc- 
 tion is also sometimes met wiih in ruptures 
 of the intestinal kind, from an alteration 
 produced on that part of the mesentery 
 which has been suffered to lie quiet for a 
 great length of time in the neck of an old 
 hernial sac. 
 
 “ The other impediment, which I mention- 
 ed to the return of old ruptures, is the con- 
 nexion and adhesion of the parts, either with 
 each other, or with the bag containing them. 
 This is common to both the intestinal and 
 omental hernia, and is produced by slight in- 
 flammations of the parts which have been 
 permitted to lie long in contact with each 
 other, or perhaps in many cases from the 
 mere contact only. T ese adhesions are 
 more or less firm in different cases, but even 
 the slightest will almost always be found an 
 invincible objection to the reduction of the 
 adherent parts, by the hand only. 
 
 “ Many, or perhaps most of these irreduci- 
 ble ruptures become so by mere time arid 
 neglect, and might at first have been return- 
 ed ; hut when they are got into this state, 
 they are capable of no relief from surgery, 
 but the application of a suspensory bag. to 
 take off or lessen the inconvemence arising 
 from the weight of the scrotum. 
 
 “People in this situation should he parti- 
 cularly careful not to make any attempts be- 
 yondtheir strength, nor aim at feats of agility; 
 they should take care to suspend the loaded 
 scrotum, and to keep it out of the way of all 
 barm from pressure, bruise, &,c. When the tu- 
 mour is very large, asoftquilted bolster should 
 be worn at the bottom of the suspensory, to 
 prevent excoriation, a id the scrotum should 
 be frequently washed for tlie same reason ; 
 a loss of skin in this part, and in such cir- 
 cumstances, being sometimes of the utmost 
 importance. They ought also to be particu- 
 larly attentive to. the office of the intestinal 
 canal, to see that they do not by any irregu- 
 larity of diet disorder it, and keep themselves 
 from being costive.” Mr. Pott observes, 
 however, that the quiet, inoffensive state of 
 this kind of hernia is by no means to be de- 
 pended upon ; many things may happen to 
 it, by which it may be so altered, as to be- 
 come hazardous, and even fatal : an inflam- 
 mation of that part of the gut which is down, 
 any obstruction to tlie passage of the aliment 
 or feces through it, a stricture made by the 
 abdominal tendon, either on what has been 
 long down, or on a new portion which may 
 at any time he added to it, are always capa- 
 
 ble of so altering the stale of the case, as to 
 put the life of the patient into danger. 
 
 “Indeed the hazard arising from a stric- 
 ture made on a piece of intestine contained 
 in the sac of an old irreducible hernia, is in 
 one respect greater than that attending one 
 that has been found at times reducible; 
 since from the nature of the case it will 
 haidly admi' of any attempl toward relief, 
 but the operation, which in these circum- 
 stances must necessarily be accompanied 
 with additional difficulty. 
 
 “ Among the ruptures, which have been 
 thought not reducible, and treated as such, 
 there have been some which, upon more ju- 
 dicious and more patient attempts, have beeu 
 found capable of reduction. 
 
 “ When this is suspected to be the case, 
 the proper method is by absolute rest, in a 
 supine posture, for a considerable length of 
 time, by great abstinence, and the use of 
 evacuants, so as to lessen the size of the 
 partsin the hernial sac, and render ihem ca- 
 pable of passing hack again into the belly.” 
 (Pott on Ruptures.) 
 
 Fabrn-ius Hildanus gives an account of a 
 man who was radically cured of a rupture, of 
 twenty years date, bv six months confine- 
 ment to bed. (Cent. 5. Obs. 54.) 
 
 Le Dran and Arnaud relate instances of 
 monstrou- bubonoceles, which disappeared 
 entirely after the patients had been long 
 confined to bed, and rendered much emaci- 
 ated by tedious illnesses. Some of the mo- 
 derns have imitated this operation of nature, 
 and by frequent bleedings, arid repeated pur- 
 ges, h -ve sometimes so far reduced the size 
 of the hernia, that it has been returned into 
 the abdomen. Mr. Hey has several times 
 succeeded in this way. (P. 219.) But the 
 practice cannot prove successful, when the 
 viscera adheres to the sac, or to the perito- 
 neum, just within the abdomen The great- 
 est objection to this method of cure, is the 
 want of an absolute criterion for distinguish- 
 ing when the parts do, or do not adhere to 
 the hernial sac, and in advanced years, 
 though one were sure that the viscera were 
 free from the sac, the possibility of hurting 
 the body by the necessary evacuations, is 
 also another objection. ( Sharp’s Critical 
 
 Inquiry, p. 15.) 
 
 Were the plan to he thought worthy of 
 trial, keeping up a constant pressure on the 
 tumour, by means of a suspensory bandage, 
 made to lace in front, would be proper for 
 promoting the absorption of the thickened 
 parts in the hernial sac. Mr. A. Cooper has 
 reduced such hernia?, after applying ice to 
 them, the good effects of which he imputes 
 to its producing a contraction of the scro- 
 tum, and thus a strong and permanent com- 
 pression of the tumour. Mr. Earle lately in- 
 formed me of a method of keeping up a ge- 
 neral pressure on the swelling, by means of 
 a bladder containing quicksilver, the quanti- 
 ty of which can be regulated according to 
 circumstances. 
 
 Whenever any attempts of this kind suc- 
 ceed, a truss should he immediately put on, 
 und \Vorn constantly without remission 
 
HERNIA. 
 
 11 
 
 However, there are instances on rpcord, 
 where the capacity of the abdomen had be 
 come so adapted to the diminished quantity of 
 the viscera, that when the contents ot the 
 hernia were reduced, serious complaints 
 arose from their introduction into the belly 
 Sell mucker met with several such cases, in 
 which he wa* obliged to take off the truss 
 again. Petit has known the reduction of a 
 hernia of this kind prove fatal, the parts not 
 descending again when the truss was remo- 
 ved, the nausea and vomiting continuing, and 
 peritonitis taking place. ( Chirurgische 
 Wahrnehm ungen , Vol. 2, p. 243. Traiti des 
 Maladies Chir. T. 2. p. 392.) 
 
 Mr. Pott remarks, that “ an omental rup- 
 ture, which has been so long in the scrotum 
 as to have become irreducible, is very seldom 
 attended with any bad symptoms, considered 
 abstractedly ; but it is constantly capable of 
 being the occasion of an intestinal hernia, 
 and all its consequences ; neither is that all, 
 for the omentum, either so altered in form 
 and texture, or so connected as to he incapa- 
 ble of reduction, may by accident inflame, 
 and either become gangrenous, or suppurate, 
 and the occasion of a great deal of trouble.” 
 In a few instances, epiploceles produce very 
 bad symptoms indeed, cases of which are to 
 be found in Garengeot, Dionis, Sz.c. 
 
 Sometimes in old cases of entero-epiplo- 
 cele, the intestine is reducible, but the omen- 
 tum is not, in which case some writers advise 
 keeping up the piece of bowel with a truss, 
 the pad of which must be so contrived as not 
 to press on the omentum. Mr. Pott, how- 
 ever, considers this method not often practi- 
 cable, and should such a truss be used, he re- 
 commends great caution in its construction 
 and application, lest a small piece of gut 
 slip down, and being pressed on by the truss, 
 produce fatal mischief. 
 
 “ Irreducible herniae must of course be ex- 
 posed to all the consequences of external 
 injury and violence ; hence, various cases 
 are recorded, in which the bowels have hewn 
 burst by blows, falls, &u.” ( Lawrence on 
 Ruptures, p. 1 10 Edit. 3.) 
 
 For examples of such accidents. .VIr. Law- 
 rence refers to A. Cooper on Hernia , Part 2, 
 Pref. p. 2, and to Travers's Inq. into the Pro- 
 cess of Nature , fyc. p. 37. A case is also 
 quoted from Scarpa, p. 310, where a violent 
 exertion caused a sudden return of a hernia, 
 which had been long regarde I as cured. The 
 viscera lay in the tunica vaginalis, which 
 was burst to the extent of an inch. 
 
 SYMPTOMS AND TREATMENT OF A STRANGU- 
 LATED, OR AN INCARCERATED ITERNI A. 
 
 MEANS TO BE TRIED, BEFORE AN OPERA- 
 TION. 
 
 “ Difficulty of reduction 'says Pott) may 
 be owing to several causes. The size of the 
 piece of omentum, or the inflamed state of 
 it ; the quantity of intestine and mesentery, 
 an inflammation of the gut, or its distention 
 by feces, or wind : or the smallness of the 
 aperture of trie tendon, through which the 
 hernia passes. But to whatever cause it be 
 
 owing, if the prolapsed body cannot be im- 
 mediately replaced, and the patient suffers 
 pain, or is prevented thereby from going to 
 stool, it is called an incarcerated hernia , a 
 strangulated hernia , or a hernia tcitli stricture. 
 
 l ' The symptoms are a swelling in the 
 groin, or scrotum, resisting the impression of 
 the fingers : if the hernia be of the intestinal 
 kind, it is generally painful to the touch, and 
 the pain is increased by coughing, sneezing, 
 or standing upright. These are the very 
 first symptoms, and if they are not relieved, 
 are soon followed by others, viz. a sickness 
 at the stomach, a frequent retching, or incli- 
 nation to vomit, a stoppage of all discharge 
 per anum, attended with a frequent, hard 
 pulse, and some degree of fever.” 
 
 A patient, thus circumstanced, is in some 
 danger, and demands immediate assistance. 
 A stricture made on the prolapsed part of 
 the gut, by the aperture through which it 
 passes, is the immediate cause of all the bad 
 symptoms, and of course, the removal of 
 such stricture is the only thing which can 
 bring relief. This object can only be accom- 
 plished by returning the bowel back into the 
 abdomen, or dividing the parts which form 
 the stricture. The former plan is always 
 the most desirable, when practicable. 
 
 We next proceed to notice the various 
 measures to be adopted for the relief of a 
 strangulated hernia, so as to obtain the best 
 chance of doing away the necessity of an 
 operation. After treating of the merits of 
 each plan, a few remarks will he offered on 
 the order in which the means should be put 
 in practice. 
 
 Taxis — This is the term applied to the 
 operation of reducing a hernia with the 
 hand. It is much promoted by the position 
 of the body ; which Winslow thought should 
 be placed on an inclined plane, and the 
 thighs bent towards the trunk. Mr. A. 
 Cooper advises the same practice, observ- 
 ing, that this posture, by relaxing the fascia 
 of the thigh, relaxes also the aperture, 
 through which the hernia passes. Every 
 degree of tension, and relaxation of the fe 
 moral fascia, must undoubtedly he attended 
 with a corresponding change in the abdo- 
 minal ring. But flexion of the thigh, besides 
 relaxing this fascia, also relaxes the abdo- 
 minal, internal iliac, and psoas muscles. In 
 cases of inguinal hernia, the pressure made 
 on the tumour by (he hands of the surgeon, 
 should always be directed upwards and out- 
 wards, along the course of the spermatic 
 cord, and Mr. A. Cooper advises it to be 
 continued from a quarter to half an hour. 
 (On Inguinal and ('ongenital Hernia.) 
 
 As the femoral hernia passes downwards, 
 and then forwards, the pressure must be di- 
 rected first backwards, and then upwards. 
 No violence should ever he used ; for, be- 
 sides being unavailing, it greatly aggravates 
 the inflamed state of the contents of the her- 
 nial sac, and has been known even to burst 
 the intestine. (See Cooper on Inguinal Her- 
 nia. <^*r. p. 23.) 
 
 Besides bending the thigh, care should 
 also be taken to rotate it inwards, wljich will 
 
1 2 
 
 HERNIA. 
 
 have great effect in relaxing the femoral 
 lascia, and tendon of the external oblique 
 muscle. Suspension of the patient over the 
 shoulders of an assistant has been thought 
 to facilitate reduction : “ I have tried it of- 
 ten, (says Mr. Hey;) but have not found it 
 to be of such superior efficacy, as some au- 
 thors have represented.’’ (P. 144.) 
 
 The return of a piece of intestine is gene? 
 rally preceded by a peculiar noise, caused 
 by the passage of air through the stricture. 
 It recedes at first gradually, and then slips 
 up suddenly. The omentum goes up slow- 
 ly to the very last portion, which must be 
 actually pushed through the opening. If the 
 taxis should not succeed at first, it will often 
 do so after the warm bath, bleeding, or cold 
 applications. Small hernias, being attended 
 with the closest stricture, are the most diffi- 
 cult to reduce, and for the same reason, cru- 
 ral ruptures do not so often yield to the 
 taxis, as inguinal hernia? in the male subject. 
 The taxis becomes less likely to succeed, 
 the longer the inflamed viscera have been 
 down, because adhesions are liable to form. 
 Mr. Lawrence observes, ( p . 6^.) a VVfien 
 the rupture becomes painful, we are no 
 longer justified in persevering in attempts at 
 reduction by the hand. A sufficient pressure 
 cannot now be endured; and the force 
 which is employed only tends to increase 
 the inflammation, and accelerate the ap- 
 proach of gangrene. At this period the ope- 
 ration is required , and should be performed 
 vjithout delay'" Desault even proscribed the 
 taxis altogether in the inflammatory strangu- 
 lation, until the previous use of other means 
 had produced a change in the state of the 
 swelling, 
 
 That the taxis is frequently abused, and the 
 cause of serious mischief; is a truth which 
 cannot be doubled. “ Strangulated herniae, 
 (says Scarpa) very frequently mortify from 
 the negligence of the patients, and their re- 
 pugnance to submit to an operation, and 
 perhaps, still more frequently from the effect 
 of the taxis, unskilfully exercised by unin- 
 formed surgeons, who are determined, at 
 any price whatsoever, to accomplish the 
 speedy reduction qf the viscera. The ma- 
 jority of them make no distinction between 
 the acuta and the chronic strangulation. In 
 both cases, no sooner are the symptoms of 
 strangulation evinced, than they begin to 
 handle the swelling roughly, and to push the 
 viscera with all their force, in order to make 
 them return into the abdomen ; whilst, when 
 the strangulation is acute , and the patient 
 young and strong, the taxis ought never to 
 be practised, before all the means proper for 
 diminishing the strength, calming spasm, 
 and relaxing the parts which are to be re- 
 duced, havr been employed for a certain 
 time. These means we know, are bleed- 
 ings, fomentations, emollient clysters, and 
 especially the warm bath, which, next to 
 bleeding, holds the first rank. At this school 
 of surgery, I have frequently had opportuni- 
 ties of observing the salutary effect of this 
 treatment. My pupils have, more than 
 once, seen hernia 4 , which had been painfully 
 
 handled without any good, reduced, as it 
 were, spontaneously, after a bleeding, or 
 whilst the patient was in the bath. If what 
 I have said upon the subject of the acute 
 strangulation, and the treatment that it re- 
 quires, w< re generally known by surgeons, 
 I think that operations for strangulated her- 
 nia? would be less frequent. Things are dif- 
 ferent with regard to the chronic strangula- 
 tion of old large hernia?, in feeble, or aged 
 persons , for in these cases, it is of great im- 
 portance to support the patient’s strength. 
 Bleeding, the warm bath, and other weak- 
 ening means, should also be avoided, which, 
 in producing a general atony, might bring 
 on gangrene of the intestine, either during 
 the strangulation, or after the reduction of 
 the viscera. It is ascertained that these 
 kinds of strangulation are almost always oc- 
 casioned by an accumulation of fecal mat- 
 ter, or an extraordinary quantity of air in 
 the hernia. Nothing is more efficacious than 
 cold applications, for promoting the action 
 of the bowel on the matter which distends 
 it, or for lessening t lie volume of the air. 
 They produce a corrugation of all the scro- 
 tum, and contractions of the cremaster, 
 which alone sometimes suffice for reducing 
 the viscera, in a much better manner than 
 could be done by the hands of the most ex- 
 perienced surgeon.” ( Scarpa , Traitts dcs 
 Hernies , p. 244 — 247.) 
 
 Bleeding. — The inflammation which at- 
 tacks the protruded viscera, and spreads 
 thence over the whole abdomen, and the 
 temporary weakness and often fainting, 
 which the sudden loss of blood induces, and 
 vyhich is a peculiarly favourable opportunity 
 for reducing the hernia by the hand, are 
 the reasons in favour of bleeding. Sharp, 
 Pott, B. Bell, Sabatier, Richter, Callisen, 
 and Scarpa, names which can never be sur- 
 passed in respectability, are all subscribed 
 in favour of bleeding. Wilmer, Alanson, and 
 A. Cooper, have published against the prac- 
 tice. Mr. Hey has related two cases, whiefi 
 strongly evince the manner in which bleed- 
 ing facilitates the return of a hernia : the 
 protruded viscera, in one instance, went up 
 spontaneously, on blood being taken away ; 
 in the other, the taxis succeeded immedi- 
 ately afterward, though the previous attempt 
 had been made in vain. (P. 125, 126.) Mr. 
 Hey’s experience, however, leads him to 
 concur so far with Wilmer and Alanson, as 
 to declare, that bleeding has generally fail- 
 ed to procure a reduction of the strangula- 
 ted intestine, though he is persuaded, that 
 in many cases it may be used with advan- 
 tage. But he cannot agree with Wilmer, 
 that it generally renders the subsequent 
 operation more dangerous. (P. 126.) The 
 majority of candid practitioners 1 believe 
 will allow r , that bleeding is always proper 
 when the hernia is small and recent ; the 
 abdomen tense and painful ; and the patient 
 young, strong, and plethoric. 
 
 Purgative Medicines. — My experience, (says 
 Mr. Hey) leads me to condemn almost uni- 
 versally the use of purgatives, while an in- 
 testine remains firmly strangulated. In the 
 
HERNIA. 
 
 13 
 
 entero-epiplocele, when the intestine has 
 retired, and the omentum remains strangu- 
 lated : or in a simple strangulation of the 
 omentum, where the intestine has not been 
 prolapsed, purgatives are of great utility. 
 So likewise in very large and old hernias, 
 where there is reason to doubt, whether she 
 disease is not to be considered as a morbid 
 affection of the intestinal canal, rather than 
 the effect of strangulation, purgatives may 
 be as useful as in the simple ileus without 
 hernia. While the intestine remains firmly 
 strangulated, they usually increase the vo- 
 miting, and add to the distress of the patient. 
 If they are to be tried at any time with hope 
 of success, the trial would appear to have 
 the greatest advantage when the vomiting 
 has been removed by means of an opiate ; 
 yet I have repeatedly given them in vain 
 during such an interval of relief (Practi- 
 cal Observations in Surgery, p. 128.) 
 
 Purgatives are supposed to operate by ex- 
 eitinglhe peristaltic action of the intestine, 
 and thereby extricating it from the stricture. 
 Besides the above eminent surgeon, Pott 
 and Richter have joined in their general 
 condemnation, and to all appearances, with 
 very great reason. Purgative clysters cer- 
 tainly have not the objection of increasing 
 the irritation ; but their efficacy is not de- 
 serving of much confidence. Mr. Hey says,, 
 that he has never seen one case, in which 
 either purgative, or emollient clysters, pro 
 duced a return of a strangulated hernia. 
 Such injections will empty the large intes- 
 tines ; but they do no more. It is common 
 also for a natural evacuation to be the im- 
 mediate consequence of strangulation. (P 
 131.) 
 
 WarmBath. — u Many instances (says Hey) 
 are upon record of the good effect of warm 
 bathing in procuring the reduction of a stran- 
 gulated hernia. I have often seen it use- 
 ful ; but I have also often seen it fail. When- 
 ever it is used in this disease, the patient 
 should be placed, if possible, in a horizontal 
 position. Gentle efforts with the hand to 
 reduce the prolapsed part are perhaps at- 
 tended with less danger, and with greater 
 prospect of success, while the patient lies 
 in the bath, than in any other position. The 
 free use of opiates coincides with that of 
 warm bathing, and under some circumstan- 
 ces, these means deserve to be tried in con- 
 junction ” (P. 132.) 
 
 Cold Bath , and Cold Applications. — The 
 cold bath, and dashing of cold water on the 
 patients, are little to be depended upon, 
 though success has sometimes been obtain- 
 ed in this manner. (Petit, Truitt dcs Chir. 
 T. 2, p. 325 ; Hey, p. 136.) 
 
 Wilmer strongly recommended the appli- 
 cation of cold to the tumour itself, and this 
 plan has acquired the approbation of the 
 most celebrated modern surgeons. It is gc 
 nerally tried in conjunction with the effect 
 of tobacco clysters, which will be j scntly 
 noticed. Cold applications, in the form of 
 ice, were indeed particularly recommended 
 by B. Bell. The best way is to pound the 
 |ce, tie it up in a bladder, and place it on 
 
 the rupture. When ice cannot be procured, 
 Mr. A. Cooper employs a mixture of equal 
 parts of nitre and muriate of ammonia. To 
 one pint of water, in a bladder, ten ounces 
 of the mixed salts are to be added “ If, 
 after four hours, (savs this distinguished 
 surgeon) the symptoms become mitigated, 
 and the tumour lessens, this remedy may be 
 persevered in for some time longer; but, if 
 they continue with unabated violence and 
 the tumour resist everv attempt at reduction 
 no farther trial should be made of the appli- 
 cation.” (On Inguinal and Congenital Her- 
 nia.) When ice is not at hand, aether some- 
 times proves a good substitute' when allow- 
 ed to evaporate from the surface of the 
 swelling. 
 
 Care must be taken, that the cold be not 
 so applied as to freeze the scrotum, and 
 bring on sloughing. (A. Cooper, p. 15.) 
 
 Opiates. — Mr. Hey met with several cases 
 in which opiates, given freely, (in athletic 
 persons after bleeding) procured a reduc- 
 tion of strangulated hernia. 
 
 He cannot say, however, that this remedy 
 is generally successful ; but it has the advan- 
 tage of removing, for a time, the pain and 
 vomiting usually attendant on strangulation, 
 even though it prove ultimately inefficacious. 
 Opiates should he given in large doses, when 
 it is wished to try their effect in procuring 
 reduction ; and whenever the symptoms of 
 strangulation return, after having been re- 
 moved bv opiates, the operation should be 
 performed without delay. (P. 134, 135.) 
 
 Tobacco Clysters.— For this purpose, some 
 surgeons prefer a decoction of tobacco, 
 made by infusing, or boiling, one dram of 
 the plant for ten minutes in a pint of water ; 
 others employ the smoke, which is prepared 
 and introduced into the rectum by means of 
 an apparatus, sold at almost every surgical 
 instrument maker's. Perhaps both methods 
 are equally efficacious ; but, as one requires 
 an apparatus, while the other does not, and 
 is equally proper, the decoction may be 
 entitled to most recommendation. The ma- 
 chine for the smoke is also frequently out 
 of order. Next to the operation, tobacco 
 clysters are the most certain means of bring- 
 ing about the reduction of the strangulated 
 parts. Besides exciting the action of the 
 intestines, they exert a peculiar depress- 
 ing influence on the whole system, reducing 
 the pulse, i.nd causing nausea and sickness, 
 cold sweats and fainting, under which cir- 
 cumstances the parts often recede, sponta- 
 neously, or may be easily reduced. Mr. A 
 Cooper prudently advises injecting half the 
 above quantity at first ; for he has seen two 
 drams, and even one, when used as an in- 
 fo- on, and introduced at once, prove fatal. 
 (P. 24.) The rest should he injected pre- 
 sently, when it appears that the tobacco 
 does not operate with the extraordinary vio- 
 lence with which it does in a few particular 
 constitutions. 
 
 A case recently published by Mr. C. Bell 
 I oks to me very much like an example of 
 t’ e occasional poisonous effects of the to- 
 bacco clyster, though not reported as such 
 
14 
 
 HERNIA. 
 
 by the author. At least, no particulars of 
 any fatal mischief, either in the tumour or 
 abdomen, are detailed, and it is remarked 
 of the patient: “ His strength held up until 
 the tobacco clyster was administered to him, 
 after which he very suddenly fell low, and 
 sunk.” (Surgical Obs Part 2 ,p 189.) The 
 smoke proved fatal in an instance witnessed 
 by Desault, ((Euvres >le Chir. T 2, p. 344.) 
 and an infusion of 3'j- 1° ^viij. °f water, 
 seemed to produce sudden mortal effects in 
 another example on record. ( Edinb . Med. 
 and Surgical Journ. Vol. 9 ,p. 159.) 
 
 Poultices and Fomentations have not the 
 confidence of any experienced or intelligent 
 surgeon Whoever, in these urgent cases, 
 wastes time in trying the effects of such 
 applications, merits censure for his credulity, 
 ignorance, and unfitness to undertake the 
 treatment of a rapid disease, in which, as 
 Pott remarks, if we do not get forward, we 
 generally go backward ; and whatever does 
 no good, if it be at all depended upon, cer- 
 tainly does harm, by occasioning an irre- 
 trievable loss of time. 
 
 OF THE ORDER IN WHICH THE PRECEDING 
 
 METHODS AND REMEDIES SHOULD BE 
 
 TRIED, AND OF THE TIME WHEN THE 
 
 OPERATION SHOULD NOT BE DELAYED. 
 
 In the treatment of a strangulated hernia, 
 a surgeon cannot be too deeply impressed 
 with the danger of spending time in the 
 triai of methods of inferior efficacy, or of 
 such as are evinced to be ineffectual in the 
 cases before them. 
 
 The rapidity with which gangrenous mis- 
 chief sometimes arises, and the palien' loses 
 his life, has been proved in a multitude of 
 unfortunate examples, and should operate 
 as a warning to all practitioners against the 
 danger of deferring the operation too long. 
 In the course of rny reading, however, I 
 have not met with so remarkable an instance 
 of the sudden mortification, and rapidly 
 fatal termination of a hernia, as the follow- 
 ing case recorded by Baron Larrey, in 
 speaking of the fatiguing and forced marches 
 performed by the French soldiers in Egypt. 
 These marches, he says, brought on in one 
 case, ‘ a hernia which formed suddenly, and 
 became at the same time strangulated. The 
 man was immediately brought to my ambu- 
 lance ; but a spontaneous gangrene, which 
 had all on a sudden attacked the intestine, 
 and extended to the other abdominal vis- 
 cera, caused the patient’s death in the space 
 of two hours, and made it impossible for me 
 to do the operation for him. This is the 
 second example that I have been acquainted 
 with, in which the effects of the accident 
 were thus rapid.” ( Larrey , in Mem. de Chi- 
 rurgie MiUlaire, T 1, p 196.) 
 
 The taxis is generally among the first 
 things to be tried, and Mr. A. Cooper 
 thinks the attempts should be continued for 
 a quarter or half an hour. ‘When these 
 have been ineffectual, the patten'. if the 
 circumstances do not forbid, should be im- 
 mediately bled, and have a large opening 
 
 made in the vein, so that the suddenness of 
 the evacuation may be most likely to bring 
 on fainting. The taxis should then be tried 
 again. 
 
 When the strangulation is very acute, and 
 the patient young and strong, perhaps it 
 may be most adviseahle to follow the advice 
 delivered bv Scarpa and Desault, which is 
 to bleed the patient and put him in the 
 warm bath, before the taxis is attempted at 
 all. 
 
 If bleeding alone has been practised, and 
 the manual efforts at reduction should not 
 now succeed, the warm bath may be em- 
 ployed, provided it can be got ready in a very 
 short time, but none should ever be lost in 
 waiting for it to be prepared. When the 
 bath is used, the taxis may be attempted as 
 the patient lies in the water ; a situation in 
 which I have succeeded in reducing several 
 herniae. 
 
 Certainly not more than one hour should 
 ever be allotted for putting in practice the 
 first attempts at reduction, bleeding, and the 
 warm bath. 
 
 The plan should be, while the trial of one 
 thing is going on, another should be pre- 
 paring. So when the preceding measures 
 have been tried in vain, the application of 
 a bladder filled with ice, or the solution of 
 nitre and muriate of ammonia, and the in- 
 jection of tobacco, in the form of smoke or 
 decoction, should never be delayed for want 
 of due previous preparation of all the requi- 
 sites. Both these measures should be prac- 
 tised at the same time, immediately after 
 the failure of the taxis, bleeding, and the 
 warm bath. Mr. A Cooper computes, that 
 four hours are enough for the trial of the 
 tobacco clyster, together with cold appli- 
 cations. 
 
 In omental herniae, the necessity for ope- 
 rating may frequently be obviated by the 
 good effects of bleeding, purgative medi- 
 cines, and clysters, and leeches applied to 
 the tumour. Mr. Lawrence has justly ob- 
 served, that “ when, as it very frequently 
 happens, the aid of the surgeon is not requi- 
 red until the complaint has lasted for some 
 time, a trial of the tobacco, together with 
 the topical use of cold, should be immedi- 
 ately resorted to, as circumstances will not 
 admit of delay in the previous use of less 
 powerful remedies (P. 148, Edit. 3.) 
 
 Every man who has seen much of herniae 
 will immediately recognize the propriety of 
 the following sentiments of the experienced 
 Mr. Hey: 
 
 “ I can scarcely press in too strong terms 
 the necessity of an early recourse to the 
 operation, as the most effectual method of 
 preserving life in this dangerous disease. If 
 Mr. Pott’s opinion be true, that the opera- 
 tion, when performed in a proper manner, 
 and in due time, does not prove the cause 
 of death often er than perhaps once in fifty 
 times; it would undoubtedly preserve the 
 lives of many, to perform >t almost as soon as 
 the disease commenced, without inc reasing 
 the danger by spending much time in the 
 
HERNIA. 
 
 15 
 
 use of means which cannot be depended 
 upon for a cure. 
 
 “ I have twice seen this disease prove 
 fatal in about twenty-four hours. In such 
 cases, it is evident there is little time for 
 delay. A surgeon who is competent to per- 
 form the operation, is not perhaps consulted 
 till the intestine is on the point of being 
 mortified, or is actually in a state of mortifi 
 cation. The dilemma into which he is then 
 cast is painful indeed. But, when the fullest 
 opportunity is afforded him of using the best 
 mode of treatment, I am satisfied that his 
 success will be the greatest when the opera- 
 tion is not long delayed. This, at least, has 
 been my own experience. When I first en- 
 tered upon the profession of surgery, its the 
 ear 1759, the operation for the strangulated 
 ernia had not been performed by any of 
 the surgeons in Leeds. My seniors in the 
 profession were very kind in affording me 
 their assistance, or calling me into consulta- 
 tion when such cases occurred ; but we con- 
 sidered the operation as the last resource, 
 and as improper until the danger appeared 
 imminent. By this dilatory mode of prac- 
 tice, I lost three patients in five, upon whom 
 the operation was performed. Having more 
 experience of the urgency of the disease, I 
 made it my custom, when called to a patient 
 who had laboured two or three days under 
 the disease, to wait only about two hours, 
 that I might try the effect of bleeding (if 
 this evacuation was not forbidden by some 
 peculiar circumstances of the case) and the 
 tobacco clyster, fn this mode of practice, 
 I lost about two patients in nine, upon whom 
 I operated. This comparison is drawn from 
 cases nearly similar, leaving out of the ac- 
 count those cases in which a gangrene of 
 the intestine had taken place. 
 
 “ I have now, at the time of writing this, 
 performed the operation tiiirty-five times; 
 and have often had occasion to lament that 
 I had performed it too late, but never that 
 I had performed it too soon. There are 
 some cases so urgent, that it is not advisca- 
 ble to lose any time in the trial of means to 
 produce a reduction. The delay of a few 
 hours may cut off all hope of success, when 
 a speedy operation might have saved the 
 life of the patienf. ” (P. 141, fyc.) 
 
 To determine the exact moment, when to 
 give up the trial of the preceding measures, 
 and to have immediate recourse to the ope- 
 ration, is certainly difficult ; but no one can 
 doubt, that it is generally better to operate 
 too early than too late. 
 
 All directions must be general ones, liable 
 to many exceptions : in rapid cases, little 
 or no time should be allotted to the trial of 
 any plan, and the operation should be done 
 without the least delay. In other instances, 
 we have full time to try the effects of every 
 thing at all likely to succeed. The symp- 
 toms, which ought to guide us, in having 
 recourse to the operation, arise from an 
 attack of inflammation in that part of the 
 intestine contained in the hernial sac, and 
 from its spreading into the abdominal cavity. 
 It is in proportion to their violence, that we 
 
 ought to urge the performance of the ope- 
 ration. Mr. Cooper considers pain on 
 pressing the belly, and tension, as the symp- 
 toms w hich point out its immediate neces- 
 sity. He adds, “ Indeed, there is scarcely 
 any period of the symptoms, which should 
 forbid the operation ; for, even if mortifica- 
 tion has actually begun, the operation may 
 be the means of saving life, by promoting 
 the ready separation of gangrenous parts.” 
 (O ' Inguinal and Congenital Hernia, p. 27.) 
 
 Whenever the surgeon has succeeded in 
 reducing the parts, without having recourse 
 to the knife, if the symptoms of pain, inflam- 
 mation, ran high before such reduction, 
 they will not alwrays cease immediately 
 afterward. As they probably depend on 
 the reduced bowel having been inflamed by 
 the stricture, the body should be kept open, 
 and the di^ { and regimen should be low <.nd 
 sparing, whilst the least degree of pain and 
 tension remain ; in short, till all complaint 
 is absolutely removed from the abdomen, 
 and the intestines do their office freely, and 
 without trouble. (Pott) 
 
 PROGRESS OF THE SYMPTOMS OF A STRAN- 
 GULATED HERNIA. 
 
 The earliest symptoms have been already 
 related, viz “ tumour in the groin, or scro- 
 tum, attended with pain, not only in the 
 part, but all over the belly, and creating a 
 sickness and inclination to vomit, suppres- 
 sion of stools, and some degree of fever. 
 These are the first symptoms, and, if they 
 are not appeased by the return of the intes- 
 tine, that is, if ttie attempts made for this 
 purpose do not succeed ; the sickness be- 
 comes more troublesome, the vomiting more 
 frequent, the pain more intense, the tension 
 of the belly greater, the fever higher, and a 
 general restlessness comes on, which is very 
 terrible to bear. When this is the state of 
 the patient, no time is to be lost; a very lit- 
 tle delay is now of the utmost consequence, 
 and if the one single remedy, which the 
 disease is now capable of, be not adminis- 
 tered immediately, it will generally baffle 
 every other attempt. This remedy is the 
 operation whereby the parts engaged in the 
 stricture rnay be set free If this be not 
 now performed, the vomiting is soon ex- 
 changed for a convulsive hiccough, and a 
 frequent gulping up of bilious matter; the 
 tension of the belly, the restlessness and 
 fever having been considerably increased 
 for a few hours, the patient suddenly be- 
 comes perfectly easy, the belly subsides, 
 the pulse, from having been hard, full, and 
 frequent, becomes low, languid, and gene- 
 rally interrupted; and the skin, especially 
 that of the limbs, cold and moist ; the eyes 
 have now a languor and a glassiness, a lack- 
 lustre not easy to be described ; the tumour 
 of the part disappears, and the skin covering 
 it sometimes changes its natural colour foi 
 a livid hue; but whether it keeps or loses 
 its colour, it has an emphysematous feel, a 
 crepitus to the touch, which will easily be 
 conceived bv all who have attended to it, 
 
16 
 
 HERNIA. 
 
 but is not so easy to convey an idea of by 
 words : this crepitus is the too sure indica- 
 tor of gangrenous mischief within. In this 
 stale the gut either goes up spontaneously, 
 or is returned with the smallest degree of 
 pressure ; a discharge is made by stool, and 
 the patient is generally much pleased at the 
 ease he finds ; but this pleasure is of short 
 duration, for the hiccough and the cold 
 sweats continuing and increasing, with the 
 addition of spasmodic rigours and subsul- 
 tus tendinum, the tragedy soon finishes.” 
 (Pott.) 
 
 ANATOMY OF INGUINAL HERNIA. 
 
 This subject must necessarily precede the 
 account of the operation, which would other- 
 wise be unintelligible. It is chiefly in the 
 anatomical information, relative to herniee, 
 and in the mode of operating, that modern 
 surgeons have a decided superiority over 
 their predecessors; for before Girnbernat, 
 Camper, Hey. Lawrence, Cooper, Scarpa, 
 and Hesselbach, published their several 
 works on hernia?, the anatomy of the disease 
 whs only imperfectly understood. 
 
 The tendinous fibres of the aponeurosis of 
 the external oblique muscle, as they run 
 downwards and forwards toward , the pubes, 
 separate from each other, so as to leave a 
 triangular opening, called the abdominal 
 ring, which is usually more capacious in the 
 male than (he female subject. The upper 
 and inner pillar (as it is termed) of this aper- 
 ture is inserted into the symphysis of the 
 pubes, and is the weakest of the two ; the 
 lower and outer one, which is (he strongest, 
 is chiefly a continuation of Poupart’s liga- 
 menl, (Hesselbach nber den Ursprung, fyc. 
 dtr Leisten-und-Szhenkelbruche, p. 4.) and is 
 fixed into the angle and crista of the same 
 bone. Some tendinous fibres cross the upper 
 and outer angle of the ring, so as to diminish 
 the triangular appearance of the whole aper- 
 ture : these are said to be very strong in old 
 hernia?. The anterior and thicker layer of 
 the aponeurosis of the internal oblique mus- 
 cle joins the tendon of the external oblique ; 
 the posterior and thinner one joins that of 
 the transversalis ; but the lower portion of 
 this tendon, together with the corresponding 
 part of the transversalis, goes wholly in front 
 of the rectus muscle. Thus the inferior bor J 
 der of the obliquus internus and transversa- 
 lis, which originates from the upper part of 
 Poupart’s ligament, lies behind the outer pil- 
 lar ot the abdominal ring. Mr. A. Cooper 
 first noticed, that a thin fascia proceeds from 
 the inner edge of Poupart’s ligament, and 
 spreads over the posterior surface of the 
 transversalis. This fascia forms the only par- 
 tition between the peritoneum and the outer 
 opening of the abdominal ring, and were it 
 not for it> existence, inguinal heroiae would 
 probably be much more frequent. The par- 
 tition in question, however, is said by Scarpa 
 to be formed by the aponeuroses of the in- 
 ternal oblique and transverse muscle*, while 
 Hesselbach, who has named the small smooth 
 point, situated directly behind (he outer 
 
 opening of the abdominal ring, its crural 
 surface , distinctly states, that it is formed by 
 delicate fleshy and tendinous fibres of the 
 internal oblique muscle; (Utber den Ur- 
 sprung, fyc. der Leisten-und-Schenkelbrnche , 
 p. 4,) and that behind them is the weakest 
 part of what he names the internal inguinal 
 ligament , in the rear of which is the perito- 
 neum, with the intervention of a very loose 
 cellular substance. (Op. cit. p. 26.) The 
 internal inguinal ligament of Hesselbach, is 
 therefore clearly the same thing as the above 
 fascia pointed out by Mr. A. Cooper. This 
 point of the abdomen is one of the three 
 weak places on the inside of the inguinal 
 region, where hernias are liable to occur; 
 yet, weak as it appears to be, it is not the 
 most common situation of such tumours. A 
 computation has been made, that in an hun- 
 dred cases of inguinal hernia, not ten occur 
 at the point here specified. (H. J. Tirttnning- 
 hausen , Unterricht uber die Bril eke, fyc. Wurzb. 
 1811.) 
 
 The spermatic vessels, joined^by the vas 
 deferens, run in front of the epigastric artery, 
 very near the place of its origin. They then 
 pass through the above fascia, go under the 
 edge of the internal oblique and transverse 
 muscles, and next obliquely downwards and 
 forwards, between the above fascia, and 
 aponeurosis of the external oblique muscle 
 to tue opening of the ring. When arrived on 
 the smooth surface, imcnedia : e!y behind the 
 ring, they describe an obtuse angle, and pass 
 forwards and downwards into the scrotum. 
 ( Hesselbach , op. cit. p. 5.) 
 
 Thus we see. that the spermatic cord, be- 
 fore it actual emerges a' what is named the 
 abdominal ring, runs through a kind of canal, 
 to which the epithet inguinal is often applied. 
 This oblique passage of the cord through the 
 abdominal parietes, was well known to, and 
 elegantly delineated by Albinus; Girnbernat 
 makes distinct mention of it in his Account 
 of a jiew Method of Operating for Femoral 
 Hernia, p. 19, 32 ; but Mr. A. Cooper has the 
 merit ot having given k the earliest correct ac- 
 count of the inguinal canal, in reference to 
 hernia ; a subject rendered complete by the 
 more recent elucidations of Hesselbach and 
 Scarpa. 
 
 The abdominal ring is then only the outer 
 opening of the canal, or passage, through 
 which the spermatic cord passes betore it 
 emerges. The inner one, at which the vis- 
 cera first protrude in tiie most common cases 
 ot inguinal hernia, is situated about an inch 
 and a half from the abdominal ring, in the 
 direction towards the anterior superior spi- 
 nous process of the ilium ; or, according to 
 Hesselbach, the inguinal canal is almost an 
 inch and a half in length, the average dis- 
 tance of the outer pillar of the abdominal 
 ring, from the inner pillar of what he iertns 
 the posterioi ring, being about sixteen Sines. 
 (Op. cit. p. 14.) This inner opening is rather 
 nearer the pubes than the ilium, and its upper 
 horde! is formed by the lower edge ot the 
 internal oblique, and transverse muscles, 
 which can he plainly felt with the finger, in 
 
HERNIA, 
 
 17 
 
 Produced upward aud outward into the abdo- 
 minal ring. 
 
 u The precise point at which the hernia 
 most commonly begins, (says Scarpa,) is that 
 which corresponds, in lhefoetus,tothe commu- 
 nication of the tunica vaginalis with the pe- 
 ritoneum, and, in the adult, to the passage 
 of the spermatic cord under the transverse 
 muscle. In the sound state, the peritoneum 
 presents at this part a small funnel-like de- 
 pression, the depth of which increases in pro- 
 portion as the spermatic cord is pulled from 
 above downwards. It is this small pouch, 
 this sort of digital appendage, whose pro- 
 gressive augmentation constitutes the hernial 
 sac. Resting upon the anterior surface of 
 the spermatic cord, it first makes its appear- 
 ance under the inferior edge of the trans- 
 verse muscle ; thence if extends itself in the 
 separation of the inferior fleshy fibres of the 
 internal oblique muscle, always following (he 
 spermatic cord, in front of which it is situa- 
 ted ; and after having in this manner passed 
 through the whole of the canal, which ex- 
 tends from the iliac region to flic* pubes, it 
 lastly protrudes at its external orifice, which 
 is the inguinal (or abdominal) ring, properly 
 so called. lu all this track, the hernial sac, 
 ns well as the spermatic cord, is situated 
 above file femoral arch, the direction of 
 which it follows. The canal, which it tra- 
 verses, is of a conical shape, the apex of 
 which is towards the flank, and the ba-e at 
 the external orifice of the ring.” ( Scarpa , 
 TraiU des Hernies , p. 44, 45.) 
 
 The epigastric artery runs behind the 
 spermatic cord, along the inner margin of 
 the interna! opening of the above canal, 
 then upwards and inwards, so as to pass at 
 the distance of half an inch or an inch from 
 the upper extremity of the outer opening, 
 or abdominal ring. 
 
 In common cases of inguinal hernia, the 
 viscera, protruded at the inner opening of 
 t he inguinal canal, lie over the spermatic 
 word, and form a tumour on the outside of 
 the abdominal ring. 
 
 When the viscera have entered the above 
 described digital pouch of the peritoneum, 
 but do not protrude through the abdominal 
 ring, the case is sometimes termed an incom- 
 plete inguinal hernia ; and complete when 
 they pass out of that opening. The viscera 
 may continue for a long while quite within 
 the inguinal canal, and even become stran- 
 gulated there: sometimes, also, they are 
 prevented from passing further towards the 
 ring by some kind of impediment; and, in 
 this circumstance, if the hernial sac have 
 any addition made to its contents, it may ex- 
 pand between the external and internal ob- 
 lique muscles, as Hesselbach bad an opportu- 
 nity of seeing in the body of a female. 
 
 { Ueher den Ur sprung, fyc. der Leisten-und- 
 tSchenkelbriiche, p. 28.) The stricture may 
 take place either at t tie internal or external 
 opening of the inguinal canal. In recent 
 and small h'-rnia, according to Mr. A. Cooper, 
 the strangulation is most frequently situated 
 at the inner opening ; in large old ruptures, 
 nt the abdominal rins:'. Even when 1 he par (3 
 Vol. II. w ' 3 
 
 are completely protruded out of the latter 
 opening, the strangulation may exist at the 
 inner one; but there may occasionally be 
 (wo strictures, viz. one at each opening. 
 (See Lawrence on Ruptures, p. 183, I. hit. 3.) 
 
 The hernial sac descends through the ab- 
 dominal ring over (lie spermatic cord, a. I ' 
 covered by a fascia, sent off’ from the tend 
 of the external oblique muscle. Rem 
 (bis fascia, the cremaster muscle is also situ- 
 ated over the sac, which, after it '-as de- 
 scended a certain way, lies on the tunica 
 vaginalis, as well as the spermatic cord. 
 
 As (lie epigastric artery naturally runs first 
 behind the spermatic cord, and then along 
 the inner margin of the internal opening of 
 the ring, and as the viscera are protruded 
 over the cord, they must be situated on t lie 
 outer side of the artery, which runs first be- 
 hind the neck of the sac, and then on its 
 inner side. Hence, the inner margin of the 
 sac, when inspected on the side towards the 
 abdomen, seems to be formed, as it were, by 
 the track of the vessel. (See Lawrence , p. 
 179) That this is the ordinary situation of 
 the epigastric artery, in relation to the ingui- 
 nal hernia, is confirmed by the concurrent 
 testimonies of Camper, Chopart, Desault, 
 Sabatier, A. Cooper, Hesselbach, Scarpa, 
 &ic. and by preparations to be seen in almos 4 
 every museum. 
 
 In recent inguinal hernia?, the internal and 
 external openings of the ring are at some 
 distance from each other, the first being • 
 ated obliquely upwards and outwards to. r 
 tion to the former; but the pressure >- 
 protruded viscera, gradually forces the truer- 
 rial opening more towards the pnbo and 
 nearer to the abdominal ring, so as to r. ..b . 
 the posterior side of the neck of the hernial 
 sac, and of the inguinal canal, very short. 
 
 ( Hesselbach . p. £9.) Thus, in large i. rroie 
 of longstanding, the opening into the nb io- 
 men is almost direct, and (be epigastric ; uy 
 becomes situated nearer the pubes, than in 
 the natural state. 
 
 Though such is the ordinary direction, in 
 which a bubonocele protrudes, (here are oc- 
 casional varieties. In one of these, the vis- 
 cera, instead of descending through ihe 
 canal of the ring, are at once thrust through 
 the abdominal ring itself, and the opening 
 into the belly is then direct : the hernial sac, 
 instead of passing op. the external side of 
 the spermatic vessels, as is usual, now.iies 
 on their inner, or pubic side ; and the epigas- 
 tric artery, which is commonly situated be- 
 hind, now pursues its course, in front of the 
 sac. at its usual distance from the upper and 
 outer angle of the abdominal ring.. 
 
 The following is Scarpa's description of 
 the displacement of the epigastric artery in 
 the greater number of cases of inguinal her- 
 nia. “ This artery, which in (he natural 
 state, runs about ten lines from the abdomi- 
 nal ring, has its situation and direction n; 
 changed, in subjects affected with cm: a, 
 that it crosses the posterior part ot the nock 
 of (he hernial sac, and is pushed from the 
 outer to the inner side of the abdominal ring. 
 In order to comprehend the reason of this 
 
HERNIA. 
 
 i3 
 
 displacement, it is necessary to recollect 
 what I have elsewhere said of the formation 
 of inguinal hernia, and of the manner, in 
 which the spermatic cord crosses tiie epi- 
 gastric artery. The hernia begins to form 
 at the very place, where the spermatic cord 
 passes under the inferior margin of the 
 transverse muscle ; and this place is rather 
 nearer the flank, than that where the epigas- 
 tric urtery passes towards the rectus muscle. 
 In its progressive extension, the hernial sac 
 constantly follows the same track as the 
 spermatic cord, since it is situated upon its 
 anterior surface. As has been already ex- 
 plained, this cord crosses the epigastric artery ; 
 consequently, the hernial sac must necessa- 
 rily pass with the cord above this artery, 
 before protruding from the canal of the 
 abdominal ring. At the same time’, the inter- 
 nal orifice of the hernia becoming larger, 
 and the inguinal canal shortened by the 
 approximation of its two orifices to each 
 other, it follows, that at the period when the 
 hernia begins to make its appearance in the 
 groin, the epigastric artery is unavoidably 
 situated behind the neck of the hernial sac, 
 and is pushed from the outer to the inner 
 side of the ring. Let us suppose a piece of 
 string to be passed from the inside of the 
 abdomen into the scrotum, all through the 
 inguinal canal, and the middle of the hernia ; 
 and that this string is pulled so as to bring 
 the internal orifice of the hernia, which is 
 situated beyond the point where Hie sperma- 
 tic cord crosses the epigastric artery ; this 
 artery will immediately be found to be car- 
 ried from the outer to the inner side of the 
 neck of the hernial sac. The same thing 
 happens from the effect of the enlargement of 
 the hernia. The removal of the epigastric ar- 
 tery from one side of the ring to the other, 
 (says Scarpa) isa phenomenon, which may be 
 regarded as almost constant in the inguinal 
 hernia. I have examined the bodies of a 
 great number of subjects, affected with this 
 species of hernia ; and it has been only in a 
 very few, that I met with the epigastric artery 
 retaining its natural situation on the outer 
 side of the abdominal ring. In investigating 
 the reason of this exception, I have obser- 
 ved, in ail the individuals who presented 
 it, a very remarkable weakness and ilaccidity 
 of that part of the abdominal parietes, which 
 extends from the flank to the pubes. Iti all 
 the displaced viscera had passed through Ike 
 aponeuroses of the transverse and internal ob- 
 lique muscles , notin the vicinity of the ilium, 
 as is commonly the case, but, at a little dis- 
 iance from the pubes, giving to the upper pil- 
 lar of the ring a curvature that is extraordi- 
 nary, and disproportioned to the smallness 
 of the hernia. I observed, also, that the neck 
 of the hernial sac did not pass in an oblique 
 direction, from the flank to the pubes, but, 
 that it protruded from the abdomen almost 
 in a direct line from behind forwards. In 
 short, in these individuals, the small cul-de- 
 sac of the peritoneum, which constitutes the 
 prigin of the hernial sac, had not begun to 
 be formed under the edge of th : transverse 
 muscle, at Ihe point where flie spermatic 
 
 cord runs ouhVard ; but, it hud passed through 
 the aponeuroses of ihe internal oblioue and 
 transverse muscles , at a little distance from th6 
 pubes, and within the point at which the sper- 
 matic eord crosses the epigastric artery. The 
 small hernial sac, having at this part come 
 into contact with and united to the sperma- 
 tic eord, protrudes at the external orifice of 
 the inguinal canal, without displacing the 
 epigastric artery from its natural situation. 
 
 This species of hernia, properly speaking, 
 isa mixture of the ventral and inguinal, it 
 resembles the former, inasmuch as the her- 
 nial sac pierces the aponeuroses of the transr 
 verse and internal oblique muscles ; the lat - 
 ter, inasmuch as it passes out at the abdomi- 
 nal ring, conjointly with the spermatic 
 cord.” ( Scarpa , Trade des Hernies,p. 68, fc.} 
 
 Hesseibach particularly adverts to a tri- 
 angular space to be seen on the inside 
 of the inguinal region : the upper bound- 
 ary of it is formed by the outer edge of 
 the rectus muscle ; the lower by the 
 horizontal branch of the os pubis ; and 
 the external shortest boundary by the 
 crural vein and epigastric artery. Now, 
 says he, when it is considered, that this 
 artery ascends obliquely inwards, between 
 the inner opening of the ring, and the 
 above triangular space, one cannot fail to 
 know on which side of the neck of the sac 
 the artery must lie in the two species of in- 
 guinal, as well as the crural, hernia; for, in 
 those hernia?, which originate in the above 
 triangular space, this artery lies at the outer 
 side of the neck of the hernial sac ; while, in 
 every hernia that takes place through the in- 
 ner opening of the inguinal canal, the same 
 vessel is situated at the inner side of the neck 
 of the sac. To one species of bubonocele, 
 Hesseibach applies the epithet external ; and 
 to the other, internal ; according to the si- 
 tuation of the point at which they first 
 protrude. The external inguinal hernia is 
 much more frequent than the internal, and 
 is said to happen oftener on the right, than 
 the left side of the body : a circumstance, 
 coinciding with another observation, viz. 
 that in children, the tunica vaginalis remains 
 longer open on the right titan the left side. 
 
 The circumstance of there being two 
 forms of inguinal hernia formerly caused 
 considerable perplexity : surgeons knew', 
 
 that the epigastric artery lay sometimes at 
 the inner, sometimes at the outer side of the 
 neck of the hernial sac, but knew not how 
 to account for this variation. Hence arose 
 the very different opinions about the proper 
 method of dividing the ring when the her- 
 nia was strangulated ; some authors direct- 
 ing the incision to be made obliquely in- 
 wards and upwards ; and others, upwards 
 and outwards. But, as a modern writer has 
 judiciously remarked, had they paid greater 
 attention to the direction of the swelling, 
 formed by the neck and body of Ihe hernial 
 sac in the groin, and to the position of the 
 spermatic cord, which is as inconstant as 
 that of the epigastric artery ; and had they 
 dissected the parts in the diseased, as w : ell 
 as healthy, state, they could not fail soon to 
 
have suspected, that every inguinal hernia 
 does not originate exactly at one and the 
 same point. For the first establishment of 
 this very important distinction, the world is 
 indebted to Mr. A. Cooper ; and the tract, 
 in which Hesselbach pointed out the fact in 
 a very particular manner, I believe, is the 
 next publication in which the subject is ex- 
 plained. {Anal. Chir. Abhandlnng fiber den 
 Ur sprung der Leistenbru ke, IVurxb. 180b ; 
 and JVeuste Anal. Pathol. Untersuehangen 
 abcr den Ursprung, fyc. der Leisten-und - 
 Schenkelbriiche, 41 o. IVurxb. 1814, p. 18. 2(5, 
 28, 4'C.) According to the latter author, 
 since each form of inguinal hernia also pre- 
 sents characteristic appearances externally* 
 the surgeon can have no difficulty in deter- 
 mining the species of hernia ; which dis- 
 crimination must he highly important in the 
 taxis, the application of atruss, and especially 
 the operation. The sac of the external 
 scrotal hernia can only pass down within 
 the expansion of the cremaster as far as this 
 part is separate from the cord and tunica 
 vaginalis. Hence, the testis, covered by its 
 tunica vaginalis, lies under the lowest part 
 of the hernial sac, while the vessels' of the 
 spermatic cord, in a more or less separated 
 form, are situated behind the posterior part 
 of the sac ; viz. the spermatic veins exter- 
 nally, and the vas deferens internally, and 
 the artery in the middle. Should the hernia 
 descend still further, the testis being inclu- 
 ded as well as the sac within the tendinous 
 expansion of the cremaster, it cannot glide 
 out of the way, but must be pressed still fur- 
 ther downwards by the sac, so as to con- 
 tinue invariably under its fundus, but some- 
 times inclined a little behind it. {Hes^clbaeh, 
 p. 34.) And, as the same author justly ob- 
 serves, the position of (be spermatic cord and 
 testis, and the oblique direction of the swell- 
 ing in the external species, are the two 
 strongest characters by which every case of 
 inguinal hernia may be discriminated. 
 
 Although the spermatic cord commonly 
 lies behind, or under, the hernial sac, there 
 are cases in which t lie vas deferens is found 
 on the cuter side of it, while the rest of the 
 spermatic cord lies, as it usually does, on 
 the inner side, or rather under it. (Cooper.) 
 Le Dran, Schmucker, and Blizard, found 
 the whole cord situated in front of the sac. 
 Sometimes the vas deferens runs on the front 
 and inner part, and the rest of the cord on 
 the back and external part of the swelling. 
 ( Camper , Hey.) The cord has been known 
 to be before, and the. vas deferens behind, 
 the sac. (Camper, A. Cooper.) 
 
 Upon this part of the subject, the reader 
 may deem the following passage interesting. 
 
 While the hernia is of moderate size, (says 
 Scarpa) the surrounding cellular substance 
 is not very greatly compressed, and no 
 change is observed in the situation of the 
 spermatic vessels. The artery and veins of 
 this nanSe always form, with tiie vas defer- 
 ens, one single cord, which is intimately ad- 
 herent to the posterior surface of the hernial 
 sac. But, in proportion as the tumour in- 
 creases in size, the cellular substance, which 
 
 immediately surrounds it, and unites it to the 
 spermatic cord, is more and more distended 
 and compressed. At length, at a certain pe- 
 riod, the distention is carried to such a pitch, 
 that the spermatic vessels are separated from 
 one another, and change their position with 
 respect to the hernial sac. This kind of 
 gradual unravelling of the spermatic cord 
 is quite similar to that, which w ould he pro- 
 duced by pulling the surrounding cellular 
 substance in two opposite directions. Such 
 is the reason, why in scrotal hernia of large 
 size, the spermatic artery, the vas deferens, 
 and the spermatic veins are found separated 
 upon the posterior surface of the sac. All 
 these vessels, instead of being conjoined in 
 one cord, are divided by interspaces, which 
 are sometimes very considerable. Ordina- 
 rily, the vas deferens is less separated from 
 the spermatic artery, than from the vein of 
 this name. In some subjects, Camper has 
 seen it situated on one side of the sac, and 
 the arlery and veins on the other. (leones 
 Herniarym, Tab. 5, L. O. Tab. 8. 1,2.) The. 
 displacement and splitting of the spermatic 
 cord take place equally in adults and in chil- 
 dren affected with 1 urge scrotal hernia?. 
 (Camper, loco cil.) In general, towards the up 
 per part and neck of the hernia, the vessels 
 are not much separated ; but as they proceed 
 downwards, they diverge more and more. 
 Sometimes, when the hernia is very old and 
 bulky, they are no longer found at the pos- 
 terior part, but rather at the sides, and even 
 on the front surface of the sac ; tiiey show 
 themselves thupugh the cremaster muscle, 
 which covers them, and form a sort of vas- 
 cular train, which arrests the hand of the 
 operator at the moment when he is about 
 to open the hernial sac. Le Dran relates, 
 that in operating upon a large scrotal hernia, 
 he found the spermatic cord on the anterior 
 surface of the hernial sac. ( Operations de 
 Cftir.p. 127.) This fact has been the cause 
 of numerous conjectures, and has appeared 
 altogether inconceivable to such surgeons 
 as have not been acquainted with the 
 changes, to which the spermatic cord is ex- 
 posed, in cases of large^scrotal hernia’. 
 (Lassus could not (Med. Opemt. T. 1, p. 
 152.) conceive the possibility of the occui- 
 rence.)" The observation of Le Dran is not 
 the less true and exact ; it exemplifies a vety 
 important fact, of which it is easy to give a 
 true explanation when the state of the sper- 
 matic cord in ordinary inguinal hernia’, and 
 in those which have obtained a considerable, 
 size, has bfeen comparatively examined. In 
 the first, the 'spermatic cord quite entire is 
 always found situated on the posterior 
 surface of the hernial sac ; but, in the second, 
 the spermatic vessels are so separated from 
 one another, that they sometimes extend 
 over the sides and even the forepart of the 
 hernial sac.” ( Scarpa , Trait ; des Herhie.Si 
 p. (51. <$-e.) 
 
 The hernial sac is commonly described as 
 an elongation of peritonauim. When more 
 minutely examined, however, it is found, in 
 cases of inguinal hernia, to consist of the 
 portion of peritoh;euin : pushed out with the 
 
20 
 
 Hernia 
 
 viscera ; of a layer 6f cellular substance on 
 the outside of this, which becomes more 
 or less thickened by the pressure of the 
 rupture in different cases} of a fascia, sent 
 off from the tendon of the external oblique 
 muscle ; and of the cremaster muscle, 
 which latter parts form the exterior cover- 
 which consisting of several layers, often 
 ■ ads the operator to fancy that he has open- 
 
 • cavity of the sac, when, in reality, he 
 bus not. 
 
 It is observed by Professor Scarpa, that 
 iho cremaster muscle, in cases of old large 
 rrotal hernia;, acquires a thickness, which 
 •> really surprising. Its fibres, which are 
 naturally very thin, become from four to 
 mx times more considerable. Being spread 
 over the neck and body of the hernial sac, 
 they sometimes present a remarkable con- 
 rosience, and a yellowish colour. Such al- 
 teration, however, does not prevent the 
 muscular texture from being discovered, 
 ad Haller was not mistaken about it. 
 {Op use. Palkolo g. p. 317.) Pathology fur- 
 nishes us with several examples of similar 
 changes of organization. In certain cases, 
 muscular coat of,tlie bladder, that of the 
 ; roach and intestines, and even the ex- 
 edingly delicate fleshy fibres of the liga- 
 ; its of the colon, are found to have be- 
 me yellow, and much thickened. 
 
 “ In old scrotal hernia? (says Scarpa) it is 
 
 • ! unusual to find an intimate adhesion of 
 
 fibres of the cremaster muscle to the 
 5 jges of the abdominal ring. This may de- 
 ad on the pressure, which the contents 
 ; the hernia makes on those edges, and per- 
 ; ps it may also depend on the union of 
 , r ^ remaster muscle with the prolongation 
 of me aponeurosis of the fascia lata, which 
 . i. ouimued from the margins of the ring to 
 .coin and scrotum. Howsoever it may 
 bi , certain it is, that in old large scrotal 
 . - map there is much difficulty in introdu- 
 cing a probe between the fleshy fibres of 
 cremaster and the margin of the abdomi- 
 .1 ring ; and that, on the contrary, in recent 
 herniae, a probe passes as easily between the 
 edges of the ring and the cremaster, as be- 
 iveen this muscle and the hernial sac. 
 
 “ Few authors (according to Scarpa) have 
 mken of tire sheath, formed by the cre- 
 ter muscle, in which are enclosed the 
 - .ml sac, the spermatic cord, and the tu- 
 ; ■> vaginalis of the testicle. Sharp (in 
 
 Uical Inquiry ) and Monro, the father, 
 and Chirurg. Works , p. 5£>3.) were 
 fhu first to dwell upon this important patho- 
 eal point. Monro had seen the cremas- 
 t«. prouscle covering the hernial sac } but he 
 not believe, that the same thing occur- 
 ln all individuals affected with inguinal 
 ■ : a. In this respect he was mistaken } 
 this disposition of the cremaster muscle 
 j-.- - of the essential characters of the dis- 
 
 Petit has not omitted to describe the 
 bn us which exist between the creraas- 
 ■ cl the hernial sac. (C Euvres Post hum. 
 
 ' > , p. 288.) On this subject, he even re- 
 , an interesting fact, from which it re- 
 that in verSarn ^ases ; this muscle may 
 
 by its contractions alone cause a reduction 
 of the hernia. Guntz explains, with tolera- 
 ble perspicuity, how the cremaster and its 
 aponeurosis form one of the coverings of 
 the inguinal and scrotal hernia. (Libellus de 
 Ilerniis , p. 50.) Morgagni once saw its 
 fleshy fibres extended over the hernial sac } 
 ( Dc sed. et cans. morb. epist. 34, art. 9; 
 cpist. 31, art. 15.) and Neubaver positively 
 assures us, that he made the same remark 
 upon the dead body of a man affected with 
 an emtero-epiplocele. ( Dissert . de Epiplo- 
 oscheocele.) After these facts, so positively 
 and accurately observed, I cannot compre- 
 hend (says Scarpa) how in our time Pott, 
 .Richter, and several other authors, should 
 have passed over in silence, or only men- 
 tioned vaguely, this point, so important in 
 the history of the inguinal and scrotal her- 
 nia.” ( Scarpa , Traiti des Hernics , p. 48, 50.) 
 
 When surgeons speak of a hernial sac be- 
 ing usually thicker and stronger, in propor- 
 tion to the magnitude and deration of the. 
 hernia, their language is not at all correct ; 
 for in fact, the peritoneal investment of 
 the hernia is seldom, or never, thus alter- 
 ed. I can declare (says Scarpa) after nu- 
 merous observations, that in the majority of 
 cases, the hernial sac, strictly so called, is 
 not perceptibly thickened, and that in gene- 
 ral it does not differ from other parts of the 
 peritonaeum, however large and old the 
 scrotal hernia may be. ( Trait6 des Her nies, 
 p. 53.) 
 
 In a very enormous hernia, the pressure 
 of the contents is so great, that instead of 
 thickening the sac, it renders it thinner, and 
 even makes it ulcerate. The protruded vis- 
 cera have been met with immediately be- 
 neath the integuments, when the sac has 
 been burst by a blow. ( Cooper ; J. L. Petit.) 
 
 The outer surface of the peritonaeal part 
 of the hernial sac, is always most closely ad- 
 herent to the other more external covering 
 by means of cellular substance. This con- 
 nexion is formed so soon, after the first 
 occurrence of a hernia, that any hopes of 
 returning a hernial sac into the abdomen 
 are now generally considered as chimerical. 
 There must, however, be a certain space of 
 time, before adhesions form, though it is, 
 no doubt, exceedingly short. 
 
 Upon this point, Scarpa does not adopt 
 the opinion commonly received. 
 
 There is no doubt, he observes, that in re- 
 cent and small inguinal hernias, the intes- 
 tine, strangulated by the neck of the hernial 
 sac, has been known, in more instances than 
 one, to have been reduced by the taxis, and 
 carried with it the whole of the sac into the 
 abdomen. Observations, not less authentic, 
 inform us, that after the operation for hernia, 
 when the viscera could not be reduced on 
 acbount of their adhesions to the sac, they 
 have been seen, notwithstanding such ad 
 hesions, to get nearer to the ring daily, and 
 at length, spontaneously to return into the 
 belly together with the hernial sac. Louis, 
 he thinks, was wrong in denying the possi- 
 bility of these facts. (sJead. Ptoyale de Chir. 
 T. 11 : p. 4SC».) 
 
HKKNIA. 
 
 Scarpk argues, that i: under certain cir- 
 cumstances, the cellular substance will bear, 
 without laceration, a considerable elonga- 
 tion, and afterward shrink again. Thus we 
 often see a viscus, which has suffered a con- 
 siderable displacement, return spontaneous- 
 ly into its natural situation. In the ingui- 
 nal hernia, the spermatic cord is elongated, 
 and descends farther, than in the natural 
 state. No laceration of the cellular sub- 
 stance, however, is then occasioned ; for, if 
 the hernia be kept reduced, the spermatic 
 cord becomes shorter, daily retracts, and at 
 last has only the same length, which it had 
 previously to the disease. When a sarco- 
 cele becomes large and heavy, the portion 
 of the spermatic cord naturally situated 
 within the belly, is by degrees drawn out 
 into the scrotum ; but, after the tumour is 
 extirpated, this portion ascends again, and 
 of itself returns into its original situation. 
 
 “ The same thing happens after the ope- 
 ration for the strangulated inguinal hernia. 
 All practitioners have noticed, that the 
 hernial sac retracts and reascends progres- 
 sively towards the ring. This alone would 
 prove, that the cellular substance, which 
 surrounds the spermatic cord, and unites it 
 to the hernial sac, is highly endued with 
 the property of yielding, and afterward re- 
 turning to its original state. Can the same 
 property be refused to the cellular sub- 
 stance, which unites the sac to the cremas- 
 ter muscle and other surrounding parts ? 
 
 “ While the inguinal hernia is recent, and 
 not of much size, the cellular substance in 
 question, possesses all its elasticity, and 
 lienee, the hernial sac and the spermatic 
 cord, may easily ascend towards the abdo- 
 minal ring. I have had occasion (says 
 Scarpa) to make this observation upon the 
 dead body of a man, who had an incipent 
 inguinal hernia. The small hernial sac was 
 capable of being pushed back into the ring 
 with the utmost facility ; and in carefully 
 examining the parts, both within and with- 
 out the belly, it appeared to me, that the 
 cellular substance, which united the sac to 
 the spermatic cord and cremaster muscle, 
 was disposed to yield equally from without 
 inwards, and in the direction precisely op- 
 posite ; that is to say, it made an equal re- 
 sistance to the protrusion and the reduction 
 of the hernial sac. Monteggia has seen a 
 case exactly similar : although, according 
 to his own expressions, ( Inslituz . Chirurg. 
 T. 3, ses. 2, p. 249,) the hernial sac was not 
 very small, it adhered very loosely to the 
 surrounding parts, and it admitted of being 
 entirely reduced into the abdomen with 
 great facility.” 
 
 In large old scrotal hernias, Scarpa allows, 
 that such reduction is quite impracticable : 
 c; Iu these, the cellular substance, which 
 unites the sac to the spermatic cord, and 
 cremaster muscle, has acquired such a den- 
 sity, that it does not oppose less resistance 
 to the further enlargement of the hernia, 
 than to the efforts of the surgeon, who en- 
 deavours to effect its reduction.” ( Scarpa , 
 Traiti das Hernias, p. -57. <*c.) Though 
 
 Scarpa thus reasons about the elasticity of 
 the cellular substance, as forming the con - 
 nexion between the sac and surrounding 
 parts, many surgeons would refer the con- 
 nexion to the adhesive inflammation, and 
 explain the diminution and shrinking of 
 parts, after the distention and weight are 
 removed, not by the elasticity of the cellu- 
 lar substance in particular, but by thesamo 
 property inherent generally in the elonga- 
 ted parts, which elasticity, and the action 
 of the absorbents together, produce the al- 
 teration in question 
 
 We shall conclude this anatomical account 
 of the inguinal hernia, with the following 
 explanation of the parts as they appear on 
 dissection : “ the removal of the integu- 
 ments exposes the exterior investment of 
 the hernial tumour, continuous with the 
 margins of the ring, and formed of tendi- 
 nous fibres from the aponeurosis, the cre- 
 master muscle, &c. This is connected by 
 cellular substance with the. proper hernial 
 sac, formed of the peritonamm. This pro- 
 duction of the peritonaeum passes within 
 the ring of the external oblique, and then 
 goes upwards and outwards. Behind ami 
 above the ring, the inferior margin of the 
 obliquus internus and transversalis crosses 
 the neck of the sac When these muscles 
 are reflected towards the linea alba, the 
 fascia, ascending from Poupart’s ligament, 
 and forming the upper opening of the ring, 
 is exposed, and the epigastric artery is dis- 
 covered emerging from the inner side of 
 the neck of the hernial sac, ( Campari leones, 
 Tab. X. F. M.) which, at this precise point, 
 becomes continuous with the peritonaeum, 
 lining the abdomen. The removal of the 
 hernial sac will disclose the course of the 
 spermatic cord in its descent towards the 
 testicle ; and when this is also elevated, the 
 first part of the course of the epigastric ar- 
 tery, and its origin from the iliac trunk, are 
 exposed.” ( Lawrence on Hernia , p. 182 
 Edit. 3.) 
 
 In females, the round ligament of the ute- 
 rus bears the same relation to the tumour, 
 as the spermatic cord in males. In the 
 former subjects, bubonoceles are uncommon. 
 Mr. Lawrence had a very rare instance 
 pointed out to him, in which a bubonocele 
 in a female was situated on the inner side of 
 the epigastric artery. A still rarer case was 
 examined by Hesselbach : it was not only 
 an example of internal bubonocele in a 
 woman, but of one in which the epigastric 
 artery arose from the obturatrix artery an 
 inch from the origin of this latter vessel 
 from the inner side of the external iliac : 
 the obturatrix first passed an inch obliquelv 
 downwards and inwards over the crural 
 vein, and immediately afterward, on the ho- 
 rizontal ramus of the pubes, made a sudden 
 turn backward and downward to the obtu- 
 rator foramen ; and at this bend arose the 
 epigastric artery, which ran transversely in- 
 ward along the horizontal ramus of the 
 pubes, behind the neck of the hernial sac, 
 at the inner side of which it ascended to 
 the rectus muscle, accompanied by the llga- 
 
HERNIA. 
 
 mentous remains of the umbilical arteries, 
 which were close behind it. ( Uebcr den 
 Ursprung, fyc. der Ltislen und Schenkel- 
 brtiche, p. 17.) 
 
 MARKS OF DISCRIMINATION BETWEEN OTHER 
 DISEASES AND INGUINAL HERNIA:. 
 
 The disorders, in which a mistake may 
 possibly be made, are Cirsocele, Bubo , Hy- 
 drocele, and Hernia Humoralis, or Inflamed 
 Testicle. 
 
 For an account of the manner of distin- 
 guishing the first complaint from a bubono- 
 cele, see Cirsocelc. 
 
 u The circumscribed incompressible hard- 
 ness, the situation of the tumour, and its 
 being free from all connexion with the 
 spermatic process, will sufficiently point out 
 a bubo, at least while it is in a recent state; 
 arid when it is in any degree suppurated, he 
 must have a very small share of the Indus 
 eruditus , who cannot feel the difference be- 
 tween matter, and either a piece of intes- 
 tine, or omentum. 
 
 “ The perfect equality of the whole tu- 
 mour, the freedom and smallness of the 
 spermatic process above it, the power of 
 feeling the spermatic vessels and the vas de- 
 ferens in that process, its being void of pain 
 upon being handled, the fluctuation of the 
 water, the gradual formation of the swelling, 
 its having begun below and proceeded up- 
 wards, its not being affected by any pos- 
 ture or action of the patient, nor increased 
 by his coughing or sneezing, together with 
 the absolute impossibility of feeling the tes- 
 ticle at the bottom of the scrotum, will al- 
 ways, to an intelligent person, prove the 
 disease to be a hydrocele.” Mr. Fott, how- 
 ever, allows that there are some exceptions, 
 in which the testicle cannot be felt at the 
 bottom of the scrotum in cases of hernia. 
 “In recent bubonoceles, while the hernial 
 sac is thin, has not been long, or very much 
 distended, and the scrotum still preserves a 
 regularity of figure, the testicle may almost 
 always be easily felt at (lie inferior and pos- 
 terior part of the tumour. But in old rup- 
 tures, which have been long down, in 
 which the quantity of contents is large, the 
 sac considerably thickened, and the scro- 
 tum of an irregular figure, the testicle fre- 
 quently cannot be felt, neither is it in gene- 
 ral easily felt in the congenital hernia for 
 obvious reasons.” (Pott.) 
 
 “ In the hernia humoralis , the pain in the 
 testicle, its enlargement, the hardened state 
 of the epidydimis, and the exemption of the 
 spermatic cord from all unnatural fulness, 
 are such marks as cannot easily be mistaken ; 
 not to mention the generally preceding go- 
 norrhoea. But, if any doubt still remains of 
 the true nature of the disease, the progress 
 of it from above downward, its different 
 state arid size in different postures, particu- 
 larly lying and standing, together with its 
 descent and ascent, will, if duly attended to, 
 put it out of all doubt, that the tumour is a 
 true hernia (Poll.) 
 
 When an inguinal hernia docs not de- 
 
 scend through the abdominal ring, but only 
 into the canal for the spermatic cord, it is co- 
 vered by the aponeurosis of the external 
 oblique muscle, and the swelling is small 
 and undefined. 
 
 Now and then, the testicle does not de- 
 scend into the scrotum till a late period, and 
 its first appearance at the ring, in order to get 
 into its natural situation, may be mistaken 
 for a hernia, unless the surgeon pay atlen- 
 tion to the absence of the testicle from the 
 scrotum, and the peculiar sensation occa- 
 sioned by pressing the swelling. 
 
 POINTS OF DIFFERENCE BETWEEN THE EX- 
 TERNAL AND INTERNAL INGUINAL HER- 
 NIA, &ic. 
 
 According to Hesselbach, the characteris- 
 tic marks of the external bubonocele and 
 scrotal hernia are ; 1st. The direction of 
 the tumour in the groin. 2dly. The fleshy 
 fibres of the cremaster. 3dly. The position of 
 the spermatic cord and testis. 4thly. The 
 situation of the epigastric artery. 5th ly. 
 The origin of the hernia itself. 6th ly. A 
 preternatural shape of the body of the her- 
 nial sac. 
 
 1. The neck of the hernial sac, distended 
 by the protruded viscera, raises up the front 
 side of the inguinal canal, and superincum- 
 bent integuments, into an oblong swelling, 
 which extends obliquely inwards and down- 
 wards towards (he abdominal ring, and ter- 
 minates in the tumour, formed by the body 
 of the hernial sac. From its origin it be- 
 comes gradually more prominent and broad, 
 and the greater the quantity of viscera pro- 
 truded, and the larger the body of the sac, 
 the more manifest is this oblique swelling, 
 particularly when the neck of the hernia is 
 of its natural length. In slrangulated cases, 
 the direction of the tumour is still more 
 striking, every part of the hernial sac being 
 then considerably distended. When the in- 
 guinal canal, and of course the neck of the 
 liernial sac are shortened, the swelling under- 
 goes a proportional diminution in its length ; 
 and then its resemblance to the tumour at- 
 tending an internal inguinal hernia, where 
 the opening through which the parls pass, is 
 long and slanting, is so great, that the cases 
 can only be discriminated by one circum- 
 stance, viz. the situation of the spermatic 
 cord, and even this criterion is of course 
 wanting in females. ( Hesselbach , p. 57, 58,) 
 Hesselbach clearly explains, that he obli- 
 quity of the swelling is seated in the neck of 
 the hernial sac. He observes, that when an 
 internal bubonocele in a female subject 
 passes into the labium, the descent takes 
 place in a very sloping direction inwards, 
 and therefore, may at first be supposed to be 
 an external case. But, on further examina- 
 tion, the oblique swelling will be found to 
 occupy Ihe body of the hernial sac, and to 
 reach upwards and outwards from the la- 
 bium to the abdominal ring. Now this her- 
 nia cannot bo mistaken for an external bu- 
 bonoceie, the course of which from the 
 ring is obliquely upwards and outwards. 
 
.HERNIA, 
 
 llcsselbach reminds us, that an internal, 
 inguinal, or scrotal hernia may be conjoined 
 with an external incomplete bubonocele ; a 
 kind of case easily made out with a little at- 
 tention ; for the place of division between 
 the two sacs is indicated by a more or less 
 deep groove, ihe nature of the disease will 
 also be still dearer, if one ot the tumours 
 admit of reduction. A specimen of such a 
 double hernia is to be seen in the museum at 
 Wurzburg. 
 
 It is further noticed by Hesselbach, that, 
 when the situations of the external and in- 
 ternal hernia) are compared, the first of these 
 swellings will be found to be rather further 
 than the other, from the symphysis of the 
 pubes : a difference ascribed to the effect of 
 the internal oblique muscle, the lower fibres 
 of which, attached to the horizontal ramus 
 of the pubes, run in a curved direction trans- 
 versely over the anterior and inner part ot 
 the neck of the hernial sac, and are applied 
 so closely to it, that it cannot approach quite 
 so much towards the symphysis of the pubes 
 as the neck of the internal bubonocele does. 
 The muscular fibres in question are situated 
 directly behind the inner pillar of the abdo- 
 minal ring. 
 
 2. Most of the fibres of the cremaster lie 
 
 on the back of the neck of the sac, blit 
 others are also scattered over its external 
 and internal sides: Some fibres may also 
 
 be perceived on its forepart, which are re- 
 markable, because they run in a transverse 
 curved direction with their convexity down- 
 wards, and two fasciculi of which descend 
 below the abdominal ring. These are the 
 fibres of the cremaster, which proceed within 
 the ring transversely upwards over the sper- 
 matic cord, and are pushed out of that 
 opening by ihe hernial sac. These arched 
 fleshy fibres are not always, though gene- 
 rally, perceptible ; and, when they are pre- 
 sent on the forepart of the hernial sac, Hes- 
 selbach accounts them a sure criterion of an 
 external scrotal hernia ; but, he has not yet 
 ascertained, whether they are visible, while 
 the rupture is confined to the groin. 
 
 3. The situation of the spermatic cord and 
 testis in the external inguinal hernia, and, 
 
 4. That of the epigastric artery, and its 
 displacement inwards by the neck of the sac, 
 have been sufficiently explained. 
 
 5. With respect to the mode, in which the 
 hernia originates, the disease often takes 
 place suddenly, without any exciting cause 
 being observed, capable of accounting for 
 the effect. Here, says Hesselbach, the pre- 
 disposing cause must have been great ; for 
 instance, the communication between the 
 cavity of the peritonaeum and that of the 
 tunica vaginalis has remained a long while 
 unclosed ; and, when a hernia of this de- 
 scription is examined, the other marks of an 
 external inguinal hernia are associated with 
 the sudden formation of the disease. In this 
 quick manner, the congenital hernia, which 
 is one of the external cases, frequently 
 .arises. The internal inguinal hernia is also 
 observed mostly to take place very sud- 
 
 denly, yet only after violent occasional 
 causes. 
 
 6. A preternatural form of the body of the 
 hernial sac, Hesselbach remarks, is particu- 
 larly sealed in the shettth of the spermatic 
 cord, and can never happen in the internal 
 scrotal hernia; for, it is only in- external 
 cases, that the above sheath is ever convert- 
 ed into the hernial sac. Hesselbach here 
 refers to the -partial contraction, often no- 
 ticed at the lower part of the above sheath 
 in cases of congenital hernia ; a circum- 
 stance, which is always discovered previ- 
 ously to the business of dividing the ring. 
 
 In adults, an external inguinal, or scrotal 
 hernia, on the right side, contains some 
 of the ileum, and, when the swelling is 
 large, it may include the ccecum, and some- 
 times a piece of omentum. In one child, 
 ten weeks old, and in another still younger, 
 the appendix vermiformis was protruded and 
 connected by a natural band to the posterior 
 side of the peritonaeum. When, in these 
 ruptures of the right side, the ccecum, or, in 
 those of the left, the colon are met with, 
 closely adherent to the hinder side of the 
 hernial sac, the adhesion is not to be looked 
 upon as the effect of disease, since it is the 
 perfectly natural connexion of those bowels 
 with the peritonaeum. On the left side, the 
 parts most commonly protruded are the 
 colon and omentum. 
 
 With regard to the internal inguinal hernia, 
 the place of its first protrusion has , been 
 already described. The protruded perito- 
 naeum and viscera, accordingto Hesselbach’s 
 account, pass from behind straight forwards , 
 between the fibres of what he names the in- 
 ternal inguinal ligament, and the fleshy fibres 
 of the internal oblique muscle : they then 
 pass, at the inner side of the spermatic cord, 
 out of the abdominal ring, where the hernia 
 presents a circular globular swelling, sud- 
 denly formed in consequence of some violent 
 effort. The neck of the hernial sac is very 
 short ; shorter than it can ever be in an ex- 
 ternal inguinal hernia, and, when the tumour 
 is of Uthe above shape, the passage through 
 which it passes is annular, narrower. in some 
 instances than others, and its margin is ten- 
 dinous. From the few cases, which Hessel- 
 bach has seen of this form of the disease, he 
 is led to conjecture, that the hernial sac is 
 rarely so large as in the external inguinal 
 hernia. (jP. 41.) The earlier dissections 
 made by Hesselbach, led him to suppose, 
 that, in the internal inguinal hernia, the 
 opening, through which the protrusion hap- 
 pens, is always annular, and the swelling in 
 front ot the ring globular ; b it subsequent 
 cases, which he has met with, have informed 
 him, that the opening is frequently sloping 
 and longisb, in which circumstance, the re- 
 semblance of the tumour to that of the ex- 
 ternal bubonocele with a shortened neck, is 
 such, that the only mark of distinction be- 
 tween the two cases is the position of the 
 spermatic cord. In females, even this crite- 
 rion is of course deficient. ( Hesselbach , p. 
 57.) Though individuals of almost every 
 age are subject to internal bubonoceles, they 
 
24 
 
 HERNIA. 
 
 arc much less common than external cases. 
 According to Hesselbach, they may be 
 known by the following characters. 1. The 
 swelling, formed by the body of the hernial 
 sac, immediately in front of the abdominal 
 ring. 2. The situation of the spermatic 
 cord. 3. That of the epigastric artery. 
 
 1. The neck of the hernial sac, besides 
 being very short, does not, like that of an 
 external inguinal hernia, take an oblique di- 
 rection, but advances straight from behind 
 forwards through the abdominal ring, and as 
 the body of the sac lies directly over the 
 neck, none of the swelling, formed by the 
 distention of the latter part, can bo felt. 
 Nor does any other tumour, produced by the 
 body a hernial sac, ever cause a circular 
 spherical swelling directly before the abdo- 
 minal ring. The situation of the neck of this 
 kind of hernia must already apprise us, that 
 the internal bubonocele is nearer, than the 
 external, to the symphysis of the pubes. In 
 women, the shape of the tumour is the only 
 character, by which the case can be distin- 
 guished. (Hesselbach, p. 43.) 
 
 2. After what has been already stated, re- 
 specting the situation of the spermatic cord 
 in the internal inguinal hernia, I shall 
 merely notice one or two observations of 
 Hesselbach. The cord lies either upon the 
 outer side, or outer half of the forepart of 
 the upper portion of the hernial sac, the 
 blood-vessels forwards, and the vas defer- 
 ens backwards. When the sac is adherent 
 to the whole length of the cord, the testis is 
 not situated under the fundus of the sac, as 
 in the external scrotal hernia, but either at 
 the forepart or outer side of the body of the 
 sac. The hernial sac, as far as the abdominal 
 ring, is excluded from the common perito- 
 naea! covering of the spermatic cord, but at 
 this opening, it descends between the cord 
 and the internal thin part of the sheath of 
 the cremaster, which, how r ever, is somewhat 
 stronger towards the front and outer side of 
 the hernia, over which part alone the fleshy 
 fibres of the cremaster are spread. (P. 44.) 
 
 3. The epigastric artery always ascends ob- 
 liquely Inwards at the outer side of the neck 
 of the hernial sac. Hesselbach has never 
 seen but one case of internal bubonocele, in 
 which there was a deviation from this rule. 
 The example has been already mentioned, 
 and was one in the epigastric artery, arose 
 from the obturatrix about an inch from the 
 origin of this last vessel. The viscera, usually 
 contained in an internal inguinal, or scrotal 
 hernia, on the right side, are the lower part 
 of the small intestines, and sometimes 
 omentum ; on the left, a paid of the 
 small intestines, frequently omentum, and 
 when the tumour is large, the colon 
 may also protrude. A protrusion of the 
 bladder may accompany the disease, but 
 that organ is of course always excluded from 
 the cavity of the hernial sac. When the re- 
 mains of the umbilical cord are situated 
 more outward than usual, and lie over the 
 centre of the space, at which the protrusion 
 happens, an internal bubonocele may he 
 double, the prolapsus happening on each 
 
 side of that ligamentous substance, which isf 
 itself also pushed outwards. In consequence, 
 of the accidental presence of some very 
 strong tendinous fibres at the centre of the 
 fascia, called by Hesselbach the internal 
 inguinal ligament, there may also he two 
 distinct protrusions, with separate hernial 
 sacs. (P. 46.) 
 
 When the surgeon, by a due consideration 
 of the foregoing circumstances, has formed a 
 judgment respecting the nature of the her- 
 nia, he will be better qualified to regulate 
 the treatment of the case. Thus, in the ex- 
 ternal inguinal hernia, he will know, that 
 the pressure, employed for the reduction of 
 the bowels, should be made in the direction 
 of the neck of the hernial sac, viz. obliquely 
 upwards and outwards, towards the anterior 
 superior spinous process of the ilium; 
 but that, when the neck of the same 
 kind of hernia is very short, and the poste- 
 rior side of the inguinal canal has been re- 
 moved, the pressure should he made nearly 
 in a straight line from before backwards. 
 For what Hesselbach terms the long-necked 
 external inguinal hernia, the pad of a truss 
 should be so constructed, as not merely to 
 press upon the abdominal ring, but also 
 upon the neck of the sac and the inner 
 opening of the inguinal canal. But, when 
 the neck of the hernia is very short, the 
 pad should be nearly of the same form, as 
 that required for an internal inguinal hernia. 
 ( Hesselbach , p. 38; and Brunninghausen, Ge- 
 meinnutziger Unlerricht fiber die Bruche, fyc. 
 Wurzb. 1811.) In attempting the reduction 
 of an internal inguinal hernia, the pressure 
 should be directed nearly straight back- 
 wards ; and the pad of the truss should only 
 act upon the abdominal ring. (Hesselbach, 
 p. 46.) 
 
 THE OPERATION FOR STRANGULATED INGUI- 
 NAL HERNIA, OR BUBONOCELE 
 
 Consists in dividing the integuments ; dis- 
 secting down to the sac, and opening it; 
 removing the stricture ; and replacing the 
 protruded viscera. 
 
 The external incision should begin an 
 inch above the external angle of the ring, 
 and extend over the middle of the tumour 
 to its lower part. The advantage of begin- 
 ning the wound so high, is to obtain con- 
 venient room for the incision of the stric- 
 ture. By this first cut, the external pudic 
 branch of the femoral artery may be divi- 
 ded ; it crosses the hernial sac near the abdo- 
 minal ring, and sometimes bleeds so freely, 
 as to require to be immediately tied. In 
 general, however, a ligature is unneces- 
 sary. 
 
 When this incision is carried low down, the 
 caution, given by Camper, should always 
 he remembered, viz. that there is a possibili- 
 ty of dividing the spermatic vessels, should 
 they happen to be situated, as they some- 
 times are, in front of the hernia. And, 
 in order to avoid such an accident, which is 
 particularly apt to occur in cases of internal 
 inguinal, or scrotal hernia, the incision 
 
.'HERNIA. 
 
 through the skin should be made obliquely 
 downwards and inwards. ( Hesselbach , jj. 
 
 • 46 .) The division of the integuments brings 
 into view the fascia, which is sent off from 
 the tendon of the external oblique muscle, 
 and covers the hernial sac. 
 
 The layers of tendinous fibres, cellular 
 substance, &.c. intervening between the skin 
 and sac, should be carefully divided, one 
 after another, with the knife and dissecting 
 forceps, the edge of the former instrument be- 
 ing turned horizontally, lest the incisions be 
 carried too deeply at once, and the viscera 
 contained in the sac wounded. 
 
 .After making a small opening through a 
 part of the fascia covering the sac, some 
 practitioners introduce a director, and di- 
 vide this fascia upward and downward as 
 far as the tumour extends. The same man- 
 ner they next pursue with regard to the cre- 
 master muscle. Thus the sac .becomes 
 completely exposed. When this method is 
 followed, Mr. A. Coope; advises the inci- 
 sions not to be carried upward, nearer than 
 ona ; nch,to the abdominal ring, for reasons 
 which will be presently explained. 
 
 However, it may be rationally doubted, 
 whether there is any good in these formal 
 and successive divisions of the whole length 
 oftke coverings of the sac ; and it is certain, 
 that they protract the operation very much ; 
 for the manner in which the sac adheres to 
 the outer investment of it, prevents the lat- 
 ter from being raised and cut without trou- 
 ble rnd delay. As the grand object, after 
 the skin has been divided, is to make a small 
 opening into the sac, sufficient for the intro- 
 duction of a director, dissecting down at one 
 particular place answers every purpose, and 
 enables us, in the end, to lay open the whole 
 of the sac and its coverings in the shortest 
 time. Let the operator only take care to 
 raise the successive layers of fibres with the 
 forceps, and divide the apex of each eleva- 
 ted portion with the knife held horizontally. 
 As there is commonly a quantity of fluid in 
 the sac, and it gravitates to the lower part, 
 to which place the intestine seldom quite 
 descends ; this is certainly the safest situa- 
 tion for making the first opening into the 
 sac. The operator, however, should not 
 rely upon the presence of such fluid, and 
 cut too boldly , for sometimes it is absent, 
 and the viscera may be in immediate con- 
 tact with, nay, adherent to, the inner sur- 
 face of the sac. 
 
 The circular arrangement of the vessels of 
 a piece of intestine, and its smooth polished 
 surface, sufficiently distinguish it from the 
 hernial sac, which has a rough cellular sur- 
 face, and is always connected with the sur- 
 rounding parts, although these adhesions, in 
 a very recent case, may be but slight. 
 
 ( Lawrence on Ruptures , p. 214, Edit. 3.) 
 
 I have mentioned, that Mr. A. Cooper 
 only advises cutting the fascia, and other 
 coverings of the sac, under the skin, to 
 within an inch of the abdominal ring; and, 
 of course, he also recommends limiting 
 the division of the sac itself to the same ex- 
 tent. His reasons for this practice, are to 
 Vor . I k 1 
 
 avoid making the closure of the wound 
 more difficult, and to lessen the danger of 
 peritonaial inflammation. 
 
 Having laid open the hernial sac with a 
 probe-pointed bistoury, guided by a direc- 
 tor, or the fore-finger introduced into the 
 opening, made at the lower part of the sac, 
 the next desideratum is to divide the stric- 
 ture, unless the viscera admit of being easily 
 reduced, without such an incision being 
 made as occasionally happens. 
 
 From the anatomical account, which has 
 been given of the bubonocele, it appears, 
 that the stricture may either be situated at 
 the abdominal ring, and be formed by the 
 margins of this opening, or else at the inner 
 aperture of the canal, about one inch and a 
 half, in a direction upward and outward, 
 from the outer opening in the tendon of the 
 external oblique muscle. This latter stran- 
 gulation is caused by the semicircular edge 
 of the transversalis muscle and its tendon, 
 which pass over the neck of the hernial sa(T, 
 and by a fascia, arising from Poupart’s liga- 
 ment, the semicircular border of which 
 passes under this part of the sac. 
 
 'file common, and probably the best prac- 
 tice is to divide the hernia! sac, together 
 with the stricture. When this is situated at 
 the abdominal ring, the surgeon is to intro- 
 duce the end of a director a little way into 
 the neck of the sac, within the aperture in 
 the tendon, and with a probe-pointed bis- 
 toury, guided on the latter instrument, he is 
 to cut the stricture upward and outward, or 
 else directly upward ; a manner, which Mr. 
 A. Cooper recommends, because it is appli- 
 cable to all cases, even the less frequent 
 ones, in which the hernia protrudes at the. 
 inner side of the epigastric artery; and, in 
 all common instances, vre know, that this 
 vessel runs upward round the inner side of 
 the neck of the sac ; a course prohibiting 
 the division of the stricture upward and in- 
 ward. 
 
 fn the external inguinal hernia, the me- 
 thod of cutting the stricture upward and 
 outward is perfectly safe ; but when the 
 case is what Hesselbach calls internal, and 
 the viscera descend on the inner side of the 
 epigastric artery; it is a plan which would 
 endanger the latter vessel, and ought never 
 to be adopted, notwithstanding any state- 
 ment made in its favour by Rudlorfier. Ab- 
 handlung iiber die einfachsle und sichersle 
 opcrations-Methodc eingesperrier Leislcn-und- 
 Schenkelbriiche. Wien. 1808.) Tn this work 
 the erroneous plan of cutting the ring in- 
 wards is inculcated, both in the external and 
 internal inguinal rapture. The author, how- 
 ever, seems to have performed many opera- 
 tions in this manner, without any accident 
 from hemorrhage; a piece of good fortune, 
 which Professor Langenbeck ascribes to the 
 circumstance of the knife having always 
 been applied, as iludtorffer directs, to the 
 middle of the inner pillar of the ring, and to 
 the cut having been very limited. Langen- 
 beck is of opinion, that, if the knife bad been 
 applied a little lower, and the incision car- 
 ried to any extent, the epigastric artery, in 
 
HERNIA. 
 
 ordinary oases, would not have escaped 
 injury. !\Ir. A. Cooper’s rule of always 
 cutting in one direction, viz. upward, which 
 I believe was first advised by Autenrieth, D/s- 
 serf. Moment, circa Hernia tom. prcccipue circa 
 evitandam art. epigastr. loesionem , , Tub. 1799) 
 is perhaps a very good one, because it is at 
 least easy for the memory, and will answer 
 very well even when it is not in the power 
 of the surgeon to pronounce positively whe- 
 ther the case is a short-necked external hu- 
 bonocele, or an internal one with an oblong 
 oval fissure, cases having a great external 
 resemblance, especially in women, in whom 
 there is not the spermatic cord as a crite- 
 rion ; for, after all, this part, when present, 
 is the surest guide, and that on which De- 
 sault founded his perfectly safe advice, viz. 
 when the cord is at the posterior or inner 
 side of the neck of the hernial sack, to divide 
 the ring upwards and outwards, but inwards 
 and upwards when it lay at the outer or on 
 the forepart of the sac. ( CEuvres Chir. de 
 Bichat , T. 2.) At least, this advice is sub- 
 ject but to one exception, which is the very 
 rare one of the epigastric running round the 
 inner side of the neck of the sac in an inter- 
 nal bubonocele ; a possibility which has 
 been already explained, and which leads 
 Hesselbach particularly to recommend the 
 division of the ring in every internal ingui- 
 nal hernia, to be made straight upwards. 
 ( P . 47.) Indeed, the long-necked external 
 bubonocele is the only case in which he 
 thinks the latter plan should give way to 
 that of cutting upwards and outwards. The 
 safety and propriety of the method of 
 always cutting upward, are strikingly illus- 
 trated by what Scarpa observes : he states, 
 that the right direction of the incision of the 
 ring is directly upwards, parallel to the 
 lineaalba. “ I have (says lie) operated in 
 the way which 1 recommend upon several 
 dead subjects, who had either external or 
 internal inguinal hernia?, directing my inci- 
 sion in the course of a line drawn from the 
 upper part of the ring parallel to the linea 
 alba; in all, I constantly left the epigastric 
 artery untouched, even when I extended the 
 cut about an inch above the inguinal ring.” 
 ( Scarpa , Traiti Pratique des Ilernies, p. 111.) 
 Only one objection, as far as I know, has 
 been made to this plan, and it is founded on 
 the alleged impossibility of introducing the 
 knife, so as to cut straight upwards, when 
 the neck of the hernial sac is long, because 
 then the posterior side of the inguinal canal 
 is in the way. ( Hesselbach , p. 40.) No more 
 of the parts forming the stricture, should be 
 cut than is just sufficient for allowing the 
 protruded viscera to be reduced without 
 bruising or otherwise hurting them ; and I 
 consider the middle of the upper margin of 
 the ring the safest place for making the ne- 
 cessary incision. 
 
 Mr. A. Cooper, in his valuable work on 
 the Inguinal Hernia, advises a mode of di- 
 viding the stricture, considerably different 
 from the usual method. He directs the fin- 
 ger of the operator to be introduced into the 
 sac, (which, in his plan, we know is left un- 
 
 divided for the space of one ipch below Ihc 
 ring.) When the stricture is felt, a probe- 
 pointed bistoury is to be conveyed over the 
 front of the sac into the ring (between the 
 two parts.) and the latter only is then 1o be 
 divided, in the direction upward, opposite 
 the middle of the neck of the sack, and to 
 an extent just sufficient to allow the protru- 
 ded parts to be returned into the abdomen 
 without their being hurt. The two chief 
 advantages which Mr. A. Cooper imputes to 
 this method, are, that the danger of perito- 
 neal inflammation will be less, and that the 
 epigastric artery, if wounded, would not 
 bleed into the abdomen. 1 am of opinion, 
 that Mr. Lawrence’s remarks, concerning 
 this proposal, are judicious : “ An accurate 
 comparative trial of both methods would be 
 necessary, in order to determine the weight 
 of the first reason. The second circum- 
 stance cannot be a matter of any importance, 
 if we cut in such a direction as to avoid the 
 risk of wounding the artery. Many circum- 
 stances present themselves as objections to 
 this proposal. The manoeuvre itself, although 
 perhaps easy to the experienced hand of 
 such an able anatomist as Mr. C., would, I 
 am convinced, be found highly difficult, if 
 not impracticable, by the generality of sur- 
 geons. This difficulty arises from the firm 
 manner in which the sac and surrounding 
 parts are connected, we might almost say 
 consolidated, together. The experience of 
 of Richter (Traitd des Hernies, p. 118) shows, 
 that this objection is founded in reality. He 
 once tried to divide the ring, without cut- 
 ting the sac, but lie found it impracticable. 
 If the stricture is so tight as to prevent the 
 introduction of the finger, there must be 
 great danger of wounding the protruded 
 parts. The practice would still be not 
 adviseable, even if it could be rendered as 
 easy as the common method of operating. 
 Mr. C. leaves an inch of the sac, below the 
 ring, undivided ; thus a bag remains ready 
 to receive any future protrusion, and the 
 chance of a radical cure is diminished. 
 It would be better to follow the advice of 
 Richter, and scarify the neck of the sac, in 
 order to promore an adhesion of its side?. 
 He has found this practice so successful in 
 accomplishing a radical cure, that he ad- 
 vises (p. 191.) its employment in every 
 operation for strangulated hernia.” (See 
 Lawrence on Ruptures, p. 321, Edit. 3.) 
 
 If the stricture should be at the inner 
 opening of the canal for the spermatic cord, 
 Mr. A. Cooper advises the operator to intro- 
 duce his finger into the sac, as far as the 
 stricture, and then to insinuate a probe- 
 pointed bistoury, with the flat part of its 
 blade turned towards the finger, between 
 the front of the sac and the abdominal ring, 
 till it arrives under the stricture, formed by 
 the lower edge of the transversalis and obli- 
 quus interims. Then the edge of the instru- 
 ment is to be turned forward, and the stric- 
 ture cut in the direction upward. This plan 
 of not cutting the neck of the sac, is liable 
 to all the objections stated by Mr. Law- 
 rence, in regard to the case in which the 
 
HE KM 
 
 27 
 
 strangulation takes place at the abdominal 
 ring. Mr. A. Cooper’s bistoury is a very 
 proper one for dividing the stricture, as it 
 only has a cutting edge to a certain distance 
 from the point. Perhaps, on the whole, we 
 may infer, that it is botli most easy and ad- 
 vantageous to divide the neck of the sac, 
 together witli the stricture, whether this be 
 situated at the ring, or more inward. The 
 method of cutting the stricture from without 
 inwards l consider objectionable, on the 
 ground of the risk of wounding the bowels 
 tu this mode, being greater, than that of 
 any accident wounding the epigastric arte- 
 ry, when it arises in an unusual manner, 
 and deviates from its regular course ; a re- 
 flection, which has made Dr. Hesselbach, 
 junior, an advocate for the practice. (See 
 Sicherste Art dts Bruckschnilles, 4 to. Bam- 
 berg. 1819.) 
 
 Room being made for the reduction of 
 the protruded parts into the abdomen, by 
 the division of the stricture, they are imme- 
 diately to be returned, if sound, and free 
 from adhesions. This object is considerably 
 facilitated by bending the thigh. The intes- 
 tines are to be reduced before the omentum, 
 but when a portion of mesentery is protru- 
 ded, it is to be returned before either of the 
 preceding parts. The intestine should al- 
 ways be reduced, unless it be found in a 
 state of actual mortification. It often ap- 
 pears so altered in colour, that an uninform- 
 ed person would deern it improper to re- 
 turn it into the abdomen. However, if such 
 alteration should not amount to areal mor- 
 tification, experience justifies the reduction 
 of the part. Mr. A. Cooper has judiciously 
 cautioned the operator not to mistake the 
 dark chocolate brown discolorations, for a 
 state of gangrene. With these the protruded 
 part is frequently found affected ; and as they 
 generally produce no permanent mischief, 
 they ought to be carefully discriminated 
 from the black-purple, or lead-coloured spots 
 which usually precede mortification. To 
 determine whether a discoloured portion of 
 ifitestine be positively mortified, some re- 
 commend pressing forward the blood con- 
 tained in the veins, and if they fill again, it 
 is looked upon as a proof that the bowel is 
 still possessed of life. 
 
 In returning a piece of intestine into the 
 abdomen, the surgeon should first introduce 
 the part nearest the ring into this aperture, 
 and hold it there until another portion has 
 succeeded it. This method is to be continu- 
 ed till the whole of the protruded bowel is 
 reduced. 
 
 Writers on surgery cannot too severely 
 reprobate the employment of any force, or 
 violence, in the endeavours to return the 
 contents of a hernia in the operation : a 
 method the more pernicious, because such 
 parts are more or less in a state of inflam- 
 mation. It is always better to enlarge the 
 stricture, than pinch and bruise the bowel 
 in trying to get it through an opening, which 
 is too small. Distention of the intestine 
 Sometimes prevents the reduction: but when 
 
 this is the only impediment, the part may 
 generally be returned, as soon as its con- 
 tents have been compressed into the intes- 
 tinal canal within the stricture. It is better, 
 however, to dilate the strangulation a little 
 more, than use any force in trying to get 
 the intestine back into the abdomen in the 
 manner just suggested. 
 
 Reduction is sometimes impeded by the 
 protruded parts adhering to each other, or 
 to the hernial sac. The intestines are not 
 often found very firmly adherent together. 
 The omentum and inside of the sac are the 
 parts which are most subject to become 
 intimately connected by adhesions. The 
 fingers will commonly serve for breaking 
 any recent slight adhesions which may have 
 taken place between the intestines and in- 
 side of the hernial sac. When those adhe- 
 sions are firm, and of long standing, they 
 must be cautiously divided with the knife •, 
 an object which can be most easily and 
 safely accomplished, in case they are long 
 enough to permit the intestine to" be eleva- 
 ted a little way from the surface of the sac. 
 
 But, provided their firmness and shortness 
 keep the external coat, of the bowel and 
 inner surface of the sac in close contact, 
 the greatest care is requisite in separating 
 the parts with a knife, so as to avoid wound- 
 ing the intestine In doing this, the most 
 prudent and safe method is not to cut too 
 near the bowel, but vather to remove the 
 adherent parts of the sac, and return (hem 
 with the intestine into the abdomen. Every 
 preternatural connexion should always be 
 separated, before the viscera are reduced : 
 Mr. A Cooper mentions, that a fatal ob- 
 struction to the passage of the intestinal 
 matter has arisen from the mere adhesion of 
 the two sides of a fold of intestine together. 
 ( P . 8i.) When the adhesions, which pre- 
 vent reduction, are situated about the neck 
 efthe sac, and out of the operator’s view, 
 it is best to make the wound through the 
 skin and abdominal ring somewhat larger, 
 so as to be able to separate the adhesions 
 with more safety. 
 
 Having reduced the parts, the operator 
 should introduce his finger, for the purpose 
 of being sure that they are fairly and freely 
 returned info the abdomen, and no longer 
 suffer constriction, either from the inner 
 opening, from the ring, or the parts just 
 within the cavity of the peritonajum. 
 
 Treatment of the omentum. 
 
 In an entero-epiplocele, this part, if heal- 
 thy and free from gangrene, is to be redu- 
 ced after the intestine. When, however, it 
 is much diseased, thickened, and indurated, 
 as it frequently is found to be, after remain- 
 ing any considerable time in a hernial sac, 
 the morbid part should be cut oft’. Its re- 
 duction, in this circumstance, would he 
 highly improper, both because an immode- 
 rate enlargement of the wound would be 
 necessary, in order to be able to put the dis- 
 eased muss back into the abdomen, arid be- 
 
HERNIA. 
 
 2 is 
 
 cause, when reduced, it would, in all pro- 
 bability, excite inflammation of the sur- 
 rounding parts, and bring on dangerous 
 symptoms. (See Hey, j>. 172.) 
 
 The diseased omentum should always be 
 cut oil' with a knife; and if any of its arte- 
 ries should bleed, they ought to be taken up 
 with a tenaculum, and tied separately with 
 a small ligature. An unreasonable appre- 
 hension of hemorrhage from the cut end of 
 the omentum has led many operators to put 
 a ligature all round this part, just above the 
 diseased portion which they were about to 
 remove. This practice cannot be reproba- 
 ted in terms too severe ; for a frequent ef- 
 fect of it is to bring on a fatal inflammation, 
 and even mortification of the omentum, ex- 
 tending within the abdomen, as high as the 
 stomach and transverse arch of the colon. 
 Mr. A. Cooper has remarked with great 
 truth, that it is surprising this custom should 
 ever have prevailed. The very object of 
 the operation is to extricate the omentum 
 from its strangulated state, arising from the 
 pressure of the surrounding tendon, and no 
 sooner has this been done, than the surgeon 
 includes it in a ligature, which produces a 
 more perfect constriction, than that which 
 existed before the operation was under- 
 taken. 
 
 “ When the omentum has suffered stran- 
 gulation for a few days (says Mr. Lawrence) 
 it often becomes of a dark red, or livid co- 
 lour ; and there is an appearance, on cutting 
 it, as if some blood were extravasated in its 
 substance. This, I believe, is the state 
 which surgeons have generally described 
 under the term of gangrene.” (P. 262.) 
 
 When cut in this state, it does not bleed. 
 I need hardly observe, that the dead part 
 must be amputated, and never reduced. 
 9ome have advised leaving the omentum in 
 the wound, especially in cases of old her- 
 nice, in which it has been a long while pro- 
 truded. Hey mentions cases, showing that 
 granulations form very well, and that the 
 wound becomes firmly healed, when this 
 plan is followed. (P. 180, fyc.) Every one ; 
 however, will acknowledge the truth of 
 what Mr. Lawrence says on this subject. 
 
 The method “ is attended with no parti- 
 cular advantage, but certainly exposes the 
 patient to the possibility of ill consequences. 
 The omentum, left in the wound, must be 
 liable to injury, inflammation, or disease ; 
 and hence arises a source of danger to the 
 patient. Unnatural adhesions, formed by 
 this part, have greatly Impaired the func- 
 tions of the. stomach. Cases are recorded, 
 where the unfortunate patient has never 
 been able to take more than a certain quan- 
 tity of food, without bringing on instant vo- 
 miting ; and even where it has been neces- 
 sary for all the meals to be taken in the re- 
 cumbent position, with the trunk curved, 
 and the" thighs bent. (Guns.) To avoid the 
 possibility of such afflicting consequences, 
 we Should, after removing any diseased por- 
 tion, carefully replace the sound part of the 
 omentum in the abdominal cavity.” (Spe 
 Lawrence on Ruptures, p. 274, Edit. 3) 
 
 Treatment, when the intestine in t hr 
 sac is mortified. 
 
 Sometimes, on opening the hernial sac. 
 the intestine is found to be in a gangrenous 
 state, although the occurrence could not be 
 previously known, owing to the integuments 
 and the hernial sac itself not being affected 
 with the same mischief. In ordinary cases, 
 however, both the skin and sac become 
 gangrenous at the same time with the con- 
 tents of the hernia. The tumour, which was 
 previously tense and elastic, becomes soft„ 
 doughy, emphysematous, and of a purple- 
 colour. Sometimes the parts also now spon- 
 taneously return ; but the patient only sur- 
 vives a few hours. 
 
 Mr. A. Cooper has accurately remarked, 
 that in other instances, the skin covering 
 the swelling, sloughs to a considerable ex- 
 tent, the intestine gives way, and as the 
 feces find vent at the wound, the symptoms 
 of strangulation soon subside. When the 
 patient continues to live in these circum- 
 stances, the living part of the intestine be- 
 comes adherent to the hernial sac, the 
 sloughs separate and come away, and thus 
 an artificial anus is established, through 
 which the feces are sometimes discharged 
 during the remainder of life. (See Anus, Ar- 
 tificial.) 
 
 Frequently, however, things take a more 
 prosperous course : the feces gradually re- 
 sume their former route to the rectum, and 
 in proportion as the artificial anus becomes 
 unnecessary, it is shut up. Many instances 
 of this sort have fallen under my own ob- 
 servation in St. Bartholomew’s Hospital. 
 
 The chance of a favourable event is much 
 greater in some kinds of hernia, than in 
 others. When the strangulation only in- 
 cludes a part of the diameter of the gut, 
 the feces are sometimes only partially dis- 
 charged through the mortified opening. 
 This quantity lessens as the wound heals, 
 and the patient gets perfectly well. (Louis, 
 Mem. de VAcad. de Chir. T. 3. P. S. Palm , 
 De Epiplo-tnterocelc crurali incarcerata spha- 
 celata, cum deperditione notabili substantia: 
 intestini , sponte separati, feliciler cur at a alvo 
 naturali restituta, 4 io. Tub. 1748. Haller f 
 Disp. Chir. 3, 2.) A small gangrenous spot, 
 or two, may end in the same manner. Mor- 
 tification, as well as wounds of the large in- 
 testines) is much more frequently followed 
 by a recovery, than the same affection and 
 similar injuries of the small intestines. Mor- 
 tification of the ccecum and its appendix, in 
 a hernial sac, has happened several times, 
 without materially disturbing the usual 
 course of the feces to the anus, and the pa- 
 tients very soon recovered. (Med. Obs. and 
 Inq. Vol. 3. p. 162; Hey's Pract. Obs. p. 
 162, fyc.) 
 
 The grand thing, on which the establish- 
 ment of the continuous state of the intesti- 
 nal canal depends, in all these cases, is the 
 adhesion which the living portion of the 
 bowel, adjoining the mortified part, con- 
 tracts with the peritonaeum all round. In 
 this manner, the escape of the content's ot 
 
HERNIA. 
 
 29 
 
 \he bowels into the cavity of the peritonae- 
 um becomes in general completely prevent- 
 ed. The two ends of the sound portion of 
 intestine, after the mortified part has separa- 
 ted, open into a membranous cavity, which 
 previously constituted a portion of the peri- 
 ton&'u' sac, and now unites the extremities of 
 the gut. The gradual contraction of the 
 wound closes the membranous eaviiy exter- 
 nally, and thus (he continuity of the canal is 
 restored. The two ends, however, are not 
 joined so ns to form a continued cylindrical 
 tube, like that of the natural gut ; but they 
 are united at an angle more or less acute, 
 and the matter, which goes from one to the 
 other describes a half circle in a newly form- 
 ed membranous cavity that completes the 
 canal ; a subject which has been more fully 
 explained in another part of this work. (See 
 Anus , Artificial.) 
 
 It is ai« observation of Mr. A. Cooper’s, 
 that the degree of danger, attending an arti- 
 ficial anu^, depends on the vicinity of the 
 sphacelated part of the intestinal canal to 
 the stomach. Thus, it the opening in the 
 jejunum, there is such a small extent of sur- 
 face for absorption, between it and the sto 
 mach, that the patient dies of inanition. 
 
 Let us now suppose, that the mortified 
 state of the intestine has only been discover 
 ed, after laying Open the nernial sac in the 
 operation. The mischief may only consist 
 of one or more spots ; or of the whole dia- 
 meter of the protruded bowel, lu the first 
 case, the proper practice is to divide the 
 stricture, and return the intestine into the ab- 
 domen, with the mortified spots towards the 
 wound. Mild purgatives and clysters are 
 then to be exhibited. The most favourable 
 mode, in which a case of this kind ends, is 
 when the intestinal matter gradually resumes 
 its natural course, after being either partly or 
 entirely discharged from the wound. But 
 sometimes the patient sinks under the dis- 
 ease, or an artificial anus continues for life. 
 
 The repeated observations of modern sur- 
 geons have now decided, that no ligature, 
 passed through the mesentery, to keep the 
 gangrenous part of the bowel near the 
 wound, is at all necessary. The parts, in the 
 neighbourhood of the ling, have all become 
 adherent together, in consequence of inflam- 
 mation, at the same time that the parts in 
 the hernial sac mortify ; and of course, the 
 partially gangrenous bowel, when reduced, 
 is mechanically hindered, by these adhesions, 
 from slipping far from the wound. Desault 
 and De la Faye, both confirm the fact, that 
 the intestine never recedes far from the ring; 
 and even were it to do so, the adhesions, 
 which it soon contracts to the adjacent sur- 
 faces, would, as Petit ha3 explained, com- 
 pletely circumscribe any matter which might 
 be effused, and hinder it from being exten- 
 sively extravasated among the convolutions 
 of the viscera. (Mem. de VAcad. de Chir. 
 T. 1, 2.) 
 
 Where the chief part, or the whole of the 
 diameter of the protruded bowel is mortified, 
 the first and most urgent indication is to re- 
 lieve the bad symptoms arising from the dis- 
 
 tention of the Intestinal canal above the 
 stricture. “ Let a free incision (says Mr. 
 Lawrence) be made through the mortified 
 part of the gut, in ord»-rto procure that eva- 
 cuation of the loaded canal, which nature 
 attempts by the process of gangrene.” If the 
 intestine has already given way, a free divi- 
 sion of the integuments and sac allows the 
 exit of the accumulated matter ; and the 
 opening in the gut may be enlarged, if ne- 
 cessary. (Lawrence on Ruptures, p. 283.) 
 
 Here the division of the stricture is unne- 
 cessary, since all the mischief, which the 
 bowel can receive from it, is done This 
 subject is well explained by Mr. Travers. 
 (See Inq. into the Process of Nature in Re- 
 pairing Injuries of the Intestines, tyc. p. 300, 
 fyc.) Mild purgatives and clysters will be 
 proper to unload the bowels, and determine 
 the course of the feces towards the anus. 
 Should, however, the stricture appear after 
 Ihe mortification, to impede the free escape 
 of the inteslina 1 contents, a moderate dilata- 
 tion of it must undoubtedly be proper. 
 
 Mr. Lawrence, in his valuable Treatise on 
 Ruptures, has clearly exposed the improprie- 
 ty of sewing the ends of the intestinal canal 
 together, introducing one within the iher, 
 supported by a cylinder of isinglass, &,c, put 
 in their cavity, in those cases, in which the 
 whole circle of the intestine lias mortified, 
 and been cut away, a? was advised by for- 
 mer writers. By drawing the intestine out 
 of the cavity, in order to remove the dead 
 part, the adhesion behind the ring, on which 
 the prospect of a care chiefly depends, must 
 be eo'irely destroyed ; and new irritation 
 and inflammation must be unavoidably pro- 
 duced, by handling and sewing an inflamed 
 part. (See Lawrence on Ruptures , p. 298, 
 
 4 *.) 
 
 Instead of such practice, this gentleman 
 judiciously recommends dilating the stric- 
 ture, and leaving the subsequent progress of 
 the cure entirely to nature. The sloughs 
 will be cast off, and the ends of the gut are 
 retained by the adhesive process in a state 
 of apposition to each other, the most favour- 
 able for their union. Thus, there is a chance 
 of the continuity of the intestinal canal be- 
 coming established again. 
 
 Whatever experiments it may be allow- 
 able to make in wounds with protrusion and 
 division of the bowels, nothing, l think, is 
 now more completely established, than the 
 absurdity and danger of attempting to stitch 
 the bowels in cases of hernia. 
 
 OPERATION FOR VERY LARGE INGUINAL 
 HERNIAL 
 
 When the tumour is of long standing, ex- 
 ceedingly large, perhaps extending half way 
 down to the knees, and its contents have 
 never admitted of being completely reduced, 
 the indication is to divide the stricture, pro- 
 vided a strangulation takes place ; but with- 
 out laying open the hernia! sac, or attempting 
 to reduce the parts. 
 
 The reasons against the common plan of 
 operating, under such circumstances, are, 
 
HERNIA 
 
 30 
 
 thfi difficulty of separating all the old adhe- 
 sions ; the hazardous inflammation, which 
 would be excited by laying open so vast a 
 tumour, and the probability that ports so long 
 protruded, might even bring on serious com- 
 plaints, if reduced. J. L. Petit, and after- 
 ward Dr. Monro, advised the sac not to be 
 opened. (See Mai. Chir. T. 2, p. 372. De- 
 scription of Bar see Mucosae, 1788.) 
 
 OPERATION WHEN THE HERNIA IS SO SMALL 
 
 THAT IT DOES NOT PROTRUDE EXTERNAL- 
 LY THROUGH THE RING. 
 
 In this kind of case, there is little appear- 
 ance of external tumour; consequently, the 
 disease is very apt to be overlooked by the 
 patient and surgeon, and some other cause 
 assigned for the series of symptons. The 
 manner of operating, in this form of the 
 disease, differs from that in the common 
 scrotal hernia ; the incision is to be made pa- 
 rallel to the direction of the spermatic cord, 
 and the stricture will be found at the inter- 
 nal ring. (H. Cooper on Inguinal Hernia.) 
 
 TREATMENT AFTER THE OPERATION. 
 
 Evacuations from the bowels should be 
 immediately promoted by means of clysters, 
 oleum ricini, or small doses of any of the 
 common salts, dissolved in peppermint water. 
 For some time, the patient must only be al- 
 lowed a low diet. When symptoms of in- 
 flammation of the bowels and peritonaeum 
 threaten the patient, general bleeding, leeches 
 applied to the abdomen, fomentations, the 
 warm bath, blisters, doses of the oleum 
 ricini, and clysters, are the means deserving 
 of most dependence, and should be resorted 
 to without the least delay. When all danger of 
 peritonaeal inflammation is past, and the pa- 
 t i e n t i s v e r y 1 o vv a n d w e a k , b a r k , w i n e , c o r d ia] s > 
 and a generous diet, must be directed. The 
 effervescing saline draught, with opium, is 
 the best medicine for quieting' sickness, 
 after the operation. Opium and cordials are 
 the most eligible for checking diarrhoea. As 
 the operation does not usually prevent the 
 parts from becoming protruded again, a truss 
 must be applied before the patient leaves 
 his bed, and afterward constantly worn. 
 
 PROPOSALS FOR THE RADICAL C\lRE OF THE 
 
 Bubonocele, 
 
 Of castrating the patient, applying caustic, 
 or of the operation of the punctum aureum, 
 with this view, I need only say, that they are 
 barbarous, and not at all adapted for the at- 
 tainment of the desired end. A description 
 of these methods may be found in Pare, 
 Wiseman, &c. 
 
 The old operation, termed the royal stitch, 
 was one of the most promising plans. It 
 consisted in putting a ligature under the 
 mc< ko( the hernial sac, close to the abdomi- 
 nal ring, and then tying that part of the sac. 
 
 as to render it impervious, by the adhesive 
 inflammation tbu= excited. 
 
 The royal Milch, performed in tins manner, 
 
 has been actually attended with success, 
 
 ( Heist er , Vol. 2.) The umbilical rupture 
 was cured by Saviard, on similar principles > 
 and Desault radically cured nine cases of the 
 exomphalos in children, by tying the hernial 
 sac. 
 
 Sehmucker cured two irreducible ruptures, 
 free from strangulation, by cutting away the 
 body of the sac, after tying its neck (Chir. 
 Wahrnehmungen , B. 2.) In one case, Mr. 
 A. Cooper found cutting away the sac, alone 
 insufficient. 
 
 Dissecting away ihe whole hernial sac, or 
 even laying it open, must be a formidable 
 operation, compared with merely making a 
 small incision down to the neck of the sac, 
 and applying one ligature. If the hernia 
 were reducible, and the upper part of the 
 sac could be rendered impervious by the li- 
 gature, all other more severe plans would be 
 superfluous. However, Petit, Sharp, Acrel, 
 &c. record cases, which tend to prove the 
 danger and inefficacy of the royal stitch ; 
 though it is true, that none of these surgeons 
 operated exactly in the simple manner above 
 suggested. 
 
 Richter recommends scarifying the neck 
 of the sac, with the view of producing an ad- 
 hesion of its sides to each other ; a plan, 
 which, he says, he found very successful. 
 
 From the account, however, which has 
 been given of the anatomy cf the bubono- 
 cele, it is obvious, that none of these me- 
 thods could do more than obliterate the sac 
 as high as the ring, and never that portion of 
 it, which is within the inguinal canal. Hence, 
 the neck of the sac must still remain open 
 for the descent of the viscera. This consi- 
 deration, and that of the chances of bad 
 and fatal symptoms from any operation un- 
 dertaken solely for this purpose, and not 
 urgently required for the relief of strangula- 
 tion, are the grounds on which these experi- 
 ments are now disapproved. 
 
 CRURAL, OR FEMORAL HERNIA. 
 
 Verheyen, who wrote in 1710, first de- 
 monstrated the distinct formation of crural 
 hernia, which umil then had been generally 
 confounded with bubonocele. 
 
 The parts, composing this kind of hernia, 
 always protrude under PouparPs ligament, 
 and the swelling is situated towards the inner 
 part of the bend of the thigh. The rupture 
 descends on the inside of the femoral artery 
 and vein, between these vessels and the os 
 pubis, through the crural ring, or canal for 
 the transmission of the same vessels. And, 
 as Hesselbach has remarked, the inner open- 
 ing of this ring or canal is the predisposing 
 cause of the disease, t lie peritonaeum spread 
 over it, being gradually propelled into it by 
 various occasional causes, so as to complete 
 the tendency to hernia. The actual pro- 
 trusion of the bowels may be formed either 
 suddenly, or by degrees. As soon as the. 
 bowels have once passed the outer npertare, 
 or what Cloquet terms more properly the 
 lower opening of the crural canal, the hernia 
 has more room for extending itself forwards', 
 
HERNIA. 
 
 31 
 
 and (o each side, and (he integuments now 
 become elevated into an aval swelling , the 
 long diameter of which is nearly transverse. 
 
 ( Hesselbach , p. 47.) Girnbernat names the 
 passage through which the femora! hernia pro- 
 trudes from the abdomen, the crual ; Iley, 
 the femoral ring; and Cloquet, the crural ca- 
 nal. 
 
 Females are particularly subject to this 
 kind of rupture. It has been computed, that 
 nineteen out of twenty married women, af- 
 flicted with hernia, have this kind ; but, that 
 not one out of an hundred unmarried fe- 
 males, or out of the same number of men, 
 have this form of the disease. ( Arnaud .) 
 
 “ The crural hernia,” says Scarpa, is fre- 
 quently observed in women who have had 
 several children ; it very seldom afflicts 
 young girls ; and still more rarely men. In 
 the latter, the viscera can more easily escape 
 through the inguinal ring, by following the 
 spermatic cord, than they can descend along 
 the crural vessels, and raise the margin of 
 the aponeurosis of the external oblique mus- 
 cle, that forms the crural arch. In women, 
 an opposite disposition prevails, in conse- 
 quence of the smallness of the inguinal ring, 
 which, in them, only gives passage to the 
 round ligament of the uterus, and besides, is 
 situated lower down, and nearer the pubes, 
 than it is in men, whilst on the contrary, the 
 crural arch is more extensive, by reason of 
 the wider form of the pelvis. Morgagni ex- 
 pressly says, that Ire never met with the cru- 
 ral hernia in the dead body of any inale sub- 
 ject. Mild, ut verum fat ear , nondum nisi in 
 feeminis accidit lit earn viderem. (De sed. et 
 caus.morb. Epist. 34, 15.) Camper gives us 
 " to understand almost the same thing. (I cones 
 Herniarum , in Prcefat.) Hevin often opera- 
 ted for this kind of hernia in females, but 
 only once in the male subject. ( Pathol . et 
 Thttup. p. 406.) Sandifort and Walter have 
 both seen but a single instance of ii in the 
 dead body of the male subject. ( Ohs . Anat. 
 Pathol, cap. 4, p. 72. Sylloge comment, anat. 
 p. 24, obs. 21.) Arnaud himself, to whom 
 modern surgery is highly indebted for many 
 important precepts on the operation for the 
 strangulated crural hernia in both sexes, 
 candidly confesses, that he never had an op- 
 portunity of dissecting a hernia of this kind 
 in the male subject.” ( Scarpa , TraiU dcs 
 Hernies.p. 201.) 
 
 Scarpa bad at his disposal a male subject, 
 in which there was a crural hernia, and he 
 availed himself of the opportunity of exami- 
 ning the parts with the utmost care. He 
 first injected the blood-vessels ; he after- 
 ward attentively dissected all the parts con- 
 cerned in the disease ; and he has published 
 an exact description of the particulars, illus- 
 trated by an engraving. 
 
 According to Hesselbach, the femoral 
 hernia, though not common in men, is more 
 frequent than is generally believed, and 
 often overlooked on account of its being 
 very small. ( Ueber den Ursprung, Spc. der 
 Leisten-und-Schenkelbriiche, p. 47.) Thus, 
 in an example published in a modern work, 
 an inguinal and femoral hernia were met 
 
 with together in a gentleman, sixty-three 
 years of age. On examination of the body 
 after death, a small piece of intestine, form- 
 ing a crural hernia, was found strangulated, 
 and concealed under an inguinal rupture and 
 a mass of fat. (C. Bell's Surgical Obs. Vol. 
 
 1, p. 187.) 
 
 According to the observations of Scarpa, 
 and all the best modern writers upon sur- 
 gery, the crural hernia forms, both in the 
 male andfemale subject, in the cellular sub- 
 stance, which accompanies the crural ves- 
 sels below Poupart’s ligament. The swelling 
 follows the internal side of those vessels, 
 and gradually descends into the fold of the 
 thigh, between the sarlorius, gracilis, and 
 pectineus muscles. u Many surgeons be- 
 lieve (says Scarpa,) that the hernial sac, 
 and the intestines, which it contains, are or- 
 dinarily situated above the crural vessels 
 arid trunk of the vena saphena, and some- 
 times between these vessels and the anterior 
 superior spine of the ileum. But as far as 
 my knowledge extends, this assertion is 
 not supported by a single accurate descrip- 
 tion of the crural hernia in the early stage. 
 It is true, that when the tumour has in time 
 acquired a large size, and its fundus is incli- 
 ned in a parallel manner to the fold of the 
 thigh, it partly or entirely covers the cru- 
 ral vessels, and even the crural nerve, as 
 Walter says he once observed. ( Sylloge 
 comment, ana!, p 24.) But it is not thence 
 to be concluded, that the tumour in the be- 
 ginning descended over the crural vessels, 
 much less betwixt them and the anterior 
 superior spinous process of the ileum. Nei- 
 ther must it be imagined, that the neck of 
 the hernial sac becomes removed from the 
 inner to the outer side of these vessels. If 
 these two cases ever happen, they must be 
 very rare ; and the best authors who have 
 treated of crural hernia, concur in stating, 
 that in performing the operation, they have 
 constantly found the viscera situated on the 
 inside of the crural vessels, but never on 
 their outsidTe. Even when the tumour, after 
 acquiring a considerable size, is situated 
 transversely over the crural vessels, the 
 neck of the hernial sac has always been 
 found upon their inner side, that is to say, 
 between them and the pubes. Le Dran, 
 ( Observ . de Chir. T. 2. p. 2.) La Faye, 
 ( Cours d' Operations de Dionis, p. 358.) 
 Petit, ( (Euvres Pasthurnes, T. 2, p. 219.) 
 Morgagni.. (De Sed. et Cans. Mcrb epist. 34, 
 15.) Arnaud, (Mem. de Chir. Tom. 2, p. 
 768.) Gunz, (De Hcrniis libeilus, p. 78.) 
 Bertrandi, (Trallato delle Operazoni, T. 1, 
 annot.p. 218.) Pott, (Chirurg. Works, Vol. 
 
 2, p. 152.) Desault, (Traite des Mai. Chi- 
 rurg. p. 191, 195.) B, Beil, (A System of 
 Surgery , Vol. 1, p. 387.) Richter, (Traite 
 des Hernies, chap. 34.) Nessi, (Instituz. Chir. 
 T. 2, p. 198.) Lassus, (Med. Oper. T. 1, p. 
 198.) and many other writers, all concur 
 upon this point. In support of their opi- 
 nion, (says Scarpa,) I could cite a great 
 number of cases of my own, which I have 
 collected either in operating on several in- 
 dividuals for crural hernia, or in dissecting 
 
32 
 
 HERNIA. 
 
 the same kind of hernia in the bodies of 
 many female subjects, and in that of the 
 man, from whom I have taken the 8th 
 plate. Lastly, also, having had an oppor- 
 tunity of dissecting in a female an enor- 
 mous crural hernia, which descended one- 
 third of the way down the thigh, I observed 
 that the ne k of Ijjie sac did not encroach at 
 all upon the r rural vessels, but lay entirely 
 on their inner side.” ( Scarpa , Traili des 
 Hernies, p. 203, 206.) 
 
 The tumour, on account of its situation, is 
 liable to be mistaken for an enlarged ingui- 
 nal gland; ant 1 man; fival events are re- 
 corded to have happened from the surgeon’s 
 ignorance of the existence of the disease. 
 Air. Lawrence once saw an hospital sur- 
 geon mistake a crural hernia for a glandu- 
 lar tumour, and the patient died, without 
 any attempt being made to afford relief by 
 the operation. fP. 391. See also Petit , 
 Traiii die s Mai. Chir. T. 2, p 293, fyc.) A 
 gland can only become enlarged by the 
 gradual effects of inflammation ; the swell- 
 ing of a crural hernia comes on in a mo- 
 mentary and sudden manner, and when 
 strangulated, occasions the train of symp- 
 toms already described in our account of 
 the inguinal her iu, which symptoms an 
 enlarged gland could never occasion. Such 
 circumstances seem to be sufficiently discri- 
 minative ; though the feel of the two kinds 
 -of swelling, is often not of itself enough to 
 make the surgeon decided in his opinion. 
 It is particularly remarked by Hesselbach, 
 that, while a femoral hernia is incomplete, 
 that is to say, within the outer opening of 
 the passage, through which the parts de- 
 scend, ;the disease presents itself as a round 
 firm swelling, on the outer side of which 
 the femoral artery can be felt pulsating: 
 this small hernia may be mistaken for an in- 
 flamed giand, and the case can only be dis- 
 criminated by the history of its origin and 
 symptoms. ( JJeber den Ursprung dcr Leis- 
 ten-i. J-Schenkelbriiche, p. 51.) A femoral 
 hernia may be mistaken for a' Bubonocele, 
 when the expanded part of the swelling lies 
 over Poupart’s ligament. As the taxis and 
 operation for the first case ought to be done 
 differently from those for the latter, the er- 
 ror may lead to very bad consequences. 
 The femoral hernia, however, tr.ay always he 
 discriminated, by the neck of the tumour hav- 
 ing Poup art's ligament above it. In the bu- 
 bonocele, the spine of the pubes is behind and 
 below this part of the sac; but in the femoral 
 hernia , it is on the same horizontal level, and 
 a little on the inside of it. (See Lawrence on 
 Ruptures, p. 392, 393, Ed. 3.) 
 
 In the male subject, 11 the crural hernia, 
 in the early stage, (says Scarpa) is situated 
 so deeply in the bend of the thigh, that it is 
 difficult, even in the thinnest persons, to 
 feel its neck, and in examining its circum- 
 ference with the extremity of the finger, 
 the tendinous margin of the opening, 
 through which the parts are protruded, can 
 only be perceived with considerable diffi- 
 culty. On the contrary, the inguinal her- 
 nia. however small it may he, is always less 
 
 deeply situated ; it is about half an inclt 
 above the bend of the thigh. In carrying 
 the finger round its neck, the tendinous 
 margin of the inguinal ring can be easily 
 felt at its circumference ; and at the poste- 
 rior part of the small tumour, the cord com- 
 posed of the spermatic vessels is distin- 
 guishable. When the crural hernia has ac- 
 quired a considerable size, its neck is always 
 deeply situated in the bend of the thigh ; but 
 its body and fundus assume an oval form, and 
 their great diam eter is situated transversely in 
 the bend, of the thigh. Whatever may be the 
 size of the inguinal hernia, it al ways pre- 
 sents a tumour of a pvramidal form, the 
 base or fundus of which; far from being di- 
 rected towards the ileum, follows exactly 
 the direction of the spermatic cord, and 
 descends directly into the scrotum. Be- 
 sides the symptoms, common to all hernial 
 swellings, the crural hernia, when it has 
 attained a certain size, presents some others 
 which are peculiar to it, such as a sense of 
 stupor and heaviness in the thigh, and oedema 
 of the leg , and even of the foot, of the same 
 side.” The reason, why oedema and numb- 
 ness of the limb, are particularly remark- 
 able in cases of femora hernia, is justly re- 
 ferred by Hesselbach, to the circumstance of 
 the femoral vessel? and nr es, with nume- 
 rous lymphatics, taking their course through 
 the crural ring, and according to his observa- 
 tion;, the numbness and cedema an especial- 
 ly great, when the protrusion is omentum, 
 which makes stronger pressure on the ves- 
 sels and nerve?, than commonly happens in 
 a case of entereeele. (P. 53.) 
 
 “ In women, however, as Scarpa observes, 
 it is less easy j distinguish the crural hernia 
 from the inguinal. In fact, the absence of the 
 spermatic cord, and the nearer situation of 
 the ring to the crurat arch, may easily occa- 
 sion a mistake. Sometimes, a woman may 
 even be supposed to have a double crural 
 hernia pf the same side, whilst, of these two 
 distinct, though neighbouring^!, urniffi, one 
 may be inguinal, and the other crural. Ar- 
 naud (Mem- de Chir. T.2.p 605,) relates an 
 instance of such a mistake.” ( Scarpa , 
 
 Trait6 des Hernies, p. 207,208.) 
 
 This interesting writer take occasion to 
 observe further, upon t his part |of the sub- 
 ject, that the portion of the inferior pillar of 
 the abdominal ring, which separates this 
 opening from the internal and inferior angle 
 of the crural arch, is so ^slender in women, 
 that it is sometimes hard to distinguish the 
 crural from the inguinal hernia, which is not 
 the case in male patients. 
 
 Until a few years ago, the stricture, in 
 cases of femoral hernia, was always supposed 
 to be produced by the lower border of the 
 external oblique muscle, or, as it isjtermed, 
 Poupart’s ligament. A total change of opi- 
 nion on this subject, however, Ims latterly 
 taken place, in consequence of the observa- 
 tions first made by Gimberuat, in 176S. “ In 
 the crural hernia, (says he) the aperture 
 through which the parts issue, is* not formed 
 by two bands, (as in the inguinal hernia) but 
 it is a foramen almost round, proceeding 
 
DERMA. 
 
 33 
 
 from the interna] margin of the crural arch 
 (Pounart’s ligament,) near its insertion into 
 the branch of the os pubis, between this 
 bone and thejiliac vein ; so that, in thisjher- 
 nia, the branch of the os pubis is situated more 
 internally than the intestine, and a little be- 
 hind ; the vein, externally, and behind ; and the 
 internal border of the arch, before. Now it is 
 tliis border which always forms the strangu- 
 lation.’’ (See A new Method of Operating 
 for the Femoral Hernia , bp Don Antonio dc 
 Gimbernat , p. 6, Trans, by Beddoes.) 
 
 The utility of knowing, that it is not Pou- 
 part’s ligament which produces the strangu- 
 lation, in cases of femoral hernia, is import- 
 ant ; for we then know, that cutting the 
 lower and outer border of the external ob- 
 lique muscle, is quite erroneous. This pro- 
 ceeding is the more to be reprobated, because 
 the lower pillar of the abdominal ring, in 
 both sexes, will be divided by directing the 
 incision upward, or upward and inward ; 
 and thus the abdominal a id crural rings will 
 be made into one common aperture, large 
 enough to make the future occurrence of 
 hernia very likely to happen. In the male, 
 there is also considerable danger of the 
 spermatic cord being cut. Cutting Pou- 
 part’s ligament obliquely outwards, is attend- 
 ed with still more danger ; for the epigastric 
 artery will infallibly be divided at ils origin ; 
 and with all these hazards, the incision must 
 be quite useless, unless carried on to the in- 
 ternal edge of the crural arch. ( Gimbernat , 
 p. 16.) 
 
 Tiie inclination, however, of several mo- 
 dern writers to refer the strangulation en- 
 tirely to Gimbernat’s ligament, is not sanction- 
 ed by the most careful observers, like Hes- 
 seibach and Langenbeck, (JVeue Bibl. B. 2. p. 
 132.) The former justly remarks, that a 
 complete femoral hernia may be strangula- 
 ted in two places, either at the out&r or in- 
 ner opening of the passage, through which 
 the protrusion happens. Nay, says he, that 
 the strangulation is sometimes caused by the 
 outer opening, was known to former sur- 
 geons, for they remarked, that the constric- 
 tion was removed by dividing the fascia. 
 (P. 53.) And, in addition to these two 
 modes of strangulation, is to be enumerated 
 a third, in which the viscera are constricted 
 by protruding through' some weaker point, 
 or accidental opening, in the anterior parie- 
 tes of the crural canal (Hesselbach, p. 4S ; 
 also Langenbeck , Op. cit. p. 132,) or even 
 through an aperture in the inner side of this 
 passage, ns we find depicted in the twentieth 
 plate of Langenbeck’s treatise, “ De Struc- 
 ture Peritonmi.” 
 
 1 know of no surgical writer, who has 
 given a clearer account of the anatomy of 
 the femoral hernia, than Langenbeck (JVeue 
 Bibl. B.2,p. 112, ^y-c.) He observes, that 
 when the dissection is begun at the inside of 
 the inguinal region, the following circum- 
 stances are noticed : after the removal of the 
 peritonaeum from the abdominal muscles, 
 and from the psoas, iliacus interims, and the 
 great vessels, the inner surface of the trans- 
 versalis still has an investment, which Clo- 
 Vol. O. 5 
 
 quet terms the fascia Iransversalis, and which 
 is always a white glistening aponeurosis. 
 From the place, where the femoral artery 
 lies under Poupart’s ligament, to the anterior 
 superior spine of the ilium, the preceding 
 fascia is extended in a strong fibrous form 
 behind the inner surface of Poupart’s liga- 
 ment, and a thin continuation of it is ex- 
 tended over the iliacus interims and psoas 
 muscles, where it is named by Mr. A. Coop- 
 er and Cloquet the fascia iliaca. The fascia 
 of the transverse muscle closes the belly be- 
 hind Poupart’s ligament, as completely as 
 the peritongeum does, so that between the 
 femoral artery and the anterior superior 
 spine of the ilium none of the bowels can 
 protrude, which occurrence is still further 
 prevented by the fascia lata, which below 
 Poupart’s ligament is closely attached to 
 the muscles of the thigh By the pelvis 
 being thus shut up, the origin of a crural her- 
 nia on the outside of the femoral vessels is 
 rendered quite impossible. (Langenbeck, op. 
 cit.) This part of the explanation very nearly 
 resembles that delivered by Mr. A. Cooper, 
 except that the latter describes the iliac fas- 
 cia, and not what Cloquet calls the trans- 
 verse fascia, as closing the pelvis from the 
 spine of the ilium to the crural vessels. But, 
 this diiTerc.ee is easily accounted for by the 
 circumstance of Mr. A. Cooper extending 
 the name fascia iliaca beyond the limits 
 given it by Cloquet and Langenbeck. 
 
 Near the anterior superior spinous process 
 of the ilium, Langenbeck remarks that the 
 fascia of the transverse muscle has some 
 strong fibres, which proceed inwards under 
 the internal opening of the inguinal canal, 
 of which they form, as it were, the bottom, 
 and are named by Hesselbach the internal 
 inguinal ligament. They go over the femo- 
 ral artery and vein, are connected above 
 with the fascia of the transverse muscle, and 
 below are continued into the fascia of the 
 psoas and iliac muscles. Where these fibres 
 pass over the femoral vessels, they expand 
 into a firm aponeurosis, which passing down- 
 wards, is intimately attached at the inner 
 side of the femoral vein to the horizontal 
 branch of the os pubis, close to the symphv- 
 sis, and then joins the aponeurosis of the 
 recti muscles. The expanded portion of 
 the foregoing tendinous fibres, thus continu- 
 ed along the crista of the os pubis to the 
 sheath of the rectus, forms the inner surface 
 of Gimbernat' s, or the femoral or crural liga- 
 ment.. The inner edge of this ligament is 
 falciform, and concave, the concavity being 
 turned towards the femoral vein. Now 
 where the fascia of the transverse muscle 
 extends downwards, on the outer side of 
 the crural artery, to the fascia of the psoas 
 and iliac muscles, so as to close the pelvis 
 between that vessel, and the anterior supe- 
 rior spinous process of the ilium, it also 
 forms, like Gimbernat’s ligament, a falciform 
 edge, the concavity of which lies close over 
 the external convexity of the crural artery. 
 Thus, partly by the concave edge of Gimber- 
 nat’s ligament, directed towards the crural 
 vein, find partly by the conclave edge of the 
 
ukrNU. 
 
 34 
 
 extension of the fascia of the transverse mus- 
 cle to the fascia iliaca, which edge is turned 
 towards i he crural artery, an aperture is pro- 
 duced, through which the femoral vessels 
 pass out of the pelvis. This opening is 
 named by Cloquet the upper opening of Ike 
 crural canal , or as many English surgeons 
 would say, of the crural or femoral ring. By 
 Hesselbach, it is called the internal opening 
 for the femoral vessels. However, as these 
 vessels do not lie loosely and uneonnectedly 
 in this aperture, the opening itself is shut up, 
 as it were, and cannot be seen without dis- 
 section. 
 
 On the above described fasciae, there is a 
 considerable quantity of cellular substance, 
 which covers the vessels in the pelvis, forms 
 a sort of sheath for the crural artery and 
 vein, and accompanies these vessels through 
 the inner opening of the crural canal, or 
 ring, which is itself accurately shut up by it. 
 When this celluiarsubstance is removed, the 
 white glistening fascia; are plainly seen pass- 
 ing through the same opening, and coming 
 nearer together in a funnel-like manner. 
 'Where the fascia of the transverse muscle 
 forms the outer falciform edge of this aper- 
 ture, and is passing over the arteria circum- 
 ilexa ilii to the psoas and iliac muscles, it 
 sends off' through the opening a process, 
 which becomes connected with the outer 
 side of the crural canal, or ring : while from 
 the internal inguinal ligament, which lies 
 above this opening, and constitutes the upper 
 edge of the inner aperture of the crural 
 canal, a production is sent, which is connect- 
 ed with the anterior side of this canal. As 
 for the posterior and inner sides, they have 
 a connexion with the fasciae of the psoas and 
 levator ani. 
 
 When the groin is externally dissected, in 
 order to have a view of the crural ring or 
 canal, on the outside of the pelvis, the fol- 
 lowing appearances present themselves: 
 after the removal of the common integu- 
 ments, one finds below Poupart’s ligament, a 
 quantity of fat, glands, lymphatics, veins, and 
 arteries, which vessels come out through 
 small openings in the fascia lata. As soon 
 as the outer surface of the external oblique 
 muscle is cleared, its aponeurosis is found to 
 become stronger at the anterior superior 
 spinous process of the ilium, and its fibres 
 to collect together, and assume the form of 
 a band, which is Poupart’s ligament, called 
 by Hesselbach the external inguinal liga- 
 ment, and by Gimbernat, Cloquet, and others, 
 the crural arch. This ligament, as is well 
 known, passes obliquely inwards and down- 
 wards towards the os pubis, and after form- 
 ing the external pillar of the abdominal ring, 
 is first closely inserted into the angle or tu- 
 bercle of the os pubis, and then being con- 
 tinued inwards, or backwards, in the form 
 of a firm fascia, is attached to the horizon- 
 tal ramus of that bone, making the anterior 
 or outer surf ace of Gimbernal's, or the femoral, 
 ligament , w hich is consequently produced 
 by the junction of Poupart’s w'ith Hessel- 
 bttch's internal inguinal ligament along the 
 ?»j»ine of the os pubis. Thus, just as the in- 
 
 ternal inguinal ligament is a strengthened 
 part of the fascia of the transverse muscle, 
 the outer inguinal ligament, (or, as it is here 
 commonly called) Poupart’s ligament, is pro- 
 duce! by the. strengthened fibres of the low 
 er portion of the aponeurosis of the external 
 oblique muscle, the fibres of it making the 
 external pillar of the ring, being continued 
 further towards the symphysis of the pubes, 
 in the form of the outer surface of Gim- 
 bernat’s ligament. ( Langenbeck , JYeue Bibl. 
 B. 2, p. 120, 121.) English surgeons make 
 the formation of Gimbernat’s, or the fe- 
 moral ligament more simple : thus Mr. 
 Lawrence states, that w 7 hen Poupart’s liga- 
 ment approaches the pubes, “ it becomes 
 suddenly broader; that it is fixed by this 
 broad portion, along the whole length of the 
 angle and crista of the pubes ; that it has 
 a rounded and strong anterior edge, a thin 
 and sharp posterior margin ; and that the 
 former of these is nearer to the surface, 
 while the latter is comparatively deeply seat- 
 ed. The breadth of this part varies, in dif- 
 ferent subjects : it is generally from three 
 quarters of an inch to an inch Sometimes, 
 as Gimbernat has stated, it measures more 
 than an inch. Dr. Monro has observed, that 
 it is broader in the male than in the female 
 subject; and from this structure, he ex- 
 plains in part the more rare occurrence 
 of this rupture in the male.” (P. 368, 
 Ed. 3.) 
 
 The fascia lata, which is spread over the 
 muscles of the thigh, is only a continuation 
 of the aponeurosis of the external oblique 
 muscle, and, as it proceeds downwards from 
 Poupart’s ligament, is very closely attached 
 to the muscles of the thigh, all the way from 
 the anterior superior spinous process of the 
 ilium, to the femoral artery, drawing as it 
 Avere Poupart’s ligament dowmwards and in- 
 wards, or backwards, towards the cavity of 
 the pelvis, so as to give to its external edge 
 a convex appearance, and shut up the out- 
 side of the pelvis, from the anterior superior 
 spine of the ilium asfarasthe crural nerve and 
 artery, so firmly, that the formation of a 
 femoral hernia at this part is impossible. 
 And, if small apertures, filled with fat, be 
 discernible in this portion of the fascia lata, 
 still no hernia can here take place, because, 
 as Langenbeck has already explained, here 
 the interior of the pelvis is again shut up by 
 fascia* already described. 
 
 Under the fascia lata are situated the an- 
 terior crural nerve, the vein and artery. The 
 vena saphena magna lies on the outside of 
 it, and passes through an opening in it into 
 the femoral vein. This aperture in the fas- 
 cia lata is at the inner side of the groin, op- 
 posite the internal opening of the crural 
 ring, or canal It is named by Hesselbach 
 the external aperture for the femoral vessels , 
 and desci’ibed by him as an oblique fissure 
 about fifteen lines in length. He takes no- 
 tice of its external semilunar edge, and two 
 horns, which are directed inwards ; the parts 
 first particularly described by Mr. A. Burns 
 of Glasgow, under the name of the semilu- 
 nar, or falciform process of the fascia lain. 
 
HERNIA. 
 
 3 * 
 
 The lower born bends rather inwards and 
 upwards, and terminates in the production 
 oi' the fascia lata spread over the pectinalis 
 muscie. The upper horn, which is less cur- 
 ved, buries itself under tiie external pillar of 
 the abdominal ring. Over the lower horn 
 of the opening, just now described, the vena 
 saphena magna ascends into the femoral 
 vein. Through the same aperture also pass 
 nearly all the superficial lymphatics of the 
 lower extremity. According to Cloquet, the 
 fascia lata consists of two layers, of whn h 
 the anterior superficial one is closely attach- 
 ed to the crural arch, extends over the femo- 
 ral vessels, and forms the anterior side of 
 the crural canal. The other layer, near the 
 pubes, quits the former, and, covering the 
 pectinalis muscle, constitutes the hinder side 
 of that canal. The anterior layer of the 
 fascia then forms an oval aperture, through 
 which the vena saphena passes, and which 
 is considered by Cloquet as the lower- opening 
 of the crural canal. This opening, called by 
 Hesselhach the external foramen for the femo- 
 ral vessels, is well delineated both in li is ex- 
 cellent work, and in the twenty-third plate 
 of Langenbeck’s book (De Strudura Perilo- 
 ned, testiculorum tunicis, fyc. 8vo. Goll. 1817.) 
 According to the investigations of the last 
 anatomist, as soon as the integuments are 
 removed, this opening in the fascia lata, 
 with its external semilunar edge, and two 
 horns, are regularly seen. The front side of 
 the crural canal is formed by the fascia lata. 
 Where this fascia proceeds in the form of Hes- 
 selbach’s upper horn under and behind the ex- 
 ternal pillar of the abdominal ring, and makes 
 the outer layer of Gimbernat’s ligament, it is 
 continued as a thin aponeurosis over the vena 
 saphena, so that it makes not merely the upper 
 horn, but reaches further downwards, and 
 forms the outer side of the crural canal. The 
 outer side then of the crural canal, or ring, 
 according to Langenbeck, extends from the 
 outer semilunar edge of the external open- 
 ing for the femoral vessels, or, as English 
 surgeons would say, from tiie edge of the 
 falciform process of the fascia lata. The larger 
 the preceding thin continuation of fascia 
 is, ihe smaller is the external opening for the 
 femoral vessels, the more is the upper horn 
 bent downwards, and the more determinate 
 is the form of the canal. ( Langenbeck , JYeue 
 Bibl. B. 2. p. 124, 125.) 
 
 According to Mr. Lawrence, “ the fascia 
 lata, or fascia of the thigh, has two distinct 
 insertions at the upper and anterior part of 
 the limb. It is attached to the front edge 
 of the pubes, over the origin of the pecti- 
 neus, the fibres of which it closely covers, 
 and it is also fixed to the front of the crural 
 arch. The former of these is continuous, 
 behind the femora! vessels, with the iliac 
 fascia : the latter is not inserted along the 
 whole length of the tendon, its attachment 
 ceasing on the inner side of the vessels, 
 which it covers anteriorly. Here, therefore, 
 the femoral artery and vein are interposed 
 between the two divisions.” (On Ruptures, 
 Edit. 3, p. 371 . ) 
 
 Where the insertion of the fascia lata 
 
 into Poupart’s ligament ends, it forms what 
 Mr. Burns of Glasgow calls the falciform 
 process, the upper part of which is attached 
 to the above ligament, while the lower pro- 
 ceeds further down the thigh. The concavi- 
 ty of the f-dciform process is directed to- 
 wards the pubes. This anatomical connex- 
 ion is one chief cau^e, why extending the 
 thigh, and rotating it outward, render the 
 crural arch tense. 
 
 The hernia, being situated in front of the 
 pectineus, must of course be exterior to the 
 fascia lata. In my opinion, surgeons are 
 very much indebted to Mr. Lawrence for 
 his able explanation of this fact. As for 
 myself, I am candid enough to own that, 
 until I read his clear and concise account 
 of the anatomy of the crural hernia, I could 
 never reap any accurate notions, concern- 
 ing t!i e relative situations of the hernial sac 
 and fascia of the thigh, from other more 
 prolix works, with the exception of those of 
 H esselbach and Langenbeck, by whom the 
 anatomy is made perfectly intelligible. Mr. 
 Lawrence reminds us. however, that the 
 particular crural hernia, contained in the 
 sheath of the femoral vessels, lies under 
 the fascia ; p. 382, Edit. 3. And he men- 
 tions, that the falciform process of the 
 fascia lata, passes along the upper and 
 outer part of the tumour. The iliac vein is 
 placed on the outer side of the neck of the 
 sac ; thf pubes is directly behind it ; and 
 the upper and inner pans are bounded by 
 the thin posterioredge of Poupart’sligamCnt. 
 
 The inner side of the crural ring or ca- 
 nal, as already explained, is connected with 
 the fascia of the transverse muscle. And, 
 according to Langenbeck, below the part 
 of the fascia lata, which forms the external 
 foramen. for the femoral vessels, the front 
 side of the crural canal is sometimes form- 
 ed by a continuation of the fascia of the 
 transverse muscle, as he found was the case 
 in both groins of one female subject. In 
 such a case, there is a good deal of fat be- 
 tween the fascia lata, and the aponeurosis 
 of the transverse muscle, and the two parts 
 are easily separable. Langenbeck admits, 
 however, that the same appearance may 
 arise from a splitting of the layers of the 
 fascia lata. Frequently the front side of 
 crural ring is so short, that the opening 
 cannot rightly be termed a canal, and it is 
 always shorter than the posterior side. 
 When the outer side exits, it is extended 
 across the inner over the space between 
 the two horns, and is then connected with 
 the aponeurosis of the pectinalis derived 
 from the fascia of the psoas and levator ani 
 muscles. In the anterior and inner sides of 
 the crural canal, there are some small open- 
 ings. Doubtless, tills stricture is referred to 
 by Hesselhach, when he says, that, in the 
 male subject the outer opening for the fe- 
 moral vessels is further closed by a net-like 
 web of tendinous fasciculi. The posterior 
 side of the crural canal, or ring, is entirely 
 formed by the part of the fascia of the 
 psoas, which enters its inner opening, and 
 joins the aponeurosis of the pectinalis mus- 
 
36 
 
 HERNIA. 
 
 cle. The outer side of the canal lies under 
 the fascia lata, and joins the anterior and 
 posterior sides, where the aponeuroses of 
 the transverse and iliac muscles proceed to 
 the outside of the femoral artery. Langeu- 
 beek thinks the opening, by which the vena 
 saphena passes over the lower horn of the 
 falciform process of the fascia lata, might 
 be named the lower aperture of ilie crural 
 canal. (See Langmbeck's JVeue Bibl. far 
 die Chirurgie, B. 2, p. 126, 127. 8vo. Ha- 
 nover 181b.) 
 
 According to Hesselbach, in femoral her- 
 nia, tne two openings of the passage now 
 termed the crural or femoral ring, are one 
 half larger than natural. The outer portion 
 of the inner of these apertures is propelled 
 more outward, and with it the epigastric ar- 
 tery. The femoral vein no longer lies at 
 the external end of this opening, but rather 
 at the back of the canal or passage. The 
 external semilunar edge (the falciform 
 process) of the outer opening, is carried 
 more outward and upward, and is tightly ap- 
 plied over the distended hernial sac. In 
 this state of the parts, the outer opening 
 forms an oval firm tendinous ring, the di- 
 rection of which, like that ot the inner 
 opening for the passage of the femoral ves- 
 sels, is transverse. The neck of the hernial 
 sac is that portion of it, which lies within 
 the canal between the two openings. The 
 posterior side of this canal, or passage, now 
 frequently named the crural, or femoral 
 ring, is longer than the anterior. In one 
 large hernia, Hesselbach found it an inch 
 and a half in length, but the anterior side of 
 the passage more than one-third shorter. 
 The greatest diameter of the inner opening 
 was one inch five lines, while that of the 
 outer one was only one inch four lines. 
 Most of the posterior part of the neck of tho 
 hernial sac, with the hinder side of the ca- 
 nal lies upon the peetineus muscle, and 
 towards the outerside upon the femoral vein. 
 The neck of the hernial sac adheres more 
 firmly to the anterior, than to the posterior 
 side of the passage. At the outer opening 
 of the passage, the neck terminates at 
 almost a right angle forwards in the body 
 of the sac, the upper portion of which lies 
 upon Poupart’s ligament, but the largest 
 part of it is situated on the deep-seated layer 
 of the femoral fascia, by which the outer 
 side of the body of the sac, as bigh as the 
 neck, is separated from the crural vessels 
 and nerves. In the male subject, when the 
 tendinous fibres, mixed with the cellular 
 substance covering the outer opening of 
 the passage, make great resistance at par- 
 ticular points, the hernial sac of a femoral 
 hernia may be double, or even divided into 
 several pouches, a preparation exhibiting 
 which occurrence- is in the anatomical 
 museum at Wurzburgh. ( Hesselbach , p. 
 
 48.) Except in a few cases, in which the 
 origin and course of the epigastric artery 
 are unusual, this vessel runs very close to 
 the external side of the neck of the hernial 
 sac, much nearer than it does in an internal 
 bubonocele. 
 
 The sac of the femoral hernia is exceed- 
 ingly narrow at its neck ; and, where its 
 body begins, it becomes expanded in a 
 globular form ; the sac of the bubonocele 
 is generally of an oblong pyramidal shape. 
 The body of the sac of the femoral hernia, 
 makes a right angle with the neck, by being 
 throw n forward and upward, a circumstance 
 very necessary to be known in trying to 
 reduce the parts by the taxis. Though the 
 tumour, formed by the body of the sac, is 
 oval and nearly transverse, it is found, when 
 attentively examined, to take the direction 
 of the groin, which extends obliquely 
 downwards and inwards, the outer, rather 
 smaller end of the swelling being somewhat 
 higher than the inner. (Hesselbach, p. 60.) 
 
 The sac of the femoral hernia is said by 
 Mr- A. Cooper to be immediately covered 
 by a kind of membranous expansion, con- 
 sisting of condensed cellular substance, and 
 named by him, the fascia propria. Accord- 
 ing to the same gentleman, a weak aponeu- 
 rosis derived from the superficial fascia of 
 the bend of the thigh, also covers the swell- 
 ing, and is described as lying immediately 
 beneath the skin and adipose substance. 
 Under this fascia is the condensed cellular 
 substance, or fascia propria, then some adi- 
 pose substance, and lastly the true perito- 
 meal sac itself. It is of infinite use to re- 
 member these circumstances in operating, 
 lest one should think the hernial sac divided 
 w hen it is not so. 
 
 All late writers on hernia, have remarked 
 how very small the aperture is, through 
 which the viscera protrude in the femoral 
 rupture ; how much greatertbe constriction 
 generally is, than in the bubonocele ; con- 
 sequently, how much more rapid the symp- 
 toms are ; how much less frequently th© 
 taxis succeeds ; andhow r much more danger- 
 ous delay proves. (See A. Cooper , Hey , 
 Lawrence, ^-c.) 
 
 Though the crural ring is almost always 
 small, yet in a few instances, in which the 
 tumour is large, and of long standing, it be- 
 comes very capacious, just as the opening 
 often becomes, through which the inguinal 
 hernia protrudes. Dr. Thomson, of Edin- 
 burgh, Mr. Hey, and Mr. Lawrence, have 
 related examples of this kind. 
 
 The remarks already made, concerning 
 the treatment of hernia, before having re- 
 course to the knife, are all applicable to the 
 present case, and need not be repeated. In 
 attempting to reduce the femoral hernia by 
 the taxis, the surgeon should recollect, how- 
 ever, that relaxing Poupart’s ligament, and 
 the femoral fascia, is of the higiiest conse- 
 quence. Hence, the thigh should be bent, 
 and rolled inwards. The pressure ought 
 also to be first made downwards and back- 
 wards, in order to push the swelling off 
 Poupart’s ligament ; and afterward, the 
 parts should be propelled upwards, so that 
 they may return through the crural ring. 
 
 OPERATION FOR THE FEMORAL, OR CRURAL 
 HERNI A . 
 
 Mr. A. Cooper says, “ the incision of the 
 
IIEKNIA* 
 
 n 
 
 integuments is to be begun an inch and a 
 half above the crural arch, in a line with 
 the middle of the tumour, and extended 
 downwards to the centre ot the tumour be- 
 low the arch. A second incision, nearly at 
 right angles with the other, is next made, 
 beginning from the middle of the inner side 
 of the tumour, and extending it across to 
 the outer side, so that the form of this double 
 incision will be that of the letter I rever- 
 sed.” The angular flaps are, of course, to 
 be next dissected oft', and reflected. 
 
 The making of two incisions, however, is 
 not deemed necessary by the majority of 
 surgeons ; and, in all the numerous opera- 
 tions which I saw performed in St. Bartholo- 
 mew’s Hospital, during a space of nearly 
 fifteen years, a transverse wound was not 
 found necessary. The division of the skin 
 should begin about an inch above the crural 
 ring, and be continued obliquely downwards 
 and outwards. In this manner, we cut 
 exactly over the place, where the incision 
 of the stricture should be made. 
 
 “ The first incision (says Mr. A. Cooper) 
 exposes tbe superficial fascia, which is given 
 off by the external oblique muscle, and 
 which covers the anterior part of the hernial 
 sac ; but, if the patient is thin, and the her- 
 nia has not been long formed, this fascia 
 escapes observation, as it is then slight and 
 delicate, and adheres closely to the inner 
 side of the skin. When this fascia is divi- 
 ded, the tumour is so far exposed, that the 
 circumscribed form of the hernia may be 
 distinctly seen ; and a person not well ac- 
 quainted with the anatomy of the parts, 
 would readily suppose that the sac itself was 
 now laid bare. This, however, is not the 
 case, for it is still enveloped by a membrane, 
 which is the fascia, that the hernial sac 
 pushes before it, as it passes through the in- 
 ner side of the crural sheath. This mem- 
 brane, the fascia propria, is to be next divi- 
 ded longitudinally from the neck to the fun- 
 dus of the sac ; and if the subject is fat, an 
 adipose membrane lies between it and the 
 sac, from which it may be distinguished, by 
 seeing the cellular membrane passing from 
 its inner side to the surface of the sac. 
 
 “ This is, in my opinion, the most diffi- 
 cult part of the operation : for the fascia 
 propria is very liable to be mistaken for the 
 sac itself ; so that when it is divided, it is 
 supposed that the sac is exposed, and the in- 
 testine is laid bare ; following upon this 
 idea, the stricture is divided in the outer 
 part of the sac, and the intestine, still stran- 
 gulated, is pushed, with the unopened sac, 
 into the cavity of the abdomen. 
 
 11 The hernial sac being exposed, is to be 
 next opened ; and, to divide it with safety, 
 it is best to pinch up a small part of it be- 
 tween the finger and thumb ; to move the 
 thumb upon the finger, by which the intes- 
 tine is distinctly felt, and may be separated 
 from the inner side of the sac ; and then to 
 cut into the sac, by placing the blade of the 
 knife horizontally. Into this opening, a di- 
 rector should be passed, and the sac opened 
 
 from its fundus lo the crural sheath. (0/t, 
 Crural and Umbilical Hernia.) 
 
 Sometimes the content* of the hernia, 
 thus exposed, admit of being returned, with- 
 out the further use of the knife. When this 
 object, however, cannot be readily done, 
 the protruded parts should never sutler in- 
 jury from repeated manual attempts ; and 
 it is safest to divide the stricture at once. 
 
 The merit of having first proposed the 
 safest plan of cutting Poupart’s ligament, 
 even before surgeons were aware of tbe 
 parts which really form the strangulation, is 
 assigned by Gimberrmi to Mr. B. Bell, who 
 introduced his finger below Poupart’s liga- 
 ment, between the ligament and the intes- 
 tine, (an evident proof, says Gimbernat, 
 that there was no strangulation there ;) he 
 then made a very superficial incision from 
 above downwards, into the thickest part of 
 the ligament to its lower edge ; and, with- 
 out rutting quite through it, he continued 
 his incision about an inch. He rested the 
 back of the scalpel upon his finger, which 
 served as a guide to the instrument, and, at 
 the same time, as a defence to the intestine. 
 The incision, however, having been con- 
 tinued for an inch, would, as Gimbernat re- 
 marks, inevitably cut the internal edge of 
 the crural arch. Now, cutting this, only 
 for a few lines, gives sufficient room, for the 
 easy reduction of the parts, and there is no 
 necessity to touch the ligament, as it never 
 occasions the strangulation. — ( Gimbernat 
 V- 27.) 
 
 Gimbernat’s method of dividing the stric- 
 ture, in cases of femoral hernia;, is now fre- 
 quently regarded as the safest and most ef- 
 fectual. “ Introduce, alongthe internalsideof 
 the intestine, a cannulated or grooved sound, 
 with a blunt end, and a channel of sufficient 
 depth. This is to be directed obliquely in 
 wards, till it enter the crural ring, which 
 will be known by the increased resistance ; 
 as also when its point rests upon the branch 
 of the os pubis. Then suspend the intro- 
 duction ; and keeping the sound (with your 
 left hand, if you are operating on the- 
 right side, and v. v.) firmly resting upon the 
 branch of the os pubis, so that its back shall 
 be turned towards the intestine, and its 
 can*l to th#symphysis pubis, introduce gent- 
 ly with your other hand, into the groove of 
 the sound, a bistoury, with a narrow blade 
 and blunt end, till it enter the ring. Its en- 
 try will be known, as before, by a little in- 
 crease of resistance. Cautiously press the 
 bistoury to the end ot the canal : and em- 
 ploying your two hands at once, carry both 
 instruments close along the branch to the 
 body of the pubis, drawing them out at the 
 same time. By this easy operation, you will 
 divide the internal edge of the crural arch at 
 its extremity, and within four or five lines of 
 its duplieature ; the remainder continuing 
 firmly attached, by the inferior band, or pil- 
 lar, of which it is the continuation. This 
 simple incision being thus made, without the 
 smallest danger, the internal border of the 
 arch, which forms the strangulation, will be 
 considerably relaxed, and the parts will be 
 
HERNIA. 
 
 3'S 
 
 reduced with the greatest ease.” ( Gimber - 
 not , p. 45, 45.) 
 
 Mr. A. Cooper recommends the stricture 
 t'o be divided “ obliquely inwards and up- 
 wards, at right angles to the crural arch.’' 
 
 After advising us to open the sac of a fe- 
 moral hernia, with particular care, on ac- 
 count of its being much thinner than that of 
 a bubonocele, and (as might be added) on 
 account of its seldom containing any fluid, 
 and often having no omentum in it covering 
 the intestine, Mr. Hey remarks, “ The stric- 
 ture made upon the prolapsed pails is very 
 great, as 1 have already observed; but if 
 the tip of the huger can be introduced 
 within the femoral ring, to guide the bubo- 
 nocele knife, a small incision (for the ring is 
 narrow) will be sufficient to set the parts at 
 liberty. If the tip of the linger cannot he 
 introduced at the proper place, a director 
 with a deep groove must be used instead of 
 the linger ; but I prefer the latter. Tne 
 finger, or director, should not be introduced 
 very near the great vessels ; but on that side 
 of the intestine or omentum which is near- 
 est to the symphysis of the ossa pubis. The 
 incision may then be made directly upwards. 
 The surgeon must take especial care to in- 
 troduce his finger or director within that 
 part where he finds the stricture to be the 
 greatest, which, in this species of hernia, is 
 the most interior part of the wound.” (P. 
 255.) 
 
 Gimbernat’s mode is preferable to Mr. 
 Key’s, because, were the operation done on 
 a male, cutting directly upward would en- 
 danger the spermatic cord. 
 
 Mr. Lawrence has noticed, that “ an inci- 
 sion oftiie most interior part of the stricture 
 is free from all danger, in the ordinary 
 course of the vessels. But that variety, in 
 which the obturatrix artery, arising from the 
 epigastric, runs along the inner margin of 
 the sac, seems to preclude us from cutting 
 even in this direction. Hesselbacn met with 
 a remarkable instance of such irregularity 
 in the origin and course of the obturatrix ar- 
 tery in the body of a female, in whom there 
 were two small crural hernias. On the right 
 side, the epigastric and obturatrix arteries 
 arose, by a common trunk, from the crural 
 artery below- Poupart’s ligament. Vlliey soon 
 separated from one another ; the epigastric 
 taking its ordinary course upwards at the 
 outer side of the neck of the hernial sac, 
 while the obturatrix made a considerable 
 turn, and ran transversely inwards over the 
 strong fibres of the femoral ligament, and 
 encircled the anterior and inner side of the 
 neck of the hernia, whence it afterward 
 proceeded obliquely downwards and out- 
 wards, behind the horizontal branch of the 
 os pubis, towards the obturator foramen. 
 ( Hesselbach , p. 52.) A mode of operating 
 has been lately proposed, ( Edinb . Med. and 
 ISurg. Journal , Pol. 2, 205.) with a view of 
 avoiding this danger. We are directed to 
 make an incision through the aponeurosis of 
 the external oblique muscle, just above the 
 crural arch, and in a direction parallel to 
 that part ; to introduce a director under the 
 
 stricture from this opening, and to divide the 
 tendon to the requisite extent, by means of 
 a curved knife passed along the groove. 
 ( Treatise on Ruptures, Edit. 3 ,p. 407 ) For 
 reasons which Mr. Lawrence states, this plan 
 is certainly not altogether eligible,- and, 
 upon the whole, Gimbernat’s method of 
 cutting the stricture is the safest. Monro 
 computes that the obturator artery may arise 
 from the epigastric, once in twenty-five or 
 thirty subjects. But, allowing that it origi- 
 nates more frequently, it then does not 
 always deviate from its usual course aiong 
 the outside of the sac. Mr. A. Cooper says : 
 “ in ad cases, wnich i have myself dissected, 
 where tins variety existed with crural her- 
 nia, tne obturator has passed into the pelvis, 
 on the outer side ot the neck of the sac, en- 
 tirely out ot the reach of any danger of the 
 knife.” (On Crural Hernia, p. 21.) Mr. 
 Lawrence concludes, that the comparative 
 number of instances, in winch it is found on 
 the opposite side, cannot be more than one 
 in twenty, and consequently if we admit, 
 that the obturatrix artery arises from the 
 epigastric once in five times, it wodld only 
 be liable to be wounded once in a hundred 
 operations. (P. 412, Edit. 3.) 
 
 When the origin and course of the epigas- 
 tric artery ditfV -r from what is common, this 
 vessel, as Hesselbach remarks, sometimes 
 passes inwards' along the horizontal branch 
 of the os pubis, ere it ascends towards tiie 
 rectus muscle; and when this variation 
 exists in a case of femoral hernia, the artery 
 does not pass over the outer side of the 
 neck of the sac, but first under it, and then 
 round its inner side. Hesselbach has seen 
 only one instance of this irregularity of the 
 epigastric artery in a female, and never in a 
 male subject. (Ueberden Ur sprung, tyc. dcr 
 Leisten-und Schenkelbriiciie , p. 6z.) 
 
 The industrious Cloquet examined 260 
 bodies, for the purpose of estimating the 
 average number of cases, in which the 
 origin and course of the obturatrix artery 
 are different from what is most common. He 
 found, that when this artery and the epigas- 
 tric arise by one common trunk, they some- 
 times separate from each other above, and 
 rarely below the upper opening of the crural 
 canal. In the first case, the longer their 
 common trunk is, the closer do they lie to 
 Gimbernat’s ligament, and to the inner edge 
 of the upper opening of the above canal. 
 In the second case, the common trunk of 
 these arteries arises within this canal, and 
 the two vessels then return into the abdo- 
 men. In ICO bodies, of which 87 were 
 male, and 73 female, the obturatrix artery 
 arose on both sides from the hypogastric, 
 and only in 55, ot which 21 were male, and 
 35 female, did it originate on both sides 
 from the epigastric. In 28, of which 15 
 were male, and 13 female, the obturatrix 
 arose on one side from the hypogastric, and 
 on the other from the epigastric. In 5 bodies, 
 viz. 2 male, and 4 female, it originated from 
 the crural. (See liecherclies Hnat.sur Its Her - 
 nits, 4to. Paris.) 
 
 If is observed by Professor Scarpa, (hat 
 
HERNIA. 
 
 3P 
 
 “ 1 lie vouml ligament of the uterus, in pass- 
 ing through the abdominal muscles, tollows 
 precisely the same track as the spermatic 
 cord. It is equally situated behind Poupart’s 
 ligament, with the difference, that it does 
 not become so distinct from the internal 
 extremity of this ligament, as the spermatic 
 cord does, because it has not so far to run, in 
 order to get from that ligament to the in- 
 guinal ring, the latter opening being situated 
 lower in the female, than the male subject. 
 The round ligament, like the spermatic cord, 
 also crosses the epigastric artery, before 
 reaching the inguinal ring. And as the 
 crural hernia always begins at the internal 
 and inferior angle of the arch of this name, 
 as well in the male as the female, it follows, 
 that, in the two sexes, the epigastric artery 
 remains in its natural situation, and invaria- 
 bly corresponds to the external side of the 
 neck of the crural hernia 5 whilst the sper- 
 matic cord, in men, and the round ligament, 
 in women, pass over the extremity of the 
 front of the neck of the hernial sac. In the 
 operation for the crural hernia, in females, 
 the incision of the neck of the hernial sac, 
 and crural arch, when directed upward to- 
 wards the linea alba, cannot wound the 
 epigastric artery, which it is of the most 
 consequence to avoid ; but it always divides, 
 either totally or partially, the round liga- 
 ment of the uterus, which cannot lead to 
 any dangerous hemorrhage ; for, except in 
 the period of pregnancy, the arteries of the 
 round ligament are very small; they are 
 almost obliterated in women advanced in 
 years ; and in general, they are quite capil- 
 lary in the extremity of the ligament ad- 
 joining the ring. Hence, it cannot be surpri- 
 sing, that so many crural hernia? have been 
 successfully operated upon in women, by 
 cutting the hernial sac and crural arch 
 directly upw ard, while not a single instance 
 can be cited of such an incision being made 
 in man without mischief, although, in both 
 sexes, the epigastric artery may have been 
 avoided in operating by this process.” 
 
 ( Scarpa , Trait 6 des Hermes, p. 240.) 
 
 In operating for the crural hernia in males, 
 Scarpa recommends us to follow a method, 
 which he calls new, but which, in fact, is 
 the same as that advised by Gimbernat. I 
 have found (says Scarpa) that, in man, the 
 neck of the hernial sac maybe divided with- 
 out danger, by giving to the incision a di- 
 rection exactly contrary to that which is 
 practised in the female subject. After 
 having opened the hernial sac, it is to be 
 drawn outward by one of its sides suffi- 
 ciently to allow the introduction of a small 
 director between its neck and the strangula- 
 ted intestine, the groove of the instrument 
 being turned downwards towards the internal 
 and inferior angle of the crural arch. A 
 probe-pointed bistoury, the edge of which is 
 also to be directed downwards towards the 
 point of insertion of PouparVs ligament to the 
 pubes, is to be pushed along the groove. By 
 this means, the neck of the hernial sac will be 
 divided its whole length, at its internal and in- 
 ferior side, and PouparVs ligament mil be cut 
 
 close to its attachment to the lop of the os 
 pubis. The epigastric artery will certainly 
 be avoided, because it ljes upon the oppo- 
 site side of the hernial sac. As for the sper- 
 matic cord, 1 have demonstrated, that it is 
 situated on the forepart of the neck of the 
 hernial sac ; consequently, it cannot be 
 touched by an incision made from above 
 dow nwards, whilst it is ■constantly cut in the 
 ordinary method, since the knife is carried 
 from beiow upwards. In the first case, this 
 part may be the more easily avoided, as it 
 lies at some distance from the internal and 
 inferior angle of the crural arch. In fact, it is 
 at this place that it quits, as we have seen, 
 the edge of Foupart : s ligament, in order 
 to ascend towards the inguinal ring. The 
 incision that 1 propose (says Scarpa) not 
 only has the advantage of slitting open the 
 neck of the hernial sac its whole length, it 
 also divides a part of the insertion of Pou- 
 part’s ligament into the upper part of the os 
 pubis, a thing that gently contributes to re- 
 lax the crural arch, and facilitate the re- 
 duction of the viscera ; of those, at least, 
 which are not adherent to the sac.” ( Scarpa 
 Op. cit. p. 235.) 
 
 Although this accurate anatomist and sur- 
 geon appears to be quite unacquainted with 
 many ot the late valuable publications oa 
 hernia, which have made their appearance 
 in this country, it is curious to find, both in 
 his account of the inguinal and crural her- 
 nia, how strongly his doctrines and observa- 
 tions tend to confirm every thing that has 
 recently been insisted upon in modem 
 works, respecting the place where the bubo- 
 nocele first protrudes, its passing through a 
 sort of canal before it comes out of the ab- 
 dominal ring, the advantage of cutting in 
 the crural hernia the internal and inferior 
 angle of Poupart’s ligament, or, in other 
 terms, that part of the ligament which was 
 first particularly pointed out by Gimbernat, 
 as causing the principal part of the strangu- 
 lation, and about which so much has been 
 said by Mr. A. Cooper, Mr. Hey, &,c. 
 
 Hesselbach considers an incision through 
 the outer side of the crural ring safer than 
 one through Gimbernat’s ligament, and safer 
 in women than men. In women, he recom 
 mends the cut to be made through the mid- 
 dle ol the forepart of the ring, nearly straight 
 upvyards, or a little inclined inwards, in 
 w hich mode the epigastric artery cannot be 
 hurt, whether it lie at the outer, or inner 
 side of the neck of the sac. In men, this in- 
 cision, directed obliquely upwards and in- 
 wards, he says, cannot be made, on account 
 of the nearness of the spermatic cord • 
 therefore, in the male subject, he advises 
 cutting the inner side of the opening, that is 
 to say, Gimbernat’s, or the femorai liga- 
 ment directly inwards towards the symphy- 
 sis of the os pubis. ( Ueber den Ur sprung t 
 tyc. der Leisteti-und-Schenkelbr « che, p. 54.) 
 YV hen the epigastric, or obturator, artery de- 
 viates from its usual course, and surrounds 
 the inner side of the neck of the hernia 
 (which variety can never be ascertained n 
 
<Q 
 
 HERNIA. 
 
 priori,) a wound of the vessel Hesselbach 
 regards ns unavoidable 
 
 From the views taken of femoral hernia 
 in this article, f consider the unrestricted 
 direction always to cut Gimbe, mat’s liga- 
 ment in the operation perfectly erroneous. 
 For, as Langenbeck has stated, the seat of 
 strangulation may either be in the external 
 aperture of the crural canal, or in an open- 
 ing of the front or inner side of this passage, 
 or in its inner opening, where then Gimber- 
 nat’s ligament is truly concerned. When 
 the strangulation is of the two first descrip- 
 tions, only the fascia lata need be cut ; but, 
 in the third, most frequent case, the inner 
 semilunar edge of the internal opening of 
 the ring must, of course, be divided. In all 
 cases, says Langenbeck, whether the stran- 
 gulation be caused by the inner or external 
 opening of the crural canal, or by an aper- 
 ture in the front parietes of this passage, the 
 stricture must be cut inwards, as directing 
 the cut in the least outwards would injure 
 the epigastric artery. When it is perceived 
 in the operation, that the neck of the hernial 
 sac is strangulated, close below and be- 
 hind the external pillar of the abdominal 
 ring, then the inner opening of the crural 
 canal must be divided inwards, with the 
 knife directed along the horizontal ramus of 
 the os pubis, under the external pillar of the 
 ring, towards the symphysis of the pubes. 
 If, in such a case, the knife were carried in- 
 wards and upwards, that part of Poupart’s 
 ligament forming the upper side of the cru- 
 ral canal might be cut, and the spermatic 
 artery injured. ( Neue Bibl. 2 B.p. 133.) 
 
 Dr. TrUstedt has published some remarks 
 in favour of employing dilatation instead of 
 an incision, in the operation for the strangu- 
 lated crural hernia. He observes, that even 
 when the common trunk of the obturalrix 
 and epigastric arteries is short, the bowels 
 may protrude under the first of these arte- 
 ries, which will lie upon the upper and inner 
 side ol the hernia. In an operation perform- 
 ed upon a woman, in la Charite, at Berlin, 
 for a strangulated femoral hernia, the crural 
 ligament was divided in Gimbernat’s way 
 by an incision exactly parallel to the hori- 
 zontal ramus of the os pubis, and the obtu- 
 ratrix artery was wounded. The patient 
 died eight days after the operation, having 
 been previously attacked by trismus and 
 opisthotonos. On dissection, about six 
 ounces of putrid blood were found in the 
 lesser cavity of the pelvis, and the above 
 artery cut. The vessel arose from the epi- 
 gastric, ran over the upperjedge of the inner 
 opening of the crural canal, or ring, and then 
 descended along its inner edge, towards the 
 obturator foramen. This occasional course 
 of the obturalrix artery leads Dr. Trtlstedt to 
 suggest the following rules : if, after the her- 
 nial sac is opened, the bowels cannot be re- 
 turned, the outer opening of the crural canal 
 should be cut directly inwards, in order to 
 produce a considerable relaxation. But, if the 
 reduction should yet be impracticable, (the 
 strangulation being at the inner opening of 
 the canal) then an attempt is to be made to 
 
 insinuate the end of the finger through the 
 constriction, a plan said to have answered 
 very often in the practice of Surgeon-Gene- 
 ral Bust. Should the resistance be too great, 
 however, for this method to succeed, Trtis- 
 tedt advises the crural ligament to be forci- 
 bly drawn inwards and upwards, towards the 
 navel, with Arnaud’s tenaculum, assisted by 
 the introduction of the finger, or with two 
 hooks. When this plan fails, he recommends 
 Schreger’s practice of dividing the anterior 
 edge of Poupart’s ligament with a pair of 
 blunt-pointed scissors, and then the u-?e of 
 Arnaud’s tenaculum again. (See Rust’s Ma- 
 gazin far die gesammle Heilkunde, B. 3, H. 
 2.) the consideration, however, which 
 will ever prevent the common adoption of 
 Dr. TrQstedt’s suggestion, is, that fifty times 
 more lives would be lost by the mischief 
 done to the protruded bowels by the forcible 
 introduction of the fingers and hooks, than 
 by hemorrhage from the obturatrix, or epi- 
 gastric artery, when the course of the vessel 
 is irregular. 
 
 CONGENITAL HERNIA. 
 
 Before the beginning of the sixth month 
 of the foetal state, the testicle is situated near 
 the kidney, where it receives a covering 
 from the peritonaeum, just like the other ab- 
 dominal viscera. Between the beginning of 
 the sixth month and end of the seventh, the 
 testicle has either descended as low as just 
 above the abdominal ring, or else is passing 
 through it, or arrived a little below r it. 
 ( Wrisberg . Comm. Reg. Societ. Got ting. 
 1785.) 
 
 When the testicle passes through the abdo- 
 minal ring into the scrotum, it is received 
 in a production of the peritonaeum, which 
 afterward constitutes the tunica vaginalis; 
 while that peritoneal investment, which was 
 given to the testicle in the loins, is closely 
 adherent to this body, and forms what is 
 named the tunica albuginea. 
 
 After the descent of the testicle into the 
 scrotum, the communication between the 
 cavity of the tunica vaginalis and that of the 
 abdomen commonly becomes obliterated, 
 w'hicb latter event is usually effected before 
 birth, sometimes not till afterward, and, in a 
 few subjects, even as late as the adult state. 
 
 In the congenital hernia, the protruded 
 viscera are situated in the tunica vaginalis, 
 in contact with the testicle : having descend- 
 ed into this position before the closure of the 
 communication with the abdomen. Of 
 course, the tunica vaginalis itself is the her- 
 nial sac. The nature of this case was not 
 understood, before it was elucidated by Hal- 
 ler in 1755, and the two Hunters in 1752 and 
 1764. (S Hunter’s Med. Comment.; Hal- 
 lers Opuscula Patholog. and Opera Minoru , 
 T. 3.) Many particulars, relating to the ori- 
 gin and formation of this hernia, having been 
 described in the 2d vol. of the First Lines of 
 Surgery, I shall not here repeat them. Be- 
 fore the periods now named, surgeons impu- 
 ted the circumstance of the contents of the 
 hernia and testicle being in contact, to the 
 
liEUNJA. 
 
 4.1 
 
 bowels having made their way, by laceration, 
 through the tunica vaginalis, (mm the ordi- 
 nary hernial sue of a bubonocele. The old 
 surgeons, indeed, frequently cite this in- 
 stance in proof of their doctrine, that some 
 hernias were attended uilh a laceration ol 
 the p'oiionajum. (See Sharp's Inquiry-) 
 
 From the term conge ital, we might sup- 
 pose that this hernia always existed at t i.e 
 time of birth. The protrusion, however, 
 seldom occurs till after this period, on the 
 operation of the usual exciting causes ol her- 
 nias in general. It does not commonly hap- 
 pen till some moftths after birth; and, in cer- 
 tain instance^, not till a late period. Mr. 
 Hey relates a ca ts in which a hernia conge 
 nita was first formed in a young man, aged 
 sixteen, whose right testis had, a little while 
 before the attack of the disease, descended 
 into the scrotum. In ihe generality of cases 
 which actually take, place when the testicle 
 descends into the scrotum before birth, the 
 event may b< referred to the testicle having 
 contracted an adhesion to a piece of intes- 
 tine. or omentum, in its passage to the ring. 
 In an infant, v\ hich died a few hours after 
 birth, Whsberg found one testicle which had 
 not passed the ring, adhering, by means of 
 a few slender filaments, to the om< ntuui,ju>l 
 above this aperture. 
 
 The appearance of a hernia in very early 
 infancy, Mr. Pott observes, will always 
 make it probable that it is of ibis kind; but 
 he was not correct in asserting, that in an 
 adult, there is no reason for supposing his 
 rupture to be of this sort, but Ins having been 
 afflicted with it from his infancy ; and that 
 there is no externa! mark, or character, 
 whereby it can be certainly distinguished 
 from one contained in a c immon hernial 
 sac. fhis statement is erroneous, inasmuch 
 as the hernia congenita is attended with an 
 Impossibility of feeling the testis, which part 
 in the common scrotal hernia is always dis- 
 tinguishable under the fundus of the hernial 
 sac. The hernia congenita, when returnable, 
 tl ought, like ail other kinds of ruptures, to 
 be reduced, and constantly kept up by a pro- 
 per bandage; and when attended with 
 symptoms of stricture, it requires the same 
 chinn'gic assistance as the common her- 
 nia."’ 
 
 Mr. Pott notices, “that in very young 
 children, a piece ol intestine, or omentum, 
 may get preo.y low down in the sac, while 
 the testicle is still in trie groin, or even 
 within the abdomen. In this case, the appli- 
 cation of a truss would lie highly iuipioper; 
 for, in the latter, it might prevent the de- 
 scent of the testicle from the belly into the 
 scrotum , in the former, it must necessarily 
 bruise and injure it, give a great deal of un- 
 necessary pain, and can prove of no real 
 use. Such bandage, therefore, ought never 
 to be applied on a rupture in an infant un- 
 less the testicle can be fairly felt in the scro- 
 tum, after the gut or caul is replaced ; and 
 when it can be so felt, a truss can never be 
 put on too soon.” 
 
 Many additional observations on the fore- 
 going topic are contained in the 2d vol. of 
 
 w>i. n o 
 
 the First Lines of Surgery, for which reason 
 I do not here expatiate upon it. Mr. Pott 
 explains, that ati old rupture, originally con- 
 genital is subject to a stricture, made by the 
 sac itself, as well as to that produced by the 
 abdominal ring, or. as might have been add- 
 ed, to that caused by the inner opening of 
 tlm inguinal canal. 
 
 The fact lie noticed several times, both in 
 the dead a d in the living. “ I have seen 
 (says he) <snch stricture made by the sac of 
 one of these hernia?, as produced all those 
 had symptoms which render the operation 
 necessary : and I have met with two differ- 
 ent strictures, at near an inch distance from 
 each other, in the body of a dead boy, about 
 fourteen, one of which begirt the intestine so 
 tight that f could not disengage it without- 
 dividing ijip sac. 
 
 11 In (bis kind of hernia I have also more 
 frequently found connexions and adhesions 
 of the parts to each other than in the com- 
 mon one ; but them is one kind of connexion 
 sometimes met with in the congenital hernia 
 which can never he found in that which is 
 a common hernial sac, and which may re- 
 quire ail the dexterity of an operator to set 
 free: I mean that of the intestine with (he 
 testicle. 
 
 “ When a common hernial sac has been 
 laid open, and the intestine and omentum 
 have been replaced, there can be nothing 
 left in it which ran require particular regard 
 from the surgeon; but by the division of the 
 sac, of a congenital hernia, the testicle is laid 
 bare, and after the parts composing the her- 
 nia have been reduced, will require great 
 regard and tenderness in all the future dress- 
 ings, as it is a part \ t ry irritable, and very 
 susceptible of ;iain, inflatnm tion, &c. 
 
 ii a large quantity ol lluid should be col- 
 lected in (be sac of a congenital hernia, and 
 by adhesions and connexions of the parts 
 within, the entrance into it from the ab- 
 domen shotiid be totally closed, (a case 
 which I have twice seen) the tightness of the 
 tumour, the difficulty of distinguishing the 
 testicle, and the fluctuation of the fluid, may 
 occasion it to be mistake n for a common 
 hydrocele ; and if, without attending to 
 other circumstances, but trusting merely to 
 (he fee! and look of the scrotum, a puncture 
 be hastily made, it may create a great deal 
 of trouble, and possihh do f j tai mischief. 
 
 “ By what lias fallen within my observa- 
 tion, ! am inclined to believe that the sac of 
 a congenital hernia is very seldom, if ever, 
 distended to the degree which a common 
 hernial sac. often is: it also, from being less 
 dilated, and ra her more confined by the up - 
 per part of the spermatic process^ generally 
 preserves a pyriform kind of figure, and for 
 the same reason, is also generally thinner, 
 and will therefore require more attention 
 and dexterity in an operator w hen he is to 
 open it. To which, 1 believe, I may add, 
 that common ruptures or those in a common 
 sac, are generally gradual!) formed, that is, 
 they are first inguinal, and by degrees be- 
 come scrotal ; hut the congenital are seldom, 
 if ever, remembered by the patient to havt? 
 
HEKN1 A. 
 
 •42 
 
 been in (he groin only. ’ (Pott on Ruptures, There the hernial sac must unavoidably 
 Vcl. 2.) terminate. On the contrary, in the eongeui- 
 
 The sac of a congenital hernia, especially tal hernia, the viscera may descend lower 
 when the cas$ is strangulated, is every where than the testicle, with which they are in 
 equally tense, (IRsselbach, p. 36) and'oelow immediate contact; and, at length, they 
 it the testis cannot be felt. even occupy the situation of this organ, 
 
 The reader must not conclude, however, which is then pushed upward and backward, 
 from the above account, that every runtuie 2. In the case of a congenital hernia the 
 
 in children is congenital. Mr. Laurence 
 has related a case of strangulated bubono- 
 cele, which took place in an infant only 
 fourteen months old. (P. 65, Edit. 3 ) 
 
 The common inguinal hernia, which first 
 protrudesat the inner opening of the inguinal 
 canal, and which has the epigastric artery 
 on the inner side of its neck, has been named 
 by Hesselbach external , while the less com- 
 mon instance, in which the viscera burst 
 directly through the aponeuroses of the 
 transverse and internal oblique njuscles, and 
 pass directly out of the abdominal ring, 
 leaving the epigastric artery on the outer 
 side of the neck of the sac, is distinguished 
 by the epithet internal. {Anal. Chir. Ab- 
 handlung uber den Ur sprung der Lcidcnbruch, 
 fVurzb. 1806.) “ The inguinal congenital 
 
 hernia (says Scarpa) cannot be divided into 
 external and internal : it is evident, that it 
 must always be external, since the neck of 
 the tunica vaginalis invariably corresponds 
 to the point, at which the spermatic cord 
 passes under the margin of the transverse 
 muscle. As for other circumstances, the 
 tunica vaginalis lies in its whole course in 
 the same manner as the sac of a common 
 inguinal hernia : like this, it passes com- 
 pletely through the inguinal canal from one 
 end to the other, resting upon the anterior 
 surface of the spermatic cord. Consequent- 
 ly, it passes between the separation of the 
 inferior fibres of the pbliquus interims, and 
 the principal origin of the cremaster muscle. 
 (See IVrisberg. syllog. comment, anal. p. 23.) 
 After coming out of the ring, as it is always 
 united to the spermatic cord, it is enclosed in 
 the muscular and aponeurotic sheath of the 
 cremaster muscle, which accompanies it to 
 the bottom of the scrotum. Since the tunica, 
 vaginalis, including the displaced viscera, 
 enters the inguinal canal on the outside of 
 the point, at which the spermatic cord crosses 
 the epigastric artery, it is manifest, that, as it 
 follows exactly the direction of this cord, it 
 must also cross the artery, and remove it 
 from the outer to the inner side of the ring, 
 according to the mechanism already explain- 
 ed in speaking of the common inguinal 
 hernia. Hence, the displacement of the 
 epigastric artery constantly happens in the 
 inguinal congenital, just as it does in the 
 ordinary external inguinal hernia. 
 
 “ But, if these two species of inguinal 
 hernia? have some analogy to each other, in 
 regard to the parts which constitute them, 
 yet, they present some remarkable differ- 
 ences. 1. The common inguinal hernia, 
 whether internal or external, when it ex- 
 tends into the scrotum, cannot descend 
 beyond the point at which the spermatic 
 vesselsenter the testicle. There the cellular 
 -ubstance of the spermatic cord terminates. 
 
 descent of the viscera from the eroin to the 
 scrotum commonly takes place in a very 
 short time, and in some measure precipitate- 
 ly : it is much slower and more gradual in 
 the ordinary inguinal hernia. The reason of 
 this difference is very plain. In the first 
 case, the descent of the testicle, and the 
 formation of the tunica vaginalis, have 
 opened and prepared the way. which the 
 viscera must follow in forming a protrusion; 
 while, in the second, the hernial sac cannot 
 descend into the scrotum, but by gradually 
 elongating the layers of the cellular sub- 
 stance, which joins it to the surrounding 
 parts. This fact is so generally known, 
 that experienced practitioners consider the 
 promptitude, with which the viscera have 
 descended from the groin to the bottom of 
 the scrotum, as a characteristic sign of a 
 scrotal congenital hernia.” ( Scarpa Traite 
 dts Hemies , p. 73, fyc. ; Ihsselbach, p. 35 ; 
 Pott fyc.) 
 
 If circumstances will admit of a truss 
 being applied and worn, in cases of con- 
 genital hernia, in young subjects, there will 
 be a considerable chance of a radical cure 
 being effected, in consequence of the natural 
 propensity of the opening between the 
 abdomen and tunica vaginalis to become 
 closed. 
 
 The only material difference in the 
 operation, from that for a bubonocele, is, 
 that the surgeon has to lay open the tunica 
 vaginalis, instead of a common hernial sac. 
 The stricture is to be divided on the same 
 principle as that of an inguinal hernia, and 
 much in the same manner. As, in a case of 
 congenital hernia, the parts are always pro- 
 iruded on the outside of the epigastric artery, 
 the stricture may be safely divided towards 
 the ilium, as well as direclly upwards. (Law- 
 rence on Ruptures, p. 48 1 Edit. 3.) The parts 
 having been reduced, the edges of the 
 wound are to be immediately brought to- 
 gether, and retained so by means of one or 
 two sutures, and sticking plaster, which is 
 much preferable .to the plan of applying 
 dressings to the testicle and inside of the 
 tunica vaginalis, so as to heal the part by the 
 granulating process. 
 
 A new species of hernia congenita was 
 described by the late Mr. Hey, in which a 
 common peritonseal hernial sac, containing 
 the viscera, is included in the tunica vagina- 
 lis. It arises from the parts being protruded 
 after the communication, between the abdo- 
 men and tunica vaginalis, is'closed, so that 
 the peritonaeum is carried dov' n along with 
 the intestine, and forms a hernial sac, within 
 the tunica vaginalis. It is evident also, that 
 such a hernia can only be produced, while 
 the original tunica vaginalis remains, in the 
 form of a bag. as high as the abdominal ring. 
 
HERNIA. 
 
 43 
 
 Operators should he aware of the possibility 
 of having a sac to divide after laying open 
 the tunica vaginalis. (See the accounts of 
 this hernia in Hep's Practical Observations,]). 
 221, <!y-e. and Ji Cooper's Work on Inguinal 
 Hernia, p. 59.) 
 
 UMBILICAL HERNIA, OR EXOMPHALOS. 
 
 “ The exomphalos, or umbilical rupture, 
 (says Pott) is so called from its situation, and 
 has (like other herniae) for its general con- 
 tents, a portion of intestine, or omentum, or 
 both. In old umbilical ruptures, the quantity 
 of omentum is sometimes very great. Mr. 
 Ranby says, that he found two ells and a 
 half of intestine in one of these, with about 
 a third part of the stomach, all adhering 
 together. Mr. Gay and Mr. \ourse found 
 the liver in the sac of an umbilical hernia ; 
 and Bohnius says, that he did also. But 
 whatever are the contents, they are origi- 
 nally contained in the sac, formed by the 
 protrusion of the peritonaeum. In recent 
 and small ruptures, this sac is very visible; 
 but in old. and large ones, it is broken 
 through at the knot of the navel, by the 
 pressure and weight of the contents, and is 
 not always to be distinguished ; which is 
 the reason why it has by some been doubted 
 whether this kind of rupture has a hernial 
 sac or not. 
 
 “ Infants are very subject to this disease 
 in a small degree, from the separation of the 
 funiculus; but in general they either get 
 rid of it as they gather strength, or are easily 
 cured by wearing a proper bandage. It is 
 of still more consequence o get this disorder 
 cured in females, even than in males, that 
 its return, when they are become adult, and 
 pregnant, may be prevented as much as 
 possible ; for at this time it often happens, 
 from the too great distention of the belly, or 
 from unguarded motion when the parts are 
 upon the stretch. During gestation, it is 
 often very troublesome, but, after delivery, 
 if the contents have contracted no adhesion, 
 they will often return, and may be kept in 
 their place by a proper bandage. 
 
 “ If such bandage was always put on in 
 time, and worn constantly, the disease 
 trjight in general b< kept within moderate 
 bounds, and some of the very terrible con- 
 sequences whicV. often attend it might be 
 prevented. The woman who has the small- 
 est degree of it, and who, from her age and 
 situation, has reason to expect children after 
 its appearance, should be particularly care- 
 ful to keep it restrained. 
 
 “ In some the entrance of the sac is large, 
 and the parts easily reducible . in others 
 they are difficult, and in some absolutely 
 irreducible. Of the last kind many have 
 been suspended for years in a proper bag, 
 and have given little or no trouble. They 
 who are afflicted with this disorder, who are 
 advanced in life, and in whom it is large, are 
 generally subject to colics, diarrhoeas, and, 
 if the intestinal canal be at all obstructed, to 
 very troublesome vomitings. (Hence, pa- 
 tients are often supposed to labour under a 
 
 stricture, when they really do not.) It 
 therefore behooves such to take great care to 
 keep that tube as clean and free as possible, 
 and neither to eat nor brink any thing likely 
 to make any disturbance in that part.” (Poll 
 on Ruptures, Vol. 2.) 
 
 Authors, who have published since the 
 time of this celebrated surgeon, have not 
 added much to the stock of information 
 which he has left, relative to the exomphalos. 
 The writings of Mr. A. Cooper, Scarpa, 
 (Traitd des Hernies, p. 327) and of all the 
 most accurate moderns, confirm the fact 
 described by Pott, that, in the umbilical 
 rupture, there is a hernial sac, just as in 
 other instances of herniae Every one, ac 
 quaintedwith anatomy, knows, that behind 
 the opening in the linea alba at the umbili- 
 cus, the peritonaeum is complete; and conse- 
 quently must protrude along with the viscera, 
 in cases of exomphalos. In the only two 
 cases which Mr. A. Cooper has seen of a 
 deficiency of the sac, the membrane had 
 been partially absorbed, or lacerated, so as 
 to allow the protrusion of its contents, and 
 threaten, from this cause, a double stricture. 
 Similar appearances, less closely inspected, 
 probably gave rise to the opinion so firmly 
 maintained by Dionis, De la Faye, Garen- 
 geot, and J. L. Petit, that, in the umbilical 
 hernia, the peritonaeum was always lacera- 
 ted, and there was no hernial sac. Accord- 
 ing to Bichat, early infancy is most subject 
 to the' umbilical hernia, strictly so called, in 
 which the parts protrude through the navel ; 
 while the other periods of life are more 
 liable to false umbilical hernia?, or such as 
 arise in the vicinity of the umbilicus. 
 ( CEuvres Chir.de Desault, T. 2./?. 315.) 
 
 Besides a true hernial sac, the exomphalos 
 is also covered by a more superficial expan- 
 sion, consisting of condensed cellular sub- 
 stance. In operating, however, a surgeon 
 should always cut with great caution ; for, 
 the integuments and hernial sac. in front of 
 the tumour, are inseparably adherent; and 
 sometimes, in large cases, when an absorp- 
 tion of part of tlie sac has been caused by 
 the pressure of the bowels, they are even 
 found adherent to the integuments. 
 
 Pregnant women, and dropsical and 
 corpulent, subjects, are peculiarly liable to 
 the exomphalos. In adults, when there is 
 intestine in the sac, there is almost always 
 omentum. The transverse arch of the colon 
 is observed to be particularly often contained 
 in umbilical hernia?, but the small intestines 
 are not (infrequently protruded: and 'even 
 the ccecum has been found in a rupture at 
 the navel. (See Lawrence on Ruptures, p. 
 427, Edit. 3 ) 
 
 In the true umbilical hernia, the stricture 
 is made by the tendinous opening in the 
 linea alba. Let us next consider the umbili- 
 cal hernia in the three particular forms, in 
 which it has been noticed by the latest 
 writers. 
 
 CONGENITAL UMBILICAL ' HERNIA . 
 
 Dr. Hamilton has met with about two 
 cases of this kind annually, for the space of 
 
HERNIA. 
 
 seventeen years ; arid they st>ictly deserve 
 the epithet congenital, as they appear at 
 l*irth The funis en Is in a sort of bag, 
 containing some of the viscera, which pass 
 out of the abdomen through an aperture in 
 The situation of the navel The swelling 
 is not covered with skin, so that the con- 
 tents of the hernia can be seen through the 
 thin distended covering of the cord. The 
 disease is owing to a preternatural deficiency 
 in the abdominal muscles, and the hope of 
 cure must-be regulated by the size of the 
 malformation, and quantity of viscera pro- 
 truded. 
 
 The plans of cure proposed, consist of the 
 employment of a ligature, or of a bandage. 
 The latter seems preferable, and was prac- 
 tised by Mr. Hey, as follows : having redu- 
 ced the intestine, he desired an assistant to 
 bold the funis compressed sufficiently near 
 the abdomen, to keep the bowel from re- 
 turning into the hernial sac. 
 
 “ I procured (says he) some plaster spread 
 upon leather, cut into circular pieces, and 
 laid upon one another in a conical form. 
 This compress I placed upon the navel, 
 after I had brought the skin on each side of 
 the aperture into contact, and had laid one 
 of the lip's a little over the other. I then 
 put round the end . - abdomen a linen belt : 
 and placed upon the naval, a thick, circular, 
 quilted pad, formed about two inches from 
 one extremity of the be it. 
 
 “ This bandage kept the intestine securely 
 within the abdomen, and was renewed 
 occasionally, The f inis was separated abo t 
 a. week afterbirth ; and at the expiration of 
 a fortnight from that time, the aperture at. 
 the navel was so far contracted, that the 
 crying of the child, when the bandage Was 
 removed, did not cause the least protrusion. 
 I thought it proper, however, to continue 
 the use of the bandage a little while longer. 
 A Small substance, S ■ k e fungous flesh, pro- 
 jected, after the funis had dropped off about 
 half an inch from the bottom of that de- 
 pression which the nave! forms. A dossil of 
 lint spread with cerat. e lapide calaminari, 
 and assisted by the pressure of the bandage, 
 brought on a complete cicatrization."’ (P. 
 227.) 
 
 This gentleman has related another exam- 
 ple, in which the intestines were quite' un- 
 covered and inflamed, the sac having burst 
 in delivery The parts were reduced;, but 
 the child died. (See also G. A Fried de Fcetu 
 intestims plane nudis extra abdomen propen -• 
 dentibus nalo. Argent. 17**0.) 
 
 UMBILICAL HER SI A IN CHILDREN. 
 
 The umbilical hernia, which is sometimes 
 formed in the fetus, from causes difficult of 
 explanation, takes place, in. other instances, 
 at t’ne moment of delivery ; and then, as 
 Sabatier remarks, should it be tied by mis- 
 take, with the funis, death would be the con- 
 sequence. Most frequently, however, it is 
 not till the second, third, or fourth month 
 after birth, that the disease occurs ; and the 
 numerous cases collected by Desault prove 
 that, of ten infants attacked with this hernia. 
 
 nine become afflicted at the periods just 
 mentioned. 
 
 The umbilicus, still open, now begins to 
 contract, so as to close the cicatrix, which 
 soon forms an obstacle capable of prevent- 
 ing a protrusion of the viscera. Sometimes, 
 however, the repeated crying of the child 
 propels the viscera through the opening, and 
 thus the closure of the cicatrix of the navel 
 is prevented. By degrees, the umbilical ring 
 becomes more and more dilated, the quanti- 
 ty of protruded bowel increases, and thus 
 a tumour arises, which, from being of trivial 
 size at first, at length attains the size of an 
 egg, or large walnut, and presents itself with 
 all the characteristic marks of a hernia. 
 
 The presence of a piece of intestine and 
 omentum in the tumour, keeps the umbilicus 
 open, and opposes the continual tendency 
 which it has to close. Such tendency, how - 
 ever, being sometimes superior to the resist- 
 ance of the protruded parts, forces them 
 back info the abdomen, obliterates the open- 
 ing through which they passed, and thus the 
 spontaneous cure of the umbilical hernia in 
 children is accomplished. Two cases illus- 
 trative of this fact, are related by Bichat. 
 ((Entires L'hir. de Desault, T. 2, p. 318 ) 
 
 f'yature, however, does no* effect many 
 su< h cures, and when the case is left to her 
 alone, she not only fails in bringing about a 
 radical cure, but gradually renders it impos- 
 sible. In short, the propensity of the open- 
 ing to lose diminishes, and is lost, as the sub- 
 ject grows older. 
 
 Thus, the umbilical hernia of children 
 seems to be essentially different from that 
 of adults, in the tendency of the aperture 
 to contract. Hence the ease of affecting a 
 radical cure in children, and the almost utter 
 impossibility of doing so in adults. In the 
 former, it is enough to keep the intestines 
 from protruding, and the opening becomes 
 of itself obliterated ; in the latter, the open- 
 ing always remains, whether the bowels con- 
 tinue in it or not. This indisposition of the 
 aperture to contract in the adult, also fre- 
 quently depends upon the protrusion not be- 
 ing through the umbilical ring itself, but 
 through a fissure in the vicinity of it, not 
 endued with* the same natural tendency to 
 close, which the umbilicus possesses in 
 young subjects. In fact, it would appear 
 from the observations of Scarpa, detailed 
 in the 2d vol. o! the First bines of Surgery, 
 that, unless a grown-up person lias the pro- 
 trusion from infancy, it nevel* occurs exact- 
 ly through the umbilical ring itself 
 
 The means of curing the umbilical hernia 
 of children, are of three kinds ; external ap- 
 plications; compression ; and the ligature. 
 The first are totally useless ; and as t hey 
 occasion a waste of time, are improper. 
 Compression, and the ligature, are the only 
 rational plans. The former is the most 
 modern ; the latter the most ancient treat- 
 ment, as it is mentioned by Celsus. Desault 
 tells us, that the design both of the ligature 
 and compression is the same, viz. to prevent 
 the lodgment of the protruded viscera in 
 the opening of the umbilicus, and thus faci ' 
 
HERNIA. 
 
 45 
 
 litate the approximation of its sides. To 
 accomplish this end, the ligature retrenches 
 the hernial sac, and skin pushed betore it ; 
 and, by the union of the cut parts, a cicatrix 
 is produced which hinders the protrusion of 
 the viscera. At the same time, the sides of 
 the opening, obeying their natural tendency, 
 compression closes the deficiency, or open- 
 ing, in the p rietes of the abdomen, hinders 
 the protrusion of the bowels, and keeps tiese 
 parts from resisting the contraction of the 
 sac. Desault remarks, that though compres- 
 sion occasions no pain, it is irksome, during 
 the great length of time its employment is 
 necessary. The ligature (he says) produces 
 momentary pain ; but it is not at all irksome, 
 and it effects in a few days, what compres- 
 sion, when successful, accomplishes in seve- 
 ral months. In one plan, long continual at- 
 tention is requisite, and if its employment 
 be only for a sli 'rt time neglected, the pre- 
 vious effect becomes almost destroyed. The 
 other method alu ays accomplishes its object 
 with certainty, independently of the crying 
 of the child, and the care of its attendants. 
 When compression is adopted, it is executed 
 either by means of a flat compress applied 
 to the opening, and which does not enter 
 it, or else by means of some round or oval 
 body, such as a ball of wax, a nutmeg, &c. 
 adapted to the shape of the aperture, and, 
 as Platner and Richter, (in his Treatise on 
 Hernia) advise, continually kept within the 
 opening. In the first case, Bichat argues, 
 that if the bandage be exactly applied, the 
 skin and sac will form a fold in the aperture 
 of the navel, hinder its closure, and operate 
 in the same manner, from without, inward, 
 as the protruded intestines did from within 
 outward In the second case, he observes, 
 the foreign body, being depressed into and 
 maintained in the opening, will occasion, 
 notwithstanding what Richter says, the same 
 inconveniences, and, in a more striking man- 
 ner, similar consequences,. But, on the con- 
 trary, when the !i ature is employed, the 
 sac and skin of the tumour are removed, 
 while the opening remains free, and nothing 
 prevents its obliteration. In this method, 
 the omentum can never protrude outward ; 
 but, in the other, if the compression should 
 ever be inexact, the parts slip out again, 
 above or below, and the disorder prevails o>i 
 one side of the useless application. The 
 ligature is also commended as producing an 
 adhesion of the sides of the opening, either 
 to each other, or the adjacent parts. This 
 adhesive process arises from the inflamma- 
 tion excited, and occasions a degree of firm- 
 ness, not producible by any other mode of 
 cure. 
 
 With respect to compression, Bichat as- 
 serts that children, on whom it is employed, 
 are miserably annoyed with it for years, 
 while the ready success of the treatment 
 with the ligature, is attested by a series of 
 well-authenticated cures, which in Desault’s 
 practice, amounted to the number of fifty. 
 In the latter years of his practice, says Bi- 
 chat, many persons were also seen bringing 
 to' his public consultations their, children. 
 
 which were immediately operated on with- 
 out any preparation, carried home, and 
 b roug'd the next, and every following 
 day, to be dressed, till the cure was com- 
 plete. 
 
 The children of the poor may be cured 
 in an hospital, with the ligature, in the space 
 of a few days But, when compression is 
 adopted, the parents are frequently put to 
 repeated expense, as the bandage wears out ; 
 and to additional loss from the time con- 
 sumed in payin, die necessary attention. 
 
 The ancients had different modes of ap- 
 plying the ligature. One consisted in redu 
 ing the parts, and afterward tying the in- 
 teguments afid sac, without opening the lat- 
 ter at all. In the other, an incision was 
 made ir. the sac, either before or after tying 
 it, for the purpose of being sure, that no 
 piece of intestine was, and could become, 
 strangulated in the ligature Celsus adopted 
 the first plan ; Paulus iEgiueta preferred the 
 second ; and he was imitated by Avicenna, 
 Atbucasis, and Guy de Chauiiac. 
 
 The first of these methods is less painful, 
 and equally safe ; for, we soon become 
 habituated to ascertaining, whether there is 
 still any intestine in the sac, by rubbing the 
 opposite sides of this bag against each other. 
 The other, which is unnecessarily cruel, in- 
 creases the pain, without making the method 
 at all more successful. Some of the old 
 practitioners simply tied the base of the tu- 
 mour ; others passed through it one, or two 
 needles, armed with ligatures for the pur- 
 pose of fixing such ligatures in a better man- 
 ner, and, for this purpose, they even some- 
 times made a circular incision. Desault’s 
 method, which much resembled that of 
 Saviard’, was simple, and is described by 
 Bichat as attended with little pain. 
 
 The child must be placed on its back, with 
 its thighs a little bent, and its head inclined 
 towards the chest. The surgeon is to re- 
 duce the protruded parts, and to hold them 
 so with bis finger, at the same time that he 
 raises the hernial sac, and rubs its sides be- 
 tween his fingers, so as to be sure that there 
 is nothing contained in it. Being certain, 
 that the parts which he lifts up, are only the 
 skin and sac, he is to direct an assistant to 
 surround their base several t^mes with a 
 waxed ligature, of middling size, each turn 
 being tied with a double knot in such a man- 
 ner as only to occasion liple pain. The tu- 
 mour, thus tied, is to be covered with lint, 
 which is to be supported with one or two 
 compresses, and a circular bandage, secu- 
 red With a sea pulary. By the following day 
 a slight swell: i has commonly taken place 
 in the constricted parts. 
 
 On the second, or third day, the parts 
 shrink, and then the ligature becomes loose, 
 so that a fresh one must now be applied in 
 the same manner as the first, taking care to 
 draw it a little more tightly. The sensibility 
 of the parts, increased by the inflammation, 
 which the constriction of the ligature has 
 already produced, usually renders th s second 
 ligature more painful After the operation, 
 the same pressings, as^at first, are to be ap. 
 
46 
 
 1IEKNIA. 
 
 plied. The tumour soon becomes discolour- 
 ed, livid, and smaller. A third ligature, put 
 on in the same way as the preceding ones, 
 entirely obstructs the circulation in it. The 
 part turns black and flaccid, and commonly 
 falls off oi the eighth orter.lh day. A small 
 ulcer is left, which, being properly dn-ssed, 
 very soon heals, and leaves a cicatrix suffi- 
 ciently strong to resist the impulse occasion- 
 ed by coughing, or other efforts of the abdo 
 initial muscles. For two or three months, 
 however, afterthe operation the child should 
 Wear a circular bandage, in order to prevent, 
 with still greater certainty, the vi cera from 
 being propelled against the cicatrix, so as to 
 interrupt the process of nature, which is now 
 producing a gradual closure of the umbilical 
 opening. Numerous cases might here be 
 adduced, in confirmation of the above prac- 
 tice ; but, several (nine) are already publish- 
 ed in the Parisian Chirurgical Journal. 
 
 But one may doubt, (says Sabatier) quo- 
 ting the article in the journal, where Desault 
 treats of the present disease, whether the 
 infants got rid of the hernia, as it might have 
 returned some time afterward. To this ob- 
 servation, Bichat replies, that numerous facts 
 remove the doubt ; for, several of the sub- 
 jects were brought to Desault’s public con- 
 sultation, for other diseases, a long while 
 after they had been operated upon, and the 
 great number of students, who examined 
 them, all acknowledged, that the ring was 
 completely obliterated, and there was no 
 impulse of the viscera in coughing, sneezing, 
 &c. Other children, in the knowledge of 
 the surgeons of the H&tel-Dien, remained 
 perfectly cured, and Bichat was acquainted 
 with two young subjects on whom the oper 
 ration had been performed four years, and 
 they had had no relapse. 
 
 In young infants the operation almost con- 
 stantly answered ; but, in proportion as their 
 age increased, it was tound to be less certain. 
 Bichat relates three cases, v\ hich tend to 
 prove, that success may be completely ob- 
 tained at the age of a year and a half ; that 
 the cure is difficult, when the child is four 
 years old ; and impossible, when it is nine. 
 (See CEuvres Chir. de Desault , par Bichat, T . 
 2, p. 315, fyc.) 
 
 Mr. Pott notices the plan of curing the 
 exomphalos with the ligature and expresses 
 himself strongly against the practice in gene- 
 ral. To adults the plan is not applicable, 
 particularly when the tumour is large. Mr. 
 Pott was decidedly in favour of compression, 
 and he observes, that, in young subjects, 
 and small herniae, a bandage, worn a proper 
 time, generally proves a perfect cure. ( Vul . 
 2 .) 
 
 Anxious that this work should be strictly 
 impartial, I next proceed to relate what has 
 been more recently urged against the em- 
 ployment of the ligature for the cure of the 
 umbilical hernia in children 
 
 The incessant care that a bandage requires, 
 either to keep it clean or make it always 
 keep tip the proper degree of pressure, n ri- 
 ders its employment difficult in the children 
 of the poorer classes. Scarpa expresses his 
 
 opinion, that “this was what induced De- 
 sault to revive the Operation for the umbili- 
 cal hernia by tire ligature, nearly such as is 
 described by Celsus, an operation (continues 
 Scarpa) which, a long while ainc> , and for 
 good reasons, was altogether abandoned. 
 Celsus has sufficientlv described the particu- 
 lars of it : (Lib. 7, Cap. 14,) he states, that 
 the tumour is sometimes to be mm ply lied, 
 and that, in other instances, its base is to 
 have a needle and double ligature introduced 
 through it, in order that it may be embraced 
 almost in the ••ame. way as a staphyloma is 
 lied Bui among the causes which contra- 
 indicate this operation, he mentions so many 
 circumstances in relation to age, constitution, 
 diseases of the skin, &c. that lie seems to consi- 
 der thecases in which it may be practised with 
 success as very few. The same reflections 
 were made by several olher ancient surgical 
 writers, especially by Fabricius ab Aquapen- 
 dente Desault himself has put some restric- 
 tions to the employment of the ligature, 
 since he observes, with his usual candour, 
 1 hat this method docs not radically cure the 
 umbilical herma of children, arrived at the 
 age ol four year?; that it is indispensable, as 
 Celsus inculcates, to employ a needle and 
 double ligature, v\ hen the base of the tumour 
 is very large ; and lastly, that even in the 
 youngest children', a radical cure cannot be 
 effected by die ligature, unless a methodical 
 compression of the navel, by means of a 
 bandage, be kept up immediately after the 
 operation, and for two or three months It 
 is perhaps to the omission of this last means, 
 that a relapse is to be ascribed in several of 
 the children operated upon by Desault. “ De- 
 sault avoit remis en vigueur la ligature tom- 
 b6e en ddsudtude. It s'abusoit sur sa valeur ; 
 et il nest pas difficile d’en connoitre la cause. 
 Tons les enfans qu'il opdroit d VH&tel-Dieu 
 sortoienf gueris el n'y revenoient plus : on 
 rtgardoit alors comme radicale une gnirison 
 morneutanee .” (Riche rand , Nosographie Chir. 
 T. 2 ,p. 456.) I have carefully watched (says 
 Scarpa) the immediate effects, and the more 
 or less remote consequences of tying the 
 umbilical hernia, either simply or by means 
 of a m edle and double ligature ; and, after 
 a considerable number of such cases, I be- 
 lieve I can assert, that this operation , how- 
 soever performed , is not alway exempt from 
 grave and sometimes dangerous accidents. / 
 can also add, that it never procures a truly 
 radical cure un'ess the cicatrix, occasioned by 
 it in the umbilical region be submitted for 
 some mouths to a methodical ancbuninterrupted 
 compression. It is not so uncommon, as some 
 surgeons pretend, to set arise after the applica- 
 tion of the ligature , a fever attended with 
 symptoms of most violent irritation, and acute 
 sufferings, which cause incessant crying, and 
 sometimes convulsions. The ulcer, which is 
 produced by the detachment of the swelling, is 
 ulv)uys very large and difficult to heal. Every 
 now and then it becomes painful, and emits 
 fungous granulations , even though dressed 
 ivith dry applications. 
 
 u Latterly, it has been explained by a cele- 
 brated surgeon, (Palette, Manor, del' lusti-, 
 
HERNIA. 
 
 47 
 
 tuie , Tom. 2, Pur/ I.) that the umbilical vein 
 and the suspensory ligament of the liver, be- 
 ing included in the ligature ot the umbilical 
 hernia, the inflammation which originates 
 in these pans may, perhaps, in certain cases, 
 be communicated to the liver, so a* to put 
 the child’s life in great danger. W hen, in 
 consequence of the ligature, symptoms ot 
 violent irritation come on, they are ordina- 
 rily attributed to certain individual circum- 
 stances, such as extreme sensibility, or a par- 
 ticular /Imposition to spasm Hence, it is 
 believed, that they should be considered as 
 exceptions, which do not exclude the gene- 
 ral rule, and prove nothing against the utility 
 of the operation. But how (says Scarpa) 
 can the surgeon ascertain the existence or 
 nonexistence of these individual dispositions 
 in the children upon which he is to operate ? 
 Assuredly those subjects, in which I have had 
 occasion to notice the >bove accidents, en- 
 joyed, before the operation, perfect health 
 in < very respect 
 
 “ Whatever process be adopted for tying 
 the umbilical hernia, it is evident that the 
 tumour can only bp constricted as far as a 
 little way on this side of the aponeurotic 
 ring of the umbilicus, whence it follows that 
 the integuments must always remain promi- 
 nent and relaxed for a certain extent, at the 
 front and circumference of this opening. 
 Also, after the separation of the strangulated 
 portion, there necessarily remains, under the 
 cicatrix, a portion of the hernial sac, and of 
 the loose integuments W’hich covered it ; and 
 as the cicatrix itself never acquires sufficient 
 firmness to resist the impulse ot the viscera, 
 which tend to insinuate themselves into the 
 remains of (he hernial sac, the hernia sooner 
 or later reappears, and, in a short time, be : 
 comes larger than it was before the opera- 
 tion. If the subject is a little girl, it may he 
 apprehended, that the first pregnancy will 
 eause a recurrence of the hernia ; for, it is 
 known, that, during gestation, the external 
 cicatrix of the umbilicus is considerably dis- 
 tended, and much disposed to give way.” 
 
 Pott has seen terrible accidents cau-ed by 
 the rupture of the cicatrix a* the navel, du- 
 ring pregnancy. (C. hirurg . Works, Vol. 2 , p. 
 169.) It is true that, according to this writer, 
 this cicatrix was not the consequence of a 
 hernia, but rather of an abscess in the umbi- 
 lical region, which abscess had forme ly 
 been opened with a bistoury ; yet, observes 
 Scarpa, it would not be impossible to raise 
 doubts upon this conjecture. Lastly, alter 
 the separation of the tumour, there always 
 remains, between (he aponeurotic ring ot (be 
 navel and the integuments, a small cavity, 
 formed by the neck of the hernial sac ; a 
 cavity into which the viscera begin to insi- 
 nuate themseives after the operation, so as to 
 binder the complete contraction of the um- 
 bilical ring. The demonstration of what I 
 have advanced is, in some measure, to be 
 found in ihe old method of operating for the 
 inguinal hernia, not in a strangulated state, 
 by (he ligature of the hernial sac and sperma- 
 tic cord. Most of the hernia?, operated upon 
 
 by (his barbarous process, were subject to 
 relapses, because, in all probability , the cica- 
 trix was noi sufficiently firm to resist the 
 impulse of the viscera, w hich entered the 
 remains of the hernial sac. In the same man- 
 ner, after the common operation for (he 
 strangulated inguinal hernia although the 
 cicatrix is formed very near the ring, there is 
 no piudent surgeon who does not advise the 
 patient to wear a bandage the rest of his life, 
 observation having prove > that the hernia is 
 still liable t<> recur. 
 
 “ The experience of several ages leaves 
 no doubt, that compression alone is an ex- 
 tremely efficacious method of radically 
 curing the umbilical hernia of young sub- 
 jects. It is attended with no risk, and, pro- 
 vided it be executed with the requisite cau- 
 tion, it is hardly ever necessary to continue 
 it longer than two or thife mouths for the 
 purpose of obtaining a complete cure. On 
 the olher side, ii it be clearly proved, by all 
 that J have been observing, that the ligature 
 never accomplishes a perfect cure without 
 compression, it is manifest, that it cannot be 
 at all advantageous for the children of the 
 poor, since a bandage cannot be dispensed 
 with. Il may be said, that in general it does 
 not shorten the treatment ; for, in the most 
 successful cases, the ulcer caused by it is 
 not healed in less than a month, and, in 
 order to make the cure certain, an exact 
 compression must afterward he kept up, by 
 means of a bandage, two months longer. It 
 has already been staled, that three months 
 are ordinarih sufficient for obtaining a radi- 
 cal cure by the mere employment of a tom- 
 pres-ive bandage.” ( Scarpa , Traitt des Her- 
 nies,p. 344 — 349.) 
 
 In the Journal G6n&ral de Medecine, T. 41. 
 1811, M. Girard has published a memoir on 
 the umbilical hernia of children, w hich was 
 read to the Medical Society of Lyons in 
 May, 1811, and the object of which was 
 to recommend compression as an effectual 
 means of cure. The arguments used were 
 very similar to those adduced by Scarpa. In 
 the course of the discussion, M. Cartier 
 affirmed, that he had seen many children 
 operated upon by Desault, who were not 
 cured of their, herniae. 
 
 The subject was afterward taken up by 
 the Medical Society of Paris, and the result 
 of the debate was, that the employment of 
 the ligature ought to be rejected. 1. Be 
 cause the cure ot umbilical herniae is often 
 accomplished by nature alone. 2. Be- 
 cause compression^ either alone or aided by 
 tonic remedies, always succeeds. 3. Be- 
 cause (he operai ion of the ligature deserves 
 the triple reproach of being painful, and not 
 free from danger, if unfortunately a piece of 
 intestine should chance to be included in the 
 ligature ; of not succeeding in general, except 
 with the as'istance of compression,* and of 
 being sometimes uselessly practiced, a- De- 
 sault himself give> us instances of. Accord- 
 ing to M. Cayol. the insufficiency of the liga- 
 ture was lung since acknowledged by 8aba 
 tier, Lassus, Richerand, fee, . 
 
48 
 
 HERNIA. 
 
 UMBILICAL HERNIA IN ADULT SUBJECTS. 
 
 This case is to be trailed on the princi 
 lies common to nil ruptures. When reduci- 
 )le., the. parts should be kept up with a band- 
 age or truss; which plan howev in grown- 
 up persons- dFords no hope ol a radical cure. 
 Mr. Hey has described some very good 
 trusses for the exornphalos, which are appli- 
 cable 'o children, when compression is pre- 
 ferred, as well as to -»duh -ubp o s Om was 
 invented by the la:e Mr. Marrison. an ingeni- 
 ous mechanic at Leeds. 
 
 “ It consists of two pieces of thin elastic 
 steel, which surround the sides of the abdo- 
 men, and nearly in et behind. At their an- 
 terior extremity they form conjointly an 
 oval ring, to one side of which is fastened a 
 spring of steel ol the form (-presented. At 
 the end of this sprit)" is placed the pad or 
 bol der ( iiat presses upon die hernia. By the 
 elasticity of this spring the hernia is repressed 
 in every position of the body, a d is thereby 
 retained constantly Within the abdomen. A 
 piece of calico or jean is fastened to each 
 side of the oval ring, .having a continued 
 loop at its edge, th'ough which a piece of 
 tape is put, that may be tied behind the bodv . 
 This contrivance helps to preserve the in- 
 strument steady in itspropei situation. (Prac- 
 tical Obs. in Surgery, p. 231.) And, i . the 
 second edition of the preceding work, ano- 
 ther truss for the exomphalos is described, 
 the invention of Mr. England, of Leeds, but 
 as some account is given of this instrument, 
 with an engraving, in the 2d. vol.of the First 
 Lines of Surgery, l shall not here repeat the 
 description. 
 
 When the exomphalos i > irreducible, and 
 large, the tumour must be supported with 
 bandages. 
 
 e ' It is observed by Scarpa, t hat the umbi- 
 lical hernia, arid those of the !i tea dii*, are 
 less subjeetto be .strangulated than die ingui- 
 nal and femora! hernia ; but tha:, when they 
 are unfortunately atfe. ed with strangulation', 
 the symptoms are more intense, and gan- 
 grene comes on more rapidly, than in every 
 other species of rupture. If the operation be 
 performed, the event is frequently unfavour- 
 able, because it is generally done too late. 
 This practical fact is proved by 1 he experi- 
 ence of the most celebrated surgeons of. every 
 age. “ II est certain (.says Din i ) que de 
 cette operation il en peril plus qu'il n'en re- 
 chappe ” ( Cours d' Operations, p. 98, Ed. 
 1777, avec les notes de la Faye.) He also 
 adds, that they who have die misfortune to 
 be afflicted with an exomplialos, should ra- 
 ther dispense with (heir shirt than a bandage. 
 Heister says nearl\ the same thing. (Insti- 
 iut. Chirurg. T. 2, Cap 94.) 
 
 When the omentum alo >e is strangulated 
 in the exomphalos, or hernia of the liuea 
 alba, observation proves, that the symptoms 
 are not less intense, than when the intestine 
 is also incarcerated. There is this dill'-rcnce, 
 however, that when the omentum alone is 
 strangulated, only nausea occurs, and, if vo- 
 miting should likewise lake place, it is less 
 frequent and violent them when the bowel 
 
 itself is strangulated. In the first case, the 
 stools are hardly ever entirely suppressed. 
 The proximity of the stomach is, no doubt, 
 t lie reason v\ hy the strangulation of the 
 omentum, in the umbilical hernia, ccasioris 
 far more inten -e symptoms ol : ympathetic ir- 
 lation than the strangulation ol the same vis- 
 cus ;:i die inguinal or crural hernia. 
 
 Here the operation is not only always ne- 
 cessary, but urgently required. It is not 
 materially different from that which is prac- 
 tised for the strangulated inguinal and crural 
 hernia} ; but . in general, it demands'greater 
 cirmm.ipee.tioi , on account ol the connexion 
 or intimate adhesions, which In quenlly exist 
 between die integuments and hernial sac, 
 and also the adhesions which often prevail 
 between the latter part and the omentum 
 winch it contains. The situation of the in- 
 testine, which is frequently covered by and 
 enveloped in the omentum, is another cir- 
 cumstance deserving earnest attention. 
 ( Scarpa , Trait 6 des Hernies, p. 361, 362.) 
 
 M:\ Potl is not such an advocate as Scar- 
 pa for the early performance of the opera- 
 tion in cases of exomphalos : “ The umbili- 
 cal, like the inguinai hernia, becomes the 
 subject of chirurgie operation, when the 
 parts are reducible by the hand only, and 
 are so bound as to produce bad symptoms. 
 But though 1 have in the inguinal and scro- 
 tal hernia advised the early use of the knife, 
 
 I cannot press it so much in this ; the suc- 
 cess of it is very rare, and 1 should make it 
 the last remedy Indeed, I am much incli- 
 ned to believe that the bad symptoms v\ hich 
 attend these cases are most frequently 
 owing t disorders in the intestinal canal, 
 and not .-<> often to a stricture made on it at 
 the navel, as is supposed. 1 do not say that 
 the latter does rot sometimes happen ; it 
 certainly does ; b it it is often believed to 
 be the case when -t is not. 
 
 “ When the operation becomes necessa- 
 ry, it consists in dividing the skin and her- 
 nia! sac, in Luch manner as shall set the in- 
 testine free from stricture, and enable the 
 surgeon t<» return it into the abdomen. 
 ( Pott on Ruptures.) 
 
 The rest of the conduct of »he surgeon is 
 to be regulated by the usual principles. 
 
 The division of the stricture is properly 
 recommended to be made directly upward, 
 in the course of the liuea alba. 
 
 In consequence of the great fatality of 
 the usual operation for the exomphalos, l 
 think the plan suggested, and successfully 
 practised by Mr. A. Cooper in two instan- 
 ct s, should always be ado ted, whenever 
 the tumour is lar .e, and free from gangrene ; 
 a plan, that has also received the high sanc- 
 tion of that distinguished anatomist and sur- 
 geon, Professor Scarpa. ( Trait6 dcs Her- 
 nie , p. 362.) Perhaps 1 might safely add, 
 that, when the parts admit of being reduced, 
 without laying open the sac, this method 
 should always be preferred. It consists in 
 making an incision just sufficient to divide 
 the stricture, without opening the sac at all, 
 or at all events, no more of it, than is inevi- 
 table. 
 
HERNIA. 
 
 In umbilical hernia?, ot’ not a large size, 
 Mr. C. recommends the following plan of 
 operating : “ As the opening into the abdo- 
 men is placed towards the upper part of the 
 tumour, l began the incision a little below it, 
 that is, at the middle of the swelling, and ex- 
 tended it to its lowest part. 1 then made a 
 second incision at the upper part of the first, 
 and at right angles with it, so that the 
 double incision w as in the form of the letter 
 T, the top of which Crossed the middle of 
 the tumour. The integuments being thus 
 divided, the angles of the incision were 
 turned down, which exposed a considerable 
 portion of the hernial sac. This being then 
 carefully opened, the finger was passed be- 
 low' the intestines to the orifice of the sac 
 at the umbilicus, and the probe-pointed bis- 
 toury being introduced upon it, I directed 
 it into the opening at the navel, and divided 
 the linea alba downwards, to the requisite 
 degree, instead of upwards, as in the former 
 operation. When the omentum and intes- 
 tine are returned, the portion of integument 
 and sac, which is left, falls over the opening 
 at the umbilicus, covers it, and unites to its 
 edge, and thus lessens the risk of the peri- 
 tonasal inflammation, by more readily clo- 
 sing the wound.” (Oil Crural and Umbili- 
 cal Hernia.) 
 
 LESS FREQUENT KINDS OF HERNIA. 
 
 The ventral hernia, described by Oelsus, is 
 not common ; it may appear at almost any 
 point of the anterior part of the belly, but 
 i -3 most frequently found between the recti 
 muscles. The portion of intestine, he. is 
 always contained in a sac, made by the pro- 
 trusion of the peritonaeum. Mr. A. Cooper 
 imputes the disease to the dilatation of the 
 natural foramina for the transmission of 
 vessels, to congenital deficiencies, lacera- 
 tions, and wounds of the abdominal mus- 
 cles, or their tendons. In small ventral her- 
 nia?, a second fascia is found- beneath the 
 superficial one ; but, in large cases, tlie lat- 
 ter is the only one covering the sac. 
 
 Hernia? in tiie course of the linea alba 
 sometimes occur so near the umbilicus, that 
 they are liable to be mistaken for true um- 
 bilical ruptures. They may take place 
 either above, or below the navel. The first 
 1 case, however, is more frequent than the 
 second, and the following is the reason of 
 this circumstance according to the opinion 
 of Scarpa. u The upper half of the linea 
 alba, that which extends from the ensiform 
 cartilage to the umbilicus, is naturally 
 broader and weaker, than the lower half, 
 the recti muscles coming nearer and nearer 
 together, as they descend from the navel to 
 the pubes. (Scarpa, Traill des Her nits, p. 
 333.) 
 
 The hernial sac of ruptures at the upper 
 part of the linea aiba may contain a noose 
 of intestine, and a piece of the omentum, 
 though in most cases, a portion of the latter 
 membrane alone forms the contents. In 
 some subjects, the linea alha is so disposed 
 ! to give way, that several hernia; are obser- 
 1 Vol. If. ' 7 
 
 lit 
 
 ved to be formed successively in the inter- 
 space between the ensiform cartilage and 
 the umbilicus. 
 
 “ With respect to the small hernia (says 
 Scarpa,) w hich is considered as formed by 
 the stomach, and concerning which Iloin 
 and Garengeot have written so much (with- 
 out either of them having related, at least 
 to my knowledge, a single example proved 
 by dissection,) it is at least unproved, that 
 it was exclusively formed by this viscus. 
 1 do not see, why the other viscera, particu- 
 larly the omentum and transverse colon, 
 might not also contribute to it. In my 
 judgment, it only differs from other hernia; 
 of the linea alba, in being situated on the 
 left side of the ensiform cartilage, a situa- 
 tion that must materially influence the 
 symptoms of the case. In fact, whatever 
 may be the viscera, which form it, a sympa- 
 thetic irritation of the stomach is occasion- 
 ed, tliat is much more intense, than that 
 which ordinarily accompanies umbilical 
 hernia?, those of the lower part of the linea 
 alba, or, in short, all other hernia;, which 
 are more remote from the stomach.” (Op, 
 cit. p. 334.) 
 
 ! he following are said to be the circum- 
 stances, by which the umbilical hernia, and 
 that which occurs in the linea alba near the 
 navel, may be discriminated. 
 
 The first, w hether in the infant or the 
 adult, has a roundish neck or pedicle, at 
 the circumference of which the aponeurotic 
 edge of the umbilical ring can be felt. 
 Whatever may be its size, its body always 
 retains nearly a spherical shape. Neither 
 at its apex, or its sides, is any wrinkling of 
 the skin, or any thing like the cicatrix ot 
 the navel, distinguishable. In some points 
 of the surface of the tumour, the skin is 
 merely somew'hat paler and thinner, than 
 elsewhere. 
 
 On the contrary, the hernia of the linea 
 alba has a neck, or pedicle, of an oval form, 
 like the fissure through W'hich it is protru- 
 ded. The body of the tumour is also con- 
 stantly oval. If the finger be pressed deep- 
 ly round its neck, the edges of the opening 
 in the linea alba can be felt ; and, if the 
 hernia be situated very near the umbilical 
 ring, the cicatrix of the navel may be ob- 
 served upon one side of it, which cicatrix 
 retains its rugosity, mid all its natural ap- 
 pearance ; a certain indication, that the vis- 
 cera are not protruded through the umbili- 
 cal ring. (Scarpa, Traill des Hernies, p. 33b.) 
 
 The distinction which Scarpa has estab- 
 lished between the umbilical hernia?, proper- 
 ly so called, and those of the linea alba, is 
 not useless in regard to practice. Indeed, 
 w hen the latter are left to themselves, they 
 make much slower m’ogress, than the form- 
 er. On account of their smallness, they 
 frequently escape notice, particularly in fat 
 persons, and, wdien situated at the side of 
 the ensiform cartilage. They occasion, 
 however, complaints of the stomach, habitu- 
 al colics, especially after meals ; and, un- 
 fortunately for the patient, he may be tor- 
 mented a very long time by these indispa- 
 
HERNIA. 
 
 AO 
 
 sitions, before the true cause of them is dis- 
 covered. 
 
 The umbilical hernia may be known, 
 from the earliest period of its formation, by 
 the alteration which it produces in the 
 cicatrix of the navel, and the rapidity of its 
 increase. 
 
 In other respects, these two kinds of her- 
 niffi demand the same means of cure ; but 
 those of the linea alba, cceteris paribus , are 
 more difficult to cure, than ruptures at the 
 umbilicus. This is probably owing to the 
 natural tendency, which the umbilicial ring 
 has to close, when tiie hernia is kept well 
 reduced, whilst accidental openings in the 
 linea alba have not the same advantage. 
 ( Scarpa , p. 340.) 
 
 Wnen a common ventral hernia is redu- 
 ced, it should be kept in its place by means 
 of a bandage or truss. When strangulated, 
 it admits, more frequently than most other 
 cases, of being relieved by medical treat- 
 ment. If attended with stricture, which 
 cannot otherwise be relieved, that stricture 
 must be carefully divided. Mr. A. Cooper 
 recommends the valvular incision, and the 
 dilatation to be made, either upward or 
 downward, according to the relative situa- 
 tion of the tumour and epigastric artery, 
 which crosses the lower part of the linea 
 semilunaris. 
 
 Pudendal Hernia . — This is the name as- 
 signed by Mr A. Cooper, to the hernia 
 which descends between the vagina and ra- 
 mus ischii, and forms an oblong tumour in 
 the labium, traceable w ithin the pelvis, as 
 far as the os uteri. He thinks, that this case 
 has sometimes been mistaken for a hernia 
 of the foramen ovale. When reducible, a 
 common female bandage, or the truss used 
 for a prolapsus ani, should be w r orn. A pes- 
 sary, unless very large, could not well keep 
 the parts from descending, as the protru- 
 sion happens so far from the vagina. Mr. 
 A. Cooper is of opinion, that, w hen strangu- 
 lated, this hernia, in consequence of the 
 yielding nature of the parts, may generally 
 be reduced, by pressing them with gentle 
 and regular force, against the inner side of 
 the branch of the ischium. If not, the warm 
 bath, bleeding, and tobacco clysters are ad- 
 vised. Were an operation indispensable, 
 the incision should be made in the labium, 
 the lower part of the sac carefully opened, 
 and, with a concealed bistoury, directed by 
 the finger, in the vagina, the stricture should 
 be cut directly inw r ard, tow r ards the vagina. 
 The bladder should be emptied, both before 
 the manual attempts at reduction and the 
 operation. (On Crural Hernia , fyc. p. 64.) 
 
 Paginal Hernia . — A tumour occurs within 
 the os externum. It is elastic, but not pain- 
 ful. When compressed, it readily recedes, 
 but is reproduced by coughing, or even 
 without it when the pressure is removed. 
 The inconveniences produced are an ina- 
 bility to undergo much exercise or exertion ; 
 for, every effort of this sort brings on a sense 
 of bearing down. The vaginal hernia pro- 
 trudes in the space, left between the uterus 
 and rectum. This space is bounded below 
 
 by the peri ton senna, whieh membrane is 
 forced downwards towards the perinamm ; 
 but, being unable to protrude further in that 
 direction, is pushed towards the back part 
 of the vagina. In one case Mr. A. Cooper 
 advised the use of a pessary, but the plan 
 was neglected. Probably, these cases are 
 always intestinal. 
 
 Some herniae protrude at the anterior part 
 of the vagina. (si. Cooper on Crural Her- 
 nia, fyc. p. 65, 66.) 
 
 Perinatal Hernia . — In men, the parts pro- 
 trude betw een the bladder and rectum ; in 
 women, between the rectum and vagina. 
 The hernia does not project, so as to form 
 an external tumour, and, in men, its exist- 
 ence can only be distinguished by examin- 
 ing in the rectum. In women, it may be 
 detected both from this part, and the va- 
 gina. 
 
 In case of strangulation, perhaps, this 
 hernia might be reduced by pressure from 
 within the rectum. An interesting case of 
 perinaeal hernia, which took place from the 
 peritonaeum being wounded with the gor- 
 get in lithotomy, is related by Mr. Brom- 
 field ; Chirurgical Obs. p. 264. 
 
 The reducible perinaeal hernia in wmmen 
 may be kept from descending, by means of 
 a large pessary. Both this kind of rupture 
 and the vaginal may prove very dangerous 
 in cases of pregnancy. (See Smellie’s Mid- 
 wifery, Case 5.) 
 
 Thyroideal Hernia, or Hernia Foraminis 
 Ovale. In the anterior and upper part of 
 the obturator ligament, there is an opening, 
 through which the obturator artery, vein, 
 and nerve proceed, and through which, oc- 
 casionally, a piece of omentum, or intestine 
 is protruded, covered with a part of the 
 peritonaeum, wdiich constitutes the hernial 
 sac. 
 
 In the case which Mr. A. Cooper met 
 with, the hernia descended above the obtu- 
 ratores muscles. The os pubis w as in front 
 of the neck of the sac ; three-fourths of it 
 were surrounded by the obturatorligament ; 
 and the fundus of the sac lay beneath the 
 pectineus and adductor brevis muscles. 
 The obturator nerve and artery were situa- 
 ted behind the neck of the sac, a little to- 
 wards its inner side. This species of hernia 
 can only form an outward tumour, when 
 very large. Garengeot, however, met with 
 an instance, in which there was not only a 
 swelling, but, one attended with symptoms 
 of strangulation : he reduced the hernia, 
 which went up with a guggling noise ; the 
 symptoms .were stopped, and stools soon 
 followed. 
 
 The hernia of the foramen ovale, when 
 reducible, must be kept up w ith a suitable 
 truss ; and if it were strangulated, and not 
 capable of relief from the usual means, an 
 operation would be requisite, though at- 
 tended with difficulties. T he division of the 
 obturator ligament and mouth of the sac 
 should be made inwards, to avoid the obtu- 
 rator artery. If this vessel, however, were 
 to arise in common with the epigastric ar- 
 tery, it. would be exposed to injury bv fo! 
 
HERMA 
 
 lowing; this plan. (See Garengeol in Mini, 
 de VAcad. de Cfiir. T. 1 ; A. Cooper on Cru- 
 ral Hernia, fyc. p. 70 : and First Lines of Sur- 
 gery, Vol. 2, p. 80. 4'C.) 
 
 < yslocele. — As Mr. Pott observes, “ The 
 urinary bladder is also liable to be thrust 
 forth from its proper situation, either through 
 the opening in the oblique muscle, like the 
 inguinal hernia, or under Poupart’s liga- 
 ment, in the same manner as the femoral. 
 
 “ This is not a very frequent species of 
 hernia, but does happen, and has as plain 
 and determined a character, as any other. 
 
 “ it has been mentioned by Bartholin, T. 
 Dorn. Sala, Platerus, Bonetus, Ruysch, Petit, 
 Mery, Verdier, & c. In one of the histories 
 given by the latter, the urachus, and imper- 
 vious umbilical artery on the left side, were 
 drawn through the tendon into the scrotum, 
 with the bladder; in another he found four 
 calculi. 
 
 “ Ruysch gives an account of one com- 
 plicated with a mortified bubonocele. Petit 
 says, he felt several calculi in one, which 
 were afterward discharged through the ure- 
 thra. ^See also J. G. F. Jahn de insoht ® 
 Calculi Ingentis per Scrotum exclusiotie. IVit- 
 tenberg. 1750.) 
 
 “ Bartholin speaks of T. Dorn. Sala as the 
 first discoverer of the disease, and quotes a 
 case from him, in which the patient had all 
 the symptoms of a stone in his bladder ; the 
 stone could never be felt by the sound, but 
 was found in the bladder (which had passed 
 into the groin) after death. 
 
 “ As the bladder is only covered in part 
 by the peritonaeum, and must insinuate itself 
 between that membrane and the oblique 
 muscle, in order to pass the opening in the 
 tendon, it is plain that the hernia cystica 
 can have no sac, and that when complica- 
 ted with a bubonocele, that portion of the 
 bladder which forms the cystic hernia must 
 lie between the intestinal hernia and the 
 spermatic cord, that is, the intestinal hernia 
 must be anterior to the cystic. 
 
 “ A cystic hernia may, indeed, be the 
 cause of an intestinal one ; for when so 
 much of the bladder has passed the ring, 
 as to drag in the upper and hinder part of 
 it, the peritonaeum which covers that part 
 must follow, and by that means a sac be 
 formed for the reception of a portion of gut 
 or caul. Hence the diiferent situation of 
 the two herniae in the same subject 
 
 “ While recent, this kind of hernia is easily 
 reducible, and may, like the others, be kept 
 within by a proper bandage ; but when it is 
 of any date, or has arrived to any consider- 
 able size, the urine cannot be discharged, 
 without lifting up, and compressing the 
 scrotum ; the outer surface of the bladder is 
 now become adherent to the cellular mem- 
 brane, and the patient must be contented 
 with a suspensory bag. 
 
 “ In case of complication with a bubono- 
 cele, it the operation becomes necessary, 
 great care must be taken not to open the 
 bladder instead of the sac, to which it will 
 always be found to be posterior. And it 
 may also sometimes by the inattentive be 
 
 51 
 
 mistaken for a hydrocele, and by being 
 treated as such, may be the occasion of 
 great or even fatal mischief.” (Vol. 2.) 
 
 The cystocele is always easily distinguish- 
 able by the regular diminution of the swell- 
 ing, whenever the patient makes water. 
 
 Verdier and Sharp have accurately de- 
 scribed the cystocle. Pott has ottered two 
 cases, which fell under his observation ; 
 Vol. 3. Pipelet le Jeune mentions a cystic 
 hernia in perinteo, and several cases of its 
 occurrence in the female ; Acad, de Cliir. 
 T. 4. Pott cut into one cystocele, by mis- 
 take. Mention is made (Edinb. Snrg. Jour. 
 Vol. 4, p. 512.) of a cystic hernia, which 
 protruded between the origins of the leva- 
 tor ani, and obturator internus muscles ; 
 the tumour made its appearance in the pu- 
 dendum of an old woman. Much additional 
 information respecting the cystocele, and 
 its various forms, is contained in the second 
 volume of the First Lines of Surgeiy, p. 49, 
 be., accompanied with references to all the 
 most interesting writers on the subject. An 
 instance of protrusion of the bladder through 
 a wound, caused by a bullock’s horn, is re- 
 corded by Larrey. (Mem. de Cliir. Mil. T. 
 4, p. 289.) 
 
 Ischiatic Hernia. — This disease is very- 
 rare. A case, however, which was strangu- 
 lated, and undiscovered till after death, is 
 related in Mr. A. Cooper’s second pait of 
 his work on hernia. It was communicated 
 by Dr. Jones, so celebrated for his book on 
 hemorrhage. The disease happened in a 
 young man, aged 27. On opening the abdo- 
 men. the ileum was found to have descend- 
 ed on the right side of the rectum into the 
 pelvis, and a fold of it was protruded into a 
 small sac, which passed out of the pelvis at 
 the ischiatic notch. The intestine was ad- 
 herent to the sac at two points: the stran- 
 gulated part, and about three inches on each, 
 side, were very black. The intestines to- 
 wards the stomach were very much distend- 
 ed with air, and here and there, had a livid 
 spot on them. A dark spot was even found 
 on the stomach itself just above the pylorus. 
 The colon was exceedingly contracted as 
 far as its sigmoid flexure. A small orifice 
 was found in the side of the pelvis, in front 
 of, but a little above the sciatic nerve, and 
 on the forepart of the pyriformis muscle. 
 The sac lay under the gluttons maximus 
 muscle, and* its orifice was before the inter- 
 nal iliac artery, below the obturator artery, 
 but above the vein. Mr. A Cooper remarks, 
 that a reducible case might be kept up with 
 a spring truss, and that if an operation were 
 requisite, the orifice of the sac should be 
 dilated directly forwards. (On Crural Her- 
 nia,\c.p. 73.) For a further account of 
 the ischiatic hernia, and references to the 
 most interesting works on the subject, see 
 First Lines of Surgery , Vol. 2, p. 84, fyc. 
 
 Phrenic Hernia.— The abdominal visceri 
 are occasionally protruded through the dia- 
 phragm, either through some of the natural 
 apertures in this muscle, or deficiencies, or 
 wounds, and lacerations in it. The second 
 kind of case is the most frequent: Morgagni 
 
 u. of u. ua 
 
62 
 
 hernia. 
 
 furnishes an instance of the fust. Two cases, 
 related by Dr. Macauley in Med. Obs. and 
 Jnq. Vol. I, two more detailed in the Medi- 
 cal Records and Researches, and two others 
 published by Mr. A. Cooper, are instances 
 of the second sort : and another case has 
 been lately recorded by the latter gentle- 
 man, affording an example of the third kind. 
 A laceration of the diaphragm by fractured 
 ribs, has produced a hernia. A case of this 
 kind was dissected by Mr. Travers* at Guy’s 
 Hospital. (Med. Ckir. Trans Vol. 0, p. 375.) 
 In this last volume, may also be found the 
 particulars of an interesting example, in 
 which a considerable part of the large cur- 
 vature of the stomach was protruded through 
 a fissure of the diaphragm. The accident 
 was unattended with any fracture of the 
 ribs, and was caused by the upsetting of a 
 stage coach, on which the patient was an 
 outside passenger. Before death, he vomit- 
 ed up a large quantity cf blood, and a small 
 semicircular aperture was discovered on 
 dissection in the lower part of t lie strangu- 
 lated portion of the stomach. (P. 378, 379.) 
 See also B. Stehelin, Tentamen Med. quod 
 vemriculum, qui in Ihoracem migraveral , SfC. 
 describit, 1721 ; (in Hallerii Disp. Anal. 6, 
 675.) Hildanus, Parc, Petit, Sehenck, Spc. 
 also mention cases of phrenic hernia. The 
 disease is quite out of the reach of art. 
 
 Mesenteric Hertua. — If one of the layers 
 of the mesentery be torn by a blow, w bile 
 the other remains in its natural state, the in- 
 testines may insinuate themselves into the 
 aperture, and form a kind of hernia. The 
 same consequence may result from a natu- 
 ral deficiency in one of these layers. Mr. A, 
 Cooper records a case, in which ail the 
 small intestines, except the duodenum, were 
 thus circumstanced. The symptoms during 
 life were unknown. (On Crural Hernia, tyc. 
 V - 82.) 
 
 Mesocolic Hernia. — So named by Mr. A. 
 Cooper, when the bowels glide between tiie 
 layers of the mesocolon. A specimen of 
 this disease is preserved at St. Thomas's 
 Hospital. 
 
 Every surgeon should be aware, that the 
 intestines may be strangulated within the 
 abdomen from the following causes : 1 
 
 Apertures in the omentum, mesentery, or 
 mesocolon, through which the intestine 
 protrudes. 2. Adhesions, leaving an aper- 
 ture, in which a piece of intestine becomes 
 confined 3. Membranous hands at the 
 mouths of hernial sacs, which becoming 
 elongated, by the frequent protrusion and 
 return of the viscera, surround the intestine, 
 so as to strangulate them within the abdo- 
 men, when returned from the sac. (See 
 A. Cooper on Crural Hernia, ..Tc. p. 85.) 
 
 Pott remarks, that “ Ruysch gives an ac- 
 count of an impregnated uterus being found 
 on the outside of the abdominal opening ; 
 and so do Hildanus and Seunertus. Ruysch 
 also gives an account of an entire spleen 
 having passed the tendon of the oblique 
 muscle. And 1 have myself seen the ovaria 
 removed by incision, after they had been 
 gome months in the groin.” (Vol. 2.) More 
 
 particulars respecting all the less frequent 
 kinds of hernia are given in the second vo- 
 lume of the First Lines of Surgery. Franco , 
 Traiti des He rules, fyc. 8 vo., Lyon, 1561 : 
 Lud. von Hammen, De Herniis , 12mo., Lugd. 
 1581. M alack- Geiger, Kelegraphia, sive De- 
 scriplio Herniarurn, cum carundem curatio- 
 nibus, lam Medicis, quam Ckirurgicis, 12 mo., 
 Monackii, 1631 ; Ant. Le Quin, Le Chirur- 
 gicn Herniaire, \2mo., Paris, 1697. J At Ire, 
 Observation sur ant JVuuvelle Espece de Her- 
 nie, Mini, de l' Acad, des Sciences; 1700. 
 Mery, in Ike same work; 1701. Litlre, sur 
 une Hernie Rare; same work; 1 7 Id. Mau- 
 chart de Hernia incarcerata nova encheiresi 
 extricatd, Tubing. 1722. Heister, Instil. Chi- 
 rurg. el De Hernia Incarcerata Suppu- 
 rala non semper tethali. Vogel, Abhandlung 
 alter Arlen der Brucke ; Lcipz. 1738. Pey- 
 ronie, Observations, fyc. sur la Cure des Her- 
 nics avec Gangrene; Mem de l' Acad, de 
 Ckir. T. 1. Gunz, Observalionum Anatomico- 
 Ckirurgicarum de Herniis lib dies; Lips. 
 17-14; el Prolusio Invdatoria in qua de 
 Eulero-Epiplocele ugebat, Lips. 1746. P. 
 Kirkschbaum, De Hernia Venlriculi , Argent. 
 1749. P. <S. Kok , De Herniis ; Roterod. 1782. 
 Arnaud on Hernias, 1748 ; also kis Mem. do 
 Ckir. Haller de Herniis Congenilis, 1749. Ca- 
 l' eng ect, sur plusieurs Hernies singulieres ; 
 Mem. de T Acad, de Ckir. tom. 2. Moreau sur 
 les suites d'une Hernie op trie ; Mem. de 
 I'Acad. di Ckir. t. 3. Benevoli , una Ernict 
 assai p articular e ; Firenso , 1750. G. H. 
 Troschel, De Morbis ex Alieno Situ Partium 
 Abdominis, Franco/. 1754: (Haller, Disp. ad 
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 and Inquiries. Poll's Works, Vols. 2 and 3. 
 Goursaud sur la Difference des Causes de 
 I'itranglement des Hernies; Mem. de I’Acad. 
 de Ckir. Tom. 4. Le Dr an, Trail i des Ope- 
 rations de Ckir. et Observations de Ckir. obs. 
 57 E. Hildanus, cent. 5. obs. 54. J. L. Petit, 
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 trandi, Truitt des Operations ; et Exemple 
 d'une Hernie formic du cote droit par t'in- 
 tesiin ileum settlement, donl une portion s’etoit 
 echappee par une des ichancrures isckiutiques, 
 en seglissant sur les ligaments sacro-sciatiques; 
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 1713. J. L. Petit sur les Hernies dc la Vessie ; 
 Acad, des Sciences, 1717. Vernier. Reckerckes 
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 de Ckir. Tom. 4. Voter de Lien is Prolapsione , 
 1746. M. G. Pfannius , De Entero- Oscheo- 
 cele antiqua, restitntione sacci herniosi f clicilcr 
 
HERNIA. 
 
 53 
 
 Nevada, absque brachtrio et sccfionc curata. die Ursache , fyc. dtr Hr ache am Bauchen and 
 Erlangee, 1748 Peyronie sur un Strangle- Hecken, ausser der Mabel und Leistengegend. 
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 his son. Gimbernat's Account of a 'ew Me- 
 thod of operating for Femoral Hernia, trawl, 
 from the Spanish' by Beddocs,Svo. 1795. Also 
 the German transl. with additions by Schreger , 
 12mo. Murnb. 1817. A. Cooper on Inguinal 
 and t o:, genital Hernia, fol. Loud. 1804; and 
 on Crural and Umbilical Hernia fol. Loud. 
 le'07. A. Monro on Crural Hernia, 1803; 
 and Ike Morbid Anatomy of the Human Gul- 
 let, Stomach, and Intestines, 8 vo. Edinb. 181 1. 
 Sabatier , Mi decine Opiratoirc, T. 1. Chopart 
 et Desnuft, Traile des Mai. Chir. Desault, 
 Parisian Surgical Journal. Wrisbtrg, in 
 Comment. Reg. Sociel. Gelling. 1778. Schmuck- 
 cr s Vtrmisc/ile Chir. Schriften. Haller's 
 Opera Minora; and Dispuiationes Chir F. 
 X. Rudtorffer, Abhandlung uber die einfachste 
 und sicherste Operal i o n s-meih o de Eingesperr- 
 ter 1 Lei sten-und- Schenkelbr&chc, 2 Bitnde, 8 vo. 
 Wien, 1808. Sull'ernie Memorie analomico- 
 chirurgiche di Antonio Scarpa, Ediz. nuora, 
 3819 ; or the French Transl. by Cayol., 1812' 
 or the English., by fVishart. C. Bell's Sur. 
 gical Observations, pt. 2. p. 177. <^c. London, 
 1816. Lassus , Pathologic Chirurgicale, T. 
 1, p. \, f 'c.. Ed. 1809. Pelleian Clinique 
 Chirurgicale, T. 3. Travers on Injuries of 
 the Intestines , fyc. 1812. A case of hernia 
 ventriculi through a laceration of the dia- 
 phragm, by T. Wheelwright, in Med. f hir. 
 Trans. Col. 6, p. 374. F. C. Hcsselbach, 
 Di.squinliones Anatomico-Pathological de orlu 
 et progressu Htrniarum Inguinalium et Cru- 
 rahum , cum tab. 17. ceneis, 4to. Wurzburg, 
 1816: the original edition in German was first 
 } published in j806. Also Beschreibung und 
 Abbildung eines neuen instrumentes zur si- 
 chern Entdeckung und St tilling einer beidtm 
 Bruchschnitte enstandenen gefahrlichen Blu- 
 Utng.4(o. War zb. 1815. Soemmcrring, uber 
 
 Gbit. 1817. For some valuable remarks on the 
 two preceding works, and on the Anatomy of 
 Hernia, see Quarterly Journal of Foreign Me- 
 dicine, Vol. i, p. 847, Spc. Lungenbeck, Bibl. 
 fur die Chir. B. 4, St. 3, and Meue Bibl . 
 B. 2 ,p. 112, Spc. Gott. 1819. Wallhcr de Her- 
 nia ( rurali 4to. Lips 1820. But, above all, 
 the work, which I feel infinite pleasure in 
 recommending, from a conviction of its su- 
 perior merit, is a Treatise on Hernia by IV. 
 Lawrence, 8vo. ; the first edition of which was 
 published in 1807, and two more have appear- 
 ed since that period, under the title of “ A 
 Treatise on Ruptures.” 
 
 HERNIA CEREBRI ( Fungus Cerebri . 
 Enccphafocele.) There are two principal 
 kinds of hernia cerebri: one presents it- 
 self in young infants, before the ossification 
 of the skull is completed ; the other takes 
 place after the destruction of a part of the 
 skull by the operation of the trephine, acci- 
 dental violence, or disease. 
 
 The congenital hernia cerebri of infants 
 occurs, however, in two very different 
 forms ; in one it is covered by the scalp ; in 
 the oiher, the corresponding integuments of 
 the head, and sometimes even the dura ma- 
 ter, are deficient. 
 
 The common encephalocele, met with iri 
 new-born children, seems to originate from 
 the imperfect ossification of the skull, espe- 
 cially in the situation of the fentanclia. and 
 sutures. This case is characterized by a 
 soft swelling, of an equal round shape, 
 which is attended with a pulsation corres- 
 ponding to that of the pulse ; it yields and 
 disappears under pressure, offers no alteration 
 in the colour of the skin, and is circumscri- 
 bed by the margin of the defective portion 
 oi the skull. ( b errand , in Mini, de VAcad. 
 de Chir. I 1 . 13, in 12 mo. p. 102.) In general, 
 the mental faculties are not affected ; and 
 we read of one example, in which a patient 
 had such a hernia cerebri thirty-three years, 
 without his intellects ever having been im- 
 paired during the whole of that period. (Op. 
 cit. T. 5, in 4lo. p. 863.) 
 
 It is tolerably well established, that the 
 congenital hernia cerebri, tvhich arises from 
 
tefiimiA, 
 
 5 4 
 
 the incomplete ossification of the skulk and 
 is covered by the scalp, ought to be treated 
 by the application of constant, yet moderate 
 pressure. M. Salleneuve communicated to 
 t he Royal Academy of Surgery in France 
 on example of the good effects of this treat- 
 ment, which reduces the size of the tumour, 
 and accomplishes a perfect cure as soon as 
 the ossification is completed. M. Salleneuve 
 put a piece of thin sheet lead, properly co- 
 vered with soft linen, under the child's cap, 
 to which it was sewed in a suitable situation, 
 and the degree of pressure was increased, 
 or lessened, according as circumstances re- 
 quired, by tightening, or loosening the cap. 
 (Op. cit. ft. 103, T. 13, Edit. 12 mo.) 
 
 The experience of Callisen also confirms, 
 that hernia cerebri, when of moderate size, 
 may be cured by the foregoing method, the 
 aperture becoming gradually closed. But he 
 adds, that large tumours of this description, 
 especially when situated about the occiput, 
 scarcely admit of any means of relief, ex- 
 cept the employment of some contrivance 
 to protect them from external injury. ( Cal- 
 lisen , St/stem. Cfiir. Hodiernce, Vol. 2, p. 513, 
 514, Ed. 1800.) 
 
 When the ossification of the sutures in 
 children is late, the cerebellum, as well as 
 the cerebrum, is liable to protrusion. In 
 1813, two such cases occurred at Paris In 
 one, Professor Lallemerit mistook the disease 
 for a common tumour, and commenced an 
 operation for its removal, when, after 
 making some of the necessary incisions, his 
 proceedings were stopped by his seeing the 
 white silvery colour of the dura mater, and 
 that the swelling came out of an aperture in 
 the occipital bone. The day after the ope- 
 ration the child was seized with violent pain 
 in the head, had a hard pulse, pros'ration of 
 strength, vomiting, &c. and died in the 
 course of a week. On dissection, a part of 
 the tentorium, and an elongation of the two 
 lobes of the cerebellum, about as large as a 
 nut, were found in the protruded sac of the 
 dura mater. Several abscesses were also dis- 
 covered in the substance of the cerebellum. 
 The other example fell under the observa- 
 tion of M. Baffos, principal surgeon to the 
 Hopital des Enfans. Upon the death of the 
 child, the dissection evinced similar appear- 
 ances. ( Richerand , Nosographie Chir. T. 2, 
 p. 319, Ed. 4.) 
 
 Such facts should teach the surgeon to be 
 particularly cautious in ascertaining the na- 
 ture of tumours about the back part of the 
 head, before he ventures to attempt their re- 
 moval. 
 
 The second kind of congenital encepha- 
 locele is that, in which not only large por- 
 tions of the cranium, but also more or less of 
 the integuments of the head, are deficient. 
 It is rather to be regarded as a malformation 
 than a disease, and, indeed, in most in- 
 stances, the infants are still-born. The case 
 sometimes consists of the protrusion of most 
 of the brain through the inferior and poste- 
 rior fontanella?, so that the child is born 
 with a largish bag, on the back of its head, 
 hanging down over the posterior part of the 
 
 neck. Several specimens of these malfor- 
 mations, taken from infants born in the Hos- 
 pice de la Maternity, are preserved in the 
 Museum of the Faculte de Medecine at 
 Paris. ( Richerand , JVosogr. Chir. T. 2, p. 
 316, Edit. 4.) In the year 1S10, a remarka- 
 ble case of this last description of congeni- 
 tal hernia cerebri was published by Dr. Bur- 
 rows. “ The whole of the forehead, sum- 
 mit, and a great part of the occiput, were 
 deficient, and in lieu of them, a substance 
 projected of a light mulberry colour, and of 
 the mushroom form, except that it was pro- 
 portionably broader. From the deficiency 
 of bone, the eyes appeared to project much 
 more than usual. — The child lived six days 
 without either taking sustenance, or having 
 any evacuation.” On dissection, the scalp, 
 the os frontis, the parietal, and a great part 
 of the occipital bones, were wanting. 
 Through the parts, at which these bones 
 were deficient, the cerebrum projected, ex- 
 hibiting its usual convolutions. It was co- 
 vered with the pia mater; was of a mul- 
 berry colour ; appeared to be more vascular 
 than the pia mater usually is ; and the edge 
 of the scalp adhered to the neck of the tu- 
 mour. The cerebellum was not more than 
 one-fourth of its usual size ; for, the poste- 
 rior part of the os occipitis was much nearer 
 to the sella turcica than natural. The child 
 was destitute of the power of voluntary mo- 
 tion, and all the secretions appeared to be 
 stopped. (See Med. Chir. Trans • Vol. 2, p. 
 52.) 
 
 The most interesting species of hernia 
 cerebri to the practitioner, is that which 
 sometimes arises after the removal of a por- 
 tion of the skull by the trephine, ortiie des- 
 truction of pact of it by disease. Various 
 examples of this disease are recorded in the 
 Memoirs of the French Academy of Sur- 
 gery, and I have myself seen many instances 
 of it Although the case has attracted con- 
 siderable notice, modern surgeons are far 
 from entertaining settled opinions concern- 
 ing the exact nature of the tumour. 
 
 In one example, recorded by Mr. Aberne- 
 thy, the hernia cerebri arose on the tenth 
 day after trephining, and was as large as 
 a pigeon’s egg. The pia mater, covering it, 
 was inflamed ; and a turbid serum was dis- 
 charged at the sides of the swelling, from 
 beneath the dura mater. On the eleventh 
 day, the tumour was as large as a hen’s egg, 
 smooth, and ready to burst. The man died 
 the next day. On examination, the swelling 
 was found still larger, and of a dark colour, 
 with an irregular granulated surface. This 
 appearance was owing to coagulated blood, 
 which adhered to its surface, as the part had 
 bled so much, that the patient’s cap was 
 rendered quite stiff with blood. The pia 
 mater was in general much inflamed, and, a3 
 well as the dura mater, was deficient at the 
 place of the tumour. The deeper part of 
 the swelling seemed to consist of fibrous 
 coagulated blood, and it was found to origi- 
 nate about an inch below the surface of the 
 brain. 
 
 Mr. Abernetliy explains the formation ol 
 
IlERMA. 
 
 the disease, a3 follows : “ In consequence of 
 the brain being injured to some depth be- 
 neath the surface, disease ot the vessels, 
 and consequent effusion of the blood, had 
 ensued ; the effusion was for a time re- 
 strained by the superincumbent brain and 
 its membranes ; but, these gradually yield- 
 ing to the expansive force exerted from 
 within, and at last giving way attogejhei , the 
 fluid tdood oozed out and congealed upon 
 the surface of the tumour.” An organized 
 fungus can hardly be produced so rapidly as 
 these tumours are formed. (On Injuries of 
 the Head , in Surgical Works , Vol. 2 p. 53.) 
 
 On the contrary, Mr. C. Bell declares, that 
 the swellingis vascular and organized. (Ope- 
 rative Surgery , Vol. 1.) 
 
 Dr. John Thomson also entertains a dif- 
 ferent opinion from that of Mr. Abernethy, 
 respecting the mode in which these hernia; 
 cerebri are formed ; but I question whether 
 he may not have confounded with the dis- 
 ease now under consideration, fungous tu- 
 mours of the dura mater. At. least, some of 
 the cases to which he alludes, as a reason 
 for his sentiment concerning their mode of 
 formation, must have been the disease so 
 well described by M. Louis. (See Dura 
 Mater.) The reader, however, must judge 
 for himself from the following passage : “In 
 a considerable number of those w ho had the 
 cranium severely contused, or fractured by 
 musket-balls, (says Dr. Thomson) fungous 
 growths took place through the openings, 
 which had been made at first by the ball 
 or afterward by the trepan. These growths, 
 I am inclined to believe, are the consequence 
 of a contusion of the substance of the brain 
 and of the membranes that cover it, which 
 gives rise to the formation of a new organi- 
 zed substance, different in its texture from 
 brain, and are not, as some late w iters would 
 endeavour to persuade us, simply protrusions 
 of the brain, resulting from the removal of 
 the natural resistance, which is made to 
 them by the dura mater and cranium. / 
 have known instances of substances , similar to 
 these growths, forming on the surface of the 
 brain, immediately under the place , where the 
 cranium had received a contusion , in cases in 
 which the trepan had not been applied , or any 
 portion of the cranium removed. 
 
 u Fungus of the brain, in the greater num- 
 ber of instances, in which we had an oppor- 
 tunity of observing it, was accompanied 
 either with stupor or paralysis, and other 
 symptoms of compressed brain. In a frac- 
 ture of the vertex of the cranium, produced 
 by a musket-ball, and followed by a fungus 
 of the brain, the paralysis took place in the 
 low 7 er extremities. In a case of wound, 
 made by a musket-ball on the right side of 
 the forehead, and in which spiculae iff bone 
 had been driven in upon the brain, a large 
 fungus protruded. The formation of this 
 fungus was followed by slow pulse, stupor, 
 dilated pupils; slight strabismus, and distor- 
 tion of the mouth. In the progress of this 
 case, escharotics w r ere applied to the fungus, 
 portions of it were torn off by the patient, 
 and all of it that was exterior to the cranium, 
 
 Go 
 
 was twice pared off by the knife, with an 
 apparent alleviation, rather than aggravation, 
 of the symptoms. On the deatli of this pa- 
 tient, nearly the w hole of the right hemis- 
 phere of the brain was found converted into 
 a soft pulpy mass. The left hemisphere was 
 not changed in structure, though much vas- 
 cular turgescence appeared on its surface.” 
 (See D‘.J. Thomson's Report tf Observations 
 made in tnc Military Hospitals in Belgium , p. 
 57, 58.) 
 
 From the investigations of Mr, Stanley, 
 the fact is placed beyond all doubt, that a 
 part of the brain occasionally constitutes 
 the substance of berniae cerebri ; and he 
 thus confirms the opinion formerly entertain- 
 ed upon this point by Quesnay and Louis. 
 Thus, in the first case which Mr. Stanley has 
 recorded, u the whole tumour w T as sliced off 
 w ith a scalpel. During the operation, the 
 boy gave no manifestation of positive pain, 
 although not unconscious of w hat we were 
 doing. Considerable hemorrhage took plaee 
 from the surface of the brain, exposed by 
 the removal of the tumour, the blood being 
 throw T n with great force, and to a consider- 
 able distance from numerous vessels, w hich 
 were attempted to be secured, but ineffect- 
 ually, by ligatures. Affter a short time, how- 
 ever, the bleeding ceased. On examination 
 of the part, which had been cut off, its exte- 
 rior was found to consist merely of a layer 
 of the coagulated blood ; the rest of the 
 mass was brain, possessing a natural appear- 
 ance, the distinction between the cortical 
 and medullary matter being readily seen, 
 with the convolutions and pia mater dipping 
 dowm between them.” In the dissection, 
 after death, “ all that part of the dura mater, 
 adjacent to the ulcerated aperture, through 
 which the brain had protruded, was black, 
 sloughy, and much thickened. The exposed 
 surface of the brain, from which the portion 
 had been cut off’, exhibited a softened and 
 broken down texture , a state of disorgani- 
 zation, which extended deep into its sub- 
 stance. About an ounce of fetid and dark- 
 coloured fluid was found between the dura 
 mater and arachnoid membrane. Several 
 small effusions of blood were met with, both 
 between the membranes and in the substance 
 of the brain. The arachnoid membrane 
 was thickened and opaque over each hemis - 
 phere. The vessels on the surface, and in 
 the substance of the brain, were remarkably 
 free from blood. The lateral ventricles were 
 large, and filled with transparent fluid, and 
 there was some found between the mem- 
 branes at the basis, so that, altogether the 
 quantity from these two sources was very 
 considerable.” (See Med. Chir. Trans. Vol. 
 S,p. 15 — 17.) In another dissection, a con- 
 siderable quantity of pus was found on the 
 arachnoid membrane, on each side of the 
 falx. (P. 27.) In most of the cases of her- 
 nia cerebri, which I have seen, the patient 
 was at first more or less sensible, but labour- 
 ing under considerable nervous agitation. 
 The stupor, paralysis, and other symptoms 
 of compressed brain, noticed by Dr. J. Thom- 
 son, did not take place, till the latter stage 
 
HERNIA. 
 
 66 
 
 of the disease, and then convulsive twitches 
 of the muscles and strabismus occasionally 
 came on. (See Med. Chir. Trans, p. 20.) 
 The disease is usually attended with great 
 frequency of the pulse. 
 
 With regard to the cause of the protru- 
 sion, it is a subject very diflicull of ex 
 planation, because, if the origin of the tu- 
 mour depended simply on the removal of 
 a portion of the skull, or on any changes of 
 the dimensions of the brain in expiration, 
 the effect would always follow such causes, 
 nnd prevail in ail patients. From the par- 
 ticulars of the dissections, performed by Mr. 
 Abernethy and Mr. Stanley, and those re- 
 ferred to by Dr. Thomson, it is clear, that 
 the hernia cerebri is a disease connected 
 with deep-seated changes throughout a great 
 part of the brain. (See also Larrey, Mem. 
 de Chir Mai. T. 4, p. 206.) The substance 
 of this organ is found more or less pulpy 
 and disorganized ; and, after ,, death, large 
 effusions of serum, and even sometimes of 
 blood, and purulent matter, are observed. 
 These appearances leave no doubt of the 
 disease being associated with inflammatory 
 action within the head. It is highly proba- 
 ble, therefore, that a hernia cerebri is only 
 produced when these deep-seated chan- 
 ges are conjoined with tiie removal of 
 bone. The changes alluded to, may be sup- 
 posed to cause an increase in the general 
 contents of the skull, and thus a disposition 
 to profusion, as rapid as the serum and other 
 fluids are effused. This statement, however, 
 can only be received as an hypothesis, be- 
 cause we find, that in one of the dissections, 
 described by Mr. Stanley, “ there existed a 
 considerable 3pace between the upper sur- 
 face of the right hemisphere, all around the 
 -situation of the protrusion and the internal 
 surface of the dura mater, while in every 
 other part, the brain and dura mater were in 
 close contact.” (See Med. Chir. Trans. Vol. 
 S. p. 27.) Now. the idea of an empty space 
 within the cranium is rather inconsistent 
 with the supposition, that the brain is thrust 
 out, in consequence of changes, which aug- 
 ment the quantity of the general contents of 
 the skull, unless such space were filled with 
 air, that had no external communication. 
 
 When the bad symptoms disappear, on 
 the tumour being no longer confined by the 
 dura mater, some practitioners deem it best 
 to interfere as little as possible, and let the 
 tumour drop off in pieces. (See Edinb. Med. 
 Comment. Vol. i,p.98. Med. Museum, Col. 4, 
 p. 463.) The mildest dressings are to be em- 
 ployed ; but whetherthe protrusion should be 
 resisted by pressure, or not, seems unsettled. 
 
 When the tumour acquires a very great 
 size it may be pared off w ith a knife, as was 
 done by Mr. Hill, in several instances with 
 success. (Castsin Surgery, 8vo. Edinb. 1772.) 
 
 In one of the cases, published by Mr. 
 Stanley, the patient, a boy about eleven 
 years of age, recovered after the upper part 
 of the tumour had been pared off, and some 
 of the removed substance found to consist 
 decidedly both of cortical and medullary 
 substance. In this instance, the reproduction 
 
 of the tumour was cheeked by firm pressure 
 with graduated compresses, and a bandage. 
 The protruded brain gradually lost its natural 
 colour; it acquired a light yellow appear- 
 ance, was -plii into several portions, and a 
 very fetid odour exhaled from it. its sub- 
 stance daily became softer, ultimately acquir- 
 ing almost a semi-fluid state, and in this con- 
 dition the whole mass gradually u asted away. 
 Fresh granulations arose to Jill vp the vacancy , 
 and they were manifestly produced from the 
 exposed substance of the brain. Compression 
 being continued, Uie part now quickly healed 
 up. (See Med. Chir. Trans, p. 20,21.) In a 
 third case, the part oi the tumour cut off, 
 consisted entirely of cortical and medullary 
 substance, quite healthy in its appearance 
 (p. 24 ;) and subsequently granulations were 
 formed from the exposed surface of the brain. 
 The case, however, bad a fatal termination. 
 By the removal of the swelling, and the use 
 of compression, one cure wa? effected by Mr. 
 Bring. (See Edinb. Med. and Surgical 
 Journ. Vol. 9.) 
 
 Richerand affirms, indeed, generally, that 
 when the brain is exposed, in consequence 
 of an injury of the head, the encephalocele 
 should be cut down with a knife, and re- 
 pressed by gentle compression. (See JYosogr. 
 Chir T. 2, p. 318, Ed. 4.) 
 
 The cases published by Mr. Stanley are 
 rather favourable to the employment of pres- 
 sure, inasmuch as it appeared evidently to 
 check the protrusion, and was mostly borne 
 without inconvenience. 
 
 The idea, however, that when the brain 
 protrudes through the dura mater, pressure 
 can effect its return, is, as Mr. Stanley judi- 
 ciously observes, quite untenable. (Med. 
 Chir. Trans. Vol 8, p. 36.) 
 
 Quesnay mentions an instance, in which a 
 patient lore off the protruded mass himself, 
 and t he cavity healed up. (M6m. del' Acad, 
 de Chir. T. 1.) Van Swieten relates a case, in 
 which ihe swelling was repeatedly removed 
 w ith a ligature, and acure ensued. (Comment. 
 T. 1. p. 440.) The danger of applying styp- 
 tics, and irritating applications, is shown by 
 Hi id turns', Obs. 14, and Mr. Hill, p. 198. 
 
 Baron Larrey considers the treatment by 
 excision, pressure, and spirituous applica- 
 tions, hurtful arid dangerous : his advice is 
 merely to apply to the swelling a pledget of 
 slightly camphorated oil of camomile; to 
 have recourse to cooling aperient beverages; 
 to remove all kind- of irritation; to exclude 
 the air; and apply the dressings with great 
 gentleness. By these means, the only case 
 which Larrey ever saw recover, was saved, 
 and in it the tumour was small. (Mem. de 
 Chir. Mil. T. 4. p. 206.) 
 
 One would suppose, that cases of this kind 
 must generally require the employment of 
 every thing at all likelv to keep off, and di- 
 minish infill intention uf the brain. Quesnay , 
 sur la Multiplied des Trepans, in Mem. dt 
 I'Acad. Roy alt de Chirurgie, T. 2, p. 25, 56, 
 Ed. in 12 mo. M. Carvin' s Dissert, in Haller's 
 Disputnl. Chir. Void. Memoire sur l' Encc- 
 phulocele par M. Ferrand, in Mem. de l', lead. 
 <lc Chir. T. 13, p. 96. Edit. 12mo. Lassus, Fa- 
 
HERNIA. 
 
 57 
 
 ihvhfth Chirurgicale , T.2,p. 140, .Edit. 1809. 
 Abernethy’s Essay on Injuries of the Head. 
 Hill's Cases in Surgery. Burroics in Med. 
 Chir. Trans. Vol. 2. Callisen , Systema Chi- 
 rurgice Hodiernts, Vol. 2, p. 512, Ed. 1800. 
 C. Bell's Operative Surgery, Vol. 1 . Richter's 
 jSnsfi angsgrti nde der Wundarzneykunst, B. 2, 
 p. 197, Ed. 1802. Richerand, Kosographie 
 Chir. T. 2, p. 316, Edit. 4, Paris, 1815. 
 Dr. J. Thomson’s Report of Observations made 
 in the Military Hospitals in Belgium , p. 57, 
 Edinb. 1816. Delpech, Precis EUmentaire 
 des Maladies Chirurgicale s , T. 2, p. 447, et 
 seq. Paris, 1816. Crell and Sand, in Haller's 
 Disput. Chir. T. 1. E. Stanley, in Med. Chir. 
 Trans. Vol. 8 ; a paper, containing many 
 valuable observations. Larrey, in Mem. de 
 Chir. Mil. 1 ’. 4, p. 203, fyc. Hennen's Milita- 
 ry Surgery, p. 311, Spc. Ed. 2. A. Solomons, 
 De Cerebri Tumoribus, Edinb. 1810. J. L. 
 Schoenlein, Von der Hirnmelamorphose, S vo. 
 IViirzb. 1816. 
 
 HERNIA HUMORALIS. {Swelled or in- 
 flamed Testicle.) A very common symptom, 
 attending a gouorrhoea, is a swelling of the 
 testicle, which is only sympathetic, mid not 
 venereal, because the same symptoms follow 
 every kind of irritation of the urethra, whe- 
 ther produced by strictures, injections, or 
 bougies. Such symptoms are not similar to 
 the actions arising from the application of 
 venereal matter; for suppuration seldom 
 occurs, and when it does, the matter is vene- 
 real. The swelling and inflammation appear 
 suddenly, and as suddenly disappear, or go 
 from one testicle to the other. The epidi- 
 dymis remains swelled, however, even for a 
 considerable time afterward. 
 
 The first appearance of swelling is general- 
 ly a soft pulpy fulness of the body of the 
 testicle, which is tender to the touch ; this 
 increases to a hard swelling, accompanied 
 with considerable pain. The epididymis, 
 towards the lower end of the testicle, is ge- 
 nerally the hardest part. The hardness and 
 swelling, however, often pervade the whole 
 of the epididymis. The spermatic cord, and 
 especially the vas deferens, are often thick- 
 ened and sore to the touch. The spermatic 
 veins sometimes become varicose. A pain 
 in the loins, and sense of weakness there, 
 and in the pelvis, are other casual symptoms. 
 Colicky pains ; uneasiness in the stomach 
 and bowels ; flatulence ; sickness ; and even 
 vomiting ; are not unfrequent. The whole 
 testicle is swelled, and not merely the epidi- 
 dymis, as has been asserted. 
 
 The inflammation of the part most proba- 
 bly arises from its sympathizing with the 
 urethra. The swelling of the testicle coming 
 on, either removes the pain in making water, 
 and suspends the discharge, which do not 
 return, till such swelling begins to subside; 
 or else the irritation in the urethra, first ceas- 
 ing, produces a swelling of the testicle, 
 which continues till the pain and discharge 
 return ; thus rendering it doubtful, which is 
 the cause, and which the effect. Occasion- 
 ally, however, the discharge has become 
 more violent, though the testicle has swelled ; 
 and such swelling has even been known to 
 Vol. II. 8 
 
 occur after the discharge has ceased; yet, 
 the latter has returned with violence, and re- 
 mained as long as the hernia humoralis. (J. 
 Hunter.) 
 
 Irritation at the mouth of the vasa defe- 
 rentia, has been mentioned as a cause ; but 
 were this true, both testicles would usually 
 be affected at the same time, and the com- 
 plaint would occur mere frequently, when 
 the irritation of the urethra extends far to- 
 wards the bladder, than when it only reaches 
 about an inch and a half, or two inches from 
 the orifice of the passage. 
 
 Hernia humoralis, with stoppage of the 
 discharge, is apt to be attended with strangu- 
 ry. It is singular, that the inflammation 
 should more frequently come on when the 
 irritation in the urethra is going off, than 
 when it is at its height. 
 
 The enlargement's of the testicle, from 
 cancer and scrofula, are generally slow in 
 their progress ; that of a hernia humoralis 
 very quick. {J. Hunter.) 
 
 Rest is the best remedy, and the horizon- 
 tal position of the body is easiest. At. all 
 events, the testicle must be well suspended ; 
 to which expedient the patient will readily 
 have recourse as soon as he knows the ease 
 which it affords. The case is treated as in- 
 flammation in general, by bleeding and purg- 
 ing, and applying fomentations and poultices. 
 In the hernia humoralis from gonorrhoea, 
 however, cold applications are sometimes 
 preferred. {James on Inflammation, p. 164.) 
 Leeches have often proved serviceable. The 
 swelling not being venereal, mercury is only 
 useful in removing the induration, after the 
 inflammation has subsided. Vomits have 
 been recommended, and found beneficial. 
 They have even been known to cure the 
 complaint in a surprisingly sudden manner. 
 Opiates are useful. When suppuration oc- 
 curs, no mercury is requisite, only common 
 treatment. 
 
 As the hernia humoralis often appears to 
 depend on the cessation of the discharge, 
 some {Bromjield) have advised irritating the 
 urethra with bougies to bring on the gonnor- 
 rhcea again ; but the practice is not followed 
 by the expected good. The introduction of 
 venereal matter into the urethra has also 
 been most absurdly suggested. 
 
 A hernia humoralis is at first very quick in 
 subsiding; but some of the swelling remains 
 a long while, and the hardness of the epidi- 
 dymis may even continue for years, nay, for 
 life. However, no inconvenience attends the 
 mere induration. In such instances, the vas 
 deferens may occasionally be rendered im- 
 pervious, though the occurrence must be by 
 no means frequent. 
 
 Frictions with camphorated mercurial 
 ointment; fumigations with aromatic herbs ; 
 and electricity ; are the best means for dis- 
 persing the induration in question. {J. Hun- 
 ter .) 
 
 The signs distinguishing a hernia humora- 
 lis from a scrotal rupture, are explained in 
 the article Hernia. 
 
 I once had under my care a patient with 
 hernia humoralis, whose symptoms were se* 
 
HERPES. 
 
 f}6 
 
 verc in an extraordinary degree, and strongly 
 resembled those of a strangulated hernia, 
 being attended with much sickness, and ob- 
 stinate constipation. A swelling of the tes- 
 tis, accompanied with all the symptoms of 
 strangulated hernia, is recorded by Guin- 
 court. (See Journ. de Med. par Corvisart, T. 
 16.) 
 
 Although I had never seen herr.ia humora- 
 lis attended with symptoms so much resem- 
 bling those of strangulated rupture, as in the 
 case which fell under my own notice, and the 
 patient would not own that he had had any 
 gonorrhoea, yet I remarked some circum- 
 stances, which made me avoid an erroneous 
 judgment. In the first place, 1 could dis- 
 cover no protrusion from the abdominal ring. 
 Secondly ; 1 observed that there was no ten- 
 sion, nor swelling of the belly, as in common 
 cases of strangulated ruptures. Thirdly, I 
 remarked, that the inflammation of the 
 scrotum did not increase as the symptoms 
 advanced, as it usually does in the latter dis- 
 ease. Fourthly ; I took notice that the pain 
 in the belly was most severe under the talse 
 ribs on the right side, though at periods it 
 was certainly very diffused; but it was never 
 augmented by pressure, as always happens 
 in strangulated hernia, peritonitis, enteritis, 
 &ic. from all which disorders too, the ab- 
 sence of tension seemed to distinguish it. 
 Sometimes likewise, the pain was entirely in 
 the tumour; sometimes altogether in the ab- 
 domen. 
 
 HERPES, (from ig7ru>, to creep.) 
 
 Nothing could be more confused, and un- 
 defined, than the idea conveyed by the term 
 herpes , as generally employed by medical 
 men before the last few years. In fact, nu- 
 merous cutaneous diseases, of the most op- 
 posite kinds, but which had a tendency to 
 creep, or spread slowly, were designated, as 
 specimens of herpes. Thus, when I first 
 entered the profession, it was common tor 
 some of the most eminent surgeons in Lou- 
 don frequently to call noli me tangere, or 
 lupus, herpes of the nose ; and to apply the 
 same term to tinea capitis, or the porrigo 
 favosa. 
 
 Happily, this vague mode of regarding dis- 
 eases of the skin is beginning to give way to 
 the judicious distinctions proposed by the 
 late Dr. Willan, and so ably perfected by Dr. 
 Bateman. The appellation, herpes, is limited 
 by these physicians. “ to a vesicular disease, 
 which, in most of its forms, passes through 
 a regular course of increase, maturation, and 
 decline, and terminates in about ten, twelve, 
 or fourteen days. The vesicles arise in dis- 
 tinct, but irregular clusters, which commonly 
 appear in quick succession, and they ate set 
 near together, upon an inflamed base, which 
 extends a little way beyond the margin of each 
 cluster. The eruption is preceded, when it 
 is extensive, by considerable constitutional 
 disorder, and is accompanied with a sensa- 
 tion of heat and tingling, sometimes with 
 severe deep-seated pain in the parts affected. 
 The lymph of the vesicles, which is at first 
 clearand colourless, becomes gradually milky 
 and opaque, and ultimately concretes into 
 
 scabs : but in some cases, a copious discharge 
 of it lakes place, and tedious ulcerations en- 
 sue. The disorder is not contagious in any 
 of its forms.’' (See Bateman's Practical 
 Synopsis of Cutaneous Diseases, p. 221, 222, 
 Edit. 3) This author notices six species of 
 the complaint: viz. herpes phlyctaenodes ; 
 herpes zoster; herpes circinatus; herpes 
 labialis; herpes praeputialis ; and herpes 
 iri9. 
 
 As most of these cases more properly be- 
 long to the physician, than surgeon, I shall 
 briefly describe three of them. 
 
 According to Dr. Bateman, the Herpes 
 Zoster, or shingles, is mostly preceded for 
 two or three days, by languor, and loss of 
 appetite, rigours, headacb, 'sickness, and t a fre- 
 quent pulse, together with a scalding heat, 
 and tingling in the skin, and shooting pains 
 through the chest and epigastrium. Some- 
 times, however, the precursory febrile symp- 
 toms are very slight. Upon some part of 
 the trunk, several red patches occur, of an 
 irregular form, at a little distance from each 
 other, upon each of which, numerous small 
 elevations appear clustered together. These, 
 if examined minutely, are found to be dis- 
 tinctly vesicular, and in the course of twenty- 
 four hours, they enlarge to the size of small 
 pearls, and are perfectly transparent, being 
 filled with a limpid fluid. For three or four 
 days, fresh clusters continue to arise, always 
 extending themselves nearly in a line with 
 the first, towards the spine at one end, and 
 towards the lines alba at the other. While 
 the new clusters are appearing, the visicles 
 of the first lose their trasparency, and, on 
 the fourth day, acquire a milky, or yellowish 
 hue, which is soon followed by a bluish, or 
 livid colour, of the bases of the vesicles, and 
 of the contained fluid. They now become 
 somewhat confluent, and flatten, or subside. 
 About this time, they frequently break, and 
 discharge for three or four days, a serous 
 fluid, which, at length, concretes into thin 
 dark scabs. These fall off about the twelfth 
 or fourteenth day, leaving the surface of the 
 subjacent skin in a red and tender state ; and 
 when the ulceration and discharge have been 
 considerable, numerous^cicatrlces, or pits, 
 are left. All the clusters go through a simi- 
 lar series of changes. 
 
 Young persons, from the age'of twelve to 
 twenty- five, are most frequently affected ; 
 although aged persons are not altogether ex- 
 empt from the complaint, and suffer severely 
 from the pain of it. Summer and autumn 
 are the seasons, in which it is most common. 
 Sometimes it supervenes to bowel com- 
 plaints, and the chronic pains remaining af- 
 ter acute pulmonary diseases. In the treat- 
 ment, Dr. Bateman thinks gentle laxatives, 
 and diaphoretics, with occasional anodynes, 
 when the severe deep-seated pains occur, all 
 that is necessary. No external application 
 is requisite, unless the vesicles be abraded by 
 the friction of the clothes, which are then 
 liable to adhere to the parts : in this case, a 
 little simple ointment inny fbe interposed. 
 For a fuller account,* see Bateman's Pract. 
 Synopsis, p. 226, &c. 
 
HER 
 
 HOR 
 
 rrj 
 
 Herpes circinatus , or ringworm, makes its 
 appearance in small circular patches, in 
 which the vesicles arise only round the cir- 
 cumference : these are small, with moderate- 
 ly red bases, and contain a transparent fluid, 
 which is discharged in three or four days, 
 when little prominent dark scabs form over 
 them. The central area, in each vesicular 
 ring, is at first free from any eruption ; but 
 the surface becomes somewfeat rough, and 
 of a dull red colour, and throws off an exfo- 
 liation, as the vesicular eruption declines, 
 which terminates in about a week, with a 
 falling off of the scabs. A succession of 
 these vesicular circles usually arise on the 
 face and neck, or arms and shoulders, thus 
 protracting the case for two or three weeks. 
 
 The itching and tingling, which are the 
 only inconveniences of the affection, may 
 be relieved by the application of the popular 
 remedy ink, solutions of the salts of iron, 
 copper, zinc, borax, alum, &.c. Some addi- 
 tional interesting observations on other forms 
 of the herpes circinatus, may be found in Dr. 
 Bateman’s Synopsis, from which I have ex- 
 tracted the few preceding particulars. 
 
 Herpes Prcepulialis. This local variety of 
 herpes was not noticed by Dr. Willan, and 
 we are indebted to Dr. Bateman for a de- 
 scription of it. The complaint begins with 
 extreme itching, and with some sense of 
 heat in the prepuce, on which one or two red 
 patches occur, about the size of a silver 
 penny. Upon these are clustered five or six 
 minute transparent vesicles. In twenty-four 
 or thirty hours, the vesicles enlarge, become 
 of a milky hue, and lose their transparency ; 
 and on the third day, they are coherent, and 
 have almost a pustular appearance. If the 
 eruption is seated on that surface of the pre- 
 puce, which is next the glans, so that the 
 vesicles are kept moist, they commonly 
 break about the fourth or fifth day, and form 
 a small ulceration upon each patch. This 
 discharges a little turbid serum, and has a 
 white base, with a slight elevation at the 
 edges ; and by an inaccurate, or inexperien- 
 ced observer, it may be readily mistaken for 
 chancre, more especially, if any escharotic 
 has been applied, which produces irritation, 
 and a deep-seated hardness, like that of a 
 true chancre. If not irritated, the slight ul- 
 ceration begins to heal about the ninth or 
 tenth day. When the patches occur on the 
 outside of the prepuce, the duration of the 
 eruption is shorter, and ulceration does not 
 actually take place. 
 
 In the treatment, Dr. Bateman recommends 
 the avoidance of all stimulating, and moist, or 
 unctuous applications ; and if the complaint 
 be within the prepuce, he advises the inter- 
 position of a little bit of dry lint between 
 the sore and the glans. 
 
 As this gentleman has truly remarked, this 
 case is particularly deserving of notice, be- 
 cause it has often been considered and treat- 
 ed as a chancre. 
 
 For a great deal more valuable informa- 
 tion respecting Herpes, I beg leave to refer 
 the reader to the publications of Drs. Willan 
 and Bateman, and also to the article Herpes , 
 
 written by this last able physician for Dr. 
 Rees’s Cyclopa?dia. 
 
 HORDEOLUM, (dim of hordcum , bar- 
 ley.) A little tumour on the eyelid, resem- 
 bling a barley corn. A Stye. As Scarpa 
 remarks, the stye is strictly only a little boil 
 which projects from the edge of the eyelids, 
 particularly often near the great angle of the 
 eye. This little tumour, like the furunculus, 
 is of a dark-red colour, much inflamed, and 
 a great deal more painful than might be ex- 
 pected, considering its small size. The latter 
 circumstance is partly owing to the vehe- 
 mence of the inflammation producing the 
 stye, and partly to the exquisite sensibility 
 and tension of the skin which covers the 
 edge of the eyelids. On this account, the 
 hordeolum very often excites fever and rest- 
 lessness in delicate, irritable constitutions; it 
 suppurates slowly and imperfectly ; and, 
 when suppurated, has no tendency to burst. 
 
 The stye, like other furunculous inflamma- 
 tions, forms an exception to the general rule, 
 that the best mode, in which inflammatory 
 swellings can end, is resolution. For, when- 
 ever a furunculous inflammation extends so 
 deeply as to destroy any of the cellular sub- 
 stance, (he little tumour can never be resol- 
 ved, or only imperfectly so. This event, 
 indeed, would rather be hurtful, since there 
 would still remain behind a greater or smaller 
 portion of dead cellular membrane; which, 
 sooner or later, might bring on a renewal of 
 the stye in the same place .as before, or else 
 become converted into a hard indolent body, 
 deforming the edge of the eyelid. 
 
 The resolution of the incipient hordeolum 
 maybe effected in that stage of it, in which 
 the inflammation only interests the skin, and 
 not the cellular substance underneath, as is 
 the case on the first appearance of the dis- 
 ease. Now repellent, cold applications are 
 useful, particularly ice. But when the hor- 
 deolum has affected and destroyed any of 
 the cellular membrane underneath, every 
 topical repellent application is absolutely 
 useless, and even hurtful ; and the patient 
 should have recourse to emollient anodyne 
 remedies. The hordeolum and eyelids should 
 be covered with a warm soft bread and milk 
 poultice, which ought to be renewed very 
 often. When a white point makes its ap- 
 pearance on the apex of the little tumour, 
 Scarpa says, the surgeon should not be in a 
 hurry to let out the small quantity of serous 
 matter which exists between the skin and 
 dead portion of cellular membrane. It 
 is better that he should wait till the skin 
 within this white point has become still 
 somewhat thinner, so as to burst of ilself, 
 and give a ready vent, not merely to (he 
 little serous matter, but to all the dead cellu- 
 lar membrane which constitutes the chief 
 part of the disease. When the contents of 
 the little tumour are stow in making their way 
 outward, through the opening, the surgeon, 
 gently compressing the base of the stye, 
 ought to force them out. After this, all the 
 symptoms of the disease will disappear, and 
 the cavity, left hv the dead cellular mem- 
 brane, in the centre of the little tumour, will 
 
CO 
 
 HOSPITAL GANGRENE. 
 
 be found quite filled up and healed in the 
 course of twenty-four hours. 
 
 Sometimes, though seldom, this process 
 of nature, destined to detach the dead from 
 the living cellular membrane, only takes 
 place incompletely, and a small fragment of 
 yellow dead cellular substance still continues 
 fixed in the cavity, arid hinders the cure. In 
 this circumstance, the further employment of 
 emollient poultices is of little or no service. 
 The surgeon should dip the point of a camel- 
 hair pencil in sulphuric acid, and touch the 
 inside of the stye with it, one or more times, 
 until the sloughy cellular membrane comes 
 away. After this, the small cavity remain- 
 ing will soon close. Should the eyelid con- 
 tinue aflervvard a little swollen and cedema- 
 lous, this affection may be removed by apply- 
 ing the lotioplumbi. acet., containing a little 
 spirit of wine. Some persons are very often 
 annoyed with this disease. Scarpa imputes 
 this most frequently to a disordered state of 
 the primes vice , often met with in persons 
 who live on acrid irritating food, and drink 
 too much spirits.* ( Scarpa , suite Malattie 
 degli Occhi, cap. 2.) 
 
 HOSPITAL GANGRENE. (Phagedecna 
 Gangreenosa; Putrid, or Malignant Ulcer; 
 Hospital Sore ; Gangroena Contagiosa.) A 
 severe and peculiar species of humid gan- 
 grene, or rather a combination of this affec- 
 tion, with phagedenic ulceration. It is par- 
 ticularly characterized by its contagious or 
 infectious nature ; its disposition to attack 
 wounds or ulcers, in crowded hospitals, 
 or other situations, where many of these 
 cases are brought together ; and its tendency 
 to convert the soft parts affected into a pu- 
 trid glutinous, or pulpy substance, in which 
 no trace of their original texture is discerni- 
 ble. (Delpech, Precis EUm. des Mai. Chir. 
 T. 1 ,p. 123.) It is generally believed to be 
 communicated from one sore or wound to 
 another, by its contagious nature ; but whe- 
 ther the infection can be transferred onlybv 
 actual contact, or both in this way and 
 through the medium of the atmosphere, is a 
 question on which the best authors differ. 
 The first origin ot the disease, however, is a 
 mysterious subject, which cannot invariably 
 be explained on any certain principles, as 
 will be hereafter noticed. 
 
 From the researches of Mr. Blaekadder, it 
 appears probable, that several of the ancient 
 writers, in their descriptions of foul, gangre- 
 nous bleeding ulcers, must have alluded to 
 the same kind of disease, which is now usu- 
 ally denominated hospital gangrene. Besides 
 the use of the actual cautery, which, accord- 
 ing to the modern French writers, is the 
 surest means of arresting this distemper, seve- 
 ral of the ancients appear also to have em- 
 
 * I have very often found an alum curd, applied 
 over night in the form of poulliee, of great, benefit in 
 this disease. When made use of just after suppuration 
 has commenced, the tumour discharges in a tew hours, 
 and the patient is freed from a very troublesome and 
 painful companion, it is prepared by putting a piece 
 oi alum, about the size of a pea, into a table spoonftd 
 ot new milk. This^by the feme of a candle, is soon 
 coagulated, and rendered of a consistence fit to be 
 matte use of as a cataplasm. — [Am. Ed.) 
 
 ployed for the cure arsenical applications ; 
 as, for instance, iEtius, Paulus, Rolandus, 
 Avicenna, Guido, &.c. The only doubt whe- 
 ther these authors actually referred to hospi- 
 tal gangrene, depends upon their not having 
 generally described its contagious nature. 
 But, on this point, I would particularly wish 
 the reader to consult Mr. Blackadder’s valu- 
 able treatise. (P. 76, <^c.) 
 
 Although La jMotte made cursory mention 
 of hospital gangrene in 1722, under the name 
 of pourrilure, and stated, that it had occurred 
 in the H6tel-Dieu at Paris, yet the first dis- 
 tinct modern account of this disease is con- 
 tained in the 3d vol. of the posthumous 
 works of Pouteau, published in 1783. In 
 the year 1788, Dusassoy, who succeeded 
 Pouteau as chief surgeon of the Hotel-Dieu 
 at Lyons, also published a short treatise on 
 the disorder. The first very accurate des- 
 cription of hospital gangrene, in the Eng- 
 lish language, appeared in the 6th vol. of 
 the London Medical Journal, printed in 
 1785. The account is entitled “ Observa- 
 tions on the Putrid Ulcer, by Mr. Gillespie, 
 surgeon of the Royal Navy.” In the edition 
 of Dr. Rollo’s work on Diabetes, published 
 1797, there is a section on this subject, enti- 
 tled, “ A short account of a morbid poison, 
 acting on sores, and of the method of de- 
 stroying it.” In 1799, Sir Gilbert Blane, 
 in the 3d edit, of his book on the diseases of 
 Seamen, gave an account of hospital gan- 
 grene, under the name of malignant ulcer; 
 and Dr. Trotter, in the 2d vol. of his Medi- 
 cina Nautica, published in the same year, 
 described that affection by the same appella- 
 tion. In the 3d vol. of the same work, Dr. 
 Trotter has added to his first account seve- 
 ral valuable communications, relating to 
 this disease, received from surgeons of the 
 Royal Navy. Mr. John Bell has also made 
 hospital gangrene the subject of particular 
 remark, in the 1st vol. of his Principles of 
 Surgery, published in 1801. According to 
 Dr. Thomson, two excellent theses have 
 likewise been published on the subject in 
 the University of Edinburgh ; the first enti- 
 tled “ De Gangrtena Contagiosa,” by Dr. 
 Leslie in 1804; the second by Dr. Charles 
 Johnson, in 1805, under the title of “ De 
 Gangraena Contagiosa Nosocomiale.” (See 
 Lectures on Inflammation, p. 456 — 458.) 
 
 Professor Thomson’s account of the sub- 
 ject, published in 1813, contained the fullest 
 history of the disease at that time collected. 
 Boyer afterward gave a very fair account of 
 the distemper. (See Trait6 des Mai. Chir. 
 T. \,p. 320, 8t?o. Paris, 1814.) 
 
 These descriptions were followed by the 
 valuable essay of Delpech, entitled “M6- 
 moire sur la Complication des Plaies?et des 
 Ulccres eonnue sous le nom de Pourriture 
 d’Hdpital;” 1815; some interesting obser- 
 vations by Dr. Hennen, in the London Me- 
 dical Repository for March, 1815; a paper 
 by Professor Brugman, of Leyden, “in the 
 Annales de LitteratUre Med.” vol. 19, 1815; 
 and lastly, the treatise of Mr. Blaekadder, 
 which contains some of the best remarks 
 ever made concerning this affection, and i« 
 
HOSPITAL GANGRENE. <5T 
 
 entitled “ Observations on Phagedsena Gan- 
 graenosa, Svo. Edinb. 1818.” 
 
 According to Mr. Blackadder, who is a 
 believer in the doctrine of the complaint be- 
 ing only communicable by the direct appli- 
 cation of the infectious matter, when the 
 morbific matter, which produces the disease, 
 has been applied to some part of the surface 
 of the body, from which the cuticle has 
 been removed, as by a blister, one or more 
 small vesicles first appear, which are filled 
 with a watery fluid, or bloody serum of a 
 livid or reddish brown colour. The situa- 
 tion of the vesicle is generally at the edge 
 of the sore. Its size is not unfrequeutly 
 that of a split garden pea, and is easily rup- 
 tured, the pellicle which covers it being 
 very thin. When the vesicle is filled with 
 a watery fluid, and has not been ruptured, 
 it assumes the appearance of a grayish-white 
 or ash-coloured slough ; but, when it con- 
 tains a dark-coloured fluid, or has been rup- 
 tured, it puts on the appearance of a thin 
 coagulum of blood, of a dirty, brownish, 
 black colour. During the formation of the 
 vesicle, there is generally a change in the 
 sensation of the sore, accompanied w r ith a 
 painful feel, like that of the sting of a gnat. 
 
 After a slough is formed, it spreads with 
 more or less rapidity, until it occupies the 
 whole surface of the original sore; and, 
 when left to itself, (which seldom happens) 
 there is little or no discharge, but the 
 slough acquires daily greater thickness. 
 
 “ When the formation of the slough has 
 been interrupted, the stinging sensation be- 
 comes more frequent and acute ; phagede- 
 nic ulceration quickly commences ; and 
 such is frequently the rapidity of its pro- 
 gress, that even in the course of a few, hours, 
 a very considerable excavation will be 
 formed, while the parts in the vicinity re- 
 tain their usual healthy appearance.” The 
 cavity, the edges of which are well defined, 
 is filled with a thick glutiuous matter, which 
 adheres strongly to the subjacent parts. 
 When this matter is removed, the surface 
 underneath presents itself of a fine granular 
 texture, which, in almost all instances, is 
 possessed of extreme sensibility, and is very 
 apt to bleed when the operation of cleaning 
 is not performed with great delicacy. At 
 each dressing, the circumference of the cavity 
 is found enlarged, and if there are more than 
 one, they generally run into each other. 
 The progress of the disease is much quicker 
 in some inividuals than others, but it never 
 ceases , until the whole surface of the original 
 sore is occupied. The stinging pain gradually 
 becomes of a darting or lancinating kind ; 
 and either about the fourth or sixth day from 
 the time when the morbific matter had access 
 to the sore, or afterward, at the period of what 
 may be termed secondary inflammation , the 
 lymphatic vessels and glands are apt to become 
 affected. The discharge becomes more co- 
 pious, its colour varying from a dirty yel- 
 lowish white to a mixture of yellow, black, 
 and brown, depending upon the quantity of 
 blood mixed with it. 
 
 f( The soft parts, in the immediate vicinity 
 
 of the sore, daily become more painful, 
 tumefied, and indurated ; and, in a great 
 number of cases, particularly in those of 
 plethoric and irritable habits, an attack of 
 acute inflammation speedily supervenes, and 
 is acccompanied by a great increase of pain, 
 the sensation being described to be such as 
 if the sore were burning. The period at 
 which this inflammation begins to subside, 
 is by no means regular. Sometimes it sub- 
 sides in the course of two days, and some- 
 times it continues upwards of five; depend- 
 ing very much on the constitution and pre- 
 vious habits of the patient, as well as the 
 treatment that has been adopted. During 
 its progress, the thick, putrid looking, and 
 frequently spongy slough which is formed 
 on the sore, becomes more and more moist, 
 and of a pulpy consistence. (Hence this 
 form of disease is actually named by Ger- 
 son pulpy gangrene.) In the course of a few 
 days, a very otfensive matter begins to be 
 discharged at its edges. The slough then 
 begins to separate; by and by it is thrown 
 off', but only to prepare the way for an ex- 
 tension of the disease by a continued pro- 
 cess of ulceration, and by a recurrence of 
 the last-mentioned symptoms. (Blackad- 
 der, on Phagedcena Gangrcenosa, p. 28 — 30.) 
 
 The first symptoms, which indicate hospi- 
 tal gangrene in a wound, or ulcer, are, a 
 more or less acute pain, and a viscid whi- 
 tish exudation on the surface of the granu- 
 lations, which lose their vermilion colour, 
 and present at several points spots of a gray- 
 ish or dirty-white hue, resembling venereal 
 ulcers, or aphthae. These ulcerated points, 
 thus engrafted (as it were) upon the original 
 ulcer, soon spread, and join together, so as 
 to give to the whole surface of the solution 
 of continuity a gray ash-colour. The surface 
 also becomes more or less indurated, and 
 sometimes bleeds. A red, purplish oedema 
 tous circle, of a greater, or lesser extent, is 
 next formed in the surrounding skin. Some 
 times, when the patient is of a good habit, 
 the causes of infection less active, and the 
 constitution sufficiently strong, the disorder 
 now stops. According to Boyer, it may not 
 even extend to the whole surface of the ul- 
 cer. But, most frequently, its progress is ex- 
 tremely rapid, and occasionally quite terri- 
 fying. The edges of the wound, or ulcer, 
 become hardened and everted, the granula- 
 tions are large and tumid, being swelled up, 
 as Boyer asserts, with a considerable quan- 
 tity of gas. They are afterward detached in 
 the form of soft reddish sloughs, which very 
 much resemble the substance of the foetal 
 brain', in a putrid state. From day to day, 
 until either nature alone, or aided by art, 
 puts limits to the disorder, it invades new 
 parts both in breadth and depth, so that its 
 ravages extend to aponeuroses, muscles, 
 blood-vessels ; nerves, tendons, the perios- 
 teum, and even the bones themselves. 
 
 Among a number of severe cases, which 
 fell under the notice of Mr. Blackadder, 
 there was one, in which the half of the cra- 
 nium was denuded, the bones having be- 
 come black as charcoal, and the integument? 
 
HOSPITAL GANGRENE. 
 
 r>2 
 
 detached posteriorly to the second cervical 
 vertebra, and anteriorly to the middle of the 
 zygomatic process of the temporal bone ; 
 and this was originally a superficial wound 
 of the scalp. In another case, the muscles, 
 large arteries, and nerves of both thighs 
 were exposed and dissected, the integu- 
 ments and cellular substance being entirely 
 removed, with the exception of only a nar- 
 row strip of the former, which remained on 
 the outer side of the thighs. This was also 
 originally a simple flesh wciuiid. In other 
 instances, the cavities of the knee, ankle, 
 elbow, and wrist, joints, were laid extensive- 
 ly open, and, in one unfortunate case, the in- 
 teguments and cellular substance, on the 
 anterior parts of the ueck, were destroyed, 
 exhibiting a horrid spectacle, the trachea 
 being also wounded.” (On Phagedcena Gan- 
 grcenenosa, p. 3.) 
 
 According to the last experienced author, 
 when the disease attacks an old sore, where 
 a considerable depth of new flesh has been 
 formed, the first thing generally observed is 
 a small dark-coloured spot, usually situated at 
 the edge of the sore. But, he states, that in 
 several cases of ulcers, the disease, when 
 carefully watched, was found to begin in 
 the form of a vesicle, filled with a livid, or 
 brownish-black fluid, which afterward burst 
 and assumed the appearance of the dark-co- 
 loured spot, which is commonly first noticed. 
 Mr. Blackadder always found, that, when 
 there had been a considerable bed of new 
 flesh formed, the phagedenic ulceration 
 made comparatively a very slow progress, 
 and put on rather the appearance of mercu- 
 rial phagedaena, until the morbific matter 
 had found access to the natural texture of 
 the part, when the progress of the disease 
 became suddenly accelerated ; acute inflam- 
 mation supervened ; and a large slough 
 xvas formed. (Op. cit. p. 31.) He notices, 
 that when the morbific matter is inserted in 
 a puncture, or scratch, the first progress of 
 the disease bears a resemblance to that of a 
 part inoculated with vaccine matter. The 
 primary inflammation in gangrenous phage- 
 tiaena commences at the end of the second, 
 or early on the third day ; the inflammation 
 is at its height about the sixth ; when the 
 scab begins to form in one disease, phagede- 
 nic ulceration begins in the other, and when 
 allowed to proceed, soon affords sufficient 
 proof of the non-identity of the two diseases. 
 (P. 33.) 
 
 According to Mr. Blackadder, when the 
 disease attacks a recent gun-shot wound, the 
 discharge, two or three days after infection, 
 is found to be lessened, and to have become 
 more of a sanious, than purulent nature. 
 The sore has a certain dry and rigid appear- 
 ance ; its edges are more defined, somewhat 
 elevated, and sharpened ; the patient is sen- 
 sible of a change in the usual sensation in 
 the sore, and complains of the occasional 
 stinging sensation, resembling that produced 
 by the sting of a gnat. At this period, but 
 sometimes a day or two later, the integu- 
 ments at the edge of the sore become in- 
 flamed, and the surface of the sore itself as- 
 
 sumes a livid or purple colour, and appears 
 as if covered with a fine pellicle, such as is 
 formed on a coagulum of blood.” (On 
 Phagedcena Gangrcenosa , p. 33.) 
 
 At Bilboa, the disease in cases of wound, is 
 said generally to have commenced with a 
 sudden attack of severe pain in the head and 
 eyes, tightness about the forehead, want of 
 sleep, loss of appetite, a quick pulse, and 
 other febrile symptoms ; while the wound, 
 which had been healthy and granulating, at' 
 once became tumid, dry, and painful, losing 
 its florid colour, and assuming a dry and 
 glossy coat. (tlennen on Military Surgery , 
 p. 214, Ed. 2.) When left to itself, the 
 above-described pellicle gradually increases 
 in thickness, forming what has been termed a 
 slough. But, Mr. Blackadder observes, that 
 at this period, the progress of the disease is 
 hardly in any two instances precisely alike. 
 Generally, in the course of from five to ten, 
 or fifteen days, a thick spongy, and putrid- 
 looking slough is formed over the whole 
 surface of the sore, and which is more or less 
 of an ash, or blackish-brown colour. When 
 the pellicle is destroyed, as frequently hap- 
 pens in the process of cleaning, it is not in 
 every case reproduced ; but, an offensive 
 matter begins to be discharged, which be- 
 comes daily more copious, is of a dirty yel- 
 low' colour, and ropy consistence, and is 
 very adherent to the sore. The substance, 
 w'hich formed the apparent bottom of the 
 wound, is raised up, and pushing the edges, 
 makes the sore appear considerably enlarged, 
 The edges, which are usually jagged, or 
 pectinated, become extremely irritable, of a 
 deep red colour, and dotted on their inner 
 surface, with numerous small elevated, and 
 angry-looking points, which may be consider- 
 ed as one of the characteristics marks of the 
 disease. The surrounding integuments be- 
 come indurated and inflamed, assuming, not 
 unfrequently, an ansarine appearance ; and 
 the patient complains of a constant burning, 
 lancinating pain. In the vicinity of the 
 sore, the integuments become more and 
 more of a dark red colour, in consequence 
 of the violence of the inflammation, w hich 
 is of an erysipelatous nature, and apt to ter- 
 minate in sloughing, and carry off' the pa- 
 tient. However, the inflammatory symptoms 
 are sometimes mild, and in other cases, ex- 
 ceedingly violent ; a fact accounted for by 
 differences oLconstitution. ( Blackadder , p. 
 34.) 
 
 In the hospitals at Bilboa, if the incipient 
 stage was overlooked, the febrile symptoms 
 very soon became aggravated ; the skin 
 around the sore assumed a highly florid co- 
 lour, which shortly became darker, then 
 bluish, and at last black, with a disposition 
 to vesicate; while the rest of the limb be- 
 trayed a tendency to cedema. All these 
 threatening appearances occurred within 
 twenty-four hours, and at this period also, 
 the wound, whatever might have been its 
 original shape, soon assumed the circular form. 
 The sore now acquired hard, prominent, 
 ragged edges, giving it a cup-like appear- 
 ance, with particular points of the lip of a 
 
HOSPITAL GANGRENE. 
 
 G3 
 
 dirty yellow hue, while the bottom of the 
 cavity was lined with a flabby blackish 
 slough. The’gangrene still advancing, fresh 
 sloughs were rapidly formed ; the increasing 
 cup-like cavity was filled up and over-topped 
 by them, and the erysipelatous livor and ve- 
 sication of the surrounding skin gained 
 ground, while chains of inflamed lymphatics 
 could be traced from the sores tothe adjoining 
 glands, these exciting inflammation and sup- 
 puration, which often furnished a new nidus 
 for gangrene. The face of the sufferer as- 
 sumed a ghastly anxious appearance; his eyes 
 became haggard, and deeply tinged with bile; 
 his tongue covered with a brownish, or 
 blackish fur; his appetite entirely failed; 
 and his pulse was feeble and accelerated. 
 In this stage, the weakness and irritability 
 of the patient was such, that the slightest 
 change of posture put him to torture, in- 
 creased by his inability to steady the iimb, 
 which, if lifted from the bed, was seized 
 with tremors and spasmodic twitches. (Hen- 
 nen's Military Surgery, p. 215, 216, Ed. 2.) 
 Authors vary considerably in their descrip- 
 tions of the state of the tongue. Dr. Hen- 
 nen found it brownish, or blackish ; Delpech 
 whitish, or yellowish, (Pr6cis. Elem. T. 1. p. 
 125,) and Mr. Blackadder, covered with a 
 white mucus. (P. 39.) 
 
 It is explained by Mr. Blackadder, that 
 when the disease attacks a large recent 
 wound, the whole surface of the injury is 
 sometimes affected from the first ; while, in 
 other instances, the disorder commences on, 
 or near the lips of the sore. When the pa- 
 tient is of aa inflammatory diathesis, the sore 
 is generally attacked with acute inflammation 
 between the seventh and fourteenth days; 
 the slough becomes softer, and of a pulpy 
 consistence ; matter, of a strong, and pecu- 
 liar odour, and of a dirty brownish gray co- 
 lour, begins to ooze out at its edges, and be- 
 comes daily more copious. The inflamma- 
 tion gradually subsides ; the slough becomes 
 loosened, and finally detached, leaving the 
 subjacent muscles, bones, fascia;, or liga- 
 ments, completely exposed. When the con- 
 stitution is not prone to acute inflammation, 
 the slough remains long adherent ; the dis- 
 charge is very copious, and burrows under 
 the skin, which then mortifies. Sometimes, 
 after the detachment of a slough, florid gra- 
 nulations spring up, and, notwithstanding a 
 slight recurrence of the phagedenic ulcera- 
 tion, the parts heal up by the almost unasisted 
 operations of nature. However, most com- 
 monly after the muscles are exposed, they 
 continue to be gradually dissected ; their 
 connecting cellular membrane is completely 
 destroyed, and they are left covered with an 
 offensive, greasydooking matter. 
 
 According to Mr. Blackadder, when a 
 muscle has-been wounded, it swells some- 
 times to a great size, and quickly assumes 
 the appearance of a large coagulum, being 
 altogether deprived of irritability. When it 
 has not been wounded, but has become 
 inflamed, it generally assumes a pale colour, 
 with an appearance as if distended with a 
 fluid, and, occasionally, before losing its 
 
 vitality, acquires a very surprising bulk ; but 
 when no inflammation has supervened, the 
 muscles become of a pale brick colour, 
 waste away daily, and the patient loses all 
 power in them. As the disease advances, 
 the integuments are undermined and slough ; 
 and hemorrhage from small vessels is a com- 
 mon occurrence ; but, in a more advanced 
 stage, some of the large vessels are apt to 
 give way, and the bleeding from them fre- 
 quently destroys the patient. 
 
 “ When a stump is the site of the disease, 
 and the patient is of a plethoric habit, or ac- 
 customed to live freely, the symptoms soon 
 begin to indicate the existence of an intense 
 inflammatory action through its whole sub- 
 stance, the tumefaction, pain, and heat in- 
 ci'ease rapidly, so that, in a few days, the 
 stump shall have acquired more than twice 
 its former size, being at the same time much 
 indurated, and causing the most excruciating 
 pain. In this state, the patient has, in some 
 instances, become delirious, and has been 
 cut off by an effusion taking place into some 
 of the larger cavities. It more commonly 
 happens, however, that gangrene seizes upon 
 the integuments, and cellular substance ; 
 large sloughs are thrown off ; and some of 
 the large blood-vessels giving way, the pa- 
 tient sinks under the effects of repeated he- 
 morrhage. For it is commonly found, that 
 the usual modes of stopping hemorrhage 
 from a stump are, in such cases, either inad- 
 missible, or totally inefficacious. 
 
 11 Sometimes, the progress of the disease 
 in a stump is more gradual, but in the end 
 nearly as fatal ; the inflammation is much 
 less acute ; there is comparatively but little 
 tumefaction, and the pain is much less se- 
 vere ; but, the discharge is much more co- 
 pious, and the cellular substance, connecting 
 the integuments and muscles, is rapidly des- 
 troyed. Hemorrhage generally comes on 
 later than in the preceding instance, but it 
 is the most common cause of death,” (Black- 
 adder on Phagedcena Gangrcenosa, p. 33 — 
 39.) 
 
 It is observed by another writer, that ar- 
 tery seems to be the texture, which resists 
 most powerfully the destructive action of 
 hospital gangrene ; (Thomson's Lectures, p. 
 460) a remark quite at variance with the 
 statement of Delpech; (Precis EUm.T. 1, 
 129) but intended to refer, as I conceive, 
 to cases in which the femoral, brachial, or 
 other large artery is seen for several days 
 completely denuded, in the midst of the ra- 
 vages of the distemper, yet not giving way. I 
 have seen the same thing frequently exem- 
 plified in mercurial phagedama, as well in 
 the groin, as in the arm. As for the smaller 
 arteries, they are quickly destroyed, to- 
 gether with other parts. 
 
 “ In some rare cases (says Dr. Hennen) I 
 have seen the femoral and axillary artery 
 pulsating awfully, and apparently unaffected 
 with disease ; while all the surrounding parts 
 were completely destroyed ; but in a vast 
 majority of cases, the blood-vessels partook 
 of the general disease, in which they were 
 imbedded. They were not only completely 
 
HOSPITAL GANGRENE. 
 
 <34 
 
 separated from their natural connexions, 
 but their coats sloughed away at the imme- 
 diate point of disease, while the, disposition 
 extended far beyond the apparently affected 
 spot. Hence, our ligatures but too often 
 failed on the main branches, and any attempt 
 on the smaller was invariably injurious. VVe 
 were here naturally induced to lie the artery 
 considerably above the seat of the disease ; 
 and this was done once on the femoral, and 
 twice on the axillary artery below the 
 clavicle ; the former burst on the third, each 
 of the latter, on the second day afterward.” 
 Dr. Hen nen further remarks, that, in general, 
 the great vessels sloughed long after the 
 acute symptoms of the disease had abated, 
 and that, in severe cases, the eleventh day 
 of the disease was always dreaded. {On 
 Military Surgery , p. 221, Ed. 2.) The in- 
 disposition of the large vessels to close, when 
 taken up in the common way, appears re- 
 ferable to three causes, viz. the tendency to 
 rapid ulceration in the arteries in the situa- 
 tion of the ligatures ; the formation of no 
 effectual coagulum in the extremity of the 
 vessel, like what happens in other cases of 
 mortification ; and the general incapacity 
 of nature in examples of hospital gangrene 
 to establish any process, which can be 
 accompanied with healthy adhesive inflam- 
 mation. 
 
 In the last stage of the disease, as it oc- 
 curred in the military hospitals at Bilboa, 
 the surface of the sore was constantly cover- 
 ed with a bloody oozing, and, on lifting up 
 the edge of the flabby slough, the probe was 
 tinged with dark-coloured grumous blood, 
 with which also its track became immediate- 
 ly filled. Repeated and copious venous 
 bleedings now came on, which rapidly sunk 
 the patient; the sloughs, whether they fell 
 off spontaneously, or were detached by art, 
 were quickly succeeded by others, and 
 brought into view thickly studded specks of 
 arterial blood. At length, an artery gave 
 way, which was generally torn through in 
 the attempt to secure it with a ligature ; the 
 tourniquet, or other pressure was now 
 applied, but in vain ; for, while it checked 
 the bleeding, it accelerated the death of the 
 limb, which became frightfully swelled and 
 horribly fetid. Incessant retchings came on, 
 and with coma, involuntary stools, and 
 hiccough, closed the scene. Often, however, 
 the patient survived this acute state of the 
 disease, and sunk under severe irritation, 
 absorption of putrid matter, and extensive 
 loss of substance, with common hectic 
 symptoms. (See Hennen's Mil. Surgery, p. 
 217, Ed. 2.) In the disease at Bilboa, the 
 skin and cellular substance seemed to be the 
 parts originally and principally affected. 
 This, says Dr. Hennen, was obvious, even 
 in the living body ; but, on dissection, the 
 disease of these parts was frequently ob- 
 served to spread much further, than external 
 appearances indicated, as a diseased track 
 was often found running up into the groin, 
 or axilla, and completely dissecting the 
 muscles and great vessels. (On Military 
 Surgery , p. 219, Ed . 2.) When the disease 
 
 had occupied the outside of the chest, the 
 same gentleman found the lungs in two 
 cases, and the pericardium in a third, cover- 
 ed with gangrenous spots ; and, when the 
 parietes of the abdomen had been attacked, 
 lie often observed the same appearances on 
 the liver. (P. 220.) 
 
 Hospital gangrene must be regarded, as 
 one of the most serious and dangerous com- 
 plications, to which wounds and ulcers are 
 liable. When the solution of continuity is 
 large, or of long standing, the disorder com- 
 mits great ravages, renews its attacks repeat- 
 edly, and the relapses prove exceedingly 
 obstinate. The same thing is said to happen, 
 when it affects persons labouring under 
 scorbutic or venereal complaints. Hospital 
 gangrene proves particularly dangerous, and 
 mostly fatal, when it complicates large con- 
 tused wounds, attended with badly fractured 
 bones. All the soft parts of the injured 
 limb are then frequently observed to be 
 progressively destroyed, and the unfortunate 
 patient falls a victim, either to typhoid 
 symptoms, frequent hemorrhages, or hectic 
 complaints. From what has been stated, 
 however, the disease varies considerably in 
 its severity in different cases, being some- 
 times of small extent, and even capable al- 
 most of a spontaneous cure. Patients have 
 been known to continue afflicted more than 
 a month, and when the duration of the dis- 
 ease was thus lengthened, the cases almost 
 always had a fatal termination. In a few 
 cases, the wound puts on a favourable 
 appearance again between the sixth and 
 ninth days ; and, in slight examples, the 
 amendment is manifested between the third 
 and fifth. Whatever may be the period of 
 the complaint, its wished-for termination is 
 always announced by a diminution of pain ; 
 the pus acquiring a white colour, and more 
 consistence, and losing its fetid nauseous 
 smell. The edges of the ulcer subside, 
 while its surface Tvecoraes less irregular, and 
 puts on more of the vermilion colour. The 
 red, purplish, cedematous circle, which sur- 
 rounds the disease, assumes a true inflam- 
 matory nature, and the solution of conti- 
 nuity, restored to a simple state, heals up 
 with tolerable quickness, even when the 
 destruction of soft parts is somewhat con- 
 siderable, unless any fresh untoward circum- 
 stances occur to interrupt cicatrization. But, 
 sometimes, when (he patient is on the point 
 of being completely well again, his condition 
 is suddenly altered for the worse ; ulcerated 
 spots make their appearance on the cicatrix, 
 and these spreading in different directions 
 occasion a relapse, which may happen several 
 times. 
 
 From numerous cases of this disease, seen 
 by Mr. Blackadder at Passage in Spain, this 
 gentleman made the following conclusions : 
 
 1. That the morbid action could almost 
 always be detected in the wound, or sore, 
 previous to the occurrence of any constitutional 
 affection. 
 
 2. That in Several instances, the constitu- 
 tion did not become affected, until some 
 
HOSPITAL GANGRENE. 
 
 05 
 
 considerable time after the disease had mani- 
 fested itself in the soie. 
 
 3. That when the disease was situated on 
 the inferior extremities, the lymphatic 
 Vessels, and glands in the groin, were ob- 
 served to be in a state of irritation, giving 
 pain on pressure, and were sometimes en- 
 larged, before the constitution showed evi- 
 dent marks of derangement. 
 
 4. That the constitutional affection, though 
 sometimes irregular, was in many cases 
 contemporary with the second, or inflamma- 
 tory stage. 
 
 5. That all parts of the body were equally 
 liable to become affected with this disease. 
 
 6. That, when a patient had more than 
 one wound, or sore, it frequently happened, 
 that the disease was confined to one of the 
 sores, while the other remained perfectly 
 healthy, and that even when they were at 
 no great distance from each other. (On 
 Phagedena Gangrcenosa, p. 19.) 
 
 Thus Mr. Biackadder espouses the opinion, 
 that hospital gangrene is at first a local, and 
 not a constitutional disease, that is to say, not 
 necessarily preceded, or originally accom- 
 panied by any diseased action in the system. 
 It is highly important to weigh this distinc- 
 tion well, not only because it is yet the chief 
 point of difference among the best writers 
 on the subject, but because it involves very 
 directly every theory respecting the causes 
 of the disease, and the great question, 
 whether its ravages are to be resisted princi- 
 pally by local or constitutional means, or 
 by remedies of both descriptions together. 
 
 In the hospital gangrene, observed by Dr. 
 Rollo in the artillery hospital at Woolwich, 
 
 “ The action of the poison seemed to be 
 limited and confined to specific effects. The 
 Jirst were local, producing only a general affec- 
 tion, by a more extensive operation on the sore. 
 Five or six days from the appearance of (he 
 small ulcer or ulceration, when it had ex- 
 tended over one-third of the former sore, 
 with pain and redness in the course of the 
 lymphatics, and the glands, through w f hieh 
 they led, with enlargement of them, general 
 indispositon of the body became evident.” 
 Delpech, in his interesting memoir, particu- 
 larly notices, that the constitutional symp- 
 toms always occurred the last in order of 
 succession. 
 
 Mr. Biackadder distinctly declares, that, 
 in no instance, which he had an opportunity 
 of observing, did the constitutional symp- 
 toms of gangrenous phagedama precede the 
 local, unless the case be held an exception, 
 in which a stump became affected, alter 
 amputation had been performed, on account 
 of Hie previous effects of the disease. The 
 period at which the constitution begins to 
 exhibit symptoms of irritation (he says) is 
 extremely irregular, — sometimes as early as 
 the third, or fourth day, and sometimes even 
 as late as the twentieth. The countenance 
 assumes an anxious or feverish aspect ; the 
 appetite is impaired ; the desire for liquids 
 increases ; and the tongue is covered with 
 a white mucus. The bowels are generally 
 rather constipated : and the pulse, what 
 Vol. If 9 
 
 may be termed, rather irritated, than accele- 
 rated. Bur, the general symptoms may 
 assume an inflammatory, or typhoid charac- 
 fer, according as the causes of one of these 
 modifications may predominate. According 
 to Mr. Biackadder, when an inflammatory 
 diathesis prevails, the system becomes gradu- 
 ally more irritated, until an attack of°acutc 
 inflammation seizes upon the sore, and 
 which frequently happens about the end of 
 the second week. At this pe iod, the pulse 
 is frequent arid sharp, and it is not uncommon 
 for the patient to be seized with one, or 
 more shivering fits, succeeded by a great 
 increase ot heat, but seldom, or never termi- 
 nating in a profuse perspiration. The cold 
 fit is sometimes followed by a bilious dis- 
 charge from the intestines, and mitigation of 
 the febrile disorder. If the local mischief 
 be not arrested, the strength becomes daily- 
 more and more exhausted ; the fever losers 
 its inflammatory character ; and, unless the 
 patient be cut off by hemorrhage, he falls a 
 victim to extreme debility. When the dis- 
 ease has a typhoid character, the pulse is 
 small and frequent ; the appetite and 
 strength gradually fail ; and the patient at 
 last sinks, retaining his mental faculties to 
 the last. Not unfrequentlv diarrhoea has- 
 tens the event. (Biackadder on Phagedccno, 
 Gangrwnosa, p. 39, 40.) 
 
 On the other band, the generality of wri- 
 ters, nay, even some of those who represent 
 the disease as always proceeding from a 
 species of infection applied to the wound, 
 take into the account the operation of con- 
 stitutional causes, as predisposing to, and of 
 course preceding the local symptoms. Dr 
 J. Thomson believes, that the constitutional 
 symptoms mostly precede the local. (On 
 Inflammation ,p. 459.) The same sentiment 
 is professed throughout Dr. Herinen's re- 
 marks, who placed reliance chiefly upon 
 internal remedies, and regarded external 
 applications, as merely a secondary object. 
 
 ( On Military Surgery, p. 222, Ed. 2.) To 
 this part of the subject, I shall return, after 
 adverting to the causes of hospital gangrene. 
 
 The hospital gangrene, which occurred in 
 the Artillery Hospital at Woolwich, and was 
 described by Dr. Rolio, did not attack .speci- 
 fic sores : venereal, scrofulous, and vario- 
 lous ulcers were not attacked, although (he 
 patients lay in the wards, where the disease 
 prevailed. 
 
 Professor Thomson admits, that specific 
 sores are less liable to attacks of hospital 
 gangrene, than common wounds and ulcers • 
 but, he declares, that he has frequently seen 
 it attack cancerous and venereal ulcers 
 (On Inflammation, p. 460.) 
 
 Dr. Hennen mentions a remarkable in- 
 stance, which also proves the possibility of 
 a specific sore becoming affected, and fatal 
 from this cause in forty-eight hours after rhV 
 patient had first been exposed to the infec- 
 tion. Dr. Hennen relates the tact to prove 
 that the contagion may be received, without 
 a long residence in a tainted air. The 
 patient, “ who had just landed from Eng- 
 land, and was under (he influence of mereu- 
 
HOSPITAL GANGRBNU. 
 
 66 
 
 vy, employed for a venereal complaint, died 
 within forty-eight hours after his admission, 
 the gangrene having seized on an open bubo 
 in his groin, eroding the great vessels in the 
 neighbourhood, and absolutely destroying 
 the abdominal parietes to a large extent.” 
 (P rinciples of Military Surgery , p. 218, Ed 2.) 
 
 The effects of hospital gangrene should 
 be carefully discriminated from those of the 
 scurvy. Ulcers, attacked with hospital gan- 
 grene, are not affected in any degree, like 
 scorbutic ulcers, by the use of vegetable diet 
 and lemon-juice, and they occur among men, 
 who are fed upon fresh meat and vegetables, 
 as readily as they do among those who have 
 been fed altogether upon salt provisions. 
 
 ( Thomson’s Lectures on Inflammation, p. 482.) 
 Hospital gangrene is almost always accom- 
 panied with severe febrile symptoms : but, 
 as to fevers, (says Dr. Lind.) it may indeed 
 be doubted whether there be any such as 
 are purely and truly scorbutic. The disease 
 is altogether of a chronic nature ; and fevers 
 may be justly reckoned among its adven- 
 titious symptoms.” ( Treatise on the Scurvy , 
 p. 106.) In cases of hospital gangrene, the 
 geueral symptoms of scurvy are also abselit, 
 such as soreness and bleeding of the gums, 
 livid blotches and wheals on the fleshy part 
 of the legs, cedematous ankles, Lc. 
 
 Hospital gangrene (says Boyer) is a spe- 
 cies of humid gangrene, which attacks in 
 some degree epidemically the wounds and 
 ulcers of patients, who happen to be crowd- 
 ed together in an unhealthy place. 
 
 Its occasional causes are ; the situation 
 of an hospital upon a low marshy ground; 
 the vicinity of some source of infection ; 
 the uncleanliness of the individuals, or of 
 the articles for their use ; the crowded state 
 of the wards, especially when they are small 
 and badly ventilated ; lastly, every thing 
 that tends to corrupt the air which the pa- 
 tients breathe An infected atmosphere 
 may produce in the most simple wounds 
 unfavourable changes, partly, as Boyer con- 
 ceives, by its immediate action on the sur- 
 face of the wound, but no doubt princi- 
 pally by its hurtful influence upon the 
 whole animal economy. The foregoing 
 causes have also sometimes produced alarm- 
 ing and obstinate gangrenes of an epidemic 
 kind, or at least, a state of the constitution, 
 under the influence of which all wounds 
 and ulcers constantly took on a bad aspect, 
 and were often complicated with the most 
 gangrenous mischief. Vigaroux saw such 
 an epidemic disease prevail for twenty 
 months in the two hospitals of Montpellier, 
 and he states, that the most powerful anti 
 septics were of little avail against the dis 
 order, which often invaded the slightest 
 scratches. 
 
 In general, this epidemic species of gan- 
 grene is not observed in new-built hospi- 
 tals, nor in those which are erected out of 
 the central parts of cities, upon high ground. 
 
 Hospital gangrene may occur in any sea- 
 son ; but, it is most common after the sultry 
 heat of summer. 
 
 A bilious constitution, mental trouble, un- 
 
 wholesome or insufficient food, a scorbutic 
 diathesis, great debility, and fevers of a 
 dangerous type, are also reckoned by the 
 French surgeons as so many predisposing 
 causes of hospital gangrene. 
 
 The observations of Pouteau, and those 
 of some other practitioners, convincingly 
 prove, that hospital gangrene may be com- 
 municated to the most simple wound, or 
 ulcer, in a subject of the best constitution, 
 and breathing the purest air, by merely 
 putting into contact with such wound or 
 ulcer, sponges, lint, or charpie, impregnated 
 with the infection of this peculiar disorder. 
 But, this inoculation is conceived to be the 
 more alarming, and to take effect the more 
 quickly, in proportion as patients have been 
 more exposed to the influence of such cau- 
 ses as are themselves capable of producing 
 the disease, and also in proportion as the 
 kind of constitution predisposes to it. 
 
 Although the contagious nature of hospi- 
 tal gangrene has been generally admitted 
 by all the best informed writers on the sub- 
 ject, the doctrine was not considered by Dr. 
 Trotter as having a good foundation. Mo- 
 dern authors, however, have not joined this 
 latter gentleman, and Dr. J. Thomson, Dr. 
 Hennen, and Mr. Blackadder, all believe, 
 that the disorder is infectious. “ The con- 
 tagious nature of hospital gangrene (says 
 Professor Thomson) appears to me to be 
 sufficiently proved, 1st, By the fact, that it 
 may be communicated by sponges, charpie, 
 bandages, and clothing, to persons at a dis- 
 tance from those infected with it. 2dly, By 
 its having been observed to attack the slight 
 wounds of surgeons, or their mates, who 
 were employed in dressing infected per- 
 sons ; and that, even in circumstances, 
 where the medical men so employed, did 
 not live in the same apartment with the in- 
 fected. 3d!y, By our being able often to 
 trace its progress distinctly from a single in- 
 dividual through a succession of patients. 
 4thly, By its attacking recent wounds, as 
 well as old sores, and that in a short time 
 after they are brought near to a patient af- 
 fected with the disease. Stilly, By our be- 
 ing able to prevent the progress of the dis- 
 ease in particular situations, by removing 
 the infected person, before the contagion, 
 which his sores emit, has had time to ope- 
 rate. 6thly, By its continuing long in one 
 particular ward of an hospital, or in one 
 particular ship, without appearing in other 
 wards, or ships, if pains be taken to prevent 
 intercourse between the infected and unin- 
 fected.” (Lectures on Inflammation, p. 
 4S4.) But, although there can be no doubt 
 of the disease spreading partly by its conta- 
 gious nauire, it appears to me equally cer- 
 tain, that the number of cases is also often 
 increased by the continued operation of the. 
 same causes, which produced the earliest 
 instance of the disorder in any particular 
 hospital. 
 
 it is alleged, that when once a patient 
 has taken the infection, he cannot avoid 
 the consequences, whatever precautions he 
 may adopt. Thus, Boyer informs us, that 
 
HOSPITAL GANGRENE. 
 
 67 
 
 helms seen hospital gangrene take place in 
 wounded patients, who, in the hope of es- 
 caping this epidemic affection, had quitted 
 the infected hospital, and retired to elevated 
 situations, where they breathed the most 
 salubrious air. (See Traitd de Mai. Chir , T. 
 \, p. 322.) 
 
 The bad state of the air of a crowded hos- 
 pital, as Mr. Blackadder observes, is a ready 
 means of accounting for the origin of pha- 
 gedena gangrenosa ; but, there are various 
 reasons fur considering such explanation 
 not altogethersatisfactory ; and he mentions 
 a case, in which the wound of a soldier was 
 found affected with the disease on his first 
 arrival at an hospital, after having been ac- 
 cidentally detained, with two other wound- 
 ed comrades, for five or six days, partly in 
 an open building, and partly in a boat, quite 
 exposed to stormy weather. ( P . 45.) Dr. 
 Hennen likewise gives an account of about 
 thirty fresh wounded men, in whom hospi- 
 tal gangrene first appeared in their journey 
 from Viltoria to the hospital near Bilboa. 
 (Principles of Military Surgery, p. 214, Ed. 
 2.) Dr. Rollo also remarked, that some 
 men in quarters were affected with thisdis- 
 ease. And, according to Air. J. Bell, ‘There 
 is no hospital, however small, airy, or well 
 regulated, where this epidemic ulcer is not 
 to be found at times.” ( Principles of Sur- 
 gery ', Vol. 1, p. 112.) For a refutation of 
 the opinion, that the disease ever strictly 
 merits the epithets endemial, and epidemic , 
 
 I must refer the reader to the observations 
 of Mr. Blackadder. (P. 143. 53.) Delpech 
 remarks, that the causes of the disease do 
 not appear to have depended upon the state 
 of the atmosphere, (P. 25;) and in almost 
 every instance, he traced the propagation of 
 the disorder to the direct application of the 
 morbific mailer to the sores. However, he 
 joins Pouteau in the belief, that it may be 
 communicated through the medium of the 
 atmosphere ; an occurrence, which Air. 
 Blackadder doubts, or, rather considers as 
 very rare, and only possible where the ef- 
 fluvia are allowed to accumulate in a most 
 negligent manner, so as to resemble a va- 
 pour bath, which mode he would also regard 
 as equivalent to inoculation. (On Phngedce- 
 na Gangrcenosa , p. 156.) On the whole, I 
 am disposed to think the views, which Mr. 
 Blackadder has taken of the manner in 
 which the disease is communicated, the 
 most correct, hitherto published, and that, 
 while particular states of the air and consti- 
 tution certainly modify the disorder, they 
 cannot generally have any share in giving 
 origin to the disease ; I say generally, be- 
 cause as various facts oblige us to admit, 
 that hospital gangrene sometimes arises, 
 without having been communicated from 
 any patient previously affected, it is impos- 
 sible to assert, that the earliest example of 
 it, under such circumstances, may not arise 
 from the operation of some unknown and 
 inexplicable circumstances on the constitu- 
 tion, or in other words, from the state of 
 the system itself. Nor can a doubt be 'en- 
 tertained, that, at all events, the disorder is 
 
 most apt to break out in crowded, Badly- 
 ventilated hospitals, and in them appear 
 more extensively and malignantly, than in 
 others, which are well-regulated, properly 
 ventilated, and healthily situated. But, the 
 idea, entertained by Delpech, that hospital 
 gangrene may originate from the same con- 
 tagion as typhus, or other diseases, is a mere 
 unsupported, irrational conjecture, quite as 
 destitute of the truth, as the suppositions 
 about the endemial and epidemic character 
 of the complaint, independent of its infec- 
 tious nature. The question, how the first 
 example of the disorder originates, is at pre- 
 sent a perfect mystery ; but, as ii cannot be 
 referred to contagion, or inoculation, we 
 should recollect, that whatever produces it 
 in one individual, may produce it in ano- 
 ther, similarly circumstanced, and, on this 
 principle, the disorder may sometimes be 
 formed independently, and at the same time, 
 in a greater or lesser number of patients in 
 the same hospital, as well as spread from 
 these to others by infection. 
 
 With the view of preventing the disor- 
 der, the wards. in which the wounded are 
 placed, should riot be crowded ; they ought 
 to be freely ventilated, and, if possible, not 
 communicate. The utmost attention to 
 cleanliness should be paid ; and all tilth 
 and stagnant water removed. It lias been 
 asserted, but with what accuracy 1 cannot 
 determine, that the predisposition of the 
 wounded to this species of gangrene may be 
 lessened bva well-chosen diet, by drinksaci- 
 dulated with vegetable acids, or with the sul- 
 phuric acid, and by the moderate use of wine. 
 The state of the stomach and bowels should 
 be particularly attended to, and, if out of 
 order, emetics and purgatives ought to be 
 immediately employed, and repeated ac- 
 cording to circumstances. The dressings 
 should be applied with extreme attention to 
 cleanliness, and too much care cannot bo 
 taken to prevent the infectious matter of 
 one wound from coming into contact with 
 another through the medium of sponges, in- 
 struments, &c. “ Whatever may be the. 
 
 source of this disease (says a late writer) it 
 is atleast'sufliciently ascertained, that, when 
 it occurs, its propagation is only to be pre- 
 vented by the most rigid attention to clean- 
 liness, and by insulating the person, or per- 
 sons affected, so as to prevent all direct in- 
 tercourse between them and the other pa- 
 tients ; for, so far as I have had an oppor- 
 tunity of observing, ninety-nine cases in the 
 hundred were evidently produced by a di- 
 rect application of the morbific matter to 
 the wounds, dressings, &,c. ; while others, 
 who were, in every other respect, equally 
 exposed to its operation, never caught the 
 disease. Tti attempting to prove this by ex- 
 periment, I have placed three patients with 
 clean wounds alternately between three 
 other patients, severely affected with the 
 disease. They lay in a part of a ward, 
 which was appropriated for patients, who 
 were labouring under the disease, and of 
 whom there were at the time a considera- 
 ble number. Their beds were on the floor, 
 
68 
 
 HOSPITAL GANGRENE. 
 
 and not more than two feet distant from 
 each other; but, all direct intercourse Was 
 forbidden, and they were made fully aware 
 of the consequences that would follow from 
 inattention to their instructions. The re- 
 sult of this trial was, that not one of the 
 clean wounds assumed the morbid action 
 peculiar to the disease, nor was the curative 
 process in any degree impeded.” (Black- 
 adder on Phage daena Gangrrenosa, p. 46 .) 
 
 As many experienced writers assert, that 
 the disease may also be communicated from 
 one person to another through the medium 
 'of effluvia in the air, I am firmly persuaded 
 that, in the present state of our knowledge 
 of the subject, the cautions, respecting 
 ventilation, cleanliness, (the chief practical 
 deduction from the latter doctrine) are high- 
 ly necessary and important. This sentiment 
 may be adopted, without implicit faith be- 
 ing placed in the opinion, that the disorder 
 can actually be transmitted from one per- 
 son to another through contagion in the air, 
 because whether the last idea be true, or 
 not, attention to cleanliness and ventilation 
 must be beneficial to the health, in this, as 
 in every other species of gangrene ; and, on 
 this principle, they must be serviceable in 
 diminishing the severity, if not the frequen- 
 cy and extent, of the disease, as I am myself 
 disposed to believe from the consideration 
 of all the evidence adduced. Where cir- 
 cumstances will permit, an entire removal 
 of the patients from the place, in which 
 the disease has either had its first forma- 
 tion, or spread to any extent, appears like- 
 wise to be a most beneficial measure. But, 
 when this change of the wards, or hospital, 
 is impracticable, the air which the patients 
 breathe, should be purified, by renewing it 
 as much as possible, fixing ventilators, and 
 especially by using the oxygenated muriatic 
 acid fumigations, as recommended by 
 Guyton-Morveu, or else those of the nitric 
 acid. 
 
 The nitric acid fumigations are made by 
 putting into a gla>s vessel, on the ground, 
 half an ounce of concentrated sulphuric 
 acid, to which an equal quantity of nitre is 
 to be added gradatim. The mixture is to be 
 stirred with a glass tube, when an abundance 
 of while vapour will be produced. 
 
 The oxygenated muriatic acid fumiga- 
 tions are made, by mixing three ounces two 
 drams of common salt with five drams of 
 the black oxide of manganese in powder. 
 These two ingredients are to be triturated to- 
 gether; they are then to he put into a glass 
 vessel; one ounce two drams of water are 
 to be added, and then if the ward, or cham- 
 ber be uninhabited, one ounce seven drams 
 of sulphuric acid are to be poured upon the 
 mixture all at once ; or gradually, if the pa- 
 tients are there. This quantity will be suffi- 
 cient for a very large ward. 
 
 When one or more of the patients, afflict- 
 ed with the disorder, before it has become 
 general, are lying in a badly ventilated part 
 of the ward, the surgeon can partly counter- 
 balance the disadvantage of not having a 
 fresh ward, by causing the patients to be put 
 
 into a more airy part of the ward, and as far 
 as possible from the quarter, in which they 
 contracted the disease. 
 
 With regard to internal medicines, while 
 irritation and febrile heat accompany hospi- 
 tal gangrene, diluent acid drinks are proper, 
 such as nitrated whey sweetened with syrup 
 of violets, lemonade, &c. Blood- letting is 
 admissible in bur few instances, not merely 
 because the orifice, made by the lancet, is 
 apt to become gangrenous, but because the 
 fever, which accompanies hospital gangrene, 
 is usually of the typhoid, or astheuic cha- 
 racter. ( Thomson , p. 49 ?.) 
 
 Mr. Blaeka ider, like Dr. Thomson, does 
 not entertain a favourable opinion of vene- 
 section, as a general practice, though he 
 would not object to the abstraction of a 
 small quantity of blood, when, owing to the 
 plethoric habit of the patient, previous treat- 
 ment, and other causes, an inflammatory ac- 
 tion in the system is present. But he con- 
 ceives, that all danger of the disease attack- 
 ing the A’oundj made with the lancet, may be 
 obviated, if care be taken that the arm of 
 the patient, the hands of the surgeon, his 
 lancet, and the subsequent dressings, be per- 
 fectly free from contamination, and that the 
 patient be prevented from undoing ihe band- 
 age, or touching the incision made with ihe 
 lancet, before it is cicatrized. (P. 135.) Mr. 
 Blackadder thinks, however, that blood-let- 
 ting should be avoided, as much as possible, 
 particularly when the previous injury has 
 been extensive. “ A general debility of the 
 system, is one of the symptoms which are 
 most to be dreaded ; for, when once it takes 
 place, there is no other disease in which it 
 is removed with greater difficulty.” (P. 137.) 
 Mow different these sentiments are from 
 those of Dr. Hennen, who, in speaking of 
 the effects of venesection, when the disorder 
 was accompanied with an inflammatory dia- 
 thesis, employs the following expressions: 
 “ The very patients themselves implored the 
 use of the lancet.” For several months 
 we used no other remedy, cither as a cure, 
 or preventive.” — “We never observed arty 
 of the lancet wounds assume a gangrenous 
 appearance, although previously, in almost 
 every other instance, the slightest puncture 
 festered.” On Military Surgery , p. 224, Ed. 
 2-> 
 
 In the beginning of the constitutional at- 
 tack, Pouteau and Dussassoy particularv re- 
 commended emetics, and Mr Briggs, Dr. J. 
 Thomson, and Dr. Hennen, are all advo- 
 cates for this practice, though the latter 
 gentleman makes his evidence rather ambi- 
 guous, by a subjoined note, in which he 
 ment ions that want of success, &,c. led to the 
 trial of venesection. (Op.cit. 222.) As for 
 Mr. Blackadder, he deems the employment 
 of emetics at the commencement of hospital 
 gangrene useful only when the stomach is 
 foul. (On Phagedeena Gang ram osa, p. 134.) 
 In the early stage of the case, writers seem 
 all to agree about the utility of purgative and 
 laxative medicines. When there is debility, 
 good generous wine should be allowed, either 
 by itself, or mixed with lemonade according 
 
HOSPITAL GANGRENE. 
 
 09 
 
 to circumstances. Bark, whose antiseptic 
 qualities have been so highly praised, is in 
 general more hurtful, than useful ; and Dr. 
 Hennen assures us, that he has seen great 
 harm done by large and injudicious doses of 
 this drug, before full evacuations had taken 
 pluce, and the sloughs begun to separate. 
 Boyer allows, however, that it may be bene- 
 ficially given, when the feverish heat has 
 abated, and the debility is very great. 
 
 In all stages of this disease, unattended 
 with diarrhoea, acids are proper. The sul- 
 phuric acid is that which is given With most 
 success ; but the acidulous tars rite of potassa 
 is also an excellent medicine. From two 
 drams to half an ounce may be given every 
 day, and the best plan is to make an acid 
 drink with it, which should be sweetened 
 and strained. 
 
 In severe cases, attended with a quick and 
 feeble pulse, depression, restlessness, and 
 anxiety, an opiate becomes necessary. 
 “ So long as we wish to excite a degree of 
 moisture on the skin, (says Professor Thom- 
 son) Dover’s powder, or laudanum with anti- 
 monial wine, form in general the best opi- 
 ates.” This gentleman, however, is not an 
 advocate for the employment of opium, in 
 the early stage of hospital gangrene, while 
 the heat and other febrile symptoms are at 
 their ne'ight (See Lectures on Inflammation, 
 p. 494,495.) For these cases, camphor, in 
 large and frequent doses, was highly praised 
 by Pouteau. 
 
 From what has been said concerning in- 
 ternal remedies, it is evident, that none of 
 them can be regarded as neans, which can 
 be at all depended upon for arresting the ra- 
 vages of hospital gangrene, however advan- 
 tageous they may prove in palliating general 
 symptom*, removing particular complica- 
 tions, enabling the system to support the ef- 
 fects of the local disorder for a greater length 
 of time, or, in a few cases, even placing na- 
 ture in a condition to throw off the diseased 
 parts herself, and communicate to the subja- 
 cent living flesh a healty action. 
 
 If credit can be given to several of the 
 authors, who have had the most extensive 
 opportunities of attending to the nature of 
 hospital gangrene, the local treatment is far 
 more effectual than internal medicines. 
 
 “ I was told by several of the French sur 
 geons (says a late visiter to Paris ) that they 
 did not rely at all on internal means for 
 stopping the progress of hospital gangrene, 
 and that their experience had proved them 
 to be insufficent, if no! wholly inefficacious. 
 Dupuytren, in reply to the account I gave 
 him of the practice and opinions of English 
 surgeons on this subject, assured me, that he 
 had no confidence but in local applications, 
 and that internal remedies alone, as far as he 
 had found, did almost nothing. The same 
 remark has been made in a very recent pub 
 lication on hospital gangrene, ( Delpech , 
 Mim. sur la Complication des Plaies, fyc. 
 1815.) although it seems to be rather at vari- 
 ance with its being a constitutional and con- 
 tagious disease, which the author has admit- 
 
 ted.” (See Sketches of the Medical Schools 
 of Paris, by J. Cross, p. 83.) 
 
 Perhaps, there is not a single antiseptic ap- 
 plication, which has not been tried as a dress- 
 ing for wounds, or ulcers, affected with hos- 
 pital gangrene. All watery applications, and 
 common poultices, and fomentations, are ge- 
 nerally condemned as inefficacious, and even 
 hurtful. 
 
 Dussassoy was convinced by the observa- 
 tion of numerous cases, that t lie best applica- 
 tion is powder of bark. He recommends 
 the wound to be covereu with several layers 
 of this powder, which are then to be moist- 
 enechwilh turpentine. When this composi- 
 tion dries, he asserts, that it forms a fragile 
 sort of coat, at the sides of which, and 
 through which, the discharge escapes. After 
 twenty-four hours, the first coat is to be re- 
 moved, an I a fresh one applied. In general, 
 according to this writer, four or five such 
 dressings are sufficient in sirnplfe cases, where 
 the disorder is confined to the skin and cel- 
 lular substance. Healthy inflammation then 
 occurs, the sloughs come away, and the 
 wound puts on a healing appearance. In bad 
 cases, D-issassoy sometimes added one-fifth 
 of powdered muriate of ammonia to the 
 bark When th's treatment failed, the actual 
 cautery was used 
 
 On the subject of bark, as a local applica- 
 tion to hospital gangrene, I need only re- 
 mark, that it is now entirely relinquished, 
 either as possessing no efficacy, ( Delpech ) or 
 even aggravating the symptoms. ( Blackad - 
 der.) 
 
 The milder forms of the disease appear 
 sometimes to have yielded to the application 
 of the vegetable and diluted mineral adds ; 
 lime juice ; lemon juice ; vinegar; and the 
 diluted nitric, and muriatic acids. And the 
 same observation may be made, with res- 
 pect to solutions of the nitrates of silver and 
 mercury. The two latter substances, and 
 the oxygenated muriatic acid, and ga«, were 
 found by Dr. Rollo to be capable of effecting 
 a cure. Delpech, in particular, speaks of 
 the benefit derived from the application of 
 strong vinegar, after all the pulpy viscid 
 matter has been carefully wiped away from 
 the surface of the living flesh. The vinegar 
 is then poured on the ulcer, which is to be 
 covered with charpie wet with the same 
 liquid. When the case is too far advanced 
 for this trea’ment to answer Delpech tries 
 caustics, especially 1 he nitrate of silver ; and 
 if these fail, he lias recourse to the actual 
 cautery, and, when the sloughs are very 
 thick, so as to hinder the cautery from act- 
 ing to a sufficient depth, he prefers thrusting 
 into the sloughs down to the living flesh an- 
 gular pieces of caustic potash at small dis- 
 tances from each other! (Prdcis. Elem. des 
 Mai. Chir. T. 1, p. 151.) Surely, this must 
 be far more torturing, and less certain of 
 success, than removing the sloughs, and ap- 
 plying the cautery. 
 
 Though the actual cautery is generally ad- 
 mitted to be one of the most powerful means 
 of stopping the progress of hospital gangrene, 
 the surgeons of this country entertain a 
 
HOSPITAL GANGRENE. 
 
 SO 
 
 strong aversion to the practice; and Icon- 
 loss, that my own dislike, to it is such as 
 Mould always lead tne to prefer any other 
 treatment, from which equal efficacy would 
 result. At the same time, if must be grant- 
 ed, that if the actual caulery will more cer- 
 tainlyarrest sotneforms of hospital gangrene, 
 than any other known applications, the sur- 
 geon’s duty is to put out of the question his 
 own prejudices against it, and consider only 
 his patient’s welfare. I am far from thinking, 
 however, that, while there are such power- 
 ful caustics as th^ undiluted mineral acids, 
 and a dressing so effectual as a solution of 
 arsenic, it can often be absolutely necessary 
 to employ red-hot irons. 
 
 The merit of having pointed out in mo- 
 dern times the great efficacy of Fowler’s 
 solution of arsenic, or the liquor arseuiealis 
 of the London Pharmacopoeia, as an appli- 
 cation to phagedaena gangrenosa, belongs to 
 ]\Ir. Biackadder. In answer to the objection, 
 that the external use of arsenic is not unat- 
 tended with danger, he assures us, that he 
 has heard but of one instance of hospital 
 gangrene, in which any deleterious effects 
 were supposed to arise from the absorption 
 of the arsenic, and the patient in question 
 was very soon cured of his uneasy, and pos- 
 sibly merely nervous symptoms ” ( P . 50.) 
 
 “ The first thing to be attended to in every 
 case of disease (says Mr. Biackadder) is 
 cleanliness , which, if always of great im- 
 portance, is, in this instance, indispensable. 
 The surface of the body ought to be made, 
 and kept perfectly clean, by means ot the 
 tepid bath, or otherwise by a plentiful use of 
 soap; and the linen, and bed-clothes, should 
 be frequently changed, particularly when 
 soiled with matter from the sore.” In order 
 to make the sore perfectly clean, and free it 
 from the viscous discharge, without produ- 
 cing considerable bleeding, and pain, Mr. 
 Biackadder recommends two large tin hos- 
 pital teapots to be filled with a weak solu- 
 tion of the subcarbonate of potass. One of 
 these solutions is to be cold ; the o»her tepid ; 
 because sometimes one, and sometimes the 
 other, is found most agreeable to the patient’s 
 feelings, though the warm is the most effec- 
 tual in cleansing the sore. The liquid is to be 
 poured over the sore, and received into a 
 basin, which ought to be immediately empti- 
 ed into another vessel placed at a distance 
 from the patient. During this ablution, the 
 glutinous matter, which adheres to the sore, 
 may be gently detached, by means of small 
 dossils of fine tow, or lint, but these (says 
 Mr. Biackadder) should never be used lor 
 two different patients, rigid ecomotny, on 
 occasions such as this, being a very mistaken 
 principle. In these cases, the use of sponges, 
 (he justly observes) ought to be entirely 
 laid aside, as they can seldom be used more 
 than once with safely. When the sore has 
 been thus cleaned, a fine piece of dry lint is to 
 be spread over its surface, and gently [tress- 
 ed into all its depressions with the points of 
 the fingers. When the lint is removed, a 
 quantity of the discharge will be found ad 
 liering to it : and this operation must be re- 
 
 peated with fresh pieces of lint, until the 
 surface of the sore is made perfectly clean 
 and dry. 
 
 According to Mr. Biackadder, the solution 
 of arsenic will generally be found strong 
 enough, when diluted with an equal part of 
 water; but, in slight cases, it answered, 
 when weakened with twice its quantity of 
 Avater ; and, in a few examples, it was em- 
 ployed without being at all diluted. Several 
 pieces of lint of the same shape as the sore, 
 but a little larger, are to be prepared : one 
 of these, soaked in the solution, is now to 
 be applied to the cleaned surface of the sore, 
 and renewed every fifteen or thirty minutes, 
 according to the time in which it becomes 
 dry. When the heat and inflammation are 
 considerable, great relief will be derived 
 from the frequent-application of linen cloths 
 moistened with cold water, which must be 
 kept from weakening the arsenical solution 
 by means of a, small piece of oilskin laid 
 over the pieces of lint. When the disease 
 extends into the track of a gunshot wound, 
 Mr. Biackadder uses a syringe for cleaning 
 the sore, and introducing the solution. “A 
 slip of fine lint, well soaked in the solution, 
 may also be inserted by means of a probe, 
 into the bottom of the wound ; and when 
 the openings are at no great distance from 
 each other, aud not in the immediate vici- 
 nity of the large nerves and blood-vessels, 
 the lint may be drawn through the wound in 
 the form of a seton. (P. 53.) When the 
 pain, caused by the application, is very se- 
 vere, and the constitution is irritable, and 
 debilitated, Mr. Biackadder prescribes an 
 opiate, though he remarks, that this practice 
 will seldom be absolutely necessary. The 
 morbid action in the sore is destroyed by 
 the arsenical solution sooner, or later, in 
 different cases : the best plan is to continue 
 the application, until an insensible, dark- 
 coloured , dry slough occupies the whole surface 
 of the sore ; and until the patient is com- 
 pletely relieved from the burning and lancina- 
 ting pain. 
 
 After the slough is formed, Mr. Biackadder 
 employs an ointment, composed of equal 
 parts of the oil of turpentine, and the yellow 
 resinous ointment, or of two parts of Venice 
 turpentine to one of the resinous ointment. 
 11 These being melted and mixed together, 
 are to be poured over the sore, as hot as the 
 patient can possibly bear.” A pledget of 
 dry lint, or tow, and a bandage, are then 
 applied ; and this dressing may be renewed 
 two or three times a day, the sore being each 
 time carefully washed with the solution of 
 potass. As soon as any part of the slough is 
 loosened, Mr. Biackadder removes it with a 
 pair of curved scissors. With the view of 
 expediting the separation of the slough, he 
 sometimes employs a linseed-meal poultice, 
 which had the desired effect, but was found 
 to he too relaxing. When it is used, there- 
 fore, Mr. Biackadder found it expedient, at 
 each dressing, to touch the new granulations 
 with the nitrate of silver. 
 
 After the detachment of the. slough, Mr. 
 Biackadder dresses the sore with the above- 
 
Hydrocele. 
 
 
 tiieulioned ointment cold, or with the addi- 
 tion of a small proportion of the subacetale 
 of copper. The pledget of this ointment is 
 covered with a piece of oilskin, lightly rub- 
 bed over with soap; and a firm bandage is 
 applied to the whole limb. (See Obs. on 
 P/iagedeena Gangreenosa , p. 49, fyc. 8vo. 
 Edinb. 1818.) The author declares, that, 
 after the introduction of the above treatment, 
 (with the exception of stumps attacked with 
 hospital gangrene) he never saw an instance 
 in which the remedy failed, when applied in 
 time and in a proper manner; that is, before 
 the disease had made such progress as to 
 preclude all rational hope of success from 
 that or any other mode of treatment. ( P . 
 23.) 
 
 In Dr. Rollo’s treatise on Diabetes, publish- 
 ed in 1797, the opinion is plainly stated, that 
 the progress of hospital gangrene might be 
 slopped by very active topical applications, 
 and, in tae same work Mr. Cruickshank says, 
 that “ it an actual caustic were to be em- 
 ployed, we should have recourse to the 
 strong nitrous acid.” According to Mr. 
 Blackadder, the oxygenated muriate of mer- 
 cury and the nitrous acid were u.ucli recom- 
 mended, and employed by surgeons in the 
 16th and 17th centuries, as escbaroties, in 
 cases of gangrene and foul ulcers. ( P . 113.) 
 Several army surgeons have informed rue, 
 that the undiluted nitrous acid was success- 
 fully used as an application to hospital gan- 
 grene in the military hospitals at Antwerp in 
 the year 1815; but that other strong acids 
 had an equally good effect. Dr. J. Thom- 
 son also notices, that “the application of 
 caustic substances, such as the strong mine- 
 ral acids, the solutions of potass, corrosive 
 sublimate, and arsenic, seemed at Antwerp 
 to arrest the progress of this sore, without 
 exciting inflammation.” ( Report of Obser- 
 xalions made in the Military Hospitals in Bel - 
 gium.) 
 
 Delpech was informed by some British 
 surgeons, belonging to the Angio-Portugueze 
 army in the Peninsula, that the muriatic 
 acid was in common use in the hospitals of 
 that army as a local application for checking 
 the ravages of hospital gangrene, being em 
 ployed in a diluted state for slight cases, and 
 in a concentrated caustic form for others. 
 
 In St. Bartholomew’s hospital , the undilu- 
 ted nitric acid has been used with great suc- 
 cess as a local application to phagedenic gan- 
 grenous ulcers, as may be seen by an inte- 
 resting paper recently published by Mr. Wel- 
 bank. (Med. Chir • Trans. Vol. 10.) 
 
 Pouteau, Dussasso) , Boyer, and Delpech, 
 all bear testimony to the efficacy of the ac- 
 tu<i; cautery, and they repeat the application 
 ©f it, until the whole surface of (he ulcer is 
 converted into a firm hard eschar. Even the 
 edges of the solution of continuity should not 
 be spa rad — ils duivent etre tor rifts et rolls 
 pour ainsi dire.” (Boyer, Trait 6 des Mala- 
 dies Chir. T. 1 ,p. 332.) The latter surgeon 
 then covers the eschar with a thick stratum 
 of bark moistened with turpentine. This 
 application is to be removed in twenty-four, 
 
 thirty-six, or forty-eight hours, and the sur- 
 geon is then to judge from the appearance 
 of the flesh, and the quality of the discharge, 
 whether a further repetition of the cautery 
 will be necessary. 
 
 Pouteau, QZurres Poslfiumes, T. 3, publish- 
 ed 1783. Dussassoy Dissertation et Observa- 
 tions sur la Gangrene des Hbpilaux , fy-c. 8vo, 
 Genive, 1788. Moreau et Burdin, Essai sur 
 la Gangrene Hu/nide des Hopilaux , 1796. 
 Observations on the Putrid Ulcer, by L. Gilles- 
 pie, in London Medical Journal, Vol. 6, 1785. 
 Rollo on Diabetes, 1797. Sir Gilbert Blanc 
 on the Diseases of Seamen , Ed 3 1797. Trot- 
 ter's Medicina JYauiica, Vols. 2 and 3, publish- 
 ed 1799. John Bell's Principles of Surgery r 
 Vol. 1,1801. Wolf Ploucquet, De G angr ve- 
 na sic dicta Nosocomiorum, Tub. 1802. Leslie , 
 De Gangreena Contagiosa. Edinb. 1804, 
 Johnston De Gangrcsn ■ oulag osa JVosocomi- 
 ale, Edinb. 1805. ./ Thomson's , ectures on 
 
 Inflammation, p. 456, et seq. Edinb. 1813, 
 and Report of Observations , made in the Mili- 
 tary Hospitals of Belgium , 8 ro. Edinb. 1816. 
 J. Hennen , Principles of Military Surgery, 
 p. 210, fyc. 8 vo. Edinb. 1820. C. J M. Lan- 
 genbeck, JYeue Bibl. 2 B. p. 611, fyc. Hano- 
 ver, 1820. Memoir e sur la Complication des 
 Plaies et des Ulc&res, connne sous le nom de 
 Pourrilure d'h6pital,par J. Delpech, 8vo. Pa- 
 ris, 1815. Also Precis Element air e dss Ma- 
 ladies Chir. T. 1, p.123, fyc. Paris 1816, 
 Brugmans und Delpech liber den Hospital- 
 brand , ubersezt mil Anmerkunvten und An hang 
 von Kieser, Jennal, 1815. Boyer, Traitd des 
 Maladies Chir. T. 1, p. 320, Paris, 1814. 
 Sketches of the Medical Schools of Paris by 
 J. Cross, p. 82, London , 1815. H. Home 
 Blackadder, Observations on Phagedcena Gan 
 greenosa, 8vo. Edinb. 1818, ivhich is unqu'es 
 tionably the best treatise on the subject , whether 
 his sentiment about the disease being always , 
 or nearly always, communicated by the direct 
 application of the infectious matter to the parts, 
 and not through the contagion in hie air, be 
 correct or not ; or whether his opinion about 
 the local nature of the disease in the beginning, 
 audits invariable commencement with the local 
 mischief , and not with constitutional symp- 
 toms, be liable to exceptions or not. The rest 
 of the subject of Gangrene is treated of in 
 , the article Mortification. 
 
 HYDRARGYRIA. A peculiar eruption 
 occasioned by the use of mercury, and na- 
 med in Dr. Bateman’s synopsis eczema ru- 
 brum (See Mercury.) 
 
 HYDROCELE, (trom deep, water, and 
 xhah, a tumour.) The term hydrocele, if 
 used in a literal sense, means any tumour 
 containing water; but. surgeons have always 
 confined it either to a collection of fluid in 
 the cellular membrane of the scrotum ; in a 
 cyst, or the common cellular texture, of 'he 
 spermatic cord ; or in the tunica vaginalis of 
 the testicle. 
 
 The celebrated Dr. Alexander Monro of 
 Edinburgh, and Mr. S. Sharp, were almost 
 the only writers, before Mr. Pott, who sensi- 
 bly and rationally explained the true nature 
 of these diseases. 
 
HYDROCELE. 
 
 12 
 
 ANASARCOUS TUMOUR OR THE SCROTUM : 
 
 The hydrocele by infiltration of French 
 writers; hydrocele cedematodes ; is most fre- 
 quently only a symptom of a dropsical habit, 
 and very often accompanies both anasarca 
 and the particular collection within the ab- 
 domen, called ascites. Mr. Pott describes 
 it as “ an equal, soft tumour, possessing every 
 part of the cellular membrane, in which both 
 the testicles are enveloped, and consequently 
 it is generally as iarge ori one side as on the 
 other ; it leaves theskin of its natural colour ; 
 or, to speak more properly, it does not red- 
 den or inflame it; if the quantity of water 
 be not large, nor the distention great, the 
 skin preserves some degree of rugosity ; the 
 tumour has a doughy kind of feel ; easily 
 receives, and for a while retains, the im- 
 pression of the fingers ; the raphe, or seam, 
 of the scrotum divides the swelling nearly 
 equally; the spermatic process is perfectly 
 free, and of its natural size , and the testicles 
 seem to be in the middle of the loaded mem- 
 brane. This is the appearance when the dis- 
 ease is in a moderate degree. But if the 
 quantity of extravasated serum be large, or 
 the disease farther advanced, the skin, in- 
 stead of being wrinkled, is smooth, tense, and 
 plainly show's the limpid state of the fluid un- 
 derneath : it is cold to the touch, does not 
 so long retain the impression of the finger, 
 and is always accompanied with a similar 
 distention of the skin of the penis ; the pre- 
 putiurn of which is sometimes so enlarged, 
 and so twisted and distorted, as to make a 
 verv disagreeable appearance. These are 
 the local symptoms: to which it maybe add- 
 ed, that a yellow countenance, a loss of appe- 
 tite, a deficiency of urinary secretion, swell- 
 ed legs, a bard belly, and mucous stools, are 
 its very frequent companions. 
 
 As the cellular membrane on one side of 
 the scrotum is a continuation of that which 
 is situated on the other, and both freely com- 
 municate ; the accounts delivered by certain 
 authors of the possibility of this species of 
 hydrocele being confined to one side of the 
 
 scrotum is not credited by some modern 
 surgeons. (See Did. des Sciences Med. T. 
 22 v 193.) At all events, such a case is 
 extremely rare, and, when it happens, is 
 probably induced by the irritation of be 
 urine in infants, or of tbe friction of the 
 clothes in old persons, only acting upon a part 
 of the scrotum ; for occasionally, though not 
 often, the disease is acknowledged to proceed 
 from these local causes. ( Vol . et loco cit.) 
 
 The cure of the original disease, when it 
 arises from constitutional causes, comes with- 
 in the province'of the physician, and requires 
 a course of internal medicine: hut sometimes 
 lhe loaded scrotum and penis are so trouble- 
 some to the patient, and in such danger of 
 mortification, that a reduction of their size 
 becomes absolutely necessary : and at other 
 limes, a discharge of ,he redund ? nt extrava - 
 ; a ted serum is ordered as an assistant to the 
 internal regimen. As Mr. Fott observes, the 
 means of making this discharge are two, viz. 
 puncture and incision: the former is made 
 
 with the point of a lancet; the latter with 
 the same instrument, or with a knife. Accord- 
 ing to the same author, and indeed every 
 man of experience, wounds in anasarcous, 
 or dropsical habits, are apt to inflame, very 
 difficultly brought to suppuration, and often 
 prove gangrenous, in spite of all endeavours 
 to the contrary. But the larger and deeper 
 the wounds are, the more probable are these 
 bad consequences. Simple punctures with 
 the point of a lancet, are much less liable to 
 be attended by them than any other kind of 
 wound ; they generally leave tbe skin easy, 
 soft, cool, and uninflamed, and in a state to 
 admit a repetition of the same operation if 
 necessary. Incisions create a painful, crude, 
 hazardous sore, requiring constant care. 
 Punctures seldom produce any uneasine s at 
 all ; and stand in need of only a superficial 
 pledget for dressing. 
 
 It is further explained by the same author, 
 that as the cavities of the cellular membrane 
 of the scrotum all communicate together, a 
 small puncture serves, as well as a large in- 
 cision, for the discharge of the fluid con- 
 tained in them, and consequently upon this 
 ground no reason exists for making any ex- 
 tensive, painful, and hazardous wound. 
 
 With respect to the practice of making 
 punctures, in cases of anasarcous hydrocele, 
 1 think that it should always be avoided as 
 much as possible, because it sometimes hap- 
 pens, that the slightest pricks of the lancet 
 occasion sloughing. The method should only 
 be adopted, when the distention of the skin 
 of the scrotum is such, as absolutely to re- 
 quire the fluid to be discharged. Care 
 should also he taken not to multiply the 
 punctures unnecessarily, nor to let them be 
 made too near together. (See Did. des Sci- 
 ences Med. T. 23, p. 195.) 
 
 When the oedematous state of the scrotum 
 is not the effect of a general constitutional 
 disease, but proceeds entirely from a local 
 cause, siicb as friction, or the irritation of 
 the urine, the mode of treatment consists in 
 the removal of the cause, the use of astrin- 
 gent lotions, and the exhibition of a dose of 
 salts. In elderly subjects, the wearing of a 
 bag-truss is recommended for the prevention 
 of the complaint. 
 
 HYDROCELE OF THE SPERMATIC CORl). 
 
 Is of two kinds; the first is described as 
 an (edematous affection, extending to more 
 or less of the cellular substance around the 
 spermatic vessels, and sometimes named the 
 encysted hydrocele of the cord ; the second 
 form of the disease is that in which the fluid 
 is collected in a particular cavity, or cyst, 
 which has no communication with the cavi- 
 ties of the common cellular substance of the 
 cord. This case is denominated according- 
 ly, the encysted hydrocele of the cord. That 
 the cellular membrane of the cord is often 
 distended with an aqueous fluid, when the- 
 scrotum is anasarcous and the habit dropsi- 
 cal, cannot admit of doubt, and hence it is a 
 frequent attendant on the case, which has 
 been described asthc hydrocele cedeirmtodor. 
 
HYDROCELE. 
 
 l 7-> 
 
 But as I have never seen au instance, in 
 which such disease was restricted to the cel- 
 lular texture of the cord, I am led to sup- 
 pose that it is a very uncommon case. The 
 following is said by Mr. Pott to be the stale 
 of the disease, while of moderate size. The 
 scrotal bag is free from all appearance of 
 disease ; except that when the skin is not 
 corrugated, it seems rather fuller, and hangs 
 lather lower on that side than on the other, 
 and if suspended lightly on the palm of the 
 hand, feels heavier: the testicle, with its 
 ©pididymus, is to be felt perfectly distinct 
 below this fulness, neither enlarged, nor in 
 any manner altered from its natural state : 
 the spermatic process is considerably larger 
 than it ought to be, and feels like a vanx, 
 or like au omental hernia, according to the 
 different size of the tumour : it has a kind of 
 pyramidal form, broader at the bottom than 
 «t the top : by gentle and continued pressure 
 it seems gradually to recede or go up, but 
 drops down again immediately upon remo- 
 ving the pressure; and that as freely in a 
 supine, as in an erect, posture : it is attend- 
 ed with a very small degree of pain or un- 
 easiness ; which uneasiness is not felt in the 
 scrotum, where the tumefaction is, but in 
 the loins. 
 
 “ If the extravasation be confined to what 
 is called the spermatic process, the opening 
 in the tendon of the abdominal muscle is not 
 at all dilated, and the process passing 
 through it may be very distinctly felt ; but 
 if the cellular membrane, which invests the 
 spermatic vessels within the abdomen, be 
 affected, the tendinous aperture is enlarged ; 
 and the increased size of the distended mem- 
 brane passing through it, produces to the 
 touch a sensation not very unlike that of 
 an omental rupture.” 
 
 While it is small, it is hardly an object of 
 surgery, and maybe kept from being trou- 
 blesome by means of a suspen&orv ; but 
 When it is large, it is very inconvenient both 
 from size and weight, and according to Pott, 
 the only method of cure which it admits, is 
 far from being void of hazard. The plan is 
 to make a free incision into the swelling, 
 it must be confessed, with a modern writer, 
 that these observations on the diffused hy- 
 drocele of the cord by Mr. Pott, are faf from 
 being satisfactory, and the symptoms, by 
 which he made up his mind to lay open 
 the disease, were but of an equivocal de 
 scription, and might have arisen from cases 
 of another nature. (See Did. dcs Sciences 
 Med. T 22, p. 215.) 
 
 the encysted hydrocele of the sperm a. - 
 
 TiC CORD 
 
 Is a complaint by no means infrequent, 
 especially in children, it was very well 
 known to many of the ancients, and has 
 been accurately described by Albucasis, Cel- 
 su>, Pauius iEgineta, &,c. When Mr. Pott 
 says, that the disease is not infrequent, it 
 ought to be understood, that its frequency, 
 though much greater, than that of the dif- 
 fused hydrocele of the cord, considered as 
 Vor . If. 10 
 
 a distinct disease independent of general 
 anasarca, is not at all equal to that of the 
 hydrocele of the tunica vaginalis. Riche- 
 rand has calculated, that the average pro- 
 portion of encysted hydroceles of the cord 
 to those of the latter description, is not more 
 than as 1 to 200. ( JYosogr . Chir T. 4, p. 
 262, Ed. 4.) According to Mr. Pott, the 
 swelling is mostly situated at the middle 
 part of the cord, between the testicle and 
 groin, and is generally of an oblong figure ; 
 whence it has by some peoplebeen compared 
 to an egg, by others to a fish’s bladder. Whe- 
 ther it be large or small, it is generally pretty 
 tense, and consequently the fluctuation of 
 the water within it, not always immediate- 
 ly or easily perceptible. It gives no pain, 
 nor (unless it be very large indeed) does it 
 hinder any necessary action, ft is perfectly 
 circumscribed ; and has no communication, 
 either with the cavity of the belly above, or 
 that of the vaginal coat of the testicle below 
 it. The testis and its epididymis, are per- 
 fectly and distinctly to be felt below the 
 tumour, and are absolutely independent of 
 it. The upper part of the spermatic process 
 in the groin is most frequently very distin- 
 guishable. The swelling does not retain the 
 impression of the fingers ; and when lightly 
 struck upon, sounds as if it contained wind 
 only. It undergoes no alteration from change 
 of the patient’s posture ; it is not affected 
 by his coughing, sneezing, &,c. and it has n» 
 effect on the discharge per anum. 
 
 The two diseases with which this kind of 
 hydrocele is most likely to be combined, 
 are, an hydrocele of the tunica vaginalis tes- 
 tis, and a true hernia. 
 
 “ One mark, or characteristic of an hydro- 
 cele of the tunica vaginalis testis is, that it pos- 
 sesses and distends the inferior part ofthe scro- 
 tum; and that thetesticle be iug nearly (though, 
 not absolutely) surrounded by the water, it. 
 very seldom happens that the former can be- 
 clearly and plainly distinguished by the fin- 
 gers of an examiner; whereas, in the en- 
 cysted collection, in the membranes of the 
 cord, the tumour is always above the tes- 
 ticle, which is obvious and plain to be felt 
 below it. 
 
 “ Another circumstance worth attending 
 to is, that although the fluid in a hydrocele 
 ofthe vaginal coat does so nearly surround 
 the testis as to render it often not very easy 
 to be distinguished, yet the different parts of 
 the tumour have always a very different feel : 
 for instance, in all those points where the 
 vaginal tunic is loose, and unconnected with 
 the tunica albuginea, the tumour is soft and 
 compressible, and gives a clear idea of the 
 contained fluid : but where these two coats 
 are continuous, or make one and the same 
 membrane, and have no cavity between 
 them (which is the case on the middle and 
 posterior part) there will always be found 
 a hardness and firmness very unlike to what 
 is to be found in ail those places where the 
 distance between the two tunics leaves room 
 for the collection of a fluid ; now -the hydro 
 cele of the cord being formed in the mere 
 cellular membrane of it, is the fame tolltf* 
 
"4 
 
 TlYDPiOCELE. 
 
 touch in all the parts of the tumour, and 
 feels like a distended bladder through every 
 point of it. 
 
 u The free state of the upper part of the 
 spermatic process, while the tumour is form- 
 ing below; the gradual accumulation of the 
 fluid, and consequently the gradual growth 
 ot the swelling ; the indolent and unaltering 
 state of it ; its being incapable of reduction, 
 or return into the belly from the first; its 
 being always unaffected by the patients 
 coughing or sneezing; and the uninterrupted 
 freedom of the fecal discharge per anum, 
 will always distinguish it from an intestinal 
 hernia ; and he who mistakes it for an omen- 
 tal one, must be very ignorant, or very 
 heedless.” 
 
 Mr. Pott met with an encysted hydrocele 
 situated so high toward the groin, as to ren- 
 der the perception of the spermatic vessels 
 very obscure, or even impracticable; but 
 then, the state and appearance of the testi- 
 cle, and the absence of every symptom pro- 
 ceeding from confinement of the intestinal 
 canal, were sufficient marks of the true na- 
 ture of the complaint. Several writers de- 
 scribe this kind of hydrocele, as in fact a 
 common encysted tumour, formed in the 
 cellular substance, between the vas deferens 
 and spermatic vessels. ( Delpech , Precis Elem. 
 dts Mai. Chir. T. 3,p. 464.) Yet, since or- 
 dinary encysted swellings are very difficult 
 to disperse, there is probably some differ- 
 ence between the two affections, at least, 
 if the observation of Mr. Pott be correct, 
 that in young children, the encysted hydro- 
 cele of the cord frequently dissipates in a 
 short time, especially if assisted by warm fo- 
 mentation, and an open belly. 
 
 If it be not absorbed, “ the point of a lan- 
 cet will give discharge to the water ; and in 
 young children, will most frequently pro- 
 duce a cure : but in adults, the cyst, formed 
 by the pressure of the fluid, does sometimes 
 become so thick, as to require division 
 through its whole length ; which operation 
 may in general be performed with great 
 case, and perfect safety.” Mr. Pott says, in 
 general, because it is most frequently so : 
 though he has even seen this, slight as it may 
 *eem, prove troublesome, hazardous, and 
 fatal. (See Pott on Hydrocele.) 
 
 The late Sir J. Earle proposed treating 
 this case in the same way as the hydrocele 
 of the tunica vaginalis, viz. by an injection 
 of red wine and water; which method is 
 often successful. (On Hydrocele , p. i 54, 
 edit. 2.) However, the cure of an encysted 
 hydrocele of the spermatic cord, by means 
 of an injection, is generally regarded by 
 modern surgeons, as less certain and advan- 
 tageous, than the excision of a part of the 
 cyst. The operation which is described by 
 Bertrandi, Mr. Hey, Richerand, &.c. consists 
 in cutting down to the cyst, and removing 
 the forepart of it, while the portion, closely 
 attached to the cord, is to be allowed to re- 
 main. For additional observations on this 
 species of hydrocele. (See the First Lines of 
 tltc Practice of Surgery , Vol. 2,p, 121.) 
 
 hydrocele of the tunica vaginalis. 
 
 If the quantity of limpid fluid, which na- 
 turally moistens the surface of the tunica 
 albuginea and the inside of the tunica vagi- 
 nalis, be secreted in an undue quantity, or 
 if regular absorption of it be by any mean3 
 prevented, it will gradually accumulate, and 
 distend the cavity of the latter membrane, 
 so as to form the present species of hydro- 
 cele. The case in which the fluid is sup- 
 posed to descend, either partly or entirely 
 from the cavity of the abdomen, in conse- 
 quence of the communication not being 
 shut up in the usual time, between the ca- 
 vity of the peritoneum and that of the tunica 
 vaginalis, is well known to surgeons under 
 the appellation of a congenital hydrocele ; 
 a disease, of which particular notice has 
 been taken in the 2d Vol. of the last edition 
 of the First Lines of Surgery , 8 vo. Lond. 1820, 
 and to which I shall therefore very briefly 
 advert in this article. Hydrocele of the 
 vaginal coat is a disease from which no 
 time of life is exempt ; not only adults are 
 subject to it, but young children are fre- 
 quently afflicted with it : and infants some- 
 times born with it. (Pott.) And it is re- 
 marked to be common in old men, and per- 
 sons who ride a good deal on horseback. 
 (Delpech Precis Elem. des Mai . Chir . T. 3 f 
 p. 177.) 
 
 The causes of hydrocele of the tunica 
 vaginalis can scarcely be said to be at all 
 understood ; and when Mr. Pott observes, 
 that whatever tends to increase the secre- 
 tion of fluid into the cavity of that mem- 
 brane, beyond the due and necessary quan- 
 tity, or to prevent its being taken up, and 
 carried off by the absorbent vessels must 
 contribute to the production of the disease, 
 nearly as much is stated, as can be advanced 
 with safety in the present state of our know- 
 ledge. Ruysch had a suspicion, that this 
 hydrocele might arise from a varicose state 
 of the spermatic veins ; but though Mr. Pott 
 acknowledges that these vessels are very 
 frequently found varicose in patients afflict- 
 ed with this disorder, he was unable to pro- 
 nounce what real foundation might exist 
 for the foregoing conjecture, or whether 
 the varicose state of the spermatic veins 
 were a cause, or an effect of the hydrocele. 
 In most instances, the accumulation of fluid 
 takes place without any evident cause ; 
 though, in a few cases, it has appeared to be 
 the effect of a contusion, or of rough long- 
 continued friction of (lie scrotum. The dis- 
 ease is observed to affect persons of the best: 
 health, and most robqst constitutions, as 
 well as others, and its existence seems quite 
 unconnected with dropsy, or debility. In 
 short, it may be regarded as a disease en- 
 tirely of a local nature. As Mr. Pott ob- 
 serves, its production is so slow and gradual, 
 and at the same time so void of pain, that 
 the patient seldom attends to it, until it has 
 arrived to some size. Not but that it some- 
 times is produced very suddenly ; and in a 
 very short space of time attains considerable 
 magnitude. 
 
HYDROCELE. 
 
 75 
 
 In general, at its first beginning, the tu- 
 mour is rather round ; but as it increases, it 
 frequently assumes a pyriform kind of figure, 
 vith its larger extremity downward ; some- 
 times it is hard, and almost incompressible ; 
 so much so, that, in some few instances, it 
 has been mistaken for an induration of the 
 testicle: at other times, it is so soft and lax, 
 that both the testicle, and the fluid surround- 
 ing it, are easily discoverable, it is perfectly 
 indolent in itself ; though its weight some- 
 times produces some small degree of un- 
 easiness in the back. According to Mr. 
 Pott, the transparency of the tumour is the 
 most fallible and uncertain sign belonging 
 to it : it is a circumstance, says he. which 
 does not depend upon the quantity, colour, 
 or consistence of the fluid constituting the 
 disease, so much as on the uncertain thick- 
 ness, or thinness of the containing bag, 
 and of the common membranes of the scro- 
 tum. 
 
 If they are thin, the fluid limpid, and the 
 accumulation made so quick as not to give 
 the tunica vaginalis time to thicken much, 
 the rays of light may sometimes be seen to 
 pass through the tumour : but this is accident- 
 al, and by no means to be depended upon. 
 The fluid is most frequently of a pale yellow, 
 or straw-colour ; sometimes it is inclined 
 to a greenish cast ; sometimes it is dark, tur- 
 bid, and bloody ; and sometimes it is per- 
 fectly thin and limpid. 
 
 With respect to Mr. Pott’s remarks on the 
 transparency of the swelling, as a symptom 
 of hydrocele, they are correct, inasmuch as 
 the absence of this sign is no proof, that the 
 disease is not of this nature ; since thickness 
 of the tunica vaginalis, and, as ought also 
 to have been admitted, the opaque quality 
 of the fluid, sometimes prevent the rays of 
 a candle from passing through the swelling. 
 But, on the other hand, it should have been 
 explained by Mr Pott, that when the transpa- 
 rency is present, it is one of the surest marks of 
 this species of hydrocele. 
 
 It is next noticed by Mr. Pott, that in the 
 beginning of the disease, if the water has ac- 
 cumulated slowly, and the tunica vaginalis 
 is thin and lax, the testicle may easily be 
 perceived ; but if the said tunic be firm, or 
 the water accumulated in any considerable 
 quantity, the tetis cannot be felt at all. In 
 most cases, the spermatic vessels may be 
 distinctly felt at their exit from the abdomi- 
 nal muscle, or in the groin ; which will al- 
 ways distinguish this complaint from an in- 
 testinal hernia. But, in a few examples, the 
 vaginal coat is distended so high, and is so full 
 that it is extremely difficult, nay, almost im- 
 possible, to feel the spermatic cord: and the 
 same kind of obscurity is sometimes occa- 
 sioned by the addition of an encysted hydro- 
 cele of the cord ; or by the case being com- 
 bined with a true enterocele. 
 
 in a hydrocele of the tunica vaginalis, the 
 swelling is first noticed at the lower part of 
 the scrotum, whence it ascends in front of 
 the testicle and spermatic cord. The pro- 
 gress of the disease is generally so slow, 
 *hat six or even eighteen months elapse, be- 
 
 fore the tumour approaches the abdominal 
 ring. And, among other characters of the 
 case, are to be noticed the disappearance of 
 the corrugations of the scrotum by the effect 
 of the distention ; inclination of the raphe 
 to the opposite side ; and the possibility of 
 feeling a fluctuation, when (lie fingers of one 
 hand are applied to one side of the tumour, 
 and the surgeon slightly taps with the fingers 
 of his other hand upon an opposite point of 
 the swelling. 
 
 In the hydroceles of children, the testis 
 occupies a lower situation, than the the same 
 organ in the hydroceles of adult persons, 
 and the swelling passes further up towards 
 the abdominal ring. 
 
 It is well explained by Mr. Pott, that the tu- 
 nica vaginalis and tunica albuginea, are so 
 inseparably united at the posterior and supe- 
 rior, or rather the posterior and middle 
 part of the tumour, that no fluid can collect 
 between them ; and therefore, the fingers 
 of an intelligent examiner must immediately 
 discover here the firmness and hardness 
 arising from the union of these parts; while 
 in all others, the two membranes being un- 
 connected, and affording a void space for 
 the collection of water, the fluctuation of it 
 will always be distinguishable. 
 
 “ This (says Pott) must for ever discrimi- 
 nate the simple hydrocele of the tunica va- 
 ginalis from the anasarcons swelling of the 
 scrotum ; from the encysted hydrocele of 
 the cord ; and from the intestinal hernia. 
 The first is every where equal, tumid, and soft; 
 and every where equally receives and retains 
 the impression of the fingers , the second, 
 though circumscribed, not very compressi- 
 ble, and affording the sensation of fluctuation, 
 yet does not pit, and is alike to the touch in all 
 parts of it ; and in the third, if the testicle 
 be distinguishable at all, it is found at the 
 inferior part of the whole tumour.” 
 
 A collection of fluid in the tunica vagina- 
 lis, complicated with a scirrhous or chronic 
 induration and enlargement of the testicle, 
 is well known under the name of hydro-ca r> 
 cocele ; a case, which should be carefully 
 discriminated from a simple hydrocele, “ one 
 of the marks of the latter being the natural, 
 soft, healthy state of the testicle : and the 
 characteristic of the former being its disea- 
 sed and indurated enlargement.” 
 
 Mr. Pott does not mean that, in a true 
 simple hydrocele, the testicle is never altered 
 from its natural state. He admits the con- 
 trary, and that it is often enlarged in size, 
 and relaxed in structure, and that the sper- 
 matic vessels are frequently varicose. But, 
 the testicle is never indurated. These two 
 diseases are extremely unlike each other, and 
 require very different treatment. That 
 which would cure a simple hydrocele, would 
 dangerously aggravate the hydro-sarcocele. 
 
 Mr. Pott observes, that “ it may, and does 
 sometimes become necessary to let out the 
 water from the vaginal coat of a testicle, in 
 some degree diseased ; but this should al- 
 ways be done with caution, and under a 
 guarded prognostic ; lest the patient be not 
 only disappointed, by not having that per- 
 
76 
 
 HYDROCELE. 
 
 manent relief, which, foT* want of better in- 
 formation, he may be induced to expect ; 
 but be also (possibly) subjected to other un- 
 expected inconveniences from the attempt. 
 
 “ When the disease is a perfect, true, sim- 
 ple hydrocele, the testicle, though frequently 
 somewhat enlarged, and perhaps loosened 
 in its vascular texture, is nevertheless sound, 
 healthy, and capable of executing its proper 
 office ; neither is the spermatic cord any 
 way altered from a natural state, except that 
 its vessels are generally somewhat dilated ; 
 neither of which circumstances are objec- 
 tions either to the palliative or radical cure 
 of the disease. But in those disorders, 
 which in some degree resemble this, the 
 case is different ; either the testicle, or sper- 
 matic cord, or both, bearing evident marks 
 of a diseased state.” 
 
 According to Richerand, a hydrocele may 
 be known from a sarcocele by the following 
 circumstances: in a sarcocele, the tumour 
 mostly retains the shape of the testicle, being 
 oval and a little flattened at the sides, and its 
 size becomes considerable in a short time, 
 without ascending so near the abdominal 
 ring, as a hydrocele does, when of the same 
 magnitude. A large hydrocele leaves no 
 interspace between that opening and the 
 tumour, so that it is difficult to take hold of, 
 and lift up the spermatic cord ; but, in a sar- 
 cocele, there is always a space between the 
 tumour and the ring, where the cord can be 
 distinctly felt. Lastly, in a sarcocele, the 
 tumour is always opaque, and its weight, in 
 reference to its size, much more consider- 
 able, than that of a hydrocele. ( JYosogr . 
 
 Chir. T. 4, p. 267, Ed. 4.) The hardness is 
 not a symptom which can be trusted alone, 
 as a criterion of a diseased testicle ; for, 
 when a hydrocele is extremely distended, it 
 ©ften feels so indurated as to deceive prac- 
 titioners of great experience, and a thick- 
 ened, hardened state of the tunica vaginalis 
 may facilitate the mistake. In some instan- 
 ces of hydro-sarcocele, the nature of Ike dis- 
 ease sometimes remains questionable, until 
 the evacuation of the fluid gives the surgeon 
 a fair opportunity of ascertaining the disea- 
 sed state of the testicle. 
 
 The complication of an hydrocele of the 
 tunica vaginalis with an encysted one of 
 the spermatic cord, may generally be known 
 by the swellings having begun at two differ- 
 ent points, and by a kind of constriction be- 
 tween them. The latter symptom, however, 
 is not infallible, because the tunica vaginalis 
 of a common hydrocele is sometimes more 
 or less contracted at the middle of the tu- 
 mour, which is thus made to appear as if 
 there were two distinct pouches. 
 
 The size of a hydrocele, and the thick- 
 ness of the tunica vaginalis, are generally 
 5 , a ratio to the time, which thejdisease has con 
 tinued. Sometimes the latter membrane 
 acquires nearly a cartilaginous hardness; 
 and portions of it have been found in an 
 ossified state ; the only circumstance, in 
 which any free excision of it is now account- 
 ed, necessary. A hydrocele has been known 
 
 to contain foul* pints of fluid. (V riglel, 
 
 Jlandbueh der Pract. Jinat. B. 3, p. 388.) 
 
 METHODS OF CURING THE HYDROCELE OF THE 
 VAGINAL COAT. 
 
 A hydrocele is by no means a dangerous 
 complaint, though its weight and size are a 
 disagreeable incumbrance, and the patient 
 is always obliged to wear a bag truss, in 
 order to prevent a painful extension of the 
 spermatic cord. Troublesome excoriations 
 are also frequently caused by the friction of 
 the tumour against the inside ot the thigh ; 
 and when the swelling is very large, it draws 
 over itself the integuments of the penis, 
 w hich appears buried, as it were, in the tu- 
 mour, and its functions are seriously inter- 
 rupted. Hence, the greater number of 
 patients are very anxious for relief. 
 
 “ The methods of cure (says Pott) though 
 various, are reducible to two, (viz.) the pallia- 
 tive, or that which pretends only to relieve 
 the disease in present, by discharging the 
 fluid ; and the radical, or that which aims 
 at a perfect cure, without leaving a possibi- 
 lity of relapse. The end of the former is 
 accomplished by merely opening the con- 
 taining bag in such manner as to let out 
 the water : that of the latter cannot be ob- 
 tained, unless the cavity of that bag be abo- 
 lished, and no receptacle for a future accumu - 
 lation left ; (a proposition, on which the ob- 
 servations of Mr. Ramsden and Mr. Wadd, 
 published since Mr. Pott’s time, have thrown 
 a degree of doubt.) One may be practised 
 at all times of the patient’s life, and in almost 
 any state of health and habit : the other lies 
 under some restraints and prohibitions ; ari- 
 sing from the circumstances of age, constitu- 
 tion, slate of the parts, &.c. 
 
 “ The operation, by which the fluid is let 
 out, is a very simple one. The only circum 
 stances requiring our attention in it, are, the 
 instrument wherewith we w r ould perform 
 it ; and the place or part of the tumour, into 
 which such instrument should be passed. 
 
 u The two instruments in use, are the com- 
 mon bleeding-lancet, and the trocar. 
 
 “The former having the finer point, may 
 possibly pass in rather the easier, (though 
 the difference is hardly perceptible) but is 
 liable to inconveniences, to which the latter 
 is not. The trocar, by means of its cannula, 
 secures the exit of the whole fluid without 
 a possibility of prevention ; the lancet can- 
 not. And therefore it frequently happens 
 when this instrument is used, either that 
 some of the water is left behind, or that 
 some degree of handling and squeezing is 
 required for its expulsion ; or, that the in- 
 troduction of a probe, or a director, or some 
 such instrument, becomes necessary for the 
 same purpose The former of these may in. 
 some habits be productive of inflammation . 
 the latter prolongs what would otherwise 
 be a short operation, and multiplies the ne- 
 cessary instruments ; which, in every ope- 
 ration in surgery, is wrong. To which it 
 may be added, that if any of the fluid be 
 left in the vaginal coat, or insinuates itself 
 
HYDROCELE, # 
 
 into the celte of the scrotum, the patient 
 will have reason to think the operation im- 
 perfect, and to fear, that he shall not reap 
 even the temporary advantage which he 
 expected. The place where this puncture 
 ought to be made, is a circumstance of 
 much more real consequence ; the success 
 of the atiempt, the case, and even some- 
 times the safety of the patient, depending 
 upon it. 
 
 “ All the anterior and lateral parts of the 
 vaginal coat are loose and detached from 
 the albuginea ; in its posterior and superior 
 part, these two tunics make one ; conse- 
 quently the testicle is, as it were, affixed to 
 the posterior and superior part of the cavity 
 of the sac of an hydrocele ; and conse- 
 quently, the water or fluid can never get 
 quite round it. This being the state of the 
 case, the operation ought always to be per- 
 formed on that pari of the tumour, where 
 the two coats are at the greatest distance 
 from each other, and w here the fluid must 
 therefore be accumulated in the largest 
 quantity ; and never on that part of it where 
 the fluid cannot possibly be. The conse- 
 quence of acting otherwise, must not only 
 produce a disappointment, by not reaching 
 the said fluid ; but may prove, and has pro- 
 ved, highly and even fatally mischievous 
 to the patient. 
 
 “ After performing this operation, present 
 practitioners content themselves with a bit 
 of lint and a plaster; and if the scrotum 
 has been considerably distended, they sus- 
 pend it in a bag truss ; and give the patient 
 no farther trouble. 
 
 “ In most people (continues Pott) the 
 orifice thus made heals in a few hours, (like 
 that made for blood-letting ;) but in some 
 habits and circumstances, it inflames and 
 festers ; this festering is generally superfi- 
 cial only, and is soon quieted by any sim- 
 ple dressing ; but it sometimes is so consi- 
 derable, and extends so deep, as to affect 
 the vaginal coat, and by accident produce 
 a radical cure. Mr. Pott has also, seen it 
 prove still more? troublesome, and even fa- 
 tal ; but then the circumstances both of 
 the patient, and of the case, have been par- 
 ticular. 
 
 “ Wiseman and others have advised de- 
 ferring the puncture, till a pint of fluid has 
 collected. When there is a sufficient quan- 
 tity, however, to keep the testicle from the 
 instrument, there can be no reason for de 
 ferring the discharge ; and the single point 
 on which this argument ought to rest, is 
 this : Whether the absorbent vessels, by 
 which the extravasation should be prevent- 
 ed, are more likely to reassume their office, 
 while the vaginal coat is thin, and has suf- 
 fered but little violence from distention ; 
 or after it has been stretched and distended 
 to ten or perhaps twenty times its natural 
 capacity ; and by such distention is (like all 
 other membranes) become thick, hard, and 
 to idi ? Mr. Pott thinks the probability so 
 much more on the side of the former, that 
 he should never hesitate a moment about 
 Getting out the water, as soon as be found 
 
 that the puncture could be made securely. 
 And from what has happened within the 
 small circle of his own experience, he is in - 
 clined to believe, that if it was performed 
 more early than it generally is. it might 
 sometimes prevent the return of the disease.’' 
 
 Ihe foregoing passage deserves to be par- 
 ticularly recollected, because it evidently 
 implies a belief by Mr. Pott himself, that, 
 under certain circumstances, a radical cure 
 may be effected, though the cavity of the 
 tunica vaginalis be not obliterated ; an 
 opinion since promulgated, as I have already 
 said, by Mr. Ramsden, Mr. Wadd, and Mr. 
 Kinder Wood, indeed, itappears probable, 
 that generally when a hydrocele is perma- 
 nently cured, by means of such external ap- 
 plications, as do not excite inflammation, 
 but operate by quickening the action of the 
 absorbent vessels, the cavity of the tunica 
 vaginalis is not destroyed ; and there cau 
 be but little doubt of the same thing, when- 
 ever what is termed a spontaneous cure 
 happens, as it sometimes does in young sub- 
 jects. But, unless the fact were demonstrated 
 by dissection, I should not believe that the 
 cavity is not annihilated, after the comple- 
 tion of a radical cure by any of the methods, 
 calculated to excite inflammation of tho 
 tunica vaginalis and tunica albuginea. 
 
 The palliative cure should in general be 
 performed at least once on those, who de- 
 termine to undergo a radical one, as it gives 
 an opportunity of examining the state of 
 the testis, and also of permitting the cavity 
 to be filled again only to such a size, as 
 may bethought to be best calculated to en- 
 sure success in any future operation. (Sir 
 J. Earle on Hydrocele, p. 13, ed. 2.) 
 
 Upon, the subject of performing the opera- 
 tion of tapping hydroceles, Professor Scar- 
 pa gives us some useful cautions. The 
 analogy, which exists between large scrotal 
 herniae and hydroceles of considerable size, 
 led this writer to suspect, that, irr the latter 
 disease, the displacement and separation of 
 the vessels of the spermatic cord from each 
 other might also happen. Careful invest! 
 gations, made upon the dead subject, fully 
 justified the conjecture. In all considerable 
 hydroceles, he found the spermatic vessels 
 so displaced and separated, that the artery 
 and vas deferens were ordinarily situated on 
 one side of the tumour, and the veins on the 
 other. Sometimes these vessels all extend- 
 ed over the lateral parts of the tumour, as 
 far as its anterior surface, principally towards 
 the bottom. 
 
 It is well known, that in many instances, 
 the operation of puncturing a hydrocele 
 has been followed by a large extravasation 
 of blood within the tunica vaginalis; but 
 Scarpa informs us, that until lately, he was 
 unacquainted with any case of this kind, 
 which was well detailed and authentic 
 enough, to be cited as an example of injury 
 of the spermatic artery in the puncture of 
 a hydrocele. This learned Professor, how- 
 ever, has had such a fact recently commu- 
 nicated to him by Gasparoli, a distinguished 
 surgeon of Pallanza, who, in introducing 
 
HYDROCELE. 
 
 *3 
 
 the trocar into the lower part of the swell- 
 ing, had the misfortune to injure the sper- 
 matic artery, and the patient was after- 
 ward castrated. The wound of this vessel 
 Was most clearly proved by the particulars 
 of the case, as detailed in Scarpa’s work, 
 to which I must refer the reader. 
 
 From the accurate knowledge, (says 
 Scarpa) which we now have upon this pa- 
 thological point, such an accident may be 
 avoided, by observing the rules, which are 
 elsewhere given for opening the sac of a 
 very large scrotal hernia. In this last ope- 
 ration, as well as that of puncturing an old 
 and voluminous hydrocele, care must be ta- 
 ken to introduce the instrument at a consi- 
 derable distance from the bottom of the tu- 
 mour, that is to say, a little below its mid- 
 dle part, and on a line, which would divide 
 the swelling longitudinally into two perfect- 
 ly equal parts. Experience proves, that 
 for the purpose of completely emptying an 
 hydrocele, it is unnecessary to make, the 
 puncture very near the bottom of the tu- 
 mour. The corrugation of the scrotum, 
 and a slight pressure, made by the surgeon’s 
 hand, will suffice for discharging all the 
 fluid contained in the tunica vaginalis, even 
 when the puncture is made at the middle 
 part of the swelling. ( Scarpa , Traits des 
 Hernies, p. 64 — 68.) On account of the 
 lower situation of the testicle in the hydro- 
 cele of a child, than in that of a grown-up 
 erson, these directions of Scarpa will also 
 e of value. 
 
 RADICAL CURE OF THIS HYDROCELE. 
 
 Besides the employment of external ap- 
 plications, wherewith a permanent cure has 
 occasionally been accomplished, as related 
 in my other work, six different operations 
 have been practised for the same purpose ; 
 Yiz. incision ; excision ; the application of 
 caustic ; the introduction of a tent ; the 
 employment of a seton, and injecting some 
 stimulating fluid into the cavity of the tuni- 
 ca vaginalis. 
 
 The principle, on which the success of 
 every plan of this kind is commonly be- 
 lieved to depend, is the excitement of such 
 a degree of inflammation in the tunica vagi- 
 nalis, and tunica albuginea, forming the ca- 
 vity which contains the water, as shall end 
 in a mutual and general concretion of those, 
 membranes with each other, by which it is 
 evident, the receptacle for a future accu- 
 mulation of fluid is completely obliterated. 
 
 All the above plans are not equally eligi- 
 ble. Some of them, indeed, are now quite 
 exploded ; and some, which are still practi- 
 sed by a few, are not more successful, 
 though certainly more severe, than one, 
 which will be presently recommended ; 
 while others are very uncertain in their ef- 
 fect, as well as painful. 
 
 Incision. 
 
 Making an incision so as to lay open the 
 cavity containing the fluid, is the most an- 
 cient method, being described by Celsus. 
 T*aulus jEgineta says, the incision is to com- 
 
 mence at the middle of the tumour, and 
 be carried to the upper part of it, in a line 
 parallel to the raphe. This incision is on- 
 ly to go through the integuments ; the bag, 
 which contains the water, is then to be 
 opened, and part of the sides of the sac ta- 
 ken away. A director is next to be intro- 
 duced, and a division of the tunica vaginalis 
 made to the bottom of the swelling. The 
 cavity is afterward to be dressed with lint, 
 and healed by granulations. Hildanus, Do- 
 donaeus, Wiseman, Cheselden, Heister, and 
 Sharp, all coincide instating the dangerous 
 and even fatal consequences sometimes fol- 
 lowing this mode. Mr. B. Bell, who pre- 
 ferred this operation to every other one, 
 acknowledges, that he has seen it produce 
 great pain and tension of the abdomen, in- 
 flammation, and fever. Pott observes, that 
 it can never be said to be totally void of 
 danger, and that it bears the appearance of 
 an operation of some severity. This emi- 
 nent surgeon abandoned the method, du 
 ring the last twenty-six years of his life. 
 Severe as it is, it has also been known to 
 fail, as Sabatier and Earle have confirmed. 
 
 Excision. 
 
 Albucasis gave the first clear accouut of 
 this operation, though Celsus has certainly 
 mentioned removing some of the sac. 
 White and Douglas used to adopt this me- 
 thod. The latter advises making two in- 
 cisions, so as to form an oval, from the up- 
 per to the lower part of the tumour ; dis- 
 secting off the oval piece of the scrotum, 
 and then making an opening into the sac, 
 and enlarging it with scissors. The tunica 
 vaginalis was next to be entirely cut away, 
 close to where it was connected with the 
 spermatic vessels. The cavity was afterward, 
 filled with lint. Sir James Earle justly noti- 
 ces, that this plan must have been tedious, ex- 
 quisitely painful in the performance, and, 
 as subsequently treated, attended with vio- 
 lent and dangerous symptoms. In modern 
 days, excision is only sanctioned, when the 
 tunica vaginalis is more or less in an ossifi- 
 ed state, for a mere thickening of it does not 
 prevent the success of milder plans of 
 treatment. With respect to a mode of ex- 
 cision, recently proposed by Mr. Kinder 
 Wood, it differs entirely from the ancient 
 method, inasmuch as it is perhaps the mild- 
 est of every plan yet suggested for the ra- 
 dical cure, since it simply consists in punc- 
 turing the hydrocele with an abscess lan- 
 cet, drawing out a little bit of the sac with 
 a tenaculum, and cutting it off. (See Med. 
 Cfiir. Trans. Vol. 9, p. 33.) But, further ex- 
 perience is requisite to determine, whether 
 this very easy plan is as certain as that with 
 an injection. Whether the cavity is oblite- 
 rated or not, as Mr. Kinder Wood himself 
 believes, appears also still questionable. 
 
 Caustic. 
 
 Paulus JF.gineta advises destroying the 
 skin with a cautery of a particular form, 
 dissecting off the eschar, and then cauterizing 
 the exposed membrane. Guido di Cauliaco 
 
HYDROCELE. 
 
 •79 
 
 is, perhaps, the first who described the ap- 
 plication of caustic for the cure of hydro- 
 cele. Wiseman practised this method. 
 Dionis advises it ; but De la Faye and 
 Garengeot make objections to it. Mr. 
 Else has left the best account of the manner 
 of using caustic. He recommends laying 
 “ a small caustic upon the anterior and in- 
 ferior part of the scrotum, which it is intend- 
 ed to affect, and, if possible, penetrate 
 through the tunica vaginalis.” 
 
 The objections to the employment of 
 caustic are, its causing an unnecessary 
 destruction of parts, and producing a tedious 
 painful sore. The action of caustic can 
 never be so regulated as to make an opening 
 with certainty through the tunica vaginalis, 
 so that either its application must sometimes 
 be repeated, or else a lancet, or trocar, used 
 after all. Its success is also less sure, than 
 that of an injection ; but, it is preferable to 
 all the other methods, except this latter, the 
 modification of excision proposed by Mr. 
 K. Wood, and, perhaps, the seton. 
 
 Tent. 
 
 This is first mentioned by Franco. The 
 operation consists in making ah opening 
 into the tunica vaginalis, and keeping the 
 wound open with a tent of lint, linen, or 
 sponge, so as to make the cavity suppurate, 
 in which the water was contained. Pare, 
 15 uilleman, Covillard, Ruysch, Heister, and 
 Marini, have all described the plan with 
 some variations, one of which consisted in 
 smearing the tents with irritating substances. 
 Dr. A. Monro senior devised the plan of 
 keeping a cannula in the tunica vagmaiis ; 
 so as to bring on a cohesion ot the parts 
 without suppuration. Fabricius ab Aqua- 
 pendente, however, has made allusion to 
 some surgeons before his time, who used to 
 keep the wound open a few days with a 
 cannula. Mr. Pott tried the cannula, but 
 found it very inconvenient, as its inflexibili- 
 ty hurt the testis whenever the patient mo- 
 ved with inattention, and consequently, 
 he preferred a tent, or bougie, though he 
 speaks of the plan as a very uncertain one. 
 
 Of late, Baron Larrey, in consequence of 
 having seen several instances, in which the 
 symptoms, following the use of an injec- 
 tion, were violent, and one case, in which 
 a fatal peritonitis was produced, has recom- 
 mended exciting the necessary degree of 
 inflammation by keeping a short piece of an 
 elastic gum catneter in the puncture, which 
 instrument also serves afterward to let any 
 fluid escape from the tunica vaginalis. 
 (Mem. de Chir. Militaire, T. 3, p. 109, &pc.) 
 This author, of course, speaks of the plan as 
 having fully answered his expectations ; 
 but, 1 much doubt whether it has any parti- 
 cular superiority over several of the former 
 methods of employing the tent; methods, 
 which the wisdom, arising from experience, 
 has long since rejected', 
 
 Seton 
 
 Was first mentioned by Guido di Cauliaco, in 
 1498, as a means of curing the hydrocele. 
 
 In modern times, Pott preferred it to everv 
 other method, if we except injection, of 
 which, according to Sir J. Earle, he express- 
 ed his approbation before his decease. Mr. 
 Pott found, that the best mode of making 
 the seton was as follows. He employed, 
 three instruments: the first was a trocar, the 
 cannula of which was about one-fourth of 
 an inch broad. The second was what he 
 called the seton-cannula, which was made 
 of silver, was just small enough to pass with 
 ease through the cannula of the trocar, and 
 five inches long. The third instrument was 
 a probe six inches and a half long, having at 
 one end a fine steel trocarppint, and, at the 
 other, an eye, which carried the seton. The 
 seton consisted of so much white sewingsilk, 
 as would just pass easily through the cannu- 
 la, arid yet fill it. The thickness of the 
 seton, however, was not so great in the lat- 
 ter part of his practice. Having pierced the 
 inferior and anterior part of the tumour 
 with the trocar, withdrawn the perforator, 
 and discharged the water, Mr. Pott used to 
 pass the seton-cannula throm h that of the 
 trocar, to the upper part of the tunica vagi- 
 nalis, so as to be felt there. The probe, 
 armed with the seton, w r as next conveyed 
 through the latter cannula, a id its point 
 pushed through the upper part of the tunica 
 vaginalis, and scrotum. The silk was then 
 draw n through the cannula, until asulficient 
 quantity was brought out of the upper orifice. 
 The two cannula being withdrawn, the ope- 
 ration was finished. 
 
 Injection. 
 
 Dr. Monro attributes the first use of injec- 
 tions for the radical cure of hydroceles to an 
 army-surgeon of his own name, who em- 
 ployed spirits of wine. This produced a 
 cure, but the inflammation was so violent, 
 that he afterward tried a milder injection, 
 which consisted of wine. However, Lam- 
 bert, in his (Euvres Chir. published at Mar- 
 seilles early in the seventeenth century ad- 
 vised injecting a solution of sublimate in 
 lime water, and he has related cases of suc- 
 cess. Mr. 5 . Sharp also made trial of spirit 
 of wine, which cured the hydrocele, but not. 
 without causing dangerous symptoms, and 
 two subsequent abscesses in the scrotum. 
 (Operations of Surgery.) Douglas, Le Dran, 
 and Pott, all disapprove of injections in their 
 works ; though Sir James Earle informs us, 
 that the latter lived to alter his opinion on 
 the subject. 
 
 The violence of the inflammatory symp- 
 toms, consequent to the first employment of 
 injections for the radical cure of hydroceles, 
 arose from the fluids used being too irrita- 
 ting. Sir James Earle, at last, preferred 
 wine for several reasons. He found, that 
 it had been used with success in France ; 
 its strength is never so great as to render it 
 unsafe ; and it may be readily weakened. 
 This injection, in short, produces less pain 
 than any other mode of cure, does nothing 
 more than is intended, and is as certain 
 as any plan. 
 
 I have commonly used ('says Sir James 
 
HYDROCELE; 
 
 80 
 
 Earle) about two-thirds of wine to one- 
 third of water; if the parts appeared in- 
 sensible, and no pain at all was produced by 
 the first quantity thrown in, I have with 
 drawn the syringe, and added to the propor- 
 tion of wine ; on the contrary, if the corn- 
 plaint was recent, and the parts irritable, I 
 have increased the proportion of water, so 
 that 1 have hitherto been principally guided 
 by the degree of sensation, which the pa- 
 tient has expressed. I have lately used pure 
 water mixed with wine, and found it answer 
 as well as when astringents were added/’ 
 
 ( P • 103, Treatise on the Hydrocele, Ed. 2.) In 
 the preface, the author says, that he has 
 long disused the pipe with a stop-cock, 
 which he once employed, on account of not 
 being well able to spare a hand, during the 
 operation, to turn it, and its consequently 
 being found awkward. A pipe, one end of 
 which is made to fit into the cannula ot a 
 trocar, the other adapted to receive the neck 
 ot an elastic bottle, with a valve, or ball, in 
 the centre of the pipe to permit the en- 
 trance, and prevent the exit, of the injection, 
 will be found infinitely more convenient and 
 useful. (Earle.) When the hydrocele is 
 very large, Sir James recommends simply 
 letting out the fluid, and waiting till the tu- 
 mour acquires a more moderate size before 
 attempting the radical cure by injection. 
 
 It appears from Sir James Earle’s interest- 
 ing cases, that a cure may be accomplished 
 in this manner, even when the tunica vagi- 
 nalis is considerably thickened. The follow- 
 ing is the common mode of operating ; the 
 hydrocele is to be tapped with a trocar at its 
 anterior and inferior part, and, when the 
 whole of the fluid is evacuated, the cavity of 
 the tunica vaginalis is to be distended to its 
 former dimensions with the above injection. 
 Thfs is to be allowed to remain in the part 
 about five minutes, upon the average, after 
 which it is to be discharged through the can- 
 nula. The patient usually feels some pain 
 in the groin, and about the kidneys, on the 
 injection being introduced : which symptoms 
 are rather desirable, as they evince that the 
 stimulus of the fluid is likely to have the 
 wished-for effect of exciting the necessary 
 degree of inflammation. This plan, which 
 was brought to a high pitch of perfection by 
 the late Sir James Earle, may be deemed 
 almost an infallible means of obtaining- a 
 permanent cure; and being, at the same time, 
 mild, is mostly preferred in England, France, 
 and Germany. 
 
 The treatment after the operation is exactly 
 like that of the common swelled testicle, 
 (see Hernia Humoralis,) consisting of the 
 use of fermentations, poultices, leeches, 
 saline purges, and, above all, of a bag truss 
 for keeping up the scrotum. 
 
 There is a particular case, that has been 
 called the congenital hydrocele, by which is 
 implied a collection of water in the tunica 
 vaginalis, w ith a communication between the 
 cavity of this membrane and that of the peri- 
 tonaeum. Desault used to cure this disease, 
 by a red wine injection. After the protruded 
 viscera had been returned into the belly, and 
 
 w f hile the opening between that and the in-' 
 side of the tunica vaginalis was carefully 
 compressed and closed 1 by a trusty assistant, 
 Desault, after letting out the water in the 
 common way, used to throw in the injection. 
 The method, it is said, succeeded without 
 causing the perilous consequence, one might 
 a priori expect, viz. inflammation of the 
 peritonaeum. 
 
 This kind of hydrocele has not been des- 
 cribed by many writers. The case is easily 
 distinguished by the fluid being capable of 
 being pushed into the belly. According to 
 Desault, this disease admits of a cure by in- 
 jections, care being first taken to press the 
 upper part of the cord, so as to keep the in- 
 jection from coming into contact with the 
 peritonaeum. A successful instance of this 
 practice is related, by which a boy was 
 cured both of a congenital hydrocele and 
 hernia. The patient was nine years old, 
 and had in his scrotum, ever since he wa3 
 born, a fluctuating semi-transparent tumour, 
 which was free from pain, of the size of a 
 large egg, and disappeared when compressed^ 
 and in a horizontal posture. (See (Euvres 
 Chir dc Desault, T 2, /v. 442.) 
 
 This subject of congenital hydrocele has 
 been more particularly considered in my 
 other work. 
 
 One caution it is necessary to offer, before 
 taking our leave of this subject ; it has some- 
 times happened, duringthe operation, thatthe 
 cannula has slipped out of the tunica vaginalis, 
 and its inner mouth become situated in the 
 substance of the scrotum, in which event 
 the operator, if he persists in propelling in 
 the injection, will fill the cellular texture of 
 the part with a stimulating fluid, which may 
 cause sloughing, and other unpleasant symp- 
 toms, wdtbout entering the cavity of the tu- 
 nica vaginalis, or producing a radical cure 
 of the hydrocele, which, however, I have 
 known happen from this cause, as I have 
 elsewhere related. (See First Lines of Sur- 
 gery, Hoi. 2.) When such an accident hap- 
 pens, it is better to defer the operation, till a 
 sufficient quantity of ffuid has collected 
 again. Hydroceles have been cured by ap- 
 plying to the scrotum a solution of muriate 
 of ammonia in vinegar and water (Kcate.) 
 But, the application frequently creates. a 
 good deal of pain and irritation, and does not 
 often succeed, to say the best of it. (Earle.) 
 
 Distending the tunica vaginalis with air, 
 cold water, or even the fluid discharged, has 
 sometimes effected a radical cure. (See 
 Supplement to Ploucquct, Tub. 1S14, p. 103.) 
 
 For many other important remarks, con- 
 cerning hydroceles, I am obliged to refer to 
 the 2d vol. of the last edition of the First 
 Lines of the Practice of Surgery, 1S20. Monro 
 on the Tumours of the Scrotum in the Ediab. 
 Med. Essays, Vol. 5. John Douglas. .1. Trea- 
 tise on Hydrocele, 8vo Loud. 1755; and 
 Answer to Remarks on that Work , 8vo. Loud. 
 1758. Pott on the Hydrocele ; Else on the 
 on the Hydrocele, 8vo. Land 1770; and the 
 Works of Joseph Else, 8vo. Loud. J782. W. 
 Dense , on the Different kinds of Hydrocele, 
 8 vo. London. 1798. Kcate ; B. Bell, on Hy'- 
 
HYDROPHOBIA 
 
 31 
 
 i i/occlc , Sarcocele, fyc. 8 vo. Edinb. 1704. Sir 
 James Earle, Treatise on llie Hydrocele , 2 d 
 Ed. Si’o. Land. 1803. Schreger Chirurgisches 
 Versuchc, B. 1, 8 vo. JYumberg, 1811 , a cure 
 effected by the injection of air, p. 30G. Ber 
 trandi. in Mem. de l' Acad. de Chir. T. 3; and 
 in Traitato delle Operazioni di Chirurgia, 
 Nizaa, 1763. Desault , Remarques, fyc. sur 
 diverses especes d' Hydrocele. (Euvres. Chir. 
 T. 2. S. Sharp's Treatise on the Operations, 
 and his Critical Inquiry. J. Howard , Obs. 
 on the Method of Curing the Hydrocele by 
 Means of a Seton, Svo. Loud. 1783. Sabatier , 
 Mldecine Optraloire , T. 1, Ed. 2. Scarpa, 
 Traili des Hernies, p. 64, fyc. Larrey , Me- 
 moir es de Chir. Militaire, T. 3, p. 400, 4'C. 
 T. Ramsden , Practical Observations on the 
 Sclerocele, §'C. Svo. Lond. 1811. IV IVadd, 
 Cases of Diseased Bladder and Testicle, 4to. 
 Lond. 1815. Kinder Wood, some Observations 
 on. the Cure of the Hydrocele of the Tunica 
 Vaginalis, without procuring an Obliteration 
 of the. Sac , in Med. Chir. Trans. Vol. 0. p 38, 
 Svo. Lond. 1818. 
 
 * H YD R O P H 0 B 1 A . (from vJcep, water, and 
 poSoj, fear. A dread of water.) This being, 
 for the most part, a striking symptom of the 
 fatal indisposition which results from the bite 
 of a mad dog, and some other animals af- 
 fected in the same way, the disease itself 
 lias been named Hydrophobia. Some have 
 used the more general term, hygrophnbia, 
 from vygpv, liquid. But strong objection has 
 been made to both these terms, because de- 
 rived from a symptom, which does not ex- 
 clusively belong to the disease, nor constant- 
 ly exist in it. 
 
 The old writers, as we learn from Caelius 
 Aureliapus, used the terms acrophobia, or a 
 dread of air, and pantephobia, or a fear of 
 all things. Since the impression of cold 
 air sometimes excites terror, and the disor- 
 der is marked by a singular degree of gene- 
 ral timidity qnd distrust. Others called it 
 phobodipson (S'i^W) signifying thirst,) because 
 the patient is thirsty, yet fears to drink. Se- 
 veral modern authors, however, objecting to 
 any appellation expressive only of one symp- 
 tom, denominate the disease rabies, and 
 rabies catiina, or canine madness. The French 
 call it la rage. 
 
 With respect to hydrophobia, orthe dread- 
 ful mdisposjtion produced by the bite of a 
 dog, or other animal, affected with rabies, or 
 by the application of some of the secretions 
 of such animal to a part of the body, the 
 first allusion to it to be found in authors, is 
 that made by Aristotle, (Hist. Animal, lib. 
 7, cap. 22 ;) but he could have had but very 
 erroneous notions upon the subject, since he 
 sets down man as incapable of receiving the 
 distemper from the bite of a rabid dog. 
 
 With respect to a name for the disorder, 
 as the patient does not commonly betray any 
 tendency to fury, While the dread of water 
 is really a customary attendant on the com- 
 plaint, the terms rabies and la rage seem 
 strictly even more exceptionable than the 
 word hydrophobia. At the same time, in 
 Order not to imbibe confused notions, what- 
 ever name be thought fittest for the illness 
 Vol. If ~ 11 
 
 arising in (he human subject from the bite 
 of a mad dog, and some other animals simi- 
 larly affected, it is necessary to understand 
 well, that hydrophobia, in the sense of a 
 horror of water, or other liquids, is an occa- 
 sional symptom of many diseases, and nei- 
 ther exclusively confined to the indisposi- 
 tion caused by the bite of a rabid dog, or 
 certain other animals, nor even constantly 
 attendant upon it. And, with the same 
 view of avoiding perplexity, all hydrophobic 
 complaints may be arranged in two general 
 divisions: 
 
 1. The first, comprising, all cases not 
 ascribable to the bite of a rabid animal, or 
 the application of some of its secretions to 
 a part of the body. 
 
 2. The second, comprehending the ex- 
 amples preceded by one of those occurren 
 ces. 
 
 The eases included in the first of these 
 divisions are subdivided into the symptomatic 
 and idiopathic, or spontaneous. By symptom- 
 atic hydrophobia is understood an aversion 
 or dread of liquids, presenting itself as an 
 occasional symptom of various diseases, as 
 of certain inflammatory, febrile, and nervous 
 disorders, hysteria, epilepsy, injuries of the 
 brain, (Trecourt, in Recueil Periodique , tyc. 
 T. 6 ; Acta Nalurce Curios. Vol. 2, Obs. 205,) ■ 
 the operation of particular poisons; (Filler- 
 may, Traite des Mai. JYer reuses, T. 1, p. 90 ; 
 Harles i/ber die Hundiswuth, Frankf. 1809; 
 Schmiedel, Diss.de Hydrophobia exusufruc- 
 tuum fagi, Erlang. 1762, fee.) gastritis, 
 pneumonia, hepatitis, angina, fcc. &c. In 
 many of the instances of symptomatic 
 hydrophobia, the aversion, or dread of fluids, 
 occurs on the same day as the cause upon 
 which it depends, or a few days afterward ; 
 and, for the most part, may be cured with 
 the disease which has given rise to it, or 
 eVtn independently of it. On the contrary, 
 the hydrophobia from the bite, or infection 
 of a rabid animal, does not come on till a 
 long time after the occurrence of the cause, 
 and, when once formed, has hitherto proved, 
 incurable, or very nearly so. Whatever 
 analogy, therefore, may be imagined to exist 
 between symptomatic hydrophobia and ra- 
 bies, they differ essentially in their causes, 
 progress, degree of curability, and also in 
 the treatment required. (See Did. des 
 Sciences Med . T. 4, p. 3S.J 
 
 Spontaneous, or idiopathic hydrophobia, 
 denotes the questionable form of the com- 
 plaint, sometimes supposed to be induced by 
 violent mental commotion, anger, fright, 
 6ic. uupreceded by any other primary dis- 
 ease, to which it can be referred as a symp- 
 tom. 
 
 Numerous facts upon record leave no 
 doubt concerning the reality of symptomatic 
 hydrophobia ; but, perhaps, none of the 
 cases adduced by Raymond (Mem. de la Sor , 
 Royale de Med. T. 2, p. 457,) Roupe (JYova 
 Ada Physico-Med. T. 4.) or Pouteau ( Essai 
 sur la Rage, Lyons, 1763,) in proof of the 
 possibility of a spontaneous idiopathic form 
 of the disease in the human subject, aro 
 sufficiently unequivocal to remove all susfi' 
 
HYDROPHOBIA. 
 
 82 
 
 cion, that the complaint either had been 
 preceded by another primary disease {Did. 
 des Sciences Med. T. 22, p. 333,) or had been 
 the result of an unobserved, or forgotten 
 occasion, on which the infection wasi re- 
 ceived from handling a dog, or cat, never 
 suspected at the time to be affected with 
 rabies. Here a wrong conclusion is the 
 more apt to be drawn, in consequence of 
 the disease being communicable without 
 any bite to fix the patient’s attention, and 
 not commencing sometimes for months 
 after the unnoticed receipt of the infection. 
 Thus, Francis Stannier died, in Nov 1787, 
 with symptoms of hydrophobia, though it 
 was not known that he had ever been bitten 
 by a mad dog, ( Loud . Med. Journ. Vol. 9,p. 
 256 3 ) yet, what safe inference can be drawn 
 from this case, when the above-mentioned 
 circumstances are recollected, and it is 
 known that the man was often drunk, and 
 in the streets at night ? These and other 
 considerations even throw 7 a doubt upon a 
 part of the cases, recorded as instances of 
 symptomatic tetanus, and they lead the 
 generality of the modern writers ta incline 
 to the sentiment of Dr. .1. Hunter, that a 
 disease, similar in its nature to what is pro- 
 duced by the bite of a mad dog, never arises 
 spontaneously in the human subject. (See 
 Trans, of a Soc.for the improvement of Med. 
 and Chir. Knowledge , Vol.\,p. 299 — 303.) 
 Many of the symptomatic cases, however, 
 or those in which more or less aversion, or 
 dread of liquids, is evinced as an effect of 
 another disease, are too well authenticated 
 to admit of doubt. In the Did. des Sciences 
 Mid. T. 22, art. Hydrophobie, may be found 
 a great deal of information likely to interest 
 such readers as wish to follow up the subject 
 of the symptomatic forms of the disease. 
 However, in looking over some of the cases 
 there detailed, a suspicion wdll sometimes 
 arise in an intelligent mind, that the disorder 
 was mistaken ; for it will be noticed, that 
 sometimes pain shooting up the limbs prece- 
 ded the general indisposition, while the 
 rapidity of the disease, arid the appearances 
 found on dissection, corresponded precisely 
 to what is usually remarked in hydrophobia. 
 In particular, one patient is described as a 
 man habituated to drinking, and, as a sports- 
 man, to dogs also ; he died on the third day, 
 and, on dissection, the stomach and intes- 
 tines were found inflamed, and even gan- 
 grenous in several places, the (Esophagus 
 and lungs also participating in the inflam- 
 mation. ( Commerc . Litter. JVoremb. 1743, 
 Hebd. 5.) 
 
 Animals of the dog kind, including the 
 wolf and the fox, are most frequently the 
 subject of rabies ; and certain writers have 
 maintained, that, although it may be recei- 
 ved and propagated by other animals, yet it 
 always originates in some of the canine race. 
 {Hillary on Diseases of Barbadoes, p. 246.) 
 However, it is asserted, that the disease 
 sometimes originates spontaneously in cats, 
 that is to say, without their having been 
 previously bitten by another rabid animal ; 
 but the moderns do not incline to the belief. 
 
 that it ever has been known to commence 
 in this manner in other animals, though such 
 an assertion is made by Ccelius Aurelianus, 
 Porphyrius, Avicenna, Valeriola, Stafpart- 
 vandei Wiel, he. not only with respect to 
 man, but horses, asses, camels, hogs, bul- 
 locks, bears, monkeys, and even poultry. 
 (See Diet, des Sciences Mid. T. 47, p. 45.) 
 
 It is interesting to inquire, what animals 
 are capable of communicating rabies, and 
 what animals of receiving it ? As far as our 
 knowledge yet extends, it appears that ani- 
 mals of the canine species, with perhaps 
 those of the feline race, are the only ones 
 in which this disorder ever arises spontane- 
 ously, and they may transmit it to animals 
 of their own kind, to other quadrupeds, and 
 to man. The experiments made by Dr. 
 Zincke, tend to prove also that birds, at 
 least the common fowl, may have the dis- 
 ease communicated to them. (Neue Jin - 
 dchten der Hundswuth , fyc. 8 vo, Jena, 1804.) 
 
 But, though it be w ell known, that animals 
 of the dog and cat kinds can propagate the 
 disorder, it is not settled whether it can be 
 communicated by other animals. In a me- 
 moir read to the French Institute, M. Hu- 
 zard explained that herbivorous quadrupeds, 
 affected with rabies, are incapable of trans- 
 mitting the disease ; a position subsequently 
 confirmed by additional experiments and 
 observations made in the veterinary school 
 at Alfort. Professor Dupuy could never 
 communicate the distemper to cows and 
 sheep, by rubbing their wounds with a 
 sponge, which animals of the same class, 
 already labouring under the disease, had 
 had in their mouths ; though the same ex- 
 periment, made with a sponge, Avhich had 
 been bitten by a rabid dog, propagated ra- 
 bies by a kind of inoculation. Dupuy has 
 likewise seen, among several flocks, sheep 
 affected with rabies, yet the distemper was 
 never communicated by them to other sheep, 
 notw ithstanding the latter were bit in parts 
 stripped of wool. Dr. Gillman inoculated 
 two rabbits with the saliva of a rabid pig ; 
 but the disease W'as not communicated to 
 them. (On the Bite of a Rabid Animal, p. 
 38.) On the other hand, Mr. King, of Clifton, 
 is stated to have communicated rabies to a 
 fowl, by inoculating it with the saliva of an 
 ox, which had just fallen a victim to the 
 disease. (J. Ashburner , Diss. de Hydrophobia , 
 p. 29 ) The author of the article Rnge (Did. 
 des Sciences Mid.) observes, respecting this 
 singular case, that, as it is accompanied with 
 no details, doubts must remain, whether the 
 fowl actually died of rabies. 
 
 As for some extraordinary cases, in which 
 the disease is alleged to have been com- 
 municated to the human subject by the 
 bites of birds, or injuries done with the claws 
 of animals, they are generally dismissed by 
 modern writers, with the inference, that 
 the complaint thus transmitted was not true 
 hydrophobia or rabies. This conclusion is 
 made, with respect to the cases of this kind, 
 reported by Ccelius Aurelianus and Bader, 
 and the notorious example mentioned by A 
 Baccius of a gardener, who died of the bite 
 
HYDROPHOBIA. 
 
 of a cock, which, according to some, was 
 rabid, according to others, merely enraged. 
 Hildanus also details an instance, in which 
 a young man was scratched on the great 
 toe by a cat: and, some months afterward, 
 was attacked with hydrophobia ( Obs Chir . 
 Cent. 1 , Obs. 16 ;) but, as a modern writer 
 observes, if the patient were really affected 
 with rabies, it is conceivable that the cat’s 
 claw, with which the scratch was made, 
 might have been wet with the animal’s 
 saliva. (Did. des Sciences Med. T. 47, p. 47.) 
 
 Another question of considerable import- 
 ance is, whether hydrophobia, that is to say 
 rabies, can be communicated from one hu- 
 man being to another ? — or whether, in man, 
 the disease is infectious or contagious ? 
 Many attempts have been made, in vain, to 
 communicate the distemper to several kinds 
 of animals, by inoculating them with the 
 saliva of patients who had perished of the 
 disease. These experiments were made in 
 this country by Gauthier, Vaughan, Babing- 
 ton, &c.; but no infection was the conse- 
 quence. In France, Giraud inoculated 
 several dogs with the saliva of a man in the 
 convulsed stage of hydrophobia, but none 
 of them afterward took the distemper. 
 ( Bosquillon , Mim. sur Its Causes de l' Hydro- 
 phobie, in Mini de la Soc. d’ Emulation, 5 me 
 annie.) M. Girard, of Lyons, collected some 
 of the frothy saliva the instant it was dis- 
 charged from a patient’s mouth, and he in- 
 serted some of it into eight punctures, made 
 on the inside of a dog’s four legs ; yet, six 
 months after this inoculation, the animal 
 had not suffered the slightest inconvenience . 
 (Essai sur le Tetanos Rabiens, p. 29.) A 
 similar experiment was made on three dogs 
 by M. Paroisse, who kept the animals be- 
 tween three and four months afterward, 
 during all which time they continued quite 
 unaffected. ( Bibl . Med. T 43.) 
 
 Dr. Bezard published the following ex- 
 periments : — Pieces of the flesh of a person 
 who had died of hydrophobia, were smeared 
 with his saliva, and given to a dog ; another 
 dog was suffered to eat the salivary glands ; 
 and a third, the sides of a wound. In three 
 other dogs, incisions were made, the cut 
 parts were then inoculated, and sewed up. 
 Not one of these six animals became affected 
 with rabies. (See Mim. et Obs. lus b la Soc. 
 Mid. Philanthropique, premiere annie , 1807, 
 V • IV.) 
 
 The preceding experiments only furnish 
 negative results : but one, to which we shall 
 now advert, tends to establish a contrary 
 opinion. On the 19th June, 1813, in the 
 Hotel-Dieu, at Paris, Magendie and Brescht t 
 took some of the saliva of a man, who 
 died a few minutes afterward of hydropho 
 bia, and, by means of a bit of rag, they 
 conveyed this saliva to the short distance of 
 twenty paces from the patient’s bed, and in- 
 oculated with it two healthy dogs. One of 
 the dogs became rabid on the 27th of July, 
 an ' rat two others, one of which was attack- 
 ed with complete rabies on the 26th of 
 August. (C. Burnout; see Collect, des Theses, 
 in 4 to. de la Faculty de Paris , 1814.) It is 
 
 83 
 
 remarked, in the work, from which I have 
 collected these particulars, that the foregoing 
 is one of the best authenticated experiments 
 on the subject ; for, in addition to the con- 
 sideration of the talents and characters of 
 the experimeners themselves, the facts 
 were witnessed by numerous medical stu- 
 dents. And, notwithstanding the objections 
 which have been urged against the account, 
 (see Journ. Gen. de Mid. T. 52, p. 13 ) the 
 main points are declared to be entitled to 
 credit. (See Did. des Sciences Mid. T. 47, 
 p. 4-h 
 
 With these relations, it is proper to notice 
 certain cases, too credulously promulgated 
 as proofs of the possibility of the disease be- 
 ing communicated from one human being 
 to another. Neither the instance of the 
 maid-servant, who died merely from seeing 
 her mistress vomit, while labouring under 
 hydrophobia (Mich. Ettmuller, Op. Med. T. 
 2 ;) the case of the peasant’s children, which, 
 all died on the seventh day , as is alleged from 
 embracing their dying father; the example 
 of a woman contracting hydrophobia from 
 her husband, as detailed by Mangor (Acta 
 Soc. Reg. Hafniens. V. 2, Obs 32, p. 40S ;) 
 nor other cases of a similar tenor ; are now 
 regarded as proving any thing more than 
 that the patients, supposed to have caught 
 the disease by contagion, fell victims either 
 to violent affections of the mind and nervous 
 system, or illnesses accidentally taking place 
 soon after the death of a near relation or 
 mistress. It is clear enough also, that some 
 of the cases were, at most, only instances 
 of symptomatic hydrophobia. 
 
 With regard to another opinion, that the 
 bite of a man, or other animal, when merely 
 enraged, may bring on hydrophobia, it is 
 now entirely discarded as erroneous. The 
 cases in support of it, recorded by Cl. Pou- 
 teau, Mangetus, Malpighi, Zuinger, Le Cat, 
 &c. when critically examined, only prove 
 that the patients were affected with tetanus, 
 or symptomatic hydrophobia, not arising 
 from any infection; for neither the mode 
 of attack, nor the progress of the symptoms, 
 in any of the examples which are related 
 with sufficient minuteness, lead to the infe- 
 rence, that the patients actually died of 
 rabies. (See Did. des Sciences, Mid. T. 47, 
 p. 49.) 
 
 Wrong notions of a very dangerous ten- 
 dency, have been generally entertained, in 
 regard to the diseasb, as it appears in the 
 canine race. The writer of the article Dog , 
 in Dr. Rees’s Cyclopasdia, appears to have 
 had extensive opportunities of observing the 
 disorder in dogs, having paid attention to 
 more than two hundred cases. From his 
 remarks, I have collected the following in- 
 formation. 
 
 The peculiar symptom which character- 
 izes the complaint in the human subject, has 
 been applied to the disease in the dog, end 
 has occasioned it to be called by the same 
 name, hydrophobia. This is a palpable mis- 
 nomer ; for, in no instance, does there ever 
 exist any dread of water; on the contrary,, 
 dogs are in general very greedy after it. 
 
84 
 
 HYDROPHOBIA. 
 
 Such unfounded supposition has often con- 
 duced to a very fatal error : for, it being 
 the received opinion, that no dog is mad 
 who can lap water, many persons have been 
 lulled into a dangerous security. Anotner 
 equally false and fatal idea has prevailed, 
 that every mad dog must be wild and furi- 
 ous ; but this is so far from being true, that, 
 in the greater number of instances, there is 
 very little of that wild savage fury that is 
 expected by the generality of persons. 
 H Hence,” says this author, u as it is evi- 
 dent that the term hydrophobia, characteri- 
 zing the affection in the dog, is a misnomer, 
 so it is evident that the term madness is 
 equally so. In no instance have 1 ever ob- 
 served a total alienation of the mind ; in 
 very few have the mental faculties been 
 disturbed. The disposition to do mischief 
 is rather an increased irritability than ab- 
 sence of sense; for, in most instances, even 
 those that are furious, they acknowledge the 
 master’s voice, and are obedient.” The 
 symptom, which is most frequently first ob- 
 servable in a rabid dog, is a certain peculia- 
 rity in his manner; some strange departure 
 from his usual habits. In a very great num- 
 ber of instances, the peculiarity consists in 
 a disposition to pick up straws, bits of paper, 
 rags, threads, or the smallest objects, which 
 may happen to be on the iloor. This is said 
 to be particularly common in small dogs. 
 ti Others again show an early peculiarity by 
 licking the parts of another dog. In one 
 instance, the approach of the disease was 
 foretold by our observing a very uncommon 
 attachment in a pug-puppy towards a kitten, 
 which he was constantly licking ; and like- 
 wise the cold nose of a healthy pug that was 
 With him. An attachment to the sensation 
 of cold appears in many cases, it being very 
 common to observe them (the dogs) licking 
 the cold iron, cold stones, &.c. Some dogs, 
 early in the disease, will eat their own ex- 
 crement, and lap their own urine. An early 
 antipathy to strange dogs and cats is very 
 commonly observed, but particularly to cats. 
 As the disease advances, the affected dogs 
 bite those with which they are domesticated, 
 and, lastly, the persons around ; but, except 
 in a moment of irritability, they seldom 
 attack the human subject. The irritability 
 that induces them to bite is very strong, but 
 is devoid of wildness. It is more like pee- 
 vishness than fury. A stick held up at them 
 always excites their anger in a violeni de- 
 gree, and throughout the disease there is 
 generally a wonderful impatience of control, 
 and the animals are with great difficulty 
 frightened. (See art. Dog, in Reefs Cyclopes - 
 dia.) 
 
 To this passage the following remarks may 
 be added : — Dr. John Hunter calculated, 
 that out of every dozen of rabid dogs, about 
 one evinces no particular tendency to bile. 
 That these animals, and wolves also, have 
 no particular dread of fluid, is proved by 
 facts. Thus, a rabid wolf, at Frejus, swam 
 across several rivers. ( Dariuc , Recucil Pe- 
 riod. d'Obs. Vol. d.) Duboueix has seen 
 tnad dogs drink without difficulty, and plen- 
 
 tifully. ( Hist, de la Roc. de Med. an. 1783.) 
 Rabid animals will sometimes eat as well as 
 drink. Thus the wolf which bit so many 
 persons at Meyne, in 1718, was found in the 
 morning devouring a shepherd’s dog. And 
 Dr. Gilman speaks of a dog, which was not 
 deemed rabid, because it eat and drauk well ; 
 but, as it seemed indisposed, it was kilted, 
 though not before it had bit a man, who fell 
 a victim to hydrophobia. (On Ike Bile of a 
 Babid Animal, p. 15.) 
 
 When a dog bites a person, it should not 
 be immediately killed, but merely chained 
 up, because, by destroying it at once, the 
 possibility of ascertaining whether it was 
 rabid is prevented, and great alarm is thus 
 kept up in the mind of the wounded person 
 and his friends. If the animal be affected 
 with rabies, it will perish in a few days. At 
 the veterinary school at Alfort, when a dag 
 has been bit, it is usual to chain the animal 
 up, for at least fifty days, before it is resto- 
 red to its master, about six weeks being 
 considered the period when a dog generally 
 becomes rabid after being bitten. 
 
 For additional details, relating to the dis- 
 ease as it appears in the dog, I must refer 
 to the above-mentioned paper. Enough, I 
 hope, has been said to make the reader 
 aware, that mad dogs are not particularly 
 characterized by an inability to lap water, 
 or any degree of fury. These animals, when 
 actually affected with rabies, from their 
 quiet manner, have even not been suspected 
 of having the disorder, and have been allow- 
 ed to run about, been fondled, and even 
 slept with. (See Mem oj Swedish Acad , 
 3777.) 
 
 The causes of this peculiar distemper in 
 dogs are at present unknown, and little 
 more than conjecture prevails upon the sub- 
 ject. It is not positively known whether 
 rabies sometimes originate spontaneously in 
 these animals, though 1 believe this opinion 
 is at present gaining ground; or whether, 
 like small-pox in the human species, it is 
 propagated only by contagion. That the 
 disease is frequently imparted in conse- 
 quence of one dog biting another, every 
 body well knows. Yet there are many in- 
 stances in which this mode of propagation 
 cannot be suspected. Several facts render 
 it probable, that, among dogs, the disease is 
 often communicated by contagion It is 
 observed, that, in insular situations, dogs 
 are seldom affected, and this circumstance 
 is ascribed to such animals being in a kind 
 of quarantine. The celebrated sportsman, 
 Mr. Meynell, secured his dogs from the ma- 
 lady by making every new hound perform 
 a quarantine before lie was suffered to join 
 tht j:ack. (See Trans. for the Improvement 
 of ed. and Chir. Knowledge, Vol. I .art. 17,.) 
 Great -heat was very commonly supposed to 
 be an exciting cause of the disease in dogs ; 
 but without much foundation. “ A very Dot 
 climate, or one exposed to the extremes ol 
 heat and cold ; a very hot and dry season ; 
 feeding upon putrid, stinking, anu magotty 
 flesh; want of water; worms in the kid- 
 neys, intestines, brain, or cavities of the 
 
HYDROPHOBIA. 
 
 tod 
 
 nose,” are set down by Boerhaave as causes 
 of the disease. {Aphorism, 1134.) We 
 learn from Dr. J. Hunter, that, in the hot 
 islund of Jamaica, where dogs are exceed- 
 ingly numerous, not one was known to go 
 mad during forty years. ( Trans, for the Im- 
 provement of Med. Knowledge, loc. cit.) Cold 
 weather has also been set down as condu- 
 cive to rabies among the canine race, as is 
 suggested, because the ponds being frozen, 
 these animals cannot quench their thirst. 
 (Le Roux.) That neither of these senti- 
 ments about heat and cold being the cause 
 of the origin of the disease in dogs is cor- 
 rect, will be manifest enough to any body 
 who has patience to look over the volume 
 of the Mem. de la Soc. Royale de Med. devo- 
 ted entirely to the consideration of rabies $ 
 and, from the investigations of M. Andry, 
 (Rechcrches sur la Rage , 8 vo. Paris, 1780,) it 
 appears that January, the coldest month in 
 the year, and August, the hottest, are those 
 which furnish the fewest instances of hydro- 
 phobia. On the contrary, the greatest num- 
 ber of rabid wolves is in March and April ; 
 and that of dogs, affected with spontaneous 
 rabies, in May and September. 
 
 According to Savarv, dogs never go mad 
 in the Island of Cyprus, nor in that part of 
 Syria which is near the sea ; and Volney 
 assures us that these animals enjoy the 
 same fortunate exemption both in the latter 
 country and in Egypt. ( Voyage in Syrie, T. 
 1.) The traveller Brown also declares, that, 
 in Egypt, they are never, or very rarely, 
 attacked with rabies. 
 
 “ Although (says Baron Larrey) hydro- 
 phobia is more frequent in warm than tem - 
 perate climates, it is not observed in Egypt, 
 and the natives assured us, that they knew 
 of no instance in which this disease had 
 manifested itself, either in man or animals. 
 No doubt this is owing to the species and 
 character of the dogs of this country, and 
 their manner of living. 
 
 “ It is remarked, that the Egyptian dogs 
 are almost continually in a state of inaction; 
 during the day, they lie down in the shade, 
 near vessels full of fresh water prepared by 
 the natives. They only run about in the 
 nighttime ; they evince the signs and effects 
 of their love but once a year, and only for 
 a few instants. They are seldom seen cou- 
 pled. On our arrival, there was a vast num- 
 ber of these animals in Egypt, because they 
 were held, like many others, in great vene- 
 ration, and were never put to death. They 
 do not go into the houses; in the day time 
 they remain at the sides of the streets, and 
 they only wander into the country at night, 
 in orderto find any dead animals which hap- 
 pen to be unburied. Their disposition is 
 meek and peaceable, and fhey rarely fight 
 with each other. Possibly all these causes 
 may exempt them from rabies.” (Larrey 
 in Mim. de Chir. Militaire, T. 2 ,p. 226.) 
 
 This observation, about the exemption of 
 the Egyptian dogs from rabies, is a very 
 ancient one, having been made by Prosper 
 Alpinus, (Rer. JEgypliarum, lib. 4, cap. 8.) 
 According to Barrow, (he dogs in the vici- 
 
 nity of the Cape of Good Hope, and in Caf- 
 fraria, very rarely go mad. (Travels into 
 the Interior of Africa.) Several authors assert, 
 that rabies never occurs in South America. 
 {Bill. Raisounte, 1750. Van Swieten Com- 
 ment iiAphor. 1129, Portal fyc.) L. Va- 
 lentin declares, that it is exceedingly rare in 
 the warm regions of America, but common 
 in the northern part of that continent. 
 ( Journ . Gen. de Med. T. 20.) Dr. Thomas, 
 who resided a good while in the West 
 Indies, never saw nor heard of a case of 
 rabies there, (Practice of Physic ;) and Dr. 
 B. 4 Moseley states that the disorder was not 
 known in those islands, down to 1783. On 
 the other hand, the disease sometimes hap- 
 pens in the East Indies, though not with 
 such frequency as at all to justify the doc- 
 trine about heat being the cause of its pro- 
 duction. The silence of Hippocrates proves, 
 that in his days hydrophobia must have been 
 very rare in Greece ; and, as the disorder is 
 not mentioned in tht Scrip ores, an inference 
 may be made, that it could not be so com- 
 mon in the hot tracts of the globe, inhabit- 
 ed by the Hebrews, as in the temperate cli- 
 mates of Europe and A merica. 
 
 Neither can the sentiment be received as 
 correct, that rabies is more frequent in the 
 north than- in the temperate parts of Europe ; 
 for De la Fontaine particularly notices how 
 extremely rare it is in Poland. (Chif. Med. 
 Abhandl. Breslau , 1792.) The disease is 
 reported to be very common in Prussian 
 Lithuania ; but mad dogs are seldom or 
 never heard of at Archangel, Tobolsk, or in 
 the country north of St. Petersburg. 
 
 In Mr. Meynell’s account, which was 
 communicated to him by a physician, it is 
 asserted, that the complaint never arises 
 from hot weather, nor putrid provisions, 
 nor from any cause except the bite ; for, 
 however dogs have been confined, however 
 fed, or whatever may have been the heat of 
 the season, the disorder never commenced, 
 without a possibility of tracing it to the 
 preceding cause, nor was it ever introduced 
 into the kennel, except by the bite of a mad 
 dog. (See art. Dog, in Rees's Cyclopedia.) 
 
 Dr. Gillman endeavours to prove, that 
 the disease in dogs is probably excited inde - 
 pendently of particular climates, of putrid 
 aliment, of deficiency of water, of want of 
 perspiration, or, of the worm under the 
 tongue, to which causes it has been at 
 different times ascribed, and he expresses 
 his belief, that it originates somewhat like 
 typhus in the human subject, and is not 
 always produced by inoculation, or by 
 means of a bite. He thinks that it maybe 
 occasionally brought on by the confinement 
 of dogs, without exercise, in close and filthy 
 kennels ; and that the success of Mr. Treval- 
 yan, as related by Dr. Bardsley, in clearing 
 his kennel of the disease, by changing even 
 the pavement, after other means of purifica- 
 tion had failed, affords presumptive evidence 
 in favour of the opinion; and, consequently, 
 this author thinks, that the method of qua- 
 rantine, adopted by Mr. Meynell, and recom- 
 mended by Dr. Bardsley, on the supposition, 
 
86 
 
 HYDROPHOBIA. 
 
 that the disease originates exclusively from 
 contagion, will not be a sufficient prevent- 
 ive alone ; and he infers, from some facts, 
 reported by Mr. Daniel, that the poison 
 sometimes lies dormant in dogs fpur, five, 
 and six months ; and, consequently, that 
 the period of two months is not a sufficient 
 quarantine. (See Gillmari’s Diss. bn the 
 Bite of a Rabid Animal.) 
 
 In opposition, however, to some of the 
 sentiments contained in the foregoing pas- 
 sage, it should be known, that Dupuytren, 
 Magendie, and Breschet, have purposely 
 kept many dogs for a long time in the most 
 disgusting state of uncleanliness, let them 
 even die in this condition for want of food 
 and water, or even devour each other, yet 
 without exciting rabies (Did. des Sciences 
 Mid. T. 47, p. 53 ) Yet Professor Rossi, of 
 Turin, is said to have produced this, or seme 
 similar disease in cats, by keeping them 
 shut up in a room. (Mem. de I'Acad. Imp. 
 de Turin , 1805, A 1808, p. 93, de la JYolice 
 des Travaux.) On the whole, I consider it 
 well proved, that neither long thirst, hun- 
 ger, eating putrid flesh, nor filth, will occa- 
 sion the disease in the canine race. At 
 Aleppo, where these animals perish in great 
 numbers from want of food and water, and 
 the heat of the climate, the distemper 
 is said to be unknown. Nor is rabies found 
 to attack dogs and cats, with particular fre- 
 quency during the copulating season, and 
 therefore, the oestrus veneris cannot be ad- 
 mitted to have any share in its production, 
 as some writers have been disposed to be- 
 lieve. (See Did. des Sciences Mid. T. 47, 
 V- 55.) 
 
 Although most writers believe in the reali- 
 ty of a poison, or specific infectious princi- 
 ple, in cases of rabies, the fact has been 
 questioned, or absolutely rejected by others. 
 Bosquillon considered the disease always as 
 the effect of fear, or an impression upon the 
 imagination. This view of the matter is far 
 from being new, and has been ably refuted 
 by many authors, and especially by M. De 
 sault, of Bordeaux, who remarks, that 
 horses, asses, and mules, quibus non est in- 
 tellects, had died rabid the very year in 
 which he wrote ; and, it is observed by Dr. 
 J. Vaughan, that an infant in the cradle is 
 som times attacked, while many timorous 
 children escape. 
 
 Another notion has partially prevailed, 
 that rabies does not depend upon any virus, 
 but upon the continuance of an irritation 
 in the bitten parts, affecting the whole ner- 
 vous system. (Percival; J. Mease ; Girard; 
 ^c.) But, this doctrine confounds rabies 
 and tetanus together, and can only apply 
 to the symptomatic non-infectious hydro- 
 phobia from an ordinary wound, or lacera- 
 tion. 
 
 The facts, in proof of the reality of a pe- 
 culiar infectious principle in cases of rabies, 
 are too numerous to leave any doubt upon 
 th- subject. Twenty -three individuals were 
 bit or, e morning by a female wolf, of whom 
 thirteen died in the course of a few months, 
 besides several cows, which had been inju- 
 
 red by the same animal. How could all 
 these unfortunate persons have had similar 
 symptoms, and especially a horror of fluids, 
 had they not been all under the influence 
 of some cause, besides the bites ? The pa- 
 tients who died, were bit on the naked 
 skin ; while in the others, who escaped in- 
 fection, the bites happened through their 
 clothes, which no doubt intercepted the sa- 
 liva, the vehicle of the virus. In the Essay 
 by Le Roux, mention is made of three per- 
 sons, bit by a rabid wolf near Autun, in July, 
 1781, and, notw ithstanding mercurial fric- 
 tions, they all died of hydrophobia. Of ten 
 other individuals bit by a wolf, nine died 
 rabid. (Rey, Mim. de la Soc. Royale de Mid. 
 p 147.) Twenty-four persons were injured 
 in the same manner near Rochelle, and 
 eighteen of them perished. ( Andry , Ri- 
 
 cherches sur la Rage, Ed. 3, p. 196.) On the 
 27th January, 1780, fifteen individuals were 
 bit by a mad dog, and attended at Senlis by 
 the commissioners of the French Royal So- 
 ciety of Physic ; ten had received the bites 
 on the naked flesh, and five through their 
 clothes. Of the first ten, only five lost their 
 lives, three of them dying of decided rabies 
 between the 27th of February, and the 3d 
 of April ; and the other two between the 
 29th of February, and the 18th of March. 
 Unless the opinion be adopted, that the dis- 
 ease is caused by an infectious principle, a 
 sort of inoculation, it would be impossible 
 rationally to explain the cause of so many 
 deaths from the bites of rabid animals. If 
 the idea, that rabies originates from fear 
 or nervous irritation were true, how could 
 we account for there being such a differ- 
 ence between the usual consequences of 
 the bite of a healthy dog, and those of the 
 bite of one affected with rabies ? Healthy 
 dogs are incessantly quarrelling, and biting 
 each other in the streets, yet their wounds 
 are not followed by rabies ; and as a mo- 
 dern author remarks, if hydrophobia were 
 referrible to nervous irritation derived from 
 the wounded part, how does it happen, that 
 among the thousands of wounded after a 
 great battle, hydrophobia is not seen in- 
 stead of tetanus. (Did. des Sciences Mid. 
 T. 47, p. 61.) But, if it were yet possible 
 to entertain a doubt of an infectious princi- 
 ple in hydrophobia, this possibility would be 
 removed by the reflection, that the disease 
 may be communicated to healthy animals 
 by inoculating them with the saliva of cer- 
 tain other rabid animals. In fact, as I have 
 stated, the bites of such animals are in every 
 point of view only an inoculation ; and the 
 same remark may be extended to the nu- 
 merous instances on record, in which the 
 disease arose in the human subject, as a 
 consequence of a rabiJ dog, or cat, (not 
 suspected to be in this state at the time) ha- 
 ving been played with, fondled, or suffered 
 to lick the naked skin, in which there was 
 at the moment some slight scratch, entirely 
 overlooked. 
 
 Many of the ancient writers not only be- ‘ 
 lieved in the hydrophobic virus, or infec- 
 tious principle, but even in its diffusion 
 
HYDROPHOBIA 
 
 87 
 
 through the blood, flesh, and secretions in 
 general ; and this hypothesis was professed 
 by Boerhaave, Van Swiet n, Sauvages, F. 
 Hoffman, &c. but, in proportion as the hu- 
 moral pathology lost ground, the foregoing 
 idea was abandoned, and the opinion adopt- 
 ed, that the infection is confined to the sa- 
 liva, and wounded part, in which it has 
 been inserted. 
 
 The tales of some old authors would lead 
 one to think, that hydrophobia may be 
 communicated by eating the flesh of a rabid 
 animal. ( Fernelius , De Obs. Rer. Caus. et 
 
 Morb. Epidem. lib. 2, cap. 14; Schenckius ; 
 Mangetus , fyc.) But, respecting these ac- 
 counts, it is remarked, that they are not en- 
 titled to much confidence ; for, it is certain, 
 that rabies never begins as is stated, with 
 regard to some of the cases in question, a 
 few hours after the application of its cause, 
 and its early stage is never characterized by 
 any fury, or disposition to bite. And, be- 
 sides, how can such relations be reconciled 
 with the practice of the ancients, who, ac- 
 cording to Pliny, employed the liver of the 
 mad dog or wolf, as a remedy ? Palmarius 
 also fed his patients for three days with the 
 dried blood of the rahid animal. (Mim. de 
 la Soc.de Mid. p. 136, et le No. 178.) The 
 fie^h of a bullock, which had been bit by a 
 mad dog, and afterward died rabid, was 
 sold to the inhabitants of Medola near Man- 
 tua, yet none of them were attacked with 
 hydrophobia. ( Andry , Richerches sur la 
 
 Rage, fyc. p. 30.) Dr. Le Camus informed 
 Lorry, that he had eaten the flesh of animals 
 which died rabid, but he suffered no incon- 
 venience from the experiment. And, it is 
 stated in the letter of Dr. L. Valentin, that 
 the negroes in the United States of Ameri- 
 ca had no illness from eating the flesh of 
 pigs, which had died of rabies. ( Journ 
 Gen. de Mid. T. 3, p. 417.) As for the ques- 
 tion, whether the blood is infected ? It is 
 generally considered to be settled in the 
 negative, notwithstanding the account given 
 by I^mery of a dog, which was attacked 
 with rabies, as is said, from lapping the 
 blood of a hydrophobic patient, who had 
 been bled. (Hist, de ’Head. Royale des 
 Sciences , 1707, p. 25.) Dupuytren, Breschet, 
 and Magendie, w r ere never able to commu- 
 nicate rabies by rubbing wounds with blood 
 taken from mad dogs ; and they even seve- 
 ral times injected such blood into the veins 
 of other healthy dogs, yet none of these 
 latter animals were attacked with rabies, 
 though they w^ere kept for a sufficient length 
 of time to leave no doubt upon the subject. 
 (See Did. des Sciences Med. T 47, p. 63.) 
 
 A point of greater practical interest than 
 the former, is, whether the drinking of the 
 milk of an animal, labouring under rabies, is 
 attended with any risk of communicating 
 the disease P It is asserted by Timaeus, that 
 a peasant, his wife, children, and several 
 other persons, were seized with hydropho- 
 bia, in consequence of drinking the milk of 
 a rabid cow ; and that the husband and el- 
 dest child were saved by medical treat- 
 ment : but, that the wife and four of the 
 
 children died. It is further stated, that 
 three or four months afterward, the maid 
 and a neighbour, who had partaken of 
 the milk of the same cow, also died of hy- 
 drophobia. (Cons. 7, Obs. 33.) In opposi- 
 tion to this account, however, several facts, 
 reported by othm writers of greater credit, 
 tend to prove, that hydrophobia cannot be 
 communicated by the milk of a rabid ani- 
 mal. ( Nova Ada Nat. Cur. Vol 1, Obs. 55 ; 
 Baudot, in Mem. de la Soc. Royale de Med. 
 an 1782 et 83, T. 2 ,p. 91 . ) 
 
 The cases reported by F. Hoffman and 
 Cbahert, with the view of proving the pos- 
 sibility of infection, through the medium of 
 the sernen, are of no weight, because, on a 
 critical examination of them, it will be 
 found, that the infection of the women is 
 stated to have taken place very soon after 
 their husbands had been bit, which is quite 
 at variance with the established character 
 of the disease, as it never commences, and 
 of course cannot be propagated in any man- 
 ner, soon after the receipt of the bite. Be- 
 sides, these histories are refuted by others of 
 greater accuracy. (See Baudot in Mem. dr, 
 la Soc. Royale de Med. an 1782, fyc., p. 92; 
 Ricallier, Vol. cit.p. 136 \ p. 211 ; Bouteille, 
 p. 237 ; Boissiere, in Journ. Gin. de Mid. T. 
 IT, p. 296.) 
 
 Neither can hydrophobia be imparted by 
 the breath, notwithstanding the statements 
 of Caelius, Aurelianus, and some other old 
 writers. A nurse, mentioned by Dr. J. 
 Vaughan, repeatedly kissed a hydrophobic 
 infant, which she had suckled, a,c^l exposed 
 herself incessantly to its breath, but with- 
 out the least ill effects. The fear which has 
 also been entertained of the disorder being 
 receivable from the application of the pa- 
 tient’s perspiration to the skin, is not found- 
 ed upon any authentic facts. 
 
 Does the infectious principle of rabies re- 
 side in the salivary secretion, or in the mu- 
 cus of the trachea and bronchiae ? The 
 common belief is, that in hydrophobia, the 
 salivary glands are considerably affected. 
 But, it has been remarked by a modern wri- 
 ter, that if these glands exhibit no morbid 
 alteration during the whole course of the 
 disorder; if they are found healthy after 
 death ; if the air-passages are the seat of 
 inflammation ; if the saliva does not con- 
 stitute the frothy slaver about the lips ; and 
 if such slaver, wherewith the disease may 
 be communicated by inoculation, is derived 
 from the inflamed windpipe and bronchiae, 
 and consists of mucus converted into a kind 
 of foam by the convulsive manner in 
 w r hich the patient breathes, there is some 
 reason for questioning, whether the saliva, 
 strictly so called, undergoes the alteration 
 generally supposed ? (See Diet, des Sciences 
 Mid. T. 47, p. 66.) However, this writer 
 is not exactly correct, w'hen he describes 
 the frothy secretion about the mouth, as be- 
 ing altogether composed of mucus from the 
 trachea, since a great part of it is unques- 
 tionably true saliva and mucus secreted in 
 the fauces and mouth. In the stomachs of 
 dogs, which died rabid, Dr. Gillman con 
 
S8 
 
 HYDROPHOBIA 
 
 slantly observed traces of inflammation, and 
 he once tried to communicate the disease to 
 two rabbits, by inoculating them with matter 
 taken from pustules, found in the stomach of 
 a rabid do^ • but no infection took place. 
 {On the Bile of a Rabid Animal, p. 32.) 
 
 According to Professor Rossi, of Turin, the 
 nerves, “ before they grew cold, participated 
 with the saliva in the property of communi- 
 cating rabies ” He asserts, that he once im- 
 parted the disease by inserting in n wound a 
 toil of the sciatic nerve, immediately after 
 it had been taken from a living rabid cat. 
 (See M6m. de I'Acad Imp. de Turin , Sciences , 
 Phys. el Mathem. de 1805 a 1808, part. 93. de 
 la Notice des Travaux.) 
 
 After all which has been stated, concerning 
 the hypothesis of the infectious principle of 
 hydrophobia being more or less diffused 
 through the solids and fluids of a rabid ani- 
 mal, and not being restricted to the saliva, 
 perhaps, the safest conclusion to be made is, 
 not to reject the opinion altogether, but to 
 consider it as at present requiring further 
 proof. And from observations of what hap- 
 pens in the human subject, the same infer- 
 ences should not always be drawn, as from 
 experiments on animals, which are liable to 
 be attacked with spontaneous rabies of \ de- 
 cidedly infectious character. (S ec Diet. des 
 Sciences Mid. T 47, p. 67.) 
 
 Although many casts are to be met with 
 in the records of medicine and surgery, 
 tending to convey an idea, that the mere ap- 
 plication of the saliva of a rabid animal to 
 the sound entire skin of tiie human subject, 
 may give rise to hydrophobia, t he assertion is 
 contrary to general experience, and liable to 
 a reflection which must overturn the hypo- 
 thesis ; viz. the slightest prick scratch, abra- 
 sion, or broken pimple on 1 he surface of the 
 body, such as would not be likely in many 
 instances to excite notice, may render the 
 application of the saliva to the part a posi- 
 tive inoculation. 
 
 Instances are also reported, the tenor of 
 which is to prove, that the hydrophobic virus 
 may take effect through a sound mucous 
 membrane. ( Palmarius , de Morbis Ccnlag. ; 
 Portal , Obs. sur la Rage,p. 131 , Mallhieuin 
 Mem. de la Soc. Royale de M6d. p 310, fyc.) 
 But that this does not happen ir, the human 
 subject is tolerably well proved by the con- 
 sideration, that formerly a class of men made 
 it their business to suck the wounds, caused 
 by the bites of rabid animais; yet none of 
 them contracted hydrophobia from this bold 
 employment. {Bosqnillon, Mem. d6 la Soc 
 d' Emulation , T.5, //. 1.) The example of die 
 nurse, who repeatedly kissed a child without 
 the least. ill effect, while it was dying of ra- 
 bies, as recorded by Dr. J. Vaughan, has 
 been already noticed. However, if hydro- 
 phobia were apparently to arise in any rare 
 instance from the application of the slaver of 
 a rabid animal to the inside of the lips, no 
 positive inference could be drawn from the 
 fact, unless the means were also possessed of 
 ascertaining, that there were no slight abra- 
 sion about the gums, or within the mouth, 
 previously to such application. 
 
 For the hydrophobic virus to take effect, 
 therefore, it is generally, if not always ne- 
 cessary, that the infectious saliva be either 
 applied to an abraded, wounded, or ulcera- 
 ted surface. In the case of a bite, the teeth 
 are (he envenomed weapons, which a* once 
 cause the solution of continuity, and deposit 
 the infection in the part. But the mere abra- 
 sion of the cuticle, and the application of the 
 infectious saliva to the denuded cutis, will of- 
 ten suffice for the future production of the 
 disease. As the mode of communication, 
 therefore, is a true inoculation, it follows, 
 that the danger must depend very much 
 upon the quantity of infectious matter con- 
 veyed into, or applied to the part, the effec- 
 tual manner, in which the saliva is lodged in 
 the flesh, the extent and number of the 
 wounds, and particularly the circumstance of 
 the teeth of the rabid animal having passed 
 through no clothes, by which the saliva 
 might possibly be effectually prevented from 
 entering the wound at all. Hence, bites on 
 the hands and face are well known to be of 
 the most dangerous description, especially 
 those on the face, the hands being sometimes 
 protected with gloves. 
 
 From what has been observed, however, 
 it is not to be concluded, that the disease al- 
 ways follows, even when the animal, which 
 inflicts the bite, is decidedly rabid, and some 
 of its saliva is actually applied to the wound- 
 ed or abraded parts. On the contrary, ex- 
 perience fuHv proves, that out of the great 
 number of individuals often bit by the same 
 mad dog, and to whom no effectual prophy- 
 lactic measure is extended, only a greater or 
 lesser number are afterward attacked with 
 hydrophobia. When this difference in the 
 fate of the individual cannot be explained 
 by the intervention of their clothes, the thick- 
 ness of the cuticle at the injured part, the 
 small size and superficial nature of the bite, 
 the ablution of the part, or some other mode 
 in which any actual inoculation may have 
 been rendered ineffectual, it can only be re- 
 ferred to some unknown peculiarities, or dif- 
 ferences in the constitutions of the several 
 individuals. The latter conjecture seems 
 more probable, when the fact is recollected, 
 that some animals are more susceptible of 
 rabies than others, and some appear to resist 
 the infection altogether. 
 
 Dogs are more susceptible of the infection 
 than the human species. Four men and 
 twelve dogs were bit by the same mad dog, 
 and every one of the dogs died of the dis- 
 ease, w hile all the four men escaped, though 
 they used no other in' an* of prevention but 
 such as we see every d:w fail. There is also 
 an instance of twenty persons being bit by 
 the same mad dog, of whom only one had 
 the disease. 
 
 Dr. Heysham has defined hydrophobia to 
 be an aversion arid horror at liquids, exciting 
 a painful convulsion of the pharynx, and oc- 
 curring at an indeterminate period after the 
 canine virus has been received into the sys- 
 tem. Dr. Culb n places it in the class ncuro - 
 ses, and order spatyni} and defines it a loath 
 irig and great dread of drinking any liquids- 
 
HYDROPHOBIA. 
 
 89 
 
 from their creating a painful convulsion of 
 the pharynx, occasioned most commonly by 
 the bite of a mad animal. Olliers have sug- 
 gested the following definition, as more com- 
 plete : melancholy, dread of cold air, of any 
 thing shining, and particularly of water ; 
 often arising from the bite of a mad animal. 
 ( Parr's Med. Diet.) However, the latter de- 
 finition is, perhaps, equally objectionable, be- 
 cause there is not invariably a dread of 
 shining bodies. (See Dr- Powel/. s Case , p. 
 S.) While some authors represent it as a 
 nervous disorder, others, among whom is 
 Boerhanve, consider it as one of an inflam 
 matory nature. In many systems of sur- 
 gery, hydrophobia is treated of with poison- 
 ed wounds, of one species of which it is 
 strict ly the effect. 
 
 With regard to the symptoms of hydro- 
 phobia, they are generally tardy in making 
 their appearance, a considerable, but a very 
 variable space of time usually elapsing be- 
 tween their commencement .nd the receipt 
 of the bite. Out of a table of 131 ca'es, 
 none of the patients became ill before the 
 eleventh day after the bite, and only three 
 before the eighteenth. It is pretended by 
 Fouteau, that one patient was bit by a dog 
 in she morning, and was attacked with hy- 
 drophobia at three o’clock in the afternoon. 
 But as this account was communicated to the 
 author a long time after the ■occurrence, and 
 not by a medical man, it deserves little con- 
 fidence. Another case, adverted (o by Mead, 
 is deprived of all its importance by the same 
 consideration. These examples, as well as 
 another reported by Astrnc, in u hich the 
 patient is said to iiave had hydrophobia in less 
 than three days after being wounded on the 
 temples, can at most be regarded only as 
 specimens of symptomatic hydrophobia. 
 (Diet, des Sciences Med. T. 47, p. 74.) There 
 appears to be no determinate period, at which 
 the disorder makes its attack after the bite ; 
 but it is calculated, that the symptoms most 
 frequently commence between the 30lb and 
 40th day, and that after (his time the chances 
 of escape increase. Of 15 patients, whose 
 cases Trolliet was acquainted with, seven 
 were attacked between the 14th and 30th 
 days; five between the 30th and 40tii ; two 
 a little beyond the iattel- period ; and one 
 after 14 weeks, in May, 1784, 17 persons 
 were bii by a rabid wolf, near Brive, of 
 whom 10 were afterward attacked with hy- 
 drophobia; viz. one on the 15th day after 
 the bite ; one o i the 18th ; one on the 19th ; 
 one on the 28th ; one on the 30th ; one on 
 the33d ; one on the 35th ; one on the 44th; one 
 on the 52d ; and the last on the6Sthday. (Hist. 
 delaSoc. RoyaledeM6d.p.2 09.) Fothergilland 
 Mo-, iy mention cases, in vv h i < b the disease 
 began four months alter ihe bile; and M 
 Matthey. ot Geneva, details an instance, in 
 which the interval was 117 days. (Journ. 
 Gen. T- 54, p. 275) , Haguenot knew ot a 
 case, in which the interval between the bite 
 and the commencement of the illness was 
 five months. (Portal, p. 183.) Dr. J. Vaugh- 
 an mentions an interval of nine months; 
 Mead, of 11; Galen, Bauhin, and Boissiere, 
 Vol. IF 12 
 
 of a year; Noursc, of 19 months; and R. 
 Lentilius, of three years. 
 
 Dr. Bardsb y, of Manchester, has recorded 
 a case, in which the rno-t careful inquiries 
 tended to prove, that the patient had never 
 suffered the least injury from any animal, ex- 
 cept the bite, inflicted twelve y*-ars previous- 
 ly to the commencement of hydrophobia, by 
 a dog apparent ! v mad. (Mem. of Liter, and 
 Phil Society of Manchester, Pol. 4, Part 2, 
 p. 431.) 
 
 A merchant of Montpellier is also stated 
 to have been attacked with hydrophobia ten 
 years after the bite of a rabid dog, which 
 also bit the patient’s brother, who died hy- 
 drophobic on the 40th day after the accident. 
 (See Diet, des Sciences Med. T. 47, p. 75.) 
 Here may also be found references to cases, 
 i t which the interval is alleged to have been 
 IS, 20, and even 30 years. It is certainly 
 difficult to attach any credit to these very 
 late periods of attack. Dr. J. Hunter consi- 
 ders 17 months, and Dr. Hamilton 19, 
 the longest interval deserving belief. (On 
 Hydrophobia, Vol. 1 ,p. 113.) Exposure to 
 the heat of the sun, violent emotions of the 
 mind, and tear, are believed to have consi- 
 derable influence in accelerating the com- 
 mencement ot the symptoms. That mental 
 alarm is also of itscif sometimes capable of 
 bringing on a simple hydrophobia, totally 
 unconnected with infection, is incontestable ; 
 a case, which has not always been duly dis- 
 criminated. A most convincing proof of 
 this fact i- recorded by Barbantini, in the 
 Italian Journ. of Physic, Ciiymistry, &c. for 
 January ami February, 1817. A young man 
 was bit by a dog, which he iancied was mad, 
 arid on the 5 tit day he evinced symptoms of 
 hydrophobia, ot which he was nearly dying, 
 when the dog which had bit him, was shown 
 to him perfectly well, atid the intelligence 
 tranquillized him so effectually, that he was 
 quite well four days afterward. Mr. John 
 Hunter is said to have mentioned in his Lec- 
 tures a very similar case, in which he believ- 
 ed the patient would certainly have died, if 
 the dog which inflicted the bite had not been 
 found, and shown to the patient perfectly 
 well. (See Journ. Gen. de Med. T. 4J, p. 
 215.) It is to the effects of terror, that seve- 
 ral modern writers are disposed to refer the 
 instances of very late attacks of hydropho- 
 bic symptoms after the period when the pa- 
 tients were bitten ; though, unless the intel- 
 lects be changed in the mean time' by other 
 causes, it is difficult to conceive, why Ihe 
 alarm should not have the greatest effect 
 earlier, while the impression of the danger 
 is undiminished by time. The idea, that the 
 symptoms begin sooner after the bite of a 
 wolf, than that of a dog, is not adopted by a 
 writer who has taken great pains to collect 
 information on the present interesting dis- 
 order. (8ee Diet, des Sciences Mid. T. 47, p. 
 77.) 
 
 Cullen has divided the disease into two 
 stages, the hydrophobia simplex and rabiosa ; 
 or the melancholy and raving stages of some 
 other writers. But as the early stage is fre- 
 quently unattended with any thing like me- 
 
hydrophobia. 
 
 00 
 
 lancholy, it is best merely to adopt the dis- 
 tinction of the first and second stages ; one 
 comprehending t he effects of the disorder 
 previously to the occurrence of a dread, or 
 decided aversion of liquids; the other, the 
 subsequent changes. The wound, if treated 
 by common methods, usually heals up at 
 first in a favourable manner. At some inde- 
 finite period, and occasionally, long after the 
 bitten part seems quite well, a slight pain 
 begins to be felt in if, or the neighbouring 
 parts, now and then attended with itching, but 
 generally resembling a rheumatic pain. If 
 the bite took place on the linger, the pain 
 successively extends from the hand to the lore 
 arm, arm, and shoulder, without any redness 
 or swelling in these parts, or any increase of 
 suffering from pressure or motion of the 
 limb. In a great number of instances the 
 trapezius muscle, and the neck, on the same 
 side as the bite, are the points to which the 
 pain principally shoots. The cicatrix, in 
 the mean while, begins to swell, inflames, 
 and often festers and discharges an ichorous 
 matter. These uneasy painful sensations re- 
 cur from time to time, and usually precede 
 any dread of water several days ; and they 
 are a just reason for apprehension. Some 
 times pains of a more flying, convulsive kind, 
 are felt in various parts of the body. As the 
 disease advances, the patient complains of 
 the pain shooting, from the situation of the 
 bite, towards the region of the heart. Some- 
 times instead of pain, there is rather a feel- 
 ing of heat, a kind of tingling, or even a sen- 
 sation of cold, extending up to the chest and 
 throat. Occasionally no local symptoms take 
 place : thus Sabatier, in giving account of se- 
 veral cases, remarks it as worthy of notice, 
 that the bitten parts did not become painful 
 previously to the accession of the fatal symp- 
 toms ; nor did any swelling, or festering 
 occur. (See Mdm. de I'lnstilut. National , T. 
 2, p. 249. <^c.) 
 
 Dr. Marcet particularly observed, that the 
 pain follows tiie course of the nerves, rather 
 than that of the absorbents. In the case 
 which he has related, as well as in one of the 
 cases detailed by Dr. Babington, there was 
 pain in the arm and shoulder, but without any 
 affection of the axillary glands ; and in ano- 
 ther case, (See Medical Communications, Vol. 
 2,) the pain, occasioned by a bite in the leg, 
 was referred to the hip and loins, without 
 any affection of the inguinal absorbents. 
 ( Medico-Chir . Trans. Vol. 1 p. 156.) Of the 
 accuracy of the foregoing statement, by Dr. 
 Marcet, there is no doubt : the observation, 
 however, in regard to the irritation not affect- 
 ing the absorbents, was long ago anticipated 
 by several authors, who urged the freedom 
 of the lymphatic glands from disease, as an 
 argument that the disorder did not depend 
 upon the absorption of any virus. It is also 
 noticed by others, who inclined to the belief, 
 in the absorption of the infectious principle. 
 “ Resorptiouem virus ope syslematis lympha- 
 tic! fieri verisimiliirnum videtur ; neque ta- 
 rnen nee vasa lymphatics, necglandulae vici- 
 nae stimulo morboso, vel tumore adfici 
 videntur ; quod in aliis resorptionibus virulen- 
 
 tis fieri sole?. ; ( CaUisen Sijsl. Ch/irurgite 
 
 Hodiernal, Vol. 1 ,p. 595, Hafnice, 1798.) 
 
 Pain and heaviness are felt in the head. 
 Sometimes, the headach is at first very se- 
 vere : sometimes but slight ; but, in the latter 
 case, it often becomes intense, general, and 
 accompanied with a sense of pressure upon 
 the temples. In certain instances, the pa- 
 tient’s sleep lasts a good while, though dis- 
 turbed by dreams; while, in other more 
 frequent examples, he is continually restless. 
 The intellectual functions generally seem in- 
 creased; the memory stronger; the concep- 
 tion more ready ; the imagination more fer- 
 tile ; and the conversation more animated. 
 However, some patients are silent and de- 
 jected, and, when questions are put to them, 
 the answers are short and peevish. But the 
 greater number are active, lively, and talka- 
 tive. At the same time, the organs of sense 
 betray signs of increased sensibility ; and 
 the eyes, which are very open and bright, 
 avoid a strong light. Sometimes, the pupil is 
 found to be considerably dilated. Extraor- 
 dinary pains are felt about the neck, trunk, 
 and limbs. It is not uncommon also for the 
 patient to evince great anxiety, or to fall into 
 a state of dull despair and melancholy. 
 These last symptoms, of which great notice 
 is taken by writers, are particularly ascriba- 
 ble to the effect of fear. The disorder of the 
 organs of digestion is sometimes manifested 
 in various ways, though it is far from being so 
 frequent and striking, as the affections of the 
 head, which precede it. The disorder refer- 
 red to, consists at first in loss of appetite; 
 nausea; vomiting; and afterward constipa- 
 tion, and sometimes colic. In the first stage 
 of the disease, the pulse is generally some- 
 what more frequent and strong than in health, 
 and the countenance appears more animated. 
 
 The above symptoms precede the second 
 stage, or that of decided rabies, only by a 
 few days, usually four or six, though some- 
 times but two or three. (Diet, des Sciences 
 Med. T. 47, p. 78.) 
 
 The second stage of hydrophobia com- 
 meuces with the first manifestation of the 
 dread, or aversion of liquids. The ungovern- 
 able agitation and distressing sense of suffo- 
 cation excited by the sight of liquids, the at- 
 tempt to drink, or even the mere idea of 
 drinking, is unquestionably the most remark- 
 able symptom of the disorder. The patient 
 is also frequently attacked with the same kind 
 of commotion and suffering, from other 
 causes, such as the least agitation of the air, 
 or exposure to a strong light. Indeed, some 
 patients are so much affected by a blast of 
 wind, that they have been known to endea- 
 vour to elude it by walking with I heir backs 
 towards it ; (Hist, de la Soc. Roy. de Med. p. 
 157,) while others scream out whenever the 
 window or door of their room is opened. 
 (Morgagni De Sed. et Cans. Morb. Epist. 8, 
 No. 28,) 
 
 Dr. Marcet, in relating the case of the pa- 
 tient affected with hydrophobia, observes, 
 that “on our proposing to him to drink, he 
 started up, and recovered his breath by n 
 deep convulsive inspiration ; yet, he express- 
 
HYDROPHOBIA. 
 
 91 
 
 cd much regret, that he could not drink, as 
 he conceived it would give him great relief, 
 his mouth being extremely parched and clarn- 
 mv On being urged to try, however, lie 
 took up a cup of water in one hand, and a 
 tea-spoon in the other. The thought of drink- 
 ing out of the cup appeared to him intolera- 
 ble ; but, he seemed determined to drink 
 with the spoon. With an expression of ter- 
 ror, yet with great resolution, he filled the 
 spoon. and proceeded to carry it to li is lips ; 
 but before it reached his mouth, his courage 
 forsook him, and he was forced to desist. 
 He repeatedly renewed the attempt ; but, 
 with no more success. His arm became rigid 
 and immoveable, whenever he tried to raise 
 it towards his mouth, and he struggled in 
 vain against this spasmodic resistance. At 
 last, shutting his eyes, and, with a kind of 
 convulsive effort, he suddenly threw into 
 bis month a few drops of the fluid, which 
 he actually swallowed. But, at the same in- 
 stant, he jumped up from his chair, and flaw 
 to the end of the room panting for breath, 
 and in a state of indescribable terror.” (See 
 Med. Chir. Trans. Vol. l,p, loS.) Even the 
 splashing or running of any liquid causes a 
 great deal of inconvenience. As the system 
 becomes more and more affected, the patient 
 loses his sleep entirely, and has frequent and 
 violent fits of anxiety and loud screaming 
 from slight causes. The woman, whom Dr. 
 Powell attended, was often attacked in this 
 way, in consequence of so trivial a circum- 
 stance as a fly settling on her face. The noise 
 of tea cups, or the mention of any sort of 
 drink, greatly disturbed het* 1 , though sbe was 
 not at all agitated by the sound of her urine. 
 The currents of air entering her room, when- 
 ever the door opened, became very distress- 
 ing to tier, and ibis more and more so. The 
 pain in her neck became so great, that she 
 could scarcely bear it to be touched ; but she 
 made use of a looking-glass without (he in- 
 convenience, which hydrophobic patients 
 usually suffer from the sight of shining bo- 
 dies. Dr. Powell states, that the paroxysms, 
 which this poor woman suffered, resembled 
 those of hysteria, and increased in duration 
 as the disorder lasted. “ She described their 
 commencement to be in the stomach, with a 
 working and fulness there, and that a prick- 
 ing substance passed up into her throat and 
 choked her; she screamed suddenly, and 
 grasped firmly hold of her attendants, as 
 if voluntarily ; and muscular convulsions 
 came on, which were 1 sometimes more, 
 sometimes less general and violent. The 
 causes from which these paroxysms arose 
 were extremely slight ; the passage of a fly 
 near her face, the attempt to swallow a pill, 
 a stream of air, the sight of oil or wine, 
 or any other liquids, even the sound of water, 
 and other such circumstances, were sufficient; 
 she now also complained of inconvenience 
 from light, which was accordingly modera- 
 ted. The effect of sounds was peculiar; for 
 though in the subsequent stages their influ- 
 ence became more general, at this period the 
 effect was rather proportionate to the ideas 
 they excited in her mind, than to their vio- 
 
 lence. Bells, and other strong noises, did 
 not agitate her, hut the clatter of earthen- 
 ware, (he noise of a distant pump, or any 
 thing connected with liquids, produced the 
 paroxysms in all their violence.” She could 
 swallow fresh currants with less resistance 
 than any thing else, taking care that they 
 were perfectly dry. Her mind had, fill now, 
 been quite cairn and composed, and her con- 
 versation and behaviour proper, during the 
 intervals of the convulsive attacks. But Dr. 
 Powell was obliged to discontinue the pills of 
 argentum nitratum, in consequence of the 
 sufferings which the attempt to swallow 
 them regularly brought ou. Fifteen grains of 
 this substance had been given without any 
 sensible effect-. The fits, and the irritability to 
 external objects, increased. The pain shot 
 from the back of the neck, round the angles 
 of the jaws, the chin, and throat. At length 
 the paroxysms became more frequent, and, 
 indeed, might be said to come on spontane- 
 ously : seven occurred in one hour. She 
 looked pale and exhausted, anil a tremor and 
 blueness of her lips and fingers were obser- 
 vable ; her pulse became weaker and more 
 rapid, and her scalp so tender, that touching 
 it brought on convulsions. She had, latterly, 
 eructations of wind, and spit up some thick 
 viscid saliva. Her urine now came away in- 
 voluntarily, and siie was ysore and more irri- 
 table and uncontrollable* indeed, she passed 
 two hours in almost constant convulsions ; 
 became extremely irritable and impatient of 
 every thing about her, complained of failure 
 of her sight ; wished to be bled to death ; 
 her words were fewer and interrupted ; she 
 struck, and threatened to bite, her attend- 
 ants ; had copious eructations of air; dis- 
 charged an increased quantity of viscid saliva 
 with much convulsive effort ; said the affec- 
 tion of her throat and stomach had quite left 
 her; and continued in a general perspiration, 
 with a weak pulse from 140 to 150. She af- 
 terward bit some of the attendants, and was 
 therefore confined with a waistcoat. From 
 (his period, she had lost all control over her 
 mind, and continued for almost four hours in 
 a paroxysm of furious insanity. She now 
 swallowed, with an effort, near half a pint of 
 water : but this was, in a few seconds, vomit- 
 ed up with some mucus, and a greenish fluid. 
 In this violent raving state, she continued till 
 within two hours of her death, which took 
 place forty-seven hours after the first marked 
 occurrence of hydrophobia. In the course 
 of the case { she swallowed, once or twice, a 
 little porter ; and also some cinnamon-water, 
 with tinct. opii : but they were always vomit- 
 ed up. (Dr. Powell's Case of Hydrophobia.) 
 
 It is by no means uncommon tor a period 
 to occur, when the horror of liquids undergut s 
 a considerable diminution, or even entirely 
 ceases; the patient quenching his thirst, and 
 this sometimes as well as if he were in peifect 
 health, and so as to raise doubts of the exist- 
 ence of rabies. But after a few hours, the 
 dread of fluidscomes on again, and with it the 
 convulsive paroxysms, which now become ge- 
 neral. violent, and incessant. Dr. Cayol at- 
 tended a girl, labouring under rabies, who 
 
HYDROPHOBIA. 
 
 92 
 
 was never affected with any very great dread 
 of liquids, nor an absolute inability to swal- 
 low them, though she certainly disliked them, 
 and swallowed >hem with difficulty. ( Journ . 
 de Med. Chir. tyc. Avril., 1811, p. 241.) IN ay, 
 patientsare sometimes seen, ho can man .ge 
 to swallow red wirie and broth, though their 
 aversion to water is alread) beyond all con- 
 trol; and other patients can sometimes look tit 
 a liquid in a black put without inconvenience ; 
 though any fluid ottered to them in a glass 
 will bring on a violent paroxysm of spasm 
 and sense of suffocation. The sight of tears 
 has even been enough to bring on the attack. 
 (See Diet. des Sciences Med. T. 47, p. 79.) 
 
 The question lias sometimes been enter- 
 tained, whether rabies can ever exis-t quite 
 unattended throughout its course with a dread 
 of liquids ? The possibility of such a case 
 was believed by Mead and others, and an in- 
 stance is recorded by Migriot, in which the 
 patient died, without having manifested any 
 sign of hydrophobia. (See Hist de la Soc. 
 Roy. de Med. an 1783, 2 me Part. p. 48.) How- 
 ever, it is asserted, that a careful perusal of 
 this case must produce a conviction, th.it the 
 disorder was not raoies ; and it is added, that 
 when the histories of this disease on record 
 are critically investigated, none will be found 
 complete, which do not make mention of a 
 more or less decided aversion to fluids. It 
 also appears from the facts referred to, that 
 the dread of liquids does not depend upon the 
 pain, which the patient has already suffered 
 from his attempts to drink, as it sometimes 
 occurs before any such attempt has been 
 actually made. ( Vol . cit.p. 80) 
 
 An inclination to bite has been noticed, 
 as happening in the patient, whose case is 
 recorded by Dr. Powell. Yet, this disposi- 
 tion is far from being usual ; and it never 
 presented itself in any of the cases which 
 fell under the observation of the author of 
 the article rage in the foregoing publication, 
 or P. Desault, Duchoisel, Dr. J Vaiighan, 
 Sabatier, Dupuytren. &c. And even when 
 the patient’s imaginalion is so disordered, 
 that he cannot help biting, he commonly 
 warns the bystanders to avoid the danger. 
 The frolhy slaver, which is voided with 
 considerable and repeated efforts, is a symp- 
 tom, which is said not to commence before 
 the respiration begins to be convulsive. As 
 the disease advances, there is no remission 
 of the sputaiion, necessary to clear the 
 throat of this viscous secretion ; and at the 
 approach of death, when it cannot be ex- 
 pelled, it collects in the mouth, and covers 
 the patient’s lips. 
 
 The symptoms of what is termed cerebral 
 excitement become stronger and more 
 marked in the second stage of the disease. 
 The eyes, the brightness of which is still 
 further increased, appear, as it were, infla- 
 med-; the patient never shuts them again ; 
 and as the daylight and brilliant colours are 
 offensive, he prefers darkness. The hearing 
 becomes very acute, and as well as the 
 sight, is troubled with hallucinations. The 
 touch is extremely fine ; the speech abrupt 
 and rapid ; and the conversation energetic, 
 
 and often expressive of the most touching 
 sentiments, {Did. des Sciences Med. T. 47, 
 V • 1 •) 
 
 Dr. Marshall made a very just distinction 
 between the real convulsions which came 
 on towards the termination of the case in 
 death, and the strong sudden action of the 
 muscles, excited in the course of the disor- 
 der by the light, the sight of liquids, and the 
 feel of the air. {The Morbid Anatomy of the 
 Brain, fyc. p. 88.) Convulsions and hic- 
 cough, in fact, are the symptoms of disso- 
 lution. 
 
 Delirium is far from being a constant 
 symptom, and only happens the last day of 
 the disorder. ^Neither is it always without 
 remissions ; for the patients affected with it 
 sometimes give rational replies. Kvery case 
 upon record, where delirium is described as 
 being one of the first symptoms, or as com- 
 ing on with the dread of liquids, is set down 
 on good authority, not as true rabies, but 
 a symptomatic hydrophobia, attended with 
 mania. 
 
 The dread of swallowing liquids, though 
 the most singular symptom of the disease, 
 constitutes but a small part of it. It is true, 
 that none, or very few recover, who have 
 this symptom, yet they certainly do not die 
 in consequence of the difficulty of swallow- 
 ing liquids ; for the human body could easily 
 exist double the time, at the end of which 
 the disease usually proves fatal, without food 
 or drink. Besides, the sick can often swallow 
 substances that are nourishing, in a pulpy 
 state, without, however, having their life 
 thereby at all prolonged. It is not, there- 
 fore, the difficulty, or impossibility of swal- 
 lowing liquids ; but the effects of the poison 
 upon the constitution at large, which occa- 
 sion dea*h. {Dr. J. Hunter in Trans, for 
 the Improvement of Med. Knowledge , Vol 1, 
 p. 305.) 
 
 The extreme sensibility of the sick to all 
 impressions, appears in the displeasure 
 which they express at even the air blowing 
 upon them ; in their dislike to a strong 
 light ; in their aversion to new faces, or even 
 tiie sight of their friends and relations ; and 
 in the terror they express at being touched, 
 which almost threatens to throw them into 
 convulsions. As the disease advances, the 
 mind is more and more filled with dreadful 
 fears and apprehensions. {Op. cit.p. 307.) 
 
 In the second stage, the epigastrium, as 
 well as the chest, is the seat of considerable 
 pain ; the patient is constipated, but the 
 urine is plentiful and high coloured. Before 
 a certain period, the pulse is generally 
 strong, regular, and a little accelerated ; but 
 towards the end of the case, it becomes 
 small, irregular, feeble, and rapid. (See 
 Did. des Sciences M6d. T. 47, p. 83.) 
 
 The duration of life, from the appearance 
 of hydrophobia till death, varies from thirty- 
 six hours to four or five days : the most 
 common period is fr. • m tvyo to three days. 
 {Dr.J. Hunter, Op. cit.p. 308.) The event is 
 said to be directly caused by asphyxia, or 
 the cessation of respiration. Of ten persons, 
 who were bitten by the same animal, nine 
 
HYDROPHOBIA. 
 
 died on the second and third day, from the 
 commencement of the horror of fluids, and 
 only one on the fifth day. There is an account 
 of a child at Senlis, who lived nine days, 
 but the description of the case, and the cir- 
 cumstance of fourteen worms being found 
 in the intestines, may raise doubts about the 
 nature of the disease. (See Hist, de la Soc. 
 Hoi/, de Med. p. 209, 155.J 
 
 Whatever may be the resemblance found 
 between rabies and hydrophobia, with re- 
 gard to the rapidity of their course, their 
 causes, and some of /their symptoms, the 
 following considerations, as a modern wri- 
 ter observes, will always serve for the dis- 
 crimination of one disorder from the other: 
 tetanus attacks the muscles of the jaw, w hich 
 remains motionless, w hile in rabies, the jaw 
 is not only moveable, but incessantly mo- 
 ving, in consequence of the efforts unremit- 
 tingly made by the patient to free bis mouth 
 from the thick saliva with which it is ob- 
 structed. In this last disorder, the muscles 
 are alternately contracted and relaxed ; but 
 in tetanus, they always continue rigid. Te- 
 tanus is rarely attended with any aversion 
 to liquids, and the patient may be kept for a 
 long time in a bath without inconvenience ; 
 and the paroxysms are neither excited, nor 
 increased by a vivid light, a noise, the pa- 
 tient’s being touched, or the sight of water, 
 or shining surfaces. In addition to these 
 differences, it is to be remembered, that 
 tetanus is most frequent in warm climates, 
 and that it mostly comes on a few days after 
 the receipt of a local injury, and may occur 
 as a complication of any kind of wound, 
 even that which is made in a surgical ope- 
 ration. (See Diet, das Sciences Med. T. 47, 
 
 p. 86.) 
 
 On the subject of prognosis, with respect 
 to the bite inflicted by a rabid animal, and 
 its effects, as evinced in the decided form 
 of rabies, there are several things worthy of 
 attention. According to some writers, small 
 wounds are not less dangerous than others, 
 and an attempt is made to account for the 
 fact, by the more copious hemorrhage from 
 larger wounds, and the frequent neglect of 
 lesser injuries. Perhaps another reason is, 
 that the virus is more likely to be confined 
 in a wound with a small orifice, than in one 
 which is ample, and admits of being more 
 effectually washed. The more numerous 
 the wounds are, the greater is the risk. If 
 it be inquired, what is the average number 
 of persons attacked with rabies out of a 
 given number w ho have received bites ? 
 The question can only be answered by r/ - 
 ferring to the extremes. Thus, Dr. J. Vaugh- 
 an speaks of between twenty and thirty 
 individuals, bit by a mad dog, ot whom only 
 one was afterward attacked with rabies ; 
 and Dr. J Hunter teljs us of an instance, 
 in which out of twenty-one persons bit, only 
 one became affected. (See also Folhergill 
 in Med. Obs. and Inq. Vol. 5, p. 195.) On 
 the other hand, out of fifteen persons bit by 
 a mad dog, and taken care of at Senlis, three 
 at least were seized with the disorder, (Hist, 
 de la Soc. Roy. de. Med.p. 130 ;) of seventeen 
 
 93 
 
 others bit by a wolf, ten were attacked ; 
 (ib. p. 130;) and of twenty-three, bit by a 
 she-wolf, thirteen died of rabies. (L. F. 
 Trolliel, Nouveau Trait 6 de la Rage, fyc. 
 Obs. Chirurgique, fyc. No. 25.) 
 
 a wo important facts should always be 
 recollected ; viz. the disease may often be 
 prevented ; it can hardly ever be cured. 
 Experience has fully proved that when hy- 
 drophobia once begins, it generally pursues 
 its dreadful course to a fatal termination, 
 the records of medicine furnishing very few 
 unequivocal and well-authenticated cases 
 to the contrary. Hence, the imperious ne- 
 cessity of using every possible means for the 
 prevention of the disorder. 
 
 Probably, however, many things which 
 possess the character of being preventive of 
 hydrophobia, have no real claim to such 
 reputation. I would extend this observation 
 to all internal medicines, mercurial fric- 
 tions, and plunging the patient for a consi- 
 derable time under water. 
 
 The instances, in which a prevention is 
 inferred to have taken place, by different 
 w riters, in consequence of such means, may 
 all be very rationally ascribed to other cir- 
 cumstances. Facts already cited sufficiently 
 prove, that out of the great number of per- 
 sons frequently bitten by the same dog, only 
 a limited proportion is commonly affected . 
 The hydrophobic poison is known to reside 
 in the saliva of the animal ; consequently, 
 the chance of being affected must greatly 
 depend upon the quantity of this fluid which 
 is insinuated into the wound ; and if the 
 teeth of the animal should have previously 
 pierced a thick boot, or other clothing, be- 
 fore entering the skin, the danger must be 
 obviously much diminished. Many patients 
 wash and suck the w r ound, immediately after 
 its occurrence, aqd thus, no doubt, very often 
 get rid of the poison. Even wdien it is lodg- 
 ed in the wound, it may not be directly ab- 
 sorbed, but be thrown off with the discharge. 
 All prudent patients submit to excision of 
 the bitten part. Now. under each of the 
 above circumstances, escapes have frequent- 
 ly occurred, while internal medicines, half 
 drowning or salivating the patients, had also 
 not been neglected, so that all the efficacy of 
 preventives has too often been most unjustly 
 ascribed to means, which probably never 
 yet had, and never will have, any beneficial 
 effect whatever. What confirms the truth of 
 the preceding statement is these facts: that 
 persons bitten by the same animal have 
 sometimes been treated exactly on the same 
 plan ; some of them escaped the disease ; 
 others had it, and of course perished : on 
 other occasions, some of the patients, bit- 
 ten by the same animal, have been treated 
 in a particular way, and have escaped hy- 
 drophobia; w hile others bitten at the same 
 time by the animal, also never had any con- 
 stitutional effects, although they took no 
 medicines, nor followed any other particu- 
 lar plan. 
 
 If to these reflections be added the con- 
 sideration, that it is frequently doubtful, 
 whether the bite has actually been inflicted 
 
94 
 
 HYDROPHOBIA. 
 
 by a truly rabid animal, and that the men- 
 tal alarm will sometimes bring on a symp- 
 tomatic hydrophobia, it is easily conceiva- 
 ble, how mistaken a person may be, who 
 believes that he has prevented the disorder, 
 and how unmerited is the reputation of the 
 means, which ho has employed for the pur- 
 pose. 
 
 The bite of a naturally ferocious beast 
 has often been thought to be attended with 
 more risk than that of an animal naturally 
 f ame ; and hence the bite of a wolf is said 
 to be more frequently followed by rabies, 
 than that of a dog. This proposition is ad- 
 mitted to be true ; but the explanation is 
 erroneous. The true reason of the differ- 
 ence is, that a wolf usually seizes the face, 
 and inflicts a deeper bite; while a dog only 
 snaps as he runs along, and mostly bites 
 through the clothes. (See Dirt, des Sciences, 
 Med. T. 47, p. 88.) The bite of a rabid ani- 
 mal may be rendered much more dangerous 
 by being situated near a part, or an organ, 
 which increases the difficulty, or risk, of 
 adopting an effectual mode of removing 
 the whole of the flesh, in which the virus 
 may be lodged. Thus, bites near the large 
 arteries, the eyes, the joints, &c. are of a 
 more serious description than others. Dr. 
 J. Hunter rated the hazard in some degree 
 by the vascularity of the bitten parts. The 
 prognosis will always he more unfavourable, 
 when no proper measures have been applied 
 to the bite soon after its infliction, and per- 
 haps the risk may be increased by certain 
 causes not having been duly avoided, which, 
 as already stated, are thought to have a ten- 
 dency to accelerate the attack of rabies. The 
 exact time after a bite, when the prevention 
 of rabies is no longer practicable, is quite an 
 undetermined point ; but every fact known 
 upon the subject, evinces in an urgent man- 
 ner the necessity of adopt big preservative 
 measures without the lea^t delay. 
 
 In almost all the dissections of patients, 
 who have died of rabies, certain indications 
 of inflammation have been perceptible *, 
 mure frequently, in some part of the space 
 between the pharynx and the. cardiac orifice 
 of the stomach, in the stomach itself, in the 
 lungs, the choroid plexus, and membranes of 
 the brain. (See Med. Repository. Vol. 3. p. 51.) 
 3V1. Troliiet opened with the greatest c ue sis 
 bodies of persons destroyed by this disease. 
 The mouth and fauces in each subject were 
 first examined, and found of a pale grayish 
 colour scarcely lubricated with mucus, and 
 quite free from all frothy matter. All the 
 salivary glands seemed perfectly healthy. 
 When the larynx, trachea, and bronchia; 
 were opened, they appeared to have been the 
 seat of inflammation, the traces of which 
 were the most marked low down, where the 
 mucous membrane was of the colour of 
 wine-lees. In four of the bodies, frothy mu- 
 cus was perceived in the bronchia;, larynx, 
 and trachea. Troliiet infers from these ap- 
 pearances, that the frothy matter seen about 
 the mouths and lips of patients affected with 
 rabies, is secreted by the inflamed mucous 
 membrane of the bronchia;, arid tlmt it is 
 
 this secretion, and riot the veal saliva, which- 
 contains the hydrophobic poison. (Nouveau 
 Trails de la Rage, 4 c ) In giving an ac- 
 count of a dissection, Faure also long ago 
 remarked, that the frothy matter was only 
 met with in the air-passages, that the sali- 
 vary organs were unaffected, and that the 
 saliva itself did not contribute to the form- 
 ation of the thick slaver, which appeared 
 to have issued from the chest. (Hist, de la 
 Soc. Roy. de M6d. ann. 17S3, p. 39.) From 
 the preceding observations, and those of 
 Mignot de Genety (Vol. cit.p. 54,) Morgagni 
 (De Sedib. et Caus. Morb. Epist. 8, art. 20, 
 25, 30.) Darlue (Journ. de Med. de Vander- 
 monde. T. 4, p. 270 ;) B. Rush; and Dupsey 
 (Obs. InMites, No. 138) it would appear: 
 
 1 That the mouth, strictly so called, 
 and the salivary glands, are without any al- 
 teration. 
 
 2. The mucous membrane of the air-pas- 
 sages is affected with inflammation, which 
 in its highest degree extends from the divi- 
 sion of the bronchia; to the pharynx. .When 
 the inflammation is of less extent, the pha- 
 rynx appears sound ; and when yet more 
 limited, it is usually not to be traced in the 
 larynx. The point where it seems to com- 
 mence and is most strongly marked, is at the 
 lower part of the trachea, or in the bron- 
 chia;. Lastly, when none of these parts are 
 found inflamed, the lungs themselves present 
 vestiges of inflammation. 
 
 With respect to the theory of Troliiet, 
 wherein the hydrophobic poison is said to 
 be contained in the mucous secretion void- 
 ed from the lungs, and to be the product of 
 inflammation of the membrane of the 
 bronchia;, and not derived from the sali- 
 vary glands; the question requires the- 
 confirmation of experiment ; for, though 
 the salivary glands are not the seat of pain, 
 swelling, fcc. it, by no means follows, that 
 their secreting process may not have been 
 subject to some peculiar modification, on 
 which the production of the hydrophobic 
 virus depended. Thus, severe and obstinate 
 ptyalisras often occur, and yet there is no 
 manifest change in the state of the salivary 
 glands. According to Van Swieten and 
 Mead, there are also sometimes no morbid 
 appearances either in the head, fauces, chest, 
 or stomach. (Comment, in Bocrh. T. 3 ,p. 
 562.) 
 
 In three cases, out of six, the lungs were 
 found emphysematous, that is to say, their 
 interlobular substance was distended with 
 air, and the pleura pulmofialis raised into a 
 great number of transparent vesicles on the 
 surface of the lungs. In a fourth instance, 
 the emphysema was not observed in the 
 lungs themselves, but in the cellular substance 
 between the two layers of the mediastinum ; 
 and under the muscles of the neck. Mor- 
 gagni also noticed vesicles of air on the sur- 
 face of the lungs of a person, that die^ of 
 hydrophobia.' (DeSed.cl Cans. Morb. Epist. 
 8, art. 30.) M. Troliiet presumes, that this 
 emphysema is occasioned by the rupture oi 
 one of the air-cells, in the convulsive efforts 
 of respiration, as sometimes happens when 
 
HYDROPHOBIA. 
 
 95 
 
 a foreign body is lodged in the larynx. (See 
 Cases by Louis and Lescure in Mem, de V Acad, 
 de Chir. T. 4 ,p. 538 ; T. 5, p. 527 ) 
 
 The lungs were of a deep-red colour in 
 all the six subjects dissected by Trolliet, and 
 they were observed to be gorged with blood 
 in cases reported by numerous writers: as 
 Bonet (See Van Swieten , T 3, § 1 140 ;) Bo- 
 erhaave (Op. Omn. p. 215 ;) Morgagni (De 
 Sedibus et Cans. Morb. F.p. S, art. 23, <^c. ; ■ 
 Mead, Darlue (Recueil Period, fyc. T. 3. and 
 4 ;) Faure (Hist, de la Soc. Roy. de Med. p. 
 39 ;) De la Caze (ib. p. 69 ;) Portal, Old- 
 know, Ballingall (Edinb. Med. and Surg. 
 Journ. :) Marshall (Morbid Anatomy of the 
 Brain, fyc. p. 69 ;) Gorey (Journ. de Med. 
 Chir. T. 13, p. 83 ;) Ferriar (Med. Hist, and 
 t Reflections , §c.) u Pnlmones in quinque 
 * nigri ex toto, aut magn& parte (says Morgag- 
 ni,) in quatuor magna item ex parte sanguine 
 pleni.” With respect to the state of the or- 
 gans of the circulation, in three of the cases 
 dissected by Trolliet, a good deal of air 
 escaped from the heart and aorta. Morgagni 
 is supposed to be the only other writer, who 
 has noticed a similar occurrence (Epid. 8, 
 Mo 30,) and who also in another case saw 
 air escape from beneath the dura mater. (Ib. 
 No. 23.) fn two of Trolliet’s cases, some 
 gelatinous clots were found in the heart and 
 large vessels ; but the great mass of blood 
 was black, and very fluid in the heart, arte- 
 ries, and veins, as in subjects, who have died 
 of asphyxia. In all the six cases, traces of 
 inflammation were noticed in the brain, or 
 its membranes. The sinuses w ere filled with 
 a dark-coloured fluid blood ; and the pia 
 mater was much injected, and of a brownish 
 hue. The same appearances were found 
 above the cerebellum, and the vessels on the 
 investment of the medulla spinalis w r ere con- 
 siderably enlarged. The surface of the ce- 
 rebrum w r as also studded with scarlet spots, 
 which appeared to arise from blood effused 
 from the small vessels of the pia mater into 
 its cellular substance. In two subjects, blood 
 was extra vasated tow r ards the base of the brain 
 in larger quantity. The plexus choroides was 
 gorged with blood, and of a brown colour. 
 Besides those and other changes, Trolhet re- 
 marked, in two of the cases, a thickening of 
 the pia mater. The substance of the brain 
 was generally softer than usual ; but the fluid 
 in the lateral ventricles was not in large quan- 
 tity, though, in tw r o cases, it had a bloody tinge. 
 Tiie late Dr. Marshall believed that in rabies, 
 the brain was the part principally affected. 
 (Op. cit. p. 145.) 
 
 Hufeland conjectured, that, in hydropho- 
 bia, the medulla spinalis is the part originally 
 affected, whence the effects of the disease 
 are propagated to the nerves of the trunk. 
 
 (Bibl. Med. T. 55, p. 395, fyc.) Dr. R. Reid 
 believed, that an alteration of the spinal 
 marrow was essentially concerned in the 
 disease. (On the Nature, fyc. of Tetanus of 
 Hydrophobia, Svo. Dublin , 1817.) A caae 
 was also published by M. Matthey, of Gene- 
 va, in which a quantity of serum was found 
 within the spinal canal. (Journ. Gen. de 
 Med. T. 54, p. 279 ) See on this subject 
 
 some observations by Dr. Abercrombie. 
 (Edinb. Med. and Surg. Journ. Vol. 14. 
 
 p. 66.) 
 
 According to Trolliet , the traces of inflam- 
 mation in the digestive organs are not so 
 constant as in the lungs and brain. In none 
 of the six cases dissected by him, was there 
 any appearance of inflammation in the pha- 
 rynx, though some parts of the alimentary 
 canal were atfected in this manner. The 
 cases recorded, however, in which the diges- 
 tive organs presented considerable mor- 
 bid appearances, are very numerous. Thus 
 Joseph de Aromatarius, Darlue (Recueil Pe- 
 riod. T. 3 , p. 189, et T. 4 , p. 270.) Sauvages 
 (p. 107,) Professor Rossi, M. Gorci (Journ. 
 de Med. Chir. tye. T 13.) and Dr. Powel (Case 
 of Hydrophobia,,) found inflammation either 
 in the pharynx, or oesophagus, or both these 
 tubes; Dr. Powell’s words are, “ the oesopha- 
 gus was rather redder than natural, and 
 covered with a thin layer of coagulable 
 lymph.” A similar coat of lymph was also 
 found by Oldknow (Edinb. Med. and Surg. 
 Journ Vol,. 5, p. 280,) Ballingall (Op. cit. Vol. 
 11, p. 76.) Dr. Ferriar (Med. Hist. S^c. Vol. 
 3 , p. 27.) In dogs. Dr Gillman found the 
 pharynx and oesophagus in a stale of inflam- 
 mation. (On the Bite of a Rabid Animal ,p, 
 13, 23, 26, 44.) It is conjectured, that 
 in many of these instances, the inflam- 
 mation extended to the oesophagus from 
 the trachea and bronchi*. (Diet, des Sci- 
 ences Med. T. 47, p. 98.) Inflammation 
 of the mucous membrane of the stomach 
 and small intestines, has likewise been 
 very generally noticed, as may be seen 
 by referring to the accounts published 
 by Morgagni, Powell, Oldknow, Ferriar, 
 Ballingall, Marshall, &.c. In d ;gs, the same 
 fact was remarked by Dr. Gillman (P. 13, 31, 
 44;) sometimes, however, according to 
 this last author, no vestiges of inflammation, 
 nor any other morbid appearances, are dis- 
 coverable in the examination of animals 
 that have died of rabies. (P 83.) Dupuy- 
 tren is stated to have found the mucous 
 membrane of the stomach and bowels in- 
 flamed in several places, and even almost 
 gangrenous (Diet des Sciences Med. T. 47, p. 
 98.) 
 
 From recent investigations, made at the 
 veterinary school at Abort, by Professor 
 Dupuy, the following are tiie usual morbid 
 appearances, noticed in the dissection of 
 dogs, horses, cows, and sheep, destroyed by 
 rabies. 1 The lungs and brain universally 
 gorged w'ith blood. 2. Greater or lesser 
 remarks of inflammation in the mucous 
 membrane of the bronchi*, trachea, larynx, 
 throat, oesophagus, stomach, and frequently 
 even in that of the bowels, vagina, ute y, 
 and bladder. 3. The air-passages filled with 
 frothy mucus. 4. - collection of serum in 
 the ventricles of the brain, and sometimes 
 even betweeh the membranes, covering the 
 spinal marrow. 5. An unusual redness of 
 tiie investment of the pneumogastric and 
 trisplanchnic nerves. (See Diet, des Sciences 
 Med. T. 47, p. 99.) 
 
 Happily, surgery possesses one tolerably 
 
HYDROPHOBIA. 
 
 DO 
 
 certain means of preventing hydrophobia, 
 when it is practised in time, and in a com- 
 plete manner Every reader will know, 
 that I he excision of the bitten parts is the 
 operation to which I allude. Indeed, as hy- 
 drophobia is often several months before it 
 begins, the wounded parts should, perhaps, 
 always be cut out, e \ eu though they are heal- 
 ed, and some weeks have elapsed since the ac- 
 cident, provided no symptoms of the hydro- 
 phobia have actually commenced. The 
 operation should be done completely; for 
 a timorous surgeon, afraid of cutting deeply 
 enough, or of removing a sufficient quantity 
 of the surrounding flesh- would be a most 
 dangerous one for the patient. All hopes of 
 life depend on the prevention of the disor- 
 der ; for in the present state of medical 
 knowledge, none can rest upon the efficacy 
 of any plan, except the extirpation of the 
 part. For this purpose, caustics have some- 
 times been employed. However, as their 
 action can never be regulated with the 
 same precision as that of the knife, and con- 
 sequently, they may not destroy the flesh to 
 a sufficient depth, excision should always 
 be preferred. The latter method is also the 
 safest for another important reason, viz. tue 
 part, and poison lodged in it, are removed 
 from the body at once; but when the cau- 
 tery or caustic is used, the slough must re- 
 main a certain time undetached. Some 
 surgeons are not content with cutting out 
 the part: but after the operation, till the 
 wound with the liquor ammoniae, or caute- 
 rize its surface, for the sake of greater secu- 
 rity. How late excision may be done with 
 any prospect of utility I am not prepared 
 to say ; but, there are practitioners, who 
 deem excision right, even when heat, irrita- 
 tion, or inflammation is observed in the bit- 
 ten part. (See Med. Repository, Vol. 3, p. 
 54.) 
 
 Cases present themselves, in which it is 
 even preferable to amputate the limb, than 
 attempt to extirpate either with the knife, 
 or cautery the whole of tiie bitten parts ; 
 an endeavour, which could not be accom- 
 plished with any degree of certainty. Thus, 
 as Delpech observes, when the hand or foot 
 has been deeply bitten in several places, it 
 is obvious, that it would be impossible to 
 make caustic, (or the cautery) certainly 
 reach every part, which the saliva of the 
 rabid animal may have touched. Besides, 
 the mischief resulting both from the injury, 
 and the other proceedings together, might 
 be such as to afford no prospect of saving 
 the limb, or at least, of preserving it in an 
 useful state. (See Precis Idem, des Mai. 
 Cliir. T. 2, p. 133.) I have known of one or 
 two cases, in which the patients lost their 
 lives, in consequence o. the excision, or de- 
 struction of the bitten parts ,iot having been 
 attempted, on account of the surgeon’s re- 
 luctance to cut tendons, or wound a large 
 artery, as one of those at the wrist. In such 
 cases, however, the fear of rendering a 
 muscle useless, or of wounding an artery, 
 is no justification of leaving the patient ex- 
 posed to a danger, so surely fatal, as that of 
 
 the hydrophobic virus, if it once affect the 
 constitution. The artery should be exposed 
 for a sufficient length, and secured with two 
 ligatures, when the requisite extirpation 
 of the parts between them may be safely 
 performed. 
 
 When once the hydrophobic symptoms 
 have commenced, there is little or no hope 
 of -aving the pa'ient, the disease having 
 almost invariably baffled every plan of 
 treatment, which the united talents of nu- 
 merous medical generations have suggested. 
 All the most powerful medicines of every 
 class have been tried again and again ; 
 mercury; opium; musk; camphor; arse- 
 nic; the nitrate of silver; cantharides ; 
 belladonna; ammonia; plunging the pa- 
 tient in the sea ; bleeding ; be. &c. 
 
 The inefficacy of opium is now generally 
 acknowledged ; in the space of fourteen 
 hours, Dr. J. Vaughan gave one patient 
 fifty -seven grains of opium, and also half an 
 ounce of laudanum in a clyster, but the fa- 
 tal termination of the disease was not pre- 
 vented. Dr. Babington even prescribed the 
 enormous quantity of 180 grains in eleven 
 hours, without the least amendment, or 
 even any narcotic effect. (Med. Records 
 and Researches, p. 121.) On the very first 
 day, that rabies decidedly showed itself in 
 a man, who had been bit by a mad dog, 
 Dupuytren injected into the vena saphena, 
 by means of Anel’s syringe, two grains of 
 the extract of opium dissolved in distilled 
 water, and as a degree of calm appeared to 
 be the result, four grains mure were thrown 
 into the cephalic vein. The patient re- 
 mained perfectly tranquil three hours longer; 
 but the symptoms afterward recurred with 
 increased violence. The next morning, 
 about six or eight grains more were dissol- 
 ved, and thrown into the circulation ; but, 
 all was in vain, as the patient died in three 
 quarters of an hour after the last injection, 
 (see Diet, des Sciences Med. T.41,p. 131.) 
 
 As for belladonna, its employment for the 
 prevention and cure of hydrophobia is very 
 ancient, its external use for this purpose ha- 
 ving been mentioned by Pliny, and its inter- 
 nal exhibition, w ith the same view, by Theod. 
 Turquetus in a posthumous work published 
 in 1696. (See Pmxeos Medicce Syntagma, 
 ^•c.) In 1763, belladonna was recommended 
 by Schmid as a remedy for hydrophobia, , 
 and in 1779 by J. H. Munch. (See Richter's 
 Chir. Bibl.) At present, this medicine, has 
 entirely lost its character of possessing any 
 power against hydrophobia. 
 
 01 late years, the public hope has been 
 raised by {he accounts given of the virtue of 
 hydro-chlorine, or oxymuriatic acid. Wen- 
 delstadt even published the story of an Eng- 
 lishman, who allowed himself to he bit seve- 
 ral times by a mad dog, and then saved him- 
 self by washing the bites with this acid. 
 And, still more recently Professor Brugna- 
 ttjlli, in the Italian Journ of Physic, Chymis- 
 try, be. ( T . 9, p. 3.4,) has published some 
 observations, lending to prove the efficacy 
 of the external and internal employment of 
 the medicine for the prevention of rabies. 
 
HYDROPHOBIA. 
 
 97 
 
 The biles are washed with it, and then co- 
 vered with chappie wet with it. And, when 
 the symptoms commence, if it could not he 
 swallowed in a fluid form, Brugnatelli gives 
 bread pills imbued with it. For a child eight 
 years old, the dose is 3ij four or five times 
 a day, but gradually increased. According 
 to Orfila, hvdro-chlorine was long since re- 
 commended by Cluzel, as an internal remedy 
 for hydrophobia. ( S&cours a dormer auxper- 
 sonnes empois niees, fyc. Svo Paris, 1818, p. 
 158.) With regard to Brugnatelii’s cases, 
 they are said to be so destitute of precision 
 and certainty, that no inference can be drawn 
 from them. ( Diet, dcs Sciences Med. T. 47, p. 
 119.) In order to ive hydro-chlorine a fair 
 trial, it was used internally and externally 
 on seven patients in the Hotel-Dieu at Lyons 
 in 1817. The bites were washed and bathed 
 with it, and some of them also cauterized ; 
 and each patient took daily a dram of the 
 acid, made into an agreeable sweetened 
 drink. All these unfortunate individuals 
 afterward died of rabies, though the treat- 
 ment was begun the day after the receipt of 
 the wounds. ( L . F. Trolliel , Nouveau Troil6 
 de la Rage, tyc.) The excision of the bites 70 
 lion rs after their infliction, and washing the 
 wound with oxymuriatic acid, did not in Dr. 
 Johnson’s case prevent the disease. (See 
 Edinb. Med. and Snrg. Journ. Vo!. 15, p. 212.) 
 In America, the plant scuteilaria lateriflora 
 has been lately extolled, as a certain specific 
 for hydrophobia. (See A History of the In- 
 troduction and Use of Scutellaria Lateriflora , 
 as a remedy for preventing and curing Hydro- 
 phobia, by Lyman Spalding, M. D. New- York, 
 1819.) I'he prussic, or hydrocyanic acid 
 has likewise been proposed, on account of 
 its reputed antispasmodic properties; but, 
 some experiments, made with it on dogs by 
 Dupuytren, iVIagendie, and Breschet, furnish 
 co results in favour of its being likely to 
 prove useful in the present disorder. (See 
 Diet, des Sciences Med. T. 47. p. 133.) By 
 Dr. Rossi, of Turin, the trial of galvanism 
 was suggested. (Alibert, Nouveaux Elemens 
 de Therapeutique , T. 2 ,p. 436, Ld. 4 ;) yet, 
 the only fact brought forward, as an en- 
 couragement to persevere with the last 
 means, appears to a modern author, from its 
 symptoms and progress, not to have been a 
 case of rabies. ( Dirt cit T.41,p. 126.) The 
 rapid and powerful effects of t.he bite of a 
 viper on the whole :-yslem, and perhaps the 
 idea, that the operation of this animal’s 
 venom might counteract that of the hydro- 
 phobic virus, led some experimenters to try 
 what would be the result of subjecting pa- 
 tients, affected with rabies, to the bite of that 
 kind of snake. Tiie project, however, was 
 attended with no success Three cases of 
 this description were communicated to the 
 Royal Society of Medicine, (Hist. p. 201 ;) 
 two additional ones were recorded by Dr. 
 Gilibert, physician to the HOtel-Dieu at Lyons, 
 { Advers . Med. Pract. p. 257;) and Viricel, 
 surgeon of the same hospital, repeated the 
 experiment on a child, which yet fell a vic- 
 tim to hydrophobia. Other trials are also 
 said to have been made in France and Ger- 
 Voj,. H 13 * 
 
 many with no better success. Dr. de Mathiis, 
 in the year 1783, let a viper bite a rabid dog 
 on the throat. '1 he dog's head was attacked 
 with considerable swelling, the hydrophobia 
 ceased, and, according to some accounts, 
 the animal perfectly recovered ; but, accord- 
 ing to other statements, though it drank 
 freely as soon as its head had swelled, it 
 only survived the experiment a few hours. 
 (See Diet, des Sciences Med T. 47, p. 126.) 
 
 Some facts which occurred a few years 
 ago in the East Indies, tended for a time to 
 raise an expectation, that a copious abstrac- 
 tion of blood might be the means of pre- 
 serving patients actually attacked with this 
 fatal disorder. Mr. Tyrnon, assistant surgeon 
 of the 22d Light Dragoons, tried successfully 
 tiie method of taking away at once an im- 
 mense quantity of blood from the patient, 
 “ I began by bleeding him (,says Mr. Tymon) 
 until scarcely a pulsation could be felt in either 
 arm.” Opium was afterward given, and 
 the patient salivated with mercury. (See 
 Madras Gazette of Nov 23, 1811.) 
 
 Although in the observations, annexed to 
 this case by Dr. Berry, there are some cir- 
 cumstances. which render it probable, that 
 the case was really hydrophobia ; yet, as the 
 successful termination of it is an event so 
 extraordinary, I much regret, that some de- 
 sirable information is omitted. For instance, 
 we have no account of any pain, or changes, 
 in the bitten part, or limb, at the first 
 coming on of the indisposition. The early 
 constitutional symptoms are not described, 
 and the violent spasms, screaming, fcc. are 
 the first things mentioned. Some particu- 
 lars of the dog would also have been inter- 
 esting. 
 
 Such information, indeed, becomes still 
 more essential, when we find it stated, that 
 another man, Serjeant Jackson, was also 
 bitten by the same doi:, and had hydrophobia 
 in a mild form, from which lie recovered 
 under the use of mercury, blisters to the 
 head, and cathartic injections, without any 
 recourse to bleeding at all. This last case is 
 even more contrary than the former, to what 
 general experience teaches; because mer- 
 cury, blisters, and injections, have been tried 
 a thousand times unavailing!}' ; while, per- 
 haps, blood-letting, in the manner practised 
 by Mr. Tymon , is a new treatment. Dr. 
 Schoolbred, of Calcutta, published a second 
 case of hydrophobia cured by bleeding ad 
 deliquium aniroi, and afterward exhibiting 
 calomel and opium. The patient, being 
 threatened with a relapse, was largely bled 
 again. The whole of tiie success is imputed 
 by Dr. Schoolbred to the venesection. But 
 this gentleman is not so sanguine as to be- 
 lieve. that, bleeding will cure every case of 
 hydrophobia. It is probable, that there is a 
 period, beyond which its curative effect} 
 cannot extend, and, therefore, it is uponihw, 
 firstappearance of unequivocal.symptomsof 
 the disease, that he thinks copious SBleed mg 
 affords a prospect of success, , -while . t lie 
 delay of only a few hours may proven fatal. 
 He observes, that the medical profession,, 
 taught by numerous disappointments, admit 
 
HYDROPHOBIA. 
 
 9S 
 
 very cautiously the claims of any new prac- 
 tice to general adoption. If several patients 
 in hydrophobia, therefore, should happen to 
 be bled in an advanced stage of (he disease, 
 and die, (as they inevitably would do, whe- 
 ther they had been bled or not,) such cases 
 would be quoted against die new practice, as 
 failures But Dr. Schoolbred rightly con- 
 tends, that numerous failures in an advanced 
 sta::e of the disease can form no just ground 
 for the rejection of a remedy, which has in- 
 contestably effected a cure in an earlier 
 stage of the disorder. He insists upon the 
 necessity of making a large orifice in the 
 vein, so as to evacuate the blood quickly, 
 which must be allowed to fiovv, without re- 
 gard to quantity, ad deliquium animi. 
 
 Dr. Schoolbred was well aware, that bleed- 
 ing in cases of hydrophobia had often been 
 tried. But, says he, owing probably to the 
 evacuation not having been pushed far 
 enough, when used in the early stage of the 
 disease ; or to the period for its beneficial 
 employment having elapsed ; the cases, in 
 which it was tried, afforded little or no en- 
 couragement to the continuance of the prac- 
 tice. 
 
 Since the preceding cases, the effect of 
 bleeding has had the fairest trials made of it, 
 and some of the reports are in favour of its 
 occasional utility. (See Particulars of the 
 successful Treatment of a case of Hydropho- 
 bia, by R. Wynne , 8 vo. Shrewsbury , 1813; 
 Also Edmonstone in Lond. Med. Repository, 
 Vol. 3, p. 93.) In almost every instance, 
 however, it fails in hindering the usual 
 melancholy event. (See Kirrison's Case and 
 Obs. in Med. Repository, Vol. 2 ,p. 197.) This 
 unpleasant truth, I think, receives confirma- 
 tion from the fact, that the practice is far 
 from being new. 
 
 Dr. Mead, who was very confident that he 
 had found an infallible preventive of the dis- 
 ease in a little liverwort and alack pepper, 
 aided by bleeding and cold bathing before 
 the commencement of the course of medi- 
 cine, says, ‘as to all other ways of curing 
 the hydrophobia, I own I have not been so 
 happy as to find any success from the many 
 I have tried. Bathing at this time is ineffec 
 tual. I have taken many large quantities of 
 blood; have given opiates, volatile salts, fee. 
 All has been in vain, because too late.” Not- 
 withstanding his disappointment, he con- 
 cludes, “ if any relief could be expected in 
 this desperate state, I think it would be from 
 bleeding, even ad animi deliquium,” tyc. 
 
 The doctrines of Boerhaave also led him 
 and his pupils to recommend and practise 
 bleeding in hydrophobia. “ The distemper 
 (says he) is to be treated asone highly inflam- 
 matory, upon the first appearance of the 
 signs which denote its invasion, by blood- 
 letting from a large orifice, continued till the 
 patient faints away ; and soon after by 
 euemata of warm water and vinegar, be.. 
 and lie adds. “ that this practice is supported 
 by some small number of trials.” But the 
 particulars of this successful practice, arc 
 not given. 
 
 Dr. Schoolbred finds, that a trial of it was 
 
 made at Edinburgh, more than sixty years 
 ago, by Dr. Rutherford who took away 
 gradually sixty ounces of blood from a pa- 
 tient, who had already been bled the same 
 morning. As the patient lived forty-eight 
 hours after the large bleeding, the method 
 was probably tried somewhat early in the 
 disease; and the case may therefore be set 
 down as a fair instance of a failure of the 
 practice. The trials, which have been made 
 in this country of the practice of bleeding, 
 in cases of hydrophobia, since the receipt of 
 the above reports from India, I am sorry to 
 say, have not confirmed its efficacy, as a 
 means which can be much depended upon 
 for saving the patients. 
 
 Bleeding was also recommended in cases 
 of hydrophobia, by Poupari. (See Hist.de 
 I'Acad. Royale des Sciences, pour I'annee 
 1699, /?.48.) The practice is likewise men- 
 tioned in the Medical Essays of Edinburgh, 
 Vol. 5, part 2, § 5; and in the writings of Dr. 
 Rush See also Dr. Burton's Case, Phil. 
 Mag. August, 1805. 
 
 After all that has been said, and the little 
 confidence assigned to any practice but that 
 of the early excision, or amputation of 
 the bitten par's, it is necessary, (hat some- 
 thing should be done after the actual com- 
 mencement of rabies, and that every practi- 
 tioner should be prepared for the adoption of 
 some mode of treatment, or another. As 
 however, my own mind is not made up upon 
 the subject, I prefer offering a conclusion or 
 two, made by a modern critical writer: “ That 
 experience authorizes the placing confidence 
 in bleeding ad deliquium; on vomiting; and 
 perhaps on use of atropa belladonna ; and, 
 on tobacco exhibited as a glyster. That it is 
 probable, advantage would result from the 
 combined employment of bleeding, vomit- 
 ing (see Dr. Sattery's Obs. in Medical Trans. 
 Vol. 4,) and purging in the early stage of the 
 disease. That analogy recommends the 
 trial of spirit of turpentine in the comvulsivo 
 stage of the disease.” ( Med . Repository, Vol. 
 3 ,p. 54.) Jos. de Aromatarius , De Rabie Con- 
 tagiosa, 4 to. Francof 1626. Sauvages sur la 
 Rage , 12mo. Paris , 1771. James on Canine 
 Madness, 8r o. Lond. 1780. Mead on the Bile 
 of a Mad Dog. Jos. S Dolby, The Virtues 
 of Cinnabar and Musk, against the Bite of a 
 Mad Dog, 41 o. Birmingh 1764. J. Hey sham, 
 De Rabie Lanina, Edinb. 1777. B. F. Munch. 
 De Belladonna, efficace in Rabie Canina re- 
 medio, Frank. Del. op. 1 . D.P. Layard? Essay 
 on the Bite of a Mad Dog, 2 d Ed. 1763. R. 
 Hamilton, Remarks on Hydrophobia, 2 Ed 2 
 Vols. 8 vo. Lond 1798. Medical Museum, 
 Vol. 2. Lond Med. Trans. Vol. 2 and 4, Ed. 2. 
 Med. Obs. and Inq. Vol 3; and Fothergill in 
 Vol. 5 of the same work. C. Nugent , Essay on 
 Hydrophobia ; to which is prefixed, the Case of 
 a Person cured , 8 vo. Lond. 1753. Le Roux , 
 sur la Rage, 8 vo. Dijon, 1780. Idem. Traite- 
 menl local de la Rage, 8vo. Paris, 1783. Edinb. 
 Med. Comment Vol. 5, p. 42. J Vaughan's 
 Cases and Obs. on Hydrophobia, 8r o. Lond. 
 1778. Dr. Powell's Case of Hydrophobia. 
 Latta's System of Surgery, Vol. 3. Cullen's 
 First Lines , Vol. 4. Enaux el Chaussier, Me- 
 
HYDRO PH THAT.MFA. 
 
 
 fhodc dt traltc.r lea Morsure a des Animaux en- 
 rages. , fyc. 12mo. Dijon , 1780. Memoirs oj the 
 Med. Society of London , Vol. 1, p 248. 
 Medical. Communications , Col. 1. J. Mease, 
 An Essay on the Disease produced by the Cite 
 of a Mad Dog, with a Preface , fyc. by J. C. 
 Lettsom, Svo. Philadelphia, 1793. Mem. de la 
 Societe Royale dr Mcdecine de Paris, pour 
 Van 1782 e.t 1788. Ferr tar's Med. Facts and 
 Observations, and his Med. Histories, fyc ‘Id 
 Ed. Svo. Loud. 1810. Callisen's Sy sterna Chi- 
 rurgiir. Hodiernts, T. 1, p. 593, Hafnice, 1798. 
 Marcel, in Med. Chir. Trans. Vol. 1, p. 132, 
 «^-e. Jesse Foote, An Essay on the Rite of a 
 Mad Dog, 8 vo. Lond. 1788. Lassus, Patholo- 
 gic t hir. T. 2, p. 239. fyc Ed. 1809. A 
 valuable Paper by Dr. J. Hunter in Trans, of 
 a Society for the Improvement of Med and 
 Chir. Knowledge, Vol. 1, art. 17. James Gid- 
 tnan's Dissertation on the Bite of a Rabid Ani- 
 mal, Svo. Lond. 1812. Leveille, Aouvelle 
 Doctrine Chir. T. 2, p. 341 , fyc. S. Bardsley 
 in Memoirs of the Literary and Philosophical 
 Society of Manchester, Vol. 4, part 2. Medi- 
 cal Reports, 4'C. ; to which are added the In- 
 quiry into the origin of Canine Madness, and 
 Thoughts on a Plan for its E Germination 
 from the British Isles, 8 vo. Lond. 1807. Ba- 
 bington, in the Medical Records and Researches, 
 Lond. 1798. R. Pearson, Arguments in favour 
 of an Inflammatory Diathesis in Hydrophobia 
 considered, Birmingh. 1798. Art. Hy drop ho 
 bia in Rees's Cyclopcedia. M. Ward. Fads 
 establishing the Efficacy of the Opiate Fraction 
 in Spasmodic and Febrile Diseases ; also an at- 
 tempt to Investigate the Nature, Causes, and 
 Method of Cure of hydrophobia and Tetanus, 
 Svo. Manchester, 1809. Richter's Anfangs. 
 grunde der IVundarzneykunsl ■ B. 1, p. 252, 
 <^c Gott 1799. Cases and Cures of Hydro- 
 phobia, selected from the Gentleman s Maga- 
 zine, 8 vo. Lund 1807. G. Pinckard, Case of 
 Hydrophobia , Svo. Lond. 1808. B. Moseley, 
 on Hydrophobia, its Prevention and Cure, 
 Svo. Lond. 1809. J. F. A. Lalouette , Essaisur 
 la Rage, Svo. Paris, 1812. A Portal, M6mo ires 
 sur la Nature , fyc. des plusieures, Maladies, 
 T. 2, p. 31, 8ro. Paris, 1800. G. C. Reich, De 
 la Ftvre en gdndral, dt la Rage, tyc. 8 vo. 
 Metz. 1800. Bosquilhn M6m. sur les Causes 
 de T Hydrophobie, Svo. Paris, 1808. S. N. 
 Sauter, Esperienze Medicht inlorna la Cura 
 dele Idrophobia, ossia della Malattia proveni- 
 ence dal Morso del Cane Rabbioso, Svo. Bolog- 
 na, 1806. Dr. Berry's Obs. and Mr. Tymon's 
 Case cured, by large blood-letting, as detailed 
 in the Madras Gazette of November 23, 1818 ; 
 and Dr. Schoolbred's Case sucessfully treated 
 by copious bleeding , as related in one of the 
 Asiatic Mirrors for May, 1812. O'Donnel's 
 Cases of Hydrophobia, i S 13. T. Arnold, Case 
 of Hydrophobia successfully treated, Svo. Lond. 
 1793. R. Wynne, Particulars of the success 
 ful Treatment of a Case of Hydrophobia, Svo. 
 Shrews, 1808. Boyer, fraite des Mai Chir. 
 T \,p. 435, fyc. Paris, 1814 C. IT. Parry, 
 Cases of Tetanus and Rabies Contagiosa, or 
 Canine Hydrophobia. Svo. Lond. 1814 A 
 Marshall, The Morbid Anatomy of the Brain 
 in Mania and Hydrophobia, with the Pathology 
 of these two Diseases, fyc. Svo. Land. 1815. 
 
 l(. htid on the Nature and Treatment of Te- 
 tanus and Hydrophobic Svo. Dublin , 1817. 
 Aulenrieth , Hiss, de hactenus preetervisa nervo- 
 rum lu dratione in sectionibus hydrophoborum, 
 4lo. Tub. 1802 Gottfr. Zinke, Neue Ansichten 
 der Hunsdwuth Svo. Jena, 1804. Did. des 
 Sciences Med. T. 22, art. Hydrophobie, et T. 
 17, art. Raze. G. Lipscombe Cautions and 
 Reflexions on Canine Madness , 8ro. Lond. 
 1807. C. Gilber , Pract Abhandl. tteber die 
 Vorbeugung , <^-c der Hundswuth, Svo. Wien. 
 1818 ; This author has confidence in the pow- 
 der of meloe maialis. C. F. Har'es , neber die 
 Behandlung der Hundswuth. 4to. Frank f. 
 1809 Stramonium recommended. 
 
 HYDROPH 1 HALAl I A. (fro., water, 
 
 and the eye.) Dropsy of the Eye. 
 
 Hydrophthalmus : Hydrophthalrnos. Also 
 Bupthalmos, or Ox-eye. As in other organs, 
 dropsy of the eye arises from a dispropor- 
 tion taking place between the action of the 
 secerning arteries, by which the tluid is de- 
 posited in the part, and the action of the 
 absorbent vessels, by which it is taken up 
 and returned to the circulation ; and, ac- 
 cording to this principle, the disease may- 
 be supposed to depend, either upon secre- 
 tion being made too rapidly, or absorption 
 being slower than is proportionate to the 
 natural activity of the vessels by which the 
 secretion of the humours of the eye is 
 effected. 
 
 According to Beer, dropsy of the eye is 
 seldom entirely a local disease, but at least 
 is generally combined with an unhealthy 
 constitution, or is a mere symptomatic » 
 effect of some other dropsical affection, 
 anasarca, hydrocephalus, Kc. Sometimes 
 it appears as a symptom of chlorosis. Beer 
 adds, that the disease may originate either 
 from a preternatural accumulation of the 
 aqueous humour ; from that of the vitreous 
 humour ; or from an immoderate accumula- 
 tion of both these humours together. ( Lehre 
 von den Augenkr. B. 2. p. 616, Wien. 117.) 
 When the vitreous humour collects in this 
 manner, it usually loses its natural consist- 
 ence, and becomes thinner and more wa- 
 tery. ( Richter Anfmgsgr. B. 3, p. 392.) 
 
 Professor Beer states, that in the case 
 proceeding from a morbid quantity of the 
 aqueous humour, the first indication of the 
 disease is an increase in the dimensions of 
 the cornea, attended with a manifest enlarge- 
 ment of the anterior chamber. The cornea 
 may become in this manner two, three, or 
 even four times wider than natural, without 
 bursting or losing its transparency ; for, 
 though a turbid appearance is discernible, 
 this depends rather upon the stale of the 
 aqueous humour itself. The iris, which, in 
 the very commencement of the disease, 
 begins to lose its mobility, soon becomes 
 completely motionless, and acquires a duller 
 colour; the pupil always remaining in the 
 mid-state between contraction and dilata- 
 tion. In the eyeball, an annoying sense of 
 pressure, tension, and heaviness is teit, 
 rather than actual pain. Lithe beginning 
 of the disease, there is a considerable degree 
 of farsightedness, or praesbvopia, which 
 
HYDROPHTHALMIA. 
 
 1«0 
 
 soon changes into a true amaurotic weak- 
 ness of sight, but never terminates in perfect 
 amaurosis The free motions of the eyeball 
 are more and more interrupted, in propor- 
 tion as the organ grows larger, and it has 
 invariably a hard feel, while the sclerotica, 
 to tiie distance of two lines from the mar- 
 gin of the cornea, is as bluish as it is in the 
 newborn infant. 
 
 Respecting the precise cause of the accu- 
 mulation of the aqueous humour, Beer 
 offers no observation worthy of repetition, 
 excepting perhaps that in which he reminds 
 us, that a similar collection happens appa- 
 rently as an effect of the conical staphylo- 
 ma of the whole cornea (See also War- 
 drop's Essays on the Morbid Anatomy of the 
 Eye, Vol 2, p. 19.) indeed, as far as onr 
 knowledge yet extends, it is impossible to 
 say whether the changes of the cornea are, 
 in the present disease, to be regarded as the 
 cause or the effect of the increased quantity 
 of the aqueous humour, or whether, as seems 
 to me most probable, both phenomena are 
 only effects of one and the same cause. 
 The examples, somewhat repugnant to this 
 idea, are those referred to by Beer, as symp- 
 tomatic of other dropsical affections. On 
 the other hand, Mr. Wardrop has never seen 
 a preternatural collection of <be aqueous 
 humour, without' its being accompanied with 
 disease of the coats of the eye. (Vol. cit.p. 
 20 .) 
 
 In hydrophthalmia, the prognosis is gene 
 rally unfavourable, and, when the sight is 
 nearly or quite lost scarcely any hope can 
 he entertained, either of restoring vision or 
 preserving the shape of the eye. Yet, ac- 
 cording to Beer, things are not always quite 
 so unpromising in the preceding form of the 
 disease, especially when the surgeon is con- 
 sulted in time, and the patient’s constitution 
 is not exceedingly impaired. The same 
 experienced author has never seen any in- 
 stance in which the eye spontaneously burst ; 
 on the contrary, when the habit was deci- 
 dedly bad, anti the treatment ineffectual, 
 the disease became gradually conjoined 
 with the second species of dropsy of the 
 eye, and terminated in a frightful disfigure- 
 ment of the whole organ, and death On 
 dissection, the innermost textures of the 
 part were found spoiled and disorganized, 
 and sometimes even the orbit itself carious. 
 (Vol. cit.p. 619.) \Vith respect to the treat- 
 ment, Beer thinks, that this must depend 
 very much upon the nature of the primary 
 disease, to which the dropsical affection is 
 ascribable as an effect. He has known 
 great benefit sometimes produced by the 
 submuriate of mercury, combined with di- 
 gitalis, and a drink containing supertartrate 
 of potassa, and borax. When the disease 
 has been preceded by the sudden cure of 
 any cutaneous disease, he has faith in the 
 method of attempting to restore the affection 
 of the skin by inoculation, or, if that be im- 
 practicable, by stimulating its surface with 
 antimonial ointment, or making an issue. 
 This plan is to be aided with internal altera- 
 tive medicines, such as camphor, the sul- 
 
 phur auratuin antimonii, and flowers of sul- 
 phur. The local applications, which he 
 prefers in the early stage, are warm dry 
 bags filled with aromatic herbs, and rubbing 
 the parts about the eyebrow, sometimes with 
 mercurial ointment, sometimes with a mix- 
 ture of ajther and liquor ammoniae. But, 
 when the disease has made considerable 
 progress, and vision is either weak or nearly 
 lost, while the sclerotica, near the cornea is 
 not much discoloured, and there are no 
 appearances of a varicose affection of the 
 blood-vessels of the organ, Beer recommends 
 making a puncture with a small lancet in 
 the lowest part of the cornea, half a line 
 from the sclerotica, so as to discharge the 
 aqueous humour. The anterior chamber is 
 then to be kept empty for several days or 
 weeks, if possible, by reopening the small 
 wound every day with the point of the lan- 
 cet. (See also Richter's Anfavgsgr. B. 3, p. 
 4(;3 ) After the operation, the eye is to be 
 dressed in the same way as after the extrac- 
 tion of a ataract. (See Cataract.) Previ- 
 ously to the paracentesis, Beer has often 
 seen every general arid focal means perfectly 
 useless, but highly beneficial, as soon as that 
 operation had been practised. Kven when, 
 the paracentesis fails in bringing about a 
 permanent cure, it may still be resorted to 
 a a palliative with real advantage, and be 
 often beneficially repeated, if care be taken 
 not to make the puncture too large How- 
 ever, when the blood-vessels are generally 
 varicose, and the constitution very bad, such 
 operation is apt to excite vioh nt inflamma- 
 tion, suppuration, and even sloughing of 
 the organ, attended with imminent danger 
 to the patient’s life. ( Beer , vol. cit. p. 620, 
 622.) 
 
 With regard to the second species ol hy- 
 drophthalmia or that depending upon a pre- 
 ternatural accumulation of the vitreous hu- 
 mour, Beer states, that, in this case, it is 
 chiefly the posterior part of the eyeball which 
 is enlarged, so that the whole organ ac- 
 quires a conical shape, in which the cornea 
 very much participates The latter mem- 
 brane remains unaltered in regard to its 
 diameter ; but it is more convex than natu- 
 ral, and its transparency is perlect. It is 
 observed by Mr. Wardrop, (on Morbid Ana- 
 tomy of the Eye, Vol. 2, p. 126,) that an in- 
 crease in the quantity of the vitreous hu- 
 mour happens not unfrequently in staphy- 
 loma, in which disease, he says, the enlarge- 
 ment of the eyeball will generally be found 
 to arise more from an increase in the quan- 
 tity of the vitreous than of the aqueous hu- 
 mour, and he then expresses his belief, that 
 the case, adduced by Scarpa to illustrate 
 the pathology of hydrophthalmia, and cited 
 in the ensuing part of this article, was an 
 example of staphyloma. B»* this as it may, 
 one character constant in staphyloma, is 
 olten absent in hydrophthalmia ; 1 mean 
 opacity of the cornea. In tin- case, which 
 consists in an immoderate collection of the 
 aqueous humour, the anterior chamber is 
 always enlarged : on the contrary, in the 
 present form of the disease, that cavity is 
 
HTDTtOPHTH ALMIA. 
 
 101 
 
 manifestly lessened, for the motionless iris 
 is gradually forced so much towards the 
 cornea, that at length the chamber in ques- 
 tion imost completely disappears. Howe- 
 ver, the colour of the iris undergoes no 
 change, and the pupil is always rather dimi- 
 nutive. Around the cornea, the sclerotica 
 is rendered bluish by distention, with a 
 somewhat smutty tinge. In the early stage, 
 the patient is affected with shortsightedness, 
 myopia ; but his power of vision is always 
 seriously diminished, and, at last, is so totally 
 destroved,that not a ray of light can be per- 
 ceived. The motions of the globe of the 
 eye ar.d eyelids are lessened or impeded at 
 a still earlier period than in the first species 
 of hydrophtiialmia, an.i o the touch the 
 organ seems like an egg-shaped ston-e. The 
 very commencement of the disease is attend- 
 ed with pain, which daily becomes more 
 and more severe, and, at length, is not con- 
 fined to the eye and its vicinity, but affects 
 all the side of the head, the teeth, and neck, 
 being sometimes so violent as almost to 
 bereave the patient of his senses, who 
 urgently begs the surgeon to puncture the 
 eye. or even is driven by desperation to do 
 it himself, as Beer once knew happen. Even 
 while the pain is less affliefing, the patient 
 is deprived of his sleep and appetite. {Beer, 
 vol. cit.p. 623.) Though an increase in the 
 quantity of the vitreous or aqueous humour 
 lias generally been treated of as a distinct 
 disease, and denominated hydrophtiialmia, 
 Mr. Wardrop has never seen a dropsy of 
 the eye without an accompanying disease of 
 the sclerotic coat, or cornea. {On the Mor- 
 bid Anatomy of the Eye, Vol 2, p. 126.) 
 Beer offers no valuable remark on the causes 
 of the preceding form of hydrophthalmia, his 
 account of the connexion with scrofula and 
 syphilis being mere con jecture, though deli- 
 vered as a positive matter of fact Howe- 
 ver, another position offered in the para- 
 graph, concerning the prognosis, seems 
 more correct : viz. that as the disease is 
 almost always conjoined with an unhealthy 
 constitution, there can be scarcely any hope 
 of a radical cure. Beer’s opinion also is, 
 that, hen the disease has made such pro- 
 gress that not a ray can be discerned, and 
 the pain in the eye and head is so violent, 
 by day and night, that the sleep, appetite, 
 and even the senses are lost ; it is fortunate 
 if only the most perilous symptoms can be 
 obviated by palliative treatment; for the 
 preservation of a good-shaped eye is then 
 quite out of the question. And even in the 
 most favourable cases, the utmost which 
 can be expected, is to stop the further 
 advance of the disease, a perfect cure being 
 extremely rare. 
 
 According to Beer, the first indication is 
 to improve the state of the health by medi- 
 cines and regimen ; for, unless this object 
 be effected, no expectation of curing the 
 dropsical affection of the eye can be enter- 
 tained. For this purpose a long time will 
 be requisite, and as for local treatment in 
 this case, little or nothing can be accom- 
 plished by it. Hence, the disease often con- 
 
 tinues to grow worse and worse, and, when 
 the pain becomes violent, the best thing 
 which the surgeon can do, both with the 
 view to the functions of the organ and its 
 form, is to let out the aqueous humour. But 
 Beer reprobates, in the strongest terms, the 
 plan sometimes recommended, of plunging 
 a trocar through the sclerotica into the vitre- 
 ous humour and keeping the tube introdu- 
 ced until a certain quantity of that humour 
 is discharged. According to Beer’s experi- 
 ence, the usual result of such practice is a 
 carcinomatous disease of the eye, termina- 
 ting in death, which the removal of the part 
 will not prevent. The method preferred by 
 Beer is that which is mentioned by Richter, 
 {Anfangsgr. B. 3, p. 400,) and consists in 
 opening the cornea and capsule of the lens* 
 as in the extraction of the cataract, dischar- 
 ging the lens and vitreous humour, and let- 
 ting the coats of the eye collapse ; but, in 
 order to prevent any reaccumulation of 
 fluid, he afterward cuts away a little bit of 
 the flap of the cornea. The eye is then to 
 be dressed in the same manner, as after 
 the extraction of the cataract. (See Cata- 
 ract.) The third species of hydrophthalmia, 
 or that produced by an accumulation both 
 of the aqueous and vitreous humours toge- 
 ther, is excellently described by Scarpa. 
 He observes, that in every case on which 
 he has performed the operation, and in other 
 examinations of the different stages of the 
 disease, made on the dead subject, he has 
 constantly found the vitreous humour more 
 or less altered in its organization, liquefied., 
 and converted into water, according as the 
 disease was ancient or ''©cent. In some 
 instances he could not distinguish whether 
 the increased quantity of the vitreous, or 
 aqueous humour, had most share in the 
 formation of the disease. 
 
 Scarpa also dissected a dropsical eye, 
 taken from the body of a child three years 
 and a half old, who died of marasmus. The 
 vitreous humour was not only wanting in 
 this eye, and the cavity destined for its 
 reception filled with water, but the vitreous 
 tunic was converted into a subtauce, partly 
 of a spongy, partly of a fatty nature. This 
 dropsical eye was one-third larger than na- 
 tural. The sclerotica was not thinner than 
 that of the other eye ; but, in consequence 
 of being yielding, flaccid, and separated 
 from the choroides, it had lost its plumpness, 
 and globular shape. The cornea formed a 
 disk, one-third larger than that of this mem- 
 brane in a sound state; it did not retain its 
 natural pulpy structure, and was obviously 
 thinner than the cornea of the healthy eye. 
 There was a considerable quantity of an 
 aqueous, reddish fluid, between the cornea 
 and iris. The crystalline lens, with its opaque 
 capsule, had been pushed forward a lit- 
 tle way into the anterior chamber, but 
 could not advance further on account of a 
 firm adhesion which the capsule had con- 
 tracted with the iris around the edge of the 
 pupil. As soon as the capsule was opened, 
 the lens issued from it half dissolved, tin- 
 rest exceedingly soft. It was impossible to 
 
102 
 
 HYDROPHTHALMl*. 
 
 detach the whole of the posterior layer of the 
 capsule from a hard substance, which seem- 
 ed to be the altered membrane of the vitre- 
 ous humour. Scarpa, therefore, slit open 
 the choroides, from the cihary ligament to 
 the bottom of the eye, when a considerable 
 quantity of a reddish aqueous fluid gushed 
 out, without, however, one particle of ihe 
 vitreous humour. In lieu of the latter body, 
 there was found a small cylinder of a sub- 
 stance, partly of a fungous, partly of a fatty 
 nature, surrounded wilh a good deal of wa 
 ter, which was effused in the longitudinal 
 axis of the eye, from the entrance of the 
 optic nerve, as far as the ciliary ligament, 
 or that hard substance to which the posterior 
 layer of the capsule firmly adhered.. This 
 little cylinder was covered for the extent of 
 two lines and a half forwards from the en- 
 trance of the optic nerve, by a stratum of 
 wh.tish matter, reflected on itself, like the 
 epiploon, when raised towards the fundus of 
 the stomach. Scarpa conceived th; t this 
 stratum of whitish matter was the relics of 
 the unorganized retina ; for, on pouring 
 rectified spirits of wine on the whole inner 
 surface of the choroides, and the little cy- 
 lindrical body, he found no vestiges of the 
 retina on this membrane, and that the whi- 
 tish substance, which was reflected on itself, 
 became very firm, just as the retina does 
 when immersed in spirits of wine. Both 
 the cylinder and the indurated substance, 
 occupying the place of the ciliary body, 
 were manifestly only the membrane of the 
 vitreous humour, destitute of water, and 
 converted, as was described, into a sub- 
 stance partly of a spongy, partly of an adi- 
 pose nature. It is not easy to determine 
 whether this altered state of the vitreous 
 tunic had preceded, or was a consequence 
 of the dropsy of the eye. However, it may 
 be this fact, in conjunction with several 
 other similar ones, that Scarpa has met with, 
 in wdiieh he found no vitreous humour in 
 the posterior cavity of the eye, b t only 
 water, ora bloody lymph, tends very much 
 to establish the fact, that this disease princi- 
 pally consists of a morbific secretion of the 
 vitreous humour, and occasionally, also, of 
 a strange degeneration of the alveolary 
 membrane, by which this humour is formed. 
 Scarpa refers to a similar case. (See Med. 
 Obs. and Inquiries , Vol. 3, art. 14.) 
 
 The augmentation in the secretion of the 
 aqueous fluid, both in the cells of the vitre- 
 ous humour and out of them, after they have 
 been ruptured from excessive distention, 
 together with a debilitated action of the 
 absorbent system of the eye affected ; Scarpa 
 regards as the probable cause of the morbi 
 fic accumulation of humours in the eye. 
 From such a lodgment, and successive in- 
 crease of the vitreous and aqueous humours, 
 the eyeball at first necessarily assumes an 
 oval shape, ending at the point of the cor- 
 nea ; the organ enlarges in all dimensions ; 
 and in the end, it projects from the orbit in 
 a manner that it cannot be covered by 
 •he eyelids, di -figuring the patient’s face as 
 
 much as if an ox's eye were placed in the 
 orbit. 
 
 This disease (says Scarpa) is sometimes 
 preceded by blows on the eye, or adjoining 
 temple ; sometimes bv an obstinate internal 
 ophthalmy. In other instances it is prece- 
 ded by no inconvenience, except an uneasy 
 sensation of tumefaction and distention in 
 the orbit, a difficulty of moving the eyeball, 
 and a < onsiderable impairment of sight. 
 Lastly, it is sometimes preceded by none of 
 these causes, or no other obvious one what- 
 ever, especially when the complaint occurs 
 in children of very tender age, from w hom 
 no information can be obtained. As soon 
 as the eye has assumed an oval form, and 
 the anterior chamber has become preterna- 
 turaily capacious, the iris seems situated 
 further backward than usual, and tremulates 
 in a very singular way on the slightest mo- 
 tion of the eyeball. 1 he pupil remains di- 
 lated in every degree of light, w f hile the 
 crystalline is sometimes brownish from the 
 very beginning of the disease; and some- 
 times it does not become cloudy till the 
 affection has arrived at its highest pitch. 
 The complaint then becomes stationary ; 
 and as the crystalline is not deeply opaque, 
 the patient can distinguish light from dark- 
 ness, and, in some degree, the contour of 
 objects, and brilliant colours. But when 
 the eye has acquired a larger volume, and 
 the whole crystalline has become opaque, 
 the retina at last remains in a state of com- 
 plete paralysis. 
 
 In the last stage of the disease, to which 
 the term bupthalmos, or ox-eye, is properly 
 applicable, when the dropsical teye projects 
 from the orbit, so as not to admit of being 
 covered by the eyelids with the inconveni- 
 ences already enumerated, says Scarpa, 
 others associate themselves, arising from the 
 friction of the cilia?, the secretion of gum, 
 the flux of tears, the ulceration of the lower 
 eyelid, on which the eye rests, and the ex- 
 coriation of the eye itself. Hence the drop- 
 sical eye is gradually attacked with violent 
 ophthalmies, attended with intolerable pains 
 in the part affected, and the whole head. 
 The ulceration, also, does not always con- 
 fine itself within certain limits; but conti- 
 nues to spread, first depriving the cornea of 
 ils transparency, next consuming the sclero- 
 tica, and lastly, destroying progressively the 
 other component parts of the eyeball. 
 
 At the first appearance of dropsy of the 
 eye, many surgeons recommend mercurials, 
 the extract of cicuta, and of pulsatilla nigri- 
 cans ; and astringent’and corroborant colly- 
 ria, a seton in the nape of the neck, and 
 compression of the projecting eye. Howe- 
 ver, Scarpa has never yet met with a single 
 well-detailed history of a dropsy of the eye, 
 cured by means of the above-mentioned 
 internal medicines. With regard to exter- 
 nals he has learnt, from his own experience, 
 that when the disorder is manifest, astrin- 
 gent and corroborant collyria, as well as 
 compression of the protuberant eye, are 
 highly prejudicial. In such circumstances. 
 
HYDROPHTHALMIA. 
 
 Ku 
 
 landing a seton in the nape of tlie neck, 
 frequently bathing the eye in a lotion of 
 mallows, and applying to it a poultice com- 
 posed of the same plant, have enabled him 
 to calm, for a time, that disagreeable sense 
 of distention in the orbit, and over the fore- 
 head and temple of the same side, of which 
 patients in this state make so much com- 
 plaint, especially when they are affected 
 with a recurrence of ophihalmy. But as 
 soon as the eyeball begins to protrude from 
 the orbit, and project beyond the eyelids, 
 he thinjcs there is no means of opposing the 
 very grievous dangers which the dropsy of 
 the eye threatens, except an operation which 
 consists in evacuating, by an incision, the 
 superabundant humours, then exciting gen- 
 tle inflammation of the membranes, and 
 suppuration within this organ, so as to make 
 it contract, and shrink into the bottom of the 
 orbit. To defer the operation any longer, 
 would be abandoning the patient to the con- 
 stant inconvenience of an habitual ophthal- 
 my, the danger of an ulceration of the eye- 
 ball and subjacent eyelid, and what is worse, 
 of carcinoma of the whole eye, with great 
 peril to the patient. 
 
 Beer’s prognosis in the third species of 
 hydrophthalmia is at least as discouraging as 
 that made by Scarpa ; for the rapidity of 
 the disease is said to be such as leaves 
 scarcely a possibility of benefit being effect- 
 ed by any mode of treatment, and the case 
 usually terminates in a carcinomatous ex- 
 ophthalmia, and death. These melancholy 
 events are said, by Beer, to be accelerated 
 by paracentesis of the eye, however execu- 
 ted ; and he thinks that the sole chance of 
 stopping the progress of the disease depends 
 upon an endeavour being made in its very 
 commencement to improve the general 
 health, though he owns that success is to be 
 regarded as a very rare and fortunateoccur- 
 rence. The same author has no faith in 
 any local treatment, and, when the disease 
 is advanced, he considers the extirpation of 
 the eye the only rational expedient, though 
 verv precarious in its result. ( Lehre von den 
 Augenkr. R. 2, p. 628, 629.) 
 
 The main point, on which Scarpa differs 
 from Beer, is that respecting the effects of 
 discharging the humours of the eye ; a prac- 
 tice, which the former represents as useful, 
 even in cases where the hydrophthalmia com- 
 bines an accumulation both of the aqueous 
 and vitreous humours. In former times, says 
 Scarpa, paracentesis of the eye-hall was 
 greatly extolled. Nuck one of the promoters 
 of this operation, punctured the eye with a 
 trocar, exactly in the centre of the cornea. 
 (De Duct. Ocul. Aquos, p. 120.) It has since 
 been thought better to puncture the sclerotica 
 about two linps from the junction of this 
 membrane with the cornea, that such a small 
 quantity of the vitreous humour may be more 
 easily discharged at the same time with the 
 aqueous, as may be deemed adequate to ef 
 feet a diminution in the morbific enlargement 
 of the eye-ball. 
 
 According to Scarpa, paracentesis of the 
 eye, done so as merely to discharge the hu- 
 
 mours, can never be a means of curing drop- 
 sy of the eye, unless the puncture, made with 
 the trocar, excite inflammation and suppura- 
 tion, and afterward a concretion of the 
 membranes composing the eye ball. Indeed 
 Nuck relates, that in a young man at Breda, 
 hp was obliged to puncture the eye five seve- 
 ral times ; that, on the fifth time of doing 
 this, it was necessary to suck through the can- 
 nulnr of the trocar, in order to evacuate the 
 greatest possible quantity of the vitreous 
 humour ; and lastly, that it seemed proper to 
 introduce a plate of lead between the eyelids 
 arid eye-ball, for the purpose of making con- 
 tinual pressure on the pye, in its empty shri- 
 velled state. In a woman at the Hague, be 
 twice punctured the eye in vain ; and she 
 submitted, two or three times afterward, to 
 the same operation, but with what degree of 
 success is not specified. Scarpa has no diffi- 
 culty in believing, that a radical cure of the 
 dropsy has sometimes bpen accomplished by 
 means of the puncture, after the trocar, and 
 other similar hard substances, have been re- 
 peatedly introduced into the eye, through 'he 
 cannula of that instrument ; but this success 
 can never be attributed to the mere evacua- 
 tion of the superabundance of the vitreous 
 and aqueous humour ; though it may be re- 
 ferred to that circumstance, conjoined with 
 the irritation produced bvthe cannula, or the 
 tents with which Muuchart kept open the 
 wound. 
 
 Scarpa condemns the plan of making a 
 circular incision through the sclerotica, s 
 disadvantageous, and even dangerous. In 
 fact, this circular recision. is constantly fol- 
 lowed by the most aggravated symptoms, 
 particularly frequent hemorrhages, an accu- 
 mulation of grumous blood at the bottom of the 
 eve-ball, vehement inflammation of the eye, 
 eyelids, and head, obstinate vomitings, con- 
 vulsions, delirium, and the most imminent 
 danger <o the patient’s life. Such modern 
 surgeons, as have faithfullv published the 
 results of their practice on this point, among 
 whom, after M Louis,- (Mim. de VAcad. de 
 Chir. T 13 p. 289, 290 ) Marchan, (Journal 
 de Med. de Paris , Janvier , 1770 : Sur deux 
 Exophthalmies , ou grosseurs contre nature du 
 Globe deV (TAl ;) and Terras, (Ibidem, Mars, 
 1776; Sur V Hydrophthafmie,) having ingenu- 
 ously declared that, after performing the cir- 
 cular recision of dropsical eyes in the scle- 
 rotica, they had the greatest motives for re- 
 penting of what they had done. Scarpa pre- 
 fers making a circular section, about three lines 
 in breadth, at the summit or centre of the 
 cornea of the dropsical eye, as directed by 
 Celsus, in cases of staphyloma. 
 
 Whether the cornea be transparent or not, 
 as sight is irrevocably lost, the surgeon must 
 introduce a small bistoury across the apex, or 
 middle of the cornea, at one line and a half 
 Irom its central poini ; and then by pushing 
 the instrument from one towards the other 
 canthus of the eye, he will cut the lower part 
 of the cornea in a semicircular manner. The 
 segment of the cornea being next elevated 
 with the forceps, the operator is to turn the 
 edge of the knife upward, and complete the 
 
104 
 
 HYD 
 
 HYP 
 
 work fev a circular removal of as much of the 
 centre of the cornea as is -qual to three li ies 
 in diameter, fhrough t his circular opening, 
 made in the centre of the cornea, the -urgeon 
 may, by mean-- of gentle pressure, di- barge 
 as much of t tie -upehab ntdanl Ini no irs in 
 the eye, as i-> requisite to make the eye-hall 
 diminish, and return into the orbit, so a- to 
 be covered by the eyelids. A- f,»r the rest of 
 the Honour lodged in the eve, i; will gradn 
 ally escape of -self. through 'he cncular 
 opening in tli • cornea, w thout any more 
 pressure bei;s.: tn -da. 
 
 Until tb^ appe trance of th“ inflamm lion, 
 that is, until the third or fif h e after the 
 operation, the dressings re to consist <u the 
 application ot a compress of dry lit sup- 
 ported by a bandage. As soon as the • ;«m- 
 
 mation and mm -faction invade the eye ope- 
 rated on, and t c eyelids, the surgeon is to 
 employ such internal remedies as are calcu- 
 lated to moderate, the progress of inflamma- 
 tion ; and he is to e iver the eyelids • ith a 
 bread and milk poultice, which must be i-e- 
 nevved at lea-, once every two hours. It is a 
 very frequent result, both in the staphyloma 
 and drop y of the eve, that, on the first ap- 
 pearance of intla -I mat ion, the eye-ball, on 
 which the operation has been done, augments 
 and protrudes again from the eyelids in th j 
 came way as before the operation. fri t--is 
 circumstance. Scarpa directs the projecting 
 part of the eye-ball to be. covered well apiece 
 ot fine linen, smeared with a liniment of oil 
 and wax, or the yelk of an egg and oleum 
 hy perici ; the apple lion of the b a.J and 
 milk poultice being continued over this other 
 dressing. Scarpa next sta'es, that when the 
 interior ot the f-ye begi -$ o suppurate, he 
 swelling of the eye-lids decreases, and the 
 eye-ball diminishes in -ize, and returns gra- 
 dually into the orbit. This stale of suppura- 
 tion may be known by observing, that the 
 dressings are smeared with a viscid lymph, 
 blended with a portion of h humours of the 
 eye, which incessantly issue from the centre 
 of the cornea ; and by noth ing the appear- 
 ance of the margin of the reci-ion, wbic.li is 
 changed into a circle of a, whitish sub, lance, 
 resembling the rind of bacon, which is after- 
 ward detached, like a -lough, so as to leave 
 a small ulcer, of a very healthy colour, ib is 
 ulcer, as well as the whole eye-ball, con- 
 tracts, and becomes mihrely cic a iiz« d. lea- 
 ving every opportunity for the placing of an 
 artificial eye between the eyelids and the 
 Stump of the eyeball. 
 
 If a mild inflammation and suppuratio in 
 the interior of the eye should not take place 
 on hue fifth day, Scarpa exposes tue eye to the 
 air, or removes a circular portion of the cor- 
 nea, half a line in breadtn, or little more, by 
 met-ns of the forceps and curved scissor--. 
 The foregoing practice is certainly p efera- 
 bie to that advised by R-cttier. who, when the 
 eyesight is lost, and the object is merely to 
 discharge the humours, and let the eye col- 
 lapse, sometimes makes a crucial division of 
 the cornea, and removes the four flaps or an- 
 gles, or even cuts away 1 ; >e whole of the 
 anterior part of the eye-ball through the 
 
 sclrrotica. {Anfangsgr. B. 3, p. 404A It* 
 order 'o lessen the -mlk of the eye, the late 
 VI r. Ford, in one instance, passed a seton 
 through the front of the organ with apparent 
 success. (See Med. Communications , Vol 1.) 
 Consult Maucharl. Dt Parac'entesi Oculi , Tub. 
 17 44. Conradi, Handbucfi der Pathol. Anat. 
 p. 523. Fieliz, in Huf eland’s Journ. 4 B. p. 
 208. Flajani , Cullesione d Ossenazioni , T. 1, 
 Obs. 43 Gendron. Mai. d s Yeux. T. 2. 
 Loins, in M6m.de I’Acad. dt Chir. T. 5,4 to. 
 Marchun in Jo m. de Med T. 32, p. 65, 
 Terras, op. cit. Vol. 45. p. 237. Scarpa , Salle 
 principali Mnlattie degli Occhi , Cm . 13 C. 
 P. Begcr , Dr’ Hydrophthnlmia Haller Disp . 
 C/nr. i 575. A. Sanvey , />e Paracentid 
 Ce di in i 7 y dr ophthalmia et Amblyopia Se- 
 nu . - ; H llcr, Disp. hir. 15- 7, Tub. 1744. 
 Benedict, de Mo. bis Hum oris Vitrei. Luke , 
 Diss.de Hydropethalnna, Jen. 1803. Rich- 
 ter. Anfangsgr. B. 3, p. 392, fyc. 67;/. 1795. 
 Beer Lthrev n den iugenkr. B. 2, Wien. 1817. 
 J W.rd op, Essays on the Morbid Anatomy 
 of the II man Eye, Chap. 18 and 40, Vol 2; 
 8vo. Load. 18i». B. Travers. Synoj is of the 
 Diseases of the Eye, p. 195, p. 1 200, 8ro, 
 
 Load 1820. 
 
 HV'DiiOPS. (from ieJa)g, uer.) A drop- 
 sy, o morbid accumulation of w a' or. For 
 hydrops articuli , refer to Joints , diseases of; for 
 hydrops oculi, see the foregoin _ article. With 
 re - i i hydrops pectoris , hydrothorax, or 
 dropsy of Ihe chest , as it is altogether a medi- 
 cal case, an account of its symptoms and 
 tree. - merit w ll hardly be required in this 
 Dictionary. Tue only concern, o itich a sur- 
 geon has ivitlj the disease, is being oceasion- 
 al'y required to make an opening for the 
 discharge of the water. (See Paracentesis 
 Thoracis) 
 
 HYDROS ARC OCtfLE. (from wfyg, water ; 
 <r* igf, flesh ; and a tumour.) A surcocele 
 a -d with a collection of fluid in the 
 tuni • va inalis 
 
 HYMEN IMPERFORATE. The incon- 
 veniences brought on by such a cause, and 
 t tie mode of relief, are explained in the arti- 
 cle Vagina. 
 
 A continuation of the hymen over a part 
 of the orifice of the meatus urinarius may 
 produce great pain and difficulty in making 
 water, and symptoms,’ w liicli may give rise 
 to suspicion of there being a stone in the 
 bladder. Foi a case illustrating the truth of 
 this observation, see Warner's Cases in ■'sur- 
 gery, p. 276, Edit. 4. 
 
 HYPOPIUM, or HYPOPYON. (from 
 vvo , under ; arid <sruty, pas.) 
 
 Bs bypopium (sa\s Scarpa) limply with 
 al surgeons, that accumulaiioroof « glutinous, 
 yeiiowi h fluid, like pus, which takes place 
 in - lie anterior chamber of aqueous humour, 
 and. fr« quently, aiso in the posterior one, in 
 conseqti' re oj severe, acute opht'ndmy. par- 
 ticularly the internal species. Though sel 
 vere, a« u e ophtualmy mostly affects par- 
 ticularly the external parts of the eye ; yet, it 
 occasionally invades, with equal violence, 
 both the external and internal coats of this 
 organ, especially the choriodes and uvea. 
 If such inflammation be not promptly check- 
 
HYPOPIUM. 
 
 ' 10 # 
 
 «<1, by chlrurgicnl means, coagulating lymph is 
 extravasated from tin- highly inflamed choroi- 
 des and uvea, and gradually, as it is effused into 
 the cavity of the eye, it passes through the pu- 
 pil into the chambers of the aqueous humour, 
 and descends to the bottom of the anterior 
 one, so as to fill sometimes one-third, 
 sometimes one-half of this space ; and occa- 
 sionally, to occupy it to such a height, as to- 
 tally to conceal the iris and pupil. 
 
 This viscid matter of hypopium, though 
 commonly called pus, Scarpa regards as 
 coagulating lymph. The symptoms, por- 
 tending an extravasation of coagulating 
 lymph in the eye, or an hypopium, are the 
 same as those which occur in the highest 
 stage of violent acute ophthalmy: viz. pro- 
 digious tumefaction of the eyelids ; the same 
 redness and swelling ot the conjunctiva, as 
 in chemosis ; burning heat and [tain in the 
 eye ; pains in the eyebrow and nape of the 
 neck ; fever, restlessness, aversion to the 
 faintest light, and a contracted state of the 
 pupil. 
 
 As soon as the hypopium begins to form, 
 (say? Scarpa) a yellowish semi-lunar streak 
 makes its appearance at the bottom of the 
 anterior chamber, and, regularly, as the glu- 
 tinous fluid is secreted from the inflamed 
 internal membranes of the eye, so as to pass 
 through the pupil, and fall into the aqueous 
 humour, it increases in all dimensions, and 
 gradually obscures the iris, first at its inferior 
 part, next where it forms the pupil, and lastly 
 the whole circumference of this membrane. 
 As long as the inflammatory stage of violent 
 ophthalmy lasts, the hypopium never fails 
 to enlarge ; but, immediately this stage 
 ceases, and the opbthalmy enters its second 
 period, or that dependent on local weakness, 
 the quantity of coagulating lymph, forming 
 the hypopium, leaves !>ff increasing, and, 
 from that moment, is disposed to diminish. 
 
 This fact sufficiently evinces (continues 
 this eminent Professors how important it is, 
 in order to check the progress of the hypo- 
 .pium, to employ, with the utmost care, the 
 most effectual means for checking the attack 
 of violent ophthalmy in its first stage. 
 Copious evacuations of blood, both generally 
 and topically, ought to be speedily pul in 
 practice ; and when chemosis exists, the 
 conjunctiva should be divided ; mild aperi- 
 ents given, blisters applied to the nape of 
 the neck, little bags of emollient herbs to 
 the eye, and other measures employed. It 
 Avill be known that they have fulfilled the 
 indication, by noticing that, some days after 
 the adoption of such treatment, though 
 there may still be redness of the conjunctiva 
 and eyelids, the lancinating pains in the eye 
 abate, the heat considerably diminishes, the 
 fever subsides, quietude and sleep are resto- 
 red, the motion of the eye becomes free, 
 and, lastly the collection of viscid matter 
 forming the hypopium, becomes stationary. 
 It is not unfrequent to see, especially among 
 the lower orders of the people, persons 
 affected with the second stage of severe 
 acute ophthalmy, bearing this collection of 
 coagulating lymph, in the chambers of the 
 Vol. 11 14 
 
 aqueous humour, with the greatest indiffer- 
 ence, and without complaining of any of 
 those symptoms which characterize the 
 acute stage of ophthalmy. It is only at 
 this crisis, or at the termination of the acute 
 stage of violent inflammation of the eye, 
 that the enlargement of the hypopium 
 ceases, and the coagulating lymph begins t® 
 be absorbed, provided this salutary opera- 
 tion of nature be not impeded, nor retarded, 
 by any injudicious regitnen. However, if 
 Scarpa had also been aware of the great 
 efficacy of mercury, in arresting the effusion 
 of lymph, I can hardly doubt, that he would 
 have modified some of the preceding obser- 
 vations, as well as his practice ; a subject t® 
 which I shall presently advert again. 
 
 Scarpa states, that persons, little versed 
 in the treatment of diseases of the eyes, 
 would fancy that the most expeditious and 
 efficacious mode of curing an hypopium, 
 after it has become stationary in the seeond 
 stage of severe acute ophthalmy, would be 
 that of opening the cornea at its most de- 
 pending part, in order to procure a speedy 
 exit for the matter collected in the chambers 
 of the aqueous humour; especially as. this 
 was once the common doctrine. But ex- 
 perience shows, that dividing the cornea, in 
 such circumstances, is seldom successful, 
 and most frequently gives rise to evils, w'orse 
 than t lie hypopium itseif, notwithstanding 
 the modification suggested by Richter, ( Obs . 
 Chir. Fasc. 1, Chap 12,) not to evacuate the 
 whole of ihe matter at once, nor to promote 
 its discharge by repeated pressure and in- 
 jections, but to allow it to flow slowly out 
 of itself. The wound made at the lower 
 part of the cornea, for evacuating the matter 
 of the hypopium, small as tbe incision may 
 be, most commonly reproduces severe acute 
 ophthalmy, and a greater effusion of coagu- 
 lating lymph into the chambers of the aque- 
 ous humour. Besides, after opening the 
 cornea, if the matter of the hypopium w’ere 
 allowed to escape gradually of itself, it 
 would be several days in being completely 
 discharged, on account of its viscidity. 
 During this time, the glutinous lymph would 
 keep the edges of the wound of the cornea 
 dilated, and make them suppurate. Thus, 
 the incision would be converted into an 
 ulcer, through which the aqueous humour 
 w r ould escape, and even a fold of the iris. 
 Opening the cornea, therefore, only converts 
 the hypopium into an ulcer of that mem- 
 brane, attended with a prolapsus of the iris, 
 and occasionally of the crystalline itself. 
 Nor can any inference be drawn, in favour 
 of making an artificial opening, during the 
 stationary state of an hypopium in the 
 second stage of severe acute ophthalmy, 
 from the matter of the hypopium having 
 sometimes made its way spontaneously 
 through a narrow aperture in the cornea, 
 with a successful result. For, there is a 
 wide difference, betw'een the effects of a 
 spontaneous opening in a natural, or preter- 
 natural cavity of the animal body, or of 
 one made with caustic, and the consequences 
 of an opening, made with a cutting iastru- 
 
10 6 
 
 HYPOPIUM. 
 
 ment. In the two first methods, the subse- 
 quent symptoms are constantly milder than 
 in the last. Besides, even in the instance in 
 which a spontaneous discharge of the hy- 
 popium takes place through the cornea, an 
 escape of the aqueous humour, and a pro- 
 lapsus of the iris, not unfrequently ensues ; 
 consequently, the spontaneous evacuation 
 of the hypopium cannot justly form a rule 
 for the treatment of the disease. There is 
 only one case, in which dividing the cornea, 
 in order to discharge an hypopium, is not 
 only useful, but indispensable ; this is, when 
 there is such an immense quantity of coagu- 
 lating lymph extravasatea in the eye, that 
 the excessive distention, which it produces 
 of all the coats of this organ occasions 
 symptoms so vehement, as not only threaten 
 the entire destruction of the eye, but even 
 endanger the life of the patient. But this 
 particular case cannot serve (says Scarpa) 
 as a model for the treatment of ordinary 
 cases. 
 
 The dispersion of the hypopium, by means 
 of absorption, forms the primary indication, 
 at which the surgeon should aim. In order 
 to stop its progress, the most efficacious 
 method is to subdue the first violence of the 
 inflammation, and to shorten its acute stage, 
 by the free employment of antiphlogistic 
 treatment, and the use of mild emollient, 
 topical remedies. And, in conjunction with 
 these means, there can now be no doubt, 
 that the practice of BrUel, published in 1809, 
 as will be mentioned at the close of this 
 article, ought to be followed : 1 mean, the 
 quick exhibition of the submuriate of 
 mercury, which has been also found at the 
 London Eye Infirmary the most powerful 
 means of checking the effusion of lymph in 
 the eye. (See Saunders's fVork on the Eye, 
 Ed. 2, and a Synopsis of the Diseases of the 
 Eye , by B. Travers, p. 135.) 
 
 If this treatment answer, the incipient 
 collection of coagulating lymph, at the 
 bottom of the anterior chamber of the 
 aqueous humour, not only ceasestoaugment, 
 but, also, in proportion as the severe 
 ophthalmy disappears, the absorbent system 
 takes up the heterogeneous fluid extravasa- 
 ted in the eye, and the white,. or yellow 
 speck, shaped like a crescent, situated at the 
 bottom of the anterior chamber, gradually 
 diminishes, and is at last entirely dispersed. 
 Janin considered an infusion of the flowers 
 of mallows, applied to the eye that is infla- 
 med apd affected with this disease, as a 
 specific resolvent in these circumstances, 
 (M6m. et Obs. surVCEil, p. 405,) but it is now 
 known, that every topical emollient applica- 
 tion, provided it be conjoined with such 
 internal antiphlogistic treatment, as is the 
 most proper for repelling the acute stage of 
 the severe ophthalmy, produces quite as 
 good an effect as this infusion. Simple 
 warm water produces the same benefit. 
 
 A young girl (says Naenoni) was struck 
 in the eye by an ear of corn. An inflamma- 
 tion was the consequence, which produced 
 a white pus of a semi-lunar shape, apparent- 
 ly behind the cornea, without a possibility 
 
 of judging whether the matter was actually- 
 situated between the laminae of that mem- 
 brane, or in the anterior chamber. Hence, 
 
 I was asked, whether it might not be evacu- 
 ated by an incision, particularly as the 
 patient complained of great pain in the eye, 
 and eyebrow. She was in the hospital ; 
 and in the presence of Dr. Lulli, and several 
 students in surgery, I said that the pain of 
 which the patient complained, was not occa- 
 sioned by the pus itself, but tbe cause which 
 produced it. This cause was inflammation, 
 which probably would be increased by 
 making a larger opening for the external 
 air, than wbat it has to the internal parts, 
 while the external ones remain entire. By 
 fomenting the eye and forehead with warm 
 ■water, the inflammation subsided, and the 
 pus disappeared. We have so often witness- 
 ed tbe fact subsequently, that we can also 
 extol the simplicity of the treatment.” 
 Such, in short, is the successful termination 
 of an hypopium, whenever the disease is 
 properly treated at its commencement, and 
 the acute stage of severe ophthalmy is 
 promptly checked by internal antiphlogistic 
 means, and emollient applications. But, in 
 consequence of the inflammatory period of 
 the severe ophthalmy having resisted, in an 
 uncommon manner, the best means, or 
 because such means have been employed 
 too late, it sometimes happens, that the 
 coagulating lymph, collected in the anterior 
 chamber, is so abundant, even after the 
 acute stage of ophthalmy, that it continues 
 for a long time to cloud the eye, and inter- 
 cept vision. Scarpa has often seen patients, 
 especially paupers, who, from indolence, 
 negligence, or ill treatment, remained a 
 long time after the cessation of the inflam- 
 matory stage of ophthalmy, with the anterior 
 chamber almost entirely filled with the 
 glutinous matter of hypopium. When the 
 inflammation had ceased, these unhappy 
 persons wandered about tbe streets almost 
 quite indifferent, and without complaining 
 of pain, or any other inconvenience, than 
 the difficulty of seeing with the eye affected. 
 In this second stage of the ophthalmy, the 
 resolution of hypopium obviously cannot be 
 accomplished by the same means, nor with 
 equal celerity, as in the first. At this crisis, 
 the great quantity and density of the gluti- 
 nous matter extravasated, and the atony of 
 the vascular system of the eye, make it 
 necessary to give nature sufficient time to 
 dissipate the thick, tenacious matter, and, at 
 length, to dispose it to be insensibly absorbed 
 with the aqueous humour which is continu- 
 ally undergoing a renovation. Hence it is 
 right, (says Scarpa) to adopt those means, 
 which are best calculated to iavigorate the 
 vascular system of the eye, more especially 
 the lymphatics. This requires more or less 
 time, according as the patient is advanced in 
 years, of a relaxed fibre and weak ; or a 
 young man of good constitution. 
 
 However, according to Scarpa, in the 
 second stage of violent acute ophthalmy, 
 complicated with hypopium, the surgeon 
 should limit his efforts to the rernovnl ot 
 
HtPOPIUM. 
 
 107 
 
 every thing, which may irritate the eye, or 
 be likely to renew the inflammation ; and 
 he should only employ such means, as are 
 conducive to the resolution of the second 
 inflammatory stage, depending on relaxation 
 of the conjunctiva and its vessels, and such 
 remedies as tend, at the same time, to invigo- 
 rate the action of the absorbents. There- 
 fore. i , this state, he ought first to examine 
 carefully the degree of irritability in the eye. 
 affected with the hypopium, by introducing, 
 between the eye and eyelids, a few drops of 
 vitriolic collyrium, containing the mucilage 
 of quince seeds. Should the eye seem too 
 strongly stimulated by this application, it 
 must not be used, and little bags of warm 
 mallows with a feu grains of camphor are 
 to be substituted for it. In the intervals, the 
 vapours of the liquor ammon. comp, may 
 be applied, and recourse had again to a 
 blister on the nape of the neck. When the 
 extreme sensibility of the eye is overcome, 
 the zinc collyrium must be used again, after- 
 ward strengthened with a few drops of 
 camphorated spirit. Under such treatment, 
 proceeds Scarpa, the surgeon may observe, 
 that, in proportion as the chronic ophthahny 
 disappears, and the action of the absorbents 
 is re-excited, the) tenacious matter of the 
 hypopium divides first into several small 
 masses ; then dissolves still further ; and, 
 afterward, decreases in quantity : descend- 
 ing towards the inferior segment of the 
 cornea ; and, finally, vanishing altogether. 
 But Scarpa accurately observes, tfiat the 
 surgeon cannot always expect to be equally 
 successful, whether the disease occur during 
 the first, or second stage of violent acute 
 opbthalmy, if the tenacious lymph, suddenly 
 extravasated in the interior of the eye, 
 prevail in such quantity, as not only to fill, 
 but strongly distend, the two chambers of 
 the aqueous humour, and the cornea in 
 particular. In this state, notwithstanding 
 the most skilful treatment, the unpleasant 
 complication is often followed by another 
 inconvenience, still worse than the hypopi- 
 um itself; viz. ulceration, opacity, and burst- 
 ing of the cornea. 
 
 The ulceration of the cornea ordinarily 
 takes place tvith such celerity, that the sur- 
 geon seldom has time to prevent it. As 
 soon as an aperture has formed, the exces- 
 sive abundance of coagulating lymph, con- 
 tained in the eye, (sometimes named em- 
 pyema oculi) begins to escape through it, 
 and a degree of relief is experienced. But, 
 this melioration is not of long continuance ; 
 for. scarcely is the glutinous fluid evacuated, 
 that distended the. whole eye, and especially 
 the cornea, when it is followed by a portion 
 of the iris, which glides through the ulcera- 
 ted aperture, protrudes externally, and con- 
 stitutes the disease termed prolapsus of the 
 iris. (See Iris, Prolapsus of.) But, if in 
 such an emergency, the cornea already 
 ulcerated, opaque, and greatly deranged in 
 its organization, should not immediately 
 burst, the surgeon is then constrained by the 
 violence of the symptoms, depending on the 
 prodigious distention of the eyeball, to 
 
 make an opening in this membrane, in order 
 to relieve the immense constriction, and 
 even the danger in which life is placed. 
 
 Were there the least chance of restoring, 
 in any degree, the transparency of the cor- 
 nea, and the functions of the organs of vision, 
 after opening the cornea, Scarpa acknowled- 
 ges that it would certainly be more prudent 
 to make the opening at the lower part of 
 this membrane. But in the case of empye- 
 ma of the eye, now considered, in which the 
 cornea is universally menaced with ulcera- 
 tion and opacity, and seems ready to slough, 
 there can be no hope of its resuming its 
 transparency at any point, and he therefore 
 decrns it the best and most expeditious me- 
 thod of relief to divide its centre with a 
 small bistoury to the extent of a line and a 
 half; and then to raise with a pair of for- 
 eeps the little flap, and cut it away all round 
 with one stroke of the scissors, so as to let 
 the humours escape without any pressure. 
 
 The eye is to he covered with a bread and 
 milk poultice, which is to be renewed every 
 two hours, the use of such general remedies, 
 as are calculated to check the progress of 
 acute inflammation, and to quiet the nervous 
 system, not being omitted. In proportion as 
 the interior of the eye suppurates, the eye- 
 ball gradually diminishes, shrinks into the 
 orbit, and at length cicatrizes, leaving things 
 in a favourable state for the application of 
 an artificial eye. 
 
 When Scarpa delivers his opinion, that in 
 the above aggravated form of hypopium, 
 there can be no chance of the cornea resu- 
 ming its transparency at any point, I think his 
 assertion rather imprudent. Nor. admitting 
 its general truth, does it follow as a matter of 
 course, that it is necessary and right to cut 
 away a piece of the centre of the cornea, 
 and absolutely destroy whatever little chance 
 may yet be left of saving the eye. In sup- 
 port of this remark, let me contrast what 
 Mr. Travers has said with the advise of Scar- 
 ps “ When the hypopium is so large as lo 
 rise towards the pupil, and the ulceration of 
 the cornea is extending, I think its discharge 
 by section near its margin adviseable. If not 
 too long delayed, the ulcerative process is 
 checked by it, which would otherwise rrin 
 into sloughing, and Ike cornea recover with 
 only partial opacity and disfigurement." (Sy- 
 nopsis of the Diseases of the Eye, p 2S0.) 
 
 Mau chart de Hypopyo. Tubingw, 1742. C. 
 P. Leporin, de Hypopyo. ilo. Goett. 1778. 
 Gotldlin, Diss. de Hypopyo. Erlang. 1810. 
 IV nit her Merkwiirdige Iieilung eines Eiter- 
 auges, fyc.. 8t'o. Landsh.nl, 1819. I observe , 
 that in Hufelahd and Himley's Journal for 
 Oclob. 1809, p. 93, there is an account of the 
 treatment of an hypopium, or case of effused 
 lymph in the chambers of the eye, by exhibit- 
 ing from 12 to 18 grains of the submuriate of 
 mercury, in the space of 12 hours , and then 
 giving bark, while as an external application 
 the tinct. opii crocat. teas employed. Thus ue 
 spe that the efficacy of mercury in checking the 
 effusion of lymph in the eye , and promoting 
 an absorption , has been known many years in 
 
Germany. A. Scarpa Saggio di Osservazioni Anatomy of the Human Eye, Chap. 6 . 
 c d'Esperitnze, suite Principali Malaltie Edinb. 1 S 08 . 
 
 degli Occhi; Venezia , 1802. Richter An- HYSTEROTOMIA. (from vo-ree,*., Ihe 
 Jdngsgriinde der Wundarzneykunst , B. 3. womb, and rifj.vu>, to cut.) See Ccesartan 
 1705. ,/. Wardrop, Essays bn the morbid Operation. 
 
 I. 
 
 I VI PERFORATE HYMEN. (See Va- 
 gina.) 
 
 1 NCARCEKAT10N. This term is usually 
 applied to cases oi hernia in the same sense 
 as strangulation. When the viscera are press- 
 ed upon either by the opening through 
 which they protrude, or by the parts them- 
 selves within the hernial sac, in such a de- 
 gree, that the course of the intestinal matter 
 to the anus is obstructed, and n usea, sickness, 
 pain, and tension of the swelling and abdo- 
 men, &lc. are occasioned, the rupture is said 
 to be in a slate of incarceration or strangula- 
 tion. 
 
 Accordingto Professor Scarpa, however, an 
 incarcerated , and a strangulated hernia, do not 
 imply exactly the same. thing. Inthefirst case, 
 says he, the course of the intestinal matter is 
 interrupted, without any considerable impair- 
 ment of the texture, or vitality of the bowel. 
 On the contrary, in the strangulated hernia, 
 besides the obstruction to (he course of die 
 fecal matter, there is organic injury of the 
 coats of the intestine, with loss of its vitality. 
 The bowel that is merely incarcerated, re- 
 sumes its functions immediately it is replaced 
 in the abdomen ; while that which is truly 
 strangulated never returns to its natural 
 state. ( Traite dcs Remits, p. 251.) 
 
 This distinction, however, is by no means 
 generally adopted. 
 
 INCONTINENCE OF URINE. (See 
 Urine, Incontinence of.) 
 
 INFLAMMATION, (from inflammo, to 
 burn.) By the term, inflammation, is gene- 
 rally understood the state ot apart in which 
 it is painful, hotter, redder, and somewhat 
 more turgid than it naturally is ; which topical 
 symptoms, when present in any considerable 
 degree, or when they atfect very sensible 
 parts, are attended with lever, or a general 
 disturbance of the system. (Burns.) 
 
 The susceptibility of the body for in- 
 flammation is of two kinds ; the one origi- 
 nal, constituting a part of the animal econo- 
 my, and beyond the reach of human investi- 
 gation ; the other acquired from the influence 
 of climate, habits ot life, and state of the 
 mind over the constitution. (Hunter.) The 
 lirst kind of susceptibility being innate, can- 
 not be diminished by art ; the second may be 
 lessened by the mere avoidance of the par- 
 ticular causes upon which it depends. 
 
 Inflammation may, with great propriety, be 
 divided into healthy and unhealthy. Of the 
 first, there can only be one kind, though di- 
 visible into different stages ; of the second, 
 there must be an infinite number of species, 
 according to the peculiarities of different 
 GO n$tftutions, and the nature of diseases 
 
 which are numberless. (Hunter.) Another 
 general division is into common and specific 
 inflammation, the latter lurm implying, that 
 the affection has some strongly marked par- 
 ticularity about it, rendering it in some de- 
 gree independent of such circumstances as 
 would control and regulate the progress of 
 common inflammation. Such are venereal , 
 variolous, vaccine, erysipelatous, gouty , and 
 rheumatic inflammation^, &. c. Inflammation 
 may ;»lv> be divided into the acute and chro- 
 nic. This division of the subject is one of 
 the most ancient, and seems to have obtain- 
 ed the. sanction of all the best surgical wri- 
 ters. Healthy inflammation is invariably 
 quick in its progress, for which reason, it 
 must always rank as an acute species of the 
 affection. However, there are numerous in- 
 flammation-, controlled by a diseased princi- 
 ple, which are quick in their progress, and 
 are, therefore, to be considered as acute. 
 Chronic inflammation, which will be treated 
 of when 1 come to the subject of tumours , 
 is always accompanied with diseased action. 
 
 My friend, Mr. James of Exeter, justly 
 impressed with the utility which would re- 
 sult from a good nosological arrangement of 
 inflammation, has lately attempted to .supply 
 what must generally be allowed to be a great 
 desideratum. To the division of inflamma- 
 tion into the acute, subacute , or chfonic, be 
 o jeets, that in many instances, these are 
 merely different stages of the same disease. 
 The arrangement into the adhesive, suppura- 
 tive, ulcerative, or gangrenous inflammation, 
 be does not altogether approve, because it is 
 merely founded on the modes in which 
 either different, or in some instances, the 
 same kinds of inflammation terminate. Un- 
 der the heads of phlegmonous, erysipelatous , 
 and gangrenous inflammation, he argues, that 
 diseases of the most opposite nature have 
 been indiscriminately brought together. The 
 disposition to terminate in gangrene, he ad- 
 mits, will afford a basis for subdivision, but 
 not for primary separation. Mr. Janies 
 makes some judicious observations on the 
 arrangement of the kinds of inflammation, 
 according to the elementary tissue in which 
 they occur, as proposed by Dr. Carmichael 
 Smith, JPinel, and Bichat." The tissues in 
 question are five, and ihe doctrine supposes, 
 that the inflammation of each is essentially 
 different. The first is phlegmonous inflamma- 
 tion, which affects the cellular membrane, 
 including the parenchyma of the several vis- 
 cera. The second is inflammation of serous 
 membranes. The third, of mucous mem- 
 branes. The fourth, which is named erysi- 
 pelatous, is of the skin. And the fifth, term- 
 
INFLAMMATION. 
 
 109 
 
 cd rheumatic, belongs to fibrous structure. 
 That in Summations differ materially from 
 tfie circumstance of their affecting one of 
 these elementary tissues, rather than another, 
 Mr. James freely admits: but the following 
 objections appear to him fatal to this system, 
 if they are tru<‘. 1. Different kinds o i in- 
 flammation are liable to occur in the same 
 tissue. 2. The same kind of inflammation 
 is often met aith iti different tissues. 3. 
 The same inflammation may be transferred 
 from one to another; an argument, however, 
 on which he lays less stress, as being difficult 
 of direct proof. (S e Obs. on the different 
 Species of Inflammation, p. 3 — 7 8 vo. Lond. 
 1821.) At though difference of structure un- 
 questionably accounts for some of the varie- 
 ties in the appearance and character of in- 
 flammation, it will not sufficiently explain 
 the principal diversities of this affection to 
 be taken s the foundation of a nosological 
 arrangement, not only for the reasons pointed 
 out by Mr. James, r>u ; because the common 
 distinctions of inflammation at present in 
 vogue, arid some of which at least are ob- 
 vious and striking, cannot be at all solved by 
 any reference merely to texture. N >r did 
 this theory satisfy Mr. Hunter, who observed, 
 that if it were true, “ we should soon be 
 made acquainted with all the different in- 
 flammations in the same person at be same 
 time, and even in the same wound. For in- 
 stance, in an arnpui *tion of a leg, where we 
 cut through the -kin, cellular membrane, 
 muscle, tendon, periosteum, bone, and mar- 
 row, the skin should ;ive us inflammation of 
 its kind, the cellular membrane of its kind ; 
 the muscles of theirs, h &c. but we find it 
 is the same i iflammation in them all. How- 
 ever, though Mr. Hunter did not ad. nil the 
 possibility >t referring the different kinds of 
 inflammation to peculiarities of texture, his 
 doctrines assign to this cause considerable 
 influence over every form of the disorder, as 
 will be presently explained. 
 
 The mode of reasoning adopted by Mr. 
 James, leads him to propose ; 1-t. The divi- 
 sion of inflammations into two great classes, 
 according to their disposition either to be li- 
 mited by the effusion of organizable coagu- 
 lable lymph, or to spread. 2<ily. The orders 
 are established on the principle of die de- 
 gree of connexion of the organ with the vital 
 functions of the animal; another cause, which 
 exerts a predominant influence over the cha- 
 racter of the inflammation ; acts invariably, 
 and cwteris paribus, in the same degree ; the 
 constitutional sympathy being in proportion 
 to the danger, the difficulty of resisting that 
 danger, and of repairing the mischief done. 
 3Jiy. The genera are founded on the original 
 disposition of inflammations to have particu- 
 lar modes of terminal ion: thus, says Mr. 
 James, in boil and whitlow, it is to suppurate ; 
 in carbuncle, to slough ; and in mumps to 
 resolve : and this disposition is so strong, 
 that it is very difficult to procure any other 
 termination. It may happen, however, that 
 there shall be more than one mode, in which 
 it (the inflammation) is disposed to terminate, 
 as in either resolution, or suppuration, in 
 
 sphacelus, or ulceration, &c. (Op. cit. p. 13 
 — 16.) Mr. James conceives, “that these 
 general principles will perhaps afford a suffi- 
 cient basis for sueli an arrangement, as shall 
 be both natural and useful in its application 
 to all kinds of common inflammation; gout, 
 rheumatism, and scrotula having peculiarities 
 which require them to be separated.” Also 
 with respect to inflammations arising from 
 external injurie-, as tin y are more simple in 
 their nature, may take place in sound consti- 
 tutions, and are accompanied with disorgani- 
 zations, which do not exist in other cases, 
 Mr. James considers them as materially dif- 
 ferent. ! his author purposely excludes from 
 his classification inflammations of ihe organs 
 of sense, and of he bones, the peculiarities 
 in their structure and functions rendering 
 them fit subjects foi separate description. 
 With respect to Mr. James’s nosological ta- 
 ble of inflammation, I consider it very inge- 
 nious, and well deserving of the attention of 
 the profession : 1 may say this without at all 
 involving inyself in the hypothesis, that the 
 limitation, or spreading of the generality of 
 inflammations, is a circumstance entirely de- 
 pendent upon their di- position or indisposi- 
 tion to effuse organizable lymph. Mr. Hun- 
 ter was well acquainted with the frequent 
 usefulness of the adhesfve inflammation in 
 setting limits to disease, yet be did not ven- 
 ture lo refer the circumscription of every in- 
 flammation to this cause, or the spreading of 
 the disorder entirely to its absence. Nor, 
 indeed, does it seem essential to Mr. James’s 
 classification, that any canse should be as- 
 signed for tlie disposition of one class of 
 inflammations to be limited, and of another 
 to spread ; the two facts themselves being 
 sufficient for the basis of the division. 
 
 There is much foundation for believing 
 that healthy inflammation is invariably an 
 homogeneous process, obedient to ordained 
 principles, and, in similar structures, similar 
 situations, and in constitutions of equal 
 strength, uniformly assuming the' same fea- 
 tures. If experience reveals to us, that here 
 it is commonly productive of certain effects, 
 and there it ordinarily produces different 
 ones, the same unbounded source of wis- 
 dom communicates lo the mind a know- 
 ledge, that there is some difference in the' 
 tone of the constitution, or in the structure 
 or situation of the parts affected, assignable 
 as the cause of this variety. A modem 
 author (Dr. Smith , in Med. Communications , 
 Vol. 2.) makes the nature of the exciting 
 cause one principal ground of the specific 
 distinctions in inflammation, and with good 
 reason, when he takes into the account the 
 action of morbid poisons, and the qualities 
 of disease in general. 
 
 The doctrine also receives confirmation 
 from what is observed in cases of burns, and 
 chilblains, where the inflammation is un- 
 questionably attended with great peculiari- 
 ty, requiring different treatment from that 
 of common inflammation in general. But, 
 when the exciting cause is strictly mechani- 
 cal, its violence and extent may cause dif 
 ferences in the degree and quantity of in ! 
 
INFLAMMATION". 
 
 no 
 
 flammation ; but, with respect to its quality, 
 this must be accounted for by constitution, 
 or other circumstances. 
 
 The attentive observation of experience, 
 the only solid basis of all medical, as well 
 as other knowledge, has informed the 
 practitioner, that parts, which from their 
 vicinity to the source of the circulation, 
 enjoy a vigorous circulation of blood through 
 them, undergo inflammation more favour- 
 ably, and resist disease bet er than other 
 parts, of similar structure, more remote 
 from the heart. The lower extremities are 
 more prone to inflammation, and disease in 
 general, than parts about the chest ; when 
 inflamed, they are longer in getting well ; 
 a ad the circumstance of their being de- 
 pending parts, which retards the return of 
 blood through the veins, must also increase 
 the backwardness of such parts in any salu- 
 tary process. (Hunter.) Healthy inflam- 
 mation is of a pale red , w hen less health)', 
 it is of a darker colour ; but, in every con- 
 stitution, the inflamed parts will partake 
 more of the healthy red. the nearer they 
 are to the source of the circulation. (Hun- 
 ter.) 
 
 Inflammation, when situated in highly or- 
 ganized and very vascular parts, is generally 
 more disposed to take a prosperous course, 
 and is more governable by art, than in parts 
 of an opposile texture. The nearer also 
 such vascular parts are to the heart., the 
 greater will be their tendency to do well in 
 inflammation. (Hunter.. Hence, inflarn 
 mation of the sk n, cellular substance, mus- 
 cles, &c more frequently ends favourably, 
 tin the same affection of bones, tendons, 
 fascia?, ligaments, he. It is also more ma- 
 nageable by surgery ; for those parts of the 
 bod > , which are not what anatomists verm 
 vascular , seem to enjoy only inferior pow- 
 ers of life, and, consequently, when excited 
 in a preternatural degree, frequently mor- 
 tify. 
 
 But, inflammation of vital parts, though 
 they may be exceedingly vascular, cannot 
 go on so favourably, as in other parts of re- 
 sembling structure, but, of different func- 
 tions ; because, the natural operations of 
 universal health depend so much upon the 
 sound condition of such organs. (Hunter.) 
 The truth of this observation is illustrated 
 in cases of gastritis, peripneumony, he. 
 
 All new-formed parts not originally en- 
 tering into the fabric of the body, such as 
 tumours, both of the encysted and sarcoma- 
 tous kinds, excrescences, he. cannot en- 
 dure the disturbance of inflammation long, 
 ror in a great degree. The vital powers of 
 such parts are weak, and when irritated by 
 the presence of inflammation, these adven- 
 titious substances are sometimes removed 
 by the lymphatics, but more commonly 
 slough This remark applies also to sub- 
 stances generated as substitutes for the ori- 
 ginal matter of the body ; for instance, 
 granulations and callus The knowledge 
 of this fact, leads us to a rational principle 
 of cure in the treatment of several surgical 
 diseases. Do we not here perceive the 
 
 cause, why very large-wens are occasion- 
 ally dispersed by the application of urine, 
 brine, and similar things, which are now in 
 great repute, on this account, with almost 
 every one out of the profession ? How 
 many verruca?, wrongly suspected to origi- 
 nate from a syphilitic cause, are diminished 
 and cured by a course of mercury ! It is the 
 stimulus of this mineral upon the whole 
 system, that accomplishes the destruction 
 of these adventitious substances — not its 
 antivenereal quality. Topical stimulants 
 vouid fulfil the same object', not only with 
 greater expedition, but with no injury to 
 the general health. 
 
 Inflammation, cceleris paribus , always pro- 
 ceeds more favourably in strong, than in 
 weak constitutions; for, when there is 
 much strength, there, is little irritability. In 
 weak constitutions, the operations of in- 
 flammation are backward, notwithstanding 
 the part in which it is seated may, compa- 
 ratively speaking, possess considerable or- 
 ganization, and powers of life. (Hunter.) 
 
 Healthy inflammation, wherever situated, 
 is always most violent on that side of the 
 point of inflammation, which is next to the 
 external surface of the body. When in- 
 flammation attacks the socket of a tooth, it 
 does not take place on the inside of the al- 
 veolary process, but towards the cheek. 
 When inflammation attacks the cellular sub- 
 stance, surrounding Ihe rectum, near the 
 anus, the affection usually extends itself t® 
 the skin of the buttock, leaving the intes- 
 tine perfectly sound, though in contact with 
 the inflamed part. (Hunter.) 
 
 We may observe the influence of this 
 law in the diseases of the lachrymal sac and 
 duct, in those of the frontal sinus and 
 antrum, and particularly in-gunshot wounds. 
 Suppose a ball were to pass into the thigh, 
 to within an inch of the opposite side of the 
 iimb we should not find, that inflammation 
 would be excited along the track of the 
 ball, but, on the side next ihe skin which 
 had not been hurt. If a ball were to pass quite 
 through a limb, and carry into the wound a 
 piece of cloth, which lodged in the middle, 
 equidistant from the two orifices, the skin, 
 immediately over the extraneous body, 
 would inflame, if the passage of the ball 
 were superficial. — (Hunter) Mr. Hunter 
 compared this law with the principle, by 
 which vegetables approach ihe surface of 
 the earth ; but, t ee solution ot it was too 
 arduous even for his strong genius and pene- 
 tration. 
 
 We see three very remarkable effects 
 follow the prevalence of inflammation ; 
 viz. adhesions of parts of the body to each 
 other; the formation of pus, or suppura- 
 tion ; and ulceration, a process, in which 
 the lymphatics are more concerned, than 
 the blood-vessels. Hence, Mr. Hunter 
 termed the different, stages of inflammation, 
 the adhesive, the suppurative, and the ulcer- 
 ative. 
 
 All parts of the body are not equally lia- 
 ble to each of the preceding consequences, 
 (Hunter.) 
 
INFLAMMATION’. 
 
 Ill 
 
 In the cellular membrane, and in the cir- 
 cumscribed cavities, the adhesive stage 
 takes place more readily than the others ; 
 suppuration may he said to follow next in 
 order of frequency ; and lastly ulceration. 
 
 In internal canals, on the inner surfaces 
 of the eyelids, nose, mouth, and trachea, in 
 the air-cells of the lungs, in ihe oesophagus 
 stomach, intestines, pelvis of the kidney, 
 ureters, bladder, urethra, and in all the ducts 
 and outlets of the organs of secretion, being 
 what are termed mucous membranes , the sup- 
 purative inflammation comes on more rea- 
 dily, than either the adhesive, or the ulcer- 
 ative stage. Adhesions, which originate 
 from the slightest degree ot inflammation in 
 other situations and structures, can only be 
 produced by a violent kind in the above- 
 mentioned parts. Ulceration is more fre- 
 quently met with upon mucous surfaces, 
 than adhesions. (Hunter.) The cellular 
 membrane appears to be much more sus- 
 ceptible of the adhesive inflammation, than 
 the adipose, and much more readily passes 
 into the suppurative. (Hunter ) Thus we 
 see the cellular substance, connecting the 
 muscles together, and the adipose mem- 
 brane to the muscles, inflaming, suppurating 
 and the matter separating the muscles, from 
 their lateral connexions, and even the fat 
 from the muscles, while the latter substance 
 and the skin are only highly inflamed. 
 (Hunter.) But, it must be allowed, that in 
 situations where fat abounds, we very fre 
 quently meet with abscesses. This is so 
 much the case, that fat has been accounted 
 a more frequent nidus for collections of 
 matter, than the cellular substance. (Brom- 
 Jield.) Abscesses are particularly liable to 
 form in the neighbourhood of the anus, 
 mamma, &c. With respect to the fat being 
 highly inflamed, however, the expression is 
 not strictly true. Fat has no vessels, princi- 
 ple of life nor action of its own ; conse- 
 quently, we cannot suppose that it can itself 
 either inflame, or suppurate. We know', 
 that it is itself a secretion, and when an ab- 
 scess forms in it, vve understand, that the 
 mode of action in the vessels, naturally des- 
 tined to deposit fat, has been altered to that 
 adapted to the formation of pus. When 
 therefore the fat is said to be inflamed, it is 
 only meant, that the membranous cells, in 
 which it is contained, and by which it is se- 
 creted, are thus affected. 
 
 The deeply-situated parts of the body, 
 more especially the vital ones, very readily 
 admit of the adhesive stage of inflammation 
 The circumstance of deeply-seated parts 
 not so readily taking on the suppurative 
 stage of inflammation, as the superficial 
 ones do, is strikingly illustrated in cases of 
 extraneous bodies, which, if deeply lodged, 
 only produce the adhesive inflammation. 
 By this process, a cyst is formed, in which 
 they lie without much inconvenience, and 
 they may even gradually change their situa 
 tion, without disturbing the parts, through 
 which they pass. But, "no sooner do these 
 same bodies approach the skin, than absces- 
 ses immediately arise. (Hunter.) 
 
 All inflammations, attended with disease, 
 partake of some specific quality, from which 
 simple inflammation is entirely free. When 
 the constitution allows the true adhesive 
 and suppurative stages to occur, it is to be 
 regarded as the most healthy. Were it in 
 an opposite state, vve should see the very 
 same irritation excite some other kind of 
 inflammation, such as the erysipelatous, 
 scrofulous, &c. (Hunter.) 
 
 In specific inflammations, the position, 
 structure, and distance of the part affected 
 from the source of the circulation, as well 
 as from t lie surface of the body, seem also 
 to have as much influence as in cases of 
 common inflammation. Upon this point, I 
 feel conscious of being a lit'le at variance 
 with what Mr. Hunter has stated ; but, the 
 undecided manner in which he expresses 
 himself, not less than the following reflec- 
 tions, encourages me not to desert my own 
 ideas. We see, that venereal eruptions 
 sooner make their appearance upon the 
 chest and face, than upon the extremities. 
 No organized part can be deemed exempt 
 from the attack of common inflammation ; 
 many appear to be totally insusceptible of 
 the venereal. We know, that scrofulous dis- 
 eases of tiie superior extremities take a more 
 favourable course, require amputation less 
 frequently, and get well oftener than when 
 situated in the inferior limbs. (Ford.) The 
 venereal disease makes more rapid advan- 
 ces in the skin and throat, than in the bones 
 and tendons ; we often see it producing a 
 specific inflammation, and an enlargement 
 of the superficial parts of the tibia, ulna, 
 clavicle, cranium, &,c. while other bones, 
 covered by a considerable quantity of flesh, 
 are very rarely affected. Gouty inflamma- 
 tion is prone to invade the small joints ,j 
 rheumatic, the large. 
 
 SYMPTOMS, NATURE, AND CAUSES OF INFLAM- 
 MATION. 
 
 Redness, swelling, heat, and pain, the four 
 principal symptoms of phlegmonous inflam- 
 mation, have been accurately noticed by 
 Celsus : Notce vero injlammationis surd qua- 
 tuor, rubor, et. tumor, eum calore et dolore , lib. 
 3, cap. 10. If we refer to any writer on this 
 interesting part of surgery, we shall find the 
 above symptoms enumerated as characteri- 
 zing phlegmon. In short, this term is usu- 
 ally applied to a circumscribed tumour, at- 
 tended with heat, redness, tension, and a 
 throbbing pain. These are ihe first appear- 
 ances observed in every case of phlegmon ; 
 and when they are slight, and the part af- 
 fected is of no great extent, they have com- 
 monly very little, and sometimes no appa- 
 rent, influence on the general system. But 
 when they are more considerable, a id the 
 inflammation becomes extensive, a full, 
 quick, and generally a hard pulse takes 
 place, and the patient, at the same time, 
 complains of universal heat, thirst, and other 
 symptoms of fever. While the inflamed part 
 becomes red, painful, and swelled, its func- 
 tions are also impaired. The same degree 
 
112 
 
 INFLAMMATION. 
 
 of inflammation is said to produce more 
 swelling in sol. parts, and less in those of a 
 harder structure. {Burns.) 
 
 Though the redness, swelling, throbbing, 
 tension, and other symptoms of phlegmo- 
 nous inflammation, are less manifest, when 
 the affection is deeply situated, yet their ex 
 isterice is undoubted. When persons die of 
 peripneumony, or inflammation of the lungs, 
 the air-cells of these organs are found 
 crowded with a larger number of turgid 
 blood-vessels than in the healthy state, and 
 of course the parts must appear preternatu- 
 rallv red. Coagulating lymph, and even 
 blood, are extrav. sated in the substauce of 
 these viscera, which become heavier, and 
 feel more solid. ( Bnillie .) 
 
 The extravasation of coagulating lymph, 
 which is one of the chief causes of the swell- 
 ing, is also one of the most characteristic 
 signs of phlegmonous inflammation. 
 
 Some writers (Smith, in Med. Commun. 
 Vol. 2.) have confined the seat of phlegmon 
 to the cellular membrane ;• but this idea is 
 erroneous. Had such authors duly discrimi- 
 nated the nature of common inflammation, 
 they would have allowed that this affection 
 existed, wherever the capillaries appeared 
 to be more numerous and enlarged '.nan in 
 the natural state, accompanied with an effu- 
 sion of coagulating lymph, whether upon 
 the surface of a membrane, or a bone, or 
 into the interstices of the cellular substance, 
 and attended with acute pain, and a throb- 
 bing pulsation in the part. 
 
 As Dr. Thomson has observed, the epithet 
 remote as applied to the causes of inflamma- 
 tion. does not appear to be happily chosen ; 
 for under this term are comprehended all 
 those agents, evtents, and states, which con- 
 tribute "immediately, as well as remotely, 
 directly as well as indirectly, to the produc- 
 tion of the affection. ( Lectures on Inflam- 
 mation, p. 50.) 
 
 The remote causes of inflammation are 
 infinite in number, but very easy of com- 
 prehension, because orny divisible into two 
 general classes. The first includes all such 
 agents as operate by their stimulant or 
 chyrnfcal qualities; for instance, canthari- 
 des, heat, the action of concentrated acids, 
 alkalies, metallic oxides, and metallic salts, 
 acrid vapours, such as ammoniaeal gas, the 
 nitrous, sulphureous, muriatic, oxygenated 
 muriatic gases, &vc. alcohol, aether, and all 
 acrid vegetable essential oils, animal poi- 
 sons, and the whole of that class of substances 
 known by the name of rubefacients. ( Thom- 
 son on Inflammation, p. 55.) The second class 
 of causes are those which act mechanically, 
 such as bruises, wounds, pressure, friction, 
 fcc. 
 
 Fevers often seem to become the remote 
 causes of local inflammation, in other in- 
 stances, inflammation appears to arise spon- 
 taneously, or, as I should rather say, without 
 any perceptible exciting cause. 
 
 The principle on which the application 
 of cold to a part becomes the remote cause 
 of inflammation, is not decidedly known. 
 “ No sublet (says a distinguished professor) 
 
 is more deserving of your study, than the 
 effects which are produced in the human 
 body by the operation of cold applied to its 
 surface ;but the subject is, at the same time, 
 exceedingly extensive, complicated, and dif- 
 ficult. .These effects differ according to the 
 degree in which the cold is applied, the 
 state of the system, the part of the body to 
 which it is applied, and the mode of its ap- 
 plication. So diversified, indeed, are these 
 effects, that it requires no mean confidence 
 in theoretical reasoning to believe, that the 
 operation of cold in producing them is ex- 
 plicable upon any single general principle.’' 
 (See Thomson on Inflammation, p. 58.) And 
 in the preceding page, he observes: “The 
 operation of cold upon the human body af- 
 fords the best example which 1 can suggest 
 to you. of the production of inflammation 
 from the operation of a power acting upon 
 a part at a distance from that in which the 
 inflammation takes place. The instances 
 formerly mentioned of inflammation of the 
 throat, chest, or belly, from the application 
 of cold to the feet, are daily occurrences in 
 these climates, of which it is impossible for 
 us, in the present stale of o ir knowledge of 
 the animal economy, to give any thing like 
 a satisfactory explanation. 
 
 “ In some instances, cold, or a diminution 
 of temperature, seems to act more directly 
 upon the parts, with which it comes into 
 contact. We have examples of this in the 
 inflammation of the mucous membranes of 
 the nose, fauces, trachea and bronchia?, 
 from the inhalation of cold air; and in the 
 production of rheumatic inflammation from 
 the accidental exposure of some part or 
 other of the body to cold. The application 
 of cold, in the instances I have mentioned, 
 seems to have somewhat of a directly exci- 
 ting effect ; and perhaps the same remark is 
 still more applicable to the local effects of 
 cold in the production of the inflammation 
 accompanying the state, which is usually 
 denominated fast-bite. Touching a solid 
 body, as a piece of metal, the temperature 
 of which has been greatly reduced, produces 
 a sensation like that of burning, and maybe 
 folhmed, like the application of fire, with a 
 blister.” (Op. cil.) 
 
 Numerous opinions have been entertain- 
 ed respecting die proximate cause of Inflam- 
 mation ; but almost every theory has been 
 built upon the supposition of there being 
 some kind of obstruction in the inflamed 
 part. 
 
 While the circulation of the blood was 
 unknown, and the hypothetical notions of 
 the power of the liver, in preparing and 
 sending forth this fluid, continued to prevail, 
 physicians were so fully persuaded of the 
 existence and influence of different humours 
 and spirits, and so little did they know of 
 the regular and constant motion of the 
 blood, that they believed in the possibility 
 of depositions and congestions of the blood, 
 the bile, or lymph ; and acknowledged these 
 as the cause of inflammation. I heir anato- 
 mists taught them, and their professors <*1 
 physic supported the opinion, that the liver 
 
INFLAMMATION. 113 
 
 was the centre of the vascular system, from 
 which the blood went forth by day to the 
 extremities, and returned again by night. If 
 then any peccant matter irritated the liver, 
 the blood was sent out more forcibly ; and 
 if, at the same time, any part of the body 
 were weakened, or otherwise disposed to 
 receive a greater quantity of fluid than the 
 rest, then a swelling was produced by ihe 
 flow of humosrs to this place. Fluxions, or 
 flows of humour to a place, might happen 
 cither from weakness of the part which al- 
 lowed the humours to enter more abun- 
 dantly, or from the place attracting the hu- 
 mours, in consequence of the application of 
 heat or other agents. The peculiar nature 
 of the swelling w as supposed to depend upon 
 the kind of humour. Blood produced the 
 true phlegmon ; bile, erysipelas ; &c. An 
 idea was also entertained, that the blood 
 and humours might slowly stagnate in a 
 part, from a want of expulsive power, and 
 this affection w as termed a congestion, w hile 
 the expression fluxion or defluxion was used 
 to denote any swelling arising from the sud- 
 den flow of humours from a distant part. 
 (J. Burns , Dissertations on Inflammation.) 
 
 From the theories of fluxion and conges- 
 tion, which were quite incompatible with 
 the laws of the circulation of the blood, 
 we turn our attention to the doctrine of ob- 
 struction. 
 
 Boerhaave inculcated, (Jlph. 375 el seq.) 
 that inflammation w as caused by an obstruc- 
 tion to the free circulation of the blood in 
 the minute vessels, and this obstruction, he 
 supposed, might be caused by heat, diar- 
 rhoea, too copious flow of urine, and sweat, 
 or whatever could dissipate the thinner parts 
 of the blood, and produce a thickness or 
 viscidity of that fluid. When the lentor did 
 not exist before the production of inflamma- 
 tion, he imagined that the larger globules 
 of the blood passed into the small vessels, 
 and thus plugged them up. This circum- 
 stance was termed an error loci. The ob- 
 struction, whether caused by viscidity or an 
 error loci, was imagined to occasion a resist- 
 ance to the circulation in the part affected ; 
 and hence, an increase of the flow of the 
 blood in the other vessels, an irritation of 
 the heart, and augmentation of the force, or 
 attraction of the blood in that part of the 
 vessel which was behind the obstruction. 
 This caused heat and pain, while the accu- 
 mulation of blood produces redness. Bo- 
 erhaave also brought into the account an 
 acrimonious stale of the fluids, which render- 
 ed resolution out of the question, and gan- 
 grene likely to follow. (Jlph. 388.) 
 
 The viscidity of the blood cannot be ad- 
 mitted as the proximate cause of inflamma- 
 tion ; because we have no proof that this 
 state ever exists ; or, granting that it did, it 
 would not explain the phenomena. Were 
 a viscidity to occur, it would exist in the 
 whole mass of blood, would affect every 
 part of the body alike, and could not be sup- 
 posed to produce only a local disorder. 
 How also could such a lentor be produced 
 by causes which bring on inflammation sud- 
 Vot.. TT 15 
 
 denly, without there being time for changes 
 of the fluids to take place ? 
 
 With regard to the doctrine of error loci , 
 or of red globules going into vessels which 
 did not formerly transmit them, the fact 
 must be admitted, at the same time, that the 
 conclusion is denied. When the eye be- 
 comes inflamed, the tunica conjunctiva is 
 seen with its vessels full of red blood, which 
 in health is not the case; but this redness 
 never appears until the inflammation has 
 commenced, and must therefore be consi- 
 dered as an effect, not a cause. Nor can 
 this error loci occasion any obstruction in 
 these vessels ; for if they be divided, the 
 blood flows freely, which shows that they 
 are large enough to allow an easy circula- 
 tion. (J. Burns.) 
 
 Boerhaave’s theory of obstruction was too 
 circumscribed, and too mechanical ; it re- 
 duced all inflammations to one species: the 
 only distinctions which could have arisen, 
 must have proceeded from the nature of the 
 obstruction itself ; and it was a doctrine that 
 never could account for the action of many 
 specific diseases and morbid poisons. (Hun- 
 ter.) 
 
 As for the supposition of the co-operation 
 of an acrimony of the fluids, the proportion 
 of the saline matter of the blood has never 
 been proved to be greater in this, than in. 
 any other state of the body. (Burns.) Even 
 were a general disorder of this kind to be 
 admitted, no rational explanation of the 
 proximate cause of local inflammation could 
 be deduced from it. 
 
 The decided impossibility of giving a ra- 
 tional explanation of the immediate cause 
 of inflammation by any supposed state of 
 the blood alone, led pathologists to investi- 
 gate how far a change in the blood-vessels 
 themselves might account for the process. 
 It belongs more properly to a physiological 
 than a surgical work, to explain the various 
 facts and experiments in support of the opi- 
 nion, that the arterial tubes, and especially 
 the capillaries, possess a high degree of vital 
 contractility, whereby the motion of the 
 fluids in them, the process of secretion, and 
 other local phenomena may be importantly 
 affected, in a manner not at all explicable, 
 by reference only to the action and power 
 of the heart. For such information,! would 
 particularly advise the x-eader to consult the 
 publications of Dr. Wilson Philip, and Dr. 
 Hastings. Accoi’ding to the latter gentle- 
 man, the actual agency of the capillaiy ves- 
 sels, “ is not only supported by such ex- 
 periments as those related, it is also coun- 
 tenanced by an extensive series of pheno- 
 mena presented during disease in the hu- 
 man subject. Of these may be mentioned, 
 irregular determinations of blood, the growth 
 of tumours, increased pulsation of arteries 
 leading to inflamed parts, of which the fol- 
 lowing is a well-marked example, the accu- 
 racy of which may be entirely relied upon. 
 The carotids, when the person alluded to 
 is in health, beat equally as to strength and 
 frequency; but when he is attacked with 
 inflammation in the right tonsil, to which 
 
114 
 
 INFLAMMATION. 
 
 he is particularly subject, and which pro- 
 ceeds sometimes so far as nearly to prevent 
 deglutition, each pulsation of the artery 
 gives a throbbing sensation on the right 
 side of the head. On the application of the 
 hand at this time to each carotid, the right 
 is found to beat much stronger and fuller 
 than the left. This diversity of action in 
 these two arteries cannot arise from any 
 impulse given by the blood to the heart : it 
 must be derived from some modification 
 of the contractile power of the artery.” And 
 Dr. Hastings expresses his belief in this ex- 
 planation, notwithstanding Dr. C.H. Parry 
 wishes to attribute to the remote influence 
 of the heart some of the phenomena of local 
 congestion and motion, and to show, that 
 the different states of vascular dilatation are 
 still more conspicuously connected with the 
 different degrees of action of the heart, and 
 the consequent momentum of the blood, 
 than with local circumstances ; and that 
 the proneness to local dilatation, or, as it is 
 called, action, is a consequence of slowly 
 succeeding, but continued impulse 
 
 The blood-vessels, through every part of 
 the system, possess a considerable share of 
 irritability, by which they contract, and pro- 
 pel forward their contents. Hence, the 
 blood, by the action of the vessels, receives 
 a new impulse in the most minute tubes, 
 and a well-regulated momentum is preser- 
 ved in every part of its course. But of all 
 parts of the sanguiferous system, the capil- 
 laries seem most eminently endowed with 
 this faculty, and are least indebted to the 
 presiding influence of the heart. Yet even 
 in these vessels, the action of the heart is of 
 high importance in sustaining the healthy 
 circulation, inasmuch as it gives the first 
 impulse to the blood, and preserves the har- 
 jnony of the sanguiferous system. 
 
 The vessels are endowed with this vital 
 property, in order that each organ in the 
 body may receive such a supply of blood 
 as will enable it duly to exercise its func- 
 tions. Hence, a healthy state of this pro- 
 perty is absolutely necessary for the preser- 
 vation of the animal functions ; for, if the 
 vital contraction* of the blood-vessels be 
 either increased or diminished, irregular 
 distribution of the blood inevitably follows, 
 and from this source numerous diseases 
 arise, and none more frequently than in- 
 flammation. However, though these senti- 
 ments, delivered by Dr. Hastings, may be 
 generally correct, 1 am not prepared to join 
 in the opinion, that inflammation is ever 
 produced simply by an inequality in the 
 distribution of the blood ; a statement 
 which this gentleman probably does nut 
 mean to make himself, as he confesses that 
 some of the phenomena of this disease de- 
 pend upon sympathy between the sanguife- 
 rous and nervous systems. (See Hastings 
 on Inflammation of the Mucous Membrane of 
 the Lungs, p. 32, 64, 65, 8 vo. Lond. 1820; 
 and C. H Parry, Additional Experiments on 
 the Arteries , fyc.p. 112, 114 ; Also Why 1 1 on 
 the Motion of the Fluids in the small Vessels ; 
 Yerscfiuir dr. Arteriarvm et Venarum vi irri • 
 
 tabiti ; Zimmermann de irritabilitatc, p. 24 j 
 Hunter on the Blood , «^c.) 
 
 Dr. Cullen attributed the proximate cause 
 of inflammation to a “ spasm of the extreme 
 arteries supporting an increased action in 
 the course. of them.” This theory only dif- 
 fers from that of Boerhaave in the cause 
 which is assigned for the obstruction, Dr. 
 Cullen conceived, however, that some 
 causes of inequality in the distribution of 
 the blood might throw an unusual quantity 
 of it into particular vessels, to which it must 
 necessarily prove a stimulus ; and that, in 
 order to relieve the congestion, the vis me- 
 dicatrix naturae increases still more the 
 action of the vessels ; which, as in all other 
 febrile diseases, it affects by the formation 
 of a spasm on their extremities.” “ A spasm 
 of the extreme arteries, supporting an in- 
 creased action in the course of them, may, 
 therefore be considered as the proximate 
 cause of inflammation ; at least, in all cases 
 not arising from direct stimuli applied ; and 
 even in this case the stimuli may be suppo- 
 sed to produce a spasm of the extreme 
 vessels” (Cullen.) 
 
 The inconsistencies in Cullen’s theory are 
 very glaring. The congestion or accumula- 
 tion of blood, which is only an effect or con- 
 sequence of inflammation, is set down as 
 the cause of the spasm of the vessels to 
 which spasmodic constriction Cullen, 
 strangely enough, assigns the name of proxi- 
 mate cause. The spasmodic contraction of 
 the extremities of the vessels, instead oi 
 propelling the accumulated quantity ot 
 blood, would render Ihe passage of the 
 blood from the arterial into the venous sys- 
 tem still more difficult. (Burns.) 
 
 We shall now notice the celebrated and 
 very original opinions promulgated on this 
 subject by John Hunter. According to him, 
 inflammation is to be considered only as a 
 disturbed state of parts, which requires a 
 new but salutary mode of action to restore 
 them to that state wherein a natural mode 
 of action alone is necessary. From such a 
 view of the subject, therefore, inflammation 
 in itself is not to tie considered as a disease, 
 but as a salutary operation, consequent 
 either to some violence or some disease. 
 F.lsewhere the author remarks, the act of in- 
 flammation is to be considered as an increa- 
 sed action of the vessels, which , at first, consists 
 simply in an increase or distention beyond 
 their natural size This increase seems to de- 
 
 pend upon a diminution of the muscular 
 power of the vessels, at* the same time lhat 
 the elastic power of the artery must be di- 
 lated in the same proportion. This is, 
 therefore, something more than simply a com- 
 mon relaxation : we must suppose it an 
 action in the parts to produce an increase 
 of size for particular purposes, and this Mr. 
 Hunter would call an act of dilatation. The 
 whole is to be considered as a necessary 
 operation of nature. Owing to this dilata- 
 tion, there is a greater quantity of blood cir- 
 culating in ihe part, which is according to 
 the common rules of the animal economy ; 
 for, whenever a part has more to do thfpi 
 
INFLAMMATION 1 . 
 
 115 
 
 Simply to support itself, the blood is there 
 collected in larger quantity. The swelling 
 is produced by an extravasation of coagula- 
 ble lymph, with some serum : but this 
 
 lymph differs from the common lymph, in 
 consequence of passing through inflamed 
 vessels. It is this lymph which becomes 
 the uniting medium of inflamed parts ; ves- 
 sels shoot into it ; and it has even the power 
 of becoming vascular itself. The pain pro- 
 ceeds from spasm. The redness is produ- 
 ced either by the arteries being more dila- 
 ted than the veins, or because the blood is 
 not changed in the veins. “ As the vessels 
 become larger, and the part becomes more 
 of the colour of blood, it is to be supposed 
 there is more blood in the part ; and as the 
 true inflammatory colour is scarlet, or that 
 colour which the blood has when in the 
 arteries, one would from hence conclude 
 either that the arteries were principally di- 
 lated, or, at least, if the veins are equally 
 distended, that the blood undergoes no 
 change in such inflammation in its passage 
 from the arteries into the veins, which I 
 think (says Mr. Hunter) most probably the 
 case ; and this may arise from the quickness 
 of its passage through those vessels .” When 
 a part cannot be restored to health, after 
 injury, by inflammation alone, or by adhe- 
 sion, then suppuration, as a preparatory 
 step to the formation of granulations, and 
 the consequent restoration of the part, takes 
 place. The vessels are nearly in the same 
 state as in inflammation ; but they are more 
 quiescent, and have acquired a new mode 
 of action. (Hunter.) 
 
 With respect to Mr. Hunter’s theory, 
 which has deservedly had vast influence in 
 regulating the judgment of professional 
 men in this country, on the nature of the 
 process called inflammation, it cannot be 
 received in the present state of knowledge 
 without some limitation. The hypothesis, 
 that the blood-vessels possess an active 
 power of dilatation, independently of their 
 elasticity, as Dr. Hastings observes, must as 
 yet be regarded as devoid of proof, and 
 therefore should not be assumed as a basis 
 on which any theory of inflammation is 
 founded. (On Inflammation of the Mucous 
 Membrane of the Lungs, fyc p. 70. ) And, as 
 another intelligent writer remarks, how dif- 
 ferent would have been Mr. Hunter’s infer- 
 ences, if, instead of trusting to the unassisted 
 eye, he had viewed the inflamed vessels 
 through the microscope. He would then 
 have seen the blood moving, and found, 
 that, “ instead of its passage being quickened 
 in the inflamed vessels , it is uniformly render- 
 ed s ower in proportion to the degree of in- 
 flammation. and, in the most inflamed parts, 
 stands still altogether .” (On the Vital Func- 
 tions, p. 288, Ed. 2.) And. in another part 
 of his writings, Dr. Philip has endeavoured 
 to prove, from several facts respecting the 
 colour of the blood, that within certain 
 limits , the accumulation of this fluid in the 
 debilitated vessels of the inflamed part neces- 
 sarily causes the blood to retain the florid, 
 colour. (On Fevers, Part 2, Introd .) 
 
 In modern times, the vague, but conve- 
 nient expression, increased action of the ves- 
 sels. has been very generally used as an 
 adequate explanation of the proximate cause 
 of inflammation. The doctrine, it is said, 
 derives support from a review of the several 
 exciting causes of the affection, which, be- 
 ing in general of an irritating nature, must, 
 when applied to any living or sensible parts, 
 occasion such increased action of the ves- 
 sels ; while the method of cure also tends to 
 confirm the opinion. But, before one can 
 judge whether this doctrine is correct, and 
 supported by facts and observation, it is 
 necessary to understand precisely what is 
 implied by increased action of vessels; for 
 it is not every affection of the vessels, capa- 
 ble of being thus denominated, which will 
 of itself constitute inflammation. In gesta- 
 tion, the arteries of the womb are enlarged, 
 and a greater quantity of blood is sent into 
 them; yet this organ is not inflamed. The 
 carotids are in a similar state during, the 
 growth of the stag’s horn ; but no inflam- 
 mation exists, if then the proximate cause 
 of inflammation is to be called an increased 
 action of the vessels, we must first be in- 
 formed not only what is meant by the term, 
 but what particular vessels are spoken of, 
 whether the arterial trunks, bio chc's, or 
 capillaries ? Because, if the phrase is intend- 
 ed to signify increased alternate expansions 
 and contractions of all the arteries of the 
 inflamed part, it is an hypothesis entirely 
 destitute of foundation. If it be meant to 
 denote an increased velocity of the mo- 
 tion of the blood in the part affected, the 
 doctrine is rather contradicted than con- 
 firmed by the latest and most carefully insti- 
 tuted microscopical experiments. But if 
 the expression onlyrefers to the dilated state 
 of the capillaries, the throbbing of the arte- 
 ries leading to the seat of inflammation, the 
 effusion of lymph, &c. less fault can be found 
 with the language, though yet requiring 
 much further explanation ere it can com- 
 municate any very precise information. 
 
 “ There are (says a learned professor) 
 two hypotheses, which at present divide the 
 opinions of pathologists respecting the state 
 of the capillary vessels affected with in- 
 flammation. According to the first of these 
 hypotheses, the inflamed vessels are in at 
 state of increased action ; according to the 
 second, they act with less force than the 
 trunks from which they are derived.” (See 
 Thomson on Inflammation, p. 64.) 
 
 The first of these opinions, according to 
 Dr. Thomson, was suggested by the views 
 which Stahl took of the animal economy, 
 and his ideas respecting the tonic or vital 
 action of the capillary vessels. The doc- 
 trine, however, was more particularly insist- 
 ed upon by his disciples and followers, 
 especially Dr. Gorter, who in one place 
 expressly states, u that the proximate cause 
 of inflammation consists in an increased 
 vital action of some particular artery or 
 arteries, by which the blood is propelled 
 with greater fofce than usual into the com- 
 mimic ating lymphatic and colourless vete 
 
INFLAMMATION. 
 
 lit) 
 
 sels.” (See his Compendium Medicines and 
 Chirurgia Repurgala ) 
 
 The doctrine which supposes the action 
 of the inflamed vessels to be diminished, or 
 to be proportionably less than that of the 
 trunk or trunks from which they are deri- 
 ved, was, as far as Dr. Thomson can learn, 
 first stated by Vacca, an Italian physician, 
 in a small treatise on inflammation, publish- 
 ed at Florence in 1765, entitled “ Liber de 
 Inflammat ionis Mo/bosce, quae in humano car- 
 port fit natur&y causis, effedibus , el curatione .” 
 
 For an account of the arguments with 
 which Vacca supports his hypothesis, my 
 limits oblige me to refer to the work of 
 Dr. Thomson. (P. 68. <^c.) 
 
 As this gentleman has observed, there are 
 certain points in which the two doctrines 
 agree, as well as in which they differ. 
 
 “ The advocates for each hypothesis agree 
 in admitting, 1st, that inflammation has its 
 seat in the capillary vessels ; and 2dly, that 
 the redness in inflammation is owing to an 
 unusual quantity of blood in the vessels of 
 the inflamed part, and consequently that 
 the capillary arteries are much dilated du- 
 ring the state of inflammation. The con- 
 tractions of these vessels, indeed, it has 
 been said, are increased also in a ratio pro- 
 portional to the dilatations ; but, this is an 
 assertion which has not yet been proved, 
 either in the way of experiment or of ob- 
 servation. 
 
 “ The sense of throbbing, which the advo- 
 cates for the hypothesis of increased capilla- 
 ry action regard as the strongest proof of 
 that action, Mr. Allen is disposed to attribute 
 to the difficulty, which the blood meets with 
 in passing from the trunk into the capillary 
 branches. This sensation of throbbing, and 
 appearance of increased action, may be 
 produced in an instant, by applying a liga- 
 ture to an uninflamed finger, so as to ob- 
 struct the motion of the blood through its 
 point. Besides, this throbbing, or pulsatory 
 motion, can afford us no criterion, by which 
 to judge of (he force, with which the artery 
 contracts, for, it is produced in the dilatation 
 of the artery, and by a power foreign to the 
 artery itself.” ( Thomson on Inflammation , 
 P- 73.) 
 
 Dr. Wilson Philip, many years ago, en- 
 deavoured to ascertain, by means of the 
 microscope, the state of the vessels in the 
 various stages of inflammation, both in the 
 Warm and cold blooded animal. I have put 
 the epithet warm in Italics, because it has 
 been very recently observed by my friend 
 Mr James, that “ analogies between the 
 higher and lower orders of animals, the 
 chief subjects of these experiments, cannot 
 be deemed conclusive.” (On some of the 
 General Principles of Inflammation, p. 29, 
 
 8 vo. Lond. 1821) as if it had escaped atten- 
 tion, that many of the experiments were 
 really made on the more perfect animals. 
 From the valuable observations, to which 
 1 here allude, (See Philip on Febrile Diseases , 
 Part 2, Inlrod.) it appears, that the state of 
 the smaller vessels in an inflamed part is 
 that of preternatural distention and debility. 
 
 As for the larger vessels, whose state rnay be 
 ascertained, without the aid of the micro- 
 scope, “they do not undergo a similar dis- 
 tention, and the increased pulsation of the 
 arteries sufficiently evinces their increased 
 action. In inflammatory affections of the 
 jaw and the head, for example, a greatly in- 
 creased action of the maxillary and temporal 
 arteries is readily perceived by the finger. 
 It is to be observed, however, that, although 
 inflammation, as was evident from the fore- 
 going experiments, begins in the capillaries, 
 if it continues, the circulation in the smallest 
 vessels becoming very languid, those imme- 
 diately preceding them in the course of the 
 circulation begin to be distended, and conse- 
 quently debilitated.” Dr. Philip adds, that 
 such distention and debility of the vessels, 
 which immediately precede the capillaries, 
 cannot go far, because when the former lose 
 their power, the circulation in the latter is 
 not supported, and gangrene soon ensues. 
 “ In short, (says Dr. Philip) inflammation 
 seems to consist in the debility of the capillaries , 
 followed by a i increased action of the larger 
 arteries ,” and is terminated by resolution, 
 when the capillaries sere so far excited, and 
 the larger arteries so far weakened, by the 
 preternatural action of the latter, that the 
 power of the capillaries is again in due 
 proportion to the vis a tergo. 
 
 “ Thus far, (says Dr. Philip) I cannot help 
 thinking the nature of inflammation appears 
 sufficiently evident. The motion of the 
 blood is retarded in the capillaries, in conse- 
 quence of the debility induced in them ; an 
 unusual obstacle is thus opposed to its motion 
 in the arteries preceding them in the course 
 of the circulation ; which are thus excited 
 to increased action. Several difficulties, 
 however, remain, on which the experiments 
 just related throw no light. Why does a 
 failure of power, of small extent in the ca- 
 pillaries of a vital part, strongly excite, not 
 only the larger arteries of the part affected, 
 bur those of the whole system ; while a 
 more extensive debility of the capillaries of 
 an external part excites less increased action 
 in the larger arteries of that part, and often 
 none at all in those of the system in general ? 
 Why does inflammation often move sudden- 
 ly from one part to another, when we see 
 no cause, either increasing the action of the 
 capillaries of the inflamed part, or weaken- 
 ing those of the part now affected ? Why 
 does inflammation often arise in parts only 
 sympathetically affected, and consequently 
 far removed from the offending cause ? 
 Why is inflammation often as apt to spread 
 to neighbouring parts, between which and 
 the part first affected, there is no direct 
 communication of vessels, as to parts in 
 continuation with that part? 
 
 “ These phenomena, it is evident, (says 
 Dr. Philip) are referrible to the agency of 
 the nervous system, and seem readily ex- 
 plained by the experiments, vhich prove, 
 that the effects of both stimuli and sedatives, 
 acting through this system, are felt by the 
 vessels, and that independently of the inter- 
 vention of any effect produced on the heart 
 
INFLAMMATION. 
 
 
 (Exp. 27, 28.) Thus, the irritation of the 
 nerves of the inflamed part may excite the 
 larger arteries of this part, or of distant parts, 
 •r of the whole sanguiferous system. It 
 will of course be most apt to do so, where 
 the irritation excit^l by the inflammation is 
 greatest and, consequently in the more im- 
 portant vital parts. It cannot appear surpri- 
 sing, that inflammation should suddenly 
 cease in one part and attack another, when 
 we know, that the nerves are capable of 
 exciting to due action the capillaries of the 
 one part, and in the other of impairing the 
 vigour of those, which have not suffered. 
 In the same way, we account for parts only 
 sympathetically affected becoming inflamed, 
 and for inflammation readily spreading to 
 neighbouring parts, which always sympa- 
 thize, although there is no direct communi- 
 cation between them, either of vessels or 
 nerves. - ’ (On the Vital Functions, p. 279, 
 fyc. Ed. 2.) 
 
 Respecting the inference, made by Dr. 
 Philip from his experiments, that the circu- 
 lation is slower in inflamed, than uninflamed 
 arteries, Dr. J. Thompson conceives, that 
 its truth “ is not necessary to the establish- 
 ment of Mr. Allen’s hypothesis ; and from 
 a number of experiments which I have at 
 different times made upon frogs, I am incli- 
 ned to believe, that a diminished velocity of 
 the blood, in the capillary branches, is by no 
 means a necessary , constant, nor even the most 
 common effect of incipient and moderate 
 degrees of inflammation .” (P. 75.) 
 
 In order to reconcile this difference in the 
 statements made by the only two writers, 
 who have examined this subject by experi- 
 ment, Dr. Hastings repeated their mode of 
 investigation with the aid of the microscope. 
 His conclusions are, “ that certain stimuli, 
 applied to living parts, produce an increased 
 velocity of the blood’s motion, and a con- 
 traction of the blood-vessels. During this 
 state of excitement, the part affected is so 
 far from giving any thing, like the appear- 
 ances of inflammation, that the size of the 
 vessels is diminished, and the part paler. 
 But, if the stimulus be long continued, or 
 increased in power, the small vessels, which 
 in the natural state admit only of one 
 series of globules, become so dilated, as to 
 allow an accumulation of a much less fluid 
 and redder blood in them, which loses its 
 globular appearance, and moves much more 
 slowly, than that which previously passed 
 through the vessels. The part now appears 
 inflamed. If the stimulus be removed, the 
 vessels do not soon regain their original 
 state ; time is necessary to allow them to 
 recover their contractile power, so as to 
 prevent the impetus, with which the blood 
 is propelled by the hear! and larger arteries 
 from keeping up the dilated state of the ca- 
 pillaries. Here then we are obliged to ad- 
 mit, with Boerhaave, that there is an error 
 loci ; for, a denser and redder blood passes 
 into small vessels, which before carried much 
 more fluid contents ; but the error loci does 
 not cause the inflammation, but results from 
 the previously weakened state of the capilla- 
 
 ries. In this manner, the blood may occa- 
 sionally be extravasated in inflammation, 
 without any actual rupture of a vessel, for 
 the exhalants may be so weakened, ami 
 dilated, as to allow globules to pass through 
 them. 
 
 “ If the stimulus, which produces the in- 
 flammation, be of a very acrid nature, de- 
 bility of the vessels is frequently induced 
 without any previous excitement. The blood 
 in all the smaller vessels becomes very red, 
 circulates very slowly, and in some vessels 
 stagnates. 
 
 u The application of a stimulus, different 
 from that which produced inflammation, 
 w ill sometimes bring on resolution. When 
 (his occurs, the dilated vessels contract; 
 they no longer contain a red, dense homo- 
 geneous fluid, but again receive blood, con- 
 sisting of small, nearly colourless globules, 
 which float in a colourless fluid ; and the 
 motion of these globules at length becomes 
 as quick as before the inflammation took 
 place. If, however, the inflammation pro- 
 ceed, the blood becomes nearly stagnant ; 
 it continues very red, and the vessels are 
 much dilated. 
 
 £ ‘ When this high degree of inflammation 
 is not relieved, sphacelus ensues. The part 
 then feels softer to the finger, and gives way 
 with less force. The vessels are much dila- 
 ted, the blood does not move, it loses its red 
 colour, and becomes of a yellowdsh brown 
 hue. The separation of the dead from the 
 living part takes place soon after this change 
 in the colour of the blood. 
 
 “ While the ulceration, produced by this 
 separation of the dead from the living part of 
 the web is healing, the capillary vessels, 
 distributed on the ulcerated surface, and the 
 contiguous parts, are much distended with 
 arterial red blood, which is moved very 
 slowly. When the ulceration is healed, the 
 vessels become contracted, and circulate the 
 fluid, with the same degree of velocity as 
 before the inflammation was excited. 
 
 i£ With respect to the seat of inflammation, 
 it may be observed, that the capillaries are 
 first affected ; but even the small arteries of 
 the web are also occasionally distended.” 
 ( Hastings on Inflammation of the Mucous 
 Membrane of the Lungs, fyc. p. 90 — 92.) 
 
 With respect to the doctrine, espoused by 
 some pathologists, that the smaller branches 
 of veins are the exclusive seat of inflamma- 
 tion, the same author observes, that the 
 microscope shows us, that the most minute 
 arterial branches, though far less numerous, 
 are equally affected with weakness and 
 distention. 
 
 In the course of Dr. Hastings’s inquiry, it 
 is proved, that the healthy circulation of the 
 blood essentially depends upon a due degree 
 of action in the vessels throughout the sys- 
 tem ; that the application of stimuli, while 
 it increases the action of the vessels, produ- 
 ces none of the symptoms of inflammation. 
 When, however, the excessive action of 
 these stimuli has impaired the excitability of 
 the small vessels, the phenomena of inflam- 
 mation are fully manifested ; and when their 
 
118 
 
 INFLAMMATION. 
 
 excitability is restored, the inflnmmation 
 subsides. It may be logically inferred, there- 
 fore. says this writer, that inflammation con- 
 sists in a weakened action of the capillaries , by 
 which the equilibrium between the larger arid 
 smaller vessels is destroyed , and the latter be- 
 come distended. And, with respect to the 
 conclusion, drawn by Dr. Thomson from his 
 experiments, that inflammation, in moderate 
 degrees, consists in an increased action of 
 the vessels. Dr. Hastings argues, that the 
 writer’s belief in the excitement of the 
 capillaries, in some cases of inflammation, 
 arises from his having denominated that a 
 state of inflammation, which ought not to 
 be so called. “ The application of the salt, 
 (says Dr. Thomson) produced an increased 
 velocity in the dilated larger and smaller 
 arteries and capillary vessels, to which it was 
 more immediately applied. In nine experi- 
 ments, the phenomena of which I have 
 minutely recorded, the application of the 
 salt was not only followed by a bright red 
 colour, visible to the naked eye, and a sensi- 
 ble enlargement of the arterial and venous 
 branches, but with an increased rapidity of 
 circulation in the capillary vessels; the glo- 
 bules becoming less distinct, than before the 
 application of the salt, and obviously less 
 distinct, from the rapidity of their motion, 
 than the globules in the capillary vessels in 
 the uninflamed part of the web in the same 
 animal. The repeated application, however , 
 of the salt to the same vessels, was always 
 sooner or later follo wed by retarded capillary 
 circulation, or even by complete stagnation.” 
 (See Thomson's Lectures, p. 68.) The results 
 of other experiments, made by this gentle- 
 man, and which coincide with the sentiments 
 of Dr. VV. Philips and Dr. Hastings, need riot 
 here be cited. 
 
 Now, with regard to those experiments, 
 which seemed to Dr. Thomson to justify the 
 inference, that moderate degrees of inflam- 
 mation may be attended with an increased 
 velocity of the ’blood in the inflamed vessels, 
 Dr. Hastings, as I have already said, objects, 
 that the appearances seen, while such velo- 
 city of the circulation presented itself in the 
 vessels affected, ought not to have been 
 denominated inflammation ; because “ it 
 constantly happened in hisown experiments, 
 that when inflammation commenced, no 
 . globules could be seen even in the blood of 
 the affected vessels It was universally con 
 verted into a bright red homogeneous fluid. 
 So that globules could never be seen in the 
 capillaries of a really inflame d part, much less 
 moving with great velocity. He argues, that 
 the state, alluded lo by Dr. Thomson, is only 
 that temporary excitement of the capillaries, 
 generally preceding their debility, which is 
 inseparable from inflammation. (See Hast- 
 ings on lnfla mmnlon fyc p. 98, 1**1.) 
 
 Of course, such writers as believe, that the 
 blood in the capillaries is not propelled by 
 these vessels themselves, but by the impulse 
 received from the heart, cannot assent to the 
 foregoing view, in which the proximate 
 cause of the inflammation is ascribed to de- 
 bility of those vessels. Dr. Parry argues, 
 
 that the theory, which represents this pr<K 
 cess as consisting in an increased momentum 
 of the blood in the part affected, is not inva- 
 lidated, were it even proved, according to 
 the opinion of Dr. Philip, that the velocity 
 of the blood in th£ vessels of an inflamed 
 part is diminished, unlefs it be also proved, 
 that the velocity is diminished in a greater 
 proportion, than the quantity is increased. 
 (Elements of Pathology, Vol.],p. 84.) As 
 far, however, as 1 can judge, the arguments 
 are in favour of Dr. Philip’s view of the sub- 
 ject ; for, with respect to quantity making 
 up for loss of velocity, if the supposition 
 were to be adopted, surely it could not be 
 retained after the inflammation has arrived 
 at that state, in which the fluid in the capil- 
 laries is seen with the microscope to b© 
 nearly or quite stagnant It must be con- 
 fessed, at the same time, that the question 
 about the proximate cause of inflammation 
 is still a topic of endless controversy, into 
 which I consider it perfectly absurd to enter 
 any further than can be avoided, without 
 having leisure at present to prosecute the in- 
 quiry by experiments. In one sense, both 
 Dr. Philip and Dr. Hastings admit, that an 
 increased action of the vessels may exist in 
 inflammation ; but then this excitement or 
 i ■ creased action is not in the capillaries, but 
 the larger arteries; and Dr. Philip even sug- 
 gests, that the presence, or absence of such 
 excitement may make the difference be- 
 tween acute and chronic inflammation. The 
 considerations in support of the side of the 
 question, to which 1 do not myself incline, 
 may be found in the writings of Dr. Parry, 
 Dr. C. H. Parry, and Mr. James of Exeter. 
 From this remark, I would not have it infer- 
 red, that I am quite convinced of the 
 propriety of referring the proximate cause of 
 inflammation to debility of the capillaries, 
 though the retarded circulation in them, like 
 their dilatation, is now a fact placed out of 
 all doubt The points, however, on which I 
 should not assent to Dr. Philip’s doctrine, 
 will be best understood, when the treatment 
 is considered. In the work of Mr. James 
 may be perused a very good summary of 
 Bichat’s doctrine, which l would willingly 
 annex, if the subject were intelligible, with- 
 out an explanation of some physiological 
 opinions, for which I have not room in this 
 edition. (See J. II James, Obs. on some of 
 the general Principles ■, tyc. of Inflammation , p. 
 38, 8vo. Load. 1821.) 
 
 Redness — This is manifestly owing to the 
 increased quantity of blood in the inflamed 
 part. More blood must necessarily be con- 
 tained there, because the vessels, which pre- 
 viously conveyed this fluid, are preternatu- 
 rally distended, and the small vessels, which 
 naturally contained only lymph, are now so 
 enlarged as to be capable of receiving red 
 blood “ I froze (says Mr. Hunter) the ear 
 of a rabbit, and thawed it again ; this occa- 
 sioned a considerable inflammation, an in- 
 creased heat, and thickening of the part. 
 This rabbit was killed when the ear was in 
 the height of inflammation, and the head 
 being injected, the two cars were removed 
 
INFLAMMATION 
 
 119 
 
 and dried. The uninflamed ear dried clear, 
 and transparent, the vessels were distinctly 
 seen ramifying through its substance ; but, 
 the inflamed ear dtied thicker and more 
 opaque, and its arteries were considerably 
 larger. - ’ 
 
 Many have supposed, that the redness of 
 common inflammation is partly occasioned 
 by the generation of new vessels. This 
 doctrine, however, seems very questionable. 
 When coagulated lymph isextravasated upon 
 the surface of a wound, or an inflamed 
 membrane, unquestionably it often becomes 
 vascular, in other words, furnished with new 
 vessels. But, in the extravasated lymph of a 
 phlegmonous tumour, we have no evidence, 
 that there is any formation of new vessels. 
 Were the lvmph to be rendered organized 
 and vascular, the swelling and redness would 
 probably be more permanent, and at least 
 not admit so easily of resolution. When 
 adhesions form between two inflamed sur- 
 faces, the organized substance forming the 
 connexion, lives after the subsidence of the 
 inflammation, and is a permanent effect In 
 the experiments detailed by Dr. Hastings, 
 when the inflammation began and termina- 
 ted, without any lesion of (he part affected, 
 new vessels were never formed. (On In- 
 flammation, fyc.p. 93.) At the same time, it 
 must be confessed, that great obscurity pre- 
 vails in this very difficult part of the subject ; 
 for when suppuration happens in a phleg- 
 monous tumour, the cavity is lined by a 
 kind of cyst, or membranous layer of lymph, 
 which is unquestionably furnished both with 
 secreting vessels and absorbents ; for, other- 
 wise, how could the continued secretion of 
 pus, or its occasional sudden disappearance, 
 be at all explicable. It was probably the 
 enlargement of the small vessels, and the 
 circumstance of their being filled with red 
 blood, that led to the theory of new vessels 
 being usually formed in inflammation. It 
 has, however, been justly observed, that the 
 supposition easily admits of refutation : for 
 heat, and many other causes of inflamma- 
 tion, operate so quickly, that there can be 
 no time for the formation of any new vessels ; 
 and, yet the redness is as great, and the in- 
 flammation as perfect in a minute as in an hour 
 ora day after the application of the exciting 
 cause. (Burns) Mr. Hunter, it is well 
 known, believed, that a coagulutn or a layer 
 of lymph might produce vessels vvi'hin it- 
 self. — (On the Blood , p. 92. fyc.) Others, 
 however, distrust this hypothesis, and incline 
 to the opinion, which refers the derivation 
 of vessels for the organization of deposits 
 to parent branches. ( Travers , Synopsis of 
 Diseases of the Eye, p 113) The latter sen- 
 timent is corroborated by the appearances 
 noticed by Dr. Hastings, in his experiments, 
 who describes the small vessels first seen in 
 the lymph, upon the surface of a wound, as 
 even then communicating with the inflamed 
 capillaries. (On Inflammation , p. 94.) Air- 
 other reason assigned for the redness of in- 
 flammation, is that the blood after it has be- 
 come venous, retains, more or less, its bright 
 scarlet colour. (Hunter.) And, in some late 
 
 very carefully conducted experiments, it was 
 remarked, that the weakened action of tho 
 smaller vessels was always accompanied 
 with an alteration in the appearance, of the 
 blood. In the natural str.te of this fluid, 
 globules can be distinctly sec, ; but, after 
 inflammation has commenced, the globular 
 structure disappears, the b!;Od becomes 
 redder, and the most minute capillaries are 
 distended with it. (Hastings on Inflamma- 
 tion, fyc. p. 95.) 
 
 Swelling. — This effect arises from several 
 causes: 1. The increased quantity of blood 
 in the vessels. 2. The effusion of coagu- 
 lating lymph, and serum, and deposition of 
 new matter. 3. The interruption of ab- 
 sorption, particularly noticed by Soemmer- 
 ing. DeMorb. Vas. Absorb. 
 
 Pain — This is observed to be the greatest 
 during the diastole of the arteries. The af- 
 fection is probably owing to the unnatural 
 state of the nerves, and not to mere disten- 
 tion, as many have asserted. Were the 
 latter cause a real one, the pain would 
 always be proportioned to it. 
 
 “ Parts, which in the sound state have 
 little, or no sensibility (as Dr. Thomson re- 
 marks) become exquisitely sensible in the 
 inflamed. That this is the case with tendon, 
 ligament, cartilage, bone, and membrane, 
 seems to be fully established by Dr. Wfaytt 
 in the very instructive controversy carried 
 on between him and Haller, respecting the 
 sensibility and irritability of the different 
 parts of man and other animals.— -(Lectures 
 on Inflammation , p. 45.) 
 
 Heat. — The heat or real increase of tem- 
 perature in an inflamed part, when judged of 
 by the thermometer, is generally much less, 
 than might be supposed from the patient’s 
 sensations. It is said never to exceed the 
 heat of the blood at the heart. This in health 
 is usually about 100°. Fahrenheit’s thermo- 
 meter; but sometimes in diseases it arises to 
 106°, or even 107°. Mr. Hunter artificially 
 excited inflammation in the chest of a dog, 
 and in the abdomen, rectum, and vagina of 
 an ass. without being able to discover any 
 obvious rise of temperature, in these parts. 
 In a patient, however, on whom he opera- 
 ted for hydrocele, the thermometer, introdu- 
 ced into the tunica vaginalis, and kept for 
 some time close to the side of the testicle, 
 was only 92° ; but rose the following day, 
 when inflammation had come on to 98° 3-4. 
 As Dr Hastings observes, the advocates for 
 excited action of the vessels in an inflamed 
 part have thought, that the increase of tem- 
 perature favours their hypothesis, and have 
 called to their aid the ingenious calculations 
 of Dr. Crawford. They have even gone so 
 far as to sav, what state of the arteries 
 enables the blood to give out most caloric. 
 They tell us, that, in consequence of excite- 
 ment of the vessels, more blood is transmit- 
 ted into the minute arteries ; the capacity of 
 a greater quantity of this fluid for heat is of 
 course diminished, and more caloric is 
 evolved in the inflamed part. (Hastings, on 
 Inflammation , p. il .) Yet, this theory, be- 
 sides involving the contradicted hypothesis 
 
INFLAMMATION. 
 
 i2e 
 
 of an increased and accelerated flow of 
 blood through the vessels of the inflamed 
 part, cannot be reconciled to various other 
 considerations. 11 Daily experience con- 
 vinces us, (says the above writer,) that the 
 temperature is not always proportional to the 
 velocity of the circulation. In fevers, the 
 author has several times ascertained, with 
 the thermometer, that the heat was 101°, 
 when the pulse beat only 45 times in a mi- 
 nute. In hydrocephalus, with a pulse from 
 60 to 70, the heat is often above the degree 
 it reaches in health. In these cases, accord- 
 ing to the theory of Dr. Crawford, the heat 
 should rather be under, than above, the na- 
 tural standard.” (Op. cit. p. 112.) And, as 
 another judicious writer has noticed, al- 
 though the former mode of explaining the 
 production of animal heat has been held 
 adequate to account for the phenomena by 
 such philosophers as Black, Crawford, La- 
 voisier, and Place, the evidence on which it 
 rests, is not so clear as to have commanded 
 universal assent, or entirely set aside objec- 
 tions. It has indeed been generally allow ed, 
 that respiration and the changes it produces 
 in the air and animal fluids, are essential con- 
 ditions of the evolution of caloric in ani- 
 mals ; but, it has been thought, that there are 
 other circumstances, hitherto, perhaps, not 
 well understood, which influence the pheno- 
 mena, In external appearance, the blood is 
 the same in all the vessels of the fcetus : is 
 this any proof, that its temperature is owing 
 to the conversion of oxygen gas into carbo- 
 nic acid ? Is the uniformity of temperature 
 in the higher animals, under varying states 
 of respiration and circulation, and the con- 
 sumption of various quantities of oxygen, 
 whether in the same, or different individuals, 
 consistent with the theory ? And can local 
 variations of temperature be explained by 
 it ? ( Rees's i.yclopcedia, art. Respiration.) 
 Doubts must also spring from the recollection 
 of the discordance of the experiments, re- 
 lated by Dr. Crawford, Dr. John Davy, De la 
 Roche, and Bernard. In fact, the determi- 
 nations of the specific heats of oxygen gas 
 and carbonic acid by the tw'o latter experi- 
 menters are conceived to be very much 
 against the probability of Dr. Crawford’s 
 theory. Other stronger grounds for scepti- 
 cism in this subject are the results of Mr. 
 Brodie’s investigations. Having pithed, or 
 decapitated animals, he kept up artificial 
 respiration, and thus maintained their t ircu- 
 lation. The blood continued to be changed 
 in the lungs from venous to arterial, and 
 from arterial to venous, in the general cir- 
 culation. The respective colours of the 
 two kinds of blood could not be distinguish- 
 ed from those, which they exhibit in living 
 and healthy animals. Yet, the temperature 
 of an animal, thufe heated, sunk faster, than 
 that of another animal simply killed and 
 left to itself ; and the former w as supposed 
 to be more quickly cooled by the air con- 
 veyed into its chest. Other experiments, 
 detailed by Mr. Brodie, tend to prove, that 
 the oyxgen of the air employed in arti- 
 ficial respiration, underwent its usual con- 
 
 version into carbonic acid. A living rabbit 
 formed 50, or 60 cubic inches of carbonic 
 acid in an hour. A decapitated animal, in 
 whom artificial respiration was kept up, 
 emitted 40 — 48 inches in the same time. The 
 thermometer krthe rectum of the latter had 
 fallen from 97 to 90, while, in another rab- 
 bit left to itself, but similarly treated in all 
 other respects, it had fallen only to 91. In 
 a rabbit, poisoned with wmorara, or the es- 
 sential oil of bitter almonds, not decapitated, 
 and, in which artificial breathing was kept 
 up, 51 cubic inches of carbonic acid were 
 emitted in an hour. The thermometer in 
 the rectum had sunk to 91 in 30 minutes; 
 while it stood at 92 in another animal, treat- 
 ed exactly in the same way, with the omis- 
 sion of the artificial breathing. From these 
 experiments, Mr. Brodie infers “ that, in an 
 animal in which the brain has ceased to ex- 
 ercise its functions, although respiration con- 
 tinues to be performed, and the circulation 
 of the blood is kept up to the natural stand- 
 ard, although the usual changes in the sen- 
 sible qualities of the blood take place in the 
 two capillary systems, and the same quan- 
 tity of carbonic acid is formed as under 
 ordinary circumstances ; no heat is genera- 
 ted, and (in consequence of the cold air 
 thrown into the lungs.) the animal cools 
 more rapidly, than one which is actually 
 dead.” (See Phil. Trans, for 1811, p. 36; 
 and for 1812, p. 378.) It appears certain, 
 therefore, that the generation of animal heat, 
 either in an inflamed, or an uninflamed part, 
 can never be satisfactorily explained by any 
 reference merely to chymical principles, 
 and that the process is essentially connected 
 with and influenced by the state of the 
 functions of the brain and nervous system, 
 and no doubt also by the principle of life 
 itself. At the same time, I think, that any 
 hypothesis, suggested without due reference 
 to the connexion, which respiration has 
 with this curious and interesting process, 
 will never be established. Neither wmuld I 
 venture so far as Dr. Philip, w ho believes, 
 that animal heat is evolved by the same 
 means, by which the formation of the se- 
 creted fluids is effected, viz. the action of 
 nervous influence on the blood, and that the 
 production of such heat is to be regarded as 
 a secretion. (On the Vital Functions, p. 169.) 
 However, the influence of the nervous sys- 
 tem over this process must be allow ed to be 
 very great, and may afford a more probable 
 explanation of the cause of the local change 
 of temperature in inflammation, than Dr. 
 Crawford’s theory, combined with the doc- 
 trine of increased action, and an accelerated 
 circulation in the vessels of the pari aff ected. 
 
 Buffy coat. — The blood, when taken out 
 of the living vessels, spontaneously separates 
 into two distinct parts, the serum and the 
 crassamentum. The last is a compound 
 substance, consisting chiefly of coagulating 
 lymph, and red globules, the most heavy in- 
 gredients in the blood. Blood, taken away 
 from persons affected with inflammation, is 
 longer in coagulating, and coagulates more 
 firmly, than in other instances. Hence, the 
 
INFLAMMATION. 
 
 led globules, not being so soon entangled 
 in the lymph, descend by ti.eir gravity, more 
 deeply Irom its surface which being more 
 or less divested of the red colouring matter, 
 is from its appearance termed the buffy coat 
 or inflammatory crust. The firmer and more 
 compact coagulation of the lymph compresses 
 out an unusual quantity of serum from it, 
 and the surface of the sizy blood is often 
 formed into a holjow, the edges being drau n 
 inward. ( Hunter ) In some cases, these 
 changes in the blood are deemed more in- 
 fallible prool of the existence of inflamma- 
 tion, than the state of the pulse itself. They 
 are however, only a criterion of some un- 
 usual operation going on in the system ; for, 
 the blood taken from pregnant women is al- 
 ways found 10 present the same phenomena. 
 In peritonaea! inflammation, the patient 
 sometimes seems to be in the most feeble 
 state, and the pulse abstractedly considered, 
 would rather induce the practitioner to em- 
 ploy tonics, and* stimulants, than evacua- 
 tions ; but, should the continuance or exas- 
 peration of the disorder, or any other reason, 
 lead him to use the lancet, then the buffy 
 coat, and the concave surface of the blood, 
 materially obviate any doubt of the exist- 
 ence of inflammation. Surgeons should 
 never forget, however, that in a few anoma- 
 lous constitutions, the blood, v\ hen drawn, 
 always exhibits the above peculiarities. 
 
 Terminations. — Inflammation is said to 
 have three different term nations; or, in 
 more correct language, we may say, that, 
 after this process has continued a certain 
 time, it either subsides entirely, induces a 
 disposition in the vessels to form pus, orcom- 
 pletely destroys the vitality of the part. 
 
 When the inflammation is to end in the 
 first manner, which is the most favourable, 
 the pain becomes less, the swelling subsides, 
 the fever, andevery other symptom gradually 
 abate till at last the part is wholly restored to 
 its natural size and colour. There is no forma- 
 tion of pus, nor any permanent injury of 
 structure ; and if Dr. Philip’stheory of inflam- 
 mation be correct, the debilitated capillaries 
 are excited to due action by the increased ac- 
 tion of the larger arteries. (On the Vital Func- 
 tions, p.298.) This termination of inflamma- 
 tion istermed by surgeons resolution. It is for- 
 tunately the most common, as well as the 
 most desirable manner, in which the affec- 
 tion ends. 
 
 If, however, notwithstanding the applica- 
 tion of the usual remedies, the several symp- 
 toms of heat, pain, and redness, instead of 
 diminishing, rather increase ; if the febrile 
 symptoms are likewise augmented, and the 
 tumour gradually acquires a larger size, 
 turns soft, somewhat prominent in the mid- 
 dle, or towards its most depending part; if 
 it should next acquire a clear shining appear- 
 ance, and become less painful, the different 
 symptoms of fever being at the same time 
 diminished, and a fluctuation perceptible in 
 the tumour ; the inflammation has ended in 
 suppuration. 
 
 The worst, but happily, the least frequent 
 consequence of common inflammation, is 
 
 v ot.. n 
 
 the death, or mortification, of the part affect- 
 ed. In the microscopical experiment ot Dr. 
 Hastings, it was observed, that, on the ap- 
 proach of gangrene, the blood entirely loses 
 its red colour, and acquires a yellowish 
 brown tinge. (On I jlammaiion,p ^l ) 111( ; 
 
 part, which was of a bright red, becomes ot 
 a livid hue; small vesicles, filled with a thin 
 fetid serum, arise on its surface, and air is 
 plainly felt within the cellular membrane. 
 The pain is indeed diminished; but the 
 pulse sinks, while the tumour is gradually 
 changed into a black, fibrous mass. 
 
 These are the three common terminations 
 of inflammation. In books, scirrhus is some- 
 times enumerated asoneot the terminations 
 of inflammation. The best modern surgeons, 
 however, do not regard scirrhus as one ot 
 the usual effects of ordinary inflammation , 
 “ the term scirrhus, as used by the older 
 medical writers, is extremely indefinite, 
 having been sometimes used to expiess 
 every kind of induration, which remained 
 after an attack ot inflammation, as well as 
 the morbid incipient state of parts about to 
 become affected with cancer. Surgeons 
 now usually limit the use of the term to the 
 last of these significations.” (Thomson on 
 Inflammation , p. 126.) 
 
 Common inflammation, particularly when 
 it affects glandular parts, is often followed 
 by induration, which afterward continues 
 for a greater or lesser time. Thus, when 
 the testis has been inflamed, a hardness ot 
 the epididymis frequently remains during 
 life. Such induration, however, is not 
 at all malignant, and, consequently, very 
 different from what is implied by a real 
 scirrhus. 
 
 TREATMENT OF INFLAMMATION. 
 
 One principal difficulty in believing the 
 fact of the retardation of the circulation in 
 the capillaries of an inflamed part, and against 
 the supposition of their being in a state o 
 debility, is, that the most effectual treatment 
 ot common inflammation consists of means,, 
 which are generally of a debilitating nature, 
 as bleeding, purging, he. And surgeons are 
 still further attached to the theory of in- 
 creased velocity of the blood’s motion, in the 
 part affected, by the recollection of the local 
 augmentation of temperature, the throbbing, 
 a d the instantaneous return of the red co- 
 lour, after the discontinuance of any pres- 
 sure, by whi- h the redness has been mo- 
 mentarily removed at some point of Hie in- 
 flamed surface. These too are all so many 
 facts, which, as far as I can judge, are ad- 
 mitted by the generality of reasoners, what- 
 ever may be their particular theory. At the 
 same time, it appears equally well pro ed 
 by careful microscopical experiments, that 
 in the capillaries of the part, which is direct- 
 ly the seat of inflammation, there is a retar- 
 dation, and sometimes even a stagnation, of 
 the circulation. But, this is not all, it is fur- 
 ther manifested, that the capillaries are con- 
 siderably dilated, the blood in them materi- 
 ally altered, and that these phenomena are 
 followed by an increased action ot the lac 
 
122 
 
 INFLAMMATION. 
 
 ger arteries leading to the part affected. 
 Now, 1 think, if we remain contented with 
 these obvious circumstances, and dismiss the 
 hypothesis of debility of the capillaries, not 
 only the necessity for venturesome conjec- 
 tures may be-avoided, but a more rational 
 account delivered of the principles of the 
 efficacy of the usual mode of treatment. 
 Thus, I would not presume to offer any sup- 
 position, why the capillaries ar« j dilated, 
 and why the m otion of the fluid in them 
 is retarded, but would he satisfied with a 
 knowledge of the facts, so as to elude a 
 source of endless controversy, viz. the ques- 
 tion, whether these changes proceed from 
 debility of the said vessels, or other causes ? 
 In the view 7 , which I take of the nature of 
 phlegmonous inflammation, 1 consider the 
 following circumstances proved: 1. The 
 
 dilated state of the capillaries in the imme- 
 diate seat of inflammation. 2. The retard- 
 ation, or even stagnation of the circulation 
 in them. 3. The increased action, or ex- 
 citement of the larger arteries leading to the 
 inflamed part. All these three main points 
 seem to me to be fully established by the 
 investigations and experiments both of Dr. 
 Wilson Philip and Dr. Hastings ; and 1 may 
 make the observation, though aware, that 
 the latter gentleman does not regard increa- 
 sed action of the larger arteries, as a consti- 
 tuent and necessary part of inflammation, 
 because cases occur, in which no such ex- 
 citement can be detected . (On Inflammation , 
 p 104,) for, I here put out of consideration 
 chronic inflammation, which I believe is 
 entirely a different process, bearing no re- 
 semblance to the acute forms of the disor- 
 der, either in the state of the capillaries, or of 
 the largerarteries. Assuming the above points 
 as proved, it is to be inquired, whether other 
 facts, such as the heat and throbbing in the 
 inflamed part, the instantaneous return of 
 redness to the spot, which has been touched, 
 and the efficacy ot common treatment, are re- 
 concileable with them, or not. 1 am dispo- 
 sed to think they are ; for, it is only asserted, 
 that the passage of the blood is more or less 
 obstructed in the capillaries in the seat of 
 fiie inflammation ; and the larger arteries, 
 leading to them, are, for the most part, ob- 
 viously in a state of increased action, where- 
 by a greater quantity of (flood must be sup- 
 posed to be determined towards the part. 
 Now, as this augmented quantity of blood 
 cannot pass freely through the smaller vessels,' 
 in the immediate place of inflammation, it 
 must be thrown into such arteries in the 
 neighbourhood, as are capable of receiving 
 it, so that, in fact, the theory of obstruction 
 of the capillaries may not be altogether in- 
 compatible both with increased action, and 
 quickened circulation, in the arteries directlv 
 around the parts, in which there is a retarded 
 circulation in the capillaries. This view of 
 the subject, I think, is not liable to greater 
 perplexity in the explanation of the heat, 
 throbbing, &.c.than former doctrines, involv- 
 ing the contracted notion of there beingan in- 
 creased action, and an augmented velocity 
 ot the blood’s motion, in all the arteries of 
 the part affected. 
 
 Resolution being the most favourable ter- 
 mination of common inflammation, it is of 
 course the object at which the surgeon 
 generally aims in the treatment. Dr. Philip’s 
 very ingenious view of inflammation leads 
 him to suppose that resolution arises from 
 the debilitated capillaries being excited to 
 due action by the increased action o the 
 larger arteries. {On the Vital Functions , 
 p. 298.) Rut I am of ' opinion, that t lie 
 doctrine of debility of the capillaries, and 
 the hypothesis of their being strengthen- 
 ed by the excitement or increased action 
 oi the larger vessels are by no means satis- 
 factory, and p rhaps, not very intelligi- 
 ble. On the contrary, if the capillaries are 
 already so weak as to be distended by the 
 ordinary impulse of the blood, how are they 
 to be restored to their natural dimensions and 
 functions by any increased action of tne lar- 
 ger arteries P the effect of which I should 
 conceive, w'ould be to gorge them still more 
 with blood, and produce e^en a greater dila- 
 tation of them. Were the above reasoning 
 correct, it would follow 7 , that a principal in- 
 dication in the treatment would be to pro- 
 mote the increased action of the larger ar- 
 teries, wfliereby so much supposed benefit 
 is communicated to the debilitated capilla- 
 ries. Yet, such practice is contrary to the 
 dictates of experience, ’and is even inconsist- 
 ent with the principles, on which Dr. Philip 
 himself thinks the treatment should be found- 
 ed. Indeed, the following directions are 
 such, as I imagine, will be perfectly appro- 
 ved of by practitioners, who, farfrom looking 
 upon the increased action of the arteries, 
 as a means of relief, are accustomed to do 
 every thing in their power to lessen and re- 
 sist it. “ All the local means (says Dr. 
 Philip) are calculated either to lessen the 
 contents of the morbidly distended vessels, or 
 to excite these vessels to expel them, i he 
 general means are regulated by the effects, 
 produced by the disease on the more distant 
 vessels, through the medium of the nervous 
 system ; the objects of this part of the treat- 
 ment being, neither to allow the action of 
 these vessels to tall so low 7 , that it is incapa- 
 ble of supporting any degree of circulation 
 in the debilitated vessels, nor to become so 
 powerful, as farther to distend by gorging 
 them with blood. Thus , when the symptoms 
 of active inflammation run high, we lessen the 
 vis a tergo ; when gangrene is threatened, we 
 increase it.” (fV. Philip , mi the Vital Func- 
 tions, p. 285, Ed. 2.) In short, as soon as the 
 fact is established, that a string flow of blood 
 towards an inflamed part tends to aggravate 
 the disorder, all difficulty ceases in reconci- 
 ling the usual means of relief to that theory 
 of inflammation, which takes into the ac- 
 count a retarded state of the circulation in 
 the distended capillaries. 
 
 The means employed for the relief of in- 
 flammation have been cursorily noticed in a 
 preceding article. (See Jin lip hi ogisl ics.) We 
 shall how devote a few more pages to u more 
 particular consideration of them. 
 
 Removal of exciting causes — In all cases 
 the first circumstance to be attended to is, 
 the removal of alisuch exciting causes as may 
 
INFLAMMATION. 
 
 123 
 
 happen to present themselves. if the irrita- 
 tion of a splinter were to excite phlegmo- 
 nous inflammation, who would not of his 
 own accord directly takeaway the extraneous 
 body ? In wounds, foreign substances fre- 
 quently excitt inflammation, and ought to be 
 taken away as speedily as possible ; splinter- 
 ed pieces of bone often give rise to the affec- 
 tion, and require removal ; the head of a 
 bone, being out of its place, may press and 
 inflame the part on which it lies; and who 
 does not immediately see the propriety of 
 putting it back into its natural situation? These 
 and other similar exciting causes may often 
 be detected and removed at once, and this is 
 doing a great de<»l towards the cure and even 
 the prevention of inflammation. However, 
 many of the exciting causes ot this affection 
 are only of monientaiy application; yet, 
 though they no longer exis: , the process of 
 inflammation must follow, as a kind of salu- 
 tary operation, without which, the injured or- 
 ganization, and lone of the parts, still remain- 
 ing, could not be rectified again. Hence 
 besides taking away the remote cause, 
 whenever this can be done, it is proper to 
 moderate, by other means, the increased 
 action of the larger arteries, and lessen the 
 velocity of the blood’s motion towards the 
 inflamed part. 
 
 Bleeding — As there is reason to believe, 
 that, in common inflammation, a greater 
 quantity of blood is impelled towards the in- 
 flamed part, than in the natural state, and 
 experience proves, that nothing has a more 
 powerful effect in checking tiie disorder, 
 than diminishing the. determination of blood 
 to the partj bleeding must be a principal 
 means of relieving inflammation : it lessens 
 the action ot the w hole sanguiferous system, 
 and, of course, of that part of it, which is 
 directly concerned in regulating the quantity 
 of blood transmitted to the part affected. 
 On ihe principle also of lessening the whole 
 mass of blood in the circulation, it must have 
 a similar effect. 
 
 Bleeding, however, is often misemployed, 
 especially when regarded as the only remedy 
 for inflammation, and other steps are ne- 
 glected. The general obstinacy and vehe- 
 mence. of the process in weak constitutions 
 prove, that bleeding is not invariably proper, 
 arid in such individuals it often appears, as if 
 their general irritability and the difficulty of 
 curing the inflammation ‘ were in a ratio to 
 their weakness. S'* hen inflammation is com- 
 plicated with disorder of the chylopoietio, 
 blood should be taken away with great cir- 
 cumspection. 
 
 A great deal of induration with little pain 
 and heat in the inflamed part ; the probability 
 of a long and copious suppuration, as is the 
 case in many compound fractures ; and the 
 connexion of ihe inflammation, with a want 
 of tone in tiie part ; are particular instances, 
 in which the praelilionershould he sparing of 
 this evacuation. Bleeding is sometimes quite 
 unnecessary, when the local inflammation 
 and symptomatic fever are trivial, when the 
 patient is feeble or very old, and when the 
 
 cause of the afi'eclioa can be entirely remo- 
 ved. (Richter.) 
 
 On the other hand, bleeding is highly be- 
 neficial when the inflammation is uncompli- 
 cated with any previously existing disorder 
 of the gastric system, while it is considerable 
 in extent and degree, and attended with a 
 good deal of febrile disturbance. The same 
 pruciice is also strongly indicated, when the 
 part affected is very sensible, ami highly im- 
 portant, in regard to its office in the system. 
 Thus the lancet must he trecly employed in 
 acute ophthalroy, or inflammation ot the eye, 
 which is a must sensible part ; and in inflam- 
 mation of the lungs, brain, or stomach ; 
 organs, the sound state of which is essential 
 to the regular continuance ot all the various 
 operations in the animal machine ; and it a 
 successful effort be not promptly made to .-(op 
 such inflammation by die most vigorous 
 means, death itseit will be the result. 
 
 Iu general, bleeding may be said to be 
 indicated, when the patient is young, robust, 
 and plethoric ; when the cause ot the disor- 
 der can neither be removed nor diminished ; 
 and when there is a very strong motive for 
 wishing to avoid the formation ot matter. In- 
 flammation of the eye is a case, illustrative 
 of the truth of the last observation ; for, if 
 suppuration lake place in this organ, the 
 com nion consequence is so serious a destruc- 
 tion ot its internal structure and organization 
 that the future restoration of sight is totally 
 impossible. In the examples, tailing under 
 the conditions specified as requiring blood 
 to be taken away, it is sometimes necessary 
 Irequeutly to repeat the evacuation. 
 
 The efficacy of bleeding is greater, the 
 sooner it is practised, and the more suddenly 
 the blood is evacuated. Bleeding near the 
 part affected is usually mure effectual, than 
 when done in a remote situation. Hence, in 
 inflammation of the eye, or brain, it is often 
 considered most advantageous to take biood 
 from the temporal artesy. 
 
 “ Iu many inflammations, particularly those 
 of the parts contained iu ihe three great 
 cavities of the head, chest, and belly, general 
 blood-letting (says a judicious writer) if not 
 the only, is the principal remedy, to which 
 vre can trust for a cure. The quantity of blood, 
 which in these inflammations it is necessary 
 to take away, varies according 16 the violence 
 of the inflammation, the temperament,, 
 strength, and habits ot the patient, and ac- 
 cording to the structure, functions, and situa- 
 tion of the organ in which it occurs. From 
 twelve to twenty ounces, or even more, ought 
 generally to be drawn every time we have 
 occasion to use the lancet in the cure of 
 inflammation, and bleeding to this extent may 
 be repeated two or three times in the course 
 of the first twenty-four hours, according to 
 t ie effects which it seems to produce, as w ell 
 as according to the violence and urgency of 
 the symptoms. In inflammation ot internal 
 parts, we judge of the effect ot bleeding, and 
 of the necessity of a repetition, from (he 
 feeling and continuance of pain, from the 
 state of the pulse, and also from the appear- 
 
124 
 
 INFLAMMATION. 
 
 anc« of (lie blood, which has been last 
 drawn 
 
 u A partial, and in some instances, an al- 
 most complete cessation ot pain takes place 
 even during the operation of blood-letting. 
 This is always a favourable symptom, and 
 indicates, that the i fl nunation has made rio 
 great, nor very alarming progress. In other 
 instances, the relief from pain, though incon- 
 siderable, at the time of bieedirg, becomes 
 afterward more sensible, and the other 
 symptoms of inflammation abate in nearly 
 the same proportion ; while, in other in- 
 stances a^ain, the pain i- either not relieved 
 by the bleeding, or, if relieved, the relief is 
 but of short duration. These last are cases, 
 in which the other symptoms ot inflamma- 
 tion continuing unabated, recourse must be 
 had again to the use of the lancet, and as 
 much blood drawn, as can be done with 
 safety to the patient. 
 
 “The changes, which take place in the 
 state of the pulse, either with regard to its fre- 
 quency, or strength, during, or soon afterthe 
 abstraction of blood, though they attend crite- 
 ria, b\ which we may judge of the stale of the 
 inflammation nd of the eff. ctsof the bleed- 
 ing, are by no mean- marks so sure ol the ad- 
 vantage, which has been obtained, as that 
 derived from the cessation of pain. 
 
 “In some inflammations of the head, for 
 example, the pulse is slower than natural, 
 though it beats with its accustomed, or even 
 with an increased degree of strength. In 
 inflammations also of the peritonaeum, and of 
 the intestinal ca. al, we find the pulse not 
 much quicker than natural, small, and con- 
 tracted. We should deceive ourselves, 
 therefore, were we to infer, that an increase 
 of inflammation had taken place, because, 
 in the first instance, the pulse had become 
 quicker, and in the second, fuller and strong- 
 er, during or soon after the abstraction of a 
 quantity of blood. 
 
 “ The pulse, it may be remarked, has often 
 a contracted, cord-like feel in inflammation, 
 and it may always be regarded as a favour- 
 able event, when it becomes softer, fuller, 
 and slower, during or soon after blood-let- 
 ting.” (See Thomson's Lectures on Inflam- 
 mation, p. lt>»>, It'S.) 
 
 With respect to I he butty coat of the blood, 
 Dr. Thomson stales, that it is not by the 
 buffy coat alone, hut by the butty coat, in 
 conjunction with the quantity and firmness 
 of the coagulum, that v\e must judge of the 
 propriety of any further detraction. When 
 the buffy coat has a firm and tenacious con- 
 sistence, and when the pain continues una- 
 bated, we may conclude, that the inflamma- 
 tion is not subdued. But, when the c lagulum 
 is soft and easily broken and when the 
 colour of the buffy coat is changed from a 
 yellowish to a greenish hu ■, Dr. Thomson 
 thinks, that little or no benefit can be derived 
 from bleeding. Efut - as already mentioned, 
 every practitioner should remember, that, in 
 particular constitutions, and in pregnancy, 
 the blood lakeri away naturally exhibits a butty 
 appearance, independently of inflammation. 
 
 The preceding remarks chiefly relate to 
 
 general bleeding ; for, in phlegmonous inflam- 
 mation. topical bleeding is scarcely ever 
 improper. It is always a point highly worthy 
 of the surgeon’s consideration, whether 
 bleeding in or near the part will answer bet- 
 ter, than taking the blood from the general 
 habit ; for, certainly less may be removed in 
 this w ay, so as to have equal effect upon the 
 part inflamed, and probably, upon every 
 other disease that is relieved by bleeding, 
 with less injury to (he constitution. Although, 
 in many case-., ihe general habit is relieved 
 by bleeding, yet it is the part affected which 
 most requires this evacuation. That local 
 bleeding lias very considerable effects on the 
 inflamed part, is proved by the sudden relief 
 u hich is often produced by the application of 
 leeches in cases of gout The mere use of 
 leeches, without other measures, will also 
 sometimes remove a tumour in the breast, 
 having all the appearances of a scirrhus, 
 which cannot be considered as inflammatory, 
 so that topical bleeding extends its power 
 further, than the mere checking of inflam- 
 mation. Some part of its effect has been 
 imputed to sympathy. (Hunter.) There 
 are three modes of performing topical bleed- 
 ing : by cupping; by leeches; and by dividing 
 or scarifying the dilated vesse|> leading to the 
 inflamed part. (See Bleeding.) Upon the 
 head and face, leeches are commonly em- 
 ployed ; upon the chest, either leeches or 
 cupping; upon the abdomen, leeches; and 
 upon the joints, either cupping or leeches. 
 When the eye is inflamed, leeches may either 
 be applied to the adjoini g temple ; or the 
 dilated vessels of the conjunctiva may be 
 scarified ; or both methods may be adopt- 
 ed. When the inflammation extends quite to 
 the surface of the body, leeches are always 
 most eligible, as their bites cause less irritation 
 in inflamed parts, than the punctures of the 
 scarificator, or the pressure of cupping 
 glasses. 
 
 Purging. The exhibition of mild laxative 
 medicines, and saline purgatives, isa principal 
 means of diminishing inflammation. Purging 
 does not produce such lasting weakness as is 
 the consequence of bleeding, and, therefore, 
 it is scarcely ever omitted, even when the 
 abstraction of blood is deeme l improper. 
 Saline purges must lessen the quantity of 
 circulating blood, inasmuch as they increase 
 the secretion from the intestinal arteries ; and 
 therefore, t hey probably operate beneficially 
 in the cure of local inflammation, much upon 
 the same principle as bleeding. Mr. Hunter 
 was of opinion, that purging lowers action, 
 without diminishing strength, by which we 
 are probably to understand, without produ- 
 cing a very lasting or permanent loss of 
 strength. With respect to mild laxative me- 
 dicines, none are superior to manna, rhubarb, 
 oleum m ini, and the like ; and of the saline 
 purgatives, the best are, the sulphate of soda, 
 tartrate of potass, phosphate of soda, and 
 sulphate of magnesia. It may here be re- 
 marked, that, besides the benefit, which the 
 local i ii II munition derives from the judicious 
 administration of purgatives, the costiveness 
 and heat, which usually attend the syropto- 
 
INFLAMMATION. 
 
 123 
 
 uiatic fever, sue also removed by the same 
 means. 
 
 “ Purgatives (says Dr. Thomson) are more 
 or less required in almost every species of 
 inflammation ; but they are more peculiar- 
 ly necessary in those, which are accompa- 
 nied with a high degree of fever, or with 
 derangement of the digestive, or biliary or- 
 gans In cases of inflammation, which have 
 a tendency to spontaneous resolution, they 
 are almost always the best, and often the 
 only remedies that are required.” ( Lectures 
 on Inflammation, p 171 ) 
 
 Considering the general approbation of 
 the employment of mild saline purgatives in 
 cases of inflammation, I confess that 1 was 
 not a little surprised to find merely the fol- 
 lowing short unfavourable notice taken of 
 them by a celebrated foreign professor, in 
 his account of the treatment of inflamma- 
 tion. “ As for purgatives, they must be 
 used with discretion. There are none of 
 them antiphlogistic, as has been pretended. 
 They always produce more or less irritation, 
 and can only be applicable, when the cause 
 of the inflammation is in the intestinal ca- 
 nal. In the beginning of the complaint we 
 ought, therefore, in general to abstai from 
 them, and confine ourselves to emollient 
 clysters ” ( Boyer , Trail6 des Maladies Chi- 
 
 rurgicales , T. 1, p. 39.) 
 
 Diaphoretic and nauseating Medicines. 
 
 Medicines, which have the power of pro- 
 ducing sickness, lessen, fora time, the ac- 
 tion, and even the general powers of life. 
 This is in consequence of every part of the 
 body sympathizing with the stomach ; and 
 the effect may be very quickly excited 
 Sickness lowers the pulse, makes the small 
 vessels contract, and rather disposes the skin 
 to perspiration But, nothing more than 
 nausea should be caused ; for vomiting 
 "rather rouses than depresses. ( Hunter ) 
 Nauseating medicines, employed after 
 bleeding has been practised once or twice, 
 are often productive of considerable bene- 
 fit ; but there are some affections, in which 
 they cannot be used, such as inflammation 
 of the stomach and intestines. In all super- 
 ficial inflammations, however, they may be 
 safely and advantageously exhibited, as 
 well as in most inflammatory affections in- 
 ternally situated. In inflammation of the 
 dura mater and brain, and, indeed, iri every 
 instance, in whieh there is an urgent reason 
 for putting as sudden a check as possible to 
 the continuance of the affection, the em- 
 ployment of nauseating doses of antimony 
 is most strongly indicated. The tarlrite of 
 antimony (emetic tartar) is the medicine, on 
 W T hich practitioners place the greatest reli- 
 ance, and it is to be prescribed for the pur- 
 pose of exciting nausea, as follows: — 1^. 
 Antimonii tartarisati grana duo ; Aquae dis- 
 tillatae uncias quatuor. Misce et cola. Do- 
 sis, Uneia dimidia sexta quaque hor<i. 
 
 The safest diaphoretics are citrate of po- 
 tass, acetate of ammonia, and tarlrite of an- 
 timony, and James’s powder. The two 
 
 latter, from theip effects in producing nausea, 
 and weakening the pulse, are sometimes 
 most efficacious, as already stated. 
 
 “ The warm bath seems fo act (as a mo- 
 dern writer says) not only by increasing the 
 tendency to perspiration, but also by occa- 
 sioning a determination of blood to those 
 parts of the body to which it is more imme- 
 diately applied. It is in this w ay that bath- 
 ing the feet seems to relieve inflammatory 
 affections of the head and throat. 1 have 
 not seen any experiments, nor am 1 ac- 
 quainted with any, which have been made 
 with a view to ascertain its use in the in- 
 flammations of the chest ; but, in all inflam- 
 mations of the belly, and of the viscera con- 
 tained within that cavity, there are no other 
 means of cure, blood-letting excepted, 
 which afford such sudden and permanent 
 relief as that which is obtained from hot fo- 
 mentations and warm bathing.” (See Thom- 
 son on Inflammation, p. 173.) 
 
 Opium. The majority of surgeons enter- 
 tain an insuperable objection to the admi- 
 nistration of opiates in almost all cases of in- 
 flammation, and the aversion to this prac- 
 tice is for the most part deducible from the 
 recollection of opium being a powerful sti- 
 mulant. The plan, however, has its advo- 
 cates. ( B . Bell ; Richter , <^c.) One of its 
 strongest partisans tells us, that opium parti- 
 cularly lessens the disturbance of inflamma- 
 tion, and allays pain, which is at once a 
 principal symptom of the process, and a 
 cause of its augmentation, as well as that of 
 the fever. Opium also quiets the inordinate 
 action of the solids, the mental agitation 
 and restlessness so powerfully, that it well 
 deserves the name of the grand antiphlogis- 
 tic remedy. It likewise occasions a mois- 
 ture on the surface of the body, which ex- 
 perience shows is eminently serviceable in 
 all inflammations affecting the skin. When 
 given with this view, it is usually conjoined 
 with antimony, camphor, calomel, or ipe- 
 cacuanha. The administration of opium is 
 a general practice in all painful inflamma- 
 tions arising from external causes, and it is- 
 attended with perfect safety when evacuations 
 from the bowels and bleeding have beenprevi- 
 oo, sly put in practice. Care must be taken 
 to give it in sufficient doses; for small quan 
 tities not only fail in fulfilling the object, 
 but frequently produce quite an opposite 
 effect. During its employment, the bowels 
 should be kept open with glysters. The 
 efficacy of opium chiefly manifests itself in 
 the early stage of the affection ; for, as soon 
 as the inflammatory fever has extended it- 
 self to the w 7 hoie system, it loses its benefi- 
 cial virtues. Hence, in cases' of external 
 injuries, it is to be given the two first days, 
 immediately after bleeding. It is to he 
 given as soon after the accident as possible, 
 in order to tranquillize the mental alarm, 
 and. if convenient, towards the evening, for 
 the sake of procuring a quiet night. ( Rich- 
 ter. ) Evacuations being premised, says the 
 other advocate for this medicine, the next 
 object of importance is to procure ease and 
 quietness to the patient, w hich, in cases of 
 
126 
 
 INFLAMMATION. 
 
 inflammation, are often of more real service, 
 than any other circumstance whatever. 
 The most effectual remedy for this purpose 
 is opium, which, when the pain and irrita 
 tion are considerable, as very frequently 
 happens in extensive inflammations, should 
 never be omitted. In large wounds, espe- 
 cially after amputations, and other capital 
 operations, and in punctures ot all kinds, 
 lar. e doses of opium are al vays attended 
 with remarkably ood effects In all such 
 cases, however, opium, in order to have a 
 proper in tuence, should he administered in 
 very la. :e doses ; otherwise, instead of 
 proving serviceable, it sterns, rather to have 
 the contrary effect. This circumstance is, 
 perhaps, the < iiief reason why opiat s in 
 general have been very u.nj stly condemn- 
 ed in every case of inflammation. ( B . Bell.) 
 
 Oil the contrary, those who are averse to 
 the use of opium, remark, that in acute in- 
 flammation daily experience shows, inde- 
 pendently of every theory, that the exhibi- 
 tion of this medicine increases the general 
 fever, and aggravates the local action. Even 
 given as a preventive of inflammation, after 
 operations anodynes are almost uniformly 
 hurtful, producing restlessness, heat, thirst, 
 and afterward headacb, sickness and fre- 
 quently troublesome, vomiting. (Burns.) 
 
 According to Dr. Thomson. “ thos«- dia 
 phoretics, into the composition of which 
 opium enters, seem to be better adapted 
 for inflammation attended with fever of a 
 typhoid character, or for cases where the 
 inflammation has existed for a considerable 
 time before diaphoretics are employed. 
 Given at an early period in acute inflamma- 
 tory diseases, opium never tails to excite 
 vascular action, and to aggravate all the 
 symptoms of fever. Opium, therefore, is 
 not to be used, unless to allay the pain and 
 irritation from a surgical operation, or from 
 the recent infliction of an external injury. 
 Indeed, unless when the patient is very 
 nervous, and complains much of pain, its 
 use, even after chirurgical operations, had, 
 I believe, in general, better be abstained 
 from, as it almost never mils to add to the 
 violence of the symptomatic fever, which is 
 the necessary consequence of the operation. 
 Tts effects are often very beneficial, when 
 the period of this fever has passed over.” 
 (See Lectures on Inflammation, p. 172.) lip- 
 on the whole, candour obliges me to own, 
 that the majority of surgeons in this country 
 are decidedly against the general use of 
 opium in inflammation ; but, after the per- 
 formance of severe operations, and in all 
 instances attended with excessive pain, 
 truth, I believe, will justify my saying, that 
 they are in favour of the exhibition of this 
 remedy. 
 
 Diet and Regimen . — In all cases, the sur- 
 geon is to forbid the use of wine and spirits ; 
 and, when the inflammation is at all consi- 
 derable, the same prohibition is to be made 
 in regard to animal food. Watery, cooling, 
 mucilaginous drinks are proper; for they 
 keep off thirst and heat, promote perspira- 
 tion. and tend to sooth the increased action 
 
 of the whole arterial system. For this pur- 
 pose, whey, buttermilk, barley- water de- 
 coctions of dried fruits, water-gruel, &c. 
 
 may be given. 
 
 When diluent drinks “ are intended to 
 allay thirst, as well as to promote perspira- 
 tion, the addition of some vegetable acid, 
 such as lemon-juice, or cream of tartar, ren- 
 ders them in general very palatable to pa- 
 tients In the earlier stages of inflammation, 
 
 and where the object is to induce a mois- 
 ture on the skin, the mineral acids, though 
 t iey might serve to quench thirst, are not 
 to be employed, as thevtend rather tocheck, 
 than promote the flow of sweat.” (Thom- 
 son on Inflammation, p. 172 ) . # 
 
 The chamber, in which the patient lies, 
 should not be warmer than hi-, comfort re- 
 quires ; for heat ten is powerfully to keep 
 up an increased action of tne sanguiferous 
 system. For the same reason, the patient 
 should not be covered with a superfluous 
 quantity of bed-clothes. 
 
 The whole bodv ; but more especially the 
 inflamed part, should be preserved as 
 complete a state of rest as po i ible. '..very 
 one k ows, that all motion, exercise, and 
 muscular exertion, accelerate the circula- 
 tion, and. hence, must have a pernicious 
 effect on inflammation, by determining a 
 larrer quantity of blood to the part affected. 
 
 Applications. With the exception of what 
 has been stated, concerning topical bleeding, 
 all the foregoing remarks relate to the ge- 
 neral treatment of inflammation : the local 
 means remain for consideration. 
 
 It has been already observed, that phleg- 
 mon is attended with an increase of heat in 
 the part affected, and it is an acknowledged 
 and well-known fact, that the action of the 
 arteries, as well as every other operation in 
 the animal economy, is promoted and in- 
 creased by the influence of heat, for this 
 reason, an obvious indication arises, viz. to 
 reduce the temperature of the inflamed part, 
 by the topical application >f cold, and, in 
 particular, bv continually abstracting the 
 heat evolved in the part, by keeping up a 
 constant evaporation from its surface. 
 
 « Of the local remedies, applied directly 
 to inflamed parts (says Dr. Thomson) cold 
 is undoubtedly one of the most powerful. 
 In reducing the temperature, cold dimi- 
 nishes the morbid sensibility and pain ot in- 
 flamed parts; and, probably, in consequence 
 of this, the action also of the vessels, by 
 which the inflamed parts are supplied with 
 blood. The most common mode ot em- 
 ploying cold is by the application to the 
 part inflamed of cloths, which have been 
 dipped in cold water. These are to be repeat- 
 ed as often as they become warm, or any 
 relief is experienced by the patient from 
 their use. When the inflammation is seat- 
 ed on the remote parts of either the upper 
 or lower extremities ot the body, the in- 
 flamed part itself may he immersed in wa- 
 ter. This immersion, as I shall afterward 
 have occasion to mention, has often been 
 found useful in superficial burns. In 1)1 ” r . 1 
 to increase the effect produced l»v cold, it 
 
IN-FLA MM \TFQN, 
 
 327 
 
 lias been proposed to reduce the tempera- 
 ture of the water below that of the surround- 
 ing atmosphere, by a proper mixture of sa- 
 line bodies, as some of these are known to 
 produce cold during their solution in water, 
 or even in very urgent cases to apply ice or 
 snow. The ice, however, must not be ap- 
 plied too long, nor in too large a quantity ; 
 for, it very quickly reduces the temperature 
 of the part to which it is applied, and, in 
 some instances, has been known to occa- 
 sion gangrene, &c. (On Inflammation, p. 
 180 .) 
 
 With the cold water applied to phlegmo- 
 nous intiammation, it is usual to blend some 
 remedies which are astringent, and suppo- 
 sed to nave also a sedative quality. Theace- 
 tite of h ad, sulphate of zinc, and vinegar, 
 seem now, indeed, to have acquired p> rma- 
 nent celebrity for their efficacy in resolving 
 intiammation. 
 
 Extensive experience, and long-establish- 
 ed trials, have now fully confirmed the vir- 
 tue of all those local remedies, in which the 
 acetite of lead is the active ingredient. M. 
 Goulard, and other French surgeons, found, 
 that the objections to the employment of 
 many other sedative applications in the 
 treatment of inflammation, did not exist 
 against the use of this preparation of lead 
 The universal assent of modern practitioners 
 proves, indeed, that the acetite of lead as a 
 local application for genuine phlegmonous 
 inflammation, is certainly unsurpassed, if 
 not unrivalled, in point of efficacy. 
 
 The preparations of lead are recommend- 
 ed by M. Goulard, as almost equally applica- 
 ble to every stage of inflammation. When 
 swellings have fully suppurated, the employ- 
 ment, of what he calls, the extractum Satur- 
 ni, will almost always render it unnecessary 
 to open them. Even in gangrene, the solu- 
 tion of lead is represented by this zealous 
 writer, as a remedy deserving of the greatest 
 confidence. 
 
 But, notwithstanding the above exaggera- 
 tion, every man of experience and observa- 
 tion will allow, that, while there is a chance 
 of accomplishing resolution, no local appli- 
 cations to phlegmonous inflammation are in 
 general so proper as cold lotions, containing 
 the acetite of lead. 
 
 “ The manner in which it operates in 
 curing inflammation (as Dr. Thomson ob- 
 serves) is not known to us, nor is it at all 
 times easy to distinguish between the share, 
 which the lead has in allaying inflammation, 
 and that which is to be attributed to the 
 coldness of the water in which it is dissolved. 
 No one, however, will doubt of the efficacy 
 of this remedy, who has ever felt it in his 
 own body, or witnessed in others the sooth- 
 ing and agreeable effects, which it produces 
 in excoriations cf the skin, or in inflamma- 
 tion of mucous membranes. Lead is a 
 remedy, which is often highly useful in 
 excoriations from friction, in punctured 
 wounds with inflammation of absorbent 
 vessels, veins, nerves, &c. in slight burns, in 
 cutaneous heat, eruptions ot the face, in frac- 
 tures and dislocations, in the inflammation 
 
 attending scirrhus and cancer, syphilis and 
 gonorrhoea, in wounds accompanied w it'a 
 excoriation from the discharges they emit, 
 and in wounds attended with a burning 
 sensation of pain.” (P. 182.) 
 
 F rom the poisonous qualities of lead, when 
 taken into the system, and from the possi- 
 bility of this mineral being absorbed from 
 the surface of the body, objections have 
 arisen against the free use of its preparations, 
 even as outv\ard remedies in cases of inflam- 
 mation. Certain it is, however, that though 
 the possibility of such absorption is proved 
 by the occurrence of the disorder called the 
 colica pictonum, which originates in painters 
 from the white lead absorbed into the sys- 
 tem, yet, any ill effects from the use of lead, 
 as an application io inflamed parts, are so 
 exceedingly rare, that they can hardly form 
 a serious objection to the practice, ft is a 
 fact, that, in inflamed parts, there is an im- 
 pediment to absorption, and this circum- 
 stance may tend to render the employ ment 
 of lead a matter of safety. Mr. B Bell ob- 
 serves, that in all the experience which he 
 had had of the external application of lead 
 and its preparations, and in many cases, par- 
 ticularly of burns, where he had known the 
 greatest part of the surface of the body 
 covered with applications of this description 
 for days, nay, for weeks together, he did 
 not recollect a single instance of any disa- 
 greeable symptom being ever produced by 
 them. Nor has Dr. Thomson ever seen the 
 colica pictonum follow the use of Goulard. 
 (See Lectures on Inflammation, p . 183.) 
 
 A lotion composed of acetite of lead, vine- 
 gar, and water, is very commonly employed. 
 
 Plumbi Acetatis jjss. Solve in Acet. pur. 
 j|iv. Et adde Aq. Fontanae distill. Ifoij. The 
 vinegar makes the solution more complete. 
 In all common cases, a teaspoonful of the 
 liquor plumbi acetatis, blended with a pint 
 of water, will be found an eligible lotion. 
 Occasionally, bread-crumb is moistened in 
 the fluid, and applied in the form of a poul- 
 tice ; but linen dipped in the lotion, and 
 kept constantly wet with it, is mostly pre- 
 ferred. Thus a continual evaporation is 
 maintained, and of course a regular abitrac- 
 tion of heat. 
 
 When the surgeon is afraid of employing 
 a solution of lead, he may try one of the 
 sulphate of zinc. One dram of this sub- 
 stance is to be dissolved in a pint of wa- 
 ter, and linen, well wet with the lotion, is 
 to be applied to the inflamed part. 
 
 Many practitioners impute very little real 
 efficacy either to the acetite of lead, or sul- 
 phate of zinc, contained in the above ap- 
 plications : and they attribute all the good 
 that is produced, entirely to the evaporation 
 kept up from the surface of the inflamed 
 part, and to the cotdnessof the fluid in which 
 the metallic salts are dissolved. Surgeons, 
 who entertain these sentiments, think the 
 application of simple cold water quite as 
 efficacious as that of any medicated lotions. 
 
 There are particular cases of inflammation, 
 in which the extravasation of blood and 
 lymph, in the interstices of the inflamed 
 
INFLAMMATION. 
 
 m 
 
 part, is exceedingly copious, and the swell- 
 ing considerable, but the pain and redness 
 not particularly great. In such instances, it 
 is an indication to rouse the action of the ab- 
 sorbents, in order that those vessels may re- 
 in >ve the extravasated fluid, and with this 
 V; mv, a more powerf d discuiieut lotion may 
 be employed than in other cases, and some- 
 times, it is even better to use embrocations 
 and linimen s, than any sort of lotion. The 
 following discutient lotions are often em- 
 ployed : Ammonite Muriataj ,^ss. 'ceti , 
 
 Spiriths Vini rectificati ; sing ft>j. M. p*. 
 Liq. Ammon. Acet. Spir. Vini rectil. ;• Aq. 
 Distillatai ; sing. §iv. M. The Liq. Ammo-, 
 nia? Acet. also alone answers very well. 
 
 When the part affect- d with inflammation 
 is not very tender, or when it lies deep, ap- 
 plications of the vegetable acid are often 
 had recourse to with considerable advan- 
 tage ; and the most effectual form of using 
 it seems to be a poultice made with vinegar 
 and crumb of bread. In such cases, it lias 
 been thought, that an alternate use of this 
 remedy, and the saturnine lo. ion, has produ- 
 ced more beneficial effects, than are com- 
 monly observed from a continued use of one 
 of them. (B. Bell.) However, surgeons of 
 the present day see to think, that vinegar 
 can be as advantageously applied in the form 
 ot a lotion, as in that of a poultice, and, 
 certainly, with less trouble. 
 
 Alcohol and aither Have acquired some 
 celebrity as local remedies for inflammation. 
 No doubt one great reason why they are not 
 more extensively used for this purpose is, 
 the expense attending such treatment, as 
 these fluids evaporate with great rapidity. 
 Alcohol may possibly prove useful from its 
 astringent qualities ; but it seems uch 
 more rational to impute both its virtue, and 
 that aether, to the powerful manner, in 
 which their evaporation deprives the infla- 
 med nart of its heat. 
 
 Warm Applications. The absurdity of at- 
 tempting to reconcile every usef-d practice 
 \vl . a philosophical theory, is, in no in- 
 stance, morestri; igly exemplified, than in 
 the opposite sorts of local applications, 
 which are of service in inflammation. The 
 g «erality of cases undoubtedly receive most 
 l* ief from the use of cold sedative astringent 
 lotions : butthere are constitutionsaud parts, 
 which derive most service from the local 
 employment of wa rn emollient remedies. 
 
 Were 1 to endeavour to define the particu- 
 lar instances, in which the latter applications 
 avail most, I should take upon me a task, 
 which has baffle-! all the most able surgical 
 writers. The first stage of the acute oph- 
 thalmy, and the hernia humoralis, or infla- 
 med testicle, may be specified, however, as 
 examples, in which, generally speaking, 
 warm emollient applications are better than 
 cold astringent ones. Yet, even with res- 
 pect to inflammation of the testis, there is 
 some difference of opinion about the supe- 
 riority of cold or warm applications. Mr. 
 James’s sentiments are as follows : in the 
 treatment it is of importance to consider the 
 differences of the cause : thus, in mumps 
 
 and rheumatism, the constitution is chietp, 
 to be attended to, and cold applications are 
 certainly improper. When it (the inflamma- 
 tion of the testis) arises from a blow, after 
 leeches have been freely employed, fomen- 
 t tions are the best remedy But Mr. James 
 thinks, that this is not the rase, in many 
 instances of hernia humoralis trom gonor- 
 rhoea, where cold applications are prefer- 
 able ; but, he owns, that the feelings of the 
 patient will best determine the point. 
 
 ( James on Inflammation, p 164.) 
 
 “ Fomentations, or embrocations with 
 warm water, (as a j dicious writer has re- 
 marked! are often a very powerful means 
 of abating internal inflammation. This ef- 
 fect is ve ,- y apparent in some of the deeper 
 seated inflammations, as in the inflammation 
 of the urinary bladder, intestines, or other 
 viscera contained within the cavity of the 
 abdomen. The warmth, in this case, may 
 be applied to the surface of the abdomen, by 
 bath or fomentation, or in the way of injec- 
 tion, by the anus, &c. In some inflamma- 
 tions of the joints, warmth also is found to 
 be very useful. These, however, are in- 
 flammations, which have a tendency to the 
 chronic state. (See Thomsonon Inflammation, 
 p . 188.) 
 
 If we may judge by the feelings of certain 
 patients, there are undoubtedly particular 
 constitutions, in which the local use ot warm 
 remedies produces greate- relief than that of 
 cold ones This circumstance, however, 
 does not generally happen ; and, as warm 
 emollient applications, of ail kinds, have the 
 most powerful influence in promoting sup- 
 puration, a fact admitted by every experien- 
 ced practitioner, the use of such remedies, 
 while the resolution of inflammation is prac- 
 tical must be highly censurable. But, I 
 am ready to grant, that in all cases of 
 inflammal: o, which manifestly cannot be 
 cured without suppuration, the emollient 
 plan of treatment ought to be at once adopt- 
 ed ; for the sooner the matter is formed, 
 
 the spoiler the inflammation itself is stopped. 
 
 The inflammation attending contused and 
 gunshot wounds, and that accompanying 
 bolls and carbuncles, are of this description. 
 The inflammation, originating in fevers, com- 
 monly ends in suppuration, and, in such 
 instances, perhaps, it might he advantageous, 
 also, to employ at once the emollient treat- 
 ment. 
 
 Warmth and moisture together, in other 
 words fomentations, are commonly had re- 
 course to in cases of inflammation ; but, 
 when the warmth is as much as the sensitive 
 principle can bear, it excites action. Whe- 
 ther it is the action of inflammation, or the 
 action of the contraction of the vessels, is 
 unknown. We see that many patients 
 cannot bear warmth, and, therefore, it 
 might he supposed to increase the action of 
 dilatation, and do harm. But, if the pain 
 should arise from the contraction of the in- 
 flamed vessels, benefit would he the result ; 
 though we must doubt that this change is 
 produced, as making the vessels contract 
 would probably give ease. ( Hunter .) 
 
INFLAMMATION. 
 
 From the preceding observations, we 
 must perceive how vain it is to theorize on 
 this subject which even puzzled the genius 
 and penetration of a Hunter. In addition 
 to what has been already observed, I feel 
 totally incapable of giving any useful practi- 
 cal advice, with respect to those cases, in 
 which warm emollient applications should 
 be used in preference to cold astringent 
 ones. I can, however, with confidence 
 remark- that the surgeon who consults the 
 feelings and comfort of the patient on this 
 point, will seldom commit any serious error. 
 Hence, in all cases, in which the first kind 
 of topical applications seem not to produce 
 the wonted degree of relief, let the second 
 sort be tried. From the opportunity of com- 
 parison, a right judgment may then be easily 
 formed. 
 
 The poultice made of the powder of lin- 
 seed is so easily prepared, that the old bread 
 and milk poultice is now seldom employed. 
 As much hot water is to be put into a basin, 
 t' as the size of the poultice, requires, and then 
 i the linseed pow r der is to be gradually mixed 
 ‘ with the water, till the mass is of a proper 
 ! consistence. Frequently, a little sweet oil 
 ; is also added to keep the application longer 
 1 soft and moist. 
 
 Fomentations are only to be considered 
 as temporary applications, while the emol- 
 lient poultices are the permanent ones. The 
 former are, at most, never used more than 
 three times a day, for the space of about half 
 an hour each time. Two cf the best are the 
 - following: — -{J,. Lini contusi ^j. Chamae- 
 meli 3jij. Aq. Distill, ftjvj. Paulisper coque 
 etcola. Or. Papaverisaibi exsiccati ^iv. 
 Aq. Purae Jfevj Coque usque remaneant 
 }feij. et cola. 
 
 Some practitioners, however, are incli- 
 ned to think warm w ater alone quite as effi- 
 caciousas the decoctiousof particular herbs. 
 Thus Dr. Thomson observes, “ herbs are 
 now seldom used in the way of fomenta- 
 tion, unless in compliance with ancient 
 custom, or with the prejudices of particular 
 individuals. The discutient power of the 
 warm water may be increased by the addi- 
 tion of various substances, such as vinegar, 
 spirits of wine; saline substances, such as 
 common salt, acetite and muriate of ammo- 
 nia. But, these warm and stimulating em- 
 brocations are used chiefly in the passive, 
 chronic, or more indolent species of inflam- 
 mation/’ (See Lectures on In jl0imaiiou. p. 
 189 .) 
 
 By pursuing the treatment recommended 
 above, the resolution of the inflammation 
 will in general begin to take place, either in 
 the course of three or four days, or in a 
 shorter space of time. At all events, it may 
 usually be known before the expiration of 
 this period, how the disorder w^U terminate. 
 If the heat, pain, and other attending symp- 
 toms abate ; and, especially, if the tumour 
 begins to decrease, without the occurrence 
 of any gangrenous appearances ; we may 
 then he almost certain, that, by a continu- 
 ance of the same plan, a total resolution will 
 hi time he effected 
 Vor„ If 
 
 12*> 
 
 On the other hand, when all the different 
 symptoms increase, and particularly when 
 the tumour becomes larger, and softish, at- 
 tended with a more violent throbbing pain, 
 we may conclude, that the case will proceed 
 to suppuration. Hence, an immediate 
 change of treatment is indicated, and such 
 applications, as were proper while resolu- 
 tion seemed practicable, are to he left off, 
 and others substituted. This remark relates 
 to the employment of cold astringent reme- 
 dies, which, when suppuration is inevitable, 
 only do harm, by retarding what cannot i e 
 avoided, and affording no relief of the pain 
 and other symptoms. If the inflammation, 
 however, should already be treated with 
 emollients, no alteration of the topical ap- 
 plications is requisite, in consequence of the 
 inevitability of the formation of matter. 
 Indeed, emollient poultices and fomenta- 
 tions are the chief local means both of pro- 
 moting suppuration, and diminishing the 
 pain, violent throbbing, & c. which always 
 precede this termination of phlegmonous 
 inflammation. 
 
 But, besides the substitution of warm 
 emollient applications for cold astringent 
 lotions, practitioners have decided, that it 
 is also prudent, as soon as the certainty is 
 manifest, to relinquish the free employment 
 of evacuations, particularly bloot-retting, 
 and to allow the patient a more generous 
 .diet. When tin* system is too much redu- 
 ced by the injudicious continuance of rigo- 
 rous antiphlogistic treatment, the progiv s 
 of the ensuing suppuration is always retard- 
 ed in a disadvantageous manner, and the 
 patient is rendered too weak to support ei- 
 ther a Ion .. -tout iriued, or ajprofuse discharge, 
 which it may not he possible to avoid. 
 
 I shall conclude this article with briefly 
 noticing blisters, rubefacients, issues, and 
 synapisms, as means often employed for the 
 relief of particular cases of inflammation. 
 “Blisters (says Dr. Thomson) are never 
 applied to a part which is actually inflamed. 
 They seem to he chiefly useful by exciting 
 inflammation in a contiguous part. It is 
 from this tendency, which blisters have to 
 produce inflammation, and of course a cer- 
 tain degree of fever, that they are seldom to 
 be employed in acute inflammatory cases, 
 till the constitutional symptoms are by other 
 means in some measure subdued.” — (P. 
 187 .) 
 
 “ Of the same nature, though milder in 
 their operation, than blisters, are the whole 
 class of rubefacients. They produce a de- 
 tennination"of blood to the parts to which 
 they are applied, and in a manner not yet 
 well understood, occasion a diminution in 
 the action of the vessels, and consequently 
 in the quantity of blood with which the in; 
 flamed parts, are supplied. This influence 
 is exerted more or less directly in different 
 instances. The extremities of the intercos 
 tal arteries may open both on the pleura 
 lining the chest, and on the surface of the 
 skin covering it, and whatever excites au 
 increased flow of blood into one of these, 
 textures, may be conceived to be attended 
 
 17 
 
INF 
 
 1N0 
 
 13# 
 
 with a proportionally diminished flow into 
 the other texture, B it, blisters are found 
 by experience to be efficacious in removing 
 inflammation, where no communication 
 whatever can be traced between the blood- 
 vessels of t e inflamed part, and that to 
 which the blister is applied. We have ex- 
 amples of this mode of action in the bene- 
 ficial effects obtained from the application 
 of blisters in inflammation of the brain and 
 the membranes immediately covering it, of 
 the lungs and intestines, or of any of the 
 viscera contained in the cavity of tiie abdo- 
 men. The nearer in such instances the 
 blister or rubefacient can be applied to tiie 
 part inflamed, the greater is the relief ob- 
 tained ; and in general, l believe, it may be 
 laid down as a rule, that the relief, which 
 they afford, will be proportional to the de- 
 gree of inflammation which they excite.” 
 (See Thomson on Inflammation , p. 187, 189.) 
 
 Synapisms, blisters, and issues are in ma- 
 ny instances applied to situations, which are 
 so remote from and unconnected by v essels 
 with the inflamed parts, that it is impossible 
 to explain their mode of operation except 
 through the medium of the nervous system. 
 
 11 The irritation of a synapism applied to the 
 foot (says Dr. Thomson) may relieve an at- 
 tack of gout in the head, or stomach. Bath- 
 ing the feet and legs gives relief in inflam- 
 mation of the bowels ; and the application 
 of a blister, or caustic to the neck, may cure 
 an inflammation of the eyes, &.c. ( P . 1«9.) 
 Here counter irritation is the principle by 
 which an explanation is usually attempted. 
 (See Blisters.) 
 
 Van Swieten's Commentaries on Boerhaave; 
 Gorler's Compendium Medici mu, 4 to. Lu^d. 
 1731 ; and Chirurgia Repur gala, 4lo. Lugd. 
 1742. Vacca., Liber dt Inflammalionis mor- 
 bosa , quae in humano corpore Jit, natures . cau- 
 sis, effectibus, et curalione, 1765. D Mage- 
 nisie,the Doctrine of Inflammations, founded 
 upon reason and experience; and entirely 
 cleared from the contradictory systems of Boer- 
 haave, Van Swieten, and others, 8 vo. t.ond. 
 1768. Cullen’s First Lines of the Practice 
 of Physic, Vol. 1. John Hunter, on the Blood, 
 Inflammation, §’C. 4to. London, 179 I. Burns's 
 Dissertations. 8vo Glasgow, lbOo. Thom- 
 son’s Lectures on Inflammation, Edinb. 1813. 
 Boyer, Trait 6 des Maladies Chir. T. 1. Del- 
 pech, Precis Elrn. des Alai. Chir. T. 1 ,chap. 
 1, Paris, 1816. John Herdmnn, Hiss on 
 White Swelling, and the Doctrine of Inflam- 
 mation, 8 vo. Edinb. 1802. F. J. V Brous- 
 sais Hist, des Phlegmasies ou Inflammations 
 Chroniques,&fC. 2 Tom. 8vo. Paris, 1808. C. 
 Wenzel, fiber die Induration und das Gesch- 
 wiir in indurioten Theilen, 8 vo Mainz. 
 
 1815, Wilson Philip, on Febrile Diseases, 
 Part 2. Introduction, Ed. 3 ; and Bn Expe- 
 rimental Inquiry into the Laws of the Vital 
 Functions, Ed. 2. 8 vo. Loud. 1818. Caleb 
 H. Parry , Elements of Pathology and The- 
 rapeutics, 8vo. Loud. 1815. Also, Bn Expe- 
 rimental Inquiry into the Nature, fyc. of the 
 Arterial Pulse, 8vo. Land. 1816. Charles H. 
 Parry, Additional Experiments on the Arteries 
 of Warm-blooded Animals, tyc. 8 vo. Loud. 
 
 1819. James Wilson, Lectures on the Blood , 
 and on the Anatomy, Physiology, and Surgi- 
 cal Pathology of the l ascular System, 8 vo. 
 Lond. 1819. C. II. Ronnefeld, Animadver- 
 siones nonnullce ad Doctrinam de Infiamma- 
 tione,4lo Lips. I S 1 7 . C. Hastings, a Trea- 
 tise on Inflammation of the Mucou Membrane 
 of the Lungs, <yc. 8lo. Lond. 1820. J. H. 
 James , Observations on some of the General 
 Principles mid on th> particular Nature and 
 Treatment of the different Species of In flam - 
 ma, ion, 8 vo. Lond. Jb21. This work, and 
 those of Mr. J. Hunter, Mr. Wilson, Mr J. 
 Burns, Drs. Parry, Philip and Hostings, de- 
 serve attentive perusal by every body desirous 
 of forming a correct judgment of the nature 
 of inflammation. 
 
 INJECTION. A fluid intended to be 
 thrown against, or into a part of the body 
 by means of a syringe. Thus port wine and 
 water form an injection, which is used by 
 surgeons for radically curing the hydrocele, 
 and, for this purpose, it is introduced into 
 the cavity of tiie tunica vaginalis, where it 
 excites the degree of inflammation necessa- 
 ry to produce an universal adhesion between 
 this membrane and the albuginea. 
 
 Thus many fluid remedies are introduced 
 int> the urethra and vagina for the cure of 
 gonorrhoea. In the article Gonorrhoea , will 
 be found an account of the best injections 
 employed for its relief. A few additional 
 remedies of this class are here subjoined. 
 
 liNJECTIO ACIDI MURIATIC!. R. 
 Aquee distil ^iv. Acid. Mur. gutt. viij. 
 Misce. Useful when the scalding is a very 
 troublesome symptom. 
 
 lAJECTlO ALUMIiNIS. — Alum 3j. 
 Aq. pur.Jjvj. Misce. — Successtully employed 
 by Dr. Cheston, as an injection in affections 
 of the rectum, either when the internal coat 
 is simply relaxed, and disposed to prolapsus, 
 or when it is studded with loose fungated 
 tumours. In such cases, camphor is also of 
 service. The quantity of alum raaj be in- 
 creased, if the parts will bear it. 
 
 1NJECTIO CUPRI AMMONIATI. R. 
 Liquoris Cupri ammon. gutt. xx. Aquas 
 rosae ^iv. Misce. Strongly recommended 
 by Mr. Foot. 
 
 liNJECTIO QUERCUS. R. Deeocti quer- 
 cus fbj Aluminis purificat. |ss. Misce. 
 May be used, when the lectum, or vagina, 
 i£ disposed to prolapsus from relaxation, or 
 in cases ot gleet. 
 
 * i.NNOMlNATA ARTER1A. By refer- 
 ing to the article Aneurism, in the Appendix, 
 will be seen the case at full length, in which 
 professor Mott of this city tied the Arteria 
 Innominata for the purpose of directing the 
 blood from an aneurism of the subclavian 
 artery ; together with some remarks upon 
 the criticisms which have appeared against 
 it. Am Ed 
 
 INOSCULATION denotes, in the lan- 
 guage of anatomy and surgery the union 
 of vessels by conjunction of their extremi- 
 ties. It is generally synonymous with 
 anastomosis , though sometimes a distinction 
 is made, anastomoses signifying the union of 
 vessels by minute ramifications, and inoscu- 
 
IiNO 
 
 I NT 
 
 13ll 
 
 lotion a direct communication by trunks. 
 The great use of inosculations is to facilitate 
 and ensure the continuance of the circula 
 tion, when the large trunks of vessels are 
 obstructed by pressure, disease, &.e. Thus, 
 in cases of aneurism, when the main artery 
 of a limb is tied, the inosculations of the 
 branches, given off above the ligature, with 
 other branches arising below it, form at 
 once a channel, through which the lower 
 part of tne limb is supplied with blood. 
 Were there no such arrangement in the 
 human body as inosculations, aneurisms 
 could never be cured by a surgical opera- 
 tion So infinitely numerous indeed are 
 these inosculations, that they do the office 
 of the subclavian, carotid, and external and 
 internal iliac arteries, when these vessels 
 are tied, and upon this fact is founded the 
 success of some of the most brilliant opera- 
 tions in modern surgery. (See Aneurism.) 
 Even the aorta itself may be perfectly ob- 
 structed, the circulation go on, and every 
 part be fully supplied with blood. (See 
 Aorta.) In dogs, the abdominal aorta has 
 been tied, without the circulation in the 
 hinder extremities being stopped. (See the 
 Experiments of Mr. A. Cooper in Med. C/iir. 
 T'rans. Vol. 2, p. 258;) and the operation, 
 performed a few years ago, in Guv’s hospi- 
 tal, tends to prove that the same thing is 
 possible in the human subject (See Aorta.) 
 From the observations of the same distin- 
 guished surgeon it appears, that the arteries, 
 which form the new circulation in a limb, 
 after the obliteration of the principal artery, 
 are not only enlarged but tortuous. Any 
 great increase, however, in the diameter of 
 the anastomosing vessels is but slowly pro- 
 duced ; for Mr. A. C ooper has injected a 
 limb several weeks after the operation for 
 popliteal aneurism, without being able to 
 force the injection through communicating 
 vessels into the parts below. The limb must 
 have active exercise before the vessels en- 
 large much. On account of the arteries 
 not very readily enlarging, the limbs of per 
 sons who have undergone the operation for 
 aneurism, are for a considerable time weak- 
 er than natural. They feel the influence of 
 cold more, and are more disposed to ulce- 
 rate from slight causes. Hence, the utility 
 of covering them with flannel, or fleecy ho- 
 siery. Hence, the rashness of applying cold 
 washes, bandages, &.c. (See A. Cooper's re- 
 marks in the above-mentioned l ol p 249, et 
 seq) 
 
 In another place, the same gentleman has 
 published an interesting description of the 
 anastomoses of the arteries of the. groin. 
 
 Hypothesis (says he) w ould lead to a be- 
 lief, that anastomosing vessels would be 
 numerous in proportion to the lime w hich 
 had elapsed from the operation ; but, the 
 reverse of this is the fact ; for, at first, ma- 
 ny vessels convey the blood, originally 
 conducted by the principal artery 7 . But, 
 gradually, tl^e number of these channels 
 becomes diminished and, after a length of 
 time, a few vessels, conveniently 7 situated 
 for the new circulation, become so much 
 
 enlarged, as to be capable of conveying an 
 equal portion of blood to that which passed 
 through the original trunk.” 
 
 The experience of Mr. A. Cooper also 
 tend* to confirm the important fact, that 
 “ it is desirable in femoral aneurism, if not, 
 indeed, in all others, to perform the opera- 
 tion in an early state of the disease,” as the 
 patient then recovers the use of the limb 
 much more quickly, than when the tumour 
 lias been suffered to attain a large size. 
 (See Medico- ( hirurg Trans. Vol. 4, p. 425, 
 et seq.) 
 
 INTERRUPTED SUTURES. See Su- 
 tures. 
 
 INTESTINES WOUNDED. See Wounds 
 of the Abdomen. 
 
 IN fitOSUSCEPTlON. or Intussusception, 
 (from ini us , within and suscipio , to receive.) 
 Called also Volvulus 1* a disease produced 
 by the passing of one portion of an intestine 
 into another, and it U commonly from the 
 upper passing into the lower part. (J. Hun- 
 ter) O this subject. Mr. G. Langstaff lias 
 published an interesting paper, in the Edinb. 
 Surg. Journal. No. XI ; which 1 shall take 
 the liberty of freely quoting. 
 
 Tub gentleman remarks, (hat the small 
 intestines of children are -so often affected 
 with iutrosusception in a slight degree, that 
 most practitioners must have had opportuni- 
 ties of observing the form of the complaint. 
 The greatest par* of three hundred children 
 who died either of worms, or during denti- 
 tion, at the HAi'ital de la Sabpetriere, and 
 came under the examination of M. Louis, 
 had two, three, four, and even more volvuli, 
 without any inflammation of the parts, or 
 any circumstances leading to a suspicion that 
 these a ft* -ct ions had been injurious during 
 life. 11 These cases (says M. Louis) stem to 
 prove, that inirosusception may be formed, 
 and destroyed again by ihe mere action of 
 the intestines.” (Mnn. de VAcad.de Chirurg. 
 4/o. Tom. 4. p 22*2.) This opinion is con- 
 firmed by the authority of Dr. Badlie, ( Mor- 
 bid Anatomy, 2 d Edit p. 162 ) w ho observes, 
 that, ‘ i iu opening bodies, particularly of in- 
 fants, an intussusception is not 'infrequently 
 found, which had been attended with rio 
 mischief ; the parts appear perfectly free 
 from inflammation, and they w ould probably 
 have been easily disentangled from each 
 Ollier by their natural peristaltic motion.” 
 
 The disease, continues Mr. Langstaff, as- 
 sumes a more dangerous, and indeed, gene- 
 rally a fatal form, uh n it occurs at the ter- 
 mination of the small intestines in the cce- 
 cum. A contracted state of ihe part to be 
 introsu cepted, and a dilatation of that por- 
 • ion of the caifal into which this pari must 
 pass, are ssenlial coudii ions to the formation 
 of a volvulus ; and those exist, nowhere so 
 completely as in Ihe situation here alluded to. 
 The extent to which the affection proceeds 
 in this situation, would appear almost incre- 
 dible, if it were not proved by well-authen- 
 ticated facts. A person who considered the 
 natural situation and connexion of the parts, 
 would of course require the strongest evi- 
 dence before he would believe, that ihe iltf- 
 
i N TROSU 8 CEPT ION. 
 
 Vdd 
 
 mn, cmcutn, ascending and transverse por- 
 tions of the colon, may descend into the 
 sigmoid flexure of the latter intestine ; nay 
 more, that they may pass through the rectum, 
 and 1)0 protruded in the form of a prociden- 
 tia ani. Sueh cases, however, are recorded. 
 (Langstaff, in Edinb. Med. and Surgical 
 Journal, No. XJ.) 
 
 This gentleman next relates the case of a 
 child three months old, the body of which 
 he inspected after death, and found to con- 
 firm t he truth of the preceding account. 
 The example was particular in their bein in 
 addition to an extensive introsascepti n in 
 the usual way, a smaller invagination in the. 
 opposite direction, like what probably occur- 
 red in the case related by Mi. Spry; Med. 
 and Physical Journal , No. Xf Sir E. Home, 
 (Trans, of a Society for Medical and Chir. 
 Knowledge, Pol. 1.) ;nvntion> anexumple ot a 
 retrograde intrdsuscepUon, in which a worm 
 was found coiled up round the iitrosuscepted 
 part. The disease took place in a boy who 
 IAd swallowed arsenic. 
 
 If the following mode of accounting for 
 introsusception be just, it will most frequent- 
 ly happen downwards, although there is no 
 reason why it may not take place in a con* 
 
 • trary direction ; in which case, the chance 
 of a cure will be increased by the natural 
 actions of tne intestinal canal tending to re- 
 place the intestine ; and probably from this 
 circumstance it may oflener occur than com- 
 monly appears. 
 
 When the introsusception is downwards, 
 it may be called progressive, and when it 
 happens upwards, retrograde. The manner 
 in which it may take place is, by one portion 
 of a loose, intestine being contracted, and 
 the part immediately below relaxed and di- 
 lated ; under which circumstances, it might 
 very readily happen by the contracted por- 
 tion slipping a little Way into that which is 
 dilated, not from any action in either portion 
 of intestine, hut from some additional weight 
 in the gut above. How far the peristaltic 
 motion, by pushing the contents on to the 
 contracted parts, may force these into the 
 relaxed, Mr. Hunter will not determine, but 
 is inclined to suppose that it will not. 
 
 By this mode of accounting for an acci- 
 dental introsusception, it may take place 
 either upwards or downwards ; but if a con- 
 tinuance or ari increase of it arises from the 
 action of the intestines, it must be when it is 
 downwards, as we actually find to be the 
 case ; yet this does not explain those in 
 which a considerable portion of intestine 
 appears to have been carried into the gut 
 below : to understand these, we must con- 
 sider the different parts which form the in- 
 trosusception. It is made up of three folds 
 of intestine ; the inner, which passes down, 
 and being reflected upwards, forms the se- 
 cond or inverted portion, which being reflect- 
 ed down again, makes the third or contain- 
 ing part, 1 hat is the outermost, which is 
 always in the natural position. (./. Hunter.) 
 
 The outward fold is the only one which is 
 active, the inverted portion being perfectly 
 passive, and squeezed down by the outer. 
 
 which inverts more of itself, so that the an- 
 gle of inversion in this case is always at the 
 angle of reflection of the outer into the 
 middle portion or inverted one, while the 
 innermost is drawn in. From this we can 
 readily see how an introsusception, once be- 
 gun, may have any length of gut drawn in. 
 
 The external portion acting upon tne other 
 folds in the same way as upon any extrane- 
 ous matter- will by its peri-taltic motion urge 
 them further ; and if any extraneous sub- 
 stance is detained in the cavity of the inner 
 portion, that part will become a fixed point 
 for the outer or containing intestine to act 
 upon l bus it will be squeezed on, till at last 
 the mesentery preventing more of the inner- 
 most part from being drawn in, will act as a 
 kind of stay, yet without entirely hindering 
 the inverted outer fold from going still fur- 
 ther. For it ‘being the middle fold that is 
 acted upon by the outer, and this action 
 continuing after the inner portion becomes 
 fixed, the gut is thrown into folds upon it- 
 self; so that a foot in length of intestine 
 shall form an introsusception not more than 
 three inches long. 
 
 The outer portion of intestine is alone ac- 
 tive in augmenting the disease when once 
 begun ; but if the inner one were capable of 
 equal action in its natural direction, the ef- 
 fect would be the same, that of endeavouring 
 to invert itself, as in a prolapsus ani ; the 
 outer and inner portions, by their action, 
 would tend to draw in more of the gut, 
 while the intermediate part only would, by 
 its action, have a contrary tendency. 
 
 The action of the abdominal muscles can- 
 not assist in either forming or continuing 
 this disease, as it must compress equally both 
 above and below, although it is capable of 
 producing the prolapsus ani. 
 
 When an introsusception begins at the 
 valve of the colon, and inverts that intestine, 
 we find the ileum is not at all affected; 
 which proves that the mesentery, by acting 
 as a slay, prevents its inversion. ( J . Hun- 
 ter.) 
 
 From the natural attachment of the me- 
 sentery to the intestines, one would, ul the 
 first view of the subject, conceive it impos- 
 sible for any one portion of gut to get far 
 within another; as the greater extent of me- 
 sentery that is carried in along with it would 
 render its further entrance more and more 
 difficult, and we should expect this difficulty 
 to be greater in the large intestines than in 
 the small, as being more closely confined to 
 their situation ; yet one of t he largest intro- 
 susceptions of any known was in the colon, 
 as related by Mr. Whateley. ( Vid . Phil. 
 Trans. Vol. 70, p. 305.) 
 
 The introsusception appeared to have be- 
 gun at the insertion of the ileum into the 
 colon, and to have carried in the cuecum 
 with ils appendix. The ileum passed on 
 into the colon, till the whole of tin; ascend- 
 ing colon, the transverse arch, and descend- 
 ing colon, were carried into the sigmoid 
 flexure and rectum. The valv^of the colon 
 being the leading part, is at last got as low as 
 the anus; and when the person went to 
 
INTROSUSCEPTION 
 
 m 
 
 stool ho only emptied the ileum, for one fore advises giving- vomits, with a view to 
 half of the large intestines being filled up by invert the peristaltic motion of the contain 
 
 the other, the ileum alone, which passed 
 through the centre, discharged its contents. 
 (J. Hunter.) 
 
 Two questions of considerable importance 
 present themselves to the mind in consider- 
 ing this subject; whether there are any 
 symptoms by which the existence ot the af- 
 fection can he ascertained during life ? And 
 whether we possess any means of relieving 
 it, supposing that its existence could he dis- 
 covered ? The symp.oms attending an intro- 
 susception are common to inflammation of 
 the intestines, hernia, and obstruction of the 
 canal, from whatever cause, and a volvulus 
 is the least frequent cause of such symptoms. 
 (Langstaff.) In the case published by this 
 gentleman, md in those related by Mr. Hun- 
 ter and Mr. Spry, the seat of *he disease was 
 clearly denoted by a hard tumour on the 
 left side of the abdomen. This circumstance, 
 together with the impossibility of throwing, 
 up more than a very small quantity of fluid 
 in cly-ters, ( Hevin , Spry, Langstaff,) and the 
 presence of the other symptoms, would lead 
 us to suspect the nature of the disorder. If 
 £he invaginated portion descended so low as 
 to protrude through the anus, and we could 
 ascertain that it was not an inversion of the 
 gut, the case might be considered as clear, 
 and we should have no hesitation in deliver- 
 ing a prognosis, which, by preparing the 
 friends for the fatal termination, would exo- 
 nerate us from ail blame on its occurrence. 
 
 ( Langstaff .) 
 
 In tfie treatment of this disease, bleeding, 
 to lessen the inflammation that might* be 
 brought on, and quicksilver to remove the 
 cause, have been recommended. 
 
 Quicksilver would have little effect eitherin 
 one way or the other, if the introsuscep ion 
 were downward ; for it is to be supposed 
 that it would easily make its way through 
 t lie innermost contained gut, and, it it should 
 be stopped in its passage, it would by increas- 
 ing its size, become a cause (as before oh-, 
 served) of assisting the disease. In cases of 
 the retrograde kind, quicksilver, assisted, by 
 the peristaltic motion, might be expected :o 
 press the introsusception back ; but even 
 under such circumstances it might get be- 
 tween the containing and inverted gut into 
 the angle of reflection, and by pushing it 
 further on, increase the disease it is intended 
 to cure. {J. Hunter.) 
 
 Every thing that can increase the action 
 of the intestine downwards, is to be particu- 
 larly avoided, as tending to increase the peri- 
 staltic motion of the outer containing gut, 
 and thus to continue the disease. Medicines 
 can never come into contact with the outer 
 fold, and having passed the inner, can only 
 act on the outer further down, and therefore 
 cannot immediately affect that portion of 
 the outer which contains the introsusception ; 
 but we must suppose that whatever affects or 
 comes into contact with the larger portion of 
 the Canal, sU as to throw it into action, will 
 a !$<> affect by sympathy any part that may 
 escape such application. Mr, Hunter there- 
 
 ing gut, which will have a tendency to bring 
 the intestines into their natural situation. 
 
 If this practice should not succeed, it might 
 be proper to consider it as a retrograde intro- 
 susception, and by administering purges 
 endeavour to increase the peristaltic motion 
 downwards. (J. Hunter.) 
 
 I cannot agree with Mr. Langstaff. that it 
 is to be regretted, Hunter’s name should be 
 affixed to the preceding proposal, or that it is 
 an absurd one ; for purgatives and emetics 
 were only recommended to increase the 
 peristaltic action, tin* former downward, the 
 latter upward, according as the supposed 
 nature of the case might require, and this 
 affect they certainly would have, notwith- 
 standing vomiting is an early and constant 
 symptom of the disease, and an insuperable 
 constipation an equally invariable attendant. 
 The method I allow, however, is not very 
 hopeful, and may sometimes be frustrated by 
 the formation of adhesions. According to 
 Mr. Langstaff, the Recherch- s Historiq'ues sur 
 la Gas'rotomie dans le cas de Volvulus, par 
 M. H via, {Mem. de VAcad. de Chirurgie , 
 Tom. 4, 4 to.) contain many interesting facts 
 and sound reasoning. There we find a very 
 ample discussion of the question, concerning 
 the propriety ot opening the abdomen, in 
 order to disentangle the introsuscepted intes- 
 tine ; a proposal which M. Hevin very pro- 
 perly condemns. 
 
 If the equivocal and uncertain nature of 
 the symptoms of volvulus were not suffi- 
 cient to deter us from undertaking an opera* 
 tion, which, under the most favourable cir- 
 cumstances, could not fail to be extremely 
 difficult, and imminently hazardous to the 
 patient, the state of the invaginated parts 
 would entirely banish all thoughts of such 
 an imprudent attempt ; for the different 
 folds of the intestine often become ag- 
 glutinated to each other, so that they can 
 hardly be withdrawn after death ; ( Simpson , 
 Edinburgh Med. Essays, Vol. 6, Hevin' s 4th 
 Obs. Malcolm, Physical and Lit. Essays, Vol. 
 2, p. 360. Hunter, Med. and Chir. Trans, and 
 Soemmering in Transl. of Bail lie’s Morb. 
 Anat.) Nay, the stricture on the introsus 
 cepted part may cause it to inflame, and 
 even mortify. ( Soemmering .) It is very 
 clear that, in this state of parts, the opera- 
 tion of gastrotomy w r ould be totally inad- 
 missible, even if the symptoms could clearly 
 indicate the nature of the case, and the 
 affected part could be easily reached and 
 examined. (Langst ff ) 
 
 The forcible injection of clysters was 
 found useless by Dr. Monro, and the agglu- 
 tination of the parts must produce an insu- 
 perable obstacle to the bowels being pushed 
 back by this means. {Langstaff.) Some 
 have proposed the employment of a long 
 bougie, or a piece of whalebone, to push 
 back the intestine : and this proposal may 
 be adopted, when we are furnished with an 
 instrument, adapted to follow the windings 
 of the large .intestine to its origin in the 
 
134 
 
 INI 
 
 mi 
 
 right ilium, without any risk of perforating 
 the gut in its course. ( Langst ff.) 
 
 it must be confessed, that both surgery 
 and medicine are almost totally unavailing 
 in the present disease. Yet, here, as in many 
 other instances, the resources of nature are 
 exhibited in a most wonderful and astonish- 
 ing manner, while those of art completely 
 fail The invaginated portion of intestine 
 sometimes sloughs, and is discharged per 
 anum while the agglutination of the parts 
 preserves the continuity of the intestinal 
 canal. The nnals of medicine furnish nume- 
 rous instances, in which long pieces of gut 
 have been discharged in this manner, and 
 the patient has recovered. Hence, some 
 hope may he allowed under the most un- 
 promising circumstances. In a case, related 
 in Duncan’s Commentaries, eighteen inches 
 of small intestine were voided per anum , 
 Vol. 9 p. 278. Three similar instances oc- 
 cur in M. Hevin’s Memoir ; twenty-three in- 
 ches of colon came away in one of these, and 
 twenty-eight of small intestines in another. 
 Other cases occur in the Physical and Litera- 
 ry Essays, Yol. 2, p. 361 ; in Duncan’s Annals, 
 Vol. 6 p. 298 ; in the Medical and Chirurgical 
 Transactions, Vol. 2; where Dr Baillie 
 states, that a yard of intestine was voided. 
 The patients did not, however, ultimately 
 survive in every one of these instances. 
 (Lang staff in Edinb. Med. and Surgical Jour- 
 nal.) 
 
 Langenbeck has recorded an instance, in 
 which a prolapsus of the large intestines 
 protruded half an ell out of the anus. The 
 disease had lasted thirty weeks. Langen- 
 beck made an incision into, or rather through, 
 the protruded inverted bowel, immediately 
 below the sphincter ani. He first divided 
 the inner vascular coat, then the muscular, 
 and lastly the outer coat with great caution. 
 He now discovered, within the protruded 
 inverted bowel, w T hich he had opened, ano- 
 ther part of the intestinal canal, which was 
 not yet inverted. He remarked upon it the ap- 
 pendices epiploicae, and the w hite shining 
 peritonajal coat. This last portion would 
 also have become inverted, had the disease 
 continued. He next reduced the latter uu- 
 inverted part, and afterward succeeded in 
 replacing the rest, of the protrusion; which 
 did not fall dowm again w hen the boy had 
 stools. No bad symptoms immediately fol- 
 lowed ; but, the lad being very weak, survi- 
 ved only eight days (See Bibl fur die Chir. 
 B. 3 p. 756, Gult. 1811.) 
 
 Hecin in Mem. de V Acad, de Chir. Hunter's 
 Observations, in the Trans, of a Society for 
 the Improvement of Medical and Chirurgical 
 Know l dge, l ol. I , p. 103, el seq V Encyclo- 
 pedic Methodique, Partie Chir. Art. Gastro- 
 tomie. A. Voter, De Invaginatione Inieslinor- 
 um; ( Halier Disp. Anal. 1, 481. > C. // Velse. De 
 Mut>ii> Intestinorum Ingrcssu, &,-c. Lugd 1742. 
 ( Haller, Disp. Anal 7 97.) J. C. Lettsom, The 
 History of an Extraordinary Intussusception, 
 wi h an account of the dissection by Mr. T. IVhael- 
 ly, 4 to. Lonl. 1786. And Laigstaff's Re- 
 marksinthe Edinb. Med. and Surgical Journal, 
 J Vo. XL 
 
 INVERSION OF THE UTERUS. See 
 
 Uterus , Inversion of 
 
 IRIS, PROLAPSUS OF. As long as the 
 humours, which fill the cavity of the eye, 
 and in which the iris is immersed and sus- 
 pended, remain in perfect equilibrium with 
 respect to each other, that membrane retains 
 its natural position, and a suitable- distance 
 from the cornea, and although of a very de- 
 licate and yielding texture, it contracts, and 
 relaxes itself, without ever forming any ir- 
 regular fold. But, when the aqueous hu- 
 mour has escaped through an accidental, or 
 artificial, opening in the cornea, the iris is 
 pressed forward by the humours situated be- 
 hind it, and is urged gradually towards the 
 cornea until a portion of it protrudes from 
 the eye, at the same opening, through which 
 the aqueous humour made its escape. Thus 
 a small turner of the same colour as the 
 iris forms on the cornea, sometimes named 
 staphyloma of the iris ; sometimes procidentia, 
 or prolapsus of the iris. 
 
 The causes of this complaint are such 
 wounds and ulcers of the cornea, as make 
 an opening of a certain extent into the an- 
 terior chamber of the aqueous humour, and 
 such violent contusions of the eyeball, as 
 occasion a rupture of the cornea. If the 
 edges of a wound in this situation, whether 
 accidental, made for the purpose of extract- 
 ing the cataract, or evacuating the matter of 
 hypopium, be not brought immediately af- 
 terward into reciprocal contact, or continue 
 not sufficiently agglutinated together to pre- 
 vent the escape of the aqueous humour from 
 the anterior chamber, regularly as this fluid 
 is reproduced ; the iris, drawn by its conti- 
 nual flux towards the cornea, glides between 
 the lips of the wound, becomes elongated, 
 and a portion of it gradually protrudes be- 
 yond the cornea, in the form of a small tu- 
 mour. The same thing lakes place, whene- 
 verthe eyeball unfortunately receives a blow, 
 nr is too much compressed by bandages, dur- 
 i g the existence of a recent w r ound of the cor- 
 nea. Also, if the patient should be affected, 
 in this circumstance, with a spasm of the 
 muscles of the eye, with violent and repeat- 
 ed vomiting, or with strong and frequent 
 coughing, a prolapsus of the iris may be 
 caused. When an ulcer of the cornea pene- 
 trates the anterior chamner of the aqueous 
 humour, the same inconvenience happens 
 more frequently, than when there is a recent 
 wound of that membrane ; for, the solution 
 of continuity in the cornea, arising from an 
 ulcer, is attended with loss of substance, 
 and in a membrane, so tense and com- 
 pact as this is, the edges of an ulcer do not 
 admit of being brought into mutual con- 
 tact. 
 
 The little tumour is likewise necessarily 
 of the same colour as the iris, viz. brown, 
 or grayish, being surrounded at its base by 
 an opaque circle of the cornea, on which 
 membrane there is an ulcer, or a wound 
 of not a very recent description. 
 
 As it usually happens, that the cornea is 
 Oidy penetrated at one port of its circumfer- 
 
IRIS. 
 
 135 
 
 ence by a wound, or ulcer, so in practice, 
 only one prolapsus of the iris is commonly 
 met with in the same eye. But if the cor- 
 nea should happen to be wounded, or ul- 
 cerated at several distinct points, the iris 
 may protrude at several different places of 
 the same eye, forming an equal number of 
 small projecting tumours on the surface of 
 the cornea. Scarpa has seen a patient who 
 had three very distinct protrusions ot the 
 iris on the same cornea, m consequence of 
 three separate ulcers penetrating the ante- 
 rior chamber of the aqueous humour; one 
 in the upper, and two in the lower segment 
 of the cornea. 
 
 If, says Scarpa, the delicate structure of 
 the iris ; the great quantity of blood-vessels, 
 which enter it; and the numerous nervous 
 filaments, which proceed to be distributed 
 to it, as a common centre ; Kfe considered, 
 the nature and severity of those symptoms 
 may be readily accounted for, which are 
 wont to attend this disease, however small 
 the portion of the iris projecting from the 
 cornea may be, even if no larger than a 
 fly’s head. The hard and continu 1 frictions 
 to which this delicate membrane is then ex 
 posed, in consequence of the motions of the 
 eyelids; together with the access of air, 
 tears, and gum to it; are causes quite ade- 
 quate to the production of continual irrita- 
 tion ; and the blood which tends to the 
 point of the greatest irritation, cannot fail 
 to render the projecting portion of the iris 
 much larger, almost directly after its pro- 
 trusion, than it was at the moment of its 
 first passing through the cornea. Hence 
 it becomes, soon after the prolapsus, more 
 incarcerated and irritated, than it was at 
 first. In the incipient state of the com- 
 plaint, the patient complains of a pain, simi- 
 lar to what would arige from a pin penetra- 
 ting the eye ; next he begins to experience, 
 at the same time, an oppressive sensation of 
 tightness, or constriction, over the whole 
 eyeballs. Inflammation of the conjunctiva, 
 and eyelids, a burning effusion of tears, and 
 an absolute inability to endure the light, 
 successively take place As the protruded 
 portion of the iris drags after it all the rest 
 of this membrane, the pupil assumes of me- 
 chanical necessity an oval shape, and devi- 
 ates from the centre of the iris, towards the 
 seat of the prolapsus. The intensity of the 
 pain, produced by the inflammation, and 
 other symptoms attendant on the prolapsus 
 of the iris, does not, however, always con- 
 tinue to increase. 
 
 Indeed, in practice, cases of old protru- 
 sions of the iris often occur, where, after 
 the disease has been left to itself, the pain 
 and inflammation spontaneously subside, 
 and the tumour of the iris becomes almost 
 completely insensible. Scarpa met with a 
 man, fifty years of age, who had had a pro- 
 lapsus of the iris in the right eye ten weeks ; 
 it was as large as two grains of millet seed ; 
 the patient bore it with the greatest indiffer- 
 ence, and without any other inconvenience, 
 than a little chronic redness of the conjune- 
 tiva, and a difficulty of moving the eyeball 
 
 freely, in consequence of the friction of the 
 lower eyelid against the tumour formed by 
 the iris. When the extremity of the finger 
 was applied, the little tumour felt hard and 
 callous. 
 
 In the early stage of ibis disease, some 
 direct the iris to be replaced in its proper 
 situation by means of a wnalebone probe ; 
 and in case of difficulty, to make a ddata- 
 tion of the wound, or ulcer of the cornea, 
 by an incision, proportioned to the exigency 
 of the case, as is done for the return of a 
 strangulated intestinal hernia. Others only 
 recommend stimulating tne prolapsed por- 
 tion of the iris with the view 01 making it 
 contract and shrink into the eye ; or sud- 
 denly exposing the eye affected to a very 
 vivid light, in the beliei, that as tiie pupil 
 then forcibly contracts, the piece of the iris, 
 engaged between the lips of the wound, or 
 ulcer of the cornea, will rise to its proper 
 place. How ever, Scarpa represents all such 
 methods as absolutely useless, and even 
 dangerous. Supposing it were possible, by 
 such attempts, to reduce the iris to its pro- 
 per situation, without tearing or injuring 
 it, still the aqueous humour would escape 
 again through the wound, or ulcer of the 
 cornea, so that the iris, when replaced, 
 would fall down the moment afterward, and 
 project from the cornea in the same way as 
 before the operation. Hence, though Scarpa 
 admits that the prolapsus of the iris is a se- 
 rious accident, he argues that as surgery has 
 no means of suppressing at once, or at least, 
 of suspending the escape of the aqueous hu- 
 mour through a wound, much less through 
 an ulcer of the cornea, when either exceeds 
 certain limits, the prolapsus of the iris, far 
 from being an evil in such unfavourable cir- 
 cumstan- es, is rather useful, and. perhaps, 
 the only means of preventing the total loss 
 of the organ of sight , for the flap of the iris 
 insinuates itself, like a plug, between the 
 edges of the wound, or ulcer of the cornea, 
 and thus completely prevents the exit of the 
 aqueous humour. 
 
 Here l ought to observe, that Scarpa's 
 unlimited condemnation of the plan oi ever 
 attempting to replace the iris is contrary to 
 the advice delivered by Beer, as may be 
 seen by referring to the article Cataract , 
 where the treatment of the protrusion of 
 the iris after the operation of extraction is 
 noticed. And even with respect to the pro- 
 lapsus of the iris from ulceration making its 
 way through the cornea, Beer distinctly 
 states, that a recent prolapsus of this kind, 
 formed iu the second still existing stu^e of 
 ophtbalmy, may not only be lessened by 
 proper treatment, calculated to produce a 
 quick cicatrization of the ulcer, but the iris 
 may be again completely removed from tne 
 cornea, w ithout any adhesion to the edge 
 ot the ulcer taking place. (B. 2 ) 
 But w'here the prolapsus of the iris remains, 
 as a consequence of previous inflammation 
 of the eye, Beer confesses that it cannot be 
 cured, without a partial adhesion of the iris 
 to the cornea being left, and a dense scar on 
 
IRIS. 
 
 m 
 
 the latter membrane in the situation of the 
 protruded iris. ( Vol . cit.p. 66.) 
 
 In conformity to Scarpa’s principles, there 
 are two principal indications in the treat- 
 ment of the recent prolapsus of the iris. The 
 first is, to diminish, as speedily as possible, 
 the exquisite sensibility in the protruded 
 part of the iris ; the other is gradually to 
 destroy the projecting portion of this mem- 
 brane to such a depth, as shall be sufficient 
 to prevent the little tumour from keeping the 
 edges of the wound, or ulcer of the cornea 
 asunder, and retarding cicatrization. The 
 adhesion, however, which connects the iris 
 with the iuside of the a eornea, must not be 
 destroyed 
 
 For fulfilling these indications, nothing is 
 more effectual, than touching the portion of 
 the iris projecting from the cornea, with the 
 oxygenated muriate of antimony ( butter oj 
 antimony,) or with what is more expeditious 
 and convenient, the argentum nitratum, so 
 as to form an eschar of sufficient depth. 
 And, in order that this operation may be 
 effected with quickness and precision, it is 
 necessary that an assistant, standing behind 
 the patient’s head, should support the upper 
 eyelid with Pellier’s elevator ; and that the 
 patient should keep his eye steadily fixed 
 on one subject. 
 
 While the assistant gently raises the upper 
 eyelid, the surgeon must depress the lower 
 one, with the index and middle fingers of 
 his left hand ; and with the right, he is to be 
 ready to touch the little prominence formed 
 by the iris, with the argentum nitratum, 
 scraped to a point like a pencil. This is to 
 be applied to the centre of the little tumour, 
 until an eschar of sufficient depth is formed. 
 The pain which the patient experiences at 
 this moment, is very acute ; but, it subsides 
 as soon as the eye is bathed with warm milk. 
 The caustic, in destroying the projecting 
 portion of the iris, destroys the principal 
 organ of sensibility, by covering it with an 
 eschar, of sufficient depth to protect the part 
 affected from the effect of the friction of the 
 eyelids, and from coming into contact with 
 the air and tears. This is the reason, not 
 only why the sense of pricking and con- 
 striction in the eye abates after the applica- 
 tion of the caustic, but also why the inflam- 
 mation of the conjunctiva undergoes a con- 
 siderable diminution, as well as the burning 
 and copious effusion of tears. 
 
 As in the case of ulcer of the cornea, these 
 advantages only last while the eschar re- 
 mains adherent to the little tumour formed 
 by the iris ; when it falls off, as it usually 
 does two or three days after the use of the 
 caustic, all the above-mentioned symptoms 
 are rekindled, with this difference, that they 
 are less intense and acute, than they were 
 previously, and the tumour of the iris is not 
 so prominent as it was before tbs caustic 
 was applied. When these symptoms make 
 their appearance, the surgeon must once 
 more have recourse to the argentum nitratum, 
 with the precautions explained above ; and 
 he is to employ it a third, and even a fourth 
 time, as occasion may rcqhire, until the 
 
 prominent portion of the iris is sufficiently 
 reduced to a level with the edges of the 
 wound, or ulcer of the cornea, and no obsta- 
 cle is left to the granulating process, and 
 complete cicatrization. 
 
 There is a certain period, beyond which 
 the application of caustic to the protruded 
 iris becomes exceedingly dangerous, though 
 at first it may have been highly beneficial : 
 beyond which, the eschar, which previously 
 soot .ed the pain, exasperates it, and repro- 
 duces the inflammation of the conjunctiva 
 in almost as vehement a degree as in the 
 beginning of the disease. This appears to 
 Scarpa to be the case, whenever the sur- 
 geon continues to employ the caustic, after 
 the little tumour of the iris has been destroy- 
 ed to a level with the external edges of the 
 wound, or ulcer of the cornea, and the 
 application begins to destroy the granula- 
 tions just as they are originating. Hence, 
 as soon as tae surgeon perceives, that the 
 part of the iris, projecting from the cornea, 
 is sufficiently lowered, and that the applica- 
 tion of the argentum nitratum, far from 
 allaying, only irritates the disease, he must 
 desist entirely from using the caustic, and be 
 content with introducing between the eye 
 and eyelids, every two hours, the collyrium 
 zinci sulphatis with tlie mucilage of quince- 
 seeds. Every morning and evening, Janin’s 
 ophthalmic ointment, weakened with a 
 double, or triple proportion of lard, is to be 
 applied. If the stimulus of such local reme- 
 dies should not disturb the work of nature, 
 the ulcer gradually diminishes, and heals in 
 the course of a fortnight. 
 
 The adhesion, which the projecting part of 
 the iris contracts to the internal margin of 
 the wound, or ulcer of the cornea, during 
 the treatment, continues the same after the 
 perfection of the external cicatrix, and of 
 course during the rest of the patient’s life. 
 Hence, even afterthe most successful treat- 
 ment of the prolapsus of the iris, the pupil 
 remains a.liltle inclined toward the place of 
 the scar in the cornea, and of an oval figure. 
 1 he change in the situation and shape of the 
 pupil, however, cause* little or no diminution 
 of the patient’s faculty of discerning distinct- 
 ly (he smallest objects; and is much less 
 detrimental to the sight, than one, inexpe- 
 rienced in these matters, might conceive ; 
 provided the scar on the cornea be not too 
 extensive, nor situated exactly in the centre 
 of this membrane. In the first case, the 
 sight is the less obstructed, as the pupil, 
 which, on the first occurrence of the pro- 
 lapsus, was narrow, oblong, and drawn 
 considerably toward the wound, or ulcer, 
 gradually enlarges, and forms a less con- 
 tracted oval. As soon as the wound is 
 completely healed, the pupil tends, in some 
 degree, to occupy its former situation in 
 the centre of the cornea ; a fact, also noti- 
 ced by Richter. 
 
 According to Scarpa, the reeision of the 
 protrusion with scissors can only be practi- 
 sed with success, when the iris has contract- 
 ed a firm adhesion to the internal edge of 
 the wound, or ulcer of the cornea : mu! 
 
IRIS. 
 
 137 
 
 tu ore especially, in that ancient prolapsus 
 of the iris, in which the projecting portion 
 of the iris has become with time almost in- 
 sensible, hard, and callous, with its base 
 strangulated between the edges of the 
 wound, or ulcer of the cornea, and besides 
 being adherent to them, having also a slen- 
 der pedicle. Scarpa indeed has seen an in- 
 carcerated one fall off of itself. 
 
 In such circumstances, the recision of the 
 old prolapsus of the iris is not attended with 
 the least danger ; for, after removing with a 
 stroke of the scissors, that prominent portion 
 of the iris, which has already contracted 
 Internal adhesions to the ulcerated margin 
 of the cornea, so as to reduce it to a level 
 with the external edges of the ulcer, there 
 is no hazard of renewing the effusion of the 
 aqueous humour, or giving an opportunity 
 for another piece of the irisTo be protruded. 
 One or two applications of the argentum 
 nitratum suffice afterward for the produc- 
 tion of granulations on the ulcer of the 
 cornea, and the formation of a cicatrix. 
 But, it is'not so in the treatment of the 
 recent prolapsus of the iris, which has rlo 
 adhesions to the internal edges of the wound, 
 or ulcer of the cornea. 
 
 In four subjects recently affected with 
 prolapsus of the iris, after Scarpa had re- 
 moved, with a pair of convex-edged scissors, 
 a portion of that membrane projecting be- 
 yond the cornea, of about the size of a fly’s 
 head, he found, on the ensuing day, that a 
 new portion of the iris, not less than the 
 iirst, had made its way through the ulcer of 
 the cornea, and that the pupil was very much 
 contracted, and drawn considerably further 
 toward the ulcer of the cornea. These 
 circumstances took place, notwithstanding 
 the wound was touched immediately after- 
 ward with the argentym nitratum- Hence 
 Scarpa apprehends, that if he were ever to 
 divide such a little tumour again, it would 
 reappear, and always with an additional 
 protrusion of the iris, and a further distortion 
 of the pupil. The advantage of caustic in the 
 recent sensible prolapsus of the iris ; and 
 the use of scissors only in old callous cases, 
 agree also with the directions given both by 
 Beer and Mr. Travers. ( Lehre von den 
 
 Augenkr. B. 2. p. 68 ; and Synopsis, p. 280.) 
 
 There is a particular species of prolapsus, 
 much less frequent, indeed, than that of the 
 iris : but, which does oceur, and, in Scarpa’s 
 opinion, is very improperly termed by mo- 
 dern oculists, “ prolapsus of the tunic of the 
 aqueous humour." ( Janirt , Peltier , Guirin, 
 Gleizc , fyc.) INeither do his sentiments upon 
 this subject agree with those of Beer, whose 
 explanation of the nature of the case is 
 given in Vol. I. of this Dictionary. We shall 
 there see, that it is a case, which he terms 
 ceratocele, and which he thinks arises from a 
 yielding of the inner layers of the cornea, in 
 consequence of the outer ones not having 
 united. And, in his second vol. p. 59, he 
 has given a description of the same kind of 
 disease from the support of the outer layers 
 of the cornea being destroyed by ulceration. 
 This is a point, on which the most hxperien- 
 Vor If '18 
 
 ced men differ so much, that it is difficult to 
 reconcile their statements. Dr Vetch seems 
 to have full reliance upon the accuracy of 
 the accounts of a protrusion of the mem- i 
 brane of the aqueous humour. {Treatise on 
 Diseases of the Eye,p. 54, fyc.) Mr. Travers 
 inclines to Beer’s view of the subject, and 
 details reasons for doubting, that the vesicle 
 is a distinct texture : “ its appearance cor- 
 responds accurately to that of the innermost 
 lamella of the cornea.’’ ( Synopsis of the 
 Diseases of the Eye, p. 116.) 
 
 It is, says Scarpa, a transparent vesicle, 
 filled with an aqueous fluid, and composed 
 of a very delicate membrane, projecting 
 from a wound, or uliper of the cornea, much 
 in the same way as the iris does under- 
 similar circumstances. Scarpa has several 
 times seen this transparent vesicle full of 
 water, elongating itself beyond the cornea, 
 shortly after the operation for the extraction 
 of the cataract, and sometimes, also, in con- 
 sequence of an ulcer of the cornea, espe- 
 cially after rescinding a prolapsed portion of 
 the iris. 
 
 The generality of oculists believe that tin's 
 little transparent tumour consists of the deli- 
 cate, elastic, diaphanous membrane, which 
 invests the inner surface of the cornea, and 
 is described by Descemet and Demours. 
 u As soon as the membrane lining the cornea 
 (they say) is exposed by the wound, or ulcer 
 of the latter, and the delicate pellicle can no 
 longer resist the impulse of the humours 
 pressing behind it, it is necessitated to yield 
 gradually, to become elongated, and to pro- 
 ject from the wound, or ulcer of the cornea, 
 exactly in the form of a pellucid vesicle.” 
 
 But, says Scarpa, how remote this theory is 
 from the truth, must be manifest: 1. The 
 delicate and elastic pellicle, described by 
 Descemet and Demours, is not separable by 
 any artifice from the inner surface of the 
 cornea, except near where the cornea and 
 sclerotica unite. Since these protruded 
 vesicles make their appearance in practice 
 at every point of the cornea, and even at 
 its very centre, where Ihe above pellicle is 
 certainly neither separable, nor distinct from 
 the compact texture of the cornea ; it may 
 at least be asserted, that the tunic of the 
 aqueous humour does not in every instance 
 constitute the transparent vesicle in question 
 2. ft is a well-known fact, that this, vesicular, 
 pellucid prolapsus happens more frequently 
 after fbe extraction of the cataract, than any 
 other occasion. In rhis case, since’ the tunic 
 of the aqueous humour has certainly been 
 divided to afford an exit to the crystalline, 
 no one can be of opinion, that the transpa- 
 rent vesicle, which protrudes from the 
 cornea after this operation, ought to h& 
 attributed to the distention and protrusion of 
 the tunic of the aqueous humour. 3. If, in 
 cases of ulcers of the cornea, the transparent 
 vesicle should sometimes appear after the 
 recision of the prolapsus of the iris, it is 
 obvious, that if it consisted of the tunic of 
 the aqueous humour, it ought invariably to 
 appear before the prolapsus of the iris! 
 
 4. Should the surgeon Remove the dfo-truded 
 
 / 
 
IRls. 
 
 138 
 
 vesicle to a level with the cornea by a stroke 
 of the scissors, a small quantity of limpid 
 water is seen to ooze out, at the moment 
 when the incision is made, without any part 
 of the aqueous humour escaping from the 
 anterior chamber. This inconvenience 
 would be inevitable, were the protruded 
 vesicle in question formed by the delicate 
 elastic pellicle, which is said to invest the 
 inrter surface of the cornea. Besides, the 
 little transparent tumour disappears when 
 the incision is made; but often another one 
 exactly similar to what was cut oft', is found 
 in the very same place the following day. 
 Iiad the little transparent tumour been com- 
 posed of the tunic of the aqueous humour, 
 elongated out of the wound, or ulcer of the 
 cornea, it could not at all events have been 
 reproduced at the same part of the Cornea. 
 
 Actuated by such reflections, it is clear to 
 Scarpa, that the pretended prolapsus of the 
 tunic of the aqueous humour is not what it 
 is imagined to be ; but strictly speaking, 
 only a forcible protrusion of a portion of the 
 vitreous humour, which, from too much 
 pressure being made on the eye, either at 
 the time of the operation, or afterward, or 
 from a spagm of the muscles of the eye, in- 
 sinuates itself between the edges of the 
 wound after the extraction of the cataract, 
 and projects in the form of a transparent 
 vesicle. The same thing also happens after 
 ulcers of the cornea, whenever the aqueous 
 humour has escaped, and a portion of the 
 vitreous humour is urged by forcible pres- 
 sure towards the ulcer facing the pupil ; or 
 whenever an elongated piece of the vitre- 
 ous humour ; after the recision of a prolap- 
 sed portion of the iris, passes by a shorter 
 route than through the pupil, between the 
 lips of the ulcer of the cornea. At length, 
 we understand, why in both these instances 
 a transparent vesicle forms, even after the 
 recision of the tunic of the aqueous humour, 
 or ulceration of the cornea ; and w r hy it very 
 often reappears in the same place, though 
 it has been cut away to a level with the cor- 
 nea. It is because one or more cells of the 
 vitreous humour, constituting the transpa- 
 rent vesicle, are succeeded after their re- 
 moval by other cells of the same humour, 
 which glide between the lips of the w ound, 
 or ulcer of the cornea, into the same situa- 
 tion. 
 
 The treatment of this species of prolapsus 
 consists in removing the transparent vesicle, 
 projecting from the wound, or ulcer, by 
 means of a pair of curved scissors with con- 
 vex edges, and bringing the edges of the 
 wound of the cornea immediately afterw ard 
 into perfect apposition, in order that they 
 iHly unite together as exactly as possible. 
 But when there is an ulcer of the cornea, as 
 soon as the vesicle is removed, the sore 
 must be touched with the argentum nitra- 
 tum, so that the eschar may resist any new 
 prolapsus of the vitreous humour, and at the 
 same time dispose the ulcer of the cornea to 
 granulate and heal. 
 
 If, in some particular cases, the vesicle 
 should pot project sufficiently ftom the 
 
 wound, or ulcer oi lire cornea, to be inclu- 
 ded in the scissors, the same object may be 
 accomplished by puncturing the tumour 
 with a lancet, or couching-needle ; for when 
 the limpid fluid which it contains is dis- 
 charged, the membrane forming it shrink? 
 within the edges of the wound, or ulcer of 
 the cprnea, and no longer hinders the union 
 of the former, or the cicatrization of the 
 latter. 
 
 Should the transparent tumour reappear 
 in the same situation, the day after its reci- 
 sion, or puncture, it is right to repeat one 
 of these operations, and to adopt further 
 measures for maintaining the edges of the 
 wound of the cornea in contact ; or if it 
 should be an ulcer, the eschar must be made 
 to adhere more deeply to its bottom and 
 sides, so as toXpnn a greater obstacle to the 
 escape of the vitreous humour. In these 
 circumstanees, the surgeon must take all 
 possible care to obviate such causes as have 
 a tendency to propel the vitreous humour 
 towards the wound, or ulcer of the cornea ; 
 particularly too much pressure on the eye- 
 lids, spasms of the muscles of the eye, cough- 
 ing, sneezing, efforts at stool, and other si- 
 milar ones ; and care must also be taken to 
 check the progress of inflammation. 
 
 The choroid coat is, likewise not exempt 
 from prolapsus. Scarpa has seen this com 
 plaint in M. Bressanini, an apothecary at 
 Bescape. "A small abscess, formed between 
 the sclerotica and choroid coats, at the dis- 
 tance of two lines from the union of the 
 cornea with the sclerotica, in the inferior 
 hemisphere of the globe of the eye, in con- 
 sequence of a severe internal and external 
 ophthalmy, which had been treated in its 
 incipient stale, with repellent remedies. 
 The abscess burst, and discharged a small 
 quantity of thick viscid lymph ; then a small 
 blackish body, composed of the choroid 
 coat, presented itself on the outside of the 
 little ulcer of the sclerotica. The treatment 
 consisted in applying the argentum nitratum 
 several times to the projecting portion of 
 the choroides, until it w r as consumed, and 
 reduced to a level with the bottom of the 
 ulcer of the cornea. The part then healed. 
 The eye remained, however, considerably 
 weakened, and the pupil afterward became 
 nearly closed. Scarpa sulle Principals Ma- 
 latlie degli Occhi. Venezia , 1802. Richter’s 
 Anfangsgmnde der Wvndarzneykunst, B. 3, 
 Von dtm Vorfalle dcr Regenbogenhaut . Pel- 
 lier, Ohs. sur l'(Eil, p. 350. G. J. Beer, 
 Lehre von den Augcnkrardcheitcn, B. 1, § 402, 
 518, and 592, and B. 2. § 58, (32, fyc. 8vo. 
 Wien. 1813 — 1817. J. War dr op, Essays on 
 the Morbid Anatomy of the Human Eye , Vol. 
 2,p.51, 8 vo. Load. 1848. •/. Vetch, A Practi- 
 cal' Treatise on the Diseases of the Eye, p. 53, 
 fyc. Lond. 8 vo. 1820. B. Travers, A Synopsis 
 of the Diseases of the Eye , p. 116, 280, fyc. 
 th'o. Lond. 1820. Weller on J)iseases of the 
 Eye, Transl. by Dr. Monlcaih , 8ro. Glasgow, 
 1821. 
 
 For a description of the manner of divid- 
 ing the iris, order to make *rn rMl'ifin.-d 
 
pupil, when the natural one is closed, rel’er 
 to Pupil, Closure of. 
 
 Iris, Effects of certain narcotics upon , see 
 Belladonna and Cataract. The follow- 
 ing work upon the subject also merits atten- 
 tion. C. Himly de la Paralysie dc V Iris par 
 tine application locale de la Jusquiaume, el de 
 son utililc dans le iraitemenl de plusieurs ma- 
 ladies des Yeux, 2 de Ed. Altona , 1805. 
 
 IRITIS. Inflammation of the iris. See 
 Ophthalmy. 
 
 ISCHU'RIA. (From ta-yje, to restrain ; 
 and agsv, the urine.) A suppression, or stop- 
 page of the urine. 
 
 The distinction between a suppression and 
 retention of urine, is practical and judicious. 
 The former most properly points out a de- 
 fect in the secretion of the kidneys ; the lat- 
 ter, an inability ot expelling the urine when 
 secreted. {Hey.) 
 
 The first disease is not very common, is 
 named ischuria rnialis, or suppression of 
 urine, and belongs to the province of the 
 physician ; the second is an exceedingly 
 frequent disorder, is n a meiVisch uria vesi calls, 
 or retention of urine , and its treatment is al- 
 together surgical. Every thing relative to 
 it will be found in the articles Catheter, and 
 Urine, Retention of. 
 
 ISSUE signifies an ulcer, made designed; 
 ly by the practitioner, and kept open a cer- 
 tain time, or even the patient’s whole life, 
 for the cure, or prevention, of a variety of 
 diseases. 
 
 The physician, in his practice, has frequent 
 occasion to recommend the making of an 
 issue, and the surgeon finds it a principal 
 means of relief in several important cases, 
 as, for instance, the while swelling, the dis- 
 ease of the hip-joint, caries of the vertebra?, 
 &c. Many persons are never in health, 
 or, at least, fancy themselves always ill, un- 
 less they have an issue formed in some part 
 of their body or another. The making of 
 an issue, indeed, is not unfrequently consi- 
 dered as an imitation of nature, who, of her 
 own accord, often forms ulcers and abscesses 
 in various parts of the body (as is not un- 
 commonly conjectured) for the purpose of 
 discharging pernicious humours, whereby 
 people are supposed to be freed from griev- 
 ous disorders, and have their health preserved. 
 The humoral pathologists were excessively 
 partial to these notions, which, at the pre- 
 sent time, will be found by every experi- 
 enced practitioner to influence the mass of 
 mankind, and render the formation of issues 
 more common, than perhaps is consistent 
 with the better established principles of me- 
 dical science. Few oid subjects will allow 
 a sore of long standing to be dried up (as 
 the expression is,) without requiring the 
 surgeon immediately afterward to make tin 
 issue for them. When an ulcer has existed 
 a great length of time, the constitution may 
 possibly become so habituated to it, that 
 the health may really sutler from its being 
 healed. 11 1 have often (says the experien- 
 ced Dr. Parry) seen various thoracic affec- 
 tions, a3 pulmonary consumption, asthma, 
 carditis, or hydrothorax, arise from flic 
 
 spontaneous, or artificial cure of ulcers, per- 
 petual blisters, or fistula?.” {Elements of 
 Pathology, fyc. p. 385.) Asthmatic com- 
 plaints, severe headachs, he. are frequently 
 observed to follow the cicatrization of an 
 oid ulcer; but whether they would have 
 happened, if an issue had been made in 
 time, is a question difficult of positive de- 
 termination ; for many persons with old 
 ulcers are not prevented from suffering 
 from asthma and headach. The plan of 
 making an issue, however, is commendable 
 both as rational and exempt from danger. 
 Whatever may be the solidity of the theo- 
 ries, which have been offered by medical 
 writers, in regard to issues, the practitioner, 
 who has his eyes open, cannot fail to see the 
 benefit often derived from such means ; and 
 if there be any unquestionable facts in me- 
 dicine and surgery, we may confidently set 
 down among them the frequent possibility 
 of relieving one disease by exciting another 
 of a less grievous, and more curable na- 
 ture. 
 
 There are two ways of making an issue ; 
 one is with a lancet, or scalpel; the other 
 with causlic. 
 
 The place for the issue being fixed upon, 
 the surgeon and his assistant are to pinch up 
 a fold of the integuments, and with a lancet 
 or knife, make in them an incision of suffi- 
 cient size to hold a pea, or as many peas as 
 may be thought proper. The pea, or peas 
 are then to be placed in the cut, and cover- 
 ed with a piece of adhesive plaster, a com- 
 press, and bandage. The peas first inserted, 
 need not be removed for three or four days, 
 when suppuration will have begun ; but the 
 issue is afterward to be cleaned and dressed 
 every day, and have fresh peas put into it. 
 The preceding is the ordinary method of 
 making such issues as are intended to con- 
 tain only one or two peas. 
 
 When the issue is to be larger, which is 
 generally proper, in cases of diseased verte 
 bra?, white swellings, he., the best plan is 
 to destroy a portion of the integuments with 
 caustic. The caustic potassa, blended with 
 quicklime, is mostly preferred for this pur- 
 pose. The situation and size of the issue 
 having been determined, the surgeon is to 
 take care that the caustic does not extend 
 its action to the surrounding parts. With 
 this view, he is to take apiece of adhesive 
 plaster, and having cut a hole in it of the 
 exact shape and size of the issue intended 
 to be made, he is to apply it to the part. 
 Thus the plaster will defend the adjacent, 
 skin from the effects of the caustic, while 
 the uncovered portion of integuments, cor- 
 responding to the hole in the plaster, is that 
 which is to be destroyed. The caustic is to 
 be taken hold of with a bit of lint, or tow, 
 and its end, having been, a little moistened 
 with water, is to be steadily rubbed upon 
 the part of the skin where the issue is to be 
 formed. The frictions ore to be continued 
 till the whole surface, intended to be de- 
 stroyed, assumes a darkish corroded appear- 
 ance. The caustic matter may now be care- 
 fully washed off with some wet tow. The 
 
HO JOINTS. 
 
 plaster is to he removed, and a linseed poul- 
 tice applied. As soon as the eschar is de- 
 tached, or any part of it is loose enough to be 
 cut away without pain, or bleeding, the peas 
 are to be inserted and confined in their pro- 
 per place with a piece of adhesive piaster. 
 Some use beans for the purpose ; others, 
 beads, which answer very well, and have 
 the advantage of serving for any length of 
 time, when washed and cleaned every day. 
 If the issue is at all of a longitudinal shape, 
 the peas, beans, or beads, may be more 
 easily kept in their places, when a thread is 
 passed through them. 
 
 Issues ought always to be made, if possible, 
 in a situation, where the peas will not he 
 much disturbed in the ordinary motions of 
 the body, nor interfere with the actions of 
 muscles. The interspaces between the mar- 
 gins and insertions of muscles, are deemed 
 the most eligible places. Thus, issues in the 
 arm are usually made just at the inferior an- 
 gle of the deltoid muscle, by the side of the 
 external edge of the biceps. In the lower 
 extremities, issues are often made at the 
 inner side of the thigh, immediately above 
 the knee, in a cavity that may be readily 
 felt there with the fingers. Sometimes, is- 
 sues are made upon the inside of the leg, 
 just below the knee. For the relief of any 
 affections of the head or eye, the nape of the 
 neck is commonly selected as a good situa- 
 tion. In caries of the vertebras, they are 
 made on each side of the spinous processes. 
 In cases of diseased hips, they are formed in 
 a depression just behind and below the tro- 
 chanter major. When the nature af the dis- 
 
 J 
 
 J OINTS, DISEASES OF. The joints are 
 subject to numerous diseases, which are 
 more or less dangerous, according to their 
 particular nature. Like ail other parts, the 
 joints are liable to inflammation and abscess 
 es ; their capsules frequently become distend- 
 ed with an aqueous secretion, and the disease 
 termed hydrops articuli is produced ; out, 
 the most important of alt their morbid affec- 
 tious, are the cases, which, a few years ago, 
 were indiscriminately called white swellings, 
 scrophulous joints, and the disease of the hip- 
 joint. Here, as Mr. Brodie remarks, the same 
 name has been frequently applied to different 
 diseases, and the same disease has received 
 different appellations. And confusion, with 
 respect to the diagnosis, always gives,. rise to 
 a corresponding confusion, with respect to 
 the employment of remedies. Although, 
 says he, diseases in their advanced stage ex- 
 tend to all the dissimilar parts, of which the 
 joints are composed, such is not the. case in 
 the beginning. Here, as elsewhere, the 
 morbid actions commence, sometimes in one, 
 and sometimes in another texture, differing 
 in their nature, and, of course, requiring to 
 be differently treated, according to the me- 
 uhanical organisation, and vital properties of 
 
 order does not particularly indicate the situa-v 
 tion for the issue, the ami should be preferred 
 to the leg, as issues upon the upper extre- 
 mities, especially the left arm, are much (ess 
 annoying, than upon either of the lower, 
 limbs. 
 
 The great art of keeping an issue open, for 
 a long while, consists in maintaining an equal 
 and effectual pressure upon the peas, by which 
 means, they are confined in their places, little 
 depressions are made for them, and the gra- 
 nulations hindered from rising. Compresses 
 of pasteboard and sheet- iead will often be 
 found highly useful. This plan is the surest 
 one of preventing the issue from healing, and 
 the most likely to save the patient all the 
 severe and repeated suffering, which the fresh 
 application of the caustic, or the use of sti- 
 mulating powders, in order to renew the sore 
 and repress the fungous flesh, unavoidably 
 occasions. 
 
 There is a method of making issues with 
 the caustic made into a sort of paste, which 
 is laid upon the part left uncovered by the 
 adhesive plaster. It seems to me to be u 
 more tedious and painful plan, and I do not 
 recommencLil. 
 
 It has been suspected, that the pain, arising 
 from the caustic, might be lessened, by mix- 
 ing opium with the application ; but, the idea 
 seems not at a!! probable ; the destruction of 
 a part of the skin must inevitably cause con 
 siderable pain, with whatever substance it is 
 produced, and opium itself, so far from being 
 likely to diminish the agony, is itself a violent 
 stimulus, whenever it comes into contact 
 with.lhe exposed extremities of the nerve : . 
 
 the part, in which they originate. (See 
 Pathological and Surgical Ohs. on Diseases of 
 the Joints, p. 2, 8vo Load. 1818.) It was this 
 idea, which led Mr. Brodie to trace, by dis- 
 section the exact parts, in which several of 
 the principal di&eases of the joints commence, 
 and how much light and discrimination his 
 successful investigations have produced, it is 
 needless for me here to insist upon, as his 
 merit will long be appreciated by every sur- 
 geon, who recollects the perplexity and 
 ignorance which prevailed only a few' years 
 ago in this very interesting branch of sur- 
 gery. 
 
 IVounds. — By the wound of a joint, surgeons 
 mean a case, where the capsular ligament 
 is penetrated, or divided. The injury is often 
 accompanied with a division of the lateral., 
 or other ligaments, and sometimes also w ith 
 that ot the cartilages and hones. That the 
 capsular ligament is u'ounded may generally 
 be learned by the introduction of a probe, and 
 frequently by a discharge of a transparent 
 viscid fluid, called the synovia. But, as a 
 similar discharge may proceed from mere 
 wounds of the bursae mucosas, we might form 
 an erroneous judgment, were we unac- 
 quainted with the situation- of thc-so little 
 
JOINTS. 
 
 141 
 
 membranous bags, Boyer has seen several 
 eases, in which a lluid, resembling synovia, 
 was discharged from wounds of the sheaths 
 of tendons. (See Trade des Maladies Chirurg, 
 T. 4, p. 408.) Here, the advice which t have 
 given in another place. (See Wounds of the 
 Abdomen J respecting the temerity of being 
 too officious with the probe, is equally im- 
 portant, inasmuch as the rough introduction 
 of this instrument into a large joint, like the 
 Icnee, would be very likely to excite inflam 
 illation of the synovial membrane, and a train 
 of dangerous and even fatal consequences; 
 while the information, gained by such em- 
 ployment of the probe, is of little use ; be- 
 cause, whenever a wound is suspected to 
 reach into the caps .lar ligament, exactly the 
 same treatment should alwas s be followed, as 
 as if the joint were positively known to be 
 penetrated. 
 
 Notwithstanding simple wounds even of 
 large joints often heal favourably, without 
 any bad symptoms, this is not constantly the 
 case, and the records of surgery furnish many 
 examples, in which the most alarming and 
 fatal consequences ensued. (See' Hunter's 
 Commentaries, Part, 1, p. 69) When pro- 
 perly treated, punctured wounds of the joints 
 , 3 ys Boyer) are not in general attended with 
 danger ; but, as some of these -v ounds, which 
 were apparently quite simple, have bee?: fol- 
 lowed by very bad symptoms, and even death, 
 we should always be extremely circumspect 
 in the prognosis. (See Traill des Mai. Chir. 
 T. 4, p. 409 ) The treatment consist- in 
 endeavouring to heal the injury by the first 
 intention; in applying cold lotions; forbid- 
 ding all motion of the part ; and employing 
 bleeding and other antiphlogistic remedies. 
 
 Baron Boyer relates two cases of punctured 
 wounds of the elbo v joint, which h aied up 
 in a few days, without any unfavourable 
 symptom. He acknowledges, however, that 
 these accidents do not always go on so Well, 
 and that the consequences are sometimes pe- 
 rilous. 
 
 Simple incised wounds present only one 
 indication ; viz. that of healing the part by 
 the first intention. At the moment of the 
 accident, some of the synovia is discharged, 
 indicating that the capsular ligament i- wound- 
 ed. Shouid this circumstance not have been 
 noticed at first, tue surgeon may see the syno- 
 via flow out again, if he move, or press upon 
 the joint. But, in making this examination, 
 the greatest gentleness should be used, lest 
 tbe irritation of the capsular ligament be in- 
 creased. When the wound is large, and there 
 is no considerable thickness of soft parts, the 
 articular surfaces are. exposed to view. 
 
 The prognosis of an incised wound of a 
 joint is not generally unfavourable, when 
 the edges have been immediately brought 
 together, the cavity of the joint has noi been 
 long exposed, arid blood is not extravasated 
 in it. This last danger is also exaggerated, as 
 will be noticed, in speaking of collections of 
 blood in joints. With these exceptions, says 
 Boyer, the wound may heal as readily, as if 
 the joint were not opened, and he has cited 
 several facts in proof of this statement. Tls 
 
 truth is also confirmed by the success which 
 attend? operations, practised for the purpose 
 of extracting cartilaginous substances from 
 the knee. 'Nay very bad cases sometimes 
 recover under judicious management, even 
 thou, h the joint be large, and ab«ce-iSes fol- 
 low. Thus I have seen in St. Bartholomew's 
 hospital, within the last year (1820) two ex- 
 amples of compound fractures oj the patella, 
 where the opening in the capsule was >o large, 
 that the finger could readily lie passed into 
 the cavit) of the joint, yet alter large ab- 
 scesses, a great deal of fever, and separation 
 of none, the patients recovered with stiff 
 joints. But, I would advise surgeon- not to 
 let am facts of this kind prejudice their 
 judgment in the Peatmen* ot gunshot 
 wounds of the large joints, where, in the 
 cireu mtam e- ehew lic e e\p|. lined (see Am- 
 putation and Gunshot Wounds } amputation is 
 the s.itest practice. In a sabie, or cut wound, 
 the principal object is to heal the wound by 
 the first intention. The res' of the treatment 
 consists in using every possible means for the 
 prevention ol inflammation, by perfect quie- 
 tude of the part; the use of cold applica- 
 tions. See. 
 
 We repeat, however, that wounds of the 
 joints do not always heai in (he above favour- 
 able manner. Even among those cases, 
 which appear the most slight and simple, 
 .’here are but too many, which are billowed 
 by such aggravated symptoms, aseither prove 
 fatal, r occasion a necessity for amputation. 
 And. in other instances of a le»s gri- vous 
 description, when the patient is cured, the 
 termination of danger is not without an an- 
 chylosis by which the motion and functions 
 ot tiie joint are permanently destroyed. 
 
 The experienced Mr. Hey has noticed 
 wounds ot tne joints, a id made some perti- 
 nent rem rksou the subject. He states, that 
 in these cases, the utmost care should be 
 taken to prevent i Humiliation. “ Upon this 
 circumstance chiefly depends a successful 
 termination. I have seen (says he) many 
 large wounds of the great joints healed with- 
 out the supervention of any dangerous symp- 
 toms, where due care has been taken to pre- 
 vent inflammation; whilst injuries, apparently 
 trifling, will often be followed by a train of 
 distressing and dangerous consequences, 
 wnere such care has been neglected. It is, 
 generally, easier to prevent inflammation in 
 the joints, after a wound, than to arrest its 
 progress when once begun I speak now of 
 inflammation affecting the capsular ligament. 
 A siigiit degree of redness and tenderness in 
 the integuments only is of little conse- 
 quence; bus, when the capsular ligament 
 becomes inflamed, the formation of abscesses 
 attended vvitu a high degree of lever, and 
 ultimately a stiffness of the joint, are the 
 common consequences, if the life of the pa- 
 tient is preserved.” (See Hep's Practical 
 Observations in Surgery, p. 354, Edit. 2.) 
 
 For facts, in confirmation of the loregoing 
 account, I particularly refer the reader to se- 
 veral cases recorded in this last publication,' 
 p. 355, etseq. and by Boyer . (Traitd des Mat, 
 Chir. T. 4, p. 426, fyc.) 
 
joints. 
 
 142 
 
 When the large joints, particularly the knee, 
 are wounded, the stomach is frequently very 
 much affected. I remember being shown by 
 Mr. Best of Newbury, a man, who. in his oc- 
 cupation as a wheelwright, happened to give 
 himself a wound by whit b one side of the 
 knee was laid open : a good deal <>f inflam- 
 mation and suppuration ensued; but, what 
 particularly struck me, nay the manner in 
 which the tfinn complained of the affection 
 of his stomach. 
 
 in speaking ot cartilaginous substances in 
 t he joints,! shall have occasion to advert again 
 to the danger attendant on wounds of these 
 parts ; and the same fact is still further con- 
 sidered, in the articles .’imputation, Disloca- 
 tions, Fractures, and Gunshot Wounds, in 
 which last part of the D ciionary, tlie senti- 
 ments ot Baron Larrey, and other writers on 
 military surgery, ate laid before the reader. 
 
 Inflammation of Joints, if we exclude from 
 consideration specific cases, may be said 
 usually to be the consequence of a contusion, 
 sprain, wound, or some other kind of injury : 
 out with respect to the inflammation of the 
 synovial membrane, as described by Mr. Bro- 
 die, no cause is so frequent, as the application 
 of cold, and hence he explains the frequency 
 of this disease in the knee, and its rarity in 
 the hip and shoulder, which are covered with 
 a thick mass of flesh. As a late writer ob- 
 serves, the inflammation, arising from a 
 wound, is infinitely the most severe after 
 it has once commenced. ( James on Inflam- 
 mation, p. 157.) 
 
 ihe inflamed joint shows thecommonsymp- 
 toms of inflammation; viz. preternatural 
 redness, increased' heat, throbbing, pain, and 
 swelling, while the constitution is also dis- 
 turbed by the common symptoms of inflam- 
 matory fever, it deserves notice, however, 
 that in these cases, the constitutional symp- 
 toms are often exceedingly severe, and the 
 pulse is more frequent, and less full and 
 ' trong, than when pans, more disposed to 
 return to a stale of health, are affected. The 
 inflammation first attacks some part of the 
 capsular ligament, and very quickly spreads 
 over its whole extent, as usually happens in 
 all inflammations of smooth serous mem- 
 branes. 
 
 The capsules of the joints are naturally not 
 very sensible ; but, like many other parts si- 
 milarly circumstanced, they often become 
 acutely painful, when inflamed. The com- 
 plain! is accompanied with an increased se- 
 cretion ot the synovia, which becomes of a 
 more aqueous, and of a less albuminous qua- 
 lity, than it is in the healthy state. lienee, 
 *itis not so well calculated for lubricating the 
 articular surfaces, and preventing the effects 
 ol friction, as it is in (he natural condition of 
 the joint ; a circumstance, which may ex- 
 plain, why a grating sensation is often per- 
 ceived on making the patella. 
 
 The capsular ligaments, like other parts, 
 are frequently thickened by inflammation, 
 and sometimes, coagulating lymph being 
 effused on their internal surfaces, organized 
 cartilaginous, or osseous bodies, arc formed 
 within the joints. * 
 
 It has been explained by Mr. Brodie, that 
 the usual consequences of inflammation of 
 the synovial membrane, or capsular liga- 
 ment, are ; 1. a preternatural secretion of 
 synovia, 2. an effusion of coagulating 
 lymph into the cavity of the joint. 3. a 
 thickening of the synovial membrane, a con- 
 version of it into a substance rdSembling 
 grisde, and an effusion of coagulable lymph, 
 and probably of serum into the cellular 
 structure, by which it is connected with the 
 external parts. The same gentleman has 
 seen several cases, where, from the appear- 
 ance of the joint, and the symptoms, there 
 was every reason to believe, that the in- 
 flammation had produced adhesions of the 
 reflected fold of the membrane to each 
 other: and, in dissection, he has occasion- 
 ally observed adhesions which might have 
 arisen from inflammation at some former 
 period. u These effects of inflammation of 
 the synovial, very much resemble those of 
 inflammation of the serous membranes. 
 There are, however, some points of differ- 
 ence. In the former, I have reason to be- 
 lieve, that suppuration rarely takes place 
 independently of ulceration ; but, this is u 
 frequent occurrence in the latter. Inflam- 
 mation of the peritonaeum, or pleura, though 
 very slight in degree, and of very short du- 
 ration, terminates in the effusion of coagu 
 lable lymph ; but it is only violent or long- 
 continued inflammation, which has this ter- 
 mination in the membranes of joints ( Bro- 
 die in Med. Chir. Trans. Vol. 4, p. 216.) 
 
 When the inflammation attains a high 
 pitch, an abscess may occur in the capsular 
 ligament, which at length ulcerates, and the 
 pus makes its way beneath the skin, and is, 
 sooner or later, discharged through ulcerated 
 openings. 
 
 An abscess rarely takes place in an im- 
 portant articulation, in consequence of acute 
 inflammation, without the system being also 
 so deranged that life itself is imminently 
 endangered. Severe febrile symptoms 
 always atflict the patient, and occasionally, 
 delirium and coma taking place, death itself 
 ensues. Two rapidly fatal cases of ulcera- 
 tion of the synovia! membrane, where mat- 
 ter had formed within it from a sprain of the 
 hip, and a contusion of the shoulder, are 
 recorded by Mr. Brodie. (See Pathol. Chir. 
 Obs. p. 65 ) 
 
 In these cases, the inflammatory fever is 
 very quickly converted into the hectic; in- 
 deed, when an abscess has taken place in a 
 large joint, in consequence of acute inflam- 
 mation, hectic symptoms almost immedi- 
 ately begin to show themselves, and the 
 strong actions of the common inflammatory 
 fever suddenly subside,; t , « 
 
 Local consequences, even worse than 
 those above described, may follow inflam- 
 mation of a joint. As the layer of the cap- * 
 solar ligament, reflected over the cartilages 
 of the articulation, is often inflamed, the 
 cartilages themselves may Imvc the inflam- 
 mation communicated to them. Parts of a 
 cartilaginous structure, being very incapa- 
 ble of bearing the irritation of disease, often 
 
JOINTS* 
 
 143 
 
 ulcerate, r, hi other words, arc absorbed, 
 so as to leave a portion, or the whole, of 
 the articular surface of the bones, completely 
 denuded of its natural covering. At length 
 the heads of the bones themselves inflame, 
 and become carious; or the consequence 
 may be anchylosis. Mr. Brodie has seen 
 some cases in which there was exten- 
 sive destruction of the cartilages, apparently 
 in consequence of neglected inflammation 
 of the synovial membrane ; but he believes, 
 that in most cases where ulceration of the 
 cartilage is combined with such inflamma- 
 tion, the former is the primary affection, 
 and the latter takes place subsequently, in 
 consequence of the formation of an abscess 
 within the joint ( Pathol . and Surg. Obs. 
 
 fyc.p. 17.) According to Mr. Brodie, who 
 speaks chiefly of the inflammation which 
 begins in the synovial membrane itself, and 
 is not communicated to it from other tex- 
 tures, the disease very seldom attacks young 
 children, but is frequent in adult persons, 
 the reverse of what happens in some other 
 diseases of the joints. 
 
 The inflammation of the capsular liga- 
 ment, or synovial membrane, frequently 
 assumes the chronic form, and is then very 
 often confounded with other more serious 
 maladies, under the general appellation of 
 white swelling. The disease often arises 
 from cold, and hence is more common in 
 the knee and ankle than in the hip or 
 shoulder. It may also arise from the immo- 
 derate use of mercury, and, in particular 
 constitutions, from rheumatism and general 
 debility of the system. In these instances 
 it often leaves one joint and attacks ano- 
 ther ; and it is less severe, and less disposed 
 to produce effusion of coagulating lymph, 
 or a thickened state of the membrane, than 
 when it is apparently a local disease. (Bro- 
 die, in Med. Chir. Trans. Vol. 4. p. 218.) In 
 the latter case the disorder is more likely to 
 assume a severe character, and may be of 
 long duration, leaving the joint with its 
 functions more or less impaired* and occa- 
 sionally terminating in its total destruction. 
 The following are the chief symptoms of 
 the complaint, pointed out by Mr. Brodie. 
 At first, although some pain is felt over the 
 whole joint, the patient refers it principally 
 to one spot, and it is not at its height be- 
 fore the end of a week or ten days. Some- 
 times, even at this period, the pain is trifling, 
 but sometimes it is considerable, and every 
 motion of the joint is distressing. In a day 
 or two after the commencement of the pain, 
 the joint is affected with swelling, which at 
 first arises entirely from a collection of 
 fluid in its cavity, and, in the superficial 
 joints, an undulation may be distinguished. 
 However, after the inflammation has pre- 
 vailed some time, the fluid is rendered less 
 j perceptible, either in consequence of the 
 • synovial membrane being thickened, or the 
 effusion of lymph ; and the more solid the 
 swelling is, the more is the mobility of the 
 I joint impaired. The form of the diseased 
 j| joint does not correspond to that of the 
 | brads of the bones ; but, as the swelling is 
 
 chiefly caused by the distention of the syno- 
 vial membrane, u its figure depends in a 
 great measure on the situation of the liga- 
 ments and tendons, which resist it -in certain 
 directions, and allow it to take place in 
 others. Thus, when the knee is affected, 
 the 3" ellingis principally observable on the 
 anterior and lower part of the thigh,” where 
 there is only a yielding cellular structure 
 between the extensor muscles and the bone. 
 
 “ It is also often considerable in the spaces, 
 between the ligament of the patella and the 
 lateral ligaments, because at these points 
 the fatty substance is propelled outward by 
 the collection of fluid. In the elbow, the 
 swelling occurs principally above the ole- 
 cranon, under the extensor muscles of the 
 forearm ; and in the ankle, it is between 
 the lateral ligaments and the tendons in 
 front of the joint. In the hip and shoulder, 
 where the disease is less frequent, the fluid 
 cannot be felt, but the swelling is percepti- 
 ble through the muscles. In the beginning 
 of this disease in the hip, a fulness both in 
 the groin and nates may be remarked ; but 
 afterward the nates become flattened, and 
 the glutaei wasted from want of use. The 
 pain is usually confined to the hip. but Mr. 
 Brodie has seen cases in which it was also 
 referred .to the knee. It may be discrimina- 
 ted from the case in which the cartilages of 
 the hip are ulcerated, by observing, that the 
 pain is more severe in the beginning than in 
 the advanced stage of the disease ; it never 
 amounts to the excruciating sensation felt 
 in the other disease ; and it is aggravated by- 
 motion, but not by pressing the cartilagi- 
 nous surfaces against each other. The 
 wasting of the glutaei is also preceded by a 
 fulness of the nates. After the inflammation 
 has subsided, the fluid is absorbed, and the 
 joint frequently regains its natural figure 
 and mobility; but, in the majority of cases, 
 stiffness and swelling remain, and the pa- 
 tient continues very liable to relapse, the 
 pain returning, and the swelling being aug- 
 mented, whenever the patient exposes him- 
 self to cold, or exercises the limb a great 
 deal. In cases where the synovial mem- 
 brane is thickened, a slow kind of inflam- 
 mation sometimes continues in the part, 
 notwithstanding the fluid has been absorbed, 
 and the principal swelling has subsided, the 
 disease at length extending to the cartilages, 
 suppuration taking place, and the articular 
 surfaces being completely destroyed. Ac- 
 cording to Mr. Brodie, in this advanced 
 stage, the history of the disease, and not its 
 present appearance, is the only thing by 
 which one can learn whether the primary 
 affection was inflammation of the synovial 
 membrane, or ulceration of the cartilages. 
 Though such is the most common character 
 of inflammation of the synovial membrane, 
 it is admitted, that its nature is sometimes 
 more acute, exhibiting the symptoms men- 
 tioned at the beginning of this section. (See 
 Brodie' s Pathol, and Surg. Obs. p. 21, fyc.') 
 It is remarked by Mr. Wilson, that, when 
 coagulable lymph is effused, the whole of k 
 docs not always adhere to the inflamed 
 
JOINTS'. 
 
 344 
 
 face, but some of it forms flakes which float 
 in the fluid within the joint in masses large 
 enough to be sometimes felt through the 
 capsular ligament. In other instances, the 
 lymph becomes solid, adheres to the inside 
 of the synovial membrane, and becomes 
 vascular. The surface of this adventitious 
 coating is sometimes smooth ; but, occa- 
 sionally, it forms thick projecting masses, 
 of different degrees of thickness and length, 
 and so numerous as to conceal every part of 
 the original smooth surface of the synovial 
 membrane, as exemplified in a preparation 
 in Windmill-street. (On the Skdeton and 
 Diseases of Bones and Joints, p. 319.) 
 
 When inflammation of the synovial mem- 
 brane has arisen from a protracted or ill- 
 conducted course of mercury, Mr. Brodie 
 recommends a trial of sarsaparilla ; and 
 when the disorder is connected with rheu- 
 matism, the medicines advised are opium 
 with diaphoretics, preparations of colchi- 
 eum autumnale, and other usual remedies 
 for rheumatic complaints. In some instan- 
 ces, however, in which several joints were 
 affected, this gentleman has known benefit 
 derived from moderate doses of mercury, 
 ( p . 31.) But whether the disease be local, 
 or dependent on the state of the constitu- 
 tion, Mr. Brodie considers topical remedies 
 of most importance. 
 
 It will considerably shorten what we have 
 to say concerning the treatment of inflamed 
 joints, to observe, that, in the acute form of 
 inflammation of the synovial membrane, the 
 antiphlogistic plan, in the full sense of the 
 expression, is to be strictly adopted. But, 
 as there is a variety of means often, adapted 
 to the same purpose, it seems necessary 
 to offer a few remarks on those which 
 Jay the greatest claim to our commendations. 
 
 There are few other surgical cases in 
 which general, and especially topical, bleed- 
 ing is more strongly indicated. The vio- 
 lence of the inflammation, and the strength, 
 age, and pulse of the patient, must deter- 
 mine with regard to the use of the lancet ; 
 but the application of leeches may be said 
 to be invariably proper. When the leeches 
 fall off, the bleeding is to be promoted by 
 fomenting the part. The surgeon should 
 daily persist in this practice, until the acute 
 stage of the inflammation has subsided. As 
 Mr. Brodie observes, attention should also 
 be paid to the state of the bowels, and 
 saline draughts and diaphoretic medicines 
 be exhibited. ( Pathol . and Surgical Obs. p. 
 32.) In conjunction with this treatment, the 
 iotio plumbi acetatis must be employed. 
 
 In a few instances, however, the patient 
 seems to derive more ease and benefit from 
 the employment of fomentations and emol- 
 lient poultices, which, according to Mr. 
 Brodie, is the case when the swelling has 
 been produced rapidly, and is attended with 
 considerable tension. But, on this point, as 
 I have remarked in speaking of Inflamma- 
 tion, the feelings of the afflicted should 
 always be consulted ; for, if the pain be ma- 
 terially alleviated bv this or that application, 
 pc employment will hardly ever be wrong 
 
 Nothing more need be said concerning 
 the rest of the treatment, proper during 
 the vehemence of the inflammation, as the 
 duty of the surgeon is not materially differ- 
 ent from what it is in other inflammatory 
 cases. 
 
 As soon as the acute stage of the affection 
 has subsided, the grand object is to remove 
 the effects which have been left. These 
 are a thickened state of the capsular liga- 
 ment, and parts surrounding the articu- 
 lation ; a stiffness of the joint, and pain 
 when it is moved ; fluid in the capsule, &c. 
 
 At first, as Mr. Brodie has observed, the 
 joint should he kept perfectly quiet, and 
 blood should be several times taken from the 
 part, by means of leeches and cupping. The 
 latter is the method to which the preceding 
 writer expresses the preference. The use of 
 cold evaporating lotions is also to be con- 
 tinued until the inflammation has further 
 abated, when a blister may be applied, and. 
 kept open with the savin cerate, or a repeti- 
 tion of blisters kept up, as preferred by Mr 
 Brodie. “ l he blisters (he says) should be 
 of considerable size ; and if the joint be 
 deep-seated, they may be applied as near to 
 it as possible; but, otherwise, at a little dis- 
 tance. Thus, when the synovial membrane 
 of the hip is affected, they may be placed on 
 the groin and nates ; but, when that of the 
 wrist is inflamed, they should be applied to 
 the lower part of the forearm. Mr. Brodie 
 thinks blisters have more effect than any 
 other means, in removing the swelling ; but, 
 excepting in very slight cases, he very 
 rightly condemns their use, unpreceded by 
 the abstraction of blood. After the subsi- 
 dence of the inflammation, moderate exer- 
 cise of the joint, and stimulating liniments 
 are recommended. The camphor liniment 
 is to be strengthened with the addition of 
 liquor ammonia?. or tinctura lyttm, or thf 
 following formula, adopted as that to which 
 the above gentleman seems to give the pre- 
 ference. p,. Olei olivae ^rss. acid, sulpli. 3 s ?- 
 M. He speaks also favourably of the effects 
 of the antimonial ointment, in the proportion 
 of 3j. of the antim. tart, to gj. ung. cetacei. 
 Plasters of gum ammoniac'' he regards a> 
 sometimes useful in preventing relapsus. 
 Issues and setons are never serviceable, un- 
 less ulceration of the cartilages has begun. 
 For the removal of the remains of the swell- 
 ing and stiffness, Mr. Brodie joins other 
 writers in praising the efficacy of friction 
 and exercise. The friction may he made 
 with camphorated mercurial ointment, or 
 with powdered starch ; but the friction is to 
 be employed with caution, as otherwise it 
 may produce a return of the inflammation. 
 When this happens, it is to be discontinued, 
 and blood taken from the part. On the 
 whole, Mr. Brodie appears to consider fric- 
 tion better adopted to cases, where the stiff- 
 ness depends upon the state of the external 
 parts, than in others, where it arises from 
 disease in the joint itself. With respect to 
 the plan of allowing a column of warm wa - 
 ter to fall on the part, as suggested by Lo 
 T'rau, and practiced «t. the v'atermg-plucr?. 
 
JOINTS. 
 
 146 
 
 he allows, that it is beneficial, but that it rc- 
 quires the same caution as the employment 
 of friction. {Pathol, and Surg. Obs.p. 30, tyc.) 
 
 1 have met with several instances, in which 
 lotions, composed of vinegar and muriate ot 
 ammonia, sufficed for the removal of the 
 chronic complaints, left after the acute stage 
 of the disorder. 
 
 The severity of the constitutional symp- 
 toms is mostly, if not always, greater, when 
 the inflammation of a large joint arises from 
 a wound, than when it is the consequence 
 of a bruise or sprain. 
 
 Loose cartilages in joints . — Hard, roundish, 
 or flattened bodies, mostly of a cartilaginous 
 nature, are sometimes formed within the cap- 
 sular ligaments, occasioning more or less 
 pain in the affected joints, and a considera- 
 ble impediment to the freedom of their 
 movements. The disorder, though not no- 
 ticed by any of the very ancient writers, is 
 far from being uncommon. Pare is the first 
 who speaks of it : he says, that a hard, polish- 
 ed, xokite body, of the size of an almond , was 
 discharged from the knee of a patient, in the 
 year 1558, in which be had made an inci- 
 sion for an aqueous aposlume, (without doubt 
 an hydrops articuli.) {Lie. 25, chap. 15, p. 
 772.) A hundred and thirty-three years 
 afterward, viz. in 1691, Pechtin published 
 the full details of another case, in which a 
 cartilaginous body was successfully extracted 
 from the knee. ( Observat . Physico-Med. 
 Obs. 38, p. 306.) Dr. Alexander Monro in 
 1726, dissected the knee-joint of a woman, 
 who had been hung, and found in the articu- 
 lation a cartilaginous body, of the shape and 
 size of a small bean. These were the only 
 examples of the disease known before the 
 year 1736, at which period Mr. Simson cut 
 out of the knee a similar substance, which 
 he supposed at the time of the operation 
 was only beneath the skin. (See Edinb. 
 Med Essays, Vol. 4.) 
 
 Since the publication of this last case, the 
 disease has been several times met with in 
 England by Bromfield, Hewit, Middleton, 
 Gooch, Ford, Home, Bell, Aberneihy, &sc. ; 
 in Germany, by Henckel, Theden, Loeffler, 
 &c. ; and in France by Desault, Sabatier, 
 and many , other practitioners. Hence, as 
 Boyer remarks, this disorder is now as well 
 known, as most others, to which the joints 
 are subject. (Traitc des Mai. Chir. T. 4, p. 
 434.) 
 
 Such detached and moveable cartilages 
 are not peculiar to the knee, as they occur 
 in other joints ; yet they are most frequently 
 met with in the knee, and it is in this joint 
 that they produce symptoms, which render 
 them the object of a chirurgical operation. 
 Morgagni and B. Bell met with them in the 
 ankle ; Haller in the joint of the jaw ; and 
 Hey in the elbow. 
 
 According to Sir Everard Home, these 
 substances are analogous in their structure to 
 hone j but in their external appearance, (hey 
 bear a greater resemblance to cartilage. 
 They are not., however, always exactly of 
 ■ he same structure, being in some instances 
 Vol. II, i y 
 
 softer than in others. Their external sur- 
 face is smooth and polished, and, being lu- 
 bricated by the synovia, allows them to be 
 moved readily from one part of the joint to 
 another. They seldom remain long at rest, 
 while the limb is in motion ; and when they 
 happen to be in situations where they are 
 pressed upon with force by the different 
 parts of the joint, they occasion considera- 
 ble pain, and materially interfere with its 
 necessary motions. 
 
 The circumstance of their being loose, 
 and having no visible' attachment, made it 
 difficult to offer good conjectures respecting 
 their formation ; and, according to Sir E. 
 Home, no satisfactory account of their 
 origin had been given, when Mr. Hunter 
 made his observations. In the course of his 
 experiments, instituted with a view to esta- 
 blish a living principle in the blood, Mr. 
 Hunter was naturally induced to attend to 
 the phenomena, which took place, when 
 that fluid was exlravasated, whether in con- 
 sequence of accidental violence, or other 
 circumstances. The first change he found 
 to be coagulation ; and the coagulum thus 
 formed, if in contact with living parts, did 
 not produce an irritation similar lo ex- 
 traneous matter, nor was it absorbed and 
 taken back into the constitution, but in 
 many instances preserved its living princi- 
 ple. and became vascular, receiving brandi- 
 es from the neighbouring blood-vessels for 
 itssupport; it afterward underwent changes, 
 rendering it similar to the parts to which it 
 was attached, and which supplied it with 
 nourishment. When a coagulum adhered 
 to a surface, which varied its position, the 
 attachment was rendered in some instances 
 pendulous, and in others it was entirely 
 broken. 
 
 Hence, it was easy to explain the mode, 
 in which those pendulous bodies are formed, 
 which are sometimes attached to the inside 
 of circumscribed cavities, and the principle 
 being established, it became equally easy 
 for Mr. Hunter, to apply it under other cir- 
 cumstances, since it is evident from a known 
 law in the animal economy, that extravasa- 
 ted blood, when rendered an organized part 
 of the body, can assume the nature of the 
 parts into which it is effused, and conse- 
 quently, the same coagulum, which, in an- 
 other situation might form a soft tumour, 
 would when situated on a bone, or in tlm 
 neighbourhood of bone, often form a hard 
 one. The cartilages, found in the knee- 
 joint, therefore, appeared to him to originate, 
 from a deposit of coagulated blood upon the 
 end of one of the bones, which had ac- 
 quired the nature of cartilage, and had 
 afterward been separated. This opinion 
 was further confirmed by the examination of 
 joints which had been violently strained, or 
 otherwise injured, where the patients had 
 died at different periods after the accident. 
 In some of these cases, there were small 
 projecting parts, preternatu rally formed, as 
 hard as cartilage, and so situated, as to bo 
 readily knocked off' by any sudden or 
 violent, motion of the joint. (Trans, for the 
 
146 JOINTS. 
 
 Improvement of Med. and Chir. Knowledge, 
 Vol. 1 .) 
 
 Mr. Brodie met with two cases, however, 
 in which the loose bodies were of a different 
 nature, and had a different origin from that 
 referred to by Sir. E. Home. Sometimes 
 disease causes a bony ridge to be formed, 
 like a small exostosis, round the margin of 
 the cartilaginous surfaces of the joint. In 
 the two examples alluded to, this preterna- 
 tural growth of bone had taken place, and in 
 consequence of the motion of the parts, 
 portions of it had been broken off, and lay 
 loose in the cavity of the joint. ( Brodie in 
 Med. and Chir. Trans. Vol. 4 p. 276.) And, 
 in a more recent publication, he remarks, 
 that, in the majority of cases, which he has 
 met with, no inflammation preceded the 
 formation of these preternatural substances, 
 and, therefore, he thinks it probable, that, in 
 some instances, they are generated, like 
 other tumours, by some different process. 
 He further observes, that they appear to be 
 situated originally either on the external sur- 
 face or in the substance of the synovial 
 membrane, since, before they become de- 
 tached, a thin layer of the latter may be 
 traced over them. ( Pathological and Sur- 
 gical Obs. p. 298.) 
 
 One or more of these preternatural bodies 
 may be formed in the same joint. Sir E. 
 Home mentions one instance, in which there 
 were three ; they are commonly about the 
 size of a horsebean, often much smaller, 
 and sometimes considerably larger ; when 
 very large, they do not give so much trouble 
 to the patient as the smaller kind. A sol- 
 dier of the 56th regiment had one nearly as 
 big as the patella, which occasioned little 
 uneasiness, being too large to insinuate it- 
 self into the moving parts of the joint. 
 Morgagni saw twenty-live in the left knee of 
 an old woman, who died of apoplexy ; and 
 Haller met with no less than twenty in the 
 articulation of the lower jaw. When there 
 are several in the same joint, it is observed, 
 that their size is generally small. (Boyer, 
 Traitd des Mai. Chir. T. 4, p. 436.) 
 
 The diagnosis of this disease, as Boyer 
 observes, is seldom attended with any diffi- 
 culty. When the formation of the extrane- 
 ous substances follows a fall, or blow upon 
 the joint, the complaint begins with a swell- 
 ing of the surrounding soft parts, and upon 
 the subsidence of this swelling, which lasts 
 for a time more or less long, the presence 
 of the little cartilaginous tumours is indica- 
 ted by certain symptoms which are peculiar 
 to them. In persons who have had no blow, 
 nor fall upon the knee, the disease some- 
 times commences with a more or less acute 
 pain in the joint, with or without swelling of 
 the surrounding soft parts, and which affec- 
 tion is usually regarded as rheumatism. To 
 these first symptoms, which are common 
 both to cases of foreign bodies in the joints, 
 and other diseases of these parts, are soon 
 added other particular signs, by which the 
 nature of the case is evinced. 
 
 As the extraneous bodies are in general 
 free and moveable in the joint, they can 
 
 easily be made to slip about from one part 
 of ihe articulation to another: a circum- 
 stance, which is facilitated by the smooth- 
 ness of their surface, as well as by the syno- 
 via, which is mostly in larger quantity than 
 natural. According to the situation, which 
 they happen to occupy, sometimes they 
 produce acute pain ; sometimes no pain 
 whatever. When they lodge in a depression, 
 where they are not compressed, they cause 
 no pain ; and if they could be always kept 
 in this position, their presence would not be 
 likely to excite any inconveniences. But, 
 when they get between the articular sur- 
 faces which in certain postures of the limb 
 come into contact with each other, the fol- 
 lowing are the effects of the compression. 
 Sometimes, the extraneous substance sud- 
 denly glides between the condyles of the 
 thigh bone and head of the tibia, and while it 
 lodges there, excites acute pain in certain 
 directions of the limb, and instantaneous loss 
 of the power of moving the knee. But, 
 when it shifts its place again, either naturally, 
 or accidentally, during an examination of the 
 affected part, the compression is removed, 
 the pain all at once ceases, and the functions 
 of the joint are as suddenly restored. Most 
 frequently, when the extraneous body gets 
 behind the patella, or the ligament of the pa- 
 tella, as the patient is walking, he is com- 
 pelled to make a sudden stop, and would 
 fall down from the acuteness of the pain, if 
 nothing were at hand to save him. Some 
 patients have been observed, however. who 
 experienced no pain in these circumstances. 
 Reimarus mentions a man, who suffered 
 great pain, and could not move his leg, when 
 the extraneous body was at the side of the 
 joint ; but was immediately relieved by push- 
 ing it under the patella. B. Bell met with 
 cases, in Which the pain was so violent at 
 the instant when the patients put their legs 
 in certain postures, that fainting was brought 
 on, and they wen- so afraid of a return of the 
 suffering, that they preferred remaining per- 
 fectly quiet to running any risk of causing 
 the pain again. He even asserts, that he 
 had known some persons, in whom the least 
 motion of the limb would cause such pain as 
 awoke them out of the deepest sleep. The 
 pain, excited by the situation of the extrane- 
 ous body betwixt the articular surfaces, re- 
 curs at intervals more or less long, and 
 always in consequence of some motion, or 
 exertion Sometimes it ceases directly by 
 the effect of a movement, contrary to that 
 which produced it ; but most frequently it 
 continues, and then the surrounding soft parts 
 are affected with swelling, which obliges 
 the patient to keep his bed, and have re- 
 course to emollient anodyne applications. 
 Sometimes, as I have already noticed, the 
 foreign body lies at a part of the joint, , 
 where it causes no inconvenience, and 
 makes no pressure on the articular surfaces. 
 In this case, all the symptoms have been 
 known to cease for several months, so that 
 the patient imagined himself cured, when 
 suddenly, the foreign body was urged by 
 some effort into another situation, where if 
 
JOINTS. 
 
 147 
 
 occasioned a renewal of all the former 
 pain. 
 
 The foregoing circumstances afford strong 
 presumptive evidence of the presence of ex- 
 traneous cartilaginous substances in the 
 joint ; but, they do not amount to certainty ; 
 this can only be acquired by the touch. In 
 handling the knee of the patient, the surgeon 
 feels a hard, prominent substance, which 
 slips about under his fingers, and glides under 
 the patella, or the ligament of this bone, and 
 sometimes under the tendon of the extensor 
 muscles of the leg, from one side of the 
 joint to the other. The extraneous body 
 may make its appearance either at the inside 
 or the outside of the articulation ; but, it 
 most frequently presents itself at the former 
 part, which is the broadest and most sloping, 
 while the capsular ligament there is loosest. 
 Desault met with one instance, in which the 
 capsular ligament and soft parts were so 
 loose, that the patient could turn the extra- 
 neous substance round and round. 
 
 In general, the complaint is not danger- 
 ous ; but, as it is painful, and obstructs, or 
 often prevents walking ; and usually can be 
 cured only by an operation, which has some- 
 times had fatal consequences ; we cannot 
 be too much upon our guard in delivering a 
 prognosis. 
 
 It 4s only in the knee, that the disease ever 
 becomes so troublesome as to require an ope- 
 ration, or, indeed, any surgical treatment. 
 
 If we except making an incision into the 
 joint, for the purpose of extracting the carti- 
 laginous tumours, we are not acquainted 
 with any certain means of freeing a patient 
 from the inconvenience of the complaint. 
 To this plan, the danger attendant on all 
 wounds of so large an articulation as the 
 knee, is a very serious objection. Middleton 
 and Gooch endeavoured to conduct the 
 extraneous body into a situation, where it 
 produced no pain, and to retain it in that 
 position a long time by bandages, under the 
 idea, that the cartilaginous substance would 
 adhere to the contiguous parts, and occasion 
 no future trouble. Some will be inclined to 
 think, that no positive conclusion ought to 
 be drawn from the cases brought forward by 
 these gentlemen, because they had no op- 
 portunity of seeing their patients again at 
 the end of a reasonable length of time, and 
 we know, that loose cartilages in the joints 
 sometimes disappear for half a year, and 
 then make their appearance again. Yet, 
 perhaps, the very circumstance of the pa- 
 tients not applying again, may justify the 
 inference, that sufficient relief had been ob- 
 tained. 
 
 However, it should not be concealed, 
 that this method was also tried in St. George’s 
 Hospital without benefit, and that in one 
 case, the pain was increased by it. (See 
 lieimarus de Fungo Jlrticulorum, § 27, 54, 
 §'C-) 
 
 Mr. Hey, aware of the dangerous symp- 
 toms, which have occasionally resulted from 
 the most simple wounds penetrating the 
 knee-joint, was induced to try the efficacy 
 of a laced knee-cap. and the cases, which 
 
 he has adduced, clearly demonstrate, that 
 the benefit thus obtained, is not temporary, 
 at least, as long as the patient continues to 
 wear the bandage. In one case, the method 
 had been tried for ten years, with all the 
 success which the patient could desire. 
 Boyer also made one patient use a knee-cap 
 for a year ; after which it was left off, the 
 patient appearing cured. And, in a second 
 instance, the same practitioner tried the 
 plan, which put a stop to the pain, and 
 enabled the patient to walk with ease; but 
 it was not known whether the method was 
 properly continued, as the patient had not 
 latterlv been seen. {Boyer, Traiti des Mai. 
 C/iir. T. 4, p. 444.) 
 
 Contemplating the evidence upon this 
 point, and the perilous symptoms, sometimes 
 following wounds of the knee-joint, I am 
 decidedly of opinion, that the effect of a 
 knee-cap, or of arollerand compress, applied 
 over the loose cartilage, ought generally 
 to be tried, before having recourse to exci- 
 sion. I say generally, because the conduct 
 of the surgeon ought, in such cases, to be 
 adapted to the condition and inclination of 
 the patient. If a man be deprived of his 
 livelihood, by not beingable to use his knee ; 
 if he cannot, or will not take the trouble of 
 wearing a bandage ; if he be urgently de- 
 sirous of running the risk of the operation 
 after things have been impartially explained 
 to him ; if a bandage should not be produc- 
 tive of sufficient relief ; and lastly, if exces- 
 sive pain, severe inflammation of the joint, 
 a great deal of symptomatic fever, and 
 lameness, should frequently be produced by 
 the complaint, (See Brodie's Pathological 
 and Surg. Obs p 299,) I think it is the duty 
 of a surgeon to operate. It is very certain, 
 that success has generally attended the ope- 
 ration ; but, small as the chance is of losing 
 the limb, and even life, in the attempt to get 
 rid of the disease, since the inconveniences 
 of the complaint are, in most cases, very 
 bearable, and are even capable of palliation 
 by means of a bandage, endangering the 
 limb and life in any’’ degree, must seem to 
 many persons contrary to the dictates of 
 prudence. At all events, we must agree 
 with Boyer, that, as a laced knee-cap can do 
 no harm, we ought always to make trial of 
 it, and never perform the operation, ex- 
 cept when pressure does not answer, and 
 the return of frequent and violent pain 
 makes the employment of the knife necessa- 
 ry. (See Traiti des Mai. Chir. T. 4, p. 445.) 
 
 I am ready to allow, with M. Brochier, 
 that the danger attendant on wounds of the 
 large joints, has always been exaggerated in 
 consequence of ancient prejudices. ( De- 
 sault's Journ. Vol. 2.) But, making every 
 allowance for the influence of prejudice, a 
 man must be very sceptical indeed, who 
 does not consider the wound of so large a 
 joint as the knee, attended with real cause 
 for the apprehension of danger. See Case 
 2, in my Treatise on the Diseases of the Joints. 
 At the end of Mr. Ford’s case, (Med. Obs, 
 and Inquiries , Pol. 5.) we read on the subject 
 of cutting loose cartilages out of the knee : 
 
148 
 
 joints. 
 
 t: The society have been informed of several 
 cases, in which the operation has been per- 
 formed ; some, like this, have healed up 
 without any trouble ; others have been fol- 
 lowed by violent inflammation, fever, and 
 death itself.” The history of a case has 
 lately been published, in which the patient 
 very nearly lost his life from suppuration in 
 the knee-joint after this operation. (See 
 Kirby's Cases , p. 76.) in the same work, 
 reference is also made to two other cases, 
 which actually had a fatal termination ; (p. 
 82:) and even in Mr. Kirby’s own instance, 
 the recovery was not effected, without the 
 entire loss of the motions of the knee. 
 
 As the disorder is often attended with a 
 degree of heat and tenderness in the articula- 
 tion ; as the danger of the operation is, in a 
 great measure, proportioned to the subsequent 
 inflammation ; and, as much of the danger 
 is at once removed, if the wound unite by 
 the first intention ; the advice to keep the 
 patient in bed a few days before operating, 
 to apply leeches and cold saturnine lotions 
 to the knee during the same time, and to 
 exhibit beforehand a saline purgative, is 
 highly prudent. 
 
 I shall next introduce an account of the 
 plan of operating, as described by several 
 of the best modern surgeons. 
 
 “ As these loose bodies cannot always be 
 found, no time canbe fixed for the operation ; 
 but the patient, who will soon become 
 familiar with his own complaint, must arrest 
 them when in a favourable situation, and 
 retain them there till the surgeon can be sent 
 for. 
 
 “ Before the operation, the limb should 
 be extended upon a table in an horizontal 
 position, and secured by means of assistants ; 
 the loose cartilages are to be pushed into 
 the upper part of the joint above the patella, 
 and then to one side ; the inner side is to be 
 preferred, as in that situation only the vastus 
 mternus muscle will be divided in the ope- 
 ration. Should there be several of these 
 bodies, they must be all secured, or the ope- 
 ration should be postponed till some more 
 favourable opportunity, since the leaving of 
 one will subject the patient to the repetition 
 of an operation, not only painful, but 
 attended with some degree of danger. 
 
 “ The loose bodies are to be secured in 
 the situation above-mentioned by an assis- 
 tant, a task not easily performed while they 
 are cut upon, from their being lubricated by 
 the synovia ; and if allowed to escape into 
 the general cavity, they may not readily, if 
 at all, be brought back into the same situa- 
 tion. 
 
 “ The operation consists in making an 
 incision upon the loose cartilage, which it 
 will be best to do in the direction of the 
 thigh, as the wound will more readily be 
 healed by the first intention. If the skin is 
 drawn to one side, previously to making the 
 incision, the wound through the parts under- 
 neath will not correspond with that made in 
 the skin, which circumstance will favour 
 their union. The incision upon the cartilage 
 must be made with caution, as it will with 
 
 difficulty be retained in its situation if much 
 force is applied. The assistant is to endea- 
 vour to push the loose body through the 
 opening, which must be made sufficiently 
 large for that purpose ; but as this cannot 
 always be done, the broad end of an eyed 
 probe may be passed under it, so as to lift it 
 out, or a sharp-pointed instrument may be 
 stuck into it, which will fix it to its situation, 
 a> d bring it more within the management of 
 the surgeon. 
 
 “ The cartilages being all extracted, the 
 cut edges of the wound are to be brought 
 together, and, by means of a compress of 
 lint, not only pressed close to one another, 
 but also to the parts underneath, in which 
 situation they are to be retained by sticking 
 plaster, and the uniting bandage. 
 
 “ As union by the first intention is of the 
 utmost consequence after this operation, to 
 prevent an inflammation of the joint, the 
 patient should remain in bed with the leg 
 extended, till the wound is perfectly united, 
 or at least all chance of inflammation at an 
 end.” ( Home , in Trans, for the Improvement 
 of Med. and Chir. Knowledge, Vol. 1 ,p. 239, 
 fyc.) 
 
 In one instance, Desault proceeded in the 
 following manner : the surgeon, after relax- 
 ing the capsular ligament by extending the 
 leg, brought the extraneous body on the in- 
 side of the articulation against the attachment 
 of the capsular ligament, and secured it in 
 this situation, between the index finger and 
 thumb of the left hand, whilst an assistant 
 drew the integuments forwards towards the 
 patella. The parts, covering this extraneous 
 body, were now divided by an incision one 
 inch in length, and its extraction accomplish- 
 ed by pushing it from above downwards, 
 and raising it inferiorly with the end of the 
 knife. This substance, on examination, was 
 found similar in colour to the cartilages that 
 cover the articular surfaces: it was three- 
 quarters of an inch in length, six lines and 
 a half in width, and three lines in thickness : 
 its surfaces were smooth, one concave and 
 the other convex : its circumference irregu- 
 lar, disseminated with red points, forming 
 small depressions ; the inside was ossified, 
 the outside of a cartilaginous texture. As 
 soon as the substance was extracted, the 
 assistant let go the integuments which he 
 had drawn forwards ; they consequently- 
 returned to their natural situation, on the 
 inner side of the knee-joint, in such a man- 
 ner, that the external wound in the integu- 
 ments was situated more inward, than the 
 one in the capsular ligament. Two advanta- 
 ges were procured by this means : on the 
 one hand, air was prevented from penetra- 
 ting into the articulation ; and on the other, 
 the floating portion of capsular ligament, 
 retained inwards by the skin, was more like- 
 ly to attach itself to the condyle, in case it 
 did not unite to the other portion of the cap- 
 sule divided near its attachment. The edges 
 of the wound were brought into contact by 
 means of a uniting bandage ; dry lint and 
 compresses were applied, and retained on 
 the part by a slight bandage : and the limb 
 
JOINTS. 149 
 
 was kept in a siate oi extension. (. Desault's 
 Journal , T. 2.) According to Mr. Abernethy, 
 the inner surface of the internal condyle of 
 the os femoris presents an extensive and 
 nearly a plain surface, which terminates in 
 front and at its upper part by an edge which 
 forms a portion of a circle. If the points of 
 the finger be firmly pressed upon this edge 
 so as to form a kind of line of circumvalla- 
 tion round these (cartilaginous) bodies, they 
 cannot pass into the joint in this direction, 
 nor can they recede in any other, on account 
 of the tense state of the internal lateral li- 
 gament. Here these substances are near 
 the surface, and may be distinctly felt: and 
 they may be exposed by simply dividing the 
 integuments, fascia, and the capsule of the 
 joint. 
 
 In an interesting case, which Mr. Aber- 
 nethy relates, the integuments of the knee 
 were gently pressed towards the internal 
 condyle, and the fingers of an assistant ap- 
 plied round the circular edge of the bone. 
 The integuments were gently drawn to- 
 wards the inner ham string, and longitudi- 
 nally divided, immediately over the loose 
 substance, to the extent of an inch and an 
 half. This withdrawing of the integuments 
 from their natural situation was designed to 
 prevent a direct correspondence of the ex- 
 ternal wound to that in the capsule of the 
 joint : for, when the integuments were suf- 
 fered to regain their natural position, the 
 wound in them was nearer to the patella, 
 than the wound in the capsule. The fascia, 
 which covers the joint, having been expo- 
 sed by the division of the integuments, it 
 was divided in a similar direction, and near- 
 ly to the same extent. The capsule was 
 now laid bare, and gently divided to the ex- 
 tent of half an inch, where it covered one 
 of the hard substances, which suddenly 
 slipped through the opening, and by press- 
 ing gently upon the other, it was also dis- 
 charged. The bodies, thus removed, were 
 about three-quarters of an inch in length, 
 and half an inch in breadth. They had a 
 highly polished surface, and were hard like 
 cartilage. The fluid contained in the joint 
 was pressed toward the wound, and 'about 
 two ounces of synovia were discharged. 
 The wound of the integuments was then 
 gently drawn towards the patella, and ac- 
 curately closed with sticking plaster. ( Sur- 
 gical Observations. 1804.) 
 
 When there are several extraneous carti- 
 laginous bodies in the joint operated upon, 
 the surgeon ought to extract them all through 
 the same wound, if it can be done without 
 producing too much irritation of the capsu- 
 lar ligament, and they will admit of it. But, 
 frequently, only one can be made to pre- 
 sent itself at a time, or can bt easily ex- 
 tracted. Each little tumour will then require 
 a separate operation, which is a far safer 
 plan, than disturbing the part by long and 
 repeated attempts to extract them all at 
 once. ( Boyer , Traile dcs Mai. Chir. T. 4, p. 
 448.) The surgeon is also often obliged to 
 make his incision at a particular point, be- 
 cause at no other can the extraneous sub- 
 
 stance be fixed. A case confirming all these, 
 latter observations was lately published by- 
 Ur. Clarke. (See Med. Chir. Trails. Vol. 5, 
 p. 67.) In this instance, the operation was 
 thrice performed upon the same knee-joint, 
 with perfect success. Mr. Brodie also ex- 
 tracted five loose cartilages, by three differ- 
 ent operations, without any subsequent un- 
 pleasant symptoms, although the patient ap- 
 pears to have been previously subject to 
 repeated attacks of severe inflammation of 
 the joint. (. Pathological and Surg. Obs. v 
 299.) 
 
 On the preceding subject some observa- 
 tions and two successful operations have 
 been lately published by Baron Larrey. 
 (See Memoir es de Chir. Militaire , T.2,p. 421 , 
 ty-c.) With the exception of a few wrong 
 theories, he appears to have given a fair ac- 
 count of the disease 
 
 Hydrops Articuli signifies a collection of se - 
 rous fluid in the capsular ligament of a joint. 
 The knee is more subject, than other joints, 
 to dropsical disease, which has been known, 
 however, to affect the wrist, ankle, and 
 shoulder joints. ( Boyer , Traitt des Mai 
 
 Chir . T. 4 ,p. 456.) 
 
 Mr. Russel adopted the opinion, that some 
 cases of this kind are venereal, and others 
 scrofulous ; but, he has not supported the 
 doctrine on any solid foundation. Hydrops 
 articuli generally arises from contusions, 
 rheumatism, sprains, exposure to severe 
 cold, the presence of extraneous cartilagi- 
 nous bodies in the joint, and in general 
 from any thing, which irritates the capsular 
 ligament ; and, as already explained, it is 
 a common attendant on inflammation of 
 the synovial membrane ; the complaint also 
 sometimes follows fevers ; but, in most in- 
 stances, it is purely a local affection, quite 
 independent of general debility. ( Boyer 
 T. 4, p. 467.) 
 
 Hydrops articuli presents itself in the form 
 of a soft tumour ; circumscribed by the at 
 tachments of the capsular ligament ; with- 
 out change of colour in the skin ; accom- 
 panied with a fluctuation ; it is indolent, 
 and very little painful ; causing hardly any 
 impediment to the motion of the joint ; 
 yielding to the pressure of the finger, but not 
 retaining any impression, as in cedema. 
 The swelling does not occupy equally every 
 side of the joint, being most conspicuous 
 where the capsular ligament is loose and 
 superficial. In the wrist it occurs at the 
 anterior and posterior parts of the joint, but, 
 especially, in the former situation, while it 
 is scarcely perceptible at the sides. In the 
 ankle, it is more apparent in front of the 
 malleoli, than any where else ; and, in the 
 shoulder, it does not surround the joint, but 
 is almost always confined to the forepart of 
 it, and can only be seen in the interspace 
 between the deltoid and great pectoral mus- 
 cles. 
 
 In the knee joint, whichTs the common 
 situation of hydrops articuli, the tumour 
 does not occur behind the articulation ; but 
 at the front and sides. Behind, the capsular 
 ligament is too narrow to admit of being 
 
160 
 
 JOINTS. 
 
 much distended with the synovia ; while, in 
 front, and laterally, it is broad, so that it can 
 there yield considerably in proportion as 
 the quantity of fluid increases. The swell- 
 ing is at first i-ircumscribed by the attach- 
 ments of the capsular ligament ; but, in 
 consequence of the accumulation of fluid, 
 it afterward exceeds these limits above, and 
 spreads more or less upward between the 
 thigh bone and the extensor muscles of the 
 leg which are lifted up by it. Boyer has 
 seen it reach to the upper third of the thigh. 
 The swelling is irregular in shape : it is most 
 prominent where the capsular ligament is 
 wi e and loose, and it is in some measure di- 
 vided longitudinally into two lateral portions, 
 by the patella, the ligament of the patella, and 
 t'he tendon of the extensor muscles of the leg, 
 all which parts the synovia raises, and pushes 
 forward, though in a much less degree than 
 the capsular ligament. Of these lateral 
 portions, the internal is broadest and most 
 prominent, because the part of the capsule 
 between the patella and edge of the inter- 
 nal condyle being larger than that situated 
 between the patella and edge of the exter- 
 nal condyle, yields in a g eater degree to 
 the distending fluid. The motions of the 
 leg, which are generally little interrupted 
 by this disease, make a difference in the 
 shape and consistence of the swelling. In 
 flexion, the tumour becomes harder, tenser, 
 and broader and more prominent at the 
 sides of the knee-pan, which is somewhat 
 depressed by its ligament. In extension, the 
 tumour is softer, and the fluctuation plainer. 
 
 In order to feel distinctly the fluctuation, 
 which is one of the best symptoms of the 
 disease, the ends of two or three fingers 
 should be placed on one side of the swell- 
 ing, while the opposite side is to b ■ struck 
 with the end of the middle finger of the 
 other hand. 
 
 The patella, being pushed forward, away 
 from the articular pulle . , is very moveable, 
 and, as it were, floating. When it is pressed 
 backward, while the leg is extended, ii can 
 be felt to move a certain ■ ay before it meets 
 with the resistance of the articular puhey. 
 And on the pressure being discontinued, it 
 immediately separates from tins part again. 
 
 By such symptoms, hydrops articuli may 
 easily be distinguished f om other diseases 
 of the joints, from tumours of the bursa mu- 
 cosa under the extensor tendons of the leg; 
 from ganglions in front of the knee-pan ; 
 from rheumatism ; oedema, foe. 
 
 The prognosis is most favourable, when 
 the swelling is recent and small, and has 
 been quick in its progress. On the contrary, 
 when the tumour is of long standing and 
 large; the effused fluid thick and viscid; 
 and the synovial membrane thickened ; the 
 removal of the fluid by absorption, and the 
 restoration oi the parts to their natural state, 
 will be more slow and difficult. The worst 
 case is that which is complicated with dis- 
 ease of the capsular ligament cartilages, md 
 bones. 
 
 The cure of the above-described dropsi- 
 cal affection of the joints, depends upon the 
 
 absorption of the effused fluid. And, when 
 the case is combined with acute or chronic 
 inflammation of the synovial membrane, th© 
 treatment is the same as th t already recom- 
 mended for those particular forms of dis- 
 ease. When i- flammation subsides, the 
 absorption of the fluid is sometimes altoge- 
 ther spontaneous, and it may always be 
 promoted, by mere friction, by rubbing the 
 joint with camphorated mercurial ointment, 
 and particularly, by the employment of 
 blisters. 
 
 The operation of a blister may be very 
 materially assisted with a moderately tight 
 bandage. Among other effectual melt ns of 
 cure, we may enumerate frictions with flan- 
 nel impregnated with the fumes of vinegar ; 
 electricity ; and the exhibition of mercurial 
 purgatives. When hydrops articuli occurs 
 during the debdity, consequent to typhoid, 
 and other fevers, the complaint can hardly 
 be expected to get well, before the patient 
 has regained some degree of strength. 
 
 As, however, hydrops articuli is generally 
 quite a local disease, Boyer contends, that 
 it should be chiefly treated with topical re- 
 medies ; and he sets down diuretics, sudo- 
 rifics, hvdragogues, foe. as improper or in- 
 efficient. (Op. cit. p. 467.) He is strongly 
 in favour of repeated blisters, both for tho 
 prevention and cure of the disease. 
 
 Circumstances do not often justify making 
 an opening into the joint : but, excessive 
 distention, in some neglected cases, might 
 certainly be an urgent reason for performing 
 such an operation. Also, if the complaint 
 should resist all other plans of treatment, 
 and the irritation of the tumour greatly im- 
 pair a week constitution, the practice would 
 be justifiable. An interesting example of 
 this kind is related by Mr. Latta. ( System 
 of Surgery, Vol. 2, p. 490.) 
 
 ft is best to make the opening in such a 
 way, that the wound in the capsular liga- 
 ment after the operation, will not remain 
 directly opposite the wound in the skin. 
 For this purpose, the integuments are to be 
 pushed to one side, before the surgeon di- 
 vides them. ( Encyclopedic Method. Part. 
 
 Chir. Art. Hydropsie des Jointures.) 
 
 The operation is not always successful, 
 being sometimes followed by alarming 
 symptoms, which either end fatally, or oc- 
 casion a necessity for amputation. The 
 fliiid also generally collects again, and as 
 the synovial membrane is mostly thickened, 
 it often inflames, and suppuration in the 
 joint ensues. Hence, when hydrops articuli 
 originates from rheumatism ; when it is re- 
 cent, indolent, and not |. rge ; and when it 
 does not seriously impair the functions of 
 the joint ; Boyer recommends the operation 
 not to be done. But, be sanctions its per- 
 formance, when the disease is combined 
 with extraneous cartilaginous bodies in the 
 joint: or when it is very considerable, at- 
 tended with severe pain, and impairment 
 of the functions of the joint. (Op. cit. T. 4, 
 p. 473.) 
 
 Collections of Blood in Joints . — Most sys- 
 tematic writers speak of this kind of case. 
 
JOINTS 
 
 
 though it must be uncommon. Tumours 
 about th£ joints, composed of blood, and 
 Set down in numerous surgical works, as 
 extravasations within the capsular ligaments 
 are generally on the outside ot them. 
 
 Certainly, if a collection of fluid were to 
 take place in a joint immediately after a 
 sprain, or contusion, and to continue to in- 
 crease gradually for some time afterward, 
 there would be reason to believe most of 
 the contents of the tumour to be blood 
 The production of an abscess, and the se- 
 cretion of any fluid, would have required a 
 longer time. 
 
 VVere blood known to be undoubtedly 
 effused in a large articulation, however, no 
 man would be justified in making an open- 
 ing for its discharge. No bad symptoms 
 are likely to result from its mere presence, 
 and the absorbents will, in the end, take it 
 away. If an incision were made into the 
 joint, the coagulated state of the extrava- 
 sated blood would not allow such blood to 
 be easily discharged. 
 
 The best plan is to apply discutient re- 
 medies ; a lotion of vinegar, spirits of wine, 
 and muriate of ammonia for the first three 
 or four days ; and afterw ard, friction with 
 camphorated liniments may be safely adopt- 
 ed. 
 
 Mr. Hey relates a case, in which the knee- 
 joint was wounded, and blood insinuated 
 itself into the capsular ligament; yet though 
 the occurrence could not be hindered, no 
 harm resulted from the extravasation, which 
 was absorbed, without having created the 
 smallest inconvenience. ( Practical Obs. in 
 Surgery, p. 354.) 
 
 White Swelling . — The white swelling, or 
 spina ventosa, as it was at one time not un- 
 frequentlv called, in imitation of the Arabian 
 writers, Khazes and Avicenna, has been a 
 name indiscriminately applied to many dis- 
 eases, which differ widely in their nature, 
 curability, and treatment. Wiseman was the 
 first who used the term Whin-S welling ; 
 and if the expression did not confuse to- 
 gether complaints of very different kinds, not 
 much fault f ould be found w r ith it, because it 
 unquestionably conveys an idea of one mark 
 of some of these distempers, which is, that 
 notwithstanding the increase of size in the 
 joint, the skin is generally not inflamed, but 
 retains its natural colour. (Pott.) 
 
 The name, therefore, appears objection- 
 able, only inasmuch, as it has tended to pre- 
 vent the introduction of a sufficient number 
 of well-founded and net.e>sary distinctions. 
 Systematic writers have generally been con- 
 tent with a distinction into two kinds, viz. 
 rheumatic , and scrofulous. 
 
 The last species of the disease they also 
 distinguish into such tumours, as primarily 
 affect the bones, and then the ligaments and 
 soft parts ; and into other cases, in w'hich 
 the cartilage*, ligaments, and soft parts be- 
 come diseased before there is any morbid 
 affection of the hones. 
 
 Mr. Brodie has endeavoured to form a 
 more correct classification of the different 
 complaints, to which the term white-swelling 
 
 is applied ; and his descriptions are valuable, 
 because confirmed by extensive observation, 
 and numerous dissections. With respect to 
 the disease beginning in the ligaments, if the 
 capsular ligaments be put out of considera- 
 tion, it is, as this gentleman observes, a rare 
 occurrence, and he has never met with a 
 case, in which the fact was ptoved by dis- 
 section. (Pathol, and Surgical Obs. p. 7.) 
 
 1. Tiie first case is mtiaimnalion ol the 
 synovial membrane, as described in the fore- 
 going pages, especially that torrn ot the dis- 
 ease which often arises from cold, and con- 
 stitutes the disease formerly often termed a 
 rheumatic w hite swelling. 
 
 2. Another form ot disease, ordinarily 
 comprised under the general name ol white- 
 swelling, has been particularly described by 
 Mr. Brodie : the disease originates in the 
 synovial membrane, which loses its natural 
 organization, and becomes converted into a 
 thick, pulpy substance, of a light brown, and 
 sometimes ot a reddish brow n colour, inter- 
 sected by white membranous lines, and from 
 1-4 to 1-2 ot an inch, or even more than an 
 inch in thickness. As this disease advances, 
 it involves ail the parts of which the joint is 
 composed, producing ulceration of ibe car- 
 tilages, caries ot the bones, wasting ot the 
 ligaments, and abscesses in different places. 
 The complaint has invariably proved slow 
 in its progress, and sometimes has remained 
 nearly in an indolent state for many months, 
 or even for one or two years ; but (says Mr. 
 Brodie) I have never met with an instance, 
 in which a real amendment was produced ; 
 much less have I known any in which a cure 
 was effected.’ (bee Medico- Chir. Trans . 
 Vol. 4, p. 220, <Jpc.) The wlio.e, or nearly 
 the whole ot the synovial membrane has 
 always been found affected; though if a 
 very early examination were made, Mr. 
 Brodie conceives that this might not be the 
 case, and in one example, he found only a 
 half of the membrane tbus altered, while 
 the rest w as ot its natural siruciure. ( Pathol 
 and Surg. Obs. p. 94.) Tnis gentleman 
 further acquaints u-, that the preceding affec- 
 tion of (he synovial membrane is rareiy met 
 with, except in the knee, that he bas never 
 known an instance ot it in the hip or shoul- 
 der; that it is peculiar to the synovial mem- 
 brane of the joints ; tliai he has never know'n 
 an instance oi it in other serous m< mbranes, 
 nor even in ihe synovial membranes, w hich 
 constitute (he ur-aj mucosae and sheaths of 
 tendons ; and that it generally lakes place in 
 young persons, under, or not much abuve the 
 age of puberty. In tact, Mr. Brodie has no" 
 met with more than one in.-tance, in which 
 it occurred afier the middle period ot life. 
 “ In the origin of this disease, there is a 
 slight degree of stiffness and tumefaction, 
 without pain, and producing only the most 
 trifling inconvenience. These symptoms 
 gradually increase : at last, the joint scarcely 
 admits of the smallest motion, the stiffness 
 being greater than where it is the conse- 
 quence of simple inflammation. The form 
 of the swelling bears some resemblance to 
 that in cases of inflammation of the synovial 
 
JOINTS. 
 
 152 
 
 membrane, but it is less regular. The swell- 
 ing is soft and elastic, and gives to the hand 
 a sensation as if it contained fluid. If only 
 one hand be employed in making the exami- 
 nation, the deception may be complete, and 
 the most experienced surgeon may be led to 
 suppose, there is a fluid in the joint when 
 there is none ; but if both hands be employ- 
 ed, one on each side, the absence of fluid is 
 distinguished by the want of fluctuation 
 “ The patient experiences little or no pain, 
 until abscesses begin to form, and the cartila- 
 ges ulcerate ; and even then the pain is not 
 so severe, as where the ulceration of the 
 cartilages occurs as a primary disease, and 
 the abscesses heal more readily, and discharge 
 a smaller quantity of pus, than in cases of 
 this last description. At this period, the pa- 
 tient becomes affected with hectic fever, loses 
 his flesh, and gradually sinks, unless the limb 
 be removed by an operation.” ( Brodie , in 
 Med. Chir. Trans. Vol. 5, p. 251, 252.) In 
 the majority of cases, this gentleman believes 
 that the gradual progress of the enlargement , 
 the stiffness of the joint without pain, and the 
 soft elastic svjelling without fluctuation , will 
 enable the practitioner readily to distinguish 
 this from all other diseases of the joints. 
 However, when the diseased synovial mem- 
 brane happens to be distended with a quanti- 
 fy of turbid serum and flakes of c-oagulable 
 lymph, the complaint somewhat resembles in 
 its feel and appearance that stage of common 
 inflammation of the synovial membrane, 
 where this part is left thickened, and more 
 or less distended with coagulable lymph, but 
 the impossibility of relieving the former ca e 
 by the same means which cure the latter, 
 and due attention to the history of the dis- 
 ease, will prove the difference between them. 
 ( Brodie , Pathol, and Surg. Obs. p. 96.) 
 
 3. Ulceration ot the articular cartilages 
 takes place in the advanced stage of several 
 diseases of the joints, and ii also exists in 
 many instances as a primary affection, in the 
 early stage ut o hich, the bones, synovial 
 membrane, and ligaments, are in a natural 
 state. If neglected, it ultimately occasions 
 the entire destruction of the an mutation. It 
 may be the consequence ot infl miiiation of 
 the cartilage itself, or of the bony surface, 
 with which it is connected ; but ,<s Mr. Bro- 
 die further observes, in many instances there 
 are no evident marks >f the disorder being 
 preceded by any inflammatory action in one 
 part or the other, and the inflammation, 
 which afterward lakes place, appears rather 
 to be theattendant upon, than thee us« of ihe 
 ulcerative process. One striking peculiarity 
 ot ulceration of the articular cartila. es is, 
 that ihe process may lake place without the 
 formaiion of pus; for the disease often pro- 
 ceeds so far as to cause caries of the bones, 
 and y et no purulent matter is found within 
 the joint. (See Brodie s Pathol, and Surgi- 
 cal Obs. tyc. p. 102.) The investigations of 
 the same author dispose him to believe, that 
 a conversion of these cartilages into a soft 
 fibrous structure, is a frequent .hough, not 
 constant forerunner of ulceration. {P. 105.) 
 When the ulceration of the cartilage occurs 
 
 in the superficial joiuts, it constitutes one of 
 the diseases which have been known by the 
 name of white-swelling. From cases which 
 Mr. Brodie has met with, he is led to con- 
 clude, that when it takes place in the hip, it 
 is this disease, which has been variously 
 designated by writers, the “ morbus coxariusf 
 the “ Disease of the Hip,” the “Scrofulous 
 Hip,” the Scrofulous Caries of the Hip 
 Joint.” At least, says Mr. Brodie, it is to this 
 disease, that these names have been princi- 
 pally applied, though probably other morbid 
 affections have been occasionally confounded 
 with it. {Med. Chir. Trans. Vol. 4,j?.236.) 
 The ulceration of the articular cartilages 
 takes place as a primary disease, chiefly in 
 children, or adults under the middle age. 
 “ Ot sixty-eight persons affected with this 
 disease, fifty-six (according to Mr.Brodie)were 
 under thirty years of age : the youngest was 
 an infant of about twelve months the old- 
 est was a woman of sixty. As the knee is 
 more frequently affected by inflammation of 
 the synovial membrane, so is the hip more 
 liable, than other joints, to the ulceration of 
 tue cartilaginous surfaces. In general tne 
 disease is confined to a single joint ; but it 
 is not very unusual to find two or three 
 joints affected in the same individual, either 
 at the same time, or in succession. Some- 
 times the patient traces the beginning of his 
 symptoms to a local injury, or to his having 
 been exposed to cold ; but for the most part , 
 no cause can be assigned for the complaint.” 
 (see Med. Chir. Trans. Vol.6,p. 319.) 
 
 The symptoms of the disease of the hip- 
 joint will be described in the ensuing section, 
 and we shall here confine our remarks to the 
 symptoms characterizing ulceration of the 
 cariilages of ihe knee, as pointed out by Mr. 
 Brodie. ihey differ from those of inflam- 
 mation ot the synovial membrane, by the 
 pain being slight in the beginning, and gra 
 dually becoming very intense, which is the 
 reverse of what happens in the latter affec- 
 tion. The pain in the commencement is 
 also unattended witu any evident swelling, 
 w Inch never comes on in less than four or 
 five weeks, and often not till after several 
 months. It is not to be inferred, however, 
 that every slight pain of thp joint, unaccom- 
 panied with swelling, must of course arise 
 from ulceration of the cartilages. But, says 
 Mr. Brodie, when the pain continues to in- 
 crease, and at last is very severe ; when it is 
 aggravated by the motion of the bones on 
 each other, and when, after a time, a slight 
 tumefaction <>t the joint takes place, we may 
 conclude that the disease consists in such 
 ulceration. The swelling arises from a slight 
 inflammation of the cellular membrane on 
 the outside of the joint : it has the form of 
 the articulating ends of the bones ; and for 
 the most part it appears greater than it really 
 is, in consequence of the muscles being 
 wasted. No fluctuation is perceptible, as 
 where the synovial membrane is inflamed ; 
 nor is there the peculiar elasticity, which 
 exists where the synovial membrane has un- 
 dergone a morbid alteration ot its structure. 
 Ml* Brodie has explained, however, that 
 
JOINTS. 
 
 153 
 
 in some cases, the swelling has a different 
 shape, and communicates the feel of a lluc- 
 tuation. This happens when inflammation of 
 the synovial membrane, attended with a 
 collection of the synovia of the joint, or 
 abscesses in the surrounding soft parts, or in 
 the articulation itself, occur as secondary 
 diseases. When there has been considerable 
 destruction of the soft parts from abscesses 
 and ulceration, the head of the tibia may 
 become dislocated and drawn towards the 
 ham. (See Med. Chir. Trans. Vol. 6, p. 326, 
 
 4^0 
 
 4. I shall pass over ulceration of the syno- 
 vial membrane, which Mr. Biodie considers 
 in a separate section, and now proceed to 
 scrofulous white-swelling. In the scrofu- 
 lous disease of the joints, the bones are pri- 
 marily affected, in consequence of which, 
 ulceration takes place in the cartilages cover- 
 ing their articular extremities. The cartilages 
 being ulcerated, the subsequent progress of 
 the disease (says Mr. Brndie) is the same as 
 where this ulceration takes place in the first 
 instance. ( Medico- Chir . Trans. Vol. 4, p. 
 266.) 
 
 By Mr. Lloyd, scrofulous white swellings 
 are divided into three stages; the first being 
 that in which the affection is confined to the 
 bone ; the second, that in which the exter- 
 nal parts become thickened and swelled ; 
 and the third being what he names the sup- 
 purative stage, attended with ulceration of 
 the cartilages, inflammation of the synovial 
 membrane, and abscesses. (On Scrofula, p. 
 321.) It was formerly a common notion, 
 that in white-swellings, the heads of the 
 bones were always enlarged. Mr. Russel, I 
 believe, is the first writer who expressed an 
 opposite sentiment, and he distinctly declares, 
 that he had never heard , nor known of an in- 
 stance in which the tibia was enlarged from an 
 attack of white-swelling. (P. 37.) The inac- 
 curacy of the opinion was afterward pointed 
 out by Mr. Lawrence, to the late Mr. Crovv- 
 ther, and the subject was mentioned in the 
 earliest edition of the li First Lines of the 
 Practice of Surgery.” 
 
 Deceived by the feel of many diseased 
 ioints, and influenced by general opinion, I 
 once supposed, that there was generally a 
 regular expansion of the heads of scrofu- 
 lous bones. But excepting an . occasional 
 enlargement, which arises from spiculae of 
 bony matter, deposited on the outside of the 
 tibia, ulna, &c. and which alteration cannot 
 be called an expansion of those bones, I 
 never until lately saw the head of a bone 
 enlarged, in consequence of the disease 
 known by the name of white-swelling. I was 
 formerly much in the habit of inspecting the 
 state of the numerous diseased joints,. which 
 were every year amputated at St. Bartholo- 
 mew’s Hospital, and though I was long at- 
 tentive to this point, my searches after a 
 really enlarged scrofulous bone always 
 proved in vain. Nor was there at that peri- 
 od any specimen of an expanded head of a 
 scrofulous bone in Mr. Abernetby’s museum. 
 Within the last few years, however, a speci- 
 
 Vo r . u * ' ' 20 
 
 men of an enlargement of the upper head of 
 the ulna has been found, and it was some 
 time ago shown to me. by Mr. Stanley. My 
 friend, Mr. Langstaflf, is said to have in his 
 possession a knee-joint, in which the femur 
 and tibia are much expanded, lt the external 
 laminae of the bones not being thicker than 
 when the bones are of their natural size, and 
 the caneelli healthy, though of rather greater 
 solidity than natural. (Lloyd on Scrofula, p. 
 148.) However, this last form of disease 
 evidently does not resemble the common 
 scrofulous affection of the heads of the bones. 
 I may add, that Mr. Wilson, whose dissec- 
 tions have beer, very numerous, concurs with 
 the best modern writers, concerning the rari- 
 ty of an actual expansion of the .substance 
 of the heads of (he bones. (On the Skele- 
 ton, fo. p. 336.) I have also heard of a few 
 other instances in which the heads of the 
 bones were actually enlarged in cases of 
 white-swelling. However, I believe the 
 occurrence is far from being usual, and 
 doubts may yet be entertained, whether 
 such enlargement is combined with the fol- 
 lowing alteration of structure. The change 
 which the head of the tibia undergoes in 
 many cases, is first a partial absorption of 
 the phosphate of lime throughout ilstexturej 
 while at first a transparent fluid, and after- 
 ward a yellow cheesy substance are deposit- 
 ed in the caneelli. In a more advanced 
 s<age, and indeed, in that stage, which most 
 frequently takes place before a joint is am- 
 putated, the head of the bone has deep ex- 
 cavations in consequence of caries, and its 
 structure is now so softened, that when an 
 instrument is pushed against the carious part, 
 it easily penetrates deeply into the bone. 
 Occasionally, as my friend Mr. Lloyd has 
 observed, all the bones of a joint are affect- 
 ed in this way ; but frequently only One of 
 them. (On Scrofula, p. 120.) 
 
 According to a modern writer, ‘“'The mor- 
 bid affection appears to have its origin in the 
 bones, which become preternaturally vascu- 
 lar, and contain a less than usual quantity of 
 earthy matter, while, at first, a transparent 
 fluid, and afterward a yellow cheesy sub- 
 stance, is deposited in their caneelli. From 
 the diseased bone, vessels, carrying red blood, 
 shoot into the cartilage, which afterward ulce- 
 rates in spots, the ulceration beginning on that 
 surface, which is connected to the bone. As 
 the caries of the bones advances, pus is collect- 
 ed in the joint. At last, the abscess bursts ex- 
 ternally, having formed numerous and circui- 
 tous sinuses.” (Brodie,in Med. Chir. Trans. 
 Vol 4,;;. 272, and Pathol Obs.p. 227.) The 
 above-described alteration of the structure of 
 the bones, this author has never seen in the 
 cranium, uor in the middle of the cylindrical 
 bones ; but, it is asserted by another iate 
 Writer, that the cheesy matter sometimes 
 pervades the canceii of the whole bone, and 
 is deposited in innumerable, portion's of the 
 most minute size. (E. A. Lloyd on Scrofu- 
 la , p. 120.) Also, with respect to the increa- 
 sed vascularity of the diseased part of the 
 bone, although Mr. Lloyd assents to the truth 
 
164 
 
 JOINTS. 
 
 of this statement, as applied to the early 
 stage of the disorder, he represents the vas- 
 cularity as afterward being diminished, in 
 proportion as the quantity of cheeselike de- 
 posit increases. ( Vol . cit.p. 122, 123.) 
 
 A cursory examination of a diseased joint, 
 even when it is cut open, will not suffice to 
 show, that the heads of the bones have not 
 acquired an increase of size. In making a 
 dissection of this kind, in the presence of a 
 medical friend, I found that, even after the 
 joint had been opened, the swelling had every 
 appearance of arising from an actual expan- 
 sion of the bones. The gentleman with me 
 felt the ends of the bones after the integu- 
 ments had been removed, and he coincided 
 with me, that the feel, which was even now 
 communicated, seemed to be caused by a 
 swelling of the bones themselves. But, on 
 cleaning them the enlargement was demon- 
 strated to arise entirely from a thickening of 
 the soft parts. So unusual, indeed, is the 
 expansion of the heads of the bones, that 
 the late Mr. Crowther, who paid great atten- 
 tion to these cases, joined Mr. Russel in 
 Relieving, that such a change never happen- 
 ed : a conclusion not entirely correct. (See 
 Practical Obs. on White-Swelling, fyc. Edit. 2, 
 p. 14, 1808.) 
 
 Mr. Russel has particularly noticed how 
 much the soft ports frequently contribute to 
 the swelling. He describes the appearances 
 on dissection thus : “ The great mass of the 
 swelling appears to arise from an affection of 
 the parts, exterior to the cavity of the joint, 
 and which, besides an enlargement in size, 
 seem also to have undergone a material 
 change in structure. There is a larger, than 
 natural, proportion of a viscid fluid, intermix- 
 ed with the cellular substance ; and the cel- 
 lular substance itself has become thicker, 
 softer, and of a less firm consistence, than in 
 a state of health.” (On the Morbid Affections 
 of the Knee, p. 30.) The manner, in which 
 the soft parts are affected, is also described by 
 Mr. Brodie : “ Inflammation takes place of 
 the cellular membrane, external to the joint. 
 Serum, and afterward coagulable lymph, 
 are effused, and hence arises a puffy elastic 
 swelling in the early, and an cedemalous 
 swelling in the advanced stage of the disease. 
 
 <£ Scrofula attacks only those bones, or 
 portions of bones, which have a spongy tex- 
 ture, as the extremities of the cylindrical 
 bones, and the bones of the carpus and tar- 
 sus ; and hence, the joints become affected 
 from their contiguity to the parts, which are 
 the original seat of the disease.” (See Medi- 
 co-Chir. Trans. Vol. 4, p. 273.) 
 
 In the cavity of the joint, we sometimes 
 find a quantity of curdy matter, and the car- 
 tilages absorbed in various places, but more 
 particularly round the edges of the articular 
 surfaces. 
 
 As the name of the disease implies, the skin 
 is not at all altered in colour. According to 
 Mr. Lloyd, the first decided symptom of dis- 
 ease going on in the articulating extremity of 
 a bone, is an occasional deep-seated, dull, 
 heavy pain, unattended by swelling, and not 
 increased by motion ; and if it be the hip, 
 
 knee, or ankle, which is affected, the patient 
 keeps the knee rather bent, and never fully 
 extends it in progression. (On Scrofula, p. 
 138.) In some instances, the swelling yields 
 in a certain degree to pressure ; but it never 
 pits, and is almost always sufficiently firm to 
 make an uninformed examiner believe, that 
 the bones contribute to the tumour. It is 
 remarked by Mr. Brodie, that while the dis- 
 ease is going on in the cancellous structure 
 of the bones, before its effects have extended 
 to the other textures, and while there is still 
 no evident swelling, the patient experiences 
 some degree of pain, which however, is ne- 
 ver very severe, and often is so slight, that it 
 is scarcely noticed. After a time, varying 
 from a few weeks to several months, the ex- 
 ternal parts begin to swell, and serum and 
 coagulable lymph to be effused in the cellu- 
 lar membrane so as to form a puffy, elastic 
 swelling. (Pathol. Obs. p. 231.) In the ma- 
 jority of scrofulous white -swellings, let the 
 pain be trivial, or more severe, it is particu- 
 larly situated in one part of the joint : viz. 
 either the centre of the articulation, or the 
 head of the tibia. Sometimes, the pain con- 
 tinues without interruption ; sometimes there 
 are intermissions; and in other instances, the 
 pain recurs at regular times, so as to have 
 been called by some writers, periodical. Al- 
 most ail authors describe the patient, as suf- 
 fering more uneasiness in the diseased pari, 
 when he is warm, and particularly, when he 
 is in this condition in bed. 
 
 In the early stage of the disease, the swell- 
 ing is mostly very inconsiderable, or there is 
 even no visible enlargement whatever, ex- 
 cepting perhaps after exercise. In the little 
 depressions, naturally situated on each side 
 of the patella, a fullness generally first shows 
 itself, and gradually spreads all over the affect- 
 ed joint. According to Mr. Lioyd, however, 
 when the soft parts on the outside of the 
 knee-joint, permanently swell, the swelling 
 often commences *on each side, just behind 
 the condyles, so that the joint appears wider, 
 and he says, that he has often seen the en- 
 largement commence by the swelling of n 
 gland, immediately above the inner condyle. 
 He observes, however, that there is no point 
 of the joint, where the swelling may not 
 begin. (Op. cit. p. 139.) 
 
 The patient, unable to bear the weight of 
 his body on (lie disordered joint, in conse- 
 quence of the great increase of pain thus 
 created, gets into the habit of only touching 
 the ground with his toes, and the knee being 
 generally kept a little bent in this manner, 
 soon loses the capacity of being completely 
 extended again. When white-swellings have 
 lasted a good while, the knee is almost al- 
 ways found in a permanent state of flexion. 
 In scrofulous cases, the pain constantly 
 precedes any appearance of swelling; hut 
 the interval between the two symptoms differs 
 very much in different subjects. 
 
 The morbid joint, in the course of time, 
 acquires a vast magnitude. Still the integu- 
 ments retain their natural colour, and remain 
 unaffected. The enlargement, however, 
 always seems greater than it really is, in con* 
 
JOINTS 
 
 sequence of the emaciation o i’ tiie limb both 
 above and below the disease. 
 
 An appearance of blue distended veins, and 
 a shining smoothness, are the only alterations 
 to be noticed in the skin covering the enlarged 
 joint. The shining smoothness seems attri- 
 butable to the distention, which obliterates the 
 natural furrows and wrinkles of (he cutis. 
 When I he joint is thus swollen, the integu- 
 ments cannot be pinched up into a fold, as 
 they could in the state of health, and even 
 in the beginning of the disease. 
 
 As the distemper of the articulation advan- 
 ces, the cartilages ulcerate, and collections 
 of matter form around the part, andat length 
 burst. Their progress, as Mr Brodie has sta- 
 ted, is slow, and when they burst, or are 
 opened, they discharge a thin pus, with por- 
 tions of a curdy substance floating in it. The 
 discharge afterward becomes, less copious, 
 and thicker. ( Pathol . Obs. p. 23d.) The 
 ulcerated openings sometimes heal up ; but, 
 such abscesses are generally followed by 
 other collections, which pursue the same 
 course. In some cases, these abscesses form 
 a few months after the first affection of (he 
 joint ; on other occasions, several years 
 elapse, and no suppuration of this kind makes 
 its appearance. They sometimes communi- 
 cate with the cavity of the diseased joint, or 
 lead down to diseased bone, portions of which 
 occassionally exfoliate. In the generality of 
 cases, several abscesses take place in succes- 
 sion, some healing up, and others ending in 
 sinuses. 
 
 As the cartilages continue to ulcerate, Mr. 
 Brodie has observed, that the pain becomes 
 aggravated, though not in a very great de- 
 gree, and, he says, that it is not severe, until 
 an abscess has formed, and the parts over it 
 are distended and inflamed. ( Pathol . Obs. p. 
 234.) : 
 
 The local mischief must necessarily produce 
 moue or less constitutional .''disturbance. The 
 patient’s health becomes gradually impair- 
 ed, he loses his appetite and natural rest and 
 sleep; bis pulse is small and frequent ; and ob- 
 stinate debilitating diarrhoea, and profuse noc- 
 turnal sweats ensue. These complaints are, 
 sooner or later, followed by dissolution, un- 
 less the constitution he relieved in time, 
 either by the amendment orj removal of the 
 diseased part. In different patients, how- 
 ever, the course of the disease, and its effects 
 upon the system, vary considerably, in rela- 
 tion to the rapidity with which they occur. 
 
 Rheumatic white-swellings, or inflamma- 
 tions and thickenings of the synovial mem- 
 brane from cold, or other causes, are very 
 distinct diseases from the scrofulous distemper 
 of the large joints. In the first, the pain is 
 said never to occur without being attended 
 with swelling. Scrofulous white-swellings, 
 on the other hand, are always preceded by a 
 pain, which is particularly confined to one 
 point of the articulation. In rheumatic 
 cases, the pain is more general, and diffused 
 over the whole joint. 
 
 Mr. Lloyd thinks, that the scrofulous 
 white-swelling may be distinguished from all 
 other diseases of the joints, by its being at- 
 
 155 
 
 teuded with less pain, by the great degree of 
 external swelling often existing for a long 
 time before matter forms in the cavity of the 
 articulation, and by the swelling being but 
 little diminished by any discharge of matter, 
 which may take place. In its first stage, before 
 the interior of the joint is affected, it may 
 be distinguished from primary ulceration of 
 the cartilages, by the pain not being much in- 
 creased by motion. The grating, produced 
 by moving the joint, is also commonly less in 
 this disease, than in ordinary ulceration of 
 the cartilages. ( Lloyd on Scrofula , p. 142.) 
 And, according to Mr. Brodie, the principal 
 criterion between scrofulous diseases ofjoints 
 and the primary ulceration of cartilages, is 
 the little degree of pain in the former cases, 
 which is never much complained of before 
 an abscess forms, not particularly severe, 
 
 11 except in a very few instances, and in the 
 most advanced stage of the disease, when a 
 portion of ulcerated bone has died, and ha- 
 ving exfoliated, so as to lie loose in the cavi- 
 ty of the joint, irritates the parts, with which 
 it is in contact, and thus becomes a source of 
 constant torment.” (Brodie's Pathol . Obs. p , 
 236.) 
 
 It seems probable, that cases, in which the 
 cancellous structure of the bones is found 
 quite undiseased, and in which the mass of 
 disease is confined to the soft parts, are not 
 scrofulous white-swellings. Few persons, 
 who have attained the age of five and 
 twenty, without having had the least symptom 
 of scrofula , ever experience, after this 
 period of life, a first attack of the white- 
 swelling of the strumous kind. The general 
 correctness of this observation, I believe, is 
 universally admitted, and that there are but 
 few exceptions to it is confirmed by the 
 statements of Volpi, of Pavia. However, 
 Mr. Lloyd attended a man, who, at the age 
 of between forty and fifty, died of phthisis 
 and had at the time a scrofulous ankle, 
 besides several abscesses about his hip and 
 groin. And tbe same gentleman met with 
 another patient upwards of forty years old, 
 with a similar disease. (On Scrofula, p. 
 137.) But, if these patients had had no marks 
 of scrofula in their younge-r days, a circum- 
 stance not specified, they form deviations 
 from what is usual, as indeed Mr. Lloyd 
 seems to admit. My own observations lead 
 me fully to concur with Mr. Brodie, that the 
 scrofulous affections of the joints, so fre- 
 quent in children, are rare after the age of 
 thirty. (Pathol. Obs. p. 229.) All cases, in 
 which the internal structure of the heads 
 of the bones becomes softened, previously 
 to the affection of the cartilages, and soft 
 parts, are probably scrofulous. 
 
 Mr. Russel has noticed the frequent en- 
 largement of the lymphatic glands in the 
 groin, in consequence of the irritation of the 
 disease in the knee ; but he justly adds, that 
 this secondary affection never proves long 
 troublesome. 
 
 When the bones are diseased, the head of 
 the tibia always suffers more than the con- 
 dyles of the thigh bone. (Russel.) The 
 articular surface of the femur sometimes has 
 
JOINTS. 
 
 104 * 
 
 not a single rough or carious point, liolwith- had not been completely cured. K. Lovveras 
 .Standing that of the tibia may have suffered also maintains a similar opinion. Even 
 a .great deal. The cartilaginous coverings though a few persons have scrofulous 
 of the heads of the bones are generally diseases of the joints, for the first time, after 
 eroded first at their edges ; and, in the knee, the age of twenty-five, this occurrence, like 
 the cartilage of the tibia is always more 
 affected, than that covering the condyles of 
 the thigh-bone. Indeed, when white-swell- 
 ings have their origin in the bones, and the 
 knee is the seat of the disorder, there is some 
 ground for supposing, that it is in the tibia, 
 that the morbid mischief usually first com- 
 mences. 
 
 the first attack of scrofula after this period 
 must be considered as extremely uncommon. 
 Another argument, in favour of the doc- 
 trine, which sets down particular kinds of 
 white-swellings as scrofulous, is founded 
 on the hereditary nature of such forms of 
 disease. 
 
 Numerous continental surgeons, particu- 
 The ligaments of the knee are occasionally larly Petit and Brambilla, have noticed how 
 so weakened, or destroyed that the tibia and very subject the English are both to scro- 
 fibula become, more or less, dislocated back- fula and white-swellings of the joints, 
 ward, and drawn towards the tuberosity of We every day see, that young persons 
 the ischium, by the powerful action of the afflicted with he present disease, are gene- 
 flexor muscles of the leg. It is observed by rally manifestly scrofulous or have once, 
 Mr. Brodie, that, just as ulceration of the been so. Frequently enlarged lymphatic 
 cartilages is sometimes followed by disloca- glands in the neck denote this fatal peculi- 
 tion of the hip, so we find, that dislocation arity of constitution ; and very often the 
 of the knee occasionally takes place from patients are known to have descended from 
 the same cause. Where there has been parents who had strumous disorders. ( Crow - 
 considerable distention of the soft parts, in ther.) The disease is also frequently com- 
 consequence of ulceration extendiiigtothem, bined w ith swelled mesenteric glands, or 
 the head of the tibia is gradually drawn back- tuberculated lungs. {Brodie' s Pathol. Obs , 
 ward by the action of the flexor muscles ; p. 221.) As the same author remarks, since 
 and Mr. Brodie has even known this hap- the disease depends upon a certain morbid 
 pen, previously to the formation cf any condition of the general system, it is not 
 abscesses. ( Pathol . Obs.p. 159.) surprising, that we should sometimes find it 
 
 I have seen a curious species of white- affecting several joints at the same time, or 
 swelling, in which the leg could be bent to that it should show itself in different joints 
 each side to a very considerable distance, in succession ; attacking a second joint after 
 both when the knee was extended and bent : it has been cured in the first, or after the 
 a state implying a preternatural looseness, first has been removed by amputation. (P. 
 or perhaps a destruction, of the ligaments of 230.) 
 
 the articulation. Besides the general emblems of ascrofu- 
 
 Scrofulous w hite-swellings, no doubt, lous constitution, which will be noticed in 
 are under the influence of a particular kind the article Scrofula , we may often observe 
 of constitution, termed a scrofulous or slru- a shining, coagulated, flaky substance, like 
 mous habit , in which every cause, capable white of egg, blended with the contents of 
 of exciting inflammation, or any morbid and such abscesses as occur in the progress of 
 irritable state of a large joint, may bring on the disease. This kind of matter is almost, 
 the present severe disease. On the other peculiar to scrofulous abscesses, and forms 
 hand, in a man of a sound constitution, a another argument in support of the foregoing 
 similar irritation would only induce common observations, relative to the share, which 
 healthy inflammation of the joint. In scro- scrofula frequently has in the origin and 
 fulous habits, it also seems as if irritation course of many white-swellings, 
 of a joint is much more easily produced, Mr. Brodie’s experience leads him to be- 
 than in other constitutions ; and no one lieve, that in scrofulous cases, the chance 
 can doubt, that when once excited in the of ultimate recovery is much less, where the 
 former class of subjects, it is much more disease attacks the complicated joints of 
 dangerous, and difficult of removal, than in the foot and hand, than when it is situated 
 other patients. in larger articulations of a more simple struc- 
 
 The doctrine of particular white-swellings ture. ( Pathol . and Surg. Obs. p. 235.) 
 being scrofulous diseases, is supported by Treatment of White-swellings — In practice 
 many weighty reasons, the opinions of the we meet with all these cases both scrofu- 
 most accurate observers, and the evidence lous and rheumatic, in two very opposite 
 of daily experience. Wiseman (j Book 4, states ; sometimes the diseased joint is 
 chap. 4) calls the sphta veniosa a species of affected with a degree of acute inflarama- 
 scrofula, and tells us, that infants and tion ; in other instances, the malady is 
 children are generally the subjects of this entirely chronic. 
 
 disease. The disorder is said by Severinus The imprudence of patients in walking 
 to be exceedingly frequent in young sub- about, and disturbing the diseased part, is 
 jects. Petrus de Marchettis has observed very olten the occasion of a degree of acute 
 both male and female subjects affected with inflammation, which is denoted by the 
 what are called strumous diseases of the tenderness of the joint when handled by the 
 joints, as late as the age of five and twenty ; surgeon, and also by the integuments feel- 
 bat not afterward, unless they had suffered ing hotter than those of the healthy knee, 
 from scrofula before that period of life, and When such stab; exists, there can be no 
 
JOINTS. 
 
 <ioubt, that topical bleeding, fomentations, 
 emollient poultices, or cold saturnine lotions, 
 are means which may be eminently service- 
 able. The antiphlogistic regimen is now 
 strongly indicated. Cooling purges of the 
 saline kind should also be exhibited. Blood 
 may be taken from the arm, and also from 
 the diseased part, either by means of leeches 
 or cupping. Mr. Latta gives the preference 
 to the latter method, whenever it can be 
 employed ; and he very properly remarks, 
 that little advantage can be expected from 
 topical bleeding of any kind, unless the 
 quantity of blood taken away be consider- 
 able. Ten or twelve ounces by cupping 
 shou.d be taken away at a time, and the 
 operation should be repeated at proper 
 intervals, till the tenderness and heat of the 
 skin have entirely subsided. When leeches 
 are used, the number ought to be consider- 
 able, and Mr. Latta recommends the appli- 
 cation of at least sixteen or twenty. ( System 
 of Surgery, Vol. 1* Chap. 6.) 
 
 Although antiphlogistic means are judi- 
 cious w hen acute inflammation prevails ; 
 yet such practitioners as lose weeks and 
 months in the adoption of this treatment, 
 are highly censurable. While the skin is 
 hot and tender, while the joint is affected 
 with very acute and general pain, and while 
 the patient is indisposed with the usual 
 symptoms of inflammatory fever, great 
 benefit may be rationally expected from the 
 above plan. When, however, the disease 
 is truly chronic, different plans are indicated. 
 In ordinary cases of scrofulous disease of 
 the joints, Mr. Brodie considers topical 
 bleeding as usually unnecessary. ( Pathol . 
 and Surgical Obs. p. 240.) 
 
 It is quite unnecessary to expatiate on the 
 mode of treating white-swellings, compli- 
 cated with acute inflammation, particularly 
 as the treatment of those cases, which con- 
 sist of inflammation of the synovial mem- 
 brane, has been already noticed, and may 
 be said to be applicable to other forms of 
 white-swelling, when they are attended with 
 heat and inflammation of the soft parts. 
 The most eligible plan of arresting the mor- 
 bid process in the bones, cartilages, and soft 
 parts surrounding the articulation, and the 
 most successful method of lessening the 
 chronic enlargement of the joint, are the 
 subjects at present demanding our earnest 
 investigation. 
 
 The works of Hippocrates, Celsus, Rhazes, 
 Hieron, Fabricius, &,c. compared with 
 modern surgical books, will soon convince 
 us, that the practice of the ancients, in the 
 treatment of diseased joints, does not differ 
 much from the plan now pursued by the best 
 modern surgeons. Mr. Crowtber remarks, 
 that the ancients used lot al and general 
 blood-letting, the actual and potential cau- 
 tery, with vesicating and stimulating applica- 
 tions to the skin. They further maintained, 
 that sores, produced by these means, should 
 have their discharge promoted, and continued 
 for a considerable length of time. 
 
 With regard to the cases which Mr. Brodie 
 describes as depending upon a total loss of 
 
 157 
 
 the natural structure of the synovial mem - 
 brane, which is converted into a pulpy sub- 
 stance, one quarter or one half of an inch 
 in thickness, though the progress of the 
 disease may be somewhat checked by rest 
 and cold lotions, it is, according to this gen- 
 tleman, incurable, and at length it ends in 
 ulceration of the cartilages, abscesses, he. 
 When there is considerable pain, in conse- 
 quence of the cartilages beginning to ulce - 
 rate, partial relief may be derived from 
 fomentations and poultices but nothing- 
 will effect a cure Hence, when the health 
 begins to suffer, he considers amputation to 
 be indicated. (Med. Chir. Trans, p. 254.) 
 
 When white-swellings are accompanied 
 with ulceration of the cartilages, all motion 
 of the joint is extremely hurtful. Indeed, as 
 Mr. Brodie well observes, keeping the limb 
 in a state of perfect quietude is a very im- 
 portant, if not the most important circum- 
 stance, to be attended to in the treatment. 
 According to this gentleman, it is in these 
 cases, in which ulceration of the cartilages 
 occurs as a primary disease, that caustic 
 issues are usually productive of singular 
 benefit ; but he deems them of little use in 
 any other diseases of the joints. He thinks 
 setons and blisters, kept open with savine 
 cerate, may also be used with advantage. 
 Bleeding is indicated only when, from 
 improper exercise, the articular surfaces 
 are inflamed, and there is pain and fever. 
 Mr. Brodie asserts, that the warm bath re- 
 lieves the symptoms in the early stage, if 
 it does not stop tiie progress of the disease ; 
 but he condemns plasters of gum ammoniac, 
 embrocations, liniments, and frictions, as 
 either useless or hurtful. (S ee Medico- Chir. 
 Trans. Vol. 6, p. 332 — 334.) 
 
 Topical applications, consisting of strong 
 astringents of the mineral and vegetable 
 kingdom, are of no service in examples of 
 ulceration of the cartilages, or of the scro- 
 fulous form of the disease, though they 
 often suffice for the cure of some mild de- 
 scriptions of white-swelling, depending 
 upon a thickening of the synovial mem- 
 brane. A decoction of oak bark, containing 
 alum, was recommended by Mr. Russel. 
 
 My own experience will not allow me to 
 say any thing in favour of electricity, as an 
 application for the relief of white-swellings; 
 and it must be more likely to do harm than 
 good, whenever the indication is to lessen 
 irritation. 
 
 “ If the tumour is quite indolent, (says 
 Richerand) the application of galvanism 
 may be proposed; it is not, however, ex- 
 empt from danger . and, on one occasion, 
 where I employed it, lancinating pains and 
 swelling of the joint were brought on by it. s 
 (JVosogr. Chir. T. 3, p. 174, Ed. 2.) 
 
 Mr. John Hunter had confidence m cicuta 
 and sea bathing, as possessing power over 
 many scrofulous diseases ; and that such 
 diseases of the joints are often materially 
 benefited by the patient’s going to the sea- 
 side and bathing, is a fact which cannot be 
 doubted, whatever may be the mode of 
 explaining the benefit thus obtained. I fully 
 
JOINTS. 
 
 138 
 
 believe that sea-air and sea-bathing have a 
 beneficial influence over scrofulous dis- 
 eases of the joints ; but probably their 
 effects are produced on the part through the 
 medium of tiie constitution, and they should 
 only be recommended as an auxiliary plan, 
 to be adopted in conjunction with other 
 still more efficacious measures. 
 
 Every one is well acquainted with the 
 efficacy of friction in exciting the action of 
 the absorbents. To this principle we are 
 to impute the great benefit which arises 
 from what is termed dry rubbing , in cases 
 of • white-swellings. This kind of friction is 
 performed by the mere hands of an attend- 
 ant, without using at the same time any 
 kind of liniment, or other application what- 
 soever, excepting sometimes a little flour, 
 or powdered starch, arid the rubbing is con- 
 tinued several hours every day. At Oxford 
 many poor persons earn their livelihood by 
 devoting themselves to this species of 
 labour, for which they are paid a stipulated 
 sum per hour. This practice, however, is 
 chiefly advantageous in the chronic stage 
 of while-swelling, arisingfrom inflammation 
 of the synovial membrane. 
 
 I look upon all mere emollient appiica- 
 eations, such as fomentations and poultices, 
 as quite destitute of real efficacy, except 
 when great pain or active inflammation is 
 present, and, though they serve to amuse the 
 patient, they ought not to be recommended. 
 That surgeon, who merely strives to please 
 his patient’s fancy, without doing any real 
 good to him. in regard to his affliction, may 
 be considered as doing harm, because the 
 semblance of something being done too 
 often hinders other really useful steps from 
 being pursued. The French surgeons are 
 particularly liberal in the praises which 
 they bestow on warm emollient remedies, 
 poultices, steam of hot water, fomentations, 
 Lc. and they adduce instances of white- 
 swellings being cured in this manner. But 
 the cases to which they refer were no doubt 
 mere inflammations, and thickening of the 
 synovial membrane ; a disease which in 
 general readily yields to several other 
 plans. 
 
 The only method of treatment which my 
 own personal experience enables me to 
 recommend for scrofulous white-swellings 
 in a chronic state, consists in keeping up a 
 discharge from the surface of the diseased 
 joints. The opportunities which I have had 
 of observing the effects of blisters, and caus- 
 tic issues, rather incline me, however, to 
 prefer the former to the latter. 1 have seen 
 great good derived from both ; but more 
 from blisters than the other kind of issue. 
 There are instances in which 1 should 
 employ vesicating applications; there are 
 others in which I should prefer making an 
 eschar with caustic. In particular indivi- 
 duals blisters create so much irritation, 
 heat, fever, and suffering, that a perseve- 
 rance in them would be rashness. 
 
 The blister should always be large. Many 
 -urgeons, instead of following Mr. Crow- 
 ther’s plan, prefer blistering, first, one 
 
 side of the joint, and then the other, alter- 
 nately, for a considerable length of time. 
 “ Blisters (says Mr. Latta) maybe put upon 
 each side of the patella, and ought to be of 
 such a size and shape as to cover the whole 
 of the swelling on the inside, from the 
 hinder part of the joint, at the .edge of the 
 hollow of the thigh, to the edge of the 
 patella, over the whole extent of the swell- 
 ing above and below. As soon as the blister 
 is taken off' from one side, it ought to be 
 applied to the other, and thus repeated, 
 alternately, until both swelling and pain be 
 completely removed. When this is the 
 case, the patient ought to be directed to 
 rub the joint well with a liniment, compo- 
 sed of half an ounce of camphor, dissolved 
 in two ounces of oil, with the addition of 
 half an ounce of spir. sal-ammon. caust. or, 
 as it is now called, liquor ammoniaj. This 
 is to be used three times a day ; and in this 
 way, (continues Mr. Latta) l have success- 
 fully treated many cases of white-swellings.” 
 (Syst. of Surgery , Vol. 1, chap. 6.) 
 
 In the beginning, caustic issues are even 
 more painful than blisters ; but they after- 
 ward become more like indolent sores, and 
 are more easily kept open for a length of 
 time than blisters. Such issues, are com- 
 monly made on each side of the diseased 
 joint, and of about the size of a half crown. 
 The manner of making the eschars, and 
 keeping these issues open, has been already 
 explained. (See Issue.) 
 
 The question has been contested, among 
 surgical writers and practitioners, whether 
 blisters and issues produce benefit upon the 
 principle of counter irritation, or in conse- 
 quence of the discharge which they occa- 
 sion. They probably operate efficaciously 
 in both ways ; for there is no doubt that 
 mere rubefacients possess the power of 
 rousing the action of the absorbents, and 
 they may also modify the vascu!ar > action 
 in diseased parts. These applications can 
 obviously only act upon the principle of 
 counter irritation, and they have not been 
 here recommended particularly for white- 
 swellings, because, it seems to me, .that 
 whenever some good might be derived 
 from their employment, much more benefit 
 might always be obtained from blisters and 
 issues. This sentiment is confirmed by ex- 
 perience, and we must, therefore, impute a 
 great degree of efficacy to the maintenance 
 of a purulent discharge from the vicinity of 
 the diseased part. 
 
 Though my own observations have led 
 me to think issues and blisters as efficient 
 as any means hitherto devised for stopping 
 the progress of scrofulous disease of the 
 heads of the bones, l am far from meaning 
 to say, that sucli disease can generally be 
 stopped by these or any other remedies, 
 local or general. Mr. Brodie has seldom 
 known any benefit derived from blisters or 
 stimulating liniments; nor has he seen the 
 same degree of good produced by issues in 
 scrofulous cases, as in examples of primary 
 ulceration of the cartilages. Cold evnpo 
 rating lotions in the early stage of the coir 
 
JOINTS. 
 
 plaint ; peiTect quietude of the joint ; atten- 
 tion to the patient’s health ; and riding in a 
 carriage in the fresh air ; are the means 
 which this gentleman particularly recom- 
 mends in scrofulous diseases ot the joints. 
 During the formation of abscesses, he ap- 
 proves of fomentations and poultices. {Pa- 
 thol. Ohs. p. 242.) 
 
 We have noticed the efficacy of friction 
 in exciting the action of the absorbents, by 
 which the thickened state of parts around 
 the affected joint may be considerably less- 
 ened, and, on this principle, the utility of 
 dry rubbing arises. We have now to notice 
 the method of producing the same effect by 
 pressure, a plan which yet seems to merit 
 a more extensive trial. I have seen in St. 
 Bartholomew’s Hospital, a few cases in 
 which the swelling of the joints was mate- 
 riaPy diminished, by encircling the morbid 
 articulations with strips of adhesive plaster, 
 applied with moderate tightness. 
 
 A somewhat similar plan, though its mo- 
 dus operandi is differently accounted for, 
 appears also to have been tried in France. 
 
 11 J’ai dans quelques occasions (says Ri- 
 cberand) obtenu les plus grands avantages 
 de ^application d’uri taffetas eire autour de 
 l’articulation tumefiee. On coupe un mor- 
 ceau de cotte etoffe, assez large pour enve- 
 lopper la totalite de la tumeur ; on enduit 
 les bords d’une gomme dissoute. dans le 
 vinaigre, et susceptible de la faire adherer 
 intimement h la peau ; on l’applique en- 
 suite de maniere que toute 1’acces soit inter- 
 dit k Pair entre lui et les teguments. Lors- 
 qu’au bout de quelques jours on leve cet 
 appareil, on trouve la peau humide, ramollie 
 par l’humeur de la transpiration condens6e 
 en goutelettes a la surface interieure du 
 taffetas. Dans ce procede, on fetablit un 
 espece de bain de vapeur autour de l’articu- 
 lation malade.” (Nosogr. Chir. T. 3 ,p 175, 
 Edit. 2.) 
 
 My friend, the late Mr. Clement Wilson 
 Cruttwell, of Bath, sent me a very excel- 
 lent case, illustrative of the efficacy of 
 treatment by pressure. He remarks that, 
 “ After cupping the part, and endeavouring 
 to quiet the inflammation, I used blisters ; 
 but they excited such intolerable pain, and 
 produced so great a degree of swelling and 
 inflammation, that I was under the necessity 
 of healing them immediately. After two 
 months strict confinement to bed, and the 
 use of leeches and refrigerant washes, the 
 inflammation having again subsided, and 
 the pain being removed, I again ventured 
 to apply one small blister, and again a 
 similar attack of pain, swelling, and inflam- 
 mation was produced. The joint became 
 distended with fluid, of which it had always 
 contained a large quantity, and the irritation 
 of the constitution was excessive. By the 
 liberal use of opium I once more succeeded 
 in quieting the disturbance, and, convinced 
 of the hazard of using blisters in such a sub- 
 ject, I applied moderate pressure, by means 
 of a roller, together with a wash, containing 
 a large proportion of spirit, in order to keep 
 up a constant evaporation. Th# skin, which 
 
 was before much inflamed, and hard, has be 
 come natural and flaccid, the pain has cea 
 sed,the swelling has diminished, and I have 
 every prospect of effecting a cure, with 
 the preservation of tolerably free motion in 
 the joint.” 
 
 Mr. Cruttwell, in a subsequent letter, in- 
 formed ine, that this case got completely 
 well by the treatment with pressure, and 
 had remained so for upwards of six months 
 under full and free exercise. 
 
 This example dearly evinces the impro- 
 priety of using blisters in certain constitu- 
 tions. In some remarks, annexed to the 
 above case, Mq. Cruttwell expresses his con- 
 viction, that absolute rest, cold applications, 
 and pressure, would succeed in very many 
 cases, without local counter irritation. 
 Pressure, he adds, succeeds best when fluid 
 is effused, and the disease is indolent ; but 
 he is convinced that it may be used with 
 advantage in later stages, when abscesses 
 have formed, and sinuses already exist ; and 
 he reminds me how very serviceable con- 
 tinued pressure is to the scrofulous finger- 
 joints of children. 
 
 The good effects of pressure in scrofulous 
 cases are confirmed by the observations of 
 Mr. Brodie: when, says he, after several 
 abscesses have taken place, the tendency 
 to suppuration has ceased, and the swollen 
 joint has become diminished, anchylosis is 
 probably disposed to take place. At this 
 period, pressure, by means of strips of linen . 
 spread with soap-cerate, or some other mo- 
 derately adhesive plaster, and applied in a 
 circular manner round the limb, will be 
 productive of benefit. ( Pathol . and Sur z 
 Obs. p. 243.) 
 
 When the knee is affected, the limb 1ms 
 a tendency to become permanently bent 
 It must undoubtedly be judicious to pre 
 vent this position, by means of splints, 
 which will also serve to prevent all motion 
 of the diseased joint, an object of the verv 
 highest importance. Were the disease to 
 end in anchylosis, the advantage of having 
 the limb in a state of extension need scarcely 
 be mentioned. 
 
 In cases which commence in the cancel- 
 lous structure of the heads of the bones, it 
 seems rational to combine, with the local 
 treatment, the employment of such internal 
 remedies as have been known to do good in 
 other scrofulous diseases. “ It is to be sup- 
 posed, (as Mr. Brodie observes) that the 
 air of a crowded city must be more or less 
 unfavourable ; and that a residence on the 
 seacoast is likely to be more beneficial than 
 a residence in the country elsewhere. The 
 patient should live on a nourishing, but 
 plain diet ; he should be in the open air in 
 summer, as much as he can, without exer- 
 cising the joint. His mode of life should, 
 in all respects, be regular and uniform, " 
 Mr. Brodie has found more benefit derived 
 from the long use of steel medicines than 
 any others, suspending their use, however, 
 and substituting the mineral acids for them, 
 when the formation of abscesses excites 
 febrile action. With such means, in child- 
 
ren, he combines Ihe occasional exhibition of 
 mercurial purgati ves. ( Pathol . Obs. p.245.) 
 In a work, whicfai Mr. Lloyd has just pub- 
 lished, it is assumed as a fact, that, in scro- 
 fula, there always is more or less disorder 
 of the functions of the digestive organs, and 
 primarily of no other important function. 
 Hence, the regulation of diet, the state of 
 the bowels, and the hepatic secretions, is 
 with this geritlema n a principal object ; and, 
 with the latter views, he employs, after 
 Mr. Abernethy’s plan, five grains of the 
 blue pill every night, and half a pint of 
 decoct, sars. twice a day, with opening 
 medicines, if necessary, to procure regular 
 daily evacuations. When acidity of the 
 stomach is present, he gives soda, and, 
 when the stomach is weak, cinchona, steel, 
 and mineral acid<;. (On Scrofula, p. 37, 
 «!pc.) However, no doubt can be entertain- 
 ed, that these means, like many others, have 
 no specific power over scrofulous diseases, 
 and, like sea-air and sea-bathing, only 
 answer by sometimes improving the state 
 of the constitution. In the local treatment 
 of scrofulous joints, Mr. Lloyd commends 
 quietude of the limb, which is to Jbe confi- 
 ned in a sling, or im splints, the occasional 
 resistance of inflammatory action by leeches, 
 and a diminution of temperature ; poul- 
 tices when abscesses form ; opening such 
 collections of matter early; and, after all 
 irritation has ceased, issues, setons, blisters, 
 or the antimoniaj ointment ; or compres- 
 sion upon Mr. Baynton’s plan. (P. 152, 
 fyc.) With respect to opening these ab- 
 scesses early, Mr. Lloyd differs from many 
 excellent surgeons, especially Dr. Albers, 
 who distinctly states, that it is generally 
 best to allow' them to burst of themselves. 
 On this subject, however, great diversity of 
 opinion prevails, and Langenbeck is among 
 the advocates for making an early opening. 
 (Bibl. B. 2, p. 39.) Hectic symptoms are 
 those which we commonly have to palliate 
 in these cases. When the appetite is im- 
 paired, and the stomach will bear bark, this 
 medicine should be given with the aromatic 
 confection. Above all internal remedies, 
 opium claims the highest recommendation, 
 as it at once tends to keep off and relieve 
 a debilitating diarrhoea, which too frequently 
 prevails, at the same time that it alleviates 
 pain and procures deep. The objection, 
 made against its exhibition on the ground 
 ihat it increases perspiration, seems exceed- 
 ingly frivolous, when the above important 
 benefits are taken into consideration. 
 
 Too often, however, the terrible disease 
 of which we are now treating, baffles all 
 human skill and judgment, and the unhappy 
 patient’s health having declined to the lowest 
 state, he is necessitated to submit to ampu- 
 tation, as the only chance of preserving life. 
 It has been explained in speaking of Amputa- 
 tion, that the condition of the patient’s 
 health, and not of the diseased joint, forms 
 the principal reason for recurring to the 
 severe operation of removing the limb. If 
 the patient’s constitution be equal to a longer 
 struggle, no man can pronounce that every 
 
 prospect oi saving the limb is at an end. 
 Many diseased joints, apparently in the most 
 hopeless condition, frequently take a favour- 
 able turn, and, after all, allow the limb to 
 
 be saved. 
 
 The proposal of cutting out diseased 
 
 joints, has been considered in the article 
 Amputation. 
 
 Disease of the Hip-joint. — This complaint 
 is very analogous in its nature to the white- 
 swelling of other articulations. In the same 
 vay ns the latter disorder, it seems probable, 
 that the disease of the hip has its varieties, 
 some of which may be connected with 
 scro f u!a, while others cannot be suspected 
 to have any concern with it. Mr. Brodie’s 
 investigations lead him to believe, however, 
 that ihe disease is of that nature, in which 
 the first change is disease and ulceration of 
 the cartilages. The present complaint is 
 most frequently seen in children under the 
 age of fourteen ; but, no age, no sex, no 
 rank, nor condition of 'life is exempt from 
 the possibility of being afflicted, so that 
 though children form a large proportion of 
 those subjects, who are attacked ; yet the 
 number of adults, and even of old persons, is 
 considerable. 
 
 The approach of the disease of the hip- 
 joint is much more insidious, than that of a 
 white-swelling. Some degree of pain always 
 precedes the latter affection ; but, the only 
 forerunner of the former is frequently a slight 
 weakness, and limping of the affected limb. 
 These trivial symptoms are very often not 
 sufficiently urgent to excite much notice, 
 and, when observed by superficial practition 
 ers, are commonly neither understood, nor 
 treated according to the dictates of surgical 
 science. As there is, also, sometimes an 
 uneasiness in the knee, w'hen the hip is 
 affected, careless practitioners frequently 
 mistake the seat of disease, and I have man) 
 times seen patients, on their entrance into 
 an hospital, having a poultice on their knee, 
 while the wrong state of the hip was not at 
 all suspected. 
 
 This mistake is extremely detrimental to 
 the patient, not on account of any bad effect, 
 resulting from the applications so employed ; 
 but, because it is only in the incipient period 
 of the complaint, that a favourable prognosis 
 can be made. In this stage of the disease, 
 mere rest and repeated topical bleeding, will 
 do more good in the course of a fortnight, 
 than large painful issues will afterward 
 generally accomplish in the long space of 
 a twelvemonth. 
 
 The symptoms of the disease of the hip- 
 joint, when only looked for in the situation 
 of that articulation, arc not very obvious to 
 the surgical examiner. Though, in some 
 instances, the attention of the surgeon is 
 soon called to the right situation of the 
 disease, by the existence of a fixed pain 
 behind the trochanter major ; yet, it is too 
 often the case, that mere pain about an 
 articulation, entirely destitute of visible en 
 largcment and external alteration ot colour, 
 is quite disregarded, as a complaint of no 
 importance in young subjects, and as a TO or*' 
 
JOINTS. 
 
 161 
 
 rheumatic, or gouty affection, in adults. 
 Patients frequently complain of their most 
 painful sensations being in the groin, and all 
 accurate observers have remarked, that, in 
 the hip disease, the pain is not confined to 
 the real seat of disease, but shoots down 
 the limb, in the course of the vastus exlernus 
 muscle to the knee. 
 
 The pain, says Mr. Brodie, is at first 
 trifling, and only occasional ; but, it after- 
 ward becomes severe and constant. It re- 
 sembles a good deal the pain of rheumatism, 
 since it often has no certain seat. As the 
 disease advances, the pain becomes exceed- 
 ingly severe, particularly at night, when the 
 patient is continually roused from his sleep 
 by painful startings of the limb. Sometimes 
 he experiences a degree of relief in a parti- 
 cular position of the joint, and no other. As 
 the pain increases in intensity, it becomes 
 more fixed. In the greater number of in- 
 stances, it is referred both to the hip and 
 knee, and the pain in the latter joint is gene- 
 rally the most severe. At other times, there 
 is pain in the knee, and none in the hip. A 
 boy, in St. George’s hospital, complained of 
 pain in the inside of the thigh near the 
 middle ; and another patient referred the 
 pain to the sole of the foot. Wherever the 
 pain is situated, it is aggravated by the 
 motion of the joint, and especially by what- 
 ever occasions pressure of the ulcerated 
 cartilaginous surfaces against each other. 
 (Brodie's Pathol. Obs. p. 139.) 
 
 The early symptoms of disease in the hip- 
 joint are only strongly delineated to such 
 practitioners, as have acquired the necessary 
 information relative to this part of surge- 
 ry, from careful study and extensive experi- 
 ence. 
 
 We shall next trace those characters of 
 the present disease, which serve to denote 
 its existence. 
 
 It is a curious circumstance, that when 
 the functions of a limb are obstructed by dis- 
 ease, the bulk of the member generally 
 diminishes, and the muscles become emacia- 
 ted. Nearly as soon as the least degree of 
 lameness can be perceived, the leg and thigh 
 have actually wasted, and their circumfer- 
 ence has diminished 
 
 If the surgeon make pressure on the front 
 of the joint, a little on the outside of the 
 femoral artery, after it has descended below 
 the os pubis, great pain will be experienced. 
 
 “ Soon after the commencement of the 
 complaint, (as Mr. Brodie remarks,) the hip- 
 joint is found to be tender, whenever pres- 
 sure is made on it either before or behind. 
 The absorbent glands become enlarged, and 
 occasionally there is a slight degree of gene- 
 ral tumefaction in the groin.” The same 
 gentleman has also adverted to the curious 
 circumstance of there being in some cases a 
 tenderness of the parts, to which, though not 
 diseased themselves, the pain is referred 
 from sympathy with the disease of the hip. 
 This occurrence he has observed in the knee 
 several times, and in one instance in the 
 course of the peroriaeal nerve. He has also 
 seen a slight degree of puffv swelling of the 
 Vol. II. ’ 21 
 
 knee in a case, in which pain was referred 
 to this joint, in consequence of disease of 
 the hip. (P. 142, 143.) 
 
 The limping of the patient is a clear proof, 
 that something about the limb is wrong, and, 
 if such limping cannot be imputed to disea- 
 sed vertebrae, or some recent accident, and 
 if, at the same time, the above-mentioned 
 emaciation of the limb exists, there is great 
 cause to suspect, that the hip is diseased, 
 particularly when the pain is augmented by 
 pressing the tront of the acetabulum. 
 
 Diseased vertebrae, perhaps, always pro- 
 duce paralytic affection of both legs at once, 
 and they do not cause painful sensations 
 about the knee, as the hip disease does. 
 
 The increased length of the liinb, a symp- 
 tom that has been noticed by all practition- 
 ers since De Haen, is a very remarkable and 
 curious occurrence, in tue early stage of the 
 present disease. This symptom is easily de- 
 tected by a comparison of the condyles of 
 the os femoris, the trochanter major, and 
 malleoli, of the diseased limb, with those 
 parts of the opposite member, taking care 
 that ihe patient’s pelvis is evenly situated. 
 The thing is the more striking, as the in- 
 creased length of the member is frequently 
 as much as four inches. The rationale of 
 this fact, John Hunter used to explain by 
 the diseased side of the pelvis becoming 
 lower than the other. (Croivther, p. 266.) 
 The same thing bad also been noticed by 
 Falconer, (On fschias, p. 9) long before the 
 period, when Mr. CrowtUer printed his se- 
 cond edition. 
 
 It is easy (says Mr. Brodie,) to understand 
 how the crista of one ilium becomes visibly 
 depressed below the level of the other, when 
 the position is remembered, in which the 
 patient places himself when he stands erect. 
 u He supports the weight of his body upon 
 the sound limb, the hip and knee of which 
 are in consequence maintained in the state 
 of extension. At the same time, the oppo- 
 site limb is inclined forward, and the foot 
 on the side of the disease is placed on the 
 ground considerably anterior to the other, 
 not for the purpose of supporting the super- 
 incumbent weight, but for that of keeping 
 the person steady, and preserving the equi- 
 librium. Of course, this cannot be done, 
 without the pelvis on the same side being 
 depressed. The inclination of the pelvis is 
 necessarily attended with a lateral curvature 
 of the spine, and hence one shoulder is 
 higher than the other, and the whole figure 
 in some degree distorted.” ( Pathol . Obs. p. 
 146.) These effects, says Mr. Brodie, are in 
 general all removed by the patient’s lying in 
 bed a few weeks, except when the deformity 
 has continued a long time in a young growing 
 subject. 
 
 In justice to the memory of the late res- 
 pected Dr. Albers, of Bremen, I ought here 
 to mention, that he appears in his work on 
 Coxalgia, to have firs! pointed out the de- 
 formity of the spine in this disease, and the 
 reason of such change, the tenor of his ob- 
 servations upon this point agreeing with 
 those subsequently made bv Mr. Brodie 
 
JOINTS. 
 
 m 
 
 An appearance of elongation of the limb 
 is not exclusively confined to the early stage 
 of the morbus coxarius : it may attend other 
 4 eases. I remember seeing in one of the 
 wards of St. Bartholomew’s Hospital, a little 
 girl, with a diseased knee, whose pelvis was 
 considerably distorted in this manner, so 
 that the limb of the same side appeared 
 much elongated Her hip- joint was quite 
 Sound. This case was pointed out to Mr. 
 Lawrence and myself by Mr. Cother, of 
 Gloucester. 
 
 Vo!pi, Albers, and several other foreign 
 vrritex’s, point out the fact, that the early 
 stage of this disease is sometimes attended 
 with an appearance of elongation, sometimes 
 with that of a shortening of the limb. An 
 explanation of the circumstance is given by 
 Mr Brodie, as follows : “ In a few cases, 
 where the patient is in the erect position, it 
 may be observed, that the foot, which be- 
 longs to the affected limb, is not inclined 
 more forward than the other, but the toes 
 only are in contact with the ground, and the 
 heel raised, at the same time that the hip 
 and knee ave a little bent. This answers to 
 the patient the same purpose of enabling him 
 to throw the weight of his body on the other 
 foot ; but it produces an inclination of the 
 pelvis in the opposite direction. The crista 
 of the ilium is higher than natural, and there 
 is an apparent shortening, instead of elonga- 
 tion of the limb on the side of the disease.” 
 ( Pathol . and Surg. Obs. p. 147.) 
 
 Mr. Ford has very accurately called the 
 attention of surgeons to the alteration, with 
 respect to the natural fulness and convexity 
 of the nates, that part appearing flattened, 
 which is usually most prominent. I he glu- 
 tasus raagnus becomes emaciated, and its 
 edge no longer forms so bold a line, as it na- 
 turally does at the upper and back part of 
 the thigh, in the sound state of the limb. 
 
 Although this symptom, in combination 
 with others, is of importance to be attended 
 to, it has been explained by Mr. Brodie, that 
 {C it is not in itself to be regarded , as a certain 
 diagnostic mark of disease in the hip ; since, 
 in its early stage, this symptom is wanting ; 
 and it is met with in other diseases, in which 
 the muscles in the neighbourhood of the hip 
 are not called into action, although the joint 
 itself is unaffected. (See Medico- Chir. Trans. 
 Vol. 6 , p. 322 .) 
 
 Though there may be more pain about 
 the knee than the hip, at some periods of 
 the malady in its incipient state, yet the 
 former articulation may be bent and extend- 
 ed, without any increase of uneasiness ; but, 
 the os femoris cannot be moved about, 
 without putting the patient to immense tor- 
 ture. 
 
 The patient soon gets into the habit of 
 bearing the weight of his body chiefly upon 
 the opposite limb, while the thigh of the 
 affected side is bent a little forward, that the 
 ground may only be partially touched with 
 the foot. This position is found to be the 
 most comfortable, and every attempt to 
 extend the limb occasions a*i increase of 
 pfttn, 
 
 This is the first stage of the disease, 
 or that which is unaccompanied with sup pu- 
 ration. 
 
 The symptoms which precede the forma- 
 tion of pus, vary in different cases, accord- 
 ing as there is acute, or chronic inflamma- 
 tion present. When the diseased joint is 
 affected with acute inflammation, as gene- 
 rally happens, the surrounding parts become 
 tense and extremely painful ; the skin is 
 even reddish ; and symptoms of inflamma- 
 tory fever prevail. When the severity of 
 the pain abates, a swelling occurs in the 
 vicinity of the joint, and a pointing quickly 
 follows. In this stage startings and catchings 
 during sleep are said to be among the most 
 certain signs of the formation of matter. 
 “ The shortening of the limb,” says Mr. 
 Brodie, “ which usually takes place in the 
 advanced stage of the disease, is usually, 
 but not always the precursor of abscess. The 
 formation of matter is also indicated by an 
 aggravation of the pain ; by more frequent 
 spasms of the muscles, by a greater wasting 
 of the whole limb, and by the circumstance 
 of the thigh becoming bent forward, and 
 being incapable of extension,” and by the 
 pulse becoming quick, the tongue furred, 
 and the whole system being in a state of pre- 
 ternatural excitement. f \ The abscess usu- 
 ally shows itself in the form of a large tu- 
 mour over the vastus externus muscle ; some- 
 times on the inside of the thigh, near the 
 middle ; and occasionally two or three ab- 
 scesses appear in different parts, and burst in 
 succession.” ( Brodie's Pathol. Obs. p. 152.) 
 
 We have noticed the commonly lengthen- 
 ed -state of the limb, in the first periods of 
 the hip disease. This condition is not of 
 very long duration, and is sooner or later 
 succeeded by a real shortening of the affect- 
 ed member. The foot may be turned in- 
 wards ; but, as Mr. Brodie observes, if left 
 to itself, it is generally turned outwards. In 
 other cases, the limb is shortened ; the thigh 
 is bent forwards ; the toes are turned inwards, 
 and do not admit of being turned outwards ; 
 (Pathol. Obs.p. 148;) and all the symptoms 
 of a luxation of the thigh upwards and out- 
 wards may be observed, the head of the bone, 
 indeed, being actually drawn into the external 
 iliac fossa, and carried betwixt the os inno- 
 minatum and glutaeus minimus, which is 
 raised up by it. (See Richerand JYosogr. 
 Chir. T. 3, p. 171, 172, Ed. 2.) 
 
 When the retraction is very considerable, 
 it arises from nothing less than an actual dis- 
 location of the head of the thigh-bone, in 
 consequence of the destruction of the car- 
 tilages, ligaments, and articular cavity. This 
 retraction sometimes comes on long before 
 any suppuration takes place The head of 
 the bone is sometimes dislocated, and the 
 disease terminates in anchylosis, without 
 any abscess whatever. However, if sup- 
 puration has not taken place, Mr. Brodie be- 
 lieves, it rarely happens, that the limb, after 
 the cure, does not regain its natural degree 
 of mobility. (See Med. Chir. Trans. Vol. 6, 
 p. 325.) 
 
 It is worthy of particular notice, that the 
 
JOINTS. 
 
 163 
 
 head of the hone is always luxated upwards 
 and outwardB ; and the only exception to 
 this observation, upon record, is a case re- 
 lated by Cocchi, in which a spontaneous dis- 
 location of the thigh-bone, as it is termed, 
 happened upwards, forwards, and a little 
 inwards. (See LeviilU, JYouvelle Doctrine 
 Chir. T. 3. p. 695.) On a egalement vu la 
 tete du femur luxee en dedans et en bas, et 
 placee sur le trou obturateur, mais cette 
 mode de deplacement consecutif, dans lequel 
 le membre est alonge, est infiniment rare. 
 (Richerand, JYosogr. Chir T 3, p. 172.) 
 
 The hip disease generally induces hectic 
 symptoms, after it has existed a certain time. 
 In some subjects, such symptoms soon come 
 on ; in others, the health remains unaffected 
 a very considerable time. 
 
 “ The health of the patient (says Mr. Bro- 
 die) usully suffers, even before abscesses have 
 formed, from the want of exercise pain, and 
 particularly from the continued disturbance 
 of his natural rest. I recollect no instance 
 of an adult, in w hom abscesses had formed, 
 and who did not ultimately sink exhausted 
 by the hectic symptoms which these indu- 
 ced. Children may recover in this ultimate 
 stage of the disease ; but, seldom without a 
 complete anchylosis of the joint.” (Med. 
 Chir. Trans. Vol A i, loco cit.) 
 
 When abscesses of the above description 
 burst, they contir.ue, in general, to emit an 
 unhealthy thin kind of matter for a long 
 time afterward. 
 
 With respect to the morbid anatomy of 
 the disease in its incipient state, until lately 
 little was known. A few years ago tw o dis- 
 sections related by Mr. Ford were, perhaps, 
 the only ones throwing light upon this point. 
 In one, there was a tea-spoonful of matter 
 in the cavity of the hip joint. The head of 
 the thigh-bone was a little inflamed, tfce cap- 
 sular ligament a little thickened, and the 
 ligamentum teres united in its natural way 
 to the acetabulum. The cartilage lining the 
 cotyloid cavity was eroded in one place, 
 with a small aperture, through which a probe 
 might be passed, underneath the cartilage, 
 into the internal surface of the os pubis on 
 one side, and on the other, into the os iscliii ; 
 the opposite, or external part of the os in- 
 uominatum showing more appearance of 
 disease, than the cotyloid cavity. In the 
 other instance, the disease was more advan- 
 ced. These examples are important, inas- 
 much as they prove that what is commonly 
 called the disease of the hip joint, primarily 
 affects the cartilages, ligaments, and bones, 
 and not the surrounding soft parts, as De 
 Haen and some others would lead one to 
 believe. 
 
 As the disorder advances, the portions of 
 the os ischium, os ilium, and os pubis, com- 
 posing the acetabulum, together with the in- 
 vesting cartilage, and synovial gland, are 
 destroyed. The cartilage covering the head 
 of the os femoris, the ligamentum teres, and 
 capsule of the joint, suffer the same fate, 
 and caries frequently affects not only the 
 adjacent parts of the ossa innominata, but 
 also the head and neck of the thigh- 
 
 bone. The bones of the pelvis, however, 
 are always more diseased than the thigh- 
 bone, a fact which displays the absurdity of 
 ever thinking of amputation in these cases. 
 Mr. Ford observes, “In every case of dis 
 ease of the hip joint, which has terminated 
 fatally, I have remarked, that the os inno- 
 minatum has been affected by the caries in 
 a more extensive degree, than the thigh bone, 
 itself’ (Observations on the Disease oj the 
 H>p joint, p. 107.) 
 
 Sometimes how ever, the head and neck 
 of the thigh-bone are annihilated, as well as 
 the acetabulum. 
 
 Mr. Brodie has had opportunities of dis- 
 secting some diseased hip joints both in the 
 incipient and advanced stage of the com- 
 plaint. From his observations, it appears ; 
 1st. That the disease commences w ith ulcera- 
 tion of the cartilages, generally that of the 
 acetabulum first, and that of the femur after- 
 ward. 2. That the ulceration extends to 
 the bones, which become carious ; the head 
 of the femur diminishing in size, and the 
 acetabulum becoming deeper and wider. 
 3. That an abscess forms in the joint, w hick 
 after some time makes its w ay by ulceration, 
 throng! i the synovial membrane and capsu- 
 lar ligament, into the thigh and nates, or even 
 through the bottom of the acetabulum into 
 the pelvis. Mr. A. Cooper showed Mr. Bro- 
 die two specimens, in which the abscess had 
 burst into the rectum. 4. In consequence 
 of the abscess, the synovial membrane and 
 capsular ligament become inflamed and 
 thickened. The muscles are altered in 
 structure ; sinuses are formed in various 
 parts, and, at last, all the soft parts are 
 blended together in one confused mass, 
 resembling the parietes of an ordinary 
 abscess. (Brodie, in Medico-Chir.' Trans. 
 Vol. 4,p. 246, 247.) 
 
 Such are the beginning and progress of 
 the ordinary disease of the hip joint; but, 
 it is admitted by Mr. Brodie, that there are. 
 other scrofulous cases, in which the mis- 
 chief begins in the cancellous structure of 
 the bones, and also other instances, which 
 consist in chronic inflammation and abscesses 
 of the soft parts in the neighbourhood of 
 the hip. (Op. cit. Vol 6, p. 326.) 
 
 External violence; lying down on the 
 damp ground in summertime ; and all kinds 
 of exposure to damp and cold; are the 
 causes to which the disease, has sometimes 
 been referred No doubt, scrofula has, 
 frequently, some concern in its origin ; but, 
 often, no rational cause is assignable for the 
 complaint. 
 
 Treatment of the disease of the Hip Joint. 
 — The writings of Hippocrates, Celsus, C&- 
 lius Aurelianus, Hi c. prove, that the ancients 
 treated the present disease much in the same 
 way, as it is treated by the moderns. Form- 
 ing an eschar, and keeping the sore open ; 
 topical bleeding ; cupping ; fomenting the 
 part, &.c. were all proceedings adopted in the 
 earliest periods ot surgery. Drs. Charlton, 
 Oliver, and Falconer, have extolled Bath 
 w ater, as a most efficacious application to 
 diseased Jiip joints, previ«us to the suppura^ 
 
164 joints; 
 
 live stage. However, had not their accounts in children, and even in grown-up persons, 
 been exaggerated, all patients of this kind when the complaint is recent, they agree in 
 would long ago have flocked to Bath, and thinking blisters capable of affording com- 
 the surgeons in other places would never plete relief. Mr. Brodie states, that in these 
 have had further occasion to adopt a more cases they are more efficacious when kept 
 painful mode of treatment. The plan pur- open with the savine ointment, than repeat- 
 sued at Bath, is to put the patient in a warm edly applied. With respect to issues, he ac- 
 bath, two or three times a week, for fifteen knowledges, that behind the great trochan- 
 
 or twenty-five minutes. 
 
 In the first stage of coxalgia, the late Dr. 
 Albers, however, had a very high opinion of 
 warm bathing, fomentations with decoctions 
 of herbs, and of bathing in mineral waters 
 and the sea. But, though he commenced 
 the treatment with the frequent use of the 
 warm hath, and continued the plan a long 
 while, it is to be remarked, that he also com- 
 bined with it an issue. After the patient 
 had been in the bath a period not exceeding 
 half an hour, he was taken out, and his w r holc 
 body well rubbed with flannel. It appears 
 to me, that one objection to this practice 
 must be the considerable disturbance occa- 
 sioned by moving the patient in this manner 
 every morning ; for if it be true, that most 
 of these diseases commence in the cartilages 
 of the joint, all motion of the limb must be 
 particularly injurious. 
 
 In the early period of the disease, entire 
 rest, the application of fomentations, and 
 the employment of topical bleeding, parti- 
 cularly cupping, are highly proper. Such 
 practice, also, is invariably judicious, when- 
 ever the case is attended with symptoms of 
 acute inflammation. When the fomenta- 
 tions are not applied, the lotio aquae lithar- 
 gyri acetati may be used. 
 
 This method of treatment ought never to 
 be employed, unless manifest signs of active 
 inflammation be present. When no such 
 state exists, this plan can only be regarded 
 as preventing the adoption of a more effica- 
 cious one, and, therefore, censurable. 
 
 “Where the cartilages of the hip are ul- 
 cerated (says Mr. Brodie,) the patient should 
 in the first instance, be confined to a couch, 
 if not to his bed . and if the disease is far 
 advanced, the limb should be supported by 
 pillows properly disposed, so as to favour 
 the production of an anchylosis, by allow- 
 ing it to vary as little as possible from one 
 position.’ (S ee Medico- Chir. Transs. Vol.6,p. 
 335.) 
 
 Quibus diuturno dolore, says Hippocrates,, 
 ischiadico vexalis roxa excidil , iis femur con- 
 tabescit et claudicant , nisi urdntnr. Forming 
 an eschar, or issue, is the most efficacious 
 plan of treating the disease even now 
 known. A caustic issue seems to me more 
 beneficial than a blister. The depression, 
 just behind and below the. trochanter major, 
 is the situation in which surgeons usually 
 make the issue, and ihe size of the eschar 
 should be nearly as large as a crown-piece. 
 It is generally necessary to keep the issue 
 open a very long time. When the thigh-bone 
 is dislocated, and the patient survives, the 
 case mostly ends in anchylosis. 
 
 For the cure of the disease ia adults, 
 Mr- Brodie and Dr. Albers have also ex- 
 pressed a preference to caustic issues ; but 
 
 ter is the most convenient place for them ; 
 but be believes that they have more effect, 
 when made on the outside of the joint on 
 the front edge of the tensor vaginae femoris 
 muscle. Instead of keeping the issue open 
 with beans, Mr. Brodie has found it a more 
 effectual practice to rub the sore, two or 
 three times a week, with the potassa fusa, 
 or sulphate of copper. In particular cases, 
 where the pain was very severe, this gen- 
 tleman made a seton in the groin over the 
 trunk of the anterior crural nerve, which 
 plan, he says, affords quicker relief, though 
 in the end it is less to be depended upon for 
 a cure, than caustic issues. 
 
 In Dr. Albers’s work, the great efficacy of 
 issues and blisters in giving immediate relief 
 to the severe pain in the knee, is illustra- 
 ted by some valuable observations. He 
 speaks also very favourably of the rnoxa, 
 the employment of which he says is not 
 very painful ; a remark, in which Langen- 
 beck concurs. (See Bibl. B. 2, p. 27.) Dr. 
 Albers, in the hectical stages, recommends 
 opium as highly useful, especially when 
 combined with musk, or camphor. 
 
 The occurrence of suppuration makes a 
 vast difference in the prognosis. “ The 
 formation of even the smallest quantity of 
 pus in the joint in cases of this disease, in 
 the young person, considerably diminishes, 
 and in the adult almost precludes the hope 
 of ultimate recovery.” ( Brodie , in Medico - 
 Chir. j£rnns. Vol. 6, p. 347.) This gentleman 
 is no^much in favour of opening the ab- 
 scesses early, at least before the joint has 
 been kept for some time perfectly at rest. 
 He has seen no ill consequences arise from 
 the puncture of the lancet remaining open, 
 and he has not found, that in cases of cari- 
 ous joints, the method of evacuating the 
 matter, recommended by Mr. Abernethy 
 (see Lumbar Abscess,) is attended with any 
 particular advantage. 
 
 Mr. J. Burns, in the second vol. of his 
 “ Dissertations on Inflammation,” p. 314, 
 has recorded a remarkable instance, in which 
 this joint was affected with that intractable 
 and fatal distemper, the fungus hasmatodes. 
 The case was at first, supposed to be the dis- 
 ease, of which we have just been treating in 
 the preceding columns. The limb seemed 
 to be elongated, and issues »vere employed, 
 without any material benefit. The upper 
 part of the thigh swelled, while the lower 
 wasted away. The patient lost ii is appetite, 
 had a quick pulse, and passed sleepless 
 nights. The part was rubbed with anodyne 
 balsam arj,d laudanum given <rvery night ; 
 but, these means were only productive of 
 temporary benefit. After some months, a 
 difficulty of making water came on, which 
 ended in a complete retention. It being 
 
KAL 
 
 KNB 
 
 105 
 
 found impracticable 4o introduce a catheter, 
 and a large elastic tumour, supposed to be 
 the distended bladder, being felt within the 
 rectum, a trocar was pushed into the swell- 
 ing. A good deal of bloody fluid was thus 
 discharged. Afterward a considerable quan- 
 tity of high-coloured fetid urine continued 
 to escape from the urethra In about a 
 week after this operation, the patient died. 
 
 On dissection, Mr. Burns found the hip 
 joint completely surrounded with a soft 
 matter resembling brain, enclosed in thin 
 cells, and here and there other cavities, full 
 of thin bloody water, presented themselves. 
 The acetabulum and head of the os femoris . 
 were both carious The muscles were quite 
 pale, and almost like boiled liver, having 
 lost their fibrous appearance. The same 
 kind of substance w as found in the pelvis, 
 and most of the inside of the affected 
 bones was carious. Large cells, cantain- 
 ing bloody water, w’ere observed in the dis- 
 eased substance, and it was into one of 
 these cavities that the trocar had entered, 
 when the attempt was made to tap the blad- 
 der. Gil. Budceus, De Curandis Articularibus 
 Morbis, 12mo. Paris , 1539. J G. Widdmann , 
 De Genuum Slructvra eorumque Morbis , 
 Hehnstad, 1744 ( Haller , Disp Chir. 4, 489.) 
 Ford’s Observations on the Disease of the Hip 
 joint, to which are added, some remarks on 
 White-Swelling, 8 vo. Lond. 1794. Doerner, 
 De Gravioribus quibusdam Cartilaginum 
 Mutationibns, 8 vo. Tubingee, 1798. Crow- 
 ther on White- Swelling. &,c. Edit. 2, 1808. 
 J. Burns on Inflammation, l of. 2, p. 311. 
 Wm. Falconer, A Dissertation on Ischias, and 
 on the Use of the Bath Waters as a Remedy, 
 8 vo. Lond. 1805. Russel on Morbid Affec- 
 tions of the Knee, 8ro. Edinb. 1802. H. 
 Park, An Account of a New Method of treat- 
 ing Diseases of the Joints of the Knee and 
 Etboxo, 8vo. Lond. 1783 Also H. Park and 
 P. F. Moureau, Cases of the Excision of Ca- 
 rious Joints ; with Obs. by Dr. J. Jeffray, 
 12 mo. Glasg. 1806. J. A. Albers, Abhand- 
 lungen uber die Coxalgie, oderdas sogenannte 
 freyiiillige Hinken der Kinder, 4to. Wien. 
 1807. This icork includes many valuable re- 
 marks, but owing to the crowded state of this 
 edition, it tins been impossible to do his merit 
 sufficient justice. G. Wirth, De Coxalgia, 
 12 mo. Wiceb. 1809. Palelta , Adversaria 
 
 Chir. Prim a, 4 to. Iley's Practical Observa- 
 tions in Surgery, p. 354, fyc. Edit. 3. Boyer, 
 TraiU des Maladies Chir. T. 4, Paris, 1814. 
 Reimarus, De Tumore Ligamentorum circa 
 articulos , Fungo articulorum diclo, Leyden, 
 1757. Brambilla, in Ada Acad. Med. Chir. 
 Vindob. T. 1. Brodies Pathological Re- 
 searches, respecting the Diseases of Joints, in 
 Vol. 4. 5, and 6 of the Medico- Chir urgical 
 Transactions. Also his Pathological and Sur- 
 gical Observations on the Joints , 8vo. Lond. 
 1818 ; a work containing a great dea< of cor- 
 rect and original information. Schreger, Chi- 
 rurgische VersHche, B. 2, p. 209, fyc. Beilrage 
 zur Nosologic der Gtltukkrankheilen, Sr o. 
 Numb erg, 1818. J N. Rust, Arthrokakolo- 
 gie , oder uber die Verrenkungen durch innere 
 Bedirigung, 4to. Wien. 18! 7. A publication 
 of great merit. Dr. Tomaso Volpi, Abhandl. 
 uber die Koxalgie, aus dem Hal. ^bersetzt von 
 Dr P. Heineken. The original I have not 
 seen, but the translation contains copious ex- 
 tracts from the prize essay, which I drew up 
 some years ago, with additional observations 
 and cases. Rtcherand's Nosogr. Chir. T. 3, 
 p. 1 70, Sgc. Ed. 4. Langenbeck, Neue Bibl. 
 B. 2, p. 337. G. Golz, De Morbis Ligamen - 
 torum 4 to. Berol. 1799. Delpech , Precis 
 
 Element, des Mai Chir. T. 2. p. 377, T. 3, 
 p. 194, p. 470, p. 711, fyc. Paris , 1816. H. 
 Mayo, on an acute Form of Ulceration of the 
 Cartilages of Joints, in Med. Chir. Trans. 
 Vol. 2, p. 104. J. Wilson, Lectures on the 
 Structure and Physiology of the Skeleton, and 
 Diseases of the Bones and Joints , 8ro. Lond. 
 1820. E. A. Lloyd , A Treatise on the Na- 
 ture; ^c. of Scrofula, Svo. Lond. 1821. The 
 two last publications deserve attentive perusal, 
 
 JUGULAR VEIN, how to bleed in. See 
 Bleeding. 
 
 Jugular vein, internal, wounded. Dr. 
 Giraud cursorily mentions a case, in which 
 a French surgeon, at the military hospital 
 of Toulouse, early in the year 1814, passed 
 a ligature round the trunks of the common 
 carotid artery and internal jugular vein. 
 Both these vessels had been wounded by a 
 musket-shot. On the sixth day from the ap- 
 plication of the ligature, nothing unfavoura- 
 ble had occurred ; but the final result of the 
 case is not related. (See Journ. G6n6rale de 
 Med. fyc. par Sedillot.) 
 
 K. 
 
 K ALT See Potassa. 
 
 KERATONYXIS. The term, keratonyxis, 
 derived from a horn, and a 
 
 puncture, is employed by the professors in 
 Germany to denote the operation of couch- 
 ing performed through the cornea, or horny 
 coat of the eye, the opaque lens being in 
 this manner sometimes depressed, some- 
 
 times broken piecemeal, and in other in- 
 stances, merely turned, so as to place its an 
 tenor and posterior surface in the horizon- 
 tal position. The latter method is what the 
 German surgeons particularly imply by the 
 phrase reclination. See Cataract. 
 
 KNEE, DISEASES, AND INJURIES 
 OF THE. See Dislocations; Fractures; 
 Gunshot Wounds ; Joints, fyc, 
 
LACHRYMAL ORGAN* 
 
 m 
 
 L. 
 
 ACHRYMAL ORGANS, Diseases of the. 
 The lachrymal gland cannot be said to 
 be apart which is frequently ihe seat of dis- 
 ease. Richerand has s< en no instance of 
 an inflammation of this gland, unless by 
 this expression be implied cases in which 
 all the contents of the orbit are more or less 
 affected. ( JVosogr . t'hir. T 2, p. 32.) I be- 
 lieve that the surrounding cellular substance 
 is more frequently attacked with inflamma- 
 tion and suppuration, than the gland itself. 
 According to Professor Beer, ( Lehre von den 
 Augenkr. B. i, p. 349,) true idiopathic in- 
 flammations of the lachrymal gland are very 
 rare, and he declares, that in the course of 
 a practice of twenty-seven years, he has but 
 seldom met with them. On this point he 
 differs from Schmidt, who fancied that he 
 had often had under his care cases of this 
 description in gouty and scrofulous sub- 
 jects. ( JJeher die Krankh. des Thranenor- 
 gans, p. 134.) When the lachrymal gland 
 is attacked with inflammation, its secretion, 
 far from being augmented, as Richerand de- 
 scribes, is always considerably lessened, 
 and therefore one of the earliest symptoms 
 is an uneasy dry state of the eye, the secre- 
 tion from the meibomian glands, and mu- 
 cous membrane of the eyelids, not being 
 alone sufficient for keeping the eye duly 
 moist and lubricated. This state is succeed- 
 ed by a throbbing acute pain in the temple, 
 shooting to the eyeball, f rehead, upper and 
 lower jaws, and back of the head. In the 
 mean while, the temporal portion of the 
 upper eyelid becomes swelled, tense, red, 
 and exceedingly tender, the tunica conjunc- 
 tiva being scarcely at all affected, and 
 merely exhibiting a slight degree of redness 
 and tumefaction towards the outer canthus. 
 However, as the swelling of the gland in- 
 creases, the eyeball becomes pushed more 
 or less downwards, and inwards towards the 
 nose. But though there is little or no red- 
 ness, nor any mark of inflammation about 
 the eye, this organ is tense, and extremely 
 tender. The freedom of its movements, 
 towards the temple is much lessened in the 
 beginning of the complaint, and, when the 
 tumour has acquired a very large size, is 
 quite destroyed. The impairment of vision 
 is always proportionate to the protrusion of 
 the eyeball, the pupil being diminished, and 
 the iris motionless. The second, or suppu 
 rative stage, Beer describes as ushered in by 
 fiery appearances before the eye ;. an in- 
 creased displacement of the eyeball ; throb- 
 bing pain; great increase of the swelling of 
 the upper eyelid, and of the conjunctiva, 
 towards the temple ; an annoying sensation 
 of cold, and heaviness in the eye and orbit. 
 Now, under febrile symptoms, rigours, be. 
 a yellowish point presents itself, either on 
 the reddened portion of the conjunctiva or 
 on the outside of the eyelid, and a fluctua- 
 tion becomes distinguishable. ( Beer L hre , 
 
 B. l,jp. 350.) beer speaks of abscesses 
 
 sometimes forming in the vicinity of the 
 lachrymal gland, and terminating in a small 
 sinus, w hich communicates with one of the 
 principal excretory tubes, and discharges 
 occasionally a thin limpid fluid. (Lehre von 
 den Augenkr. B. 2,p. 184.) The experience 
 of this author leads him to consider these 
 sinuses either as a consequence of an un- 
 skilfully treated abscess of the upper eye- 
 lid, or of a similar neglected affection of the 
 •cellular membrane, near the lachrymal 
 gland ; or, lastly, of the presence of a por- 
 tion of the sac of a burst encysted tumour. 
 According to Mr. Travers, the lachrymal 
 gland often suppurates in children, and oc- 
 casions an excessive swelling above the 
 upper eyelid, depressing the tarsus so as 
 completely to conceal the eye. The ab- 
 scess, he says, may be conveniently opened, 
 and discharged beneath the eyelid. (Sy- 
 nopsis of the Diseases of the Eye, p. 228.) 
 With respect to the treatment of any local 
 inflammation in and about the lachrymal 
 gland, the best means of relief would be 
 leeches, fomentations, emollient poultices, 
 and other common antiphlogistic remedies. In 
 the suppurative stage, Beer recommends mix- 
 ing with the poultice a good deal of hemlock. 
 
 Ti>e lachrymal gland is subject to scirrhous 
 enlargement, and, in cases of carcinoma of 
 the eye, it is one of the parts in which a re- 
 turn of the disease is apt to occur. Hence, 
 it is now generally considered right to re- 
 move, it as soon as the eyeball has been taken 
 away. (See Eye.) Sometimes the gland is 
 primarily affected, and Guerin removed one 
 in the state of scirrhus, and so much enlarged, 
 that the eye was entirely covered by it. 
 This operation was performed with such 
 dexterity, that the ex’ernal straight muscle 
 was not at all injured. Mi . Travers has also 
 removed a scirrhous and enlarged lachrymal 
 gland. The vision of the eye had suffered 
 considerably during the growth of the tu- 
 mour. The only deformity after the opera- 
 tion, was a slight prolapsus of the eyelid. 
 'This gentleman recommends operations of 
 this kind to be always done, if possible, be- 
 neath the eyelid. ( Synopsis , fyc. p. 22<S.) 
 
 The caruncula lachrymalis is liable to 
 chronic induration and enlargement, consti- 
 tuting the disease already spoken of in a 
 foregoing part of this work, under the name 
 of Encanthis , of which there is also a scir- 
 rhous, carcinomatous, or malignant form, 
 quickly extending its effects to the eyeball, 
 and the adjacent thin hones of the orbit. 
 (Beer, Lehre von den Augenkr. B. 2 ,p. 188.) 
 
 From these subjects, I proceed to consider 
 the diseases of the excreting parts of the 
 lachrymal organs; cases which, though of 
 the most various natures, were formerly all 
 confounded together under the title ol fistula 
 lachrymalis, and it is only within the last 
 few years, that these complaints have been 
 subjected to tin same principles and distinc- 
 tions, which are conceived to be highly nw- 
 
LACHRYMAL ORGANS. 
 
 Ittf 
 
 \ 
 
 tul iu ether branches ot surgery. As Mr. 
 M‘Kenzie has judiciously remarked, the 
 consequence of not distinguishing the dif- 
 ferent diseases of the excreting parts of the 
 lachrymal organs from each other, has been 
 an attempt to discover some single successful 
 method of curing them all. “ Now, there 
 is no one method of treatment by which this 
 can be accomplished ; and hence it is, that 
 the several remedies which have been pro- 
 posed, being eminently successful in one or 
 other of these diseases, but not adapted to 
 all the rest, have at different times been held 
 in such various degrees of estimation.” (On 
 Diseases of the Lachrymal Organs , p. 10, 8 vo. 
 Lond. 1819.) And an intelligent critic ob- 
 serves, that in lachrymal diseases, obstruction 
 of the nasal duct appears to be almost the 
 only circumstance against which the treat- 
 ment recommended by the surgeons of 
 France and England, has been directed. 
 “ On sait qu’au r6tr6cissement ou k l oblitera- 
 tion du canal nasal produits par une cause 
 quelconque, cst due, dans presque tous les 
 cas, la maladie qui nous occupe ; soit que., 
 restees intactes, les parois du sac presentent 
 une tumeur lachrymale, d\>u les larmes re- 
 fluent continuellement sur les joues, k t ravers 
 les points lachrymaux: soit qu’en partie de- 
 truites et ulcerees, res parois presentent une 
 fistule, qui offre aux larmes un passage rontre 
 nature, sans cesse entretenue par elles ; en 
 sorte que ces deux htats, latumeur et la fistule, 
 soot presque toujours des degres differeus 
 d’une meme affection, et que le traiteraent 
 qui convient k Tune repose sur les tnemes 
 bases que celui indiquh dans I’autre.” (( Euv - 
 res Chir. de Desault, T.2,p. 120.) It is evi- 
 dent from the writings of Pott and Ware, 
 that even these authors considered the ob- 
 struction of the nasal duct, as the foundation 
 of all the train of varied symptoms present- 
 ed by the excreting lachrymal organs. “ An 
 obstruction in the nasal duct is most fre- 
 quently the primary and original cause of the 
 complaint.” “ The seat of this disease is the 
 same in almost every subject,” says Mr. 
 Pott ( Obs . on the Fistula Lachrymalis ;) and 
 Mr. Ware, in his observations on the same 
 disease, sets out with the same assumption. 
 Now, obstruction of the nasal duct is an oc- 
 casional consequence merely of inflamma- 
 tion of the excreting lachrymal organs ; in 
 most of their diseases, obstruction of the 0 
 nasal duct has no part; and one might, with 
 as much propriety, treat all the affections of 
 the bladder and urethra, by the dilatation of 
 the latter part, as treat all the diseases of the 
 excreting lachrymal organs, by dilating the 
 nasal duct. The false assumption in ques- 
 tion has led to most erroneous treatment. 
 For instance, in blennorrhcea of the sac, 
 and in hernia of the sac. though in both 
 these diseases the nasal duct is patent, 
 the common treatment in this country 
 is to open the sac by the knife, and thrust 
 down a style, or some other instrument 
 into the nose . thus destroying the organiza- 
 tion of the parts which are affected merely 
 with a gleety secretion in the one case, and 
 with extreme relaxation in the other. Sup- 
 
 pose (says the some critical writer) that 
 some charlatan should make oath at the 
 Man-ion-t louse, that hp had cured fiftv or a 
 hundred cases of gonorrhoea by opening the 
 urethra in the perinmum, and passing a bou- 
 gie through that tube, from behind forwards, 
 who would approve of such an operation ? 
 Yet the laying open of the lachrymal sac, 
 and thrusting a probe down into the nose, 
 when the nasal duct is either perfectly pa- 
 tent, oral the most, slightly tumid from inflam- 
 mation, is neither less preposterous, nor less 
 cruel. (See Quarterly Journ. of Foreign 
 Medicine Vol. 1, p. 293.) Indeed, it is some- 
 what surprising, that errors of this kind should 
 have prevailed so long, particularly as expe- 
 rience had taught Mr. Pott, that slight cases 
 might be benefited by the simple employment 
 of a vitriolic collyrium ; a fact which ought 
 to have convinced him, that the disease 
 did not always depend upon obstruction of 
 the nasal duct. It is curious, therefore, that 
 he did not fully see this mistake ; for, that 
 he knew of these diseases having great va- 
 riety, is evident from the following remark: 
 As the state and circumstanc.es of this disease 
 are really various, and differ very essentially 
 from each other, the general custom of call- 
 ing them all by the one name of fistula lach- 
 rymalis is absurd.’* I believe, that one 
 great cause of deception has been the fact, 
 that, though laying open the lachrymal sac, 
 and the introduction of instruments down 
 the nasal duct, have been frequently practi- 
 sed, when milder plans would have answer- 
 ed every purpose, yet a cure has often fol- 
 lowed the practice, and thus confirmed the 
 supposition of relief having been effected by 
 the removal of the imaginary obstruction in 
 the nasal duct. Thus the late Mr. Rums- 
 den, of St. Bartholomew’s, with whom I 
 served my apprenticeship, always followed 
 the common plan of passing a probe down 
 the nasal duct, and letting the patient keep a 
 piece of bougie, or a style, in the part for 
 two or three months afterward; and I 
 scarcely recollect an instance in whicb he 
 failed to accomplish a cure, though I have 
 no doubt that the same benefit might some- 
 times have been obtained without any opera- 
 tion at all. And a discerning practitioner 
 should never forget that, if no permanent 
 obstruction exist in the nasal duct, a cure 
 will generally follow, on the subsidence of in- 
 flammation, and a change taking place in the 
 action of the parts, whether a probe, style, can- 
 nula, bougie, or seton- be employed, or net. 
 Erysipelas of the Parts covering the La- 
 chrymal Sac . — Beer considers it highly ne- 
 cessar> that this case should bediscriminated 
 from infl ruination of the sac it- elf, which is 
 otten but little affected, and this even when 
 an abscess forms. Unless the true ; ature of 
 the disease be comprehended, the surgeon is 
 apt to suppose, that the matter is in the sac 
 itself, and believes that, when he makes an 
 opening, he is puncturing that receptacle, 
 \vherea9 lie is in reality, merely dealing with 
 a superficial abscess of the integuments. 
 Nor, as Beer has observed, is the mistake 
 free from ill consequences ; for, imagining 
 
LACHRYMAL ORGANS. 
 
 KiS 
 
 that the wound is made into the sac, the 
 surgeon pokes about with his probe so long, 
 that a good deal of unnecessary pain and in- 
 flammation is produced. According to the 
 same author, the case is not very frequent, 
 and is mostly met within scrofulous subjects, 
 who have had for a considerable time a 
 blennorrhcea of the lachrymal sac. The in- 
 flammation partakes of the usual characters 
 of erysipelas, and commonly extends to the 
 eyelids, particularly (tie upper one. The ab- 
 sorption and conveyance of the tears into 
 the lachrymal sac are interrupted, because 
 the inflammation constantly fleets the la- 
 chrymal ducts and papillae, the latter appear- 
 ing considerably shrunk. When the inflam- 
 mation spreads over the side of the face. 
 Beer says there is usually a discharge ol thin 
 mucus from the nose; anil when the affec- 
 tion extends more deeply to the anterior por- 
 tion of the lachrymal sac, as may easily hap- 
 pen when <he case is neglected, or treated 
 in its first stage with stimulating applications, 
 a bean-shaped, circumscribed, hard, painful 
 tumour may be felt, oris even denoted by its 
 very red appearance. The puncta lacbry- 
 tnalia are now completely closed, the papil- 
 lae shrivelled up, and the nostril on the af- 
 fect'd side very dry and tender. 
 
 If in the first stage of the disorder, the la- 
 chrymal papillae and canals have not been 
 too violently affected, the former parts ex- 
 pand again, and the absorption of the tears 
 recommences with the second stage. But, 
 at this period, according to the observations 
 of Professor Beer, a good deal of mucus is 
 secreted from the caruncula lachrymalis and 
 Meibomian glands, and collects and glues 
 the eyelids tegether, especially during sleep. 
 At the same time, mucus generally accumu- 
 lates in the lachrymal sac itself, and may 
 be voided both through the puncta lachry- 
 malia and nasal duct, by gentle pressure. 
 The mucous discharge from the nostril also 
 acquires a thicker consistence. Should the 
 lachrymal papiilse and ducts have suffered 
 more severely in the first stage of the dis- 
 ease, the due absorption of the tears does 
 not begin after the subsidence of the inflam- 
 mation, and a dropping of them over the 
 cheek, a slillicidium lachrymarum frequently 
 continues a long while after the termination 
 of the other symptoms. It depe ds upon the 
 atony of the lachrymal puncta and ducts, 
 and is very troublesome in cold wet weather. 
 And, when the lachrymal sac itself has been 
 a good deal inflamed in the first stage of the 
 complaint, a large quantity of mucus collects 
 within it in the second stage, and may be 
 discharged by pressure. Sometimes the 
 subcutaneous abscess actually communicates 
 with the cavity of the sac ; a case, which 
 Beer terms a spurious fistula of the lachry- 
 mal sac, the matter not being formed in that 
 receptacle itself, but getting into it from the 
 external abscess. As the skin is generally 
 rendered very thin, these abscesses near the 
 bridge of the nose usually burst by several 
 openings. Beer remarks, that it is easy to 
 learn, whether the ulceration extends through 
 the lachrymal sac ; for when this has hap- 
 
 pened, the slightest pressure upon the supe* 
 rior part of the sac produces a discharge of 
 pus and mucus from the external opening, 
 and, if the lachrymal canals have already 
 recommenced their functions, the discharge 
 will also be mixed withtears. (See M‘Kenzie 
 on Diseases of the Lachrymal Organs, p. 22.) 
 The quantity of matter, which flows out, is 
 likewise so copious, that it is evident it 
 could not have been all lodged between the 
 skin and orbicularis palpebrarum muscle, but 
 must have come partly out of the lachrymal 
 sac. I he use of a fine probe will remove 
 any doubt which may be left. (Beer, Lehre 
 von den Jhtgenkr B. 1, p. 332 — 35.) 
 
 On the subject of the causes of this com- 
 plaint, the preceding author delivers no re- 
 mark worthy of notice. In speaking of the 
 prognosis, he observes, that when the case is 
 not neglected, nor wrongly treated in its first 
 stage, and the inflammation has not extend- 
 ed to the lachrymal sac, the prognosis is 
 very favourable ; for, after the subsidence 
 of the inflammation, a temporary atony of 
 the lachrymal puncta and ducts, an imper- 
 fect conveyance of the tears into the nose, 
 and of course a slight oozing of them over 
 the cheek, most troublesome in cold, wet 
 weather, are the chief inconveniences which 
 remain. But, when the lachrymal sac par- 
 ticipates in the inflammation, the prognosis 
 is much less favourable ; because, when 
 suppuration takes place, ulceration is apt to 
 form an opening in the front part of the sac, 
 or else, during (he second stage, a large 
 quantity of mucus may collect in the sac, 
 and, if not skilfully treated, it frequently 
 ends in a very obstinate blennorrhcea of that 
 part. As Beer observes, this is a case which 
 is often, though quite erroneously, named 
 a fistula lachrymalis. (B. 1, p. 336.) 
 
 The prognosis is also very favourable in 
 the second stage of the complaint, as long 
 as the suppuration is restricted to the inte- 
 guments, and it is characterized by desqua- 
 mation and scabbing ; but, the case is more 
 serious, when a large collection of matter 
 forms, and particularly when the abscess 
 makes its way into the lachrymal sac. In 
 these last circumstances, an obstinate blen- 
 norrhoea from the sac often follows, notwith- 
 standing the fistulous sore be treated in the 
 most skilful manner, and sometimes the 
 PAatter spreads so far around, as to spoil, and 
 even annihilate, I he lachrymal canals, and 
 cause an irremediable dropping of tears 
 over the cheek, during the rest of the pa- 
 tient’s life. (Beer.) 
 
 The suppuration (says Mr M'Kenzie) may 
 destroy the ligamentous layer of the lower 
 eyelid, and end in the total obliteration of 
 the cavity of the sac. But when the sac is 
 not thus annihilated, and the lachrymal 
 canals are destroyed, it is necessary that the 
 cavity of the sac should be obliterated by 
 artificial means ; for otherwise a form of dis- 
 ease will follow, which Beer denominates 
 hydrops sued lachrymalis , and Mr. M‘Kenzie, 
 mucocele, as will be hereafter noticed. 
 
 “ In common cases, a piece of folded 
 linen, dipped in cold water, and applied to 
 
LACHRYMAL ORGANS 
 
 ' tic parts affected, and the administration of 
 gentle doses of sulphate of magnesia, make 
 op the treatment. In severe gases, it will 
 be found necessary, not only to continue the 
 cold applications, and to open the bowels, 
 but to administer an emetic of tartrate of 
 antimony, to purge freely, and even some- 
 times to take away blood from the arm.” 
 (M‘Kenzit, p. 24.) 
 
 In the second stage, a warm dry air, and 
 a linen compress, are commended, with the 
 exhibition of diaphoretics. In the two first 
 ot these means, 1 confess, that I should place 
 little or no confidence. When the formation 
 of matter cannot be prevented, poultices are 
 to be used. Beer particularly cautions us 
 not to leave the abscess to burst of itself, 
 but to open it immediately a fluctuation can 
 be felt, so as to prevent an ulcerated open- 
 ing from taking place in the anterior part of 
 the lachrymal sac. And, if the surgeon has 
 not been consulted before such a commu- 
 nication has been established between the 
 sac and subcutaneous abscess, he should 
 avoid all unnecessary disturbance of the 
 parts with probes and syringes, and at most, 
 only wash out the abscess once a day with 
 An el's syringe, filled with lukewarm water 
 and a little of the vinous tincture of opium. 
 Beer also recommends introducing into the 
 superficial abscess, but not into the sac, a 
 small quantity of lint, dipped in the tincture. 
 If the blennorrhoea of the sac continue, it is 
 to be treated as will be explained in consi- 
 dering the second stage of inflammation of 
 that part. 
 
 Inflammation of the Lachrymal Sac. — Ac- 
 cording to Beer, the symptoms of the first 
 stage of this complaint are as follows : in the 
 corner of the eye, precisely in the situation 
 of the lachrymal sac, a circumscribed, very 
 hard, tender swelling arises, of tbe shape of 
 a bean, producing a lancinating pain when it 
 is touched, and gradually acquiring consi- 
 derable redness. The absorption and con- 
 veyance of the tears into the lachrymal sac, 
 and thence into the nose, are completely in- 
 terrupted ; the lachrymal papillae are shrunk; 
 the puncta cannot be seen ; and of course 
 the tears fall over the cheek. The nostril on 
 the affected side is at first very moist, but 
 soon becomes perfectly dry, the mucous 
 membrane being a good deal affected. As 
 the inflammation also constantly spreads to 
 the orbicular muscle and integuments in the 
 corner of the eye, the complaint often pre- 
 sents an erysipelatous appearance, extending 
 to the eyelids and down the cheek ; but, 
 the circumscribed swelling, caused by the 
 inflamed sac, is still not only capable of 
 being distinctly felt, but even seen. It 
 rarely happens, in cases of common in- 
 flammation, that on the change of the first 
 stage into the second, the nasal duct is ren- 
 dered impervious by an effusion of lymph ; 
 but such an occurrence is more frequent 
 where the inflammation is not of a healthy 
 description, and the patient is scrofulous. 
 Gnder these circumstances, the lachrymal 
 canals may also be rermanentlv obliterated. 
 Vol, !!. 22 
 
 1(59 
 
 In weak, irritable constitutions, towards the 
 end of the first stage of the inflammation, a 
 degree of symptomatic fever prevails, with 
 severe headach, great redness.and swelling 
 of the whole inner canlhus, involving the 
 caruncula lachrymalis, the semilunar fold, 
 the conjunctiva, the edges of the eyelids, 
 and the lachrymal puncta. 
 
 Here as in inflammation of every mucous 
 membrane, at the very commencement of 
 the second stage, a copious morbid secretion 
 takes place, and accumulates in large quan- 
 tity ; for, either in consequence of the 
 thickening of the mucous membrane, ‘the 
 adhesion of the sides of the nasal duct 
 together, or there being no mixture of the 
 tears, the secretion within the sac cannot 
 escape either into the nostril, or out of the 
 lachrymal puncta, and consequently it dis- 
 tends in a prodigious degree the anterior 
 side of the sac, where it is uncovered by 
 bone. Hence, the swelling is here very 
 manifest, and a fluctuation may be felt in ii, 
 even before the suppurative stage lias actually 
 begun. According to Beer, whoever is in- 
 duced by the fluctuation to open the lachry- 
 mal sac at this period, will certainly bring 
 on a very hurtful suppuration of the part, 
 exceedingly likely to render the excreting 
 parts of the lachrymal organs completely un- 
 serviceable. At the beginning of the second 
 stage, there is also a morbid secretion from 
 the mucous membrane of the nostril and 
 caruncula lachrymalis. Now not only the 
 swelling of the lachrymal sac increases 
 more. and more, the redness acquires a 
 deeper colour, the. skin becomes more shining, 
 the fluctuation still more evident ; and, at. 
 length, in the centre of the tumour formed 
 by the lachrymal sac, a yellowish, soft point 
 presents itself. In this state of things, in 
 order to prevent a true fistula, the surgeon 
 should make an opening in the lachrymal 
 sac, without the least delay ; for, if the ab- 
 scess be left to itself, the pus will at last 
 make a passage for itself through the orbi- 
 cular muscle and integuments . but it will 
 only be a small fistulous opening, surrounded 
 with callous hardness, and merely capable 
 of letting some of the pus and mucus of the 
 sac escape, so that the thicker part of tbe 
 matter remains behind, and, consequently, 
 though the swelling diminishes after the 
 formation of a spontaneous opening, it does 
 not entirely subside. A quantity of hlood is 
 also remarked to be blended with the dis- 
 charge from the sac. This last is the case, 
 which Beer denominates a true fistula of 
 lachrymal sac. Y\ hen the abscess bursts of 
 itself, the fistulous opening in the sac is not 
 alwaj^s exactly opposite the aperture in the 
 skin, and, though there is commonly but one 
 communication with the sac, it sometimes 
 happen^, that several small external openings 
 are produced more or less distant from the 
 sac. The diagnosis is easy enough ; for, on 
 pressing upon the upper portion of that re- 
 ceptacle, mucus and pus, blended together, 
 are immediately discharged from ali thefistu- 
 lous apertures. After the disease has lasted 
 a good while, it net unfreque fitly happen-. 
 
170 LACI1R1MA 
 
 that tears are also voided from the fistulous 
 opening ; a grcumstance, indicating the re- 
 stored action of the lachrymal puncta and 
 canals; but, according to Beer, such tears 
 are never duly blended with the mucous and 
 purulent matter. He further remarks, that, 
 when the second period oi the second stage, 
 or the suppurative process is over, a morbid 
 secretion of mucus still continues in the 
 third period of the second stage, that secre- 
 tion becoming whitish, thick, opaque, and 
 onty partly resembling pus. As, in con- 
 quence of its thickness, and the swelling of 
 the mucous membrane of the nasal duct, the 
 secretion cannot descend into the nose, it 
 collects in the sac, and sometimes pushes off 
 any piece of lint, or plaster, with which the 
 external opening in the sac has been closed. 
 At length, by means of judicious treatment, 
 this third period of the second stage is also 
 brought to a termination ; the mucus is se- 
 creted again in due quantity ; it becomes 
 transparent like white-of-egg, and viscid ; 
 but white streaks maybe for some time per- 
 ceived in it. Afterward the mucus becomes 
 thinner, and, if the functions of the lachry- 
 mal puncta arid ducts are not destroyed, it is 
 thoroughly mixed with the tears. The open- 
 ing in the lachrymal sac now either heals up 
 of itself, or under skilful treatment ; but, in 
 general, a minute fistulous aperture still re- 
 mains, from which the tears and mucus are 
 occasionally voided, if the passage through 
 the nasal duct be not free. However, if the 
 small fistulous aperture should happen to 
 heal up completely, the mucus and tears 
 accumulate in the sac, and the patient is 
 obliged to press them out through the puncta 
 lachrymalia several times a day. 
 
 When the surgeon is consulted early 
 enough, and proper treatment is adopted, 
 Beer sets down the prognosis in the first 
 stage of the inflammation as very favourable. 
 But, if the practitioner be called in later, it 
 will not be in his power completely to dis- 
 perse the inflammation, and prevent the 
 morbid secretion, and accumulation of mu- 
 cus in the lachrymal sac ; the blennorrhea of 
 this part, of professor Beer, or the dacryops 
 bltnnoideus, of Schmidt ; a state, however, 
 which soon gives way to judicious treatment. 
 But, when the case is neglected, or wrongly 
 managed at the period, when the lachrymal 
 sac is violently inflamed, a complete, or par- 
 tial closure of the nasal duct by adhesive 
 inflammation is apt to be the consequence. 
 And, the same effect may also be produced 
 in die lachrymal canals, in which event, the 
 absorption of the tears is for ever impeded, 
 and the patient must remain the rest of his 
 life afflicted with a stillicidiumlachrymarum. 
 
 With regard to the prognosis in the second 
 stage of inflammation of the lachrymal sac, 
 Beer considers it as very dubious, on account 
 of the impairment of the functions of the 
 excreting parts of the lachrymal organs; for, 
 v says he, no surgeon can exactly know, what 
 may have been the result of the first stage, 
 in relation to the perviousness of the nasal 
 duct and lachrymal canals, and an officious 
 examination of thi parts with a probe, for 
 
 b ORGAAA' 
 
 llio purpose of obtaining information, would 
 be attended with considerable mischief. 
 However, generally speaking, the prognosis 
 is most hopeful at the first period of the se- 
 cond stage, just when the morbid secretion 
 of mucus is beginning; the suppuration may 
 yet be moderated by right treatment, and 
 the excreting parts of the lachrymal organs 
 preserved. But, if the suppurative stage has 
 already come on, much will depend upon 
 the consideration, whether the matter has 
 been originally formed in the lachrymal sac, 
 has lodged there a good while, and the sac 
 is ready to burst, or whether there is actually 
 an opening in the sac opposite that in the 
 skin, or, lastly, whether the openings do not 
 correspond. In the first case, the suppura- 
 tion yet admits of being regulated by judi- 
 cious treatment, and the lachrymal sac can 
 be punctured; but, in the other circumstan- 
 ces, the management of the case is far more 
 difficult, especially when the patient s con- 
 stitution is not good. However, the surgeon 
 should be careful not to disfigure the patient 
 with a large scar ; and the aim should be to 
 prevent atony of the lachrymal puncta and 
 ducts, and a consequent stillicidium lachrj- 
 marum. These are the least serious evils to 
 be apprehended from mismanagement ; for, 
 if the case be ill treated, or neglected, in the 
 latter stage of the suppurative process, ne- 
 cessarily attending a fistulous state of the 
 sac, the lachrymal organs may be rendered 
 quite useless, or even entirely destroyed, 
 and the nasal duct obliterated, or obstructed 
 by the effects of caries. In some few in- 
 stances, indeed, the whole lachrymal sac is 
 destroyed, or will require to be so by art, as 
 will be presently explained. It is always 
 a favourable circumstance when the tears 
 are seen to issue from the fistulous opening 
 with the mucus and pus, as it is a proof that 
 the absorption and conveyance of the tears 
 into the lachrymal sac are established again, 
 and that now the only question is about the 
 state of the nasal duct, which point cannot 
 be determined before the fistula is com- 
 pletely healed, and the third period ot the 
 second stage is entirely obviated. (Beer, 
 Lehre von den Jhigenkr. B. 1 ,p. 356 — 367.) 
 
 lu the first stage, the indication is to en- 
 deavour to resolve the inflammation. “ It 
 is, (as Mr. M‘Kenzie observes) by combat- 
 ing the inflammation, that we are to cure 
 this disease, and not by attacking merely 
 one, or even several of the symptoms. Di- 
 latation, for instance, by the introduction 
 of probes through tbe canals into the sac 
 and even into the nose, would only be sub- 
 jecting the inflamed parts to a new cause 
 of irritation, and might thus produce ^^cts 
 which would render a complete cure diffi- 
 cult, if not impossible.” On the contrary, 
 in the first stage, Mr. M‘Kenzie joins Beer 
 in praise of antiphlogistic measures ; the 
 application of cold lotions to the part; and, 
 in severe cases, venesection and leeches 
 are set down as proper, together with open- 
 ing and diaphoretic medicines. (On Dis- 
 eases of the Lachrymal Organs , p. 33, 34.) 
 in the second stage, when resolution i 
 
LACHRYMAL ORGANS. 
 
 no longer practicable, emollient applications 
 are the most beneficial, and all debilitating 
 means are to be stopped, by the further use 
 of which an incurable blennorrhcea of the 
 lachrymal sac would be likely to be indu- 
 ced. And, as soon as the sac is so distended 
 with mucus and matter, that the centre of 
 the swelling begins to be soft, and a fluctu- 
 ation is perceptible, the sac should be freely 
 opened, so as to let its contents have a rea- 
 dy outlet. If, after this evacuation, there 
 should be any deep-seated hardness of the 
 lachrymal sac, Beer recommends the ap- 
 plication of a camphorated hemlock poul- 
 tice. Afterward, the wound in the skin and 
 sac is to have introduced into it a little bit 
 of lint, dipped in the vinous tincture of opi- 
 um, over which dressing a piece of diachy- 
 lon plaster may be placed. When, under 
 such treatment, the suppuration diminishes, 
 but a preternatural secretion of mucus yet 
 continues, Beer introduces into the wound 
 every day a piece, of lint, on which is spread 
 a little bit of the following ointment : H 
 Butyri recentis insulsi, ^ss. Hydrargyri Ni- 
 trico-Oxydi, gr. x. tutia3, ptt. gr. vj. M. And, 
 on changing the dressings, some of the fol- 
 lowing lotion may be dropped into the in- 
 ner canthus, and injected lukewarm into 
 the sac itself: Subacetatis Cupri, Potas- 
 
 saj Nitratis, aluminis, a a gr. iij. — vj. Cam- 
 phors: tritee grij. — iv Aqua3 distillates gss. 
 Solve et cola. Liquori colato adde Vini 
 Opii 3j. — 3ij. Aquae Rosae ^iv. JV1 Pro 
 lessor Beer makes a mass of the three first 
 articles melted together in equal propor- 
 tions, and terms it the lapis divinus , of which 
 he makes the lotion, and then adds the 
 other ingredients. When, by means of such 
 treatment, the mucous secretion from the 
 sac has been brought into a healthy state, 
 and all the induration has subsided, the pe- 
 riod has arrived for the surgeon to think of 
 taking measures for the re-establishment of 
 the passage through the nasal duct, if it 
 should not already have become pervious of 
 itself, which, when the inflammation has 
 been of a healthy kind, and the treatment 
 iudicious, very frequently happens. ( Beer , 
 Lehre, fyc. B. 1, p. 369—371.) 
 
 Chronic Blennorrhcea of the excreting Parts 
 of the Lachrymal Organs. — Mr. M £ Kenzie, 
 whose Essay contains a faithful account of 
 Beer’s opinions upon the present subject, 
 describes the inflammation, with which this 
 iorm of disease commences, as seldom con- 
 siderable, and in scrofulous patients, it is 
 said to be not unfrequently quite disregard- 
 ed, no advice being taken until the lachry- 
 mal sac is much distended with mucus. By 
 means of pressure upon the bean-shaped tu- 
 mour, caused by such distention of the sac, 
 a quantity of puriform mucus is forced out 
 of the puncta lachrymalia, and overflows 
 the eye ; and so far are the lachrymal ca- 
 nals from being obstructed, that, excepting 
 when any return of inflammation happens, 
 they even absorb, and convey the tears into 
 the sac. Pressure, however, will rarely 
 make the contents of the sac pass through 
 tlie nasal duct, on account of the thickened 
 
 state of the mucous membrane, and there- 
 fore the nostril is generally very dry. “ In 
 the course of this tedious disease, the accu- 
 mulated mucus varies much both in quantity 
 and quality. For instance, the mucus ac- 
 cumulates more rapidly, aqd is much thick- 
 er after a good meal, than at other times. 
 The secretion of it is very plentiful, but 
 thinner than usual, when the patient con- 
 tinues long in a moist cold atmosphere. In 
 this case, the overfilling of the sac takes 
 place so rapidly, that the compression ot 
 the orbicularis palpebrarum in the action ot 
 winking is sufficient to evacuate the sac 
 through the canals to such a degree, that 
 the whole surface of the eyeball is suddenly 
 overflowed, and the puriform fluid runs 
 down upon the cheek. After the patient 
 remains for a short time in a warm and dry 
 atmosphere, the morbid secretion becomes 
 sparing and ropy. We find, that this chro- 
 nic blennorrhcea almost completely disap- 
 pears in many individuals during warm 
 weather, upon which the yet unexperienced 
 patient and the unexperienced surgeon arc. 
 apt to express a great, but a premature joy, 
 for, on the very first change to cold and wet 
 weather, the ^disease most frequently re- 
 
 turns.” 
 
 During chronic blennorrhcea, the lachry- 
 mal sac is extremely liable to repeated at- 
 tacks of inflammation and sometimes a lis 
 tula, with a good deal of induration of the 
 surrounding cellular substance, is produced. 
 Mr M £ Kenzie represents this disease as the 
 most frequent of all those to which the ex- 
 creting parts of the lachrymal organs are 
 liable, and as consisting in inflammation ot 
 these organs, modified by scrofula, gene- 
 ral debility, disorder of the digestive or- 
 gans, or other constitutional causes which 
 prolong its second stage. “ Even regarded 
 locally, the present disease is seldom a pri- 
 mary affection, but is most frequently ex- 
 cited by catarrhal inflammation ot the 
 Schneiderian membrane, or by a long-con - 
 tinued disorder of the Meibomian glands.' 
 (j \PKenzie on Diseases of the Lachrymal Or 
 gans, p. 37 — 40.) 
 
 Scarpa’s opinions on the present subject 
 are in some degree peculiar to himself ; for 
 he considers the affection of the Meibomian 
 glands and inside of the eyelids, the puri- 
 form palpebral discharge, as he terms it, as 
 constituting the first degree of all those 
 complaints which have usually gone under 
 the name of fistula lachrymalis ; the sepond 
 degree, or effect, being the tumour of the 
 lachrymal sac ; and the third, the fistula, or 
 ulcerated opening in thelatter part. Scarpa 
 asserts, that the chief part of the yellow 
 viscid matter, whieh accumulates in the 
 lachrymal sac, is secreted by the lining ot 
 the eyelids, and by the little glands of Met- 
 bomius ; and that the altered quality of this 
 secretion has a principal share in the cause 
 of the disease. He states, that the truth 
 of this fact may at once be ascertained by 
 everting the eyelids, and especially the 
 lower one of the affected side ; and by com- 
 paring them with those ol the opposite eye. 
 
LACHRVMAL ORGANS' 
 
 The former will always exhibit an unnatural 
 redness of the interna! membrane, which 
 has a villous appearance till over the extent 
 of the tarsus; while the edge of tiic lid is 
 swollen, and numerous varicose vessels are 
 distinguishable on it. The follicles of Mei- 
 bomius are also turgid and prominent, and 
 when examined with a magnifying glass, 
 not unfrequently appear to be slightly ulcer- 
 ated. 
 
 “ The villous structure then, which the 
 surface of the internal membrane of the 
 palpebra assumes in these cast s, becomes 
 an organ secreting a larger quantity of fluid 
 than usual, resembling viscid lymph, which, 
 as before stated, being mixed with the seba- 
 ceous matter, copiously effused from the 
 glands of Meibomius, constitutes the whole 
 of the viscid fluid, with which the eyelids 
 are imbued, and which is continually car- 
 ried by the puncta lachrymaliajnto the sac, 
 so as to fill and also frequently distend it, 
 until it forms a Tumour. 
 
 “ if, indeed, the lachrymal sac is emptied 
 of this matter, by means of compression, 
 and the eye and internal surface of the pal- 
 pebrae are carefully washed, so that none of 
 the glutinous humour, pressed from the sac, 
 may remain upon them, and the eyelids are 
 everted half an hour afterward, the internal 
 surface, especially of the lower one, will be 
 found covered with a fresh effusion of mu- 
 cus mixed with sebaceous matter, which 
 has evidently not flowed back from the 
 lachrymal sac to the eve, but has been 
 generated between the eye and the pal- 
 pebral.” Another argument, brought for- 
 ward by Scarpa, in support of his theory, is, 
 that, if the morbid secretion of the eyelids 
 be retarded, or suppressed, either accident- 
 ally or by means of astringent applications, 
 little or none of the viscid secretion collects 
 in the lachrymal sac, or can be forced out 
 « of the puncta lachrymalia. He has also 
 constantly observed, that the puriform dis- 
 charge may be radically cured at its com- 
 mencement, and before it has induced any 
 flaccidity of the sac by a timely correction 
 of the morbid secretion from the inside of 
 the eyelids, and keeping the lachrymal pas- 
 sages cleansed, by means of injections, of 
 simple water through the puncta lachrynra 
 lia into the nose. As for the internal mem- 
 brane of the sac itself, he argues, t hat its 
 structure does not qualify it for secreting a 
 tenacious unctuous matter, like what is 
 chiefly discharged from it, as it is entirely 
 destitute of sebaceous glands, and can in 
 reality only furnish a thin mucus. However, 
 he admits, th<jt if the sac happen to he in- 
 flamed and ulcerated, a turbid matter may 
 issue frtffn it with the tears; but, says 
 he, this matter is true pus, and quite differ- 
 ent from the curdy unctuous fluid which 
 takes place in the puriform palpebral dis- 
 charge. (On the Principal Diseases of the 
 Eyes, Trmsl. by Briggs, Ed. 2. p. 3—7) 
 
 The foregoing opinions of Scarpa have 
 not met with universal assent, and though 
 there is probably much truth in them, he 
 r ay have overlooked too much the possible 
 
 simultaneous affection of the mucous tnetifi 
 brane of the lachrymal sax; and nasal duct. 
 To Scarpa’s hypothesis, Himly and Flajani 
 have made the following objections : First, 
 that they iiave observed the fistula lachry- 
 inalis, without the least morbid alteration 
 of the eyelids and Meibomian glands. Se- 
 condly, that every puriform discharge of the 
 eyelids is not succeeded by a fistula lachryma- 
 lis. vastly, that the fistula lachrymalisis cured 
 by means of the operation alone, without 
 any attention being paid to the morbid state 
 of the eyelids, when it exists. And Mr. 
 Travers aiso regards Scarpa’s account of the 
 origin of the disease, independently of a 
 permanent stricture, as 'hypothetical ; for if 
 founded in fact, the distention of the lachry- 
 mal sac, and tee regurgitation of the fluid 
 on pre sure, would attend every severe lip- 
 pitudo, or ophthalmia with puriform dis- 
 charge, which is not the case. If Scarpa’5 
 account were correct, .r. i'ravers sees no 
 reason why the fluid, once admitted, should 
 be arrested, or regurgitate, instead oi pass- 
 ing into the nose, (see also Nicod. in Rente 
 Med. T 1, p. 155,) and he thinks there is 
 every reason to believe that the fluid, so 
 discharged, is the proper secretion of the 
 sac. and cases are frequent, in which it 
 is retained and cannot be expressed, owing 
 to strictures both of the lachrymal and nasal 
 ducts. ( Synopsis of Ike Diseases of the Eye , 
 p. 360.) Some of the arguments with which 
 Scarpa meets this reasoning, are already 
 anticipated, especially that which refers to 
 the difference between the secretion of the 
 sac itself, and thai of the sebaceous glands 
 t the eyelids. Also, in asserting that the 
 origin of the fistula lachryrnalis generally 
 manifests itself on the eyelids, before the 
 lachrymal passages are affected, Scarpa de- 
 clares, that he does not pretend thereby to 
 exclude altogether the possibility of a case, 
 in which the membranes of the nasal duct 
 and lachrymal sac may not he thickened 
 and ulcerated, independently of the disease 
 of the eyelids. That this is the case, 1 think 
 is evident from the account already deliver- 
 ed in the two first sections ot this article, of 
 Beer’s opinions, respectingthe consequences 
 of inflammation of the integuments and 
 other parts about the inner angle of the eye, 
 as well as respecting the effects of acute in- 
 flammation of the lachrymal sac itself. How- 
 ever Scarpa admits the fact, and the ques- 
 tion left is, whether he is right in assigning 
 the morbid secretion from the inside of the 
 eyelids, as the most common cause of the 
 swelling, ulceration, &c. of the lachrymal 
 sac ? That every puriform discharge from 
 the eyelids is not followed by fistula lachry- 
 malis, he allows, is unquestionable ; ami 
 this, he conceives, most probably happens, 
 because the lippitudo has not been entirely 
 neglected, or because the secretion being 
 less dense and viscid than usual, descends 
 freely with the tears into the nose through 
 the lachrymal canals, which are large and 
 pervious. But in the acute stage of the pu- 
 rulent ophthalmia, he asserts that the reason 
 why the discharge is not conveyed into the 
 
lachrymal organs 
 
 '-ac is, that the inflammation and swelling ac- 
 tually close the puncta lachrymalia, and 
 change their direction, so that both the pu- 
 riform matter and the tears fall over the 
 cheek, and cannot descend into the sac. 
 
 As for the instances of cure, without any 
 remedies being applied for the correction of 
 the state of the eyelids, Scarpa deems the 
 argument inconclusive, because particular 
 vices of the constitution, under the use of ap- 
 propriate internal remedies and a well-regu- 
 lated diet, disappear, or are tra sferred to 
 other parts, without the use of topical re- 
 medies. 
 
 For my own part, I am disposed to believe, 
 that, whether the disease begin in the eyelids, 
 or elsewhere, generally both their lining, and 
 that of the sue and nasal duct are also more 
 or less affected ; and, consequently* though 
 Scarpa’s theory may not be in every Ye'spect 
 satisfactory, nor at all applicable to certain 
 disorders of the excreting parts of the la- 
 chrymal organs, the practice, to which his 
 sentiments lead, will, in the generality of 
 cases, which Beer denominates chronic bleu- 
 ziorr/ixa, be highly advantageous. 
 
 According to Mr. M‘Kenzie, he local 
 treatment of chronic blennorrbcee does not 
 differ essentially from that of inflammation 
 of the excreting pans of the lachrymal or- 
 gans. But, every possible means must also 
 be employed for improving the general 
 health ; for, otherwise all local remedies will 
 be unavailing. In scrofulous cases, particu- 
 lar attention must be paid to diet and mode 
 of living. In weakly persons, the preparations 
 of iron will be highly beneiicial : and, when 
 t he disease is eonnecied with disorder of the 
 digestive organs, the treatment recommended 
 by Mr. Aberaetby is that to which Mr. M‘ 
 Kenzie expresses a preference. The employ- 
 ment of Anel’s syringe and probe are’ strongly 
 reprobated. “ i grant, (say r s this author,) 
 that the application of certain substances to 
 the mucous membrane affected, is one of the 
 most powerful means, which we possess, of 
 correcting its disposition to chronic blennor- 
 rheea. But, he who believes, 1 hat the best man- 
 ner of applying these substances, is to inject 
 them with AneTs syringe, introduced through 
 the puncta, is lamentably mistaken. He. i?, 
 in fact, closing his eyes upon what h<- must 
 know of the functions of the several pai ls of 
 the lachrymal organs, and is doing that very 
 thing, which is calculated to prolong and tx- 
 aspeiate the disease. Except at the time of 
 a smart renewal of the inflammation, the 
 puncta and canals, during thisdise .se. con- 
 tinue in the exercise of their functions. Wh t- 
 ever fluid, therefore, is dropped into the lacus 
 lachrymarum, will be taken up by ike puncta, 
 conveyed through the canals, and applied to 
 the whole internal surface of the Sic. Even 
 ointments, placed within reach of the puncta, 
 will be absorbed in the same manner. “ We 
 ought then first of all to empty the sac by 
 pressure, and, if possible, through the nasal 
 duct into tiie nose. Having placed the pa- 
 tient upon his back, we drop into the lacus 
 I.mbrymarura a small quantity of a weak so- 
 
 i i i# 
 
 lution of corrosive sublimate. aq. ros. 
 t-iv. hydrarg. oxymunatis gr.ss. grj Muciioj. 
 vmi opii 3j. M. Atier remaining lor a quarter 
 of an hour in that position, he ought to rise, 
 byt without wiping away any ot the colly - 
 rium, which may remain. After another quar- 
 ter of an hour, tfie eyelids are to be careiully 
 dried, and a little ol Janins’s ophthalmic oint- 
 ment applied with a caincl-haii pen il to the 
 carunculu'lrtcbry maiis and edges of the eyelids. 
 All this is 10 he carefully repeated twice a 
 day.” Professor Schmidt recommends the 
 following col!) rium. ]^. Aq. rosaj |vj. acid 
 nitrici 3j. alcnoholis 3j- M. For in, iemo- 
 v.d ot Uic induration over the sat gentle tric- 
 tion, with camphorated mercurial ointment is 
 recommended. And, says Mr. lYPKenzie, 
 it the bleuiiorrhoeo depend upon chronic in- 
 flammation ol the Meibomian glands, the 
 diluted ciirin ointment is to he applied every 
 evening at bed-time. (On Diseases of the, 
 Lachrymal Organs, p. 43, «^c.) In tue first 
 Stage ui what Scarpa terms the puriform 
 discharge ot the palpebral, when the weeping' 
 is incipient, this author slates, that a cure 
 may be effected, without dividing the sac, or 
 any other painful operation. His practice 
 consists m restraining the immoderate 
 secretion from the Meibomian glands and 
 internal membrane ol the palpebral, and 
 in cleansing the viae laciirymales through 
 their whole extent by means it injec- 
 tions of warm water, rendered more ac- 
 tive by the addition of a little spirit of wine, 
 aud thrown into the puncta lachrvmaiia 
 every morning and evening; a measure, 
 which, u? already stated, is disapproved of 
 by Mr. .VTKenzie, Schmidt, k.e. Scarpa 
 considers Janins’s ophthalmic ointment, 
 weakened with lard, or fresh butter, as the 
 best application tor correcting the moibid 
 secretion of the eyelids. A portion, equal to 
 the size ot a barley corn, is to be introduced 
 upon ihe point ol a bium probe, every morn- 
 ing 'tint evening, between the eye and eye- 
 lids, near he external angle, and ihe edges of 
 the )ends are to be smeared with it. The 
 eye ts .nen to be shui- and the eyelids gently 
 rubbt.d, so lhai the ointment may be distri- 
 buted upon ihe whole of their internal sor- 
 lace. A compress and bandage should be 
 applied, and t tie eyelids kept closed for two 
 hours. At the end ot this tune, ine eye 
 stiou.d be washed with the zinc colfynum. 
 When there are superficial ulcerations at ihe 
 edges ot the tyeiiu's, Scarpa applies to them 
 either Janins’s ointment, or die uugueulum 
 hydrarg. nitrat., and in very obsi male cases, 
 the argentum nuraiura itself, li the vessels 
 ot die co.ijuiu ivaare varicose, he drops into 
 .lie eye me on mra thebaica. (bcarpa, Ed, 
 2, by Briggs, chap. 1.) 
 
 Tue i.t;e .vi.. VV a iv was earlier than Scar- 
 pa in pointing out the advantage ot making 
 applications to the inside ot the ey( lias, for 
 the leliei of certain tonus ol disease, usually 
 classed with fistula lachrymalis. 
 
 ‘‘ When an epiphora (says he) is occasioned 
 by an acrimonious discharge from the seba- 
 ceous glands on the edges of the eyelids, it 
 must be evident, that injections into the sac 
 
174 
 
 LACHRYMAL ORGANS. 
 
 will be very insufficient to accomplish a cure, 
 because the sac is not the seal of the disorder. 
 The remedies that are employed must be di- 
 rected, on the contrary, to the ciliary glands 
 themselves, in order to correct the morbid 
 secretion that is made by them ; and for this 
 purpose, I do not know any application that 
 is so likely to prove so effectual as the unguen- 
 turn hydrargyri nitratn, of the new London 
 Dispensatory, which should be used here in 
 the same manner, in which it is applied in 
 common cases of the psorophthalmy. It will 
 be proper to cleanse the eyelids every morn- 
 ing, from the gum that collects on their edges 
 during the night, with some soft unctuous 
 applications ; arid I usually advise to apply to 
 them, two or three times, in the course of 
 the day, a lotion composed of three grains of 
 white vitriol, in two ounces ot rose or elder- 
 flower w’ater.” (Additional Remarks on the 
 Epiphora.) 
 
 In a modern periodical work may be pe- 
 rused some interesting remarks by M. Nicod, 
 which perfectly accord with the sentiment 
 already expressed, that whatever may be its 
 primary seat the chronic inflammation is not 
 gener'dly limited to the inside of the eyelids, 
 but extends throughout the membranous li- 
 ning of the sac and nasal duct, and that this 
 circumstance, in conjunction with the altered 
 and viscid nature of the secretion.^, accounts 
 for their not readily descending into the nose, 
 but regurgitating tmough the puncta. M. 
 Nicod also relates cases exemplityingthat the 
 ointment applied to the inside of the eyelids 
 actually passes with the matter into the la- 
 chrymal sac, and thence into the nose, so as 
 to act upon and cure the chronic inflammation 
 of the sac and nasal duct, as well as that of 
 the Meibomian glands and lifting of ihe eye- 
 lids. (S f, e Revue Medicate Historique, ty-c. T. 
 
 p. 156, 8 vo. Paris, 1820.) The proceedings 
 for adoption, when tne nasal duct is obstruct- 
 ed, vvili now be considered. 
 
 Obstruction of the Nasal Duct. — That a 
 permanent closure of this canal does notso fre- 
 quently attend diseases of the lachrymal 
 organs, as writers have generally imagined, 
 must be evident from the remarks already 
 delivered ; and also that its perviousness, 
 when, interrupted partly by inflammation and 
 thickening of its lining, and partly by the 
 viscid curdy nature of the matter, may gene 
 rally be restored, w itnout thrusting any 
 probes, tubes, or other instruments down the 
 passage, (measures, more likely, under these 
 circumstances, to do harm than good,) is a 
 fact, which is no longe; questionable. The 
 treatment, necessary in such cases, mu-t be 
 already i telligible from what has been said 
 in the preceding sections, ’he indication being 
 the diminution of the thickened state of the 
 mucous membrane, by means adapted to the 
 acute, or chronic form of (he inflammation, 
 an i, in n any cases, the correction also of the 
 morbid state ol the Meibomian glands arid 
 internal membrane of the eyelids. It is only 
 when the treatment, conducted upon these 
 mild principles, is found ineffectual, that the 
 surgeon should think of examining the state 
 of the nasal duct, ami learning, bv the intro- 
 
 duction of a fine probe into the passage, 
 whether any permanent stricture, orobstruo 
 tion, is present. It does not appear to me, 
 that it is a matter of much importance, ube 
 t her the probe he made of whalebone, as 
 Beer recommends, or of silver ; but, that it 
 should nut be too thick is a thing certainly de- 
 serving greater attention. Supposing there is 
 no direct opening through the skin into the 
 lachrymal sac, one should be made with a 
 lancet. However, a mere puncture will suf- 
 fice, as a large incision, beginning just below 
 the tendon of the orbicularis palpebrarum 
 muscle, and extending in a semilunar form, 
 nearly an inch dounw r ards and outwards, as 
 used to be the old practice, can here answer 
 no rational object, the surgeon merely having 
 occasion for a small direct opening, through 
 which he may conveniently pass a small 
 probe, for the purpose of ascertaining the 
 state of the nasal duct. “ The probe, (as Mr. 
 iVPKenzie observes,) is to be introduced hori- 
 zontally till it touches the nasal side of the 
 sac; it should then be raised into a vertical 
 position, and its point directed down wards 
 and a little backwards. Turning ihe probe 
 upon its axis, we pass if from the sad into the 
 duct; and as we continue to press it gently 
 downwards, the instrument, it the sac is per- 
 vious- enters the nose. If its point meets w ith 
 some obstruction, we must not immediately 
 conclude, that there is an obliteration of the 
 duct. We must press down the probe a lit- 
 tle more strongly, yet w ithout violence, turn- 
 ing it round between the fingers, and giving 
 it different directions. By these means, the 
 obstacle is frequently overcome, and the 
 probe suddenly descends. If the obstacle 
 remains as before, and is extremely firm, still 
 this is no: sufficient ground for us to conclude, 
 that there is a real obliteration,” because, as 
 the author proceeds to point out, the difficulty 
 may arise from a mere thickening of the mu - 
 cous membrane and swelling and induration 
 of its cryptic. {M : Kensie on the Lachrymal 
 Organs , p. 78.) 
 
 When the probe has entered a good way 
 down the n.isai duct, and becomes, as it 
 were, wedged, Beer leaves the instrument in 
 this position, until the next time of dressing, 
 taking! are, however, to fix it to the forehead, 
 so that it may not slip out again. At the same 
 time, he introduces into the. lachrymal sac a 
 tent, which he keeps in with a piece of stick- 
 inn piaster. ( Lehre von den Augenkr. B. 2, 
 p. 168 ;) a measure which I conceive may he 
 advantageously dispensed with. When, at 
 length, the probe can be made to pass with 
 some trouble into the nostril, Beer recom- 
 mends introducing the instrument regularly 
 every day, u til the increased diameter of 
 the passage allows it to be put in and with- 
 draw n without ihe slightest difficulty. The 
 period is now arrived, when Beer conceives, 
 that some measure should be taken for ten- 
 dering the perviousne<s of the nasal duct 
 complete and permanent, and thus entirely 
 re-establishing (he efficiency of the excre- 
 ting parts of the lachrymal organs. But 
 says this author, whoever merely aims at; 
 restoring the natural diameter of the nast 
 
LACHRYMAL ORGANS 
 
 duct by mechanical means, fulfils only one, 
 and that not the most essential indication. 
 And in order that the duct may retain its 
 natural diameter, and the tears and mucus 
 descend freely into the nose, it is necessary, 
 that the morbid state of the mucous mem- 
 brane be first removed, and the action of the 
 excreting parts of the lachrymal organs 
 rectified again ; objects which cannot be 
 performed by any mechanical means. Hence, 
 Beer places considerable stress upon the ne- 
 cessity of obviating every unfavourable 
 state of the health, likely to affect the mucous 
 membrane of the lachrymal sac. For the 
 purpose of restoring the natural diameter of 
 the nasal duct, the experience of many years 
 has convinced him, that pieces of violin cat- 
 gut, which are to be gradually increased in 
 size, are the best. The end of the piece, 
 which is to be introduced, is to be first sof- 
 tened a little between the teeth, straightened, 
 and dipped in sweet oil. Then at least six 
 inches of it are to be introduced, so that its 
 lower end may be easily drdvvri out of the 
 nostril; a business, which Beer always lets 
 ;he patient do himself. The upper portion of 
 the catgut is coiled up, and kept within a lit- 
 tle linen compress, on the patient’s forehead. 
 Beer also places in the opening of the sac a 
 imal) dossil of lint, and covers it with bit of 
 sticking plaster. In two hours, the patient is 
 to try to force the lower end of the catgut 
 out of the nostril, by driving the air through 
 the opening, while the mouth and opposite 
 nostril are shut. As soon as the end of the 
 catgut is secured, it is to bp turned over the 
 side of the nose, and fixed there with a piece 
 of sticking piaster. The next day,’ the bit 
 of plaster over the sac is to be loosened with 
 warm water, and together with (he dossil of 
 lint, taken awav, and one of the lotions, 
 hereafter specified, injected down the pas- 
 sage. The upper end of the catgut on the 
 forehead is next to be unfastened, and a fresh 
 portion of it covered with some of the ap- 
 plications, presently mentioned, wheri the 
 patient is to draw it into the sac and duct, by 
 gently pulling the end, which hangs out of 
 the nostril. The superfluous lower piece of 
 catgut is now cut away, and the new piece 
 turned up, and fixed to the side of the nose. 
 The injection is again repeated, and he 
 dressings applied, as before. The same me- 
 thod is to be continued, until ihe whole of the 
 first piece of catgut is expended. Sotne wa- 
 ter, coloured ‘with the vinous tincture of 
 opium, is now to be thrown down die sac, 
 in order to see, whether any part of the fluid 
 will pass into the nose, and what progress 
 lias been made. Then a larger piece of cat- 
 gut is to be employed, exactly in the manner 
 ol the first, and when if is ali exhausted, the 
 coloured injeeiion is to be used again, in or- 
 der to learn w hat advance has been m de in 
 the re-establishment of the natural diameter 
 of the passage. Lastly, a catgut of still larger 
 size is to be used^ after which the coloured 
 injection w ill be found, when the patient in 
 dines bis bead forwards, to run freely out of 
 the nostril, and not merely drop into it, as it 
 did previously When this is the stste of 
 
 things, all further dilatation becomes unne- 
 cessary. (Beer, Lehr e von den Augenkr.B. 
 2,p. 169—172.) 
 
 This author then repeats his decided 
 opinion, that the mechanical treatment with 
 catgut, bougies, cannula;, &c., will only- 
 answer, when attention is paid to rectifying 
 the morbid state of the mucous membrane 
 of the lachrymal sac by means of suitable 
 applications, the use of which, he thinks, 
 ought to commence with the first employ- 
 ment of the catgut. And, he adds, that even 
 such treatment will only succeed, w hen the 
 diseased state of be membrane of the sac is 
 entirely a local complaint, and uncomplica- 
 ted w ith any unfavourable condition of the 
 health. In the beginning, if the probe can 
 be introduced without any great trouble, 
 and the lining of the duct js only trivially 
 thickened, Beer moistens the catgut, on its 
 daily introduction into the passage, with the 
 vinous tincture of opium, and injects into 
 the sac a lukewarm lotion, containing the 
 proportions of subacetate of copper, nitrate 
 of potass, alum, camphor, and vinum opii, 
 specified in one of the preceding columns. 
 The lint, wdiich Beer places in the orifice of 
 the sac, is also dipped in the vinum opii. 
 When the probe meets with more resist- 
 ance, the catgut is smeared with the ungu- 
 entum hydrargyri nitrati, which is to be at 
 first weakened, and afterward gradually in- 
 creased in strength. The wound is also to 
 be dressed with the same application, and 
 some of the following lotion injected down 
 the sac twice a day : Aq Ros J!v. Hy- 
 
 drarg. Oxyrnur. grj. ss. gr. j. Mucil pur. 3j* 
 Vim opii 3j. M. When any irregularities 
 and indurated points are felt with the probe 
 in the course of the nasal duct, Beer smears 
 the catgut with an ointment, containing a 
 small quantity of red precipitate, and directs 
 frictions w ith a little camphorated mercurial 
 ointment to be employed every day round 
 the external opening. 
 
 Beer joins the generality of writers in be- 
 lieving. that a long perseverance in the me- 
 chanical means is necessary, in order to re- 
 move all disposition in the nasal duct to 
 close again. (P. 176.) And, as the use of 
 the probes, syringe, catgut, and dossils of 
 lint, may be supposed to have done more or 
 less injury to the lachrymal ducts, so as to 
 cause some impediment to the due convey- 
 ance of the tears into the lachrymal sac, 
 Beer advises a trial to be made, whether a 
 couple of drops of some coloured fluid, in- 
 troduced into the inner canthus, while (he 
 patient is lying upon his hack, w ill pass into 
 the lachrymal sac ; and, if they will not do 
 so, the same author thinks, that an attempt 
 should be immediately made to clear the la- 
 chrymal ducts, by means of Anel’s probe, 
 (P. 1 77.) 
 
 According to Beer, the foregoing treat 
 ment is perfectly useless, whenever the la- 
 chrymal puncta and ducts are obliterated 
 because, even ij^ it were practicable to re- 
 store their perviousness, it would yet be im 
 possible to communicate to the new-formed 
 apertures and canals the potver of absorbin'.. 
 
i7b 
 
 LACHRYMAL ORGANS. 
 
 the tears and conveying them into the la- 
 chrymal sac. He thinks, that, in this state 
 of things, the practitioner need not trouble 
 himself about the condition of the nasal 
 duct; because, even if it were rendered 
 duly pervious, this improvement would not 
 continue long, as Beer’s experience has fully 
 convinced him, that, when the mucous se- 
 cretion of the lachrymal sac is not blended 
 with the tears, a closure of the nasal duct 
 sooner or later ensues, and of course an ac- 
 cumulation of the mucus of the sac, a dis- 
 ease sometimes termed, under such circum- 
 stances, hydrops sacculi lachry walls. And in 
 order to prevent this complaint in the state 
 of things just now described, Beer is an ad- 
 vocate for the total obliteration of the cavi- 
 ty of the sac with escharotics. (B. 2, p. 
 181.) 
 
 Such is the practice of Beer, with the 
 view of clearing away obstruction in the 
 nasal duct, and restoring its natural diame- 
 ter. Let us now consider what methods 
 have been suggested by others. Beginning 
 then with the screw, invented by Fabricius 
 ab Aquapendente, for compressing the dis- 
 tended lachrymal sac, f need only remark 
 with M. Nicod,that, as this plan was not di- 
 rected against the cause of 1 he disease, it is 
 not surprising, that it should have been una- 
 vailing. and ultimately banished from prac- 
 tice. In the year 1716, Anel invented a 
 probq of so small a size, that it was capable 
 of parsing from the upper punctual lachry- 
 male into the lachrymal sac, and nasal duct, 
 the obstructions in which latter passage it 
 was intended to remove. Anel also invented 
 a syringe, v\ hose pipe was sm >11 enough to 
 enter one of the puncta, and by that means 
 to furnish an opportunity of injecting a liquor 
 into the sac and duct ; and with these two 
 instruments he pretended to be able to cure 
 the disease whenever it consisted in obstruc- 
 tion merely, and the discharge was not much 
 discoloured. “ The first of these, viz. the 
 passage of a small probe through the puncta, 
 ('says Mr. Pott) has a plausible appearance, 
 but will, upon trial, be found very unequal 
 to the task assigned ; the very small size of 
 it, its necessary flexibility, and the very little 
 resistance it is capable of making, are mani- 
 fest deficiencies in the instrument ; the quick 
 sensation in the lining of the sac and duct, 
 and its diseased state, are great objections on 
 the side of the parts, supposing that it was 
 capable of answering any valuable end, 
 which it most certainly is not.” {Poll.) 
 
 It must be at once obvious, that Anel’s 
 instruments were devised with the view of 
 avoiding a puncture in the lachrymal sac ; 
 but the principle has been strongly objected 
 to by Beer, there being no comparison be- 
 tween the inconveniences of a small open- 
 ing made in the sac, and the injury done to 
 rhe lachrymal puncta and canals by the long 
 and repeated introduction of instruments 
 through them, whereby their functions are 
 likely to be for ever ruined, of which Beer 
 has seen some sad examples. ( Lekrc , ^-c. B. 
 2, p. 169.) 
 
 The next practice deserving notice, is that 
 
 of Laforest, who used to introduce into the 
 termination of the nasal duct in the nostril a 
 probe, with* which he cleared away the ob- 
 struction in the passage. He also introdu- 
 ced into the same orifice a curved tube, 
 which was left in the part three or four 
 months, for the purpose of employing injec- 
 tions. The method, however, was found not 
 only troublesome and difficult, on account 
 of the anatomical varieties to which the ter- 
 mination of the nasal canal was liable, but 
 also on account of the treatment, when 
 practised, being subject to frequent failures. 
 
 Following up the principles of Anel, 
 another French surgeon, Mejean, dilated the 
 nasal duct with a seton, which was drawn 
 up into the lachrymal sac by means of a 
 thread first introduced fro m the upper punc- 
 tual lachrymaie. But it was soon discover- 
 ed, that what was gained on one side, was 
 lost on the other ; the lodgment of the 
 thread in the lachrymal duct for several 
 months, and the irritation of its orifice in 
 changing the seton every day, not only 
 causing inflammation of the punctum lachry- 
 maie, but even such ulceration and cicatri- 
 ces, as sometimes destroyed the functions of 
 the parts. 
 
 J. L. Petit, sensible of live inconveniences 
 of Mejean’s practice, and disgusted with the 
 barbarous imitation of the ancient! in cauter- 
 izing th^ fistula, sac,, and os unguis, concei 
 ved that, instead of these plans, or that of 
 perforating the os unguis, as proposed by 
 Woodiouse, it would be better to endeavour 
 to restore the natural passage, by removing 
 the obstruction in the nasal duct, which ob- 
 struction Petit regarded as the cause of the 
 disease. His method consisted in opening 
 the lachrymal sac with a small bistoury, in- 
 troducing through the wound, sac, and nasal 
 duct a probe, down into the nostril, anil 
 then using bougies for the dilatation of the 
 passage. This method may be said to be 
 the model of that which has been most ex- 
 tensively followed even down to the present 
 time. Pellier and Wathen recommended 
 introducing a metahic tube down the ductus 
 nasalis, and leaving it for a time in that situa- 
 tion, with a view of preventing the duct from 
 closing again ; and the use of a cannula is 
 even now preferred by Dupuytren, the 
 greatest surgeon of France. 
 
 The desire of avoiding any puncture of 
 the sac has influenced many practitioners 
 besides Anel, and given rise to various inge- 
 nious inventions. Thus, in 17S0, Sir William 
 Blizard proposed, instead of injecting water, 
 to introduce quicksilver through a small 
 pipe, communicating with a long tube full 
 of this fluid. I he specific gravity of the 
 quicksilver, when the sa was distended 
 with it, he believed would have more power 
 than water propelled through a syringe, to 
 remove the lachrymal obstruction. 
 
 The late Mr Ware, after trying Sir Wil- 
 liam Blizard’s plan, gave the preference to 
 Anel’s syringe, with which he generally in- 
 jected warm water, through the lower punc- 
 tual lachrymaie, into the lachrymal sac, and 
 put a finger over the superior puUCt »nf» 
 
m 
 
 LACHRYMAL ORGANS. 
 
 prevent the Quid from escaping through it. 
 With his finger he also occasionally com- 
 pressed the lachrymal sac, in order to assist 
 in propelling the water down into the nose. 
 Mr. Ware sometimes used the injection 
 thrice a day, though, in general, much less 
 frequently. (See Ware on the E pi for a.) 
 
 11 1 in general begin the treatment by in- 
 jecting some warm water through the infe- 
 rior punclum laebryrnale, and I repeat the 
 operation four or five days in succession. 
 If in this space of lime, none of the water 
 pass through (he duct into the nose, and if 
 the watering of the eye continue as trouble- 
 some as it was before the injection was em- 
 ployed, I usually open the angular vein, or 
 direct a leech to be applied near the lach- 
 rymal sac ; adding here a caution, that the 
 leech be not suffered to fix on either of the 
 eyelids, lest it produce an extravasation of 
 blood in the adjacent cells. About the same 
 time that blood is taken away in the neigh- 
 bourhood of the eye, I usually vary the 
 injection, and try the effects cither of a 
 weak vitriolic, or anodyne lotion. In some 
 instances also, when I have found it impos- 
 sible, after several attempts, to inject any 
 part of the liquid through the duct, I have 
 introduced a golden probe, about the siae 
 of a bristle, through the superior puncturn 
 lachrymale, and, attending to the direction 
 of the duct, have insinuated its extremity 
 through the obstruction, and conveyed it 
 fully into the nose; immediately after which 
 I have found that a liquid, injected through 
 the inferior puncturn, has passed without 
 any difficulty ; and by repeating these ope- 
 rations for a few successive days, I have at 
 length established the freedom of t he pas- 
 sage, and completed the cure. In other in- 
 stances, I have recommenced a strongly 
 stimulating sternutatory to he snuffed up 
 the nose, about an hour before the time of 
 the patient’s going to rest, which, by exciting 
 a large discharge from the Schneiderian 
 membrane, has sometimes also greatly con- 
 tributed to open the obstruction in the nasal 
 duct 
 
 “ Cases occur very rarely which may not 
 be relieved by some of the means above re- 
 lated.” {Ware's Additional Remarks on the 
 
 Epiphora. ) 
 
 Wfrfen the discharge was fetid, Mr. Ware 
 sometiipes found, that a vitriolic lotion in- 
 jected into the sac, quickly corrected the 
 quality of the matter. 
 
 In a subsequent tract, Mr. Ware observes, 
 that if, after “ about a week or ten days, 
 there be not some perceptible advance to- 
 wards a cure, or, if, from the long continu- 
 ance of the obstruction, there be reason to 
 fear, that it is too firmly fixed to yield to 
 this easy mode of treatment, I do not hesitate 
 to propose the operation which is now to be 
 described. .The only persons, with respect 
 to whom I entertain any doubts as to the 
 propriety of this opinion, are infants. In 
 such subjects, 1 always think it adviseable to 
 postpone the operation, unless the symp- 
 toms-be particularly urgent, until they are 
 eigljX or nine years old. 
 
 Yh t, FT ' * 
 
 “ If the disease has not occasioned an 
 aperture in the lachrymal sac, or if this 
 aperture be not situated in a right line with 
 the longitudinal direction of the nasal duct, 
 a puncture should be made into the sac, at a 
 small distance from the internal juncture of 
 the pnlpebr®, and nearly in a line drawn 
 horizontally from this juncture toward the 
 nose, with a very narrow spear-pointed 
 lancet. The bl unt end of a silver probe, of 
 a size rather smaller than the probes, that 
 are commonly used by surgeons, should then 
 be introduced through the wound, and gently, 
 but steadily, be pushed on in the direction 
 of the nasal duct, with a force sufficient to 
 overcome the obstruction in this canal, and 
 until there is reason to believe, that it has 
 freely entered into the cavity of the nose. 
 The position of the probe, when thus intro- 
 duced, will be nearly perpendicular ; its 
 side will touch the upper edge of the orbit : 
 and the space between its bulbous end in 
 the- nose and the wound in the skin will 
 usually be found, in a full-grown person, to 
 be about an inch and a quarter, or an inch 
 and three-eighths The probe is then to be 
 withdrawn, and a silver style of a size nearly 
 similar to that of the probe, but rather small - 
 er, about an inch and three-eighths in length, 
 with a Hat head like that of a nail, but. 
 placed obliquely, that it may sit close on the 
 skin, is to be introduced through the duct, in 
 place of the probe, and to be left constantly 
 in it. .For the first day or two after the 
 style has been introduced, it is sometimes 
 adviseable to wash the eye with a weak satur- 
 nine lotion, in order to obviate any tendency 
 to inflammation which may have been exci- 
 ted by the operation ; but this in general is 
 so slight, that l have rarely had occasion to 
 use any application to remove it. The style 
 should be withdrawn once every day for 
 about a week, and afterward every second 
 or third day. Some warm water should 
 each time be injected through the duct into 
 the nose, and the instrument he afterward 
 replaced in the same manner as before. I 
 formerly used to cover the head of the style 
 with a piece of dyachylon plaster spread on 
 black silk ; but have of late obviated the 
 necessity for applying any plaster by black- 
 ening the head of the style with sealing 
 wax.” 
 
 Mr Ware did not. on first trying this me- 
 thod, expect any relief, till the style was left 
 off. However, he found, that the watering 
 of the eye ceased, as soon as the style was 
 introduced, and the sight became proportion- 
 ably more useful and strong. 
 
 The wound, which Mr. Ware makes in the 
 sac, when there is no suitable ulcerated 
 aperture, is only just large enough to admit 
 the end of the probe, or style ; and this soon 
 becomes a fistulous orifice, through which 
 the style may be passed without the least 
 pain. In short, in about a week or ten 
 days, the treatment becomes so easy, that 
 the patient, or any friend, is fully competent 
 to do what is necessary. It merely consists 
 in withdrawing the style, two, or three times 
 a week, occasionally injecting some warm 
 
 23 
 
ns 
 
 LACHRYMAL ORGANS. 
 
 water, and then replacing the instrument as 
 before. 
 
 Some, finding no inconvenience from the 
 style, and being afraid to leave it off, wear it 
 for years; many others disuse it in about a 
 month, or six weeks, and continue quite 
 well. The ulcerations, sometimes existing 
 over the lachrymal sac, commonly heal, as 
 soon as the tears can pass down into the 
 nose ; but Mr. Ware mentions two instances, 
 in which such sores did not heal until a 
 weak solution of the hydrargyrus rauriatus, 
 and bark, were administered. (See Ware 
 on the Fistula Lachrymalis.) 
 
 Great as the recommendation of the fore- 
 going practice is, as delivered by Mr. Ware, 
 Mr. Travers is strongly disposed to doubt, 
 whether any permanent benefit was ever 
 derived from letting the style remain in the 
 passage. When an abscess over the sac has 
 been opened, this gentleman, instead of the 
 introduction of a style into the ductus nasa- 
 l’s, recommends simply the examination of 
 the duct with a fine probe. “ if the probe 
 passes without resistance into the nose, the 
 ease requires no further operative treatment, 
 the integument recovers its healthy condi- 
 tion under an emollient application, the 
 discharge gradually diminishes, and the 
 wound heals. If, on the other hand, upon 
 examination with the probe, introduced 
 through the wound, into the sac, resistance 
 is offered to its passage into the nose, no 
 more favourable opportunity will be pre- 
 sented for overcoming such resistance. 
 This, therefore, should be accomplished, 
 but to this the operative process should be 
 limited, and the wound should be suffered 
 to heal without further disturbance.” When 
 there is what Mr Travers terms a stricture 
 in the nasal duct, and the passage of the 
 probe is more firmly resisted, he admits that 
 some means must be employed for keeping 
 the duct pervious, after it has been reopen- 
 ed. He never interferes with the integu- 
 ments, except in the case ol abscess disco- 
 louring the skin, and threatening to produce 
 a fistula ; and for the purpose of restoring 
 the passage, he uses a set of silver probes, of 
 about five inches long, of various sizes, 
 flattened at one end, and. slightly bulbous at 
 the point. When there is no obstruction, 
 these, he says, may be introduced with 
 perfect facility from either of the puncta 
 lachrymalia into the nostril. lt If the punc- 
 tual be constricted, it is readily entered, and 
 dilated by a common pin ; and, upon with- 
 drawing it, by one of the smaller probes. 
 The direction and relative situation of the 
 lachrymal ducts, the sac, and nasal canal, 
 point out the proper course of the instru- 
 ment. It is confirmed by its advance, with- 
 out the employment of force, and the sensa- 
 tion conveyed by the free and unincumbered 
 motion of its point. Until the point is fairly 
 within the sac, it is necessary to keep the 
 eyelid gently stretched and slightly everted ; 
 the upper lid being drawn a little upward 
 toward the brow ; the lower, as much down- 
 ward toward the zygoma. The point carried 
 borne to the sac, and touching lightly its 
 
 nasal side, the lids may be left at liberty, 
 while a half circular motion is performed by 
 the instrument ; the surgeon neither suffer- 
 ing the point to recede, nor, on the other 
 hand, allowing it to become entangled in 
 the membrane. The probe now rests, in a 
 perpendicular direction, upon the eyebrow, 
 toward its inner angle, and, in this direction, 
 it is to be gently depressed, until it strikes 
 upon the lloor of the nostril, where its pre- 
 sence is readily ascertained by a common 
 probe passed beneath the inferior turbinated 
 bone. The probe, of smallest dimensions, 
 is of sufficient firmness to preserve its figure 
 in its passage through the healthly duct, but 
 it is too flexible to oppose any considerable 
 obstruction. For the stricture of the lachry- 
 mal ducts, it is of sufficient strength. Very 
 many, cases of recent origin, and in which 
 the stricture has no great degree of firmness, 
 (Mr. Travers says) are completely cured by 
 three or four introductions of the probe into 
 the nostril, at intervals of one, or two days. 
 
 I have seldom met with a stricture so firm as 
 not to yield^to the full-sized probe.” When 
 the resistance is not altogether removed, 
 after this plan has been tried some' days, 
 Mr. Travers introduces a style, having a small 
 fiat head, a little sloped, through the pane- 
 turn lachrymale into the nose, and leave it 
 in the nasal duct for twenty-four hours. It 
 worn longer, he says, that it causes ulcera- 
 tion of the orifice. A day or two is to elapse, 
 before the style is again introduced, which 
 must now be passed through the other lach- 
 rymal duct. On the intervening days, tepid 
 water should be injected with Anel s syringe. 
 (Synopsis of the Diseases of the Eye. p. 369, 
 370, 372, 374.) 
 
 Thus, we see, that Mr. Travers’s practice 
 bears a considerable resemblance to that of 
 Anel, inasmuch as the sac is never opened, 
 except when likely to ulcerate, and nearly 
 every thing is done with probes and injec- 
 tions, introduced through the lachrymal 
 puncta and ducts. I wish that my views of 
 the nature of these diseases, and of the parts 
 concerned, would allow me to think the 
 latter proceedings, in the ease of stricture of 
 the nasal duct, as commendable as another 
 part of Mr. Travers’s practice, where, in 
 cases of slighter obstruction, he contents 
 himself with opening the sac, clearing away 
 the stoppage of the nasal duct with a probe, 
 and healing up the wound, without leaving 
 an> style, cannula, or seton in the passage. 
 Where the obstruction is very slight, such 
 practice must be judicious. But if, in other 
 cases, it he deemed right for the prevention 
 of a relapse, that the nasal duct should be 
 either filled with some dilating instrument a 
 certain time, or repeatedly probed, I am 
 decidedly of opinion with Professor Beer, 
 M. Nicod, &c. that the object of not making 
 a small opening in the sac is attended with 
 no advantage, at ali likely to counterbalance 
 the mischief, which must be done to the 
 lachrymal puncta and ducts, not only by 
 the repeated introduction of probes and of 
 syringes, but by the lodgment of the former 
 in them for the space <»i twenty-four hour* 
 
LACHRYMAL ORGANS, 
 
 m 
 
 together. If there be an opening in the sac, 
 its convenience iri permitting the easy use 
 of a probe is generally acknowledged ; and, 
 in order to gain this advantage, and avoid 
 the evils, which are inseparable from taking 
 too much liberty with the lachrymal puncta 
 and ducts, surely a slight puncture in the 
 sac, if there be no opening already , must be 
 the most rational, simple, and successful 
 practice. 
 
 When the perviousness of the nasal duct 
 cannot be restored by any use of the probe, 
 and the obstructed part has a very elastic 
 feel, is of inconsiderable extent, and near 
 the termination of the duct in the nostril, 
 Beer recommends a perforation to be made 
 with a trocar-shaped probe, the point of 
 which is to be covered with a bit of wax, 
 in order that it may not hurt the parts in its 
 passage downward. Some discharge of 
 blood from the nose indicates, that the perfo- 
 ration is made. The sharp-pointed probe is 
 then to be withdrawn, a blunt one used for 
 the purpose of dilating the passage, and, at 
 length, the catgut, as already explained. 
 (Beer, B.2,p. 181.) 
 
 Supposing the nasal duct to be obliterated 
 for a considerable part of its extent, by a 
 firmer substance, what practice should then 
 foe followed ? Ought the formation of an 
 artificial passage to be attempted ? On this 
 point, modern practitioners differ, but, as 
 the expedients adopted for this purpose 
 cannot be judged of previously to their 
 description, it will be better in the first place 
 briefly to notice them. As Mr. Pott has re- 
 marked, the upper and hinder part of the 
 lachrymal sac is firmly attached to the os 
 unguis, a small, and very thin bone, just 
 within the orbit, which bone is so situated, 
 that, if it be by any means broken through, 
 the two cavities of the nose and orbit com- 
 municate with each other: consequently, 
 the os unguis forms the partition Jaetween 
 the hinder part of the lachrymal sac, and 
 the upper part of the cavity of the nose ; 
 and it is by making a breach in this partition, 
 that the formation of an artificial passage 
 has been attempted. In Mr. Pott’s time, 
 the cautery had long been disused for ma- 
 king an aperture in the os unguis, and vari- 
 ous instruments were recommended for this 
 object, such as a large strong probe, a kind 
 of gimblet, a curved trocar, &sc. each of 
 which, says this practical writer, if dexter- 
 ously and properly applied, will do the 
 business very well ; the one necessary cau- 
 tion is, so to apply whatever instrument is 
 used, that it may pierce through that part of 
 the bone which ifes immediately behind the 
 sacculus laArymalis, and not to push too 
 far up into the nose, for fear of injuring the 
 os spongiosum behind, while it breaks its 
 way. Mr. Pott adds, that he himself has 
 always used a curved troc&r, the point of 
 which should be turned obliquely down- 
 ward, from the angle of the eye, toward the 
 inside of the nose. The accomplishment of 
 the broach will be known by the discharge 
 of blood from the nostril, and of air from the 
 woalid, upon blowing the nose. Care -must 
 
 be taken to apply the instrument to the part 
 of the bone, anterior to the perpendicular 
 ridge, which divides it. 
 
 As soon as the perforation is made, a tent 
 of lint should be introduced, of such size as 
 to fill the aperture, and so long as to pass 
 through it into the cavity of the nose : this 
 should be permitted to remain in two, three, 
 or four days, and afterward a fresh one 
 should be passed every day, until the clean 
 granulating appearance of the sore makes 
 it probable, that the edges of the divided 
 membrane are in the same state. The 
 business now is to prevent the incarnation 
 from closing the orifice ; for which purpose, 
 the end of the tent may be moistened with 
 diluted vitriolic acid, or a piece of lunar 
 caustic, so included in a quill, as to leave 
 little more than the'extremity naked, may at 
 each dressing, or every other, or every 
 third day, be* introduced ; by which the 
 granulations will be repressed, and the open- 
 ing maintained ; and when this has been 
 done for some little time, a piece of bougie 
 of proper size, or a leaden cannula, may be 
 introduced instead of the tent; and leaving 
 off all other dressings, the sore may be suf- 
 fered to contract as much as the bougie will 
 permit; which should be of such length, 
 that one extremity of it may lie level with 
 the skin in the corner of the eye, and the 
 other be within the nose. 
 
 The longer time the patient can be prevail- 
 ed upon to wear the bougie, the more likely *> 
 will be the continuance of the opening ; and 
 when it is withdrawn, the external orifice 
 should be covered only by a superficial 
 pledget, or plaster, and suffered to heal un- 
 der moderate pressure . (Pott.) 
 
 After the perforating instrument was with- 
 drawn, Mr. Ware recommended a nail- 
 headed style, about an inch long, to be in- 
 troduced through the aperture, in the same 
 way in which it is introduced through the 
 nasal duct, in cases in which the obstruction 
 is not so great as to prevent its. passing in 
 this direction ; and it may remain here with 
 as much safety as in this last-mentioned in- 
 stance, for as long a time as its continuance 
 may be thought necessary to establish the 
 freedom of the communication. 
 
 Unfortunately for the scheme of making an 
 artificial passage, nature was generally so 
 busy, that sin 1 completely frustrated the aim 
 of the surgeon by gradually filling up the 
 new aperture again. Hence, some practi- 
 tioners were not content with drilling a hole 
 through the os unguis, but actually removed 
 a portion of this bone either with the for- 
 ceps proposed by Lamorier in 1729. (See 
 M6m. de l’ Acad, des Sciences ,) or with cutting 
 instruments, among which the most celebra- 
 ted is the sharp-edged kind of cannula de- 
 vised by Hunter. While this was being ap- 
 plied, however, it was necessary to sup- 
 port the os unguis with something passed up 
 ihe nose, and a piece of horn was found to 
 answer very well. Instead of these methods, 
 Scarpa prefers destroying a portion of the 
 os unguis with the actual cautery passed 
 through a cannula; a practice; long ago ba- 
 
LACHRYMAL ORGANS. 
 
 isv 
 
 11 i shed from good surgery, and most justly 
 condemned by Richter. 
 
 1 do not feel it necessary to enter very 
 particularly into the details of these methods 
 of forming an artificial passage between 
 the lachrymal sac and nostril, i have never 
 seen a case, in which' 1 should have deemed 
 such practice adviseable, and that the neces- 
 sity for it must be rare must be inferred from 
 what Mr. Travers has observed, viz. that he 
 does not believe the perforation of the os un- 
 guis ever really required it. (Synopsis, p. 379.) 
 Beer’s remarks are also decidedly against 
 the practice ; for, he states that, in order 
 that the new opening may not be closed 
 with lymph, it must be made too high up to 
 serve the purpose of a diain, through which 
 the mucus can descend by its own gravity. 
 He has not met with a single case, either in 
 his own practice, or among the patients 
 whom he has had opportunities of seeing 
 under other practitioners, where the per- 
 foration of the os unguis had a successful 
 result. On the contrary, in one healthy lad, 
 the operation, which had been done by an 
 experienced surgeon, was followed by the 
 destruction of the nasai process of the up- 
 per maxillary bone, one of the ossa nasi, 
 and all the bones contributing to the forma- 
 tion of the passage from the orbit into the 
 nose. (See Lehre von den Augenkr. B. 2, 
 p. 182) Hence, Beer thinks, that the pa- 
 tient had better either submit to the incon- 
 venience of being obliged to empty the dis- 
 tended sac by pressure several times a day, 
 or let the cavity of the sac be obliterated by 
 means, calculated to excite the adhesive in- 
 flammation in it. But, if the lachrymal 
 puncta and ducts, as well as the nasal duct, 
 are obliterated, Beer conceives that there is 
 no alternative, because, if the cavity of the 
 sac be left, tjie case, which he terms hydrops 
 sacculi lachrymalis,will ensue, whenever the 
 fistula is closed. 
 
 Of Hernia and Hydrops of the Lachrymal 
 Sac. — The diseases, described by Beer undgr 
 these appellations, are not discriminated in 
 this country, although they are characteri- 
 zed by widely different symptoms, and re- 
 quire opposite methods of treatment. In 
 the case of hernia, or simple relaxation, the 
 lachrymal sac forms a tumour, which never 
 surpasses the size of a common horse-bean, 
 the integuments are of their natural colour, 
 the tumour is soft and yielding to pressure, by 
 which the contents of the sac are readily dis- 
 charged through the puncta, or nasal duct. 
 Hydrops grows tothe s.ze oi a pigeon’s egg, is 
 purplish from the beginning, very hard and in- 
 capable of being emptied by t he strongest 
 pressure. Hernia is cured by compression, 
 and the application of astringents to the re- 
 laxed parts ; hydrops requires the incision 
 of the sac. In hernia, the nasal duct is 
 natural; in hydrops, it and sometimes the 
 puncta are obstructed. 
 
 Stillicidium Lachrymarum. — According to 
 Beer, the valuable treatise of Schmidt is the 
 only work, in which the important practical 
 distinction is drawn between stillicidium 
 
 lachrymarum and epiphora; the immediate 
 cause of the first complaint being some im- 
 pediment to the passage of the tears from 
 the lacus lachrymarum into the lachrymal 
 sac ; while the other affection consists in a 
 redundant and extraordinary secretion of 
 the tears. The curable form of stillicidium, 
 here to be noticed, arises from relaxation of 
 the lachrymal puncta and canals, in conse- 
 quence of previous inflammation of the 
 parts. The puncta are widely open ; but in 
 other respects, have quite a natural appear- 
 ance. When touched with Anel’s probe, 
 they do not contract, as in the healthy 
 state. The tears, which from time to time 
 fall over the cheek, are not in considerable 
 quantity, only trickling from the inner can- 
 thus by drops at intervals; and the nostril 
 on the affected side is found to be rather 
 drier than natural. 
 
 Erysipelatous inflammation of the eyelids 
 and parts over the lachrymal sac, and the 
 purulent kinds of ophthalmy, frequently 
 cause this sort of stillicidium. The latter 
 cases indeed the more readily produce the 
 disorder, inasmuch as the semilunar fold of 
 the conjunctiva is relaxed and swelled, so 
 as to push the puncta out of their right po- 
 sition for the due performance of the absorp- 
 tion of the tears, and obstruct this function 
 more than Would be the case, if the dimi- 
 nished action of those orifices and the la- 
 chrymal ducts were the only thing con- 
 cerned. 
 
 Beer delivers an exceedingly favourable 
 prognosis, observing, that the complaint 
 often disappears of itself on the approach of 
 warm dry weather, and may almost always 
 be readily cured, by means of astringents. 
 Among other remedies specified by this au- 
 thor, 1 need only mention a solution of the 
 sulphate of iron, to which a small quantity 
 of camphorated spirit, or tincture of opium, 
 has been added It is to be dropped out of 
 a pen into the inner angle frequently in the 
 course of the day, the patient lying upon his 
 back for some time after each application, 
 so as to let the medicine have more effect 
 upon the parts (See Lehre von den Au * 
 genfer. B. 2, p. 41 — 43.) 
 
 Mr. Travers mentions a constricted state 
 of the lachrymal puncta and canals, which is 
 curable by the introduction of a small probe. 
 
 ( Synopsis , fyc. p. 366.) All moden. write s 
 agree, that the obliterated puncta and canals 
 can never be restored. (See Memoires de 
 I'Academie de Chirurgie, T. 5, Edit. 12 mo. in 
 which are several essays on fistula lachrymalts 
 viz. one by M. Bordenavc, entitled, “ Examen 
 des (inflexions critiques de M. j\k>linelli, inve- 
 rses dans les MSmovres de l i nsiimt de Bolvgnc , 
 contre le Mcmoire de M. Petit, sur la Fist ale 
 Lachrymale, insure parmi ceux de l' Acad. Hoy • 
 ale aes Sciences de Paris. Annie 1734. Another * 
 essay by M. de la Forest, styled u JVouvcllc Me - | 
 thodc de Iraitcr les Maladies du Sac Lack - 
 ryrnal, nominees commandment Fislults Lack- 
 ry mules .” A third by M. Louis , called “ Be- if 
 flexions sur V Operation de laflstuU Lachry- 
 male." O. E. Stahl , Programma da Fistula 
 
LAC* 
 
 lAfe 
 
 Lachrymali, Halve, 1702'. J. C. Scholunger, 
 J9e Fistula Lachrymali , Basil, 1730. D. 
 Metzger, Curationum Chir. quce ad Fistulam 
 Lachrymalem sive usque J'uere adliibitee , Hislo- 
 ria Critica, 8 vo. Monarferii , 1772. P. 
 
 Qucestio, <^c. An fistula-, lachrymali cau- 
 terium actuale? Paris , 1738. J. L PefiJ, 
 Tra/te des Mai. Chir. T. \\,p. 289, fyc. 8vo. 
 Paris, 1774. M. A Magnabal. De Morbis 
 Viarum Lachrymalium, ac pracipue de fistula 
 lachrymali, Monlp. 1765. A. Berlrandi, 
 Traite des Jpdrations, p. 297, 8 vo. Paris, 
 1784. Ariel has described his plan of treat- 
 ment in various icorks : Observation sivgu- 
 
 licre sur la fistule lacrymale , dans laquelle I on 
 apprendra la methodt de la guerir radical e- 
 ment .” Turin, 1713) in 4 to. u Nouvelle 
 Mtihode de gu6rir les fistules lacry males." 
 Turin, 1713, in4to. u Suite de la JYouvelle 
 Methode," fyc. ibid. 1714 , in 4 to. “ Disst r- 
 
 lation sur la nouvelle. d6couverte de I’hydropisie 
 du conduit lacrymat ," Paris, 1716, in 12 mo. 
 And , lastly , Anti has published in the M6m. 
 de 1'Acad. des Sciences, annee 1713, “ Pricis 
 de sa nouvelle mamtre de gudrir les fistules 
 lacrymales." Me jean in Mdm. de VAcad. de 
 Chir . T. 2, p. Iy3, 4to. Palucci, Methodus 
 curanda fistulce lachrymalis, l 'indob. 1762; 
 a tube preferred. Sabatier, Midecine Opdra- 
 foire, T. 2, Ed. 2. Richter's Anfanccsgriinde dtr 
 fVundarzneykunst, B. 2. Kap. 11. Pott's 
 observations relative to the disorder of the 
 comer of the eye, commonly called the Fistula 
 Lachrymalis, 8 vo. Loud. 1758. Sir W. Bli- 
 zard , A New Method of treating the Fistula 
 Lachrymalis, 4lo. Lond. 1780. Ware on the 
 Epiphora and Fistula Lachrymalis; 8vo. 
 Lond. 1792 — 95. Scarpa sulle principali 
 Malattie degli Occhi, Capo 1. Walken's New 
 and easy Method of applying a Tube for the 
 Fistula Lachrymalis, Lond. 1781, and 2d Ed. 
 1792. Sprengel, Geschichte der Wichtigsten 
 Chir. Operalionen, p. 105. Nicod, Memoire 
 sur la Fistule Lacrymale in Revue M6d. 
 Historique, fyc. livr. 1 et 2, 8 vo. Paris, 
 1820. Fournier, Diss. de lAppare.il des voies 
 lachrymales ; Montpellier, 1803 J. L. Angely, 
 Cornmentatio Medica de Oculo Organisque La- 
 chrymalibus ratione Alt at is, Sexus. Gentis, et 
 Variorum Animalium . S vo. Erlangce, ISOS. 
 Reil, Diss. de Chir. Fistulas Lachrymalis Cu- 
 ratione, Berol. 1812; Flajani , Collezione d' Os- 
 servazioni, T. 3. Desault, (Euvres Chir. T. 
 2,p. 119, 8 vo. Paris, 1801. J. C. Rosenmul- 
 ler, Partium Externarum Oculi Humani , im- 
 primis Organorum lachrymalium, Descriplio 
 Anatomica ; ico?iibus illuslrata, 4 to. Lips. 
 1810. C. H. T. Schreger, Versuch einer 
 Vergleichenden Anatomic des Auges und der 
 Tiirdnenorgane des Menschen und der vbrigen 
 Tkitrklassen, 8vo. Leipz. 1810. Beer, Lehre 
 von den Augenkrankheiten^ 2 B.Sco. Wien, 
 1813 — 1817. Wm. Mackenzie, An Essay on 
 
 the Diseases of the Excreting Parts of the La- 
 chrymal Organs, 8 vo. Lond. 1819 ; contains 
 many valuable observations from the writings 
 of Beer . B. Travers , A Synopsis of the Dis- 
 eases of the Eye,p. 228 — 359, fyc. 8 vo. Lond. 
 1820. Ph. v. Waltaer ueber die steinigen 
 Concrctionen der Thrcinenjlussigkeit, in Journ. 
 far Chirurgie von C. Graefe, B. I, p. 163. 
 
 iSl 
 
 8vo. Berlin, 1820. J. A. Schmidt iiber die 
 Krankheiien des Thriineuorgans ; a work of 
 the highest reputation. 
 
 L AGOPHT H AL MIA, orLAGOPHTHAL 
 MOS. (from \oyos, a hare ; and c< an 
 eye.; The Hare's Eye. Oculus Leporinus. 
 A disease, in which the eye cannot be com- 
 pletely shut. The following complaints 
 may arise from it ; a constant weeping of 
 the organ, in consequence of the interrup- 
 tion of the alternate closure and opening of 
 the eyelids, which motions so materially 
 contribute to the propulsion of the teurs 
 into the nose ; blindness in a strong light, in 
 consequence of the inability to moderate 
 the rays, which enter the eye ; on the same 
 account, the sight becomes gradually very 
 much weakened , incapacity to sleep where 
 there is any light; irritation, pain, andredne s 
 of the eye, from this organ being exposed 
 to the extraneous substances in the atmos- 
 phere. 
 
 An enlargement, or protrusion of the 
 whole eye, o a staphyloma, may obviously 
 produce lagophthalmos. But, affections of 
 the upper eyelids are the common causes. 
 Heister lias seen the complaint originate 
 from a disease of the lower one. Now and 
 then lagophthalmos depends on paralysis of 
 the orbicularis muscle. A cicatrix, after a 
 wound, ulcer, or burn, is the most frequent 
 cause. 
 
 When lagophthalmos arises from a paraly- 
 tic affection of the orbicularis palpebrarum, 
 the eyelids may be rubbed with a liniment 
 containing the tinctura lyttas, or the linimen- 
 tum camphorae. Electricity and cold bath- 
 ing are also considered principal means of 
 cure, ( Chandler ) together with the exhibition 
 of bark, the use of the shower-bath, &c. 
 
 When the affection arises from spasm of 
 the levator palpebrai superioris, electricity, 
 admail blister on the neighbouring temple, 
 and rubbing the eyelid and eyebrow with 
 the tinctura opii, are recommended, together 
 with antispasmodic medicines. 
 
 WTien lagophthalmos arises from the con- 
 traction of a cicatrix, its relief is to be at- 
 tempted precisely on the same principles a5 
 the ectropium. (See Ectropium .) How 
 ever, when*the eyelid is shortened as well 
 as everted, nothing will remove the defor- 
 mity 
 
 The inconveniences, depending on the 
 eye being unable to shelter itself from the 
 light, are to be obviated by wearing agreeri 
 shade. 
 
 Whoever is acquainted with German, and 
 is desirous of more minute information on 
 this subject, may find an excellent account 
 of lagophthalmos in Richter's Anfavgsgr. 
 der Wundarzn. B. 2. Von dem Hasenauge. 
 See also Beer's Lehre von den Angenkr. B. 2, 
 p. 239, 8fC. 87-0. Wien, 1817. 
 
 LARYNGO 1'OMY. (from the la- 
 
 rynx; a nd^Mva, to cut.) The operation of 
 making an opening into the larynx. (See 
 Bronchotomy .) 
 
 LATERAL OPERATION. One mode of 
 cutting for the stone. (See Lithotomy 
 LENTICULAR, (from leniim!aire r doubly 
 
convex.) An instrument, contained in every 
 trephining case, and employed for removing 
 the irregularities of bone from the edge of 
 the perforation, made in the cranium with 
 the trephine. One side of its blade is con- 
 vex, the other concave ; and one of its 
 edges is sharp. On the end of the blade is 
 fixed a little shallow cup, with its concavity 
 towards the handle of the instrument. This 
 part serves the purposes of receiving the 
 little pieces of bone, when detached, keep- 
 ing the end of the blade from hurting the 
 dura mater, and, when applied under the 
 margin of the opening, enables the operator 
 to guide the edge of the instrument all round 
 it, w ith steadiness and security. 
 
 LEUCOMA. (from \euxos, white.) Leu- 
 comaand albugo are often used synonymous- 
 ly, to denote a white opacity of the cornea. 
 Both of them, as Scarpa remarks, are essen- 
 tially different from the nebula of the cornea ; 
 for, they are not the consequence of chronic 
 ophthalmy, with varicose veins, and an 
 effusion of a milky serum into the texture of 
 the delicate continuation of the conjunctiva 
 over the cornea ; but, are the result of vio- 
 lent acute ophthalmy. In this state, a dense 
 coagulating lymph is extravasated from the 
 arteries ; sometimes superficially, at other 
 times deeply into the substance of the 
 cornea. On other occasions, the disease 
 consists of a firm callous cicatrix on this 
 membrane, the effect of an ulcer, or wound, 
 with loss of substance. The term albugo , 
 Strictly belongs to the first form of the disease ; 
 leucoma to the last, more particularly when 
 the opacity occupies the whole, or the chief 
 part, of the cornea. 
 
 The recent albugo, remaining after the 
 cure of severe acute ophthalmy, is of a clear 
 milky colour; but, when of ancient date, it 
 becomes pearl-coloured. Some cases, which 
 have existed a considerable time, do not 
 seem to have any connexion with the vascu- 
 larity of the cornea ; for they continue insu- 
 lated in the middle of the transparent por- 
 tion of this membrane, withoul occasioning 
 the least uneasiness to the patient, the least 
 disturbance of the rest of the eye, or any 
 attempt of the absorbents to remove them. 
 
 The recent albugo, provided* the organi- 
 zation of the cornea be not destroyed, may 
 generally be dispersed by the means em- 
 ployed for the relief of the first and second 
 stages of acute ophthalmy; viz. general and 
 topical blood-letting with internal antiphlo- 
 gistic medicines, and topical emollients for 
 the first; slightly irritating and corroborant 
 applications for the second- As soon as the 
 inflammation has subsided, the latter ^should 
 be employed ; for, by making the absorbents 
 remove the coagulating lymph, deposited in 
 the cornea, they restore the transparency of 
 this membrane. 
 
 But, though this may often be accomplish- 
 ed in the recent state of albugo, it is more 
 difficult when the long duration of the dis- 
 ease has paralyzed the absorbents of the af- 
 fected part ; or when the deposition of a 
 dense tenacious substance into the cornea 
 has subverted its organization- (Scarpa.) 
 
 The recent condition of the disease, with 
 out disorganization of the structure of the 
 cornea; its occurrence in young subjects, 
 whose absorbents are readily excited by ex- 
 ternal stimulants; are circumstances favour- 
 able to the cure. In children, the albugo, 
 arising from severe ophthalmy after the 
 small pox, and insulated in the centre of the 
 cornea, very often disappears of itself in the 
 course of a few months. Heister, Langguth, 
 and Richter, make the same observation. 
 The event can only be imputed to the vigor- 
 ous action of the lymphatics in children, 
 and to the organization of the cornea not 
 being destroyed. For promoting the absorp- 
 tion, Scarpa recommends the following colly- 
 rium : 3 ,. Ammon, muriata*. Qij.Cupri acetati 
 gr. iv. Aquae Calcis^viij. Misce, The fluid is to 
 be filtered, after standing twenty-four hours. 
 He praises also this ointment : Tutiae 
 
 praepar. 3j- Aloes, s. p. gr. ij. Hydrargyri 
 submur. gr. ij. Adipis suillae. 55 s. Misce 
 And the unguentum ophthalmicuin of Janit?. 
 He mentions the gall of the ox, sheep, pike, 
 and barbel, applied to the cornea, two or 
 three times a day, with a small hair pencil, if 
 top much irritation should not be produced. 
 In some subjects, when the eyes are very irri- 
 table, and cannot bear the latter applications, 
 Scarpa has found the oil of walnuts an use 
 ful application. But it is generally neces- 
 sary to persevere, at least three or four 
 months, before the case can be reckoned in- 
 curable. 
 
 All the expedients, proposed for the inve 
 terate albugo or leucoma from a cicatrix, 
 consisting of scraping or perforating the 
 layers of the cornea, and exciting ulceration 
 there, are unavailing. For, though the en- 
 largement of the cornea should be lessened 
 by such means, its diaphanous state could 
 not be restored ; or should the patient per- 
 ceive a ray or two of light immediately after 
 the operation, the benefit would only be 
 transient; for, as soon as the wound had 
 healed, the opacity would recur. The for- 
 mation of an artificial ulcer might prove use- 
 ful, if leucoma depended on a mere extrava- 
 sation of lymph ; but, the fact is, the disease 
 arises from the deposition of an opaque sub- 
 stance, and the disorganization of the tex- 
 ture of the cornea, conjointly : in this lies 
 the difference between albugo and leucoma. 
 
 See Scarpa suite Malatlie degli Occhi ; 8 vo. 
 Venezia, 1802. Richter, Anfangsgrunde dec 
 Wundarzn. B. 3. Essays on the Morbid Ana- 
 tomy of the Eye, by J. IV ar dr op ; Edinb. 1808 : 
 chap. 11. 
 
 LIGATURE. In the article Hemorrhage , 
 it has been explained, that the immediate 
 effect of a tight ligature on an artery, is to 
 cut through its middle and internal coats, a 
 circumstance that tends very much to pro- 
 mote the adhesion of the opposite sides ot 
 the vessel to each other. Hence, 1 think 
 with Dr. Jones, in opposition to Scarpa,' that 
 the form and mode of applying a ligature to 
 an artery should be such, as are most 
 certain of dividing the above coats ot tin*, 
 vessel, in a regular manner. A broad flat 
 ligature does not seem likely to answer H 1 > ■ 
 
LIGATURE. 
 
 purpose well ; because it is scarcely possible 
 to t:e it smoothly round the artery, which is 
 apt to be thrown into folds, or to be puck 
 ered by it, and, consequently, to have an 
 irregular bruised wound made in its middle 
 and internal coats. (Jones.) A ligature of 
 an irregular form is likely to cut through 
 these coats more completely at some parts, 
 than others; and if.it does not perfectly 
 divide them, though adhesion may yet take 
 place, it is a slower and less certain event, 
 and secondary hemorrhage more likely to 
 follow. The fear of tying a ligature too 
 tight may often lead to the same disadvan- 
 tages. ihese, and many other important 
 circumstances, are noticed in the article 
 Hemorrhage. 
 
 Ligatures are commonly made of inkle, 
 and rubbed with white wax. They should 
 be round, and very firm, so as to allow being 
 tied with some force, without risk of break- 
 ing. (See Jones on Hemorrhage , p. 172.) 
 
 The principles, which should guide the 
 surgeon in the use of the ligature, were not 
 known until the late Dr. Jones published his 
 valuable treatise on hemorrhage. As an 
 able surgeon has observed, “ he has banished 
 (at least in this country) the use of thick and 
 Ibroad threads, of tapes, of reserve ligatures, 
 of cylinders of cork and wood, linen coin 
 presses, and all tLi€5 contrivances, 'which, em- 
 ployed as a security against bleeding, only 
 served to multiply the chances of its occur- 
 rence.” ( Lawrence , in Med. C/iir. Trans. 
 Vol. 6, p. 162.) 
 
 In the article Amputation , l have noticed 
 the method of cutting off both ends of the 
 ligature close to the knot, on the face of the 
 stump, with the view of lessening the quan- 
 tity of extraneous matter in the wound, and 
 promoting a complete union of the divided 
 parts, without suppuration 
 
 This plan has been tried by Mr. Lawrence : 
 u The method I have adopted (says this 
 gentleman) consists in tying the vessels with 
 fine silk ligatures, and cutting off the ends as 
 close to the knot as is consistent with its 
 security, Thus the foreign matter is reduced 
 to the insignificant quantity, which forms 
 the noose actually surrounding the vessel, 
 and the knot, by which that noose is fastened. 
 Of the silk, which i commonly employ, a 
 portion sufficient to tie a large artery, when 
 the ends are cut off, weighs between one- 
 fiftieth and one-sixtieth of a grain : a similar 
 portion of the thickest kind I have tried, 
 weighs one-twentieth of a grain, and of the 
 slenderest one-eightieth.” 
 
 Mr. Lawrence states, that the kind of silk 
 twist which is commonly known in the 
 shops by the name of dentist’s silk, and 
 which is used in making fishing lines, is the 
 strongest material, in proportion to its size, 
 and therefore the best calculated for our 
 purpose, which requires considerable force 
 in drawing the thread tight enough lo di- 
 vide the fibrous and internal coats of the 
 arteries. This twist is rendered very hard 
 and stiff by means of gum, which may be 
 removed by boiling it in soap and water ; 
 but the twist then loses a part of its strength. 
 
 ina 
 
 The stoutest twist which Mr. Lawrence has 
 used, is a very small thread comp red with 
 ligatures made of inkle. The quantity of 
 such a thread, necessary for the noose and 
 knot on the iliac artery, weighs one-twenti- 
 eth of a grain ; or, if the gum has been 
 removed, about one-twenty-sixth. But the 
 finest twist, kept in the silk shops, is strong 
 enough in iTS hard slate for any surgical 
 purpose ; and the noose and knot, accord- 
 ing to Mr. Lawrence’s statement, would not 
 weigh one-fortieth of a grain. 
 
 It anther appears, from the report of this 
 gentleman on the subject, that there is no 
 danger ot these ligatures cutting completely 
 through the vessel, as some surgeons have 
 apprehended; and that, although he has 
 not yet ascertained what becofnes of the 
 piece of ligature after the wound is united, 
 he has never seen abscess nor any other bad 
 symptom occasioned by them. At the time 
 when Mr. Lawrence wrote, he had employ- 
 ed this method of securing the arteries in 
 ten or eleven amputations, in six operations 
 Oil the breast, and in the removal of two 
 testicles. The cases all did well, excepting 
 a man w ho lost his thigh, and who died of 
 an affection of tne Sungs. (See Lawrence on 
 a JYew Method of Tying the Arteries in Aneu - 
 rism, 4’C. in Medico- Chit. Trans. Vol. 6, p. 
 156, Hfc.) 
 
 The foregoing method was tried by myself 
 in several amputations, which 1 performed 
 in 1815 at Brussels, and in a larger number 
 of cases by my friend, Mr. Collier. Our 
 ligatures, however, though small, were not 
 so small as those judiciously recommended 
 by Mr. Lawrence ; and, on this account, no 
 accurate inferences can be drawn from our 
 examples, which, however, as far as I could 
 learn, were not unfavourable to the practice. 
 
 This subject was mentioned by Mr. Gu- 
 thrie, as follows : — Some military surgeons, 
 both French and English, have lately adopt- 
 ed the practice of cutting off’ both ends of 
 the ligatures close to the knot on the artery, 
 uniting the parts, if possible, over them, and 
 allowing the knots to find their way out as 
 they can. The edges of the wound, in some 
 instances, have united thoroughly in a few 
 days, and when the knots have come off the 
 ends of the arteries, they have caused small 
 abscesses to be formed, which point at the 
 nearest external surface, and are discharged 
 with little uneasiness. 1 know that many 
 cases, treated in tills manner, in the cam- 
 paign of 1813, ended successfully, and heal- 
 ed in as short a time as the most favourable 
 ones by the usual method ; and at Montpel- 
 lier, in June, 1814, Motis. Delpech, Professor 
 of Surgery in that university, showed ine at 
 least twenty cases in which he had, and was 
 still practising this method with success. 1 
 have seen, however, in two or three instan- 
 ces, some ill-looking abscesses formed by 
 them, and I suspect some disagreeable con- 
 sequences .will ensue, if this practice be 
 continued. 
 
 “ I consider this improvement as very va- 
 luable in all cases, that will not unite by the 
 first intention. The ligatures, if there he 
 
many, form into ropes, ano the cause of much 
 irritation, and are frequently pulled away 
 with the dressings ; by cutting them off. these 
 evils are avoided, and the knots will come 
 away with the discharge. 7 (See Guthrie on 
 Gunshot IVounds of the Extremities, p. 93, 
 94.) 
 
 With respect to the abscesses, which this 
 gentleman saw produced by the method, it 
 is properly observed by Mr. Lawrence, that 
 as this statement is not accompanied by any 
 description of the materials, or size of the 
 ligature, nor by any details of the unfavour- 
 able cases, we cannot judge, whether the 
 events alluded to are to be attributed to 
 f.he method itself, or to the way in which 
 it was executed. (See fifed. Chir. Trans. 
 Vol. 6, p. 171.) 
 
 M. Roux has tried the plan in three ope- 
 rations on the breast ; the £ases did well ; and 
 no ill consequences arose from the presence 
 of the bits of thread under the cicatrix. (See 
 Relation d'un Voyage faith Londres en 1814, 
 ou Parallele dtla Chiruraie Angloise avecla 
 Chirurgie Franchise; Paris, 1815. p. 134 — 
 136.) For other remarks, connected with 
 the foregoing topics, see Amputation, Aneu- 
 rism,, and Hemorrhage. 
 
 LIMMENTUM ACIpI SULPHURICI. 
 — Olei Olivae 3 i -s. Acid. Sulph. ~;s. M. 
 Recommended by Mr. Bi odie, for the remo- 
 val of the effects left by inflammation of the 
 synovial membrane. (See Joints.) 
 
 LIMMENTUM AMMONIA FORTIUS. 
 - — 1^. Liq. ammou. Zj. Qlei olivae §iij. Misce. 
 Proper! ies stimulai in g. 
 
 LIMMENTU VI CALCIS — ft. Aquae cal- 
 cis, Olei olivae, sing. |viij. Spirit, vinosi recti- 
 fieati Misce. A common application to 
 burns and scalds. 
 
 LINI vIENTUM CAMPHORS COMPO- 
 S1TUM. ft. Camph. ^ij. Aq. atnmon. ^vj. 
 Spirit, lavend. ^xvj Sixteen ounces are to 
 be distilled of the two last ingredient-, from 
 a glass retort, and the camphor then dissolved 
 in the distilled fluid. For bruises, sprains, 
 rigidities of the joints, incipient chilblains, &e. 
 
 LIMMENTUM CAMPHOR/E A FH E- 
 I1EUM. — ft Camphurae drach. j. Atheris 
 unc. ss. Olei. viperarma drach. ij. Misce 
 The camphor is to be dissolved in (lie aedier, 
 and the oil afterw rd incorporated with it. 
 The lale Mr. Ware sometimes used this ap- 
 plication, in certain obscure affections of the 
 eye, in which it was not easy to determine, 
 whether the imperfection of the sight pro- 
 ceeded from an incipient cataract, or a defect 
 of sensibility in the optic nerve. The mode 
 of applying it is to moisten the finger with it, 
 and to rub it for two or three minutes toge- 
 ther, morning and evening, on the outside and 
 edges of the eyelids. (Pharm. Chirurgica.) 
 
 LIMMENTUM HYDKARGYRI CO.Vi- 
 POSITUM — ft. Ung. hydrargyri fortioris, 
 Adipis suillae, sing. §i. Camph, 3 j Spirit, 
 vinos, rectif. 3>j- Liq. ammou. ?j. The 
 camphor being dissolved in the spirifof wine, 
 add the liq. amtnon. and the ointment pre- 
 viously blended with the hog’s lard. (Pharm. 
 Sancti. Barlhol.) An excellent formula for 
 all surgical cases, in which the object is to 
 
 quicken the action of (lie absorbents, and 
 gently stimulate the surfaces of parts. It is 
 a capital application for diminishing a chro- 
 nic indurated state of particular muscles, 
 every now and then met with in practice • 
 and it is particularly well calculated for les- 
 sening the stiffness and chronic thickening 
 often noticed in the joints. 
 
 LIMMENTUM POTASSA SULPHU- 
 RETI. — Saponis Albi... ^iv. Olei Amyg- 
 dalae |viij. Potassae Sulphureti 3 v j- Olei 
 Thy mi gr. xv. vel 3j. This liniment, used 
 twice a day, will cure the itch in five days, 
 or, at latest, in eight. It has very little un- 
 pleasant smell, and would be preferable to 
 sulphur ointment, if equally efficacious. (See 
 London Medical Repository, Vol. 3, p. 242 and 
 Cross's Sketches of the Medical Schools of Pa- 
 ris ,p. 176.) 
 
 L1NMENTUM SAPONIS COMPOSi- 
 TU.*j. — ft. Sapon. ?iij. Camph. ^j. Spi- 
 rit. rorismar. iftj. Dissolve the soap in the 
 spirit, and then add the camphor. Uses the 
 same as those of the iinimenturn camph. 
 
 LIMMENTUM SAPONIS CUM OPIO, 
 ft. Lin. sapon. comp. ^vj. Tinct. opii. ^ij. 
 Misce. For dispersing indurations and swell- 
 ings attended with pain, but no acute inflam- 
 mation*. 
 
 LIMMENTUM TEREBINTHINA.— ft. 
 Ung. resinse fiavae ^iv. 01 terebinthina?, 
 q. s. Misce. The well-kno&n application for 
 burns, recommended by Kentish. (See Barns.) 
 
 LIMMENTUM TEREBINTHINA SUL- 
 PHURICUM. — ft. Olei oiivee 3X. 01. te 
 rebinth. 3iv. Acidi Sulph: 3 * *« j - Misce. Said 
 to be efficacious in chronic affections of the 
 joints, and in the removal of the old effects 
 of sprains and bruises. (Pharm. Chirurgica .) 
 
 LIP, CANCER OF. The lips are subject 
 to ulcers, which put on a very malignant as- 
 pect, although some of them are not in re- 
 ality malignant ; and many occurring just on 
 the inside of these parts, will be found to 
 depend on the bad state of the constitution, 
 and the irritation and disturbance which the 
 sores are continually suffering from the inces- 
 sant motion of the parts, and their rubbing 
 against a projecting, or rough tooth. 
 
 Arsenic is frequently useful in subduing the 
 obstinacy and malignity of certain ulcers and 
 diseases of the lip, reputed to lie cuncerous. 
 (Stark, Dc Cancro Labii Inferioris.) Ot this 
 essay. P otessor Langenbeck speaks in high 
 terms. Tue following formula is recom- 
 mended. ‘‘ ft. Arsenici Albi drachm dimid. 
 Aq. comm stfflaticiai unc. sex. M. Digeranlur 
 vase vitreoclauso in balueo arenas justi ca- 
 loris ope per boras sex, turn adde Potassai 
 Carbon) is pura? drachm, dimid. antea soluf. 
 in aq. Cinnamon, sjmpl. unc. duab. M. Dige- 
 rantur denuo per aliquot horas in loco tem 
 perato. Mac solutione bis terve quotidie ad 
 guttas 8 — 10 — 15, utimur.” 
 
 When cancer takes place, it is usually in 
 the lower, and very seldom in the upper lip. 
 
 The disease sometimes puts on the appear- 
 ance of an ulcerated, wart-like excrescence, 
 occasionally acquiring a considerable size. 
 Sometimes it is seen in the form of a very 
 destructive ulcer, which consumes the stir- 
 
LIQUOR. 
 
 185 
 
 rounding substance of the lip ; and, in other 
 examples, the disease resembles a hard lump, 
 which, at length, ulcerates. The disease, in 
 its infancy, is often no more than a pimple, 
 which gradually becomes malignant. When- 
 ever there is reason to believe, that the dis- 
 ease is of an unyielding cancerous nature, 
 and it does not soon give way to arsenic, 
 hemlock, and mercurials, the sooner it is ex- 
 tirpated the better. For this purpose, some 
 surgeons admit the propriety of using caus- 
 tic, when the whole disease can he com- 
 pletely destroyed by one application. But as 
 the action of caustic is not capable of being 
 regulated with so much precision as the ex- 
 tent of a wound can be, and as caustic will 
 not allow the parts to be united again, the 
 knife is the only justifiable means, especially 
 as it occasions also less pain. Two incisions 
 are to be made, meeting at an angle below 
 (supposing it to be the lower lip,) and inclu- 
 ding the whole of the disease. The sides of 
 the wound are then to be united by the 
 twisted suture. (See Hare-Up.) When the 
 affection is extensive, however, the surgeon 
 is frequently necessitated to remove the 
 whole of the lip, or too much of it to admit 
 of the above plan being followed. This 
 circumstance is particularly unpleasant, as 
 the patient's spittle can only be prevented 
 from continually running over his chin by 
 some artificial contrivance. The deformity 
 also is very great, and pronunciation and 
 swallowing can only be imperfectly per- 
 formed. 
 
 LIPPITUDO. (from lippus, blear-eyed.) 
 Blearedness. The ciliary glands, and lining 
 of the eyelids, only ^secrete, in the sound 
 state, a mere sufficiency of a sebaceous fluid 
 to lubricate the parts in their continual mo- 
 tions. But, it sometimes happens, from dis- 
 ease, that this sebaceous matter is secreted 
 in too great a quantity, and glues the eye- 
 lids together during sleep, so that, on waking, 
 they cannot be easily separated. Hence, 
 the margin of the eyelids becomes red all 
 round, and the sight itself even weakened. 
 
 The best remedies are the unguentum liy- 
 drargyri nitrati, smeared, at night, on (lie 
 edges and inside of the eyelid with a hair 
 pencil, after being melted in a spoon ; the 
 unguentum tutiae, applied in the same way ; 
 and a collyrium, composed of 3j. of the 
 sulphate of zinc in v^iij. of rosewater. 
 
 "When alterative medicines are requisite, 
 a grain of calomel may be exhibited daily, 
 or the compound calomel pill, containing 
 one grain of calomel, one of sulphur anti- 
 monii preecipitatum, and two of guaiacum, 
 put together with soap. 
 
 Persons who have lippitudo and cataracts 
 together, bear couching much better than 
 one would expect from the appearance of 
 the eyes in that disease ; and Mr. Hey never 
 rejects a patient on this account, provided 
 such state is habitual. ( Practical Observa- 
 tions, p. 51.) Scarpa, however, recommends 
 the lippitudo to be removed before the 
 operation is undertaken. 
 
 LIQUOR AMMON. ACET. (L. P.)— 
 This is given in the dose of half an ounce in 
 
 Vol. II. 24 
 
 many surgical cases, in which the object is 
 to keep up a gentle perspiration. 
 
 LIQUOR ARSEN1CALIS.— ft. Arsenic! 
 Oxydi pneparati in pulverem subtilissimuni 
 triti, Potassa? Subcarbonatis ex tartaro, sin- 
 gulorum gr. 64. Aq. distill, jfej coque si.mul 
 in vase vitreo, donee arsenicum omne lique- 
 tur. Liquori frigefacto adjice Spiritfts Lavan- 
 dulae com. 3iv. Denique adjice insuper Aq. 
 distil, quantum satis sit, ut inensurarn octarii 
 accurate impleat. For internal use the dose 
 is iv. drops gradually increased to xx. twice 
 a day. It is frequently given in cases of 
 anomalous ulcers, and cancerous affections 
 of the lip. It is also used as an external 
 application in similar cases, and especially 
 in hospital gangrene. (See Arsenic , and 
 Hospital Gangrene,) 
 
 LIQUOR CALCIS (L. P.)— Sometimes 
 used as an astringent injection, or lotion, in 
 cases of gonorrhoea, gleet,, psora, porrigo, 
 abscesses, &c. 
 
 LIQUOR CUPRI SULPHATIS CAM- 
 PHORATA. — 1^, Cupri sulphatis. Boli Gal- 
 lici sing. une. ss. Camphorm drach.j. Aquas 
 ferventis lib. iv. Boiling water is to be 
 added to the other ingredients, and the liquor 
 filtered when cold. It is chiefly employed 
 in a diluted state, as a collyrium ; hopit may 
 also prove of service as an application to 
 foul ulcers. 
 
 When used for the cure of the purulent 
 ophthalmy, the lotion is to be injected under 
 the eyelids, by means of a blunt syringe, 
 and, if necessary, the application may be 
 repeated once or twice every hour. (See 
 Ophthalmy.) 
 
 LIQUOR POTASSES SUBCARBONATIS 
 (L. P.) — This remedy is principally deserving 
 of notice on account of its having been 
 given with a view of dissolving calculi in 
 the bladder, so as to remove the necessity 
 of performing the dangerous and painful 
 operation of lithotomy. The principle, on 
 which the liquor potassm subcarbonatis acts, 
 is by the potassa attracting and combining 
 with the uric acid of the calculus. The 
 medicine may be exhibited in doses of 20 
 or 40 drops, or of a dram, in a basin of 
 gruel. Experience does not seem to justify 
 the indulgence of much hope, with regard 
 to the complete efficacy of the medicine in 
 dissolving urinary calculi, and on some kinds 
 it is not calculated to act at all, even ou 
 chymieal principles ; but, it would appear, 
 from the reports of writers, that it has often 
 materially palliated the pain which attends 
 the presence of a stone in the bladder. 
 Some practitioners place more confidence 
 in the liquor potassae. 
 
 LIQUOR KALI ARSENIC ATI, ■ — ]J. Kali 
 Arsenicati grana duo. Aquae Menthae Sativa^ 
 uncias quatuor. Spiritus Vinosi tenuiori^l 
 unciam. Misce et cola. Two drams of this 
 may be given thrice a day in cases of cancer. 
 My friend, Mr. Barnes, oi Exeter, when for- 
 merly a student at St. Bartholomew's, show- 
 ed me a case of lupus, or noli me tangere, 
 which was greatly benefited by this remedy 
 externally applied. Mr. Barnes was using 
 the lotion with double the proportion of 
 
LITHOTOMY 
 
 arsenic. There are many ulcerations round 
 the roots of the nails of the (ingers and toes, 
 to which Plunket’s caustic is sometimes 
 applied ; but, the liquor kali arsenicati 
 would, in all probability, be <|uite as effica- 
 cious, and, certainly, it is a neater applica- 
 tion. 
 
 LIQUOR TOTASS^E (L. P.) This has 
 been given with a view of dissolving urinary 
 calculi, in considerable doses> for a length 
 of time. The trials, however, have not pro- 
 ved so successful as could have been wish- 
 ed, nor is the exhibition of so active a re- 
 medy unattended with disadvantageous 
 consequences to the system; for which 
 reason, soda water and other alkaline wa- 
 ters, supersaturated with fixed air, have of 
 late been much substituted. 
 
 The proper dose of the liquor potassse at 
 first, is from ten to twenty drops twice a 
 day, in some linseed tea. At St. Thomas’s 
 Hospital, the following is the way in which 
 the liquor potasssk is prescribed : — Liq. 
 Potass;e §i. Aquae Distillatae %\j. Misce. 
 Dosis Drachma una bis die ex unciis quatuor 
 infusi liui. 
 
 LIQUOR PLUMB! ACETATJS (L. P.) 
 — Is extensively used, largely diluted with 
 water, as an application to inflamed parts. 
 (See Inflammation.) One dram to a quart 
 of water is quite strong enough for common 
 purposes. Mr. Justamond and Dr. Cheston 
 used to apply it, mixed with an equal pro- 
 portion of a spirit resembling the tinctura 
 lerri muriati, to the edges of cancerous 
 sores. 
 
 k LITHONTRIPTICS. (from wfloc, a stone ; 
 and d-gv7rra>, to break.) Medicines for dis- 
 solving stone in the bladder. (See Urinary 
 Calculi.) 
 
 ^'LITHOTOMY, (from xtSog, a stone; 
 and <rs ( MV&), to cut.) The operation of cutting 
 into the bladder, in order to extract a stone. 
 
 It has been correctly remarked, that no 
 single operation of surgery has attracted so 
 much notice, or had so much written upon 
 it, as lithotomy. A full and minute account 
 of the sentiments of every writer, who has 
 treated of the subject, and a detail of the 
 infinite variety of particular modes of ma- 
 king an opening into the bladder, would 
 occupy as many pages as are allotted to the 
 whole of this dictionary. It must be my 
 endeavour, therefore,' rather to describe 
 what is most interesting anil important, 
 than pretend to offer an article which is to 
 comprehend every thing. 
 
 May I be allowed to premise, that through- 
 out the following columns, l suppose the 
 reader to be already well informed of all 
 that relates to the anatomy of the bladder 
 and adjacent parts, and that of the perinai- 
 urn ? Without correct knowledge of this 
 kind, a man must be presumptuous indeed, 
 to set himself up for a good lithotomist ; 
 and if he were to distinguish himself at all, 
 it would only be by the murders which he 
 committed, while his successful feats, if he 
 achieved any, could redound little to his 
 honour, since every young student would 
 soon find ouf, that they vrere not the effect 
 
 of science, but ot mechanical habit and inn 
 tation. I would particularly recommend 
 every one, who wishes to understand well 
 the anatomy of the pelvic viscera and peri 
 namm, with a view to lithotomy, in the. 
 first place to dissect those parts himself, and 
 then avail himself of the valuable instruc 
 t ions to be derived on the subject from 
 Winslow’s Anatomy ; Le Dran’s Parallele 
 de Tailles ; Le Cat’s Deuxieme Recueil , 
 planche 5 et f> ; Haller’s Inst. Med. of Bo- 
 erhaave, and Elem. Physiol. T. 5 ; Mor- 
 gagni, Adversar. Anat. 3, p. 82, 97 ; Cam- 
 per’s plates ; Sabatier’s Anatomy ; John 
 Bell's Principles of Surgery ; Deschamp’s 
 Trailts Historique, fee. de [’Operation de la 
 Taille, T. 1, p. 7, fee.; and Langenbeck’s 
 description of the parts, and the matchless 
 plate which he has given of them in his 
 valuable work on lithotomy, cited at the 
 end of this article. 
 
 /V few subjects which are closely connect- 
 ed with the present, will be found in other 
 parts of this dictionary. For instance, the 
 nature of stones in the bladder will be consi- 
 dered under the head of Urinary Calculi , 
 where also will be seen some observations 
 on lithontriptics. The manner of searching 
 for the stone, or, as it is now more common 
 ly expressed, of sounding, will be explained 
 in the article Sounding. 
 
 Here I shall principally confine myself to 
 the symptoms of the disease, and the chief’ 
 methods of executing the much diversified 
 operation of lithotomy. 
 
 SYMPTOMS OF THE STOKE. 
 
 The symptoms of a stone in the bladder 
 are, a sort of itching along the penis, parti- 
 cularly at the extremity of the glans ; and 
 hence the patient often acquires a habit of 
 pulling the prepuce, vvhich becomes very 
 much elongated ; frequent propensities to 
 make water, and go to stool ; great pain in 
 voiding the urine, and difficulty of retaining 
 it, and often of keeping the feces from being 
 discharged at the same time ; the stream of 
 urine is liable to stop suddenly, while flow- 
 ing in a full current, although the bladder is 
 not empty, so that the fluid is expelled bv 
 fits, as it w^ere ; the pain is greatest towards 
 the end of, and just after, the evacuation ; 
 there is a dull pain about the neck of the 
 bladder, together with a sense of weight, or 
 pressure, at the lower part of the pelvis ; and 
 a large quantity of mucus is mixed with the 
 urine ; and, sometimes, the latter is tinged 
 with blood, especially after exercise. ( Sharpy 
 Earle , Sabatier.) 
 
 Frequently (says Deschamps) a patient 
 will have a stone in his bladder a long while 
 without the occurrence being indicated by 
 any symptom or accident. Most commonly, 
 however, the presence of the stone is an- 
 nounced by pain in the kidneys, more espe- 
 cially in adults and old persons, children 
 scarcely ever suffering in this way, because 
 in them the stone is hardly at all detained 
 in the kidneys and ureters, but descends im- 
 mediately into the bladder, the preceding 
 
LITHOTOMY - 
 
 18V 
 
 tubes being in them more dilatable, and the 
 rudiment, or nucleus of the stone smaller. 
 
 It seldom happens, that calculous patients 
 void blood with their urine, before the symp- 
 toms and accidents, usually caused by the 
 stone, have taken place. It is not till after 
 the foreign body has descended into the 
 bladder, acquired some size, and presented 
 itself at the orifice of that viscus, that pain is 
 occasioned, particularly when the surface of 
 the stone is unequal. The patient then ex- 
 periences frequent inclination to make wa- 
 ter, attended with pain. The jolting of a 
 carriage, riding on horseback, and much 
 walking, render the pain more acute. The 
 urine appears bloody, and its course is fre- 
 quently interrupted, and sabulous matterand 
 particles of stone are sometimes discharged 
 with it. The want to make water becomes 
 more frequent and more insupportable. The 
 bladder is irritated, and infiames ; its parietes 
 become thickened and indurated ; and its 
 diameter is lessened. A viscid, more or 
 less, tenacious matter is observed, in greater 
 or lesser quantity, in the urine, and is pre- 
 cipitated to the bottom of the vessel. The 
 urine becomes black and putrid, and exhales 
 an intolerable alkalescent smell, which is 
 perceived at the very moment of the evacua- 
 tion, and is much stronger a little while af- 
 terward. The patient can no longer use 
 any exercise, without all his complaints be- 
 ing redoubled. Whenever he walks in the 
 least, the urine becomes bloody ; the pain 
 about the hypochondria, which was dull in 
 the beginning, grows more and more acute ; 
 the ureters and kidneys participate in the ir- 
 ritation with the bladder; they inflame and 
 suppurate, and very soon the urine brings 
 away with it purulent matter. The fever 
 increases, and changes into one of a slow 
 type ; the patient loses his sleep and appe- 
 tite ; becomes emaciated and exhausted ; 
 and death at length puts a period to his mise- 
 ry. (See Traits Historique et Dogmatique de 
 /.'Operation de la Taille par J. F. L. Des- 
 ehamps, T. I, p. 163, Paris , 1796.) 
 
 It is acknowledged by the most experien- 
 ced surgeons, that the symptoms of a stone 
 in the bladder are exceedingly equivocal, 
 and may be produced by several other dis- 
 orders. “ Pain in making water, and not 
 being able to discharge the urine without 
 the feces, are common consequences of ir- 
 ritation of parts about the neck of the blad- 
 der, from a diseased prostate gland, and 
 other causes. The urine stopping in a full 
 stream is frequently caused by a stone alter- 
 ing its situation, so as to obstruct the pas- 
 sage; but the same thing may happen from 
 a tumour, or fungus in the bladder. I have 
 seen an instance of this, where a tumour, 
 hanging by a small pedicle, would sometimes 
 cause obstruction, and by altering the pos- 
 ture, would retire, and give a free passage. 
 The dull pain at the neck of the bladder, and 
 the sensation of pressure on the rectum, are 
 frequently owing to the weight of the stone, 
 &c. ; but these may proceed from a diseased 
 enlargement of the prostate glan^. Children 
 generally, and grown persons frequently, are 
 
 subject to a prolapsus ani, from the irritation 
 of a stone in the bladder;, but it will like- 
 wise be produced by any irritation in those 
 parts.” (Earle.) The rest of the symptoms 
 are equally fallacious ; a scirrhous enlarge- 
 ment of the os tincae, and disease of the kid- 
 neys may occasion a copious quantity of 
 mucus in the urine, with pain, irritation, &c. 
 “ The least fallible sign (says Sir James 
 Earle) which I have remarked, is the patient 
 making the first portion of urine with ease, 
 and complaining of great pain coming on 
 when the last drops are expelled. This may 
 readily be accounted for, from the bladder 
 being at first defended from contact with the 
 stone by the urine, and, at last, being pressed 
 naked against it. But, to put the matter out 
 of all doubt, and actually to prove the exist 
 ence of a stone in the bladder, we must 
 have recourse to the operation of sounding.' 
 
 A stone in the ureter, or kidneys, or an in- 
 flammation in the bladder from any other 
 cause, will sometimes produce the same ef 
 fects ; but if the patient cannot urine, ex- 
 cept in a certain posture, it is almost a sure 
 sign that the orifice of the bladder is ob- 
 structed by a stone. If he finds ease by 
 pressingagainstthe perinaeum with his fingers, 
 or sitting with that part upon a hard body, 
 there is little doubt the ease is procured by 
 taking off the weight of the stone ; or, lastly, 
 if, with the other symptoms, he thinks he 
 can feel it roll in his bladder, it is hardly pos- 
 sible to be mistaken ; however, the only sure 
 judgment is to be formed from searching. 
 (Sharp on the Operations.) 
 
 An enlarged prostate gland is attended 
 with symptoms resembling those of a stone 
 in the bladder ; but with this difference, that 
 the motion of a coach, or horse, does notin- 
 crease the grievances, when the prostate is 
 affected, while it does so in an intolerable 
 degree in cases of stone. It also generally 
 happens, that the fits of the stone come on at 
 intervals ; whereas, the pain from a disea- 
 sed prostate is neither so unequal, nor so 
 acute. ( Sharp in Critical Inquiry , p. 165, 
 Edit. 4.) 
 
 Though, from a consideration of all the 
 circumstances above related, the surgeon 
 may form a probable opinion of there being 
 a stone in the bladder, yet he must never 
 presume to deliver a positive one, nor ever 
 be so rash' as to undertake lithotomy, with- 
 out having greater reason for being certain 
 thatthere is a stone to be extracted. Indeed, 
 all prudent surgeons, for centuries past, have- 
 laid it down as an invariable maxim, never 
 to deliver a decisive judgment, nor under- 
 take lithotomy, without having previously- 
 introduced a metallic instrument called a 
 sound, into the bladder, and plainly felt the 
 stone. 
 
 Within the last five years, at least seven 
 cases have corne to my knowledge, and at 
 two of them I was present, where the pa- 
 tients were subjected to all the torture and 
 perils of this operation, without there being 
 any calculi in their bladders. The maxim, 
 therefore, cannot be too strictly enforced, 
 that the operation ought never to be at- 
 
188 
 
 UthotomY. 
 
 tempted, unless the stone can be distinctly 
 felt with the sound or staff. In one of the 
 examples, of which I was a spectator, not 
 only the symptoms, but the feel, which the 
 sound itself communicated when in the 
 bladder, made the surgeons imagine, that 
 there was a calculus, or some extraneous 
 body in this organ. Mostof the above cases, 
 I understand, recovered, which may be con- 
 sidered fortunate ; because when the stone 
 cannot be found, the disappointed operator 
 is apt to persist in roughly introducing his 
 fingers, and a variety of instruments, so long, 
 in the hope of catching what cannot be got 
 hold of, that inflammation of the bladder and 
 peritoneum is more likely to follow, than 
 when a stone is actually present, soon taken 
 out, and the patient kept only a short time 
 upon the operating table. 
 
 In a valuable practical work is recorded 
 an instance, in which what is called a horny 
 cartilaginous state of the bladder, made the 
 sound communicate a sensation, like that 
 arisingfrotn the instrument actually touching 
 a stone, and the surgeon attempted lithoto- 
 my. This patient unfortunately died in 
 twenty-four hours. (See Desault's Parisian 
 Chir. Journal , Vol. 2 ,p. 125.) 
 
 However, were the symptoms most une- 
 quivocal, there is one circumstance which 
 w ould always render it satisfactory to touch 
 the stone with an instrument, just before 
 venturing to operate ; I mean the possibility 
 of there actually being a stone in the bladder 
 to-day, and not to-morrow. It is said, that 
 stones are occasionally forced, by the vio- 
 lent contractions of the bladder, during fits 
 of the complaint, between the fasciculi of 
 the muscular coat of this viscus, together 
 xvith a portion of the membranous lining of 
 the part, so as to become what is termed 
 encysted. The opening into the cyst is 
 frequently very narrow, so that the stone is 
 much bigger than the orifice of the cyst, in 
 consequence of which it is impossible to 
 lay bold of the extraneous body with the 
 forceps, and the operation would necessa- 
 rily become fruitless. ( Sharp's Critical In- 
 quiry, p. 228, Edit. 4.) 
 
 In the article Urinary Calculi, I have no- 
 ticed the probability of this having occur- 
 red in some of the instances in which Mrs. 
 Stevens’s medicine was supposed to have 
 actually dissolved the stone in the bladder; 
 lor an encysted stone is not likely to be hit 
 with the sound, nor to cause any inconve- 
 nience, compared with what u calculus, 
 rolling about in the bladder, usually oc- 
 casions. 
 
 It is remarked by Deschamps, that when 
 the stone is lodged in an excavated corner 
 of the bladder, in a particular cyst, or de- 
 pression ; when it projects hut very little ; 
 when it cannot shift its situation in the blad- 
 der, so as to fall against the orifice of this 
 viscus ; and when it is also smooth, polished, 
 and light; the patient may then have it a 
 long while without experiencing any afflict- 
 ing symptoms. He may even live to an 
 advanced age, if not without some degree of 
 -uffering, at all events, with such pain as is 
 
 very supportable. Daily experience prove*, 
 that persons may live a considerable time, 
 with one, two, or even three stones in the 
 bladder, and, during the whole of their lives, 
 have not the least suspicion of the existence 
 of these foreign bodies. 
 
 According to Deschamps, this must have 
 been the case of M. Portaiieu, a tailor. This 
 individual, eighty years old, was frequently 
 attacked with a retention of urine from pa- 
 ralysis, and Deschamps introduced a sound 
 several times, and distinctly felt a stone in 
 the bladder.” The patient, however, never 
 had any symptom of the disorder, nor even 
 at the end of two years from the time when 
 Deschamps was first consulted. Very large 
 and exceedingly rough stones have also 
 been found in the dead bodies of persons 
 who had never complained of the symp- 
 toms of the disease. Thus, at the anatomi- 
 cal Theatre of La Charit6, Richerand found 
 an enormous mulberry stone in the bladder 
 of a person who died altogether of another 
 disease, and never had any symptoms that 
 led to the suspicion of the stone. ( JVoso - 
 graphic Chir. T. 3, p. 530, Edit. 4.) But 
 cases of this kind must be rare, because it 
 is rvell known that the pain, which a stone 
 produces, is less in a ratio to its size than 
 to its shape and situation. A small stone, 
 owing to its situation, may be more painful 
 than an enormous calculus which fills the 
 bladder, as is proved by the following case, 
 by Deschamps. 
 
 Pechet, a watchmaker, until the age of 
 forty-five, had never had any infirmity, ex- 
 cept that of not being able to retain his wa- 
 ter a long while. One day, while he W’as 
 carrying a very heavy clock, he made some 
 exertions which probably, by changing the 
 situation of the calculus, caused at the in- 
 stant an acute pain in the hypogastric re- 
 gion. Symptoms of the stone soon came 
 on ; the pain became intolerable, and the 
 patient went into the tlopital de la Charite. 
 He was sounded ; the stone w r as felt, and 
 judged to be of considerable size. The in- 
 cision in the neck of the bladder not suffi- 
 cing for its extraction, the patient was put 
 to bed again. The next morning he was 
 operated upon above the pubes by Frere 
 Come, who extracted an oval calculus that 
 weighed twenty -four ounces. The patient 
 died four and twenty hours after this second 
 operation. This case proves, then, that 
 very large stones may lie in the bladder 
 without occasioning any serious complaints, 
 since the preceding patient apparently had 
 had such a calculus a long time without 
 suffering inconvenience from it, and it 
 seems likely that he might have continued 
 well still longer, had it not been for the acci- 
 dental effort which first excited the symp- 
 toms. ( Deschamps , in Traitc Hislorique , 
 dc la Traille , Tom. 1, p. 166, 167.) 
 
 A priest, in whom Morand had ascertain 
 ed the presence of a stone by sounding, 
 could not be persuaded that his case was of 
 this nature. However, he bequeathed his 
 body at hi^decease to the surgeons, and the 
 tycsnnluatiol of the bladderfully justified Me- 
 
LITHOTOMY. 
 
 189 
 
 rand's prognosis. Tne celebrated D'Alem- 
 bert also died with a stone in his bladder, 
 having always refused to be sounded. ( Ri - 
 chcrand, Op. cit. T. 3, p. 538.) 
 
 A question may here suggest itself : ought 
 lithotomy to be practised where calculi are 
 under a certain size ? Certainly not, be- 
 cause they frequently admit of being dis- 
 charged with the urine, without any opera- 
 tion at all, even from the male subject, and 
 how much more likely this is to happen in 
 females, must be plain to every body who 
 recollects the direct course, the shortness, 
 ample size, and dilatability of the meatus 
 urinarius. On this subject, various facts 
 will be adverted to in considering the ope- 
 ration of lithotomy in women. Sometimes, 
 also, when a calculus is too large to pass 
 completely through the male urethra, it 
 lodges in this passage, where it may be 
 more safely cut upon and removed, than 
 from the bladder; and sometimes it is actu- 
 ally discharged by an ulcerative process. 
 Thus, Dr. R. A. Langenbeck has published 
 an example in which a stone made its way 
 out by ulceration, and was discharged im- 
 mediately behind the testes. (See J. C. 
 Langenbeck, Bibl. ftir die Chir. Gott. 1809.) 
 And G. Coopmans has recorded an almost 
 incredible case, in which a calculus, weigh- 
 ing five ounces, one drachm and a half, 
 when being dried-, was discharged on the 
 left side of the urethra of an elderly man, a 
 little below the glans penis. In fact, with- 
 out some further explanation, this case 
 would be pronounced impossible , but it 
 should be recollected, that after a small cal- 
 culus has made its way out of the urethra 
 by ulceration, if the urine have still access 
 to it, it will continue to increase in size in 
 its new situation ; and this is what happen- 
 ed in the present example ; for the extrane- 
 ous body, when first felt externally, was 
 not larger than a pea. The calculus is now 
 preserved in Camper’s museum. ( G . Coop- 
 r nans , Keurologia , Svo. Franequerx, 1795.) 
 I am not meaning, however, to recommend 
 surgeons to let the patient encounter all the 
 sufferings which must inevitably attend lea- 
 ving the business to be completed by ulcera- 
 tion, because, as soon as the nature of the 
 , case is known, an incision should be made 
 into the swelling, and the foreign body taken 
 out. In many cases, also, small calculi may 
 be voided by dilating the male urethra with 
 elastic gum catheters of very large diameter, 
 and then desiring the patient to expel his 
 urine with considerable force, a plan which 
 Baron Larrey has found repeatedly answer. 
 Of late, Mr. Weiss, surgical instrument ma- 
 ker, in the Strand, has invented a kind of 
 sound, the end of which, when in the blad- 
 der, admits of being opened, like a pair of 
 forceps, and closed again, so as to grasp 
 calculi under a certain size, and draw them 
 out through the urethra. The instrument 
 has been tried with great success by Mr. A. 
 Cooper, who removed with it from one pa- 
 tient at different times 84 calculi. And, 
 even when the stone cannot be drawn com- 
 pletely out of the urethra, but only into this 
 
 passage, it is a great 'advantage, because, 
 then it may easily be cut down to, and ex- 
 tracted, without any w ound or injury of the 
 bladder. (See A. Cooper in Med. Chir . 
 Trans. Vol. 11.) 
 
 I shall next describe the various methods 
 of cutting for the stone, beginning with the 
 most ancient, called the apparatus minor , 
 and ending with the modern proposal of 
 employing a knife in preference to a gorget. 
 
 OF THE APPARATUS MINOR, CUTTING ON 
 THE GRIPE, OR CELSUS’S METHOD. 
 
 The most ancient kind of lithotomy was 
 that practised upwards of two thousand 
 years ago by Ammonius, at Alexandria, in 
 the time of Heropbilus and Erasistratus, and 
 by Meges, at Home, during the reign of Au- 
 gustus; and. being described by Celsus, is 
 named Litholhomia Celsiana. From cutting 
 directly on the stone, fixed by the pressure; 
 of the fingers in the anus, it has been called 
 cutting on the gripe, a knife and a hook be- 
 ing the only instruments used. The appel- 
 lation of the lesser apparatus was given to 
 it by Marianus, to distinguish it from a me- 
 thod which he described, called the appara- 
 tus major, {com the many instruments em- 
 ployed. 
 
 The operation was done in the following 
 way. The rectum w T as emptied by a clys- 
 ter a few hours previously ; and, immedi- 
 ately before cutting, the patient was desired 
 to walk about his chamber, to bring the 
 stone down to the neck of the bladder; he 
 was then placed in the lap of an assistant, 
 or secured in the manner now practised in 
 the lateral operation. The surgeon then in- 
 troduced the fore and middle fingers of his 
 left hand, well oiled, into the anus ; while 
 he pressed with the palm of his right hand 
 on the lower part of the abdomen above the 
 pubes, in order to promote the descent of 
 the stone. With the fingers the calculus 
 was next griped, pushed forward toward the 
 neck of the bladder, and made to protrude, 
 and form a tumour on the left side of the 
 perinaeum. The operator then took a scat- 
 pel, and made a lunated incision through 
 the skin and cellular substance, directly on 
 the«tone, near the anus, down to the neck 
 of the bladder, with the horns towards the 
 hip. Then, in the deeper and narrower 
 part of the wound, a second transverse inci- 
 sion was made on the stone into the neck 
 of the bladder itself, till the flowing out of 
 the urine showed that the incision exceeded 
 in some degree the size of the stone. The 
 calculus being strongly pressed upon with 
 the fingers, next started out of itself, or was 
 extracted with a hook for the purpose. 
 ( Celsvs , lib. 7, cap. 26. J. Bells Principles, 
 Vol 2, p. 42. Allan on Lithotomy, p. 10.) 
 
 The objections to cutting on the gripe, 
 are; the impossibility of always dividing the 
 same parts; for those which are cut will 
 vary, according to the degree of force em- 
 ployed in making the stone project in the 
 perinEeum. When little exertion is made, 
 if the incision be begun just behind the scro 
 
LITHOTOMY. 
 
 190 
 
 turn, the urethra maybe altogether detach- 
 ed from the prostate: if the stone be much 
 pushed out, the bladder may be entered 
 beyond the prostate, and both the vesiculas 
 serninales and vasa deferentia inevitably 
 suffer. Lastly, if the parts are just suffi- 
 ciently protruded, the bladder will be cut 
 upon its neck, through the substance of the 
 prostate gland. (Allan on Lithotomy. Burns , 
 in Edinb. Surg. Journal, No. XIII. J. Bell , 
 Vol. 2, p. 59.) 
 
 The preceding dangers were known to 
 Fabricius Hildanus, who attempted to obvi- 
 ate them by cutting on a staff, introduced 
 through the urethra into the bladder. He 
 began his incision in the perinaeum, about 
 half an inch on the side of the raphe ; and 
 he continued the cut, inclining the knife as 
 he proceeded towards the hip. He continu- 
 ed to divide the parts till lie reached the 
 staff ; after which he enlarged the wound to 
 such an extent, as permitted him easily with 
 a hook to extract the sione, which he had 
 previously brought into the neck of the 
 bladder, by pressure with the fingers in the 
 rectum. (Burns.) In this way Mr. C. Bell 
 has operated with success. (J. Bell.) 
 
 The apparatus minor, as practised by 
 Fabricius, with the aid of a staff, is certainly 
 a very simple operation on children, and 
 some judicious surgeons doubt the propriety 
 of its present neglected state. You cut, says 
 an eminent writer, upon the stone, and make 
 of course, with perfect security, an incision 
 exactly proportioned to its size. There is 
 no difficult nor dangerous dissection; no 
 gorget, nor other dangerous instrument, 
 thrust into the bladder, with the risk of its 
 passing betwixt that and the rectum ; you 
 are performing, expressly, the lateral inci- 
 sion of Raw and Cbeselden, in the most 
 simple and favourable \yay. The prisca sim- 
 plicity instrumentorum seems here to have 
 been deserted, for the sake of inventing 
 more ingenious and complicated operations. 
 (J. Bell.) 
 
 Celsus has delivered one memorable pre- 
 cept in his description of lithotomy, ul pla- 
 ga paulo major qurnn calculus sit ; and he 
 seems to have known very well, that there 
 was more danger from lacerating, than cut- 
 ting the parts. 
 
 The simplicity of the apparatus minor, 
 however, formerly emboldened every quack 
 to undertake its performance ; and as this 
 circumstance was necessarily followed by 
 the evils and blunders, unavoidably origina- 
 ting from ignorance, and also diminished the 
 emolument of regular practitioners, it be- 
 came the grand cause of the downfall of 
 this operation. (See Heister on this subject.) 
 It was longer practised, however, than all 
 the other methods, having been continued 
 to the commencement of the 16th century ; 
 and it was performed at Bourdeaux, Paris, 
 and other places in France, on patients of 
 all ages, by Raoux, even as late as 150 
 years ago. Frere Jacques occasionally had 
 recourse to it ; and it was successfully exe- 
 cuted by Ileister. ( Part 2, clftip. 140.) A 
 modern author recommends it always to be 
 
 preferred on boys under fourteen. (Allan, 
 V • 12 .) 
 
 APPARATUS MAJOR, 
 
 So named from the multiplicity of instru- 
 ments employed; or the Marian method, 
 from having been first published by Ma- 
 rianus Sanctus, in 1524, as the invention of 
 his master, Johannes de Romanis. (See 
 Marianus de lapide Vesiccc per mcisionem ex 
 trahendo.) 
 
 This operation, which came into vogue, 
 as we have noticed, from avaricious causes, 
 was rude, and painful in its performance, 
 and very fatal in its consequences. The 
 apology for its introduction was the decla- 
 ration of Hippocrates, that wounds of mem- 
 branous parts.are mortal. It was contended, 
 however, that such parts might be dilated 
 with impunity ; and on this principle of di- 
 latation, Romanis invented a complex and 
 dangerous plan of operating ; one very in- 
 competent to fulfil the end proposed ; one, 
 which, though supposed only to dilate, really 
 lacerated the parts. (Burns.) 
 
 The operator, kneeling on one knee, made 
 an incision with his razor along the peri- 
 naeum, on one side of th»* raphe ; and feel 
 ing with his little finger for the curve of the 
 staff, he opened the membranous part of the 
 urethra ; and fixing the point of the knife in 
 the groove of his staff, gave it to an assistant 
 to hold, while he passed a probe along the 
 knife into the groove of the staff, and thus 
 into the bladder. The urine now flowed 
 out. and the staff was withdrawn. The 
 operator next took two conductors, a sort 
 of strong iron probes ; one. named the fe- 
 male conductor, having in it a groove, like 
 one of our common directors ; the other 
 the male conductor, having a probe point, 
 corresponding with that groove. The groov- 
 ed, or female conductor, being introduced 
 along the probe into the bladder, the probe 
 was withdrawn, and the male conductor 
 passed along the groove of the female one, 
 into the bladder. Then commenced the 
 operation of dilating. The lithotomist took 
 a conductor in each hand, and by making 
 their shafts diverge, dilated, or, in plain lan- 
 guage, tore open (he prostate gland. (J.Bell.) 
 
 It would be absurd in me to trace the 
 various dilating instruments contrived for 
 the improvement of this barbarous operation , 
 by the Colots, Marechal, Le Dran, Parfe, be. 
 Among the numerous glaring objections to 
 (he apparatus major, we need only notice 
 the cutting the bulb of the urethra, not di- 
 viding the membranous part of the urethra, 
 nor the transversalis perinaii musele, which 
 forms a kind of bar across the place where 
 the stone should be extracted ; violent dis- 
 tention of the membranous part of the ure- 
 thra and neck of the bladder ; laceration of 
 these latter parts; large abscesses, extrava- 
 sation of urine, and gangrene ; frequent 
 impotency afterward, and extensive fatali- 
 ty. Bertraudi even saw the urethra and 
 neck of the bladder torn from the prostate 
 by the violerme employed in tins vile nv- 
 
LITHOTOMY. 
 
 191 
 
 hot] of operating. ( Operations de Chir. p. 
 169.) Pare, Le Dran, Le Cat, Mery, Mo- 
 rand, Mareschal, Raw, and all the best sur- 
 geons in Europe, most strangely practised 
 this rash method, for two hundred years, 
 till Fr&re Jaques, in 1697, taught at Paris 
 the original model of lithotomy, as com- 
 monly adopted at the present day. 
 
 OF THE HIGH OPERATION'. 
 
 This method of cutting for the stone was 
 first published in 1556, by Pierre Franco, 
 wbo, in his Treatise on Hernia, Ed. 1, says, 
 he once performed it on a child with suc- 
 cess, but discourages the farther practice of 
 it. After him, Rossetus recommended it, 
 with great zeal, in his book entitled Partus 
 Cwsarius, printed in 1591 ; but he never 
 performed the operation himself. Tolet 
 mentions its having been tried in the H6lel 
 Dieu, but without entering into the particu- 
 lar causes of its discontinuance, merely says, 
 that it was found inconvenient. About the 
 year 1719, it was first done in England, by 
 Mr. Douglas ; and after him, practised by 
 others. ( Sharp’s Operations.) 
 
 The patient being laid on a square table, 
 with his legs hanging off, and fastened to 
 the sides of it by a ligature, passed above 
 the knee, his head and body lifted up a little 
 by pillows, so as to relax the abdominal 
 muscles, and his hands held steady by some 
 assistants ; as much barley-water as be could 
 bear, w'hich was often about eight ounces, 
 and sometimes twelve, was injected through 
 a catheter, into the bladder. 
 
 The bladder being filled, an assistant, in 
 order to prevent the reflux of the water, 
 must grasp the penis, the moment the cathe- 
 ter is withdrawn, bolding it on one side, in 
 such a manner as not to stretch the skin of 
 ^he abdomen ; then, with a round-edged 
 knife, an incision, about four inches long, 
 was made between the rfl(kti and pyramidal 
 muscles, through the membrana adiposa, 
 as deep as the bladder, bringing its extremity 
 almost down to the penis; after this, with a 
 crooked knife, the incision was continued 
 into the bladder, and carried a little under 
 the os pubis; and immediately upon the 
 water’s flowing out, the forefinger of the left 
 band was introduced, which directed the 
 forceps to the stone. ( Sharp's Observations.) 
 Sabatier condemns making the cut in the 
 bladder from below upward, lest the knife 
 injure the peritonaeum. {Med. Operatoire , 
 , T. 3, p. 160.) 
 
 Although this is one of the easiest, and 
 to all appearance, the safest method of 
 operating, several objections soon brought 
 it into disuse. 1. The irritation of a 
 stone often causes such a thickened and 
 contracted state of the bladder, that this 
 viscus will not admit of being distended so 
 as to rise above the p?ibes. 2. If the ope- 
 rator should break the stone, the fragments 
 cannot be easily washed away, and remain- 
 ing behind will form a nucleus for a future 
 stone. 3. Experience has proved, that the 
 high operation is very commonly followed 
 
 by extravasation of urine, attended with 
 suppuration and gangrenous mischief in the 
 cellular membrane of the pelvis. This hap- 
 pens because the urine more readily escapes 
 out of the wound in the bladder, than 
 through the urethra ; and also because when 
 the bladder contracts, and sinks behind the 
 os pubis, this wound ceases to be parallel 
 to that in the linea alba and integuments, 
 and becomes deeper and deeper. For the 
 prevention of these ill consequences, says 
 Sabatier, it will be in vain to make the pa- 
 tient lie in a horizontal posture, and keep a 
 catheter introduced, as Roussetand Morand 
 recommended : experience evincing, that 
 the bad efFects are neither less frequent, nor 
 less fatal (See Medecine Operatoire, T. 3, 
 p. 161, Edit. 2.) And Sir Everard Home 
 confesses, that while the high operation for 
 the stone had no other channel but the 
 wound for carrying off the urine, it seemed 
 to him a method which ought never to be 
 adopted ; “ the urine almost always insinu- 
 ating itself into the cellular membrane be- 
 hind the pubes, producing sloughs, and con- 
 sequently abscerses.” (On Strictures , Vol. 
 3. p. 359, 8vo. Land. 1S2I.) 4. The danger 
 
 of exciting inflammation of the peritonaeum. 
 5. The injection itself is exceedingly pain- 
 ful, and however slow the fluid be injected, 
 the bladder can seldom be dilated enough 
 to make the operation absolutely secure : 
 and when hastily dilated (to say nothing of 
 the possibility of" its bursting,) its tone may 
 be destroyed. (See Sharp, Bilan , Sabatier , 
 4'C.) 
 
 In many men, however, we know by 
 searching, that the bladder is very large, so 
 that there is no risk <4 meeting with it in a 
 contracted state, and the objection is of no 
 weight, when the bladder extends a consider- 
 able way above the pubes, and will admit a 
 large quantity of injection. Stones are some- 
 times known to be of large size, and they arc 
 less likely to be btoken in this, than any other 
 mode of lithotomy, so that the objection of 
 the difficulty «>f extracting small calculi and 
 fragments is less forcible. Mr Carpue even 
 declares, that if the stone should break, the 
 particles can be extracted with much greater 
 certainty, in less time, and with considerably 
 less pain, than in the lateral operation, 
 (History of the High Operation , p. 154.) 
 
 I may add, that some judicious surgeons 
 of the present day are decidedly of opinion, 
 that when a stone in the bladder is known 
 to be very large, no attempt ought ever to 
 be made to extract it from the perinaeum. 
 Professor Scarpa also declares, that the 
 lateral operation should not be practised, 
 when the calculus exceeds twenty lines in 
 its small diameter. (See Memoir on the Cut- 
 ting Gorget of Hawkins, p. 8, transl. by Briggs.) 
 In such cases, it is true, the surgeon might 
 do the lateral operation, and try to break the 
 stone. But it is a question whether one 
 ought not to prefer to this unpleasant, un- 
 satisfactory proceeding, the high operation. 
 I speak particularly ot cases, in which the 
 stone is known to be of very large dimen- 
 sions before any operation is begun Were 
 
LITHOTOMY 
 
 192 
 
 the lateral operation commenced, the stone, 
 •f too large for extraction, must of course be 
 broken ; for, it is then too late to adopt the 
 high operation with advantage. That such 
 things have been done, however, arid yet 
 the patients escaped, is a truth, which cannot 
 be denied. Deschamps mentions an in- 
 stance, initwhich M. Lassus, after using 
 Hawkins’s gorget, could not draw out the 
 calculus, and he therefore immediately did 
 the high operation, and the patient recover- 
 ed. Indeed, the first example of the . high 
 operation on record was done by Franco 
 under similar circumstances, and the patient 
 was saved. I have also heard of a modern 
 French surgeon, who began with the lateral 
 operation, but, finding a large calculus, end- 
 ed with performing the high operation, with- 
 out the least delay or hesitation : the patient 
 died. 
 
 Mr. Samuel Sharp, an excellent practical 
 surgeon in his time, after noticing with great 
 impartiality the objections which were then 
 urged against the high operation says, that 
 he should not be surprised, if hereafter it 
 were revived and practised with success; an 
 observation, which implied, that Mr. Sharp 
 himself foresaw, that the method was capa- 
 ble of being so improved, as to free it from 
 its most serious inconveniences. In fact, 
 since his time, various attempts have been 
 made to introduce the high operation anew, 
 and upon improved principles. Frere Come, 
 i s particular, knew very well, that there 
 were circumstances, as for instance, a calcu- 
 lus above a certain size, disease of the ure- 
 thra, or prostate gland, &lc., where the late- 
 ral operation was liable to great difficulties 
 and disadvantages, and where the high 
 operation, if it could be perfected, would 
 be a fitter and safer mode of proceeding. 
 However, it was only in such cases, and 
 not in all, that Frere C6me thought the 
 method better than the lateral operation. 
 He had also discernment enough to perceive, 
 that it was extremely desirable to invent 
 some means, whereby the painful and hurt- 
 ful distention of the bladder, for the purpose 
 of making this organ rise behind the pubes, 
 would be rendered unnecessary; fit the 
 same time, that some measure was adopted 
 for letting the urine have a more depending 
 outlet, than the wound in the hypogastric 
 region. In the former editions of this 
 dictionary, the error was committed of 
 representing C6me to have cut the neck of 
 the bladder, as well as its fundus ; a mistake, 
 which I first became aware of upon the 
 perusal of Mr. Carpue’s interesting work on 
 lithotomy. The fact is, that Come did not 
 wound the bladder in two places ; but ope- 
 rated after the following .way : he first intro- 
 duced through the urethra into the bladder 
 a staff, which was then held by an assistant. 
 An incision, an inch in length, was now 
 made in the perinteum in the same direction, 
 as in the lateral operation. Another incision 
 was made in the membranous part of the 
 urethra along the groove of the stalf, as fur 
 as the prostate gland. A very deeply 
 grooved director was then passed along the 
 
 staff into the bladder, and the latter instru- 
 ment was withdrawn. By means of the 
 director, a sonde a dard , or kind of catheter 
 furnished with a stilette, was now introduced 
 into the bladder, and, when this had Ufeeu 
 done, the director was taken out. An in- 
 cision was then made, about three or four 
 inches in length, just above the symphysis 
 of the pubes, down to, and in the direction 
 of the linea alba. A trocar, in which there 
 was a concealed bistoury, was next passed 
 into the linea alba, close to the pubes, and 
 the blade of the knife then started from its 
 sheath towards the handle of the instrument, 
 while its other end remained stationary. In. 
 this manner, the lower part of the linea alba 
 was cut from below upwards, and an aper- 
 ture was made, which was now enlarged 
 with a probe-pointed curved knife, behind 
 which a finger was kept so as to push the 
 peritonaeum out of the way. Come then 
 took hold of the sonde a dard with his right 
 baud, and elevating its extremity, lifted up 
 the fundus of the bladder, while with the 
 fingers of his left hand he endeavoured to 
 feel its extremity in the wound. As soon 
 as the end of the instrument was perceived, 
 it was taken hold of between the thumb and 
 middle finger, the peritoneum was carefull }/ 
 kept up out of the way, and the stilette was 
 pushed by an assistant from within outwards, 
 through the fundus of the bladder. The 
 bladder being thus pierced, the operator in- 
 troduced into a groove in the stilette a 
 curved bistoury, with which he divided the 
 front of the bladder, from above downwards, 
 nearly to its neck. He then passed his fin- 
 gers into the opening, and keeping up the 
 bladder with them, withdrew the sonde a 
 dard altogether. But, as it was useful that 
 both his hands should be free, the bladder 
 was prevented from slipping away by means 
 of a suspensory hook held by an assistant 
 as soon as the opening was found to be 
 already ample enough, or had been enlarged 
 to the necessary extent. Cdme next intro- 
 duced the forceps, took out the stone, and 
 passed a cannula, or elastic gum catheter 
 through the wound in the perineeum into 
 the bladder, so as to maintain a ready outlet 
 for the urine, and divert this lluid from the 
 wound in the bladder. In women, of course, 
 the catheter was passed through the meatus 
 urinarius. And, 1 ought here to observe, 
 that C6me thought the high operation espe- 
 cially adviseable for females, because his 
 experience had taught him, that the division, 
 or dilatation , of the meatus urinarius was 
 generally followed by an incontinence of 
 urine. (See JYouvclle Mbthode d'exlraire la 
 Pierre de la Vessie par dessus le Pubis , fyc. 
 S vo. Bruxelles , 1779.) 
 
 Another modification of the high operation 
 was suggested by Deschamps, who, instead 
 of opening the membranous part of the 
 urethra as C6me did, perforated the bladder 
 from the rectum, and through the cannula 
 of the trocar effected the same objects, 
 which the latter lithotomist accomplished by 
 means of the incision in the membranous 
 part of the urethra. Of the two plans, that 
 
LITHOTOMY 
 
 
 Revised by Gome is unquestionably the best, 
 because not attended with a double wound 
 of the bladder ; a thing which, I conceive, 
 must always be highly objectionable. 
 
 Dr. Souberbielle, who practices Come’s 
 method, introduces a silver wire hrough the 
 cannula of the sonde a dard , and passes it 
 through the wound made in the tinea alba. 
 The wire is then held while the sonde a dard 
 is withdrawn, and a flexible gum-catheter is 
 passed by means of the wire into the blad- 
 der through the wound in-the membranous 
 part of the urethra. The wire is now with- 
 drawn, and the catheter is fixed with tapes, 
 passed round the thighs and pelvis, and a 
 bladder is tied to it for the reception of the 
 urine. “ A piece of soft linen, half an inch 
 wide, and six or eight inches long, is to be 
 introduced, by means of a pair of forceps 
 into the bottom of the bladder;” the object 
 of which slip of linen is to carry off such 
 urine, as may not escape through the cathe- 
 ter. Lint and light dressings are applied, 
 and a bandage round the abdomen. Great 
 care is to be taken to keep the catheter per- 
 vious, and, usually on the third day, the slip 
 of lirftn may be taken out, and the wound 
 closed with adhesive plaster. (See Carpue’s 
 Hisiory of the High Operation , p.l 71, 172.) 
 
 Sir Everard Home made trial of Dr. Sou- 
 berbielle’s method in St. George’s Hospital, 
 and though some difficulty and delay occur- 
 red in the operation, on account of the stone 
 .being encysted, the result was successful. 
 Subsequently to this case, however. Sir 
 Everard has invented and practised another 
 method, which, as far as I can judge, is 
 better than that of Come, or Souberbielle, 
 though its principles are the same. When it 
 is considered, that in the operation of these 
 last lithotomists, the neck of the bladder is 
 not opened, and the catheter enters that re- 
 ceptacle through the prostatic portion of the 
 urethra, it must be immediately obvious, that 
 the incision in the perinaeum cannot answer 
 any material object, because a tube may be 
 placed in the same position by passing it 
 through the urethra from the orifice in the 
 glans. The retainer, or bracelet, invented 
 for keeping the catheter in the bladder, in 
 cases of enlargement of the prostate gland, 
 seemed to Sir Everard Home peculiarly ap- 
 plicable to the high -operation, since it keeps 
 the tube steadily in the natural canal, and * 
 renders the wound in the perinaeum unneces- 
 sary. Bracelets, for this purpose, extremely 
 elastic, and producing no irritation, are 
 sold by Mr. Weiss, of the Strand. They are 
 furnished with small rings, to which the 
 outer end of the catheter is fixed by means 
 of string. 
 
 Sir Everard Home performed his new 
 operation, for the first time, in St. George’s 
 Hospital, on the 26th of May, 1820. An in- 
 cision was made in the direction of the linea 
 alba, between the pyramidales muscles, be- 
 ginning at the pubes, and extending four 
 inches in length : it was continued down to 
 the tendon. The linea alba was then pierced 
 close to the pubes, and divided by a probe- 
 pointed bis tour v to the extent of three 
 
 Vol. I Ft 25 
 
 inches. Tfle pyramidales muscles had a por- 
 tion of their origin at the symphysis pubis 
 detached, to make room. When the finger 
 was passed down under the linea alba, the 
 fundus of the bladder was felt covered with 
 loose, fatly, cellular membrane. A silver 
 catheter, open at the end, was now passed 
 along the urethra into the bladder, and when 
 the point was felt by the finger in the wound, 
 pressing up the fundus, a stilet, that had 
 been concealed, was forced through the 
 coats of the bladder, and followed by the 
 end of the catheter. The stilet was then 
 withdrawn, and the opening, through the 
 fundus of the bladder, enlarged towards the 
 pubes, by a probe-pointed bistoury, suffi- 
 ciently to admit two fingers, and then the 
 catheter was. withdrawn. The fundus of the 
 bladder was held up by one finger, and the 
 stone examined by the forefinger of the right 
 hand. A pair of forceps, with a net attached, 
 was passed down into the bladder, and the 
 stone directed into it by the finger : the sur- 
 face being very rough, the stone stuck upon 
 the opening of the" forceps, and being re- 
 tained there by the finger, was extracted. A 
 slip of linen had one end introduced into the 
 bladder, and the other was left hanging out 
 of the wound, the edges of which were 
 brought together by adhesive plaster. A 
 flexible gum catheter, without the stilet, was 
 passed into the bladder by the urethra, and 
 kept there by an elastic retainer surrounding 
 the penis. The patient was put to bed, and 
 laid upon his side, in which position the 
 urine escaped freely through the catheter.” 
 As no blood had been lost i:i the operation, 
 twelve ounces were taken from the arm. 
 iup next day the slip of linen was with- 
 drawn, as useless and irritating, the catheter, 
 while pervious, preventing any urine from 
 escaping by the wound- Sir Everard thinks, 
 that in future the linen nbed only be left in 
 the external wound, so as to prevent col- 
 lections of matter, and carry off any urine, 
 which may issue from the opening in the 
 bladder, when the catheter happens to be 
 stopped up. For this operation, Sir Eve- 
 rard particularly recommends catheters, with 
 their insides polished like their outsides, in 
 order that they may better resist the 
 effects of the urine. Suffice it to add, with, 
 respect to the above case, that the boy soon 
 recovered, the bladder having resumed its 
 healthy functions in ten days, although the 
 calculos was of the roughest possible kind. 
 
 Sir Everard Home has repeated his new 
 method on a gentleman, who went out in his 
 carriage, with the external wound con - 
 pletely healed, on the 14th day after the ope- 
 ration. The only particulars, which need 
 here be noticed, in regard to the latter case, 
 are, that some difficulty was experienced in 
 bringing the point of the catheter forwards 
 toward the pubes, and the slit in the front of 
 the instrument made it so incapable of bear- 
 ing lateral -motion, that the two sides were 
 twisted over one another. (On Strictures, 
 Vol. 3, p. 359, Svo. Load. 1820.) 
 
 Whoever follows this method of ooeratin*** 
 should always be« .provided with 1 severed 
 
LITHOTOMY 
 
 T94 
 
 tubes and stilets, of different lengths and 
 curvatures ; for, in the only case, in which I 
 have seen the operation attempted, the ex- 
 tremity of the catheter could not be made 
 to project the fundus of the bladder towards 
 the pubes, and, after long-protracted endea- 
 vours had been made to bring the end of the 
 instrument upwards and forwards, the tube 
 broke, and the operation was left unfinished. 
 The impression upon my mind was, that no 
 resistance of the bladder could account for 
 what happened, and that the fault lay in the 
 instrument itself, which should have been 
 exchanged for anotherof more suitable form, 
 as soon as it was found to be inapplicable. 
 And, l believe, that if attention be paid to this 
 suggestion of always having at hand a suf- 
 ficient number of tubes and stilets of differ- 
 ent lengths and curvatures, Sir Everard 
 Home’s new method will be the best modifi- 
 calion of the high operation yet proposed. 
 The slip of linen, however, I think is more 
 likely to do harm by its irritation, than any 
 good, as a conductor of the urine or matter 
 out the wound. At all events, as Sir Eve- 
 rard has observed, it should never be passed 
 into the bladder itself. Whenever I am 
 asked my opinion, respecting the preference, 
 which should be given to the high operation, 
 as a general practice, I venture no further 
 than to express a favourable opinion of it for 
 cases, in which the calculus is known be- 
 forehand to be of very large size, or the 
 urethra and prostate gland are diseased. 
 The reasons urged by Mr. Carpue, in favour 
 of a preference to the high operation in 
 most cases, are : 1. Because, it is generally 
 performed in less time; a point, which may be 
 disputed, though it is perhaps not worth con- 
 testing, since the danger of an operation can- 
 not always be truly estimated by the length 
 of time, which the patient remains in the 
 operating room, slow and gentle proceedings 
 sometimes contributing to his safety. 2. There 
 is less pain ; a remark, the justness of which 
 must depend, perhaps, upon the manner in 
 which each operation is done. 3. There is no 
 fear of a fatal hemorrhage ; a consideration, 
 which I admit is one good reason in favour 
 of the high operation ; though the lateral ope- 
 ration is only subject to risk of hemorrhage, 
 when the incisions are directed in a manner 
 not sanctioned in this dictionary. 4. There 
 is no division of the prostate and inferior 
 part of the bladder : no, but there is one 
 of the fundus, so that perhaps on this point 
 the two operations stand upon an equality, 
 As for ‘there being no danger in the high 
 operation of wounding the rectum, it 
 is undoubtedly an advantage, though the 
 accident, as far as L have seen, is not 
 followed by any serious consequences, and 
 can only happen from inattention to rules 
 easily followed. 5. The stone, if of a cer- 
 tain size, cannot be extracted by the lateral 
 operation, but admits of being so by the high 
 operation. Of all the reasons for the latter 
 practice, this appears to me the strongest, 
 with the exception perhaps of disease in the 
 urethra and prostate. 6. A small stone is 
 more readily discovered ifi this method, than 
 
 in the lateral operation : a point which i 
 consider questionable, and at all events, not 
 sufficiently important to form a ground for 
 the high operation. 7. If a stone breaks, 
 the particles can be extracted with more 
 certainty, than in the lateral operation : on 
 this question authors differ. 8. The high 
 operation enables the surgeon to remove 
 encysted calculi with greater ease : a reason 
 which may perhaps be generally true, but 
 which is somewhat weakened by the consi- 
 deration that encysted calculi are not very 
 frequent. Mr. Carpue allows, that the high 
 operation should not be selected when the 
 patient is corpulent, and the bladder is thick- 
 ened and diseased, so that its fundus cannot 
 be raised above the pubes. (See Hist, of 
 the High Operation, p. 173, 8 vo. Lond. 1819.) 
 
 As it is not my object to discourage the 
 practice of the high operation, under the par- 
 ticular circumstances which have been speci- 
 fied, I decline entering into any strict con 
 sideration of the inconveniences to which 
 this method is exclusively subject, especially, 
 the greater vicinity of the wound to the 
 peritoneum and small intestines, and the 
 division of that membrane and protrusion of 
 the viscera ; accidents, which w ill be found 
 by any body, who chooses to look over the 
 cases on record, not to have been unfre- 
 quent. On the contrary, as I believe this 
 method is advantageous in certain cases, the 
 recent attempts to bring it to greater perfec- 
 tion give me sincere pleasure. 
 
 In December, 1818, Mr. Kirby, of Dublin, 
 performed the high operation for the extrac- 
 tion of an elastic gum catheter, which had 
 slipped into the bladder through the cannula 
 of a trocar, with which paracentesis had been 
 performed. No contrivance was found 
 necessary for lifting up the fundus of the 
 bladder. The puncture, already made, was 
 enlarged, and after the operation was fin- 
 ished, a catheter was placed in the wound, 
 but was withdrawn on the 4th day, as the 
 urine passed out by the side of it. The case 
 terminated well. (See Kirby's Cases, p. 92, 
 tyc. 8 vo. Dublin , 1819.) 
 
 LATERAL OPERATION. 
 
 So named from the prostate gland, and 
 neck of the bladder, being laterally cut. 
 
 From some quotations made by Mr. Car- 
 pue from the works of Franco, it appears 
 clear enough, that the latter w r as not only 
 the inventor of the lateral operation, but 
 that he placed his patients in the position 
 adopted at the present time, used similar in- 
 struments to those now employed, (except- 
 ing that his gorget bad no sharp side) and 
 made the same incisions. Now, as this claim 
 of Franco to an invention of such import- 
 ance had been nearly, or quite forgot, when 
 Mr. Carpue’s work made its appearance, the 
 latter gentleman deserves much praise for 
 reminding (he profession of what may be 
 due to the memory of an old surgeon, whose 
 name must flourish, as long as the history of 
 the rise and progress of surgery isinterestingto 
 mankind. But, though Franco appears proba- 
 bly to havej*ractiscd the lateral operation, or 
 
LITHOTOMY. 
 
 J95 
 
 something very much like it, he never esta- 
 blished the method as a permanent improve- 
 ment of surgery, which measure was left to be 
 completed long afterward by ari ecclesiastic, 
 who called himself Frere Jacques : he came 
 to Paris in 1697, bringing with him abun- 
 dance of certificates of his dexterity in ope- 
 rating ; and making his history known to the 
 court and magistrates of the city, he got an 
 order to cut at the H6tel Dieu, and the Cha- 
 rity, where he performed this operation on 
 about fifty persons. His success did not 
 answer the promises which he had made, 
 and from that time his reputation seems to 
 have declined in the world, if we may give 
 credit to Dionis, who has furnished us w ith 
 these particulars. — ( Sharp's Operations.) 
 
 Frere Jacques used a large round staff With- 
 out a groove, and when it was introduced 
 into the bladder, be depressed its handle, 
 with an intention of making the portion of 
 this viscus, which he wished to cut, approach 
 the periuaeum. He then plunged a long 
 dagger-shaped knife into the left bip, near 
 the tuber ischii, two finger-breadths from the 
 periuaeum, and pushing it towards the blad- 
 der, opened it in its body, or as near the 
 neck as he could, directing his incision up- 
 ward from the anus. He never withdrew 
 his knife, till a sufficient opening bad been 
 made for the extraction of the stone. Some- 
 times he used a conductor to guide the for- 
 ceps, but more commonly directed them 
 with his finger, which he passed into the 
 wound after withdrawing the knife. When 
 he had hold of the stone, he used to draw it 
 out in a quick rough manner, heedless of the 
 bad coiisequences. His only object was to 
 get the stone extracted, and he disregarded 
 every thing else ; all preparatory means, ail 
 dressings, all after-treatment. (Allan, p. 23.) 
 
 Totally ignorant of anatomy, and thus 
 rude and indiscriminate in practice, Frere 
 Jacques soon sunk into disrepute. However, 
 there were several eminent surgeons, who 
 conceived, from considering the parts which 
 be cut, that his method might be converted 
 into a most useful operation. ( Sharp's Ope- 
 rations.) 
 
 The principal defect in his first manner of 
 cutting, was the want of a groove in his staff, 
 which made it difficult to carry the knife into 
 the bladder. At length, Frere Jacques was 
 prevailed upon to study anatomy, by which 
 his judgment being improved, he readily 
 embraced several improvements, which were 
 suggested to him. Indeed, we are informed 
 that he now succeeded better, and knew 
 more, than is generally imagined. Mr. Sharp 
 says, that when he himself was in France 
 in 1702, he saw a pamphlet, published by 
 this celebrated character, in which his me- 
 thod of operating appeared so much impro- 
 ved, that it scarcely differed from the practice 
 of that time. Freire Jacques had learnt the 
 necessity of dressing the wound after the 
 operation, and had profited so much from 
 the criticisms of Mery, Fagon, Felix, and 
 Hunauld, that he then used a staff with a 
 groove, and what is more extraordinary, had 
 
 cut thirty-eight patients successively, without 
 losing one. (Sharp's Operations.) 
 
 In short, as a modern writer has observed, 
 he lost fewer patients than we do at the pre- 
 sent day, in operating with a gorget. He is 
 said to have cut nearly 5000 patients in the 
 course of his life, and though persecuted by 
 the regular lithotomists, he was imitated by 
 Marechal at Paris, Raw in Holland, and by 
 Bamber and Cheselden in England, where 
 his operation was perfected. (Allan.) 
 
 For a particular history of Frere Jacques, 
 and his operations, Allan refers us to Bus- 
 siere's Letter to Sir Hans Sloane , Philos. 
 Trans. 1699. Observations sur la Mani&re de 
 tailler dans Us deux Sexes, pour V Extraction 
 de la Pierre , praiiqu6e par F. Jacques , par J. 
 Mery. Lister's Journey to Paris in 1693. 
 Cours d' Operations de Chirurgie , par Dionis. 
 Garengeot Traiti des Operations, T. 3, Ma- 
 raud, Opuscule Chirurgie, Part 2. 
 
 Among the many who saw Fre e Jacques 
 operate, was the famous Professor Raw, who 
 carried his method into Holland, and practi- 
 sed it with amazing success. He never pub- 
 lished any account of it himself, though he 
 admitted several to his operations; but after 
 his death, his successor Albums, gave the 
 world a very circumstantial detail of all the 
 processes, and mentions, as one of Raw’s 
 improvements, that he used to open the blad- 
 der, between its neck and the ureter. But 
 either Albinus, in his relation, or Raw him- 
 self in his supposition, w’as mistaken ; since 
 it is almost impossible to cut the bladder in 
 that part upon the common staff, without 
 also wounding the neck.” (Sharp in Opera- 
 tions and Critical Inquiry.) 
 
 Raw’s method was objectionable, even 
 when accomplished, as the urine could not 
 readily escape, and became extravasaied 
 around the rectum, so as to produce terrible 
 mischief. There is little doubt, that Raw’s 
 really successful plan was only imitative of 
 Frere Jacques’s second improved one, though 
 he was not honourable enough to confess it, 
 (See Ferhius de Culculo Vcsicce .) 
 
 Dr. Bamber was the first man in England, 
 who made a trial of Raw’s method on the 
 living subject, which he did in St. Bartholo- 
 mew’s Hospital. Cheselden, who had been 
 in the habit of practising the high operation, 
 giadly abandoned it, on receiving the ac- 
 count of Raw’s plan and success, and a few 
 days after Bamber, he began to cut in tin’s 
 way in Si. Thomas’s Hospital. 
 
 Cheselden used at first to operate in -the 
 following manner. The patient being pla- 
 ced, and tied much in the same way, as is 
 done at this day, the operator introduces a 
 hollow grooved steel catheter into the blad 
 der, and with a syringe, mounted with an 
 ox’s ureter, injects as much warm water into 
 it, as the patient can bear without pain. The 
 water being kept from running out by a slip 
 of fiannel tied round the penis, the end of 
 the catheter is to be held f»y an assistant, 
 whose principal care is to keep it from rising, 
 but not at all to direct the groove to the 
 place where the incision is to be made. 
 
 With a pointed convex-edged knife, the 
 
LITHOTOMY 
 
 
 operator beginning about an inch above the 
 anus, on 1 he left side of the raphe, between 
 the accelerator u rinse, and erector penis, 
 makes an incision downwards, by the side of 
 the sphincter ani, a little obliquely outward.*? 
 ns it descends, from two and a half to four 
 inches in length, according to the age of the 
 patient, or size and structure of the parts. 
 This incision he endeavours to make aii at 
 one stroke, so as to cut through the skin, tut, 
 and all, or part of the levator ani, which lies 
 in his way. This done, he passes his left 
 fore-finger into the middle of he wound, in 
 order to press the rectum to one side, that it 
 may be in less danger of being cut ; and 
 taking a crooked knife in his other hand, 
 with the edge on the concave side, he thrusts 
 the point of it through the wound, close by 
 his linger, into (he bladder, between the ve- 
 sicula setninalis and os ischium of the same 
 side. This second incision is continued up- 
 wards, till the point of the knife comes out at 
 the upper part of the first. The incision be- 
 ing completed, the operator passes his left 
 fore-finger through the wound into the blad- 
 der, and having felt, and secured the stone, 
 he introduces the forceps, pulls out his finger, 
 and extracts the stone. 
 
 As the bladder was distended, Cheselden 
 thought it unnecessary to cut on the groove of 
 the staff, and that, as this viscus was suffi- 
 ciently pressed down by the instrument, the 
 forceps could be very well introduced with- 
 out the use of any director, except the finger. 
 ( Postscript to Douglas's History of the Lateral 
 Operation , 1726.) 
 
 With respect to this first of Cheselden’s 
 plans, Sharp says, the operations were ex- 
 ceedingly dexterous ; but the wound of tile 
 bladder retiring back, when it was empty, 
 did not leave a ready issue for the urine, 
 which insinuated itself among the neighbour- 
 ing muscles and cellular substance, and four 
 out of the ten patients on whom the operation 
 was done perished, and some of the others 
 narrowly escaped. ( Sharp's Operations.) 
 
 Cheselden, finding that he lost .-<> many 
 patients in imitating Raw*, according to the 
 directions given by Albinus, began a new 
 manner of operating, which he thus de- 
 scribes : “ I first make as long an incision as 
 1 well can, beginning near the place where 
 the old operation ends, and cutting down 
 between the rnusculus accelerator urina? and 
 erector penis, and by the side of the intesti- 
 num rectum : 1 then feel for the staff, and cut 
 upon it the length of the prostate gland 
 straight on to the bladder, holding down the 
 gut all the while with one or two fingers of 
 my left hand.” {Anatomy of the Human 
 Body , Edit. 1730.) 
 
 Jt deserves remark, that it was Cheselden’s 
 second manner of cutting, which ivasdescri 
 bed in the Opuscules de Chirurgie , of Morand, 
 who was deputed, and had Ins expenses de 
 frayed by the Royal Academy of Sciences in 
 Paris, to come over to England, and learn 
 from Mr. Cheselden himself, his way of ope- 
 rating for the stone ; and, accordingly, we 
 find, that most French authors, taking their ac- 
 count from Morand, describe Cheselden ’s se- 
 
 cond, not his third operation, as that which 
 he invented, and bears his name. But, that 
 Mr Cheselden never resumed his second 
 manner of cutting may be inferred from his 
 continuing to describe the third only in all 
 (he editions of his anatomy published after 
 1730. {See anote by J. Thomson , M. D. an- 
 nexed to his new edition of Douglas's Appen- 
 dix. Edinb 1808.) 
 
 The insirumenis which Cheselden employ- 
 ed in his third, and most improved mode of 
 cutting for the stone, were a stall', an incision 
 knife, a gorget, a pair of forceps, and ga 
 crooked needle carrying a waxed tiiread. The 
 patient being placed on a table, his wrists are 
 brought down to the outsides of his ankles p 
 and secured there by proper bandages, his 
 knees having first been bent, and his heels 
 brought back near his buttocks. 
 
 Cheselden used then to take a catheter, 
 first dipped in oil, and introduce it into the 
 bladder, where having searched for, and 
 discovered the stone, he gave the instru- 
 ment to one of his colleagues, whom he de- 
 sired to satisfy himself, whether there was a 
 stone, or not. The assistant, standing on his 
 right hand, held the handle of the staff be- 
 tween his fingers and thumb, inclined it a 
 little towards the patient's right thigh, and 
 drew the concave side close up to the os pu- 
 bis, in order to remove the urethra as far as 
 possible from the rectum. 
 
 The groove of the staff being thus turned 
 outwardly and laterally, Cheselden sat down 
 in alow chair, and keeping the skin of the 
 perinaeum steady with the "thumb and fore- 
 finger of his left hand, he made the first or 
 outward incision, through the integuments, 
 from above downwards, beginning on the 
 left side of the raphe, between the scrotum 
 arid verge of the anus, almost as high up as 
 where the skin of the perinaeum begins to 
 form the bag containing the testicles. Thence 
 he continued the wound obliquely outwards, 
 as low down as the middle of the margin of 
 the anus, at about half an inch distant from it r 
 and consequently, beyond the tuberosity of 
 the ischium. He was always careful to make 
 this outward wound as large as he could with 
 safety. Having cut (he fat rather deeply, 
 especially near the rectum, he used to put his 
 left fore-finger info the wound, and keep it 
 there till the internal incision was quite finish- 
 ed ; first to direct the point of his knife into 
 the groove of the staff, which he now felt 
 with the end of his finger • and secondly, to 
 hold and prevent the rectum from being 
 wounded, by the side of which his knife was 
 to pass. This inward incision Cheselden 
 made with more caution, than the former. 
 H is knife first entered the groove of the ros- 
 trated, or straight part of the staff, through 
 the side of the bladder, immediately above 
 the prostate, and its point was afterward 
 brought along the same groove in the direc- 
 tion downwards, and forwards, or towards 
 himself. Cheselden thus divided that part 
 of the sphincter of the bladder, which lay 
 upon the prostate gland, of which he next 
 cut the outside of one half obliquely, accord- 
 ing to the direction and whole length of the 
 
tlTHOIOMY. 
 
 197 
 
 urethra within it, and finished tlie internal in- 
 cision, by dividing the membranous portion 
 of the urethra, on the convex part of his staff’. 
 
 A sufficient opening being made, Che- 
 selden used to rise from his chair, bis finger 
 still remaining in the wound. Next he put 
 the beak of his gorget in the groove of the 
 staff', and then thrust it into the bladder. 
 The staff was now withdrawn, and while he 
 held the gorget with his left hand, lie intro- 
 duced the forceps with the Hat side upper- 
 most, with great caution along the concavity 
 of the gorget. When the forceps was in the 
 bladder, he withdrew the gorget, and taking 
 hold of the two handles of the forceps with 
 both his hands, he searched gently for the 
 stone, while the blades were still kept shut. 
 As soon as the calculus was felt, the forceps 
 Was opened, and an attempt made to get the 
 lower blade under the stone, in order that 
 it might be more conveniently laid hold of. 
 This being done, the stone was extracted 
 with a very slow motion, in order to give 
 the parts time to dilate, and the forceps was 
 gently turned in all directions. 
 
 When the stone was very small, and did 
 not lie well in the forceps, Cheselden used 
 to withdraw this instrument, and introduce 
 his finger into the bladder, for the purpose 
 of turning the stone, and disengaging it from 
 the folds of the lining of the bladder, in 
 which it was sometimes entangled. Then 
 the gorget w as passed in again on the upper 
 side of his finger, and turned as soon as the 
 fatter was pulled out. Lastly ; the forceps 
 was introduced, and the stone extracted. 
 With the view of hindering a soft stone 
 from breaking during its extraction, Chesel- 
 den used to put one or more of his fingers 
 between the branches of his forceps, so as 
 to prevent any greater pressure upon it, 
 than what was just necessary to hold it to- 
 gether. But when it did break, or there 
 were more calculi than one, he used to 
 extract the single stones, or fragments, one 
 after another, repeating the introduction of 
 his fingers and forceps, as often as there 
 was occasion. Cheselden took care not to 
 thrust the forceps so far into the bladder as 
 to bruise or wound its opposite side; and he 
 was equally careful not to pinch any folds 
 of its inner coat. In this w ay, Cheselden 
 saved 50 patients out of 52, whom he cut 
 successively in St. Thomas’s Hospital. (Ap- 
 pendix to the History of the Lateral Opera- 
 tion, by J. Douglas. 1731.) 
 
 Cheselden, with all the enthusiasm of an 
 inventor, believed, that he had discovered 
 an operation, which was not susceptible of 
 improvement ; yet, he himself changed the 
 manner of his incision not less than three 
 times, in the course of a few years. 1st, He 
 cut into the body of the bladder, behind the 
 prostate, when he imitated Raw. 2dly, He 
 cut another part of the bladder, viz. the 
 neck and the thick substance of the pros- 
 tate ; this is his lateral mode of incision. 
 3dly, He changed a third time, not the es- 
 sential form of the incision, but the direc- 
 tion, in which he moved the knife ; for in 
 his first operation, when imitating the sup- 
 
 posed operation of Raw and Frcre Jacques, 
 he struck his knife into the body of the 
 bladder, betwixt the tuber ischii and the 
 vesiculac seminales, and all his incision lav 
 behind the prostate gland. In this second 
 operation, he pushed his knife into the 
 membranous part of the urethra, imme- 
 diately behind the bulb, and ran it down 
 through the substance of the gland ; but his 
 incision shopped at the membranous *part, 
 or body, of the bladder. But in his third 
 operation, after very large external inci- 
 sions, he passed his knife deeply into the 
 great hollow under the tuber ischii, entered 
 it into the body of the bladder immediately 
 behind the gland, and drawing it towards 
 himself, cut through the whole substance of 
 the gland, and even a part of the urethra, 
 “ cutting the same parts the contrary way.” 
 By carrying the fore-finger of the left hand 
 before the knife, in dissecting towards the 
 body of the bladder, he protected the rec- 
 tum more perfectly, than he could do in 
 running the knife backwards along the 
 groove of the staff’; and by striking his 
 knife into the body of the bladder and 
 drawing it towards him, through the whole 
 thickness of the gland, he was sqre to make 
 an ample wound. (J. Bell's Principles of 
 Surgery, Vol. 2, Part 1, p. 152.) 
 
 LATERAL OPERATION AS PERFORMED AT TUB 
 
 PRESENT DAV WITH CUTTING GORGETS. 
 
 The gorget has the same kind of form as 
 one of the instruments used by F. Colot 
 and others in the performance of the appa- 
 ratus major, and the common opinion, that 
 the conductor of Hildanus was the first mo- 
 del of it, is not exactly true ; but it differs 
 from the instruments employed by these 
 older surgeons in having a cutting edge. 
 Sir Cesar Hawkins thought that, when its 
 right side was sharpened into a cutting 
 edge, it might be safely pushed into the blad- 
 der, guided by the staff, so as to make the 
 true lateral incision in the left side of the 
 prostate gland more easily, and with less 
 risk of injuring the adjacent parts, than 
 Cheselden could do with the knife ; and 
 surgeons were pleased with a contrivance, 
 which saved them from the responsibility 
 of dissecting parts, with the anatomy of 
 which all were not equally well acquainted. 
 (J. Bell. Allan.) 
 
 As Scarpa observes : To render the exe- 
 cution of the lateral operation easier to 
 surgeons of less experience than Chesel- 
 den, was the motive which induced Haw- 
 kins to propose his gorget. He thought, 
 that two great advantages would be gained 
 by the use of this instrument ; one of exe- 
 cuting invariably the lateral incision of 
 Cheselden ; the other, of constantly guard- 
 ing the patient through the whole course of 
 the operation, from injury of the rectum, 
 and of the arteria pudica profunda. The 
 utility of the latter object (says Scarpa) 
 cannot be disputed, as it is evident, that the 
 convexity of the director of the instrument de- 
 fends the rectum from injury, and that its 
 cutting edge not being inclined horizontally. 
 
198 
 
 LITHOTOMY. 
 
 inwards iitc tuberosity and ramus of the ischi- 
 urn, but turned upwards in the direction of the 
 longitudinal axis of the neck of the urethra , 
 cannot wound the pudic artery. But, with 
 respect to the first advantage, or that of 
 executing precisely the lateral incision of 
 Cheselden, it must be admitted that it does 
 not completely fulfil the intention which he 
 |)roposed, not only on account of the cutting 
 edge of his instrument not being raised 
 enough above the level of the staff, to pene- 
 trate sufficiently the substance of the pros- 
 tate gland, and consequently to divide it to 
 a proper depth ; but, because being too 
 much turned upwards at that part of it, 
 which is to lay open the base of the pros- 
 tate gland, it does not divide it laterally, 
 but rather at its upper part, towards the 
 summit of the ramus of the ischium, and the 
 arch of the pubes ; an opening, of all others 
 in the perinaDum, the most confined, and 
 presenting the greatest impediment to the 
 passage of the stone from the bladder. The 
 breadth of the point of the director is, be- 
 sides, so disproportionate to the diameter of 
 the membranous part of the urethra, that, 
 from the great resistance with which it 
 meets, the instrument may easily slip from 
 the groove of the staff, and pass between 
 the bladder and rectum, a serious accident, 
 which has very often happened even in the 
 hands of experienced surgeons. 
 
 Scarpa considers all the modifications of 
 Hawkins’s gorget, proposed by B. Bell, 
 Desault, Cline, and Cruikshanks, as deteri- 
 orations of the original instrument. B. Bell 
 (he observes) has diminished the breadth 
 of the director, but has given the cutting 
 edge an horizontal direction. The horiz >n- 
 tal direction of the cutting edge is also pre- 
 ferred by Desault, Cline, and Cruikshanks ; 
 but they have enlarged the director, and 
 flattened the part which was previously 
 concave. Aware of the danger of wound- 
 ing the pudic artery, by the horizontal di- 
 rection of the gorget, they direct the handle 
 of the staff to be inclined towards the pa- 
 tient’s right groin, and the gorget to be 
 pushed along it, inclined in such a manner, 
 that its obtuse edge may be directed towards 
 the rectum, and its cutting edge placed at 
 a sufficient distance from the tuberosity and 
 ramus of the ischium to avoid wounding 
 the artery. Scarpa contends, however, 
 that it is difficult to give a proper degree of 
 obliquity to the staff, and that such inclina- 
 tion of the instrument must be incommo- 
 dious, arbitrary, and unstable, in comparison 
 with that position of it, in which the handle 
 of the staff is held in a line perpendicular to 
 the body of the patient, and its concavity 
 placed against the arch of the pubes ; on 
 which stability of the instrument (says Scar- 
 pa) the safety and precision of the lateral 
 operation depend. According to this emi- 
 nent professor, the defects of Hawkins’s 
 original gorget arise from the excessive 
 breadth of the director, particularly at the 
 point ; the want of sufficient elevation of 
 the cutting edge, above the level of the 
 groove of the staff, and the uncertain incli- 
 
 nation of the edge to the axis of the urethra 
 and prostate gland. The cervix of the ure 
 thra, in a man between thirty and forty 
 years of age, is only three lines in diameter 
 at the apex of the prostate gland, four lines 
 in its centre, and five near the orifice of the 
 bladder. The apex of the prostate gland is 
 rather more than two lines in thickness, the 
 body or centre four, and the base six, and 
 sometimes eight, which surrounds the orifice 
 of the bladder. In an adult of middle sta- 
 ture, from eighteen to twenty years of age, 
 the thickness of the base of the prostate 
 gland is about two lines less, compared with 
 that of a man of forty, and of a large size. 
 The precise line in which the lateral incision 
 of the prostate gland should be made in an 
 adult, (says Scarpa) is found to be inclined 
 to the longitudinal axis of the cervix of the 
 urethra, and of the gland itself, at an angle 
 of 69°. Now, from these data, drawn from 
 the structure of the parts, Scarpa makes the 
 director of his gorget only four lines broad, 
 and two deep ; the breadth decreasing at 
 the beak. The cutting edge of the instru- 
 ment is straight near its point, but gradu- 
 ally rises, and becomes convex above the 
 level of the staff, so that its greatest con- 
 vexity is seven lines broad. Lastly ; the 
 inclination of the cutting edge to the lon- 
 gitudinal axis of the director, is exactly 
 at an angle of 69° ; that is to say, the 
 same as the left side of the prostate gland 
 to the longitudinal axis of the neck of the 
 urethra. (See Scarpa’s Memoir on Haw- 
 kins’s Gorget; transl. by Mr. Briggs , p. 
 12, 17.) 
 
 For nearly twenty years past, the instru- 
 ment-makers in London have been in the 
 habit of selling a gorget, which Mr. Aberne- 
 thy first had constructed, and which in the 
 particularity of having its cutting edge turn- 
 ed up at an angle of 45°, bears much analo- 
 gy to the instrument lately recommended 
 by Scarpa. The cutting edge is straight, 
 and that useless and dangerous part of a 
 gorget, sometimes called the shoulder, is re- 
 moved. Admitting that the principles of 
 the lateral operation as inculcated by Scar- 
 pa, are correct, and of which 1 shall present- 
 ly speak, it appears to me, that Mr. Aberne- 
 thy’s gorget is far preferable to that very re- 
 cently proposed by Scarpa. Its edge is not 
 so immoderately turned up, and it will enter 
 with more ease, and less risk of slipping from 
 from the staff, because it has not any pro- 
 jecting shoulder, which, while the staff is 
 firmly held with the beak of the gorget in it, 
 can have no other effect but that of obstruct- 
 ing the passage of the last instrument. 
 
 Gorgets, which cut on both sides, have 
 also been sometimes employed in England, 
 and as a larger opening can be obtained by 
 them, even without trespassing the limits of 
 the incision, fixed by Scarpa, that is to say, 
 without cutting any part of the body of the 
 bladder, they appear to promise utility, es- 
 pecially when the stone is suspected to be 
 large. However, they are less used now, 
 than they were some years ago, when Sir 
 Astley Cooper employed them in Guv’s* Ho i: 
 
LITHOTOMY. 
 
 pital ; but I aui unacquainted with the par- 
 ticular reasons of this change. 
 
 Some criticisms on Scarpa’s method of 
 operating, and a few remarks on the size and 
 direction of the lateral incision, will be 
 found in a subsequent section of the present 
 article. 
 
 As inflammation of the bladder and peri- 
 tonaeum is the principal danger of this ope- 
 ration, and, under an equal degree of injury 
 and violence, is most likely to happen in a 
 plethoric subject, it ha3 been a question, 
 whether venesection should not be practised 
 a day or two before the patient is operated 
 upon, supposing that his age and weakness 
 form no prohibition. The chief reason, 
 which prevents the common observance of 
 this practice is, that a great deal of blood is 
 sometimes lost in the operation itself. But 
 when this has not happened, and the patient 
 is young and strong, and particularly when 
 the operation has been tedious, and the 
 bladder has suffered a good deal, I am dis- 
 posed to think very favourable of the rule, 
 which is followed by many surgeons, of 
 bleeding the patient as soon as he is put to 
 bed, and recovered from the first depressing 
 effects of the operation. An opening medi- 
 cine should also be given*the day before the 
 patient is cut, and a clyster injected a cou- 
 ple of hours before the time fixed upon for 
 the operation, in order to empty the rectum, 
 and thus diminish the chance of its being 
 ■wounded. 
 
 As it is advantageous to have the bladder 
 somewhat distended, the patient should be 
 requested to retain his urine a certain time 
 before being cut. Formerly, a jugum penis 
 was sometimes used for confining the urine 
 in the bladder ; but, since my entrance into 
 the profession, I have never heard of this 
 contrivance being employed. 
 
 Before the operation, the following instru- 
 ments should all be arranged ready on a 
 table : a staff of as large a diameter as will 
 easily admit of introduction, and the groove 
 of which is very deep, and closed at the ex- 
 tremity. A sharp gorget, with a beak nicely 
 and accurately adapted to the deep groove 
 of the preceding instrument, so as to glide 
 easily and securely. A large scalpel for 
 making the first incisions. Forceps of va- 
 rious sizes, for extracting the stone. A 
 blunt-pointed curved bistoury for enlarging 
 the wound in the prostate, if the incision of 
 the gorget be not sufficiently large, as the 
 parts should never be lacerated. A pair of 
 Le Cat’s forceps with teeth for breaking 
 the stone, if too large to come through any 
 wound reasonably dilated. A syringe for 
 washing out clots of blood, or particles of 
 the stone. A scoop for the removal of 
 small calculi or fragments. Two strong 
 garters, or bands, with which the patient’s 
 hands and feet are tied together. 
 
 The curvature of the staff is a matter of 
 considerable importance ; because the di- 
 rection of the incision through the prostate 
 gland and neck of the bladder is partly de- 
 termined by it. The French surgeons, con- 
 vinced of the advantage of introducing the 
 
 199 
 
 gorget in the direction of the axi3 of the 
 bladder, always use a staff, which is much 
 more curved than what English surgeons 
 employ. (See Roux, Voyage fait a Londres 
 en IS 14, ou Par allele de la Chir. Angloise , 
 <£'C. p. 319 ) But, I am inclined to believe 
 with Scarpa, that, upon the whole, it is best 
 to let the curvature of the staff correspond 
 exactly to that of the axis of the neck of the 
 urethra and prostate gland. ( Memoir on 
 Hawkins's Gorget, <^c. p. 17.) 
 
 After introducing the staff, and feeling that 
 the stone is certainly in the bladder, the 
 patient is to be secured in the same position, 
 as was described in the account of Chesel- 
 den’s latest method of operating. 
 
 The assistant, holding up the scrotum 
 with his left hand, is with his right to hold 
 the staff, inclining its handle towards the 
 right groin, so as to make the grooved con- 
 vexity of the instrument turn towards the 
 left side of the perinaeum. Some operators, 
 also, like the assistant to depress the handle 
 of the staff towards the patient’s abdomen, 
 in order to make its convexity project ia 
 the perinaeum, while others condemn this 
 plan, asserting, that it withdraws the instru- 
 ment from the bladder. {Allan, fyc.) 
 
 Professor Scarpa disapproves of inclining 
 the handle of the staff towards the patient’s 
 right groin, ( p . 15.) and he expressly recom - 
 mends this instrument to be held firmly 
 against the arch of the pubes, in a line per- 
 pendicular to the body of the patient, so 
 that the convex part of the director may be 
 placed towards the rectum, and take the 
 exact course of the axis of the neck of the 
 urethra and prostate gland. (P. 20.) This 
 position of the staff is the firmest and most 
 commodious to the surgeon, and Scarpa 
 maintains, that on such stability of the instru- 
 ment the safety and precision of the lateral 
 operation depend. (P. 15.) 
 
 The first incision should alw r ays com- 
 mence below f the bulb of the urethra, over 
 the membranous part of this canal, at the 
 place, where the operator means to make bis 
 first cut into the groove of the staff, and the 
 cut should extend at least three inches, ob- 
 liquely downward, to the left of the raphe 
 of the perinaeum, at equal distance from the 
 tuberosity of the ischium and the anus. In a 
 large man, the first cut should pass the anus 
 an inch and a half or more ; for it is a 
 general rule in surgery to make free exter- 
 nal incisions, by w hich the surgeon is ena- 
 bled to conduct the remaining steps of his 
 operation with greater facility, and nowhere 
 is it so necessary, as where a stone is to be 
 extracted. {Allan.) That excellent surgi- 
 cal writer, Callisen, lays it dow r n as a rule 
 to be observed in the lateral operation, that • 
 the incision ought not to extend to such parts 
 as can make no impediment to the extraction 
 of the stone ; and therefore, (says he) the bulb , 
 and that part of the urethra, vjhich is sur- 
 rounded by the corpus spongiosum, should 
 never be cut. Only those parts ought to be 
 divided, which firmly resist the safe intro- 
 duction of instruments into the bladder, and 
 the extraction of the- stone. Hence, the in- 
 
LITHOTOMY. 
 
 StJO 
 
 teguments must be opened by an ample in- 
 cision, and the membranous part of the ure- 
 thra, transversales perinaei muscles, levater 
 uni, and prostate gland, be properly divided. 
 ( Callisen , Systema Chirurgiee Ilodicrnce, Pars 
 2, p. 655.) Like Scarpa, however, he is 
 fearful of making a free cut through the 
 neck of the bladder, and in lieu of doing so, 
 prefers a slow and cautious dilatation of the 
 parts. When the external cut through the 
 integuments has been executed, the next 
 object is to divide the transversales perinsei 
 muscles, which stand, like a bar, across the 
 triangular hollow, out of which alone the 
 stone can be easily extracted. A part of the 
 membranous portion of the urethra, adjoin- 
 ing the prostate gland, is next to be laid 
 open ; but an extensive cut through it, as far 
 forward as the bulb, is quite unnecessary, 
 because it will not at all facilitate the pas- 
 N sage of the stone outward. 
 
 Having placed the beak of the gorget in 
 the groove of the staff, the operator takes 
 firm hold of the latter instrument with his 
 left hand, raises its handle from the abdo- 
 men, so that it may form nearly a right an- 
 gle with the body, and stands up. Before 
 attempting to push the gorget into the blad- 
 der, however, he should slide it backwards 
 and forwards, with a wriggling motion, that 
 he may first be sure of its beak being in the 
 groove of the staff. The bringing forward of 
 the handle of the latter instrument, so as to 
 elevate its point, before introducing the gor- 
 get into the bladder, is also considered of 
 great importance : for it is by this means, 
 that the gorget is introduced along the 
 groove of l he staff in the axis of the blad- 
 der, the only direction unattended with risk 
 of wounding the rectum. In fact, the gor- 
 get should be introduced nearly in a direc- 
 tion, corresponding to a line drawn from 
 the os coccygis to the umbilicus. It is ob- 
 vious, however, that the degree in which 
 the handle of the staff' should be depressed, 
 must depend very much upon the curvature 
 of i he instrument. 
 
 The utmost attention to the ride last no- 
 ticed is especially necessary, when a staff 
 with a groove not closed at the end is em- 
 ployed. The neglect of it in this case 
 might make the operator cut the bladder 
 with the gorget in several places, as has 
 actually happened, as we learn from the 
 observations of Mr. B. Bell. But since the 
 gorget, when introduced as nearly as possi- 
 ble in the axis of the bladder, may transfix 
 and otherwise injure this organ, if introdu- 
 ced either too far, or at all beyond the ex- 
 tremity of the staff, I am decidedly of opi- 
 nion that every surgeon, who chooses to 
 perform the lateral operation with a gorget, 
 should employ a staff, the groove of which 
 is closed at the extremity, as is invariably 
 done in France, and is expressly enjoined 
 by Professor Scarpa. (See Sabatier's Mt- 
 ilecine Optroioire, T 3 ,p. 223. Edit. 2; and 
 Scarpa's Memoir on Hawkins's Gorget, p. 18, 
 <^c.) There can also be no doubt of the 
 prudence of endeavouring to have only a 
 fixed and limited length of the stafLin the 
 
 bladder. Scarpa specifies an inch and a 
 half as the proper distance to which the end 
 of the staff’ should enter the bladder. How- 
 ever, as it is known, that this distinguished 
 Professor is an advocate for a very limited 
 incision, and that consequently, he would 
 not require the staff to extend further than 
 an inch and a half into the bladder, I infer 
 that operators, who prefer making a freer 
 opening, must use a staff' that reaches into 
 this viscus rather further. Much, however, 
 will depend upon the kind of gorget em- 
 ployed, particularly its breadth. 
 
 As soon as the gorget is introduced, the 
 staff is to be withdrawn. Some operators 
 next pass the forceps alopg the concave 
 surface of the gorget into the bladder; while 
 others, with every appearance of being right, 
 recommend the cutting gorget to be with- 
 drawn immediately it has completed the 
 wound ; for then the bladder contracts, and 
 its fundus is liable to be cut. The gorget 
 should be withdrawn in the same line in 
 which it entered, pressing it towards the 
 right side, in order to prevent its making a 
 second wound. If, however, the operator 
 should prefer passing the forceps into the 
 bladder, along the gorget, the latter instru- 
 ment must be kepf quite motionless, lest its 
 sharp edge do mischief; and, at all events, 
 as soon as the forceps is in the bladder, the 
 cutting gorget is to be withdrawn. 
 
 Some operators withdraw the cutting gor- 
 get, and introduce a blunt one for the gui- 
 dance of the forceps ; a step certainly un- 
 necessary, as the latter instrument will ea- 
 sily pass, when the incision into the bladder 
 is ample and direct, as it ought always to be. 
 
 The operator has next to grasp the stone 
 with the blades of the forceps ; for which 
 purpose, he is not to expand the instrument 
 as soon as it has arrived in the bladder ; but 
 he should first make use of the instrument as' 
 a kind of probe, for ascertaining the exact 
 situation of the stone. If this body should 
 be lodged at the lower part of the bladder, 
 just behind its neck, the operator is to open 
 the forceps immediately over the stone, and 
 after depressing the blades a little, is gently 
 to shut them, so as to grasp it. Certainly 
 it is much more scientific to use the forceps 
 at first, merely for ascertaining the position 
 of the stone : for when this is known, the 
 surgeon is much more able to grasp the ex- 
 traneous body in a skilful maimer, than if 
 he were to open the blades of the instru- 
 ment immediately, without knowing where 
 they ought next to be placed, or when 
 shut. No man of experience can doubt 
 that the injury, which the bladder frequent- 
 ly suffers from rough, reiterated, awkward 
 movements of the forceps, is not an unconr 
 mon cause of such inflammation of this' 
 viscus, as too often extends to the perito- 
 naeum, and occasions death 
 
 If the surgeon cannot readily take hold 
 of the stone with the forceps, he should in- 
 troduce his fore and middle fingers into the 
 rectum, and raise up the extraneous body, 
 when it may generally be easily grasped. 
 The stone should be held with sufficient 
 
LITHOTOMY. 
 
 '2d l 
 
 instance, however, the surgeon should gently 
 examine the cavity of the bladder with his 
 fore-finger ; for, it would be an inexcusable 
 neglect to put the patient to bed with ano- 
 ther stone in his bladder. 
 
 After the operation, a simple pledget 
 should be laid on the wound, supported by 
 a T bandage ; the patient should lie in bed 
 on his back, with his thighs closed ; a piece of 
 oil cloth, and some folded napkins should 
 be laid under him for the reception of the 
 urine, and, if there be much pain, a large 
 opiate should be administered ; but, as the 
 latter medicine is a stimulant, if it can be 
 dispensed with, so much the better. 
 
 An occasional embarrassment to lithoto- 
 
 iirmness to keep it from slipping away 
 trom the blades, but not so forcibly as to 
 incur the risk of its breaking. 
 
 Sometimes the extraction of the stone is 
 attended with difficulty, owing to the ope- 
 rator having chanced to grasp it in a trans- 
 verse position, in which circumstance, it is 
 better to try to change its direction, or let 
 it go altogether, and take hold of it in ano- 
 ther manner. When the stone is so large, 
 that it cannot be extracted from the wound 
 without violence and laceration, the surgeon 
 may either break the stone by means of a 
 strong pair of forceps, with teeth construct- 
 ed for the purpose ; or he may enlarge the 
 ■wound with a probe-pointed crooked bis- 
 toury, introduced under the guidance of the mists is the circumstance of stones in the 
 tore-finger of the left hand. The latter plan bladder not being always free and detached • 
 is generally the best of the two ; for, break- some are embraced verv tightly bv the coats 
 ing the stone is an exceedingly unpleasant of this viscus ; others are partially en^ed 
 circumstance, as it creates serious danger of in the ureters : they are sometimes fixed” in 
 calculous fragments remaining behind. the neck of the bladder; and are not uii- 
 However, as nothing can justify the exer- frequently found lodged in saccuii accident- 
 tion of force m pulling out a stone, if the ally formed. These cysts are of different 
 operator should be afraid of making the sizes: some are small, and exist in a consi- 
 wo.un.d ra ^ re am ple, (<t being already large derable number; some are deeper, with an 
 and direct) he must break the stone as above orifice smaller than their base. They appear 
 described As many of the fragments are to be formed by a prolongation of the in- 
 then to be extracted w ith the common li- ternal coat of the bladder. ^ Other saccuii are 
 thotomy forceps, as can be taken away in occasionally found which seem to be com- 
 th.s method, after which the surgeon should posed of all the tunics of the bladder, and 
 introduce his finger, in order to feel whether they are sometimes of such magnitude, that 
 any pieces of the stone still remain behind, the bladder appears as if it were divided into 
 Perhaps some of these may be most conve- two or more cavities of nearly equal size, 
 mently taken out with the scoop ; but if Stones, found in these saccuii, sometimes 
 J y er y small, it is best to inject luKe- present depressions and irregularities, in 
 warm water with moderate force into the which fungi of the bladder have been re- 
 wound for the purpose of washing them out. ceived. When this happens, a portion of 
 e surgeon however, cannot be too such fungous productions is often extracted 
 
 " e abS ° IUte 116 wilh tbe stone ; a circumstance that has 
 cessit} of using the greatest care not to re- deceived some practitioners, and led them 
 
 move the patient from the operating table, 
 while any calculus, or fragment, remains in 
 the bladder. For, the distressing pain of 
 the disorder has been know r n to recur upon 
 the healing of the wound, and a second 
 operation become necessary. It is a me- 
 lancholy truth, however, that a fresh calcu- 
 lus may form again in the short space of a 
 few months. I have seen several patients 
 who have been cut for the stone, more than 
 once ; and Richerand mentions the case 
 of a surgical instrument maker, resident at 
 the gate of La CharTte, in Paris, who has 
 undergone the operation three times in the 
 course of a year and a half, although after 
 each operation several eminent surgeons 
 carefully examined the bladder, and could 
 not find any calculus remaining in it. (See 
 JYosogr. Chir. T. 3 , p. 549 , Edit. 4 .) 
 
 The stone should always be attentively ex- 
 amined immediately it is extracted ; because 
 its appearance conveys some information 
 
 to suppose, that the calculi actually adhered 
 to the coat of the bladder. (See Desault's 
 Parisian Chirurgicale Journal. Vol. 2, p. 386. 
 387 .) ^ * 
 
 Tne extraction of encysted stones requires 
 different modes of proceeding from those 
 which have been related. Littre conceived 
 that they might be removed in two ways. 
 Wneri they made only an inconsiderable 
 projection into the bladder, he recommended 
 the introduction of a probe, with which 
 the membrane, covering the calculus, was 
 to be rubbed, a linger being put into the 
 rectum, in order to keep it down, and facili- 
 tate the action of the probe in opening the 
 cyst. When the calculi w’ere very prominent. 
 Littre recommended taking hold of them 
 with a pair of forceps, and contusing and 
 breaking the membranous pouch, with the 
 points and asperities upon the inside of the 
 blades of the instrument. He. conceived 
 
 that suppuration would then destroy the in- 
 
 o7oi;;;r and M the rr 
 
 surface, „,e smoo.buess is S e„era,,v US 
 
 it is plain, that this theory, which is found- 
 ed on the idea entertained bv Littre of the 
 
 to arise from the friction of other stones 
 still in the bladder ; but, when it is uniformly 
 rough, it is a presumptive sign, that there is 
 uo other one remaining behind In every 
 Tot U. 
 
 *2 fi 
 
 manner in which stones become eficysted 
 i? totally inadmissible in practice 
 
3Q3 
 
 LITHOTOMY. 
 
 Garengeol. ventured to pass a bistoury into 
 the bladder for the purpose of disengaging a 
 calculus lodged in a particular cyst at the 
 fundus of this organ, behind the pubes. The 
 knife had some tape twisted round the great- 
 est part of its length , and was introduced 
 under the guidance of the left index finger, 
 which was passed in as far as it could reach. 
 The patient was not more than ten, or eleven 
 years old, and consequently of a size, which 
 favoured the operation. The stone was 
 oosened and taken out, and the child re- 
 covered However, as Sabatier remarks, 
 there are many instances, in which this mode 
 of proceeding cannot be imitated ; for, if 
 the calculus should be in a sort of cul-de- 
 sac, as often happens, the entrance of which 
 is narrower than its bottom, and the stone 
 be of considerable size, the incision cannot 
 be made large enough, without risk of cut- 
 ting through the whole thickness of the blad- 
 der, and producing certain death by the 
 effusion of urine in the abdomen. 
 
 Other practitioners fancied, that the cal- 
 culus might be taken hold of with the for- 
 ceps, and turned about in different directions 
 so as to lacerate its connexions, or even 
 that it might be forcibty extracted, with any 
 serious ill consequences. Houstet mentions, 
 (See Mem. de VAcad. de Chir. T. 2, p. 307, fyc. 
 Edit. 12 mo*) that Peyronie adopted this me- 
 thod on a patient, thirty-one years of age. 
 The calculus did not resist long, and its sur- 
 face was found covered with fleshy substan- 
 ces, which formed the adhesions to the blad- 
 der. The operation was painful, follow- 
 ed by considerable hemorrhage, tension of 
 the belly, hiccough, cold extremities, and 
 death. 
 
 There are some examples, however, in 
 which this bold practice had better success. 
 In 1730, Le Drari extracted from a woman 
 an enormous stone, adherent to that part of 
 the.bladder which lies upon the rectum. 
 The irritation of the inequalities of the 
 stone had produced ulceration of the blad- 
 der, and fungous growths, which insinuated 
 themselves into the substance of the extra- 
 neous body. The adhesions readily yielded, 
 and the excrescences came away with the 
 calculus. Ten days afterward, some thick 
 membranous sloughs were voided. This 
 calculus is engraved in Le Dran’s Treatise 
 on the Operations. 
 
 Le Dran afterward extracted similar 
 stones, which adhered by a less extensive 
 surface ; and he relates an operation done 
 by Mar&chal, who, in 1715, extracted with 
 a pair of forceps a stone shaped like a cala- 
 bash, and having its narrow part surrounded 
 by a fungus. In one case, the position of 
 the calculus led Le Dran to suspect that it 
 was fixed in the extremity of the ureter ; he 
 shook it occasionally with a pair of forceps ; 
 and, lastly, it fell into the bladder, whence 
 it was extracted without difficulty. It re- 
 sembled a cucumber in shape, and its large 
 extremity had been lodged in the ureter, 
 from which it could only be gradually re- 
 moved. Sabatier believes, that a case of 
 
 this description, which must be very un- 
 common, is the only one in which there is 
 any prospect of removing an encysted stone 
 with success. In other examples, he con- 
 ceives, that it is more prudent to leave the 
 stone, and let the wound heal, than expose 
 the patient to an almost certain death by 
 repeated attempts to extract it. ( M6decine 
 Opdraloire, T. 3, p. 190, 194, Edit. 2.) De- 
 sault employed a sort of concealed knife, 
 called a coupe-bride, for opening the cavity 
 or cyst; and he has recorded one example, 
 in which he thus successfully extracted from 
 a woman, aged sixty-two, a stone, lodged 
 at the insertion of the ureter into the blad- 
 der. The bistoury, used by Garengeot, De- 
 sault did not consider a safe instrument, as 
 the stones are round, and the knife may slip 
 and pierce the bladder; an objection to 
 which, he says, the coupe-bride is not liable. 
 No injury can be received from its point, as 
 the blade is concealed, nor can any part be 
 divided, except what the surgeon intends. 
 If the incision should not be completed at 
 first, the blade may be withdrawn, the semi- 
 circular notch of the instrument pushed 
 more forward, and the incision prosecuted 
 to any extent. This instrument was invent- 
 ed for the express purpose of dividing mem- 
 branous bands in the rectum ; but it was 
 afterward employed with the greatest suc- 
 cess for the excision of diseased tonsils and 
 fungous tumours situated in cavities. The 
 blade is so contrived, that when it passes 
 through the semicircular notch, it firmly 
 fixes the parts which are to be divided : a 
 thing that cannot be done either with the 
 scissors or bistoury, as the moveable parts 
 recede, and render the section difficult. (See 
 Desault's Parisian Chirurgicale Journal, Vol. 
 
 hp- 33 , 4 *.) 
 
 A stone perfectly encysted would not be 
 expected to produce symptoms equal in 
 severity to those which arise from an extra- 
 neous body actually in the cavity of the 
 bladder. And yet, in Houstet’s interesting 
 dissertation, several cases are recorded, 
 which prove that encysted stones do some- 
 times cause the same distressing symptoms 
 which proceed from the presence of a loose 
 calculus in the bladder. Hence, the pa- 
 tients were sounded, and in consequence of 
 the sacs, or pouches, in which the stones 
 lay, not being entirely closed, the calculi 
 were distinctly struck by the instrument, 
 and lithotomy attempted. It deserves par- 
 ticular remark, also, that, in a large propor- 
 tion of these cases, the pouches, or cysts, 
 were not single, but numerous, occupying 
 different parts of the bladder. In some dis- 
 sections, referred to by Houstet, cysts ot 
 this kind were found, not containing any 
 stones whatever ; a circumstance that would 
 rather lead one to suspect, that, in general, 
 the formation of these sacs precedes that ot 
 the calculi commonly found in them. (Sec 
 Observations sur les Pierres EnkisUes et Ad- 
 herent es a la Vessie par M. Houstet, in M6ui. 
 de PAcad. de Chir. T. 2, p. 258, Edit. >'/■ 
 I2/7J0.) 
 
LITHOTOMY'. 
 
 203 
 
 OF SOME PARTICULAR METHODS AND IN- 
 STRUMENTS. 
 
 M. Foubert, a very eminent surgeon at 
 Paris, devised and practised a plan of his 
 own, which, however, has not been consi- 
 dered by others as worthy of being imitated. 
 The patient having retained his urine, so as 
 to distend his bladder, an assistant, with a 
 convenient bolster, presses the abdomen a 
 little below tbe navel in such a manner, 
 that, by pushing the bladder forwards, he 
 inay make that part of it protuberant which 
 lies between the neck and the ureter. The 
 operator, at the same time, introduces the 
 fore-finger of his left hand up the rectum, 
 and drawing it down towards the right but- 
 tock, pushes in a trocar on the left side of 
 the perinasum, near the great tuberosity of 
 the ischium, and about an inch above the 
 anus. Then the trocar is to be carried on 
 parallel to the rectum, exactly between the 
 erector penis and accelerator urinae muscles, 
 so as to enter the bladder on one side of its 
 neck. As soon as the bladder is wounded, 
 the operator withdraws his fore-finger from 
 the anus. 
 
 In the upper part of the cannula of the 
 trocar, there is a groove, the use of which is 
 to allow some urine to escape, immediately 
 the instrument enters the bladder, so that 
 the trocar may not be pushed in any fur- 
 ther ; but its principal use is for guiding the 
 incision. As soon as the urine began to 
 flow, Foubert, retracting the trocar a little, 
 without drawing it quite out of the cannula, 
 introduced the point of a slender knife into 
 the groove in the cannula ; and by the gui- 
 dance of this groove he ran it onwards into 
 the bladder, and was aware of the knife 
 having actually entered this viscus, by the 
 urine flowing still more freely. Then rai- 
 sing the knife from the groove, he made his 
 incision about an inch and a half in length, 
 through the neck of the bladder, by moving 
 the knife from that point at which it had 
 entered upwards towards the pubes. And 
 finally, by moving the handle more largely 
 than the point of the knife, he opened the 
 outer part of the w ound to whatever extent 
 the size of the stone seemed to require, and 
 then, withdrawing the knife, he introduced 
 a blunt gorget to guide the forceps. 
 
 An effort was made by Thomas to im- 
 prove thi3 method ; but he failed, and it 
 was never much adopted. The inability of 
 many bladders to bear being distended, is 
 an insuperable objection ; for, without this, 
 the trocar is liable to pass between the. blad- 
 der and rectum, and even through the blad- 
 der into the pelvis. ( Memoires de l’ Acad. de 
 Chir. 663, Vol. 1. Le Dran’s Parallllt. 
 Sharp's Critical Inquiry. J. Bell's Princi- 
 ples, Vol. 2.) 
 
 In the year 174S, Frere Come’s method 
 of performing the lateral operation began to 
 attract considerable notice. The operation 
 was done with a particular instrument, call- 
 ed the lithotome cache , by means of which 
 the prostate gland and neck of the bladder 
 were divided, from within outwards# The 
 
 lithotome cach6 is entitled to much atten- 
 tion, because it is still generally used in 
 several parts of the continent, and some- 
 times in this country, especially by the sur- 
 geons of the Westminster Hospital. “ In 
 France (says M. Roux) if there is any 
 mode of operating more common than 
 others, and preferred by the majority of 
 practitioners, it is that in which the instru- 
 ment, named the lithotome cache , is employ- 
 ed.” (See Parall&le de la Chirurgie Ang- 
 loise , tyc. P- 3 IS. Frere Come does not 
 ascribe the invention of this instrument to 
 himself ; but acknowledges that it resembles 
 ihe knife for operating upon hernia, said to 
 have been devised by a French surgeon-of 
 the name of Bienaise. It consists of a han- 
 dle and the blade part. The latter is slightly 
 curved, about as thick as a quill, furnished 
 with a beak, and excavated so as to form a 
 sheath for a knife of its own length. By 
 means of a kind of lever, the knife can be 
 made to pass out of the sheath, and the 
 distance to which the blade projects also 
 admits of being regulated with precision. 
 For this purpose, the handle is divided into 
 six sides, numbered 6, 7, 9, 11, 13, and 15, 
 and which, according as they are more or 
 less elevated, allow the lever to be depress- 
 ed in different degrees, and the knife to 
 move out of its sheath in the same propor- 
 tion. Thus the surgeon can at his option 
 make an incision through the prostate gland 
 and neck of the bladder ot six different 
 lengths. 
 
 When the lithotome cache is to be used, 
 the patient must be placed in the same pos- 
 ture as in every other mode of practising 
 the lateral operation ; and after a staff has 
 been introduced, an oblique incision is to be 
 made from the raphe of the perinajum, to a 
 point situated rather more towards the anus, 
 than the innermost part of the tuberosity of 
 the ischium. The bulb of the urethra should 
 not be cut, and not too much of the mem- 
 branous part of the urethra The fat and 
 transverse muscles having been divided, arid 
 the urethra opened, exactly as in tbe com- 
 mon operation, the scalpel is to be put down, 
 and the beak of the lithotome introduced 
 into the groove of the staff. Of course, the 
 surgeon, previously to the operation, will 
 have settled the distance, to which the blade 
 of the instrument is to pass out of the sheath, 
 and which must necessarily depend upon 
 the age of the subject, and the presumed 
 size of the calculus. When the beak of the 
 lithotome has been inserted in the groove of 
 the staff, the surgeon is to take hold of the 
 handle of the latter instrument with his left 
 hand, and bring it a little towards himself, 
 at the same time pushing the lithotome into 
 the bladder, with the handle depressed as 
 much as possible. The staff is now to be 
 withdrawn, and the surgeon is to try to feel 
 the stone with the sheath of the other in- 
 strument, in order to be able to judge of the 
 size of the calculus, and whether the dis- 
 tance, to which the blade of the knifs is in- 
 tended to move out of the sheath, is such as 
 Tc likely to make an opening of due. but net. 
 
2.0/t 
 
 LITHOTOMY 
 
 unnecessary magnitude. Things being pro 
 perly determined, the lithotorne is to be held 
 in a position calculated to make a division 
 of the parts which is parallel to the cut in the 
 integuments, and, by means of the lever, the 
 cutting blade of the instrument is then to be 
 disengaged from its sheath. The surgeon is 
 next to draw the opened lithotorne towards 
 himself, in a perfectly horizontal manner, so 
 as to make the requisite division of the pros- 
 tate gland and orifice of the bladder. 
 
 As Sabatier observes, Frere Come’s me- 
 thod undoubtedly possesses all the advanta- 
 ges of the lateral operation, besides being 
 more easy than Cheselden’s plan, and most 
 of the other modes, subsequently proposed, 
 for cutting the neck of the bladder with per- 
 fect smoothness, and to a sufficient extent to 
 allow the calculus to be removed, without 
 any laceration of the parts. ( Mtdecine Ope- 
 ratoirc, T. 3, p. 199.) 
 
 There have been several objections urged 
 against the use of the lithotorne cache. 
 
 1. ft is said that the size of the incision 
 is not? always proportioned to the distance, 
 to which the knife moves out of the sheath, 
 and that the instrument, when opened to 
 No. 13 or 15, sometimes makes a smaller in- 
 cision, than when opened only to No. 5 or 
 f 7. This uncertainty is said to depend upon 
 the greater or less contraction of the bladder 
 in different subjects. 
 
 For my own part, I confess, that I am not 
 inclined to put much credit in the accuracy 
 of this last explanation, and suspect the dif- 
 ference sometimes observed must depend 
 upon the operator not taking care to draw 
 out the instrument in a horizontal direction, 
 a thing which is always easy to be done. 
 
 2. Frere Come himself made his incision 
 too high, so that an extravasation of urine in 
 the scrotum followed some of his opera- 
 tions ; but the above method of operating is 
 free from any objection of this kind. 
 
 3. Some surgical writers have exaggera 
 ted the danger of cutting the body of the 
 bladder too extensively with the lithotorne, 
 and thus producing internal hemorrhage. 
 However, this cannot happen, unless the 
 surgeon raise the handle of the instrument 
 improperly at the moment of withdrawing 
 it, and as Sabatier himself allows, it is rather 
 the fault of the operator than of the opera- 
 tic n. 
 
 4. The arteria pudica profunda and the 
 rectum, which some authors conceive to be 
 endangered, must always he in absolute 
 safety, if the edge of the knife of the litho- 
 tome be turned in the direction above re- 
 commended. 
 
 I think that for a surgeon, who under- 
 stands the right principles of lithotomy, this 
 is one of the best ways of performing the 
 operation. 
 
 When I was at Paris in 1815, I saw Dr. 
 Souberbielle operate very skilfully with the 
 lithotorne cache. A stone of considerable 
 size was extracted from a, gentleman, who 
 was, I should think, not less than 70. No 
 apprehensions were entertained of ill suc- 
 
 cess, as I understood that this operator hard- 
 ly ever lost a patient. 
 
 M. Roux, when he visited England, seems 
 not to have been informed, that at the West- 
 minster Hospital, the lithotorne cache has 
 been commonly employed for many years 
 past. It has also been sometimes used at 
 Guy’s Hospital by Sir A. Cooper. When 
 M. Roux likewise finds fault with the bad 
 construction of this instrument, as made in 
 London, I suspect, that he cannot have seen 
 those which are made and sold by Mr. 
 Evans. (See Voyage fait a Londres, ou Pa- 
 ralltle de la Chirurgie Angloist , fyc. p . 318.) 
 
 Le Cat, a surgeou of Rouen, in Norman- 
 dy, devised a mode of lithotomy which 
 would be too absurd to be described, were 
 it less renowned. He thought the neck of 
 the bladder might be dilated, like the wound, 
 and his operation was deformed with all the 
 cruelty of the Marian method, and every er- 
 ror attendant on the infant state of the late- 
 ral operation. He first introduced a long 
 wide staff; he cut forward with a common 
 scalpel, through the skin and fat, till he could 
 distinguish the bulb, the naked urethra, and 
 the prostate gland. Secondly, with another 
 knife, the urethrotome, having a groove on 
 one side, he opened the urethra, just before 
 the prostate, and fixing the urethrotome in 
 the groove of the staff, and holding it steady, 
 rose from the kneeling posture, in which he 
 performed the outward incision. Thirdly, 
 holdingthe urethrotome in the left hand, he 
 passed another knife, the cystotome, along 
 the groove of the urethrotome, and the beak 
 of the cystotome being lodged in the groove 
 of the urethrotome, it was pushed forwards, 
 through the substance of the prostate gland 
 into the bladder. Fourthly, drawing the 
 cystotome a little backwards, he gave the 
 staff to an assistant to be held steadily, and 
 lifting a blunt, gorget in the fight hand, he 
 placed the beak of it in the groove of the 
 cystotome, and pushed it onwards, till it 
 glided from the groove of the cystotome., 
 along the groove of the staff into the bladder. 
 Then, true to the principles of the apparatus 
 major, and never forgetting his own pecu- 
 liar theory, little incision, and much, dilate 
 lion, he forced his fingers along the gorget, 
 dilated the neck of the bladder, and so made 
 way for the forceps. (J. Bell's Principles , 
 Vol. 2 ) 
 
 In 1741, Le Dran described an operation, 
 the introduction of which has been claimed 
 by several since his time. A staff being in- 
 troduced, and two assistants keeping open 
 the patient’s knees, while a third stands on 
 one side of him on a chair, (Le Dran says,) 
 “ l then raise up the scrotum, and directing 
 the last assistant to support it with both 
 hands, so as to avoid bruising it, by pressing 
 it either against the staff, or the os pubis, I 
 place his two fore-fingers on each side of 
 the part, where the incision is to be made ;, 
 one of the fingers being laid exactly along 
 that branch of the ischium, which rises to- 
 wards the pubes, and the other pressed upon 
 the raphe, that the skin may be kept fixed 
 and tight. While 1 thus place the fingers of 
 
LITHOTOMY. 
 
 205 
 
 the assistant, who supports the scrotum, I 
 still keep hold of the handle of the staff, and 
 direct it so as to form a right angle with the 
 patient’s body ; at the same time taking 
 care that the end of it is in the bladder. 
 This position is the more essential, as all the 
 other instruments are to be conducted along 
 the groove of this. If the handle of the 
 staff were kept, inclined towards the belly, 
 the end of it would come out of the bladder, 
 and the gorget, missing its guide, would slip 
 between that and the rectum. 
 
 “ The staff being rightly placed, I take 
 the knife from the assistant, who holds the 
 instruments, and put it into my mouth ; 
 then pressing the beak of the staff against 
 the rectum, I feel the curvature of it through 
 the perinaeum. The incision ought to ter- 
 minate an inch and a hall below where we 
 feel the bottom of the curvature. If we do 
 not carry this incision sufficiently low, it may 
 happen not to be of a size to allow the ex- 
 traction of a large stone, and might lay us 
 under the necessity of extending it further 
 afterward, for the skin will not lacerate here, 
 nor easily give way for the passage of the 
 stone. 1 therefore begin the incision from 
 the lower part of the os pubis, continuing it 
 down to the place that I before directed for 
 its termination ; after which I pass the point 
 of the knife into the groove of the staff, and 
 cutting from below- upwards, without taking 
 the point out of the groove, I open the an- 
 terior part of the urethra as far as the inci- 
 sion that is in the skin. 
 
 “ The Leak of the staff, which w T as press- 
 ed upon the rectum, must now be raised 
 and pressed against the os pubis. At the 
 same time, I turn the handle towards the 
 right groin, that the groove, which is at the 
 beak of the staff, may face the space be- 
 tween the anus and the tuberculum isehii on 
 the left sid.e. Then carrying the point of 
 the knife down the groove, I slide it along 
 the beak, turning the edge, that it may face 
 the space between the anus and tuberosity 
 of the ischium. By this incision, I exactly 
 divide the bulb of the urethra, and by doing 
 this on its side, we are sure to avoid wound- 
 ing the rectum, w hich for want of this pre- 
 caution has been often cut. This first inci- 
 sion being made, I again pass the point of 
 the knife into the curvature of the staff to 
 the part where it bears against the peri- 
 nseum, and direct it to be held there by the 
 assistant who supports the scrotum. This 
 done, I take a large director, the end of 
 which is made with a beak, like that of a 
 gorget, and conveying this beak upon the 
 blade of the knife, into the groove of the 
 staff. I draw 1 the knife out. 1 then slide the 
 beak of this director, along the groove of the 
 staff, into the bladder, and I withdraw the 
 staff, by turning the handle towards the pa- 
 tient’s belly. The following circumstances 
 will sufficiently satisfy us, that the director is 
 introduced into the bladder; first, if itstrikes 
 against, the end of the staff, which is closed ; 
 secondly, if the urine runs along the groove. 
 I next feel for the stone with this director, 
 and having found it, endeavour to distin- 
 
 guish its size and surface, in order to make 
 choice of a proper pair of forceps ; that is, 
 one of a stronger or weaker make, or of a 
 large or small size, agreeably to that of the 
 stone ; after which I turn the groove towards 
 the space, between the anus and tuberosity 
 of the ischium, and resting it there, convey a 
 bistoury along the groove, the blade of 
 which is half an inch broad, and about three 
 quarters of an inch long. I continue the in- 
 cision made by the knife in the urethra, and 
 entirely divide the prostate gland laterally, 
 as also the orifice of the bladder; and, I am 
 very certain, that the introducing the use of 
 these two instruments, which are not em- 
 ployed by other lithotomists, does not pro- 
 long the operation a quarter of a minute, 
 but rather shortens the time, both by facili- 
 tating the dilatation, that is afterward to be 
 made with the finger, and by rendering the 
 extraction of the stone more easy. The bis- 
 toury being withdrawn, the groove of the 
 director serves to guide the gorget into the 
 bladder. I then introduce my fore-finger 
 along the gorget, (which is now easily done, 
 as the urethra and prostate, being divided, 
 do not oppose its entrance) and with it I di- 
 late the passage for the stone, in proportion 
 to the size, of w'bich I discover it to be 
 This dilatation being made, I withdraw my 
 finger, and use the proper forceps.” (Le 
 Dran's Operations, Edit. 5, 1784, London .) 
 
 Professor Pajola, of Venice, was the pupil 
 of Le Cat, and his method resembles that of 
 his master He is stated to have cut for the 
 stone 650 patients with success ; which de- 
 serves notice, because his operation has for 
 its principles, dilatation, and no division of 
 any part of the bladder. He makes an inci- 
 sion into the groove of the staff, with a lan- 
 cet-pointed, double-edged knife, called an 
 urethrotome, the blade of which has upon its 
 centre a groove, that is continued to its very 
 point, and serves to guide the beak of ano- 
 ther instrument, called the eystotome, into 
 the groove of the staff. As the professed in- 
 tention of the eystotome is only to cut the 
 prostate gland, its name is ridiculous. It 
 consists of a handle, and very slender blade, 
 which is not connected with the handle, but 
 with its sheath, by means of a little joint, 
 close to the beak of the instrument. When 
 the eystotome is opened as far as possible, 
 the end of the blade furthest from the beak, 
 is twelve lines from the sheath. In this po- 
 sition, it is held by a transverse piece of steel, 
 which admits of being pushed more or less 
 out at the option of the surgeon, and can be 
 fixed by means of a screw. Pajola, like 
 Scarpa, considers cutting the neck of the 
 bladder dangerous, and he merely divides the 
 prostate, after which he introduces a blunt 
 gorget, and along this a species of forceps for 
 dilating the neck of the bladder in all direc- 
 tions. (X. F. Rudtorffer uber die Operation 
 des Blasensleins nach Pajola' s Methode.) As 
 Langenbeck observes, great as the success of 
 this lithotomist has been, his method of ope- 
 rating has little to recommend it ; and every- 
 thing must be ascribed to his individual skill, 
 and intimate knowledge of the parts. Lan- 
 
LITHOTOMY. 
 
 206 
 
 genbeck even prefers Le Cat’s method, in 
 which there is no need of such a multiplicity 
 of instruments. The blunt gorget and dila- 
 tor are perfectly unnecessary, as the finger 
 would do the purpose of both. 
 
 In the former editions of this Dictionary, I 
 have not taken any notice of what has been 
 termed by the French, “ Operation a deux 
 temps," and which was first mentioned by 
 Franco. If, by this plan, it be intended, that 
 the incision should be made at one period, and 
 the extraction of the stone not attempted till 
 u subsequent period, I cannot too strongly re- 
 probate the practice. But, if I am to under- 
 stand, that the postponement of the comple- 
 tion of the operation is only to be adopted, 
 as a matter of necessity, when the patient 
 cannot bear the longer continuance of the 
 unsuccessful efforts to extract the stone, of 
 course, I can only say, that every endeavour 
 should be used to avoid this very disagreeable 
 dilemma, by making in the first instance an 
 adequate opening, and (if this cannot be done) 
 by breaking the calculus, and carefully remo- 
 ving all the fragments. Some further consi- 
 derations against delaying the completion of 
 the operation will be found in the 2d vol. of 
 the First Lines of Surgery. 
 
 The danger of the beak of the gorget slip- 
 ping out of the groove of the staff, is one of 
 the chief objections urged agtiinst the em- 
 ployment ot the first of these instruments, 
 in order to obviate this inconvenience, Sir 
 Charles Blicke bud the groove of the staff, 
 and the beak of the gorget, so constructed 
 that they locked into each other, and conti- 
 nued fixed till near the extremity of ttie staff. 
 The contrivance, though plausible and inge- 
 nious, is not much used : the point of con- 
 tact of the beak and body of the instrument 
 is necessarily so small, that it is liable to break. 
 It is allowed, however, that this objection 
 might be removed ; but another one is still 
 urged, viz. the beak and groove catching on 
 each other, so as to resist the efforts made to 
 introduce the gorget into the biuddei. Every 
 operator knows, that much of the satety of 
 the lateral operation, as performed at present, 
 depends on the ease with which the beak of 
 the gorget slides along (he groove of the staff. 
 Le Cat, in 1747, is said to have devised a si- 
 milar intention. 
 
 Some operators have a good deal of trou- 
 ble in dissecting into the groove of the staff. 
 Sir James Earle invented an instrument to 
 render this part of the operation more easy. 
 It consists ot a short staff, with an open 
 groove, connected by a hinge with the han- 
 dle of another staff, ot the usual size, shape, 
 curvature, and length, which may be called 
 the long staff. The hinge, by means ot pm, 
 is capable ot being disjointed at pleasure. 
 Tbe short staff is sufficiently curved to go 
 over the penis and scrotum, and long enough 
 to reach to that part ot the long staff winch is 
 just below llte beginning ot its curvature. 
 The end of the short staff, made somewhat 
 like a pen, with the sides sharpened and finely 
 pointed, is adapted to shui into tbe gioove of 
 the long staff, and its cutting edges are de- 
 fended from being injured by a proper recep- 
 
 tacle which is prepared for it in the groove 
 of the long staff. When the instrument is 
 shut, the groove of the short staff leads into 
 that of the long one, so as to form one con- 
 nect and continued groove. The short staff' 
 is rendered steady by the segment of an arch 
 projecting from the long one through it. 
 
 The long staff, separated from the short 
 one, is first introduced in the usual rnanuer, 
 and, the stone having been felt, the short staff' 
 is to be put on tbe other at the hinge. Tbe 
 incision is then to be made in the usual man- 
 ner, through the skin mid cellular membrane, 
 and a second incision through the muscles, 
 so as nearly to lay bare the urethra. The 
 operator then being perfectly convinced that 
 (lie extremiiy of (he long staff is sufficiently 
 within the bladder, must bring the end of the 
 short staff down, and press it against the 
 urethra, which it will readily pierce, and pass 
 into the cavity prepared for it in the groove 
 of the long staff. The two pieces being now 
 firmly held together by the operator’s left 
 hand, nothing remains to be done, except 
 applying the beak of the gorget to the groove 
 of the short staff*, and pushing it on till it is 
 received in the groove of the long one ; and 
 if this latter be made with a contracted 
 groove, it will just enter where the contrac- 
 tion begins, and thus must be saiely conduct- 
 ed into the bladder. ( Earle on the Stone ; 
 Appendix; Edit. 2, 1796.) Deschamps des- 
 cribes an instrument, invented by Jardaa, 
 surgeon of Montpelier, which bears a resem- 
 blance to Earle’s double staff, but was more 
 complicated, being designed to support the 
 scrotum, and also press the rectum out of the 
 way. 
 
 The late Mr. Dease, of Dublin, and Mr. 
 Muir, of Glasgow, considering that the gor- 
 get was more apt to slip from the staff’ in con- 
 sequence of the latter being curved, and that 
 its beak never slips from tbe groove of the 
 staff in operating on women, proposed, like 
 Le Dran, to convert the male into the temale 
 urethra. They introduce, as usual, a curved 
 grooved staff' into the bladder, make the 
 common incisions, and open the membra- 
 nous part of the urethra ; but -instead of in- 
 troducing a gorget on the curved staff, they 
 conduct along the groove a straight director, 
 or staff’, into the bladder, and immediately 
 withdraw the other. The gorget is then in- 
 troduced. In this manner the operation may 
 be very well performed with a narrow bis- 
 toury, as was advised by Mr. A. Burns. 
 
 LITHOTOMY, AS PERFORMED WITH A KNIFE, 
 
 INSTEAD OF A CUTTING GORGET, LY SE- 
 VERAL OF THE MODERNS. 
 
 We have alreidy described, bow Fr^re 
 Jacques and Chesclden, used to operate with 
 a knife, without any cutting gorget, in the 
 early state of the lateral operation. The 
 success which attended Uie excellent prac- 
 tice of ihe latter surgeon, certainly far ex- 
 ceeds what attends the present employment 
 of the gorget, for, out of 52 patients whom 
 he cut successively for the stone, he only 
 lost two; and out’of 213, of all age?, cm,- 
 
LITHOTOMY. 
 
 207 
 
 stitutions, (co . only 20. These facts are 
 strongly in favour of abandoning the use of 
 the gorget, and doing its office with a knife. 
 
 The objections to the gorget are nume- 
 rous and well founded. In the hands of 
 many skilful operators, its beak has slipped 
 out of the groove of the staff, and the in- 
 strument has been driven either betvveen the 
 rectum and the bladder, or into the intestine 
 instead of the latter viscus. Sir James Earle 
 remarks : (l I have more than once known a 
 gorget, though passed in the right direction, 
 pushed on so far, and with such violence, as 
 to go through the opposite side of the blad- 
 der.” Bromfield, even when operating with 
 a blunt gorget, perforated the bladder and 
 peritonaeum, so that the abdominal viscera 
 came out of the wound. (P.1270.) I now know 
 of at least three instances, in which the gor- 
 get, slipping from the staff, completely sever- 
 ed the urethra from the bladder ; the stone 
 was not taken out ; and the patients died. 
 
 We will suppose, however, that the pre- 
 ceding dangers of the gorget are surmounted, 
 as they certainly may be, by particular dex- 
 terity, seconded by the confidence of expe- 
 rience. The gorget is introduced, but what- 
 ever kind of one has been used, the wound 
 is never sufficiently large for the easy pass- 
 age of any stone, except such as are below 
 the ordinary size. Camper has noticed this 
 fact : “ Hawkensius solo conductore, cujus 
 margo dexter in aciem assurgit, idem praes- 
 tat : omnts plagam dilatant, ut calculum ex - 
 trahant : dilacerentur igitur semper vesicce 
 ostium et prostata .” (P. J 14.) Dease says : 
 
 ct In ail the trials that I have made with the 
 gorget on the dead subject, l have never 
 found the opening into the biadder sufficient- 
 ly lar^e for the extraction of a stone of a 
 middling size, without a considerable lacera- 
 tion of the parts. I have frequently taken 
 the largest-sized gorget, and could not find, 
 in the adult subject, I ever entirely divided 
 the prostate gland, if it was any way large ; 
 and in the operations that were performed 
 here on the living subject, if the stone was 
 large, the extraction was painfully tedious, 
 and effected with great difficulty ,**• and, in 
 some cases, not at all.” 
 
 I shall dismiss this part of the subject with 
 referring the reader to the spirited and cor- 
 rect remarks on the objections to the gorget 
 in Mr. John Bell’s Principles, Vol. 2. Part 2. 
 
 The latterauthor recommends the external 
 incision, in a large man, to commence about 
 an inch behind the scrotum, and to be car- 
 ried downwards three inches and a half, 
 midway between the anus and tuberosity of 
 the ischium. The fingers of the left hand, 
 which at first kept the skin tense, are now 
 applied to other purposes. The fore-finger 
 now guides the knife, and the operator pro- 
 ceeds to dissect through fat and cellular 
 substance, and muscular and ligamentous 
 fibres, till the wound is free and open, till all 
 sense of stricture is gone ; for it is only by 
 feeling opposition and stricture that we re- 
 cognize the transverse muscle. When this 
 hollow is fairly laid open, the external inci- 
 sion, which relates merely to the free extrac- 
 
 tion of the stone, is completed. If it were the 
 surgeon’s design to operate only with the 
 knife, he would now push his fingers deeply 
 into the wound, and, by the help of the fore- 
 finger, dissect from the urethra along the 
 body of the gland, till he distinguished its 
 thickness and solidity, and reached its back 
 part. Then, plunging his knife through the 
 posterior portion of the gland, and settling it 
 in the groove of the staff, he would draw it 
 firmly and steadily towards him, at the same 
 time pressing it into the groove of this instru- 
 ment, and then the free discharge of the 
 urine, assuring him that the prostate and neck 
 of the bladder were divided, he would lay 
 aside his knife, pass the left fore-finger into 
 the bladder, withdraw the staff, and intro- 
 duce the forceps. ( John Bell , p. 197.) 
 
 Mr. Charles Bell describes the following 
 method of operating with a knife, instead 
 of a gorget. A staff grooved on the right 
 side, a scalpel with a straight back, and the 
 common lithotomy forceps, are the indis- 
 pensable instruments. The staff is kept in 
 the centre, and well home into the bladder. 
 The surgeon making his incision under the 
 arch of the pubes, and by the side of the 
 anus, carries it deeper towards the face of 
 the prostate gland ; cutting near to the stall', 
 but yet not cutting into it, and avoiding the 
 rectum by pressing it down with the finger. 
 Now carrying the knife along the staff, the 
 prostate gland is felt. The point of the knife 
 is run somewhat obliquely into the urethra, 
 and into the lateral groove of the staff^just 
 before the prostate gland. It is run on, until 
 the urine flows. The fore-finger follows the 
 knife, and it is slipped along the back of it, 
 until it is in the bladder. Having carried 
 the fore-finger into the bladder, it is kept 
 there, and the knife is withdrawn. Then 
 the forceps, directed by the finger, are 
 introduced. (C. Bells Operative Surgery, 
 Vol. 1, p. 361.) 
 
 Mr. Allan Burns, of Glasgow, recommends 
 the following method : “ The plan (says he) 
 introduced by Cheselden, and revived by 
 Mr. J. Bell, I would assume, as the basis of 
 the operation ; but still, along with their 
 mode, I would blend that of Mr. Dease, by 
 which, I imagine, we may overcome some 
 of the disadvantages attendant on each con- 
 sidered individually. 
 
 u For more than twelve months, I have 
 been in the habit of showing such an ope- 
 ration, which is as simple in its performance, 
 as the one in general use, is attended with 
 less danger to the patient, permits of an in- 
 cision varying in size, according to the wish 
 of the operator, and completely prevents 
 injury of the rectum, or pudic artery. To 
 perform this operation, I introduce into the 
 urethra a common curved staff, then make 
 the usual incision into the perinaeum, di- 
 vide fully and freely the levator ani, so as to 
 expose the whole extent of the membranous 
 part of the urethra, the complete extent of 
 the prostate gland, and a portion of the 
 side of the neck of the bladder. When this 
 part of the operation is finished, I open the 
 membranous part of the urethra, and intro- 
 
L1TH0T0MV. 
 
 2u3 
 
 duce through the slit a straight or female 
 staff, with which l feel the stone, and then 
 withdraw the curved staff. This done, I 
 grasp the handle of the staff firmly in my 
 left hand, and with the right lay hold of the 
 knife. Having ascertained that the two in- 
 struments are in fair contact, l rest the one 
 hand upon the other, pressing them together, 
 and then by a steady extraction, I pull out 
 the knife and staff together, which is prefer- 
 able to drawing the knife along the staff ; 
 it prevents the risk of the one slipping from 
 the other ; it guards the bulb of the urethra, 
 and every other part from injury ; for, be- 
 tween them and the cutting instrument, the 
 staff is interposed &c. “ When introdu- 
 
 cing the knife, the side of the blade must 
 belaid flat along the fore-finger of the right- 
 hand which is to project a little beyond the 
 point. In this state the finger and knife are 
 to enter the wound, opposite the tuber 
 ischii ; but, in proportion as they pass along, 
 they are to be inclined forward, till at last, 
 with the point of the finger, the staff is to be 
 felt through the coats of the bladder, a little 
 beyond the prostate, and rather higher than 
 (he orifice of the urethra. Here the knife is 
 to be pushed, with the finger, through the 
 bladder, and when the point is fairly fixed 
 in the groove of the staff, the operation is 
 
 he judges the incision in the fneck of the 
 bladder to be too small for the easy extrac- 
 tion of the stone, he next introduces into 
 the bladder a straight probe-pointed bistoury, 
 with its side close to the forepart of his 
 finger, and its cutting edge upwards. By 
 turning this edge towards the left side, and 
 by keeping the point of his finger always 
 beyond the point of the bistoury, he may 
 safely divide, in the direction of the first in- 
 cision, as much of the prostate gland, and 
 neck of the bladder, as he shall deem neces- 
 sary.” (See Observations on Lithotomy , <^c. 
 with a Proposal for a new Manner of Cutting 
 for the Slone, by J. Thomson , M. D. one of the 
 Surgeons of the Royal Infirmary , $-c. Edinb . 
 1808.) In this small work, the reader will 
 find additional particulars. 
 
 Mr. Allan, who is a strenuous advocate for 
 using the knife instead of the gorget, directs 
 us, after laying bare the urethra, and bring- 
 ing the staff so as to form a right angle with 
 the patient’s body, to feel that the instru- 
 ment is fairly lodged in the bladder. The 
 operator is to use the fore-finger of his left- 
 hand as a director in feeling for the groove 
 in the staff, and in distinguishing the pros- 
 tate eland ; and, with this finger, he is to de- 
 press the rectum, and direct the deeper part 
 of his dissection. “ Feeling the gland, with 
 
 to be finished by the steady extraction of the point of the fore-finger of the left-hand, 
 
 both instruments.” (Man Burns , in Edin- 
 burgh Surgical Journal , No. 13.) 
 
 The knife of Cheselden does not require 
 so much violence to divide the parts as the 
 gorget does ; cannot slip in some instances 
 before, in others behind the bladder ; and it 
 will make a wound sufficiently ample for 
 the easy extraction of the stone, without the 
 least laceration. The possibility of its wound- 
 ing the rectum, Dr. Thomson thinks might 
 be obviated by employing it as follows 
 “ After having made the external incisions, 
 and divided the membranous part of the 
 urethra, in the way that it is usually done for 
 the introduction of the beak of the gorget, a 
 straight-grooved staff is to be introduced into 
 the groove of the curved staff, and pushed 
 along it into the bladder. The curved staff 
 is then to be withdraw n, and the surgeon, 
 
 and the groove of the staff in the upper part 
 of the wound, the assistant is desired to 
 steady his hand, and the operator, holding 
 his knife as he does a writing pen, his fin- 
 gers an inch and a half from the point, turns 
 up its edge towards the staff, and strikes its 
 point through the membranous part of the 
 urethra into its groove, half an inch before 
 the prostate gland. He now turns the back 
 of the knife to the staff, slides it a little back- 
 wards and forwards in the groove, that he may 
 be sure he has fairly entered ; then shifts the 
 fore-finger, with which he guidesthe incision, 
 places it under the knife, and carries always 
 before the point of it, to prevent the rectum 
 being wounded ; he then lateralizes the knife, 
 enters the substance of the prostate, is con- 
 scious ©f running the scalpel ihrough its 
 solid and fleshy substance, and judges, by the 
 
 laying hold of the handle of the straight staff finger, of the extent of the incision which he 
 with his left hand, and turning the groove now makes. The urine flow's out ; he slips 
 upwards and a little outwards, presses the his finger into the opening, withdraws the 
 back of it downwards towards the right scalpel, and gives it to an assistant, who 
 tuber ischii, and holds it steadily in that o- hands him the forceps, which he passes into 
 sition. The point of a straight-backed seal- the bladder, using the fore-finger of his left- 
 pel being now introduced into the groove of hand, which is still within the wound, as a 
 the staff, with its cutting edge inclined up- conductor. The forceps instantly encoun- 
 wards and a little outwards, is to be pushed ter the staff, w hich serves to conduct them 
 
 gently forwards into the bladder. The size of 
 the scalpel need only be such as will make a 
 wound in the prostate gland and neck of 
 the bladder, sufficiently large to admit the 
 fore-finger of the left-hand. The scalpel 
 being removed, this finger is lo be introduced 
 into the bladder, through the wound which 
 has been made, and the staff may then be 
 withdrawn. With the finger the surgeon 
 endeavours to ascertain the size and situa- 
 tion of the stone. If. after this examination, 
 
 safely into the bladder, while the finger guides 
 them through the wound ; &c.” (Allan on 
 Lithotomy, p. 48, Edinb. 1808.) 
 
 1 leave the reader to judge, which of the 
 foregoing modesof operating with a common 
 knife claims the preference. Perhaps Chesel- 
 den’s manner, which is also Mr. John Bell’s, 
 is as deserving of recommendation as any. 
 
 The methods of operating with a knife, as 
 practised by Klein and Langenbcck, I shall 
 not here repeat, as they were described in tlw 
 
LITHOTOMY 
 
 209 
 
 last edition of the First Lines of Surgery, ac- 
 companied with many valuable practical 
 observations made by these judicious and 
 skilful surgeons. 
 
 That the performance of lithotomy with a 
 knife, when the operator has ihe assistance 
 of a proper staff, cannot be difficult, may 
 be inferred from there being no particular 
 difficulty in the method, even when no staff 
 at all is employed. In the spring of the 
 year 1814, when at Oudenbosch in Holland, 
 I was requested by Sergeant Ryan, of the 
 1st Foreign Veteran Battalion, to see his 
 little boy, about four years old, who was 
 troubled with symptoms, which made me 
 immediately suspect, that there was a stone 
 in the bladder. As I had no sound, I in- 
 troduced into this viscus a small silver cathe- 
 ter, which distinctly struck against a cal 
 cuius. Without taking the instrument out 
 again, I determined to perform lithotomy 
 with a common scalpel. Indeed, no other 
 mode could be adopted, as we had neither 
 staff, gorget, nor lithotomy instruments of 
 any kind. After making the external part 
 of the incision in the common way, I found 
 that the catheter afforded me no guidance. 
 I therefore withdrew it, and dissected deeply 
 by the side of the prostate gland, till the 
 fore-finger of my left hand passed rather be- 
 yond it. The scalpel was then plunged into 
 the bladder, behind this gland, under the 
 guidance of my left fore-finger, and with the 
 edge turned towards the urethra. The ne- 
 cessary division of the prostate and neck of 
 the bladder was then made by cutting in- 
 wards and upwards in the direction of the 
 rest of the wound. With a small pair of 
 ordinary dressing forceps, a calculus, rather 
 larger than the end of the thumb, was easily 
 extracted. This operation was done at the 
 Military Hospital, in the presence of Dr. 
 Shanks of the 56th regiment, and several 
 other medical officers. Not a single bad 
 symptom ensued, although the army unex- 
 pectedly moved into the field three days 
 afterward and the child travelled about for 
 some time in a baggage cart, in an exposed 
 and neglected state. The wound was conse- 
 quently rather longer in healing than usual ; 
 but, this was the only ill effect. The little 
 boy in the end completely recovered. 
 
 Of late years, many surgeons have chosen 
 to perform lithotomy with several kinds of 
 beaked scalpels. The practice, indeed, is 
 still gaining ground. Mr. Thomas Blizard’s 
 knife is one of the best. Its blade is long, 
 straight, and narrow, and, like the gorget, is 
 furnished with a beak, by means of which it 
 admits of being conducted along the groove 
 of the staff into the bladder, after the ex- . 
 ternal incisions have been made. The staff 
 is then withdrawn, and the operator has now 
 the power of making the incision through 
 the prostate and neck of the bladder down- 
 wards and outwards to any extent, which 
 the parts w'ill allow, or the case require. 
 This is one of the principal advantages 
 which beaked long narrrow knives have over 
 gorgets, which, after their introduction, can- 
 not be further used for the enlargement of the 
 
 Vojl If 27 
 
 wound. The narrow knife will also cut more 
 safely dow awards and outwards than any gor- 
 get ; nor is it subject to the serious danger of 
 slipping away from the staff, and going we 
 know not where ; because the moment its beak 
 and extremity have entered the bladder, the 
 staff is no longer necessary, as the proper 
 extent of the blade will then readily pass in 
 without the aid of any conductor at all. I 
 need hardly observe, also, that, in this 
 method, we have nothing like the perilous 
 and violent thrust of the gorget, which, in 
 the event of a lMle unsteadiness in the ope- 
 rator’s hand, or of any fault either in the 
 position of the staff, or the direction of the 
 gorget, will do irremediable and fatal mis- 
 chief. 
 
 A FEW GENERAL REMARKS ON THE BEST 
 
 MODE OF MAKING THE INCISION IN, THE 
 
 LATERAL OPERATION : AND SOME REFLEC- 
 TIONS ON THE PRINCIPLES INCULCATED BV 
 
 PROFESSOR SCARPA. 
 
 Perhaps of all the great operations in sur- 
 gery, lithotomy is that, in which great awk- 
 wardness, mortifying failures, and dangerous 
 blunders, are most frequently observed. 
 Many a surgeon, who contrives to cut off 
 limbs, extirpate large tumours, and even tie 
 aneurismal arteries, w'ith eclat , cannot get 
 through the business of taking a stone out 
 of the bladder in a decent, much less, a 
 masterly style. This fact is so familiarly 
 known in the profession, and its truth so ofteii 
 exemplified, that I may well be excused the 
 unpleasant task of relating in proof of it all 
 the disasters, which have come to my own 
 personal knowledge. But. I must take the 
 liberty of remarking, that, in this branch of 
 surgery, a great number of individuals d» 
 not profit by these instructive lessons of ex- 
 perience. The more they see of lithotomy, 
 the more they are convinced of its dangers ; 
 yet, too often, instead of studying the causes 
 of ill success, they merely derive from the 
 examples before them, a suspicion of the un- 
 skilfulness of the operator, or some dis- 
 couraging conjectures about the difficulties 
 of the operation. 
 
 The establishment of certain prineiplesto 
 be observed in lithotomy, appears the most 
 probable way of diminishing the frequency 
 of the accidents and failures of this common 
 operation. If these principles are not viola- 
 ted, it is of less consequence what instru- 
 ment is employed, for the surgeon may do 
 nearly the same thing with an ordinary dis- 
 secting knife, a concealed bistoury, a beaked 
 Scalpel, or a well-made gorget. 
 
 After the very opposite principles, and 
 different methods of cutting for the stone, 
 which are explained in the preceding 
 columns, as preferred by different surgeons, 
 
 I think it maybe useful to offer a few gene- 
 ral observations on the proper direction and 
 size of the incision. These points, which 
 are of the highest practical consequence, in 
 regulating the principles, w hich ought to be 
 observed in lithotomy, are far from being 
 Settled, as must be plain to every body wbo 
 
LITHOTOMY. 
 
 210 
 
 recollects that Desault, Mr. John Bell, Klein, 
 and Langdenbeek, have recommended a 
 free opening ; Scarpa, Callisen, and others, 
 a small one ; that Mr. Ahernetby and Scarpa 
 employ gorgets, which cut upwards and 
 outwards, at angles of 45° and 69° from the 
 axis of the urethra ; and t hat the gorgets of 
 of Cruickshank, B. Beil, Desault, Mr. Cline, 
 and most other surgeons arp constructed for 
 cutting either directly outwards, or outwards 
 and inwards. 
 
 It appears to tne, that the incision, through 
 the whole of the parts cut in lithotomy, 
 should always be made in a straight, regular, 
 direct manner, from the surface of the skin 
 in the perinasurn to the termination of the 
 wound in the urethra and bladder. In an 
 adult subject, trie external wound should 
 commence about an inch above Ihe anus. 
 The impropriety of beginning it higher up 
 has been duly insisted upon bv Sharp, Ber- 
 trandi, Callisen, and every g.fod writer on 
 the operation. “ II ne faut couper I’uretre 
 que le nioins, qu’on peut, parcequ’on obtient 
 par ce moyen one meilleure voie pour pene- 
 trer dans la vessie sous Tangle du pubis. 
 C'est avec raison que Sharp dit que I’incision 
 de 1’uretre faite au dessus de cet angle est si 
 peu utile pour l’extraclion de la pierre, qu’on 
 n’en retireroit pas plus d’avantage en le r ou- 
 pant presque dans toute sa longueur.” ( Ber - 
 trandi, TraiUdes Operations, p. 127.) And 
 Callisen lays it down as a maxim : “ Ut pffl 
 partes baud sectione attingan'ur, quae pro 
 calculi egressu nihil faciunt ; adeoque bulbus 
 urethrae, et hujus pars norpore spongioso cir- 
 cumdata intacta relinquatur.” (Sy sterna Chi- 
 rurgice Ilodiernce ; Pars Posterior ; p.655.) 
 
 Extraordinary as it may seem, it i3 not the 
 less true, that cutting too much of t ie ure- 
 thra is one of the most common faults still 
 committed by modern surgeons. The inci- 
 sion in the integuments is to be large, that is 
 to say, at least, three inches in length in an 
 adult subject, because a free opening in the 
 skin is not only exempt from danger, but at- 
 tended with many advantages, especially 
 those of facilitating the other steps of the 
 operation, and preventing any future lodg- 
 ment and effusion of urine. The external 
 wound ought to be directed towards a point 
 situated a very little towards the anus, from 
 the innermost part of the tuberosity of the 
 ischium. From the line, thus made, the in- 
 cision should he carried inward and upward, 
 through all the parts between it and the side 
 of the prostate gland. Another line, extend- 
 ing from the inferior angle of the wound to 
 the termination of the cut in the bladder, 
 forms the precise limits, to which the depth 
 of the incisions should reach, and no further. 
 
 The great principle of making the axis of 
 the wound as straight and direct as possible, 
 should always be kept in view, whether the 
 surgeon employ a common scalpel, which 
 cuts into the bladder, from without inwards, 
 or other instruments, which divide the pros- 
 tate gland, and neck of the bladder, from 
 within outwards, like the bistoire cache, 
 beaked knives, and every kind of cutting 
 gorget Tn the latter circumstance, the only 
 
 difference consists in cutting, from the blad- 
 der and urethra, downwards and outwards 
 towards a point , situated a little way more in- 
 wardly than the tuberosity of the ischium, 
 instead of carrying the incision from this 
 point, upwards and in wards, through the side 
 of the prostate gland and the orifice of the 
 bladder. The following may be enumerated 
 as important advantages of attending to the 
 foregoing principle : 
 
 1. The wound is made in that direction, 
 which affords the greatest room for the ex- 
 traction of large stones; and the axis of the 
 incision being also as nearly straight as pos- 
 sible, the introduction of forceps, and the 
 passage of the calculus outward, are mate- 
 rially facilitated. 
 
 Thai these are important advantages, I 
 think every surgeon will allow, who knows 
 bow much the pain and danger of lithotomy 
 depend upon the injury which the parts 
 suffer from the force sometimes used in the 
 extraction of the stone, and the repeated in- 
 troduction of the forceps. Cheselden, the 
 most successful lithotornist England ever 
 produced, made the incision in the direction 
 here recommended, sometimes inward and 
 upward ; sometimes outward and downward. 
 The following remarks of another excellent 
 surgeon merit particular attention : — J’ai vu 
 plusieurs fois dans les H6spitaux de Paris, 
 que les Chirurgiens, coupant tiop en haul 
 vers I’angle du pubis, sentoient une grand 
 resistance au perine, quand ils vouloient re- 
 tirer le calcul avec les lenettes ; on voyoit le 
 p6rin6 se tum6!ier par la pression, qu’y faisoit 
 la pierre ; en ce cas, quelques operateurs 
 plussages abandonnoient la pierre, introduis- 
 oient de nouveau le gorgeret, et en tournant 
 en dessous la cannelure de celui ci, prolonged 
 em I’incision obliquernent vers la tuberosite 
 de l’os isohion ; et erifin a la faveur de cetle 
 plus grande ouverture, retiroient la pierre 
 sans causer de deonirernens.” ( Berirandi , 
 Traiti des Operations , p. 133.) Larger 
 stones may likewise be thus extracted, with- 
 out being broken, than in any other mode of 
 making the lateral incision, as must be ob- 
 vious to every practitioner, who recollects 
 the very limited room, afforded at the upper 
 part of the triangular space, between the 
 arch of the pubes, the ramus of the ischium, 
 and the neck of the bladder. This conside- 
 ration cannot fail to have great weight with 
 all surgeons, who feel duly convinced, how 
 unsatisfactory a method it is to break a cal- 
 culus, in order to get it out of the bladder 
 The measures necessary for the removal of 
 all the fragments protract the completion of 
 the operation, and seriously increase its dan- 
 ger; while the continuance of a single part 
 ' of the stone behind may cause a renewal of 
 all the grievances, for the cure of which the 
 patient submitted to the operation. By these 
 remarks, however, I am far from meaning to 
 say, that large calculi should nut be broken ; 
 on the contrary, my only wish is, that the 
 necessity for the practice may be avoided, 
 as much as possible, by making a free inci- 
 sion into the bladder, and even enlarging the 
 opening, if necessary, as far ns can be done 
 
LITHOTOMY. 
 
 211 
 
 with safety, in snort, instead of breaking 
 the stone, I prefer the practice of Mr. Marti- 
 neau, of Norwich, perhaps the most success- 
 ful lithotomist now living in this country, as 
 out of 84 patients, whom he has cut, only 
 two have died ; a statement highly favourable 
 to operating with a knife, and making an 
 adequate opening. “ Should the stone be 
 large, or there be any difficulty in the ex- 
 traction. rather than use much force, while 
 the forceps have a firm hold of the stone 
 (says Mr. Martineau,) I give the handles to 
 an assistant, who is to draw them outwards 
 and upwards, while the part forming the 
 stricture is cut ; which is easily done, a3 
 the broad part of the blade becomes a 
 director to the l^nife ; and rather than lace- 
 rate, I have often repeated this enlargement 
 of the inner wound two or three times.” 
 (See Med. Ckir. Trans. Vol. 11, jj. 411.) The 
 great advantage of the knife over the gorget, 
 and even the necessity of employing it for 
 adapting the size of the opening in the blad- 
 der to the magnitude of the stone, or its 
 fragments, are most convincingly exemplified 
 in several cases recently put upon record. 
 Thus Klein, with the aid of a common 
 scalpel, extracted a calculus, which weighed 
 twelve ounces, thirty grains ; and the patient 
 recovered. ( Pract . Ansichten Bedeutendsten 
 Operationen , H. 1.) In 1818, M . Mayo, of 
 Winchester, operated with a knite, and 
 extracted a calculus, which broke in the for- 
 ceps, weighing fourteen ounces, two drachms, 
 a voirdupoise, and the patient recovered. 
 (See Med. Chir. Trans. Vol. 11, p 54, fyc.) 
 Mr. W. B. Dickenson, of Macclesfield, aim 
 succeeded with Mr. Gibson's knife, in taking 
 out of the bladder a calculus, the fragments 
 of which v\ eighed eight and a half ounces, 
 and the patient was saved. ( Vol.cit.p . 61.) 
 An I in the same volume may be seen other 
 instances, in which immense calculi were 
 removed from the bladder with various re- 
 sults, but particularly one which weighed 
 sixteen ounces, and which Sir A. Cooper 
 could not succeed in breaking : he was 
 therefore obliged to enlarge the wound, first 
 made with the gorget >l to the sacro-sciatic 
 ligament,” when with the aid of a hook 
 applied to the forepart of the stone behind 
 the pubes, and the simultaneous assistance 
 of the forceps, he succeeded with consider- 
 able difficulty in removing thi immense 
 mass. The patient lived, however, only four 
 hours after the operation. (See Med '. Ckir. 
 Trans. Vol. 11, p. 73.) 
 
 2. The arteria pudica profunda can never 
 be injured, because the surgeon does not let 
 the knite, or gorget, approach nearer to the 
 ischium, than a point which is situated a lit- 
 tle way from the tuberosity of that bone to- 
 wards the anus; and consequently the edge 
 of the instrument cannot come into contact 
 with the inside of the tuberosity and ramus 
 of the ischium where the great pudic artery 
 is situated. 
 
 3. The rectum will not be wounded, 
 because the direction of the axis of the inci- 
 sion, either downwards and outwards to 
 the above-mentioned point, or from that 
 
 point inwards and upwards, sufficiently 
 removes the edge of the knife, or gorget, 
 from the intestine. But, the rectum will be 
 in still greater safety, if it be pressed down- 
 ward with the fore-finger of the left-hand in 
 the wound, and the prudent custom of emp- 
 tying it, by means of a clyster, a short time 
 before the operation, he not omitted ; for, no 
 lithotomist should ever forget, that, when 
 this bowel is considerably distended with 
 feces, it rises up a little way on each side of 
 the prostate gland. 
 
 4. As the seminal duct penetrates the lower 
 part of the substance of the prostate gland, 
 in order to reach the urethra, and the knife, 
 or other instrument, employed, divides the 
 upper portion of the side of that gland in- 
 ward and upward, or outward and down- 
 ward, it is obvious that the duct will not be 
 in the least danger of. being cut. 
 
 The judicious Callisen is well aware of 
 the advantages of making a smooth, even, 
 direct incision into the bladder ;* but, like 
 Professor Scarpa, he is averse to making a 
 free cut through the neck of that viscus. In- 
 deed, as we shall presently notice, Scarpa 
 does not sanction cutting any portion of 
 the bladder at all. 
 
 Every practitioner, who will take the 
 trouble to look ove the history of the late- 
 ral operation, will find, that the greater num- 
 ber of lithotomists, who have particularly 
 distinguished themselves by their unparallel- 
 ed success, as Frere Jacques, Cheselden, 
 Cosme, Mr. Martineau Dr. Souberbielle, 
 &tc. m tde a free incision into the bladder. 
 This fact alone is enough to r ise doubts of 
 the goodness of the advice delivered upon 
 this subject by Callisen and Scarpa ; espe- 
 cially, as neither they, nor any other modern 
 surgeon (with the exception, perhaps, of 
 Pajola, who-e individual skill is said by 
 Langenb'wk to make amends for the disad- 
 vantages of his method.) can boast of having 
 cut patients for the stones with a degree of 
 success at all equal to that of the above-men- 
 tioned operators. The extraordinary success 
 which characterized Cbeselden’s practice we 
 1 ^ve already detailed in this volume. The 
 accounts, which we nave, of the successful 
 operation done by Frere Jacques and Cosme, 
 are equally remarkable. 
 
 Mr. Martineau, as I have noticed, has lost 
 hut two patients out of 84, on whom he has 
 operated, and this without making any se- 
 lection, as he never rejected any one who 
 was brought for operation. Mis patients 
 were always kept a week in the house be- 
 fore operating ; and this precaution, with a 
 regulated diet, and perhaps a dose or two of 
 opening medicine, was the only preparatory 
 treatment. (Med. Chir. Trans. Vol. 11, p. 
 409.) 
 
 During my stay at Paris, in 1815, I saw 
 Dr. Souberbielle extract a stone of consider- 
 
 *„Vulnus sit equate, hand angtilatum, conicae figu- 
 vae. apice vesicam respiciente, externa pla'ga ampa > 
 et quatuor pollicum longitudine, mideeflluxus sangui- 
 nis, puris, loth, arena?, facilitatur. See Systema Ohi- 
 rurp-iae Hodiernse ; Pars Posterior, p 660. fctafnias, 
 1800. 
 
LITHOTOMY. 
 
 a 2 
 
 able size, on the plan of his well-known an- 
 cestor. The incision was ample and direct, 
 so that the calculus was taken out with per- 
 fect ease. Now, as the operations of this 
 professed lithotomist are very numerous, and 
 lie enjoys the reputation of scarcely ever 
 losing a patient, are we not justified in in- 
 ferring, that the advocates for a small open- 
 ing are promulgating the worst advice which 
 can be offered to the practitioner? My own 
 observations certainly tend to such a con- 
 clusion as will be presently explained. The 
 tract recently published by Scarpa (Memoir 
 on the Cutting Gorget of Hawkins , tyc. trans. 
 by Briggs ,) has for its main objects the ie- 
 commendation of a modification of Haw- 
 kins’s gorget, audit he inculcation ol the pro- 
 priety of making a small limited incision in 
 the prostate gland, without cutting any 
 part of the bladder. As sufficient room can 
 not thus be obtained for the extraction of 
 even a stone of moderate size, he is an ad- 
 vocate for the gradual dilatation of the ure- 
 thra and orifice of the bladder. He observes, 
 that the lateral operation, though executed 
 with the greatest precision, does not exempt 
 the surgeon from dilating in a certain degree 
 the orifice of the bladder, and cervix of the 
 urethra, the dilatation of those parts, how- 
 ever moderate, being always necessary even 
 where the calculus is of middling size. He 
 states, that, in the adult, the orifice of the 
 bladder dilates almost spontaneously to the 
 diameter of five lines ; and he adds, that the 
 lateral incision, within proper limits, divides 
 the body and base of the prostate gland to 
 the depth of four, or, at most, five lines, 
 forming with the five, to which the orifice 
 of the bladder naturally yields, an apertu/e 
 of ten lines. But, says Scarpa, in an adult, 
 a stone of ordinary size and oval figure is 
 sixteen lines in the small diameter, to which 
 must be added the thickness of the blades of 
 the forceps : consequently, even after the 
 incision has been made with the most scru- 
 pulous exactness, the stone, though of mode- 
 rate size, cannot pass out of the bladder, un- 
 less the dilatation of the base of the gland 
 and orifice of the bladder be carried to the 
 extent of nearly eight lines, beyond the size 
 of the aperture made with the knife. But, 
 says Scarpa, if, in order to avoid distending 
 the parts to the extent of eight lines, the base 
 oi the prostate gland, together with the 
 orifice of the bladder, and a part of its lun- 
 dus, be divided to a depth equivalent to it, 
 the event would necessarily be an effusion of 
 urine into the cellular membrane, between the 
 rectum and bladder, and consequently suppu- 
 ration, gangrene, Jislulce, and other serious 
 evils. (Page 4, 5.) 
 
 According to Scarpa, the apex of the 
 prostate gland forms the greatest resistance 
 t.> the introduction of the forceps and the 
 extraction of the stone, and, therefore, 
 ought to be completely divided ; (P. 7 ) 
 but, he contends, that two, and sometimes 
 three, lines of the substance of the base of 
 the gland, should be left undivided ; which, 
 be asserts, is a matter of great importance, 
 because the untouched portion, around the 
 
 orifice of the bladder, prevents the effusion, 
 of urine, and the formation of gangrene, or 
 fistulae, between that part and the rectum 
 (P. 22.) 
 
 After this statement of one of the great 
 principles, which Scarpa wishes to be ob- 
 served in the performance of the lateral 
 operation, a question or two naturally arise. 
 Are we then to conclude, that the plan of 
 making a free and direct incision into the 
 bladder ought to be abandoned ? Must we 
 forget, that it is this method, which has an- 
 swered so well in the hands of Cheselden 
 and the several renowned lithotomists al- 
 ready enumerated ? And must we believe, 
 that the advice delivered upon this point by 
 Bertrandi, Desault, Mr. John Bell, and all 
 the best modern surgeons in this country, is 
 founded only upon a capricious partiality to 
 the free use of cutting instruments ? 
 
 Earnestly as I respect the names of a Cal- 
 Jisen and a Scarpa, their authority cannot 
 influence me further, than I find it coincide 
 with the dictates of experience, — the great 
 arbitrator of every disputed point in practice. 
 
 We have seen, that an apprehension of 
 effusion of urine, gangrene, fistulae, he. is 
 the only reason assigned by Scarpa for his 
 aversion to making a complete division of 
 the side of the prostate gland, and orifice 
 of the bladder. But, I would inquire, do 
 we find extravasation of the urine, between 
 the rectum and bladder, and gangrene, and 
 fistulae, so frequent after lithotomy in Eng- 
 land, as to render it probable, that these ill 
 consequences can ever proceed from our 
 usual mode of dividing completely, not only 
 the side of the prostate gland, but also the 
 adjoining part of the bladder? Are such 
 bad effects so often experienced in this coun- 
 try, as to constitute a material source of un- 
 easiness in the mind of a surgeon about to 
 undertake lithotomy ? Do they form a sub- 
 stantial reason for abandoning the inaxim of 
 always endeavouring, as far as circumstances 
 will allow, to make an incision of sufficient 
 size for the easy removal of the calculus ? 
 And, would not Scarpa’s method of stretch- 
 ing and dilating the wound, in order to get 
 the stone out of the bladder, often danger- 
 ously prolong the operation; lead to much 
 mischief from the repeated use of the for- 
 ceps ; cause serious contusion and lacera- 
 tions of the parts ; and, for all these reasons, 
 render inflammation of the bladder and pe- 
 ritoneum very likely to follow ? 
 
 In the course of the twenty-four years 
 that I have been in the profession of surge- 
 ry, I have seen the lateral operation perform- 
 ed an immense number of times, either 
 with various kinds of gorgets, beaked knives, 
 the lithotomie cache, or common scalpels. 
 In all these examples the avowed intention 
 of the surgeon was to make a free opening 
 into the bladder. 1 do not mean, however, 
 to say, that this was always actually accom- 
 plished, since the bad construction of the 
 instruments employed, and other causes, 
 sometimes frustrated the wise design of the 
 operator. But, what was the consequence ? 
 Generally speaking, those surgeons who 
 
LITHOTOMY. 
 
 made only a small incision into the bladder, 
 and kept their patients a long while upon 
 the operating table, ere they succeeded in 
 getting out the stone, by the repeated and 
 foicibleuse of the forceps, had the mortifi- 
 cation to see very few of their patients re- 
 cover : a large proportion of them being 
 carried off by peritonitis, on the third or 
 fourth day after the operation. 
 
 On the contrary, when the incision was 
 ample and direct, so that the calculus could 
 be easily and gently removed, the patients 
 were almost always saved. 
 
 During the first six or seven years of the 
 long time during which I have enjoyed fre- 
 quent opportunities of seeing lithotomy per- 
 formed in St. Bartholomew’s Hospital, gor- 
 gets were invariably used, most of which 
 instruments made an insufficient opening. 
 The consequence was, that many of the 
 patients were detained a long while upon 
 the operating table, before the stone could 
 be extracted, and some considerable num- 
 bers were lost by peritonitis. Of late years, 
 however, in the same institution, common 
 scalpels and beaked knives have been often 
 used ; a freer opening has been generally 
 made ; and the proportion of deaths from 
 peritonitis is strikingly lessened. 
 
 The following observation, made by Mr. 
 Martineau, is also worthy of particular at- 
 tention : — “ In the first years of my prac- 
 tice,” says he, “ I was not very successful ; 
 and often witnessing many untoward circum- 
 stances in myself and others, which appeared 
 to arise from the use of the cutting gorget, 
 
 1 determined to lay that instrument aside, 
 and employ the knife only, and the blunt 
 gorget as a conductor for the forceps.” (Med. 
 Chir. Trans,, p. 405.) 
 
 Now, when we remember that this gentle- 
 man has lost only two out of eighty-four 
 patients, on whom he has operated, his re- 
 marks are of great importance ; and his 
 cases, and the other facts, which I have spe- 
 cified, strongly impress my mind with the 
 truth of all that I have urged, respecting 
 the advantages of making the opening large, 
 and in the best direction for the easy pas- 
 sage of the stone outward. 
 
 In Mr. Martineau’s manner of operating, 
 it is true, he does not make the external 
 wound parallel to that in the bladder, as I 
 venture to recommend, but directs it nearly 
 in a line with the raphe ; a circumstance 
 which may, perhaps, account for his continu- 
 ing the use of the blunt gorget as a conduc- 
 tor for the forceps. Neither is his internal 
 incision carried downwards and outwards, 
 as Bertrandi, Desault, and many other judi- 
 cious surgeons consider most advantageous. 
 But these defects (if I may presume to call 
 them so) are i-endered of less consequence 
 by the rule, which Mr. Martineau observes, 
 of making his first incision long and deep , and 
 avoiding all stretching and laceration of the 
 parts. Like Langenbeck (See First Lines of 
 Surgery, Vol. 2,) he uses a-staff, the groove of 
 which is much wider and deeper than usual, 
 and therefore more easily felt. This instru- 
 ment his assistant holds, in the way preferred 
 
 2io 
 
 by Scarpa, nearly in an upright straight 
 direction. “After the first incision (says 
 Mr. Martineau) I look if the stall’ is not al- 
 tered in its situation, and then feeling for the 
 groove, I introduce the point of the knife 
 into it, as low down as I can, and cut the mem- 
 branous part of the urethra , continuing my 
 knife through the prostate into the bladder .,* 
 when , instead of enlarging the wound down- 
 wards, and endangering the rectum, I turn 
 the edge of the blade towards the ischium, and 
 make a lateral enlargement of the wound in 
 withdrawing the knife." (See Med . Chir. 
 Trans. Vol. 11, p. 409.) This description is 
 particularly interesting, as coming from a 
 gentleman, who has had so much experience 
 and success; and its value would have been 
 increased, had the direction in which the 
 edge of the knife was turned in the division 
 of the prostate gland, been exactly speci- 
 fied. 
 
 With respect to the degree of importance* 
 which ought to be attached to the fear of 
 effusion of urine, between the bladder and 
 rectum, gangrene, fistulae, &c., I can only- 
 say, that they are inconveniences which are 
 not commonly observed after lithotomy in 
 this country. In two or three instances only 
 I have known the urine come through the 
 wound longer than usual, and these cases 
 ended well. As for the extravasation of 
 urine and sloughing, I shall merely remark, 
 that although there cannot be a doubt of 
 their occasional occurrence, they have not 
 taken place after any of the numerous ope- 
 rations, with the results of which 1 have 
 been acquainted. 
 
 All these facts and considerations, there- 
 fore, incline me to doubt whether the appre - 
 hension of the effusion of urine, fistulae, 
 &c. be sufficiently serious and well-founded 
 to make it adviseable for surgeons to relin- 
 quish the plan of making a complete division 
 of the side of the prostate gland, and neck of 
 the bladder, in the operation of lithotomy. 
 Nor is it at all clear to my mind, that effusion 
 of urine and sloughing are likely to be the 
 effect of practising a free opening. Indeed, 
 whenever they do happen, I believe they 
 proceed from a totally different cause, viz, 
 from the incision in the skin being too small 
 and too high up, and from the axis of the 
 internal part of the incision not correspond- 
 ing with that of the external wound. Hence 
 the urine does not readily find its way out- 
 ward, and some of it passes into the neigh- 
 bouring cellular membrane. 
 
 In confirmation of the foregoing remarks, 
 I beg leave to cite the sentiments of one 
 of the greatest and most experienced of 
 modern surgeons. Speaking of the defects 
 of Hawkins’s gorget, Desault observes, “ La 
 methode de l’enforcer horizontalement dans 
 la vessie sur la catheter tenu h angle droit 
 avec le corps, a deux grands desavantages : 
 d’un cote celui de p^netrer par l’endroit le 
 plus retreci du pubis, et par consequent de 
 ne faire que difficilement une ouverture 
 suffisante; d’un autre cote, celui de ne pas 
 etablir de parallelisme entre l’incision exte- 
 rieure des teguraens qui est oblique et celle 
 
LITHOTOMY. 
 
 214 
 
 du col de la vessie et de la prostate, qui sc perceptible through the thin parietes ot the 
 trouve alors horizontale. De-Ik la possibi- rectum and bladder While the latter instru- 
 
 lite des infiltrations par les obstacles qui les 
 urines trouveront k s’ecouler.” 
 
 No doubt also some of the worst, and most 
 dangerous urinary extravasations after li- 
 thotomy. have proceeded from another 
 cause, pointed out by the same excellent 
 surgeon. “ Imprudemment port6 dan:> la 
 vessie, le gorgeret peut alier par le stylet 
 beaueoup trip long qui le term ie, heurier, 
 dechirer, perforer merae la '/embrane de la 
 vessi -, et donner iieukdes infiltrations d’au- 
 tant plus daugereuses, que le lieu d’ou elles 
 partent est plus inaccessible. Cet accident 
 est surtout k craindre, lorsque, comtne les 
 Anglais, on se sert de catheter sans cul-de- 
 sac.” (See (Euvres Cliir. de Desault par Bi- 
 chat, T. 2, p. 460, 461.) 
 
 LITHOTOMY THROUGH THE RECTUM. 
 
 This method may be said to have been 
 first suggested in a work published at Bkle, 
 in the 16th century, by an author who assu- 
 med the name of Vegetius : “ Jubet per vul- 
 nus recti intestini, et vesicse aculeo lapidem 
 ejicere,” says Haller, in speaking of this wri- 
 ter. (Bibl. Chir. Vol. 1, p. 102.) But the 
 proposal never received much attention un- 
 til the year 1S16, when M. Sanson, in 
 France, gave an account of this manner of 
 operating, and urged several considerations 
 in favour of the practice. In that country, 
 however, the operation has been performed 
 only by Dupuytren, and, though the opera- 
 tion proved successful, the other French 
 surgeons do not appear »o have imitated 
 him. Nor am 1 aware, that Dupuytren him- 
 self now continues the practice. Almost as 
 soon as this method was heard of on the 
 other side of the Alps, it was put to the test 
 of experience by Barbantini, in a case where 
 every other plan of operating appeared hard- 
 ly practicable. The connexion of the ure- 
 thra with the rectum, prostate gland, and 
 posterior part of the bladder, (says M. San- 
 son) made me easily perceive, that by divi- 
 ding the sphincter ani and some of the rec- 
 tum near the root of the penis, I should x 
 pose, not only the apex of the prostate 
 gland, but a more or less considerable por- 
 tion of this body, and that I should then be 
 able to penetrate into the cavity of the blad- 
 der, either at the neck through the prostate, 
 or at its posterior part,” It was the latter 
 method, which M. Sanson first tried upon 
 the dead subject. The body was placed in 
 the position usually chosen for the common 
 ways of operating, and a staff was introdu- 
 ced, and held perpendicularly by an assist 
 ant. A bistoury, with its blade kept flat on 
 the left fore-finger, was now introduced into 
 the rectum, and the edge being turned up- 
 wards, M Sanson, with one stroke, in the 
 direction of the raphe, cut the sphincter ani, 
 and the lower part of the rectum. The bot- 
 tom of the prostate gland being thus expo- 
 sed, the finger was next passed beyond its 
 solid substance, where the staff was readily 
 
 ment was steadily maintained in its original 
 osition, M. Hanson here introduced the 
 nife into the bladder, and, following the 
 groove of the staff, made an incision about 
 an inch in length At this instant, the flow 
 of urine from the wound indicated that the 
 bladder liad had an opening made in it. On 
 examination, the parts divided were found 
 to be the sphincter, the lower part of the 
 rectum, the back part of the prostate, and 
 the adjacent portion of the bladder. Ano- 
 ther mode, contemplated by M. Sanson, 
 was. after dividing the sphincter ani, to cut 
 the termination of the membranous part of 
 the urethra along the groove of the staff 
 held perpendicularly, and by the same gui- 
 dance to expend the incision in the median 
 line through the prostate gland and neck of 
 the bladder. 
 
 In Barbantini’s case, the calculus was so 
 large, that it made a considerable promi- 
 nence in the rectum, where it was felt ex- 
 tending across from one tuberosity of the 
 ischium to the other. On account of its 
 size, its extraction by the lateral operation 
 was considered impracticable, and, as it was 
 not thought adviseable or easy to break 
 such a mass, and Barbantini regarded the 
 high operation as more, difficult and uncer- 
 tain in its results than the common method, 
 it was determined to operate through the 
 rectum. The attempt w T as delayed some 
 days, by the impossibility of introducing 
 effectually the staff', which was stopped at 
 its entrance into the bladderby the calculus. 
 But, as a grooved instrument was judged to 
 be an essential guide, Barbantini caused a 
 long director to be constructed, which he 
 thought might be passed more conveniently 
 than the staff, into the first incision. He 
 aho provided himself with long forceps, the 
 blades of which were very broad, and ad- 
 m 1 ted of being put separately over the 
 stone. A staff having been introduced, the 
 operation was done after M. Sanson’s man- 
 ner, except that a wooden gorget was intro- 
 duced for the protection of the rectum, and 
 the prostate gland was left undivided at the 
 forepart of the wound. When the bladder 
 had been opened at the lower part of the 
 rectum, as far as the groove of the stafF 
 served as a guide, the latter instrument was 
 withdrawn, and the long director introdu- 
 ced into the incision, which, under its gui- 
 dance, was then enlarged to the necessary 
 extent. With some difficulty the stone was 
 then extracted, and found to weigh nine 
 ounces and a half. For about eighteen days 
 the urine passed away bv the anus, only a 
 a few drops occasionally issuing from the 
 urethra. As this circumstance gave Barban- 
 tini some uneasiness, he introduced hiS‘ ( 
 finger into the bladder, the inner surface of 
 whicl), near the wound, he found covered I 
 with encysted calculous mailer, which was j 
 very adherent. At length, however, it was j 
 gradually removed, with a portion of new- 
 formed membrane, by attempts repeated 
 
LITHOTOMY. 
 
 -215 
 
 with the linger several days in succession. 
 
 A catheter was then introduced, through 
 which, at first, almost the whole of the 
 urine (lowed. But the tube being after- 
 ward obstructed with mucus, it became ne- 
 cessary frequently to clear it by injecting 
 tepid water. The cure now seemed to pro- 
 ceed with rapidity. When the feces were 
 hard, none of them passed into the bladder ; 
 but when they were liquid, a part of them 
 were voided with the urine through the 
 tube, though without any inconvenience. 
 At the end of fifty days, s arcely any urine 
 passed out of the wound ; the patient, 
 therefore, went into the country, where, in 
 the course of another month, the cure was 
 complete. 
 
 About a year ago, I saw an example, in 
 which a calculus had made its way through 
 the prostatic portion of the urethra, and 
 formed, with the swelling of the soft parts, 
 a considerable prominence within the rec- 
 tum. If the patient had been under my 
 care, I should certainly have made an inci- 
 sion directly on the tumour just within 
 the sphincter, by which means the calculus 
 might have been removed with great ease, 
 and less risk than dividing the prostate. 
 However, the latter method was followed, 
 and the case had a very favourable termina- 
 tion. In this instance, as the sound, in its 
 passage, only occasionally touched a small 
 point of the calculus, which approached the 
 urethra, and this just at the instant before 
 its entrance into the cavity of the bladder, 
 the exact nature of the case was for some 
 lime a matter of doubt to several skilful 
 surgeons who were consulted. Respecting 
 the merits of lithotomy through the rectum, 
 'l think the practice well deserving the con- 
 sideration of the profession, where the cal- 
 culus is known beforehand to be of unusual 
 size. It must be less painful, I apprehend, 
 than the high operation, and, perhaps, more 
 easy of execution. But it is difficult, with 
 the scanty experience before us, to offer any 
 very decided opinion whether, on the whole, 
 it ought to be preferred either to the high 
 or the lateral operation, by which last, 
 stones of larger size than that extracted by 
 Barbantini, have been successfully taken out 
 by Mr. Mayo, of Winchester, Dr. Klein, of 
 Stuttgard, and others. The most serious 
 consideration is, whether a large incision, 
 forming a communication between the blad- 
 der and rectum, will generally heal up, as 
 well, or even more favourably, than in Bar- 
 bantini’s case. This is a point which can 
 only be decided by further observation. A 
 smaller wound in the same part, it appears, 
 is soon cured ; for in the instance reported 
 by Sanson, the boy was quite well on the 
 twentieth day. For further information, 
 consult Sanson, DcsMoyens de Parvenir a la 
 Vessie par le Rectum, 4to. Paris , 1817 ; JV*. 
 Barbantini Obs. relative a. Vextruction d’un 
 calcul urinaire ires volumineux , operec au 
 moyen de la taille vesicoreclnle, 8 vo. Lucques , 
 1819 ; Journ. Complem. du Did. des Sciences 
 Med. T. 6, p. 79, 8vo. Paris , 1820 ; Diet des 
 Sciences Med. T. 28, p. 422, 
 
 LITHOTOMY IN WOMEN. 
 
 Women suffer much less from the stone 
 than men, and far less frequently stand in 
 need of lithotomy. It is not, however, that 
 their urine will not so readily produce the 
 concretions which are termed urinarv <-il- 
 culi. The reason is altogether owin to he 
 shortness, largeness, and very dilatab na- 
 ture of the female urethra ; circumstances 
 which in general render the expulsion of 
 the stone with the urine almost a matter of 
 certainty. The records of surgery present 
 us with numerous instances, where calculi 
 of vast size have been spontaneous ly voided 
 through the meatus urinarius, either sud- 
 denly without pain, or after more or less 
 time and suffering. Heister mentions seve 
 ral well-authenticated examples. Middle- 
 ton has also related a case, where a stone, 
 weighing four ounces, was expelled in a 
 fit of coughing, after lodging in the passage 
 a week. Coiot speaks of another instance, 
 where a stone, about as large as a goose’s 
 egg*, after lying in the meatus urinarius 
 seven or eight days, and causing a retention 
 of urine, was voided in a paroxysm of pain. 
 A remarkable case is related by Dr. Moli- 
 neux in the early part of the Philosophical 
 Transactions : a woman voided a stone, the 
 circumference of which measured the long- 
 est way seven inches and six-tenths, and 
 round about, where it was thickest, five 
 inches and three quarters ; its weight neav 
 two ounces and a hall troy. And Dr. Yel- 
 loly has related an interesting example, in 
 which a calculus, weighing three ounces, 
 three and a half drachms troy, and lodged in 
 the meatus urinarius, was easily taken out 
 with the fingers. (See Med. Chir. Trans. 
 Vol. 6, p. 577.) Dr. Yelioly also refers to 
 several very remarkable instances, described 
 in the Phil Trans. Vols. 12, 15, 17, 20, 34, 
 42, and 55, proving what large stones will 
 pass out of the female urethra, either spon- 
 taneously or with the aid of dilatation and 
 manual assistance. Were any doubts now 
 left of this fact, they would be immediately 
 removed by other histories, especially those 
 contained in a paper drawn up by Sir A, 
 Cooper. (See Med. Chir. Trans. Vol. 8, p. 
 427, 4 r C .) 
 
 Sometimes, after the passage of large 
 calculi, the patient has been afflicted with an 
 incontinence of urine; but, in general, this 
 grievance lasts only a short time. 
 
 The occasional spontaneous discharge of 
 very large calculi through the meatus uri- 
 narius led Frederic de Leauson to deliver 
 the advice not to interfere with them, as he 
 thought they would all present themselves 
 sooner or later at the orifice of that passage, 
 and admit of being taken away with the 
 fingers. (See Trait 6 Nouveau pour ai seme at 
 parvenir a la 'Vraie Curation de plusieurs 
 belles Operations, fyc. Geneve. 1674.) 
 
 When surgeons began to consider what 
 very large calculi were sometimes sponta- 
 neously voided, and the large size, and di- 
 latable nature of the female urethra, they 
 suspected that it would be a good practice 
 
LITHOTOMY. 
 
 210 
 
 to dilate this passage by mechanical con- 
 trivances, until it would allow the stone to 
 be extracted, and thus all occasion for cut- 
 ting instruments might be superseded. With 
 this view, Tolet first proposed suddenly di- 
 lating the passage with two steel instru- 
 ments, called a male and female conductor, 
 between which the fingers, or forceps, were 
 passed for the removal of the calculus. 
 (Traits de la Lithotomie, Paris , 1681.) But 
 as it was afterward rightly judged, that the 
 dilatation would produce less snffering and 
 injury, if more gradually effected, Douglas 
 suggested the practice of dilating the mea- 
 tus urinarius with sponge or dried gentian 
 root. 
 
 Mr. Brom field has published the case of 
 a young girl, in whom he effected the ne- 
 cessary dilatation by introducing into the 
 meatus urinarius the appendicula coeci of a 
 small animal in a collapsed state, and then 
 filling it with water by means of a syringe ; 
 thus furnishing a hint for the construction of 
 instruments on the principle of Mr. Arnott’s 
 dilator. The piece of gut, thus distended, 
 was drawn out in proportion as the cervix 
 vesicae opened, and, in a few hours, the dila- 
 tation was so far accomplished, that the 
 calculus had room to pass out. (See Chir. 
 Obs. and Cases, Vol 2, p. 276.) 
 
 Mr. Thomas met with a case, in which, 
 after dilating the meatus urinarius with a 
 sponge tent, he succeeded in extracting an 
 earpicker which lay across the neck of the 
 bladder. The passage was so much enlar- 
 ged, that the left fore-finger was most easily 
 introduced, and (says this gentleman) “ 1 
 believe had the case required it, both thumb 
 and finger would have passed into the blad- 
 der without the smallest difficulty.” After 
 adverting to this, and other facts, proving 
 the ease with which the female urethra can 
 be dilated, Mr. Thomas remarks : “ If these 
 relations can be credited, and there is no 
 reason why they should not, l can hardly 
 conceive any case, in a young and healthy 
 female subject, and where the bladder is 
 free from disease, where a very large stone 
 may not be extracted, without the use of 
 any other instrument tnan the forceps, the 
 urethra having first been sufficiently dilated 
 by means of the sponge tents For this 
 purpose, the blades of the forceps need not 
 be so thick and strong as those commonly 
 employed. (See Medico- Chir. Trans. Vol. 
 1, p. 123 — 129.) Many facts of a similar 
 kind are on record, and one in which a large 
 needlecase was extracted, is referred to in 
 a modern periodical work. (See Quarterly 
 Journ. of Foreign Med. Vol. 2, p 331.) 
 
 Some surgeons have extracted stones from 
 the female bladder in the following manner: 
 the patient having been placed in the posi- 
 tion commonly adopted in the lateral opera- 
 tion, a straight staff, with a blunt end, is in- 
 troduced into the bladder, through the mea- 
 tus urinarius. The surgeon then passes 
 along the groove of the instrument the 
 beak of a blunt gorget, which instrument 
 becoming wider towards the handle, effects 
 n part of the necessary dilatation. The staff 
 
 being withdrawn, and the handle of the gor* 
 get taken hold of with the left hand, the 
 right fore-finger with the nail turned down- 
 wards, is now introduced slowly along the 
 concavity of the instrument. When the 
 urethra and neck of the bladder have thus 
 been sufficiently dilated, the finger is with- 
 drawn, and a small pair of forceps passed 
 into the bladder. The gorget is now remo- 
 ved, and the stone taken hold of, and ex- 
 tracted. ( Sabatier , Medecine Opdratoire, T. 
 2, p. 103.) 
 
 This plan, however, is liable to the objec- 
 tions arising from the dilatation being too 
 suddenly effected ; and the practice now 
 generally preferred is that of gradually ex- 
 panding the meatus urinarius with sponge 
 tent. And, as the retention of the urine, 
 during the continuance of the sponge, causes 
 great irritation, I consider Mr. C. Hutchin- 
 son's suggestion of placing a catheter in its 
 centre, as mentioned by Sir A. Cooper, as 
 meriting attention. (See Med. Chir. Trans. 
 Vol. 8, p. 433.) 
 
 Notwithstanding these favourable ac- 
 counts of the practice of dilating the female 
 urethra, for the purpose of removing cal- 
 culi from the bladder, there are very good 
 surgeons who deem an incision the best 
 practice. It is certain, that some patients 
 have found the method insufferably tedious 
 and painful. But the strongest objection is 
 the incontinence of urine, which occasion- 
 ally follows any great distention of the ure- 
 thra and neck of the bladder. Klein, one 
 of the most experienced operative surgeons 
 in Germany, states that he has tried both 
 plans, and that the use of the knife is much 
 less frequently followed by incontinence of 
 urine. On the other hand, Mr. Thomas be 
 lieves, that this unpleasant symptom is quite 
 as often a consequence of the operation of 
 lithotomy, as now usually performed. (Med. 
 Chir. Trans. Vol. 1, p. 127.) When the stone 
 is not very large, perhaps dilatation should 
 be preferred ; and, in other cases, an inci- 
 sion. 
 
 In females, lithotomy is much more easy 
 of execution, and less dangerous, than in. 
 male subjects. It may be done in various 
 ways ; but the surgeons of the present time 
 constantly follow the mode of making the 
 requisite opening by dividing the urethra 
 and neck of the bladder. Louis employed 
 for this purpose a knife which cut on each 
 side, and was contained in a sheath; Le 
 Blanc, a concealed bistoury, which had only 
 one cutting edge ; Le Cat. his gorgeret-cys- 
 titome ; Frere Come, his lithotome cache ; 
 and Fleurant a double-bladed lithotome 
 cache. Of these instruments, the best, I 
 think, is that of Frere Come. But, at pre- 
 sent, every surgeon knows, that the opera 
 tion may be done, as conveniently as possi- 
 ble, with a common director and a knife, 
 that has a long, narrow r , straight blade. A 
 straight staff, or director, is introduced 
 through the mealus urinarius ; the groove is 
 turned obliquely downwards and outwards, 
 in a direction parallel to the ramus of tin- 
 left os pubis ; and the knife is thus conduct* 
 
LITHOTOMY. 
 
 217 
 
 ed into (lie bladder, and makes the necessary 
 incision through the whole extent of the 
 passage, and neck of the bladder. 
 
 Louis and Fleurant, as I have said, were 
 the inventors of particular bistouries for di- 
 viding both sides 'of the female urethra at 
 once. The instrument of the former effect- 
 ed this purpose, in passing from without 
 inwards; that of the latter, in passing from 
 within outwards. Fleurant’* bistoury bears 
 some resemblance in principle to Frere 
 Gome’s lithotome cache or to the cutting 
 forceps, with which Franco divided the 
 neck of the bladder. The reason assigned 
 in recommendation of these bistouries is, 
 that they serve to make a freer opening for 
 the passage of large stones, than can be safe- 
 ly made by cutting only in one direction. 
 When the calculus is large, it is certainly dif- 
 ficult to procure a free opening, without cut- 
 ting the vagina, in front of which passage, 
 there is but little space under the pubes for 
 the removal of the stone. Hence, Dubois 
 invented a new method, which consists in 
 dividing the meatus urinarius directly up- 
 wards towards the symphisis of the pubes, 
 dilating the w r ound and keeping the vagina 
 out of the way by means of a blunt gorget, 
 and then taking out the calculus with the 
 forceps. This method seems to me better 
 devised for the protection of the vagina, than 
 the acquirement of more room for the cal- 
 culus, and whatever space is gained, is only 
 gained by the distention of the parts, and 
 the propulsion of them downwards. The 
 plan is acknowledged to be very painful, yet 
 generally successful, and not followed by 
 any serious symptoms or incontinence of 
 urine. (See Did. des Sciences, Med. T. 28, 
 p. 43b.) When the stone is known to be 
 very large, Sabatier and some other modern 
 surgeons prefer the apparatus altus. 
 
 A case may present, itself, in which the 
 posterior part of the bladder, drawn down- 
 wards by the weight of the stone, may dis- 
 place a portion of the vagina, and make it 
 protrude at the vulva in the form of a swell- 
 ing. Here, there w r ould be no doubt of the 
 propriety of cutting into the tumour, and 
 taking out the foreign body contained in it. 
 Rousset performed such an operation, and 
 Fabricius Hildanus in a case, where the 
 stone had partly made its way into the va- 
 gina, enlarged the opening, and successfully 
 extracted the foreign body. 
 
 Mery proposed to cut into the posterior 
 part of the bladder through the vagina, after 
 introducing a common curved staff ; but the 
 apprehension of urinary fistulae made him 
 abandon the project. 
 
 The existence of extraordinary circum- 
 stances may always render a deviation 
 from the common modes of operating not 
 only justifiable, but absolutely necessary. 
 Thus, Tolet met with a case, where a wo- 
 man had a prolapsus of the uterus, with 
 which the bladder was also displaced. In 
 the latter viscus, several calculi were felt: 
 an incision was made into it, and the stones 
 extracted, after which operation, the dis- 
 placed parts were reduced, and a speedy 
 
 Voi,. If 28 
 
 cure followed. (Sabatier, Medecine 0p6ra - 
 loirt , T. 2, p. i07.) 
 
 The incontinence of urine, consequent 
 to lithotomy in women, is by no means an 
 unlrequent occurrence. Mr Hey cut two 
 female patients for the stone, both of whom 
 were afterward unable to retain their urine, 
 and were not quite well when discharged 
 from the Leeds Infirmary. These cases led 
 Mr. Hey in a tliifd example lo endeavour to 
 prevent the evil, by introducing into the va- 
 gina a cylindrical linen tent, two inches 
 long and one broad with a view of bring- 
 ing the edges of the incision together, with- 
 out obstructing the passage of urine through 
 the urethra. The plan answered, if it be 
 allowable to make such an inference from 
 a single trial. (See Hep's Practical Obs. in 
 Surgery, p. 560. Ed. 1810.) 
 
 TREATMExf AFTER THE OPERATION. 
 
 If the interna] pudendal artery should be 
 wounded, and bleed profusely, the best plan 
 is, .f possible, first to take out the stone, and 
 then introduce into the wound a piece of 
 firm sponge, with a large cannula passed 
 through its centre. The expanding property 
 of the sponge, on its becoming wet, will 
 make the necessary degree of compression 
 of the vessel, which lies too deeply to be 
 tied. When there is much coagulated blood 
 lodged in the bladder, it is customary to 
 wash it out by injecting lukewarm water. 
 
 I cannot say that it has fallen to my lot 
 to see any cases (out of the great number 
 which I have seen in Bartholomew’s Hos- 
 pital,) in which death could be imputed to 
 hemorrhage, notwithstanding the bleeding 
 has often been so profuse, and from so deep 
 a source, jus! after the operation, as to cre- 
 ate suspicion that it proceeded from the in- 
 ternal pudendal artery. Such hemorrhage 
 generally stopped before the patient was put 
 to bed. 
 
 The majority of patients who die after 
 lithotomy perish of peritoneal inflammation. 
 Hence, on the least occurrence of tender- 
 ness over the abdomen, copious veuesection 
 should be put in practice. At the same time, 
 eight or ten leeches should be applied to the 
 hypogastric region The belly should be fo- 
 mented, and the bowels kept open with the 
 oleum ricini. The feebleness of the pulse 
 should not deter the practitioner from using 
 the lancet ; this symptom is only fallacious; 
 and it is generally attendant on all inflam- 
 mation within the abdomen. It is a curious 
 fact, that Mr. Martineau, who has lost only 2 
 out of 84 patients, whom he has operated upon 
 for the stone, should never have found it re- 
 quisite to bleed ; but it appears to me, that, 
 it is a much better argument in favour of the 
 superior safety of operating with the knife 
 and making a f: ee opening, than reason for 
 discouraging venesection, when inflamma- 
 tion of the peritoneum has come on, which, 
 however, may not be this gentleman’s mean- 
 ing, as he says, “ I believe, it will be found 
 in adults, that death follows oftener from ex- 
 haustion, after a tedious operation, or from 
 
despondency, &tc. than from acute disease ; 
 (Med. Chir. Trans. Vol 11, />. 412.) a senti- 
 r merit, which 1 am sure this gentleman would 
 not have entertained, had he been present 
 with me at the opening of tbd many unfor- 
 tunate cases, which used formerly to occur 
 in the practice with badly made gorgets in 
 St. Bartholomew’s Hospital. Together with 
 the above measures, the wajjrn bath, a blister 
 on the lower part of the abdomen, and 
 emollient glysters, are highly proper I have 
 seen several old subjects die of the irritation 
 of a diseased thickened bladder, continuing 
 after the stone was extracted. They had 
 not the acute symptoms, the inflammatory 
 fever, the general tenderness and tension of 
 the abdomen, as in cases of peritonitis ; but 
 they referred their uneasiness to the lower 
 part of the pelvis ; and instead of dying in the 
 course of two or three days, as those usually 
 do, who perish of peritoneal inflammation, 
 they, for the most part, lingered for two or 
 three weeks after the operation. In these 
 cases, opiate glysters, and blistering the hy- 
 pogastric region, are the best measures. In 
 some instances of this kind, abscesses form 
 about the neck of the bladder. 
 
 Whoever wishes to acquire a perfect 
 knowledge of the history of lithotomy 
 should consult the following works : Ctlsus 
 de Re M edict ). , lib. 7, cap. 26. Remarques 
 sur la Chirurgie de Chauliac , par M. Simon 
 de Mingelouzeaux, tom. 2. ; Bourdeaux. 1663. 
 La legende du Gascon par Drelincourt ; Paris, 
 1665. Van Horne's Opuscul a Marianus de 
 Lapide Vesicce par Incisionem exlrahendo ; 
 1552. G. Fair. Hildanus, Lilhotomia Vesicce, 
 S vo. Lond. 1640. M. S. Baroliianus , De Lapide 
 Renum. Ejusdem de Lapide Vesicce per Inci- 
 sionem exlrahendo, 4lo. Paris, 1540. Lc Dr an , 
 Par allele des Dfferenles Manic res de lirer la 
 Pierre hors de la Vessie, 2 Vol. 8 ro. 1730. 
 Sharp's Operations. Sharp's Critical Inqui- 
 ry. Le Bran's Operations, Edit. 5 ; London, 
 1781. Franco's Trail6 des Ilernies, 1561. 
 Roselus de Partu Ccesario. Traitt de la Lilho- 
 tomie, par F. Tolet, Paris , 5 me Ed. 1708. 
 Heister’s Surgery, Part 2. Lilhotomia Doug- 
 lassiana, 1723. J. Douglas , Ilislory of the 
 Lateral Operation , 4 to. Lond. 1726. Er. M. 
 Colot , Trade de V Operation de la Taille, fyc. 
 12 mo Paris, 1727. Murand, Traiti dc la 
 Taille au haul appareil, 12 mo. Paris, 1728 ./. 
 Mery, Observations sur la Maniere de Tailler, 
 $-e. pratiqu6e par Frere Jacques, 12wo. Pari. , 
 1700. Cours d' Operations de Chirurgie por 
 Dionis. Trade des Operations par Garengeot , 
 Tom. 2 . Morand Opuscules de Chirurgie. 
 Bertrand i. Trait6 des Operations. Index Su- 
 pellectihs Analomicw Ravi once ; Leidce, 1725. 
 ,/. G. Lsemann, De Lilhotomia Celsiance 
 Freest antice ; Helmst. 1745. Le Cat, Recueil 
 de Pieces sur V Opdration de la Taille Part 1 ; 
 Rouen , 1749. Cosme, Recueil de Pieces Ana- 
 tomiques import antes sur l' Operation de la 
 Taille ; Paris, 1751 — 1753. J. Douglas, 
 
 Postscript to Hist, of the Lateral Operation ; 
 1726. J. Douglas , Appendix to Hist, of the 
 Lateral Operation ; 1731. A short Historical 
 Account of Cutting for the Stone, by IV. Che- 
 widen, in his own last edition of his Anatomy . 
 
 Falconet in Thes. Chirurg. HaVtn ; the.'. 
 103, T. 4, p. 196. Hartinkeil ; Tract at us de 
 Vesicce Urinaria: Calculo, fye. 1785. Trditc 
 Historique et Dogmatiquc de V Operation de la 
 Taille, par J. F. L. Deschamps, 4 Tom. 8 vo. 
 Paris, 1796. This last work is a very Com- 
 plete amt full account of the subject up to the 
 time of its publication, arid well merits a care- 
 ful perusal. Richerand s Nosogr. Chir. T. 3, 
 p. 538 , fyc. Ed. 4. Leviillt, J\ouvelle Doc- 
 trine Chir T. 3, p. 533. John Bell's Princi- 
 ples of Surgery . Vol. 2, Part 1. A. Burns , 
 in Edinb. Med and Surg. Journal, January, 
 1808 C. Bell's Operative Surgery, Vol. 1, 
 
 1807. Sabatier, de la Medecint Ophaloire , 
 Tom. 3. Edit. 2, 1810. Dr John Thomson'i. 
 Observations on Lithotomy ; Edinb. 1808. 
 Also an Appendix to a. proposal for a new 
 manner of catling for the Slone, 8 vo. Edinb. 
 1810. Allan's Treatise on Lithotomy ; Edinb. 
 
 1808. Earle's Practical Observations on Ope- 
 
 rations for the Stone ; 2d Ed. with an Appen- 
 dix containing a description of an instrument 
 calculated to improveihal operation , 8 ro. Lond. 
 1803. Wm. Dense . Ohs. on the different me- 
 thods for the radical cure of the Hydrocele, fyc. 
 Tojwhich is added a comparative view of the 
 different methods of cutting for the Stone , fyc. 
 8 vo. Load. 1798. ( Euvres Chir. de Desault 
 
 par Bichat ; Tom. 2. Wm. Simmons, Cases 
 and Obs. on Lithotomy, 8 vo. Manchester, 1808. 
 C. B. Trye , Essay on some of the Stages of the 
 Operat ion of cutting for the Stone, 8 vo. Loud. 
 1811 Roux, Voyage fail a Londres en 1814, 
 ou Par allele de la Chirurgie Angloise avec 
 la Chirurgie Francoise, p 315, fyc. Paris, 
 1815. Schregtr, Chirurgisihe Versnche, B. 
 2. von Steinschnitlen an Weibern, p. 135, fyc. 
 8v o. Number”,' 1S18. C. J. M. Langenbeck, 
 iiber tine einfache und sichcre methodcdcs 
 Steinschnittes , 4 to. Wurzburg, 1802. F. X. 
 Rudtorjfer, Ablmndluvg iiber die Operation 
 des Blasensteines nach Pajolu's Methods, 4 to. 
 Leipz. 1S08. A. Scarpa, A Memoir on the 
 Cutting Gorget of Hawkins, §-c. Trunsl. by 
 J. II. Wishart, 8 vo. Edinb. 1816. If. Mayo, 
 IV. Dickenson, II. Earle, and P. M. Marli- 
 neau in Med. Chir. Trans. Vol. 11. Klein, 
 Tract. Ansichten bedeutendsten Operalioner, 
 4 to. Stulgart, IS 16. J. S. Carpue, Hist, of 
 the High Operation, and An Account of the 
 various Methods of Lithotomy, 8 vo. Lond. 
 1819. Sir E. Home on Strictures , tyc. Vol 3, 
 8 vo. Lond. 1821 For a minute description 
 and delineations of the parts concerned in 
 the operation, see Camper's Demonslrationes 
 Anatomico-palhologirce , lib. 2. Also L. F Von 
 Froriep iiber die Lage der Eingcweide un 
 Becken , nebsl enter Darstellung dcrselben , 4lo. 
 Weimar, 1815. 
 
 LOTIOA LUMINIS. — ft. Aluminis purif- 
 ^ss. Aquas distillatae Jftj. Misce. — Some- 
 times used as an astringent injection; some- 
 times as an application to inflamed parts. 
 
 LOTH) AMMONLE ACETATE.— ft. 
 Liq. nimnon. acetaia} ; Spirit, vin. rectil. ; 
 Aqua} distillata}; sing. 3* v - Misce. — Proper- 
 ties disculient. 
 
 LOTIO AMMONITE MURIATE.— ft. 
 Ammon, muriata} 3 j. Spirit, rorismarini H>j. 
 — Has the same virtues as the preceding 
 
LOT 
 
 LUM 
 
 Justamond recommended it in the early 
 stage of the milk-breast. 
 
 LOTIO AMMONIA MURIATE CUM 
 ACETO. — R. Ammon. Mur. Zss. Aceti, 
 Spirit, vinos, rectif. sing. fbj. Misce. This 
 is one of the most efficacious discutient lo- 
 tions. it is, perhaps, the best application 
 tor promoting the absorption of extravasa- 
 tcd blood, in cases of eechymosis, contu- 
 sions, sprains, &.c. 
 
 LOTIO AMMONLE OPIATA. — R. Spi- 
 ntusammon. comp. 3'*iss. Aqua; distilla'ae 
 ^iv. Tinct. Opii. ^ss. Misce. Applied by 
 Kirkland to some suspicious swellings in the 
 breast, soda and bark being also given inter- 
 nally. 
 
 LOTO CALCIS COMPOSlTA.— -R. 
 
 Aquae calcis R>j. Hydrargyri oxymuriatis 
 3j Misce. — Properties strongly astringent. 
 Ringworms, tetters, and some other cutane- 
 ous affectionsyield to this application, which 
 however, should generally be diluted. In 
 the latter state, it may occasionally be used 
 as an injection for various purposes. 
 
 LOTIO GALLvE. — R. Gallarum contusa- 
 rum 3 U- Aquae ferventis ibj. To be ma- 
 cerated one hour, and strained. — This 
 astringent lotion is sometimes used with a 
 view of removing the relaxed state of the 
 parts, in cases of prolapsus ani, prolapsus 
 uteri, &.c. 
 
 LOTIO HYDRARGYRI AMYGDALINA. 
 — R. Amygdalurum amararum ^ j. Aquas 
 distil fRj. Hydrar^. oxymuriatis ^j. Rub 
 down me almonds with the water, which is 
 to be gradually poured on them ; strain the li- 
 quor , then add the oxymuriute of mercury. 
 Tib- will cure several cutaneous affections. 
 
 LOTIO HYDRARGYRI OXYMURIATIS. 
 — R. Hydrargyri oxymuriatis gr. ij-s. Ara- 
 bic! gurnmi ^;s. Aquae distillptae R,j- Misce. 
 — This is the injection of corrosive sublimate 
 in u*e ai St. Bartholomew’s Hospital. 
 
 LOTIO HYDRARGYRI OXYMURIATIS 
 COMPOSITA — R. Hydrarg. oxyinur. gr. x. 
 Aq. distillat. bullientis giss. Tinct. canthar. 
 ^ss. Misce. — This was ordered by Dr. H. 
 Smith, to be applied every night to scrofu- 
 lous swellings. 
 
 LOTIO HELLEBORI ALB!. — R. Decoct i 
 hellebori albi R,j. Potassae sulphured ^ss. 
 Misce. — This is occasionally employed as an 
 application for curing tinea capitis, and 
 some other cutaneous diseases. 
 
 LOTIO PLUM BI ACE TAT IS. — R. Liq. 
 plumbi acet 3 j- Aq. distill. JRj- Spirit vinos, 
 tenuioris 3u- The first and last ingredients 
 are to be mixed before the water is added. 
 
 This is the'common whitewash, an appli- 
 cation universally known. 
 
 LOTIO POTASSjE SULPHURETI — 
 R. Potassse sulph. 3'j- Aqua; distill. jRj. 
 Misce. — It is used in the same cases as the 
 preceding application. 
 
 LOTIO OPII. — R. Opii ptirif. 3jss. Aquae 
 dislillatae R>j Misce. — A very excellent ap- 
 plication to irritable painful ulcers of 
 every description. It is best to dilute it, es- 
 pecially at first. 
 
 LOTIO PICJS. — R. Picis liquids; ^iv. 
 Calcis Zvj. Aqua; ferventis fb>ij. — To be 
 
 2i9 
 
 boiled till half the water is evaporated. The 
 rest is then to be poured off for use. This 
 application is sometimes employed tor the 
 cure of tinea capitis ; it is also of singular 
 service in removing an extensive scorbutic 
 redness, frequently seen on the legs, accom 
 panying old ulcers. 
 
 LOTIO ZIJNCI SULPH ATI >. — R. Zinci 
 sulphatis 3j. Aq. ferventis Ibj. Misce. This 
 is sometimes used by practitioners in lieq of 
 the lotio plumbi acet. It forms a good as- 
 tringent application fora variety of cases. 
 When diluted, by adding two pints more 
 water, it forms the common injection, so 
 much recommended in cases of gonorrhoea. 
 
 LUES VEIN ERE A. See V EX ERE A L 
 DISEASE. 
 
 L UM B A K A BSC ES 5. Psoas Mscess. By 
 these terms are understood chronic collec- 
 tions of matter, which form in the cellular 
 substance of the loins, behind the peritone- 
 um, and descend in the course of the 
 psoas muscle. Patients, in the incipi- 
 ent stage of the disease, cannot walk so 
 well as usual ; they feet a degree of uneasi- 
 ness about the lumbar region ; but in gene- 
 ral, there has been no acute pain, even when 
 the abscess has acquired such a size as to 
 form a large tumour, protruding, externally. 
 In short, the psoas abscess is the best in- 
 stance, which can possibly be adduced, in 
 order to illustrate the nature of those collec- 
 tions of matter, which are called chronic, 
 and which form in an insidious manner, 
 w ithout, serious pain, or any other attendant 
 of acute inflammation. 
 
 The abscess sometimes forms a swelling 
 above Poupart’s ligament ; sometimes below 
 it ; and frequently the matter glides under 
 the fascia of the thigh. Occasionally it 
 makes its way through the sacro-ischiatic 
 foramen, and assumes rather the appearance 
 of a fistula in ano. When the matter gravi- 
 tates into the thigh, beneath the fascia, Mr. 
 Hunter would have termed it a disease in, 
 not of, the part. The uneasiness in the 
 loins, and the impulse communicated to the 
 tumour by coughing, evince, that the di ease 
 arises in the lumbar region ; but, i-t must be 
 confessed, that we can hardly ever know the 
 existence of the disorder, before the tumour, 
 by presenting itself externally, leads 11 s to 
 such information. The lumbar abscess is 
 sometimes connected with diseased verte- 
 brae, which may either be a cause, or an 
 effect, of the collection of matter. — The 
 disease, however, is frequently unattended 
 with this complication. 
 
 The disease of the spine, we may infer, is 
 not of the same nature as ihat treated of by 
 Pott, as there is usually no paralysis. When 
 the bodies of patients with lumbar abscesses 
 are opened, it is found, that the matter is 
 completely enclosed in a cyst, which, in 
 many cases, is of course very extensive. 
 If the contents of such abscesses were not 
 circumscribed by a membranous boundary 
 in this manner, we should have them spread- 
 ing among the cells of (he cellular substance, 
 just like the water in anasarca. The cysts 
 are both secreting and absorbing surfaces as 
 
LITHOTOMY. 
 
 is proved by the great quantity of matter, 
 which soon collects again alter the abscess 
 has been emptied, and by the occasional dis- 
 appearance of large palpable collections of 
 matter of this kind, either spontaneously, or 
 in consequence of means which are known 
 to operate by exciting the action of the ab- 
 sorbents. In slx.rt, the cyst becomes the 
 suppurating surface, and suppuration is now 
 well ascertained to be a process, similar to 
 glandular secretion. While the abscess re- 
 mains unopened, its contents are always un- 
 dergoing a change; fresh mailer is continu- 
 ally forming, and a portion of what was pre- 
 viously in the cyst is undergoing t lie neces- 
 sary removal by the absoi bents. This is not 
 peculiar to lumbar abscesses ; it is common 
 to all, both chronic and acute, buboes and 
 suppurations in general. It is true, that, in 
 acute abscesses, there often has not been 
 time for the formation of so di tinct a mem- 
 brane as the cyst of a large chronic abscess ; 
 hut their matter is equally circumscribed by 
 the cavities of the cellular sub lance being 
 filled with a dense coagulating lymph ; and 
 though it generally soon makes its way tothe 
 surface, it also is occasionally absorbed. 
 
 The best modern surgeons make it a com- 
 mon maxim to open very few acute ab- 
 scesses ; for the matter natural!) tends with 
 great celerity to the surface of the body, 
 where ulceration allows it to escape sponta- 
 neously ; alter which, the case generally 
 goes on better, than if it had been opened 
 by art. But, in chronic abscesses, the matter 
 has not that strong tendency to make its 
 way outward ; its quantity is continually in- 
 creasing; the cyst is, of course, incessantly 
 growing larger and larger; in short, the 
 matter, from one ounce, often gradually in- 
 creases to the quantity of a gallon. When 
 the disease is at length opened, or bursts by 
 ulceration, the surface oi the cyst, irritated 
 by the change, inflames ; and its great ex- 
 tent, in this circumstance, is enough to ac- 
 count for the terrible constitutional disorder, 
 and fatal consequences, which too frequently 
 soon follow the evacuation of the contents 
 of such an abscess. Hence, in cases of 
 chrOnic suppurations of every kind, and not 
 merely in lumbar abscesses, it is the sur- 
 geon’s duty to. observe the opposite rule to 
 that applicable to acute cases; and he is 
 called upon to open (he collection of matter, 
 as soon as he is aware of its existence, and 
 its situation will allow it to be done. 
 
 Certainly, if would be highly advanta- 
 geous to have some means of a-certaining 
 whether the vertebrae are also diseased ; for, 
 as in this instance, the morbid bones would 
 keep up suppuration, until their affection had 
 ceased, and there would be no reasonable 
 hope of curing the ab-cess sooner, it might 
 be better to avoid puncturing it under such 
 circumstances. The propriety of this con- 
 duct seems the more obvious, as issues, which 
 are the means most likely tostop and remove 
 the disease of the spine, are also such as 
 afford most chance of bringing about the ab- 
 sorption of the abscess itself. However, if 
 the collection cannot be prevented from dis- 
 
 charging itself, and ulceration is at Land, it 
 is best to meet the danger, make an opening 
 with the lancet, in a piace at some distance 
 from where the pointing threatens, and after- 
 ward heal it, in the way which will be pre- 
 sently detailed. 
 
 Though we have praised the prudence of 
 opening all chronic abscesses while small, the 
 deep situation of the lumbar one, and the 
 degree of doubt always involving its early 
 state, unfortunately prevent us from taking 
 this beneficial step in the present case. But 
 still the principle is equally praiseworthy, 
 and should urge us to open the tumour as soon 
 as the fluctuation of the matter is distinct, 
 ami the nature of the case is evident. For 
 this purpose, Mr. Abernethy employs an ab- 
 scess lancet. which will make an opening 
 large enough for the discharge of those flaky 
 substances so frequently found blended with 
 the matter of lumbar abscesses, and by some 
 conceived to be an emblem of the disease 
 being scroiulous. Such flakes seem tocon- 
 sist of a part of the coagulating matter of 
 the blood, and are very commonly secreted 
 by the peculiar cysts of scrofulous ab- 
 scesses. The puncture must also be of a cer- 
 tain fize, in order to allow the clots of blood, 
 occasionally mixed with the matter, to 
 escape. Mr. Abernethy considers the open- 
 ing of a lumbar abscess a very delicate ope- 
 ration. Former surgeons used to make large 
 openings in these cases; let out the con- 
 tents; leaye the wound open: the usual 
 consequences of which were, great irritation 
 and inflammation of the cyst ; immense dis- 
 turbance 6f the constitution ; putrefaction 
 of the contents of the abscess, in conse- 
 quence of the entrance of air into its cavity; 
 anil, too often, death. While such practice 
 prevailed, very few, afflicted with lumbar 
 abscesses, were fortunate enough to escape. 
 The same alarming effects resulted from 
 allowing the abscess to attain its utmost 
 magnitude, and then burst by ulceration - If 
 then a more happy train of events depend 
 upon the manner, in which lumbar abscesses 
 are punctured, the operation is certainly a 
 matter of great delicacy. 
 
 Until the collection is opened, or bursts, 
 the patient’s health is usually little, or not at 
 all impaired ; indeed, we see in the faces of 
 many persons with such abscesses, what is 
 usually understood by the picture of health, 
 lleuce, how likely our professional conduct 
 is to be arraigned, when great changes for 
 the worse, and even death occur very soon 
 after we have let out the matter, seemingly, 
 and truly, in consequence of the operation. 
 Every plan, therefore, which is most likely 
 to prevent these alarming effects, is entitled 
 * to infinite praise; and such, I conceive, is 
 the practice recommended by Mr. Aber- 
 nethy. 
 
 This gentleman’s method is to Jet out the 
 matter, and heal the wound immediately 
 afterward by the first intention. He justly 
 condemns all introductions of probes, and 
 other instruments, which only irritate the 
 edges of the puncture, and render them un- 
 likely to grow together again. The wound 
 
LUMBAR ABSCESS 
 
 is to be caret ul ly closed with sticking plaster, 
 and it will almost always heal. 
 
 These proceedings do not put a stop to 
 the secretion of matter within the cavity of 
 the abscess. Of course, a fresh accumula- 
 tion takes place ; but, it is obvious that the 
 matter, as fast as it is produced, will gravitate 
 to the lowest part of the cyst, and, conse- 
 quently, the upper part will remain tor a 
 certain time undistended, and have an oppor- 
 tunity of contracting. 
 
 When a certain quantity of matter has 
 again accumulated, and presents itself in the 
 groin, or elsewhere, which may be in about 
 a fortnight after the first puncture, the ab- 
 scess is to be punctured again, in tire same 
 manner as before, and the w ound healed in 
 the same way. The quantity of matter will 
 now be found much less, than what was at 
 first discharged. Thus the abscess is to be 
 repeatedly punctured at intervals, and the 
 wounds as regularly healed by the first 
 intention, by which method, irritation and 
 inflammation of the cyst will not be induced, 
 the cavity of the matter will never be allow- 
 ed to become distended, audit will be ren- 
 dered smaller and smaller, till the cure is 
 complete. * 
 
 In a few instances, the surgeon may, per- 
 haps, be unable to pers vere in healing the 
 repeated punctures which it may be neces- 
 sary to make ; but, after succeeding once 
 or twice, the cyst will probably have had 
 sufficient opportunity to contract so much, 
 that its surface will not now be of alarming 
 extent. It is also a fact, that the cyst loses 
 its irritability and becomes more indolent, 
 and less apt to inflame, after the contents 
 have been once or twice evacuated, in the 
 above way. Its disposition to absorb be- 
 comes also stronger. 
 
 The knowledge of the fact, that the cysts 
 of all abscesses are absorbing surfaces, 
 should lead us never to.neglect other means, 
 which Mr. Abernethy suggests, as likely to 
 promote the dispersion of the abscess by 
 quickening the action of the absorbents. 
 Blisters kept open with savine cerate, issues, 
 electricity, occasional vomits of the sulphate 
 of zinc, are the means in st conducive to 
 this object. When the vertebrae are diseased, 
 issues are doubly indicated 
 
 In the latter complication, the case is 
 always dangerous. If an opening be made 
 in the abscess, the cyst is at first more likely 
 to be irritated, than when the bones are not 
 diseased, and the affection of the spine is 
 rendered much less likely to undergo any 
 improvement, in consequence of the mere 
 formation of an outward communication. 
 The same bad effect attends necrosis ; in 
 which case, the absorption of the dead bone* 
 is always^ retarded by the presence of un- 
 healed fistulas and sores, which lead down 
 to the disease. 
 
 Mr. Crowther succeeded , in dispersing 
 some large lumbar abscesses without opening 
 them. Large blisters, applied to the integu- 
 ments covering the swelling, and kept open 
 with the savine cerate, effected the cure. 
 
 s&l 
 
 When this gentleman punctured such collec 
 tions of matter, he used a small trocar, which 
 he introduced at the same place as often as 
 necessary. He observes, that the aperture 
 so made does not ulcerate, and allows no 
 matter to escape after being dressed. I 
 cannot, however, discover any reason for 
 his preferring the trocar to the abscess lan- 
 cet, except that the cannula enables the 
 surgeon to push back with a probe any 
 flakes of lymph, &c. which may obstruct its 
 inner orifice. But, this is scarcely a reason, 
 when Mr. Abernethy informs us, that the 
 opening, made with an abscess lancet, is 
 large enough to allow such flakes to be dis- 
 charged ; arid when they stop up the aper- 
 ture, a probe might also be employed to 
 push them back. A wound made vvi h a 
 cutting instrument will, cceteris paribus, 
 always unite more certainly by tne first 
 intention, than one made with such an in- 
 strument as a trocar. Mr, t rowther may 
 always have succeeded in healing the aper- 
 ture ; but, I do not believe, that other prac- 
 titioners would experience equal success. 
 Were the tumour not very prominent, from 
 the quantity ol matter being small, suddenly 
 plunging in a trocar might even endanger 
 parts, which should, on no account, be in- 
 jured. 
 
 Some writers recommend opening lumbar 
 abscesses with a seton. The matter being 
 made to form as prominent a swelling as 
 possible, by pressing the abdomen, and 
 putting the patient in a position, which will 
 make the contents of the abscess gravitate 
 towards the part where the seton is to be 
 introduced, a transverse cut is first to be 
 made in the integuments down to the fascia. 
 A flat trocar is next to be introduced within 
 the incision, which should only be just large 
 enough tp allow the instrument to pass 
 freely up under the skin, for at least three 
 quarters of an inch ; when the hand is to be 
 raised, and the trocar pushed obliquely and 
 gently upwards, till the cannula is within 
 tile lower part of the sac. The trocar must 
 now be withdrawn, and the matter allowed 
 to flow out gently, stopping it every now 
 and then for some minutes. The assistant 
 must now withdraw his hand, to take away 
 the pressure, and the thumb of his left hand 
 upon the opening of the cannula, holding it 
 between his fore and middle fingers. It 
 must then be pushed upward, nearly to the 
 top of the tumour, where its end may be 
 distinctly fell with the fore-finger of the 
 right hand. As soon as it can be plainly felt, 
 it must be held steadil} in the same position, 
 and the trocar is to be introduced into it 
 again, and pushed through the skin, at the 
 place where it is felt and the cannula along 
 with it. The trocar being next withdrawn, 
 a probe with a skein of fine soft silk, dipped 
 in oil, must be passed through the cannula, 
 which being now taken away, leaves the 
 seton in its place. A pledget of mild oint- 
 ment is then to be applied over the two 
 openings, the more completely to exclude 
 the air. A fresh piece of the silk is to he 
 
<>.) I 
 
 MAMMA. 
 
 drawn into the abscess, ami that which was 
 in before cut off, as often as necessary. (See 
 Latta's System of Surgery, Vol. 3, p. 307.) 
 
 Mr. Crowther states, that Deckers, who 
 wrote in 1696, discharged a large abscess, in 
 a gradual manner, with a trocar, the cannula 
 of which was not withdrawn, but was 
 stopped up with a cork, and the latter let 
 out at intervals. B. Bell also advises the 
 cannula not to be taken out. 
 
 I cannot quit this subject without mention- 
 ing a remarkable case of lumbar abscess, 
 which 1 once saw in Christ’s Hospital, under 
 the care of the late Mr. Ramsden. The 
 tumour extended from the ilium and sacrum 
 below, as high up as the ribs. The diameter 
 of the swelling from behind forward, might 
 be about six or eight inches. It was attended 
 with so strong a pulsation, corresponding 
 with that of the arteries, that several emi- 
 nent surgeons in this city considered the 
 case as an aneurism of the aorta. After 
 some weeks, as the tumour increased in size, 
 the throbbing of the whole swelling gradu- 
 ally became fainter and fainter, and at 
 length, could not be felt at all. The tumour 
 was nearly on the point of bursting. Mr. 
 Ramsden suspected that it was an abscess, 
 and determined to make a small puncture 
 in it. The experiment verified the accuracy 
 of his opinion ; a large quantity of pus was 
 evacuated as intervals ; but the boy’s health 
 suffering, he went to his friends at Newbury, 
 and I did not afterward hear the event. 1 
 
 have never seen any popliteal aneurism, 
 whose pulsations could be more plainly 
 seen, and strongly telt, than those of the 
 abscess we have just been describing. A 
 singular case is related by Mr. Wilmot of a 
 psoas abscess, the matter of which was at 
 length absorbed, and its cavity filled with 
 air, attended with a considerable increase in 
 the size of the tumour, a conical elongated 
 shape, and elastic feel, instead of a fluctua- 
 tion, previously quite evident, and the subsi- 
 dence of all the hectical symptoms. A 
 complete dispersion of the swelling was 
 effected by a bandage and compress wet 
 with a strong decoction of oak bark and 
 alum. (See Trans, of the King's and Queen's 
 College of Physicians in Ireland, Vol.2,p. 
 26, tyc. 8co. Dublin, lbIS. F. Schoenmczel, 
 Obs. de Musculis Psoa et lliaco suppurntis , 
 Frank. Del. Op. V. R. Beckwith de Morbo 
 Psoadico. Edinb. 1784. Abernethy's Surgical 
 and Physiological Essays, Part 1 and 2. 
 Crowther' s Observations on White- Swelling, 
 ^c. 1808. Latta's System of Surgery , Vol. 3. 
 Callisen's Syslema Chirurgioe Hodi ernes, Vol. 
 1 ,p. 370. Pearson's Principles of Surgery, 
 p. 102, Edit. 2. Richter's Anfangsgrunde 
 der Wundarzneykunst, B. 5, 1 13; Gottingen , 
 1801.) 
 
 LUNAR CAUSTIC. (See Argentum ni- 
 tratum.) 
 
 LUPUS. See Noli me tangere. 
 
 LUXATION. See Dislocation. 
 
 Ifc/TAMMA, REMOVAL OF. The opera- 
 ill. ration of cutting away a diseased 
 breast, is done nearly in the same manner 
 as the removal of tumours in general, and is 
 indicated whenever the part is affected with 
 an incurable disease, which admits, how- 
 ever, of being entirely removed with the 
 knife. When the breast is affected with 
 scirrhus, or ulcerated cancer, the impru- 
 dence of tampering with the disease cannot 
 be too severely censured. Were the disor- 
 der unattended with a continual tendency 
 to increase, some time might properly be 
 dedicated to the trial of the internal reme- 
 dies, and external applications, which have 
 acquired any character for doing good in 
 these unpromising cases. But, unfortunately, 
 by endeavouring to cure the disease by 
 medicine, we only afford time for it to in- 
 crease in magnitude, and, at length, attain a 
 condition, in which even the knife cannot 
 be employed so as to take away the whole 
 of the diseased parts. When the case is 
 marked by the characteristic features of 
 scirrhus, noticed in the article Cancer, the 
 soouer the tumour is cut out, fb^ietter. 
 There are also some malignant kiYra's*5.f,sar 
 coma, to which the female breast is subject, 
 (as will be explained in the article Tumour,) 
 which cannoi be removed at loo early a 
 period after their nature is suspected, or 
 
 i/i 
 
 known. Indeed, though there is not equal 
 urgency for the operation when the tumour is 
 only an indolent, simple, fatty, or sarco- 
 matous disease, yet as all these tumours are 
 continually growing larger, and little success 
 attends the attempt to disperse them, the 
 practitioner should never devote much time 
 to the trial of unavailing medicines and 
 applications, and let the swelling attain a 
 size, which would require a formidable 
 operation for its excision. Besides, many 
 simple, fleshy, indolent tumours, are accom- 
 panied with a certain degree of hazard of 
 changing into very malignant forms ol 
 disease. 
 
 It is not meant to be denied, however, 
 there are many swellings and indurations of 
 the breast, which it would be highly injudi- 
 cious and unnecessary to extirpate, because 
 they generally admit of being discussed. 
 Such are many tumours, which are called 
 scrofulous, from their affecting patients of 
 this peculiar constitution ; such are nearly 
 all those indurations which remain after a 
 sudden and general inflammatory enlarge- 
 ment of the mamma ; such are most other 
 tumours, which acquire their full size in a 
 few days, attended with pain, redness, Lc. ; 
 and, of this kind, also, are the hardnesses 
 in the breast, occasioned bv the mammary 
 abscess. 
 
'MAMMA. 
 
 2iid 
 
 to the removal ot' all malignant or cance- 
 rous tumours, their nature makes it neces 
 sary to observe one important caution in 
 the operation, via. not to rest satisfied with 
 cutting away the tumours just at their cir- 
 cumference ; but to take away also a con- 
 siderable portion of the substance in which 
 they lie, and with which they are surrounded. 
 In cutting out a cancerous breast, if the ope- 
 rator were to be content with merely dissect- 
 ing out the disease, just where his eyes and 
 lingers might equally lead him to suppose 
 its boundary to be situated, there would 
 still be left behind white diseased bands, 
 which radiate from the tumour into the sur- 
 rounding fat, and which would inevitably 
 occasion a relapse. In a vast proportion of 
 the cases also, in which cancer of the breast 
 unfortunately recurs after the operation, it is 
 found that the skin is the part, in which the 
 disease makes its reappearance. Hence the 
 great prudence of taking away a good deal 
 of it in every case suspected to be a truly 
 scirrhous or cancerous disease. This may 
 also be done so as not to prevent the impor- 
 tant objects of uniting the wound hy the first 
 intention, and covering the whole of its sur- 
 face with sound integuments. So frequent- 
 ly does cancer recur in the nipple, whenever 
 it does recur any where, that many of the 
 best modern operators always make a point 
 of removing this part in every instance, in 
 which it is judged expedient to take away 
 any portion of the skin at all. The surgeon, 
 indeed, would be inexcusable, were he to 
 neglect to take away such portion of the in- 
 teguments covering scirrhous tumours, as is 
 evidently affected, appearingto bediscolour- 
 ed, puckered, and closely attached to the 
 diseased lump beneath. Nor should any 
 gland, in the axilla, at all diseased, nor any 
 fibres of the pectoral muscle, in the same 
 state, be ever left behind. There is no doubt, 
 that nothing has stamped operations for can- 
 cers with disrepute, so much as the neglect 
 to make a free removal of the skin, and 
 •parts surrounding every side of the tumour. 
 Hence, the disease has frequently appeared 
 to recur, when, in fact, it has never been 
 thoroughly extirpated ; the disease, though 
 entirely a local affection, has been deemed 
 a constitutional one ; and the operation 
 frequently rejected as ineffectual and use- 
 less. 
 
 But, strongly as I have urged the pru 
 dence, the necessity of making a free remo- 
 val of the skin covering, and of the parts 
 surrounding, every cancerous or malignant 
 tumour, the same plan may certainly be re- 
 garded as unnecessary, and therefore, unsci- 
 entific, in most operations for the removal 
 of simple, fatty, fleshy, or encysted tumours, 
 to which the breast and almost every other 
 part are liable. However, even in the lat- 
 ter cases, when the swelling is very large, 
 it is better to take away a portion of skin •, 
 for, otherwise, after the excision of the tu- 
 mour, there would be a redundance of in- 
 teguments, the cavity of which would only 
 serve for the lodgment of matter. The 
 loose superfluous skin also would lie in 
 
 folds, and not apply itself evenly to the 
 parts beneath, so as to unite favourably by 
 the first intention ; nor could the line of the 
 cicatrix itself be arranged w ith such nice 
 evenness as it might be, were a part of the 
 redundant skin taken au r ay at the time of 
 operating. 
 
 The best method of removing a diseased 
 breast is as follows : The patient is usually 
 placed in a sitting posture, well supported 
 by pillows and assistants ; but the operator 
 will find it equally convenient, if not more 
 so, to remove the. tumour with bis patient 
 in a recumbent position ; and this posture 
 is best whenever the operation is likely to 
 be long, or much blood to be lost, which 
 circumstances are very apt to bring on 
 fainting. I remember that Mr. Abernethy, 
 in his lectures, used to recommend the latter 
 plan ; which, however, without the sanction 
 of any great name, or authority, possesses 
 such obvious advantages, as will always en- 
 title it to approbation. 
 
 The arms should be confined back, by 
 placing a stick between (hem and the bo'dy, 
 by which means, the fibres of the great 
 pectoral muscle will he kept on the stretch, 
 a state most favourable for the dissection of 
 the tumour off its surface The stick also 
 prevents the patient from moving her arm 
 about, and interrupting the progress of the 
 operation. 
 
 When the tumour is not large, and only 
 a simple sarcoma, free from malignancy, it 
 will be quite unnecessary to remove any of 
 the skin, and, of course, this need only be 
 divided by one incision, of a length propor- 
 tionate to the tumour. The cut must be 
 made with a common dissecting knife; and 
 as the division of the parts is chiefly accom- 
 plished with the part of the edge towards 
 the point, the instrument will be found to 
 do its office best when the extremity.of the 
 edge is made of a convex shape, and this 
 part of the blade is turned a little back, in 
 the way in which dissecting knives are ’now 
 often constructed. 1 he direction of the 
 incision through the skin should be made 
 according to the greatest diameter of the 
 tumour to be removed, by which means it 
 will be most easily dissected out. 
 
 The direction of the incision is various 
 with different practitioners ; some making 
 it perpendicular, others transverse. In ge- 
 neral, the shape of the tumour must deter- 
 mine which is the best. In France, it has 
 been said, that when the incision follows 
 the second direction, it heals more expedi- 
 tiously, because the skin is more extensible 
 from above downward, than laterally, par- 
 ticularly towards the sternum, and conse- 
 quently allows the sides of the wound the 
 more readily to be placed in contact ; and 
 that the action of the pectoral muscle tends 
 to separate the edges of the wound when it 
 is perpendicular. On the other hand, it is 
 allowed that the wound, made in the latter 
 manner, is the most favourable for the 
 escape of the discharge, if suppuration 
 should occur. (See (Euvres (h Desault var 
 Bichat , p, 312. T. 2.Y 
 
MAMMA. 
 
 sm 
 
 The cut through the skin should always 
 be somewhat longer than the tumour ; and 
 as it is perhaps, the most painful part of the 
 operation, and one attended with no danger 
 whatever, it should be executed with the 
 utmost celerity, pain being more or less 
 dreaded, according to its duration, as well 
 as its degree. The fear, however, of giving 
 pain, has probably led many operators to 
 err, in not making their first incision through 
 the integuments large enough, the conse- 
 quence of which has often been that there 
 was not sufficient room for the dissection of 
 the tumour with facility ; the patient has 
 been kept nearly an hour in the operating 
 room, instead of five minutes, and the sur- 
 geon censured by the spectators, as awk- 
 ward and tedious. It is clear also, that, 
 besides the great deal more blood lost, from 
 this error, than would otherwise happen, 
 the vessels being commonly not tied till all 
 the cutting is finished, the avoidance of 
 pain, that fear, which led to the blunder, is 
 not effected, and the patient suffers much 
 more, and for a much longer time, in conse- 
 quence of the embarrassment and obstacles 
 in the way of the whole operation. 
 
 When the disease is of a scirrhous or ma- 
 lignant nature, the skin covering the tu- 
 mour should at all events, be in part remo- 
 ved. As I have said before, all that portion 
 which is discoloured, puckered, tubercula- 
 ted, or otherwise altered, should be taken 
 away. Some must also be removed, in 
 order to prevent a redundance, in all cases 
 in which the tumour is large. We have 
 said too, that in cases of scirrhus and cancer 
 of the breast, the nipple is considered a 
 dangerous part to be left behind. For the 
 purpose of removing the necessary portion 
 of skin, the surgeon must obviously pursue 
 a different mode from that above described; 
 and, instead of one straight incision, he is to 
 make two semicircular cuts, one immedi- 
 ately after the other, and which are to meet 
 at their extremities. The size of these 
 wounds must be determined by that of the 
 disease to be removed, and by the quantity 
 of skin, which it is deemed prudent to take 
 away ; for the part, which is included in the 
 two semicircular cuts, is that which is not 
 to be separated from the upper surface of 
 the swelling, but taken away with it. The 
 shape of the two cuts together may approach 
 that either of a circle or oval, as the figure 
 of the tumour itself may indicate, as most 
 convenient. The direction of the incisions 
 is to be regulated by the same consideration. 
 
 In the above ways, (he first division of the 
 integuments is to be made in removing tu- 
 mours of every description, covered with 
 skin. The same principles and practice 
 should prevail in all these operations; and, 
 whether the swelling is the mamma, or any 
 other diseased mass, whether situated on the 
 chest, the back, the head, or extremities, the 
 same considerations should always guide the 
 operator’s hand 
 
 The incision, or incisions, in the skin 
 having been made, the next object is to 
 detach every side of the tumour from its 
 
 connexions, and the separation of its ba3e 
 will then be the last and only thing remain- 
 ing to be done. When the tumour is a 
 scirrhus, or other malignant disease, the 
 operator must not dissect close to the swell- 
 ing, but make his incisions on each side, at 
 a prudent distance from it, so as to be sure 
 to remove, with the diseased mass, every 
 atom of morbid mischief in its vicinity. But 
 when the tumour is only a mere fatty, or 
 other mass, perfectly free from malignancy, 
 the cellular bands and vessels forming its 
 connexions, may be divided close to its 
 circumference. It is astonishing with what 
 ease fatty tumours are removed, after the 
 necessary division is made in the skin ; they 
 may almost be turned out with the fingers, 
 without any cutting at all. When they have 
 been inflamed, however, they are then more 
 adherent to the surrounding parts. 
 
 Thus we see, that the first stage of the 
 operation of removing a tumour, is the divi- 
 sion of ttfe skin ; the second, the separation 
 of the swelling from the surrounding parts 
 on every side ; the third and last stage is the 
 division of the parts to which its under 
 surface, or base, is attached. The latter 
 object should be accomplished by cutting 
 regularly from above downward, till every 
 part is divided. 
 
 It is a common thi«g to see many opera- 
 tors constantly embarrassed and confused, 
 whenever they have to remove a large tu- 
 mour, on account of their having no parti- 
 cular method in their proceedings. They 
 first cut a few fibres on one side, then on 
 another ; and, turning the mass of disease 
 now to this side, now to that, without any 
 fixed design, they both prolong the opera- 
 tion very tediously, and present to the 
 bystanders a complete specimen of surgical 
 awkwardness. On the contrary, when the 
 practitioner divides the cutting part of the 
 operation into the three methodical stages 
 above recommended, in each of which there 
 is a distinct object to be fulfilled, he pro- 
 ceeds with a confidence of knowing what 
 he is about, and soon effects what is to be 
 done, with equal expedition and adroitness. 
 
 Having taken out the tumour, the operator 
 is immediately to tie such large vessels as 
 may be pouring out their blood ; indeed, 
 when the removal of the swelling will ne- 
 cessarily occupy more than three or four 
 minutes, it is better to tie all the large arte- 
 ries as soon as they are divided, and then 
 proceed with their dissection. This was the 
 celebrated Desault’s plan, and it is highly 
 deserving of imitation in this country, not 
 only because many subjects cannot afford 
 to lose much blood, but also because the 
 profuse effusion of this fluid keeps the ope- 
 rator from seeing what parts he is dividing. 
 
 The largest arteries being tied, the surgeon 
 should not be immediately solicitous about 
 tying every bleeding point which may be 
 observed. Instead of this, let him employ 
 a little while in examining every part of (he 
 surface of the wound, in order to ascertain 
 that no portion of the swelling, no hardened' 
 lump, nor diseased fibres remain behind. 
 
MAMMA. 
 
 !Evcn if any part of the surface of the pec- 
 toral muscle should present a morbid feel, 
 or appearance, it must on every account 
 be cut away. Also, if any of the axillary 
 glands are diseased, the operator should now 
 proceed to remove them. After the time 
 .spent in such measures, many of the small 
 vessels, which bled just after the excision 
 of the swelling, will now have stopped, the 
 necessity for several ligatures will be done 
 away, and, of course, the patient saved a 
 great deal of pain, and more of the wound 
 be likely to heal by the first intention. 
 
 Some information may be derived, res- 
 pecting whether any of tbe tumour is left 
 behind, by examining its surfaces, when 
 taken out, and observing whether any part 
 of them is cut off ; for, if it is, it may always 
 be found in the corresponding part of the 
 wound. 
 
 The axillary glands may invariably be 
 taken out without the least risk, if the plan 
 pursued by Desault in France, and the late 
 Sir Charles Blicke, and other eminent sur- 
 geons in this country, be adopted. The 
 method alluded to is, after dividing the skin 
 covering the gland, and freeing the indura- 
 ted part from its lateral connexions, to tie 
 its root, or base, by which it is connected 
 with the parts on the side towards the cavity 
 of the axilla Then the indurated gland 
 itself may be safely cut off, just above the 
 ligature. Were the gland cut off in the first 
 instance, the artery which supplies it with 
 blood would be exceedingly difficult to tie, 
 on account of its deep situation ; and by 
 reason of its shortness and vicinity to tbe 
 heart, it would bleed almost like a wound of 
 tbe thoracic artery itself. In this way, there 
 is also not the least hazard of injuring the 
 latter vessel. It would be a great improve- 
 ment in the mode of operating for tbe re- 
 moval of these glands, if surgeons were 
 always to make the patient lie down, with 
 the arm placed in such a position as would 
 let the light fall into the axilla. How much 
 the steps of the operation would be facili- 
 tated in this way, I need not attempt to 
 explain. 
 
 The above directions will enable a sur- 
 geon to remove tumours in general. They 
 apply also in a great measure to encysted tu- 
 mours ; but, a few particular rules how to 
 operate in the latter cases, will be found in 
 the article Tumours. One half of each liga- 
 ture is always to be cut off before dressing 
 the wound. The edges of the incision are to 
 be brought together with strips of adhesive 
 plaster ; and, before this can be done with 
 ease, the stick confining the arm back must 
 be removed, and the os brachii brought for- 
 ward, so as to relax the pectoral muscle, and 
 integuments of the breast. No sutures should 
 ever be employed, as they are useless, pain- 
 ful, and irritating. The wound being closed 
 with sticking plaster, and a pledget of simple 
 cerate, a compress of folded linen, or flan- 
 nel, may be put over the dressings ; these 
 are to be secured with a broad piece of linen, 
 which is to encircle tbe chest, be fastened 
 with pins, or stitches, and kept from slipping 
 VoL. II 29 
 
 down by two tapes, one of which is to go 
 from behind forward, over each shoulder, 
 and be stitched to the upper part of the 
 bandage, both in front and behind. The 
 arm on the same side as that, on which the 
 operation has been done, should be kept 
 perfectly motionless in a sling; for, every 
 motion of the limb must evidently disturb the 
 wound, by putting the great pectoral muscle 
 into action, or rendering its fibres sometimes 
 tense, sometimes relaxed. It is scarcely ne- 
 cessary to say, that, after so considerable an 
 operation as the removal of a large breast, 
 or any other tumour of magnitude, the pa- 
 tient should be given about thirty drops of 
 the tinctura opii. A smaller dose always 
 creates restlessness, headach, and fever, af- 
 ter operations, instead of having the desi- 
 red effect. 
 
 Here it becomes me to state, that as I 
 could not find in any surgical book with 
 which I am acquainted, what I conceived to 
 be a proper description of the mode of re- 
 moving a diseased breast, and tumours in 
 general, the foregoing remarks are given 
 chiefly on my own authority. Whetherthey 
 are just, or not, must he decided by the pro- 
 fession. 
 
 The removal of a diseased breast rarely 
 proves fatal of itself, unless the parts cut 
 away extend to a considerable depth, and 
 occupy a very large space, or the patient is 
 much reduced before the operation. How- 
 ever, about two years ago, a patient in St. 
 Bartholomew’s Hospital died, without any 
 very apparent cause, very soon after being 
 operated upon ; and Schmucker has record- 
 ed an instance, in which the operation was 
 followed by tetanus. ( Wahmehmungen. B. 
 2, p. SO.) 
 
 W ith respect to the average success, fol- 
 lowing the removal of cancerous diseases, 
 this is a topic, which has been noticed in the 
 article Cancer. The statement lately made 
 by Baron Boyer is exceedingly unfavoura- 
 ble ; for, in one hundred cases, in which he 
 has removed the diseased parts, only four or 
 five of the patients continued radically cu- 
 red. ( Traile des Mai. Chir. T. 7 p. 237, 8 ro. 
 Paris, 1821.) 
 
 The principal writers on the removal of 
 the mamma are, Garengeot, Dionis, Le Dran, 
 Bertrandi, Sharp, and Sabatier, in their res- 
 pective treatises on the operations. B. Bell, 
 Latta, &,c. have also treated on the subject 
 in their Systems of Surgery ; and there is a 
 memoir Sur V Operation du Cancer au Sciiiy 
 in Les (Euvres de Desault par Bichat. T. 2. 
 
 MAMMARY ABSCESS. Milk' Mscess. 
 With regard to inflammations of the mamma, 
 as my friend, Mr. James has observed, there 
 is “ either simple phlegmon, or mammary 
 abscess, which, as it depends upon a peculi- 
 arity of state and function, ought to stand 
 alone. Mr. Hey alsp describes a deep-seat- 
 ed abscess, to which this gland is liable, of 
 rather a chronic character, and is the same, 
 perhaps, as that which Dr. Kirkland has de- 
 scribed as the encysted. Dr. K. describes 
 also two others, under the titles of chronic 
 and encysted.” Certain cases most frequent* 
 
MAMMA. 
 
 226 
 
 ly occurring in unmarried females, and ha- 
 ving very little tendency to suppuration, 
 Mr. James suspects, are the result of inflam- 
 mation of the gbmdular part of the breast 
 from disorder in the digestive organs, uterine 
 system, or both. (On Inflammation, p. 171.) 
 
 Women who suckle are particularly sub- 
 ject to inflammation and suppuration in the 
 breast. The part enlarges, becomes tense, 
 heavy, and painful. The integuments of the 
 breast sometimes assume an uniform red- 
 ness ; sometimes they are only red in parti- 
 cular places. The inflammation may affect 
 the mammary gland itself, or be confined to 
 the skin and surrounding cellularsubstar.ee. 
 In the latter case, the inflamed part is equally 
 tense ; but, when the glandular structure of 
 the breast is also affected, the enlargement is 
 irregular, and seems to consist 6f< one or 
 more large tumours, situated in the sub- 
 stance of the part. The pain often extends 
 to the axillary glands. The secretion of the 
 milk is not always suppressed, when the in- 
 flammation is confined to the integuments, 
 and suppuration is said to come on more 
 quickly, than in the affections of the mam- 
 mary gland itself When the symptoms of 
 inflammation continue to increase for four 
 or five days, suppuration may be expected ; 
 unless the progress of the inflammation be 
 slow, and its degree moderate, in which cir- 
 cumstances, resolution may often be obtain- 
 ed, even as late as a fortnight after the first 
 attack. Inflammations of the breast are 
 almost always attended with symptoms of 
 the sympathetic inflammatory fever. (See 
 Fevers, Surgical .) 1 think authors err, who 
 
 describe the febrile disorder as generally 
 preceding the local complaint 
 
 Women are most liable to mammary ab- 
 scesses within the first three months after 
 parturition , but they are also very much 
 exposed to the disorder as long as they con- 
 tinue to suckle. 
 
 The most common causes occasioning the 
 mammary abscess, as enumerated by writers 
 in general, are, repressing the secretion of 
 milk at an early period, mental disturbance, 
 fright, &c. ; exposure to cold, moving the 
 arms too much while the breasts are very 
 large and disteuded, bruises, and other ex- 
 ternal injuries. The causes are not always 
 obvious. 
 
 The matter is sometimes contained in one 
 cyst, or cavity ; sometimes in several ; but 
 the abscess generally breaks near the nipple. 
 
 As all inflammations of the mamma are 
 attended with considerable induration, these 
 cases should be carefully distinguished from 
 other swellings of a more incurable kind. 
 Jt is said, that scrofulous tumours of the 
 mamma, which have existed a long while, 
 often disappear after the occurrence of a 
 milk abscess. Women who have never 
 been pregnant are sometimes affected with 
 suppuration in the breast, supposed by Mr. 
 James, of Exeter, to be connected with ute- 
 rine, or gastric disorder. Even men are 
 suiti to be. liable to similar complaints. 
 
 In the early period of the affection, reso- 
 lution should be attempted. The following 
 
 are the principal means for this purpose : — 
 topical blood-letting, saline purges, low 
 diet, keeping the inflamed breast from hang- 
 ing down, gentle friction of the breast, w ith 
 a soft sponge, wet w itb some w arm emollient 
 liquor ; having the milk tenderly sucked out 
 at proper intervals ; saturnine applications, 
 or lotions containing the muriate of am- 
 monia 
 
 VY hen matter cannot be prevented from 
 forming, an emollient poultice is the best 
 application, and the abscess should in gene- 
 ral be allowed to break of itself unless of a 
 somewhat chronic nature, in . hich case it 
 should be opened in a depending part with 
 a lancet. Sinuses sometimes form, in con- 
 sequence of abscesses in the breast, and will 
 not heal till freely opened with a director 
 and curved bistoury. When the cavity of 
 the abscess begins to fill up with granula- 
 tions, the poultice may be left oft', and su- 
 perficial dressings applied. 
 
 The indurations, often remaining in the 
 breast, in consequence of acute inflamma- 
 tion and abscesses, generally yield to fric- 
 tions with camphorated mercurial ointment, 
 the application of a piece of soap plaster, 
 and the exhibition of calomel, cicuta, and 
 other alteratives. 
 
 Mr. Hey describes a very deep-seated ab- 
 scess of the breast, not of frequent occur- 
 rence, and not confined to pregnant nor 
 suckling women. Its situation renders all 
 superficial applications ineffectual. The 
 inflammatory stage is tedious ; and when 
 the matter has made its way outward, the 
 discharge continues, and there is no ten- 
 dency to healing. Sometimes the matter 
 lodges behind the mamma, as well as in the 
 substance of the gland, and breaks out in 
 different places, the intermediate parts of the 
 breast feeling as if affected with a scirrhous 
 hardness. There are numerous sinuses run- 
 ning in different directions, and, when 
 opened, a soft purple fungus appears w ith- 
 in them. The disease goes on in this state 
 for a long while, keeping up hectic symp- 
 toms. 
 
 Mr. Hey’s practice is to trace the course 
 of all the numerous sinuses, and lay them 
 open, and, unless this be done, with respect 
 to every one of them, the cure cannot be 
 accomplished. If he finds any two sinuses 
 running in such directions, that when fully 
 opened, they leave a small part of the mam- 
 ma in a pendulous state, be removes such 
 part entirely. As the sinuses are filled with 
 fungus, their continuations present no visi- 
 ble cavity, and can only be detected by the 
 greater softness of parts of the w ouud, 
 w here, on breaking down the fungus, the 
 orifice of the collateral sinus may be found. 
 Mr. Hey has found, that even in the most un- 
 favourable subjects the wounds heal quickly, 
 and the natural shape of the breast is pre- 
 served. 
 
 Consult Pearson's Principles of Surgery , 
 chap 3. Iiey's Practical observations, p. 
 604. Kirkland has also treated of several 
 kinds of abscesses of the breast, in his Inquiry 
 into Hit present State oj Medical Surgery , Vol 
 
MERCURY. 
 
 227 
 
 2, p. 161. Callisen's Syslema Chirurgicc IIo- 
 ditrrue , Vol. 1, p. 332. Gibbons , De Mulie- 
 brum Alain mis tt Morbis quibus obnoxice sunt, 
 St’o. Edinb. 1775. «/. Clubbe , Treatise on the 
 
 Inflammation of the Breasts, peculiar to Ly- 
 ing-in Women, fyc. 8 vo. Ipsivich, 1799. M. 
 Under wood, Treatise upon Ulcers , fyc. and on 
 the Mammary Abscess, fyc. 8ro. Land 1783. 
 J. H. James, on the Principles of Inflamma- 
 tion, p. 171, 8vo. Lond. 1821. Boyer, Traiti 
 des Mai. Chir. T. 7, p. 211,4-c. 8vo. Par<s, 
 1821. The German reader may refer to 
 Richters An fangsgr. der Wundarzn. B. 4, 
 chap. 16. 
 
 [*M AXILLA INFERIOR. Byareference 
 to the article Osteo Sarcoma, in the Appen- 
 dix, will be found recorded three instances 
 wherein portions of the lower jaw were ex- 
 tirpated by Professor Mott, of New-York, 
 for the removal of this disease; the carotid 
 artery, in the several instances, having been 
 previously tied. — Am. Ed.] 
 
 MELICERIS. (from /u&j, honey, and 
 xnpoc, wax. A tumour of the encysted kind, 
 filled with a substance resembling wax, or 
 honey, in consistence. (See Tumours, En- 
 cysted.) 
 
 MENINGOPHYL \X. (from /Amy%, a 
 membrane, and to guard.) An in- 
 
 strument used by the ancients for guarding 
 the dura mater and brain from injury, in 
 their mode of trepanning. It seems to have 
 been something like the lenticular, only its 
 blade was completely round without an 
 edge. It ended in a lentiform cup, like the 
 latter. ( Encyclopedic Methodique, Partie 
 Chirurgicale.) Pott gives an engraving of 
 a meningophylax, which resembles a com- 
 mon elevator. (See Vol. 1. of, his Works.) 
 
 MERCURY". ( Quicksilver . Mercurius. 
 
 Hydrargyrus.) The medicinal virtues of 
 this mineral were almost totally unknown 
 to the ancients, who considered it as a poi- 
 son It was first employed for purposes of 
 medicine by the Arabians, who made use of 
 it in the form of ointments for the cure of 
 certain diseases of the skin and the killing 
 of vermin. In modern times mercury is 
 one of the most important articles of the 
 materia medica; arid though pe haps recent 
 investigations will not strictly allow it to 
 be regarded as a specific for the venereal 
 disease, which may be cured by other 
 means, or sometimes even spontaneously, 
 while mercury, so far from being always a 
 certain cure, is sometimes highly detrimen- 
 tal, yet notwithstanding these facts, mercury 
 still retains the character of being generally 
 the most expeditious means of relief. The 
 possibility of curing the venereal disease 
 without mercury, by no means establishes 
 the propriety of abandoning this remedy, 
 any more than its unfitness for certain states 
 of the same disease is a reason for not avail- 
 ing ourselves of its superior utility in others. 
 
 Mercury, taken into the stomach in its 
 metallic state, has no action on the body, 
 except what arises from its weight or bulk. 
 It is not poisonous, as was vulgarly suppo- 
 sed, but perfectly inert. But, in its various 
 state* of combination, it produces certain 
 
 sensible effects. Tt is a powerful and gene- 
 ral stimulant, quickening t lie circulation, 
 and increasing all the secretions and excre- 
 tions. According to circumstances, the 
 habit of the patient, the temperaturd' in 
 which he is kept, the nature of the prepara 
 tion, and the quantity in which it is exhibit- 
 ed, its effects are, indeed, various. Some- 
 times, it more par'icularly increases one 
 secretion; sometimes another ; but its most 
 characteristic etfect is the increased flow of 
 saliva, which it generally excites, if given 
 in sufficient quantity. (Edinb. Dispensatory.) 
 
 From the writings of Theodoric, it appears 
 that mercury was employed in the practice 
 of medicine aad surgery as early as the 13th 
 century. But, its use in venereal cases was 
 first mentioned in a tract by Almeriar, pub- 
 lished in 1516' (See Thompson's Dispensatory , 
 p. 205, Edit. 2.) 
 
 it has been said, that the efficacy of mer- 
 cury in curing the venerea! disease was an 
 accidental discovery ; but it seems more 
 probable, that the good effects, which it pro- 
 duced in cutaneous diseases, first led to the 
 trial of it in venereal cases, which being 
 frequently attended with eruptions on the 
 skin, ulcers, &c. seemed to present an 
 analogy to the affections, in which mercury 
 had already been found successful. 
 
 In the times, immediately following the 
 origin of the venereal disease, practitioners 
 only ventured to employ this remedy with 
 timorous caution, so that, of several of their 
 formulae, mercury scarcely composed a 
 fourteenth part, and either on this account, 
 or some difference in the disease itself at that 
 period from what is now remarked, few 
 cures were effected. On the other hand, the 
 empirics, who noticed the little efficacy of 
 these small doses, ran into the opposite ex- 
 treme, and exhibited mercury in quantities 
 so large, and with such liitle care, that most 
 of their patients were suddenly attacked 
 with violent salivations, frequently attended 
 with very dangerous, and even fatal symp- 
 toms ; or such as after making them lose 
 their teeth, left them pale, emaciated, ex- 
 hausted, and subject, for the rest of their 
 lives, to tremblings, or other more or less 
 dangerous affections. From these two very 
 opposite modes of practice, there originated 
 such uncertainty, respecting what could be 
 expected from mercury, and such fears of 
 the consequences, which might result from 
 its employment, that every plan was eagerly 
 adopted, which offered the least chance of 
 cure, without havingrecourse to this mineral 
 
 A medicine, however, so powerful, and 
 whose salutary effects had been watched by 
 attentive practitioners amidst all its incon- 
 veniences, could not sink into oblivion. 
 After efforts had been made to discover an 
 equally efficacious substitute for it, and it 
 had been seen, how inferior other means 
 were, on which the highest praises had been 
 lavished, the attempts to extend its utility 
 were renewed. A medium was pursued, 
 between the too timid methods of those 
 physicians, who had first administered it, 
 and the inconsiderate boldness of the empL 
 
MERCURi . 
 
 
 l ies. Thus the causes, from which both par- 
 ties failed, were avoided ; the character of 
 the medicine was revived in a more durable 
 way, and from this period, its reputation has 
 always been maintained. 
 
 The renowned Paracelsus first taught practi- 
 tioners that mercury might be given internal- 
 ly with safety ; for, before he set the exam- 
 ple ; it had only been externally employed, 
 in three manners. The first was in the 
 form of an oiniment or liniment ; the second 
 as a plaster ; and the third, as a fumigation. 
 
 The basis of the ointment, or liniment, was 
 quicksilver, which was blended, by means of 
 trituration, with hog s lard, goose’s fat, &c. 
 and composed scarcely one-sixth or one- 
 eighth of the whole ; a proportion, however, 
 much greater, than what had been at first 
 employed. But from a fear, that the mi- 
 neral might prove hurtful to the nerves, by 
 the cold property which they fancied it 
 possessed, and that it might occasion numb- 
 ness, tremblings, or palsies, they combined 
 with it a multitude of ingredients of a warm, 
 aromatic nature, or supposed to possess such; 
 for example, oil of camomile, sesame-seeds, 
 aniseeds, the roots of zedoary, and the floren- 
 tine iris, and a thousand other substances, 
 which were incorporated with the ointment. 
 The members, joints, and the whole of the 
 body, except the head, belly, and chest, 
 were rubbed with this composition ; and the 
 frictions were repeated, at suitable intervals, 
 until obvious signs of salivation appeared. 
 
 The ingredients of the plasters resembled 
 those of the ointments ; only they contained 
 less fat, for which was substituted a sufficient 
 quantity of wax, to give them a proper con- 
 sistence. This composition was applied to 
 the skin, and the whole body was covered 
 with it, excepting the parts on which it was 
 not usual to put ointment. The plasters 
 were kept on, till salivation began. 
 
 The fumigations were made with quick- 
 silver, triturated with turpentine, or saliva, 
 or else with cinnabar. These substances 
 were mixed with fatty, or resinous ones, 
 such as myrrh, nutmeg, &c. and, all the in- 
 gredients being reduced to powder, were 
 made into a paste, with a sufficient quantity 
 of turpentine, or gum tragacantb. The pa- 
 tient was then placed in a box made on pur- 
 pose, or under a little kind of tent, out of 
 which the head was generally allowed to 
 protrude. A chafing-dish, containing burn- 
 ing coals, was placed near his feet, and 
 every now and then, bits of mercurial paste 
 were thrown into the vessel. The patient 
 was left exposed to the fumes, which arose, 
 until he broke oulinto a profuse perspiration, 
 which they took great pains to keep up and 
 increase, by putting him into a warm bed, 
 loading him with bedding, for about two 
 hours, after which he was rubbed t^ite dry, 
 and given some food. This plan was' persist- 
 ed in every day, till a salivation* W'eIS. pro- 
 duced, which was kept up as long as neces- 
 sary. The method of fumigation is, described 
 by Astriic, and particular preparations, and 
 apparatuses for the purpose, have been since 
 
 recommended by La'lonette in France, and # 
 more recently, by Abernethy in England. 
 
 Of the three methods, which we have just 
 described, only the first is at present much in 
 use, and even this is considerably altered. It 
 was found, not only that mercurial plasters 
 caused heat, redness, itching, and disagree- 
 ble eruptions, but, that the method was ex- 
 ceedingly slow and uncertain. Hence, 
 plasters are now only used as topical discu- 
 tient applications. 
 
 Fumigations, considered as the only means 
 of cure, fell also into discredit, because, 
 although they formed a method of applying 
 mercury in a very active manner, they were, 
 as anciently managed, liable to several ob- 
 jections. In this way, it was next to impos- 
 sible to regulate the quantity of mercury 
 used, which varied according to the greater 
 or lesser activity of the fire, the position of 
 the patient, and other circumstances. The 
 effect of the vapour on the organs of respira- 
 tion also frequently proved very oppressive 
 and mercury, applied in the way of fumiga- 
 tion, more frequently occasioned tremblings, 
 palsies, &lc. than in any other manner. In 
 Mr. Abernethy’s mode, however, fumigation 
 is, under certain circumstances, not only an 
 eligible, but, the very best way of affecting 
 the constitution. 
 
 f rictions with ointment have always been 
 regarded as the most efficacious. They have 
 undergone considerable change, and by 
 being rendered more simple, have been 
 greatly perfected. All the warm aromatic 
 substances have been retrenched from the 
 ointment, not only as useless, but as irritating 
 and inflaming to the skin. In modern times, 
 the proportion of mercury to the fat has 
 also been very much increased. 
 
 GENERAL REMARKS ON THE ADMINISTRA- 
 TION OF MERCURY, ITS OCCASIONAL CON- 
 SEQUENCES, &C. 
 
 With regard to the preparations of the 
 medicine, and the modes of applying it, we 
 are to consider two things ; first, the prepa- 
 ration and mode attended with the least 
 trouble or inconvenience to the patient : 
 and secondly, the preparation, and mode of 
 administering it, that most readily conveys 
 the necessary quantity into the constitution. 
 Mercury is carried into the constitution in 
 the same way as other substances, either by 
 being absorbed from the surface of the body, 
 or that of the alimentary canal. It cannot, 
 however, in all cases, be taken into the con- 
 stitution in both ways; for, sometimes the 
 absorbents of the skin will not readily 
 receive it, at least, no effect is produced, 
 either on the disease or constitution, from 
 this mode of application. In this circum- 
 stance, mercury must be given by the mouth, 
 although the plan may be very improper in 
 other respects, and often inconvenient. On 
 the other hand, the internal absorbents some 
 dimes will not take up the medicine, or, at 
 Toast, no effect is produced on the disease, 
 or the constitution. 
 
 In such cases, all the different preparation; 
 of the medicine should be tried for some 
 
MERCURY. 
 
 229 
 
 .iiaes oue succeeds, when another will not. 
 In some cases, mercury seems to have no 
 effect, either applied outwardly, or taken in- 
 to the stomach. Many surfaces seem to ab- 
 sorb mercury better than others : such are 
 probably all internal surfaces and sores. 
 Thirty grains of calomel, rubbed in on the 
 skin, have not more effect, than three, or 
 four, taken by the mouth. Dressing small 
 ulcers with red precipitate sometimes causes 
 a salivation. (See Hunter on the Venereal 
 Disease, p. 335,336.) 
 
 Besides the practicableness of getting tiie 
 medicine into the constitution in either way, 
 it is proper to consider the easiest for the 
 patient, each mode having its convenience 
 and inconvenience, depending on the nature 
 of the parts to which it is applied, or on 
 certain situations of life at the time. Hence, 
 it should be given in the way most suitable 
 to such circumstances. 
 
 In many, the bowels can hardly bear mer- 
 cury at ail, and it should then be given in 
 the mildest form possible, conjoined with 
 such medicines as will lessen or correct its 
 violent local effects, although not its specific 
 ones on the constitution. 
 
 When mercury can be thrown into the 
 constitution with propriety by the external 
 method, it is preferable to the internal plan, 
 because the skin is not nearly so essential to 
 life as the stomach, and therefore, is capable 
 in itself of bearing much more than the sto- 
 mach. The constitution is also less injured. 
 Many courses of mercury would kill the pa- 
 tient, if the medicine were only given inter- 
 nally, because it proves hurtful to the 
 stomach and intestines, when given in any 
 form, or joined with the greatest correctors. 
 Every one, however, has not opportunities 
 of rubbing in mercury, and is therefore 
 obliged, if possible, to take it by the mouth. 
 (Hunter, p. 338.) 
 
 Mercury has two effects ; one as a stimu- 
 lus on the constitution and particular parts; 
 the other as a specific against a diseased ac- 
 tion of the whole body, or of parts, ihe 
 latter action can only be computed by the 
 disease disappearing. 
 
 In giving mercury in the venereal disease, 
 the first attention should be to the quantity, 
 and its visible effects in a given time, which, 
 when brought to a proper pitch, are only to 
 be kept up, and the decline of the disease 
 to be watched ; for by this we judge of the 
 invisible, or specific effects of the medicine, 
 and know what variation in the quantity 
 may be necessary. The visible effects of 
 mercury affect, either the whole constitu- 
 tion, or some parts capable of secretion. In 
 the first, it produces universal irritability, 
 making it more susceptible of all impres- 
 sions. It quickens the pulse, increases its 
 hardness, and occasions a kind of temporary 
 fever. In some constitutions, it operates 
 like a poison ; whife, in others, it produces a 
 kind of hectic fever, that is, a small quick 
 pulse, loss of appetite, restlessness, want of 
 sleep, and a sallow complexion, with a num- 
 ber of consequent symptoms; but, sucli 
 effects commonly diminish, on the patient 
 
 becoming a little accustomed to the medi- 
 cine. Mercury often produces pains like 
 those of rheumatism, and nodes of a scro- 
 fulous nature. ( Hunter , p. 339, 340.) 
 
 The quantity of mercury to be thrown 
 into the constitution, for the cure of 
 any venereal complaint, must be propor- 
 tioned to the violence of the disease. How- 
 ever, we are to be guided by two cir- 
 cumstances, namely, the time in which 
 any given quantity is to be thrown in, and 
 the effec ts it has on some parts of the body, 
 as the salivary glands, skin, or intestines. 
 For, mercury may be thrown into the same 
 constitution in very different quantities, so as 
 to produce the same ultimate effect , but the 
 two very different quantities, must also 
 be in different times . for instance, one 
 ounce of mercurial ointment, used in two 
 days, will have more effect upon the consti- 
 tution, than two ounces used in ten. The 
 effects of one ounce, used in two days, on 
 the constitution and diseased parts, are con- 
 siderable. A small quantity, used quickly, 
 w II have equal effects, to those of a large 
 one employed slow ly ; but, if these effects 
 are principally local, that is, upon the glands 
 of the mouth, the constitution at large not 
 being equally stimulated, the effect upon the 
 diseased parts must be less, which may be 
 known by the local disease not giving way 
 in proportion to the effects of mercury on 
 some particular part. If it is given in 
 very small quantities, and increased gradual - 
 ly, so as to steal insensibly on the constitu- 
 tion, a vast quantity at a time may at length 
 be used without any visible effect at all. 
 ( Hunter , p. 341 .) 
 
 Tiie ecircumstances being known, mercu- 
 ry becomes a much more efficacious, ma- 
 nageable, and safe medicine, than it was 
 f rmerly thought to be ; but, unluckily, its 
 visible effects upon the mouth and the intes- 
 tines are -ometimes much more violent, than 
 its general effect upon the constitution at 
 lar^e. Ihese parts must therefore not be sti 
 mulated so quickly as to hinder the necessary 
 quantity of mercury from being used. 
 
 The constitution, or parts, are more sus- 
 ceptible of mercury at first, than afterward. 
 If the mouth is made sore, and allowed to 
 recover, a much greater quantity may be 
 thrown iu, a second time, before the same 
 soreness is produced. However, anomalous 
 cases occur, in which, from unknown causes, 
 mercury cannot at one time be made to pro- 
 duce any visible effects ; but, afterward, tho 
 m mth Hid intestines are all at once affected. 
 ( Hunter , p. 342.) 
 
 Mercury occasionally attacks the bowels, 
 and causes violent purging, even of blood. 
 This effect is remedied by discontinuing the 
 use of the medicine, and exhibiting opium. 
 Ai otl^er times, it is suddenly determined to 
 the mouth, e and produces inflammation, ulce- 
 ration, and ari excessive flow of saliva. To 
 obtain relief in this circumstance, purga- 
 tives, nitre, sulphur, gum-arabic, lime-w T ater, 
 camphor, bark, the sulphuret of pot isb, 
 blisters, &ic. have been advised. Mr. Pear- 
 son, however, does not seem to place ranch 
 
MERCURY. 
 
 230 
 
 confidence in the efficacy of such means, 
 and the mercury being discontinued for a 
 time, he recommends the patient to be freely 
 exposed to a dry cold air, with thp occa- 
 sional use of cathartics, peruvian bark, and 
 mineral acids, and the assiduous application 
 of astringent gargles. “ The most material 
 objection, (says Mr. Pearson,) which I fore- 
 see against the method of treatment I have 
 recommended, is the hazard to which the 
 patient will be exposed, of having the saliva 
 suddenly checked, and of suffering some 
 other disease, in consequence of it. 
 
 {{ That the hasty suppression of a ptyalism 
 may be followed by serious inconveniences, 
 has been proved by Dr. Silvester, {Med. Obs. 
 and Inq. Vol. 3.) who published the cases of 
 three persons, who had been under his own 
 care ; two of whom were afflicted with vi- 
 olent pains; and the third scarcely retained 
 any food in her stomach for the space of 
 three months. I have seen not only pains, 
 but even general convulsions produced from 
 the same cause. But, this singular kind of 
 metastasis of the mercurial irritation does 
 not appear to me to owe its appearance to 
 simple exposure to cold and dry air ; be- 
 cause I have known it occur in different 
 forme, where patients continued to breathe 
 a warm atmosphere, but used a bath, the 
 water of which was not sufficiently heated. 
 Cold liquids, taken in a large quantity info 
 the stomach, or exposure of the body to cold 
 and moisture, will also prove extremely in- 
 jurious to those, who are fully under the 
 influence of mercury ; whereas breathing a 
 cool air, while the body is properly covered 
 with apparel, has certainly no tendency to 
 produce any distressing, or dangerous con- 
 sequences. 
 
 “ If, however, a suppression of the ptya- 
 lism should be occasioned by any act of in- 
 discretion, the remedy is easy and certain ; 
 it consists only in the quick introduction of 
 mercury into the body, so as to produce a 
 soreness of the gums, with the occasional 
 use of a hot bath.” ( Pearson on the 
 
 Effect of various Articles in the Cure of Lues 
 Venerea, Edit. 2, p. 163, 164.) 
 
 Mercury, when it falls on the mouth, pro- 
 duces, in many constitutions, violent inflam- 
 mation, which sometimes terminates in 
 mortification. In these habits, great caution 
 is necessary. The ordinary operation of 
 mercury does not permanently injure the 
 constitution ; but occasionally, the impair- 
 ment is very material ; mercury may even 
 produce local disease, and retard the cure of 
 chancres, buboes, and certain effects of the 
 lues venerea, after the poison has been des- 
 troyed. ( Hunter , p. 342.) 
 
 From mercury occasionally acting on the 
 system, as a poison, quite unconnected with 
 its agency as a remedy, and neither propor- 
 tionate to the inflammation of the mouth, 
 nor the actual quantity of the mineral ab- 
 sorbed, Mr. Pearson noticed that one, or two 
 patients in general died suddenly every year 
 in the Lock Hospital. The morbid state of 
 the system, which tends to the fatal event, 
 during a mercurial course is named by Mr 
 
 Pearson ereihismus, and is characterized by 
 great depression of strength, a sense of 
 anxiety about the prascordia, Irregular ac- 
 tion of the heart, frequent sighing, trem- 
 bling, a small, quick, and sometimes an in- 
 termitting pulse, occasional vomiting, a 
 pale contracted countenance, a sense of 
 coldness ; but the tongue is seldom furred, 
 and neither the vital, nor natural functions 
 are much disordered. They, w r ho die sud- 
 denly of the mercuiial ereihismus, have 
 frequently been making some little exertion 
 just before. To prevent the dangerous con- 
 sequences of this state of the system, the 
 use of mercury must be discontinued, what- 
 ever may be the stage, extent, or violence of 
 the venereal symptoms. The patient should 
 be directed to expose himself freely to a dry 
 and cool air, in such a manner, as shall be 
 attended w ith the least fatigue, and he should 
 have a generous diet. In this manner, pa- 
 tients often recover sufficiently in ten or 
 fourteen days, to resume the use of mercu- 
 ry with safety. In the early stage, the mercu- 
 rial erethismus may often be averted by 
 leaving off the mercury, and giving the mis- 
 tura camphorata with large doses of ammo- 
 nia. When the stomach is unaffected, sar- 
 saparilla sometimes does good. ( Pearson , 
 p. 164, <^c.) 
 
 Occasionally, the use of mercury brings 
 on a peculiar eruption, which has received 
 the several names of hydrargyria, mercurial 
 rash, eczema mercuriale, eczema rubrum, 
 lepra niercurialis, mercurial disease, and 
 erythema mercuriale. 
 
 “ Eruptions of various kinds are very 
 common symptoms of syphilis, but a very 
 unusual effect of mercury. Therefore, until 
 the real nature of this erythema was lately 
 discovered, whenever it occurred in patients 
 undergoing a mercurial course for syphilitic 
 complaints, it was naturally enough consi- 
 dered, as an anomalous form of lues venerea. 
 The mercury was consequently pushed to a 
 greater extent, in proportion to the violence 
 of the symptoms, and, from the cause of the 
 disease being thus unconsciously applied for 
 its removal, it could not fail to be aggrava- 
 ted, and hurried on to a fatal termination. 
 The observation of this fact, conjoined with 
 another, of less frequent occurrence, name- 
 ly, that a similar eruption did sometimes ap- 
 pear in patients using mercury for other com- 
 plaints, and in whom no suspicion of syphilis 
 could be entertained, at last led some judi- 
 cious practitioners in Dublin to the impor- 
 tant discovery, that the eruption was entire- 
 ly an effect of mercury, and not at all con- 
 nected with the original disease. This dis 
 covery was not published till 1804.” ( M‘Mul 
 lin in Edinburgh, Medical and Surgical Jour- 
 nal, No. 5.1 Mr. Pearson states, however, 
 that he has been acquainted with the disease 
 ever since 1781, and has always described 
 its history and treatment i«i his lectures, since 
 1783. 
 
 The eruption is attended with more or 
 less indisposition, is not confined to either 
 sex, or any particular constitution, and seems 
 to be equally prodneed by mercury applied 
 
MERCURY. 
 
 231 
 
 externally, and by any of its preparations 
 taken inwardly. Mr. Pearson has never 
 seen it in subjects above 50 ; and he says, 
 its occurrence is more common about eight, 
 or ten days after beginning a mercurial 
 course. ( P . 166.) 
 
 Dr. M'Mullin has described three distinct 
 stages ot the erythema mercuriale. “ The 
 ■ first stage commences with languOh lassitude, 
 and cold shiverin<s ; these symptoms are 
 succeeded by increased temperature of tiie 
 body , quick pulse, nausea, headacb, and 
 thirst. The patient is troubled with a dry 
 cough, and complains of difficult respiration, 
 anxiety, and sense of stricture about the 
 pnecordia. The tongue is usually moist, and 
 covered with a white glutinous slime : it 
 sometimes appears clean, and brightly red 
 in the centre, whilst the margins remain 
 foul. TheskifS feels unusually hot and itchy, 
 with a sense ot prickling, not unlike lie 
 sensation experienced from the application 
 of nettles. 1‘lie belly is generally costive ; 
 but a diarrhoea is often produced by very 
 slight causes. 
 
 “ On tiie first, or second day, an eruption 
 most commomy shows itaelt, the colour of 
 which is either dark or bright red : the pa - 
 pulae are at first distinct and elevated, re- 
 sembling very much those in rubeola. Some- 
 times, but rarely, the eruption appears like 
 urticaria, and in such instances the disease 
 is observed to be very mild. The papma3 
 very speedily run together in such a manner 
 as to term a suffused redness, which disap- 
 pears on pressure. In most cases, it begins 
 first on the scrotum, inside of the thighs, 
 fore-arm, or where mercurial friction has 
 been applied, and the integuments of the 
 parts affected become much swoln. There 
 have also been observed instances, where 
 an eruption of a purplish colour,and unaccom- 
 panied by papulae, has diffused itself suddenly 
 over the entire body . Thi-, however, may be 
 considered a 5 uncommon. la every instance, 
 which came under my observation, it was 
 confined at first to a few places, and from 
 thence gradually extended, until the differ 
 ent portions ot the eruption bad united, and 
 the papulae were also rough to the feel. But 
 in those cases, which resemble urticaria, a 
 number ot minute vesicles, which contain a 
 serous fluid, appear from the commence- 
 ment, interspersed among the papulm. 
 Contrary to what happens in most diseases 
 accompanied with cutaneous affections, the 
 febrile symptoms are much aggravated, and 
 continue to increase after the eruption has 
 been completed. The pulse in genera! beats 
 from 120 to 130 in a minute, the thirst con- 
 tinues urgent, and the pauent extremely 
 restless, seldom enjoys quiet sleep. When 
 the eruption has continued in this in timer 
 fora certain period, the cuticle begins to 
 peel off in thin, whiti>h, scurfy exfoliations, 
 not unlike those observed in rubeola. This 
 desquamation has not been attended to by 
 Dr. Moriarty or Mr. Alley, if they have not, 
 by giving the same naras to the decrustation 
 which occurs in the last stage, confounded 
 both together. It commences in those 
 
 places where the eruption first made ils ap- 
 pearance, and in this order spreads to other 
 parts. About this period the fauces become 
 sore, the tongue swells, and the eyes appear 
 somewhat inflamed. 
 
 “The duration of this stage is very va- 
 rious; sometimes it continues from ten to 
 fourteen days, and, in oilier cases, it termi- 
 nates in half that time. When she disease 
 has appeared in ils mildest form, the patient 
 recovers immediately after the desquamation, 
 a new cuticle having formed underneath; 
 but, if severe, he has onty experienced the 
 smallest part ot his sufferings, and the skin 
 now assumes a new appearance, which I 
 have considered as the second stage. 
 
 “ t he skin at this period appears as if 
 studded with innumerable minute vesicles, 
 which are fi led with a pellucid fluid. These 
 vesicles may be expected, if the patient, at 
 the close ot the first stage, complains ot in- 
 crease! itching, and sense of burning heat, 
 in those parts Irom which the cut icuiar ex- 
 foliations have fallen. They rein fin some- 
 times tor a day or two, but ate most com- 
 moidy burst, immediately after their forma- 
 tion, by the patient rubbing them, in order 
 to relieve the troublesome iichiness with 
 which these parts ate affected. They dis- 
 charge a serous, acrimonious fluid, which 
 possess such a very disagreeable odour as to 
 induce nausea in the patient himself, and 
 thuse who approach near his bedside. The 
 odour is so peculiar, that it can easily be re- 
 cognized by any person who has once ex- 
 perienceu it. 
 
 “This fluid is poured out most copiously 
 from the scrotum, groin, inside of the thighs, 
 or wherever the skin forms folds, and seba- 
 ceous glands are most numerous. The 
 serous discharge from these minute vesicles 
 forms, with the cuticle, an incrustation, 
 which may be considered as the third or last 
 state. 
 
 ‘‘ These crusts are generally very large, 
 and, when detached, retain the figure of the 
 parts from which they have lallen. Their 
 colour is yellowish; but sometimes appears 
 dark and dirty, this period of the disease 
 might be termed, ! ;hink, with much pro- 
 priety, the '.ta„e 61 decrustation, in order to 
 distinguish n more imiy troui the desquama - 
 tion, which has been a< ready notic.d. From 
 the u.-e of the two last terms indi- runi- 
 nately , tbos who have described the d siase 
 have introduced into their descriptions a 
 degree ul confusion which has caused its 
 progress not to be well understood. When 
 this stage appears, the fauces become more 
 affected, T>e ey< s intolerant of light, end the 
 tarsi tender, inflamed, and sometimes in- 
 verted. The crusts torm< d on the face, as in 
 other parts ot the body, before tailing off, 
 divide asunder, so as to leuv*-: cracks and 
 fissures, which produce an hideous expres- 
 sion ot countenance ; and the eyelids are 
 also, from the general swelling of the lace, 
 completely closed. The back und hairy 
 scalp are last affected, and, even in very 
 severe cases, these parts are sometimes ob- 
 served to escape entirely. The patient. 
 
MERCURY 
 
 m 
 
 whilst in this state, is compelled to desist 
 from every kind of motion, on account of 
 tile pain which he experiences on the slight- 
 est exertion, and which he describes as if his 
 flesh were cracking. The crusts also fall off 
 in such abundance, that the bed appears as it 
 strewed with the cones of hops. Whilst the 
 eruption is only making its appearance in 
 one place, another part may have arrived at 
 its most advanced form ; so that all the dif- 
 ferent stages ot the disease may he present 
 atone lime in the same individual. It is 
 attended with typhus through its entire 
 course } but it is very curious to observe, 
 that the appetite for food, in most cases, re 
 mains unimpaired, and sometimes is even 
 voracious. This circumstance was particu- 
 larly remarkable in a patient who laboured 
 under the disease, in its worst form. for the 
 space of three months, in the Royal Infirm 
 ary of Edinburgh ; for double the usual hos- 
 pital allowance of food was scarcely suffi- 
 cient to satisfy his hunger. When the 
 catarrhal symptoms have continued during 
 the progress of the complaint, they are, at 
 this advanced period, particularly aggrava- 
 ted : the anxiety and pain of the breast are 
 also very severe, attended with cough, and 
 bloody expectoration, and the patient always 
 feels languid and dejected. The pulse be- 
 comes frequent, feeble, and irregular, the 
 tongue black and parched, and at length 
 diarrhoea, delirium, convulsions, gangrene of 
 the surface of the body, and death, super- 
 vene. In its mild form, it only goes through 
 the first stage, and terminates, as we have 
 already stated, in a few days, by a slight 
 desquamation. But, when severe, it is often 
 protracted more than two months, every 
 stage of the eruption continuing proportion- 
 abiy longer} and when, in this manner, it 
 has run its course, it repeatedly breaks out 
 on the new surface, and passes through the 
 same stages.” (M'Mullin in Edinb. Med. 
 and Surg. Journal, No. 5.) 
 
 With respect to the remote cause, this is 
 the employment of mercury. Dr. M‘Mullin 
 is inclined to believe with Dr. Gregory, that 
 the application of cold to the body, while 
 under the action of mercury, is absolutely 
 necessary, for its production; an opinion 
 strengthened by the constant prevalence of 
 catarrhal symptoms. However, Mr. Pearson 
 thinks, that cold has no concern in bringing 
 on the complaint in patients under the influ- 
 ence of mercury. At the same time it merits 
 particular attention, that the disease is not 
 exclusively occasioned by mercury either in 
 its general, or more partial attacks: it has 
 been observed to follow exposure to cold, 
 and to recur in the same individual, at irre- 
 gular intervals, without any obvious or ade- 
 quate cause. ( Bateman's Synopsiq, p. 256, 
 Ed. 3 ; Rutter in Edin. Med. and Surg. Journ. 
 Vol. 5, p. 143 } Marcet in Med. Chir. Trans. 
 Vol. 2, art. 9.) 
 
 In the early stage, Mr. Pearson recom- 
 mends small doses of antimonial powder, 
 with saline draughts, or the ammonia acetata. 
 A genlle purgative should be given every 
 three or four days, and opium to procure 
 
 sleep. The latter medicine sometimes dot ■ 
 most good, when joined with camphor, or 
 Hoffman’s anodyne liquor. Sarsaparilla and 
 bark may be given, when the discharge is no 
 longer ichorous, and the tumefaction has 
 subsided. Vitriolic acid lias seemed to give 
 relief. The diet may be light and nutritive, 
 without fermented liquors, however, till the 
 desquamation has somewhat advanced. Fre- 
 quent use of the warm bath, and often chan- 
 ging the patient’s linen and sheets, which 
 soon become stiff and rough with the dis- 
 charge, afford much benefit. If the warm 
 bath cannot be had, Mr. Pearson advises 
 washing the body very tenderly with warm 
 water-gruel ; he also covers parts, from 
 which the cuticle is detached, with a mild 
 cerate, and renews the application twice a 
 day. (. P . 178.) 
 
 Dr. M‘Mullin advises the immediate dis- 
 continuance of mercury ; the removal of 
 the patient from wards, where this mineral 
 is in use ; emetics and diaphoretics ; but on 
 account of the very irritable state of the 
 bowels, he says antimonials are hardly ad- 
 missible, and that when purgatives are indi- 
 cated, only the mildest ones, such as ol. ri- 
 cini, sulphate of magnesia, &c. ought to be 
 given. He advises mucilaginous draughts 
 with opium for relieving the soreness of the 
 fauces. In the second stage, the cold infu- 
 sion of bark with aromatics and opium, or 
 what is more praised, wine, porter, &c. To 
 relieve the ophthalmia tarsi, the unguentum 
 oxidi zinci, and to appease the painful sensa- 
 tion of the skin cracking, the linimentum 
 calcis, which should be liberally applied as 
 soon as crusts appear. 
 
 Consult Essay on a Peculiar Eruptive Dis- 
 ease, arising from the Exhibition of Mercury , 
 by G. Alley , 8vo. Dublin , 1804 ; also Ubser- 
 vaiions on the Hydrargyria , or that Vesicular 
 Disease arising from the Exhibition of Mer- 
 cury, 4to. Land. 1810. A Description of the. 
 Mercurial Lepra, by Dr. Moriarty , 12mo. 
 Dublin , 1804. SpensandJ WMullin, in Edin- 
 burgh Med. and Surgical Journal, No. 1, and 
 5. Pearson on Lues Venerea, Edit. 2. Rate- 
 man's Synopsis, p. 256, fyc. Ed. 3. 
 
 Frictions toith Mercurial Ointment. 
 
 No metal acts in its pure metallic state ; 
 it must first be more or less combined with 
 oxygen. The mercury, contained in the 
 unguentum hydrargyri, becomes in a cer- 
 tain degree oxydated, when triturated for 
 the purpose of blending it with the fat. The 
 metal, however, in. mercurial ointment, is in 
 the most simple, and least combined form, 
 of all its preparations, and hence, it not ortly 
 generally operates with more mildness on 
 the system, but with more specific effect on 
 the disease. Various salts of mercury, when 
 given internally, operate more quickly than 
 mercurial frictions ; yet there are many 
 practitioners, who do not like to confide 
 solely in any internal preparations for curing 
 the venereal disease, particularly, when the 
 virus has produced effects in consequence 
 of absorption. We shall only just mention 
 in this part of the work, that rubbing in 
 
MERCURY. 
 
 233 
 
 mercurial ointment is the mode of affecting 
 the system with mercury, which is gene- 
 rally considered to agree best with most 
 constitutions, and to act with most certainty 
 on the venereal disease. 
 
 Mercurial Fit migatio ns. 
 
 We have mentioned this method, as being 
 one of the most ancient plans of affecting 
 the constitution with mercury, and Lalo- 
 nette and Abernethy have stated circum- 
 stances in its favour, which certainly render 
 it sometimes a very eligible mode. The 
 latter is of opinion, that if the peculiar ad- 
 vantages of mercurial fumigations were ge- 
 nerally known to practitioners, they would 
 be much more frequently employed. The 
 advantages of the method consist in its af- 
 fecting the constitution, when other means 
 have failed, and in producing its effects in a 
 much shorter time than any other mode re- 
 quires. How desirable this celerity of ope- 
 ration must often be, when venereal ulcera- 
 tion is making great ravages in the palate, 
 throat, &.c it is needless to insist upon. In 
 patients, who have not strength to rub in 
 ointment, and whose bowels will not bear 
 the internal exhibition of mercury, the mode 
 of fumigation may prove of great service. 
 
 “ In the year 1776, the Chevalier Lalo- 
 nette, a physician at Paris, laid before the 
 public an account of a new mode of mercu- 
 rial fumigation, free from the inconvenien- 
 ces of former ones, and which in the space 
 of thirty-five years, he had successfully em- 
 ployed in more than four hundred cases, 
 that had resisted all the ordinary methods 
 of cure. His method consisted in enclosing 
 the patient, previously undressed, in a kind 
 of box resembling a sedan chair, with an 
 opening at the top to let out the head, and 
 another at the bottom, to which was fitted a 
 small grate or furnace, having in it a heated 
 iron for converting the mercurial remedy 
 into fume. The preparation he made use of 
 was a kind of calomel, which by repeated 
 sublimation from iron filings, was so far de- 
 prived of its muriatic acid, as to be in part 
 reduced into running quicksilver ; and, while 
 it possessed considerable volatility, was per- 
 fectly'unirritating. Some of this powder, 
 being strewed upon the hot iron placed be- 
 low, was immediately converted into smoke, 
 which surrounded the patient’s body, and 
 after some time settled on his skin in the 
 form of a white and very fine calx of quick 
 silver : a complete dress, having its inner 
 surface fumigated with the same powder, 
 was then put on. — The remedy being thus 
 generally applied to the mouths of the cu- 
 taneous absorbents, soon got admission into 
 the circulating fluids, and the constitution 
 became thereby more speedily affected than 
 by any other process known before.” {Aber- 
 nethy's Surgical and Physiological Essays, 
 Part 3.) 
 
 As the fumigating powder used by M. La- 
 lonette was very operose, and consequently 
 a very expensive preparation, and appeared 
 to have no advantage over one made by 
 abstracting the muriatic acid from calomel 
 
 Vor.. II 30 
 
 by means of ammonia. Mr. Abernethy has 
 always employed the latter, which is pre- 
 pared at the hospital in the following man- 
 ner: Two drachms of liquor ammoniae are 
 added to six ounces of distilled water, and 
 four ounces of calomel are thrown into this 
 liquor, and shaken up with it; the powder 
 is afterward separated by a filter, and dried. 
 
 The powder th is obtained is of a gray co- 
 lour, and contains a good deal of quicksilver 
 in its metallic state, which of course is ex- 
 tremely volatile, but becomes oxydated when 
 raised into fume, and afterward condensed 
 into a white subtile powder. 
 
 In local disease of the joints, such, for in- 
 stance, as frequently takes place in the knee, 
 and in sarcomatous enlargements of the 
 breast in women, the late Mr. Sharp and Sir 
 C. Blicke were accustomed to direct fumi- 
 gated stockings, or under- waistcoats, to be 
 worn ; by which these complaints were re- 
 lieved, and the constitutions of the patients 
 affected, without the trouble and unplea- 
 santness arising from the use of the common 
 mercurial ointment (See Abernethy's Sur- 
 gical and Physiological Essays, Part 3.) 
 
 Mr. Pearson procured Lalonette’s ma- 
 chine, and made a considerable number of 
 experiments to determine the comparative 
 advantages of this method, and mercurial 
 frictions. He found, that the gums became 
 turgid and tender very quickly, and that the 
 local appearances were sooner removed, 
 than by the other modes of introducing 
 mercury into the system ; but that it soon 
 brought on debility, a rapid and premature 
 salivation, and, of course, that the medicine 
 could not be steadily continued. This - gen- 
 tleman concludes, that where checking the 
 progress of the disease suddenly is an object 
 of great mo ment, where the body is covered! 
 with venereal ulcers, or where the eruptions 
 are large and numerous, so that there scarce- 
 ly remains a surface large enough to absorb 
 the ointment, the vapour of mercury will 
 be advantageous. But he thinks it extreme- 
 ly difficult thus to introduce a sufficient 
 quantity of mercury into the system to se- 
 cure the patient from a relapse, and there- 
 fore the plan by no means eligible as a ge- 
 neral practice. The vapour of mercury, he 
 says, is singularly efficacious, when applied 
 to venereal ulcers, fungi, and excrescences; 
 but this plan requires an equal quantity of 
 mercury to be given in other ways, as if the 
 local application itself were not a mercurial 
 one. ( Pearson on Lues Venerea , p. 145, fyc.) 
 
 For the purpose of fumigating sores, the 
 hydrargyri sulphuretum rubrum is common- 
 ly used. Ulcers and excrescences about the 
 pudendum and anus in women are said to 
 be particularly benefited in this way ; and 
 in these cases the fumes are most conveni- 
 ently applied by placing a red-hot heater at 
 the bottom of a night-stool pan, and after 
 sprinkling on it a few grains of the red sul- 
 phuretof quicksilver, placing the patient on 
 the stool On other occasions, a small ap- 
 paratus, sold at the shops, is used, which en- 
 ables the surgeon to direct the fumes through 
 a funnel against the ulcer in any situation 
 
MERCURY. 
 
 Though mention has just been made of ve- degree of soreness of the gums, and (he 
 vercat excrescences, L am of opinion with common specific effect of mercury in the 
 Mr. Abernethy, that it is very questionable, animal system. But it will often fail of re- 
 whether any are ever really of this nature, moving even a recent chancre ; and where 
 [ know, that many excrescences and verru- the symptom has vanished during the ad- 
 cae about the anus, and parts of generation, ministrations of corrosive sublimate, I have 
 diminish and are cured by a course of mer- known a three month’s course of that medi- 
 cury. This is the only argument in favour cine fail of securing the patient from a con- 
 of their being venereal ; for. when tied, cut stitutional affection. The result of my ob- 
 oif, or made to fall off by stimulating them servations is, that simple mercury, calomel 
 with pulv. sabina*, and the subacetate of or calcined mercury, are preparations more 
 copper, they are as effectually cured, as if to be confided in, for the cure of primary 
 mercury had been given. In the military symptoms, than corrosive sublimate. The 
 
 hospital at Cambray, I remember a man, on 
 whose scrotum there were several warty ex- 
 crescences of considerable size. Mr. Booty, 
 assistant staff surgeon, prescribed mercury, 
 by which they were certainly cured with 
 surprising expedition In this particular 
 case, I think the plan of treatment adopted 
 was the best, because on account of the 
 number of excrescences, and the situation of 
 some of them at the lower and back part of 
 the scrotum, it would have been difficult to 
 have treated them altogether by local appli- 
 cations. 
 
 PREPARATIONS FOR INTERNAL EXHIBITION. 
 
 The acetite of mercury is supposed to be a 
 mild preparation, and was the active ingre- 
 dient in the celebrated Keyser’s pills. In 
 solution it has also been recommended to be 
 applied externally for the removal of some 
 cutaneous affections. It may be made into 
 pills with crum of bread. The dose is from 
 one to five grains every night. 
 
 When it is wished to excite a salivation 
 quickly, when mercurial ointment alone will 
 not produce this effect, or cannot be em- 
 ployed, and when fumigations are not con- 
 venient nor agreeable, the hydrargyri oxy- 
 dum rubrum is often prescribed. The com- 
 mon dose is a grain, which may be increa- 
 sed to two, a day. It is apt, however, to 
 disagree with the stomachs and bowels of 
 many patients; an inconvenience sometimes 
 obviated by conjoining the preparation with 
 opium. 
 
 At present, the hydrargyrus cum creta is 
 rarely or never prescribed for the cure of 
 the venereal disease. But it is frequently 
 prescribed as a mild alterative for children 
 in doses of from gr. v. to gr. x. twice a day, 
 blended with any viscid substance. 
 
 The oxymuriate of mercury (corrosive 
 sublimate) was a medicine highly praised for 
 its antisyphilitic virtues by the celebrated 
 Van Swieten, and, indeed, there is no doubt, 
 that, like other preparations of mercury, it 
 possesses such qualities. It retains great 
 reputation, even now, and, probably, will 
 always do so. However, like the red oxide, 
 it sometimes deranges the stomach and bow- 
 els, and from some surgeons does not receive 
 the same degree of confidence, in respect to 
 its power over syphilis, as mercurial frictions. 
 Mr. Pearson remarks, that “ when the subli- 
 mate is given to cure the primary symptoms 
 of syphilis, it will sometimes succeed ; more 
 especially when it produces a considerable 
 
 latter will often check the progress of secon- 
 dary symptoms very conveniently ; and I 
 think it is peculiarly efficacious in relieving 
 venereal pains, in healing ulcers of the 
 throat, and in promoting the desquamation 
 of eruptions. Yet, even in these cases, it 
 never confers permanent benefit ; for, new 
 symptoms will appear during t the use of it 
 and, on many occasions, it will fail of afford- 
 ing the least advantage to the patient, from 
 first to last. I do sometimes, indeed, employ 
 this preparation in venereal cases ; but it is 
 either at the beginning of a mercurial course, 
 to bring the constitution under the influence 
 of mercury at an early period, or during a. 
 course of inunction, with the intention of 
 increasing the action of simple mercury. I 
 sometimes, also, prescribe it after the con- 
 clusion of a course of frictions, to support 
 the mercurial influence in the habit, in or- 
 der to guard against the danger of a relapse. 
 But. on no occasion whatever do l think it 
 safe to confide in this preparation singly and 
 uncombined, for the cure of any truly vene 
 real symptom.” ( Pearson on Lues Venerea.) 
 
 The dose of oxymuriate is a quarter of a 
 grain. 
 
 The following is a common mode of or- 
 dering it : f^. Hydrargyri oxmuriatis gr. 3 
 Aquae Nucis Moscbatae ^ij. Misce. ^ss. Omni 
 nocte sumenda. 
 
 The muriate of mercury (calomel) is not 
 very much used by modern surgeons for the 
 cure of the venereal disease. Sometimes, 
 indeed, it is given in cases of gonorrhoea, 
 both with the view of preserving the consti- 
 tution from infection, and keeping the bow- 
 els regular. It is more extensively given as 
 an alterative, and for the cure of such surgi- 
 cal diseases as require the system to be 
 slightly under the influence of mercury. It 
 generally proves actively purgative, when 
 more than two or three grains are given. 
 
 The most simple preparations of mercury 
 have generally been deemed the most effec- 
 tual in eradicating the venereal disease. The 
 pilulae hydrargyri are the most simple of the 
 internal formulae, being merely mercury 
 triturated with mucilaginous or saccharine 
 substances. Next to mercurial frictions, 
 they are, perhaps, most frequently employed 
 for the cure of the incipient form of the ve- 
 nereal disease, that is, while a chancre is 
 the only complaint. They are also very 
 commonly given in all stages of the disease, 
 to aid mercurial frictions in bringing the sys- 
 tem under the influence of the specific 
 remedy. Ten grains of the mass, kept for 
 
MOLLITIES OSSIUM. 
 
 235 
 
 these pills, is the usual dose. When they 
 purge, opium will sometimes prevent this 
 effect. See Venereal Disease. 
 
 Mercury is employed both constitutional- 
 ly and locally in numerous surgical cases ; 
 for the removal of indolent thickenings and 
 indurations o: parts ; for the relief of porri- 
 go, herpetic diseases, tetanus, hydrophobia, 
 hydrops articuli, iritis, and a multitude of 
 other affections, which need not here be spe- 
 cified. 
 
 MEROCELE. (from yuego?, the thigh, and 
 a tumour.) A femoral or crural hernia. 
 See Hernia. 
 
 MEZEREON was recommended by Dr. 
 A. Russell for a particular class of venereal 
 symptoms, in the following terms : “ The 
 disease, for which I principally recommend 
 the decoction of the mezereon root as a cure, 
 is the venereal node that proceeds from a 
 thickening of the membrane of the bones. 
 In a thickening of the periosteum, from 
 other causes, I have seen very good effects 
 from it : and it is frequently of service in the 
 removal of those nocturnal pains, with 
 which venereal patients are afflicted ; though, 
 in this last case, excepting with regard to the 
 pain that is occasioned by the node, I own I 
 have not found its effects so certain, as 1 at 
 first thought I had reason to believe. I do 
 not find it of service in the cure of any other 
 symptom of the venereal disease. {Med. 
 Obs. and Inq. Vol. 3, p. 194, 195.) Mr. Pear- 
 son, however, asserts, unequivocally, that 
 mezereon has not the power of curing the 
 venerea] disease in any one stage, or under 
 any one form, and if the decoction should 
 ever reduce the venereal node, yet there will 
 be a necessity for taking mercury in as large 
 quantity, and for as long a time, as if no 
 ^mezereon had been exhibited. Cullen found 
 this medicine of use in some cutaneous af- 
 fections, but, excepting an instance or two 
 of lepra, Mr. Pearson has very seldom found 
 it possessed of medicinal virtue, either in sy- 
 philis, or the sequela? of that disease, scro- 
 fula, or cutaneous affections. ( Pearson on 
 Lues Venerea, p. 55, 59.) 
 
 As the possibility of curing most forms of 
 the venereal disease, not only without mer- 
 cury, but without any internal medicines 
 whatever, is now well established, it is diffi- 
 cult to know what degree of importance to 
 attach to observations, declaring certain ar- 
 ticles of the materia medica efficient or inef- 
 ficient in the cure of that disease ; because, if 
 it admit of a spontaneous cure, but will not 
 get well when mezereon, or any other parti- 
 cular medicine is exhibited, we are necessa- 
 rily-obliged to suppose, that such medicine 
 is worse than useless. 
 
 MODIOLUS. The crown or saw of a 
 trepan. 
 
 MOLLITIES OSSIUM. A morbid soft- 
 ness of the bones, which become preterna- 
 turally flexible, in consequence either of the 
 inordinate absorption of the phospate of 
 lime, from which their natural solidity is de- 
 rived, or else of this matter not being duly 
 secreted into their texture. The bones af- 
 fected become specifically lighter. ( Sail - 
 
 lant, Hist, de la Soc. Royale de Med. T. 8 .) 
 Dr. Bostock made some experiments, with 
 the view of ascertaining the proportion of 
 earthy matter in bones affected with molli- 
 fies : he examined a dorsal vertebra of a 
 woman whose bones were found soft and 
 flexible after her decease. In one part of 
 the diseased bone, he found, that the quanti- 
 ty of earthy matter only amounted to one- 
 fifth of its weight, and in another, only to 
 one-eighth, while the proportion in healthy 
 bones amounted to more than one half of 
 their whole weight. (See Med. Chir. Trans. 
 Vol. 4, and Wilson on the Bones and Joints, 
 p. 253.) In rickets, the bones yield and be- 
 come distorted only by slow degrees, and 
 retain their natural inflexibility ; but, in the 
 present disease, they may be at once bent in 
 any direction, and frequently admit of being 
 readily divided with a knife. The mollifies 
 ossium is an exceedingly uncommon disease, 
 and its causes are buried in obscurity. It is 
 supposed, however, to depend upon some 
 peculiar state of the constitution, and the in- 
 dividuals, attacked with it, have been re- 
 marked to be mostly about, or rather be- 
 yond, the middle period of life, {J. Wilson , 
 Vol. cit. p. 252.) and generally, if not always, 
 women. (Neumann in Abhandl. der K. K. 
 Josephs Acad. 2 B. p. 173 ; Portal Cours 
 d'Anatomie, T. 1, p. 15.) One instance, how- 
 ever, is reported, in which the patient was a 
 young man seventeen years of age. ( Thom - 
 massin, in Journ. de Med. T. 43. p. 222.) 
 Surgical writers have usually considered 
 mollities and fragilitas ossium as two dis- 
 tinct and different affections. Boyer thinks, 
 however, that this point is by no means well 
 established. He admits, that there have 
 been a few rare instances of mollities, where 
 the bones were completely flexible, without 
 any degree of fragility. But, he contends, 
 that in almost all the cases on record, the 
 fragilitas and mollifies have been combined. 
 He regrets that bones, affected wfith fragility, 
 have never been chymically nor anatomi- 
 cally examined, particularly as there have 
 been persons who, while living, merely be- 
 trayed the symptoms of mollities ossium, 
 yet, in whom unsuspected fractures, evi- 
 dently of long standing, were discovered 
 after death ; while other fractures also hap- 
 pened from the slightest causes during the 
 examination of the same bodies. (See Boyer , 
 Traite des Maladies Chir. T. 3, p. 607 — 609.) 
 The truth of these observations is well illus- 
 trated in the case lately reported by Mr. 
 Wilson. (On the Bones, fyc. p. 254.) In the 
 present place, I shall merely describe the 
 pure mollities ossium, or that disorder of the 
 bones, in which they become completely 
 flexible, and lose all their natural firmness. 
 And in order to give an idea of the disorder, 
 I shall quote the case of Madame Supiot. 
 In the year 1747 she had a fall which occa- 
 sioned her to keep her bed for some time, 
 and left great pain and weakness in her 
 loins and lower extremities. In about a 
 year and a half afterw r ard, she began to per- 
 ceive her left leg particularly affected. 
 Along with this weakness, she had violent 
 
MGLLIT1ES OSSIUM. 
 
 Hid 
 
 pains over her whole body, which increased 
 after a miscarriage, and still more alter a 
 natural delivery, in the year 1751. She was 
 now seized with startings, great inquietude, 
 and such violent heats, that she was almost 
 continually in a sweat, and could not In-ar 
 the least covering even in the coldest wea- 
 ther, and while her pains continually increa- 
 sed, she took notice that her urine precipi- 
 tated a white sediment. Her pains abated 
 on the appearance of the sediment, but she 
 now observed that her limbs began to bend, 
 and from this time the softness of them gra- 
 dually increased till her death. In the 
 month of April, 1752, the trunk of the body 
 did not exceed 23 inches in length ; the 
 thorax exceedingly ill formed, and the bones 
 of the upper part very much distorted ; those 
 of the lower part were very much bent, and 
 the thigh bones became so pliable that her 
 feet might easdy be laid on each side of her 
 head. The right side did not, till after some 
 time, become so deformed as the left; but 
 it was surprising to observe the alterations 
 which daily took place, and the different 
 figures assumed by the limbs, in conse- 
 quence of the increased softness .of the 
 bones ; so that when the sediment in the 
 urine was considerable, the disease of l he 
 bones seemed to be at a stand, increasing 
 considerably when it was suppressed. Be- 
 sides this, she had violent pains, startings, 
 difficulty of breathing, spitting of blood, and 
 lastly, a fever, with convulsions. She d.ed 
 in the beginning of November, 1752 and, 
 on dissecting her body, the following ap- 
 pearances were observed : 1 The muscles 
 in general were of a very soft and pale con- 
 sistence, the vastus externus, fascialis, qua 
 driceps, biceps, and external parts of the 
 gracilis, were much shorter than in their na- 
 tural state, and more firm and tense ; while 
 those on the opposite side were much elon- 
 gated, thin, and very tender; in short, the 
 whole muscular system had sulfered more 
 or less, according to the action of the mus- 
 cles in her Jifetime. 2. The bones were 
 entirely dissolved, the periosteum remaining 
 unhurt, so that they exhibited only the form 
 of a cylinder. 3. The heart and large blood- 
 vessels, both veins and arteries, contained 
 large black polypi, of a viscid consistence, 
 and very unlike those usually found in dead 
 bodies. 
 
 A case of softness of the bones is related 
 by Mr. Gooch, but considerably different 
 from the above, as it was attended with a 
 remarkable fragility of them before they 
 became soft. It likewise began with pains 
 through the whole body, attended with fe- 
 verish symptoms ; but after some weeks, 
 these pains were confined chiefly to the legs 
 and thighs, and they were not increased by 
 pressure. This fragility of the bones does 
 not appear to have been the case u ith Ma- 
 dame Supiot. In the month of June, 17-19, 
 ]Vlr. Gooch’s patient broke her leg in walk- 
 ing from her bed to a chair, and heard the 
 bone snap. No callus, however, formed, 
 though the fracture was instantly reduced, 
 and treated by one of the best surgeons iu 
 
 her part of the country ; but instead of this, 
 the bones began to grow flexible, and in a 
 few months, were so from the knee to the 
 ankle. The disease still continued to in 
 crease, so that, in a short time, the other 
 leg and thigh were atfected in the same 
 maimer, after which both legs became cede 
 matous, liable to excoriations, and to dis- 
 charge a thin yellow ichor. Scorbutic 
 symptoms began to appear in the winter 
 after the leg was broken, and her gums be- 
 gan to bleed. Tonic medicines were exhi- 
 bited without any success, except that her 
 menstruation became more regular, and her 
 appetite and digestion better than before ; 
 but towards the end of her life, her breathing 
 became difficult, the spine distorted, and a 
 pain in the loins took place upon every 
 motion of the vertebra; : and as her limbs 
 were now quite useless, she was obliged to 
 sit upright in bed. At last, trie ends of the 
 bones on which she sat, having become 
 also very soft, spread much, and the ends of 
 her lingers and thumbs, by frequent endea- 
 vours to raise herself, became also very 
 broad and the phalanges crooked. The 
 flexibility of the bones gradually increased, 
 and became more general, attended with a 
 wasting of the flesh, and excessive difficulty 
 of breathing. Hie menstrual flux totally- 
 ceased four months before her death ; her 
 legs, which were anasarcous, and excoriated 
 almost all over, became erysipelatous; but 
 she retained her senses to the last. She ex- 
 pired suddeidy, having talked in a composed 
 manner concerning her miserable situation 
 and approaching end only a few moment* 
 before. 
 
 On examining the body, she was found 
 to have lost two feet two inches of her na- 
 tural stature. The heart and lungs appear-* 
 ed sound, but had been much confined, 
 principally by the liver, which was enlar- 
 ged in an extraordinary degree ; it was not, 
 however, scirrhous, nor in any other way- 
 diseased. The spleen was very small, and 
 the mesentery had one large scirrhous 
 gland. All the bones, except the teeth, 
 were softened, so that scarcely any of them 
 could resist the knife ; but those of the 
 lower extremities were the most dissolved, 
 being changed into a kind of parenchymous 
 substance, like s >ft dark-coloured liver, 
 without any offensive smell. So complete- 
 ly, indeed, were they decomposed, that the 
 knife met with less resistance in efttting 
 through them than in sound muscular flesh, 
 though some bony lamella; were here and 
 there to be met with, but as thin as an egg- 
 shell. The most compact bones, and those 
 which contained the greatest quantity of 
 marrow, were the most dissolved; and it 
 was observable, that the dissolution began 
 internally, for the bony lamina; remained 
 here and there on the outside, and nowhere 
 else. The periosteum was rather thicker 
 than ordinary, and the cartilages thinner ; 
 bul not in a state of dissolution. The bones 
 were found to contain a great quantity of 
 oily matter and little earth. No cause could 
 be assigned for the disease ; and in the ease 
 
MORTIFICATION 
 
 237 
 
 of Madame Supiet, the one assigned, viz. 
 that of her eating too much salt, seems to- 
 tally inadequate to explain the origin of the 
 disorder. All the cases of mollities ossium 
 on record have proved fatal, and no means 
 of cure are yet known. 
 
 For additional observations, connected 
 with this subject, reter to tragilitas Ossium 
 and Rickets. Royer and Kicherand treat ot 
 the mollities ossium, and rickets, as one and 
 the same disease. Rut, as Mr. Wilson ob- 
 serves, the first difters trom rickets, in at- 
 tacking people of middle age, or rather 
 older, and not particularly children ; and it 
 differs also in the change produced in the 
 bones themselves, which, when dried, do 
 not appear as if they had been long steeped 
 in weak acid, with their animal part nearly 
 unchanged ; but both the phospnat ot Ihne 
 and the animal matter appeal to have been 
 absorbed, so as to leave mere shells, which 
 are also softer than natural bone of the 
 same thickness. Mr. Wilson further inform's 
 us, that large cavities are met with in the 
 substance of tbe bones, and sometimes com- 
 municate with the soft parts surrounding 
 them. In some of these c..viiies is contain- 
 ed oily matter, like boiled marrow ; and in 
 others, masses of coagulated blood, and a 
 soft inorganic substance. ( J . Wilson on the 
 Bones , ty-c. p. 253. Acrel, Diss. Descriplion- 
 em et Casus aliquot Osteomalacia: sistens; Up- 
 sal, 1788. Morandin Joura.des Savans, 1792, 
 et M6m. de VAcad des Sciences , i 752. Morand , 
 junr. in Mem. de l' Acad, des Sciences , 1764, 
 p. 206. See also T. Lambert , Relation de la 
 Matadie de Bernard d'Armagnac, sur un 
 Ramollissement des Os ; Toulouse, 170o. Fer- 
 nelius , in lib. de abditis rerum causis. Th. 
 Bartholinus, Hist. Auat. Cent. 4. P til , 
 Histoire d6 l' Acad, des Sciences, 1722. Horn, 
 ibid. 1764. Gagliardie, Anatomes Ossium, 
 Romes , 1789. C. G Ludwig, Pro^ratnma, 
 quo observata in sectione Cudaveris Fcemina 
 cujus ossa emollita erant proponit ; Lips 1757. 
 Fries, Dissert.de Emolliti one Jssium, Argent- 
 tor. 1775. Thompson m Med. Ob e cations and 
 Inquiries. Vol. 5. p. 259. Chirurgiccu Ob- 
 servations and Cases, by Wiilium Bromjield, 
 Vol. 2, p. 50, 4-’C. Boyer, i r ait e des Maladies 
 Chir. T. 3, p. 607, s,c. Pa is, lb 14. tiiche- 
 rand, JYosogr. Chir. T. •>. p 14 2. What these 
 
 two writers say , however, chiefly relates to 
 rickets. We meet with casi s of Mollities 
 Ossium in the Philosophical Transactions ; 
 Act. Haffniens ; Ephem.JVat. Cur. ; Sudani's 
 Obs Chir. ; the writings of Foresius ; Gooch's 
 Chirurgical Works, Vol. 2 ,p. 593 — 399. Ed. 
 1792, ty-c. James W.san Lectures on the 
 Structure and Bhysiology of the Paris com- 
 posing the Skeleton ; and on the Diseuses of 
 the Bones and Joints, p. 252, <£-c. 8co. Load. 
 1820 .) 
 
 MONOCULUS. (from ptova?, single, and 
 oculus, the eye.) A bandage formerly ap- 
 plied to the fistula lacbrymalis, and diseases 
 of the eye. It consists of a single-headed 
 roller three ells iong^ In order to apply it 
 to the right eye, it is to be held in the hand, 
 and its end in the left? et vice versa. This 
 
 end is to be put on the back of the neck, and 
 one turn of the roller is to be carried round, 
 over the forehead, so as to meet the ex- 
 tremity of the bandage. The roller is then 
 to descend under the ear of the side affected, 
 and to pass obliquely over the cheek under- 
 neath the eye, and next over the root of the 
 nose, and opposite the parietal bone, to the 
 nape of the neck. The third turn of the 
 roller is to overlap the second a little : the 
 third the fourth ; making what the French 
 call doloires ; and the application of the ban- 
 dage is completed by making turns round 
 the head, l he use of the monoculus was 
 only to retain dressings. ( Encyclopedic 
 Mcthodique ; Partie Chir.) 
 
 MORTIFICATION is of two kinds; the 
 one, without inflammation; the other, pre- 
 ceded by it. To this last species of mortifi- 
 cation, the terms inflammatory, humid, or 
 acute gangrene, are often applied, while 
 the second, or that which is not preceded 
 by any or much inflammation, has been 
 distinguished by the epithets, dry or chronic, 
 and sometimes idiopathic, when no cause 
 for the origin of the disease can be assigued. 
 According to Mr. Hunter, inflammation is 
 an increased action of that power, which a 
 part naturally possesses ; and in healthy in- 
 flammations, at least, ii is probably attended 
 with an increase of power. In cases, how- 
 ever, which are to terminate in mortifica- 
 tion, there is no increase of power ; but, on 
 the contrary, a diminution of it. This, when 
 joined to an increased action, becomes a 
 cause of mortification, by destroying the 
 balance, which ought to subsist between the 
 power and action of evt-ry part, i here are, 
 besides, cases of mortification, preceded by 
 inflammation, which do not arise holly 
 from that, as a cause : of this kind, are the 
 carbuncle and the slough formed in the 
 small-pox pustule. (Hunter.) 
 
 The first general division of mortification, 
 therefore, is into two kinds; first, into the 
 inflammatory, humid , or acute; and secondly, 
 into the dry, or chronic. Rut the disorder is 
 also subdivided into many species, which 
 are determined by the nature of tneir 
 particular exciting causes, as will be present- 
 ly detailed. 
 
 However, it is remarked, that acute, or 
 rapid mortifications, are not necessarily hu- 
 mid, as the slougu from the application kali 
 purum proves, and the c onverse also is true 
 in some cases of sphacelus senilis ( James 
 
 on Inflammation, p. 96.) Another modern 
 writer also asserts, tnat mortification from 
 wounds and external injuries may be either 
 humid, or dry* or of both kinds together, 
 where tlie circumstances are particular. 
 (Guthrie on Gunshot Wounds , fyc.p. 122, Ed. 
 2.) The doctrine also that any case of 
 mortification is entirely without inflamma- 
 tion, has sometimes been deemed question- 
 able ; and Mr. James expresses bis belief 
 that the disorder is generally preceded by 
 inflammation, and invariably accompanied 
 with some degree of it. And, says he., 
 “ w hether mortification be a consequence of 
 
MORTIFICATION. 
 
 238 
 
 inflammation, or not, it may, perhaps, with 
 reason be considered, as standing in the 
 same relation to inflammation, as adhesion, 
 suppuration, or ulceration : they may all be 
 preceded by a high degree, or it may be 
 scarcely sensible.” (P. 84, 85,) 
 
 When any part of the body loses all mo 
 tion, sensibility, and natural heat, and be- 
 comes of a brown, livid, or black colour, it 
 is said to be atfected with sphacelus , that is, 
 complete mortification. As long as any 
 sensibility, motion, and warmth, continue, 
 the state of the disorder is termed gangrene 
 This word is here made use of to signify 
 only a degree of sphacelus, or rather the 
 process, by which any local disorder falls 
 into the state of complete mortification. 
 Many authors use both terms synonymously ; 
 but it is to be observed, that gangrene does 
 not invariably end in sphacelus ; nor is the 
 latter always preceded by the former. 
 ( Richler , Anfangsgr. der IVundarzn. B. 1, 
 Kap. 3.) There are some surgical writers, 
 who make the distinguishing circumstance 
 of sphacelus to be the extension of the disor- 
 der to the bones as well as the soft parts. 
 ( Lassus . Pathologie Chir. T. 1 , p. 30, Ed. 
 1809.) 
 
 At present, however, this last application 
 of the term sphacelus is never made ; for, as 
 Mr. Pearson has rightly observed, the dis- 
 tinctions, “ which are founded merely upon 
 the parts, that suffer, or upon the profundity, 
 to which the disease has penetrated, seem 
 inadequate and useless.” ( Principles of 
 Surgery , p. 115, Ed. 2) The manner, in 
 which Dr. J. Thomson views the subject, 
 may be considered as coinciding with the 
 general sentiments of the best modern sur- 
 geons. “ I shall employ the term gangrene, 
 (says he) to express that state of mortifica- 
 tion, in inflamed parts, which precedes the 
 death of the part ; a stage, in which there is 
 a diminution, but not a total destruction of 
 the powers of life ; in which the blood ap- 
 pears to circulate through the larger vessels ; 
 in which the nerves retain a portion of their 
 sensibility ; and in which, perhaps, the part 
 affected may still be supposed to be capable 
 of recovery. The word sphacelus, I shall 
 use to denote the complete death, or mor- 
 tification of a part ; that state, in which the 
 powers of life have become extinct ; in which 
 the blood ceases to circulate ; and in which 
 the sensibility of the nerves is lost, whether 
 the dead, or mortified part has, or has not, 
 become actually putrid, or shown any ten- 
 dency to separate and fall away from the 
 living and sound parts. Putrefaction or the 
 spontaneous process, by which animal ho lies 
 are decomposed, is an accidental, and not a 
 necessary effect of the state of mortification. 
 It takes place at very different periods, after 
 the death of particular parts ; and these 
 periods, it may be remarked, are always 
 regulated, not only by external circumstan- 
 ces, such as the humidity and temperature 
 of the atmosphere, but, also, by the peculiar 
 structure and morbid conditions of the ani- 
 mal texture, or organ, in which the putre- 
 faction occurs. The term sphacelus, has, 1 
 
 know, been employed to express, that a part 
 is not only completely dead, or mortified, 
 but, also, that that part has become putrid, 
 and is in a state of separation from the sur- 
 rounding and living parts. But, as putrefac- 
 tion is not a necessary, or immediate conse- 
 quence of mortification, or partial death in 
 animal bodies, this use of the term sphacelus 
 is obviously improper.” (See Thomson’s 
 Lectures on Inflammation, p. 504 ) 
 
 The causes of mortification are either 
 internal, or external. It is commonly taught 
 in the medical schools on the continent, that 
 the internal ca ises probably operate after 
 the rna oner of a deleterious substance, 
 vhich being introduced into the circulation, 
 occasions a putrefaction of the fluids. ( Lassus , 
 op. et loc. cit.) — Boyer also professes a simi- 
 lar notion, (See Trnite des Maladies Chir. T. 
 1, p. 140.) as well as Larrey in his account 
 of traumatic gangrene ; a statement, which 
 has drawn forth the criticisms of Mr. Gu- 
 thrie. The doctrine is supported by no sort 
 of proof, and may be considered as entirely 
 hypothetical, if not decidedly erroneous. 
 There .are, indeed, as Boyer has noticed, 
 some spontaneous mortifications, the primi- 
 tive cause of which is not always well un- 
 derstood : an inflammation, apparently slight, 
 may become gangrenous immediately it has 
 made its appearance. In scorbutic, venere- 
 al, and small-pox cases, we have daily in- 
 stances of this fact Other internal causes, 
 without any very evident pre-existing dis- 
 ease, sometimes destroy persons, bv gan- 
 grenous mischief, who are but little advanced 
 in years. ( Saviard . Obs. 16. Haller , Disput. 
 Chir. T.4,/7.551.) Certain poisonous, acrid, 
 caustic substances taken inwardly, or intro- 
 duced under the skin, may have the same 
 effect, by annihilating the vital action, or 
 destroying the texture of the paris. ( Lassus , 
 Pathologie Chir T. 1 , p. 31.) But, though 
 these observations may all be entirely cor- 
 rect, they by no means justify the conclusion, 
 that the internal causes of mortification ever 
 act like a deleterions matter producing a 
 putrefaction of the fluids. The mortification 
 of the toes and feet so well described by 
 Mr. Fott, is supposed to proceed chiefly from 
 unknown internal causes, though sometimes 
 attended with an ossified state of the arte- 
 ries. 
 
 Another remarkable specimen of mortifi- 
 cation from an internal cause, is that origin- 
 ating from eating bread made of bad black 
 wheat, or rye. Besides occurring as an 
 original idiopathic disease, and from obstruc- 
 tion of arteries, chronic, or dry gangrene 
 (observes Dr. Thomson) may be induced 
 by the action of substances taken into the 
 stomach, which seem to produce it as a spe- 
 cific effect in parts remote from the source 
 of the circulation. The most singular ex- 
 ample, which we have of this, is in the gan- 
 grene produced by the eating of a particular 
 kind of unsound or diseased rye. This 
 species of mortification has been rarely- 
 observed in England ; but it lias been fre- 
 quently seen on the continent, where it ha s 
 been repeatedly known to prevail in som 
 
MORTIFICATION. 
 
 239 
 
 districts, where rye forms a principal article alone. In others, Noel was obliged to have 
 
 of food, as an endernial disease. It occurs, 
 however, in such districts only after wet 
 seasons, in which that grain is affected with 
 a particular disease, well known in France 
 by the name of the Ergot , or cockspur rye. 
 In this disease, the grains of rye grow to a 
 large size, acquire a black colour, and have 
 a compact horny consistence. The species 
 of mortification, produced hy eating this 
 substance, was first particularly described 
 by Dodard. (See Journ. des Savans, an. 
 1676.) The part affected became at first 
 insensible and cold, and, in the progress of 
 the disorder, dry, hard, and withered. In 
 very malignant cases, there was delirium. 
 Dodard’s description of the complaint was 
 very imperfect ; but he has mentioned a 
 circumstance, tending strongly to prove, 
 that the disease actually arose from the 
 alleged cause ; viz. that fowls, fed with cock- 
 spur rye, are killed by it. Saviard informs 
 us, that he saw this disease in the year 1694, 
 at the Hotel Dieu of Orleans It attacked 
 the upper and lower extremities, which 
 were rendered, in the course of the disorder, 
 as dry as touch-wood, and as emaciated as 
 Egyptian mummies. In 1710, Noel, sur- 
 geon to the Hotel Dieu at Orleans, transmit- 
 ted to the Royal Academy of Sciences at 
 Paris an account of this peculiar mortifica- 
 tion. About fifty people, men and children, 
 had come that season into his hospital, with 
 the affliction. According to Noel, the disor- 
 der always began in the toes, and extended 
 itself gradually along the foot and leg, till it 
 sometimes rose to the upper part of the 
 thigh. He had never seen any of the female 
 sex affected with it, and had observed only 
 one instance of it in the upper extremities. 
 The Academy received the history of one 
 case, in which the lower extremities were 
 separated from the body in the articulations 
 of the thigh-bones with the acetabula ; the 
 first example, (Dr. Thomson believes) of this 
 separation upon record ; and it was the oc- 
 currence of this, and of similar cases, that 
 probably first suggested the operation of am- 
 putation at the hip-joint. (See Thomsons 
 Lectures on Inflammation, p. 54E) As Noel’s 
 patients did not come under his care, till 
 after the disease had existed some time, he 
 could not describe from his own observation 
 the early symptoms ; but the patients had 
 often told him, that the disease generally 
 began in one, or both feet, with pain, red- 
 ness, and a sensation of heat, as burning as 
 the fire ; and that, at the end of some days, 
 these symptoms ceased, as quickly as they 
 had come on, when the extreme sensation 
 of heat, which they had formerly felt, was 
 changed into cold. The part affected (adds 
 Noel) was black, like a piece of charcoal, 
 and as dry as if it had passed through the 
 fire. After some time, a line of separation 
 was formed between the dead and living 
 parts, like that which appears in the separa- 
 tion of a slough produced by the cautery ; 
 and the complete separation of the limb 
 was, in many cases, affected by nature 
 
 recourse to amputation. 
 
 This disease appeared in Switzerland in 
 1709 and 1716, and its symptoms and pro- 
 gress in that country have been accurately 
 described by Langius in a dissertation, enti- 
 tled, “ Descriplio Morborum ex esu Clavo- 
 rum Secalinorum." 
 
 Gassaud, physician in Dauphiny, where 
 this disease appeared also in 1709, states, 
 that many of the patients were affected with 
 swellings of the feet and legs, and of the 
 hands and arms, which degenerated into a 
 gangrene, that penetrated to the bone, and 
 produced a separation of the affected limb. 
 The disorder w r as attended with different 
 symptoms in different individuals. Some 
 suffered very violent pain, accompanied by 
 an insufferable sensation of heat, although 
 the part affected often felt cold to the touch. 
 In other patients redness, with much swell- 
 ing, supervened, attended with fever and 
 delirium. Other patients were without any 
 fever, or delirium, though they seemed to 
 suffer equal pain In some patients, the 
 parts affected became withered, dry, and 
 black, like charcoal. The separation of 
 the dead parts from the living took place 
 with the most excruciating pain, and a sen- 
 sation resembling that produced by the di- 
 rect application of fire. This sensation was 
 sometimes intermittent ; and, in other in- 
 stances, it was succeeded by an equally 
 harassing sensation of cold. 
 
 According to Bossau, surgeon to the hos- 
 pital of St. Antoine, in Dauphiny, the cases, 
 which he saw, were not all of the dry kind, 
 the limb sometimes becoming putrid, and 
 maggots being generated. He says that the 
 disease was not infectious, and it attacked 
 indiscriminately men, women, and chil- 
 dren. 
 
 The degree of fatality caused by this spe- 
 cies of mortification seems to have been 
 extremely various. In the Memoirs of the 
 Royal Academy of Sciences for 1748, M, 
 Duhamel mentions, that of 120 persons 
 afflicted, scarcely four or five recovered with 
 their lives. According to Langius, it was 
 equally fatal in Switzerland. 
 
 Dr. Thomson believes, that the preceding 
 sort of gangrene has never occurred in this 
 country, excepting, perhaps, the cases re- 
 corded by Dr. Charlton Woolaston, in the 
 Phil. Trans, for 1762; and which proceeded 
 from eating unsound wheat, not rye. (See 
 Lectures on Inflammation, p. 548.) For fur- 
 ther particulars relating to this curious kind 
 of mortification, I must refer the reader to 
 this valuable work. 
 
 The external causes of mortification, 
 which are manifest, and act mechanically or 
 chymically, are burns; excessive , cold ; the 
 application of caustics ; the presence of any' 
 ichorous, urinary, or fecal matter effused in 
 the cellular substance ; violent contusions, 
 such as are produced by gunshot wounds, 
 or bad fractures ; the strangulation of a part, 
 as in cases of hernia, or when polypi, or 
 other tumours are tied ; a high degree of in- 
 
MORTIFICATION. 
 
 240 
 
 fl animation; and, lastly, everything, that 
 has the power of stopping the circulation 
 and nervous energy in parts. ( Lassus , Pa- 
 thologic Chir. T. 1, p. 34, 35.) 
 
 Inflammation is one of ihe most frequent 
 occasional causes of mortification. But, as 
 we have already remarked, the death of a 
 part may take place without any well-mark 
 ed appearance of previous inflammatory 
 disorder ; and the latter even when present 
 has frequently less share in the mischief, 
 than other incidental circumstances, and is 
 in reality, only an effect of the very same 
 cause, which produces the sphacelus itself, 
 ft is oftentimes a matter of doubt, whether 
 actual inflammation precedes the occur- 
 rence or not ; for a part, before it mortifies, 
 Is in certain instances only affected with 
 pain, and with no degree of preternatural 
 redness. Lastly, when mortification is, un- 
 questionably, preceded by inflammation, 
 there are so many varieties of the disorder 
 depending on incidental causes, that these 
 latter demand more attention than the inflam- 
 mation. (Richter, .inf angsgr B 1 Kap. 3.) 
 
 Mr. James enumerates the following cir- 
 cumstances, as capable of influencing, in a 
 very great degree, the disposition of inflam- 
 mation to terminate in mortification. 1. 
 The powers of the part, in which the in- 
 flammation occurs, being naturally weak, as 
 in fibrous membranes, the scrotum, &.c. 2. 
 
 The remote supply of blood, or nervous 
 energy, as in the lower extremities. 3. Ob- 
 struction to the return of blood. 4. To the 
 supply of blood. 5. Disease in the heart or 
 vessels. 6. Debility from age, habits of life, 
 disorder of the digestive organs, or fever. 
 7. Poor living, foul air, improper food, scur- 
 vy, &c. 8. Impairment of organization 
 
 from external injury, 0. Of the nervous 
 power by poisons. 10 Undue excitement 
 of weakened parts. 11. Depressing reme- 
 dies. 12. Pressure and tension. 13. Ex- 
 cessive violence of inflammatory action. 
 34. Peculiar disposition in the constitution. 
 (James on Inflammation, p. lo2.) 
 
 Healthy phlegmonous inflammation sel- 
 dom ends in mortification, except when it is 
 unusually violent and extensive. 
 
 Of all the inflammatory complaints, to 
 which the system is liable, erysipelas is ob- 
 served most frequently to terminate in gan- 
 grene ; and whenever phlegmon is, in any 
 degree, conjoined with an erysipelatous af- 
 fection, which it not unfrequently is, it seems 
 thereby to acquire the same tendency, being 
 more difficult to bring to resolution or sup- 
 puration than the true phlegmon, and more 
 apt to run into a mortified state. 
 
 The symptoms of mortification from in- 
 flammation take place variously, yet gene- 
 rally as follows: — The pain and sympathetic 
 fever suddenly diminish, the part affected 
 becomes soft, and of a livid colour, losing, 
 at the same time, more or less of its natural 
 warmth and sensibility In some places, the 
 cuticle is detached ; while, in other situa- 
 tions, vesicles arise, filled with a clear, or 
 turbid fluid. Such is the state, to which we 
 apply the term gangrene, and which stage of 
 
 the disorder too often rapidly advances to 
 sphacelus, when the part becomes a cold, 
 black, fibrous, senseless substance, called in 
 technical language, a slough. 
 
 It merits notice, however, that, “ in cases, 
 in which gangrene immediately succeeds to 
 inflammation, these two morbid states may, 
 in some measure, be regarded as stages, or 
 periods, of the same disease. They pass in- 
 sensibly info one another; nor is it possible 
 to say precisely where the one state ends, 
 and the other commences. The symptoms 
 of inflammation, in these cases, do not dis- 
 appear before those of gangrene come on ; 
 but seem rather to undergo a gradual and 
 almost imperceptible change, or conversion, 
 into one another. The redness acquires a 
 deeper tin^e, and spreads further, than for- 
 merly ; the swelling increases and becomes 
 more doughy; and, in this incipient stage, 
 the gangrene, particularly when it attacks 
 the cuta eous texture, often bears a consi- 
 derable resemblance to erysipelas.” (Sfee 
 Thomson's Lectures on Inflammation, p. 506.) 
 
 It is to be observed, also, that u the part 
 of the body which becomes affected with 
 gangrene, does not immediately lose its sensi- 
 bility ; for the pain, on the contrary, is often 
 very much aggravated by the approach of 
 this state. I'he blood also still continues to 
 circulate, at least in the larger vessels of the 
 part, but, perhaps, with less force : and from 
 the resistance which it meets with in passing 
 through the capillaries, in less quantity, than 
 formerly. The serous effusion into the cel- 
 lular membrane continuing to increase, and 
 the action of the absorbent and sanguiferous 
 vessels to diminish, the part becomes at 
 length incapable of being restored to its 
 former office in the animal economy. It is, 
 therefore, in its earlier stages only, that 
 gangrene is to be considered as an affection 
 admitting of cure ; for there are limits, be- 
 yond which, if it pass, recovery becomes 
 impossible. These limits it may not, in 
 every instance, be easy to define . but 
 they form the boundaries between incipient 
 gangrene and the ultimate termination of 
 that state in sphacelus.” (Thomson, op. cit. 
 p. 507.) • 
 
 The causes which produce mortification 
 by impeding the return of blood from the 
 part affected, for the most part operate by 
 making pressure on the trunk or principal 
 branches of a vein. In these instances, 
 there is always an accumubition of blood in 
 the part which first swells, becomes of a 
 livid colour, tense, and very painful. Soon 
 afterward, blisters arise and the part be- 
 comes soft, oedematous, cold, insensible, 
 emphysematous, black, and fetid. Such are 
 the circumstances which happen in strangu- 
 lated hernia, in tied polypi, and in a limb 
 in which the veins have been so compressed 
 by any hard swelling, such as the*liead of a 
 dislocated bone, as to excite mortification. 
 
 Other causes operate by preventing the 
 entrance of arterial blood. The application 
 of a ligature to an artery, as practised in 
 several surgical cases, and all external 
 pressure, that, closes the artery, or arteries- 
 
MORTIFICATION 
 
 241 
 
 on which a pari entirely depends for its 
 siipply of blood, have this effect. Mortifica- 
 tion does not, however, always take place 
 when the trunk of an artery is rendered im- 
 pervious, because nature furnishes the ne- 
 cessary supply of blood through collateral 
 ramifications. But when the disorder does 
 happen, the part commonly first becomes 
 pale, ffaccid, and cold, and soon afterward 
 shrinks, loses its sensibility, grows black, and 
 perishes. 
 
 It is usually represented by writers, that 
 mortification may proceed from a mere less- 
 ening of the communication of blood and 
 nervous energy to a part. However, it is 
 to be observed, that parts, deprived of all 
 connexion with the sensorium, by the divi- 
 sion or paralytic state of their nerves, do not 
 frequently perish on this account. But as 
 their functions are carried on with less vi- 
 gour, and their vitality is weakened, the 
 same causes which sometimes produce mor- 
 tification iu parts differently circumstanced, 
 must much more readily occasion it in 
 them. Among the causes of the present 
 species of mortification, maybe mentioned 
 great universal debility ; extreme old age ; 
 a thickening and ossification of the coats of 
 the arteries, and a consequent diminution 
 of their capacity, and of their muscular and 
 elastic power. 
 
 Cowper, the anatomist, was one of the 
 earliest writers who took notice of this ossi- 
 fication of the arteries of the leg, in persons 
 who had died of mortification of the feet 
 and toes. (See Phil. Trans. Vol 23, p. 1195, 
 and Vol. 24, p. 1970.) A similar case was 
 remarked by Mr. Becket, of which he has 
 given an account in his Chirurgical Obser- 
 vations. The occurrence was also men- 
 tioned by Naish. (See Philosoph. Trans. 
 Vol. 31, p. 226.) Dr. J. Thomson has seen 
 one example of a very complete ossification 
 of the arteries of the leg, accompanying 
 a mortification of the feet and toes. (0?i 
 Inflammation, p. 537.) SpeaKing of the 
 same subject, Mr. Hodgson remarks : 11 Ex- 
 perience has proved this condition of the 
 arteries to be at/least a constant attendant 
 upon one species of gangrene, to which the 
 extremities of old subjects are liable ; and I 
 have found the three principal arteries of 
 the leg nearly obliterated by calcareous 
 matter in two fatal cases of this disease. 
 But our knowledge of the power of collate- 
 ral circulation, in every part of the body, 
 will not allow us to admit the obliteration 
 of the trunks as a sufficient cause of mortifi- 
 cation, from a deficient supply of blood. It 
 is therefore necessary for us to remember, 
 that the same disease may probably exist in 
 the collateral branches, upon which it has 
 produced similar effects. But if an extent 
 of vessel be converted into a calcareous cy- 
 linder, it loses its elasticity and organic pow- 
 ers, so as to be unable to afford any assist- 
 ance to the propulsion of the blood ; and 
 the existence of parts, supplied by vessels in 
 this state, constitutes a strong argument 
 against the agency of the arteries in the cir- 
 culation of the blood- The above observa- 
 Vol, II 31 
 
 tions, on the cause of this species of gan- 
 grene, at once expose its incurable nature ; 
 and this stale of the blood-vessels renders 
 the danger of amputation very considerable, 
 unless fortunately the disease in the arteries 
 does not extend to the part at which the 
 ligature is applied.” (See Hodgson’s Trea- 
 tise on the Diseases of the Arteries and Veins , 
 p. 41.) However, although the ossified 
 state of an artery must certainly be unfa- 
 vourable to its healing, it does not con- 
 stantly prevent this desirable event. (See 
 Case in Medico- Chir. Trans. Vol. 6, p. 193.) 
 
 The preceding facts are particularly enti- 
 tled to attention, because, as we shall pre- 
 sently find, the opinion that the mortification 
 of the toes and feet arose from an ossifica- 
 tion of the arteries, was considered by Mr. 
 Pott as destitute of foundation. 
 
 It is probable, however, that sometimes 
 other causes are concerned. Fabrieius Hil- 
 danus mentions a fatal case of mortification 
 of the feet and legs, where the patient was 
 in the vigour of life, and apparently of good 
 constitution. After death, a scirrhous tu- 
 mour was found surrounding and compress- 
 ing the inferior vena cava, and aorta, near 
 their bifurcation, so as to prevent the free 
 circulation of the blood in the lower extre- 
 mities. Mortification of the extremities also 
 sometimes occurs from deficient circulation, 
 in the progress of diseases of the heart. 
 
 The mortification, arising from long con 
 tinuance in the same posture, is chiefly attri- 
 butable to the unremitted pressure which 
 parts sustain, and which obstructs the cir- 
 culation Surgeons have frequent occasion 
 to see melancholy examples of this kind of 
 mortification, particularly in cases of frac- 
 tures, paralysis from disease of the vertebrae, 
 &x. The mischief most readily occurs 
 where the bones have the least flesh upon 
 them, and, consequently, where all external 
 pressure has the greatest effect ; as, for 
 instance, about the os sacrum, os ilium, 
 •spines of the scapula, &c. The disordered 
 part always first becomes soft, livid, red at 
 the circumference, and cedematous, after- 
 ward losing its sensibility, and acquiring a, 
 black appearance : at length it is converted 
 into a foul sloughing ulcer. 
 
 Though long continuance in the same 
 posture is the grand cause of this kind of 
 mortification, yet incidental circumstances 
 are frequently combined with it, and have 
 great influence ever the disorder. These are, 
 great debility, the same state of the system 
 as exists in typhus fever, impure air, unclean 
 bedding, &c. 
 
 There are some causes which produce 
 death in a part at once, by the violence of 
 their operation. A very powerful blow on 
 any portion of the body may destroy the 
 vitality of the fibres and vessels in this sud- 
 den manner. Lightning, strong concentra- 
 ted acids, and gunshot violence, sometimes 
 act in a similar way. When a bail enters 
 the substance of parts with great force and 
 rapidity, many of the fibres, which are in 
 its track, are frequently "killed at once, and 
 must be thrown off’ in the form of sloughs, 
 
MORTIFICATION, 
 
 242 
 
 before the wound can granulate and heal. 
 (See Hunter on Gunshot Wounds.) 
 
 Cold is often another 'cause of mortifica- 
 tion, and when parts which have been fro- 
 zen, or frostbitten, are suddenly warmed, 
 they are particularly apt to slough. 
 
 I find in Baron Larrey’s valuable publica- 
 tion, some interesting observations on the 
 gangrene from cold. He acquaints us, that 
 after the battle of Eylau, one of the most 
 grievous events to which the French sol- 
 diers were exposed, was the freezing of their 
 feet, toes, noses, and ears: few of the van- 
 guard escaped the affliction. In some, the 
 mortification was confined to the surface of 
 the integuments of the toes or heels ; in 
 some, the skin mortified more deeply, and 
 to a greater or lesser extent; 'while, in 
 otters, the whole of the toes, or foot, was 
 destroyed (See Programma quo frigoris 
 acrioris in corpore humano effectus expendit. 
 Haller , Disp. ad Morh . Lips. 1755.) 
 
 “ All the writers, on this species of morti- 
 fication (says Larrey) have considered cold 
 as the determining cause; but, if we attend 
 to the period when the complaint begins its 
 progress, and the phenomena which accom- 
 pany it, we shall be convinced, that cold is 
 merely the predisposing cause. In fact, 
 during the three or. four exceedingly cold 
 days which preceded the battle of Eylau, 
 (the mercury having then fallen to 10, 11, 
 12, 13, 14, and 15 degrees below zero of 
 Reaumur’s thermometer) and until the se- 
 cond day after the battle, not a soldier com- 
 plained of any symptom depending upon the 
 freezing of parts. Nevertheless, they had 
 passed these days, and a great portion of the 
 nights of the 5 th, 6th, 7th, 8th, and 9th of 
 Feb. in the snow, and the most severe frost. 
 The imperial guard especially had remained 
 upon watch in the snow, hardly moving at 
 all for more than four and twenty hours, 
 yet no soldier presented himself at the am- 
 bulance,* nor did any one complain of his 
 feet being frozen. In the night of the 9th, 
 and 10th of February, the temperature sud- 
 denly rose, the mercury ascending to 3, 4, 
 and 5 degrees above zero. A great quantity 
 of sleet, that fell on the morning ofThe 10th, 
 was the forerunner of the thaw whhj^took 
 place in the course of that day, and continu- 
 ed in the same degree for several days. 
 From this moment, many soldiers of the 
 guards and the line applied for succour, 
 complaining of acute pain in the feet, and 
 of numbness, heaviness, and prickings in- the 
 extremities. The parts were scarcely swol- 
 len, and of an obscure red colour. In some 
 cases, a slight redness was perceptible about 
 the base of the toes, and on the back of the 
 foot. In others, the toes were destitute of 
 motion, sensibility, and warmth, being alrea- 
 dy black, and, as it were, dried. All the 
 
 * The ambulances of the French army are caravans, 
 furnished with an adequate number of surgeons, and 
 every requsite for the dressing of w ounds, and the im- 
 mediate performance of operations, upon which last 
 circumstance, in particular, the life of the wounded 
 soldier often depends. These caravans follow the most 
 rapid movements of the army, and are always capable 
 of beeping- up with the vanguard. 
 
 patients assured me, that they had not expe- 
 rienced any painful sensation during the 
 severe cold to which they had been exposed 
 on the night-watches of the 5th, 6th, 7th, 
 8th, and 9th of February, and that it was 
 not till the night of the 10th, when the tem- 
 perature had risen from IS to 20 degrees, 
 that they felt the first effects of the cold.” 
 It is further noticed by Larrey, that such pa- 
 tients as had opportunities of warming them- 
 selves in the town, or at the fires of the 
 night-watches, suffered in the greatest de- 
 gree. (See Larrey' s Memoires de Chirurgis 
 Militaire, T. 3, p. 60 — 62.) 
 
 Sometimes mortification seems to depend 
 either upon the operation of some infectious 
 principle, or, at all events, upon causes 
 which simultaneously affect numerous indi- 
 viduals; for instances have been known, in x 
 which almost all the ulcers and wounds in 
 large hospitals became nearly at the same 
 time affected with gangrenous mischief. 
 (See Hospital Gangrene.) 
 
 Mortification is very frequently occasion- 
 ed by the injury which parts sustain from 
 the application of fire and heated substances 
 to them. When the heat is very great, the 
 substance of the body is even decomposed, 
 and of course killed at once. On other oc- 
 casions, when the heat has not been so vio- 
 lent, nor sufficiently long applied, inflamma- 
 tory symptoms precede the sloughing. 
 
 Cutaneous texture is that in which, we 
 have the best opportunity of observing the 
 phenomena and progress of gangrene. When 
 it occurs as a consequence of inflamma- 
 tion, the colour of the skin changes from 
 the florid red to a darker shade ; and in 
 the progress of the disease it acquires a livid 
 hue. The cuticle often separates at certain 
 points from the skin, and the vesications, 
 termed phlyctenee, are formed, which usu- 
 ally contain a bloody-coloured serum. As 
 sphacelus comes on, the livid hue disap- 
 pears, and a slough is formed, which is 
 sometimes ash-coloured ; sometimes black. 
 
 It is not always easy to judge of the extent 
 of mortification from the appearance of 
 the skin ; for, when the subjacent cellular 
 membrane is affected, the disorder may 
 occupy a greater extent internally, than 
 upon the surface. 
 
 In a spreading gangrene, the red colour of 
 the affected skin is insensibly lost in the sur- 
 rounding integuments ; but, when gangrene, 
 followed by sphacelus stops, a red line, of a 
 colour more lively than that of gangrene, 
 is generally perceptible between the dead 
 and living parts. It is at the inner edge of 
 this inflamed line, where we usually see the 
 ulcerating process begin, by which the se 
 paration of the dead from the living parts is 
 affected. (See Thomson's Lectures on Inflam- 
 mation , p. 511, 512.) 
 
 Mortification occurs frequently in cellular 
 texture. The skin which covers dead cellu- 
 lar substance, generally has a gangrenous ap - 
 pearance, and afterward either ulcerates, or 
 sloughs. In some coses, the portion of spha- 
 celated cellular texture is small, as in the ma 
 Jignant boil ; in others, extensive, as in case* 
 
MORTIFICATION 
 
 ot carbuncle. In erysipelas phlegmonoides, 
 the cellular membrane, connecting together 
 the muscles, tendons, nerves, blood-vessels, 
 &e. often perishes to a great extent. Here 
 large portions of skin are frequently also 
 destroyed by sloughing, or ulceration, so 
 that Smuscle, blood-vessel, tendon, nerve, 
 &c. are exposed to view, quite denuded of 
 their proper coverings, and in different states 
 of disease. 
 
 Artery is the texture, endowed with the 
 greatest power of resisting its own destruc- 
 tion by mortification. “ 1 have (says Dr. 
 Thomson) in various instances of erysipe- 
 las phlegmonoides, seen several inches of 
 the femoral artery laid completely bare by 
 the gangrene, ulceration, and sphacelus of 
 the parts covering it, without its giving way 
 before death. The arteries in these, and 
 other similar instances, in which 1 have seen 
 them laid bare in the neck and arm, by ab- 
 scess terminating in fortification , had the 
 appearance of raw flesh, and were obviously 
 thicker and more vascular than natural. The 
 blood circulated through them, and assisted 
 in supplying with nourishment the parts upon 
 which they were distributed.” (P. 513.) I 
 have often seen tbe truth of the foregoing 
 statement sadly illustrated in cases of slough- 
 ing buboes, by which several inches of the 
 femoral artery were exposed. I have seen 
 the throbbing brachial artery denuded for 
 more than a month, nearly its whole extent 
 along the inside of the arm, by the ravages 
 of malignant and pseudo-syphilic ulceration, 
 attended with repeated sloughing ; and yet 
 hemorrhage had no share in carrying off the 
 unfortunate patient. 
 
 ft is a curious fact, that the blood coagulates 
 in the large arteries, which lead to a morti- 
 fied part. This occurrence takes place for 
 some distance from the slough, and is the 
 reason why the separation of a mortified 
 limb is seldom followed by hemorrhage. 
 
 The same occurrence also affords an ex- 
 planation, why, in the amputation of a mor- 
 tified limb, there is sometimes no hemorrhage 
 from the vessels, although the incisions are 
 made in the living part. This fact was first 
 particularly pointed out by Petit, the sur- 
 geon. (See Mim. de VAcad. des Sciences, 
 1732.) “ When a gangrened limb (says (his 
 
 celebrated surgeon) is cut off in (be dead 
 'part, no hemorrhage occurs, because the 
 blood is coagulated a great way in the ves- 
 sels.” He adds, l£ We have several exam- 
 ples of limbs amputated, on account of gan- 
 grene, in which no hemorrhage occurred, 
 although the amputation was made a consi- 
 derable way in the living parts ; because the 
 clot was not confined in these cases to the 
 dead part, but was continued forwards into 
 the living as far as the inflammatory dispo- 
 sition extended.” 
 
 According to Dr. Thomson, cases, in con- 
 firmation of the foregoing statement, are 
 recorded by other practical writers, espe- 
 cially Quesnay, and Mr. O’Halloran. Tri 
 one of the cases, mentioned by tbe latter 
 gentleman, and in which no hemorrhage 
 followed the removal of the limb, the irici- 
 
 2 43 
 
 sions were made four inches above the divi- 
 sion of the dead from the living parts. Dr. 
 Thomson has seen a still longer portion of 
 femoral artery dosed up with coagulated 
 blood, after a mortification of the foot and 
 leg.; and, in one example, where the morti- 
 fication began in the thigh, he saw the coa- 
 gulation of the blood in tbe external iliac, 
 extending up to the origin of this vessel 
 from the aorta. “ So common, indeed, is 
 this coagulation of the blood in the limbs 
 affected with mortification (observes Dr. 
 Thomson,) that it has been supposed to be a 
 necessary and constant effect of Ibis disease. 
 This opinion, however, does not appear to 
 be well founded ; for I have now seen seve- 
 ral instances in which a limb has mortified 
 and dropped off, without hemorrhage having 
 occurred from tjie vessels divided by na- 7 
 ture : and yet, in examining the vessels of 
 the stumps of these patients after death, 1 
 have not been able to find any clots, either 
 of coagulated blood, or ot coa .able 
 lymph. In the cases to which I allude, the 
 adhesive inflammation, occurring in the line 
 of separation between the dead and living 
 parts, had extended to the blood-vessels, and 
 their inner surfaces being inflamed arid press- 
 ed together by the swelling which occurs, 
 had adhered so as to close up their extremi- 
 ties. It is in Ibis way we shall find, that the 
 common ligature acts, which is applied to 
 the divided extremities of arteries and veins; 
 and it is this obliteration, by the process of 
 adhesion of the extremities of the arteries 
 and veins in the neighbourhood of the spha- 
 celated parts, that in reality prevents the 
 occurrence of hemorrhage, when the morti- 
 fied limbs fall off', or are removed by the 
 knife. The coagulation of the blood in the 
 canal of the vessel is not alone sufficient. If; 
 may tend, in the cases in which it occurs, 
 for a time to restrain hemorrhage ; but it 
 is by tbe obliteration by adhesion, offthe 
 canal in the extremities of the arteries 
 and veins, that the occurrence of hemor 
 rliage can be securely and permanently pro- 
 vided against. Indeed, to me it seems 
 doubtful, whether that coagulation of blood, 
 which takes place in mortified limbs, ever 
 takes place in the canal of the vessel, till 
 its extremity and lateral communications 
 have been plugged up by the coagulating 
 lymph, which is extending during the state 
 of the adhesive inflammation.” (See Thom- 
 son's Lectures on Inflammation, p. 554.) 
 
 When gangrene and sphacelus happen to 
 any extent, the patient is usually troubled 
 with an oppressive hiccough; a symptom 
 well known to the surgeon of experience , 
 and often an indication of the mischief, 
 when external signs are less instructive 
 The truth of this remark is frequently seen 
 in strangulated hernise. 
 
 The’ constitution also suffers immediately 
 a considerable dejection. The patient’s 
 countenance suddenly assumes a wild, ca- 
 daverous look ; the pulse becomes small, 
 rapid, and sometimes irregular; cold per- 
 spirations come on, and the patient is often 
 affected with diarrhoea and delirium 
 
MORTIFICATION 
 
 244 
 
 As Dr. Thomson observes, the constitu- 
 tional symptoms “ form fevers, which par- 
 take in individual cases, more or less, of an 
 inflammatory, typhoid, or bilious character, 
 lint, the degree of these fevers varies, in 
 every particular case, from their almost total 
 absence to the highest degree of intensity. 
 The skin is usually hot, and dry at the com- 
 mencement of the attack ; the tongue is 
 without moisture, brown and hard; the pulse 
 is quicker, and less full and strong, than in 
 inflammation ; and this state of the pulse is 
 often attended by flattering intermissions, 
 and a considerable degree of subsultus ten- 
 dinum. The fever has, in general, more of 
 the asthenic, than of the sthenic character ; 
 or it is more of the typhoid, than of the in- 
 flammatory type ; a circumstance of great 
 importance in the constitutional treatment 
 of mortification. The fever in gangrenous af- 
 fections is often accompanied with great un - 
 easiness and restlessness, dejection of spirits, 
 wildness of the looks ; and, in severe cases, 
 with almost always more or less delirium. 
 In the progress of the disease, cold sweats, 
 palpitations, and convulsions, sometimes oc- 
 cur ; a hiccough, accompanied with nausea, 
 often comes on, and proves a most distress- 
 ing symptom to the patient. Frequently, 
 this hiccough is the forerunner of death. 
 Some patients die comatose ; others, after 
 suffering severe pain, spasms, and delirium. 
 But, in some, a slow, in others, a sudden 
 abatement of the constitutional symptoms 
 takes place, accompanied also with the ame- 
 lioration of the local affection. The gangre- 
 nous inflammation stops, and a red line is 
 formed by the adhesive inflammation in the 
 extreme verge of the living parts ; the dead 
 part separates, and granulations form , and 
 when the constitution has strength to sus- 
 tain the injury it has received, recovery 
 takes place.” (See Lectures on Inflamma- 
 tion, p. 509.) 
 
 In cases of sphacelus, the prognosis chiefly 
 depends on the nature of the cause of the 
 disorder. The more easy the cause is of re- 
 moval, the less room is there for alarm. It 
 is an erroneoussupposition,that mortification 
 arising from an external local cause is more 
 easy to be stopped and cured, than that 
 originating from an internal cause. The lo- 
 cal cause is sometimes exceedingly difficult, 
 or even incapable, of removal ; and a spha- 
 celus, which is at first entirely local, may 
 afterward become a general disorder, by the 
 universal debility and derangement of the 
 system, resulting from the complaint. Hence, 
 it is obvious, that a sphacelus may easily ex- 
 tend beyond the bounds of its outward local 
 cause. On the other hand, a mortification 
 may be reduced to one of a nature entirely 
 local ; though it arose at first from constitu- 
 tional causes. Sphacelus from extreme de- 
 bility, or from such a state of the system, as 
 attends the scurvy, typhoid fevers, he. is 
 constantly perilous, because these causes 
 are very difficult to remove. It is also a fact, 
 that, when numerous causes are combined, 
 it is an unfavourable occurrence, not merely 
 because the surgeon is apt overtook some 
 
 of them, but because there are in reality 
 more obstacles to the cure. 
 
 Humid gangrenes, which are frequently 
 accompanied with emphysema of the cellu- 
 lar membrane, usually spread with great ra- 
 pidity. “ Some authors, (says a modern 
 writer,) have attributed this to the influence 
 of the air extricated, and Dr. Kirkland has 
 described emphysematous gangrene, as dis- 
 tinct from the others, and some have impu- 
 ted this disposition, in a considerable degree, 
 to the putrefaction of the juices, which are 
 effused. ” With regard to the former, the 
 author has mistaken an effect for a cause ; 
 yet, “ it is important to recognize the fact, 
 that gangrene, when accompanied with em- 
 physema, has a remarkable disposition to 
 spread.” {James on Inflammation, p. 96.) 
 
 Sometimes a mortification spreads so 
 slowly, that it does not occupy much extent 
 at the end of several months, or even a 
 whole year. The case, however, is often 
 not the less fatal on this account. The dan 
 ger is never altogether Over, until the dead 
 part has completely separated. The en- 
 trance of putrid matter into the circulation 
 (says Richter) is so injurious, that patients 
 sometimes perish from this cause, long after 
 the mortification has ceased to spread. {An- 
 fangsg. der Wundarzn. B 1, Kap. 3, p. 78. 
 79.) _ 
 
 This last circumstance is very much insist- 
 ed upon, by all the modern continental sur- 
 geons ; but the doctrine has never gained 
 ground among Fmglish surgeons, who enter- 
 tain little apprehension of the bad effects of 
 the absorption of putrid matter in cases of 
 mortification ; and the opinion of Mr. Gu- 
 thrie may be more correct, that nature re- 
 ceives the shock through the nervous system, 
 and not through the absorbents. (On Gun- 
 shot Wounds, p. 123, Ed. 2.) 
 
 The idea of a deleterious principle being 
 absorbed was long ago well refuted by Mr. 
 J. Burns, who pointed out, that the impression 
 upon the constitution was in no degree com- 
 mensurate with the size of the slough, and 
 consequently with the quantity of putrid 
 matter, as the effects produced by a small 
 slough of intestine, or cornea, will exempli- 
 fy. But when the sloughs are of equal size, 
 and in the same parts, the differences of con - 
 stitutional sympathy, as Mr. James observes, 
 may depend upon the nature of the surround- 
 ing inflammation, which, however, he con- 
 ceives, may itself be affected by the quantity 
 of putrid irritating fluids. {On Inflammation , 
 p. 98.) 
 
 The danger of sphacelus is also propor 
 tioned to the size and importance of the part 
 affected. The event of the distemper like- 
 wise depends very much on the patient’s age 
 and constitution. 
 
 Parts, affected with gangrene, do not ini 
 mediately lose the whole of their sensibility; 
 the circulation is still continued in a certain 
 degree ; and when the progress of the dis 
 temper does not surpass certain bounds, the 
 functions of such parts may be completely 
 re-established. Gangrene, strictly speaking, 
 is not a decided mortification : but only the 
 
MORTIFICATION. 
 
 245 
 
 forerunner of this latter mischief, and may 
 he regarded as the intermediate link, be- 
 tween the most violent stage of inflamma- 
 tion and sphacelus. The presence of this 
 last implies the total loss of life in the part 
 affected, the destruction of its organization, 
 the abolition of all its functions, and an ab- 
 solute inability to resume them again. How- 
 ever, even when we see the surface of a 
 part manifestly sphacelated, we must not 
 always conclude, that the entire destruction 
 of its whole substance pr thickness is cer- 
 tain ; for, in many cases, the disorder only 
 atfects the skin and cellular substance. In 
 this state, the integuments frequently slough 
 away, leaving the tendons, muscles, and 
 other organs, perfectly sound. 
 
 It is only in external affections of the body 
 that the progress of inflammation to gan- 
 grene and sphacelus can bp marked with any 
 degree of precision. The approaches of the 
 latter are also not invariably announced by 
 the distinct and manifest symptoms of gan- 
 grene, even when the disorder is quite su- 
 perficial. There are cases, which justify the 
 conclusion, that a small part of the body 
 may be affected with sudden death, just in 
 the same manner as the whole machine. 
 Sphacelus is often seen making its appear- 
 ance in a part, which is apparently quite 
 healthy, without being preceded by any 
 other symptoms, than a sudden acute pain in 
 the seat of the mischief. Sometimes, in the 
 earliest period of the complaint, a black spot, 
 which rapidly spreads on every side, is the 
 only change that can be observed 
 
 Jn order to form a just prognosis, all the 
 above circumstances must be taken into 
 consideration, and, in particular, we must 
 never deliver an opinion, without having 
 closely examined the progress of the disor- 
 der ; for, should we make a favourable prog- 
 nosis from such appearances. as might justify 
 us as much as possible in so doing, there 
 would be great risk of finding ourselves 
 most miserably mistaken by the event of the 
 case. In all cases of considerable mortifica- 
 tion, even when arising from an external 
 cause, the patient cannot be deemed exempt 
 from danger, not only while no separation of 
 the mortified parts has begun, but also, not 
 before such parts have been completely 
 detached. 
 
 TREATMENT OF MORTIFICATION. 
 
 I shall arrange under two heads what is to 
 be said of the treatment of mortification. 
 Under the first will be comprehended every 
 thing, which relates to internal remedies, 
 and such other means, as are indicated by 
 the general slate of the system ; under the 
 second, topical remedies, and the local treat- 
 ment of the parts affected. 
 
 In the treatment the surgeon will always 
 have one thing for immediate consideration; 
 viz. whether the case before' him is one of 
 acute mortification, attended with inflamma- 
 tion and inflammatory fever ; or whether 
 it is a chronic mortification, beginning with- 
 out fever, or attended with a fever of a ty 
 
 phoid nature and great prostration of 
 strength ? By making up his mind upon 
 this point, the practitioner will establish an 
 useful general principle for his guidance, 
 especially in the commencement of the 
 treatment. 
 
 1. When mortification is acute, and seems 
 to depend on the violence of inflammation , 
 the first indication is to moderate the inor- 
 dinate action of the sanguiferous system, 
 by the prudent employment of such means 
 as are proper for counteracting inflamma- 
 tion. In short, relief is to be sought in the 
 antiphlogistic regimen, which consists in 
 the employment of blood-letting, purgatives, 
 diaphoretics, and diluents, and in abstinence 
 from all vegetable or animal substances, 
 which have a tendency to excite, or to aug- 
 ment the febrile action It is a regimen 
 which must be pursued, so long as inflamma- 
 tory fever continues. It is only in cases in 
 which the fever from the first assumes a ty- 
 phoid character, or where the mortification 
 takes place without the previous occurrence 
 of fever, that any deviation from the anti 
 phlogistic regimen can be allowed. 
 
 Dr. Thomson, from whom l have borrow- 
 ed the foregoing passage, also notices tho 
 present common aversion to bleeding in 
 compound fractures, erysipelas, carbuncle, 
 hospital gangrene, burns, and frostbite , 
 cases in which the patient, it is said, can 
 seldom bear with impunity any considerable 
 loss of blood. “ In many instances of these 
 injuries and affections (says he) blood-let- 
 ting, 1 know, is not required ; but I am 
 doubtful, even if it were generally employed, 
 whether it would produce all the mischiefs, 
 which have of late years been ascribed to 
 it. I believe it to be the most efficacious*ot‘ 
 any of the remedies that can be employed, 
 in all cases of inflammatory fever threaten- 
 ing to terminate in gangrene, and that its 
 use in such cases ought never to be omitted 
 in the young, strong, and plethoric.” (See 
 Lectures on Inflammation, p. 559.) When 
 bleeding has not been sufficiently practised, 
 during the state of the inflammation anteoe 
 dent to the mortification ; when the general 
 symptoms, which point out the existence of 
 this state, continue violent ; and, especially, 
 when the pulse is still quick, hard, or fulf ; 
 it is absolutely necessary to empty the ves - 
 sels a little more, even though mortification 
 may have begun, particularly if the patient 
 be young and plethoric. Bleeding, by dimi- 
 nishing the fever, and abating the general 
 heat, is frequently the best means.of all. It 
 may then be considered better, than all anti- 
 septics, for stopping the progress of the dis- 
 order. But this evacuation is to be employed 
 with a great deal of circumspection : for, 
 should it he injudiciously resorted to, from 
 the true state of the system not being under 
 stood, the error may be followed by the 
 most fatal consequences. It should also hs 
 well remembered, that however strongly 
 bleeding may be indicated, the moment is 
 not far off, when this evacuation is totally 
 inadmissible, especially if the mortification 
 make much progress. 
 
246 
 
 MORTIFICATION. 
 
 In cases of acute mortification, after as 
 much has been taken away as may be deem- 
 ed safe or proper, the other parts of the 
 antiphlogistic regimen must be continued, as 
 long as any increased action of the heart and 
 arteries continues. “ The use of purgatives 
 seems to be particularly required in those 
 cases, in which the local inflammatory affec- 
 tion is accompanied with derangement of 
 the digestive and biliary organs. Antimonial 
 diaphoretics are those from which 1 should 
 be inclined to expect most advantage in the 
 commencement of the attack; but, after 
 the inflammatory action has been subdued, 
 opiates, either alone, or combined with anti- 
 mony, or what is still better, with ipecacuan- 
 ha, as in Dover’s powder, are frequently of 
 singular service, not only by diminishing 
 pain, bu* also, by inducing a soft and moist 
 state of the skin.” {Thomson, p. 560.) A 
 strict regimen, which may have*been useful, 
 and even necessary, during the inflammatory 
 stage, may have a very bad effect, if conti- 
 nued too long, by diminishing the patient’s 
 strength, which, on the contrary, should be 
 supported by the most nourishing food. 
 
 A vegetable diet, as Dr. Thomson ob- 
 serves, is to be preferred in the commence- 
 ment both of acute gangrene w ith inflamma- 
 tory fever, and of chronic gangrene w'ith a 
 fever from thp first of a typhoid nature. 
 Wine and animal food given too early in dis- 
 eases, which have a tendency to gangrene, 
 increase the febrile heat and frequency of 
 the pulse, oppress the stombeh, render the 
 tongue foul, the patient restless and deli- 
 rious, and his situation dangerous, if not 
 hopeless. In the transition from gangrene 
 to sphacelus, an abatement of the sympto- 
 matic fever usually takes piace in almost all 
 cases, which have ultimately a favourable 
 termination Dr. Thomson beieves, that 
 this is the first period, at which it is safe to 
 allow vinous liquors, or diet, ckiejly animal. 
 
 (. P . 561.) 
 
 I next come to a second very essential 
 and important indication, to he fulfilled, as 
 soon as the symptoms, announcing the ex- 
 istence of the inflammatory state, appear to 
 abate, and the patient begins to be debili- 
 tated. This indication i- to prevent excessive' 
 weakness by the suitable employment of cor- 
 dials, and, particularly, of tonics. These 
 same means also contribute to place the 
 system in a proper state for treeing itself 
 from the mortified parts, or, in other words, 
 for detaching them. For, inflammation is 
 the preparatory step, whicli nature takes to 
 accomplish the separation of mortified parts 
 from the living ones, arid such salutary in- 
 flammation cannot take place, if the ener- 
 gies of life be too much depressed. 
 
 In order to fulfil the above indication, it is 
 necessary to prescribe a nourishing diet, with 
 a r.-rtain quantity of good wine, propor- 
 tio d to the patient’s strength, and the 
 symptom- of the complaint. This diet is 
 generally productive of more real benefit 
 than tiie whole class of cordial and stimu- 
 lating medicines. However, when the. pa- 
 tient is much weakened, when the mortifi- 
 
 cation of the pari affected is complete, ami 
 the disorder is spreading to others, some of 
 the following remedies may be ordered 
 ammonia, aromatic confection, aether, &c 
 In general, however, wine is best, because 
 more agreeable than cordials ; and for this 
 purpose, one ought to prefer the most per- 
 fect wines, such as those of Spain and Ma- 
 deira. 
 
 Of all the medicines, hitherto recom- 
 mended for the cure of mortification, there 
 is certainly not one, that has acquired such 
 a character for efficacy, as the Peruvian 
 bark. It is said, that this remedy often stops, 
 in a very evident and expeditious manner, 
 the course of the disorder. Being a very 
 powerful tonic, it is thought to operate by 
 strengthening the system, and thus main- 
 taining in every part the necessary tone for 
 resisting the progress of mortification. But, 
 w'hat x ever may be its mode of acting, the ad- 
 vocates for this medicine contend, that it is 
 now' a v/ell-knovvn fact, that it ought to be 
 employed in almost all cases of mortification, 
 as soon as the violence of the inflammatory 
 symptoms has been appeased. 
 
 It was Mr. Rush worth, a surgeon at North- 
 ampton, who made this discovery in the year 
 1715. Arnyand and Douglas, two surgeons 
 in London, soon afterward confirmed the 
 virtue of this remedy. Mr. Shipton. another 
 English surgeon, has also spoken, in the 
 Philosophical Transactions, of the good ef- 
 fects which he has seen produced by this 
 medicine. In the Medical Essays of Edin- 
 burgh, Drs. Monro and Paisley published 
 several cases, illustrative of the efficacy of 
 bark in cases of mortification. We are 
 there informed, tfiat when its exhibition was 
 interrupted, the separation of the eschars 
 was retarded, and that, on the medicine 
 being resorted to again, such a separation 
 went on again more quickly. Since this 
 period, all practitioners, both in England 
 and elsewhere, have had recourse to this 
 remedy, which has every where obtained the 
 highest praises. Unfortunately, these praises 
 have induced surgeons to employ it indis- 
 criminately, and with equal confidence, in 
 all cases. 
 
 We cannot, indeed doubt, that bark has 
 frequently had the most salutary effect, in 
 cases of mortification, though sometimes it 
 may probably have had imputed to it effects, 
 which were entirely produced by nature. 
 
 I he follow ing observation, made by Dr. 
 Thomson, is highly worthy of recollection : 
 In attending to the effects, supposed to re- 
 sult from the operations of the external and 
 internal remedies, w hich are daily employed 
 for the cure of mortification, there are two 
 facts, well ascertained, which appear to me 
 to be peculiarly deserving of your regard. 
 The first ot these is, that mortification often 
 stops spontaneously, without any assistance 
 whatever from medicine; the second, that 
 it often begins, and continues to spread, or 
 even after it has stopped fora while, recom- 
 mences and proceeds lo a fatal termination, 
 in spite of the best directed efforts of the 
 healing art” (See Lectures on In ft a mm a {ion. 
 
MORTIFICATION. 
 
 p. 55V.) In many cases, bark is evidenlly 
 hurtful, when exhibited prematurely. There 
 are other instances, in which it is impossible 
 to employ it in a sufficient quantity, the sto- 
 mach not being able to bear it in any form- 
 In general, it should never be administered, 
 when the pulse is high, and other inflamma- 
 tory symptoms exist ; but, when the tension 
 of the part diminishes, the pulse sinks, and 
 symptoms of weakness commence, and par- 
 ticularly, when with these circumstances, 
 we perceive a separation beginning to take 
 place between the dead and the living part, 
 bark hardly ever fails to support the strength 
 of the constitution, and powerfully to acce- 
 lerate the separation of the mortified parts. 
 ( Encyclop . Method. Art. Gangrene .) 
 
 However, as I have already remarked, it 
 is quite wrong to prescribe bark, in every 
 instance, as the sole remedy ; for there are 
 many cases, in which it is unnecessary ; 
 some, in which it does harm ; and others, in 
 which it is totally inefficacious. It is a medi- 
 cine obviously of no service, when the 
 mortification arises from an external cause, 
 and is the only complaint, in a healthy, 
 strong constitution. It is equally unneces- 
 sary, when the sphacelus is of the dry sort, 
 and has ceased to spread, at the same time, 
 that the living margin appears to be in a state 
 of inflammation, without any universal de- 
 bility. But it deserves particular notice, that 
 the circumstances of each individual case 
 are liable to such considerable variation, that 
 though bark may be at first unnecessary, it 
 may afterwards be indicated. 
 
 In some cases of sphacelus, bark is hurt- 
 ful. The disorder is generally attended w ith 
 fever, which may be of three kinds ; inflam- 
 matory ; typhoid, or attended with extreme 
 debility ; or one connected with a disorder- 
 ed state of the abdominal viscera. 
 
 Inthe lattercase, which isfar more common 
 than is supposed, bark is manifestly perni- 
 cious. Here, the indication is to empty the 
 stomach and bowels as quickly as possible. 
 When this has been done, if bark should now 
 be indicated by any of the circumstances 
 already pointed out, it may be safely admi- 
 nistered. But there is a great necessity for 
 procuring evacuations as speedily as possi- 
 ble, before much debility has occurred. 
 
 Sometimes, mortification is accompanied 
 with a low typhoid kijs-d of fever, which, 
 whether the cause, or the consequence of 
 the local mischief, demands the exhibition 
 of bark. 
 
 However, mortification may be attended 
 with common inflammatory fever, and then 
 the living margin is generally inflamed and 
 painful. This is particularly the case, when 
 mortification is the consequence of genuine 
 acute inflammation, or of an external injury 
 in a healthy subject. Here, bark must ob- 
 viously be injurious. Still, it is wrong to 
 regard this medicine as invariably hurtful, 
 whenever sphacelus is the effect of inflam- 
 mation. It has already been observed, that 
 the inflammation frequently has less share 
 in the origin of the disorder than gome inci- 
 dental cause, which oftentimes requires the 
 
 exhibition of bark. Even when mortifica - 
 tion is the pure effect of inflammation, great 
 prostration of strength may subsequently 
 arise, and indeed does mostly take place at. 
 a certain period of the disorder. In this cir- 
 cumstance, the voice of experience loudlj' 
 demands the employment of bark, though 
 its exhibition would have been at first use- 
 less or hurtful. While genuine inflamma- 
 tory fever, and local inflammation, are co- 
 existent with mortification, antiphlogistic 
 means are undoubtedly useful ; but, great 
 caution is requisite, since, in cases of humid 
 gangrene, as it is termed, the inflammatory 
 state very soon changes into one, in which 
 the great feature is prostration of strength. 
 
 When there is mere prostration of strength . 
 without any symptom of gastric disorder, or 
 of inflammation, or typhoid fever, bark is 
 evidently proper, though seldom effectual 
 alone ; diaphoretic, and nervous medicines 
 being also proper, opium, wine, camphor, 
 ammonia, brandy, &lc. The constitutional 
 disorder may be either inflammatory, ty- 
 phoid, or on6 connected with gastric disor- 
 der. Consequently, there are three plans 
 of constitutional treatment, and it is easy to 
 determine the particular cases, in which 
 bark is unnecessary, hurtful, or ineffica- 
 cious. 
 
 We meet with one species of mortifica- 
 tion, in which the patient experiences se- 
 vere pain in the part, w ithout the smallest 
 appearance of inflammation. Here bark is 
 never of any use, and opium is regarded as 
 the only medicine of much efficacy. This 
 subject will be more fully considered pre- 
 sently, when Mr. Pott’s remarks on a pecu- 
 liar mortification of the toes and feet will 
 be introduced. 
 
 Bark sometimes occasions purging, and 
 then it also proves inefficacious and hurtful. 
 
 This effect, however, may frequently be 
 prevented by adding a few drops of lauda- 
 num to each dose. 
 
 Bark often disagrees wdth the stomach ;. 
 but it less frequently does so, when given 
 in an exceedingly fine powder, which also 
 generally proves most inefficacious. Also 
 the administration of bark with w ine, some 
 aromatic water, or in the form of the cold 
 infusion, is less likely to disorder the sto 
 rnach. (Richter, Anfangsgr. dcr Wundarzn . 
 Kap. 3.) 
 
 Several years ago I published a critique 
 on the indiscriminate employment of bark 
 in cases of mortification, and my remarks 
 were inserted in the article Gangrene in Dr. 
 Rees's Cyclopaedia. Many of them were in- 
 troduced into the 2d edition of this Surgical 
 Dictionary, printed in 1813. (See Cinchona.) 
 Since this period, I am happy to find, that 
 the blind enthusiasm with which bark was 
 prescribed is beginning to subside, and that 
 on this subject some eminent surgeons have 
 of late publicly avowed sentiments, which 
 entirely coincide with my former state- 
 ments. I think (says Dr. Thomson) ! have 
 frequently seen it prove hurtful, when ad- 
 ministered in cases of mortification, by load- 
 ing the Stomach of the patient, creating a 
 
248 
 
 MORTIFICATION 
 
 dislike to food, and sometimes by exciting 
 an obstinate diarrhoea. I believe il to be, in 
 mortification , a medicine completely inert and 
 inefficacious.” (See Lectureson Inflammation, 
 p. 563.) By this expression, Professor Thom- 
 son does not mean to say that bark can ne- 
 ver be useful in cases of mortification, but 
 only that it has no specific power in check- 
 ing the disorder, as many have erroneously 
 inculcated. 
 
 a Bark (says Professor Boyer) has been 
 considered by several distinguished English 
 practitioners, as a true specific against gan- 
 grene in general, and especially against that 
 which depends upon an internal cause ; but, 
 subsequent observations to those published 
 in England have proved, that it has no 
 power over the immediate cause of gan- 
 grene, and that it only acts as a powerful 
 tonic in stopping the progress of the disor- 
 der, and promoting tbe separation of the 
 mortified parts.” (See Traiti des Maladies 
 Chir. T. 1 .p. 151, Paris , 1814.) Boyer alscP 
 particularly objects to bark being given 
 while inflammatory fever prevails ; but, 
 whenever he prescribes bark in cases of 
 mortification, he seems to entertain the old 
 prejudice of expecting benefit in proportion 
 to the quantity which can be got into the 
 stomach. On the contrary, Mr. thrie de 
 dares, that he has not found hark useful, 
 “ further than as a tonic, and given in such 
 quantities as not to overload the stomach.” 
 (On Gunshot Wounds , p. 148, Ed. 2.) a 
 plan which I have always recommended. 
 For further observations on bark, the reader 
 is referred to the article Cinchona. 
 
 The sulphuric acid may frequently be ad- 
 vantageously given at the same time with 
 the bark, and the best method of exhibiting 
 it is to acidulate with it every thing w^hich 
 the patient drinks. Other acids are also 
 sometimes used for the same purpose. 
 
 Carbonic acid gas is another remedy of 
 the highest efficacy in cases of chronic mor- 
 tification. It has even been knowm to have 
 the most beneficial effects when bark has 
 failed in doing good. Water impregnated 
 with this gas should be recommended, as a 
 most beneficial kind of drink. 
 
 The hospital gangrene is a case for which 
 bark has been much recommended. The 
 best mode of treating this particular case, 
 how-ever, has been detailed in a separate 
 article. (fsee Hospital Gangrene.) 
 
 A third indication, which should be ob- 
 served together with the second, or which 
 should even precede it in many instances, 
 is to lessen the irritability and sufferings of 
 the patient, by the use of opium. Attention 
 1 o this desideratum frequently contributes 
 more than any thing else to stop the pro- 
 gress of the disorder, and is often indispen- 
 sable in order to promote the operation of 
 other remedies. In all cases of mortifica- 
 tion, every thing wdiich heats, irritates, or 
 adds to the patient’? sufferings, appears, in 
 general, to augment the disorder, and in- 
 i' crease the rapidity of its progress. On the 
 other hand, every thing which tends to calm, 
 assuage, and relax, frequently retards the 
 
 progress of mortification, if it produce no 
 greater good. The pain also, which is a 
 constant mark of too much irritation, con 
 tributes of itself to increase such irritation 
 and, in this double point of view, w r e can 
 not do better, in the majority of cases, than 
 endeavour to appease it by the judicious and 
 liberal use of opium. When the inflamma- 
 tory stage evidently prevails, tlm medicine 
 may be conjoined with antiphlogistic reme- 
 dies, such as the nitrate of potassa, antimo- 
 ny, &tc. In other instances, attended w ith 
 debility, it may be given with bark and cor- 
 dials. 
 
 Mr. Pott has described a species of morti- 
 fication, for which bark is most frequently 
 ineffectual, and opium the remedy which is 
 to be depended upon. It is that particular 
 kind, which, beginning at the extremity of 
 one or more of the small toes, does, in more 
 or less time, pass on to the foot and ankle, 
 and sometimes to a part of the leg, and, in 
 spite of all the aid of physic and surgery, 
 most commonly destroys the patient. 
 
 It is very uniike the mortification from in 
 flammation, that from external cold, from 
 ligature, or bandage, or from any known and 
 visible cause, and this as well in its attack 
 as in its progress. In some few instances, 
 it makes its appearance with little or no 
 pain ; but, in by much the majority of 
 these cases^, the patients feel great uneasiness 
 through the whole foot and joint of the an- 
 kle, particularly in the night, even before 
 these parts show any mark of distemper, or 
 before there is any oiher, than a small dis- 
 coloured spot On the end of one of the little 
 toes. 
 
 It generally makes its first appearance on 
 the inside, or at the extremity of one of the 
 smaller toes, by a small black or blueish 
 spot : from this spot the cuticle is always 
 found to be detached, and the skin under it 
 to be of a dark red colour. 
 
 If the patient has lately cut his nails, or 
 corn, it is most trequently, though very un- 
 justly, set to the account of such operation. 
 
 In some patients, it is slow 7 and long in 
 passing from toe to toe, and from thence to 
 the foot and ankle ; in others, its progress 
 is rapid and horridly painful : it generally 
 begins on the inside of each small toe, be- 
 fore it is visible either on its under or upper 
 part; and when it makes its attack on the 
 foot, the upper part of it first shows its dis 
 tempered state, by tumefaction, change of 
 colour, and sometimes by vesication ; but 
 wherever it is, one of the first marks of it is 
 a separation or detachment of the cuticle. 
 
 Each sex is liable to it; but, (says Mr 
 Pott) £: for one female in whom I have met. 
 with it. I think I may say, that I have seen 
 it in at least twent) males. I think also that 
 1 have much more often found it in the rich 
 and voluptuous, than in the labouring poor 
 more often in great caters, than free drink - 
 ers. It frequently happens to persons ad- 
 vanced in life, but is by no means peculiar 
 to old age. It is not, in general, preceded 
 or accompanied by apparent distemperaturo 
 either oftflPhe part, or of the habit. I do no 
 
MORTIFICATION 
 
 241 ) 
 
 know any 'particular kind 01 constitution 
 which is more liable to it than another ; but 
 as far as my observation goes, l think that I 
 have most frequently observed it to attack 
 those who have been subject to flying un- 
 certain pains in their feet, which they have 
 called gouty, and but seldom in those who 
 have been accustomed to have the gout re- 
 gularly and fairly. It has, by some, been 
 supposed to arise from an ossification of 
 vessels', but for this opinion I never could 
 find any foundation but mere conjecture.” 
 
 In this article 1 have already stated the 
 observations of Cowper, Dr. Thomson, and 
 Mr. Hodgson upon the ossified state of the 
 arteries in this species of mortification. The 
 facts, recorded by the two latter writers, at 
 least prove, that the opinion is founded, not 
 upon mere conjecture, as Mr. Pott alleges, 
 but upon actual observation and experience. 
 
 With respect to the insufficiency of Peru- 
 vian bark, Mr. Pott observes : “ I believe I 
 may venture to say, that I have tried it as 
 fairly, as fully, and as' variously as any man 
 has or can ; * I have given it in the largest 
 quantity, at the shortest intervals, and for 
 the longest possible space ; that is, as long 
 as the patient’s life would permit : I have 
 given it by itself iu decoction, extract, and 
 substance ; I have combined all these toge- 
 ther; l have joined it with nitre, sal. ab- 
 synth. with snakeroot, with confect, car- 
 diac. with volatile salts, and with musk, as 
 different circumstances seemed to require, 
 or admit ; 1 have used it as fomentation, as 
 poultice, as dressing ; I have assisted it with 
 every thing which has been usually thought 
 capable of procuring or assisting digestion ; 
 still the distemper has continued its course, 
 perhaps a little more slowly, but still it has 
 ended in death.” 
 
 Mr. Pott afterward relates the first cases 
 in which he gave opium. His plan was ge- 
 nerally to give one grain every three or 
 four hours ; but never less than three or four 
 - grains in the course of four and twenty 
 hours. Mr. Pott, however, did not propose 
 opium as an universal infallible specific ; 
 but only as a medicine which would cure 
 many cases not to be saved by bark. 
 
 The observations of Mr. Pott on the local 
 treatment of these cases are of great practi- 
 cal importance : no part of his writings has 
 a stronger claim to attention. 
 
 “ I have found (says he) more advantage 
 from frequently soaking the foot and ankle 
 in warm milk, than from any spirituous or 
 aromatic fomentations whatever ; that is, I 
 have found the one more capable of allevi- 
 ating the pain which such patients almost 
 always feeT, than the other; which circum- 
 stance I regard as a very material one. 
 Pain is always an evil, but, in this particular 
 case, 1 look upon it as being singularly so. 
 Whatever heats, irritates, stimulates, or gives 
 | uneasiness, appears to me always to increase 
 ‘ the disorder, and to add to the rapidity of 
 j its progress ; and, on the contrary, I have 
 | always found, that whatever tended merely 
 I to calm, to appease, and fo relax, at least 
 I retarded the mischief; it it did no more. 
 
 ! Vot. il. 'S2 
 
 “ The whole plan ot the chirurgic treat- 
 ment ol this disease is founded on a general 
 idea of warming, invigorating, stimulating, 
 and resisting putrefaction ; and the means 
 generally made use of are very proper for 
 such purpose : but 1 must own that I think 
 the purpose, or intention, to be improper.” 
 
 Mr. Pott afterward observes: “ Cases ex- 
 actly similar, in all circumstances, are not to 
 be met with every day, but I am from expe- 
 rience convinced, that of two, as nearly 
 similar as may be, in point of pain, if the 
 one be treated in the usual manner, with a 
 warm, stimulating cataplasm, and the other 
 only with a poultice made of the fine farina 
 seminis lini, in boiling milk or water, mixed, 
 with ung. sambuc. or fresh butter, that the 
 pain, and the progress of the distemper, 
 v wiil be much greater and quicker in the 
 former than in the latter. 
 
 “ When the black or mortified spot has 
 fairly made its appearance on one or more 
 of the toes, it is the general prfctice to 
 scarify or cut into such altered part with the 
 point of a knife or lancet. If this incision 
 be made merely to learn whether the part be 
 mortified or not, it is altogether unnecessary, 
 the detachment of the cuticle, and the colour 
 of the skin, render that a decided point : if 
 it be not made quite through the eschar, it 
 can serve no purpose at all : if it he made 
 quite through, as there is no confined fluid 
 to give discharge to, it can only serve to 
 convey such medicines as may be applied 
 for the purpose of procuring digestion to 
 parts capable of feeling their influence, and 
 on this account they are supposed to be 
 beneficial, and therefore right. 
 
 “ When the upper part of the foot begins 
 to part with its cuticle, and to change colour, 
 it is a practice with many to scarify imme- 
 diately ; here, as in the preceding instance, 
 if the scarifications be too superficial, they 
 must be useless ; if they be so deep as to 
 cause a slight hemorrhage, and to reach the 
 parts which have not yet lost their sensi- 
 bility, they must do what indeed they are 
 generally intended to do, thift is, give the 
 medicines, which shall be applied, an 
 opportunity of acting on such parts. 
 
 “ The medicines most frequently made use 
 of for this purpose are, like the theriaca, 
 chosen for this supposed activity ; and con- 
 sist of the warm, pungent oils and balsams, 
 whose action must necessarily be to stimu- 
 late and irritate : from these qualities they 
 most frequently excite pain, which, accord 
 ing to my idea of the disease, is diametri- 
 cally opposite to the proper curative inten 
 tion ; and this I am convinced of from re- 
 peated experience. 
 
 “ The dressings cannot consist of materi 
 als which are too soft and lenient ; nor are 
 any scarifications necessary for their appli- 
 cation. But I would go farther and say, 
 that scarifications are not only useless, but, 
 in my opinion, prejudicial, by exciting pain, 
 the great and chiefly to be dreaded evil in 
 this complaint. The poultice should be 
 also soft, smooth, and unimtating ; its in- 
 tention should be merely to «oftcu and relax . 
 
M0JKT1F1CATI03S. 
 
 i( should comprehend the whole foot, ankle, 
 and part of the leg and should always be 
 so moist or greasy as not to be likely to be- 
 come at all dry or hard, between one dress- 
 ing and another.” 
 
 When the toes arc, to all appearance, 
 perfectly mortified, and seem so loose as to 
 be capable of being easily taken away, it is, 
 in general, thought right to remove them. 
 But, however loose they may seem, if they 
 be violently twisted olF, or the parts, by 
 which they hang, be divided, a very con- 
 siderable degree of pain vviil most common- 
 ly attend such operation, which therefore 
 had much better be avoided ; tor Mr. Fott 
 has seen this very pain, thus produced, bring 
 on fresh mischief, and that of the gangre- 
 nous kind. 
 
 If the patient does well, these parts will 
 certainly drop off ; if he does not, no good 
 can arise from removing them. (Pott's 
 Works.) 
 
 In case*, in which the disorder is attended 
 with a great deal of irritation, many subse- 
 quent practitioners have attested the efficacy 
 of opium ; though it has not always had the 
 same success in their hands, when the 
 mortification depended chiefly on constitu- 
 tional debility. Dr. Kirkland observes, that 
 we must be careful not to force the doses, 
 especially at first ; and that the medicine 
 does more harm than good, when its sopo- 
 rific effects go so far as to occasion delirium, 
 take away the appetite? or cause affections 
 of the heart. 
 
 Some authors have also recommended the 
 use of camphor, which, by reason of its 
 narcotic virtue, has sometimes produced 
 good effects. Pouteau attributes consider- 
 able efficacy to it. especially in the erysipe- 
 latous gangrene arising from wounds. In 
 such cases, he recommends it to be given 
 in the dose of live grains, with a double 
 quantity of nitre, every four hours. 
 
 Few surgeons of the present day believe, 
 that opium possesses as much power in the 
 preceding cases, as Mr. Pott represented. 
 While Dr. Th Anson allows, that opium is 
 much more entitled to the attention of 
 practitioners than bark, as an useful medi- 
 cine in the treatment of mortification, yet, 
 “in saying so much in favour of opium, (he 
 observes,) I would not Jby any means have 
 you to place the same reliance on its powers 
 for stopping, even the mortification of the 
 toes and feet in old people, which appeal's 
 to have been done by Mr. Pott. From the 
 trials which I have made, and which I have 
 seen made by others, 1 cannot allow myself 
 to believe, that its powers in stopping this 
 particular sort of mortification are greater, 
 than in stopping any other form, or variety 
 of the disease. It is obvious, however, from 
 Mr. Pott’s account, that his mind was strong- 
 ly impressed with a very different opinion. 
 His opinion seems to me to have been form- 
 ed from the results of*a very small number 
 of cases, and in complete forgetfulness of 
 the invaluable observations of his preceptor 
 Mr. Sharp, with regard to the frequent spon- 
 taneous stoppage of mortification in cases 
 
 in which no medicines whatever are used.' 
 (See Thomson's Lectures on Inflammation , p. 
 568.) 
 
 2. With respect to the external, or local 
 treatment of mortification, the first indication 
 consists in removing, if possible, such ex 
 ternal causes, as may have occasioned, or 
 kept up the disorder ; as the compression of 
 bandages, ligatures, tumours? all irritating 
 substances, &c. 
 
 When mortification arises from inflamma- 
 tion, which still prevails in a considerable 
 degree, it is evident, that the dead part itself 
 only claims secondary consideration, and 
 that the principal desideratum is to prevent 
 the mortification from spreading to the living 
 circumference, by lesseningthe inflammation 
 present. Henee, under such circumstances, 
 the application of linen, wet with the satur- 
 nine lotion, and the maintenance of a con- 
 tinued evaporation, from the inflamed parts 
 surrounding the mortified flesh, must be just 
 as proper as if the mortification itself did 
 not exist, and were quite out of all con- 
 sideration. 
 
 It has been justly remarked by an eminent 
 man, ( Hunter ) that the local treatment of 
 mortification, (meaning that in consequence 
 of inflammation) has been as absurd as the 
 constitutional ; scarifications have been made 
 down to the living parts, in order that stimu- 
 lating and antiseptic medicines might be 
 applied to them such as turpentines, the 
 warmer balsams, and sometimes the essential 
 oils. Warm fomentations have been also 
 applied, as being congenial to life ; but, 
 warmth always increases action, and should, 
 therefore, be well adjusted to the case ? for, 
 on the other hand, cold debilitates or lessens 
 powers, when carried too far, though it first 
 lessens action. Stimulants are likewise im- 
 proper, as the actions are already too violent. 
 It is proper to keep the parts cool, and all 
 the applications should be cold. In cases of 
 mortification from inflammation, good effects 
 have also been seen to arise from the topical, 
 as well as internal employment of opium. 
 
 But it must be acknowledged, that how- 
 ever proper the employment of cold appli- 
 cations may be in principle, in cases of 
 mortification, attended with inflammation, 
 fomentations and emollient poultices are 
 most commonly preferred in practice. 
 
 Besides common poultices, there are 
 several others, which have acquired great 
 celebrity, as topical applications In cases of 
 mortification. Of this kind are the cata- 
 plasma carbonis,* cataplasnia cerevisiae,f 
 and the cataplasma eft'ervescens.t 
 
 These local remedies are, perhaps, in nine 
 cases out of ten, superior to all others. 
 
 With respect to stimulating and spirituous 
 applications, such as brandy, spirit of wine, 
 
 * Prepured by mixing' about oz. ij. of finely powder- 
 ed wood-charcoal with half a pound of the common 
 linseed poultice. 
 
 t Prepared by stirring into the grounds of strong 
 beer ns much oatmeal, as will make tbe mass of a suita- 
 ble consistence. 
 
 + prepared by stirring into an infusion of malt ns 
 much oatmeal, as will render the substance of a proper 
 thickness, and then adding about a siroonfulof vest. 
 
MORTIFICATION 
 
 251 
 
 balsams, resins, and aromatic substances, 
 which have been recommended by a vast 
 number of authors, they are almost entirely 
 laid aside by modern practitioners. Though 
 such things are indeed really very useful in 
 preserving dead animal substances from 
 becoming putrid, a very little knowledge of 
 the animal economy is requisite to make us 
 understand, that they cannot act in this 
 manner on parts still endued with vitality; 
 but, on the contrary, that they must have 
 highly prejudicial effects, in the cases under 
 consideration, by reason of the violent irrita- 
 tion which they always excite, when applied 
 to the living fibres. It may now and then, 
 however, be justifiable to apply spirituous 
 applications to the dead parts themselves 
 with a view of diminishing the fetid effluvia, 
 which, by contaminating the air, have some 
 share in injuring the patient’s health ; but 
 the greatest care is requisite to keep these 
 stimulants from coming into contact with 
 the living surfaces around and beneath the 
 sloughs. 
 
 There are a few surgeons, however, who 
 still place confidence in certain stimulating 
 applications. ■“ in the less acute and more 
 chronic cases of gangrenous inflammation, 
 as in malignant erysipelas and carbuncle, in 
 the gangrene of the toes and feet of old peo- 
 ple, in the sphacelating state of hospital gan- 
 grene, and in severely contused wounds, in 
 which gangrene and sphacelus have super- 
 vened, the emollient poultice, which is ap- 
 plied to promote the separation of the dead 
 parts, may have an addition made to it of a 
 greater or less quantity of the unguenturn 
 resinosum, or even of oil of turpentine itself. 
 In the more severe of these cases, where we 
 have reason to dread the extension of the 
 sphacelus, warm dressings, as they have-been 
 termed, which are formed by dipping pled- 
 gets of ebarpie in a mixture of equal parts of 
 the unguenturn resinosum and oil of turpen- 
 tine, may be applied, of a temperature as 
 hot as the patient can bear without pain ; 
 and over thgse we may lay an emollient 
 poultice, of a large size and soft consistence. 
 
 u After the sphacelus stops, aqd the pro- 
 cess of ulceration begins in the inflamed line 
 -of contact, between the dead arid living 
 parts, it will often be found, that the turpen- 
 tine dressings are too stimulating, and occa- 
 sion a considerable degree of pain. When 
 this happens, we must either diminish the 
 quantity of the turpentine in the dressings, 
 or remove it altogether, according to circum- 
 stances. Besides the pain, a considerable 
 extension of the ulceration would be, in 
 general, the effect of continuing these appli- 
 cations after they begin to produce uneasi- 
 ness. The ulcerating surface is, in the pro- 
 gress of separation, liable to pass under 
 every mode of treatment, into the state of a 
 painful and irritable ulcer; and in this state, 
 it may require to be treated with decoctions 
 of poppy-heads, or with the application of 
 the turnip, carrot, fresh hemlock leaf, stale 
 beer, fermenting, poultices, fee.” (See 
 Thomsons Lectures, p. 577 , 578.) 
 
 The hospital gangrene is undoubtedly a 
 
 case, which requires powerful applications, 
 like Fowler’s solution of arsenic, or the un- 
 diluted mineral acids ; and, in Guy’s Hospi- 
 tal, phagedenic sloughing ulcers are usually 
 treated by Sir A. Cooper with the nitric acid 
 lotion, 50 drops to a quart of water, and the 
 internal exhibition of the subcarbonato of 
 ammonia. The cases also teTmed sloughing 
 phagedeenaby Mr. Welbank, find considered 
 by him as analogous to hospital gangrene, 
 may be cured by dressing them with the un- 
 diluted nitric acid. (See Med. Chir. Trans. 
 Vol. 1 1.) I conceive, that it has only been 
 in hospital gangrene, and other cases of 
 sloughing phagedenic ulcers, that various 
 acids, diluted, or undiluted, other caustic 
 substances, and the actual cautery, have 
 sometimes proved really serviceable The 
 muriatic acid, diluted with six times its 
 quantity of water, was particularly recom- 
 mended by Van Swieten, who applied it 
 after making scarifications. In this manner, 
 he stopped a slpughlng disease extending all 
 over the scrotum and penis. This author 
 strongly recommends the same topical ap- 
 plication to the sloughy state of the gums in 
 cases of scurvy. In this kind of case, he 
 mixed the muriatic acid with honey, in vari- 
 ous proportions ; sometimes, he even em- 
 ployed the pure acid itself for touching the. 
 parts, which were likely to slough. It is 
 also by supposing, that the diseases referred 
 to, were of a phagedenic character, that I 
 account for the good effects, imputed by Dr. 
 Kirkland and others, in cases of mortifica- 
 tion, to another still more active caustic, 
 namely, a solution of mercury in nitrous 
 acid, with which the edges of the living flesh 
 were touched. At all events, if the diseases 
 were common cases of sloughing, I infer, 
 that such remedies were not really necessa- 
 ry, and that nature triumphed both over the 
 disease and the supposed remedy The fol- 
 lowing is a case related by Dr. Kirkland : 
 
 A man met with a fracture of the fore- 
 arm, and the ends of the bones projected 
 through the integuments. The fracture was 
 very expeditiously reduced ; but, at the end 
 of five or six days, the whole arm seemed 
 to be completely mortified up to the shoul- 
 der. Amputation was performed as near 
 the joint as possible, and the stump, which 
 had mortified as far as the acromion, was 
 cauterized. The following day the mortifi- 
 cation had reached the inferior extremity of 
 the scapula. A little of the solution of mer- 
 cury in nitrous acid was now applied, by 
 means of a probe, along the edges of lh*e 
 parts affected, and from this moment the dis- 
 order made no further progress. This cau- 
 terizing was repeated every day, for seven 
 teen or eighteen days. The sloughs, and 
 even the scapula itself, were detached, and 
 the patient got well. 
 
 On the continent, liquid caustics are some- 
 times used as topical applications to gangre- 
 nous diseases, more especially, however, in 
 cases of hospital gangrene, and malignant 
 carbuncle. Of this last disorder, Larrey has 
 recorded a very dangerous example, in 
 which lie effected a cure by f<r.t cutting 
 
1VJ0 LITIFf C AT IO!S 
 
 away as much of tiic sloughs as possible, piial Gangrene, and. Nitric Acid.) The com 
 and then applying to the disorganized sur- rrion employment of these terrible applica 
 face underneath liquid caustics. Under the tions, viz. the actual cautery, the undiluted 
 use of emollients, two persons had already mineral acids, and boiling oils, is as uriscien- 
 fallen victims to the disease in the, same ti tic, and unnecessarily painful, as it is un- 
 family. (See Mtmoires de Chirurgie Mill- productive of any essential good. The 
 taire, Tom. 1, p. 53.) grand object in almost every case of mortifi 
 
 With respect to the actual cautery, Celsus cation, is to diminish the irritation of the 
 
 recommended ft to be applied to Ihe line, 
 which separates the dead parts from those 
 which are still living, whenever medicines, 
 and, particularly, topical emollient applica- 
 tions, failed in stopping tiiejprogress of the 
 disorder. Pouteau ventured to revive this 
 practice, which had been entirely exploded 
 from modern surgery, and he was of opi- 
 nion, that the method would have the most 
 beneficial effects, in cases of erysipelatous 
 gangrene, which is so often seen in hospitals, 
 in consequence . of w ounds. For this pur- 
 pose, he recommends cauterizing chiefly 
 the- edges of such parts, as are of a dark red 
 colour, and are on the point of perishing; 
 and he advises this to be done with a heated 
 iron, or boiling oil, and to repeat the cauter- 
 izing of the dead parts, at every time of 
 dressing them, until the sensation of heat is 
 even felt with a certain degree of force in 
 ihe sound parts. The whole of the affected 
 part is afterward to be covered with a large 
 emollient poultice. 
 
 Pouteau relates a case of anthrax, which 
 took place on a woman’s cheek, and which 
 he cured in the above manner. The tumour, 
 which, on the third day, was quite black, 
 and as large as a walnut, was accompanied 
 by an erysipelatous oedema, which extended 
 over the whole cheek, eyelids, and front of 
 the neck. Pouteau, after having opened 
 the tumour in different directions with a 
 lancet, introduced the red hot cautery, and 
 repeated the application several times, until 
 the heat was felt by the sound flesh. The 
 patient felt herself very much relieved imme- 
 diately after this had been done ; an oppres- 
 sive beadach, and a very afflicting sense of 
 strangulation, which she had before experi- 
 enced, were got rid of, and, in ten days 
 more, the slough w as detached on the oc- 
 currence of suppuration. ( Encyclopedic Me- 
 thodique , Partie Chirurgicale, Art. Gan- 
 grene.) 
 
 But perhaps, of all the species of mortifica- 
 tion, the hospital gangrene is that, for which 
 the use of caustics and the actual cautery 
 itself, has had the most numerous and respect- 
 able advocates. The heated iron is even 
 jioav •employed by the first surgeons of Paris 
 for this particular case. (See Sketches of 
 ihe Medical Schools of Paris, by J. Cross, p. 
 S4, and Hospital Gangrene.) . 
 
 The foregoing observations are introduced 
 into this work, that the reader may not be 
 left entirely ignorant of what violent mea- 
 sures have been adopted in cases of mortifi- 
 cation, and the account is not given, in or- 
 der that such practice may be again imita- 
 ted, with the exception perhaps of certain 
 cases of phagedeena arid hospital gangrene, 
 cases, in which the most powerful local 
 implication's seem indispensable. See IIos- 
 
 partsin immediate contact withthose already 
 dead. This is indicated, lest the parts still 
 alive, and so situated, should experience the 
 same fate as the contiguous ones. In most 
 of the other cases specified by Dr. Thomson, 
 my experience leads me to prefer emollient 
 soothing applications, none of which are 
 stronger than the cataplasma carbonis, or 
 the stale beer, fermenting, hemlock, or car- 
 rot poultices. When the process, by which 
 a slough is detached, is somewhat advanced, 
 
 1 have seen a weak solution of the extract 
 of opium in water put under the emollient 
 poultice, along the line of separation, give 
 considerable ease, at the same time that it 
 seemed to promote the changes, by which 
 the dead parts were loosened. 
 
 In the gangrene produced by pressure and 
 weakness in persons, who are compelled by 
 diseases and injuries to lie for weeks and 
 months in one posture, the mode of treat- 
 ment is a matter of extreme importance, 
 and frequently makes the difference of life 
 or death to the poor sufferer. This affection 
 usually has its seat in parts which are but 
 thinly covered with muscular flesh. It oc- 
 curs towards the latter stages of long-conti- 
 nued febrile diseases, as after typhus, or 
 hectic fever, attended with tedious suppu- 
 rations ; or even without these fevers, as in 
 paralysis, and in very bad compound frae 
 tures. However, as Dr. Thomson observes, 
 there are tw r o forms of disease, arising from 
 pressure, which have not always been ac- 
 curately discriminated. One of these is the 
 preceding sort of sloughing; Ihe other is a 
 chafed, excoriated, and ulcerated state of 
 the parts. 
 
 sometimes uncleanliness tends to cause 
 this sort of mortification, that is, when the 
 urine wets the patient’s clothes. When this 
 is the case, such irritation must he prevented 
 by every possible means. If the skin be ex- 
 coriated and broken, the powder of tutty, or 
 lapis caiaminaris, should be sprinkled over 
 the part ; or if an ointment be required, 
 says Dr. Thomson, those which contain zinc 
 or lead are the best. But, when the ulcera- 
 tion threatens to extend, these remedies afe 
 to be laid aside, and an emollient, hemlock, 
 carrot, or fermenting poultice used. (P. 
 580.) 1 have seen in the irritable state of 
 
 such ulceration, the solution of opium under 
 a common linseed poultice do more good 
 than any other application. 
 
 But no topical remedies will in any of 
 these cases avail, unless the chief cause of 
 the disorder he removed. This is to he ef- 
 fected by change: of position, and laying 
 pillows and cushions of Ihe softest materials 
 in convenient places under the patient ; not 
 directly under the disease itself, but in situ- 
 ations where they will tend to raise the 
 
MORTIFICATION". 
 
 25B 
 
 parts affected from the contact of the bed- 
 ding. A circular hollow pillow will often 
 accomplish this important object; but, when 
 possible, an entire change of posture is to be 
 preferred. 
 
 When sphacelus succeeds to gangrene 
 from pressure, I have often seen campho- 
 rated spirit applied ; but never with decided 
 advantage. A common emollient poultice, 
 and in very bad cases, the topical use of the 
 solution of opium along the living margin, 
 are the means upon which I place most reli 
 ance, care being taken to improve the ge- 
 neral health, without which grand indication, 
 neither the removal of the pressure, nor the 
 virtues of any dressings, will answer. Dr. 
 Thomson speaks most highly of the ferment- 
 ing poultice, which I believe to be in these 
 cases an excellent application. He confesses, 
 however, that he has sometimes found it too 
 stimulating, and been obliged to substitute 
 the simple emollient, carrot, or turnip poul- 
 tice. (P. 580.) 
 
 When mortification arises from cold, every 
 sort of warm emollient application must be 
 avoided, and cold water, or even snow, or 
 ice, employed. See Chilblains. 
 
 The local treatment of the mortification 
 of the toes and feet, as described by Mr. 
 Pott, has been already considered, and is 
 that to which my observations incline me 
 to give the preference. 
 
 The gangrenous affection of the pudenda, 
 to which female children are liable, was 
 imccessfnlly treated by Mr. X. Wood by ap- 
 plying the liquor plumbi acet. dilutus in a 
 tepid state, and bread poultices ffraae with 
 the same lotion. As soon as the ulcers' be- 
 came clean, they were dressed with the uii- 
 guentum zinci. (See Med. Chir. Trans. Vol. 
 7.) Other cases, which also ended well, 
 have been dressed with lint, dipped in cam- 
 phorated spirit, and covered with a poul- 
 tice ; or, at first, poultices made with the 
 opium lotion, and after the separation of the 
 sloughs, the ulcer was dressed with port 
 wine and decoction of bark in equal pro- 
 portions. In some cases,' however, mild 
 stimuli proved injurious. ( Jameson Inflam- 
 mation, p. 289.) 
 
 The old practitioners used to give vent to 
 putrid matter, by making deep scarifications 
 in the integuments. The majority of authors 
 who have treated of mortification have very 
 much insisted upon this plan, which they 
 recommend in all cases. They even advice 
 the incisions to be made down to the sound 
 parts, in order to facilitate the application 
 of topical stimulants, and to favour the ope- 
 ration of the supposed antiseptic qualities of 
 these dressings. But, with the exception of 
 cases, in which the gangrenous parts lie un- 
 der an aponeurosis, or others in which the 
 integuments, which have escaped destruc- 
 tion, cover a mixture of matter and sloughy 
 cellular substance, either in consequence of 
 foregoing inflammation, or any other cause, 
 such as the extravasation of urine in the 
 scrotum, all scarifications which penetrate 
 as far as the living parts, are often produc- 
 tive of the most serious mischief, instead of 
 
 advantage. Such incisions cannot be prac - 
 tised, without occasioning a great deal ot 
 pain, and producing inflammation, which 
 often makes the mortification spread still, 
 further. But, as parts, which are in a com 
 plete state of sphacelus, are absolutely ex- 
 traneous substances, in regard to those which 
 still retain their vitality, all such portion of 
 them as is already loose should be removed. 
 By lessening the size of the putrid mass, the 
 fetor is diminished, an outlet may sometimes 
 be made for the escape of a great deal of 
 putrid discharge, which being confined, 
 might have a bad effect on the neighbouring 
 living parts ; and the latter are enabled to 
 free themselves more easily from the rest of 
 the* sloughs. 
 
 The too common practice of accelera- 
 ting, with a cutting instrument, the separa - 
 tion of the mortified parts, previously to the 
 completion of the process, by which nature 
 breaks the connexion between them and the 
 living flesh, in general ought to be strongly 
 reprobated, as causing unnecessary pain, and 
 irritation,. and creating the risk of a renewal 
 of the sloughing. As far as my experience 
 goes, gangrenous phagedeena is the only in- 
 stance, in which it seems useful to remove 
 the sloughs, before they are loose, so as to 
 let the topical applications extend their ac- 
 tion without delay to the subjacent living- 
 surface. (Sec Hospital Gangrene.) Pott s 
 sentiments, with respect to the danger and 
 inutility of cutting the tendonsand ligaments, 
 in the mortification of the toes and feet, 
 have been already stated. 
 
 If the surgeon prudently await the event; 
 of things, the separation of the mortified 
 from the living parts will soon follow the 
 establishment of inflammation and suppura- 
 tion at the*cdgcs of the slough. 
 
 But when the whole thickness of a limb 
 is affected with mortification, ought the sur-, 
 geon to leave things, to nature ? or ought In- 
 to have recourse to amputation. 
 
 In general, the performance of amputation 
 is indispensable; not that nature would not in 
 raanv instances detach the sphacelated part ; 
 but, because a great length ot time^ would 
 be required for the completion of the pro- 
 cess, and' a serviceable stump would rarely 
 be left. 
 
 Another important question then arises, 
 Should the surgeon amputate, while the mor- 
 tification is in a spreading state ? Or ought 
 he to defer the operation, until a line of se- 
 paration begins to form between the dead 
 and living parts ? 
 
 “ Amputation (says a distinguished profes- 
 sor) was long regarded as one of the most 
 effectual means which could be employed to 
 prevent the extension of gangrene. This 
 practice, however, has not received the 
 sanction of experience ; on the contrary, it 
 has been generally found, wherever it has 
 been practised, in either acute or chronic 
 gangrene, to accelerate much the progress of 
 the disease ; and, in this way, to hasten the 
 death of the patient. The parts, which were 
 divided in amputation, though at a distance 
 from a spreading gangrene and from sphace 
 
'ICATION. 
 
 254 
 
 Ins, were found speedily to assume the ap- 
 pearance of the affection, for which the ope- 
 ration had been performed. Till, therefore , 
 the adhesive inflammation comeson , and a dis- 
 tinctly marked separation of the dead from the 
 sound parts takes place , amputation is, in few , 
 if any cases of mortification , admissible. We 
 never know, previously to this, where a gan- 
 grene, or sphacelus, is to stop, nor whether 
 the powers of the constitution be sufficient 
 to sustain the injury that the mortification 
 has inflicted. Even when the adhesive in- 
 flammation comes on, it is in most cases 
 best to allow some time to elapse before we 
 operate, partly with a view to give time for 
 the constitutional symptoms to abate, in 
 other instances, to allow the patient’s 
 strength to be recruited by nourishment and 
 cordials ; and partly also with a view to 
 learn whether the constitution of the patient 
 be indeed capable of so great a fresh shock, 
 as that which amputation must necessarily 
 occasion.” (See Thomson's Lectures, p. 582.) 
 
 According to Richter, there is never any 
 certainty, that we are amputating in living 
 parts. Mortification rapidly ascends along 
 tiie cellular substance, surrounding the large 
 blood-vessels, and is frequently much more 
 extensive internally, than external appear- 
 ances would lead one to supp -se. The ad 
 jacent surface,, still apparently alive, is often 
 so affected, that it must inevitably slough, 
 though, at present, it may not actually have 
 sphacelated. The surgeon imagines, that am- 
 putation is performed on living parts; but, 
 soon, afterward discovers, that he has been 
 dividing those which are dead. The opera- 
 tion, he observes, can do no good, while the 
 mortification is in a spreading sla e, and it 
 may do considerable mischief. I he disorder 
 enlarges its limits, because its eause still 
 operates, and this is not removable by ampu- 
 tation If the operation be now injudicious- 
 ly undertaken, the sphacelus invades the 
 wound, and is the more certainly mortal, as 
 the patient has been further weakened by 
 amputation, and its consequences. 
 
 Many mortifications, especially those which 
 arise from external causes, very often spon- 
 taneously stop and separate. But the place 
 where this will happen, can never- be fore- 
 seen. By amputating in this circumstance, 
 we run a risk of disturbing nature in her sa- 
 lutary work, and rendering the disorder fajal. 
 
 The following are the only cases, in which 
 Richter allows that the use of the knile is 
 justifiable and proper. There exists a spe- 
 cies of sphacelus, which rapidly occasions 
 death, before it is yet of great extent. Here 
 indeed, amputation might be really advisa- 
 ble ; but, die nature of the case is unfortu- 
 nately never disclosed, before the fatal catas- 
 trophe. Some external injuries would be, 
 without the operation, inevitably followed by 
 mortification. In such cases, early amputa- 
 tion is evidently proper ; for, the simple in- 
 cision is attended with less danger than 
 sphacelus. Sometimes, says Richter, a spha- 
 celus spontaneously ceases to spread. This 
 happens most frequently, in cases which 
 originate from an extern;-! cause, such as a 
 
 violent contusion, burn, Sic. But, the occur- 
 rence is not restricted to this kind of casc^ 
 nor is it invariably attendant on it. When 
 there are no other occasional causes present, 
 the mortification does not readily go beyond 
 the limits of the contusion, or violent burn : 
 but the interference of surgery can hardly 
 ever put a stop to its progress, before it has 
 spread as far as the extent of the local injury. 
 (Anfangsgrunde der Wundarzneykunst , Band. 
 1, Kap. 3.) 
 
 How different are the doctrines of Baron 
 Larrey upon this subject from those enter- 
 tained by Richter, and, indeed, the generality 
 of eminent modern surgeons “ Writers on 
 gangrene, or sphacelus of the extremities, 
 (says Larrey) indiscriminately recommend 
 the amputation of a sphacelated limb never 
 to be undertaken before the mortification is 
 bounded or limited by a reddish circle, form- 
 ing a true line of separation between the 
 dead and living parts. This circumstance 
 can only occur in a case of spontaneous 
 gangrene from an internal cause ; or if it 
 happens, as is very unusual, in a case arising 
 from a wound, its progress is different, and 
 it. would be exceedingly imprudent to wait 
 for it. The gangrene from external injuries 
 almost always continues to spread ■; the infec- 
 tion becomes general ; and the patient dies.” 
 (Mem de Chirurgie Militaire , T. 3, p. 142.) 
 Respecting the want of foundation for this 
 hypothesis of infection, I need here offer no 
 remarks, having already expressed my opi- 
 nion upon it in a foregoing page. On the 
 other hand, Larrey asserts, that, in the dry. 
 or spontaneous ga igrene, absorption takes 
 place with more difficulty, and it is not un- 
 common to see the sphacelated parts sepa- 
 rate from the living ones by the powers of 
 nature alone, without the general functions 
 being impaired. He argues that there is a 
 manifest difference between what he terms 
 the traumatic and the spontaneous gangrene, 
 or, in other words, between the humid gan - 
 grene from an external cause, and the dry 
 gangrene, which ordinarily proceeds from 
 an internal cause. (P 148.) 
 
 In cases of mortification, arising from ex- 
 ternal injuries, Larrey maintains, that, “ not- 
 withstanding any tiling that writers and prac- 
 titioners may allege to the contrary, we 
 should not hesitate about promptly perform - 
 ing amputation, as soon as the necessity for 
 the operation is decidedly established. There 
 is no reason to apprehend, that the stump 
 will be seized with gangrene, as in the spon- 
 taneous mortification, which has not ceased to 
 spread, because the traumatic gangrene, after 
 having arisen from a local cause, is only pro- 
 pagated by absorption, and a successive affec- 
 tion of the texture of parts by continuity of 
 the vessels. Amputation, performed in a 
 proper situation, stops (he progress and fatal 
 consequences of the disorder. 
 
 a Supposing then the lower half of the leg 
 should be affected with sphacelus, in con- 
 sequence of a gunshot injury, attended 
 with a violent contusion ot tiie part, and 
 a forcible concussion of the vessels, nerves, 
 and ligaments, if the skin, is elsewhere unin- 
 
M0RT1F1CATICJA 
 
 juved, the operation may he clone in (he 
 place of election, without any fear of the 
 stump becoming gangrenous, notwithstand- 
 ing the cellular membrane of the upper part 
 of the member may be already atFected. 
 But, when the skin of the whole leg is struck 
 with mortification, the operation must be 
 done on the thigh, and no time should be 
 lost. The same practice is applicable to 
 the upper extremities. We must be careful 
 not to mistake a limb affected with stupor 
 for one that is actually sphacelated. In the 
 first case, warmth, motion, and sensibility 
 are still retained, although the skin may be 
 blackish and the parts may be swollen. 
 Besides, if there were any doubt, it would 
 be proper to try at first tonic repellent 
 applications, and cordial medicines, &.c.” 
 (See Mim de Chirurgie Militaire, T. 3, p. 
 152, 153.) 
 
 When amputation has been practised, 
 this author recommends the exhibition of 
 bark, good wine, tonics, &c. in order to pro- 
 mote the good effects of the operation. 
 (P. 154.) 
 
 “ The facts (says Larrey) which I shall 
 relate in the course of this dissertation, will 
 prove, {I think, in an incontestable manner, 
 the truth of the principle which I laydown, 
 that when gangrene is the result of a mechani- 
 cal cause , and puts the patient's life in danger , 
 amputation ought to be performed , without 
 leading until the disorder has ceased to spread. 
 
 “ 1 have been a witness of the death of 
 several individuals, from too rigorous an ad- 
 herence to the contrary precept ; and, at 
 length, grievously impressed with this loss, l 
 had long ago determined to depart from an 
 axiom, which was always considered by me 
 as false. Besides, following the maxim of 
 Celsus, I preferred employing an uncer- 
 tain remedy, rather than abandon the pa- 
 tient to an inevitable death. Salius csl enirti 
 anceps auxilium experiri quam nullum. 
 
 a I made the first attempt at Toulon, in 
 the year 1796, upon a soldier, who, in con- 
 sequence of a violent contusion of the foot, 
 was afflicted with a gangrenous ulcer, which 
 soon threw the whole part into a sphacelated 
 state. While the mortification was yet spread- 
 ing, I resolved to amputate the leg. The 
 success of the operation surpassed my ex- 
 pectations ; the stump healed ; and, in less 
 than forty-five days, the patient got quite 
 well. This case served to encourage me. 
 
 During the siege of Alexandria, in Egypt, 
 in 1801, a second case, very analogous to 
 the preceding, occurred in my practice ; it 
 happened in a dragoon of the lSlh regiment, 
 w hose fore-arm and afterward arm sphace- 
 lated, in consequence of a gunshot wound 
 in the articulation of the left arm. The mor- 
 tification had extended nearly as high as the 
 shoulder, and the patient’s life w T as in great 
 danger, when I determined to amputate the 
 limb at the shoulder-joint. The disorder 
 was manifestly spreading, and the patient’s 
 brain already affected, for he had symptoms 
 of ataxia : the operation, however, arrested 
 the progress of the sloughing, and saved the 
 
 patient’s life, who, at the conclusion of the 
 siege of Alexandria, was quite cured. 
 
 “ After the taking of Uhn, M. Ivan, sur- 
 geon to his majesty the Emperor, performed 
 in my presence, and at my ambulance es- 
 tablished at Elchiugen, the amputation of the 
 thigh of a soldier belonging to the 76th regi- 
 ment of the line, the leg having sphacelated 
 in consequence of a gunshot injury. The 
 gangrene was not limited, and evidently ex- 
 tending itself ; yet, the effects of the dis- 
 order were destroyed, and the patient was 
 quite cured on our return to Austerlitz. 
 
 “ A fourth patient, an officer in the same 
 regiment, shot in the ankle, at the capture of 
 the same town, was conveyed to my ambu- 
 lance, in order to be dressed : it was the 
 third day after the accident ; the foot was 
 gangrenous, and the leg was swelled, and 
 threatened likewise with mortification. Fe- 
 brile symptoms had also come on. 1 has- 
 tened to amputate the leg a little above the 
 place of election. The cellular membrane 
 of the stump, of a yellow* blackish colour, 
 was already infected with the gangrenous 
 principle (as Larrey terms it.) The opera- 
 tion, however, stopped the progress of the 
 mischief; suppuration took place in the 
 stump ; some sloughs were detached ; the 
 wound assumed a cleaner appearance ; and 
 cicatrization was completed on the fifty- 
 second day. The patient could already 
 w alk w’ith a wooden leg, w hen he caught the 
 hospital fever, which w r as epidemic at (Jim, 
 where he awaited his regiment, and, to my 
 great regret, he was carried off by this dis- 
 ease, after having escaped the former 
 danger. 
 
 “ After the battles of Austerlitz and Jena, 
 (continues Larrey.) several of my colleagues, 
 surgeons of the first class, undertook, in 
 consequence of my advice, and the exam- 
 ples of success which I had recited to them, 
 the amputation of limbs equally sphacelated, 
 although the mortification was not limited, 
 rather than abandon the patient to a death, 
 which appeared inevitable. In general, these 
 practitioners experienced the same success 
 as I did myself.” ( Larrey , in Mim. de Chirur- 
 gie Militaire, T. 3. p. 154 — 157.) 
 
 In Larrey’s memoir upon this subject, 
 there are some additional facts and argu- 
 ments in favour of what he endeavours to 
 prove, viz. that, in cases of mortification 
 from external injuries, if the patient’s life is 
 in danger, amputation ought to be performed, 
 although the sloughing may yet be in a 
 spreading state. I must be content, however, 
 with having stated the particulars already 
 explained ; and the reader, desirous of more, 
 must refer to Larrey’s own publication. Cer- 
 tainly, the facts, which this gentleman has 
 adduced, are highly important : they tend 
 to. subvert a doctrine, and to prove-the error 
 of a practice, which have been urged in 
 most forcible terms by most of the distin- 
 guished surgeons of modern times. The 
 sentiments of Mr. Sharp are rendered ques- 
 tionable; and the truth ofthe positive assertion 
 of Mr. Pott is yet a matter to be examined. 
 The latter, it is well known, tells us. that he 
 
MORTIFICATION. 
 
 tia 0 
 
 has often seen tiie experiment made of am- 
 putating, while a mortification wasspreadirig, 
 but never knew it answer. Are we to con- 
 clude, that all these cases, which Pott 
 alludes to, were mortifications from an inter- 
 nal cause ? Or, are w e to suppose that the 
 operation failed from having been delayed 
 too long ? Or, must V ve imagine, that the 
 nature of the human constitution has been 
 changed between the era of Pott, and that 
 of Larrey ? 
 
 It should be remarked, that the practice, 
 of amputation, in cases of spreading morti- 
 fication, has generally had some partisans 
 for many years past • but the weight of au- 
 thorlies has unquestionably been against it, 
 and few surgeons in this country have ven- 
 tured to deviate from the advice of Sharp 
 and Pott. It is curiou Sj however, that Mehee, 
 a writer who wrote for the express purpose 
 of declaring bis disapprobation of the early 
 performance of amputation in gunshot 
 wounds, should have admitted of only one 
 case, in which the operation is proper, 
 namely, gangrene succeeding the wound made 
 by a cannonskot. Here he thinks, that am- 
 putation ought to be performed on the first 
 appearance of the gangrene, in order to 
 prevent it from spreading up the limb. (See 
 Trait 6 des Plaies d’Armes dfeu. Paris , 1799.) 
 It appears, that about the year 1809, Mr. A. 
 C. Hutchison performed with success two 
 amputations in cases of spreading gangrene 
 from gunshot wounds. (See Practical Ob- 
 servations on Surgery, p. 72.) 
 
 My friend Mr. Lawrence has also success- 
 fully amputated at the shoulder joint in a 
 spreading mortification of the arm, the con- 
 sequence of external violence. ei The skin 
 of the amputated limb was greenish and 
 livid ; but the cuticle not yet detached. The 
 cellular substance distended with air, and 
 with a discoloured offensive sanies ; its ap- 
 pearance was not quite natural, where the 
 incision took place ; it was yellowish and 
 anasarcous. Small effusions of blood were 
 observed here and there in the course of the 
 nerves ; even as high as the amputated part. 
 No coagulation of blood in any of the arte- 
 lies, even down to the ulnar and digital 
 branches. All the soft parts were disco- 
 loured, dark red, and livid, and a frothy 
 reddish fluid issued on incision.” This case 
 had the most favourable termination, and it 
 clearly proves, that the humid kind of gan- 
 grene, which occurs in a healthy subject 
 fro m severe local injury, which so rapidly 
 affects a whole limb, and reaches the trunk 
 in a few hours, must constitute an exception 
 to the general maxim, that ampuiation should 
 never be done, before a line of separation is 
 established between the dead and living 
 Parts. Mr. Lawrence, however, would not 
 be Understood as meaning to recommend 
 the practice in all instances of mortification 
 from local injury. He conceives, that a 
 gangrene may arise, in an unsound constitu- 
 tion, from a comparatively slight accident ; 
 so that it may be regarded as the result of 
 constitutional disposition, rather than of the 
 local cause Amputation wonld be hopeless 
 
 under such circumstances, it is particularly 
 in mortification, following very severe injury, 
 in a subject otherwise healthy, that Mr. 
 Lawrence believes the operation to be pro- 
 per. (See Medico- Chir. Trans. Vol. 6, p. 
 184.) 
 
 Mr. Lawrence also reports another in- 
 stance, in which he saw the operation suc- 
 ceed, though the mortification was in a 
 spreading stale. About three years ago, I 
 was asked my opinion about the propriety of 
 amputating at the shoulder in a spreading 
 mortification of the arm from external vio- 
 lence. The operation was done, and the 
 patient lived a fortnight afterward, which is 
 favourable to the practice, inasmuch as he 
 would certainly have perished in a few 
 hours, if the operation had not been done. 
 
 Among the experienced approvers of Lar- 
 rey’s advice, I must not omit to mention 
 Dr. Hennen, who has repeatedly amputated, 
 under the circumstances above pointed out, 
 without waiting for the line of separation ; 
 “ and (says he) although I certainly was not 
 uniformly successful, I have no reason to 
 imagine, that death was occasioned by a de- 
 parture from the rule so generally laid down 
 by authors.” (On Military Surgery, p. 243. 
 Ed. 2.) 
 
 With regard to the early performance o^ 
 amputation, where the substance of a limb 
 perishes after exposure to eold, I find some 
 difference of sentiment between two very 
 high authorities. jThus Schmucker observes 
 “The mortification, which comes on after 
 a part has been frozen, increases so rapidly, 
 it the limb be exposed to warmth, that, in the 
 space of twenty-four hours, its vitality and 
 organization are quite destroyed, and no- 
 thing will now avail in restoring its sensi- 
 bility. Here the speedy performance of am- 
 putation is the only means of preservation 
 to be depended upon. In mortification 
 from an internal cause, the case is different.” 
 (See Vermischte Chirurgtsche Schriften, B. 1, 
 p. 15, 8 vo. Berlin, 1785.) According to 
 Larrey, however, this species of gangrene 
 at length stops, and a line of separation 
 forms between the dead and healthy parts. 
 If the disorder be superficial, the sloughs are 
 usually thrown off' between the ninth and 
 thirteenth days, leaving an ulcer of propor- 
 tionate extent, that soon heals up. If the 
 whole of the limb be sphacelated, nature 
 cannot of herself effect a cure, or but very 
 rarely, the patient mostly falling a victim to 
 the effects of absorption, when the sloughs 
 are detached, and the mouths of the lym- 
 phatics are opened ou the occurrence of 
 suppuration. Larrey assures us that he has 
 seen numerous patients carried off by this 
 'cause, while the examples of a spontaneous 
 cure were exceedingly few, and, in these, 
 the stump was left irregular, t#ul unfit for 
 bearing the pressure of a wooden leg. Ho 
 agrees, therefore, with the generality of sur- 
 geons, that it is in these instances advanta- 
 geous to amputate the mortified portion of 
 the limb, but not before the extension of the 
 gangrene, has ceased , and the mischief >r 
 
bounded by an inflammatory line. (bee 
 Mem. de Chir. Mil. T. 3, p. <55 — 72.) 
 
 In the article amputation , notice has been 
 taken of a sloughing, which commences in the 
 loot, and extends up the leg, and sometimes 
 follows gunshot injuries of the thigh, which 
 involve the femoral artery : this is a case 
 particularly instanced by Mr. Guthrie, as re- 
 quiring the very early performance of am- 
 putation. Sir Astley Cooper also refers to 
 cases, in which the rule was successfully de- 
 viated from, of noi amputating, before limits 
 nre set to the spreading of mortification ; the 
 instances in question arose from injury of 
 blood-vessels, and other local violence, in 
 patients of a healthy constitution. In such 
 cases, it is admitted by this very experienced 
 surgeon, that the practice should be different 
 from what is usually pursued in mortification 
 from constitutional causes. ( Surgical Essays , 
 Part 2, p. 1S6.) 
 
 Fabricii Hilda ni Traci. Method tens de Gan- 
 grcena et Sphacelo. Quesnai, Traile de la 
 Gangrene , 12 mo. Paris , 1749. Encycloptdie 
 Meihodique , Parlie Chirurgicale , Art. Gan- 
 grene. Kirkland on Gangrene, and on the 
 Present State of Medical Surgery. Richter , 
 An fangsgr. der Wundarzn. B. i , Kap. 3. 
 Various parts of Hunter on Inflammation, fyc. 
 Sharp's Critical Inquiry into the present Slide 
 of Surgery , Chap. 8. Richtrand, Nosographie 
 Chir. T. 1, p. 215, fyc. Edit. 4. Lassus , Pa- 
 thologic Chir. T. 1 , p. 30, fyc. Edit. 1809. 
 Levtillt, JYouvelle Doctrine Chir T. 4, p. 
 321, dye. Paris, 1812. Larrey, Mtmoires de 
 Chirurgie Militaire, T. 3, particularly the 
 Mdm.sur la Gangrene de Congelation, p. 60, 
 and that sur la Gangrene Traumaiique,p. 141. 
 Callisen, Systema Chirurgice Hoditrnce, Vol. 
 2, p. 374, Edit. 1800. Dr. J. Thomson's 
 Lectures on Inflammation, p. 501, Edinb. 
 1813. O’ Halloran on Gangrene and Sphacelus , 
 8 vo. Dublin, 1765. Pott's Obs. on the Mor- 
 tification of the Toes and Feet in his Ch irurg. 
 Works, Vol. 3. J. Kirkland , Thoughts on 
 . Imputation , <*yc. with a short Essay on (he 
 Use of Opium in Mortification, 8 vo London, 
 1780. J. Harrison, The remarkable Effects 
 affixed Air in Mortifications of the Extremi- 
 ties, Sro. Loud. 1785. ./ A. Murray, In 
 
 Gangnenam Scroti Obs. {Frank. Del. Op. 10.) 
 C. White, Observations on Gangrenes and 
 Mortifications, accompanied, fyc. with convul- 
 sive spasms, 8 vo. 1790. Pearson's Principles 
 of Surgery, p. 114, Edit. 2. Lawrence in 
 Medico- Chir. Trans. Vol. 6, p. 184, fyc. Del- 
 pech , Mdmoire sur la Complication des Plaies 
 cl des Ulceres, eonnue sur le Norn de Pov.rri- 
 ture d'Hopital ; also, Precis Element air 6 des 
 Maladies Reputees Chirurgicales, T. 1 , p. 73, 
 fyc. Paris, 1816. Boyer, T raites des Ma- 
 ladies Chir. T. 1, p. 105, fyc, Paris, 1814. 
 John Bell's Principles of Surgery. Professor 
 Himly's Abhandlung uber der Brand der 
 Weichen und harlen Thtile, Git. 1800. For 
 an Account of the dry gangrene, see particu- 
 larly the Writings of Hildanus, Tulpius, 
 Quesnai Mtmoires de la Sociele Roy ale de 
 Medecine, Tom. 1. Operc di Bertrandi ; Me- 
 dical Museum, fyc. For a description of the 
 mortification caused by eating cockspur rye, see 
 
 Vox If 33 
 
 Dodard's letter in Journal des Savans, 1676, 
 Noel, in Mem. de TAcad. des Sciences, 1710. 
 Langius. “ Descriptio Morborum ex esu Cla- 
 vorum Secalinorum." Duhamel, in M6m. de 
 TAcad. des Sciences, 1748.' Dr. C. Woolaston , 
 in Philosophical Trans. 1762. Tessier, in 
 Mtm. de la Societt Royale de Medecine, T. i, 
 and 2, tfc. 0. Presscott, A Dissertation on 
 the Natural History and Medicinal effects of 
 the Secale cornutum. or Ergot. 8 vo. Land. 
 1813. D. F. Heffter , Doctrines de Gangrana 
 brevis Expositio, 4 to. Lips. 1807. C. L. G 
 Liessehing, De Gangrana, 4lo. Colt. 1S11. 
 Hennen's Principles of Military Surgery , p. 
 241, &pc. Ed. 2, 8 vo. Loud. 1820. G. J. 
 Guthrie on Gunshot Wounds, fyc. p. Ill, 8fc. 
 Ed. 2, St’o. Loud. 1820. J. H. James, Obs. 
 on the Principles of Inflammation, p. 84.287, 
 dye. 8vo. Land. 1821. Sir Astley Cooper, 
 Surgical Essays, Part 2, p. 186, Sro. Loud. 
 1820. 
 
 MOXA. A soft lanuginofrs substance pre- 
 pared from the young leaves of a species of 
 mugw’ort. It is used in the following way : 
 A little cone of the moxa is laid upon the 
 part, previously moistened, and set on fire at 
 the top. It burns down w ith a temperate 
 glowing heat, and produces a dark-coloured 
 spot, the separation of which is promoted 
 by applying a little garlic. The ulcer is left 
 to discharge, or is healed up according to the 
 object in view. The moxa is famous in the 
 East for curing several diseases ; and the 
 French are much in the habit of using it ; 
 but, when English surgeons wish to produce 
 a slough, they generally have recourse to 
 caustics, in preference to actual fire. 
 
 M. Roux, when he visited the London hos- 
 pitals, had two opportunities afforded him 
 of applying the moxa, in order to convince 
 the rising generation of surgeons in this 
 country of its superior efficacy. The first 
 was in a ca-e of spontaneous paralysis of the 
 deltoid muscle at St. Bartholomew’s. The 
 moxa was applied a lit ? le below the acro- 
 mion, and a few T days afterward the motion 
 of the arm began to be restored. This, 
 however, was a case, which, according to 
 (he account of Roux himself, had relapsed, 
 after having been cured by other means. I 
 think one of the surgeons of St. Bartholo- 
 mew's informed me, that notwithstanding 
 the moxa, the relief proved again only tern-, 
 porary. If, however, the moxa had suc- 
 ceeded, a caustic issue, a blister, or volatile 
 liniments, would probably have answered 
 equally well. The second instance, in which 
 M Roux applied the rnoxa, was a case of 
 white swelling at Guy’s Hospital ; but the 
 disease had advanced too far to allow any 
 hope of •* favourable issue. (See Voyage 
 fait a Londres en 1814, ou Par allele de la 
 Chirurgie Angloise avec la Chirurgie Fran - 
 caise, p. 19, 20 ) M. Roux flatters himself 
 that, “ Its chirurgiens Anglois repugneront 
 sans doute moins a I'avenir a faire usage du 
 moxa." The truth is, English surgeons, as 
 well as English farriers, knew very well be- 
 fore the arrival of M. Roux what might be 
 done with moxa and the actual cautery. 
 But, though the application of fire still pre 
 
MURIATIC ACii*. 
 
 vails in Hie veterinary art, as a mode of disease, in which a cure tons' effected without 
 
 curing diseases, it has long been abandoned 
 as a means of relief in the English practice 
 of surgery : not on the ground of its being 
 always ineffectual ; but, because equal good 
 has been found to result from measures, 
 which are milder, always less terrific, and 
 frequently less painful. In order to con- 
 vince an English surgeon that moxa and the 
 actual cautery ought to be introduced into 
 practice, M Roux should prove, that there is 
 at least some particular disease, which may 
 in this manner be cured, but which cannot 
 be cured by other means, ordinarily em 
 ployed in our practice. He should also 
 make us forget, that the application of actual 
 fire was once as common in English surgery 
 as in French ; but that it had not attractions 
 enough to maintain if- ground. 
 
 MURIATIC ACID. Acidum Muriaticum. 
 Gargles, containing this acid, are often made 
 use of with advantage in various cases of 
 sore throat, and the disease known by the 
 name of eancrum oris. The following for- 
 mula is employed at St. Bartholomew’s Hos- 
 pital. JJ. Rosas rubrae exsiecatae 3<j- Aquae 
 ferventis fbj. lnfunde per horam dimidiam, 
 dein colaet adde Accidi muriatici 3j- Mellis 
 Rosae ^ij. Sacchari purificati 3 v j- Misce. 
 
 Muriatic acid appears to have been tried 
 in syphilis earlier than the nitric, Dr. Zeller, 
 of Vienna, having employed it as a success- 
 ful remedy for this disease ever since the 
 year 1789. ( Vid . Sim. Zeller's Prakt. Bem'erk 
 aber den vorzugl. JVutzen d. allerem. bekannt. 
 Badeschwamens , fyc. JVebst. einetn Anhange v. 
 d. SalzaUre, fyc. Wien. 1797.) 
 
 As a medicine capable of improving the 
 appearance of venereal ulcers, and of re- 
 straining for a time the progress of the dis- 
 ease, it has been known to Mr. Pearson 
 many years. He says, that he was first in- 
 duced to give this acid in venereal ulcers of 
 the tongue, and of the throat, in consequence 
 of the great benefit which he had seen re- 
 sult from its use in examples of cancrum 
 oris : and without viewing it as an antidote 
 for lues venerea, he has frequently availed 
 himself of its useful qualities, when it was 
 desirable to gain a little time previously to 
 the commencement of a mercurial course. 
 ( Obs . on the Effects of Various Articles in the 
 Cure of Lues Venerea, p. 193, Ed. 2.) From 
 what he saw, however, he never inferred 
 that the sulphuric and muriatic acids could 
 radically cure the venereal disease ; and he 
 ascribed the benefit derived from them 
 partly to their salutary effects on the sto- 
 mach and constitution, and partly to their 
 agency on ulcers of the throat and tongue, 
 as local applications. (P.117.) When Mr. 
 Pearson made these observations, the fact, 
 which has now been so unequivocally de- 
 monstrated in the army hospitals, that nearly, 
 if not all, the forms of disease, going under 
 the name of syphilis, maybe cured without 
 mercury, had not undergone the strict and 
 impartial investigations which have of late 
 years been devoted to the subject. (See 
 particularly Obs. on the Treatment of Syphi- 
 lis, with an account of several cases of that 
 
 the use of Mercury , by T. Rose, in Medico- 
 Chir. Trans. Vol. 8, p. 349 ) If this point 
 be admitted as fully established, the ques- 
 tion about the antisyphilitic virtues of vari- 
 ous articles of the materia medica requires 
 to be taken up in a very different light, not 
 clouded with a notion that the disease will 
 certainly get worse and worse, if no remedy 
 whatever be exhibited, or that it cannot 
 finally get well of itself. While these doc- 
 trines prevailed, the amendment of any sy- 
 philitic affection during the use of muriatic, 
 or any other acid, w r as entirely referred t© 
 some specific effect, supposed to appertain 
 to such medicine. But now the question 
 involves several considerations ; first, the 
 actual virtue of the medicine in expediting 
 the cure of the disease; secondly, the 
 changes which might happen if the com- 
 plaint wqre left to itself; and thirdly, the 
 benefit sometimes ascribable to the improve- 
 ment produced in the constitution, under 
 particular circumstances, by the discontinu- 
 ance of mercury. The latter mineral no 
 longer claims the name of a specific for the 
 venereal disease, either in the sense of the 
 only, or a completely certain, antidote ; be- 
 cause nature herself would in time bring 
 most cases to a favourable conclusion; be- 
 cause the cure can be completed by a variety 
 of other medicines, noticed in this publica- 
 tion; and, lastly, because mercury, though 
 it may be generally the quickest means of 
 cure, is, in particular cases, complicated 
 with much debility and constitutional irrita- 
 bility, the surest medicine for aggravating 
 the complaint, and preventing any progress 
 towards a favourable termination. Here it 
 is enough to know, (and Mr. Pearson him- 
 self acknowledges the fact) that in the cir- 
 cumstances above specified, muriatic acid 
 is a safer medicine than mercury. The do$e 
 is from ten to twenty drops, which are to be 
 mixed with a proper quantity of water. 
 
 Muriatic acid has sometimes been ein 
 ployed as the active ingredient in injections 
 for the cure of gonorrhoea, in the proportion 
 of eight or ten drops to four ounces of dis- 
 tilled water. 
 
 In cases of poison from muriatic acid, the 
 experiments made by Orfila lead him to con 
 sider calcined magnesia and prepared soap 
 the most fit substances for neutralizing suclu 
 portion of the acid as may not yet be com 
 bined w r ith the texture of the (esophagus, 
 stomach, &.c. They should be given as soon 
 as possible after the corrosive poison has 
 been swallow’ed, care being taken to let the 
 patient drink copiously of warm water, 
 milk, broth, or some mucilaginous diluting 
 liquid. When, from the symptoms, there is 
 reason to believe that inflammation exists in 
 the viscera, or w hen spasms and convulsions 
 come on, antiphlogistic remedies, and anti- 
 spasmodics, are indicated. (Trait d des Poi- 
 sons, p. 476, Vol. 1, Ed. 2, Paris, 1818.) In 
 order to detect the presence of muriatic 
 acid, when mixed with wine or other fluids, 
 we are recommended to distil a portion ot 
 it from a small retort, over a candle, into n 
 
US. 
 
 phial containing a solution of nitrate of sil- 
 ver. The precipitation of muriate of silver, 
 which is soluble in ammonia, hut not in 
 nitric acid, will take place if the poison 
 contain muriatic acid. ( Thomson's Dispen- 
 satory, p. 434, Ed. 2.) 
 
 By Morveau, who employed himself in 
 investigating the merits of Dr. Carmichael 
 Smith’s mode of destroying infection, the 
 muriatic acid, in the new form of gas, was 
 alleged to have the very important quality 
 of neutralizing putrid miasmata. The gas 
 
 is extricated from common salt by means of 
 sulphuric acid In this way it is often em- 
 ployed in hospitals as a mode of preventing 
 and obviating infection. 
 
 The use of muriatic acid, as an application 
 to certain cases of sloughing, and phagedee- 
 na, has been explained in the articles* Hos- 
 pital Gangrene and Mortification. 
 
 MYDRI'ASIS. (from y.iS'im, to abound in 
 moisture.) A preternatural dilatation of the 
 pupil. 
 
 N. 
 
 TVTiEVlJS. (Congenitce No tee ; Envies; 
 JLl Mvlter-mahl ; Mother-spots, fyc.) A 
 molp, or congenital mark, or excrescence of 
 the skin. INeevi materni signify the little 
 spots, excrescences, or swellings, with which 
 many children are born. Some of them 
 (says Dr. Bateman) are merely superficial, 
 or stain-like spots, and appear to consist of 
 a partial thickening of the rete mucosum, 
 sometimes of a ydlow, or yellowish brown, 
 sometimes of a bluish, livid, or nearly black 
 colour. To these the term spilus has been 
 more particularly appropriated Others 
 again exhibit various degrees of thickening, 
 elevation, and altered structure of the skin 
 itself, and consist of clusters of enlarged and 
 contorted veins, freely anastomosing, and 
 forming little sacs of blood These are some- 
 times spread more or less extensively over 
 the surface, occasionally covering even the 
 whole of an extremity, or one half of the 
 trunk of the body ; and sometimes they are 
 elevated into prominences of various form 
 and magnitude. Occasionally, these marks 
 are nearly of the usual colour of the skin ; 
 but most commonly they are of a purplish 
 red colour, of varying degrees of intensity ; 
 such as the presence of a considerable col- 
 lection of blood-vessels, situated near the 
 surface, and covered with a thin cuticle, na- 
 turally occasions. (See Batemans Practical 
 Synopsis of Cutaneous Diseases, p. 324, Edit. 
 4.) When a naivus is of a dark red colour, 
 its intensity is generally augmented by every 
 thing which tends to accelerate the circula- 
 tion of the blood. Fits of anger, hot wea- 
 ther, fevers, and the period of menstruation, 
 in particular, are observed to be attended 
 with an increased turgescence and disco- 
 louration of the part affected. Indeed the 
 excrescence sometimes bursts, and pours out 
 a dangerous quantity of blood, and in fe- 
 males it has been known to become the seat 
 of a regular menstrual discharge. {Boyer, 
 Trail6 des Maladies Chir T.2,p. 277; and 
 John Bell's Principles, Discourse 9.) Some 
 naevi, especially those usually called moles , 
 frequently have long irregular hairs grow- 
 ing upon them ; while the surface of others 
 is streaked, and even granulated. Such as 
 appear rn the form of a mere red, purplish 
 stain, have been absurdly supposed to arise 
 from a desire for claret, or some other wine 
 
 of that colour, entertained by the mother of 
 the patient during her pregnancy. The 
 granulated naevi have been compared with 
 raspberries, strawberries, mulberries, &tc. for 
 which the mother’s longing is ascribed by 
 the vulgar as a cause. The truth is, howe- 
 ver, that this doctrine, imputing the origin of 
 na3vi to fancies of the mother, is neither 
 consistent w ith experience nor sound phy- 
 siology. The causes (as Callisen observes) 
 “ potius autem in evolutione prirnorum fla- 
 minum, a naturaj'solita via aberrante, uti in 
 aliis rebus monstrosis quserenda? erunt.” 
 ( Syst . Chir. Hodiernee . Pol. 2. p. 201.) 
 
 From what has been said, then, it appears 
 that certain ntevi are merely cutaneous spots, 
 of a red, violet, or purplish colour, of 
 greater or lesser extent, and with scarcely 
 any perceptible’ elevation. They are aii 
 organic malformation of the skin, the natu- 
 ral texture of which does not exist, but has 
 substituted for it a plexus of vessels, not en- 
 dued with the natural sensibility of the cutis 
 itself. These naevi generally continue sta- 
 tionary during life, and may be regarded 
 rather as a deformity than a disease. ( Lassus , 
 Pathologic Chir. Tom. 1, p. 477.) Other 
 naevi are either of the same nature as the 
 disease, well known by the name of the 
 aneurism by anastomosis, or bear a consi- 
 derable resemblance to it. They are some- 
 times of great size, and their shape is subject 
 to much variety. They are soft and indo- 
 lent, and of a violet or dark red colour. The 
 skin which covers them is very thin, and, 
 when they are opened, their structure is 
 like that of a spleen, whose blood-vessels are 
 varicose. Some are covered with a delicate 
 white skin, and do not increase with age. 
 Others are more disposed to grow large. 
 These tumours frequently occur in the skin 
 of the face, and in other parts of the integu- 
 ments, on the inside of the labia pudendi, 
 and cheeks, and in the substance of the up- 
 per and lower lip, where they sometimes 
 form a kind of elongation, attended with 
 great disGgurement. Nrevi of this kind, so 
 situated in new-born infants, may produce 
 a serious obstacle to the action of sucking. 
 M. A. Severinus-has particularly described 
 them under the appellation of “ tuberculnm 
 atro-cruentum labii inferioris.” (De Ah&es- 
 smtm natum, Cop 29. p . 803.) 
 
\ECROSl'- 
 
 26,0 
 
 The mevi, which form in the subcutane- 
 ous cellular substance, and were named by 
 Petit “loupes variqueuses,” ((Lucres Post- 
 humes, Tom. 1, p. 276.) are also of the same 
 nature as the aneurism by anastomosis. In 
 time, they attain a very large size. Mr. 
 Latin says, he once saw in a child, two 
 years old, a tumour of this kind weighing 
 fourteen ounces, which, at the time of birth 
 was only equal in size to a large bean During 
 the first year, it did not enlarge much ; but 
 it afterward grew rapidly to the size already 
 specified. (System of Surgery Vol. 2, Chap. 
 22.) Lassus nas even seen a tumour of this 
 description as large as a man’s head. (Pa- 
 thologie Chir. Tom. I, p. 479.) Having 
 treated particularly of the aneurism by 
 anastomosis,” in another place, (see Aneu- 
 rism,) I shall merely repeat the necessity 
 there is for cutting every particle of the 
 disease away, every portion of the congeries 
 of vessels and cells of which it consists, 
 whenever it is meddled with at all. Punc- 
 turing the swelling, or the partial removal 
 of it, has cost many persons their li .es by 
 hemorrhage, as the records of surgery fully 
 prove. (Petit, Traits des Maladies Chir. T. 
 1 ; Lassus, Palhologie Chir. T. 1, p. 484, 
 
 Although the original causes of naevi are 
 buried in obscurity, experience proves, that 
 whatever produces irritation in the part af- 
 fected, or an increased determination of 
 blood to it, has generally the effect of acce- 
 lerating the growth and enlargement of the 
 swelling. Tims, a trifling bruise, or a tight 
 hat, will sometimes excite a mere stain-like 
 speck, or a minute livid tubercle, into that 
 diseased action, which occasions its growth. 
 (Bateman's Pract. Synopsis , p. 327, 
 
 Edit. 3.) 
 
 With regard to the treatment of naevi, the 
 subject may be explained in a few words. 
 When these marks, or swellings, are super- 
 ficial, without any disposition to enlarge, or 
 spread, and their trivial elevation does not 
 expose them to accidental rupture, there 
 appears to be no good reason for interfering 
 with them. Indeed, they could only be 
 destroyed with caustic, or the knife, and 
 these severe means would leave scars, ac- 
 companied with nearly the same degree of 
 disfigurement. 
 
 But, as a valuable writer observes, when 
 naevi evince a tendency to enlarge, or are 
 very prominent excrescences, and either 
 troublesome from their situation, or liable to 
 be ruptured, either their growth must be 
 repressed by sedative applications, or the 
 whole congeries ol vessels extirpated with 
 the knife. Mr. Abernelhy has proposed the 
 application of cold washes, and the pressure 
 of a bandage. This practice was found by 
 him in several instances to have the desired 
 effect of checking the growth of the tu- 
 mours, which afterward shrunk, and be- 
 came no longer objects of any consequence. 
 (See Aberntthy's Surgical Works , Vol. 2, p. 
 224.) Boyer also knew of a casp, in which 
 a naevus of the upper lip was cured by the 
 mother pressing the part with her finger 
 
 unremittingly for seven hours at a timev 
 and the use of alum wash. (Traitd des 
 Maladies Chir. T. 2, p. 269.) Boyer, how- 
 ever, is" not generally an advocate for this 
 inode of treatment ; and Dr. Batemen ex 
 pressly states, that, in the majority of cases, 
 pressure is the source of great irritation to 
 these maculae, and cannot be employed. 
 (P 329.) 
 
 For all those examples, which partake of 
 the nature of aneurism by anastomosis, and 
 are disposed to grow, the best general 
 mode of cure is extirpation with the knife. 
 The prudence of this practice, and the ne- 
 cessity of taking away every particle of the 
 disease, has been already explained : this is 
 what was advised by F. Hildanus, (Cent. 
 5. Obs. 46.) what was strongly urged bv the 
 celebrated Petit, ((Euvres Posthumes, T. 1.) 
 what was recoin mende in still more ani- 
 mated terms by Mr. John Beil, (Principles 
 of Surgery , Discourse 9. ;) and it is what is 
 particularly insisted upon in another part of 
 this Dictionary. See Aneurism. 
 
 In general, stimulating applications can- 
 not he made to naevi, without risk of exas- 
 perating, instead of lessening them. Mere 
 thickenings, and discolourations of the rete 
 mucosum, however, have sometimes been 
 removed by a mixture of spirit and the liquor 
 potasses. ( Bateman , p. 330.) 
 
 Formerly caustic was much in vogue for 
 the removal of naevi ; but, unless its action 
 extend deeply enough to destroy every part 
 of (he disease, il may cause a dangerous 
 degree of irritation, copious hemorrhages, 
 and a sudden and fatal enlargement of 
 the tumour. Therefore, as it is a more 
 painful measure than the knife, and less cer- 
 tain in its effects, it should be on every ac- 
 count discarded from practice. It cannot be 
 denied, however, that the old surgeons had 
 success with their caustics, where the nasvi 
 were altogether superficial. Thus, in speak- 
 ing of caustic femedies, Callisen observes 
 “ inter quae eximio cum successu adhibetur 
 sapo cum aequali parte calcis vivas subtilissi- 
 tna? coinmixtus, naevo per emplastrum per- 
 foratum aduif vendus,et alio ernplastro impo 
 sito firmandus; hoc remedioesebara inuritur, 
 qua soluta, cicatrix alba remanere solet.” 
 (Syst. Chirurgice Hodiernce, Vol. 2, p. 202.) 
 
 Consult Petit's ( Euvres Posthumes, T. 1 . 
 Lassus, Pathologie Chir. V. 1 , p. 476, <^e. Ed. 
 1S09. Callisen' s Systema Chirurgice Hodi- 
 ernce, Vol. 2, p. 201, Hafnice, 1800. Aber 
 nethy's Surgical Works, Vol. 2, p. 224, fyc. 
 Lalta's System of Surgery, Vol. 2. Chap. 22 
 J. Bell's Principles of Surgery , Vol. 1, Dis- 
 course 9. Boyer, Traitt des Maladies Chi- 
 rurgicales, T. 2, p. 225, fyc. Paris , 1814. A 
 Practical Synopsis of Cutaneous Diseases by 
 T. Bateman , M. D. Edit. 3, 181,4. Delpeck 
 Precis Elimentaire des Maladies Chir. T. 3, 
 p. 244, Paris , 1816. J. Wardrop, On one 
 Species of JVeevus, with the Case of an Infant , 
 where the Carotid Artery was tied , in Med. 
 Chir. Trans. Vol. 9, p. 199, «!pc. 
 
 NECROSIS, (from vat^c®. to destroy.) This 
 word, the strict meaning of which is only 
 mortification, is, by the general consent of 
 
NECROSIS 261 
 
 surgeons, confined to this affection of ihe 
 bones. It was first used, in this particular 
 sense, by the celebrated M. Louis, who re- 
 stricted its application, however, to exam- 
 ples, in which the whole thickness of a bone 
 was destroyed. (See Mem. de l' Acad. Roy- 
 alt de Chirurgie, T. 5. 4/o.) By the ancients 
 the death of parts of bones was not distin- 
 guished from caries. However, necrosis 
 and caries are essentially different ; for, in 
 the first, the affected part of the bone is de- 
 prived of the vital principle . but this is not 
 the case when it is simply carious. Caries 
 is very analogous to ulceration, while ne- 
 crosis closely resembles mortification of the 
 soft parts. 
 
 Between caries and necrosis, says Weid 
 mann, there is all that difference, which exists 
 between ulcers and gangrene, or sphacelus 
 of the soft parts. In caries, the nutrition of 
 the bone is only impaired, and an ir egnlar 
 action disunites the elements of the bony 
 structure, which consequently sustains a loss 
 of substance; but every remaining part of 
 il is yet alive. In necrosis, on the contrary, 
 the vitality and nutritive functions cease 
 altogether in a certain portion of the bone, 
 the separation of u'hich then becomes indis- 
 pensable. ( DtJYecrosi Ossium, p.l .) 
 
 I have men-soned that M. Louis confined 
 the term necrosis to cases, in which the 
 whole thickness of a bone perished ; but 
 Weidmann jud;r •< usly criticises this limita- 
 tion of the word, and maintains, that the 
 nature of the disorder is the same whether 
 it aff -ct a single scale, the whole, or a mere 
 point, of the bone. He also objects to the 
 definition of necrosis proposed by Chopart, 
 (Dissert, de Necrosi Ossium, Paris , 1765,) 
 and adopied by David. ( Obs. sur une Mala- 
 die connue sous le nom de JY6cn.se. Paris, 
 1782.) These two authors have defined 
 necrosis io be a disorder, in which a portion 
 of bone perishes, ancHmrns dry, in order to 
 be soon separated from the living parts, and 
 replaced by a new bony substance, which is 
 to perform its functions. But as Weidmann 
 observes, it may happen, that a piece of 
 bone, which dies and separates, may not be 
 replaced by any new formation of bone, 
 though tht disease is of the same character, 
 and merely varies in some modifications. 
 He therefore argues, and every rational sur- 
 geon will agree with him, that a true necro- 
 sis must always be said to exist, whenever a 
 dead portion of bone has either separated, 
 oris about 1o separate. “ Vera demum nec- 
 rosis semper est, si aliquod ossis rumentum, in 
 quo vis vitce exiinda est, absctssii,vel proxime 
 abscessurum est.” ( P . 7.) 
 
 The tibia, femur, lower jaw, clavicle, hu- 
 merus, fibula, radius, and ulna, are the 
 bones most frequently affected with necro- 
 sis. Excepting the lower jaw and scapula, 
 the process of regeneration has only been 
 noticed, in the cylindrical bones. From 12 
 to 18 years of age, is the time of life, most 
 subject to necrosis. The necrosis of the 
 lower jaw, however, seldom occurs before 
 the age of 30. In some persons, the bones 
 
 are affected at once, owing to constitutional 
 causes. 
 
 No climate, age, sex, mode of life, nor 
 condition, (says Weidmann) is exempt fr«>m 
 t his disorder. Childhood and puberty, how- 
 ever, are the periods most liable to it. The 
 same thing may l^said ot persons, who la- 
 bour hard, and aremiuch exposed to external 
 injuries. Every bone of the human body is 
 subject Ui necrosis ; but those which are 
 superficial, and enter into the formation of 
 the extremities, are more frequently affected 
 than others whose situation is deeper. Ne- 
 crosis less commonly attacks the spongy 
 substance of the bones, because this being 
 endued with a. higher degree of vascularity 
 and life, suppuration is most apt to occur. 
 Necrosis, on the contrary, is oftener seen in 
 the compact substance, where the vital prin- 
 ciple is less energetic, and more readily ex - 
 tinguished. Lastly, tbe disorder may affect 
 the long bones, or the broad ; the large oe 
 small ; and even ttiose of the very least 
 size ; ince it is well known, that the ossi- 
 cula of the ear m v be destroyed by necrosis, 
 and separate. I have seen this happen in 
 two instances, and the fact is recorded by 
 several writers. (See As true de Morbis Ve - 
 nereis, lib. 4. cap. 1. Henri , Journal d<i 
 Medicine, T. 15. p. 363.) 
 
 Though necrosis rnos’ly attacks the cylin- 
 drical bones, the fl w ones are not exempt 
 from (he disease. Pott makes mention of 
 a parietal bone, the whole of which was 
 detached, and of an os fi ontfe, the greatest 
 part of which came awa\ . In a thesis on 
 necrosis, in 1776, aux ecoles de chirurgie 3 
 may be found the case of a young man, a 
 very large part of whose scapula perisned 
 and separated. Chopart^ who relates the* 
 case, mentions, that he saw the patient quite 
 recov< : ed, and felt a new triangular movea- 
 ble bon?, firmly^upporting the clavicle, but 
 smaller and Hatter thau natural, and without 
 any spinous process. The same has happen- 
 ed to the lower jaw. as m.r, be seen by 
 referring to the EphemeridesjYat. Cur. nd 
 M6m. de I' Acad, de Chirurgie. In the fifth 
 volume of the latter work, is an account of 
 a woman, who applied to be relieved of some 
 venereal complaints. From the beginning 
 of the treatment, the bone was discovered 
 to be loose just under the gums, and seemed 
 shortly afterward, to move backwards and 
 forwards with a tooth. M. Guernery took 
 hold of the tooth with a key-instrument, 
 and found it firmly inserted in the moveable 
 jaw ; he made with caution the necessary 
 manoeuvres for extracting the portion of 
 bone; but was greatly surprised on -finding 
 what an extensive part yielded to his very 
 moderate efforts. It was the whole of the 
 lower jaw, above its right angle from its di- 
 vision into the coronoid and condyloid pro- 
 cesses to the -p Te betw-sen the first and se- 
 cond of the front grinders of the left side. On 
 the right, there only remained the condyle in 
 the articular cavity of the temporal bone. 
 This destruction left a considerable empty 
 space, from which great deformity was appre - 
 hended, in consequence of the unsupported 
 
NECROSIS. 
 
 162 
 
 soft part s falling do w n . The woman , h o w - 
 ever, got well in two months, and had the 
 most perfect use of a new jaw. A similar 
 fact is recorded in the Journal de M6d6cine, 
 1791. 
 
 When the body of a cylindrical bone, or 
 the middle portion of a bone, is destroy- 
 ed by necrosis, their exs Amities, which are 
 of a cellular texture, continue unaffected, so 
 that, for example, in the cylindrical bones, the 
 articularends are always formed of portions 
 of the original bone, which are engrafted, 
 as it were, on t he new production. There 
 are, however, a few had cases, in which the 
 necrosis does not altogether spare the heads 
 of the bones, and the disease communicates 
 with the joint. These examples are very 
 uncommon, and are attended with consider 
 able danger to the limb ; indeed, they tre- 
 nerally require amputation. (See Boyer , 
 Traitt des Mai. Chir. T. 3, p. 442.) Ivj • . 
 Brodie has known an instance, in which, 
 without any obvious cause, a large portion 
 of the head of the tibia died, and exfoliated? 
 and the destruction of the knee-joint was 
 the consequence. ( Pathol . and Surg. Obs. 
 on tlic Joints, p. 269.) 
 
 Besides the differences arising from ihe 
 particular bones affected, necrosis also va- 
 ries, according ns the portion of bone 
 attacked happens to be thin, and of iittle 
 extent, or large and of considerable thick- 
 ness. The disease is simple, when it is con- 
 fined toorie bone, and the patient is in other 
 respects healthy ; compound , when several 
 different parts of the sam^ bone, or several 
 distinct bones, are affected at the same 
 time; when the health is bad; and other 
 parts of the body are also diseased. It should 
 also be known, hecause the information is 
 of practical importance in the treatment, 
 that necrosis has three different stages, or 
 periods. In the first, the bone affected pe- 
 rishes ; in the second, the process of exfolia- 
 tion or separation of the dead hone from the 
 living, is going on : and, in the third, the se- 
 paration is completed. (See Weidmann, 
 V- 8 -) 
 
 The causes of necrosis are not essentially 
 different from those which produce ulcers 
 and gangrene of the soft parts. As, how- 
 ever, the vitality of the bones are weaker, 
 we may infer, that necrosis may be occa- 
 sioned in them by causes which are less nu- 
 merous and intense, and such as would only 
 give rise to suppuration in the soft parts. 
 Everything, whether in the periosteum or 
 the substance of the bone itself, 1 hat tends 
 to interrupt the nutrition of the bone, must 
 be regarded as conducive to the origin of 
 necrosis. It is observed, however, that 
 •when the mischief in the periosteum, me- 
 dulla, or substance of the bone, is of trivial 
 exterit,the consequence is merely an abscess. 
 Some of the causes of necrosis are external, 
 while others are internal, or constitutional. 
 Sometimes the life of the bone is instanta- 
 neously destroyed by them ; but in other in- 
 stances, the bone is first stimulated and en- 
 larged. so that its death is preceded by true 
 inflammation- 
 
 The external causes, which injure the pe- 
 riosteum and medullary structure, and thus 
 produce necrosis, are wounds, contusions, 
 pressure, fractures, comminutions, acrid sub- 
 stances, caustics, and extreme degrees of 
 heat or cold. 
 
 When the periosteum, in consequence of 
 an external cause, inflames and sloughs, or 
 is at once deprived of its vitality, as it may- 
 be by the action of caustic, fire, or intense 
 cold, the vessels which conveyed nourish- 
 ment to the bone are destroyed, and the 
 death and exfoliation of the denuded por- 
 tion of the bone are inevitable. But, if the 
 detachment of the periosteum is of little ex- 
 tent, the patient young and healthy, and the 
 treatment calculated to prevent inflamma- 
 tion, and preserve uninjured the vessels 
 distributed to the bone, hopes may be en- 
 tertained that no part of the hone will die, 
 but that granulations will very soon arise 
 from its surface, being adherent to it as the 
 periosteum was, and that they will grow to 
 and cicatrize with the surrounding parts. 
 Weidmann has explained, that this fact of 
 bones not always exfoliating when deprived 
 of the periosteum, which is of great practi- 
 cal importance in the treatment of wounds, 
 was inculcated by Felix Wurtz, Cesar Ma- 
 gatus, and Belloste, at a time when the con- 
 trary opinion prevailed. Weidmann also 
 adverts to his own experience and to the 
 experiments of Tenon, in further proof of 
 ihe preceding fact. (Mem de I'jQcad. dcs 
 Sciences, 1758, p. 372.) 
 
 On the other hand, when the detached 
 piece of die periosteum is extensive ; when 
 the bone itself is contused ; or when it has 
 been long exposed to the air, the effect of 
 which is to drv up the few vessels which 
 belong to it ; when the inflammation is vio- 
 lent and extensive ; when the patient is old. 
 deerepit, or of bad constitution ; and more 
 especially when improper applications are 
 used, as was almost always the case in for- 
 mer times ; necrosis cannot he avoided. 
 
 An internal necrosis, affecting the spongy 
 texture of bones, generally arises from con- 
 stitutional causes, though sometimes an ex- 
 ternal cause, which seems to affect only the 
 surface of a bone, extends its action to the 
 interior, so as to destroy the medullary 
 membrane, and produce an internal ne- 
 crosis. 
 
 In external injuries of the head, where 
 the pericranium is lacerated, contused, or 
 otherwise hurt, or where the outer table, or 
 the diploe,of the skull, is injured, theinflam- 
 mation frequently extends to the inner table, 
 and the dura mater becomes detached. 
 Hence, a collection of matter forms, which 
 may occasion many bad symptoms, and 
 even death itself ; or if the patient survive, 
 exfoliation of part of both tables of the skull 
 is the consequence. (See Pott's Chir. Works , 
 Londo", 1779, Vol. I, p. 32.) 
 
 The same thing may occur • i other bones, 
 as well as those of the cranium. Broitifiold 
 had an opportunity of seeing a necrosis of 
 the spongy substance of the upper nnd in- 
 ternal part of t.he tibia, brought ou bv five 
 
NECROSIS 
 
 
 improper uaode iu which au issue was dress- 
 ed. in order to keep the peas from slipping 
 out of their places, a compress with a shil- 
 ling in it, and a tight bandage were applied ; 
 but the part was attacked with excruciating 
 pain, and the spongy texture of the tibia in 
 the vicinity became affected with necrosis. 
 ( Chir . Observations and Cases, Vol. 2 ,p. 9.) 
 
 This circumstance, as Weidmann observes, 
 ought not to surprise us : as numerous ves- 
 sels quit the periosteum to descend into the 
 substance of the bone, to ramify on the me- 
 dullary cells themselves, and freely anasto- 
 mose there, it cannot be difficult to con- 
 ceive, how inflammation, which is at first 
 confined to the outside of the bone, may 
 (through the medium of the vessels which 
 serve as conductors to it) penetrate more 
 deeply, and extend its ravages in every di- 
 rection. 
 
 But necrosis may proceed from another 
 description of causes, which are of a con- 
 stitutional nature. In fevers of bad type, 
 in the small-pox and in the measles, expe- 
 rience has fully proved, that the bones are 
 sometimes attacked with necrosis. Scrofula, 
 lues venerea, and the scurvy, are also dis- 
 eases, which, according to the testimony of 
 all surgical writers, frequently produce such 
 mischief in the bones as terminates in ne- 
 crosis. It is likewise well ascertained, that 
 mercury, the judicious ernploymentof which 
 in venereal cases will prevent necrosis, or 
 cure them when formed, may itself give 
 rise to the disorder, especially in the lower 
 jaw-bone. (See M6m. de VAcad. de Chir. T. 
 5, p. 356, 4 to.) 
 
 This happens either in consequence of 
 mercury having been introduced too quick- 
 ly into the system, or because the patient 
 exposes himself to cold, or deviates in some 
 other respect from a proper regimen. Cer- 
 tain necroses of the lower jaw, however, 
 appear also to have been caused by blows, 
 and the application of acrid substances to 
 carious teeth. But, says Weidmann, “ I feel 
 it incumbent upon me particularly to de- 
 clare, that the irrational treatment pursued 
 by the ancient practitioners, who neither 
 understood the nature of the bones, nor the 
 differences of their diseases, and which 
 treatment is too confidently adopted in our 
 own days, had frequently the effect of kill- 
 ing these parts, by attacking with spirituous, 
 acrid, oVcaustic remedies, or even with the 
 knife, diseases which required the mildest 
 applications, and to be left in a great mea- 
 sure to nature. The old surgeons were 
 afraid of laying on the exposed injured sur- 
 face of a bone unctuous emollient dressings, 
 and yet, for what reason I know not, they 
 subjected the part to the action of spiritu- 
 ous, acrid,, drying applications. As for my- 
 self, I deem it proved by infallible and fre- 
 quently repeated trials, not only that an ex- 
 posed injured bane may be dressed with a 
 mild ointment without any ill consequences, 
 but even with the greatest advantage. Why 
 should that which is beneficial to the soft 
 parts, be so prejudicial to the bones ? In 
 ulcers of the soft parts, indeed, tlie employ- 
 
 ment of the remedy which i recommend, is 
 less important, because these parts are na- 
 turally humid, and there is no risk of their 
 becoming dry. But with regard to the 
 bones, whose dry texture is only penetrated 
 by few vessels, which may easily be destroy- 
 ed if they be suffered to become quite dry, 
 it h absolutely necessary to use an emol- 
 lient ointment, as a dressing, well calculated 
 to defend these vessels, which are. the sup- 
 port of life, and preserve them from the bad 
 effects of exposure to the air. Therefore, 
 observes Weidmann, if a surgeon would 
 avoid producing a necrosis himself, and not 
 neglect any means that tend to prevent such 
 disorder, he should make it a rule never to 
 apply any thing acrid to exposed bones, but, 
 on the contrary, to defend them with a dress- 
 ing of some unirritating ointment .” {De jYe- 
 crosi Ossium, p. 11.) 
 
 It was formerly supposed, that purulent 
 matter, collected near a bone, might in time 
 become acrimonious, corrode the bone, and 
 produce necrosis. Hence, it was a rule to 
 open such an abscess as soon as its exist- 
 ence was known. But Weidmann questions 
 whether there was any real necessity for 
 this practice. No doubt, says he, the pre- 
 ceding erroneous opinion arose from the 
 circumstance of the bones being often found 
 bare, carious, or even affected with neero 
 sis, when abscesses were near them ; but 
 things happened thus, because the inflam- 
 mation which caused the suppuration, had 
 also extended its effects to the periosteum 
 and bone. He affirms, that he has witness- 
 ed ulcers, in which the surface of bones, 
 bare and uncovered by the periosteum, lay 
 bathed in pus fora very considerable time j, 
 yet, being dressed with a mild ointment, 
 they continued entire, granulations grew 
 from them, and cicatrization followed. He 
 had also in his possession portions of bones 
 affected with necrosis, which had lain for 
 years in pus ; still their surface was smooth, 
 and presented no marks of erosion. If then 
 these pieces of bone underwent no altera 
 tion, how much less likely to do so are 
 bones, which are endued with life ! 
 
 But though Weidmann wisely rejects the 
 doctrine of pus being capable of destroying 
 the periosteum and bones by any corrosive 
 qualities, he acknowledges his belief, that 
 the matter of an abscess may by its quantity 
 compress and inflame the adjacent parts, 
 and occasion their removal by the absorb- 
 ents. While the periosteum intervenes be- 
 tween an abscess and the bone, he does not 
 see how the latter Can be hurt by the pus 
 but when the abscess is copious and lodged 
 between that membrane and the bone, the 
 vessels passing from the former will be de- 
 stroyed, and either caries or necrosis ensue. 
 
 The inflammation arising from the causes 
 which, excite necrosis, may be either acuta 
 or chronic. It is chronic, when it begins 
 and passes through its different stages slow- 
 ly, and when the mildness of the symptoms 
 may lead us to mistake the nature of fbe 
 case. This sort of inflammation chiefly hap- 
 pens in debilitated constitutions- in which 
 
INECKOalb 
 
 “64 
 
 the necrosis only afreets the external part of 
 a bone, and originates from some chronic 
 cause, such as scrofula, lues venerea, and 
 the scurvy. But when necrosis attacks the 
 interior, and the disease occurs in a strong, 
 irritable, plethoric subject, inflammation is 
 immediately kindled, attended with the 
 most acute symptoms, severe pain, consider- 
 able fever, restlessness, delirium, &c. Chro- 
 nic inflammation is more supportable ; but 
 its duration is longer : acute inflammation is 
 more afflicting, but sooner comes to a crisis. 
 
 The part in which a necrosis is situated, 
 is aft'ected with swelling. What has been 
 observed, respecting the inflammation, is 
 also applicable to this tumour, which most 
 frequently forms gradually, but sometimes 
 with great rapidity. In the first- case, the 
 accompanying pain is dull and inconsidera- 
 ble ; in the second, it is violent. The swell- 
 ing has not, like that of abscesses, an eleva- 
 ted apex. On the contrary, it is so widely 
 diffused, that the limits which circumscribe 
 it, can hardly be distinguished. 
 
 This diffusion of the swelling is the 
 greater, in proportion as the diseased bone 
 is more deeply buried in soft parts : it may 
 extend over the whole morbid bone, or even 
 over the whole limb. 
 
 The swelling comes on at the very begin- 
 ning of the disorder, and continues to in- 
 crease, until the matter which it contains 
 finds its way out, when the evacuation is 
 followed by a partial subsidence of the tu- 
 mour. The swelling is sometimes also com- 
 bined with oedema, especially in persons 
 whose constitutions have been impaired by 
 the severity of the disease, the violence of 
 the sufferings, and the long and profuse dis- 
 charge. 
 
 When the inflammation is acute, purulent 
 matter of good quality soon collects in the 
 vicinity of the necrosis. In the contrary 
 case, the pus forms slowly, and is thinner 
 and less healthy. 
 
 The abscess which accompanies a necro- 
 sis, naturally soon bursts when it arises 
 from intense inflammation, and is situated 
 near the skin, which is itself inflamed. But 
 when the bone is surrounded by a great 
 thickness of soft parts, and the inflammation 
 is chronic, the quantity of matter daily in- 
 creases, the cavity which it occupies be- 
 comes larger and larger, and considerable 
 pressure is made in the abscess on every 
 side. The bones and tendons resist for a 
 long while the progress of the matter ; but 
 the cellular substance yields, and different 
 sinuses form, which sometimes run to a vast 
 distance from the main collection of matter, 
 especially when the abscess lies under an 
 aponeurosis. 
 
 It was supposed a few years ago, that in 
 cases of necrosis, the matter was invariably 
 sanious, acrid, and fetid. But the celebrated 
 Weidmann exposed the error of this opi- 
 nion. He had often seen abscesses and ul- 
 cers, arising from necrosis, discharge a whi- 
 tish, inodorous, thick pus, absolutely devoid 
 of any bad quality whatsoever. He had 
 particularly seen this happen in patients 
 
 whose necroses proceeded trom an external 
 cause, or an internal one of a slight nature, 
 and whose health was generally good. ( Dc 
 JVecrosi Ossium,p. 16.) If, says the same ex- 
 cellent writer, we sometimes find in prac- 
 tice the suppuration dark and fetid, we 
 must not ascribe it to the affection of the 
 bone, but to the weakness and bad state of 
 the patient’s health. Under the same cir- 
 cumstances, common sores of the soft parts 
 would also emit a discharge of bad quality. 
 
 After the ulcerated openings have emit- 
 ted for some time a profuse discharge, the 
 sinuses, if considerable, receive the appella- 
 tion of fistula;, on account of their edges 
 putting on a callous appearance, throwing 
 out fungous granulations, and there being 
 impediments to cicatrization. These im- 
 pediments are caused by the dead portions 
 of bone, which, whether loose or adherent, 
 act as extraneous bodies in hindering the 
 sores from healing. In some instances also, 
 the ulcers will not heal though the dead 
 bone has come away, because they run to a 
 great depth, and! such a quantity of pus is 
 secreted from every point of their surface, 
 as prevents all contact, and the adhesions 
 which would result from it. 
 
 The fistulas vary in number ; but they are 
 fewer in proportion as the disease is slighter 
 In an extensive necrosis, several of these 
 openings are seen, either near together, or 
 separated by considerable spaces ; and, 
 when the necrosis affects every side of the 
 bone, the fistula; in the integuments occur 
 on every side of the limb. 
 
 Besides the inflammatory fever, which at- 
 tends the beginning of every severe case of 
 necrosis, which is sometimes accompanied 
 with exceedingly violent symptoms, and 
 which usually abates when matter is form- 
 ed, the patient is subject to another fever of 
 a slow hectic type. This takes place in the 
 decline of the disease, is the effect of the 
 long-continued profuse suppuration, gradu- 
 ally reduces the patient, and at length brings 
 him to the grave, unless the timely removal 
 of the sequestrum be effected either by na- 
 ture or art. 
 
 Let us next endeavour to trace the signs, 
 by which we may not only ascertain the 
 presence of the disease, but its modifications. 
 
 In the first place, we should make our- 
 selves acquainted with every thing, which 
 may have predisposed to the disorder; as, 
 for instance, what accidental circumstances 
 have occurred, and what symptoms followed 
 them. We should also inquire into any pre- 
 vious treatment which may have been 
 adopted ; for, as Weidmann truly remarks, 
 injudicious remedies have caused many a 
 necrosis that would not have occurred at 
 all, if the case had been properly treated, or 
 confided to nature. 
 
 The kind of inflammation with which the 
 disease commences, may afford grounds for 
 suspecting that rfecrosis will happen : it is 
 generally slow and deeply seated, passing 
 through its stages tardily, and the attendant 
 symptoms are severer. The skin retains its 
 natural colour a long while : but, at length. 
 
.NECROSIS. 
 
 265 
 
 exhibits a reddish, or livid discolouration. 
 The matter does not reach the skin till a 
 considerable time has elapsed, and when 
 the abscess bursts, the inflammatory symp- 
 toms are still slow in subsiding. When the 
 inflammation is acute, the patient suffers in- 
 tolerable pain a long time. 
 
 There are also other symptoms of a ne- 
 crosis; viz. the swelling which accompa- 
 nies the inflammation, is situated upon a 
 bone, or rather the bone is included in the 
 tumour ; the swelling is at the same time 
 very diffused ; and the suppuration lies deep- 
 ly, and can only be felt in an obscure 
 way. 
 
 The ulcers, beneath which a necrosis is 
 situated, discharge a large quantity of mat- 
 ter, and their edges are bent inward. The 
 granulations are either yellowish and pale, 
 or else of an intense red colour; they are 
 also irregular, and generally not very ten- 
 der, though sometimes extremely painful, 
 and on being slightly touched, they bleed. 
 
 It has been already noticed, that, some 
 years ago, the discharge from the sores, 
 which atteud necrosis, was described as be- 
 ing always thin, fetid, and sanious ; and 
 such qualities of the matter were regarded 
 as a symptom of the disease of the bone. 
 But that excellent practical writer, Weid- 
 mann, has well explained, that it is a symp- 
 tom undeserving of confidence. In cases of 
 necrosis the pus is often thick, white, and 
 inodorous ; while other ulcers, unattended 
 with diseased bone, sometimes discharge 
 thin fetid matter. Weidmann, at the same 
 time, does not mean to assert, that in cases 
 of necrosis the sores never emit unhealthy 
 pus ; but he firmly believes, that such dis- 
 charge is not always the result of a disease 
 of the bone. As far as he could judge, the 
 suppuration from ulcers, situated over dis- 
 eased bones, continues white and laudable 
 as long as the patient’s general health is 
 good ; but, that it deviates from these pro- 
 perties, in proportion as the health becomes 
 impaired. 
 
 Neither is the black colour, imparted to 
 the dressings of ulcers, a circumstance which 
 necessarily indicates the existence of ne- 
 crosis; for it may occur when the bone is 
 sound, and may not happen when the bone 
 is affected. 
 
 None of the preceding symptoms convey 
 such information, as leaves no doubt of the 
 positive existence of necrosis, the touch 
 is the only thing which can give us this 
 knowledge, when the bone is not too deeply 
 situated, and the sinuses not tortuous, nor 
 obstructed with fungous growths. 
 
 When the openings of the ulcers are con- 
 siderable, the finger may be introduced. If 
 in this way the bone can be felt to be ex- 
 tensively uncovered by the periosteum, the 
 surgeon may conclude that all such portion 
 of the bone has perished. He may be still 
 more certain of the fact, when he finds the ed- 
 ges of the denuded bone unequal and rough. 
 
 The examinations, made directly with the 
 finger, give the most correct and exact in- 
 formation of the state of the bone ; but the 
 Vox. If 34 
 
 orifices of the sores are sometimes so small, 
 that the finger cannot be introduced without 
 causing great pain. A probe must then be 
 used for the purpose of ascertaining the ex- 
 tent of the denudation of the bone ; whe- 
 ther its edges are rough ; whether the dead 
 portion is loose, and likely to separate 
 soon. 
 
 Sometimes the dead fragment of bone 
 protrudes from the ulcer, or is visible on se- 
 parating its edges. When it is black, there 
 cannot be a doubt of its being actually dead ; 
 but, on the other hand, when its whiteness 
 is increased, the diagnosis is difficult, be- 
 cause bones being naturally white, much 
 experience is necessary to be able to judge 
 whether they are so in excess. 
 
 It merits attention, also, that the black 
 colour of the bone is not owing to the ne- 
 crosis itself, but seems rather to depend upon 
 the fragment having been exposed to the 
 air. In fact, dead pieces of bone with which 
 the air comes into contact, turn black, 
 while those which are covered with matter, 
 retain their whiteness. The cylindrical por- 
 tion of a humerus, which was almost totally 
 affected with necrosis, was universally black 
 at the part, which protruded through the 
 flesh ; but the rest, which lay under the in- 
 teguments, remained white. ( Weidmann dt 
 JYecrosi Ossium,p. 19, et Tab. 9, fig. 1.) 
 
 When the early symptoms of the disease 
 are mild, the surgeon may infer that it is 
 only a superficial portion of the bone which 
 is about to be separated. But this judgment 
 will be more certain if confirmed by exami- 
 nation with the finger or probe ; or, if the 
 swelling which occurred in the beginning, 
 has nor spread beyond the affected point, 
 and if the pain affects only the outer part 
 of the bone. In this sort of case, there is 
 also great probability that the dead bone 
 will be separated within a moderate time. 
 
 It is also of importance to ascertain the 
 existence of an internal necrosis, and to 
 learn whether it is situated in the spongy 
 substance, or in the internal parietes of the 
 canal of the bone ; whether it affects on- 
 ly a part, or extends to the whole body 
 of the bone. When there is an internal 
 necrosis, says Weidmann, the disease is 
 generally more aggravated, and of longer 
 duration ; and in the first stage, the patient 
 is affected Avith severe symptoms, intolera- 
 ble pain, loss of rest, ardent fever, profuse 
 perspirations, and such disorder of the sys- 
 tem, as may prove fatal, unless the patient 
 be young and strong. The hard swelling 
 which Avas observable at the commence- 
 ment of the disease, increases but slowly, 
 and extends very gradually over the cir- 
 cumference of the limb, while the skin yet 
 remains free from redness and tension. If 
 the part be somewhat roughly handled , the. 
 pain, which is fixed in the bone, is not ren- 
 dered more acute, as would happen, were 
 the case an external inflammation. In this 
 suffering condition the patient continues a 
 good Avhile, before the formation of matter 
 brings a degree of relief. When the matter 
 is formed, it spreads through the adjacent 
 
266 
 
 NECROSIS. 
 
 cellular substance, among the muscles and 
 other parts, and the abscess generally bursts 
 after a considerable time, by several open- 
 ings, very distant from the main collection 
 of matter, as also remote from each other, 
 sometimes in diametrically opposite situa- 
 tions. 1 he evacuation of the matter, how- 
 ever, does not produce any material subsi- 
 dence of the swelling. The pus is of good 
 quality, and issues in large quantities from 
 the ulcerated apertures, the quantity, how- 
 ever, not being increased when pressure is 
 made . If some of the openings heal, others 
 are formed ; but, in general, the edges be- 
 come callous, and they lose all disposition 
 to cicatrize. When the case presents the 
 foregoing circumstances, and the weakened 
 limb can neither bear the action of the 
 muscles, nor the weight of the body, and by 
 either of these causes, its shape becomes al- 
 tered, the surgeon may conclude that the 
 disease is an internal necrosis. But, in or- 
 der to avoid mistake, he should introduce 
 into the sinuses a probe, which, passing 
 through the openings in the subjacent bone, 
 will touch the dead piece, which it con- 
 tains, and which will sometimes be even 
 distinguished to be loose and moveable. 
 The extent of the sequestrum must be jucged 
 of by the extent of the swelling , and the dis- 
 tances between the apertures in the bony shell, 
 which includes the sequestrum. 
 
 The surgeon should also endeavour to 
 ascertain with the probe, whether there is 
 only a single sequestrum, or several. When 
 there are several, they may be felt with the 
 probe in different places, down to which this 
 instrument is passed, and the removal of one 
 or two of the fragments is not followed by 
 a cure. It ought to be remembered, how- 
 ever, that the same fragment may be touched 
 by the probe in several different places, 
 when it is very extensive. If there are 
 several dead pieces of bone, situated at a 
 distance from each other, each of them is 
 generally accompanied with a distinct swell- 
 ing, and sinuses. Frequently, these frag- 
 ments are so concealed, that they cannot be 
 felt with a probe ; but, their existence may 
 then be suspected from the ulcers not heal- 
 ing, which can be ascribed to nothing else. 
 
 It is also necessary to distinguish with the 
 greatest attention the different stages of the 
 disease. Theirs! stage may be considered 
 as existing, when the attack is yet recent, 
 and the inflammation and its concomitant 
 symptoms, the pain, swelling, and symptom- 
 atic fever, prevail in a high degree, and 
 when no suppuration has taken place, or at 
 least no discharge of matter. The second 
 period, in which the dead bone is undergoing 
 the process of separation, is indicated by a 
 diminution of the inflammation, a partial 
 subsidence of the swelling, and the discharge 
 of purulent matter. When a probe is passed 
 into the ulcers, the bone is felt bare, and dry, 
 and, towards the limits of the swelling, it is 
 rough, where, as will be afterward noticed, 
 an excavation is formed. Every part of the 
 bone, however, which is to be detached, 
 *till continues adherent to the rest of the 
 
 living bone. At length, the surgeon knows, 
 that the disease has reached its last stage, or 
 that in which the dead portion of bone is 
 entirely separated, when sufficient time for 
 the completion of this separation has expired, 
 and when the dead bone can be distinguished 
 with the finger, probe, or even the eye, to be 
 loose and free from all connexions 
 
 Although a necrosis must generally be 
 classed with diseases w hich are serious and 
 of long duration ; yet, the character of the 
 disorder 'is not essentially bad, since it is 
 often cured by nature, or with the assistance 
 of surgery. Confident hopes of a cure may 
 be entertained when the necrosis is confined 
 to the external part of a bone ; when it 
 is simple and of moderate extent ; when it is 
 not situated in a bone, destined for impor- 
 tant uses, or near any viscus, or organ, that 
 may be injured by it ; and w hen it proceeds 
 from an external cause, and the general 
 health is good. On the contrary, the cure is 
 difficult, and the prognosis doubtful, when 
 the disease is extensive, and complicated 
 with other affections, either of the same, or 
 different bones : when it attacks bones, which 
 are of high importance on account of their 
 functions, or situation; w r hen it is situated 
 in the interior of the bone, and affects seve- 
 ral parts of it ; w hen it arises from an internal 
 cause, for which there is no certain and 
 quick-acting specific ; when the patient is 
 weakened by age, or disease ; and especially, 
 when the sinuses extend into the neighbour- 
 ing articulations. ( Weidmann de Neci'osi 
 Ossium, p. 22 ) 
 
 The process of cure is said to take place 
 with more celerity in the lower jaw, than 
 any other bone, and may be completed in 
 three months. Mr. Russell has never known 
 a necrosis of the tibia get well in less than a 
 year; but, in general, nearly two years 
 elapse first ; sometimes, the cure is protract- 
 ed to a much greater length of time. 
 
 Necrosis of the lower jaw and clavicle 
 never proves fatal : that of the lower ex- 
 tremities, which is the worst case, does so 
 very seldom, and only from the violence of 
 the first inflammatory symptoms, which ra- 
 pidly bring on a hectic fever, which proves 
 incurable, unless its local cause be removed 
 by a timely amputation. When the violence 
 of the first stage, however, has abated, the 
 irritation ceases, and the hectic symptoms, 
 if there are any, are generally moderate. 
 Nor is this state of tranquillity disturbed, till 
 the sequestrum, in making its way outward, 
 again produces irritation. At this second 
 period of urgency, extensive inflammation 
 may originate, ulcerations spread all over 
 the surface of the limb, assume an unhealthy 
 appearance, violent fever succeed, and the 
 patient either perish, or sink into a state, in 
 which he must consent to amputation, as the 
 only means of saving his life. This is the 
 last crisis of imminent danger; but, in gene- 
 ral, it is less perilous, than when the inflam- 
 mation comes on in the incipient stage of 
 necrosis. (Russell.) 
 
 In the treatment of necrosis, the first grand 
 object of the surgeon should be to aid nature 
 
NECROSIS. 
 
 267 
 
 in her endeavours to effect a cure, and not 
 to disturb her operations by any superfluous, 
 or unseasonable interference. The second 
 should be to assist her sometimes by the 
 boldest proceedings, when she loses her 
 way, and cannot by herself accomplish the 
 end. 
 
 But, in order not to attempt any thing 
 wrong, the surgeon must understand cor- 
 rectly what nature does in this disease, what 
 it is in her power to perform ; what she either 
 cannot accomplish at all, or not with any 
 degree of certainty ; and lastly, the circum- 
 stances in which she may err, and endanger 
 the patient’s life. 
 
 When a portion of bone dies, nature uses 
 all her endeavours to bring about its separa- 
 tion from the part of the bone which still 
 remains alive. Surgeons have denominated 
 this process, exfoliation, (see this word) which 
 resembles the separation, that occurs be- 
 tween parts affected with gangrene and 
 sphacelus, and the living flesh. An exfolia- 
 tion of bone, however, happens much more 
 slowly, than the separation of a slough of 
 the soft parts. Neither are all exfoliations 
 completed at a regular period ; for they 
 proceed most quickly during youth, when 
 the constitution is usually more full of ener- 
 gy, the bones more vascular, and less replete 
 with solid inorganic earthy matter. On the 
 other hand, the process is slower, in old, de- 
 bilitated subjects, whose vitality is less ac- 
 tive. A thin small scale of bone separates 
 sooner, than a large thick portion ; and the 
 most tedious exfoliation is that of a thick 
 bone, from which a portion, including its en- 
 tire diameter, is coming away. The separa- 
 tion of a necrosis takes place more expedi- 
 tiously in bones of a light texture, than in 
 those of a solid structure ; and sooner, in the 
 less compact parts of bones, such as the epi- 
 physes and spongy substance, than in those 
 of greater density. 
 
 When a necrosis has originated from the 
 scurvy, syphilis, &.c. and appropriate reme- 
 dies are not administered, nature cannot ef- 
 fectually accomplish the process, by which 
 the dead bone is separated ; the case becomes 
 worse ; and life endangered. 
 
 The separation happens precisely at the 
 different points where the living and dead 
 parts of the bone come into contact ; and it 
 is obvious, that the particles of the dead 
 bone, which are at a distance from the part 
 that retains its vitality, cannot be acted upon 
 by it. 
 
 A variety of opinions have been entertain- 
 ed, concerning the means employed by na- 
 ture in effecting this separation. Hippo- 
 crates believed, that the dead part was push- 
 ed away by a fleshy substance, which grew 
 underneath it. (De Cap. vuln. Cap. xxiv.) 
 Ludwig, Aitken, Bonn, and many others, 
 adopted the same idea. (See Adversaria 
 Med. Pract. Vol. 3, p. 63 ; Systematic Ele- 
 ments of the Theory and Practice in Surgery , 
 p. 287. Thesaur. Oss. Morb. p. 1.) 
 
 Van Swieten conceived, that the dead part 
 was forced away by the incessant beating of 
 the arteries. ( Comment . inAphor. Boerrhavii , 
 
 § 252.) M. Fabrc ascribed the separation to 
 the extension and expansion of the vessels. 
 ( Mem . de VAcad. de Chir. Tom. 4, p. 91.) 
 Others supposed that the exfoliating piece 
 of bone became loosened partly by the sup- 
 puration, and partly by the rising of the new 
 granulations. (See B. Bell on Ulcers.) 
 
 As Weidmann observes, there is unques- 
 tionably a reddish fleshy substance formed 
 between the dead and livingbone, and which 
 Celsus has noticed under the appellation of 
 caruncula. ( De Medecina , lib. 8, cap. 3.) 
 
 But, it would be erroneous to refer the ex- 
 pulsion of the dead portion of bone to it, 
 since it can never be produced, before a 
 change has taken place in the structure of 
 bone, there being in fact no space for it to 
 grow in ; and hence, it is never seen before 
 the disunion of the parts has considerably 
 advanced. There must consequently be 
 some other power, which destroys the cohe- 
 sion between the dead and living bone, and 
 produces the groove, or interspace, in which 
 the soft granulations arise. Besides, among 
 other facts proving the falsity of the idea, 
 that the granulations push off the dead bone, 
 Weidmann particularly adverts to the occa- 
 sional exfoliations of the whole circumfer- 
 ence of a cylindrical bone. Here, if the 
 granulations had the power of causing a 
 disunion on one side, they could not have 
 the same effect on the opposite one ; but 
 would tend to make the contact more inti- 
 mate. 
 
 The separation also cannot be made by 
 the pulsation of the small arteries, nor by 
 the weak expansive motion of the vessels of 
 (he bone. Weidmann knows not what mo- 
 tives have induced certain writers to impute 
 the effect to suppuration, and observes, that 
 as the doctrine is not founded upon reason- 
 ing, it is superfluous to offer any arguments 
 against it. If the least attention be paid to 
 what nature really tries and accomplishes in 
 this operation, nothing will be more mani- 
 fest, than that it is completed in a very differ- 
 ent manner. Swelling first affects the peri- 
 osteum and bone, which by degrees softens. 
 
 ( Vid . Troja passim. Bonn. Thesaur. Oss.Mor- 
 bos, p. 122, and Weidmann de JYecrosi Ossiutn , 
 Tab. 4, Fig. 1, and 3.) At the margins of 
 the necrosis, the bony surfaces, which were 
 smooth, become rough, and irregular. A 
 fissure is there produced, which extends in 
 every direction under the piece of bone, that 
 is about to be detached. The bony texture 
 is also daily rendered less solid, so that the 
 number of adhesions between the dead and 
 living parts diminish, and in the end are to- 
 tally destroyed. Weidmann then explains, 
 that the true mode by which the separation 
 is effected consists in the absorption of the 
 particles, situated betwixt the livingand dead 
 parts of the bone, in such a way, however, 
 that the first loses a great deal of its sub- 
 stance ; the last, scarcely any thing. (P. 
 25.) After the dead bone has come away, 
 the swelling of the periosteum subsides, and 
 the living bone recovers its original hardness 
 and solidity. (Troja, p. 67.) 
 
 For a further account of the process, by 
 
268 
 
 NECROSIS. 
 
 which dead portions ot' bone are separated 
 from the living, see Exfoliation. 
 
 When dead portions of bone are separated 
 and loose, they still lodge in the cavities of 
 the ulcers, and, like all other extraneous bo- 
 dies, occasion irritation of the soft parts, and 
 keep up a discharge of matter. Sometimes, 
 however, nature of herself succeeds in ex- 
 pelling them. This happens in cases, where 
 the size and shape of the ulcer are calculated 
 to facilitate the issue of the dead bone, 
 which does not lie too deeply, and is pro- 
 pelled outward by its own weight. In ne- 
 croses of trivial size, indeed, it is asserted, 
 that the small fragments of bone may be 
 dissolved in the pus, and come away with it ; 
 {David ; Bousstlin , Hist, de la Society Royale 
 de Medecine, Tom. 4, p. 308 ; Weidmann de. 
 JYecrosi Ossium, p. 26;) but, such an event 
 can never be expected when the dead por- 
 tion of bone is at all extensive. 
 
 The last thing which nature does, is to re- 
 store the loss of substance w’hich the bone 
 has suffered. Although this operation is so 
 extraordinary and wonderful, that one might 
 be disposed to doubt its reality, numerous 
 examples, recorded in the annals of surgery, 
 prove not only its possibility, but, also, its 
 frequency. 
 
 In works referred to at the conclusion of 
 this article, the following authors speak of 
 the regeneration of a part, or the w hole of 
 the lower jaw-bone : viz. Bonetus, Bayer, 
 Guernery, Belmain, Acrel, Van Wy, Trioen, 
 Bonn, Reiplein, Desault, Henkel, and Dus- 
 saussoir. A student show r ed Weidmann a 
 lower jaw-bone, which had been thus rege- 
 nerated, and taken from the body of a man, 
 whom the latter distinguished writer had 
 been w 7 ell acquainted wdth. The bone could 
 not be freely depressed ; but, yet it per- 
 formed its functions tolerably well. 
 
 Moreau saw a case, in which the clavicle 
 was regenerated, and the new bone was pre- 
 sented by Dangerville, after the patient’s 
 decease, to the Academy of Surgery at Paris. 
 {De JYecrosi Ossium Theses , Prccs. F. Chopart, 
 resp. P. G. Robert , Parish's, 1776.) 
 
 Chopart had an opportunity of witnessing 
 the death and reproduction of a scapula. 
 
 Weidmann saw an instance, in wdiich 
 nearly the whole cylindrical shaft of the hu- 
 merus perished, and was afterw ard regene- 
 rated ; a phenomenon, that had been obser- 
 ved at earlier periods by Job of Mekren, 
 Cajetano Taconi, E. Blancard, Buhamel, 
 David, Acrel, Bcehmer, Cheselden, and Vi. 
 garoux, whose respective works are cited at 
 the end of this article. 
 
 Morand, Cheselden, and Bromfield pub- 
 lished engravings, respecting a reproduction 
 of the upper part of the humerus, where the 
 old dead bone was included in a sort of bony 
 tube. 
 
 Regenerations of the ulna have been ob- 
 served by Ruysch, Duverney, and Fowles. 
 (See Thesaur, X. JYo. 176. Trait6 des Mai, 
 des Os. Paris, 1751 ; and Phil. Trans. JYo. 
 312.) 
 
 A similar reproduction of the lower ends 
 of the radius and ulna was witnessed by Acrel. 
 
 {Chirurgische Vorfdllt von Murray, Vel. 1 ,p. 
 194.) 
 
 Similar reproductions of the thigh-bone 
 are recorded by Wedel, Battus, Koschius, 
 Hofmann, Scultetus, Diemerbroeck, Wright, 
 Fabricius Hildanus, Raw 1 , Dobyns, M‘Ken- 
 zie, Ludwig, David, Rousselin, Larrey, 
 Hutchison, &c. in publications specified at 
 the conclusion of this subject. 
 
 The followingcase of necrosis of the thigh- 
 bone is related by Dr. M‘Kenzie. William 
 Baxter, a boy thirteen years old, received a 
 blow on his thigh at school, of which he at 
 first hardly complained ; but, in a few 
 months, he began to have pain in the thigh, 
 which inflamed, swelled, and appeared to 
 have matter in it. The parents being poor A 
 no surgeon was called, and the boy was al- 
 lowed to linger for a great while. At length 
 the matter made its way through the skin, 
 by a small opening, on the interior part of 
 the thigh, about three inches above the knee, 
 and a thin sanies continued to be discharged 
 for eighteen or tw enty months. At length, 
 the hole in the skin enlarged, and the point 
 of a bone began to protrude, and give a good 
 deal of pain, when the clothes rubbed against 
 it. After suffering in this manner for two 
 years and a half, the boy, as he lay irj bed 
 one morning, felt the bone looser, and pro- 
 jecting more than ordinary. He gave it a 
 strong pull, and brought the piece a.vay en- 
 tirely, w hich proved to be seven inches and 
 a half of the thigh-bone. A good deal of 
 bleeding followed ; but, the w r ound soon 
 healed, and he has never since found the 
 least inconvenince. Dr. M‘Kenzie, hearing 
 of this singular case, sent for the boy, care- 
 fully examined his thigh, and found it as firm 
 as the other. The only difference was, that 
 it was somewhat thicker, and a little more 
 curved. The muscles retained their natural 
 softness, and looseness on the bone. The 
 detached piece of bone w r as a portion of its 
 whole circumference. (See Med. Obs. and 
 Inquiries, Vol. 2.) 
 
 We may infer, that the occurrence is more 
 frequent in the tibia than any other bone, 
 from the accumulated facts, mentioned by 
 Albucasis, La Marche, Muralto, De La 
 Motte, Ellinchuys, Ruysch, Tacconi, Laing, 
 Johnson, Hunter, David, Boehmer, Sigwart, 
 Th. Bartholine, Hofmann, Saviard, Le I >ran, 
 Duverney, Trioen, Gunther, Ludwig, Mi- 
 chael, Bousselin, Weidmann, Russell, 
 Whately, Desault, &,c. See the works refer- 
 red to at the end. 
 
 Dr. Hunter mentions a tibia which was 
 sent to him by a Mr. Inett, after amputation. 
 On examination, the case at first sight seem- 
 ed to be a swelling of the whole bone, with 
 a loose internal exfoliation. However, it 
 proved to be a remarkable instance of the 
 separation of the greatest part of the origi- 
 nal bone, whose place was supplied by a 
 callus. The external surface of the enclo- 
 sed loose piece of bone was smooth. A 
 small part of the surrounding bony substance 
 being removed, the contained piece was 
 taken out, and found to be the whole body 
 of the tibia. It had separated from the epi- 
 
Necrosis. 
 
 269' 
 
 pbysis at each extremity. The middle part 
 of the bone had perished, consequently, had 
 lost its connexion witli the periosteum, and 
 was gradually thrown off from the living 
 parts of the bone at each end. A callus ex- 
 tended from end to end, united the two ex- 
 tremities of the original tibia, preserved the 
 length, and gave firmness and inflexibility 
 to the part. The exfoliation was so encom- 
 passed by the new bony case, that though 
 quite loose, it could not be thrown out. 
 (Med. Obs. and Inq. Vol. 2.) 
 
 Weidmann saw a shoemaker, who, after 
 much suffering, extracted himself the great- 
 est part of the diaphysis of the tibia ; yet, 
 the loss wa3 so well repaired, that the man 
 could walk afterward nearly as ably as ever- 
 (De Necrosi Ossium,p. 29.) 
 
 “ We are not to imagine, (says Weid- 
 mann) that these regenerations happen by 
 chance : experiments made upon living ani- 
 mals by Troja, Blumenbach, Koehler, De- 
 sault, and myself, prove that they invariably 
 follow certain laws.” 
 
 In fact, whenever the medullary structure 
 of the long bones of pigeons, or dogs, is 
 destroyed, these bones become affected w ith 
 necrosis, and are afterward reproduced to 
 the full extent of their destruction. 
 
 The observations and experiments, cited 
 by Weidmann, also prove, that it is the long 
 bones which are usually reproduced ; though 
 the flat ones are not entirely destitute of the 
 power of regeneration, since experience 
 fully evinces, that, when a portion of the 
 skull is removed, either by a wound, by 
 disease, or by the trepan, nature always 
 endeavours to cover the deficiency, the 
 edges of the aperture extending themselves 
 by means of a bony substance, furnished by 
 the periosteum, the dura mater, and cranium 
 itself. (Tenon Mem. de l' Acad. des Sciences, 
 1758, p. 412, 413, 415, 416, 418.) But still 
 the reproduction is imperfect, as a space 
 unfilled up is always left, even when the 
 bone has lost only a small piece, like what 
 is taken out by the trephine ; and when the 
 destruction of the cranium is very extensive, 
 no reproduction at all happens. This fact 
 is proved by examples mentioned by 5avi- 
 ard,Pott, Sabatier, &tc 
 
 When in a case of necrosis, says Weid- 
 mann, a scale or table, of either a long or 
 flat bone, is separated, no regeneration fol- 
 lows, because the granulations, which rise 
 up under the sequestrum, then serve as a 
 periosteum, and as soon as the dead bone 
 19 removed, they become united to the ad- 
 jacent parts. 
 
 It is likewise ascertained, that the power 
 of reproduction in the bones is particularly 
 active in the early periods of life, and in 
 healthy subjects ; and that it is languid and 
 even annihilated in old persons, pregnant 
 women, (Bonm Thesaur. p. 174,) and in ve- 
 nereal. cancerous, and rickety patients. 
 
 ( Callisen , Syst. Chir. Hodiernce , Pars 1, p. 
 636.) 
 
 In order that a new bone may form, the 
 periosteum and other membranes, concern- 
 ed in the ^nutrition of the original bone, must 
 
 have been spared from destruction. In fact, 
 continues Weidmann, we observe that in 
 cases where the tube of a long bone has 
 suffered necrosis, the bone is never repro- 
 duced, when the periosteum has been de- 
 stroyed by inflammation or other causes. 
 Surgeons ought also to understand that it is 
 not always a reproduction which has hap- 
 pened, when a part of a bone perishes ; not 
 even when a tubular portion of a long bone 
 dies, and is contained in the medullary 
 canal. For, says \\ eidmann if the inner- 
 most layers of a long bone perish, while 
 those which compose, as it w ere, the bark, 
 are preserved, the latter swell and soften, 
 as if they were actually a new bone. Se- 
 veral round apertures are observable upon 
 their surface, w'hieh serve for the transmis- 
 sion of vessels, and are larger than those 
 which perform this office in the natural 
 state. There are likewise formed large 
 openings, or fistulae, which, as in a new 
 bone, lead to the medullary canal. Here 
 it would be erroneous to conclude that a 
 new bone has been produced, and a very 
 little attention will discover that all is limit- 
 ed to some changes in the external part of 
 the bone, which the necrosis has not 
 affected. 
 
 When, therefore, the interior of the canal 
 of a long bone is destroyed by a necrosis, 
 which does not extend to the external lay- 
 ers, the case is not a reproduction of the 
 bone. 
 
 When, however, w 7 e find the tube of any 
 long bone included in a sort of osseous shell, 
 and the surface of this tube smooth, like that 
 of a bone in the natural state, we may be 
 certain that it has been detached directly 
 from the periosteum, and that the bony 
 shell w hich contains it, is a new production. 
 On the contrary, if the surface of the dead 
 tube is rough, we may infer that the separa- 
 tion has taken place between the innermost 
 layers of the bone and those which are 
 superficial, the latter composing now the 
 osseous shell, in which the sequestrum is 
 included. (Weidmann De A r ecrosi Ossium, 
 p. 31*) 
 
 This fhst theory, concerning the produc- 
 tion of the osseus shell in necroses of the 
 long cylindrical bones, is adopted by Riche- 
 rand as the true one, not only in the in- 
 stances specified by Weidmann, but in every 
 other example w here the old bone seems to 
 be included in another which has the ap- 
 pearance of being a new’ production, and 
 which w as supposed by Troja, David, &c, 
 to be formed by the vessels of the perioste- 
 um. (See JYusographie Chir. T. 3, p. 158, 
 161, Edit. 4.) Boyer does not espouse this 
 theory exclusively ; but represents the thing 
 as sometimes happening. (See Traiti des 
 Mai. Chir. T. 3 ,p. 426.) 
 
 As far as the observations of Weidmann 
 informed him, the short or cuboid bones do 
 not appear to be capable of reproduction. 
 (P. 31.) Duverney mentions an astragalus, 
 w 7 hich was destroyed by necrosis , but does 
 not state that any substitute for it was after- 
 
270 
 
 NECROSIS. 
 
 ward formed. ( Trait6 des Maladies des Chir. 
 Os. p. 458.) 
 
 Weidmann also never witnessed a repro- 
 duction of the spongy substance, such as it 
 was before its destruction, round the me- 
 dulla. He always found the substituted 
 matter dense and compact, at least for some 
 time after its formation. 
 
 It is now admitted, however, that in pro 
 cess of time, the inner surface of the new 
 bone becomes cellular, and is lined with a 
 membrane containing medulla. The rege- 
 neration of the medulla was first observed 
 by Koehler, and afterward in an extensive 
 series of experiments, which Professor 
 Thomson made with Dr. Alexander McDo- 
 nald, and which were published in the lat 
 ter gentleman’s inaugural dissertation, in 
 1799. (See Thomson's Lectures on Inflam- 
 mation. p. 393.; Mr. Russel does not ap- 
 pear to adopt this opinion concerning the 
 regeneration of the medulla; for, he states 
 that, after the absorption or removal of the 
 sequestrum, the cavity of the new bone be- 
 comes filled up with granulations, which are 
 at length converted into bony matter Thus, 
 be says, the new bone differs from the ori- 
 ginal one, in being solid instead of hollow. 
 Authorities, however, are decidedly against 
 Mr. Russell on this point : in the 5th vol. of 
 the M6m de VAcad. de Chir. is the history 
 of a man, the whole of whose clavicle came 
 away without his being deprived of any of 
 the motions of the arm. The death of this 
 patient, which happened shortly afterward, 
 afforded an opportunity of examining how 
 nature had repaired the loss. Another cla- 
 vicle was found regenerated, which neither 
 differed from the original one in length nor 
 solidity ; but only in shape, being flatter, and 
 not so round. It was connected with the 
 acromion and sternum, just like the primi- 
 tive bone. 
 
 The power, which thus reproduces bones, 
 is only a modification of that which unites 
 fractures. Indeed, w hat consolidates bro- 
 ken bones, and is known by the name of 
 callus, presents all the characters of new 
 bone, begins and grows in the sarnejvay, 
 and may be impeded and retarded m its 
 formation by the same causes. (See Callus 
 and Fractures.) It is further highly probable, 
 as Weidmann remarks, that the power which 
 effects the reproduction of bones, is the 
 same as that, which. in the sound state, nou- 
 rishes and supports these*parts. But to what 
 organ appertains the function of reprodu- 
 cing bones ? 
 
 Many able men have ascribed the whole 
 work to the periosteum. (C. Havers; Du- 
 hamel, Mem. de l' Acad, des Sciences, 1739, 
 1741, 1742, 1747. Fougeroux, Mem. sur les 
 Os; Paris, 1760. Swencke , Hnrlemer Ab- 
 handlungen 1, th. p. 39. Berlin, Osteologie. 
 Marigues, Abhandlung von der Fatur und 
 Erzeugung des Callus, p. 199.) 
 
 Haller, ( Elem . Physiol. T. 8, p. 352.) 
 Callisen, ( Collect . Hafn. T. 2, p. 187.) Te- 
 non, ( Mem de VAcad. des Sciences, 1758 ,p. 
 415.) Bordenave, (Mem. sur les Os,p. 227) 
 and many others, have seen a part of the 
 
 new production spring up from the substance 
 of the old bone ; a thing, says Weidmann, 
 which one is also led to believe by the fact, 
 that, when the whole tube of a long bone 
 is affected with necrosis, the epiphyses 
 which remain sound and untouched, unite 
 and grow' to the new tube, though no peri- 
 osteum exists in the situation of the union. 
 
 Nor does Weidmann think that the speci- 
 men of a fractured thigh, of which Blumen- 
 bach has published an engraving, proves the 
 contrary. (Geschichte und Berschreibung der 
 Knocker; Gottingen, 1786, Tab. I, Jig. 1.) 
 This preparation exhibits an union which 
 had taken place by means of a very broa 
 osseous ring, encompassing the ends of th 
 fracture w hich lie far asunder. The even 
 appears to Weidmann to have been thi 
 result of rachitis, or lues venerea, with wdiic! 
 the young patient, according to Blumenbac' 
 himself, had been affected, and by whicl 
 the nutrition of this bone had been disorder 
 ed For, says Weidmann, in other exam 
 pies of united fractures, the ends of the bom 
 are so connected together by the callus, 
 that there does not exist a single point be- 
 tween them, where this substance is not 
 effused, and the medullary canal itself is 
 obstructed and filled with it. In the Journ. 
 Comptem. du Did. des Sciences Med. T. 8, 
 may be found some considerations, offered 
 by Larrey, against the doctrime that the 
 periosteum is the organ of ossification. 
 
 That, however, the periosteum is fre- 
 quently the organ of the reproduction of 
 the bones, seems proved by the experiments 
 of Troja, Blumenbach, Desault, and Koeh- 
 ler, since in these the bones were invariably 
 regenerated, though there was nothing left 
 of the old bone that could furnish the new 
 reproduction, except the periosteum. 
 
 If we examine the new bone, at different 
 periods of its developeinent, it appears in 
 the earliest state in the form of a redidsh 
 fluid, as has been observed by Duhamel. 
 Fougeroux, Bordenave, Haller, Callisen, 
 and others. If we also attend to the pro- 
 gressive changes which this fluid undergoes, 
 we cannot but believe that, as in the em- 
 bryo, an organic and fixed arrangement of 
 parts takes place. Indeed, it would be er- 
 roneous to consider such fluid as destitute 
 of organization and extravasated at random. 
 Thin and little in quantity on its first appear- 
 ance, its consistence and quantity afterward 
 gradually increase (Troja, p. 42, 44,) so 
 that what at first appeared like a liquid, 
 soon becomes a gelatinous substance, in 
 which are developed, especially at its inner 
 surface and towards its lower part, bony 
 fibres, which incessantly become more and 
 more numerous. These fibres in a short 
 time form little layers and cells, and extend 
 themselves every where, so that at length 
 all which was fluid disappears, and the new 
 bone is produced. While young, however, 
 it is still spongy and reddish, (Troja, p. 44;) 
 but soon becomes denser, harder, and more 
 solid, than that was for which it is a substi- 
 tute, and it acquires the ordinary colour o 
 the rest of the bones. 
 
NECROSIS. 
 
 271 
 
 The external surface of the new bone, 
 which, during the period of its formation, 
 was irregular, and studded with several ex- 
 crescences of various sizes, and pierced with 
 apertures of different dimensions, becomes 
 in the course of time smooth and regular, 
 especially after the expulsion of the seques- 
 trum. 
 
 The sides, or walls of the new bone which 
 at first were of considerable thickness, in 
 time also grow thinner. ( Truja , p. 21.) 
 When the entire dead bony cylinder con- 
 tinues in its cavity, the new bone is neither 
 shorter, nor longer, than the original. But, 
 should one of the ends of the dead tube 
 protrude from the cavity, while by the side 
 of the affected bone, there is not another 
 one capable of resisting the action of the 
 muscles, the new bone will be shortened, 
 and undergo some change in its shape and 
 direction. Indeed, says Weidmann, the new 
 bone in its early state, from want of con- 
 sistence, must yield to the efforts of the 
 muscles. 
 
 Its shape is not exactly like that of the 
 original bone: the sides are flatter; the 
 usual angles, depressions, and eminences 
 are not observable, and sometimes others 
 are formed. 
 
 How admirable is the process, by which 
 the muscles, detached from a bone affected 
 with necrosis, have other insertions given to 
 them, and are thus rendered capable of per- 
 forming their functions ! (Troja, p. 27.) 
 
 The periosteum, which swells as soon as 
 the exfoliation of the old bone commences, 
 shrinks, and is not at all thickened, when 
 the exfoliation is finished. Troja, having 
 destroyed the medullary structure of a long 
 bone, found the periosteum swelled at the 
 end of 36 hours; but he observed, that the 
 whole, of such swelling disappeared before 
 the 25th day. (P. 43, 67.) 
 
 The periosteum, which thus survives, ad- 
 heres to the new bone, as it did to the old 
 one : its vessels, which are now increased 
 in diameter, and convey a larger quantity of 
 blood, dive into large apertures in the re- 
 generated bone, ramify every where in its 
 substance, and nourish it. 
 
 Dr. Macartney’s observations nearly agree 
 with those of Troja and Weidmann, respect- 
 ing the formation of the new bone by ihe 
 periosteum, with this difference, however, 
 that he does not describe the original perios- 
 teum as becoming afterward attached to the 
 new bone, but as disappearing. Dr. Macart- 
 ney remarks, “ that the first and most im- 
 portant circumstance is the change, which 
 takes place in the organization of the perios- 
 teum ; this membrane acquires the highest 
 degree of vascularity, becomes considerably 
 thickened, soft, spongy, and loosely ad 
 herent to the bone. The cellular substance, 
 also, which is immediately connected with 
 the periosteum, suffers a similar alteration : 
 it puts on the appearance of being inflamed, 
 its vessels enlarge, lymph is shed into its 
 interstices, and it becomes consolidated with 
 the periosteum. These changes are prepara- 
 + orv to the absomtion of the old bone, and 
 
 the secretion of the new osseous matter, and 
 even previous to the death of the bone, 
 which is to be removed. In one instance, I 
 found the periosteum vascular and pulpy, 
 when the only affection was a small abscess 
 of the medulla, the bone still retaining its 
 connexion with the neighbouring parts, as it 
 readily received injection. The newly or- 
 ganized periosteum, &c. separates entirely 
 from the bone, after which it begins to re- 
 move the latter by absorption and, while 
 this is going on, its inner surface becomes 
 covered with little eminences, resembling 
 granulations. “ In proportion as the old 
 bone, is removed, new osseous matter is dis- 
 persed in the substance of the granulations, 
 whilst they continue to grow upon the old 
 bone, until the whole, or a part of it, is com- 
 pletely absorbed, according to the circum- 
 stances of the case. What remains of the 
 investment, after the absorption of the old 
 bone, and the formation of the osseous tube, 
 w T hich is to replace it, degenerates, loses its 
 vascularity, and appears like a lacerated 
 membrane. I have never had an opportuni- 
 ty of examining a limb, a sufficient time after 
 the termination of the disease, to ascertain, 
 whether the investment be at last totally ab- 
 sorbed, but in some instances, 1 have seen 
 very little remaining. During the progress 
 of the disease, the thickened cellular sub- 
 stance, which surrounded the original perios- 
 teum, becomes gradually thinner ; its vessels 
 diminish, and it adheres strictly to the new- 
 formed bone, to which it ultimately serves 
 as a periosteum.” Dr. Macartney states, 
 that the anatomical preparations, which au- 
 thenticate the above observations, are pre- 
 served at St. Bartholomew’s Hospital. (See 
 Crowther on Whitt Swelling, p. 183. Ed. 2.) 
 
 Mr. Stanley, however, lately showed me 
 in the same museum, a preparation, which 
 tends to confirm the accuracy of Troja's 
 account of the old periosteum becoming 
 adherent to the new bone. In this example, 
 the periosteum is perfectly continuous with 
 that covering the epiphyses. If this were 
 not the fact, w r e should have to explain iu 
 what way the periosteum of the new bone is 
 formed. We know that the vessels of the 
 original periosteum enter the new bone, in 
 order to complete its formation, and it seems 
 more consonant with the uniform simplicity 
 of nature’s operations, to suppose that this 
 connexion is kept up, than that the old 
 periosteum should be totally removed, after 
 the production of the new bone, and another 
 membrane of the same kind be then gene- 
 rated. 
 
 An interesting example of necrosis of the 
 thigh-bone, published some time ago by Mr. 
 C. Hutchison, tends also to prove, that the 
 new osseous shell is commonly formed by 
 the periosteum, as, in this case, the medulla- 
 ry bags, or cells, were found completely 
 ossified, ( Practical Obs. in Surgery , p. 135) 
 and could not therefore be supposed to be 
 capable of the work. Among the moderns, 
 also; Dr. McDonald deserves to be mention- 
 ed as one of the most distinguished advo- 
 cates for the truth of Troia’s explanation of 
 
.272 
 
 NECROSIS. 
 
 this subject. (See MDonald’s Thesis de 
 JYecrosi ac Callo ; Edinb. 1799.) Another 
 late writer has adduced many arguments to 
 prove that the pulpy mass, which extends 
 from one epiphysis to the other, and is itself 
 at last converted into bone, is formed quite 
 independently *>f the original bone, or the 
 periosteum. (See R ussell's Practical Essay 
 on Necrosis, p. 27, Edinb. 1795.) This ac- 
 count, however, is contrary to the observa- 
 tions of Troja, David, Weidmann, ATDouald, 
 Macartney, and numerous other observers. 
 Indeed, a modern author seems to think the 
 periosteum so essential to ossification, or the 
 production of a new bone, that he attempts 
 to explain the cause of fractures of the 
 patella not becoming united by a bony sub- 
 stance, by adverting to the deficiency of 
 periosteum upon it ; a circumstance which 
 lie deems also a strong argument against 
 Mr. Russells doctrine. (See Hutchison's 
 Practical Observ. in Surgery, p. 141, 142.) 
 
 These very same cases, however, fractures 
 of the patella, do sometimes unite by bone, 
 and, therefore, while Mr. Hutchison is urging 
 them as facts against Mr. Russell’s opinion, 
 Baron Larrey is actually adducing them in 
 its support. (See Journ. Compttm. du Did. 
 des Sciences. Med. T. 8.) The experiments 
 of Breschet and Villerme are decidedly 
 against the periosteum being exclusively 
 the organ of ossification. 
 
 Professor Boyer does not refer all the 
 work of reproducing bones exclusively to 
 the periosteum in every instance ; but joins 
 Weidmann in believing, that what seems a 
 new bone is sometimes only a separation 
 and thickening of the external layers of the 
 original bone, which have escaped destruc- 
 tion. He notices the modifications, to 
 which the phenomena of necrosis are sub- 
 ject when the disorder affects the whole 
 thickness, and the whole, or the greater pari, 
 of the circumference of a long cylindrical 
 bone. When the periosteum is destroyed 
 together with the bone, and the medullary 
 membrane, which does the office of an in- 
 ternal periosteum, is preserved, Boyer 
 represents the latter membrane as under- 
 going similar changes to those which we 
 have mentioned as taking place, under 
 other circumstances, in the external perios- 
 teum, and he describes it as becoming the 
 organ by which the new bone is formed. 
 (See Traiii des Maladies Chir. T. 3, p. 432.) 
 But when the whole thickness and circum- 
 ference of along bone are destroyed, together 
 with the medullary membrane, while the 
 periosteum survives, Boyer agrees with 
 Troja, kc. in believing the latter membrane 
 to be the means by which the new bone is 
 generated. 
 
 The internal surface of the new bone is 
 lined by a new membrane, which serves as 
 a periosteum, and is at first hardly distin- 
 guishable. ( Troja , p. 56.) In the early 
 state, it is soft and pulpy ; (ibid, p 22 .) but, 
 by degrees, it grows thicker and firmer, and 
 is at length converted into a true membrane, 
 which sends a great number of vessels into 
 jhe substance of the bone. When this mem- 
 
 brane is torn off, the surface, which it cover- 
 ed, is found somewhat smooth, the edges of 
 the bony layers, and projections of the fibres 
 being blunt and rounded 
 
 The cavity of the new bone includes, and 
 almost entirely onceals the dead fragments. 
 Sometimes, however, the new bone forms a 
 sort of bridge over the sequestrum, in such a 
 manner that the cavity is open above and 
 below, in both which situations the seques- 
 trum can be felt. ( Hunter , in Med. Obs. and 
 Inquiries Vol. 2, p 418.) 
 
 Sometimes, it is only a narrow cross-piece, 
 which forms the bridge retaining the seques- 
 trum. ( Weidmann . vid Tab. 5, Fig. 1, a.) 
 
 The new bone may also have an opening 
 in it, out of which the dead portion protrudes. 
 (lb. p 35.) 
 
 Sometimes the cavity of the new bone is 
 single ; while in other instances, there are 
 several successive cavities in the direction of 
 the length of the bone, with transverse 
 interspaces between them ; or else the cavi- 
 ties are situated laterally with respect to 
 each other, and divided by partitions. 
 
 ( Weidmann , 77*6.7, Fig 2.) 
 
 These cavities are proportioned in size 
 and shape to the fragments of dead bone, 
 w'hich lodge in them. It occasionally hap- 
 pens. that they open into some neighbouring 
 joint, and bring on suppuration there : a 
 very unfavourable complication. (Ibid.p. 
 34, and Tali. 6, Fig. 3; also , Boyer , Trail6 
 des Mai. Chi-. Tom 3 ,p. 435.) 
 
 Let us next follow Weidmann, and take 
 notice of the holes, by which the cavities, 
 including the dead pieces of bone, open 
 externally, which Troja denominated the 
 large foramina, and which the preceding ex- 
 cellent writer preferred calling the cloacae , 
 because they serve to convey outward the 
 matter and any separated pieces of bone. 
 In the beginning of the disorder, they are not 
 observable, a certain space of time appear- 
 ing to be requisite for their formation. They 
 are noticed in long cylindrical bones, whe- 
 ther original, or of new production, whose 
 cavities contain dead fragments. 
 
 These openings vary in number: when 
 the sequestrum is small, only one is found ; 
 but, when the piece of dead bone is exten- 
 sive, there may be two, three, or four. 
 Weidmann never saw' more than five. But 
 Troja met with eight. ( P . 58.) Weidmann 
 possessed a small portion of the diploe of 
 the os innominatum, which was affected 
 with necrosis, and contained in a bony 
 cavity, that had no external opening what- 
 ever. 
 
 When there are several distinct cavities 
 iu the same bone, containing dead frag- 
 ments, each cavity has at least one external 
 opening. 
 
 These cloacae, or apertures, are commonly 
 situated at the lower and lateral parts of the 
 cavities ; pass obliquely outwards; and com- 
 municate with fistulous ulcers, which open 
 on the surface of the skin. (David, p. 186.) 
 Some of the cloacas, however, form uttlie 
 middle, or (what is exceedingly rare) at the 
 upper part of the cavities, and proceeding 
 
NECROSIS'. 
 
 *2.73 
 
 outward, without any oblique track, go to 
 the front, back, or lateral parts of the limb. 
 
 They are of a round, or oval shape, or 
 nearly so. Their usual size is such, that it 
 will just admit a quill, and they vary very 
 little from this dimension. 
 
 They terminate internally by converging 
 approaching edges, in the manner of a fun- 
 nel ; while, on the contrary, the margins of 
 their outer extremity expand. The canal 
 between these two orifices is sometimes 
 long, sometimes short, and in certain cases, 
 of no extent at all. 
 
 Different opinions have been broached, 
 respecting the causes which produce the 
 apertures in the new bone, termed by YVeid- 
 mann the cloaca. 
 
 M. David says, that the pus collecting in 
 an eariy stage of the disease between the 
 bone and periosteum, distends and corrodes 
 this membrane, and that the openings which 
 form in it become afterward a cause of fis- 
 tulas in the new bone. (P. 186.) But it is 
 observed by Weidmann, that this explana- 
 tion is inadmissible, since the existence of 
 the collection of pus, mentioned by M. Da- 
 vid, is not proved by observation : in fact, 
 it was never met with by Troja, Blumen- 
 bach, Desault, Koehler, and many others, in 
 repeated experiments made on the subject. 
 (Troja, p. 56 and 66 ; Weidmann , p. 36.) 
 
 Koehler thought he had seen the new bone 
 itself destroyed by the pus, and cloaca thus 
 produced. (P. 68 — 72.) 
 
 YVeidman, however, deems this opinion 
 quile as improbable as the preceding, for 
 the fact of the surface of these bony aper- 
 tures being always smooth, always formed 
 in one manner, and constantly lined by the 
 periosteum, decidedly proves that they can- 
 not arise from erosion. 
 
 Troja, in his third experiment upon the 
 regeneration of bones, remarked, that forty- 
 two hours after the destruction of the me- 
 dulla, there took place, between the bone 
 and the periosteum, an effusion of lymph, 
 which was at first thin and little in quantity, 
 but afterward became thicker. He noticed, 
 in the midst of this gelatinous substance, some 
 small spaces , where il teas deficient, and which 
 had. instead of it, a subtile, whitish, dry in- 
 crustation, which, though tolerably adherent , 
 could be rubbed ojf. These small spaces, ac- 
 cording to Troja, produce, the apertures called 
 the cloaca. ( Troja, p. 45.) 
 
 In another experiment, he had an opportu- 
 nity of examining the above little spaces 
 at the end of forly-eight hours ; he affirms, 
 that they were replaced by the large aper- 
 tures, or cloacae, of the new bone (P. 47 ;) 
 and that such openings were invariably 
 formed in the place of the small incrusted 
 spaces already described. (P. 58.) As 
 Troja took notice that no lymph was effused 
 at these particular points, he was inclined to 
 impute the circumstance to adefect in the os- 
 sification, and, perhaps, to the death of some 
 ]iartsif the periosteum. Weidmann acknow- 
 ledges, thai the mode, in which the lorma- 
 tion of the cloacee happens, is exceedingly 
 obscure ; and expresses his belief, that 
 
 Vot II 35 
 
 Troja’s account of it approaches the nearest 
 to the truth. But, says he, one thing is cer- 
 tain, namely, that these openings have no 
 other use, but that of conveying outward 
 the pus which collects in the cavity, and 
 the small bony fragments, since, as soon as 
 every atom of dead bone has passed out, 
 they diminish, and, at length, are lotally 
 obliterated. ( W eidmann Dt JYecrosi Ossi um , 
 p. 36.) 
 
 It is a remarkable circumstance, in the 
 history of necrosis, that, in favourable in- 
 stances of the disease, the inflexibility and 
 firmness of the limb are preserved during 
 the whole of the process, by which the new 
 bone is formed. Consequently, the new 
 bone must have begun to grow, and have 
 acquired firmness before the old bone sepa- 
 rates, «r is absorbed. Were this not the 
 case the limb must become flexible and use- 
 less, the moment the dead bone is removed. 
 Another consequence of the new bone being 
 formed, before the removal of the old one, 
 is that the former must surround and include 
 the latter. For, since the lifeless portion of 
 bone completely occupies the space between 
 the two living ends, these cannot be imme- 
 diately connected by the new bony matter. 
 The connexion can alone be completed by 
 the new bone being deposited on the outside 
 of the old one, from one end to the other, and 
 attaching itself to the portions which still 
 remain alive. The new bone must also be 
 necessarily larger than the old one, because 
 externally situated, and hence the affected 
 limb, after the cure is complete, will always 
 continue larger, clumsier, and less shapely 
 than the other. The length of it, however, 
 remains unaltered, because the old bone re- 
 tains its attachment, while the rudiments of 
 the new bone are lying on its outside, and 
 connect the living ends of the old one, by 
 an inflexible mass, equal in length to the 
 portion which is destroyed. 
 
 Thus we see, that, in the process which 
 nature follows in the formation of the new 
 osseous shell, the old bone serves as a mould 
 for Ihe new one, and the first stef) of the 
 process is to surround the old bone with an 
 effusion of coagulating lymph. (See Russell 
 on Necrosis, p. 2 — 7.) 
 
 When the sequestrum isthrow'n off slowly, 
 the inflammation is moderate ; but when it 
 separates quickly, while the new bone is in a 
 soft stale, the detachment is always preceded 
 by severe inflammatory symptoms, and fol- 
 lowed by a temporary loss of the natural 
 firmness of the limb. This premature sepa- 
 ration of the sequestrum often occurs in ne- 
 crosis of the lower jaw, and the chin conse- 
 quently falls down on the neck. In certain 
 cases, the sequestrum separates at each end 
 from the living portions of the old bone, 
 before the new osseous shell has acquired 
 firmness, so that the limb feels as if it were 
 broken in two places. (Russell.) 
 
 Let us next consider the states and circum- 
 stances of necrosis, in which the art of sur- 
 gery may be advantageously exerted in the 
 assistance of nature, and the means which 
 may be employed for this purpose. 
 
NECKUS1S. 
 
 A common error of medical and surgical 
 practitioners is always to impute the cure of 
 every disease to whatever remedies happen 
 to be employed, and successes are loo oiten 
 boasted of, the merit of which belongs en- 
 tirely to nature. It is, indeed, not very u»- 
 frequent to hear remedies panegyrically 
 spoken of, which counteract the salutary 
 efforts of nature, who, in this case, is obliged 
 to overcome both the disease, and the i> ra- 
 tional treatment, which is applied to it. As 
 Weidmann observes, this erroneous mode of 
 considering things has happened particularly 
 often among surgeons who have bad cases 
 of necrosis under their care, all of whom 
 boast of the cures which they have accom- 
 plished, although some employed absorbent 
 earths, others, aromatics ; some, spirituous 
 applications ; others, balmy remedies ; some, 
 acids; others, caustics; and some, armed 
 with a wimble, made numerous perforations 
 in the dead bone ; while many others rasped 
 the part, or attacked it with the trepan, cut- 
 ting forceps, the gouge and mallet, or even 
 the actual cautery ; and a certain number 
 did nothing more, than apply dry lint. Na- 
 ture, who was favourable to all, did her ow n 
 work in silence, whatever were the remedies 
 employed for her assistance, whether mild 
 and inert ; acrid and corrosive ; or hurtful 
 and improper. 
 
 We have already noticed, that a dead 
 portion of bone separates from the living 
 exactly in the same way, as gangrenous soil 
 parts spontaneously drop off, without the 
 interference of art. The separation happens 
 precisely at the points to which death has 
 extended ; limits, w hich are w ell understood 
 only by nature, and of course can be mea- 
 sured only by her. Art w ould incur great 
 risk of either going beyond them, or else of 
 not reaching them at all. Perhaps, it may 
 be deemed unsafe to confide the process of 
 separation, or exfoliation, to nature. Bui, 
 in what other manner could it be more safely 
 accomplished, without hemorrhage, or pain 
 to the patient — w'itbout any risk of a recur- 
 rence of inflammation, or of a fresh necrosis? 
 
 Is there reason to fear, that when every 
 thing is left to nature, the separation cannot 
 be finished till after a very long period of 
 time ? It is true, say Weidmann, that the 
 process frequently requires a considerable 
 time ; but, as the vitality of the bones is not 
 possessed of much energy, and their compo- 
 nent parts strongly cohere, slow ness is in- 
 evitable in an operation, which depends 
 entirely upon the vital power. What is it 
 then which surgery can do to accelerate the 
 process ? 
 
 Will any of the above-mentioned topical 
 applications have this effect ? They are put 
 upon the inert surface of a dead piece of 
 bone, in which no vital power, or action, 
 can be again excited. When acrid, they 
 prove irritating, inflaming, and destructive of 
 the neighbouring flesh, without any utility — 
 and cause pain to the patient, which is com- 
 pensated by no good. Would the perfora- 
 tions, recommended by Celsus,Belloste, and 
 many others,, have the desired effect ? If, 
 
 says Weidmann, they are confined to the 
 dead hone, they cannot have more effect, 
 than the scarifications, which were formerly 
 practised by ignorant surgeons in cases of 
 gangrene ; and, if they extend to the living 
 bone, this will be injured or at least run the 
 risk of being so. Lastly; Weidmann demands, 
 if the separation can be accelerated by the 
 actual cautery, which cannot act upon every 
 point of the necrosis, and which, unless 
 applied with the greatest precautions, will 
 burn the subjacent parts, and bring on a 
 new attack of inflammation, without for 
 warding the exfoliation in the smallest de- 
 gree ? 
 
 Of what use can rasping and scraping in 
 struments be, which act merely upon the ' 
 dead part ? Or will the gouge, and other 
 cutting instruments, do more good? They 
 cannot take away the whole of the dead 
 portion, w ithout injuring the adjacent living 
 bone, and causing a risk of another necrosis . 
 And, if they leave any pieces of the old 
 dead bone behind, nature will be as long in 
 effecting the separation of these, as she 
 would have been in detaching the entire ne- 
 crosis. 
 
 Weidmann mentions a case, w hich occur- 
 red in the hospital of St. Roch at Mentz. A 
 man’s legs were seized with mortification, in 
 consequence of exposure to cold ; the whole 
 of the dead parts separated ; and the bones 
 were sawn through on a level with the 
 living flesh. A portion of the end of each 
 bone, however, was afterward thrown oft 
 altogether by nature, and Weidmann thence 
 concludes, that the previous use of the saw- 
 had been fruitless. Weidmann then cites 
 another case of mortification of the leg and 
 half of the thigh, which was the conse- 
 quence of a putrid fever. The leg sloughed 
 aw r ay, leaving the lower portion of the thigh 
 bone uncovered and projecting. Under a 
 tonic plan of treatment, this part of the 
 bone spontaneously separated. As, however, 
 a considerable quantity of integuments had 
 been destroyed, the ulcer was slow- in heal- 
 ing ; but, it cicatrized at last, and the young 
 woman continued well long afterward. 
 
 Weidmann has quoted the memorable case, 
 in which Mr. Charles White first sawed oft' 
 the upper part of a diseased humerus. (See 
 Amputation.) As, in this instance, nature 
 accomplished of herself the separation of 
 another dead portion of the same bone, two 
 months after the operation, Weidmann seems 
 disposed to think the cure would have hap- 
 pened equally w r ell without it. 
 
 In cases of slight superficial necrosis, sur- 
 geons have frequent opportunities of trying- 
 every kind of topical application ; and when 
 the cure takes place, during the use of any 
 of them, the benefit is ascribed to whatever 
 happens to be in use. But, says Weidmann. 
 in numerous more serious examples of ne- 
 crosis, itis impossible to make these applica- 
 tions reach the whole surface of the dead 
 bone; but, notwithstanding this circum- 
 stance, the separation is not impeded. Some 
 exfoliations happen, without our knowing of 
 their occurrence, nnrl without a thought 
 
.NECROSIS 
 
 2 75 
 
 navingbeen entertained of promoting them 
 by any vaunted applications. We even see 
 necrosis separate, whose situation rendered 
 them inaccessible to our remedies ; such are 
 the necrosis, which occur within the long 
 bones, and comprehend the whole of their 
 cylindrical shaft or body. What surgeon 
 shall presume to boast of his having etfected 
 by topical applications, the separation of the 
 whole lower ja w-b one . atiiing, w-iich nature 
 has very frequently accomplished ? And, 
 when, as often happens, the entire diaphysis 
 of the thigh-bone, tibia, or other long bone, 
 comes a. tv; or, split longitudinally, such 
 bone loses \ half of its cylinder ; h -w is it 
 possible for any topical applications to reach 
 every point, at which the separation occurs ? 
 
 The internal remedies, such as assafcetida, 
 madder, sarsaparilla, hemlock, belladonna, 
 oaopordum, lime-vvater, &c. recommended 
 by numerous practitioners, have in reality 
 no direct efficacy in promoting the separa- 
 tion of necrosis : if, says Weidmann, they 
 do any good, it can only be by their tonic 
 and alterative qualities, or rather by keep- 
 ing the patient amused, so as to gain the re- 
 quisite time for the completion of the pro- 
 cess of exfoliation. The employment of all 
 these ineffectual means, Weidmann con- 
 ceives, must have originated from ignorance 
 of the process, followed by nature in separa- 
 ting dead portions of bone, and from ascri- 
 bring to the arterial puisations or the power 
 of the granulations, what certainly depends 
 upon the action of the absorbent vessels. 
 
 A < aestion here naturally presents itself. — 
 Wou J there be any utility in exciting by 
 stimulants the action of the lymphatic ves- 
 sels, in order to accelerate the separation, of 
 which it is the efficient cause ? 
 
 Weidmann thinks, that very beneficial 
 effects might result from the plan. But, he 
 asks, what means should be used for this ob- 
 ject ? Cold ? Purgative medicines ? Repeat- 
 ed vomits ? Squills ? Camphor r Neutral 
 Salts ? Issues ? (Fi’d. Wrisberg, Comment , Soc. 
 Reg. Gotl. Vol.9, p. 136, 1789.) He adds, 
 that, perhaps, many valuable discoveries will 
 hereafter be ma le on this subject. 
 
 The reasons already detailed, and a varie- 
 ty of experiments successfully made by Weid- 
 mann, lead him to set it down as an esta- 
 blished principle, that the separation of a 
 necrosis is almost entirely the work of nature, 
 and that surgery tan do very little in the 
 business. 
 
 Ignorance of this important fact paved 
 the way to the wrong practice of making 
 incisions, for the purpose of exposing the 
 whole surface of a necrosis, immediately 
 the existeuce of the disorder was known. 
 As such incisions very soon closed up again, 
 so as to leave only a small outlet for the 
 matter, they were in many cases repeated- 
 ly practised before the dead bone became 
 loose. 
 
 The avowed design of the incisions was 
 to make room for the topical remedies, which 
 w ere to render the exfoliation quicker ; but, 
 as these remedies possess no real efficacy, 
 it follows, that making incisions, before the 
 
 dead bone is loose, only torments the patient, 
 without producing the least benefit. 
 
 The orifices of the ulcers, then, which 
 allow the discharge to escape freely, are, 
 says Weidmann, sufficient as long as the frag- 
 ments of bone are not entirely detached, 
 and. the surgeon should all this period ab- 
 stain from the use of the knife. 
 
 Although Weidmann condemnsevery mode 
 of treatment, which is inefficacious, painful, 
 and sometimes even hurtful, he would not 
 hwe it supposed that he altogether rejects 
 all assistance from medicine. On the con- 
 trary, he approves of all those means, which 
 are consistent, with - the views of nature, 
 which ireally assist her. and do not tease the 
 patient to no purpose. In short, says he, the 
 indications are limited to removing the origi- 
 nal cause of the disease ; to alleviating the 
 symptoms ; to supporting the patient's strength, 
 and improving the state of the constitution , in 
 whatever respect it may be bad; and , lastly, 
 removing the dead portions of bone, when they 
 become loose. 
 
 Above all things (continues this sensible 
 practitioner) the surgeon must not regard 
 every piece of exposed bone, as necessarily 
 affected with necrosis, and, in consequence 
 of such idea, have recourse to acrid, dry- 
 ing caustic applications. Such means are 
 not only useless, but absolutely pernicious; 
 because they may actually cause a necrosis, 
 which did not exist, before they were used, 
 and which would not have taken place at 
 all, if only mild simple dressings had been 
 employed. 
 
 VYT . the disease presents itself with vio- 
 lent symptoms, the inflammation and fever 
 being intense, the severity of the case is to 
 be assuaged by low diet, antiphlogistic reme- 
 dies, emollient applications, and venesection 
 in moderation, the disease being one which 
 is of long duration, and apt to wear out the 
 patient’s strength. Here, perhaps, topical 
 bleeding ought always to be preferred to 
 venesection. When the necrosis has arisen, 
 from syphilis, scrophula, or scurvy, &c. the 
 medicines, calculated for the cure of these 
 affections, must be exhibited, ere any fa- 
 vourable changes can be expected in the 
 state of the diseased bone. 
 
 Lastly, it is the duty of the practitioner to 
 extract the fragments of dead bone, in order 
 Ihat the deficiencies produced by them may 
 be filled up, and the ulcers of the soft parts 
 heal. 
 
 Nature, who succeeds by herself in detach- 
 ing the dead pieces of bone, can do very 
 little in promoting their passage outward. 
 Frequently, indeed, she has no power at all 
 in this process, and it is only from surgery 
 that assistance can be derived. When a 
 dead piece of bone is still adherent at some 
 points, its extraction should be postponed, 
 until it has become completely loose. If it 
 were forcibly pulled away, there would he 
 danger of leaving a part of it behind, which 
 must have time to separate, ere the cure can 
 be accomplished. 
 
 But, when a fragment is entirely detached, 
 and the orifices of the sores are sufficiently 
 
NECROSIS 
 
 276 
 
 large, it is to be taken hold of with a pair of adherent to the adjacent parts ; and, if they 
 forceps, and extracted. 
 
 When the ulcer has only a very narrow 
 opening, suitable incisions must be practised, 
 
 • fv. fsw.ilitatft th« removal of the Toosf 
 
 in order to facilitate the removal of the foose 
 dead bone. 
 
 Sometimes, the dead fragment protrudes 
 from the ulcer, and projects externally, so 
 that, if loose, it admits of being taken hold 
 of with the fingers, and removed. In this 
 way, Weidmann took away a large dead 
 piece of the humerus, which protruded near- 
 ly two inches out of an ulcer in the middle 
 of the arm. The patient was a young lad, 
 14 years of age ; and the limb concave 
 within, convex externally, thicker, and one 
 inch shorter than its fellow. He got quite 
 well three weeks after the removal of the 
 dead bone. 
 
 delay too long, the patient may be irreco- 
 verably reduced, while the new bone, on 
 account of the hardness which it has 
 now acquired, cannot be so easily perfora- 
 tecf 
 
 Patients are met with, who have been 
 afflicted with necrosis several years. In 
 such cases, great circumspection is necessa- 
 ry, and the practitioner should carefully 
 endeavour to ascertain, that the dead pieces 
 of bone have not been absorbed, or come 
 away piecemeal in the discharge, lest an 
 useless operation should be done, as once 
 happened in the practice of M. Bousselin. 
 (M6m. de la Sucirte Royale de Mddecine, T. 4, 
 />.304.) Therefore, when the disease is of 
 long continuance ; when the discharge is 
 much less than it v\ as at the commencement ; 
 
 We have already adverted to the example, when small pieces of bone have at times 
 recorded by Weidmann, in which a shoe- been voided ; and the sequestrum cannot 
 maker removed by himself nearly the whole be felt with a probe; it is doubtless, says 
 body of the tibia. " Doubtless, the projection Weidmann, most prudent to abandon all idea 
 of the bone, and its looseness, enabled the of operating, and allow nature to finish what 
 
 man to do this easily with his fingers. But, 
 there are cases, which present more difficulty ; 
 such arc those, in which the sequestrum is 
 included in a cavity, either of the original, 
 or new bone. 
 
 she has so well begun. In short, when the 
 sequestra are undergoing a gradual absorp- 
 tion, without ever making their appearance 
 externally, or giving any considerable dis- 
 turbance to the constitution, or, w hen the 
 
 The old surgeons were in the habit of am- dead bone is making its way outward, with 
 putating limbs which were in this state; out occasioning urgent inconveniences ; the 
 although instances were not wanting in their surgeon should interfere very little with the 
 days to prove the possibility of relieving the natural progress of the case. When the 
 disease, w ithout amputation. Thisbiamable dead bone does not tend to make its way 
 custom of removing every limb, thus affect- through the skin, but lies quietly concealed 
 ed, is justly exploded from modern surgery, in the new osseous shell, the occurrence of 
 Aibucasis was the first who attempted to extensive suppurations may be prevented, 
 
 cure such a case of necrosis, by the judicious 
 employment of the knife and saw. (Lib. 2, 
 cap. 88.) The same kind of practice wms 
 successfully adopted in iwo instances by the 
 celebrated Scultetus. vSee Armament Chi- 
 rurg. Tab. 46, and Obs. 81.) This commen- 
 dable method, however, afterward fell into 
 disuse, until M. David, by twenty examples of 
 success, refuted all the objections which had 
 been urged against it. (P. 197.) Since the 
 
 by occasionally applying leeches, and keep 
 iug open a blister w iih the savine cerate, as 
 recommended by Mr. Abernethy in his lec- 
 tures, and Mr. Crowther, in his work on the 
 White-Swelling. The blister will, at the 
 same time, have great effect in promoting 
 the absorption of the sequestrum, and, 
 of course, in accelerating the process of 
 cure. 
 
 If the surgeon operate as soon as the se- 
 period of this distinguished author, the prac- questrum becomes loose, he will find the 
 tiee has been imitated by all enlightened new bone so soft, that it can be divided with 
 surgeons, so that the case is no longer re- a knife ; a circumstance, which materially 
 warded as a disease necessarily requiring facilitates and shortens the operation, 
 amputation. M. Bousselin has cut out the Keeping in mind the foregoing precepts, 
 sequestrum eight times from the tibia, and the surgeon is to begin with exposing the 
 four times from the thigh-bone, with per- bone in which the sequestrum is contained, 
 feet success. ( Rid J\I6m. de la Society Royale 
 de M6decine, Tom,. 4.) 
 
 The method consists in exposing the bone, 
 and making in it an opening of sufficient 
 size for the removal of the loose dead frag- 
 ments. 
 
 Experience has proved, not only that, 
 
 When the bone lies immediately under the 
 skin, Weidmann recommends making such 
 incisions as will lay bare the whole of its 
 surface, and when its situation is deeper 
 beneath the muscles, he even sanctions cut- 
 ting away as much of the flesh as may be 
 necessary to allow the instruments to be 
 
 patients affected with necroses, easily bear freely worked upon the bone. I cannot, 
 
 this operation, but also that after its perform- 
 ance, the ulcers commonly heal very 
 favourably, the health becomes re establish- 
 ed, and the functions of the part affected are 
 hardly at all impaired. 
 
 Surgeons, however, are not indiscriminately 
 to choose any period for doing the operation. 
 If they are too hasty, they will run a risk 
 of finding the dead portion of bone still 
 
 however, see the propriety of this advice ; 
 exposing the wdiole surface of the bone in 
 the first instance, before it is known whether 
 the saw need be so extensively used as to 
 require such a denudation, certainly appears 
 irrational. And, as for cutting away any 
 portions of muscle, this can be no more ne- 
 cessary here, than it is in the operation of 
 trephining. But it is unquestionably proper 
 
Necrosis. 
 
 to make with the bistoury sufficient space 
 for the use of whatever instrument is em- 
 ployed for the division of the bone. Yet it 
 is only necessary to make this exposure in 
 the first instance in one place. The surgeon 
 can afterward enlarge the incision or prac- 
 tise others, as circumstances may indicate. 
 The surface of the bone being brought into 
 view, if the cavities, in which the dead frag- 
 ments lodge, present apertures which are too 
 nariow, these apertures must be rendered 
 larger by means of small trephines, or saws 
 constructed on the principles of those des- 
 cribed by Mr. Hey of Leeds. The perpen- 
 dicularly acting wheel-like saw, turned by 
 machinery, and invented by Mr. Machell, 
 here promises also to be of important assist- 
 ance. It has been used by Sir Astley Coo- 
 per, who has given an engraving of it in bis 
 Surgical Essays. Part I. PI. 8. Fig. 7. And 
 another saw, constructed on somewhat si- 
 milar principles, has been employed by 
 Graefe of Berlin with great advantage for 
 several years. A tract, giving an account 
 of it, was sent to me by the late Dr. Albers, 
 a little before his death ; but as I have now 
 lent the publication to Mr. Stanley for the 
 purpose of assisting Mr. Evans in the con- 
 struction of the instrument, I shall merely 
 add, that Graefe’s saw is turned by a handle 
 which projects horizontally from the cutting 
 part of the instrument and that it has a 
 frame or fulcrum, on which it works With 
 such instruments the pieces of bone extend- 
 ing across the above openings, and imped- 
 ing the extraction of the sequestra, may also 
 be removed. 
 
 But when the preceding cavities are closed 
 on every side, and it is impossible to reach 
 into them in any other way, than through 
 the cloacae, a trephine is to be applied, 
 which must comprise within its circle a half 
 of the fistulous opening. The crown of the 
 trephine, however, must not be broader than 
 the cavity of the bone, nor yet narrower 
 than the sequestrum. 
 
 If, after making a perforation in this man- 
 ner, the sequestrum should be found too 
 large to pass through the opening, a small 
 saw must be employed for enlarging the 
 aperture, * * 
 
 When the bone is so hard and thick that 
 it cannot be well cut with a saw, the sur- 
 geon has the sanction of authority and ex-./ 
 perience, for using a gouge and mallet. 
 
 When the sequestrum is found to be very 
 large, it will be necessary to expose more 
 of the surface of the bone by incisions. In 
 this sort of case, Weidraann recommends 
 applyingthe trephine to the upper and lower 
 parts of the cavity, and then cutting away 
 the intervening portion of bone with the 
 saw or gouge. But there can be no doubt 
 that a more prudent way would be to goon 
 with the enlargement of the aperture in the 
 bone, at the place where the first perforation 
 took place, if the sequestrum presented it- 
 self equally well there, because, by pro- 
 ceeding in this manner, the surgeon might 
 discover that the dead fragment could be 
 taken out without so great a destruction of 
 
 bone as is caused in the other mode ; and, 
 if this were not to be the case, no harm is 
 done, as the necessary removal of bone can 
 be continued. 
 
 When the bone, which includes the se- 
 questrum, is a new production, and the ope- 
 ration is not too long deferred, the soft state 
 of the bone will enable the operator to 
 perform the needful excisions with the 
 bistoury alone. 
 
 When the sides of the cavity, in the ori- 
 ginal bone, are thin, fragile, and pierced 
 with numerous holes, the surgeon can break 
 away a sufficient portion with a pair of for- 
 ceps. 
 
 When several sinuses exist in the bone, 
 each may be dilated, in the manner which 
 seems most advantageous. 
 
 Sufficient openings having been made into 
 the cavities including the sequestra, the 
 next object is to extract these dead portions 
 of bone. In accomplishing this part of 
 the operation, Weidmann particularly ad- 
 vises two things; first, that no piece of the 
 sequestrum be left behind; secondly, that 
 no injury be done to the membrane, which 
 lines the cavity in which the dead bone is 
 lodged. 
 
 This author observes, that there are ex- 
 amples, in which the vicinity of certain 
 parts impedes the surgeon from making an 
 opening in the bone, large enough for the 
 extraction of a voluminous sequestrum in 
 an entire state. In this circumstance, he 
 recommends the sequestrum to be broken 
 into pieces by any convenient means, and 
 the fragments to be separately removed. 
 
 Weidmann has recorded an extremely in- 
 teresting case to prove how much may 
 sometimes be effected by taking away the 
 sequestrum. A man, 34 years of age, who 
 had an internal necrosis of the tibia, with 
 abscesses and cedema of the whole limb, 
 and who Was reduced to the lowest ebb of 
 weakness, was put under this excellent sur- 
 geon’s care. A perforation was made with 
 a trephine in the upper head of the tibia ; 
 but, this opening not proving ample enough, 
 it was enlarged with a small saw', and a 
 gouge and mallet. The sequestrum was 
 then extracted. The patient’s state after- 
 ward gradually' improved, and in nine 
 months he was completely well. 
 
 It is not to be dissembled, however, that 
 cases do exist, in which amputation affords 
 the only chanco of saving the patient’s life. 
 In fact, it sometimes happens, that the cavi- 
 ties, in which the sequestra are contained, 
 communicate with those of the neighbour- 
 ing joints, which then become filled with 
 matter, and caries attacks part of the bones, 
 to which the necrosis does not extend. On 
 some occasions, the dead pieces of bone 
 are very numerous, and each has a sepa- 
 rate cavity ; while, in other instances, me 
 sequestra lie so deeply, that a passage for 
 their extraction cannot be prudently at- 
 tempted. Sometimes, also, a necrosis is 
 complicated w ith another disease in its vi- 
 cinity. Lastly, such may be the reduced 
 state of the patient’s health, and the parti* 
 
NKCKGSIS. 
 
 ::s 
 
 cular condition of the necrosis itself, that 
 the constitution cannot hold out during the 
 whole time which would be requisite for 
 the detachment of the sequestrum. Under 
 circumstances like these, amputation is ne- 
 cessary, and ought not to be delayed. 
 
 For the authorities of many of the obser- 
 vationsand cases in the foregoingarticle, and 
 for additional information on the subject, see 
 Albu casts, lib. 2, cap. 88. Scultelus , .firma- 
 ment. Chir. Tab. 46, and Obs. 81. Belloste , 
 Le Chirurgien d' Hdpital, part 1, chap 12. J. 
 Louis Petit , Traite des Mi ladies des Os, 
 Tom. 2, chap. 16. Monro's Works by his 
 Son. Tenon in M6m. de l' Acad, des Sciences, 
 1758. Aitken, Systematic Elements of the 
 Theory and Practice of Surgery, Edinb. 
 1779, p. 288. Some interesting cases and re- 
 marks, chiefly about the question of amputa- 
 tion, are contained in Schmucker's Vermischte 
 Chir. Schriften. B. 1, p. 17, \c. Ed. 2. Cal- 
 lisen, Sy sterna Chirurgice Hodiernce, Vol. 2, 
 p. 893, Gott. 1800. C. White, Cases in Sur- 
 gery, London, 1770, p 57, fyc. Wrisberg, 
 Comment. Soc Reg. Gott. Vol. 9, p. 136, fyc. 
 Boussclin, in Mem de la Society Royale de 
 Medecine, Tom. 4. Louis, in Mem. de l' Acad, 
 de Chirurgie, Tom. 5. Chopart, Dissert, de 
 Necrosi Ossium, Paris, 1776. David, Obs 
 sur une Maladie connue sous le nom de JYd- 
 crose, Paris, 1782. Poll's Chirurgical Works, 
 Land. 1779, Vol. 1 ,p. 32. Bloomfield's Chir. 
 Cases and Observations, Vol. 2, p. 9. C G. 
 Kortum, Comment, de Viiio Scrofuloso. Lem- 
 govice, 1789, T. 2, part 3, cap. 11. Knolli, 
 Dissert, de Carie Ossium venerea ; Lips, 1763. 
 S.G.Rcederer Progr. de Ossium Vitiis Observa- 
 / iones continens ; Goetling(e,\760. Lind's Trea- 
 tise on the Scurvy, Fabre in M6m. de VAcad. 
 de Chir. T.4,p, 91. Bonn's Thesaurus Ossium 
 Morbos Bond, Med. Septentr. L. 2, Sect. 4. 
 cap. 25. Ephemer. Acad. Nat. Cur. Ann. 7 
 el 8, obs. 4. Guerney, in M6m. de I' Acad, de 
 Chir. Tom. 5, in 4 to. p. 355 — 368. Belmain, 
 ibid. p. 363. Acrel, Chirurgische Vorfalle, 
 Ucbers. Von Murray, Vol. 1. p. 194. Van 
 Wy, Vermischte Chirurgische Schrifteh, Nu- 
 remberg, 1786, p. 192. Trioen , Observat. 
 Med. Chir. Fascic. L. B. 1743,/?. 46. Rei- 
 pleinin Richter's Chirurgische Bibiiothek , T. 
 7 ,p 569. Henkel, ibid. T. 2, p. 42. Dus- 
 saitssoir , ibid. T. 8, p. 71. Meckren, Obs. 
 Med. Chir. cap. 69. Taconi De nonnullis 
 Granii Ossiumque Fracturis, fy-c. Bunonice, 
 1751, p. 17 Blancard, Inst. Chir. p. 549. 
 Duhamel, Mtim. de V fiend, des Sciences, 1741. 
 Boehmcr, Dus. de Ossium Callo ; Lips. 1748, 
 p. 17 and 21. C heselden, Osteographia. or 
 Anat. of the Hu nan Bones, London. 1733, 
 Tab. 49, Fig 4. Morand, in Pldtner's Vermis- 
 chte Chirurgische Sdtriflen, p. 447. Ruysch , 
 Thesaur. 10, No. 176. Duverney, Traili 
 des Maladies des Os, p. 457, Pans, 1751. 
 Phil. Trans. No. 312. Wedel, in Ephem. 
 Natur. Cur. Dec. 2, Jinn. 2, p. 396. C. Ban- 
 tus in Chir. Tract. 4, Cap. 8, p. 275. Kos- 
 chius,in Roonhuy sen's Historische Heilkuren, 
 B. 1, p. 217 ; Nuremberg, 1674. Hofmann, 
 in Eph. Nat. Cur. Dec. 3, Ann. 9 el 10. p. 
 310. Dumcrbroeck, vid. Wolfli Obs. Chir. 
 Med Lib. 2. Ohs. 18,/?. 212, Wright, iv Phil. 
 
 Trans, abridged, Vol. 9, p. 252. Fabricius 
 Hildanus, Obs. Chir. Cent. 4, Obs. 91. Raw 
 Supellex Anatom. Edit.d B. S. Albino ; Ludg. 
 Batav. 1725, p. 13. Dobyns in Cheselden's 
 Osteographia, Tab. 49, Fig. 4. Mackenzie, in 
 Med. Obs. and Inquiries, Vol. 2, p\ 299. 
 Ludwig Advers Med. Prncl. Vol. 3 p 60. 
 Bousselin, in Hist, de la Soc. Royale de Mede- 
 cine, 1780, 1781, Paris, p. 121—297—305. 
 Slalpart Van der Wielin Cent. 1, Obs 96. 
 Muralto, in Schriften von der Wundarzn. 
 Bale , 1711, Obs. 202, p. 655 De la Moite , 
 Traite Complel de la Chirurgie, T. 4, p. 284. 
 Ellinckhuys in Trioen s Obs. Med. ( hir.fasc . 
 Ludg. 1743, p . 115. Ruysch Opera Omnia 
 Anat. Med. Chir. Amst. 1721, Tom. 1, p. 94. 
 Laing, in Med. Essays and Obs. Edinb. Vol. 
 1, art. 23. Johnson , ibid. Vol. 5, art. 23. 
 Hunter, in Med. Obs. and Inquiries, Vol. 2, 
 p. 303. Sigwart, Diss. de Carie consumptie 
 tibice notabili jactura, Tab. 1756. T. Bartho- 
 line. Act. Med. el Phil. Hafn. Vol. 3, Obs. 
 114, p. 287. Hofmann, Mantissa, Obs. Se- 
 lect. Obs. 28. Saviard. Nouveau Recueil 
 d'Observ. Chirurgicales, Paris, 1702, Obs. 
 126. Le Dran, Obs. de Chirurgie, T. 2, Obs. 
 104. Michael , in Richter's Bibiiothek. T.o 
 Troja, de Novorum Ossium in integris aut 
 maximis, ob morbos. deperdilionibus, Regent- 
 ratione , Experimenta. Lutetice Parisiorum, 
 1775. Troja' s Work, though drawn up in 
 
 an incorrect style, as Weidmann remarks, con- 
 tains many highly interesting experiments. 
 Blumenb tch, in A. G. Richter's Bibiiothek, 
 T. 4. p. 107. Desault's Parisian Chirurg. 
 Journal. Vol 1, p. 100, and Vol. 2, p. 199. 
 Koehler , Experimenta circa Regeneralionem 
 Ossium , Gott. 1786. This is a valuable work , 
 and contains the original discovery of the re- 
 production of medullary structure. I. V. 
 Weidmann De Necrosi Ossium Fol. Franco- 
 furti ad Moenum 1793 ; el de Necrosi Os- 
 sium adnotatio ; Frank. Del. 4. This publican 
 tiori is, perhaps, the best general account of the 
 whole subject of necrosis. It is not only en- 
 riched with the observations of numerous other 
 writers on the disease, but contains the most 
 approved theories and opinions respecting many 
 other affections of the bones, Caries, Exfolia- 
 tions tyc. It was a great assistance to me in 
 the composition of the foregoing article. Con- 
 sult also Richerand Nosogr. Chir. T. 3. p. 
 153, tyc. Ed. 4, Paris, 1815. Dr. Alex. 
 tM‘ Donald’s Thesis de Necrosi ac Callo, 
 • Edinb. 1799. Hutchison's Pract. Obs. in 
 Surgery, p. 180, §-c. London, 1816 James 
 ; Russell's Practical Essay on a certain Disease 
 of the Bones , termed Necrosis, 1794. Whale - 
 
 ly's Pract. Obs. oti Necrosis of the Tibia, 
 1815. Macartney, in Crowther's Obs. on 
 While-Swelling, \~c. Edit, 2. Encyclopedic 
 Mithodique, Parlie Chir. art. Necrose. Le - 
 viilii Nouvelle Doctrine Chir. T. 4, p. 321, 
 fyc. Paris, 1812. Larrey’s Mam. de Chirur- 
 gie Miiitaire, T. 3, p. 367, fyc. Thomson's 
 Lectures on Inflammation, p. 39 <Vc. Edinb. 
 1813. Boyer s Traite des Maladies Chirur- 
 gicales, T.3 p 418, Paris, 1814. Del- 
 pcch , Precis Elemenlaire des Mai. Chir. T I, 
 Chap. 3 ; Paris, 1816. Some account of an 
 operation in wnioij !Yf. Oupuytren,. of Paris. 
 
NITRIC AND NITROUS ACID; 
 
 '9 
 
 removed the mental portion of the lower 
 jaw, may be found in the London Medical 
 Repository , Vol. 3, p. 432. The wound heal- 
 ed by the first intention, and the patient 
 recovered. 
 
 ^NEEDLE. See Appendix. 
 
 NEPHROTOMY, (from ve^os, a kidney; 
 and T«,uy®, to cut.) The operation ot cut- 
 ting a stone out of the kidney ; a proceeding 
 which, perhaps, has never been actually put 
 in practice. In the Mr6gi Chronologique 
 de V Historic de France, par M6zerai, and in 
 the Phil. Trans, for 1696, two cases of what 
 is called nephrotomy are mentioned ; but 
 several circumstances in the accounts led 
 Haller and others to conclude, that the 
 operation alluded to in the first work was 
 nothing more than the high operation for 
 the stone. With respect to the example in 
 the latter work, the particulars are not de- 
 tailed enough to prove that an incision w 7 as 
 really made into the kidney. There is no 
 doubt that stones have often been extracted 
 from abscesses about the region of the kid- 
 ney, after being touched with a probe. But, 
 with regard to cutting into the kidney, the 
 deep situation of this viscous, and the want 
 of symptoms by which the lodgment of a 
 stone in it can be certainly discovered, will 
 always be strong objections to the practice. 
 When a stone, from its size, cannot pass 
 from the kidney, and excites inflammation 
 and suppuration, no doubt the surgeon may 
 make an incisiou into the tumour, and ex- 
 tract the calculus. In this sense, nephroto- 
 my is certainly a practicable operation. 
 Warner contends that it can only be prac- 
 tised in such circumstances, notwithstanding 
 whatever may have been said by Marchetti 
 or others, upon the subject. In such a case, 
 the operation would not be attended with 
 any greater difficulty than the opening an 
 abscess in any other part of the body. (See 
 Warner's Cases in Surgery, p. 241, Edit. 4.) 
 
 NITRIC and NITROUS ACIDS. As 
 these are medicines of considerable import- 
 ance in surgery, they claim particular no- 
 tice. Nitrous acid is a yellow, or orange- 
 coloured fluid, emitting when exposed to the 
 air, deep orange-coloured extremely suffo- 
 cating fumes. It consists of nitrous gas, 
 loosely combined with nitric acid and wa- 
 ter ; and the colour varies according to the 
 proportion of nitrous gas which is present. 
 
 Nitric acid is a colourless, or very pale 
 yellow, limpid fluid, emitting when exposed 
 to the air, white suffocating vapours. It is 
 highly corrosive, and tinges the skin yellow, 
 the tint remaining till the epidermis peels 
 off. The constituents of nitric acid, inde- 
 pendent of the w 7 ater, which gives it the fluid 
 form, are 25.97 azote, and 74.03 oxygen, in 
 100 parts. (See Thomson's Dispensatory, p. 
 433, 439, Ed. 2.) 
 
 Both these acids, in a diluted state, have 
 been extensively tried, as a substitute for 
 quicksilver in the cure of lues venerea ; and 
 really upon looking over the mass of evi- 
 dence brought forward in proof of the pow- 
 er which they seem to possess over this dis- 
 ease, it is at first difficult to entertain the 
 
 slightest doubt of their efiicacy. The cases 
 adduced are numerous, some of them mi- 
 nutely detailed, the gentlemen who have 
 published them, men of reputation and abi- 
 lities, and (w hat especially claims attention) 
 these examples of successful treatment are 
 generally allowed to have been syphilitic, 
 or, at all events, complaints, the differences 
 of which from the venereal disease have 
 not been, and could not be, specified. Who- 
 ever impartially considers the immense body 
 of facts published by Dr. Kollo, Mr. Cruick- 
 shank, Dr. Beddoes. Dr. P. G. Prioleau, of 
 Charleston, South Carolina, and others, ex- 
 emplifying the success witn which the ve- 
 nereal disease may be treated by the nitrous 
 or nitric acid, must be surprised to find, that 
 the accounts delivered by these gentlemen 
 by no means correspond to those of some 
 other eminent practitioners. How 7 to re- 
 concile these seemingly discordant state- 
 ments, whether by supposing some undefined 
 differences in the nature of the cases addu- 
 ced, or some variation in the goodness of 
 the medicine itself, is indeed perplexing. 
 Nor is a solution of the question at all faci- 
 litated, by the results of later investigations 
 tending to prove the general curability c 
 syphilis without mercury, or any medicine 
 whatever; because, if we admit this as a 
 fact, the circumstance of a considerable 
 proportion of cases not yielding, or bein<r 
 radically cured, when the nitric and nitrous 
 acids are exhibited, as asserted by Mr 
 Pearson and others, w r ould argue, that giv- 
 ing such acids is worse than leaving the 
 disease entirely to itself. The more I reflect 
 upon all that we know about the venereal 
 disease, however, the more I am inclined to 
 adopt the sentiment, that it is not one dis- 
 order, but probably many, w 7 hich go under 
 this name, their exact shades of difference 
 not having yet been detected nor described. 
 If this supposition be admissible, the con- 
 tradictory statements, given by various au 
 tbors about what their experience has taught 
 them of this or that mode of treating the 
 , disease, may all be immediately reconciled 
 The practice of exhibiting nitric acid, in 
 lieu of quicksilver, began with Mr. Wm 
 Scott, a surgeon at Bombay, who is said to 
 have been led to the experiment by a sug- 
 gestion thrown out by Girtanner, that the 
 efficacy of the various preparations of quick- 
 silver probably depended upon the quantity 
 of oxygen combined with them. (Grens 
 Journ. d. Physick. B. S,p. 31, 1790.) In Au- 
 gust, 1793, Mr. Scott being himself afflicted 
 with chronic hepatitis, resolved to take a. 
 quantity of oxygen, united to some sub- 
 stance, for which it has no great attraction 
 and after some reflection, nothing appeared 
 to him belter than nitric acid. September 
 11th, he took at different times about a dram 
 of the strong nitric acid diluted wrnter. Soon 
 after drinking it, he felt a sense of w armth 
 in his stomach and chest ; but no disagree- 
 able sensation, nor any other material effect. 
 The two following days the medicine was 
 continued, the gums beginning to be some- 
 w'hat red, and enlarged He slept ill ; but 
 
NITRIC AND NITROUS ACIDS 
 
 280 
 
 could lie for a length of time on his left 
 side, which the disease of the liver had pre- 
 vented him from doing during many months 
 previous to this period. He also felt a pain 
 in the back of his head, resembling what he 
 had commonly experienced, when taking 
 mercury On the fourth day, his gums were 
 a little tender ; the headach and pain about 
 his jaws still troubled him: but the symp- 
 toms of his liver complaint had already left 
 him. The acid w r as continued on the 4th, 
 5th, and 6th days ; the soreness of the 
 mouth increasing, and a salivation taking 
 place. On the 7th day, he felt his mouth 
 so troublesome, that he took no more acid. 
 His mouth got gradually well, and he found 
 his health considerably improved. 
 
 Mr.' Scott likewise administered the nitric 
 acid in several cases of tedious intermit- 
 tents, in two cases of diabetes, and in many 
 syphilitic cases, with the happiest effect. 
 
 This gentleman's account of the nitrous 
 acid was first published in the Bombay Cou- 
 rier of April 30th, 1796, and soon afterward 
 republished in this country. (See “ An Ac- 
 count of the Effects of the Nitrous Acid, on the 
 Homan Body," by JV. Scott, in Duncan's An- 
 nals of Medicine for 1796, Vol. 1, p. 375 — 
 383.) The hypothesis suggested by Girtan- 
 ner, in 1790, that the efficacy of mercury in 
 the treatment of the venereal disease de- 
 pended upon the oxygen combined with 
 this mineral, required but little extension to 
 lead to the discovery of the antisyphilitic 
 virtues of the acids. Yet Girtanner had all 
 his attention so fixed on mercury, that it 
 never struck him, that the principle on 
 which he explained the efficacy of this me- 
 dicine, might apply to other substances, 
 which abound with oxygen, and are readily 
 separable from it. This was the idea, which 
 made Mr. Wm. Scott begin to suspect, that 
 the nitric acid might be as efficacious as 
 mercury in venereal cases ; and as he had 
 already observed a great analogy between 
 the effects of this acid and mercury in the 
 experiments which he made with the first 
 of these medicines in his own case of chro- 
 nic hepatitis, and other diseases, he ventured 
 to recommend the trial of it in syphilis. 
 The result was, that the acid was found not 
 only to equal the preparations of mercury, 
 but sometimes to surpass them ; for it had 
 the best effect in some cases where mercu- 
 ry had been tried in vain, and it was observ- 
 ed to remove the disease in less time than 
 the common remedy. Nor were any of the 
 inconveniences, usually known under the 
 names of mercurial symptoms, mercurial fe- 
 ver, found to be the consequence of its em- 
 ployment, however long continued. With 
 it alone many syphilitic cases are stated to 
 have been cured, the disease not having re- 
 turned at the end of two years. (See Dun- 
 can's Annals of Medicine, fyc. Vol. 1, 1796, p. 
 383, fyc.) 
 
 The letter from Mr. Scott to Sir Joseph 
 Banks, describing these effects of the nitric 
 acid in India, soon excited the attention of 
 medical practitioners both in Europe and 
 America* the inquiry being taken up with 
 
 all the zeal which the preceding accounts 
 were calculated to inspire. In 1797, Mr 
 G. Kellie, a surgeon of the navy, gave the 
 nitric acid to five sailors affected with go- 
 norrhoea, venereal sores, and buboes. Three 
 of them were perfectly cured. A fourth, 
 who had sores on the glans, and who had 
 been much debilitated by the long use of 
 mercury, recovered nearly his original 
 strength, while taking the acid ; but the 
 sores were not healed, before mercury had 
 been repeatedly exhibited. In the fifth pa- 
 tient, who was aho scrofulous, ibe nitric 
 acid contributed very essentially to heal the 
 sores. On the whole, Mr. Kellie seems to 
 regard this medicine as possessing very 
 efficient power of stopping and eradicating 
 the venereal disease. (See Letters from G. 
 Kellie, respecting the Effects of Nitrous Acid 
 in the Cure of Syphilis. ' Duncan's Annals of 
 Medicine for 1797 ,p. 254, 277.) 
 
 In the same year appeared a letter, in a 
 German periodical w ork ( Hufeland's Jonrn. 
 der Prakt. Heilk. 4 Bd. p. 356—359.,) writ- 
 ten by Albers, giving the history ot a vene- 
 real ulcer on the breast, successfully treat- 
 ed by the nitric acid. 
 
 The reports of Dr. Prioleau, who tried 
 the nitric acid in the autumn of 1797, are 
 particularly favourable to the practice. 
 “We have seen (says he) every stage and 
 form of syphilis cured by this medicine, and 
 even in habits broken down by the antece- 
 dent use of mercury, under which the dis- 
 order had gained ground. The patients re- 
 covered their health and strength in a short 
 time, without the use of diet-drinks, bark, 
 or any other tonic medicine whatever.” 
 See Caldwell's Medical Theses, p. 103, 8 vo 
 Philadelphia, 1805.) 
 
 The praise of the nitric acid from nume- 
 rous quarters induced Dr. Rollo to try it in 
 the military hospital at Woolwich, and in 
 conjunction with Mr. Cruikshank to examine 
 further into the antisyphilitic virtues of oxy- 
 genated substances. The results of Mr. 
 Cruikshank’s investigations constitute the 
 second part of Rollo’s work on diabetes, 
 published in 1797 The medicines which 
 were selected for the experiments, were the 
 nitric, citric, and muriatic acids, and oxyge- 
 nated muriate of potash. Of these, the nitric 
 acid and the oxygenated muriate of potash 
 were found to possess the greatest efficacy; 
 the first acting in many cases with remark- 
 able mildness; the second, with greater ex- 
 pedition and certainty. The new plan was 
 tried upon young persons, affected with pri- 
 mary venereal complaints, who had never 
 used mercury, and no other internal medi- 
 cine was given, except opium, when requi- 
 red for diarrhoea, or colic. The liquor plumbi 
 acetatis dilutus was used as a wash for chan- 
 cres. In debilitated subjects, sure and spee 
 dy good effects were observed uniformly to 
 follow, and hence, previously to giving the 
 acid to strong, plethoric patients, the me 
 thod of preparing them for this treatment 
 by purging and bleeding was adopted, as is 
 alleged, with great success. In some cases, 
 after the nitric acid had been continued, a 
 
NITRIC AND NITROUS ACIDS. 
 
 281 
 
 good while without producing a salivation, 
 the exhibition of mercury for a short time 
 completed the cure. Mr. Cruikshank’s opi- 
 nion in favour of the new remedies was on 
 the whole extremely sanguine, as he ven- 
 tures to express his conviction, that they 
 would render the employment of mefcury 
 in the cure of the venereal disease un- 
 necessary. (See An Account of two Cases 
 of Diabetes Mellilus , with Remarks fyc., by 
 John Hollo , M. D. Vol. 2, Svo. Lond. 1797.) 
 
 In the same year, Dr Beddoes published 
 a valuable work, comprising all the informa- 
 tion, which had then transpired respecting 
 the antisyphilitic virtues of the nitric acid, 
 with additional communications from his 
 medical friends. (See Reports principally 
 concerning the Effects of JVitrous Acid in the 
 Venereal Disease , by Thom. Beddoes , Bristol , 
 1797.) And two years afterward, the same 
 author finished a still more comprehensive 
 volume on the subject. (A Collection of 
 Testimonies , respecting the Treatment of the 
 Venereal Disease by JYitrious Acid. Lond. 1799.) 
 
 From the preceding work we learn, that, 
 in the Plymouth hospital, Mr. Haimnick, 
 gave the nitric acid to between sixty 7 and 
 seventy venereal patients ; and that the cures 
 were generally more speedily accomplished, 
 than with mercury, no ill effects being pro- 
 duced on the system, similar to those usually 
 remaining after the use of the latter mi- 
 neral. He assures us, that, after the remo- 
 val of the symptoms, the disease never re- 
 turned, and that for debilitated, scorbutic, 
 or scrofulous patients, affected with vene- 
 real compiniais, the acid was found a most 
 valuable means of relief. 
 
 Dr. Geach of the same hospital is also 
 staled to have employed the nitric acid with 
 such effect, that he rarely had occasion for 
 mercury, the livid colour of the counte- 
 nance, sordid fetid excoriations of the scro- 
 tum, and other symptoms, which had long 
 resisted the latter mineral, all quickly 
 giving way to the new medicine. Another 
 practitioner of the name of Giedlestone, 
 however, had not equal success in his expe- 
 riments, for, in several cases, the acid did 
 not bring about a cure, and, after being con- 
 tinued eight or ten days, and inducing a sa- 
 livation, it even rendered the condition of 
 some patients worse. On the other hand, 
 Mr. Sandford, a surgeon at Worcester, found 
 the acid a very useful and effectual medicine 
 in venereal cases, where rpercurials had 
 been long exhibited in vain. The trials of 
 the nitric acid, made by Professor Ruther- 
 ford at Edinburgh, had various results ; the 
 medicine sometimes proving completely in- 
 effectual ; and, in other instances, appearing 
 to be a perfect antidote for the worst syphi- 
 litic complaints. 
 
 Dr. Beddoes concludes with some obser- 
 vations in answer to Mr. Blair, who had 
 become averse to the new practice. 
 
 In 1798, Dr. Ferriar published some re- 
 marks on the nitrous acid. (See Medical 
 Histories and Reflections , Vol. 3, p. 290 — 3 JO.) 
 He tried this medicine, in various ways, 
 either alone, or after, or in conjunction with, 
 
 Vol. U 36 
 
 the exhibition of mercury. His inferences 
 are, that, in the treatment of the venereal 
 disease, the nitrous acid is useful only in 
 protracted cases. He corroborates, how- 
 ever, the generally received opinion, that 
 where the patient lias been considerably re- 
 duced by the long, or injudicious employ- 
 ment of mercury, the nitrous acid is a 
 most beneficial medicine. 
 
 In the same year, Mr. Blair wrote some 
 observations on the venereal disease, and tiic 
 new method of treating it. (Essays on the 
 Venereal Disease , and its concomitant Affec- 
 tions, Lond. 179S.) In this work, the new 
 remedies are generally condemned, as inef- 
 fectual, and hence originated a paper-war 
 between this writer and Dr Beddoes, ‘ lile- 
 rarium certameri, non sine b le gestum,” as 
 Dr. Holst has expressed it. (De Acidi Kitrici 
 Usu Medico, p. 73, Svo. Christian te , 1816.) 
 In this controversy, numerous other practi- 
 tioners readily joined, as for instance, Ma- 
 cartney, Rowley, Philips, Hooper, Lidder- 
 dale, &,c., all of whom adduced cases, in 
 proof of the frequent inefficacy of nitrous 
 acid, ami these were collected and published 
 by Mr. Blair, who suspecting the cases of 
 failure with this medicine to be more nu- 
 merous, than those of success, considers 
 himself unjustified in regarding it as an 
 antisyphilitic to be depended upon. At the 
 same time, he bears testimony to the virtues 
 of the acids, exhibited in venereal cases either 
 singly, or alternately with mercury, w 7 here 
 the patient’s strength had been much redu- 
 ced ; and he confesses, that venereal buboes, 
 indurated glands, noctu rnal pains in the bones, 
 and gonorrhoea, yielded to these remedies. 
 
 Seven years after the appearance of Mr. 
 Blair’s work, Mr. Pearson delivered his sen- 
 timents in a book of considerable merit. 
 (Observations on the Effects of various Articles 
 of the Materia Medico in the Cure, of Lues 
 Venerea, 2 d Ed. Lond. 1807, p. 198, fyc.) 
 He relates a very few examples, in which 
 the nitrous acid appeared effectual in curing 
 chancres, and one of its virtues in gonor- 
 rhoea ; the only one, which this gentleman 
 had ever seen. The rest of his observations 
 are unfavourable to the character of the 
 medicine, as an antisipbylitic meriting con- 
 fidence. The first trials, which Mr. Pearson 
 made, were of the nitric acid ; but, as he 
 did not remark any of its effects to be dif- 
 ferent from those produced by the nitrous 
 acid, he commonly employed the latter in 
 the following form. Nitrous acid, two 
 drachms, pure water a pint and a half, syrup 
 four ounces. This mixture was usually ta- 
 ken in the space of twenty-four hours. As 
 local applications, he employed a saturnine 
 lotion to the sores ; and emollient poultices 
 to tumours and inflamed parts. All mercu- 
 rial applications were absolutely prohibited. 
 (P. 200.) In making his inferences, in a sub- 
 sequent page, he says, “ The nitric and ni- 
 trous acids have removed both primary and 
 secondary symptoms of syphilis; and, in 
 some instances, it seems that the former have 
 not recurred, nor have secondary symptoms 
 appeared at the period they commonly show 
 
NITRIC AND NITROUS ACIDS. 
 
 
 themselves, when tlie cure has been imper- 
 fect. But, as far as my own experience ex- 
 tends, and that of many respectable friends, 
 who are connected with large hospitals, a 
 permanent cure has never been accomplish- 
 ed by these acids, where secondary symp- 
 toms have been present. The same acids, 
 when exhibited with the utmost care and at- 
 tention to many patients, labouring under 
 the primary symptoms of the venereal dis- 
 ease, and where they have agreed perfectly 
 well with the stomach, have been never- 
 theless found inadequate to the cure of those 
 symptoms. Indeed, the failures which have 
 occurred, both in my own practice, and that 
 of many of my surgical friends, have been 
 so numerous, that I do not think it eligible 
 to rely on the nitrous acid, in the treatment 
 ef any one form of the lues venerea.” How- 
 ever, Mr. Pearson joins several other writers 
 in bearing witness to the good effects of this 
 medicine, where impairment of the constitu- 
 tion renders the employment of mercury in- 
 convenient, or improper. Here, he says, it 
 will restrain the progress of the disease, and 
 improve the health and strength. On some 
 occasions, he thinks, that it may be given, in 
 conjunction with a course of/mercurial in- 
 unction, and he agrees with other practition- 
 ers about its supporting the tone of the sto- 
 mach, acting as a diuretic, and counteracting 
 the effects of mercury on the mouth and 
 fauces. (P. 236—238.) 
 
 While these inquiries, were going on in 
 England, numerous experiments on the same 
 subject were undertaken in France. In a 
 work, published in 1797, Alyon positively 
 declares, that mercury ought to be entirely 
 relinquished in the cure of the venereal dis- 
 ease. (Essai sur les Proprieties Medecinales de 
 VOxyghie, et sur V application de ce principt 
 dans les maladies vinkriennes, psoriques, et 
 dartreuses ; Paris, an. 5, 8 vo.) Here we find 
 a relation of many cases, successfully treat- 
 ed in t^e hospitals of Val-de-Graee and St. 
 Dennis, by the oxygenated muriate of pot- 
 ash, the nitric, oxymuriatic, and citric acids, 
 an ointment of the author’s own invention, 
 called the unguentum oxygenatum, being ap- 
 plied to the sores. (See Unguentum.) In a 
 second edition of the above book, which 
 came out in 1799, the same doctrine and 
 practice are corroborated by further obser- 
 vations. 
 
 In 1798, Dr. Swediaur brought out the third 
 edition of his treatise on the venereal dis- 
 ease, (TraitJ Comp let sur les Symptdmes , les 
 EffSts , la Nature, et le Traitement des Mala- 
 dies Syphilitiques,) in which he highly com- 
 mended the virtues of the nitrous acid, and 
 oxygenated acid, as expediting the cure, with 
 very few exceptions. But, in the fourth 
 edition, he retracts, and details the results of 
 the new practice, as tried upon twenty-six 
 venereal patients in the Hospice d'Humanite : 
 of these only seven cases remained perma- 
 nently cured ; the issue of seven others was 
 doubtful ; and, in twelve, no amendment was 
 observed. 
 
 Nor were the statements of Lagneau much 
 more favourable to the reputation of the ni- 
 
 trous acid as an antisyphilitic ; for, from the- 
 trials which he had seen made of it, he con - 
 cluded, that it was not unfrequently ineffec- 
 tual, while it was apt to excite an obstinate 
 cough and hcemoptysis. ( ExposS des >iymp- 
 tomesde la Maladie VSndrienne, des diverses 
 MSthodes de traitement, fy-c. 3m e Ed. Paris, 
 1812.) 
 
 The reports of Dr. Odier, of Geneva, how- 
 ever, were rather more propitious, as he 
 says, the nitrous acid increases the efficacy 
 of mercury, and lessens or removes the in- 
 conveniences arising from its unskilful ad- 
 ministration. Ruthe candidly acknowledged, 
 that his experience had not been great 
 enough to enable him to pronounce, what 
 degree of confidence ought to be put in the 
 acid as a remedy for syphilis. (Man. de 
 M6d. Pratique ; Geneve, p. 249.) 
 
 The practice of exhibiting the nitric acid 
 for the cure of syphilitic affections was not 
 tried in Germany so soon as in England and 
 France. Albers, however, in 1797, gave an 
 account of Scott’s successful experiments, 
 and of the efficacy which they evinced in 
 some cases seen by that gentleman in the 
 Infirmary at Edinburgh. (Hufeland Journ. 
 d. Prukt. Heilk. Vol.20,p. 68;) while Behn, 
 who had visited Paris in the winters of 1797 
 and 1798, briefly noticed the various results 
 of the trials, which he had seen made of 
 this acid, in the “ Clinique de Perfectionne- 
 ment,” for the cure of obstinate syphilitic 
 cases. ( Erirmerun gen an Paris, zuntichst fllr 
 Jierzte gescrieben von G. H. Pehn Erst. Heft. 
 Berl. 1799, p. 110.) At length, in 1799, 
 Struve, who translated Mr. Blair’s first pub- 
 lication into German, communicated to the 
 profession the particulars of some experi- 
 ments made by himself with the acid; he 
 declares, that he bad very often found it an 
 excellent remedy for inveterate pains in the 
 bones, and derangement of the constitution;, 
 produced either by the syphilitic virus or the 
 injudicious employment of mercury. How- 
 ever, in common cases, mercury is repre- 
 sented as the best antisypliilitic medicine. 
 
 Afterward Professor Wiirzer was induced 
 to try the nitrous acid in a case, that had re- 
 sisted mercury for six months, the patient 
 having got rid of some chancres and a sore 
 throat, but being left with violent noctur- 
 nal pains, blotches, and sores all over his 
 body, and in a very reduced condition, with 
 out the least appetite. Here, in 27 days the 
 acid, together with sarsaparilla and the warm 
 bath, not only removed all the complaints, 
 but actually restored the patient’s original 
 strength, and healthy appearance. In a 
 short note annexed to this case, Hufeland 
 gives it as his opinion, derived from experi- 
 ence, that the nitrous acid is effectual in ob- 
 viating the sequela? and anomalous diseases 
 induced by lues venerea, but that it does not 
 permanently cure the latter affection itself. 
 (Etwas aber die Keilkraft der Salpetersatire yn 
 venerischen Kranklieiteu, Hufel. Journ. d. 
 Prakt. Heilk. 8 Bd. 4 St. p. 139—143.) 
 
 These vague and endless contradictions 
 induced Schmidt, an eminent professor at 
 Vienna, to make a series of experiments with 
 
NITRIC AND NITROUS ACIDS 
 
 m 
 
 liie nitric acid, for the purpose of ascertain- 
 ing its power in cases of syphilis. (See Beo- 
 bacht, der Kaiserl. Kvnigl. Med. Chir. Josephs 
 Akademit zu Wien. 1, Bd. Wien 1807, p. 147 — 
 189.) Under his directions, the acid was 
 given in the winter of 1799 to five soldiers, 
 affected with the venereal disease in various 
 degrees and forms. In every one of these 
 cases, the medicine was found efficacious ; 
 but the degree of efficacy was remarked to 
 vary considerably according to the nature 
 of the constitution, and the kind of local 
 complaints. Thus, in robust patients, mode- 
 rate doses of the acid soon produced bene- 
 fit . while, in weak persons, disposed to scurvy 
 or scrofula, a larger quantity of the medicine, 
 and more time were requisite. This asser- 
 tion we see is exactly the reverse of what 
 appeared to happen in the cases treated 
 by Mr. Cruikshank. However, Professor 
 Schmidt entertains strong doubts, whether 
 the nitric acid is adequate to the cure of all 
 the forms of syphilis, and he thinks, that 
 neither this nor any similar medicines will 
 ever supersede the necessity for mercury. 
 
 Ontyd, a Dutch practitioner, approves of 
 the use of the nitric acid, with some limita- 
 tion : while he admits its efficacy in remo- 
 ving local symptoms, he is strongly against 
 its employment in cases of confirmed lues, 
 as they used formerly to be termed. The 
 latter assertion, I conceive, is exactly con- 
 trary to the results of modern experience, 
 most of these protracted bad cases being 
 those, which are particularly benefited by 
 this acid. (JViewve scheidekundige Bibl. te 
 Amsterdam ; by Doll. 6de St. 1799, p. 166.) 
 The tracts of Boetticher, (Betnerk. fiber Medi- 
 cinal-verfass. Hospit, u. Cnrarten. ‘lies Hefr. 
 Kdnigsb 1800, 8,) of Ritter ( Erfahr fiber 
 die innerl u. afisserl. Anwendung d. Salpeters. 
 Hufel. Journ. 10 B 3 St. p. 191 — 197.) and 
 of Frankenfeld ( Hufelund's Journ. der Prakt. 
 Heilk. 22 Bd. 4 St. p. 96 — 98) need only be 
 specified here, as decidedly unfavourable to 
 the character of the nitrous acid, as areme- 
 _dy for syphilis. 
 
 The following German practitioners are to 
 be classed with the moderate approvers of 
 the medicine, though as Holst observes, {De 
 Acidi JYitric (Jsu Medico , p. 88 ; Christiana, 
 1816,) they do not appear to have made 
 any new experiments of their own with it, 
 viz. Munchmeyer {Comm, de Viribus Oryge- 
 wii in procreandis et sanandis Morbis ; Goetl. 
 1801, p. 54:) Burdach {Hdb. d. neuest Eut- 
 deck, in d. Heilmittellehre ; Leipz. 1806pp. 
 11, 12 ;) Aronsson ( Vollst. Abhdl. aller vene- 
 rischtn Krankh. Berl. 1808, p. 211 ;) Horn 
 \Hdb. der Prakt. Arzneymittellehre, 2/e. Aujl. 
 Berl. 1805, p. 95 ;) Consbruch ( Taschb . d. 
 Arzneymittellehre, 2 te. Aujl. Leipz. 1810, p. 
 283 ;) Toepelmann (JVeuere Erfahr. fiber 
 zweekem. Behdl. venerisch. Schleim ausfUisse , 
 ^c. Leipz. 1809, p. 151 ;) and Wolikopfs 
 {Pharmac. extemp. Leipz. 1811, p. 92.) 
 
 Another German author, who has entered 
 into the present inquiry, is F. A. Waich, 
 whose statements are very unfavourable to 
 the use of the nitrous acid, as he absolutely 
 denies, that it ever accomplishes a lasting 
 
 cure. ( Aitsfnhrl . Darslell. d. Urs)rr. fye. d. 
 Venerisch. Krankh. Jena, 1811, p. 197, 198.) 
 
 In a periodical work, mention is made of 
 one case, which, after resisting a long course 
 of mercury, and also the nitric acid, was ul- 
 timately cured by restricting the patient for 
 a few weeks to a very reduced diet. {Hujel. 
 Journ. d. Prakt. Heilk. 34, Bd. 2 St. p. 66.) 
 
 For much of the foregoing historical ac- 
 count, I am indebted'to Holst s Diss. de Acidi 
 Nitrici Usu Medico, 8vo. Christ. 1816; in 
 which an explanation of the results of fur- 
 ther trials of the medicine in Denmark and 
 Sweden may be perused. From these coun- 
 tries, the reports are mostly less favourable 
 to the reputation of the medicine, than the 
 accounts already delivered. 
 
 According to Holst the following are the 
 chief circumstances, under which the em- 
 ployment of nitrous, or nitric acid is gene- 
 rally sanctioned. 
 
 1 . Where the disease is complicated with 
 scurvy. 
 
 2. Where it is attended with scrofulous en- 
 largement of the glands, and other strumous 
 symptoms. I may remark, however, that 
 these complaints are often as undefinable, as 
 some of the forms of syphilis, and therefore 
 tiie rule is frequently difficult of application. 
 
 3. Where the disease is accompanied with 
 considerable debility, either brought on by 
 mercury, or febrile indisposition. 
 
 4. Where from idiosyncrasy, mercury can- 
 not be safely exhibited. Experience fully 
 proves, that there are some patients, more 
 especially females, in whom a few grains of 
 mercury taken inwardly, or mercurial fric- 
 tions on the most limited scale, bring on 
 vomiting, rheumatic pains, nervous febrile 
 symptoms, colic, spasms, severe headachy 
 and a rapid immoderate salivation. 
 
 5. Where pregnant women are the subjects 
 of the disease, several practitioners forbid 
 the use of mercury, during the latter months 
 of pregnancy. ( Bangri , Prax. Med. Haj'n. 
 1789, p. 570 ; Swediaur ; Aronsonn Vollst. 
 Abhdl. aller Ven. ICrkht. Berlin, 1811, p. 211.) 
 Holst observes, that the reason of this ad- 
 vice is not stated, though no doubt it must 
 proceed from an apprehension of mercury 
 exciting a miscarriage. 
 
 Mi .Pearson’s mode of exhibiting the nitrous 
 acid has been already mentioned. Some 
 practitioners give it as follows: 1^. Gum. 
 Arab. 3>v. aqua* menth. |viij. acid, nitrosi, 
 vel nitrici 3‘j- 3«ij- F. M. Of this mixture, a 
 table spoonful is to be taken every hour 
 mixed w ith some sweetened water. Should 
 the acid occasion colic, or diarrhoea, its 
 quantity must be lessened, and opium added 
 to the mixture. 
 
 As the nitrous and nitric acids decompose 
 and destroy the teeth, some care must be 
 taken to prevent so serious an effect. Their 
 being properly diluted, and blended with 
 sugar, syrup, or mucilage, will materially 
 tend to hinder the evil. But the safest way 
 is always to drink the mixture through a 
 glass tube, and wash the mouth well imme- 
 diately after every dose. 
 
 Strong nitrous acid, extricated in Ore? 
 
NIT 
 
 NOL 
 
 2.84 
 
 form of vapour, is often employed as a means 
 of purifying the air of large crowded hospi- 
 tals and sick-rooms ; a subject on which the 
 observations of Dr. J. C. Smyth and G. de 
 Morveau are particularly interesting. The 
 nitrous acid is sometimes taken by accident, 
 or design, as a poison. Here, according to 
 the observations of Tartra Orlila, he. the 
 best antidote is calcined magnesia, or soap. 
 If the first of these articles be at hand, a 
 dram of it, suspended in a glass of water, 
 is to be instantly given, followed by copious 
 draughts of some mucilaginous drink, the 
 design of which is to fill the stomach, and 
 excite it to reject the diluted poison. While 
 the vomiting is going on, the doses of mag- 
 nesia are to he repeated, and followed as in 
 the first instance by draughts of linseed tea, 
 solution of gum arable, milk, or broth. 
 
 The nitrous acid has also been extensively 
 tried as a means of curing syphilitic com- 
 plaints, in the form of what is termed the 
 nilro muriatic bath , of which a description 
 will be given in speaking of the Venereal 
 Disease. 
 
 When reiterated courses of mercury in- 
 duce dropsy, as not unfrequently happens 
 in very impaired constitutions, Mr. Carmi- 
 chael prescribes the nitrous acid, in as large 
 doses as the stomach will bear, conjoined 
 with digitalis. ( Essays on Venereal Diseases, 
 fyc.) Taken in doses of eight, ten, or fifteen 
 drops, two or three times a day, it is alleged 
 to be efficacious in the cure of some erup- 
 tive complaints, especially of the lower ex- 
 tremities, connected with disorder of the 
 liver. (fVihon's Pharm. Chir. p. 6.) Another 
 well-informed writer also bears testimony 
 to its good effects when used together with 
 mercury, for old obstinate ulcerations of the 
 legs, though no venereal taint can be sus- 
 pected ; and, he says, it may be applied 
 with benefit as a local stimulant to fetid 
 ulcers, attended with a thin ichorous dis- 
 charge, and in some examples of caries. In 
 such cases 3>j- of the diluted acid is to be 
 mixed with Jj of water. (See A. T. Thom- 
 son's Dispensatory, p. 441, Ed. 2.) With 
 respect to caries, in the sense of necrosis, 
 however, the reader will understand from 
 what is stated in the article on that subject, 
 that it can rarely be adviseable to apply this 
 or any other acid either to the exfoliating 
 portion of bone or to that which is yet alive. 
 The nitrous acid has sometimes been used 
 for destroying warts, condylomata, and 
 other excrescences. By Sir E. Home it is 
 praised as a local application for certain 
 ulcers when properly diluted. (See Ulcers.) 
 It is likewise commended by some writers 
 as a very useful local application in cases of 
 hospital gangrene. And an interesting paper 
 has been just published by Mr. R. Welban k, 
 detailing the excellent effects of the undilu- 
 ted nitric acid as an application to diseases 
 which he has described under the name of 
 sloughing phagedeena, and which he consi- 
 ders as identical with hospital gangrene. “ If 
 the disease be not far advanced, (says this 
 gentleman) I at once apply the undiluted 
 acid, after cleansing the surface with tepid 
 
 water, and absorbing the moisture with lint. 
 Where, however, there is a thick and pulpy 
 slough, it is better to remove as much of it 
 as possible, with forceps and scissors, before 
 the application is made. The surrounding 
 parts being then protected by a thick coat- 
 ing of lard, or cerate, I proceed to press 
 steadily, and, for some minutes, a thick 
 pledget of lint, previously immersed in the 
 undiluted acid on every point of the disea- 
 sed surface, till it appears converted into a 
 firm and dry mass. The parts may be then 
 covered with simple dressings, and evapora- 
 tion kept up externally by cooling lotions. 
 An opiate is afterward given, and the eschar 
 removed at the end of 16 or 20 hours. When 
 there is no pain, and the subjacent parts 
 present a florid healthy appearance, the sore 
 may now be treated as a common wound, 
 though stimulant dressings are generally 
 best. Mr. Welbank uses the ceratum lapidis 
 calaminaris, or a solution of the argentum 
 nitratum, in the proportion of two or three 
 gr. to an ounce of distilled water. But, if 
 there is any recurrence of pain, whether the 
 affection be slight or severe, and the remain- 
 ing slough deep or superficial, Mr. Welbank 
 advises the reapplication of the undiluted 
 acid. (See Med. Chir. Trans. Vol. 11, p. 
 369.) The cases reported by this gentle- 
 man are highly favourable to the practice 
 which, as may be seen by reference to the 
 article Hospital Gangrene, is not entirely 
 new with respect to this disease, and in 
 speaking of Mortification, I have mentioned, 
 that it was Dr. Kirkland’s practice some- 
 times even to dress certain sloughing disea- 
 ses with a solution of mercury in nitrous 
 acid. But, notwithstanding these facts, and 
 the well-known custom of Sir Astley Cooper 
 to apply to sloughing phagedenic ulcers the 
 nitric acid lotion, composed of 50 drops 
 of the acid, and a quart of distilled water, I 
 feel that Mr. Welbank has rendered a ser- 
 vice to the profession by drawing their 
 attention still more particularly to the use 
 of undiluted nitric acid in the forms of 
 phagedeena, which he has so well descri- 
 bed. 
 
 NODE. A swelling of a bone; a thick- 
 ening of the periosteum, .or a fascia ; or a 
 tumour on a tendon, from a venereal cause. 
 See Exostosis and Venereal Disease. 
 
 NOLI ME TANGERE. A species of 
 lupus, under which term Dr. Willan intend- 
 ed to" comprise, together with the noli me 
 tangere affecting the nose and lips, other 
 slow tubercular affections, especially about 
 the face, commonly ending in ragged ulcer- 
 ations of the cheeks, forehead, eyelids, and 
 lips, and sometimes occurring in other parts 
 of the body, where they gradually destroy 
 the skin and muscular parts to a considera- 
 ble depth. ( Bateman's Synopsis of Cutane- 
 ous Diseases, p. 296, Ed. 3.) 
 
 Sir K. Home says, that the ulcers, for 
 which he has been led to employ arsenic, 
 are named, from (he virulence of their dis- 
 position, noli me tangere, and are very nearly 
 allied to cancer ; differing from it in not. 
 contaminating the neighbouring parts by 
 
NOLI ME TANGERE. 
 
 285 
 
 absorption, but only spreading by immedi- 
 ate contact. Ulcers of this kind differ ex- 
 ceedingly from one another in their degree 
 of virulence ; but they are all so far of the 
 same nature that arsenic in general agrees 
 with them, and puts a stop to their progress, 
 while they are aggravated by milder dress- 
 ings. ( Home on Ulcers , Edit. 2, p. 267.) 
 
 The disease generally commences with 
 small tubercles, which change after a time 
 into superficial, spreading ulcerations on the 
 alas of the nose, more or less concealed be- 
 neath furfuraceous scabs. The whole nose 
 is frequently destroyed by the progressive 
 ravages of this peculiar disorder, which 
 sometimes cannot be stopped or retarded 
 by any treatment, external or internal. 
 
 The specific ulcerations do not generally 
 extend to the parts far within the nostrils ; 
 but, at the time that I am writing this article, 
 there is, under Sir L. Harvey, in St. Bartho- 
 lomew’s Hospital, a curious example, in 
 which the greatest part of the nose is de- 
 stroyed and the ulceration proceeds even 
 through the front part of the palate into the 
 mouth. The morbid process sometimes 
 stops for a considerable time, and then is 
 renewed with increased violence. The 
 following case illustrates the nature of noli 
 me tangere, and one mode of treatment, to 
 which it yielded. Jane Chatillon, 45 years 
 of age, w’as attacked, in the course of Sep- 
 tember, 1788, with an inflammation on the 
 left ala of the nose. Some time afterward 
 the part ulcerated, which occasioned a trou- 
 blesome and sometimes a painful itching ; 
 different means were unsuccessfully employ- 
 ed, and the case remained nearly in the 
 same situation till the month of September 
 in the following year. At this period the 
 ulcer spread very fast ; the_septum nasi, 
 the muscles and cartilages of both sides 
 were, in a short space of time, destroyed. 
 The ulceration extended on the left -ide, 
 along the loose edge of the upper lip. This 
 w as the state of her case on her admission 
 into the Hospital of St. Louis, in the month 
 of October, 1789. 
 
 A poultice moistened with aq. veg. was 
 applied twice a day to the ulcer ; a sudorific 
 ptisan prescribed, and a pill, composed of 
 one grain of calomel and one grain of sulpb. 
 aurat. anlimonii, ordered to be taken every 
 day. From the fifth day, the inflammation 
 lessened. No other sensible alteration took 
 place till the 21st. The suppuration, which 
 till this time had been black and putrid, 
 now became w r hite and inodorous. 
 
 On the 37th the discharge was trifling, 
 and the part was dressed with pledgets dip- 
 ped in a solution of verdigris and corrosive 
 sublimate, in the proportion of six grains of 
 each to a pint of water. On the 40th day, 
 cicatrization began to take place, and was 
 finished by the 60th. 
 
 Some time before the disease was com- 
 pletely cicatrized, an issue was made in the 
 arm, which was healed up without any in- 
 convenience to the patient, six months after 
 the cure. (Parisian Chirurgical Journal, 
 Vol. 1.) 
 
 One of the best external applications to 
 noli me tangere is the following lotion : fj ; . 
 Kali arsenicati, gr. iv. Aq. menthae sativa?, 
 ^iv. Spiritus vini tenuioris, ^j. Misce et 
 cola. 1 have seen several cases in St. Bar- 
 tholomew’s Hospital, which were either 
 cured or seemed disposed to get well 
 with this useful application. The solu- 
 tion of arsenic, which Sir E. Home has 
 always used, is made by boiling white 
 arsenic in water for several hours, in a sand 
 heat. When given internally, the dose is 
 from three to ten drops ; when for external 
 application, a dram is to be diluted with fLij. 
 of w ater ; and this solution is gradually made 
 stronger, as the parts become accustomed 
 to it, till it is of double strength. However, 
 this mode of using arsenic is by no means a 
 well-regulated one ; and Plunket’s caustic 
 (see Arsenic) for outward employment, i ; 
 not nearly so neat an application as the 
 above-mentioned lotion. At St. Bartholo- 
 mew’s Hospital, arsenic is administered in- 
 ternally in the following formula : Kali 
 
 arsenicati, gr. ij. Aquae menthae sativae, |iv. 
 Spiritus vin. ten. ^j. Misce et cola. Dosis 
 3ij. ter quotidie. ~In this way, the quantity 
 of arsenic is nicely determined. We shall 
 only just add, with regard to this medicine, 
 that, both as an external application and an 
 inward remedy, in cases of noli me tangtre , 
 it perhaps deserves the highest rank. One 
 scruple of the argentum nitratum, dissolved 
 in half an ounce of distilled water, makes a 
 very good application which, although ge- 
 nerally inferior, in point of efficacy, to ar- 
 senical ones, in the present disease, occa- 
 sionally does good, when nothing else seems 
 to produce any benefit. The above case 
 makes us acquainted with another lotion, 
 which deserves further trial All fluid reme- 
 dies must be applied to the part, by dipping 
 little bits of lint in them, placing these on 
 the ulcerations, and covering the whole 
 with a pledget. 
 
 The ointments which seem most likely to 
 prove useful applications to noli me ta?igere , 
 are the unguentum hydrargyri nitrati, the 
 unguentum picis, and unguentum sulphuris. 
 As far as my experience extends, they are 
 generally less efficacious than lotions in the 
 present cases ; but, in particular instances, 
 they prove superiorly useful, and it deserves 
 especial notice, that surgeons can often make 
 no progress against this inveterate disease, 
 unless they apply a different sort of dressing 
 every day ; sometimes a lotion ; at other 
 times an ointment. The little ulcers may 
 occasionally be touched with the argentum 
 nitratum. The small furfuraceous scabs, 
 which are continually forming on the part 
 affected, should be softened with a little of 
 the unguentum spermatis ceti,and removed 
 with as much tenderness as possible. 
 
 We have already remarked, that arsenic 
 is a good medicine to be given internally, 
 and the best mode of exhibiting it has been 
 already explained. Another medicine, w'bieh 
 is often useful in these cases, is what is 
 known by the name of Plummer’s pill, or 
 the compound calomel pill. Hydrargyri 
 
NYCTALOPIA. 
 
 1286 
 
 submuriatis, sulphuris antimonii pra?cipitati, 
 singulorum gr xii. Guaiaci gum mi resinae, 
 gr. xxiv. Saponis quod satis sit Misce ; fiant 
 pilulae duodecim. Dosis una bis quotidie. — 
 In other instances, we may try the decoctum 
 ulmi, or sarsaparilla?, with one of the fol- 
 lowing pills thrice a day: Hydrargyri 
 
 submuriatis gr. vj. Succi spissati cicuta? 3j 
 Misce ; fiant pilula? duodecim. The hy- 
 drargyrus sulphuratns has occasionally been 
 given as an alterative medicine, for the 
 relief of noli me tangere ; with what good 
 effect I cannot pretend to say. 
 
 In three or four less severe cases of lupus 
 tubercles on the face, which had made no 
 progress towards ulceration, Dr. Bateman 
 saw the solution of muriate of barytes, taken 
 internally, materially amend the complaint. 
 Sqmetimes, also, a separation of the diseased 
 parts from the sound has been effected with 
 the knife, or caustic, and the progress of the 
 complaint been stopped. (Synopsis of Cu- 
 taneous Diseases, p. 296, Edit 3.) 
 
 NYCTALOPIA, (from vu|, night; and 
 the eye ; or 07rra>, to see.) An affection 
 of the sight, in which the patient is blind in 
 the daylight, but sees very well at night 
 
 Nyctalopia, visus nodurnus, or day-blind- 
 ness, vulgarly called owl-sight, (says M. 
 Lassus) is an affection in which the patient 
 either cannot see at all, or sees l ut very 
 feebly, objects, which are in the open day- 
 light, or situations where there is a strong 
 light ; bu\ discerns them very well, w hen 
 they are in a darkish place, or at sunset, or 
 in the nighttime, if not immoderately dark. 
 (See Pathologic Chirurgicale , T. 2, p. 539, 
 540.) 
 
 The Greek physicians are divided in their 
 opinions concerning the now uncommon 
 disease nyctalopia. Hippocrates expressly 
 says, “ we call those nyctalopes who see by 
 night.” The author of Dejin. Medic. “that 
 they see nothing in the daytime, but have 
 their sight by night.” On the contrary, 
 Paulus iEgineta and \ctuarius are as explicit 
 in asserting, that they have their sight perfect 
 in the daytime, but are blind by night. 
 iEtius is of the same mind, though he is 
 thought to favour the contrary opinion, when 
 lie says, “ they see better by night than in 
 the day, and if the moon shines they are 
 blind.” The author of Isagoge embraces 
 both opinions, when he says, “ they call 
 those nyctalopes who, in the daytime, see 
 more obscurely, at the setting of the sun 
 more clearly, but, when it is night, much 
 better ; or, on the contrary, by day they see 
 a little, but, in the evening, or at night, they., 
 are blind.” Galen explains the word by a 
 night blindness. Pliny, Varro, Nonius, Fes- 
 t.us, Celsus, and other writers, give equally 
 opposite definitions of the disorder. Dr. 
 'JPye questions, whether these two descrip- 
 tions of nyctalopia, so diametrically opposite 
 to each other, may not be reconciled by 
 considering the disorder as an intermittent 
 one. The difference then will only consist 
 in the different times of the approach of the 
 disease ; that of Hippocrates came on in the 
 morning ; that of j^figineta, in the evening ; 
 
 both were expressly periodical, and the dis* 
 tance of time between the paroxysms, in 
 both, was respectively the same ; a whole 
 day, or a whole night. The various shapes, 
 in which intermittents appear, very much 
 favour, says Dr. Pye, such an opinion ; and 
 the apparent success of bark in the case, 
 which he has related, notwithstanding the 
 unfavourable circumstances of the evacua- 
 tions his patient laboured under, and the 
 consequent necessity of its disuse, seem to 
 confirm it in this gentleman’s mind. (Med. 
 Obs. and Inq. Vol. 1.) 
 
 In this work I shall follow Callisen, Rich- 
 ter, and the best modern surgical writers, in 
 calling day-blindness, nydalopia, and night- 
 blindness, hemeralopia. (See Callisen , Syst. 
 Chir. Hodiernal, Vol. 2, p. 392 and Richter , 
 Anfangsgr. der JVundarzn. B. 3, p. 479.) 
 
 Nyctalopia, in the sense of day-blindness, 
 is a very rare disease, in comparison with 
 hemeralopia, which is a very common disor- 
 der in warm climates. According to Dr. 
 Hillary, there are a people in Siam, in the 
 East Indies, and also in Africa, w ho are all 
 of this cat-eyed species, or subject to *he 
 disease of being blind in the daytime, and 
 seeing well by night. (Mod. Univ. Hist. Vol. 
 7.) The same author notices the general 
 rarity of the disorder, and mentions his 
 having met with but two examples of it. 
 
 With respect to the causes of the com- 
 plaint, Dr. Hillary observes, that it proceeds 
 from too great a tenderness and sensibility 
 of the iris and retina. M. Lassus thinks the 
 causes may be of different kinds. “ If. for 
 instance, (says he) there were a very small 
 opacity, like a point, exactly opposite the 
 pupil, or centre of the crystalline lens, the 
 pupil, contracting in the open daylight, 
 would stop the entrance of the rays of light 
 into the eye, and a day-blindness arise, which 
 would be diminished by the expansion of the 
 pupil in the shade. Here, the cure would 
 depend upon the removal of the opacity. 
 
 “ Persons, wdiose pupils do not move 
 freely, but remain much dilated, and do not 
 sufficiently contract in light situations, are 
 also affected with nyctalopia ; for. so large 
 a quantity of the rays of light pass into their 
 eyes, that it serves rather to destroy, than 
 assist vision. Such persons see tolerably 
 w r ell, and better than the preceding class of 
 patients, in a darkish place, and they ought 
 to wear green spectacles in the daytime, in 
 order to weaken the impression of the rays 
 of light. When a person is shut up a long 
 while in a dark place, the pupils become 
 habitually dilated, and ii he exposes himself 
 suddenly and incautiously to a strong light, 
 the eyesight may be destroyed. There are 
 other individuals, who, from excessive sensi- 
 bility of the iris, cannot bear much light ; 
 their pupils instantly contract, and close, 
 This case (continues M. Lassus) may be 
 brought on by too great indulgence in vene- 
 real pleasures, and in persons, who have 
 debilitated their constitutions during their 
 youth.” The same author mentions other 
 cases, which seem to depend upon a species 
 of irritability of the iris. In one instance, an 
 
<EDE 
 
 (Es>0 
 
 issue in the arm effected a cure, and he 
 mentions the utility of blisters. He admits 
 likewise witli Dr. Pye cases of intermittent 
 or periodical nyctalopia, which begin regu- 
 larly in the morning, and go off in the even- 
 ing, the patient continuing blind, whether 
 he keep himself in a dark or a light place. 
 The cause of these instances, which, he ob- 
 serves, are very uncommon, is generally 
 seated in the primal via?, and requires eme- 
 tics, resolvents, purgatives, and bark. (See 
 Palhologie Chir. T 2, p. 540 — 542. Also 
 Richter, Anfangsgr. der fVundarzn. B. 2, p. 
 481.) In 1787, Baron Larrey met with a 
 case of day-blindness in an old man, one of 
 the galley-slaves at Brest, who had been shut 
 up incessantly for thirty-three years in a 
 subterraneous dungeon. His long residence 
 in darkness had had such an effect on the 
 organs of vision, that he could only see in 
 
 the dark, and was completely blind in the 
 daytime. (See M6m. de Chir. Militaire , T. 
 
 hp-6-) 
 
 Nyctalopia may sometimes depend on a 
 peculiarity in the structure and organization 
 of the eye ; by reason of which, the quantity 
 of light, which only suffices for vision in an 
 eye of natural formation, proves too abun- 
 dant for a nyctalops, and absolutely prevents 
 him from seeing at all. We know, that in 
 the eye there is a black substance, named 
 the pigmentum nigrum ; one supposed use of 
 which is to absorb the redundant rays of 
 light, which enter the pupil. A deficiency of 
 it might perhaps account for a nyctalops 
 being blinded with daylight, and seeing 
 best at night. 
 
 For an account of nyctalopia, in the sense 
 of night-blindness, refer to Hemeralopia, 
 
 DEMA. (from oi4ia>, to swell.) The 
 ancients understood, by this term, all 
 kinds of tumours ; but it is now restricted to 
 a swelling, arising from the effusion of a 
 serous fluid in the cellular substance of a 
 part ; the affection, when more extensive, 
 and accompanied with a general dropsical 
 tendency, becoming a medical case, and 
 receiving the name of anasarca. An oedema- 
 tous part is usually cold, and of a pale 
 colour; and, as it is little, or not at all 
 elastic, it pits, as surgeons express themselves, 
 or, in other words it retains, for some time, 
 the mark of the finger, after being handled, 
 or pressed. (Edematous swellings are often 
 connected with constitutional causes. In 
 many cases, however, they seem to be en- 
 tirely local affections, arising from such 
 causes as only act upon the parts, in which 
 the swelling is situated. Thus we observe, 
 that after violent sprains of the wrist, or 
 ankle-joint, the bands and feet often become 
 (edematous ; and limbs are frequently affect- 
 ed with oedema, in consequence of the re- 
 turn of blood through the veins being ob 
 structed by the pressure of tumours on them, 
 or that of splints, bandages, &c. Pregnant 
 women are known to be particularly subject 
 to oedema of the legs, owing to the pressure 
 of the gravid uterus on the iliac veins Per- 
 sons who have been confined in bed, with 
 fractured thighs, or legs, generally have 
 more or less oedema in their feet and ankles, 
 on first getting up again ; and the affection 
 in these cases is probably quite dependent 
 on loss of tone in the vessels of the limb. 
 
 In the treatment of oedema, great attention 
 must always be paid to the nature of the 
 cause, in order to determine whether the 
 disease originates from a mere local, or a 
 eneral constitutional affection. When it 
 epends on the pressure of a tumour on the 
 veins, as we often see happen in cases of 
 aneurisms, the effect cannot be got rid of 
 
 till the cause is removed ; and the aneuris- 
 mal swelling must be lessened, before the 
 cedeinatous one can admit of the same be- 
 neficial change. When oedema is the effect 
 of vascular weakness in a limb, in conse- 
 quence of sprains, contusions, &c. the best 
 means of relief is to support the parts affect- 
 ed, with a laced stocking or a flannel roller, 
 while they are also to be rubbed with lini- 
 ments, and bathed with cold spring water, 
 till they have perfectly recovered their 
 tone. 
 
 With regard to the oedema, attendant on 
 the advanced stage of pregnancy, a com- 
 plete cure cannot be expected till after deli- 
 very. The affection is generally more con- 
 siderable in the afternoon than the morning, 
 owing to the different effects of an erect 
 and a recumbent position. Some relief 
 may be obtained by the patient’s keeping as 
 much as possible in a horizontal posture ; 
 and, when much inconvenience and pain 
 are felt, the parts may be fomented with any 
 aromatic or spirituous application. 
 
 Frequently, oedema is one of the symp- 
 toms of suppuration, and, when the collec- 
 tion of matter is very deeply situated, some- 
 times leads to its discovery, as is exem- 
 plified in cases of empyema. 
 
 There is a species of oedema, accompanied 
 with a degree of heat, pain, &c. in the part, 
 and which, in short, seems combined with 
 phlegmon In this case, cold evaporating* 
 lotions, the application of leeches, and the 
 exhibition of saline purgatives, are proper. 
 An erysipelatous oedema is also met with, in 
 which the treatment should very much re- 
 semble what is explained in the article 
 Erysipelas. 
 
 (ESO P H A GOTO MY. (from oesophagus and 
 'n/uvcD, to cut ) The operation of cutting 
 into the oesophagus, in order to take out of 
 this tube any foreign body which lodges in 
 it, and can. neither be extracted through the 
 
(ESOPHAGOTOMY. 
 
 ■ 28 S 
 
 mouth, nor pushed down into the stomach, 
 though its removal is absolutely necessary 
 for the preservation of the patient’s life. A 
 substance, above a certain size, lodged in 
 the upper part ot the oesophagus, not only 
 obstructs deglutition, but by its pressure 
 against the trachea, produces the most urgent 
 symptoms of suffocation. In this circum- 
 stance, if relief cannot be expeditiously af- 
 forded in any other manner, and the situation 
 of the foreign body is denoted by a prominence 
 distinguishable in the neck , oesophagotomy 
 should be practised without delay. How- 
 ever, when the symptoms are pressing, yet 
 unattended with any possibility of feeling 
 the foreign body, either externally or with a 
 probang, desperate as the situation of the 
 patient may be, modern surgeons do not 
 sanction the practice. And this difference 
 from the opinion of the first proposers of 
 cesophagotomy, does notarise so much from 
 any reflections upon the greater difficulty of 
 the operation in this circumstance, as from 
 the consideration of its being unlikely to 
 answer the only purpose, which makes its 
 performance at anytime proper, viz. enabling 
 the practitioner to extract with reasonable 
 certainty the substance, whose continuance 
 and pressure in the oesophagus are the imme- 
 diate cause of the patient’s danger. Hence, 
 when the symptoms of suffocation are ex- 
 tremely urgent, but the foreign body produ- 
 ces no external prominence in the neck, the 
 surgeon should in the first instance perform 
 tracheotomy, so as to obviate the imminent 
 peril arising from the impeded state of respi- 
 ration, and afterward try such measures for 
 the removal of the substance lodged in the 
 oesophagus as experience points out as most 
 likely to prove successful. Though oesopha- 
 gotomy was cursorily mentioned by Verdue 
 in his “Pathologie Chirurgicale,” Guattani, 
 formerly a distinguished surgeon at Rome, is 
 entitled to the honour of having published 
 the first valuable observations on the subject. 
 (M6m. de l’ Acad, de Chir. T. 3, 4to.) Guatta- 
 ni proved by experiments, that the operation 
 might be safely performed upon dogs, which 
 recovered after it very well, and he demon- 
 strated on the dead body, that it was equally 
 practicable on the human subject Nay, 
 what is still more to the point, he brought 
 forward two instances, in which the practice 
 had been successfully adopted on living pa- 
 tients. “ In May, 1738, Goursauld, a sur- 
 geon at Coussat-Bonneval, in Limousin, was 
 called to a man, in whose oesophagus a bone 
 w r as lodged, an inch long and half an inch 
 broad. Various ineffectual endeavours were 
 made to force it down into the stomach, and, 
 as it was perceptible on the left side of the neck , 
 Goursauld ventured to make an incision for 
 its extraction. The bone was thus easily ta- 
 ken out, no bad symptoms followed and the 
 wound healed up favourably with the aid of 
 an uniting bandage. For six days the pa- 
 tient was not allowed to sw r allow any kind 
 of food, but was nourished entirely with 
 clysters. According to Morand, a similar 
 operation was performed, with equal suc- 
 bv Roland, surgeon-major of the regi- 
 
 ment of Mailly.” ( Mem.de VAcad. de Clive. 
 T. 3.) 
 
 Although the deep situation of the oeso- 
 phagus, among the most important parts in 
 the neck, makes cesophagotomy an operation 
 of considerable delicacy in the hands even 
 of a skilful surgeon, and one of great danger 
 irnthose of a man, deficient in anatomical 
 knowledge, and ignorant of the right way 
 of proceeding, yet the propriety of perform- 
 ing it, under the circumstances, which have 
 bee.n specified, is universally admitted. 
 When, however, I refer to the delicacy and 
 difficulty of the operation, 1 arn meaning a 
 case, in w hich a deliberate dissection is made 
 down to (he oesophagus, without any gui- 
 dance from the projection of the foreign 
 body within it; a case, in which my views 
 of the subject lead me to think, contrarily to 
 Guattani, that the experiment would gene- 
 rally be attended with no practical benefit ; 
 which is also the sentiment of Baron Boyer. 
 For, with respect to opening the oesophagus, 
 with the view of tracing a substance in it, not 
 externally perceptible, and either of taking 
 hold of the same substance with forceps, or 
 pushing it down into the stomach with other 
 instruments, introduced through the incision, 
 as suggested by Guattani, the chances of 
 success must be too small to justify a practice, 
 in which it is above all things of consequence 
 to have the guidance afforded by the promi- 
 nence in the throat, as a test of the foreign 
 body being actually lodged in the oesophagus, 
 and capable of being removed from it by tbe 
 proposed operation. Indeed, the uncertainty 
 of being able to reach and extract the foreign 
 body, when its precise situation is not indi- 
 cated by any external swelling, appears to 
 me an objection of greater validity, than any 
 consideration either of the increased diffi- 
 culty of cutting into the oesophagus under 
 these circumstances, or of the usual conse- 
 quences of such an incision, after it has been 
 accomplished; because the practicable na- 
 ture of the operation, and the tendency of 
 wounds of the oesophagus to heal favourably , 
 when not complicated with other mischief 
 of too serious a description, are facts proved 
 beyond the possibility of dispute. In at- 
 tempts at suicide and murder, and in cases 
 of gunshot injury, the oesophagus is some- 
 times wounded, together with other parts in 
 the neck, and yet the patients frequently re- 
 cover; and, when they die, their fate seems 
 to depend rather upon other unfavourable 
 circumstances in their cases, than upon the 
 accidental injury of the gullet. The cures 
 of wound? of the neck, involving the latter 
 tube, as well as the trachea, are reported by 
 numerous writers, B. Bell, Desault, Bohnius, 
 &c. and some have fallen under my own 
 observation. If it w'erc necessary to sub- 
 stantiate this point further, I might cite the 
 instance, recorded on the authority of Dr. 
 James Johnson, where a man recovered 
 after the larynx had been Completely severed 
 between the thyroid and cricoid cartilages, 
 and one half of the calibre of the oesophagus 
 divided. (See llenncn's Military Surgery , p 
 301, Ed. 2.) But, supposing a wound of the 
 
(ESOPHAGUS.. 
 
 289 
 
 oesophagus, abstractedly considered, were 
 more dangerous, than it really is, the ques- 
 tion of the propriety of oesophagotomy 
 would npt be materially affected by it, be- 
 cause the operation is never recommended, 
 except as a matter of necessity, and without 
 which the patient would have no chance of 
 preservation. 
 
 As the oesophagus does not descend ex- 
 actly in a straight line, between the. trachea 
 and vertebra;, but inclines rather to the left 
 side of the spine, Guattani directs the left 
 side of the neck to be preferred for the per- 
 formance of oesophagotomy. But, Boyer 
 has justly remarked, that as the operation 
 should never be attempted, unless there be 
 projection of the foreign body, the place for 
 the incision is always to be determined by 
 the situation of the projection, the left side 
 being chosen only when the prominence is 
 either most distinguishable there, or at all 
 events not less, than on the opposite side of 
 the neck. (Traiti desMal. Chir. T. 7 .p. 192.) 
 
 The parts, which cover the oesophagus, 
 from the middle and external part uf the neck 
 to the upper part of the sternum, are the 
 skin, fat, cellular substance, muscles pro- 
 ceeding front the sternum to the larynx, the 
 thyroid gland, the thyroid arteries and veins, 
 the trachea, the recurrent nerve, &.c. Guat- 
 tani, who preferred the left side of the neck, 
 recommended the following mode of opera- 
 ting. The patient is to sit on a chair, with 
 his bead inclined backward, and steadily sup- 
 ported by an assistant. The skin having 
 been pinched up into a transverse fold, an 
 incision is to be made in the integuments 
 from the upper part of the sternum. The 
 cellular substance, between the sterno-hyoi- 
 deus and sterno-thyroideus muscles and 
 trachea, is next to be divided. With two 
 blunt hooks, the lips of the wound are to be 
 kept open ; and, on separating the cellular 
 substance at the side of the trachea with 
 the aid of the finger and a few strokes of 
 the knife, the oesophagus will be seen. The 
 lower part of this tube is then to be opened, 
 and the wound in it enlarged with a pair of 
 curved blunt-pointed scissors, a director being 
 employed, if any difficulty arise. With a 
 small pair of curved forceps, similar to those 
 used for the extraction of polypi, the foreign 
 body may then be removed. According to 
 Guattani, the wound will serve for the ex- 
 traction of the foreign body, whether this be 
 situated above, or below it, and he asserts, 
 that the opening will even be useful, when the 
 extraneous substance bas passed so far down, 
 that it cannot be taken out, as it can now be 
 easily pushed into the stomach. Guattani 
 lays great stress ou the usefulness of en- 
 deavouring to unite the wound, and adverts 
 to his experiments, proving that, in animals, 
 wounds of the oesophagus heal very favoura- 
 bly. If, says he, the vein, which brings 
 back the blood from the inferior parts of 
 the thyroid gland, and runs into the subcla- 
 vian, happen to be cut, the hemorrhage may 
 be stopped with a dossil of lint held upon 
 the aperture in the vein during the operation, 
 and afterward if the bleeding continue, 
 
 Vm„ IT. B7 
 
 compression, or a ligature, is to be employed. 
 The recurrent nerve, if at all likely to be 
 touched with the knife, is to he cautiously 
 drawn a little out of the way with the blunt 
 tenaculum. Guattani also particularly insists 
 upon opening the oesophagus as near as pos- 
 sible to the trachea, especially at its upper 
 part, where the artery, which goes from the 
 subclavian to the thyroid gland, sometimes 
 runs. When the foreign body requires an. 
 ample opening, and particularly when the 
 thyroid gland is enlarged, Guattani approves 
 of separating this part a little from the side 
 of the trachea. (See Mini- de I'Acad. Chir- 
 T. 3, 4fo.) 
 
 There can be no doubt, that Guattani’s di- 
 rections for finding the oesophagus are very 
 good ; but his chief defect is representing 
 the place for the incision as beiugalways the 
 same, whereas it ought to be partly regulated 
 by the situation of the foreign body itself. 
 However, his advice to make the incisions 
 close to the trachea -appears to me more ju- 
 dicious, than that recently delivered by 
 Boyer, who directs them to lie made through 
 the cellular substance between the sterno- 
 byoideus and sterno-thyroideus muscles, 
 and the omo-hyoideus, (see Traite des 
 Mai. Chir. T. 7, p. 193, 8 vo. Paris, 1821,) 
 in which method, he quits the trachea, 
 which is the best guide to the oesophagus, 
 and approaches unnecessarily the large 
 blood-vessels of the neck. Yet, I agree 
 with Boyer, respecting the general impro- 
 priety of attempting oesophagotomy, when 
 the situation of the foreign body is not indi- 
 cated by any prominence in the neck, and 
 the prudence of determining the place of 
 the incision in a great measure by such pro- 
 jection. Boyer also cautions the operator 
 to let his incisions always be made in such 
 manner, as to leave unhurt the trachea and 
 recurrent nerve at the inner edge of the 
 wound ; the carotid and internal jugular vein 
 at its outer edge ; the superior thyroideal 
 vessels, above ; and the inferior ones, below. 
 With this view, the cellular substance is to 
 be slowly divided layer by layer, and the 
 blood repeatedly absorbed with a sponge ; 
 but, if any vessel bleed freely, it is to be 
 immediately tied. 
 
 After the operation, an elastic gum ca- 
 theter should be passed from one of the nos- 
 trils down the pharynx and oesophagus, by 
 which means, the requisite food and medi- 
 cines may be injected iuto the stomach, 
 without any risk of their passing through 
 the incision, and retarding the cure. But, 
 a still stronger motive for this practice is the 
 avoidance of the convulsive action of the 
 muscles in deglutition ; a source^ of very 
 hurtful disturbance to the parts. Before the 
 advantages of this contrivance were duly 
 appreciated, the patient, for the first week, 
 was allowed to swallow scarcely any thing, 
 and was kept alive with broths injected up 
 the rectum. 
 
 (ESOPHAGUS, Foreign bodies in the . 
 There are few situations, in which foreign 
 bodies lodge more frequently, than in the 
 
 oesophagus ; a fact, explicable bv the eon- 
 
(ESOPHAGUS. 
 
 sissr 
 
 federation of Hie iunclion of this tube, the 
 Nearness of part of which to the windpipe 
 at the same time accounts for the frequent 
 danger of suffocation, when a substance, 
 above a certain size, is lodged in it. The 
 lodgment often takes place at the lower part 
 of the pharynx, or beginning of the oeso- 
 phagus, and sometimes just above the dia- 
 phragm; hut very rarely in the intervening 
 portion cm i hat canal. 
 
 Foreign bodies liable to lodge in the oeso- 
 phagus, arc not only articles of food, such 
 as pieces of crust, or meat imperfectly 
 chewed, the yolk of an egg, boiled very 
 hard, and not masticated, a chesnut, or small 
 apple, &c. ; but also various substances, 
 which are accidentally swallowed either 
 alone, or together with the food, such as 
 pieces of bone, stones, pins, needles, buttons, 
 pieces of money, knives, forks, scissors, 
 spoons, keys, fcc. - These latter articles, by 
 lodging in the pharynx, or oesophagus, may 
 occasion very bad and fatal symptoms, and, 
 if forced down into the stomach, may pro- 
 duce effects of a not less serious description. 
 Hence, an immediate attempt should always 
 be made to extract them. For this purpose, 
 the lingers may be employed, and, if they 
 will not reach far enough, a pair of long 
 curved forceps should be used. But, no 
 instrument seems better calculated for cases, 
 in which the body lodged in the oesophagus 
 13 not too wide, than the urethra-forceps, 
 invented by Mr. Weiss, of the Strand, and 
 used by Sir Astley Cooper for the re- 
 moval of calculi under a certain size, from 
 the bladder. (See Med. Chir. Trans. Vol. 
 31.) Nooses of wire, and bunches of thread 
 with a multitude of nooses, fastened upon 
 the end of a probang, and a piece of sponge 
 fixed on the extremity of the same instru- 
 ment, or on that of the strong wire stilet of 
 a long elastic gum-catheter, and various other 
 contrivances have been made with the view 
 of extracting different articles from the oeso- 
 phagus. The hunch of thread seems well 
 calculated for catching hold of small sub- 
 stances, like fish-bones, needles, &,c. ; and 
 the sponge, when expanded with moisture 
 and withdrawn, will sometimes bring up ar- 
 ticles, which on its introduction, it bed 
 passed in its dry and diminished state. 
 When the stomach is full, the excitement of 
 vomiting has sometimes answered ; but, if 
 the foreign body be sharp and pointed, the 
 method is not free from danger, and, instead 
 of relieving the patient, may put him to great 
 pain, and bring on violent inflammation of 
 the passage, and the most distressing symp- 
 toms. 
 
 When the substances are not of a very 
 hurtful kind, and cannot be extracted, they 
 must be pushed down into the stomach with 
 a large bougie, or a whalebone prohang, 
 fifteen or sixteen inches long, and on the end 
 of which a piece of line sponge is securely 
 fastened. But such practice is not ndviseabJe, 
 when the foreign bodies have a sharp, point- 
 ed form, so as to be likely to prove n source 
 of at least equal danger and suffering, if 
 placed in contact, willr the inner surface of 
 
 the stomach. Experience proves, that hardy 
 angular substances, and pointed bodies, like 
 nails, pins, needles, &c. which surgeons have 
 not ventured, or not been ahle^to force 
 down into the stomach, have often made 
 their way, after a time, to the surface of the 
 body, where an abscess has formed, out of 
 which they have been discharged. 
 
 When very hard, irritating bodies have 
 either passed of themselves, or been pushed 
 with a prohang into the stomach, their ill 
 effects should be counteracted, and then- 
 passage through the bowels promoted, with 
 mucilaginous draughts, containing the oleum 
 amygdalarum, or oleum ricine. When the 
 substances, lodged in the oesophagus, can 
 neither be extracted, nor pushed down into 
 the stomach, if respiration be not danger 
 ously obstructed, and liquids can yet be 
 swallowed, the wisest plan is to avoid irrita- 
 ting the passage with the further use of in- 
 struments, and leave the case to nature, that 
 is to say, as far as manual interference is 
 concerned ; for, bleeding, and macilaginous 
 oily draughts, may be in some cases useful. 
 But, when the lodgment of a foreign body 
 in the oesophagus dangerously obstructs re- 
 spiration, aud the substance itself can be 
 felt externally, the patient would perish, if 
 some means of facilitating the breathing 
 were not immediately adopted ; and, under 
 these circumstances, perhaps, the most pru- 
 dent plan would be to make an opening in 
 the trachea. (See Bronchotomy.) The sub- 
 sequent treatment, with reference to the 
 foreign body itself might be determined by 
 the circumstances of the case. 
 
 In this part of surgery, one fact deserves 
 to be particularly remembered, which is, 
 that after a sharp, hard substance has been 
 either ejected, orpropelled into the stomach 
 b} 7 nature, or art, the same painful sensations 
 in the throat frequently continue a certain 
 time afterward, which were experienced 
 while the foreign body was actually lodged 
 in the passage. These sensations, however, 
 are only owing to the manner, in which the 
 oesophagus has been irritated, and, conse- 
 quently, would he seriously aggravated by 
 the further unnecessary introduction of pro- 
 bangs. and other instruments. 
 
 There may be cases, in which the patient 
 would lose his life by suffocation, if a 
 foreign body of considerable size were not 
 taken out of the oesophagus, so as to remove 
 the compression of the iracbea. Here, if it 
 could neither be extracted, nor pushed into 
 the stomach by common means, and its 
 situation were indicated by any hardness, or 
 prominence in the neck, an operation would 
 be necessary for its removal. (See (Esopfia - 
 gotomy.) 
 
 A foreign body, not large enough to cause 
 danger ot suffocation by pressure on the 
 trachea, may yet bring on fatal symptoms, 
 as is exemplified in a case, which fell under 
 the notice of Guattani. As a man was throw- 
 ing up a boiled chesnut in the air, and catch- 
 ing it in his mouth, it passed down his throat;, 
 cud he was immediately seized with a difli- 
 c ul tv of swallowing, and scut, to the ho.- pda! 
 
 i 
 
(ESOPHAGUS. 
 
 29 i 
 
 However, as lie breathed and spoke with 
 facility, and had vomited since the accident, 
 which happened when he was tipsy, the 
 story of his having swallowed the chesnut 
 was disbelieved. His symptoms grew worse, 
 and he died on the 19th day. Guattani 
 made an incision in the left side of the neck, 
 below the larynx and thyroid gland, which 
 was considerably swelled, and soon came to 
 a large abscess, formed around the portion 
 of the oesophagus enclosing the chesnut. 
 
 When the extraneous body is sharp and 
 pointed, so as to stick in the mucous mem- 
 brane of the passage, and it cannot be 
 removed, nature will sometimes expel it 
 herself, without any dangerous symptoms 
 being the consequence. The foreign body 
 is gradually loosened by ulceration, and is 
 then either ejected by vomiting, or descends 
 into the stomach, whence it is voided either 
 through the bowels with the feces, or, as is 
 more common, by making its way through 
 some part of the alimentary canal, and 
 approaching the surface of the body, where 
 an abscess forms, out of which it is discharged. 
 In other instances, foreign bodies, like pins 
 and needles, which cannot be removed, 
 pierce the oesophagus itself, gradually pass 
 completely out of this canal, and afterward 
 travel to remote parts of the body, without 
 exciting much inconvenience, until, perhaps, 
 at the end of some years, they come near the 
 surface of the body, in a very remote situa- 
 tion from the throat ; and an abscess is pro- 
 duced, in which they are unexpectedly found. 
 However, this transport of sharp-pointed 
 substances from one part of the body to 
 another, which is effected by a process, in 
 which the absorbents have a principal share 
 in the work, is not conducted in every 
 instance with so little disturbance, and, 
 when foreign bodies of this description come 
 into contact with particular organs, symptoms 
 of a dangerous and fatal kind may be 
 excited. 
 
 The great art of passing any instrument 
 down the oesophagus, for surgical purposes, 
 consists in putting its extremity at once 
 directly against the posterior part of the 
 pharynx, and keeping it closely against the 
 vertebrae so as to avoid touching the epiglottis. 
 The knowledge of this circumstance will be 
 found extremely useful in passing probangs 
 and bougies. When elastic gum-catheters 
 are intended to be left in the passage, they 
 are introduced down the pharynx from one 
 of the nostrils, and, being secured, they 
 serve for the conveyance of liquid food and 
 medicines into the stomach with great ad- 
 vantage, in many cases, either where the 
 patient cannot swallow at all, or where the 
 disturbance of swallowing would be attend- 
 ed with considerable harm. When, however, 
 the plan is not to leave the instruments 
 introduced, as Boyer observes, they may be 
 passed through the mouth. 
 
 (ESOPHAGUS, Strictures, and other Dis- 
 eases of the. Properly speaking, a difficulty, 
 or impossibility, of swallowing should not be 
 regarded as a disease itself; but only as a 
 symptom of different affections, to which the 
 
 organs of deglutition are liable, or of other 
 diseases, which affect parts in the vicinity of 
 the pharynx and oesophagus. The object of 
 the present article is not the consideration of 
 all the diseases, which may produce dyspha- 
 gia, as a symptom, but chielly to notice this 
 effect, as depending upon spasm, paralysis, 
 or some morbid change of structure affecting 
 the pharynx or oesophagus. 
 
 Spasmodic dysphagia, as Baron Boyer has 
 remarked, principally occurs in nervous in- 
 dividuals, hysterical females, and hypochon- 
 driacal men. It is sometimes an attendant on 
 fevers ; it is declared to be constant in hydro- 
 phobia, and epilepsy, and occasionally pre- 
 sent in particular forms of mania. ( TraiU deS 
 Mai. Chir T.7,p. 151.) However, with re- 
 spect to hydrophobia, the foregoing assertion 
 should be received with some qualification, 
 for reasons so fully detailed in another part 
 of this work (see Hydrophobia,) that it is 
 unnecessary here to dwell upon the subject.. 
 Spasmodic dysphagia is said also to be some-*, 
 times a consequence of taking cold drink, 
 after a violent lit of anger; of strong im- 
 pressions on the imagination ; of worms in 
 the stomach, &.c. 
 
 When the spasm is situated in the pharynx 
 and upper part of the oesophagus, and is 
 considerable, neither solids nor liquids can 
 be swallowed, and the patient has great pain 
 and a sense of constriction in his throat... 
 When he tries to swallow any thing soft, or 
 even fluid, he is seized with acute pain, insuf- 
 ferable nausea, and violent agitation of the 
 whole frame. In this case, the spasm is 
 never restricted to the pharynx and upper 
 portion of the oesophagus, but extends to 
 other organs, the inability of swallowing 
 coming on in the midst of numerous other 
 spasmodic symptoms, exceedingly compli- 
 cated, and sometimes of a very alarming 
 nature. When it is the middle, or lower, 
 part of the oesophagus, which is concerned, 
 as is frequently the case in hysterical women . 
 the food passes through the pharynx and 
 unaffected portion of the oesophagus with 
 tolerable facility ; but, as soon as it reaches 
 the seat of the spasm, it is either stopped, or 
 descends further with great difficulty and 
 effort. Liquids, especially when warm, and 
 swallowed slowly in small quantities at a 
 time, usually pass down with more ease, than 
 solid substances. When the matterto be con- 
 veyed into tbe stomach reaches the point of 
 obstruction, the generality of patients are 
 attacked, with pain extending along the 
 spine between the shoulders, and sometimes- 
 shooting to the stomach, which is consider- 
 ably disturbed, and often discharges jis con- 
 tents. In some cases, however, no sucti 
 pain is experienced, and whatever the pa- 
 tients try to convey into their stomachs 
 regurgitates quietly into their mouths. Al- 
 though spasmodic dysphagia is mostly com- 
 plicated with other marks of disorder of the 
 nervous system, it is sometimes unattended 
 with any particular impairment of the health. 
 {Boyer, T. 7, p. 152.) 
 
 As the treatment of spasmodic affection's 
 of the pharynx and oesophagus belongs rat her 
 
292 OESOPHAGUS. 
 
 to the physician than the surgeon, [ shall 
 be very brief on the subject. This removal 
 of the cause of the infirmity, that is to say, 
 of the particular state of the mind, or con- 
 stitution, giving rise to the spasm, is the 
 principal thing, at which the practitioner 
 should first aim. Thus, Boyer cured an 
 hysterical woman of a difficulty and dread 
 of swallowing solid food attending her, at 
 her meals twice every day for a month, and 
 gradually convincing her of the absurdity of 
 her apprehension of being suffocated by at- 
 tempting to swallow solid aliment. (Vol. 
 cit.p. 154.) Sauvages makes mention of an 
 hysterical female, whose difficulty of swal- 
 lowing was cured by a regimen consisting 
 of regular exercise, cold bathing, and milk- 
 diet. The most successful remedies, how- 
 ever, are said to have been camphor in 
 large doses, and opium taken in draughts, 
 or pills, or administered in clysters; blisters 
 and cupping-glasses applied to the nape of 
 the neck, or to the epigastrium. Anodyne 
 embrocations are also stated to have been 
 useful. At the present day, the common 
 idea, that many anomalous affections depend 
 upon disorder of the liver and digestive or- 
 gans, leads to the frequent employment of 
 the compound calomel pill, and decoct, 
 ■sarsaparilla, with draughts of senna, rhubarb, 
 and gentian pro re nala. 
 
 Dysphagia may originate from a weak- 
 ened, or paralytic state of the muscular 
 fibres, which enter into the structure of the 
 pharynx and oesophagus. The affection may 
 be either symptomatic, or idiopathic. The 
 first case frequently occurs in febrile dis- 
 eases, and is generally set down by writers, 
 as a very unfavourable omen. The idio- 
 pathic form of the complaint may be 
 complete, or incomplete, and is chiefly 
 seen in persons of advanced age, though 
 occasionally the patients are young and in 
 the prime of life. The causes may be said 
 to be little, or not at all understood, and the 
 only remark, which can be safely made re- 
 specting them, is, that they are usually con- 
 nected with constitutional derangement. 
 
 With regard to the symptoms of paralysis 
 of the oesophagus, when the disorder is com- 
 plete, deglutition is absolutely prevented, 
 and, if the patient tries to swallow, the 
 food lodges in the pharynx, and sometimes 
 produces violent fils of coughing. Some pa- 
 tients eat solid substances with moderate 
 facility ; but, find more or less difficulty in 
 taking liquids. Others can swallow hastily a 
 large quantity of fluid at a time, yet, cannot 
 drink slowly and a little at once. Morgagni 
 relates an instance of still greater singularity, 
 which was an ability to sw r allow all kinds of 
 food very well, except the last mouthful, 
 which always remained in the oesophagus until 
 the next repast. ( DeSed . et Caus. J\1orb. Epist. 
 28, art. 14.) In cases of dysphagia from 
 paralysis the patient suffers no pain, nor 
 sense of choking ; if the neck be examined, 
 no hardness nor swelling can be felt ; and a 
 probang descends down the gullet without 
 the slightest impediment. (Boyer, T.7,p. 158.) 
 
 In its duration and termination, dysphagia 
 
 from paralysis presents considerable variety 
 the complete paralysis sometimes proves ra- 
 pidly fatal, not however, as l conceive, on 
 account of the affection of the oesophagus 
 alone, but other complications, and the 
 exhaustion arising from inadequate nutrition. 
 Thus, Tulpius relates an instance, in which 
 a woman died on the seventh day from the 
 commencement of the inability to swallow, 
 notwithstanding every endeavour was made 
 to support her with nourishment thrown up 
 the rectum, which was the only thing that 
 could be done, as she would not allow a tube 
 to be passed down the oesophagus. In other 
 cases the patients live a considerable time, 
 and afterward perfectly recover, and this 
 sometimes under the disadvantage of having 
 been entirely supported for several weeks 
 with broth-clysters, as we find exemplified 
 in a case recorded by Ramazzini. Certain 
 examples are also reported, in which the 
 patients had their food forced into the 
 stomach by means of probangs, for years, and 
 either ultimately recovered their power of 
 swallowing, or in this manner prolonged 
 their days, without any cure taking place. 
 (Stalpart van der Wiel, Vol. 2, Obs. 28 ; 
 Willis , Pharrti. Rat. Sect. 2, cap. 1 ,p. 45.) 
 
 Paralysis of the oesophagus is to be treated 
 on the same principles, as other paralytic 
 affections ; a subject, which I shall not be 
 expected to discuss ; but, it is of importance 
 that practitioners recollect, in these cases, 
 the very essential service derived from the 
 use of elastic gum-catheters, with which the 
 requisite food and medicines may be in- 
 jected into the stomach. 
 
 Dysphagia from organic disease, or mor- 
 bid change of structure, is the most frequent 
 case, and generally the most difficult of cure. 
 In dissections, the parietes of the oesophagus 
 are often found considerably thickened, 
 indurated, and scirrhous, or sometimes 
 almost cartilaginous, and even ossified. The 
 parts, where the pharynx terminates in the 
 (Esophagus, and where the latter tube joins 
 the stomach, are occasionally converted 
 into thick scirrhous rings with or without 
 ulceration, exactly in the same manner as 
 the pylorus. But, such diseases are not re- 
 stricted to those parts of the (esophagus, but 
 sometimes occupy other points of the pas- 
 sage. However, the organic disease, 
 producing a difficulty, or impossibility of 
 deglutition, is not always situated in the 
 coats of the (Esophagus itself ; for the parts, 
 surrounding this canal, are subject to various 
 diseases, which may have the same effect. 
 Thus, dysphagia may depend upon enlarge- 
 ment of the thyroid gland ; tumours formed 
 between the trachea and oesophagus, or at 
 some other point near the latter tube ; swell- 
 ing and induration of ^thc thymus gland ; 
 aneurism of the aorta ; enormous enlarge- 
 ment of the liver ; and diseased lymphatic 
 glands in the vicinity of that portion of the 
 oesophagus, which is covered by the perito- 
 neum, and the largest of which glands are 
 situated near the fifth dorsal vertebra?, just 
 at the point where the oesophagus inclines* 
 
(ESOPHAGUS 
 
 29.3 
 
 little to the right side to make way for the 
 aorta. (Boyer, T.7,p. 162.) 
 
 This last author sets down every case of 
 dysphagia, depending upon organic disease 
 of the oesophagus, as incurable ; and with 
 respect to the cure of other examples, in 
 which that tube is compressed by swellings 
 in its vicinity, as these are almost always 
 beyond the power of medicine and surgery, 
 the prognosis is nearly as unfavourable, as 
 where there is a change of structure in the 
 oesophagus itself. There are no unequivocal 
 symptoms, by which a case of dysphagia 
 from enlargement of glands in the vicinity 
 of the oesophagus can be known from seve- 
 ral other forms of the complaint. Hence, it is 
 difficultto estimate the correctness of certain 
 cases, recorded by Ruyscb (Advers. Anat. 
 Med. Chir. Dec. 1, art. 10, p. 24.) anti Haller 
 ( Opuscul . Pathol. Obs. 78.) where .dysphagia, 
 stated to have been produced by enlarged 
 lymphatic glands, was cured by mercurial 
 frictions, or pills composed of calomel, aloes, 
 and camphor. As Boyer justly remarks, 
 these accounts of the nature of the diseases, 
 thus cured, are the more doubtful, inasmuch 
 as the resolution of chronic swellings of 
 lymphatic glands, even when externally situ- 
 ated, is very difficult, and frequently imprac- 
 ticable, notwithstanding the use of topical 
 applications may here be combined with the 
 exhibition of internal medicines (T.7,p. 
 169.) However, dismissing the question, 
 whether the cases really arose rrom the 
 pressure of enlarged lymphatic glands, or 
 not, the facts ot the cures having taken 
 place, under the use of mercurial medicines, 
 are of themselves interesting. Several wri- 
 ters consider, that there is a great analogy 
 between certain forms of constriction of the 
 oesophagus, and strictures of the urethra, and 
 Mauchart recommended the two diseases to 
 be treated, on the same principles, u it h bou- 
 gies, and elastic gum-catheters. Baron Boyer, 
 however, represents this doctrine as com- 
 pletely erroneous, declaring that the affec- 
 tion of the oesophagus is of the nature of 
 scirrhus, and absolutely incurable. He 
 relates one case, in which a woman’s life 
 was prolonged by the. use of an elastic gum- 
 catheter, though it proved of no service as a 
 means of permanently dilating the diseased 
 part ; and, notwithstanding nourishing li- 
 quids were plentifully injected into the 
 stomach, the patient suffered a good deal 
 from hunger, and died exhausted about three 
 years after the beginning of the disorder. 
 This case, however, cannot be received, as 
 a proof of the inefficacy of bougies for what 
 is commonly implied by a stricture of the 
 oesophagus, because the nature of the disease 
 was not ascertained by an in pection of the 
 oesophagus after death, and the case might 
 have depended upon some organic disease 
 either of this tube, or the parts in its vicinity 
 not classed by the generality of modern 
 writers with strictures of the passage. 
 
 The following are some of Sir Everard 
 Home’s sentiments, respecting these last 
 cases. 
 
 As the oesophagus is required to be wider 
 
 at one time, and narrower at another, in or- 
 der to be fitted for conveying the different 
 kinds of food into the stomach, it is nearly 
 under the same circumstances, with respect 
 to the formation of stricture, as the urethra. 
 For obvious reasons, strictures of the oeso- 
 phagus are much less frequent than those of 
 the urethra. However, they are by no 
 means uncommon, and produce symptoms 
 even much more distressing and dangerous, 
 than those, which ordinarily arise from ana- 
 logous obstructions in the passage for the 
 urine. 
 
 Of course, the most remarkable symptom 
 of a stricture in the oesophagus is the diffi- 
 culty of swallowing, which must be greater 
 or less, according as the obstruction is more 
 or less complete. Sometimes no solid food 
 whatever can pass down into the stomach, 
 and fluids can only descend with great diffi- 
 culty, and in very small quantities. This is, 
 in some instances, attended with considera- 
 ble pain, which extends along the fauces to 
 the basis of the skull, and through the eusta- 
 chian tube to the ear. The pain sometimes 
 returns at intervals, and lasts a considerable 
 time, even when no effort is made to swal- 
 low. If a bougie ot proper size be intro- 
 duced down the pharynx, it will often be 
 stopped by the stricture just behind the 
 thyroid, or cricoid cartilage; for from Sir 
 Everard Home's remarks, it appears that the 
 obstruction is generally as high up as this 
 situation. However, there are other cases, 
 in which the obstruction is only of a spas- 
 modic nature, and in these a bougie may be 
 passed quite own. It is curious, that stric- 
 tures high up in the cesophagus, often occa- 
 sion ulceration in this tube very low down 
 towards the stomach, just as strictures in 
 the urethra occasion ulceration in that pas- 
 sage towards the bladder. This is most apt 
 to occur, when strictures of (he oesophagus 
 have been of long continuance, and may 
 arise from the efforts in retching, which 
 frequently come on, and must strain the 
 parts already deprived of their natural 
 actions, and of the benefit of the secretions, 
 with w hich they are lubricated in a healthy 
 state. When such ulceration takes place, 
 the characters of the original disease are 
 lost ; and when the ulceration extends up- 
 wards, the stricture itself may be destroyed. 
 A bougie, introduced under such circum- 
 stances, will, in general, have its point en- 
 tangled in the ulcer ; and when so skilfully 
 directed as to go down into the oesophagus, 
 it will meet with a difficulty while it is pass- 
 ing .the commencement ol the ulcerated 
 part of the oesophagus, and ano ! her impedi- 
 ment where it leaves the ulcer, and enters 
 the sound portion ot the oesophagus below. 
 These two resistances may lead to the sup- 
 position, that there are two strictures, while 
 in fact there is not one, only ulceration as 
 above described. 
 
 Strictures in the oesophagus are sometimes 
 so complete, that swallowing even fluids is 
 utterly prevented ; the patient is obliged to 
 have nil* nourishment injected infra anum , 
 
OLE 
 
 294 CES.O 
 
 and in general, soon perishes in a most ema- 
 ciated condition. 
 
 Though any part of the oesophagus is 
 liable to the kind of contractions forming 
 strictures, the part immediately behind the 
 cricoid cartilage, where the pharynx ends, 
 and the oesophagus begins, is the most fre- 
 quent seat of the obstruction. Those which 
 are situated further down do not so easily 
 admit of being examined, and relieved by 
 any surgical operation. Strictures of the 
 oesophagus occupy very little extent of the 
 passage, consist of a transverse fold of the 
 internal membrane, and are attended with 
 little thickening of the adjacent parts. 
 These latter circumstances are such as ren- 
 der the disease capable of receiving relief 
 either from simple or armed bougies. 
 
 There are two other diseases of the oeso- 
 phagus, which have symptoms similar to 
 those of strictures. One is a thickening of 
 the coats of the oesophagus, which extends 
 to the surrounding parts, and generally ends 
 in a cancer, or an incurable disease. The 
 other affection is an ulcer of the lining of 
 the passage, commonly situated a little 
 below the seat of the stricture, on the hack 
 part of the tube. In the early stale, these 
 diseases can only be distinguished from a 
 stricture, by an examination with a bougie; 
 afterward their nature becomes clear 
 enough from other symptoms which arise. 
 Strictures also take place more commonly 
 in young subjects ; the other two diseases 
 in the more advanced periods of life. 
 
 Sir E. Horne has found, that a bougie can 
 be more easily introduced into the cesqpha- 
 gus, when the tongue is brought forwards 
 out of the mouth. This gentleman remarks, 
 that when a bougie is passed, with a view of 
 learning the nature of the case, if it passes 
 down to the distance of eight inches, mea- 
 suring from the cutting edge of the front 
 teeth in the upper jaw, its extremity has 
 gone beyond the usual seat of stricture. If 
 it he withdrawn without any resistance, the 
 aperture in the oesophagus must then be lar- 
 ger than the bougie employed. But if the 
 bougie stops at the distance of six inches 
 and a half, or even lower, it must be re- 
 tained there with a uniform pressure for 
 halt a minute, so as to receive on its point 
 an impression of the surface by which it 
 was opposed. If the end of the bougie 
 retains its natural form, or nearly so, and 
 there is an indentation on one side of it, or 
 all round it, the surgeon may conclude there 
 is a stricture. On the other hand, should the 
 bougie descend without impediment, as far 
 as seven inches and a half, and, when with- 
 drawn, the surface of its point appear irre- 
 gular, and jagged, the disease is an ulcer on 
 the posterior part of the oesophagus. 
 
 The mode of treatment adopted by Sir 
 E. Home, consists either in passing a com- 
 mon bougie occasionally through the stric- 
 ture, and employing one of a larger size, in 
 proportion as the dilatation oT the obstruc- 
 tion is effected ; or else in introducing an 
 armed bougie at convenient intervals. The 
 \ views, which I take of the disease,- would 
 
 lead me to prefer giving a full and fair tria. 
 to the employment of elastic gum-cathe- 
 ters. Consult Practical Observations on the. 
 Treatment of Strictures in the Urethra and 
 (Esophagus, 3 Vols. Edit. 3, 1805. Vol. 2, 
 1803, and Vol. 3, 1821, by Sir E. Home , 
 Ph.H.Beuttelde Struma (Esophagi ; hujusque 
 coalitu dijfficili ac abolitce deglulitionis Causis: 
 (in Haller's Disp. Chir. 2, 395,) Tubing. 
 1742, Mauchart de Struma (Esophagi , Tu- 
 bing. 1742. J. Warner, Cases in Surgery , p. 
 130, Ed. 4 F. A. J. Zinckernagel, de Clyste- 
 rum JYutrienlum Antiquit ate, el Usu, ( Trilleri 
 Opusc. 1,399.) A. Vater , el F. A. Zincker- 
 nagel de Deglutitionis difficilis et imp edit is, 
 causis abditis : (Halleri Disp. ad Morb. 1, 
 577.) E. F. Bulisius de Fame lethali ex 
 callosa oris ventriculi anguslia. J. M. Ec - 
 cardus , dc his qui dm vivunt sine alimento, 
 4 to. Kilice Holsat. 1711. Boyer Trail6 de 
 Mai. Chir. T 7, 8 vo. Paris, 1821. 
 
 OLEUM CAMPHORATUM. ft. Olei 
 oliv®. Jb.i- Camphor® ^iv. Misce ut solva- 
 tur camphora. Sometimes employed for 
 promoting the suppuration of indolent, 
 particularly scrofulous swellings, which are 
 to be rubbed with it once, twice, or thrice 
 a day according to circumstances. 
 
 OLEUM LINI. In surgery, linseed oil is 
 sometimes used as an application to hums, 
 either alone, or mixed with an equal quan- 
 tity of the liquor calcis. It has also been 
 applied to cancerous ulcers. 
 
 1 OLEUM ORIGAMI. The oil of marjoram 
 is often used for dispersing ganglions : the 
 tumours are to be rubbed with it two or 
 three times a day. 
 
 OLEUM PALMiE CAMPHORATUM. 
 ft. Camphor® |ij. Olei palm® jftj. The 
 camphor is to be reduced to powder, and the 
 palm oil, being melted, and suffered to be- 
 come almost cold, is to be mixed with it in 
 a mortar. This application is a mild topical 
 stimulant ; and has been used for promoting 
 indolent suppurations, especially those of a 
 scrofulous nature, which take place under 
 the jaw, and are attended with a good deal 
 of chronic induration. 
 
 OLEUM RICIJNI. In surgical cases, re- 
 quiring the bowels to be opened with the 
 slightest degree of irritation possible, the 
 oleiim ricini is the best and safest medicine. 
 The usual dose is one large table-spoonful, 
 which must be repeated every two or three 
 hours, till the desired effect is produced. 
 
 OLEUM TERKBINTHINAT. Oil of tur- 
 pentine is employed externally as a stimula- 
 ting liniment and a styptic. In the article 
 Liniment may be seen some formul®, in 
 which turpentine is the most active ingre- 
 dient. It is sometimes exhibited internally, 
 for the cure of gleets. 
 
 OLEUM TEREBINTH! NATUM. ft. 
 
 Olei arnygdal® ^ss. Olei terebinthin® gutt. 
 xr.. Misce. 
 
 In deafness, occasioned by defective, or 
 diseased action of the glandnl® cerumine®, 
 Mr. Maule directs a little of this oil to be 
 dropped into the patient’s ear, or applied at 
 the end of a small dossil of cotton. 
 
 WU*3U a thin secretion takes place, the 
 
OPHTHALMY. 
 
 
 cure is also promoted by a small blister, 
 which is placed as near the ear as convenient, 
 and kept open with the savine cerate. The 
 meatus auditorius externus must also be 
 cleansed every day with a lengthened bit of 
 soft cotton, affixed to a probe. (See Phar- 
 macop. { shirurgica .) 
 
 OMPI-fALOCE'LE. (from ojuyxkoc, the 
 navel, and a rupture.) A rupture, or 
 hernia at the navel. (See Hernia.) 
 
 ONYCHlA. (ovw|, the nail.) An abscess 
 near the nail of the finger. (See Whitlow.) 
 
 ONYX. (from ovv%, the nail.) A small 
 collection of matter, situated in the anterior 
 chamber of the aqueous humour, and so 
 named from its being shaped like a nail. It 
 is of the same nature as Hypopium, to which 
 word I must refer the reader. Maitre-Jean, 
 Mauchart, and several other oculists, imply 
 by the term onyx, a small abscess between 
 the layers of the cornea. 
 
 OPHTHALMY. (from opfla tx/aot, the eye.) 
 Ophthalmia. Ophthalmitis. Inflammation 
 of the eye. This is not only a consequence 
 of several affections of the eye, and adjacent 
 parts, on the existence of which other dis- 
 orders its continuance entirely depends, but 
 is frequently the primary complaint, and too 
 often the forerunner of such irreparable 
 mischief as for ever bereaves the patient of 
 vision. The determination of a preternatu- 
 ral quantity of blood into the organ, and 
 fulness of its vessels, or a congestion, as se- 
 veral writers express themselves, is, accord- 
 ing to Beer, the earliest change which occurs 
 in ophthalmy in general. The next symp- 
 tom is said to be redness, which becomes 
 more intense, as the disorder makes progress, 
 and if the complaint be protracted, the red 
 assumes a dark hue, then a brownish, and 
 lastly a bluish tinge. However, when the 
 arteries and veins affected soon return to 
 their natural state, the redness of the textures 
 of the eye may not attain the greatest in- 
 tensity. Professor Beer seems to adopt si- 
 milar views of the nature of the process of 
 inflammation to those which are taken by 
 Dr. W. Philip, and some other writers alrea- 
 dy mentioned, (see Inflammation ,) for, in 
 consequence of the small arteries and veins 
 being deprived of their propelling power, he 
 considers that the blood in the texture, 
 w hich is the immediate seat of inflammation, 
 is in a state of actual stagnation. ( Lehre 
 von den Jhigenkrankheiten , B. 1 ,p. 30.) The 
 third general symptom of ophthalmy, des- 
 cribed by Beer, as closely following the 
 redness, is a tense, hard, painful -swelling of 
 the texture, directly affected. Lastly, in 
 proportion as the pain, redness, and swelling 
 are considerable, the more obvious is ano* 
 ther common effect of inflammation, viz* 
 an increase of temperature or heat. But 
 although the disturbed intercourse between 
 the arterial and venous systems is more ob- 
 vious than the effects of inflammation in 
 other parts of the organization of the eye, 
 yet, that the secreting and excreting vessels, 
 and the absorbents, are also affected, is 
 evinced by the augmented secretion and 
 excretion in the early stage of the disorder, 
 
 followed, when the inflammation has be- 
 come more intense, by a suppression of 
 these functions, and a dryness and want of 
 pliancy in the inflamed textures of the eye. 
 The disturbance of the connexion between 
 the nerves and muscles also produces first 
 various involuntary movements, which, as 
 the inflammation makes progress, become 
 more and more limited, and, at length, there 
 is a complete loss of action in the textures 
 of the eye, which are the seat of inflamma- 
 tion. 
 
 But, inasmuch as every disease of the eye 
 presents some differences, depending upon 
 the nature of the disorder itself, and others 
 arising from the peculiar organization of the 
 texture, which happens to be principally 
 affected, the characteristic appearances of 
 ophthalmy must be subject to a vast num- 
 ber of modifications, according as this or 
 that structure of the eye is inflamed ; and 
 hence, sometimes one symptom of inflam- 
 mation, sometimes another, chiefly predo- ** 
 minates, while Others are less conspicuous, 
 and often scarcely distinguishable. Yet, says 
 Beer, none of the characteristic marks of 
 inflammation are ever entirely absent. This 
 author represents the degree of pain as be- 
 ing proportioned in a great measure to the 
 tough unyielding nature of the parts imme- 
 diately around the inflamed texture of the 
 eye, to the firm nature of the inflamed tex- 
 ture itself, and to the quantity of nerves 
 with which such texture, and the parts in 
 its immediate vicinity, are supplied. In 
 proof of the truth of this doctrine, he in- 
 stances whitlows and internal ophthalmy, 
 where the .pain is very severe ; while in- 
 flammations of the conjunctiva, not extend- 
 ing to the deeper textures of the eye, are 
 described as cases in which the pain is 
 slight, because the structure affected is loose 
 and yielding. But, without scrutinizing 
 every reason assigned by Beer, for the va- 
 rieties observable in the symptoms accord- 
 ing to the texture which happens to be most 
 affected, I shall briefly state a few 7 other ex- 
 amples quoted by the same author. That 
 the degree of redness, as well as of pain, 
 varies considerably in different states of 
 ophthalmy, is a fact universally known. In 
 the beginning of the complaint, such red- 
 ness is generally less perceptible than when 
 the inflammation has attained its highest 
 pitch ; but it is not equally great in every 
 individual, nor in every species of ophthal- 
 my, being sometimes more intense and dif- 
 fused,' sometimes less both in degree and 
 extent. This diversity is referred by Beer, 
 and probably with reason, to the texture 
 affected in the eye, being furnished with 
 many considerable blood-vessels, obvious to 
 the sight, or only containing vessels, more 
 concealed and rather filled with a colourless 
 fluid than with red blood. The looseness 
 or unyielding nature of the texture is also 
 represented as making a difference in the 
 degree of redness. In inflammation, prin- 
 cipally affecting the conjunctiva and sclero- 
 tica, says Beeivthe redness is so intense, as 
 to give the eye a frightful appearance, as i- 
 
OPHTHALMY. 
 
 296 
 
 seen in ciiemosis ; while in inflammations 
 of the innermost textures of the organ, the 
 redness is scarcely perceptible, and, in the 
 erysipelatous inflammation of the eyelids, 
 the redness is very faint, (j B eer, Lehre von 
 den Augenkrankheiten , B. \,p. 34 — 36.) 
 
 Dr. Vetch remarks, that the conjunctiva is 
 capable of being stretched to a great extent, 
 owing to the loose structure of the cellular 
 membrane on which it lies, and consequent- 
 ly little resistance is made to the enlarge- 
 ment of its vessels. From slight irritation, 
 they soon become distended with red blood, 
 il but their tone or power of reaction is spee- 
 dily exhausted, and, if the exciting cause is 
 not kept up in an increasing ratio, they 
 quickly fall into a chronic or varicose en- 
 largement, or again contract to the diame- 
 ter of the serous vessels.” On the other 
 hand, (as the same experienced writer has 
 pointed out,) inflammation of the sclerotic 
 coat is slow in its commencement, and often 
 insidious in its progress, even when its ulti- 
 mate violence is great. In the early stage of 
 conjunctival ophthalmia, the inflammation is 
 most observable at a distance from the cornea , 
 round which the membrane often preserves 
 for a length of time its natural appearance. 
 Precisely the reverse takes place in the case of 
 sclerotic inflammation , which invariably ap- 
 pears at the circumference of the cornea , 
 forming a zone , more or less complete around 
 it , and most conspicuous above it , the form and 
 colour of the vessels being at the same time 
 wholly different from those which appear in 
 the course of conjunctival inflammation. 
 Intolerance of light (says Dr. Vetch,) in va- 
 riably accompanies sclerotic inflammation, and 
 is entirely unconnected with that of the 
 conjunctiva. (A Practical Treatise on the 
 Diseases of the Eye, p. 10.) If the latter ob- 
 servation be strictly correct, it is to be in- 
 ferred that, in all common cases of acute 
 ophthalmy, involving the conjunctiva on 
 the front of the eyeball, the sclerotica is 
 more or less affected, as in the beginning of 
 the disorder, light may be said to be seri- 
 ously annoying to every patient. 
 
 According to Mr. Travers, when the scle- 
 rotica partakes of the inflammation of the 
 conjunctiva, the vessels, which pursue a 
 straight course to the margin of the cornea, 
 are strongly distinguished, and have a some- 
 what darker hue, than the areol ar vessels upon 
 the loose portion of (he conjunctiva. ( Synop- 
 sis of the Diseases of the Eye, p. 128.) 
 
 Diversified as the pain, redness, swelling, 
 and heat, the four characteristic symptoms 
 of inflammation, may be in cases of oph- 
 thalmy, the incidental appearances in the 
 eye are not less subject to numerous modi- 
 fications. Thus, sometimes an extraordinary 
 involuntary action of the muscles of the 
 eyeball and eyelids, or of the secreting and 
 excreting lachrymal organs, and of the Mei- 
 bomian glands may be noticed ; and some- 
 times the action of all these parts is either 
 diminished, or completely stopped. These 
 differences Beer refers to the latter parts 
 being either themselves inflamed, or sympa- 
 thizing with the inflamed texture of the eve 
 
 lathe first case, the action of the muscles, and 
 the functions of the lachrymal organs, and 
 Meibomian glands, are more and more inter- 
 rupted in proportion as the inflammation 
 increases, and must thus remain, while the 
 inflammation lasts in its genuine form ; but, 
 in the second case, they go on, and this 
 even with greater activity, while the inflam- 
 mation continues, and until it has ceased to 
 become more violent. ( B . 1 ,p. 39.) 
 
 Acute ophthalmy in general, when at all 
 severe, and particularly when the inner tex- 
 tures of the eye are affected, produces a 
 febrile disturbance of the whole constitution. 
 This change from a local to a general indis- 
 position takes place with greater certainty 
 and quickness, in proportion as the focus of 
 inflammation is extensive, the constitution 
 irritable, the disorder of the eye neglected, 
 and the mischief considerable, which is ac- 
 tually produced in the organ, whether acci- 
 dentally, or in consequence of unskilful 
 treatment. (Beer, Vol. cit. p. 42.) 
 
 Many of the appearances and effects of 
 ophthalmy are different, as the inflammation 
 happens to be of an acute, or chronic na- 
 ture. And, as Scarpa has taken particular 
 pains to impress upon the minds of surgical 
 practitioners, every acute ophthal my, though 
 treated in the best possible manner, is never 
 so completely resolved as not to be followed 
 by a certain period, at which ail active dis- 
 turbance ceases, in the place of which a 
 degree of chronic ophthalmy remains in the 
 conjunctiva, or lining of the eyelids ; the 
 effect either of local weakness in the vessels, 
 or of the continuance of a morbid irritability 
 in the eye, after the removal of the acute 
 stage of the inflammation. As it occasions 
 a diseased secretion in the organ, and a 
 slow accumulation of blood and coagulating 
 lymph, (he inexperienced are apt to suppose,, 
 that the acute stage is not yet entirely sub- 
 dued, while it is completely so. Now, if the 
 inculcations of Richter and Scarpa be 
 correct, immediately the critical moment 
 arrives, when the acute stage changes into 
 the chronic, attended with local weakness, 
 it is of the highest importance to alter the 
 treatment without delay, and to substitute 
 for emollient relaxing applications, such as 
 partake of an astringent corroborant quality, 
 as the former only protract the turgescence 
 of the vessels, and the redness of the con- 
 junctiva. “Quo major autem fuit inflam- 
 mationis vehementia (says Richter,) eq 
 major pleruraque sequitur partiutn affecta- 
 rum atonia, eoque major opus est adstrin 
 gentium et roborantiurn longo usu, ut 
 auferanlur penitus reliquiae inorbi, &,c." 
 
 ( Fasical . Obs. Chir. 1 ,p. 109.) 
 
 It is on the accession of the second stage 
 of ophthalmy, that one may remark the 
 sudden increase of redness in the inflamed 
 texture, with a brown and afterward a blue 
 tinge , actual extravasations of blood in the 
 chambers of the aqueous humour; ecchy- 
 mosis of the conjunctiva ; a considerable in- 
 crease of swelling; the decline and irregu- 
 larity of the pain ; the decrease of the in- 
 flammatory heat and throbbing : a sensation 
 
OPHTHALMY 
 
 297 
 
 of cold and heaviness in the organ ; and 
 more or le$s oedematous swelling of the 
 surrounding parts. It is also in the second 
 stage, that suppuration is liable to happen. 
 (Beer, Lehre, fyc. B. 1, p. 46.) And in an- 
 other page the same author observes, that 
 the characteristic signs of the second stage 
 of ophthalmy consist in the following ap- 
 pearances : while the redness and swelling 
 undergo a sudden and striking increase, the 
 hardness manifestly diminishes, and the pain 
 becomes very unequal, and not continual ; 
 the secretions and excretions also, which, 
 during the first stage, were completely stop- 
 ped, commence again, but more copiously, 
 and are of a very different quality from what 
 they were in the state of health. The dis- 
 order is now quite in its second stage, and 
 this is the time when purulent matter may 
 begin to be formed. (B. 1, p. 50.) Accord- 
 ing to Beer, the duration of idiopathic oph- 
 thalmy depends upon the circumstances of 
 each individual case ; first, the nature of 
 the causes giving rise to the affection ; se- 
 condly, the irritability of the patient in re- 
 lation to constitution, sex, and age ; thirdly, 
 Avhat may be termed the constitution of the 
 affected eye itself, and the texture in it im- 
 mediately inflamed. Thus ophthalmy is like- 
 ly to be attended with great severity, when 
 it attacks plethoric individuals, in whom 
 there has been for some time previously a 
 great determination of blood to the head 
 and eyes, or whose sight has been strained 
 by looking at shining objects, or constitu- 
 tions hurt by good living and hard drinking. 
 Every severe ophthalmy runs through its 
 first stage much more rapidly in weak, irri- 
 table subjects and children, than in robust 
 individuals. It is also another remark 
 made by Beer, that every inflammation of 
 the eye, at all considerable, is generally of 
 shorter continuance in gray or blue-eyed, 
 than in dark, or black-eyed perstms ; and 
 in the same manner, inflammation of the in- 
 ternal, sensible, and tender textures of the 
 eyeball always passes through its first stage 
 more quickly, than inflammation of the eye- 
 lids. 
 
 With respect to the causes of ophthalmy in 
 general, as the disorder frequently affects 
 the innermost parts of the eye, and when 
 severe, is attended with some risk of the loss 
 of the organ, the annihilation of its func- 
 tions, or the spoiling of some of its textures ; 
 and also, as inflammation is the most fre- 
 quent complaint to which the eye is subject, 
 il is important to learn, as far as possible, 
 the causes, which either directly or indi- 
 rectly give rise to it. 
 
 jThe atmospheric air and light have a di- 
 rect and powerful operation upon the eyes ; 
 and in order that the former may have no 
 hurtful effect upon these organs, it should be 
 pure, that is to say, its regular component 
 parts should not be altered, nor blended 
 with extraneous substances. The tempera- 
 ture of the air is likewise described by Beer, 
 as making a good deal of difference in the 
 susceptibility of the eyes for inflammation, 
 either a very warm, or cold air, being, in 
 Vol.H. 3s 
 
 this respect, hurtful. The observation, how- 
 ever, is qualified with the admission, that 
 the terms warm and cold have only a rela- 
 tive signification to individual circumstances. 
 The effect of a blast of cold air on the eye, 
 in exciting inflammation, is universally 
 known, and needs no comment. It is an 
 opinion of Beer, that the eye is much affect- 
 ed by the quantity of electricity in the at- 
 mosphere, and he says, that on this account, 
 no experienced practitioner would under- 
 take the extraction of a cataract during, or 
 on the approach of a storm. ( B . 1, p. 65.) 
 
 Passing over many interesting observa- 
 tions made by Beer, on the contamination 
 of the atmospheric air by the admixture of 
 other gases, and the injurious effect of this 
 change upon the eyes, I come to his re- 
 marks on the operation of light upon these 
 organs. Though light, he observes, is indis- 
 pensable to the functions of the eye, it be- 
 comes pernicious, when suddenly increased 
 beyond what the organ can bear, so as to be 
 a source of irritation As a proof of this 
 fact, he cites an instance, in which a young, 
 plethoric, strong man, whose eyes had been 
 for some time unavoidably strained by im- 
 moderate exercise of them, was suddenly 
 attacked with a violent ophthalmy, while 
 looking at an optical representation of the 
 rising sun, and carried home in great agony. 
 But with respect to the influence of light^ 
 Beer observes, that every statement is to be 
 received only in a relative sense ; for the 
 degree of light which would answer very 
 well for the eye of an African, would de- 
 stroy many European eyes ; and the same 
 light, which is borne without inconvenience 
 by the eye of an adult, would excite in the 
 eye of a new-born infant the ophthalmia neo- 
 natorum , by which so many children are de 
 prived of the most valuable of the senses in 
 the first days of their existence. Beer fur- 
 ther explains, that the same degree of light 
 produces a stronger, or weaker effect, ac- 
 cording to the greater or lesser irritability 
 of the eye of the same person at different 
 times, as we see exemplified in every indi- 
 vidual in the tenderness of his eye to light 
 when he first awakes in the morning. Light 
 is also not hurtful to the eyes, merely ac- 
 cording to its quantity ; for the direction of 
 the rays makes a great deal of difference, 
 the eye being less capable of bearing them 
 with impunity the more they recede from a 
 perpendicular line, and strike the organ slo- 
 pingly, or horizontally. Much likewise de- 
 pends upon the kind of light ; that which is 
 reflected from a scarlet surface, being even 
 more prejudicial than the sunshine which 
 is reflected from a country covered with 
 snow ; another convincing proof, that the 
 bad effects are not always in proportion to 
 the quantity of rays. The light of burning- 
 glasses, concave mirrors, white screens, the 
 full moon, &c. and the shining of diamonds, 
 are well known to render the eyes weak, 
 and prone to inflammation. Among other 
 occasional causes of ophthalmy, Beer enu- 
 merates the custom of washing the eyes im- 
 moderately with cold water, a renjark in 
 
ophthalmy. 
 
 2f rs 
 
 which I do riot place much confidence my- 
 self; the application of various stimulating 
 medicated substances to them ; compresses 
 and bandages : the badness of instruments 
 employed in operations upon the eyes ; the 
 employment of spectacles unnecessarily, or 
 of such as are not adapted to ibe eyes of 
 the individual ; and every immoderate ex- 
 ertion of the eyesight. 
 
 But, among the most important and fre- 
 quent exciting causes of ophthalmy, are 
 extraneous bodies, which insinuate them- 
 selves between tire eyeball and eyelids, and 
 every kind of wound or injury of the eye. 
 
 Foreign bodies, liable to enter under the 
 eyelids, are of three kinds; first, they may 
 either be such as are in themselves corn 
 pletely innoxious to the eye ; or such as are 
 likely to hurt the eye only when strongly 
 pressed upon by the spasmodic closure of 
 the eyelids, or by the patient's imprudently 
 rubbing the eye ; or they may be of a qua- 
 lity which injures the eye the moment they 
 come into contact with it. Foreign bodies 
 of the first description lie loose under one of 
 the eyelids, and, for the most part, either 
 immediately behind its edge in the groove 
 destined for the conveyance of the tears, or 
 else in the fold, seen when the eyelid is 
 everted, exactly at the line where the pal- 
 pebra and sclerotic conjunctiva join toge- 
 ther. They never actually lodge in the 
 coats of the eye ; but they irritate it either 
 mechanically or chymically, or in both ways 
 together, according to their size, shape, and 
 chymical properties. 
 
 In the list of such extraneous substances 
 are inverted eyelashes ; particles of dust ; 
 snuff . pepper . minute insects ; and other 
 small things generally carried under the 
 eyelids by the wind. 
 
 As these foreign bodies are all of them 
 more or less irritating to the eye, they mud 
 Be considered as a principal exciting cause 
 ©f ophthalmy, which frequently follows 
 their entrance under the eyelids with extra- 
 ordinary rapidity. However, the redness 
 and effusion ot tears, sometimes instantly 
 following the insinuation of extraneous sub- 
 stances under the palpebrre.and as suddenly 
 ceasing on their removal, Beer considers 
 rather as preliminaries to inflammation, than 
 as this disorder itself. (B. 1 ,p. 92.) 
 
 Wounds and other injuries of the eye, 
 regarded as causes of ophthalmy, Beer di- 
 vides into three kinds ; viz. mechanical, chy- 
 mical, and mixed. A prick of the eye with 
 a fine needle is an example of a simple me- 
 chanical injury ; the action of quicklime 
 upon the organ is an instance of one purely 
 chymical ; and the violent propulsion of a 
 red-hot bit of iron against the eye is a le- 
 sion, which may be said to be both mecha- 
 nical and chymical. The same author makes 
 a variety of original reflections upon the 
 differences connected with the extent and 
 intensity of such injuries. Their intensity, 
 be views only as something relative ; thus, 
 either the force, with which the eye is inju- 
 red, is of itself too great ever to be resisted, as 
 is seen in a gunshot wound ; or the organic 
 
 powers of the patient are, from age, sex, c/r 
 constitution, much too feeble for the eye to 
 bear favourably any considerable injury, as 
 is the case with children and weak unheal- 
 thy females ; or the organization of the eye 
 itself may Ire weak, and the effects of the 
 violence therefore greater, as exemplified in 
 the fact of a brown or black eye generally 
 bearing a wound better than a gray or blue 
 one ; or, lastly, the organic powers of the 
 texture of the eye, immediately injured, 
 may be too feeble to bear even a slight le- 
 sion, as is the case with the retina. (B. 1, 
 p.9o.) 
 
 Mechanical injuries of the eye may be 
 made either with sharp or obtuse bodies. 
 Sharp-pointed and cutting instruments are 
 capable of readily penetrating the eye, 
 without occasioning at the moment of their 
 entrance, any violent compression, or lace- 
 ration of the neighbouring textures ; and 
 consequently the injury inflicted is a simple 
 puncture, or an incision. Sabre-cuts of t he 
 eye, however, are to be excepted ; for, 
 though the weapon may be sharp, the blow' 
 is always attended with more or less con - 
 cussion, and injury of the textures, adjoin- 
 ing the wound, which are very delicate and 
 readily spoiled. Blunt weapons, or bodies, 
 can only enter the texture of the eye by 
 dint of great force, and, in this case, always 
 cause a serious degree of compression, 
 stretching, and laceration ; but sometimes 
 when they do not penetrate the organ, the 
 contusion is such as is productive of not less 
 mischief. 
 
 In the case of a simple puncture or inci- 
 sion of the eye, Beer seems to think that the 
 subsequent ophthalmy is generally more 
 owing to the incapacity of the wounded or- 
 gan to bear the effects of the light, air, he. 
 than to the injury itself abstractedly consi- 
 dered. He observes, that a proof of the 
 truth of this opinion is seen in the extraction 
 of the cataract ; for, if the operator is care- 
 less in the operation itself, opening the flap 
 of the cornea very wide, so as to let the at- 
 mospheric air have free access to the inner 
 textures of the eye ; or if after the operation 
 is finished, he do not apply the dressings 
 with caution, and properly darken the pa- 
 tient’s chamber, he is letting the eye he sub- 
 jected to some of the most active causes of 
 inflammation. But though Beer is unques- 
 tionably correct, in regard to the injurious 
 effects of light on the W'ounded eye, it may 
 be doubted, whether his theories do not 
 make him attribute too much to the irrita- 
 tion of the air, and too little to that of the 
 mechanical division of the parts. 
 
 Passing over many of Beer’s observations 
 on injuries of the eye produced by blunt 
 bodies, and substances acting chymically 
 upon it, 1 leave the topic of the direct exci- 
 ting causes of ophthalmy, and come to the 
 consideration of those which lie regards as 
 indirect. And the first to which he adverts, 
 is every thing that has a tendency to keep 
 up a determination of a large quantity of 
 blood into the small vessels of the head and 
 eyes. Immoderate bodily exercise ; violent 
 
GJPHTHALM*. 
 
 299 
 
 emotions of the mrnd ; injudicious clothing ; 
 and high living, are afterward enumerated 
 as having an indirect effect in the produc- 
 tion of ophthalmy; but it does not appear 
 to me, that Beer's sentiments upon these 
 points are entitled to much attention. With 
 respect to infection and contagion, as causes 
 of inflammation of the eye, Beer under- 
 stands by infection, what at first takes effect 
 only upon a small point of the body, but 
 never the whole animal economy directly, 
 that is to say, before absorption has taken 
 place. Hence, says he, infectious diseases 
 are very seldom the cause of ophthalmy, 
 unless some of their matter be applied im- 
 mediately to the eye itself; but he admits 
 that they often dispose this organ to inflame 
 from slight causes, by the impairment which 
 they produce of the general health On the 
 other hand, he considers all contagions as 
 very quickly affecting the whole of the con- 
 stitution directly through the medium of the 
 skin, or the trachea, lungs, oesophagus, &c. 
 Hence, contagion is set down as being much 
 more frequently, than infection, the indirect 
 cause of ophthalmy. Beer conceives, how- 
 ever, that as the contagious principle is 
 blended with the atmosphere, it may also 
 have an immediate operation upon the eyes, 
 and thus he attempts to account for the or- 
 gans not unfrequently exhibiting a tendency 
 to inflammation at the very moment of the 
 contagion taking effect. (3. l,p. 121.) But 
 this is a difficult and obscure subject, which 
 can be viewed to more advantage when 
 particular kinds of ophthalmy are considered. 
 
 In Beer’s general observations on the 
 treatment of inflammations of the eyes, the 
 first indication specified, is to remove imme 
 dialely every thing, which is obviously produ- 
 cing an irritating effect upon the eye and to 
 take care that no fresh source of irritation to 
 the organ incidentally lake place. And, as 
 Itfrequently happens, even in healthy, strong 
 individuals, that ophthalmy is occasioned by 
 foreign bodies, either lodged under the eye- 
 lids, or inserted in some part of the eyeball, 
 and not suspected to be there, the earliest 
 attention should always be paid to their 
 gentle and skilful removal. Easy as this 
 object is of accomplishment, when not de- 
 layed, when the eye has not been seriously 
 irritated by friction and pressure, and the 
 patient is not of a weak, irritable constitu- 
 tion, it is often attended with great difficulty 
 under one, or the other of these circumstan- 
 ces, especially the last. In this case, strong 
 convulsive rotations of the eyeball, followed 
 by a violent and obstinate spasmodic closure 
 of the eyelids, render it impossible to sepa- 
 rate them ; and the spasm is the stronger 
 and more lasting, the more -the extraneous 
 substances are calculated by their shape and 
 ehymica! quality, to irritate the eye ; and 
 the greater the irritability of the patient is. 
 In this state of things, every attempt forcibly 
 to open the eye, or to examine it in the light, 
 is not oniy useless, but increases and keeps 
 up the spasm, which nothing will lessen and 
 shorten, except darkness and perfect repose. 
 But, as timid irritable persons are exceeding- 
 
 ly apprehensive of the consequences of the 
 lodgment of extraneous substances in the 
 eye, the surgeon should endeavour to lessen 
 their inquietude, by assuring them that every 
 thing will be right again, which is strictly 
 true when the foreign bodies are of the first 
 class. Then the spasmodic closure of the 
 eyelids will cease, and the extraneous sub- 
 stance admit of being properly taken away. 
 
 Success, however, does not always attend 
 this simple method ; for, in very weak sub- 
 jects, the spasm of the orbicularis palpebra- 
 rum is so violent and obstinate, especially 
 when a foreign body lodges in the eye, and 
 at the same time mechanically and chymi-' 
 cally irritates it, (as is the case with particles 
 of snuff,) that it becomes indispensable to 
 have recourse to medicinal applications. For 
 this purpose, Beer’s experience has convin- 
 ced him, that the best thing is a bread poul- 
 tice, made either with milk or water, and 
 containing some of the vinous tincture of 
 opium. Care is to be taken, however, never 
 to let it become quite cold, during its appli- 
 cation ; for then the spasm would only be 
 aggravate.! by it ; and if such spasm has 
 been of long continuance, when the surgeon 
 is first sent for, the poultice, according to 
 Beer, may be rendered more efficacious bv 
 tlie addition of hyosciamus to it. In very 
 irritable hysterical and hypochondriacal per- 
 sons, such local treatment alone is frequently 
 insufficient, and recourse must be had to the 
 internal exhibition of antispasmodic ano- 
 dyne medicines. At length, when the spasm 
 of the orbicular muscle is so far diminished, 
 that the eyelids can be effectually opened 
 without any force for the extraction of the 
 foreign body, great caution and gentleness 
 will yet be necessary, and, in particular, the 
 eye should be kept in a very moderate 
 light, as the spasm would be immediately 
 excited again, either by sudden exposure of 
 the eye to too much light, or rough handling 
 of the eyelids. 
 
 Sometimes, a person rubs his eye at first 
 awaking in the morning, and if the eyelashes 
 are very numerous and rigid, one of them 
 will lodge between the eyeball and lower 
 eyelid : it may readily be taken away with 
 the end of a fine moist sponge, or camei- 
 hair pencil, the eyelid being depressed ns 
 much as possible and the eye itself turned 
 upward, so that the hair may not be conceal- 
 ed in the fold of the conjunctiva. When the 
 hair is situated underthe upper eyelid (which 
 Beer says rarely happens) it always lodges 
 in the fold of the preceding membrane, 
 whence it may be extracted in the manner 
 above directed, with the difference tiiat the 
 eyelid must be raised or everted, and the eve 
 rotated downwards. (Lehre von den Krankh. 
 B.\,p. 128, 130.) 
 
 For directions respecting the treatment of 
 redundant and inverted cilia?, see Dislichiasis 
 and Trichiasis. 
 
 Small globular smooth extraneous bodies, 
 lodged under the eyelids, are very easily ex- 
 tracted, when the eyelid is gently taken hold 
 of both byits edg? and the eyelashes, and tiff, 
 ed up from the eye, while the patient inclines 
 
OPIITHALMY. 
 
 m 
 
 hishead forwards, and the eye is turned com- 
 pletely downwards : the effusion of tears, 
 excited by these manoeuvres, will now gene- 
 rally wash these extraneous substances out 
 of the eye, as they are not at all fixed. 
 When the fissure between the eyelids is 
 wide and open, but the eyeball at the same 
 time very prominent, the object may also 
 be easily accomplished, when the upper 
 eyelid is gently and repeatedly stroked with 
 the finger from the outer towards tiie inner 
 canthus ; in which case, the round smooth 
 foreign body soon makes its appearance 
 above the caruncula lachrymalis, whence 
 it falls out of itself, or may be taken with 
 the corner of a pocket handkerchief. The 
 worst cases are those, in which the eyes are 
 very prominent, and the fissure of the eye- 
 lids small, as ail the above methods are then 
 useless, and only productive of irritation. 
 In this circumstance, therefore, Beer recom- 
 mends the surgeon to take hold of the eye- 
 lid by the cilia;, and its edge with the thumb 
 and forefinger, and separate it from the eye- 
 ball, w hich is to be tui ned downw ards, while, 
 with Daviel s small scoop, or the head of 
 any large curved needle, introduced straight 
 under the eyelid, at the outer canthus, as 
 high as possible, the extraneous substance is 
 to be extracted with a semicircular move- 
 ment, directed towards the nose. Though 
 this method will almost alw ays succeed, Beer 
 confesses, that it is not without the pro- 
 duction of a great deal of mechanical irrita- 
 tion. 
 
 In consequence of the detention of such 
 substances under the eyelids, the* conjunctiva 
 sometimes becomes thickened ; this change, 
 when slight, soon disappears of itself alter 
 the removal of the foreign bodies ; but, iu 
 other cases, Beer recommends the diseased 
 part of the membrane to be removed with a 
 pair of scissors ; and, after the bleeding has 
 ceased, the frequent application of the lotio 
 plumbi acetatis to the eye. 
 
 Particles of common dust, and of the 
 sand and powders, frequently thrown over 
 letters, and very apt to get into the eyes of 
 persons who open their letters carelessly, 
 or from short-sightedness, are obliged to 
 bring them close to the nose, are generally 
 more difficult of extraction. In the attempt, 
 however, the eye must never be subjected 
 to too much irritation. According to Beer, 
 these extraneous particles of dust, or sand, 
 may sometimes be removed by washing the 
 eye well, or by dropping into it milk, or 
 some other viscid fluid, while the patient 
 lies upon his back, and the eyelid is lifted 
 up from the eye. But, the most expeditious 
 and certain plan is to employ a syringe, the 
 pipe of which is to be introduced under the 
 upper eyelid near the outer canthus, and the 
 fluid thrown briskly in the direction towards 
 the nose. If all the extraneous matter can- 
 not be thus removed, the rest may some- 
 times be taken out with a camel-hair pencil, 
 dipped in some viscid fluid, or fresh butter, 
 and the eye is then to be washed again. 
 
 When particles of sugar, or other soluble, 
 not very irritating substances, happen to in- 
 
 sinuate themselves into the eye, professional 
 aid is seldom required, as they generally 
 dissolve in the tears, and are voided before 
 a surgeon can arrive. Snuff, pepper, and 
 other minute irritating bodies, as well as 
 small winged insects, are to be removed in 
 the same manner, as particles of dust and 
 letter-sand ; but, particular care is to be 
 taken afterward to wash the eye well with 
 some lukewarm mucilaginous coliyrium, 
 until the irritation, caused by the chymical 
 effect of such foreign bodies, has been com- 
 pletely obviated. 
 
 The removal of foreign bodies of the 
 second class is usually attended with more 
 difficulty, because they, as well as those of 
 the third class, more frequently produce a 
 violent and obstinate spasmodic closure of 
 the eyelids, and are seldom loose, being 
 generally fixed in the cornea. However, 
 when they happen to be detached, they 
 may be extracted in the same way, as 
 small round smooth extraneous bodies, 
 except that the stroking of the eyelid with 
 the finger should be omitted, not only as 
 useless, but likely to press any of these sub- 
 stances, which are of a pointed shape, into 
 the loose conjunctiva, so as to injure the 
 eye itself, which would otherwise not be 
 hurt, l he nibs of pens, the parings of the 
 nails, and s’inall hard-winged insects, when 
 lodged in a depression of the cornea, or 
 white of the eye, Beer says, may be easily 
 dislodged by means of a small silver spatula. 
 Other foreign bodies of the second class are 
 not only fixed in a depression, but even 
 penetrate more deeply than the conjunctiva • 
 and, in old subjects, in particular, they 
 often insinuate themselves into the loose 
 cellular membrane under the conjunctiva in 
 the white of the eye, partly in consequence 
 of the convulsive motions of the eyeball 
 and eyelids, and partly by reason of the 
 attempts made to loosen them. Hence, 
 they frequently become situated a great 
 way from the place of their entrance, and 
 are complete!) covered by the conjunctiva. 
 But, even when they lie immediately in the 
 wound, they are so intimately connected 
 with the subjacent luose cellular membrane 
 of the conjunctiva, that every attempt to 
 remove them with forceps is not only una- 
 vailing, but hurtful to the eye, inasmuch as 
 the injury is thereby rendered deeper. They 
 may be taken away with facility, however, 
 when lifted up with a pair of small forceps, 
 and are cut away withja pair of scissors, toge- 
 ther with the piece of cellular membrane, 
 with which they are directly connected. 
 If such extraneous substance should be ac- 
 tually underneath the sclerotic conjunctiva. 
 Beer recommends the eyelids to be well 
 opened, and the eye to be brought into a 
 position, in which the part of the conjunctiva 
 covering the foreign body, is rendered tense 
 when an incision is to be made with a lancet 
 down to the extraneous substance, which is 
 to he taken hold of, and removed with a 
 pair of scissors, the assistant being curetul 
 to keep hold of the eyelids during the ope- 
 ration,. On the other hand, when the 
 
 i 
 
OPHTHALMY. 
 
 ‘6i)L 
 
 foreign body is actually lodged between the 
 layers of the cornea, Beer considers that its 
 extraction may be best accomplished with a 
 lancet-pointed couching needle. But, what- 
 ever instrument is used, its point must be 
 passed with great caution closely and ob- 
 liquely under the foreign body ; and care 
 must be taken not to introduce it too deeply, 
 lest the anterior chamber be opened, which 
 may readily happen in young subjects ; and 
 when it does, the aqueous humour flows out, 
 and the cornea becomes so flaccid, that the 
 removal of the extraneous substance is quite 
 impracticable, before the puncture has heal- 
 ed, and the anterior chamber is again dis- 
 tended. 
 
 The removal of foreign bodies of the 
 third class mostly demands very great cau- 
 tion, first, because, as Beer observes, no 
 particles of them should be allowed to re- 
 main in the eye, which, without the utmost 
 vigilance, is apt to be the case ; and second- 
 ly, because the wound of the eye, already 
 considerable, should not be made larger 
 than can be avoided. The extraction of 
 small bits of glass is particularly difficult, as 
 they cannot be seen, but must be found out 
 entirely by the feelings of the patient, or 
 the tactus eruditus of the surgeon, assist- 
 ed with a probe. When in this way, a 
 particle of glass is detected, Beer directs 
 us to take hold of it with a pair of forceps, 
 and cut it away with scissors. The place 
 from which it has been removed, must 
 then be carefully probed, in order that 
 no other fragment may be left iri it. {Beer.) 
 
 According to the same author, pieces of 
 iron and steel, which strike the eye so forci- 
 bly as to enter it, as well as all other frag- 
 ments of metals, which are readily oxyda- 
 ted, should be as carefully removed as bits 
 of glass; for the more easily they combine 
 with oxygen, and the longer they remain, 
 the more brittle they become, and the more 
 apt are minute particles to be left in 
 the eye, especially in the corneR. A speck 
 on the part of this membrane, where the 
 splinter has lodged, is the least serious con- 
 sequence of such an event. When frag- 
 ments of steel, which have quite a black 
 appearance, remain fixed in the cornea 
 several hours, it is found, after their removal, 
 that the whole circumference of the depres- 
 sion, from which they have been extracted, 
 is of a reddish-brown colour, produced by 
 the rust left behind, and firmly adhering to 
 the cornea. Every particle of rust must be 
 carefully removed with a couching needle, 
 or else a permanent speck will ensue ; but, 
 caution must be used not to puncture the 
 anterior chamber. The extraction of parti- 
 cles of lead and gunpowder is generally 
 difficult, as they have mostly been project- 
 ed with great force against the eyelids, so as 
 to produce not only a great deal of spasm, 
 but instantaneous swelling of those parts. 
 Hence, Beer says, that they should com- 
 monly be taken hold of with forceps, arid 
 cut away. Particles of cantharides are easi- 
 ly removed with a small silver spatula, or 
 the end of an eye-probe : but, their violent 
 
 chymical effect must be obviated, by fre- 
 quently applying to the part a little fresh 
 butter, touching it with a camel-hair pencil, 
 dipped in diluted liquor ammonia?, or drop- 
 ping into the eye lukewarm mucilaginous 
 collyria. 
 
 The attempt to wash out of the eye parti- 
 cles of quicklime, mortar, he. Beer says, 
 only has the effect of rendering the violent 
 chymical operation of these substances more 
 diffused, and he recommends them to be ta- 
 ken out of the eye, by means of a fine hair 
 pencil, dipped in fresh butter, or oil. This 
 is the only way of immediately counteract- 
 ing their chymical effect, and, after their 
 extraction, the application of unctuous sub- 
 stances to the part should still be continued. 
 
 The stings of small insects, when lodged 
 in the sclerotic conjunctiva, are often very 
 difficult of detection ; but they are more 
 readily seen on the skin of the eyelids. 
 Beer directs us to remove them with a pair 
 of forceps, or a couching needle, and then 
 to have recourse to means calculated to 
 diminish the ophthalmy, which, in these ca- 
 ses, always begins on the first occurrence of 
 the accident. Small shots, lodged in the 
 loose cellular texture of the conjunctiva, 
 must be cut out. In general, says Beer, it is 
 necessary to divide the conjunctiva, as they 
 are mostly situated some distance from the 
 place of their entrance, and of course are 
 quite covered by that membrane. 
 
 As soon as a foreign body has been ex- 
 tracted from the eye, all precursors of oph- 
 thalmy diminish, as for instance, the redness, 
 intolerance of light, and the increased se- 
 cretion and effusion of tears. Even the in- 
 flammation itself, when already developed, 
 subsides; but, this affection is slight, if the 
 eye has not itself been injured by the extra- 
 neous body. On the other hand, when the 
 eye has suffered more or less irritation from 
 the nature of the substance itself, and the 
 treatment requisite for its complete extrac- 
 tion, the inflammation may become more 
 severe, unless the surgeon pay immediate at- 
 tention to the injury left on the eye. (Beer.) 
 
 According to the principles laid down in 
 the foregoing columns, the first indication in 
 the treatment of wounds of the eye in gene- 
 ral is to remove every kind of extraneous 
 substance, which might impede the cure. 
 Hence, the necessity of observing whether 
 the instrument with which the wound has 
 been inflicted, or any part of it, is lodged in 
 the eye. When this is the case, the foreign 
 body 1 " should be quickly extracted, oreise no 
 recovery of the organ can take place. But, 
 says Beer, this is more easily said than done ; 
 for in many instances, it is very difficult to 
 find and remove the fragments of instru- 
 ments, on account of the great delicacy of 
 the. organ, the irritability and alarm of the 
 patient, and the bleeding from the part. 
 However, the attempt must be made with 
 the greatest gentleness possible ; and Beer 
 particularly advises a fine elastic whalebone 
 probe to be used, instead of a silver one, for 
 the purpose of detecting the fragment He 
 also sanctions making an incision, for facili- 
 
OPHTHALMY. 
 
 tating the finding of the extraneous sub- comes both unnecessary and impracticable., 
 stance, provided it is certainly lodged, and and all that can be done is to drop frequent- 
 cannot otherwise be traced. This aulhor ly into the eye a mucilaginous colly rium, 
 attaches great importance to the fulfilment and cover the organ with a light bandage, 
 of this first indication n all wounds of the which will not make any hurtful pressure, 
 eye, and relates a case, to which he was In simple contusions of the eye, unaccom- 
 called sixteen years ago, where a piece of panied with wound, Beer deems a bandage 
 tobacco pipe had been driven so forcibly and the otdy requisite application ; but, when 
 deeply at the external can thus between the these accidents are co joined with effusion 
 eyeball and orbit of a young student, aged of blood, he recommends the use of spiri- 
 ts), and of delicate make, that the eye was tuous aromatic fomentations, with the view 
 immediately pushed out of its socket, and, of promoting absorption, 
 on Beer’s arrival, it lay with the cornea In healthy individuals small punctures of 
 quite against the nose. Its very position led the eye, made with instruments like needles, 
 Beer to suspect, that some extraneous body and perforating only the conjunctiva, or 
 was lodged in the orbit, and, notwilhstand- cornea, but not reaching the deeper textures 
 ing the assurances of all the bystanders to of the organ, are generally followed by no 
 the contrary, and the patient’s being affected serious consequences, even when all the 
 with violent spasms, he part was examined aqueous humour is voided. It is only ne- 
 Xvith a fine flexible whalebone probe, by cessary to keep the eye quiet, and the air 
 which means, a piece of the pipe, nearly an and light excluded from it by means of alight 
 inch in length, was felt, and immediately compress, suspended over it from the fore- 
 extracted with a pair of forceps. Scarcely head. Under this treatment, such punctures 
 had this substance been removed, when the are so firtnlyclosed in twenty four hours, with- 
 ©yeball was spontaneously drawn back into out any opacity, that the chambersare nearly 
 the orbit, though w ith the cornea still turned filled again with aqueous humour, and the 
 towards the nose, and the twiichings of the intoleranceof light, which was only the effect 
 muscles also instantly ceased ; but the eye of the loss of that fluid is entirely removed. 
 Was blind, and had but a very faint percep- In large clean cut wounds of the eye, 
 tion of light. By very careful treatment, the whether accidental or made in the extraction 
 eyesight was restored in five weeks ; but, of the cataract, the prognosis must be very 
 the eye could not turn towards the temple, cautious, and the treatment conducted with 
 owing to the considerable injury, which the the utmost care ; for, says Beer, it too readi- 
 external straight muscle had sustained. With ly happens, that, though the wound is not 
 the aid of electricity, the power of rotating important in itself, its effects become from 
 the eye about half its natural extent out- the least mismanagement highly dangerous 
 wards was in the end regained, and the re- to the eye. Hence, when the patient is 
 maining infirmity resisted every method, known to be either an individual not likely 
 deemed worthy of trial. (Beer, 8. 1, p. 146. to take proper care of himself, or one too 
 See also the article Exophthalmia.) much alarmed about tbe fate of his eye, the 
 
 Fragments of broken instruments are not prognosis should be very guarded, even 
 the only kind of extraneous substances, where the eonsitution is of the best descrip- 
 which may lodge in the wounded eye ; for, tion, because a violenl and dangerous attack 
 as Beer observes, when the injury is exten- of ophthalmy is apt to ensue, and destroy 
 sive, contused, and lacerated, there may be the eye, sooner than effectual succour can 
 splinters of bone, or pieces of membrane, be administered. On the other hand, when 
 cellular substance, muscle, &.c. so detached the patient is steady and intelligent, and the 
 as to be quite incapable of reunion, on case is properly treated, the prognosis is very 
 which account, this author sets them down favourable. 
 
 as foreign bodies requiring to be taken away. In considerable cuts of the eye, it is only 
 However, I conceive, that, with respect to possible to promote their union with asuita- 
 fhe soft parts, the advice here delivered ble bandage, and by effectually preventing 
 should be received with much limitation all motion of the eye and eyelids, which is 
 Wounds of the eye, like those of most best accomplished, when the sound as well 
 other parts of the body, may be healed as the injured eye is covered, and the patient 
 either by direct union, or a slower process, kept quiet in bed until the sidesof the wound 
 in which suppuration, the filling up of the have grown together. (Beer, B. \,p. 164.) 
 chasm, by granulations, and the gradual but As cases of deeply penetrating wounds of 
 not complete approximation of its edges to the eyeball itself, Beer enumerates the punc- 
 each other, are the most conspicuous effects, tures made in the depression and reclination 
 Clean incised wounds may be cured in the of the cataract, and in every mode of form- 
 first way, (see Cataract ;) and lacerated, ing artificial pupil ; and lacerations of the 
 contused wounds, or such as are attended co junctiva with ears of corn, pointed pieces 
 with loss of substance, in the second. But, of iron, splinters of wood, &.c. In these 
 whichever plan be attempted, the eye must cases, the prognosis, he says, is always very 
 be kept quiet, and excluded from the air and favourable, when the patient can put him- 
 light, with a light suitable bandage As in self under all t lie conditions which the treat- 
 wounds arid chymical injuries of the eyeball rnent requires, and his constitution is good, 
 itself, not admitting of reunion, tiie eyelids, The first thing here to be carefully fulfilled, 
 when dosed, completely cover the wounded is the removal of any fragments of the in- 
 part, , the application of dressings to it be- sfrument, or body, with which the injury ha** 
 
OFHTHALMY 
 
 been inflicted, and it should be recollected, 
 that, in these cases, minute splinters, which 
 are scarcely discernible, frequently lodge in 
 the conjunctiva, and, if not immediately tra- 
 ced and removed, produce the very worst 
 consequences. By the weapon being sud- 
 denly withdrawn, pieces of the conjunctiva 
 are sometimes nearly torn away, and hang 
 from the eye ; these Beer directs to he cut 
 off with scissors. The best applications, he 
 says, are either lukewarm mucilaginous lo- 
 tions, or, (when blood is effused under the 
 conjunctiva,) vinous, spirituous collyria. 
 To these cases, he thinks fomentations 
 scarcely applicable. When the quantity of 
 blood, effused in the loose cellular texture 
 under the conjunctiva, is very considerable, 
 he recommends scarifications but, where 
 this practice does seem likely to answer, and 
 vinous spirituous collyria are ineffectual, 
 some of the liquor ammonia? should be 
 added to them. When any fragment of the 
 instrument has been overlooked, and remains 
 in the part, either a copious suppuration en- 
 sues, and the fragment is at length detached, 
 or else, in a patient of inferior sensibility, a 
 soft, spongy, readily bleeding, pale-red ex- 
 crescence is formed all round the extraneous 
 body, and sometimes even projects between 
 the eyelids. Here, according to Beer, the 
 first requisite step is to cut away the fungus 
 with a knife, so as to reach the irritating frag- 
 ment under it, and then the rest of the ex- 
 crescence may be removed by touchingit wit h 
 the tinctura thebaica, or vinous tincture of 
 Opium. 
 
 With respect to lacerated wounds of the 
 cornea, they either penetrate the anterior 
 chamber, or not. They are all of them at- 
 tended with more or less concussion, lacera- 
 tion, stretching, and partial contusion of 
 the delicate anterior textures of the eyeball ; 
 a consideration, as Beer observes, materially 
 affecting the prognosis. When, in such in- 
 juries of the cornea, inflammation and sup- 
 puration cannot be prevenied, or the dis- 
 charge is protracted, an obvious scar is 
 always the consequence, which, when situa- 
 ted in the centre of the cornea, is a serious 
 impediment to vision. Every endeavour 
 should therefore be made to unite the wound 
 by the first intention ; and the best chance 
 will be afforded by treating the eye precise- 
 ly in the same manner ns after the extraction 
 of the cataract. (See alaract ) And. whi n 
 fortunately the plan succeeds, the flow of 
 the aqueous humour out of t he eye ceases 
 in about 36 or 48 hours, and the anterior 
 chamber becomes distended again ; but, the 
 site of the injury continues visible for some 
 time afterward. The speck, however, ulti- 
 mately disappears, though much sooner in 
 young healthy subjects, than in the aged and 
 feeble. When the opacity does not go off 
 of itself, Beer finds a collyrium, containing 
 some of the lapis divinus, (see Lachrymal 
 Organs ,) and the vinous tincture of opium, 
 the most effectual means of dispersing it. 
 Through large wounds, penetrating the cor- 
 nea near its edge, a fold of the iris is apt to 
 protrude, and, when it does, it should be re- 
 
 30ii 
 
 placed, which can only be effected without 
 mischief to the eye by gently rubbing the 
 upper eyelid, and then letting a strong light 
 suddenly strike the organ. In this case, the 
 employment of\ instruments is < onsidered 
 by Beer highly objectionable. When the 
 iris is not immediately reduced, it as well as 
 the cornea is attacked with inflammation; 
 and soon becomes firmly adherent to the 
 edges of the wound. (S te Iris, Prolapsus of 
 the,) 
 
 Large wounds penetrating the eyeball, and 
 reaching, to the ris, are always of a very 
 serious nature, even though the latter part 
 may have received only a prick, or cut, be- 
 cause as tile injury iias been produced by 
 accident, and not by art, the wound of the 
 iris cannot be free from all laceration and 
 contusion. It is incredible, says Beer, what 
 extensive injuries the iris will bear in healthy 
 individuals at its pupillary and ciliary edges, 
 especially when produced bv very sharp" in- 
 struments; nay, rents n ay happen at noth 
 its edges, without any ill consequences, if 
 the constitution be favourable; a proof of 
 which fact is seen in the two common me- 
 thods of forming an artificial pupil viz. tho 
 excision of a piece of the iris and the de- 
 tachment of the iris from the ciliary liga- 
 ment, as practised both by Schmidt and 
 Scarpa. But, according to Beer, all violent 
 pressure, or actual contusion, particularly 
 when it affects the portion of this organ be- 
 tween its tw o circles, cannot be borne even 
 in the best constitutions, and the least grie- 
 vous consequence is inflammation, oon fol- 
 lowed by a partial or complete closure of 
 the pupil, or suppuration in the eyeball. 
 When the instrument, causing such injury, 
 passes to the iris through the cornea, as is 
 mostly the case, and the wound in the latter 
 tunic is extensive, the torn iris is frequently 
 pulled between the edges of the wound, at 
 the moment when the eapon is withdrawn, 
 and protrudes in a lacerated state. In this 
 case, Beer recommends the torn projecting 
 piece of the iris to be cut away with scis- 
 sors close to the wound in the cornea, 
 when the rest, he says, is generally retract- 
 ed within the eye. Thus an adhesion of the 
 iris to the cornea, termed synechia anterior , 
 may often be prevented, which, when the 
 lacerated iris is suffered to hang out of the 
 cornea, is inevitable, surrounded by a large 
 opaque cicatrix. 
 
 Some violent blows on the eye, though 
 they cause no woi nd, are attended with 
 such a concussion of the anterior hemis-- 
 ph re of the organ, that more or less of the 
 iris is instantaneously separated from the 
 part of the ciliary ligament, where the force 
 is most vehement. The consequence of 
 this accident is either a double pupil, or the 
 natural pupil closes, and the artificial one 
 remains open. Such injuries may be pro- 
 duced by the lash of a whip, or a horse’s 
 tail, (a common accident in the narrow 
 streets of Vienna) or the thrust of any 
 bluntish weapon against the outer part of 
 the cornea ; and they are purposely inflict- 
 ed in the method of forming an artificial. 
 
0PHTHALM5T. 
 
 ‘M 
 
 pupil, recommended both by Schmidt and 
 Scarpa. 
 
 Wounds which enter the eye through the 
 sclerotica near the cornea, usually produce 
 a considerable effusion of blood in the 
 chambers of the aqueous humour; but 
 Beer thinks that there is never any necessity 
 for making an opening for its discharge at 
 the lower part of the cornea, except when 
 it is so considerable as completely to hide 
 the iris, at the same time that the eyeball is 
 affected with very painful tension and hard- 
 ness. In all wounds of the iris, it is like- 
 wise proper to follow the same treatment 
 as applies to penetrating wounds of the cor- 
 nea, with this difference, that when the 
 effusion of blood in the chambers of the eye 
 is considerable, the action of the absorbents 
 should be promoted by the immediate em- 
 ployment of vinous aromatic collyria, and 
 afterward warm spirituous lotions. 
 
 Wounds of the eyeball, affecting the cor- 
 pus ciliare, are set down by Beer as ex- 
 tremely dangerous, independently of the 
 inflammation, which quickly follows. How- 
 ever, such injuries are most serious when 
 they consist in a real contusion, or lacera- 
 tion of the corpus ciliare, >vhich can hardly 
 take place without a severe concussion, or 
 actual disorganization of the retina, and 
 laceration of the principal ciliary nerves 
 and vessels. Hence, besides an effusion of 
 blood in the chambers of the aqueous hu- 
 mour, a partial or complete amaurotic blind- 
 ness' is instantly produced, and the iris, in 
 the vicinity of the place where the instru- 
 ment entered, is so retracted towards the 
 margin of the cornea, that neither of its 
 circles can be seen. In cases of this de- 
 scription it also frequently happens, says 
 Beer, that the patient, or the person who 
 inflicted the wound, suddenly and roughly 
 pulls the w r eapon out of the eye again, and 
 together with it a part of the corpus ciliare, 
 which is then to be regarded as an extrane- 
 ous substance, and immediately cut off. 
 With respect to the prognosis and treatment, 
 the observations already made on these 
 topics, in reference to wounds of the iris, 
 are here quite applicable, excepting that as 
 the effused blood is less copious than in the 
 latter cases, there can never be here any 
 necessity for letting it out by a depending 
 opening in the cornea. 
 
 Wounds of the eye, affecting the crystal- 
 line lens, are not unfrequently follow ed by 
 the formation of a cataract, and so are blows 
 on the eye, which may be supposed to pro- 
 duce this effect by destroying some of the 
 minute nutrient vessels naturally connect- 
 ing the capsule w ith the lens. (Beer, B. 1, 
 p. 218.) The treatment of these accidents 
 resembles that of injuries of the iris, except 
 that the surgeon has rarely any extravasation 
 of blood to deal with. However, when the 
 lens has slipped into the anterior cham- 
 ber, Beer recommends its immediate extrac- 
 tion through an incision in the cornea, in 
 order to prevent the eye from being de- 
 stroyed by a violent attack of traumatic 
 inflammation and suppuration. Nor -when 
 
 inflammation has come on, should this mea 
 sure be postponed, as Beer has constantly 
 found the disorder lessen, after the lens has 
 been taken out. 
 
 Considerable w ounds of the eye, attend- 
 ed with loss of the vitreous humour, are 
 described by Beer as of a very serious na- 
 ture ; but they rarely take place acci- 
 dentally, being almost alw r ays the conse- 
 quence of a surgical operation. Accidental 
 injuries of this kind are generally combined 
 with so large or complete a discharge of the 
 vitreous humour, and with such mischief to 
 the organization of the eye, thal the conse- 
 quence is a loss of the eyeball, or such a 
 dwindling of it, that the fissure of the 
 eyelids becomes nearly closed. Accord- 
 ing to Beer’s experience, injuries of the 
 foregoing kind, arising from accident, are 
 mostly produced by the horns of cows. On 
 the contrary , the effusion of the vitreous 
 humour in operations upon the eye, he ob- 
 serves, is seldom followed by the loss of the 
 eye. Kortum, in his Manual on the Disea- 
 ses of the ftye, adverts to some instances 
 which he had seen, or fancies that he had. 
 seen, w r here the whole of the vitreous humour 
 was lost, and yet the eyesight afterward be- 
 came as strong as if no such accident 
 had happened. On the other hand, Beer 
 has never met with any of these fortunate 
 cases ; but has always found the sight to be 
 seriously impaired when the quantity of vi- 
 treous humour lost has amounted to nearly 
 its half, and that complete blindness w r as 
 the result w r hen the loss much exceeded 
 that quantity. He conceives also, that 
 Kortum had probably seen but few cases of 
 this nature, and therefore might have been 
 mistaken, as to the proportion of the vitre- 
 ous humour discharged, which to the inex- 
 perienced seems larger than it really is, and 
 he cautions surgeons not to promise too 
 much in cases of this description. (B. 1 ,p. 
 222.) See Cataract. 
 
 Considerable injuries of the eyeball, com- 
 plicated with a concussion, bruise, or actual 
 wound of the retina, produce, either gradu- 
 ally or immediately, an amaurosis, which is 
 almost always incurable. When the con- 
 cussion of the retina is less violent, and does 
 not affect every part of this texture, it may 
 occasion only an amaurotic weakness of 
 sight. In worse cases, the surgeon mny 
 think himself very successful if he can pre- 
 vent the figure of the eye from being de- 
 stroyed by the subsequent inflammation, all 
 idea of the recovery of the eyesight being 
 out of the question. The treatment is the 
 same as that commonly adopted after ope- 
 rations for the removal of an opaque lens 
 (see Cataract ;) but there is one particular 
 circumstance, sometimes attending injuries 
 of the retina and ciliary nerves, claiming 
 notice, viz. violent vomiting; a symptom 
 which Beer says may even attend contu- 
 sions of the sclerotica and of the ciliary 
 nerves and retina, without any wound. In- 
 juries of the ciliary nerves, he observes, are 
 denoted by a very peculiar appearance ; for, 
 near the injured part, the iris is drawn up 
 
OPHTHALMY. 
 
 0O0 
 
 ao close 10 the edge of the cornea, that its strongish mineral acids. And even in these 
 colour can scarcely be seen. When the examples, says Beer, the prognosis is net 
 surgeon is consulted in a case of this kind, unfavourable, and a complete recovery 
 though some inflammation may have com- may be effected when the treatment is con- 
 menced, the prognosis is yet favourable, in ducted according to the directions already 
 regard to the preservation of the eye ; for a given with respect to such accidents in 
 
 gentle opiate will relieve the vomiting 
 when merely a nervous effect, not depend- 
 ing upon the loaded state of the gastric 
 organs but, if the case be of this last de- 
 scription, the prima 1 viae should first be emp- 
 tied. However, when a traumatic inflam- 
 mation is con.pletely established, before the 
 treatment is begun, the eye is generall) de- 
 stroyed, asthe repeated and violent vomiting 
 cause a great determination of blood to the 
 head and eyes, and increase of the inflamma- 
 tion ; an effect which the opiates, given for 
 the relief of the vomiting, also tend to pro- 
 duce 
 
 Beer has seen two cases in which the eye 
 was pricked with a needle n-ar the insertion 
 of the external straight muscle into the scle- 
 rotica ; in both instances, the punctures 
 were so small, that they w r ould scarcely 
 have been found, had not the patients know n 
 their situation exactly by the pain, and they 
 were then only perceptible w ith a magnify- 
 ing glass. The punctures were soon follow- 
 ed by a convulsive rolling of the eyeball, 
 and afterward by trismus, which continued 
 severe in one patient a day and a half, and 
 in another two days, but yielded to large 
 doses of musk and opium given at short 
 intervals, the warm bath, and the applica- 
 tion of warm poultices containing byos- 
 ciamus. 
 
 As chymical injuries of. the eye produce 
 an actual loss of substance, they are even 
 more serious than common mechanical 
 lesions. However, chymical injuries of 
 little extent are generally repaired with 
 tolerable facility and expedition. Quietude 
 of the organ, and moderating the outward 
 noxious effects by lukewarm mucilaginous 
 applications, eithf r in the form of fomenta- 
 tions, or eye waters, are the only requisite 
 measures. If the cornea itself be hurt, as 
 frequently happens w hen boiling hot fluids 
 strike the eye, a kind of vesicle arises on 
 the injured part, which becomes more and 
 more white. The vesicle either bursts of 
 itself, or subsides without breaking. In 
 both cases, the production of the conjunc- 
 tiva, of which the cyst of the vesicle is 
 composed, shrivels up, and peels off, a new 
 membrane of a similar nature being regene- 
 rated underneath. An opaque speck is fre- 
 quently apprehended 5 but, says Beer, it the 
 surgeon will merely avoid being too much 
 in a hurry to open the vesicle, and not 
 disturb the work of nature by applying 
 various remedies to the eye, there will be 
 no danger of such an occurrence. 
 
 More extensive chymical injuries of the 
 «ye, which at first are not in themselves 
 very severe, frequently become dangerous, 
 in consequence of care not being taken to 
 prevent the influence of external stimuli. 
 To this class of cases belongs the accidental 
 sprinkling of the eve with boiling fluids, or 
 Vor. If. ‘ 39 
 
 general. While this author apjwove.s of 
 cutting away any substance which is dead 
 and partially detached, he strongly cau- 
 tio.s surgeons not to remove the thin layer 
 of the conjunctiva, nor to puncture any 
 vesicle which may form. 
 
 When the burning or corrosion is not 
 limited to the conjunctiva of the eyeball, 
 but extends to the lining of one or both eye- 
 lids, Beer recommends covering the injured 
 parts with mucilaginous applications, and 
 mildly astringent ointments, containing 
 tutty, or the white oxide of lead. In these 
 cases, keeping the eye perfectly motionless 
 must be hurtful, as it tends to promote the 
 formation of adhesions, either between the 
 eye and eyelids, (Symblepharon) or be- 
 tween the eyelids themselves. (Ancbylo- 
 blepharon.) 
 
 Extensive, deeply penetrating, chymical 
 injuries of the eyeball. Beer -describes as 
 being almost always followed by more or 
 less impairment of the functions of the 
 organ, or of some of its particular textures, 
 because such accidents never happen w ith- 
 out a loss of substance. Thus a part, or the 
 whole, of the cornea may be entirely de- 
 stroyed, as in injuries caused by quicklime ; 
 and, frequently, adhesions between the eye 
 and eyelids, or betw een the tw o latter parts, 
 cannot be prevented by any kind of skill. 
 {Beer.) These serious degrees of mischief, 
 as the same author observes, are mostly 
 occasioned by slaked or unslaked lime, con- 
 centrated mineral acids, fire, he. Unslaked 
 lime, especially when extensively diffused 
 over the eye by the immediate application 
 of w ater, not unfrequently produces a sud- 
 den destruction of the whole of the cornea, 
 which is changed into a grayish, pappy sub- 
 stance, capable of being removed from the 
 subjacent iris with a camel-hair pencil. 
 Such an annihilation of texture, however, 
 is generally restricted to particular points, 
 or the surface of the cornea. Wherever 
 this membrane has been so much decom- 
 posed, that a manifest depression is directly 
 perceptible in it when inspected sidewrays, 
 a snow-white shining speck must be expect- 
 ed to be the consequence. Slaked lime 
 never operates upon the cornea with so 
 much violence, usually causing (as Beer 
 states) only a superficial corrosion, or a 
 coagulation of the lymph between the layers 
 of the cornea. Nor are mineral acids, 
 even when concentrated, genera! ly so de- 
 structive to the cornea as qu'cklime; first, 
 because, as fluids, they do not long remain 
 in contact with the eye ; and secondly, be- 
 cause the immediate mixture of the tears 
 with them weakenstheir operation ; whereas 
 it only increases that of unsiaked lime. Tfce 
 local treatment here consists in carefully 
 removing every particle of the hurtful sub- 
 stance, afterward dropping frequently into 
 
OFHTHALUfir 
 
 M 
 
 the eye lukewarm mucilaginous decoctions 
 or collyrin, or covering the injured place 
 with a mild cerate, and excluding the 
 air and light from the eye. Every endea- 
 vour must also be made to prevent the 
 formation of adhesions between the injured 
 surfaces. 
 
 In very severe burns of the eyeball, of 
 course, all idea of restoring its functions is 
 out of the question i he violence of the in- 
 jury is the greater, the more numerous the 
 vesicles are upon the conjunctiva, and the 
 more the eyeball and the iris are incapable 
 of motion. Here the only indication is to 
 moderate the inflammation, and avert such 
 additional mischief, as might otherwise be 
 produced by it. With this view, the eye 
 should be kept at rest, and excluded from the 
 light and air. According to Beer, the most 
 common injuries of the eye, partaking both 
 of a mechanical and chymical nature, are 
 those caused by mortar, or the accidental 
 touching the eye with hot curling irons. 
 When the mortar contains no particles of 
 quicklime, it often occasions, at particular 
 points of the cornea, very white specks, 
 which Beer describes as being composed of 
 coagulated lymph, and admitting of disper- 
 sion. He even declares, that when the 
 whole of the cornea is in this state, its trans- 
 parency may be restored by_ proper treat- 
 ment, as has been frequently exemplified to 
 the gentlemen attending his clinical lectures. 
 (B. i,p. 234.) The pricking of the eyeball 
 with a red-hot needle, and the stinging of i 
 by bees, wasps, and other insects, are also 
 both chymical and mechanical injuries. 
 Whether the sting be left in the skin of the 
 eyelid, or in the conjunctiva, or not, a 
 considerable inflammatory swelling immedi- 
 ately takes place ; and, if the sting be lodged, 
 and not now taken away, the inflamma- 
 tion spreads, and the eye itself is endangered. 
 In two eases, where the stings of bees were 
 left in the skin of the upper eyelid, Beer has 
 known gangrene arise in the short space of 
 a day and a half, and the patients were 
 saved with great difficulty. The treatment 
 of such cases consists in immediately ex- 
 tracting the sting, if lodged, and applying 
 folds of linen over the eye, wet with cold 
 water. 
 
 After noticing the destructive effects of 
 burning substances, the explosion of gun- 
 powder, and fulminating silver on the eve, 
 (cases in which, when the functions of the 
 organ are annihilated, the only indication is 
 to diminish the subsequent infiammat o:: and 
 its consequences,) Boer inquires, what is the 
 reason why the slightest mechanical, or 
 chymical, injuries of the eye, in an appa- 
 rently healthy subject, are sometimes fol- 
 lowed by an immoderate degree of inflam- 
 mation, and even the loss of the organ from 
 suppuration ? It is, says he, an observation 
 made by Schmidt, that there are some eyes, 
 which the greatest bunglers may abuse for 
 hours at a time, without being spoiled, their 
 powerful organization defying all such un- 
 skilful disturbance ; while other eyes are 
 met with, which the most skilful opera- 
 
 tors can hardly touch, without inducing a*, 
 destructive degree of inflammation and sup- 
 puration. It was to this peculiar idiosyn- 
 crasy that Schmidt applied the tevm vulnera- 
 bility ( Verwundharkeit.) Patients of this habit 
 are said to possess an exceedingly fine soft 
 skin, with a reddish polish upon it, and their 
 cheeks are not only red, but exhibit a net- 
 work of very minute vessels, which seem as 
 if injected. Such individuals appear as if 
 they were in the bloom of health ; and, says 
 B er, in some respects they are really so. 
 When their spirits are raised by the slightest 
 causes, their complexion is universally red- 
 dened ; but the least fear turns them as pale 
 as a corpse. Their skin is described as being 
 uncommonly irritable, sensible of every im- 
 pression. and attacked wiih an erysipelatous 
 redness, whenever any fatty substance touch- 
 es it. In such habits, the utmost caution is 
 necessary whenever the eyes have been in- 
 jured, and the prognosis should be reserved. 
 And, when an operation is to be done on 
 their eyes, Beer recommends the previous 
 exhibition of opium, and the application of a 
 blister to some part of the skin, at a consi- 
 derable distance from them. As a prophy- 
 lactic measure, he also directs regular fric- 
 tion of the surface of the body. 
 
 In severe ophthalmies, particularly those 
 which affect the eyeball itself, all mental 
 emotions, anger, joy, &,c. should be avoided. 
 Hence, no talkative nor quarrelsome per- 
 sons should be suffered to remain with the 
 patient; and noisy childien ought to be kept 
 away from him. The apartment should 
 be ventilated at least once a day, without the 
 patient being exposed to any current of w ind. 
 All touching of the eye, or rubbing it with 
 the bed-clothes during sleep, must be strictly 
 prohibited. Stimulating, spicy food, spiritu- 
 ous drinks, and great bodily exercise are like- 
 wise to b>- forbidden. In the list of things 
 which have a hurtful effect, Beer also in- 
 cludes all exertions of the lungs, every kind 
 of disturbance, an atmosphere impregnated 
 with tubacco-smoke, &.c. 
 
 Having fulfilled the first general indication 
 by removing, if possible, every kind of irrita- 
 tion acting upon the eye, the second central in- 
 dication specified by Beeras proper in the first 
 stage of ophthalmy, is to be observed, which 
 is to moderate , according to Ifv degree of in- 
 flammation, the agem y of several things to the 
 effect of which, the organ is naturally subjected. 
 Thus, the inflamed eye should not be exer- 
 cised, even though the eyeball itself may not 
 be immediately inflamed ; and the operation 
 of the light and air should be diminished 
 partly by green silk eye-shades, and partly 
 by window blinds. Attention to this rule 
 is still more necessary, when the eyeball 
 itself is affected. With respect to the exclu- 
 sion of light, it is to be well remembered, 
 that it is only adviseable, as Dr. Vetch 
 observes, in the very early stage of inflam- 
 mation, the eye becoming more irritable and 
 less manageable, w! en the access of a 
 moderate degree of light is afterward pre- 
 vented. ( Vetch on Diseases of the lyc, p. lb.) 
 
 The third general indication , mentioned 
 
OPHTHALMY. 
 
 307 
 
 by Beer, as proper in tbe first stage of 
 ophthalmy, when the disorder threatens to 
 extend to the whole organ, and to bring on 
 a febrile disturbance of the system, is to 
 counteract these effects by covering the eye 
 with folded linen wet with simple cold 
 water, or vinegar and water; and having 
 recourse to leeches, or when the nature of 
 the case allows, to scarifications (B. 1 , p. 
 242.) Here, however, it merits particular 
 notice, that, Beer, in expressing a general 
 preference to cold lotions in the first stage 
 of ophthalmy, differs from Richter, Scarpa, 
 and Mr. Travers, ( Synopsis of the Diseases of 
 the Eye,p . 250,) all of whom, in the painfully 
 acute stage, recommend tepid emollieut ap- 
 plications. 
 
 With regard to leeches, also, the late Mr. 
 Ware objected to their being put on, or very 
 near the e) elids, as they sometimes cause a 
 cons.derable swelling of these parts, and 
 increase, instead of lessening the irritation. 
 In ordinary cases, his method was to apply 
 three on the temple, about an inch and a 
 half from the outer part of the orbit. 
 Scarpa recommends applying the leeches to 
 the vicinity of the eyelids, especially about 
 the inner canthus, on the vena angularis, 
 where it joins the frontal, deep orbitar, and 
 transverse vein of the face. Beer prefers 
 nearly the same situation, as that»specified 
 by Scarpa, viz. the inner canthus, immediately 
 below the under eyelid ; and he forbids the 
 application of leeches above either canthus, 
 as likely to produce a disagreeable ecchy mods 
 in the cellular membrane of the upper eyelid. 
 The number of leeches, and the time, which 
 they should be allowed to suck, he thinks, 
 ought to depend upon the severity of the 
 inflammation. According to Beer, when this 
 mode of bleeding is to be of any service, 
 the patient will experience a considerable 
 abatement of the throbbing pain, tension, 
 &c. in the affected eye. Hence, when any of 
 the leeches fall off prematurely, the bleeding 
 from the bites is to be kept up, with a sponge 
 dipped in warm water, until such relief is 
 felt. In the acute stage, Beer considers the 
 abstraction of blood by means of scarifica- 
 tions rarely admissible. (B. \,p. 243.) Mr. 
 Travers also sets down scarifications of the 
 conjunctiva as mostly objectionable in the 
 acute stage ; though highly beneficial in the 
 chronic, where the lining of the eyelids is 
 thickened and over vascular; and a con- 
 siderable discharge of blood may be thus 
 obtained, if the operation be briskly done 
 With a sharp lancet, and the lower lid kept 
 everted, and fomented. The same gentle- 
 man states, that cupping has a decided supe- 
 riority over leeches, but that both are well 
 adapted to relieve local congestion. Yet, he 
 deems these methods too indirect to answer 
 as substitutes for the lancet, where it is de- 
 sirable to make the system “ sustain and feel 
 a reduction of power,” in which case blood 
 must betaken from a vein, or the temporal 
 artery. ( Synopsis , fyc. p. 249.) While inflam- 
 mation of the conjunctiva is described by 
 Dr Vetch, as not much affected by bleeding, 
 unless the Quantity of blood taken away be 
 
 such as to occasion syncope, he states, that 
 the abstraction of blood, in quantities pro- 
 portioned to the violence of the symptoms, 
 more especially, by means of cupping and 
 leeches, has for the most part sufficient con- 
 trol over the various states and individual 
 symptoms of sclerotic inflammation. In 
 some obscure cases of what this author 
 terms amaurotic inflammation, he has seen 
 great benefit derived from the application of 
 leeches to the septum nasi, and he represents 
 their being put directly on ihe conjunctival 
 li .ing of the eyelids, as being sometimes 
 more advantageous than on the adjacent 
 integuments the orifices bleeding with great 
 freedom. (On Diseases of the Eye,p 15.) 
 
 If some of the above remarks are correct, 
 scarifications are rather too boldly praised 
 by the late Mr. Ware, as applicable to the 
 acute stage of ophthalmy. But, supposing 
 the first violence of the attack past, his re- 
 commendation of the practice either in the 
 vascular and turgid state of the lining of the 
 eyelids, or in the eversion of the lower one 
 from a similar cause, seems perfectly unob- 
 jectionable. When the upper eyelid was 
 very cedematous, and its thickness prevented 
 the application of proper remedies to the 
 eye, Mr. Ware also thought a few punctures 
 near the cilite useful, by causing a discharge 
 of bloody serum, and a quick subsidence of 
 the swelling. And he speaks of the excision 
 of a piece of the excessively tumid lining of 
 each eyelid, in cases of ophthalmy with 
 ev ersion, as having afforded ; reat and speedy 
 relief. (Ware on Ophthalmy. fyc. p. 39 ) 
 
 The fourth general indication , enumerated 
 by Beer, is that, which has for its objects a 
 diet and reirimen suited to the state of the 
 case, after it has attained a degree, in which 
 its effects begin to be felt throughout the 
 system. When therefore the plan is to be 
 rigorously practised, the patient’s ordinary 
 diet is to be reduced, and he is to be allowed 
 only vegetable food, cooling drinks, water, 
 weak lemonade &.c. And not merely the 
 eye itself is to be kept at rest, but the whole 
 body. 
 
 Should the disorder be further advanced, 
 and attended with a great deal of inflamma- 
 tory fever, the observance of the foregoing 
 indications will not suffice for checking the 
 inflammation and preventing suppuration, 
 unless the fifth indication, laid down by 
 Beer, be fulfilled, which is to employ suck 
 remedies as operate upon the whole constitution, 
 1 Purgative and gently aperient medicines, 
 which will empty the bowels well, and lessen 
 the determination of blood to the head and 
 eyes. 2. Clysters, which are useful on the 
 same principles. 3. The frequent exhibition 
 of the nitras potassee. 4. General bleeding, 
 the efficacy of which will much depend upon 
 the blood being voided in a full stream. 
 Beer seems to prefer opening a vein on the 
 foot ; but, in England, the most experienced 
 practitioners generally open a vein in the 
 arm, and sometimes the temporal artery. 
 The blood, as Beer remarks, should be allow- 
 ed to flow until the hard small pulse rises and 
 becomes plainly softer;- for, otherwise tho 
 
OPHTHALMT. 
 
 am 
 
 operation will be completely useless. Also, 
 when in these cases, general bleeding is no 
 longer indicated, the employment of leeches 
 will yet be advantageous, and afterward, sca- 
 rifications may be practised, which, at any 
 earlier period, would have aggravated all the 
 inflammatory symptoms. 
 
 By strict attention to the five above ex- 
 pl lined indications, either without precipita- 
 tion. or too much delay, the first stage of 
 opVhalmy, even when in its most violent 
 degree, may be certainly checked and re- 
 solved ; and all suppuration avoided, so 
 that the eye may be restored to a perfectly 
 sound state again, provided the patient, 
 previously to the attack, was quite healthy, 
 and of course the affection of the eye a 
 genuine idiopathic inflammation. {Beer, B. 
 
 1. p. 246, 247.) 
 
 Respecting the prognosis and indications in 
 the second stage of ophthalmy in general, and 
 of idiopathic cases in particular, Beer offers 
 many interesting remarks. He observes, 
 that when ophthalmy has reached its second 
 stage, which may be known by circum- 
 stances already referred to in the preceding 
 columns, it must be clear, that the above 
 indications are no longer valid, and the ful- 
 filment of them would destroy the eye. 
 
 In the second stage, every thing yv hich has 
 a tendency to produce further weakness of 
 the eye must be avoided, or suppuration 
 will be the consequence : the first indication, 
 therefore, specified by Beer, is to let the eye 
 he cautiously exposed according as its tendency 
 will allow , to its wonted stimuli again. 1. 
 By letting fresh, dry, and, if possible, a 
 warmish air, have free access to the organ. 
 
 2. By exposing the eye to as much light (not 
 of a reflected description) as can be borne, 
 not only without difficulty, but with pleasure, 
 
 3. By moderately exercising the organ, 
 especially in the inspection of agreeable 
 diversified objects ; a plan, which is of infi- 
 nite service, when the eyeball itself has 
 been affected. 
 
 The second indication, proposed by Beer 
 in the second stage of ophthalmy in general, 
 is to apply tonic remedies, particularly those of 
 a volatile kind, to the eye, which are to be dis- 
 continued in the event of suppuration. 1. 
 Beer praises the application of well-warmed 
 linen compresses, which, if necessary, may 
 be sprinkled with camphor ; or, in urgent 
 cases, he uses little bags of aromatic herbs 
 and camphor ; a practice, in which I am 
 disposed to think surgeons here will have 
 little or no confidence 2. However, when 
 the eye is too irritable to bear the applica- 
 tion of bags of aromatic substances, Beer 
 sanctions the employment of poultices nude 
 of bread crum and warm herbs, or the pulp 
 of a roasted apple. But, this experienced 
 author is very particular in qualifying his 
 approbation of moist applications with a 
 caution, that they must never be allowed to 
 become completely cold on the eye, where- 
 by they would do more harm in a quarter of 
 an hour, than any good, which may have 
 been attained in many hours by their pre- 
 vious use. Hence, Beer employs poultices 
 
 only in cases of necessity. In this country, 
 “ when the extreme vascular congestion and 
 excessive sensibility are reduced, and the 
 inflammation tends to become chronic, the 
 U3c of cold lotions, of a slightly ton c quality, 
 is substituted with great advantage for ablu- 
 tions of warm water. The sulphates of 
 alum and zinc are the best.” {Tracers, Sy- 
 nopsis, tyc. p. 252.) The employment of 
 astringents also agrees with the advice 
 delivered by Richter and Scarpa. Here 
 then we find a point on which Beer differs 
 from the generality of writers ; but, nothing 
 is clearer to me, than that his alarm about 
 the ill effect of cold upon the eye in the 
 second stage of ophthalmy is only the fruit 
 of some theories, which he entertains, and 
 not of impartial experience 3. When there 
 are small ulcers, or pustules, on the eyeball 
 itself, Beer assures us, that great benefit is 
 derived from dropping between it and the 
 eyelids a tepid solution of the lapis divinus, 
 the composition of which is elsewhere des- 
 cribed (see Lachrymal Organs,) and bathing 
 the eye with the same application, to which 
 a little of the vinous tincture of opium is 
 added. Should this remedy fail in checking 
 the progress of the ulcers, or pustules, Beer 
 reeommends the addition of acetate of lead. 
 
 4. And, says the same author, when no deci- 
 ded amendment is produced, within twenty- 
 four hours, the suppurating points must be 
 touched once or twice a day, according to 
 the urgency of the danger, with a camel-hair 
 pencil, dipped either in a watery solution of 
 opium, or the vinous tincture of opium. In 
 the worst cases, he even directs Hoffman’s 
 balsam, vitas, naphtha, or the Peruvian balsam 
 to be mixed with the vinous tincture of 
 opium. 
 
 But, Beer observes, that when these reme- 
 dies have been too precipitately employed, 
 and any granulations, or excrescences form, 
 the treatment must be less active, and then 
 these new productions will frequently recede 
 of themselves ; but, if they should not do so, 
 they may be removed with burnt alum, or 
 caustic. {B. I, p.252.) 
 
 The third-rule, laid down by Beer, in the 
 treatment of the second stage of ophthalmy , 
 cautions the practitioner not to apply the 
 caustic or the knife, to any of the morbid 
 changes, which either originate during the 
 first stage, and continue in the second, or 
 make their first appearance at the period of 
 suppuration, as, for instance, opacities of the 
 cornea, eversion of one or both eyelids, &c. 
 However, as exceptions to this advice, Beer 
 adverts to the treatment of new-growths 
 under the circumstances above specified, 
 and to that of abscesses of the eyeball, where 
 the matter is of an unhealthy quality, and 
 so copious as to make an opening ad\ iseable, 
 which practice, however, as a general one, 
 he condemns. The other morbid changes, 
 already alluded to, the practitioner must 
 endeavour to remove simply by proper treat- 
 ment of the second stage. {Beer, B. 1, p. 
 254.) 
 
 Beer’s fourth rule in the treatment of the 
 seebnd stage of ophthalmy in general, and of 
 
OPHTHALM-l . 
 
 J0i> 
 
 idiopathic ophthalmy in particular, when 
 the suppurative process is extending itself, 
 and threatening to impair the health, is, 1st. 
 To allow the patient such food as is both easy 
 of digestion, and of a very nutritious quality, 
 and even a moderate quantity of wine and 
 spirituous drinks, if he h s been accustomed 
 to them. 2dly. To direct the patient to keep 
 his eye exposed the greater part of the day, 
 in a fresh, dry, and (if possible) mild air, and 
 take just exercise enough in various ways 
 to p'roduce a slight degree of fatigue. 3dly. 
 When the eye itself is affected with suppura 
 tion, and the sight is either thereby much 
 impaired, or quite lost, and, of course, the 
 patient very unhappy and depressed, Beer 
 considers it highly beneficial to let his spirits 
 be improved by society. 
 
 The fifth rule , or, general indication in the 
 second stage , laid down by Beer, refers to the 
 necessity of supporting the constitution, 
 when the suppurative process is attended 
 with a general febrile disturbance. For this 
 purpose, he recommends, 1st. The exhibition 
 of calamus aromaticus, naphtha, and cam 
 phor. 2dly. If they prove ineffectual alone, 
 they are to be joined with other tonics, espe- 
 cially bark. 3dly. The warm bath, which, 
 in consequence of the sympathy between 
 the skin and eyes, is particularly efficacious. 
 4thly. Rubefacients, applied not far from the 
 eye ; means, which are exceedingly bene- 
 ficial in the second stage of ophthalmy. ( B . 
 P-257.) 
 
 As an appendix to these general remarks, 
 delivered by Beer, on the general treatment 
 of ophthalmy in its first and second stages, I 
 annex the sentiments of some other writers, 
 as either confirming, or rendering question- 
 able, some of his statements. 
 
 According to Scarpa, when bleeding and 
 other evacuations have been practised, the 
 next most useful measure is the application 
 of a blister to the nape of the neck. He ob- 
 serves, that the skin here and behind the 
 ears, has a stronger sympathy with the eyes, 
 than any other part of the integuments. 
 On the other hand, the late Mr. Ware pre- 
 ferred blistering the temples, and says, 
 “ When the leeches have fallen off, and the 
 consequent hemorrhage has ceased, I would 
 advise a blister of the size of half a crown to 
 be applied on the temples, directly over the 
 orifices made by the leeches, and I have 
 found, that the sooner the blister has followed 
 th • b feeding , the more efficacious both have 
 proved .” He adds, that when ophthalmy is 
 very violent, and resists common methods, 
 the most beneficial effects are sometimes 
 produced by the application of a blister 
 large enough to cover the whole head. ( P . 
 43, 44.) 
 
 With respect to blisters, another modern 
 writer particularly objects to their being 
 applied near the eye, or on the temples, 
 ‘ l where they never fail to prove injurious.” 
 There is (says he) “ but one exception to this, 
 as a general rule ; for, it would seem, that 
 blisters applied to the external surface of 
 the palpebra, in cases of purulent ophthal- 
 mia, tend considerably to diminish the pum- 
 
 lency and chemosis.” ( Vetch on Diseases of 
 the Eye,p. 17.) 
 
 In the second stage of acute ophthalmy, 
 the vinous tincture of opium (the tinctura 
 thebaica) has been very extensively used, 
 as a topical application. In common cases, 
 two or three drop- may be insinuated be- 
 tween the eyelids and globe of the eye? twice 
 a day ; but, in other instances, attended with 
 more sensibility, once at first will be suffi- 
 cient The late Mr. Ware, who brought this 
 application into great repute, found, that in- 
 troducing two, or three drops, of this medi- 
 cine at the inner canthus, and letting them 
 glide gradually over the eye, by gently 
 drawing down the lower eyelid, proved 
 equally beneficial, and less painful than 
 letting them fall directly upon the eyeball. 
 Immediately the application is made, it usu- 
 ally creates a copious flow of tears, a smart- 
 ing, and a sense of heat in the eyes ; which 
 inconveniences, however, soon cease, and 
 the eyes become clearer, and feel decidedly 
 improved. But, notwithstanding every ex- 
 aggeration, unbiassed surgeons are now fully 
 convinced, that the vinous tincture of opium 
 is a proper application only when the in- 
 flammatory action has been previously di- 
 minished by bloodletting, aperient medi- 
 cines, and blisters, and when the action of 
 the vessels has been weakened by the con- 
 tinuance of the disease. Nor is any doubt 
 entertained, that the late Mr. Ware went 
 much too far, when he recommended the 
 vinous tincture of opium, as a most effectual 
 application in every species and stage of 
 the disorder, from the most mild and recent 
 to the most obstinate and inveterate. (P, 
 51.' Scarpa has seen the necessity of limiting 
 the use of the remedy in question, and has 
 expressly pointed out, that it is useful only 
 when the violence of the pain, and the 
 aversion to light, have abated. Indeed, Mr. 
 Ware himself, a little before sanctioning its 
 employment in all cases, has acknowledged, 
 that, in certain instances, in which the com- 
 plaint is generally recent, the eyes appear 
 shining and glossy, and feel exquisite pain on 
 exposure to the light, no relief at all was 
 obtained. (P 48, 49.) Mr. Travers has re- 
 marked, that “ there are inflammations, 
 which assume a chronic character in their 
 commencement, evidently depending on a 
 state of atony, of very partial extent, void of 
 pain, and scarcely possessing any sign of 
 inflammation, except the congestion of the 
 vessels, or, if any, so feebly marked, as to 
 encourage us to disregard them in the treat- 
 ment. in such cases, a single stimulus will 
 often restore the healthy action at once. 
 The vinous tincture of opium has acquired 
 a nostrum-!ike importance from its restora- 
 tive operation in such casas ; a virtue, I be - 
 lieve, not proper to it. A drop or two of 
 the zinc, or the lunar caustic solution, or 
 water impregnated with calomel, or a minute 
 portion of the citrine ointment, or any other 
 stimulant, would do as much.” ( Synopsis , 
 fyc. p. 252.) 
 
 Whenever the patient can easily bear a 
 moderate degree of light, Scarpa directs all 
 
orHTHALMY. 
 
 aiy 
 
 coverings to be removed irom the eyes, ex- 
 cept a shade of green, or black silk. A 
 brighter light should be gradually admitted 
 into the chamber every day, so that the eyes 
 may become habituated, as soon as possible, 
 to the open daylight ; for, as Scarpa truly 
 states, nothing has a greater tendency to pro- 
 long and increase the morbid irritability of 
 the eyes than keeping them unnecessarily 
 long in a dark situation, or covered with 
 compresses and bandages. 
 
 Dr. Vetch has such a dislike to the plan of 
 covering the eye, that he never suffers a 
 shade to be worn, conceiving that, in con- 
 junctival inflammation, it always does a great 
 deal of harm by preventing a free exposure 
 of the eye to a temperate atmosphere. (On 
 Diseases of the Eye,p 17.) 
 
 Besides the common remedies for inflam- 
 mation, there are some very powerful 
 means, which may be employed for the re- 
 lief of particular state* of ophthalmy with 
 great effect. Thus, as the latter author has 
 observed, by means of hysoscinmus, bella- 
 donna, and stramonium, (See Belladonna) 
 the important structure of the iris may be 
 secured from injury, at the same time that 
 other measures are adopted for checking the 
 inflammation. Such medicines may even 
 be applied, as a mechanical force, for de- 
 taching any recent adhesion. (Op. cit.p. 18.) 
 
 The uses of the argentum nitratum are 
 also very extensive : “the slightest applica- 
 tion of it in substance (says D . Vetch) can 
 often remove the highest degree of morbid 
 sensibility to light, and instantaneously re- 
 store quietude to the organ; it can prevent 
 incipient changes, and obviate advanced 
 ones; and may also be used io solution, as a 
 valuable sedative.” 
 
 The mention of so stimulating and active 
 a substance as the nitrate of silver having a 
 .sedative effect may excite surprise ; but the 
 fact is unquestionable, and well illustrated in 
 the treatment of several diseases. (See 
 Cornea and Iris.) As another modern writer 
 correctly states, it is remarkable that even 
 the weaker forms of medicated lotions irri- 
 tate, and none more than such as contain 
 opium. Tlie relief, afforded by anodyne 
 fomentations in general, is very various. “ I 
 have known them (says Mr. Travel-*) ob- 
 jected to as painful, and patients inquire if 
 they might not substitute warm water tor 
 the aqueous solution of opium and infusions 
 of poppy and hemlock. The same observa- 
 tion applies especially to painful herpetic 
 cutaneous affections, and acutely irritable 
 ulcers. Upon these a solution of opium 
 often acts as a stimulant, and augments pain, 
 while the lunar caustic solution as often as- 
 suages it.” At the same time, Mr. Travers 
 admit*, that exceptions occur, and that lie 
 has met with case-, “ in which no other ap- 
 plication than the aqueous solution of opium 
 could be borne.” He has also known the 
 vapour of laudanum afford the most marked 
 relief to the irritability to light accomtmny 
 ing strumous opVhahny. ( Synopsis of the 
 Diseases of the Eye, p. 251.) 
 
 .According to Dr. Vetch, it is impossible, 
 
 in cases of conjunctiva! ophthalmia, to poj 
 sess an application of greater efficacy, than 
 the undiluted liquor plumbi subacetaii-, for 
 altering the morbid and purulent state of 
 that membrane; he also describes iico 
 tiana. externally employed as a n r otic and 
 astringent, as being of singular service in 
 lessening the pain, and turnelaction. (P. 19.) 
 However, the discordance among the best 
 writers, about the effects of favourite local 
 applications, would lead me to enjoin rather 
 attention to the leading principles of*the 
 treatment, than confidence in the superior 
 efficacy of any particular drug or composi- 
 tion. As also the local applications should 
 vary in the different stages of purulent 
 ophthalmy, no single one will always be 
 right, li Bper had d -livercd no observa- 
 tions of greater importance, than his con- 
 demnation of Bates’s camphorated lotion, 
 and liis praise of other styptic stimulating 
 applications, his remarks would be of little 
 value ; but, as he has pointed out the differ- 
 ent stages of purulent ophthalmia in a very 
 correct manner, and adapted his remedies to 
 these various states of the disease, his infor- 
 mation comprehends scientific principles, 
 and becomes peculiarly interesting. The 
 same praise belongs also to Dr. Vetch’s ob- 
 servations on purulent ophthalmy, who in 
 some points, both of the description of 
 the complaint and its treatment, has surpass- 
 ed Beer. 
 
 Of the different Kinds of Ophthalmy . 
 Beer’s classification is very comp enensive. 
 According to the situations, in which oph- 
 thalmic iufiaminatio first originates, he pro- 
 poses a general division ot it into three (qrms, 
 as suggested. bv some of the older writers; 
 viz inflammation of the eyelids , or blepha- 
 rophthalmitis ; inflammation of the parts 
 between the orbit and globe of the eye ; and, 
 lastly, inflammation of the eyeball itself or 
 ophthalmitis. He observes, however, mat 
 these distinctions seem to assign a considera- 
 ble extent to the original seal of th<- aff ct ion ; 
 for the expression, inflammation of the. eye- 
 lids, can only denote a case, in winch the 
 disorder begins at once in all the parts com- 
 posing the eyelids. In the same way, inflam- 
 mation of the parts between the eysbull and 
 orbit appears to signifv, that all those parts 
 constitute the original sphere of th** com- 
 plaint; while inflammation of the eyeball 
 seems to denote that the disorder has begun 
 at once in all the textures, of which this 
 organ is composed. But, fortunately, as 
 Beer remarks, the extent of the original seat 
 of genuine idiopathic inflammation of the 
 eye is but seldom thus considerable ; being 
 mostly restricted to particular textures, from 
 which it first spreads further only when 
 neglected, or injudiciously treated. Hence, 
 certain subdivisions of the complaint are 
 necessary ; and. accordingly, Beer subdivides 
 inflammation of the eyelids , first, into the 
 erysipelatous , or blepharophthalmilis erysipc - 
 latosa , which commences in the integuments 
 oi these parts. Secondly, into that, which 
 originates at the edges of the pulpebrai, in 
 the conjunctiva lining these parts, and tbc 
 
OPIlTlIAUn 
 
 
 Meibomian glands, and which Beer denomi- 
 nates glandular inflammation of the eyelid s 
 or blepkarophthalrnitis glandulusa ; a case, 
 described by writers under an infinite num- 
 ber of names, and often confounded with 
 complaints of a totally different nature. 
 Thirdly, when the eff ets of the inflamma- 
 tion ar * confined to a -mall portion of the 
 eyelid it rnn-ti«ute» the disease, termed the 
 inflammatory stye, or hordeolum, which Beer 
 say-- is larely a simple inflammation, but 
 complicated with a scrofulous habit ; a pro- 
 position, which, I think, will not receive any 
 credit in England. Fourthly, as there is one 
 more form of inflammation of the eyelids. 
 Beer xives it the name of the erysipelatous 
 swelling of the cornea of the eye, or anchy- 
 lups erysiptlalosa , which affects the skin of 
 the inner canthus, immediately over the 
 lachrymal sac. The name, here suggested, 
 expresses precisely the seat of the inflamma- 
 tion, and, as Beer thinks, will tend to prevent 
 the case from being mistaken for inflamma- 
 tion of the lachrymal sac. Inflammation of 
 the parts in the orbit comprehends, first, in- 
 flammation of the lachrymal gland ; secondly, 
 inflammation of the lachrymal sac, a disorder, 
 which begins in the lachrymal sac and nasal 
 duct, and generally extends with great ra- 
 pidity over all the excreting parts of the la- 
 chrymal organs ; and, thirdly, influrn "'’on 
 of the caruncula lachrymalis, or the erica, this 
 inflammetoria. 
 
 I; the Same way, inflammations of tl 
 eyeball a lini' of a classification, which is of 
 the high .-t practical importance^ first, into 
 the erysipelatous inflammation of the sclerotic 
 conjunctiva , the ophthalmitis erysipelatosa, 
 which denotes that torm of the disorder, 
 which is first entirely confined to the mem- 
 brane connecting together the eyelids and 
 eyeball. Secondly, into inflammation of the 
 outer textures of the eyeball , the ophthalmitis 
 externa , originating in the cornea and sclero- 
 tica. Thirdly, into inflammation of the in- 
 nermost textures of the eyeball, the ophthal- 
 mitis interna , which has two forms highly 
 necessary to be recollected in practice; for 
 the inflammation may begin immediately in 
 the retina ehoroides, the membrane of vi- 
 treous humour, &ic. and spread from these 
 textures t<> all the rest of the eyeball, being 
 n ined true internal inflammation of the eye- 
 ball, or ophthalmitis interna vera, and thus 
 discriminated from another case, which is 
 originally seated in the iris, the adjoining 
 corpus ciliare, the lens, and its capsule, and 
 afterward extends from these parts to the 
 more deeply situated coats, and to the texture 
 of t lie vitreous humour. This last form of 
 internal inflammation of the eyeball is named 
 both by Schmidt und Beer, iritis. The clas- 
 sification then embraces a view of the dif- 
 ferent form 5 of ophthalmy, as modified by 
 constitutional causes, as the effect of con- 
 tagious and infectious diseases, measles, 
 small-pox, &c. ; and as a complication of 
 eeriain cachexia;, like gout, rheumatism, and 
 scurvy. 
 
 Although I have thus given a brief deline- 
 ation of Beer’s classification of ophthalmic 
 
 inflammation?, it Is not my design in the sub- 
 sequent columns, to enter into a full consi- 
 deration of every particular case, above 
 enumerated ; first, because the limits of this 
 work will not permit me to do so; and se- 
 condly, because some of these cases have 
 been already considered in other parts of the 
 work. (6ee Lachrymal Organs.) 
 
 Common Inflammation of the Eyelids. 
 This form of disease is said by Beer to affect 
 the upper much more frequently, than the 
 lower eyelid, because the former obviously 
 has a larger surface exposed to injuries from 
 without ; nor does the complaint always 
 spread to the latter. From the margin of 
 the eyelid, a very red, tense, painful swelling 
 arises, attended with heat, throbbing, and a 
 great deal of tenderness, when touched. It 
 gradually extends over the whole eyelid : 
 but seems to be plainly bounded by the edge 
 of the orbit. The motion of the eyelid is 
 always more or less obstructed, and, at 
 length, when the inflammation has reached 
 its greatest degree, it is completely prevent- 
 ed. Nor is there any difficulty in compre- 
 hending why, when tiie inflammation has 
 become severe, the eye should he excessively 
 dry, and every attempt on the part of the 
 patient to move the eyelid should be produc- 
 tive of considerable pain, and of a sensation, 
 ns if some sharp extraneous substances lay 
 under the lid ; for at this period, the palpe- 
 bral conjunctiva is already severely inflamed, 
 and, consequently, the secretion of mucus 
 from the Meibomian giands is immediately 
 stopped by the inflammation itself, while that 
 of the tears is interrupted partly by the ex- 
 tension of the inflammation to the sclerotic 
 conjunctiva, and partly by the effect of the 
 sympathetic connexion existing between the 
 conjunctiva of the eyelid, and that of the 
 eyeball. To this last cause, viz. sympathy. 
 Beer refers the supervening dryness and shri- 
 velling up of the lachrymal papilla;, as well 
 as the apparent closure of the puncta lachry- 
 rnalia, and the uneasy dry state of the 
 edgvs of the eyelids. Hence, also, the dry- 
 ness of the adjacent nostril, and a very disa- 
 greeable smell of dust obliging the patient 
 to sneeze repeatedly, w hich act is constantly 
 attended with a great increase of pain in the 
 swelling, a transient shooting of it to the 
 eye and bead, and a sensation as if flashes of 
 light we e elicited within the eyeball; a 
 kind of hallucination, technically named 
 photopsia. As the original seat of the in- 
 flammation is already extensive, one may 
 readily understand, says Beer, why the affec- 
 tion in its first stage, particularly when 
 neglected, or badly treated, should frequently 
 give rise to some febrile disturbance of the 
 system. 
 
 In the second stage of the case, or that of 
 suppuration, which billows when the inflam- 
 mation is violent and not soon dispersed, 
 matter forms with the annexed train of 
 -ymptoms. The redness suddenly increases 
 very much, the eyelid becoming of a brown* 
 i-b red, and lastly of a purplish red colour. 
 The swelling becomes more prominent, and 
 present? a conical eminence, either in the 
 
OPHTHALMV 
 
 3J.2 
 
 middle of the eyelid, or close to the outer or 
 inner canthus. The pain is irregular, and of 
 a stinging, burning kind, a throbbing being 
 felt only in the deeper part of the tumour. 
 At length, the swelling becomes somewhat 
 softer, and Ies9 sensible at its most projecting 
 point. The secretion from th<* Meibomian 
 and lachrymal glands, which in the first stage 
 of the disorder was suppress* d, is now quite 
 re-established, but more copiously, than in 
 the healthy state. During sleep, a quantity 
 of mucus accumulates between the edges of 
 the eyes, and glues them together. An ex- 
 traordinary sensation of cold and heaviness 
 is felt all about the eye. Ultimately the most 
 prominent point of the swelling presents a 
 pale red colour, followed by a yellowish 
 livid tinge. As the abscess is now com- 
 pletely formed, the fluctuation of the matter 
 can be plainly felt. (Beer, B. 1 ,p. 269, fyc ) 
 
 According to the same author, nothing 
 very particular is known respecting the 
 causes of the preceding form of ophthalmic 
 inflammation, and, with the exception of 
 blows, he has not been able to discover the 
 precise circumstances which give rise to it. 
 
 With regard to the prognosis, if the treat- 
 ment be neglected, or injudicious, the in- 
 flammation may suddenly become so violent, 
 as to produce in weak subjects gangrenous 
 mischief. But, when the case is properly 
 managed in its first stage, the second, or that 
 of suppuration, never ensues; yet, says 
 Beer, the curative measures must be decisive, 
 and valuable time not wasted on trifling 
 means, although due regard must be paid to 
 the constitution. When the inflammation 
 subsides favourably, it le -ves no vestiges of 
 it behind, and even the redness, which is the 
 latest in disappearing, completely goes off in 
 a few days, and the function of the eyelid 
 becomes perfect again. 
 
 If gangrene and sloughing take place, the 
 outer coverings of the eyelid are destroyed, 
 and the consequences are an incurable 
 eversion of the part. (S eo Ectr opium) ora 
 hare-eye, (see Lagophihalmus.) When 
 suppuration happens favourably, the abscess 
 sometimes breaks very well of itself on the 
 upper eyelid; but, according to Beer, this 
 does not readily occur on the lower one, 
 nor without the formation of sinuses, which 
 sometimes run quite into the orbit. After 
 the abscess has burst, or been opened, the 
 part heals up with great celerity in favour- 
 able constitutions, but slowly in others ; 
 vermilion granulations arise from the bot- 
 tom of the cavity, and a cicatrix follows 
 which is scarcely perceptible. When the 
 abscess is very large, however, and bursts of 
 itself, the upper eyelid continues for some 
 time very much weakened. If the collec- 
 tion of matter be neglected, or wrongly 
 treated, or the subject be unhealthy, or the 
 disease be aggravated by the etFects of a 
 damp atmosphere, hurtful food, severe 
 mental trouble, wet poultices, or too long 
 confinement of the matter, then, says Beer, 
 fistulae are apt to be produced, sometimes 
 complicated with necrosis of the,bone, the 
 certain effects of which are some perma- 
 
 nent and mostly incurable disease of the 
 eyelid, and impairment of its functions : 1st. 
 A closure of the lachrymal canals, with a 
 permanent stiilicidium. 2. A complete 
 obliteration of the same lubes, with an in- 
 curable stiilicidium- 3. A prolapsus of the 
 upper eyelid, from distention of the skin by 
 the long confinement of the matter. 4. 
 Inversion of the edge of the eyelid, from a 
 shrinking of its cartilage. 5. Eversion of 
 the eyelid, and hare-eye, from loss <»f kin. 
 (Beer.) 
 
 As, in this species of inflammation, says 
 the same author, the organ of sight cannot 
 well be affected, unless the disorder after- 
 ward extend itself very much, the exclusion 
 of air and light is here but of little use 
 Linen compresses, well wet with very cold 
 water, or vinegar and water, are to be ap- 
 plied ; and, while the complaint is local, 
 leeches are to be used ; but, if the constitu- 
 tion be threatened with febrile symptoms, 
 then Beer urges the necessity of venesec- 
 tion, low diet, purgatives, and general 
 antiphlogistic measures. (B. \,p. 275.) 
 
 In the second stage, with the exception 
 of a few points, Beer states, that the case is 
 to be treated like any other common abscess. 
 When the matter is situated in the middle 
 of the upper eyelid, not far beneath the skin, 
 the abscess may be allowed to burst of 
 itself, especially, if the patient have a great 
 dread of the knife. But, if the matter lie 
 near the outer, or inner canthus, it should be 
 let out w ith a lancet as soon as its fluctua- 
 tion is quite distinct, the incision being 
 made in the direction of the fibres of the 
 orbicular muscle. When fistulae- or gan- 
 grene, have already taken place, the treat- 
 ment should be like that, which is applicable 
 to the s;im* j kind of mischief in most other 
 parts of the skin. 
 
 Erysipelatous Inflammation of the Eyelids 
 usually affects both these parts together, 
 very seldom only the upper one, and never 
 the lower alone. When also both are 
 affected, the disorder always presents itself 
 in the greatest degree in the upper eyelid 
 A pale, yellowish red, seemingly transparent, 
 shining swelling arises from the edges of the 
 eyelids, and rapidly extends itself, without 
 any determinate boundary, the faint red 
 colour being gradually lost upon the eyebrow 
 above, and not unfrequently upon the cheek 
 below. When the inflamed part is gently 
 touched, the redness disappears, but only for 
 a moment. At length, (be swelling towards 
 the margins of the eyelids becomes exceed- 
 ingly soft, and feels like a vesicle that has 
 been raised by a blistering plaster. The 
 pain is inconsiderable, not attended with 
 throbbing, but rather with a sense of heat and 
 stiffness; when the part is slightly touched, the 
 patient experiences a lancinating sensation 
 in it. Its temperature is not much increased. 
 The secretions from the Meibomian glands, 
 lachrymal gland, and mucous membrane 
 of the nostrils, are much augmented. — 
 In a strong subject, the disorder, if genuine 
 and idiopathic, is not productive of any 
 constitutional disturbance '• but, in bad 
 
OPHTHALM\ 
 
 313 
 
 habits, and weak females and children, it is 
 sometimes attended with fever. However, 
 when the complaint partakes of the phleg- 
 monous character, and is badly treated, the 
 general symptoms are occasionally very se- 
 vere at the change from the first to the 
 second stage, and the case may then termi- 
 nate in a gangrenous kind of suppuration. 
 In irritable, delicate children, says Beer, 
 when the disease spreads over the face, the 
 case requires the most skilful treatment for 
 the prevention of a disastrous termination. 
 
 In sirong persons, the second stage of this 
 disorder rarely ends in a manifest suppura- 
 tion ; but there is rather an exudation of 
 lymph, which becoming dry, forms very 
 small, delicate, branny scales, in the com- 
 position of which the desquamated cuticle 
 has also a considerable share. In other 
 instances, vesications of various sizes are 
 formed on the erysipelatous surface, and 
 burst, and discharge a fluid, which is con- 
 verted into yellowish scabs. 
 
 According to Beer, the skin of the eye- 
 lids is particularly prone lo erysipelatous in- 
 flammation, which is therefore more easily in- 
 duced in it, than in the integuments of other 
 parts. Beer considers the sudden effect of a 
 cold blast of air, or of very cold water, upon 
 the skin of the eyelid, while in a slate of 
 free perspiration, as the most common cause 
 of its being attacked with erysipelas, parti- 
 cularly in weak subjects. He states, how- 
 ever, that the complaint may be occasioned 
 by the stings of bees, wasps, and other 
 insects ; accidents, which when the stings 
 are not extracted, are liable to be followed 
 by a violent and dangerous general inflam- 
 mation of the eyelid, not unfrequentiy 
 extending in a perilous degree to the eyeball 
 itself. (B. 1 , p. 281.) 
 
 With regard to the prognosis, no other 
 case of ophthalmic inflammation so fre- 
 quently subsides without the aid of surgery 
 as this, provided the constitution he healthy 
 and strong; and, when the complaint is 
 resolved in its first stage, the vestiges of it 
 afterward are as little as those consequent 
 to common inflammation of the eyelids. 
 
 The second stage, however well treated, 
 is followed fora long time by a peculiar sen- 
 sibility of the skin to the impression of cold 
 damp air, and a strong propensity to relapses. 
 If, when the cuticle peels off, a patient of 
 weak constitution sit in a current of damp 
 cold air, or try to wash away the scales and 
 scabs with cold water, Beer states, that an 
 cedematous affection of the eyelid will be 
 produced, which is often very obstinate, and 
 apt to occasion a temporary inversion of 
 the ciliae ( Trichiasis ,) or a similar state of 
 the edge of the eyelid ( Entropium .) And, 
 he observes, that when from neglect, or 
 bad treatment, an erysipelatous inflamma- 
 tion of the eyelid terminates in suppuration, 
 the abscess is not like a common one, hut 
 the matter rapidly makes its way out through 
 several openings in the already partially 
 disorganized skin, and, in general, this state 
 is followed by ill-conditioned tedious ulce- 
 rations, vvherebv a good deal of skin is 
 Yol. IT 49 
 
 always destroyed. Under these circum- 
 stances, all those consequences may be 
 produced, which have been described as 
 liable to take place from the second, or 
 suppurative stage, of common inflammation 
 of the eyelid. Gangrene and sloughing may 
 even occur, when erysipelas of the eyelids 
 is brought on hy the unremoved sting of an 
 insect, and efficient treatment is delayed. 
 
 The treatment, recommended by Beer in 
 the first stage, consists in the application of 
 cold water, and he remarks, that exposure 
 of the part for a time to a cool, moist, hut, 
 in other respects, pure atmosphere, will often 
 suffice for the removal of the complaint. 
 When, however, the disorder increases, and 
 assumes a phlegmonous character, the direc- 
 tions given for the treatment of blepharoph- 
 thalmitis, are to be followed. 
 
 In the second stage of erysipelas of the 
 eyelids, Beer praises the good effects of a 
 mild, dry air, of an equal temperature, and 
 recommends covering the parts with a light 
 bandage, under which are to be put well 
 warmed linen compresses, which, for ‘weak 
 persons, should be sprinkled with camphor ; 
 or he directs the eyelids to be covered with 
 hags of aromatic herbs; generally a very 
 favourite plan with Beer, whenever he ob- 
 jects to moist applications. In such indivi- 
 duals, he observes, that the cure is promoted 
 by keeping up the function of the skin with 
 gentle diaphoretic medicines, with which, 
 when the debility is very great, camphor 
 should be joined. Should an abscess form, 
 the same treatment is proper as in the se- 
 cond stage of common inflammation of the 
 eyelids, or (what Beer calls) blepharophthal- 
 mitis. 
 
 Glandular Inflammation of the Eyelids, or 
 the Blephar ophthalmitis Glandulosa, as Beer 
 terms it, is considered by this author as the 
 disease, of which all the various cases of pu- 
 rulent ophthalmy are only modifications, 
 which he describes under the names of idio- 
 pathic catarrhal ophthalmy ; idiopathic catar- 
 rhal-rheumatic ophthalmy ; and blepharo-blen- 
 norrhcen, or ophtlialmo-blennorhcea. The two 
 latter terms comprehend the purulent oph- 
 thalmy of infants, the Egyptian ophthalmy, 
 the gonorrhoeal ophthalmy, &c. 
 
 Glandular Inflammation of the Eyelids , 
 Beer knew very well was so far a defective 
 term, that it seemed to imply merely an af- 
 fection of the Meibomian and mucous glands 
 of those parts, whereas he means to express 
 by this name the kind of inflammation, of 
 which all the cases, usually called in this 
 country purulent ophthalmies , are varieties 
 and modifications, and in which the con- 
 junctiva is also particularly affected. 
 
 Acute suppurative inflammation of the con- 
 junctiva, divisible into the mild and severe 
 forms, as proposed by Mr. Travers, appears, 
 perhaps, a better name ( Synopsis , fyc. p. 96, 
 &c.) Dr. Vetch, who also prefers the gene- 
 ral term conjunctival inflammation, observes, 
 that from many internal and external causes, 
 the membrane of the conjunctiva is liable 
 to become the seat of inflammation, more 
 especially that portion of it, which gives 
 
314 
 
 ©phthalmy: 
 
 a lining to\the inner surface of the eyelids. 
 The disease, in its general nature, he says, 
 differs little from that which is met with in 
 other parts having a similar surface, as the 
 nose, the fauces, the bronchial cells, and the 
 urethra ; but, the continuation of the mem- 
 brane forward upon the anterior portion of 
 the eye, and the consequent liability of the 
 inflammation to affect this important organ, 
 attach much interest to all the circumstan- 
 ces. capable of producing it. (Vetch on 
 Diseases of the Eye,p. 148.) In the common 
 glandular inflammation of the eyelids, des- 
 cribed by Beer, which seems to me to cor- 
 respond to the more moderate forms of 
 purulent ophlhalmy met with in this country, 
 either the whole, or pnly that part of the 
 edges, which is near one, or both canthi, is 
 affected with a very red, hardish, sensible 
 swelling, attended with a violent annoying 
 degree of itching. This swelling, Beer ob- 
 serves, does riot extend far over the outside 
 of the eyelid upwards, or downwards, at 
 most, not more than a few lines ; but it 
 spreads over the palpebral conjunctiva, es- 
 pecially when neglected, or badly treated, 
 and the constitution is w eak. This, he says, 
 can only be discovered when the eyelid is 
 everted. The further the swelling extends 
 over the inside of the eyelid, the more is 
 the motion of the part obstructed, not on 
 account of any want of power in the orbi- 
 cular muscle, but from the fear of the pain, 
 with which every attempt to move the 
 eyelid is accompanied. The itching, which 
 continually distresses the patient, more or 
 less, is often succeeded by an irritating, 
 burning kind of pain, which is particularly 
 experienced w ? hen the eyelids are moved, 
 and hence, the patient is obliged, as it were, 
 to keep his eye closed. While the inflam- 
 mation is restricted to the edges and con 
 junctiva of the eyelids, and the Meibomian 
 glands situated under it. though the secretion 
 from these glands is entirely stopped, that 
 from the lachrymal gland is much augment- 
 ed,, and consequently, the disease is- asso- 
 ciated with a true epiphora , which is seri- 
 ously aggravated whenever the eye is ex- 
 posed to a strong light. As, under these 
 circumstances, the tears are not properly 
 blended with the Meibomian secretion, they 
 must of course be very irritating to the eye 
 and its surrounding parts, and less fitted for 
 properly lubricating its surface. Hence, the 
 pain now becomes burning, and not unfre 
 quently the cheek, over which the tears 
 run, is excoriated. As soon as the inflam- 
 mation of the eyelids spreads further, and 
 begins to affect the sclerotic conjunctiva, 
 the effusion of tears ceases the eye becomes 
 preternaturnlly dry, and the patient con- 
 stantly thinks that he feels sand under the 
 eyelids, which sensation is rendered almost 
 intolerable by any motion of the eye, or 
 eyelids. Children and women have so great 
 a dread of this painful feel, that much per- 
 suasion is often requisite to induce them to 
 Jet the eye be properly examined. If the 
 glandular inflammation of the eyelids attain 
 a considerable degree, the lachrymal papilla; 
 
 shrink, and the puncta seem closed, winch 
 is particularly the case when the disorder 
 begins at the inner canthus. 
 
 In the second stage of the complaint, Beer 
 describes the itching, burning sensation, and 
 dryness of the eye, as undergoing a remark- 
 able diminution, as either the canthi, or the 
 whole extent of (he edges of the eyelids, 
 become more and more moist, and smeared 
 with mucus, an increased secretion of a pu - 
 riform sebaceous fluid from the Meibomian 
 glands being the first symptom, denoting the 
 commencement of the second stage of the in- 
 flammation. As this mucous secretion is 
 not mixed with an adequate quantity of 
 tears, it inspissates in the form of while, 
 thin delicate layers, which, from time to 
 time, cover the cornea, and make the patient 
 very apprehensive of becoming blind, as the 
 flame of a candle in the evening, and other 
 objects appear to him more or less conceal- 
 ed by a dense mist When, under these 
 circumstances, however, the eyelids are 
 repeatedly and briskly moved, or the eye 
 is wiped, these appearances soon go off, the 
 flakes of mucus being removed from the 
 cornea. These accumulations of thickened 
 mucus, Beer remarks, are apt to be most 
 frequent and troublesome some time after a 
 meal ; and the eyelids become so firmly 
 glued to ether during sleep with yellowish 
 crusts, that, when the patient awakes in the 
 morning, it is not till after a great deal of 
 washing and bathing of his eyes with warm 
 water, that he is able to open them again. 
 The above described change in the quantity 
 and quality of the secreted matter, as al- 
 ready mentioned, indicates th e first period of 
 the second stage ; for Beer wishes it to be 
 particularly noticed, that here, as in all in- 
 flammations of mucous membranes, the se- 
 cond stage of the disorder has three periods, 
 as will be presently seen, to which the prac- 
 titioner cannot be too attentive. 
 
 This morbid secretion of a mucous seba- 
 ceous matter does not continue long unat- 
 tended with other efiects ; and, very soon, 
 the peculiar appearances of suppuration are 
 seen, at the same time that the conjunctiva 
 of the eyelids becomes more considerably 
 swelled, and a discharge takes place not 
 only from the cantiii or margins of the eye- 
 lids, but from the whole of the thickened 
 villous surface of the palpebral conjuuctiva, 
 and which discharge is distinguishable at 
 first view from the mucus, which, at an ear- 
 lier period, accumulated in much smaller 
 quantity only between the edges of the eye- 
 lids, and at the canthi. It is now no longer 
 white, but ye!low r , completely like pus, with 
 which it is in reality blended, and so viscid 
 is it, that the crusts which collect on the 
 eyelids in the nighttime cannot be removed, 
 without pulling the eyelashes away with 
 them. Sometimes, says Beer, at the moment 
 of suppuration, minute pustules, which are 
 scarcely distinguishable, form either at the 
 canthi, or along the edges of the eyelids, 
 and are sooti burst by the constant friction 
 of the parts. These pustules indicate the 
 second, or suppurative period of the second 
 
UPHTHALMY. 
 
 315 
 
 s * age ot the case, when either merely the 
 canthus, or the whole of the margin of the 
 eyelid, constantly becomes excoriated, and 
 secretes mucus and purulent matter, the 
 sore fretted places smarting so severely on 
 exposure to the airy particularly to such as 
 contains a large proportion of carbonic acid 
 gasjind nitrogen, that the patient is afraid 
 of opening his eye. When the patient neg- 
 lects himself, and continues in an unhealthy 
 atmosphere, these excoriations of the skin, 
 occurring in the suppurative stage, are al- 
 ways more extensive ; nay, they sometimes 
 spread over the lower eyelid, and down the 
 cheek 
 
 At length, after the excoriations have 
 lasted, perhaps, several weeks, the suppura- 
 tive process is checked and suppressed, ei- 
 ther by surgical treatment, or accidental fa- 
 vourable circumstances, as change of regi- 
 men, the weather, climate, &lc., and then 
 the excoriations immediately diminish. 
 However, a morbid secretion from the Mei- 
 bomian glands still continues, making the 
 third period of the second stage, and is apt to 
 become habitual, if not rectified by art, or 
 removed by the effect of accidental favour- 
 able circumstances, when it changes into a 
 thin serous discharge, and then terminates. 
 
 Beer refers the causes of glandular inflam- 
 mation of the eyelids , or simple purulent oph- 
 tha'.my , to the immediate operation of va- 
 rious stimuli acting chymically upon the 
 edge of the eyelid, where it is covered with 
 a very delicate cuticle, and upofi the ex- 
 posed follicles of t e glands of the eyelid 
 towards the inner canthus. Hence, says he, 
 when many men are living together in a 
 polluted, noxious air, impregnated with ex- 
 traneous substances, this form of inflamma- 
 tion is found to occur even in the strongest 
 constitutions with such frequency, that it 
 seems as if it were epidemic. And, accor- 
 ding to Beer, the principal cause of the dis- 
 ease will be found to be in the atmosphere, 
 and the next most frequent occasion of it, 
 be observes, is uncleanliness, as washing 
 the eyes with foul water, &.<■. At the same 
 time, this experienced oculist seems aware 
 that this explanation would not of itself be 
 always quite satisfactory ; for, he adds, that 
 although, under the above circumstances, 
 no constitution, no sex, nor age, is spared, 
 there must be some particular condition 
 which is conducive to the disorder, or at all 
 events, to its more rapid and severe course, 
 and the quick extension of the inflamma- 
 tion in certain individuals, which condition 
 Beer supposes must depend either upon 
 weakness of constitution, or upon excessive 
 irritability, or as he terms it, vulnerability of 
 the whole surface of the body. Beer makes 
 •no mention of the effect of damp nocturnal 
 air in warm countries in giving origin to pu- 
 rulent ophtbalmy. so much insisted upon by 
 Assalini and Dr. Vetch, but, which doctrine, 
 in reference to the origin of purulent oph- 
 thalmies in England, I think completely 
 fails ; and what is still more worthy of no- 
 tice, Beer never attempts to explain the 
 propagation of the disease by its infectious 
 
 nature. It is observed by Dr. Vetch, that 
 the history of all diseases, originating from 
 some particular impression received from 
 the atmosphere, but capable, when formed, 
 of propagating themselves by contagion, is 
 rendered particularly difficult; because the 
 same circumstances, which favour the com- 
 munication by contagion, produce also a 
 predisposition to be acted upon by the more 
 general causes existing in the atmosphere. 
 The principal cause which gives force and 
 opportunity to the action of contagion, is 
 the crowding individuals together into too 
 limited spaces. The same circumstance Dr. 
 Vetch has seen give a predisposition to dis- 
 eases of an epidemic, but not a contagious 
 nature ; and hence he infers, that it may 
 produce the same predisposition to diseases 
 which are both contagious and atmospheric. 
 “ The appearance of ophthalmia among the 
 crews of ships and in barracks 'was often 
 met with long before the late destructive 
 and virulent disease (presently to be des- 
 cribed.) In the army, such an ophthalmia 
 has extended to whole regiments, without 
 any appearance of the disease among the 
 inhabitants of the neighbourhood ; and 
 while the free intercourse which subsists 
 among the men. as to washing in the same 
 water, u-ing the same towels, and sleeping 
 more than one in a bed, readily accounts for 
 the rapid extension of the disease in the 
 same corps, yet the excessive crowding to- 
 gether of men will often of itself engender 
 inflammation of the conjunctiva.” {Fetch 
 on Diseases of the Eyes. p. 171.) I be- 
 lieve with respect to the causes of all pu- 
 rulent ophthahnies, our present knowledge 
 will permit us to venture no further than 
 the tenor of the preceding observations, 
 which is, that they originate epidemically, 
 but probably multiply both in this manner, 
 and by the infectious matter of the disease 
 being inadvertent ly applied in various ways 
 to the eyelids of other persons. This spe- 
 cies of inflammation of the eyelids is rarely 
 met with by the surgeon in its first stage, 
 because only very timorous patients then 
 seek medical advice, and most individuals, 
 who feel in other respects well, relieve 
 themselves by washing the eyes with cold 
 water, and applying cold poultices, made of 
 bread crum softened in water. Besides, 
 when the disease is not very severe, it fre- 
 quently subsides of itself, as in a favourable 
 constitution, a better air is sometimes capa- 
 ble of restoring the healthy state of the eye. 
 If, however, the disease at its very com- 
 mencement should be violent, or attack an 
 individual of very w T eak habit, Beer states 
 that it may immediately affect, not only the 
 Meibomian glands, but the perichondrium 
 of the cartilage of the eyelid, and produce 
 an incurable entropium, which is also sure 
 of taking place when the case is neglected, 
 and followed by deeply extending ulcerative 
 mischief. When the complaint is strictly 
 idiopathic, it never brings on any general 
 indisposition, except by improper treatment 
 it should happen to be converted into a 
 violent inflammation of the whole eyelid, 
 
OPHTHALMic . 
 
 816 
 
 or what Beer terms a complete blcpharoph- 
 Ihalmitis ; which he says, only happens in 
 •weak subjects, and women and children, 
 whose skin is in a very irritable state, or 
 when a person of apparently good consti- 
 tution remains under the influence of cir- 
 cumstances which tend to augment the in- 
 flammation, as for instance, exposed to the 
 air of a stable, privy, foe. in which event. 
 Beer describes the inflammation of the eye- 
 lids as being quite of a peculiar description. 
 
 As for the prognosis in the second stage, 
 Beer observes, that, if the excoriations at 
 the suppurative period should spread all 
 over the edges of the eyelids, and compel 
 the patient to keep his eye incessantly shut, 
 a partial adhesion of the eyelids to each 
 other ( ancliyloblepharon ) may be the result. 
 Also, when at either of the periods of the 
 secretion of mucus, or at that of suppura 
 lion, the patient is content with merely sof- 
 tening with warm water the thick matter 
 glueing the eyelids together, so as just to be 
 able to open his eye ; and does not com- 
 pletely free the eyelashes from the crusts, 
 clusters of the hairs will project inwards, 
 (see Trichiasis ) whereby a secondary in- 
 flammation of the conjunctiva of the eye- 
 ball will be excited, which, Beer says, 
 should be carefully discriminated from a 
 mere extension of the glandular inflamma- 
 tion of the eyelid. Such a trichiasis, he 
 observes, may easily become incurable, 
 when the edge of the eyelid is seriously in- 
 jured by the depth of the excoriations. 
 But, if the suppurative process be restricted 
 chiefly to the canthus, especially the outer 
 one (which case, according to Beer, is not 
 unfrequent in old, debiliated subjects, of a 
 relaxed constitution) and if the excoriations 
 should deeply penetrate the commissure of 
 the eyelids this may be completely destroy- 
 ed, and the lower eyelid everted. 
 
 As the state of the atmosphere, unclean- 
 liness, crowded and close places, &c. are 
 considered by Beer to be the principal causes 
 of the glandular inflammation of the eye- 
 lids, or simple purulent ophthalmy, one of 
 the most important indications, in the first 
 stage of the disorder, seems to him to be 
 the removal of these hurtful circumstances. 
 And, he declares, that, if immediate atten- 
 tion be not paid to such indication, it will 
 be quite impossible to prevent a dangerous 
 increase of the disorder. A cool fresh air, 
 and bathing the eye with cold water, or a 
 weak lotion of vinegar arid water, Beer 
 represents to be means, usually adequate 
 to stille this inflammation in its birth. In 
 the second stage, he says, the indication is 
 entirely different. 
 
 But, also in the beginning of this stage, 
 and even at its second period, namely that 
 of suppuration taking place, the disorder, 
 according lo Beer, seems for a short time to 
 be benefited by the employment of cold 
 water, but the consequences are rendered 
 by such treatment a great deal worse ; for 
 a fresh, much more extensive inflammation 
 of the same kind again takes place. At 
 the first period of the second stage, viz. 
 
 while the secretion is a pure mucous au& 
 sebaceous matter, Beer says, that it is abso 
 lutely necessary to employ such external 
 means, as are calculated to promote the ac- 
 tion of the veins and absorbents. For this 
 purpose, he recommends the following col- 
 lyrium : ]j^. Aq. rosa3 Z\v. Hydrarg. oxymur. 
 gr. j. vcl.gr. dimidium. Mucil. sem cydori. 3j- 
 Tinct opii vinos. Qj- Misce. This eyewater 
 is to be used lukewarm from four to six 
 times a day, and the eye afterward care- 
 fully and completely dried. JSo eye, in this 
 state, he says, will bear more than the pro- 
 portion of one gr. of the oxymuriate of 
 quicksilver, and only seldom more than 
 half a grain. 
 
 But, as soon as the suppurative period 
 commences, attended with excoriations, 
 gentle astringents, like the liquor plumbi 
 subacetatis, in a solution of the lapis divinus 
 (See Lachrymal Organs) should bt added to 
 the above lotion, for which they may at 
 length be entirely substituted. And, when 
 the suppurative period has terminated, but a 
 morbid secretion of mucus yet obstinately 
 continues, and threatens to become habitual, 
 recourse should be bad, without the least de- 
 lay, to one of the following eyesalves, a bit 
 of which, about the size of a small pea, 
 Beer directs to be smeared once a day over 
 the edges of the eyelids. Butyr. recen - 
 tis insulsi ^ss. Hydrargyri nitrico-oxydi 
 gr. x. Tutia? ptt. gr. vj. Misce. This oint- 
 ment, he says, will sometimes answer ; but, 
 that it is mostly necessary to use Janin’s 
 salve, composed as follows: f^. Butyri re- 
 centis insulsi ^ss. Hydrargyri praecipitati 
 albi. gr. xv. Boli albi 3j. Misce. 
 
 According to Mr. Travers, the mild acute 
 suppurative inflammation of the conjunctiva 
 is not attended w ith that excessive swell- 
 ing of the eyelids, that intense pain, nor 
 that profuse secretion, w ith which the vehe- 
 ment acute form of the disease is character- 
 ized. In the treatment, he directs a solution 
 of alum to be early substituted for emollient 
 fomentations, which he recommends to be 
 freely used during the acute period. Simple 
 purging and abstinence, he says, are gene- 
 rally sufficient to allay the febrile irritation, 
 which is moderate. Topical bleedings, and 
 blisters, kept open on the back of the neck, 
 are also stated to be of great efficacy. 
 “ When the pain and irritability to light 
 subside, and the discharge becomes gleety, 
 the conjunctiva pale and flaccid, tonics, es- 
 pecially the extract of bark and the acids, 
 do gri:at good.” ( Synopsis , fyc. p. 264.) 
 
 Catarrhal uphlkalmy, so called by Beer, is 
 described by him as a species of glandular 
 inflammation of the eyelids, attended with 
 a simultaneous atfection of the mucous mem- 
 brane of the nose, trachea, foe. brought on 
 by particular states of the weather, and at- 
 tacking so many persons at once, as to ap- 
 pear epidemic. The prognosis and indica- 
 tions are the same as those in common glau 
 dular inflammation of the eyelids, with this 
 exception, that attention must be paid lo 
 the affection of other organs, and both at. 
 the first and second periods of the second 
 
dPHT'HALMV. 
 
 Si r 
 
 Stage, such remedies given as operate power- 
 fully on the mucous membranes and skin, 
 and, in general, during the second stage, an 
 equal warm temperature, and gentle diapho- 
 retics, with camphor, are highly beneficial. 
 
 Severe Purulent Ophlhalmy. — The Blepha- 
 ro-blenorrhcea , and Ophthnlmo-blenorrhcea , of 
 Schmidt and Beer; including the ophthalmia 
 neonatorum; the Egyptian ophlhalmy ; the 
 gonorrhoeal ophlhalmy, fyc., on w hich varie- 
 ties, however, 1 shall annex to this account 
 some further particulars, as they relate to 
 each of these cases individually, because, 
 though the following history contains an ex- 
 cellent general description of the severe 
 forms of suppurative inflammation of the 
 conjunctiva, it leaves unexplained some of 
 the circumstances on which its varieties de- 
 pend. 
 
 The vehement acute suppurative inflam- 
 mation of the conjunctiva is described by 
 Mr. Travers as being sudden in its attack ; 
 a feature, in which it particularly differs from 
 the milder cases usually met with in schools. 
 (See Lloyd on Scrofula, p. 321.) It is accom- 
 panied with most severe darting pains ; and 
 the upper eyelid is sometimes in a few hours 
 prolonged upon the cheek, owing to the in- 
 filtration and enormous swellingof the tissue, 
 connecting the conjunctiva to the tarsus. 
 ( Travers , Synopsis, c %-c. p. 265.) 
 
 According to Beer, the modification of 
 glandular inflammation of the eyelids, here 
 to be considered, consists entirely in the ra- 
 pid extension of the inflammation and sup- 
 puration, the disorder affecting, ere it is sus- 
 pected, not only the whole of the conjuncti- 
 va of the eyelid, but also that of the eye- 
 ball, and the sclerotica and cornea. The 
 swelling of the palpebral conjunctiva is de- 
 scribed by Beer as being unusually great ; 
 at first, soft, somewhat elastic, smooth, and 
 readily bleeding; but, afterward, in the se- 
 cond stage, hard and granulated, or, as ano- 
 ther writer says, it “ becomes pi eternaturally 
 vascular, thickened, and scabrous, or forms 
 fleshy eminences.” ( Travers , Synopsis, fyc 
 p. 96.) The first stage is rapidly over. At 
 the first period of the second stage, the se- 
 cretion both of mucus and pus is surprisingly 
 copious. First, the mucus is whitish and 
 thin ; but, as soon as the suppurative pro- 
 cess begins, it becomes yellowish and thick, 
 and when an attempt is made to open the 
 eyelids, it gushes out with such force, and 
 in so large a quantity, as frequently to cover, 
 in an instant, the whole cheek. Sometimes, 
 this mixture of mucus and matter contains 
 light-coloured streaks of blood ; but, in 
 worse cases, these streaks are dark and 
 brownish, or else a thin ichor is discharged, 
 in which case, the progress of the disease 
 is so rapid, that the eye can seldom be sa- 
 ved. The swelling of the conjunctiva of 
 the eyelids, especially of that of the upper 
 one, always increases during the first period 
 of suppuration, and, when the discharge is 
 more ichorous, the membrane is more gran- 
 ulated, so that if the eyelid be opened care- 
 lessly, or during the child’s crying, fits of 
 pain. &c. the whole tumefied conjunctiva of 
 
 the upper eyelid is immediately thrown 
 outward, in the form of ectropium, and it is 
 sometimes difficult, and even impracticable 
 to turn the part inward again, especially, 
 when the conjunctiva is already changed 
 into a hard sarcomatous substance. While 
 the swelling at the inner surface of the eye- 
 lids continues to increase, their outer sur- 
 face, particularly that of, the upper one, 
 becomes reddened ; but the redness is dark- 
 coloured, inclining to brown, and when the 
 child cries, to blue. In children, the w hole 
 cheek on the affected s : de is very often 
 swelled, and sometimes the mucous mem- 
 brane of the lachrymal sac and even of the 
 nose, participates in the effects of the dis- 
 order. Sometimes, at first, only one eye is 
 affected, and the other is afterward attack- 
 ed And, according to Beer, just before the 
 period of suppuration, it is by no means un 
 common for rather a profuse bleeding to 
 to take place from the eye ; an event, 
 which thou h it seriously alarm the parents 
 of the child, or an adult patient, is hailed by 
 the experienced surgeon as a favourable 
 omen ; for, in such cases, the suppuration 
 is generally very mild, and not of a destruc 
 five kind, and the swelling of the « onjunc- 
 tiva of the eyelids, as well as that of the 
 sclerotic^ conjunctiva, if already present, 
 soon undergoes a remarkable diminution 
 after such hemorrhage, which often recurs 
 two or three times. When during the first, 
 very short ami transient stage, the inflam 
 mation extends also to the sclerotic con- 
 junctiva, this membrane forms a pale-red, 
 soft, irregular swelling, all round the cor- 
 nea, which at length seems so buried, that 
 at the period of the mucous secretion, its 
 centre can hardly be discerned ; and, when 
 suppuration begins, both rnucus and pus 
 are discharged from the conjunctiva of the 
 eyeball in profust' quantity, particularly ac- 
 cumulating over the cornea, and not unfre- 
 quently drying into a thick pellicle, when 
 long detained in the eye. Hence, the case 
 looks as if the whole eyeball, or at least, all 
 the cornea, were in a state of complete sup- 
 puration. At length, the tumefied conjunc- 
 tiva of the eyeball becomes sarcomatous, 
 though never in such a degree as that of the 
 eyelids. hen the suppurative period cea- 
 ses, and with it the most urgent danger to 
 the eye, the secretion of mucus alone con- 
 tinues, as at the first period of the second 
 stage, the swelling of the conjunctiva of 
 the eyelids, and of the sclerotic conjuncti- 
 va, when this has also been affected, dimi- 
 nishes, and the disorder ends in an increased 
 effusion of tears or true epiphora. When 
 the effects of the suppuration upon the con- 
 junctiva of the eyeball are more severe, the 
 corneal production of this membrane in the 
 most favourable cases is raised from the sub- 
 jacent cornea, and so opaque, that the eye- 
 sight is lost, or at all events seriously impair- 
 ed, until the transparency returns, which is 
 sometimes late, especially when efficient 
 treatment is not put in practice. Should 
 the suppuration be very deep, the cornea, 
 which always turns whiter and whiter, pre- 
 
QPHTH ALMV, 
 
 318 
 
 sents near the edge of the swelling of the 
 conjunctiva an arrangement, similar to that 
 of the leaves of an old book, and at length 
 seems converted into a mass of purulent 
 matter, which projects more and more out 
 of the depression in the swelled conjunc- 
 tiva, and then bursts in its centre either 
 quickly and with very violent pain, or slow- 
 ly without any suffering, an oval hole being 
 left, behind which the yet transparent crys 
 ta 1 line lens appears, included in its undama- 
 ged capsule. At this period, adults can often 
 see very plainly, and fancy their recovery 
 near at hand, or, at least, all danger over. 
 Already, however, every part of the cornea 
 has been more or less perforated by ulcera- 
 tion, the iris protrudes through all these 
 apertures, so as to form what has sometimes 
 been named the staphyloma racemosum. 
 In a very short time, not exceeding a few 
 hours, the capsule of the lens is affected, 
 and bursts like the cornea, when it is dis- 
 charged either with, or without, a portion 
 of the vitreous humour. At length, the 
 suppuration subsides, and with it the pro- 
 trusions of the iris, the opening in the cornea 
 becoming closed with a brown, or bluish, 
 opaque fiat cicatrix But, if in this destruc- 
 tive form of suppuration, nothing is done 
 for the relief of the disease, the whole eye- 
 ball suppurates, theeyelids become concave 
 instead of convex, and the fissure between 
 them closes for ever. In adults of feeble 
 constitutions, when the case is not properly 
 treated, but particularly in weak children, 
 this excessively violent form of conjuncti- 
 val inflammation and suppuration spreads 
 with such rapidity, that a considerable ge- 
 neral disturbance of the system is occasion- 
 ed. Indeed, according to Mr. Travers, in 
 the common course of this vehement form 
 of conjunctiva! suppurative ophthalmy, the 
 system sympathizes ; chilliness is succeeded 
 by a hot and dry skin ; and the pulse is 
 frequent and hard. Yet, it is particularly 
 pointed out by the army surgeons, that one 
 peculiarity of the Egyptian purulent oph- 
 thalmy is its being generally attended with 
 little constitutional disturbance. When the 
 above-described annihilation of the eyeball 
 takes place, it always creates violent gene- 
 ral indisposition in unhealthy weak chil- 
 dren, and even leaves adults for along while 
 afterward in an impaired state of health. 
 
 According 1o Beer, who appears to have 
 no idea of infection being concerned the 
 particular cause ot this unfortunate exten- 
 sion of idiopathic glandular inflammation 
 of the eyelids, both in infants and adults, 
 frequently depends altogether upon the foul 
 atmosphere, in which they are residing, and 
 hence, says he, the disorder is, as it were, 
 endemic in lying-in and foundling hospitals, 
 where the air is much contaminated by ef- 
 fluvia, from the lochia, the crowding toge- 
 ther of many uncleanly persons, dirty clouts, 
 &,c The unjustifiable folly of exposing the 
 eyes of new-born infants to every degree 
 of light ; a tedious labour, in which the 
 child’s head is detained a long while in the 
 vagina ; and roughly washing the eyes after 
 
 birth with a coarse sponge; are other cir- 
 cumstances, supposed by Beer to be condu- 
 cive to the origin of the complaint, in new- 
 born infants. The reality of many of these 
 causes I regard myself with a great deal of 
 doubt ; and nsfor hisconjecture, thatsprink- 
 liug cold water on the head in baptism, 
 while in a state of perspiration, may pro- 
 duce the complaint, it is too absurd to need 
 any serious refutation. The disorder, he 
 says, is always more rapid and perilous in 
 new-born infants than adults; ( B . 1, p. 
 318,) a remark which does not agree with 
 the statements usually made, if the Egyp- 
 tian ophthalmy, as seen in the army, be 
 comprehended. It is observed by Mr. 
 Travers, that the highly contagious nature 
 of the suppurative ophthalmia, whether in 
 the mild, or vehement acute form, is suffi- 
 ciently proved. For one person, affected 
 with this disease above three months old, 
 he thinks at least twenty are attacked under 
 that age. “ The mother is the subject of 
 fluoralbus, or gonorrhoea, and the discharge 
 is usually perceived about the third day.’’ 
 ( Synopsis , fyc. p. 97.) Some further obser- 
 vations on the causes of some of these severe 
 modifications of glandular inflammation of 
 the eyelids will be introduced, after the 
 prognosis and treatment have been consi- 
 dered. This will be the more necessary, as 
 the propagation of the disorder by infection 
 is here entirely overlooked. 
 
 According to Beer, whenever an idiopa- 
 thic inflammation of the glands of the eye- 
 lids attains the severe forms, exhibited in 
 the purulent ophthalmy of infants, the Egyp- 
 tian ophthalmy, and gonorrhoeal ophthalmy, 
 the prognosis must naturally be unfavoura- 
 ble, and this in a greater degree, the more 
 the inflammation and suppuration have ex- 
 tended to the eyeball itself. The cases are 
 still more unpromising, when they happen 
 in poor, half-starved, distressed individuals, 
 whom it is impossible completely to extri- 
 cate from the circumstances, which either 
 cause, or have a pernicious effect upon the 
 disease. Should an incidental ectropiurn 
 not be immediately rectified, says Beer, it 
 will continue until the end of the second 
 stage, and even frequently longer, so as to 
 require particular treatment. When at the 
 period of suppuration, merely the layer of 
 the conjunctiva, spread over the cornea, is 
 destroyed, the prognosis, in respect to the 
 complete recovery of the eyesight, is fa- 
 vourable, although it takes place but slow- 
 ly. If the effects of the disease at this 
 period should be deeper, yet the cornea 
 not destroyed, only rendered flat and 
 somewhat opaque ; or, if the cornea 
 should be ulcerated only at a very lim- 
 ited point; there will remain in the first 
 case, an opacity of the cornea ; but, in the 
 second, a partial adhesion of the iris to the 
 latter membrane (synechia anterior) is apt 
 to follow, with a more or less extensive ci- 
 catrix on the cornea, covering in a greater 
 or lesser degree the lessened and displaced 
 pupil, and thus diminishing, or preventing 
 vision. When, during the inflammation 
 
OPHTHALMY. 
 
 819 
 
 aud suppuration, a considerable part, or the 
 whole of the iris adheres to the cornea, and 
 this is not penetrated by ulceration, the re- 
 sult, in the first case, is a partial , in the se- 
 cond, a complete staphyloma of the cornea, 
 which does not fully develope itself, until 
 towards the decline of the second stage of 
 the ophthalruo-blennorrhcea. If the inflam- 
 mation should spread to the tejitures of the 
 eyeball itself, so as to produce severe con 
 Stitutional disturbance, the eye wastes away 
 in the midst of the profuse discharge, the 
 eyelids sink inwards, and the fissure between 
 them becomes permanently closed. (Beer, 
 B. 1, p. 319.) 
 
 Beer notices the opinion of the celebrated 
 Schmidt, which was, that the opthalmo- 
 hlennorrhcea, orpurulent ophthalmy involv- 
 ing the sclerotic conjunctiva, always has a 
 fixed duration of a mouth, in new-born in- 
 fants, and of six, eight, or twelve weeks, in 
 very weak individuals. Beer acknowledges 
 the correctness of this opiuion, only in 
 cases where the surgeon has to deal with a 
 completely formed ophthalmo-blennorrhoea, 
 and not in a more recent case, or one in 
 which the disease is chiefiy confined to the 
 inside of the eyelids. ( Blepharo-blennor - 
 rhoea.) When the disorder is met with in 
 the first period of the second stage, or it is 
 confined to the palpebral conjunctiva and 
 Meibomian glands, and truly idiopathic, 
 Beer asserts, that its course may be restrict- 
 ed by efficient treatment to a few days, as 
 he has often proved in the establishment for 
 foundlings at Vienna. 
 
 It is further remarked by Beer, that, in 
 this modification of genuine idiopathic glan- 
 dular inflammation of the eyelids, the in- 
 dications have something peculiar in them. 
 If, by chance, the surgeon meet with the 
 disease in its first stage, it will be most bene- 
 fited by the application of folded linen wet 
 with cold water ; and sometimes a brisk 
 purge of jalap and calomel, and putting a 
 leech over the lachrymal sac at the inner 
 canthus, will promote the subsidence of 
 this dangerous species of ophthalmy. The 
 case, however, jrarely presents itself for me- 
 dical treatment thus early, and, in hospitals, 
 Beer says, antiphlogistic treatment is, on this 
 account , hardly ever indicated. 
 
 With some exceptions of importance, the 
 treatment, advised by Beer, for the second 
 stage of these severer forms of purulent 
 ophthalmy, resembles that proposed by him 
 for the second stage of simple glandular in- 
 flammation of the eyelids, or the milder 
 varieties. These more severe kinds of puru- 
 lent inflammation of the eye, implied by 
 blepharo-blennorrhcea and ophthalmo-blen- 
 norrhoea, he says, should never be viewed 
 and treated merely as local disorders ; but 
 that, both in children and adults, internal 
 remedies should be exhibited, particularly 
 volatile tonic medicines. In cases, where 
 the cornea is already attacked by a destruc- 
 tive ulcerative process, manifold experience 
 has convinced him, that bark, combined with 
 naphtha, and the tincture of opium, is the 
 only means of saving the eye : but, that if 
 
 the suppuration be confined to the eye- 
 lids, the decoction of calamus aromati- 
 cus with naphtha and opium will mostly 
 answ r er. When, on the supervention of 
 suppuration, the pain in the eye and neigh- 
 bouring parts is excessively severe, Beer 
 assures us, that friction with a liniment of 
 opium will give great relief. In new-born 
 infants, the maternal milk of right quality 
 will mostly do more good, than internal 
 medicines : but if the case be very urgent, 
 and the child feeble, Beer thinks volatile 
 medicines may sometimes do good. 
 
 With respect to particularities made ne- 
 cessary in the local treatment by the modified 
 nature of the inflammation. Beer otters the 
 following information. First, in new-born 
 infants, or very young children, the oxymu- 
 muriate of mercury cannot be used without 
 danger, though blunted with mucilage; and 
 even in adults, it should be employed in 
 these cases with great circumspection. Se- 
 condly, the mucus and purulent matter 
 should not be allowed to remain long under 
 the eyelids, as such lodgment is found to 
 promote the destruction of the layer of the 
 conjunctiva situated on the cornea; but, at 
 the same time, Beer thinks, that leaving any 
 water on the eyes, after cleaning them, and 
 letting it become cold there, will have quite 
 as pernicious an effect. Hence, he is very 
 particular in directing all the mucus and 
 purulent matter to be wiped away from the 
 eye with a bit of fine sponge moistened with 
 a warm mucilaginous collyrium, but not so 
 w et as to let the fluid drop out of it ; or when 
 they are very copious, and in large flakes, 
 he even recommends them to be washed 
 away by means of Anel’s syringe ; but. he 
 says, that every part about the eye should be 
 immediately afterward well dried with a 
 warm napkin, and then covered with a w arm 
 camphorated compress. Thir-ily , during the 
 suppurative period, according to Beer, com- 
 mon tincture of opium, or the vinous tincture 
 is the best local application, the parts being 
 smeared with it twice a day, by means of a 
 fine camel-hair brush. It is only in a few 
 instances, that a small proportion of the 
 lapsis divinus (see Lachrymal Organs ,) mixed 
 with the mucilaginous collyrium, can be 
 endured. Beer declares, that he has never 
 seen any good produced by Bates’s campho- 
 rated lotion, w hich was so highly praised 
 by the late Mr. Ware. Fourthly, when the 
 suppurative period has terminated, the mu- 
 cous secretion again becomes vvliite and thin, 
 as at the very commencement of the second 
 stage, but it is always more copious ; now 7 is 
 the time, (as in the last stage of simple 
 glandular inflammation of the eyelids) when 
 the topical use of mercury, joined w 7 ith 
 styptics, especially in the form of an eye- 
 salve, is indicated. Fifthly, if an eversion 
 of the upper eyelid should happen from 
 washing the eye carelessly, or the mere 
 crying of the infant, in consequence of the 
 thickened granulated state of the palpebral 
 conjunctiva, the position of the eyelid must, 
 if possible, be immediately rectified ; for 
 afterward, this cannot be done. In order to 
 
OPHTHALMY. 
 
 mo 
 
 avoid this ectropium, the eyelids should irritation are past, and the cornea retains ite 
 never be opened while the child is crying, or tone and brightness, Mr. Travers considers 
 in any way agitated; for, at such periods, the the case safe, and states, that the prompt 
 thickened scabrous conjunctiva will sudden exhibition of tonics, with the use of cooling 
 ly protrude, and cannot be kept buck. Beer astringent lotions, will prevent its lapsing 
 says, that the eyelid should be replaced in into a chronic form. “ But if, when the 
 the manner directed by Schmidt. ( Ophthal - lowering practice has been pushed to the 
 mo/ Bibl. 3. R. 2. Stuck, p. 149.) The surgeon extent of arresting acute inflammation, the 
 having smeared the e^ds of the thumb and patient being at the same time sunk and ex- 
 forefinger of each of his hands with fresh hausted. the cornea shows a lack lustre and 
 butter, is to take hold of the everted raggedness of its whole surface, as if shrunk 
 cartilage of the eyelid at the outer and by immersion in an acid, or a gray patch in 
 innercanthus, draw it slowly a little upwards, the centre, or a line encircling, or half en- 
 and then suddenly downw ards. Thus, the circling its base, assuming a similar appear- 
 fhickened conjunctiva, if not too fleshy and ance, the portion so marked out will infalli- 
 granulated, may be quickly reduced, and bly be deta* bed by a rapid slough, unless by 
 the ectropium removed. But, if the swelling a successful rally of the patient’s powers, we 
 ot this membrane should he already very can set up the adhesive inflammation, so as 
 considerable, and have begun to be hard and to preserve in situ that which may remain 
 studded with excrescences, tiiethumbs should transparent.” (Synopsis, fyc. p. 266.) Here 
 be placed so as to compress rather the we find some approximation of practice, be- 
 middle of the eyelid. However, if the ectro- tween Mr. Travers and Professor Beer ; but 
 piura cannot be at once removed, it is to be it is almost the only point, in which any re- 
 treated, after the termination of the second semblance can be found in their modes of 
 stage of the purulent opbthalrny, as a sequel treatment. 
 
 of this disorder. (See Ectropium .) The granulated, or fungous state of the 
 
 In the ophthal mo-blennorrhcea the altera- palpebral conjunctiva, produced by puru- 
 tion of the sclerotic conjunctiva is said by lent ophthalmy, sometimes demands parti- 
 Beer to be very different from chemosis ; a cular treatment, after the original disease is 
 vemark, which is strictly correct, inasmuch subdued. If such state of the eyelid be not 
 as ordinary chemosis is not attended with rectified, it often keeps up a “ gleety dis- 
 til at change in the surface of the sclerotic charge, irritability to light, drooping of the 
 conjunctiva, which fits it for the secretion upper lid, a pricking sensation as of sand in 
 of pus. But, if we are to understand by the eye, and a preternaturally irritable and 
 chemosis, a copious effusion of lymph in the vascular state of the sclerotic conjunctiva j 
 loose cellular substance between the con- with these are frequently combined opaci- 
 junctiva and the eyeball, this state must be ties of the cornea.” (Travers, op. cit. p. 271.) 
 admitted as one of the usual effects of severe The affection, as conjoined with opaque 
 purulent ophthalmy. cornea, is particularly noticed by Dr. Vetch, 
 
 “ It is after this morbid condition, which who describes the disease of the palpebrae as 
 is characteristic of the suppurative ophthal- consisting, at first, in a highly villous state of 
 mia (says Mr. Travers) that the conjunctiva their membranous lining, which, if not 
 forms fungous excrescences, pendulous treated by appropriate remedies, gives birth 
 flaps, or hard callous rolls protruding be- to granulations, which in process of time 
 tween the palpebraS and globe, and everting become more deeply sulcated, hard, or 
 the former, or, if not protruding, causing the warty. Along with the villous and fleshy 
 turning of the lid over against the globe, appearance of the lining of the eyelids, there 
 The tarsal portion takes on from the same is a general oozing of purulent matter, which 
 cause the hard granulated surface, which may at any time be squeezed out by press- 
 keeps up incessant irritation of the sclerotic ing the finger on the part. The diseased 
 conjunctiva, and at length renders the cornea structure is highly vascular, and bleeds most 
 opaque.” (Synopsis, Q-c.' p. 9 8.) profusely when cut. It possesses, as all 
 
 The treatment recommended by Mr. Tra- granulated surfaces do, a very great power ' 
 vers for the vehement acute suppurative of growth or reproduction. Dr. Vetch has 
 inflammation of the conjunctiva consists in seen many cases in which it has been remo- 
 a very copious venesection, by which, be ved with more zeal than discretion, twenty 
 says, the pain is mitigated, if not removed ; or thirty times successively, without this 
 the pulse softened ; and the patient sinks disposition to reproduction having suffered 
 into a sound sleep and perspires freely. The any diminution. Indeed, he assures us, that 
 high scarlet hue and bulk of the chemosis the operation was very unfavourable to the 
 are sensibly reduced, and the cornea is ultimate recovery of the part ; “ a new sur- 
 brighter. The blood-letting, if necessary, is face is produced of a bright velvety appear- 
 to be repeated, and the patient briskly ance, much less susceptible of cure than the 
 purged, every dose of the opening medicine original disease, and which, even if at length 
 being followed by a lea-spoonful of a solu- healed, does not assume the natural appear- 
 tion of emetic tartar, so as to keep up a ance of the part, but that of a cicatrized 
 stale of nausea, perspiration, and faintness, surface,” not attended with a return of the 
 When the discharge becomes thin, gleety, transparency of the cornea. It is s&tisfacto- 
 and more abundant, the swelling of the eye- l ily proved, by the observations of Dr. 
 lid subsides, the conjunctiva sinks and be- Vetch, that this diseased state of the inner 
 pale and fiebbv. the pain and febrile surface of the eyelid was not. only known to 
 
©PHTHAUVTY. 
 
 .321 
 
 ilhases, and other old practitioners, under 
 the names of sycosis, trachoma, scabies pal- 
 pebrarum, &c. but that its treatment by the 
 actual cautery, excision, and friction, was 
 also recommended by them. The honour 
 of having introduced the preferable mode of 
 cure with escharotics, Dr. Vetch assigns to 
 St. Ives. No substances appear to Dr. Vetch 
 more effectual for this purpose than the 
 sulphate of copper and nitrate of silver. He 
 says, that they should be pointed in the form 
 of a pencil, and fixed in a port-crayon. 
 They are to be applied, not as some have 
 conceived, with the view of producing a 
 slough over the whole surface, but with 
 great delicacy, and in so many points only, 
 as will produce a gradual change in the 
 condition and disposition of the part. As 
 long as any purulency remains, Dr. Vetch 
 states, that the above applications will be 
 much aided by the daily use of the liquor 
 plumbi subacetatis. When the disease re- 
 sists these remedies, and the surface is hard 
 and warty, he applies very minute quanti- 
 ties of finely levigated powder of verdigris, 
 or burnt alum, to the everted surface, with 
 a fine camel-hair pencil, but carefully 
 Washes them off with a syringe before the 
 eyelid is returned. The caustic potassa, 
 lightly applied to the more prominent parts 
 of the diseased surface, will also answer. 
 (See Vetch on Disease's of the F.ye p. 73, 
 <y c.) Mr. Lloyd also gives his testimony in 
 favour of the superiority of the nitrate of 
 •silver, which he lias employed in the form 
 of a saturated solution for restoring the 
 healthy state of the inner surface of the 
 eyelid. (On Scrofula, p. 328.) Others, 
 however, still adhere to the practice of ex- 
 cision, which, as already observed, was fol- 
 lowed by the ancients, and revived of late 
 years in England by Mr. Saunders, who did 
 with scissors what Sir W. Adams and others 
 have subsequently performed with a knife 
 or lancet. Mr. Travers, I may observe, is 
 also one of the advocates for the excision of 
 the granulations and hardened excrescences 
 of the conjunctiva. If there be a nebula of 
 the cornea, with a plexus of vessels extend- 
 ing to it, these are then divided, near the 
 edge of the cornea, in the manner recom- 
 mended by Scarpa. Mr. Travers afterward 
 applies a solution of the sulphate of copper, 
 the liquor plumbi subacetatis, or the vinous 
 tincture of opium. One remark which he 
 makes tends very much to confirm the gene- 
 pal advantage of the practice inculcated by 
 Dr. Vetch ; for, it is observed, “ the appli- 
 cation of the bluestone, or of the lunar caus- 
 tic, is often useful in preventing the regene- 
 ration of the granulations after their exci- 
 sion.” ( Synopsis , fyc. p. 272.) My friend, 
 Mr. Law rence, whose experience in diseases 
 of the eye is very considerable, lately in- 
 formed me, that he finds caustic the sure 
 mode of permanently removing the granu- 
 lated fungous state of the inner surface of 
 the eyelid, and that, when the granulations 
 are cut away, they are frequently reprodu- 
 ced ; a fact on which Dr. Vetch has particu- 
 larly insisted 
 Vot, II 
 
 Egyptian Ophlhalmy. One of the best 
 accounts of this disease, as it appeared iri 
 the army, is that delivered by Dr. Vetch. 
 Although there can be no doubt that the 
 disorder, in all its general characters, 
 closely corresponds to the severe form of 
 acute suppurative inflammation of the con- 
 junctiva, as described by Beer; yet thero 
 are some peculiarities with which it appears 
 to have been characterized. Thus, one 
 thing noticed in the Egyptian ophlhalmy, 
 but not in other purulent ophthalmies, fs, 
 that the firs' appearance of inflammation was 
 observable in the lining of the lower eyelid, 
 (Peach in f din ' . Med and Surgical Journ. 
 for January, 1807. Vetch, on Diseases of the 
 Eye. p 196.) According to the latter wri- 
 ter, the feeling of dirt, or sand, rolling in 
 the eve is a symptom requiring particular 
 attention, as its accession is a certain index 
 of the disease being on the increase. It b 
 subject to exacerbations and remissions, the 
 attacks always taking place in the evening, 
 or very early in the morning. The first 
 stage of the disease is said by Dr. Vetch to be 
 characterized by its great and uniform redress , 
 ivithout that pain , tension, or intolerance of 
 light , which accompanies most other forms of 
 Ocular inflammation ; and, in particular, that 
 in which the sclerotic coat is affected. From 
 the very beginning of the complaint, there 
 is a disposition to puffiness in the cellular 
 texture between the conjunctiva and the 
 globe of the eye, often suddenly swelling 
 out into a state of complete chemosis, and 
 at other times making a more gradual ap- 
 proach to the cornea. While effusion is 
 thus taking place upon the eye, cedema is 
 likewise going on beneath the integuments 
 of the eyelids. This enormous tumefaction 
 of the eyelids is said to be generally consen- 
 taneous with the complete formation of 
 chemosis; entropium is produced, and the 
 integuments of the two eyelids meet, lea- 
 ving a deep sulcus between them. When 
 the external swelling begins, the discharge, 
 w hich was previously moderate, and consist- 
 ed of pus floating in a watery fluid, changes 
 into a continued stream of yellow matter, 
 which, diluted with the lachrymal seer# 
 tion, greatly exceeds in quantity that deri- 
 ved from any gonorrhoea. Although, says 
 Dr. Vetch, the tumefaction may be, at first, 
 farther advanced in one eye than the other, 
 it generally reaches itsgreatest height In both 
 about the same. The patient now* begin?* 
 to suffer attacks of excruciating pain in the 
 eve; a certain indication of the extension 
 of the mischief. “ An occasional sensation, 
 as if needles were thrust into the eye, ac 
 companied with fulness and throbbing of 
 the temples, often precedes the deeper seat- 
 ed pain ” This last is often of an intermit- 
 ting nature, and a period of excruciating 
 torture is succeeded by an interval of perfect 
 ease. Sometimes the pain shifts instanta- 
 neously from one eye to the other, and is 
 seldom or never equally severe in both at 
 the same time and sometimes, instead of 
 being in the eye, it occurs in a circumscri- 
 bed soot of the head, which the patient <?e- 
 
 41 
 
OPHTHALMT . 
 
 W 
 
 scribes by saying, be can cover the part 
 with his finger. Sooner or later, one of 
 these attacks of pain is terminated by a sen- 
 sation of rupture of the cornea, with a gush 
 of sc liiirig water, succeeded by immediate 
 relief to the rye ii which this evtfnt has 
 happened, bur generally soon followed by 
 a increased violence of the symptoms in 
 the other. At length the attacks of pain 
 become shorter, and less severe, though 
 they do not cease altogether till after the 
 lapse of many weeks, and even months. 
 During this stage of the disease , according 
 to Dr. Vetch, then > is seldom the slightist 
 alteration of the pulse, unless the lancet hare 
 been freely employed. The patient’s general 
 health is little impaired, his appetite conti- 
 nues natural, but sleep almost totally for- 
 sakes him. 
 
 As the pain abates, the external tumefac- 
 tion also subsides, and a gaping appearance 
 of the eyelids succeeds, their edges, instead 
 of being inverted, now becoming everted. 
 This is what Dr Vetch designates as the 
 third stage of the disease. 
 
 After the swelling of the second stage has 
 subsided, the eyelids are prevented from 
 returning to their natural s ate by the gra- 
 nulated change of the conjunctiva which 
 lines them ; and an eversion of them now 
 occurs in a greater or lesser degree ( Vetch 
 on Diseases of the Eye , p. 196, 2< 2 ) Among 
 other interesting remarks, made by the same 
 author, he states, that there is no reason to 
 warrant the idea that the ulceration ever 
 proceeds from within outwards. He ob- 
 serves, that, when any large portion of the 
 cornea sloughs, an adventitious and vascu- 
 lar membrane is often produced, which 
 finally forms a staphyloma. “In some few 
 cases, (says he) 1 have seen the lens and its 
 capsule exposed, without any external co- 
 vering whatever, and, for a short time, the 
 patient saw every thing with wonderful ac- 
 curacy; but, as soon as the capsule gives 
 way, the lens, and more or less of the vitre- 
 ous humour, escape, the eye shrinks, and 
 the cornea contracts into a small horn-co- 
 loured speck.” This total destruction of 
 the globe of the eye is said generally to en- 
 sure the other, and renders it less liable to 
 be affected by future attacks of inflamma- 
 tion. 
 
 A few years ago, an ophthalmy, supposed 
 to be of the same nature as the Egyptian, 
 though milder, like that which has generally 
 been observed in schools, occurred to a 
 great extent in the Royal Military Asylum 
 at Chelsea, and Mr. M ‘Gregor, the surgeon 
 of that institution^ has favoured the public 
 with an excellent description of the disease, 
 and some highly interesting facts and reflec- 
 tions upon the subject. In the Military 
 Asylum the symptoms of this species of 
 ophthalmy generally made their appearance 
 in the following order: “A considerable 
 degree of itching was first felt in the even- 
 ing; this was succeeded by a sticking toge- 
 ther of the eyelids, principally complained 
 (>f by the patient on waking in the morning, 
 ’(the eyelids appeared fuller externally than 
 
 they naturally are ; and on examining their 
 internal surface this was found inflamed. 
 The sebaceous glands of the tarsi were con- 
 siderably enlarged, and of a redder colour 
 than usual. The caruncula lachrymalis had 
 a similar appearance. 
 
 “ In 24 or 30 hours after the appearance 
 of the above-mentioned symptoms, a viscid 
 mucous discharge took place from the inter- 
 nal surface of each eyelid, and lodged at the 
 inner canthus, till the quantity was sufficient 
 to be pressed over the cheek by the motions 
 of the eye. The vessels of the tunica con- 
 junctiva, covering the eyeball, were distend- 
 ed with red blood, and the tunica conjunc- 
 tiva was generally so thickened, and raised, 
 as to form an elevated border round the 
 transparent cornea. This state was often 
 accompanied with redness of the skin round 
 the eye, which sometimes extended to a con- 
 siderable distance, and resembled, in colour 
 and form, very much what takes place in 
 the cow-pox pustule, between the 9th and 
 12th days after inoculation. 
 
 “ When the purulent discharge was con- 
 siderable, there was a swelling of the ex- 
 ternal eyelids, which often prevented the 
 patient from opening them for several days. 
 The discharge also frequently excoriated the 
 cheeks as it trickled down Exposure to 
 light caused pain When light was excluded, 
 and the eye kept from motion, pain was sel- 
 dom much complained of 
 
 “These symptoms, in many, subsided, 
 without much aid from medicine, in 10 , 12, 
 or 14 days, leaving the eye for a considera- 
 ble time in an irritable state. In several, 
 however, the disease continued for a much 
 longer time, and ulceration took place oa 
 the internal surface of the eyelids, and in 
 different parts on the eyeball. If one of 
 those small ulcers happened to be situated 
 on the transparent cornea, it generally, on 
 healing, left a white speck, which, however, 
 in the young subjects under our care, was 
 commonly soon removed. In some few 
 instances, an abscess took place in the sub- 
 stance of the eyeball, which, bursting ex- 
 ternally, produced irrecoverable blindness.” 
 (P Gregor, in Trans, of a Socirty for the 
 Improvement of Med. and Chirwg. Knowledge, 
 Tot. 3, p. 3»— 40.) 
 
 Whet! the local symptoms had prevailed 
 two or three days, some febrile disturbance 
 occurred ; but, except in severe cases, it was 
 scarcely observable. 
 
 Mr M ‘Gregor considered this ophthalmy 
 to be of the same nature as that which has 
 raged with such violence in the army at dif- 
 ferent periods, since the return of our troop' 
 from Egypt in 1800, 1801, and 1802. How- 
 ever, he has found that its consequences 
 have not been so injurious to children as to 
 adults; for, out of the great number of 
 children that were afflicted with the disease 
 at the Military Asylum, only six lost the 
 sight of both eyes, and twelve the sight <n 
 one eye. (Op.cit.p. 49.) On the other hand. 
 Dr. Vetch informs us, that, in the second 
 battalion of the 52d regiment, which con- 
 sisted of somowhat more than TOO m«n. 63f» 
 
OPHTHALMY. 
 
 323 
 
 eases of ophthalmy were admitted into the 
 hospital between August, 18 5, and August, 
 1806 ; and that, ‘‘ of this number, fifty were 
 dismissed with the loss of both eyes, and 
 forty with that of one.” And, as Mr. M‘Gre- 
 gor observes, it is a melancholy fact, as ap- 
 pears from the returns of Chelsea and Kil - 
 mamham Hospitals, that 2317 soldiers were, 
 on the 1st of December, 1810, a burthen 
 upon the public from blindness, in conse- 
 quence of ophthalmy. The cases, in which 
 only one eye was lost, are not here included. 
 
 The attacks of the disease appear to be 
 much more frequent, severe, and obstinate, 
 in hot, sultry weather, than in cold or tem- 
 perate seasons. (P M Gregor, op. cit. p. 37, 
 64, 4 , 0 .) 
 
 This gentleman also observed, that the 
 ophthalmy was more severe and protracted 
 in persons having red hair, or a scrofulous 
 habit, than in others. The right eye was 
 more frequently a d violently affected than 
 the left. In females the symptoms are 
 greatly aggravated for some days previous 
 to the catamenia; but, on this evacuation 
 taking place, they are quickly lessened. Mr. 
 M‘Gregor further remarks, that the measles, 
 cow-pox, and mumps, go through their 
 course as regularly in persons affected with 
 this species of ophthalmy, as when no other 
 disease is present ; a circumstance whi h, 
 with some others, proves that the disorder 
 is entirely local. ( P . 54, 55.) 
 
 With respect to the causes of the Egyp- 
 tian Purulent Ophthalmy , much difference 
 of opinion has prevailed, and, indeed, there 
 was a time when the disease was regarded 
 by the majority of army surgeons, who 
 alone had opportunities of judging of it, as 
 not being in real ity contagious, but dependent 
 upon local epidemic causes ; the irritation of 
 "and ; peculiarly of climate , fyc. The late 
 Mr. Ware even doubted tiie propriety of 
 calling this ophthalmy Egyptian, and he con- 
 tended that a disease precisely similar in its 
 symptoms and progress had been noticed 
 long ago in this and other countries ; and 
 that, in Egypt, several varieties of ophthalmy 
 prevail. He preferred calling the disease 
 the Epidemical Purulent Ophthalmy. On 
 the other hand, 'rir W. Adams conceives, 
 that it ought rather to be called Asiatic 
 Ophthalmy , as recent investigations prove 
 that it prevails in the greater part of Asia, 
 and was long ago described by Avicenna. 
 ( Graefe , Journ. der Chir 1 B. p. 170.) 
 
 That there has been long known in this 
 country an infectious species of purulent 
 ophthalmy cannot be doubted. The case, 
 described by many surgeons, as proceeding 
 from the sudden stoppage of gonorrhoea, or 
 the inadvertent application of gonorrhasal 
 nr tter to the eyes, which disorder will be 
 presently noticed, is certainly an infectious 
 purulent ophthalmy. It is also admitted, 
 that it resembles Egyptian ophthalmy, by 
 the intensity and rapidity of its svmptorns ; 
 but the latter case is strongly characterized 
 by the quickness with which it causes, espe- 
 cially in adults, opacities or ulcerations of 
 cornea; the long continued irritability 
 
 of the eves after the subsidence of inflam- 
 mation ; but, more particularly, its very in- 
 fectious nature, by which it spreads to an 
 extent, that has never been observed with re- 
 gard to any other species of purulent oph- 
 ih dmy. There have been epidemic oph- 
 thalmies of other kinds, which have been 
 known to affect the greater part of the 
 population of certain districts and tow T ns in 
 England. The celebrated ophthalmy, which 
 happened at Newbury, in Berks, some years 
 ago, is an instance, that must be known to 
 every body. But 1 know of no purulent 
 inflammation of the eyes, which everspread 
 to a great extent in England, before the 
 return of our troops from Egypt. 
 
 The reflections and observations of Mr. 
 M‘Gregor, as well as those of Dr. Vetch, 
 and Dr. Edmondstone, I think, leave no 
 doubt o two facts first, that this ophthalmy 
 .vasat all events brought from Egypt; and 
 secondly, that it is infectious, but only ca- 
 pable of being co imunicaled from one person 
 to another by actual contact of the discharge. 
 “ If (says Dr. Vetch) any belief were en- 
 t- taine I by tlv officers of Use British array, 
 during the first expedition to Egypt, that the 
 disease was contagious, it was of a nature 
 y< rv vague and indefinite. Combined as its 
 opt rations necessarily must be in tha coun- 
 try with other exciting causis, there would be 
 more difficulty in the'first recognition of the 
 fact. But, the continuau e of thr- complaint 
 with the troops, fter their departure from 
 he country, could scarcely f 1 to lead to 
 the obvious conclusion of its posse-sing a 
 power of propagation. Before the disease 
 reached this country, the opinion of its 
 being contagious was adopted by many. 
 Dr. Edmund done , in the account which he 
 published of the disease, as it appeared in 
 the regiment, to which he was surgeon, 
 after its return to England, first made the 
 public acquainted with the fad of the disease 
 being communicable. In an account of the 
 Egyptian ophthalmia, as it appeared in this 
 country, print' d in the early part of 1807, / 
 first established , that the communication of Ike 
 disease was exclusively produced by the appli- 
 cation of the discharge from the eyes of the 
 diseased to those of the healthy .” ( Vetch on 
 
 Diseases of the Eye, p. 178.) 
 
 The opinion that the disease is ever com- 
 municated from one person to another, 
 through the medium of the atmosphere, is 
 at present nearly abandoned. During the 
 whole lime that Dr Vetch had the manage- 
 ment oft he ophthalmic hospitals, there never 
 was an instance of any medical officer 
 contracting the disease, although exposed 
 to what might be supposed to be the greatest 
 concentration of any contagion that could 
 arise in the worst stage of the complaint. 
 Two orderlies only contracted the disease, 
 and both in consequence of the accidental 
 application of the virus. However. Sir YV. 
 Adams maintains, that he has seen many 
 cases which p^ove, that the disorder, like 
 small-pox, may spread contagiously, without 
 any kind of inoculation. (See Graefe' s Journ, 
 B l,p. 174.) That the disease rh ay also •lie 
 
OPHTHAlMF 
 
 partly propagated by epidemic chuses in 
 certain places, 1 think as certain and clear, 
 as t hat there must be a cause for the first 
 commencement of the disorder in situations 
 Where infection by contact is out of the 
 question. And, as Dr. Vetch has observed, 
 “ from whatever cause inflammation of the 
 conjunctiva may originate, when the action 
 is ot that nature, or degiee of violence as 
 to produce a puriftmn or purulent discharge ; 
 the discharge, so produced, operates as an 
 animal virus, when applied to the conjunc- 
 tiva. of a healthy eye Considering the 
 various modes, by which such a contact 
 must inevitably occur in the usual relations 
 of life, it must be obvious, that wherever 
 ophthalmia prevails, whether it be the effect 
 of local conditions of the soil, or of the at- 
 mosphere, naturally or artificially produced, 
 this contagious effect must sooner or later 
 mix, or unite its operation with that of the 
 more general and original one ; and hence, 
 without regard to this property of the disease, 
 Its occurrence must often remain inexplica- 
 ble, and at variance with the more general 
 cause existing in external circumstances, 
 And further, as the disease, produced by 
 infection, is of a nature more violent and 
 malignant, than that produced by the impres- 
 sion of atmospheric causes, it will, in every 
 instance of extensively prevailing ophthal- 
 mia, occasion two different forms of disease, 
 which, as long as they are considered as one 
 and the same, w ill produce, according as the 
 one orthe other predominates, very discor- 
 dant results.” ( Vetch on Diseases of the Eye , 
 p. 175.) 
 
 Mr. McGregor relates three cases, which 
 prove, that the matter, after its application, 
 produces its effects in a very short time. 1 
 shall only cite the following example : — On 
 the 21st of October, 1809, about four o’clock, 
 e. m. Nurse Flannelly, while syringing the 
 eyes of a boy, let some of the lotion, which 
 bad already washed the diseased eyes, pass 
 out of the syringe into her own right eye. 
 She felt little or no smarting at the time ; 
 but, towards nine o’clock the same evening, 
 her right eye became red, and somewhat 
 painful, and when she awoke next morning, 
 her eyelids were swelled, there was a puru- 
 lent discharge, pain, &e. {Op. cit, p. 51.) 
 
 The late Mr. Ware, though he admitted, 
 that the infection was brought into this coun- 
 try from Egypt by the troops, conceived 
 that the same disease also sometimes arose 
 from the matter of gonorrhoea being applied 
 to the eyes, and that it had been prevalent 
 in this country before the return of the army 
 from Egypt. He thought, however, that 
 the infection was generally communicated 
 by contact. Mr. Ware observes, some of 
 the worst cases of the purulent ophthalu y of 
 children have happened, in those whose 
 luotbers were subject to an acrimonious dis- 
 charge from the vagina at the time of partu- 
 i-lti’./n. Some of the worst forms of the 
 virulent oj hthalmy in adults have occurred 
 thoSe. v ho, either shortly before the at- 
 tach of the opbthalmy, or at that very time, 
 
 laboured either under a gonorrhoea, or & 
 gleet. Mr. Ware does not mean to impute 
 every purulent opbthalmy to such a cause f 
 but, in the majority of adults, whom he has 
 seen affected, if the disorder had not been 
 produced by the application of morbid mat- 
 ter, from a diseased eye, it could be traced 
 to a connexion between the ophthalray 
 arid disease of the urethra. Other causes, 
 Mr. Ware acknowled ges, may contribute to 
 aggravate, and perhaps produce the disorder, 
 and the purulent opbthalmy in Egypt has 
 been attributed to a great number. The 
 combined influence of heat and light, of a 
 burning dust continually raised by the wind;, 
 and of the heavy deWs of the night, may 
 powerfully tend to excite inflammations of 
 the eyes. Yet something more must operate 
 in causing the malignant ophthabny now- 
 under consideration ; for the same causes 
 operate with equal violence in some other 
 countries, besides Egypt, and yet do not 
 produce the same effect ; and, in this coun- 
 try, (says Mr. Ware) the disorder prevailed 
 during the last summer, to as great a degree, 
 and upon as great a number of persons 
 within a small district of less than a mile, 
 as it ever did in Egypt ; and yet, beyond 
 t*his space, on either side, scarcely a person 
 was affected with it. The disorder was cer- 
 tainly brought into this country by the sot- 
 diers who returned from Egypt, and was 
 probably communicated from them to many 
 others. Now, as the action of the atmos- 
 phere alone cannot account for the spread- 
 ing of the disease, he. Mr. Ware is led to 
 believe, that this particular disorder is only 
 communicable by absolute contact ; that is, 
 by the application of some part of the dis- 
 charge, which issues, either from the con- 
 junctiva of an affected eye, or from some 
 other membrane secreting a similar poison* 
 to the conjunctiva of the eye of another 
 person. In schools and nurseries, in conse- 
 quence of children using the same basins 
 and towels, as others who had the complaint, 
 the disease has been communicated to 
 nearly twenty, in one academy. Hence, 
 Mr. Ware censures the indiscriminate use of 
 those articles, in schools, nurseries, hospitals, 
 ships, and barracks. ( P . 14, 15.) 
 
 That in Egypt the origin of the disease 
 cannot rightly be imputed to the effect of 
 the sand and hot winds of the country, is 
 clearly proved ; 1st, Because, if this were 
 the case, the disease would not be most pre- 
 valent in the autumnal season, during the 
 inundation of the Nile. 2dly, The inhabi- 
 tants of the Delta would not be more subject 
 to it, than the Bedouin Arabs, who live ou 
 the sands of the desert. Not only the Be- 
 douin Arabs, says Dr. Vetch, remain free 
 from the disease, but Europeans, who are 
 not particularly exposed to the night air , are 
 also safe from its attacks . “ The nature of mi 
 litary duty prevented our soldiers from 
 using this precaution, and in a particular 
 manner they bec ame victims to the com- 
 plaint. The men suffered more in propor- 
 tion to the officers of the English army ; n« 
 
OPHTHALMY 
 
 
 ale Utter eujoyed a better, though often an 
 incomplete defence from the coldness and 
 dampness of the night ; and officers, em- 
 ployed in strictly military duty, suffered 
 more than those attached to the civil de- 
 partments.” (Vetch on Diseases of the Eyes, 
 p. 157.) And \ssalini remarks, that if the 
 dust or sand were the sole cause of ophthal- 
 mia, we ought to be exempted from the 
 disease, where the cause does not exist. 
 The contrary, however, was the case in the 
 Delta, and principally on the cultivated 
 borders of the Nile, during its inundations. 
 When we were exposed to the air during the 
 flight, we were immediately attacked with oph- 
 thalmia, though the dust and sand were then 
 under water. Larrey also imputes the ori- 
 gin of the disease to the cold damp nocturnal 
 air, after the great heats of the day. ( Graefe's 
 Journ. BA, p. 179.) 
 
 Whoever reads the account of the Egyp- 
 tian ophthalmia, as given by Mr. M‘Gregor 
 and Dr. Vetch, will be convinced that the 
 disorder is only communicable from one 
 person to another by the application of the 
 infectious matter to the eyes. Probably, 
 the common mode of propagation is the in- 
 advertent use of the same towels, or even 
 merely touching the same articles, which 
 have been in the hands of infected persons, 
 Who must be supposed occasionally to apply 
 their fingers more or less to the eyelids. In 
 this last way. the commencement of the 
 disease may be accounted for in regiments 
 upon their entering into barracks, which 
 have been quitted by other infected soldiers. 
 “ Flics, in warm weather, (says Mr. McGre- 
 gor) are seen in great numbers surrounding 
 patients labouring under ophthalmia ; and 1 
 much suspect are very frequently the medium 
 by which the disease is communicated.” 
 (P. 54.) The matter is observed to be most 
 infectious, when the disease is in an acute 
 state. 
 
 Dr. Vetch adverts to two important ques- 
 tions connected with the history of the 
 Egyptian ophthalmy. The first relates to 
 the length of time which the disease has, at 
 different periods, lain dormant, and espe- 
 cially between the return of the troops from 
 Egypt, and the breaking out of the disease 
 in the 52d regiment. An explanation of this 
 fact is attempted by supposing, that the 
 complaint exists, and is liable to a renewal 
 of its infectious quality, long after the eye 
 seems to have recovered its natural and 
 healthy appearance. Perhaps, it would be 
 as well to be content with the fact, that, in 
 Crowded barracks, under particular circum- 
 stances, soldiers, who have once had the 
 disease, are very liable to relapses. The 
 other question is, why has the disease pro- 
 duced such ravage in the array in England, 
 and not in that of France P ft is well 
 known, that the French soldiers in Egypt 
 suffered as much as our own troops from 
 the affection, and great numbers of them re- 
 turned to France with the disease in a chronic 
 form. “In many (says M. Roux) the influence 
 of their native climate has sufficed for the 
 removal of all vertigo of the disorder. On 
 
 the contrary, in others, it has continued in 
 a chronic state, either attended with the loss 
 of one, or of both eyes ; and many of oar 
 invalids remain with the affliction. But, it 
 has not been found, that these soldiers, who 
 returned from Egypt, have ever communi- 
 cated a contagious ophthalmia, either in 
 regiments, in which many of them have 
 been incorporated ; or in invalid houses, 
 where others have obtained their retire- 
 ment ; or in the individuals belonging to the 
 different classes of society. Such is the 
 objection that has been made, and may 
 always be again urged, against the opinions 
 and observations of the English, respecting 
 the Egyptian ophthalmy.” (Roux, Voyage 
 faite a Londres en 1814, ou Parall&le de la 
 Chir. Angloise , <^c. p. 49.) 
 
 Baron Larrey, who admits that the dis- 
 ease may be communicated by application 
 of the matter, argues, that it is not conta- 
 gious in any other way, because, in Egypt, 
 for want of sufficient hospital room, pa- 
 tients with this and other diseases were 
 mixed togelher, without the ophthalmia 
 being propagated to any of the patients, 
 who were careful to avoid the above mode 
 of infection. (Graefe's Journ. B. 1 , p. 179.) 
 Larrey) however, need not have used this 
 rea-o- ing with us, because it is a mistake in 
 him to suppose, that the disease is here com- 
 monly regarded as communicable through 
 the medium of the atmosphere. While, 
 however, English surgeons chiefly explain 
 the extension of the disease by the infec- 
 tious nature of the discharge when applied to 
 the eyelids, and Larrey admits that the mat- 
 ter is thus infection', the latter, as w T elI as 
 Roux, assures us, that none of the healthy 
 soldiers, who came home with the blind 
 invalids from Egypt, were attacked with this 
 species of ophthalmy. A great number of 
 those invalids were received in the hospital 
 of the guards at Paris, and treated there 
 without any of the other patients bifing 
 infected. (Graefe's Journ. loc. cit.) On 
 my return from the Mediterranean through 
 France in 1802, I saw many of the F.ench 
 troops in a town between Marseilles and 
 Lyons, with bad eyes, contracted in Egypt, 
 associating with other soldiers, whose eyes 
 were perfectly healthy, and living in the same 
 barracks ; a proof, that the French soldiers, 
 with the exception of climate, or some 
 other protecting cause, were placed appa- 
 rently in circumstances, in which the 
 disease here made such extensive ravages. 
 This is a point which 1 humbly conceive, is 
 not at all solved by Dr. Vetch’s belief, that 
 the difference is explicable by the French 
 troops being sent into the field ; for, in fact, 
 the soldiers with diseased eyes were in 
 barracks, or hospitals, as well as our own 
 troops. 
 
 But, notwithstanding it seems proved, that 
 the discharge from the eyes in the Egyptian 
 ophthalmy is so actively infectious in Eng- 
 land, it appears from an experiment, made 
 by Mr. Mackesy, that its application mav 
 sometimes be made to a healthy eye, without 
 the disease followingas aftiiatter ot’ certainty 
 
OPHTHALMY. 
 
 32b 
 
 This gentleman, who was sitrgeon to the 
 62d regiment, applied to his own eyes linen 
 impregnated with matter discharged from 
 the eyes of patients in the fully formed 
 stage of the disease, and even allowed so ne 
 of the matter to pass under the eyelids ; yet 
 the complaint was not communicated. 
 (See Edinb. Med. and Surg. Journ. Vol. 12, 
 p. 411.) 
 
 One of the most material circumstances 
 in which the practice of English surgeons 
 differs from that of foreign practitioners in 
 cases of severe purulent, and especially 
 Egyptian ophthalmy, is the freedom and 
 boldness, with which the former attack the 
 disease in its first stage. Mr. Peach recom- 
 mends taking away a' once as much as 60 
 ounces of biood ; (Edinb. Med. and Surg. 
 Journ. for January, 1807) and Dr. Vetch 
 lavs great stress on the striking benefit of 
 bleeding the patient till syncope is produced. 
 il When inflammation has its seat in the 
 sclerotic coat, (says this gentleman) general 
 blood letting may for the most part be dis- 
 pensed with, and even when employed to 
 the greatest extent, the same benefit does 
 not ensue. In the purulent inflammat ion of 
 the conjunctiva, however, although some 
 good may be derived from depletion, yet a 
 perfect command over the disease depends 
 less on- lowering the system, than on the 
 temporary cessation of arterial action by 
 syncope, which it becomes the object of 
 tbe operation to produce. This practice, 
 besides its efficacy, will accomplish the cure 
 with a much less expenditure of blood, than 
 is occasioned by the repeated bleedings 
 generally had recourse to, u here this method 
 of rendering one equal to the cure of the 
 complaint bas been neglected. Some 
 time before the approach of faint tie g, 
 the redness of the conjunctiva for the most 
 part disappears; but this is no security 
 against the return ol the disease, if the flow 
 of blood be stopped, without «'eliquium 
 animi succeeding.” (Vetch on Diseases 
 of the Eye , p. 206.) The attacks of a pain- 
 ful sensation, as if gravel were in the eye, 
 are considered by this gentleman as a proof 
 of the disease increasing, and are regarded 
 by him, in the early stage of the diease, as 
 a better indication of the necessity for 
 bleeding, than the appearance of the eye it- 
 self. 
 
 With respect to applications, Dr. Vetch 
 speaks very highly of the beneficial effects 
 produced in the beginning of the case by 
 dropping into the eye the undiluted liquor 
 plumhi subacetatis, which he says, dimi- 
 nishes the discharge, lessens the inflamma- 
 tion, and is incapable of doing harm in any 
 stage of the disease. He places great con- 
 fidence in the salutary results of a free ex- 
 posure of the eye to the atmosphere ; and 
 speaks in high lerms of the good derived 
 from applying at night to the eye an infusion 
 of tobacco, I wo drachms of the leaves to 
 eight ounces of water. “ It possesses (says 
 Dr. Vetch) the valuable properties of acting 
 as a powerful astringent, restraining the pu- 
 : dent discharge, anddiirinjshiog tbe cedcuta, 
 
 or external swelling of the palpebrte ; at the 
 same time, that its narcotic qualities often 
 relieve the pain and the perpetual watchiul- 
 ness, which the largest dose* of opium can- 
 not subdue.” (P. 211 ) Bleeding, however, 
 is the c - sheet am hor,” and the only means 
 of preventing the destruction of ihe cornea, 
 whenever attacks of pain in the eye, or or- 
 bit, deno’e the unsubdued slate of ihe dis- 
 ease. (P.212.) When I fie di-ease shifts its 
 violence from one eye to the other, and is of 
 long duration, Dr Vetch recommends cup- 
 ping, amt the eye to be more carefully clean- 
 ed by the injection of tepid water, or any 
 gentle astringent lotion, and afterward 
 wiped dry. When the discharge continues 
 acrid and scalding, he directs blisters to be 
 applied to the nape of the neck, and beoind 
 the ears. He wishes it to be distinctly kept 
 in mind, that the time for the employment 
 of bl -eding, w ith the view of saving he eye, 
 is during the first stage, or early part of the 
 second ; and when ulceration of the cornea 
 has commenced, the case is to be treated on 
 the principles applicable to sclerotic inflam- 
 mation. 
 
 With regard to the plan of diminishing in 
 flammatory action by medicines which ex- 
 cite nausea and sickness, instead of having 
 recourse to the lancet, Dr Vetch states, that, 
 in soldiers, it does not answer so well, and ia 
 the end proves more debilitating. 
 
 As soon as the external oedema of the eye- 
 lids subsides, and they begin to be everted. 
 Dr. Vetch begins the cure of the gr nutations 
 and general villosify, by a very light and 
 careful application of the argentum nitratuua- 
 The everted portion is then to be returned, 
 and secured in its place with a compress and 
 bandage. This method is to he repeated 
 every time the eye is cleaned, and in the 
 course of a fortnight, the tendency to ectro- 
 pium will be removed (P. 229.) 
 
 Assalini found venesection, all emollient 
 applications, and eyewaters, hurtful. He 
 first purged his patients, and then introduced 
 into their eyes a few drops of a solution of 
 the lapis divinus, (see Lachrymal Organs,) 
 to which was sometimes added a small quan- 
 tity of the acetate of lead. He speaks fa- 
 vourably of leeches, and sometimes he put a 
 small blister on Ihe temple, or behind the 
 ears (See Manuale di Chirurgia ; Milano , 
 1812.) 
 
 Perhaps the best inode of putting an im- 
 mediate stop to the Egyptian ophthalmy, 
 when it prevails ex ensively in a regiment in 
 garrison, ot barracks, is to put the men actu- 
 ally affected into a detached hospital, at n 
 considerable distance from the rest of the 
 corps, which should be dispersed as much 
 as possible in separate billets and villages. 
 Purulent ophthalmv is a disease which makes 
 great head only when large numbers of per- 
 sons are either exposed together to the epi- 
 demic causes, which first give birth to it, or 
 to the causes which occasion the disease to 
 be communicated from one individual to 
 another, as when soldiers are crowded to- 
 gether in the same building, using the same 
 towels and water, fee Notwithstanding the* 
 
OPHTHALMY. 
 
 reports of Koux and Larrey prove, that tho 
 disease did not spread in the French army, 
 after the return of unctired soldiers from 
 Egypt to France, though these were freely 
 mixed with their comrade* in hospitals and 
 barracks the same security did not extend 
 to the British tr<>ops lately in the latter coun- 
 try, who at one time were threatened w ith a 
 very extensive renewal of the Egyptian nph- 
 thalmy among Item, but which was w isely 
 checked by attention to the principles above 
 specified, and in which Dr. Grant, the head 
 of tiie medical department of that army, had 
 the greatest confidence. 
 
 In the cases under Mr. M‘Gregor, local 
 applications were found most advantageous. 
 Dating the inflammatory stage, however, 
 this gentleman also had recourse to antiphlo- 
 gistic means, spare diet, bleeding, neutral 
 salts, &,c. The topical treatment was as fol- 
 lows: Leeches were freely and repeatedly 
 applied near the eye. But while there was 
 much surrounding redness, instead of leeches, 
 which created too much irritation, fomenta- 
 tions, with n weak decoction of poppy-heads, 
 and a little brandy, were used. A weak so- 
 lution of acetate of lead, and sulphate of 
 zinc, had mostly a good effect when applied 
 to the eye. The vinous tincture of opium 
 did not answer the expectations entertained 
 of it. But of all the remedies, the ung. hy- 
 drarg. nitrat.was found most frequently suc- 
 cessful. It W'as applied by means of a camel- 
 hair pencil and at first weakened with twice 
 its quantity of lard. The red precipitate, 
 well levigated, and mixed with simple oint- 
 ment, sometimes answered when the ung. 
 hydrarg. nit rat . failed. Well levigated verdi- 
 gris, and a quack medicine, called the golden 
 ointment, proved also sometimes efficacious. 
 ( P . 41 — 43.) According to Mr. M‘ Gregor, 
 blisters behind the ears, and upon the neck, 
 ore useful ; but hurtful when put nearer to 
 the eye. In cases wdiere the disease seems 
 to resist antiphlogistic means, and ulceration 
 has commenced on the external surface of 
 the cornea, thi- gentleman approve; of dis- 
 charging t he aqueous humour by a puncture, 
 os advised by Mr. Wardrop. 
 
 When the violence of the inflammation 
 has subsided, Mr. M Gregor recommend- the 
 us** of Bates’s camphorated water, diluted 
 with four, five, or six times its quantity of 
 wafer. But the astringent collyrium, from 
 which he saw most good derived, was a so 
 lution of the nitrate of silver, in the propor- 
 tion of half a grain to every ounce of dis- 
 tilled water. In some cases, it may be used 
 stronger. 
 
 Tepid sea-w-ater sometimes proved ser- 
 viceable in removing the relics of the com- 
 plaint. ( P . 56 tye.) 
 
 The late Mr. Ware was in favour of bleed- 
 ing ; but he rardy carried it to the ex:ent 
 which has been done in the army. In weak 
 persons, instead of repealed venesection, he 
 preferred topical bleeding, either from the 
 vein that passes on the side of the nose, or 
 by means of five or six leeches put on the 
 temple. Sometimes he thought it better to 
 scarify the inside of the lower eyelid with 
 
 the point of a lancet, carried along parallel 
 to, and very near the margin of this part 
 He objects to pricking the eyelid in an infi- 
 nite number of places, as very painful, and 
 likely to increase the irritation. The lancet 
 (he says) never need be applied more than 
 twice, and rarely more than once ; and, per- 
 haps, less pain w ill be occasioned by making 
 the incision with the edge, rather than the 
 point of the lancet. After taking away 
 blood, Mr. Ware says, a large blister on the 
 h**ad, or back, is often useful. Anodynes 
 should be given, with occasional purgatives, 
 and an antiphlogistic regimen. {Ware on 
 Purulent Ophthalmy , ISOS p. 26, <^c-) 
 
 As a local application, Mr. Ware preferred 
 tiie aqua camphorata, which was used exact- 
 ly in the same way, as will be described i« 
 speaking of his method of treating the puru- 
 lent ophthalmy of children. When the in- 
 flammation was very great, he only put four 
 or five grains, instead of eight, of the sul- 
 phate of copper to eight ounces of water. 
 He usually employed the lotion cold, espe- 
 cially in children; but in adults, in whom 
 the general fever and local inflammation 
 were considerable, he was obliged to use it 
 warm. In cases of great pain and swelling, 
 it should be very weak, less often applied, 
 and sometimes only warm water injected. 
 In such circumstances, Mr. Ware also sanc- 
 tions fomenting the eye with a flannel, or 
 sponge, wet with a hot decoction of poppy - 
 li&nds, or mere hot water. When i he cor- 
 nea threatens to burst, this gentleman ap- 
 proves of opening it, in order to discharge 
 the aqueous humour, by making an incision 
 in a place where the scar will not obstruct 
 vision, as first suggested by Mr. Wardrop. 
 
 Purulent Ophthalmy oj Infants. Dr. Vetch 
 describes the external appearances of this 
 case as not materially different from those of 
 the purulent ophthalmy of adults; but, he 
 states, that its nature is considerably modi- 
 fied by the more delicate texture and great- 
 er vasculari'y of the parts affected, and the 
 more intimate connexion, subsisting between 
 the vessels of the conjunctiva and those of 
 the scleiotic coat. Hence, he says, the in- 
 flammation is sooner communicated to this 
 coal, and sloughing and ulceration of the 
 cornea occur earlier in infants, than adults. 
 When the oedema ceases, the inner surface 
 of the palpebrse becomes sarcomatous, and 
 this diseased surface, when the eyelids are 
 opened; forms an exterior fleshy circle, be- 
 yond which the relaxed conjunctiva of the 
 eye comes forward as a second ; and often 
 the caruncula lachrymalis adds still farther to 
 the valvular appearancp, which the pmrt pre- 
 sents. (On Diseases of the Eye , p. 256— 
 258 .) 
 
 According to the late Mr. Ware, the prin- 
 cipal difference between the purulent oph- 
 th almy in infants and that in adults, consists 
 i'll the different states of the tunica conjuncti- 
 va: in the former, notwithstanding the quan- 
 tity of matter confined within the eyelids is 
 often profuse, the inflammation of the con- 
 junctiva is rarely considerable, and when- 
 ever the cornea become? impaired, it is rather 
 
328 
 
 OPHT 
 
 owing to the lodgment of such matter on it 
 than to inflammation ; a statement, which 
 appears to me very questionable. But, in 
 the purulent ophthalmy of adults, the dis- 
 charge is always accompanied with a violent 
 inflammation, and generally wilh a tumefac- 
 tion of the conjunctiva, by which its mem- 
 branous appearance is destroyed, and the 
 cornea is nntde to seem sunk in the eyeball. 
 ( Ware on Epidemic Purulent Ophthalmy , p. 
 123.) In children, the alfection of the eyes 
 is occasionally accompanied with eruptions 
 on the head, and with marks of a scrofu- 
 lous constitution. (See Ware , p. 138, fyc.) 
 The only inference to be drawn from this 
 fact is, that scrofulous, as well as other chil- 
 dren, are liable to this disorder of their eyes. 
 
 The following is the treatment recommend- 
 ed by Mr. Ware. If the disease be in its 
 first stage, the temporal arteries are to be 
 opened, or leeches applied to the temples, 
 or neighbourhood of the eyelids, and a Mis 
 ter put on the nape of the neck and temples. 
 The child should be kept in a cool room, 
 not covered with much clothes, and if no 
 diarrhcea prevail, a little rhubarb or mag- 
 nesia in syrup of violets should be prescribed. 
 
 A surgeon, however, is seldom called in 
 before the first short inflammatory stage has 
 ceased, and an immense discharge of matter 
 from the eyes has commenced Of course, 
 (says Mr. Ware,) emollient applications must 
 generally not be used. On the contrary, as- 
 tringents and corroborants are immediately 
 indicated, in order to restore to the vessels 
 of the conjunctiva and eyelids their original 
 tone, to rectify the villous and fungous ap- 
 pearance of the lining of the palpebrae, and 
 thus finally to check the morbid secretion of 
 matter. For this purpose Mr. Ware strongly 
 recommends the aqua camphorata of Bates’s 
 Dispensa ory : Capri sulphatis, bol. ar- 
 
 rnen. a a |iv. Camphorae, Jj. M. &f. pulvis, 
 de quo projice ^j. in aqua? bullientis 
 amove ab igne, ef subsidant foeces. Mr. 
 Ware, in his late Remarks on Purulent Oph- 
 thalmy, 1803, observes, that he usually directs 
 the aqua camphorata as follows: Cupri 
 
 sulphatis. bol. armen. a & gr viij. Camphorae 
 gr ij. Misce, et affunde aqua? bullientis ?viij. 
 CCtm lotio sit frigida, effundatur limpidus li- 
 quor, et saepissirne injiciatur paululum inter 
 oculum et palpebras. This remedy possesses 
 a very styptic quality ; but, as directed in 
 Bates’s Dispensatory, it is much too strong 
 for use before it is diluted; and the degree 
 of its dilution must always be determined 
 by the peculiar circumstance of each case. 
 Mr. Ware ventures to recommend about one 
 dram of it to be mixed with an ounce of cold 
 clear water, as a medium or standard, to be 
 strengthened or weakened ns occasion may 
 require. (P. 143.) The remedy must be ap- 
 plied by means of a small ivory or pewter 
 syringe* the end of which is a blunt-pointed 
 cone. The extremity of this instrument is 
 to be placed between the edges of the eye- 
 lids, in such a manner, that the m» dicated li- 
 quor may be carried over the whole surface 
 of the eye. Thus the. matter will be entirely 
 washed aw ay, and enough of the styptic me- 
 dicine left behind to interrocf and diminish 
 
 HAT Ml. 
 
 the excessive discharge. According to the 
 quantity of matter, and the rapidity with 
 which it is secreted, the strength of the ap- 
 plication, and the frequency of repeating it, 
 must he regulated. In mild recent cases, the 
 lotion may be u-ed once or twice a day. and 
 rather weaker than the above proportions ; 
 but, in inveterate cases, it is necessary to ap- 
 ply it once or twice every hour, and to in- 
 crease its styptic power in proportion ; and 
 when the complaint is somewhat relieved, 
 the strength of the lotion may bo, lessened, 
 and its application be less frequent. 
 
 “The reasons for a frequent repetilion of 
 the means just mentioned, in bad cases, are. 
 indeed, of the most urgent nature. Until 
 the conjunctiva is somewhat thinned, and 
 the quantity of the discharge diminished, it 
 is impossible to know in what state the eye 
 is ; whether it is more or less injured, totally 
 lost, or capable of any relief. The continu- 
 ance or extinction of the sight frequently de- 
 pends on the space ot a few r hours : nor can 
 we be relieved from the greatest uncertainty 
 in these respects, until the cornea becomes 
 visible.” (Ware- p. 145.) 
 
 This author condemns the use of emollient 
 poultices, which must have a tendency to in- 
 crease the swelling and relaxation of the con- 
 junctiva. If poultices are preferred, he par- 
 ticularly recommends such as possess a tonic 
 or mild astringent property; as one made of 
 the curds of milk, turned with alum, and an 
 equal part of the unguentum 9ambuci, or 
 axungia porcini. This is to be put on cold, 
 and frequently renewed, without omitting 
 ,he use of the injection. (Ware, p. 147.) 
 
 When the secreted matter is glutinous, 
 and makes the eyelids so adherent together, 
 that they cannot be opened, after being shut 
 for any length of lime, the adhesive matter 
 must be softened with a little fresh butter 
 mixed with warm milk, or by means of any 
 othersoft oleaginous liquor, after the poultice 
 is taken off, and before using the lotion. (P.. 
 147.) 
 
 If the eversion of the eyelids only occurs 
 when the child cries, and then goes off, no- 
 thing need be done in addition to the above 
 means. When, however, the eversion is con- 
 stant, the injection must be repeated more, 
 frequently than in other cases; the eyelids 
 put in their natural position, after its use ; 
 and an attendant directed to hold on them, 
 with his finger, for some length of- time, a 
 compress dipped in the diluted aqua camplio 
 rata. (P. 148.) 
 
 In some cases, when the inside of the eye- 
 lids has been very much inflamed, the tine- 
 tura thebaica, insinuated between the eye 
 and the eyelids, has been useful. If, after 
 the morbid secretion i3 checked, nny part 
 of the cornea should be opaque, the unguert- 
 tum bydrargyri nitrati, melted in n spoon, 
 and applied accurately on the speck, with u 
 fine hair pencil ; or Janin’s ophthalmic, oint- 
 ment, lowered and used in the same mariner, 
 may produce a cure, if the opacity' he not of 
 too deep a kind. When the local disease 
 seems to be kept up by a bad habit, altera- 
 tives should be exhibited, particularly 
 
tiPH'VH ALM \ . 
 
 32l> 
 
 black sulpburet of mercury, or small dosesof eyes, was freely applied to (be orifice of (he 
 calomel. urethra. No effect followed (his trial, which 
 
 The treatment, recommended by Dr. was repeated on some other, patients, all la- 
 Vetch, is as follows: if the inflammation has bouring under the most virulent state of the 
 not extended to the conjunctiva of the eye, Egyptian disease, and in all the application 
 its further progress may he checked by re- was perfectly innocuous. But, in another 
 moving the infant to a healthy atmosphere, case, where the matter was taken from the 
 and washing the eye with any mild collyri- eye of one man, labouring under purulent, 
 um. Leeches are commended throughout ophthalmia, and applied to the urethra of ari- 
 the whole course of the complaint. On the other, the purulent inflammation of the nre 
 first accession of the tumefaction, t he best thra commenced in thirty-six hours after- 
 effect will- often be produced by the applica- ward, and became a very severe attack of 
 tion of a small portion of ointment, composed gonorrhoea. From the result of these cases, 
 of lard, or butter 3yj. and x gr. of the red ni- (says Dr. Vetch) l could no longer admit the 
 trate of mercury, without any wax. As the possibility of infection being conveyed to 
 purulency advances, the liquor plumbi suba- the eyes from (he gonorrhoeal discharge of (he 
 cetatis, he says, will be found not less ser- same person. Some time after this, the im 
 viceahle, than in other instances of purulent probability, or rather impossibility of this ef- 
 ophthalmy. For promoting the separation feet, was rendered decisive by an hospital 
 of any slough, he recommends a solution of assi-tant, who conveyed the matter of gonor- 
 the nitrate of silver: and for curing the re- rhcea to his eyes, without any affection of the 
 laxed state of the conjunctiva, a solution of conjunctiva being the consequence.” (See 
 alum, or of the sulphate of copper. (On Vetch on Diseases of the Eye , p. 242.) 
 Diseases of the Eye , p. 260.) Hence, this gentleman is led to refer the con 
 
 The Purulent Ophthalmy arising either nexion, between gonorrhoea and ophthalmia, 
 from suppression of gonorrhoea, or from the in the same person, to peculiarity of consti- 
 ihadvertent conveyance of gonorrhoeal matter tutiou; but the theories on which this opi 
 to the eyes, is said to produce rather 1 a swell- nion rests, my limits will not allow me to 
 ing of the conjunctiva, than of the eyelids, examine 
 
 which is followed by a discharge of a yei- If it be actually true, that, in adults, a spe • 
 low greenish matter, similar to that of clap, cies of purulent ophthalmy does originate 
 The heat and pain in the eyes are con- from the sudden suppression of a gonorrhoea, 
 siderable ; an aversion to light prevails, and, are we to consider the complaint so pro- 
 in some instances, an appearance of hypopi- ducedas a metastasis of the disease from the 
 on is visible in the anterior chamber oi the urethra to the eyes ? This ophthalmy does 
 aqueous humour. When the complaint pro- not regularly follow the suppression of gonor- 
 eeeds from the secondcause.it is described rhcea; nay, it is even a rare occurrence: 
 as being less severe, than when it arises from also, when it is decidedly known, that the 
 the first. However, by such gentlemen, purulent ophthalmy has arisen from the in- 
 ( Ware , Travers, fyc.) as have seen unequivo- faction of gonorrhoea, namely, in those in 
 cal instances of purulent ophthalmy excited stances in which the matter has been incau- 
 in the second way, the disease is said to be tiously communicated to the eyes, it appears 
 remarkable for its violence and intensity, that such an affection of these organs, so pro- 
 The reality of cases of purulent ophthalmy duced, is different from the one alluded to, 
 from the application of gonorrhoeal matter to inasmuch as it is slower in its progress, and 
 the eyes, seems supported by such a mass of less threatening in its aspect. When the 
 evidence, that I believe the fact must be ad- eyes are affected, the disease of the urethra 
 mitted. Yet, from some statements, lately is not always suspended. (Vetch on Diseases 
 published b\ Dr. Vetch, it would appear, that of the Eye. p. 239.) Hence, there is good 
 the frequency of this mode of infection must reason for supposing that no metastasis takes 
 be very much lessened by the circumstance place in (his species of purulent ophthalmy, 
 of the matter taken from the urethra, not supposed to be connected with a suppressed 
 being capable of communicating the dis- gonorrhoea: but, we must be content with 
 ease to the eyes of the individual, by whom inferring that, if it really has such a cause, it 
 such matter is secreted, though probably originates from a sympathy, prevailing be- 
 capable of doing so to the eyes of another tween the urethra and eyes, and, that the 
 person. difference of irritability, in different people, 
 
 In the same way, the urethra caunot be is the reason, why it is not an invariable 
 affected by the application of matter taken consequence of the sudden stoppage of a 
 from the purulent eyes of the individual, on gonorrhoea. 
 
 Whom the experiment is made. At least, of The injection of warm oil, the introduc 
 these circumstances, there is a negative proof tion of a bougie into the urethra, and the 
 in some facts recorded by Dr. Vetch. “ In application of cataplasms to the perinaeum, 
 the case of a soldier, received in a very ad- with a view of renewing the discharge from 
 vanced stage of the Egyptian ophthalmia, in the urethra, form the outline of the practice 
 whom destruction of the cornea had to a cer of those who place implicit reliance in the 
 tain extent taken place, I took occasion to suppression of gonorrhoea being the cause 
 represent the possibility of diverting the dis- of the complaint. The rarity of the occur- 
 ca«e from the eyes to the urethra, by apply- rence; the frequency of the sudden cessa- 
 ing the discharge 1o the latter surface. Ac- tion of the urethral discharge ; the possibi- 
 cordingly, some of the matter taken from the lity of an ophthalmy arising, as well at this 
 V 0L . II. 42 
 

 OPHTIIALMF 
 
 particular moment, as at any other, totally 
 independent of the other complaint ; cannot 
 fail lo raise in a discerning mind a degree of 
 doubt concerning the veracity of the assign- 
 ed cause. Besides, admitting that there is a 
 sympathy between the urethra and eyes, 
 how are we to ascertain whetherthe suppres- 
 sion of gonorrhoea be the cause or the effect 
 of the ophthalmy, supposing that the one 
 ceases and the other commences about the 
 same time ? Actuated by such reflections, I 
 am induced to dissuade surgeons from adopt 
 ing any means calculated to renew a dis- 
 charge of matter from the urethra. When 
 the purulent ophthalmy, in adult subjects, is 
 decidedly occasioned by the actual contact, 
 and infection of gonorrhoeal matter, applied 
 accidentally to the eyes, no one has recom- 
 mended this unnecessary and improper prac- 
 tice. 
 
 The first indication in the treatment of the 
 disease from either cause, is to oppose the 
 violence of the inflammation, and thus re- 
 sist the destruction of the eye and opacity of 
 the cornea. A copious quantity of blood 
 should be taken away both topically and ge- 
 nerally ; mild laxatives should be exhibited, 
 and a blister applied to the nape of the neck, 
 or temples. The eyes ought to be often fo- 
 mented with a decoction of white poppy- 
 heads, and warm milk repeatedly injected 
 beneath the eyelids. To prevent the palpe- 
 brse from becoming agglutinated together, 
 during sleep, the spermaceti cerate should 
 be smeared on the margins of the tarsi every 
 night. 
 
 When the heat and pain in the eyes, and 
 febrile symptoms have subsided ; when an 
 abundant discharge of pus has commenced; 
 all topical emollients are to be relinquished, 
 and a collyrium of Aq. rosse |x. containing 
 Ilydrarg. oxy. mur. gr. j. used in their place. 
 Scarpa slates, that in the ophthalmia, origi- 
 nating from the inadvertent communication 
 of the matter of gonorrhoea to the eyes, ap- 
 plications, in the form of ointment, such as 
 the ung. hydrarg. and Janin’s salve, to 
 which might be added the ung. hyd. nitrat. 
 avail more, than fluid remedies. 
 
 Inflammation of the Eyeball in general. 
 From cases in which the eyelids are at first 
 chiefly affected, I pass to the consideration 
 of inflammation, as commencing in the eye- 
 ball itself. As Beer remarks, fortunately it 
 is only very seldom, that the whole ol the 
 organ is at once attacked with genuine idio- 
 pathic inflammation, without any part of its 
 texture being spared. Although this kind of 
 ophthalmy is far more frequent than com- 
 mon inflammation of the orbit, it is much 
 more rare than the same disorder of the eye- 
 lids. For the most part, healthy inflamma- 
 tion of the eyeball has a limited point of ori- 
 gin, from which it spreads, sometimes quick- 
 ly, sometimes slowly over the whole organ. 
 During an exceedingly violent, tense, throb- 
 bing pain, affecting not only the eye itself, 
 but extending to all the surrounding parts, 
 the bottom of the orbit, and within the head, 
 the white of the eye becomes suffused with 
 
 an uniform redness, which, on attentive ex- 
 amination, is found to be seated not only in 
 the conjunctiva of the eyeball, but also in 
 the sclerotica, and to exhibit at first a very 
 fine vascular network, which, as the redness 
 grows more intense, assumes the appearance 
 of scarlet cloth, forming all round the cor- 
 nea an uniform circular prominent fold, 
 which has a very firm feel, and is so tender, 
 that, when touched in the gentlest manner, 
 the patient cries out with agony. The cir- 
 cumference of the cornea continues to be 
 more and more covered by this increasing 
 swelling of the conjunctiva, until at length 
 only a portion of its centre remains visible. 
 At the same time, the pupil is very much 
 contracted ; the iris motionless ; and though 
 vision is nearly or entirely lost, the patient 
 is seriously disturbed by fiery appearances 
 before the eye. When the iris is naturally 
 gray, or blue, it turns greenish, and when 
 brown, or black, it becomes reddish. Every 
 movement of the eyeball and upper eyelid 
 is suspended, and the orbit feels to the pa- 
 tient, as if it were too small, which, Beer 
 says, is in reality the case, because the 
 whole of the eyeball, and not merely the 
 conjunctiva, is enlarged, so as to project 
 like a lump of raw flesh further and further 
 between the edges of the palpebrae, and com- 
 pletely fill every part of the orbit. While 
 the eyeball enlarges, the cornea always loses 
 its transparency, and the inflammation 
 spreads to the eyelids, the lower one at 
 last becoming everted by the excessive 
 and firm tumefaction of the parts behind 
 it, and the upper one presenting the most 
 unequivocal marks of phlegmonous in- 
 flammation. The secretion of tears and 
 mucus is now entirely suppressed, and of 
 course, the eye preternaturally dry. At 
 the very commencement of this violent 
 form of ophthalmy, the constitution is 
 disturbed by a t-vere attack of inflam- 
 matory fever, and irritable patients are 
 not unfrequently seized with delirium. — 
 Here, says Beer, terminates the first stage of 
 this very dangerous disorder. 
 
 When the disease is left to itself, suppura- 
 tion comes on, attended with fever and 
 constant shiverings ; the swelling of the scle- 
 rotic conjunctiva undergoes a remarkable 
 increase, and assumes a dark red colour, at 
 the same time that it becomes softer. The 
 pain becomes irregular, throbbing, and. 
 when the eye or eyelids are touched, of a 
 lancinating description. As a morbid secre- 
 tion now begins to take place from the Mei- 
 bomian glands, the swelled conjunctiva has 
 a more moist appearance. The upper eyelid, 
 has a purple hue, and, on account of the con- 
 tinually increasing size of the eyeball, is 
 pushed further and further outward. The 
 portion of the cornea, still discernible in the 
 middle of the protuberant conjunctiva, ac- 
 quires a snowy whiteness, which afterward 
 changes to yellow. The patient feels an op- 
 pressive sense of heaviness in the orbit, and 
 a disagreeable kind of coldness all round 
 the eye. At length the throbbing and ten 
 
OPIITHALMV. 
 
 331 
 
 sion are so agonizing, that the patient often 
 expresses a wish to have the eyeball extir- 
 pated. If no effectual treatment be adopted, 
 the eye now bursts, and a mixture of matter 
 and blood, together with the scarcely per- 
 ceptible remains of the lens and vitreous 
 humour, is discharged with considerable 
 force to some distance in front of the pa- 
 tient ; an occurrence sometimes termed 
 rhexis , or rhegma oculi. From this moment, 
 the pain all at once subsides into a very mo- 
 derate feel of burning in the eye ; and sup- 
 puration goes on, until all the textures of the 
 organ are annihilated, the orbit has an emp- 
 ty appearance, and the closed eyelids sink 
 into a concavity. Thus ends, as Beer ob- 
 serves, the second stage, after much tedious 
 and general indisposition. But, he remarks, 
 that the course of the case is quite different, 
 when it has been wrongly treated in its first 
 stage with stimulants, or exposed to the ill 
 effects of tobacco smoke, the drinking of 
 spirits, improper diet, immoderate exercise, 
 &.c.; for, under the operation of these unfa- 
 vourable circumstances, the second stage 
 may commence with dreadful gangrenous 
 mischief, every vestige of the organization 
 of the eye disappearing, and the parts at 
 length sphacelating, while large abscesses 
 form around, and, unless efficient medical 
 aid be promptly given, the patient loses his 
 life. 
 
 With respect to the causes of such an at- 
 tack of the whole eyeball at once by com- 
 mon inflammation in a healthy subject, they 
 must be of an exceedingly violent descrip- 
 tion, such as injuries produced by gunpow- 
 der, burns, and lesions either of a mechani- 
 cal kind, or acting both chymically and me- 
 chanically together, a subject already fully 
 treated of in the foregoing columns. 
 
 The following are the observations which 
 Beer delivers on the prognosis : While, in 
 the first stage of this dangerous form of oph- 
 thalmy, the eyesight yet remains, and the 
 eyeball itself is not enlarged, if the patient 
 can be properly taken care of, some hope 
 may be entertained of dispersing the inflam- 
 mation so favourably, that, with the excep- 
 tion of a weakness of sight, of longer or 
 shorter continuance, no ill effects will be 
 left. It is manifest, however, that under 
 these circumstances, the surgeon should not 
 be too bold in promising a perfect cure; for, 
 the very commencement of such an inflam- 
 mation of the whole eyeball, even when the 
 disorder is purely idiopathic, is unavoidably 
 attended with some risk, not only of perma- 
 nent blindness, but of the eye itself being 
 destroyed in the most painful manner; 
 and, when things turn out rather better, a 
 tolerably favourable termination of the 
 case is uncommon. But, as soon as the 
 power of seeing is quite lost, the pupil nearly 
 closed, and the eyeball prodigiously swelled, 
 it will be fortunate, if the inflammation can 
 be resolved, so as to preserve the shape of 
 the organ ; for the restoration of the eye- 
 sight is entirely out of the question. But, 
 besides the irremediable loss of vision, the 
 disorder under these circumstances always 
 
 produces a greater ®r lesser closure of the 
 pupil, which, however, lias no share in caus- 
 ing the blindness. 
 
 In the second stage of the case, of course, 
 the hope of restoring vision is quite past , 
 and if the eyeball itself, and not merely the 
 conjunctiva, has been considerably swelled 
 in the first stage of the case, the chance of 
 preserving the natural shape of the organ 
 extremely unpromising. But, when the eye 
 bursts, the latter desideratum is impossible. 
 If the first stage should have been so violent 
 as to have induced gangrene, the practition- 
 er will have enough to do in preventing 
 sphacelus, and death, the danger of which 
 is considerable, on account of the intimate 
 connexion between the eye and parts in the 
 orbit, and the brain and its membranes. 
 
 In the first stage, antiphlogistic treatment, 
 in the general sense of the expression, is 
 indicated, and the case is not to be re- 
 garded merely as a local disorder. Howe- 
 ver, with respect to topical bleedings, the 
 surgeon, says Beer, should be more active, 
 than in other examples of ophthalmy, and, 
 after copious venesection and the use of 
 leeches have produced some relief, the pro- 
 tuberant conjunctiva, round the cornea, 
 should be deeply scarified with a lancet. If, 
 in the first stage, delirium come on, as it 
 sometimes does during the violence of the 
 inflammatory fever, Beer directs one of the 
 external jugular veins to be opened: or 
 blood might be taken from the temporal 
 artery. 
 
 In the second stage of the case, when 
 the re-establishment of vision is quite im- 
 impossible, and the objects are to endeavour 
 to keep the eye of a good shape, and quick- 
 ly lessen the suppuration, warm emollient 
 poultices, and particularly those made of 
 apples, are the applications, on which Beer 
 bestows his praises. This topical treatment 
 is to be assisted with internal means, as ex- 
 plained in the preceding pages, because the 
 disorder is attended with a general disturb- 
 ance of the constitution. When matter is 
 fully formed, and its fluctuation can be dis- 
 tinctly felt, Beer approves of opening the 
 abscess with a lancet; for, it is only by this 
 means, that the annihilation of the eyeball 
 can be prevented. If the eye has already 
 burst, the preservation of its form is no lon- 
 ger possible, and, according to Beer, both 
 the topical and general treatment should be 
 partly of a tonic description. When gan- 
 grenous mischief has occurred, the practice 
 ought to conform to the principles explain- 
 ed in the article Mortification. 
 
 External Ophthalmy. Inflammation of the 
 Outer Coats of the Eye. Ophthalmitis Externa 
 Idiopathica , of Beer. The modifications of 
 this common species of ophthalmy, as the 
 latter author observes, have a variety of 
 names applied to them, as ophthalmia levis , 
 ophthalmia angutaris, tar axis, and sotnetim* £ 
 chemosis, and ophthalmia sicca. Together 
 with a preternatural dryness of the eye, and 
 a sensation, as if the eyeball were compress- 
 ed on every side, the white of the eye be- 
 jeoeaes covered with a general rednejs.Sj 
 
OPHTHALMV. 
 
 332 
 
 which, though it, affect both the sclerotica and 
 the conjunctiva, will be found on attentive 
 examination to be much more considerable 
 in the former, than the latter membrane, in 
 which only a delicate plexus of blood-ves 
 sels is at first perceptible. The motions of the 
 eye and eyelids are not absolutely prevent- 
 ed ; yet, the patient never moves these parts 
 except when he is actually obliged to do so, 
 as every motion of them, if not actually 
 painful, occasions a good deal of annoy- 
 ance. Though the cornea cannot be said 
 to become opaque, its clearness is always 
 much diminished, and this change is the 
 greater, the redder the white of the eye ap- 
 pears. These effects, which occur almost 
 simultaneously, are followed by pain, which 
 increases every moment, at first extending 
 over the whole eyeball, and then to the sur- 
 rounding parts, and to the top of the head. 
 As the pain grow s more severe, every move- 
 ment of the eyeball and palpebraj becomes 
 more distressing, the dryness of the eye 
 greater, and the redness of the sclerotic 
 conjunctiva augments, either more slowly, 
 or quickly, according to the degree of in- 
 flammation until the network of blood-ves- 
 sels, which was at first distinguishable, en- 
 tirely disappears, and the conjunctiva looks 
 like a piece of red cloth, quite concealing 
 the sclerotica, and forming round the cor- 
 nea a very painful, firm, uniform circular 
 projection. Thus, the cornea seems as if 
 it lay in a depression, with its margin partly 
 covered by this inflammatory swelling of 
 the conjunctiva. At the period, when the 
 protuberance of the latter membrane takes 
 place, the cornea itself always becomes less 
 and less clear, and of a reddish gray colour, 
 so that neither the iris nor the pupil can be 
 any longer distinguished, and the power of 
 vision is reduced to a faint perception of 
 light. The pain, which was that of heavi- 
 ness and tension, now becomes of a throb- 
 bing description, and the eyelids, which 
 now begin to participate in the effects of 
 the inflammation, are no longer capable of 
 covering properly the swelled conjunctiva. 
 The eyeball and eyelids are perfectly mo- 
 tionless ; and, if an attempt be made by 
 the patient to move them, the efforts of 
 the muscles may be perceived, but still no 
 movement of the parts intended is perform- 
 ed. The orbit feels as if it were too small 
 for the eye, and the constitution suffers a 
 severe attack of inflammatory fever. Thus, 
 says Beer, does the first stage of this form 
 of ophthalmv gradually rise to its highest 
 degree, to which he applies the name of 
 true chemosis. 
 
 However, it is observed, that idiopathic 
 external ophthalmy does not always be- 
 come so violent, as for instance, when the 
 complaint has been excited merely by the 
 lodgment of some small foreign body under 
 tbe eyelids ; for though in such a case the 
 conjunctiva and sclerotica are both redden- 
 ed together, yet even when no aid is afford- 
 ed, if no other sources of greater irritation 
 are present, the redness does not readily 
 increase so as quite to conceal the sclero- 
 
 tica, or to be attended with an inflamma- 
 tory swelling all around the cornea. This 
 milder form of external ophthalmy has 
 sometimes received the name oi tar axis. It 
 is the mild acute ophthalmy of Scarpa, cha- 
 racterized, as this author says, by redness of 
 the conjunctiva and lining of the eyelids, 
 an unnatural sensation of heat in the eyes, 
 uneasiness, itching, and shooting pains, as if 
 sand w ere lodged between the eye and eye- 
 lids. At the place where the pain seems 
 most severe, Scarpa remarks, that some 
 blood-vessels appear more prominent and 
 turgid than other vessels of the same class. 
 The patient keeps his eyelids closed ; for he 
 feels a weariness and restraint in opening 
 them, and by this means be also moderates 
 the action of the light, to which he cannot 
 expose himself, without increasing the burn- 
 ing sensation, lancinating pain, and effusion 
 of tears. If the constitution be irritable, 
 the pulse w ill be a little accelerated, parti- 
 cularly towards the evening ; the skin dry ; 
 and sometimes slight shiverings, and nausea 
 and sickness take place. 
 
 According to Scarpa, mild acute ophthal- 
 my is often the consequence of a cold, in 
 which the eyes, as well as the pituitary ca- 
 vities, fauces, and trachea, are affected. It 
 is not unfrequently occasioned by change 
 of weather, sudden transitions from heat to 
 cold, the prevalence of easterly winds, jour- 
 neys through damp unhealthy, sandy coun- 
 tries, in the hot season of the year, exposure 
 of the eyes to the vivid rays of the sun., 
 draughts of cold air, dust, &c. Hence, it 
 does not seem extraordinary, that it should 
 often make its appearance as an epidemic, 
 and afflict persons of every age and sex. 
 As additions to the list of remote causes, 
 authors enumerate the suppression of some 
 habitual evacuation, as bleedings from the 
 nose, or piles, the menses, he. a disordered 
 state of the prima* viae, worms, dentition, &c. 
 
 Between Beer and some late w riters, there 
 is either one point of difference in their de- 
 scriptions of external ophthalmy, or else 
 they mean different cases ; for while Beer 
 represents the redness as affecting the scle- 
 rotica at first more than the conjunctiva, 
 other writers describe the affection of t he scle- 
 rotica as generally secondary, when it hap- 
 pens at all ; for according to modern obser- 
 vations, it is not unavoidably either an at- 
 tendant upon, or an effect of simple inflam- 
 mation of the conjunctiva. 
 
 As the second stage of external ophthal- 
 my comes on, the symptoms vary, accord- 
 ing to the degree of the complaint in its 
 first stage ; but when what Beer calls a true 
 chemosis is produced, the following are de- 
 scribed by him as llie usual appearances. 
 The circular prominent fold of the conjunc- 
 tiva round the cornea, becomes of a dark 
 red colour, and the swelling increases, but 
 it becomes softer and less painful. The 
 hardly visible portion of the cornea, situated 
 iu the depression formed by the circular 
 protuberance of the conjunctiva, seems at 
 first perfectly white, and afterward yellow- 
 ish, being the seat of more or less purulent 
 
matter. Though the swelled conjunctiva 
 is every where moistened with a thin whi- 
 tish mucus, this secretion, says Beer, is never 
 so copious as to run over the face, as in 
 the case of ophthalmo-blennorrhcea. In 
 this stage, the lower eyelid is turned some- 
 what outwards, in consequence of its lining 
 becoming more swelled. While suppura- 
 tion is taking place in the cornea, attended 
 with the febrile symptoms which usually ac- 
 company the formation of acute abscesses, 
 little collections of matter sometimes occur 
 at different points of the conjunctiva, and 
 after they have burst, a probe may easily 
 be passed rather deeply into them, without 
 any particular pain. (Beer, B. 1,/). 412.) 
 The suppuration continually advancing, the 
 swellingof the conjunctiva, and of the whole 
 eyeball now diminishes, the effects of the 
 inflammation penetrate deeply into the or- 
 gan, and the structure of the eye is so alter- 
 ed as not to be cognizable, the part shrivel- 
 ling up, as Beer says, into a motionless, 
 whitish mass. However, according to this 
 author, these deep effects of suppuration 
 are sometimes produced only in a certain 
 part of the eyeball, especially when the 
 chemosis is the consequence of an external 
 injury, and in this circumstance, the rest of 
 the circumference of the globe of the eye 
 exhibits its natural organization, while in 
 the part above alluded to, there is a funnel- 
 like depression, attended with a considera- 
 ble diminution in the size of the organ. 
 
 But, says Beer, when an idiopathic exter- 
 nal inflammation of the eye has only attain- 
 ed the milder degree, expressed by the term 
 taraxis ; as, for instance, when the com- 
 plaint is principally owing to the lodgment 
 of some mechanically, or chyriucally irrita- 
 ting substance under the eyelids . the red- 
 ness of the conjunctiva and sclerotica un- 
 dergoes a remarkable increase on the ac- 
 cession of the second stage ; the first of 
 these membranes becomes somewhat swell- 
 ed ; the pain is lancinating and irregular ; 
 and the secretion of tears unusually pro- 
 fuse ; but at the point where the extraneous 
 substance lodges, an open superficial sup- 
 puration occurs, and according to Beer, the 
 case both in the first and second stage, is 
 generally accompanied with no febrile 
 symptoms. 
 
 In the first stage, Beer represents the 
 prognosis as very favourable, provided the 
 disorder does not exceed that degree, to 
 which the name of iaraxis is applied; for 
 with the aid of proper treatment, the in- 
 flarnmaiion. when of a healthy kind, may 
 be soon so favourably removed, as not to 
 leave a vestige of it behind. If the cause of 
 the disorder be not greater than a moderate 
 injury or wound of the eve, any traces of 
 the lesion, which are perhaps still remain- 
 ing, will disappear as soon as the inflamma- 
 tion subsides. On the other hand, when 
 this kind of ophthalmy presents itself in 
 the form of true chemosis, the prognosis is 
 serious, and must be made with great re- 
 serve, especially when the patient is of a 
 
 weak irritable constitution, a child, very- 
 stubborn and unmanageable, or incapable 
 of following strictly the advice which he 
 receives froth his medical attendant ; for, 
 under these circumstances, it will not be in 
 the power of the latter to prevent the com- 
 plaint from advancing unremittingly to its 
 second stage, in which event the ill conse- 
 quences of suppuration w ill be incalculable. 
 But if these unfavourable conditions are not 
 present, though the genuine idiopathic che- 
 inosis may really have attained a violent, 
 and almost its highest degree in the first 
 stage, not only the eye may be saved by 
 prompt and judicious treatment, but als© 
 the eyesight ; nor will the result be differ- 
 ent, even when the cornea continues for 
 some time deprived of its transparency, and 
 the power of vision impaired by a slight 
 varicose affection of its conjunctival cover- 
 ing. These effects, says Beer at length 
 completely disappear, less in consequence 
 of the aid of medicine, than of a proper 
 regimen, the uninterrupted enjoyment of 
 a fresh, dry air, &c. 
 
 The prognosis in the second stage, is un- 
 der very different circumstances ; for, a^ 
 Beer observes, though the inflammation, in 
 the first stage may really not exceed that 
 degree which is implied by the term iaraxis, 
 yet if any suppurating point, occasioned by 
 some slight preceding injury, be not effi- 
 ciently treated, or if there be any loss of 
 substance, already produced by the injury 
 itself, a more or less opaque, white cicatrix 
 is apt to remain on the cornea, and cause a 
 permanent impediment to vision in a degree 
 determined by the situation and extent of 
 the opacity. And in addition to this risk it 
 is to be remembered, that if the suppurating 
 point be entirely neglected, or erroneously 
 treated, the cornea or sclerotica may be 
 penetrated by ulceration, and in the first 
 case, a prolapsus of the iris, an adhesion of 
 this organ to the cornea, (synechia anterior,) 
 a disfigurement of the pupil, or an irregu- 
 larity of the cornea, be produced ; while, 
 in the second, the consequences may be a 
 partial wasting away of the eyeball, attend- 
 ed with loss of sight, and of the natural 
 shape of the part. (Beer. B. 1, p. 417.) 
 
 Beer further observes, that when this 
 species of ophihalmy presents itself in its 
 first stage in the form of true chemosis, the 
 prognosis in the second stage is very unfa- 
 vourable ; for when the cornea is generally 
 pervaded by suppuration, the eyesight, and, 
 in some degree, the form of the eyeball, are 
 for ever lost, and it will be lucky, if the 
 case can be brought to a conclusion with 
 the mere destruction of the cornea. Br?t 
 when the matter points at once in several 
 places of (he conjunctiva, round the cornea, 
 all idea of preserving (he shape of the eye 
 sufficiently for the application of an artifi- 
 cial eye is out of the question, and the sur- 
 geon will be very successful, if he can now 
 check in moderate time the suppuration, 
 which continues with a good deal of gene- 
 ral indisposition. An extraordinary relaxa- 
 tion of the con junctiva of the lower eyelid, 
 
OPHTHALMY. 
 
 334 
 
 and a consequent ectropium, are the least 
 disastrous effects of the abscesses of the eye 
 thus produced. Lastly, Beer remarks, that 
 when chemosis is in the second stage, that 
 is to say, attended with suppuration of the 
 eye, it rarely happens, under the most fa- 
 vourable circumstances, that the eyesight 
 and shape of the organ can be preserved 
 entirely free from permanent injury. ( B . 1, 
 j V • 418.) 
 
 Let us next consider the treatment of idio- 
 pathic external ophthaliny in its modifica- 
 tions of simple inflammation of the con- 
 junctiva, mild acute ophthalray, or taraxis, 
 and severe acute opi.thalmy, with che- 
 tnosis. 
 
 According to Mr. Travers, simple inflam- 
 mation of the conjunctiva unconnected 
 with injury of tiie eye, and neither depend- 
 ing upon any established disorder of the 
 system, nor modified by a scrofulous dia- 
 thesis, may be easily and speedily reduced, 
 even in its most acute form, by bleeding 
 and some brisk doses of purgative medicine. 
 
 ( Synopsis of the Diseases of the Eye, p. 247.) 
 For the relief of mild acute ophthaliny, 
 Scarpa recommends low diet, gentle purging 
 with small repeated doses of aritimonium 
 tartarizatum, the removal of any extraneous 
 body lodged under the eyelid, and frequently 
 washing the eye with a warm decoction of 
 mallow leaves, and covering it with a very 
 soft emollient poultice, included in a fine 
 little muslin bag. Mr Travers also expresses 
 his decided preference to a tepid application 
 in the painfully acute stage of inflammation, 
 and considers simple warm water generally 
 better than medicated lotions, like the aque- 
 ous solution of opium, or infusions of poppy 
 and hemlock. 
 
 When the disease presents itself in its first 
 stage, in the mild form of taraxis, says Beer, 
 it usually runs its course, quite uncomplica- 
 ted with any general indisposition, and may 
 be cured by moderate antiphlogistic treat- 
 ment, in which, indeed, since the eyeball it- 
 self is affected, particular attention must be 
 paid to lessening the action of the light and 
 air upon the organ. But when a true che- 
 mosis is present, every antiphlogistit means 
 must be promptly and rigorously put in 
 practice, internal as well as external reme- 
 dies being employed, and besides common 
 measures, the conjunctiva, round the cor 
 nea, is to be scarified ; a proceeding never 
 necessary in the case of taraxis. Such sca- 
 rifications, Beer observes, have a wonderful 
 effect when practised at the proper period, 
 aft r veneseci ion and topical bleeding with 
 leeches have been fully put in execution, 
 and when the cuts are made deep, so as 
 to produce immediately a copious discharge 
 of blood. “ By means of such scarifica- 
 tions (says he) I have seen the inflam- 
 mation and all its threatening effects re- 
 cede, as it were, before my face, when no 
 material relief could be effected by other 
 measures.” ( B . 1, p. 419.) 
 
 According to the late Mr. Ware, there 
 cannot be, in chemosis, an easier or more 
 effectual remedy than set her. A few drops 
 
 are to be poured Into the palm of the hand., 
 and diffused over it, which may be imme- 
 diately done by pressing the other hand 
 against it The hand is then to be applied 
 to the eye, and kept so close to it that the 
 spirit, as it evaporates, may insinuate itself 
 into the part affected, and act on the extra- 
 vasated blood, so as to disperse it. In a few 
 instances of chemosis, in which the swelling 
 and inflammation have been considerable, 
 this gentleman found the following applica- 
 tion of singular service : f^. lnteriorum fo- 
 
 liorum recentiurn Lactucae Sissilis ^iij. 
 Coque cum aq. pur. 3-ss. in balneo mariao 
 pro semihora ; tunc exprimatur succus, et 
 applicetur paululum ad oculos et ad palpe- 
 bras saepe indie. (Ware, p. 54) As these 
 applications are not noticed by the genera- 
 lity of modern writers, I infer, that the supe- 
 rior efficacy imputed to them by the late 
 Mr. Ware, is not such as to obtain the con- 
 fidence of all other ophthalmic practitioners. 
 
 General and local bleeding, and, if chemo- 
 sis be present, scarifications having been put 
 in practice, the treatment is to be continued 
 by administering purgatives of the mildest 
 description, and, after their operation, apply- 
 ing blisters, according to the directions 
 given in a preceding part of this article. Ia 
 the first stage of severe acute ophthalmy, 
 Scarpa considers topical emollient applica- 
 tions to the eye most beneficial, such as 
 mallows boiled in new milk; bread and 
 milk poultices; or the soft pulp of a baked 
 apple ; all included in fine little muslin bags. 
 Remedies of this description should be re- 
 newed at least every two hours. The pa- 
 tient should be directed to observe perfect 
 quietude, and to lie with his head in an 
 elevated position. To keep the eyelids 
 from adhering together in the night-time, 
 the spermaceti cerate is proper. When 
 ophthalmy is accompanied with a violent 
 pain in the head, the late Mr. Ware recom- 
 mended a strong decoction of poppy-heads 
 to be applied as a fomentation. (P.51.) 
 
 Under the preceding plan of treatment, 
 the first stage of severe ophthalmy com- 
 monly abates in about a week The burning 
 heat and darting pains in the eyes, and the 
 febrile disturbance of the constitution sub- 
 side. The patient is comparatively easy, 
 and regains his appetite. The eyes become 
 moist again, and can now be opened without 
 experiencing vast irritation from a moderate 
 light. In this state, notwithstanding they 
 may continue red, and the conjunctiva 
 swelled, all evacuations are to be left off, 
 as well as the use of topical emollients, for 
 which iatter astringent, corroborant collyria 
 are to be substituted. Scarpa recommends 
 the following application : f^. Zinci sul- 
 
 phatis gr vj. Aquae distillate ^vj. Mucil. 
 sein. cydon. mali j. Spiritfis vini cam- 
 phor guttas paucas. Misce et cola. This 
 collyriutn maybe injected with a syringe, 
 between the eye and eyelids, once every 
 two hours; or the eye may be bathed in it 
 by means of an eye-cup. Such persons as 
 cannot bear cold applications to the eye, 
 must have the same hind ef collyriutn a little 
 
OPHTHALMY 
 
 ib& 
 
 unarmed ; but as soon as the irritability is 
 lessened, it may be used cold. 
 
 Scarpa then speaks of the good effects 
 produced in the second stage of ophthalmy 
 by the application to the eye of two or three 
 drops of the vinous tincture of opium, once 
 or twice a day ; a subject already consider- 
 ed in the foregoing columns. The utility 
 of letting the eye be habituated to the light, 
 as soon as it can bear it, is next strongly 
 commended; a rule of great importance, 
 but on which 1 need not here dwell, be- 
 cause it has been already insisted upon in 
 the general observations. 
 
 When idiopathic external ophthalmy has 
 terminated in suppurations of little extent, 
 Beer speaks highly of the benefit derived 
 from a solution of the lapis divinus, (see 
 Lachrymal Organs) containing the liquor 
 plumbi subacetatis, or from smearing the 
 suppurating points with a little laudanum. 
 In worse cases, Beer states, that, when such 
 local treatment is combined with the inter- 
 nal exhibition of bark and naphtha, and a 
 diet and regimen conducive to the support 
 of the system, its efficacy is very great. And 
 here, says he, it is worth observing, that 
 while the solution of the lapis divinis is of 
 great service in the second stage of true 
 chemosis, it is more or less detrimental in 
 the kind of chemosis which accompanies 
 purulent ophthalmy, especially if not blend- 
 ed with mucilage, and, even w hen thus qua- 
 lified, it cannot be endured by weak and 
 irritable subjects, affected with the latter 
 complaint ; a fact not observed in other in- 
 stances of chemosis. (B. 1, p. 42u.) To 
 Mr. Ware’s use of ajther in chemosis, 1 have 
 already adverted. 
 
 When pustules, or abscesses in the swell- 
 ed conjunctiva point round the cornea, a 
 free outlet to the matter must be immedi- 
 ately made in each of them with a lancet; 
 for, if this be not done, as Beer observes, 
 the matter will spread extensively, and the 
 eyeball be in danger of being destroyed. 
 For an account of the method of treating the 
 eversion of the lower eyelid, sometimes re- 
 maining as a consequence of the disorder, 
 see Eclropium. 
 
 Inflammation of the Sclerotica. Sclerotitis. 
 - — The modern attempts to class ophthal- 
 mies, according to the texture of the eye 
 first or chiefly affected promises, I think, to 
 load to clearer views of the subject, and 
 sounder practice. One circumstance, par- 
 ticularly adverted to, both by Dr. Vetch and 
 Mr. Travers, in inflammation of the sclero- 
 tica, is the appearnuce of a vascular zone 
 at the margin of the cornea. By the latter 
 gentleman, this effect is ascribed to the par- 
 ticular distribution of the vessel's. “Branches 
 from the straight vessels of the conjunctiva, 
 penetrate Ihe sclerotica obliquely towards 
 the margin of the cornea, and the long ci- 
 liary vessels pass in sulci of this membrane 
 to the plexus ciliaris at the root of the iris. 
 At the interior border of the sclerotica, 
 where the annulus ciliaris is adhering closely 
 to this tunic, the ciliary communicate with 
 the : muscular branches, and being in deep- 
 
 seated inflammation fully injected with red 
 blood, the condensation of colour gives the 
 well-known and remarkable appearance of 
 a vascular zone at the margin of the cornea.” 
 
 ( Synopsis , tyc. p. 126.) According to Dr. 
 Vetch, only a few interspersed trunks are 
 posteriorly observed, “which do not affect 
 the natural appearance of the intermediate 
 space, but these, diverging as they come 
 forwards. produce a zone more or less com- 
 plete, of minute hair-like vessels, distin- 
 guished by their rectilinear direction, and 
 their uniform concentration towards the 
 margin of the cornea ; their colour advances 
 w ith the progress of the disease, from that 
 of a delicate pink, or damask rose, to a 
 deeper hue, and imparting a faint blush to 
 the part immediately surrounding it.” (On 
 Diseases of the Eye. p 27.) There appears, 
 however, to be a good deal of variety in the 
 symptoms of sclerotitis ; for rheumatic in- 
 flammation of the eye, described by Pro- 
 fessor Beer and Mr. Ward rop, as particularly 
 affecting the sclerotica in common with 
 other fibrous membranes, is not noticed by 
 these authors as characterized by the red 
 zone round the edge of the cornea. Indeed, 
 instead oi there being posteriorly only a few 
 interspersed trunks, Mr. Wardrop states, 
 “that (in rheumatic ophthalmy) the blood- 
 vesseis are generallv. equally numerous over 
 the whole white of the eye, passing forwards 
 in nearly straight lines from the posterior 
 part of the eyeball, and advancing close to 
 the cornea ; but neither passing over it nor 
 leaving the pale circle around it , which is so 
 striking when either the choroid coat or iris is 
 inflamed. If the vessels be closely exami- 
 ned, the genera! redness will be found pro- 
 duced more from numerous small ramifica- 
 tions than a few large trunks.” (Med. Chir. 
 Trans. Vol. 10, p. 3.) However, as if there 
 must be no harmony on this subject, Beer 
 describes the blood vessels, in rheumatic 
 ophthalmy, not as being equally numerous 
 over the whole white of the eye, but as be- 
 ing in some places collected in larger numbers 
 or clusters, and he differs again from Mr. 
 Wardrop, in describing the redness as 
 coming on with considerable intolerance of 
 light, ( Lehre von den Angenkr. B. 1, p. 397 
 — 398,) while the latter :-uthor distinctly 
 mentions, that “ the eye does not seem to 
 suffer from exposure to lights” (Med. Chir. 
 Trans. Vol. 10, p. 6.) I can only reconcile 
 these accounts by concluding, that sclero- 
 tic inflammation, like that of other textures 
 of the eye, has stages and modifications 
 which account for these seeming contradic- 
 tions. And, with respect to the vascular 
 zone round the edge of the cornea, it would 
 appear, at all events, to belong to iritis, as 
 well as sclerotic inflammation. The vessels 
 of the sclerotic coat are observed by Dr. 
 Vetch tu'follow the motion of the eye, and 
 he says, that they may, by this circumstance, 
 be distinguished from those of the conjunc- 
 tiva, “ the vessels of the latter, independent 
 of their darker colour, their more tortuous 
 form, and varying size, have likewise a more 
 longitudinal direction, and as they proceed 
 
336 
 
 OPHiHALMV 
 
 from the angles ot the orbit, they form radii 
 of a larger circle. The distinction between 
 the inflamed vessels of the conjunctiva and 
 the sclerotica, (says Dr. Vetch) I consider 
 to be, therefore, obvious ; but, that any dif- 
 ference can be observed in the arrangement - or 
 appearance of the vessels of the I, alter, suffi- 
 ciently distinct to indicate the peculiarity of the 
 exciting came , or specific nature of the case, 
 is more than l have been uole to perceive. The 
 general character, as it arises out of the 
 structure of the part, will be found the same, 
 whether the cause be gout, rheumatism, or 
 syphilis. The vessels, such as l have de- 
 scribed them, will always be most observa- 
 ble on the upper portion of the eye, as it is 
 in that place that the inflammation is most 
 intense, except when its locality is affected 
 by any external exciting cause, in which 
 case it will be greatest near the injured 
 part.” {On Diseases of the Eye, p. 29.) 
 
 While Dr. Vetch describes the vessels of 
 the conjunctiva as exhibiting in sclerotic 
 inflammation a darker colour than that of the 
 vessels of the sclerotic coat itself, Mr. Tra- 
 vers represents the vessels of the latter mem- 
 brane, which pursue a straight course to the 
 margin of the cornea, as having a somewhat 
 darker hue than the areolar vessels upon the 
 loose portion of the conjunctiva. 
 
 It should be mentioned, however, that 
 by sclerotic inflammation. Dr. Vetch signi- 
 fies inflammation of the eye itself, as con- 
 trasted with conjunctival inflammation ; 
 but, how far this will account for the differ- 
 ences, above pointed out, between his des- 
 cription and that of Mr. Travers, 1 am not 
 prepared to say. According to Mr. Travers, 
 ordinary inflammation of the sclerotica is 
 secondary, that is to say, this membrane is 
 usually affected only as intermediate to the 
 conjunctiva and the other tunics. How- 
 ever, he has occasionally observed, in a re- 
 cent ophthalmia, a turgescence of the ves- 
 sels, which pur&ue a straight course to the 
 cornea, unaccompanied with any affection 
 of the iris, and so slight a vascularity of 
 the loose conjunctiva, that he was disposed 
 to regard the case as a primary sclerotitis. 
 The inflammation he says, is not acute, and 
 the motions of the eyeball are painful. It 
 sometimes accompanies, and sometimes fol- 
 lows rheumatic inflammation. If continued, 
 it presents the vascular zone and a pupil 
 contracted, or drawn a little to one side. 
 It is often seen in company with eruptions, 
 or sorethroat, of a pseudo-syphilitic cha- 
 racter, oris secondary to gonorrhoea. ( Tra- 
 vers , Synopsis, tyc.p. 123.) 
 
 The practice, recommended by this gen- 
 tleman, is as follows : obtuse pain in the 
 eyeball, he says, may he materially relieved 
 by blood-letting, and by antimony and ipeca- 
 cuanha with opiates. Mercury is stated to 
 have much less power over this case, than 
 iritis. In general, the patient is seriously 
 reduced, and very irritable, from suffering, 
 rheumatic inflammation in the elbow, knee, 
 or ankle; a state, to the produc ion of 
 which the previous use of mercury has com- 
 monly contributed but though such is 
 
 stated to be the case, the moderate ana cau- 
 tious employment of this mineral is set down 
 as generally indispensable in the treatment 
 And in the interval of the mercurial action, 
 the nitric acid is alleged often to be of great 
 service. The preparations of mercury pre- 
 ferred by Mr. Travers in these cases, are the 
 oxymuriate in doses of one 1-12 or 1-8 of a 
 grain, and the hydrargyrus cuin crela, in 
 doses of from five to ten grains, twice or 
 thrice a day. As auxiliaries for allaying ir- 
 ritation, he prescribes the pulv. ipecac, comp, 
 hemlock, hyosciamus, and the extract of sar- 
 saparilla; either dissolved in the decoction, 
 or taker* solid. (Vol. cit.p. 289.) 
 
 On rheumatic inflammation of the eye, a 
 few observations will be hereafter inserted. 
 Idiopathic Inflammation of the Internal Tex- 
 tures of the Eyeball, or Internal Ophthalmy 
 in general. According to Beer, internal in - 
 flammation of the eye does not always ori 
 ginate in one particular texture, but, in some 
 instances, commences in the retina, choroi 
 des, &.c. ; while, on other occasions, its prin - 
 cipal seat is in the iris, from which mem- 
 brane it quickly extends itself to the corpus 
 ciliare, and the crystalline lens and its cap- 
 sule. or else in another direction to the scle- 
 rotica, cornea, &.c. These differences in the 
 seat of the disorder obviously depend upon 
 the way in which the exciting causes have 
 operated ; for, when they are such as imme- 
 diately affect the retina only, the inflamma- 
 tion must have Us origin in this texture, as 
 when the disorder is produced by the effect 
 of the sudden entrance of any very strong 
 vivid or reflected light into die organ. This 
 case Beer denominates ophthalmitis internet 
 idiopathica, proprie sic dicta. 
 
 The exciting causes, however, may not 
 affect directly the retina, and parts immedi- 
 ately next to if, but may operate chiefly upon 
 the iris, in which event, this part is the chief 
 seal of the inflammation and the complaint 
 i- named both by Schmidt and Beer, iritis 
 idiopathica. This form of inflammation, Beer 
 say-, i seen after the extra*- ion of the cata- 
 r i t, and accidental injuries of the eye, where 
 the w upon, with which they were produced, 
 has either penetrated directly to the iris, and 
 more or less caused it, or roughly entered 
 the eyeball near the ciliary edge of this 
 membrane, without actually wounding it. 
 ( Lehre von den Jingenkrankh. B. 1 ,p. 421.) 
 
 Symptoms of the first stage of idiopathic 
 internal ophthalmy, properly so called. While 
 a very uneasy sensation of general constric 
 tion and tension affects the whole eyeball, 
 and soon changes into an obtuse, deep throb 
 bing pain, increasing every instant, and 
 quickly propagating itself over the eyebrows 
 to the top of the head, as Beer observes, the 
 power of vision gradually declines, and, at 
 the ‘•arne time, the pupil, which pi only loses 
 i.s dear shining blackness, contracts without 
 bring deprived of its circular figure, or drawn 
 out *it its natural position, until, at length, it 
 i,> so completely closed, that the iris seems 
 as it it had no aperture w hatever. But long 
 before this periect closure of the pupil lias 
 taken place, the power of seeing is entity 
 
OPHTHALMY. 
 
 437 
 
 gone, though after the faculty of perceiving 
 the external light is extinguished, fiery ap- 
 pearances, which trouble the patient serious- 
 ly are seen at each pulsation of the blood- 
 Ves-els within the eye. As the developernent 
 ol these symptoms is going on, the iris evi- 
 dently loses its natural colour, becoming, ns 
 Bo r says, greenish, when it vvas gray, or 
 blue ; and reddish, when its was brown, or 
 black. In consequence of the iris swelling, 
 and projecting towards the cornea, the ante- 
 rior chamber becomes considerably diminish- 
 ed. Immediately the least mark of the swell- 
 ing of the iris is seen, together with a mode- 
 rate degree of contraction of the pupil, the 
 whole sclerotica assumes a pink-red colour ; 
 f» plexus of innumerable blood-v essels is seen 
 in the conjunctiva ; and the cornea loses a 
 good deal of its natural brilliancy, without 
 being actually opaque. The lattersymptoms 
 of this form of ophthalmy are attended with 
 manifest general indisposition, and intolera- 
 ble headach. Sometimes in the first stage 
 of the case, the pupil, though much lessened, 
 is not absolutely closed, but thickish, and if 
 examined with a magnifying glass, it has a 
 red ish-gray appearance, and the power of 
 vision, notwithstanding the continuance of 
 the aperture, is quite lost. (Beer.) 
 
 Symptoms in the second stage. According 
 to the same author, while the eye is snffernig 
 very irregular throbbing pain, attended with 
 a sensation of heaviness and cold in the eye, 
 an increase of the redoes* of the conjuncti- 
 va, severe constitutional disturbance, and 
 constant shivering, there is suddenly formed 
 at the bottom of the anterior chamber a col- 
 lection of matter which above presents a 
 horizontal line, but on every inclination of 
 the head sideways, changes its position. This 
 matter continues to accumulate more and 
 more, until it not only teaches the pupil, but 
 fills the whole of the anterior chamber, con- 
 stituting the case termed Hypopium. If the 
 disease be left to itself, says Beer, the matter 
 collects in such quantity, that the cornea is 
 rendered more prominent, and afterward 
 conical, very like an abscess, ultimately 
 bursting during an aggravated attack of pain, 
 when the eye shrinks, and the sufferings gra- 
 dually cease. This kind of hy opium Beer 
 names true, in order to distinguish it from 
 the case, in which the matter passes into the 
 anterior chamber out of an abscess in the 
 cornea, and which he terms a false hypopj- 
 um. When, at the end of the first stage, the 
 pupil is not entirely dose.), one may discern 
 in the second slags, at the period of matter 
 presenting itself hi the bottom of the anterior 
 chamber, (though not easily wiilj the unas- 
 sisted eye) whitish filaments, extending from 
 the edge of that opening towards its v-ntie, 
 produced by the coagulahle lymph effused in 
 the aqueous humour, the secretion of which 
 was interrupted in the first stage, but now 
 commences again. And, continues Beer, 
 one may perceive, with a good magnifying 
 glass, a very delicaie cobweb-like mem 
 brane, which, when the matter collected lies 
 over the pupil, and remains fora good while 
 unabso.bed, at length becomes unite ye!- 
 ?ol. IL ~ * -13 
 
 low, the matter being really encysted by it in 
 the form of a small lump, which remains in 
 the pupil, nd partly projects into the ante- 
 rior chamber, forming the case, which Beer 
 de nominates a spurious purulent cataract , to 
 which the edge of t lie iris is so closely adhe- 
 rent, that sooner than a separation could be 
 effected, the whole of the iris would be torn 
 in pieces. W en the pupil has been t om- 
 pletely closed in the first stage, these effects 
 of course cannot take place. 
 
 Beer remarks, with respect to the causes of 
 this form of ophthalmy, tha , as there are 
 not many circumstances which can produce 
 it, the case belongs rather to the less fre- 
 quent kinds of inflammation of the eye. 
 As predisposing, he mentions plethora and 
 irritabilityof the eyes, occasioned by little ex- 
 ercise of them. Experience has convinced 
 him, however, that by far the most usual 
 ca se of this internal ophthalmy is an extra- 
 ordinary, long-continued straining of the eye 
 in the inspection of small microscopic objects 
 in a strong reflected light. 
 
 Respecting the prognosis, it is remarked 
 by Beer, that this is not unfavourable, when 
 the inflammation of the eyeball is moderate, 
 proper treatmentcan be immediately employ- 
 ed, the pupil is not yet very much contracted, 
 and the power of seeing not considerably 
 impaired. But if the power of vision should 
 seem as it it were abolished, the prognosis is 
 extremely uncertain. And if the pupil should 
 close after the entire stoppage of vision, no 
 hope can he entertained of the recovery of 
 the sight ; for if the pupil open again on the 
 subsidence of the inflammation, it will yet 
 continue very small and motionle-s, and the 
 eye blind. When the case is mistaken in its 
 first s age, and neglected or erroneously 
 treated, Beer says, it changes into a very 
 perilous general inflammation of the whole 
 eyeball ; a disorder already consider' d. 
 
 In the second stage the prognosis is al~ 
 ways unfavourable; for the eyesight has I- 
 ways been already destroyed at the end of 
 the first one, and the only expectation of t he 
 practitioner can now be to preserve e 
 shape of the eye, while as speedy a check as 
 possible is put to the suppuration. If the 
 case has been so mismanaged in its first 
 stage, that a violent inflammation of the 
 whole eyeball is inevitable, and traces of 
 chemosis are already present, the chances of 
 the figure of the eye being lost in the second 
 stage are still greater, and as Beer observes, 
 the surgeon will be fortunate, if he can now 
 prevent afrigiitful morbid change of the organ. 
 
 In t he trea inent of the first stage, Beer 
 describes the indications is being exactly the 
 same as in common ophthalmy, except that 
 no scarifications are necessary, unless the 
 case change into a violent inflammation of 
 the whole eyeball. However, great promp- 
 titude in the applica’ ion of proper curative 
 measures is here particularly called for, as 
 the least delay is apt to cau-e either a total 
 loss of sight . or at least a serious impairment 
 off. (Beer.) 
 
 Wi h tew exceptions, the treatment of the 
 
 second stage is also !:ka that of ophthalmy 
 
OPHTiSALMi. 
 
 in general. Warm poultices, Beer says, can 
 only he employed with great circumspection. 
 When matter collects in the anterior cham- 
 ber, Beer strongly condemns making an 
 opening in the cornea, hv which practice, he 
 states, tliat th* eye would certainly he ren- 
 dered quite deformed. He recommends 
 leaving every thing to the absorbents, the 
 action of which is to he invigorated hy gene- 
 ral and local remedies. Poultices are now 
 to be laid entirely aside, and the effect of 
 warmth tried. Blisters are to he applied al- 
 ternately behind the ear and on the temple. 
 The eye is to be smeared with the vinous 
 tincture of opium, two or three time- a day, 
 by means of a camel-hair brush, or even 
 four times, when the anterior chamber is 
 filled to the extent of one half of it. Beer’s 
 experience leads him to approve of opening 
 the cornea only in very urgent cases, that is 
 to say, when the eye is so distended with 
 matter, that the cornea is in a state of an ab- 
 scess, which threatens to bur-t. In one part 
 of his observations, Beer describes the mat- 
 ter in these instances as fluid; a point on 
 which he differs from Scarpa: but he alier- 
 ward confesses, that when an opening is 
 practised, the matter mud not he expected 
 to flow out immediately like that of a com- 
 mon abscess For furt'.er information on 
 this subject, see Hyp opium. 
 
 Idiopathic Iritis. The following is Beer's 
 description ot the disease. Together with 
 an obtuse, heavy, deep pain in the eye. pro- 
 ducing a position, as if the eyeball were 
 continually pressed upon by one of the fin- 
 gers, a manifest and incessantly increasing 
 uniform contraction of the pupil takes place, 
 as well ,v> a gradual diminution of the move- 
 ments of the iris; yet the pupil neither loses 
 its circular shape, nor changes its position in 
 the eye, and at ihesame time, an intolerance 
 q! 1 bt commences. When the pupil is ex- 
 omi ed v ii h a glass, it is found to have al- 
 ready 'os- he shining blackness, which is 
 peculi r to the healthy state. While 
 
 these changes "curring in the pupil, the 
 col ur ■! the iris undergoes a mate i d altera- 
 tion, first at its le -:«» Ircie, which grows 
 much darker, and afterward at its greater 
 circle, which turns greenisn, i n it was gray 
 
 or blue, but reddish whet, it wn= brown or 
 black. At the same time, the margin of the 
 pupil becomes mdi !inc»,and ep ( ,ears not so 
 sharp a n eural. A -oon as tin- greater ring 
 of the iris S s under.* me a considerable 
 change of colour, this membrane becomes 
 evidently swelled, nd p, ojects towards the 
 cornea, so hut In- interior chamber is very 
 much lessened. As * !y as the period when 
 th contraction of >h" pu ;'!. and the 1 1 n m > • 
 bilitv of the "i are oh err , »ie, a serious di- 
 minution <>f the p.iwfrr of vision occurs; be- 
 cause, in all cases, the iuflarnmat on extends 
 more or less over the anterior i r of (lie 
 crystalline capsule, and after u ai , the. 
 
 Case is somewhat m >re advanced, - '■■■> B er, 
 one may perceive quit*- plainly, with he 
 unassisted *ye, those ••ff-, - f infl -intimation 
 on the r.apsub , which live b e so ex<:« I- 
 lentJ|f described by Professor Walt her- (/. lb - 
 
 handl. aus dan G&bielhe der Vraciist’ttn Me ■ 
 dicin, 1 B. Landshut , 1810.) In proportion a; 
 the inflammation makes progress, the pain 
 grows more severe and exterfsive, and to- 
 wards the end of the first stage, it shoots par- 
 ticularly up to the top of the head; a cir- 
 cumstance strikingly proved whenever any 
 tiling like slight pressure aggravates the pain 
 in the eye. The redness perceptible in the 
 eye during the whole of the first stage is in- 
 considerable, and seems to be not at all pro- 
 portioned to the violence and danger of the 
 inflammation ; for the sclerotica is only of a 
 rose-red colour, and even this pale redness 
 fades towards the circumference of tlie eye- 
 ball (B. 1, p 434.) 
 
 According to Beer, idiopathic iritis is al- 
 ways attended with a corresponding general 
 disturbance of the system ; but a good deal 
 depends upon whelher the inflammation 
 spends immediately 'o the deeper textures 
 o |f the eye. or to its outer coats, or in both 
 directions at once. In the first case, the 
 constitutional indisposition is always more 
 severe, and the danger of the disease in- 
 creases every moment; in the second in- 
 stance, the augmentation of the general symp- 
 toms is less striking; but in the third, the 
 inflammation, and the corresponding febrile 
 symptoms soon rise to such a pilch that the 
 possibility of preserving the eyesight be- 
 comes very doubiful. The continued ope- 
 ralion of hidden exciting causes, neglect, 
 and erroneous management of the disease, 
 also produce considerable differences ; and, 
 as Beer observes, it not unfrequent ly hap- 
 pens that a genuine idiopathic iritis, which 
 does not appeal* at first very dangerous, nor 
 rapid in its progress, vvi l suddenly change, 
 under the unfortunate concurrence of tfie 
 circumstances, above alluded to, into a com- 
 plete inflammation of the whole eyeball, de- 
 stroying the organ in a tew days, unless the 
 most efficient treatment be speedily adopted. 
 
 In the second stage, says Beer, in c.o junc- 
 tion with a corresponding still more mani- 
 fest general indisposition, the pain in the 
 eye grows very irregular ; luminous appear- 
 ances flash within the organ, and seriously 
 annoy the patient, especially in the dark, 
 vvhi'e the power of seeing the external light 
 undergoes a great decrease; the redness, 
 even in the conjunctiva, .increase^ ; and the 
 pupil, which hitherto has been perfectly cir- 
 cular, becomes more or less angular. At 
 Miese angles, something of a light grayish co- 
 lour mav be seen projecting behind the pu- 
 pillary edge of the iris, and on examination 
 with a glass, plai* !> appears to be a very de- 
 licate layer of coagulating lymph, by which, 
 fi st the lesser ring of the uvea, and (if pro- 
 per treatment be not expeditiously employ- 
 ed) also its greater ring, are soon rendered 
 adherent to the an'erior po tion • »f 'he cap- 
 sule >1 the lens. ( synechia posterior ,) which 
 membrane, a*- ill di-u a <■ advances, becomes 
 more arid more deprived ol its transparen- 
 cy. Under llie-e circumstance*, it is evident, 
 that the pov\er of vision must dailv decline, 
 and that if this process of the effusion ot 
 lymph and its organization be not jjpvHcd by 
 
0PHTHA1MY 
 
 339 
 
 powerful measures, (he patient will suon be 
 Heft just capable of faintly distinguishing the 
 light. While the above-described changes 
 an taking place between the uvea at dante- 
 terior position of the capsule, very pec uliar 
 effects are occurring in the anterior cham- 
 ber , for, ns the iris continues to project fur- 
 ther towards the cornea, the latter mem- 
 brane grows less and less transparent, and 
 the iris seems as if concealed in a mist, at 
 the same time that a small, yellowish, red, 
 round prominence is formed at one or more 
 places together, generally hptween the great- 
 er and lesser rings of the iris, and proves af- 
 terward to be a small abscess, which ulti- 
 mately bursting, pours its contents into the 
 anterior chamber, and thus occasions n true 
 Hypopium. For several days, the flakes of 
 (he burst little cyst, still connected with the 
 Iris, may be seen floating in the aqueous hu- 
 mour, until they gradually disappear. When 
 there is not merely one, hut several of these 
 little abscesses, says Beer, the greater part of 
 the anterior chamber may be filled with 
 matter, so that little more of the iris can be 
 distinguished. In weak subjects, at this pe- 
 riod ol suppuration, blood may not unlre- 
 quenlly be perceived in the chamber of the 
 eye ; a circumstance regarded by Beer as a 
 very unfavourable omen, in respect to the 
 recovery of sight, as in such cases, portions 
 of blood and matte: are • pt to lie in the pos- 
 terior chamber entangled in the lymph. Ac- 
 coiding to the same author, the matter in 
 the anterior chamber is at last absorbed ; the 
 pupil, if it has been concealed, can again be 
 seen, but it appears angular and very turbid ; 
 and in consequence ol the layer of lymph 
 in the posterior chamber, the eyesight is ex- 
 ceedingly dimim-hed, or even re dinted to 
 the mere power ot knowing light horn dark- 
 ness Su< h, says Bee , is the course ot the 
 second stage oi idiopathit iritis,, w hen the 
 inflammation has not extended tar beyond its 
 proper locu', and has been principally con- 
 fined to the iris, corpus ciliare, the lens and 
 its capsule, and the anterior part of the scle- 
 rotica. But if it should spread more deeply 
 to the vitreous humour, the retina, the mem- 
 brane Ruyschiana, and the chorotdes, symp- 
 toms ot internal ophthidmy (strictly so call- 
 ed) then occur with great vehemence in the 
 first stage, and at the termination of the se- 
 cond, the eyesight is for ever certainly de- 
 stroyed in such a degree, that not the least 
 perception of light remains ; and even it the 
 patient should think that he can distinguish 
 it, the feel is only a deception ; a develope- 
 ment ol light v\ ithin the eye itself ; of w Inch 
 the surgeon may i usriy assuie himself by 
 placing the patient with his back towards 
 the light, and asking him to point out where 
 it is; or by putting him directly opposite a 
 window, and moving the hand slowly along 
 before his eyes; of which proceeding the 
 patient will be quite unconscious. The ef- 
 fects left in the eye after such an iritis, and 
 indicating its mischievous extension, ate so 
 characteristic, that, on the first inspection of 
 the eye, no surgeon can entertain a doubt of 
 (ha deeper textures of the eye having been 
 
 involved in the inflammation. But when 
 idiopathic iritis extends rather to the exter- 
 nal, than the deep textures of the eye, the 
 swelled iris, as early as the end ol the first 
 stage, approaches so near the cornea, which 
 grows le.-s and less clear, that they seem as 
 if they were adherent, ere the second stage 
 has commenced. And,- indeed, on the ac- 
 cession of this stage, they actually adhere 
 together at every point, either directly, or 
 with the intervention of a mass of coagula- 
 ting lymph. In the first event, at the end 
 of the second stage, the cornea forms a co- 
 nical protuberance, and a total staphyloma 
 arises ; (se> Staphyloma ;) but in the second, 
 the cornea is said not to undergo this change. 
 On the contrary, it becomes rather flat, and 
 on account of the layer of organized lymph, 
 which fill- up the space between the cornea 
 and iris, little of the Idler membrane can 
 be discerned, and what can be seen, appears 
 to have its organization entirely subverted. 
 When idiopathic iritis in its first stage ex- 
 tends its effects directly over the whol* eye- 
 ball, the eye becomes nearly or quite de- 
 stroyed in the same manner as in cases of vi- 
 olent acute ophthalmy. 
 
 The causes which give rise to idiopathic 
 iritis, mut always be such as operate direct- 
 ly upon the iris; and, hence, the disorder 
 is usually a consequence of injuries and 
 wounds of the eye, produced by accident, 
 or in operations. And, says Beer, although 
 rheumatic inflammation of the eye, when 
 neglected, or w rongly treated, may at length 
 aff ct the iris, and adjacent textures, yet 
 such an iritis is but a secondary effect, deri- 
 ved from the pre-existing rheumatic oph- 
 thalmy. All injure- in which' the weapon, 
 or in-trumenl, has more or les- pre-sed 
 against, pushed, irritated, < r v iolently brui ed, 
 or torn, the iris itsel,. and ail largish wounds 
 of the cornea, are to tie accoun t'd the prin- 
 cipal exciting causes ot idiopathic iritis. 
 Hem e, extra ion ol the cataract is not un- 
 Irequentlv followed by this i flammation, 
 when t hr flap of the cornea i- kept too long 
 opened, and the iris is hurt with any blunt 
 instrument ; when the incision in the cor- 
 nea is too small, and a hard cataract pushes 
 the iris between I tie lips of the wound, and 
 is slow ly pressed out of the eye ; when many 
 pieces of the cataract break off, and it is ne- 
 cessary repeatedly to introduce Dniel’s 
 scoop for their removal ; or when, notwith- 
 standing the operator proceed with the ut- 
 most delicacy, the patient is excessively 
 timid, and unmanageable, or particularly ir- 
 ritable ar.d prone to inflammation. This 
 torm of iritis is also produced by couching, 
 reclmation through the sclerotica kerato- 
 nyxis, and operations for artificial pupil. Nor, 
 as Beer observes, is it at all surprising, that 
 iritis should follow these last operations, as 
 the surgeon has often to meddle w ith an irid 
 that has been already violently inflamed. 
 
 Prognosis in the first stage. Serious as the 
 disorder always is; important as the textures 
 are, in which the inflammation is most se- 
 vere ; and quickly as vision may be for ever 
 annihilated by it; yet, says Beer, the prog- 
 
OPHTHALMY. 
 
 mo 
 
 nosls, in tho first stage, is very favourable, 
 when the true nature of the caso is at once 
 understood, and treated as it ought to be. 
 The prognosis is the most favourable when 
 the inflammation is not extensive ; but it 
 must be very reserved, when the inflamma- 
 tion extends either deeply backward, for- 
 ward, or in both directions. Beer remarks, 
 that, when iritis is purely idiopathic, ami ju- 
 diciously treated in its first stage, it is mere- 
 dible with what rapidity its effects re ede. 
 When it is produced immediately by an in- 
 jury of the iris us if, and some part of this 
 membrane i torn, the risk of the inflamma- 
 tion is not the only thing for consideration ; 
 for the chance of the function oi the iris be- 
 ing permanently impaired by the injury 
 must also be taken into the accoun*. And, 
 says Beer, as in these severe injuries of the 
 eyeball, it is impossible to foretell what may- 
 be the result of the traumatic inflammation, 
 it is a good maxim always either to deter 
 making any prognosis, or to deliv r only a 
 doubtful one. When idiopathic iritis has al- 
 ready changed either into a complete inter- 
 nal ophthalmy, m* into a violent inflamma- 
 tion of the whole eyeball, no incautious pro- 
 mises shonid be made about the recovery of 
 the eyesight, or even about preserving the 
 shape of tbeeje. {Beer.) 
 
 Prognosis in the second stage. Though, 
 says Beer, this is much les- favourable than 
 in the first stage, yet il proper measures be 
 riot deferred, <> perfect recovery of she eye 
 may often be effected. Here a great deal 
 depends upon the state of the layer of lymph 
 effused in the po-terior chamber, and of sup- 
 puration. If it be plain to the naked eye, 
 that no coagulating lymph lies in that cham- 
 ber behind the contracted pupil, but slight 
 grayish filaments are discernible with a mag- 
 nifying glass, projecting only a little way 
 from behind the pupillary edge of the iris; 
 if the colour merely of the lesser circle of 
 the iris be changed, while no little cyst of 
 matter is yet formed on the latter membrane, 
 a d the sight is lessened only in a small de- 
 gree, being somewhat cloudy ; the com- 
 plaint may be so completely cured by pro- 
 per means, that not a vestige of it wiil re- 
 main. How ever, for some time after theter- 
 jni atiou of the second stage, the motions of 
 the iris will be more sluggish th in natural, 
 though the pupil effectually adapt itsell to 
 the variations of light. On he other hand, 
 when a considers le, though fine, web-like 
 membrane can be plainly seen behind the 
 pupil ; when the colour of the larger circle 
 of tile iris is somewhat altered ; and the 
 power of vision is seriously lessened; though, 
 by effectual treatment, the sight may be re- 
 established sufficiently to enable the patient 
 to read and write; yet, says Ben*, it will 
 for ever continue weak; the pupillary edge 
 of the iris will never regain its perfect free- 
 dom, but constantly remain more or less an- 
 gular ; and the pupil never assume again the 
 clear shining blackness, which in persons 
 not of gr at age it naturally exhibits. Still 
 moie remarkable are the sequelae of idiopa- 
 thic iritis, when a small cyst of matter has 
 
 been formed on the iris, and discharged- ihr 
 contents into the anterior chamber ; for, in 
 this case, under the best circumstances, the 
 former colour of the iris never entirely re- 
 turns. According to Beer, when at the first 
 visit of the surgeon, vision is quite interrupt- 
 ed by the effusion of lymph in the posterior 
 cha thee so that the patient can no longer 
 perceive any object with the affected eye, 
 though capable of distinguishing the light, 
 and th>* outlines of <orne things ; when the 
 pupil is at the same time very contracted, 
 and the cm our of the greater circle of the 
 iris entirely changed ; there is no hope of 
 recovery of the sight at first, though some 
 chance of benefit may he subsequently af- 
 forded by the formation of an artificial pu- 
 pil. If, says Beer, in such a case, matter lias 
 been - ffused from several lit* le suppurating 
 points of the iris, so copiously into the an- 
 terior chamber, that nearly all this cavity, or 
 at least the half of it, tS filled up, though after 
 absorption some power of distinguishing 
 light may return, little or no hope can be en- 
 tertained of any effectual benefit from a fu- 
 ture operation for an artificial pupil. When, 
 at I he termination of the first stage, the cor- 
 nea is so severely inflamed, that the iris al- 
 most touches this membrane in its outruns- 
 parent thickened state, all prospect of saving 
 th eyesight is over, and it will bi* fortunate 
 if the natural shape of the eye can now be 
 preserved, and the formation of a staphylo- 
 ma of the cornea prevented. When the 
 layer of lymph between the cornea and the 
 iris is extensive, and considerable blood-ves 
 sels can be seen proceeding into it from the 
 iris, Beer says, nothing will succeed in re- 
 establishing vision. And he observes, that, 
 \ hen an idiopathic iritis, at the close of its 
 first stage, has changed into a true internal 
 ophthalmy, and the pupil is already quite 
 blocked ip, so that even the light cannot be 
 distinguished, tbe recovery of sight is quite 
 impossible, and the surgeon must make every 
 exertion to prevent the shape of ihe organ 
 from being destroyed. In this disease, says 
 Beer, a relapse, even w hen the inflammation 
 has not been very considerable in the first 
 attack, almost constantly nds in partial or 
 complete blindness ol the affecied eye, as 
 the progress of the tvise is so rapid, that there 
 is not time enough to render effectual assist- 
 ance. 
 
 Beer directs idiopathic iritis to be treated 
 in its first stage like a case of pure internal 
 ophthalmy, (he practice being somewhat mo- 
 dified, however, according to the direction 
 and degree in which the inflammation has 
 spread, when the surgeon is first consulted. 
 When the inflammation continues a good 
 while limited, or spreads but very gradually 
 to the outer texture of the eyeball, general 
 and local antiphlogistic remedies are to be 
 employed with moderation ; ut if it imme- 
 diately extend itself to the innermost parts 
 of the eye, or both inwards and outwards to- 
 gether, and threatens to end in an universal 
 inflammation of the eyeball, antiphlogistic 
 treatment must be most rigorously adopted. 
 (Beer.) This author then notices the unfnr* 
 
OTHTHALMY . 
 
 tunafe state of the case, when, towards the 
 end of (be first stage, the eyesight happens to 
 be entirely destroyed, the iris is close to the 
 cornea, and there is danger of a staphyloma. 
 In this desperate state of things, his appre- 
 hensions of this Iasi disease lead him to sug- 
 gest a plan, (the propriety of which 1 re- 
 gurd with much suspicion ,) which is nothing 
 less than actually trying 10 increase the in- 
 flammation, by stimulating the eye several 
 times a day with laudanum, sulphuric aether, 
 &, c. with the view ol doing what ? Why, of 
 obliterating the sources of the aqueous hu- 
 mour ! the continuance of the secretion of 
 which is set down as one of the essentials to 
 the production ot staph) loma. (B. 1 . p. 447.) 
 
 The treatment of idiopathic iritis in its 
 second stage, as recommended by Beer, is 
 on the whole, both generally and locally, 
 like what has been advised for the same 
 stage of pure internal ophtbalmy ; but here, 
 he says, it is necessary to pay particular at- 
 tention to the direction, in which the in- 
 flammation extends itself in the fi st stage, 
 so that the treatment may be regulated with 
 greater precision. Beer also advises great 
 attention to be paid to the effusion of lymph 
 in the posterior chamber ; as towards the 
 end of the second stage much may fie done 
 which would afterward be too late. Thus, 
 when the surgeon perceives towards the 
 end of the second stage, that the layer of 
 lympu in the posterior chamber does not 
 completely prevent, though it seriously di- 
 minisues vision, and that it is likely to re- 
 main in the. same state, after the termination 
 of the second stage, Beer recommends to- 
 pical applications to the eye, and if these 
 prove unavailing, internal alterative medi- 
 cines, and even mercury, which, he says, 
 when the treatment is judiciously conduct- 
 ed, ought not to be omitted. Here, also, he 
 observes, another deviation must be made 
 from the usual practice in the second stage 
 of ophtbalmy: calomel joined with opium, 
 is to be exhibited w 7 ith calamus aromaticus, 
 bark, &c. Externally, Beer speaks highly 
 of the benefit of a collyrium, containing 
 the oxymuriate of mercury, without any 
 mucilage, but with a considerable addition 
 of the vino s tincture of opium. When 
 these remedies cease to be efficacious, or 
 the eye ca .not bear fluid applications, as is 
 sometimes tiie case, Beer recommends a bit 
 of the following salve to be smeared once 
 a day, between the edges of the eyelids, 
 and allowed slowly to melt there, and be- 
 come diffused over the eye : Butyri re- 
 
 ceutis iusulsi 3ij Hydrargyri nitrico-oxydi 
 rubri gr. vj. Extract opii gr. viij. JVl Beer 
 also states that rubbing a little mercurial 
 ointment, with w hich some opium is blend- 
 ed, once a day into the eyebrow, w'ili great- 
 ly promote the removal of the lymph effu- 
 sed in the posterior chamber. (B. 1, p. 
 450.) 
 
 Excellent as Beer’s description of idiopa- 
 thic iritis certainly is, there are some im- 
 perfections in his method of treatment. 1st, 
 ?t docs not appear to me, that he insists suf- 
 ficiently upon the necessity of taking away 
 
 341 
 
 a very large quantity of blood at the com- 
 mencement ot the case, and of repeating 
 the general and topical bleeding, until the 
 circulation is duly lowered, and the violence 
 of the inflammation checked. 2dly,'l hough 
 his recommendation of rigorous antiphlo- 
 gistic treatment implies the approbation 
 both of bleeding and cathartics, he says 
 nothing of ttie use of moderate doses of 
 tariarized antimony, in weakening the 
 pulse ; a practice highly praised by the late 
 Mr. Saunders. (On some Practical Points 
 relating to Diseases of the Eye, p. 26, 8 vo. 
 Land. 181 1.) 3dly, If mercury has the pow- 
 er of arresting acute inflammation of the iris, 
 “ both prior to, and after, the effusion of ad- 
 hesive matter,” and of rapidly removing, “by 
 an excitement of the absorbing system, 
 peculiar to itself, the newly-effused mat- 
 ter, ( Travers , Synopsis , <^c. p. 2b 1,) then 
 Beer must delay too long the employment 
 of this powerful medicine, since he does 
 not commence its use until the close of the 
 second stage, when he has found, that the 
 absorption of the effused lymph cannot be 
 effected by other means. 4thly, Beer en- 
 tirely overlooks the important utility of bel- 
 ladonna and byosciamus in producing a 
 dilatation of the pupil, whereby adhesions 
 of the iris to the capsule oi the lens, or to the 
 cornea itself, may frequently be prevented, 
 or their ill effects considerably lessened. 
 Belladonna, (says Mr. Saunders,) “ if 
 properly applied to the eye, during the ad- 
 hesive process of inflammation, will cause 
 the inner margin of the iris to expand, and 
 recede from the axis of the pupil, and will 
 thus overcome the restraint arising trom the 
 agglutination of lymph, by elongating the 
 organized bands, which connect the iris and 
 capsule, if they have not been of long 
 duration. Thus, the adhesions are drawn 
 out t., a degree of tenuity, and consequently 
 transparency, and a considerable quantity 
 of light is admitted. If the effect of the 
 inflammation has been slight, the adhesions 
 will be trivial, and tne pupil only slightly 
 irregular. The iris will retain a certain 
 power of action, and vision will be very 
 little injured. In general, the pupil is 
 misshapen, and the iris perfectly fixed ; but, 
 if the aperture be of sufficient size, and the 
 capsule not rendered too opaque, the patient 
 will e.ijoy a very useful degree of sight.” 
 (Saunders, p. 32.) Respecting belladonna, 
 it is observed by Langenbeck, that, as all 
 applications directly to the inflamed eye 
 itself are frequently hurtful, and render it 
 still more painful and irritable, it is a good 
 plan to let the extract of belladonna be 
 smeared upon the eyebrow, instead of 
 putting a solution of it immediately in 
 contact w ith the conjunctiva. (JVeue Bibl. 
 B. 2, p. 236.) The same author expresses 
 his attachment to Beer’s method of rubbing 
 mercurial ointment with opium into the 
 eyebrows ; and, after dwelling, with due 
 force, on the necessity of copious and re- 
 peated bleedings, leeches, evacuations, &c. 
 he cautious practitioners not to be led into 
 the supposition, that the efficacy of beHa- 
 
342 
 
 ©PHTHALMY. 
 
 donna will supersede the occasion for taking 
 away blood. He even dec lares, that, during 
 the first vehemence of the inflammation, 
 the application is quite inefficient, and that 
 it frequently will not succeed in producing 
 a dilatation of the pupil, before bleeding 
 has been practised. “ If, (says Langenbeck,) 
 bleeding is to be useful in iritis, it must be 
 copious, and often repeated.” 
 
 Specific Cases of Iritis. The foregoing ob 
 servations refer to idiopathic iritis, or in- 
 flammation of the iris uncomplicated with 
 any specific disease. But there is an iritis, 
 which “ appears in company with rheuma- 
 tism of the chronic form ; sometimes with 
 gout ; with the constitutional signs of the 
 lues venerea ; and during, or following, the 
 action of mercury upon the system.” (Tra- 
 vers, Surgical Essays, Part 1, J>- 59.) 
 
 Mr. Hunter entertained doubts, whether 
 any inflammations of the eyes are syphilitic, 
 and he appears to found his opinion upon 
 two circumstances ; one is, that, if such 
 cases be venereal, the disease is very diffe- 
 rent from what it is when it attacks other 
 parts, and is attended with more pain than 
 venereal inflammation, arising from an af- 
 fection of the constitution : the second is, 
 that he never sa these cases, attended with 
 such ulceration, as occurs when the com- 
 plaint invades the mouth, throat, and tongue. 
 (Hunter on the Venereal Disease, p. 324.) 
 On the other band, the generality of modern 
 surgeons believe in the reality of venereal 
 ophtiialmy, though their accounts of the 
 symptoms and appearances of the com- 
 plaint are in some respects discordant. 
 Scarpa says, the venereal ophthalmy is pe- 
 culiar in not discovering manifest signs of 
 inflammation, stealing on clandestinely, 
 without much uneasiness. It afterward re- 
 laxes the vessels of the conjunctiva and 
 lining of the palpebrse, and changes the se- 
 cretion of Meibomius’s glands. In time it 
 causes ulceration of the margins of the eye- 
 lids ; the ciliae fall off, and the cornea grows 
 opaque. In the worst stage it excites itch- 
 ing in the eyes, which is exasperated at 
 night, and abates in violence tow ards morn- 
 ing, as do almost all the effects of syphilis. 
 It never attains the state of chemosis. 
 With the exception of the venereal oph- 
 thalmy, in the form of iritis, 1 cannot dis 
 cover, that any thing very certain has yet 
 been made out. By this observation, how- 
 ever, it is not meant to assert, that cases, 
 corresponding to Scarpa’s description, do 
 not present themselves, and may not be 
 relieved by his method of treatment ; but, 
 that their venereal character is not fairly 
 proved. In examples, like those described 
 by Scarpa thedecoct.sarsap.theqxymuriaie 
 of mercury ; mezereon ; guaiacum ; and 
 even mercurial frictions, may be employed, 
 with leeches and blisters. Scarpa particu- 
 larly recommends a collyrium, made with 
 the oxy muriate of mercury. When the 
 eyelids are ulcerated, the unguenturn hv- 
 drargyri nitratri, weakened at first with twice 
 or thrice its quantity of the unguenturn ce- 
 taepurn, is the best topical application. 
 
 The iris is now supposed to be more lia- 
 ble than any other part ot the eye, to vene- 
 real inflammation. ( Wardrop's Essays era 
 the Morbid Anat. of the Eye, Vol 2, p. 36.) 
 The case is mentioned by Mr. Sounders, 
 who recommends the vigorous exhibition of 
 mercury, and the use of belladonna. Us 
 symptoms and treatment, however, have 
 been more particularly detailed by Beer. 
 (Lehre von den Augenkr B. 1, p. 553.) As 
 this case, and some other specific forms of 
 iritis, are described in the first vol. of the 
 last edition of the First Lines of Surgery, 
 1 need here only refer the reader to that 
 volume, and to a few works containing ad- 
 ditional information on iritis in general; aat 
 Sounder's Treatise on some Practical Points, 
 relating to Diseases of the Eye p. 21,8t'o. 
 1811 ; and particularly the latter editions, in 
 which the utility of mercurials is noticed. 
 Beer's Lehre von den Augenkr. B. 1, 8ro, 
 Wien. 1813. 
 
 In the article Hypopium , I have referred 
 to an early case, in which the quick exhibi- 
 tion of mercury and its good effects were 
 exemplified in Germany. But whatever 
 claims the continental surgeons may have 
 respecting the first administration ot mer- 
 cury in iritis, 1 believe it a justice due to Dr. 
 Farre and Mr. Travers to state, that these 
 gentlemen have undoubtedly given notonly 
 the best practical directions on the subject, 
 but laid the greatest s ress upon the neces- 
 sity of the practice, establishing the efficacy 
 of mercury, as a means as well of resisting 
 the effusion of lymph in the eye, as of exci- 
 ting the absorption of it, after it has been 
 effused. (See Travers, in Surgical Essays, 
 Part l.) Consult also J. l etch , A Practical 
 Treatise on the Diseases of the t.ye. p. 88, fyc. 
 S vo. Lond. 1820. Weller’s Manual of the 
 Diseases of the Human Eye, Trans by Mon- 
 teath, 8 vo. Glasgow, 1821. J. War drop j 
 Morbid Anatomy o the Eye, Vol. 2, chap 
 20, 8 vo. Lond. 1818. H. B. Schindler, de 
 Jrilide Chronica, Vralislacice, lb 19. J. A. 
 Schmidt liber Nachstaar und Iritis nach Staar - 
 Opera ionen, 4 to. Wien. 1801 ; a work of 
 high repute. Carmichael in Obs. on the Spe- 
 cific Distinctions oj Venereal Diseases, p. 31* 
 Quarterly Journ. of Foreign Medicine , JYov. 
 1818. 
 
 Rheumatic Inflammation of the Eye. Ac- 
 cording to Mr. VVardrop, the albuginea ac- 
 quires a brick-red tinge, or an admixture of 
 yellow w ith crimson red, which colour, be 
 supposes, is probably caused by the serous 
 part of the blood being tinged with bile* 
 “ an effect, likely to take place from the 
 marked derangement of the biliary organs, 
 which usually acco • panics this disease.” 
 Contrary to the statement of Beer, who de- 
 scribes the blood vessels as being in clusters, 
 Mr. Wardrop observes, that they are gene- 
 rally equally numerous over the whole 
 white of the eye, passing torwards in near- 
 ly straight lines from the posterior part ot 
 the eyeball, and advancing close to the cor- 
 nea ; but neither passing over it, nor leaving 
 the pale circle around it, which is so striking 
 when cither the choroid coat, or the iris k 
 
OPHTHALMY. 
 
 
 unilaraed. If the v essels be closely examin- 
 ed, the general redness will be found produ- 
 ced more by numerous small ram ideations, 
 than a few large trunks. There is frequent- 
 ly a little swelling of the conjunctiva, 
 which sometimes forms a slightly elevated 
 ring round the cornea. In mild cases, little 
 change takes place in the anterior chamber 
 in the early stage ; but, as the disease ad- 
 vances, the cornea becomes dull and turbid. 
 Upon close examination, one or more of 
 the layers of the conjunctiva on the cornea 
 will generally be found to be abraded espe- 
 cially towards its circumference. At the 
 commencement of the disease, there is of- 
 ten a disagreeable feeling of dryness of the 
 eye ; but sooner or later, a very copious 
 secretion of tears takes place. The eyelids 
 are observed to be very little affected. At 
 first, the chief seat of pain is generally in 
 the head, though sometimes in the eyeball 
 itself. Mr. Wardrop describes the pain as 
 usually most severe in the temple of the af- 
 fected side, but, he says, that it is often seat- 
 ed in the brow, the cheek-bone, the teeth, 
 or the lower jaw. “ Sometimes the pam is 
 precisely confined to one half of the head, 
 and sometimes there is a severe pain in the 
 cavity of the nose, or in the ear. The pains 
 are more of a dull agonizing kind, than 
 acute, and though unceasing, they vary 
 much in degree, coming on at times in very 
 severe paroxysms, and with great violence, 
 when the head is bent downwards. Some- 
 times the pain is excited by merely touch- 
 ing the scalp, and the patient is unable to 
 rest his head on the affected side, or 
 even lean it on a pillow. In most cases, 
 the pain is said to be remittent, the 
 paroxysm coming on in the evening, 
 continuing during the night, being most 
 severe about midnight, and abating towards 
 morning. 
 
 In the eyeball, says Mr Wardrop, the pa- 
 tient generally complains more of a sense of 
 fulness and distention, than of pain ; and, 
 though there is a great degree of external 
 redness, the eye does not seem to suffer from ex- 
 posure to light ; a point, on which Professor 
 Beer delivers a directly opposite statement, 
 at least, in relation to the first stage of the 
 disease. However, these authors both agree 
 in considering the sclprotica, as generally the 
 chief seat of rheumatic inflammation ; but 
 Beer sets down the iris as likewise a subject 
 to be attacked. He admits also, that in the 
 second stage, the aversion to light under- 
 goes a considerable diminution According 
 to Mr. Wardrop, rheumatic ophthalmy is 
 always accompanied with more or less 
 symntomatic fever, severe paroxysms of 
 which take place toward evening, and the 
 functions of the prim® vise are much de- 
 ranged, “ the appetite being impaired, and 
 the evacuation always changed in quality.” 
 In severe cases, the pain in the head soon 
 becomes agonizing, the r^d mss of the eye- 
 ball increases, the whole white of the eye is 
 crowded with blood vessels, and the con- 
 junctiva swelled. At length ulceration com- 
 mence* in the cornea, through which the 
 
 aqueous humour is discharged, and the eye- 
 ball collapses, when all pain ceases ; or 
 abscesses may form within the posterior 
 chamber, and burst through the sclerotic 
 coat. ( Wardrop , in Med. Chir. Trans Vol. 
 10.) Beer describes small watery vesicles 
 as forming on the cornea, or white of the 
 eye, and changing during severe pains into 
 small ulcers, which occasion an appearance, 
 as if a small piece were torn out of the sur- 
 face of the cornea. He adds, that they 
 seldom leave scars behind ; but generally 
 little pits, which are soon filled up in healthy 
 subjects. (See Weller on Diseases of the Eye, 
 Vol. 2, p. 217.) 
 
 The causes of rheumatic ophthalmy. enu- 
 merated by writers, are change of weather, 
 vari ation of temperature, exposure to damp, 
 a cold current of air directly striking the 
 eye, and a constitution disposed to rheuma- 
 tism. Mr. Wardrop states, that both sexes 
 are equally subject to the disease ; but that 
 he has observed it most frequently in adults, 
 and persons of rather advanced age. Only 
 one eye is usually affected ; and when the 
 second is attacked, the disease is almost 
 always less severe in it, than that which is 
 first inflamed. 
 
 According to Mr. Wardrop, rheumatic 
 ophthalmy resembles syphilitic more than 
 any other kind of inflammation of the eye. 
 But, he notices, that, in rheumatic ophthalmy , 
 th° proper vessels of the sclerotic coat are 
 enlarged, which is the cause of the redness 
 being generally diffused over the whole 
 albuginea, whereas in syphilitic inflammation, 
 it is the anterior ciliary arteries , passing along 
 the sclerotica on thnr way to the iris , which 
 are ch efiy affected ; and hence the pale ring, 
 which is always observed between the cor- 
 nea and the enlarged vessels. Mr. Wardrop 
 further explains, that though these diseases 
 resemble each other in the pains round the 
 orbit, and their evening exacerbation, pa- 
 tients , with syphilitic ophthalmy. aluays have 
 the constitutional symptoms of syphilis. 
 
 When the disease has made much progress, 
 and the symptoms have not yielded to other 
 remedies, Mr. Wardrop recommends the 
 evacuation of the aqueous humour, as a prac- 
 tice, from which the most beneficial effects 
 may be expected. After the operation, fo- 
 mentations are the only necessary applica- 
 tions ; but, if the eye continue long irritable, 
 the vinous tincture of opium is to be used. 
 
 Mr. Wardrop enjoins attention to the state 
 of the biliary organs in every stage of the 
 disease, and speaks highly of the sudden relief 
 sometimes afforded by an emetic, care being 
 taken to empty the bowels afterward with 
 calomel and rhubarb, or other purgatives. 
 If t ie functions of the skin were suddenly 
 interrupted by a -hill just before the attack, 
 this author prescribes a couple of grains of 
 aniimoniai powder, alone, or combined with 
 opium, to be taken every four or six hours. 
 Little advantage, ne says, is derived from 
 local bleeding, and where venesection may 
 become necessary, on account of the com- 
 plaint resisting other means, it to be prr.c 
 ti c ed with moderation 
 
344 
 
 OPHTHALM**. 
 
 In the early stage, Mr. Wardrop has found, 
 that the pain in the eye and eyebrow are 
 sometimes much alleviated by a fomentation 
 with the decoction of poppy-heads. He also 
 praises blisters to the nape of the neck, or 
 behind the ear; but, disapproves of their 
 being put near the eye itself. The vinous 
 tincture of opium, he says, is the only local 
 application which he has ever seen deci- 
 dedly beneficial ; but, its use is to be deferred, 
 till a late stage of the inflammation, when 
 all febrile symptoms have been subdued. 
 “ After the primae viae have been well 
 evacuated, the tongue may still remain very 
 white, and the pulse quicker than natural.” 
 In this state, small doses of bark, either alone, 
 or with the mineral acids, will be most 
 serviceable. ( Wardrop in Med. Chir. Trans. 
 Vol. 10.) The outlines of Beer’s practice may 
 be given very briefly : in the first stage, he 
 applies a leech to the inner canthus, and 
 covers the eye with a cold poultice, with a 
 small proportion of vinegar in the water, 
 with which it is made. Diaphoretics are also 
 prescribed. In the second stage, guaiacum, 
 camphor, arnica, antimonials, blisters to the 
 neck, or behind the ears, frictions with 
 opium over the eyebrows, and covering the 
 eyes with bags of aromatic herbs and cam- 
 phor, are the means of the relief. When 
 abrasions, or ulcerations exist on the con- 
 junctiva, sclerotica, or cornea, a collyrium 
 of the lapis divinus. with a large addition of 
 the vinous tincture of opium, is commended ; 
 or if the ulcers are large, and on the cornea 
 itself, they may be touched with the latter 
 tincture by means of a camel-hair pencil. 
 After each use of the collyrium, Beer covers 
 the eye again with the bags of aromatic herbs 
 and c .mphor. (See Weller on Diseases of the 
 Eye, Vol. 2, p. 218.) Respecting the last 
 application, I have already expressed my 
 belief, that it is one which is not likely to 
 obtain credit among English surgeons. 
 
 Scrof l ous Ophthalmy. According to Mr. 
 Travers, the inflammation of the conjunctiva, 
 termed strumous, when it has not proceeded 
 to a eba* ge of texture, is not marked by any 
 prominent local character.” The vascularity 
 is inconsiderable This inflammation some- 
 times accompanies pustule of the sclerotic 
 conjunctiva, in which case, the vascularity 
 is diffused, instead of being partial, as in 
 pure puslular inflammation, and the intole- 
 rance of light, characteristic of ike strumous 
 inflammation , is present in a greater or lesser 
 degree. It accompanies also (he morbid 
 secretion of the lids, when the eyeball 
 becomes affected by the acuteness and dura- 
 tion of that disease, and the pustule on the 
 cornea, especially the variolous pustule. In 
 its simplest form, it is almost peculiar to 
 voting children, stationary, marked by a 
 very slight redness of the sclerotic conjunc- 
 tiva, and the greatest possible degree of 
 intolerance (of light ”) The same author 
 attributes the disease to n morbid sympathy 
 of the retirm with the secreting surfaces of 
 he primae vice and skin. The following is 
 *he treatment proposed by Mr. Travers for 
 each form of scrofulous ophthalmy ■ 
 
 1. Strumous inflammation, without chaugt 
 of texture, vascularity more or less, intole- 
 rance (of light) excessive. Calomel and opium, 
 at night ; emetic tartar to continued nausea , 
 gentie alvine evacuants ; diaphoretic drinks ; 
 large open blister on the nape of the neck ; 
 leeches ; tppid bath ; tepid or cold water 
 washes, as must agreeable ; vapour of opium ; 
 large bonnet shade ; no bandages ; spacious 
 airy apartments ; and light bed-clothing. 
 
 2. With recent diffused opacity of the corneal 
 conjunctiva , and vessels raised upon and over- 
 shooting the corneal margin. Calomel and 
 opium to slight ptyalism ; purgatives on 
 alternate days ; leeches; blisters alternated 
 behind the ears and on the nape of the neck 
 and temples. As the acute stage passes off, 
 repeated circular sections of the vessels on 
 the sclerotica, near the margin of the cornea. 
 
 3. With herpetic ulcers of the corned. The 
 same ; blisters on the temples ; as the in- 
 flammation yields, solut. argent, nitrat.; vin. 
 opii ; solut. cupr. sulph. ; dilute zinc lotion. 
 
 4. With pustules. If partial, weak zinc, 
 or alum lotion ; ung. hydrarg nitrat. ; occa- 
 sional brisk purgatives ; infusion of roses 
 with additional acids ; tonic bitters ; colum- 
 ba ; gentian, he. blisters behind the ears, 
 repeated if necessarv ; if the vascularity is 
 diffused by the multiplication of pustules, 
 or the duration of inflammation, with irrita- 
 bility to light, treatment as in strumous in- 
 flammation without breach. Ung. sub-acet. 
 plumbi. 
 
 5. With inflammation of the follicles and 
 puriform discharge. Active measures at first, 
 but not long continued. Blisters; when be- 
 coming chronic, with thickened lids, scarifi- 
 cations ; zinc, alum, or copper wash, dilute ; 
 ung. hydr. nitrat.; hydr. nitr. oxid.; sub-ncet. 
 cupri ; tonics and sedatives ; if obstinate, 
 issue or seton. 
 
 6. Convalescent state. Infusion of roses ; cas- 
 carilla ; columba ; decoction of bark . with 
 dilute sulphuric, or nitric acid : steel, rhu- 
 barb, and soda ; or magnesia, as aperients ; 
 tonic collyria and gently stimulant oint- 
 ments; nutritive diet ; country air ; shower, 
 or sea-balh, in the warm months. (Travers's 
 Synopsis, fyc. p. 92 — 260, fyc. 
 
 When I look at the discordant accounts 
 of what are called scrofulous affections of 
 the eye, and the difference of practice laid 
 down by different writers I leave the subject 
 with an impression, that the terms scrofu- 
 lous and strumous are here employed as much 
 at random as in any other cases, which ran 
 be specified. Indeed the attempt to recon- 
 cile the various statements and descriptions 
 of scrofulous ophthalmy, would puzzle the 
 most able man in the profession : and it is 
 with this belief, that I avoid contrasting the 
 sentiments of Beer, Weller, Lloyd, and 
 other modern writers with those already de- 
 livered. (See particularly Beer's Lehre vou 
 den Augenkr. B. 1, p. 588- fyc.; Weller's 
 Manual of the Diseases of the Eye , Vol. 
 2, p. 265, <^c. ; and Lloyd on Scrofula , p. 
 312, <^c.) 
 
 The following observations explain the 
 
 Practice of Scarn?. and the late Mr. Wan* 
 
OPHTHALMY. 
 
 Sip 
 
 No specific being known for scrofula, 
 the treatment, in this instance, rather con- 
 sists in preventing the aggravation, than in 
 attempting the radical cure of the complaint. 
 Every thing debilitating is hurtful, as all 
 evacuations ; indigestible food; intense study ; 
 a sedentary life . damp marshy habitations ; 
 uncleanliness ; frequent transitions from heat 
 to cold. On the other hand, observing to 
 regulate the action of the bowels with the 
 mildest laxatives ; and the administration of 
 bark, either alone or conjoined with the 
 tinct. guaiaciammoniata,do good. Alterative 
 medicines, and especially aethiops mineralis, 
 from gr. ss. to gr. xx. in the day, taken for a 
 few weeks uninterruptedly ; liquor calcis, in 
 broth or gruel, at first, in the dose of Jiij. 
 at breakfast, and atterward the same quan- 
 tity, twice daily for a few months ; together 
 with the uniform observance of a good regi- 
 men ; may tend much to abbreviate the du- 
 ration of this obstinate species of the dis- 
 ease. (Scarpa.) 
 
 Mr. Ware found, that the addition of xx to 
 xxx gr. of the potassai sulphas to each dose 
 of bark, suffices to keep the bowels in a re- 
 gular state, when there is a tendency to cos- 
 tiveness. In some cases, in which there 
 was little appearance of inflammation, this 
 gentleman found the eyelids so relaxed, and 
 the eyes so irritable, that children would not 
 open their eyes, even in the darkest room. 
 In some of these relaxed cases, very benefi- 
 cial effects were produced by administering 
 internally small doses of opium, night and 
 morning, to abate the irritability. Sea-bath- 
 ing is always serviceable in scrofulous oph- 
 thalmy, and, probably the mere residence on 
 the seacoast, and the respiration of the sea- 
 air, may bring about some of those advan- 
 tages, which have been exclusively, attri- 
 buted to bathing. Friction of the body with 
 a fresh brush or flannel, should be employed 
 morning and evening. 
 
 With regard to topical applications, those 
 of a soft relaxing kind prove injurious, as 
 also retirement in dark situations. Slightly 
 astringent collyria ; the ung. tutiag, and the 
 ung. hyd. nitrat. are proper when there are 
 excoriations upon the eyelids, and when, 
 from their occasional adhesion to each other, 
 there is reason to suspect, that the sebaceous 
 gffinds secrete an acrimonious fluid. Mr. 
 Ware also found that one drop of the thebaic 
 tincture, dropped into the eye, once or twice 
 in the course of the day, contributed greatly, 
 both to abate the irritability and to increase 
 the strength of the relaxed vessels. (On 
 Scrofulous Ophthalmy p. 26.) The same 
 gentleman occasionally mixed old verjuice 
 with cold spring- water, at first, in the pro- 
 portion of one part of the former to six of 
 the latter, and sometimes increased the 
 quantity of verjuice, until its quantity equal 
 led that of the water. All coverings should 
 be removed from the eyes, except a shade 
 of green silk, and patients should be 
 gradually habituated to a stronger light. 
 Good air and exercise always tend to im- 
 prove scrofulous constitutions, and thus, 
 V'jj, u 44 
 
 indirectly, the disease under consideration. 
 Scrofula often disappears spontaneously, as 
 children approach the adult state, and, if 
 we only have it in our power to check its 
 progress in the early stage" of life, it seems 
 to wear itself out afterward, and whatever 
 local effects it may have produced, often 
 disappear 
 
 Chronic Ophthalmy. Unfavourable pecu- 
 liarities are met w'ith in practice, which 
 prevent the complete cure of the second 
 stage of acute ophthalmy, or that connected 
 with a weak vascular action in the part 
 affected ; whence the protracted disease 
 becomes purely chronic, and threatens the 
 slow destruction of the eye. 
 
 These peculiarities may be chiefly re- 
 ferred to three causes : 1. To an increased 
 irritability continuing in the eye after the 
 cessation of acute inflammation. 2. To 
 some other existing affection of the eye, or 
 neighbouring parts, of which the chronic 
 ophthalmy is only an effect. 3. To consti- 
 tutional disease. 
 
 1. That chronic ophthalmy may depend 
 upon a morbid irritability of the eye is 
 evinced, not only from its resisting topical 
 astringents and corroborants, to which the 
 disease from simple relaxation and weakness 
 yields, but from its being exasperated by 
 them, and even by cold water. The patient 
 complains of a sense of weight in the upper 
 eyelid, and restraint in opening it ; the con- 
 junctiva has a yellowish cast, and when 
 exposed to the damp cold air, or a brilliant 
 light, or wffien the patient studies by 
 candlelight, its vessels become injected 
 and turgid with blood. If, in combination 
 with such symptoms, the habit of body 
 be weak and irritable ; subject to spasms ; 
 hypochondriasis, &c. then, it is manifest, 
 that the chronic ophthalmy is connected 
 with a general impairment of the nervous 
 system. 
 
 2 Besides extraneous bodies, lodged be- 
 tween the palpebras and eyeball, the inver- 
 sion of the ciliae and hairs, growing from 
 the caruncula lachrymalis ; ulcers of the 
 cornea ; prolapsus of the iris ; herpetic 
 ulcerations of the margins of the eyelids ; 
 a morbid secretion from the Meibomian 
 glands ; a diseased enlargement of the cor- 
 nea, or of the whole globe of the eye, &c, 
 may occasion and maintain chronic ophthal- 
 my. — it is only my part here to mention such 
 remote causes ; for, the particular treatment 
 of them is described in other articles. (See 
 Cornea , Ulcers of; Iris, Prolapsus of ; Lippi - 
 tudo ; Staphyloma ; Hydrophlhalmy ; Tri- 
 chiasis, fyc.) 
 
 3. The cure of thp second stage of acute 
 ophthalmy may be retarded by the preva- 
 lence of scrofula in the system ; or by the 
 small-pox affecting the eyes. According to 
 Scarpa, chronic ophthalmy isalso sometimes 
 a consequence of lues venerea; but l know* 
 nothing certain on this subject, in addition 
 to what has been stated in the foregoing 
 columns. 
 
 When chronic ophthalmy depends upo'n 
 
OPHTHaLMY. 
 
 316 
 
 preternatural irritability, the internal exhi- 
 bition of bark with valerian is proper ; 
 animal food of easy digestion ; gelatinous 
 and farinaceous broths; wine in moderation ; 
 gentle exercise; living in salubrious and mild 
 situations ; are all severally productive of 
 benefit. Externally , the applications should 
 be of a sedative and corroborant kind ; such 
 as aromatic spirituous vapours (from the 
 spiritus ammon. comp.) applied to the eye 
 through a funnel, for half an hour, three or 
 four times a day ; and the eyelids and eye- 
 brows may also be rubbed with the linimen- 
 tutn camphors?. 
 
 Patients, both during the treatment and 
 after the cure, must refrain from straining 
 the eye, and, immediately the least uneasi- 
 ness is felt, must desist from exercising it. 
 When they write or read, it should con 
 stantly be in a steady, uniform light, and too 
 little, as well as too much exercise of the 
 organ, aggravates the disease. Having once 
 begun to wear spectacles, they should never 
 study orsurvey minute objects without them. 
 {Scarpa.) 
 
 Intermittent Ophthalmy. It is the charac- 
 ter of certain forms of ophthalmy, like the 
 rheumatic and venereal, to be liable to 
 periodical exacerbations ; but I am not 
 certain that there are any cases specifically 
 claiming the name of intermittent ophthalmy . 
 The late Mr. Ware, however, ha- noticed 
 some examples, which intermitted, or at 
 least, remitted at stated periods. In these, 
 he did not find bark so useful, as in scrofu- 
 lous ophthalmy; but he had seen the most 
 beneficial effects produced by the oxy mu- 
 riate of mercury, sometimes joined with the 
 compound decoction of sarsaparilla. (See 
 IVare on Intermittent Ophthalmy .) 
 
 Variolous Ophthalmy . As the small pox 
 inoculation has at present almost generally 
 been abandoned by the faculty in favour of 
 the vaccine disease, there seems less occasion 
 now for detailing circumstantially a very 
 obstinate species of ophthalmy, induced by 
 the former complaint. When the small-pox 
 eruption is very abundant in the face, it 
 causes a considerable swelling of this part 
 of the body ; the eyelids become tumefied, 
 the eyes redden, and there ensues a dis- 
 charge of a very thick adhesive matter, 
 which agglutinates the palpehra? together ; 
 so that if no steps be taken, the eyes will 
 continue closed for several days in succes- 
 sion. The matter, confined between the 
 eyelids and globe of the eye, being per- 
 haps of an irritating quality, and injurious 
 from the pressure it occasions on the sur- 
 rounding parts, seems capable of exciting 
 ulceration of the cornea, and even of irre- 
 mediably destroying vision. When the 
 pustules of the small-pox in other parts of 
 the body have suppurated, they cicatrize ; 
 but those, which happen within the margin 
 of the cartilage (if the eyelids, are prevented 
 from healing by the diseased secretion, 
 which is then made from the Meibomian 
 glands, and such ulcers result, as will some- 
 titpes last for several years, and even during 
 
 life, if unremedied by art. {St. Yves sur Us 
 Mai. des Yeux, p. 216, Edit. 12 mo.) After 
 the employment of the antiphlogistic treat- 
 ment. should the disease, when treated with 
 topical astringents and corroborants, yet 
 baffle the efforts of the surgeon, setons in 
 the nape of the neck, kept open for a long 
 while, prove one of the most useful reme- 
 dies. Scarpa has experienced much advan- 
 tage from giving every morning and evening, 
 to a child, ten years old, a pill, containing 
 one grain of calomel, one grain of thesulph. 
 aur. antun. and four grains of cicuta in 
 powder. It is obvious, that so potent an 
 alterative, if ever serviceable in this case, 
 will soon evince its efficacy ; nor would it 
 be justifiable to sport with the patient’s 
 constitution by continuing its use beyond a 
 certain period, unless sanctioned by evident 
 signs of its salutary effects on the disease of 
 the eyes. 
 
 When great irritability prevails, a mixture 
 of three drams of the vinum antimoniale, 
 and one dram of the tinctura thebaica, 
 given in doses of five or six drops, in any 
 convenient vehicle, and at the same time, 
 applying externally the vapours of the spiri- 
 tus amnion, comp, to the eye, constitute an 
 excellent plan of treatment. In othei cases, 
 saturnine collyria, with a little camphorated 
 spirit of wine, or white wine, in which a 
 little sugar is dissolved ; tinct. thebaica ; 
 Janin’s ointment. &c. avail most. This 
 treatment is also applicable to the chronic 
 ophthalmy from measles. - 
 
 When inveterate ulcers remain upon the 
 edges of the palpebral, the disease may then 
 be regarded as the psorophthalmy, described 
 by Mr. Ware, and will demand the same 
 method of cure. (See Psorophthalmy.) 
 
 Operation of discharging the aqueous hu- 
 mour. To this practice, some allusion has 
 been already made in the preceding co- 
 lumns ; and as the proposal is intended to 
 apply to several forms of inflammation of 
 the eye, 1 have not given any particular 
 account of it in treating of the various cases. 
 Mr. Wardrop remarked, that if the eye of a 
 sheep, or ox, be squeezed in the hand, the 
 whole cornea instantly becomes cloudy, and 
 whenever the pressure is removed, this mem- 
 brane regains its transparency. From this cu- 
 rious phenomenon in the dead eye, it was evi- 
 dent that, in the living body, the transparen- 
 cy of the cornea might vary according to the 
 degree of its distention ; and that, in cases 
 of opacity of the cornea, accompanied with 
 fulness of the eyeball, its transparency might 
 be restored by the evacuation of the aque- 
 ous humour. The cornea is little sensible, 
 and, as every body knows, its wounds are 
 free from danger. Mr. Wardrop soon met 
 with a case, favourable for making the 
 experiment; the cornea was milky and 
 opaque, and the eyeball distended and pro- 
 minent, attended with acute inflammatory 
 symptoms. The aqueous humour was dis- 
 charged by a small incision, and the operation 
 produced not only a removal of the cloudiness 
 of the cornea, but an abatement of the 
 
OPHTHALMY. 
 
 347 
 
 pain, anda sudden check to ail the inflamma- 
 tory symptoms. From the successof this case, 
 Mr. YVardrop was led to perform the opera- 
 tion on others, not only with a view of 
 diminishing the opacity of the cornea, but 
 also of alleviating the inflammation. Four 
 interesting cases are related by this gentle- 
 man, very much in favour of the practice, 
 when the eye is severely inflamed, attended 
 with fulness of the organ, a cloudy state of 
 the cornea, and a turbidness of the aqueous 
 humour. Mr. YVardrop also advises fhe ope 
 ration, whenever there is the smallest quan- 
 tity of pus in the anterior chamber, ac- 
 companied with violent symptoms of inflam- 
 mation. He thinks, that the great and im- 
 mediate relief, which the method affords, is 
 imputable to the sudden removal of tension ; 
 and he performs the operation with a small 
 knife, such as is used for extracting the 
 cataract. The instrument is to be oiled, and 
 introduced so as to make a wound of its 
 own breadth, at the usual place of making 
 an incision in the extraction of the cataract. 
 By turning 1 the blade a little on its axis, the 
 aqueous humour flows out. (See Edinb 
 Med. and Surg Journal. Jan. 1807 ; also 
 Med. Chir. Trans. Vol. 4.) The late Mr. 
 Ware approved of Mr. YVardrop’s operation 
 in the epidemic , purulent , or Egyptian oph- 
 thalmy , when, notwithstanding general eva- 
 cuations topical bleeding, mildly astringent 
 lotions, and a strict antiphlogistic regimen, 
 the symptoms still continue, and especially 
 if the cornea begin to lose its transparency, 
 and a white rim appear round its circumfer- 
 ence. Mr. Ware did not object to using a 
 small knife, of the kind employed in extract- 
 ing the cataract ; but preferred a lancet, or 
 a sharp-pointed couching needle, w r ith a 
 blade somewhat wider than usual, and a 
 groove in its middle. The instrument, he 
 advises, to be introducedabout one-tenth of 
 an inch before the connexion of the cornea 
 with the sclerotica, and pushed gently on, 
 parallel to the plane of the iris, until the aque- 
 ous humour makes its escape. ( Ware on the 
 Purulent Ophthalmy, p. 41, 1808.) As alrea- 
 dy explained, Mr. YVardrop also recommends 
 this practice in certain states of rheumatic oph- 
 thalmy. Consult Avicenna, Canon L. 3, Fen. 
 3, Tract. 1 , cap. 6. Maitre-Jun Traite des Mai . 
 de VCEil, 12 mo Paris 1722. St. Yves , Traitd 
 des Mai. des Yeux, p 170, fyc. Janin, Mem 
 sur VCEil. fyc. 8 vo. Paris , 1772. L F. Gendron , 
 Trait 6 des Mai. des Yeux . 2 T. 12mo Paris , 
 3770. C. F. Reuss, Dissertation es Med. Selectee 
 Tubingenses Oculi Humani Affect us Medico- 
 chirurgice consederatas sislenles, 3 Vo Is. 8 vo. 
 Tub. 1783. Trnka de Krzowitz, Hist Ophthal- 
 mia omnis aevi observata medica continens, 8ve. 
 Vindob. 1 783. G. Power, Attempt to investigate 
 the causes of the Egyptian Ophthalmy; with 
 obs. on its nature and cure, 8 vo. Load. 1803. H. 
 Read, An Essay on Ophthalmia, 8vo. Portsea , 
 1806-7. J. B Serney, Treatise on Local In- 
 flammation, more particularly applied to Dis- 
 eases of the Eye, fyc. 8 vo. Land. 1809 J. P. 
 Marat, An Inquiry into the Nature. Cause, 
 and Cure of a singular Disease of the Eyes, 
 hitherto unknown , and yd common, produced 
 
 by the use of certain mercurial preparations , 
 4lo. Land. 1770. James Ware, Chir. Ob- 
 servations relative to the Eye, 2 Vols. 8vo. 
 Loud. 1805. Richter, Anfangsgr. der Wun- 
 darzn. B. 3. G. Peach and J. Wardrop in 
 Edinb. Med. Surg. Journ.for January, 1807. 
 Also J. Wardrop, in Med. Chir. Trans. 
 Vols. 4 and 10; and Essays on the Morbid 
 Anatomy of the Eye, 2 Vols. 8 vo. 1808 — 
 1818. John Vetch , An Account of the Oph- 
 thalmia, which has appeared in England since 
 the return of the British Army from Egypt , 
 8 vo. Loud i807. Also Obs. relative to the 
 Treatment by Sir Wm. Adams of the Oph- 
 thalmic Cases of the Army, 8 vo. Loud. 1818. 
 Letter on the Ophthalmic Institution for the 
 Cure of Chelsea Pensioners, 4to. Lond. 1819. 
 And A Practical Treatise on the Diseases of 
 the Eye, 8 vo. Lond. 1820. W. Thomas, Obs. 
 on the Egyptian Ophthalmia, and Ophthalmia 
 Purulenta, 8 vo. Lond. 1805. P. Assalini on 
 the Plague, Dysentery, and Ophthalmy of 
 Egypt, &/-c. Transl. by A. Neale, Lond. 1804. 
 Also Manuale di Chirurgia, 8 vo. Milano , 
 1812. F. Vasani Sloria daV Ottalmia con- 
 tagiosa dello Spedalt Mililare d' Ancona, 8vo. 
 In Verona, 1816. Also Risposta a do che la 
 riguarda nei Cenni del D, f. Omodei sulV 
 Ottalmia d'Egitto et sulla sua propagazione in 
 Italia, 12 mo In Verona, 1818. T F Balfz, 
 de Ophthalmia Catarrhali Bellica, 4 to. Hei- 
 delb. 1816 Arthur Edmonstone, A Treatise on 
 the Varieties and Consequences of Ophthalmia , 
 with a preliminary inquiry into its conta- 
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 C. Farrell, On Ophthalmia and its conse- 
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 Med. Surg. Journ. No. 58, p. 156. R. C. 
 Graefe, Journ. der Chir. B. 1. Also Re- 
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 Humani Inflammatoriis, 4 to. Lips. 1811 
 J. C. Saunders on Same Practical Points re- 
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 Farre, Lond. 181 1, or rather the later editions. 
 Karl Himly Ophthalmologische Beobachtun- 
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 Syntagma de Oahihalmologia Veterum, 8 vo. 
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 1817. C. H Weller, A Manual of the Di S r 
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 B. Travers on Iritis , in Surgical %s$ays } 
 
348 
 
 OSTEOSARCOMA 
 
 Part 1. Also a Synopsis of the Diseases of 
 the Human Eye , Svo. Loud. 1820. Eusebius 
 A. Lloyd on Scrofulous and Purulent Oph- 
 thalmia , in a Treatise on Scrofula , Svo. Lond. 
 1821. 
 
 OSCHEOCELE, (from oer%eov, the scro- 
 tum, and km a tumour.) A hernia which 
 has descended into the scrotum. 
 
 *OSTEOSARCOM A, or Osteosarcosis. 
 (from oo-Ttov, a bone, and era />%, flesh.) This 
 term signifies the change of a bone into a 
 substance, of the consistence of flesh. Bones 
 are sometimes converted into a soft, lardy, 
 homogeneous substance resembling a can- 
 cerous gland, and it is this affection, to which 
 Boyer thinks, that the appellation ought to 
 be confined, 
 
 Callisen seems also to regard the osteosar- 
 cosis as a disorder by which the texture of 
 the bones is converted into a fleshy or fatty 
 substance, accompanied with a tendency to 
 carcinoma. ( System . Chirurgice Hodiernce , 
 p. 204. Vol. 2. Edit. 1800.) We are to un- 
 derstand by osteosarcoma, says Boyer, an 
 alteration of the osseous structure, in which, 
 after more or less distention, the substance 
 of the bone degenerates, and is transformed 
 into a diversified mass but, more or less 
 analogous to that cancer of the soft parts ; 
 while the local and general symptoms still 
 more strikingly resemble those of the lat- 
 ter disease. (See Traite des Mol. Chir. T. 
 3, p. 587.) 
 
 According to this writer, all the bones are 
 liable to such a disease ; but it has been 
 more frequently observed in the bones of 
 the face, those of the base of the skull, the 
 long bones of the limbs, particularly the 
 ossa irinorninata, which are perhaps oftener 
 affected than any other bones of the body. 
 {Op. cit. p. 588.) 
 
 Foreign surgeons do not appear to enter- 
 tain precisely the same ideas respecting 
 cancer, which prevail in England : at least, 
 they apply the term to many complaints in 
 which there are no vestiges of a carcinoma- 
 tous structure, and numerous diseases of an 
 incurable nature receive abroad very indis- 
 criminately the name of cancer. Thus, 
 the French surgeons have not yet distinguish- 
 ed the strongly marked differences between 
 carcinoma and fungus haematodes (See 
 JRoux , ParalWe de la chir. Angloise, fyc. ; 
 and the article Fungus Hcematodes.) 
 
 Fungous diseases in the antrum expand 
 the bones of the face, make their way out, 
 and present a frightful specimen of disease. 
 This change of the bones, though known to 
 have nothing to do with cancer, (see An- 
 trum,) is considered by Boyer as a kind of 
 osteosarcoma, proceeding from carcinoma- 
 tous mischief in the neighbouring soft parts ; 
 and this he adduces as an example of his 
 first species of osteosarcoma, or that arising 
 in consequence of previous disease in other 
 parts. In the second species, the disorder 
 commences in the bones, and the soft parts 
 are secondarily affected. In all cases, 
 osteosarcoma comes on with deeply-seated 
 pain, which sometimes lasts a considerable 
 time before any swelling is manifest. Some- 
 
 times the pain becomes more and more 
 afflicting, and of the lancinating kind, im 
 pairing the health even before there is 
 any change in the form of the limb. At 
 length, the swelling takes place, occupying 
 the whole circumference of the member. 
 Its nature and situation are in some measure 
 indicated by its hardness and depth. It is 
 unequal and tuberculated, as it were. Pres- 
 sure does not lessen its size, nor make the 
 pain worse. The soft parts are still in their 
 natural state. The tumour, however, grows 
 more or less rapidly and the lancinating 
 pains become more severe. In time, the 
 soft parts themselves inflame, and become 
 painful. Sometimes, the skin ulcerates, and, 
 in this very uncommon case, the sore pre- 
 sents a cancerous appearance. Hectic 
 symptoms are induced, the patient gradually 
 loses his strength, and, at length, falls a vic- 
 tim to the disease. 
 
 The alteration, which the structure of 
 the bones undergoes in the osteosarcoma, 
 (says Boyer) deserves great attention. Most 
 frequently, when the disease has made con- 
 siderable progress, and the tumour has exist- 
 ed a long while, the bony texlure has disap- 
 peared more or less completely ; in lieu of 
 it, an homogeneous grayish, yellowish, lard- 
 like substance is found, the surface of a slice 
 of which is smooth, much like that of a 
 very hard white of egg, or old cheese, the 
 consistence varying from that of cartilage 
 to that of very thick bouillie. The sur- 
 rounding soft parts, which have participated 
 in the disease of the bones are converted 
 into a similar matter; muscles tendons, 
 periosteum, ligaments, vessels, cellular sub- 
 stance, all are confounded in the same 
 homogeneous mass, and have undergone the 
 same degeneration. 
 
 In some examples, the disease is less ad- 
 vanced : portions of the bone are then met 
 with hose texture and consistence are 
 nearly natural, and which are merely some- 
 what enlarged. But in proceeding towards 
 the centre of the disease, the substance of 
 the bone is found softened, and its consist- 
 ence less than that of cartilage, still mani- 
 festly retaining, however, a fibrous texture ; 
 while more deeply, it is converted into a 
 lard-like substance, resembling (says Boyer) 
 that of parts affected with carcinoma. In 
 these tumours, cysts are often found, some- 
 times containing a fetid ichor, — some- 
 times a matter like clear bouillie ; and, in 
 certain cases, a quantity of semi-transpa- 
 rent, tremulous, gelatinous matter is found 
 in the middle of the lard-like substance. 
 Boyer records an instance, in which nearly 
 the whole humerus was changed into a 
 gelatinous mass. (See Lecqns sur les Mai, 
 des Os, T. 1. Chap. 22.) 
 
 The prognosis of this disease must always 
 be unfavourable ; for. it is equally incurable, 
 and disposed to bring on fatal consequences, 
 whether Boyer’s opinion, concerning its 
 being cancer of the bones, be true or not. 
 This author notices, that, even after ampu- 
 lation, the complaint almost always recurs. 
 (P.591.) The only chance of relief, how- 
 
PAR 
 
 PAR 
 
 249 
 
 ever, obviously depends upon the possibility 
 and success of the operation. In the Traitt 
 des Mai. Chir. T. 3, p. 594—605, Boyer re- 
 cords two cases of osteosarcoma ; one of 
 the thigh ; the other, of the os innominatum 
 The first patient was saved by amputation. 
 Some further particulars relative to osteo- 
 sarcoma may be found in Boyer, Traile des 
 Maladies Chir , T. 3; Haller's Element. Phy- 
 siol. T. 8, p. 2, pag. 5; S. A. Kulmus, Diss 
 de Exoslosi Sleatomaiode Claviculee ; Gedan. 
 3732; S. F Hundertmark, Diss. sistens Os- 
 teostealomatis Casum rariorem ; Lips. 1752; 
 5. G. Hermann, Hiss, de Ost< osteatomate , Lips. 
 1767: S. C. Plenck , de Osteosarcosi : Tub. 
 1781 fyc. B. C. Brodie in Pathol, and Surgi- 
 cal Obs. on the Joints, p. 301. 
 
 OZiENA. (from o?», a stench.) An ulcer 
 situated in the nose, discharging a fetid pu- 
 rulent matter, and sometimes accompanied 
 with caries of the bones. Some authors have 
 Sig-nified by the term, an ill-conditioned ulcer 
 in the antrum. The first meaning is that 
 which mostly prevails. The disease is des- 
 cribed as coming on with a trifling tumefac- 
 tion and redness about the ala nasi, accom- 
 panied with a discharge of mucus, with 
 which the nostril becomes obstructed. The 
 matter gradually assumes the appearance 
 of pus, is most copious in the morning, and 
 is sometimes attended with sneezing, and a 
 little bleeding. The ulceration occasionally 
 extends round the ala nasi to the cheek, but, 
 seldom far from the nose, the ala of which, 
 also, it rarely destroys. The ozaena is often 
 connected with scrofulous and venereal 
 complaints. In the latter cases, portions of 
 the ossa spongiosa often come away. After 
 the complete cure of all venereal complaints, 
 an exfoliating dead piece of bone will often 
 keep up symptoms, similar to those of the 
 ozama, until it is detached. Mr. Pearson 
 remarks, that the ozaena frequently occurs, 
 as a symptom of the chachexia syphyloidea. 
 It may perforate the septum nasi, destroy 
 the ossa spongiosa, and even the ossa nasi. 
 Such mischief is now more frequently the 
 effect of the chachexia syphyloidea, than of 
 lues venerea. The ozaena must not be con- 
 founded with abscesses in the upper jaw- 
 bone. (See Antrum.) 
 
 The constitutional disease, on which the 
 ozaena generally depends, and which acts as 
 the remote cause, must be relieved, before a 
 cure of the local effect can be expected. 
 The internal medicines, which may be ne- 
 cessary, are preparations of mercury, and 
 
 antimony ; sarsaparilla, elm bark, Peruvian 
 bark, muriated barytes, and muriate of lime 
 Sea-bathing may also do good, by improving 
 the health. The best external applications 
 are said to be, preparations of copper, zinc, 
 arsenic, mercury, the pul vis sternutatorius, 
 and diluted suphuric acid. ( Pearson's Prin- 
 ciples of Surgery, Chap. 12 F. A. Mayer t 
 Commentatio de Ozaena, Frank. Del. op. 
 11 .) 
 
 OYYMURIATIC ACID. Besides the ni- 
 trous and nitric acids, other medicines, con- 
 taining alarge proportion of oxygen, and easy 
 of decomposition, have been recommend- 
 ed to be tried as remedies for the venereal 
 disease ; viz. oxygenated vinegar, oxalic acid, 
 oxygenated muriate of potash, &c. (See 
 Caldwell's Medical Theses. Vol. T p. 111.) 
 But, perhaps, nothing has been put to the 
 test of experiment with greater expectation 
 of success, than the oxygenated muriatic 
 acid. Mr. Cruikshanks made a very early 
 trial of it in syphilitic cases, and, as is al- 
 leged, w ith the utmost benefit.. He also em 
 ployed the nitric acid, and the oxygenated 
 muriate of potash, and found them eligible 
 remedies The latter medicine w r as likewise 
 given by M Alyon in cases of chancre and 
 secondary ulcers, who found the good ef- 
 fects from it, more expeditious, and more 
 certain, than those of any mercurial prepa- 
 ration. (Essai sur les Pr opr Hies Mcdicinales 
 de rOxyaene, fyc. 8 vo. Paris, an 7 me.) On 
 the other hand, as much contrariety of sen- 
 timent respecting the real and permanent ef- 
 ficacy of all these medicines prevails in the 
 numerous reports about them, as in the ac- 
 counts delivered of the effects of the muria- 
 tic and nitric acid; and, therefore, I do not 
 think that the reader, after the copious state- 
 ments given in this book concerning the 
 nitric and nitrous acids, (see these words) 
 would be pleased to hear again a repetition 
 of very similar contradictions, respecting the 
 oxygenated muriatic acid. I may observe, 
 however, that, if oxygen be the principle, 
 on which the efficacy of many antisyphili- 
 tic remedies truly depend, this acid must 
 possess greater virtue than the common mu- 
 riatic acid. From 3 SS. to 3'j- mixed in 
 ^viij. of water, sweetened with syrup, may 
 be taken in divided doses in the course of 
 the day. 
 
 Oxygenated muriatic acid was strongly- 
 praised by Guyton de Morveau, as a means 
 of disinfecting sick-rooms, and purifying the 
 air of crowded hospitals. 
 
 P. 
 
 P ANA RIS, (from zrapn, uear, and cvw|, 
 ihe nail.) See Whitlow. 
 
 PANNUS. (from •■srsva. lo labour.) When 
 two or three pterygia, of different sizes oc- 
 curred on the same eye, with their points di- 
 rected towards the centre of the cornea, 
 where they met and covered all the surface 
 of this transparent membrane with a dense 
 
 pellicle, the ancients named the disease, 
 pannus. (Scarpa, Chap. 14.) 
 
 PaRACEN 1 E'SIS. (from ftrcipctzsvTea), to 
 perforate.) The operation of tapping or 
 making an opening into the abdomen, tho- 
 rax, or bladder, for the purpose of discharg- 
 ing th» fluid confined in these parts in cases 
 of ascites, empyema, bydrothorax, and 
 
PARACENTESIS. 
 
 ' 5*50 
 
 retention of urine. Eft*u«ed blood may also 
 require an opening to be made into the chest; 
 and so may confined air in the instance of 
 emphysema. 
 
 TAPrr'G, OH PARACENTESIS ABDOMINIS. 
 
 When the swelling extends equally over 
 the whole abdomen, tin* fluid is usually diffu- 
 sed atnongall the viscera, and is only circum- 
 scribed by the boundaries of the peritonae- 
 um. The water is occasionally included in 
 different cysts, w hich are generally formed 
 in one of the ovaries ; and in this ca^e, the 
 tumour which is produced, is not so uniform, 
 the fluctuation is noi so distinct as in the 
 former instanc-, at least this is the case 
 while the disease has not made very great 
 progress. The difference, also, in the con- 
 sistence of the fluid, may render the fluctua- 
 tion more or less difficult of detection. 
 When the water is contained in different 
 cysts, it is frequently thick and gelatinous; 
 but when it is uniformly diffused all over the 
 cavity of the peritonaeum,, it is generally 
 thinner, and even quite limpid. Sometimes 
 a con iderable number of hydatids are found 
 floating in the fluid, discharged in cases of 
 ascites. 
 
 Whatever may bp the efficacy of digitalis, 
 mercury, diuretics, and other evacuants in 
 ascites, they are rarely of any service in 
 cases of focal and encysted dropsies. When 
 such swellings continue to enlarge, notw ith- 
 standing the adoption of a few measures 
 which wifi presently be suggested, the soon- 
 er the fluid is evacuated the better. It is 
 also well known, that all efforts to produce 
 a radical cure even of dropsies, which 
 ar< not encysted, too frequently fail. I am 
 decidedly of opinion, however, with Dr 
 Fothergill, that physicians u'ould meet with 
 much more success in the treatment of asci- 
 tes, if they were to recommend paracentesis 
 to be done sooner than they generally do. 
 This operation is, for the most part, much 
 too long delayed; and during a long space, 
 the bowels are continually suffering more 
 and more, from the effect of the large 
 quantity of fluid which oppresses them. 
 What ought to render the practice of eaily 
 tapping more entitled to approbation is, that 
 the operation, when done in the situation 
 which will be presently advised, is perfectly 
 free from danger, attended with very little 
 pain, and need not interrupt the further trial 
 of such medicines as the physician may 
 place confidence in. Paracentesis only be- 
 comes a serious measure when the disease 
 has existed for a great length of time, and 
 the patient has been much weakened by 
 it. Indeed there seems much reason to 
 suspect that the operation should be done as 
 soon as the tension of the abdomen, and the 
 fluctuation, leave no doubt concerning the 
 nature of the malady ; especially when the 
 first t rials which have been made of internal 
 remedies, seem to promise no success. Dr. 
 Fothergill has demonstrated by facts the ad- 
 vantages of this method. On the commence- 
 ment of an ascites, this celebrated practi- 
 
 tioner advises the trial of diuretics and other 
 evacuants* He then adds, that “ if by a 
 reasonable perseverance in this course, no 
 considerable benefit accrues ; if the viscera 
 do not evidently appear to be obstructed, 
 and unfit for the purposes of life; if the 
 complaints have not been brought on by a 
 long habitual train of intemperance, and 
 from which there seems little hope of re- 
 claiming the patient ; if the strength and time 
 of life are not altogether against us ; I desist 
 from medicine, except of the cordial 'kind : 
 and let the disease proceed til! the operation 
 becomessafely practicable. When this isdone 
 by the moderate use of the warm diuretics, 
 chalybeates, and biiters,also the preparations 
 of squills, in doses below that point at which 
 the stomach would be affected, I endeavour 
 to prevent (he abdomen from filling again.” 
 (Med. Obs. and Inq. Vol. 4, p. 112.) The 
 same author remarks, with regard to encyst- 
 ed dropsies, that tapping sometimes effects a 
 radical cure. 
 
 The operation should not only be per- 
 formed in as early a stage of the disease as 
 is compatible with the safety of the parts 
 within the abdomen, it should also he repeat- 
 ed as soon as the quantity of fluid accumu- 
 lated again is sufficient to make the puncture 
 practicable without danger. Desault used 
 to tap dropsical patients once a week, and 
 in many ca^es, after he had performed the 
 operation two or three times, the disease was 
 stopped. 
 
 The great number of times that the ope- 
 ration has been repeated in some individu- 
 als is surprising; for in tance, twenty nine 
 times (Schmucker, J¥ahrnehmungen,2 B. p 
 102;) fort\-<>ne times (Med. Communica- 
 tions, , Vol. 2;) fifty-two times (Schmucker, 
 Vol..cit. p. 187;) sixtv-five times (Mead ;) 
 one hundred times (Callisen, Syst. Chir. Ho- 
 diernal Vol. 2, p. 55;) one hundred and 
 fifty-five times (Phil. Trans. Vol. 69 ;) and 
 if it be possible to credit Bezard, even six 
 hundred and sixty-five times upon one wo- 
 man in the course of thirteen years. When 
 the patient died, the peritoneum was found 
 to he three lines in thickness. The omen- 
 tum, mesentery, and even the liver, gall- 
 bladder, spleen, pancreas, kidneys, and blad- 
 der, had almost disappeared, a scirrhous mass 
 containing pus occupying their place towards 
 the right side. (See Bulletin de la Socidtd- 
 Medicate d' Emulation, No. 12, Dec.1815.) 
 
 Whenever a considerable quantity of fluid 
 is suddenly let out of the abdomen by tap- 
 ping, the quick removal of t he pressure of 
 the water oft* the large blood-vessels and 
 viscera, may produce swooning, convulsions, 
 and even sudden death- These consequen- 
 ces led the ancients to consider paracentesis 
 as a very dangerous operation, and when 
 they ventured to perform it, they only 
 let out the w'ater gradually , and at intervals 
 
 Dr. Mead, after considering what might 
 occasion the bad symptoms resulting from 
 too su den an evacuation of a large quanti- 
 ty of fluid from the abdomen, was led to try 
 what effect external pressure would have in 
 preventing such consequences. This practi*- 
 
PARACENTESIS. 
 
 351 
 
 tioner thought that in this way be might keep 
 up the same degree of pressure which the 
 fluid made on the viscera. The success at- 
 tending some trials of this plan, fully justi- 
 fied the opinion Dr Mead had conceived ; 
 for when the compression is carefully made, 
 the whole of the water co tained in the b- 
 domen of a dropsical palidnt, may be safely 
 discharged as quickly as the surgeon chooses. 
 For this purpose, however, the w hole abdo- 
 men must be equally compres-ed, the pres- 
 sure increased in proportion as the evacua- 
 tion takes place, and kept up in the same 
 degree for several days alterward. In St. 
 Bartholomew’s Hospital, while the water is 
 flowing out, the necessary degree ot pressure 
 is usually made wit a sheet, which is put 
 round the abdomen. Two assistants, who 
 hold the ends of the sheet, gradually tighten 
 it, in proportion as the fluid is discharged. 
 Immediately after the operation, some 
 folded flannel sprinkled w ith spirit of wine, 
 is laid over the whole anterior part of the 
 belly, and covered with a broad linen roller, 
 applied with due tightness round the body. 
 Dr. Monro invented a particular kind of belt 
 for the purpose ; but though it may be well 
 adapted to the object in view, it is, perhaps, 
 unnecessary, as the above method seems to 
 answer every end. 
 
 Tiie instrument used for tapping the abdo- 
 men, is called a trocar. (See Trocar.) 
 
 Of this instrument there are -everal varie- 
 ties; but Richter and many other experien- 
 ced surgeons, give a decided preference to 
 the common trocar. Most ofth- modern al- 
 terations which have been made in the 
 construction of trocars, have only tended, 
 says Richter, to render the employment of 
 these instruments more difficult. There is 
 no reason for the ordinary objection, t hat 
 the corjiiion trocar cannot be introduced 
 without considerable force. If the part into 
 which it is about to be passed, be made 
 tense, very little force will be necessary, 
 especially if care be taken to rotate the in- 
 strument gently, as well as push it forward. 
 Hence all the invention- which have origi- 
 nated from this supposed imperfection, are 
 represented by Richter to be entirely useless. 
 He condemns the trocar with a double-edged 
 point, as a bad instrument. The proposal of 
 Mr. Cline to make a puncture w'ith a lancet 
 first, and then ! o introduce into Hie opening 
 a blunt-pointed trocar, is alleged to be su- 
 perfluous. Nay — these innovations are de- 
 clared to be worse ihan useless. A cutting 
 instrument is liable to injure blood-vessels, 
 and bring on a weakening degree of hemor- 
 rhage ; and it is said, that the wound thus 
 made does not heal so readily as that made 
 with a common trocar. That sharp-edged 
 instruments are attended with the inconve 
 nienceof being apt to wound enlarged veins, 
 and produce an unpleasant degree of hemor- 
 rhage, is a truth of w hich I have myself met 
 with a convincing example. A female who 
 had a strong aversion to being tapped w ith a 
 trocar, prevailed upon me to make tiie open- 
 ing wish a lancet. The puncture was made 
 in the linea alba, about three inches below 
 
 the navel. A stream of dark-coloured ve- 
 nous blood continued to run from the wound, 
 the whole time the water was flowing out of 
 the cannula, and did not cease until a com 
 press was applied. The quantity of blood 
 lost could not be less than a pint, or a pint 
 and a half. In many rases the loss of «o 
 much blood would prove fatal to dropsical 
 patients, and is what one must alway s feel 
 anxious to avoid. 
 
 The most convenient position for the ope - 
 ration, is certainly when the patient is sitting 
 in an arm-chair. However, weakness and 
 other circumstances frequently make it ne- 
 cessary to operate on the patient as he lies in 
 bed. 
 
 Until of late, the place in which surgeons 
 used to puncture the abdomen, In cases of 
 ascites, was the centre of a line drawn 
 from the navel to the anterior superior spi 
 nous process of the ilium, and on the left 
 side, which was preferred in consequence of 
 tiie liver not being theie. The place for the 
 puncture was usually marked with ink, and 
 was supposed to be always situated just over 
 a part of the linea semilunaris, w here In e 
 is n< fleshy substance, nor any large blood- 
 vessel, exposed to injury. This calculation, 
 however, u as made w ithout considering that, 
 in dropsy, the parietes ol the abdomen do 
 not yield equaily in every situation. On the 
 contrary, it is known, that the front is always 
 more distended than the lateral parts, and 
 that the recti muscles, in particular, are 
 sometimes very much widened. In conse- 
 quence of these alterations induced by the 
 disease, no dependence can be put on any 
 measurement, made with the view ot ascer- 
 taining the piecise situation of tiie linea 
 semilunaris. The surgeon who trusts to his 
 being aide to introduce the trocar exactly in 
 this place, from any calculation of the above 
 kind, will frequently wound a great thickness 
 of muscle, instead ol a part where the abdo 
 ininal parietes are thinne-t. But a still 
 stronger objection is to be urged against the 
 practice of attempting t-o tap in the linea 
 semilunaris. Men v\ell acquainted with 
 anatomy, have frequently been deceived 
 in their reckoning, and instead of hitting the 
 intended line with their trocars, they have 
 introduced these instruments through the 
 rectu- muscle, and wounded the epigastric 
 artery. Patients have died from this error, 
 with large extravasations of blood in the 
 cavity of the peritonaeum. n a dropsical 
 person, who has been tapped, it is to be ob- 
 served 'also, that an effusion td biood in the 
 abdomen will of course more readily take 
 place, in consequence of the parts not being 
 in the same close, compact state, in which 
 they are in the healthy condition. 
 
 Let every prudent practitioner, therefore, 
 henceforth abandon the plan of tapping in 
 the linea semilunaris, and he may the more 
 easily make up his mind to do so, as there 
 is another place where the operation may 
 be done with the utmost facility and safety. 
 The iitiea alba is iro vv commonly preferred 
 by the best surgeons ; because, here no 
 muscular fibres need be xvounded. the place 
 
PARACENTESIS. 
 
 B&2 
 
 can be hit with certainty, and no large 
 blood-vessel can be injured. About the 
 middle point, between the navel and pubes, 
 is as good a situation for making the punc- 
 ture as can possibly be chosen. The sur- 
 geon should introduce the trocar in a steady, 
 firm manner, never in an incautious, sud 
 den way, lest parts contained in the perito- 
 naeum should be rashly wounded. For the 
 same reason, immediately the point of the 
 trocar has entered the abdomen, a thing 
 always known at once by the sudden ces- 
 sation of resistance to its passing inward, it 
 should be introduced no further, and its 
 office of making a passage for the cannula 
 is already accomplished. The surgeon, con- 
 sequently, is now to take hold of the cannula 
 with the thumb and index finger of his left 
 hand, and gently insinuate it further into 
 the cavity of the peritonaeum, while with 
 his right hand he is to withdraw the stilette. 
 The fluid now gushes out, and regularly as 
 it escapes, the sheet which is round the pa- 
 tient’s body is to be tightened. All the wa- 
 ter having been evacuated, a piece of flan- 
 nel and a roller are to be immediately ap- 
 plied, as above explained, a piece of lint 
 and soap-plaster having been previously 
 applied to the wound. 
 
 It is not uncommon for the water suddenly 
 to stop, long before the full quantity is dis- 
 charged. Sometimes this happens from a 
 piece of intestine, or omentum, obstructing 
 the cannula. This kind of stoppage may he 
 removed by just introducing a probe or di- 
 rector, and holding the portion of bowel 
 back. When the w ater is very viscid, the 
 only thing we can do is to introduce a large 
 trocar, if doing so should premise to facili- 
 tate the evacuation. Also, when hydatids 
 obstruct the cannula, a larger instrument 
 might allow them to escape. In encysted 
 dropsies, the practitioner, of course, can 
 only let the fluid out of those cavities which 
 he can safely puncture. 
 
 When a dropsy of the ovary is very large, 
 it also admits of being tapped in the linea 
 alba; but, in this particular case, it is gene- 
 rally best to make the puncture where the 
 swelling is most prominent. In this disease, 
 the ovary is either converted into one large 
 cavity, filled with fluid or else it contains 
 several distinct cells. The contents are 
 sometimes exceedingly viscid. In the early 
 stages of the case, the tumour is situated 
 towards one side of the abdomen, and seems 
 to ascend out of the pelvis. This kind of 
 progress at once distinguishes the disease 
 from a common ascites, which is attended, 
 from the first, with an equal, gradual, uni- 
 versal swelling of the abdomen. The cyst 
 of the ovary, when it has attained a large 
 size, generally adheres, in different places, 
 to the inner surface of the peritonaeum, and, 
 in this state, the whole abdomeu often 
 seems uniformly swollen, in consequence of 
 the immense magnitude of the disease. (See 
 G. D. Mots, (le Structure ! , Usu, el M or bis Ora- 
 riorum, 4lo Jeiur', 178S.) The impairment 
 of the health, arising from the pressure of 
 the viscera, and interruption tbmr func- 
 
 tions, and the great difficulty of breathing' 
 produced by the pressure on the diaphragm, 
 make it necessary to let out the fluid, and 
 paracentesis must be done in the way alrea- 
 dy related. The disease is often attended 
 with an almost total stoppage of the secre- 
 tion of urine. Sometimes the urine is duly 
 secreted, but a retention occurs, so that the 
 use of the catheter becomes indispensable. 
 Tapping, however, can only be regarded as 
 a palliative measure ; the water collects 
 again, the same grievances recur, and the 
 operation must be repeated. While an ova- 
 rial dropsy is recent, aud even after it has 
 been tapped, some attempts may be made 
 to effect a radical cure. Blistering the sur- 
 face of the abdomen, keeping up a discharge 
 with the savine cerate, and applying a tight 
 roller, have been known to do good. In 
 France, the celebrated Le Dran laid open 
 the cysts of ovarial dropsies. His patients 
 did not die of the consequent inflammation, 
 and the dropsy, indeed, was cured ; but 
 there remained either a sarcomatous en- 
 largement of the ovary, which continued to 
 increase till death, or else incurable fistula;, 
 leading into the cyst, were the consequen- 
 ces. 'J£he large size of a wound necessary 
 for this purpose, the danger of inducing in- 
 flammation in so extensive a surface as the 
 cyst of a large ovarial dropsy, and the events 
 of Le Dran s cases, are circumstances, on 
 the whole, which ought to keep the prac- 
 tice from ever being revived. 
 
 A still more absurd plan has been attempt- 
 ed, viz. to cure the disease by injections, 
 like hydroceles. I formerly saw' tw r o cases 
 in which port wine and water were inject- 
 ed, by the late Mr. Ramsden of St. Bartho- 
 lomew’s Hospital; one patient died very 
 soon afterward of the inflammation, and the 
 other perished more lingeringly from the 
 same cause. Setons have been tried with- 
 out success. 
 
 Sometimes, though very seldom, the ope- 
 ration of paracentesis is necessary for giving 
 vent to collections of air in the abdomen 
 Air, when confined in this manner, is gene- 
 rally contained in the bowels, which it in- 
 flates to an enormous size. Instances, how- 
 ever, are related of quantities of air being 
 confined between the peritonaeum and intes- 
 tines : but, in some of these cases, it is said 
 that the air yvas known to have escaped 
 through a small hole in some part of the in- 
 testinal canal, and it is probable, that all the 
 other examples were of the same kind. This 
 disease is named tympanites , and may ren- 
 der making an opening into the abdomen 
 necessary. Notwithstanding authors gene- 
 rally recommend a small trocar for the pur- 
 pose, there can be no doubt that dividing 
 the skin, and making a cautious puncture 
 with a lancet through the linea alba and 
 peritonaeum, would be a preferable mode of 
 proceeding. The abdomen must also be 
 compressed with a sheet while the air is 
 escaping, and afterward with a roller, just 
 as if the case were an ascites, liven when 
 the air is contained in the bowels, it it should 
 
 enbrutoMs in qmudijv, occasion urgent 
 
FAR 
 
 PAR 
 
 o63 
 
 symptoms, anti cannot be got rid of in other 
 ways, authors recommend paracentesis. 
 
 PARACENTESIS OF THE THORAX 
 
 The necessity for this operation is indica- 
 ted when the heart or lungs are oppressed 
 by any kind of fluid confined -in the cavity 
 of the chest. Every body knows that the 
 free and uninterrupted performance of the 
 functions of these organs is essential to the 
 support of life. When the action of these 
 viscera is disturbed by the lodgment of a col- 
 lection of any kind of fluid in the thorax, no 
 internal medicines can be much depended 
 upon for procuring relief. The only means 
 from which benefit can be rationally ex- 
 pected, is letting out the fluid by making an 
 opening in the parietes of the chest. 
 
 The nature of the effused fluid can make 
 no difference in regard to the propriety of 
 discharging it in this manner; and, though 
 some authors have only treated of this ope- 
 ration as applicable to cases of hydrops pec- 
 toris and empyema, it may also be of the 
 greatest service when air is confined in the 
 chest, (see Emphysema ) or blood extravasa- 
 ted there, (see Woundsof the Thorax) so as 
 to make dangerous pressure on the lungs 
 and diaphragm. 
 
 In this place I shall content myself with 
 describing the best method of performing 
 paracentesis thoracis, referring the reader to 
 the articles just mentioned for information 
 concerning the particular symptoms and 
 circumstances which may render the opera- 
 tion proper, and the rest of the surgical 
 treatment peculiar to each affection. 
 
 The safest and most convenient situation 
 for making an opening into the chest, is be- 
 tween the sixth and seventh true ribs, on 
 either side, as circumstances may ^render 
 necessary. The surgeon should only recol- 
 lect, that the two cavities of the pleura are 
 completely distinct from each other, and 
 have no communication whatsoever, so 
 that, if fluid were contained on the left side 
 of the thorax, making an opening into the 
 right cavity would not serve for discharging 
 the accumulated matter. The practitioner 
 should also remember, that, when there is 
 a fluid on both sides of the chest, paracente- 
 sis must never be done for the relief of the 
 two collections at the same time; because 
 there is great reason to believe that, as the 
 lungs on one side usually collapse, when 
 there is a free communication between the 
 air and inside of the thorax, they would do 
 so on both sides, were an opening made at 
 the same time into each bag of the pleura. 
 It is hardly necessary to remark, that, in 
 this condition, the patient could not breathe, 
 and would die suffocated. The operation 
 consists in making an incision, about two 
 inches long, through the integuments which 
 cover the space between the sixth and 
 seventh true ribs, just where the indigita- 
 tions of the serratus major anticus muscle 
 meet those of the externus obliquus. Here 
 it is unnecessary to divide any muscular 
 fibres, except those of the intercostal mus- 
 Voi. II 4.5 
 
 cles, and, by putting the patient in a proper 
 posture, the opening that is to be made will 
 be depending enough for any purpose what- 
 soever. The surgeon, avoiding the lower 
 edge of the upper rib, where the intercostal 
 artery lies, is then cautiously to divide the 
 layers of the intercostal muscles, till he 
 brings the pleura into view; when this 
 membrane is to be very carefully ided 
 with a lancet. The instrument should never 
 be introduced in the least deeply, 1 . e 
 lungs should be injured. The size of the 
 opening in the pleura should never be larger 
 than necessary. The discharge of blood 
 and matter will of course require a freer 
 aperture than that of air or water. If requi- 
 site, a cannula may be introduced into the 
 wound for the purpose of facilitating the 
 evacuation of the fluid, and it may even in 
 some cases be proper to let this instrument 
 remain in the part, in order to let the w r ater 
 or pus escape, as often as another accumu- 
 lation takes place. It is obvious, however, 
 that a cannula for this object should only 
 be just long enough to enter the cavity of 
 the pleura, and should have a broad rim to 1 
 keep it from slipping into the chest. A piece 
 of sticking-plaster would easily fix the can- 
 nula, which might be stopped up with a 
 cork, or any other convenient thing, or left 
 open, according as the circumstances of the 
 case, and the judgment of the surgeon should 
 direct. 
 
 Paracentesis of the abdomen, and that of 
 the thorax, are described in all treatises on the 
 operations and systems of surgery. The works 
 of Sharp, Le Dran, Bertrandi, Callisen, Rich- 
 ter, Sabatier, Larrey , and Boyer , are particu- 
 larly deserving attention. A case, in which 
 eleven pints of a fluid, resembling whey, were 
 discharged from the chest by paracentesis, and 
 the patient recovered, is detailed by Dr. Archer 
 in the Trans, of the King's and Queen's Col- 
 leges of Physicians in Ireland, Vol. 1 , art. 1. 
 
 See also JY. Friedreich, Vorzuge des Bauch- 
 stichesin der Bauchwassersucht, 12 mo. Wurzb. 
 1816, 1817. 
 
 For an account of the paracentesis of the 
 bladder, refer to Bladder, Puncture of. Con- 
 sult also Emphysema, Empyema, and Wounds 
 of the Thorax. 
 
 PARAPHYMO'SIS, or Paraphimosis. 
 (from mget, back, and cpifxo to bridle.) This 
 signifies the case in which the prepuce is 
 drawn quite behind the glans penis, and 
 cannot be brought forward again. See 
 Phymosis, with which it will be considered. 
 
 PAKONY'CHIA. (from near, and 
 
 ovv$j, the nail.) An abscess at the end of the 
 finger, near the nail. See Whitlow. 
 
 PAROTID DUCT. Every one acquaint- 
 ed w ith anatomy is aware, that behind the 
 jaw 7 , on each side, there is situated a large 
 conglomerate gland, being the principal one 
 of such as are destined to secrete the saliva, 
 with which the cavity of the mouth, and the 
 food which we swallow, are continually 
 moistened. The parotid duct crosses the 
 cheek, being situated about one-third from 
 the zygofoa, and two-thirds from the basis' 
 of the jaw. After passing over the ma&setev 
 
PAH 
 
 PAR 
 
 354 
 
 muscle, it pierces the buccinator, and ter-, 
 mrnates in the mouth by a considerable ori- 
 fice opposite the space, between the second 
 and third bicuspid grinders of the upper jaw. 
 As soon as it has passed the masseter, it 
 dives deeply into the fat of the cheek, and, 
 as M. Louis observes, makes an angle be- 
 fore it opens into the mouth. ( M6m . de 
 Acad. de Chir. T. 3, p. 457 ) 
 
 From the situation of the parotid duct it 
 is liable to be wounded, and this has even 
 been done by the surgeon’s lancet, through 
 ignorance. (See Monro’s Works, p. 520.) 
 In cases of this kind, the continual escape 
 of saliva may prevent the wound from heal- 
 ing, and, what is called a salivary fistula 
 would be the perpetual consequence, if no 
 steps were taken to afford relief. The pa- 
 rotid duct has sometimes been ruptured by 
 blows. ( CEuvres Chir. de Desault, T. 2, p. 
 221.) Cases also occur, in which the face 
 becomes considerably swollen, in conse- 
 quence of the saliva insinuating itself into 
 the cellular substance, just as the air does 
 In emphysema. Respecting the last circum- 
 stance, I shall only just mention, that mis- 
 chief of this kind must always be prevented 
 lrom becoming very extensive, by making 
 a depending opening for the ready escape 
 of the fluid. 
 
 With regard to the treatment of salivary 
 fistulae, if the division of the parotid duct is 
 recent, the sides of the wound should be 
 ■brought into contact, and a steady pressure 
 maintained on that part of the cheek, by 
 means of suitable compresses and a roller. 
 In this manner, a salivary fistula may often 
 be prevented altogether : either the divided 
 ends of the duct reunite, and the spittle re- 
 sumes its original course into the mouth ; 
 or, what is more probable, the wound in the 
 face heals at every part, with the exception 
 of a small fistulous track, which serves as a 
 continuation of the duct into the inside of 
 the mouth. The latter kind of cure, how- 
 ever, can only take place when the wound 
 extends quite through the cheek ; but the 
 chance of the two portions of the duct uni- 
 ting, and becoming continuous’again, should 
 always be taken in recent cases. 
 
 When a salivary fistula is actually form- 
 ed, a seton, introduced from the external 
 fistulous orifice into the mouth, is a method 
 which seems to have, with justice, the great- 
 est share of approbation. The celebrated 
 Monro adopted this plan with success ; he 
 k^ept in the selon till the channel, which it 
 had formed, had become fistulous, after 
 which it was withdrawn, the external orifice 
 being touched with the argentum nitratum, 
 healed up, and the saliva in future flowed 
 through the artificial fistulous channel into 
 the mouth. 
 
 Desault used to practise the seton as fol- 
 lows : — He introduced two fingers of his 
 left hand into the patient’s mouth, and pla- 
 cing them between the teeth and the cheek, 
 opposite the fistula, thus kept the integu- 
 ments tense, and the gums from being in- 
 jured. He then introduced a small hydro- 
 cele trocar, with its cannula, just before the 
 
 opening of the posterior part of the doct, 
 and pushed it through the cheek, in a direc 
 tion a little inclined forward. An assistant 
 now took hold of the cannula, while Desault 
 withdrew the perforator, and passed through 
 the tube a bit of thread into the cavity of 
 the mouth. The cannula was next taken 
 out, and a seton, which was then fastened 
 to the end of the thread in the mouth, was 
 drawn from w r ithin outward ; but not so far 
 as to come between the edges of the exter- 
 nal opening, where the thread alone lodged, 
 and this was fastened with sticking-plaster 
 to the outside of the cheek. The outer 
 wound was dressed with lint and compres- 
 ses. Desault used to change the seton daily, 
 introducing regularly rather a larger one, 
 and taking especial care not to bring it be- 
 tween the edges of the wound, which was 
 afterward covered with sticking plaster. 
 He enjoined the patient not to move the 
 jaw much, and only allowed him, for some 
 time, liquid food. In about six weeks he 
 used to omit the seton, leaving in the thread, 
 however, for a little while longer. This 
 being taken way, he used to finish the cure 
 by touching the little aperture remaining, 
 with caustic. 
 
 The making of an artificial passage is one 
 of the most ancient plans of curing salivary 
 fistulae. Every author has had his particu- 
 lar method of doing it, and numerous va- 
 riations are to be met with, either in the 
 instrument employed for piercing the cheek, 
 or in the substance intended for maintaining 
 the opening. For the first step of the ope- 
 ration, surgeons sometimes used the actual 
 cautery, as Saviard furnishes us an instance 
 of ; sometimes an awl, as Monro did ; some- 
 times a common knife, or lancet ; some- 
 times a straight needle, which drew in the 
 thread after it ; but Desault’s trocar gene- 
 rally merits the preference, because the 
 cannula, by remaining in the wound after 
 the perforator is withdrawn, allows the 
 thread to be introduced, which in every 
 other way is either difficult to accomplish, 
 or requires the use of several instruments. 
 
 For the second step of the operation, viz. 
 keeping the opening distended, cannula; 
 were employed by Duphenix, w r ho used to 
 make a suture over them ; a plan objection - 
 able, inasmuch as it w r as attended with the 
 inconvenience of a solid body left in the 
 parts, and also that of the instrument being 
 apt to slip into the mouth. The setoti, 
 therefore, ought to be preferred, and there 
 can be no doubt that Desault’s method is 
 better than the one followed by Monro 
 (See on this subject, Monro's Works; CEu- 
 vres Chir. de Desault, par Bichat, T. 2, p 
 221. Also M&m. de l' Acad, de Chir. T. S. 
 J. B. Siebold, Diss. sistens Historiam Syste- 
 matis Salivalis physiologice et pathologice con 
 siderati,fol. Jencc, 1797.) 
 
 PAROTID GLAND, EXTIRPATION 
 OF. (See Tumours.) 
 
 PARU'LIS. (from r^ar, and 
 
 the gum.) An inflammation, boll, or ab 
 sues? in the gums- 
 
PENIS. 
 
 PENIS, AMPUTATION OF. No part of 
 The penis should ever be amputated, on ac- 
 count of a mortification, because the dead 
 portion will be naturally thrown off, and 
 the ulcer heal without the least occasion 
 for putting the patient to any pain from the 
 employment of the knife. Some cancerous 
 and fungous diseases, are the cases in which 
 it is often really proper and necessary to 
 amputate more or less of this organ. 
 
 However, before a surgeon ventures to 
 do the operation, he ought to be certain 
 that it is the substance of the penis which 
 is incurably diseased ; for, as that judicious 
 surgeon Callisen remarks, tumours, excres- 
 cences, ulcers, and gangrenous mischief, of 
 the prepuce, sometimes present appearances 
 which may lead an inexperienced practi- 
 tioner to fancy the whole thickness of the 
 part affected with irremediable disorder, 
 while the glans is actually in a sound state. 
 Hence, whenever the least doubt exists, it 
 is better to remove first the prepuce and 
 skin, in order that the true condition of the 
 glans may be detected. ( Callisen , Systema 
 Chirurgia Hodiemce, pars posterior, p. 420, 
 Hafnicc , 1800.) 
 
 The old surgeons, fearful of hemorrhage, 
 used sometimes to extirpate a part of the 
 penis, by tying ligatures round it with suffi- 
 cient tightness to make it mortify, and 
 slough off. Thus Ruysch once performed the 
 operation. (See Obsv. 30) The plan, how- 
 ever, is exceedingly painful, and notwith- 
 standing the authority of Heister, has been 
 most properly rejected from modern surgery. 
 
 The amputation may be done in the fol- 
 lowing manner : — A circular incision is to 
 be made through the skin, abcuit a finger- 
 breadth from the cancerous part. As Calli- 
 sen observes, it is hardly ever requisite to 
 draw' the skin back before it is cut ; be- 
 cause after the corpora cavernosa are divi- 
 ded, they retract so considerably, that there 
 is always a sufficiency of the integuments. 
 (Syst. Chir. Hodiemce, pars posterior, p. 421.) 
 As soon, therefore, as the circular incision 
 through the skin has been made, the cor- 
 pora cavernosa and urethra are to be cut 
 through, by one stroke of the knife, on a 
 level with the cut edges of the integuments. 
 Sabatier even advises us to draw the skin 
 towards the glans penis, before we employ 
 the knife, so convinced is he of the inutility 
 of saving any of it, and of the inconveni- 
 ences which may result from its lying over 
 and obstructing the orifice of the urethra. 
 His mode of operating is also particularly 
 simple, as he cuts through the integuments 
 and penis together by one stroke of the 
 knife, without making any preliminary cir- 
 cular division of the skin. ( Mddecine Op6- 
 ratoire , T. 3, p. 305, Edit. 2.) 
 
 The bleeding arteries are now to be im- 
 mediately tied : the chief are, one on the 
 dorsum of the penis, and *one in each cor- 
 pus cavernosum. When a general oozing 
 from the wound still continues, some re- 
 commend ( IVhile, Hey, §'c.) applying sponge 
 to its surface ; others ( Latta ) finely scraped 
 agaric, with a small proportion of pounded 
 
 35o 
 
 white sugar, or gum arabic. Perhaps, how- 
 ever, finely scraped lint, supported with 
 compresses, would be quite as effectual as 
 any styptics, and certainly the latter appli- 
 cations should be avoided, if possible, be- 
 cause stimulating, and productive of pain 
 and inflammation. A surer and preferable 
 method of stopping the oozing of blood, and 
 at the same time of healing the wound, 
 might be to bring the skin forward over the 
 end of the stump, with two strips of sticking 
 plaster, after introducing a flexible gum ca- 
 theter into the continuation of the urethra, 
 so as to keep its orifice unobstructed, and 
 the urine from coming into contact with 
 the wound. There can be little doubt that 
 the gum catheter would be better than a 
 silver one, or any metallic cannula, com- 
 monly advised for the above purposes, be- 
 cause it lies in the passage with less irrita- 
 tion. It is but justice to Callisen to state, 
 that he seems to be one of the few good 
 surgical writers, who have particularly re- 
 commended in these cases the elastic gum 
 catheter, in preference to that made of sil- 
 ver. (Op. cit. p. 421.) In one case, in 
 which Mr. Hey operated, he made a longi- 
 tudinal division of the integuments, at the 
 inferior part of the penis, so as to make them 
 cover its extremity without puckering, or 
 lying over the orifice of the urethra. The 
 corpora cavernosa, however, do not readily 
 granulate, and unite to the skin by the first 
 intention. (Hey, p. 452.) After the first 
 dressings are removed, the part should be 
 dressed with the unguentum spermatis ceti, 
 or any mild unirritating salve. 
 
 In consequence of the introduction of a 
 cannula being neglected, Le Dran mentions 
 his having seen the orifice of the urethra 
 become closed a few hours after the opera- 
 tion, so that the patient could not make 
 water. The orifice of the passage could 
 not be discovered without great difficulty. 
 A lancet being introduced at the point, 
 against which the urine seemed to be forced, 
 a quantity of it gushed out, and as a cannula 
 was not at hand, a sound was introduced 
 till one could be procured. (Traitd des 
 Oper. de Chirurgie.) 
 
 Pearson, in his Practical Observations on 
 Cancerous Complaints , has treated of this 
 operation : he particularly advises the skin 
 not to be drawn back, because, when saved 
 in this manner, it impedes the free exit of the 
 urine- He likewise disapproves of introducing 
 cannula), as creative of pain, and spasms of 
 the urethra, and unnecessary, since the 
 stream of urine will always preserve the 
 urethra in a permeable state. (P. 103.) 
 
 When the penis is amputated near the 
 pubes, the remainder shrinks under that bone 
 and within the integuments so far, that it is 
 difficult to tie the arteries. 1 n order to obviate 
 this inconvenience, Schreger recommends 
 the skin to be drawn forwards, and fixed 
 with a band ; then to make an incision only 
 deep enough to divide the dorsal arteries, 
 which are to be tied, before the knife is 
 used again. The incision is then to be con- 
 tinued perpendicularly, till the two arteries 
 
35.6 
 
 PEN 
 
 PH a 
 
 of the eo: pora cavernosa are cut. These are 
 now to be tied. Then the corpus spongiosum 
 and its two arteries are to be cut through, 
 which last are to be secured. Lastly, the 
 rest of the skin of the penis is to be divided. 
 In this way Schreger amputated a diseased 
 penis, of which ofily a part, about an inch in 
 length, was sound. . 
 
 (Sharp, Le Dran, Eertrandi , and Sabatier's 
 books on the operations , may be consulted. 
 Also, I' Encyclopedic Melhodique ; Par lie 
 Chir. Art. Verge. Hey' s Practical Observa- 
 tions in Surgery, p. 445. Pearson on Can- 
 cerous Complaints, p. 103, fyc. Warner's 
 Cases in Surgery, p. 278, Edit. 4. E. C. 
 Biener, De Exlirpalione Penis per Ligatu- 
 ram,4to. Lips. 1S16. J. H- Thaut, Diss. de 
 Virgce Virilis Statu sano et morb. ejusdem im- 
 primis ampulalione. B. G. Schreger’s Chir. 
 Fersuche; JYeue Melhode den Penis zu Am- 
 putvren , B. l,p. 242, 8 vo. JVurnberg, 1801.) 
 
 PENIS, CANCER OF. A wart, or a 
 tubercle, on the prepuce, the fraenum,or the 
 glans penis, is generally the first symptom, 
 and it often remains in a quiet state for ma- 
 ny years. When irritated, however, it be- 
 comes painful, and enlarges, sometimes 
 enormously in a very short time. At the 
 same time ulceration, and a discharge of sa- 
 nious fetid matter, take place. The disease 
 sometimes also occasions in the urethra fis- 
 tulous openings, out of which the urine es- 
 capes, and the lymphatic glands in the groin 
 may become affected as the disease advances. 
 Mr. Pearson says, that “ cancerous excres- 
 cences have a broad base, often more exten- 
 sive than their superficies; they seem to 
 germinate deeply from within, or rather to 
 be a continuation of the substance of the 
 part ; and. in their progressive state, the 
 contiguous surface has a morbid appear- 
 ance.” What Mr. P. considers as a venereal 
 wart, has a basis smaller than its surface ; 
 its roots have rather a superficial attach, 
 ment, and the contiguous parts have a na- 
 tural appearance (p. 97.) Such are this 
 gentleman’s marks of discrimination. We 
 might question, however, whether Mi*. 
 Pearson, notwithstanding his great opportu- 
 nities, ever saw a really venereal wart. For 
 many years past 1 have never seen any ex- 
 crescences of this kind in St. Bartholomew’s 
 hospital, which truly required mercury for 
 their cure, or which, when cured without 
 it, were followed by any inconvenience. If 
 my memory does not fail me, Mr. Aberne- 
 thy also disbelieves in the doctrine of vene- 
 real warts. 
 
 Foul, spreading, sloughy ulcers of the 
 penis, should be discriminated from cancer. 
 It is worthy of attention that almost all the 
 cases of cancer of the penis recorded by 
 Mr. Hey were attended with a congenital 
 phymosis. The same complication also ex- 
 isted in another example, in which Boyer 
 performed amputation of the penis in la 
 Charitfc, on account of a cancerous affection 
 of the part. In the only two opportunities 
 of doing this operation, which M Roux has 
 had, the cases were likewise accompanied 
 with a natural phyrnosi's. Hence, this au- 
 
 thor considers such a state of the prepuce 
 as particularly conducive to cancer of the 
 penis, and earnestly enjoins surgeons to re- 
 commeud their patients to have the first 
 inconvenience rectified, so that no risk of 
 the other more serious affection may be en- 
 countered. (See Parallele de la Chirurgie 
 Angloise , fyc. p. 306, 307.) In two out of 
 three cases which were reported to be can- 
 cerous, and for which amputation was done 
 under my notice, it did not appear that any 
 degree of phymosis existed. (See Pearson 
 on Cancerous Complaints. Hey's Practical 
 Observations in Surgery . Roux, Voyage fait 
 en Aagleterre en 1814, ou Parallele. de la 
 Chir. Angloise, tyc. p. 306.) 
 
 PERINEUM, FISTULA OF. (See 
 Fistulce in Perinoeo.) 
 
 PE'RNIO. (from <arygva,or <©-TS£vsi,the heel.) 
 A chilblain, especially on the heel. (See 
 Chilblain.) 
 
 ^PESSARY, (from ^tro-a>, to soften.) The 
 intention of pessaries among the old prac- 
 titioners, was to keep medicinal substances 
 applied within the pudenda. They are now 
 never made use of, except lor preventing a 
 prolapsus of the uterus or vagina, or for 
 keeping up a very uncommon kind of rup- 
 ture, explained in the article Hernia. 
 
 PIIAGEDvE'NA. (from <t>u.yce, to eat.) 
 An ulcer which spreads, and as it were 
 eats away the flesh. Hence the epithet, 
 phagedenic, so common among surgeons. 
 For an account of the phagedoena, gangree- 
 nosa, see Hospital Gangrene. 
 
 PHARYNGOTOMY. (from <p*$ oy the 
 pharynx, and rtywoo, to cut.) See (Esopha - 
 gotomy. 
 
 PHARYNGO'TOMUS. (from p<*gi uy f, the 
 throat, and to//#, an incision.) An instru- 
 ment for scarifying the tonsils, and for open- 
 ing abscesses about the fauces. It was in- 
 vented by Petit, and is nothing more than a 
 sort of lancet which is enclosed in a sheath. 
 By means of aspring the point is capable of 
 darting out to a determinate extent, so as to 
 make the necessary wound, without risk of 
 injuring other parts. 
 
 PHLEBO TOMY, (from yyef, a vein, and 
 n/uva, to cut.) The operation of opening a 
 vein, for the purpose of taking away blood. 
 See Bleeding. 
 
 PHLE'GMON. (from qxiyce, to burn.) 
 Healthy inflammation. (See Inflammation.) 
 
 PHLOGO'SIS. t(frorn <p*cyoa>, to inflame.) 
 An inflammation. A flushing. 
 
 PHRENI'TIS. (from the diaphragm, 
 supposed by the ancients to be the seat of 
 the mind.) An inflammation of the brain. 
 Phrensy. 
 
 Inflammation of the brain is a frequent 
 consequence of injuries of the head. The 
 symptoms are an increased and disordered 
 state of the sensibility of the whole nervous 
 system ; the retina cannot bear (lie usual 
 stimulus of light ; the pupils are contracted ; 
 the pulse is frequent and small ; the eyes 
 are red and turgid, arid the iris sometimes 
 actually inflamed, (E ardrop, Essays on the 
 Morbid Anal, of the Eye, Vol. 2,1 the coun- 
 tenance is flushed, and the patient is rest 
 
W-IYMOSJS 
 
 ie.'?, mutters incoherently, and grows wild 
 and delirious. 
 
 Phrenitis is treated on the antiphlogistic 
 plan. Copious bleedings and other evacua- 
 tions, are highly proper. Some of the blood 
 should be taken from the temporal arteries. 
 The skin ought to be kept moist with anti- 
 monials, and a counter-irritation should be 
 excited on the scalp by blisters. 
 
 PHY'MA. (from <pva>, to grow.) Tuber- 
 cles comprehend eight genera, and we 
 learn from Dr. Bateman, that, under the ge- 
 nus phyma, the late Dr. Willan intended to 
 comprise the terminthus, the epinyctis, the 
 furunculus, and the carbuncle. (See Bate- 
 man's Synopsis of Cutaneous Diseases, p. 270, 
 Edit. 3.) According to Pott, this term was 
 formerly applied to an inflammation near 
 the anus. See Anus , Abscesses of . 
 
 PHYMOSIS, or rather Phimosis, (from 
 Vi/uoc, a muzzle.) A case in which the pre- 
 puce cannot be drawn back, so as to unco- 
 ver the glans penis. It is of two kinds, 
 viz. accidental , and natural or congenital. 
 Both the accidental phymosis, and para- 
 phymosis, according to Mr. Hunter, arise 
 from a thickening of the cellular membrane 
 of the prepuce, in consequence of an irrita- 
 tion capable of producing considerable and 
 diffused inflammation. A chancre is a fre 
 quent cause ; but a mere inflammation and 
 discharge from the glans and prepuce, and 
 also a gonorrhoea, may bring on these affec- 
 tions. The inflammation often runs high, 
 and is frequently of the erysipelatous kind. 
 The cellular membrane being loose, the tu- 
 mefaction becomes considerable, and the 
 end of the prepuce being a depending part, 
 the serum often lodges in it, and makes it 
 oedematous. A congenital contraction of 
 the aperture of the prepuce is very common, 
 and persons so affected have a natural and 
 constant phymosis. Such a state of parts 
 (says Mr. Hunter) is often attended with 
 chancres, and it produces very great incon- 
 veniences during the treatment. When 
 there is considerable diffused inflammation, 
 a diseased phymosis similar to the natural 
 one, unavoidably follows; and whether 
 diseased or natural, it may produce a para- 
 phymosis, simply by the prepuce being 
 brought back upon the penis. This tight 
 part, then acting as a ligature round the 
 body of the penis, behind the glans, retards 
 the circulation beyond the constriction, so 
 as to produce an oedematous inflammation 
 on the inverted part of the prepuce. 
 
 When the prepuce is very long, phymosis 
 may also arise from the swelling of the 
 glans penis, produced by sores on the latter 
 part, or the irritation of a severe gonor- 
 rhoea. ( Travers in Surgical Essays, Part 1, 
 p. 132.) My own observations lead me to 
 consider an irritation and swelling of the 
 prepuce itself as by far the most common 
 causes of the accidental phymosis. 
 
 In some children, the natural or congenital 
 phymosis is so considerable, that the urine 
 cannot pass with ease ; but the aperture of 
 the prepuce generally becomes larger as 
 they grow older, and the bad consequences 
 
 which the phymosis might have occasioned 
 in disease, are thus avoided. 
 
 In certain individuals, especially old men, 
 the prepuce sometimes contracts without 
 any visible cause whatever, and becomes so 
 narrow as to hinder the water from getting 
 out, even after it has got free of the urethra, 
 and consequently, the whole cavity of the 
 prepuce becomes filled with urine, attended 
 with great pain. 
 
 In phymosis, when the prepuce swells and 
 thickens, more and more of the skin of the 
 penis is drawn forwards over the glans, and 
 the latter part becomes at the same time 
 pushed backward by the ^welling against 
 its end. From such a cause Mr. Hunter has 
 seen the prepuce projecting more than 
 three inches beyond the glans, with its 
 aperture much diminished. 
 
 Mr. Hunter also notices, that the prepuce 
 often becomes, in some degree, inverted, 
 by the inner skin yielding more than the 
 outer, and the part seems to have a kind of 
 neck where the outer skin naturally termi- 
 nates. From the tightness and distention 
 of the parts, the prepuce now cannot be 
 drawn more back, so as to expose any sores, 
 which may be situated under it. This state 
 is frequently productive of bad consequen- 
 ces, especially when there are chancres be- 
 hind the glans ; for, the glans being between 
 the orifice of the prepuce and the sores, the 
 matter sometimes cannot get a passage for- 
 ward, between the glans and prepuce, and, 
 consequently, it accumulates behind the co- 
 rona glandis, so as to form a kind of abscess, 
 which produces ulceration on the inside of 
 the prepuce. This abscess bursts externally, 
 and the glans, often protruding through the 
 opening, the whole prepuce becomes thrown 
 towards the opposite side, and the penis 
 seems to have two terminations. On the 
 other hand, (says Mr. Hunter) if the pre- 
 puce is loose and wide, and is either accus- 
 tomed to be kept back in its sound state, or 
 is pulled back to admit of the chancres be- 
 ing dressed, and is allowed to remain in 
 this situation, till the above tumefaction 
 takes place, the case is then named a para- 
 phymosis. Also, when the prepuce is pulled 
 forcibly back, after it is swelled, it is then 
 brought from the state of a phymosis to 
 that of a paraphymosis. The latter case is 
 often attended with worse symptoms than 
 the former, especially when it has first been 
 a phymosis. According to Mr. Hunter, the 
 reason of this is, that the aperture of the 
 prepuce is naturally less elastic than any 
 other part of it ; therefore, when the pre- 
 puce is pulled back upon the body of the 
 penis, that part grasps it more tightly than 
 any other portion of the skin of Ihe penis, 
 and more so, according to the inflammation . 
 Hence, there are two swellings of the pre- 
 puce, one close to the glands; the other 
 behind the stricture. The constriction is 
 often so great as to interrupt the circulation 
 beyond it. This increases the swelling, adds 
 to the stricture, and often produces a morti- 
 fication of the prepuce itself, by which means 
 the whole diseased part, together with the 
 
356 
 
 PHIMOSIS. 
 
 stricture, is sometimes removed, forming, 
 as Hunter ably expresses himself, a natural 
 cure. In many cases, the skin and pre- 
 puce are not the only parts affected ; adhe- 
 sions, and even mortification may also take 
 place in the glans, corpora cavernosa, &,c. 
 (See Hunter on the Venereal, 221, ^c.) 
 
 An accidental phymosis should always be 
 prevented if possible, and therefore, says 
 Mr. Hunter, upon the least signs of a thick- 
 ening of the prepuce, which is known by 
 its being retracted with difficulty and pain, 
 the patient should be kept quiet ; if in bed, 
 so much the better, as in a horizontal posi- 
 tion, the end of Jhe penis will not be so de- 
 pending. If confinement in bed cannot be 
 complied with, the end of the penis should 
 be kept up, though this can hardly be done 
 when the patient is walking about. The 
 object of this plan is to keep the extrava- 
 ted fluids from gravitating to the prepuce, 
 which they would hinder from being drawn 
 back again even more than the inflammation 
 itself. 
 
 When phymosis is recent, and attended 
 with swelling of the glans or prepuce from 
 inflammation, Mr. Travers recommends in- 
 jections of tepid water, or milk and water, 
 beneath the foreskin ; and the immersion of 
 the penis three or four times a day, in a te- 
 pid bath, keeping the end of the penis up- 
 wards ; and the use of leeches ; which I 
 think with him and other writers, (see Did. 
 des Sciences Med. T. 41, p. 334,) should ne- 
 ver be put exactly on the swelled prepuce 
 itself. As the inflammation subsides, injec- 
 tions of weak goulard, or the solution of 
 alum, or liquor calcis and calomel, may be 
 substituted. ( Travers, Surgical Essays, Part 
 l,p.l36.) Instead of warm applications, 
 some practitioners prefer cold : and it is yet 
 an unsettled question which remedies an- 
 swer best. 
 
 When the inflammation is of longer 
 standing, the swelling compresses the ure- 
 thra, and there is tendency to abscess, ul- 
 ceration of the latter passage, extravasation 
 of urine, land gangrene of the skin, Mr. 
 Travers advises the employment of emol- 
 lient poultices and fomentations (the com- 
 mon practice, I believe,) and the introduc- 
 tion of a small elastic gum-catheter into the 
 bladder. “ This (says he) is not a practice 
 indicated by the degree of stricture, which 
 is seldom considerable enough to require 
 it : but, by the approaching danger of ex- 
 travasation. It should not , therefore, be taken 
 up, unless the cellular membrane of the penis 
 has advanced to suppuration.'' 
 
 As when there are sores, they cannot be 
 dressed in the common way, injections must 
 frequently be thrown under the prepuce, or 
 the operation for phymosis performed. Mr. 
 Hunter advises mercurial injections ; either 
 crude mercury, rubbed down with a thick 
 solution of gum-arabic ; or calomel with 
 the same, and a proportion of opium ; or 
 else a solution of one grain of the oxymu- 
 riate of mercury in one ounce of water. 
 Mr. Hunter also recommends the applica- 
 tion of emollient poultices, with laudanum 
 
 in them, and to let the part, previously to 
 the application being made, hang over the 
 steam of hot water, with a little vinegar and 
 spirit of wine in it. 
 
 When, in a case of phymosis, chancres 
 bleed, Mr. Hunter recommends the oil of 
 turpentine as the best stimulus for making 
 the vessels contract ; but, when the hemor- 
 rhage proceeds from irritation, he recom- 
 mends sedatives. Whatever is used, he 
 says, must be injected under the prepuce. 
 Under such circumstances, it has always 
 been a rule with me to avoid irritating ap- 
 plications, and on this account I have never 
 used turpentine, particularly as any trouble- 
 some bleeding from chancres may always 
 be effectually checked by covering the pe- 
 nis with linen kept well wet with very cold 
 water. When the inflammation has abated, 
 Mr. Hunter advises moving the prepuce oc- 
 casionally, to prevent its becoming adhe- 
 rent to the glans. He says, he has seen the 
 opening of the prepuce so much contract- 
 ed, from the internal ulcers healing and uni- 
 ting, that there was hardly any passage for 
 the water. If the passage in the prepuce, 
 so contracted, be in a direct line with the 
 orifice of the urethra, a bougie must be 
 used. If otherwise, the operation of slit- 
 ting up, or removing part of the prepuce, 
 becomes necessary. 
 
 When matter is confined under the pre- 
 puce, in the manner above described, Mr. 
 Hunter recommends laying the prepuce 
 open, from the external orifice to the bot- 
 tom, where the matter lies, as in a sinus or 
 fistula. However, Mr. Hunter thinks laying 
 open the prepuce for the :nre purpose of 
 applying dressings unnecessary, as the sores 
 may be washed with injections, by means 
 of a syringe. 
 
 I happened to serve my apprenticeship at 
 St. Bartholomew’s, at a time when the fa- 
 shion of cutting every phymosis, inflamed 
 or not, was far too common, and I had 
 abundant opportunities of witnessing the ir- 
 reparable gangrenous mischief frequently 
 thus produced. It gives me pleasure, there- 
 fore, to find this villanous practice justly 
 disapproved of by a modern writer. “ It 
 is not adviseable, (says Mr. Travers,) to cut 
 the inflamed prepuce, nor, indeed, any in- 
 flamed part. I lately saw a phymosis indu- 
 ced by a thickened and rigid state of the 
 membrane of the prepuce, during the free 
 use of mercury, constitutionally and locally, 
 for the cure of two sores, each of the size 
 of a split pea, situated one on each side of 
 the anterior fold of the prepuce. It was 
 the opinion of an eminent surgeon, that 
 those sores, wdiicli were thoroughly intract- 
 able, would not heal unless the prepuce 
 was freely divided ; and, impressed with 
 the same idea, after poulticing for some 
 days, I slit it up. The sores immediately 
 healed ; but the wound as quickly assumed 
 the same indolent and intractable character 
 which had belonged to the sores, and was 
 so slow in healing, that it seemed to he 
 only a transfer of the disease from one part 
 to another.” (P. 139.) f have not only 
 
PHYMOSIS 
 
 359 
 
 >vitnessed the same fact, in several cases 
 under the late Mr. Ramsden, and in St. 
 Bartholomew’s Hospital, but have seen mor- 
 tification brought on by the still more rash 
 practice of cutting the prepuce either when 
 the part was in a state of acute inflamma- 
 tion, or there were ulcers within it, when 
 the constitution was in a reduced and very 
 disordered state from the injudicious and 
 immoderate use of mercury. 
 
 The common operation, for the cure of 
 phymosis, consists in slitting open the pre- 
 puce, nearly its whole length, in the direc- 
 tion of the penis. This plan is certainly the 
 most eligible, when the matter of a chancre 
 cannot escape from under the prepuce ; be- 
 cause circumcision, which many surgeons, 
 since Mr. Hunter’s time, have preferred, 
 would not suffice forgiving vent to the ac- 
 cumulated pus. In many cases of phymo- 
 sis, says Mr. Hunter, an operation is impro- 
 per; for, while the inflammation is very 
 considerable, such a measure might bring 
 on mortification. He acknowledges, how- 
 ever, that there are cases, in which a free- 
 dom given to the parts would prevent the 
 latter event. When matter is confined un- 
 der the prepuce, an opening is indispensa- 
 ble, and, if the patient should object to the 
 common operation, an opening should be 
 made with a lancet directly through the 
 prepuce, or else with a caustic. (See Hun- 
 ter on the Venereal Disease, p. 232, etseq .) 
 
 When the prepuce is to be slit open, a di- 
 rector is first to be introduced under it, and 
 the division is then to be made with a curved 
 pointed bistoury, from, within upward. 
 
 Many surgeons object to this operation, 
 because the prepuce continues afterward in 
 a very deformed state ; and they perform 
 circumcision, or amputation of the prepuce, 
 ?n the following manner. The prepuce is 
 first taken hold of with a pair of forceps, 
 •as much of the part being left out, as is 
 judged necessary to be removed. The re- 
 moval is then accomplished by one sweep 
 of the knife, which directed by the blades 
 °/ the forceps, is sure of making the inci- 
 sion in a straight and regular manner. A 
 fine suture is next passed through the edges 
 of the inner and outer portions of the skin 
 of the prepuce so as to keep them together. 
 
 The anly necessary dressings are lint, and 
 over it an emollient poultice. 
 
 At the period when I first entered the 
 profession, it was the custom to salivate 
 every patient who happened to have a phy- 
 mosis. How r ever, now that the fact of any 
 irritation about the prepuce and glans penis, 
 even that of common warts, being capable 
 of producing the complaint is well known, 
 such absurd practice has been relinquished, 
 and the cause and condition of the disease 
 are always considered previously to the de- 
 termination for any particular method of 
 treatment. Nay, even when phymosis does 
 arise from chancres, if there be a great 
 deal ot inflammation, the use of mercury 
 may rather do harm than good, and the 
 practitioner should not be precipitate in its 
 administration On this point. I fully coin- 
 
 cide with Mr. Travers : — Upon many oc- 
 casions (says he) practitioners are too 
 anxious to contend with the scientific cha- 
 racter of the venereal disease, to the neglect 
 of the inflammatory state of the affected 
 parts exhibited duringits height. The abuse 
 of administering mercury for an acute go- 
 norrhoea, and recent sores, accompanied by 
 phymosis, or an approach to that state, is of 
 common occurrence, and it is far from being 
 recognized by the profession, as an estab- 
 lished rule of practice, that its constitutional 
 administration is inadmissible during the 
 existence of active inflammation, in cellular 
 textures.” ( Surgical Essays, Part 1 ,p. 131.) 
 
 In nine cases out of twelve, in which the 
 experienced Mr. Hey had occasion to am- 
 putate the penis for cancerous disease, the 
 patients were also affected with a natural 
 phymosis. ( Pract . Obs. in Surgery.) Roux 
 has noticed the same thing in three similar 
 examples, and, therefore, as he conceives 
 that phymosis may be conducive to carci- 
 noma of the penis, he thinks that it should 
 always be remedied in time. (Parallble de 
 la Chir. Angloise, p. 306.) 
 
 TREATMENT OF PARAPHYMOSIS. 
 
 The removal of the stricture in this case 
 should always be effected, because its con- 
 tinuation is apt to produce a mortification 
 in the parts, between the stricture and the 
 glans. It may be done in two ways ; either 
 by compressing with the fingers all the 
 blood out of the swelled glans so as to ren- 
 der this part sufficiently small to allow the 
 constricting prepuce to be brought forward 
 over it, with the aid of the two fingers ; or 
 by dividing the stricture with a knife. In 
 the last edition of this work, as Mr. Dunn 
 of Scarborough has reminded me, the power 
 of cold applications, in promoting the re- 
 duction of the glans, should have been men- 
 tioned. This method should always be put 
 in practice, before the reduction by com- 
 pression is attempted, as a preliminary 
 measure, wiiich sometimes succeeds of 
 itself, and renders unnecessary any painful 
 handling of the parts. From the great 
 success, which I have seen attend the 
 first mode, I should not conceive the second 
 one so frequently necessary, as Mr. Hunter 
 seems to lay down. This operation is 
 always troublesome to accomplish, because 
 the swelling, on each side of the stricture, 
 covers or closes the tight part, which cannot 
 be got at without difficulty. Mr. Hunter 
 says, the best way is to separate the two 
 swellings, as much as possible, where you 
 mean to cut, so as to expose the constricted 
 part ; then take a crooked-pointed bistoury, 
 pass it under the constriction, and divide 
 it. None of the swollen skin, on each side, 
 should be cut. The prepuce may now be 
 brought forward, unless it be thought more 
 convenient, for the purpose of dressing the 
 chancres, to let it remain in its present situ- 
 ation. (See Hunter on the Venereal Dis- 
 ease, p. 238, 239.) 
 
 The original disease producing phymosis 
 and parapbymosis, must always be attended 
 
/*()0 
 
 PIL 
 
 PIL 
 
 to, and the employment of mercury must be 
 necessary or unncessary, according to the 
 nature of the affection, of which these are 
 only effects. 
 
 One of the most interesting writers on Phy - 
 inosis and Paraphymosis is J. L. Petit, Trails 
 (Its Mai. Chir. T. 2 ; many of whose valuable 
 observations are contained in the 2 d vol. of the 
 First Lines of Surgery , 8 vo. 1820. Consult 
 also J. Hunter on the Venereal Disease. Sa- 
 batier, Medecine Op&ratoire, T.S, 8 vo. Paris, 
 1810. Travers , in Surgical Essays, Part 1, 
 8 no. Loud. 1818. There is also a valuable 
 chapter on this subject in Richter's Anfangsgr. 
 der Wundarzn. B. 6. 
 
 PILES. (See Hemorrhoids.) 
 
 PILULES AMMONIARETI CUPRI — 
 ft. Cupri Ammoniareti gr. xvj. Micee Panis 
 3)iv. Liquoris Ammon, q. s. M. fiant pilulae 
 xxxii. (Edinb. Disp.) This is said to be the 
 best form of exhibiting copper internally, 
 which mineral some think worthy of trial in 
 cases of gleets. 
 
 PILULE ARGENTI NITRAT1S. ft. 
 Argenti Nitratis gr. iij. Aquae Distillates gutt. 
 aliquot. Micae Panis q. s. ut fiant pil. xx. 
 The author of the Pharmacopoeia Chirurgica 
 suggests the trial of these pills in obstinate 
 leprous, and other cutaneous affections, and 
 phagedenic, anomalous ulcers, connected 
 with constitutional causes. Two or three 
 may be given twice a day. Dr. Powell gave 
 the’argentum nitratum internally, in a case 
 of hydrophobia, but without any sensible 
 
 effect. 
 
 PILULE COLOCYNTIIIDIS CUM 
 HYDR. SUBM. ft. Extracti Colocynth. 
 comp. 3’»j. Hydr. Submur. gr. xii. Saponis 
 3j. Misce. ut fiant pilulae duodecim. Two 
 of these pills operate as a purgative, and 
 they ace often prescribed in various surgi- 
 cal cases. 
 
 PILULES CONIL ft. Extracti Conii 3ss. 
 Pulv. Herb. Cicutae q. s. fiant pil. lx. These 
 are the hemlock pills in use at Guy's Hos- 
 pital. Cicuta is occasionally given in scro- 
 fulous, cancerous, and venereal cases. 
 The surgeon should begin with small doses, 
 and increase them gradually, till nausea and 
 headach arise. From one to a greater 
 number of these pills may be given, in this 
 manner, every day. 
 
 PILULE CUPRI SULPHATtS. ft. 
 Cupri Sulphatis gr. xv. Olibani Extracti 
 Cinchona;, sing. 3'j- Syrup, simpl. q.s. fiant 
 pil. lx. From one to four of these pills may 
 be given in a day, for gleets. ( Pliarm . 
 Chirurg.) 
 
 PILUL E HYDRARGYRI. Of these, I 
 need only observe here, that the usual dose 
 is ten' grains. (See Mercury.) 
 
 PILULAE HYDRARGYRI OXYDI RU- 
 
 BRI. One grain of this preparation in each 
 pill is the dose, which is commonly taken at 
 bedtime. (See Mercury.) 
 
 PILULE HYDRARGYRI CUM CONIO. 
 ft. Hydrargyri puriiicati drach. j. Arabici 
 gummi pulverisati drach. ij. Extracti Conii 
 drach. j. Herb® Cicutae foliorum,in pulve- 
 rem tritorum, q. s. The quicksilver is to be 
 first reduced by triture with the gum arabic, 
 
 moistened with a little rain water. The in- 
 spissated juice of hemlock is afterward to her 
 added, and lastly, the powdered leaves in 
 sufficient quantity to make a suitable mas* 
 for pills. These with a slight variation in 
 the proportion of the hemlock, are the 
 pilules mercuriales of Plenck, who directs 
 three or four pills, each of three grains, to 
 be given every night and morning. 
 
 There are, no doubt, many cases, to which 
 this formula must be very suitable ; as for 
 instance, the enlarged prostate gland, and 
 some forms of bronchocele, &c. For such 
 diseases. Dr. Saunders, in his Formulce Selectee , 
 directs equal parts of pil. hydrarg. andex- 
 tractum conii. ( Pharm . Chir.) 
 
 PILULE HYDRARG. SUBMUR. ft. 
 Hydrarg. Submur. gr. xij. Conservae Cynos- 
 bati quod satis sit. M. fiant pil. xii. These 
 are the calomel pills in common use. Sur- 
 geons give one, or two of them daily, as al- 
 teratives, in numerous cases. At Guy’s Hos- 
 pital, they add three grains of the pulvis 
 opiatus to each pill, using syrup, instead of 
 the conserve. 
 
 PILUL/E HYDRARG. SUBMUR. CUM 
 CONIO. ft. Hydrarg. Submur. gr. vj. Ex- 
 tracti Conii 3j. M. fiant pil. xii. One maybe 
 given thrice a day, in scirrhous, cancerous, 
 scrofulous, and some anomalous diseases, 
 resembling venereal diseases. 
 
 PILULE: HYDRARGYRI SUBMUR. CUM 
 ANTIMONIO TARTARISATO. ft. Hy- 
 drarg. Submur. 3j- Antimon. Tga-t. gr. xv. 
 Opii. Pur. 3ss. Syrupi simpl. q. s. fiant pil 
 Jx. One of these is given twice a day, in St. 
 Thomas’s Hospital, in cases of diseased 
 joints. As the author of the Pharm. Chirurg. 
 adds, they are also of use in herpetic 
 affections, and obstinate ulcers. The union 
 of antimony with quicksilver, according to 
 Dr. G. Fordyce, quickens the specific opera- 
 tion of the latter. 
 
 pilule: hydrarg. submur. com- 
 posite:. ft. Hydrarg. Subm. Sulph. An- 
 tim. Prajcip. sing. gr. xii. Guaiaci Gummi 
 Resina; gr. xxiv. Saponis q. s. M. fiant pil. 
 xii. Similar to Plummer’s pills: In porrigo, 
 herpetic affections, and many anomalous 
 diseases, they are exceedingly useful. Some 
 diseased enlargements of the breast, and tes- 
 ticle, seem also to be benefited by them. 
 
 PILULE! OPII. These need ^mly be 
 mentioned among such as are of eminent 
 utility in surgery. 
 
 pilule: opii composite:, ft. Opii 
 
 Purif. Camphor®, sing. 3j- Antim. Tart. gr. 
 xv. Syrup. Simpl. q. s. fiant. pil. Ix. Used 
 for alleviating pain, and keeping up a gentle 
 perspiration ; are particularly useful in pre- 
 venting painful erections, in cases of gonor- 
 rhoea, chordee, &c. (See Pharm. Chir.) 
 
 PILULE: PLUMBI ACETATIS. ft. Plum- 
 bi Acetatis gr. xii. Opii Purif. gr. vj. Con- 
 serv. Cynosbati q. s. M. fiant pil. xii. One 
 may be given thrice a day. Gleets are, 
 perhaps, the only cases, in which surgeons 
 can employ these pHls. . 
 
 pilule: sode: cum sapone. ft. 
 
 Sod® 3j. Saponis 3j. M. Fiant pil. xii. 
 Four may be given thrice a clay, in cases ol 
 
POLYPUS. 
 
 lbtonchoceie, and indurations of the absor- 
 bent glands from scrofula. 
 
 PILULE ZINCI SULPHATIS. R. Zinci 
 Sulphatis, 3 * j - Terebiuthinse q. s. Fiant pi!, 
 lx. One, or two, are occasionally given, in 
 cases of gleets, thrice a day. 
 
 PLAN 1'ARIS MUSCLE. This long slen- 
 der muscle of the leg is said to be sometimes 
 ruptured, particularly in dancing and leap- 
 ing. The surgeon can do little more than 
 advise rest, and the same posture of the limb, 
 as in the rupture of the tendo Achillis. 
 (See Tendon.) 
 
 POLYPUS, (from .-a row;, many, and 
 a foot.) A kind of tumour, w hich is gene- 
 rally narrow where it originates, and then 
 becomes wider, somewhat like a pear ; 
 which is most commonly met with in the 
 nose, uterus, vagina, andjantrum ; and which 
 received its name from an erroneous idea, 
 that it usually had several roots, or feet, like 
 polypi, or zoopkites. 
 
 Polypi more frequently grow in the cavity 
 of the nose, from the Schneiderean mem- 
 brane, than any other situation, and are 
 visibly of different kinds ; some being red, 
 soft, and sensible ; but free from pain, and 
 exactly like a piece of healthy flesh. This, 
 which has been termed the fleshy polypus , is 
 the most common, and fortunately the most 
 easy of cure. Other polypi are called ma- 
 lignant, being hard, scirrhous, and painful : 
 some are said to be even capable of con- 
 version into carcinoma. Richter describes 
 another kind of nasal polypus, which is pale, 
 very tough, and secretes a viscid discharge ; 
 which undergoes an alteration of its size 
 with every change of the weather; and 
 which is rather a relaxation, or elongation, 
 of a part of the Schneiderean membrane, 
 than a polypous excrescence. The whole 
 membranous lining of the nostrils is some- 
 times relaxed, and thickened in this manner, 
 so as nearly to till all the cavity of the nose 
 ( Jinfangsgr . der Wundarzn. B. 1, Knp. 21.) 
 
 Mr. Pott has taken great pains to explain, 
 that there is one kind of polypus, originally 
 benign; another originally malignant. He 
 states, that those which begin with, or are 
 preceded by considerable, or frequent pain 
 in the forehead and upper part of the nose, 
 and, which, as soon as they can be seen, are 
 either highly red, or of a dark purple colour ; 
 those, which from the time of their being 
 first noticed, have never been observed to 
 be sometimes bigger, sometimes less, but 
 have constantly rather increased ; those, in 
 which coughing, sneezing, or blowing the 
 nose, gives pain, or produces a very disa- 
 greeable sensation in the nostril, or forehead; 
 those which, when within reach, are painful 
 to the touch, or which, upon being slightly 
 touched, are apt to bleed ; those which 
 seem to be fixed, and not moveable by the 
 action of blowing the nose, or of driving the 
 air through the affected nostril only (when 
 the polypus is only on one side;) those which 
 are incompressibly hard, and which, when 
 pressed, occasion pain in the corner of the 
 eye, and forehead, and which, if they shed 
 anv thing, shed- blood ; those which hv 
 Tor. I f 46 
 
 361 
 
 adhesion occupy a very considerable space, 
 and seem to consist of a thickening, or of 
 an enlargement of all the membrane cover- 
 ing the septum narium ; those which some - 
 times shed an ichorous, offensive, discolour- 
 ed discharge ; and those, round whose lower 
 part, within the nose, a probe cannot 
 easily and freely be passed, and that to some 
 height, ought not to be attempted, at least 
 by the forceps, nor indeed by any other 
 means ; and this for reasons obviously dedu- 
 cible from the nature and circumstances of 
 the polypus. On the one hand, the very large 
 extent and quantity of adhesion will render 
 extirpation impracticable, even if the dis- 
 ease could be comprehended within the for- 
 ceps, which it very frequently cannot ; and 
 on the other, the malignant nature of the 
 distemper may render all partial removal, all 
 unsuccessful attacks on it, and indeed any 
 degree of irritation, productive of the most 
 disagreeabie consequences. 
 
 But, the polypi, which are of a palish or 
 grayish light-brown colour, or iook like a 
 membrane just going to be sloughy ; which 
 are seldom or never painful, nor become so 
 upon being pressed ; which have appeared 
 to be at one time larger, at another less, as 
 the air has happened to be moist or dry ; 
 which ascend and descend freely by the action 
 of respiration through the nose ; which the 
 patient can make to descend by stopping the 
 nostril which is free, or even most free, and 
 then driving the air through that which the 
 polypus possesses ; which when pressed give 
 no pain, easily yield to such pressure, be- 
 come flat thereby, and distil a clear lymph ; 
 and round whose lower and visible part a 
 probe can easily, and that to some height, 
 be passed, are fair and fit for extraction ; 
 the polypus, in these circumstances, fre- 
 quently coming away entire : or, if it does 
 n >t, yet it is retnoveable without pain, he- 
 morrhage, or hazard of any kind ; the se- 
 cond of which circumstances Mr. Pott can 
 with strict truth affirm, he never yet met with 
 when thedisease was at all fitforthe operation. 
 
 Of the benign kind of polypus, fit for ex- 
 traction, there are (says Mr. Pott) two sorts, 
 whose principal difference from each other 
 consists in their difierent origin or attach 
 ment. That which is most freely moveable 
 within the nostril, upon forcible respiration ; 
 which has been found to be most liable to 
 chanoe of size, at different times and seasons; 
 which has increased the most in the same 
 space of time ; which seems most limpid, 
 and most freely yields lymph upon pressure, 
 has its origin most commonly by a stalk or 
 kind of peduncle, which is very small, com- 
 pared with the size of the polypus. The 
 other which, although plainly moveable, 
 is much less so than the one just mentioned, 
 which has been less liable to alteration from 
 air and seasons ; and which has been rather 
 slow in arriving at a very troublesome size, 
 is most frequently an elongation of the 
 membrane covering one of the ossa spon- 
 giosa. These latter may be extracted with 
 no kind of hazard, and with very little pain, 
 and hemorrhage : but the former require 
 
'POLYPI S. 
 
 362 
 
 the least force, ami mostly come away en- 
 tire ', while the others often break, come 
 away piecemeal, and stand in need of the 
 repeated use of the forceps. (Pott, on the 
 Polypus of the Nose.) 
 
 Mr. John Beil criticises the distinctions 
 drawn by the preceding writer, and he says, 
 that a polypus is never mild, and never ma- 
 lignant ; time, and the natural growth of the 
 tumour, and the pressure it occasions within 
 the soft and bony ceils of the nostrils and 
 jaws, must bring every polypus to one inva- 
 luable form, in its last and fatal stage. Po- 
 lypus, says Mr. John Bell, is indeed a dread- 
 ful disease ; but it becomes so by a slow 
 progression, and advances by gradations 
 easily characterized. Every polypus in its 
 early stty r e, is, according to this writer, a 
 small moveable tumour, attended with a 
 sneezing and watering of the eyes ; swelling 
 in moist weather ; descending with the 
 breath ; but easily repressed with the point 
 of the finger. It is void of pain, and not at 
 all alarming ; it may also be easily extracted, 
 so as to clear for a time the passage for the 
 breath. Yet this little tumour, simple as it 
 may appear, is the germ of a very fatal and 
 loathsome disease, and this easy extraction 
 often the very cause of its appearing in its 
 most malignant form The more easily it is 
 extracted, (says Mr. J. Bell,) the more easily 
 does it return ; and whether carelessly ex- 
 tracted, or altogether neglected, it soon re- 
 turns. But when it does return, it has not 
 really changed its nature ; it has not ceased 
 to be in itself mild, it is then to be feared, 
 not from its malignity, but from its pressure 
 among the delicate cells and membranes of 
 the nose. It soon fills the nostrils, obstructs 
 the breathing, and causes indescribable anx- 
 ieties. The tears are obstructed, and the 
 eyes become watery from the pressure on 
 the lachrymal sac ; the hearing is in like 
 manner injured, by the pressure of the tu- 
 mour against the mouth of the eustachian 
 lube ; the voice is changed, and its resonance 
 and tone entirely lost, by the sound no lon- 
 ger passing through the cells of the nose 
 and face. The swallowing is in some de- 
 gree affected by the soft palate being depress- 
 ed by the tumour. The pains arising from 
 such slow and irresistible pressure are un- 
 ceasing. From the same pressure the bones 
 become carious, and the cells of the face and 
 nose are destroyed by the slow growth of 
 the swelling. It is not long before the tu- 
 mour begins to project from the nostril in 
 front, and over t lie arch of the palate be- 
 hind. One nostril becomes widened and 
 thickened ; the nose is turned towards the 
 opposite side of the face, and the whole 
 countenance seems distorted. The root of 
 the nose swells, and becomes putty, the fea- 
 tures tumid and flabby, the face, yellow, and 
 the parts round the eye livid. The patient 
 is affected with headachs, which seem to 
 rend the bones asunder, and with perpetual 
 stupor, and dozing. The bones ore now ab 
 sorbed, and the membranes ulcerate ; a foul 
 and fetid matter, blackened with blood, is 
 discharged from the nostrils, and excoriates 
 
 them. The blood-vessels next give way, ami 
 sudden impetuous hemorrhages weaken the 
 patient ; the teeth fall from the sockets, and 
 through the empty sockets a foul and fetid 
 matter issues from the antrum. 
 
 Now the disease verges to its conclusion 
 The patient has terrible nights, and experi- 
 ences a sense of suffocation. The repeated 
 loss of blood renders him so weak, that he 
 cannot quit his bed for several days together ; 
 and when he does get up, he is (to use Mr 
 Bell’s words) pale as a spectre, his lips co- 
 lourless, and his face like wax, yellow, and 
 transparent. He now suffers intolerable 
 pain, while his saliva is continually dribbling 
 born bis mouth, and a fetid di-charge from 
 his nose. In this state, he survives a few 
 weeks ; during the last days of his illness, 
 lying in a state of perpetual stupor, and dy- 
 ing lethargic. Mr. J. Bell afterward ob- 
 serves, that “ if horrid symptoms could es- 
 tablish the fact of malignity, there is not to 
 be found in all nosology a more malignant 
 disease than this : but aneurism, though it 
 destroys the thigh bone, the sternum, or cra- 
 nium, is not accounted malignant ; neither 
 is polypus malignant, though it destroys 
 the cells of the face, and penetrates even 
 through the ethmoid bone to the brain. 
 These consequences result merely from 
 pressure.” (John Belt's Principles of Surge- 
 ry, Vol. 3, Purl 1 ,p 90 — 92.) 
 
 in April, 1817, there was a boy in St. Bar- 
 tholomew’s Hospital, only twelve years old, 
 who had just fallen a victim to the ravages 
 ot the largest and most disfiguring disease 
 within the nose which I have ever had an 
 opportunity of beholding. The tumour be- 
 fore death had expanded the upper part of 
 the nose to an enormous size, while below 
 the left nostril was immensely enlarged 
 The distance between the eyes was extraor- 
 dinary, being more than four inches. The 
 left eye vvu3 affected with amaurosis, brought 
 on by the pressure of the swelling ; the right 
 retained to the last the faculty of seeing. 
 The tumour nearly covered the mouth, so 
 that food could only he introduced with a 
 spoon, and an examination of the slate of 
 the palate was impossible. About a fortnight 
 before death, the leg became paralytic, and 
 during the last week of the boy’s existence, 
 an incontinence of the urine and feces pre- 
 vailed. On examination of the head after 
 death, a good deal of the tumour was found 
 to be of a cartilaginous consistence, and, 
 what was most remarkable, a portion ot it, 
 which was as large as an orange, extended 
 within the cranium, where it had annihila- 
 ted the anterior lobe ol the left hemisphere 
 of the brain. Yet, notwithstanding this ef- 
 fect, the boy was not comatose, nor insensi- 
 ble, till a few hours before his decease. All 
 the surrounding bones had been more or less 
 absorbed, and the place from which the ex- 
 crescence first grew could not be determined 
 The celebrated Professor Richter has de- 
 nied the validity of (he objections urged by 
 Pott against attempting to relieve the pa- 
 tient : neither the malignant nature ot a po- 
 lypus, it» adhesions, iinn)ovcubleness t nice- 
 
POLYPUS. 
 
 363 
 
 rations, dot disposition to hemorrhage, &,c. 
 are, according to Richter, any* apology for 
 leaving the disease to itself. (See An- 
 fangigr. dtr IVundarxn. B. I, cap. 21.) 
 
 Mr. J. Bell refutes the common notions, 
 that polypi may be caused by picking the 
 nose, blowing it too forcibly, ‘colds, and local 
 injuries. He asserts, that a polypus is not 
 in general a local, solitary tumour: he has 
 only found it so in three or four instances. 
 Both nostrils are usually affected. He states, 
 that no finger can reach that part of Ihe nos- 
 tril whei e the root of the swelling is situated, 
 as it is deep and high in the no-trils, towards 
 tile throat, and near the opening of the eus 
 tachian tube. The finger cannot be intro- 
 duced further than ihe cartilaginous wing of 
 the nose extends and can hardly touch the 
 anterior point of the lower spongy bone. 
 The anterior and posterior chambers of the 
 nostril are separated Irom each other by a 
 narrow slit, which (he finger can never pass, 
 and which is divided, in consequence of the 
 projection ot the lower spongy bone, into 
 two openings, one above, the other below. 
 Through these the heads of the polypus pro- 
 ject. These tangible parls of the tumour, 
 however, are very distant from its root, which 
 is in the highest and narrowest part of the 
 nostril. (See p. 103, lu4.) Mr. J. Bell also 
 says, that three or four polypi are often 
 crowded together in one nostril, while more 
 are formed, or forming, in the other. 
 
 He dwells upon the difficulty and imprac- 
 ticableness of tying the root of a polypus; 
 and explains, in all attempts to extirpate 
 such tumours, the surgeon’s aim should be 
 to reach a point nearly under the socket of 
 the eye, in the deepest and highest part of 
 the nostrils, and that instruments can only 
 do good w hen introduced beyond the narrow 
 cleft, formed by the projection of the spongy 
 bone. (P. 108.) 
 
 Though Mr. John Bell is probably right in 
 his opinion, that polypi do not proceed from 
 the several circumstances which have been 
 above noticed, yet they are, in most instan- 
 ces, diseases of an entirely local nature. 
 Certainly, in general, it is very difficult to 
 describe what is the cause of a nasal polypus. 
 Frequently the patient is, in other respects, 
 perfectly well ; and after the removal of the 
 tumour, no new one makes its appearance. 
 In this circumstance, it must originate from 
 a local cause, though it is generally difficult 
 to define what the nature of this is. Some- 
 times several catarrhal symptoms precede 
 the polypus, and, perhaps, constitute its 
 cause. It is possible, they may only bean 
 effect of the same cause which gives bir h 
 to the tumour ; but, no doubt, they are some- 
 times the effect of the polypus itself. Some- 
 times, perhaps, a faulty slate of (he constitu- 
 tion really contributes to the disease ; for se- 
 veral polypi frequently grow in both nostrils, 
 and even in o:her situations at the same 
 time ; are reproduced immediately after 
 their removal ; and the patient often has an 
 unhealthy appearance. Notwithstanding it 
 has been asserted, that a solution of the mu 
 riate ot ammonia, frequently injected into 
 
 the nose, sometimes disperses polypi, the ef- 
 ficacy of tile remedy remains unestablished 
 by experience ; as, indeed, the very nature 
 of the disease might lead one to anticipate. 
 An operation affords the only rational chance 
 of a cure. 
 
 There are four modes of extirpating a na- 
 sal polypus : viz. extracting it with forceps ; 
 tying it with a ligature ; cutting it out ; and 
 destroying it with caustic. 
 
 Extraction is i he most common and pro- 
 per meihod. It is performed with the ordi- 
 nary polypus forceps, the blades of which 
 have holes in them, and are internally ra- 
 ther rough, in order that they may take hold 
 of the tumour more firmly, and not easily 
 slip off it. The front edge of each blade 
 must not be too thin and sharp, lest, with its 
 fellow, it should pinch off a portion of the 
 polypus. The blades must necessarily have 
 a certain breadth ; for when they are too 
 small, they cannot properly take hold of and 
 twist the tumour. When the handles are 
 rather long, the instrument may be more 
 firmly closed, and more conveniently twisted. 
 
 However, the forceps is not applicable to 
 all cases. The anterior part of the polypus, 
 lying in the nostril, distending, and totally 
 obstructing it, is sometimes quite hard, and 
 when theforeeps is introduced, it presses the 
 blades in such a manner, from each other, 
 as it lies between them, that the instrument 
 cannot be introduced sufficiently far to take 
 hold of the tumour at a proper depth. If 
 introduced fo a proper distance, it cannot 
 be closed. In such a case, says Richter, one 
 might, perhaps, advantageously make use of 
 a pair of forceps, the pieces of which may 
 be separately introduced, and then fastened 
 together again at Ihe joint, and the blades of 
 which diverge from each other behind the 
 joint, and touch again at their extremities 
 The anterior indurated portion of the poly- 
 pus lies in the interspace, and does not pre- 
 vent the closure of the instrument. 
 
 It is generally deemed of importance to 
 take hold of the polypus with the forceps 
 close to its root ; and, indeed, when this rule 
 is observed, the whole of the polypus, to- 
 gether with its root, is commonly extracted, 
 and there is less reason to apprehend he- 
 morrhage, which is naturally more profuse 
 when the polypus is broken at the thick, mid- 
 dle portion of its body. It is also a rule fre- 
 quently easy of observance, especially when 
 the polypus is not too large. But in many 
 instances the tumour is so large, and the nos- 
 tril so completely occupied by it, that it is 
 impracticable to get hold of its root. In tins 
 circumstance it is often altogether impossi- 
 ble to discover even where the root lies. 
 Here we must be content to take hold of 
 the polypus as high as possible. The conse- 
 quences are of two kinds. The tumour 
 sometimes gives way at its root, though it be 
 only taken hold of at its anterior part ; and, 
 in other cases, breaks where it is grasped, a 
 portion being left behind, and a profuse he- 
 morrhage ensuing. This is, however, void 
 of danger, if the surgeon does not waste 
 time in endeavouring to suppress the effu- 
 
POLYPUS 
 
 364 
 
 sion of blood ; but immediately introduces 
 the forceps again, grasps the remnant piece, 
 and extracts it. The most infallible method 
 of diminishing the bleeding, is to extract 
 what remains behind at its root. In this way, 
 a large polypus is frequently extracted, piece- 
 meal, without any particular loss of blood. 
 
 After the polypus has been propelled as 
 far forward, into the nostrils, as it can be by 
 blowing strongly through the nose, its ante- 
 rior part is to be taken hold of by a small 
 pair of common forceps, held in the left 
 hand ; and is to be drawn gradually and 
 slowly out, to make room for the introduc- 
 tion of fhe polypus-forceps into the nostril. 
 The more slowly we proceed in this ma- 
 noeuvre, the more the polypus is elongated, 
 the narrower it becomes, the greater is the 
 space in the nostril, for the introduction of 
 the polypus-forceps, and the higher can this 
 instrument grasp the tumour. Atier it has 
 taken hold of the polypus as high as possi- 
 ble, it is to be twisted slowly round, and, at 
 the same time, pulled outward, til! the tu- 
 mour breaks. It is a very important maxim, 
 rather to twist the instrument than to pull it, 
 and thus rather to writhe the polypus off than 
 to drag it out. The longer and more slowly 
 the polypus-forceps is twisted, the more the 
 part where the excrescence separates is 
 bruised, the less is the danger of hemor- 
 rhage, and the more certainly does the tu- 
 mour break at its thinnest part, or root. 
 When the extraction is done with violence 
 and celerity, only a piece is usually brought 
 away, and we run hazard of occasioning a 
 copious bleeding. 
 
 As soon as the polypus has given way, the 
 surgeon is to examine whether any part re- 
 mains behind. When the polypus is very 
 narrow at the place where it has bf-en broken, 
 and the patient can breathe through the nose 
 freely, there is reason to presume that the 
 polypus has given way at its root, and that 
 none continues behind. The finger, if it 
 can be introduced, procures the most certain 
 information ; or the probe, when this, for 
 want of room, cannot be employed. The 
 ancients proposed several means for the ex- 
 tirpation of the remaining piece of polypus ; 
 but they are, for the most part, objectiona- 
 ble. It is best to introduce the forceps again, 
 under the guidance of the finger, or probe, 
 and thus pinch, and twist off, the part con- 
 tinuing behind. 
 
 Hemorrhage invariably succeeds the ope- 
 ration ; and by many writers has been re- 
 presented as exceedingly perilous and alarm 
 ing. But it is not constantly so, and in some 
 cases is quite insignificant. Frequently, 
 however, it is really serious ; and as the sur- 
 geon can never know beforehand to what 
 extent it will happen, he is always to furnish 
 himself, before the operation, with the most 
 effectual means for its suppression. The 
 danger of hemorrhage may always be less- 
 ened, as was before mentioned, by slowly 
 twisting the polypus at its root, in preference 
 to pulling it directly out. When only a por- 
 tion of the tumour has been extracted, the 
 surest mode of slopping the effusion of blood 
 
 is to extract the remaining part without Ge 
 lay. When the polypus has given way at ite 
 root, if there should be profuse bleeding, 
 we may first try ice-cold water and strong 
 brandy, which may either be sucked or in- 
 jected into th§ nose. This single remedy 
 proves effectual in numerous instances. If 
 the hemorrhage should still prevail, it may 
 always be checked with certainty, how co- 
 pious soever it may be, in the following man- 
 ner. Roll a considerable piece of lint, as 
 fast as possible, round the extremity of a 
 probe ; wet it completely through with a 
 strong solution of the sulphate of zinc ; in- 
 troduce it into the nostril, and press it as 
 strongly as possible against the part whence 
 the blood issues. When the nostril is very 
 much dilated, the fingers may be used for 
 this purpose with more advantage than the 
 probe. The point from which the blood is 
 effused, may easily be ascertained, by press- 
 ing the finger on various points. As soon as 
 the blood ceases to flow, we may conclude 
 that the finger is on the situation of the he- 
 morrhage. This method is so efficacious, 
 that there is seldom occasion for any other. 
 When the bleeding point lies deeply in the 
 nostril, it might be difficult to reach it with 
 the finger. At all events, we may then em- 
 ploy a plan which has been strongly praised 
 in urgent cases. 
 
 A piece of catgut may be introduced into 
 the nostril, and by means of a pair of for 
 ceps, be brought out of the mouth. A roll 
 of lint is then to be attached to it, and drawn 
 through the mouth into the nose ; thus the 
 posterior aperture of the nostril may be 
 stopped up. Then the nostril in front is to 
 be filled with a sufficient quantity of lint, 
 moistened in the solution of zincum vitrio- 
 latum. 
 
 The objections to extracting some polypi, 
 says Richter, have been much exaggerated. 
 When the polypus is so large, that its root 
 cannot be got at, its anterior part is to be 
 taken bold of, and the tumour extracted 
 piecemeal. It has already been noticed, 
 that this practice is free from danger. Ex- 
 perience does not prove, that the polypus, 
 which often bleeds profusely, is apt to 
 occasion a violent hemorrhage in the opera- 
 tion ; and even if it should do so, powerful 
 measures may be adopted for the stoppage 
 of the bleeding. The malignity and ulcera- 
 tions attending a polypus, are no objections 
 to the operation ; but are rather motives for 
 its being promptly performed, as delay must 
 occasion more manifest and urgent danger. 
 If the polypus should be here and there 
 adherent to the membrane investing the 
 nostrils, it is proper to separate it before the 
 operation. This object cannot be accom- 
 plished by straight inflexible instruments 
 such as have been invented by various 
 surgeons. It may be very conveniently 
 done, according to Richter, with thin, long, 
 flat pieces of tortoise-shell, introduced as 
 deeply as possible into the nostril, on 
 every side of the polypus. As it can seldom 
 be known with certainty, a priori, that ad- 
 hesions are not present? it is proper whene- 
 
I'OLYl'Ufe 
 
 3(i5 
 
 ver the tumour is large, to introduce these 
 instruments before the operation. 
 
 Sometimes, the greatest part of the polypus 
 extends backward, hanging down behind 
 the palatum molle, towards the pharynx. If 
 there should be but little of the polypus 
 visible in the nostril, its extraction must be 
 performed backward, in ihe throat. This is 
 usually done with a pair of curved polypus 
 forceps, which is to be introduced through 
 the mouth, in order to seize and tear off the 
 tumour as high as possible above the soft 
 palate. Care must be taken not to irritate 
 the root of the tongue, or else a vomiting is 
 produced, which disturbs the operation. 
 When the polypus cannot be properly taken 
 hold of, we may, according to the advice of 
 some surgeons, divide the soft palate. But 
 this is very rarely necessary. As, by this 
 mode, the polypus is not twisted, but pulled 
 away, the hemorrhage is, in general, rather 
 copious. If a fragment of the tumour should 
 remain behind, it may commonly be extract- 
 ed through the nose. 
 
 Some recommend, for the extraction of 
 polypi in the throat, a ring, consisting of 
 two semicircular portions, with a kind of 
 groove externally, which are capable of 
 being opened and shut, by being fixed on 
 the ends of an instrument constructed like 
 forceps. A ligature is to be placed round 
 the ring, and its end is to be brought to the 
 handle of the instrument, and held with it 
 in the hand. The instrument is to be intro- 
 duced into the mouth, under the polypus, 
 and expanded as much as the size ot the 
 tumour requires. Its ring is then to be 
 carried upward, over the polypus, so as to 
 embrace it ; and afterward is to be shut., 
 whereby the noose, after being carried up- 
 ward, is disengaged from the ring. The 
 noose is to be pushed as high as possible 
 over the tumour, by means of forceps, and 
 the extremity of the packthread is then to 
 be drawn, so as to apply the noose tightly 
 round the polypus. When this is done, the 
 ring of the instrument is to be turned round 
 firmly closed, and placed in front of the 
 polypus, on the noose, in such a way, that 
 the packthread is to lie between two little 
 pegs, made for the purpose, at the ends of 
 the ring. On drawing the packthread firmly, 
 and pressing the instrument at the same 
 time downward so as to make it act like a 
 lever, the polypus in general easily breaks. 
 Another peg projects in the direction of the 
 ring, so as to prevent the ligature from in- 
 sinuating itself within the circle. (See 
 Theden’s Bemerk. Part 2. and Platt 6. fig. 1. 
 in Richter's Jlnfangsgr.) 
 
 The employment of this instrument, 
 however, is attended, says Richter, with 
 many difficulties, and little advantage. Po- 
 lypi in the throat are most conveniently 
 extracted by the ordinary straight polypus 
 forceps, with which they may be seized, 
 and gradually drawn out through the mouth. 
 The tumour generally allows itself to be 
 drawn out without trouble, and the inclina- 
 tion to vomit, which at this moment occurs, 
 also contributes to propel it outward. When 
 
 it is so stretched, that it cannot be drawn 
 out further, without considerable force, a 
 spatula is to be introduced into the mouth, 
 and to be carried as high as possible behind 
 the polypus, in order to press it downward, 
 toward the root of the tongue. When the 
 tumour is at the same time forcibly pulled 
 outward by the forceps, it usually gives way. 
 
 When the polypus is situated partly in the 
 throat and partly in the nostril, though it 
 admits of being extracted, in the same way, 
 through the mouth, yet its anterior part often 
 continues attached, and must afterward be 
 saparately removed through the nostril. It 
 is also frequently adviseable to twist off the 
 anterior portion of the polypus first, by 
 which the mass in the throat is often ren- 
 dered so loose, that it can be easily extract- 
 ed. Whenever it is conjectured, that the 
 polypus will come away in two pieces, it is 
 always preferable first to extract the part in 
 the nostril, and afterw ard that in the throat 
 because tiie separation of the last is con- 
 stantly productive of more bleeding, than 
 the removal of the first. Sometimes, the 
 following plan succeeds in detaching the 
 whole polypus at once. Both the part iri 
 the nostril, and that in the throat, are to be 
 firmly take hold of w ith the for; ms, and 
 drawn at first gentlv and then more f cibly,, 
 backward and forward. By such repeated 
 movements, the root is not unfrequently 
 broken, and the whole polypus brought 
 away from the mouth. 
 
 Frequently the polypus grow s again. Po- 
 licy requires that the patient should be 
 apprized of this beforehand. Some of the 
 root remaining behind, may often be a cause 
 of the relapse. Hence the surgeon should 
 examine carefully, after the operation, the 
 part at wnich the root of the polypus was 
 situated, and separate, and twist off, most 
 diligently, with the forceps, any fragments 
 that may still continue attached. I he re- 
 currence of the disease, however, may 'arise 
 from other causes. The tumour is occasional- 
 ly reproduced, after it has been extracted 
 in the most complete manner; and doubt 
 less, this circumstance is sometimes ow ing 
 to the continued agency of constitutional 
 causes, which so often remain undiscovered 
 and unremoved Sometimes, also, the re- 
 currence of the disease is owing to a local 
 morbid affection oi the Schneiderian mem- 
 brane, or of the bones situated beneath the 
 root of the poly [ius. Richter, in this case, 
 approves ot the cautery ; but few English 
 surgeons will coincide w ith him. The po- 
 lypus, sometimes observed subsequently to 
 tin operation, is fr< quently not, in fact, a 
 a new' substance, but only a part of the 
 original tumour, not previously noticed by 
 the surgeon. Sometimes it occurs, thai a 
 smaller and larger polypus are found in the 
 nose at the same time The larger one is 
 extracted, while the other remains undisco- 
 vered ; and when it has increased in magni- 
 tude, it is apt to be mistaken for a repro- 
 duction of the one previously extirpated. 
 (See Richter's Anfangsgr. drr Wuvdarsn , B 
 1. Kap. 21 A 
 
POLYPUS. 
 
 Ligature. As the extraction of the poly- 
 pus is invariably attended wiih hemorrhage, 
 which is sometimes profuse, another more 
 modern method of cure has been proposed 
 as more convenient and secure. This con- 
 sists in tying the root of the tumour with a 
 ligature, by which the polypus is thrown 
 into the state of inflammation, suppuration, 
 and sphacelus ; and at length becomes de- 
 tached. Many instruments have been in- 
 vented for applying the ligature ; but 
 Levret’s double cannula seems to be the best. 
 Through this, a silver wire is to be introdu- 
 ced, so as to form a noose at the upper end 
 of the instrument, proportioned in size to 
 the anterior part of the tumour, situated in 
 the nostril. t he two ends of the wire are 
 t> hang out of the two lower apertures of 
 the dou! e ^nnula ; and one of them is to 
 be iastened to a small ring on its own sid8 
 of the instrument. The other is to remain 
 loose. Ti.e wire must be made of the 
 purest silver, and ought to be as flexible as 
 possible, tnat it may not readily break It 
 must also not be too thin lest it should cut 
 through the root of the polypus. The can- 
 nula is to be somewhat less than five inches 
 long By the assistance of this cannula, the 
 noose is to be introduced into the nose, and 
 put round the polypus. But as the cannula, 
 which is usually constructed of silver, is 
 straight and inflexible, while the inner 
 surface of the nostril is preternaturally 
 arched, especially when much distended by 
 the polypus, it is easy to discern that its 
 introduction must be attended with consi- 
 derable difficulty, in fact, it can seldom be 
 introduced as deeply as the root of (he 
 polypus. There are two ways of avoiding 
 this obstacle. The cannula may either be 
 passed under the polypus, over the ossa 
 palati, which present a tolerably straight 
 surface, or it must be curved a little. Per- 
 haps, a tortoise-shell cannula, says Richter, 
 might be convenient. 
 
 The noose is to be applied in the follow- 
 ing manner. r lbe polypus is to be taken 
 hold of with the forceps, and drawn a little 
 out of the nose. The noose is then to be 
 carried over the forceps and polypus, into 
 the nostril. In order to carry it as high as 
 possible, it is necessary not to push the can- 
 nula st'-aight forwards into the nose, but to 
 move it from one side of the polypus to the 
 other. The more deeply the instrument 
 has entered the nose, the more of the 
 loose end of the wire must be drawn out of 
 the lower aperture of the cannula, so as to 
 contract the noose, which otherwise might 
 stop in the nostril, and not be carried suffi- 
 ciently high. The elasticity of the silver 
 wire tends to assist in raising it over the 
 p ! vpus, and hence, it is more easy of appli- 
 c lion than a more flaccid kind of a ligature. 
 When there is cause to conclude, that the 
 polypus is complicated with adhesions, they 
 must be previously broken, in the way 
 already mentioned. 
 
 As soon as the noose has been introduced 
 as deeply as possible, the loose extremity of 
 
 the wire is to be drawn out. of the lower 
 aperture of the cannula, and rolled round 
 the ring on that side of the instrument. 
 Thus the root of the polypus suffers con 
 striction. The wire must not be pulled 
 too forcibly, nor yet too feebly. In the 
 first circumstance, it readily cuts through 
 the root of the polypus: in the second, 
 great tumefaction of the excrescence, and 
 many inconveniences arise, which a tenser 
 state of the wire prevents. As the noose 
 gradually makes a furrow where it surrounds 
 the polypus, it grows slack after a short 
 time, and no longer constricts the tumour. 
 One end of the wire, therefore, is to be daily 
 unfastened, and drawn more tightly. The 
 more tense it is kept, the sooner the separa- 
 tion of the polypus is brought about. Hence, 
 when it is particularly indicated to produce 
 a speedy attachment of the polypus, the 
 wire should be tightened, at least, once a 
 day. 
 
 In this mannner the cannula is to remain 
 in the nose until the noose is detached, to- 
 gether with the poiypus. There is another 
 method of tying the tumour, without leav- 
 ing the cannula in the nose. After the 
 noose has been introduced as far as possible 
 into the nostril, the two ends of the wire 
 are to be twisted round the two rings, and 
 the cannula is to be turned round a couple 
 of times. The wire is then to be unfastened 
 from the rings, and the cannula withdrawn. 
 In this way the noose is made to embrace 
 the poi pus, round which it remains fastly 
 applied. Whenever it is wished to produce 
 a greater constriction, the cannula may be 
 again introduced into the nose, the ends of 
 the wire fastened to the rings, and the in- 
 strument turned round again ; after which 
 it is to be taken away, as before. As the 
 cannula, when it continues long in the nose, 
 may occasion pain, and other inconveni- 
 ences, the last method seems preferable to 
 the former. However, introducing and 
 withdrawing the cannula every day, as 
 Richter adds, may, perhaps, be equally trou- 
 blesome and painful. The cannula for this 
 purpose being necessarily straight, is by no 
 means handy. One might, at all events, 
 make use of a single cannula, the upper 
 opening of which is divided by a bridge ; 
 this could be much more conveniently twist- 
 ed than a double one. 
 
 Although the ligature has been very much 
 praised by some of the moderns, it is at- 
 tended with so many difficulties, that in the 
 majority of cases, the forceps is infinitely 
 preferable. Hemorrhage is the only incon- 
 venience, for which extraction is abandon- 
 ed for the employment of the ligature. But 
 this, as was before stated, is much less dan 
 gerous than is represented. The inconve- 
 niences of the ligature are far more serious, 
 and numerous. The cure bv the ligature is al- 
 ways accomplished with much less expedi- 
 tion than by extraction. When the polypus is 
 of such a size as to occupy the whole of the 
 nostril, it is generally impracticable to in- 
 troduce the noose to a sufficient depth 
 
POLYPI S. 
 
 •The figure oi the polypus renders it almost 
 impossible to tie its root ; for commonly the 
 tumour expands very much before and 
 behind, and the wire must be brought over 
 the posterior part of the polypus, ere it can 
 be applied to its root. In general, also, the 
 noose only includes the front part of the 
 polypus, while the root, and back portion 
 remain untied, and consequently do not 
 become detached. — It is, indeed, asserted, 
 that the ligature, when only applied to the 
 front part of the polypus, is capable of bring- 
 ing about inflammation, suppuration, and 
 a detachment of the whole of the tumour. 
 This may sometimes be the case; but ana- 
 logous instances prove, that it is undoubted- 
 ly not constantly so. The ligature seldom 
 accomplishes an entire destruction of the 
 disease, and there is usually reason to appre- 
 hend its recurrence. If the polypus be very 
 large, and the w hole nostril occupied, it is 
 frequently utterly impossible to introduce 
 the wire ; and when this is done, the front 
 of the tumour alone can be tied. 
 
 The polypus nasi is commonly highly sen- 
 sible, and consequently, tying it proves very 
 painful. As soon as the noose is drawn 
 tight, not only the polypus inflames, but the 
 whole extent of the Schneiderian mem- 
 brane. The pain and inflammation often 
 extend even to parts at some distance, such 
 as the throat, eyes, he. occasioning acute 
 fever, which requires the strict observance 
 of low diet v the exhibition of cooling physic, 
 and the evacuation of blood Hence, it is 
 adviseable in many cases, to prepare pa- 
 tients for this treatment, by diet and medi- 
 cines. 
 
 When the polypus is tied, it swells very 
 much, and all the complaints which it pre- 
 viously caused are exasperated. But, in 
 particular, the part situated in the throat, 
 sometimes obstructs deglutition and respi- 
 ration, in such a degree, that prompt re- 
 lief becomes necessary ; and one of the 
 best plans for affording it, is to make a few 
 punctures in the tumour. These excite a 
 bleeding, that very speedily lessens the 
 swelling, but is sometimes difficult to check. 
 Hemorrhage from a part of the polypus 
 that is tied, is most effectually stopped by 
 twisting the wire so tight, that it closes the 
 arteries distributed to it. 
 
 The wire sometimes breaks off' close to 
 the lower aperture of the cannula, in con- 
 sequence of being twisted so much and 
 thus the progress of the cure is interrupted. 
 A new wire may be introduced ; but it is 
 difficult to apply it exactly in the situation 
 of the other. A fresh place is commonly 
 tied, which is almost the same thing as com- 
 mencing the cure anew. It is better to 
 prevent this interruption of the treatment 
 by employing very flexible w ire, made of 
 the purest silver ; and by not twisting and 
 untwisting regularly the same extremity of 
 it, but sometimes one and sometimes the 
 other. A strong piece of catgut might be 
 a very good substitute for silver wire. 
 
 Immediately the polypus is tied, it swells, 
 inflames, and becomes painful; in. a few 
 
 days, it becomes shrunk, free from pain, 
 and sphacelated. The fetid discharge now 
 occasions considerable inconvenience to 
 the patient, and ought to be washed awrny 
 by repeated injections. Towards the 'ter- 
 mination of the case, the surgeon ought to 
 take hold of the polypus with the forceps, 
 to try whether any of it is loose. When 
 the polypus is extracted, one may inject a 
 solution of alum, tor a day or two after- 
 ward, in order to diminish the effect of the 
 irritating discharge on the Schneiderian 
 membrane, and the suppuration in the situa- 
 tion of the ligature, as it is sometimes pro- 
 fuse, and of long duration. 
 
 Though one might also tie polypous 
 tumours in the throat; and, indeed, the 
 introduction of the cannula through the 
 mouth, and the application of the noose, 
 would be attended with no great difficulty; 
 and, though the treatment might be rendered 
 more tolerable to the patient, by withdraw- 
 ing the cannula afier tw isting the wire ; yet, 
 the swelling of the tied portion of the tumour 
 would, probably, create immense inconve- 
 nience. In this case, therefore, extraction 
 usually merits the preference, and the liga- 
 ture is only fit to be practised in the throat, 
 when tin* polypus is very small, or there is 
 some especial cause forbidding extraction. 
 When deglutition and respiration are impe- 
 ded by the swelling of the tied portion of 
 the polypus in the throat, the swollen part 
 must be scarified by means of the pharyngo • 
 tomus. so as to excite a bleeding, ai.d 
 thereby produce a diminution of the swell- 
 ing. The noose is to be frequently and 
 strongly tightened, in order to accelerate 
 the detachment of the polypus, and shorten 
 the inconveniences. When the excrescence 
 has not only descended towards the pha- 
 rynx, but also into the nostril, its front por- 
 tion is to be tied first. The result of this 
 may be, such an inflammation and suppura- 
 tion of the whole polypus, that, after the 
 separation of its anterior portion the pos- 
 terior one may also become detached, or 
 at least, easy of removal. 
 
 Caustics. The cautery, formerly recom- 
 mended for the cure of the polypus nasi, is 
 now almost entirely rejected, and indeed, 
 in the manner it w r as customary to use it, 
 little good could be done. It was applied 
 to the anterior surface of the tumour in the 
 nostril, and its employment was repeated 
 every time the slough separated. Its opera- 
 tion could naturally be but of small extent, 
 as it only came into contact with a trivial 
 portion of the polypus. Its irritation aug- 
 mented the determination of blood to the 
 excrescence, and accelerated its growth ; 
 w hile as much ot the the tumour was repro- 
 duced. ere the slough separated, as was thus 
 destroyed; and the design of completely 
 extirpating the disease, in this way seldom 
 or never proved successful. However, says 
 Richter, there is one particular example, 
 where the cautery is the only means from 
 which relief can be derived ; and, used in 
 a certain way, it always speedily produces 
 the desired effect . 
 
POLYPUs 
 
 
 Tliere are some nasal polypi, much dis- 
 posed to profuse bleeding. Touching them 
 in the gentlest manner, and every trivial con- 
 cussion of the body, give rise to hemorrhage. 
 The patient is exceedingly debilitated by re- 
 peated loss of blood ; his countenance is 
 pallid; his feet swollen; he is affected with 
 hectic fever; and faints whenever there is any 
 considerable bleeding. Doubtless, exirac- 
 tion,in this case, is a very precarious method, 
 as the patient is so circumstanced, that any 
 copious effusion ot blood must be highly 
 perilous. Sometimes the polypus is, at the 
 same time, so large, and the nostril so com- 
 pletely occupied and distended, that it is 
 impossible to apply a ligature. Such is the 
 ease, to which alone the cautery promises 
 assistance, (Richter.) 
 
 In employing the cautery, (says the latter 
 author,) the object is not to effect, by its 
 direct agency, a gradual destruction of the 
 polypus ; but to excite such an inflammation, 
 and suppuration, of the whole of it, as shall 
 lead to this event. To fulfil this purpose, a 
 common trocar, three inches long, may Jae 
 used. The cannula ought to be two inches 
 shorter than the trocar, whereby the latter 
 may protrude from it so far ; and it should 
 be constructed with a handle. The cannula 
 should be made wider than i’t is in common, 
 so as to allow the trocar to be introduced, 
 and withdrawn with facility. It is to be 
 wrapt round with apiece of wet linen, and 
 applied to the polypus. The red-hot trocar 
 is then to be pushed into the tumour, as far 
 as the cannula will allow it, which is, of 
 course, two inches. 
 
 When the patient entertains a dread of 
 the actual cautery, Richter sanctions the 
 introduction of a tent of the emplastrum 
 cantharidum, ora tent smeared with butter 
 of antimony, into the puncture of the un- 
 heated trocar, and as soon as suppuration 
 has taken place!, emollient and detergent 
 lotions are to be injected. ( Richter's An- 
 faitgsgr.) In England, the actual and 
 potential cauteries are never used for the 
 destruction of nasal polypi. 
 
 Excision. In the treatment of the poly- 
 pus, the use of cutting instruments has al- 
 ways been reprobated, because they usually 
 occasion a profuse hemorrhage, and c.tn 
 hardly ever be passed, without mischief, to 
 a sufficient dentil into the nose to divide the 
 root of the tumour. Yet. there are instan- 
 ces in which their use might be productive 
 of advantage. The anterior part of the po- 
 lypus, situated in the nostril, is sometimes 
 so thick and hard that it is utterly imprac- 
 ticable to introduce the forceps for the 
 performance of extraction, or the cannula 
 for the application of the ligature. In such 
 a case, it might be a judicious step to cut off 
 the front of the polypus with a sharp in- 
 strument, of a suitable. shape, in order to 
 make room for the use of the ligature, or 
 forceps. The polypus is sometimes of a 
 ligamentous structure, and neither admits of 
 being tied hor extracted. There is no means 
 of removing such a polypus except the knife, 
 by which it b to be. cut away piecemeal. 
 
 Mr. Whately, after tailing in several at- 
 tempts to extract and tie a considerable po- 
 lypus of (he nose, succeeded in cutting it 
 out. He used a narrow, straight bistoury, 
 with a probe point, having a sheath fixed 
 upon* its edge, by a screw put into a hole in 
 the handle. An eye was made at its point, 
 to receive one end of a thread intended to 
 be passed round the polypus, for the pur- 
 pose of directing the knife to the extremity 
 of the tumour. There was also a contri- 
 vance by which the knife could be unsheath- 
 ed at its extremity, the length of three-quar- 
 ters of an inch. This was done by means 
 of a screw, which might be fixed in another 
 hole, by drawing back the sheath. By ex- 
 posing such a length of edge only, the in- 
 terior parts of the nose were defended from 
 the danger of being wounded.” Whoever 
 wishes a particular account of the manner 
 of using the instrument, must consult Mr. 
 Whately’s Cases of two extraordinary Po- 
 lypi , §'C. 1805. 
 
 In the polypus which arises from a relax- 
 ation of the Schneiderian membrane, ex- 
 ternal astringent applications may be first 
 tried ; such as ice-cold w^ater, solutions of 
 acetite of lead, alum, muriate of ammonia. 
 &c. These remedies (says Richter) common - 
 ly lessen it, and frequently, when it is not 
 very large, accomplish its entire removal 
 If this should not happen, there is no reason 
 against putting a ligature round it. Here, 
 also, w^e may venture to employ a cutting 
 instrument, if it be in our power to do so ; 
 which, as far as my experience goes, will 
 very rarely be the case. But the practice 
 of extraction is here prohibited. 
 
 When the Schneiderian membrane is pre- 
 ternaturally swollen all over the nostril, 
 which is quite obstructed, the pervious state 
 of the cavity is to be restored by the intro- 
 duction of catgut or bougies. A thin piece 
 is at first passed into the nose, and afterw ard 
 a larger and larger one gradually, until the 
 passage for the air is perfectly re-established. 
 But usually, this relief is only of short dura- 
 tion, as the nostril very soon closes again 
 Hence, such patients are advised to make 
 constant use of flexible tubes passed into the 
 nose ; or, when this is too troublesome, to 
 fill the nose regularly at bedtime w ith cat- 
 gut, and take it out again in the morning. 
 (See Richter's Anfangsgr. B. 1.) 
 
 POLYPI OF THE UTERUS. 
 
 Polypi of the uterus are of three kiuds, 
 in respect to situation : they grow either 
 from the fundus, the inside of the cervix, 
 or the lower edge of the os uteri. The first 
 case is the most frequent ; the last the most 
 uncommon. Polypi of the uterus are always 
 shaped like a pear, and have a thin pedicle. 
 They are almost invariably of that species, 
 which is denominated fleshy, hardly ever 
 being scirrhous, cancerous, or ulcerated. 
 
 A polypus of the first kind, grow ing from 
 the fundus uteri, is very difficult to detect 
 in its incipient state. While small, it pro- 
 duces not the smallest perceptible change in 
 
fOLYPLfc. 
 
 •U) { J 
 
 the organs ol generation. As it enlarges, it 
 distends the uterus, and often excites a sus- 
 picion of pregnancy, which, however, a 
 more attentive examination soon dispels. 
 The swelling of the abdomen does not take 
 place in the degree and space of time, which 
 it does in pregnancy ; the menstrual dis- 
 charge continues to flow ; the breasts do not 
 become full ; and, in the progress of the 
 case, no motion is to be felt. While the 
 polypus lies in the uterus, its growth is slow. 
 At this early period it frequently occasions 
 profuse bleeding. Women, afflicted with 
 the disease, are seldom pregnant, and when 
 they are so, parturition commonly happens 
 prematurely. However, they sometimes 
 bold out to the end of the regular time, and 
 experience an easy and safe delivery. 
 
 As the polypus increases, it expands the 
 os uteri, and at length protrudes into the 
 vagina. This takes place either suddenly, 
 from an accidental concussion of the body ; 
 or slowly and gradually. In the latter cir- 
 cumstance, pains similar to those of labour 
 occur, and cause the tumour to be expelled 
 into the vagina. As soon as it has arrived 
 in this situation, and is no longer confined 
 and compressed by the uterus, it begins to 
 grow more rapidly, and gives rise to far 
 more troublesome complaints ; for it presses 
 the bladder and rectum, and thus, more or 
 less, disturbs the evacuation of the urine and 
 feces. But in particular, it causes repeated 
 and profuse hemorrhages, which weaken 
 the patient exceedingly, and often bring her 
 to the brink of the grave. The root of the 
 polypus is situated in the os uteri, and is 
 there so compressed, that the blood in the 
 tumour is prevented from returning through 
 the veins ; consequently, all the vessels be- 
 come turgid, and the above effusions of 
 blood are the result. Though they generally 
 cease spontaneously, the least circumstances 
 cause their recurrence ; such as slight con- 
 cussions of the body in riding, walking, &,c. 
 In the mean while, a quantity of mucous 
 and aqueq,i>s fluid is voided, by which the 
 patient’s strength is more reduced. The 
 polypus, the source of this blood and mu- 
 cus, is frequently misunderstood, and the 
 patient is in a perilous state. So necessary 
 is it in cases of preternatural discharge , 
 from the uterus, always to examine with the 
 finger, per vaginam. 
 
 At length, after the polypus has been 
 some time in the vagina, it begins to pro- 
 trude externally. This happens gradually 
 or suddenly, from some effort or concussion 
 of the body. Hence additional grievances 
 are again excited. As the polypus cannot 
 descend so low without dragging the fundus 
 of the uterus downward Avith it, and occa- 
 sioning a prolapsus of this organ, the pa- 
 tient, in walking or standing, commonly 
 experiences a very painful sense of dragging 
 or stretching, in the pelvis. As the bladder 
 and ureters are also forced into a deranged 
 
 E osition, the evacuation of urine is, more or 
 ;ss, disturbed, or rendered difficult. Lastly, 
 the dribbling of the urine over the polypus, 
 and the friction which the part accidentally 
 Vox. II. 47 
 
 suffers, frequently cause it to inflame, and 
 become painful, and ulcerated. 
 
 A polypus, situated in the vagina, or pro 
 truding from it externally, may easily be 
 mistaken for a prolapsus uteri ; an error 
 Avhich, though not difficult to avoid when a 
 careful examination is made, may have very 
 perilous consequences. The polypus is softer 
 and less sensible than the uterus in the state 
 of a prelapsus. The imperfect prolapsus 
 uteri, in which this viscus is not turned in- 
 side out, is betrayed by the os tincae, at the 
 lower part of which it is plainly perceptible 
 In this situation, the polypus may occasion- 
 ally have a depression resembling the mouth 
 of the w omb, but easy of discrimination 
 from it. A probe can be passed deeply into 
 the os uteri ; but, not so into this other 
 opening. The polypus resembles an in- 
 verted pear, that is, it is thickest beloAV, and 
 becomes gradually thinner upward. The 
 above species of the prolapsus uteri is thin- 
 nest below 7 , and gradually increases in width 
 upward. The fallen uterus may easily be 
 pressed back, and when it is so, the patient 
 experiences relief. The polypus does not 
 admit of being pressed back, and, during an 
 attempt to do this, the patient is put to 
 much inconvenience. A probe may be in- 
 troduced by the side of the polypus deeply 
 to the fundus uteri. When passed by the 
 side of the fallen uterus, it is, very soon 
 stopped at the upper part of the vagina, 
 which has sunk down with the cervix of 
 this organ. 
 
 A polypus, protruding externally from the 
 vagina, may be much more easily distin- 
 guished from a perfect prolapsus uteri, with 
 out inversion. The os uteri at once'charac- 
 terizes the uterus, as it can here not only be 
 felt, but seen. A probe may be passed 
 deeply into the vagina, along the side of the 
 polypus ; but, not so by the side of the ute- 
 rus, for reasons easy of comprehension. The 
 figure of the tumour, and the state of the 
 patient, on an effort being made to reduce 
 the protruded part, also betray its real na- 
 ture. 
 
 The inversio uteri is usually the conse- 
 quence of a difficult labour, arid hence is 
 easily discriminated from a polypus, by its 
 occasional cause. While the inverted ute- 
 rus lies in the vagina, its shape is broad 
 above and narrow 1 below ; whereas the po- 
 lypus is thin above and broad below. Hence 
 in cases of very large polypi in the vagina, 
 the os uteri is but little dilated ; uffiile it is 
 extremely distended by the incemplete de- 
 scent of the inverted uterus itself. Here, 
 likewise, the reduction of the part is at 
 tended with relief ; while every effort to 
 push back a polypus causes an aggravation 
 of all the complaints. 
 
 When the inverted uterus hangs out of 
 the vagina, its figure, like that of the poly- 
 pus, is thin upward, and broad downward ; 
 and, like the latter tumour, has no aperture 
 at its lowest part Here an erroneous opi- 
 nion is very liable to be formed. An atten- 
 tive observer, however, will easily avoid it. 
 The inverted uterus includes a circular fold 
 
370 
 
 POLYPUS. 
 
 at its upper part, next to the orifice of the 
 vagina. This fold is nothing less than the 
 os uteri itself, through which the body of 
 this viscus has descended. There is nothing 
 of this kind to be felt in cases of polvpi. By 
 the side of a polypus the finger or probe 
 may be passed deeply into the vagina ; but 
 not so by the side of the uterus. The root 
 of the polypus is firm and hard to the touch , 
 the upper thin [tart of the uterus, which is 
 hollow, has a soft flabby feel. Useful light 
 is also generally thrown on the case, by the 
 above-mentioned occasional cause of the 
 prolapsus uteri with inversion. However, 
 in particular cases, the diagnosis is much 
 more difficult, and the observations of 
 a modern writer fully prove that it is al- 
 ways difficult, and perhaps sometimes im- 
 possible to distinguish a partial and chronic 
 inversion of the uterus from a polypus. 
 (IV.Newnham, Essay on the Symptoms-, Causes , 
 and Treatment oj Inversio Uteri , with the His- 
 tory of the successful Extirpation of that Or- 
 gan during the Chronic Stage of the Disease , 
 p 82, iyc. 8 vo. Lond. 1818 ; also First Lines 
 of the Practice of Surgery, Vol. 2, p 317.) 
 
 In the two last descriptions of uterine 
 polypi, situated either on the inside of the 
 cervix, or at the margin of the os uteri, the 
 disease is, as it were, from its commence- 
 ment in the vagina, and the tumour, when 
 large, produces all the complaints attendii g 
 polypi of the first kind, except frequent 
 profuse bleedings. These seldom occur, 
 and when they do, are slight, because the 
 root of the polypus suffers no constriction 
 in the os uteri. As the tumour descends out 
 of the vagina, it occasions a prolapsus uteri 
 without inversion, in addition to the other 
 inconveniences. 
 
 Experienceproves that uterine polypi, when 
 once extirpated, have not that propensity to 
 be Reproduced, which those of the nose 
 have. Here, for obvious reasons, extrac- 
 tion is not the right practice Sometimes, 
 however, uterine polypi are met with which 
 have such a thin and soft pedicle, that, al 
 though they ought not to be pulled out, they 
 admit of being twisted off with facility and 
 safety. Also, numerous complaints of a 
 serious nature are occasionally the result of 
 tying a polypus of the uterus. In this cir- 
 cumstance, after the ligature has been ap- 
 plied some days, an attempt may be made 
 to shorten such complaints, by twisting off 
 the tumour altogether. This object is most 
 conveniently performed with a pair of forceps 
 made somethinglike Smeilie’s midwifery for- 
 ceps. As the part of the polypus in the li- 
 gature is constricted, thin, and already part- 
 ly detached, the tumour, with a little cau- 
 tion, may frequently be easily twisted off, 
 ■without any material bleeding. 
 
 The ligature is the must proper means of 
 extirpating uterine polypi, and is here much 
 more easy of application, than in the nose. 
 Large as the polypus may be, there is always 
 abundance of room for the introduction of 
 ihe necessary instruments. The polypus of 
 the uterus has commonly a thinner pedicle 
 than that of the nose ; hence its cure by the 
 
 ligature is more expeditious ; and on account 
 of the greater room and more yielding na 
 ture of the parts, the swelling of the tumour, 
 after the ligature is applied, produces less 
 inconvenience than in the same mode of 
 treatment of nasal polypi. The inconve- 
 niences which do arise are easy of remo- 
 val ; for instance, the retention of urine 
 may be relieved by the catheter; costive- 
 ness by clysters, lie. Uterine are also less 
 sensible than nasal polypi ; and hence, 'less 
 pain and fever follow the application of a 
 ligature to them. The fetid matter, formed 
 as soon as the polypus sphacelates, has a 
 free vent out, and may easily be washed 
 away by injections. 
 
 That the polypus cannot be tied while it 
 lies in the uterus, is easily comprehensible. 
 But immediately it has descended into the 
 vagina, the operation may be undertaken, 
 and may be performed with the same kind 
 of double cannula, as was employed in the 
 nose. However, here it is extremely re- 
 quisite that the cannula should be rather 
 longer than that already described, and 
 somewhat curved. But, as the silver wire 
 sometimes breaks, two other very conveni- 
 ent instruments have been invented. 
 
 The first is Levret s instrument. It con- 
 sists of two silver cannula;, which are cur- 
 ved in such a manner, and so united by a 
 joint, that they are shaped like a pair of for - 
 ceps. After introducing a ligature through 
 the two tubes, so that its ends hang out of 
 their lower apertures, the instrument is to 
 be shut, and passed upwards into the vagi- 
 na, over the polypus, on whichever side 
 seems most convenient. Then it is to be 
 opened, and the polypus is to be pushed 
 through the two branches of the instrument, 
 which is to be brought over the opposite 
 side of the tumour. In doing this, the li- 
 gature becomes applied round the root of 
 the polypus, and forms a noose. The ex- 
 tremities of the ligature are next drawn as 
 tightly as possible out of the lower openings 
 of the cannulas, and tied first in a surgical 
 knot, and then in a slip-knot. The instru- 
 ment is then shut, and the ligature con- 
 stricts the root of the polypus. Afterward 
 it is to be tightened daily, until the tumour 
 separates. 
 
 It is plain that this instrument has some 
 defects, which, however, are easily amend- 
 ed. It is very inconvenient that the surgeon 
 should be obliged to have several such in- 
 struments of various sizes and curvatures, 
 so as to be able to select that which seems 
 most calculated for the magnitude and shape 
 of the polypus. And, as the size and figure 
 of the polypus cannot always be ascertain- 
 ed beforehand, it is often indispensable to 
 try several instru nents, ere the most suita- 
 ble one is found out, and such fruitless at- 
 tempts must be distressing and painful to the 
 patient. The worst is, that though the upper 
 ends of the instrument were to touch, when 
 the lower are tied together, yet there would 
 always be a space between the two aper- 
 tures, where no ligature would be applied 
 to the root of the polypus, and where, con* 
 
POLYPUS 
 
 371 
 
 sequently, its separation would not easily 
 be accomplished. The tubes may also bend 
 w ith the force used in applying them, and 
 the pain caused by the expansion of the in- 
 strument would then be very considerably 
 increased. 
 
 All these defects are done away in the 
 instrument described by Nissen, de polypis 
 uteri, (See Richter's Chir. Bibl. 9. B. S. 613 ) 
 It consists of two silver tubes, twelve inches 
 in length, and as thick as an ordinary wri 
 ting pen. Both are curved about as much 
 as the os sacrum ; but, as they are made of 
 pure silver, the curvature may easily be in- 
 creased or diminished, according to circum- 
 stances. Through each of the cannulae a 
 strong ligature is 10 be passed, so that its 
 ends hang out of the lower apertures, while 
 its middle portion forms a noose between 
 the upper apertures of the cannulae. . 
 
 The tubes are to be kept together until 
 they have been introduced into the vagina, 
 as far as the root of the polypus. One is 
 then to be held fast, while the other is to 
 be carried round the tumour, to the opposite 
 side of the cannulae that remains stationary. 
 Thus the ligature becomes applied round 
 the root of th# polypus. After introducing 
 the finger into the vagina, to ascertain that 
 the ligature lies in its proper situation, its 
 ends are to be drawn through a small dou- 
 ble cannula, which is only one third of an 
 inch long, but so wide that it can be pushed 
 over both the tubes a certain way w ith the 
 finger, and the upper end of the long can- 
 nulee with the aid of a sort of long probe, 
 with a forked extremity. Then a third 
 double cannula, through wffiicb the ends of 
 the ligatures have likewise been passed, and 
 the width of which is sufficient is to be 
 pushed over the lower ends of the long can- 
 nulae so as to unite them. The ligatures are 
 next to be drawn tight in the ordinary way, 
 and fastened to the rings. The manage- 
 ment of this instrument is so easy as to need 
 no further explanation. 
 
 Besides the above instruments, many 
 others have been devised and recommended 
 for tying polypi of the uterus. In particular, 
 one invented by Desault, claims the atten- 
 tion of such surgeons as wish to be informed 
 of others. 
 
 Acute symptoms frequently follow the ap- 
 plication of the ligature, and are either of 
 an inflammatory or spasmodic kind. The 
 former require antiphlogistic treatment. 
 Sometimes fever arises, and the polypus 
 becomes exceedingly painful ; in this case, 
 venesection is necessary. Spasmodic symp- 
 toms require the exhibition of opium. When 
 this is ineffectual, and the symptoms are 
 severe, it may be proper to slacken the liga- 
 ture a little. As the polypus at first always 
 swells, it produces great prp«sure on the 
 adjacent parts. For this reason, it is gene- 
 rally necessary, for the first few days, to 
 draw off' the urine with the catheter, and to 
 open the bowels with clysters. Sometimes 
 hemorrhage takes place. This may gene- 
 rally be suppressed with astringents ; but 
 when they prove ineffectual; tying the liga- 
 
 ture more tightly answers the purpose. The 
 rest of the treatment resembles that of nasal 
 polypi. 
 
 When the polypus is large, it is often ne- 
 cessary in the end to use forceps for its ex- 
 traction. The inflammation, <y- ulceration, 
 liable to be occasioned in the vagina during 
 the treatment, requires injections and anti- 
 phlogistic remedies. As the ligature is ge- 
 nerally applied mund the pedicle, close to 
 the os uteri, and seldom to the very root of 
 the polypus, usually situated at the fundus 
 uteri, a portion of the root almost always 
 remains behind, alter the tumour has se- 
 parated ; but, in all probability, it after- 
 ward diminishes and fall off”, and however 
 this may he, it is an undoubted fact, that a po- 
 lypus uteri is seldom reproduced. (Richter.) 
 
 This author observes, that cutting instru- 
 ments are, in general, improper for polypi 
 of the uterus, as their employment would 
 injure the vagina, and for (he most part, 
 occasion a dangerous hemorrhage. Howe- 
 ver, there is one case where the knife is in- 
 dispensable. The polypus has occasionally 
 a ligamentous pedicle, and consequently can 
 neither be lied nor extracted. This circum- 
 stance is usually undiscovered till after a 
 ligature ha? been applied, which here com- 
 monly produces extraordinary pain, and 
 though it be applied ever so long and forci- 
 bly , occasions no detachment of the poly- 
 pus. In this instance, the surgeon may 
 either cut off the polypus closely to its 
 root in 'he vagina; or he may first draw it 
 gradually downward out of this situation, 
 and then remove it : perhaps the first object 
 might he performed with a sharp hook, 
 somewhat curved at its side, and similar to 
 w’hat is used for tearing the foetus piecemeal 
 in the uterus ; or with what seems better* a 
 pair of long curved, blunt-pointed scissors. 
 The last object may be accomplished With 
 an instrument resembling Smellie’s midw ife 
 ry forceps, which is to be introduced into 
 the vagina in the ordinary w'ay. The 
 polypus is then to be taken hold of, and gra- 
 dually drawn so far out of the vagina, that 
 its pedicle may be divided with a knife. 
 This is, indeed, not done without pain, and 
 a forcible inversion of the uterus; but it 
 may be executed without dangerous conse- 
 quences. When a polypus, whose root is 
 attached to the fundus uteri, lies in the vagi- 
 na, the uterus is always, in some degree, in- 
 verted beforehand ; and this state is, there- 
 fore, only increased by the foregoing plan, 
 which, does not create danger wffien done 
 slowly and cautiously. It is a plan which 
 has been successfully practised. (See Her- 
 biniaux , Par allele des differens Instrumens 
 pour la Ligature des Polypes.) 
 
 Wben a p-dypus tbat has its pedicle at- 
 tached to the fundus uteri, suddenly falls 
 downward, it occasions a sudden inversion 
 of this viscus. In order to relieve, a- speedily 
 as possible, the great pain and danger of 
 this case, the surgeon must tie the root of 
 the polypus as soon and as firmly as he can. 
 and pass the ligature, by means of a needle, 
 through the pedicle, before the place where 
 
an 
 
 POL 
 
 PGR 
 
 it is tied, allowing the ends afterward to 
 hang down for some length. Then th«k 
 polypus is to be amputated belew the liga- 
 ture, and the uterus immediately reduced. 
 This is another example, where a cutting 
 instrument % may be usfed with advantage. 
 The ordinary method of tying such tumours, 
 so situated, accomplishes only a slow de- 
 tachment of them, and does not afford relief 
 with sufficient expedition. 
 
 Fleshy excrescences > Iso occasionally form 
 in the vagina, some of which have a broad 
 basis, and others a thin pedicle. The last 
 merit the appellation of polypi- Their ex- 
 istence is easily ascertained by the touch. 
 By making pres u re on the bladder and rec- 
 tum, they occasion several impediments to 
 the evacuation of the urine and fttces. They 
 may be conveniently tied, by means of the 
 double cannula. Should the polypus be 
 situated at the lower part of the vagina, the 
 cannulae would not be required. The liga- 
 ture might be applied with the hand, and the 
 tumour cut off below the constricted, part. 
 
 There is still another kind ot tumour in 
 ♦lie vagina, to be classed in the rank of po- 
 lypi. It resembles, in many points, the po- 
 lypus of the mucous membrane of the nostril, 
 consisting altogether of the membranous 
 lining of the vagina which, at the part 
 affected, becomes relaxed, thickened, and 
 elongated; hence the (uraour might be . ore 
 properly termed aprolapsus of the membranous 
 lining of the vagina, than a pulypus. When 
 it resists the efficacy of astringent and corro- 
 borant injections, if may be tied, or what is 
 better, cut off. 
 
 A polypus in the oesophagus renders de- 
 glutition difficult ; and when of large size, 
 puts an entire stop to it. When an inclina- 
 tion to vomit is excited by irritating the 
 throat with the finger, or a feather, the poly- 
 pus, if situated tow ards the upper part of the 
 tube, ascends in'o the mouth, so as to become 
 visible. But as it impedes respiration dunng 
 its residence in the inmitfa, the patient is 
 soon necessitated, as it were, to swallow it 
 again. When the polypus is situated far 
 dowm the oesophagus, of course it cannot be 
 brought into the mouth, and is very difficult 
 to detect. The difficulty of swallowing, its 
 only symptom, may result from other causes. 
 In this case it is also incurable ; for it is 
 impossible to take hold of it with instru- 
 ments. An operation can only be practi- 
 sed, when the polypus is situated in the 
 upper part of the oesophagus. The tumour 
 cannot be extracted ; and the tying of it is 
 difficult. 
 
 Polypi in the rectum may bp tied with the 
 aid of the cannuiae. Excre c‘*nces in the 
 meatus auditorius externus, resembling po- 
 lypi, have been successfully extirpated by 
 extraction, or rather by twisting them off. 
 
 For many of the foregoing remarks, I am 
 indebted to Richter, who has very ably 
 treated of polypi in his Ansfangsg. der Wun - 
 darzn. B. 1, Kap. 21. See also J. B. de 
 Lamsweerde, Historia JValuralis Malorum 
 Uteri, 12 mo. Lugd. 1700. P. G Schachev, 
 Programma de Polypi*, Lips. 1721. G. F. 
 
 Balt schmid, De Mola scirrhosa in ulero 
 inverse extirpata, Jenee , 1754. C. Schunck , 
 De polypo post febrern Epidemicum ex utero 
 egresso. Witiemb. 1739. A. Levret, Obs. 
 sur la Cure radicate de plusieurs Polypes de 
 la Matrice , de la Gorge, et du Nez. Svo. Paris , 
 1749. M. G. Hcrbiniaux, Traill sur divers 
 Accouchemens laborieux , et sur les polypes de 
 la Matrice, fyc. 2 Tom. 8 vo. Bruzelles, 
 1782 — 1794. E. Grainger, Medical and Sur- 
 gical tie m arks, including a descript ion of a 
 simple and effectual method of removing 
 polypi from the uterus, tyc. Svo. Lond 1815. 
 Denman’s Plates of a Polypus with an In- 
 version of tht Uterus, and of a Polypus of the 
 Ulerus. fol lSol. F. A. Waller, Annotationes 
 Academii ce 4 to Btrol 1786 W. JYewnham , 
 An Essay an the Symptoms, fyc. of Inversio 
 Uteri , with a History of the successful Extir- 
 pation of that Organ, Svo. Lond. 1818. Pott's 
 Remarks on the Polypus of the Nose. Whate- 
 ly's Two Cases of extraordinary Polypi, Svo. 
 Lond. 1805. John Bell's Principles of Sur- 
 gery, Vol. 3, Part 1. Encyclopedic M6tho- 
 dique, Art. Polype. J. G. Haase, De Narium 
 Morbis Comment. Lips. 1794 — 1797. Lassus, 
 Pathologic Chir. T. I, p. 528 — 538, fyc. Edit. 
 1809. Callisens Systema CHrurgice Hodier- 
 nce. Vol. 2, p. 169. fyc. J. L. Deschamps, 
 Traite des Maladies dts Fosses JYnsales, et de 
 leur Sinus , Svo. Paris, 18o4. JVauche, des 
 Mai. de V Uterus, Svo. Paris, 1816. 
 Schmeider, Schediasma de Polypo (Esophagi 
 vermiformi rarissimo, fyc. Delitii, 1717. See 
 Halleri Disp. Morb. 7, 595. 
 
 PORRIGO. TINEA CAPITIS, (called 
 also Ringworm of the Scalp, Scald-head , 
 is, according to Dr. Bateman’s excellent 
 account of the subject, a contagious disease, 
 principally characterized by an eruption cf 
 of the pustules denominated fan and achorcs 
 The achor is defined to be a small acumina- 
 ted pustule, containing a straw-coloured 
 matter, which has the appearance and nearly 
 the consistence of honey, and is succeeded 
 by a thin brown or yellowish scab. The 
 favus is larger, flatter, and not acuminated, 
 and contains a more viscid matter ; its base, 
 which is often irregular, is slightly inflamed : 
 and it is succeeded by a yellow', semi- 
 transparent, and sometimes cellular scab, 
 like a honey-comb ; whence it has obtained 
 its name. (See Bateman's Synopsis of 
 Cutaneous Diseases, p. xxiv. and 159, Edit. 
 3.) 
 
 This intelligent physician has noticed sis 
 species of Porrigo, of which my limits will 
 allow me to give only a very abridged de- 
 scription. 
 
 1. The Porrigo larvalis, or crusta lactea of 
 authors, begins with an eruption of numerous 
 minute whitish achores, upon a red surface. 
 These pustules soon break, and discharge a 
 viscid fluid, which concretes into thin yel- 
 lowish or greenish scabs. The disease in- 
 creases in extent, and the scabs become 
 thicker and larger, until the forehead and 
 cheeks, even the whole face, excepting the 
 eyelids and nose, become enveloped, as it 
 w ere, in a mask, whence the epithet larvalis. 
 Small patches of the disease sometimes 
 
FORRTGO. 
 
 
 appear about the uecfc and breast, and on 
 the extremities ; and the ears and scalp are 
 usually affected in the progress of the case. 
 The infant suffers more or less from the 
 itching and irritation When the discharge 
 is copious and acrid, Dr. Bateman recom- 
 mends the part to be washed two or three 
 times a day with tepid milk and water, and 
 the application of the unguentum zinci 
 alone, or mixed with the saturnine cerate. The 
 latter, he says, will be useful for the relief 
 of the excoriation left after the cessation of 
 the discharge. Small doses of the submu- 
 riate oi mercury, cither alone, or in combi- 
 nation with a testaceous powder, wili «lso 
 expedite the cure. If ibe bowels are very 
 irritable, the bydrargyrus cum creta, or the 
 cinereous oxide, may be exhibited instead 
 of the calomel. When the health is good, 
 soda, precipitated sulphur, and the tesiacca, 
 will lessen the local inflammation and dis- 
 charge. 
 
 When the irritation is removed, and the 
 crusis are dry and falling off, the unguentum 
 bydrarg. nitrat. much diluted, may be used, 
 and the decoction of bark, or the vinum ferri 
 prescribed. 
 
 2. Porrigo furfurans begins with an erup- 
 tion of small achores : The excoriation is 
 slight, and the discharge, which is not 
 abundant, soon concretes and falls off in 
 innumerable thin laminated scabs. At irre- 
 gular periods fresh pustules arise, and follow 
 the course of the preceding. The com- 
 plaint is confined to the scalp, which is 
 affected with itching and soreness ; and the 
 hair, which partly (alls off, becomes tbin, less 
 strong, and sometimes of a lighter colour 
 than natural. This species of porrigo occurs 
 principally in adults, and it is sometimes 
 attended with swelling of the glands in the 
 neck. Dr. Bateman observes, that the 
 treatment requires the hair to be closely cut 
 off the scalp. The branny scabs are then to 
 be gently washed .away with some mild 
 soap and water twice a day ; and an oil silk 
 cap should be worn. In the beginning, w'ben 
 the surface is moist, tender, and inflamed, 
 the zinc ointment, or one made w ith 3>j* of 
 the cocculus indicus and 2j. of lard. After- 
 ward, when the scalp is 'dry and free from 
 irritatioo, it may be washed with common 
 soft soap and water: or with a mixture of 
 equal parts of soft soap and unguentum 
 sulphuris. Then the unguentum hydrargyri 
 nit rati, the ung. bydrarg. nitrico oxydi, the 
 tar and sulphur ointments, or the ung. acidi 
 nitrosi of the Edinb. Pharm. may be employ- 
 ed. These last stimulant applications, 
 however, must be left off, if the inflammation 
 and discharge return. 
 
 3. Porrigo lupinosa is characterized, ac- 
 cording to Dr. Bateman, by dry, circular, 
 yellowish white scabs, set deeply in the 
 skin, with elevated edges, and a central 
 depression, and somewhat resembling, on the 
 whole, the seeds of lupines. These scabs 
 are formed upon the separate cluster.' of 
 achores, and attain on the scalp the size of 
 a sixpence ; but when on the extremities. 
 
 they are not more than two lines in diame- 
 ter. 
 
 In the treatment ol the porrigo lupinosa 
 the scabs arc first to be gently washed oft' 
 with some soap and water, and the scalp is 
 to be shaved, if it be the part affected. When 
 the scabs are difficult of removal, the liquor 
 potassaj, or a weak lotion of muriatic acid 
 may be u-ed for loosening them. Then the 
 ointment of cocculus indicus is to be applied 
 to the red cuticle, and afterward any of 
 the more stimulant ointments above enu- 
 merated 
 
 4. Porrigo Scutulata, or ringworm of the 
 Scalp, as Dr Bateman has observed, makes 
 its appearance in separate patches, of an 
 irregular circular shape, upon the scalp, 
 forehead, and neck. It commences with 
 clustersof small, light-yellow pustules, which 
 soon break, and form thin scabs, which, it 
 neglected, become thick and hard. If the 
 scabs are removed, however, the surface un- 
 derneath is left red and shining, but studded 
 with slightly elevated points or pustules. 
 When the disorder is neglected, the patches 
 become confluent, and the whole head 
 affected Where the disease is siti^ed, the 
 hair becomes lighter in its colour, it falls oft', 
 and its roots are destroyed. The porrigo 
 scutulata generally occurs in children three 
 or four years old and upwards, and fre- 
 quently proves exceedingly obstinate. Ac- 
 cording to Dr. Bateman, it seems to origi- 
 nate spontaneously in children of feeble and 
 flabby habit, and who are ill fed, uncleanly, 
 and not sufficiently exercised ; but he thinks 
 that it is chiefly propagated by contagion, 
 i. e. by the actual conveyance of the matter 
 from the diseased to the healthy, as may 
 happen in the frequent contact of the heads 
 of children, the use of the same towels, 
 combs, caps, and hats. 
 
 While the patches are inflamed and irrita 
 ble, it is necessary to limit the local appli- 
 cations to washing the parts with warm wa- 
 ter. Even shaving the scalp, which must 
 be repeated at intervals of eight or ten days, 
 produces a temporary irritation. Nothing 
 but a light linen cap is now to be worn, and 
 it must be often changed. 
 
 The disease afterward forms dry scabs, 
 and becomes for a time less irritable ; but 
 a fresh eruption of achores soon follow's, 
 and the inflammation and redness return. 
 
 In the inflamed states. Dr. Bateman recom- 
 mends the use of ointments, made either 
 with the cocculus indicus, submuriate of 
 mercury, oxide of zinc, superacetate of lead, 
 opium, or tobacco ; or else the infusion of 
 poppy-heads, or tobacco. Where there is 
 an acrimonious discharge, Dr Bateman pre- 
 scribes the zinc, or saturnine ointments, the 
 ung. hydrarg. prascip. calomel ointment, or 
 a lotion of lime-water and calomel. 
 
 In the less irritable stages, the ung. hv 
 drarg. praecip. the ung. hydrarg. nitrico- 
 oxydi, and especially the ung. hydrarg. 
 nitrat. are often effectual remedies. So arc 
 the ointments of sulphur, tar, hellebore, and 
 turpentine, and lotions of the sulphates of 
 zinc and copper, the oxymuriate of mercury 
 
374 
 
 POR 
 
 PRE 
 
 1 have often seen a solution of 3j of the 
 sulphuret of potassa in a pint of lime-water, 
 succeed when most other applications had 
 failed. In the very dry and inert state of 
 the patches, Dr. Bateman has seen the dis- 
 ease removed by a lotion, containing from 
 three to six grains of the nitrate of silver in 
 an ounce of distilled water. The applica- 
 tion of the diluted mineral acids, or of a 
 blister, has also been known to put a perma- 
 nent stoppage to the morbid action. 
 
 In general, no local application agrees 
 well, if long continued, and it is necessary 
 to have several, which must be alternately 
 employed. 
 
 The cure may often be expedited by cin- 
 chona, chalybeate, and alterative medi- 
 cines; and attention must be paid to the 
 patient’s diet, exercise, &,c. 
 
 5. Porrigo decalvans consists in bald 
 patches, surrounded by hair which is as 
 thick as usual It is not known whether 
 any eruption of minute achores actually 
 precedes the detachment of the hair. 
 
 Dr. Bateman remarks, that if the scalp is 
 regular^T shaved, and some stimulating 
 linimeAf be applied to it, this obstinate 
 affection may at length be overcome, and 
 the hair will regain its usual strength and 
 colour. Two drams of oil of mace, in three 
 or four ounces of alcohol, are said to make 
 an excellent liniment. 
 
 6. Porrigo favosa consists of an irruption 
 of the large, soft, straw-coloured flattened 
 pustules, denominated favi, which may 
 occur on any part of the body ; but most 
 commonly spread from the scalp, especially 
 behind the ears, to the face, or from the lips 
 and chin to the scalp. They are attended 
 with considerable itching, and are most fre- 
 quently seen in children from six months to 
 four years of age, though adults are also often 
 affected. The pustules pour out a viscid 
 matter, which concretes into greenish or 
 yellowish semi-transparent scabs. When 
 the hair and moist scabs are matted together, 
 pediculi are often generated in great num- 
 bers, and aggravate the itching and irrita- 
 tion. If the disease be allowed to increase, 
 the scabs are thickened into irregular masses, 
 not unlike honey comb ; and considerable 
 ulcerations sometimes form, especially when 
 the heel and toes, or other parts of the lower 
 extremities, are affected. The ulcerating 
 blotches are generally soon followed by irri- 
 tation and swelling of the lymphatic glands, 
 which sometimes slowly suppurate, lhe 
 contact of the discharge inoculates the dis- 
 ease ; thus, in young children, the breast is 
 inoculated by the chin ; and the arm and 
 breast of the nurse may be infected in the 
 same way ; though adults do not take the 
 complaint so quickly as children. 
 
 The porrigo favosa requires the same 
 alteratives, internally, as the porrigo larva- 
 lis. The diet should consist of milk, pud- 
 dings, and a little plain animal food. When 
 the habit is bad, and the glands swelled, 
 bark, chalybeates, and a solution of the mu- 
 riate of barytes, are proper. 
 
 As local applications, Dr Kateman pre- 
 
 fers the unguentum zinci, or the ung. by- 
 drarg. praecip. mixed with this or the satur- 
 nine ointment, especially when the discharge 
 is copious. He also speaks favourably of 
 the ung. hydrarg. nitrat. the strength of 
 which is to be diminished by an addition of 
 simple cerate, according to the degree of 
 irritation present. 
 
 For the preceding particulars I am indebt- 
 ed to Dr. Bateman’s valuable Synopsis of 
 Cutaneous Diseases, where the reader, de- 
 sirous of additional information respecting 
 porrigo, will be amply gratified. 
 
 POTASS* ARSENICATA. Kali Arstni- 
 catum. Arsenias Kali. Oxydi albi arseni- 
 ci, potassa? nitratis sing Crucibulo am- 
 plo igne candenti injice nitrum, et liquefacto 
 adde gradatim arsenicum in frustulis donee 
 vapores nitrosi oriri eessaverint. Solve ma- 
 teriam in aqua? distillatae ft>iv. et post ido- 
 neara evaporationem sepoue ut fiant crys- 
 talli. These crystals may be given in the dose 
 of one-tenth of a grain, thrice a day. 
 ( Pharm . Saadi Barthol. 1799.) Justamond 
 strongly recommended the internal exhibi- 
 tion of arsenic in cases of cancer. (See 
 Cancer.) 
 
 POTASSiE CARBONAS. Two drams of 
 this medicine have been given, as a lithon- 
 triptic, at St. Bartholomew’s Hospital, in a 
 pint of distilled water, twice a day. 
 
 POTASSA FUSA. Caustic Potash. This 
 is one of the most useful caustics for de- 
 stroying fungi, making issues in cases of 
 diseased vertebrae, white swellings, &.C.; 
 and it is recommended be used in a par- 
 ticular manner, by Mr. Whately, for the cure 
 of strictures in the urethra. When surgeons 
 prefer opening buboes, or any other ab- 
 scesses, with caustic, the caustic potassa is 
 very commonly employed. When surgeons 
 used to cure hydroceles, by destroying a 
 part of the scrotum and tunica vaginalis with 
 caustic, the potassa fusa, either alone or 
 mixed with quicklime, was made use of. 
 (See Vertebra, Urethra , Strictures of, fyc.) 
 
 POTASSiE SULPHURETUM. Sulphu- 
 ret of Potash, Liver of Sulphur. Two drams, 
 dissolved in a pint of lime or distilled water, 
 make an excellent lotion for the cure ot 
 porrigo. Many other cutaneous affections 
 yield also to the same remedy. When arse- 
 nic has been swallowed as a poison, twenty 
 grains of the sulphate of zinc may be given as 
 an emetic of the quickest operation ; and, 
 after keeping up the vomiting by drinking 
 warm water, and, what is better, sweet oil, 
 some authors recommend making the pa- 
 tient drink as much as possible of a solution 
 of the sulphuret of potash. 
 
 PREGNA1NCY is set down by some wri- 
 ters as preventive of the union of broken 
 bones ; but many exceptions to the remark 
 present themselves in practice ; for I have 
 attended myself a female, six months gone 
 with child, who broke both bones of her 
 leg, yet they grew together again in the 
 usual time. (See Fractures.) Pregnant wo- 
 men also frequently bear operations much 
 better than might be expected. Thus M. 
 JNicod bus recently published a successful 
 
PROSTATE GLAAD. 
 
 amputation of the left leg during pregnancy, 
 in a case where the right tendo Achillis was 
 also ruptured. Both the wound, and the 
 broken tendon, united very well. (See 
 Annuaire Med. Chir. des Hdpitaux de Paris, 
 p. 509 4 to. Paris, 1819.) 
 
 PROBANG A long slender bit of whale- 
 bone, with a bit of sponge at its extremity, 
 intended for the examination of the oesopha- 
 gus, or the removal of obstructions in it. 
 
 PROCIDENTIA. Prolapsus. A falling 
 down of any part. (See Anus, Prolapsus 
 of. Uterus, Prolapsus of, fyc.) 
 
 ^PROSTATE GLAjND, DISEASES OF. 
 It is an observation, made by Mr. Hunter, 
 that the use of this gland is not sufficiently 
 known to enable us to judge of the bad con- 
 sequences of its diseased state, abstracted 
 from swelling. Its situation (says he) is 
 such, that the bad effects of its being swelled 
 must be evident, as it may be said to make 
 a part of the canal of the urethra, and there- 
 fore, when it is so diseased that its shape and 
 size are altered, it must obstruct the passage 
 of the urine. (On the Venereal Disease , p. 
 169.) A swelling of the prostate gland, 
 however, may be of very different kinds : 
 thus it may depend either upon common 
 inflammation of the part, abscesses, calculi 
 formed within its substance, a varicose en- 
 largement of its vessels, or a scirrhous chro- 
 nic induration, (.->ee (Euvres Chir. de De- 
 sault par Bichat, T. 3, p. 220.) 
 
 Modern anatomists describe the prostate 
 gland as not being itself a very sensible part, 
 and hence it is more subject to chronic than 
 acute disease, to which, however, it is also 
 liable. We have the authority of Desault, 
 Hunter, and Dr. Baillie, for setting it down 
 as subject to scrofula. The latter physician, 
 after stating that he has seen a common 
 abscess situated in it, adds, that it is also 
 subject to scrofulous disease, as, on cutting 
 into it, he has met with the same white 
 curdy matter which is formed in a scrofu- 
 lous absorbent gland ; he has likewise forced 
 out of its duct scrofulous pus. (Morbid 
 Anatomy, fyc.) 
 
 Mr. Lloyd states, that he has also met 
 with fleshy enlargements of the gland, in 
 the substance of which several small ab- 
 scesses were formed, containing “ a com- 
 plete scrofulous matter. ' He has also known 
 enormous enlargements of this gland hap- 
 pen in young men who were labouring, at 
 the same time, under other scrofulous dis- 
 ease. Other instances of supposed scrofu- 
 lous svvellings of the same part in young 
 patients are likewise cited by this author, 
 one of w hich is particularly remarkable, as 
 in it the gland was found after death to be 
 of the size of a child’s head, though its na- 
 tural consistence was not much changed. 
 (On the Nature and Treatment of Scrofula, 
 p. 107.) Other chronic, or as they are more 
 often called, scirrhous enlargements of the 
 prostate gland, rarely occur in subjects un- 
 der the age of fifty. To these cases I shall 
 presently return. 
 
 Like every other part of the body, the 
 prostate gland is .sometimes, but not often. 
 
 the seat of common phlegmonous inflamma- 
 tion Mr. Wilson has known two or three 
 instances of this kind take place soon after 
 puberty ; one case was from a fall ; the 
 others arose without any assignable cause, 
 (On the Male Urinary and Genital Organs, 
 p. 327.) There is also a phlegmonous swell- 
 ing of the prostate gland, sometimes an 
 effect of strictures, as will be presently no- 
 ticed. \s Desault observes, the retention 
 of urine, arising from such a cause, comes 
 on very suddenly and rapidly increases. 
 The patient at first complains of a sense of 
 heat and weight about the perinaeum ; and, 
 soon afterward, of a continual throbbing 
 pain about the neck of the bladder. The 
 pain is severely increased when the patient 
 goes to stool ; and there is tenesmus, and 
 frequent inclination to make w r ater. How- 
 ever, according to Mr. Wilson, the desire to 
 evacuate the urine is here less constant than 
 in cases where the inner membrane of the 
 bladder is inflamed. (Vol. cit.p. 327.) The 
 patient feels also as if a large mass of excre- 
 ment filled the extremity of the rectum, and 
 were ready to come out. If a finger oe in- 
 troduced within the rectum, the swelling of 
 the gland is plainly distinguishable; and, 
 according to J. L. Hetit, the projection of 
 the prostate gland in the bowel makes a 
 corresponding hollow groove along the 
 concave side of the excrement, as may be 
 noticed, when what is voided is hard. How- 
 ever, Bichat conceiv es, that such an appear- 
 ance must generally be obliterated as the 
 excrement is passing through the sphincter. 
 When the patient attempts to make water, it 
 is a long while befor, the first drops come 
 out, and asstraining has the effect of pro- 
 pelling the swelled prostate more against 
 the neck of the bladder, it only increases 
 the difficulty, and no urine will come out 
 until such efforts are discontinued. The 
 more violent the inflammation is, the smaller 
 is the stream of urine, and the more acute 
 the pain felt during its expulsion. Accord- 
 ing to Desault, it is likewise particularly re- 
 markable in such cases, that if an attempt, 
 be made to introduce a catheter, the instru- 
 ment passes without the least resistance as 
 far as <he prostate gland, where it stops, and 
 causes great pain. The pulse is hard and 
 frequent ; and the patient is exceedingly 
 thirsty and feverish. Desault considered 
 the retention ot urine in cases of this kind, 
 and, indeed, in all enlargements of the 
 prostate gland, or other obstruction of the 
 urethra, as generally more dangerous than 
 other retentions, merely depending upon 
 weakness of the bladder, where there is 
 little risk of this organ giving way. When 
 the urethra is free from obstruction, the 
 urine, after distending the bladder in a cer- 
 tain degree, generally oozes through that 
 canal and the patient may live in this con- 
 dition for years without any alarming symp- 
 toms. But the case is different when the 
 retention of urine depends upon any stop- 
 page or stricture in the urethra. The urine 
 does not then partially escape, but stagnates 
 in bladder; the distention increases; 
 
376 
 
 PROSTATE GLAND. 
 
 and if speedy relief be not afforded, a peril- 
 ous extravasation follows. The datiger, 
 however, of such a retention of urine de- 
 pends very much upon the extent and seve- 
 rity of the inflammation. However, this 
 statement will not apply to the chronic 
 scirrhous enlargement of the prostate, be- 
 cause, as w . 1 1 be presently explained, in this 
 affection some of the urine begins to drib- 
 ble away alter the bladder has become dis- 
 tended in a certain degree. 
 
 In cases of phlegmonous inflammation of 
 the prostate gland, antiphlogistic treatment 
 is indicated ; especially venesection, leeches 
 to the perinaeum and near the anus, the 
 warm bath, emollient clysters, poultices, 
 and fomentations, a. id a low regimen. JHow r - 
 r.ver, as Desault admits, the efficacy of these 
 means is often too slow', and the symp- 
 toms too urgent, to allow the surgeon to 
 wait for the urine to flow of itself. Fre- 
 quently, also, the distention has so weaken- 
 ed the bladder, that this organ cannot expel 
 its contents; in which event the catheter 
 must be used, though the diminished dia- 
 meter and altered course of the prostatic 
 portion of the urethra sometimes renders its 
 introduction difficult, and always very pain- 
 ful. The practical observations respecting 
 the best kind of catheters, and the mode of 
 introducing them in cases of swelled pros- 
 tate gland, w r ill be more conveniently intro- 
 duced when the chronic enlargement of this 
 part is considered. (See also Catheter and 
 Urine, Retention of.) In every instance of 
 retention of urine from acute inflammation 
 about the neck of the bladder, whether the 
 case he an abscess forming near the anus, 
 or a phlegmonous inflammation of the pros- 
 tate gland, or other adjacent part, it has 
 always appeared to me ihat antiphlogistic 
 and anodyne remedies should first be fairly 
 tried, and the catheter, which always in- 
 creases the pain and irritation, only used 
 where such means do not afford relief w ith 
 sufficient expedition. 
 
 When a catheter has been introduced, 
 ought it to be left in the bladder, or with- 
 drawn, after the discharge of the urine ? 
 Its presence no doub^wili increase the irri- 
 tation about the neck of the bladder; but 
 on the other hand, if it be taken out, the 
 surgeon may noi be able to introduce it 
 again. No general precept, says Desault, 
 can be laid^dow n on this point. The course 
 which the practitioner will pursue, must 
 depend upon the difficulty he has experien- 
 ced in getting the instrument into the blad- 
 der, anil upon the confidence w hich he may 
 have in his own skill, and which must be 
 founded upon constant success in analogous 
 instances. 
 
 According to Desault, when an abscess 
 follows inflammation of the prostate, the 
 body of the gland itself does not suppurate, 
 but only the surrounding parts, and the cel- 
 lular substance, which connects its lobes 
 together. This, at least, was what was ob- 
 served in examining several dead subjects, 
 who were publicly opened in the amphi- 
 theatre of the Hotel-Dien. 
 
 When the symptoms of inflammation have 
 lasted a week, and all this time have con- 
 tinued to increase ; W'hen, after this period, 
 they have abated a little, and then become 
 violent again ; and when the febrile symp- 
 toms grow worse in the evening, and have 
 been preceded by shiverings ; there is rea- 
 son to suspect the formation of matter. It 
 cannot be known, whether the pus is col- 
 lected in one particular place, or diffused. 
 When the matter is external to the gland, 
 the case is less serious than when it occu- 
 pies the cellular substance connecting the 
 lobes. According to Desault, the latter 
 form of the disease seldom gets w r ell. There 
 are no peculiar symptoms which denote it; 
 the matter does not readily make its way 
 outward ; and the state of things is not clear 
 enough to admit of an incision being made. 
 Besides, Desault doubted whether an inci- 
 sion could be of much use, since it would 
 probably only discharge the manner in its 
 vicinity. 
 
 I hings are different when the pus is col- 
 lected in one place, and is more superficial 
 If situated betw'een the gland and neck of 
 the bladder, Desault says, it will often 
 spontaneously burst into this viscus, or it 
 may be let out with the point of the cathe- 
 ter. It will then either be discharged through 
 the instrument, or come away with the 
 urine. However, according to Mr. Wilson, 
 abscesses of the prostate gland generally 
 burst into the urethra behind the caput gal- 
 linaginis, but sometimes before it ; and he 
 has seen more than one instance, in which 
 they have burst in the perinaeum. (On the 
 Male Urinary and Genital Organs, p. 329.) 
 Should the abscess lie near the rectum and 
 perinaeum, and admit of being distinctly 
 felt, Desault conceived, that a free opening 
 would expedite the cure. 
 
 In all these cases, the use of the catheter 
 is requisite, in order to let out the urine, 
 and as the instrument must be left in the 
 passage some time, Desault preferred one 
 made of elastic gum. As Mr. Wilson has 
 remarked, soothing means should also be 
 employed ; internal narcotic medicines, 
 anodyne clysters, the mixtura amygdala- 
 rum, &,c. 
 
 Morgagni has taken notice of the reten- 
 tions of urine, arising from the presence of 
 calculi in ihe prostate gland. The nature 
 of these concretions will be described in 
 the article Urinary Calculi Calculi also 
 sometimes form in or about the prostate 
 gland, when, after lithotomy, the outer part 
 of the wound heals sooner than the bottom. 
 A kind of urinary fistula then ensues ; and 
 as the extraneous substance is constantly 
 exposed to the contact of fresh urine, it may 
 increase to a very large size. The diagnosis 
 of prostatic calculi is seldom very clear. 
 A retention of urine, and an impediment 
 to the emission of the semen, are said to be 
 the only symptoms, and these are common 
 to several other affections of the prostate 
 gland and urethra. When the finger is in- 
 troduced into the rectum, the gland inay 
 indeed be felt, to be enlarged ; but the hr- 
 
ROSTAPTE GLAND 
 
 Jure and cause of such enlargement cannot 
 * n general be distinguished. In one instance, 
 however, lately recorded by Dr. Marcet,the 
 calculi could be plainly felt through the 
 coats of the rectum, and a proposal was 
 made to extract them by an incision in that 
 situation ; but the patient did not accede to 
 so judicious a measure. (Med. and Chym. 
 Hist, of Calculous Disorders , 8 vo. 1817.) 
 When a calculus projects from the prostate 
 gland into the urethra, the end of a sound 
 will strike against it ; but then it can rarely 
 be known whether the extraneous substance 
 may not be a calculus that has passed out 
 of the bladder into the urethra, or lies close 
 to the neck of this viscus. 
 
 Whether the case be of one description or 
 the other, however, the treatment should be 
 the same ; viz. the calculus should be ex- 
 tracted by an incision, resembling that prac- 
 tised in the lateral operation. 
 
 A considerable varicose affection of the 
 vessels of the prostate gland, which is also 
 itself generally somewhat enlarged, is an- 
 other disease, treated of by writers as one 
 cause of a retention of urine. In this case 
 the water should be drawn off with an elas- 
 tic gum-catheter, which should be kept in 
 the urethra ; and a large instrument is to be 
 preferred to a smaller one. For an account 
 of the symptoms of this case, I must refer to 
 Les (Euvres Chir. de Desault, T. 3, p. 234. 
 The practice of this author was gradually to 
 dilate the portion of the urethra which 
 passes through the prostate, with bougies, 
 or elastic catheters, which were worn a 
 long while, and cleaned and changed at 
 proper intervals. I am not aware, that these 
 cases are recognized in the practice of sur- 
 gery in England. 
 
 The most frequent disease of the pros- 
 tate gland, and, of course, that which is 
 most "interesting to the practical surgeon, is 
 a slow hardening and enlargement of it, 
 sometimes denominated scirrhvs , whereby 
 its natural size, which is that of a common 
 chesnut, is sometimes gradually changed to 
 that of a man’s fist. (J L. Petit.) Accord- 
 ing to the observations of Mr. Hunter, De- 
 sault, and Sir Everard Home, this chronic 
 swelling of the prostate gland is most com- 
 mon in the decline of life ; one circum- 
 stance in which it differs from scrofulous 
 diseases of the same part, which are well 
 known to happen chiefly in youngish persons. 
 
 It is observed by Mr. Hunter, that when the 
 prostate gland swells, “ it does not lessen 
 the surface of the urethra at the part, like a 
 stricture ; on the contrary, it rather in- 
 creases it ; but the sides of the canal are 
 compressed together , producing an obstruction 
 to the passage of the urine, which irritates the 
 bladder , and brings on all the symptoms in 
 that viscus, usually arising from a stricture , 
 or stone. From the situation of the gland, 
 which is principally on the two sides of the 
 canal, and but little, if at all, on the fore- 
 part, as also very little on the posterior side, 
 it can only swell laterally, whereby it presses 
 the two sides of the canal together, and, at 
 Von. II. 
 
 377 
 
 the same time, stretches it from the anterior 
 edge, or side, to the posterior, so that the 
 canal, instead of being round, is flattened 
 into a narrow groove, sometimes the gland 
 swells more on one side than the other , which 
 makes an obliquity in the canal passing 
 through it. 
 
 u Besides this effect of the lateral parts 
 swelling, a small, portion of it which lies be- 
 hind the very beginning of the urethra, swells 
 forwards, like a point, as it were, into the 
 bladder, acting like a valve to the mouth of 
 the urethra, which can be seen even when 
 the swelling is not considei'able, by looking 
 upon the mouth of the urethra from the ca- 
 vity of the bladder in a dead body. It Some- 
 times increases so much as to form a tumour , 
 projecting into the bladder some inches. This 
 projection turns, or bends the urethra for- 
 wards, becoming an obstruction to the passage 
 of a catheter, bougie, or any such instrument • 
 and it often raises the sound over a small stone 
 in the bladder , so as to prevent its being felt.” 
 (Hunter on the Vencrbal Disease, p. 169.) The 
 valvular production just behind the begin- 
 ning of the urethra, here described, particu- 
 larly merits attention, because it is repre- 
 sented by Sir Everard Home as arising from 
 the enlargement of what he considers a new- 
 ly discovered part in anatomy, viz. a third, 
 or middle lobe of the prostate gland. (See 
 Phil. Trans. 1806.) In the dissections, 
 which Sir Everard mentions, as having led 
 to this discovery, “the urinary bladder was 
 distended with water, and the surfaces of 
 the prostate gland, vesicula? seminales, and 
 vasa deferentia, were fairly exposed. This 
 being done, the vasa deferentia and vesi- 
 culae seminales were carefully dissected off 
 from the bladder, without removing any 
 other part. These were turned down upon 
 the body of the prostate gland. An accurate 
 dissection was then made of the circumfer- 
 ence of the two posterior portions of the 
 prostate gland, and the space between them 
 was particularly examined. In doing this, 
 a small rounded substance was discovered, 
 so inuch detached that it seemed a distinct 
 gland, and so nearly resembling Cow per s 
 glands in size and shape, as they appeared 
 in the same subject, in which they were 
 unusually large, that it appeared to be a 
 gland of that kind. It could not, how ever, 
 be satisfactorily separated from the prostate 
 gland, nor could any distinct duct be found 
 leading into the bladder. 
 
 “ A similar .examination was made of this 
 part in five different subjects. The appear- 
 ance was not exactly the same in any two 
 of them. In one, there ivas no apparent glan- 
 dular substance, but a mass of condensed cel- 
 lular membrane : this, however, on being 
 cut into, differed from the surrounding fat. 
 
 In another there was a lobe, blended late- 
 rally with the sides of the prostate gland. 
 These facts (says Sir Edward Home) are 
 mentioned in proof of its not being always 
 of the same size x or having exactly the same 
 appearance.” 
 
 This is found also to be the case with 
 
PROSTATE GLAND. 
 
 378 
 
 Cowper’s glands : they are sometimes large 
 and distinct ; in other subjects, they are 
 scarcely to be detected ; and, in others 
 again, are .in all the intermediate states. 
 The most distinct and natural appearance 
 of this part was in a healthy subject, 
 twenty-five years, of age, of which the 
 following is an account. On turning off the 
 vasa deferentia and vesiculai semlnales, 
 exactly in the middle of the sulcus, between 
 the' two lateral portions of the prostate 
 gland, there was a rounded prominent body, 
 the base of which adhered to the coats of 
 the bladder. It was imbedded, not only 
 between the vasa deferentia and the bladder, 
 but also, in some measure, between the 
 lateral portions of the prostate gland and 
 the bladder, since they were in part spread 
 over it, so as to prevent its circumference 
 from being seen, and they adhered so closely 
 as to require dissection to remove them ; 
 nor could this be done, beyond a certain 
 extent, after which the same substance was 
 continued from one to the other. This 
 proved it to oe a lobe of the pfostate gland ; 
 its middle had a rounded form, united to 
 the gland at the base next the bladder, but 
 rendered a separate lobe by two fissures on 
 its opposite surface. Its ducts passed 
 directly through the coats of the bladder, 
 on which it lay, and opened immediately 
 behind the verumontanum. By means of 
 this lobe, a circular aperture is formed in 
 the- prostate gland, which gives passage to 
 the vasa deferentia. “ Previous to this 
 investigation (says Sir Everard) it was not 
 known to me, that any distinct portion of 
 the prostate gland was situated between the 
 vasa deferentia and the bladder/’ (On 
 Diseases of the Proslate Gland, p. 9, 8vo. Land. 
 1811.) Notwithstanding this explanation, 
 to the correctness of which most English 
 anatomists have acceded, it is worthy of no- 
 tice, that Langenbeck, the present distin- 
 guished Professor of Anatoipy and Surgery 
 at Gottingen, in a review of Sir Everard’s 
 account, declares, that he has never, in the 
 natural state of the parts, found the middle 
 lobe, as it is called, which he considers as a 
 partial induration, rising up in the shape of 
 a lobe. (JVeuc Bibl. B. 1, p. 360, 12mo. 
 Hanover, 1818.) This dissent would seem 
 extraordinary, if it were not possible to 
 suppose, that it may proceed, not from all 
 the subjects at Gottingen differing from 
 Londoners in being destitute of, what Sir 
 Everard Home has named, the middle lobe 
 of the prostate gland, but from Langenbeck’s 
 not having traced in the healthy slate of 
 the gland, any portion which he thought 
 deserving of that name. But though 
 differences of opinion may be entertained 
 about the name, none l presume can remain 
 about the thing itself, which appears to 
 have been long ago mentioned, though not 
 perfectly described, by Morgagni. (Adversa- 
 ria Anal. 4, Animad. 15.) The paper by Mr. 
 C. Bell, illustrating how i’arour predecessors 
 bad a knowledge of this portion of the 
 gland, seems to me one of his best produc- 
 tions: and it is therefore with pleasure that 
 
 I refer to it. (See An Account of the MuscUn 
 of the Ureters in Med. Chir. Trans. Vol. 3, 
 p. 171, 4*.) However, as this author 
 impartially acknowledges, it is not because 
 a fact was anciently known, or perhaps 
 only cursorily noticed, that there may not 
 be great merit in reviving the recollection, 
 or perfecting the description of it ; and as 
 far as I can learn, none of the anatomical 
 teachers in this city, previously to Sir 
 Everard’s paper, particularly adverted, in 
 the healthy original state of the prostate 
 gland, to the structure, which-he has pointed 
 out, by whatever name it be distinguished. 
 
 According to Sir Everard Home, this lobe, 
 in the earlier periods of life, when the body 
 of the gland is in a sound state, is small ; 
 nor does it appear to become enlarged, even 
 when the body and the lateral lobes have 
 been considerably increased in size ; but, 
 in subjects of advanced age, this part, as 
 well as the cest of the gland, is usually found 
 somewhat enlarged, even in cases where no 
 disease has been suspected during life. (P. 
 17.) When the middle lobe begins to 
 enlarge, it presses inwards towards the 
 cavity of the bladder, putting the internal 
 membrane upon the stretch, and communi- 
 cating to it by immediate contact the in- 
 flammation, which occasioned its -own 
 enlargement. Hence, pain in making water, 
 particularly after the last drops are voided, 
 and a desire and strairiingto discharge more, 
 after the bladder is empty. 
 
 As this organ cannot now retain much 
 urine, the desire to make watfr becomes 
 frequent, and there is commonly more or 
 less constitutional disturbance, or sympto- 
 matic fever. According to Sir Everard 
 Home, in prop uon as the middle lobe 
 increases in size:; it projects into the cavity 
 of the bladder in the form of a nipple ; but 
 after a further augmentation, it loses the 
 nipple-like appearance, becomes broader, 
 and forms a transverse fold by pushing for- 
 ward, and stretching, the membrane, con- 
 necting it to the lateral lobes, “ As the tu- 
 mour , arid the transverse fold, are situated im- 
 mediately behind the orifice of the urethra, they 
 are pushe.il forwards before the urine in every 
 attempt that is made to void it, acting like a 
 valve, and closing up the opening, till the cavi- 
 ty °f the bladder is very much distended, when 
 the anterior pari of the bladder being pushed 
 forward, and the tumour being drawn back, 
 in consequence of the membrane of the poste- 
 rior part of the bladder being pul on the stretch, 
 the valve is opened, so that a certain quantity 
 of water is allowed to escape, but the blad- 
 der is not completely emptied. (P. 19.) 
 Sir Everard Home afterward explains, that, 
 as the tumour enlarges, the quantity voided 
 at each time becomes smaller, and that 
 which is retained is increased, until at 
 length, the disease becomes so much aggra- 
 vated, that there is a complete retention of 
 urine. The body of the gland, and the late- 
 ral lobes, though less disturbed tlffm the 
 middle lobe by the patient’s repeated ef- 
 forts to void the urine, become more or less 
 enlarged ; but it is remarked, that they do 
 
PROSTATE GLAND 
 
 not preserve either their natural, or any 
 regular, proportion, to the middle lobe, nor 
 do they always swell equally together, the 
 left in some instances becoming much larger 
 than the right. (P. 22.) When Sir Everard 
 Home published his first vol. on diseases of 
 the prostate gland, he had seen only the left 
 lobe form the greatest projection within the 
 bladder ; but, in his second vol. published 
 in 1818, there is an engraving, representing 
 the right lobe thus altered ; and he mentions 
 two instances, in which a similar enlarge- 
 ment of the same lobe had taken place. 
 Mr. Wilson has also more than once met 
 with this greater swelling of the right lobe. 
 ( On the Male Urhiary and Genital Organs , 
 p. 336.) The recollection of these facts will 
 often enable the practitioner to incline the 
 beak of a catheter in the direction by which 
 it may be conducted into the bladder, and 
 thus, as Sir Everard Home has remarked, 
 the surgeon, after trying gently on the left 
 side, and not succeeding, is not to perse- 
 vere in that direction, but try whether the 
 passage will offer less resistance on the op- 
 posite side. 
 
 The diseased state of the body of the 
 prostate gland, and of the lateral lobes, here 
 alluded to by Sir Everard Horne, he says, 
 is very different from that, which is met 
 with in the earlier periods of life, in conse- 
 quence of strictures of the urethra, and 
 which subsides when the obstruction in that 
 canal is removed. This enlargement of the 
 prostate gland from strictures, he observes, 
 may not be unaptly compared to the swell- 
 ing of the testicle in gonorrhoea, a case of 
 accidental inflammation in a healthy tes- 
 ticle ; while the other disease of the pros- 
 tate is analogous to the more permanent 
 disease of the latter organ. This author 
 adverts, however, to a few instances, in 
 which the enlargement of the body of the 
 prostate gland from strictures, in persons 
 50 years of age, did not subside immediate- 
 ly the latter affection was cured, a common 
 bougie stopping at the neck of the bladder, 
 although a catheter, ' which had a regular 
 curve, readily passed. According to Sir 
 Everard Home, as in such cases, the patients 
 were able to empty their bladders, it is evi- 
 dent, that there .could be no enlargement 
 of the middle lobe. In cases like these, no 
 symptom of importance is produced, and, 
 whether the swelling of the prostate readily 
 subsides, or not, is of no consequence ; 
 though, if the stricture do not return, it will 
 always ultimately diminish. (On Diseases 
 of the Prostate Gland , Vol. 1, p. 24.) In 
 patients under 50 years of age, Sir Everard 
 Home has rarely found the middle lobe so 
 swelled as to produce retention of the urine, 
 or an inability to empty the bladder, not- 
 withstanding the rest of the gland might be 
 much enlarged. (P. 23.) When the middle, 
 and one of the lateral lobes, project consi- 
 derably into the bladder together, their sur- 
 face is sometimes excoriated, and has an 
 ulcerated appearance. Under such circum- 
 stances, the pain, after voiding the last 
 drops of urine, is said to be very severe, 
 
 and attended with spasmodic affections of 
 the neck of the bladder, of the most dis- 
 tressing kind. 
 
 According to Sir Everard Home, another 
 effect of a similar enlargement of the pros- 
 tate gland is to render its secretion extreme •' 
 ly viscid and very abundant. A question, 
 might arise about the real source of this 
 ropy mucus, and some might infer, that it 
 was secreted by the bladder ; but that it 
 comes entirely from^the inflamed prostate 
 gland is proved, says this gentleman, by its 
 having been found in one instance with one 
 extremity floating in the bladder in the dead 
 body, while the other extremity appeared 
 divided into small filaments, terminating in 
 the orifices of the excretory ducts of the 
 gland at the verumontanum. The quantity 
 of secretion rs observed to depend more 
 upon the degree of irritation, than the actual 
 enlargement of the gland, and, as this in- 
 creased secretion happens in cases of swell- 
 ing of this part from strictures, where the 
 body and lateral lobes are alone affected, it* 
 is inferred, that the disease of the middle 
 lobe only contributes to this effect by keep- 
 ing up a straining, and disturbance of every 
 part of (he gland. (P. 32.) The internal 
 membrane of the bladder inflames, and be- 
 comes extremely irritable, so that, even 
 when the quantity of urine is small, there is 
 a great deal of straining. When the size 
 and form of the tumour are such as to allow' 
 the greater part of the urine to pass, though 
 with great effort, Sir Everard states, that 
 the symptoms may continue nearly the same 
 for months ; liable, however, to occasional 
 aggravations from slight causes, and becom- 
 ing more or less relieved, when these are 
 removed/* Nay, he observes, that the symp- 
 toms may even lessen, although the disease 
 is not at all diminished ; a circumstance, 
 which is ascribed to the muscular coats 
 of the bladder having acquired greater 
 strength, and the internal membrane having 
 lost, from habit, the sensibility, which it 
 possessed in the earlier stage. (P. 34.) He 
 further explains, that, in this disease, when 
 the inside of the bladder is inflamed, fila- 
 mentous portions of coagulating lymph arc 
 thrown off from it, which, when the in- 
 flammation increases, subside in the urine 
 evacuated, looking not unlike white hair- 
 powder ; and, when the irritation is very 
 violent, perfectly formed pus is met with 
 in the urine. (P. 35-) After the inflam- 
 mation subsides, the bladder becomes 
 again capable of retaining a larger quan- 
 tity of urine, though its power of com- 
 pletely emptying itself is still further dimi- 
 nished. 
 
 According to Mr. Wilson, the symptoms, 
 which generally attend an enlarged prostate 
 gland, are similar to those of an irritable 
 bladder : — constant, heavy, dull pain in the 
 gland, and sometimes sharp lancinating 
 pains, darting fronvit to the urethra, and 
 occasionally to the bladder and ureters. 
 Frequent calls to void the urine, which is 
 passed with difficulty, only a small quantity 
 being discharged at a time, as more or less 
 
PROSTATE GLANDS. 
 
 350 
 
 always remains behind in the bladder. A 
 complete retention of urine may be produ- 
 ced, so that not one drop will pass, although 
 much straining is used. Great difficulty in 
 . expelling the feces, and after each evacua- 
 tion, a feeling is still experienced, as if the 
 gut were not yet emptied. During the ef- 
 forts to expel the urine and feces, a quantity 
 of the mucous secretion of the prostate 
 gland is not unfrequently forced out. Most 
 of these symptoms, a» Mr. Wilson observes, 
 are similar to those produced by stone, and, 
 therefore, when they occur, the gland 
 should be examined by the rectum, and, if 
 it be not found diseased, a sound should be 
 introduced nto the bladder. (On the Male 
 Urinary and Genital Organs, p. 339.) The 
 particular differences, bet ween the symptoms 
 of stone, and those arising from disease of 
 the prostate gland, are explained in the ar- 
 ticle Lithotomy. 
 
 Mr. Hunter first pointed out a fact, which 
 . the practical surgeon should never forget, 
 viz. that the swelling of what is now called 
 the middle lobe of the prostate gland, often 
 raises the sound o\?er u small stone in the 
 bladder, and prevents it from being felt. (On 
 the Venereal Disease, p. 170.) Hunter also 
 first noticed another circumstance well de- 
 serving recollection, viz. that an enlarge- 
 ment of the same part may account for the 
 disappearance of all the symptoms of stone 
 in patients who have already suffered greatly 
 from them, as the swelling prevents the cal- 
 culi from falling down upon, and irritating 
 the neck of the bladder. These truths are 
 exemplified by cases which are highly inte- 
 resting. It appears also probable, from the 
 observations of Sir Everard Home, that an 
 enlargement of the middle lobe conduces to 
 tiie formation and lodgment of calculi in the 
 bladder, partly by preventing the evacua- 
 tion of small ones through the urethra, and 
 partly by hindering the bladder from com- 
 pletely discharging its contents. (Vol. 1, p. 
 40.) Lastly, it is explained, that in disease 
 of the prostate gland, patients secrete less 
 urine than natural, and that death is some- 
 times produced by the retention of urine 
 suppressing such secretion altogether. In 
 cases of enlargement of the middle lobe, 
 one symptom, on which Sir Everard Home 
 lays great stress, is hemorrhage produced by 
 riding on horseback. (Vol. 2, p. 27.) In- 
 flammation and even ulceration of the mem- 
 brane covering the middle lobe, he says, are 
 more frequent than he was at first aware of, 
 and are produced by the rough introduction 
 of instruments. Hence, the burning heat at 
 the neck of the bladder, the great pain and dis- 
 tress attending the passage and the continu- 
 ance of an instrument, the occasional neces- 
 sity of taking it out, and the duration of the 
 pain for sometime afterward. (Vol.cit.p. 
 29.) 
 
 According to Mr. Wilson, in a case of 
 what is named scirrhous prostate gland, the 
 enlargement at first takes place slowly, at- 
 tended with pain, and no particular altera- 
 tion of the structure is apparent in the gland, 
 \vhen examined in this stage after death, nor 
 
 is any change discoverable when the part is 
 felt from the rectum in the living patient. 
 As the disease proceeds, the structure of the 
 whole gland changes, and the part enlarges, 
 sometimes regularly so as to preserve its 
 shape, to the size of a moderate orange ; 
 sometimes very irregularly, projecting in a 
 lobulated manner. When the gland in this 
 sta'e is cut inio, its substance feels firm, the 
 cut surface is of a whitish brown colour, and 
 the membranous septa, extending through it 
 in various directions, are often very strongly 
 marked. In general, before the urethra and 
 bladder are opened, the gland appears most 
 enlarged laterally. It also swells backwards 
 towards the rectum, producing that appear- 
 ance of the excrement particularly noticed 
 by J. L. Petit, and already mentioned in 
 speaking of common inflammation of the 
 gland. Mr. Wilson further states, that its an- 
 terior part is generally least enlarged, be- 
 cause its connexion with the pubes prevents 
 it from passing far forward However, this 
 gentleman has seen some instances, in whieh 
 the enlargement above, or in front of the 
 urethra, was considerable. The extent of 
 the lateral and posterior swelling may be 
 readily felt with the finger, introduced with- 
 in the rectum. That these very irregular 
 windings in the prostatic portion of the ure- 
 thra are frequently occasioned by the dis- 
 ease, is also confirmed by Mr. Wilson’s ex- 
 perience, and numerous preparations in the 
 Museum of the College of Surgeons. “ In 
 the progress of the enlargement, the two 
 sides do not always swell equally ; one of- 
 ten enlarges most, and often swells more in 
 one particular part than another. This pro- 
 duces a lateral bend, or obliquity in the 
 passage, which will of course increase the 
 difficulty of passing the urine, and of intrp- 
 ducing the catheter. I have seen from the 
 irregularity of the lateral swelling, the 
 passage through the gland bend in suc- 
 cession to both sides ” (J. Wilson on the 
 
 Male Urinary and Genital Organs , p. 332, 
 335.) 
 
 As every considerable enlargement of the 
 prostate gland is attended with great difficul 
 ty of voiding the urine, the muscular coat 
 of the bladder always becomes more or less 
 thickened, in consequence of the efforts 
 which it is obliged make. 
 
 In relation to the third, or middle lobe, it 
 is to be observed, that from some dissections 
 made by Mr. Shaw, it would appear, that in 
 many cases the enlarged portion of the pros- 
 tate, projecting into the bladder, is not the 
 third lobe, but a part of the gland situated 
 more forwards. (See Bell's Surgical Obs. 
 Vol.l,p.223,fyc.) 
 
 According to Sir Everard Home, a stric- 
 ture may be distinguished from an enlarge 
 ment of the prostate gland, by the following 
 circumstances : the distance of the obstruc- 
 tion from the external orifice is to be deter- 
 mined by passing a soft bougie, which is to 
 be left in the canal for a minute, so as to re- 
 ceive an impression from the obstruction. 
 If the bougie does not pass further than se 
 ven inches, and the end is marked by an ori- 
 
PROSTATE GLAND. 
 
 38 1 
 
 lice of a circular form, (it is immaterial as to 
 the size of the orifice,) the disease is cer- 
 tainly a stricture ; but if it passes further 
 on, and the end is blunted, a disease in 
 the prostate gland is to be suspected. This 
 in general may be ascertained by the possi- 
 bility of passing into the bladder a flexible 
 gum-catheter with a stilet, very much curved, 
 which in most cases of enlargement of the 
 gland may he accomplished. 
 
 On the subject of the causes of a scirrhous 
 enlargement of the prostate gland, it ap- 
 pears to me, that little certain is known, ex- 
 cepting that it is a disease seldom met with 
 under the age of fifty. Desault suspected, 
 that it was sometimes venereal, and common 
 in individuals who had repeatedly had go- 
 norrhoeu. ( Traiti des Mai. Chir. T. 3, p. 
 238.) I believe neither of these sentiments 
 is entertained by the best surgeons of the 
 present day. According to Sir Everard 
 Home, it is a rare occurrence for a man to 
 arrive at 80 years of age, without suffering 
 more or less under disease of this part. 
 ** The more common causes (says he) of in- 
 flammation of the prostate gland, are full 
 living of every kind, inebriety, indulgence 
 to excess with women, a confined state of 
 the bowels, and exposure to the effects of 
 cold ; indeed, whatever increases the circu- 
 lation of the bloo!-' in these parts (the geni- 
 tals I suppose) beyond the healthy standard, 
 tnay become a cause of inflammation in this 
 gland, the blood-vessels of which lose their 
 tone in the latter periods of life.” ( On Dis- 
 eases of the Prostate Gland, Vol. 1, p. 18, 
 19.) If we are to credit another statement, 
 the disease occurs most frequently either in 
 persons who have not used the genital or- 
 gans so much as nature intended, or in others 
 who have led a life of excess. ( Wilson on 
 the Urinary and Genital Organs, p. 332.) It 
 seems to me better to confess, that the etio- 
 logy of this complaint is unknown. Nor are 
 we rendered much wiser by conjectures 
 about the effects of horse exercise, or those 
 of a retarded venous circulation in old sub- 
 jects, in creating a tendency to the disease. 
 
 1 have known several persons afflicted, who 
 had led very sedentary lives. 
 
 I am afraid, that the observation formerly 
 made by Mr. Hunter still continues true, 
 which is, that a certain cure for the scirrhous 
 enlargement of the prostate gland is not yet 
 discovered. But though such is the fact, 
 surgery is undoubtedly capable of affording 
 a great deal of relief, so as to lengthen the 
 patient’s days, and render them much more 
 comfortable. This is accomplished princi- 
 pally by anodyne medicines, and drawing off 
 the patient’s water, when he cannot void it 
 himself either at all, or but imperfectly, and 
 with considerable straining and suffering. 
 As a temporary relief from pain, and also as 
 a means of removing spasm, opiate clysters' 
 should be administered once or twice a day. 
 (Hunter, p. 174.) Scrofulous enlargements 
 ot the prostate gland, occurring in younger 
 subject! 1 , are probably more under the con- 
 trol of judicious treatment. Thus, Mr. Hun- 
 ter informs us, that in several cases he had 
 
 seen hemlock of service. “ It was given 
 upon a supposition of a scrofulous habit. On 
 the same principle, (he adds,) I have re- 
 commended sea-bathing ; and have seen 
 considerable advantages from it, and in two 
 cases, a cure of some standing.” In one 
 case, burnt sponge had reduced the swelling ; 
 and in another the same effect was produced,, 
 and the irritability of the bladder lessened, 
 by means of a seton in the perinasum. Af- 
 ter the healing of the seton, however, the 
 symptoms returned, and on a trial of the 
 plan again, the former good effects were not 
 experienced from it. Some time ago, I at- 
 tended a gentleman under Mr. Lawrence, 
 who was trying the effect of an issue in the 
 same situation ; but I am not at present ac- 
 quainted with the result. In these cases, the 
 pilulaj hydrargyri cum conio (see Pilulce) 
 have been very commonly prescribed, as an 
 eligible alterative. Sir Everard Home men- 
 tions an instance, in which suppositories of 
 opium and hemlock, passed up the funda- 
 ment, and allowed to dissolve there, gave 
 more relief than any other plan, not only 
 lessening the irritation, but producing a di- 
 minution of the projection of the gland. 
 
 In the first stage of the enlargement of the 
 middle lobe, when there is no absolute ob- 
 struction to the passage of the urine, Sir 
 Everard recommends bleeding from the 
 loins, opiate clysters, and the pulv. ipecac, 
 comp. (On Diseases of the Prostate Gland, 
 Vol. 1 ,p. 70.) The tepid bath, the use of 
 which he formerly advised, he now con- 
 demns as a practice “ as little applicable to 
 this disease, as putting the head in warm wa- 
 ter would be to remove the symptoms of 
 apoplexy ; if any applications are to be made 
 to the parts, they should be such as produce 
 cold.” (Vol. 2, p. 83.) In this stage, he 
 observes, that catheters and bougies should 
 on no account be introduced, more especial- 
 ly those of the metallic kind, since they pro- 
 duce a degree of disturbance which the parts 
 are not in a state to bear, and if unskilfully 
 employed, they will increase the swelling, 
 and bring on a complete retention of urine. 
 Sir Everard is an advocate for keeping the 
 bowels open, for which purpose he prefers 
 the infusion and tincture of senna, with the 
 tartrate of potash. (Vol. 2, p. 84.) If, in 
 defiance of these means, the patient becomes 
 unable to make any water, or, although able 
 to pass a few' ounces, is every hour obliged 
 to make the attempt, and after much strain- 
 ing, discharges only the same quantity, Sir 
 Everard directs a flexible gum-catheter, 
 without a stilet, to be passed into the blad- 
 der, in the gentlest manner possible. This 
 instrument is to be kept introduced with the 
 catheter bracelet, or retainer, made and sold 
 by Mr. Weiss of the Strand, and the water 
 drawn off at regular intervals, not only till 
 the first symptoms go off, but till the bladder 
 retain the urine for the usual length of time, 
 and what is voided has the appearance of 
 heathly urine. If, when the catheter is with- 
 drawn, the patient should not be able to 
 empty his bladder, it must be re-introduced, 
 and after six or seven days, taken out again 
 
PRO 
 
 PSD 
 
 382 
 
 When the disease is somewhat more ad- 
 vanced, and the patient cannot keep himself 
 quiet, the above practice of course cannot be 
 adopted, and it becomes necessary to pass 
 the catheter three or four times a day. But 
 even under such circumstances, when irri- 
 tation is brought on by accidental circum- 
 stances, SirEverard recommends keeping the 
 instrument in the bladder until the attack 
 has subsided. (Vol. 2,p. 92, 96.) This gen- 
 tleman finds that, for cases of diseased pros- 
 tate gland, common flexible gum-catheters, 
 originally made straight, are disadvantageous, 
 as it is a long while before they can be made 
 to keep a permanent curved form. “ When 
 (says he) the curvature of the catheter is no 
 part of its original formation, although it may 
 have been produced by being long kept in a 
 curved state, yet, wjien allowed to remain in 
 the bladder, it gradually returns to its straight 
 form by being moistened, and when it has 
 acquired it, the point is no longer kept di- 
 rected upwards in the cavity of the bladder, 
 but is constantly pressing against the pos- 
 terior coats, pushing itself out of the urethra, 
 and the irritation it gives the muscular coat 
 of the bladder, will often be the means of 
 its being expelled by a spasm with consider- 
 able violence.” (On Diseases of the Pros- 
 tate Gland , Vol. 2, Chap. 5.) Sir Everard 
 further informs us, that Mr. Weiss, No. 33, 
 in the Strand, has at length succeeded in 
 making flexible gum-catheters, originally 
 curved, so that they always retain their shape. 
 Their polish is great, and they can be had 
 of any size : they are also made particular- 
 ly strong, a quality necessary to secure them 
 from being broken in vioient attacks of 
 spasm. Sir Everard stales, that he has 
 kept them fifteen days in the bladder, 
 without their being spoiled by the urine, or 
 mucus ; whereas, common French and Eng- 
 lish catheters become in a shorter period so 
 rough as to be unfit for further use. Metal 
 catheters, he asserts, should never be em- 
 ployed but in cases of necessity, where the 
 patient cannot be relieved by milder means. 
 (Vol 2, p. 87.) To such instruments, he 
 ascribes the frequently noticed ulceration of 
 the middle lobe, the abrasion of its surface, 
 the wounds throygh its substance, the gene- 
 ral inflammation of the whole internal mem- 
 brane of the bladder, and quick destruction 
 of the patient’s life. The gum catheter, 
 however, is to be as large as the urethra will 
 easily admit, in order that it may more rea- 
 dily disengage itself at the turns into the 
 bladder. (Vol. 1, p. 75.) * 
 
 According to Desault, a large catheter 
 generally answers better than a small one, 
 and it may either be of silver, or elastic gum. 
 The latter, though the best for the purpose 
 of being kept in the passage, he says, has 
 not always sufficient firmness to get through 
 the obstruction in the canal, not even with 
 the aid of a stilet. In this respect, a silver 
 catheter is sometimes preferable. But 
 whatever may be the kind of catheter em- 
 ployed, it generally passes as far as the 
 prostate with perfect facility, where it is 
 stopped, rot, only by the narrowness, but 
 
 also by the new curvature of the passage. 
 For the prostate cannot be enlarged, with- 
 out pushing forward and upwards, or to one 
 side, that portion of the urethra behind 
 which it, is situated. This circumstance 
 ought never to be forgotten, in regulating 
 the length and direction of the beak of the 
 catheter, which should also be longer, have 
 a more considerable curvature, and be more 
 elevated, at the time of its introduction, 
 than in other cases of obstruction in the 
 urethra. 
 
 In swellings of the prostate gland, Mr. 
 Hey has particularly pointed out one ad- 
 vantage, which belongs to elastic catheters, 
 viz. that their curvature may be increased 
 while they are in the urethra. This gentle- 
 man was introducing an elastic gum-cathe- 
 ter in a patient, whose prostate gland was 
 much enlarged, and finding some obstruction 
 near the neck of the bladder, he withdrew 
 the stilet, in doing which he accidentally 
 repressed the tube, Which then yveht into 
 the bladder. In fact, lie found that the act 
 of withdrawing the stilet increases the cur- 
 vature, and lifts up the point of the catheter. 
 (Pract. Obs. in Surgery , p. 399, Edit. 2.) 
 For further remarks connected with this 
 subject, see the articles Cathether, and Urine , 
 Retention of. Sir Everard Home states with 
 confidence, that if the symptoms of the fore- 
 going disease" be prevented in their early 
 stage from increasing by the treatment which 
 he has recommended, the disease will get 
 well. (See J. Hunter's Treatise on the Vene- 
 real Disease, p. 169, &c. 2 d Ed. 4 to. Lond. 
 1788. Baillie's Morbid Anatomy. P. J. De- 
 sault , (Euvres Chir. T. 3, p. 220, fyc. 8 vo. 
 Paris, 1803. Sir Everard Horne, On the 
 Treatment of Diseases of the Prostate Gland , 
 2 Vols. 8vo. Lond. 1811—1818. Also, On 
 Strictures, 3 Vols. 8 vo. 3 d Edit. 1S05 — 1821. 
 C. Bell, On the Muscles of the Ureters in 
 Med. Chir. Trans. Vol. 3. J. Shaw, On the 
 Structure of the Prostate Gland, in C. Bell's 
 Surgical Obs. Vol. 1,8 vo. 1816*. E.A. Lloyd 
 on Scrofula, p. 107, <^c. 8 vo. Lond. 1821. 
 ./. How skip , Pract. Obs. on Diseases of the 
 Urinary Organs, fyc. 8 vo. Lond. 1816. J. 
 Wilson, On the Male Urinary and Genital 
 Organs, 8 vo. Lond. 1821.) 
 
 PSEUDOSYPHILIS. (from false, 
 
 and Syphilis, the venereal disease.) Disease 
 resembling the venereal, but not really of 
 this nature. The spurious venereal disease. 
 (See Venereal Disease.) 
 
 PSOAS ABSCESS. (See Lumbar Ab- 
 scess.) 
 
 PSORIASIS. Scaly tetter. A disease of 
 the order Squamae, in Dr. Bateman’s Sy- 
 nopsis. It is attended with more or less 
 roughness and scaliness of the cuticle, with 
 a subjacent redness. The skin is often di- 
 vided by deep fissures ; and the complaint 
 is generally attended with constitutional 
 disorder, and liable to cease and return at 
 certain seasons. For a particular account ot 
 its varieties and treatment, see the above 
 work. 
 
 PSOROPHTHALMY. (from 4*ga, the 
 itbh, and o<pB»hyia., an inflammation of the 
 
pye.) An inflammation of. the eyelids, at- 
 tended with ulcerations, which itch very 
 much. Beer actually understands by the 
 expression, such a disease, from the sudden 
 repression of the itch, or the infection of 
 th*>se parts with psoric matter. ( Lelire von 
 den Augenkr. B. 1 ,p. 566.) Weller not only 
 adopts the same notion, but makes an ad- 
 dition to it, by extending the tern^flriso to 
 cases, in which the eyelids are affected with 
 psoriasis, porrigo, and impetigines. (Ma- 
 nual of the Diseases of the Eye, Vol. 2, p. 
 264.) By psoropktkalmy, the late Mr. Ware 
 meant a case, in which the inflammation of 
 the eyelids is attended with an ulceration of 
 their edges, upon which a glutinous matter 
 lodges, in crusts, and becomes hard, so that, 
 in sleep, when they have been long in con- 
 tact, they become so adherent, that they 
 cannot be separated without pain. He has 
 remarked, that “ the ulceration in the pso- 
 rophthalmy is usually confined to the edges 
 of the eyelids ; but sometimes it is seen to 
 'extend over their whole external surface, 
 and even to excoriate the greater part of 
 the cheek. In cases of the latter kind, the 
 inflammation which accompanies, has often 
 much the appearance of an erysipelas, and 
 will receive most relief from the cooling ap- 
 plications. The use of the citrine ointment, 
 which will hereafter be recommended, must 
 in such instances, be deferred until the 
 irritability of the skin is in a good degree 
 abated. 
 
 il This disorder is also sometimes attend- 
 ed with ^ contraction of the skin of the 
 lower eyelid ; in consequence of which that 
 lid is drawn down, and. the inner part turn- 
 ed outward, so as to form a red, fleshy, and 
 most disagreeable appearance, called ectro- 
 pium. Whenever this happens, it proves the 
 complaint to be of the most obstinate na- 
 ture ; though it is generally, removed by the 
 cure of the psorophthalmy, whichristhe oc- 
 casion of it.” ( Remarks on Ophthalmy, fyc. 
 p. 112.) Mr. Ware recommended, for the 
 cure of this disease, the unguentum hydrar- 
 gyri nitrati. This is to be melted into an 
 oil, and rubbed with the end of the fore-fin- 
 ger, or the point of a small pencil-brush, 
 into the edges of the affected eyelids, once 
 every night, on going to bed. A plaster of 
 ceratum album is then put over the eyelids 
 to keep them from adhering together. If 
 they should still adhere in the morning, they 
 are to be cleaned with milk and butter, well 
 mixed together. In a few cases, it is neces- 
 sary to touch the ulcers, formed on the 
 edge ot the eyelid, after the small-pox, with 
 the argentum nitraturn. When the globe of 
 the eye is inflamed, the vinous tincture of 
 opium is applied, as directed in the article 
 Ophthalmy. In scrofulous subjects, altera- 
 tive medicines ; an issue, or perpetual blis- 
 ter; and attention to diet, &c. are proper. 
 (See Ware on Ophthalmy , <^c.) 
 
 In the treatment of psorophthalmy, Beer 
 lays considerable stress upon the necessity 
 ot cleanliness. The itehy places he directs 
 to be frequently washed with a tepid infu- 
 c ton of scordiuiri, and afterward well dried. 
 
 When the uneasiness and tension of the 
 skin are thus quite removed, Beer adds to 
 the preceding infusion some of the sulphu- 
 ret of potash, the proportion being at first 
 small, and gradually increased. This plan 
 is to be followed, until the ulcerations dry 
 and the scabs fall off of themselves, leaving 
 the subjacent skin yet red and sensible, and 
 sometimes moist ; in this state, a small bit of 
 the annexed salve may be smeared with a. 
 camel-hair pencil along the edges of the 
 eyelids, and upon the affected points of the. 
 skin : R. Butyri recentis insulsi, ^ss. Cu- 
 pri Sulphatis, gr. x. Camphoree, gr. iv. Tu 
 tise ptt. gr. vj. Misce. If the disease prove 
 obstinate, Beer recommends Hufeland’s 
 salve, wbich consists of equal parts of fresh, 
 butter, yellow wax, and the pulv. hydrarg. 
 nitneo-oxydi rubr. ; and, in still more inve- 
 terate cases, Janin’s eye salve, which, he 
 says, must rarely be used oftener, than 
 every other day. In the psorophthalmy, 
 conjectured by Beer to depend upon the 
 sudden cure of the itch, he-states, that in- 
 ternal medicines are necessary, as antimo- 
 nials, joined with sulphur and camphor. 
 He also praises sulphur baths, and irrita- 
 ting the part of the skin where the itch 
 has receded, by th$ application of antimo- 
 nial ointment ; or /if such part should be 
 very far from the eyes, he advises such 
 ointment to be rubbed on the skin behind 
 the ears. Attention to diet is particularly 
 enjoined, and eating pork, lard, and sub- 
 stances difficult of digestion, is prohibited, 
 (B. 1. p. 569, fyc.) 
 
 (tlim. of <vr<rigo^, a wing.) 
 As Scarpa remarks, surgeons usually apply 
 the term “ pterygium'’ to that preternatural, 
 reddish, ash-coloured, triangular little mem - 
 brane, which most frequently grows from 
 the internal angle of the eye, near the ca- 
 run cula lachrymalis, and gradually extend* 
 over the cornea, so as to cause considerable 
 impediment to vision. 
 
 The disease, however, presents itself some 
 times in the form of a semitransparent thin 
 grayish membrane, not furnished with many 
 visible vessels ; and sometimes as a thick, 
 red, fibrous mass, very like muscle, being 
 very prominent even on the cornea, where 
 it seems to terminate in a substance like 
 tendon, and it is observed to be pervaded 
 by numerous blood-vessels. The first is the 
 pterygium tenue of Beer ; the second the 
 pterygium crassum ( Lehre von den Augenkr. 
 B. 2, p. 636.) or, the membranous and fleshy 
 pterygia of other writers. 
 
 Though the pterygium most commonly 
 proceeds from the internal angle, (also Beer , 
 B. 2, p 637.) it is observed to arise some- 
 times from the external one, and, in some 
 instances, from the superior or inferior he- 
 misphere of, the eyeball. • But, whatever be 
 *ts origin, its figure is invariably that of a tri- 
 angle, with its base on the white of the eye, 
 and its apex more or less advanced over the 
 cornea, towards its centre, and that of the 
 pupil. Indeed, there are a few cases in 
 which two or three pterygia of different 
 sizes occur on the same eye, and are arran- 
 
TTERtGim 
 
 384 
 
 round its circumference at interspaces 
 of various breadths. Tbeir points are di- 
 rected towards the centre of the cornea, 
 and if they should unfortunately conjoin 
 there, the whole of that transparent mem- 
 brane becomes covered with an opaque veil, 
 and a total loss of sight is the consequence. 
 It seems to Scarpa, that the term “ p annus” 
 was applied by t lie ancients to exactly this 
 sort of complication. However, the occur- 
 rence of more than- one pterygium on the 
 same eye is uncommon, as may be interred 
 from the experienced Beer having met with 
 but two cases of a double pterygium, and 
 with only one instance of three pterygia on 
 the eye. (B. 2, p. 638.) 
 
 According to Scarpa, (whose observations 
 apply chiefly to the membranous form ot the 
 disease) chronic varicous ophthalmy, with 
 relaxation, and thickening of the conjuncti- 
 va ; opacity of the cornea ; and the ptery- 
 gium ; only differ in the degree of the dis- 
 ease In reality, all the three complaints 
 consist of a more or less extensive varicous 
 state of the vessels of the conjunctiva, com- 
 bined with a. degree of preternatural relaxa- 
 tion, and thickening of that membrane. 
 
 In chronic varicous ophthalmy, the e *tra- 
 ordinary amplitude, and knottiness of the 
 vessels; the flacciditv, and thickening of 
 the conjunctiva ; are limited to the white 
 of the eye. In opacity of the cornea, 
 certain veins even dilate, andbecome knotty 
 for some way over that delicate layer of 
 the coniunctiva, which is continued over 
 the surface of the cornea. In the pterygium, 
 an extraordinary swelling of this subtile 
 membranous expansion is added to the v at 1 - 
 cous slate of its veins. Hence, the ptery- 
 srium seems at first like a new membrane 
 *ormed on the cornea, while it is really 
 nothing more than the delicate continuation 
 of the conjunctiva just mentioned, deprived 
 of its transparency, and degenerated, in 
 consequence of chronic ophthalmy, into a 
 thick, opaque membrane, on which theie is 
 a plexus of varicous blood-vessels. Con- 
 sequently, in the case of pterygium, there is 
 no new production of the eye, but only an 
 alteration. of one of the thin transparent 
 membranes, which naturally cover it. The 
 following circumstance, as will be more 
 fully explained presently, illustrates, says 
 V Scarpa, the veracity of the preceding state- 
 ment. The incipient pterygium may be 
 cured in the name mariner as opacity of the 
 cornea, viz. by merely cutting off that por- 
 tion of it, which is situated at the J ul * ct,OI J 
 of the cornea with the sclerotica, without 
 detaching the whole of it from the surface 
 of the former membrane ; just as is practi- 
 sed in the opacity of the cornea, m order to 
 destroy the communication of the varicous 
 veins of the conjunctiva, with their trunks, 
 the ramifications of which produce, and 
 maintain the disease. 
 
 Scarpa observes, that the pterygium would 
 be as common a complaint as the varicous 
 chronic ophthalmy, so often occupying the 
 white of the eye, if the delicate continua- 
 tion of the conjunctiva over the surface ot 
 
 the cornea were not naturally ot a denser* 
 and more compact texture than the rest of 
 the membrane, from which it is produced, 
 and if its vessels were not very minute and 
 delicate, and not so dilatable as those of the 
 other part of the conjunctiva. This is the 
 reasp n why the pterygium is comparatively 
 a rare case, in respect to the great fre- 
 quency^!' varicous, chronic ophthalmies. 
 But shmnd the vessels of the transparent lay- 
 ers of the conjunctiva once yield to the im- 
 pulse of the fluid propelled into them ; 
 should they once become varicose, the cel- 
 lular texture, in which they are enveloped, 
 never fails to swell gradually, and thus 
 the delicate, diaphanous membrane in ques- 
 tion changes into a pulpy, reddish tunic, 
 precisely similar to the pterygium. 
 
 That the pterygium is truly nothing else 
 but the natural, delicate, transparent ex- 
 pansion of the conjunctiva, on the cornea, 
 converted, for a certain extent, into a pulpy 
 flaccid varicous membrane, may be inferred 
 (continues Scarpa) from the tolds, which 
 the pterygium and conjunctiva form at the 
 same time, when the morbid eye is turned 
 towards the origin of the disease. The 
 same inference is equally deductible from 
 the tension occasioned in both these paits, 
 whenever the eye is moved in the opposite 
 direction. We become still more convin- 
 ced of the fact on observing, that in the 
 first position of the eye, both the pterygium 
 and the corresponding portion of the con- 
 iunctiva (which is equally relaxed, varicous, 
 and reddish,) may be easily taken hold ot 
 with a small pair of forceps, and raised 
 together in the form of a fold. 
 
 The pterygium is observed by Mr. Travers 
 to be most prevalent in warm climates. 
 (Synopsis fyc. p. 101.) It is also said to be 
 most frequent in old people, though Mr. 
 Wardrop, and Dr. Monteath have seen it 
 in very young infants.-W/er’s Manual 
 of the Diseases of the Eye, Vol. l,p. -18.) 
 
 The constancy of the triangular figure o 
 the pterygium, with its basis on the white ot 
 the eye, and its apex on the cornea, is one 
 of its principal diagnostic characters, by 
 which the true disease may be discriminated 
 from every other soft, fungous, reddish ex- 
 crescence, obscuring the cornea, kor, on 
 this membrane, excrescences sometimes 
 form, which, from having the colour and 
 consistence of a soft membrane, bear a very 
 great resemblance to the pterygium, though 
 they are really widely different, and^ strictly 
 speaking, consist of the texture of the cornea 
 itself, degenerated into a soft, fungous sub- 
 stance. Such pellicles, however, not only 
 almost always create a greater prominence 
 on the cornea, than what accompanies the 
 pterygium, but they are constantly of an 
 irregular tuberous form, and never represent 
 a triangle, with the apex pointing towards 
 the centre of the cornea, like the genuine 
 
 Pt Another distinguishing ehwactep of ptery- 
 <r*,uin, ns Scarpa has observed, is the taulity, 
 with which the whole of ltmay be taken hold 
 of with a pair of forceps, and raised into - 
 
PTERYGIUM. 
 
 3 
 
 fold on the cornea. Every other kind of 
 excrescence, attached to this membrane, 
 continues firmly adherent to it, and cannot 
 be folded, and raised from the surface of 
 the cornea, in any manner whatever. This 
 particularity is of the highest importance 
 in the treatment of the disease ; for the 
 genuiue pterygium may be cured by simple 
 means, while fungous excrescences of the 
 cornea, can only be radically removed, 
 and perfectly cicatrized with the utmost 
 difficulty. Plenck very properly observes, 
 on this head : Pterygia, qua jfilamemis solum- 
 modb adherent, facile abscinduntur, difficilime 
 qiue ubique aecreta sunt cornece , ac in plicam 
 elevari non possunt. 
 
 Scarpa’s belief in the reality of a malig- 
 nant or cancerous pterygium must appear a 
 doctrine requiring confirmation, when it 
 is considered, that Mr. Travers makes no 
 mention of the disease assuming this charac- 
 ter, and Beer distinctly states, that, in a 
 practice of thirty-two years, he has cured 
 376 pterygia, of various sizes and thickness, 
 without one bad symptom, or consequence. 
 And, hence, he justly concludes, that the 
 disease is strictly local. ( B . 2, p. 641.) 
 This statement, however, is qualified with 
 the condition, that the knife only be em- 
 ployed when requisite, and that no consi- 
 derable portion of the disease be left unre- 
 moved. 
 
 The true benign pterygium, says Scarpa, 
 which has a triangular figure, is ash colour- 
 ed, or pale red, is free from pain, and admits 
 of being raised in the form of a fold on the 
 surfeu^e of the cornea, may be cured by cut- 
 ting me opaque triangular little membrane 
 accurately from the surface of the cornea, 
 which is in part covered by it. But, as it 
 appears, from what has been said, that the 
 pterygium is nothing, but a portion of the 
 delicate, transparent layer of the conjunc- 
 tiva, converted by chronic varicous oplithal- 
 rny into a thick, opaque tunic, it follows, 
 that the pterygium cannot be removed in 
 any way, without the spot, which it occu- 
 pies on the cornea, being bereft of its 
 natural external covering. Also, as this 
 denudation of the cornea renders a cicatrix 
 unavoidable at the place, it equally follows, 
 that the knife cannot be employed in the 
 cure of the disease, without the cornea 
 being rendered more or less opaque at the 
 part, where the pterygium was before 
 situated. 
 
 Scarpa’s experience enables him to state, 
 however, that the superficial, indelible 
 speck, remaining on the cornea, after the 
 recision of the pterygium, is always less ex- 
 tensive, than the space previously occupied 
 by the disease. 
 
 It is customary (says Scarpa) to remove 
 the pterygium by making the incision on 
 the cornea, and extending it over the white 
 ol the eye, as far as the base of the disease 
 reaches on the conjunctiva; so lhat when 
 the pterygium grows from the internal 
 angle of the eye, most surgeons continue 
 the section as far as the caruncula This 
 practice is disadvantageous, first, because it 
 
 Voi. V 49 
 
 denudes too much of the white of the eye , 
 secondly, because, in consequence of the 
 large portion of the conjunctiva removed 
 at the base of the pterygium, and in conse- 
 quence of the direction of the wound, the 
 cicatrix in the white of the eye forms an 
 elevated frgenum, which, like a little cord, 
 keeps the eyeball approximated to the ca 
 ruucula lachrymalis, and destroys the free- 
 dom of its motions, particularly towards 
 the external angle. 
 
 In the treatment of pterygia with bases 
 extending far in the white of the eye, Scarpa 
 prefers detaching them at their apex, as far 
 as the junction of the cornea with the scle- 
 rotica, and then to separate them at their 
 base by a semicircular incision, comprehend- 
 ing one line in breadth of the substance 
 of the conjunctiva, and made in a direction 
 concentrical with the edge of the cornea. 
 Scarpa has observed, that in this mode of 
 operating, the subsequent cure takes place 
 sooner, than when the common method is 
 adopted ; the cicatrix occasions no sort of 
 fraenum, and the conjunctiva, circularly 
 stretched by the cicatrix, lies smoothly over 
 the white of the eye, and loses that relax- 
 ation, and varicous slate, which are the 
 groundwork of the pterygium. Such atten- 
 tion, however, is not requisite, when the 
 pterygium is small, and its base does not 
 extend far in the white of the eye. 
 
 The operator, after desiring the patient 
 to move his eyeball towards the part cor- 
 responding to the base of the pterygium, is 
 to take hold of the membrane with a pair 
 of forceps held in his left hand, and pinch 
 it into a fold, at about one line from its apex. 
 The duplicature is now' to be raised, and 
 drawn out gently until a sensation of some- 
 thing giving w ay is felt, which indicates the 
 detachment of the pterygium from the 
 delicate cellular texture by which it is con- 
 nected with the subjacent cornea. Next, 
 by means of a pair of scissors, the surgeon 
 must dissect this fold, as closely as possible, 
 from the cornea, proceeding from the apex 
 towards the base of the pterygium. The 
 section being completed to where the cor 
 nea and sclerotica meet, the fold is to be 
 again elevated still more, and, with one 
 stroke of the scissors, the pterygium, and 
 the relaxed portion of the conjunctiva, 
 forming its base, are to be detached, as 
 concentrically, and closely to the cornea, 
 as possible. This second incision will have 
 a semilunar shape, the horns of which ought 
 to extend two lines beyond the relaxed part 
 of the conjunctiva in following the curvature 
 of the eyeball. 
 
 When the operation is finished, the sur- 
 geon must promote the hemorrhage, by- 
 washing the part with w r arm water, and 
 then cover the eye, that has been operated 
 on, with a pledget of dry lint, or lint moist- 
 ened in the liquor plumbi acet. dilutus, kept 
 on with,a bandage, that does not make too 
 much pressure. 
 
 If no particular symptoms arise, such as 
 pain, tension of the eye, considerable tume- 
 faction of the eyelids, it is sufficient to wash 
 
PTE 
 
 PTO 
 
 38(5 
 
 the eye, and inside of the eyelids, three or 
 four times a day villi a warm lotion of 
 mallows, and carefully keep these parts 
 from being exposed to the air, without 
 compressing them. If the symptoms just 
 mentioned should occur, antiphlogistic treat- 
 ment must be adopted. 
 
 On the fifth or sixth day, at latest, after 
 the operation, all the surface, from which 
 the pterygium was cut. appears yellowish, 
 and covered with a fluid like mucus. The 
 edges of the wound, and the adjoining part 
 of the conjunctiva, assume a reddish colour. 
 Afterward, the surface of the wound con- 
 tracts more and more daily, and at length, 
 completely closes. 
 
 During the whole treament, subsequent 
 to the operation, there is no occasion to 
 employ any other topical applications, but 
 the warm lotion of mallows, three or four 
 times a day. Numerous cases have convin- 
 ced Scarpa that astringent collyria, and 
 the boasted powders of the florentine iris 
 and alum, cause great irritation to the 
 eye operated on, and give rise to tume- 
 faction, and a fungous state of the con- 
 junctiva, which are impediments to the 
 cure. What is still more incommodious, 
 
 is, that such means produce fungous ex- 
 crescences on the middle '-of the wound 
 itself, which admit of being repressed and 
 cicatrized with difficulty. Scarpa has seen 
 all these inconveniences arise from one 
 single unnecessary application of the argen- 
 tum nitratum. On the other hand, when a 
 lucre lotion of mallows is the only remedy 
 employed in the treatment, the cure pro- 
 ceeds regularly ; the yellowish surface of the 
 incision diminishes daily, arid in three, or, 
 at most, four weeks, the wound is quietly 
 healed. The zinc coliyrium, containing a 
 few drops of camphorated spirit of u ine, can 
 only be prudently instilled, Ihree or four 
 times a day into the eye, for the purpose of 
 obviating the relaxation of the conjunctiva 
 and its vessels, after the wound is perfectly 
 cicatrized. 
 
 The incipient pterygium (adds tbisauthor) 
 is not a dense, opaque membrane, but a 
 pellicle as fine as a cobweb, interwoven in 
 different places with varicous blood-vessels, 
 the iris continuing tolerably visible behind 
 
 it. In this early state of the pterygium, it 
 is unnecessary to deprive the cornea of its 
 natural covering ; it is quite enough to cut 
 off a portion of it, in order to intercept all 
 communication between the dilated venous 
 ramifications of the pterygium, and the va- 
 riccms truiiksin the white of the eye. 
 
 Therecision, says Scarpa, is accomplished 
 by cutting out with a pair of forceps and 
 scissors a semilunar piece of the conjunc- 
 tiva, at the point where the cornea and 
 sclerotica conjoin, anti exactly at the base 
 of the incipient pterygium, just as is prac- 
 tised for opacity of the cornea. The recent 
 pterygium is observed to disappear gradu- 
 ally after the operation, or to change into a 
 slight dimness of the cornea, extending over 
 a part of the space previously occupied by 
 the disease. This opacity is commonly 
 
 much more trivial than what follows a cica - 
 trix. Acrel, in his Surgical Obsecrations, 
 mentions having successfully treated an 
 incipient pterygium in this manner. Scarpa, 
 has also tried the plan several times with 
 success. Such treatment must be better 
 than merely making two or three deep cuts, 
 or scarifications, in the membrane near the 
 edge of the cornea, as advised by Beer. 
 ( B . 2, p. 641.) And in proof of the uncer- 
 tainty of the latter method, vve find Beer 
 himself speaking of the necessity of using 
 stimulating applications, like powdered su- 
 gar, alum, the vinous tincture of opium, &c. 
 if the operation is not of itself sufficient. 
 In the pterygium crassum, Beer recommends 
 the knife, as the best means of cure ; buf 
 he differs essentially from Scarpa, not mere- 
 ly in preferring a knife to the scissors, but 
 in beginning the operation by making a 
 deep cut through the base of tbe pterygium 
 in the white of the eye, from which point 
 he continues the dissection of the ptery- 
 gium, till this is all removed as far as its 
 apex on the cornea, when he uses either 
 the knife, or scissors, -as most convenient 
 (£. 1. p. 643.) 
 
 Beer mentions that it sometimes happens, 
 especially in cases of thin pterygia, that the 
 disease stops at the edge of the cornea, and 
 spreads no further, as long as the patient 
 lives. ( B . 2, p. 641.) Under such circum 
 stances, of course the complaint will give 
 no trouble, and may be left to itself, as par- 
 ticularly advised by Mr. Travers. ( Synop - 
 sis, 4 C • p • 274.) When, however, it en- 
 croaches upon the sight, this gentleman 
 says, that “ it should be raised by dissection, 
 as close as possible to the margin of the 
 cornea, and the relaxed portion of the mem 
 brane removed by an incision, midway be- 
 tween ilit base of the pterygium, and the cor- 
 nea, and concentric to that membrane.*' 
 For further information, consult ./. War dr op. 
 Essays on the Morbid Anatomy of the Human 
 Eye, Vul. 1, p. 22, tiro. Edinb. 1808 
 Scarpa sulle Malailie degli Occhi. cap. 11. 
 Jlichter's Anfangsgr. dec Wundarzneyhunst , 
 B. 3, p. 141, fyc. Gottingen, 1795. Sabatier , 
 De la M&decine Operaloire, T. 2, p. 190, 
 Edit. 2. Beer's Lehre von den Augenkr. B 
 2, p. 636, fyc. Svo. Wien. 1817. B. Travers , 
 Synopsis of the Diseases of the Eye, 8 ro. Loud. 
 1820. Weller's Manual, Vol. 1, 8ru. Glas- 
 gow, 1821. 
 
 PTOSIS, (from tmnrra), to fall down.)- 
 Blcuharoptasis. Lapsus Palp three Superions,. 
 An inability of raising the upper eyelid. 
 According to Beer, ptosis always arises from 
 a considerable relaxation and extension of 
 t lie common integuments of the upper eye- 
 lid, which hang down in a kind of fold over 
 the/fissure of theclosed palpebrse, and when 
 the levator muscle has been more or less 
 weakened by the same causes, which 
 have produced t his state of the skin, the 
 weight of the redundant integuments pre- 
 vents the eyelid from being properly open- 
 ed. lienee, when the patient tries to raise 
 the eyelid, the efforts of the levator muscle 
 may be seen ; but, the object cannot be per - 
 
FfO 
 
 reetly accomplished. With the exception of 
 the inability of raising the upper eyelid, the 
 patient has not the slightest ailment ; the eye 
 is not at all red, though, when opened, it 
 does not bear the light well, on account of 
 not being accustomed to the stimulus ; no 
 stiliicidum lachrymarurn is observable ; and 
 the edge of the eyelid, with all the eyelashes 
 quite dry, is seen directly trie part is eleva- 
 ted with the thumb* When the relaxed fold 
 of the skin is taken hold of between the 
 til mib and forefinger, without pulling or 
 stretching it, but o;.ly just so as to take oft" 
 the weight opposed to the levator muscle, 
 by the redundance of skin, the patient is 
 immediately able to raise the eyelid without 
 any difficulty ; but, as soon as the surgeon 
 relinquishes his hold of the skin, the part 
 falls down again. The relaxed fold of skin 
 is sometimes situated rather over the outer 
 commissure, than the middle of the eyelid, 
 in which case, the latter part can be opened 
 towards the nasal commissure, and the eye- 
 ball becomes habitually rotated towards the 
 nose for the purpose of vision, whereby 
 strabismus, and if the disorder be not soon 
 rectified, an obliquity of sight, are occasioned. 
 Beer adds, that some eyelids are formed 
 with a predisposition to such an elongation 
 of their integuments. 
 
 According to the same writer, a prolapsus 
 of the upper eyelid may be the consequence 
 of any inflammation of the part, accom- 
 panied with considerable oedema, or ecchy- 
 mosis, as happens from severe wounds of 
 the forehead, eyebrow, or the eyelid itself, 
 particularly when no attempt is made to 
 unite the parts by the first intention. The 
 infirmity may also be the consequence of 
 ophthalmy, that has been either long neglect- 
 ed, or badly treated with relaxing poultices, 
 and it is said, that scrofulous patients have a 
 disposition to the complaint. (Beer, B.2.p. 
 109 — 111 .) 
 
 The case, as described by this author, 
 may be cured by the excision of a long slip 
 of skin from the eyelid, just broad enough 
 for the removal of the redundant quantity. 
 For taking hold of the portion of integu- 
 ments, Beer employs forceps, the extre- 
 mities of which are broad, with a somewhat 
 concave edge. As much of the superfluous 
 skin is to be taken hoid of, and raised, as 
 will enable the patient to open the eyelid, 
 which circumstance is the criterion of the 
 quantity selected for removal being enough. 
 The excision may then be performed with 
 scissors, as Beer directs, or with a knife, as 
 others may prefer; and the wound is to be 
 dosed with a suture. The slip of skin 
 chosen for removal, should not be too near 
 the edge of the eyelid, for then the skin 
 of the lower edge of the wound, would 
 foe too narrow for the application of the 
 the suture. {Beer, B. 2 ,p. 1 (5.) Some wri- 
 ters refer particular cases of ptosis altogether 
 to paralysis of the levator muscle ; and other 
 instances to spasm of the orbicular muscle. 
 When the disease depends entirely on para- 
 lysis, the eye and surrounding parts, may be 
 frequently bathed with cold spring water, 
 
 TCB 387 
 
 and the eyelid and eyebrow rubbed with the 
 camphor liniment, to which a little of the. 
 tinctura lytUe is added. The shower bath, 
 bark, and other tonics are also indicated. 
 The cure of spasmodic ptosis, which is 
 rather a symptom ot other diseases, Tike 
 hysteria, chorea, worms, ike. than a distinct 
 affection, c insists in the removal of Ifie 
 original complaint, tlowever, generally 
 speaking, antispasniodic medicines; blisters 
 on the temple, or behind the ear; an issue 
 between the mastoid process and angle of 
 the jaw, as recommended by Adam Schmidt, 
 on account of some nervous ramifications of 
 the third branch of the fifth pair, which give 
 twigs to the eyelids, lying irt that situation ; 
 and fomenting and bathing the eye, eyelids, 
 and face, with a decoction of poppy heads 
 and cicuta ; are means, which merit the 
 consideration of the practitioner. (See Rich- 
 ter's Anfangsgr. der Wundurzn. B. 4, p. 488, 
 Svo. od Edit. GoU. 1802. Weller's Manual , 
 TransL by Monteath, FoL 1, p. 97, fyc. 8 tic*. 
 Glasgow, 1821. 6’. J Beer, Lehr e von den 
 
 Augtnkr. B. 2 ,p. 109, <yc. Svo. Wien. 181 7.) 
 PUNCTURED WOUNDS. See Wounds. 
 
 PUPIL. When the opening in the centre 
 of the iris is preternaturally large, and this 
 organ more or less deprived of its power of 
 motion, the disease is technically named 
 mydriasis, which is jpither symptomatic , or 
 idiopathic. The first lorm of the complaint, 
 as Weller observes, is exemplified in cases 
 of hydrocephalus, hydrophthalmia, pressure 
 on the brain from various causes, worms, 
 amaurosis, ike T he second often presents 
 itself as a paralytic affection of the iris; a 
 state, frequently induced by the application 
 of certain narcotics, like belladonna and 
 hyosciamus. Congenital cases of mydriasis 
 are also met with, as well as instances 
 brought on by a loug residence in darkness. 
 
 A dilatation of the pupil may likewise be 
 the consequence of an adhesion of the uvea 
 to the anterior capsule of the lens. When 
 the retina continues sensible, the inconve- 
 niences, produced by mydriasis, are intole- 
 rance of light, complete blindness in the day- 
 time, and in the end amaurotic mischief, 
 occasioned by the irritation of the immo- 
 derate quantity of the rays of light, admitted 
 within the eye. The kind of prognosis, 
 and the mode of treatment, must often 
 depend entirely upon the primary affection, 
 of which many cases of mydriasis are only 
 symptomatic. Of course, the original dis- 
 order must always be cured, if possible. 
 When mydriasis appears to arise from para- 
 lysis of the iris, blisters may be applied over 
 the eyebrows, and the same remedies tried, 
 which are usually employed in other locaL 
 paralytic disorders. Tire entrance of too 
 much light into the eye may be moderated 
 with shades, and tubulated spectacles. 
 
 The case, which is the reverse of the pre- 
 ceding, is a preternaturally contracted, more 
 or less immoveable state of the pupil, termed 
 myosis. According to Weller, it is sometime^ 
 congenital. It is often met with as a symp- 
 tom of other disorders, especially ophthalmy, 
 inflammation of the dura mater, phreuilrs,- 
 
PUPIL. 
 
 ;sh 
 
 concussion of the brain, &ic." Persons, whose 
 business is to be looking at small shining ob- 
 jects, as watchmakers, often acquire a mvo- 
 sis from habit, and they cannot be cured of 
 it, unless they avoid the causes which 
 brought it on, keep themselves in a darkish 
 room, and use a green shade, or tubulated 
 spectacles. (See Wellefs Manual : tyc. Tran si. 
 byMonieath , Vol. ( 2,p. 54.) It is noticed by 
 Beer, that rnyosis, when a sequel of ophthal- 
 my, is less obvious than most other conse- 
 quences of ocular inflammation ; for though 
 the iris is motionless, and the pupil consider- 
 ably diminished, this opening is perfectly 
 clear and black, and not drawn out of its 
 usual position, nor its pupillary edge in the 
 slightest degree angular, i he patient, though 
 he is continually complaining of weakness 
 of sight, is able to distinguish (with some 
 trouble indeed) even the smallest objects in 
 the daytime, and in very light situations, 
 but, his sight is evidently worse in the even- 
 ing, and in darkish places in the daytime ; 
 for, when both his eyes are affected, he is in 
 the dusk nearly blind, and can scarcely find 
 his way. Beer remarks, that almost every 
 considerable internal ophthalmy, or iritis, 
 however favourably the disorder may be. 
 cured, and the eyesight restored, always 
 leaves after it more or less contraction of 
 the pupil, which affection, though not the 
 least portion of coagulating lymph can be 
 perceived iri the posterior chamber, is com- 
 bined with a partial, or complete immobility 
 of the iris. Beer assures us, that every ex- 
 pedient, which he has y 7 et tried for the per- 
 manent removal of this complaint has failed, 
 the dilatation of the pupil, thus produced, 
 being but temporary. And, with respect to 
 the most powerful narcotics, he states, that 
 in two cases, they were worse than useless, 
 as they caused a still greater contraction of 
 the pupil, which, however, after a few hours, 
 resumed its former diameter. Hence, this 
 experienced oculist is disposed to set down 
 the rnyosis, following internal ophthalmy, 
 as an incurable complaint. (See Lehre van 
 den Angenkr. B. 2, p. 261, fyc.) 
 
 The next case, demanding some notice in 
 this work, is a closure of the pupil ( atresia 
 pupillce.) According to Beer’s observations, 
 there is only one exception, in which in the 
 adult patient a closure of the pupil is not 
 the consequence of ophthalmy, and the case, 
 here signified, is termed a collapse, of the 
 pupil , or synizesis pupillce, , the causes of 
 which are said to be, either a very consider- 
 able loss of the vitreous humour from a 
 wound of the eye,orelseadissolved,or rather 
 disorganized state of the same humour, 
 known among the oculists under the name 
 of synchysis (See Beefs Lehre , fyc. B. 2, p. 
 390.) Every internal ophthalmy, extending 
 to the retina and choroides, when in its 
 highest degree, is apt to produce a complete 
 closure of the pupil. However, in such cases, 
 as Beer remarks, the obliteration of this 
 opening is not the only cause of blindness, 
 for, long before this state of the iris happens, 
 the sight is destroyed by considerable, and 
 frequently irremediable, injury of the retina, 
 
 and neighbouring textures, in which the in- 
 flammation is directly situated. An incom 
 plete closure of the pupil, he says, is still 
 more disposed to take place at the period, 
 when the iritis passes from its first into 
 its second stage, and syphilitic iritis is said 
 to be particularly apt to leave after it this 
 disagreeable consequence. (Fol. cit. p. 191.) 
 In cases of the latter description, vision is 
 not always quite prevented, but only more 
 or less diminished, the coagulating lymph, 
 effused in the posterior chamber having 
 formed only a delicate, semi-transparent web. 
 However, if in (he second stage of the in- 
 flammation, such lymph should be converted 
 into a dense membrane, with opacity of 
 the lens and its capsule, the eye then only 
 retains more or less perfectly the faculty of 
 just distinguishing the light. But, when in 
 such a case, the patient is completely insen- 
 sible of the difference between light and 
 darkness, the blindness, as in the examples 
 mentioned above, is not owing to the clo- 
 sure of the pupil, or to the cataract, but to 
 other morbid changes, resulting from the 
 same inflammation, which caused the defect 
 in the pupil itself, and capable of being as- 
 certained by certain appearances in the eye. 
 Passing over obstructions of the pupil by the 
 unabsorbed matter of hypopium, and by the 
 continuance of effused blood in the chambers 
 of the eye, I come to the case, next noticed 
 by Beer, in which a closure of the pupil 
 arises from a partial adhesion of the iris to 
 the cornea, ( synechia anterior ,) and will 
 inevitably happen, when a considerable por- 
 tion of the iris, or a great part, or the whole, 
 of its pupillary edge protrudes through an 
 opening in the cornea, and becomes ad- 
 herent to it. However, as Beer observes, 
 sometimes, in these cases, the pupil becomes 
 completely obstructed, though the protrusion 
 of the iris is inconsiderable, and its pupillary 
 edge not engaged in the cicatrix ; a circum- 
 stance exemplified, when the cicatrix over 
 the adherent part of the iris expands very 
 much, and has an extensive leucomatous 
 surface, so that, though the pupil may be of 
 considerable size, it is concealed, and vision 
 impeded. And, even w'hen there is no ad- 
 hesion of the iris to the cornea, no synechia 
 anterior, as it is termed, and no distortion of 
 the pupil, a large dense cicatrix of the cor- 
 nea may obstruct vision by lying exactly over 
 that aperture. Lastly, usBeerhasexplained, 
 the greater part of the cornea may be in an 
 opaque, spoiled condition, sothat the healthy 
 iris can be discerned only here and there be- 
 hind its circumference, no vestige of the 
 pupil itself being distinguishable ; and such 
 concealment of the pupil, may be either 
 combined, or not, with a partial adhesion of 
 the iris to the cornea, in such cases, the 
 patient can frequently perceive the light 
 very well. (B. 2 ,p. 194, 95.) 
 
 From what has been stated, it is manifest, 
 says Beer, that in many cases of atresia iri- 
 dis, the prognosis must be highly unfavour- 
 able, and that no attempt to form an arti- 
 ficial pupil should ever be made when the 
 patient’s blindness proceeds from other 
 
eauses, besides the imperforate state of the 
 iris. Such an operation, Beer observes, can 
 only be proper when the blindness is en- 
 tirely owing to the closed or concealed 
 state of the pupil ; when the different de- 
 grees of light can be plainly distinguished ; 
 when the case is uncomplicated with any 
 disease of other important textures of the 
 eye, capable of rendering the manual pro- 
 ceedings difficult or impracticable ; when 
 the eye has been for a long time perfectly 
 free from inflammation ; when the patient 
 f i healthy, without any tendency to scro- 
 fula, syphilis, or gout ; and both his eyes 
 are completely blind. (B 2 p. 196.) Some 
 questions may be entertained respecting this 
 absolute prohibition of the operation in un- 
 healthy subjects, because the line between 
 the degree of health, requisite for the suc- 
 cess of the operation, is difficult.to specify, 
 and gout, syphilis, and scrofula, are often 
 vague expressions. Yet, no doubt can exist, 
 I think, about the propriety of Beer’s ad- 
 vice never to attempt the formation of an 
 artificial pupil, when the patient enjoys vi- 
 sion with one of his eyes; for, when the 
 new opening is made, as it is not in the axis 
 of vision, the sight is confused in the other 
 eye, unless the imperfect mae be kept closed, 
 and the operation can n^er be done with- 
 out exposing the patient to the risk of more 
 or less inflammation in the eye, which is at 
 present so useful to him. Whatever may be 
 the differences of opinion about operating 
 in cases of single cataract, I believe that all 
 surgeons will unanimously join Beer in the 
 foregoing advice respecting the imprudence 
 of attempting to make an artificial pupil, 
 when the patient can see with one eye. 
 
 Beer represents the event of the opera- 
 tion as being very uncertain, when the pa- 
 tient cannot plainly discern the various de- 
 grees of light; when the cornea is affected 
 with leucoma, or scarred and spoiled nearly 
 to its very circumference ; when there is 
 only a partial staphyloma of it ; or the con- 
 stitution is unhealthy or impaired by the 
 effects of former attacks of scrofula, syphi- 
 lis, or gout. Lastly, Beer *ets down the 
 operation as certainly useless, or even as 
 likely to cause an entire destruction of the 
 eye, when the patient is quite insensible of 
 light; when the iris and neighbouring tex- 
 tures, such as the corpus ciiiare, corona ci- 
 liaris, the membrane of the vitreous hu- 
 mour, this humour itself, and the blood- 
 vessels of the organ, are in a morbid state, 
 or the whole eyeball manifestly in a preter- 
 natural condition. However, an opacity of 
 the lens and its capsule, even when the 
 latter is completely adherent to the uvea 
 forms no prohibition to the formation of an 
 artificial pupil, though it is a circumstance 
 that has great weight in the selection of the 
 method of operating. (Beer, B. 2, p. 197.) 
 
 The following information, from the same 
 source, is highly important to the practi- 
 tioner : the morbid state of the iris and 
 other adjacent textures of the eyeball, con- 
 tradicting the operation, may be known by 
 the annexed circumstances. Together with 
 
 the smaller circle of the iris, the larger one 
 is strikingly changed, in respect to its co- 
 lour, its consistence, and its layers. Its ra- 
 diated fibres are collected into dark blue or 
 blackish fasciculi, between which there is 
 an appearance of empty interspaces, pro- 
 duced by the indentations of the iris, and 
 actually semi-transparent, in consequence of 
 the tapetum of the uvea having always been 
 in these casts more or less annihilated by the 
 previous inflammation. Around the cornea, 
 the scleroticaseems bluish, or rather of a smut- 
 ty grayish blue colour ; and sometimes certain 
 points of this membrane are protuberant. The 
 morbid states of the whole eyeball, which may 
 complicate the atresia iridis, and render the 
 operation not only useless, but hazardous to 
 the preservation of tire eye, are its dropsical 
 enlargement, (see Hydrophthalmia ,) its atro- 
 phy ; its preternatural firmness, from a ge- 
 neral varicose affection of its blood-vessels ; 
 and its morbid softness from a disorganiza- 
 tion of the vitreous humour. (Beer, Vol. 
 cit. p. 198.) 
 
 Before proceeding further into the sub- 
 ject, 1 think it will simplify it very much to 
 state, that numerous as the plans of opera- 
 ting for artificial pupils are, if we except 
 the occasional plan of making a kind of 
 artificial prolapsus of the iris, in order to 
 change the position or shape of the imper- 
 fectly closed pupil, they may all be classed 
 into three principal methods. 1. The sim- 
 ple transverse, perpendicular, or otherwise 
 directed incision in the iris, now termed 
 corotomia 2. I he excision of a piece of 
 the iris, technically named corectomia. 3, 
 The separation of a part of its circumfe- 
 rence from the ciliary ligament, called in 
 the language of oculists corodialysis. The 
 excision of a portion of sclerotica, close to 
 the cornea, with the view of forming an 
 inlet for the rays of light to the retina, as 
 proposed by Autenrieth, when the cornea 
 is entirely opaque, may be considered a 
 hopeless proceeding. With respect also to 
 the three other methods, it is now well un- 
 derstood by all impartial surgeons, that the 
 choice of them must depend upon the par- 
 ticular circumstances of the case, and that 
 here it is as absurd to think of employing 
 in ail instances only one plan of operating 
 as to have the idea of extending the same 
 principle to all the forms and varieties of 
 cataract. 
 
 Where the thing is possible, it is consi- 
 dered by Beer most advantageous to make 
 the artificial pupil rather towards the inner 
 canthus ; though others express a preference 
 to the centre of the iris. But, as Beer very 
 truly remarks, since the new opening must 
 be where the cornea is transparent, the ope- 
 rator is frequently obliged to form it either 
 below, or towards the temple, or quite 
 above ; for there is often only just room 
 enough left at one point for conducting the 
 necessary manoeuvres, with any degree of 
 precision. 
 
 Cheselden first devised and executed a 
 section of the iris, for the purpose of form- 
 ing an artificial pupil. He .introduced a 
 
P'to'PlL. 
 
 390 
 
 couching needle, having a sharp edge only 
 on one side, through the sclerot ca, at the 
 distance of a line and a half from the cor- 
 nea, into the anterior of the eye. After 
 perforating the iris towards the external an- 
 gle, and then pushing the point of the nee- 
 dle through the anterior chamber of the 
 aqueous humour, as far as that side of tile 
 iris which is nearest the nose, ho turned the 
 edge of the instrument backward, and with- 
 drew it, so as to make a transverse division 
 of that membrane. This operation seems 
 to have been attended with the greatest 
 success. However, Janin (Mem. sur i'CEil) 
 assures us, that having performed it on two 
 subjects with the utmost care possible, he 
 did not find the smallest benefit follow it; 
 for, in these two patients, as soon as the 
 symptoms, produced by the operation, sub- 
 sided, the transverse section made in the 
 iris by the edge of the needle, reunited, and 
 Sharp had experienced the same thing ear- 
 lier than Janin. (On Operations, chap. 29.) 
 
 An accident occurred to Janin, in the act 
 of extracting a cataract ; viz. he included 
 the iris together with the cornea, in Daviei’s 
 scissors, and cut it perpendicularly, and the 
 division remained permanent. This led him 
 to propose a perpendicular incision as the 
 best expedient for making an artificial pupil. 
 His plan consisted in opening the cornea, as 
 Is practised for the extraction of the cata- 
 ract, and in dividing the iris perpendicularly 
 with scissors, near that part of the pupil 
 which is next to the nose ; for, he affirms, 
 that he has seen strabismus result from 
 making the section towards the external 
 side, on account of the two great divarica- 
 tion of the optical axes. 
 
 Although the practice of making an inci- 
 sion in the iris or corotomia, is severely 
 disapproved of by Beer, who states that it 
 admits of being practised only in very few 
 cases, and is rendered quite unnecessary by 
 what he considers the two other better plans, 
 (B. 2. P. i99.) the operation is still consi 
 dered by some men of experience, as having 
 recommendations, and they have therefore 
 endeavoured to improve it. However, it 
 will only be in my power to notice in this 
 work a few of its modifications. 
 
 In 1812, Sir VV. Adams recommended the 
 revival of Cheselden’s method of forming 
 an artificial pupil, with the difference of 
 using for the purpose a particular sort of 
 knife. "With a cataract needle (says this 
 oculist) I could not cut through the iris by 
 a gentle force ;. and if l ventured to apply a 
 greater force, the iris separated from its at- 
 tachment to the ciliary ligament, which ren- 
 dered all further attempts to effect a central 
 aperture useless The sarcw accident appears 
 to have happened to Mr. Sharp in his trials 
 of this operation. In the hopes of procuring 
 an appropriate instrument, 1 twice went to 
 London, at the interval of a lew months : 
 but though I described to different instrument- 
 makers the purposes for which it was in- 
 tended, still I could only procure the needle, 
 which cuts on one edge, and the spear- 
 pointed knife, of different sizes, described by 
 
 Chese'den. At length it occurred fco me that 
 the curved edge of the common dissecting 
 scaipel \va3 well adapted to cut with facility, 
 I therefore, when in London a third time, 
 got a small knife made, two-thirds of an inch 
 in length, and nearly a line in width, with a 
 straight back, sharp point, and a curved 
 edge, which cuts back towards the handle 
 for about three lines.” (Adams's Pract. Ob*, 
 on Edropium, fyc. p. 30.) According to this 
 gentleman, in all cases where there is no 
 crystalline lens, and the cornea is free from 
 opacity, the division of the iris should bo 
 made in the centre, and should extend across 
 at least two-thirds of its transverse diameter. 
 In a later work, however, this author states, 
 that experience has convinced him, that 
 so extensive a division of the iris is unneces- 
 sary for the prevention of the reunion of this 
 membrane* and that a cut through one-third 
 of its diameter is sufficient. The eye being 
 gently fixed, either with the finger of the 
 assistant, who supports the upper eyelid, or 
 with a concave sort of speculum, placed 
 under the upper eyelid, the artificial pupil 
 knife is to be introduced through the coats 
 of the eye. about a line behind the iris, with 
 its cutting edge turned backwards. The point 
 is next to be hi^ugbt forward through the 
 iris, somewhat than a line from its 
 
 temporal ciliary attachment, and cautiously 
 carried through the anterior chamber, until 
 it has nearly reached the inner edge of that 
 membrane, (or as is expressed in a later 
 description,) “ until it has traversed more 
 than two-thirds of the width of the iris,” 
 when it should be almost withdraw n out of 
 the eye, gentle pressure being made with 
 the curved part of the cutting edge of the 
 instrument against the iris, in the line of its 
 transverse diameter. If in the first attempt, 
 the iris should not be sufficiently cut, the 
 point of the knife is to be again carried for- 
 ward, and similarly withdrawn, until the 
 incision is of a proper length. After ihe 
 operation, the eye is to be covered with a 
 plaster of simple ointment, and the patient 
 put into bed, with his head raised. (P. 3(5, 
 37.) When the closure of the pupil is at- 
 tended with a cataract, the primary steps of 
 the operation are the same ; but Sir William 
 Adams takes care also to cut the cataract 
 into pieces, some of which he brings forward 
 into the anterior chamber, while others he 
 leaves in the opening of the iris, where they 
 at first serve as a plug, hindering union by 
 the first intention, (P. 38.) and are after- 
 ward absorbed. For an account of this 
 gentleman’s particular methods in all the va- 
 rious complications of these cases the reader 
 mu i consult bis publications, where many 
 successful examples of the operation are re- 
 corded. 
 
 That Cheselden’s method ought not to be 
 entirely rejected, there can now he no doubt 
 Like all other modes of forming an artificial 
 pupil, it certainly does not merit exclusive 
 preference. Besides the authority ot Sir W. 
 Adams, we have the testimony ot Mr. Ware, 
 to prove that Cheselden’s operation fre- 
 quently .succeeds. This gentleman informs 
 
PUPIL 
 
 us, that when the pupil has become closed, 
 after an unsuccessful operation of extracting 
 the cataract, he has in several instance's 
 made a new pupil, agreeably to Cheselden’s 
 mode of performing the operation, with the 
 most perfect and striking success. “The 
 fibres of the iris retracted as soon as they 
 were divided, and left the pupil very nearly 
 of its natural size. Its shape was not quite 
 round ; but the sight was immediately re- 
 stored, and to so great a degree, as to enable 
 the patient, by the help of suitable convex 
 glasses, to see distinctly both near and distant 
 objects, neither pain nor inflatnmqtion being 
 consequent to the operation.” 
 
 Where there is a prolapsus of the iris, 
 through a breach of the cornea, involving 
 more or less of t lie pupillary margin, Mr. 
 Travers considers Cheseldens method the 
 most applicable; “viz. the transverse divi- 
 sion of the stretched fibres of the ins, and 
 which, if the section be made in front of 
 the membrane, i. e. from before backwards, 
 admits of no improvement. The edges of *the 
 section instantly recede and form an excel- 
 lent pupil.” However, he afterward adds, 
 “ that a partial adhesion of the pupillary 
 margin may be combined with a healthy 
 lens In this case, the removal of the free 
 border of the pupil, drawn by means of for - 
 ceps, through an incision in the cornea, will 
 Vre preferable, on account of reserving (lie 
 transparency of the lens.” (Synoj>sis of the 
 Diseases of ike Eye , p. 343.) 
 
 In a modern work, Professor Maunoir of 
 Geneva, has published a very successful 
 case, in which an artificial pupil was former^ 
 and a caseous cataract extracted. u I ope- 
 rated, (says M. Maunoir) on the right eye in 
 the following manner. The patient being 
 seated on a chair, and having the head in- 
 clined upon a cushion, I placed myself be- 
 hind him, and with the fore-iingei of the left 
 hand, confining the upper eyelid, 'whilst an 
 assistant depressed i be lower. I made with the 
 right hand a semicircular incision in t lie lower 
 and external part of the cornea This incision 
 occupied a full third of the circumference of 
 the membrane. On reopening th<? eye, the iris 
 was seen projecting a little from the wound 
 in the cornea. I replaced it with the blunt 
 point ol my scissors. Introducing the two 
 blades closed into the anterior chamber, and 
 then opening them, I caused the pointed 
 blade to penetrate the iris, leaving the blunt 
 blade between that membrane and the cor- 
 nea ; then closing the scissors, a perpendicu- 
 lar incisiou of the iris resulted, describing a 
 little more than half the chord of an arc of 
 two-fifths of the circumference of the iris, 
 traced on the side of the temple. The first in - 
 eision not having occasioned ihe formation 
 of a pupil of the necessary size, I introduced 
 the scissors into the iris a second lime a 
 little obliquely ; and immediately the pupil 
 appeared of a satisfactory form and size, but 
 exhibiting the crystalline entirely opaque. 
 The second stroke of the scissors had divided 
 the capsula : I therefore introduced a small 
 curette, in order to endeavour to destroy 
 v/hat. adhered of the crystalline to the shrunk 
 
 and contracted circumference of the old 
 pupil. This attempt did not succeed. Lastly, 
 ! effected the passage of a portion of the 
 opaque lens, by means of a slight pressure 
 with a large scoop, exercised on the lower 
 part of the globe of the eye. The crystal- 
 line, which was of a cheesy consistence, 
 came out with the greatest ease, and though 
 it was not entirely removed, yet a sufficient 
 quantity was discharged to leave the artifi- 
 cial pupil of a most perfect black. This 
 new pupil was on the side of the temple ; 
 and at the exterior and lower part of the 
 n o.” (See Med. Chir. Trans. Vol. 7. p. 305, 
 et seq .) hi this communication are also two 
 other cases, in which Professor Maunoir 
 operated with success, though complicated 
 with cataracts, and adhesions of the lens to 
 the iris. In some remarks annexed by Pro- 
 fessor Scarpa to the preceding account, the 
 latter expresses his opinion, that it is not ne 
 cessary to be scrupulous, whether the crys- 
 talline be partly or entirely opaque, whene- 
 ver the capsule is opaque, and adheres to the 
 iris, behind the edge of she interior and en- 
 closed pupil. “ I i thi- case only one reme- 
 dy can be pointed out, namely, the removal 
 of the opaque adherent capsule, and conse- 
 quently of the crystalline, \hether it he 
 transparent or opaque. In the second place, 
 (says Scarpa) 1 think there is no reason to 
 doubt, that in similar cases, it is adviseabio 
 to make an incision upon the iris, propor- 
 tioned to the size of the body to he extract - 
 ed. rather than to make i! -mall, which 
 obliges the operator to divide the crystalline 
 and the capsule, with the intention of ex- 
 tracting a part, and of abandoning the rest 
 to the powers of absorption. Thirdly: I 
 would establish as a fundamental principle, 
 in sL-ilar cases, that after the complete ex 
 traction of the crystalline, with its opaque 
 capsule, by means of the leas! possible in- 
 troduction of i«e instruments, the artificial 
 pupil ougin not to be too near the incision 
 in the cornea, and consequently not loo 
 near the cicatrix occasioned by it.” ( P 
 317.) Scarpa then recommends a particular 
 method of operating, in ease3 where there 
 are cataracts: after caving made, in the man- 
 ner of Wenzel, a transverse incision in the iris, 
 at d in the cornea, he would introduce Mau- 
 noir’s scissors, blunted at both points, into 
 the anterior chamber of the aqueous humour, 
 and make an incision in the iris, diverging 
 from the cut made with the knife. The aper- 
 ture thus made, Scarpa thinks would be 
 large enough to allow easy egress to the 
 opaque lens. 
 
 Among other late'opinions professed by 
 this distinguished surgeon, we find the fol - 
 lowing ; that no instrument is so proper as 
 the scissors for making an incision in the 
 iris , that when the case is not complicated 
 by cataract, a very soiail wound in ihe cor- 
 nea is sufficient ; that the formation of a 
 triangular edge in the iris, by means of a 
 double incision with the scissors, is the most 
 easy and least ‘painful of all uie methods 
 hitherto proposed for obtaining a permanent 
 artificial pupil *, and lastly, that spots of the 
 
JPUTIL. 
 
 392 
 
 cornea present no obstacle, because it is 
 possible to produce the artificial pupil op- 
 posite the transparent part of that mem- 
 brane. (Med. Cflir. Trans. Vol. 7, p. 320,321.) 
 
 As 1 have already noticed, the contraction 
 of the natural pupil is sometimes occasioned 
 by the iris being stretched towards some 
 point of the cornea, to which it is adherent. 
 This state, as Scarpa observes, is most fre- 
 quently accompanied with partial opacity of 
 the cornea, around the adhesion, or prolap- 
 sus of the iris, as well as with opacity of the 
 tens and its capsule. At other times, 
 however, these internal parts preserve 
 their natural transparency, notwithstand- 
 ing the deviation of the natural pupil. In 
 the latter case the pupil, though removed 
 from its situation, is not in reality obliterated, 
 but merely very much contracted, and inca- 
 pable of admitting the quantity of light ne- 
 cessary for vision, especially if the opposite 
 part of the cornea be slightly opaque. In 
 such an example, Scarpa recommends 
 making a small incision in the cornea at the 
 most commodious part, when with Maunoir’s 
 scissors closed, and constructed with little 
 buttons at the ends of both the blades, an 
 endeavour is to be made to break the adhe- 
 sion existing between the iris and the cornea. 
 If this can be effected, the natural pupil ge- 
 nerally recovers its former situation and 
 size ; but if the adhesion be very firm, Scar- 
 pa introduces one of the blades v\ ithin the 
 contracted pupil, behind the posterior surlace 
 of the iris, until the other blade has reached 
 the confines of the cornea with the sclerotica. 
 The iris is then to be divided in the form of the 
 letter V, without at all injuring the capsule 
 or lens, both of which are transparent. (On 
 the Principal Diseases of the Eyes, p. 384, 
 Ed. 2- Transl. by Briggs.) When, after ex- 
 traction of the cataract, the pupil has been 
 dragged down in t his manner by adhesion 
 to the lower third of the cornea, the upper 
 two-thirds of which are transparent, Dr. 
 Monteath, of Glasgow, has succeeded five 
 times in forming an artificial pupil, and resto- 
 ring vision by making a small opening in the 
 upper and outer part oft be edge of the cornea, 
 capable of admitting Maunoir’s eye-scissors, 
 with which the overstretched fibres of the 
 iris are to be cut across by one simple inci- 
 sion, three lines in length. The cut edges 
 instantly recede, and leave an oval pupil of 
 sufficient size- (See Weller's Manual. Vol. 
 2, p. 70.) In the cases above specified by 
 Scarpa, Sir Wm. Adams, instead of per- 
 forming corotomia, endeavours to separate 
 the iris from the cornea, and then to alter 
 the position of the pupil by drawing it to- 
 wards that part of the cornea which has 
 remained transparent. For this purpose he 
 punctures the. cornea about ne line in front 
 of the iris, separates the adhesion, and then 
 makes the disengaged portion of the iris pro- 
 trude through the puncture, -and leaves it 
 there, even using the forceps, if necessary, 
 for drawing it out as far as is deemed neces- 
 sary for its being securely fixed. This method 
 is disapproved of by Scarpa, because a se- 
 cond prolapsus of the iris in the same eye 
 appears to him a very serious disease, and 
 
 rather calculated to increase the opacity of 
 the cornea, and augment the contraction 
 of the pupil, than afford relief. 
 
 According to Beer, the excision of a por 
 tion of the iris, corectornia is particularly in- 
 dicated in all cases in which there is a sound 
 transparent lens, as iti many examples of 
 synechia anterior, concealment of the 
 natural pupil by a central opacity of the 
 cornea, Hie. Beer admits, however, as an 
 exception, the instances in which the trans- 
 parent portion of the cornea is so small, that 
 no opening can be made in it with the knife, 
 large enough to permit the iris to be taken 
 hold of w ith a small hook or forceps, and a 
 piece ol it cut out above the ciliary pro- 
 cesses. (B. 2, p. -200.) The reason here 
 given, does not appear to myself very strong, 
 because it may be asked, why not acquire 
 more room by cutting a portion of the 
 opaque part of the cornea? Weller assigns 
 a better reason against corectornia, viz. 
 when he refers to the risk of a sufficient piece 
 of the cornea not being left transparent, 
 opposite the new pupil, after the cicatrization 
 of that membrane. (Vol. 2, p. 65.) Beer 
 further states, that corectornia may be per- 
 formed, in cases of atresia iridis consequent 
 to the operation of extracting the cataract, 
 when the surgeon is certain that no coagu 
 lating lymph, effused during the previous in- 
 flammation, in the posterior chamber, reaches 
 above the lesser circle of the uvea, or is con- 
 joined with opacity of the remaining capsule 
 of the lens. The first state may be learned 
 from the singular colour and form of the 
 greater ring of t lie iris ; the second, from the 
 very indistinct manner in which the patient 
 is sensible of the different degrees of light. 
 (Betr. B. 2, p. 200.) 
 
 The excision of a piece of the iris, says 
 Beer, requires the preliminary formation of 
 a flap in the cornea, one line in length, w ith 
 the cataract knife, and as close as possible 
 to the sclerotica, so that no subsequent 
 opaque cicatrix may interfere with the suc- 
 cess of the operation. The second part of 
 the business, viz. the excision of a piece of 
 the iris, must be done in three ways, accord- 
 ing to circumstances. 1st. The iris may be 
 nowhere prefernaturally adherent to the cor 
 nea,in which case, afteran opening has been 
 made irt the latter membrane, the iris is pro- 
 pelled out between the edges of the wound 
 by the aqueous humour, yet left in the pos- 
 terior chamber, which opportunity the sur- 
 geon must immediately avail himself of for 
 taking hold of the projecting piece of the iris 
 w ith a very tine hook, and cutting it off with 
 David’s scissors. The remainder of the iris 
 is instantly retracted behind the cornea, and 
 a well-formed pupil is immediately seen 
 2. Only the part of the edge of the pupil may 
 remain not adherent to and drawn towards 
 the cornea, w here it is intended to form the 
 artificial pupil ; a state best ascertained by a 
 lateral inspection of the eye. In this case, 
 after opening the cornea, Beer says, the ope- 
 rator is directly to introduce a small hook 
 between the iris and cornea, so as not to in- 
 jure either of these parts W'ith its point, and 
 he is then, with the instrument directed 
 
Hmi, 
 
 tfyS 
 
 obliquely, to get hold of the pupillary edge 
 of the iris, and while the iris is drawn out 
 between the edges of the incision, the pro- 
 jecting piece is to be cut off with Daviel’s 
 scissors. Thus the natural pupil is to be ex- 
 tended behind the transparent part of the 
 cornea, towards the edge of this membrane. 
 3. The pupillary edge of the iris may be ad- 
 herent to the cornea exactly in the situation 
 where the artificial pupil is to be formed : 
 in this case, Beer directs the iris to be taken 
 hold of at its greater circle with the hook, 
 or, (if this should tear its way out) with a pair 
 of fine-pointed forceps with teeth, drawn out 
 between the edges of the wound, and the 
 point of the cone, thus produced, cut off 
 somewhat within the edges of the wound, as 
 drawing the iris further out might tear it, and 
 have a prejudicial effect. In all these cases, 
 says Beer, the undiseased lens and its cap- 
 sule will not be injured, if the patient keep 
 tolerably steady, and the operator have al- 
 ready acquired dexterity in the extraction of 
 the cataract. The operation being finished, 
 the subsequent treatment is like that gene- 
 rally adopted after the extraction of the ca- 
 taract. (See Cataract .) When corectomia 
 is to be performed for a closure of the pupil, 
 consequent to extraction of the cataract, 
 Beer particularly recommends the forceps 
 to he used, though he adds, that such opera- 
 tion is applicable only when the remaining 
 capsule has not been spoiled by the trauma- 
 tic inflammation, and the quantity of lymph 
 in the posterior chamber is not so great as 
 to reach above the lesser circle of the uvea. 
 
 The only other species *of corectomia, 
 which I deem it necessary to notice in this 
 Dictionary, is what was proposed in the 
 year 1811, by the late Mr. Gibson of Man- 
 chester. It is described as follows : “ The 
 first step of the operation is to secure the 
 eyelids, as in the operation for extracting a 
 cataract. A puncture is then to be made in 
 the cornea, with a broad cornea knife, with- 
 in a line of the sclerotica, to the extent of 
 about three lines. All pressure is now to 
 be removed from the eyeball, and the cornea 
 knife gently withdrawn. The consequence 
 of this is, that a portion of the aqueous hu- 
 mour escapes, and the iris falls into contact 
 with the opening in the cornea, and closes 
 it like a valve. A slight pressure must now 
 be made upon the superior and nasal part 
 of the eyeball, with the fore and middle 
 finger of the left-hand, till at length, by an 
 occasional and gentle increase of the pres- 
 sure, or by varying its direction, the iris gra- 
 dually protrudes, so as to present a bag of 
 the size of a large pin’s head. This protru- 
 ded portion must be cut off with a pair of 
 fine curved scissors, and all pressure at the 
 same time removed : the iris will then re- 
 cede within the eye, and the portion which 
 has been removed will leave an artificial 
 pupil more or less circular.” ( Gibson's 
 Practical Observ. on the Formation of an 
 ■Artificial Pupil, fyc. London , 1811.) Such 
 was this surgeon’s mode of operating, when 
 the closure of the pupil was attended with 
 central opacitv of the cornea, uncombined 
 V * 50 
 
 with adhesions. The effect ot a slight ad - 
 hesion of the inner border of the iris to the 
 cornea, will he to prevent the protrusion of 
 the first of these membranes through the 
 puncture in the cornea, which protrusion so 
 much facilitates the operation. In this case, 
 a portion which does not adhere, must be 
 drawn out with a small hook, and then re- 
 moved. Sometimes the adhesion may be 
 separated at the time of making the punc- 
 ture, and then the iris will protrude. When 
 the whole, or greater part of the inner bor- 
 der of the iris is involved in adhesions to 
 the cornea, these must be separated with the 
 cornea knife after making the puncture, and 
 the iris may then either be drawn out with 
 the hook, or a portion of it be removed by- 
 means of very minute scissors. In every 
 case, however, the removal of a portion is 
 essential to success. 
 
 When a cataract is known to exist, which 
 it cannot often be, Mr. Gibson recommends 
 it to be depressed, or broken to pieces with 
 a needle, before making the artificial pupil; 
 and, when the whole cornea is transparent, 
 he advises forming a flap in the centre of the 
 iris with the cornea knife, and then cutting 
 such flap off witii the iris scissors. ( Gibson , 
 Op. cit.) 
 
 Coredialysis , or the mode of formiug an 
 artificial pupil by detaching a portion of the 
 iris from the ciliary ligament, is said to have 
 been devised by Ad. Schmidt and Scarpa 
 about the same time, and has been variously 
 modified by Resinger, Langenbeck, Himly, 
 Graefe, and others. ( Weller on Diseases of 
 the Eye , Vol. 2, p. 65.) According to Beer, 
 this plan of operating is indicated, first only 
 when the coagulating lymph, effused in the 
 posterior chamber after the extraction of 
 the cataract or reclination, (see this word) 
 reaches from above the lesser circle of the 
 uvea towards the ciliary processes; a cir- 
 cumstance which may be known by the 
 considerable change of colour in the greater 
 circle of the iris, and by the 1 indistinct man- 
 ner in w'hich the patient perceives the light. 
 Secondly, wben the uvea is every where 
 adherent to a secondary capsular cataract, 
 or capsulo-lenticular cataract, or the closure 
 of the pupil has been occasioned by a puru- 
 lent or bloody cataract. Whenever the 
 attempt is made in these last cases, how ever, 
 the patient should be capable, as he some- 
 times is, of plainly discerning the light. 
 Lastly, coredialysis is sanctioned by Beer 
 when the cornea is every where incurably 
 opaque, excepting so small a part of if, that 
 it could not be w ell opened for the excision 
 of a portion of the iris. (B 2 , p. 203.) 
 
 The feeble union of the iris w r ith the cili- 
 ary ligament, and, consequently, the greater 
 facility of detaching its edge from that liga- 
 ment with wdiich it is connected than of 
 lacerating its body, induced Scarpa to try a 
 new method of forming an artificial pupil, 
 when the natural one has become too much 
 contracted, or quite obliterated, after the 
 extraction or depression of the cataract. 
 I-Iis method of operating consists in detach 
 ing, by means of a couching needle, a cev- 
 
lain extent of the circumference of the iris 
 from the ciliary ligament, without making a 
 section of the cornea. The attempt met 
 with success. 
 
 The patient being seated and supported, 
 ns if he were about to have the operation 
 for the cataract performed, a straight slender 
 couching needle is to be introduced through 
 the sclerotica, at the external angle of the 
 eye, about two lines from the union of this 
 membrane with the cornea ; and its point is 
 to be pushed ^.s far as the upper and inner 
 edge of the iris; in other words, as far as 
 that side of the iris which is nearest the 
 nose. The needle advances nearly to the 
 ciliary ligament, and the surgeon perforates 
 the internal edge of the iris, at its upper part, 
 so that the point of the instrument scarcely 
 appears in the anterior chamber, because 
 that part of it being very narrow, the point 
 of the instrument, however little it advance 
 beyond the iris, would enter the substance 
 of the* cornea. The moment the needle 
 appears in the anterior chamber, the instru- 
 ment nlftist be pressed on the iris from above 
 downward, and from the internal towards 
 the external angle, so as to bring it in a pa- 
 rallel line to the anterior surface of the iris, 
 for the purpose of detaching a portion of 
 the edge of this membrane from the ciliary 
 ligament. This separation being effected, 
 the operator must depress the point of the 
 needle, in order to apply it to the inferior 
 angle of the slit that he has begun to make. 
 Then the aperture may be enlarged at plea- 
 sure by pushing the iris towards the temple, 
 and withdrawing the needle from before 
 backward, parallel to the anterior surface of 
 the iris and the greatest axis of the eye. If, 
 when this detachment has been accom- 
 plished, no opaque body appear at the bot- 
 tom of the eye, the needle is to be with- 
 drawn altogether. If any portion of opaque 
 capsule, left behind after the depression or 
 extraction of the cataract, should afterward 
 advance, and present itself in the vicinity of 
 the new pupil, the little opaque membrane 
 must be reduced to fragments, and pushed 
 through the artificial opening into the ante- 
 rior chamber, where, Scarpa says, they will 
 in time be dissolved and absorbed. 
 
 This separation of the iris from the ciliary 
 ligament invariably occasions an extravasa- 
 tion of blood, which always renders the 
 aqueous humour more or less turbid ; but 
 the turbidness is afterward absorbed, and the 
 eye recovers its original transparency. 
 
 The patient, says Scarpa, complains, du- 
 ring the operation, of a vast deal more suf- 
 fering than at the time when he undergoes 
 the extraction or depression of a cataract. 
 It cannot be otherwise; for, in detaching a 
 part of the edge of the iris from the ciliary 
 ligament, some filaments of the ciliary 
 nerves, which proceed to be distributed to 
 the iris, must at least be dragged or lacera- 
 ted. However, on the whole, the symptoms 
 consequent to this operation, have neither 
 been obstinate nor fatal in the two cases 
 which Scarpa has seen. From some expe- 
 Fmcf ts math? on the dead subject. Scarpa 
 
 thinks the curved needle, which he use?, 
 for the depression of the cataract, would 
 also be . better than the straight one, for 
 making an artificial pupil. ( Scarpa mile 
 
 Malattie degli Occhi , Capo 16.) 
 
 The celebrated Ad. Schmidt performed 
 coredialysis with a lancet-pointed curved 
 needle, which was introduced through the 
 sclerotica into the posterior chamber, with 
 its concavity towards the uvea. Its point 
 is to pass as far as the portion of the ciliary 
 ligament, where it is designed to make the 
 artificial pupil. The iris is then to be pier 
 ced from behind forwards, about the fourth 
 part of a line from the ciliary ligament, from 
 which it is to be separated, the surgeon 
 taking care at the moment to catch well 
 hold of the iris with the point of the instru- 
 ment, which is then to be withdrawn a little 
 from the eye. If the new pupil should not 
 be now large enough, the iris is to be again 
 hooked with the needle, near the ciliary 
 ligament, and the opening enlarged at its 
 upper or lower angle, as may appear most 
 advantageous. This plan is said to be ad- 
 viseable when the whole cornea is opaque 
 excepting a small spot. 
 
 When, however, the diseased state of the 
 cornea does not forbid it, Beer and Schmidt 
 very properly recommend the needle to be 
 introduced into the anterior chamber, and 
 the iris thus separated from the ciliary liga- 
 ment ; a plan which, as Weller observes, 
 has proved more successful than the prece- 
 ding method. In both modes, the lens will 
 be pushed away from the new pupil by the 
 movement of the needle, so that whether it 
 be opaque already, or become so afterward, 
 vision will not be obstructed by it. (See 
 Beer's Lehre, fyc. B. 2, p. 204 — 206, and 
 Weller's Manual , Transl. by Dr. Monleathj 
 Vol. 2, p. 66, ^c.) 
 
 With the view of removing all risk of the 
 new opening becoming closed again, Rei- 
 singer forms an artificial pupil, by making a 
 small incision in the cornea, and introducing 
 a minute double hook, which opens and 
 shuts like a pair of forceps. After passing 
 the hook closed into the anterior chamber, 
 as far as the greater circle of the iris, he 
 turns the points, of both the small hooks 
 towards this membrane, then opens the in- 
 strument a little, and hooks hold of the iris, 
 which is to he separated from the ciliary 
 ligament, when the instrument is to be shut 
 again, and the part of the iris taken hold of 
 drawn a little through the opening of the 
 cornea, where it adheres, and cannot re- 
 cede again towards the ciliary ligament 
 (See Darstellung eiries neuen Vtrfahrens die 
 Mastdarmjislel zu unterbind^n, und einer 
 leichten und sichern meihodc fennstliehe Pu - 
 pillen zu bilden. 12wo. Jiugsburg, 1816.) 
 Under certain circumstances, however, as 
 there may be difficulty in drawing the iris 
 through the cornea, or apprehensions may 
 be entertained of the opacity of the cornea 
 being increased by the protrusion and ad- 
 hesion of the iris (the great consideration 
 unquestionably against this m thod,) Reisin- 
 ger approves of obviating the. chance of the 
 
PUPIL 
 
 395 
 
 new opening being closed again, by remo 
 ving a part of the iris, after its detachment 
 from the ciliary ligament ; a combination of 
 coredialysis wit’ll coredomia, in the technical 
 language of modern ophthalmology. Were 
 I a patient, and coredialysis were deemed 
 most applicable to the circumstances of my 
 case, l should dispense with any excision of 
 the iris, preferring the chance of tne new 
 opening being permanent, to the dangers of 
 too complicated and protracted an opera- 
 tion. 
 
 Langenbeck is the inventor of an instru- 
 ment for the formation of an artificial pupil : 
 it is a silver tube, to one end of which is 
 attached a very small gold one, containing a 
 minute hook, capable of being moved back- 
 wards or forwards, to the extent of only two 
 lines, by means of a spring in the silver 
 tube. The following is the account of Lan- 
 genbeck’s method, as extracted by Mr Gu- 
 thrie from his writings. “ A very small 
 opening is to be made in the cornea, in or- 
 der that the iris, when brought out, may not 
 recede. The hook enclosed in the golden 
 tube, (to prevent its bending from ilstenuity) 
 is to be directed to the spot where the iris is 
 to be laid hold of. The hook is then to be 
 pushed out by the spring to the extent of 
 one line, which will be sufficient to enable 
 it to penetrate the iris As soon as the hook 
 
 is affixed, it is to be allowed to recede to its 
 usual place in the golden lube, draw ing with 
 it the iris, which will be caught between it 
 and the end of the tube, something in the 
 manner of a pair of forceps. As soon as the 
 hook begins to recede, a small black spot 
 will be seen at the edge of the iris from its 
 incipient separation, and care should be 
 taken to insert the hook at, or even under 
 the edge of the sclerotica, and as near as 
 possible to the ciliary processes. The hook 
 must recede gradually, the finger being kept 
 steadily on, and moved slowly with the 
 knob regulating the spring in the silver tube. 
 
 As the chance of tearing off a part of the 
 Iri3 is proportionate to the distance it has 
 to be drawn out. the opening is to be made, 
 as near as possible, to the spot where the 
 separation is to be effected, taking care that 
 the pupil shall be large enough, so that the 
 prolapsed iris and subsequent opacity of the 
 cornea cannot obstruct the entrance of the 
 rays of light. The great advantage of this 
 instrument, in Langenbeck’s opinion, is, 
 that the separation is effected, by means of 
 the spring, more gently and gradually than 
 by the finger alone, so that if a commence- 
 ment of the separation be effected, the com- 
 pletion of it is certain, without any risk of 
 tearing the iris. As soon as the hook has 
 receded to the golden tube, carrying with 
 it the iris, the whole instrument is to be 
 gently withdrawn, moving it slowly up and 
 down, in order to loosen the upper and 
 lower attachment of the iris ; for this mem- 
 brane may be torn, if there has been much 
 previous inflammation, or if direct force be 
 employed in withdrawing it. The instru- 
 ment always keeps its hold as firmly as the 
 • b**st forceps, and with much more advan- 
 
 tage, for it occupies less space, and enables 
 the operator to make the incision in the 
 cornea small, on which the correct strangu- 
 lation of the iris depends. In all his opera- 
 tions, the capsule of the lens has never been 
 injured by this instrument, which he consi- 
 ders another advantage, and, he conceives, 
 that it may be used through the sclerotica, 
 without rendering the lens opaque, as by 
 the methods of Scarpa and Schmidt.” (The 
 latter author, however, as I have explained 
 in this article, did not operate through the 
 sclerotica, when the lens was transparent.) 
 When the cornea is transparent only at its 
 outer edge, Langenbeck sometimes performs 
 excision ; but, when this membrane is 
 opaque opposite the natural pupil, he opens 
 the cornea near the edge of the sclerotica, 
 and, if the iris will not protrude, he takes 
 hold of its pupillary edge with the hook, and 
 draws it between the lips of the wound, 
 where he leaves it strangulated. (See G. 
 F. Guthrie on Artificial Pupil, p. 63. fyc . Svo. 
 Lond. 1819; also Langenbeck' s Neue Bibl. 1 
 B. p. 3,454, and 676, 8ro. Hanover , 1817— 
 19, and 2 3. p. 13 ayidt 106, where he an- 
 swers some objections made to his instru- 
 ment by Schiagintweit.) Doubtless, one 
 cause of the failure of many operations for 
 artificial pupil is one to which Mr. Guthrie 
 has adverted, viz. the omission to keep 
 down the subsequent inflammation of the 
 iris and adjacent textures by the timely em- 
 ployment of the lancet and other antiphlo- 
 gistic measures. On this subject, however, 
 I need not here dwell, as the proper treat- 
 ment is already described in that part of the 
 article Ophthalmy w4iich refers to idiopathic 
 iritis. 
 
 As it is impossible for me to allot further 
 room at present to the consideration of alt 
 the numerous modes of forming artificial 
 pupils, I shall conclude with a list -of works,, 
 in which further information may be found. 
 Cheselden in Phil. Trans, for 1735, p. 451, 
 fyc. Sharp's Operations, Chap. 29. Janin 
 Mem.sur VCEil. Richter von der Ferschlos- 
 senen Pupille in Anfangsgr. der Wundarsri . 
 B. 3. Gutt. 1795. Scarpa , sulle Malattie degli 
 Occhi, cap. 16; or the English Transl. by Mr, 
 Briggs, Ed. 2. Gibson's Practical Observa- 
 tions on the Formation of an Artificial Pupil, 
 fyc. 8 vo Lond. 1811 ; a work of considerable 
 merit. Wenzel on the Cataract. Sir W. Adams, 
 Practical Observations on Edropium, and on 
 the modes of forming an Artificial Pupil, fyc. 
 8 vo. Lond. 1812 ; also on Artificial Pupil, 8 vo, 
 Lond. 1819. Roux, Parallele de la Chirurgie 
 Angloise. fyc. p. 283, fyc. 8vo. Paris, 1815. 
 Maunoir and Scarpa in Med. Chir. Trans. 
 Vol. 7, p. 301, fyc. G. J. Beer Ansi c fit der 
 Staphyloma tosen. Metaniorphosen des Auges , 
 und der kunsllichen Pupillenbildung, Wien, 
 1815; and Lehr e von den- Augenkr. B. 2, 
 Wien, 1817. P. Assalini , Ricerche sidle 
 Pupille Artificial! ; in Milano, 1811. This 
 author practises the detachment of the iris 
 from the ciliary ligament with a particular 
 kind of forceps. He must have an early 
 claim to the invention, as he began the method 
 in 1786. Jules Cloquet, Mem. svr la Mem- 
 
RANULA 
 
 396 
 
 brane Pupiilaire. Paris, 1818. Maunoir snr 
 V Organization de l' Iris, 8 vo. Paris, 1812. 
 Benedict , De Pupilloc Ariificialis Conforma- 
 tione. Lips. 1810. R, Muter, Practical Obser- 
 vations on Various JVovel Modes of Operating 
 on Cataract , and of forming an Artificial 
 Pup'l,8ro. IVisbeach 1811. G. F. D. Evans, 
 Practical Observations on Cataract and losed 
 Pupil, fyc. 8 vo. Loud. 1815. Ch. Jnngktn , 
 Das Coreoncion, tin B ilrag zur Kuntslichen 
 Pupiltenbildung. l2mo Berlin , 1817. G. 
 W agner, Commenlalio de Corumorplwsi, sistens 
 brtvem method. ad Pupillce artific. conforma- 
 tionem, novique ad TridodialyAn ins'rumenti 
 descriptionem, cum tab. cen. 8 vo. Brunswig. 
 1818. Schmidt and Himly Ophthal. Bibl. B. 
 ! *2 and 3. Flajani Collezione di <)sservazioni, 
 T. 4, 8vo. Roma, 1801 . Ryan, in Dublin Hos- 
 pital Reports . 1818. Ouadri Annotazioni Pra- 
 iicht suite Malattie degli Occhi, 4to. In JVea- 
 poli, 1818. Langenbeck JYeue Bibl. fur die 
 Chir. B 1 el 2, 12mo. Gott. 1817—1819. 
 
 Reisinger Darstellung, einer leichten , tyc. 
 
 Methode Kunslliche Pupillen zu bildtn 12 mo. 
 Augsb. 1816. Schlagintweil, Ueber den gegen- 
 wuriigtn Zu stand der Kuntslichen , pupillen - 
 bildung in Deutschland, 8vo. Munich, 1818. 
 Donegana, Ration ament o sutlu Pupilie Arti- 
 ficiali ; Milano, 1809: this work suggests the 
 method of opening the sclerotica, under cer- 
 tain circumstances, for the purpose of dividing 
 the iris from behind forwards. G. F. Guthrie 
 on the Operations Jor the Formation of an Ar- 
 tificial Pupil, 8 vo Load 1819 ; a work, con- 
 taining a de scrip i on of nearly every method 
 hitherto suggested, accom panied with remarks. 
 B. Travers , Synopsis of the Diseases of the 
 Eye, p. 334, &, c. 8vo. Loud. !820. C. H. 
 Weller, A Manu al of the Diseases of the Hu- 
 man Eye ; transl. by Dr. Montealh , Vol . 2, 
 p. 55, &pc. 8 vo. Glasgow, 1821. 
 
 PUS. (from <zm)ov, matter.) The fluid, 
 formed by the process of suppuration. 
 (See Suppuration.) 
 
 R. 
 
 ACH1TIS. (from the spine of 
 
 the back, because the disease was once 
 supposed to depend on disease of the spinal 
 marrow.) The rickets. See this word. 
 
 RANULA. (dim. of rana, a frog.) A 
 whimsical name applied to a tumour under 
 the tongue, arising from an accumulation of 
 saliva and mucus, in the ducts of the sub- 
 lingual gland. The term has either been 
 derived from an imaginary resemblance of 
 the swelling to a frog, or from the disease 
 making the patient, as it were, croak when 
 lie attempts to articulate. Such writers as 
 have treated of this disease, before it was 
 known that the parts affected by it were 
 destined for the secretion of the saliva could 
 have no accurate notions of its true nature. 
 Celsus is supposed to have alluded to the 
 ranula, in the fifth section of his seventh 
 book, where, after treating of the diseases 
 of the tongue, he continues with the follow- 
 ing passage: sub lingud quoque interdum ali- 
 fjuid abcedit , quod fere consistit in tunica, dolo- 
 resque magnos movet. The latter circum- 
 stance, however, renders it probable, that 
 some other affection was signified, as a ranula 
 is rather attended with a sense of restraint, 
 than of pain. Fabricius ab Aquapendente 
 considered ranula as an encysted tumour of 
 the meliceris kind. Dionis is of a similar 
 opinion. Munick, better acquainted with 
 the modern discoveries of anatomy, does 
 wot mistake the nature of the present dis- 
 ease ; and he expressly says, that the affec- 
 tion originates from a thick saliva, which, 
 not b6ing able to pass out of the salivary 
 ducts, accumulates under the tongue, so as 
 to cause a swelling in that situation. Far 
 from adopting the opinion of Munick, Heis- 
 ter fell back to that of Fabricius, and 
 borrows every thing from this author. — 
 Lastly, De La Faye, in his notes on Dionis, 
 has taken up Munick’s sentiments ; he says, 
 
 that “ there are two sorts of ranulae ; some 
 which are round, and situated beneath the 
 tongue, seem only to be produced by a 
 dilatation of the excretory duct of the 
 sublingual gland ; the others are longer 
 than they are round ; are situated at the 
 side of the tongue, and are formed by a di- 
 latation of the excretory duct of the inferior 
 maxillary gland. The fluid, which fills such 
 tumours, is the saliva, which gradually ac- 
 cumulates in them, in consequence of its 
 viscidity and the atony of the duct. 
 
 Ranula is said to be frequently met with 
 in persons who move their tongue a great 
 deal, and in those who sing. The fluid in 
 the tumour is precisely like white of egg; 
 but it is thicker after having remained a long 
 while in the swelling, and it is occasionally 
 of a calcareous, and even stony nature. 
 Ranula does not proceed from an inspissa- 
 tion of the saliva, as De la Faye supposed, 
 but from an obliteration of the duct, or ori- 
 fices of this tube. The collection often 
 produces a tumour of very large size ; but 
 the swelling generally bursts when it has at- 
 tained the dimensions of a walnut, and then 
 leaves an ulcer, which cannot be healed 
 while the real cause of the disorder remains 
 unknown. 
 
 Mr. B. Bell mentions his having seen an 
 ulcer of this kind treated with the utmost 
 care for several months ; various detergent 
 and corrosive applications had been employ- 
 ed ; and even a mercurial course ; but all 
 in vain. At length, the true cause of the 
 disease having been ascertained, a cure was 
 accomplished in a few days, by removing a 
 piece of calcareous matter, which, by ob- 
 structing the ducts, had first caused a swell- 
 ing, and then ulceration. 
 
 The opening, when made with a lancet, 
 and not of sufficient size, frequently closes 
 up again. In w this case the swelling reap- 
 
RANUX. \ 
 
 3W 
 
 pears some time afterward. The ancients 
 made the same remark ; and hence Pare 
 preferred the actual cautery to the lancet. 
 Dionis also mentions having seen ranulae, 
 which recurred in consequence of a mere 
 opening having been made with a lancet, 
 and he recommends, for the prevention of 
 this inconvenience, the application of a 
 mixture of honey of roses, and vitriolic 
 acid to the inside of the cyst, so as to destroy 
 it. As Louis remarks, all authors seem to 
 regret that the situation of the tumour should 
 prevent the sac from being totally dissected 
 out. The success, which Fabricius ab 
 Aquapendente experienced, when he merely 
 opened the tumour its whole length, did 
 not free him from this prejudice ; and Heis- 
 ter says, he should prefer extirpation, if the 
 nature of the adjacent parts, liable to be 
 wounded, were not a formidable objection. 
 But if this pretended cyst, this pouch, is 
 nothing else than the gland itself, or its duct, 
 dilated by the retention of the saliva, it 
 should not be irritated. Whenever a suffi- 
 cient opening is made, no relapse takes 
 place. Munick particularly advises such 
 an incision, and Rossius mentions the small- 
 ness of the opening, among the defects in 
 the treatment, and its being a cause of the 
 disease returning. However, he also re- 
 commends destroying the sac ; but specifies 
 for the purpose only astringent drying ap- 
 plications, which act in a less powerful 
 manner. 
 
 In a ranula of moderate size, there is 
 nothing like a cyst absolutely requiring ex- 
 tirpation. it is generally enough to lay the 
 cavity open, and cut off the edges of the 
 incision, when they will not otherwise unite. 
 M. Louis always observed that the radical 
 cure depended on a fistulous aperture, 
 through which the saliva continued to flow ; 
 and that, when this opening was situated 
 behind the lower incisor teeth, a very an- 
 noying ejaculation of the saliva took place, 
 in certain motions of the tongue. The cure 
 cannot be complete unless this inconve- 
 nience be obviated. For this purpose, such 
 an opening for the saliva must be made, as 
 Will not close. 
 
 The ranula, when of long standing, is 
 sometimes so large as absolutely to hinder 
 a person from articulating. Le Clerc has 
 recorded a case, in which the root of the 
 swelling extended under the tongue ; the 
 tumour filled the whole mouth ; the promi- 
 nence which it formed outwardly was as 
 large as a duck’s egg ; and the disease, in its 
 progress, had made the teeth of both jaws 
 project outward. At some parts of its sur- 
 face, a fluctuation was perceptible ; other 
 places were exceedingly hard. The patient, 
 who could scarcely breathe, demanded as- 
 sistance ; and a puncture was made in the 
 softest part of the outside of the swelling. 
 A thick yellowish fluid issued out of the 
 ranula. The opening was enlarged with a 
 knife, and about a pint of gritty inodorous 
 matter was extracted. There was no he- 
 morrhage from the cut; and no sooner had 
 the contents of the swelling been let out. 
 
 th^n the patient began to urticulate, which 
 he had not been able to do for a long while. 
 The sides of the tumour being so pfodigious- 
 ly distended, Le Clerc thought proper to 
 destroy the inside of the cavity with a tent 
 dipped in a mercurial solution. The cure 
 was completed in a month, and the tongue 
 gradually regained its original size, a part 
 of which it had lost. 
 
 But, as M. Louis observes, fortunate as 
 the termination of this case was, it must not 
 be indiscriminately set down, that destroy- 
 ing the cyst, or even opening the tumour, is 
 always requisite. A more simple method 
 will sometimes succeed. In a particular 
 case, which this gentleman has related, a 
 sinuosity, which divided the swelling into a 
 right and left portion, made him suspect 
 that it consisted of two sacs, in contact with 
 each other. On each side, in front, and ill 
 the same line, there was a point, which was 
 the orifice of the salivary duct, somewhat 
 dilated, and blocked up with a viscid matter. > 
 Having very easily passed a small probe 
 into the orifices, a matter similar to white 
 of egg, made its escape. A small leaden 
 probe was passed into each opening, and 
 two days afterward, the sacs were emptied 
 again, and two pieces of lead, somewhat 
 larger, introduced. The man was advised 
 to take out the pieces of lead every morning, 
 empty the swelling, and then replace them. 
 In a fortnight, the openings having been 
 kept continually dilated, had no tendency 
 to close ; the saliva did not accumulate, and 
 the ranulae never appeared again. 
 
 In certain cases, the above means are quite 
 inadequate, and the tumour must be totally 
 extirpated. Boinet has related to the French 
 academy, a case in which the swelling not 
 only filled the whole mouth, but one half of 
 the tumour projected out, and a cure could 
 only be accomplished in the latter manner. 
 The two upper incisor teeth on the left side, 
 were lodged in a depression observable 
 there; and the canine tooth, of the same 
 side, forced outward by the mass of the 
 disease, had pierced the lip near its commis- 
 sure. A fluid resembling mucus, flowed 
 from a narrow aperture at the lower part of 
 the swelling. The tongue could not be 
 seen, so much was it pushed backward, and 
 for some time, the patient had only subsisted 
 on liquid food, which he was first obliged to 
 convey to the back t>f the throat with some 
 mechanical contrivance. The tour incisor 
 teeth, two canine, and first grinders of the 
 lower jaw, had been pushed out of their 
 sockets, by the pressure of the swelling. 
 The patient’s aspect was alarming, and he 
 was threatened with suffocation. Extirpa- 
 tion was deemed necessary, and it was per- 
 formed with all the caution which the situa- 
 tion of the tumour demanded. The large 
 cavity thus occasioned was filled with lint. 
 The lower jaw being diseased, Boinet scra- 
 ped some of its surface oft', and covered the 
 places with lint, either dry or dipped in spirit 
 of wine. Some exfoliations followed, and the 
 fungous granulations which grew were re 
 pressed with proper applications. In three 
 
RECTUM. 
 
 months, the parts were healed in so regular 
 a manner, that the motion of the tongue was 
 not in the least obstructed, and no change 
 continued, except the alieration of the voice, 
 occasioned by the loss ol teeth. This case 
 is very interesting and proves how much 
 may be hoped for in difficult cases, from 
 prudent and judicious measures. (S»e E ncy- 
 clop6die M6tkodique,Art. Grenouillette. M6m 
 de V Acad, de Chirurgie , T. 3, Sabatier. Me- 
 decine Ophatoire , T. 2, p. 19, fyc. Ed. 2. 
 Callisen , Systems Chirurgicc Hodiernce , Vol. 
 2, p. 108, ty-c. II af nice, 1800. Lassus, Pa- 
 thologic Chir. T. 1, p. 402, fyc. 8 vo Paris , 
 1809. Richter, Anfangsgr. der Wundarzn. 
 B. 4, Kap. 1, Gottingen, 1800. J J. Stahl , 
 et J. F. E. de Schoenerben de Ranula, sub lin- 
 gud, speciali cum casu , Erford. 1 i 34.) 
 
 RECLI NATION. A term much employ- 
 ed abroad, to denote the operation of turn- 
 ing a cataract, so as to change the position 
 of its anterior and posterior surfaces. (See 
 Cataract.) 
 
 RECTUM. Many cases in which this 
 bowel is more or less concerned, are treated 
 of elsewhere in this Dictionary, and therefore 
 it will only be necessary for me here to re- 
 fer to them, and then notice some diseases 
 of the part, which are not considered in 
 other articles. For an account of piles, he- 
 morrhoidal excrescence, and other tumours 
 of Ihe rectum, see Hemorrhoids; and for 
 that of prolapsus ani, fistuia in ano, and im- 
 perforate anus, see Anus. Under the head of 
 divine Concretions. I have noticed the dan- 
 gerous obstruction of this bowel by masses 
 of indurated matter. In the article Lylhoto- 
 my, the mode oi cutting through the rectum 
 into the bladder, for the purpose of extract- 
 ing a calculus irorn the latter organ, is ex- 
 plained ; and if the reader refer to Bladder, 
 fie will there find a description of the method 
 of tapping it from the rectum. 
 
 Scirrhus, or stricture of the rectum, some- 
 times called the scirrho-coniracted rectum, 
 and sometimes cancer, especially when the 
 case is inveterate and in a state of ulcera- 
 tion, is a disease which has received much 
 elucidation from the writings of Desault, Sir 
 Everard Home, Dr. Sherwin, and Mr. Cope- 
 land. In the various descriptions given of 
 the complaint by these and other writers, 
 one great point of difference is remarkable, 
 viz. that some of them represent the case as 
 always of an incurable pature, while others 
 consider it as admitting of relief, at least 
 when it has not made considerable progress, 
 and the parts are free from ulceration. Ac- 
 cording to Desault, scirrhus of the rectum is 
 not uncommon at an advanced period of 
 life, and the disease is said to afflict women 
 more frequently than men, as from a table 
 kept at the Hotel Dieu, it appeared that ten 
 cases out of eleven occurred in females, if 
 it were not for the fact, that Desault some- 
 times effected a cure of the disease in its 
 early stage, I should venture to conclude, 
 that his observations apply entirely to the 
 true scirrhus, or cancer of the rectum, which 
 1 believe rarely or never occurs in young 
 patients, but as Desault states, is not very 
 
 unfrequent in elderly persons. My friend, 
 Mr. Copeland, in his practical remarks, does 
 not v confine himself to really scirrhus and 
 cancerous affections, but comprehends stric 
 tures of the rectum from a variety of causes; 
 and this accounts for his statement, that the 
 disease “ attacks people of almost all ages ; 
 but is most common about the middle age.” 
 However, he agrees with D**sauU, that wo - 
 men are more frequently affected th .n men. 
 He admits that it is sometimes cancerous, 
 though not so often as is generally imagined, 
 the mere induration not being an unequivocal, 
 proof of it. When the disease is really can- 
 cer, it is usually attended with more severe 
 pain, darting through the pelvis to the blad- 
 der and the groin. The countenance is of a 
 sallow leaden cast. (Copeland on the prin- 
 cipal Diseases of the Rectum and Anus, p. 15 
 —17. 
 
 Sometimes the disease extends over a 
 considerable length of the gut, but is gene- 
 rally more circumscribed. The coats of the 
 bowel become much thicker and harder than 
 natural. The muscular is subdivided by 
 membranous septa, and the internal coat is 
 sometimes formed into hard, irregular folds. 
 The surface of the inner membrane is occa- 
 sionally ulcerated, so as to form a cancerous 
 disease. Every vestige of the natural struc- 
 ture is sometimes lost, and the gut is changed 
 into a gristly substance. The cavity of the 
 bowel is always rendered narrow at the scir- 
 rhous part, and is sometimes almost oblitera- 
 ted. When Ihe passage through the gut is 
 very much obstructed, the bowel is always a 
 good deal enlarged just above the stoppage 
 or stricture, from the accumulation of the 
 feces there. As the disease advances, adhe- 
 sions form between the rectum and adjacent 
 parts, and ulcerations produce communica- 
 tions between them. 
 
 As the disease at first is not very painful, 
 it is usually not much noticed till somewhat 
 advanced. The patient is habitually cos- 
 tive, and usually voids his stools with a little 
 difficulty. In time, a good deal of pain is 
 felt in the part affecied, especially at stool, 
 after which some relief is experienced. “ As 
 the gut continues to decrease in diameter 
 (says Mr. Copeland,) the efforts to expel the 
 feces become more violent, and the conse- 
 quent progress of the .disease more rapid. 
 The stools, which have been long evacuated 
 with difficulty, become contracted in size, 
 appearing like earth- worms in their form, or 
 small pellets;” and if the finger be intro- 
 duced into the rectum, “ the gut will be 
 found either obstructed with small tubercles, 
 or intersected with membranous filaments ; 
 or else the introduction of the finger will be 
 opposed by a hard ring of a cartilaginous 
 feel, composed of the diseased inner mem- 
 brane of the intestines.” These states, as 
 Mr. Copeland observes, are very different 
 from the regular tumour on t ;, c anterior 
 part of the rectum, occasioned by an en- 
 largement of the prostate gland ; a case apt 
 to be suspected. u As the disease advan- 
 ces (says the same author,) the feces become 
 more fluid, and there is a thin saneous div 
 
KECTUM 
 
 399 
 
 charge from the anus, accompanied with 
 tenesmus.” According to Desault, pus and 
 blood may sometimes be noticed with the 
 excrement, particularly when the disease 
 has advanced to the ulcerated state. The 
 patient at length becomes sallow, frequent 
 eructations of air from the bowels, as Mr. 
 Copeland observes, torment the patient, and 
 render his life miserable ; the constitution 
 suffers, and dissolution follows. Severe 
 tenesmus attends the whole course of the 
 disease. (CEuvres Chir. par Bichat , T 2.) 
 
 Sometimes a small fistulous orifice at the 
 verge of the anus communicates with the 
 inferior portion of the diseased part. Such 
 a fistula, in a case recorded by Sir Everard 
 Home, was half an inch in length. ( Obs . 
 on Cancer , p. 133.) 
 
 Desault has often seen the disease form 
 a communication between the rectum and 
 vagina, and the feces passed through the 
 latter part. In the latter stage of the afflic- 
 tion, the rectum, bladder, vagina, uterus, 
 and adjacent parts, are all involved in one 
 common ulceration. 
 
 When the disease has attained the ulcera- 
 ted state, it is probably always incurable. 
 Palliatives can only now be resorted to, 
 such as anodyne and emollient glysters, the 
 warm bath, foe. with the exhibition of me- 
 dicines like opium, cicuta, uva ursi, foe. 
 Claudinus applied his remedies to the inside 
 of the bow r el, by means of tents, and did not 
 employ the latter as a mode of curing the 
 disease when less advanced. Valsalva in- 
 troduced a cannula, pierced with numerous 
 holes, and then made his patient get into a 
 bath, so as to let, the fluid enter the intestine. 
 Numerous practitioners, among whom is 
 Morgagni, made mercurials the base of their 
 treatment, from a supposition that the com- 
 plaint was of venereal origin. J believe the 
 latter opinion is at present entirely abandon- 
 ed by all the most judicious surgeons in 
 England, and this, whether mercury ever 
 prove useful or not. 
 
 When the disease is not .attended with 
 ulceration, the contraction and thicken- 
 ing of the gut may be diminished by in- 
 troducing bougies, keeping them for a 
 certain time, every day, so introduced, 
 and increasing their size gradually. The 
 pressure of these instruments seems to 
 lessen the disease, and stop its progress ; a 
 proof that its nature differs from that of a 
 common malignant scirrhus. Desault used 
 to employ long tents made of lint, smeared 
 with cerate, and passed into the bowel by 
 means of a probe with a forked end. Their 
 size was gradually increased, so as to keep 
 up the compression, to which, it was con- 
 ceived, all the good was owing. Their 
 length was also augmented by degrees. At 
 first, fresh ones were introduced twice a 
 day. When any hardnesses were situated 
 on the outside of the anus, Desault cured 
 them on the same principle, viz. by making 
 pressure on them with compresses and a 
 bandage. In this manner he effected the 
 cure of a seirrho-cpntracted rectum. The 
 patient was taught to pass occasionally the 
 
 tents, without assistance, in order to pre- 
 vent a relapse. 
 
 Instead of tents, modern surgeons employ 
 bougies for the dilatation of strictures in the 
 rectum. When from habitual costiveness, 
 the altered figure of the stools, and other 
 circumstances, there is reason to suspect 
 organic obstruction to the passage of the 
 fee ed, and this suspicion is confirmed by an 
 examination of the rectum with the finger, 
 a the first object of the surgeon (says Mr. 
 Copeiand) should be an enlargement of the 
 obstructed part, by the introduction of a 
 bougie. This should be of such a size as to 
 pass, when well lubricated with oil, without 
 much difficulty or pain. Sometimes, when 
 the disease has been of long continuance, it 
 will be necessary to begin even with a large- 
 sized urethra bougie, or one of the same 
 size as those which are made for a stricture 
 of the oesophagus, and of a length that is 
 likely to pass beyond the end of the stric- 
 ture, that is, about six, or seven, or eight 
 inches. But I think it of consequence to 
 use a bougie, at first, which is rather too 
 small than too large.” (P. 29.) When it 
 has remained for half an hour, or more, it is 
 to be removed, and passed again the next 
 day, the same sized bougie being continued 
 for several days. In the introduction of the 
 bougie, Mr. Copeland cautions the practi- 
 tioner not to mistake the projection of the 
 sacrum for a stricture of the gut ; a mistake 
 which, he says, has often been made, and, 
 as I believe, too often wilfully, and from 
 motives of imposition. Mr. Copeland fur- 
 ther advises the bowels to be ke*pt constantly 
 lax, by the use of castor oil, or electuary of 
 senna, during the whole of the treatment. 
 (P. 30.) Whatever be the nature of the 
 stricture, whether it be that kind in which 
 the rectum is obstructed by tubercles, by 
 membranous filaments intersecting its canal, 
 (which two species, Mr. Copeland says, are 
 the most easily relieved) or whether it be 
 the indurated stricture, from a thickening of 
 the coats of the intestine, this local treat- 
 ment is equally necessary. The pian is to 
 be persisted in until a full-sized bougie will 
 readily pass, and even after all symptoms 
 have disappeared it is recommended to in- 
 troduce the bou ie, and withdraw it again 
 once every two or three days, for some 
 time, in order to prevent a relapse. The in- 
 durated annular stricture, which long resists 
 the bougie, Mr. Copeland sometimes divides 
 with a probe-pointed curved bistoury on the 
 side which is contiguous to the os sacrum ; 
 and he has frequently seen the late Mr. Ford 
 perform the same operation. (P. 34.) When 
 the disease is either combined with venereal 
 symptoms, or there is any reason for sus- 
 pecting it to be itself “ the solitary symp- 
 tom” of lues. Mr. Copeland joins Desauk 
 in recommending a trial of the effect of 
 mercury, in conjunction with bougies. (P. 
 44.) The formation of abscesses, he re- 
 marks, is very frequent in the advanced 
 stages of the disease, and he has often seen 
 the common operation for fistuladone under 
 such circumstances tvithout success. (P.3 5 • 
 
HICKEXS. 
 
 'IWU 
 
 When uny stoppage of urine occurs in 
 the advanced stage of the disease, Mr. Cope- 
 land advises surgeons not to use the catheter 
 hastily. ( P . 39.) And, in the event of great 
 pain and irritation in the rectum, he has 
 seen the greatest benefit derived from the 
 local application of opium either in a glys- 
 ter, or by the introduction of one or two 
 grains of the medicine within the anus. He 
 also speaks favourably of the effects of the 
 warm bath, and fomentations, in giving 
 temporary relief ; and he has also exhibited 
 in these cases the pil extracti conii cum 
 hydrarg. submur. with considerable advan- 
 tage. 
 
 A fatal case of mortification of the rec- 
 tum is detailed by Larrey. ( Parisian Chi- 
 rurgical Journal, Vol. 2, p. 398, <^c. See J. 
 L. Petit , CEuvres Posthum. T. 2. Dr. Sher- 
 win on the schirrho-conlraded rectum, in Mem. 
 of the London Medical Society , Vol. 2. Sir 
 Everard Home , Obs. on Cancer , p. 129, fyc. 
 S vo. Lond. 1805. L. F. J. Duchadoz , De 
 Prodostenia , seu de Morbosis Intestini Recti 
 Angustiis, Monsp. 1771. C. G. Siebold, De 
 Morbis Intestini Recti Baillie's Morbid Anato- 
 my, p. 1116. CEuvres Chir. de Desault par 
 Bichat , T. 2, p. 422. Observations on the 
 principal Diseases of the Rectum , fyc. by T. 
 Copeland , 1814. W. White, Observations 
 on the Contracted Intestinum Rectum, 8 vo. 
 Bath, 1812.) 
 
 RESOLUTION. (from resolvo.) The 
 subsidence of inflammation without any 
 abscess, ulceration, mortification, &c. Also 
 the dispersion of swellings, indurations, &c. 
 
 RETENTION OF URINE. See Urine, 
 Retention of. 
 
 RETROVERSIO UTERI, a turning back- 
 ward of the womb. See Uterus , Retrover- 
 sion of. 
 
 RICKETS. (Rachitis.) Is mostly met with 
 in young children ; seldom in adults. Mo- 
 rand, however, (Acad, des Sciences, 1753.) 
 mentions an instance, in which an adult 
 became affected. The disease it is said, 
 may even take place in the foetus in utero ; 
 but the most common period of its com- 
 mencement is in children, between the ages 
 of seven or eight months, and two years. 
 Hence, as Mr. Wilson observes, its origin 
 has frequently been imputed to the effects 
 of dentition. He adds, that he has often 
 known it to make its appearance after this 
 time, and that it not unfrequently attacks 
 the spine a little while before puberty, 
 and may do so even later. (On the Struc- 
 ture and Physiology of the Skeleton, fyc. p. 
 162.) Pine! has given a description of the 
 skeleton of a rickety foetus. (Fourcroy’s 
 Journal.) The disease seems to consist of 
 a want of due firmness in the bone9, in con- 
 sequence of a deficiency in the phosphate 
 of lime in their structure. The causes of 
 the affection are involved in great obscurity. 
 Authors have referred them to scrofula, 
 scurvy, lues venerea, difficult dentition, &c. ; 
 nnd Richerand still firmly believes, that 
 rachitis is only one of the effects of scrofula 
 in its worst forms. (JVosographie Chir. T. 
 3. v ■ 148, Edit.. 4.) But these are merely 
 
 conjectures, which will not bear a rigorous 
 investigation. Professor Boyer, in particu- 
 lar, has well exposed their invalidity. Traitd 
 des Mai. Chir. T. 3, p. 611.) 
 
 Rickety subjects are often at the same 
 time scrofulous ; and this is, probably, the 
 only reason for scrofula being accounted a 
 cause of the other affection. The particu- 
 lar appearances of rickety children we 
 need not detail, as every one is familiarly 
 acquainted with them : such children are 
 usually of a bad, weak constitution, and 
 their limbs and bones become bent in direc- 
 tions determined by the action of the mus- 
 cles, and the weight and pressure which 
 they have to sustain. When the affection 
 is very general, the spine becomes shorter, 
 and is curved in various directions ; the 
 breast becomes deformed not only in con- 
 sequence of the curvature of the spine, but 
 by the depression of the ribs, and projection 
 of the sternum. The bones of the pelvis 
 fall inwards, and the os pubis generally ap- 
 proaches the sacrum. The latter circum- 
 stance is one of the causes of difficult 
 parturition. The clavicles become more 
 bent and prominent forward ; the os humeri 
 is distorted outward ; the lower ends of 
 the radius and ulna are twisted in the same 
 direction ; the thighs are curved forwards 
 or outwards ; the knees fall inwards ; the 
 spine and front surface of the tibia become 
 convex ; and the feet are thrown out- 
 wards. 
 
 According to the observations of Mr. 
 Stanley, when the tibia and fibula become 
 curved, they sometimes “ acquire increased 
 breadth in the direction of the curve, losing 
 a proportionate degree of thickness in the 
 opposite direction. Hence the bones be- 
 come, as it were, newly modelled, passing 
 from the cylindrical into the flattened form. 
 This would seem to be designed for the pur- 
 pose of enabling them to support more 
 efficiently the weight of the body, since by 
 this alteration they acquire increased breadth 
 and power of resistance in that direction, 
 where the greatest strength is required. I 
 have never noticed (says Mr. Stanley) any 
 expansion in the articular ends of rickety 
 bones, as is mentioned by some authors, 
 I should therefore feel inclined to believe, 
 that there has existed only the appearance 
 of such a phenomenon, the ends of the 
 bones having appeared swollen, in conse- 
 quence of the emaciation of the surround- 
 ing soft parts. (See Med. Chir. Trans. Vol. 
 7, p. 402— 405.) 
 
 When the thoracic viscera are considera- 
 bly oppressed by the alteration in the figure 
 of the chest, produced by rickets, the dis- 
 ease may bring on fatal consequences. 
 
 Boyer has thus described the appearances 
 of rickety bones : They are lighter than 
 natural, and of a red, or brown colour. 
 They are penetrated by many enlarged 
 blood-vessels, being porous, and, as it were, 
 spongy, soft, and compressible. They are 
 moistened by a kind of sanies, which may 
 be pressed out of their texture, as out ©f ai 
 sponge, or rather a macerated hide after it 
 
has been tanned. The walls of the medullary 
 cylinder of the great bones of the extremi- 
 ties are very thin, while the bones of the skull 
 are considerably increased in thickness, and 
 become spongy and reticular. All the af- 
 fected bones, especially the long ones, ac- 
 quire a remarkable suppleness ; but if they 
 are bent beyond a certain point they break, 
 &c. Instead of being filled with medulla, 
 the medullary cavity of the long bones con- 
 tains only a reddish serum, totally devoid of 
 the fat oily nature of the other secretion in 
 the natural state. \See Boyer , Trait6 des 
 Maladies Chir. T. 3, p. 619.) The consis- 
 tence of several rickety bones, examined by 
 Mr. Stanley, was nearly that of common 
 cartilage. They presented throughout an 
 areolated texture, and the cells were in some 
 parts large, and contained a brownish gela- 
 tinous substance. This gentleman did not 
 find the periosteum thickened, as Bichat has 
 described it. ( Analomie Generate , T. 3.) 
 The investigations of Mr. Stanley have also 
 discovered, that, in the process by which 
 rickety bones acquire strength and solidity, 
 there is always an undeviating regularity in 
 the situation, extent, and direction of the 
 deposited earthy matter. “ Thus it is obvi- 
 ous (says this gentleman) that, in the curved 
 bone, the part where there is the greatest 
 need of strength, to prevent its further 
 yielding, is in the middle of its concavity, 
 or in other words, in the line of its interior 
 curve; and it is just in this situation, that 
 strength and compactness will be first im- 
 parted to the bone by the deposition of phos- 
 phate of lime. It will be further found, that 
 the greatest resistance being wanted at this 
 part, the walls are accordingly rendered 
 thicker here than elsewhere, and the degree 
 to which this excess in thickness is carried, 
 bears an exact ratio to the degree of curva- 
 ture, which the bone has undergone.” 
 
 Mr. Stanley’s observations also prove, that 
 the bony fibres are arranged obliquely across 
 the axis of the bone, in a direction calcula- 
 ted to augment its strength. Lastly, we 
 learn from the same authority, that if a long 
 bone, like the tibia, be very much bent, 
 while it has to support a great superincum- 
 bent weight, the deposition of the bony mat- 
 ter may not be confined to the thickening 
 of the walls of the concave side, but may 
 extend across the medullary cavity, render- 
 ing the bone here perfectly solid, and there- 
 by greatly strengthened. (See Obs. on the 
 Condition of the Bones in Rickets , fyr. by E. 
 Stanley, in Medico- Chir. Trans. Vol. 7, y. 
 404, et seq.) 
 
 We learn from Mr. Wilson, that for many 
 3 r ears past, he has also exhibited in his lec- 
 tures preparations, illustrating the fact of 
 the abundant deposition of osseous matter, 
 “ when the bones begin to recover from the 
 disease, at the part where it is most wanted, 
 viz. on the inner part of the concave surface 
 of their curve.” (On the Skeleton , fyc. p. 
 167.) 
 
 Many very rickety and deformed infants 
 improve as they grow up, and acquire 
 strertgtb. The defermit v of their limbs snori- 
 7 ' >r Jr 
 
 taneously diminishes, and the bones gain a 
 proper degree of firmness, a due quantity of 
 the phosphate of lime being deposited in 
 their texture. 
 
 it is a question, whether the restoration 
 of the proper figure of the bones can be pro 
 moled by the constant pressure of bandages, 
 and mechanical contrivances, sold in the 
 shops. Some authors contend, that in very 
 young children machines are useless, as the 
 confinement and inactivity of the muscles, 
 necessarily occasioned by such contrivances, 
 must increase the general debility, and con- 
 sequently the disease. 
 
 Notwithstanding the praises which have 
 been bestowed on those mechanical means 
 by their inventors, and even by respectable 
 authors, says Boyer, they are not now used 
 by any enlightened judicious practitioners, 
 it being generally agreed, that it is best to 
 leave to nature alone, aided by good medi- 
 cal treatment, the duly of rectifying bones 
 deformed by the rickets. ( Trait e des Mai. 
 Chir. T. 3 p. 627.) Delpech expresses him- 
 self still more strongly against the employ- 
 ment of machinery. (See Precis Elemen- 
 tal re des Maladies Chir. T. 3, p. 740, fyc.) 
 However, these opinions against mechani- 
 cal contrivances for the improvement of 
 rickety bones, are not meant to apply to ma- 
 chines for rectifying distortions of the fool. 
 In such cases, the malformation does not de- 
 pend on constitutional causes, and mechani- 
 cal means will do whatever is possible. 
 
 No medicine is known, which possesses 
 any direct efficacy in cases of rickets. To- 
 nics are indicated, and should be employed. 
 The state of the bowels must in particular 
 be attended to. The disease appearing to 
 consist in a deficiency of lime in the bones, 
 proposals have been made to exhibit inter- 
 nally the phosphate of lime ; but this chy 
 mical project has had no success. (See Bon 
 homme’s Memoir on Rachitis , in Duncanhst 
 Annals for 1797. 
 
 Several circumstances considered by M.‘ 
 Wilson, tend to prove, that this scheme could 
 present no chance of benefit, because there 
 is no proof of a deficiency of lime in the 
 system, though the arteries of the bones do 
 not deposit it in the natural degree. (See 
 Wilson on the Skeleton , fyc. p. 163, fyc.) 
 
 More good is generally effected by keep- 
 ing children in healthy situations, and in a 
 salubrious air, than by any medicines what- 
 ever. Light, wholesome, nutritious, easily 
 digestible food; cold bathing; good nur- 
 sing; regular gentle exercise; or airings in 
 a carriage ; the use of the flesh-brush, fee. 
 are also highly serviceable. The constitu- 
 tional treatment of rickets belongs more 
 properly to the physician than the surgeon ; 
 and it is not necessary to introduce more of 
 the subject into a Dictionary expressly al- 
 lotted to surgery. 
 
 See the article Mol, lilies Ossium , and con- 
 sult particularly Buchner de Rachitide perfec- 
 ta et imperfecta Disput. Argent. 1754. G iis- 
 son, de Rachiiide , sive,. morbo puerili. Ludg. 
 Batav. 1671. Bonhomme’s Mem. on Rachitis, 
 in Duncan's Medical Annals for 1797. Riche- 
 
-SAR 
 
 SAR 
 
 (A«2 
 
 vmd, JVosographie Chir. T. 3, p. 142. fyc. 
 Edit. 4. LcvMM, in Mem. de Physiologic et 
 de Chirurgie , par Scarpa, fyc. Boyer, Trailt 
 des Maladies Chir. T. 3, p. 607, fyc. Stan- 
 ley's Ohs. in Med. Chir. Trans. Vol. 7,p 404 
 Delpech Precis EUmentaire des Mala ies 
 Chir. T. 3, p. 749, fyc. Tmka de Krzowltz, 
 Jlistoria Rachitidis, 8 vo. Vindob. 1787. R. 
 Hamilton Remarks on Scrofulous Affections, 
 fyc. &ve. Lond. 1791. A. Portal, Obs. sur la 
 
 Nature et sur le Trailemenl du Rachilisme, 
 ou des Courbures de la colonne Vertebrate et 
 de celles des Extremites. 8 vo. Paris , 1797. 
 And particularly, Lectures on the Structure 
 and Physiology of the Skeleton, Diseases of 
 Bones, fyc. by James Wilson, p. 159, fyc. 8 vo. 
 Lond. 1820. 
 
 RINGWORM. See Herpes. 
 
 RUPTURE. A protrusion of the abJomi 
 nal viscera. See Hernia. 
 
 s. 
 
 ^4 \BINA. (said to be named from the Sa- 
 k 3 bines, whose priests used it in their re- 
 ligious ceremonies.) Savine. The use of 
 the leaves of this plant, in forming the active 
 ingredient in the ointment commonly pre- 
 ferred for keeping open blisters, has been 
 explained in the article Blisters. The other 
 chief surgical use of savine, is as a stimula- 
 ting application for destroying wart?, and 
 other excrescences. For the latter purpose, 
 it is generally powdered, and mixed with an 
 equal proportion of siibacetate of copper. 
 The same powder is also sometimes employ- 
 ed by surgeons for maintaining the hollows 
 into which peas are inserted in issues. The 
 best plan is, first to wet the peas, then roll 
 them in the powder, and put them in this 
 state on the issue. But when the whole sur- 
 face of the issue has risen high, above the 
 level of the skin, the powder must be sprin- 
 kled all over the sore, so as to produce an 
 absorption of the high granulations. — indeed, 
 even in this manner, a good cavity often 
 cannot be obtained ; and it becomes neces- 
 sary to destroy the surface of the issue, by 
 rubbing it with caustic potassa, or potassa 
 cum caice. 
 
 SACCHARUM SATURNI. Sugar of 
 Read. Cerussa Acetata. Acetate of Lead. 
 This is very extensively used in surgery, 
 chiefly as a local application to inflamed 
 parts, and in the form of a lotion. See In- 
 domination, Collyrium, Lotio, Gonorrhoea , 
 Ophthaimy, and numerous other articles of 
 tins Dictionary, for an explanation of (he 
 uses of acetate of lead. 
 
 SAL-AMMONIAC. Ammonia Muriata. 
 Muriate of Ammonia. Employed a good 
 deal by surgeons, as an ingredient in discu- 
 tient lotions. See Lolio Ammon. Mur. 
 
 SALIVARY FISTULAS. See Parotid 
 Duct. 
 
 SANIES. (Latin ) A thin, serous, fetid 
 matter, discharged from fistulm, unhealthy 
 sores, fee. It is sometimes tinged with blood. 
 
 SAI'O TE RE B I N T H I N 7E . ( Starkey's 
 
 Soap.) f^. Potassa; Subcarbonatis calidi, 
 Olei Terebinth, £iij. — The oil of tur- 
 pentine is gradually blended with the hot 
 suhearbonate of potassa in a heated mortar. 
 Indolent swellings were formerly rubbed 
 with this application, and, perhaps, some 
 chronic affections of the joints might still be 
 bcuefliied by it. 
 
 : A.RCOCE'* E. ffrom <r«w|h flesh : and 
 
 a tumour.) A fleshy enlargement of 
 the testicle. See T> slide, Diseases of.) 
 
 SARCO'MA, or Sarcbsis. (from cctp£ , 
 flesh.) A fleshy tumour on any part of the 
 body. (See Tumours, Sarcomatous.) 
 
 SARSAPARI LLA The root of sarsapa 
 rilla was brought into Europe about 1530. 
 It was at first reputed to possess singular effi- 
 cacy in venereal cases ; but afterward lost 
 -all its fame. Sarsaparilla was again brought 
 into notice' by Di. \V. Hunter, who advised 
 Dr. Chapman to make trial of it in a bad 
 case of phagedenic bubo ; and the benefit 
 obtained in t his instance, led Dr. Hunter to 
 extend the recommendation of the medicine 
 Sir W. Fordyce stated, that sarsaparilla 
 would quickly relieve venereal headachs, and 
 nocturnal pains, and if persisted in, cure 
 them ; that in emaciated or consumptive ha- 
 bits, from a venereal cause, it was the great- 
 est restorer of appetite, flesh, colour, and 
 strength, which he knew of; that when mer- 
 curial frictions had been previously employ- 
 ed, it would generally complete the cure of 
 the disease of the throat, nose, palate, or 
 spongy bones ; and that ii would promote 
 the cure of blotches and ulcers, and some- 
 times accomplish it, even without mercury ; 
 though, in this circumstance, there was dan 
 ger of a relapse. Sir YV. Fordyce pronoun- 
 ced sarsaparilla to be of little use in chan- 
 cres ; but that when these, or buboes, could 
 not be healed by mercury, it would often 
 cure, and always do good. He allows, how 
 ever, that, in all venereal cases, sarsaparilla 
 is nol to be trusted, unless preceded by, or 
 combined with, the use of mercury ; and he 
 thought sarsaparilla would, probably, always 
 cure what resisted mercury. (Medical Obs. 
 and Inq. Col. 1.) 
 
 The celebrated Cullen considered sarsa- 
 parilla as possessing no virtues of any kind ; 
 for, says lie, “tried in every shape, 1 have 
 never found it an effectual medicine in sy- 
 philis, or any other disease.” (Mat. Med. 
 Vol. 2.) 
 
 Mr. Bromfield declares, that he never 
 saw a single instance in which sarsaparilla 
 cured the venereal disease without the aid 
 of mercury, either given before, or in con 
 junction with it. (Tract. Obs. on the Use of 
 Corrosive Sublimate , tyc. p. 78.) Mr. Pear- 
 son also contends that sarsaparilla has not 
 the power of curing any one form of the lues 
 reverea ; but ho allows that it may suspend,. 
 
SCROFULA 
 
 40o 
 
 Jtor a tune, tlx* ravages of that contagion, the 
 disease returning if no mercury should have 
 been used. This gentleman ndinits, also, 
 that sarsaparilla will alleviate symptoms de- 
 rived from the venereal virus. He maintains, 
 that the exhibition of sarsaparilla does not 
 diminish the necessity for giving les« mercu- 
 ry. Nocturnal pains in the limbs, painful en- 
 largements of the elbow and knee, mem- 
 branous nodes, cutaneous ulcerations, and 
 certain other symptoms, resemhling venereal 
 ones, are often experienced after a full course 
 of mercury. Such complaints. Mr. Pearson 
 allows, are greatly benefited by sarsaparilla, 
 and exasperated by mercury ; and he ob- 
 serves, that it is from these complaints ha- 
 ving been mistaken for venereal ones, that 
 the idea has arisen, that sarsaparilla has cured 
 syphilis when mercury had failed. Mer- 
 cury, and the venereal poison, may jointly 
 produce, in certain constitutions, symptoms 
 W’hieh are not strictly venereal and are some- 
 times more dreadful than the simple effects 
 of syphilis. Some of the worst of these ap- 
 pearances are capable of being cured by sar- 
 saparilla, while the venereal viris still re- 
 mains in the system. When this latter dis- 
 ease has been eradicated by mercury, sarsa- 
 parilla will also cure the sequelae of a course 
 of the other medicine. ( Pearson on the Ef- 
 fects of various Articles in ihe ire of Lues 
 Venerea , 1807.) 
 
 The value of many of the foregoing opi- 
 nions is mucha fleeted by the results of mo 
 dern inquiries into ihe nature of the vene- 
 real disease, the possibility of generally 
 curing which, without the aid of mercury, 
 seems well established, though the expedien- 
 cy of the method is another question. - 
 
 SCALPEL, (from scalpo . to scrape.) 
 Originally a raspatory, or instrument for 
 scraping diseased hones, &c. The term now 
 generally signifies a common, straight, sur- 
 gical knife. 
 
 SCA'RIFICATION. (from scariflco , to 
 scarify.) The operation of making tittle cuts, 
 or punctures, in a part, for the purpose ot 
 taking away blood, letting out fluid in ana- 
 sarcous cases, or air, in instances of emphy- 
 sema. 
 
 SCIRRHUS ; SCIRRHOMA 5 SCIR- 
 RHO^IS. (from trHippcoe, to harden.) The 
 etymological import ol these terms seems 
 merely to be any induration. The first is 
 now generally restricted to the induration 
 which precedes cancer in the ulcerated state. 
 
 SCLER1ASIS ; SCLER0-1S. (from 
 anKn^ou, to harden.) A hard tumour, or m- 
 dui lion. 
 
 SCRO TULA, or SCROPHULA. (from 
 scrofa , a sow.) So named, as is commonly 
 supposed, because swine an- s>id to be sub- 
 ject to it, though the correctness of this ety- 
 mology is rendered very questiona le by the 
 remarks of Dr. Henning, and the statement, 
 that pigs are really liable to scroful < \ould 
 appear to be erroneous. (See Critical In- 
 quiry into the Pathology of Scrofula , fyc. p. 
 1,9.) Called also, struma , and t he King's 
 evil, from the custom of submitting patients 
 
 formerly to the supposed beneficial effects of 
 the royal touch. A disease, one of 1 lie chief, 
 or most palpable symptoms of which is a 
 chronic swelling of the absorbent gland*, in 
 various parts of the body, which glands ge- 
 nerally tend very slowly to imperfect suppu- 
 ration. Oar notions of scrofula, however, 
 would be very imperfect, were we to define 
 the disorder to be a morbid state of the Ijrn- 
 phatie glandular system. The first appear- 
 ances, indeed, frequent ly consist of spots on 
 different parts of the body, and of eruptions 
 and ulcerations behind the ears. As a ju- 
 dicious author remarks, the system of absorb 
 ent gland®, it is true, seldom or never fails to 
 become affected in the progress of the dis- 
 ease ; but there is reason to believe, that 
 scrofula frequently appears, for the first time, 
 in parts which are not of a glandular nature. 
 Tin re are, perhaps, but few, if any, of the 
 textures of the human body, or of the or- 
 gans, which these textures form, that are not 
 liable to attacks of scrofula, and to scrofula 
 as an original idiopathic affection. (Thomp - 
 son’s Lectures on Inflammation , p. 134.! 
 These sentiments are entirely at variance 
 with those of Alibert, and many other mo- 
 derns, who describe the disease as having its 
 commencement in the conglobate glands, 
 especially thosp of the neck, (Nosol. Natu 
 rclle , T. l,p. 441,4/o. Paris, 1817 ;) and they 
 are equally opposite to the doctrine of Dr 
 Henning, who argues, that the superficial ab- 
 sorbent glands alone are susceptible of the 
 original ac»ion of the cause of this disease, 
 and that if other parts become affV- ted by it, 
 such affe’ tion is consequential. (On the Pa- 
 thology of Scrofula. Chap. 6.) 
 
 Scrofula generally shows itself during in- 
 fancy, between the age of three and seven ; 
 sometimes rather sooner; but frequently as 
 late as puberty, and in some instances, though 
 a ver> few, not till a much more advanced 
 period of life. In the latter cases, the dis- 
 ease is said to be rarely so complete, or w ell 
 marked, as it is in young subjects. u Cette 
 maladie (says Alibi rt) est commun&ment le 
 partage de la premiere enfauce. Ill est rare 
 qu’elle se d 6 veioppe chez les adultes. Je 
 Pai pourtnnt observee chez des septuage- 
 naire- ; mais presque toujours, ce sont, les 
 effects de la dentition qui la font eclore, et 
 ceux de la | ubeite, qui la font evanouir 
 (Nosol. Nalurelle,p. 448.) 
 
 By some authors, it is stated, that the di- 
 ease seldom attacks the glands in children 
 under two years of age. Dr. Thomson,, 
 however, ha- seen the glands affected before 
 this period, and Dr. Cullen used to mention 
 a case, in which the disease broke out in ari 
 i fant only th>ee months old; which, ac- 
 cor iing to Dr. Thomson, is uncommon. But 
 though glandular scroful . occurs most fre- 
 qu utly in child en, it is by no means confi- 
 ned to that period of life. Di. Thomson has 
 even found the lacteal gland- affected with 
 scrofulous inflammation in per-ons of v<-ry 
 advanced age. (Lectures on Inflammation , 
 p 136.) Probably, however, such patients 
 had laboured unfijr scrofulous complaints in 
 their earlier days : and it merits notice; that 
 
SCItOfU L \ 
 
 m 
 
 some authors, like Dr. Henning, ( Z\ 110.) do 
 not regard enlargement of the mesente- 
 ric glands, as an unequivocal specimen of 
 scrofula It is observed by Mr. Lloyd, that 
 the susceptibility of different parts to the dis- 
 ease “ is altered by age; thus, in children, 
 the upper lip, eyes, glands of the neck, and 
 those of the mesentery, are generally the 
 pan's first affected; the lungs, bones, and 
 other parts being subsequently attacked. 
 It happens sometimes too in children, that 
 small lumps iorm under the skin in various 
 parts of the bod), which suppurate, ulce- 
 rate, and pursue the same course with scrofu- 
 lou- abscesses in general.” (On the Nature 
 and Treatment of Scrofula, p. 5.) The same 
 gentleman likewise states, that a species of 
 warts also often forms about the face and 
 neck of children of a scrofulous habit, but 
 seldom in adults. “ In more advanced age, 
 the eyes, upper lip, and lymphatic glands are 
 comparatively seldom affected ; while the 
 lungs, the other viscera, and the spongy parts 
 of the boms are frequently attacked.” 
 Scrofula is also as hereditary as any dis- 
 ease can be ; that is to say, it is so as far as 
 any particular kind of temperament, or con- 
 stitution, can descend, more or less com- 
 pletely, from parents to children. Mr. 
 White, Dr. Henning, and others have strong- 
 ly censured calling the disease hereditary ; 
 but their observations only lead to these 
 conclusions, that children, born of scrofulous 
 parents, are not invariably affected with 
 scrofulous diseases ; and that sometimes one 
 child has some strumous affection, w hile the 
 parents, and all the rest of the family, have 
 no appearance of scrofulous habits. How- 
 ever, I still conceive that neither Mr. White, 
 nor any other writer will maintain the opi- 
 nion, that scrofula does not much more 
 frequently afflict the children of scrofulous 
 parents, than the offspring of persons who 
 have always been perfectly free from every 
 tendency to any form of this affliction. Too 
 numerous are the facts which occur to my 
 ow n mind, to allow me to entertain the 
 smallest doubt, that scrofula runs very 
 much in certain families. In this sense, I 
 think the term hereditary perfectly accurate 
 and allowable. But, at the same time, I 
 beg the reader to understand, that 1 have 
 no intention of questioning what seem to 
 be irrefragable truths, viz. that the children 
 of scrofulous parents often continue, as long 
 they live, entirely free from the disease ; 
 and that one child is sometimes afflicted, 
 while its father, mother, brothers, sisters, 
 and all the rest of its relations, have never 
 had any tendency to strumous disorders. 
 It, should also be recollected, that the doc- 
 trine of a congenital tendency to ihe dis- 
 ease in particular families is one which in- 
 terferes with some theories which have 
 been offered about the predisposing cause 
 of the disease, as for instance, with that of 
 Dr. Henning, w ho declares that such cause 
 is foreign to the body, and depends upon 
 peculiarities of climate; (On the Pathology 
 of Scrofula, p. 69, &c.) an Opinion, which is 
 incorrect only in rej ect to its exclusion 
 
 of the iniluence of oiher circumstances. 
 Two curious specimens of tuberculated lungs 
 in the foetus are preserved in Mr. Langstaff’s 
 museum, and have been adduced by Mr 
 Lloyd, as positive proofs of scrofula being 
 hereditary, (On Scrofula , p. 23 ;) how- 
 ever, I am not certain that they will be 
 admitted as such by all parties, as tubercles 
 of the lungs are not constantly regarded 
 as a scrofulous disease 
 
 When scrofula does not actually take 
 place at a very early period of life, it is ge- 
 nerally staled by writers, that the particular 
 constitutions, in which there is a disposition 
 to the disease, are, in a certain degree, dis- 
 tinguishable. In the individuals, possessing 
 the disposition in question, a peculiar soft- 
 ness and flaccidity of fibre are remarkable ; 
 their hair is more frequently light coloured 
 than dark ; and tbeir eyes are said to be 
 more often of a blue, than any other colour. 
 Their skin is generally very fine, and even 
 handsome, both in regard to its outward 
 texture and complexion. Subjects with 
 scrofulous constitutions frequently have a 
 thickening of the upper lip ; this swelling is 
 sometimes very considerable, and occasion- 
 ally extends as far as within the nostrils. 
 Scrofula is also very often complicated with 
 rachitis, or follows the latter affection; but 
 there is as little reason for supposing rickets 
 to arise from scrofula, as this latter from 
 rickets. In some instances, however, the 
 complexion is dark, and the skin coarse ; 
 but in these subjects, at least wben young, 
 the face is generally tumid, and the look 
 unhealthy. (Burns on Inflammation , Vol. 2, 
 p. 232.) 
 
 In many instances, the last joints of the 
 fingers have been observed to be enlarged, 
 and the belly is generally larger than usual. 
 (Thomson, p. 134.) 
 
 Mr. White, as I think, with some appear- 
 ance of truth, denies that gray, or blue eyes, 
 light hair, and a fair complexion, ought to 
 be considered as marks of a scrofulous dis- 
 position ; for the majority of children in 
 this country have light hair, and eyes while 
 young, which become darker as they ad- 
 vance in life. Now, as the majority of scro- 
 fulous patients are children, and young sub- 
 jects, and as most children in this country 
 have naturally the kind of hair and eyes 
 above described, it seems inaccurate to lay 
 any stress on persons affected with struma, 
 or predisposed to this disease, having such 
 appearances. (See White on the Struma or 
 Scrofula, p. 38, Ed. 3.) However, it is to 
 be recollected, that the greater frequency 
 of scrofula in fair people is noticed in 
 France, where the eyes are mostly dark. 
 Thus, Alibert in his description of a patient 
 disposed to the disease, takes notice of his 
 swelled nostrils and upper lip; his florid 
 complexion ; his fair, delicate, glossy skin ; 
 his cheeks of a lively red colour; circum- 
 scribed, however, by a pallid bloatedness 
 of the rest of the face. His blue eyes ; di- 
 lated pupils ; light hair ; short neck ; largo 
 head and lower jaw ; flabby flesh ; large, 
 protuberant belly ; strong intellectual 
 
SCROFULA 
 
 405 
 
 powers, &e. (Nosol. Naturelle , p. 442 ; 
 also, Did. des Scietices Med. T. 50, p. 2S1.) 
 
 Dr. Thomson expressly declares, that 
 some of the worst cases of scrofula, which 
 he has seen, occurred in persons whose com- 
 plexion and hair were of a very dark co- 
 lour. ( Lectures , p. 134.) Another fact, 
 which I think tends to impeach the accura- 
 cy of the common doctrine about complex- 
 ion, is the circumstance of so many negroes 
 being afflicted in this country with scrofula 
 in its worst forms. Does not this fact indi- 
 cate, at the same time, that it is climate, 
 which is most powerfully concerned in the 
 production of the disease ; since the African 
 black, in his own country, is nearly ex- 
 empt from scrofula? After all, however, as 
 the disease is undoubtedly very frequent in 
 persons of fair skin, light eyes, he. the term 
 alike , at least in the sense of equally , may 
 not be altogether correct in the following 
 inference, viz. ‘‘ that persons of every va- 
 riety of complexion are alike subject to this 
 disease, and that it is only necessary to 
 place them in circumstances favourable to 
 its developement, to have it fully formed.” 
 ( Lloyd on Scrofula , p. 7.) 
 
 1 believe the fact is now almost generally 
 admitted, that females are rather more sub- 
 ject than males, to scrofulous disease. (See 
 Alibert , Nosol. Vaturelle, p. 449.) 
 
 According to Mr. White, struma prevails 
 more extensively in temperate latitudes, 
 than in very hot or very cold climates. It 
 is also more frequent in some parts of Eu 
 rope than others ; and in this country it has 
 been found to be most general in the coun- 
 ties of Suffolk and Lancashire. At all pe- 
 riods, it seems to have been a very common 
 complaint in this island. From history, we 
 learn, that it was denominated the king’s 
 evil in the time of Edward the Confessor, 
 who is supposed to have been the first that 
 attempted to cure it by the royal touch. 
 From a register kept in the royal chapel, 
 we find that Charles the Second touched 
 92,107 persons, in a certain number of 
 years ; and this equally bigoted and useless 
 practice was not discontinued till a recent 
 period, when kings were found to be, as 
 well as their poorest subjects, totally desti- 
 tute of all supernatural pow'er. 
 
 Scrofula is not communicable from one 
 person to another ; neither can it be con- 
 veyed into the system by inoculation. The 
 opinion also that scrofulous nurses may in- 
 fect children, seems quite destitute of foun- 
 dation. (See White, p 56, 57.) 
 
 Pinel and Alibert have purposely kept 
 scrofulous and healthy children together in 
 the same ward, without any of the latter 
 receiving the complaint. Hebreard could 
 not communicate the disease to dogs by ino- 
 culation. And G.T. Korturn, whose valua- 
 ble work contains every thing know n about 
 scrofula at the period when it was written, 
 tried in vain to impart the distemper to a 
 child, by rubbing its neck every day with 
 the pus discharged from scrofulous ulcers. 
 Lepelletier, desirous of ascertaining the 
 correctness of such experiments, has of late 
 
 repeated them, he has made guinea pigs 
 swallow scrofulous matter, and he has in 
 jected it into the veins, and applied it to 
 wounds ; but in no instance was there even 
 a temporary appearance of the disease be 
 ing communicated. The same author also 
 mixed scrofulous with vaccine matter, and 
 inoculated with it ; yet he never found the 
 vaccine vesicle, thus produced, deviate in 
 the least from its regular course. Lastly, 
 Lepelletier inoculated himself with pus, dis- 
 charged trom scrofulous sores, as well as 
 with the serum, collected under the cuticle 
 of a strumous patient after the application 
 of a blister ; but he has remained free from 
 every scrofulous ailment. (See Did des 
 Sciences Med. T. 50, p. 294.) Our country- 
 man, Mr. Goodlad, inoculated himself seve- 
 ral times with the discharge from scrofulous 
 sores and abscesses, and the result was, that 
 the disease could not be thus transmitted. 
 (On the Diseases of the Vessels and Glands of 
 the Absorbent System, p. 113.) 
 
 The parts which ^re most frequently affect- 
 ed by scrofula, next to the lymphatic glands, 
 and perhaps the skin, are the spongy heads 
 of the bone*, and the joints. The form 
 which the disease assumes in the latter parts, 
 is particularly described iu the article Joints 
 The disorder of the spine, attended with a 
 paralytic affection of the lower extremities 
 is no doubt very frequently of scrofulous ori- 
 gin. (See Vertebree.) The spina bifida is a 
 congenital disease, which is found to occur 
 most frequently in children whose parents 
 are scrofulous. (Thomson's Lectures, p. 133.) 
 The abscess, which forms in the cellular sub- 
 stance, between the peritoneum and psoas 
 muscle, is often regarded as a strumous dis- 
 ease ; and when the contents of the abscess 
 are found to contain flakes of a curdy mat- 
 ter, somewhat resembling white, -of-egg, a 
 substance peculiar to scrofulous abscesses, 
 no one can doubt that the complaint is con- 
 nected with this constitutional affection. 
 (See Lumbar Abscess .) The chronic enlarge 
 meat ot the thyroid gland, is sometimes con- 
 sidered as scrofulous : but though patients, 
 with this affliction, very often have, at the 
 same time, other complaints, w hich are une- 
 quivocally strumous, though the enlargement 
 of the thyroid gland most frequently com 
 mences at an early period of life, like scro- 
 fulous diseases, and (hough, like them, it 
 is sometimes benefited by the carbonate of 
 soda, the opinion, I think, is rather on the de- 
 cline. (See Brontliocele.) Scrofula also 
 frequently makes its appearance in the form 
 of imperfect suppurations in various parts of 
 the body ; the contents of such abscesses 
 bping a curdy kind of matter, and the skin 
 covering them having an unhealty red ap- 
 pearance, and a thickened doughy feel. The 
 mesenteric glands are often found univer- 
 sally diseased and enlarged in scrofulous sub- 
 jects ; and as all nutriment has to pass 
 through these parts, before it can arrive in 
 the circulation, we cannot he surprised at 
 the many ili effects which must be produced 
 on the system, when such glands are thus 
 diseased. However, as l have already hint 
 
406 
 
 SCROFULA 
 
 erf, doubts are entertained by Dr. Henning, 
 whether enlarged mesenteric glands are de- 
 cidedly scrofulous ; but if his sentiment be 
 incorrect 1 fear he has been led to adopt it 
 by wis particular theory, which limits the ori- 
 gin of scrofula to the superficial absorbent 
 glands. Scrofula frequently makes its attack 
 on the testicle. (See Testicle , Diseases of.) 
 The female breast is also subject to scrofu- 
 lous tumours and abscesses 
 
 Dr. Thomson believes, that more or less 
 local inflammation occurs in every form and 
 stage of scrofulous diseases. He observes, 
 that the swellings are very often from the 
 first attended with a sensible increase of heat 
 and redness, and lh -t the pain, though sel- 
 dom acute, is always present in a greater or 
 less degree. Pressure on scrotulou- swell- 
 ings never fails to create pain ; and the tem- 
 perature of the skin covering them, is usu- 
 ally two or three degrees hi her than that of 
 the contiguous parts. ( Lectures , fyc. p. 
 131.) 
 
 Scrofulous inflammation (as Mr John 
 Burns observes.) is marked by a soft swell- 
 ing of the affected part, which very fre- 
 quently is one of the lymphatic glands. 
 The covering, or coat of tlje gland, be- 
 comes slightly thickened, and its substance 
 more porous and doughy. The swelling 
 increases, and the doughy feel changes by 
 degrees into that of elasticity, or fluctuation, 
 and a firm, circumscribed, hardened margin, 
 can be felt round the base of the tumour. 
 The skin is slightly red. If, at this time, 
 an incision, or puncture, be made, either no . 
 matter, or very little is evacuated, the lips 
 of the wound inflame and open, displaying 
 a sloughy-looking substance within ; and, 
 betwixt this and the skin, a probe can often 
 be introduced for some way all round If, 
 however, the disease should have advanced 
 further, then there is very little elasticity in 
 the tumour; it is quite soft, rather flaccid, 
 and fluctuates freely; the skin becomes of 
 a light purple colour, and small veins may 
 be seen ramifying on its surface. Some 
 time after these appearances, the skin be- 
 comes thinner at one particular part, and 
 here it is also generally rendered of a darker 
 colour. It afterward bursts, and discharges 
 a thin fluid, like w hey, mixed with a curdy 
 matter, or thick white floccuii. The red- 
 ness of the skin still continues; but the 
 aperture enlarges as the tumour subsides, 
 and thus a scrofulous ulcer is produced. 
 The margins of this kind of sore are gene- 
 rally smooth, obtuse, and overlap the ul- 
 cer ; they are of a purple colour, and 
 rather hard and tumid. The surface of 
 the sore is of a light red colour ; the gra- 
 nulations are flabby and indistinct, and 
 the aspect is of a peculiar kind, which, 
 says Mr. Burns, cannot be described. The 
 discharge is thin, slightly ropy, and copious, 
 with curdy flakes. The pain is inconsidera- 
 ble. When this ulcer has continued for 
 some time, it either begins slowly to cica- 
 trize, or as more frequently happens, the 
 discharge diminishes and becomes thicker. 
 An elevated scab is next formed, of a dirty 
 
 white, or yellowish colour. This continues 
 on the part a good while ; and when it falls 
 off', leaves the place covered with a smooth 
 purple cicatrix- Mr. Burns adds, that the 
 preceding description corresponds to the 
 mild scrofula, or the struma marisuela of 
 the old writers This gentleman next re- 
 marks, that occasionally, especially if a 
 bone be diseased below the ulcer, the sore 
 has a more liery appearance, the surface i 
 dark-coloured, the margins soft, elevated, 
 and inflamed, and sometimes retorted. The 
 discharge is watery, the pain very consider- 
 able, and the surrounding skin inflamed. 
 This has been called the struma maligna. 
 Such overacting scrofulous sores are most 
 frequently met with over the smaller joints, 
 particularly those of the toes. (Burns.) 
 Sometimes a scrofulous abscess, after it has 
 burst, forms a sinus ; the mouth of which 
 ulcerates, and assumes the specific scrofulous 
 appearance, w hile the track of the sinus 
 still continues to emit a discharge. Mr. 
 Burns also remarks, that scrofulous swellings 
 are often disposed to subside in w inter, and 
 recur on the approach of summer; but, he 
 adds, that this is not an invariable law'. 
 The glandular enlargements are very apt to 
 become smaller, in a short time, in one 
 place, wrfiile other glandular sw'ellings origi- 
 nate with equal suddenness, somewhere in 
 the vicinity of the former ones. Ulcers, 
 also, very often heal upon the appearance 
 of the disease in other parts. (See Disser- 
 tations on Inflammation , Vol 2, 1800.) 
 
 The glandular swellings, which occur in 
 syphilis, says Dr. Thomson, are of a more 
 acute character, than those w r hich proceed 
 from scrofula. They arise from the absorp- 
 tion of a specific poison ; and they do not, 
 like those of scrofula, admit of a spontane 
 ouscure. Chronic swellings of the lymphatic 
 absorbent glands occur also in carcinoma ; 
 but these manifest little or no disposition to 
 suppuration ; they succeed most frequently 
 to carcinomatous indurations, or ulcers ex- 
 isting in the neighbourhood of the glands 
 affected ; and they are accompanied in their 
 progress and grow th by a peculiar lancina- 
 ting pain. (See Thomson on Inflammation , 
 p. 135 ) 
 
 With regard to the proximate cause oi 
 scrofula, medical men may be said to re- 
 main, even at the present day* ’ n entire ig- 
 norance of it. After the ridiculous theory, 
 referring scrofula to certain humours in the 
 constitution, or chymical changes in the 
 blood, had been exploded, the opinion gra- 
 dually arose, that it was a disease of the 
 lymphatic system ; and indeed, that the ab- 
 sorbent glands are often visibly the seat of 
 its attack, when no changes are distinguish- 
 able in other textures, is a fact, that admits 
 of no dispute. I believe, at the same time, 
 that whoever supposes scrofula to be ex- 
 clusively confined to the lymphatic system, 
 must have a very imperfect conception ot 
 what is really the case. On the contrary, 
 
 I fully participate in the sentiments of Pro- 
 fessor I homson, already adduced upon tins • 
 point, and in the belief of another modem 
 
SCROFULA. 
 
 •writer, that strumous complaints t{ are not 
 to be considered as dependent on disease of 
 any particular system, as the lymphatic.” 
 {Lloyd, p. 10.) Such writers as have fixed 
 upon the absorbent vessels, as the particular 
 seat of scrofula, can throw no useful light 
 upon its origin, by following up the theory, 
 whether they imagine the cause to be ob- 
 struction of the vessels and glands ; or take 
 up the wild speculation of Cabani, that in 
 scrofula, the mouths of the lymphatics are 
 in a state of increased activity, while the 
 vessels themselves are in a state of atony ; 
 or the doctrine of Soemrnerring, that scro- 
 fula depends upon a passive relaxation and 
 dilatation of the absorbents ; or the hypo- 
 thesis of Girtanner, that these vessels are in 
 a state of increased irritability. The idea 
 of obstruction being the cause, has of late 
 years been much on the decline ; and that the 
 convolutions of lymphatic vessels, forming 
 the glands, are quite pervious, and may 
 readily be injected, even when diseased, is 
 a fact, first demonstrated by Soemrnerring, 
 which must weigh heavily against this opi- 
 nion. Of the exciting causes, very little is 
 also known. Mr. John Hunter remarks, 
 that “ in this country, the tendency to scro- 
 fula arises from the climate, which is in 
 many a predisposing cause, and only re- 
 quires some derangement to become an im- 
 mediate cause, and produce the whole dis- 
 ease.” (Treatise on the Venereal Disease, p. 
 20.) The disease is remarked to be most 
 common in females ; in cold, damp, marshy 
 countries, and in all places near high moun- 
 tains, where the temperature is subject to 
 great vicissitudes. “ Nous voyons presque 
 toujours, (says Alibert) que les tumeurs et 
 ies ulceres se rouvrent au printemps pourse 
 fermer ensuite vers la canicule.” (Nosol. 
 Naturelle, p. 449.) 
 
 In the work quoted the last but one, Mr. 
 Hunter takes notice of slight fevers, colds, 
 small-pox, and measles, exciting scrofulous 
 diseases. He observes, that in particular 
 countries, and in young people, there will 
 sometimes be a predisposition to scrofula : 
 and that, in such subjects, buboes will more 
 readily become scrofulous. ( P . 27.) In 
 short, it was one of Mr. Hunter’s opinions, 
 and probably a most correct one, that the 
 venereal disease is capable of calling into 
 action such susceptibilities as are remarkably 
 strong, and peculiar to certain constitutions 
 and countries ; and that, as scrofula is pre- 
 dominant in this country, some effects of 
 other diseases may partake of a scrofulous 
 nature. (P. 96.) Mr. Hunter, speaking of 
 venereal buboes, mentions his having long 
 suspected a mixed case, and add 3 , I am 
 now certain that such exists. I have seen 
 j/jases, where the venereal matter, like a 
 col.d, or fever, has only irritated the glands 
 1 to disease, producing in them scrofula, to 
 which they were predisposed. In such ca- 
 ses, the swellings commonly arise slowly, 
 give but little pain, and seem to be rather 
 hastened in their progress, if mercury is 
 given to destroy the venereal disposition, 
 ^ome come to suppuration, while under 
 
 407 
 
 this resolving course ; and others, which 
 probably had a venereal taint at first, be- 
 come so indolent, that mercury' has no ef- 
 fect upon them ; and in the end, they get 
 well of themselves, or by other means.” 
 (P. 269.) For such buboes, Mr. Hunter 
 used to recommend sea-bathing ; and, in 
 case of suppuration, poultices made of sea- 
 water. 
 
 In the words of a well-informed Profes- 
 sor, scrofula readily forms an alliance with 
 almost every morbid affection, occurring 
 either from external injury, or from internal 
 disease ; it modifies the appearance of other 
 diseases, and seems to convert them gradu- 
 ally into its own nature. Indeed, there are 
 few of the local inflammatory affections, 
 which occur in this country in which the 
 symptoms and effects of these affections, 
 and the operation of the food and remedies 
 employed for their cure are not morn or 
 less modified by the -degree of scrofulous 
 diathesis, which prevails in the constitution 
 of those who are affected by them. The 
 scrofulous diathesis, wherever it exists, usu- 
 ally gives more or less of a chronic charac- 
 ter to local inflammatory affections. (Thom- 
 son's Lectures, p. 131.) 
 
 It ba- been the fashion of late years to 
 ascribe the origin of a vast number of dis- 
 eases to disorder of the digestive organs, 
 little tro able being generally taken to con- 
 sider with any impartiality whether the de- 
 rangement of those organs may not be 
 rather the common effect, than the common 
 cause, of so many various diseases. Nume- 
 rous circumstances tend to perpetuate the 
 delusion, into who h y< ung practitioners are 
 falling upon this topic. They see various 
 diseases, attended with dyspepsia, flatulence, 
 loss of appetite, costiveness-, and a torpid 
 state of the bowels ; they observe that such 
 diseases and the latter con, plaints of the 
 alimentary canal, generally diminish toge- 
 ther ; that, when the functions of the sto- 
 mach and bowels are deranged, any other 
 diseases, which the patient may be labouring 
 under, either grow worse, or are retarded 
 in their amendment ; and, lastly, the treat- 
 ment, to which the theory leads, improves 
 the health, by rectifying the state of the 
 alimentary canal, and the sore, tumour, or 
 other complaint, in the end, with the addi- 
 tional aid of time, nature, and other favour- 
 able circumstances, gets well But, how- 
 ever simple, % safe, and benefioiaftbe prac- 
 tice may be, and plain as the facts are 
 which lead to it, there is no proof, that the 
 other disease was truly a consequence of 
 the disorder of the digestive organs. The 
 latter symptom i believe, is very frequently 
 an effect mistaken for a cause, and perhaps, 
 always so, in relation to scrofula. Besides, 
 if it were to be assumed, (as indeed it actu- 
 ally is) that, in scrofula “ there always is 
 more or less disorder of the digestive or- 
 gans, and primarily ;.f no other important 
 function, ” 1 do not see that we advance one 
 step hearer the truth ;. because as the same 
 cause is generally assigned, by gentlemen 
 attached to this theory, for a vast number 
 
40S 
 
 SCROFULA. 
 
 of other eases, we stilt remain in the dark, 
 as to the circumstances, which make so 
 many complaints of different kinds spring 
 from one and the same cause. These cir- 
 cumstances, though buried in silence, are 
 still the mystery — still the secret which is 
 desired ; and, if it be answered, that the ef- 
 fect will only happen in particular constitu- 
 tions, then we are brought back at once to 
 the point from which we lirst started, viz. 
 that scrofula is a disease depending upon 
 some unknown peculiarity of constitution, 
 congenital or acquired, and capable of be- 
 ing excited into action by various causes, as 
 climate, mode of living, &.c. However, 
 lest I may not have attached sufficient im- 
 portance to the doctrine of gastric disorder 
 being the cause of scrofula, I feel pleasure 
 in referring, for the arguments in its support, 
 to the writings of Mr. Abernethy, Dr Car- 
 michael, and Mr. Lloyd, whose sentiments 
 appear highly commendable, as far as they 
 tend to teach surgeons rather to place con- 
 fidence in means calculated to improve the 
 health in general, as the most likely mode 
 of benefiting the scrofulous patients, than 
 to encourage foolish dreams about new spe- 
 cifics for the distemper. Thus far, 1 can 
 follow these gentlemen safely ; but no far- 
 ther, except as a sceptic. However, per- 
 haps none of the believers in the effect of 
 disorder of the digestive organs mean to 
 say, that such disorder is any thing more 
 than one of the many exciting causes of 
 scrofula ; and with this qualification, then- 
 theory may, or may not, be correct. It is 
 the doctrine of Alibert, and indeed of near- 
 ly all writers : “ ce sont, les vices de la 
 puissance digestive, qui preparent de loin 
 ies scrophules. Rien n’ infiue davantage 
 sur leur developpcment que la mauvaise 
 qualite des alimens, &.c.” ( Nosol Naturelte, 
 p. 449.) “ Ajoutez a cet cause le sejour 
 
 dans les habitations malsaines;” But, every 
 explanation, even of exciting causes, re- 
 mains unsatisfactory, as long as we find 
 children living in the same air, under the 
 same roof, and feeding and sleeping toge- 
 ther, and clothed also exactly alike, yet, 
 only one or two of them become scrofulous, 
 while all the rest continue perfectly free 
 from the dise'ase. Here, then, we are again 
 compelled to return to predisposition, con- 
 stitution, diathesis, and a congenital tenden- 
 cy to the complaint, as a solution of the dif- 
 ficulty. In short, then, respecting the eti- 
 ology of scrofula, little is known, except 
 that certain constitutions probably have a 
 congenital disposition to the disease ; that 
 such disposition may probably be increased, 
 or diminished, by the operation of climate, 
 mode of life, age, tkc. ; and that irritations 
 of a thousand kin s nay excite, the disease 
 into action, when the system is predisposed 
 to it, by inexplicable causes. That otirnate 
 has great influence cannot be doubted, 
 when it is reflected, that the inhabitarWs of 
 certain countries, in which the temperature 
 is invariably warm, never suffer from scro- 
 fula. There ca n be no doubt that, with 
 
 age, the disposition to scrofula diminishes) 
 for, children much afflicted while young, 
 frequently get quite well when they ap- 
 proach the adult state ; and, if a person 
 has remained perfectly free from any mark 
 of a scrofulous constitution till the age of 
 twenty-five, he may be considered as near- 
 ly out of all danger of the disease. 
 
 TREATMENT OF SCROFULA. 
 
 “ For the cure of scrofula, (says the cele- 
 brated Cullen,) we have not yet learned any 
 practice that is certainly, or even generally 
 successful. The remedy which seemstobethe 
 most successful, and which our practitioners 
 especially trust to, or employ, is the use of 
 mineral waters But, (adds this eminent 
 physician,) in very many instances of the use 
 of these writers, l have not been well satisfied, 
 that they had shortened the duration of the 
 disease more than had often happened when 
 no such remedy had been employed. With 
 regard to the choice of the mineral waters 
 most fit for the purpose, (says Cullen,) 1 can- 
 not with any confidence give an opinion. 
 Almost all kinds of mineral waters, whether 
 chalybeate, sulphureous, or saline, have been 
 employed for the cure of scrofula, and seem- 
 ingly, with equal success and reputation ; a 
 circumstance, which leads me to think, that 
 if they are ever successful, it is the element- 
 ary water that is the chief part of the remedy. 
 Of late, sea-water has been especially re- 
 commended, and employed ; but, after nu- 
 merous trials, I cannot yet discover its 
 superior efficacy. ” ( First Lines of Physic, 
 
 Vol. 4.) On the subject of mineral waters, 
 Dr. Thomson very properly remarks, that 
 they are now usually employed as pur- 
 gative and tonic remedies, and not as speci- 
 fics. In employing them it is often difficult 
 to distinguish between the effects, which 
 they in reality produce, and those which are 
 to be attributed to the slow operation of 
 time, thfe season of the year, change of 
 situation, alteration in the mode of life, or 
 exercise in the open air. ( Lectures on Jn- 
 flammatiom, <^c. p. 195.) 
 
 In scrofulous diseases, Dr Fordyce had a 
 high opinion of bark ; and he endeavoured to 
 prove, that, in cases of tumefied glands, at- 
 tended with a feeble habit, and a weak cir- 
 culation, it is a most efficacious medicine, 
 and acts as a resolvent and discutient. He 
 also brings forward a case, in support of bark 
 being a means of cure for the ophthalmia 
 strumosa. (See Med. Obs. andlnq. Vol. \,p 
 184.) Dr Fothergill, in the same work, p. 
 303, writes in favour of the good effects 
 of bark in similar cases ; small doses of ca- 
 lomel bei »g sometimes given with it. 
 
 Dr. Cullen considered the efficacy of bark 
 in scrofula very dubious and trivial. ^ First 
 Lines } fyc. Vol. 4.) 
 
 According to Mr. Burns, bark has been 
 frequently found useful in the cure of scro- 
 fulous inflammation, but more often of ulce- 
 ration, than tumefaction of the glands. But, 
 says he, it does not appear to possess, bv any 
 means, that certain power of curing scrofulous 
 
SCROFULA. 
 
 i u'J 
 
 affections, which is attributed to it by Dr. 
 Fothergill and several other authors. He 
 observes, that we are not to suppose it will 
 infallibly cure scrofulous inflammation, or 
 ulceration of parts, which, even when af- 
 fected with simple inflammation, are very 
 difficult of cure. If it be difficult to cure a 
 simple inflammation, or ulceration, of a 
 rendon, cartilage, or bone, we must not be 
 disappointed if even a specific remedy for 
 scrofula, (were such ever discovered) should 
 prove ineffectual in procuring a speedy re- 
 storation to health. Mr. Burns contends, 
 that bark is often ineffectual, because impro- 
 perly administered. Given in small quan- 
 tities, once or twice a day, it may prove a 
 stomachic, and increase, like other tonic 
 bitters, the power of the stomach, or the 
 functions dependent on it ; but, in order to 
 obtain the benefits of the specific action of 
 bark, he maintains, that it should be given 
 in large quantities, for several weeks, with a 
 good diet, air, and proper exercise. — Disser- 
 tations on Inflammation, Vol. 2, p. 371.) Dr. 
 Thomson does not believe, that bark, or iron, 
 has any specific virtue in curing scrofula ; 
 but, he admits, that either of these medi- 
 cines may sometimes prove useful in proving 
 the tone of the digestive organs, when given 
 after, or occasionally along with, a course 
 of purgative mineral waters. {Lectures, p. 
 197.) 
 
 As far as I can judge, Mr. White has with 
 much reason recommended paying attention 
 to such circumstances as may have effect in 
 preventing the disease, viz. air, cleanliness, 
 exercise, and diet. He mentions cold-bath- 
 ing among the preventives of struma, and 
 speaks of sea-bathing as being the best. He 
 advises attention also to be paid to the 
 manner of clothing children, keeping them 
 more covered in winter than summer. Mr. 
 White thought, that allowing children to 
 sleep a great deal was prejudicial ; but this 
 seems to me only conjecture. 
 
 In noticing the treatment of the disease, 
 Mr. White states, that “ the general idea of 
 the struma is, that it is a disease of debility ; 
 and therefore, the great object is, to invigo- 
 rate the habit by every possible means ; the 
 chief of which are tonic medicines, and sea- 
 bathing. Some are of opinion, that in the 
 case of young patients, this should be con- 
 tinued, during the summer months, every 
 year, to the age of fourteen or sixteen. 
 Many recommend it, not only in the sum- 
 mer, but throughout the year; whilst others 
 are for administering alteratives, principally 
 the alkaline salts, with or without anti- 
 monials, and the different tonics, during the 
 winter ; a nd the sea-water and sea-bathing, or 
 cold-bathing, during the summer, for a conti- 
 nuance of two or three years from the com- 
 mencement of the disease ; with this general 
 observation, that they will outgrow the com- 
 plaint.” Mr. White adds, that the chief exter- 
 nal means are fomentations of sea- water, and 
 cataplasms, made with the same. With re- 
 spect to regimen, some recommend a milk 
 and vegetable diet ; others animal food and 
 fermented liquors. 
 
 Vol, II. 
 
 Mr. White maintains, that the preceding 
 plans of treatment are not, in general, effi- 
 cacious, though, in some instances, they may 
 prove useful. “ In early affections of the 
 lymphatic glands, (says this gentleman,) and 
 from the want of a pure air, and proper 
 exercise, where children are delicate and 
 irritable, a change of situation to the sea- 
 side, together with bathing, when they have 
 acquired some strength, must be exceeding- 
 ly proper ; and, in gross plethoric subjects, 
 who have diseased lymphatics, from impro- 
 per feeding, and want of necessary exercise, 
 a journey to the sea-coast may be very use- 
 ful, particularly if the salt-water is drank 
 often, and in a sufficient quantity to become 
 purgative. This, with the novelty of their 
 situation, which may naturally produce an 
 increase of exercise, might answer every 
 expectation ; but these are the kind of cases 
 that, with a very little attention, are easily 
 cured. ( White on the Struma, Edit. 3 ,p. 104.) 
 
 The conclusion, to which Mr. White’s re- 
 marks upon this part of the subject tend, is, 
 that sea-bathing only deserves praise, as a 
 preventive, and in the early stages of the 
 disease. He particularly condemns cold-bath- 
 ing, for poor, weakly, debilitated children, 
 whose thin visage, enlarged belly, and fre- 
 quent tickling cough, sufficiently indicate 
 diseased viscera ; such do not recover their 
 natural warmth, after cold-bathing, for hours, 
 and their subsequent headach, livid lips, and 
 pale countenance, are sufficient marks of its 
 impropriety. ( P . 107.) 
 
 Dr. Cullen entertained a very favourable 
 opinion of cold-bathing, since he affirms, 
 that he had seen scrofulous diseases more 
 benefited by it, than any other remedy. 
 ( First Lines of Physic , Vol. 4.) 
 
 “ Cold-bathing, especially cold sea-bath- 
 ing (says Mr. Russell) is a remedy universally 
 employed in scrofula, and I believe with 
 great advantage in many cases ; for it not 
 only appears to improve the patient’s gene- 
 ral health and strength, but likewise to pro- 
 mote the tumescence of enlarged glands, and 
 the resolution of indolent swellings in the 
 joints, even after they have attained a 
 considerable size, and have existed for a 
 great length of time. But, in order that 
 cold-bathing may be practised with safety 
 and advantage, the constitution must have 
 vigour to sustain the shock of immersion 
 without inconvenience. If the immersion be 
 succeeded by a general glow over the surface 
 of the body, and the patient feels cheerful, 
 and has a keen appetite, we may conclude 
 that the cold bath agrees with him ; but if 
 he shivers on coming out of the water, con- 
 tinues chill, and becomes drowsy, we may 
 be assured that the practice of cola-bathing 
 does no good, and had better be omitted. 
 
 li In estimating the comparative merit of 
 cold-bathing and warm-bathing, in the cure 
 of scrofulous complaints, my own experience, 
 together with the result of different conver- 
 sations on the subject with some of the most 
 judicious practitioners of my acquaintance, 
 would lead me to bestow much more com- 
 mendation on the effects of warm-bathing. 1 
 
 52 
 
410 
 
 SCROFULA. 
 
 should not even be inclined to circumscribe 
 the practice to cases of emaciation and de- 
 bility, since from observation, I am fully 
 satisfied with regard to the beneficial etfects 
 of the warm bath to patients of plethoric 
 constitutions, who were much affected with 
 those swelled scrofulous glands. Several of 
 instances occurred in young women, about 
 the prime of life, who were in all res- 
 pects healthy and vigorous, abating the 
 swellings of the glands, and those symptoms 
 of distress which were connected with ful- 
 ness of blood. 
 
 “ The sensation of the warm bath is ex- 
 ceedingly grateful to most patients, and the 
 practice is universally safe. It may be em- 
 ployed at all seasons of the year, and in all 
 weather, without danger or inconvenience ; 
 the risk of suffering from exposure to cold, 
 immediately after immersion in the warm 
 bath, having been much magnified by preju- 
 dice. There is not even any good reason to 
 believe in the existence of such a risk. The 
 precautions, however, which are employed 
 to avert it, are perfectly innocent ; and pro- 
 vided they do not impose any unnecessary 
 and incommoding restraints upon the prac- 
 tice, may be encouraged, so far as to relieve 
 the patient’s mind from uneasiness and 
 groundless apprehensions. 
 
 “ It requires many weeks, and sometimes 
 several months, to ascertain the full effects 
 of warfil-bathing in relieving scrofulous com- 
 plaints ; but, as the practice is not attended 
 with any inconvenience, nor followed by 
 any bad consequence, there can be no rea- 
 son to intermit the course, till the trial is 
 completely satisfactory ; and I am convin- 
 ced, that the practice of warm-bathing, in 
 cases of scrofula, will be more universally 
 adopted, after the knowledge of its benefi- 
 cial effects is more widely diffused.” (See 
 Russell's Treatise on Scrofula.) 
 
 Nothing can be more satisfactory (says 
 Professor Thomson,) than the evidence 
 which is on record, of the efficacy of the 
 muriate of soda, as it exists in sea-water. In 
 reading this, one only wonders how so effi- 
 cacious a remedy should ever have fallen into 
 neglect. (P. 196.) In a subsequent passage, 
 however, the same gentleman evinces only 
 a limited confidence in this means of relief. 
 u Local sea-bathing, both cold and warm, 
 has often appeared to be of use in procuring 
 the resolution of scrofulous swellings. The 
 temperature of the bath must always be 
 varied according to circumstances, according 
 to the season of the year, the strength and 
 habits of the patient, and the particular 
 effect, which the bath seems to produce. It 
 is at all times difficult to distinguish between 
 the effects immediately arising from the ap- 
 plication of salt water to the body, and those 
 which arise from the increased warmth of 
 temperature in the bathing seasons of the 
 year ; from the exercise which patients 
 going to sea-bathing generally take in the 
 open air ; from the change of situation and 
 amusements ; and, among the poorer classes, 
 from the more nourishing diet and exemption 
 from labour, in which they are usually per- 
 
 mitted to indulge, during their residing at 
 sea-bathing ^quarters. It is not improbable, 
 that those living on the sea-coast, who 
 become atfected with scrofula, would for 
 similar reasons, derive equal benefit by going 
 from the sea-coast to reside for a time 
 in the interior of the country.” (See Thom - 
 son’s Lectures, fyc. p. 203, 204.) A still 
 later writer declares his belief, that cold 
 sea-bathing has no specific power over the 
 disease. ( Lloyd on Scrofula, p. 43.) Yet 
 the plain surgeon, in search of practical 
 truths, will not care whether any plan has 
 a specific power or not over a complaint, if 
 that disorder is sometimes relieved by it. 
 And, that this is the fact is admitted by Mr. 
 Lloyd, when he says, u cold sea-bathing, 
 however, is certainly useful when judiciously 
 applied, &c. &c. - ’ (P.44.) 
 
 With regard to electricity, Mr. While 
 thinks it useful, when from length of time 
 the enlarged glands have acquired a degree 
 of hardness and insensibility. 
 
 Mr. White, after enjoining attention to 
 air, exercise, and diet, as promotive of a 
 recovery, as well as a preventive of the 
 disease, proceeds to explain his own prac- 
 tice. The internal cases, which properly 
 belong to the physician, we shall dismiss 
 from consideration. The first external 
 symptoms, such as swellings of the lips, 
 side of the face, and of glands under the 
 chin, and round the neck ; also other symp- 
 toms, usually considered as strumous, viz. 
 roughness of the skin, eruptions on the back 
 of the hand, and different parts of the body, 
 redness, and swelling of the eyelids, and 
 eyes ; are accompanied, according to Mr 
 While’s conceptions, with an inflammatory 
 diathesis, though seldom such a one as to 
 require bleeding. Calomel is the medicine, 
 which this gentleman recommends for the 
 removal of the foregoing complaints. It is 
 not to be given in such quantities, as to 
 render it a powerful evacuant, either by the 
 intestines, or any other way; but, in small 
 doses, at bedtime. Thus, says Mr. White, 
 “ it remains longer in the intestinal canal, 
 a greater quantity is taken into the habit, 
 and the patient is less susceptible of cold, 
 than when taken in the daytime. The first, 
 and, perhaps, the second dose may prove 
 purgative, which is, in general, a salutary 
 effect; but, afterward, the same quantity 
 will seldom do more, than is sufficient to 
 keep the body open ; and should it fail of 
 answering that purpose, I have usually re- 
 commended some gentle purgative, every 
 third or fourth morning, according to cir- 
 cumstances. If there should be a prevail- 
 ing acidity, a few grains of the sal sodec, 
 magnesia, or some testaceous powder, may 
 be added to the medicine. By this simple 
 method (continues Mr. White) most of the 
 symptoms before mentioned will, in a short 
 time, disappear; but if the tumours should 
 continue hard, and retain their figure, with- 
 out dividing into smaller ones, we may de 
 rive some benefit from external applications, 
 particularly the steam of warm water. I 
 have used a variety of medicinal herbs with 
 
SCROFULA. 
 
 41 j 
 
 success; but am inclined to believe, that 
 the advantage was principally derived from 
 the warm water, kc. At other times, I 
 have stimulated the part affected with elec- 
 tricity, insulating the patient, and drawing 
 sparks from the tumour, until a slight de- 
 gree of inflammation was excited. After 
 the application of the steam, or the use of 
 the electrical machine, I have sometimes 
 rubbed a little of the unguentum mercuriale 
 into the tumour, and neighbouring parts, or 
 applied the emplastrum saponaceum, or 
 mercuriale cum ammoniaco, over the swell- 
 ing, or a liniment with camphor, ol. oliva- 
 rum, and sp. terebinth.” Mr. White adds, 
 that in such cases, if the tumours should 
 suppurate, and burst, the parts will, in most 
 instances, heal without much trouble. For 
 eruptions on the head, he recommends ap- 
 plying the ung. saturn. album camphoratum, 
 or the cerat. alb. cum hydrarg. prrecip. alb. 
 For the roughness of the skin, which is ge- 
 nerally followed by eruptions, he also ad 
 vises the aqua-vegeto-mineralis, aqua calcis, 
 solutions of sal. tartar, or of the hydrarg. 
 raur. as outward applications. “ This last 
 (says Mr White) will seldom fail to check 
 the progress of the complaint, and dry the 
 sores ; and in the quantity of ten or twelve 
 grains, to a quart of warm water, the use of 
 it will not be productive of any pain. If 
 the eruption should ulcerate, and require 
 any unctuous application, to prevent the 
 adhesion of the linen, the ointment before- 
 mentioned may be applied ;. the best re- 
 medy will be warm-bathing, and when prac- 
 ticable, the sea- water claims a preference.” 
 (P. 114) The author next mentions his 
 having occasionally recommended the vi- 
 num antimoniale, tartarum emeticum, de- 
 coctum Lusitanicum, decoctum lignorum, 
 or sarsaparillae ; and that he sometimes 
 found advantage derived from artificial 
 drains. We need not detail this gentleman’s 
 mode of treating affections of the eyelids, 
 as notice is taken of scrofulous diseases of 
 the eye and eyelids, in the articles Ophthal- 
 my and Psorophlhalmy. 
 
 For the cure of indurations in the breast, 
 remaining after mammary abscesses, Mr. 
 White speaks very highly of the effects of 
 the steam of warm water; and cautions us 
 against indiscriminately employing calomel, 
 which will often affect the mother little, but 
 the child violently. Mr. White mentions 
 his employing a small tin machine, large 
 enough to hold a pint and a half, or two 
 pints of boiling water. From the top pro- 
 ceeded a narrow tube, ten, or twelve inches 
 long, through which the steam passed. 
 .Near its end, which was moveable and 
 curved, was a joint, for the greater conve- 
 nience of directing the steam to the diseased 
 parts. The water was easily kept boiling, 
 by means of a lamp under the machine. 
 Mr. White says, that the steam should be 
 employed twice, or thrice a day, and a piece 
 of flannel, or skin, afterward applied. The 
 body should also be kept open. In obsti- 
 nate, neglected cases, mercurial prepara- 
 tions, according to Mr. White, must likewise 
 
 be given, and, if they affect the child much, 
 sucking should be suspended. (P. 117.118.) 
 
 Mr. White speaks largely of the treatment 
 of cases, in which the mesenteric glands 
 are diseased ; but, this subject strictly be- 
 longs to the physician. When, in these in- 
 stances, the glands of the neck, or other 
 parts of the body, tend to a state of suppu- 
 ration, it is very slowly, the skin appearing 
 uniformly thin, and of a deep red colour, 
 and the tumour seeming flaccid. In such 
 cases, Mr. White recommends the use of the 
 lancet or caustic ; for if no artificial open 
 ing is made, it will be a long time before 
 the skin gives way; and when it does, the 
 aperture will not only be very small, but 
 often unfavourable in its situation. Mr. 
 White adds, that the contents will often be 
 more like mucus than pus, or like a mixture 
 of both ; and the discharge wili continue for 
 a great length of time, if no remedy is ap- 
 plied. This gentleman mentions his having 
 found a solution of gum myrrh® in aqua 
 calcis, used as a lotion, and the ceratum 
 saponaceum, or some similar outward ap- 
 plication, the best method of treating this 
 symptom. 
 
 We need not describe Mr. White’s prac- 
 tice in the treatment of scrofulous joints, as 
 the subject is fully considered in the article 
 Joints. It appears, however, that he con- 
 firms the efficacy of stimulating applications, 
 and pressure with bandages, w hen the fin- 
 gers and toes are affected with strumous 
 disease. (P. 143.) 
 
 Whoever compares the practice of Mr. 
 White in administering calomel, occasional 
 purgatives, the decoctum Lusitanicum sar- 
 saparilla, kc. with the blue-pill, sarsaparilla, 
 and laxative treatment of the present day, 
 will perceive no very material difference 
 between them, especially when the stress, 
 which Mr. White laid upon attention to 
 diet, clothing, &,c. is taken into the account. 
 Mr. Lloyd, who has detailed Mr. Abernethy's 
 practice in scrofula, lays it dow n as an ax- 
 iom, that “ the disease is only to be cured 
 by avoiding all sources of irritation, and re- 
 storing the natural and healthy functions of 
 the digestive organs.” ( P . 48.) By sources 
 of irritation, Mr. Lloyd means exciting 
 causes ; the advice is therefore excellent, as 
 far as it can be followed, or such causes 
 are decidedly known. The restoration of 
 the functions of the digestive organs is also 
 a tiling worth aiming at, and the only dif- 
 ference in my views from those of Mr. 
 Lloyd is, that as I look upon the disorder 
 of the digestive organs to be in general only 
 a complication, or effect of the scrofulous 
 disease, ulcer, abscess, diseased joint, kc. 
 and not the exciting cause, the treatment, 
 when beneficial, becoming so only on the 
 principle of improving the general health, 
 by the removal or diminution of one of the 
 most hurtful consequences of the original 
 disease. It is hardly necessary to inform 
 the profession, that the treatment, described 
 by Mr. Lloyd, in addition to the usual ad- 
 vice about diet, clothing, the avoidance of 
 damp and cold, and the utility of good air. 
 
SCROFULA. 
 
 4j2 
 
 exercise, &c. consists in giving the patient 
 five grains of the pil. hydrarg. every night, 
 and half a pint of decoct, sarsap. c. twice a 
 day. And, if at a certain hour of the day, 
 there has been no motion, recourse is had 
 to opening medicines. This plan is pur- 
 sued, till the bowels become regular; and 
 then, with the view of preventing a relapse 
 of the bowels into their former state, Mr. 
 Lloyd continues the exhibition of alterative 
 doses of mercury for an indefinite time, the 
 preference being given to the compound 
 calomel pill, in doses of five grains every 
 night. In children, the practice is exactly 
 like that of Mr. White, viz. small doses of 
 calomel with purgatives. When acidity 
 prevails in the stomach, small doses of soda 
 are commended ; and when the stomach is 
 weak, with loss of appetite, cinchona, steel, 
 and mineral acids. A full diet, with porter 
 and wine, is disapproved of, and, as already 
 stated, not much confidence is placed in 
 sea-bathing. ( Lloyd on Scrofula, p. 38.) 
 
 Crawford, Pinel, and others, have tried 
 the muriated barytes, as a remedy in scro- 
 fulous cases. (Med. Communications, Vol. 2. 
 JYosogr. Philo sophique, Pol. 2. p. 238.) It 
 has the recommendation of the celebrated 
 Hufeland. Mr. Burns says, that the muriate 
 of barytes has no effect on diseased glands ; 
 but that it is occasionally serviceable in 
 scrofulous ulceration, though he adds that 
 it deserves little dependence. ( Dissert . on 
 Inftam. Vol. 2, p. 372.) This gentleman re- 
 commends the following formula : fy. Terrae 
 Ponder. Salit. Chryst. gr. x. Aq. Font. Aq. 
 Cassiae, utriusque, ^iij. Syrup. Aurent. ^ij. 
 Half an ounce of this may be given at first 
 twice or three times a day, and gradually 
 increased to such quantity, as the stomach 
 can bear without sickness. At present few 7 
 practitioners have any faith in the antiscro- 
 fulous virtues of the muriate of barytes ; 
 and, as Dr. Thomson remarks, it has had a 
 much shorter-lived reputation than sea- 
 water, or its successor the muriate of lime. 
 (See Lectures on Inflammation, p\ 196.) 
 
 Fourcroy proposed trying the muriate of 
 lime ; but its efficacy is very doubtful, and 
 inconsiderable. “ Professor Thomson (says 
 Mr. Russell) has favoured me with the fol- 
 lowing observations on the effects of muri- 
 ate of lime. He employed muriate of lime 
 in various cases of scrofula, without having 
 derived benefit from it in a single instance. 
 Some patients, indeed, he admits, got well, 
 while under a course of muriate of lime ; 
 but then he had no reason to ascribe the 
 cure to the effect of the medicine. In other 
 cases, on the contrary, the muriate of lime 
 produced severe sickness and oppression at 
 the stomach, and the patients got daily 
 worse, till the muriate of lime w as intermit- 
 ted, and other medicines employed. The 
 relief experienced from the intermission of 
 the muriate of lime, left no doubt with re- 
 gard to the injurious effects which the use 
 of it had produced ; and from extensive ex- 
 perience and accurate observation on the 
 subject, Professor Thomson is satisfied, that 
 muriate of lime is attended w r ith prejudicial 
 
 effects in many cases ot scrofula. ' (See 
 Russell's Treatise on Scrofula.) Since the 
 publication of the last edition of this Dic- 
 tionary, I have seen the muriate of lime 
 given in several cases of scrofula ; hut with- 
 out any beneficial effect on the disease. 
 How long the muriate of lime will be per- 
 mitted to enjoy its present fame, Dr. Thom- 
 son will not venture to say ; but from what 
 he has seen of its use, he imagines its repu- 
 tation will only last, till some other new 
 remedy is proposed by those, who are still 
 sanguine in their hopes of discovering a 
 specific for scrofula. (Lectures, tyc. p. 196.) 
 Iron, given either alone, or joined with the 
 fixed, or volatile alkali, also deserves very 
 little confidence. Burnt sponge, millipedes, 
 and sulphate of jspotassa, have all been ex- 
 tensively tried ; the first of these is, in my 
 opinion, sometimes useful in diminishing 
 enlarged scrofulous glands ; and that it has 
 this effect on bronchoceles, is indisputable. 
 
 The Mariscbal de Rougeres employed a 
 remedy composed of iron filings, muriate of 
 ammonia, subcarbonate of potassa, &c. 
 (Journ. de Med. tom. 40, p. 219.) 
 
 Several narcotics have been tried, such 
 as opium, hyoscyamus, the solanum dulca- 
 mara, &.c. ; but, though their virtues against 
 scrofula have been sometimes cried up very 
 highly, the moderns have lost all faith in 
 them. The attention of the public to the 
 effects of cicuta, in cases of cancer and 
 scrofula, was first particularly excited by 
 the accounts of its virtues published by Ba- 
 ron Stork. 
 
 Fothergill also praises cicuta, and per- 
 haps it is as good an internal medicine as 
 can be tried ; but it is far from being gene- 
 rally efficacious. It is highly deserving of 
 recommendation for irritable scrofulous ul- 
 cers. There is now not the least doubt, 
 however, that the statements of Baron 
 Stork are greatly exaggerated. He consi- 
 dered cicuta indicated, whenever obstruc- 
 tions and tumours existed ; and, under this 
 treatment, he says that he found the swell- 
 ings melt aw^ay like ice. What is extraor- 
 dinary, every sort of tumour yielded to ci- 
 cuta. But, (as Dr. Thomson judiciously re- 
 marks) universal success is alw r ays one of 
 the most suspicious circumstances, which 
 can be mentioned in the history of the ef- 
 fects produced by any new' remedy. (Lec- 
 tures, fyc. p. 199.) Dr. Cullen frequently 
 employed hemlock, and sometimes found it 
 useful in discussing obstinate swellings ; 
 but, he says, it also frequently disappointed 
 him, and he never saw it dispose scrofulous 
 ulcers to heal. 
 
 With regard to mercury, we have already 
 noticed, that calomel was much employed 
 by Mr. White. Some have exhibited the 
 sublimate : others the acetite of mercury. 
 All these preparations have been at times 
 conjoined with cicuta, antimony, &io. Ca- 
 lomel is, perhaps, the best mercurial prepa- 
 ration in scrofulous cases; but mercury, 
 given internally with any view of exciting 
 a salivation, is justly deemed hurtful by all 
 the best practitioners. As ap alterative, and 
 
SCROFULA 
 
 413 
 
 an occasional purgative, it is undoubtedly a ly against antimony. As a modern writer 
 good medicine for strumous patients. Mer- observes, no great dependence seems ever 
 cury was much disapproved of by the to have been placed in the use of diaphoretic 
 celebrated Cullen, as a medicine for scrofu- medicines for the cure of scrofula. The 
 Ja. As a distinguished Professor observes : different preparations of antimony, indeed, 
 “From the great apparent similarity of the have been occasionally administered ; but 
 symptoms, progress, and seats of scrofula, chiefly in cutaneous affections, supposed to 
 to those of syphilis, and from the well- he of a scrofulous nature. Guaiacum, sar- 
 known effects of mercury in curing syphilis, saparilla, sassafras, and mezereon, singly, 
 it need not seem strange, that medical men and in combination, have all been supposed 
 should have been a little obstinate in their to be useful in the cure of scrofula ; but 
 attempts to obtain benefit from the use of they are now seldom given with this view, 
 mercury in scrofula. These expectations except in cases of scrofula combined with 
 are in general abandoned, and mercury is syphilis, or excited by the too free and 
 now given for the cure of scrofula as a injudicious use of mercury. ( Thomson's 
 purgative only. Along-continued, or ini- Lectures, fyc. p. 199.) 
 
 properly-administered course of this medi- With respect to Alibert’s practice, among 
 cine, has often been known to aggravate all the vegetable bitters, he prefers the hop, 
 the symptoms of scrofula; and, in many burdock, gentian, and bark. He seems to 
 instances, to excite these symptoms in have no confidence in specifics, like hem- 
 persons, in whom they did not previously lock, belladonna, aconitum, &.c. Neither 
 exist.” (See Thomson's Lectures on Infiam- does he express himself favourably of alka- 
 motion, p. 194, 195.) line medicines, the muriate of ammonia, 
 
 Mr. Burns thinks the nitrous acid has and the muriate of barytes. However, he 
 some effect in promoting the suppuration of praises the good effects of steel medicines 
 scrofulous glands and tumours, and disposing on enlarged glands. He affirms, that he has 
 ulcers to heal. He says, two or three drams seen most good derived from external means ; 
 may be given every day, for a fortnight ; aromatic fumigations in an apparatus prepa- 
 but if in this time it should do no good, its red by the cbymist Darcet. What he calls 
 employment ought to be discontinued. The scrofulous eruptions, he covers with a 
 mineral acids, diluted with water, (says Pro- strong solution of the nitrate of silver, 
 fessor Thomson,) are often used with views Swelled glands he rubs with the antimonial 
 similar to those, which guide us in the em- ointment. He commends also change of 
 ployment of tonic remedies. Their medici- air, and the avoidance of low damp places ; 
 nal powers appear to be nearly the same ; and speaks favourably of sea-bathing, sea 
 but the nitric acid has of late been preferred, voyages, sulphureous mineral waters, and 
 particularly in the scrofulous affections, particularly of the good effects derived from 
 which are sometimes induced by the action the solar warmth. (See Nosol. JVat. p. 449.) 
 of mercury. {Lectures, fyc. p. 197.) The local treatment, preferred by Mr. 
 
 The pills containing carbonate of soda, White, has been already described. I hav« 
 
 (see Pilulce,) and the different soda waters, only a few words to add concerning this 
 sold at the shops, have repute, for their good part of the subject. Dr. Cullen states, that, 
 effects on scrofulous constitutions and dis- in his practice, he had very little success in 
 eases. A spirituous infusion ot gentian, into discussing incipient scrofulous tumours bv 
 six ounces of which are put thirty-six grains, topical applications ; and that a solution of 
 of the carbonate of soda, or the same quan- the saccharum saturni, though sometimes 
 tity of the carbonate of ammonia, is a useful, more frequently failed. Dr. Cullen 
 medicine highly spoken of by Richerand found the aqua ammonias acet. not more 
 for scrofulous cases. (Nosogr. Lhir. T. 1, p. successful. “ Fomentations of every kind 
 184, Ed. 4.) (says he) have been frequently found to do 
 
 Potassa in large doses, with mercurial harm ; and poultices seem only to hurry on 
 frictions, is the practice lately extolled by a suppuration. 1 am doubtful if this last 
 Mr. Farr; but it appears to me, that mer- be ever practised with advantage; forscro- 
 cury and potassa had been repeatedly tried, fulous tumours sometimes spontaneously 
 long before this author delivered his senti- disappear, but never after any degree of 
 ments to the public ; and that such practice inflammation has come upon them; and 
 cannot be entitled to be called a method therefore, poultices, which commonly in- 
 for the eradication of the disease. (See duce inflammation, prevent that discussion 
 Farr on Scrofula, 8vo. Lond. 1820.) of tumours, which might otherwise have 
 
 According to Mr. Burns, eight or ten happened.” Even when scrofulous tumours 
 drops of hydrosulphuret of ammonia, given have advanced towards suppuration, Dr. 
 thrice a day, are useful in irritable strumous Cullen thought, that hastening the sponta- 
 ulcers. The breathing of oxygen gas has neous opening, or making one with a lancet, % 
 oeen proposed; but of this plan l know was hurtful. 
 
 nothing from experience, and, as it now With respect to ulcers, Dr. Cullen re 
 makes less noise in the world than formerly, marks, that escharotic preparations, of either 
 1 conclude that either its usefulness has been mercury, or copper, have been sometimes 
 exaggerated, or the difficulty of the practice useful in bringing on a proper suppuration, 
 is too great to allow of its extensive adop- and thereby disposing the ulcers to heal ; 
 lion. but they have seldom succeeded, and more 
 
 The sentiments of Dr. Cullen are decided- commonly, they have caused the ulcer * 
 
4B /vSCBOFULA. 
 
 spread more. The escharotic, from which 
 Cullen saw most benefit result, is burnt 
 alum, mixed with some mild ointment. 
 But this celebrated writer gives the prefer- 
 ence to keeping the sores continually co- 
 vered with linen wet with cold water in the 
 daytime, and some ointment or plaster at 
 night. Cullen says, that he usually found 
 sea-water too irritating, and no mineral 
 water better than common water. ( First 
 Lines of the Pract. of Physic , Vol. 4.) 
 
 Formerly, the extirpation of scrofulous 
 tumours was advised ; but this method is 
 now considered as being, for the most part, 
 injudicious and unnecessary, with the ex- 
 ception of diseased joints, and a few other 
 parts, which frequently require being am- 
 putated for the sake of saving the patient’s 
 fife. Certainly, no particular danger (gene- 
 rally speaking) would attend cutting out 
 scrofulous glands and tumours; the objec- 
 tions to the plan are founded on the pain of 
 the operation ; on the number of such 
 glands frequently diseased ; on their often 
 subsiding, either spontaneously, or by surgi- 
 cal treatment ; on the operation doing no 
 good to the general affection of the system, 
 &x. When, however, a scrofulous testicle, 
 breast, or joint, seriously impairs the health, 
 and endangers life, the very existence of 
 the patient demands the immediate removal 
 of the diseased part. W iseman relates, that 
 he was in the habit of cutting out scrofulous 
 glands and tumours with great success ; but 
 for reasons already alleged, most of the 
 moderns think such operations in general at 
 least unnecessary. 
 
 Caustics have been employed for the 
 same purpose, instead of the knife ; but, as 
 they effect the object in view less certainly, 
 more painfully and tediously, and cause 
 extensive ulcers, they are disused by all th£ 
 best surgeons of the present day. 
 
 Some authors have advised making issues, 
 and keeping them open, in order to prevent 
 any ill effects from healing scrofulous ulcers. 
 Issues are certainly quite unnecessary for 
 any purpose of this kind ; but they are emi- 
 nently useful as a part of the local treatment 
 of scrofulous joints and abscesses, as we 
 have more particularly explained in the ar- 
 ticles Joints , Lumbar Abscess , and Vertebra. 
 
 Mr. Burns notices, that issues have hither- 
 to been chiefly used in diseases of the bones 
 and joints ; hut he adds, that it is reasonable 
 to suppose that they ought likewise to be use- 
 ful in the cure of enlargements of the glands, 
 and other scrofulous tumours, if inserted in 
 the immediate vicinity of the part. The 
 only objection to their use is the scar which 
 they leave, and which, in certain situations, 
 one would particularly wish to avoid. When 
 the tumour is thickly covered with the in- 
 teguments, the issue may be made directly 
 over it, and kept open with the savine oint- 
 ment. In other cases, a small pea issue or 
 seton may be inserted by the side of the 
 tumour. This method would be objection- 
 able, for scrofulous glands in the neck, in 
 consequence of the scar; but it might be 
 employed when the mamma is disused. 
 
 (Dissertations on Inflammation, Vol. 2.) The 
 late Mr. Crowther used to apply blisters to 
 scrofulous swellings, and maintain a dis- 
 charge from the part. And a more modern 
 practice is that of producingjj irritation of 
 the integuments, covering tumours and 
 abscesses, by means of the tartar emetic 
 ointment. ( Alibert Nosol. Naturtlle, p. 449 ; 
 Goodlad on Diseases of the Absorbents, p. 162, 
 fyc.) 
 
 Preparations of lead; cloths dipped in 
 cold water, sea-water, or weak vegetable 
 acids ; aether ; sea-salt mixed with bile ; 
 the linimentum camphorae ; a mixture of 
 aether and the linimentum opiatum ; and 
 hemlock poultices ; form a long list of 
 applications, which have been employed for 
 scrofulous tumours. 
 
 According to Mr. Burns, moderate pres- 
 sure, by means of adhesive plaster, con- 
 joined with the application of cold water, 
 is one of the best plans of treating mild 
 scrofulous ulcers, when their situation ad- 
 mits of it. In other cases, he recommends 
 applying a powder, five parts of which 
 consist of cerussa acetata, and the sixth of 
 burnt alum. A piece of dry lint is next to 
 be applied, and a compress, with such pres- 
 sure as can be used. Benefit occasionally 
 results from dipping the compress in cold 
 water. 
 
 The ceratum e lapid. calamin. is a good 
 common dressing, when it is wished not to 
 interfere much with the progress of the 
 ulcer. The ung. hydrarg. nitrat. rub. and 
 the ung. hydrarg. nitrat. are the best stimu- 
 lating ointments. Poultices of bread and 
 sea-water; solutions of alum, cuprum vi- 
 triolatum, and the hydrarg. mur. ; solutions 
 of the nitrates of copper, bismuth, and 
 silver ; the recent leaves of the wood-sorrel 
 bruised ; lint dipped in lemon-juice, or 
 vinegar and water , are among the applica- 
 tions to common scrofulous ulcers. 
 
 For irritable sores, diluted hydrosulphuret 
 of ammonia ; ointments containing opium ; 
 carrot and hemlock poultices ; a solution ot 
 opium; and carbonic acid gas; are com- 
 monly recommended.' 
 
 The following are Mr. Russell’s sentiments 
 respecting the treatment of scrofulous ul* 
 cers : “ Scrofulous complaints in general do 
 not agree well with stimulant applications, 
 la the treatment of scrofulous ulcers, under 
 the ordinary circumstances ot complaint, 
 the simplest and mildest dressings answer 
 best. When the patients are using a course 
 of sea-bathing, it is usual to wash the sores 
 with sea-water, over and above the momen- 
 tary application of the sea-water during the 
 immersion of the whole body. Cold spring- 
 water is likewise a favourite application with 
 many practitioners; and from much obser- 
 vation, it appears that the operation of cold 
 is well suited to counteract the slate of in- 
 flammation, which accompanies scrofulous 
 sores. Preparations of lead are, upon the 
 whole, very convenient and useful applica- 
 cations, provided the solutions be used in a 
 state of sufficient dilution to prevent irrita- 
 tion Liquid applications are applied by 
 
means of wet linen, which is renewed 
 whenever it dries, so that the suiface of the 
 sore may be kept constantly moist when un- 
 der this course of management. Upon the 
 same principle, simple ointment and Gou- 
 lard’s cerate, furnish the best dressing in 
 ordinary cases. 
 
 “ Scrofulous congestions, of a solid na- 
 ture, in the more external parts of the body, 
 are little adapted to the practice of local 
 bleeding, unless they be attended with 
 symptoms of inflammation ; but as some 
 degree of inflammation is, in general, pre- 
 sent during the incipient stage, it may be 
 prudent to employ local bleeding in modera- 
 tion at the commencement of the attack, 
 although there may be no indication to per- 
 sist in the practice, after the complaint has 
 advanced farther in its progress. If, how- 
 ever, these congestions are more of an indo- 
 lent nature, unaccompanied with heat or 
 pain, there is no benefit to be expected from 
 the local detraction of blood ; warm fo- 
 mentations, together with the use of stimu- 
 lants, and a repetition of blisters, are the 
 most serviceable class of remedies : such 
 cases, too, are the best adapted to the use 
 of friction as a discutient. Friction, indeed, 
 has long been employed for this purpose ; 
 but, of late years, it has been introduced to 
 an extent, and with an effect, far beyond 
 the experience of all former practice. As 
 yet it has been circumscribed to the prac- 
 tice of a very few individuals, with whom 
 it is said to have performed very great cures ; 
 and if, upon the test of more extensive ex- 
 perience, it is found to answer its present 
 high character, I shall consider the use of 
 repeated frictions to be one of the most valu- 
 able improvements which has been introdu- 
 ced into practice in modern times. The 
 safety and simplicity of the practice recom- 
 mend it very strongly to favour, though I 
 am afraid they are the very circumstances 
 which retard its adoption by the public in 
 general. I only regret that I do not feel 
 myself entitled to give a decided opinion 
 upon the subject from my ow n experience, 
 though I have known some instances of 
 successful cures; but the reports of success 
 are so numerous and so well supported, that 
 I am inclined to think very favourably of the 
 practice. 
 
 u There is no substance interposed be- 
 tween the surface of the swelling and the 
 hand of the person who administers the fric- 
 tion, excepting a little flour, to prevent the 
 abrasion of the skin. The friction is applied 
 regularly two or three hours every day, with 
 great celerity, the hand being made to move 
 to and fro one hundred and twenty times in 
 a minute, and the course may require to be 
 continued, without interruption, for some 
 months.’' (See Russell on Scrofula.) 
 
 I shall not enlarge upon this endless sub- 
 ject, which still stands in need of elucida- 
 tion as much as any disease that can be in- 
 stanced- The scrofulous affections of the 
 joints are explained in Joints ; Bronchocele ; 
 Lumbar Abscess ; Spina bifida; and Vertebras, 
 
 are other articles, containing matter con- 
 nected with the preceding observations. 
 
 The reader may consult Wiseman's Chi- 
 rurgical Treatises. J. Brown , Adenochoira- 
 dtlogia , or an anatomick-chirurgical Treatise 
 of Glandules and Strumals , or King's Evil 
 Swellings , together with, the Royal Gift of 
 Healing , or Cure thereof by contact , or impo- 
 sition of hands, fyc. 8i>o. Lend. 1684. Wm , 
 
 Clowes , A right f rule full and approved Trea- 
 tise, for the Artificial Cure of the Struma, or 
 Evil, cured by Kings and Queens of England , 
 4 to. Lond. 1602. Cullen's First Lines of the 
 Practice of Physic , Vol. 4. Feme on the 
 King's Evil. Cfieyne on the King's Evil. R. 
 Russell, A Dissertation on the Use of Sea- 
 Waler in the Diseases of the Glands, fyc. 8 vo. 
 Lond. 1769. B. Bell's Surgery, Vol. 5. B. 
 Bell on Ulcers. Tumor Strumosus Colli 
 post vomitorium imminutus. 8 vo. ( Weikard , 
 Collect. 88.) Kirkland's Medical Surgery, Vol. 
 2. J. Morley, Essay on the Nature and Cure 
 of Scrofulous Disorders, <^c. New Ed. 8 vo. 
 Lond. 1778. While on the Struma, Edit. 2, 
 1 794. P . Lalonette, Traite des Scrophules, fyc, 
 Paris, 1780. A. G. Kort urn's Comment, dc 
 Vilio Scrophuloso , in 2 Vol. 4 to. Lemgovice, 
 1789. R. Hamilton, Observations on Scrofu- 
 lous Affection, fyc. 8 vo. Lond. 1791. London 
 Med. Obs and Inq. Vol. 1. 5. T. Soemmer 
 
 ring, De Morbis Vasorum Absorbentium Cor- 
 poris Humani. 8 vo. Traj. 1795. C. W. 
 Hufeland, Ueber die Natur, fyc. dtr Skrophel - 
 krankheit. Svo. Jena. 1795. Dissertations on 
 Inflammation, by John Burns , Vol. 2. M. 
 Underwood, Treatise upon Ulcers, <^c. with. 
 Hints on a Successful Method of treating some 
 Scrofulous Tumours, fyc Svo. Lond. 1785, 
 Crowther's Obs. on the Disease of the Joints , 
 commonly called White Swelling ; with re- 
 marks on Caries , Necrosis, and Scrofulous 
 Abscesses, fyc. Edit. 2, 1808. A Treatise on, 
 Scrofula , by James Russell, Svo. Edinburgh , 
 1808. Lectures on Inflammation by John 
 Thomson, M. D. p. 130, etseq. p 155— 191* 
 <fy>c. Edinb. 1813. This work contains as good 
 and as rational an account of the subject as 
 any book which I have examined. Wm. Good- 
 lad, A Practical Essay on the Diseases of the 
 Vessels and Glands of the Absorbent System, 
 Svo. Lond. 1814. G. Henning, A Critical 
 Inquiry into the Pathology of Scrofula, Svo, 
 Lond. 1815. Richerand, Nosographie Chirj 
 T. 1, p. 165, etseq. Edit. 4. Delpech , Precis 
 EUmentaire des Maladies, Chir. T. 3 ,p. 617, 
 fyc. Paris, 1816. Lassus, Pathologie Chir. 
 T 2, p. 383, fyc. Edit. 1809. Callisen , Sys - 
 tem a Chirurgice Hodiernce, Vol. 2, p. 113 t 
 Hafnits, 1800. Boyer , Trait6 des Maladies 
 Chir. T 2, p. 414, fyc. Paris, 1814. Ciu 
 Brown, Treatise on Scrofulous Diseases, show- 
 ing the good Effects of factitious Airs. Svo. 
 Lond. 1798. Baume, Traite sur It vice Scro - 
 phuleux, Svo. Paris, 1808. J. Brandish , Obs. 
 on the use of caustic alkali in Scrofula, and 
 other chronic Diseases, Svo. Lond. 1811. C\ 
 Armstrong, Essay on Scrofula, in which an 
 account of the Effects of the Carbonas Ammo- 
 nias is submitted to the Profession , Svo. Lond. 
 1812. W . Lambe, Inquiry into the origin , ijc. 
 of Constitutional Disorders , particularly Scro - 
 
SCROTUM. 
 
 416. 
 
 fala, Consumption^ Cancer, tyc.8vo. Lond. 1805. 
 Also Additional Reports on the Effects of a 
 peculiar Regimen in cases of Cancer, Scrofu- 
 la, fyc. 8 vo. Lond. 1815. R. Carmichael , 
 Essay on the Nature and Cure of Scrofula, 
 and a demonstration of its origin from Disor- 
 der of Digestive Organs, 8 vo. Dubl. J. Rab- 
 ben, De Prcecipuis Causis Mali Scrofulosi 
 cjusque Remediis efficacissimis commentatio, 
 12 mo. Goth. 1817. Alibert, Nosologie Natu- 
 relle, p. 448, fol. Paris, 1820. Did. des 
 Sciences Med. T. 50, art. Scrofules, 8vo. Paris, 
 1820. E. A. Lloyd on the Nature and Treat- 
 ment of Scrofula, 8vo Lond. 1821. 
 
 SCROTOCE'LE. (from Scrotum, and ma», 
 a tumour.) A rupture or hernia in the 
 scrotum. 
 
 SCROTUM, CANCER OF. ( Chimney- 
 
 sweeper's Cancer. The soot-wart .) Mr. Pott 
 gives the following account of this peculiar 
 disorder. 
 
 u It is a disease which always makes its 
 first attack on, and its first appearance in, 
 the inferior part of the scrotum ; where it 
 produces a superficial, painful, ragged, ill- 
 looking sore, with hard and rising edges ; 
 the trade call it the soot-wart. I never saw 
 it under the age of puberty, which is, I sup- 
 pose, one reason why it is generally taken, 
 both by patient and surgeon, for venereal, 
 and being treated with mercurials, is thereby 
 soon and much exasperated : in no great 
 length of time, it pervades the skin, dartos, 
 and membranes of the scrotum, and seizes 
 the testicle, which it enlarges, hardens, and 
 renders truly and thoroughly distempered ; 
 from whence it makes its way up the sper- 
 matic process into the abdomen, most fre- 
 quently indurating and spoiling the inguinal 
 glands : when arrived within the abdomen, 
 it affects some of the viscera, and then very 
 soon becomes painfully destructive. 
 
 “ Other people, besides chimney-sweep- 
 ers, (says Pott) have cancers of the same 
 part ; and so have others, besides lead- 
 workers, the Poictou colic, and the conse- 
 quent paralysis : but it is nevertheless a dis- 
 ease to which they are peculiarly liable ; 
 and so are chimney-sweepers to the cancer 
 of the scrotum and testicles. 
 
 “ If there be any chance of putting a stop 
 to, or preventing this mischief, it must be 
 by the immediate removal of the part affect- 
 ed ; I mean that part of the scrotum where 
 the sore is ; for if it be suffered to remain 
 until the virus has seized the testicle, it is 
 generally too late even for castration. I 
 have many times made the experiment; but 
 though the sores, after such operation, have, 
 in some instances, healed kindly, and the 
 patients have gone from the hospital seem- 
 ingly well, yet, in the space of a few months, 
 it has generally happened that they have 
 returned, either with the same disease in the 
 other testicle, or in the glands of the groin, 
 or with such wan complexions, such pale 
 leaden countenances, such a total loss of 
 strength, and such frequent and acute inter- 
 nal pains, as have sufficiently proved a dis- 
 eased state of some of the viscera, and which 
 have soon been followed by a painful death. 
 
 “ If extirpation ever bids fair for the cure 
 of a cancer, it seems to be in this case ; but 
 then the operation should be immediate; 
 and before the habit is tainted. The disease, 
 in these people, seems to derive its origin 
 from a lodgment of soot in the rugae of the 
 scrotum, and at first not to be a disease of 
 the habit. In other cases of a cancerous 
 nature, in which the habit is too frequently 
 concerned, we have not often so fair a pros- 
 pect of success by the removal of the dis- 
 tempered part ; and are obliged to be con- 
 tent with means which I wish I could say 
 were truly palliative ; but here the subjects 
 are young, in general in good health, at 
 least at first ; the disease brought on them 
 by their occupation, and in all probability 
 local ; which last circumstance may, I think, 
 be fairly presumed from its always seizing 
 the same part : all this makes it (at first) a 
 very different case from a cancer which 
 appears in an elderly man, whose fluids are 
 become acrimonious from time, as well as 
 other causes ; or from the same kind of 
 complaint in women who have ceased to 
 menstruate. But be all this as it may, the 
 scrotum is no vital organ, nor can the loss 
 of a part of it ever be attended with any, 
 the smallest degree of inconvenience ; and 
 if life can be preserved by the removal of 
 all that portion that is distempered, it will 
 be a very good and easy composition ; for 
 when the disease has got head, it is rapid in 
 its progress, painful in all its attacks, and 
 most certainly destructive in its event.” 
 (PoH s Works, Vol. 3. See also W. Simmons’s 
 Cases and Obs. on Lithotomy, to which are 
 added Obs. on Chimney-sweeper's Cancer, 8vo 
 Manchester, 1808.) 
 
 SCROTUM. Sarcomatous Thickening and. 
 Enlargement of. The investigations of Ba- 
 ron Larrey lead him to believe, that cases of 
 enormous growth of the scrotum are ende- 
 mial in warm countries, or, at least, that 
 they are seldom observed in cold climates 
 since most of the examples which have been 
 seen in Europe came from Asia and Africa. 
 The scrotal tumour of Delacroix, formerly 
 minister of externa! relations, says Larrey, 
 is perhaps the only well-authenticated in- 
 stance of the origin of such a disease in our 
 own climate ; and it was also much smaller 
 than the instances related in the Epheme- 
 rides German, for the year 1692, in the 
 surgical writings of Dionis, in the 9th vol. 
 of the Bibliotheque de M6decine, and those 
 which Larrey was surprised to meet with 
 in Egypt. The smallest of these latter, after 
 they had attained their full size, weighed 
 more than 25 kilograms (between 60 and 
 70 pounds.) 
 
 Several cases of this curious disease are 
 recorded by other writers, particularly by 
 Dr. Cheston, Dr. Titley, and the celebrated 
 Sandifort. I lately saw in Mr. AbernethyV. 
 museum, a considerable fleshy substance, 
 which was a portion of diseased scrotum. 
 
 In the cases which Larrey had an oppor- 
 tunity of seeing in Egypt, the fleshy mass, 
 into which the scrotum was converted, was 
 broad below, and suspended from the pube* 
 
A ETON 417 
 
 by a sort ot peuicle. “ Externally, (as Lar- 
 >'ey observes) the tumour presents rugosi- 
 ties of different sizes, separated by particu- 
 lar lines or sinuses, to which the mucous 
 cryptae and roots of the hairs correspond. 
 Upon a large portion of its surface, espe- 
 cially when the case is of long standing, yel- 
 lowish scaly crusts are always seen, the 
 detachment of which constantly leaves so 
 many small herpetic ulcers, which emit an 
 ichorous discharge. The tumour is indolent 
 and hard at some points, but softish at 
 others. It may be handled, and pressed in 
 different directions, without the least pain. 
 The patient is only incommoded by its 
 weight, and the impediment which it causes 
 to his walking well. Hence he is necessi- 
 tated to employ a suspensory bandage. In 
 consequence of the situation of the urethra, 
 the urine dribbles over the swelling; but 
 without causing any excoriation.” Inmost 
 of the cases seen by Larrey, the spermatic 
 chord and testicles were in the natural state, 
 situated at the sides and at the root of the 
 swelling. The spermatic vessels, however, 
 are somewhat enlarged and elongated. All 
 the patients were likewise more or less 
 affected with elephantiasis. 
 
 Baron Larrey attempts to explain the cau- 
 ses of the complaint in Egypt, but, as I think, 
 without any degree of success. As the af- 
 fection is seldom seen in old countries, cli- 
 mate has certainly a chief effect. Employ- 
 ments w hich keep persons a good deal in a 
 sitting posture ; the loose breeches w r orn by 
 the Egyptians, and the consequently pendu- 
 lous state of the scrotum ; diseases of the 
 humours, and particularly itchy pustules on 
 the part, an ordinary consequence of syphi- 
 lis in that country ; bad regimen ; abuse of 
 venery ; and the immoderate use of the 
 warm bath ; are merely conjectures, which 
 will not bear the test of reasoning. 
 
 The enormous magnitude, w'hich this sort 
 of disease may attain, is almost incredible. 
 The case, recorded in the Ephemerides Ger- 
 man, weighed about a hundred kilograms, 
 or more than two hundred weight. Another, 
 described by Larrey, w r as calculated to 
 weigh about one hundred and twenty 
 pounds, and this surgeon likewise saw in 
 Egypt ten or twelve more instances, nearly 
 as large, and all of the same character 
 
 A very curious example, in which a simi- 
 lar disease affected the labia pudendi in a 
 surprising degree, is also detailed by Larrey. 
 The woman was a native of Cairo. 
 
 In the early stage of the disorder, we may 
 try preparations of antimony combined with 
 sudorifics ; drinks acidulated with sulphuric 
 acid, lotions containing the same acid, or 
 the oxymuriate of mercury, the oxyde of 
 copper, or the muriate of ammonia. These 
 means are to be assisted by a gradual, uni- 
 form compression of the whole tumour. In 
 one case, incisions and the application of 
 caustic, proved of no service, and Larrey 
 very properly condemns such experiments. 
 
 When the disease resists every plan tried 
 for its relief, and its increase renders the pa- 
 tient’s life irksome, and vyretched, the extir- 
 ■Vqt. If 53 
 
 pation ot the turnout with a knife becomes 
 proper. In this proceeding, the chief skill 
 consists in doing no injury to the spermatic 
 chords and testicles, which are generally 
 perfectly sound. As the substance of the 
 swelling is uQt furnished with large vessels, 
 the hemorrhage need not be feared. Care 
 must also be taken not to injure the corpora 
 cavernosa penis, and the urethra. After the 
 operation, the skin is to be brought over the 
 exposed testicles, as much as possible, with 
 adhesive plaster and a bandage. 
 
 M. Delonn.es successfully removed the dis- 
 eased mass in the celebrated case of the 
 French minister Delacroix, and Larrey per- 
 formed the same operation with success, 
 when he w as in Egypt. Dr. Titley, of the 
 island of St. Christopher, also cut away 
 such a tumour, which weighed seventy 
 pounds, and the patient, who was a negro, 
 and also affected with elephantiasis, speedily 
 recovered. (See Medico- Chir urgical Trans. 
 Vol. 6, p. 73, fyc.) 
 
 It is probable, that some of the cases, 
 which occur in w arm countries, are analo- 
 gous to the elephantiasis ; but I do not be- 
 lieve, that the scaly incrustations, which are 
 represented by Larrey as occurring in the 
 cases which he saw in Egypt, have been 
 always noticed in the instances which have 
 taken place in colder countries. Nor, in- 
 deed, did they take place in the instance re- 
 corded by Dr. Titley, the surface of the tu- 
 mour having been quite smooth. (/Larrey, 
 Mimoires de Chirurgie Militaire , T. 2. p. 110, 
 et seq. Richerand JVosograpliie Chir. T.4,p. 
 314, fy-c. Edit. 4. Jllso Delonnes ’ Memoir. 
 Dr. Cheston's Case , &c. Med. Chir. Trans. 
 Vol. 6.) 
 
 SEARCHING. The operation of intro- 
 ducing a metallic instrument, through the 
 urethra into the bladder, for the purpose of 
 ascertaining whether the patient has a stone 
 or not. See Sounding. 
 
 SETON. ( Setaceum , from seta , a bristle, 
 because horse- hairs were formerly used for 
 keeping open the w r ound.) A kind of issue. 
 It is usually made by means of a particular 
 needle, which is of various breadths, from 
 half an inch to a full inch. The needle is 
 commonly a little curved, but, if straight, it 
 would be better calculated for the purpose. 
 From the point to its broadest part, it is dou- 
 ble edged, and behind it has a transverse 
 eye, through which a skein of thread or silk, 
 of exactly the same breadth as the needle, 
 is placed. 
 
 A fold of skin is to be pinched up at the 
 part where the seton is designed to be 
 made, and the needle is to be pushed through 
 it, together with the skein of thread, which 
 is first dipped in sweet oil. The instrument 
 is not to be introduced too low into the base 
 of the fold, nor too high, near its edge. In 
 the first case, the muscles, and parts which 
 ought to be avoided, might be wounded ; in 
 the second, the interspace between the tw r o 
 wounds would be very narrow, and the se- 
 ton soon make its way through it. 
 
 When no seton needle is at hand, the fold 
 of the skin may be punctured with a lancet. 
 
oKrlli 
 
 418 
 
 and the skein ot thread intuniuced by means 
 of an eye-probe. A seton may be applied 
 almost to any part of the surface of the body, 
 ■ when circumstances require it; but one of 
 its openings should always be made lower 
 than the other that the matter may readily 
 flow out. The skein of thread is to remain 
 untouched for a few days after the operation, 
 until the suppuration loosens it. Afterward 
 the part of the thread nearest the wound is 
 to be smeared with oil, white cerate, or any 
 digestive ointment, and drawn under the 
 fleshy interspace between the two wounds, 
 and what was there before is to be cut off. 
 The seton is to be drawn in this manner 
 once or twice a day, according as the quan- 
 tity of matter may require. A new skein of 
 silk, or thread, is to be attached to the pre 
 ceding one, as often as necessary. Care is 
 to be taken to keep the thread on the outside 
 of the wound well covered, and free from 
 the discharge, which would make it stiff 
 and hard, and apt to occasion pain and 
 bleeding on being drawn into the wound. 
 If the discharge should be deficient in quan- 
 tity, powdered cantharides may be mixed 
 with the digestive ointment. 
 
 SH5 -GLES. See Herpes. 
 
 SIGHT, DEFECT OF. There are per- 
 sons, who, from their infancy, are incapable 
 of distinguishing one colour from another. 
 A man who was affected with this infirmity, 
 could not distinguish green at all. Green 
 and red appeared to him' the same. Yellow 
 and blue be could discern very well. With 
 regard to dark-red and dark-blue, he fre- 
 quently made mistakes. In other respects, 
 his vision was sound and acute. The father 
 of this patient was afflicted with the same 
 infirmity. The mother and one sister were 
 free from it Another sister and two of her 
 children had it. The patient himself had two 
 children, who did not labour under the dis- 
 order. (See . Phil. Trans. Vol. 68, Part 2.) 
 Another subject, whose eyes were in other 
 respects healthy, and whose eyesight was 
 sharp, could not distinguish a dark-green 
 from a dark-red. 
 
 An interesting example of this curious 
 imperfection of vision has lately been pub- 
 lished by Dr. Nicholl, of Cowbridge. (See 
 Med. Chir. Trans. Vol. 7, p. 477, fyc.) The 
 subject was a healthy boy, eleven years of 
 age, whose eyes were gray, with a yellow 
 tinge surrounding the pupil. He never call- 
 ed any colour green. Dark bottled green 
 he called brown. He could distinguish light 
 yellow ; but darker yellows and light browns- 
 he confounded with red. Dark brown he 
 mistook for black. Pale green be called 
 light red; common green he termed red. 
 Light red and pink he called light blue. 
 Red be called by its proper name. He could 
 distinguish blue, both dark and light. On 
 the mother’s side the boy had some rela- 
 tions whose sight was similarly affected. 
 An interesting chapter on what is termed 
 coloured vision, may be read in a modern 
 valuable work, to which I have great plea- 
 sure in “referring. (See War dr op's Esmys on 
 
 the Morbid Anatomy of the Human Eye, Vol. 
 2, p. 196, 8 vo. Load. 1818.) 
 
 Sometimes objects appear to the eye to 
 be of a different colour from what they real- 
 ly are, not because there is any thing wrong 
 in the eye itself, but in consequence of tbe 
 unclear and coloured light by which the ob 
 ject is illuminated. Thus, for instance, a. 
 bad tallow candle, which emits a yellow 
 flame, makes every thing appear yellow 
 When brandy is burning, all objects appear 
 blue. In short, it is only by the light of the 
 sun, that any object can be seen in its clear 
 natural hue. In certain cases, the infirmity 
 is owing to the transparent parts and hu- 
 mours of the eye, which do not happen to 
 be of a proper colour. Thus, persons hav- 
 ing the jaundice in a high degree, see all 
 things yellow, because the transparent parts 
 of the eye are of that colour. When, in 
 consequence of external violence applied to 
 the eye, blood is effused, and the aqueous 
 humour rendered red by this fluid, all ob- 
 jects seem to the patient to be red; and 
 white, when the aqueous humour has been 
 made of this colour by the couching of a 
 milky cataract. Sometimes this defect in 
 vision is ascribable to the duration of an 
 impression. When one has surveyed a 
 bright-coloured object a long while, as, for 
 example, a bright red or yellow wall, on 
 which the sun shines, fi^at colour will often 
 remain a good while before tbe eyes, al- 
 though one may not be looking any more 
 at au object of this hue. There are some 
 eyes, which seem much disposed to retain 
 the impression of objects, which are not 
 very bright coloured ; but, such a disposition 
 always betrays great weakness and irrita- 
 bility of those organs. The most frequent 
 cause of this defect in vision, is an irrita- 
 tion operating upon the optic nerves, so as 
 to produce the irritability in them, which 
 alone makes objects appear of one colour. 
 The seat of such irritation, according to 
 Richter, is also most commonly in the abdo- 
 minal viscera, and the case demands evacu- 
 ations, tonics, and anodyne medicines. But, 
 the disorder may also originate from other 
 causes. The operation of bright-coloured 
 or shining objects upon the eye, sometimes 
 has, for a certain time afterward, the effect 
 of making objects of diverse colours appear 
 to be moving before the eyes. In extreme 
 terror, or fright, things may also seem to 
 have a different colour from their real one. 
 The same often happens in fevers attended 
 with delirium. A sudden exposure of the' 
 head to cold, at a period when it was per- 
 spiring much, in one instance, caused many 
 coloured appearances before tbe eyes ; but, 
 the disorder subsided in a couple of days. 
 (Richter, A nfangsgr. der Wundarsn. B. 8, p 
 523.) 
 
 Also a healthy eye sees a distant object 
 with uncertainty, and error, in a room, or 
 space, the extent, length, and breadth, of 
 which are unknown, when the size of the 
 object itself is unascertained, and when 
 there are few or no other objects interve- 
 ning at a smaller distance between the cyo 
 
SOL 
 
 ski 
 
 and the thing looked at. The mope nume- 
 rous the objects are between the eye and 
 the principal thing looked at, the more dis- 
 tant it is made to appear; the fewer they 
 are, the nearer it seems to be. In a coun- 
 try covered with snow, and upon the sea, 
 very distant objects appear to be close. 
 The smaller an object is to the eye, in rela- 
 tion to its known magnitude, the further off’ 
 it seems. The errors which the eye makes, 
 in regard to the distance of objects, also 
 tend to deceive. But, there are certain ca- 
 ses, in which the eye is almost entirely inca- 
 pable of judging of the distance of objects. 
 The first is, when the object, of which we 
 wish to ascertain the distance, is looked at 
 with only one eye. Hence all one-eyed 
 persons, and persons affected with strabis- 
 mus, are unable to judge well of the real 
 distance of objects. However, they are 
 only so for a certain time ; and. by practice 
 they gradually acquire the faculty. Even 
 when two eyes are employed, it requires 
 some exercise, in order to enable them to 
 judge of the right distance of objects. Per- 
 sons, born blind, but who have their sight 
 restored in both eyes by the operation for 
 the cataract, are a long while incapable of 
 judging of distances, and only obtain this 
 power very gradually. Lastly, this infirmity 
 is sometimes owing to an irritation affecting 
 the optic nerves, whereby their sensibility 
 is so altered, that distant objects make the 
 impression upon them of near ones. In this 
 circumstance, all objects appear to the pa- 
 tient closer than they really are. This is the 
 only case, which admits of being treated as 
 a disease. The irritation, producing the 
 disorder, is mostly seated in the abdominal 
 viscera, and requires evacuations and such 
 medicines as invigorate the nerves. A sup- 
 pression of the perspiration is alleged to be 
 sometimes a cause ( Richter , Anfangsgr. 
 
 der IVundarzn. B. 3, p. 525.) 
 
 A sound eye likewise does not always 
 judge with accuracy and uniformity of the 
 magnitude of objects. This may arise from 
 three causes. In order to judge rightly of 
 the size of any thing, its precise distance 
 must be known ; for the more remote it is, 
 the smaller will it seem to the eye. Hence, 
 any conjecture respecting the magnitude 
 of an object is constantly erroneous, unless 
 the distance be ascertained. Size is invari- 
 ably something relative. A single large ob- 
 ject, surrounded by many small ones, always 
 appears to be larger than it really is, et vice 
 ' versa. An object whose magnitude is known, 
 seems smaller than it actually is, when one 
 has been a little previously looking at ano- 
 ther that is still larger. Lastly, the refrac- 
 tion of the rays of light in the eye, by which 
 operation an object is made to appear large 
 or small, is not always accomplished in the 
 same degree, as the eye is not at all times 
 equally full and distended with its humours. 
 Hence, at one time, the same object will 
 appear to the same eye, and at the same 
 distance larger ; at another time smaller. 
 Sometimes, however, the eye judges so er- 
 roneously of the magnitude of objects, that 
 
 419 
 
 there is reason for regarding the case as an 
 infirmity, or disease. It is for the most part 
 owing to a defective sensibility in the nerves, 
 caused by some species of irritation acting 
 upon the eye, and generally seated in the 
 gastric organs. A man, to whom every 
 thing seemed one half smaller and nearer 
 than it really was, was cured by means of 
 an emetic, bark, an issue and valerian, 
 ( Ltulin , obs.fascic.) 
 
 Sometimes to the eye, under circum- 
 stances of disease, straight lines appear ser- 
 pentine ; perpendicular objects, sloping, 
 things standing upright, to be inverted, &,c. 
 All these cases are set down by Richter as 
 depending upon a wrong sensibility of the 
 nerves, occasioned by the effect of some 
 irritation. The irritation, he says, may be 
 of many kinds ; but experience proves that 
 it is mostly seated in the gastric organs. 
 These defects of sight may generally be 
 cured by first exhibiting emetics and purga- 
 tives, and afterward having recourse to re- 
 medies for strengthening the nerves, bark, 
 oleum animale, valerian, issues, &c. One 
 mark of a very weak and irritable eye, is 
 when objects, after being looked at a good 
 while, and presenting a right appearance, 
 begin to move, swim about, mix together, 
 and, at length, become quite indistinguish- 
 able. This principally happens when the 
 objects regarded are small and strongly 
 illuminated. Here such remedies, both 
 general and topical, as have the effect of 
 invigorating the nerves, are indicated. How- 
 ever, sometimes, the infirmity is partly ow= 
 ingtothe operation of some species of irri- 
 tation, which will require removal, ere the 
 tonic medicines and applications can avail. 
 Indeed, in particular cases, the dispersion 
 of such irritation is alone sufficient to ac 
 complishtbe cure. 
 
 Sometimes, all objects appear to the eye, 
 as if they were in a more or less dense mist . 
 This defect in vision is always owing either 
 to some slight opacity of one of the humours 
 of the eye, or to excessive debility of the 
 optic nerves. (See Richter, Anfangsgr. da 
 IVundarzn. B. 3, p. 521, fyc.) 
 
 SINUS. — A long, .narrow, hollow track, 
 leading from some abscess, diseased bone, 
 &c. 
 
 SOLUTIG ARGENTI NITRATI. — Ar 
 genii nitrati 3j. Aq. distillat. ^ss M. This is 
 a very good application for sores, which are 
 frequently met with round the roots of the 
 nails, both of the fingers and toes. It is 
 also useful in herpetic affections, noli-me 
 tangere, and several kinds of ulcers. The 
 proportion of the argentum nitratum may 
 be lessened, or increased, as occasion re- 
 quires. A strong solution of this substance 
 is a good application for destroying warts, 
 to which it must be applied, by means of a 
 hair-pencil. When used for sores, it is best 
 to dip little bits of soft lint in it, lay them 
 on the part affected, and cover them with a 
 common pledget. 
 
 SOLUTIO FERRI SULPHATIS.— ft, 
 Ferri sulphatis ad albidinem calcinati 3j 
 Aq. Distillat, ?viij. Misce. Has been re*- 
 
commended as an application tor sores on 
 the nipple, and other ulcers. 
 
 SOUND. An instrument, which surgeons 
 introduce through the urethra into the blad- 
 der, in order to discover, whether there is a 
 stone in this viscus, or not. The sound is 
 usually made of very highly polished steel, 
 that it may be well calculated for Conveying 
 to the surgeon’s fingers the sensation of any 
 thing, against which its end may strike. It 
 is also generally rather less curved, than a 
 catheter, so that its extremity may be more 
 easily inclined to the lower part ot the blad- 
 der, where the stone is most frequently si- 
 tuated. 
 
 SOUNDING. The operation of introdu- 
 cing the foregoing instrument. 
 
 Sounds are generally introduced much in 
 the same way as catheters, either with the 
 concavity towards the abdomen, or the con- 
 vexity, in which last method, it is necessary, 
 as soon as the beak of the sound has arrived 
 in the perineum, to bring the handle of the 
 instrument downward by a semicircular 
 movement to the right, while the other end 
 is kept as much fixed as possible. This is 
 what the French term the coup, or tour de 
 maitre •, a plan, that is often followed at 
 the present day, though, except in very cor- 
 pulent subjects, it has no particular recom- 
 mendation. 
 
 When a patient is to be sounded, he is 
 visually put into a posture very similar to 
 that adopted in the lateral operation for the 
 stone, with the exception that he is not 
 bound in this position, as there is sometimes 
 an advantage in making the patient stand 
 up, in order that the stone may come into 
 contact with the end of the sound. The 
 instrument having been introduced, its ex- 
 tremity is to be turned, and moved in every 
 direction, when if there be a calculus, its 
 presence will usually he indicated by the 
 collision against the beak of the sound. 
 
 Stones have sometimes been found in the 
 bladder after death, although they could 
 never be discovered with a sound while the 
 patient was alive, suffering all the symptoms 
 of the complaint. The celebrated French 
 surgeon La Peyronie jvas thus circumstan- 
 ced : he was so fully convinced of there 
 being a stone in his bladder, notwithstand- 
 ing neither he, nor any of his friends could 
 feel it with a sound, that on bis death-bed, 
 lie gave directions for ascertaining the fact. 
 Hence, when the usual symptoms of a 
 stone in the bladder continue, patients 
 should be searched several times, before a 
 positive opinion is delivered respecting the 
 nature of the disease. When during the 
 operation of sounding, all the urine has 
 escaped from the biadder, the inner surface 
 of this viscus comes into contact with U-e 
 end of the sound, and such a sensation may 
 be communicated to the surgeon’s fingers as 
 leads him to suspect that a fungus, or some 
 other hardish extraneous substance is con- 
 tained in the bladder. In such cases, pa- 
 tients have actually been cut for the stone, 
 when no foreign body whatever was pre- 
 sent. (See. Mtdecine Operatoire , 
 
 Tom. 3, p. 127, 128, Edit. 2. See UiiiG - 
 lomy.) 
 
 SPECULUM. An instrument intended 
 for facilitating the examination of parts, 
 and also the performance of operations on 
 them : thus we have specula ani, specula 
 oculi, auris, &.c. 
 
 SPHACELUS. (from to de- 
 
 stroy.) Surgeons imply, by this word, com- 
 plete mortification, which is mostly prece- 
 ded by a stage of the disorder, termed gan- 
 grene. See Mortification. 
 
 SPICA. (from rv&yyc, an ear of corn.) 
 A name, given to a kind of bandage, in 
 consequence of its turns being thought to 
 resemble the rows of an ear of corn. 
 
 In order to apply the spica bandage to 
 the shoulder, the margins of the axillae must 
 first be protected from the effects of the 
 pressure, by means of soft compresses, and 
 the end of a common roller is then to be 
 placed under the opposite arm-pit. After 
 conveying the bandage backward, obliquely 
 over the scapulai, the surgeon is to bring it 
 forward over the injured shoulder. The 
 roller is next to descend under the arm-pit, 
 then be carried upward again, and made to 
 cross on the deltoid muscle. It is now to be 
 carried obliquely over the front of the chest, 
 and under the opposite arm-pit, where the 
 end of it is to be pinned, or stitched. The 
 bandage is next to pass across the back, 
 over the part of the roller previously applied 
 in this situation, and is to be conveyed 
 round the head of the os brachii, so as to 
 form a turn, or doloire, with the first circle 
 of the roller. Three or four doloires, or 
 turns, each of which covers about one-third 
 of the preceding one, are to be made, and 
 then the upper part of the arm is to be once 
 surrounded with a plain circle of the ban 
 dage. This last circular application leaves 
 between it and the cross previously made, a 
 triangular equilateral space, technically 
 named by writers geranis. The roller is now 
 be to carried upward in a spiral manner ; its 
 head is to be brought to the opposite arm- 
 pit, and the application of the whole con- 
 cludes with a few turns round the body. 
 The bandage is to be fastened with pins at. 
 the place where it commenced. 
 
 In applying the spica inguinis , the end of 
 the roller is to be placed on the spine of 
 the os ilium, ot the affected side. The ban- 
 dage is then to be carried obliquely over 
 the groin, and under the perinaeum. Then 
 it is to pass over the back of the thigh, and 
 next forward, so as to cross the part pre- 
 viously applied on the front of the groin 
 The application is continued by carrying 
 the roller over the pubes, over the opposite 
 os ilium, and next round the body above 
 the buttocks. The bandage thus returns to 
 the place where it began. Its application 
 is completed by making a few turns, like 
 the. preceding ones, and lastly, a few circles 
 round the body, 
 
 SPINA BIFIDA, (i. e. the Cloven Spine.) 
 Hydro-Rachitis. A disease, attended with 
 an incomplete state of some of the verte- 
 brae, and a fluid swelling, which is most coni' 
 
SPINA BIFIDA. 
 
 421 
 
 in only situated over the lower lumbar verte- 
 tebrai, sometimes over the dorsal and cervi- 
 cal ones, and in some instances, over the os 
 sacrum. The same name has also been given 
 to an analogous tumour, which sometimes 
 occurs on children’s heads, attended with an 
 imperfect, ossification of a part of the crani- 
 um. The malformation of the spine seems 
 to consist in a deficiency of one or more of 
 the spinous processes. Sometimes, indeed, 
 these processes are wanting the whole 
 length of the vertebral column, as was 
 seen in the case reported by Fieliz. (See 
 Richter’s Ckir. Bibl. B 9, p. 185.) 
 
 The Arabians, who first treated of this 
 disease, erroneously imputed the deficiency 
 of one, or more of the spinous processes 
 to the tumour, while it is well known, that 
 the incomplete state of the affected verte- 
 brae is a congenital malformation, and that 
 the swelling is only an effect. In fact, the 
 tumour generally becomes larger and larger, 
 the longer it continues. The spina bifida 
 may be regarded as an affliction only met 
 with in children : few. very few, live to 
 the adult age with this incurable affection. 
 Warner, however, has related a case, in 
 which the patient lived till he was twenty. 
 (Cases in Surgery, p. 134. Edit. 4.) 
 
 As I have remarked, the swelling is most 
 frequently situated towards the lower part 
 of the spinal canal, particularly at the place 
 where the lumbar vertebrae join the sacrum. 
 The fluid which it contains resembles serum, 
 being somewhat more liquid than the white 
 of egg, and, like the latter, frequently coa- 
 gulable. It is in general limpid and colour- 
 less; but, occasionally, it is turbid, and 
 tinged w ith blood. On pressing the tumour, 
 a fluctuation is very perceptible, and a pre- 
 ternatural space may also be felt existing 
 between some of the spinous processes. The 
 fluid is contained in a kind of cyst, which is 
 composed of the continuation of the dura 
 mater, investing the spinal canal, and is 
 usually closely adherent to the integuments. 
 
 According to Morgagni, spina bifida is 
 mostly attended with hydrocephalus, and 
 the enlargement of the head has been known 
 to undergo a considerable diminution after 
 the tumour of the spine had casually burst. 
 (De Sed. et Cans. Morb. Epist. 7. art. 9. 
 Epkern. Cur. Nat. Dtcad. 3, Art. 1, Decad. 
 2. Art. 2.) The fluid which was lodged in 
 the lateral ventricles, and third ventricle, 
 passed into the fourth, through the aqua- 
 ductus Sylvii, ruptured the calamus scripto- 
 rius, and thus passed into the spinal canal. 
 
 Spinas bifida? usually occur on the lower 
 part of the spine ; but they occasionally 
 take place on the cervical vertebrae, where 
 the tumours have the same characteristic 
 marks as those near the sacrum. Many 
 facts recorded by lii/ysch, in his Anatomical 
 Observations, confirm the preceding account. 
 
 The present affliction is one of a most 
 incurable nature ; for, w’ith the exception of 
 one case mentioned by Morgagni, (De Sed. 
 et Cause Morb. Epist. 12, art. 9,) a second, 
 recorded by Keilmann, { Prodrom . Act. Havn. 
 p. 136.) and two or three others more re- 
 cently published by Sir Astt^v Cooper, there 
 
 is not, I believe, in all the records of medi 
 cine, or surgery, any case, which either got 
 w'ell of itself, or was benefited by any mode 
 of treatment. Opening the tumour, either 
 with caustics, or cutting instruments, has 
 generally only tended to hasten the fatal 
 event of the disease. Death soon follows 
 an operation of this kind, and sometimes in- 
 stantly. Tulpius observes on this subject; 
 quam calarnitateyn si quidem reformides , chi 
 7-urge, cave sis iw provide aperias quod tarn, 
 facile occidit hominem. (Observ. Med.) 
 
 Bui whether the tumour he opened or notj 
 still the disease is one of the most fatal, to 
 which children are exposed. When afflicted 
 with it, they very seldom live till three 
 years of age : but after lingering several 
 months from their birth, suddenly die. It 
 has been said, that children with spina bifida 
 always have their legs in a paralytic state 
 However, this is not true ; for the largest 
 spina? bifidia? I ever saw, was under my 
 friend .Vir. Maul, of Southampton, and was 
 unattended with any weakness of the legs 
 Indeed the child was, to all appearance, as 
 stout, healthy, and full of play as possible. The 
 fatal event, how ever, took place after a time, 
 as usual ; and if my memory does not fail 
 me, Mr. Maul noticed, that a little before 
 death, a remarkable subsidence of, the 
 swelling occurred, though it never burst ex 
 ternally It is a fact notwithstanding, that 
 many infants with spina bifida, have paralytic 
 lei:s, and can neither retain their feces nor 
 urine. 
 
 If we draw our inferences from the cases 
 and remarks offered by almost every writer 
 on spina bifida, we must regard all attempts 
 to cure the disorder, by making any kind of 
 opening, as exceedingly perilous, if not posi- 
 tively fatal. It is to be observed at the same 
 time, that some practitioners have not alto- 
 gether abandoned the idea of devising a 
 mode of accomplishing a cure, at least in a 
 few instances. Mr. B. Bell says, that if the 
 tumour proceeded from disease of the spinal 
 marrow or its membranes, no means of cure 
 will probably ever be discovered. But if the 
 the deficiency in the spinous processes of the 
 vertebra?, with which the disease is always 
 accompanied, is not an effect of the com- 
 plaint as was commonly imagined, and if the 
 collection of fluid takes place from the want 
 of resistance in the dura mater, in conse- 
 quence of the imperfection of the bones, 
 Mr. B. Bf-ll questions, whether it would not 
 be proper io tie the base of the tumom with 
 a ligature, not merely with a view of remo- 
 ving the swelling, but in order to resist the 
 propulsion of the cyst further outward. Mr 
 Beil acknowledges, that the event of this 
 practice must be considered as very dubious; 
 but expresses his w ish to devise any plan , 
 that would afford even the least chance of 
 success, in a case which must terminate in 
 an unfavourable manner. Mr. Bell men- 
 tioned the design of putting the method to a 
 trial, on the first opportunity, and after the 
 detachment of the swelling on the outside of 
 the ligature, he intended to keep a soft' com- 
 press on the part with a proper bandage. I 
 do not know whether this gentleman ever 
 
SPINA BIFIDA 
 
 422 
 
 pat file above scheme in practice ; but sup- 
 pose not. It is properly objected to by the 
 author of the article Spina Bifida, in the En- 
 cyclopedic Mithodiquc , Parl.Chir. because the 
 disease is often attended w ith other mischief 
 of the spinal marrow and brain, and the base 
 of the swelling is almost always too large to 
 admit of being tied at all, or not without 
 hazard of dangerous consequences. 
 
 Richter has proposed the trial of two caus- 
 tic issues at a little distance from the swell- 
 ing ; but I am not acquainted with any facts 
 in favour of this practice. 
 
 Mr. Abernethy first suggested the trial of 
 a gentle degree of pressure on the tumour 
 from its commencement, with the view of 
 producing absorption of the fluid, and pre- 
 venting the distention of the unsupported 
 dura mater. Were the fluid to continue to 
 increase, notwithstanding such pressure, Mr. 
 Abernethy thinks, that as death would be 
 inevitable on the tumour bursting, it might 
 be vindicable to let out the fluid by means 
 of a puncture made with a finely-cutting in- 
 strument. The wound is to be immediately 
 afterward closed with sticking plaster, and 
 if possible, healed. Another accumulation 
 is then to be prevented if practicable, with 
 bandages and topical applications. Mr. 
 Abernethy actually made the experiment of 
 a puncture in one hopeless instance, in 
 which, indeed, the swelling had previously 
 just begun to burst. The puncture was re- 
 peated every lourth day for six weeks, during 
 which time the child’s health continued un- 
 affected. The wounds were regularly heal- 
 ed ; but the plaster having been rubbed off 
 one of the punctures, the part ulcerated, the 
 opening could not be healed, t tie discharge, 
 from having been of an aqueous quality, be- 
 came purulent, and death ensued. This 
 case was also unfavourable for the trial of 
 the method, as the integuments covering the 
 tumour w ere diseased, and had no disposi- 
 tion to contract. 
 
 . The annexed case, published by Sir Ast- 
 ley Cooper, will serve to show the benefit 
 which may be derived from pressure. 
 
 “ James Applebee, Baldwin-Street, Old- 
 Street, was born on the 19ih of May, 1807, 
 and his mother, immediately after his birth, 
 observed a round and transparent tumour on 
 the loins, of the size of a large walnut. On 
 the 22d of June, 1807, the child was brought 
 to my house, and I found, that although it 
 bad spina bifida, the head was not unusually 
 large ; and the motions of its legs were per- 
 fect ; and its stools and urine were dischar- 
 ged naturally. I applied a roller around the 
 child’s waist, so as to compress the tumour, 
 being induced to do so from considering it 
 as a species of hernia, and 'hat the deficien- 
 cy of the spine might be compensated for by 
 external pressure. The pressure made by 
 the roller, had no unpleasant influence on its 
 voluntary powers; its stools and urine con- 
 tinued to be properly discharged, but the 
 mother thought that the child was occasion- 
 ally convulsed. At the end of a week, a 
 piece ol plaster of Paris, somewhat hollow 
 ed, and that hollow partly filled with a piece 
 
 of. loose lint, was placed upon tne surface of 
 the tumour: a strap of adhesive plaster vyas 
 applied to prevent its changing its situation, 
 and a roller w r as carried around the waist, to 
 bind the plaster of Paris firmly upon the back, 
 and to compress the tumour as much as the 
 child could bear. This treatment was con 
 tinned until the month of October, during 
 which time, the tumour was examined about 
 three times a week, and the mother reported 
 that the child was occasionally convulsed. 
 When the child was five months old, a truss 
 was applied, similar in form to that which i 
 sometimes use tor umbilical hernia in chil- 
 dren, and this has been contained ever 
 since. At the age of fifteen months, it be- 
 gan to make use of its limbs ; it could crawl 
 along a passage, and up two pair of stairs 
 At eighteen months, by some accident, the 
 truss slipped from the tumour, which had 
 become of the size of a small orange, and 
 the mother observed, when it was reduced, 
 that the child appeared in some degree dull ; 
 and this was always the case if the truss was 
 left off fora few minutes, and then reapplied. 
 At fifteen months he began to talk ; and at 
 two years of age, he could walk alone. He 
 now goes to school, runs, jumps, and plays 
 about as other children. His powers of 
 mind do not appear to differ from those of 
 other children. His memory is retentive, 
 and he learns with facility. He had the 
 measles and small-pox in the first year, and 
 the hooping-cough at three years. His head 
 previously and subsequently to the bones 
 closing, has preserved a due proportion to 
 other parts of the body. The tumour is 
 kept by the truss entirely within the channel 
 of the spine ; but when the truss is removed, 
 it soon becomes of the size of half a small 
 orange, it is therefore necessary, that the 
 use of the truss should be continued. When 
 the truss is removed, the finger can be readily 
 pressed through the tumour into the channel 
 of the spine.” {Med. Chit. Trans. Vol.2,p 
 323 4-c.) 
 
 The next case, also published by Sir 
 Astley Cooper, will prove, that spinse bifi- 
 da? may sometimes be treated on another 
 plan, so as to accomplish a permanent cure 
 
 “January 21sf, 1809, Mrs. Little of No 
 27 Limehouse Causeway, brought to my 
 house her son, aged ten weeks, who was 
 the subject of spina bifida. The tumour 
 was situated on the loins ; it was soft, elas- 
 tic, and transparent ; and its size about as 
 large as a billiard ball when cut in half; his 
 legs were perfectly sensible, and his urine 
 and feces were under the power of the will, 
 &,c. Having endeavoured to push the water 
 contained iu the tumour, into the channel 
 of the spine, and finding that if the whole 
 was returned, the pressure would be too 
 great upon the brain ; I thought it a fair 
 opportunity of trying what would be the 
 effect of evacuating the swelling by means 
 of a very fine pointed instrument, and by 
 subsequent pressure to bring it into the state 
 of the spina bifida in Applebee’s child. 1 
 therefore immediately punctured the tumour 
 with a needle, and drew off about two 
 
SPhN'A VENTOSA, 
 
 ounces ot water. Un Hie 25th January, 
 finding the tumour as large as before it bad 
 been punctured, I opened it again, and 
 in the same manner, and discharged about 
 four ounces of fluid. The child cried when 
 the fluid was evacuated, but not whilst it 
 was passing off. On January 28th, the tu- 
 mour was ns large as at first ; I opened it 
 again, and discharged the fluid. A roller 
 was applied over the tumour, and around 
 the abdomen. February 1st, it was again 
 pricked, and two ounces of fluid discharged. 
 On the 4tb, three ounces of fluid were dis- 
 charged. On the 9th, the same quantity of 
 fluid was evacuated as on the 4th ; but in- 
 stead of its being perfectly clear as at first, 
 it was now sanious, and it had been gradu- 
 ally becoming so in the three former opera- 
 tions. On the 13th, the same quantity of 
 fluid was taken away; a flannel roller was 
 applied over the tumour and around the ab- 
 domen ; a piece of pasteboard was placed 
 upon the flannel roller over the tumour, and 
 another roller over the pasteboard to confine 
 it. On the 17th, three ounces of fluid, of a 
 more limpid kind, were discharged the 
 pasteboard was again applied: On the 27th, 
 the surface of the tumour inflamed ; the fluid 
 not more than half its former quantity, was 
 mixed with coagulable lymph, and the child 
 suffering considerable constitutional irrita- 
 tion, was ordered calomel and scaromony, 
 and the rollers were discontinued. On the 
 26th, the tumour was not more than a quar- 
 ter of its former size ; it felt solid ; the inte- 
 guments were thickened, and it had all the 
 appearance of having undergone the adhe- 
 sive inflammation. On the 28ib, it was still 
 more reduced in size, and felt solid. March 
 8th, the swelling was very much lessened ; the 
 skin over it thickened and wrinkled ; a roller 
 was again had recourse to a card was put 
 over the tumour, and a second roller was 
 applied. March 1 1 tb, the tumour was much 
 reduced ; the skin covering it was a little 
 ulcerated. On thq 15th, it was flat, but still 
 a little ulcerated. On the 27ih, the effused 
 coagulable lymph was considerably reduced 
 in quantity, and of a very firm consistence. 
 
 the 2d of May, nothing more than a 
 loose pendulous bag of skin remained, and 
 the child appearing to be perfectly well, the 
 bandage was soon left off. On December 
 the 18lh, the child was attacked with the 
 small-pox, ar.d went well through the dis- 
 ease. The skin now hangs flaccid from the 
 basis of the sacrum ; its centre is drawn to 
 the spine, to which it is united, and thus the 
 appearance of the navel is produced in the 
 tumour by retraction of the skin. The pricks 
 of the needles are very obvious, forming 
 slight indentations.” (See Med. Chir. Trans. 
 Vol. 2, p. 326—329.) 
 
 At the time when Sir A. Cooper trans- 
 mitted this case to the Medical and Chirur- 
 gical Society, it had been under bis observa- 
 tion two years and a half. 
 
 'I he first of the preceding observations 
 exemplifies the palliative treatment, adopted 
 by the latter gentleman, and consisting of 
 ’he application of pressure, in the manner of 
 
 423 
 
 a truss for hernia ; the second shows the 
 radical mode of cure by puncturing the 
 swelling from time to time with a needle, 
 and exciting the adhesive inflammation, 
 which, with the assistance of pressure, 
 stops the disease altogether, that is to say, in 
 such examples as admit of cure. 
 
 Children are sometimes born with tu- 
 mours, analogous to spinae bifidae, but situa 
 ted on the bead. There is a deficiency of 
 bone at some part of the skull, and through 
 the opening a sac, composed of the dura ma 
 ter, protrudes, covered only by the integu- 
 ments. Mr. Earle lately met with such a 
 swelling situated upon the occipnt of a fe 
 male infant. The plan of repeatedly making 
 small punctures with a common needle, dis 
 charging the fluid, healing up the punctures 
 and applying pressure, was tried, and fol 
 lowed up for some time without the occur- 
 rence of any unpleasant symptoms. Even 
 punctures were sometimes made with an 
 ordinary lancet ; yet the child suffered no 
 harm from the operation, and somtf'hopes 
 of a cure were indulged. At length, howe- 
 ver, ulceration of the swelling took place, 
 the child became indisposed, and rapidly sunk 
 (See Med. Chir. Trans. Vol. 7, p. 427.) Con 
 suit Ruyschii Obs. Anat. Warner's Cases in 
 Surgery. B. Bell’s System of Surgery , Vol. 
 5. Acrel in Schwed. Abhandl. x. B. p. 291,, 
 &pc. Murray , Opusc. 2, No. 5, et Med. Pract. 
 Bibl. 3, p. 612. Portal Cours d'Anat, Med 
 T. 4, p. 66. Lassus, Pathologic Chir. T. 3, 
 p . 260, et seq. Edit. 1809. Abernethy’s Sur- 
 gical and Physiological Essays, Part 1 and 3. 
 T. V. Okes, An Account of Spina Bifida, with 
 Remarks on the Method of Treatment pro 
 posed by Mr Abernelhy, Sro. Cambridge , 
 1810. Encyclopedic M6lhodiqve, Part . Chir 
 Art. Spina Bifida. Richter. Ahfangsgr. dec 
 JVtmdarzn. B. 5, Kap. A. Cooper, Med , 
 Chir. Trans. Vol. 2. p. 322, fyc. H. Earle , 
 in the same work, Vol. 7, p. 427, fyc. Edinb 
 Med. and Surg. Journ. No. 67. 
 
 SPINA VENTOSA. The Arabian writers 
 first employed this term', to express a dis- 
 ease, in which matter formed in the interior 
 of a bone, and afterward made its way out- 
 ward beneath the skin. Until the matte; 
 had escaped from within the bone, these au- 
 thors describe the pain as being incessant 
 and intolerable ; but that after the pus had 
 made its way outward by fistulous openings, 
 the pain underwent a considerable diminu- 
 tion. The matter sometimes insinuated it- 
 self, from the interior of the bone, into the 
 cellular substance, so as to render it soft and 
 flabby, though not always attended with 
 any change of colour in the skin. The 
 swelling had some of the appearance of 
 emphysema. To express this state, the 
 Arabians added the term ventosa to that of 
 spina, which was employed, before their 
 time, to express the nature of the pain at- 
 tendant on the disease. (See an account of 
 this subject in the Encyclopedic M6thodique, 
 Part. Chir. Art. Spina' Ventosa.) 
 
 The term spina ventosa has, since the time 
 of the Arabian writers, been used by many 
 to signify the disease named white-swelling, 
 
424 i»ri 
 
 find the former might also mean by it a simi- 
 lar affection, though the contrary may be 
 inferred from their account of the matter 
 passing from the interior of the bone under 
 the integuments, a thing which I believe 
 never yet happened in any case of white- 
 swellin/. Another, and perhaps a decisive 
 argument, against the original signification 
 of the word being the same as that of 
 white-swelling, is, that it was not restricted 
 to diseases of the joints and heads of the 
 bones ; but was also applied to abscesses, 
 which commenced in the cavities of the 
 middle portions of the long bones, where, I 
 need hardly observe, white -swellings never 
 make their attack. 
 
 For these reasons, many respectable au- 
 thors have implied by the term spina vento- 
 Mi an abscess in the interior of the bone. 
 (See, on this subject, Lalta's System of Sur- 
 gery, Vol. t, p. 165.) Cases of this latter 
 kind, I know, are infinitely rare, compared 
 with that common disorder, the white- 
 swelling ; and, I am also certain, from the 
 descriptions given by some authors, that 
 *heir cases of spina ventosa were in reality 
 instances of necrosis. But that abscesses 
 do occur, and begin in the interior of the 
 bones, more particularly of those of young 
 persons, 1 have no doubt myself, both from 
 two or three cases, which 1 remember ha- 
 ving seen in St. Bartholomew s Hospital, 
 and from some cases recorded by the most 
 authentic writers. 1 cannot conceive, how- 
 ever, that suppuration can take place to any 
 extent within a long bone, without being 
 followed by necrosis. . 
 
 J L Petit relates, that a man, with a tu- 
 mour on the middle of the tibia, who had 
 been treated by him as a venereal patient, 
 found, a fortnight afterward, that the pains 
 which had never ceased, now began to grow 
 more violent. The patient was feverish, 
 his legs became red, and even painful, exter- 
 nally. An incision was made in the situa- 
 tion of the tumour with a view of letting 
 out the matter which was suspected to be 
 the occasion of the bad symptoms, and to 
 have insinuated itself under the periosteum. 
 The incision was of no service, and, two 
 days afterward, the trepan was applied, by 
 which means, a large quantity ol matter 
 was let out. The medullary part of the 
 bone seemed quite annihilated, and the ca- 
 vity almost empty. Petit made three other 
 perforations with the trepan, and cut away 
 die intervening pieces of bone, lbe actual 
 cautery was also used several times to de^ 
 stroy the caries, and the patient at length 
 got well. ( Traili des Maladies des Os, de J. 
 L. Petit.) If any one doubt, that abscesses 
 now and then form in the middle of the 
 long bones, 1 must request him to consult 
 Mr. Hey’s Practical Observations in Surgery , 
 p 22, where he mav peruse two very inter- 
 esting eases illustrative of what Mr. Hey 
 calls Abscess in the Tibia with Caries. . 
 
 It must be confessed, however, that these 
 were only cases of necrosis, for which af- 
 fection the term caries is too often inaccu- 
 rately used. Indeed, it would appear, from 
 
 3PL 
 
 tin, observations of Dr. Macartney, that a 
 very small suppuration in the medulla is ac- 
 companied with the beginning of those 
 changes of the periosteum, which attend 
 necrosis. (See Necrosis, p. 762.) 
 
 For an account of spina ventosa, in the 
 sense of white-swelling, refer to Joints. J. 
 Pandolphinus, De Venlositalis Spince Scevissi- 
 mo Morbo, 12 mo. Norib. 1674. A. J. van dec 
 Meer, de Spina Ventosa, Duisb. 1 729. F. L 
 Augustin, de Spina Ventosa Ossium, Icon. 4, 
 4 io Halce, 1797. F. H. Schuchardt, Annota- 
 ta quoedam de Spina Ventosa, cum annexa 
 singulari hujus morbi observatione , 12 mo 
 
 Marburg. 1817. 
 
 SP1RITUS AMMONliE COMPOSJTUS. 
 Besides the well-known uses of this medi 
 cine internally exhibited, its vapours are an 
 exceedingly proper application to the eye 
 in some cases of chronic ophthalmy. Scar- 
 pa recommends a remedy of a similar na- 
 ture. 
 
 SPLINTS. Long thin pieces of wood, 
 or tin, or strong pasteboard, employed for 
 preventing the ends of broken bones from 
 moving so as to interrupt the process by 
 which fractures unite. These instruments 
 are sometimes used in other cases, for the 
 purpose of keeping limbs from moving, 
 particularly in some kinds of dislocationsj 
 wounds, &.c. 
 
 In simple fractures of the arm, forearm, 
 or even of the thigh, or leg, in young in- 
 fants, it matters not whether the splints be 
 made of wood, pasteboard, or tin. In this 
 country, surgeons usually keep sets of splints 
 made expressly for the leg. These are of 
 different sizes, excavated and shaped to the 
 part, and furnished below with apertures 
 for the projecting malleoli. When the limb 
 is laid upon its outside, the foot is also usu- 
 ally supported and kept steady by the under 
 splint, extending some distance towards the 
 toes. Very excellent splints for the legs of 
 young children are made of strong paste- 
 board, accommodated in shape to the con- 
 tour of the limb. Splints for the thigh, arm, 
 and forearm, whether made of tin, or wood, 
 should always be' slightly concave on the 
 side, which is to be applied to the broken 
 limb. They should likewise be made as 
 thin and light, as is consistent with the neces- 
 sary degree of strength for preventing the bro- 
 ken bone from bending. The sets of splints, 
 which are usedfor fractured legs and thighs in 
 England, are frequently furnished with straps, 
 which have a great many small perforations 
 in them at stated distances, and can thus be 
 easily fastened by means of little pegs for 
 the purpose. Tapes are also sometimes em- 
 ployed ; but they often get loose, and can- 
 not be depended upon so well as leather 
 straps. Pasteboard, as a material lor splints, 
 has one advantage, viz. j when wet, it. 
 becomes soft, and admits of being accurate- 
 ly applied to every point of the surface of 
 the limb: consequently, as soon as it dries 
 and recovers its firmness again, it retains 
 the exact shape of the part, and makes every 
 where equal pressure on it, without incom- 
 moding the patient, Pasteboard, however. 
 
SP 0 
 
 Si A 42a 
 
 js hardiy strong and durable enough for 
 many fractures ; nor will it answer when 
 there is any discharge, nor when the sur- 
 geon wishes to employ any fluid applica- 
 tions. But, it is generally allowed, that no 
 substance is better calculated for supporting 
 the fractured lower jaw ; for, it is perfectly 
 strong enough for this particular case, and 
 if wet before being applied, it forms when 
 dry a solid covering, most accurately corres- 
 ponding to the shape of the jaw. 
 
 Whatever may be the substance of which 
 splints are made, they ought always to be 
 at least as long as the fractured bone ; and, 
 if the situation of the limb will allow, they 
 ought, says Boyer, to extend its whole 
 length. a For instance, (says he) for sim- 
 ple fractures of the thighs of very young 
 children, the pasteboard splints, which I 
 employ, reach from the upper part of the 
 thigh, to the lower part of the leg. Gene- 
 rally speaking, the longer splints are, the 
 better they fix the limb, and keep the frac- 
 ture steady.” ( Boyer Traitd dts Mai. Chir. 
 T. 3, p. 60.) 
 
 The number of splints must depend upon 
 their breadth, and the thickness of the limb. 
 For the forearm, two are sufficient; for 
 the upper arm and thigh four are often 
 used and for the leg two, and sometimes 
 three. 
 
 In cases of fractured thighs, when the 
 straight position is preferred, the external 
 splint should extend from the crista of the 
 ilium to some little distance beyond the 
 sole of the foot ; while the inner one should 
 reach from the upper and internal part of 
 the thigh also beyond the sole of the foot. 
 With respect to the anterior splint it is indif- 
 ferent whether itonly reachesfrom the groin 
 to the knee, or as far as the lower part of 
 the leg. 
 
 The lateral splints for a broken leg ought 
 to be sufficiently long t6 embrace the knee, 
 and confine the motions of the foot and 
 ankle. When the straight posture is adopt- 
 ed, a splint is frequently laid along the front 
 of the leg, from the patella to the lower 
 part of the tibia. None however can ever 
 be required under the limb, as there the 
 bedding itself more conveniently affords the 
 necessary degree of support. 
 
 Of all the different pieces of the appara- 
 tus for the treatment of fractures, the 
 splints are by far the most important and 
 essential. Without them, indeed, it would 
 be in vain to attempt to keep the extremities 
 of the fracture from being displaced. 
 
 As splints are generally composed of 
 hard materials, the bad effects of their pres- 
 sure upon the skin must always be counter- 
 acted by placing a sufficient quantity of tow, 
 wool, or other soft substance between them 
 and the limb. 
 
 In order to understand, however, the 
 principles, which should guide the surgeon 
 in the choice and application *of splints, 
 many remarks, offered in the article i Frac- 
 ture, must be consulted. 
 
 SPONGIA PR.® PAR AT A. {Prepared 
 Sponge; Sponge-tent.) Formed by dipping 
 Vol, II, 54 
 
 pieces of sponge in hot melted emplastrum 
 cerae compositum, and pressing them be- 
 tween two iron plates. As soon as cold, 
 the substance thus formed may be cut into 
 pieces of any shape. It was formerly much, 
 used for dilating small openings, for which 
 it was well adapted, as when the wax melt- 
 ed, the elasticity of the sponge made it ex 
 pand and disteud the opening. However, 
 the best modern surgeons seldom emplov it. 
 
 SPONGIA USX A. {Burnt Sponge.) This 
 is often given in the torus of lozenges, in 
 cases of bronchocele, in which particular 
 instances much efficacy is imputed to allow- 
 ing the lozenges to dissolve gradually in the 
 mouth, after putting them under the tongue. 
 Burnt sponge is also exhibited in many scro- 
 fulous diseases, and in cases of chronic en- 
 largement of the prostate gland. The dose 
 is from a scruple to a dram. 
 
 STAFF. An instrument of considerable 
 importance in the operation of lithotomy, 
 being in fact the director for the gorget, or 
 knife. It is made of steel, and its handle 
 is generally rough, in order that it may be 
 more securely held. As it is intended to be 
 introduced through the urethra, its shape- 
 ought to be principally determined by the 
 natural course of that passage. The English 
 generally employ a staff, the curvature of 
 which forms the segment of a larger circle 
 than that described by the curvature of o. 
 staff used by the French practitioners. (See 
 Roux , Voyage fait a Londres en 1S14, ou Pa- 
 rallele de La Chirurgie Angloise , tyc. p. 319.) 
 In other words, the French staff turns more 
 upward than ours, as it approaches and en- 
 ters the bladder. There may be some ad- 
 vantage in this construction, inasmuch as it 
 tends to make the gorget enter in the direc- 
 tion of the long axis of the bladder; yet, a 
 great deal more seems to me to depend upon 
 the position in which the staff is held, than 
 upon its shape. Lithotomists should always 
 employ as large a staff as can be easily in- 
 troduced, because the operation will thereby 
 be facilitated. The groove, the most im- 
 portant part of the staff, is of course situated 
 upon the convexity of the curved part of 
 the instrument, or upon that portion, which, 
 when introduced, lies in the membranous 
 part of the urethra, prostate gland, and the 
 bladder. It should always be made very 
 broad and deep, as recommended by Lan- 
 genbeck, and Mr. Martineau. (See Lithoto- 
 my.) The termination of the groove at 
 the end of the instrument should be closed, 
 so as to stop the further entrance of the 
 gorget, and prevent the beak of the latter 
 instrument from doing mischief. English 
 surgeons have been justly censured by De- 
 sault and Sabatier, for neglecting this es- 
 sential caution ; for, certainly, the most fa- 
 tal injury may be done by the gorget slipping 
 beyond tbe end of the staff. (See Lithoto- 
 my.) For ray own part, if I am more sure 
 of any one thing in surgery, than another, 
 it is this, that the beak of a gorget in the 
 bladder ought never to pass out of, or be» 
 yond the groove of the staff. 
 STAPHYLOMA, (frouti sratpvMf a grape. 
 
oi'AMIYLOMA; 
 
 4 26 
 
 from its being thought to resemble a grape.) 
 Is that disease of the eyeball, in which the 
 cornea loses its natural transparency, rises 
 above the level of the eye, and even pro- 
 jects beyond the eyelids, in the form of an 
 elongated, whitish, or pearl-coloured tu- 
 mour, which is sometimes smooth, some- 
 times uneven, and, according to Scarpa, 
 attended with total loss of sight. However, 
 staphyloma is either partial or total, that is 
 to say, it affects only a part or the whole 
 of the cornea; and in the first case, if th<re 
 be not too much additional injury of the 
 eye, a degree of vision may yet be left, and 
 even admit of further improvement. The 
 circumstance of Scarpa’s observations ap- 
 plying only to cases in which the eyesight 
 is already destroyed, accounts for some im- 
 portant differences between him and other 
 writers, who, in the practice which they 
 advise, refer to the partial staphyloma, and 
 cases in which the sight is not quite annihi- 
 lated. Scarpa does not mention adhesion 
 of the iris to the diseased cornea, as a part 
 of the definition of staphyloma ; a point in 
 which he differs both from Richter and 
 Beer. ( Lehre von den Augenkr. B. 2, p. 69.) 
 Yet Scarpa may be correct ; for though, as 
 Mr. Wardrop remarks, “ the internal sur- 
 face of the cornea adheres to the iris in al- 
 most every case of staphyloma.” ( Essays on 
 the Morbid Anal, of the Eye, Vol. 1, p. 101.) 
 yet, as it does not invariably do so, the cir- 
 cumstance forms no essential part of the 
 nature of the disease. In some instances, 
 Mr. Wardrop has seen the opacity confined 
 to one half of the cornea, and this generally 
 the lower one. (Vol. cit.p. 100.) 
 
 Scarpa observes, that infants are often at- 
 tacked by this disease soon after their birth, 
 and mostly in consequence of the purulent 
 ophthalmy. It is also produced by the small- 
 pox, yet never during its eruption, which 
 is singular; nor during the stage of suppura- 
 tion ; but, when the pustules dry, and even 
 after the detachment of the variolous scabs. 
 
 In a great number of subjects, says Scarpa, 
 when the staphyloma has attained a certain 
 elevation above the cornea, it becomes sta- 
 tionary, or only increases in due proportion 
 to the rest of the eye. In other instances, 
 the small tumour of the cornea enlarges in 
 all its dimensions, and in such a dispropor- 
 tion to the rest of the eye, that at length it 
 protrudes considerably between the eyelids, 
 to the great molestation and deformity of 
 the patient. 
 
 This disease is justly considered as one of 
 the most serious to which the eyeball is sub- 
 ject ; for, to the total and irremediable loss 
 of sight that it occasions, are added all the 
 evils which necessarily result from the bulk 
 and protuberance of the staphyloma, after 
 the swelling of the cornea has acquired 
 such a size, that it can no longer be covered 
 by the eyelids. In such circumstances, the 
 continual exposure of the eyeball to the 
 contact of the air, and particles of matter 
 suspended in it; the friction of the eye- 
 lashes ; the incessant flux of tears down the 
 subjacent cheek render the eye painful 
 
 and inflamed ; the sound one is affected by 
 sympathy, and the diseased one at length 
 ulcerates, together with the lower eyelid 
 and cheek, on which it presses. 
 
 According to Richter (Obs. Chir. Fasc. 2.) 
 staphyloma is generally formed, without the 
 swelling of the cornea being preceded by 
 any of those morbific dispositions which are 
 generally considered capable of weakening 
 the texture and elasticity of the cornea; 
 which, in fact, acquires a much greater 
 thickness, than what it has in its natural 
 state, and consequently, staphyloma, far 
 from being concave within, is every where 
 compact and solid ; though it ought to be 
 quite the contrary, if the tumour were oc- 
 casioned, as Beer yet appears to believe, by 
 an immoderate distention, operating on the 
 cornea from within outward, with absorp- 
 tion of its natural texture. 
 
 Scarpa thinks, that Richter has general- 
 ized his doctrine too much, by not drawing 
 any line of distinction between the staphy- 
 loma of recent occurrence in infants, and 
 that ot adult subjects, in whom the disease 
 has acquired so large a volume, as to pro- 
 trude considerably beyond the eyelids. He 
 agrees with Richter, >hat the recent staphy- 
 loma in infants is quite compact and solid, 
 on account of the augmented thickness of 
 the cornea ; but he is convinced by repeated 
 observation, that, in this very same staphy- 
 loma, originally quite solid and compact, 
 the cornea becomes thinner, or, at all events, 
 is not thicker than natural, after the disease 
 has existed a series of years in adult sub- 
 jects, and in whom the swelling of the cor- 
 nea has attained such a size as to protrude 
 beyond the eyelids. The tumour, he ob- 
 serves, is not solid throughout, except in 
 regard to its containing, in its amplified 
 state, the iris, the crystalline, and very 
 often, also, a portion of the vitreous hu- 
 mour. 
 
 The cornea of infants, in its natural state, 
 is at least twice as thick and pulpy as that 
 of adults, and, consequently, the anterior 
 chamber of the aqueous humour, in the 
 former, is comparatively so contracted, to 
 what it is in the latter, that, in infants at the 
 breast, the cornea may be considered as in 
 contact with the iris. 
 
 To such qualities of the cornea, in child- 
 ren of tender years, and to the natural nar- 
 rowness of the anterior chamber of the 
 aqueous humour, Scarpa imputes the cause 
 why ophthalmies in infants so often pro- 
 duce opacity and thickening of this mem- 
 brane. The cornea swells, becomes preter- 
 naturally thickened, and is very soon con- 
 verted into a pointed, whitish, or pearl-co- 
 loured tumour, without any cavity inter- 
 nally, and either in perfect contact with, or 
 adherent to, the iris. In the course of years, 
 however, Scarpa remarks that this disease 
 undergoes new modifications. For, as the 
 whole eye enlarges with age, the iris and 
 crystalline, from causes not sufficiently un- 
 derstood, abandon their natural situation, 
 and are propelled forward, nearer and 
 nearer to the cornea; which they in time 
 
STAPHYLOMA 
 
 ■distend in all its dimensions, so as to make 
 it project beyond the eyelids, at the same 
 time rendering it thinner in a ratio to its 
 bulk and magnitude. Scarpa has never met 
 with a voluminous staphyloma, projecting 
 beyond the eyelids in adult persons, which 
 had not originally made its first appearance 
 in infancy ; and he has invariably found, 
 that the thickness and density of the cornea, 
 both in the living and dead bodies ot those 
 who have been affected with this disease, 
 were in an inverse ratio to the eye. Jn in- 
 veterate cases of staphyloma, forming a 
 large protuberance beyond the eyelids, the 
 iris may here and there be clearly discerned 
 through the diseased cornea, and if it be 
 not equally manifest at all points of the tu- 
 mour, it is because the conjunctiva exter- 
 nally spread over the cornea forms, in con- 
 junction with its varicose vessels on the 
 surface of the tumour, a stratum of matter, 
 not every where equally dense and opaque. 
 This dense stratum of the conjunctiva, 
 spread over the cornea, easily causes decep- 
 tion in a staphyloma of considerable bulk. 
 The more the tumour increases, the more 
 the substance of the cornea seems to be- 
 come dense and thickened ; while in reality 
 the contrary happens ; for the augmentation 
 in the density of the layer of the conjunc- 
 tiva, covering the cornea, only partly sup- 
 plies the diminution in the thickness of the 
 latter membrane. In staphyloma, as Mr. 
 Wardrop observes, “ the pupil is hid accord- 
 ing to the situation and degree of the opa- 
 city of the cornea ; but, in most cases it is 
 altogether obliterated, and even in those, 
 where a transparent portion of the cornea 
 is opposite to it, the vision is much impair- 
 ed ; for, as the eye has lost its form as an op- 
 tical instrument, the change in its refractive 
 power must render objects very indistinct .” 
 {Morbid Anat. of the Eye, Vol. 1 ,p. 101.) 
 
 The sclerotica is also subject to staphy- 
 loma, that is, to a partial distention and pro- 
 minence ?of its anterior hemisphere in the 
 white of the eye. Scarpa never met with 
 any tumour or prominence on the front sur- 
 face of the sclerotica, corresponding to the 
 white of the eye ; but in the dead subject he 
 has met with two examples of staphyloma 
 in the posterior hemisphere of the sclerotica. 
 According to Mr. Travers, in the spheroidal 
 staphyloma of the cornea, the sclerotica 
 sometimes yields so much as greatly to in- 
 crease the deformity. “This happens in 
 hydropic and other degenerations of the 
 humours. It also frequently becomes ex- 
 tenuated, or bulged near its junction with 
 the cornea in the amaurosis, which follows 
 inflammation of the choroid. This protru- 
 sion, larger or smaller, is sometimes cir- 
 cumscribed, and in other instances diffused 
 over a large portion of the ball. It is often 
 seen encircling the cornea, and presenting 
 a sacculated or pouched appearance. It 
 has a bluish gray tint, &-c.‘’ ( Synopsis of 
 
 the Diseases of the Eye, p. 130.) 
 
 When in the staphyloma of the cornea, 
 this part is affected with irremediable opa- 
 city, Scarpa thinks that if the disease be re- 
 cent. and in a child, the only object must be 
 
 to hinder the increase Of the swelling of the 
 cornea, the organization of which is already 
 destroyed. The tumour must be levelled, 
 and flattened as much as possible ; and 
 when the swelling of the cornea is invete- 
 rate, very large, and prominent beyond the 
 eyelids, it is to be diminished by surgical 
 means, so as to return within the orbit, suf- 
 ficiently to permit the deformity of the face 
 to be amended by the application of an ar- 
 tificial eye. 
 
 In cases of recent staphyloma, Richter 
 used to make at the bottom of the tumour 
 of the cornea an artificial ulcer, by repeat- 
 edly applying the argentum nitratum, or the 
 oxygenated muriate of antimony (butter of 
 antimony,) and to keep the little sore open 
 by the continued use of the same caustic, 
 with the view of effecting a diminution of 
 the swelling of the cornea. In this way 
 Richter frequently succeeded in lessening 
 staphyloma, and be one particular case he 
 even restored the transparency of the cor- 
 nea. Ter repetitd operalione, quarto scilicet , 
 septimo et decimo die, ne vestigium quidem 
 morbi die decimo-quarto superabat. Obs. 
 Chir. Fasciculus 2. 
 
 Though Scarpa has frequently attempted 
 to cure the recent staphyloma of infants' by 
 the above method, he has never yet met 
 with such success, as can be at ail compared 
 with Richter’s, either in restoring the trans- 
 parency of the cornea, or accomplishing a 
 diminution of the volume of the staphyloma. 
 Having formed with the argentum nitratum 
 a small ulcer, at the bottom of the cornea, 
 arid kept the sore open thirty days and 
 more, he failed in obtaining any benefit, in 
 respect to. the diminution, much less the 
 opacity of the cornea, in three infants, one 
 a year and a half old, and the two others 
 somewhat more than three, all which sub- 
 jects had been recently attacked with sta- 
 phyloma in one eye, in consequence of the 
 small-pox. A violent chemosis, in a very 
 short time produced a staphyloma in the 
 eye of a child five years old. Scarpa made 
 an ulcer at the bottom of the cornea, in the 
 unorganized swollen substance of which he 
 introduced, for a little depth, the flat part 
 of a lancet. Scarpa kept the sore open for 
 five weeks, with a solution of the argentum, 
 nitratum, and he remarked that the staphy- 
 loma became somewhat flatter, so as to 
 lose the acute prominence which it had at 
 its centre ; but the cornea continued, as be- 
 fore, every where opaque. - Though Scarpa 
 employed the same method in two otjier 
 subjects, of about the same age, and in the 
 same circumstances ; though he kept the 
 ulcer open fifty days, he was never able to 
 effect any depression or diminution cf the 
 staphyloma; and, consequently, the point- 
 ed, pearl-coloured projecting part of the 
 tumour continue’d in the same state as it was 
 before. The conical shape which the cor- 
 nea assumes in this disease, he observes, is 
 a characteristic symptom by which a sta- 
 phyloma may be distinguished from a leu- 
 coma, with total opacity of the cornea. 
 
 If, also, in the course of further trials, 
 partial benefit be found to accrue from thi c ' 
 
STAFHYtOMA 
 
 42k 
 
 plan, adopted not tor the purpose of re- 
 establishing the transparency of the cornea, 
 but for that of merely checking and dimi- 
 nishing the recent staphyloma in infants, 
 still Scarpa is of opinion, that no one will 
 be easily persuaded that the same treatment 
 can ever prove of the least service in dimi- 
 nishing the size of the large, inveterate 
 staphyloma in adults ; in other words, of 
 that which projects beyond the eyelids, and 
 rests on the cheek. Under these circum- 
 stances, he believes, that there is no effect- 
 ual means of restraining the progress of the 
 complaint, and removing the deformity, but 
 cutting away the staphyloma, and when the 
 place is healed, an artificial eye may be ap- 
 plied. 
 
 Celsus thus expresses himself on the sub- 
 ject of this operation : — Curalio duplex est. 
 Altera ad ipsas radices per medium transuere 
 acu, duo lina ducente , deinde atlerius Uni duo 
 capita ex superiore parte , alterius ex inferiore 
 adslringere inter se quce paulatim secando id 
 excidant. Altera insumma parti ejus ad len - 
 iiculcB magnitudinem exscindere ; dtinue spo- 
 dium , nut cadmiam inf Heart. Utrolioet au- 
 tern facto , album ovi lana excipiendum, et im- 
 ponendum ; posleaque vapore aquee ealidee 
 fovendus o cuius, et ienibus medicamentis un - 
 guendus est. De Medicina, lib. 7, cap. 6. 
 
 Though, says Scarpa, the first plan, or that 
 of the ligature, is at present abandoned, the 
 majority of surgeons still persevere in pass- 
 ing a needle and ligature through the lower 
 part of the staphyloma, not for the purpose 
 of tying or constricting the tumour, it is true, 
 but of making a noose, in order to fix the 
 eye conveniently, when the staphyloma is to 
 be cut off in a circular manner. This use of 
 a needle and ligature, which 1 observe is 
 sanctioned by Mr. Travers, (Synopsis, fyc. p. 
 285,) i is strongly disapproved of by Scarpa. 
 
 With regard to the second method of re- 
 moving the staphyloma, or that of excision, 
 Scarpa thinks that sufficient attention has not 
 hitherto been paid to what Celsus has written 
 on this subject. In fact, Celsus does not for- 
 bid cutting away the staphyloma, by a circu- 
 lar incision at its base, as is practised at the 
 present day, but says that this operation is to 
 be done in the centre, or conical point of the 
 tumour, and that as much of this part of the 
 staphyloma is to be cut away as will equal a 
 iontil in size : In summd parte ejus ad lenticu- 
 he magnitudinem exscindere. Scarpa remarks, 
 that the great importance of this precept of 
 Celsus, in regard to the successful treatment 
 of the staphyloma, can only be duly appre- 
 ciated by surgeons who have often had oc- 
 casion to compare the advantages of Celsus’s 
 doctrine, with the serious inconveniences 
 which result from the common practice of 
 cutting away the staphyloma circularly at its 
 base ; and with the evils produced by a se- 
 micircular sectioii, comprehending the scle- 
 rotica, in Woolhouse’s manner, always fol- 
 lowed by acute inflammation of the eyeball 
 and eyelids, violent pains in the head, rest- 
 lessness, spasms, copious, and somotimes gan- 
 grenous, suppurations of the eye and eyelids. 
 
 The patient being seated, Scarpa directs 
 an assistant to support his head properly ; 
 
 then taking in his hand a knife, similar to 
 what is used in the extraction of the cata- 
 ract, he passes the instrument completely 
 across the staphyloma, at the distance of one 
 line and a half, or two lines, from the centre 
 or apex of the tumour, from the external to- 
 wards the internal angle of the eye, and by 
 passing the knife forward in the same direc- 
 tion, just as is done in the extraction of the 
 cataract, he makes a semicircular incision 
 downwards, in the most prominent part of 
 the tumour. Having done this, be takes 
 hold of the segment of the staphyloma with 
 the forceps, and turning the edge of tl\e 
 knife upward, he completes the circular re- 
 cision of the apex of the tumour, in such a 
 way that the detached portion is one, two, 
 three, or four lines in diameter, according to 
 the size of the staphyloma. As a portion of 
 the iris adhering to the cornea, from the very 
 commencement of the disease, is commonly 
 included in this section of the pointed part 
 of the tumour, no sooner is the circular di- 
 vision of the apex of the staphyloma made, 
 than the crystalline, or its nucleus, issues 
 from the eye, followed by a portion of the 
 vitreous humour. In consequence of this 
 evacuation, the eyeball often diminishes in 
 such a degree, that it can be covered by the 
 eyelids, to which Scarpa immediately ap- 
 plies a pledget of dry lint, supported by a 
 retentive bandage. 
 
 When the eye and eyelids begin to be pain- 
 ful, inflame, and swell, as they generally do 
 on the fourth day, the eye is to be covered 
 with a bread and milk poultice. When 
 things proceed in a regular manner, the swell- 
 ing of the eyelids subsides about the seventh 
 or ninth day, and purulent matter is seen on 
 the poultice, blended with the vitreous hu- 
 mour. The matter afterward becomes thick 
 and whitish, the patient feels great relief, and 
 the eyeball shrinks and sinks into the orbit. 
 
 At this period, on gently separating the 
 eyelids, the conjunctiva is found swelled, 
 and reddish, and the margin of the wound 
 seems like a whitish circle. This is usually 
 detached on the twelfth or fourteenth day af- 
 ter the operation, when the edge of the sur- 
 face, from which the staphyloma was cut, 
 becomes red, contracts, and daily diminishes, 
 so that at last the wound is entirely closed. 
 There only remains in the centre of the cor- 
 nea, for a few' days, a small fleshy promi- 
 nence, resembling a little reddish papilla, 
 which, after being touched a few times with 
 the argentum nitraturn, contracts, and heals. 
 
 So far, says Scarpa, are alarming symp- 
 toms from following this operation, that in 
 a great number of cases the surgeon is even 
 obliged, several days afterward, to stimulate 
 the eye on which it has been performed, in 
 order to make it inflame, partly by leaving it 
 a long while uncovered, and exposed to the 
 air, partly by enlarging the circular recision, 
 made in the centre of the staphyloma, of 
 which another circular portion, half a line 
 broad, is removed, in order to facilitate the 
 more abundant discharge of the humours, 
 and the ingress of air into the cavities ot the 
 eye, which are so backward to inflame. An 
 soon as inflammation has invaded tho infe 
 
STL 
 
 SUL 429 
 
 tior of the eye, and suppuration has taken 
 place, the rest of the cure regularly follows 
 under the use of topical emollients, and is 
 soon completed with all possible mildness. 
 
 It should be particularly recollected, that 
 Scarpa means the foregoing practice for in- 
 veterate cases of staphyloma, where the eye- 
 sight is totally lost, and (he projection of the 
 diseased coruea produces serious annoyance. 
 Under other circumstances, the method 
 can hardiy be admissible. Among others, 
 Dr. Vetch particularly objects to the remo- 
 val of the apex of the tumour, as destructive 
 of all chance of the recovery of a degree of 
 vision ; a consideration, however, which 
 would not exist in the hopeless cases spoken 
 of by Scarpa. Dr. Vetch also disapproves 
 of letting out the aqueous humour in cases 
 of staphyloma as art endless operation, from 
 which no permanent effect takes place, the 
 humour collecting again in a few hours; a 
 sentiment which is likewise expressed by 
 Mr. Travers. (See Vetch on the Diseases of 
 the Eye, p. 63 ; and B. Travers , Synopsis , fyc. 
 p. 286.) For the purpose of accomplishing 
 the gradual diminution of the tumour, and 
 bringing the eye into a stale in which an arti- 
 ficial pupil may be made , Dr. Vetch has em- 
 ployed caustic (the method commended both 
 by Richter and Beer) and the introduction of 
 a seton through the tumour. Beer confirms 
 the statement of Scarpa, concerning the im- 
 possibility of restoring the transparency of 
 any part of the cornea affected with staphy- 
 loma. For the relief of a partial staphylo- 
 ma, he prefers the cautious application of 
 the oxygenated muriate of antimony, by 
 means of the point of a camel-hair brush, 
 while the eyelids are held asunder. The dis- 
 eased part of the cornea is to be smeared 
 with it until a small white superficial slough 
 is formed, when every particle of the caus- 
 tic must be immediately washed out of the 
 eye with another larger camel-hair brush, 
 dipped in water, or milk. The application 
 is not to be repeated until the subsequent in- 
 flammation has quite subsided, and the slough 
 been thrown off. Beer condemns all escha- 
 rotic salves, because the iraction extends to 
 pcrts which should be left uuirritated. ( Lehre 
 ■von den Augenkr. B. 2, p. 74.) 
 
 Wenzel, and numerous other writers, im- 
 ply by staphyloma, a protrusion of a piece 
 of the iris through a wound or ulcer of the 
 eye. (See Iris, Prolapsus of.) 
 
 R. Fr. B. Ho elder. De Staphylomale, Tu- 
 bing# , 1748. Scarpa Suite Malatlie Degli 
 Occhi, Ed. 5. G J. Beer's Ansicht der Sta- 
 phylomatosen Melamorphosen des Auges , tyc. 
 IVien. 1805. jYachtrag zur Ansicht , $-c. 
 1806; and Lehre von den Augenkr. B. 2 ,p. 
 69,8 vo. Wien. 1817. Richter, Anfangsgrunde 
 der Wundarz n eykunst , B. 3. p. 153. fyc. Gotl. 
 1795. Sabatier, Mddecine Operaloire. T. 2, 
 p. 191, Ed. 2, 1810. James Wardrop . Essays 
 on the Morbid Anatomy of the Human Eye, 
 Vol. 1 , p. 99, 8 vo. Edinb. 1808. £. Travers , 
 Synopsis of the Diseases of the Eye, 8 vo. Load. 
 1820. J. Vetch , A Practical Treatise on the 
 Diseases of the Eye, 8 vo. Lond. 1821. 
 
 •STEATOMA. (from <r]e*e, fat.) A wen. 
 
 or encysted tumour, containing fat. See Tu- 
 mours, Encysted. 
 
 STELLA, or STELLATED BANDAGE. 
 A bandage so named because it makes a 
 cross, or star, on the back. It is a roller, ap- 
 plied in the manner of a figure 8, so as to 
 keep back the shoulders. It is often em- 
 ployed in cases of fractures and dislocations 
 of the clavicle. 
 
 STRAMONIUM. A series of interesting 
 experiments were detailed in illustration of 
 the properties of stramonium, in a Disserta- 
 tion, which was read to the Medical Facul- 
 ty of the University of Pennsylvania, on 
 the 12th of May, 1797, by Dr. Samuel 
 Cooper The experiments No. 15 and 16, 
 merit particular notice in this Dictionary, as 
 being, perhaps, the earliest discovery of the 
 effect of the local application of powerful 
 narcotics in dilating the pupil. A drop cf 
 an infusion of the powder of stramonium 
 was let fall into the left eye. In half an hour 
 the pupil began to enlarge, and attained its 
 greatest dimensions about twelve hours after 
 the experiment, at which time it was viewed 
 in a considerable light, and seemed thrice as 
 large as the other. It continued dilated two 
 days. In a strong light, objects were seen 
 more distinctly with the right eye; but in a 
 weak light, with the left. Some other gen- 
 tlemen, however, on whom the experiment 
 was tried, experienced no increased power 
 of seeing in the -dark. A drop of the ex- 
 pressed juice, dropped into the eye of a cat, 
 soon converted the whole of the coloured 
 part of the eye into pupil. (See Caldwell's 
 Medical Theses, p. 173, 8ro. Philadelphia, 
 1805) Stramonium, then, resembles bella- 
 donna and hyosciamus in its action upon the 
 iris. It has been exhibited internally, in epi- 
 lepsy, tic douleureux, and severe chronic 
 pains, and used in poultices for dispersing in- 
 durations of the breast, and in ointments for 
 allaying the pain of piles. The doses should 
 at first be only gr. ss. of (lie extract twice a 
 day, but they may be gradually increased to 
 five grains. 
 
 STRICTURE, (from stringo, to bind.) 
 A diminution, or contracted state of some 
 tube, or duct, in the body. See Urethra , 
 Strictures of; (Esophagus , 4' c - Rectum , fyc. 
 Stricture also means, in cases of strangula- 
 ted hernia, the narrowest part of the open- 
 ing, or passage through w hich the bowels 
 protrude, which narrowest part makes on the 
 viscera the pressure causing all the bad symp- 
 toms. See Hernia. 
 
 SI RUMA. (from slrno, to heap up.) Scro- 
 fula, or Scrophula. The King’s Evil. See 
 Scrofula, 
 
 STYE A little inflammatory tumour on 
 the eyelid. See Hordeolum. 
 
 SULPHURIC ACID. The strong sulphu- 
 ric acid is not much used in the practice of 
 surgery, except as a means of extricating 
 from the nitrate ot potash, or muriate of 
 soda, certain gases for the purpose of purify- 
 ing the air of sick rooms, or infected places. 
 A few' practitioners have also sometimes 
 employed it, blended with sixteen times its 
 weight of lard, aa a local application for the 
 
48>i) 
 
 SUFPU RATION 
 
 cure of scabies. Asa caustic, it is not gene- 
 rally eligible, because it is difficult to limit 
 its operation exactly to the parts which are 
 intended to be destroyed. A few years ago, 
 a proposal was made to apply this acid along 
 the outside of the eyelid, in cases of trichia- 
 sis, so as to produce a slough, and subsequent 
 ulcer, the cicatrization of which draws out 
 the inverted tursus. Nay, it is alleged that 
 the application sometimes produces an in- 
 stantaneous amendment of the position of 
 the eyelid. I have seen one example, in 
 which the experiment was tried ; but whe- 
 ther it was owing to the acid not having 
 been sufficiently applied, or other causes, the 
 method did not answer so well as the usual 
 plan of removing a part of the integuments 
 with a cutting instrument. 
 
 Diluted sulphuric acid is frequently em- 
 ployed as an ingredient in gargles. It is also 
 commonly exhibited with a view of check- 
 ing passive hemorrhages, and profuse noctur- 
 nal sweats in hectic fever. The dose is from 
 ten to thirty drops. 
 
 This acid, in the diluted form, has been 
 tried in venereal cases. According to Mr. 
 Pearson, when a bad state of health prohi- 
 bits the introduction of mercury, the case 
 has not yet put on an unequivocal appear- 
 ance, or dyspeptic symptoms, attended with 
 profuse perspirations, harass the patient, it 
 is an useful remedy, capable of giving a 
 temporary check to the progress of the dis- 
 ease. He says, that he has often seen it 
 arrest the progress of venereal ulcers of the 
 tonsils, and make venereal eruptions fade 
 and nearly disappear ; but that these bene- 
 ficial effects were never permanent. At 
 the same time he acknowledges that the 
 medicine will confer actual and durable be- 
 nefit in ulcers of the penis, groin, and throat, 
 sometimes remaining stationary after a mer- 
 curial course. He has likewise found this 
 acid very efficient, when mercury acts too 
 violently upon the mouth. (See Pearson's 
 Obs. on the Effects of various Art hies in the 
 Cure of Lues Venerea, p. 189 — 191, Ed. 2.) 
 
 In cases of poison by sulphuric acid, the 
 most successful treatment consists in ma- 
 king the patient drink large quantities of 
 water, in which calcined magnesia is sus- 
 pended. Should this last medicine, how- 
 ever, not be at hand, soap, blended with 
 water, is the best substitute. While these 
 remedies are preparing, copious draughts of 
 some mucilaginous beverage, milk, or even 
 of common water, should be administered 
 without delay ; for the practitioner should 
 ever be mindful, that so rapidly does sulphu- 
 ric acid operate upon the texture of the parts 
 with which it comes into contact, that all 
 chance of saving the patient must depend 
 upon the quickness with which the means 
 to counteract the poison are applied. After 
 the acid has been diluted and neutralized, 
 local and general bleeding, emollient clys- 
 ters, and mucilaginous drinks, constitute the 
 best remedies. ( Orfila , Traitt des Poisons , 
 fyc. Vol. 1. p. 434, Ed. 2.) 
 
 SUPPRESSION OF URINE. See Urine , 
 Retention of. 
 
 SUPPURATION. A process, by which a 
 peculiar fluid, termed pus, is formed in the 
 substance, or from the surface of parts of 
 the body. From the observations made in 
 the article inflammation , it appears, that 
 when this last affection is above a certain 
 pitch, it sometimes terminates in suppura- 
 tion. 
 
 When purulent matter accumulates in the 
 part affected, it is termed an abscess , which 
 is distinguished into several kinds, the ccw/e, 
 chronic, venereal, scrofulous , &c. 
 
 It is observed by Professor Thomson, that 
 the texture, in which suppuration seems to 
 be most readily produced, by a certain de- 
 gree of inflammation, is mucous membrane, 
 whether this lines excretory ducts, or canals, 
 or covers the inner surfaces of the respira- 
 tory, or urinary organs. In a few hours, 
 after an irritating cause has been applied to 
 these surfaces, the physical and cbymical 
 qualities of the fluid which they secrete in 
 their natural state, are changed. From 
 being a tough viscid substance, not easily 
 miscible with water, the mucus of the nose 
 and bronchia becomes, during an attack of 
 inflammation, very readily miscible with 
 water, of a yellowish white colour, and fluid 
 consistence. If, in this state, the secretion 
 from these membranes be examined with 
 the microscope, it will be found to contain 
 small globules, similar to those which are 
 seen in the blood ; and these globules are 
 found to increase in number in proportion 
 to the degree and continuance of the inflam- 
 mation. We have examples of the produc- 
 tion of this pus, or at least of a puriform 
 fluid, in the respiratory organs of persons 
 affected with catarrh, and in the urinary 
 organs of those who labour under gonor- 
 rhoea. In the progress of these diseases, 
 we can generally trace the changes, which 
 take place by slow, but sensible degrees, 
 in the nature of the secretion, from mucus 
 to pus, and from pus back again to the state 
 of mucus. This puriform discharge from 
 mucous membranes, in a state of inflamma- 
 tion, may be kept up for months without 
 these membranes appearing to undergo auy 
 other morbid changes than a slight degree 
 of redness and swelling. A loss of substance, 
 or ulceration, is found not to happen of- 
 tener than in one case out of ten examples 
 of suppuration from mucous membranes. 
 
 ( Thomson's Lectures on Inflammation, p. 305, 
 306.) 
 
 The same well-informed writer afterward 
 proceeds to explain, that suppuration may 
 be readily produced in the skin, or cutane- 
 ous texture, by whatever excites inflamma- 
 tion in that texture, and causes a separation 
 of the cuticle. We have examples of this 
 fact in blisters from cantharides, and in ve- 
 sications of the cuticle from superficial 
 burns. If the cuticle covering a recent 
 blister, or burn be removed, and the cutis 
 exposed to the irritation of stimulating sub- 
 stances, pus will soon be discharged from 
 the abraded surface. Suppuration can be 
 kept up in cutaneous texture, for an indefi- 
 nite length of time, as we see done every 
 
SXJPPURATIOX 
 
 
 uay iu the management ot perpetual blis- 
 ters. Ulceration is seldom observed in these 
 cases, and consequently, in cutaneous tex- 
 ture, loss of substance is by no means ne- 
 cessary for the production of pus. 
 
 If the cutis be divided, as in a wound, or 
 a portion of it remov ed, as in the extirpation 
 of tumours, and either the air, or any other 
 external body, be permitted to remain in 
 contact with the divided surfaces, the pro- 
 cess of suppuration is speedily induced in 
 the cellular texture subjacent to the skin. 
 After the hemorrhage, which takes place 
 from the small vessels, has ceased, an oozing 
 of a fluid, at first resembling serum, occurs, 
 which is gradually changed into pus. But 
 in this case, as Dr. Thomson has correctly 
 observed, the surface of the wound is pre- 
 viously covered with a layer of coagulable 
 lymph, which is penetrated with blood-ves- 
 sels, and gradually raised into the little red 
 eminences, termed granulations. 
 
 Appearances similar, though slighter in 
 degree, says Dr. Thomson, are observed in 
 cutaneous suppuration, giving probability to 
 the opinion of Sir E. Home, that in inflam- 
 mation, a vascular surface is produced pre- 
 viously to the formation of pus in a cellular 
 membrane, and perhaps also in cutaneous 
 texture. Dr. Thomson is inclined to be- 
 lieve, however, that no new vascular sur- 
 face is generated in the inflammation of 
 mucous membrane. Thus, we see, that in 
 the formation of pus in raucous membrane, 
 cutaneous texture, and exposed cellular sub- 
 stance, no ulceration, no breach of sub- 
 stance occurs : but that, on the contrary, 
 in two of these textures, the cutaneous and 
 cellular, there is an addition made to the 
 parts by the exudation of coagulable lymph, 
 which becomes organized. ( Thomson , p. 
 305—308.) 
 
 SYMPTOMS OF SUPPURATION. 
 
 When matter is fully formed in a tumour, 
 there is a remission of all the symptoms. 
 The throbbing pain, which was before fre- 
 quent, now goes off, and the patient com 
 plains of a more dull, constant, heavy pain 
 A conical eminence, or pointing , as it is 
 termed, takes place at some particular part 
 of the tumour, generally near its middle. 
 In this situation, a whitish, or yellowish ap- 
 pearance is general observable, instead of 
 a deep red, which was previously apparent, 
 and a fluctuation of a fluid underneath may 
 be discovered, on a careful examination 
 with the fingers. Sometimes, indeed, when 
 an abscess is thickly covered with muscles 
 and other parts, the fluctuation cannot be ea- 
 sily distinguished, though, from other concur- 
 ring circumstances, there can hardly be the 
 least doubt of there being even a very con- 
 siderable collection of matter. An oedema- 
 tous swelling over the situation of deeply- 
 situated abscesses is a symptom which of- 
 ten occurs, and is well worthy the attention 
 of every practical surgeon. 
 
 The discovery of the existence of deep 
 abscesses is a circumstance of the highest 
 importance in practice, and one which 
 
 greatly involves the practitioner's reputa- 
 tion. In no part of the surgeon’s employ- 
 ment is experience in former similar cases 
 of greater use to him than in the present ; 
 and however simple it may appear, yet no- 
 thing, it is certain, more readily distinguishes 
 a man of observation and extensive prac- 
 tice, than his being able easily to detect 
 collections of deep-seated matter. On the 
 contrary, nothing so materially injures the 
 character and professional credit of a sur- 
 geon, as his having in such cases given aa 
 inaccurate or unjust prognosis ; for, in dis- 
 orders of this kind, the nature and event of 
 the case are generally at last clearly demon- 
 strated to all concerned. 
 
 Together with the several local symptoms 
 of the presence of pus, already enumerated, 
 may be mentioned the frequent shiverings , 
 to which patients are liable on its first for- 
 mation. However, these rigours seldom oc- 
 cur so as to be distinctly observed, unless 
 the collection of matter is considerable, or 
 situated internally in some of the viscera. 
 
 In the progress of the fever, accompa- 
 nying acute inflammation, (says Professor 
 Thomson) rigours, or cold shiverings not 
 un frequently take place, which recur at ir- 
 regular intervals, and are in general follow- 
 ed by a hot fit, and slight increase of the 
 febrile symptoms. These rigours, or cold 
 shiverings, in general indicate, when they 
 occur in the progress of inflammatory dis- 
 eases, that pus either is formed, or is about 
 to be so. In inflammation, succeeding to 
 injuries of the head, these rigours are often 
 the first constitutional symptoms which give 
 alarm to the well-informed practitioner : 
 for they are generally, though not always' 
 an indication that inflammation has already 
 made a dangerous, if not fatal progress. 
 These rigours also accompany the forma- 
 tion of pus in the viscera contained within 
 the cavities of the chest and belly, and are 
 often the first symptoms which inform the 
 practitioner, that his endeavours to procure 
 resolution have not been successful.” (See 
 Thomson's Lectures on Inflammation, p. 321.) 
 
 Rigours, as Mr. Hunter remarked, are 
 more common at the commencement of 
 spontoneous inflammations, than in inflam- 
 mations from external injury. They seldom 
 occur in the suppurations which follow- 
 operations. 
 
 The constitutional symptoms which attend 
 the formation of pus in the progress of chro- 
 niesuppurations, are generally comprehend- 
 ed under the name of hectic fever. (See 
 Fevers.) 
 
 The pain attending what Mr. Hunter 
 termed the suppurative inflammation, is in 
 creased at the time when the arteries are 
 dilated, and this gives the sensation called 
 throbbing, in which every one can count 
 his own pulse, by merely paying attention 
 to the inflamed part. Perhaps, this last 
 symptom is one of the best characteristics of 
 this species of inflammation. When the in- 
 flammation is moving from the adhesive 
 state to the suppurative, the pain is conside- 
 rably increased ; but when suppuration has 
 
sUPPUKATICtt 
 
 *6-1 
 
 taken place, the pain m some degree sub- 
 sides. (Hunter.) 
 
 The redness that took place in the adhe- 
 sive stage is now increased, and is of a pale 
 scarlet colour. The part which was firm, 
 hard, and swelled, in the previous stage of 
 the inflammation, now becomes still more 
 swelled, in consequence of the greater dila- 
 tation of the vessels, and the greater quan- 
 tity of coagulating lymph thrown out. 
 (Hunter.) 
 
 THEORY OF SUPPURATION. 
 
 The dissolution of the living solids of an 
 animat bod) 7 into pus, and the power of this 
 fluid to continue the dissolution, are opinions 
 which are no longer entertained . by any 
 well-informed surgeons of the present day ; 
 and the use of such phrases as a pus corrodes,” 
 :l it is acrid,” &c c. expressions vrbich imply 
 an erroneous way of thinking, is very pro- 
 perly almost entirely discontinued in the 
 language of every sinsible medical man. If 
 these notions were true, no sore which dis- 
 charges matter, could be exempted from a 
 continual dissolution. Such ideas probably 
 arose from the circumstance of an abscess 
 being a hollow cavity in the solids, and 
 from the supposition, that the whole of the 
 original substance of that cavity was now 
 the matter, which was found in it. This 
 was a very natural way of accounting for 
 the formation of pus by one entirely igno- 
 rant of the moving juices, the powers of the 
 arteries, and what takes place in an abscess 
 after it is opened. The knowledge of these 
 three subjects, abstracted from the know- 
 ledge of the abscess before its being opened, 
 should have led surgeons to account for the 
 formation of pus from the blood by the pow- 
 ers of the arteries alone. According to the 
 above erroneous principle, abscesses would 
 continue to increase after being opened, as 
 fast as before. Upon the principle of the 
 solids being dissolved into pus, was founded 
 the practice of bringing ail indurated parts 
 to suppuration if possible, and not making 
 an early opening. This was done for the 
 purpose of giving time for the solids to melt 
 down into pus ; but it was apparently for- 
 gotten, tiiat abscesses formed matter after 
 they were opened, and therefore the parts 
 stood the same chance of dissolution into 
 pus as before. Blinded with the idea that 
 ?he solids entered into the composition of 
 pus, the partisans of this doctrine could never 
 see pus flowing from any internal canal, as 
 from the urethra, in cases of gonorrhoea, 
 without supposing the existence of an ulcer 
 . the passage. Such sentiments might be 
 forgiven before it was known that those sur- 
 faces could, and generally did, form pu3 
 without a breach of the solids ; but the con- 
 tinuance of this way of thinking now is not 
 mere ignorance, but stupidity. The forma- 
 tion of pints of matter in the cavities of the 
 chest and abdomen, without any breach in 
 the solids, could not have been overlooked 
 by the most zealous advocates for the doc- 
 trine of dissolution. (Hunter.) 
 
 The moderns have been still more ridicu- 
 lous; for knowing that it was denied, that 
 
 the solids were ever dissolved into pus, acd 
 that there was not n single proof of it, they 
 have been busy in producing what to them 
 seemed a proof. They have been putting 
 dead animal matter into abscesses, and find- 
 ing that it was either wholly or in part dis- 
 solved, they therefore attributed the loss 
 to its being formed into pus. This, howe- 
 ver, was putting living and dead animal 
 matter upon the same footing, which is a 
 contradiction in itself; for if the result of 
 this experiment were really what they sup- 
 posed it to be, the idea of living parts being 
 dissolved into pus must be abandoned, be» 
 cause living and dead animal matter can 
 never be considered in the same light- 
 (Hunter.) 
 
 It might have been remarked, that even 
 extraneous animal matter w ould lie in ab- 
 scesses for a considerable time without be- 
 ing dissolved, and that in abscesses arising 
 either from violence, or from a species of 
 erysipelatous inflammation, there were often 
 sloughs of the eeiluiar membrane, which 
 sloughs would come away like wet tow, and 
 therefore were not dissolved into pus. (Hun- 
 ter.) 
 
 It might also have been noticed, that in 
 abscesses in tendinous parts, as about the 
 ankle, a tendon often mortified and sloughed 
 away, and that the sores would not heal til! 
 such sloughs were detached ; but though this 
 separation was sometimes not completed be- 
 fore the expiration of months, yet the sloughs 
 at last were thrown off, and consequently 
 could not be converted into pus. Pieces of 
 dead bone often lie soaking in matter for many 
 months, without being changed into pus; 
 and although bones, so circumstanced, may 
 lose a considerable deal of their substance, 
 a loss which some might impute to the dis- 
 solution of the bone into pus, yet that 
 waste can be accounted for and proved on 
 the principle of absorption. The loss is 
 always upon that surface, upon which the 
 continuity is broken off, and it is a part of 
 the process by which exfoliation of a dead 
 piece of bone is accomplished. The forma- 
 tion of pus has been attributed to a kind of 
 fermentation, in which both the solids and 
 fluids were concerned. This doctrine is 
 easily retuted by stating what happens in 
 internal canals, which naturally secrete mu- 
 cus, but frequently form pus, without any 
 loss of substance, or any previous ferment- 
 ing process. Were we to suppose a fer- 
 mentation of the solids and fluids, the imme- 
 diate cause of the production of pus, whence 
 could the solids come, which enter into the 
 composition of discharges from the urethra ? 
 for the whole penis could not afford matter 
 enough to form the pus, which is discharged 
 in a common gonorrhoea. How also could 
 the fermentation of the solids ever cease ? 
 for there is the same surface secreting its 
 mucus, whenever the formation of pus is 
 discontinued. It may be asked likeivise, by 
 w hat power the first particle of pus in an 
 abscess, or on a sore, is formed, before there 
 is any particle existing, which is capable of 
 dissolving the solids? An abscess may be 
 
SUPPURATION. 
 
 433 
 
 * 
 
 stationary for months, and at last be absorb- 
 ed ; what becomes of the fermentation all 
 the while the collection of matter continues 
 stationary ? 
 
 Extravasated blood has been supposed to 
 be capable of being converted into pus. We 
 find, however, that blood, when exiravasa- 
 ted, either from violence, or a rupture of a 
 vessel, as in aneurism, neverof itself becomes 
 pus ; nor was pus ever formed in these cases, 
 without being preceded by inflammation. 
 Both the blood and matter are also found 
 together in the same cavity, under such cir- 
 cumstances. If the blood had coagulated, 
 which it seldom does in cases of violence, 
 it would be found still coagulated ; and if it 
 bad not coagulated, the pus would be bloody. 
 (Hunter.) 
 
 The modern theory of suppuration is, that 
 tbe matter is separated from the bjood by 
 the secreting power of the vessels of the 
 inflamed part, which acquire a new mode of 
 action. 
 
 That pus is formed in the-vessels from 
 which it exudes, by an action of these ves- 
 sels analogous to secretion, was, so far as I 
 know, (says Professor Thomson) first dis- 
 tinctly suggested by Dr Simpson of St An- 
 drew’s, in his *• Dissertationes de Re Medico,,’ 
 published in tbe year 1722. An opinion 
 similar to that of Dr. Simpson’s suggested 
 itself, about the year 1756, to De Haen, from 
 the consideration of what takes place in 
 some cases of phthisis pulmonalis. This 
 author observes, that pus was often expecto- 
 rated, for a great length of time, by patients 
 affected with phthisis, in whom, after death, 
 no mark of ulceration could be perceived, 
 not even the place in which the pus had 
 been formed. The hypothesis of pus being 
 a secretion was afterward more fully con- 
 sidered by Dr. Morgan of Philadelphia, in 
 his inaugural thesis printed at Edinburgh in 
 1763, entitled “ Puopoioses, sive Tentamen 
 Medicum de Puris Confectione.” The belief 
 that pus is a secretion, or formed at least by 
 an action of the vessels analogous to secre- 
 tion, was adopted by Mr. Hunter. Indeed, 
 the merit of the original suggestion of this 
 hypothesis has been ascribed to him, though 
 improperly. Bruggraan, professor of botany 
 at Leyden, has maintained the same doc- 
 trine in an excellent thesis 11 De Puogenia ,” 
 published in 1785; and it is that which is 
 now very gen rally taught ail over Europe. 
 (See Thomson’s Lectures on Inflammation, p. 
 316, 317.) With respect to suppuration 
 from exposed surfaces, however, it is more 
 proper to say, that the vessels secrete a fluid, 
 which becomes pus; for Sir Everard Home 
 has proved, that this fluid has not the puru- 
 lent appearance, when first secreted, but 
 acquires it while it remains on the inflamed 
 surface, and does not acquire it the less 
 readily, when removed from that surface in 
 a colourless state, provided its proper tem- 
 perature be preserved, and it be kept ex- 
 posed to the air, which promotes the change. 
 
 The opinion that suppuration is a process 
 analogous to glandular secretion, was at 
 first hastily rejected by many who were 
 Vox,. II 55 
 
 swayed by tbe fact, that no pus is ever found 
 blended with the blood in the circulating 
 system. By this mode of reasoning, howe 
 ver, such thinkers must be led to deny the 
 universally received and undoubted doctrine, 
 that the bile is a secretion ; and yet it is well 
 known, that nothing like this fluid can be 
 detected in an analysis of the blood, and, in- 
 deed, a very small quantity would be suffi- 
 cient to tinge the whole mass of circulating 
 blood with a yellow 7 colour, the same as we 
 see in cases of jaundice- No one would 
 wish to defend the idea of there being 
 either pus, or bile, actually in the circula- 
 tion ; but only the matter, or modifications 
 of the matter, w hich, by tbe combinations, 
 or whatever changes we may choose to 
 term them, taking place in the secreting 
 vessels, and by their operations are com 
 verfed into one of the particular fluids in 
 question. 
 
 Violence done to parts is one of the great 
 causes of suppuration ; but simply, violence 
 does not always occasion it. The violence 
 must be followed by a prevention of a cure 
 in a more simple way, viz. by a restoration 
 of the structure, so as to carry on the animal 
 functions of the part. The parts must be 
 kept long enough in that state into which 
 they were put by the violence. Or what is 
 somewhat similar to this, the violence must 
 be attended with death in a part, as, in many 
 bruises, all mortifications and all sloughs, in 
 consequence of the application of caustic, 
 which, when the dead pnrls separate, leave 
 internal surfaces exposed. (Hunter.) 
 
 As every injury or effect of outward vio* 
 lence, under the above circumstances, is 
 more or less exposed to the surrounding air, 
 the application of air to internal surfaces has 
 been assigned as a cause of suppuration ; 
 but certainly the air has not the least effect on 
 parts, circumstanced as above, for a stimulus 
 would arise from a wound, were it even 
 contained in a vacuum. In circumscribed 
 abscesses, the air cannot possibly get to the 
 parts, so as to have any share in making them 
 suppurate 
 
 In cases of emphysema, when the air is dif- 
 fused over tbe whole body, no suppuration 
 is tbe consequence, unless an exposure or 
 imperfection of some internal surface should 
 be made, for the purpose of allowing the air 
 to escape. A stronger proof, that it is not 
 tbe admission of air, which makes parts in- 
 flame, is, that the cells in the soft parts of 
 birds, and many of the cells and canals of 
 their bones, communicating with the lungs, 
 and always containing air, never inflame 
 but if these cells are exposed in an unnatural 
 way, then the stimulus of imperfection is 
 given, these cavities then inflame, and their 
 surfaces either form adhesions together, or 
 produce pus. (Hunter.) 
 
 When the interior of an abscess is exa- 
 mined, the cavity which contained the mat- 
 ter is observed to be lined w ith a smooth, 
 raeinbranous-looking substance, which is of 
 a whitish ash-colour, and has a strong re- 
 semblance to coagulating lymph. This 
 membrane-like substance has been termed 
 
43'4 
 
 SUPPUKATlOps 
 
 the sac or cyst of the abscess. This sac or 
 cyst seems in general to adhere by a vascu- 
 lar union to the surrounding cellular mem- 
 brane, which is itself likewise denser in tex- 
 ture, and more vascular than in the natural 
 state, {Thomson' s Lectures , p. 310.) its cells 
 being closed by coagulating lytnph, effused 
 in consequence of that species of inflamma- 
 tion which Mr. Hunter termed the adhesive. 
 Thus by the formation of a cyst, and the 
 etfusion of coagulating lymph in the cellular 
 substance around the abscess, the collection 
 of matter is bounded, and cannot become 
 diffused, as it otherwise would do, in the 
 communicating cavities of the cellular mem- 
 brane, like the water in oedema. 
 
 Something like this diffusion of pus seems 
 to occur in erysipelas phlegmonoides. “ But 
 in this case, (says Professor Thomson) the 
 vitality of greater or less portions of the 
 cellular substance is destroyed, the deadened 
 portions are converted into dirty, whitish, 
 ash-coloured sloughs, and it becomes ex- 
 tremely difficult to say, whether any part of 
 the pus contained in the deadened cellular 
 membrane has been formed in the cells, in 
 which itis contained, or has been absorbed 
 into these cells, after being separated from 
 the parietes of the cavities containing the 
 sloughs themselves.” ( Lectures , p. 310.) 
 
 There can be no doubt, that after an ab- 
 scess has received a membranous lining or 
 cyst, the secretion of pus is continued from 
 the surface of the latter part entirely, as well 
 as whatever degree of absorption of the 
 same fluid happens to be going on. In fact, 
 the cysts must be both secreting and absorb- 
 ing surfaces. The circumstances which 
 leave no doubt of this point, are the frequent, 
 sudden, or gradual removal of very large 
 manifest collections of matter ; the continu- 
 al changes occurring in the quantity and con- 
 sistence of the pus ; and the speedy filling of 
 the cavity with purulent matter again after 
 the first contents of the abscess have been 
 discharged. 
 
 Another thing which is yet a subject of 
 controversy is, whether suppuration ever 
 happens unpreceded by inflammation ? Pro- 
 fessor Thomson, of Edinburgh, believes that 
 the affirmative opinion on this point was 
 first suggested by De Haen of Vienna ; but 
 lie thinks that much of the difference of sen- 
 timent in this matter has proceeded from 
 the vague “ notions entertained with regard 
 to the symptoms which necessarily charac- 
 terize the state of inflammation, and also 
 with regard to the properties by which pus 
 is to be distinguished from other animal 
 fluids. Accordingly, in almost ail the exam- 
 ples which De Haen has adduced to prove 
 the formation of pus, without the previous 
 existence of inflammation, he has himself 
 occasion to remark the exudation of coagu- 
 lating lymph, and the existence of preterna- 
 tural adhesions; phenomena which we know 
 are produced by that state, which Mr. Hun- 
 ter denominated adhesive inflammation.” 
 But De Haen uses the term inflammation 
 to express that state, which we deuorni- 
 eatc ulceration, or ulcerative absorption ; 
 
 for in speaking of the cases of suppuration, 
 which he has adduced, he observes, that 
 “ in many of them no previous loss, or con- 
 sumption of substance could be perceived.” 
 An observation similar to this was made 
 about the same time, or perhaps a little 
 earlier, by Dr. William Hunter, and an 
 account given of it in the second volume 
 of the London Medical Observations and 
 Inquiries. 
 
 Mr. Hunter, though he endeavours to 
 establish it as an invariable fact, that no 
 suppuration takes place, which is not pre- 
 ceded by inflammation, is of opinion, that 
 collections of what he terms extraneous 
 matter, something like pus, may form in 
 various parts of the body, without the pre- 
 vious existence of inflammation in the parts 
 in which it is formed ’; and accordingly you 
 will find, at page 300 of his Treatise on In- 
 flammation, a chapter entitled, ‘ Of Collec- 
 tions of Matter without Inflammation.’ ” 
 Professor Thomson doubts, however, 
 
 “ whether these collections of matter, said 
 to be formed without inflammation, would 
 not have been more properly denominated 
 scrotulous abscesses, or chronic suppurations. 
 
 I am disposed to believe (says he,) that, in 
 whatever texture or organ of the body 
 scrofula manifests itself, there inflammation 
 will be found to exist. The phenomena, it 
 is true, of inflammation, both local and con- 
 stitutional, are modified by the existence of 
 the scrofulous diathesis ; but they are, I be- 
 lieve, always present in such a degree as to 
 justify us in giving to them the name of in- 
 flammation* and in classing most, if not all, 
 local scrofulous affections, among inflamma- 
 tory diseases. When the indolent swellings, 
 of which Mr. Hunter speaks, occur near to 
 the surface of the body, that part feels 
 warmer than usual, as may be felt in white 
 swellings of the joints. The swelling also 
 is either preceded or accompanied with 
 some degree of pain, though, when the 
 afl'ection is internal, the patient may not 
 always be very accurate with regard to the 
 precise seat of this pain. .When cut into, 
 the parts also affected with scrofulous swel- 
 lings are always found more vascular than 
 usual ; in short, all the symptoms occur by 
 which the state of inflammation is charac- 
 terized.” (See Thomson's Lectures on In- 
 flammation, p. 313, 314.) In another place, 
 this author admits that the matter, which is 
 formed in chronic suppurations, does not 
 always accurately resemble that which is 
 formed in acute abscesses; but yet he con- 
 tends that it is so analogous both in its 
 physical and chymical.characters, as well as 
 in the circumstances in which it is produced, 
 that he can see no reason why it should not 
 be called pus, or a puriforra fluid, (fl. 315.) 
 
 q.UAUTIES OF PUS. 
 
 True pus has certain properties, which, 
 when taken singly, may belong to other se- 
 cretions, but which, conjointly, form the 
 peculiar character of this fluid, viz. globules 
 swimming in a fluid, which is coagulabte 
 
SUPPURATION. 
 
 435 
 
 by a solution of the muriate of ammonia, 
 which no other animal secretion is, and at 
 the same time a consequence of inflamma- 
 tion. 
 
 The colour and the consistence of pus are 
 the two qualities, which first attract the 
 notice of every, the most superficial obser- 
 ver. The colour arises from the largest 
 portion of this fluid being composed of very 
 : mall round bodies, very much like the 
 globules of cream. The fluid in which the 
 globules of pus swim, might at first be 
 supposed to be the serum of the blood, for 
 it coagulates with heat like the latter fluid. 
 Pus is also probably mixed with a small 
 quantity of coagulating iytnph ; as it partly 
 coagulates after it is secreted. However, 
 the fluid part of pus is found to have pro- 
 perties which serum has not. There being 
 a similarity between pus and milk, experi- 
 ments have been made to ascertain whether 
 the fluid of pus could be coagulated with 
 the gastric juice of animals: but no coagu- 
 lation could be effected in this manner ; a 
 solution of muriate of ammonia made the 
 fluid part of pus coagulate ; but not any 
 other secretion or natural fluid ; and hence 
 it was concluded, that whenever globules 
 were found swimming in a fluid, coagulable 
 by muriate of ammonia, the matter was to 
 be considered as pus. (Hunter.) 
 
 The proportion which the white globules 
 bear to the other parts of pus, depends on 
 the health of the parts producing the dis- 
 charge. When the globules are very abun- 
 dant, the matter i3 thicker and whiter, and 
 is called healthy pus ; the meaning of which 
 is, that the solids which produced it are in 
 good health; for these appearances in the 
 matter are no more than the result of certain 
 salutary processes going on in the solids, 
 the effect of which processes is to produce 
 the disposition,' on wfaieh both suppuration 
 and granulation depend (Hunter.) 
 
 Pus is specifically heavier than water, and 
 is probably about as heavy as blood. . 
 
 Besides the above properties, pus has a 
 sweetish mawkish taste, very diflereut from 
 that of most other secretions, and the same 
 taste takes {dace, whether it is pus from a 
 sore, or an irritated inflamed surface. 
 
 Pus has a smell in some degree peculiar 
 to itself ; but this differs in different cases. 
 Some diseases, it is said, may be known by 
 the smell, as for instance, a gonorrhoea. 
 
 Pus sinks in water ; mucus floats. Pus 
 communicates to water an uniformly trou- 
 bled white colour; mucus gives the appear- 
 ance of stringy portions floating in it. 
 Mucus is said to be more readily dissolved 
 by sulphuric acid than pus is. It has also 
 been asserted, that if water be added to 
 such solutions, the pus is precipitated to the 
 bottom of the vessel ; while the mucus, 
 instead of being completely precipitated, 
 forms swimming flakes. A solution of caus- 
 tic alkali dissolves both pus and mucus ; 
 but when water is added, the pus is said to 
 become separated, but not the mucus. 
 
 Though solutions in chymical menstrua 
 and precipitations, have been thought a 
 
 test of the distinction between these two 
 fluids, yet the method has been thought 
 absurd and unphilosophical. It has been 
 conceived, that all animal substances what- 
 ever, when in solution, either in acids or 
 alkalies, would be in the same state, and 
 therefore, that the precipitation would be 
 the same in all. Calcareous earth, when 
 dissolved in muriatic acid, is in that acid in 
 the same state, whether it has'been dissolved 
 from chalk, limestone, marble, or calcareous 
 spar, and precipitations from all are the same. 
 Hence, experiments were made on organic 
 animal matter, such as muscles, tendon, car- 
 tilage, liver, and brain ; and on inorganic, 
 such as pus and the white of an egg. Ail 
 these substances were dissolved in sulphuric 
 acid, and precipitated with potassa. Each 
 precipitation was examined with such mag- 
 nifiers, as plainly showed the forms of the 
 precipitates, all which appeared to be flaky 
 substances. The precipitate by ammonia 
 had exactly the same appearance. The same 
 appearances were seen, when the above 
 kinds of animal matter were dissolved by 
 caustic potassa, and precipitated with the 
 muriatic acid. A flaky substance, void of 
 any regular form, composed each precipi- 
 tate. (Hunter.) For additional observations 
 on the tests of pus, and an account of those 
 suggested by Dr. Young and Grasmeyer, see 
 the First Lines of the Practice of Surgery ) 
 Vol. l,p. 32, Ed. 4. 
 
 Pus does not irritate the particular surface 
 which secretes it, though it may be very ir- 
 ritating to any other. Hence, no suppura- 
 ting surface of any specific kind, can be 
 kept up by its own matter; if this had not 
 been the case, no sore of a specific quality, 
 or producing matter of an irritating kind, 
 could ever have been healed. This is simi- 
 lar to every other secretion of stimulating 
 fluids, as the bile, tears, &c. which fluids do 
 not stimulate their own glands, or ducts, but 
 are capable of stimulating any other part of 
 the body. (Hunter.) 
 
 Whenever a real disease attacks, either 
 the suppurating surface, or the constitution, 
 the production of true pus ceases, anti 
 the fluid becomes changed in some measure, 
 in proportion to these morbid alterations. 
 In general it becomes thinner and more 
 transparent, and it partakes more of the na- 
 ture of the blood, as is the case in most 
 othersecretions under similar circumstances. 
 Sanies is the term usually applied by surge- 
 ons to pus, in this degenerated state. This 
 unhealthy sort of matter has more of the se- 
 rum, and frequently more of the coagula- 
 ting lymph in it, and less of the combination 
 which renders it coagulable by a solution of 
 muriate of ammonia. It has also a greater 
 proportion of the extraneous parts of the 
 blood, which are soluble in water, such as 
 salts ; and it has a greater tendency, than 
 true pus, to become putrid. Such unheal- 
 thy matter may even be irritating to the 
 surface which produces it. 
 
 The discharge, when of an irritating sort, 
 is more stimulating to the adjoining parts 
 with which it comes in contact, than to its 
 
SUPPURATION. 
 
 '136 
 
 own secreting surface. In this manner it cns silver probes, and preparations of lead, 
 frequently produces excoriation of the skin This effect is imputed by Dr. Crawford to 
 smd ulceration. Thus the tears excoriate the sulphurated hydrogen gas, generated in 
 the skin of the cheek, in consequence of the the matter. (Phil. Trans, vol. 80, Fear 1790 3 
 quantity of salts which they contain. From p. 385.) Further interesting observations 
 this effect, matter has been called corrosive, on the nature of pus may be found in an 
 a quality which it has not ; the only proper- Essay on the Differences between Pus and 
 ty which it possesses being that of irritating Mucus, by Dr. Darwin, junior ; also in Dr. 
 parts which it touches, so as to cause their G. Pearson’s Paper in Philos. Trans. 1811. 
 absorption. (Hunter.) 
 
 When the vessels thus lose the power of use of pus. 
 
 producing good pus, they also lose more or 
 
 less the power of forming granulations. By some it is supposed to carry off hu- 
 This may depend on some deviation from mours from the constitution. Suppuration 
 the due structure and action, which such is sometimes regarded as a constitutional 
 vessels should possess, in order to be qua- disease, changed into a local one, which con- 
 lifted for the performance of these two ope- stitutional malady is discharged, or thrown 
 rations. out of the body, either in the form of pus. 
 
 Pus, from several circumstances, would or together with this fluid. Critical abscess- 
 appear in general to have a greater tenderly es have been thought to be cases of this 
 cy to putrefaction than the natural juices sort. Suppuration has also been imagined 
 have; but, perhaps, this is not the case with to carry off local complaints from other 
 pure pus, which, when first discharged from parts of the body, on the old principle of 
 an abscess, is commonly perfectly sweet, derivation or revulsion. For this reason, 
 There are, however, some exceptions to this, sores or issues are made in sound parts be- 
 but these depend on circumstances entirely fore allowing other sores to be dried up. 
 foreign to the nature of pus itself. Thus, if Suppuration is sometimes excited u T ith a 
 the abscess had any communication with the view of making parts, such as indurated 
 air, while the matter was confined in it ; or swellings, dissolve into pus ; but I have en- 
 if the collection has been so near the colon deavoured to show, that no dissolution of 
 or rectum as to have been infected by the the solids is concerned in the production of 
 feces, then we cannot wonder that the mat pus. ) 
 
 ter should become putrid. When blood is A secretion of pus is looked upon as a ge* 
 blended with pus; when sloughs are mixed neral prevention of many, or of all the cau- 
 with it ; when the parts forming the seat of ses of disease. Hence, issues are made to 
 the abscess are in a gangrenous state from an keep off both universal as well as local dis- 
 erysipelatous affection ; the matter has a eases. However, the use of pus is perhaps 
 greater tendency to putrify than the pure unknown ; for it is formed most perfectly 
 pus discharged from sound abscesses or heal- from healthy sores, and in healthy constru- 
 ing sores. Pure matter, though easily ren- tions ; and large discharges from parts not 
 dered susceptible of change, by extraneous very essential to life, produce very little 
 additions, is in its own nature tolerably uni- change in the constitution, and as little upon 
 form and immutable. It appears so un- being healed up, whatever some may sup- 
 changeable, that we find it retained in an pose to the contrary. (Hunter.) 
 abscess for weeks, without having undergone This is certainly the case with many old 
 any alteration. These qualities, however, ulcers, the suppuration from which seems 
 only belong to perfect pus. If a healthy to have little or no effect in impairing the 
 sore inflames, the matter now produced from health. Nor is there any real reason to be 
 it, though unmixed with extravasated blood, afraid of healing such ulcers, when possible, 
 or dead solids, becomes much sooner putrid, lest a worse disease should follow from the 
 and much more irritating, than the discharge stoppage of a discharge to which the system 
 formed before this alteration of the ulcer, is supposed to be so habituated that the 
 (Hunter.) continuance of it must be essential to 
 
 In the preceding paragraph it is stated, health 
 that matter remains very often unchanged Every one know s, that when there is no 
 in abscesses for weeks. This expression of interference of art, that is. when the surface 
 Hunter’s is not strictly correct ; for it is w ell of a sore is left uncovered, the thin part of 
 known, that the surfaces of the cavities of the matter evaporates, and the thick part 
 abscesses are always absorbing, as well as dries and forms a scab. Nature, therefore, 
 secreting ones ; consequently, there must seems to have designed that one use of pus 
 be a continual mutation going on in the con- should be to make a cover, or protection 
 tained matter. for ulcerated surfaces. But I cannot agree 
 
 When there are diseased bones, or other w r ith what has been asserted, (Hunter) that 
 extraneous bodies, exciting irritation, some- the natural healing of a sore under a scab 
 times even in so great a degree as to make\ takes place more quickly than when surgi- 
 the vessels bleed, and often wounding the cal dressings are employed, 
 vessels of the part, the matter is always On ulcers, as would appear from modem 
 found to be very offensive. This state of microscopical observations, u the coagula- 
 the discharge is one mark of a diseased ted pus is rendered tubular by the extrica- 
 fcone. tion of its carbonic acid gas, and that these 
 
 The discharge of an unhealthy sore black- tubes, or canals, are immediately filled with 
 
SUPPURATION 
 
 red blood, and thus connected with the cir- 
 culation.” If this point be established, Sir 
 Everard Home conceives that there will 
 then be little difficulty in making out the 
 succeeding changes, by means of which 
 the coagulated pus afterward becomes or- 
 ganized. (On the conversion of Pus into 
 Granulations or new Flesh , in Phil. Trans. 
 Vol. 109, p. 109, Lond. 1819) These state- 
 ments are curious, and ought to have been 
 noticed in the article Granulations, to which 
 they more immediately relate. 
 
 Among the secondary uses of suppura- 
 tion, maybe mentioned, opening a commu- 
 nication between a disease and the external 
 surface of the body ; forming a passage for 
 the exit of extraneous bodies, be. 
 
 TREATMENT WHEN SUPPURATION MUST TAKE 
 PLACE. 
 
 In cases of inflammation, arising from 
 accident, but so circumstanced, that w r e 
 know suppuration cannot be prevented, the 
 indication is to moderate the inflammation, 
 which, if the powers are great, and the in- 
 jury done considerable, will probably be 
 very violent. If the constitution should also 
 be much affected, certain general means are 
 proper, such as bleeding, purging, and nau- 
 seating medicines. While the constitution 
 continues to be disturbed, suppuration can- 
 not take place in the most favourable man- 
 ner. In these cases, also, such medicines 
 as produce a gentle perspiration greatly re- 
 lieve the patient, for instance, the pulv. 
 ipecac, comp.; antimonials; aq. ammon. 
 acet.; saline draughts, fee. Opiates may 
 produce a temporary diminution of action; 
 but it is not always the consequence of this 
 medicine, as there are constitutions which 
 it renders more irritable, and of course 
 where it aggravates the inflammatory ac- 
 tion. 
 
 The applications to inflammations, which 
 are to suppurate and form an abscess, com- 
 monly used are poultices and fomentations. 
 These, however, appear to be applied with- 
 out much critical exactness or discrimina- 
 tion ; for they are applied before suppura- 
 tion has taken place, and when this event 
 is not desired ; and they are also applied 
 after suppuration has taken place. With 
 respect to suppuration itself, abstracted from 
 all other considerations, the indication 
 cannot be the same in every state . but if 
 poultices and fomentations are found to be 
 of real service in the two stages of the dis 
 ease, there must be something common to 
 both, for which they are of service, inde- 
 pendently of simple suppuration. Poultices 
 are useful when the inflammation attacks 
 therskin, either in the first instance or after 
 an abscess has approached so near the skin 
 that this becomes secondarily affected. This 
 benefit appears to arise from the skin being 
 kept soft and moist. Such is the use of a 
 poultice in inflammation, either before or 
 after suppuration, until the abscess is open- 
 ed. But, when poultices and fomentations 
 are applied to inflamed parts, in which we 
 
 wish to avoid suppuration, reason and prin- 
 ciple will not justify the practice, though 
 such applications may be proclaimed by 
 experience to be very proper. (Hunter.) 
 
 TREATMENT' AFTER SUPPURATION HAS TAKEI7 
 PLACE. 
 
 When suppuration cannot be stopped, or 
 resolved it is in general to be promoted. 
 
 How far suppuration can be usefully pro- 
 moted by medicines or applications, is 
 questionable; but attempts are generally 
 made, and, for Ibis purpose, suppurating 
 cataplasms and plasters, composed of the 
 warm gums, seed's, kc. were formerly much 
 recommended. Mr. Hunter doubted, whe- 
 ther such applications had any considerable 
 effect in the way intended ; for, if they were 
 put on a sore, they would hardly increase 
 the discharge from it, and perhaps even di- 
 minish it. However, in many cases in which 
 the parts are indolent, and hardly admit of 
 true inflammation, in consequence of which 
 a perfect suppuration cannot take place, 
 stimulating the skin brings on a more salu- 
 tary, and of course a quicker inflammation. 
 Thus the antimonial ointment, and blister - 
 ing the skin, over chronic swellings and 
 abscesses, are sometimes indicated. 
 
 These applications have been found, how- 
 ever, to bring the matter more quickly to 
 the skin, even in the most rapid suppura- 
 tions. This effect has been mistaken fox 3 
 an increased formation of pus ; but this 
 consequence can only follow in cases in 
 whi> h the inner surface of the abscess is 
 within the influence of the skin. The ac- 
 celerated progress of the matter to the sur- 
 face of the body arises from another cause, 
 viz. the promotion of ulceration in the parts, 
 between the collection of matter and the cu- 
 ticle. 
 
 Emollient poultices are commonly ap- 
 plied to inflamed parts, when suppuration 
 is known to have taken place. These can 
 have no effect upon suppuration, except 
 that of lessening the inflammation, or ra- 
 ther making the skin. more easy. The in- 
 flammation must have reached the skin 
 before poultices can have much effect, for 
 they can only affect that part. The ease of, 
 the patient, however, should be considered, 
 and We find that fomentations and poultices 
 are often beneficial in this way. By keep- 
 ing the cuticle moist and warm, the sensi- 
 tive operations of the nerves of the parts 
 are soothed. On the contrary, if the infla- 
 med skin is allowed to dry, the inflamma- 
 tion is increased, and as suppuration is pro- 
 bably not checked by the above treatment, 
 it ought to be put in practice. As warmth 
 excites action, the fomentation should be 
 as warm as the patient can bear without in- 
 convenience. (Hunter.) 
 
 “ The local treatment in phlegmonous 
 abscesses (as professor Thomson observes) 
 is still more simple than that by which we 
 endeavour to procure resolution. It con- 
 sists almost solely in the application of a 
 moderate degree of warmth and moisture 
 
Suppuration. 
 
 4.3s 
 
 to the inflamed pari, either by means of 
 fomentations or poulticed. The manner in 
 which these means act in promoting sup- 
 puration is unknown, independently of 
 their temperature, it seems very doubtful 
 whether fomentations and poultices have 
 any power of promoting suppuration in the 
 parts to which they are applied. They keep 
 the cuticle moist and warm, they promote 
 perspiration, they sooth and allay pain in 
 many inflammations, and these are probably 
 the only immediate effects which they pro- 
 duce. The rest is the work of nature. In 
 suppurations, attended by very sevefe pain, 
 the use of w arm fomentations is often found 
 to atford singular relief, not only by their 
 effect in easing pain, but also by their seem- 
 ing to shorten the duration of the suppura- 
 tive stage. In the cases of suppuration, in 
 which they give relief, they should be re- 
 peated every four or six diours. The most 
 common way of employing them is by 
 wringing linen, or woollen cloths, out of 
 warm water, and applying these to the in- 
 flamed part, of as high a temperature as the 
 feelings of the patient can bear. Decoc- 
 tions of herbs were formerly much employ- 
 ed in the way of embrocation, and were 
 then, and are still, by many practitioners, 
 supposed to possess peculiar virtues in pro- 
 moting suppuration. Whether embroca- 
 tions with the narcotic herbs might not in 
 some cases be beneficial, by producing a 
 sedative effect in allaying pain, I arn una- 
 ble to say, though 1 am inclined to believe 
 that even they act chiefly by their warmth 
 and moisture. In cases where you find it 
 necessary to use an embrocation with herbs, 
 the flowers of chamomile may in general be 
 substituted in place of the leaves or flowers 
 of almost every other plant. These flow- 
 ers readily imbibe and retain moisture. 
 They are, when moist, of a soft consistence, 
 and can be easily moulded to the figure of 
 the parts to which they are applied.” 
 (Thomson’s Lectures , p. 333.) Oatmeal, 
 crumb of bread, and especially linseed 
 meal, are the ingredients mostly preferred 
 in this country for emollient poultices. 
 When bread is used, it is generally boded 
 in milk. The observations, however, Which 
 have been offered on poultices in another 
 place, are here equally applicable. (See 
 Inflammation.) 
 
 OF THE TIME WHEN ABSCESSES SHOULD BE 
 OPENED. 
 
 As abscesses, wherever formed, must in- 
 crease that part of their cavity which is 
 next to the skin, more quickly than the 
 bottom, they must become, in some degree, 
 tapering towards the latter part, with their 
 greatest breadth immediately under the 
 skin. This shape of an abscess, when allow- 
 ed to take place is favourable to its healing, 
 for it puts the bottom, which is the scat of 
 the disease, more upon a footing with the 
 mouth of the abscess than it otherwise could 
 be. As the bottom, or part where the ab- 
 scess began, is more or less in a diseased 
 
 state ; and as the parts between the seat of 
 the abscess and the external surface are 
 sound parts, having only allowed a passage 
 for the pus, they, of course, have a stronger 
 disposition to heal than-the bottom has. 
 
 To keep the mouth of an abscess from 
 healing before its bottom, the collection of 
 matter should be allowed to break of itself; 
 for although abscesses in general only open 
 by a small orifice, more especially when 
 sound, yet, in such cases, the skin over the 
 general cavily of the matter is so thinned, 
 thatit has very little tendency to heal, and 
 often ulcerates and makes a free opening. 
 If the latter event should not spontaneously 
 occur, it may now be more easily obtained 
 by the interference of the surgeon. 
 
 Abscesses w hich are the most disposed to 
 heal favourably, are the quickest in their 
 progress to the skin, and the matter comes 
 to the surface almost at a point ; the swell- 
 ing is not so conical as in other cases, and 
 when it bursts the orifice is exceedingly 
 small. On the other hand, when there is 
 an indolence in the progress of the abscess, 
 the collection spreads more, or distends the 
 surrounding parts in a greater degree, in 
 consequence of their not being so finely 
 united by inflammation in the one as they 
 are in the other instance ; nor will ulcera- 
 tion so readily take the lead, and the matter 
 will come to the skin by a broad surface, 
 so as to thin a large portion of the cutis. 
 (Hunter.) 
 
 It may be set down as a general axiom, 
 that alf phlegmonous abscesses should be 
 allowed to break, and not be opened by the 
 surgeon. When punctured unnecessarily, 
 or prematurely, they never heal so favoura- 
 bly as when left to themselves. 
 
 Particular cases, however, should be 
 opened as soon as the existence of matter 
 is ascertained. Abscesses should only be 
 allowed to burst of themselves, when the 
 confinement of the matter can do no mis 
 chief. Abscesses in tbe abdomen or tho- 
 rax, under the cranium, near the eye, or in 
 joints, should be mostly opened very soon. 
 When suppuration takes place beneath liga- 
 mentous expansions, or aponeuroses, which 
 invariably retard the progress of the matter 
 to the surface of the body, an early opening 
 should be made. It this be not done, the 
 matter spreads to a great extent, separating 
 such ligamentous expansions from the mus- 
 cles, and the muscles from each other, and, 
 as the pus cannot get to the surface of the 
 body; the length of the disorder is of course 
 increased. When matter is so situated as 
 to be liable to insinuate itself into the chest 
 or abdomen, or into the capsular ligaments 
 of the joints, it is highly proper to prevent 
 this extension of mischief, by making a 
 timely opening into the abscess. 
 
 u Those abscesses ought to be opened 
 early, (says Professor Thomson) that are 
 situated in parts through which the matter 
 is liable to become widely diffused. This 
 is particularly the case with abscesses that 
 are situated on the forepart of the neck, or 
 in the cavity of the axilla, or by the side of 
 
SUPPURATION. 
 
 433 
 
 iii e rectum. When matter is formed In the 
 cavity of the axilla, if it does not speedily 
 obtain an external outlet, it is very liable to 
 pass up towards the clavicle in the course 
 of the axillary plexus of nerves and vessels, 
 or forwards under the pectoral muscle. I 
 have repeatedly seen axillary abscess take 
 both of these directions at the same time, 
 forming one of the most painful and diffi- 
 cult cases to treat which occurs in the ma- 
 nagement of abscesses.” Dr. Thomson also 
 considers an early opening proper and ne- 
 cessary, where the matter is lodged, as in 
 some cases of whitloe, in the sheaths of the 
 tendons; where matter is formed under the 
 periosteum ; where it collects under fas- 
 ciae, or in the vicinity of large arteries, 
 joints, or the greater cavities of the body: 
 also when the abscess is deep-seated. (See 
 Thomson’s Lectures on Inflammation , p. 
 336 — 338 .) 
 
 With respect to making an early opening 
 into abscesses, situated near large arteries, 
 
 I am not aware, that any danger of the ar- 
 tery ulcerating in consequence of the near- 
 ness of the pus, really exists. Therefore, 
 some doubts may reasonably be entertained 
 of Professor Thomson’s advice in this par- 
 ticular case, as the general rule of opening 
 abscesses nearHarge blood-vessels, in an 
 early stage of the disease, would be objec- 
 tionable on the ground of the practice ex- 
 posing the vessels themselves to injury. 
 Indeed, this well-informed writer distinctly 
 mentions, in considering the subject in 
 question, that the arteries are not very 
 susceptible of ulcerating absorption. (P. 
 337 .) 
 
 OF THE PLACE WHERE THE OPENING SHOULD 
 BE MADE. 
 
 If a free opening is not required, or ma- 
 king one is not practicable, it is at least pro- 
 per to make whatever opening can be made 
 in a depending situation. By this means 
 the matter will more readily escape, and all 
 pressure arising from the confinement or 
 lodgment of pus, will be prevented. Avery 
 small degree of pressure on that side of the 
 abscess which is next to the skin, may pro- 
 duce ulceration there ; and although such 
 pressure might not, in many cases, be so 
 great as to produce ulceration at the bottom 
 of the abscess ; yet it might be sufficiently 
 great to prevent granulations from forming 
 on that side, and thereby retard the cure, 
 as no union can take place, but by means 
 of granulations. The pressure is always 
 most, and retards the formation of granula- 
 tions in the greatest degree, at the most de- 
 pending part of the abscess. Hence, if no 
 opening be made in this situation, tbw upper 
 part of the abscess readily heals to a small 
 point, which becomes a fistula. 
 
 When circumstances forbid making an 
 opening at the most depending part of an 
 abscess, perhaps nothing more can be done, 
 than to evacuate the matter as often as ne- 
 cessary, and gently^to compress fixe sides of 
 
 the abscess together, when the situation of 
 the case admits of the practice. 
 
 But abscesses are not always to be open- 
 ed at the most depending part. The distance 
 between the matter and- the skin at this part 
 is the common reason against the method. 
 If an abscess is rather deeply situated, and 
 points in a place which is higher than where 
 the collection lies, it is proper to make the 
 opening where the conical eminence, or as 
 it is terme.d, the pointing, appears. Thus, if 
 an abscess should form in the centre of the 
 breast, and point at the uppermost part, 
 which is often the case, jt would be impro- 
 per to cut through the lower half of the 
 mamma, in order to make a passage for the 
 matter in that direction. If an abscess 
 should form on the upper part of the foot, 
 it would be wrong to make an opening 
 through the sole of the foot to get at the 
 most depending part of the abscess ; (or, 
 besides cutting such a depth of sound 
 parts, a great many useful ones would be 
 destroyed. 
 
 When the abscess does not point in a de- 
 pending situation, as in the instances just 
 cited, since the place where the matter 
 threatens to open a passage is likely to be 
 the future opening, and this situation is dis- 
 advantageous to the healing of the deep 
 part of the abscess, it is generally best to 
 let tbe collection of matter first burst of 
 itself, and then dilate the opening as freely 
 as necessary. By allowing abscesses to 
 burst spontaneously, the opening is not so 
 apt to heal as if made by art, and therefore, 
 is better in such situations. (Hunter.) 
 
 In most cases, it is more advantageous 
 erven to cut through a certain thickness of 
 parts, for the sake of obtaining a depending 
 opening, than to make an opening, where 
 the pointing appears, that is, where the parts 
 are thinnest, and the matter nearest the sur- 
 face. This remark is highly worthy of re- 
 membrance, when there is no doubt of the 
 existence of matter at the depending place, 
 and when the parts to be divided are not im- 
 portant ones. Collections of matter be- 
 neath the fasciae of the fore-arm and thigh 
 particularly demand attention to this direc 
 tion, as they commonly point where thgsc 
 ligamentous expansions are thinnest, not 
 where the matter can most readily escape. 
 
 Abscesses in the sheath of the rectus ab- 
 dominis should also be opened in a low situ- 
 ation. 
 
 DIFFERENT METHODS OF OPENING AB 1 
 SCESSES. 
 
 All abscesses will naturally burst of them- 
 selves, unless the matter be absorbed, and, 
 in general, they ought to be allowed to 
 take this course. There are, however, as I 
 have already explained, particular circum 
 stances which require an early opening ; 
 but, when the skin over the abscess is very 
 thin, it is not (ff so much consequence, 
 whether the case be permitted to burst of 
 itself, or it be opened by the surgeon. 
 
 When abscesses are large, it is generally 
 
SUPPURATION, 
 
 m 
 
 necessary to open them by art, whether they 
 have hurst of themselves or not; for, the 
 natural opening will seldom be sufficient 
 for the completion of a cure ; and, although 
 it may be sufficient for the free discharge of 
 the matter, yet these abscesses will heal 
 much more readily when a free opening is 
 made ; for, the thin skin over the cavity 
 granulates but indifferently, and therefore 
 unites but slowly with the parts underneath. 
 (Hunter.) 
 
 Abscesses may be opened either by an 
 incision or by making an eschar with caus- 
 tic. To the latter pjan, however, many urge 
 strong objections : the use of caustic is not 
 usually attended with any advantage which 
 may not be obtained by a simple incision ; 
 upon a tender inflamed part it gives much 
 more pain ; it is more slow in its effects ; 
 and the surgeon can never direct the ope- 
 ration of the caustic so accurately as to de- 
 stroy exactly the parts which he wishes, and 
 no more. If the eschar be not made deep- 
 ly enough, the lancet must, after all, be 
 used Caustic also leaves, after its applica- 
 tion, a disagreeable scar, a consideration of 
 some importance in opening abscesses about 
 the female neck or face. To these nume- 
 rous objections we have to add, that the 
 eschar is, very frequently, ten or twelve te- 
 dious days in becoming detached. 
 
 When there is a redundance of skin, or 
 when there is a good deal of it thinned, 
 however, an opening made with caustic 
 will answ r er, perhaps, as well as an incision. 
 The application of a caustic may also some- 
 times be advantageously resored fo when 
 there is a good deal of indolent hardness 
 around a small abscess. 
 
 The calx cum polassa, or the potassa alone, 
 is the best caustic for opening abscesses. 
 The part is first to be covered with a piece 
 of adhesive plaster, which has a portion 
 cut out exactly of the same figure and size 
 as the opening intended to be made in the 
 abscess. The best way of making the eschar 
 is to dip the end of the caustic in water, and 
 to rub it on the part till the skin becomes 
 brown. The active substance is then vo be 
 immediately washed off with some wet tow, 
 the plaster is to be removed, and an emol- 
 lient poultice applied. 
 
 In almost all cases, it is better to use the 
 lancet, or double-e iged bistoury. Either 
 of these instruments opens the abscess at 
 once, and with less pain, than results from 
 the use of caustic; it occasions no loss of 
 substance, consequently a smaller cicatrix ; 
 and, by using it, the opening may be made 
 in the most advantageous direction, and of 
 the exact size required. 
 
 DRESSINGS AFTER OPENING ABSCESSES. 
 
 When an abscess has burst of itself, and 
 it is unnecessary to enlarge the opening, the 
 only thing requisite is to l^ep the surround- 
 ing parts clean. The continuation of the 
 same kind of poultice, which was before 
 used, is, perhaps, ns good a practice as any ; 
 and when the tenderness, arising from the 
 
 inflammation, is over, lint and a pledged 
 may be made use of, instead of the poul- 
 tice. 
 
 But, an abscess, opened by a cutting in- 
 strument, is both a w r ound and a sore, and 
 partakes more of the nature of a fresh 
 wound in proportion to the thickness of the 
 parts cut. Hence, it is necessary that some- 
 thing should be put into the opening to keep 
 it from healing by the first intention. If it 
 is lint, it should be dipped in some salve, 
 which will answer better than lint alone, as 
 it will allow of being taken out sooner. 
 This is advantageous, because such sores 
 should be dressed the next day. or at latest 
 on the second day, in order that the pus may 
 be discharged again. When the cut edges of 
 the opening have suppurated, which will be 
 in a few days, the future dressings may be as 
 simple as possible, for nature will, in gene- 
 ral, complete the cure. 
 
 If the abscess has been opened with caus- 
 tic, and the slough has either been cut out: 
 or separated of itself, the case is to be re- 
 garded altogether as a suppurating sore, and 
 dressed accordingly. 
 
 Perhaps, dry lint is as good a dressing as 
 any, till the nature of the sore is known. 
 If it should be of a good kind, the same 
 dressing may be continued*; but, if not, 
 then it must be dressed accordingly. Parts, 
 which at first appear to be sound, some- 
 times assume every species of disease, 
 whether from indolence, from irritability, 
 from scrofulous, and other dispositions. 
 This tendency to disease arises, in some ca- 
 ses, from the nature of the parts affected, 
 as, for instance, bone, ligament, &o. (Hun- 
 ter.) 
 
 Consult particularly John Hunter's Trea- 
 tise on.the Blood , Inflammation, nnd Gunshot 
 Wounds , a work, in which more interesting 
 knowledge respecting Abscesses and Suppura- 
 tion is contained, than in any other ever pub- 
 lished. See also Traite de la Suppuration 
 de F Ouesnay, 1749. J Grashuis, A Diss. 
 on Suppuration, 8 vo. Load. 1752. Various 
 parts of the Memoir es de 1' Academic de Chi- 
 r /rgie. J B Boyer , De Suppuratione et Cu- 
 ratione Inflammatvmis per Suppuralionem ter- 
 minandee. Monsp. 1766. U Encyclopedic Me 
 thodique. Partie Chirurgicale, article Abces. 
 Dissertations on Inflammation by John Burns, 
 1800. Sir E Home's Dissertation on the 
 Properties of Pus , 1788 ; and his Pract. Obs. 
 on Ulcers, 2d Edit. 1S01 James Hendy, 
 Essay on Glandular Secretion, containing an 
 experimental Inquiry into the Formation of 
 Pus, fyc.8vo. Loud. 1775. JY. Romayne, De 
 Puris Generatione,8vo. Edinb. 1780. C. Dar- 
 wins Experiments, establishing a criterion be- 
 tween mucilaginous and purulent matter, fyc. 
 Litchfield, 1780. P. Clare, Essay on Abscesses. 
 Loud. 1781. Several parts of Poll's Chirurgi- 
 cal Works, but especially his Treatise on the 
 Fistula in Ano. T. Brand , Strictures in Vin- 
 dication of some of the Doctrinesmisreprcsented 
 by Mr. Foot in his two pamphlets, entitled “Ob- 
 servations upon the new opinions of J. Hunter , 
 in his Treatise on the Venereal, including Mr. 
 Pott' Plagiarisms, and misinfomal'bv p*r. 
 
SURGERY. 
 
 4.41 
 
 Pus," fyc. 4 to. Load. 1787. Richter, Anfangs- 
 griinde der Wundarzneykunst, B. 1, Kap. 2. 
 Dr. J. Thomson's Lectures on Inflammation, 
 p. 305. tyc. Edinb 1813 ; a work, in which a 
 profound knowledge of medical science, and 
 of surgery in particular , is every where con- 
 spicuous. J. F. Crevecwur, De Diagnosi 
 Puris ; Longchamps, 1793. Pearson's Prin- 
 ciples of Surgery, p. 34, §'C. Edit. 2. Lassus 
 Pathologic Cfururgicale. T 1 , p. 21, fyc. fyc. 
 Edit, of 1809. Stb.J. Brugmans, De Puo- 
 genia, sive mediis quihus naturautitur in cre- 
 au do pure, 8vo. Groningce, 1785. Dr. G. 
 Pearson s ' ibs . and Experiments on Pus in the 
 Philosophical Trans, for 1811. C. J. M. 
 Langenbeck, Von der Behandiung der Fistel- 
 gttnge, der Schusscanale , und grosser Eiter 
 absonderndtr Holden, in Neue Bibl. far die 
 Chirurgie, 12mo. Hanover, 1817. 
 
 SURGERY, or C 111 RURGERY, (derived 
 from chirurgeon, from the hand, and 
 
 s e,yov, work,) has been by many considered 
 to be that branch of medicine, which prin- 
 cipally effects the cure of diseases by the 
 application of the hand alone, the employ- 
 ment of instruments, or the use of topical 
 remedies. (Encyclopedic Mcthodique, Padie 
 Chir. Tom. I, Art. Cliirurgie.) But, although 
 this definition certainly conveys to us some 
 idea of the nature of this most useful pro- 
 fession, it is not entirely accurate as applied 
 to the present state of practice. It might, 
 indeed, be correct during that short unfa- 
 voured period of surgery upon the conti- 
 nent, some centuries ago, when its practice 
 was denounced by the Council of Tours, 
 as unfit for the hands of priests and men of 
 literature, and when the surgeon became 
 little better than a sort of professional ser- 
 vant to the physician, the latter alone not 
 only having the sole privilege of prescribing 
 internal medicines, but even that of judging 
 and directing when surgical operations 
 should be performed. Then the subordi- 
 nate surgeon was only called upon to exe- 
 cute with his knife, or his hand, duties 
 which the more exalted physician did not 
 choose to undertake ;.and, in fact he visit- 
 ed'the patient, did what was required to be 
 done, and took his leave of the case alto- 
 gether under the orders of his master. In 
 modern times, however, the good sense of 
 mankind has discovered that surgery is de- 
 serving of an eminent rank among such 
 arts as ought to be cultivated for the gene- 
 ral benefit of society ; that the man who is 
 not himself accustomed to the performance 
 of operations, cannot be the best judge of 
 their safety and necessity j and that, in 
 every point of viewy the surgical practition- 
 er merits as much favour and independence 
 in the exercise of his profession, as he 
 whose avocation is confined to physic. 
 Hence, the surgeon is now exclusively con- 
 sulted about many of the most important 
 diseases to which the human body is liable. 
 Being no longer under the yoke of the phy- 
 sician, he follows the dictates of his own 
 judgment and knowledge ; he prescribes 
 whatever medicines the case may demand, 
 internal as well as external ; and under the 
 Vor,, 11 
 
 encouragement of an enlightened age, he 
 sees his profession daily becoming more 
 scientific, more respected, and more exten- 
 sively useful. 
 
 By some writers, physic is said to have 
 for its object the treatment of internal, 
 surgery that of external diseases. This 
 definition, however good and plausible it 
 may at first appear, can only be received 
 with numerous exceptions in regard to 
 modern surgery : for instance, the psoas 
 abscess, stone in the bladder, an extravasa- 
 tion of blood withiritheskullin consequence 
 of accidental violence, are universally allow- 
 ed to be strictly chirurgical cases ; yet no 
 man in his senses would call these disorders 
 external. 
 
 Others have defined surgery to be the me- 
 chanical part of physic, “ quod in therapeia 
 mechanicum but, although this has obtain- 
 ed the assent of so eminent a modern sur- 
 geon as Professor Richerand, of Paris, (Did. 
 des Sciences Medicates, Tom. 5, p. 85.) I 
 believe few on this side of the water will be 
 of his opinion. As Mr John Pearson has 
 observed, “ Many people have imagined 
 that when a man has learnt the art of dress- 
 ing sores, of applying bandages, and per- 
 forming operations with a little dexterity, 
 he must necessarily be an accomplished 
 surgeon. If a conclusion so gross and falla- 
 cious had been confined to the vulgar and 
 illiterate, the progress of scientific surgery 
 would have suffered little interruption ; but 
 if young minds are directed to these objects, 
 as the only important matters upon which, 
 their faculties are to be exercised ; if the 
 gross informations of sense constitute the 
 sum of their knowledge, little more can be 
 expected from such a mode of study, than 
 servile imitation, or daring empiricism. In- 
 deed, some people have affected to oppose 
 surgery as an art, to medicine as a science ; 
 and if their pretensions w T ere justly founded, 
 the former would certainly be degraded to 
 a mere mechanical occupation. But it is 
 not very easy to comprehend the grounds 
 of such a distinction. The internal and 
 external parts of the body are governed by 
 the same general laws during a state of 
 health ; and, if an internal part be attacked 
 with inflammation, the appearances and 
 effects will bear a great similarity to the 
 same disease situated externally ; nor are 
 the indications of cure, in general, materi- 
 ally different. If by science, therefore, be 
 meant ‘ a knowledge of the laws of nature,* 
 he who knows what is known of the order 
 and method of nature, in the production, 
 progress, and termination of surgical dis- 
 eases, merits as justly the title of a scienti- 
 fical practitioner as the well-educated phy- 
 sician. The practical parts of physic and 
 surgery are very frequently disunited ; but 
 their theory and principles are indivisible, 
 since they truly constitute one and the same 
 science.” (Pearson's Principles of Surgery , 
 Preface.) 
 
 But, though we can object on good grounds 
 to the above-mentioned definitions of surge- 
 ry. it seems impossible to offer any other. 
 
SURGERY 
 
 •142 
 
 against „which equal objections could not 
 be brought. Tn fact, how is it possible to 
 define surgery with any degree of accuracy, 
 until the boundaries between it and physic 
 can be determined ? Richerand talks indeed 
 of the Medical School of Paris having now 
 successfully established the limits and 'ob- 
 jects of surgery, and he boasts of this as an 
 original improvement reflecting credit on 
 his countrymen. (See Did. des Sciences 
 Med. T. 5, p. 88.) Yet, what are we to 
 think, when we remember, not only that 
 he has, in the commencement of the very 
 same article, defined surgery to be u quod 
 in therapeia mechanicum ” but that by way 
 of illustrating what the Parisian School has 
 accomplished, he says, that surgery was first 
 demonstrated by it to be only a means of 
 physic, and not a separate and distinct 
 science ? (See also Dicl. des Sciences Med. 
 article Chirurgicales , Maladies.) 
 
 As a learned Professor notices, the limits 
 between physic and surgery are not very 
 precisely marked, and the respective func- 
 tions of the physician and surgeon, long as 
 those names have existed, are still but very 
 * ^accurately defined. “The most superfi- 
 cial acquaintance with the symptoms, pro- 
 gress, and termination of the various mor- 
 bid affections to which the human body is 
 liable, must be sufficient to convince every 
 unprejudiced inquirer, that there is but a 
 slight foundation, if indeed there be any, 
 for this distinction, in the nature of the dis- 
 eases, which these practitioners are required 
 to treat, or in the modes of treatment, by 
 which the diseases themselves may be cured 
 or relieved. Experience has long shown, 
 that the use of internal remedies is not only 
 required in a large proportion of the diseases, 
 which are regarded as strictly chirurgical, but 
 also, that there are few diseases, which come 
 under the care of the physician, in which 
 morbid affections, requiring the manual aid, 
 or practical skill of the surgeon, do not fre- 
 quently occur. 
 
 “ The treatment of febrile and internal 
 inflammatory diseases, it will be allowed, 
 belongs exclusively to the province of the 
 physician, w herever the distinction between 
 physician and surgeon has been introduced, 
 and is rigidly observed ; yet, in some species 
 of fevers, and in all internal inflammatory 
 diseases, blood-letting is often the principal, 
 if not the only remedy that is required. 
 But this is an operation, however urgent the 
 necessity for it be, which from engagement 
 the physician cannot, and, from the fear of 
 degrading his province of the profession, 
 will not perform. Retention of urine not 
 unfrequently takes place in symptomatic 
 febrile diseases, and this is an affection 
 which does not always yield to the use of 
 internal remedies; but it is an affection 
 also, from the painful uneasiness, which it 
 immediately excites, as well as from the dan- 
 ger which it threatens, that will not admit 
 of delay. When internal remedies, therefore, 
 fail in relieving the patient, the urine must 
 be speedily drawn off by means of a chirur- 
 
 gical operation ; otherwise inflammation, 
 mortification, and rupture of the bladder, 
 must necessarily ensue. Febrile and in- 
 ternal inflammatory affections terminate not 
 unfrequently in the formation of fluids, 
 w hich it is necessary to let out by a chirur- 
 gical operation ; and abscesses, fistulous 
 openings, and ulcers are formed, which re- 
 quire the aid of the surgeon. In patients, 
 also, affected with severe febrile diseases, 
 from being long fixed down to their beds in 
 one position, some of the parts of the body, 
 upon which they rest, occasionally acquire a 
 disposition to mortify, larger or smaller 
 portions of the skin and subjacent cellular 
 membrane becoming dead, separate from 
 the living parts, and sores are formed, wffiich 
 are but too often the subject of unavailing 
 chirurgical practice. To employ, in the 
 different stages of this species of mortifica- 
 tion, from its first commencement to the 
 complete separation of the dead parts, and 
 the formation of a new r skin, the appropri- 
 ate external and internal remedies, requires 
 a greater share of chirurgical skill than can 
 reasonably be expected in those who make 
 a profession solely of physic. Unhappy, 
 therefore, must be the lot of that patient, 
 who in circumstances similar to those w'hich 
 I have described, has the misfortune to have 
 for his sole medical attendant, a physician 
 ignorant of surgery. 
 
 “ Bui (continues Professor Thomson , ) if 
 a knowledge of surgery be necessary to the 
 student who intends to practise physic, the 
 knowledge of physic, on the other hand, 
 is no less necessary to him w r ho intends to> 
 devote his attention exclusively to the pro- 
 fession ot surgery; for, indeed, there are 
 few chirurgical diseases, which are not in 
 some period or another of their existence, 
 accompanied by mobid affections of the 
 same nature with those which fall properly, 
 and most frequently under the care of the 
 physician. It will only be necessary to men- 
 tion, as examples of these affections, the 
 symtomatic fever, which attends inflamma- 
 tion, whetherthis affection has been induced 
 by external injury, or has occurred spontane- 
 ously in the body from internal disease ; the 
 hectic fever, supervening to long-continued 
 processes of suppuration ; the febrile state 
 and other morbid affections, which are some- 
 times brought on by the too sudden and in- 
 judicious use of mercury ; bilious fevers, 
 and the various derangements of the di- 
 gestive organs, which are sometimes the 
 cause, and at other times the consequence, 
 of local diseases ; the nervous affections, 
 such as apoplexy, convulsions, paralysis, 
 and mania, which arise not unfrequently 
 from injuries of the head ; and locked jau r , 
 or tetanus, which, in warm climates parti- 
 cularly, is so very liable to be induced by 
 punctured wounds. These are morbid af- 
 fections, the proper study and treatment of 
 which, when they occur without local inju- 
 ry, are supposed to belong to the physiciu.% 
 rather than the surgeon ; but occuring very 
 frequently as they do in chirurgical diseases, 
 and always modifying, or aggravating, the 
 
SUHGEKi 
 
 
 «tfects oi these diseases, ignorance of their 
 nature, relations, and modes of cure, is not 
 only inexcusable, but highly criminal in the 
 practitioner, who ventures to undertake 
 their treatment.” ( Thomson's Lectures on 
 Inflammation , Introduction. Also J. R. C. 
 Bollman, Tentamen, ostendens Chirurgiam a 
 Medicina hand impune separari, 12 mo. Rintel , 
 1803.) 
 
 From what has been stated, I think it 
 very certain, that there never can be a com- 
 plete scientific division of the healing art 
 into physic and surgery ; and that all at- 
 tempts to distinguish the numerous diseases 
 and injuries of the human body into medi- 
 cal and surgical cases, must in a great mea- 
 sure be decided by custom, and the mutual 
 agreement of practitioners, rather than by 
 any rules, or principles, which are at all 
 consistent. 
 
 In the earliest periods, the same men 
 cultivated the whole field of medicine. The 
 writings of Hippocrates, Galen, Celsus, Pau- 
 ius (Egineta, Albucasis, &c. prove that the 
 Greeks, Romans, and Arabians never had an 
 idea of the human body being susceptible of 
 only two classes of diseases, one of which 
 formed the province of physic, while the 
 other constituted a separate and distinct 
 science called surgery. All these ancient 
 authors treat successively of fevers, frac- 
 tures, wounds, and nervous diseases, and 
 none of them appear to have supposed, that 
 there could be any disorders which really 
 deserved to be called external , and others 
 internal. Nor was it until the middle of the 
 twelfth century, that the ecclesiastics were 
 restrained from undertaking any bloody ope- 
 ration. Surgery was then rejected from the 
 universities, under the empty pretext, “ Ec 
 clesia abhorret a sanguine ,” often expressed 
 in its decrees, as Professor Thomson well 
 observes, but never acted upon, except in 
 this instance, by the church of Rome. It is 
 to this epoch that we must refer the true 
 separation of physic from surgery, the latter 
 being abandoned to the laity, who, in those 
 ages of barbarism, were totally illiterate. 
 
 It is an observation made by the celebra- 
 ted Bichat, that two things are essentially 
 necessary to form a great surgeon, viz. genius 
 and experience. One traces for him the 
 way, the other rectifies it ; both recipro- 
 cally assist in forming him. Without expe- 
 rience, genius would be unprofitably fertile ; 
 without genius, experience would only be 
 a barren advantage to him. ( CEuvres Chir. 
 de Desault , par Bichat, T. 1, Discours Prelim.) 
 Out of the large number of hospital surgeons, 
 who are to be met with in every country of 
 Europe, and who enjoy ample opportunities 
 of profiting by the lessonsof experience, bow 
 few distinguish themselves, or ever contri- 
 bute a mite to the improvement of their 
 profession. Opportunity, without talents 
 and an aptness to take advantage of it, is 
 not of more use than light to a blind man. 
 On the other hand, splendid abilities, with- 
 out experience, can never be enough to 
 make a consummate surgeon, any more 
 
 than a man with the greatest genius for 
 painting can excel in his particular art with- 
 out having examined and studied the real 
 objects which he wishes to delineate. In 
 short, as a sensible writer has remarked, 
 
 “ Les grands chirurgiens sont aussi rares, que 
 le gdnie, le savoir, et les talens.” (Mem. de 
 V Acad, de Chir. T. 1, Pref. p. 41, Edit. 
 12 mo.) 
 
 The description of the qualities which a 
 surgeon ought to possess, as given by Celsus, 
 is excellent as far as it goes. A surgeon^ 
 says he, should be young, or, at any rale, 
 not very old; his hand should be firm and 
 steady, and never shake ; he should be able 
 to use his left hand with as much dexterity 
 as his right ; his sight should be acute and 
 clear; his mind intrepid and pitiless, so that 
 when he is engaged in doing any thing to a 
 patient, he may not hurry, nor cut less than 
 he ought, but finish the operation, just as if 
 the cries of the patient made no impression 
 upon him. Ul. C. Celsi Med. Prcef. ad 
 lib. 7.) 
 
 By the word “ immisericors ,” as Richerand 
 has observed, ( JYoscgr . Chir. Tom. 1, p. 42, v 
 Edit. 2,) Celsus did not mean that a surgeon 
 ought to be quite insensible to pity; but 
 that during the performance of an operation, 
 this passion should not influence him, as all 
 emotion would then be mere weakness. 
 This undisturbed coolness, which is still more 
 rare than skill, is the most valuable quality 
 in the practice of surgery. Dexterity may 
 be acquired by exercise ; but firmness ot 
 mind is a gift of nature. Haller, to whom 
 nature was so bountiful, in other respects, 
 was denied this quality, as he candidly con- 
 fesses. “ Although (says he) I have taught 
 surgery seventeen years, and exhibited the 
 most difficult operations upon the dead body, 
 
 I have never ventured to apply a cutting in- 
 strument to a living subject, through a fear 
 of giving too much pain.” (Bibl. Chir. 1775;, 
 Vol. 2.) 
 
 Surgery may boast of having had an ori- 
 gin, that well deserves to be called noble, 
 for the earliest practice of it arose from the 
 most generous sentiment which nature has 
 implanted in the heart of man, viz. from that 
 sympathetic benevolence, which leads us to> 
 pity the misfortunes w T hich we behold, and 
 inspires us with an anxious desire toalleviate 
 them. He who first saw his fellow-creature 
 suffer could not fail to participate in the pain, 
 and endeavour to find out the means of 
 affording relief. Opportunities of exercising 
 this useful inclination were never wanting. 
 In the first ages of the world, man in his des- 
 titute state was under the necessity of earn- 
 ing by force or stratagem, a subsistence 
 which was always uncertain, and in the 
 combats into which this sort of life drew 
 him, he frequently met with wounds and 
 other injuries. Wherever the chace was in 
 vogue as a means of livelihood or amuse- 
 ment ; wherever broils and contests occa- 
 sionally arose ; and man was the same ani- 
 mal he now is, liable to various diseases 
 and accidental hurts ; there must have ex- 
 isted a necessity for c urgery ; nor can there 
 
SURGERY 
 
 444 
 
 be a doubt, that the origin of this valuable 
 practice is as ancient, as the exposure of 
 mankind to several of the same kinds of in- 
 juries, as befall the human race at the pre- 
 sent day. At length wars became more 
 frequent and extensive; wounds were conse- 
 quently multiplied; and the necessity for 
 surgical assistance was increased, and its 
 value enhanced. 
 
 In fact, among the ancients, the profes- 
 sion of medicine and surgery constituted a 
 sacred kind of occupation, and the practice 
 of it belonged only to privileged persons. 
 JEsculapius was the son of Apollo. In the 
 armies, the highest princes gloried in dress- 
 ing the wounds of those who had fought the 
 battles of their country. Among the Gre- 
 cians, Podalirius, Chiron, and Machaon, 
 were not only distinguished for their valour, 
 but also for their skill in surgery, as we 
 learn from the poem of the immortal Homer. 
 The value which was placed upon the ser- 
 vices of Machaon by the Grecian army may 
 well be conceived from the anxiety which 
 they evinced to have him properly taken 
 care of when he was wounded in the shoul- 
 der with a dart. “ O Nestor, pride of Greece, 
 (cries ldomeneus) mount, mount upon thy 
 chariot! and let Machaon mount with thee! 
 Hasten with him to our ships ; for a warrior, 
 who knows, as he does, how to relieve pain, 
 and cure wounds, is himself worth a thou- 
 sand other heroes.” (See Iliad , lib. xi.) Hip- 
 pocrates was one of the first citizens of 
 Greece ; he nobly refused all the rich offers 
 of several kings, enemies of his country, to 
 entice him into their service ; and, in parti- 
 cular, he disdained to accept those of Xerxes, 
 whom he regarded as a barbarian. 
 
 It is in the immortal poems of the Iliad 
 and Odyssey, that we find the only certain 
 traditions respecting the state of the art be- 
 fore the establishment of the republics of 
 Greece, and even until the time of the Pelo- 
 ponnesian war. There it appears that sur- 
 gery was almost entirely confined to the 
 treatment of wounds, and that the imaginary 
 power of enchantment was joined with the 
 use of topical applications. 
 
 In the cures recorded in the sacred wri- 
 tings of the Christian religion, the interven- 
 tion of a supernatural power is always com- 
 bined with what is within the scope of hu- 
 man possibility. The same character evinces 
 itself in the infancy of the art in every na- 
 tion. The priests of India, the physicians 
 of China and Japan, and the jugglers of the 
 savage or half-civilized tribes of the old and 
 new continents, constantly associate with 
 drugs and manual operations certain myste- 
 rious practices, upon which they especially 
 rely for the cure of their patients. Such 
 was also, no doubt, the character of the 
 medicine of the Egyptians, in the remote 
 times, previous to the invention of the alpha- 
 bet, and upon which so very little light is 
 now thrown. 
 
 It is curious, however, to find, from some 
 late observations made by the men of 
 science, who accompanied the French ex- 
 pedition to Egypt, in 1798, that, among the 
 
 ruins of ancient Thebes there are documemB, 
 which fully prove that surgery, in the early 
 limes of the Egyptians, had made a degree 
 of progress, of which few of the moderns 
 have any conception. It is noticed by Lar- 
 rey,that when the celebrated French Gene- 
 ral Desaix had driven the Mamelukes beyond 
 the cataracts of the Mile, the Commission 
 of Arts had an opportunity of visiting the 
 monuments of the famous Thebes, and the re- 
 nowned temples of Tentyra, Karnack,Medy- 
 net, Abou, and Luxor, the remains of which 
 still display their ancient magnificence. It is 
 upon the ceilings and walls of these tem- 
 ples that basso-relievos are seen . representing 
 limbs that had been cut off with instruments 
 very analogous to those which are employed 
 at the present day for amputations. The 
 same instruments are again observed in the 
 hieroglyphics, and vestiges of other surgical 
 operations may be traced, proving that, in 
 these remote periods, surgery kept pace with 
 the other arts, which had already attained a 
 high degree of perfection. ( Larrey , Me- 
 moir es de Chir. Militaire, T. 1, p. 233 ; T. 2, 
 p. 223.) 
 
 We next come to the epoch when, by the 
 union and arrangement of scattered facts, 
 the science truly arose. Hippocrates, born 
 in the island of Cos, four hundred and sixty 
 years before the common era, collected the 
 observations of his predecessors, added the 
 results of his own experience, and composed 
 his first treatises. In the hands of this great 
 genius, medicine and surgery did not make 
 equal progress. The former reached the 
 highest degree of glory. Hippocrates drew 
 up the history of acute diseases in so mas- 
 terly a style, that twenty past centuries have 
 hardly found occasion to add any thing to 
 the performance. But surgery was far from 
 attaining the same degree of perfection. 
 The religious veneration for the asylums of 
 the dead, and the impossibility of dissecting 
 the human body, formed an insurmountable 
 obstacle to the study of anatomy. An im- 
 perfect acquaintance with the structure of 
 animals, reputed to bear the greatest resem- 
 blance to man, could only furnish venture- 
 some conjectures, or false inferences. These 
 circumscribed notions sufficed for the study 
 of acute diseases. In these cases, the atten- 
 tive observation of strongly-marked symp- 
 toms, and the idea of the operation of a sa- 
 lutary principle, derived from remarking the 
 regular succession of such symptoms, and 
 their frequently beneficial termination, en- 
 lightened the physician in the employment 
 of curative means ; while surgery, deprived 
 of the assistance of anatomy, was too long 
 kept back in an infant state. Whatever 
 praises may have been bestowed on those 
 parts of the works of Hippocrates particu 
 larly relating to surgery, and which amount 
 to six in number (de ojirina medici ; de frac- 
 turis ; de capitis vulneribvs; de articulis vel 
 luxatis ; de ulceribus; de Jistulis;) when com- 
 pared with his other acknowledged legiti- 
 mate writings, they appear only as the rough 
 sketches of a picture by a great master. 
 
 Excepting the fragments, collected or 
 
sURGERY 
 
 M6 
 
 cited by Galen, we possess no work written 
 by any of the successors of Hippocrates un- 
 til the period of Celsus ; which leaves a bar- 
 ren interval of almost four centuries. In 
 this space lived Erasistratus, as well as He- 
 rophilus, celebrated for the sects which they 
 established, and particularly for having been 
 the first who studied anatomy upon the hu- 
 man body. 
 
 Celsus lived at Rome in the reigns of Au- 
 gustus, Tiberius, and Caligula. He appears 
 never to have practised the healing art, on 
 which, however, he has written with much 
 precision, elegance, and perspicuity. His 
 work is the more precious, inasmuch as it is 
 the only one, which gives us information, 
 with regard to the progress of surgery in the 
 long interval between Hippocrates and him- 
 self. The four last books, and especially 
 the seventh and eighth, are exclusively al- 
 lotted to surgical matter. I he style of 
 Celsus is so elegant, that he has generally 
 been regarded quite as the Cicero of medi- 
 cal writers, and long enjoyed high reputation 
 in the schools. His surgery was entirely 
 that of the Greeks, notwithstanding he wrote 
 at Rome : for, in that capital of the world, 
 physic was then professed only by persons 
 who had either come from Greece, or had 
 received instruction in the celebrated schools 
 of this native soil of all the arts and sciences. 
 
 Let us pass over the interval which sepa- 
 rates Celsus and Galen This latter was 
 born at Pergamus in Asia Minor, and came 
 to Rome in the reign of the emperor Marcus 
 Aurelius. He practised surgery and physic 
 there about the year 165 of the Christian era. 
 ( Galeni Opera Omnia , 1521, Edit. Aldi , 5 
 Vols. in fol .) These two sciences were at 
 that time still united, and though some wri 
 ters of much earlier date speak of the divi- 
 sion of physic into dietetical, chirurgical, 
 and pharmaceutical, no such distinction w as 
 followed in practice. As Galen had been a 
 surgeon at Pergamus, he continued the same 
 profession at Rome ; but, being soon attract- 
 ed by the predominating taste of the age in 
 which he lived, for a science which more 
 easily yields to the systems and dazzling 
 speculations of philosophical sects, he after- 
 ward neglected surgery which strictly re- 
 jects them. His writings prove, however, 
 that he did not abandon it entirely. His 
 commentaries on the treatise of Hippocrates, 
 De Officina Medici , and his essay on banda- 
 ges, and the manner of applying them, show 
 that he was well versed even in the minor 
 details of the art. Besides it is known. that 
 he paid great attention to pharmacy, and in 
 his work upon antidotes, chap 13* he tells 
 us himself, that he had a drug shop in the 
 Via Sacra, which fell a sacrifice to the 
 flames that destroyed, in the reign of Corn- 
 modus, the Temple of Peace, and several 
 other edifices. 
 
 To Galen succeeded the compiler Oriba- 
 sius, (Etius of Amida, a physician, who lived 
 towards the close of the fifth century, Alex- 
 ander of Tralles, and Paulus (Egineta, so 
 called from the place of his birth, though he 
 practised at Rome and Alexandria. Paulus 
 
 collected into one work, still justly esteem- 
 ed, all the improvements, which had been 
 made in surgery up to his own time. He 
 concludes the series of Greek and Roman 
 physicians, and may be looked upon as the 
 last of the ancients, unless it be wished to 
 let the Arabians have a share in the honours 
 of antiquity. “He appears, says Portal, to 
 be one of those unfortunate writers, to whom 
 posterity has not done justice. It seems as 
 if he had been decried without having been 
 read ; for if pains had been taken to examine 
 his works, he would neither have been re- 
 garded as a mere copyist, nor been called 
 the “ape of Galen,” with whom he does not 
 always coincide. Nay, in some places, he 
 ventures to oppose the doctrines of Hippo- 
 crates. He was perfectly acquainted with 
 the practice of the ancients, and when he 
 agrees with, or differs from them, it is not 
 from a spirit of contradiction, but because 
 the reasons, which led him to take one side, 
 or the other, appeared to him well founded.” 
 {Portal, Hist, de VAnat. fyc. T. 1, p. 123.) 
 All now agree, that surgery is much indebted 
 to him. (See R. A. I’ogtl , De Pauli (Egineta , 
 Meritisin Medicinam imprimisque Chirurgiam, 
 4 to Golt. 1768.) Afterward the downfall 
 of surgery followed tbatof all the other scien- 
 ces, and from thecaptureof the Alexandria by 
 the Saracens under Amrou, viceroy of Egypt, 
 1641, until the end of the tenth century, 
 nothing prevailed but the dark clouds of ig- 
 norance and barbarism. The Arabians, who 
 became masters of a great part of the Ro- 
 man empire, dug up the Greek manuscripts, 
 which lay buried under the ruins of the li- 
 braries ; translated them ; appropriated to 
 themselves the doctrines which they con- 
 tained ; impoverished them with additions ; 
 and transmitted 1o posterity only enormous 
 compilations In a word, such are the trea- 
 tises of Rhazes, Hali- Abbas, Avicenna, Aver- 
 rhoes, and Albucasis, the most celebrated of 
 the Arabian authors. Inventors of a prodi- 
 gious number of instruments and machines, 
 they appear to have calculated the efficacy 
 of surgery by the richness of its arsenals, 
 and to have been more anxious to inspire 
 terror, than confidence. As an instance of 
 the cruelty of their methods, I shall merely 
 notice, that, in order to stop the bleeding 
 after amputation of a limb, they plunged 
 the stump in boiling pitch. 
 
 The fate of medicine was not more for- 
 tunate. In vain the school of Salernum, 
 founded about the middle of the seventh 
 century, made some attempts to revive its 
 splendour. As a modern writer observes, 
 medical science, seated on the same benches 
 where the doctrine of Aristotle, accommo- 
 dated to religious opinions, was the subject 
 of endless controversies, imbibed, as it were 
 by contagion, the argumentative and so- 
 phistical mania, and became enveloped in 
 the dark hypotheses of scholastic absurdity. 
 {Richer and, Nosogr. Chir. T. 1, Ed. 2.) 
 
 The universal ignorance (continues this 
 author ;) the pretended horror of blood ; the 
 dogma of a religion which shed it in tor- 
 rents for useless quarrels; an exclusive re 
 
SURGERY. 
 
 iish for the subtleties of the school, and 
 speculative theories ; are circumstances fur- 
 ther explaining the profound darkness which 
 followed these empty labours. About the 
 middle of the twelfth century, (1163,) the 
 Council of Tours prohibited the ecclesias- 
 tics, who then shared with the Jews the 
 practice of medicine in Christian Europe, 
 from undertaking any bloody operation. 
 It is to this epoch that the true separation 
 of medicine from surgery must be referred. 
 The latter was abandoned to the laity, the 
 generality of whom, in those ages of barba- 
 rism, were entirely destitute of education. 
 The priests, however, still retained that 
 portion of the art which abstained from the 
 effusion of blood. Roger Rolandus, Bruno, 
 Gulielmus de Salicetus, Lanfranc, Gordon, 
 and Guy de Chauliac, confined themselves 
 to commentaries on the Arabians, and if 
 the latter author be excepted, they all dis- 
 graced surgery by reducing it nearly to the 
 mere business of applying ointments and 
 plasters. Guy de Chauliac, however, the 
 last of the Arabians, is to be honourably ex- 
 cluded from such animadversion. His work 
 written at Avignon, in 1363, in the pontifi- 
 cate of Urban the fifth, to whom he was 
 physician, continued to be, for a long while', 
 the only classical book in the schools. It 
 may be observed, that as he imitated in 
 eveiy respect the other Arabian physicians, 
 and like them thought that it did not be- 
 come an ecclesiastic to deviate from the 
 austerity of his profession, he passed over 
 In silence the diseases of women. 
 
 Atlength Antonio Beneveni, a physician 
 of Florence, began to insist upon a truth, 
 of the highest importance to the extension 
 of surgical knowledge, viz. that the compi- 
 lations of the ancients and Arabians ought 
 to be relinquished for the observation of 
 nature. ( De abditis rerum causis, Florent. 
 1507, 4to.) A new era now began. The 
 moderns were convinced, that by treading 
 servilely in the footsteps of their predeces- 
 sors, they should never even equal, much 
 less surpass them. The labours of Vesalius 
 also gave birth to anatomy, illuminated by 
 which science, surgery put on quite a dif- 
 ferent appearance in the hands of Ambroise 
 Fare, the first and most eminent of the 
 French surgeons. For the credit of Italy, 
 however, it should be recorded, that the 
 sensible writings published in that country 
 prior to the time of Par6, had the greatest 
 influence in creating a due sense of the 
 value and importance of surgery, and in 
 disposing men of talents and education to 
 cultivate it as a liberal profession. 
 
 Obeying the dictates of his genius, Par6 
 made authority yield to observation, or 
 sought to reconcile them. However, his 
 superior merit soon excited the ignorant, 
 the jealous, and the malignant against him ; 
 he became the object of a bitter persecution, 
 and his discoveries were represented as a 
 crime. Although he was the restorer, if 
 not the inventor, of the art of tying the 
 blood-vessels, the power of his persecutors 
 compel! ed bint to make imperfect extracts 
 
 from Galen, and alter his text, in order to 
 rob himself, in favour of the ancients, of the 
 glory which this distinguished improvement 
 deserved. 
 
 Surgeon of King Henry the second, Fran- 
 cis the second, Charles the ninth, and Henry 
 the third, of France, Pare practised his pro- 
 fession in various places, followed the 
 French armies into Italy, and acquired such 
 esteem, that his mere presence in a besieged 
 town was enough to reanimate the troops 
 employed for its defence. In the execrable 
 night of Saint Bartholomew, his reputation 
 saved his life. As he was of the reformed 
 religion, he would not have escaped the 
 massacre, had not Charles the ninth himself 
 undertaken to protect him. The historians 
 of those days < Mem de Sully ) have pre- 
 served the remembrance of this exception, 
 so honourable to him who was tile object of 
 it; but which should not diminish the just 
 horror which the memory of the most weak 
 and cruel tyrant must ever inspire. u II 
 n’en voulut jamais sauver aucun (says Bran- 
 tome) siuon maistre Ambroise Pare, son 
 premier chirurgien, et le premier de la chr6- 
 tiennetfi ; et l’envoya querir et venir le soir 
 dans sa chambre et garderobe, lui comman- 
 dant de n’en bouger ; et disait qu’il n’etait 
 raisonnable qn’un qui pouvait servir h tout 
 un petit monde, feust ainsi massacre.” 
 
 Ambroise Pare was not content, like his 
 predecessors, with exercising his art with 
 reputation ; he did not follow the example 
 of the Quatre-Maitres of Pitard, so justly 
 celebrated for having composed the first 
 statutes of the College of Surgeons at Paris, 
 -in the reign of St. Lewis, whom he had at- 
 tended in his excursions to the Holy Land ; 
 and of several other surgeons, the fruits of 
 whose experience were lost to their suc- 
 cessors. Par6 transmitted the result of his 
 own experience in a work that will remain 
 immortal. (See (Euvres d' Ambroise Par£ y 
 Conseiller et premier Chirurgien du Roi , di - 
 visees in 28 livres , in folio , Edit. 4 to. Paris, 
 1535.) 
 
 His writings, so remarkable for the vari- 
 ety and number of facts in them, are emi- 
 nently distinguished from all those of his 
 time, inasmuch as the ancients are not 
 looked up to in them with superstitious 
 blindness. Freed from the yoke of autho- 
 rity, he submitted every thing to the test of 
 observation, and acknowledged experience 
 alone as his guide. The French writers are 
 with reason proud of their countryman 
 Pai6 to this day : they allege, that he must 
 ever hold among surgeons the same place 
 that Hippocrates occupies among physi- 
 cians. Nay, they add, that perhaps there 
 are none, either of the ancients or moderns, 
 who are worthy of being compared with 
 him. (Richerand JVosogr. Chirurg. T. 1.) 
 
 After the death of this great man, surgery, 
 which owed its advancement to him, con- 
 tinued stationary, and even took a retro- 
 grade course. This circumstance is alto- 
 gether ascribable to the contemptible state 
 into which those who professed the art fell 
 
SURGERY. 447 
 
 alter being united to the barbers by the to the grave the secret of hi's admirable in- 
 most disgraceful association. jections. (See also his Thesaur. Anat. x. in 
 
 Pigrai, the successor of Ambroise Part% 4 to. Adversariorum anatomicorum medico - 
 was far from being an adequate substitute chirurgicorum Decad. 3, in 4 to. Amstelodam .) 
 for him. A spiritless copyer of his master, Roonhuysen also made a secret of his lever, 
 he abridged his surgery in a latin work, which, before the invention of the forceps, 
 where the unaffected graces of the original, was the only resource in difficult labours, 
 the sincerity, and the ineffable charm inse- Raw, who successfully cut fifteen hundred 
 parable from all productions of genius, en- patients for the stone took such pains to 
 tirely disappeared. He received, however, conceal his manner of operating, that Heis- 
 equal praise from his contemporaries ; ter and Albinus, his two most distinguished 
 doubtless, because, he filled a high situation ; pupils, have each given a different explana- 
 but, as Richerand remarks, his name, which tion of it. Such a disposition, which was 
 is to-day almost forgotten, proves sufficient- extremely hurtful to the advancement of 
 ly, that dignities do not constitute glory. surgical knowledge, would materialy have 
 Rousset and Guillemeau distinguished retarded the progress of surgery in Holland, 
 themselves, however, in the art of mid- had not Camper, in the following century, 
 wifery, while Covillard, Cabrol, and Habi- effaced this imputation by the great number 
 cot enriched surgery w r ith a great number of his discoveries, and his zealous desire to 
 of curious observations, (~ee Obs. Chir. make them public. 
 
 pleines de remarques curieuses, Lyon, 1639, While great improvements were going on 
 in 8 vo. Alphabet Anatomique, Gen&ve, 1602, in Italy, England, and Holland, surgery fan 
 in 4 to. Semaine Anatomique; Question guished in a humiliated state in France 
 Chir. sur la Bronchotomie, Paris, 1620, The accoucheur Mauriceau ( Trait6 des Ma- 
 in 8v o.) ladies des Femmes grosses , Paris, 1668, in 
 
 In the next or seventeenth century, a 4/o.) Dionis, (Cours d’ Operations de Chi- 
 fresh impulse produced additional improve- rurgie, Paris, 1707, 8vo.) Saviard, 
 inents. Then appeared in Italy, Ca?sar veau Recueil d'Obs. Chir. Paris, 1702, in 
 Magatus, who simplified the treatment of 12mo.) and Belloste ( Chirurgien d’Hopital, 
 wounds, (de rarct vulnerum medicalione, Paris, 1696, in 8vo.) were the only French 
 libri 2, Venet. 1616, in folio ;) Fabriciusab surgeons of note who could be contrasted 
 Aquapendente, even less praise-worthy as a with so many distinguished men of other 
 surgeon than as a physiologist, ( Opera nations. Richerand observes, that the splen- 
 Chir. Paris, 1613 in fol. ;) and Marcus Au- did days of Louis the Fourteenth were an 
 relius Severinus, that restorer of active sur- iron age for discouraged surgery. And yet 
 gery. Dt ejfficac) Medicina , libri 3, Franco - this monarch seems to have been personally 
 furt, 1613, in folio. De recondita abscessu- interested in the melioration of this irapor- 
 um natura libri 7, Koapoli, 1632, in 4 to taut art ; for he was very nearly falling a 
 and Trimembris ( hirurgia . ^c. Franco fur t. victim to a surgical disease, a fistula in ano, 
 2653, in4to.) Among the English surgeons and was not cured till after a great number 
 flourished Wiseman, w ho was the Pare of of blundering operations and useless experi- 
 England (See Several Chinirgical Treatises, ments. 
 
 Lond. 1676, in fol.;) and William Harvey, Chronology teaches simply the history of 
 whose discovery of the circulation of the dates. In the study of the sciences, the 
 blood had such an influence over the ad- only method of impressing the memory 
 vancement of surgery, that he must be class- with facts, consists in connecting the epoch 
 cd among the principal improvers of this °f them with the learned men by whom 
 science. (See Exercitatio Anatomica de they have been illustrated. But the great- 
 motu cordis et sanguinis in animalibus, F>an - est surgeons of the eighteenth century have 
 cofurti, 1653, in 4to.) In Germany, Fabri- not altered the face of their profession, 
 eius Hildanus, (Obs. et Curationum, Cen although they have powerfully contributed 
 turitzG, 2 Vol.in4to. 1641) who was far to its advancement. In surgery, as an au- 
 superior, as a surgeon, to the Italian Fabri- thor has remarked, some feeble rays always 
 cius Scultetus, so well known for his work, precede brilliant lights, and it approaches 
 entitled Armamentarium Chirurgicwn ; Ul- perfection in a very gradual way. In the 
 mce, 1653, in folio. Purmann and Solingen, last century, however, among the distin- 
 whohad the fault of being too partial to the guished surgeons of France, there are two 
 use of numerous complicated instruments, of extraordinary genius, round whom, as it 
 (See Cursre Obs. Chir. Lipsice, 1710, in 4 to. were, all the others might be grouped and 
 Mqnuale Obs. der Ckirurgie, Amsterdam, arranged, and whose names deserve to be 
 1684, in 4to.) affixed to the two most brilliant epochs of 
 
 Holland, restored to liberty by the gene- French surgery. These are, first, J. L. 
 rous exertions of its inhabitants, did not Petit, whose glory was shared by the Aca- 
 remain a stranger to 4 the improvement of demy of Surgery; and, secondly, the cele- 
 surgery. This nation, so singular in many brated Desault. 
 
 respects, presents us with one particularity It is not with surgery, as with physic, 
 which claims the notice of a medical bisto- strictly so called ; the epochs of the latter 
 nan, Ruysch, who was an eminent ana- are distinguished by hypotheses ; while those 
 tomist, and merits equal celebrity for his of surgery are marked by discoveries. The 
 Obs. Anatomico- Chirurgicorum Centuriae, eminent men in this last branch of the pro 
 Amstelodam. 1691, in 4to . carried with him fession have not? like the most renowmed 
 
SURGERY. 
 
 **48 
 
 physicians, created sects, built systems, de- 
 stroyed those of their predecessors, and con- 
 structed a new edifice, which in its turn has 
 been demolished by other hands. All of 
 them have been satisfied with combating an- 
 cient errors, discovering new facts, and con- 
 tinuing their art, the sphere of which they 
 have enlarged by their discoveries, without 
 making it bend under the yoke of systems, 
 which it would have ill supported. To this 
 steady and uniform course, (says Richerand,) 
 which is a striking proof of the superiority 
 of surgery, and of the certainty and invaria- 
 bleness of its principles, shall we oppose the 
 numerous revolutions of physic ? The Chris- 
 tian religion, which abounds in sects, has not 
 a greater number of them than physic. fs'a- 
 turi-tes, solidistes, humoristes, vitalistes, ani- 
 misies, semi-animistes, mecaniciens, chi- 
 roistes; le plus grand nombre des medecins 
 honore Hippocrate d’un culte presque super- 
 stitieux ; ceux-ci marchent sous les ban- 
 nieres de Staahl ; ceux-las’*ppuient du grand 
 nom de Boerhaave ; tels autres invoquenl 
 Sydenham, Hoffmann, Stoll, absolument 
 comcne les iheologiens combattent pour Lu- 
 ther, Zuiugle, Calvin, ou Jansen.” ( Nosogr 
 Chir. T. 1.) 
 
 The elogy on J. L. Petit, delivered in the 
 midst of the Royal Academy of Surgery, of 
 which he was one of the first and most dis- 
 tinguished members, represents him as blend- 
 ing the study of anatomy with his amuse- 
 ments when a boy ; and ardently seeking 
 ever, opporl unity to increase his knowledge 
 by observaiion. He had had experience 
 enough to publish at an early period of his 
 life his Traitd sur les Maladies des Os, Paris, 
 17o5, in l'2mo. ; a work which for a centu- 
 ry was esteemed the best upon the subject. 
 His success was most virulently opposed by 
 the envious critics; and it was uot till after 
 more than thirty years of academical labours 
 an t extensive practice, that he was unani- 
 mously chosen the head of hisassociates. This 
 acknowledged superiorly, however, was the 
 more flattering, as the honour was obtained 
 at a period when surgery was in a flourishing 
 state in France, and when Petit held no of- 
 fice, from which he could derive an influence 
 foreign to his peisonat merit. While Mares- 
 chal. La Peyronie, and La Martiniere assured 
 him of the royal favour, Quesriay, Morand, 
 and Louis, who corrected his writings, made 
 him speak a language which does honour to 
 that famous collection, to which he contribu- 
 ted his observations, (>ee Mimoires et Prix 
 de l' Academic Royale de Chirurgie, 10 Pols, 
 in 4 to.) and in which, it some theoretical ex- 
 planations be put out of consideration, no- 
 thing lias lost its value by age. J. L. Petit 
 was al o the author of a “ Traile des Mala- 
 dies Chirurgicaies et des Operations qui leur 
 conviennent. Outrage Podhume ;" a pro- 
 duction that will always sl *nd high in the 
 estimation of the judicious surgeon. 
 
 The history of this epoch, so glorious for 
 the profession of surgery, is completely de- 
 tailed in the Me moires and Prix of the Royal 
 Academy of Surgery ; a work which is ab- 
 solutely indispensable, and the various parts 
 
 of which cannot be too often considered. 
 In it are preserved the labours of Mareschal, 
 Quesnay, La Peyronie, Morand, Petit, De la 
 Martiniere, Le Dran, Garengeot, De la Faye, 
 Louis, Verdier, Foub> rt, Hevin, Pibrac, Fa- 
 bre, Le Cat, Bordenave, Snbatier, Puzos, 
 Levret, and several other practitioners, who, 
 though less famous, contributed by their ex- 
 ertions and know ledge to form this useful 
 body of surgical facts. Many of the prece- 
 ding surgeons also distinguished themselves 
 by other productions, which, however, I 
 shall not here enumerate, as they are quoted 
 in many other parts of this work. 
 
 To the foregoing list of eminent French 
 surgeons, must be added the names of La 
 Motte, Maim-Jean, Goulard, Daviel, Rava- 
 ton, Mejean, Pouteau, David, and Frere 
 Cosme. 
 
 While surgery was thus advancing in 
 France, other nations were not neglectful of 
 it. At this period flourished in England, 
 White, Cheselden, Douglas, the two Monros, 
 Sharp, Covvper, Warner, Alanson, Percival 
 Pott, Hawkins, Suiellie, and the two Hun- 
 ters. 
 
 White’s Cases in Surgery, 1770: Chesel- 
 den’s Treatise on the High Operation for the 
 Stone, London, 1723 in Hvo. ano his Treatise 
 on the Anatomy of the Human Body ; Dou- 
 glas’s Tract, entitled. Lithotomia Douglass - 
 iana;" Sharp’s Treatise of the Operations ; 
 and his “ Critical Inquiry into the present 
 State of Surgery Monro's Works by his 
 son; Warner's Cases in Surgery, 1754, and 
 his Description of the Eye and its Diseases, 
 1775; Alanson' s Treatise on Amputation; 
 Pott’s Chirurgical Works ; Smellie's Midwife- 
 ry ; and John Hunter on the Blood, Inflam- 
 mation, fyc. ; his Treatise on the Venereal 
 Disease ; Animal Economy , the Teeth, and 
 all the papers written by himself and his 
 brother, in the Phil. Trans. Med. Obs. and 
 Inquiries , and Trans, of a Society for the Im- 
 provement of Med. and Chir. Knowledge ; 
 are productions which reflect the highest 
 credit on the state of surgery in England. 
 
 But of all these eminent men, none con- 
 tributed more powerfully than Mr. Percival 
 Pott, to the improvement ot the practice of 
 surgery in England. His life, indeed, forms 
 a sort of epoch in the history of the profes- 
 sion. Before his inculcations and example 
 had produced a desirable change, the maxim 
 of “ dolor medicina doloris ,” as we learn 
 from Sir James Earle, remained unrefuted. 
 The severe treatment of the old school, in 
 the operative part and in the applications, 
 continued in force. The first principles ot* 
 surgery, the natural process and powers of 
 healing, were either not understood, or not 
 attended to ; painful and escharoiic dress- 
 ings were continually employed; and the 
 actual cautery was iiLsuch frequent use, that 
 at the times wuen Ine surgeons visitej the 
 hospiial, it was regularly heated, and prepa- 
 red as a necessary part of the apparatus. 
 Where shall we find more sensible, or more 
 truly practical observations on the treatment 
 of abscesses, than in his excellent treatise ou 
 the fistula in nuo ? Where shall we meet with 
 
&LRGERY '449 
 
 belter remarks on the local treatment of gan- 
 grenous parts, than in his valuable tract on 
 tthe mortification of the toes and feet ? What 
 author abounds with so many just observa 
 tions on the injuries of the head, blended, it 
 is true, with rather too great a partiality to 
 the trepan, the so frequent necessity for which 
 is now less generally acknowledged ? His 
 description of the inflammation and suppu- 
 ration of the dura mater, and of the treat- 
 ment, is matchless. The account which he 
 has left us of the disease of the vertebra?, at- 
 tended with paralysis of the limbs, is per- 
 haps his most original production. His ce- 
 lebrated essay on fractures, was also very 
 original, and has had in this country consi- 
 derable influence over the treatment of these 
 injuries ; but there can now be no doubt, 
 that the effects of position were exaggerated 
 5n this part of bis writings, and that surgeons 
 ought still to make every possible exertion 
 to render their apparatus for broken bones 
 more effectual. (See Fractures.) A more 
 peally valuable production of this eminent 
 surgeon is his remarks on amputation. The 
 necessity for that operation in certain cases 
 is there convincingly detailed ; and the most 
 advantageous period for its performance 
 clearly indicated. The urgency for its prompt 
 execution, after particular injuries, he has 
 indeed so perfectly explained, that the late 
 inculcations on the subject by Larrey, and 
 several other modern surgeons, appear to be 
 in a great measure anticipated ; the only dif- 
 ference being, that Pott’s remarks applied 
 principally to compound fractures, while 
 Larrey’s refer to gunshot wounds. All these, 
 however, are cases of accidental violence, 
 and of course should be treated upon the 
 same general principles 
 
 A longer comment on the writings and 
 improvements of Percival Pott would here 
 be requisite to do him every degree of jus- 
 tice; but his name, advice, and opinions are 
 so conspicuous throughout this volume, that 
 1 shall be excused for not saying any thing 
 more in the present place, than that he was 
 in his time, the best practical surgeon, the 
 best lecturer, the best writer on surgery, the 
 best operator, of which this large metropo- 
 lis could boast. 
 
 Another character of still greater genius 
 and originality, though of inferior education, 
 was the ever memorable John Hunter, sur- 
 geon to St. George’s Hospital, who was at 
 once eminent as a surgeon, an anatomist, a 
 physiologist, a naturalist, and philosopher. 
 If Pott materially improved many parts of 
 the practice of surgery in England, and 
 evinced himself to be the most skilful ope- 
 rator of his time, John Hunter was also not 
 less importantly employed in extending the 
 boundaries of physiological knowledge, and 
 in the investigation of human, and particu- 
 larly comparative anatomy. The knowledge 
 which he derived from his favourite studies, 
 fie-oonstantly applied to the improvement of 
 the art of surgery, and he omitted no oppor- 
 tunity of examining morbid bodies, whereby 
 he collected facts which are invaluable, as 
 Vol. II 57 
 
 they tend lo explain the real causes of (he 
 symptoms of numerous diseases. 
 
 In the practice of surgery, whenever ope 
 rations proved inadequate to their intention, 
 Mr. Hunter always investigated with uncotn 
 rnon zeal the causes of ill success, and in 
 this way he detected many fallacies, as well 
 as made some important discoveries in the 
 healing art. He ascertained the cause of 
 failure, common to all the operations in use 
 for the radical cure of the hydrocele, and 
 was enabled to propose a mode of operating 
 attended with invariable success. He ascer 
 tained, by experiments and observations, 
 that exposure to atmospherical air, simply, 
 can neither produce nor increase inflamma- 
 tion. He discovered in the blood so many 
 phenomena connected with life, and not to 
 be referred to any other cause, that he con- 
 sidered it alive in its fluid state. He impro- 
 ved the operation for the fistula lachrymalis, 
 by removing a circular piece of the os un- 
 guis, instead of breaking it down with the 
 point of a trocar. He explained better than 
 any of bis predecessors, all the highly inte- 
 resting modern doctrines relative to inflame 
 (nation, union by the first intention, suppura- 
 tion, ulceration, and mortification. His 
 writings also throw considerable light on the 
 growth, structure, and diseases of the teeth 
 As instances of his operative skill, it deserves 
 to be mentioned, that he removed a tumour 
 from the side of the head and neck of a pa- 
 tient at St. George’s Hospital, as large as the 
 head to which it was attached ; and by bring- 
 ing the cut edges of the skin together, the 
 whole wound was nearly healed by the first 
 intention. He likewise dissected out of the 
 neck a tumour, which one of the best opera- 
 tors in (his country had declared, rather too 
 strongly, that no one but a fool or a mad- 
 man would meddle with ; and the patient 
 got perfectly well. But perhaps the greatest 
 improvement which he made in the practice 
 of surgery, was his invention of a new mode 
 of performing the operation for the popliteal 
 aneurism, by taking up the femoral artery on 
 the anterior part of the thigh, without open 
 ing the tumour in the ham. (See Trans, of 
 a Society for the Improvement of Med ^ and 
 Chir. Knowledge.) The safety and efficacy 
 of this method of operating have now been 
 fully established, and the plan has been ex 
 tended to all operations for the cure of this 
 formidable disease. (See Aneurism.) 
 
 According to Sir Everard Home, Mr. 
 Hunter was also one of the first who taught, 
 that cutting out the bitten part was the only 
 sure mode of preventing hydrophobia ; and 
 he lengthened the time in which this pro- 
 ceeding might be reasonably adopted, be- 
 yond the period which had been generally 
 specified. 
 
 His researches into the nature of the ve- 
 nereal disease, and his observations on the 
 treatment, will for ever be a lasting monu 
 raent of his wonderful powers of reasoning 
 and investigation. If he left some points of 
 the subject doubtful and unsettled, he has 
 admirably succeeded in the elucidation of 
 others : and his work on this interesting di- 
 
SURGERY . 
 
 order, is, with ail its defects, the best which 
 is jet extant. 
 
 Even (he language and mode of expression 
 of this great man were his own ; for so ori- 
 ginal were his sentiments, that they could 
 hardly be delineated by any ordinary arrange- 
 ment of words. His phrases are still adopt- 
 ed in all the medical schools of this country, 
 and continue to modify the style of almost 
 every professional book. Great as Mr. Hun- 
 ter’s merit as a surgeon was, it was stdl great- 
 er as a comparative anatomist and physiolo- 
 gist. The museum of the Royal College of 
 Surgeons, and his papers in the Phil. Trans, 
 will for ever attest hts greatness in these cha- 
 racters. 
 
 At the period, when the preceding distin- 
 guished men upheld the character of their 
 profession in Great Britain, Lancisi, Mor- 
 gagni, Molinelli, Bertrandi, Guattani, Mas- 
 cagni, Matani, Troja. and Moscati, were 
 doing the same thing in Italy. Bertrandi’s 
 Treatise on the Operations of Surgery, and 
 Troja’s Work on the Regeneration of Bones, 
 are even at this day works of the highest 
 repute. Of late years, the credit of the Ita- 
 lian surgeons has been honourably main- 
 tained by Monteggia, Scarpa, Paletta, Qua- 
 dri, Assalini, Morigi, and others. In Hol- 
 land flourished Albinus, Deventer, Sandi- 
 fort, and Camper; and in Germany, and 
 the north of Europe, the immortal Haller, 
 Heister, well known for his “ Institutiones 
 ChirurgicB Piatner; Rcederer ( Elemtnla 
 Artis Obstetricicc. Goeit. 1752. Obs. de Partu 
 Laborioso. Decad. 11, 1756.) stein, Bilguer, 
 Acrell, Callisen, {System a Chirurgice Hodi- 
 crnce , 2 Vol. 8 vo.) Brambilla, Thecien, ( Pro - 
 gres ulterieurs de la Chirurgie.} Sch mucker, 
 ( V crmischte Chvrurgische Sckriften, B. 3, and 
 Chir. Wahrnchmungf,n.) Richter, ( Traite des 
 Hernies, 2 Vol.&vo. Bibl. fur die Chirurgie ; 
 Ansfangsgr. der Wundarsn. 7 B. and Obs. 
 ChirurgicaruniFa.sc.) Also Arnemann, Weid- 
 niaun, Beer, Soemmering, Creutzenfeldt, 
 Hesselbach, Idufeland, Graefe, Klein, Him- 
 iy, Langenbeck, Walther, J A. Schmidt, G. 
 J. Beer, &c. should not be forgotten, seve- 
 ral of whom are still pursuing their useful 
 and honourable career. Be it also record- 
 ed as a part of the great merit of the Ger- 
 mans, that they now rank among the best 
 and most minute anatomists ; that they are 
 zealous cultivators of comparative anato- 
 my ; that their industry allow s no improve- 
 ment in medical science, wherever made, 
 to escape their notice ; and that surgery is 
 greatly indebted to them for the best descrip- 
 tions of the diseases of the eye. 
 
 On the continent, the Academy of Surge- 
 ry at Paris was long considered quite as the 
 solar light of this branch of science. The 
 French Revolution, which, by a fatal abuse, 
 involved in the same prohibition both use- 
 ful and pernicious societies, did not spare 
 even this beneficial establishment. Al- 
 though the Academy was deprived of the 
 talents of Louis, who died a short time be- 
 fore its suppression, it yet had at this period 
 several members, worthy of continuing its 
 labours, and supporting its reputation : Sa- 
 
 batier, Desault, who may be regarded ay 
 the Pott of France, Chopart, Lassus, Pey- 
 rilhe, Dubois, Percy, Baudeloque, Pelletan, 
 
 Sue, &c. 
 
 The Academy of Surgery in France was 
 succeeded by what is named the Ecole de 
 Medecine. Desault, who was almost a stran- 
 ger in the former, became quite the leading 
 character in the latter. Several things re- 
 commended him strongly to the remem- 
 brance and admiration of posterity ; the ex- 
 actness and method which he introduced 
 into the study of anatomy ; the ingenious 
 kinds of apparatus which he invented for 
 the treatment of fractures,.; a noble ardour 
 in his profession, which he knew how to 
 impart to all his pupils ; his clinical lectures 
 upon surgery, "which were the first ever de- 
 livered ; and the boldness and simplicity of 
 bis modes of operating. Indeed, such was 
 his genius, that even when he practised only 
 methods already understood, he did them 
 with so much adroitness, that he rather ap- 
 peared to be the inventor of them. From 
 the Ecole de Medecine have issued Dupuy- 
 tren, Boyer, Richerand, Dubois, Lheritier. 
 Manoury, Lallemant, Petid de Lyon, Bi- 
 chat, &c. 
 
 The researches of Bichat, who quitted 
 surgery, powerfully contributed to the ad- 
 vancement of physiological science. His 
 mind, richly stored with the positive facts 
 which he had learned in the study of surge- 
 ry, conceived no less' a project than that of 
 rebuilding the whole edifice of medicine. 
 Some courses of lectures upon the materia 
 medica, internal clinical medicine and mor- 
 bid anatomy, announced this' vast design, 
 which was frustrated by a premature death. 
 
 Bichat, as a physiologist, and man of very 
 original genius, may be consideral as the 
 John Hunter of France; but his qualities 
 were of a different cast, and hardly admit 
 of comparison with those of Hunter, whose 
 investigations were not limited to man, but 
 extended to the whole chain of animated 
 beings. Bichat died in the midst of his la- 
 bours, and in dying his greatest regret was 
 that of not having completed them. His 
 example, says Richerand, proves most con- 
 vincingly what Boerhaave always inculcu 
 ted, how indispensable the study and even 
 the practice of surgery are to him, who 
 would wish to be a distinguished and sue 
 cessful physician. (Nosogr. Chir. Tom. 1, 
 p. 25.) 
 
 Perhaps nothing contributed so materially 
 to the improvement of surgical knowledge, 
 as the establishmentof the Royal Academy of 
 Surgery in France; anomie institution, which, 
 fora long while, gave our neighbours infinite 
 advantage over us, in the cultivation of this 
 most useful profession. Indeed, every one 
 truly interested in the improvement of sur- 
 gery, cannot fail to regret the discontinu- 
 ance of a society, in which emulation and 
 talents were so long united for the benefit 
 of mankind. The various dissertations pub- 
 lished by the illustrious members of the aca- 
 demy, will serve as a perpetual memorial 
 of the spirit, ability, and success, with which 
 
SURGER\ 
 
 the objects of the institution were pursued ; 
 and centuries hence, practitioners will reap 
 from the pages of its memoirs the most va- 
 luable kind of surgical information. Unfor- 
 tunately, this establishment, which was 
 overthrown by ihe agitation of the French 
 Revolution, has had only a very inferior 
 substitute in the Ecole de Mfidecine 
 
 Were l to name any one thing, which, in 
 my opioion, would have the greatest influ- 
 ence in giving life to the study and cultiva- 
 tion of surgery in this country, I should 
 without hesitation assign such importance 
 to the establi-hment of an institution in the 
 metropolis, on the same grand, liberal, and 
 encouraged plan, as the late Royal Acade- 
 my of Surgery in France. 
 
 At the same time, 1 am conscious that the 
 present Medical and Chirurgical Society of 
 London have every claim to the encourage- 
 ment and gratitute of the profession. No 
 other institution of the kind has ever done 
 so much in so short a space of time. Many 
 of the facts which they have collected and 
 published, are of considerable importance, 
 especially those relating to the subj'ects of 
 aneurism and hemorrhage. Their library is 
 already the most select, valuable, and com- 
 plete collection of medical literature in 
 Great Britain ; and it is daily receiving ad- 
 ditions both by large purchases at borne and 
 abroad, and by the liberal donations of its 
 members. The intercourse and correspond- 
 ence ^hich such a society continually main- 
 tain among the innumerable scattered mem- 
 bers of tbe profession, cSnnot fail to be at- 
 tendedwith the most beneficialconsequences. 
 A generous and useful sort of emulation is 
 thus kept alive ; the spirit of inquiry is pre- 
 vented from slumbering ; and every indivi- 
 dual vrho ascertains a new fact, has now 
 the means of making it known to the world, 
 with all the expedition which its import- 
 ance may demand. 
 
 Within the last twenty or thirty years, 
 most important improvements have certain- 
 ly been made in almost every branch of 
 surgery; and it must gratify every English- 
 man to find, that his own countrymen have 
 acted a very leading part in effecting an 
 object, in which the interests of mankind 
 are so deeply concerned. 
 
 Before the time of Mr. John Hunter, onr 
 ideas of the venereal disease were surround- 
 ed with absurdities ; and it is to this lumi- 
 nary that we are in an eminent degree 
 indebted for the increased discrimination 
 and reason, which now prevail, both in the 
 doctrines and treatment of the complaint. 
 It must be confessed, however, that much 
 yet remains to be made out. respecting the 
 nature and treatment of syphilitic disorders. 
 Need 1 mention a greater proof of the truth 
 of this remark, than the sudden change of 
 practice in some of the principal hospitals 
 in London, mercury being now not exhibited 
 in more than one out of ten cases, for which 
 this medicine a few years ago was always 
 deemed indispensable ? Numerous cases, 
 having all the characters of primary' vene- 
 real sores, seem now to be curable by sim- 
 
 401 
 
 pie dressings and cleanliness. In short, so 
 different is every thing from what it used to 
 be, that many surgeons are tempted to sup- 
 pose the nature of the venereal disease to 
 tally (altered. Some observations on this 
 important topic are offered in another place. 
 See Venereal Disease. 
 
 Strictures in the urethra, an equally com- 
 mon and distressing disease, were not well 
 treated of before Mr. Hunter published on 
 the venereal disease ; at*d the advantage of 
 armed bougies in the treatment of certain 
 cases has been subsequently pointed out 
 by Sir Everard Home. 
 
 In modern times, hernial diseases, those 
 common afflictions in every country, have 
 received highly interesting elucidations 
 from the labours of Pott, Camper, Richter, 
 Sir Astley Cooper, Hey, Gimbernat, Hes- 
 selbach, Scarpa, Lawrence, he. 
 
 The treatment of injuries of the head 
 has been materially improved by Quesnay, 
 Le Dran, Pott, Hill, Desault, and Aber- 
 nethy. 
 
 I he disease of the vertebra?, which oc- 
 casion* paralysis of the limbs, formerly al- 
 ways baffled the practitioner; but the me- 
 thod proposed by Air. Pott is now frequently 
 productive of considerable relief, and some- 
 times of a perfect cure. The diseases of the 
 joints in general may also be said to be at 
 present viewed with much more discrimina- 
 tion than *hey were a veryfew r years ago; and 
 this great step to better and more successful 
 practice reflects great honour on Mr. Brodie, 
 while it keeps up a well-founded hope, that 
 morbid anatomy, the study which has of late 
 banished so much confusion from this part 
 of surgery, will yet be the means of bring- 
 ing to light other useful fact^ and observa- 
 tions, relative to the diseases of the joints in 
 general. 
 
 The mode of treating lumbar abscesses has 
 been rendered much more successful than 
 formerly, and for this change the world is in- 
 debted to Mr/ Abernethy. 
 
 The almost infallible plan of curing hy- 
 droceles by an injection, as described by Sir 
 James Earle, may also be enumerated among 
 modern improvements. 
 
 The increasing aversion to the employment 
 of the gorget in lithotomy, and the many dis- 
 tinguished advocates for the use of better in- 
 struments in this operation, may be hailed 
 as propitious omens of beneficial changes in 
 this part of practice. 
 
 The diseases of the eyes, to which affec- 
 tions English surgeons seemed to pay much 
 less attention than was bestowed by foreign 
 practitioners, now obtain due attention in 
 this country. Although we have generally 
 had some distinguished oculists, our regular 
 surgeons have generally been wonderfully 
 ignorant of this part of their profession, and 
 uninformed on the subject, they have given 
 up to professed oculists and quacks one of 
 the most lucrative and agreeable branches 
 of practice. However, the able writings of 
 Daviel, Wenzel, and Ware, begin now to be 
 familiarly known to practitioners: and the 
 observations of Scarpa, Richter, Beer, 
 
SURGERY 
 
 Wardrop, Travers, and Saunders, will soon 
 have immense effect in diffusing in the pro- 
 fession a due knowledge of the numerous 
 diseases, to which the organs of vision are 
 liable. As likewise the generality of the 
 hospital surgeons of London, have, during 
 the last thirty years, grossly neglected the 
 study of the diseases of the eye, and consci- 
 entiously refused to have any thing to do 
 with these cases, the public at length saw 
 the necessity of establishing Eye Infirma- 
 ries, where such afflictions might be more 
 attentively observed and relieved. Some 
 of these have now become excellent schools, 
 in which the rising generation of surgeons 
 have abundant opportunities of studying the 
 nature of all the diseases of the eyes, and 
 the most approved methods of treatment. 
 
 While, however, 1 am thus commending 
 separate institutions for disorders of the eye, 
 it becomes me to express my regret for the 
 long-continued neglect, and the ignorance 
 of these diseases, manifested by several 
 hospital surgeons, which were in fact the 
 original causes of those distinct establish- 
 ments. For, according to my conceptions, 
 it would have been far better to have had 
 the practice in eye-cases exhibited in the 
 common great schools of surgery, the large 
 hospitals of London. 1 am of this opinion, 
 not only because I think these diseases 
 would then have met with more general 
 and public observation ; but also because I 
 have always considered all unnecessary sub- 
 divisions of practice, in short all measures 
 which tend to throw particular cases into 
 the hands of a few individuals, hurtful to the 
 best interests, and degrading to the charac- 
 ter of the profession. 
 
 In the treatment of aneurisrnal diseases, 
 English surgeons have much to be proud of. 
 All the boldest operations in this branch of 
 surgery have been devised by the genius, 
 and executed by the spirit and skill of British 
 surgeons. Even M. Roux himself is here 
 obliged to confess our superiority. ( Paral - 
 lele de la Chirurgie Angloise , fyc. p. 249.) 
 The carotid artery, the external and internal 
 iliac, and the subclavian, have all been suc- 
 cessfully tied by surgeons of this country. 
 The first operation, in which the external 
 iliac was tied, I was a spectator of : it was 
 performed by Mr. Abernethy in Bartholo- 
 mew’s hospital, and it has subsequent!) been 
 repeated in many examples, both iri this 
 country and others, with considerable suc- 
 cess. I bad also the honour of seeing the 
 same gentleman likewise tie the carotid, in 
 the first instance of that operation in Eng- 
 land. This important measure has also now 
 been frequently practised with success, and 
 it constitutes one of the great improvements 
 in the operative part of modern surgery. 
 
 In the article Aneurisoi, I have cited 
 many examples, in which the carotid artery 
 has been successfully tied ; and the safety 
 and propriety of the operation are now ge- 
 nerally known and acknowledged. Indeed, 
 so little are surgeons now afraid of the ill 
 effects upon the brain, that the carotid arte- 
 ry has lately been tied merely for the purpose 
 
 of enabling the operator (o fake away a large 
 tumour, including the whole of the parotid 
 gland, from the side of the neck, without risk 
 of hemorrhage ; a mode of proceeding, 
 however, which ought not to be encouraged 
 into a common practice. (See Medico-Chir . 
 Trans. Vol. 7, p. 112.) Before 1 quit this 
 subject, my feelings call upon me to express 
 tbe high opinion which I entertain of Mr 
 Hodgson’s Treatise on the Diseases of Arte- 
 ries and Veins, published in 1815, a work 
 which reflects great credit on English sur- 
 gery, and contains practical precepts far su 
 perior to those of Scarpa. 
 
 In the modern practice of surgery, a 
 variety of old prejudices are gradually va- 
 nishing. Peruvian bark not many years 
 ago, was regarded as a sovereign remedy 
 and specific for nearly all cases of gangrene „ 
 and in these and many other instances, it 
 was prescribed without any discrimination, 
 and in doses beyond all moderation. But 
 the false idea, that this medicine has any 
 specific effect in checking mortification, no 
 longer blinds the senses of the most superfi- 
 cial practitioner. He neither believes this 
 doctrine, nor tbe still more absurd opinion, 
 that strength can be mysteriously ex- 
 tracted from this vegetable substance, and 
 communicated to the human constitution, in 
 proportion to the quantity which can be 
 made to remain in the stomach. This sub 
 ject, however, has been duly discussed in the 
 articles Cinchona and Mortification. 
 
 The removal of this deeply-rooted pre- 
 judice, concerning the virtues of bark, in 
 stopping mortification, will pave the way to 
 better and more successful practice. 
 
 But upon the subject of mortification, the 
 present day opens to us the investigation of 
 a point, which is of the first-rate conse- 
 quence. Every surgeon is aware, that when 
 a limb is affected with mortification, ampu 
 tation is absolutely necessary to effect a 
 cure. This is generally acknowledged; but 
 the performance of the operation has, since 
 the time of Mr. Pott, only been sanctioned 
 when the mortification has manifestly ceased 
 to spread, and a line of separation is formed 
 between the dead and living parts. All 
 other instances, in which the disorder was 
 in a spreading state, were left to their fate 
 It is true, some of tbe old surgeons occasion - 
 ally ventured to deviate from this precept , 
 but as they did so without any discrimina- 
 tion, or knowledge of the particular exam- 
 ples which ought to form an exception to 
 the general rule, their ill success cannot con- 
 stitute a just argument against the plan of 
 amputating earlier in a certain description of 
 cases. 
 
 Now if modern experience can prove, 
 that many lives may be saved by a timely 
 performance of amputation, under circum- 
 stances in which it has until lately been ge 
 nerally condemned, it must be allowed that 
 the established innovation will be one of the 
 greatest improvements in the practice of the 
 present time. 
 
 For reviving the consideration of this 
 question, and venturing to deviate from the 
 
SURGERY 
 
 beaten path, the world is much indebted to 
 that eminent military surgeon, Baron Lar- 
 rey. How different his doctrines and prac- 
 tice are from those usually taught in the 
 schools, the article Mortification will suffi- 
 ciently prove. 
 
 In the treatment of ununited fractures, the 
 simple and ingenious practice proposed by 
 Dr. Physick of Philadelphia, merits particu- 
 lar notice, not only on account of the seve- 
 ral successful trials which have been made 
 of it in this country and France; (See Me- 
 dico- Chir. Trans. Vols. 5 7, and Buyer's 
 
 Trait6 des Maladies Chir.) hut also because 
 it is perhaps the first improvement of con- 
 sequence, that has hitherto been made in 
 the practice of surgery by our transatlantic 
 brethren. 
 
 The inestimable treatise of Dr. Jones on 
 Hemorrhage, has now produced quite a re- 
 volution in all the principles, by which the 
 surgeon is guided in the employment of the 
 ligature for the stoppage of bleeding and the 
 cure of aneurisms. Instead of thick clumpy 
 cords, small firm silks or threads, are now 
 generally used; and so far is the practitioner 
 I from being fearful of tyjng arteries too tight- 
 f ly, lest the ligature cut through them, that it 
 is now a particular object with him to apply 
 the silk or thread, with a certain degree of 
 force, in order that the inner coat of the ves- 
 i sel may be divided. If this be not done, the 
 effusion of coagulating lymph within the ar- 
 tery, an important part of the process of ob- 
 literation, cannot be expected as a matter of 
 certainly, and secondary hemorrhage is 
 more likely to occur- But in order to con- 
 vey an adequate idea of the beneficial 
 changes which Dr. Jones’s observations are 
 tending to produce in practice, we have 
 been careful in the article Hemorrhage, to 
 give a tolerably full account of the results of 
 all his interesting experiments. 
 
 Besides using very small, firm, round 
 threads, instead of large fiat tapes or cords, 
 t as was the custom a few years ago, modern 
 surgeons begin to suspect, that much benefit 
 may also arise from cutting off both portions 
 of the ligature close to the knot, after am- 
 putation, the removal of the breast, &c. ]\o 
 
 one has insisted so much as Mr. Lawrence 
 upon the propriety of examining further the 
 merits of this innovation. If no bad effects 
 result from leaving so small a particle of ex- 
 traneous substance in the flesh, as the- little 
 bit of silk composing the knot and noose on 
 1 the artery, the practice will form a consider- 
 able improvement. The wound may then 
 be brought together at every point ; the 
 quantity of extraneous matter in the wound 
 i will be lessened to almost nothing ; the dan- 
 1 ger of convulsive affections w ill bp reduced 
 
 i in proportion as a serious cause of pain or 
 
 irritation is diminished ; and the chance of 
 accomplishing perfect union by the first in- 
 tention will be materially increased. Mr. 
 Lawrence has tried the plan in many instan- 
 ces, and hitherto his experience has not 
 found any ill consequences follow, while it 
 lias proved, that many advantages are un- 
 i doubtedly the result of it. In amputations, 
 
 453 
 
 the method has been practised by several of 
 our military surgeons ; and although they 
 have probably not employed exuctly such 
 ligatures as this mode absolutely requires, 
 the greater part of them have met with hard- 
 ly any instances of future trouble from the 
 bits of ligature enclosed in the wound. 
 However, if larae ligatures be used, the prac- 
 tice is not lairly tried, or rather the practice 
 is not tried at all; because the great princi- 
 ple, on which it answers, is the very small 
 atom of silk composing the extraneous sub- 
 stance left in the wound, when such liga- 
 tures as Mr. L .vvrence particularly recom- 
 mends are employed. Delpech and Rous 
 have also sometimes adopted the plan of re- 
 moving the ends of the ligature close to the 
 knot. (See Parldlble de la Chir. Angloise 
 avec la Chir. Fanqoise, p. 131.) See Ampu- 
 tation, Aneurism , Hemorrhage , and Liga- 
 ture. 
 
 Among other real improvements in mo- 
 dern practice, I must not forget the present 
 more rational method of dressing the wound, 
 alter the majority of capital operations, 
 with light, cooling applications, instead of 
 laying on the part a farrago of irritating’ 
 pledgets and piasters, and a cumbersome 
 mass of lint, tow, flannel, and other banda- 
 ges, woollen caps, &c. The fewer the adhe- 
 sive strips are the better, if they bold the 
 lips of the wound together. This is all they 
 are intended to do. Whereas, if you apply 
 more than are necessary for this purpose, 
 they do harm by heating the part, and co- 
 vering the wound so entirely as to prevent 
 the issue of the discharge. Over the adhe- 
 sive plasters, let the surgeon be content with, 
 placing a simple pledget of spermaceti 
 cerate, and some linen wet with cold wa- 
 ter, which will often avert hurtful degrees of 
 pain and inflammation, by keeping the parts 
 cool. 
 
 Wars, which are unfavourable to most 
 other sciences, are rather conducive to ad- 
 vances in surgery. The many new and in 
 teresting observations which Baron Larrev 
 has made in the course of his long and ex 
 tensive military experience, are a proof of 
 the foregoing remark. Pitard, almost the 
 founder of surgery in France, was a milita 
 ry surgeon. Ambrose Paieand Wiseman also 
 collected their most valuable knowledge 
 principally in the service of the army. Mr. 
 Hunter himself gained much of bis practical 
 information in the same line of life. To 
 Baron Larrey surgeons are indebted for many 
 highly important observations, relating to 
 amputation in cases of gunshot wounds. In 
 particular he has adduced a larger and more 
 convincing body of evidence, than was ever 
 before collected to prove, that in gunshot 
 injuries, the operation of amputation should 
 always be performed without the least delay, 
 in every instance in which such operation is 
 judged to be unavoidable, and the ullimate 
 preservation of the limb either impossible, 
 or beyond the scope of all rational probabi 
 lity. He has established the truth of this 
 most important precept in military surgery 
 by innumerable facts, drawn chiefly from 
 
454 
 
 SU3 
 
 his own ample experience, and partly from 
 the practice of many able colleagues. The 
 great operations of the shoulder-joint, and 
 hip-joint amputations, he has executed w ith 
 success. The necessity for the former, 
 however, he proves may sometimes be su- 
 perseded, and the limb be saved, by making a 
 suitable incision for the extraction of the 
 splintered portions of the upper part of the 
 humerus. This method, which was in many 
 instances done with success in the peninsu- 
 lar war was, 1 believe, originally proposed 
 and practised by Boucher. (See Mem. de 
 I'Acad. de Chir. T. 2, Ato.) However, it 
 was more particularly described and even 
 practised by Mr, C. White, of Manchester. 
 (See his Cases in Surgery.) It has been re- 
 peated wiib success by Mr. Morell in the 
 York Hospital. (See Med. Chir. Trans. Vol. 
 7.) See Amputation. 
 
 Amputation at the hip-joint, performed 
 only in the most dreadful cases, because 
 itself the most dreadful operation in surgery, 
 Bar m Larrey has performed five limes, and 
 twice (I believe) with success. This pro- 
 ceeding has also been adopted by Mr 
 Brownrigg and Mr. Guthrie, and their pa- 
 tients ^recovered. As must be the case, 
 however, on account of the desperate cir- 
 cumstances under which the operation is 
 performed, and the severity of the operation 
 itself, the examples of recovery bear only a 
 small proportion to the large number of 
 deaths, known to have followed amputation 
 at the hip in the many cases, in which it has 
 now been undertaken. However, the un- 
 fortunate truth should not be exaggerated 
 into a reason for a general condemnation of the 
 practice, which is adopted as the only means 
 affording a chance of life. But as there may 
 he diffic dty in deciding whether the patient 
 will have the best chance with or w ithout 
 the operation, it is to be hoped that no sur- 
 geons will perform it, except under the 
 authority of ;be united opinion of a board, or 
 consultation of the best-informed practition- 
 ers, whom circumstances will allow to assem- 
 ble. See Amputation. 
 
 In military surgery, the useful innovation 
 of ambulances, or light caravans, furnished 
 with a proper number of surgeons, assist- 
 ants, and orderlies, and capable of keeping 
 up with the vanguard, if requisite, is un- 
 doubtedly the best means of affording speedy 
 surgical assistance to the w'ounded on the 
 field of battle, and ought to be enumerated 
 as one of the greatest modern improvements 
 Barons Percy and Larrey deserve the chief 
 praise for their successful exertions in organi- 
 zing and bringing to perfection so indispensa- 
 ble mi establishment. The account of this 
 subject well deserves perusal ; and ii may 
 be s en eiiher in Larrey' s Mtmoires de Chi- 
 rurgie Militaire, or in tht Diet, des Sciences 
 Mi icales, T. 5 
 
 SUSPENSORY. A bandage for support- 
 ing the scrotum ; a bag-truss. Bandages of 
 this kind are now usually sold at the shops, 
 and seldom made by surgeons themselves ; 
 therefore a particular description of them is 
 not. essential in this work. In cases of her- 
 
 Sti’l 
 
 nia humoralis, varicocele, cirsoceie, some, 
 particular ruptures, and several other affec- 
 tions of the testicle, and spermatic chord, a 
 suspensory bandage is of infinite service. 
 
 SUTURES, (from suo, to sew.) A suture, 
 in surgery, means a mode of uniting the 
 edges of a wound, by keeping them in con- 
 tact with stitches. 
 
 Mr. Sharp remarks, that “ when a wound 
 is recent, and the parts of it are divided by 
 a sharp instrument, without any further vi- 
 olence. and. in such manner, that they may 
 be made to approach each other, by being 
 returned with the hands, they will, if held 
 in close contact for some time, reunite by 
 inosculation and cement, like one branch 
 of a tree ingrafted on another. To maintain 
 them in this situation, several sorts of su- 
 tures have been invented, and formerly 
 practised, but the number of them has, of 
 late, been very much reduced. Those mow 
 chiefly described are the interrupted , the 
 glover's, the quilled, the hoisted, and the dry , 
 sutures : but the interrupted and twisted are 
 almost the only useful ones, for the quilled 
 suture is never preferable to the interrupted ; 
 the dry suture is ridiculous in terms, since it 
 is only a piece of plaster, applied in many 
 different ways, to reunite the lips of the 
 wound ; and the glover’s, or uninterrupted 
 stitch, which is recommended in superficial 
 wounds, to prevent the deformity of a scar, 
 does rather, by the frequency of the stitches, 
 occasion it, and is therefore to be rejected, 
 in favour of a compress and sticking plaster. 5 
 ( Oper . of Surgery.) The twisted suture is 
 described in speaking of the harelip ; and 
 gaslroraphe, w hich also properly belongs to 
 the present subject, forms a distinct article 
 in this Dictionary. 
 
 Interrupted Suture. — The wound being 
 cleansed from all clots of blood, and its 
 lips being brought evenly into contact, the 
 needle, armed with a ligature, is to be care- 
 fully carried from without inwards to the 
 bottom, and so on from within outwards 
 G’are must be taken to make the puncture 
 far enough from the edge of the wound, lest 
 the ligature should tear quite through the 
 skin and flesh. This distance, according to 
 Mr. Sharp, may be three, or four-tenths of 
 an inch. The other stitches required are 
 only repetitions of the same process. The 
 threads having beeu all passed, “ you are 
 in general to begin tying them in the middle 
 of the wound ; though, if the lips be held 
 carefully together, (says Mr. Sharp,) it will 
 not be of great consequence, which stitch is 
 tied first.” ( Operations , Chap. 1.) 
 
 Surgical writers in general state, that the 
 number of stitches must, in a great measure, 
 depend upon the extent of the wound. The 
 common rule is, that one suture is sufficient 
 for every inch of the wound ; but that in 
 some instances, a stitch must be more fre- 
 quently made, particularly when a wound 
 gapes, very much, in consequence of a trans- 
 verse division of muscles. As w'e have al- 
 ready explained, it is necessary to pierce the 
 skin, at a sufficient distance from the sides 
 of the wound, lest the thread should cut 
 
SUTURES. Too* 
 
 through the flesh in a short time : but, though 
 Mr. Sharp lays down the necessary distance, 
 in general as three, or four-tenths of an inch, 
 and others advise the needle to be always 
 carried through the deepest part of the 
 wound, we must receive these directions, 
 particularly the last, as subject to numerous 
 exceptions. When a wound is very deep, 
 it would be conspicuously absurd, and even, 
 in many instances, dangerous, to drive the 
 needle through a vast thickness of parts. 
 Other wounds, of considerable length, might 
 not be, in some places, four-tenths of an 
 inch deep ; though it is true, sutures could 
 never be requisite at such points. 
 
 The needles for making the interrupted 
 suture will pass with the greatest facility, 
 when their shape corresponds exactly with 
 the segment of a circle, and they should al- 
 ways form a track of sufficient size to allow 
 the ligatures, which they draw after them, 
 to pass through the flesh with the utmost 
 ease. 
 
 The interrupted suture obviously receives 
 its name from the interspaces between the 
 stitches ; and it is the one most frequently 
 employed. Its action is alw T ays to be assisted 
 and supported, either with the uniting ban- 
 dage, (see Bandage ) or with strips of adhe- 
 sive plaster, compresses, &e. 
 
 Quilled Suture. — As Mr. John Bell has 
 observed, “ when the wound was deep 
 among the muscular flesh, the old surgeons 
 imagined, that so large a wound could not 
 be commanded by the common interrupted 
 suture, how r ever deep the stitches might be 
 driven among the flesh ; they were besides 
 ' fearful of using the continued (glover’s) su- 
 ture in deep gashes, lest the wound should 
 be made to adhere superficially, w'hile it w as 
 still open within, forming perhaps a suppu 
 ration, or deep collection of matter They 
 believed, that a deep muscular wound could 
 not be safely healed, without a degree of 
 suppuration ; while they wished to bring it 
 together at the bottom, they were afraid to 
 close it very exactly at the mouth, lest the 
 matter should be collected in the deeper 
 parts of the wound ; it was for this purpose 
 (says Mr. John Bell) that they used what 
 they called the compound , or quilled suture. 
 It is merely the interrupted suture, w r ith this 
 difference, that the ligatures are not tied 
 over the face of the wound, but over two 
 quills, or rolls of plaster, or bougies, which 
 are laid along the sides of the wound. In 
 performing this suture, we make first two, 
 three, or four stitches, of the interrupted 
 suture very deep, and then, all the ligatures 
 being put in, we lay two bougies along the 
 sides of the wound, then slip one bougie 
 into the loop of the ligatures on one side, 
 drawing all the ligatures from the other side, 
 (Mr. Bell should rather have said towards 
 the other side,) till that bougie is firmly bra- 
 ced down. Next we lay the other bougie, 
 and make the knots of each ligature over 
 it, and draw' it also pretty firm ; and thus the 
 ligatures, in form of an arch, go deep into 
 the bottom of the wound, and hold it close, 
 while the bougies, or quills, keep the mid- 
 
 dle of the wound, and lips of it pressed to- 
 gether with moderate closeness, and prevent 
 any strain upon the threads, or any coarse 
 and painful tying across the face of the 
 wound.’’ In a note Mr. J. Bell says, that 
 Dionis violently reprobates the quilled su- 
 ture; but, that De la Faye (the annotator on 
 Dionis) says, it is good for deep muscular 
 wounds. The quilled suture is now scarcely 
 ever employed ; nor has it any advantages, 
 except, perhaps, in some wounds in the 
 belly. (See Principles of Surgery, Vol. \,p. 
 50 .) 
 
 I think the reader will more easily com- 
 prehend the manner of making the quilled 
 suture, from the following simple directions. 
 Take as many needles, as stitches intended 
 to be made ; arm them with a double liga- 
 ture, or one capable of being readily split 
 into two ; introduce the ligatures through 
 the wound ; cut off the needles : lay a piece 
 of bougie along one side of the wound, and 
 tie the ends of the ligatures over it. Next 
 draw the other extremities of the ligatures, 
 so as to bring the first piece of bougie into 
 close contact with the flesh ; lay the second 
 piece of bougie along the opposite side of 
 the wound, and tie the other ends of the li- 
 gatures over it with sufficient tightness. 
 
 Glover's Suture. This had also the name of 
 the continued suture. It was executed by 
 introducing the needle first into one lip of 
 the wound, from within outw ards, then into 
 the other in the same w ay ; and, in this 
 manner the whole track of the wound was 
 sewed up. 
 
 The glover’s suture has long been rejected 
 by all good surgeons, as improper to be em- 
 ployed in cases of common wounds. It 
 was not, however, till very lately, that this 
 suture was totally abandoned; for JVJr. Sharp, 
 and several eminent writers since his time, 
 have advised its adoption in wounds of the 
 stomach and intestines. From what has 
 been said in the articles Wounds of the Abdo- 
 men and Hernia, the reader will perceive, 
 that even in such particular instances, the 
 glover’s suture would not be adviseable ; so 
 that it may, in every point of view, be now 
 considered as totally disused in every case 
 of surgery which can possibly present itself. 
 When we remember, in making this suture, 
 how many stitches are unavoidable ; how 
 unevenly, and in w hat a puckered state the 
 suture drags the edges of the skin together, 
 and what irritation it must' produce, we can 
 no longer be surprised at its now being ne- 
 ver practised on the living subject. It is 
 commonly employed for sewing up dead 
 bodies; a purpose for which it is well fitted, 
 but for the honour of surgery, and the sake 
 of mankind, it is to be hoped that it will 
 never again be adopted in practice. 
 
 False, or Dry Suture . — Modern surgeons 
 commonly understand by this expression 
 nothing more, than the plan of bringing 
 the sides of a wound together, by means of 
 adhesive plaster ; nor did Mr Samuel Sharp 
 attach any other meaning to the phrase, 
 wTjich he sets dowm as highly ridiculous, 
 as there is no sewing employed. For the 
 
456 • SUTURES 
 
 following remarks, i am indebted to Mr. 
 Carwardine, of Earls Colne Priory, near 
 Halsted, Essex. Alluding to what was sta- 
 ted in the last edition of this Dictionary, 
 concerning the dry suture, he observes, 
 e( you do not appear to be aware any more 
 than Mr. Sharp, of the precise mode of its 
 application, or why it was so called. In- 
 deed, it is a curious circumstance, how this 
 method of dry suture should have been so 
 lost, as not to be described by any modern 
 surgeons, who laugh at the very term, speak- 
 ing of it as a mere application of a strip of 
 adhesive plaster. In the sulura sicca, so call- 
 ed in opposition to the sulura crumta, 
 where blood followed the needle, some ad- 
 hesive plaster was spread on linen, having 
 a selvage. A piece of this was applied 
 along each side of the wound (the selvages 
 being opposed to each other,) and then 
 drawn together by sewing them with a com- 
 mon needle, without bloodshed. Hence 
 the term sulura sicca. The dry suture was 
 used in all wounds of the face to avoid 
 scars. You will find it thus described 
 by our countryman Thomas Gale in his 
 Enceiridion, 1563 ; and also by A. Pa- 
 rey, who gives a figure of it in his folio 
 work, 1579.” I feel much obliged to my 
 friend Mr. Carwardine for this explanation, 
 without which the expression dry suture is 
 undoubtedly absurd. As the common way 
 of dressing wounds with sticking plaster 
 will come under consideration in a future 
 part of this work, (see Wounds,) I shall not 
 here detain the reader upon that topic. 
 
 Sutures, by which I mean such as were 
 made in the flesh with a needle and ligature, 
 were much more frequently employed by the 
 old surgeons, than they are by the moderns. 
 The best practitioners of the present day 
 never resort to this method of holding the 
 sides of a wound in contact, except in cases 
 in which there is a real necessity for it, and 
 other modes will not suffice. 
 
 There were, indeed, certain instances, in 
 which the employment of sutures was long 
 ago forbidden. Of this kind were enve- 
 nomed wounds, in which accidents the des- 
 truction of the poison always :ormed a prin- 
 cipal indication in the treatment. — Wounds, 
 accompanied with considerable inflamma- 
 tion, were not deemed proper tor the use of 
 sutures, as the stitches had a tendency to in- 
 crease the inflammatory symptoms. Also, 
 as contused wounds necessarily suppurated, 
 and, consequently, could not be united, su- 
 tures were not recommended for them ; nor 
 were they judged expedient for wounds at- 
 tended with such a loss of substance as pre- 
 vented their lips from being placed in con- 
 tact. Formerly, wounds penetrating the 
 chest, were not united by sutures ; nor were 
 those in which large blood-vessels were in- 
 jured ; at least, until all danger of hemor- 
 rhage was obviated by the vessels being 
 tied. 
 
 Dionisbelieved, with several otherautliors, 
 that wounds should not he united, when 
 bones were exposed, on account of the ex- 
 foliations which might he expected, '.rids 
 
 precept is no longer valid ; lor when bones 
 are neither altered nor diseased, and are 
 only simply denuded, or divided with a cut- 
 ting instrument, no exfoliations will com- 
 monly follow, if the surgeon take care to 
 replace the fresh-cut soft parts so as to cover 
 the exposed portion of the bone. The 
 practicable ness of uniting wounds, attended 
 with the division of a bone, is confirmed 
 by numerous facts. De la Peyronie com- 
 municated to the French Academy of Sur- 
 gery, a case conclusive on this point. A 
 man was wounded with a cutting instru- 
 ment, in an oblique direction, on the exter- 
 nal and middle part of the arm. The bone 
 was completely cut through, together with 
 the integuments and muscles, in such a 
 manner that the arm only hung by an un- 
 divided pox’tion of the skin, about an inch 
 wide, under which were the large vessels. 
 De la Peyronie tried to unite the parts, be- 
 ing convinced that it would be time* enough 
 to amputate afterward, if the case should 
 require it. He placed the two extremities 
 of the divided bone in their natural situa- 
 tion ; made several sutures for promo- 
 ting the union of the soft parts, and ap- 
 plied a bandage to the fracture. In this ban- 
 dage there were slits, or apertures, over the 
 wound, to allow the dressings to be applied. 
 Spirit of wine, containing a little muriate of 
 ammonia, was used as a topical application, 
 and the forearm and hand, which were cold, 
 livid, and insensible, were also fomented 
 with the same. By these means the natural 
 warmth was restored, and the wound was 
 dressed in a week the dressings were re- 
 moved, through the opening in the bandage ; 
 in a fortnight they were changed a second 
 time, and the wound seemed disposed to 
 heal. On the eighteenth day, the healing 
 had made considerable progress ; the part 
 had a natural appearance ; and the beating 
 of the pulse was very perceptible. De la 
 Peyronie now substituted a common roller 
 for the preceding bandage, and care was ta- 
 ken to change the dressings every ten days. 
 In about seven weeks all applications were, 
 left off, and at the end of two months the 
 patient was quite well, with the exception of 
 a little numbness in the part. This case is 
 one of the most important in all the records 
 of surgery , for it displays, in a most stri- 
 king manner, what very had wounds it is the 
 duty of the surgeon to attempt to unite ; 
 and above all, it exemplifies the propriety 
 of attempting to save many compound frac 
 tures, which, judged of only from first ap- 
 pearances, would lead almost any one to 
 resort to amputation. In such cases, when 
 the divided parts are put in contact, the ap 
 pearances are quite altered. 
 
 From what has been already stated, it ap- 
 pears that surgeons, a considerable time 
 back, did not at once sew up every sort of 
 wound ; though the considerations, which 
 led them not to close the wound, were 
 erroneous, as may, perhaps, he said with re- 
 spect to the apprehension of bleeding and 
 exfoliations. The best modern practitioners 
 employ sutures much less frequently than 
 
SUTi 
 
 Ikeir predecessors. Pibrac ? s dissertation on 
 the abuse of sutures, inserted in the third 
 volume of the Memoirs of the Academy of 
 Surgery, has had considerable effect in pro- 
 ducing this change, and I may safely add, 
 this improvement in practice. This judi- 
 cious and enlightened practitioner opposed 
 the method of uniting wounds by means of 
 sutures, which, he contended, ought never to 
 be adopted in practice, except in certain 
 cases in which it vsas absolutely impossible 
 to keep the sides of the wound in contact, 
 by means of a suitable posture, and the aid 
 of a methodical bandage. Such circum- 
 stances Pibrac represents as exceedingly rare, 
 if they ever occur at all. He speaks of 
 sutures as seldom fulfilling the intention of 
 the surgeon, who, in the majority of cases 
 in which he employs them, finds himself ne- 
 cessitated to remove them, before they have 
 accomplished the wished-for end. Pibrac 
 believes that sutures are generally more 
 hurtful than conducive to the union of 
 wounds ; and that when they succeed, they 
 do not effect a cure more speedily than apro- 
 per bandage. He cites numerous cases of 
 very extensive wounds of the abdomen, 
 neck, fee. for the cure of which a bandage 
 proved effectual, and this even in many in- 
 stances in which sutures had previously 
 failed, and cut their way through the flesh. 
 Louis, who adopted the opinions of Pibrac, 
 published in the fourth volume of Mem. de 
 V Acad de Chirurgie, a valuable dissertation, 
 in which he endeavours to provd; that even 
 the harelip can be better united, by means 
 of the uniting bandage than sutures ; a case, 
 however, which the best modern surgeons 
 very rightly agree to consider, for particular 
 reasons elsewhere noticed, (see Harelip ,) as 
 an example, in which a suture is adviseable. 
 
 As far as 1 can judge, the fair statement 
 of the matter is, that sutures are by no 
 means requisite in the generality of wounds; 
 but that there are particular cases, in which 
 either their greater convenience, or superior 
 efficacy, still makes them approved, and 
 employed by all the most eminent practi- 
 tioners of the present day. Since sutures 
 cannot be practised, without additional 
 wounds being made, and pain occasioned, 
 and since the threads always act as extrane- 
 ous bodies in the parts, exciting more or less 
 inflammation and suppuration round them ; 
 there can be no doubt that their employ- 
 ment is invariably wrong, whenever the 
 sides of a wound can be maintained in con- 
 tact by less irritating means, with equal 
 steadiness and security. For, what is it 
 which generally counteracts the wishes of 
 the surgeon, and renders his attempts to 
 make the opposite surfaces of wounds grow 
 together unavailing? Is not the general cause 
 too high a degree of inflammation, which 
 necessarily ends in suppuration ? Are not 
 sutures likely to augment inflammation, both 
 by the additional wounds of the needles, and 
 the still more pernicious irritation of the 
 threads which always act as foreign bodies, 
 sometimes producing not merely an increase 
 "f inflammation and suppuration in their 
 voL.n 58 
 
 JilES. 4*7 
 
 track ; but frequently such ulceration as en- 
 ables them to cut their way out, or else 
 sloughing of the parts ; or, in particular con- 
 stitutions, a very extensive erysipelatous 
 redness. 
 
 In consequence of the ulcerative process, 
 sutures very often cease to have the power 
 of any longer keeping the edges of wounds 
 in contact ; as the observations of Pibrac, and, 
 indeed, what every man may daily remark 
 in practice, fully testify ; and the violent 
 inflammaiory symptoms which are excited, 
 frequently oblige the surgeon to cut the 
 threads, and withdraw them altogether. 
 
 But, even admitting, that by the general 
 adoption of sutures some wounds would be 
 united, which could not be so were this 
 means of accomplishing the union aban- 
 doned, still it must be allowed, on the other 
 hand, that the cause of some wounds not 
 uniting is entirely ascribable to the irritation 
 occasioned by the sutures themselves. Hence, 
 if it be only computed, that as many wounds 
 are prevented from uniting by the irritation 
 of sutures, as other wounds which are united 
 by their means, and could be united by no 
 other methods, we must still perceive, that 
 mankind would be no sufferers, and surgery 
 undergo no deterioration, were sutures alto- 
 gether rejected from practice. 1 believe, 
 however, that every man, who has had op- 
 portunities of observation, and has made use 
 of them with an unprejudiced mind, will 
 feel persuaded that more wounds are hin- 
 dered from uniting by sutures, than such as 
 are healed by them, and could not be united 
 by other means. 
 
 But prudent practitioners are not obliged, 
 either to condemn or praise the use of su- 
 tures, in every instance, without exception 
 Men of independent principles will always 
 adopt the line of conduct which truth points 
 out to them as that which is right ; nor will 
 they obstinately join Pibrac and Louis, in 
 contending that sutures are always improper 
 and disadvantageous, nor with other bigoted 
 persons, who may use sutures in every kind 
 of wound whatever. Perhaps, sutures arc 
 still rather too much employed, and, in all 
 probability, will long be so. It will be 
 difficult entirely to eradicate the prejudices, 
 ou which their too frequent use is founded, 
 as long as, what may be called, the teachers 
 of surgery are seen holding up the practice 
 for imitation in every principal hospital in 
 the kingdom. Such surgeons, however, as 
 are ready to imbibe fair and candid senti 
 ments on the subject, and to qualify them - 
 selves for practising this part of surgery with 
 judgment, should by no means neglect to 
 read both what Pibrac and Louis have writ- 
 ten on the subject. I know that the latter 
 authors are a little too sanguine in their re- 
 presentations ; but, as I have already re- 
 marked, sutures are still rather too much 
 used, and something is yet necessary to do 
 away a certain unwarranted habit of having 
 recourse to them without real necessity. 
 Nothing will tend to produce this desirable 
 change so much, as the perusal of every ar- 
 gument against their employment. 
 
T BANDAGE 
 
 m 
 
 I am decidedly of opinion, not from what 
 I have read, but what 1 have actually seen, 
 that the sides of the generality G f wounds 
 are capable of being effectually kept in con- 
 tact, by means of a proper position of the 
 part, and the aid of strips of adhesive plaster, 
 compresses, and a bandage. I believe that 
 such success can be obtained with every ad- 
 vantage which can be urged in favour of 
 sutures, and without their disadvantages ; 
 such as greater pain, inflammation, &x I 
 even think, with Louis, that the harelip 
 might in general be united very well by 
 means of a bandage ; but still I am of opi- 
 nion, that the twisted suture is attended with 
 least trouble, is most suited for universal 
 practice, and that, unless such pains were 
 taken as many practitioners would not, and 
 others could never take, the method by ban- 
 dage would frequently fail. 
 
 I find it exceedingly difficult to lay down 
 any fixed principles for the guidance of the 
 surgeon, in respect to when he ought, and 
 when he ought not, to use sutures. 
 
 Perhaps, sutures should be made use of 
 for all cuts and wounds, which occur in 
 parts which are subject to an unusual degree 
 of motion, such as would be apt to derange 
 the operation of bandages, sticking plaster, 
 and compresses. Hence the propriety of 
 using the twisted suture for the harelip. 
 
 Sutures are probably, for the most part, 
 advantageous in all wounds of the abdomen, 
 of a certain length, and attended with ha- 
 zard of the viscera making a protrusion. In 
 this situation, the continual motion and ac- 
 tion of the abdominal muscles, in respiration, 
 besides the tendency of the viscera to pro- 
 trude, may be a reason in favour of the use 
 of sutures. 
 
 When tw'o fresh-cut surfaces positively 
 cannot be brought into contact by sticking 
 plaster, bandages, the observance of a pro- 
 per posture, &e. there can be no doubt of 
 the advantage of using sutures, if they will 
 answer the purpose. Some wounds of the 
 trachea ; some wounds made for the cure of 
 certain fistulous communications between 
 the vagina and bladder, or others for the cure 
 of similar affections in the perinaeum, afford 
 instances of cases to which I allude. 
 
 1 observe, that many surgeons in this me- 
 tropolis use sutures for bringing the sides of 
 the wound together alter several operations ; 
 as that of removing a diseased breast, castra- 
 tion, and operations for strangulated hernia. 
 
 The reason for using sutures in the scro- 
 tum, I suppose, arises from the difficulty of 
 keeping the edges of the wound in contact, 
 owing to the great quantity and looseness 
 of the part. In this case, I cannot deter- 
 mine whether sutures are really necessary 
 
 or not ; but, alter the amputation of the 
 breast, I have no hesitation in pronouncing 
 their employment wrong and injudicious. 
 
 I shall conclude with referring to what PL 
 brae and Louis have written on the above 
 subjects, in Mini. de l’ Acad, de Chir. Tom. 3 
 and 4, Sharp, Dionis , Gooch , Le Dran , Btr 
 trandi , Sabatier B . Beil , and J. Bell , have all 
 treated of sutures. See also C. E. Boeder 3 
 Sutures Vulnerum ; Upsnl , 1772. 
 
 SYMPA THETIC BUBO. See Bubo. 
 
 SY ACHYSIS. (from a-vyyyu*. to confound.;' 
 The term synchysis sometimes denotes the 
 confusion of the humours of the eye occa- 
 sioned by blows, and attended with a rup- 
 ture of the internal membranes and capsules 
 Beer understands by the expression, a 
 dissolution of the vitreous humour, or the 
 state of it in which its consistence is en - 
 tirely destroyed. (See Lthre von den An - 
 genkr. B. 2, p. 257.) 
 
 SYNECHIA. The case in which the iris 
 adheres to the cornea is termed synechia 
 anterior; that in which the uvea adheres to 
 the capsule of the lens, synechia posterior.. 
 Beer has delivered two valuable chapters 
 on these subjects. The synechia posterior, 
 on account of the frequent delicacy of the 
 adhesions, is apt not to be detected unless 
 the eye be examined with particular care. 
 A magnifying glass should be used, and 
 the pupil be first dilated with hyoscia- 
 mus, or belladonna. The treatment, as far 
 as the prevention and removal of such ad- 
 hesions are practicable, strictly belongs to 
 the subject of iritis. (See Ophthalmy.) With 
 the view of dispersing them, Beer praises 
 the good effects of applying to the eye itself 
 ointments containing preparations of mer- 
 cury, or a collyrium hydrarg. oxymuriatis, 
 to which some of the thebaic tincture is 
 added. As an inward medicine, he says, 
 calomel is the most effectual. When 
 eye-salves are used. Beer recommends a 
 little of the extract of hyosciamus to be 
 mixed with them, so that they may dilate 
 the pupil, and thus suddenly break any 
 slight threads of lymph. ( B . 2, p. 58.) For 
 additional information on the synechia pos- 
 terior and anterior, see Lehre von den Au~ 
 genkr. B. 2, p. 54 and p. 263. Also Beger t 
 De Synechia seu prelernaturali adhesione cor - 
 nnc cum iride. Haller , Disp. Chir. T. 1, p. 
 435. 
 
 SYNTHESIS, (from <rvv t together, and 
 6e<r/c, position, situation.) A generic term, 
 formerly much used in the schools of surge 
 ry,and comprehending every operation, by 
 which parts, which had been divided, were 
 reunited. 
 
 SYPHILIS. Lues Venerea. The veno 
 real disease. (See Venereal Disease.) 
 
 T. 
 
 F#1 BANDAGE. A bandage, so named tion for the cure of fistula in ano, in disease- 
 A from its figure. I( is principally used of the perinamm, and those of the groin' 
 for supporting the dressings after the opera- anus, &<*. It is composed of two lougUmU 
 
TENDONS. 
 
 »al pieces of cloth, of greater or lesser 
 breadth, according as occasion requires. 
 The transverse piece of doth serves to go 
 round the body above the hips : the per- 
 pendicular piece is sewed at one of its ends 
 to the middle of the latter; and in general, 
 its other extremity is slit into two portions, 
 or tails, about six or eight inches long. The 
 perpendicular piece of the T bandage applies 
 itself between the glutaii muscles, and to the 
 perinaeum : while its two ends, j jst descri-' 
 bed, are to he carried betwfeen the thighs and 
 the pudenda to the right and left, and fasten- 
 ed to the transverse piece surrounding the 
 body. Besides the common T bandage, 
 there is another one named double, which 
 has two perpendicular pieces, sewed to the 
 transverse one, about four inches apart. 
 The double T bandage is said to be more 
 particularly applicable after lithotomy, and 
 tor the diseases of the perinaeum ; because 
 one may make the two perpendicular pieces 
 cross each other on the part affected, and 
 leave the anus uncovered ; an advantage 
 which the simple T bandage certainly has 
 not. The T bandage may be used in some 
 other ways, which have been noticed in 
 the article Bandage. 
 
 TALPA. (a mole.) A tumour which 
 creeps under the skin as a mole under the 
 surface of the ground. Such is the etymo- 
 logy. It is often applied to an encysted tu- 
 mour, which forms on the head, and contains 
 a paplike matter. (See atheroma, and TV 
 mours, Encysted.) 
 
 TAPPING. See Paracentesis. 
 
 TARAXIS. (from r&gaao-a), to disturb.) A 
 slight ophthalmy.or inflammation of the eye. 
 
 Taxis, (from 'mcrcra, to put in order.) 
 The operation of reducing a hernia with 
 the hand. (See Hernia.) 
 
 TENDONS, RUPTURE OF. The tendons 
 liable to be broken by the violent action of 
 the muscles with which they are connected, 
 are the tendo Achillis, that of the extensor 
 muscles of the leg, and the tendon of the 
 triceps extensor cubiti. The ancient sur- 
 geons seem not to have been well acquaint- 
 ed with the rupture of the tendo Achillis, 
 which they probably might mistake for a 
 sprain, or some other complaint. In cases 
 in which this part had been cut, they re- 
 commended approximating the separated 
 portions, and maintaining them in contact 
 by means of a suture. 
 
 When the ruptured tendo Achillis was 
 afterward better understood, the plan just 
 mentioned was even adopted in this case, 
 the integuments having been previously 
 divided, for the purpose of bringing the 
 tendon into view. But there is no necessity 
 fot having recourse to this painful proceed- 
 ing. (Encyclopedic Mtthodiqw , Par tit Chir. 
 T. 1 . p. 55.) 
 
 The superficial situation of the tendo 
 Achillis always renders the diagnosis of its 
 rupture exceedingly obvious, and the acci- 
 dent can only become at all difficult to 
 detect, when there is a considerable de- 
 gree of swelling, which is very rare. When 
 the tendon has been cut. the division of the 
 
 skin even allows the accident to be seen. 
 When the tendon tias been ruptured, the 
 patient hears a sound, like that of the smack 
 of a whip, at the moment of the occurrence. 
 In whatever way the tendon has been di- 
 vided, there is a sudden incapacity, or at 
 least, an extreme difficulty eilhei of standing 
 or walking. Hence, the patient falls down, 
 and cannot get up again. Besides these 
 symptoms, there is a very palpable depres- 
 sion between the ends of the tendon, which 
 depression is increased when the foot is 
 bent and diminished, or even quite removed 
 when the foot is extended. 
 
 The patient can spontaneously bend his 
 foot, none of the flexor muscles being in- 
 terested. The power of extending the foot 
 also is still possible, as the peronaei muscles, 
 the tibialis posticus, and long flexors of the 
 toes (see a cast recorded by J. L. Petit) re- 
 main perfect, and may perform this motion. 
 (( Euvrcs Chir.de Desault, par Bichat, T. 1.) 
 
 I he indications are to bring the ends of 
 the divided part together, and to keep them 
 so, until they have become firmly united. 
 The first object is easily fulfilled, by putting 
 the foot in a state of complete extension , 
 the second, namely, that of keeping the 
 ends of the tendon in contact, is more dif- 
 ficult. 
 
 In order to have a right comprehension ol 
 the indications, we should consider what 
 keeps the ends of the tendon from being in 
 contact. The flexion of the foot b.-s this 
 effect on the lower portion ; the contraction 
 of the gastrocnemius, and solaeus, on the 
 upper one. The indications then are to put 
 the foot in an unalterable state of extension, 
 and to counteract the action of the above 
 muscles. 
 
 The action of the muscles may be oppo- 
 sed : — 1. By keeping these powers in a 
 continual state of relaxation. For this 
 purpose the leg must be kept half bent upon 
 the thigh. 2. By apply ing methodical pres- 
 sure to the muscles; methodical, because 
 it is to operate on the fleshy portion of the^ 
 muscles, and not on the tendon, the ends oi 
 which, being depressed by it, would be 
 separated from each other, and, instead of 
 growing together, would unite to the adja- 
 cent parts. The pressure should also operate, 
 so as to prevent the ends of the. tendon from 
 inclining either to the right or left. 
 
 J. L. Petit seems entitled to the honour of 
 having first devised the plan of treating the 
 ruptured or divided tendo Achillis, by keep- 
 ing the leg and foot in a particular posture, 
 with the aid of an apparatus. Seeing that 
 the extension of the foot brought the ends 
 of the tendon into contact, it occurred to 
 him, that such extension should be main- 
 tained during the whole of the treatment, 
 in order to bring about a permanent union 
 This aim is, in fact, the common basis ot alt 
 the numerous methods of cure, which have 
 been since recommended. 
 
 Dr. Alexander Monro, primus, happened to 
 rupture his tendo Achillis. When the acci- 
 dent took place, he heard a loud crack, as 
 if he had suddenly broken a nut with his 
 
TEN 
 
 heel, am] he experienced a sensation as it 
 the heel of bis shoe had made a hole in the 
 iloor. This sensation, he says, has also 
 been observed by others, though some have 
 complained of a smart stroke, like what 
 would be produced by a stone or cane. 
 Immediately suspecting what had happened, 
 the doctor extended his left fool, in which 
 the occurrence had taken place, as strongly 
 as he could with his right hand, while with ^ 
 the left he pressed the muscles of the calf 
 downward, so as to bring the ends of the 
 broken tendon as near together as possible. 
 In this position he sat, until two surgeons 
 came to his assistance. They applied com 
 presses, and a bent board to the upper part 
 of the foot and forepart of the leg, both 
 which they kept, as nearly as possible, in a 
 straight line, by a tight bandage made with 
 a long roller. But as this mode of dressing 
 soon became very uneasy, it was changed 
 for the following one. A foot-sock, or slip- 
 per, was made of double quilted ticking, 
 from the heel of which a belt or strap pro- 
 jected, of sufficient length to come up over 
 the calf of the leg. A strong piece ot the 
 same materials was prepared of sufficient 
 breadth to surround the calf, and this was 
 fastened with lacings. On the back part of 
 this was a buckle, through which the strap 
 of the foot-sock was passed, so that the 
 foot could be extended, and the calf brought 
 down at pleasure. The leg and foot were 
 wrapt up in soft flannel, fumigated with 
 benzoin, and the bandage was kept on day 
 and night, the belt being made tighter when 
 the doctor was about to go to sleep, and 
 loosened when he was awake, and on his 
 guard. For a fortnight he did not move 
 bis foot and leg at all, but was conveyed in 
 a chair on castors from one part of the 
 room to another. After this, he began to 
 move the ankle-joint, but in such a gentle 
 manner as not to give any pain. The de- 
 gree of motion w r as gradually increased as 
 the tendon became capable of bearing it. 
 care being taken to stop when the motion 
 began to create uneasiness. The affected 
 limb was moved in this way for half an 
 hour at a time. In a few days the hollow, 
 between the separated ends of the tendon 
 became imperceptible, though the part con- 
 tinued soft much longer. It became, how- 
 ever, gradually thicker and harder, until a 
 knot was at last formed in it, apparently of a 
 cartilaginous nature. Though this was at 
 first as large as a middling plum, and gra- 
 dually became softer and smaller, yet it did 
 not disappear entirely. Having occasion to 
 go out six weeks after the accident, the 
 doctor put on a pair of shoes, with heels 
 two inches high, and contrived a steel ma- 
 chine to keep his foot in the proper position. 
 This machine, however, lie afterward changed 
 for another, made of the same materials as 
 the former. It was not till five months after 
 the accident, that he thought proper to lay 
 aside all assistance, and to put the strength of 
 the tendon to a trial. (See Monro’s Works , 
 p. 661.) 
 
 Both in a wouad and rupture in the tendo 
 
 TE8f 
 
 Aehillis, the ancient method of using a 
 suture for keeping the ends of the tendon 
 in contact, is at present quite exploded, and 
 position of the limb is the grand agent, by 
 which the cure is now universally accom- 
 plished. Thefollowing was Desault’s method, 
 which, though it was expressly designed to 
 fill all the above-mentioned indications, may 
 not be a more valuable practical plan than 
 what was adopted by Dr. Monro. After 
 the ends of the tendon had been brought 
 into contact by moderate flexion of the 
 knee, and complete extension of the foot, 
 Desault used to fill up the hollows on each 
 side of the tendon, with soft lint and com- 
 presses. The roller, applied to the limb, 
 made as much pressure on these compresses 
 as on the tendon ; and hence, this part could 
 not be depressed too much against the sub- 
 jacent parts. Desault next took a compress 
 about two inches broad, and long enough to 
 reach from the toes to the middle of the 
 thigh, and placed it under the foot, over the 
 back of the leg and lower part of the thigh. 
 He then began to apply a few circles of a 
 roller round the end of the foot, so as to 
 fix the lower extremity of the longitudinal 
 compress. After covering the whole foot 
 with the roller, he used to make the bandage 
 describe the figure of 8, passing it under the 
 foot, and across the place where the tendon 
 was ruptured ; and the method was finished 
 by encircling the limb upward with the 
 roller, as far as the upper end of the longi- 
 tudinal compress. (See Monro’s Works. 
 Encyclopedic Methodique , article Achilla, ten- 
 don de, and Memoirs sur la Division du 
 Tendon d'Achille, in (Euvres Chirurgicales 
 de Desault, par Bichat, T. 1 ,p. 806.) 
 
 A rupture of the tendon of the extensor 
 muscles of the leg, would require nearly the 
 same kind of treatment as a fracture of the 
 patella. However, pressure exactly on the 
 broken part of the tendon should be avoid - 
 ed, the limb should be kept extended, and 
 somewhat raised; a bandage might be put 
 round the thigh, and antiphlogistic treatment; 
 be at first adopted. In the course of two 
 or three weeks, the surgeon should cause 
 the joint to be very gently moved, without 
 any muscular exertion on the part of the 
 patient himself. When the tendon of the 
 triceps extensor cubiti is ruptured, the limb 
 is to be kept straight ; cold applications are 
 to be used for a few days, and if necessary, 
 strict antiphlogistic treatment pursued. 
 
 TENT. A roll of lint for dilating open- 
 ings, sinuses, &lc. 
 
 TEREBELLA. (dim. of terebra, a perfo 
 rating instrument.) A trepan, or instrument 
 for sawing out circular portions of the skull, 
 A trephine. 
 
 TEREBRA. (from to bore.) A tre- 
 pan, or trephine. Also an instrument called 
 a perforator. 
 
 TESTICLE, DISEASES OF. For au 
 account of many of these affections, I must 
 refer to distinct articles in this Dictionary ; 
 for instance, Cirsocele, Fungus Haniatodes, 
 Hernia Humoralis, Hccmalocele , Hydrocele , 
 fyc. 
 
TESTICLE. 
 
 jNIr. Pott defines sarcoc.de to be a disease 
 of the body of the testicle, and, as the term 
 implies, it consists, in general, in such an 
 alteration, made in the structure of that or- 
 gan, as produces a resemblance to a hard, 
 fleshy substance, instead of that fine, soft, 
 vascular texture, which it naturally presents. 
 u Sarcocele (says Call isen) is a name applied 
 to every chronic swelling of the testicle, 
 attended with a total, or partial, conversion 
 of the part into an heterogeneous sub 
 stance.” ( Systema Chirurgice Hodiernce, 
 Pars 2, p. 144.) According to these defini- 
 tions, sarcocele becomes a term admitting 
 of almost general application to the mor- 
 bid affections of the testicle, since most of 
 them are attended with induration and 
 swelling of the part. In fact, we find that 
 the old writers, and a great many of the 
 moderns, call all diseased indurations and 
 enlargements of the testicle sarcoceles , whe- 
 ther the disorder be a simple, chronic, in- 
 dolent tumour, unaccompanied with any 
 symptoms of specific disease, or malignan- 
 cy, or whether it be a scrofulous, or, what 
 is still more different and more serious, a 
 truly scirrhous disorder of the organ. Even 
 the fungus heematodes of the testicle was, 
 until lately, often termed sarcocele. 
 
 That this vague method of employing the 
 word sarcocele can be attended with no 
 advantage, but, on the contrary, must have 
 a tendency to destroy all useful discrimina- 
 tion, is a proposition, the truth of which is 
 -self-evident. I am well aware, that Mr. 
 Pott, and many late writers, set out with an 
 idea that every sarcocele has a propensity 
 to change into scirrhus, and actual carcino- 
 ma, and, therefore, the latter states are con- 
 sidered by these authors only as stages of 
 the same disease. Indeed, it is universally 
 admitted by the best and most experienced 
 observers, that a common indolent sarco- 
 cele, a simple fleshy enlargement of the 
 testicle, may change into the peculiar ma- 
 lignant disease, called scirrhus, or cancer. 
 But yet it is by no means proved, that all 
 the diseases which are comprehended under 
 the name of sarcocele, are accompanied 
 with a risk of their assuming the nature of 
 scirrhus and cancer ; for nothing can be 
 more certain, than that the enlargement of 
 the testicle, produced by fungus ha?matodes, 
 is, from the first to the last, always of one 
 character, and can never change into ordi- 
 nary scirrhus, or carcinoma. Neither do 
 indolent scrofulous swellings of this organ 
 ever undergo such an alteration as to de- 
 serve the epithets of scirrhous and cancerous. 
 In opposition to the belief of Mr. Hunter, 
 (see his Treatise on ihe Venereal Disease, p. 
 59,; some surgeons still imagine, that there 
 is really one kind of chronic enlargement 
 of the testicle, arising from a venereal cause. 
 (Roux, Parallele de la Chirurgie Angloise, 
 fyc.p. 305. Richerand, Nosographie Chir. T. 
 4, p . 300, Edit. 4.) Now this also has usu- 
 ally been called a sarcocele ; it was so na- 
 med by Pott himself, and if there be such a 
 ca>e, no one will suppose that it, or any 
 other form of lues venerea, is capable of 
 
 ■161 
 
 changing into a true scirrhous or cancerous 
 disease. Perhaps, therefore, it might be 
 more consistent and advantageous to restrict 
 the appellation of sarcocele, to an indolent 
 fleshy enlargement of the testicle, unac- 
 companied with any present symptoms of 
 malignancy, or any marks of its being the 
 effect of a specific disease ; and as soon as 
 the case evincesanothercharacter, the name 
 should correspond with the particular nature 
 of the disease. 
 
 We need not here enter into a minute ac- 
 count of the various sarcomatous diseases, 
 to which the testicle is subject ; for, they 
 have no peculiarity in them, except what 
 depends upon their situation,, and the gene- 
 ral characters of the different species of sar- 
 coma will be considered in a future article. 
 (•See Tumour.) -The testicle is especially 
 liable to three kinds of sarcoma, which have 
 been named, by Mr. Abernethy, the common 
 vascular, the cystic , and the medullary. The 
 latter case, however, which is often called 
 soft cancer of the testicle, I shall describe in 
 the present article, in order that the reader 
 may judge whether there is any material 
 difference between this case and another 
 distemper to which the testicle is subject, 
 (See Fungus Hcematodes.) Sometimes the 
 testicle is converted into a truly scrofulous 
 mass. It is increased in size, and when cut 
 into, a whitish, or yellowish coagulated 
 matter is discovered, mixed with pus. The 
 complaint is not attended with so much 
 pain and induration as a scirrhous disorder 
 of the testicle ; nor does it produce any un - 
 favourable state of the health. 
 
 As Dr. Buillie observes, the testicle is of- 
 ten found converted into a hard mass, of a 
 brownish colour, and generally intersected 
 with membranes. Sometimes, there are 
 cells in the tumour, which are filled with a 
 sanious fluid. ( Morbid Anatomy , <^c. p. 352, 
 353, Edit. 2.) This is the truly scirrhous its 
 tide which is attended with great hardness, 
 severe pains darting along the spermatic 
 chord to the loins, and an unequal knotty 
 feel. In general the health becomes impair 
 ed To use Mr. Pott’s words, sometimes 
 the fury of the disease brooks no restraint : 
 but, making its way through a!! the mem 
 branes, which envelope the testicle, it either 
 produces a large, foul, stinking, phagedenic 
 ulcer, with hard edges, or it thrusts forth a 
 painful gleeting fungus, subject to frequent 
 hemorrhage. (Pott's Chimrgical Works , 
 Vol. 2, p. 390, Edit. 1808.) These latter 
 states of the disease are denominated cancer 
 of the testicle. 
 
 Sooner or later, the scirrhous induration 
 extends from the epididymis upward along 
 the spermatic chord, even within the abdo- 
 minal ring. In the latter circumstance, the 
 lymphatic glands in the groin usually be- 
 come diseased ; and this extension of mis 
 chief, together with the impossibility of re- 
 moving the whole of the diseased chord, too 
 frequently deprives *the patient of every 
 chance of getting well. 
 
 I have already stated, that some of the 
 most simple sarcomatous enlargements of 
 
TESTICLE. 
 
 462 
 
 the testicle are capable of assuming, in a 
 very sudden manner, a malignant and can- 
 cerous tendency ; and that sometimes the 
 scirrhous induration of the chord makes a 
 rapid progress upward. Hence, that sur- 
 geon acts with prudence, who recommends 
 the early extirpation of every, testicle, which 
 is incurably diseased, and so deprived of its 
 original organization, as to be totally unfit 
 for the secretion of the semen. 
 
 Chronic enlargements of the testicle are 
 sometimes attended with an accumulation of 
 limpid fluid in the tunica vaginalis, and the 
 disease is then termed , hydro arcocele, an ap- 
 pellation first employed by Fabricius ab 
 Aquapendente. 
 
 The hardness and swelling of the epididy- 
 mis, remaining after an acuie inflammation 
 of the testicle (see Hernia Humaraii •>,) do 
 not Constitute a complaint, which surgical 
 authors class with sarcocele ; for, the dis- 
 ease hardly ever, increases so as to give 
 trouble. 
 
 I have stated, that sarcoceles, in common 
 with the generality of other sarcomatous tu- 
 mours, may change into dis, tempers, which, 
 in point of malignity, and the manner in 
 which they injure the health, are quite as 
 bad as cancer itself, ft is said, however, 
 that sarcocele of the epididymis rarely be- 
 comes malignant, and is much more easy 
 of cure, than the same disease of the glan- 
 dular portion of the testicle ; but both parts 
 are often diseased together. 
 
 Sarcoceles sometimes continue for years, 
 without undergoing any particular change ; 
 in other instances, they increase with sur- 
 prising rapidity. t he inconveniences, which 
 they excite, often proceed chiefly from their 
 weight and magnitude : their weight occa- 
 sions an uneasy, and even a painful sensa- 
 tion in the loins, especially when the pa- 
 tient neglects to wear a suspensory bandage, 
 or a bag truss for the support of the part. 
 The danger of a sarcocele arises from the 
 increase and extension of the hardness up 
 the spermatic chord, and from the change 
 of the tumour from its indolent state into a 
 painful, ulcerated, and incurable disease. 
 
 A sarcocele sometimes 1 'bears a resemblance 
 to hydrocele of the tunica vaginalis. It 
 sometimes has the usual pyramidal shape 
 of the latter disease, and, like it, is always 
 situated at the lower end of the spermatic 
 chord. The chief difference between the 
 two cases seems to be, that the sarcocele is 
 bard, while the hydrocele has a soft, yield- 
 ing, elastic feel. It should be known, how- 
 ever, that the fungus haematodes of the tes- 
 ticle is remarkable for the deceitful feel of 
 fluctuation and elasticity, which it presents ; 
 and every surgeon ought to be aware, that a 
 sarcocele is not always particularly hard, 
 and that hydroceles are sometimes exceed 
 ingly indurated. The sarcocele, indeed, is 
 not transparent; neither is the hydrocele in 
 certain instances ; and, .these are cases, in 
 which a mistake may easily be made. Still, 
 with due attention, both diseases may be 
 discriminated with tolerable precision, the 
 sarcocele, when held in the surgeon’s hand, 
 
 seems heavier than the hydrocele. Every 
 part of a diseased te ticle is seldom equally 
 indurated, so that the sarcocele is usually 
 much softer in some places than others. 
 The hydrocele presents the same kind of 
 feel at every point, except behind, where 
 the testicle is felt. When, in the case of 
 hydrocele, pressure is made in this latter 
 situation, the patient experiences a much 
 more acute sensation, than when the pres- 
 sure is made upon any other part of the tu- 
 mour ; but, in the example of sarcocele, 
 the patient commonly has the same kind of 
 feel let the pressure be applied to any part 
 of the -.welling whatsoever. When the up- 
 per portion of the spermatic chord can be 
 fell, and it seems quite hard and thickened, 
 the surgeon has reason for suspecting the 
 case to be a sarcocele. Lastly, though a 
 hydrocele, w r hen gently handled, may seem 
 very hard, yet, on being more strongly com- 
 pressed, it will generally betray a soft, elas- 
 tic feel, which, excepting instances of fungus 
 haematodes, is never the case with an indu- 
 rated sarcocele. 
 
 It has been already explained, that a sar- 
 cocele is sometimes conjoined with a hy- 
 drocele, which case is well known among 
 surgeons by tbe appellation of hydro-sarco - 
 cele. As the diseased testicle is then sur- 
 rounded with fluid, it cannot be felt and 
 examined by the fingers. However, when 
 an unusual degree of hardness is percepti- 
 ble at the back part of the tumour, where 
 the testicle is situated, or when the upper 
 portion of the spermatic chord is found to 
 be quite indurated, there is reason for sus- 
 pecting that the testicle is diseased. The 
 sarcocele also is commonly the original and 
 principal complaint, the hydrocele not oc- 
 curring till some time after the enlargement 
 of the testicle. 
 
 In some unusual cases, the substance of 
 the scrotum is converted into an indurated 
 mass, which occasionally attains a vast size, 
 and presents the appearance of an enormous 
 sarcocele. An example in which the tu- 
 mour weighed 701b. has been lately publish- 
 ed by Dr. Titley (See . Med. Chir Trans . 
 Vol. 6, p. 73.) In one case, recorded by Dr. 
 Cheston, a swelling of this kind was as large 
 as a child’s head. On dissection of the 
 parts, the testicle and tunica vaginalis were 
 found to be quite free from disease. The 
 tumour proceeded entirely from an indura- 
 tion of the cellular membrarfe, which im- 
 mediately covers the external surface of 
 the vaginal coat. This curious disease is 
 more common in warm climates, and seve- 
 ral instances of it were met with in Egypt 
 by Baron Larrev. (See Mem. de Chir. Mili- 
 laire, T. 2, p. 1 10, et serp) Some interesting 
 particulars relative to it will be found in 
 another part of thte Dictionary. (See Scro- 
 tum.) 
 
 The operation of castration -is the most 
 certain means of relieving the patient from 
 sarcocele. This measure, however, is not 
 invariably practicable, nor is it always ne- 
 cessary ; for, sometimes the induration of 
 the testicle admits of being dispersed by the 
 
TESTICLE. 
 
 judicious employment ot internal medicines 
 and external applications. The hope of ac- 
 complishing this desirable object may De 
 reasonably entertained, when the swelling 
 is not very large, when it has not existed a 
 considerable time, and when it is not at- 
 tended w ith very great induration Expe- 
 rience has proved, that some kinds of s-tr- 
 cocele have yielded to the exhibition of 
 emetics, ( Warner, Pringle, and Home i?i 
 Chymical Experiments ;) to a decoction ot 
 ono .isspinos. ( Bergius Mai. Med. Richter's 
 Chir. Bibl. 7 B. p 6U5 ;) to cicuta and bark 
 (Warner ;) to mercurial frictions {Le bran- 
 B. Bell, Richer and, Detpech ; to the external 
 use of the liquor amnion, acetatis (Rich er's 
 Chir. Bibl. B.p. 127 ;) to poultices contain- 
 ing opium (Fothergill, in Med. Obs.ty Inq. 
 Vol. 5 ;) to a lotion made of a strong de- 
 coction of hemlock ( Warner ,') to the steam 
 of vinegar, the repeated employment of 
 leeches, and the ap lication of cold, foe. 
 The operation of all these means w ill be ad- 
 vantageously assisted by the continual use 
 of a bag-truss, the observance as much 
 as possible of an horizontal position, and 
 attention to a suitable low diet. 
 
 "Mr. Pott believed that the man who has 
 the misfortune to be afflicted with a sarco- 
 cele, has very little chance of getting rid 
 of the disease by any plan except extirpa- 
 tion ; and all the time the operation is de- 
 ferred, he carries about him a part, not only 
 useless but burdensome, and which is every 
 day liable to become worse, and unfit for 
 such an operation. JNow, although there 
 is a great deal of truth in this opinion, yet, 
 I conceive, it is rather exaggerated, and that 
 it would tend to authorize the practice f 
 castration to an extent beyond all necessity. 
 I certainly think, with Mr. Pott, tha : there 
 never was a sarcocele cured, w here the or- 
 ganization of the testicle had been destroy- 
 ed by disease, or where its structure had 
 suffered so much as to render it incapable 
 of the office for w hich it is destined. But 
 such state cannot always be known by m 
 spection or manual examination, and were 
 a surgeon to condemn to the knife every 
 testicle which he finds affected with indo- 
 lent swelling and induration, he w r ould re- 
 move many wdiich, under some of the^above 
 plans of treatment, might, be perfectly cu- 
 red. That there are some chronic enlarge- 
 ments ot the testicle which may be resolved, 
 is a truth of which experience must have 
 convinced the generality of surgeons. 
 
 The scrofulous induration, and several 
 other swellings of this organ, which are 
 very imperfectly understood, may some 
 times be benefited, and even entirely cured, 
 just like some analogous affections of the 
 breast. What is termed the venereal sarco 
 cele (Mr. Pott allows) always gives way to 
 a mercurial course properly conducted. 
 The diagnosis of this case, it must be con- 
 fessed, is not very clearly explained by sur- 
 gical w riters, nor w r as its reality acknow- 
 ledged by Mr. blunter. According to Mr. 
 Pott, it is seldom an early symptom, and 
 he does not remember ever to have seen 
 
 403 
 
 an instance in wdiich it was not either im 
 mediately preceded, or accompanied by 
 some other appearances plainly venereal. 
 He adds, that it has neither the inequality 
 nor darting paii s of scirrhus. But the 
 question, whether the case is truly syphilitic 
 or not, is lar less interesting than the ques- 
 tion, whether there are not many sarcoceles 
 which may be diminished and cured by 
 mercury P The affirmative cannot be ques- 
 tioind. I have seen many such cases my- 
 self, and there are numerous examples on 
 record. v statement of several has been 
 lately published by Richerand. (See A r oso - 
 graphic Chirurgicale, T. 4, p. 300, et seq. 
 Edit. 4.) The authority of Delpech is also 
 on the same side. Precis Element air e dcs 
 Maladies Reputees , Chir T. 3 ,p. 564.) 
 
 Indeed this last writer maintains, that 
 many common sarcoceles and scirrhi of 
 the'esticle are so much alike in their symp- 
 toms. that the difference of their nature 
 cannot always be at once detected by the 
 practitioner. Hence, although I am an 
 advocate tor the early performance of cas- 
 tration in cases of sarcocele, w here there is 
 reason to suppose the disease so far advan - 
 ced, that the organization of the testicle is 
 totally destroyed; or where internal and 
 external remedies have been tried a certain 
 time in vain ; yet these sentiments do not 
 incline me to recommend the operation for 
 other examples in which the disease is 
 quite recent, and no plan of treatment what- 
 soever has been fairly tried, i have already 
 enumerated various plans of treatment, 
 which have been proved by experience to 
 be sometimes capable of affording relief. 
 The disease of the testicle, which is usually 
 called the scrofulous sarcocele, like other 
 forms of scrofula, often gets well spontane- 
 ously after a certain time, and it may fre - 
 quently be considerably benefited by admi- 
 nistering internally the conium maculatum, 
 and small doses of the submuriate of mer- 
 cury ; lotions of sea-water, or poultices of 
 sea-w eetis, being applied to tne scrotum. 
 Several other indolent enlargements of the 
 testicle yield to frictions with ca . phorated 
 mercurial ointment on the scrotum. The 
 late Mr. Ramsden thought that some sarco- 
 celes might be relieved by removing with 
 bougies a supposed morbid irritability of the 
 urethra, with which bis theories led him to 
 connect the origin of the complaint. (See 
 Pracl. Obs. on Sdemceie, fyc.) The novelty 
 of this suggestion for a time attracted con- 
 siderable notice ; but the interest which it 
 once excited has now died away; a suffi- 
 cient proof to my mind, that the practice 
 inculcated was not of much value. 
 
 From the preceding observations, it may 
 be inferred, that all chronic enlargements 
 of the testicles are not incurable ; but that 
 w e ought at the same time to be duly im- 
 pressed with the expediency of not wasting 
 too much time in the trial of means which 
 are not (6 be depended upon, and which 
 if continued immoderately long, might 
 allow the disease to advance too far to be 
 capable of beipg afterward effectually extiv 
 
TESTICLE. 
 
 464 
 
 pated. According to Mr. Foil, the circum- 
 stances in which the operation of castration 
 is adviseable, or not, are of two kinds, and 
 relate either to the general habit of the pa- 
 tient, and the disorders and indispositions 
 of some of the viscera, or to the state of the 
 testicle and spermatic chord 
 
 A pale, sallow complexion, in those who 
 used to look otherwise ; a wan counte- 
 nance, and loss of appetite and ilesh, with- 
 out any acute disorder ; a fever of the hec- 
 tic kind; and frequent pain in the back 
 and bowels are, in those who are afflicted 
 with a scirrhous testicle, such circumstances 
 as would induce a suspicion of some latent 
 mischief in some of the viscera; in which 
 case, as Mr. Fott truly observes, success 
 from the mere removal of the testicle is not 
 to be expected. They whose constitutions 
 are spoiled by intemperance, previous to 
 their being attacked with this disease; who 
 have hard livers, arid anasarcous limbs; be 
 says, are not proper subjects for such an 
 operation. Hard tumours within the abdo- 
 men, in the regions of the liver, spleen, 
 kidneys, or mesentery, implying a diseased 
 state of the said viscera, are very material 
 objections to the removal of the local evil 
 in the scrotum, in short, whenever there 
 are manifest appearances, or symptoms of 
 a truly diseased state of any of the principal 
 viscera, the success of the operation be- 
 comes very doubtful. 
 
 “ The state of the mere testis can hardly 
 ever be any objection to the operation ; the 
 sole consideration is the spermatic chord : 
 if this be in a natural state, and free from 
 disease, the operation not only may, but. 
 ought to be performed, let the condition of 
 the testicle be what it may ; if the sperma- 
 tic chord be really diseased, the operation 
 ought not to be attempted. And Mr. Pott 
 afterward remarks, “ when the spermatic 
 vessels are not only turgid and full, but firm 
 and hard; when the membrane which in- 
 vests and connects them has lost its natural 
 softness and cellular texture, and has con- 
 tracted such a state, and such adhesions 
 as not only greatly to exceed its natural 
 size, but to become unequal, knotty, and 
 painful, upon being handled, and this state 
 has possessed all that part of the chord 
 which is between the opening in the oblique 
 muscle and the testicle, no prudent, judi- 
 cious, or humane man, will attempt the 
 operation; because he will, most certainly, 
 not only do no good to his patient, but will 
 bring on such symptoms as w ill most ra- 
 pidly, as well as painfully destroy him.” 
 
 “ On the other hand,” says Pott, “ every 
 enlargement of the spermatic chord is not 
 of this kind, nor by any means sufficient to 
 prohibit or prevent the operation. 
 
 “These alterations or enlargements arise 
 from two causes, viz. a varicose dilatation 
 of the spermatic vein, and a collection, or 
 collections, of fluid in the membrane in- 
 vesting and enveloping the said vessels.” 
 Shortly afterward the same practical writer 
 continues: — “ The diseased state of a truly 
 r-cirrhous testicle, its weight, and the altera- 
 
 tion that must be made in the due and pro- 
 per circulation of the blood, through both 
 it and the vessels from which it is depend- 
 ent, may and do concur in inducing a vari- 
 cose dilatation of the spermatic vein, with- 
 out producing that knotty, morbid altera- 
 tion and hardness, which forbid our at- 
 tempts. Between these, a judicious and 
 experienced examiner will generally be able 
 to distinguish. 
 
 “ In the former, (the truly diseased state) 
 the chord is not only enlarged, but feels 
 unequally hard and knotty ; the parts of 
 which it is composed are undistinguishably 
 blended together; it is either immediately 
 painful to the -touch, or becomes so soon 
 after being examined ; the patient com- 
 plains of frequent pains shooting up through 
 his groin into his back ; and from the dis- 
 eased state of the membrane composing 
 the tunica communis, such adhesions and 
 connexions are sometimes contracted, as 
 either fix the process in the groin, or render 
 it difficult to get the finger and thumb quite 
 round it. 
 
 “ In the other (the mere-varicose disten- 
 tion) the vessels, though considerably en- 
 larged and dilated, are nevertheless smooth, 
 soft, and compressible ; the whole process 
 is loose and free, and will easily permit the 
 fingers of an examiner to go quite round it, 
 and to distinguish the parts of w r hich it is 
 composed ; it is not painful to the touch ; 
 nor does the examination of it produce or 
 occasion those darting pains which almost 
 always attend handling a process malig- 
 nantly indurated.” 
 
 Mr. Pott next explains that, “ in the 
 cellular membrane, leading to a diseased 
 testicle, it is no very uncommon thing to 
 find collectionsof extravasated fluid. These, 
 as they add considerably to the bulk and 
 apparent size of the process, make the com 
 plaint appear more terrible; and, as I have 
 just said, less likely to admit relief. 
 
 “ When the extravasation is general, 
 through all the cells of the investing mem- 
 brane. and the spermatic vessels themselves 
 are hardened, knotty, and diseased, the 
 case is without remedy ; for, although a 
 puncture, or an incision, will undoubtedly 
 give discharge to some, or even the greatest, 
 part of the fluid; yet this extravasation is 
 so small and so insignificant a circumstance 
 of the disease, and the parts, in this state, 
 are so little capable of bearing irritation, 
 that an attempt of this kind must be inef- 
 fectual, and may prove mischievous. 
 
 “But, on /the other hand, collections of 
 water are sometimes made in the same 
 membrane, from an obstruction to the pro- 
 per circulation through the numerous lym- 
 phatics in the spermatic process, while the 
 vessels themselves are really not diseased, 
 and therefore very capable of permitting the 
 operation. In this case, the fluid is generally 
 in one cyst, or bag, like to an encysted 
 hydrocele, and the spermatic chord, cyst 
 and all, are easily moveable from side to 
 side ; contrary to the preceding ,state in 
 which the general lead in the membrane 
 
TESTICLE. 
 
 465 
 
 fixes the whole process, and renders it 
 almost in moveable. 
 
 “ A discharge of the fluid will, in this 
 case, enable the operator to examine the 
 true state of the process, and, as I have 
 t wice or thrice seen, put it into his power to 
 free his patient from one of the most terri- 
 ble calamities which can befall a man.” 
 (See Pott on Hydrocele, tyc.) 
 
 The testicle is subject to a disease often 
 called soft cancer , which, though of a 
 very malignant and incurable nature, is 
 different from the true cancer, already de- 
 scribed. It has been particularly noticed 
 by Mr. Abernethy. under the name of Me- 
 dullary Sarcoma. In most of the instances 
 which this gentleman has seen, the tumour, 
 when examined after removal, appeared to 
 be of a whitish colour, resembling on a 
 general and distant inspection, the appear- 
 ance of the brain, and having a pulpy con- 
 sistence. He has also often seen it of a 
 brownish red appearance. The following 
 case is related, to illustrate the nature and 
 progress of the disease. 
 
 “ A tall, thin, healthy-looking man, of 
 about forty years of age, had, about fifteen 
 years before, a swelled testicle from a go- 
 norrhoea ; the epididymis remained indura- 
 ted. Six years afterward it became enlar- 
 ged, and a hydrocele at the same time 
 formed. Half a pint of water vvas dischar- 
 ged by a puncture, but inflammation suc- 
 ceeded the operation, and this testis became 
 very large. An abscess formed, and burst 
 in the front of the scrotum, and the testis 
 subsided in some degree. Mercury was 
 employed to reduce it, but without effect. 
 The part, however, was indolent, and gave 
 the patient no trouble but from its bulk. 
 
 “ About a year afterward, a gland enlar- 
 ged in the left groin, (ihe same side as the 
 testis.) another then became swoln in the 
 right groin, and in the course of two years, 
 several, glands in each groin had attained a 
 very considerable magnitude. At this peri- 
 od, he was admitted into St. Bartholoon w’s 
 Hospital, under the care of Mr. Long. j.he 
 testis was, at this time, between four and 
 five inches in length, and about three in 
 breadth: it resembled its natural foim, 
 
 and wa- indolent in its disposition. The 
 spermatic chord was thickened, but not 
 much indurated. Four or five glands were 
 enlarged in the groin on both sides ; each 
 of which was of the size of a very large 
 orange ; and when observed together, they 
 formed a tumour of very uncommon shape 
 and magnitude. 
 
 “ They gradually increased in size for 
 several months, till at last the skin appeared 
 as if unable to contain them any longer. It 
 became thin, inflamed, and ulcerated, Tlrst 
 in the left groin, and thus exposed one of 
 the most prominent tumours. The exposed 
 tumour inflamed and sloughed progressive- 
 ly, till it entirely came away. As the 
 sloughing exposed its vessels, which were 
 large, they bled profusely, insomuch that 
 the students endeavoured, but in vain, to 
 secure them by ligatures : for the substance 
 Pox> IF, 59 
 
 of the tumour was cut through, and tom 
 away in the attempt. Pressure by the fin- 
 ger, eoniinued for some time, was the only 
 effectual mode of restraining this hemor- 
 rhage. 
 
 “ The loss of one gland relieved the dis- 
 tended skin, which had only ulcerated on 
 the most prominent part of the tumour, and 
 had not become diseased. It now lost its 
 inflamed aspect: granulations formed, and 
 a cicatrix took place. In the opposite groin 
 a similar occurrence happened. One gland, 
 exposed by the ulceration of the skin, slough- 
 ed out, being attended by the circumstances 
 just recited. However, htTorethe skin was 
 cicatrized, ulceration had agaUntken place 
 in the right groin, in conseqlwice of the 
 great distention of the skin from the growth 
 of the tumour; and sloughing had begun in 
 the tumour, when the patient, whose vital 
 powers had long been greatly exhausted, 
 died.” (See Mlrnethys Surgical Observa- 
 tions, 8fc°. 1S04.) 
 
 The preceding kind of disease is now ge- 
 nerally considered to be fungus haematodes 
 If there are any differences, they consist in 
 the parts sloughing out, and then healing, 
 instead of a fungus shooting out, and con- 
 tinually increasing in size. (See Fungus 
 Haematodes.) 
 
 JDi. Bail lie has noticed some affections, in. 
 which the testicle becomes bony, cartilagin 
 ous, &o. ; but on these it is not necessary 
 for us to dwell in this Dictiouary. The 
 preceding observations may be considered as 
 relating expressly to the diseases for which 
 castration is generally pertormed. (See Cas- 
 tration.) 
 
 Besides the fungus, which arises from the 
 testicle in the advanced stage of carcinoma, 
 arid the bieeding fungous growth, which 
 arises from tliis organ in the ulcerated state 
 of fungus hajmatodes, there is another su 
 perficial fungous excrescence, to which the 
 testicle is subject, and which is entirely free 
 from all malignancy. The disease to which 
 I refer, has been noticed by Callisen, under 
 the name of lipoma of the testicle. “ Si ex 
 superlicie albugineas vel ipsa tunica vaginali 
 excrescentiae surgunt, totum demum testem 
 involventes, et scirrhum seu fungum, men- 
 tientes, ipsius tamen testis substantia parum 
 aut vix de statu naturali aberrante ; malum 
 naturam lipomatis sequitur, vix unquamm 
 scirrhum et carcinoma abiens.” (See Sys- 
 tema Chirurgice Hodi&rnce , Vol. 2, p. 145, 
 Edit. i800.) The superficial fungus, or lipo- 
 ma of the testicle, was noticed in an early 
 edition of another publication, and described 
 as “ a particular affection of the testicle, iii 
 which a fungus grow's from the glandular 
 substance of this body, and in some instances, 
 from the surface of the tuniea albuginea. 
 This excrescence is usually preceded by^tu 
 enlargement of the testicle, in consequence 
 of a bruise, or some species of external vio- 
 lence, A small abscess takes place and 
 bursts, and from the ulcerated opening the 
 fungus gradually protrudes.” I then proceed- 
 ed to represent how unnecessary and impro- 
 per it was to extirpate the testicle, on account* 
 
1ES 
 
 'i'ET 
 
 406 
 
 of this affection, if after the subsidence of 
 tiie inflammation, the part should not seem 
 much enlarged and indurated. I recom- 
 mended the fungus to be cut off, or else de- 
 stroyed with caustic; and 1 founded my ad- 
 vice on a successful attempt of the first kind, 
 which was made in St. Bartholomew’s H os- 
 pital, by Sir Janies Earle, a little while before 
 my book was published. (See First Lines of 
 the Practice of Surgery , p. 399.) 
 
 An interesting little paper has also been 
 written on the subject, by my friend Mr. 
 Lawrence, who has favoured the public with 
 a more particular account, and nine cases 
 iliustrativigtf the causes, symptoms, and 
 progress tlWe disorder. According to Mr. 
 Lawrence, the patient generally assigns some 
 blow’, or other injury, as the cause of the 
 complaint ; in other instances, it originates 
 in consequence of the hernia humoralis 
 from gonorrluea, and sometimes appears 
 spontaneously. A painful swelling of the 
 gland, particularly characterized by its hard- 
 ness, is the first appearance of the disease. 
 After a certain length of time, the scrotum, 
 growing gradually thinner, ulcerates; but 
 the opening which is thus formed, instead of 
 discharging matter, gives issue to a firm, and 
 generally insensible fungus. The surround- 
 ing integuments and cellular substance are 
 thickened and indurated by the complaint, 
 so that there appears to be altogether a con- 
 siderable mass of disease. The pain abates, 
 and the swelling subsides considerably, when 
 t he scrotum has given way. In this state, 
 the disorder appears very indolent ; hut if 
 the fungus be destroyed by any means, the 
 integuments come together, and a cicatrix 
 ensues, which is inseparably connected with 
 the testicle. Mr. Law rence next informs us, 
 that if the part be examined while the fun- 
 gus si ill remains, the excrescence is found to 
 have its origin in the glandular substance of 
 the testicle itself ; that the coats of the part 
 are destroyed to a certain exteut ; and that 
 a protrusion of the tubuli seminiferi takes 
 place through the aperture thus formed. 
 Mr. Lawrence says, he has often ascertained 
 the continuity of the excrescences with the 
 pulpy substance of the testicle, of which 
 more or less remains, according to the differ- 
 ence in the period of the disorder. The 
 same gentleman thinks, that the glandular 
 part ot the testicle experiences an inflamma- 
 tory affection in the first instance, in conse- 
 quence of the violence inflicted on it ; and 
 that the confinement of the swollen sub- 
 stance, by the dense and unyielding tunica 
 albuginea, sufficiently explains the peculiar 
 hardness of the tumour, and the pain w hich 
 is always attendant on this stage of the dis- 
 order. The absorption of the coats of the 
 toslis, and of the scrotum, obviates the ten- 
 sion of the parts, and (hereby restores ease to 
 the patient, at the same time that the fungus 
 makes its appearance externally. 
 
 With regard to the, treatment, Mr. Law- 
 rence is of opinion, that if thecomplaint were 
 entirely left to itself, the swelling would pro- 
 !' bably subside, the fungus shrink, and a com- 
 plete cure ensue, without any professional 
 
 assistance ; but lie adds, that the disorder is 
 so indolent in this stage, that a spontaneous 
 cure would not be accomplished till after 
 much time. He says that the excrescence 
 may be removed wiih a knife, or if the na- 
 ture of its attachment permit, with a ligature, 
 or that it may be destroyed with escbarotic 
 applications. Mr Lawrence very judicious- 
 ly gives die preference to removing the 
 tumour to a level with the scrotum, by means 
 of the knife, as the most expeditious and ef- 
 fectual mode of treatment. He can discern 
 no ground whatever for proposing castration 
 in this malady, since in no part of its progress, 
 nor in any of its possible consequences and 
 effects, can it expose the patient to the slight- 
 est risk. 
 
 Mr. Lawrence also mentions the possibili- 
 ty of there being other kinds of tungi, which 
 may be met with, growing from the testicle, 
 and quotes an distance, in which Dr. Ma 
 cartney found a fungus, of a firm and dense 
 Structure, growing from the tunica albugi- 
 nea, while all the substance of the testicle 
 it self was sound. Dr. Macartney was so kind 
 as to show me the preparation, affording a 
 clear specimen of the second kind of fungus. 
 The cases drawn up by Mr. Lawrence are^ 
 in my opinion, highly interesting, and may 
 be read in The Edinb. Med. and Surg. Jour 
 nal,for July , 1808. 
 
 I have already noticed, that Cailisen repre 
 seats the lipoma, as sometimes originating 
 from the surface of the tunica vaginalis, a 
 kind of case which has not yei fallen under 
 my observation. 
 
 In the preface to the last edition of this 
 Dietionai y, p. 10, I quoted a case, published 
 by Dr. H. Weinhold, in which the operation 
 for bubonocele was performed, and^is the 
 testicle w T as diseased, the surgeon ftade a 
 complete division of (he spermatic chord, tied 
 the spermatic arteries, and then left the tes- 
 ticle in its natural situation. After a 
 time, the absorbents had diminished the part 
 to a very inconsiderable little tumour. (See 
 Journ. der Pracl. Heilkunde von C. IV. Hufe- 
 land and K. Himly , 1812, Zehntes, Stack, 
 p. 112.) This case merits attention, and 
 ought to have been cited in the article Cas- 
 tration, because it is the first instance, l be- 
 lieve, m which such practice was tried 
 Subsequently, the following work has been 
 published, (hough I have not yet met with 
 it. u JYouvelle Methode de trailer le Sarcocele. 
 sans avoir rccours a V extirpation du Testicule , 
 par C. Th. Maunoir , 8i>o. Geneve, 1820 
 The new plan consists in dividing and 
 tying the spermatic arteries, and leaving 
 the rest of the chord and the testis undis- 
 turbed. 
 
 TETANUS. (from <rziva>, to stretch.) 
 Tetanus is defined by all authors to be a 
 more or less violent, and extensive controc 
 tipn of the muscles of voluntary motion, at- 
 tended with tension and rigidity of the parts 
 affected. 
 
 The excessive contraction of the muscles 
 is kept up without any intervals of complete 
 relaxation, in which respect the disorder dif- 
 fers from ordinary spasms and convulsions. 
 
TETANUS'. 
 
 467 
 
 where the contractions and relaxations alter- 
 nate in rapid succession. In tetanus, the 
 powers of sensation and intellect also re- 
 main unimpaired, in which particularity it 
 forms a contrast to epilepsy. ( Rees's Cyclo- 
 pedia, art. Tetanus.) 
 
 When its effects are confined to the mus- 
 cles of the jaw or throat, it is called trismus 
 or locked jaw ; when all the body is affected 
 and becomes rigid, but retains its ordinary 
 straightness, the case is named tetanus. 
 When the body is bent forwards, the di-ease 
 is termed emprosihotonos : and opisthotonos , 
 when the muscles of the back are principally 
 affected. 
 
 To these four forms, some writers have 
 added a fifih, which they denominate pltu- 
 rosthotonos, and w hich is characterized by 
 the body being drawn to one side. It is the 
 tetanus lateralis of Sauvages. 
 
 The different terms which are applied to 
 tetanic affections, do not imply so many 
 particular diseases; but only the seat and 
 various degrees of one and the same com- 
 plaint. 
 
 A far more important division of tetanus, 
 is into the acute and chronic , according to its 
 greater or lesser intensity. The first is ex- 
 ceedingly dangerous, and usually fatal ; whiie 
 the latter, on account of the more gradual 
 progress of the symptoms, affords more op- 
 portunity of being successfully treated. ( Lar - 
 rey, in Mem. de Cliirurgie. Militairc, T. 1, p. 
 235, 236.; 
 
 Tetanus may also be distinguished into 
 the traumatic , or that arising from wounds, 
 being the case with which surgeons have 
 principally to deal; and into the idiopathic, 
 or that proceeding from a variety of other 
 causes. 
 
 atraumatic tetanus sometimes comes or. in 
 a surprisingly sudden manner, and quickly 
 attains its most violent degree. The most 
 rapidly fatal case that has ever been record- 
 ed, is one that we have on the authority of 
 the late Professor Robison of Edinburgh. It 
 occurred in a negro, who scratched his 
 thumb with a broken china plate, and died 
 of tetanus a quarter of an hour after this 
 slight injury. (See Rees's Cyclopaedia , art. 
 Tetanus.) But commonly, the approaches 
 of the disorder are more gradual, and it 
 - slowly advances to its worst 6tage. In this 
 sort of case, the commencement of the dis- 
 order is announced by a sensation of stiff- 
 ness about the neck, a symptom, which in- 
 creasing by degrees, renders the motion of 
 the head difficult and painful. In propor- 
 tion as the rigidity of the neck becomes 
 greater, the patient experiences about the 
 root of tbe tongue, an uneasiness which 
 soon changes into a difficulty of mastication 
 and swallowing, which after a time became 
 totally impossible. The attempt at degluti- 
 tion is abended with convulsive efforts, es- 
 pecially when an endeavour is made to 
 swallow* liquids ; and so great is the distress 
 which accompanies these convulsions, that 
 the patient becomes very reluctant to renew 
 the trials, an* refuses all nourishment. 
 Sometimes it even inspires him with a dread 
 
 of the sight ot water, and a great resemblance 
 to hydrophobia is produced. 
 
 One of the next remarkable symptoms is 
 a very severe pain at the bottom of the ster- 
 num, darting from this point backward to 
 tbe spine, in the direction of the diaphragm. 
 As soon as this pain commences, the spasms 
 of all the muscles about the neck become 
 exceedingly violent, and tbe head is drawn 
 backwards or forwards, according as the 
 contraction of the extensor or flexor mus- 
 scles happens to be strongest ; but in the 
 majority of cases, the hea I and trunk are 
 curved backwards, (Royer, Traite dts Mai. 
 Chir. T. 1 ,p. 288.) and the contractions in- 
 creasing in force, the body is frequently 
 raised in the form of a bow, resting upon 
 the head and feet alone ; a state which is 
 more particularly denominated opisthotonos. 
 (Rees's Cyclopaedia, art. Tetanus.) At the 
 same time, the muscles w r hich close the 
 lower jaw, and which were affected with 
 spasm and rigidity in the very beginning of 
 the disorder, now contract with great pow- 
 er, so as to maintain tbe lower jaw-bone in- 
 separably applied to the upper one. The 
 last state, which has been considered as a 
 particular affection under the name of tris- 
 mus or the locked-jaw, Boyer conceives may 
 be regarded as tbe pathognomonic symptom 
 of tetanus, which in many instances is limit- 
 ed to such an affection of the jaw. 
 
 The muscles affected in tetanic cases are 
 never altogether relaxed, as long as the dis- 
 ease continues ; but still they become more 
 violently contracted in the frequent parox- 
 ysms of spasm, which always attend the 
 complaint, and increase as it advances. 
 
 The continuance of the disease is marked 
 by the increasing spasm of the diaphragm, 
 which now returns every ten or fifteen mi- 
 nutes, and is instantly succeeded by a 
 stronger retraction of the head and rigidity' 
 of the muscles of the back, and even of those 
 of the lower extremities. The abdominal 
 muscles are also strongly contracted, so that 
 the belly feels as hard and tense as a board. 
 By the violence of the contractions, indeed, 
 tbe recti muscles have been known to be 
 lacerated, as l shall relate an example of 
 hereafter. Sometimes the spasm and ten- 
 sion extend only to the muscles on one par- 
 ticular side of the body : the tetanus lateralis 
 of Sauvages, and the pleuroslholonos of other 
 nosologists. 
 
 When the disease reaches its most violent 
 stage, the flexor muscles of the head and 
 trunk contract so powerfully, that they 
 counterbalance tbe force of tbe extensors, 
 and hold tiiose parts in a straight, fixed, im- 
 moveable position. This is the condition to 
 which the appellation of tetanus more par 
 ticularly belongs. The muscles of the lower 
 extremities become rigid ; and even the 
 arms, which till now were little affected, 
 also partake of the general spasm and stiff- 
 ness, with the exception of the fingers, 
 which often retain their moveableness to 
 tbe last. The tongue likewise continues a 
 long while endued with the power of volun- 
 tary motion ; but. at length, the viol err 
 
T ETA IN OS. 
 
 -HiS 
 
 spasms do not leave it unaffected, and it is 
 then liable to be forcibly propelled between 
 the teeth, where it is sometimes dreadfully 
 lacerated. 
 
 In the extreme period of the disorder, all 
 the muscles destined for voluntary motion, 
 are affected ; among others, those of the 
 face ; the forehead is drawn up into fur- 
 rows ; the eyes, sometimes distorted, are 
 generally fixed and motionless in their sock 
 ets ; the nose is drawn up, and the cheeks 
 are retracted towards the ears ; so thai the 
 features undergo a most extraordinary 
 change When tetanus arrives at this stage, 
 and the spasms arc universal, a violent con- 
 vulsion usually puts an end to the patient’s 
 misery. 
 
 Wherever the muscular contractions are 
 situated in cases of tetanus, they are always 
 accompanied with the most , excruciating 
 pain. They sometimes last, without any 
 manifest remission, to the end of the disor- 
 der ; but in almost all cases, their violence, 
 and the sufferings excited by them, undergo 
 periodical diminutions every minute or ttto. 
 The relaxation, however, is never such as to 
 let the muscles, which experience it yield 
 to the action of their antagonists ; and it is 
 in nearly all cases followed, in ten or twelve 
 minutes, by a renewal of the previous con- 
 tractions and suffering. The recurrence of 
 these aggravated spasms frequently happens, 
 without any evident cause; but it is often 
 determined by efforts which the patient 
 makes to change his posture, swallow, 
 speak, &c. 
 
 As Dr. Cullen observes, the attacks of 
 this disease are seldom attended with any 
 fever. When the spasms are general and 
 violent, the pulse is contracted, hurrie 1 . and 
 irregular, and the respiration is affected in 
 tike manner; but during the remission, both 
 the pulse and respiration usually return to 
 their natural state. The heat of the body is 
 commonly not increased ; frequently the 
 face is pale, with a cold sweat upon it ; and 
 very often the extremities are cold, with a 
 cold sweat over the whole body. When, 
 however, the spasms are frequent and vio- 
 lent, the pulse is sometimes more full and 
 frequent, than natural ; the face is flushed, 
 and a warm sweat is forced out over the_ 
 whole body. 
 
 “ Although fever be not a constant attend- 
 ant of this disease, especially when arising 
 from a lesion of nerves ; yet in those cases 
 proceeding from cold, a fever sometimes 
 .has supervened, and is said to have been 
 attended with inflammatory symptoms. 
 Blood lias often been drawn in this disease, 
 but it neve? exhibits any inflammatory crust ; 
 and all accounts seem to agree, that the 
 blood drawn seems to be of a looser texture 
 than ordinary, and that it does not coagu- 
 late in the usual manner. 
 
 “In this disease the head is seldom af- 
 fected with delirium, or even confusion of 
 thought, till the last stage of it ; when by 
 the repeated shocks of a violent distemper, 
 every function of the system is greatly dis- 
 ordered /tfk 
 
 “ It is no less extraordinary,’ that in tin. 
 violent disease the natural functions are not 
 either immediately or considerably affected. 
 Vomitings sometimes appear early in the 
 disease but commonly they are not conti- 
 nued ; and it is usual enough for the appe- 
 tite of hunger to remain through the whole 
 course of the disease ; and what food hap- 
 pens to be taken down seems to be regularly 
 enough digested. The excretions are some- 
 times affected, but not always. The urine, 
 is sometimes suppressed, or is voided with 
 difficulty and pain. The belly is costive; 
 but as we have hardly any accounts, ex- 
 cepting of those cases in which opiates have 
 been largely employed, it is uncertain whe- 
 ther the costiveness has been the effect of 
 the opiates or of the disease. In several 
 instances of this disease a miliary eruption 
 , has appeared upon the skin, but whether 
 this be a symptom of the disease, or the ef- 
 fect of a certain treatment of it, is undeter- 
 mined. In the mean while, it has not been 
 observed to denote either safety or danger, 
 or to have any effect in changing the course 
 of the distemper. ’’ — ( First Lines of the Prac- 
 tice of Physic , Vol. 3.) 
 
 According to Baron Larrey, the opistho- 
 tonos is not so often observed in Egypt as 
 the einprostbotonos, and the experience of 
 this gentleman taught him that the former 
 was the most rapidly fatal. We must not 
 adopt, however, his curious opinion, that 
 the violent extension of the vertebra? of the 
 neck, and the manner in which the head is 
 thrown back, cause strong compression of 
 the spinal marrow, and a permanent con- 
 traction of the larynx and pharynx, (Mem. 
 dc Chirurgie Militaire, T. 1, p. 240.) since 
 this sort of compression, if it did not at ^ice 
 destroy the patient, would at any rate jroru 
 lize most of the muscles, and instantly stop 
 their extraordinary contraction. 
 
 This experienced writer notices how 
 much the nerves of the neck and throat 
 seetn generally to be affected on the inva- 
 sion of this disease. The consequent con- 
 traction of the muscles of these parts, he 
 says, is soon attended with difficulty of de- 
 glutition and respiration. The patients then 
 experience, if not a dread of liquids, at least 
 a great aversion to them, which often pre- 
 vents the administration of internal reme- 
 dies ; and if the wound is out of reach of 
 the interference of art, (he patient is doom- 
 ed to undergo the train of sufferings attend- 
 ant on this cruel and terrible disorder. No- 
 thing can surmount the obstacles which 
 present themselves in the (esophagus. The 
 introduction of an elastic gum-catheter into 
 this canal, through the nostrils, is followed 
 hy convulsions and suffocation. “ I have 
 tried this means (says Larrey) on the per 
 son of M. Navailh, a surgeon of the second 
 class, who died of a locked-javV, brought on 
 by a wound of the face, accompanied with 
 a comminuted fracture of the bones of the 
 nose,' and part of the left orbit. 
 
 “ In the examination of£fe bodies of pri- 
 son's dead of tetanus, I have found the pha 
 rynx and oesophagus much contracted, and 
 
TETAMj:- 
 
 their internal membrane red, inflamed, and 
 covered with a viscid reddish mucus. 
 
 “ Hydrophobia, hysteria, and several 
 other nervous diseases, likewise produce 
 their chief effects upon these organs, and 
 the result appears to be the same. So, I 
 have just remarked, when tetanus is ar 
 rived at its worst degree, the patients have 
 a great aversion to liquids, and if they are 
 forced to swallow them, immediate convul- 
 sions are excited. This circumstance was 
 particularly observed in M. Navailh.” — 
 (Mm. da Chirurgie Mi lit air e, T. 1, p. 247, 
 248.) 
 
 Sometimes tetanic affections deviate from 
 their ordinary course and nature. The most 
 singular of these anomalies is recorded by Sir 
 Gilbert Blane ; it is a case in which tetanus 
 prevailed to a very considerable extent, 
 without any degree of pain. The spasms 
 were accompanied with a tingling sensation, 
 which was even rather agreeable than dis- 
 tressing. The case, however, terminated 
 fatally ; but, to the last, no pain was expe- 
 rienced. In two examples, mentioned by 
 the same author, the spasms affected only 
 the side of the body in which the wound 
 was situated. 
 
 The dissection of patients who have died 
 of tetanus, has thrown no light upon the 
 nature of this fatal disorder. Sometimes 
 slight effusions are found within the cra- 
 nium ; but, in general, no morbid appear- 
 ance whatever can be detected in the head. 
 There is always more or less of an inflam- 
 matory appearance in the oesophagus and 
 in the villous coat of the stomach about the 
 cardia. But those who are conversant a ith 
 dissections must be well aware, that these 
 appearances are common to a great num- 
 ber of diseases, and are uniformly met with 
 in every case of rapid or violent death. 
 Besides the redness and increased vascula- 
 rity of these parts, Baron Larrey, as I have, 
 already stated, found the pharynx and oeso- 
 phagus much contracted, and covered with 
 a viscid reddish mucus. He also found nu- 
 merous lumbrici in the bowels of the- seve- 
 ral patients who died. — (See Mem. de Chir. 
 Mililaire, T. 3 ,p. 2S7.) This, however, could 
 only be an accidental complication, and 
 not a cause. In several cases, Dr. M’Arthur 
 found the intestines much inflamed, and in 
 two of them a yellow, waxy fluid, of a pe- 
 culiar offensive smell, covered their internal 
 surface : but whether the inflammation was 
 primary, or only a consequence of the pres- 
 sure erf the abdominal muscles, which con- 
 tract so violently in this disease, he is una- 
 ble to decide, — (See Med. Chir. Trans. Col. 
 7, p. 475, and Rees's Cyclopaedia , art. Teta- 
 nus.) 
 
 Dr. Lionel Chalmers, of Charleston, 
 South-Carolina, states, that when the disease 
 forms very quickly, and invades the unfor- 
 tunate persons with the whole train of its 
 mischievous symptoms, in a few hours, the 
 danger is proportioned to the rapidity of the 
 attack, and that the patients thus seized, 
 generally die in 24, 3o, or 48 hours, and 
 very rarely survive the third day. Rut 
 
 469 
 
 when the. disease is less acute, few arc lost 
 after the ninth or eleventh. (See Mid. Ob s. 
 and Imp Vol. 1 , p. 92, 93.) 
 
 From the valuable report of Sir Jamc 
 Macgrigor, it appears, that several hundreds 
 of cases of tetanus occurred in our army, 
 during tiie late campaigns in Spain and Por- 
 tugal. The disease was observed to come 
 on at uncertain periods after the receipt of 
 the local injury ; but it terminated on the 
 second, third, and fourth days, and even as 
 late as the seventeenth and twentieth day ; 
 though it was usually not protracted beyond 
 the eighth. (Med. Chir. Trans. Vol. 6, p. 
 353.) — 1 had a patient, however, who lin- 
 gered in the military hospital at Oudenbosch 
 five weeks, with chronic tetanus, before he 
 died. This happened in the year 1814, soon 
 after the assault on Bergcn-op-Zoom, where 
 the patient had been wounded, and suffered 
 amputation of the thigh. 
 
 Although tetanus is a disease which has 
 been observed in almost ail parts of the 
 world, experience proves that its frequency 
 is much the greatest 1 in warm climates, and 
 especially in the hot seasons of those cli- 
 mates.- It is also more common in marshy 
 situations, and countries bordering upon the ' 
 sea, than in places which are very dry, ele- 
 vated, and at a distance from the sea-coast. 
 Every class of individuals is exposed to its 
 attacks , but infants, a few days after their 
 birth, and middle-aged persons, are said to 
 be oftener affected than older subjects, or 
 others in the youthful period of life. The 
 male sex more .frequently suffer than the 
 female ; and tiie robust and vigorous more 
 frequently than the weaker. 
 
 According to Dr. Cullen and other medi- 
 cal writers, the causes of tetanus are cold 
 and moisture applied to the body while it is 
 very warm, and especially the sudden vicis- 
 situdes of heat and cold. Or the disease is 
 produced by punctures, lacerations, or other 
 injuries. Cullen admits, however, that there 
 are probably some other causes, which are 
 not distinctly known. 
 
 Baron Larrey observed, that gunshot 
 wounds in the course of the nerves, and 
 injuries of the joints, often produced teta- 
 nus in the climate of Egypt, particularly 
 when the weather, or temperature, passed 
 from one extreme to the other, in damp 
 situations, and in those— which were adja- 
 cent to the Nile, or the sea. What he terms 
 dry and irritable temperaments, were the 
 most subject to the disorder, the event of 
 which was found to be almost always fatal 
 ( Larrey , Op. et Loc. cit.) ' 
 
 Traumatic tetanus is remarked to proceed 
 oftener from wounds of the extremities, 
 than from similar injuries of the trunk, head, 
 and neck. Sometimes it originates at the 
 moment of the accident, as in the instance 
 mentioned by die late Professor Robison of 
 Edinburgh ; but in general, it does not 
 come on till several days afterward, some- 
 times not till the wound is nearly or per- 
 fectly healed, and free from all pain and 
 uneasiness. Wounds of every description 
 may give rise to tetanus, and in warm cli 
 
TETANUS. 
 
 
 mates, very trivial injuries produce it. Thus, 
 in Egypt, Larrey had one case which pro- 
 ceeded from the lodgment of a small piece 
 of fish-bone in one of the sinuses of the 
 fauces. ( M6m.de Chir urgie Militaire, T. 1, 
 p. 254.) There can be no doubt, however, 
 that in colder regions, traumatic tetanus 
 seldom happens except from contused, punc- 
 tured, or lacerated wounds ; or wounds of 
 the ginglimoid joints, with iaceration of the 
 tendons and ligaments ; compound fractures, 
 or dislocations; deep pricks in the sole of 
 the foot ; and especially lacerations of the 
 fingers and toes. A partial division of a 
 nerve has been suspected as a cause ; but 
 as some nerves must be imperfectly cut 
 through in almost every wound, and yet 
 tetanus does not arise, the reajity of this 
 cause is doubtful. Besides, if it were true, 
 the cure would be easily effected by making 
 the division of the nerve complete, which 
 experience contradicts. Baron Larrey, how- 
 ever, has recorded a fact, which favours the 
 opinion, as I shall presently notice. The 
 inclusion of the nerves in the ligatures ap 
 plied to arteries is another alleged cause of 
 tetanus; but as this fault is very "common, 
 and tetanus rather rare in this country, 
 while it may follow all sorts of wounds, 
 whether accidents or operations, the accu- 
 racy of this opinion may also be doubled. 
 In support of it, however there are some 
 cases and observations adduced by Larrey, 
 which will be quoted in the sequel of this 
 article. (See T. 3, of his Mem. de Chir. Mil.) 
 I do not mean to hint, however, that the 
 nerves are not sometimes tied in tetanic 
 cases, or that the practice is not on every 
 account blaineable. Amputation and cas- 
 tration are the only great surgical operations 
 to which 1 have seen tetanus succeed ; 
 though it may follow the- employment of 
 the knife on less severe occasions. 
 
 In warm countries, tetanus is an ordinary 
 consequence of all kinds of wounds. 
 
 There cannot be a doubt, that difference 
 of climate makes considerable difference in 
 the degree and danger of tetanus. Larrey 
 found, that in Egypt the disease was more 
 intense, and bore a greater resemblance to 
 hydrophobia, than in the colder climate of 
 Germany. In both these countries, he re- 
 marked, tiiat when the wounds causing te- 
 tanus, injured nerves situated on the fore- 
 part of the body, emprosthotonos was occa- 
 sioned ; that if the posterior nerves were 
 .hurt, opisthotonos followed ; and that when 
 the wound extended quite through a limb, 
 so as to injure equally both descriptions of 
 jierves, complete tetanus ensued. lie no- 
 ticed, also, that the disease commonly arose 
 from wounds, when the seasons and tempe- 
 rature passed from one extreme to another. 
 Exposure to the cold damp nocturnal air, he 
 found particularly conducive to it. (Bee 
 jtfthn. de Chirurgie Militaire, T. 3. p. 286.) 
 
 In the late campaigns of our armies iri 
 Spain and Portugal, according to the report 
 of Sir James Macgrigor, tetanus occurred in 
 every description, and in every stage of 
 wounds, from the slightest to the, most for- 
 
 midable : it followed the healthy and Jhfe 
 sloughing ; the incised and the lacerated , 
 the most simple, and the most complicated. 
 It occurred at uncertain periods ; but it 
 was remarked, that if it did not commence 
 before 22 days from the date of the wound, 
 the patient was sate. (See Med. Chir. Trans. 
 Vcl 6 , j>. 453.) Li Egypt, as we learn from 
 Larrey, the latest period of the commence- 
 ment of tetanus after a wound, was from 
 the filth to the fifteenth day. {Mem. dc 
 Chir. Militaire , T. l,p. 263.) 
 
 It is observed by Dr. Dickson, that as the 
 acute toi m ot tetanus is so uniformly fatal, 
 it is ot the greatest consequence to attend to 
 whatever may assist in detecting the dis- 
 ease early, or in warding it off. Ricberand 
 states, that in wounds threatening convul- 
 sions and tetanus, a persevering extension 
 of the limbs during sleep often manifests 
 itself, before any affection of the lower jaw 
 and we should naturally pay more attention 
 to any admonition of this kind in punctured, 
 or extensive lacerated wounds, particularly 
 of tendinous, or ligamentous parts, and es- 
 pecially in injuries of the feet, hands knee- 
 joint, back, &c. Some prelusive indications 
 of danger may often be derived from the 
 increase of pain, irritation, restlesness, ner- 
 vous twitchmgs, pain and difficulty in de- 
 glution, or in turning the head ; spasms, or 
 partial rigidity of some of the voluntary 
 muscles : pain at the scrobiculus cordis ; a 
 suppressed, or vitiated state of the discharge. 
 &c. which mark the slower approaches of 
 the disease. Larrey adduces several in- 
 stances of telanus, in which the wound was 
 either dry, or afforded only a scanty serous 
 exudation, and where the symptoms were 
 relieved on suppuration being re-establish- 
 ed ; and Dr. Reid, in the Edinburgh Medical 
 and Surgical Journal for July 1*15, remarks, 
 that on removing the dressing, the wound 
 was covered with a darkish unhealthy-look- 
 ing matter, and that he had seen this change 
 the forerunner of tetanus in two other in- 
 stances. A torpor of the intestines has ge- 
 nerally been observed to precede, as well 
 as accompany the disease, and Boyer, in 
 particular, enumerates an obstinate cousti 
 pation among the predisposing causes. 
 {Traiti des Mai. Chir. '/’. I, p. 287.) Mr. 
 Abernethy also informs us, that in four cases 
 where he inquired into the state of the bow- 
 els, the evacuations were not like feces; 
 and he proposes as a question, in investiga- 
 ting the cause, what is the state of the bow- 
 els between the infliction of the injury, and 
 the appearance of this dreadful malady 
 {Abernethy' s Surgical Works. Vol. 1, p ■ 1R4.) 
 Dr Parry thinks the velocity of the circula- 
 tion an useful criterion of the danger of the 
 disease, and observes, tiiat if the pulse be 
 not above 1(H), or 1 10, by the fourth or fifth 
 day, the patient almost always recovers; 
 but that it it be quickened early, the disease 
 mostly proves fatal, and yet there are a few 
 instances of recovery, where the pulse has 
 risen to 120 on the first day. Baron Larrev 
 remarks, that when the perspiration, which 
 so often attends the disease is symptomatic 
 
iKTAiNiJS 
 
 it begins upon the iiead ami extremities; but 
 that when it is critical, it occurs over the 
 chest and the abdomen. ( Mtmoires de Chir. 
 Militaire , T. 1 ,p. 256.) It must be confess- 
 ed, however, that in many cases, perspira- 
 tion Hows very freely, without bringing re- 
 lief. ( Rees's Cyclopaedia, arl. Tetanus.) 
 
 I next proceed to consider the treatment 
 of tetanus a subject of infinite difficulty, be- 
 cause the disease frequently baffles every 
 mode of practice, and in certain instances, 
 get well under the employment of the very 
 same remedies, which decidedly fail in other 
 similar cases of the disorder. Every plan 
 has occasionally succeeded, and every plan 
 lias still more frequently miscarried. The 
 great difficulty, therefore, is to ascertain, 
 among numerous discordant accounts, what 
 practice is found on the whole to be attend- 
 ed with the least ill-success? For, in the pre- 
 sent state of our knowledge, the most cre- 
 dulous practitioner will not flatter himself 
 with the supposition, that any effectual re- 
 medy for tetanus has yet been discovered. 
 As, however, tetanus was regarded by Hip- 
 pocrates and the ancients as certainly mor 
 tal, and it does not always prove so in mo- 
 dern times, it seems allowable to conclude 
 that the recoveries, which now happen, 
 must be ascribed to improvements in prac- 
 tice This reflection should lead us not to 
 give up the subject as hopeless ; but to re- 
 double our exertions for the discovery of a 
 more successful method of treatment, and 
 if possible, of some new medicine, possess- 
 ing more specific power over the disorder. 
 
 As it is justly observed by a well-inform- 
 ed writer, w hen we reflect upon the obscu- 
 rity which involves both the ratio sympto- 
 matum , and the proximate cause of tetanic 
 affections, we need not wonder, that the 
 practice in these disorders should still be 
 entirely empirical. The indication of cure, 
 which is generally applicable in all diseases, 
 namely, the removal of the exciting causes, 
 has but little place in a morbid condition, 
 which is the consequence of causes, that in 
 general have ceased to act, or which it is 
 not in our power either to remove or con- 
 trol. In those cases, where we could sup- 
 pose local irritation to be still operating, the 
 most effectual method o£ counteracting its 
 effects on the system, would obviously be 
 to intercept all communication between 
 the seat of the irritation and the sensorium. 
 If, however, the disease has already esta- 
 blished itself, and the severe symptoms have 
 come on, it does not appear that this would 
 succeed iti arresting the course of the disor- 
 der. Experience has but too fully shown, 
 that the amputation of the limb, from the 
 injury of which the tetanus has arisen, will 
 very seldom procure even a mitigation of 
 the symptoms, if performed after a certain 
 period from their first appearance. ( Rees's 
 Cyclopaedia, art. Tetanus.) Baron Larrey 
 has been the greatest modern advocate for 
 the performance of amputation in cases 
 where tetanus depends upon a wound of the 
 extremities ; but the facts which he has ad- 
 duced in its favour are not numerous, and 
 
 4U 
 
 he limits lus recommendation of ike measure 
 chiefly to chronic cases, and extends it to ho 
 others, except on the very first accession of 
 the symptoms. 
 
 “ The equally unexpected and entire suc- 
 cess (observes Larrey,) obtained by the am 
 putation of the injured limb, in the person 
 of an officer attacked with chronic tetanus, 
 leads me to propose the question, whether , 
 in this disorder, occasioned by a wound of 
 sme part of the extremities, it would not be 
 better to amputate the injured limb immedi- 
 ately the symptoms of tetanus commence, rather 
 than expect from the resources of nature, and 
 from very uncertain remedies , a cure which so 
 seldom happens ? 
 
 u If tetanus is chronic, as is sometimes ob- 
 served. amputation may be done at every 
 period of the disorder, provided a choice be 
 made of the time when there is an inter- 
 mission of the symptoms. The operation 
 would not answer so well in acute tetanus, 
 if the disease were advanced, and the mus- 
 cles to be divided were strongly contracted 
 and rigid, as l have observed at the siege of 
 Acre in a soldier, who was seized with teta- 
 nus in consequence of a gun-hot wound of 
 the left elbow.” ( Mim.deChir . Militaire. T. 
 
 1 ,p. 262.) 
 
 Larrey did, indeed, try amputation in a few 
 instances of acute tetanus. In the case last 
 cited, the symptoms were already considera- 
 bly advanced, when the experiment of am- 
 putating the arm was made ; yet, says Lar- 
 rey, the operation was followed by consider- 
 able ease. The symptoms recurred, how- 
 ever, a few hours afterward, and proved 
 fatal on the third day. In another example, 
 this gentleman repeated the experiment, 
 though acute tetanus had begun, 'the ope- 
 ration is described as having stopped all the 
 symptoms, as it were, by enchantment ; the 
 patient even passed twelve hours in perfect 
 ease ; but being exposed to the damp cold 
 air, the disorder returned, and carried him 
 off. (See Mem. rle Chirurgie Militaire, T. 1 , 
 j p. 263 — 269.) The Baron also records some 
 cases in favour of amputation at the com 
 mencementof tetanus from wounds, and es- 
 pecially for (he relief of the disease in the 
 cliroruc form. He has likewise adduced an 
 interesting example, in which speedy relief 
 and a cure followed cutting off’ all commu- 
 nication between the nerves of the wound 
 ed part and the sensorium by a suitable in- 
 cision. 
 
 In this place I think it right to remind the 
 reader, that although Baron Larrey once or 
 twice amputated when acute tetanus was 
 somewhat advanced, he does not advise the 
 practice, and he expressly restricts his sanc- 
 tion of amputation to chronic or quite inci- 
 pient ( ases of tetanus, and to a few instances 
 in which the ginglimoid joints are fractured, 
 accidents, which, independently of tetanus, 
 would generally require the operation. (See 
 Mem. de Chir. Mil. T. 3.) The report of Sir 
 James Macgrigor fully confirms the stale; ent 
 of 1 jarrey ; namely, that free incisions are 
 of little avail in the acute and fully formed 
 disease, and that amputation fails in the same 
 
TETANUS. 
 
 "kind of case. After Ihe battle, of Toulouse, 
 this operation was extensively tried ; but 
 without success. Th>' French are also. said 
 to have lo3t an immense number of s Idieis 
 from tetanus after I lie battle of Dresden, 
 when S i James infers that the practice, of 
 amputation must have been fairly tried. (See 
 Medico -Chir urgica l Trans. Vol. 6, p 456.) 
 We have seen, however, that according to 
 the precepts of Larrey, (lie French -urgeons 
 would only have performed the operation in 
 chronic cases, which are not the most fre- 
 quent, or if in other instances only on the 
 very first accession of Ihe symptoms. Bui 
 upon the whole, notwithstanding the partial 
 degree of success attending Larrey’s experi- 
 ments, I have no hesitation in declaring my 
 belief, that amputation of the i jured part in 
 cases of chronic tetanus will never be exten- 
 sively adopted. Tne uncertain efficacy of 
 this severe measure, and the occasional pos- 
 sibility of curing this form of the complaint 
 by milder (dans, will tor ever constitute insu- 
 perable arguments against the practice. 
 
 Since the last edition of this Dictionary 
 was printed, Sir Astley Cooper has published 
 his sentiments respecting the plan of ampu- 
 tating in cases of tetanus, and ihpy tend to 
 confirm tRF opinion which I have always 
 given upon the subject. In one case of te- 
 tanus, i rom a compound fracture just above 
 the ankle, the operation seemed to precipi- 
 tate the fatal event. In another case, the 
 finger was amputated without any good ; and 
 a third case is referred to, in which the ope- 
 ration also failed in saving the patient's life. 
 In chronic tetanus, amputation is regarded 
 by Sir A. Cooper as unjustifiable, as the pa- 
 tient often recovers w ithout this proceeding. 
 The medicine which has appeared to this gen- 
 tleman most useful in Mich cases, is the sub- 
 muriate of rne cuiy, joined with opium 
 (Surgical Essays. Part 2 ,/>. 190.) 
 
 On the subject of making incisions for the 
 purpose of separating the nervps of the 
 wounded part from the seusorium, Larrey 
 states, that they should be practised before 
 inflammation lias come on ; for if this has 
 made progress, (hey would be useless, and 
 even dangerous. They should comprehend, 
 as much as possible, all the nervous filaments 
 and membranous parts ; but he cond- m ns 
 all incisions into joints, as exasperating the 
 symptoms of tetanus, instances of which lie 
 has witnessed.. The Baron has recorded 
 some convincing proofs ot the benefit some- 
 times arising from completely dividing the 
 trunk of the injured nerve.' in one instance, 
 tetanic symptoms followed an injury of the 
 supraorbitary nerve, but were immediately 
 slopped by dividing some of the fibres of the 
 occipito-frontalis, and the nerves and vessels, 
 down to the bone. 
 
 On the principle of destroying the. parts, 
 which are Ihe scat of the local irritation, 
 Banm Larrey also frequently applied the 
 actual and potential cautery to the wound. 
 The application ot caustics, says he, may be 
 practised with advantage on the lit si attack 
 of the symptoms, the same precept being ob- 
 served as in making the incision: Bleeding, 
 
 if necessary, and the use ot topical emollients 
 and anodynes, may follow these operations , 
 though in general they have little effect 
 (Man. de. Chir. Militairc , T.\,p. 249.) In the 
 third volume ot this interesting work, p. 297 
 are several cases', in which the cautery 
 was employed with success. We must not 
 conclude, however, that much dependence 
 ou ht <o he placed in the use of the cautery, 
 since Larrey observes in another place ; 
 “ The moxa and actual cautery recommend 
 ed Ity the Father of Medicine, have been 
 equally unavailing. The moxa was employ- 
 ed a 1 Jaffa upon three wounded men ; the 
 disease notwithstanding followed its usual 
 course, and terminated fatally. 
 
 ‘ l have cited a striking instance of the 
 i efficacy of t he second method, in a case 
 ot opisthotonos.”. (T.l, p.258 ) This au- 
 thor also adduces some cases which tend to 
 support the opinion, that tetanus occasional- 
 ly proceeds from the inclusion of a large 
 nerve in the ligature applied to an artery. 
 The. son of General Darmagnao died of te 
 tanus consequent to amputation, and upon 
 examining the slump, the median nerve was 
 found in eluded in the ligature with the arte 
 ry, and its extremity reddish and swollen 
 (Mini, de Cfiir. Mil. T 3, p. 287.) In ano 
 tiler case, Larrey suspected the tetanic disor- 
 der to proceed from a principal branch of 
 the crural nerve being tied together with the 
 femoral artery, and he cut the ligature ; but 
 the relief was only partial and temporary 
 The cautery was therefore applied deeply to 
 the whole surtace of the slump. A marked 
 amendment took place a few hours after- 
 ward, and the patient recovered. A diapho 
 retie mixture, with camphor and opium, was 
 also exhibited. ( T. 3, p. 297.) 
 
 Among other local means for the relief of 
 tetanus, we miirht as well notice the employ- 
 ment of blisters as near as possible to the 
 wound, or their application, or that of the 
 O) ut uteri! of cantharides, to the wound itself. 
 Almost all modern writers have observed, 
 that tetanus is accompanied at its commence- 
 ment and in its progress with an interruption, 
 or total cessation of suppuration in the 
 wound. Hence the indication to excite this 
 process again by the means which I have 
 specified. Larrey seems to have adopted 
 both plans ', but he particularly applied the 
 ointment of cantharides to the wound itself 
 in an early stage of the symptoms, and in 
 cases vyhere there not only was a suppression 
 of the discharge, but where he suspected the 
 nerves of the wounded part had suffered 
 from exposure to the cold damp air, on the 
 detachment of the sloughs. For facts in fa 
 vour of these local means, the reader must 
 refer to the first and second volumes of the 
 Memoires de Chirurgie Militaire. 
 
 It appears also from Larrey’s experience 
 iu Egypt, that poultices made of the leaves 
 of tobacco, and applied to the wounds of 
 persons labouring under tetanus, are follow- 
 ed by no advantageous effect. The alka- 
 lies also proved of no service. (Toni. I ,p. 
 257.) 
 
 ) shall conclude these remarks on what 
 
TETANUS. 
 
 may be called the local treatment ot' tetanus, 
 with mentioning, that the celebrated Dr. 
 Itush recommended the wound to be dilated 
 and dressed with oil of turpentine. (See 
 Trans, of the American Philos. Society , Vol. 
 2 ;) and that our naval surgeons often use 
 tincture of opium as a dressing. 
 
 A great degree of obscurity prevails re- 
 specting the most eligible general or constitu- 
 tional plans of treating tetanus, and I am 
 afraid it must be confessed, that our internal 
 remedies cannot be more depended upon, 
 than the local means already described. 
 This opinion is fully confirmed by adverting 
 to the discouraging fact, recorded by Sir 
 James Macgrigor, viz. that out of several 
 hundreds of cases which occurred in the 
 British army during the late- campaigns in 
 Spain and Portugal, there were very few 
 which terminated successfully, or in which the 
 remedies, however varied, seemed to have 
 any beneficial influence after the disease had 
 made any progress. {Medico- Chir. Trans. 
 
 Vol. 6, p. 449.) The possibility of doing 
 much good by internal medicines is also 
 sometimes totally prevented by the inabili- 
 ty of swallowing which afflicts the patient. 
 In short, the present state of our knowledge 
 respecting tetanus, will not allow us to in- 
 dulge much hopes of cure from any means 
 yet discovered, except in the chronic form 
 of the complaint, the instances of success 
 in the treatment of acute tetanus being by 
 no means numerous. 
 
 Of all medicines, opium is that which has 
 raised the greatest expectation, and been the 
 most extensively tried in cases of tetanus. 
 Indeed, there cannot be a doubt, that in 
 many chronic, mild cases, it is competent to 
 effect a cure. But for this purpose, it is ab- 
 solutely necessary that its use be begun from 
 the earliest appearance of the symptoms ; 
 that it be given in very large doses ; and that 
 the doses be repeated at short intervals, so 
 that the system be kept constantly tinder the 
 influence of the remedy, ft is, indeed, as- 
 tonishing how the system, when labouring 
 under a tetanic disease, will resist the opera- 
 tion of this and other remedies, which, in its 
 ordinary state, would have been more than 
 sufficient to overpower and destroy it. Pa- 
 tients with tetanus will bear, with impunity, 
 quantities of opium, which at any other time 
 would have been certainly fatal. Instances 
 are upon record of five, ten, and even twen- 
 ty grains, being taken every two or three 
 hours, for many days, without any extraor- 
 dinary narcotic effects being produced upon 
 the sensorium. It is always adviseable, how- 
 ever, to begin with comparatively moderate 
 doses, such as forty or sixty drops of the 
 tincture of opium, which may be repeated 
 at intervals of three or four hours, and in- 
 creased at each repetition, until some sensible 
 effect is produced on the spasms. It seems 
 requisite to augment the dose rapidly, a9 the 
 disease presses upon u? every hour, and no 
 time must be lost while there is yet a chance 
 of controlling its fury. The approaching 
 closure of the jaw, and difficulty of degluti- 
 tion, which may increase so as to render it 
 Vol. II SO 
 
 hardly possible to introduce medicines into 
 the stomach, are additional motives for push- 
 ing our remedies before such obstacles arise. 
 {Rees's Cyclopaedia, art. Tetanus.) I once sup- 
 posed it might be possible to overcome this 
 impediment by introducing a flexible cathe- 
 ter down the cesophagus from oue of the nos- 
 trils; but the attempt to do this always 
 brings on a violent paroxysm of spasms, at- 
 tended with such a sense of suffocation that 
 it cannot be endured. The experience of 
 my friend, the late Mr. Cruttwell, of Bath, 
 and that of Baron Larrey, have fully proved, 
 that no assistance can be derived in these 
 circumstances from the use of any flexible 
 tubes. (See M6m. de Chir. Militaire , T. l,p. 
 247.) Sometimes, however, the obstacle to 
 the administration of medicines, arising from 
 the closure of the jaw, is prevented bv loss 
 of some of the incisor teeth, and, in a few 
 instances, Baron Larrey adopted the plan of 
 extracting two of them. This would be use- 
 less; however, when deglution is totally hin- 
 dered, as happened in one instance recorded 
 by the latter eminent surgeon. {Op. cit. T. 
 3,p. 301.) Glysters are the only resource, 
 when the spasms of the fauces cannot be 
 overcome. In this way, as much as a 
 drachm of the extract of opium has been in- 
 troduced into the bowels at oue dose. Opi- 
 ate frictions upon the jaws, throat, and other 
 parts of the body, have been practised. Opi- 
 ate plasters have also been applied to the 
 masseter muscles, and behind the ears. This 
 external use of opium, however, can only 
 be regarded as a feeble, and probably useless 
 method. 
 
 As the costivemess always produced by 
 tetanus is rendered still more obstinate by 
 opium, laxative medicines and glysters should 
 constantly accompany its employment. The 
 testimony of the army physicians, as we learn 
 from the reporhof Sir James Macgrigor, is 
 highly in favour of a rigid perseverance in 
 the U9e of purgatives, given in adequate doses 
 to produce daily a full effect. Dr. Forbes 
 states, that a solution of sulphate of magne- 
 sia, in infusion of senna, was found to an- 
 swer better than any other purgative ; and it 
 was daily given in a sufficient quantity to 
 procure a copious evacuation, which was 
 always dark-coloured and highly offensive ; 
 and to this practice he chiefly attributes, in 
 one severe case, the removal of the disease. 
 (Medico- Chir. Trans. Vol. 6, p. 452.) 
 
 A spasmodic rigidity of the muscles being 
 the most prominent symptom of tetanus, it 
 was natural for practitioners to try the effica- 
 cy of some other antispasmodic medicines be- 
 sidesopium, and thosewhich have been prin- 
 cipally the subject of experiment, are casto- 
 reum, rether, the conium maculatum, musk, 
 camphor, and latterly the digitalis. In many 
 cases, opium and camphor have been exhi- 
 bited together. Indeed, Larrey asserts, that 
 of all the medicines hitherto proposed by 
 skilful practitioners, the extract of opium 
 combined with camphor, and the nitrate of 
 potassa, dissolved in a small quantity of the 
 almond emulsion, and given in doses more 
 or less strong, produces the most favourable 
 
 ( 
 
effects, since patients, who have an aver- 
 sion to other fluids, take with pleasure this 
 mixture, the action of which must be pro- 
 moted by bleeding, if necessary, and blis- 
 ters, under the circumstances which have 
 been specified. (See Mini, de Chir. Militaire, 
 T. 1, p. 271.) In the same work several 
 ea£es are detailed which were benefited by 
 such treatment. 
 
 Although some practitioners have thought 
 that they have seen good effects result from 
 musk, yet the majority of practitioners, who 
 have made trial of both this and camphor, 
 in cases of tetanus, have found no reason to 
 recommend these medicines. Possibly this 
 may be owing, in some instances to sufficient 
 doses not having been exhibited, or to the 
 musk not being of a good quality. One 
 hundred and fifty grains of musk, however, 
 have been given in the space of twelve 
 hours, to a young girl, thirteen years old, 
 affected with an incipient tetanus ; but no 
 salutary effect on the disorder was produced. 
 
 We learn also from Sir James Maegrigor, 
 that aether, camphor, musk, and other anti- 
 spasmodics, as likewise the alkalies, were 
 tried by our military surgeons in Spain, and 
 found unsuccessful. (Medico- Chir. Trans. 
 Vol. 6,p. 458.) 
 
 From the same authority we find, that 
 digitalis, in large doses, was tried in several 
 cases in the peninsula ; and that it, with se- 
 veral other medicines enumerated, failed in 
 almost every case of acute tetanus which 
 occurred. (P.454.) In one case recorded, 
 the jaw remained fixed to the last, and the 
 patient was never entirely free from spasms. 
 (P. 458.) I am not acquainted with any 
 cases in which belladonna has been given ; 
 but it is certainly a remedy well worthy of 
 trial. 
 
 Analogy has also led to the employment 
 of the warm bath, as a plan which seemed 
 to promise great benefit, by producing a re- 
 laxation of the contracted muscles. But, 
 notwithstanding this means has appeared in 
 a few instances, to occasion some little re- 
 lief, particularly when the practitioner has 
 been content with mere fomentations, it 
 generally fails and often has even done 
 mischief. This may perhaps be, in some 
 measure, ascribable to the disturbance and 
 motion which the patient must necessarily 
 undergo, in order to get into the bath ; for 
 it is very well known, that every exertion 
 on the part of the patient is very apt to ex- 
 cite most violent paroxysms of spasm. The 
 author of the article Tetanus, in the Ency- 
 clopedic Methodique, mentions his having 
 seen the warm bath do harm, in two or three 
 cases in which it was expected to do good. 
 Though numerous writers have recommend- 
 ed the trial of the plan, it would be difficult 
 to trace, in their accounts, any facts which 
 decidedly show that its adoption has ever 
 been followed by unequivocal benefit. The 
 warm bath was tried in Spain, and found to 
 produce only momentary relief. ( Medico - 
 Chir. Tram. Vol. 6, p. 457.) Dr. Hillary, 
 Avho practised a long while in the warm 
 climate of America, where tetanus is very 
 
 common, disapproves of this method oi 
 treatment. He observes, that although the 
 use of the warm bath may appear to be 
 very rational, and promise to be useful, he 
 has always found it much less serviceable 
 than emollient and antispasmodic fomenta- 
 tions; and he also mentions, that he has 
 sometimes seen patients die the very mo- 
 ment when they came out of the bath, not- 
 withstanding they had not been in it more 
 than twenty minutes, the temperature of the 
 water being likewise not higher than 29 or 
 30 of Reaumur’s thermometer. (See Hilla- 
 ry on the Air and Diseases of Barbadoes.) 
 
 De Haen also relates a similar fact of a 
 patient dying the instant he was taken out of 
 the warm bath. 
 
 It was in all* probability, the bad effects 
 and inefficacy of the warm bath which in- 
 duced practitioners to try what might be ef- 
 fected by the cold one. The advantages of 
 the cold bath were first explained by Dr, 
 Cochrane, in the Edinb. Medical Commen- 
 taries ; and the plan has subsequently re- 
 ceived the praises of Dr. Wright, the emi- 
 nent Dr. Currie of Liverpool, and others. 
 Of all the remedies, which have been em- 
 ployed in cases of tetanus, the cold bath 
 seems to be that which has been attended 
 with the greatest success. Dr. Wright has 
 published, in the Medical Observations and 
 Inquiries , Vol. 6, a paper, in which may be 
 found a narrative of the first trials of this 
 method, which were all successful. The plan 
 is said to be at present preferred throughout 
 the West Indies, The way adopted consists 
 in plunging the patient in cold water, and 
 in that of the sea, when at band, in prefer- 
 ence to any other; or else in throwing from 
 a certain height several pails of cold water 
 over his body. After this has been done, he is 
 to be very carefully dried with a towel, and 
 put to bed, where he should only be lightly 
 covered with clothes, and take twenty or 
 thirty drops of laudanum. The symptoms 
 usually seem to give way, in a certain de- 
 gree, but the relief which the patient expe- 
 riences is not of long duration, and it is ne- 
 cessary to repeat the same measures at the 
 end of three or four hours. They are to be 
 repeated in this manner; that is to say, at 
 such intervals, until those of freedom from 
 the attacks of the disorder increase in length. 
 This desirable event generally soon follows, 
 and ends in a perfect cure. Wine arid bark 
 were sometimes conjoined with the forego- 
 ing means, and seemed to co-opeiate in the 
 production of the good effects. Dr. Wright 
 concludes the account with the following 
 remark, sent to him with a case by Dr. 
 Drummond of Jamaica ; — “ I am of opinion 
 that opiates and the cold bath will answer 
 every intention in the tetanus and such like 
 diseases; for whilst the opium diminishes 
 the irritability, and gives a truce from the 
 violent symptoms, the cold bath produces 
 that wonderful tonic effect so observ- 
 able in this and some other cases. Per- 
 haps the bark, joined with these, would 
 render the cure more certain. May we not. 
 then have failed in many cases, by using 
 
IETANUS. 
 
 opiates alone in targe doses, or what proba- 
 bly is worse, with the warm bath, instead 
 of the cold bath ? And have we not reason 
 to suspect that the increased doses of opium, 
 that seemed requisite when the warm bath 
 was used, may have proved pernicious ?”■ — 
 ( Vol . 6, p. 161.) 
 
 Our urmy surgeons, who were in Spain, 
 are said to have found the cold bath worse 
 than useless, (Medico- Chir. Trans. Vol. 6, p. 
 254.) and here 1 beg to remark particularly, 
 that the plan seems to present no hope of 
 benefit in cases of tetanus from wounds, 
 however strong the evidence is of its utility 
 in other examples of the disease. This was 
 the opinion of Dr. Cullen, and it is adopted 
 by Callisen, who observes, “ Immersio subita 
 iterata totius corporis in aquam frigidam in 
 tetano a causa interna mire prodest, in teta- 
 no a causa externa minorem e dec turn praes- 
 tat.” (Systema Chirurgice Hodierncc , Part. 
 1, p. 169, 170, Edii. 179S.) On the sub- 
 ject of cold effusion and bathing, there 
 are on record two cases which are curious. 
 One is related by Baron Larrey. It was an 
 instance of tetanus from a gunshot wound. 
 The cold bath was used. The two first trials 
 gave the patientextreme pain, and no amend- 
 ment followed. The sight, of the bath the next 
 time filled him with an invincible dread of 
 the water, into which he refused to be put. 
 He was covered, how ever, with a blanket, 
 and immersed. The tetanic stiffness was im- 
 mediately increased, and dreadful convul- 
 sions excited. It became necessary to re- 
 move him directly from the bath, and put him 
 to bed Deglutition was from the moment 
 utterly impeded, and the contraction of the 
 muscles carried to the most violent degree. 
 A tumour, about as large as an egg, suddenly 
 made its appearance near the linea alba, 
 below the navel. After death, this was 
 found to be caused by a rupture of one of 
 the recti muscles, and a consequent extrava- 
 sation of blood. (See M6m. de Chirurgie 
 Mil. T. 3, p. 287 — 289.) This case is deci- 
 dedly in support of the truth of what Pro- 
 fessor Cullen and Callisen have observed. 
 The next is not so: it is mentioned by Sir 
 James Macgrigor, that, in the march of the 
 guards through Gallicia, one of them was 
 attacked with tetanus, in consequence of a 
 slight w 7 ound of the finger. As it was impos- 
 sible to think of leaving the man in the 
 wretched village where he w 7 as taken ill, he 
 was carried ou a bullock car, in the rear of 
 the battalion. During the first part of the 
 day he was drenched with rain, the thermo- 
 meter standing at 52° ; but, after ascend- 
 ing one of the highest mountains in Gallicia, 
 the patient w 7 as in a cold of 30° ; and he 
 W 7 as exposed from six in the morning till 
 ton at night, when he was found half starved 
 to death, but free from every symptom of 
 tetanus. (See Medico- Chir. Trans. Vol.5 } p. 
 450.) 
 
 Another remedy, which is said to have 
 frequently effected a cure in tetanus, is 
 mercury. It has been employed in France 
 with the greatest success, as maybe seen bv 
 referring to the forty-fifth volume of Journal 
 
 475 
 
 de Medicine. This remedy, however, should 
 be resorted to, in an early period of the dis- 
 order. Mercurial frictions are preferred, 
 and these are to be put in practice so as to 
 bring on a quick affection of the mouth ; 
 care being taken, however, not to render 
 the soreness and salivation too violent. Some 
 contend, that itmatters not, whether mercury 
 be rubbed into the body, or given internally. 
 It is generally allowed, that opium may be ad- 
 vantageously exhibited at the same time. This 
 practice w as first adopted in the West Indies, 
 (see Edinb. Physical and Literary Essays , 
 Vol. 3,) where it succeeded in many cases. 
 Whatever benefit, however, may have been 
 experienced from this plan in mild cases, 
 it completely fails in the acute form of the 
 disease. Mercurial frictions appeared to 
 Baron Larrey to aggravate the symptoms, 
 in the cases where the plan was tried in 
 Egypt (Mem. de Chir. Mil. T. I, p. 257;) 
 and Dr. Emery, Mr. Guthrie, and other me- 
 dical officers, attached to our army in the 
 peninsula, tried inunction of the w 7 hole 
 body, three times a day, w 7 ith strong mercu- 
 rial ointment, in unlimited quantity, with no 
 degree of success. Alter the battle of Tou- 
 louse, a fatal case even occurred in a man 
 strongly under the influence of mercury, 
 which he had been previously using for the 
 cure of the itch. (Sir J. Macgrigor in 
 Medico- Chir. Trans. Vol. 6, p. 454.) The 
 submuriate of mercury, combined W'ith 
 ipecacuanha, also proved inefficacious in 
 acute cases; but, in chronic ones, the for- 
 mer medicine proves serviceable in keeping 
 open the bowels. 
 
 Another method of treating tetanus is 
 that of administering the most powerful 
 tonics and stimulants, such as wine, brandy, 
 aether, preparations of ammonia, bark, cor- 
 dials, &c. The introduction of this plan 
 was chiefly owing to the eminent Dr. Rush, 
 Professor of Medicine in Philadelphia, who 
 published in the Transactions of the Arne 
 riaan Philosophical Society, Vol. 2, a paper 
 entitled “ Observations on the Cause and Curt 
 of Tetanus Dr. Rush considers tetanus 
 as a disease essentially connected with de- 
 bility, and he recommends for it the exhibi- 
 tion of the preceding class of remedies. He 
 particularly advises the liberal use of w 7 ine 
 and Peruvian bark ; apd, as w r e have already- 
 stated, when tetanus arises from a wound, 
 he directs the dilatation of it, and dressings 
 with oil of turpentine. Considerable suc- 
 cess is represented as having attended the 
 practice. Several other instances of suc- 
 cess are also recorded by Dr. Hosack. 
 (American Medical Repository , Vol. 3.) 
 
 Nothing is a more certain proof of our not 
 being acquainted w 7 ith any very effectual 
 method of treating a disease, than a multi- 
 plicity of remedies, which are as opposite 
 as possible in their effects. We have seen 
 that the celebrated Dr. Rush conceived, that 
 tetanus was a disease connected with debili- 
 ty, and he has recorded examples, in which 
 it was successfully treated by tonics and 
 stimulants. Extraordinary, however, as it 
 may appear, many practitioners ars advc- 
 
1L X 
 
 THR 
 
 476 
 
 cates for venesection, especially in the early 
 stage of tetanus. Dr. Dickson thinks, that 
 in a full habit, where the wound is swelled, 
 inflamed, and painful, venesection, with 
 free purging, and such other means as are 
 calculated to allay the general and local 
 irritation, affords the fairest chance of avert- 
 ing the danger. (See Medico- Chir. Tram. 
 Vol. 7, Pari 2.) Larrey has also published 
 several cases, in which bleeding had a good 
 effect. We are informed by Sir James Mac- 
 grigor, that, in our military hospitals in 
 Spain, venesection bad a fair trial. In three 
 cases at St. Andero, detailed by Mr. Gu- 
 thrie, this was the principal remedy. One 
 patient with tetanus, from a wound of the 
 back part of the hand, was bled nearly ad 
 deliquium several times with good effect, 
 calomel and diaphoretics being also given, 
 arid he recovered. Another patient was 
 bled in the same manner with such amend- 
 ment, that he suffered but little from spasm, 
 and could open his mouth very well, when 
 he was seized with diarrhoea, which in his 
 debilitated state, carried him off. la the 
 third case, which was one of acute tetanus 
 venesection, pushed to the utmost, totally 
 failed. (Op. cit. Vol. 6,p. 455, 456.) 
 
 The powerfully relaxing effects of tobac- 
 co clysters, in cases of hernia and enteritis, 
 have suggested a trial of them in tetanus. 
 In one very acute case, the plan was tried 
 by Mr. Earle, but it only afforded a tempora- 
 ry alleviation of the spasms, and, as it caused 
 severe agitation, it was discontinued. Ac- 
 cording to Sir James Macgrigor, tobacco 
 clysters, tried in the advanced stage of the 
 disease, seemed to have no effect. He con- 
 siders, however, the tobacco fume as deserv- 
 ing farther trial. 
 
 A remarkable case is recorded by Dr. 
 Phillips, in which the jaw suddenly fell upon 
 the exhibition of an enema with oil of tur- 
 pentine. (See Medico- Chir. Trans. Vol. 6, 
 p. 65.) 
 
 According to Barcn Larrey, frictions, with 
 oily liniments, as recommended by some 
 authors, were tried by the French surgeons 
 at Cairo; but they produced no change in 
 the state of the disease. We learn, from the 
 same authority, that the application of blis- 
 ters to the throat also failed in checking 
 the symptoms. 
 
 The Barbadoes tar, mentioned by Cullen, 
 electricity, the colchicum autumnale, or 
 meadow saffron, recommended by Dufres- 
 noy, and several other means formerly in 
 repute for their virtues in cases of tetanus, 
 have now been fully proved by experience 
 to possess little or no claim to this character. 
 
 Consult Hippocrates de Morbis Populari- 
 bus, Lib. 6 et 7. Ccelius Aurelianus de Morbis 
 atiitis. Medical Observations and Inquiries , 
 Vol. !, p. 1 and 87 ; Vol. 6, p. 143. Hillary 
 on the Air and Diseases of Barbadoes , Edin. 
 Physical and Literary Essays, Vol. 3. Dr. 
 Carter , in Medical Trans. Dr. Cochrane in 
 Edin. Medical Commentaries. Cullen's First 
 Lines of the Practice of Physic, Vol. 3. 
 Hush’s Observations on the Cause and Cure of 
 Tetanus , in Vol. 2 of the Transactions of the 
 
 American Philosophical Society. Sir Gilbert 
 Blanc's Observations on the Diseases of Sea- 
 men, Edit.S. M. Ward , Facts establishing the 
 Efficacy oj the Opiate Friction in Spasmodic 
 and I ebrile Diseases, fyc. 8 vo. Manchester , 
 1809. Larrey, Mdmoires de Chir. Mi lit air e, 
 T. 1, p. 235, ; T. 3, p. 236, <^c. Callisen , 
 
 Systema Chir ur give llodiernre, Pars 1, p. 
 165, &/-c. Sir James Macgrigor, in Med. 
 Chir. Trans. Vol. 6, p. 449, <^c. Dr. Phil- 
 lips’s Case in the same work and volume , p. 65. 
 Dr. Dickson's Observations on Tetanus, and 
 Dr. Macarthur’s Letter in Vol. 7, p. 448, 
 tyc. oj the same book. Trnka de Krzowitz , de 
 Tetuno tommentarius, Vindob. 1777. Riche- 
 rand, JSosogr. Chir. T. 2, p. 338, fyc. Edit . 
 4. Edinb. Med. and Surgical Journal, Vol. 1 , 
 p. 67 ; Vol. 2, p. 255—430 ; Vol. 4, p. 45, 
 tyc.fyc. Boyer, Trait6 des Mai. Chir. T. 1, 
 p.285, fyc. Paris, 1814. Rees's Cyclopaedia , 
 art. Tetanus. C. H. Parry, Cases of Tetauns, 
 and Rabies Contagiosa, tyc. 8t?o. Lond. 1814. 
 John Morrison, a Treatise on Tetanus, 8 vo. 
 Newry, 1816. Robert Reid, on the Nature 
 and Treatment of Tetanus and Hydrophobia, 
 8vo. Dublin, 1817, Stewart, in Med. Chir . 
 Journ. ; Oil of Turpentine tried. Sir Astley 
 Cooper, Surgical Essays, Part 2, p. 190. 
 Burmester, in Med. Chir. Trans. Vol. 11. 
 
 THORAX, WOUNDS OF. See Wounds 
 of the Thorax. 
 
 THROAT, WOUNDS OF. Injuries of 
 this kind are often attended with considera- 
 ble danger, on account of the great number 
 of important parts, which are interested ; 
 but mere cuts of the integuments of the 
 throat and neck are not (generally speaking) 
 dangerous cases, and do not materially 
 differ from common incised wounds of the 
 skin in any other part of the body. They 
 are not liable to be followed by any parti- 
 cular consequences, and require the same 
 kind of treatment as cuts in general. (See 
 Wounds — Incised Wounds.) 
 
 In wounds of the throat and neck, how- 
 ever, the larynx and trachea, pharynx and 
 oesophagus, the trunk of the carotid artery, 
 and all the principal branches of the exter- 
 nal carotid, the large jugular vein, the eighth 
 pair of nerves, and the recurrent nerve, are 
 all exposed to injury; some much more so 
 than others, but all of them being occasion- 
 ally reached by the edge of the knife or 
 razor, or the point of the sword, or other 
 instruments. 
 
 It would be absurdity to offer an account 
 of what is to be done in cases attended with 
 some part of the mischief above pointed 
 out ; for no patient thus wounded would 
 ever be found alive. Wounds of the eighth 
 pair of nerves are generally considered fatal, 
 though some doubts begin to be entertained 
 on the point. Indeed, Klein positively 
 states, that such an injury is not fatal. (See 
 Journ. der -Chir. B. 1, p. 123, Sro. Berlin , 
 1820.) However, if such a wound is not 
 absolutely fatal, tiiere can be no doubt of 
 its being highly perilous, and that it should 
 be cautiously avoided. These nerves as is 
 well known, proceed down the neck in the 
 
THROAT, 
 
 477 
 
 same shcatli of cellular substance which 
 includes the carotid artery, and lie on the 
 outside of this vessel, between it and the 
 internal jugular vein. 
 
 Wounds, either of the carotid artery or 
 internal jugular vein, must generally prove 
 immediately fatal, in consequence of the 
 great and sudden loss of blood. However, 
 were any surgeon on the spot at the mo- 
 ment, he should instantly secure the wound- 
 ed vessel. In tying the carotid, one cau- 
 tion is highly necessary, viz. always to be 
 sure that the par vagum is excluded from 
 the ligature : for were this nerve to be tied, 
 the mistake, if not absolutely mortal, would 
 leave but a slight possibility of recovery. 
 
 If the mouth of the vessel could not be at 
 once secured, pressure should be instantly 
 resorted to, for the purpose of producing a 
 temporary suppression of the hemorrhage. 
 The surgeon should then either make the 
 necessary enlargement of the wound in the 
 integuments, with a due and constant recol- 
 lection of the important parts near the place, 
 or else, in the case of the carotid being in- 
 jured, he should cut down to this vessel in 
 the manner explained in the article Aneu- 
 rism. 
 
 In lacerated wounds, the carotid artery 
 may be injured, and yet the patient not 
 immediately bleed to death ; for it is the 
 nature of all wounds, attended w ith much 
 laceration and contusion, not to bleed so 
 freely as clean cuts. Mr. Abernethy has 
 related a case in which the carotid, and all 
 the chief branches of it, were wounded in 
 a man who was gored in the neck with a 
 cow’s horn ; yet death did not directly 
 follow T , and there was time to have recourse 
 to the ligature. Baron Larrey even reports 
 one or two cases in which the bleeding 
 from the carotid, injured by a gunshot, w r as 
 permanently stopped by pressure. (See 
 Mem. de Chir. Milil.) Dr. Hennen also 
 refers to another instance of a similar na- 
 ture. (On Military Surgery , p. 106, Ed. 2.) 
 
 Punctured w ounds might obviously injure 
 either the carotid, or the internal jugular 
 vein, w ithout the patient expiring of hemor- 
 rhage at once ; . because the smallness of 
 the wound in the skin might hinder the fa- 
 tal effusion of blood. 
 
 However, frequently, when these vessels 
 are wounded, the par vagum is also injured, 
 and the case is mortal, either immediately, 
 from the direct effects both of the injury of 
 the nerve, and sudden loss of blood, or very 
 soon afterward, the bleeding being of a 
 slower and more interrupted kind ; w'hich 
 circumstance must depend on the lacerated 
 nature of the wound, the small size of the 
 opening in the vessel, or of that in the 
 skin, & c. 
 
 Persons w 7 ho attempt suicide, by cutting 
 their throats, do not often divide the carotid 
 artery, on account of their incision being 
 made too high up. Where the carotid arte- 
 ries emerge from the chest, they are situa- 
 ted by the side of the trachea, and even a 
 little more forward than it. However, as 
 these vessels proceed up the neclc, they be- 
 
 come more laterally situated with respect 
 to the trachea ; and when they have arrived 
 at the upper part of the neck, where per- 
 sons, w r ho aim at suicide, almost always cut, 
 they become situated more backward than 
 the trachea, inclining towards the angle of 
 the low er jaw. 
 
 The oesophagus is so deeply situated, lying 
 close to the bodies of the vertebrse, and be- 
 hind the trachea, that if is not often interest- 
 ed in any incised wounds, which do not 
 immediately prove fatal, in consequence 
 of the division of other important parts. 
 Yet numerous cases are recorded, in which 
 the oesophagus is said to have been wound- 
 ed ; and what is usually set down as a crite- 
 rion of the fact, is the passage of victuals 
 through the wound. In many of these 
 narrations the writers seem to have forgot- 
 ten, that w^ounds, made above the os hyo- 
 ides, as they frequently are, may enter the 
 mouth, and the victuals escape through the 
 cut, w ithout the oesophagus, or pharynx, be- 
 ing at all concerned. 
 
 However, no doubt, the oesophagus has 
 occasionally been wounded, together with 
 the trachea, not only without the patient 
 perishing so immediately as to be incapable 
 of receiving any succour, but without every 
 chance of recovery being destroyed. Stabs, 
 and gunshot wounds, may injure the oeso- 
 phagus, and leave all other important parts 
 untouched. Nay, w’hen other parts of con- 
 sequence are injured, the patient is some- 
 times saved. (See Hennen's Military Sur- 
 gery , p. 363, Ed. 2.) 
 
 Even where the oesophagus is know'n to 
 be wounded, its deep situation would pro- 
 hibit us from doing any thing to the breach 
 of continuity in the tube itself. The best 
 plan w r onld be to have recourse to antiphlo- 
 gistic means, and to introduce a flexible 
 elastic gum catheter from one of the nos- 
 trils down the oesophagus, for the purpose 
 •of conveying nourishment and medicines 
 into the stomach, without any risk of their 
 passing out at the wound. An instrument 
 of this kind will lie in the above situation 
 for any length of time without occasioning 
 much inconvenience ; and, besides being 
 advantageous for injecting nourishment and 
 medicines down the passage, and keeping 
 them from issuing at the wound, it prevents 
 all necessity for the wounded oesophagus to 
 act and become disturbed, when there is 
 occasion to take any kind of liquids, whe- 
 ther in the way of medicine or food. The 
 outer wound should be brought together, 
 and treated on common principles. 
 
 When persons cut their throats, as I have 
 explained, they do not often divide the 
 carotid artery, owing to their incision being 
 usually made high up in the neck, w'here 
 this vessel has attained a very backward 
 situation. When any serious hemorrhage 
 does arise, it is sometimes from the lower 
 branches of the lingual artery, but most 
 frequently from the superior thyroideal ar- 
 teries. Such arteries may occasion a fatal 
 bleeding, which, indeed, would more fre- 
 quently be the event, than it actually is, did 
 
THIi 
 
 THU 
 
 47S 
 
 not the patient often faint, in which state 
 the bleeding spontaneously ceases, and gives 
 time for the arrival of surgical assistance. 
 
 I need hardly tell the reader, that these 
 arteries are to be tied, and that this impor- 
 tant object is the first to which the surgeon 
 should direct his attention. The danger of 
 bleeding to death being obviated, as soon as 
 possible, the other requisite measures may 
 be more deliberately executed. 
 
 With respect to wounds of the trachea, 
 the same plan of conveying food and medi- 
 cines into the stomach, through an elastic 
 gum catheter, introduced from one of the 
 nostrils down the oesophagus, is highly 
 proper, though too much neglected. For 
 nothing creates such disturbance of the 
 wound as the convulsive elevation and de- 
 pression of the larynx and trachea, which 
 are naturally attendant on the act of swal- 
 lowing. 
 
 When the trachea is cut, the patient’s 
 power of forming the voice is more or less 
 impaired, in consequence of the air passing 
 into and out of the lungs, chiefly through 
 the wound. Besides air, a considerable 
 quantity of the natural mucus of the trachea 
 is also continually coming out of the wound. 
 
 The grand means of accomplishing the 
 union of wounds of the trachea, are a pro- 
 per position of the head, and a rigorous 
 observance of quietude. By raising the 
 patient’s head with pillows, and keeping 
 his chin close to his breast, the edges of the 
 wound, both in the skin and trachea, are 
 placed in contact even without any other 
 assistance, unless the division of the trachea 
 be exceedingly large. It is proper, howe- 
 ver, to assist the effect of a suitable position 
 with strips of sticking plaster, and some- 
 times with a suture or two But the neces- 
 sity for sutures must depend on the extent 
 of* the division of the trachea ; for unless 
 most of the circle of this tube be cut, and 
 position be neglected, the wound in it will 
 not gape. The stitches should never be 
 passed through the lining of the trachea, as 
 this method would be likely to make it in- 
 flame, and occasion considerable coughing 
 and irritation, attended with very pernicious 
 effects. * 
 
 Should there be much coughing, apparent- 
 ly arising from irritation and inflammation 
 in the trachea, bleeding is proper if other 
 considerations do not forbid it. The sperma- 
 ceti mixture, with opium, is also frequently 
 of great service I never saw a wound of the 
 trachea unite by the first intention (See John 
 Bell on Wounds, Ed. 3. Mermen's Military 
 Surgery, p. 356, fyc. Ed. 2. 8 vo. Edinb. 1820. 
 Among other references made by Dr. Hennen, 
 the following seem to me to merit particular 
 notice : — An interesting case of wound of the 
 neck, succeeded by hemiplegia, and another of 
 gunshot wound of the throat, succeeded by 
 paralysis and convulsions, says Dr. Hennen, is 
 •riven by Forestus in his Surgical Observations. 
 "Another, with loss of motion in the arm, from 
 a wound in the neck , is to be found in the 
 Edinb. Med. Essays, Vol. 1. And in the Med. 
 Commentaries, try Dr. Dvrcan , Vol. 4, p. 
 
 434, and Vol. 8, p. 356, are two interesting 
 cases. Murinna, in his Med. Chir. Btobach - 
 tungen, relates a case of removal of the thyroid 
 gland by a cannon ball ; the patient survived 
 fourteen days , and died of dysentery. Wounds 
 of the oesophagus often remain open for inde- 
 terminate periods , as is exemplified in a case 
 reported by Trioen, in his Fasciculus Obser • 
 valionum, Ludg. 1745, p. 40. Mr. Bruce has 
 recorded an interesting case of wound of the 
 (Esophagus, in Med. Chir. Journ. Vol. 1, p. 
 369. I would also refer to various parts of 
 M6m de ( hir. Milit. 4 Tomes, by Baron Ear • 
 rty. And Thomson's Report of Obs. made in 
 Mil. Hospitals in Belgium, 8vo. Edinb. 1816.) 
 
 THROMBUS, (from 3-go/zCoc, coagulated 
 blood.) A clot of blood. The term is also 
 applied to a tumour, formed by a collection 
 of estravasated, coagulated blood, under the 
 integuments after bleeding. When such an 
 extravasation is not considerable, it is usual- 
 ly called an ecchymosis. (See this word, 
 and Bleeding.) 
 
 A thrombus after bleeding generally arises 
 from the opening in the vein not corres- 
 ponding to that in the skin. The patient’s 
 altering the posture of his arm, while the 
 blood is flowing into the basin, will often 
 cause an interruption to the escape of the 
 fluid from the external orifice ot the punc- 
 ture ; and consequently, it insinuates itself 
 into the cellular substance in the vicinity of 
 the opening in the vein. In proportion as 
 the blood issues from the vessel, it is effused, 
 in the cellular membrane, between the skin 
 and fascia, covering the muscles, and this, 
 with more or less rapidity, and in a greater 
 or lesser quantity, according as the edges of 
 the skin more or less impede the outward es- 
 cape of the fluid. Sometimes, also, a throm- 
 bus forms after venesection, when the usual 
 dressings, compress, and bandage, have been 
 put over the puncture, and the patient im- 
 prudently makes use of the arm on which 
 the operation has been done. This is more 
 particularly liable to happen when the open- 
 ing in the vein has been made large. 
 
 When the extravasation i3 not copious, it 
 is of little importance, the tumour generally 
 admits of being easily resolved, by applying 
 linen, dipped in any discutient lotion. It 
 the swelling be more extensive, applying to 
 it a compress, wet with a solution of com- 
 mon sea-salt, is deemed an efficacious plan 
 of promoting the absorption of the extrava- 
 sated blood. Brandy, and a solution ot the 
 muriate of ammonia in vinegar, are likewise 
 eligible applications. 
 
 It sometimes happens, that a thrombus 
 induces inflammation and suppuration of the 
 edges ot the puncture. The treatment is 
 now like that of any little abscess : a com- 
 mon linseed poultice may be applied, and 
 any considerable accumulation of matter 
 should be prevented by making an opening 
 with a lancet in proper time. As soon as 
 the inflammatory symptoms have ceased, 
 discutients should be employed again, tor 
 the purpose of dispersing the remaining clots 
 of blood, and surrounding induration. 
 
 When the quantity of blood is large, manv 
 
THYROID GLAND. 
 
 auliiors recommend opening the tumour at 
 once; and, despairing of the power of the 
 absorbents to remove the extravasation, they 
 recommended as much of the blood as possi- 
 ble to be pressed out through the incision. I 
 believe, however, that making an opening 
 is seldom necessary, and often brings on in- 
 flammation, and suppuration, when they 
 might be avoided. I have never seen any 
 case, in which there was real occasion 
 to make an opening for the discharge of the 
 blood. A case of this kind, however, may 
 be conceived. 
 
 THYROID GLAND, DISEASED. (See 
 JBronchocele.) 
 
 THYROID GLAND, EXTIRPATION OF. 
 That such an operation, though attended 
 with great difficulties, is not impracticable, 
 is proved by the following example : — 
 
 On the 20th of March, 1791, a woman 
 presented herself for admission at the HOlel- 
 Dieu, with a tumour of the right portion of 
 the thyroid gland. The swelling was two 
 inches in diameter, round, hard, and at- 
 tached to the right and middle part of the 
 trachea, and it pushed outwards the sterno- 
 mastoideus muscle. Independently of its 
 being sensibly raised by each pulsation of 
 the arteries, it obeyed the motions of de- 
 glutition, and in a slight degree impeded 
 the passage of solid aliment. The patient 
 earnestly desiring to get rid of so inconve- 
 nient a deformity, determined to submit to 
 its extirpation, which appeared tne only re- 
 source. The danger, the length of time, 
 and the pain necessarily annexed to the ope- 
 ration, were not concealed from her. De- 
 sault made a longitudinal incision through 
 the middle of the tumour, beginning one 
 inch above, and finishing one inch below the 
 swelling. By the first stroke, he cut down 
 as far as the gland, dividing the integuments, 
 the platysma-myoides, and some fibres of 
 the sterno-hyoideii and sterno-thyroidei 
 muscles. An assistant, with the view of 
 fixing the tumour, drew towards aside the 
 inner edge of the wound, whilst the surgeon 
 detached the swelling from the sterno-mas- 
 toideus muscle. In dissecting the cellular 
 substance, which united the parts, two small 
 arteries were divided, which were secured 
 with ligatures. The outer portion of the 
 tumour being thus disengaged, the inner was 
 detached in the same way. The tumour 
 was then drawn outwards by means of a 
 hook, that it might be separated with more 
 ease from the trachea. In the course of this 
 dissection, the branches of the thyroid arte- 
 ries were successively tied, as fast as they 
 were divided. The assistant, who held the 
 hook, pulled the gland from within and tor- 
 wards, whilst the surgeon finished the dis- 
 section outwards and from above down- 
 wards. This part of the operation was the 
 most difficult: it was necessary continually 
 to wipe away the blood with a sponge, 
 which necessarily prevented the parts from 
 being easily distinguished, and obliged the 
 surgeon to cut but a little at a time, and 
 always to examine well with his finger those 
 parts which he was about to rut. By this 
 
 479 
 
 cautious dissection, the superior and inferior 
 thyroid arteries were laid bare, and after- 
 ward tied with the aid of a blunt crooked 
 needle. They were then transversely di- 
 vided, and the remaining part of the tumour 
 detached from the trachea, to which it 
 strongly adhered, l'he wound resulting from 
 this operation was near three inches in 
 depth ; it was outwardly bounded by the 
 sterno-mastoideus muscle, and inwardly by 
 the trachea and oesophagus ; posteriorly by 
 the carotid artery, and par vagum, which 
 were exposed at the bottom of the wound. 
 The extirpated tumour w T as five inches in 
 circumference ; and on examination was 
 found to differ in no particular from scirrhous 
 glands, except that in the centre there was 
 a cartilaginous nucleus. The patient left 
 the hospital perfectly well, the thirty-fourth, 
 day after the operation. (See Desault's Paris- 
 ian Chir. Journ. Vol 2, p. 292, 296.) 
 
 The extirpation of the thyroid gland is an 
 operation extremely difficult, and certainly 
 highly dangerous* when performed by an 
 operator but moderately exercised in the 
 practice of his profession. The number 
 and size of the arteries divided, the proxi- 
 mity of the trachea, oesophagus, and carotid, 
 near which the knife must necessarily pass, 
 are the principal dangers. They have de 
 terred the majority of practitioners from 
 performing the operation, and it must be 
 allowed, that they are such as ought to in- 
 timidate every man, who is not endued with 
 anatomical knowledge, and the most un- 
 daunted coolness. Examples of this opera- 
 tion are very rare. The first time that 
 Gooch undertook it, he was deterred from 
 finishing it by the hemorrhage, and his pa- 
 tient died on the eighth day. The second 
 time he succeeded better, but was incapable 
 of securing the vessels, and succeeded in 
 stopping the hemorrhage, which would oth- 
 erwise have been mortal, by causing the 
 parts to be compressed by the hand of an 
 assistant for the space of eight days. ( Gooch's 
 Med. and Chir. Obs. p. 130. Bell's System of 
 Surgery, Vol. 5, p. 525. Richter's Bibl. T. 
 
 2, p. 128.) 
 
 A. F. Vogel and Theden practised the 
 operation with complete success. All dan- 
 ger from the hemorrhage, or inconvenience 
 arising from the discharge of blood, maybe 
 obviated by taking up the small vessels, ty - 
 ing them as fast as they are divided, and by 
 discovering and tying the large vessels pre- 
 vious to their division. Other parts that 
 cannot be wounded without danger, are to 
 be avoided by dissecting slowly and a little 
 at a time, and feeling with the finger every 
 part previously^ i*s division with the bis- 
 toury. 
 
 A case, in which Klein removed a vejv 
 large thyroid gland,' has been recently pub- 
 lished. The patient, a boy eleven years of 
 age, died, however, on the operating table, 
 as would seem from Klein’s account, in con- 
 sequence of apoplexy. (See Journ. dec 
 Chir. B. 1 ,p. 120, 6 vo. Berlin, 1820; or the 
 Quarterly Journ. of Foreign Medicine , Vol. 2. 
 p. 380.) On the whole, I consider that the 
 
TIC DOUXOUREUX 
 
 
 practice of tying the thyroidal arteries is 
 generally a safer experiment than the re- 
 moval of the enlarged gland with a knife. 
 (See Bronchocele .) 
 
 *TIC DOULOUREUX. This term is used 
 to signify a disorder, the most prominent 
 character of which consists in severe at- 
 tacks of pain, affecting the nerves of the 
 face ; most frequently the filaments of that 
 branch of the fifth pair, which comes out of 
 the infra-orbitary foramen ; but sometimes 
 the other branches of the fifth pair, and oc- 
 casionally the numerous filaments of the 
 portio dura of the auditory nerve, which 
 are distributed upon the face. The com- 
 plaint is not continual, but occurs in violent 
 paroxysms, which vary in duration in dif- 
 ferent instances. It is the trismus dolorijicus 
 of Sauvage ; the Faciei Morbus Nervorum 
 Crucians of Dr. S. Fothergill; and of that 
 order of diseases which Professor Chaussier 
 has so aptly denominated neuralgies (from 
 vi'j gov, a nerve, and ctxyo s, pain ;) for it should 
 be known, that many other parts of the 
 body are subject to a similar affection. 
 
 The first excellent description of the tic 
 douloureux was published in the year 1776, 
 by the late Dr. Fothergill. (See Med. Obs. 
 and Inq. l ol. 5.) It is not true, however, 
 as is generally stated in modern medical 
 works, that this gentleman was the first au- 
 thor who noticed the complaint. This in- 
 deed is so far from being correct, that we 
 even find an account of an operation done 
 long ago by Louis, for the relief of the dis- 
 ease, (See No. 36 de la Gazette Salutaire , 
 1766 ;) and this identical case actually be- 
 came a subject of hot dispute between the 
 physicians and surgeons of the French me- 
 tropolis. (See a Thesis, entitled u Utrum in 
 pertinacibus capitis et faciei doloribus aliquid 
 prodesse possit, sectio ramorum nervi quinti 
 paris ? Proponebat Viellart, 1768, conclusio 
 negativa 
 
 Tic douloureux conveniently admits of 
 being divided into four species, called by the 
 French frontal , suborbitary, and maxillary 
 neuralgia, and the neuralgia of the facial 
 nerve. 
 
 In the frontal neuralgia, the pain usually 
 begins in the situation of the supra-orbitary 
 foramen, extending at first along the branch- 
 63 and ramifications of the frontal nerve 
 distributed to the soft parts upon the crani- 
 um, and afterw ard shooting in the direction 
 of the trunk of the nerve towards the bot- 
 tom of the orbit. In a more advanced 
 stage, the conjunctiva and all the surface of 
 the eye participate in the effects of the dis- 
 order, and become affected with chronic in- 
 flammation, which is described as a particu- 
 lar species of ophthalmy. At length, the 
 pain passes beyond the distribution of the 
 branches of the frontal nerve, and affects all 
 the corresponding side of the face and head. 
 It seems as if it extended itself to the facial, 
 sub-orbitary, maxillary, and even to the 
 temporal and occipital nerves, through the 
 communications naturally existing between 
 the filaments of all those organs of sensa- 
 tion. Each paroxysm produces a spasmo- 
 
 dic contraction of the eyelids, and a eopi 
 ous effusion of tears. 
 
 The sub-orbitary neuralgia is first felt 
 about the sub-orbitary foramen. The seat 
 is probably in the nerve of this name, and 
 the pain extends to the lower eyelid, the 
 inner canthusof the eye, the muscles about 
 the zygoma, the buccinator, cheek in gene- 
 ral, ala of the nose, and the upper lip. At 
 a later period, the pain appears to extend 
 backward to the trunk of the nerye, and 
 those branches which are given off in its 
 passage through the sub-orbitary canal. 
 Hence, pains are then experienced in the up- 
 per teeth, the zygomatic fossa, the palate, 
 tongue, and within the cavity of the nose. 
 As the disorder advances, it may extend, 
 like other neuralgiae of the face, to all the 
 same side of the head. During the pa- 
 roxysms, w r hen the disease i9 fully formed, 
 an abundant salivation usually takes place. 
 In general the attendant toothach deceives 
 the practitioner, who in the belief that the 
 pain arises from another cause, uselessly 
 extracts several of the teeth. 
 
 The tic douloureux of the lower jaw, or 
 maxillary neuralgia, is usually first felt about 
 the situation of the anterior orifice of the 
 canalis mentalis, and it extends to the lower 
 lip, chin, neck, teeth, and temple. This 
 form of the complaint is more uncommon 
 than the preceding ; but, after it has pre- 
 vailed some time, is equally remarkable for 
 its intensity. 
 
 With respect to the neuralgia of the facial 
 nerve, or portio dura of the auditory nerve, 
 it is a case, which very soon cannot easily 
 be distinguished from the other species of 
 tic douloureux. The pains at an early pe- 
 riod are no longer confined to the passage 
 of the principal branches of this nerve be- 
 tween the parotid gland and ramus of the 
 jaw. The numerous communications of the 
 portio dura with the rest of the nerves of 
 the face seem to facilitate the extension of 
 the disease, so that the agony is soon felt 
 over the whole side of the head. The original 
 source of the disorder can only be detected 
 by attentively considering the progress of 
 the complaint in all its stages. (See Del- 
 pech, Traitd des Maladies Reputes Chirurgi- 
 cales , T. 3, Sect. 7, p. 214, $*.) 
 
 Tic douloureux may be known from 
 rheumatism by the paroxysm being excited 
 by the slightest touch, by the shortness of 
 its duration, and the extreme violence of the 
 pain. In acute rheumatism, also, there is 
 fever, with redness, heat, and generally some 
 degree of swelling ; and, in chronic rheu- 
 matism, the pain is obtuse, long-continued, 
 and often increased at night ; none of which 
 symptoms characterize tic douloureux. 
 
 It may easily be distinguished from henii- 
 crania by the pain exactly following the 
 course of the branches of the affected nerve. 
 
 It is known from the toothach by the com- 
 parative shortness of the paroxysms ; the 
 quickness of their succession ; the intervals 
 of entire ease; the darting ol the pain ill 
 the track of the particular nerve affected . 
 the more superficial and lancinating kind ol 
 
TIC DOULOUREUX 
 
 481 
 
 $>ain j and the convulsive twitchings, which 
 sometimes accompany the complaint. 
 
 The dhuses of tic douloureux may be said 
 to be in general unknown ; but there are a 
 tew instances recorded which appear to 
 be the consequence of external violence, 
 wounds, contusions, &c. A modern writer 
 has related a very curious instance of a re- 
 sembling disease in the arm, where the af- 
 fection proceeded from the lodgment of a 
 small bit of a bullet in the radial nerve. ( Den - 
 snark, in Med. Chir. Tram. Vol. 4, p. 48.) 
 Dr. Parry attributed the pain to increased 
 vascularity, or determination of blood, (per- 
 haps amounting to inflammation) to the neu- 
 rilerna, or vascular membranous envelope of 
 the nerves affected. {Elements of Pathology 
 and Therapeutics.) 
 
 Stimulating embrocations, blisters, caustic 
 issues, fomentations, leeches, frictions w ith 
 mercurial ointment, ( Edinb . Med. and Surg. 
 Journ. Vol. 3,) electricity, opium in large 
 doses, the arsenical solution, and a variety 
 of antispasmodic medicines, are the princi- 
 pal means, which have been tried ; but for 
 the most part, they only afford partial and 
 temporary relief. From some facts recent- 
 ly published by Dr. Marcet, the extract of 
 stramonium, in doses of one-eighth and half 
 a grain thrice a day, seems to be sometimes 
 capable of alleviating the distressing agony 
 of the present disorder. (See Med. Chir. 
 Trans. Vol. 7, p. 75, fyc. also Kirby's Cases , 
 S vo. Lond. 1819.) 
 
 The operation of dividing the trunk of the 
 affected nerve, and even of dissecting out a 
 portion of it, so as to prevent all chance of 
 a relapse from the reunion of the ends of the 
 nerve, is a plan, which has sometimes been 
 practised with permanent benefit. Thus, any 
 one of the three branches of the fifth pair of 
 nerves may be divided at the point, where it 
 comes out upon the face. But, before having 
 recourse to this means, the surgeon should be 
 sure, that the particular nerve, which he is 
 about to expose and divide, is really the prin- 
 cipal seat of the disease ; for, when all the 
 nerves of the face generally are affected, or 
 when the branches of the portio dura are 
 especially concerned, there is little hope of 
 success. In fact, it must be confessed, that 
 the operation has had many failures and re- 
 lapses, either from the cases not having been 
 duly discriminated, or from the neglect to 
 remove a portion of the exposed nerve. 
 Richerand, Delpech, and most of the lead- 
 ing surgeons in France express their prefe- 
 rence to the application of the moxa, or 
 cautery, which, they say, proves more fre- 
 quently successful, than the knife. This 
 should be done directly over the apertures, 
 from which the nerves emerge on the fore- 
 head, cheek, or chin, and Richerand asserts, 
 that by such treatment, the pains may al- 
 ways be cured, or at all events, rendered 
 supportable. ( Nosogr . Chir. T. 2, p 218, 
 Edit. 4.) Delpech also affirms, that the sec- 
 tion of the nerve very often fails, and that 
 issues, and the repeated use of the cautery 
 have been attended with the greatest suc- 
 cess. (See Pr6cis dzs Mai Chir. T. 3, p. 213 > 
 
 Vol, II, <51 
 
 The disfigurement of the countenance by 
 burning applications must, how’ever, be very 
 objectionable, and, as I think there is no 
 positive evidence of the superiority of this 
 method over the use of the knife, l consider 
 what Richerand and Delpech have staled 
 only as another instance of the extreme 
 partiality of the French surgeons to the 
 moxa and cauterization. Delpech confesses, 
 however, that, when the pains seem to be 
 the consequence of a ganglion, or thicken- 
 ing of a part of a nerve, the excision of 
 such part is indispensable. There can be 
 little doubt, that this would have been more 
 proper than amputation in Mr. Denmark's 
 case, to which I have already referred. 
 The theories of Dr. Parry, senior, who was 
 generally inclined to refer the effects of dis- 
 ease to increased determination of blood to 
 the parts affected, led him to believe that the 
 operation of cutting the nerve, as performed 
 by Dr. [faighton and others, did good rather 
 by the division of the arterial branch sup- 
 plying the affected ramification of the trige- 
 minus nerve, than by the division of that ra- 
 mification itself. {Parry, Elements of Pa- 
 thology, fyc.) 
 
 There have been many examples of tic 
 douloureux, which, after resisting all at- 
 tempts to cure them, have been left to them- 
 selves, and, after a long time spontaneously 
 subsided. ( Delpech , Traite des Maladies 
 Chir. T. 3, p. 212, 215.) This author has 
 seen the operation of dividing the chief 
 branches of the portio dura, in front of the 
 parotid gland, undertaken, and even a por- 
 tion of the soft parts cut away ; but without 
 any favourable consequences. (P.218.) 
 
 I have already stated, that the nerves of 
 the extremities are subject to affections very 
 analogous to tic douloureux. The following 
 instance related by Mr. Abernethy will be 
 found interesting ; — 
 
 A lady became gradually affected with «• 
 painful state of the integuments under, and 
 adjoining to, the inner edge of the nail of 
 the ring-finger of the left hand. No injury 
 to the part was remembered, which could 
 have brought on this disease. The pain oc- 
 curred at irregular intervals, and was ex- 
 tremely severe during the time of its con- 
 tinuance, which was fora day or two, when 
 it usually abated. Accidental slight injuries 
 always produced great pain, and frequently 
 brought on the paroxysms, which however 
 occasionally occurred spontaneously, or 
 without any evident exciting cause. In all 
 these particulars, the disease correctly re- 
 sembled the tic douloureux of the nerves of 
 the face. As the pain increased, the disor- 
 der seemed to extend up the nerves of the 
 arm. After the patient had endured this 
 painful affliction for seven years, she sub- 
 mitted to have the skin, which was the ori- 
 ginal seat of the disorder, burnt with caustic. 
 This application gave her intense pain, and 
 on the healing of the wound, she found her 
 sufferings rather augmented than diminished, 
 by the experiment. After four more years 
 of suffering, she consulted Mr. Abernethy, 
 when the circumstances of the case wert 
 
4 *: 
 
 TOE 
 
 TIC 
 
 such as to render an operation indispensably 
 necessary. The pain of the part was into- 
 lerable, and it extended all up the nerves of 
 the arm ; and this general pain was so con- 
 stant during the night, as to deprive the pa- 
 tient of rest. The muscles of the bach of (he 
 neck were occasionally affected with spasms. 
 The integuments of the affected arm were 
 much hotter than those of the opposite arm, 
 and sometimes the temperature was so in- 
 creased as to cause a burning sensation in 
 them. Underthese circumstances, Mr. Aber- 
 nethy did not hesitate to divide the nerve of 
 the finger, from which all this disorder seem- 
 ed to originate.' He laid it bare by a longi- 
 tudinal incision of about three quarters of an 
 inchin length, from the second joint of the 
 linger, and divided it opposite to that joint, 
 by a curved sharp-pointed bistoury, which 
 xvas conveyed under it. He then took hold 
 of the nerve with a pair of forceps, and re- 
 jecting it downwards, removed a portion of 
 it, half an inch in length, so that the possibi- 
 lity of a quick reunion might be prevented. 
 The wound was brought together with stick- 
 ing plaster, and it united by adhesion ; but 
 the upper part of the wound, opposite to the 
 upper end of the nerve, became slightly in- 
 flamed, and was very painful. However, in 
 the course of three weeks, ihe appearance 
 of inflammation gradually went off. After 
 the operation, Mr. Abernethy pinched the 
 originally affected integuments sharply with 
 bis nails, without causing any sensation ; but 
 if, in so doing, he moved the finger, then 
 pain was felt. He found it difficult to con- 
 vince the patient that the skin at that part 
 was actually devoid of sensation ; for she 
 still continued to feel similar sensations to 
 those which formerly occurred, though in a 
 much diminished degree; but she became 
 gradually as perfectly convinced as any me- 
 dical man could be, that these sensations 
 arose from (he irritated state of the end of 
 the nerve, above the place where it was di- 
 vided. The painful affection of the nerves 
 of the arm still continued, though considera- 
 bly lessened in violence ; however it was suf- 
 ficiently severe to make the patient appre- 
 hend that little permanent benefit would 
 arise from the operation. This pain conti- 
 nued occasionally about four months with 
 varying degrees of severity, but the tempe- 
 rature of the skin was not hotter than that 
 of the opposite side, as it hhd been before 
 the operation. At the expiration of three 
 months, the patient ascertained that the in- 
 teguments at the end of the finger actually 
 felt when any thing was applied to them, 
 arid this proved a new source of alarm. Mr. 
 Abernethy adds, that mure than nine months 
 have now elapsed since the performance of 
 the operation, and the general pains in the 
 nerves have become very trivial ; but the 
 sensation in the integuments at the end of 
 the finger, has during that time gradually in- 
 creased, and the skin has now its natural 
 sensibility, so as accurately to distinguish 
 the tangible properties of any body applied 
 to it. If also the originally affected part be 
 slightly compressed, painful sensations re- 
 sembling those which formerly occurred 
 
 take place. (Mernethy's Surgical Work 
 Fol. 2, p. 203.) In a case resembling the 
 former, but the consequence of a wound of 
 the finger, M . Laurence also cut down to the 
 nerve, and removed » portion of it wi‘h per- 
 manent success Father fill's Paper in ol. 
 5 of the Medical Ohs. and Inq. Dr. Haigh - 
 Ion's Obs. in Ihe Med. Recants and Researches . 
 Darwin's Zoononia. JlbenvAhf s Surg. 
 
 Works, Fol 2, p. 20*3, fyc. Richerand, No- 
 sogr. ( hir . T. 2 p. 216. ifc. Edit. 4. Del- 
 pech, Precis des Maladies Chir. T. 3, p. 206, 
 fyc. Dr. S Fothergill'.s Systematic Account of 
 Tic Douloureux, 1804. Mcdico-Chir. Trans . 
 Fol 4, p. 48, Fol. 7, p. 575, fyc. Kirby's 
 Cases, 8vo. Lond. 1819. 
 
 TINCTURA KERRI MURIATIS. This 
 tincture has sometimes been exhibited in 
 gleets ; but a more important use has been 
 assigned it by Mr. Cline, who orders it in 
 dysuria from stricture, in the dose of ten 
 drops every twenty or thirty minutes, until 
 nausea is excited. Where chalybeates are 
 indicated, (his preparation is one very much 
 approved of 
 
 “ Mr. Justamond^s liquid for external use 
 in cancers, and which the original inventor 
 called his panacea anticancrosa, partook con- 
 siderably of the nature of this tincture, 
 which, indeed, with an equal quantity of 
 spirit ol wine, was sometimes substituted for it, 
 
 “ Lastly, it is remarkably efficacious in 
 destroying venereal or other warts, either 
 used alone, or diluted with a small propor- 
 tion of water ” ( Pharm . Chir.) 
 
 TINCTURA LYTTdS. Sometimes em- 
 ployed in cases of gleets, and incontinence 
 of urine, arising from a want of proper ac- 
 tion in the sphincter vesicae muscle. The 
 usual dose is from ten to forty drops, 
 twice or thrice a day ; but its effects should 
 be carefully w atched ; for it is apt to occa- 
 sion dangerous inflammation* of the urinary 
 organs, violent stranguries, and retention of 
 urine If is occasionally used in various 
 liniments, when die object is to stimulate 
 the skin considerably, and rouse the action of 
 the nerves and absorbents, as in certain ca- 
 ses of ptosis, paralysis, &,c. Mr. Anthony 
 Todd Thomson has found it an useful appli- 
 cation in the mortification of the extremities, 
 sometimes happening without any apparent 
 cause ; and also to frost-bitten parts. ( Lon- 
 don Dispensatori /, p. 65S, Ed. 2.) 
 
 TINCTURA THEBAIC A. (See Vinum 
 Opii.) 
 
 TINEA CAPITIS. (See Porrigo.) 
 
 TOBACCO is used for promoting the re- 
 duction of strangulated hernia, either in 
 the form of a fluid clyster, or of smoke, which 
 latter is introduced up the rectum by means 
 of an Apparatus. Excepting the operation, 
 the power of tobacco, particularly, when 
 assisted by the topical application of cold 
 to the tumour, is most to be depended upon 
 for bringing about the return of the protru- 
 ded viscera. (See Hernia, and Enema.) It 
 has also been tried in tetanus ; and Mr. Earle 
 has found tobacco clysters very efficacious 
 in certain cases of retention of urine. (See 
 Tetanus, and Urine , Retention of.) Consult 
 T Fowhr . Medical Reports of the Effects of 
 
TONGUE 
 
 Tobacco, Svo. Lond. 1785. A. P. Wilson, An 
 Experimental Essay on the manner in which 
 Opium and Tobacco act on the living animal 
 Body, Svo. Edinb. 1 795. It. Hamilton , He 
 JYicotiams Viribus in Medicina, fyc. Svo. 
 Edinb. 17S0. 
 
 TONGUE, DISEASES OF. This part 
 is subject to various diseases, as ulcers, tu- 
 mours, and such enlargements as sometimes 
 put the patient in imminent danger of suffo- 
 cation. 
 
 Carious teeth, with points and inequali- 
 ties, producing continual irritation, are the 
 most frequent cause of ulcerations of the 
 tongue. The sores, thus arising, often re- 
 sist every kind of remedy, and ignorance of 
 the cause sometimes leads the practitioner 
 to consider them as incurable ; whereas, a 
 cure may easily be effected by extracting 
 the carious tooth, or simply filing off its 
 sharp irregularities, as was anciently direct- 
 ed by Celsus. 
 
 The glandular papillae which are situated 
 on the dorsum, or upper surface of the 
 tongue, have a narrow base, and a broad 
 termination or head, like a mushroom. 
 They are capable of becoming considerably 
 enlarged, so as to form preternatural 
 tumours, which may be mistaken for can- 
 cerous excrescences. 
 
 A young man, eighteen years of age, had 
 on the middle of his tongue a circumscribed 
 tumour, about as large as a middle-sized 
 nutmeg. Louis, who was consulted, per- 
 ceived that the swelling was only of a fun- 
 gous nature, and he tied its base with a liga- 
 ture, with the noose of which he con- 
 tracted the diameter of the pedicle, while, 
 with the ends, he kept down the tongue. 
 Then with one stroke of a pair of cur- 
 ved scis ors, he cut off the tubercle. Caus- 
 tic was afterward applied to the base of 
 the tumour, and the patient was. perfectly 
 well in five or six days. ( Sur les Maladies 
 de la Langue, in M6 moires de I'Acad. de Chir. 
 f.b.) 
 
 Morgagni speaks of similar tubercles ; 
 but he never advised their extirpation, not 
 even when they were hard and scirrhous ; 
 for, if he had not deemed the operation im- 
 practicable, he should not have had any 
 confidence in the surgeons who were .con- 
 sulted. 
 
 The tongue is occasionally affected with 
 a true cancerous disease*, one of the most 
 afflicting cases, indeed, which can possibly 
 happen, as may be conceived, when it is 
 known, that, in the advanced stage of the 
 disease, the patient can hardly take his food, 
 which must be conveyed over the tongue 
 by some means or another, before it can be 
 swallowed, while he is obliged to w r rite what- 
 ever he wishes to say. (See Home's Pract. 
 Obs. on Cancer , p. 112.) Cancer of the 
 tongue seems to differ from other carcino- 
 matous affections in frequently occurring in 
 youngish subjects. In the course- of the 
 disease, the glands behind the jaw and in 
 the neck are sometimes affected. Louis 
 saw a lady, who had an ulcerated cance- 
 rous tubercle on the left edge of the tongue. 
 The little swelling was circumscribed, , ; *its 
 
 483 
 
 size did not exceed that of a filbert; the 
 pains were lancinating ; the sore had pene- 
 trated deeply ; and its tuberculated edges 
 were affected with a scirrhous hardness. 
 Extirpation of the disease seemed to present 
 the only chance of cure *, but the patient 
 refused to accede to any thing but palliative 
 plans, and she died in the course of a few 
 months. 
 
 Forestus makes mention of four women, 
 who were attacked with cancer of their 
 tongues, and died from the ravages of the 
 disease, and hemorrhage. In the writings 
 of Hildanus, there is a description of the 
 origin and progress of a cancerous tubercle 
 on a young man’s tongue, whose breath 
 was intolerably fetid and who died in the 
 most excruciating pain. The same author 
 informs us of another case, exhibiting the 
 good effects of sedative remedies in palliat- 
 ing a cancerous ulcer of the tongue, and 
 the fatal consequences of an opposite line 
 of conduct. In authors, many other ex- 
 amples of the same kind are to be met with. 
 
 Surgery, however, is not destitute of re- 
 sources against diseases of so formidable a 
 nature. The following case exemplifies the 
 benefit which may be effected by this useful 
 profession, when not exercised by men of 
 too timorous a character. 
 
 An elderly woman had an ulcerated hard- 
 ness on her tongue. It had been several, 
 times cut away, and as repeatedly returned.. 
 Ruysch was called into consultation with 
 one of the surgeons, who was attending the 
 patient, and who had already extended his 
 incisions very deeply for the removal of the 
 disease. The result of their deliberations 
 was another attempt to extirpate the tu- 
 mour, and they also determined that after 
 it had been cut away, the actual cautery 
 should be freely applied, with a view of 
 destroying the roots of the fungus. The pa- 
 tient consehted to the plan, and bore the 
 operations with great fortitude. The 
 tongue was taken hold of with a cloth, and 
 Pierre Le Memnonite, a sufgeon of emi- 
 nence, removed the disease with a curved 
 bistoury. The inside of the mouth was then 
 protected with wet cloths, and the actual 
 cautery applied several times to the wound 
 in the tongue. The pain was appeased, and 
 the separation of the eschar promoted by 
 emollient gargles. Under, the use of a gar- 
 gle of honey of roses, and the tincture ot 
 myrrh and aloes, the place soon healed. 
 
 It is much easier to cut off a portion of 
 the tongue, through all its diameter, than to 
 remove a cancerous ulceration, situated-at 
 one of its edges. 
 
 In both cases, there is a good deal of dif- 
 ficulty in fixing the part, for it is so very 
 moveable, that it is not easy to keep it in a 
 steady position. For this purpose, Louis re- 
 commended the employment of forceps, 
 with blades terminating in hook-like extre- 
 mities. With this instrument, the part of 
 the. tongue to be amputated can be kept 
 from slipping away. 
 
 However, very malignant ulcers on the 
 tongue have sometimes been cured by mild- 
 er means. Sores of this description are re- 
 
48.4 
 
 lOXGTJE. 
 
 ported t6 have yielded to the repeated ap- 
 plication of leeches under the tongue, after 
 a vast number of other remedies had been 
 tried in vain. In the Encyclopedic MAlho- 
 dique, art. Langue , there is an account of a 
 very alarming affection of the tongue, (re- 
 puted to be cancerous, though this may be 
 doubted,) which got completely well under 
 a very simple plan of treatment. A woman, 
 thirty-five years of age, subject to cutaneous 
 diseases, and ill-conditioned ulcers, com- 
 plained, for seven or, eight months, of little 
 swellings, accompanied with heat and pain, 
 which made their appearance on the edge, 
 and towards the apex of the tongue. At 
 length, the part affected began to swell, grow 
 hard, and cause lancinating pains. Its sur- 
 face .became irregular and rough ; and all 
 the side of the tongue was considerably 
 swelled. The patient could not put her 
 tongue out of her mouth, nor swallow any 
 thing except liquids ; and her breath was 
 intolerably fetid. Various sedative remedies 
 had been employed without success. Ci- 
 euta had been used as a topical application ; 
 it had been exhibited internally in large 
 doses; the patient had taken for a long 
 while, the oxymuriate of mercury ; but no- 
 thing proved of any avail. At length the 
 palieni was so tired of trying the effects of 
 medicines and applications, that she gave 
 them up entirely; and contented herself with 
 trying the experiment of keeping some ho- 
 ney continually in her mouth. As this method 
 seemed to give her some ease, she was pre- 
 vailed upon to persist in it, and in this way, 
 the pains were gradually appeased ; the 
 swelling was diminished, and at the end of 
 two or three months, the woman was quite 
 well, except that an indurated cicatrix re- 
 mained on the part affected, and considera- 
 bly obstructed the extension of the tongue 
 on that side. 
 
 On this case, however, it might be re- 
 marked, the retardation of the cure seem 3 
 also ascribable to the injury of the health 
 produced by the hemlock, mercury, &c. and 
 that the amendment, following their dis- 
 continuance, might rather arise from the 
 consequent improvement of the patient’s 
 health, than from any effect of the honey. 
 
 Many writers confirm the fact, that very 
 inveterate diseases of the tongue are some- 
 times cured by hemlock. Jn the work last 
 cited, is mentioned an instance of a very 
 unhealthy looking ulcer, near the apex of 
 the tongue, attended with a considerable 
 thickening of the part, and of some dura- 
 tion, which was cured by giving large doses 
 of cicuta. But of all the medicines which 
 have the greatest reputation for their bene- 
 ficial effects upon malignant ulcers of the 
 lip and tongue, none perhaps is deserv- 
 ing of so much confidence, as arsenic. (See 
 C. Lane's case of iU-condilioned Ulcer of Ike 
 Tongue , successfully treated by arsenic ; Med. 
 Chir. Trans. Vol. 8, p. 201.) 
 
 However, notwithstanding many facts, of 
 this kind on record, medicines should not 
 be tried too long, that is to say, so as to let 
 the disease attain a condition, in which it 
 will no longer admit of being cut away. 
 
 When the disease makes progress, the kniie 
 should be employed before it is too late. 
 
 When any part of the tongue is to be am- 
 putated, authors very properly recommend 
 the chief vessels to be tied, if possible ; but 
 when this cannot be accomplished, they 
 advise the employment of astringent gar- 
 gles, such as a strong solution of alum, dis- 
 tilled vinegar, or diluted sulphuric acid. 
 When these methods fail, the continental 
 surgeons recommend the actual cautery as 
 the only resource. Where only a piece of 
 the tongue is cut out, in the shape of the 
 letter V, the best mode of stopping tbe 
 bleeding is to bring the sides of the in- 
 cision together with a suture, by which 
 means the deformity will also be lessened, 
 and the union expedited, as is exemplified 
 in a case recorded by Langenbeck. (Neuc 
 Bibl. B. 2, p. 489.) Bather than suffer a 
 patient to die of hemorrhage, if the cautery 
 and other means fail, the lingual artery 
 should be taken up where it passes over the 
 cornu of tbe os hyoides. Diseased portions 
 of the tongue admit of removal with the 
 ligature. (La Motle Chirurgit Obs. 208; 
 Godarl in Journ. de Med. T. 13, p. 66 ; Sir 
 Everard Home , Pract. Obs. on Cancer , p. 
 207 ; Inglis , in Edinb. Med. and Surgical 
 Journ. 1805, No. 1, p. 34.) Sir Everard 
 Horne generally passed a double ligature 
 through the centre of the tongue, behind 
 the diseased portion, and then tied the 
 threads tightly over each half of the organ, 
 so as to make all the part in front of the 
 constriction slough away. 
 
 The whole of the tongue sometimes in- 
 flames, and becomes considerably enlarged, 
 either spontaneously, and without any ap- 
 parent cause, or in consequence of some 
 other disease ; or else from some particular 
 irritation, such as that of mercury, or some 
 poisonous substance. Siegel, a German 
 physician, who was at Paris about the mid- 
 dle of the 17th century, saw a patient in a 
 salivation, whose tongue became so enor- 
 mously enlarged, that the mouth could not 
 contain it. Pimprenelle, an eminent sur- 
 geon of that time, was sent for, and finding 
 that all trials to relieve the affection were in 
 vain, amputated one half of the tongue, 
 with the view of preventing its mortifica- 
 tion. After the wound had healed, it is said 
 the patient could articulate very well. Louis, 
 from whom this fact is quoted, very justly 
 remarks, that the measure resorted to by 
 Pimprenelle was an exceedingly violent 
 one; for he has often seen urgent symptoms 
 occasioned, during a salivation, by a rapid 
 and enormous swelling of the tongue, very 
 quickly yield to bleedings, purgative glys- 
 ters, change of air, and leaving off meren- 
 cury. Two or three facts, confirming this 
 statement, have fallen under my own notice. 
 
 Trincavellius mentions two women, who 
 had considerable enlargements of their 
 tongues. Ono of these patients, who was 
 young, had been rubbed with mercurial 
 ointment even on her head ; and the other, 
 who was about fifty years old, had her 
 tongue attacked with the ravages of the 
 smfuLpox. The excessive swelling of the 
 
TONSILS, 
 
 longue, in both these instances, terminated 
 in resolution. 
 
 When the urgency is such, that an imme- 
 diate diminution of the swelling becomes 
 necessary for the relief of the symptoms, 
 the plan of making one or two deep inci- 
 sions along the tongue is strongly recom- 
 mended. See the cases inserted by De la 
 Malle, in the 5th vol. 4to. of the Mem. de 
 VAcad. Chirurgie , and some others, related 
 by Louis in the paper above cited. 
 
 A man, recovering from a bad fever, was 
 suddenly attacked with a pain in his tongue, 
 followed by a swelling equaliy large and 
 rapid in its formation. In less than five 
 hours the part became thrice as large as it 
 is in its natural state, and in this space of 
 time De la Malle, who had been consulted, 
 had bled the patient successively in his arm, 
 neck, and foot. The man felt very acute 
 pain ; his skin was excessively hot ; his face 
 was swelled; his pulse was hard and con- 
 tracted ; and his look wild. He could hardly 
 breathe: the tongue filled all the cavity of 
 the mouth, and protruded out between the 
 lips. In this very urgent case, the mouth 
 was kept a little more open than the swell- 
 ing of the tongue actually caused it to be, 
 and three parallel incisions were made along 
 this organ, one along its middle, and the 
 other two between the one in the centre 
 and the edges of the part affected. The 
 cuts extended through two-thirds of the 
 preternatural swelling, and had all the good 
 effect which could possibly be desired. 
 There was a great deal of hemorrhage, and 
 the enlargement of the tongue subsided so 
 much, that, an hour after the operation, the 
 patient was able to speak. The next day 
 the incisions had the appearance of being 
 only superficial scarifications, and the tongue 
 was in its natural state. In short, the inci- 
 sions healed in a few days, with the use of 
 a simple gargle. 
 
 De la Malle quotes several other cases, 
 all of which tend to show the success which 
 he met with from this practice in other 
 similar cases. He confirms his own senti- 
 ments, by quoting the testimony of some 
 authors, antecedent to him, who have re- 
 commended the method ; and in particular, 
 he cites a case, in which Job a Meckren 
 adopted this practice, in a case where the 
 tongue, together with the tonsils and palate, 
 became spontaneously affected with a sud- 
 den and dangerous degree of swelling. 
 
 From the preceding observations it may 
 be concluded, that making incisions in the 
 tongue would have saved numerous patients, 
 who have been suffocated in consequence 
 of enormous enlargements of this organ. 
 In the small-pox, the tongue sometimes be- 
 comes immensely swelled ; and it is more 
 than probable, that, in many instances, the 
 employment of the above method would 
 have afforded great relief to patients, whom 
 the disease has been known to have entirely 
 bereaved of the power of swallowing. It 
 is a curious fact, that after the loss of very 
 considerable portions, or even what may be 
 called the whole tongue, patients often re- 
 
 tlSb 
 
 cover the power of speech, mastication, and 
 deglutition. ( Louis in M6m. de VJicad. de 
 Chir. T. 5 ; also, J. Rowland , Aglossostomo- 
 graphie , ou Description d’une Bouche sani 
 langue , laquelle parle, el fait naturellement 
 toutes sts autres functions, l2ino. Saumur , 
 1630. Louis, sur les Maladies de la Langue t 
 Mdmoires de VAcad. de Chir. T. 5 ; also the 
 memoir of De la Malle in the same volume. 
 Encyclopedic Methodique, Fartie Chir. art. 
 Langue. Sir Ecerard Home's Fract. Obs. on 
 C ncer,8vo. Loud. 1805. Langenbeck , JYeue 
 Bibl. B. 2 ,p. 487, 8ro. Hanover , 1820.) 
 
 TONSILS. The tonsils, like all other 
 parts at the back of the mouth, are subject, 
 to different kinds of swelling, which vary as 
 much in their nature as their conseqhences. 
 Some are rapid in their progress, and these 
 are frequently observed to affect persons of, 
 what is termed, a sanguineous temperament. 
 They are also prone to attack young peo- 
 ple, and such as labour bard, and they have 
 all the essential characters of inflammation. 
 
 Other swellings of the tonsils are slower 
 in their progress, occur in damp cold wea- 
 ther, and in indolent, and, what the old 
 physicians used to call, phlegmatic consti- 
 tutions. 
 
 Lastly, another kind of enlargement of 
 the tonsils, which is usually contagious, 
 readily falls into a sloughing, gangrenous 
 state, sometimes extends to the neighbour- 
 ing parts, and too often proves fatal. Hence 
 the various species of angina have been 
 named by some writers inflammatory, ca- 
 tarrhal, and gangrenous. The two first 
 kinds frequently terminate in resolution ; 
 but sometimes the affected tonsils after- 
 ward assume a scirrhous hardness, obstruct 
 respiration and deglutition, so that it be- 
 comes indispensably necessary, either to 
 extirpate the diseased parts with the ligature 
 or knife. 
 
 The cutting away of enlarged tonsils was 
 an operation which was performed by the 
 ancients, and in different ways. Sometimes 
 they tore with their fingers the membrane 
 covering the tonsil, and then pulled this 
 part out of the situation which it occupies 
 between the pillars of the velum pendulum 
 palati. In other instances, in which they 
 experienced too much resistance, M they sei- 
 zed the diseased tonsil with a kind of hook, 
 and then cut it away with a bistoury, which, 
 Paulus iEgineta informs us, was concave on 
 the side tow r ards the tongue. 
 
 The moderns, who, for a long while, were 
 timid in the employ ment of both these me- 
 thods, adopted plans of a more cruel de- 
 scription. The actual cautery was proposed, 
 and some partial success which followed its 
 use, at once established its reputation. 
 Caustics were afterward employed, instead 
 of actual fire ; but the inconvenience of not 
 being able to limit their action, and the 
 hazard of their falling down the oesophagus, 
 soon caused them to be relinquished by all 
 rational practitioners. Then the operation 
 of cutting away the tonsils was revived, and 
 it was performed, sometimes in the manner 
 of the old surgeons, sometimes with various 
 
TONSILS. 
 
 486 
 
 kinds of curved scissors, or knives. Instead 
 of the simple tenaculum used by the 
 ancients, a sort of double one came into 
 fashion. 
 
 Bichat describes the following, as once 
 the common plan : the surgeon is to open 
 the mouth very wide, and depress the tongue 
 with any flat instrument, which is to be 
 held by an assistant. The operator is then 
 to take hold of the diseased tonsil with a 
 tenaculum, and with a common scalpel, 
 having the back half of its blade covered 
 with rag, he now removes as much of the 
 tonsil as ought to be taken away. In com- 
 mon cases, it is deemed sufficient to cut on 
 a level with the pillars of the velum pendu- 
 lum palati. Any other portion, needing re- 
 moval, should next be taken away. The 
 operation being finished, the patient is fre- 
 quently to wash his mouth with proper gar- 
 gles. 
 
 The preceding method was long adopted 
 by Desault. However, one objection is 
 urged against it, viz. that when the end of 
 the knife is conveyed far into the mouth, it 
 may do mischief, not (as has been alleged) 
 to the internal carotid artery, the backward 
 situation of which completely keeps it out 
 of ali danger of being wounded, but to the 
 membranous covering of the palate, in a 
 place not corresponding to the tonsils. De- 
 sault thought this objection was the more 
 forcible, as when the hook is introduced in- 
 to the tonsil, the danger of the above mis- 
 chief is considerably increased by a general 
 spasm, which seems to aifect every part of 
 the mouth. Hence this eminent surgeon 
 used to employ, for the removal of diseased 
 tonsils, an instrument, which w'as first in- 
 vented for dividing cysts of the bladder. It 
 consisted of a sharp-edged blade, which w T as 
 included in a silver sheath. The latter had 
 at its extremity a kind of notch, in which the 
 gland, which was to be extirpated, W'as re- 
 ceived. The rest of the instruments were 
 similar to those commonly used. Desault 
 proceeded as follows: 
 
 1. The patient being seated on a high 
 chair, w ith his head supported on an assist- 
 ant’s breast, he is to open his mouth very 
 wide, and the lowmrjaw is to be kept thus 
 depressed, by some solid body placed be- 
 tween the teeth, and held there by an assist- 
 ant. 
 
 2. The tongue is to be kept down with a 
 broad spatula. 
 
 3. The surgeon is next to take hold of the 
 tonsil with a double hook, w ith which he is 
 to raise and draw it a little towards him. 
 He is then to take the above cystitome, and 
 put the tonsil in the notch, on a level w ith 
 the place where the incision is intended to 
 be made. 
 
 4. When the portion which is to be cut 
 oft', is engaged in the notch, the operator is 
 to draw the part towards him, so -as to 
 stretch it, and press the instrument against 
 it from below upward. The blade being 
 next pushed across the notch, the necessary 
 section is accomplished. When the division 
 is not complete, which is particularly liable. 
 
 to happen, when the diseased gland is of 
 considerable magnitude, the blade is to be 
 drawm back, and the section completed by 
 applying the instrument to the wound, 
 W’hiph it has already made. Sometimes 
 even a third application may possibly be- 
 come requisite. 
 
 5. The patient is to be directed to wash 
 his mouth. Bichat states, that this plan of 
 operating, adopted by Desault, is as simple 
 and easy as the method above related, with 
 the advantage of being safer. Such is the 
 construction of the blade of the instrument, 
 that when it slides across the notch, it 
 presses against, and steadily fixes the parts 
 which are to be d.vided ; an advantage 
 which neither the knife nor scissors have, 
 under the action of which the parts are 
 quite moveable. Hence there is difficulty 
 in cutting them. Wnen the introduction of 
 the instrument from above downward is 
 difficult, it is better to withdraw it ; and, 
 alter turning the notch in the opposite di- 
 rect ion, pass it from below upward. In 
 general, however, the first of these methods 
 is preferable, because the gland, when half 
 cut through, cannot now fall back and db- 
 struct the rima glottidis, so as to bring on 
 danger of a sudden suffocation ; a circum- 
 stance which Wiseman and Moscati saw 
 happen. With a view of preventing this 
 occurrence, Louis recommended the com- 
 mon scalpel to be used, with its edge direct- 
 ed upward, as has been advised for the 
 above instrument ; which latter contrivance, 
 however, being, according to Bichat’s ac- 
 count, more easy and safe, merits the pre- 
 ference. Besides the advantage of fixing 
 the soft parts, which are to be cut, it has 
 that of not contusing them, like most other 
 instruments ot this nature, as, for instance, 
 scissors. The oblique disposition of its 
 blade enables it to divide parts, in the man- 
 ner of a saw. 
 
 This invention, as Bichat allows, is cer- 
 tainly increasing the number of surgical in- 
 struments ; a thing, w'hich all the best mo- 
 dern surgeons endeavour to avoid But it 
 is to be recollected, that this instrument is 
 not exclusively applicable to any particular 
 operation. It may be employed for cutting 
 away the tonsils and uvula ; dividing mem- 
 branous fraena in the rectum, vagina, and 
 bladder; amputating lungous excrescen- 
 ces, polypi of the nose, (if this mode of 
 extirpating them were preferred) and va- 
 rious tumours in general, which are deeply 
 situated in different cavities of the body, 
 where instruments introduced unguardedly 
 might injure parts which should be avoided, 
 or where the base of the tumour should be 
 steadily fixed, when its division is to be ac- 
 complished. The latter object cannot safely 
 be rife, ted by scissors When the base ot 
 t ie tumour is too large to be received in the 
 notch, one part is first to be divided, and 
 then another, till its whole thickness is cut 
 through. 
 
 In England, when a diseased tonsil is to 
 be cut away, surgeons generally prefer a 
 common scalpel 
 

 rot/ 487 
 
 As a general practice, I consider, that 
 the excision of an enlarged tonsil is a better 
 practice than the extirpation of it with a li- 
 guture, which also sometimes answers very 
 well, and, perhaps, in children and timid 
 patients may merit the preference. The 
 chief objections to the ligature are. that its 
 operation is rather tedious, sometimes pro- 
 ductive of a great deal of irritation, and, on 
 the whole, at least as painful as the knife. 
 
 Moscati having once adopted Ibis plan, 
 very severe pain and inflammation ensued; 
 the difficulty of swallowing and breathing 
 ) compelled him to amputate the tumour at 
 the place where the ligature was applied, 
 and all the bad symptoms immediately ceas- 
 ed. Besides, when the ligature is used, 
 there is no oozing of blood from the vessels, 
 a circumstance which tends so much to di- 
 minish the inflammation. The base of the 
 ! swelling is also sometimes broader than its 
 upper part, and does not admit of being 
 properly surrounded with a ligature. And, 
 when it has a narrow base, it can then be 
 so easily removed with a scalpel, or with 
 Desault’s instrument, and with so little pain, 
 that one of the last modes is generally pre- 
 ferable. 
 
 The Hgature, however, has had its advo- 
 cates. Heister recommends it, in certain 
 cases ; Sharp praises it ; and others approve 
 its use ; while the plans ot employing it 
 have been as various as the inventive genius 
 of the different partisans of the practice. 
 Some make use of Levret’s double cannula, 
 which is furnished with a silver wire noose, 
 in which the tumour is to be engaged By 
 twistingthe instrument, the diseased part be- 
 comes constricted ; and this plan being 
 repeated every day, the circulation is inter- 
 cepted, and the gland mortifies, and sloughs 
 away. Some, after putting the noose of a 
 ligature over a kind of tenaculum, hook 
 hold of the tonsil, push the ligature over 
 the enlarged gland, which they tie, without 
 having any means of increasing the con- 
 striction afterward. Some employ Bello- 
 que’s instrument for putting the ligature 
 over the tonsil. Others require no instru- 
 ment whatever for the purpose, and accom- 
 plish the business with their fingers. 
 
 Desault employed an instrument, which 
 the French call un Serrc-ncnid, which is in 
 fact, nothing more, than a long, narrow, 
 round piece of silver, terminating at one end 
 in a little ring, or hole, and, at the other, in 
 a kind of groove or notch. 
 
 The following was Desault’s method of 
 extirpating the tonsils with a ligature. 
 
 1. The patient w T as seated on a high chair, 
 I with his head held back, on an assistant’s 
 ; breast; his mouth was opened very wide, 
 
 his tongue depressed, and the diseased ton- 
 sil taken hold of with a double hook. 
 
 2. The surgeon took the serre-noeud , in 
 which a ligature had been passed, so as to 
 
 | form a noose. The noose was put over the 
 * handle of the hook, which was committed 
 1 to the charge of an assistant, and the noose 
 then pushed over the tonsil, so as to embrace 
 it completely 
 
 i>. The surgeon now drew the ligature 
 strongly towards him, and pushed forward 
 the serre-noeud, so as to product the requisite 
 constriction of the tumour. In general, the 
 ligature was not made very tight the first 
 day. 
 
 4. When the necessary constriction had 
 been made, the double-hook was withdrawn, 
 and the ligature tw isted round the notch, at 
 the outward end of the instrument. 
 
 5 The next day, the gland became unu- 
 sually large, in consequence of the impedi- 
 ment to the return of the venous blood. 
 The ligature was unfastened from the notch- 
 ed end of the instrument and drawn more 
 out, so as to increase the constriction, after 
 which it was again twisted round the notch, 
 
 I his plan w r as followed up t IS the tumour 
 was detached, which usually happened on 
 the fourth, or fifth day. 
 
 Mr. Chevalier, a few years ago, described 
 a particular mode of passing and securing 
 the ligature. He passes a flat spear pointed 
 hook behind the diseased tonsil, and its 
 point is then pushed forward, so as to perfo- 
 rate it through the middle of its base. The 
 needle is then to be withdrawn, and an eye > 
 probe, very much curved, and armed with, 
 a long double ligature, may then be readily 
 passed through the perforation, and brought 
 out at tne mouth, the ligature divided, and 
 one portion tied round the upper half of the 
 tonsil, and the other round the lower. “ A 
 single knot being first made upon one end of 
 the thread, the end so knotted, is to* be 
 brought forward upon the other, and to 
 make a single noose upon itself including 
 the other, and to be drawn tight upon it, 
 close to the first knot. The free end of the 
 thread is then to be passed” through a ring 
 at the end of an instrument for the purpose, 
 and ‘ beingthen held firm, and thering push- 
 ed forward upon the knot, the loop, now 
 formed, may be readily tightened, so as 
 completely to strangulate the diseased part ; 
 and in the same manner, it may be tighten- 
 ed, from Jay to day, till the part is entirely 
 detached.” (See Med. Chi'. Trans. I ol.3,p, 
 80, fyc.) The subject is more intelligible 
 with the plate. 
 
 In cases of angina, the tonsils are some- 
 times suddenly attacked with such a degree 
 of swelling, that respiration is dangerously 
 obstructed. This c^se is analogous to the 
 occasional enormous inflammatory swelling 
 of the tongue, and, if it resist venesection 
 and leeches, the most prompt mode of re- 
 lief is that of making several deep scarifi- 
 cations with a knife in the part. Many 
 cases, confirming the good effects of this 
 practice, have been seen by Langenbeck, 
 (See JVeue Bibl. B. 2, p. 492, fyc.) 
 
 TOPHUS. A swelling, w r hich particular- 
 ly affects a bone, or the periosteum. See 
 JYode. 
 
 TORTICOLLIS, (from torqueo , to Iwdst ; 
 and collvm, the neck.) The wry-neck. See 
 Wry-neck. 
 
 *TOURl\IQU£T. ( French , from lourner, 
 to turn.) An instrument used for stopping the 
 flow of blood into a limb, until some reqm- 
 
I017KNIQUET. 
 
 
 site operation has been performed, or some 
 more permanent plans of checking hemor- 
 rhage have been put in practice. 
 
 The old surgeons used to surround the 
 limb with a band, with which they made 
 such a degree of constriction, that the cir- 
 culation was quite stopped. They also be- 
 lieved, that the pressure of the band was ad- 
 vantageous, in benumbing the limb, and 
 moderating the pain of operations. 
 
 The violent pain and contusion, how- 
 ever, which such a tourniquet occasioned, 
 being frequently followed by mortification 
 and abscesses, surgeons found it necessary 
 to devise some other method of checking 
 hemorrhage. The application of the circu- 
 lar band was first improved, so that it caused 
 less pain, and less mischief to the skin. 'I he 
 limb was surrounded with a very thick com- 
 press, over which the band was placed. 
 Two small sticks were nest put under the 
 band ; one on the inside, the other on the 
 outside of the limb ; and they were twisted 
 till the band was rendered sufficiently tight. 
 It is in this manner, says Dionis, in his 
 Trait6 d- Operations, that carriers tighten the 
 cords which fasten the bales of goods in 
 their carts. A French surgeon, named 
 Morel, is said to have maJe this first im 
 provement in the application of tourni- 
 quets. 
 
 J. L. Petit, in 1718, presented to the Aca- 
 demy of Sciences a tourniquet of his own 
 invention, which was much more perfect 
 than any previously contrived. It consists 
 of two pieces of wood, one of which is su- 
 perior, the other inferior. The inferior 
 piece is about four inches and a half long, 
 and nearly two broad. Its under surface is 
 somewhat concave, while its upper one is a 
 Tittle convex, and the ends are hollowed 
 out. From its middle part rises a round 
 eminence, about seven lines high, and eight 
 and a half broad. The superior piece is 
 almost the same as the inferior one, but 
 rather shorter. The eminence, which as- 
 cends from its middle part, is six lines high, 
 and an inch and a half in diameter. This 
 eminence is hollow within, and calculated 
 to receive a w T ooden screw, the top of which 
 is a sort of button for turning the screw. 
 The grooves of Petit s screw were about 
 four, or live, and each of them four lines in 
 diameter, in order that a half turn might 
 produce the necessary elfect. Lastly, all 
 the pieces of the instrument were fastened 
 together with an iron pin, which went 
 through the middle of the two pieces of 
 wood, and through the w hole length of the 
 screw. This iron pin was riveted under the 
 inferior piece, and at the top of the button, 
 in such a manner, however, that the screw 
 was capable of turning on it, as on a pivot. 
 
 In order to apply this tourniquet, the limb 
 is to be surrounded with a double strap, 
 about four finger-breadths wide, and made 
 of chamois leather, which is the softest ma- 
 terial that can be used. To one end of the 
 strap a double little cushion is fastened, of 
 the same length and breadth as the lower 
 piece of the tourniquet. A narrow com- 
 
 press, or cylindrical pad, is also requisite- 
 for the purpose of compressing the track of 
 the vessels. This compress consists of a 
 very firm roll of linen, covered with cha- 
 mois leather. The ends of a piece of tape 
 are sewed to the outer part of the pad, and 
 thus the tape leaves a passage for the lea- 
 ther strap. By this artifice, the pad can be 
 moved to any situation on the strap, as the y 
 bulk of the limb may require. . The middle 
 of the tape is to be fastened to the outside 
 of the leather strap. The cylindrical com- 
 press, or pad, is to be put over the course of 
 the vessels. The double cushion is to be 
 placed on the opposite side of the member, 
 while the leather strap is to surround the 
 limb. All the different pieces of the appa- 
 ratus are next to be retained by means of 
 the tape, which is to be tied at the side of 
 the cushion. 
 
 The tourniquet is now r to be put over the 
 cushion, on that side of the limb which is 
 furthest from the track of the large vessels, 
 and is to be fastened in this situation with a 
 double band, that has a hole in it for the re- 
 ception of the upper part of the screw. 
 
 In order to make the proper compression, 
 the screw is to be half turned round, from 
 the right to the left. The upper piece of the 
 tourniquet becoming now further from the 
 lower one, the double band draws the pad, 
 and presses it against the vessels, so as to 
 make the due degree of compression. 
 
 The following are the advantages, attend- 
 ing the use of Petit’s tourniquet : 1. It com- 
 presses the lateral parts of the limb less 
 than the tourniquet previously in use. 2. It 
 requires the aid of no assistant, either to 
 hold, tighten, or loosen it. 3. The operator 
 is able of himself to stop the flow of blood 
 in the artery, by means of the screw. 4. 
 When there is any danger of hemorrhage 
 after an operation, this kind of tourniquet 
 may be left on the limb, and, in case of the 
 bleeding coming on, the patient, if no one 
 be at hand, can tighten the instrument him 
 self, as much as is necessary. 5. The con-’ 
 striction, which this tourniquet produces, 
 does not create any danger of mortification, 
 because it does not altogether stop the flow 
 of blood through the collateral arteries. 
 
 The tourniquet here described is certainly 
 very complex, when compared with that, 
 which is used by the best modern practi- 
 tioners; but, still it is the original of the 
 latter, and both are constructed on the same 
 principles. All the pieces of modern tour- 
 niquets are kept connected together, and in- 
 stead of two pieces of w r ood, used by Petit, 
 there is contrived a brass bridge, which is 
 capable of being elevated, or depressed, by 
 means of a screw, made of the same metal 
 Over this bridge a very strong band pro- 
 ceeds, and by passing under tw o little roll- 
 ers, at each end of the bridge, it .always re- 
 mains connected with the instrument. A 
 convex firm pad is sewed to the band, and 
 put immediately over the artery, where the 
 instrument is applied. There are no cush- 
 ions for the opposite side of the limb under 
 the screw ; but. a thick piece of leather 
 
TREPHINE. 
 
 4S9 
 
 through which the baud proceeds in two 
 places, is always situated under the lower 
 surface of the brass, and serves to prevent 
 any bad effects of its pressure. It is usual 
 also for the surgeon to fold some rag, and 
 to put it in this situation, at the time of ap- 
 plying the instrument. (See Hemorrhage.) 
 The interruption of the circulation in parts 
 of the body by the tourniquet, has been tried 
 as a means of relieving diseases. (See G. 
 Kellie, Obs. on the Medical Effects of Com- 
 pression by the Tourniquet, 8vq. Edinb. 1797.) 
 
 TRACHEA, Wounds of. See Throat. 
 
 TRACHEOTOMY. (from r^ua, the 
 windpipe, and re/uvee, to cut.) The opera- 
 tion of cutting an openinginto the windpipe 
 for various surgical purposes. See Bron- 
 chotomy. 
 
 TREPAN, (from rpi >7r*u, to perforate.) 
 Trepanum ; Terebellum ; Modiolus. A cir- 
 cular saw, by means of which the skull is 
 perforated in the operation called trepan- 
 ning, or a circular portion of any bone may- 
 be sawn out. It bears a considerable re- 
 semblance to the well-known instrument 
 named a wimble, and is worked in the same 
 manner. Formerly, the saw was sometimes 
 made of a conical shape ; (see Abapliston ) 
 but this construction rendered the action 
 of the instrument difficult. In this country, 
 the trepan is now superseded by the instru- 
 ment called a trephine, which has a different 
 handle, and is not worked in the same way. 
 On the continent, however, the trepan still 
 has the preference. 
 
 TREPHINE. The instrument now com- 
 monly preferred for perforatingthe cranium, 
 for purposes which I shall presently explain. 
 It consists of a simple cylindrical saw, with 
 a handle placed transversely, like that of a 
 gimlet ; and, from the centre of the circle, 
 which the teeth of the saw describe, a sharp 
 little perforator projects, named the centre- 
 pin. The upper part of the centre-pin is 
 made to screw in a corresponding hole at 
 the inside of the top of the saw, and is ca- 
 pable of being taken out, or put in, at the 
 surgeon’s option, by means of a little key 
 for the purpose. Its use is to fix the tre- 
 phine, when it is first applied, that is, before 
 the teeth of the instrument have made a 
 sufficient circular groove, in w hich they can 
 steadily work. When this has been ac- 
 complished, the centre-pin must always be 
 removed; because now it is not only not 
 needed, but if left, it would retard the pro- 
 gress of the operation, and inevitably wound 
 the dura mater and brain, when the teeth of 
 the saw had cut to a certain depth through 
 the cranium. My trephines have their 
 centre-pins contrived to slide up, or dow n, 
 and to lie fixed in either position by turning 
 a little screw. This method seems to me 
 both ingenious and convenient. 
 
 The cylindrical part of the trephine is often 
 termed the crown of the instrument. The 
 surgeon should have at least two or three 
 cylindrical saws of various sizes ; for it is 
 always a commendable rule, never to saw 
 away any more of the cranium than is abso- 
 lutely requisite for the accomplishment of 
 Vo l. II 
 
 some rational objpct. There is no occasion, 
 however, for having any more than one han- 
 dle, which maybe made to screw on any of 
 the saws. 
 
 Trephines are also occasionally applied to 
 other bones, besides those of the cranium. 
 In the articles Antrum , Caries, Exostosis , 
 Fractures of the Sternum, JYecrosis, Spina 
 Ventosa, other cases are mentioned, in which 
 the employment of these instruments some- 
 times becomes proper. 
 
 It is not always desirable to remove a com- 
 plete circular portion of the cranium, the 
 taking away a piece of smaller size, and of 
 a different shape, being frequently much more 
 advantageous. Some surgeons, i understand, 
 who object to removing any unnecessary- 
 quantity of the cranium, have been in the 
 habit of employing a trephine, terminating 
 only in a semi-circular, instead of a circular 
 saw, by which means they can often cut 
 across the base of a depressed portion of the 
 skull, and take it away, without any occasion 
 for removing also a circular piece of bone. 
 An i -ftrument of the latter kind may cer- 
 tainly be sometimes useful. 
 
 The saws, however, which Mr. Hey has 
 described, should constantly be kept in every 
 case of trephining instruments. This prac- 
 tical writer remarks, that “the purposes for 
 which any portion of the cranium is remo- 
 ved, are, to enable the surgeon to extract 
 broken Iragments of bone, to elevate what 
 is depressed, and to afford a proper issue to 
 blood or matter that is, or may be, confi- 
 ned, kc. 
 
 “ When a broken fragment of bone is 
 driven beneath the sound contiguous part of 
 the cranium, it frequently happens, that the 
 extraction cannot be executed without remo- 
 ving some of the unbroken part, under which 
 the fragment is depressed. This might gene- 
 rally be effected with very little loss of sound 
 bone, if a narrow portion of that which lies 
 over the broken fragment could be removed. 
 But such a portion cannot be removed with 
 the trephine. This instrument can only saw 
 out a circular piece. And as, in executing 
 this, the central pin of the saw must be placed 
 upon the uninjured bone, it is evident that a 
 portion of the sound bone, greater than half 
 the area of the trephine, must be removed 
 at every operation. When the broken and 
 depressed fragment is large, a repeated ap- 
 plication of the trephine is often necessary, 
 and a great destruction of sound bone must 
 be (he consequence. 
 
 “ When the injury consists merely of a 
 fissure with depression, a small enlargement 
 of the fissure would enable the surgeon to 
 introduce the point of the elevator, so as to 
 raise the depressed bone. But a small en 
 largement of the fissure cannot be made with 
 the trephine. When it is necessary to apply 
 the elevator to different parts of the de- 
 pressed bone, a great deal of the sound cra- 
 nium must be removed, where a very narow 
 aperture would have been sufficient. 
 
 li The same reasoning will apply to the 
 case of openings, made for the purpose of 
 
I 
 
 TREPHINE. 
 
 
 giving a discharge to extravas&led blood or 
 matter. 
 
 “ If a saw could be contrived which might 
 be worked with safety in a straight, or gently 
 curvilineal direction, it would be a great ac- 
 quisition to the practical surgeon. Such a 
 saw I can now with confidence recommend, 
 after a trial of twenty years, during which 
 time I have rarely used the trephine in frac- 
 tures of the skull. Its use has been adopted 
 by my colleagues at the General Infirmary 
 in Leeds ; and will be adopted, I hope, by 
 every surgeon who has once made trial of 
 it.” Mr. Hey next informs us, that the in- 
 strument was first shown to him by Dr. 
 Cockell, of Pontefract ; but that there is a 
 saw formed on the same principle in Scul- 
 tetus’s Armamentarium Chirurgicum. The 
 saws alluded to are very short ones, fixed at the 
 end of a longish straight handle ; theTr edges 
 are made eiihe> straight or semicircular. The 
 latter construction qualifies the instrument 
 for cutting in a curvilineal direction, which 
 is often proper. The edge of the saw should 
 always be made a little thicker than the rest 
 of the blade, by which means it will work 
 in the groove, which is cut with more faci- 
 lity. 
 
 Saws made on the principle just described, 
 are also oi infinite use in cutting away dis- 
 eased portions of other bones besides the 
 skull, exostoses, &c. In cases of necrosis, 
 when a dead part of a bone is quite wedged 
 in the substance of the surrounding new 
 bony matter, Mr. Hey’s saws may often be 
 advantageously employed tor cutting away 
 the parts, which mechanically prevent the 
 detachment of the dead pieces. The saws 
 invented by Mr. Machell and Professor 
 Graefe, are also highly ingenious, and parti- 
 cularly merit attention, when there is very 
 little room for the working of the instrument, 
 and the bone to be cut lies rather deep. 
 They are wheel-like saws, turned by ma- 
 chinery. 
 
 Besides trephines of various sizes, and the 
 saws just now noticed, the surgeon should 
 also take care to have in his case of trephi- 
 ning instruments a little brush for occasion- 
 ally cleansing away the particles of bone 
 from the teeth of the saw in the progress of 
 the operation 3 a pair of forceps for extract- 
 ing the round piece of bone after it has been 
 detached by the saw ; a lenticular for remo- 
 ving any inequalities which may present 
 themselves round tlfte sawn edge of the cra- 
 nium after the circular piece is taken out j 
 a raspatory for the same purpose, and also 
 for scraping the bone in order to see whether 
 it will bleed, which is a eircumsta'gce in some 
 cases very important to be attended to j 
 (see Head , Injuries of ,*) a largish common 
 scalpel for dividing the scalp, &i.c. ; and some 
 elevators for raising depressed pieces of 
 bone. 
 
 The common elevator is now generally 
 used by all the best English surgeons ; but 
 several others have been proposed, as, for 
 instance, the tripod elevator ; and another 
 invented by J. L. Petit, and afterward im- 
 proved by M. Louis. 
 
 Before beginning the description of Che 
 operation, I think it highly proper to remind 
 ttie reader of what has been so forcibly dwelt 
 upon in the article. Head, Injuries of ’ — that, 
 generally, the removal of pressure off the 
 brain, w hich pressure must also actually oc 
 casion dangerous symptoms, can form the 
 only true and vindicate reason for employ- 
 ing the trephine, or sawing away any portion 
 of the skull. There are very few exceptions 
 to this remark : it may, indeed, be now and 
 then proper to saw away the bony edges- 
 around some fungous excrescences, which 
 grow from the dura mater, and make their 
 way outward, by occasioning ari absorption 
 of the part of the skull immediately over 
 them. (See Dura Mater.) Ii may also be 
 sometimes proper to saw out diseased por- 
 tions of the skull, though, it must lie confess 
 ed, that in general their separation should bo 
 left to time and nature. 
 
 In the records of surgery, innumerable 
 facts may be consulted, where the prudent 
 and judicious employment of ihe trepan has 
 effected wonderful cures, and been the only 
 thing by which, the patients’ lives could pos 
 sibly have been saved. Ihe benefit which 
 the operation brings about, is also sometimes 
 so sudden and >stouishirig, that in no in- 
 stance does the interposition of the surgical 
 art display itself to greater advantage. The 
 immediate restoration of sight by the de 
 pre-siun, or extraction of an opaque sub- 
 stance from (he eye, is not more beautiful 
 and striking, than the instantaneous conitnu- 
 ideation of the intellectual faculties, and of 
 the powers of speech, of feeling, &.c. toge- 
 ther with voluntary motion, to a person ly- 
 ing in an apparently lifeless state from an in- 
 jury of the head. The utility of the trepan 
 is occasionally manifested even in this de- 
 gree. In the valuable essay of Mr. Aberne- 
 thy on injuries of the head, a case may be 
 seen, in which the patient, who had been in 
 a condition almost bereft of animation, rose 
 up and spoke the instant the exlravasated 
 blood was removed from the surface of the 
 brain. And among the wounded at the bat- 
 tle of Waterloo, there was a soldier of the 
 44th regiment, whose case is of equal inte- 
 rest. He had been struck by a musket-ball 
 on the right parietal bone, which was expo- 
 sed, but had no appearance of being fractu- 
 red. As however the symptoms of com- 
 pression were urgent, and (he patient w as in 
 nearly a lifeless state, I conceived it right to 
 apply the trephine to Ihe part on which the 
 violence had acted. I had not sawn long 
 before the external t * ble came away in the 
 hollow 7 of the trephine, leaving ihe inner 
 table behind, which was not only splintered 
 but driven at one point more than half an 
 inch into the membranes and substance of 
 the brain. No sooner were the fragments 
 taken out with a pair of forceps, than the 
 man instantly sat up in his bed, looked round , 
 and began to speak with the utmost rationali- 
 ty. It is a most extraordinary fact, that this 
 patient got up and dressed himself (he same 
 day, without leave from the medical officers, 
 and never had a bad symptom afterward. 
 
TREPHINE. 
 
 ‘191 
 
 Immediately the operation was finished, the 
 temporal arteries were opened, and some 
 purgative medieines exhibited. 
 
 In a case of fungus of the dura mater, 
 with diseased bone, mentioned by Schmuck 
 er, the trepan was applied eleven times in 
 less than a month, and the operation U3ed to 
 cause so little indisposition, that the patient 
 hardly ever required to go to bed afterward, 
 and, on one occasion, actually went to mar- 
 ket an hour after its performance. ( Wahrneh- 
 w 1 tnvngen, D. I,;?. 456.) 
 
 Let not the young surgeon, however, draw 
 from these dagzling cases of success an im- 
 moderate solicitude to perform the opera- 
 tion ; for it should never be undertaken but 
 in the most pressing circumstances, and 
 when the symptoms unequivocally show 
 that a dangerous degree of pressure on the 
 brain exists. 1 recollect an unfortunate ex- 
 ample, in which the late Mr. Ranisden, of St. 
 Bartholomew’s Hospital, ventured to saw out 
 a portion of the frontal bone for a mere tong- 
 continued pain in the part : the patient was 
 attacked with inflammation of the dura ma- 
 ter, and perished in three or four days. We 
 may therefore conclude, that the operation 
 is not itself exempt from danger j and it is 
 certain, that it ought never to be resolved 
 on without deep cons deration. “ Gravis 
 tam&n satis est operatio , ut nunquam , nisi in- 
 dicaliones sujjwienles admit, instil ui debet ” 
 (Callisen Syst. Chir. Hodiern. Tom. I, p. 
 658.) 
 
 The trepan, or trephine, is never neces- 
 sary in injuries of the head, except for the 
 purpose of relieving the brain from pressure. 
 Such pressure may be caused by a depressed 
 portion of the cranium, or it may be pro- 
 duced by an extravasation of blood, or the 
 lodgment of matter, betwixt the skull and 
 the dura mater. The chief danger of con- 
 cussion, when the accident is not directly 
 or soon fatal from the disorganization and 
 mischief done to the brain, depends upon 
 > the consequent inflammation of this organ, 
 and therefore can be little likely to be be- 
 nefited by the use of the trepan. If the 
 operation becomes proper in such a case, it 
 is when an abscess has formed under the 
 cranium, and when the confined matter it- 
 self creates bad symptoms by its pressure 
 on the brain. This state of things, how- 
 ever, cannot come on till after the inflam- 
 mation of the brain and its membranes has 
 prevailed a certain time, and it is always 
 accompanied with a detachment of the pe- 
 ricranium and a puffy tumour of the scalp 
 or, if there be a wound of the latter part’ 
 immediately over the abscess, the lips of 
 the injury suddenly acquire an unfavour- 
 able appearance, arid lose their vermilion 
 „ colour. I he patient has also had much 
 preceding febrile disorder, pain and tension 
 over the whole head, redness and turges- 
 cence of the eyes, and generally more or 
 less delirium. When the matter is forming, 
 there are usually some rigours, and, as soon 
 as it is formed, the patient falls into a co- 
 matose state, and paralytic symptoms show 
 { themselves. Here the urgency for the 
 
 i 
 
 prompt application of the trephine is very 
 great, and the patient’s chance of living is 
 almost essentially connected with the imme- 
 diate performance of the operation. This 
 important case has been particularly dwelt 
 upon in the writings of Mr. Pott. 
 
 In the article, Head, Injuries of, I have 
 laid down the most remarkablasymptoms of 
 concussion, and compression of the brain, a 
 subject which every surgeon should study 
 with earnest attention, before he ever pre- 
 sumes to employ the trepan. For, some- 
 times these accidents are extremely difficult 
 to be discriminated ; sometimes they exist 
 together in the same individual ; a compli- 
 cation which is peculiarly embarrassing; and 
 in every instance where the symptoms are 
 those of concussion, the operation, so far 
 from being indicated, would be a step of 
 all others the most likely to do harm, by in- 
 creasing the irritation and inflammation of 
 the brain and its membranes. A fall upon 
 the back, or upon the head, occasions a di- 
 rect concussion of the brain, and the shock 
 not being materially weakened by the in- 
 tervention of any yielding elastic structure, 
 is the more dangerous. When«a person has 
 fallen from a certain height, and pitched on 
 his head, his back, the buttocks, the knees, 
 or even the soles of the feet; when he has 
 been instantly deprived of his senses, and 
 then by degrees recovered them and come 
 to himself again ; the fact of his having suf- 
 fered cory^ussion of the brain is clear and 
 indisputable. Concussion has likewise taki n 
 place, though in a slighter degree, when the 
 patient has been only stunned by the fall, 
 and experienced a sensation of sparks. But 
 a multitude of degrees separate this feeble 
 concussion from that in which the substance 
 'of die brain is instantaneously disorganized, 
 so that (lie patient has not the possibility of 
 recovery. 
 
 The symptoms of concussion of the brain 
 are attended with coma, and the compres- 
 sion of this organ by an extravasation is 
 also accompanied with lethargic heaviness. 
 How then is the surgeon to ascertain, 
 whether the comatose disorder arises from 
 one or the other of these aflectious ? 
 
 Here in order to avoid repetitions, I beg 
 leave to refer to the observations already 
 made in the article quoted above. But there 
 is one criterion of such first-rate importance, 
 that it may prevent innumerable fatal mis- 
 takes, and, indeed, without the continual re- 
 collection of it, no man ought to be rash 
 enough to interfere with this dark and ab- 
 struse part of surgery. On (bis account, f 
 shall mention it here, notwithstanding it has 
 been already noticed elsewhere. If the pa- 
 tient is knocked down and stunned directly 
 by the blow, and remains in a state of insen- 
 sibility, these primary symptoms are ascri- 
 babie to the concussion. On the contrary, 
 when the coma and loss of sense do not 
 take place till an hour or two alter the 
 blow, they are to be imputed to an extrava- 
 sation. 
 
 The shock given to the brain by concus- 
 sion must, like every other impulse comma- 
 
TREPHINE. 
 
 192 
 
 nicated, continue to diminish until it ceases 
 altogether. If at the very time of the blow, 
 the shock has not been forcible enough to 
 produce alarming symptoms, such symptoms 
 will not afterward come on when their cause 
 is weakened. Hence the reason why com- 
 pression can be distinguished from concus- 
 sion of the brain, when there has been an 
 interval of sense between the receipt of the 
 blow and the occurrence of the bad symp- 
 toms. But the distinction of the symptoms 
 into primary and consecutive cannot be 
 made when concussion and extravasation 
 exist together. 
 
 Having made these few remarks on con- 
 cussion arid compression of the brain, re- 
 marks which seemed necessary before I 
 entered into a description of the operation 
 of the trepan, I shall next premise some 
 observations relative to contusions and 
 fractures of the skulj, cases on which the 
 most erroneous opinions have been enter- 
 tained. It is true, that l have in another 
 place (see Head , Injuries of ) considered the 
 subject; but it may be better to recapitulate 
 certain points here, because they have such 
 immediate # connexion with the application of 
 the trephine. 
 
 Contusions of the head not unfrequently 
 occasion a small kind of tumour which is 
 soft in the centre, but hard and resisting at 
 the circumference, especially when the vio- 
 lence has been considerable. Now the ease 
 with which the centre or seat of the extra- 
 vasated fluid admits of being depressed, 
 while the circumference remains hard and 
 elevated, is extremely apt to give rise to the 
 belief, that a fracture with depression has 
 happened. The true nature of this accident 
 was first clearly explained by J. L. Petit, 
 and since his time the proper cautions not 
 to fall into a mistake concerning it, have 
 been laid down by tbe generality of surgical 
 \v iters. 
 
 Often nothing is more obscure, than the 
 diagnosis of fractures of the craniu m : their 
 existence indeed can only be made out with 
 certainty, when they can be felt or seen. 
 Thus a fracture of the skull, attended with a 
 wound of the scalp, and exposure of the 
 bone, shows itself in the form of a fissure 
 more or less wide and extensive, and taking 
 various directions. The accident may also 
 be known by the touch even when the soft 
 parts continue entire, particularly if the frac- 
 t ire is accompanied with splinters, or the edges 
 of the fissure are materially separated. When 
 there are many splinters entirely detached, 
 a crepitus will likewise serve to explain the 
 nature of the accident; but unassisted by 
 these symptoms, imparted to him by the 
 sight, the hearing, or the touch, the prac- 
 titioner cannot at once offer a decided 
 opinion as to whether a fracture exists or 
 not. 
 
 In order to procure more positive infor- 
 mation, would it be right and judicious to 
 make several incisions and uncover the 
 bone ? But here tbe surgeon would be em- 
 barrassed in the very commencement of his 
 proceedings : for how would he be able to 
 
 judge where the kite should be applied:' 
 Why also should he resort to an useless and 
 painful operation, which (to say the best of 
 it) could only render the patient’s cure more 
 distant ? 
 
 The symptoms indicating compression of 
 the brain, can alone justify an examination 
 of the fracture. These symptoms also must 
 be urgent and alarming ; for when they pre- 
 vail in a slight degree, bleeding and evacua- 
 tions promise more benefit than any opera- 
 tion on the skull, and consequently all exa- 
 mination of the part supposed to be broken, 
 must be unnecessary. The precept too 
 commonly given, to cut through the scalp 
 for the purpose of bringing tbe fracture into 
 view, will no longer be matter of surprise, 
 when it is known, that among some sur 
 geons, the operation of the trepan is a thing 
 of course in all fractures of the cranium. 
 
 Even w hen the cranium has been denu- 
 ded, so that the sight can convey due infor- 
 mation respecting the solution of conti- 
 nuity in the bone, care must be taken not to 
 be deceived by a suture, or by the groove of 
 a vessel. In cases of doubt, a modern sur- 
 gical author advises us to scrape the outside 
 of the bone ; and he tells us, that if after the 
 removal of the external scale, the fissure yet 
 appear, and a thread of blood be seen at its 
 outer part, no doubt exists of its being a real 
 fissure. As however making this examina- 
 tion can answer no purpose, except with a 
 view to determining the place where the 
 trepan should be applied, I cannot recom- 
 mend the plan, except where the sj’rnptoms 
 are such as to render this information de- 
 sirable. On the contrary, it appears to me, 
 that all examinations of the bone, made 
 seemingly from mere curiosity, and without 
 any true surgical object, should be depreca- 
 ted as rash and hurtful. 
 
 The danger of fractures of the skull does 
 not depend upon tbe simple solution of con- 
 tinuity : it bears altogether a relation to the 
 concussion and compression of the brain, 
 with which the injury of the bone may be 
 complicated. The pressure which is caused 
 by depressed splinters of bone, is less alarm- 
 ing, inasmuch as the cause of the compres- 
 sion is easy of removal. The pressure arising 
 from extravasated fluid is far more serious, in 
 consequence of the difficulty of ascertaining 
 positively the existence and precise situation 
 of such extravasation. 
 
 The seat of the extravasation is sometimes 
 between the skull and the dura mater, which 
 has been detached from the bone. More 
 frequently it occurs either between the dura 
 mater and tunica arachnoides ; in the sub- 
 stance of tbe brain ; or else in the ventri- 
 cles. The quantity of extravasnted fluid is 
 generally less in those extravasations, which 
 are situated between tbe dura mater and the 
 skull. The extravasations which are formed 
 in the substance of the brain itself, are not 
 only more considerable, but also, as they 
 mostly depend upon concussion, are more 
 alarming than effusions on the surface of the 
 dura mater. It is indeed extremely difficult, 
 if not impossible, to ascertain the situation 
 

 of the extravasated fluid. In such cases the 
 trepan is likewise of no use ; while concus- 
 sion, when so violent as to produce internal 
 extravasation, is invariably fatal. In extrava- 
 sations between the dura mater and the skull, 
 which are almost the only cases of the kind 
 to which surgery can administer relief, when 
 the effused fluid lies under a part of the skull 
 accessible to the trepan, the extravasated 
 fluid is almost always small in quantity. 
 The danger, however, is not the less : ten or 
 twelve drops of fluid are sometimes enough 
 to produce a fatal compression. When the 
 extravasation Tias happened in the substance 
 of the brain, the compression is far more 
 perilous : in short, it may be said to prove 
 with very few exceptions, certainly mortal. 
 The danger is not so great, when the extra- 
 vasation is situated between the skull and 
 dura mater. 
 
 The lethargy, the degrees of which in- 
 crease from mere drowsiness into the most 
 perfect coma ; and the paralysis of the op- 
 posite side of the body to the seat of the ex- 
 travasation ; are the characteristic symptoms 
 of this accident in cases of injury of the 
 head. Having explained elsewhere (see 
 Head, Injuries of) some other symptoms, 
 such as stertorous respiration, dilated pupils, 
 &c. which usually indicate pressure on the 
 brain, it is unnecessary here to dwell upon 
 them. The subsequent increase of the coma, 
 and paralytic affections, and the gradual 
 augmentation of their intensity, serve to 
 render these symptoms distinguishable from 
 others, which are suddenly brought on by 
 concussion. But there are instances, as every 
 man of experience knows, in which concus- 
 sion ruptures the blood-vessels, and produces 
 an extravasation of blood. In this circum- 
 stance, it is obvious that the symptoms of 
 compression are blended with those of con- 
 cussion. The symptoms proceeding from 
 the latter cause always diminish in propor- 
 tion to the time, which has elapsed from the 
 moment of the injury ; w'hile those of com- 
 pression succeed, and on the contrary, in- 
 crease in intensity, in proportion as the 
 quantity of extravasated fluid becomes more 
 considerable. Notwithstanding these dis- 
 tinctions, however, it must be acknowledged, 
 tbat there are many cases in which the sur- 
 geon is obliged to remain in doubt, with re- 
 gard to the particular cause of the symptoms. 
 This indecision is the more embarrassing, 
 because the operation of the trepan is neces- 
 sary in cases of extravasation, but useless in 
 those of concussion. Even when extrava- 
 sation is known to exist, the practitioner re- 
 quires more information ; for he ought to 
 Know the precise situation of the effused 
 fluid. It is true, indeed, that paralysis of 
 one side of the body generally indicates the 
 pressure to be upon the opposite hemisphere 
 of the brain. But what surgeon would ven- 
 ture to follow the practice advised by Van 
 Swieten,and apply to the suspected side o£ 
 the head three crowns of the trepan ? Possi- 
 bly not one of them might fall on the situa- 
 tion of the extravasated fluid. When the 
 - c kul! is broken, tbe extravasation exist? on 
 
 493 
 
 the same side as the fracture. When it is the 
 effect of concussion, or when the breach of 
 continuity in the skull is what is termed a 
 counter-fissure ; the effusion is generally on 
 the side of the head most remote from tbe 
 blow. If the pressure is caused by a detach- 
 ment of the internal table of the skull, the 
 nature of the case cannot be ascertained be- 
 fore tbe operation of the trepan has been 
 performed on the part of the skull, upon 
 which the violence has acted. When there 
 are two extravasations ; one depending upon 
 a fracture, and situated immediately under 
 it, between the dura mater and the skull ; 
 the other arising from concussion, and situa- 
 ted at some point directly opposite, either 
 between the dura mater and tunica arach- 
 noides, or within the substance of the brain 
 itself; paralysis may occur on tbe same side 
 as the fracture, and hence it may be inferred, 
 that the palsy does not always take place on 
 the side opposite to the extravasation. But, 
 says Richerand, an examination of the body 
 quickly proves, that the case does not devi- 
 ate from the common rule. The extravasa- 
 tion produced by concussion, being almost 
 invariably more considerable than that 
 caused by a fracture, accounts for the ex- 
 tension of the palsy to the same side of the 
 body. Sometimes the side which is not pa- 
 ralytic, is effected with convulsions ; the 
 pulse is full and hard ; and the respiration 
 stertorous ; in short, the symptoms are analo- 
 gous to those caused by apoplexy. 
 
 The evacuating plan, recommended for 
 the treatment of concussion, (see Head , 
 Injuries of) is all that can be done, when 
 every thing is uncertain relative to the situa- 
 tion of the extravasation. It is all that can 
 be done in those frequent instances, where 
 the effusion has taken place in the substance 
 of the brain, so that it cannot possibly be 
 voided. The trepan then is indicated only 
 when there is an extravasation between the 
 dura mater and the bone, the fracture being 
 situated at a part of tbe skull accessible to 
 instruments, and not at the base. We will 
 not here dwell upon the doubtful example, 
 w here the fluid lies between the dura mater 
 and the arachnoides. But, are the cases, 
 which have just been described, as frequent 
 as they are supposed to be ? Cannot the 
 effused blood be sometimes discharged 
 through the interspaces of the broken pieces 
 of bone ? Is the trepan usually necessarv 
 for the relief of injuries of the head, as 
 Quesnay, Pott, and the members of the 
 French Academy of Surgery maintained ? 
 Many of the best surgeons now think not — 
 The operation is often useless, and some- 
 times dangerous. I believe that it should be 
 limited to a small number of cases, in which 
 not only the existence and situation of the 
 pressure are known, but in which the 
 symptoms, arising from this cause, are ur- 
 gent and dangerous, and the pressure can 
 be removed by no other means. 
 
 Richerand contends, that extravasations 
 between the skull and the dura mater, so 
 considerable as to produce compression of 
 the brain, and render the trepan necfessarv. 
 
TREPHINE. 
 
 494 
 
 are much less common than many surgeons 
 think. Even when they do occur, the dura 
 mater is always detached to a certain extent, 
 and, according to this writer, if the bone is 
 much broken, the interspaces of the frag- 
 ments are quite sufficient for the evacuation 
 of the effused blood. The following case is 
 quoted in proof of this observation. A wo- 
 man injured her head by falling from a 
 height of fifteen feet. The fracture reached 
 the whole breadth of the skull, so that when 
 the os frontis was taken hold of with one 
 hand, and the os occipitis with the other, 
 the two halves of the cranium admitted of 
 being manifestly moved and separated. 
 Blood issued from the fissure, the edges of 
 which were kept apart by a small wedge of 
 wood in such a manner, that the pulsations 
 of the brain were visible. On the sixth day, 
 as nothing was discharged from the fissure, 
 the bit of wood w'as removed, and on the 
 fifty-second the wound had completely heal- 
 ed without any exfoliations. On the seventy- 
 second, the patient was discharged from the 
 H6tel-Dieu, perfectly cured. ( JYosogr . Chir. 
 T. 2, p. 292, Edit. 3.) 
 
 Thus we see, that the trepan is not always 
 necessary in injuries of the head with frac- 
 ture of the skull, notwithstanding there may 
 be some degree of bleeding from the edges 
 of the bone. This doctrine is very different 
 from what is taught in t|ie memoirs of M. 
 Quesnay in the first volume of those of the 
 French Academy of Surgery. Desault in 
 the last years of his practice abandoned the 
 operation of the trepan altogether. It had 
 been remarked for many years, that, in the 
 H6tel-Dieu, this operation was almost always 
 unsuccessful ; a circumstance, which once 
 excited a suspicion, that the foul air of the 
 wards of that establishment might have a 
 share in bringing on the unfavourable event. 
 I shall not here expatiate on the bad effect 
 of the atmospheric air on the membranes of 
 the brain; a thing, of which B. Bell seems 
 to have convinced Richerand. 
 
 When the skull is fractured by a blow', or 
 fall, and the case is a simple fissure, the 
 trepan ought to be applied upon the solu- 
 tion of continuity, if the symptoms indicate a 
 dangerous degree of pressure on the brain, and 
 the edges of the fracture are not sufficiently 
 separated to let the extravasated lluid es- 
 cape. 
 
 When the detached portions of bone are 
 depressed, so as to compress the brain, the 
 operation is still requisite, if they cannot 
 be elevated by other means. But Richerand 
 maintains, that a positive indication for tre- 
 panning is not frequent, either because it is 
 difficult to judge of the existence and situa- 
 tion of extravasations, or because extrava- 
 sated fluids readily escape through the in- 
 terspaces of the fragments, when there is a 
 splintered fracture. Such facility is also 
 increased, when one of the portions of 
 broken bone is totally detached, so that it 
 can be removed, leaving an aperture equi- 
 valent to what would be produced by the 
 , application of the trepan. 
 
 When the operation is determined on, it 
 
 is more convenient to have the head sha- 
 ved : indeed, this is often done immediately 
 the surgeon is called, in order that he may 
 have abetter opportunity of seeing what parts 
 of the scalp have been struck ; for it Is in 
 such situations that he has most reason to 
 apprehend fractures of the bone, or extra- 
 vasations beneath it. If, however, the 
 violence has occasioned a large wound, or 
 laceration of the scalp, the practitioner, 
 knowing where the force has been applied, 
 is frequently content with having a little of 
 the hair shaved off the parts surround- 
 ing the injury. All that need be said on 
 this subject is, that it is always better to 
 have enough of the hair taken away, to 
 afford the surgeon an uninterrupted oppor- 
 tunity of examining the scalp freely, and 
 doing whatever may be necessary. The loss 
 of a little hair is of very little consequence, 
 while the concealment of the seat of a de- 
 pressed fracture, or extravasation, might 
 lead to fatal consequences. 
 
 When the propriety and necessity of tre- 
 phining are fully indicated, provided the 
 wound, or laceration of the scalp, should 
 not have exposed a sufficient surface of the 
 bone for the application of the crown of the 
 trephine, an adequate dilatation of such 
 wound ought immediately to be made. If, 
 in the situation of the blow, there should 
 only be a contusion, or a lump, unattended 
 with any wound, a division of this part of 
 the scalp is to be made by carrying the 
 knife quite down to the bone. In those 
 cases, in which the swelling occasioned by 
 the violence is considerable, and attended 
 with the sensation of a crepitus ; as well as 
 in other instances, in which there is only 
 a contusion, under which a fracture and dis- 
 placed pieces of bone may be felt ; the 
 scalp must be divided in the same manner, 
 only with greater caution, lest the point of 
 the knife should insinuate itself through the 
 fracture, and do mischief to the dura mater 
 and brain. 
 
 Authors recommend the shape of the in- 
 cision to be different according to the kind 
 of fracture, and the parts of the head, on 
 which the violence has operated. When 
 the whole extent of the injury can be 
 brought into view, by means oi an incision, 
 having the form of a letter T, the surgeon 
 should be content with such a division ; but 
 if this be not sufficient, he may give it a 
 crucial shape. When the trephine is to be 
 applied to the squamous part of the temporal 
 bone, we are recommended to make the 
 incision as much as possible, in shape of the 
 letter V, the branches of which are to be 
 upward, and the angle downward, in order 
 that as little as possible of the temporal 
 muscle may be cut, and that the division ot 
 its fibres may be avoided as far as it is in 
 our power. 
 
 Having divided the scalp, the next object 
 Is to reflect it ; but no man would be w ar- 
 ranted in cutting any part of it away, al- 
 though such practice is advised by Pott and 
 many other eminent writers. 1 he purposes 
 of the operation do nol require any removal 
 
TREPHINE. 
 
 490 
 
 ot this kind ) and the method would leave 
 a wound, which would be long in healing, 
 and when healed, never exempt from de- 
 formity. In short ,4he reflected flaps ot the 
 scalp are capable of adhering to the parts, 
 on which they are laid after the operation, 
 and consequently ought never to be wan- 
 tonly cut away. 
 
 The scalp being reflected, authors nejit 
 advise us to scrape aw*ay the pericranium, 
 either w ith the knife, or the raspatory. Per- 
 haps this measure may be considered as 
 one, which does neither much harm nor 
 much good. The design is to facilitate the 
 application of the trephine to the bone. 
 How r ever, the teeth of a proper instrument, 
 in good order, will not be impeded by the 
 slender periosteum ; and scraping this mem- 
 brane away from parts of the skull, which 
 are not to be removed, must be conducive 
 to exfoliations. 
 
 Sometimes the bleeding from branches of 
 the temporal, or occipital artery, is so co- 
 pious, that the bone cannot be very conveni- 
 ently perforated before the hemorrhage is sup- 
 pressed. If it be prudent to wait a little, 
 and the case (as it generally does) should be 
 likely to be benefited by the evacuation of 
 blood, it is as w r ell to let the bleeding con- 
 tinue for a certain time. The surgeon may 
 then just direct an assistant to put the end 
 of one of his fingers on the mouth of the 
 vessel, and proceed in the operation. ll> 
 some cases the bleeding might be so trou- 
 blesome, that it would be better to tie the 
 artery at once. 
 
 All parts of the cranium do not admit of 
 being trephined wdth equal convenience and 
 safety. It has usually been set dow'n by 
 surgical authors, that the trephine cannot 
 be applied below r the transverse ridge of the 
 os occipitis. There are some cases, how r - 
 ever, which prove that such an operation 
 may be safely done, and that we ought not 
 in urgent circumstances, to be afraid of di- 
 viding the trapezius and complexus muscles, 
 in order to be enabled to apply the trephine 
 to the bone. (See Hutchison's Casein Med. 
 Chir. Trans. Vol. 2, p. 104, fyc.) 
 
 The majority of writefs also forbid the 
 application of the trephine to the frontal 
 sinuses, in consequence of the indeterminate 
 depth of these cavities, and the apprehen- 
 sion of incurable fistulas. Howrever, Larrey 
 has deviated from this precept in several 
 instances, and his practice confirms the 
 statement of Mr. C. Bell, that, by opening 
 the frontal sinus with a large trephine, and 
 then using a small one, the internal parietes 
 of this cavity may be trephined with perfect 
 safety, and no risk of injuring the dura 
 mater with the saw. (See Larrey' s Mem. de 
 Chirurgie Militaire, T. 2 ,p. 135 — 138, T. 4.) 
 
 Writers also caution us not to apply the 
 trephine to the anterior inferior angle of 
 the parietal bone, in consequence of the 
 middle artery of the dura mater lying un- 
 der it, generally in a groo.ve of the bone, 
 and occasionally in a canal in its very sub- 
 stance. In the latter circumstance, this 
 portion of the parietal bone could not pos- 
 
 sibly be taken away, without wounding the 
 vossel. However, notwithstanding this ad- 
 vice, which has been unthinkingly banded 
 down by one writer to another, from genera- 
 tion to generation, I very much question the 
 soundness of the doctrine. We undoubtedly 
 ought to avoid trephining this part of the cra- 
 nium, when w e can prudently do so. But the 
 causes demanding this operation are ahvays 
 so urgent, that the patient’s sole chance of 
 existence depends on their cjuiek removal. 
 Hence, wrnre there pressure on the brain, 
 either from a depressed portion of bone, 
 from blood, or matter, and such pressure 
 could not be removed without trephining 
 the anterior inferior angle of the parietal 
 bone, w r hat operator would be afraid of do- 
 ing so ? Besides, the fear of the hemor- 
 rhage has been very, unfounded ; for the 
 lodgment of the artery? :i a bony furrow, or 
 canal, which authors have pointed out as 
 rendering the suppression of the hemorrhage 
 more difficult, is a mere visionary idea, as 
 it is well known, that a little plug of lint 
 pushed into the orifice of a vessel so situa- 
 ted, will ahvays stop the bleeding, with as 
 much certainty and ease as can 'possibly be 
 imagined. 
 
 The foregoing suggestion was made in the 
 early editions of my w'orks, and I now’ see 
 the safety of the practice has-been confirm- 
 ed. “ I have also applied the trepan (says 
 Larrey) over the track of the spheno-soi- 
 *nous artery, at the inferior anterior angteof 
 the parietal bone. The artery w^as divided - 
 but I stopped the hemorrhage almost imme- 
 diately, by applying an iron probe red-hot.” 
 (Mem,, de Chir. Militaire, T. 2, p. 138.) 
 
 Writers, until very lately, also prohibited 
 us from trephining over any of the sutures, 
 and especially over the sagittal suture, be- 
 neath which the longitudinal sinus is situa- 
 ted. The fear of the dura mater being in- 
 jured, and of this vessel being- wounded, 
 w r as the reason for the advice. With regard 
 to the sutures in general, the trephine may 
 be applied to them, as well as to any other 
 part ; and as for the sagittal suture, many 
 facts confirm the propriety of not being de- 
 terred even by it, though situated immedi- 
 ately over the longitudinal sinus. Jt is to 
 be remembered, also, that the dura mater, 
 in cases of extravasated blood and matter, 
 beneath the cranium, is detached by the 
 intervention of such fluids from the inner 
 table. 
 
 By means of a perforation practised over 
 the sagittal suture, Garengeot successfully 
 elevated a portion of bone which pressed 
 upon the longitudinal sinus, and made the 
 patient quite comatose. The depressed 
 piece of the cranium could not have been 
 so advantageously raised, had the trepan 
 been applied in any other situation. But a 
 still stronger argument in favour of this 
 practice, when the case at all requires it, is 
 the fact, that wounds of the longitudinal 
 sinus, and the hemorrhage resulting from 
 them, are not attended with any serious 
 danger. Sharp mentions his having twice 
 seen a bleeding of this kind. Another in 
 
490 TftErHINK. 
 
 stance is also recorded in Warner's Cases' 
 A child received a wound on its forehead : 
 the two parietal bones were fractured, and 
 a portion of each was depressed on the dura 
 mater. The child lived a month, without any 
 operation being done; but at the end of this 
 time, Warner applied the trepan. He found 
 a splinter of bone sticking in such a way 
 into the longitudinal sinus, that it could not 
 easily be got out; consequently, he enlar- 
 ged with a lancet the opening in which the 
 splinter was entangled. The hemorrhage, 
 which was copious, was easily suppressed 
 by the application of a little dry lint, and 
 the child was relieved, though it died at the 
 end of two months, after suffering a variety 
 of symptoms, which had no connexion with 
 the wound of the sinus, the opening of 
 which soon healed. The fourth case, rela- 
 ted by Marchettis, also proves, that wounds 
 of the longitudinal sinus are not fatal. Pott 
 and Callisen have since recorded other 
 facts, tending to the same conclusion. (See 
 Syst. Chir. Hodierna , Part 1, p. 659, Edit . 
 1798.) 
 
 Whenever a depressed fracture can be ele- 
 vated to its proper level, without applying the 
 trephine, and with the mere aid of a pair of for- 
 ceps, or an elevator, trephining should never 
 be performed, unless there be strong reason 
 to apprehend, that blood, or matter, lodged 
 on the surface of the dura matter, contributes 
 to the production of the bad symptoms, and 
 ought to be discharged. 
 
 The scalp having been divided, if neces- 
 sary, and the pericranium scraped from the 
 surface of the bone, according to the com- 
 mon precepts and practice, the next thing is 
 the application of the crown of the trephine. 
 
 The surgeon is first to make a little impres- 
 sion with the point of the centre-pin, for 
 the purpose of marking the place where it 
 will work, when the crown of the trephine is 
 applied in the proper situation ; for, where 
 such impression is made, the operator must 
 make a small hole with a perforator, in order 
 to fix the point of the centre-pin, on which 
 the crown of the instrument turns back- 
 ward and forward, as on an axis, during the 
 first stage of the operation. Mr. Savigny’s 
 centre-pins make a perforation, without the 
 need of any particular instrument for the 
 purpose, and, in this respect, are advan- 
 tageous. 
 
 The point of the centre-pin having been 
 fixed, the trephine is to be turned by regular 
 semi-circular motions, alternately to the 
 right and left, which object is effected by 
 steady pronations and supinations of the 
 operator’s hand. The teeth of the saw 
 having made a tolerable circular groove, in 
 which they can steadily work, the centre-pin 
 becomes useless, and, as it would, if not 
 withdrawn, or removed, certainly injure the 
 dura mater and brain, by reason of its pro- 
 jecting further than any other part of the 
 instrument, it would be an unpardonable 
 blunder to let it’ remain, after a proper cir- 
 cular groove has been formed by the teeth 
 of the saw. 
 
 The beginning of the sawing may be 
 
 executed boldly and quickly ; for, the 
 operator runs no hazard of doing mischief. 
 It is necessary occasionally, with a view of 
 facilitating the action of the instrument, to 
 clean away the particles of bony matter, 
 vfith a little brush, usually kept for the pur- 
 pose in every box of trephining instruments. 
 Were this plan neglected, the action of the 
 cylindrical saw would be very much clogged. 
 
 The operator, however, must increase his 
 caution, when the sawing has made greater 
 progress ; for, were he to be too bold, he 
 might sometimes lacerate the membranes of 
 the brain with the teeth of the instrument, 
 particularly, as the thickness of the cranium 
 is subject to infinite variety, both in different 
 parts of the same head, and in different sub- 
 jects. Let the surgeon, therefore, never for- 
 get to examine frequently with the point of 
 a quill, whether any part of the circular 
 groove is cut through or nearly so ; for, 
 when this is the case, the instrument must 
 only be worked in such a way, as to make 
 pressure upon, and cut the part of the cir- 
 cle which yet remains to be divided. In 
 some few cases, it is said, that the surgeon 
 can distinctly feel, when the teeth of the 
 saw reach the diploe, or medullary struc- 
 ture, between the two tables of the cranium, 
 and some writers have rashly directed us to 
 saw with boldness, till the sensation of this 
 occurrence is communicated to our hand and 
 iibgers.” However, I believe, this possibi- 
 lity of discriminating the arrival of the teeth 
 of the saw at the diploe is so uncommon, 
 and so fallacious, that it should never be ex- 
 pected, or relied cn. Nor ought the surgeon 
 to saw with incautious force and rapidity, 
 till he sees the teeth of the trephine bloody, 
 which appearance has been set dowti as 
 another criterion of their having reached 
 the diploe. I have already stated, that a 
 great many skulls have hardly any space be- 
 tween several parts of the two tables. 
 This is particularly often the case in old 
 persons. 
 
 A prudent man will always prefer exerting 
 a little force for the purpose of breaking 
 some of the bony connexion, retaining the 
 circular piece of bone, to running any hazard 
 of injuring the dura mater, by sawing too 
 deeply. After a certain time, therefore, it 
 is better to lay down the trephine, and 
 endeavour to elevate the portion of bone, 
 with the aid of a pair of forceps, construct- 
 ed for the purpose, and kept in most cases of 
 trephining instruments, or else by means of 
 an elevator, which is still more calculated 
 for the purpose. 
 
 When the circular piece of bone has been 
 taken out,' and the edges of the perforation 
 are unequal, and splintered, the irregularities 
 are to be cut off with the lenticular knife. 
 When there is extravasated blood under- 
 neath the opening which has been made, 
 it sometimes spontaneously makes its escape, 
 and, if it should not do so, the surgeon 
 must remove it himself. If one perforation 
 of the skull should not suffice for letting out 
 the blood, as much more pf the cranium 
 ought to be removed with the trephine. 
 
TftEFHINL. 
 
 mi 
 
 circumstances way require ; there being no 
 comparison between the danger of repeating 
 the application of the instrument, and that 
 of leaving a quantity of undischarged, com- 
 pressing fluid, on the surface of the brain. 
 Certainly, many facts on record evince, that 
 the dura mater may be very extensively un- 
 covered, without dangerous consequences. 
 Sarrau saw a whole parietal bone exfoliate, 
 in consequence of a blow on the head. 
 Blegny relates a similar case ; and Saviard 
 makes mention of a woman, who had lost 
 the upper part of the os frontis, both the 
 parietal bones, and a large portion of the os 
 occipitis, all of which had come away at the 
 same ; yet she recovered. Vaugion, how- 
 ever, who also seems to relate this identical 
 case, describes the exfoliation as not being 
 quite so extensive. 
 
 I am of opinion, notwithstanding these 
 facts, that exposing a large part of the dura 
 mater with the trephine is, by no means, an 
 operation exempt from serious danger. And, 
 what I conceive confirms this statement, is 
 my having known instances, in which per- 
 sons, who had been rashly advised to submit 
 to being trephined, for the cure of violent 
 pains in the head, &,c. died, in consequence 
 of the operation. I make this observation, 
 well aware of the successful instance of the 
 practice recorded by Schrnucker. ( Walir - 
 7iehin. B. 1 , p. 434.) 
 
 However, [perfectly coincide with writers, 
 who direct the removal of as much bone, as 
 is necessary in order to be able to remove 
 the whole of the pressure from the surface of 
 the dura mater. 
 
 The application of the trephine, in cases 
 of large extravasations, must in particular 
 be made several times, when the situation 
 of the fluid does not favour its escape. 
 However, in this circumstance, Sabatier 
 iays, that we should not make numerous 
 perforations all along the extent of the ex- 
 travasation ; but, only a counter opening, as 
 is done on the soft parts. This author ex- 
 presses his surprise at there not being on re- 
 cord many examples of counter-openings 
 made in the cranium, since analogy demon- 
 strates their utility. I cannot help remark- 
 ing on this part of the subject, that one very 
 obvious objection to make openings of this 
 kind in the cranium, is the impossibility of 
 knowing with certainty, whether blood lies 
 under any particular part of the skull ; 
 whereas, in abscesses of the soft parts, the 
 surgeon feels the fluctuation of the matter, 
 and knows that his counter-opening will be 
 made in the cavity containing it. One might 
 also have occasion to make more than one 
 perforation, in order to discharge blood ex- 
 travasated beneath the skull, when the blow 
 has happened near a suture, to which the 
 dura mater continues adherent ; for, a single 
 opening made only on one side of the suture, 
 might only give vent to a part of the extra- 
 vasation. 
 
 If we should not find blood lodged under 
 the cranium ; but the dura mater should 
 seem elevated, tense, dark-coloured, forming 
 a prominent fluctuating tumour, outward, it 
 
 Vor. U* A3 
 
 may be cautiously opened with a lancet, or 
 bistoury, with a view of letting out any 
 collection of blood underneath. In the arti 
 cle Head , Injuries of, l have stated the result 
 of Mr. Abernethy’s experience, in' regard to 
 the operation of opening the dura mater. 
 This gentleman found, that the method never 
 effectually discharged all the blood, but 
 only the serous part^of it. The evacuation 
 of any of the compressing fluid must, how- 
 ever, be desirable ; and, if the surgeon can 
 not do more, yet he has fulfilled bis profes- 
 sional duty. 
 
 The utility of trephining is not limited to 
 discharging extravasated blood, or matter, 
 lodged underneath the skull. This operation 
 frequently enables us to elevate depressed 
 portions of bone. The latter objects can 
 often be accomplished by merely making 
 one perforation. Sometimes, several per- 
 forations are requisite to be made near each 
 other. Authors even state, that it may also 
 become necessary to remove the interve- 
 ning portions of bone with a pair of cutting 
 forceps. The depressed part may then be 
 easily raised by means of an elevator. Oc- 
 casionally, indeed, I may say very often, 
 the best practice is to remove the depressed 
 portion entirely, when its total separation 
 from the rest of the skull can be accom- 
 plished by cutting across the base of the de- 
 pressed piece. If any splinter stick in the 
 dura mater, and should not admit of being- 
 withdrawn, without enlarging the wound in. 
 the membraue, the surgeon ought not to be 
 afraid of doing this with a sharp instrument 
 
 According to some quick-inferring writers, 
 if, after dividing the dura mater, the surface 
 of the brain appears smooth and flabby, with 
 a fluctuation, we may conclude there is an 
 abscess in its substance ; and these authors, 
 more enterprising with their pens, it is to be 
 hoped, than with their scalpels, sanction the 
 method of carrying the point of the bistoury 
 to the depth of an inch, if circumstances ren- 
 der so deep a puncture necessary. “ But,” 
 says Richerand, “ prudence forbids us to go 
 further. Cutting the surface of the brain 
 causes no pain, and it produces less danger, 
 than one might apprehend ; but, experience 
 and observation have proved, that the essen- 
 tial parts of this organ are situated near its 
 base, and that its surface may be removed 
 without danger, or pain .” ( JVosogr . Chir. T 
 
 2, p. 301, Edit. 3.) 
 
 After the operation of trephining, the di- 
 vided scalp is to be placed as nearly as possi- 
 ble in its natural situation, and lightly dress- 
 ed with a simple pledget of any common 
 unirritating ointment. In applying the dress- 
 ings, the surgeon should invariably keep in 
 view these objects ; namely, to let whatever 
 •is put on the wound be as light as possible, 
 not apt to make pressure on the brain, and 
 of a nature, which cannot excite irritation. 
 All stimulants are to be strictly avoided ; 
 nor will any bandage be better than an 
 ordinary night-cap of sufficient size to be put 
 on with facility. It may be secured with bits 
 of tape, which are to be tied under the jaw. 
 
 The practitioner should not now conceive, 
 
TRICHIASIS. 
 
 iite 
 
 that he has done ail that he ought to do. 
 Let him remember the urgent necessity of 
 keeping off", or diminishing, the inflamma- 
 tion of the dura mater and brain, which is 
 still to be feared. Let him bleed the pa- 
 tient largely and repeatedly ; exhibit saline 
 purges, glysters, and antimonials ; and if the 
 symptoms continue, let him apply a blister 
 to some part of the head I shall avoid, 
 however, any repetitions on this subject, by 
 referring to Head, Injuries of. 
 
 The aperture in the skull usually becomes 
 closed with soft granulations, which slowly 
 acquire a hard consistence. These almost 
 constantly grow from the edge of the per- 
 foration, and seldom from the surface of the 
 dura mater. While the cicatrix is soft, it 
 should be protected from external injury 
 with a thin piece of horn, or metal. Exfo- 
 liations from the margin of the perforation 
 sometimes retard the healing of the wound ; 
 but, now that the practice of dressing with 
 drying spirituous applications has been ex- 
 ploded, and the removal of any part of the 
 scalp is condemned by all the best surgeons, 
 these unpleasant consequences are rendered 
 much less frequent, than in former days. 
 
 The reader may find an account of the 
 operation of trepanning, or trephining, in 
 every system of surgery ; but, he should 
 particularly consult the writings of Sharp, 
 Le Bran, Dionis, Bertrandi, Pott, Sabatier, 
 Schmucker, Abernethy, Desault, Callisen, 
 liicherand, &c. Several parts of the Me- 
 moires de l’Acad. de Chirurgie are also high- 
 ly deserving of perusal 
 
 TRICHIASIS, (derived from the 
 
 hair) denotes a faulty inclination of the eye- 
 lashes inwards against the globe of the eye. 
 According to Scarpa, the disease presents 
 itself under two distinct forms : the first is, 
 where the cilia are turned inwards, without 
 the natural position and direction of the 
 tarsus being at all changed ; the second con- 
 sists in a morbid inclination of the tarsus in- 
 wards, ( Entropium ) and consequently of the 
 eyelash towards the eyeball. ( Trichiasis .) 
 
 The first form of this disease is said both 
 by Beer and Scarpa to be uncommon, nor 
 has it come under the observation of the 
 latter writer more than once- and, in this in- 
 stance, only some of the hairs had changed 
 their direction. On this point, however, Mr. 
 Travers is completely at variance with the 
 foregoing authors, as he describes an inver- 
 sion of the cilia as frequently existing inde- 
 pendent of entropeon. {Synopsis, p. 232.) 
 The second species, or form of trichiasis, or 
 that which consists in a folding inwards of 
 the tarsus and cilia at the same time, is the 
 case which is commonly met with in prac- 
 tice. It may be either complete, affecting 
 the whole of the tarsus ; or incomplete, oc- 
 eupying only a certain portion of the edge 
 of the eyelid, most frequently near the ex- 
 ternal angle of the eye. Sometimes, the 
 disease is confined to one eyelid ; at other 
 times, it affects both ;. and occasionally the 
 patient is afflicted with it in both eyes. 
 
 Some writers, among whom is Beer, 
 ( hrjnr r.on fan Avgenkr. R. 2, v- U8,) ad- 
 
 mit a case, which they call disliehiasis, aim 
 which they suppose to be produced by a 
 double and unusual row of hairs. But ac- 
 cording to Scarpa, this third species is only 
 imaginary, and the reason of such subdivi- 
 sion seems to have arisen from not recol- 
 lecting, what was long ago remarked by 
 Winslow and Albinus, that although the 
 roots of the cilia appear to be disposed in 
 one line only, they form two, three, and in 
 the upper eyelid even four rows of hairs, 
 unequally situated, ‘and as it were confused. 
 Whenever, therefore, in consequence of dis- 
 ease, a certain number of hairs are separated 
 from each other in a contrary direction and 
 disorderly manner, the eyelash will appear 
 to be composed of a new and unusual row 
 of them, while, in fact, there is no change^ 
 either with respect to their number, or na- 
 tural implantation. 
 
 It is not an easy matter to determine pre 
 cisely, says Scarpa, what are the causes, 
 which sometimes make a few of the hairs 
 deviate from their natural direction, while 
 the tarsus continues in its right position 
 They are commonly referred to cicatrices 
 in consequence of previous ulceration, 
 whereby the cilia fall off, and those which 
 are growing are hindered from taking their 
 proper direction. There must, however, be 
 other causes sometimes concerned ; for, in 
 the case seen by Professor Scarpa, two or 
 three hairs were turned inwards against the 
 eyeball, although there had been no preced- 
 ing ulceration, nor cicatrices, of any part of 
 the tarsus. Indeed, Scarpa is inclined to 
 believe, that the small ulcers and scars, 
 which are sometimes formed upon the in- 
 ternal margin of the tarsus, are more likely 
 to cause the second form of the disease, or 
 the inversion of the edge of the eyelid, and, 
 consequently, of the cilia towards the globe 
 of the eye. As these ulcers, when neglect- 
 ed, destroy the internal membrane of the 
 eyelids near the tarsus, it necessarily follows 
 that, in proportion as they heal and dimi- 
 nish, they draw along with them and turn 
 inwards the tarsus, and hairs inserted into 
 it. And since they do not always occupy 
 the whole extent of the internal margin of 
 the eyelid, but are sometimes confined to a 
 few lines, in the middle, or extremity, near 
 the external angle of the eyelid, so alter the 
 cicatrices are formed, the whole of the hairs 
 are not invariably turned inwards, but only 
 a certain number of them, which correspond 
 to the extent of the ulccr9 previously situa- 
 ted along the internal edge of the tarsus. 
 Indeed, in every case of imperfect trichiasis 
 from a cicatrix of the inner margin of tk6 
 eyelid, the tarsus and cilia are every where 
 in their natural situation, except opposite the 
 part, where the ulcers formerly existed 
 Also, if the eyelid be everted, its internal 
 membrane, near that part of the margin cor- 
 responding to the seat of the trichiasis, will 
 be found pale, rigid, and hardened, the inver- 
 sion of the cartilaginous border and of the 
 cilia being plainly the effect of the contrac- 
 tions of the cicatrized point. 
 
 Chronic, ophthalmies of lon£Continuanre 
 
TRICHIASIS, 
 
 *m 
 
 sometimes bring on the complaint, in conse- 
 quence of the skin of the eyelids being kept 
 for a long time in a state of distention and 
 oedema, terminating in a considerable relax- 
 ation of it. And, according to Beer, the too 
 long continued use of emollient poultices 
 may have the same effect. ( Lehre , 4'C. B. 2, 
 p. 113.) The cartilaginous margin of the 
 eyelid then loses the proper support of the 
 integuments, inclines towards the eyeball, 
 and afterward turns inwards, drawing the 
 eyelashes along with it in the same impro- 
 per direction. Long-continued puriform 
 discharges from the ciliary glands likewise 
 spoil the shape and consistence of the car- 
 tilage of the eyelid, and therefore not unfre- 
 quently occasion trichiasis. Scarpa doubts, 
 whether a spasmodic contraction of the 
 orbicularis palpebrarum muscle can ever be 
 a cause of the disease. 
 
 The annoyance, which must necessarily 
 result from the hairs perpetually pressing 
 upon the cornea and white of the eye, as 
 Scarpa observes, may be easily imagined. 
 The evil is rendered still greater by the hairs, 
 which are turned inwards, becoming much 
 longer and thicker, than those wffiich retain 
 their natural direction. And although the 
 trichiasis be confined to one eye, both the 
 eyes usually suffer from the effects of the 
 disease. Indeed, generally, the eye on the 
 sound side cannot be moved without occa- 
 sioning pain in that which is exposed to the 
 irritation and friction of the inflected hairs. 
 In almost all instances, both the eyes are 
 very irritable, and incapable of bearing the 
 light. As, in cases of incomplete trichiasis, 
 she patient retains some little power of open- 
 ing the eyelids for the purpose of seeing, and 
 that most frequently towards the internal 
 angle of the eye, the head and neck are 
 often inclined in an awkward manner, so 
 that in children a distortion of the neck and 
 shoulders is at last produced, which cannot 
 he rectified without difficulty, even after the 
 trichiasis is cured. Unfortunately, also, 
 children are impatient of the uneasiness ari- 
 sing from the inflected hairs, and, therefore, 
 are continually rubbing the eyelids, whereby 
 all the ill effects of the complaint are much 
 increased. 
 
 The cure of the second species of trichia- 
 sis, or that which is commonly met with in 
 practice, is accomplished by artificially 
 everting the eyelid, and fixing it permanently 
 in its natural position, together with the 
 eyelashes, which irritate the globe of the 
 eye. According to Professor Scarpa, this 
 indication is perfectly fulfilled by the exci- 
 sion of a piece of the skin close to the edge 
 of the eyelid, of such a breadth and extent 
 that, when the cicatrix is formed, the tarsus 
 and margin of the eyelid may be turned out- 
 wards, and sufficiently separated from the 
 eyeball, the cicatrix of the integuments af- 
 fording a point of support fully adequate to 
 keeping the parts in their natural position 
 and direction. Scarpa believes, that there 
 are now very few modern surgeons, who, 
 with a view to the radical cure of this dis- 
 ease, place any confidence either in pluck- 
 ing ont the inverted eyelashes, bending them 
 
 outwards, .and retaining them so by means 
 of adhesive plaster; or in plucking them 
 out, and destroying their roots with caustic : 
 much less in extirpating the edge of the 
 eyelid along with the hairs, or dividing, the 
 orbicularis muscle on the internal surface of 
 the eyelid, under an idea that the disease is 
 sometimes produced by a spasmodic con- 
 traction of it. 
 
 The following is the mode of proceeding 
 recommended by Scarpa. The patient be- 
 ing seated in a chair, if an adult, or, if a 
 child, laid upon a table, with the head rais- 
 ed, and firmly held by an assistant, who must 
 stand behind the patient ; the surgeon is to 
 
 ( )nsh outward, with the end of a probe, the 
 lairs, which irritate the eye. Then, with a 
 pair of dissecting forceps, or the ends of his 
 fore-fingerand thumb (which answer equally 
 well, and in many cases much better, than 
 forceps,) the operator should lift up a fold 
 of the skin ot ihe affected eyelid, taking 
 great care that the piece which is taken hoid 
 of corresponds exactly to the middle of the 
 whole extent of the trichiasis ; for some- 
 times the whole, sometimes a half, and, in 
 other instances, only a third of the extent 
 of the tarsus is inverted. The surgeon, with 
 bis left band, must raise the fold of the skin, 
 more or less, according as the relaxation of 
 the integuments, and the inversion of the 
 tarsus, are more or less considerable. The 
 reason of this is evident, viz. the greater the 
 quantity of skin is which is raised, the greater 
 is the quantity which will be cut away. Sup- 
 posing the patient to he an adult, as soon as 
 the fold of skin has been raised in a certain 
 degree, the surgeon must request him to open 
 his eye, and if in this act the tarsus and eye- 
 lashes resume their natural place and direc- 
 tion, file portion of skin already raised will 
 be sufficient for the purpose. When the in- 
 teguments are elevated, by means of a pair 
 of dissecting forceps, and care is taken to 
 lay hold of the skin precisely at the middle 
 point of the whole extent of the trichiasis, it 
 necessarily follows, that the consequent sec 
 tion^f the skin will form an oval, and that 
 the greatest width of the wound will cor- 
 respond exactly, or nearly so, to the middle 
 of the eyelid, and its narrowest parts to the 
 angles, or commissures of the same. This 
 contributes very materially to make the ci 
 catris correspond to the natural fold of the 
 eyelid, and hinder the origin of a disease of 
 an opposite nature to the one about to be re- 
 medied, towards the angles of the eye, viz. 
 a turning out of the commissures of the eye 
 lids. See Ectropium. 
 
 Besides this caution, relative to the situa- 
 tion and figure of tue fold of the integuments 
 to be cut off, the surgeon must be careful 
 that the division of the skin be made very 
 near the inverted tarsus. Were this circum- 
 stance neglected, the operator might have 
 the mortification of finding after the wound 
 is healed, that although the eyelid is shorten* 
 ed on the whole, from the eyebrow to the 
 place of the recision, yet it is not equally so 
 at the space which is between tbe edge of the 
 eyelid and the cicatrix of the skin IJcnce 
 the tarsus would not be turned ontward 
 
5.00 
 
 TRICHIASIS. 
 
 ficiently to keep the eyelashes from rubbing 
 against the eye. 
 
 The surgeon holding up the fold of skin 
 by means of the forceps in his left hand, is 
 with a pair of probe-pointed, sharp-curved 
 scissors, to cut off (he whole of the duplica- 
 ture, being first sure (hat one of the blades 
 of the instrument is applied close to the 
 edge of the eyelid. If the eyelids should be 
 affected, the same operation musr immedi- 
 ately be done upon bolh of them, with such 
 cautions, and in such proportion, as the ex- 
 tent of the disease, and the degree of inver- 
 sion of each eyelid may require. 
 
 Scarpa next dissuades us from employing 
 any suture to unite the wound, and repre- 
 sents that it will be sufficient to keep the 
 eyebrow as much downward as possible, if 
 Ihe operation has been done on the upper 
 eyelid, or if on the lower, to support it against 
 the inferior arch of the orbit, by pressing it 
 from below upwards, so as to keep the edges 
 of the wound from becoming separated. 
 Then the lips of the wound arj^to be brought 
 exactly together by means of adhesive plas- 
 ter, which should extend from the superior 
 arch of the orbit to the zygoma, and the 
 maintenance of this state of the wound will 
 be still more securely effected, by placing 
 two compresses, one on the eyebrow, and 
 another on the zygoma, together with a 
 bandage. On the other hand, Laugenbeck 
 disapproves of the omission of sutures, by 
 which he finds that the wound may be both 
 more accurately and expeditiously united. 
 Indeed, he expresses himself generally in fa- 
 vour of sutures, where the wounded part is 
 liable to be disturbed by the continual ac- 
 tion of the muscles. ( JYeue Bibl. B. 1, p. 
 4J5, fyc. 12mo. Hanover , 1818.) Langen- 
 feeck, however, takes care to withdraw the 
 ligatures in about twelve, or at most twenty- 
 four hours, as their longer continuance 
 would produce suppuration. Beer also par- 
 ticularly insists upon the utility of bringing 
 the edges of the incision together with a su- 
 ture ; and both he and Langenbeck employ 
 forceps, the ends of which have transverse 
 pieces, calculated to take better hold of the 
 slip of skin to be removed. (Le/tre, fye. B. 
 ‘2,p. 114.) 
 
 On taking off the first dressings, the third 
 day after the operation, the surgeon will 
 find, says Scarpa, that the patient can open 
 his eye with ease, and that the inverted 
 tarsus and eyelashes have resumed their 
 natural position and direction. In the par- 
 tial or incomplete trichiasis, or that which 
 only occupies a half, or a third of the whole 
 length of the tarsus, and in subjects who 
 have had the skin of the eyelids very loose, 
 Scarpa has often found the wound perfectly 
 united on removing the first dressing. 
 
 When, however, only a part of the inci- 
 sion has healed, while the rest seems dispo- 
 sed to heal by suppuration and granulation, 
 the surgeon i3 to cover the wound with a 
 small piece of lint, spread with the unguen- 
 tum cerussai ; and if the sore should be- 
 come flabby. it must be occasionally touched 
 
 with the argentum nitratum, until the cure 
 
 is finished. 
 
 With regard to the first form of this dis- 
 ease, or that in which the eyelashes pro- 
 ject against the eyeball, without the natural 
 position of the tarsus being at all altered, 
 (a case which is fortunately rare) the ac- 
 complishment of a cure is very difficult, 
 since neither the pulling out of the hairs, 
 nor burning the situation of their roots, are 
 means at all to be depended upon for pro- 
 ducing a complete cure of the disorder ; 
 and turning the tarsus out of its natural po 
 sition would make the patient liable to an 
 irremediable dropping of the tears over the 
 cheek attended with a chronic thickening 
 of the lining of the eyelid. It has only- 
 been in youngish individuals that Beer has 
 ever seen the repeated and careful extrac- 
 tion of the cilia effect a radical cure. (See 
 Lehr e von den Augenkr. B. 2, p. 121.) In 
 the instance of this form of the disease, 
 which Scarpa met with, only two or three 
 of the eyelashes inclined against the eyeball. 
 He found, on turning the eyelid a little out, 
 opposite to the situation of the faulty hairs, 
 that he could not, indeed, completely put 
 them in their natural position ; but he saw' 
 that he could thus remove them so far from 
 the cornea that they would not rub against 
 it without altering the position of the eye- 
 lids so much as to occasion a perpetual dis- 
 charge of the tears over the cheek. And, 
 as in the patient alluded to, the skin about 
 the eyelid was very tense, Scarpa made an 
 incision with the back of the lancet, near 
 the tarsus, three lines long, and took away 
 a small piece of skin of the same length, but 
 very little more than one line broad. When 
 the cut healed, the operation was found to 
 answer as well as the nature of the case 
 would allow, though the cure was not 
 complete. 
 
 The trichiasis being cured, something 
 more always remains to be done for the 
 purpose of correcting the cause of the dis- 
 ease, as well as curing the disorder of the 
 eye, occasioned by the previous friction and 
 irritation of the inverted hairs. The usual 
 indications are to restore the tone of the 
 vessels of the conjunctiva, to lessen the 
 swelled Meibomian glands, and obviate opa- 
 city of the cornea. 
 
 Some new methods of performing the 
 operation for the cure of trichiasis, have 
 been proposed by Dr. Crampton, Mr. Saun- 
 ders, and Schre^er. 
 
 The following is the account which Dr. 
 Crampton gives of his plan, which lie tried 
 in one instance with complete success 
 “ Let the eyelid be well turned outwards 
 by an assistant ; let the operator then, with 
 a lancet, divide the broad margin of the 
 tarsus completely through by two perpendi- 
 cular incisions, one on each side of the in- 
 verted hair or hairs ; let him then, by a 
 transverse section of the conjunctiva of the 
 eyelid, unite the extremities of the perpen- 
 dicular incisions. The portion of cartilage 
 contained within the incisions, can then, 
 if inverted, with case he restored to its ori- 
 
TRICHIASIS. 
 
 oinal situation, and retained there by small 
 strips of adhesive plaster, or, perhaps what 
 is better, by a suspensorium palpebrec, 
 adapted to the length of the portion of the 
 tarsus, which it is intended to sustain, should 
 one or two hairs be displaced without in- 
 version of the tarsus.” ( Essay on the En- 
 tropeon, p. 55.) 
 
 Mr. Travers informs us, that, in cases of 
 a circumscribed inversion, “ produced by ci- 
 catrix from burn or wound," he has found 
 Dr. Crampto'n’s method an etfeciual remedy. 
 
 It is,added ; that the complete division of 
 the conjunctiva and tarsal cartilage, inclu- 
 ding the inverted portion, and parallel to 
 its border, with the aid of sticking plaster, 
 sometimes proved sufficient. Mr. Travers 
 also sees no objection to the entire removal 
 of that portion of the tarsal edge which is 
 incorrigibly . inverted from such a cause, 
 especially when combined with a preterna- 
 tural growth of cilia from the Meibomian 
 border of the tarsus. ( Synopsis , p. 356.) 
 In one inveterate case, which was not 
 effectually relieved by the frequent extrac- 
 tion of the cilia, cauterizing the edge of the 
 tarsus, the excision of a slip of skin, and 
 smearing the eyelid with concentrated sul- 
 phuric acid, as proposed by Helling, ( Hufe - 
 land's Journ. St. 4, p 115) Schreger, with a 
 pair of curved scissors, cut out a triangular 
 piece of the cartilage of the eyelid at the 
 place where the cilia were most trouble- 
 some. The great benefit derived from the 
 operation then led the same practitioner to 
 suggest the removal of the whole of the in- 
 verted edge of the tarsus, towards the inner 
 canthus, where some irritation was yet 
 maintained. The plan, though followed by 
 severe pain, appears to have succeeded. 
 (C7«r. Versilche , B. 2, p. 253.) 
 
 Mr. Saunders entertained a favourable 
 opinion of Dr Crampton’s operation for the 
 cure of the disease in its early stage; but, 
 he contended, such a vicious bending of 
 the tarsus inward was often the consequence 
 of repeated ophthalmy, attended with ulce- 
 ration of the conjunctiva and inside of the 
 eyelid, so that every endeavour to rectify 
 the wrong position of the tarsus, and restore 
 its original direction, would be fruitless. 
 Hence he believed that its excision was de- 
 cidedly indicated ; an operation which is 
 said to be followed by no pain nor uneasi- 
 ness, and which is 6ure in its effect. No 
 particular shortening of the eyelid ensues ; 
 the deformity is materially lessened ; and, 
 unless the cornea be already too opaque, 
 perfect vision is re-established. Mr. Saun- 
 ders directs a piece of thin horn or a plate 
 of silver, having a curvature corresponding 
 to that of the eyelid, to be introduced un- 
 der this part, with its concavity towards the 
 eyeball. On this instrument the eyelid is 
 to be stretched. An incision is to be. made 
 through the integuments aud orbicularis 
 palpebrarum down to the tarsus, immedi- 
 ately behind the roots of the cilia. The cut 
 should extend from the punctum laebry male 
 to the external angle. The exterior sur- 
 face of the tarsus is then to be dissected 1 
 
 until the orbital margin is exposed, when 
 the conjunctiva is to be cut through di 
 rectly by the side of the tarsus, which must 
 now be disengaged at each extremity. The 
 punctum lachrymale must be left uninjured. 
 The operation is described as being simple, 
 and if any embarrassment arises, it is from 
 the hemorrhage of the ciliary artery, the 
 blood sometimes obscuring the punctum 
 lachrymale, just when the operator is about 
 to divide the tarsus by the side of it. No 
 dressings are required, it being merely ne- 
 cessary to keep the eye covered for a few 
 days. The skin will continue to be eleva- 
 ted, just as the perfect eyelid was ; and, 
 though less completely, yet enough to leave 
 the pupil clear when the eye is moderately 
 directed upward. In all the cases in which 
 Mr. Saunders operated, a fungus grew from 
 the wound. He recommends the excres- 
 cence to be destroyed with caustic or the. 
 knife. 
 
 Respecting this operation I shall merely 
 observe, that it is more, severe than that 
 advised by Professor Scarpa, and even than 
 the method of Schreger, and must leave 
 greater disfigurement. Unless, therefore., 
 the latter methods prove ineffectual,! should 
 consider the practice unjustifiable. Nor is 
 Schreger’s method allowable, except in 
 cases which resist the milder plan, sanction 
 ed by Beer, Scarpa, and all the best practi- 
 tioners in ophthalmic surgery. 
 
 Inversion of the lower eyelid is much less 
 common than that of (be upper one. The 
 late Mr. Saunders never saw this disease 
 arise from the same causes which induce it 
 in the upper eyelid, though he acknowledges 
 the possibility of such a case. However, 
 he met with several instances of the affec- 
 tion, in consequence of encysted tumours, 
 which, as they increased, carried the orbital 
 edge of the tarsus outwards, and, in the 
 same proportion, inclined the ciliary edge 
 towards the globe of the eye. 
 
 An inversion of the inferior palpebra is 
 sometimes produced by inflammation and 
 swelling of that part of the conjunctiva 
 which connects the eyelid with the eyeball. 
 In cases of ophthalmy this membrane often 
 forms between the latter parts a distinct 
 fold, which is situated just on the inside of 
 the orbital edge of the tarsus, and pushes it 
 outward; while the contraction of the orbi- 
 cularis muscle turns the ciliary edge in- 
 wards, and inclines it between the swelling 
 of the conjunctiva and the eye. In this 
 particular case, Mr. Saunders assures us v , 
 that replacing the eyelid in the early stage 
 of the disease, and maintaining it so until 
 the ophthalmy has been lessened by proper 
 means, will be found effectual. But when 
 the conjunctiva is much, thickened and in- 
 durated, Mr: Saunders recommends cutting 
 such diseased part of it away, and the ap- 
 plication of compresses to keep the orbital 
 margin of the tarsus inward. (See also 
 Travers’s Synopsis, p. 234 and 355.) 
 
 Albinus has recorded a species of trichi- 
 asis which originated from the growth and 
 inversion of one of the linjrs upon the ffa- 
 
\J jAOSSj* 
 
 5U2 
 
 runcula lachrymalis. The plan ot relief con- 
 sisted in plucking out the irritating hair ; 
 but it is not mentioned whether the hair 
 grew again. 
 
 J. Scultetus , Trichiasis Admiranda , sive 
 Jlforbus Pilaris Mirabilis, 12 mo. Norib. 1658. 
 Scarpa suite principali Malattie dtu.ll Occhi. 
 II. Crampton, Essay on the Entropeon, Lond. 
 1805. Saunders's Obs. on several practical 
 Points relative to the Diseases of the Eye, 
 Edit. 3. Richter's Anfangsgriinde der fVun- 
 darzneykunst , B 3. G. J. Beer, Lchre von 
 den Augen/crankeiteri, B.2,p. 1 1 1—1 17, 8t>o. 
 Wien. 1817. Schreger, Chirurgische Ver- 
 stiche, B. 2. JYeue Methods die Trichiasis zu 
 Operiren, p. 253, 8vo. JYilrnberg. 1818. B. 
 Travers, Synopsis of the Diseases of the Eye, 
 p. 232—354. fyc. 8 vo. Lond. 1820. 
 
 TRISMUS, (from to gnash the 
 
 teeth.) The locked jaw. See Tetanus. 
 
 TROCHAR, or Trocar. (from the 
 French, trois-quart, three-fourths, from its 
 point being of a triangular form.) An in- 
 strument used for discharging aqueous fluids, 
 and now and then, matter from different 
 cavities in the body, particularly those of 
 the peritoneum, and tunica vaginalis, in 
 oases of ascites and hydrocele. Trocars 
 are also employed for tapping the bladder, 
 dropsical ovaries, &c. 
 
 A trocar consists of a perforator, or sti- 
 lette, and of a cannula, which latter is so 
 adapted to the first piece of the instrument, 
 that when the puncture is made, they both 
 enter the wound together, with perfect ease, 
 after which the stilette being withdrawn, 
 the cannula remains in the wonnd, and gives 
 a ready passage for the fluid outward. 
 
 Such are the uses of a trocar, and the 
 principles on which it should be construct- 
 ed, It would be unnecessary in this w ork 
 to detail every little particularity in the in- 
 strument. I shall merely observe, that the 
 triangular-pointed trocars seem to retain 
 the greatest share of approbation ; for, al- 
 though those of a flat, lancet-pointed shape 
 outer parts with more ease, their cannulas 
 are not large enough for the ready escape of 
 fluids which are at all thick, gelatinous, or 
 blended with hydatids, and flaky substan- 
 ces. 
 
 The trocar for puncturing the bladder 
 from the rectum, should be longer than a 
 common trocar, and of a curved form ; but 
 as Mr. Carpue has explained, it should not 
 be passed too high up the rectum, lest the 
 peritonaeum be wounded. 
 
 Surgeons ought always to have, at least 
 three trocars ; one of full size, another of 
 middling width, and a third of small dimen- 
 sions. In cases of hydrocele, the latter is 
 often preferable. 
 
 *TRUSS. ( trousse . French.) Rracherium. 
 A bandage, or apparatus, for keeping a her 
 ilia reduced. A truss, which fulfils its in- 
 tention properly, should compress the neck 
 of the hernial sac, and the ring, or external 
 opening of th~ hernia, in such a manner, 
 teat a protrusion of any of the contents of 
 the abdomen will be prevented w ith com- 
 plete, security. Hence, it. is the indispensa- 
 
 ble quality of a good truss, first to make 
 effectual and equal pressure on the parts in- 
 dicated, without causing pain, or inconve 
 nience to the patient , secondly, not easilv 
 to slip oat of its right situation, in the vary- 
 ing motions and positions of the body. 
 
 Trusses are either of an elastic or non- 
 elastic kind. The latter are composed of 
 leather, fustian, dimity, or similar materials. 
 These cannot be at all depended on, and 
 should, therefore, be entirely banished from 
 surgery. Since, (as Mr. Lawrence has re- 
 marked) the size of the abdomen varies, 
 according to the different states of the vis- 
 cera, and to the motions of its parietes in 
 respiration, a non-elastic bandage must vary 
 constantly in its degree of tightness, and 
 keep up either too great, or too little pres- 
 sure. The omentum, or intestine, easily 
 slips out when the opening is not exactly 
 closed, and the patient who wears such a 
 bandage must be in a state of constant inse- 
 curity. Those who lead an active life, or 
 are obliged to use laborious exertions, will 
 be more particularly exposed to risk. If 
 the patient, after experiencing these defects, 
 endeavours to remedy them by drawing the 
 bandage tighter, he may confine the viscera , 
 but he produces other inconveniences. The 
 increased pressure injures the spermatic 
 chord, and may affect the testicle : the inte- 
 guments become red, painful, and excori - 
 ated ; and the bandage must be entirely laid 
 aside, until the parts have recovered. Rich - 
 ter has often seen painful tumefaction of 
 the testicle, hydrocele, and even cirsocele, 
 produced from this cause, and entirely dis- 
 sipated by the employment of a proper truss. 
 ( Trait6 des Hernies, p. 24.) He also saw the 
 pad of a non-elastic bandage excite, in the 
 region of the abdominal ring, a consider 
 able inflammation, which terminated after 
 a few days in suppuration. The hernia ne- 
 ver appeared again after the cure of the 
 abscess. The inflammation nad extended 
 to the neck of the sac, and obliterated that 
 part. — ( Lawrence on Ruptures , Edit. 3, p. 69, 
 70.) The spring is a very essential part 
 of every elastic truss, and it consists of a 
 flat long piece of steel, which is adapted to 
 the side of the body,f>n which the hernia 
 is situated It is not a great many years 
 since the spring used to be made of com- 
 mon iron, and Arnaud and Richter express 
 their preference to a mixture of malleable 
 iron and steel, so that the instrument may 
 be moulded by the hand to any particular 
 shape ; but, as Mr. Lawrence well observes, 
 a truss, which admits of such management, 
 must be more or less liable to the objections 
 which apply to inelastic bandages, and the 
 only material, which possesses the requisite 
 qualities of firmness and elasticity, •» well- 
 tempered steel. The front part of the steel 
 spring has an expanded form, anil, w hen 
 the truss is properly applied, ought to be 
 situated over the mouth of the hernial soc. 
 The spring of a truss has commonly been a 
 semicircle, with/the posterior end resting 
 on the spine. Camper proposed to carry 
 it round to the anterior superior spine of 
 
TltUSo. 
 
 the ilium oa the sound side ; a plan, of 
 which Scarpa highly approves. Trusses of 
 this form lit with a degree of steadiness, 
 which cannot be given to others, by tighten- 
 ing the strap. They keep up the rupture 
 better than even a stronger spring of the 
 common kind. Under the back surface of 
 the anterior end of the spring is placed the 
 pad, which should be adapted in shape and 
 size to the passage, which is intended to be 
 shut up. The steel spring is usually covered 
 with leather, is lined with soft materials, 
 and after being put on the patient, is fas- 
 tened in its situation by means of a strap, 
 which extends from the two ends of the 
 spring, round that side of the body, on 
 which the hernia is not situated. Hare- 
 skin; with the fur outwards, is sometimes 
 considered the best covering for preserving 
 the spring from the ill effects of perspi- 
 ration. 
 
 When it is necessary to make strong 
 compression, as in large old ruptures, and 
 in persons who cannot avoid labour and 
 exercise, the elastic spring should be made 
 accordingly thicker and broader. But, an 
 object of the first-rate importance is to 
 make the spring press equally upon every 
 point of the body which it touches. This 
 is what demands the earnest atteation both 
 of the surgeon and the instrument-maker, 
 especially as the hips of some individuals 
 are fiat and narrow, while those of other 
 persons are broad and prominent. A thick, 
 flexible, metallic wire, accurately applied 
 round the pelvis, will serve to take the mea 
 sure and proper shape of the spring, which 
 may afterward be altered a little if found 
 necessary. The wire, however, should be 
 somewhat longer, on account of the length 
 of the spring.' 
 
 The springs of trusses intended for chil- 
 dren, and persons who do not undergo 
 much labour and exertion, need not be 
 made so strong as those designed for hard- 
 working, active people. 
 
 The idea, that children cannot wear steel 
 trusses, is as erroneous as it is dangerous in 
 its practical consequences ; a point, on 
 which tVjr. Pott has strongly insisted. 
 
 Trusses are sometimes fabricated with a 
 pad moveable on the spring, instead of 
 being riveted to it. This may be inclined 
 upwards, or downwards, according to the 
 form of the abdomen ; and it is retained at 
 the desired point by a spring fitting into the 
 teeth of a rack, in others, the plate con- 
 tains a screw, by which the cushion is 
 pushed further inward, or allowed to recede 
 at pleasure. Although there cannot be a 
 doubt, that some of these inventions possess 
 considerable merit, and are in certain in- 
 stances superiorly useful, it must be con- 
 fessed, that, in general, their utility is not 
 samuch greater, than that of common pads, 
 as to. make amends for the want of simpli- 
 city and the increase of expense. I should 
 be sorry, however, to say any thing that 
 would unfairly discourage all such inge- 
 nious endeavours to improve an instrument. 
 
 603 
 
 so difficult 10 bring lo perfection a3 a truss; 
 especially as I believe there are particular 
 cases, in which pads, with racks, screws,, 
 springs, kc. gaay be employed with great 
 advantage. 
 
 jNot withstanding every care, sometimes 
 even elastic trusses cannot be hindered 
 from slipping away from the part, which 
 they are designed to compress. Sometimes 
 they slip downwards, which in fat subjects 
 is generally caused by the projection of the 
 abdomen. Occasionally, ‘the fault consists 
 in the instrument becoming displaced in 
 the direction upwards, which mostly hap- 
 pens in thin persons, and is produced by the 
 flatness of the abdomen. In the first case* 
 the displacement is to be prevented by the 
 use of an elastic scapulary ; in the second, 
 the slipping of the pad- upwards is to be 
 prevented by the employment of a thigh 
 strap. 
 
 When a patient is afflicted with a rupture 
 on each side, the two protrusions may be 
 very well kept up by means of a single 
 truss, made with two pads, which are joined 
 together, at the exact distance of the rings 
 from each other, by a piece of steel, ap- 
 plied over the convexity of the symphysis 
 of the pubes, and proportioned in length to 
 the space between the two openings, through 
 which the viscera descend. In such cases,, 
 however, it is absolutely necessary to have 
 the spring stronger, than if there were only 
 one rupture. The truss should also be put 
 ou that side of the body, upon which the 
 hernia most difficult to retain is situated. 
 There are some practitioners, however, who 
 give the preference to the use of two single 
 trusses, joined together in front and behind 
 with suitable straps. 
 
 With respect to the application and use 
 of trusses, the following instructions seem 
 to merit attention. 
 
 1. A truss should never be first applied, 
 or changed, except when the patient is in 
 the horizontal posture, and it is known P 
 with certainty, that all the contents of the 
 rupture are completely reduced. 
 
 2. The first applications of a truss should 
 always be made under the superintendency 
 of the surgeon himself j and care should be 
 taken to put on the instrument in such a 
 manner, that the lower third of the pad will 
 compress the neck of the hernial sac against 
 the os pubis, while the upper portion will 
 compress the abdominal ring. The surgeon 
 should also make the patient acquainted 
 with the right manner of applying the 
 truss ; the principles on which it keeps up 
 the bowels, and affords a chans e of a rad cal 
 cure ; the requisite cautions to be observed, 
 he. When a patient first begins to wear a 
 truss, he should be particularly careful not 
 to he guilty of any imprudent exertions, and 
 it behoves him to observe most attentively, 
 that the instrument does not slip from its 
 proper situation It will also be necessary 
 for him to pay attention to the instrument 
 being neither too ti^ht, nor too loose. 
 
TRET 
 
 &04 
 
 3. The patient ought to be' provider with 
 at least two trusses, which should be chan- 
 ged every morning in bed. In order to save 
 the truss, especially in fat persons who per- 
 spire a gr^at deal, it is a good plan to lay a 
 soft piece of calico under the pad. 
 
 4. An uneasiness about the ring, which 
 always gives rise to a suspicion that a por- 
 tion of intestine, or omentum, is protruded, 
 makes it proper to take off the truss, care- 
 fully examine the parts, and reduce them if 
 they have descended. 
 
 5. When the skin is excoriated by the 
 truss, the part may be cured by sprinkling 
 upon it the povvder of acetite of lead, Ful- 
 ler’s earth, lapis calamiriaris, &.c or bathing 
 the part with an astringent lotion, it will 
 also be right to protect the excoriated place 
 with a piece of linen put under the truss. 
 
 <5. When the pressure of the truss excites 
 affections and swellings ot the spermatic 
 chord and testicle, either the thigh strap 
 must be relaxed, or the lower part of the 
 pad made less prominent. And when strong 
 pressure is absolutely necessary to keep the 
 hernia reduced, the pad should have an ex- 
 cavation in it over the spermatic chord. 
 Whoevef wears a truss should be careful to 
 employ it day and night, without interrup- 
 tion, so that there may be no opportunity 
 for the hernia to protrude again. If under 
 the employment of a truss, the rupture once 
 descends again, either a strangulation hap- 
 pens from the narrowness of the neck of the 
 sac ; or, at all events, the hope of a radical 
 cure, which may have been entertained for 
 years and months, is destroyed in a mo- 
 ment ; for, experience has put it beyond all 
 doubt, that, by the continual unremitted use 
 of a truss, and the steady retention of the 
 contents of the hernia, the neck of the her- 
 nial sac, and the nog, may be gradually 
 lessened in diameter, until they are entirely 
 closed, and n radical cure of the rupture 
 effected. This is more frequently observed 
 in young subjects, seldom in aduits, and 
 scarcely ever in persons of advanced years. 
 But trusses must be worn along while ; nor 
 should the patient venture to lay aside their 
 use till after many cautious attempts ; be- 
 ginning the experiment at first only in^the 
 night-time, and not making it in the day till 
 after a considerable period from the time, 
 when he first thinks himself safe. The 
 longer and more attentively a truss is worn, 
 the greater is the hope of a radical cure. 
 ( Callisen , Syst. Ckir. Hod. T. 2.) 
 
 In the 2d vol. of the last edition of the 
 First Lines of the Practice of Surgery, the 
 truss for navel ruptures, which was devised 
 by Mr. England and latterly preferred by 
 Mr. Hey, is described ; and in the article 
 Hernia , an account is given of the truss for 
 umbilical hernia, invented by Mr. Murrison 
 of Leeds, and described by Mr. Hey. In 
 the same part of this Dictionary may also be 
 found some observations, relative to the 
 place, against which the pressure of the 
 pads of trusses should be directed in cases 
 of inguinal hernia, iri conformity to Sir A. 
 Cooper’s description of the situation, at 
 
 t m. 
 
 which the parts first protrude from the ab- 
 domen. 
 
 TUMOUR. A swelling. In the present, 
 article, I intend only to treat of what are 
 usually called sarcomatous and encysted 
 tumours. Mr. Abernethy thinks, that the 
 manner in which tumours are formed is best 
 illustrated by those which hang pendulous 
 from the membranous lining of different ca- 
 vities. This gentleman adverts to an ex- 
 ample noticed by Mr. Hunter, in which, ca 
 the cavity of the abdomen being opened, 
 there appeared lying upon the peritoneum, 
 a small portion of red blood recently co- 
 agulated. This, on examination, was found 
 to be connected with the surface, upon 
 which it bad been deposited, by means of 
 an attachment, half an inch long, and this 
 neck had been formed before the coagulum 
 had lost its red colour. (See Trans. for the 
 Improvement of Med. and Ckir. Knowledge, 
 Vol. 1, p. 231.) Mr Abernethy observes, 
 that if vessels had shot through the slender 
 neck, and organized the clot of blood, this 
 would then have become a living part : it 
 might have grown to an indefinite magni- 
 tude, and its nature and progress would 
 probably have depended on the organiza- 
 tion, which it had assumed. He mentions 
 his possession-of a pen, found growing from 
 the surface of the peritoneum, and which 
 was undoubtedly formed in the same man- 
 ner as the tumour noticed by Mr. Hunter, 
 viz. by vessels shooting into a piece cf ex- 
 travasated blood, or lymph, and rendering 
 it a living organized substance. Tumours, 
 in every situation, and of every description, 
 are probably formed in the same way. The 
 coagulating lymph being effused, either ac- 
 cidentally, or in consequeiTee of disease, is 
 afterward converted into a living part, by 
 the growth of the adjacent vessels and 
 nerves into' it. Mr. Abernethy remarks, 
 that, when the deposited substance has its 
 attachment by a single thread, all its vascu- 
 lar supply must proceed through that part : 
 but, in other cases, the vessels shoot into it 
 irregularly at various parts of its surface 
 Thus, an unorganized concrete becomes a 
 living tumour, which has at first no percep- 
 tible peculiarity as to its nature. Although 
 its supply of blood is furnished by the ves- 
 sels oi the surrounding parts it seems to live 
 and grow by its own independent powers, 
 while its future structure seems to depend 
 on the operation of its own vessels. Mr. 
 Abernethy conceives, that the altered struc- 
 ture of an enlarged gland affords no contra- 
 diction to the above account, as, in this 
 latter case, the substance of the gland is the 
 matrix, in which the matter, forming the 
 tumour, or enlargement, is deposited. The 
 structure of a tumour, he observes, is some- 
 times like that of the parts, near which it 
 grows. Such as arc pendulous in joints, 
 a re cartilaginous, or osseous. Fatty tumours 
 frequently' form in the midst of the adipose, 
 substance ; and he has seen some tumours 
 growing from the palate, which had a slen- 
 der attachment, and resembled the palate 
 in structure. 
 
TUMOUR. 
 
 However, this resemblance of the struc- 
 ture of a tumour to that of the neighbouring 
 parts, is not always observable. I have in 
 my own possession a completely cartilagi- 
 ft nous tumour, which I found in the midst of 
 the fat near the kidneys. The pendulous 
 portion of fat, growing from the perito- 
 neum, and mentioned by Mr. Abernethv, 
 serves as another instance of the fact ; and, 
 one might add, that every polypus which 
 we meet with, bears no resemblance in struc- 
 ture to the neighbouring parts. Mr Aberne- 
 thy mentions his having seen bony tumours, 
 which were unconnected with bone, or the 
 periosteum, and he observes, that the struc- 
 ture of a tumour is, in general, unlike that 
 of the part in which it is produced. 
 
 When the eoagulable part of the blood is 
 effused, and the absorbents do not take it 
 away, the surrounding blood-vessels are sup- 
 posed to grow into it, and convert it into a 
 vascular tumour. The effusion of the coa- 
 gulable part of the blood may be the effect 
 of accident, or of a common inflammatory 
 process, or it may be the consequence 
 of some diseased action of the surround- 
 ing vessels, which (diseased action) may in- 
 fluence the organization, and growth ot the 
 tumour. 
 
 In the former cases, the parts surrounding 
 the tumour maybe considered simply as the 
 sources, from which it derives its nutriment, 
 while it grows apparently by its own in- 
 herent powers, and its organization depends 
 upon actions begun and existing in itself. If 
 such a tumour be removed, the surrounding 
 parts being sound, soon heal, and a complete 
 cure ensues. But if a tumour be removed, 
 whose existence depends on the disease of 
 the surrounding parts, which are still left, 
 and this disease be not altered by the sti- 
 mulus of the operation, no benefit is ob- 
 tained. These parts again produce a dis- 
 eased substance, which has generally the ap- 
 pearance of fungus, and, in consequence of 
 being irritated by the injury of the operation, 
 the disease is in general increased by the 
 means which were designed for its eure. it 
 appears, therefore, that in some cases of tu- 
 mours, the newly-formed partalone requires 
 removal, whilst in others, the surrounding 
 substance must be taken away, or a radical 
 cure cannot be effected. {Abernethy’s Surg. 
 Obs. 1804.) This gentleman conceives, that 
 the irritation of the tumour itself, when 
 once the swelling has been produced, keeps 
 up an increased action in the surrounding 
 vessels, so as to become a sufficient cause of 
 the disease continuing to grow larger. As 
 the tumour becomes of greater magnitude, 
 it condenses the surrounding cellular sub- 
 stance, and thus makes for itself a sort of 
 capsule. The close, or loose manner, in 
 which tumours become connected with the 
 surrounding parts, seems to depend very 
 much on the degree of irritation and inflam- 
 mation excited in the circumjacent parts. 
 When a tumour has been at all tender, pain- 
 ful, and inflamed, it is generally found inti- 
 mately adherent to all the neighbouring parts. 
 Mr. Abernethv also believes, that the increa' 
 Voi. II 64 
 
 sed irritation whicli a tumour creates when 
 it has exceeded a certain size, may explain 
 why some tumours, which are at first slow 
 in their progress, alterward begin to grow 
 with great rapidity. 
 
 Ihe process by which tumours are form- 
 ed, is commonly thought to be attended 
 with an increased action of the vessels, 
 which supply the swellings with blood. It 
 is supposed, in short, to be (he same kind of 
 process, which forms all the thickenings and 
 indurations, which, under various circum- 
 stances, occur in different parts of the human 
 body. It has sometimes been named chronic 
 inflammation, to distinguish it from that 
 which is more quick in the production of 
 certain effects, aud is often attended with a 
 manifest throbbing in the part affected. 
 This subject of chronic, or passive inflamma- 
 tion is one, about which very little certain 
 is known ; and the very name has commonly 
 been admitted only on the supposition, that 
 some kind of increased action exists in the 
 vessels, though of a slower and less evident 
 kind, than what prevails in acute inflamma- 
 tion. According to Dr. Wilson Philip, the 
 difference between what is called active and 
 passive inflammation seems to depend upon 
 “ the degree, in which the arteries supplying 
 the i«a a tergo to the debilitated vessels are 
 excited.” ( Laws oj the Vital Functions, p. 
 ^82, Edit. 2.) If this position be satisfac- 
 torily established, one important step will be 
 made to a knowledge of the differences be- 
 tween acute and chronic inflammation ; but, 
 much would yet remain for explanation be- 
 fore our ideas of the latter process would be 
 at all complete 
 
 In a work of considerable merit, Dr. Baroa 
 of Gloucester, offers many considerations 
 against the correctness of the ordinary doc- 
 trines, respecting the formation of tubercles 
 and tumours. By tubercles, he means disor- 
 ganizations composed of one cyst, “ what- 
 ever be its magnitude, or the nature of its 
 contents,” and by tumours, he would under- 
 stand “ morbid structures, that appear to be 
 composed of more than one tubercle.” {On 
 1 uberculated Accretions of Serous Membranes t 
 fyc. p. 213.) From certain appearances, 
 traced in dissections, Dr. Baron infers, (hat 
 all tubercles, wherever situated, and of what- 
 ever 9ubs(ance composed, were at their 
 commencement small vesicular bodies, with 
 fluid contents ; hydatids, as he endeavours to 
 prove. “ It is impossible to say, how minute 
 they may have been at their origin, nor how- 
 large they may grow, before their transfor- 
 mations begin ; nor are we acquainted with 
 the circumstances which occasion such 
 transformations.” To these changes in hyda- 
 tids, (accordingtothis writer,) certain tuber- 
 cles owe their existence, and on the size, 
 relative position, and structure of the tubercles, 
 which are so formed, depend the characters of 
 many of the most formidable disorganisations, 
 to which the human body is exposed. (P. 
 215.) A single hydatid, when it is trans- 
 formed (says Dr. Baron) will give rise to 
 one tubercle. “ It may be pendulous, or 
 embedded in any soft part, or it mav be- 
 
TL'MOl/H 
 
 
 found between the layers of membranes, 
 ami wherever the textures are of such a na- 
 ture as to admit of its growth. It may be 
 so small as to be scaicely visible, or, it may 
 acquire a very great magnitude. Single tu- 
 bercles are often seen in a viscus, while all 
 the rest of the organ is free from disease, and 
 its functions are performed in 'an uninter* 
 vupted manner. But, it is evident, that the 
 same state of the system, (whatever that 
 may be,) which calls one tubercle into ex- 
 istence, may generate an indefinite number. 
 They may be diffused through the whole of 
 a viscus, leaving nothing of its original tex- 
 ture, or they may occupy any proportion of 
 it, or extend to the contiguous parts, and in- 
 volve them in the same form of disease.” 
 (P. 216.) When hydatids growing in clusters, 
 and hanging within cavities, become changed 
 into tubercles, Dr. Baron conceives, that the 
 morbid appearances must of course corres- 
 pond in some degree, with the original dis- 
 tribution of the parts. He has seen tubercles 
 attached in this form to the choroid plexus, 
 to the valves of the heart, to the. fimbriated 
 extremities of the Fallopian tubes, aud to 
 the omentum, and convolutions of the bow- 
 els. In the latter instance, they were very 
 minute, the largest not being bigger than the 
 head of a pin, and their number defied all 
 calculation. 
 
 “ Other varieties in the arrangement of 
 the elementary parts of morbid growths, 
 will of course cause corresponding varieties 
 in their appearance. Thus, when hydatids 
 art enclosed, the one within the other , and are 
 transmitted into solid substances , a section of 
 these substances will exhibit a series of concen- 
 tric laminae .” 
 
 Another variety pointed out by Dr. Baron, 
 is “ when an immense number of very small 
 tubercles are generated in juxtaposition, and 
 unite together. Wherever such an event 
 occurs, the original texture of the part is en- 
 tirely lost, and a mass of varying degrees of 
 density and firmness formed. In the earlier 
 stages of its growth, a granulated appearance 
 may be distinctly traced ; but, in process of 
 time, this disappears, the consolidation be- 
 comes more complete, and substances of a 
 gristly, or cartilaginous, or scirrhous texture 
 may be found. 1 have traced (says Dr. 
 Baron,) the whole of these gradations in 
 the liver, the lungs, the pleura, the omentum, 
 the peritoneum, and in tumours in other 
 parts.” (P. 219.) 
 
 “ Sometimes, small hydatids grow from 
 the outer or inner surface of large ones, or 
 float within them. I have seen, (says Dr. 
 Baron,) from a source of this kind, the uterus 
 and its appendages converted into an enor- 
 mous misshapen mass, tubercles of the size 
 of the fist growing from it, while these 
 again were surmounted by smaller ones in 
 many gradations. Some had glairy contents, 
 others were in a state of scirrhosity, and 
 others were but little changed, having thin 
 delicate cysts, and containing a transparent 
 fluid. 
 
 “ But, perhaps, (remarks Dr. Baron) the 
 xuost important variety of all, is when tuber- 
 
 cles, originally distinct irom each other, ap - 
 proximate as they increase in size, ulti- 
 mately unite, and form tumours, which have 
 received different designations, according to 
 the predominant character of their contents 
 and internal structure. It was chiefly to 
 elucidate this part of the subject, that I 
 made the distinction between the words 
 tumour and tubercle, Sic.” (P.219.) By thus 
 adverting to the primitive arrangement, 
 number, size, &.c. of hydatids, and their sub- 
 sequent mutations, Dr. Baron tries to ac- 
 count for the varieties of encysted and sar- 
 comatous tumours, fungus hcematodes, tu~ 
 berculated sarcoma, scirrhous swellings, &c. 
 kc. The late Dr. Adams, as is well known, 
 referred cancer to the living state, growth, 
 and multiplication of the hydatid. (On the 
 Cancerous Breast , p. 77.) In order to account 
 for the various appearances of the disease, 
 he has divided hydatids into a number of 
 species, as iymphatica, cruenta, and carcino- 
 matosa, and suspectsthat there may be others. 
 These, he affirms, are lodged in different 
 cavities, or enclosed in a fungus, which is 
 occasioned by any individual, or numbers, 
 stimulating the surrounding parts to gene- 
 rate it, for the purpose of dividing the dead 
 from the living. This fungus is a nidus, 
 formed altogether for the protection of an- 
 other generation ; by means of it, the living 
 families are separated from the dead, and 
 their preservation is secured. They die, he 
 says, without otherwise affecting the body 
 in which they existed, but by their local 
 stimulus, and he declares, that his object is 
 to prove the animalcular existence of carci- 
 noma. Now, according to Dr. Baron, this 
 main position is the fundamental error of 
 Dr. Adams’s book; for, “ in no rational, nor 
 legitimate point of view may cancer be 
 said to have an animalcular existence ; be- 
 cause admitting, for the sake of argument, 
 that hydatids are animalcules, it has, I trust, 
 been shown, (says Baron,) that it is to the loss 
 of the hydatical character altogether, and the 
 transformations of these bodies , that the mor- 
 bid appearances in this, and many other dis- 
 eases, ure to be referred .” (P. 276.) 
 
 Although 1 consider the evidence and re- 
 marks, which Dr. Baron has adduced, in sup- 
 port of his opinions in many respects inter- 
 esting, the facts brought forward do not ap- 
 pear to me to justify the conclusion, that the 
 formation of tubercles and tumours original- 
 ly depends upon hydatids, and their transfor- 
 mation. That hydatids are sometimes found 
 within diseased structures, and that cells, 
 cysts, granulated, and tuberculated appear- 
 ances ure often noticed in tumours of differ- 
 ent kinds, are facts universally received 
 But the presence of hydatids in the unchanged 
 state is only an occasional circumstance, 
 whereas, if they were generally a cause of 
 tumours by undergoing some unexplained 
 transformation, it is impossible to suppose, 
 that some of them, at least, would not be 
 more commoulyfou d in a distinct, unaltered 
 form within, or around all swellings, imagined 
 to proceed from clusters of them. As the 
 growth of tumours, formed on these prind 
 
11 MOL R 
 
 507 
 
 pies, could not, 1 imagine, "be accounted for, 
 without supposing a continual multiplication 
 and transformation of hydatids, either witli- 
 in, or around the swellings, one would ex- 
 pect, that some visible hydatids, previously 
 to tbeir transfiguration, would certainly be 
 apparent on minutely examining the interior 
 and the circumference of the diseased struc- 
 ture. Yet, I am not aware, that, such fact 
 has been proved to be generally the case, 
 either by the aid of the scalpel, or the mi- 
 croscope. The observation of cavities, cells, 
 and tuberculated appearances in some kinds 
 of tumours, is no proof that such modifica- 
 tions of structure are transformed hydatids. 
 Besides, if my limits would allow me to con- 
 sider this topic further, many reasons might 
 be urged against the hydatid doctrine, arising 
 from the consideration of the changes evi- 
 dent in the blood-vessels, supplying parts, 
 in which a considerable tumour is situated. 
 Thus, we often see the trunks of the arteries, 
 running towards such parts, doubled in size, 
 just as is noticed, with respect to the carotid 
 in the natural growth of the stag’s horn, 
 and indicating, at least, that the formation 
 and increase of swellings are effected through 
 the medium of the blood-vessels. The sud- 
 den effect of tying the arteries, by which a 
 tumour is supplied with blood, would also be 
 difficult to explain, if the growth of the 
 swelling really depended upon some unde- 
 fined transformation of hydatids. 
 
 It seems to be generally admitted, that the 
 growth of all tumours may be retarded, and 
 that sometimes they may even be diminished 
 by means of topical bleeding w ith leeches, 
 and keeping the parts in a continuaiiy cool 
 state, by the incessant application of cold 
 sedative washes. Afterward, when the in- 
 creased action of the vessels seems checked, 
 and the tumour ceases to enlarge, discu- 
 tients are indicated, such as frictions with 
 mercurial ointment, pressure, electricity, 
 rubefacient plasters, solutions of salts, blis- 
 ters, and issues. Very few sarcomatous or 
 encysted tumours, how r ever, are ever com- 
 pletely removed by these local means. The 
 swelling, on the contrary, generally increas- 
 es, notwithstanding them, and the irritation 
 of the disease by stimulants is not altogether 
 unattended with danger of the affection be- 
 coming changed by them into very malig- 
 nant and dangerous cases, sometimes to a! I 
 appearances cancerous. The most odviseable 
 plan is to recommend the removal of sar- 
 comatous tumours with the knife, while 
 they are small, and in an incipient state. 
 For thus they are got rid of by an operation, 
 which is certainly trivial, compared with 
 what might afterward become requisite, if 
 the disease were allow ed to proceed, and 
 attain an enormous magnitude. 
 
 Tumours, Sarcomatous. These have 
 been so named, from their firm, fleshy feel. 
 They are of many kinds, some of which are 
 simple, while others are complicated w ith 
 a malignant tendency. Mr. Abernethy has 
 attempted to form a classification of sarco- 
 matous tumours, for the different species of 
 which be has proposed names, deduced from 
 
 the structure, which they exhibit on dissec- 
 tion. This gentleman has named the kind 
 of swellings, which lie first considers, Com- 
 mon Vascular, or Organized Sarcoma. Un- 
 der this title, Mr. Abernethy includes all 
 those tumours, which appear to be con 
 posed of the gelatinous part of the blood, 
 rendered more or less vascular by the 
 growth of vessels through it. The vessels 
 which pervade this substance are, in differ- 
 ent instances, either larger or smaller ; and 
 more or less numerous; being distributed 
 in their usual arborescent manner, without 
 any describable peculiarity of arrangement. 
 Perhaps all the varieties of sarcomatous tu- 
 mours are at first of this nature. The struc- 
 ture under consideration, is met with not 
 only in distinct tumours, but also in the 
 testis, mamma, and absorbent glands. When 
 a common vascular, or organized sarcoma 
 has attained a certain magnitude, the veins 
 of the skin seem remarkably large, and their 
 winding under the integuments excites no- 
 tice. This kind of sarcoma is not at all 
 tender, so that it may be freely handled, 
 and also electrified, without, giving pain. 
 The tumour sometimes grows to such a size 
 that the skin bursts, the substance of the 
 swelling sloughs out, and the disease isgot 
 rid of. However, this mode of cure is at- 
 tended with such terrible local appearances, 
 and so much fever, &ic. that the removal of 
 the disease w ith the knife is to be preferred. 
 
 The second kind of sarcomatous tumour, 
 noticed in Mr. Abernethy ’s classification, is 
 the Adipose Sarcoma. Every one, at all in 
 the habit of seeing surgical diseases, must 
 know, that fatty tumours are exceedingly 
 common. Mr. Abernethy believes, that 
 these swellings are formed in the same 
 manner as others, viz. in the first instance 
 they were coaguiablc lymph, rendered vas- 
 cular by the grow th of vessels into it, and 
 that their future structure depended on the 
 particular power and action of the vessels. 
 According to Sir Astley Cooper, “ they are 
 not composed of fatty matter only ; but the 
 adipose membrane is increased, and their 
 structure is similar, only somewhat more 
 compact, to that of the fatty membrane i:i 
 other parts of the body.” (Med. Chir. Trans. 
 Vol. 11, p. 440.), This fact is very muck 
 against the doctrine, which ascribes the ori- 
 gin of tumours to hydatids and their trans- 
 formation. Adipose sarcomatous tumours 
 always have a thin capsule, formed by the 
 simple condensation of the surrounding cel- 
 lular substance. It adheres very slightly to 
 the swellings, and, chiefly by means of ves- 
 sels, which pass through this memoranons 
 covering in orderto enter the tumour. As 
 Mr. Abernethy has accurately described, 
 the vessels are so small, and the connexion 
 so slight, that, in removing the tumour, no 
 dissection is requisite, as the operator may 
 easily put his fingers between the swelling 
 and its capsule, so as to break the little vas- 
 cular connexions, and entirely detach the 
 disease. 
 
 The substance of adipose tumours is never 
 furnished with verv large blood-vessels, and 
 
I'UMOUB 
 
 the fear of hemorrhage, w^ich frequently 
 deters surgeons from operating, is quite un- 
 founded. It is an undoubted Tact, that there 
 is no species of tumour, that c air be removed 
 with so much celerity, with such apparent 
 dexterity, or with such complete security 
 against future consequences, as those of an 
 adipose nature. However, now and then, 
 when the tumour has been at all in an in- 
 flammatory state, the capsqle becomes thick- 
 ened, and intimately adherent to the surface 
 ot the swelling, so that the separation of the 
 disease is more difficult, and requires the 
 knite to be more freely employed. The 
 tumour also sometimes becomes, after in- 
 flammation, closely adherent to the conti- 
 guous parts. Adipose tumours often ac- 
 quire an enormous magnitude. Indeed, 
 there can be no doubt of the fact stated by 
 Sir Astley Cooper, that they acquire a 
 greater magnitude than any other swelling 
 ever reaches. Mr. Abernethy relates an 
 example of one, removed by Mr. Cline, 
 which weighed between 14 and 15lbs., and 
 which I saw myself previously to the opera- 
 tion. Sir Astley Cooper also mentions the 
 successful extirpation of several adipose tu- 
 mours of immense size : one weighing 141b. 
 105. removed by himself; another. weigh- 
 ing I5lbs. removed by Mr. Cline and a 
 third, weighing 221bs. removed from a lady’s 
 thigh by Mr. Copeland. But the most re- 
 markable case is one, in which Sir Astley 
 Cooper lately removed a fatty swelling which 
 weighed, independently of the blood in it, 
 371bs. lOozs., and was situated on the ab- 
 domen of a man, aged 57. (See Med. Ckir. 
 Trans. Vol. 11 ,p. 440.) Although it is true, 
 that when adipose swellings attain an enor- 
 mous bulk, the immense size of a wound 
 requisite for their removal, must he danger- 
 ous, and is a strong argument in favour of 
 having recourse to the operation at an ear- 
 lier period, yet it is equally true, that large 
 fatty swellings may be taken out, with a 
 greater prospect of success, than any other 
 kind of tumour of equal size. 
 
 The next species of sarcoma, noticed in 
 Mr. Abernethy’s classification, is what this 
 gentleman names pancreatic, from the re- 
 semblance of its structure to that of the pan- 
 creas. This kind of disease, according to 
 Mr. Abernethy, is occasionally formed in 
 the cellular substance ; but, more frequent- 
 ly, in the female breast, on that side of the 
 nipple which is next to the arm. When a 
 pancreatic sarcoma is indolent, and in- 
 creases slowly, the surrounding parts, and 
 the glands in the axilla, are not affected. 
 But some of these swellings deviate from 
 their common character, and become of a 
 very irritable nature, occasioning severe 
 and lancinating pain, and producing an in- 
 flammatory state of the skin covering them, 
 so that it becomes adherent to their surface. 
 The absorbents leading to the axiila are also 
 irritated, and the glands enlarged. Pancre- 
 atic sarcoma does not grow to a very large 
 size ; but, when its progress is unrestrained, 
 the pain attendant on the disease becomes 
 Janeinating, and so severe as to make the 
 patients Feverish, and lose tbeir health and 
 
 strength. Mr. Abernethy remarks, that, 
 when the axillary glands become affected, 
 one generally swells at first, and is extreme- 
 ly tender and painful ; but afterward the 
 pain abates, arid the part remains indurated. 
 Another is then affected, and runs ihrougk 
 the same course. 
 
 To another species of sarcoma, Mr. Aber- 
 nethy applir s the epithet mastoid, or mam- 
 mary, from the resemblance which this gen- 
 tleman conceives its structure bears to that 
 of the mammary gland. This kind of dis- 
 ease, Mr. Abernethy says he has not often 
 seen. In the example which he met with, 
 the tumour was about as large as an orange, 
 and situated on a woman’s thigh. The 
 swelling was removed by an operation ; but 
 the wound afterward degenerated into a 
 malignant ulcer, attended with considerable 
 induration of the surrounding parts, and the 
 woman died of the disease in two months. 
 Mr. Abernethy conceives, that the whole of 
 the s morbid part had been cut away, but 
 that the contiguous parts had a disposition 
 to disease, which was irritated by the ope- 
 ration, and that if the nature of the case 
 could have been known beforehand, it 
 would have been right to have made a freer 
 removal of the substance surrounding the 
 tumour. 
 
 Mr. Abernethy places the mastoid sarco- 
 ma, between such sarcomatous swellings as 
 are attended with no malignity, and the fol- 
 lowing ones, which have this quality in a 
 very destructive degree. 
 
 The tuberculated sarcoma is composed of 
 a great many small, firm, roundish tumours 
 of different sizes and colours, connected to- 
 gether by cellular substance. Some of the 
 tubercles are as large as a pea ; others equal 
 a borsebean in size ; most of them are of 
 a brownish red colour; but some are yel- 
 lowish. Mr. Abernethy mentions his hav- 
 ing seen this species of sarcoma chiefly in 
 the lymphatic glands of the neck. The dis- 
 ease proceeds to ulceration ; becomes a 
 painful and incurable sore, and ultimately 
 occasions death. 
 
 Another kind of sarcoma, mentioned in 
 Mr. Abernethy’s classification of tumours, 
 is distinguished by the epithet medullary , 
 from its having the appearance of the me- 
 dullary matter of the brain. It appears to 
 be an exceedingly malignant disease ; com- 
 municates to the lymphatic glands a similar 
 distemper; ulcerates and sloughs, and at 
 last proves fatal. It is particularly apt to 
 make its attack on the testis, and it is treat- 
 ed of in another part of this book. (See 
 Testicle, Diseases of.) 
 
 Mr. Abernethy includes also in his classi- 
 fication, carcinomatous sarcoma. (See Can 
 cer.) 
 
 1 must refer to another article, (Mamma. 
 Removal of) for an account of the plan of 
 removing sarcomatous tumours. 
 
 Besides many operations, which have of 
 late years been performed, and are remark- 
 able, on account of the great size ot the 
 swellings removed, others, still more inte- 
 resting, claim attention, on account ot the 
 nature and situation of the parts extirpated, 
 
TUMOUR. 
 
 509 
 
 On the excision of the thyroid gland, I need 
 not here dwell, as it is elsewhere noticed. 
 (See Thyroid. Gland ;) but I feel called up- 
 on to mention some other very bold ope- 
 rations, executed within the last few years- 
 The first is that performed by Mr. Goodlad, 
 oi Bury, in Lancashire. The case was an 
 immense tumour, situated on the left side 
 of the face and neck, and the base of which 
 was about twenty-eight inches in circum- 
 ference. The disease extended from the 
 external canthus of the eye above to within 
 three-quarters of an inch of the clavicle 
 below, and some idea of the depth of its at- 
 tachments may be conceived, when it is 
 known, that the whole parotid gland was 
 involved in it. For the purpose of obvia- 
 ting all danger of hemorrhage, Mr. Goodlad 
 began with tying the carotid artery. The 
 nature of the operation will be best under- 
 stood by adverting to the appearances after- 
 ward presented by the wound. “ The 
 whole sterno-mastoid muscle was exposed, 
 and its fibres dissected clean, except about 
 half an inch from its insertion into the cla- 
 vicle. The wound extended backwards 
 from behind the mastoid process to the tra- 
 chea anteriorly, but became narrower in 
 the direction of the muscle at the lower part 
 of the neck. The submaxillary gland was 
 exposed, and about one-fifth of its substance, 
 not appearing healthy, was removed. The 
 digastric and the greater portion of the 
 myln-hyoideus were exposed The ramus 
 of the jaw w as only covered by periosteum, 
 except where covered by the masseter mus- 
 cle, part of which, not appearing healthy, 
 was dissected away The w r ho!e of the 
 condyloid process of that bone was laid 
 bare in the same manner, and behind it the 
 pterygoid muscles were also exposed. The 
 membrane of the cheek was only covered 
 by a cellular substance, which did not ap- 
 pear healthy; but sufficient skin was saved 
 to cover the zygoma. The parotid gland 
 was entirely removed This enormous 
 wound healed in ten weeks ; but unfortu- 
 nately the cure was not permanent ; the 
 disease returned, and, fifteen months after 
 the operation, the poor w^oman died. (See 
 Med. Chir. Tram. Vol. 7, p. 112, fyc. Vol. 8, 
 
 1 5 § 2 -) 
 
 Respecting the foregoing severe opera- 
 tion, many surgeons may be inclined to 
 doubt the propriety of tying the carotid ar- 
 tery, as a preparatory step, and, indeed, it 
 is positively condemned in an anonymous 
 note attached to the above case, simple 
 temporary pressure on the exposed vessel 
 being represented as preferable. It appears 
 tome, however, that Mr. Goodlad's method 
 was justifiable, and on the whole the best, 
 because the application of the ligature to 
 the carotid not only removed the dangers of 
 hemorrhage during the operation, but obvi- 
 ated them afterward, and no doubt lessened 
 the necessity for a prodigious number of 
 ligatures, for vessels, wdiich w T ould other- 
 wise have poured out a profuse quantity of 
 blood. 
 
 Nay f the hemorrhage is so profuse from 
 
 the main branches of the external carotid, 
 and mere pressure so uncertain of always 
 commanding the flow' of blood, that the pa - 
 tient may actually die from sudden loss of 
 blood, as nearly happened in another very 
 interesting case of removal of a large tu- 
 mour involving also the parotid gland, and 
 connected with the transverse process of 
 the atlas, the basis of the skull, the meatus 
 auditories, mastoid process, and angle of 
 the jaw. The operator, Mr. Carmichael, in 
 order to complete the dissection, was obli - 
 ged to divide the trunk of the facial artery ; 
 “ instantly (says he) an alarming gush of 
 biood, which evidently came from a large 
 vessel, followed the division ; and the dan- 
 ger appeared the more imminent as the pres- 
 sure, which Mr. Todd applied, with all the 
 force he could exert vpon the carotid trunk , 
 was actually incapable of repressing the ior- 
 rent. There was not a moment to be lost. 
 Mr. Collbs plunged a dry sponge to the bot- 
 tom of the wound, and firmly pressed on the 
 bleeding vessel, while 1 made a horizontal 
 section of the tumour, till 1 arrived at the 
 cavities occupied by the sponge, with the 
 view of exposing as quickly as possible 
 the mouth of the bleeding vessel. This 
 was accomplished in sufficient time to save 
 the patient’s life.’ Mr. Carmichael, at the 
 conclusion of the history, remarks, that, if 
 he were called upon to perform such an 
 operation again, he would , in the frsl in- 
 stance, pass a ligature under the carotid trunk, 
 which might be tightened, or not, as occasion 
 should require. The case here spoken of 
 had a successful termination. One remark- 
 able consequence was a paralysis of one 
 side of the face, brought on by the division 
 of the trunk of the portio dura in the opera- 
 tion. (Bee Trans, of the King’s and Queen’s 
 College of Physicians, Vol. 2, p. 101, 8vo. 
 Dublin, 1818.) 
 
 The next instance which I shall notice, of 
 the removal of an enormously enlarged pa- 
 rotid gland, is that lately recorded by Klein, 
 the eminent operating surgeon at Stuttgardt. 
 The patient w as a woman of seventy, and 
 the swelling extended from the ear to the 
 shoulder. In the operation, all the branches 
 of the facial nerve were divided ; a piece 
 of the masseter was left hanging ; the ex- 
 ternal carotid artery and par vagum were 
 left quite bare ; the dissected sterno-mastoid 
 lay on on side ; and the temporal, external 
 maxillary, and auricular arteries were of 
 course divided, along with several arteries 
 of the neck, yet the largest of these being 
 tied, the bleeding was very inconsiderable. 
 The event was so successful, that at 'the be- 
 ginning of the third week, the wound was 
 entirely healed. 
 
 The same distinguished surgeon also re- 
 moved a fatty tumour, extending from the 
 buttock to the ham, and measuring thfoe feet 
 one inch in length, and two feet six inches in 
 circumference. Klein undertook its remo- 
 val, on the supposition, that it was an en- 
 cysted tumour lying above the fascia lata ; 
 but it turned out to be a steatoma coming 
 from beneath it, and reaching to the thigh- 
 
>10 
 
 TUMOUR. 
 
 bone, and in every direction among the 
 muscles, nerves, and blood-vessels of the 
 thigh. At length, partly with the fingers, 
 and partly with the knife, the fatty mas3 
 was separated from all its important con- 
 nexions. Several vessels were tied, and 
 among them the profunda femoris. How- 
 ever, not more than a pound of blood was 
 lost. The tumour, after its removal, weigh- 
 ed 27lb. and three quarters. The patient, a 
 woman 44 years of age, went on very well 
 for eight days; but on the ninth, she was 
 constantly complaining of uneasiness in the 
 foot of the affected limb ; her pulse became 
 weak and intermitting ; and she sunk in the 
 most unexpected manner. (See Journ.fiir 
 Chirurgie herausgegeben von D. L. Graefe 
 und D. P. F. Walther, B. 1 , p. 106, fyc. Svo. 
 Berlin, 1820; or Quarterly Journal of Fo- 
 reign Medicine, $fc. Vol. 2, p. 373, <^c.) 
 
 A question may be entertained, whether, 
 in some morbid enlargements of the parotid 
 gland, and parts extending deeply about the 
 throat, it would not sometimes be better to 
 be content with simply tying the carotid 
 artery, and trying whether stopping this 
 large supply of blood to the diseased parts, 
 would not be followed by an absorption of 
 the tumour ? Some facts, appertaining to 
 this question, are noticed in the article 
 Aneurism , where the aneurism by anasto- 
 mosis falls under consideration. It will 
 there be seen, that the result of this experi- 
 ment is not sure of permanently repressing 
 the growth of a tumour of this last kind, 
 even when it has this effect at first. This 
 uncertainty will, no doubt, incline many 
 practitioners to prefer the bold method of 
 extirpation. Yet others will perceive, that 
 such an operation, notwithstanding its suc- 
 cess in a few examples, is dreadfully severe, 
 and must of itself in the generality of cases 
 have fatal consequences. They will also 
 be encouraged, in any similar instance, to 
 try the effect of the ligature, by the cure 
 which Sir A. Cooper accomplished, of an 
 enormous cutaneous enlargement of the 
 lower extremity by tying the artery in the 
 groin. Indeed, I atn sure, that as the im- 
 provements in modern surgery advance, the 
 plan of curing tumours by cutting off their 
 main supply of blood, will be much more 
 extensively adopted, than has hitherto been 
 the case. In this way, the surgeon may 
 4 attempt the dispersion of many tumours, 
 which could not be meddled with in any 
 other manner, and which, if left to them- 
 selves, must have a fatal termination. 
 
 Tumours Encysted. These, which are 
 commonly named wens, consist of a cyst, 
 which is filled .with different substances. 
 When the contained matter is fatty, it is 
 termed a steatoma ; when somewhat like 
 honey, meliceris ; when like pap, atfuroma. 
 These are the three species, into which 
 writers usually divide encysted tumours. 
 However, some of these swellings do not 
 conform to either of the above distinctions, 
 as their contents are subject to very great 
 variety indeed, and are occasionally of an 
 earthy, bony, or horny nature. Some en- 
 
 cysted tumours of the latter description 
 occasionally burst, and assume the appear- 
 ance of horns, by the gradual projection of 
 the matter secreted within their cysts. 
 (See Sir Evcrard Home's Obs. on the Growth 
 of Horny Excrescences , in Phil. Trans, for 
 1791.) . I remember seeing an excrescence 
 of this kind removed some years ago from 
 the scrotum of a man in St. Bartholomew’s 
 Hospital. Sir James Earle performed the 
 operation, and if I am not mistaken, the 
 preparation of the disease is now in Mr. 
 Abernethy’s museum. But still more re- 
 markable specimens of such excrescences 
 are preserved in the Anatomical Museum of 
 St. Thomas’s Hospital ; one in particular, 
 which resembles a ram’s horn in shape, and 
 was removed from a gardener’s head at 
 Kingston, by Dr. Roots. A further account 
 of the case is given in Rees’s Cyclopajdia, 
 article Horny Excrescence. 
 
 I suppose every body in London has now 
 seen in the British Museum the horn depo- 
 sited there as a curiosity, and which, with 
 another ol the same size, grew upon the 
 head of a human subject What i3 equally 
 curious, hairs are not unfrequently found 
 growing in the cavities of encysted tumours, 
 ( Delpech Precis des Mai. Chir. T. 3, p. 412 ;) 
 and even teeth, more or less perfectly form- 
 ed, have been strangely met with in the 
 same situations. An interesting specimen 
 of the latter occurrence, in a double encys- 
 ted tumour in the orbit, was published some 
 time ago by my friend Mr. Barnes, of Exe- 
 ter. (See Med. Chir. Trans. Vol. 4, p. 316.) 
 
 It is observed by Sir Astley Cooper, that it 
 is when encysted tumours are situated upon 
 the temple, and near the eyebrows, and 
 other hairy parts, that they sometimes con- 
 tain hairs : these 11 have no bulbs, nor ca- 
 nal, and differ therefore from those, which 
 are produced in surfaces of the body, which 
 naturally form hair.” In sheep, the cysts 
 sometimes contain wool. ( Surgical Essays , 
 Part 2, p. 233.) The manner in which 
 these horny excrescences are produced, is 
 stated to be as follows : “ The horn begins 
 to grow from tiie open surface of the cyst ; 
 at first, it is soft, but soon acquires consider- 
 able hardness ; at first it is pliant, but after 
 a few weeks, it assumes the character of 
 horn.” (Vol. cit. p. 235; see also Home in 
 Phil. Trans, for 1791.) 
 
 Encysted tumours are generally of a 
 roundish shape, and are more elastic than 
 fleshy swellings. However, the latter cir- 
 cumstance depends very much upon the 
 nature Of their contents, and the thickness 
 of their cysts. As far as my observation 
 extends, encysted tumours form more fre- 
 quently on the head than any other part ; 
 but they are very frequently met with in all 
 situations under the integuments, and some- 
 times in deeper places. Encysted tumours 
 are also very often seen on the eyelids. 
 
 According to Sir Astley Cooper, they mein 
 general nearly globular, and when seated 
 on the head, feci very firm, but upon tho 
 fare they are attended with a fluctuation, 
 
TUMOUR 
 
 51 1 
 
 more or less obscure. The skin covering 
 them, is generally uninflamed ; but it is now 
 and then streaked with blood-vessels, which 
 are larger than those of the surrounding in- 
 teguments. “In the centre of the tumour 
 on the skin, it often happens that in its early 
 state, a black, or dark-coloured spot may be 
 seen, which sometimes continues through 
 the whole course of the disease. In general 
 they are unattended with pain, are never in 
 themselves dangerous, and only require re- 
 moval from the parts in which they occur, 
 and the unseemly appearance they produce. 
 They move readily within the cellular 
 membrane, if they are free from inflamma- 
 tion, but the skin in general does not easily 
 move over them.” (Surgical Essays, Pari 
 2, p. 230.) The greatest number of encyst- 
 ed tumours, which this experienced surgeon 
 has met with in the same individual, was 
 sixteen, situated upon the head ; and he has 
 seen nine in another patient, as many as 
 which number on one person I have seen 
 myself. Four, five, and six, as Sir Astley re- 
 marks, are not uncommon. The largest, 
 which he has ever seen, was equal in size to 
 an ordinary cocoa nut, and grew upon the 
 head ; but in general, they are not more 
 than one or two inches in diameter. He 
 considers them in some degree hereditary, 
 as he has often heard a patient observe ; “ I 
 have several swellings upon my head, and 
 ray father (or my mother) had several.” 
 They also frequently occur in several of 
 the same family. (A 231.) 
 
 According to Sir Astley Cooper, when en- 
 cysted tumours are dissected, some part of 
 their surface is found firmly adhering to the 
 skin, while other parts are connected to it 
 merely by the cellular membrane. The cyst 
 itself is imbedded more or less deeply in 
 the cellular membrane, and its thickness is 
 different in different parts of the body. On 
 the face, or near the outer canthus, the cyst 
 is very thin; but on the back, it is much 
 thicker, and on the head, it is so thick 
 and firm, that it retains its form after the 
 discharge of its contents, and is so elastic, 
 that after being compressed, it readily ex- 
 pands again to its former size. Within the 
 cyst, Sir Astley Cooper remarks, there is a li- 
 ning of cuticle, which adheres to its interior, 
 and several desquamations of the same sub- 
 stance are formed within the first lining. If 
 the vessels of the cyst are injected, they 
 are found to be numerous, but of small size. 
 The cysts are occasionally met with in an 
 ossified state. ( Surgical Essays, Part 2, p. 
 232,233.) It is the opinion of Sir Astley 
 Cooper, that encysted tumours arise from 
 the enlargement of the follicles, or glandu- 
 lar pores, in consequence of the obstruction 
 of their orifice. (P. 23d.) If this senti- 
 ment were correct, the fact would furnish 
 another consideration against the view 
 taken of the formation of the tumours by 
 Dr. Baron. However, it appears to me, that 
 there are some reasons, which render the 
 adoption of Sir Astley’s explanation diffi- 
 cult; for, if encysted tumours were only 
 enlarged follicles, they would not be found 
 
 so far from the skin as they frequently are, 
 as for instance within the orbit, and in other 
 situations yet further from the surface of 
 the body ; and the collections of sebaceous 
 matter, which so often collects, as this gen- 
 tleman observes, in the follicles of the skin 
 of the nose, and may be pressed from them 
 in the form of worms, would, if the cause 
 assigned were true, make encysted swell- 
 ings on the nose itself exceedingly com- 
 mon ; yet this part is not so often the seat 
 of such tumours, as other parts of the face. 
 As far also as my observations extend, pres- 
 sure cannot be said to have any share in 
 giving rise to the formation of encysted tu- 
 mours, because 1 have seen them chiefly in 
 situations, where this kind of cause could 
 not be suspected, as for instance, on the 
 face and about the vertex, and not particu- 
 larly round that part of the head, which 
 is compressed by the hat. If also encys- 
 ted swellings were owing to obstruction of 
 the cutaneous pores with sebaceous matter, 
 i apprehend few persons would escape the 
 disease. The cure in the early stage would 
 also be as easily effected by the timely re- 
 moval of the alleged obstruction, as the 
 cure of the little tender points on the nose, 
 really caused by the lodgment of the seba- 
 ceous matter in the cutaneous pores. This 
 does not appear to me to be consonant to 
 general experience. How the formation of 
 steatomatous encysted swellings is to be 
 thus accounted for, I cannot at all conceive. 
 And, lastly, it is to be noticed, that the lit- 
 tle swellings on the nose, arising in the way 
 described, are, when they occur, frequently 
 attended with soreness, from which true 
 encysted tumours, at least in, the early 
 stage, are completely free. These, and 
 other reflections, lead me to believe, that 
 the origin of encysted swellings cannot be 
 satisfactorily explained upon the principles 
 suggested by the above distinguished prac- 
 titioner. However, as all his opinions on 
 surgical questions are deservedly valuable, 
 I subjoin the advice which he has given, 
 founded upon the preceding doctrine. If 
 the follicle can be seen only as a black spot . 
 filled with hardened sebaceous matter, Sir 
 Astley Cooper recommends introducing a 
 probe into it, and squeezing the sebaceous 
 matter out of the tumour, which is done 
 with little inconvenience. But, if the con- 
 tents cannot be pressed out without such 
 violence as would create inflammation, he 
 says, that the best plan is to make the open 
 ing larger. Other surgeons have tried to 
 cure encysted tumours by pricking them 
 with needles, and squeezing out their con 
 tents ; or by applying stimulating and dis- 
 cutient applications to them. However, it 
 is a practice which mostly fails, and, some- 
 times, converts the case into a terrible dis- 
 ease, in which a frightful fungus shoots out 
 from the inside of the cyst, attended with 
 immense pain and irritation, and often pro- 
 ving fatal. (See Mernethy’s Surgical Ob- 
 servations, 1804, p. 94.) 
 
 Similar dangerous fungous diseases may 
 also arise, whenever the surgeon, in cuttin? 
 
51 2 
 
 TUMOUR. 
 
 out encysted tumours, leaves any part of 
 the cyst behind. 
 
 The most adviseabie method, I believe, is 
 to have recourse to the knife, before an en- 
 cysted tumour has attained any considera- 
 ble size. However, if it is large at the time 
 of the operation being done, a portion of 
 the skin must be taken away with the swell- 
 ing, in the manner described in the article 
 Mamma, Removal of. The chief piece of 
 dexterity in the operation consists in detach- 
 ing all the outside of the cyst from its sur- 
 rounding connexions, without wounding it. 
 Thus, the operator takes the part out in an 
 entire state, and is sure, that none of the 
 cyst remains behind. When the cyst is open- 
 ed, some of the contents escape, it collapses, 
 and the dissection is rendered more tedious 
 and difficult. 
 
 Such is the common opinion, which has 
 always appeared to me correct. However, 
 Sir Astley Cooper states, that the best man- 
 ner of doing the operation is to make an in- 
 cision into the swelling, and then to press 
 the sides of the skin together, by which 
 means the cyst may be easily everted and 
 removed. If the attempt be made to ex- 
 tract the tumour whole, “ the dissection is 
 most tedious, and before it is completed, 
 the cyst is either cut, or burst. So many 
 incisions, and so much pain, maybe readily 
 prevented by opening it freely by one inci- 
 sion, raising its edge between the forceps,” 
 and dissecting it from its adhesions to the 
 surrounding membrane. ( Surgical Essays, 
 Part 2, p. 240.) When the swelling is in 
 the scalp, Sir Astley directs an incision to 
 be made through its centre, from one side 
 to the other, when its contents, which in 
 this situation are very solid, are immedi- 
 ately discharged in a mass of the same shape 
 as the tumour. The cyst being raised with a 
 tenaculum, may then be easily separated. 
 
 With respect to encysted tumours of the 
 eyelids, the atheroma and meliceris are said 
 by Beer to form only upon the upper eyelid, 
 on the side towards the temple, while he has 
 always found the steatoma to be seated ei- 
 ther in the vicinity of one of the eyelids, or 
 sometimes over the lachrymal sac. The athe- 
 roma and meliceris, he says, usually lie in the 
 loose cellular substance directly under the 
 skin of the eyelid, though sometimes more 
 deeply under the orbicularis muscle, or even 
 quite underneath the levator palpebrae supe- 
 rioris, upon the convex surface of the tarsal 
 cartilage, to which the swelling is then ge- 
 nerally so firmly adherent, that it is impos- 
 sible to remove this part of the cyst. En- 
 cysted tumours of the upper eyelid are com- 
 monly so moveable, that they can be push- 
 ed above the superciliary ridge of the os 
 frontis ; which is regarded by Beer as a very 
 favourable circumslance in the operation. 
 Though the atheroma and meliceris of the 
 upper eyelid occasionally become as large 
 as a pigeon’s egg, Beer has never known a 
 stentoma in the vicinity of the eyelids ex- 
 ceed the size of a hazel nut. Encysted tu- 
 mours of the upper eyelid itself sometimes 
 appear moveable, though they may be at 
 
 the same time closely adherent to the car- 
 tilage. Hence, Beer recommends moving 
 the tumour about for a few days before the 
 operation, and trying to push it above the 
 superciliary ridge ; and if this cannot be 
 done, the circumstance will prove that the 
 swelling is connected with the cartilage, or, 
 at least, is under the orbicular muscle, and 
 the mode of operating regulated according- 
 ly. With the yellow pappy substance, found 
 in the cysts of arethoraatous tumours of the 
 eyelids, fine short hairs, scarcely one line 
 in length, are frequently blended. Some- 
 times, as Beer remarks, the whole inside of 
 the cyst is covered with these little short 
 hairs, which may all be washed out, and 
 are destitute of bulbs ; a fact also noticed 
 by Sir Astley Cooper. It merits attention, 
 however, that in tumours of the meliceris 
 kind, formed upon the eyelid, Beer never 
 met with hairs. ( Lekre von den Augenkr. 
 B. 2, p. 607 — 609.) He remarks, that when 
 encysted swellings of the eyelid are let 
 alone, he has never known them produce 
 any injury to the eye itself, excepting the 
 hinderance to the opening of it, when they 
 are large. On the other hand, if they be 
 unskilfully removed, or rashly attacked 
 with caustic, various ill consequences may 
 ensue ; as for instance, fistulae of the lachry- 
 mal gland, entropium from a shrinking of 
 the tarsal cartilage, ectropium from destruc- 
 tion of the skin, and the hare-eye from an 
 actual shortening of the upper eyelid. In 
 consequence of the inflammation caused 
 by escharoties, Beer has more than once 
 found the integuments so adherent to the 
 tumour, that in the operation, the removal 
 of a considerable piece of them was una- 
 voidable. But, says he, when swellings of 
 this nature are properly treated in good 
 time, they may be removed without leaving 
 any vestige behind, excepting a trivial scar. 
 Professor Beer joins all the best modern 
 surgeons in considering the entire removal 
 of the sac, and the reunion of the wound by 
 the first intention, as the safest and most ef- 
 fectual method of curing encysted tumours 
 of the eyelids. He admits, however, that 
 the hinder portion of the cysts of some 
 swellings of this nature upon the upper eye- 
 lid cannot be dissected out, because it may 
 be so closely adherent to the cartilage, that 
 its excision would injure the latter part too 
 much, and produce either an incurable eu- 
 tropium, or an irremediable shortening of 
 the eyelid. But steatomatous tumours, near 
 the eyelids, may almost always be com- 
 pletely dissected out, the only exceptions 
 being cases in which the swellings happen 
 to be situated between the lachrymal sac 
 and the orbicular muscle, and so intimately 
 connected with the first of these parts, that 
 the back portion of the cyst could not be 
 cut away, without permanently destroying 
 the functions of the excreting parts of the 
 lachrymal organs. However, when the 
 swelling is not too strongly attached to the 
 cartilage of the eyelid, Beer sanctions the 
 removal of the whole of the cyst. He par 
 ficularly insists upon the utility ol moving 
 
TUMOUR. 
 
 the tumour a good deal about daily, for a 
 few days before the operation, so as tt> 
 loosen its connexions, and enable the sur- 
 geon to push it over the edge of the orbit, 
 where it may be steadily fixed during its re- 
 moval. (Z>\ 2, p. 612.) Excepting a few 
 instances, in which the skin was diseased, 
 and firmly adherent to the cyst, Beer has 
 never found it necessary, in the excision of 
 encysted swellings of the eyelids, to remove 
 any portion of the integuments, and he has 
 cut away some tumours of this kind which 
 were as large as a pigeon’s, or hen’s egg. 
 The incision through the skin, he says, 
 should be longer than the tumour, so as to 
 facilitate the extraction of the distended 
 cyst. ( B . 2, p. 613.) When it is not ad vise- 
 able, for reasons above stated, to attempt 
 to dissect out every particle of the cyst, 
 Beer fills the cavity with lint, lets the wound 
 suppurate, and if this plan is not sufficient, 
 he applies stimulants and caustic. It is no- 
 ticed by Sir Astley Cooper, that encysted 
 tumours, at the outer canthus, are often dif- 
 ficult of removal, on account of their extend- 
 ing into the orbit, and being adherent to 
 the periosteum. (Surgical Essays f Part 2 ,p. 
 241.) Professor Scarpa has strongly recom- 
 mended making the incision for the extrac- 
 tion of encysted swellings of the palpebraj, 
 on the inside of these parts. But, as Mr. 
 Travers correctly remarks, the swellings 
 are often situated superficially, and loosely 
 connected with the tarsus, in which case 
 the operation should be done on the outside 
 of the eyelid. The latter writer admits, 
 however, that the cyst is often formed be- 
 twixt the cartilage and the ligamentary, 
 membrane which covers it, and, in his opi- 
 nion, it is only when an intricate adhesion 
 subsists, and the appearance of a white cir- 
 cumscribed indentation is seen upon the 
 everted tarsus, that the excision should be 
 performed on the inside of the eyelid, by 
 dividing the cartilage. Synopsis of Hit Dis- 
 eases of the Eye , p. 357.) 
 
 I shall conclude the subject of tumours 
 with a few observations, delivered by Sir 
 Astley Cooper, and Professor Langenbeck 
 “ The removal of encysted tumours, (the 
 first gentleman observes,) is not entirely 
 unattended with danger. I have seen three 
 instances of severe erysipelatous inflamma- 
 tion succeed the operation of removing 
 these swellings upon the head, and I believe 
 it is owing to the tendon of the occipito- 
 frontalis being wounded in the attempt to 
 dissect them out whole ’ (Surgical, Essays, 
 Part 2 , p. 241.) 
 
 In the extirpation of tumours about the 
 neck, Langenbeck adopts the following 
 rules: he makes a free division of the in- 
 * teguments, and dissects the muscles from the 
 tumour which lie over it, but he avoids cut- 
 ting through, or injuring them : in this man- 
 ner the swelling is rendered more moveable. 
 By the situation of the muscles, he is then 
 enabled to know the place of the chief 
 blood-vessels ; and on this account, he par- 
 ticularly advises young surgeons to study 
 myology with the greatest care As Lan 
 Vot.iL 65 
 
 513 
 
 genbeck remarks, it is indeed an important 
 advantage, after a muscle is exposed, to 
 know vvliat vessels lie at its edges, or under 
 neath it. Thus, the surtorius is a sure 
 guide to the crural artery, arid the sterno- 
 cleido-masloideus to the carotid. A surgeon 
 who knows correctly the anatomy 9 ! the 
 parts, will not be in danger of wounding 
 unintentionally any large vessel. When 
 the surface of the tumour has been cleared, 
 but t lie base of it is yet firmly attached, 
 Langenbeck commences the separation on 
 the side which presents the 'east risk, that is, 
 where the least considerable blood-vessels 
 are, and thence he proceeds by degrees to- 
 wards the most hazardous side. In favour 
 of this method, lie offers the following con- 
 siderations-: if. by chance) an artery requi 
 ring a ligature should be cut, it can now be 
 more easily secured, as the base of the tu- 
 mour is already partly detached. The loos- 
 ened swelling may also be drawn away 
 from the large vessels with the hand, or a 
 tenaculum. Langenbeck never introduces 
 the knife deeply, when there are large blood 
 vessels there, but pulls the swelling out- 
 ward, and then divides the cellular sub- 
 stance thus stretched, which is situated up- 
 on the already exposed portion of the tu- 
 mour. In this manner the swelling can al- 
 ways be drawn more and more away from 
 the vessels, until, at last, there is no danger 
 of wounding them. By attending to these 
 principles, Langepbeck has succeeded in re- 
 moving many very large tumours from the 
 neck, where nearly ail the muscles of that 
 part were exposed in- the dissection, and the 
 carotid denuded. After one of these ope- 
 rations, not only the styloid process could 
 be felt, but ail tne muscles, originating from 
 it, could be distinctly seen. (Bibl. fur die 
 Chir. B. 2, p. 312, fyc. 12 rno.Goliingen, 1808.) 
 C. G. Slenlsei, De Sleatomatibm in prim ipio 
 Aorta 1 , rc perlis et Cysticis in gen* re excrescen- 
 tibus. lit!: sb. 1723. J. J. P.enck, JYovupi 
 Sy sterna Tumoruni, quo hi morbi in sun ge- 
 nera ct species rediguntur . Purs prior. I'P.mo. 
 Vienna. 1767. lVui. Ogle., Letter concerning 
 the Cure of Encysted and other kinds of Tu- 
 mours with : at the Knife. 8 10 . Lend. 1754. 
 Ph. Tr. Walther, aber die angebohrnen Fd 
 thaulgeschmdsien mid and ere Bildungsjeh - 
 ler. fol. Landshul. 1814. .< P. IV cidmanu , 
 
 Annolatio de Siealomatibus 4to. Maguntiaci , 
 1817. JV. Hey, Practical Observations in 
 Surgery, p 517, Eci 2, 8 vo. Land. 1810 Al- 
 lan Bui us, Surgical Anatomy of the Head 
 and Neck,8vo. Edin. ■ 1.81-1 : this work coi<,- 
 tains much valuable in forma: ion , respecting 
 the extirpation of swellings about the neck. 
 Schreger Chirurgisrhe Versiiche . B. \ ,p. 297 ; 
 Ueber Lipoma und Ex tir patio derselben. Svo. 
 JVurubcrg. 1811, John Baron, An Inquiry, 
 illustrating the nature of Tuberculoled Accre- 
 tions 'of Serous Membranes, and the Origin cf 
 Tubercles and Tumours in different textures 
 of the Body $ko. Loud. 1819. Sir Astley 
 Cooper. Surgical Essays, Part 2. C. J. ,W. 
 Langenbeck , Bibl. far die Chir B. 2, p. 312. 
 Gutt. 1808. Also, Gesrhichte einer gross en 
 Speckgesehvjulst wehher mit deni Unterkiefer 
 
•14 
 
 ULCERATION 
 
 so fcst zusanuneuliing , dass die Trennung mit 
 dir Sage verrxchtel werden music : Neue Bibl. 
 B. I, p. 295. 12mo. Hanover. 1817. B. H. 
 Jacobsen, de Tumoribus Cysticis , 4 to. Jena , 
 3793. C. G. Ludwig Manila de cxscindcn- 
 
 dis Tumoribus tunica inclusis, 4 io. Lips. 
 
 1758. 
 
 TYMPANUM. For an account of its dis- 
 eases, see Ear . 
 
 u. 
 
 i 
 
 LCERATION, is the process by which 
 sores or ulcers are produced in animal 
 bodies. In this operation, the lymphatics 
 appear to be, at least, as active as the blood- 
 vessels. An ulcer is a chasm formed on the 
 surface of the body by the removal of parts 
 back into the system by the action of the 
 absorbents. At first, it may be difficult to 
 conceive how a part of the body can be re- 
 moved by itself; but there is not more diffi- 
 culty in conceiving this, than how the body 
 can form itself. Both facts are equally well 
 confirmed. When it becomes necessary that 
 some whole living parts should be removed, 
 it is evident, says Mr. Hunter, that nature, 
 in order to effect this object, must not only 
 confer a new activity on the absorbents ; but 
 must throw the part to be absorbed into a 
 state which yields to this operation. The 
 absorption of whole parts in disease, arises 
 from five causes; pressure : irritation of sti- 
 mulating substances ; weakness; inutility of 
 parts; death of them. ( Hunter on Inflam- 
 mation, *c. p. 442 — 446.) 
 
 Ulceration takes place much more readily 
 in the cellular and adipose substance, than 
 in muscles, tendons, ligaments, nerves, and 
 blood-vessels. Hence, in the progress of 
 pus to the surface of the body, ulceration of- 
 ten takes a circuitous course for the purpose 
 of bringing the matter to the skin. The 
 skin itself, also, being highly organized, con- 
 siderably retards the bursting of abscess- 
 es. On the same account, when ulce- 
 ration is spreading, the edges of the skin 
 hang over the ulcerated surface. ( Hunter , 
 p. 447.) 
 
 New-formed parts, such as cicatrices, cal- 
 lus, and all adventitious new matter, such 
 as tumours, readily admit of being absorbed. 
 The adventitious matter, indeed, is more 
 prone to be absorbed than that which is a 
 substitute for the old. Mr. Hunter explain- 
 ed this circumstance on the principle of 
 weakness. 
 
 When ulceration takes place, in conse- 
 quence of the death of an external part, it 
 occurs first on the outer edge, between the 
 dead and living substance. 
 
 Abscesses constantly make their way to 
 the surface of the body by ulceration ; but 
 as some textures more readily admit of 
 being absorbed than others, the matter of- 
 ten follows a circuitous course, before it 
 can arrive at the skin. ( Hunter , p. 448, 
 449.) 
 
 A tumour, when it makes equal pressure 
 in every direction around, will only make 
 
 its wav in an external course, because 
 
 what Mr. Hunter termed interstitial absorp- 
 tion happens in n« other direction. (P. 
 
 449.) 
 
 The parts which are situated between an 
 abscess, or any extraneous substance, and 
 the nearest surface, are those which are most 
 susceptible of ulceration. This is one of 
 the most curious phenomena connected with 
 the process under consideration. It shows 
 that there is a principle in the human body, 
 by which parts are always prone to free 
 themselves frbm disease. Slight pressure 
 from without will often produce a thicken- 
 ing of parts, and hence Mr. Hunter remarks, 
 there even appears to be a corresponding 
 backwardness to admit disease. ( P . 449.) 
 Both these facts, he observes, are shown in 
 the case of fistula lachrymalis ; for though 
 the matter is nearest the cavity of the nose, 
 still it makes its way externally, by means of 
 ulceration, while the Schneiderian mem- 
 brane even becomes thickened, so as to be- 
 come a barrier against the progress of the 
 disease inward. (P. 451.) 
 
 There is one difference between the ad- 
 vancement of an encysted tumour to the 
 surface of the body, and the progress of an 
 abscess in the same direction, viz that the 
 former does not excite ulceration of the 
 c> st : but an interstitial absorption of the 
 sound parts between the cyst and skin, 
 till the cyst and external skin come into con- 
 tact, at which period inflammation takes 
 place, and absorption becomes accelerated 
 into ulceration. In an abscess, the progres- 
 sive ulceration begins in the cyst, at the 
 same lime that the interstitial absorption in 
 the sound part covering the matter is going 
 on. (P. 452—457.) 
 
 The action of progressive absorption is to 
 remove surfaces contiguous to irritating I 
 causes, which Mr. Hunter referred to pres- 
 sure, irritation, and weakness. In cases of 
 tumours, pressure becomes a cause. The 
 buttocks and hips of persons who lie long 
 on their backs, often ulcerate. The heels of 
 many patients, with fractures, who lie for a 
 great while in the same position, are apt to 
 ulcerate. In the latter instances, Mr. Hun 
 ter conceived that ulceration is a substitute 
 for mortification, and is at the same time, a 
 proof of a certain degree of strength ; for if 
 the patient’s constitution were very weak, 
 the same parts would mortify. (P. 453.) 
 That pressure is a frequent cause of ulcera- 
 tion, is also evinced by the occasional ef- 
 fects of chains on prisoners, and harness on 
 horses. 
 
ULUEKS. 
 
 515 
 
 ihat irritating substances produce ulcera- 
 tion, needs no illustration. 
 
 Progressive absorption may occur either 
 with or without suppuration. We have in- 
 stances of the latter in cases of extraneous 
 bodies, which travel about the, body with- 
 out producing irritation enough to give 
 rise to the secretion of pus. In the pro- 
 gress of aneurisms of the aorta, and of 
 fungous tumours of the dura mater to the 
 sort ace, the same tact is also illustrated. (P. 
 455.) 
 
 Absorption with suppuration, in other 
 words, ulceration either happens in conse- 
 quence of suppuration already begun, in 
 which event the pus acts as pressure ; or 
 else absorption attacks external surfaces 
 from particular irritations or weakness, in 
 which case suppuration must follow. (P. 
 45fl.) 
 
 The production of ulceration requires 
 much greater pressure from without than 
 from within. The process is always dis- 
 posed to take place more quickly, when near 
 the surface of the body, and its progress be- 
 comes accelerated in proportion as it arrives 
 near the skin. 
 
 The adhesive inflammation precedes the 
 suppurative, and prevents the pus from be- 
 coming diffused, as soon as it is secreted, 
 and w hen the cyst afterward ulcerates, in 
 order to let the matter approach the skin, the 
 adhesive inflammation still continues to go 
 before the ulcerative process, and thus pre- 
 vents the matter from insinuating itself into 
 the interstices of the cellular substance. (P. 
 457.) 
 
 The pain of ulceration is, in some degree, 
 proportioned to its quickness. When ulce- 
 ration begins on a surface, or takes place for 
 the purpose of bringing matter to the skin, 
 the pain is always considerable. When ul- 
 ceration takes place, in order to separate a 
 dead part, as in sloughing, exfoliations, &c. 
 there is seldom any particular pain. (P. 
 459.) 
 
 The ulcerating sore always exhibits little 
 cavities, while the edge ol the skin is scal- 
 loped, and thin, at the same time turning a 
 little out, and overhanging, more or less, 
 the ulcerated surface. The face of the 
 sore appears foul, and the discharge is very 
 thin. 
 
 When ulceration stops, the edges of the 
 skin become regular, smooth, a little round- 
 ed, or turned in, and of a purple colour, 
 covered with a semi-traiispaivnt while. 
 (Hunter on Inflammation, fyc. p. 460.) 
 
 The reader, desirous of further informa- 
 tiorijshuuld particularly consult this last pub- 
 lication, and Professor Thomson's Lectures on 
 Inflammation , p. 349, <§/-c. 
 
 ULCERS. Surgeons usually define an 
 ulcer to he a solution of continuity in any 
 of the soft parts of the body, attended with 
 a secretion of pus, or some kind of dis- 
 charge. 
 
 In the present part of this Dictionary, there 
 will not be occasion to speak ot several kinds 
 of sores, which have been treated of in other 
 
 articles. (See Cancer, Scrofula, and Vene- 
 real Disease.) 
 
 Ulcers are divided into local and constitu- 
 tional. As Professor Thomson has well ob- 
 served, however, it is only within certain 
 limits, that this distinction is well founded; 
 for an ulcer, which is at first completely lo- 
 cal, may in time affect the system, so as to 
 become constitutional ; and ulcers which 
 derive their origin from some general affec- 
 tion of the system, may remain after the re- 
 moval of the constitutional disorderly which 
 they were originally produced. ( Lectures on 
 Inflammation, p. 427.) 
 
 “ Ulcers (sa\s Dr. Thomson) have usually 
 been distinguished from each other by the 
 causes by which they are induced, by the 
 symptoms whi^h they exhibit, and by the parts 
 of the body in which they occur. The wantof 
 a disposition to heal in a suppurating surface 
 may depend upon some specific action in 
 the cause from which it proceeds, upon 
 something peculiar in the constitution of the 
 patient in whom it exists, or merely upon 
 an improper mode of management : and 
 hence, rhe distinction that has long been 
 made of ill-conditioned -ores, or ulcers, into 
 those which are specific in their nature, and 
 into those which are simple. 
 
 “ Specific sores, or ulcers, may be occa 
 sioned by specific poisons, or by particular 
 diatheses. The sores or ulcers which arise 
 from specific poisons, may be either local, 
 that is, confined, tike a primary syphilitic 
 ulcer, to one spot ; or constitutional, that is, 
 liable to occur in any part, texture, or or- 
 gan, such as secondary syphilitic ulcers. 
 Of diatheses, predisposing to ulcers, we have 
 examples in the scrofulous, scorbutic, and 
 arthritic diatheses, and also in the syphiloid 
 diatheses, or that which arises not unfre- 
 quently in those who have had syphilis, from 
 the too tree and injudicious use of mercury. 
 
 lt Every ulcer, strictly speaking, is of a 
 local nature; but there are ulcers, which, 
 though necessarily local iif their appearance, 
 are connected with, or dependent upon, dis- 
 eases, which affect the general system. 
 These ulcers ought to be regarded as modi- 
 fications of, or forms in which the diseases 
 appear, with which they are connected. 
 Considered in this light, it is obvious, that 
 specific ulcers can be treated of with pro- 
 priety, only under the head of the diseases 
 to which they respectively belong. 
 
 “ We call those sores, ulcers, simple, which 
 do not appear to proceed from any specific 
 disease, or morbid diathesis existing in the 
 constitution of those, in whom they take 
 place. They are usually solitary occurren- 
 ces, and the consequences of accidental 
 injuries, and improper modes of manage- 
 ment. They may occur in every part of 
 the body, but they appear most frequently 
 upon the lower extremities.” 
 
 Professor Thomson afterward remarks, 
 that “ the appearances, which different ul- 
 cers exhibit, seem, at first view, to afford an 
 excellent foundation for distinctions. among 
 them, and so they undoubtedly do in .manj; 
 respects ” 
 
“ But (says he) it is to be regretted, that 
 the characters, upon which the distinctions 
 of ulcers, as well as of many other local 
 diseases, are founded, are neither very uni- 
 Gjnti in their appearance, nor are very easily 
 distinguishable from one another. JNotonly 
 are the local appearances which present 
 themselves in simple ulcers liable to great 
 variations in the different stages of the same 
 ndividual affection,' but they are often ap- 
 parently the same with, or at least not easily 
 distinguishable from, those which occur in 
 specific diseases, and which require for their 
 cure peculiar modes of treatment. It is 
 this circumstance, winch renders it so ne- 
 cessary for us, in endeavouring to distinguish 
 a. nl to cure ulcers, to avail ourselves of all 
 the information, wuich we can procure from 
 tiic history of the ulcer, from ihe nature ot 
 the exciting cause, by which it lias been in- 
 duced, and from ihe efiects of the remedies 
 which have been employed, as well as from 
 ihe particular. appearances, which the ulcer 
 itself exhibits.” 
 
 In noticing another ground of distinctions 
 among ulcers, or that derived from the parts 
 in -a hich they occur, Dr. Thomson observes 
 that “ every texture and organ of the body 
 possesses physical and vital qualities pecu- 
 liar to itself ; and these qualities must neces- 
 sarily modify the appearances), which each 
 texture and organ respectively exhibits in 
 the state of disease. Specific diseases ren- 
 der some parts more liable than others to 
 attacks of ulceration. Thus, secondary 
 syphilis appears most frequently in the 
 throat ; scurvy in the gums; cancer in the 
 lower lip ; and lupous and scroiulous ulce- 
 rations in the upper lip, or in the nose. 
 Cancer seldom or never appears primarily 
 • rt the upper lip ; but syphilis, when it at- 
 tacks this part, puts on many of the appear- 
 ances of cancer j” a fact, which Dr. Thom- 
 son says he iirT.t.bmmsd from Mr. Pearson. 
 (Bee Lectures *•;! 'Inflammation, p. 427 — 430 ) 
 
 in the vikm'aie treatise on ulcers, publish* 
 edvby Sir Everard Home, these complaints 
 are divided into six principal kinds, viz. : 
 
 1. Ulcers in parts, which have sufficient 
 strength to carry on the actions, necessary 
 for their recovery. 
 
 2. Ulcers in parts, which are too weak for 
 that purpose. 
 
 ‘6. Ulcers in parts, whose actions arc too 
 violent to form healthy granulations, whe- 
 ther this arises from the state of the parts, 
 or of the constitution. 
 
 . 4. Ulcers in parts, whose actions are too 
 indolent, whether tins arises from the stale 
 of the parts, or of the constitution. 
 
 5. Ulcers in parts', which have acquired 
 some specific action, either from a diseased 
 state of the parts, or of the constitution. 
 
 6. Ulcers in parts, which are prevented 
 from healing by a varicose state of the su- 
 perficial veins of the upper part of thedimb. 
 
 Ait hough I have chosen, in the subse- 
 quent columns, to adopt this nomenclature, 
 I am perfectly aware of its being on some 
 accounts objectionable, but especially be- 
 cause it assumes hypotheses, the truth of 
 
 which can never be established, nor proved 
 This is one of the considerations, which 
 have induced Professor Thomson to prefer 
 the old names usually applied to ulcers ; 
 (Op. cit.p. 4 35, 438.) and he therefore treats 
 of the simple purulent ulcer ; Inflamed ulcer ; 
 
 F ungo us ulcer ; Callous ulcer ; Sloughing ul- 
 cer ; Ulcerative ulcer ; Carious ulcer ; and 
 Specific ulcers. 
 
 or ULCEUS IN PARTS, WHICH HAVE SUFFICIENT 
 STRENGTH TO CARRY ON TIIE ACTIONS NE- 
 CESSARY FOR THEIR RECOVERY, SIMPLE 
 PURULENT, OR HEALTHY ULCERS. 
 
 Sir E. Home remarks, that in this species 
 of ulcer, the pus is of a white colour, thick 
 consistence, and readily separates from the 
 surface of the sore, and when diluted, and 
 examined in a microscope, is found to be 
 made up of small globules, swimming in a 
 transparent fluid. The granulations are 
 small, florid, and pointed at the top. As 
 soon as they have risen to the level of the 
 surrounding skin ; those, next to the old 
 skin, become smooth, and are covered with 
 a thin, semi-transparent film, which after- 
 ward becomes opaque, and forms cuticle. 
 
 In the treatment ot this ki/id of ulcer, it 
 is only necessary to keep the surface clean, 
 and prevent the natural processes from being 
 interrupted. Sir E. Horne observes, that 
 this is in general best done by the applica- 
 tion of dry lint, for the purpose of absorbing 
 and retaining, the matter, which serves as a 
 soft covering for the granulations, and by 
 putting over the lint a pledget of any simple 
 ointment, in order to hinder the matter from 
 evaporating, by which means the dressings 
 will not become adherent, and may be easily 
 taken off, as often as requisite 
 
 Although healthy ulcers require no medi- 
 cated application to be made to them, the 
 dressings must be such as do not disagree 
 with the granulations, or surrounding skin. 
 
 With some patients, a roller applied with 
 moderate lightness* with a view of retaining 
 the dressings, which cause uneasiness in 
 the part, and make the ulcer lose its healthy 
 appearance. Bir E Horne states, that he 
 has seen several such cases, in which the 
 proper appearance of the sore 'returned as 
 soon as the bandage was discontinued. 
 
 In some patients, ointment irritates and 
 inflames the neighbouring skin ; and certain 
 superficial ulcers will not heal, while kept in 
 a moist state, and unexposed to the air ; but 
 heal, when allowed to become dry and co- 
 vered with a scab. 
 
 Sir E. Home refers these particularities to 
 constitutional causes, and not disease ; for 
 the ulcers neal as soon as *the particular 
 things, which disagree with them, are dis- 
 continued. These peculiarities in certain 
 healthy sores may also attend others of a 
 dilferent description, and should always be 
 discriminated from the effect* ot disease. 
 
 Sir E. Home very judiciously recom- 
 mends inquiring of patients, who have pre- 
 viously had sores, what kind of applications 
 they derived most benefit from, and what 
 dressings were found to disagree. 
 
ULCERS. 
 
 ■A1 
 
 TREATMENT. 
 
 1. Applications in the form of vapour, and 
 fomentations, should never be employed, as 
 they render the texture of the granulations 
 looser, and diminish the disposition to form 
 skin. 
 
 2. With respect to fluid applications, Sir 
 E. Home also very properly condemns poul- 
 tices, as well as fomentations. He speaks 
 of alcohol, as being an application, which 
 promotes the formation of a scab, when this 
 mode of cure is chosen 
 
 3. in regard to ointments, their only use, 
 in cases of healthy ulcers, is to keep the 
 matter from evaporating. The most simple 
 ointments are the best for the purpose ; par- 
 ticularly the one composed of white wax 
 and olive oil. 
 
 Sir E. Home observes, that the great ob- 
 jections to the common simple ointments 
 are, that they sometimes disagree with the 
 skin, even when recent a*nd free from all 
 rancidity. When they have acquired the 
 latter quality, they still more frequently 
 create a greater degree of irritation. 
 
 4. With respect to applications in the form 
 of powder. Sir E. Home remarks, that when 
 it is desirable to form a scab on the ulcer, 
 any inert powder mav be sprinkled on the 
 sore; but he prefers dry lint. Nothing 
 should touch the powder, or lint; and to 
 prevent this circumstance. Sir E. Home re- 
 commends applying a little bolster on each 
 side of the sore, and over them a roller, 
 which will go from one bolster to the other 
 in the manner of a bridge. 
 
 For healthy ulcers, dry lint is to be re- 
 garded as being upon the whole the most 
 eligible application. When the sore does 
 not secrete pus enough in twenty-four hours 
 to moisten the lint, the dressings are only to 
 be changed every other day. 
 
 When a moderately tight bandage is not 
 forbidden by constitutional peculiarities, it is 
 useful both in supporting the muscle? and 
 skin, which are often in a flabby state from 
 the unexercised state of the limb, and in de- 
 fending the newly formed parts. (See Home 
 on Ulcers.) 
 
 ULCERS IN PARTS WHICH ARE TOO WEAK TO 
 
 CARRY ON THE ACTIONS N ECESsAR V FOlT 
 
 THEiR RECOVERY ; THE OVERACTING UL 
 
 CERS OF MR. BURNS ; THE FUNGOUS ULCERS 
 
 OF OLDER WRITERS. 
 
 This is the second of the classes, into 
 which Sir Everard Home has divided ulcers 
 in general. 
 
 The granulations of these sores are larger, 
 more round on their external surface, and 
 of a less compact texture, than those formed 
 on ulcers in healthy parts. Sir E. Home 
 has aiso noticed their semi-transparent ap- 
 pearance. When they have filled up the 
 cavity of an ulcer to a level with the surface 
 of the body, they do not readily form skin, 
 but, rising up in a still higher manner, often 
 lose altogether the power of producing new 
 mtis. When the parts are still weaker, the 
 
 granulations sometimes continue gradually 
 to fill up the hollow of the ulcer, and then, 
 all on a sudden, are s iddenly absorbed, so 
 as to leave the sore as deep as it was before. 
 
 Ulcers may be weak from the firs% or be- 
 come so in the progress of the case Even 
 granulations of the most healthy kind, if 
 they are not skinned over in a certain time, 
 gradually lose their primitive strength. 
 
 Sores on the legs are greatly under the in- 
 fluence of all natural peculiarities of the 
 constitution, and every thing which affects 
 the health. When the constitution becomes 
 in the least weaker or stronger, the appear- 
 ance of the granulation becomes changed 
 accordingly, and this effect of constitutional 
 weakness , or strength on ulcers is greater, 
 in proportion as the sores are further from 
 the source of the circulation. 
 
 V\ bile the constitution is undergoing anv 
 kind of disturbance, the healing of an ulcer 
 is suspended. Mental anxiety is very apt 
 to retard cicatrization. 
 
 Such effects of the constitutional kind ou 
 ulcers are greater in weak and delicate per- 
 sons, than in the strong and robust. Change 
 of weather nas considerable influence over 
 the healing of sores. Sir E. Home mentions 
 in proot of this fact, that when there were 
 several hundreds of uicers in' the Naval 
 Hospital at Plymouth, in 177S, every time 
 the weather changed from a dry to a moist 
 state, the ulcers universally assumed an un- 
 healthy appearance ; but put on a better as- 
 pect when the weather became dry again. 
 
 In the treatment of this kind of ulcer, 
 tonics are to be exhibited, particularly bark 
 and steel, and every thing which disagrees 
 with the constitution is to be avoided. Wine 
 and cordial medicines are also usually pre- 
 scribed. Porter, however, is deemed better 
 than wine for working people. 
 
 bir E. Home observes, that the first ob- 
 ject in the local part of the treatment, is to 
 keep he granulations from rising above the 
 edge of the surrounding skin. This gentle- 
 man (jn my opinion) very judiciously repre- 
 sents the greater propriety of preventing 
 the granulations from ever becoming, loo 
 high by the employment of proper applica- 
 tions, than following the com -non plan of 
 destroying the high granulations with es- 
 char*. tics, after they have risen toa-i impro- 
 per height. There cannot be the smallest 
 doubt, that if the granulations could always 
 be prevented from rising too much the pa- 
 tient would suffer a great deal less pain. 
 
 Instead of applying to the surface of the 
 uic-rs, now uridr-r consideration, lunar caus- 
 tic, blue vitriol, red precipitate, &e. bir E. 
 Home prefers mixing these escbarotles 
 with other substances, so us to render ihem 
 only strong stimulants; ami using them in 
 this latter torm. He conceives, that when 
 toe high granulations are destroyed with 
 escharotics, the disposition of iht- surface 
 underneath to reproduce them is increased, 
 but that this is not the case when the luxuri- 
 ant parts me only stimulated, so as to be 
 come absorbed. 
 
 The same gentleman seems to think, that 
 
ULCERS. 
 
 G18 
 
 when animal substances grow with great ra- 
 pidity. the) are, like vegetable ones, weaker 
 than when produced in a slower manner. 
 Hence Sir E. Home is of opinion, that the 
 growth of granulations ought to be cheeked 
 in the early stage of their formation, by some 
 resistance which they are just able to over- 
 come, under which circumstances they de- 
 rive strength from the limited increase of ac- 
 tion which they are obliged to undergo. 
 
 On the same principle, according to Sir 
 E. Home, the pressure of tight bandages is 
 advantageous, and ulcers which heal while 
 the patient is vv Iking about* are not so apt 
 to break out again as others healed while the 
 parts are in a state of perfect rest. 
 
 In the treatment of these ulcers, when the 
 granulations have come to a proper height, 
 and do not form k thm, semi-transparent pelli- 
 cle upon their surface, they are t<- be consi- 
 dered as weak parts, and treated according- 
 ly. Sir E. Home tlouks, that in this circum- 
 stance, the best plan, when no particularity 
 of constitution forbids, is pressure, made 
 with a thin piece of lead over the dressings, 
 and supported with a tight bandage. 
 
 OF APPLICATIONS TO ULCERS ATTENDED 
 WITH WEAKNESS. 
 
 Although strictly we have no topical ap- 
 plications which can directly communicate 
 strength to granulations, there are certainly 
 some which prevent the granulations from 
 exhausting themselves by luxuriant growth, 
 and stimulate them to draw more blood from 
 the arteries ; which effects, as Sir E. Home 
 remarks, render such granulations stronger. 
 
 1. This gentleman very properly con- 
 demns, as applications to w r eak ulcers, all 
 relaxing fomentations commonly employed ; 
 and recommends, instead of them, the use 
 of spirits of wine, and the decoction of pop 
 pies, in equal proportions, not, however, to 
 be applied hot. 
 
 2. Wuh regard to moist applications, the 
 same gentleman expresses his disapprobation 
 of poultices, and mentions a weak solution 
 of the argentum nitratum. as the most eligi- 
 ble application in an aqueous form. 
 
 3. On the subject of powdered substances, 
 as applications to weak ulcers, SirE. Home 
 says, be has often tried bark, and the lapis ca- 
 laminaris, without perceiving that the former 
 had any power of strengthening granulations, 
 or the latter any virtue in disposing them to 
 form new 7 skin ; properties commonly im- 
 puted to these applications. 
 
 Sir E. Home entertains no better opinion 
 of plaster of Paris, or powdered chalk, em- 
 ployed w ith a view of promoting the forma- 
 tion of skin. Powdered carbon he speaks of 
 as being more adapted to irritable, than weak 
 ulcers. He praises powdered rhubarb, as 
 particularly applicable to the latter kind of 
 ulcer, because it represses the luxuriant 
 growth of the granulations, renders them 
 small and compact, and disposes them to 
 form skin. When, however, the granulations 
 have arisen above the level of the skin, it is 
 not powerful enough to reduce them. When 
 
 the rhubarb is too stimulating, it is to be 
 mixed with a fourth part of crude opium in 
 powder. 
 
 A piece of lint, a little less than the sore, 
 is always to be put over the powder, and co- 
 vered with a pledget of simple ointment. 
 
 4. Ointments, according to Sir E Home, 
 are particularly apt to disagree with weak 
 ulcers. When other applications fail, how- 
 ever, greasy ones must be tried, and the 
 above gentleman gives a preference to the 
 ung. hydrarg. nitrat. mixed with hog’s lard,, 
 in the proportion of one to live, or else to 
 common cerate, blended with a small quanti- 
 ty of the hydrarg. nitrat. ruber. 
 
 OF ULCERS IN PARTS, WHOSE ACTIONS ARE 
 TOO VIOLENT TO FORM HEALTHY GRANU- 
 LATIONS, EITHER FROM TH1 STATE OF 
 THE PARTS, OR THE CONSTITUTION : SIM- 
 PLE VITIATED ULCERS OF MR. B. BELL. 
 
 There are three states of the constitution 
 influencing the nature of ulcers ; an .irrita- 
 ble state, in which aJI the actions of the ani- 
 mal economy are more rapid than in health ; 
 an indolent state, in which they are unusual- 
 ly languid ; and, lastly, a diseased state, by 
 which they are affected. 
 
 An irritable and an indolent ulcer cannot 
 in general be distinguished from each other 
 by mere appearances, though they may be 
 so in a few instanc s. Sir E. Home informs 
 us, that the disposition of an ulcer, like the 
 disposition of a constitution, can only be ac- 
 curately ascertained by determining the ac - 
 tions which arise from the different impres- 
 sions made upon it. 
 
 The same gentleman notices, that the fol- 
 lowing appearances at once show the ulcer 
 to be of an irritable kind. The margin of 
 the surrounding skin being jagged, and ter- 
 minating in an edge, which is sharp and un- 
 dermined. The bottom of the ulcers being 
 made up of concavities of different sizes 
 There being no distinct appearance of gra- 
 nulations, but a whitish spongy substance, 
 covered with a thin ichorous discharge. 
 Every thing th»t touches the surface gives 
 pain, and very commonly makes it bleed. 
 The discharge is altered from common pus 
 to a thin fluid, in proportion to the degree of 
 irritability communicated to the sore by con- 
 stitutional causes: 
 
 The pain of an irritable sore in general 
 gradually becomes less. When it is not con- 
 stant, but comes on in paroxysms chiefly in 
 the evening, or night-time, with great vio- 
 lence, convulsive motions of the limb arc 
 apt to occur, and extend to various other 
 parts. Sir E. Home refers this symptom to 
 irritation, communicated along the course of 
 the nerves, and producing an action in them, 
 attended with a violent contraction of the 
 muscles, which they supply. 
 
 When the above-mentioned signs of an ir- 
 ritable ulcer are not present, we must ionn 
 a judgment, of the nature ot the sore irorn 
 listening to the history of the case, the effects 
 of various applications. &c. When this kind 
 
ULCERS. 
 
 of information cannot be obtained, Sir E. 
 Home recommends the treatment to begin 
 on the supposition of the ulcer being of an 
 irritable nature. 
 
 When an ulcer occurs just over the mal 
 leolus externus, it is generally of an irritable 
 kind, in consequence of the nature of the 
 part on which it is situated, quite inde- 
 pendently of any constitutional or local 
 disposition to irritability. Sir E Home 
 conceives, that the periosteum, which here, 
 lies immediately under the skin, becomes the 
 seat of the ulcer, is the cause of its being 
 very difficult to heal, and gives it the irrita- 
 ble appearance. The fact that sores, situa- 
 ted on the ligament of the patella, and over 
 the periosteum of the anterior surface of the 
 tibia, assume a similar appearance, and are 
 equally difficult to heal, made the above gen- 
 tleman more confbmed in his sentiment. 
 
 In treating ulcers in general, the surgeon 
 will find it exceedingly advantageous to be 
 acquainted with the effects of a great many 
 external applications ; lor a very few cases 
 will continue to heal beyond a certain time, 
 without some alteration in the treaunent. 
 The necessity of changing the applications, 
 after they have been continued for a certain 
 time, is strikingly illustrated by the fact, (bat 
 leaving off a powerful application, and em- 
 ploying one which at first would have had 
 no effect, often does a great deal of service. 
 When the change is made to a medicine of 
 powers equal to those of the previous one, 
 the benefit will be more lasting than in the 
 preceding circumstance. 
 
 Sir E. Home compares the principle of 
 this occurrence with that by which change 
 of air, even of a very salubrious air, for one 
 that is less so, often produces an infinite im- 
 provement of the health. 
 
 OF APPLICATIONS TO IRRITABLE ULCERS. 
 
 I. SirE. Home recommends applications 
 in the form of vapour as being particularly 
 useful, by their quality of allaying irritation 
 and soothing pain. 
 
 The steam of warm water is productive 
 of benefit in this way, though seldom u>ed 
 by itself. Its good effects are increased 
 when it is mixed with spirits. 
 
 Sir E. Home speaks also in favour of the 
 benefit derived from fomentations contain- 
 ing opium ; such as the tincture of opium 
 sprinkled on flannel, wrung <>ut of warm 
 water ; or the application of flannels, wet 
 with a warm solution of the extract of opi- 
 um, or with a decoction of poppy heads. 
 A decoction of chamomile flow ers, the tops 
 of wormwood, or hemlock leaves, may also 
 be employed lor the same purpose. 
 
 Sir E. Home points out particular irrita- 
 ble ulcers, however, which are rendered 
 more painful by warm applications ; and he 
 states, that the sores alluded to are generally 
 attended with a mottled purple discolora- 
 tion of the limb for some way from them, 
 and a coldness of the low'er part of the leg, 
 and that they are often disposed to mortify, 
 which event is promoted by warmth. 
 
 2. As for moist applications, lb© poultice 
 made of linseed meal is the rnoSt simple, and 
 most easily made ; and as it does not neces- 
 sarily require any addition of oil, is to be. 
 preferred, when this disagrees with the sore. 
 
 Sir E. Home does not say much in favour 
 of the use of the extract of lend in pouhices ; 
 for though he allows that ii often answers very 
 well, he adds, that it also frequently disa- 
 grees with the ulcer, and, if long used, is apt 
 to bring on the lead-colic. 
 
 A decoction of poppy -heads is said to be 
 a very good liquor for making poultices. 
 
 The carrot poultice is also found to agree 
 with a great many irritable sores. 
 
 fhe great objection to poultices in these 
 cases being the weight of such applications, 
 the limb should always, if possible, rest upon 
 the poultice, and not the poultice upon the 
 limb. When the weight cannot be avoided, 
 and is hurtful, a lighter application should be 
 chosen. 
 
 If poultices be employed, their use is to 
 be continued as long as the granulations are 
 small, and the ulcer is rapidly diminishing in 
 size, and this even till the cicatrization is 
 complete. When the granulations become 
 large, and loose in their texture, poultice, 
 should be left off. 
 
 When the weight of poultices prohibits 
 their use, Sir E. Home advises the trial of 
 lint, dipped in one of the following lotions, 
 and covered w ith a pledget of some simple 
 ointment : a solution of the extract of opi- 
 um ; a decoction of poppies ; the tincture 
 of opium ; a decoction of cicuta ; the liquor 
 plumbi acetatis dilutis ; or a weak solution 
 of the argentum nitratum. 
 
 3. Powdered applications are generally 
 too stimulating for irritable ulcers. Carbon 
 has been found useful ; so has powdered ex- 
 tract of opium, mixed w ith an equal quantity 
 of carbon, or linseed flour. How ever, opium 
 occasionally affectsthe constitution, in conse- 
 quence of absorption, and it has been known 
 to excite violent inflammation, ending in 
 mori ideation. 
 
 4. Ointments are not often proper appli- 
 cations for irritable ulcers, as they are always 
 more or less rancid, and generally disagree 
 with the skin of persons most subject to such 
 diseases. 
 
 Sir E. Home mentions cream as being a 
 very useful application, particularly in cases 
 in which warmth is found to do harm. The 
 same gentleman recommends, as a substitute 
 for it ; an ointment composed of hog’s lard, 
 purified by being repeatedly washed in spring 
 water, and then mixed with a small quantity 
 of white wax and rose water. 
 
 The observations made respecting the so 
 iutions of lead, apply to the unguentum ce- 
 russse acetalaj. 
 
 5. The pressure of bandages is generally 
 hurtful to irritable sores, though a slight de 
 gree of it proves serviceable to certain ulcers, 
 which are somewhat less irritable, and arise 
 from weakness. 
 
 OF ULCERS IN PARTS, WHOSE ACTIONS ARE 
 
 TOO INDOLENT TO FORM HEALTHY CPA- 
 
ULCERS. 
 
 m 
 
 NULATIONS, WHETHER THIS INDOLENCE 
 ARIt .£g' FROM THE STATE OF THE PARTS, 
 on of THE constitution: THE callous 
 ulcers of several writers. 
 
 Surii is the next division of ulcers adopt- 
 rd by Sir C. ilorne, in his treatise on the 
 subject The indolent ulcer terms in its 
 apoearance'a complete contrast to the ini- 
 tlble one. Tiie edges of Hie surrounding 
 ski,, are thick, prominent, . smooth, and 
 rounded. The surface of tire granulations 
 is smooth and glossy. The pus, ...stead of 
 being of a perfect kind, is thin and watery, 
 being composed of a mixture of pus and 
 coagulating Ivinph. The lymph consists of 
 flakes, which cannot be easily separated 
 from the surface of the sore. The bottom 
 cf the ulcer forms quite a level, or nearly 
 <o; and, as Sir E. Home very accurately 
 remarks, the general aspect conveys an 
 idea, that a portion of the skill and p its 
 underneath has been for some removed, 
 without the exposed surface haying begun 
 any new action to fill up the cavity. 
 
 When, however, the indolence of the 
 ulcer is not so strongly marked, the sore 
 does not correspond to the preceding de- 
 scription; but resembles in appearance the 
 ulcer, which possesses an inferior degree of 
 irritability, and can only be discriminated 
 from it by receiving no benefit from smooth- 
 
 >n? fbo odT circumstance of some indolent 
 sores having, the appearance of irritable 
 ones, is, in some degree, explained by ul- 
 cers always being influenced by changes in 
 the constitution, and accidental cncum- 
 stances' affecting the parts 
 
 Most of the ulcers, which are to be seen 
 in the Londop hospitals, are ot the undo ept 
 S ind An indolent disposition m the ulcer 
 may proceed altogether from the long ex- 
 istence of the disease; and hence, >~ir L. 
 Home very justly observes, it is immaterial 
 “Xer atWh was healthy, weak, or 
 irritable, for, if not cured within a ccitaiu 
 . ; m P ;+ becomes indolent, with the excep- 
 of a few of the irritable kind, which 
 
 never change their nature. 
 
 Indolent sores do form granulations; but 
 tUf.se C verv now and then, are all on a sud- 
 wCbld, and, in the course oi four 
 and twenty hours, the sore becomes as 
 much incieasc.i in size, as it had been d - 
 i finished in as nnr.iiy days, or weeks. 1 » 
 
 ahsorptiou of the granulat ions .arise* princi- 
 pally iro;n their not being o t a healthy 
 biitd : but the event is promoted by changes 
 in the weather, anxiety . fatigue, fcc ; 
 
 The object in the tre.-ti.ucnt ot indolent 
 v leers is nos simply to produce a cure, but 
 in wider such erne r, permanent as po.‘- 
 jujje* This cart only be accomplished by 
 alterin 0 ' the disposition of the granulations^ 
 and rendering them strong enough to stand 
 their mound after the ulcer is tilled up 
 When an ulcer,, wbu n lms existed six 
 months is dressed with poUH.ces for a vvee , 
 the granulations, at the end of tm. In ‘ , 
 .vill partfv have filled up the hollow of tl- 
 
 sore, but they will present a large, loose, 
 and glossy appearance. Should the poul 
 tice be now discontinued, and some proper 
 stimulating application used for another 
 week, the granulations will be found, at the 
 expiration of this time, to have become 
 smaller, more compact, redder, and free 
 from the glossy appearance. The ulcer, 
 when healed by the latter application, will 
 not be so likely to break out again, as when 
 healed with large> loose, flabby, glossy gra- 
 nulations. $ * 
 
 Sir E. Home states, that the number of 
 indolent sores, which heal under the use of 
 stimulating applications, and do not break 
 out agaju, compared with similar cases, 
 treated with mild dressings, are as four to 
 one. 
 
 AFFLIC A.TIONS TO INDOLENT ULCERS. 
 
 1. Medicines in the form<of vapour can- 
 not heal indolent sores, so as to accomplish 
 a lasting cure. It is only when these ulcers 
 assume a foul appearance, and are in a tem- 
 porary state of irritation, that such applica- 
 tions can be advantageously employed. 
 
 In general, patients, on their first admis- 
 sion into hospitals with sore legs, have their 
 ulcers in a temporary state of irritation from 
 neglect, exercise, excesses, Hence, it 
 is generally found advantageous, for the 
 first few days, or even a week, to have re- 
 course to poultices and fomentations. 
 
 I believe, that any common fomentation., 
 whether of chamomile, poppy-heads, or 
 mere warm water, answers equally well. 
 The time for using it is while a fresh poul- 
 tice is preparing, and this latter application 
 should be changed twice a day. 
 
 2. Moist applications, such as poultices, 
 are to be employed when fomentations are 
 proper, and they may be made of bread, 
 oatmeal, or linseed. 
 
 ‘Sir. E. Home describes a species of indo- 
 lent ulcers, which occur in patients of de- 
 bilitated constitutions which put on a 
 sphacelated appearance, without any appa- 
 rent cause, even after they have made some 
 progress towards a cure, and in this way 
 spread to a very large size. Some of these 
 ulcers, if judged of from their appearances, 
 would be ranked ns irritable ones; but, as 
 soothing applications 'do not agree with 
 them, they are not to be--, classed with the 
 latter kind of sores. They are said to occur 
 particularly in seamen and soldiers, who 
 have been long at sea, and have been 
 termed scorbutic ulcers. Sir E. Home re- 
 presents them, however, as not being ne- 
 cessarily connected with the scurvy, and 
 being oTten tncl with in patients wild have 
 not been on the sea. He states that they 
 are not of necessity joined with any specific 
 disease ; but are common to all kinds ol 
 patients, whose constitutions have been im- 
 paired either by salt provisions, warm cli- 
 mates, or drinking. , . „ 
 
 From some trials, first made by Di Har- 
 ness, and afterward by Sir E. Home, .1 
 appears that these particular ulcers, when 
 
LJLCERS. 
 
 1 
 
 in a sphacelated state, are benefited by em- 
 ploying the gastric juice of ruminating 
 animals, as an external application. It 
 makes the sloughs fall off, and the sore as- 
 sume abetter appearance. Some pain fol- 
 ' lows on its being first applied, and it is to 
 tTfe regarded as a stimulating application. 
 
 Sir E. Home mentions, that in the West 
 Indies such ulcers are advantageously 
 dressed with the fresh root of the cassada, 
 grated into a pulp. Lime-juice has also 
 heen found a useful application, and solu- 
 tions of vitriol and alum have been recom- 
 mended. 
 
 When indolent ulcers are not attended 
 with certain peculiarities, a solution of the 
 argentum nitratum is one of the best of the 
 watery applications. It stimulates the gra- 
 nulations, and makes them put on a more 
 healthy appearance, and its strength may be 
 increased according to circumstances. An 
 ulcer, which at first cannot bear this solu- 
 tion above a certain strength without pain, 
 and without the granulations beingabsorbed, 
 becomes able, after the application has been 
 used, about ten days or a fortnight, to bear 
 it twice as strong, without such effects 
 being produced : a proof of the granulations 
 having acquired strength. 
 
 The tincture of myrrh is often employed 
 as an application to indolent ulcers. Hune- 
 zowsky has praised a decoction of the 
 walnut-tree leaves, and soft covering of the 
 walnut, for the same purpose. (Ada Acad 
 Med. Chir. Vindob. T. 1, 1788.) Sir E.Home 
 gives his testimony in favour of both the 
 latter dressings. 
 
 Diluted sulphuric acid, aud the expressed 
 juice of the pod of different species of pep- 
 per in a recent state, are mentioned by Sir 
 E. Home as having been used as applica- 
 tions to indolent ulcers : the latter one in 
 the West Indies. 
 
 This gentleman recommends also a scru- 
 ple of nitrous acid, mixed with eight ounces, 
 of water, as a very useful medicine for ex- 
 ternal use. The strength must be increased 
 or diminished, according to circumstances. 
 Sir E. Home has found that this application 
 promotes, in a very uncommon manner, the 
 . progress of the cure. 
 
 The first . application of diluted nitrous 
 acid gives a good deal of pain, which lasts 
 about half an hour, and then goes off. 
 
 When an indolent ulcer heals with the 
 diluted nitrous acid, the process of skinning 
 is accomplished with more rapidity than 
 when other applications are employed ; and 
 the new skin is said to be more completely 
 formed. The acid coagulates the pus as 
 soon as it is secreted. 
 
 Sir E. Home states, that several patients, 
 who had ulcers dressed with the diluted 
 nitrous acid, were allowed to walk about, 
 without finding the progress of the cure re- 
 tarded, although no bandage to support the 
 limb was made use of. This gentleman in- 
 forms us, also, that in ulcers of the leg, at- 
 tended with an exposure of a piece of bone, 
 which retards the cure, because it does not 
 exfoliate, and come a wav. the application 
 
 VoL.Il, ’ ' «<> 
 
 521 
 
 of diluted nitrous acid to the bone removes, 
 the earthy part, and excites the absorbents 
 to act upon the remaining animal portion. 
 
 3. The only application, in the form of 
 powder, adapted to indolent ulcers, is, ac- 
 cording to Sir E. Home, the hydrargyrum 
 nitratus ruber. It may be occasionally 
 used for ulcers of the most indolent kind. 
 
 4. Ointments are represented as being 
 particularly good applications for indolent 
 sores. 
 
 Ihe idea of the air having bad effects on 
 sores, which are exposed to it, is now dis- 
 believed. That air lias no irritating pro- 
 perty of this kind is proved by the fact, 
 that, when the abdomen of an animal is 
 filled with it, no inflammation is excited. 
 When the cellular membrane is loaded with 
 it, in cases of emphysema, the parts do not 
 afterward inflame. Nor do ulcers in the 
 throat, as Sir E. Home justly remarks, heal 
 less favourably than others, although they 
 are of necessity always exposed to the air. 
 
 Whatever ill effects arise, may probably 
 be explained by the consequences of evapo- 
 ration, which converts the soft pus into a 
 scab. The granulations are, in all probabi- 
 lity, most favourably circumstanced when 
 they are covered with their own matter, 
 which should only be now and then re- 
 moved, in order that such applications may 
 be made as will stimulate them to secrete a 
 more perfect pus. F rom what has been 
 just stated, it must be obvious that indolent 
 ulcers should not be frequently dressed, and 
 that if they are so, and the dressings are 
 stimulating, the practice will do harm. 
 Changing the dressings once in twenty-four 
 hours is deemed quite sufficient, unless the 
 quantity of matter be very great, which, 
 seldom happens. 
 
 One part of the unguentum hydrargyr’f 
 nitrati, mixed with three of hog’s lard, is 
 one of the best applications. Its strength, 
 however, must be increased after being 
 used for some time, as a dressing for th& 
 same ulcer. 
 
 The unguentum hydrargyri nitrati has the- 
 effect of quickly removing the thickness of 
 the edges of indolent ulcers, and the sur- 
 rounding dark red colour of the skin. It 
 seems also to have particularly great power 
 in making the granulations become small 
 and healthy, and, of course, the ulcer less 
 likely to break out again. 
 
 With some ulcers, however this ointment 
 is found to disagree. 
 
 The unguentum resinoe flavae, and the un- 
 guentum elemi, mixed with the balsam of 
 turpentine, or that of copaiba, are other 
 common applications to indolent sores Sir 
 E. Horne states, that the resins and turpen- 
 tines are not so powerful as the acids and 
 metallic salts in giving the granulations a 
 healthy appearance, and a disposition to re- 
 sist being absorbed. 
 
 Cases, attended with a degree of indolent 
 thickening, are sucli as are most likely to be 
 improved by camphorated ointments. 
 
 In numerous crises, the applications, what- 
 ever they are, soon lose their effect', anil 
 
ULCERS. 
 
 Sm- 
 
 others should then he substituted for them. 
 The past and present states of the sore are 
 always to be considered. Although the ulcer 
 may be in its nature indolent, it is liable to 
 temporary changes from constitutional 
 causes; and hence a temporary alteration 
 in the treatment becomes proper. 
 
 5. Bandages are undoubtedly of the most 
 essential service in healing many hinds of 
 ulcers ; but their efficacy is so great in cur- 
 ing numerous indolent sores, that they are 
 sometimes considered the principal means 
 of cure. But among modern advocates tor 
 rollers Mr. Whately is one of the most zea- 
 lous. While this gentleman acknowledges 
 that the efficacy of pressure in counteract- 
 ing the effects of the dependent posture was 
 known to Wiseman, who recommended the 
 use of the laced stocking for this purpose, 
 he conceives that the effects of pressure, in 
 the cure of ulcers on the extremities, pre- 
 viously to the appearance of Dr. Under- 
 wood’s treatise, were not duly insisted upon 
 by surgical writers. However, he confesses, 
 that there always have been practitioners, 
 who were acquainted with the importance 
 of this mode of treatment, and adopted it in 
 their practice. He then criticises the work 
 of Sir Everard Home, in which, it is re- 
 marked, that the effect of pressure is not 
 much relied upon for the cure of these com- 
 plaints. Indeed, says Mr. Whately, it is 
 stated in that book, not only that no benefit 
 is derived from compression in several spe- 
 cies of these ulcers, but that many ulcers 
 are rendered worse, more painful, and more 
 unhealthy in their appearance by its use ; 
 -truths which it would be impossible for Mr. 
 Whately to refute. They are, 1 conceive, 
 admitted by himself, when he observes that 
 there are certain conditions of an ulcer 
 which will not bear compression. Whether 
 Sir Everard Home has not given a suffi- 
 ciently favourable account of the effects of 
 pressure in the cure of ulcers of the leg, ! 
 will not presume to determine. Perhaps he 
 may' not have insisted so much upon this 
 treatment as it deserves ; but I can find no 
 fault with him for speaking of it as frequent- 
 ly injurious, because the fact is notorious. 
 
 In the cases, published in Mr. Whately’s 
 essay, very little variety of dressing was used ; 
 pressure being the principal means of cure, 
 with some exceptions particularly specified 
 in the work. 
 
 I cannot doubt (says Mr. Whately) that 
 the practice here recommended must in the 
 end, prevail, notwithstanding it has this 
 great obstacle to contend with, that surgeons 
 must condescend, for the most part, to ap- 
 ply the bandages with their own hands. The 
 clumsy and ineffectual manner, in which this 
 business is too frequently done, can never 
 be expected to produce the desired effect. 1 
 am certain, that if the necessary pains be 
 taken, according to the directions here laid 
 dowu, such effects will uniformly follow, as 
 must convince the unprejudiced mind, that 
 to have recourse to the operation of tying 
 varicose veins, and the application of a great 
 variety of remedies, can be i^ery rarely, most 
 
 probably never necessary. I can safely de* 
 clare, that all such cases as are described by 
 Sir E. Home to be cured by this operation^ 
 have readily yielded under the proper ma 
 n age merit of pressure alone.” 
 
 With respect to Mr. Baynton’s mode of 
 treatment, while Mr. Whately regards it as 
 a confirmation of the principles insisted 
 upon in his own tract, he considers the plan 
 of making the pressure with adhesive plas- 
 ter inconvenient, and on several accounts 
 objectionable. In every case related by 
 Mr. Baynton, he is sure that the proper ap- 
 plication of compresses and fiannel rollers, 
 would have produced similar good effects. 
 The instances of success by this method, 
 after the supposed failure by the roller, he 
 attributes to the pressure made with the 
 plasters, having beer; applied with Mr. Bayn- 
 ton’s own hands, whereas that with the roller 
 was probably so made, that the effect intend- 
 ed by it could not possibly be obtained. No 
 surgeon, he observes, who will not be at the 
 trouble of applying the roller and compres- 
 ses himself, can be a judge of what maybe 
 effected by the proper management of them. 
 
 The following is the calamine cerate, 
 which Mr. Whately has usually employed, 
 f^. Axung. Porcin. depur. lib. iij. 
 
 Empl PI umbi. lib. iss. 
 
 Lap. Calarn. preep. ap. lib. j. M. 
 
 “To this formula, (says Mr. Whately) I 
 shall add another for making a cerate, which 
 nearly resembles the unguentum tripharrai- 
 emu of the old Dispensatory, but being less 
 oily, it makes a much more adhesive plas- 
 ter. It should be spread on rag, or silk, as 
 an external covering to the dressing on lint, 
 where a tow plaster cannot be conveniently 
 used, as in wounds of the face or hands, a 
 bubo, or any other sore, where an external 
 plaster cannot be readily retained in its si- 
 tuation by a bandage. This plaster is like- 
 wise so mild, that it never irritates the skin. 
 I have found it also a very useful plaster in 
 fractures. The following is the formula : 
 j^. Empl. Plumbi lib. j . 
 
 Axung. Porcin depur. unc. vj. 
 
 Aceti unc. iv. M.” 
 
 With respect to the proper method of ap- 
 plying the roller and compresses, Mr. 
 Whately offers the following remarks : 
 
 “ The best width for a Hannel roller, de- 
 signed for those who have slender legs, is 
 three inches; but for those whose legs are 
 of a large size, they should always be three 
 inches and a half in width. They must 
 therefore be at first lorn a little wider, that 
 they may be of their proper width when 
 repeatedly washed. It will likewise be 
 found, that rollers made of fine, soft, and 
 open flannel, will answer much better than 
 those made of coarse or hard fiannel. 
 
 “ For those who have full-sized legs, the 
 length of six yards is but just sufficient to 
 answer all the purposes intended by a roller ; 
 but in those who have very small legs, five 
 yards is a sufficient length. Care should he 
 taken that the rollers be washed in very hot 
 water, and they should be hung up to dry 
 immediately on being washed. II these pre 
 
ULCERS. 
 
 cautions be not attended to, repeated wash- 
 ing them will, in some kinds of flannel, make 
 them as narrow as tape, by which they will 
 be rendered almost useless. They should be 
 often washed, as they are much softer, and 
 of course sit easier, when quite clean than 
 when they are soiled. 
 
 “ In applying a roller, (says this gentle- 
 man) the first circle should be made round 
 the lowest part of the ankle, as near as 
 possible to the heel; the second should be 
 formed from thence round the foot; the 
 third should be passed again round the foot 
 quite to the toes The roller should then be 
 passed from the foot round the ankle and 
 instep a second time to make the fourth cir- 
 cle. In doing this, it should be brought 
 nearer (but not over) the point of the heel 
 than it was at the first time of going round 
 this part. The fifth circle should pass over 
 the ankle again, and not more than half an 
 inch higher up (he leg than the fourth cir- 
 cle. The sixth, seventh, eighth, and ninth 
 circles should ascend spirally along the small 
 of the leg, at the exact distance of three- 
 fourths of an inch from each other. Ha- 
 ving proceeded thus far up the leg, we may 
 begin to increase the distances of the circles 
 from each other : they may succeed each 
 other upward to the knee at the distance of 
 from one to two inches, according to the 
 size and shape of the !e^. At that part 
 where the calf of the leg commences, it is 
 generally necessary to let the upper edge of 
 the roller be once, twice, s or thrice turned 
 downwards for about half the circumference 
 of the leg, in order to make the roller lay 
 smooth between the middle of the calf and 
 the small of the leg. When the roller has 
 been thus applied as far as the knee, there 
 will be a portion of it to spare, of perhaps 
 a yard in length ; this remainder should be 
 brought down by spiral windings, at greater 
 distances from each other than those which 
 were made on the ascent of the roller. The 
 windings should in general be completed in 
 the small of the leg, where the roller should 
 lie pinned. 
 
 “In many cases, it is necessary to apply 
 the roller over the keel. It should be brought 
 as low as possible round the ankle ; as in the 
 , former description. From thence, the se- 
 cond circle of the roller should pass from 
 the instep over one side of the heel, and be 
 brought over the other side of the heel to 
 the instep again. The third circle should 
 be passed round the ankle a second time, 
 but stili nearer to the heel than the first cir- 
 cle was. The roller should after this be 
 brought back to the foot, and passed round 
 it to make the fourth circle. A fifth circle 
 should be again made (though it is not in all 
 cases absolutely necessary) round the foot, 
 to the toes. To make the sixth circle, the 
 roller should be brought back, and passed 
 round the ankle again. The seventh, eighth, 
 ninth, tenth, and eleventh circles should 
 ascend spirally at the exact distance of three- 
 fourths of an inch from each other ; these 
 distances commencing at the sixth circle. 
 The roller should then be carried to the 
 
 ■m 
 
 knee, and be brought , flown -again to the 
 small of (he leg, as described in the former 
 instruction. 
 
 “ In applying the compresses, it is neces- 
 sary in every instance to put them on one 
 by one, and not all in a mass, though they 
 be of a proper size and number. They 
 should be crossed in different directions ; the 
 largest ot them should in no case be longer 
 than just lo meet on the opposite side of the 
 leg to which they are applied. I have in 
 many instances seen the compresses applied 
 by the patients of such a length as to go 
 round the. leg like a roller, and be fastened 
 together with pins. This met hod generally 
 wrinkles and blisters the skin; and by no 
 means answers tin 1 purpose of making a com- 
 pression on the part where it is most want- 
 ed. I never suffer a pin to be used in (he 
 compresses. If the same compresses in a tty 
 case be applied two days together, they 
 should always be turned on the contrary 
 side at each reapplication, in order to pre- 
 vent wrinkles on the skin.” 
 
 Mr. Whately notices two objections* made 
 by Mr. Baynton to rollers. “ The first is, 
 that it is difficult to retain the roller on the 
 parts to which it is applied ; the second is, 
 that it gives pain to the patient.' ” Mr. 
 
 Whately’s experience, however, warrants 
 him in saying, that a flannel roller will, in 
 almost every instance, keep the exact posi- 
 tion in which it was first placed, for a much 
 longer time than is necessary. “ I have 
 seen these rollers (says Mr. Whately) many 
 hundred times keep their situations without 
 any variation whatever for two days ; and 
 that too without the least restraint ujaon ex- 
 ercise. This has happened in those cases 
 where, from the distance of the patient, or 
 from the circumstance of his being nearly- 
 cured, l have wished to dress the leg only 
 every forty-eight hours. I must go a step 
 further, and observe, that I have seen re- 
 peated instances in which these rollers have 
 remained in their situation for three or four 
 days, and even nearly for a week without 
 being applied afresh. In short, it is one of 
 the best properties of a flannel roller, that it. 
 is easily retained in its situation when well 
 applied. In every instance in which it is 
 necessary to use one, I could pledge myself 
 to apply it in such a manner, as should pre- 
 vent its altering its position for two days. 
 The method I should use, I have already 
 described ; in addition to which nothing 
 more would be necessary, even in those 
 cases where the shape of the leg is peculi- 
 arly unfavourable to the retention of a ban- 
 dage, than the insertion of a few pins. 
 
 “ In answer to the second objection, I 
 observe, that I have invariably found, that 
 when a flannel roller has been applied in the 
 manner here described, and has not been 
 drawn unnecessarily tight, it gives no pain. 
 It sits nearly as easy as a common stocking, 
 and allows a very free motion and exercise 
 of the limb.” (See Practical Observations on 
 the Cure of Wounds and Ulcers on the Legs t 
 ivithout rest ; by Thomas Whately , 1799.) 
 
 6. I shall next introdnee an account of 
 
£24 
 
 V) LCKIi< 
 
 Mr. Baynton s p*lau of curing old ulcers of 
 ihe leg, by means of adhesive plaster. Were 
 1 to say, that any particular method of 
 dressing such sores is entitled to superior 
 praise, 1 should certainly decide in favour 
 of this gentleman’s practice. I have seen it 
 most successful myself, and I h ins it highly 
 spoken of by numerous professional frie. ids, 
 in whose unprejudiced judgment i place 
 much reliance. 
 
 Mr. Baynton acquaints us, that the means 
 proposed by him will be found, in most in- 
 stances, sufficient to accomplish cures in 
 the worst cases, without pain or confine- 
 ment. After having been repeatedly disap- 
 pointed in the cure of old ulcers, Mr. 
 .Baynton determined on bringing their edges 
 ' nearer together by means of slips of adhesive 
 plaster. To this he was chiefly led, from 
 having frequently observed, that the proba- 
 bility of an ulcer continuing sound, depend- 
 ed much on the size of the cicatrix which 
 remained after the cure appeared to be ac- 
 complished ; and from well knowing that 
 the true skin was a much more substantial 
 support and defence, as well as a better co- 
 vering than the frail one, which is obtained 
 by the assistance of art. But when he had 
 recourse to the adhesive plaster, with a view 
 to lessen the probability of those ulcers 
 breaking out again, he little expected that 
 an application so simple would prove the 
 easiest, most efficacious, and most agreea- 
 ble means of treating ulcers. 
 
 Although the first cases in which Mr. 
 Baynton tried this practice, were of an un- 
 favourable nature, yet he had soon the sa- 
 tisfaction to perceive that it occasioned very 
 little pain, and materially accelerated the 
 cure, while the size of the cicatrices were 
 much less than they would have been, had 
 the cures been obtained by any of the com- 
 mon methods. 
 
 At first, however, the success was not 
 quite perfect ; as, in many instances, he was 
 not able to remove the slips of plaster, with- 
 out removing some portion of the adjacent 
 skin, which, by occasioning a new wound, 
 proved a disagreeable circumstance in a 
 part so disposed to inflame and ulcerate, as 
 that in (he vicinity of an old sore. He 
 therefore endeavoured to obviate that in- 
 convenience by keeping the plasters and 
 bandages well moistened with spring-water, 
 for some time, before they were removed 
 from the limb. He had soon the satisfaction 
 to observe, that the inconvenience was not 
 only prevented, but that every succeeding 
 case justified the confidence he non' began 
 to place in the remedy. He also discover- 
 ed, that moistening the bandages was attend- 
 ed with advantages which he did not ex- 
 pect : while the parts were wet and cool, 
 the patients were much more comfortable, 
 and the surrounding inflammation was soon- 
 er removed, than he had before observed it 
 to be. 
 
 By the mode of treatment here recom- 
 mended, Mr. Baynton found that the dis- 
 charge was lessened, the offensive smell 
 Ye moved, and the pain abated in a very- 
 
 short time. But, besides these advantages, 
 he also found that the callous edges were 
 in a few days level with the surface of the 
 sore ; that the growth of fungus was pre- 
 vented, and the necessity of applying pain - 
 ful escharotics much lessened, if not entirely 
 done away. Mr. Baynton gives the follow- 
 ing description of his method. 
 
 The parts should be first cleared of the 
 hair, sometimes found in considerable quan- 
 tities upon the legs, by means of a razor, 
 that none of the discharges, by being retain- 
 ed, may become acrid, and inflame the 
 skin, and that the dressings may be remo- 
 ved with ease at each time of their renewal, 
 which, in some cases where the discharges 
 are very profuse, and the ulcers very irrita- 
 ble, may perhaps be necessary twice in the 
 twenty-four hours, but which I have, in 
 every instance, been only under the neces- 
 sity of performing once in that space of 
 time. 
 
 u The plaster should be prepared by 
 slowly melting, In an iron ladle, a sufficient 
 quantity of litharge plaster, or diachylon, 
 which, if too brittle when cold, to adhere, 
 may be rendered adhesive by melting half 
 a dram of resin with every ounce of the 
 plaster: when melted it should be stirred 
 till it begins to cool, and then spread thinly 
 upon slips of smooth porous calico^ of a 
 convenient length and breadth, by sweep- 
 ing it quickly from the end held by the 
 left hand of the person who spreads it, to 
 the other, held firmly by Another person, 
 with the common elastic spatula used by 
 apothecaries ; the uneven edges must be 
 taken ofF, and the pieces cut into slips about 
 two inches in breadth, and of a length that 
 will, after being passed round the limb, 
 leave an end of about four or five inches. 
 The middle of the piece so prepared is to 
 be applied to the sound part of the limb, 
 opposite to the inferior part of the ulcer, so 
 that the lower edge of the plaster may be 
 placed about an inch below the lower edge 
 of the sore, and the ends drawn over the 
 ulcer with as much gradual extension as 
 the patient can well bear; other slips are 
 to be secured in the same way, each above 
 and in contact with the other, until the 
 whole surface of the sore and the limb are 
 completely covered, at least one inch be- 
 low, and two or three above the diseased 
 part. 
 
 il The whole of the leg should then be 
 equally defended with pieces of soft calico, 
 three or four times doubled, and a bandage- 
 of the same, about three inches in breadth, 
 and four or five yards in length, or rather 
 as much as will be sufficient to support the 
 limb from (he toes to the knee, should be 
 applied as smoothly as can be possibly per- 
 formed by the surgeon, and with as much 
 firmness as can be borne by the patient, 
 being first passed round the leg at the ankle 
 joint, then as many times rotnid the foot ns 
 will cover and support every part of it, ex- 
 cept the toes, and afterward up the limb till 
 it reaches the knee, observing that each 
 turn of the bandage should have its lower 
 
ULCERS 
 
 edge so placed as to be about an inch above 
 the lower edge of the fold next below. 
 
 “ If the parts be much inflamed, or the 
 discharge very profuse, they should be well 
 moistened, and kept cool with cold spring- 
 water, poured upon them as often as the 
 heat may indicate to be necessary, or per- 
 haps at least once every hour. The patient 
 may take what exercise he pleases, and it 
 will be always found that an alleviation of 
 his pain and the promotion of his cure will 
 follow as its consequence, though under 
 other modes of treating the disease, it aggra- 
 vates the pain, and prevents the cure. 
 
 u These means, when it can be made 
 convenient, should be applied soon after 
 rising in the morning, as the legs of persons 
 affected with this disease are then found 
 most free from tumefaction, and the advan- 
 tages will be greater than when they are 
 applied to limbs in a swollen state. But at 
 whatever time the applications be made, 
 or in whatever condition the parts be found, 
 I believe it will always happen that cures 
 may be obtained by these means alone, 
 except in one species of the disease which 
 seldom occurs, but that will hereafter be 
 described. The first application will some- 
 times occasion pain, which, however, sub- 
 sides in a short time, and is felt less sensibly 
 at every succeeding dressing. The force 
 with w'hich the ends are drawn over the 
 limb must then be gradually increased, and 
 when the parts are restored” to their natural 
 state of ease and sensibility, which will soon 
 happen, as much may be applied as the ca- 
 lico will bear, or the surgeon can exert ; 
 especially if the limb be in that enlarged 
 and compressible state which has been de- 
 nominated the scorbutic, or if the edges of 
 the wound be widely separated from each 
 other.” 
 
 Mr. Baynton afterward takes notice of 
 the breaking of the skin near the ulcers ; a 
 circumstance which sometimes proved trou- 
 blesome, and arose partly from the mecha- 
 nical effect of the adhesive plasters, and 
 partly from the irritating quality of the 
 plaster. Mr. Baynton, however, only con- 
 siders such sores of serious consequence 
 when they are situated over the tendon of 
 Achilles, in which situation they are some- 
 times several weeks in getting well. This 
 gentleman recommends, with a view of 
 preventing these ulcers, a small shred of 
 soft leather to be put under the adhesive 
 plaster. 
 
 Mr. Baynton next adds, “that cures will 
 be generally obtained without difficulty by 
 the mere application of the slips and band- 
 age ; but when the parts are much inflamed, 
 and the secretions great, or the season hot, 
 the frequent application of cold water will 
 be found a valuable auxiliary, and may 
 be always safely had recourse to where the 
 heat of the part is greater than is natural, 
 and the body free from perspiration.” (See 
 •fl Descriptive Account of a new Method of 
 treating old Ulcers of Ike Legs. Edit. 2, 
 I; 1799.) 
 
 ft ne circumstance, strongly in favour of 
 
 520 
 
 the advantages of the foregoing mode of 
 treatment deserves particular notice: when 
 M. Roux lately visited the London Hospi- 
 tals, he had for the first time an opportunity 
 of seeing this practice, which had never 
 been tried in France. The plan appeared 
 to' him so different from every thing which, 
 he had been accustomed to see in his own 
 country, where ulcers were almost alwavs 
 treated by rest in an horizontal posture, and 
 emollient applications, that he left London 
 somewhat prejudiced against the new me- 
 thod. Subsequently to his return to Paris, 
 however, he has given it a fair trial, and 
 experience has now entirely changed his 
 opinion,- as he has had the candour to ac- 
 knowledge. (See Relation d’un Voyage fait 
 a Londres en 1814, ou Par allele de la Chi - 
 rurgie Angloise avec la Chirurgie Francoisr it 
 par P. J. Roux, p. 159.) 
 
 OF ULCERS ATTENDED WITH SOME SPECIFIC 
 
 DISEASED ACTION, EITHER CON5TITC- 
 
 TIOSAL, OR LOCAL. 
 
 1 . Ulcers which yield to Mercury. 
 
 Here we shall exclude from considera- 
 tion venereal ulcers, as this subject is treat- 
 ed of in the article Venereal Disease. At 
 present we shall only notice such sores as 
 are produced by other diseases of the gene- 
 ral system, or of the parts, aud are capable 
 of being cured by mercury. 
 
 Perhaps there is no greater source of 
 error in the whole practice of surgery, than 
 the supposition that a sore, when it yields 
 to mercury, must be of a syphilitic nature. 
 Surgeons, however, who run into this ab- 
 surdity. can hardly be imagined to be una- 
 ware that so potent a medicine must have 
 effects on numerous diseases of very differ- 
 ent descriptions. Sir E. Home accurately 
 remarks, that many ulcers unconnected 
 with the venereal disease, which receive no 
 benefit from other medicines, heal under a 
 mercurial course, or yield to mercurial ap- 
 plications. Insome cases, the ulcer remains 
 in the same state, w hile mercury is used : 
 but begins to look better as soon as the me- 
 dicine is discontinued, in consequence of 
 the beneficial change produced in the sys- 
 tem by the mercurial course. In these 
 cases mercurial frictions are the best, be- 
 cause they occasion least impairment of 
 the constitution, in consequence of the 
 stomach continuing undisturbed, and capa- 
 ble of digesting welt. 
 
 Another description of ulcers, noticed by 
 SirE. Home as derivingbenefit from mercu- 
 ry, occur on the instep and foot, have a very 
 thickened edge, and are attended with a dis- 
 eased state of the surrounding skin, so as 
 to bear some resemblance to elephantiasis. 
 They are frequently observed affecting ser- 
 vants who live in opulent families in an in- 
 dolent and luxurious way. Sir E. Home 
 states, that fumigations with hydrargyrus' 
 sulphuratus ruber heal these ulcers, and re- 
 solve in a great degree the swelling of the 
 surrounding parts. In some instances, an 
 ointment of calomel and hog’s lard : In 
 
b26 
 
 ULCERS. 
 
 others, the camphorated weak mercurial 
 
 ointment, is the best application. 
 
 Many diseased ulcers, particularly those 
 of a superficial kind, with a thickened edge, 
 may be healed when they are dressed with 
 a solution of one grain of the hydrargyrus 
 muriatus in an ounce of water containing a 
 little spirit. 
 
 heals, while the skin beyond is in a slate of 
 ulceration. 
 
 2. Ulcers curable by Hemlock. 
 
 Sir E. Home places more reliance on 
 hemlock as. an external than an internal 
 remedy for ulcers. The ulcers which usually 
 receive benefit from hemlock applications, 
 look like those of an irritable sort ; but the 
 surrounding parts are thickened in conse- 
 quence of some diseased action. Such 
 sores occur near the ankle, which joint is at 
 the same time enlarged. Spmetknes, but 
 not so often, they take place over the ligd* 
 ments of the knee. On account of their 
 situation, and the swelling of the joint, 
 they may be suspected to be scrofulous, 
 though they are more sensible than stru- 
 mous ulcers usually are. The sores just 
 described are rendered less painful, their 
 diseased disposition is checked, and the 
 swelling of the joint diminished, by hem- 
 lock Several irritable scrofulous ulcers 
 are also particularly benefited by this me- 
 dicine.” , . . * 
 
 SirE. Home gives the preference to hem- 
 lock poultices, unless their weight should 
 be objectionable, in which case he. advises 
 lint to be dipped in a decoction of the herb, 
 and put on the s<»re. . . 
 
 Of the ointment made with the inspissa- 
 ted juice, Sir E. Home says but little in 
 regard to its efficacy. 
 
 3. Ulcers curable by Sail- Water. 
 
 Sir E. Home takes notice of other specific 
 ulcers which yield to this application, alter 
 resisting oilier remedies. Foultices, made 
 ■with" sea-water, are often employed ; but 
 this .gentleman seems to prefer keeping the 
 part immersed in the wafer in a tepid state, 
 about a quarter of. an hour, twice a day. 
 
 When sea-water poultices bring out pim- 
 ples in cases of scrofulous ulcers on the 
 jeer/ and feet, Sir E. Home informs us that 
 this disagreeable circumstance may be ob- 
 viated by diluting such water with an; equal 
 quantity of a decoction of poppies. After 
 a time, the salt water may be tried by itself 
 again. While each fresh poultice is prepa- 
 ring, the part should also be immersed in 
 such water wanned. 
 
 When there is a tendency to anasarca, or 
 when there is an unusual coldness in the 
 limb, unattended with any propensity to 
 mortification, tepid salt-water may be used 
 with infinite advantage. 
 
 wane uiv. v ' > " — - 
 
 becomes larger and larger. Tne discharge 
 consists of a thin, acrid fluid, which seems 
 
 CUiisiais KJI 7. , 
 
 to have a great share in making the disease 
 spread. 
 
 For all the three preceding diseases, a so- 
 lution of the argentum nitratum is strongly 
 recommended by Sir E. Home. 
 
 Of this description are, a leprous eruption, 
 mostly seen in men impressed in Ireland ; 
 a disease of the skin induced by buboes, 
 which have continued a great while after 
 the venereal virus has been destroyed ; and 
 the ringworm. 
 
 All these diseases are most easily cured 
 by applying to them a solution ot the argen- 
 tum nitratum. 
 
 The leprous eruption is communicated by 
 contact, and makes its appearance in the 
 form of a boil. This is converted into an 
 ulcer, which discharges a fetid fluid, by 
 which the surrounding skin is excoriated, 
 and the ulceration is extended over a large 
 surface. The pain is the most severe, and 
 the discharge greatest, in hot weather. The 
 parts first diseased heal, while others are 
 becoming ulcerated, and the disease is 
 always rendered worse by spirituous liquors, 
 salt provisions, and catching cold. 
 
 Sir E. Home remarks, that the disease in 
 the skin, produced by the effects of very irri- 
 table buboes, in constitutions broken down 
 by mercury, is attended with ulceration of a 
 more violent, deep, and painful kind, than 
 the foregoing distemper. The progress of 
 tli is disorder is, in other respects, very simi- 
 lar to that of the leprous eruption. 
 
 Although the ringworm only occurs in the 
 form of an ulcer in warm climates, a mild 
 species of the affection takes place in sum- 
 mertime in this country. It seems to be 
 infectious ; though it .often occurs without 
 infection. It commences with an efflores- 
 cence, which is attended with very trivial 
 swelling, and spreads from a central point. 
 The circumference of the efflorescence be- 
 comes raised into a welt, while the rest 
 assumes a scurfy appearance. The welt be- 
 comes covered with a scab, which falls off', 
 and leavef an ulcerated ring, in general, not 
 more thah a quarter of an inch wide. The 
 outer bargin of this ring continues to ulcerate, 
 while the inner one heals, so that the circle 
 
 4. Ulcers curable by Ike Argentum Mtrajum . 
 
 SirE Home notices, under this head, an 
 
 'ulcer which does not penetrate more deeply 
 than the cutis, hut spreads in all directions, 
 producing ulceration on the surface of the 
 skin, and often extending nearly through its 
 whole thickness. The part, first affected 
 
 5. Ulcers which yield to Arsenic. 
 
 Thesores. which comeunderthe definition 
 of noli me tangere or lupus, derive great 
 benefit from this powerful remedy. SirE. 
 Home observes, that they are nearly allied 
 to cancer, differing from it in not contamina- 
 ting' the neighbouring parts by absorption, 
 and only spreading by immediate contact. 
 
 From some cases, which tell under Sir E 
 Home’s observation, he discovered, that ar- 
 senic was not only efficacious as an external,, 
 but also as an internal remedy. 1 shall not 
 unnecessarily enlarge upon tins subject m 
 the present place, as the reader may refer to 
 the articles Arsenic , Cancer, Lupus, Hospital 
 Gangrene. &c. for additional information rc 
 
ULCEUS. 
 
 Native to the uses of this mineral in the prac- 
 tice of surgery. 
 
 Sir E. Home is an advocate for its employ- 
 ment, both internally and externally, tor 
 ulcers of untoward appearance on the legs. 
 The fungated ulcer is particularly pointed 
 out by this gentleman as being benefited by 
 arsenic. This ulcer occurs on the calf of the 
 leg, and on the sole of the foot. From its 
 surface, a fungus shoots out, which is entire- 
 ly different from common granulations, 'lhe 
 neo -formed substance is radiated in its 
 structure, the bottom of the ulcer being lhe 
 central point, and the external surface, which 
 is continually increasing, the circumference. 
 The substance of this fungus is very tender, 
 and readily bleeds. The first stage of the 
 •disease sometimes has the appearance of a 
 scrofulous affection of the metatarsal bones; 
 but the parts seem more enlarged, and, when 
 the skin ulcerates, a fungus shoots out. and 
 betrays the nature of the case. 
 
 One species of the fungated ulcer is capa- 
 ble of contaminating the lymphatic glands ; 
 the other is not so. The first is represented 
 by Sir E. Home as being incurable by arsenic, 
 or any other known medicine. 
 
 The second yields to this remedy. Sir E. 
 Home uses a saturated solution made by 
 boiling white arsenic in water, for several 
 hours, in a sand heat. He gives from three 
 to ten drops internally ; and, for outward 
 use, dilutes a dram with two pints of water, 
 making it afterward gradually stronger and 
 stronger, till it is of double strength. The 
 application may either be made in the form 
 of a poultice, or of lint dipped in the lotion. 
 
 The best and safest preparation of ar- 
 senic, both for internal and external use, is 
 the kali arsenicatum The mode of em- 
 ploying it may be learnt by turning to the 
 articles Arsenic, Cancer, Potassa, Lupus, kc. 
 
 6. Ulcers attended with Varicose Veins. 
 
 A certain kind of ulcer is very apt to oc- 
 cur on the inside of the leg, and is equally 
 difficult to cure, and liable to break out 
 , again. It has the look of a mild, indolent 
 sore; but, the branches and trunk of the 
 vena saphena are enlarged, and this varix of 
 the veins keeps the ulcer from healing. The 
 sore is seldom deep, usually spreads along 
 the surface, and has an oval shape, the ends 
 of which are vertically situated. There is a 
 pain affecting the limb rather deeply, extend- 
 ing up in the course of the veins, and exas- 
 perated by keeping the leg a long while in an 
 i erect posture. 
 
 This is a kind of ulcer, which derives 
 immense benefit from a light roller, applied 
 from the toes totbe knee, although the direct 
 operation of the pressure of the bandage on 
 the sore is itself productive of no particular 
 good. 
 
 Sir E. Home found, however, that many 
 patients could not bear to w'ear laced stock- 
 ings, or tight bandages, and that others 
 received no relief from them. Hence, this 
 gentleman was led to consider what else could 
 be done for the cure of the varicose state 
 of the veins. He represent?, that, in con- 
 
 02? 
 
 sequence of the size of the vena saphena, 
 and its numberless convolutions, the return 
 of blood from the smaller branches is so im- 
 peded, as to retard the circulation in the. 
 smaller arteries, and to interfere with their 
 action in forming healthy granulations. The 
 coats, and valves of the veins also become 
 thickened, so that the latter parts (the valves) 
 do not do their office of supporting the weight 
 ot the column of blood. 
 
 These reflections induced Sir. E. Home to 
 think, that some benefit might be obtained 
 by taking off a part of the pressure of this 
 column of blood, by making a ligature round 
 the vena saphena, where this vessel passes 
 over the knee joint. Thus the cavity of the 
 vein at this part would be obliterated, and a 
 kind of artificial valve formed. 
 
 This gentleman recommended the follow- 
 ing way of performing the operation : “ As 
 the veins are only turgid in the erect posture, 
 the operation should be performed while 
 the paiient is standing ; and if placed upon a 
 table, on which there is a chair, the back of 
 the chair will serve him to rest upon; and he 
 will have the knee-joint at a very con- 
 venient height for the surgeon. The* leg to 
 be operated upon must stand with the inner 
 ankle facing the light, which will expose 
 very advantageously the enlarged vena sa- 
 phena passing over the knee-joint. While 
 the patient is in this posture, if a fold of the 
 skin, which is very loose at this part, is 
 pinched up transversely, and kept in that 
 position by the finger and thumb of the sur- 
 geon, on one side, and of an assistant on the 
 other, this fold may be divided by a pointed 
 scalpel, pushed through with the back of the 
 knife toward the limb to prevent the vein 
 being wounded ; much in the same way as 
 the skin is divided in making an issue. This 
 will expose the vein sufficiently; but, there 
 is commonly a thin membranous fascia con- 
 fining it in its situalion ; and, when that is 
 met with, the vein bad better be laterally 
 disengaged by the point of the knife. This 
 is most expeditiously done by laying hold of 
 the fascia with a pair of dissecting forceps, 
 and dividing it; for it is difficult to cut upon 
 parts, which give little resistance, and there 
 is a risk of wounding the vein. After this a 
 silver crooked needle, with the pointrounded 
 off, will readily force its way through the 
 cellular membrane connected with the vein, 
 without any danger of wounding the vessel, 
 and carry a ligature round it. This part, or, 5 
 indeed, what may be considered as the 
 whole of the operation, being finished, the 
 patient had better be put to bed, so as to 
 allow the vein to be in its easiest slate, be- 
 fore the ligature is tied, and then a knot is to 
 be made upon the vein: this gives some 
 pain ; but it is by no means severe. The 
 edges of the wound in the skin are now to 
 be brought together by sticking-plaster, ex- 
 cept where the ligature passes out, and a 
 compress and bandage applied, so as to keep 
 up a moderate degree of pressure on the 
 veins, both above and below the part in- 
 cluded in the ligature.” (Home on Ulcers o 
 2J)f>. Edit. 2.) 
 
lag 
 
 LAG 
 
 It appears that A. Parc proposed and per- 
 formed an operation, similar to that des- 
 cribed by Sir E. Home. (The Works of A. 
 Parti translated by Johnson ; folio , p. 319.) 
 An account of Mr. Brodie’s operation for the 
 cure of varicose veins, and some additional 
 remarks on the treatment of ulcers accom- 
 panied with varices, will be found in a 
 subsequent article. See Varicose Veins. A 
 description of what has sometimes been 
 called the hospital sore , is given under the 
 head of Hospital Gangrene. 
 
 For information on the subject of ulcers, 
 consult Michael Underwood' s Treatise on Ulcers 
 of the Legs, fyc. 8vo. Lond. 1783, and Surgical 
 Tracts: 3d edit. 1799. B. Bell, A Treatise 
 on the Theory and Management of Ulcers , fyc. 
 New edit. 8 vo. 1791 ; and his System of Sur- 
 gery. J. Meric , Be Curationibus Ulcerum 
 diffcilium pretseriim in cruribus obviorvm. 
 4to. Goett. 1776. Baynton's Descriptive Ac- 
 count of a new Method of Treating Old Ulcers 
 of the Legs, 1799, ed. 2. 8 vo. Bristol, 1799. 
 Whalely's Practical Observations on the Cure 
 of Wounds and Ulcers on the Legs , without 
 rest, St o. Lond. 1799. Practical Obs. on the 
 Treatment of Ulcers on the Legs, to which are 
 ad^ed, some Observations on Varicose Veins 
 and Piles, by Sir Ererard Home, 1801, edit. 
 2. Principles of Surgery, by John Bell, Vol. 1. 
 1801. Hunter on the Blood, Inflammation, fyc. 
 C. Curtis, An Account of the Diseases of In- 
 dia, fyc. with Observations on Ulcers and the 
 Hospital Sores of that country, fyc. 8 vo. Edinb. 
 1807. Brodie on the Treatment of Varicose 
 Veins of the Legs, in Med. Chir. Trans. Vol. 
 7, P 195, <U- Bicker and, Nosographie Ckir. 
 T. 1, p. 121,4 re. ed. 4. Boyer, TraiU des 
 Maladies Chir. T. 2, p. 365. fyc. Paris, 1S15. 
 Roux, Voyage fait a Londres en IS 14, ou Pa- 
 rallel c de la Chirurgie Angloise avec la Chi- 
 rurgie Franqoise, p. 142, fyc. Paris, 1815. Dr. 
 John Thomson's Lectures on Inflammation , p. 
 423, fyc. Edinb. 1813. Dr. Dewar on the 
 Treatment of Sinuous Ulcers , in Med. Chir. 
 Trans. Vol. 7, p. 482, 4 c- The stages of se- 
 veral cutaneous affections, attended with ulcera- 
 tion., have been excellently described by Dr. 
 Bateman in his valuable Synopsis of Cutane- 
 ous Diseases. 
 
 UNGUENTUM ACIDI SULPHURIC!. 
 — R. ’Acidi Sulphurici 3j- Adipis Suillce 
 pr separata} j|j. — These are to be well mixed 
 together in a glass mortar. 
 
 This ointment has been used by Dr. Dun- 
 can, of Edinburgh, for curing the itch. It 
 has the character also of being efficacious 
 in the reduction of some chronic swellings 
 of the joints; and when mixed with a good 
 deal of camphor, it was rubbed upon the tu- 
 mour, in cases of bronchoceie, by Mr. Nay- 
 Ipr, of Gloucester, with considerable effect. 
 
 As the sulphuric acid is particularly de- 
 structive of vegetable substances, the parts, 
 to which this ointment is applied, should 
 always be covered with flannel, instead of 
 linen. 
 
 UNGUENTUM ANTIMQNII TARTA- 
 RS Z ATI. — R, Antim. Tart. 3j. Ung.Cetacei 
 ■ j. Misce. The nntini.onial ointment, fre- 
 
 quently used for exciting irritation of the 
 skin, with the view of relieving diseases in 
 the vicinity of the irritated part, as is exem- 
 plified in the treatment of some diseases of 
 the eyes and joints, and a variety of indo- 
 lent swellings. 
 
 UNGUENTUM CETACE1. — R. Cetacei 
 3vj. Cerae Albae 3>j- Oliva? Olei. fluid un- 
 cias tres. These are to be melted upon a 
 slow fire, and then briskly stirred till cold. 
 This ointment, spread on lint, serves as a 
 simple dressing for wounds, ulcers, &c. 
 
 UNGUENTUM CER7E CUM ACETO. 
 — R- Cera; Alba? |iv. Olei Olivse fbj. Aceti 
 Distillati ^ij. The vinegar is to be gradu- 
 ally mixed with the two first ingredients, 
 after these have been melted together. Dr. 
 Cheston recommends this ointment for su- 
 perficial excoriations, cutaneous eruptions, 
 &c. 
 
 UNGUENTUM CONTI— R. Foiiorum 
 Conii recentium. Adipis Suiliae praeparatae, 
 sing. ^iv. The hemlock is to be bruised 
 in a marble mortar, after which the lard is 
 to be added, and the two ingredients tho- 
 roughly incorporated by beating. Tbey are 
 then to be gently melted over the fire, and 
 after being strained through a cloth, and the 
 fibrous part of the hemlock well pressed, 
 the ointment is to be stirred till quite cold. 
 To cancerous Or scrofulous sores, th '13 oint- 
 ment may be applied'with a prospect of ad 
 vantage. ( Pharm . Chirurg.) 
 
 The Pharmacopoeia of St. Bartholomew's 
 Hospital directs the unguentum conii, vel 
 cicutae, to be made as follows: — R. Foiio- 
 rum Cicutae fbj. Adipis Suiliae ftjiss. Boil 
 the leaves in the melted hog’s-Iarct until they 
 become crisp. Then strain the ointrnent- 
 A similar ointment might be more conve- 
 niently made, by mixing the extraction conii 
 with anv common salve. 
 
 UNGUENTUM DIGITALIS.— R. Fo 
 
 liorum Digitalis Purpureae recentium. Adi- 
 pis Suiliae praparatie, sing. ^iv. This oint- 
 ment may be made in the same manner as 
 the unguentum conii, and tried in the same 
 cases. 
 
 UNGUENTUM ELEMI COMPOSITUM. 
 — R. Elemifbj Terebinthinae ^x. Sevi 
 Ovilli praeparati ft>ij. Olei Olivae ^ij. Melt 
 the elemi with the suet ; remove them from 
 the fire, and mix them immediately with 
 the turpentine and oil. Then strain the 
 mixture. — Sometimes employed for dressing 
 ulcers, which stand in need of stimulating 
 applications. 
 
 UNGUENTUM GALL/E CAMPHORA- 
 TUM. — R. Gall arum Pulveris Submission 
 3 *j • Camphorae 3ss. Adipis Suilla? prrnpii- 
 ratae ^ij. Misce. — This is a very good ap- 
 plication to piles, after their inflammatory 
 state has been diminished by the liq.plumbi. 
 acet. dibit, and leeches. 
 
 UNGUENTUM HELLEBORl ALBL— 
 R. Hellebore Albi pulv. gj. Adipis Suiliae 
 praeparata? t-iv. Olei Limonis 3ss. Misce. 
 This ointment will cure the itch, and several 
 other cutaneous diseases. Tinea capitis will 
 sometimes vield to it' 
 
UNO 
 
 UNO 
 
 629 
 
 * UNGUENTUM HYDRARGYRI FOR- 
 TIUS. — JJ,. Hydrargyri purificati Jfoij. Adi- 
 pis Suilla 1 pracparafa? gxxiij. Sevi Ovilli 
 pfaeparati !$j. First rub the quicksilver with 
 the suet, and a little of the hog’s-lard, until 
 the globules disappear ; then add the remain- 
 der of the lard, and make an ointment. — 
 This is the common slrong mercurial oint- 
 ment. Of its uses we need say nothing in 
 this place. 
 
 UNGUENTUM HYDRARGYRI CAM- 
 PHORATUM. — R. Unguent i Hydrargyri 
 
 ^j- Camphorae 3 SS - Misce. — This is often 
 recommended to be rubbed on thickened, 
 indurated parts, with the view of exciting 
 the action of the absorbents. Rubbed 
 along the course of the urethra, it is very 
 serviceable Jn diminishing and removing 
 chordee. 
 
 UNGUENTUM HYDRARGYRI MI- 
 TIUS. — R. Unguenti Hvdrargyri fort. Rjj. 
 Adipis Suilla? pra?parata? ffoij. Misce. — The 
 weaker mercurial ointment is often rubbed 
 on indurated, thickened parts and tumours, 
 when the object is merely to promote their 
 absorption; and it- is not adviseable to em- 
 ploy the unguentum hydrargyri fort, lest a 
 salivation should be induced. 
 
 UNGUENTUM HYDRARGYRI N1TRA- 
 TCS. — R. Hydrarg. Purificati Jj. Acidi 
 
 Nitrosi Zij. Adipis praeparata? ^ v j . Ole; 
 Oliva? ^iv. Dissolve the quicksilver in the 
 nitrous acid ; and whilst the solution is yet 
 hot, mix with it the oil and hog’s lard, pre- 
 viously melted, but beginning to concrete, 
 by being exposed to the air. This ointment 
 is a celebrated application to the inside of the 
 eyelids, in cases of chronic ophthalmy, and 
 also to specks on the cornea? When blend- 
 ed with a little olive oil, it also forms a very 
 eligible stimulating dressing for numerous 
 kinds of sores. It is particularly efficacious 
 in curing tinea capitis, and many other cuta- 
 neous diseases. 
 
 UNGUENTUlM HYDRARGYRI NITKI- 
 CO-OXYDI. — R. Hydrargyri nitrico-oxydi 
 -p. Cera? Albas ^ij. Adipis prrnpar. ^vj. 
 Misce. — This is a common stimulating ap- 
 plication to indolent ulcers, and sores in ge- 
 neral. 
 
 UNGUENTUM HYDRARGYRI PRiC- 
 CI PIT ATI ALBI — R. Hvdrarg. Prcemp. 
 Albi 3j- Adipis prajparatae ?iss. Misce. — 
 An useful application in certain cases of por- 
 rigo, and some other cutaneous diseases. 
 See Porrigo. 
 
 UNGUENTUM LIQ. PLUMBI ACETA- 
 TIS. — R. Liquoris Plumbi Acetatis ^v. 
 
 Adipis Suilla? fbj- Cerae Aibae Z\v. Melt 
 the ingredients together, and continue to 
 stir them till cold. — This ointment is em- 
 ployed with great advantage as a simple 
 
 *The preparation of this article will be greatly expe- 
 dited by rubbing the mercury in the first instance, with 
 a small proportion of the article familiar to us by the 
 appellation of goose-grease; this can be done in a glass 
 mortar, or even upon a marble slab, by a spatula; it 
 has such immediate effect upon the mercury. One ounce 
 of this article will be sufficient, with trituratiw for the 
 space of one minute, to make the globules of the quirk- 
 silver entirely disappear, and render it at once fit for 
 admixture with the proper proportion of lard. — Am. Ed, 
 
 Vnj, . jr ft? 
 
 dressing. According to Mr. Dunn, of Scar- 
 borough, it is much improved by pouring 
 the liquified mixture, before the lead has 
 been added to it, into cold water. It is 
 then to be rubbed in a mortar, or on a 
 slab with the liq. plumbi acet. The water 
 occasions a fine white cloudy precipitation, 
 which gives to the composition abetter ap- 
 pearanc* 1 . 
 
 UNGUENTUM OPHTH ALMICUM.— ft. 
 Adipis Suilla? praeparatae |s«. Tutiae praepa 
 rata?, Bol Armen, sing. 3'j- Praecip. Hy- 
 drarg. Albi 3j. Misce. — Janin’s celebrated 
 ophthalmic ointment, frequently mentioned 
 in the parts of this work, which relate to dis- 
 eases of the eye and eyelids. 
 
 UNGUENTUM OXYGENATUM, vel 
 ACIDI NITROSI. — R. Axungia? Suillae re 
 cenlis; non salsa? uneias sedecim. Leni 
 calore in vase vilreo lente liquefactis ant con- 
 tiuua a-itatione instillentur, Acidi Nitrici 
 unciae dua?. Massa igni exponatur, donee 
 ebullire coepit ; tunc ab igne removeatur, fri- 
 gefactaque servelur. 
 
 In this process the nitric acid is decom- 
 posed, the nitrous gas escaping, and the oxy- 
 gen combining with the lard. This oint- 
 ment was particularly recommended by Aly- 
 on,as an application to venereal and herpe- 
 tic ulcers. Its virtues are said to vary consi- 
 derably, according to the strength of the acid 
 employed, and it is not generally deemed so 
 efficacious as the ointment of nitrate of mer- 
 cury. 
 
 UNGUENTUM PICIS.— ft. Picis, Sevi 
 Ovilli prmparati, sing. ftss. Melt, and then 
 strain them. 
 
 UNGUENTUM PICIS COMPOSITUM, 
 — R- Unguenti Picis, Unguenti Plumbi 
 
 Superacetatis sing. Rjss. Misce. 
 
 The two preceding ointments are applica- 
 ble to cases of tinea capitis, and some erup- 
 tive complaints. Also to some kinds of irri- 
 table ulcers. 
 
 UNGUENTUM PICIS CUM SULPHU- 
 RE.— R. Unguenti Picis, Unguenti Sul- 
 pburis, sing, ^iv, Misce. — This is one of the 
 most common, and, I believe, the most effi- 
 cacious applications for curing tinea capitis, 
 or porrigo. 
 
 UNGUENTUM PLUMBI SUPERACE- 
 TATIS. — R. Plumbi Superacetatis 3»j* Cera? 
 Alba? Zij. Olei fbss. The superacetate of 
 lend, previously powdered, is to be triturated 
 with part of the olive oil. Th# melted wax 
 and rest of the. oil are then to be added. This 
 is a good dressing for cases requiring a mild 
 astringent application. 
 
 UNGUENTUM RESINiE.— R. Resina? 
 Flavee, Cerae Flavae sing. ft>j. Olei Oliva? Jbj 
 Melt the resin and wax with a slow fire ; 
 then add the oil, and strain the mixture while 
 hot. — This is a common application to ul- 
 cers, which stand in need of being gently sti- 
 mulated. 
 
 UNGUENTUM SAMBUCI, — ft. Florum 
 Sambuci, Adipis Suillae, singulorum ft>j. 
 The hag’s lard being melted, boil the elder 
 flowers in it till they become crisp, then 
 strain the mixture. 
 
 UNGUENTUM SULPHURIS— R, 
 
URETHRA 
 
 u&j 
 
 pis Suilla? lt>ss. Florutn bulphuris ?iv. 
 Misce. 
 
 UNGUENTUM TUTIjE.— ft. Tutiac pnc- 
 parata?, Unguenti Celacei q. s. Misce.--- 
 Used for smearing the borders and inside of 
 the eyelids, in cases of chronic ophtbalmy, 
 &c. 
 
 UNGUENUJM TUTliE COMPOS1TUM. 
 — 15;. Tuliae prseparatae, Lapidis Cularriinaris 
 pra;parati, sing. 3vj. Camphorae 3<j- Un- 
 guenti Sambuci jftj. Misce. 
 
 This formula is contained in the Pharma- 
 copoeia of St. Bartholomew’s Hospital. It 
 is occasionally applied to the inside of the 
 eyelids, piles, ulcerations, excoriations, Sic. 
 
 ^ UNGUENTUM ZINCl.— ft. Zinci oxyrii 
 3 J. Adipis prtepar. fvj. Misce. — An astrin- 
 gent application in very common use. 
 
 UNGUIS. (A Nail.) Some surgical au- 
 thors apply this term to a collection of pus, 
 or matter in the eye, when the abscess ap- 
 pears, through the cornea, to be shaped like 
 a finger nail. 
 
 UNION BY THE FIRST INTENTION. 
 
 • — When the opposite surfaces of a wound are 
 brought into contact, and grow together at 
 once, without suppurating, union by the first 
 intention is said to take place. When 
 wounds heal by suppurating, granulating, 
 Sic. they are sometiipes surgically described 
 as getting well by the second intention. See 
 Wounds. 
 
 URETHRA, DESTRUCTION OF PART 
 OF THE. — The attempts to complete the 
 canal by operations, .performed on theTalia- 
 eotian principles, will be noticed in the arti- 
 cle URINARY FISTULA. 
 
 URETHRA, STRICTURES OF.— A stric- 
 ture of the urethra, as a modern writer ob- 
 serves, “ consists of some morbid alteration 
 of action, or of structure, by which a part of 
 the canal is rendered narrower than the 
 rest.” ( Wilson on the Malt ' Urinary and 
 Genital Organs, p. 361.) According to Mr. 
 John Hunter, most obstructions to the pas- 
 sage of the urine, if not all, are attended 
 with nearly the same symptoms. Few per- 
 sons take notice of the first symptoms of a 
 stricture, till they have either become vio- 
 lent, or other inconveniences have been t he 
 consequence. A patient may have a consi- 
 derable stricture, yet be unconscious that his 
 Urine does not freely come away; and in 
 consequence of a stricture, there may even 
 be a tendency to inflammation and suppura- 
 tion in the perinaeum, while he feels no ob- 
 struction to the passage of his urine, and 
 does not suspect that he has any other com- 
 plaint. 
 
 There are three kinds of strictures viz. 
 the true permanent one, which arises from 
 an alteration in the structure of a part of the 
 urethra ; the mixed case, consisting of a per- 
 manent stricture and a spasm ; and, thirdly, 
 the true spasmodic stricture. 
 
 Whether the urethra is a truly muscular 
 canal, and whether a variety of circumstan- 
 ces, remarkable in its healthy and dieased 
 state, can be accounted for by its elasticity, 
 the action of the muscles in the perina j utn, 
 and other principles, without supposing tue 
 
 canal to be ilseli muscular, are questions on 
 which the writers on surgery entertain dif- 
 ferent opinions. However, the generality of 
 modern practitioners in this country have 
 inclined to that view of the subject, which 
 refers the property of muscularity either to 
 the membrane of the urethra itself, or to the 
 substance immediately surrounding it. The 
 latter is now alleged to be the real case 
 “ From Mr. Bauer’s examinations (says Sir 
 Everard Home) we find that the human 
 urethra is made up of two parts, an internal 
 membrane, and an external muscular cover- 
 ing. The internal membrane is exceedingly 
 thin, and no fibres are met with that can 
 give it a power of contraction. When it is 
 put on the stretch in a transverse direction 
 the circumference of the canal is no ways 
 increased ; but when stretched longitudinal- 
 ly a small degree of elongation is produced 
 When a transverse section of the urethra is 
 made, while in a collapsed state, the inter- 
 nal membrane is found thrown into folds, 
 pressed together by the surrounding parts, 
 it is afterward explained, that “the muscu- 
 lar covering, by which the membrane is 
 surrounded or enclosed, is made up of fasci- 
 culi of very short fibres, which appear to be 
 interwoven together, and to be connected by 
 their origins and insertions with one another 
 They all have a longitudinal direction. There 
 is a greater thickness of this muscular struc- 
 ture upon the upper, than the under surface 
 of the urethra, which is still more evident as 
 it approaches nearer to the external orifice 
 The fasciculi are united together by an elastic 
 substance of the consistence of mucus. Im- 
 mediately beyond the muscular portion of 
 the urethra, is the cellular structure of the 
 corpus spongiosum. 
 
 Formerly “ it was believed, that either the 
 lining of the urethra was composed of circu- 
 lar fibres, possessed of a power of contrac 
 tion, or that it was immediately surrounded 
 by such fibres ; and therefore that the dis 
 ease, commonly known by the name of a 
 stricture in the urethra, was produced by a 
 contraction of some of these circular fibres ; 
 and the permanent stricture was a term ap- 
 plied to these parts, when in consequence 
 of inflammation they became confined to 
 that particular state. We now find, that the 
 lining of the urethra is never ?net with in a 
 contracted stale, but is thrown into folds by 
 the action of the elastic ligamentous cover- 
 ing of the corpus spongiosum, and the swell 
 of the longitudinal muscular fibres within it; 
 and when these fibres have, by acting 
 through their whole length, reduced the 
 urethra to its shortest state, the pressure 
 upon the internal membrane is so great, that 
 there is not room for the urine to pass, till 
 these fibres are relaxed by elongating the 
 whole canal. 
 
 “ A spasmodic stricture is in reality a con 
 traction of a small portion of the longitudinal 
 muscular fibres, while the rest are relaxed , 
 and as this may take place either all round , 
 or upon any one side, it explains what is 
 met with in practice, and could not before 
 be satisfactorily accounted for ; the mark, 
 or impression of a stricture sometimes form 
 
UUETHIU* 
 
 mg a circular depression upon the bougie 
 at other times, only on one side. 
 
 “ A permanent stricture is that contraction 
 of the canal, which takes place, in consequence 
 of coagulable lymph being exuded between the 
 fasciculi of muscular fibres, and upon the in- 
 ternal membrane , in different quantities, ac- 
 cording to circumstances ; and, in the same 
 proportion, diminishing the passage for the 
 urine at that part, or completely closing it 
 up. (Sir Everard Home in Phil. Trans. 1820, 
 and Pract. Obs. on Strictures , Vol. 3, p. 20, 
 fyc. Svo.Lond. 1821.) 
 
 For a particular detail of the arguments 
 and remarks, urged against the doctrine of 
 the urethra being a tube, capable of having 
 its diameter suddenly lessened at every point 
 by the contraction of muscular fibres, 1 
 must refer to the writings of Mr. C. Bell 
 and Mr. Shaw, whose statements, indeed, 
 have been noticed in my introductory work. 
 (See First Lines of the Practice of Surgery, 
 cd. 4, Vol. 2.) 
 
 In all obstructions of the urethra, Mr. 
 Hunter remarks, that the stream ot water 
 becomes small in proportion to the stop- 
 page ; but, though this symptom is probably 
 the first, it is not always observed by the 
 patient. In some instances, the water is 
 voided only by drops, and then it cannot 
 escape notice. In other cases, the stream 
 of urine is forked, or scattered. Under such 
 circumstances, Mr. Hunter recommends the 
 passage to be examined with a bougie ; and, 
 if one of a common size can be readily in- 
 troduced, the difficulty of voiding the urine 
 is likely to depend on a diseased enlarge- 
 ment of the prostate gland, which should, 
 therefore, be examined. See Prostate Gland. 
 
 The spasmodic stricture may be known 
 by its being only of temporary duration. 
 This kind of case, and more particularly the 
 permanent stricture, are generally attended 
 with a gleet. The latter complaint is often 
 for a long while suspected as being the only 
 one, and the surgeon finds all his efforts, to 
 effect a cure, fruitless. 
 
 In diseases of the urethra, and also of the 
 prostate gland and bladder, there is com- 
 monly an uneasiness about the perinajum, 
 anus, and lower part of the abdomen. 
 (Hunter.) 
 
 The first progress of the contraction is, in 
 general, very slow ; but, when once it has 
 so far increased, that the longitudinal fibres 
 are not wholly relaxed by the force of the 
 urine, its subsequent advances are more 
 rapid, and nevv symptoms are perceived. 
 The urine is voided more frequently, ^does 
 not pass without a considerable effort, at- 
 tended with pain, and a straining sensation 
 continues, after the bladder is emptied. If 
 the patient accidentally catches cold, drinks 
 a glass of spirituous liquor, acid beverage, 
 or punch, commits an excess in drinking 
 wine, or removes quickly from a w r arm to a 
 cold temperature, the urine will, perhaps, 
 pass only in drops, or be entirety obstructed. 
 These causes induce, in the longitudinal 
 fibres at the contracted part, a spasmodic 
 action, by which it fa closed. Cold, exter- 
 
 031 
 
 nally applied to the body, has so great an 
 effect upon a spasmodic stricture, that a 
 patient, who can make water without the 
 smallest difficulty in a warm room, is often 
 quite unable to void a drop, on making the 
 attempt in the open air. However, on re- 
 turning to a warm room, and sitting down 
 a little while, he becomes able again to 
 expel his urine. The symptoms of a stric- 
 ture are more frequent in persons who lead 
 a sedentary life, than in those whose pur 
 suits are active. 
 
 Strictures in the urethra, being attended 
 with a discharge and pain in making water, 
 especially after any excess, are frequently 
 regarded and treated as a gonorrhoea. 
 These two symptoms often come on a few 
 hours after connexion w ith women ; the 
 degree of inflammation is very slight ; the 
 discharge is the first symptom, and is more 
 violent at the commencement, than at any 
 other period. The inflammation subsides 
 in a few days, leaving only the discharge, 
 which also frequently disappears in five or 
 six days, whether any means are employed 
 or not for its removal. (Home.) 
 
 What renders* a stricture particularly apt 
 to be mistaken for a gonorrhoea, is the cir- 
 cumstance that, in both diseases, the pain 
 in making water is experienced about an 
 inch and a half from the orifice of the glans 
 penis. 
 
 In a more advanced stage, the part of the 
 urethra which is the seat of stricture, is 
 always much narrower than the rest of the 
 canal. The stricture is permanent, being 
 combined With a thickening of structure, 
 whereby the diameter of the diseased part 
 of the passage is lessened. However, the 
 diameter of the affected portion of the canal 
 even now varies, according as the spasm 
 and projection of the longitudinal fibres, the 
 spasmodic action of the muscles about the 
 peri n am m, and the effects of inflammation, 
 contribute more or less 1o a temporary in- 
 crease of the obstruction. In the language 
 of Sir Everard Home, the case is now botli 
 a permanent stricture, and a spasmodic one 
 permanent, because the diseased part of the 
 urethra is always narrower than the rest of 
 this passage ; and spasmodic, inasmuch as 
 the stricture may be rendered still more 
 contracted by spasm affecting the muscular 
 structure, adjoining the disease. In the 
 contracted state the passage is closed up 
 iu the relaxed, the urine can passthrough it 
 in a small stream. 
 
 The spasmodic contraction must act with 
 considerable force, sincQjtyhe urine cannot 
 even pass in a small strehm, and a small 
 bougie, which, in a relaxed state of the ure- 
 thra, met with no resistance, can now be 
 scarcely introduced at all. Also, if the 
 bougie be allowed to remain for a few mi- 
 nutes in the stricture, it is not unfrequently 
 grasped so tightly by the spasmodic con- 
 traction, that, when an attempt is made to 
 withdraw it, some force is requisite to suc- 
 ceed. The bougie, when examined, seems 
 as if it had had an impression made round it 
 by a piece of packthread. iHomCr.) 
 
URETHRA. 
 
 
 in old cases of stricture* the muscular 
 coat of the bladder becomes thickened and 
 stronger than natural, in consequence of 
 more force being necessary to propel the 
 uiine through the obstructed part. The 
 bladder, in this thickened state, does not 
 admit of the usual dilatation, so that the 
 patient is obliged to make water very fre- 
 quently, and he is unable to pass the whole 
 night without making this evacuation once 
 or twice. (Home.) 
 
 A nocturnal emission of the semen is 
 another very common symptom of a stric- 
 ture ; and some patients seem to have no 
 other complaint attendant on the disease of 
 the urethra. 
 
 A periodical discharge is sometimes 
 brought on by cold, or other occasional 
 causes. When the inflammation extends to 
 the bladder, the frequency of making water 
 is considerably increased, and the urine very 
 turbid. It is voided for twelve, or twenty- 
 four hours, once or even twice every hour; 
 and, when allowed to stand, it deposits a 
 substance in the form of powder, consisting 
 of coagulable lymph. This is the slightest 
 kind of attack. 
 
 Sometimes the bladder is inflamed in a 
 greater degree, and secretes pus, which is 
 discharged with the urine. In a still more 
 violent attack, the discharge is similar to 
 the white of an egg, and particularly adhe- 
 sive. Sir Everard Home states, that it has 
 been discovered by examinations after death, 
 to be the vitiated secretion of the prostate 
 gland. When the inflammation of the blad- 
 der becomes still worse, the afleetion some- 
 times extends to the peritoneum, and the 
 patient dies. 
 
 As strictures of long standing always im- 
 pede the passage of the urine, the bladder 
 acts with augmented force to overcome the 
 resistance. In this manner, the stricture is 
 kept in a continual state of irritation, and 
 the obstruction becomes more and more 
 considerable. 
 
 In a few cases, indeed, the diseased part 
 of the urethra is rendered quite impervious ; 
 and the patient’s life is preserved by the 
 urethra ulcerating, at some point within the 
 obstruction, and fistulous openings taking 
 place in the perinseum. See Fistula, in Pe- 
 unao. 
 
 Strictures are frequently attended with 
 constitutional symptoms, one of the most 
 common of which, in warm climates, is a 
 complete paroxysm of fever. The cold tit 
 is very severe ; ***is is followed by a hot fit, 
 and then a very profuse perspiration. Du- 
 ring the rigour, nausea and vomiting gene- 
 rally occur, and at this period the "patient 
 has occasion to make water frequently, sel- 
 dom experiencing at the same time any 
 strangury. When the fit is tolerably com- 
 plete, the patient suiters, in general, only 
 one; in the opposite circumstance, two ; 
 but a greater number rarely happen. Such 
 febrile paroxysms are not frequent in cold 
 countries ; but do every now and then take 
 place, particularly in consequence of expo- 
 
 sure to cold, excesses, and the introduction 
 both of common and armed bougies. 
 
 According to the principles of Sir Everard 
 Home, the longitudinal muscular fibres on 
 the outside of the membrane of the urethra, 
 are liable to a spasmodic contraction, in 
 which state their swell lessens the diameter 
 of the passage, and they are incapable of 
 becoming relaxed again, until the spasm is 
 removed. This spasmodic stricture is only 
 a wrong action of these longitudinal fibres; 
 and, if the parts could be examined in their 
 relaxed state, there would be no appearance 
 of disease. 
 
 When the contraction is not considerable, 
 it appears, on examination after death, to 
 be merely a narrowing of the urethra ; but a 
 permanent stricture, in a more advanced 
 state, usually consists of a ridge, which 
 forms a projection in the passage. (Home.) 
 
 Mr. Hunter informs us, that the disease 
 generally occupies no great length of the 
 passage ; at least, that this was the case in 
 most of the instances which he examined. 
 In these cases, the contraction was not 
 broader, than if it had been produced by 
 surrounding the urethra with a piece of 
 packthread ; and in many it had a good 
 deal of the appearance, which one may 
 fancy such a cause would produce. Mr. 
 Hunter states, however, that he had seen 
 the urethra contracted for above an inch in 
 length, owing to its coats, or internal mem- 
 brane being irregularly thickened, and form- 
 ing a winding canal. 
 
 A stricture does not always arise from an 
 equal contraction of the urethra all round ; 
 for, in some instances, the contraction is 
 only on one side ; a fact, which appears to 
 me to be better accounted for by the con- 
 sideration of the longitudinal arrangement 
 ot the muscular fibres in packets, on the 
 outside of the membrane of the urethra, 
 than the circular kind of stricture, only oc- 
 cupying as small an extent of the passage, 
 as the constriction which would arise from 
 the application of a piece of packthread 
 round it. The contraction of one side of 
 the canal only throws the passage to the 
 opposite side, which often renders the in- 
 troduction of a bougie difficult. The con- 
 tracted part is whiter than the rest of the 
 urethra, and is harder in its consistence. 
 In some cases there* are several strictures. 
 Mr. Hunter mentions his having seen half 
 a dozen in one uiethra, and he observes, 
 that a stricture is frequently attended with 
 small tightnesses in other parts of the pas- 
 sage. 
 
 Mr. Hunter remarks, that every part oi 
 the urethra is not equally subject to stric- 
 tures, the bulbous portion being much the 
 most subject to the disease. A stricture is 
 sometimes situated on this side of the bulb, 
 but very seldom beyond it, that is, nearer 
 the bladder. Mr. Hunter never saw a stric- 
 ture in that part of the urethra, which passes 
 through the prostate gland ; and the bulb, 
 besides being the most frequent seat of this 
 disease, is also subject to it in its worst 
 forms. ( Hunter.) 
 
URETHRA 
 
 air Everaid Home lias measured the 
 iongth of the urethra in different subjects, 
 and examined the diameters of the several 
 parts of the passage. Strictures, according 
 fo this gentleman, occur most commonly 
 just behind the bulb of the urethra, the dis- 
 tance from the external orifice being 6 1-2 
 or 7 inches. The situation, next in the or- 
 der of frequency, is about 4 1-2 inches from 
 the orifice of the glans. The disease does 
 also occur at 3 1-2 inches, and sometimes 
 almost close to the external orifice. The 
 two parts of the urethra, most frequently 
 affected with strictures, are naturally the 
 narrowest. Sometimes the very orifice of 
 the urethra is contracted, and the circum- 
 stance often leads to an erroneous supposi- 
 tion, that the whole canal is naturally form- 
 ed of the same size. The prepuce also is 
 observed to be particularly often affected 
 with a natural phymosis, in persons who 
 have strictures in the urethra. 
 
 In almost all the cases which Sir E. 
 Home has met with, there has been one 
 stricture, about seven inches from the exter- 
 nal orifice, whether there w r ere any others, 
 or not. 
 
 With respect to the causes of strictures, 
 some writers have imputed the disorder to 
 the effects of the venereal disease, and 
 often to the method of cure. Mr. Hunter 
 entertained strong doubts however, whether 
 strictures commonly, or ever proceeded 
 from these causes ; though he acknowledges, 
 that since most men have had venereal 
 complaints, arefututionof the above opinion 
 is very difficult. Mr. Hunter was led to 
 think, that strictures did not commonly 
 arise from venereal causes, from reflecting 
 that strictures are common to most passages 
 in the human body. They often take place 
 in the oesophagus ; the intestines, particu- 
 larly the rectum ; the anus ; the prepuce so 
 as to produce phymosis; and in the lachry- 
 mal duct, so as to occasion a fistula lachry- 
 malis. Strictures sometimes take place, 
 when there have been no previous venereal 
 complaints Mr Hunter mentions his hav- 
 ing seen an instance of this kind in a young 
 man, nineteen years of age, who had had 
 the complaint for eight years, and w hich 
 therefore began, when he was only eleven 
 years old. He was of a weak scrofulous 
 habit. Mr. Hunter had also seen a stricture 
 in a boy only four years old, and a fistula 
 in perinaeo in consequence of it. Strictures 
 happen as frequently in persons, who have 
 had gonorrhoea in a slight degree, as in 
 others, w ho have had it in a severe form 
 
 It is not an uncommon belief, that stric- 
 tures arise from the use of astringent injec- 
 tions in the treatment of the gonorrhoea. Sir 
 Everaid Home is of this sentiment, and so 
 is Mr. Wilson. (On the Male Genilal and 
 Urinary Organs, p. 370.) The latter gentle- 
 man however, mentions some circumstan- 
 ces, calculated to raise doubts on this point, 
 especially the fact, that wrhile injections 
 rarely enter far into the urethra, the most 
 common seat of a stricture is where the 
 membranous part of the canal joins the 
 
 033 
 
 bulb. Mr. Hunter himself deemed the opin- 
 ion founded on prejudice, and states that he 
 had seen as many strictures after gonorrhoea, 
 which had been cured without injections, 
 as after cases which had been treated with 
 these latter applications. 
 
 He rejected also the old doctrine, that 
 strictures are a consequence of ijcers in 
 the urethra ; for ulcers hardly ever occur in 
 this passage, except when there are stric- 
 tures ; and it is now generally admitted, 
 that in gonorrhoea, there are no sores in the 
 urethra. Strictures are sometimes produced 
 by external violence, though the passage 
 would appear to be capable of frequently 
 bearing considerable wounds and other in- 
 juries, without this consequence. Thu- 
 strictures are not common from lithotomy, 
 and in a modern w r ork, we read the case of 
 a serious gunshot wound of the urethra, 
 where no stricture, ensued. (See Jlnnuairc 
 Med. Chir. des Hopitaux de Paris, 4to. 1819.) 
 
 TREATMENT OF STRICTURES, W'lTH COMMON 
 
 ROUGIES, ON THE PRINCIPLE OF DILATA- 
 TION. 
 
 Mr. Hunter remarks, that the cure of stric 
 tures may be accomplished, either by a di- 
 latation of the contracted part, or a destruc- 
 tion of it by ulceration, or escharotics. To 
 these methods are to be added, first the plan 
 of forcing a passage through the stricture 
 w ith a conical sound, as practised by the 
 French surgeons, when they cannot other- 
 wise pass the stricture, and the symptoms 
 are urgent. (See J. Cross, Sketches of the 
 Medical Schools of Paris, Svo. Lond. 1815, p. 
 Ill ; and First Lines of the Practice of Sur- 
 gery, Vol. 2, ed. 4;) and secondly, the me- 
 thod of cutting down to obliterated portions 
 of the urethra, and attempting to cure the 
 obstruction by the removal of the diseased 
 parts, tracing the continuation of the pas- 
 sage, and trying to heal the wound over a 
 catheter. Both these practices are attended 
 with such difficulties and dangers, as should 
 make every prudent surgeon very reluctant 
 to adopt them, except under very urgent 
 circumstances, in which every milder me- 
 thod tails. The dilatation is accomplished 
 by means of bougies or catheters ; but Mr. 
 Hunter considered, that acure thus effected 
 was seldom or never more than temporary 
 The removal of the stricture by ulceration 
 may also be effected with bougies. Its de- 
 struction w ith caustic used formerly to be 
 executed through a cannula, contrived for 
 the purpose ; but is now performed by 
 means of caustic or armed bougies. 
 
 The cure by dilatation is principally me- 
 chanical, when effected by bougies, the 
 powers of which are generally those of a 
 wedge. However, Mr. Hunter conceived, 
 that their ultimate effect was not always so 
 simple as that of a u edge upon inanimate 
 matter: tor pressure makes living parts 
 either adapt themselves to their new posi- 
 tion, or else recede by ulceration. Bougies 
 of course, either dilate strictures, or make 
 them ulcerate 
 
URETHRA 
 
 i>34 
 
 The disease has generally made consider- 
 able progress, before surgical assistance is 
 required, and the stricture may be so ad- 
 vanced, that a small bougie cannot be made 
 to pass, without a great deal of trouble. If 
 the end of a small bougie, let it be ever so 
 small, can be introduced through the stric- 
 ture, ih»t cure is then in our power. How- 
 ever, a small bougie frequently cannot pass 
 in the first instance, and even not after re- 
 peated trials. 
 
 Often when the stricture is very consider- 
 able, a great deal of trouble is given by 
 occasional spasms, which either resist the 
 introduction of a bougie altogether, or only 
 allow a very small one to pass. At other 
 periods, however, a larger one may be in- 
 troduced. In these circumstances Mr. 
 Hunter mentions, that he was sometimes 
 able to make the point of the bougie enter, 
 by rubbing the outside of the perihasum 
 with the finger of one hand, while he push- 
 ed the bougie on with the other. The same 
 eminent practitioner often succeeded by. 
 letting the bougie remain a little while close 
 to the stricture, and then pushing it on. 
 Sometimes the spasm may also be taken off 
 •by dipping the gians penis in cold water. 
 
 Although in cases of permanent stric- 
 tures, the bougie may not pass at first, yet 
 after repeated trials, it will every now and 
 then find its way. In this manner future 
 attempts become more certain and easy. 
 
 However, the success of the subsequent 
 trials to introduce a bougie does not always 
 depend on the instrument having been once 
 or twice passed. Sometimes it can be in 
 produced to-day, but not to-morrow ; and 
 in this state, the case may continue for 
 weeks, notwithstanding every trial which 
 can be made. Mr. Hunter observes how- 
 ever, that in general, the introduction of 
 the bougie becomes gradually less difficult, 
 and therefore, that we ought not to despair 
 of success in any case. 
 
 When the passage is very small, it is not 
 easy to know whether the bougie has enter- 
 ed the stricture or not ; for bougies as slen- 
 der as those which must be at first employ- 
 ed, bend so very easily, that the surgeon is 
 apt to fancy, that they are passing along the 
 urethra, while they are only bending. Mr. 
 Hunter advises the surgeon first to make 
 himself acquainted with the situation of the 
 stricture, by means of a common-sized 
 bougie ; and then to take a smaller one, 
 and when its point arrives at the stricture, 
 the instrument is to be gently pushed for- 
 ward, but only for a short time. If the 
 bougie has passed further into the penis, the 
 surgeon may know how far it has entered 
 the stricture, by taking the pressure off (he 
 bougie. For, if it recoil , he maybe sure 
 that it has not passed ; at least, has not pass- 
 ed far, but only bent. On the contrary, if 
 it remain fixed , and do not recoil, it has cer- 
 tainly entered the stricture. 
 
 However, the preceding remarks are said 
 not to be so applicable when a very small 
 bougie is employed, which may become 
 
 bent, without our being aware of the cir- 
 cumstance,. 
 
 A bougie may frequently be introduced a 
 very little way, for instance, only one-tenth 
 of an inch, and then it bends, and cannot be 
 pushed further. To determine whether this 
 is the case, Mr. Hunter says, it is necessary 
 to withdraw the bougie and examine its \ 
 end. If the end be blunted, we may be 
 sure, that the bougie has not entered at all ; 
 but if it be flattened, for an eighth, or tenth 
 of an inch, be grooved, or have its outer 
 waxen coat pushed up to that extent; or it 
 there be a circular impression made upon 
 the bougie,* or only a dent on one side, 
 made by the stricture ; we may be sure that 
 the instrument has passed ns far as these 
 appearances extend. It then becomes ne- 
 cessary to introduce another of exactly r the ' 
 same size, and in the same manner, and to 
 let it remain as long as the patient can bear 
 it, or convenience will allow. By repeti 
 tions of (his plan, the stricture will be over- 
 come. 
 
 Mr. Hunter remarks, that the time which 
 each bougie ought to remain in the passage 
 must be determined by the feelings of the 
 patient ; for if possible, no pain should ever 
 be given. If the patient should experience 
 very acute pain when the bougie is passing, 
 it ought not to be left in the urethra above 
 five; or at most, ten minutes ; pr not so long 
 if the pain be exceedingly severe. Each 
 time of application should afterward be 
 lengthened so gradually as to be impercep- 
 tible to the feelings of the patieql, and the 
 irritability of the parts. Mr. Hunter affirms, 
 that he has known many patients, who 
 could not bear a bougie to remain In the 
 passage ten, or even five minutes, till after 
 several days, and even weeks, but who in 
 time were able to wear the instrument for 
 hours, and this, at last without any diffi- 
 culty. The best time for keeping a bougie 
 in the urethra, is when the patient has least 
 to do; or in the morning, while he is in 
 bed, if he can introduce the instrument him- 
 self. 
 
 Mr. Hunter next observes, that the bougie 
 should be increased in size, according to the 
 facility with which the stricture becomes di- 
 lated, and the case with which the patient 
 bears the dilatation. If the parts are very 
 firm, or very irritable, the increase of the 
 size of the bougie should be very slow, so as 
 to allow them to become gradually adapted 
 to the augmented size of the instrument. 
 But if the sensibility of the parts will allow, 
 the increase of the size of the bougie may 
 be somewhat quicker, but never more siuR 
 den than the patient can easily bear. The 
 surgeon must continue to increase the size 
 of the bougie, till one of the largest size can 
 freely pass ; nor should the use of this be dis- 
 continued till after three weeks, ora month, 
 in order that the dilated part may have time 
 to become habituated to its new position, 
 and lose its disposition to contract again. 
 However, Mr. Hunter believed, that the 
 permanency of a cure, effected on the pvin 
 
URETHRA 
 
 
 • ipie ol mlataiiou, could seldom be depend- 
 ed upon. 
 
 At the present day, many surgeons prefer 
 bougies composed of metal, flexible enough 
 to allow their curvature to be adapted to the 
 bend of the urethra, yet sufficiently firm to 
 retain the figure given them, while they are 
 employed. Others very commonly use iron 
 sounds, which, in cases where it is necessa- 
 ry to have an instrument possessing more 
 firmness than a wax bougie, and having a 
 point more unchangeably turned upwards 
 than that of the latter instrument, may have 
 advantages. But, for all ordinary cases, 1 
 consider a common bougie a safer and bet 
 ter instrument ; one with which the surgeon 
 is less apt to exert unwarrantable force, 
 so as to occasion a dangerous degree of irri- 
 tation, or, what is worse, a false passage 
 
 CURE OF STRICTURES BY ULCERATION. 
 
 This is also accomplished by means of a 
 wax or metallic bougie, and the plan may 
 be tried both when the instrument can, or 
 cannot be introduced through the stricture. 
 In the first instance, the method is less pro- 
 per, because the stricture admits of being 
 dilated. 
 
 In order to cure a stricture by making it 
 ulcerate, the bougie is to be introduced as 
 far through the contracted part as possible, 
 and the size of the instrument is to be aug- 
 mented, as fast as the sensations of the pa- 
 tient can well bear. In this manner ulcera- 
 tion will be produced in the part which is 
 pressed; and Mr. Hunter remarks, that the 
 cure will be more lasting, because more of 
 the stricture is destroyed than when the parts 
 are simply dilated. This eminent surgeon 
 notices, however, that few patients w ill sub- 
 mit to this practice, and that few indeed 
 would be able to bear it, since it is apt to 
 bring on violent spasms in the part, attend- 
 ed with a very troublesome retention of 
 urine 
 
 If the smallest bougie cannot be made to 
 pass a stricture, by using some degree ot 
 torce, dilatation becomes impracticable ; 
 and as the stricture must be destroyed, 
 something else must be tried. In many 
 cases, says Mr. Hunter, it may be proper to 
 get rid ot the stricture, by making it ulce- 
 rate, or, in other w'ords, be absorbed. Bou- 
 gies,-intended to excite ulceration, need not 
 be so small as in the foregoing cases, as they 
 are not designed to be-passed through the 
 stricture ; and, in consequence of being of 
 the common size, they may be more surely 
 applied to the parts causing the obstruction. 
 The force applied to a bougie, in this case, 
 should not be great : for a stricture is the 
 hardest part of the urethra ; and it a bougie 
 
 forcibly pushed on, its end may slip off 
 the stricture, before ulceration has com- 
 menced, and make a false passage for itself 
 in the corpus spongiosum urethrae. 
 
 In trying to cure strictures by ulceration.' 
 the utmost attention must be paid ; and if 
 the patient does not make wmter better, not- 
 withstanding the bougie passes further, the 
 
 surgeon may be sure be Is forcing a false 
 passage. 
 
 When the stricture has so far yielded, as 
 to allow a small bougie to be introduced, 
 the treatment is then to be conducted on 
 the principle of dilatation. 
 
 Mr. Hunter observes, that whenever a 
 bougie ot a tolerable size passes with ease, 
 and the parts and the patient have become 
 accustomed to it, the surgeon need no longer 
 attend for the purpose of introducing it, 
 1 he patient may now be allowed to intro- 
 duce bougies himself; and when he can do 
 tins with ease, the business may be trusted 
 to him,, as he can make use of the instru- 
 ments at the most convenient times, so that 
 they may be more frequently and longer 
 applied. In the mean while, the surgeon 
 should only pay occasional visits. Mr. Hun- 
 ter adds, that this practice of the patient, 
 under the surgeon’s eye, by which means 
 the former learns the art of introducing bo; - 
 gies, is the more necessary, since strictures 
 are diseases which commonly recur ; and, 
 therefore, no man w ho has ever had a stric 
 ture, and is cured of it, should rely on the 
 cure as lasting ; but should always be pre- 
 pared for a return, and always have some 
 bougies by him. He should not go a jour- 
 ney, even of a week, without them ; and the 
 number should be according to the time 
 which he is absent, and the place to which 
 he is going , for in many parts of the world 
 he cannot be supplied with them. 
 
 To prevent the inconvenience of a bougie, 
 slipping out, or the mischief of its gliding 
 intd the urethra, a soft cotton thread must 
 be tied round that end of the bougie which 
 is out of the urethra, and then round the 
 root of the glans. This last part of the 
 thread should be verv loose. The projecting 
 portion of the bougie should also be bent 
 down upon the penis, by which means it is 
 rendered less troublesome, and more secure, 
 (See Hunter on the Venereal Disease. When 
 a considerable part of the bougie remain, 
 out of the urethra, surgeons usually clip a 
 piece d{ it off. 
 
 In many examples, .in which a stricture i 
 accompanied with excessive irritability in 
 the urethra, much pain, and a tendency to 
 frequent retentions of urine, when a com - 
 mon bougie is employed, it becomes advisea 
 ble to alter the plan of treatment, and use 
 either flexible metallic, or elastic gum bon 
 gies. (See Bougie.) Desault commonly cured 
 all strictures by the skilful employment of 
 flexible gum catheters, which his patients 
 were directed to wear a certain length of 
 time every day. These last instruments 
 produce less pain and irritation than any 
 kind of bougie, more especially when thc ( 
 wires are withdrawn ; and were I to be my 
 self altiicted with strictures, I should feel 
 strongly disposed to attempt their removal 
 by the use of elastic gum catheters, which 
 are unquestionably the mildest and least 
 painful means of cure. I have seen cases, 
 however, in which the flexible metallic bou- 
 gie seemed to cause much less irritation than 
 any other kind of bougie: but in general. 
 
URETHRA 
 
 fi3ti 
 
 those made ot elastic gum give the least 
 pain. Metallic bougies possess the advan- 
 tage of retaining the exact curvature of the 
 passage better than others ; and, as I have 
 observed, they enable the surgeon to employ 
 more force, and this with more precision 
 than can be done with a wax bougie. Yet, 
 as force is not a principle to be much com- 
 mended in the treatment of ordinary stric- 
 tures, I Uoubt whether such instruments will 
 long retain as many employers as they have 
 now acquired, and many of whom use them 
 indiscriminately in all cases. Small catgut 
 bougies are chiefly eligible, when the cure 
 by dilatation is preferred, and the smallest 
 bougies of other descriptions cannot be in- 
 troduced through the stricture. 
 
 CORE OP STRICTURES WITH THE ARGENTUM 
 N1TRATUM. 
 
 Wiseman makes mention of the plan of 
 curing strictures in the urethra by means of 
 caustic. He observes, that when the ob- 
 struction is a caruncle, and you cannot pass 
 it, you may well conclude it is callous : 
 •‘in which case, you may pass a cannula 
 into the urethra to that caruncle, and, whilst 
 you hold it there steady, you may convey a 
 grain of caustic into the cannula, and press 
 the caustic to it ; and whilst you hold it 
 there, you will perceive its operation, by 
 the pressing forward of the cannula.” 
 
 About the year 1752, Mr. Hunter attended 
 a chimney-sweeper, who had a stricture. 
 JNot finding that any benefit was derived 
 from the use of common bougies, for a space 
 of six months, Mr. Hunter, unaware of the 
 above passage in Wiseman, conceived, that 
 the stricture might be destroyed by escharo- 
 tics, and the first attempt, which he made, 
 was with red precipitate. He put some 
 salve on the end of a bougie, and then dip- 
 ped it in red precipitate. The bougie in this 
 state, was passed down to the stricture ; but 
 Mr Hunter found, that it brought on con- 
 siderable inflammation all along the inside 
 of the passage, as he thought, in conse- 
 quence of the precipitate being rubbed off, 
 while the bougie was passing to the stricture. 
 He then introduced a silver cannula down 
 to the stricture, and again passed the bougie 
 with precipitate through the tube. As the 
 patient, however, did not make water any 
 better, and the smallest bougie could not 
 be introduced through the stricture, it was 
 suspected, that the precipitate had sufficient 
 power to destroy the obstruction. Mr. 
 Hunter was induced, therefore, to fasten a 
 small piece of the argentum nitratum on the 
 end of a piece of wire with sealing-wax, 
 and introduce the caustic through the can- 
 nula to the stricture. After having made 
 the application ) three times, at intervals of 
 two days, he found that the man voided his 
 urine much more freely, and on applying 
 the caustic a fourth time, the cannula went 
 through the stricture. A bougie was intro- 
 duced for a little while afterward, till the 
 man bad completely recovered. 
 
 Having experienced this success, Mr. Hun- 
 
 ter was encouraged to apply his mind to the 
 invention of some instrument, better suited 
 to the purpose, than the above contrivance ; 
 and an improved instrument was devised, 
 although he acknowledges, that it was not 
 perfectly adapted to strictures in every situ- 
 ation in the urethra. He remarks that the 
 caustic should be prevented from hurting the 
 unaffected part of the urethra by introducing 
 the active substance, through a cannula, 
 down to the stricture ; and that it should be 
 capable of protruding a little beyond the end 
 of the cannula, by which means it will only 
 act upon the stricture. The caustic should 
 be fixed in a small portcrayon, and it is ne- 
 cessary to have a piece of silver of the length 
 of the cannula, with a ring at one end, and 
 a button at the other, of the same diameter 
 as the cannula. The button forms a kind of 
 plug, which should project beyond the end 
 of the cannula in the urethra, so as to make 
 a rounded end ; or, Mr. Hunter says, the 
 portcrayon may be formed with this button 
 at its other end. The cannula, with the 
 button, is to be passed into the urethra, and 
 when it reaches the stricture, the silver plug 
 should be withdrawn, and the portcrayon with 
 the caustic introduced in its place ; or, if the 
 plug and portcrayon are on the same instrn- 
 ment, then it is only necessary to withdraw the 
 plug, and introduce the portcrayon with the 
 caustic. The plug, besides giving a smooth 
 rounded end to the cannula, answers ano- 
 ther good purpose, by preventing the tube 
 from being filled with the mucus of the ure- 
 thra, when the instrument is passing in- 
 ward, which mucus would be collected iu 
 the end of the cannula, dissolve the caustic 
 too soon, and hinder its application to the 
 stricture. 
 
 When the stricture was beyond the straight 
 pari of the urethra, Mr. Hunter owned, that 
 it was difficult to apply caustic to the disease 
 through a cannula. 
 
 A better mode of applying lunar caustic lo 
 strictures was afterward devised by Hunter, 
 and has since been extensively introduced 
 into practice by Sir E. Home. This gentle- 
 man directs us to take a bougie of a size 
 that can be readily passed down to the stric- 
 ture, and to insert a small piece of lunar 
 caustic into the end of it, letting the caustic 
 be even with the surface, but surrounded 
 every where laterally by the substance 
 of the bougie. This should be done 
 some little time before it is required to bo 
 used; for the materials of which the bou- 
 gie is composed, become warm and soft by 
 being handled in inserting the caustic; and. 
 therefore, the hold which the bougie has of 
 the caustic, is rendered more secure after 
 the wax has been allowed to cool and hard- 
 en. The bougie thus prepared, is to be oiled 
 and made ready for use ; but before passing 
 it, a common bougie of the same size is to 
 Or- introduced down to the stricture, in or- 
 der to clear the canal, and to measure the 
 exact distance of tho stricture from the ori- 
 fice of the urethra. This distance being 
 marked upon the armed bougie, it is to be 
 passed down to the stricture, a? soon ns (hr 
 
URETHRA. 
 
 037 
 
 other is withdrawn. The caustic, in its pas- divided parts a flexible’ gum-cat lietcr into 
 sage, is scarcely allowed to come into con- the bladder. This I have done myself, and 
 fact with -any part of the membrane, because have frequently seen it performed by Mr. 
 the point of the bougie, of which the argen- Hunter, and it always succeeded ; neither 
 turn nitratum forms the central part, always bringing on so much inflammation as was 
 moves in the middle line of the canal ; and, expected, nor being attended with any 
 indeed, the quickness with which it is con- symptoms of irritation, 
 vcyed to the stricture, prevents any injury “ This practice has by othersurgeons been 
 of the membrane lining the passage when carried still further ; the portion of diseased 
 the caustic accidentally touches it. urethra has been dissected out, and entirely 
 
 In this mode the caustic is passed down removed ; nor has so severe an operation 
 with little or no irrilation to (he lining of always brought chi untoward symptoms; 
 the urethra ; it is applied in the most advan- and patients have recovered, 
 tageems manner to the stricture, and can be “ If the membrane of the urethra, when 
 
 retained in that situation sufficiently long to 
 produce the desired effect. 
 
 The reasons urged in favour of the em- 
 ployment of bougies armed with the lunar 
 caustic, arc, that a permanent cure is effect- 
 ed, which common bougies cannot accom- 
 plish ; that the pain arising from the applica- 
 tion of the argentum nitratum to the stric- 
 ture, is very inconsiderable ; and that nei- 
 ther irritation nor inflammation is found to 
 ensue. The meaning of these remarks, 
 however, is to be received as a general one, 
 liable to exceptions. Indeed, SirE. Home 
 himself has candidly acknowledged, that 
 some inconveniences occasionally follow the 
 . use of armed bougies. But w bat practice, 
 however judicious and eligible, is altogether 
 free from occasional ill consequences? Sir 
 E. Home remarks, that against treating stric- 
 tures of the urethra with caustic bougies, 
 numerous objections have been adduced, 
 and many bad consequences have been at- 
 tributed to the practice, without any real 
 foundation ; “for whatever, <1 priori, might 
 be supposed the effects of so violent an ap- 
 {^icr.tion, to a membrane so sensible and ir- 
 ritable as the urethra, and I will admiit tiiat 
 it is very natural to conceive they would be 
 very severe, (lie result of experience, the 
 only thing to be relied on, evinces the 
 contrary. The pain that is brought on, 
 is by no means violent ; and neither irrita- 
 tion nor inflammation is found to take 
 place. 
 
 “ That cases do occur, in which strictures 
 have produced so much mischief, and ren- 
 dered so great an extent of the canal dis- 
 eased, that the use of the caustic has proved 
 unsuccessful, is certainly true; and several of 
 these cases have fallen within my own know- 
 ledge. But when it is stated that none, 
 even of these, were made worse by its use; 
 that no bad consequences attend it ; and 
 that no other mode, at present known, is 
 equally efficacious ; «»y occasional want of 
 success cannot be considered as an objec- 
 tion to this mode of practice. 
 
 “ But if the apprehension of violent 
 effects from the caustic, however ill-found- 
 ed, cannot be removed, let the alternative 
 be considered ; namely, the only operation 
 previously in use, where a stricture cannot 
 be dilated by the bougie. . 
 
 “ In those cases we are obliged to have 
 recourse to means certainly more severe 
 and violent, laying open with a knife the 
 diseased urethra, and passing through the 
 
 Yol. H 
 
 diseased, is capable of suffering so much 
 injury without any consequent symptoms 
 of irritation, it cannot be doubted that it 
 will bear with impunity to be touched, in 
 a very partial manner, several different 
 times with lunar caustic.” 
 
 Sir Everard afterward proceeds: “Having 
 met with a number of facts, from which a 
 general principle appears to be established, 
 that the irritable state of a stricture is kept 
 up, and even increased, by the use of the 
 bougie, but lessened and entirely destroyed 
 by the application of lunar caustic ; I am 
 desirous to communicate my observations 
 upon these facts, and to recommend the use 
 of the caustic in many cases of irritable 
 stricture, in preference to the bougie. 
 
 “ As the use of the caustic upon this prin- 
 ciple is, I believe, entirely new, and is con- 
 trary to every notion that has been formed 
 upon the subject, it will require something 
 more than general assertion to gain even 
 the attention of many of my readers, snil 
 more their belief; 1 shall therefore detail 
 the circumstances as 'they occurred, by 
 which I conceive the propriety of this prac- 
 tice to be established : and afterward make 
 some observations upon the principle on 
 which it depends. 
 
 “ My connexion in practice with Mr 
 Hunter afforded me opportunities of attend- 
 ing to cases of stricture in all their different 
 stages; many of them brought on duringa 
 long residence in India, attended with great 
 irritability, and exceedingly difficult of 
 cure. 
 
 “ One case of this kind admitted the pass- 
 ing of a small bodgie ; but, in the course of 
 three years, very little was gained hv a 
 steady perseverance in the use of that in- 
 strument, either in dilating the canal, or 
 palliating the symptoms of stricture ; this 
 made me look upon the bougie as less effi- 
 cacious than I had always been taught to 
 believe it. I was willing, however, to con- 
 sider this as an uncommon case, depending 
 more on the peculiarities of the patient’s 
 constitution than on the nature of the dis- 
 ease: but I found, on a particular inquiry, 
 that several other gentlemen from Jntha 
 were under circumstances nearly similar; 
 the bougie only preventing the increase of 
 the stricture, but being unable to dilate it 
 beyond a certain size ; and when it was left 
 off, the stricture in less than two months 
 returned to its former state of contrac- 
 tion. • 
 
tJKETHRA. 
 
 
 l{ What plau ought to be followed in such 
 cases, I was then unable to determine ; but, 
 that the bougie could not be depended on 
 was evident: During the suspense, the fol- 
 
 lowing case came under my care. 
 
 “In August, 1794, a gentleman consulted 
 me for some symptoms which had been 
 considered as indicating the presence of 
 gonorrhoea; but, as they did not yield to 
 the common treatment in the usual time, 
 he was induced to take my advice res- 
 pecting the nature of his complaint In the 
 necessary inquiry, to obtain a perfect his- 
 tory of the case, among other things it was 
 stated, that, nineteen years before, there 
 was a stricture which became very trouble- 
 some, and that Mr. Hunter, by the desire 
 of the patient, had applied the caustic, by 
 which the stricture was removed, and never 
 afterward returned. He said that he was 
 one of the first persons on whom the caus 
 tic had been used. From this account, I 
 was naturally led to believe that the stric- 
 ture had gradually returned, and was now 
 increased, so much as to produce the pre- 
 sent symptoms ; a discharge being almost 
 always a symptom of stricture when it is 
 much contracted ; but, upon exaininingthe 
 canal, a bougie of full size passed on to the 
 bladder without the smallest impediment. 
 I therefore took up the case as an inflamma- 
 tion in the urethra ; and large doses of the 
 balsam of copaiva, given internally, effected 
 a cure. 
 
 11 The circumstance of a stricture having 
 been removed nineteen years before, and 
 not returning, made a strong impression on 
 my mind, and made, me desirous to ascer- 
 tain whether this practice could be employ- 
 ed in cases of stricture in general, and the 
 cure produced by it equally permanent. A 
 short time afterward, I had an opportunity 
 of trying it in the following case. 
 
 “ A captain in the East India Company’s 
 service, in September, 1794, applied to me 
 for assistance. His complaints were, great 
 irritation in the urethra and bladder, con- 
 stant desire to make water, and an inability 
 to void it, except in very small quantities. 
 These symptoms had been at first supposed 
 to arise from gonorrhoea, afterward render- 
 ed more severe by catching cold ; but, not 
 yielding to the usual remedies for gonor- 
 rhoea, they were investigated more minute- 
 ly, and a stricture was discovered in the 
 urethra. The mode of treatment was now 
 changed, and the bougie employed ; but its 
 use aggravated all the symptoms, and 
 brought on so great a degree of irritability 
 in the bladder and urethra, that there was 
 nn alarm for the patient’s life, which was 
 the reason for applying for my assistance. 
 
 il Besides thejocal symptoms, this patient 
 had those of quick pulse, white tongue, hot 
 and dry skin, loss of appetite, and total 
 want of sleep, with frequent attacks of spasm 
 on the bladder and urethra. A very small 
 flexible gum-catheter was passed, and the 
 water drawn off, in quantity about a pint, 
 which gave him great Fefief : this was re- 
 pe ged morniug and evening, to keep the 
 
 bladder in as easy a state as possible ; but, 
 in other respects, he continued much the 
 same. 
 
 “ As the present symptoms were brought 
 on by the use of the bougie, little good was 
 to be expected from that instrument; and 
 where the urethra- had been so easily irrita- 
 ted, and was disposed to continue in that 
 state, there was no prospect of the use of 
 the bougie afterward effecting a cure. These 
 circumstances I explained to the patient; 
 and mentioned, in proof of my opinion, the 
 case in which so little had been effected in 
 three years. 
 
 “ I then proposed to him a trial of the 
 caustic, with a view to deaden the edge of 
 the stricture, as the only probable means 
 of effecting a cure. The degree of irritation 
 was already great ; I was, however, led to 
 believe that the application of the caustic 
 was not likely to increase it ; since, by 
 destroying the irritable part, it might lessen 
 and even remove the spasmodic affection ; 
 but if, contrary to my expectation, the 
 irritation continued, we still should be able 
 to draw off' the water, as the slough formed 
 by the caustic would prevent the edge of 
 the stricture from acting and obstructing the 
 instrument. 
 
 “ The application of the caustic was, 
 upon these grounds, determined on ; and it 
 was applied in the following manner. 
 
 “ I passed a common bougie, nearly the 
 size of the canal, down to the stricture, to 
 ascertain its exact situation, and to make 
 the canal of the urethra as open as possible 
 The distance was then marked upon a 
 bougie armed with caustic, of the same 
 size, which was conveyed down as quickjpr 
 as the nature of the operation would admit. 
 It was retained upon the stricture with a 
 slight degree of pressure ; at first there was 
 no pain from the caustic, but a soreness 
 from pressure ; in less than a minute a 
 change was felt in the sensation of the part, 
 it was at first a heat, succeeded by the 
 burning pain peculiar to caustic ; as soon 
 as this was distinctly felt, the bougie and 
 caustic were withdrawn, having remained 
 in the urethra about a minute altogether. 
 The soreness, he said, was entirely local, 
 by no means severe, was unaccompanied 
 by irritation along the canal, and he thought 
 the uneasiness in the bladder diminished 
 by it. He described the pain as resembling 
 very exactly the first symptoms of gonor- 
 rhoea. This sensation lasted half an hour 
 after withdrawing the bougie. 
 
 “ The caustic was applied about one 
 o’clock in the forenoon, and he passed 
 the day more free from irritation than he 
 had since the beginning of the attack, which 
 had lasted six days. In the evgning, the 
 water was drawn off with more ease than 
 the night before. He passed a tolerable 
 night, and, the next day, continued free 
 from irritation. On the third day, the caus- 
 tic was again applied in the forenoon ; the 
 painful sensation was less than on the for- 
 mer application, lasted a shorter time, and 
 in an hour after the armed bongio was with- 
 
btfETHKA. 
 
 Orawn, he made water freely tor the first 
 time since the commencement of his indis- 
 position. He said the irritation in the blad- 
 der was removed, and lie felt very well, his 
 appetite returned, he slept very well, and 
 continued to void his urine with ease. 
 
 “ In this state, nothing was done till the 
 fifth day, leaving always a day between the 
 applications of the caustic. 
 
 * “ Qn this day a common-sized bougie 
 went readily into the bladder; it was im- 
 mediately withdrawn, and the cure was 
 considered as complete ; no bougie was 
 afterward passed, lest it might bring back 
 an irritation upon the passage. I met this 
 gentleman twelve months afterward, and 
 he assured me he had continued perfectly 
 well, and 1 have since learned that, in three 
 years, there has been no return. 
 
 “ From the result of this case, I was en- 
 couraged to hope that the caustic might be 
 applied to strictures in the urethra with 
 more confidence than I had hitherto be- 
 lieved, since it evidently did not bring on 
 or increase the general irritation, but,- on 
 the contrary, seemed to allay it.” 
 
 The foregoing case, together with ano- 
 ther which Sir E. Home has related, con- 
 vinced this gentleman that he had disco- 
 vered an effectual mode of treating such 
 strictures as do not admit of being relieved 
 by the common bougie. Hence he adopted 
 the use of armed bougies as a general prac- 
 tice ; but he has not concealed the circum- 
 stances under which the method does not 
 prove successful. Sir Everard informs us, 
 that “ in some constitutions, where the pa- 
 tients have resided long in warm climates, 
 every time the caustic is applied to a stric- 
 ture, a regular paroxysm of fever, called by 
 the patient an ague, takes place ; and this 
 has been so violent as to render it impossi- 
 ble to pursue this mode of practice. Of this 
 I have met with two instances. I consider 
 this disposition to fever as the effect of cli- 
 mate, and not of any natural peculiarity of 
 constitution; for the brother of one of these 
 patients laboured under the same disease, 
 but as he had not been in warm climates, It 
 was removed by the caustic without his ex- 
 periencing such attacks.” 
 
 In gouty constitution?, attacks of the gout 
 have in two instances brought on spasmo- 
 dic constrictions, after the stricture had 
 been removed by caustic. This, however, 
 cannot be called a failure of the caustic. It 
 only shows that gout can affect strictures, 
 and reproduce them. 
 
 “In some patients the strictures are so 
 obdurate, that the use of the caustic is ne- 
 cessary to be continued for a longer time, 
 than the parts can bear its application, or 
 even that of the bougie passing along the 
 urethra; irritation therefore comes on, and 
 stops the progress of the cure, and when the 
 same means are resorted to again, the same 
 thing takes place. The cases of failure ot 
 this kind that I have met with, some of 
 which may yet ultimately be cured, if the 
 patients will take the necessary steps for 
 that purpose, amount in all to six 
 
 539 
 
 “ In some patients the stricture is readily 
 removed by the caustic, but, in a few weeks 
 contracts again. The stricture being wholly 
 spasmodic, the caustic, by taking off the 
 spasm, is allowed to pass through, and can- 
 not completely destroy the stricture. Of 
 this kind I have met with one instance 
 which I must consider as a failure, as I 
 have hitherto been unable to get the better 
 of it. 
 
 “ In those cases where the caustic gradu- 
 ally removes the stricture, and brings the 
 urethra to a size that allows the patient to 
 make water perfectly well, if there is any 
 return, it is not to be attributed to the fail- 
 ure of the caustic, but to the want of proper 
 management, either from the caustic being 
 too small, or its use left off too soon ; but 
 all such cases are, I believe, within the pow- 
 er of being cured by the caustic, if its use 
 is recurred to when that is found ne- 
 cessary.” 
 
 For the generality of strictures in the 
 urethra, which do not occupy more extent 
 of the canal than if caused by a piece of 
 packthread being tied round it, bougies, 
 armed with lunar caustic, answer very well, 
 and so, I believe, do common bougies, to 
 which the general preference ought per- 
 haps to be given. For cases, also, in which 
 the urethra is diminished in diameter, for aa 
 inch or more, common bougies must be 
 most advantageous, that is to say, when 
 they can be introduced through the stric- 
 t re, so as to cure it on the principle of 
 dilatation. 
 
 Whether, in ‘certain cases, where no pro- 
 gress can be made with common bougies, it 
 is better to try caustic, or attempt to force 
 the obstruction with a sound, is a question on 
 which there is a great deal of difference of 
 opinion. “ The practice of pressing firm 
 bougies, or metallic instruments, so as to 
 force the stricture, or to produce an ulcera- 
 tion of it, (says a modern writer,) so fre- 
 quently has been found to form false pass- 
 ages, fistula?, and gangrene, that I need here 
 make no further observation on the practice, 
 or its consequences. All the advantages that 
 can be gained by pressure, tearing through 
 the stricture, or producing ulceration of it, 
 may be obtained by a careful and judicious 
 use of the caustic, which will be found on 
 the whole a safer application, and will be at- 
 tended with less inflammation and pain.” 
 ( Wilson on the Male Urinary and Genital Or- 
 gans, p. 383.) This gentleman is not, how- 
 ever, an advocate for the caustic in every 
 case. “ I consider it,” says he, “ the safest 
 practice in cases which will not yield to the 
 introduction of bougies, and which require 
 a portion of the stricture to be destroyed ; 
 but the symptoms which sometimes attend 
 its use, and the injury which may be done by 
 its improper application, should confine it to 
 those cases.” ( p . 385.) 
 
 I shall conclude this part of the subject of 
 strictures, with inserting some of the general 
 directions given by Sir £. Homeisovv to arm 
 the bougie, and apply the lunar caustic to- 
 strictures. 
 
540 
 
 URETHRA. 
 
 In arming a bougie, it will be difficult to 
 get a piece of caustic of a proper shape and 
 aize for (he purpose, unless it be cast in a 
 small cylindrical mould. “ If these pieces 
 are thicker than the bougie can readily en- 
 close, by putting them in water the outside 
 quickly dissolves, so as to diminish their size 
 as much as is required. The piece of caus- 
 tic, so prepared, is to be cut into small por- 
 tions, about a quarter of an inch in length, 
 and an orifice being made in the end of a 
 bougie, the caustic is to be inserted into it, 
 and the bougie rolled so as to be made per- 
 fectly smooth, taking care that the sides of 
 the caustic are every where covered, and 
 only the end exposed. 
 
 “ This was the mode (says Sir Everard) in 
 which I armed bougies, when I first took up 
 this practice ; but it happened, that, in two 
 or three instances, the caustic was left in the 
 urethra ; that canal, when in a very irritable 
 state, grasped the bougie, and pulled the 
 caustic out ; I was therefore led to consider 
 how such an accident might he prevented, 
 and applied to the makers of bougies for that 
 purpose. Mr. Pass, the late beadle of the 
 Surgeon’s Company, who dealt in bougies, 
 discovered a very ingenious and effectual 
 mode of securing the caustic. In forming 
 the bougie, a piece of wire, the size of the 
 caustic, is rolled up along with it, passing 
 into the substance for half an inch ; when 
 the bougie is nearly finished, the wire i3 
 withdrawn, and the caustic inserted in iis 
 place after this, the bougie is rolled again, 
 so that the sides of the caustic become firmly 
 cemented to the linen, by means of the com- 
 position of the bougie, and when cold, can- 
 not be separated by any force. In this way 
 bougies are now generally armed. 
 
 “ After the bougie has been thus prepared, 
 the distance of the stricture from the exter- 
 nal orifice is to be measured, and the canal 
 cleared by passing a coramoft bougie fully as 
 large as that which is armed. The armed 
 bougie, wiib the distance marked upon it, is 
 then to be introduced, and applied to the 
 stricture; when it is brought in contact with 
 the obstruction, it is to be steadily retained 
 there, with a moderate degree of pressure at 
 first, and less as it is longer continued, since 
 the bougie becomes soft by remaining in the 
 urethra, and readily bends if the pressure is 
 too great. The time it is to remain depends 
 a good deal upon the sensations of the pa- 
 tient, and the length of time the parts have 
 been diseased ; but on the first trial it should 
 be less than a minute, as it then commonly 
 gives greater pain than on any subsequent 
 application. The pain produced by the 
 caustic Js not felt so immediately as it would 
 be natural to expect; the first sensation arises 
 from the pressure of the bougie on the stric- 
 ture ; a little afterward, there is the feeling 
 of heat in the parts ; and lastly, that of pain. 
 
 “ As soon as the caustic begins to act, the 
 surgeon who makes the application is made 
 sensible of it by the smaller arteries of the 
 parts beating with unusual violence, which 
 is very distinctly felt by the finger and thumb 
 dial grasp (be penis 
 
 4 The pain that is brought on by the caus- 
 tic lasts for some time after it is withdrawn J 
 but this period differs in almost every patient, 
 being sometimes extended to half an hour, 
 and sometimes only a few miuutes. 
 
 “ The kind of pain is heat and soreness, 
 which is not severe, not being accompanied 
 with the peculiar irritation, upon so many oc 
 casions experienced by patients who have 
 strictures ; an irritation that cannot tfe de- 
 scribed, which is most insupportable, and is 
 too often brought on by dilating strictures 
 with the bougie.” In the vol from which 
 the above directions are taken, Sir Everard 
 Home recommends the patient to make wa- 
 ter, as soon as the armed bougie is with- 
 drawn ; but in a subsequent vol. he explains 
 bis change of opinion upon this point : “ I 
 not only have no wish that the patient should 
 make water immediately after the applica- 
 tion, but would rather that it be retained 
 some time.” (On Strictures, vol. 3, p. 51 
 8i;o. Lond. 1821.) 
 
 “ It happens not unfrequently,” says Sir 
 Everard Home, “ that at the first time of 
 making water, some blood passes along with 
 it. This is rather favourable ; as, when the 
 parts bleed, the stricture usually proves to be 
 so far destroyed, that at the next trial the 
 bougie passes through it. Every other day 
 appears, in general, to be as often as it is 
 prudent to apply the caustic. I have, how'-, 
 ever, done it every day in very obstinate 
 cases, where ihe parts are less sensible, with- 
 out any detriment.” 
 
 In his third volume, lately published, he 
 states, that he now rarely passes the bougie 
 oftener than every third day, and never 
 when the pain from the last application has 
 not entirely gone off. He also never con- 
 tinues any one application beyond the time 
 when the pain begins to extend further than 
 the spot to which the armed bougie is ap- 
 plied. (Vol. 3, p. 51.) 
 
 The bougie which is passed down to pre 
 pare the way for the caustic, and measure 
 the distance for the armed bougie, must be 
 made of soft materials, that it may readily 
 receive an impression from the part against 
 which it is pressed, and its colour should be 
 light, so as to admit of those impressions 
 being more distinctly seen. With the assis- 
 tance ol such bougies, I am able to discover 
 the size and shape of the orifice of the stric- 
 ture ; to ascertain with accuracy the progress 
 of the caastic upon it; to see whether it is 
 on one side of the canal, or equally nil round 
 and to apply the caustic accordingly. 
 
 “ When the soft bougie passes through the 
 stricture, by leaving it in the canal a few 
 minutes, it can be kqown whether the stric 
 ture is completely destroyed or only relaxed ; 
 in the last case, there is an impression on the 
 side of the bougie.” (Home on Strictures , 
 vol. 1.) 
 
 CURE OF STRICTURES WITH TIIE POTASSA 
 FUSA- 
 
 Mr. Whately, in his publication on slric 
 tures, endeavours to convince the reader 
 
URETHRA- 
 
 that they are uot merely contracted fibres of 
 the urethra, but really diseased portions of 
 the membrane lining that canal, with a con- 
 tinued disposition to increased contraction. 
 Hence this gentleman seems to conceive, 
 that the application of a remedy, calculated 
 both to remove, the diseased affection, and 
 to dilate the contracted part, might perfectly 
 cure the complaint,' without putting the pa- 
 tient to the inconvenience of wearing a bou 
 gie. Mr. Whately affirms, that such a reme- 
 dy is caustic, when judiciously used. Hither- 
 to the lunar caustic has been chiefly employ- 
 ed ; but this gentleman states, that it has 
 been his good fortune to discover a more effi- 
 cacious, and at the same time a less painful 
 and hazardous remedy for the disease in ques- 
 tion. The potassa^usa is the application al- 
 luded to, which IVm Whately says, if used 
 in the manner and with the precautions 
 about to be described, will be found to pos- 
 sess singular efficacy in curing the complaint. 
 He avows, that he has already had so much 
 experience of it, and that be is so perfectly 
 convinced of its superiority over the lunar 
 caustic, as well as over the common bougie, 
 that he now use3 it in a considerable number 
 of the cases which come under his care. Of 
 its safety he is also as well convinced as of 
 its efficacy ; for if used with circumspection, 
 experience proves that there is little danger 
 of its producing any disagreeable effect. 
 
 However, if the potassa fusa be applied 
 while the parts are in a highly inflamed, or 
 irritable state, or (as Mr. Whately expresses 
 himself) tending to gangrene ; if the habit 
 be bad, and the patient very far advanced in 
 years, the most mischievous effects may be 
 expected from the application ; and the U3e 
 of any kind of caustic, under such circum- 
 stances, for strictures in the urethra, is cen- 
 sured as dangerous in the extreme. 
 
 Mr. Whately represents, that if the patient 
 be affected with fever, or any other acute 
 disease ; if he be much indisposed from any 
 cause ; if, in particular, he have a gonorrhoea, 
 attended with much inflammation and irrita- 
 tion in th< urethra; if the prepuce, glans, or 
 any other part of the penis, or the parts ad- 
 joining to it, be swelled and inflamed ; if the 
 urethra, and especially the strictured part of 
 it, be so irritable as uot to bear the touch ot 
 a bougie ; the use of the caustic is for the 
 present forbidden. Mr. Whately also en- 
 joins great caution in applying this remedy 
 to persons advanced in years. Even when 
 no objections of the above kind exist, the 
 caustic should not be resorted to in the first 
 instance. Mr. Whately maintains, that in 
 every case of stricture, before venturing to 
 employ the caustic, we ought to be able to 
 pass into the bladder a bougie of at least a 
 size larger than one of the finest sort. This 
 is necessary, both to let the caustic^be applied 
 to the whole surface of the stricture, and 
 to relieve a retention of urine, should it oc- 
 cur during the use of the caustic. 
 
 When a bougie of the preceding descrip- 
 tion can be introduced, without occasioning 
 pain, faintness, or great dejectiou of spirits, 
 ? he use of caustic may commence itnmedi- 
 
 54A 
 
 ately, provided none of the above -described 
 objections exist. 
 
 When the urethra is very irritable, Mr. 
 Whately recommends a common bougie t© 
 be introduced every day, and kept in the 
 urethra ; at first, for a few minutes only ; 
 but by degrees for a longer time ; til i the 
 irritability of the parts has been sufficiently 
 lessened. 
 
 When she urethra is rendered so impervi- 
 ous by a stricture, that a small bougie cannot 
 be passed into the bladder, which viscus is 
 also in a painful inflamed state, Mr. Whately 
 asserts, that caustic, in any form or quantity, 
 must not be immediately employed ; but 
 that the stricture should be first rendered ca- 
 pable of allowing a bougie a little larger than 
 one of the finest size, to be introduced into 
 the bladder. When this is done, the urine is 
 more freely evacuated, and the consequent 
 irritation and inflammation of the bladder 
 lessened, if not removed, together with the 
 danger of • retention of urine. Caustic may 
 then be advantageously conveyed into the 
 centre of the stricture. 
 
 Mr. Whately considers 'he practice of at 
 once thrusting down, in this sort of case, an 
 armed bougie considerably larger than the 
 narrowest part of the contracted canal, as 
 most dangerous, and horridly painful. For, 
 says this gentleman, it frequently happens, 
 that nearly the vs hide of the urethra anterior 
 to the bulb is so much contracted by nume- 
 rous, and uncommonly rigid strictures, that 
 it is impossible, by any art whatever, to di- 
 late the passage to its natural size. If, there- 
 fore, the canal, whilst in such a slate, be 
 rudely torn open by a large caustic bougie, 
 hemorrhage, pain, dangerous suppressions of 
 urine, inflammation, mortification, and death 
 itself, must sometimes inevitably ensue, — 
 even before the caustic can be applied to the 
 principal seat of the disease. In cases like 
 the one just mentioned, the first step prepa 
 ratory to the use of the caustic should be, ac- 
 cording to Mr. Whately, to dilate the strictu 
 red part of the urethra; for which purpose, 
 he advises the slow and gentle introduction 
 of a fine bougie, with its point inclined to 
 the lower side of the canal, in order to avoid 
 the large lacunce situated on its upper part. 
 When the surgeon, by steady perseverance 
 and dexterity, has succeeded in getting a fine 
 bougie through the worst stricture into the 
 bladder, the instrument should be worn for a 
 few hours every day, till the passage is suffi- 
 ciently dilated to admit a larger one. 
 
 Mr. Whately, after explaining that caustic 
 potassa ought not to be applied to strictures 
 of the urethra till a bougie of a proper size 
 can be passed into the bladder, pointing out 
 the methods to be taken before applying 
 this caustic, and enumerating certain cases 
 and circumstances in which its employment 
 is interdicted, next proceeds to describe the 
 mode of practice, which it is the particular 
 object of his book to recommend. 
 
 For the purpose of arming a bougie, Mr. 
 Whately advises us to put a small quantity 
 of caustic potassa upon a piece of strong 
 paper, and to break the bit of caustic yvitii 
 
URETHRA. 
 
 
 a hammer into small pieces of about the 
 size of large and small pins’ heads. In doing 
 this, care should be taken not to reduce it 
 to powder. Thus broken, it should be kept 
 for use in a phial, closed with a ground 
 stopper. The bougie should have a proper 
 degree of curvature given to it, by drawing 
 it several times between the finger and 
 thumb of the left hand. 
 
 Mr. Whately next acquaints us, that be- 
 fore the caustic is inserted into the bougie, 
 it is necessary to ascertain the exact dis- 
 tance of the stricture (to which the caustic 
 is to be applied,) from the extremity of the 
 penis. For this purpose, the bougie, which 
 should be just large enough to enter the 
 stricture with some degree of tightness, 
 ought to be gently introduced into the 
 urethra; and when its point stops at the 
 stricture, which it almost always does be- 
 fore it will enter it, a notch is to be made 
 with the finger-nail on the upper or curved 
 portion of the bougie, on the outside of the 
 urethra, exactly half an inch from the ex- 
 tremity of the penis. When the bougie is 
 withdrawn, a small hole, about the sixteenth 
 part of an inch deep, should be made at the 
 extremity of its rounded end. A large 
 blanket-pin, two inches and a half in length, 
 with the head struck off, will answer the 
 purpose ; the hole being made with the 
 point of the pin. The extremity of ihe 
 bougie should then be made perfectly 
 smooth with the finger and thumb, taking 
 care that, in doing this, the hole in its 
 centre be not closed. Some of the broken 
 caustic should then be put on a piece of 
 writing paper, and a piece less in size than 
 the smallest pin’s head should be selected ; 
 the particle, indeed, says Mr. Whately, can- 
 not be too small for the first application. 
 Let this be inserted into the hole of the 
 bougie with a pocket-knife, spatula, or some 
 such instrument ; and pushed into it with 
 the blunt end of the pin, so as to make the 
 caustic sink a very little below the margin 
 of the hole. To prevent the potassa fusa 
 from coming out, the hole should then be 
 contracted a little with the finger, and the 
 remaining vacancy in it is to be filled with 
 bog’s lard. This last substance (continues 
 Mr Whately) will prevent the caustic from 
 acting on the sound part of the urethra, as 
 the bougie passes to the stricture. When 
 the bougie is quite prepared, let it be first 
 oiled, arid immediately afterward intro- 
 duced, by a very gentie motion, with the 
 curvature upwards as far as the anterior 
 part of the stricture, upon which the caustic 
 is to be applied. In doing this, the end of 
 the bougie, held by the finger and thumb, 
 should be a good deal inclined towards the 
 abdomen, on the first introduction of the 
 instrument, in order to prevent its curva- 
 ture. After it has passed about five inches, 
 this end should be gradually brought down- 
 wards, as the bougie passes on, till it forms 
 a right angle with the body. The bougie is 
 known to have arrived at the stricture by 
 the resistance made to its progress. 
 
 As «oou as the bougie lias reached the 
 
 anterior part of the stricture, it should rest 
 there for a few seconds, that the caustic 
 may begin to dissolve. It should then be 
 pushed very gently' forward about one- 
 eighth of an inch ; after which, there should 
 be another pause for a second or two. The 
 bougie should then be carried forward in 
 the same gentle manner till it has got 
 through the stricture. The sense of feeling 
 will generally inform the operator when the 
 point of the bougie has proceeded so far ; 
 but the notch in the bougie is to be an ad- 
 ditional guide, by becoming very near the 
 orifice of the urethra when the end of the 
 instrument has just got through the stricture 
 
 The bougie should now be immediately 
 withdrawn by a very gentle motion to the 
 part at which it was forst made to rest 
 awhile. Then it shouV be very slowly 
 passed through the stricture a second time; 
 but without letting the bougie stop in its 
 passage. If the patient complain of pain, 
 or be faint, the bougie should be immedi- 
 ately withdrawn ; but, if these effects are 
 not produced, we may repeat the operation 
 of passing and withdrawing the bougie 
 through the stricture once or twice more 
 before we finish the operation, which will 
 take up, in the whole, about two minutes. 
 
 The first application of the potassa fusa, 
 in this manner, gives, according to Mr. 
 Whately’s account, a very little pain. A 
 slight scalding in making water, and a tri- 
 fling discharge during the first day or two, 
 however, are commonly produced. 
 
 At the end of seven days the application 
 of the caustic is to be repeated in the same 
 manner. When the first application has 
 enlarged the aperture of the stricture, which 
 may be known by passing a bougie through 
 it of the same size as that by which the 
 caustic was conveyed, the bougie used in 
 the second operation should be a size larger 
 than the one used in the first ; but it must 
 not be too large to pass through the stric- 
 ture. If the patient had no pain on the first 
 application, the bit of potassa fusa may also 
 be trivially larger. At the end of seven 
 days more, the armed bougie should be in- 
 troduced a third time. At this, and all future 
 applications, the bougie should be increased 
 in size in proportion as the aperture in the 
 stricture becomes dilated. The quantity of 
 caustic, however, is never to be increased 
 in a ratio to the size of the bougie. In no 
 cases whatever does Mr. Whately apply 
 more of the potassa fusa at a time than a 
 piece about the size of a common pin’s 
 head. Twelve bits of the largest size, 
 which this gentleman ever uses, weigh one 
 grain. 
 
 When there are several strictures, the 
 potassa fusa should be generally applied to 
 only one at a time. 
 
 An interval of seven days is what Mr. 
 Whately generally allows to elapse between 
 the applications of the caustic. The rule, 
 however, may now and then be deviated 
 from ; but the potassa fusa ought never to 
 be reapplied till the action of the last ap- 
 plication has completely ceased. In a few 
 
URETHRA 
 
 S4M 
 
 instances, the interval may only be five 
 days ; in some others, it may be eight, nine, 
 or even a longer space. 
 
 In the above method of using the potassa 
 fusa, Mr. YVhately represents that this sub 
 stance is equally diffused over every part of 
 the strictured surface, and only abrades the 
 membrane of the stricture, without produ- 
 cing a slough. The degree of this abrasion, 
 he says, may be increased or lessened as 
 circumstances dictate, by paying attention 
 to the quantity of the caustic. 
 
 The foregoing account will suffice for 
 conveying an adequate idea of Mr. Whate- 
 ly ’s method. I am sorry I cannot add my 
 favourable opinion of the practice. To 
 abrade, without destroying, is rather too 
 nice a distinction for a practical man, doing 
 business as it were in the dark. Nor can 1 
 conceive, that a liquid caustic (for so it is 
 represented as becoming) can be applied 
 with the accuracy to strictures, which Mr. 
 Whately seems to suppose happens. This, 
 however, is merely my own sentiment ; 
 and I do not wish to conceal that there are 
 yet a few surgeons who believe that Mr. 
 Whately’s plan is the most eligible. for all' 
 cases, in which the stricture is irritable, or 
 far advanced. (See Howship's Pract. Obs. 
 on the Urinary Organs, p, 207.) On the 
 other hand, I know some very eminent 
 surgeons, who formerly took up this prac- 
 tice with great zeal, yet now have entirely 
 abandoned it. I consider it myself the 
 worst and most random mode of applying 
 caustic to strictures, and more likely to act 
 on the sound than the diseased portion of 
 the urethra. 
 
 Upon the whole, I may safely declare, 
 that caustic bougies are now much less 
 frequently used by the best surgeons in 
 London than they were about fifteen years 
 ago; Several distinguished practitioners, 
 who to my knowledge were then accus- 
 tomed to recommend and employ them, 
 have at present returned either to the use 
 of common bougies, or those made of me- 
 tal, or elastic gum, to which, after many 
 comparative trials, I acknowledge, a gene- 
 ral, but not universal, preference seems to 
 me to be due. We learn from M. Roux, 
 that caustic bougies never had many advo- 
 cates in France ; and the inquiries which 
 he made when he was in London autho- 
 rized him to announce to his countrymen 
 after his return, that such instruments are 
 at present not more in general favour here 
 than they are at Paris. (See Voyage fait a 
 Londres en 1814, ou Par allele de la Chirur- 
 gie Angloise, tye.p. 315.) 
 
 Cases of stricture, however, where the 
 disease is far advanced, of long standing, 
 and attended with such obstruction that no 
 kind of common bougie can be introduced, 
 appear to me to be the examples in which 
 the employment of bougies, armed with the 
 nitrate of silver, ought principally to be con- 
 tinued. This mode seems to me less vio- 
 lent than that of employing a common 
 bougie, or iron sound, with sufficient force 
 to make it? wav through the stricture by 
 
 laceration. It must also be attended with 
 less risk of rupturing the urethra, and pro - 
 ducing a false passage. At the same time, 
 if the stricture occupy some length of the 
 passage, and a common bougie, which is 
 the best instrument in this circumstance, 
 cannot be introduced through the obstruc - 
 tion so as to dilate it, 1 believe a passage 
 through it must often be attempted on the 
 principle of exciting ulceration, and that 
 for this purpose a sound or metallic catheter 
 should be employed. In the first instance, 
 however, 1 would try the armed bougie. 
 
 1 have already explained that the armed 
 bougie has likewise been particularly re- 
 commended for what has been termed the 
 irritable stricture ; and it is even declared, 
 in Sir Everard’s third volume, that lunar 
 caustic has a greater power of removing 
 spasm than any other kind of caustic. 
 
 A Treatise on the Venereal Disease, by 
 John Hunter, 2 d Edit. Practical Obs. on 
 the Treatment of Strictures in the 'Urethra 
 and (Esophagus, by Sir Everard Home, in 3 
 Vols. 8 vo. bond. An Improved Method of 
 Treating Strictures in the Urethra, by Tho- 
 mas Whately, Edit. 2, 1806. M. W. Andrews's 
 Obs. on the Application of Lunar Caustic to 
 Strictures in the Urethra and (Esophagus, 
 8r o. Lond. 1807. T. Luxmore's Practical- 
 Observations on Strictures , fyc. 8i o. Lond. 
 1800. Howship's Practical Obs. on the Dis- 
 eases of the Urinary Organs, 8 vo. Lond. 1816. 
 Soemmering Abhandlvng fiber die schnell 
 und langsam todtlichen Krankheitcn der 
 Harnblase und Harnrohre bey Mannern im 
 hohen Alter. 4 to. Frankf. 1800. Letters con- 
 cerning the Diseases of the Urethra, by C. 
 Bell , 1810 ; subsequently republished with ad- 
 ditions by Mr. Shaw. James Wilson, Lectures 
 on the Structure and Physiology of the Male 
 Urinary and Genital Organs, and their Dis- 
 eases, Svo. Lond. 1821.' James Arnott, a 
 Treatise on Stricture of the Urethra, 8r c. 
 Lond. 1819. Having given an account of 
 this gentleman's dilator, and his method of 
 treatment, .in the 2d Vol. of the last<cdition of 
 the First Lines of the Practice of Surgery, I 
 have not considered it necessary to repeat the 
 statement in the present work. J. Cross, 
 Sketches of the Medical Schools of Paris, p. 
 Ill, fyc. Svo. Lond. 1815. 
 
 URETHRA, FALSE PASSAGE IN. 
 One of the worst consequences of using 
 catheters and bougies in an improper man- 
 ner, is the rupture of the urethra, or the for- 
 mation of a false passage by ulceration. 
 With bougies, this accident is generally oc- 
 casioned by trials to excite ulceration by the 
 application of the end of the bougie to the 
 stricture, when this instrument cannot be 
 passed through it. When once the new pas- 
 sage has been formed, whenever the bougie 
 is introduced, it cannot be hindered from 
 going into the false track, and its action on 
 the stricture is altogether frustrated. 
 
 In this kind of case Mr. Hunter has ad- 
 vised the following operation to be practised. 
 Pass a staff, or any such instrument into the 
 urethra as far as it will go, which will pro- 
 bably be to the bottom of the new passage. 
 
URINARY ABSCESSES. 
 
 644 
 
 and this, we may be certain, is beyond the 
 stricture. Feel for the end of the instru- 
 ment externally, and cut upon it, making 
 the wound about an inch long, if the disease 
 be before the scrotum ; and an inch and a 
 half, or more, if in the perineum. If the 
 new passage be between the urethra and 
 body of the penis, you will most probably 
 get into the sound urethra, before you come 
 to the instrument, or new passsage. If%so, 
 introduce a probe into the urethra, through 
 the wound, and pass it towards the glans 
 penis, or, in other words, towards the 
 stricture. When it meets with an obstruc- 
 tion, this must be the stricture, which is 
 now to be got through, and afterward dila- 
 ted. To complete the operation, withdraw 
 the probe, and, instead of it introduce a 
 hollow cannula forwards to the stricture. 
 Then introduce another cannula from the 
 glans downward, till the two tubes are oppo- 
 site each other, having the stricture between 
 them. An assistant is now to take hold of 
 the urethra on the outside, with his finger 
 and thumb, just where the two cannulse 
 meet, in order to keep them in their places. 
 Through the upper cannula next introduce a 
 piercing instrument, which is to perforate 
 the stricture, and enter the lower cannula. 
 The piercing instrument is now to be 
 withdrawn, and a bougie introduced through 
 the first cannula and stricture, into the 
 second cannula. The tubes are to be 
 withdrawn, and the end of the bougie, 
 in the wound, directed into the bladder, 
 through the further portion of the urethra. 
 It may also be necessary to lay the whole of 
 the false passage open, in order to make it 
 heal; for otherwise it might still obstruct the 
 future passage of bougies into the proper 
 canal. 
 
 When the new passage is between the 
 skin and urethra, the surgeon must extend 
 his incision more deeply, for the purpose of 
 finding out the natural passage. Then he is 
 to proceed as above explained. 
 
 The longer the first bougie is allowed to 
 remain in the canal, the more readily will 
 the second pass. The bougies must be gra- 
 dually increased in size, and used til! the 
 wound is healed. The only improvement 
 wliicli seems proper to be made in this plan, 
 is to employ flexible gum-catheters, which 
 might be worn longer than common bougies, 
 as the patient could void his urine through 
 them. (See Hunter on the Venereal Disease.) 
 Additional Observations on this subject are 
 contained in the 2dvol. of the First Lines of 
 Surgery. 
 
 URINARY ABSCESSES Extravasations 
 of urine may be in three different states. 
 This fluid may be collected in a particular 
 pouch ; it may be widely diffused in the 
 cellular membrane : or, lastly, it may pre- 
 sent itself in a purulent form, after having 
 excited inflammation and suppuration in the 
 parts, among which it is situated. This case 
 is termed an urinary abscess. 
 
 Such extravasations of urine always im- 
 ply a rupture, either in the kidneys or ure- 
 ters, the bladder or the urethra. The solu 
 I ■ 
 
 lion of continuity may be produced by a. 
 variety of causes. It is most frequently the 
 effect of a forcible distention of these pas- 
 sages, in consequence of a retention of 
 urine. The bursting of phlegmonous ab- 
 scesses into the same passages, may occasion 
 the breach. It may also be produced by 
 the penetration of the parts with a sword, 
 or'other foreign body: there are likewise ex- 
 amples of effusion of urine from the displace- 
 ment of the cannula of the trocar, after the 
 operation of puncturing the bladder. Others 
 are caused by false passages in the urethra ; 
 or by violent contusions of the perineum, 
 attended with laceration of the urethra. 
 
 In Desault's Surgical Works, ( T . 3.) it is 
 observed, that the ravages, which extravasa- 
 ted urine makes, are usually greater and 
 more extensive, when it enters the cellular 
 membrane, than when it is confined in a 
 particular cyst. The mischief is also less 
 when the excretory passage is free, than 
 when it is closed by any obstacle, as in cases 
 of retention. The more or less loose tex- 
 ture of the parts in which such effusions 
 happen, likewise makes a considerable dif- 
 ference in their progress and formation. 
 When the pelvis, or infundibulum of the 
 kidney, or the upper part of the ureter, gives 
 way, the urine is commonly effused in the 
 loins and the fossae iliacae, between the pe- 
 ritoneum and the adjacent parts. When the 
 lower part of the ureter, or the bladder, near 
 its lower portion, gives way, the extravasa- 
 tion is generally included within the pelvis. 
 
 But when the rupture occurs in the ante- 
 rior parietes of the bladder, near its upper 
 part, and especially when it takes place at. 
 a time w hen this organ is extremely distend- 
 ed and dilated, the urine becomes effused 
 behind and above the pubes, sometimes as- 
 cends to the epigastric region, between the 
 peritoneum and the abdominal muscles, 
 and after having followed the course of the 
 spermatic vessels, it often makes its exit at 
 the ring, and is extravasated in the groins 
 and scrotum. If (he rupture has happened 
 in the urethra, the most common situation 
 of the effusion is in the perineum and scro- 
 tum. The extravasation frequently extends 
 to the penis and upper part of the thighs, 
 and even sometimes propagates itself under 
 the skin of the abdomen, up to the hypo- 
 chondria and sides of the chest. 
 
 There is no fluid, the extravasation of 
 which is so fatal, as that of the urine. If it 
 is not promptly discharged, it soon excites 
 suppuration and sloughing of the cellular 
 membrane, a gangrenous inflammation of 
 the skin, and almost always a mortification 
 of the parts among which it flows. 
 
 W T hi!e the extravasation of urine is con- 
 fined to t lie interior of the pelvis, and lum- 
 bar and iliac regions, without manifesting 
 itself externally, there is no certain sign oi’ 
 its existence. The circumstances which 
 may be recollected, however, joined with 
 the symptoms which the patient complains 
 of, may lead to a suspicion of the extrava- 
 sation. Thus, when in consequence of a 
 retention of urine in the ureters or bladder^ 
 
UKijNARl ABaCES'SEt 1 
 
 Uie patient has suddenly experienced great 
 relief, without any of the urine having been 
 discharged the natural way ; when he lias at 
 the same instant felt a kind of pricking in the 
 loins, or pelvis ; when to the ease, which 
 lasted only a few hours, symptoms, more 
 severe than the former ones, have succeed- 
 ed, such as violent fever, hiccough, vomit- 
 ing, &c. an internal extravasation is to be 
 suspected. 
 
 As soon as the extravasation is apparent 
 externally,; the case is announced by symp- 
 toms which hardly ever deceive. The pre- 
 ceding retention of urine ; the sudden ap- 
 pearance of the swelling caused by this 
 fluid ; the rapid progress of the tumour ; 
 the kind of crepitation perceptible in it, like 
 that which occurs in emphysema ; the shi- 
 ning tension and cedema of the skin ; the 
 diminution of sueh symptoms as depended 
 entirely upon the retention ; are the first 
 changes which are observable, when the ex- 
 travasation is somew hat considerable. 
 
 If the patient is not speedily assisted, and 
 the urine continues to be extravasated, the 
 tumour spreads more and more ; the skin 
 assumes a red violet colour; gangrenous 
 eschars are formed, the separation of which 
 gives issue to a very fetid sanies, in which 
 the smell of urine is readily distinguishable. 
 Portions of dead cellular membrane are pre- 
 sently discharged together with the sanies ; 
 the ulcer grows larger; and the dressings 
 are continually wet with the urine. 
 
 When one of the ureters has given way, 
 and an urinary abscess is formed in the 
 loins, the aid to be derived from surgery is 
 limited to making an opening in the extra- 
 vasation, as soon as it can be felt external- 
 ly. It is then not in the power of art to re- 
 establish the natural course of the urine, or 
 to hinder this fluid from passing through 
 the wound, and rendering it fistulous. How- 
 ever, there are some circumstances in which 
 a radical cure maybe attempted. Tor ex- 
 ample, if the abscess were produced by a 
 calculus lodged in the infundibulum, or ure- 
 ter, and it could be felt and taken hold of 
 with a pair of forceps, introduced into the 
 opening, the extraction of the foreign body 
 might promote the healing of the ulcer, by 
 rendering the natural channel for the urine 
 free. 
 
 When the opening, by which the urine 
 has become extravasated, exists in the blad- 
 der or urethra, one indication that does 
 not present itself in the foregoing case, may- 
 be fulfilled, viz. the urine maybe drawn off 
 by means of a catheter passed into the blad- 
 der, and kept there. By this means, we not 
 only immediately stop the progress of the 
 extravasation, but attack the very cause of 
 the malady, by removing the obstacles 
 which oppose the natural course of the 
 urine. The introduction of the catheter 
 then becomes a matter of the most urgent 
 necessity. This operation is often attended 
 with the greatest difficulties. Besides the 
 ordinary obstruction of the canal, we have 
 also to surmount the obstacles which the 
 urinary swellings situated in the course of 
 
 Vot JI <59. 
 
 the urethra, create to the passage of the in 
 strument. When these tumours are consi- 
 derable, they ought to be opened before 
 the catheter is employed. The subsidence 
 of the swellings would render catheterism 
 more easy. Besides, Desault was assured 
 by daily experience, that with a little skill, 
 exercise, and patience, the catheter might 
 always he got into the bladder. If, how- 
 ever, the thing could not be done, ought we 
 to puncture the bladder, or have, recourse 
 to the operation termed by the French bou - 
 tonniere ? 
 
 Desault was an advocate for neither of 
 these proceedings : he thought it was a more 
 simple and beneficial practice merely to 
 make an external opening in the collection 
 of effused urine. This measure would both 
 afford an outlet for the urine, and arrest 
 the extension of the extravasation. Besides, 
 such an opening is often indispensably re - 
 quisite for the purpose of putting a stop to 
 the symptoms depending upon the effusion 
 and stagnation of the urine. But if the ca- 
 theter can be introduced, there maybe cases 
 in which an opening would not only be use- 
 less, but hurtful ; for instance, when the 
 swelling caused by the urine is of little ex- 
 tent, or when it is situated in the thickness 
 of the parietes of the passage, or along its 
 track, it almost always admits of dispersion 
 by the simple employment of the catheter 
 But it seldom happens, that this swelling* 
 however small, ends in resolution ; it al- 
 most always suppurates ; yet, as it breaks 
 into the urethra, the matter escapes between 
 this canal and the catheter, and renders 
 the making of an external opening needless. 
 Experience teaches us, also, that when the 
 tumour is situated in the scrotum, or be- 
 tween the root of the penis and the symphy^ 
 sis pubis, even after the healing of the inci 
 sions made in these situations, a fistula will 
 often remain, which is very difficult of cure. 
 With the exception of these particular cases, 
 Desault was an advocate for opening all 
 urinary abscesses. 
 
 The manner of opening such collections 
 varies according as the urine may be in one 
 cavity,, or widely effused in the cellular 
 membrane In the first case, a simple inci- 
 sion, the whole length of the cavity, will 
 suffice for emptying and healing it. In the 
 second, if the extravasation is extensive, 
 the incisions must be multiplied. It would 
 be absurd to spare the parts ; for all those, 
 with which the urine has come into con- 
 tact. seldom escape mortification. The in- 
 cisions which are made, hardly ever have 
 the effect of saving them ; but by accelera- 
 ting the discharge of putrid sanies and stag- 
 nant urine, they prevent mischief, which 
 would originate from a further lodgment. 
 At all events, when the operation is at all 
 delayed, the destruction of all the parts in 
 contact with this irritating fluid, is inevita- 
 ble. The approach of mortification is indi- 
 cated by the crepitation under the bistoury, 
 resembling the kind of noise produced by 
 tearing parchment. The extent and depth 
 of the incisions must be proportioned l.o 
 
URINARY CALCULI 
 
 U>lt> 
 
 those of the abscess. When the extravasa- 
 tion occupies the scrotum, long deep scarifi- 
 cations should be made in that part, as well 
 as in the skin of the penis, and in every 
 place where the urine is effused. 
 
 Practitioners, unaccustomed to see such 
 diseases, would be alarmed at the extent of 
 the sore produced by the separation of the 
 eschars. Sometimes the whole scrotum, 
 skin of the penis, and that of the groins, 
 perinseum, and upper part of the thigh, mor- 
 tify, and the naked testicles hang by the sper- 
 matic chords, in the midst of t his enormous 
 ulcer. It is hardly conceivable how cica- 
 trization could take place over the exposed 
 testicles; but the resources of nature are 
 unlimited. She unites the testicles and the 
 chords to the subjacent parts, and drawing 
 the skin from the circumference to the 
 centre of the ulcer, she covers these organs 
 again, and furnishes them with a sort of 
 new scrotum. This statement is founded 
 upon numerous cases, in which nature al- 
 ways followed this course. The cicatriza- 
 tion of the ulcer is even more expeditious 
 than might be apprehended, considering its 
 extent. In all this business, what does art 
 do? If the introduction of the catheter is 
 excepted, which indeed is absolutely neces- 
 sary for the radical cure, her assistance is 
 very limited, and almost nothing, in the ge- 
 nerality of instances ; for, when patients are 
 not exhausted by the tediousuess of the 
 disorder, when they are of a good constitu- 
 tion, and in the prime of life, they get well 
 as quickly and certainly with the aid of a 
 good diet and simple dressings, as when 
 they take internal medicines, and use a 
 multiplicity of compound topical applica- 
 tions. The practice of Desault at the Hotel- 
 Dieu, consisted in applying emollient poul- 
 tices, until the sloughs were detached. The 
 ulcer was then sometimes dressed with 
 pledgets charged with styrax ; but frequent- 
 ly mere dry lint was used, and continued 
 till the cure was completed. If any com- 
 plication occurred in the course of the 
 treatment, suitable remedies were prescri- 
 bed for it. Thus, when prostration of strength 
 and tendency to sloughing existed, bark, 
 cordials, and antiseptics were ordered. But 
 iu every case, the catheter is the essential 
 means of cure ; without it, the treatment is 
 almost always imperfect, and the ulcer will 
 not heal without leaving several urinary 
 fistulae. (See CEuvres Chir. de Default, par 
 Bichat , T. 3, p.277— 287.) 
 
 URINARY CALCULL A true explana- 
 tion of the nature of urinary calculi was 
 quite impossible, before chymistry had made 
 considerable progress, and the methods of 
 analysis had advanced a great way towards 
 perfection ; and as will appear in the course 
 of this article, all the valuable knowledge 
 which now exists upon this subject, is in 
 reality the fruit of modern investigations. 
 It is to be regretted, however, that our in- 
 formation on many points is far from being 
 settled, or complete, as any impartial and 
 judicious reader may soon convince himself 
 bv a reference to the able and scientific 
 
 views, lately taken by Dr. Prout, of various 
 questions, relative to the formation of gra- 
 vel and calculi, and the treatment of such 
 cases in all their varieties. (See An Inqui- 
 ry into the Nature and Treatment of Grave . 
 and Calculus , and other Diseases connected 
 with a deranged operation of the Urinary Or- 
 gans, 8 vo. Lond. 1821.) 
 
 Mechanical deposites from the urine are 
 divided by Dr. Prout into three classes. 1. 
 Pulverulent, or amorphous sediments. 2. 
 Crystalline sediments, usually denominated 
 gravel. 3. S'olid concretions, or calculi, 
 formed by the aggregation of these sedi- 
 ments. 
 
 Pulverulent, or amorphous sediments , are 
 described by Dr. Prout, as almost always 
 existing in a state of solution in the urine 
 before it is discharged, and even afterward 
 until it begins to cool, when they are depo- 
 sited in the State of a fine powder, the parti - 
 cles of which do not appear to be crystal- 
 line. Their colour js for the most part brown, 
 or yellow, and generally speaking, they con- 
 sist of two specie's of neutral saline com- 
 pounds ; viz. the lithates of ammonia, soda, 
 and lime, tinged more or less with the co- 
 louring principle of the urine, and with the 
 purpurates of the same bases, and consti- 
 tuting what are usually denominated pink 
 and laleritious sediments; and, secondly, 
 the earthy phosphates, namely, the phos- 
 phate of lime, and the triple phosphate of 
 magnesia and ammonia, constituting for the 
 most part sediments nearly white. The 
 two species of sediments are frequently 
 mixed together; though the lithates general- 
 ly prevail. 
 
 Crystalline Sediments, or Gravel, ore com- 
 monly voided in the form of minute angular 
 grains or crystals, composed, 1. Of lit hie 
 acid, nearly pure. 2. Of triple phos- 
 phate of magnesia and ammonia ; and, 3. Of 
 oxalate of lime. The crystals of 1 it hie acid, 
 which are by far the most frequent, are al- 
 ways more or less of a red colour. Those 
 composed of the triple phosphate of mag- 
 nesia and ammonia are nearly white; while 
 others, composed of the oxalate of lime,u hich 
 are extremely rare, are of a dark, blackish, 
 green colour. It is further remarked by Dr 
 Prout, that ’these different varieties of crys- 
 talline deposites are never voided together, 
 though they not unfrequently occur with 
 amorphous sediments. {Prout, Op. cit. p. 79, 
 
 Solid Concretions, or Urinary Calculi, ari - 
 sing trorn the precipitation arid consolidation 
 of the urinary sediments, may be formed in 
 any of the cavities 10 which the urine has 
 access; and hence, they are met with in the 
 kidneys, meters, bladder, and urethra 
 Their various appearances, and chymical 
 properties, will be presently described. 
 Most of them are believed to be originally 
 produced in the kidneys, from which they 
 afterward descend with the urine. To this 
 statement, however, the cases in which cal- 
 culi are formed upon foreign bodies intro- 
 duced into the bladder through the urethra, 
 an accidental wound, or some ulcerated 
 
URINARY CALCULI 
 
 communication between the intestines and 
 the bladder, are manifest exceptions. In the 
 centre jdi urinary calculi, bullets, splinters 
 of bone, pieces of bougies, and wood, pins, 
 needles, nuts, &lc. are frequently observed ; 
 and it would appear, that a very minute 
 substance is capable of becoming a nucleus ; 
 a mere clot ef blood, ora little bit of chaff, 
 if not soon voided, being sufficient to lead 
 to the formation of a stone in the bladder 
 The litbic acid itself is a common nucleus, 
 even where the whole calculus is not of the 
 same material. 
 
 That many urinary calculi ore originally 
 produced in the kidney, is certain ; first, 
 from (he severe pain, which the passage of 
 such foreign bodies down the ureter always 
 excites ; and, secondly, from their being of- 
 ten discovered in the infundibula and pelvis 
 of that viscus after death. This last fact is 
 well illustrated in the first plate of Dr. Mar- 
 cel’s interesting “ Essay on the Chymical 
 History and Medical Treatment of Calculous 
 Disorders ,” 8 vo. 1817. The engraving is 
 taken from a preparation in the Museum of 
 Guy’s Hospital. In this instance, there 
 were several calculi closely pressed against 
 each other ; but in another example, drawn 
 from a specimen in Mr. Abernethy’s muse- 
 um, the renal concretion was composed of a 
 single mass, which represented a complete 
 cast of the pelvis and part of the infundibula 
 of the kidney. In this form of the disease, 
 the kidney loses at last all vestiges of its 
 natural structure, and is converted into a 
 kind of cyst, filled with the extraneous sub- 
 stance. As Dr. Marcet observes, when such 
 a complete alteration of the structure takes 
 place, th« secretion of urine, must of course 
 be entirely carried on by the other kidney. 
 However, in some instances, the inconve 
 nience thus produced is so slight, that it al- 
 most escapes notice; and sometimes even 
 both kidneys are diseased in a very great 
 degree, and yet life is preserved for a con- 
 siderable time. (Op. cit. p. 3, 4.) 
 
 Calculi are sometimes found in the ureters, 
 especially at the upper part ; but it is not 
 supposed that they are originally formed there; 
 an event not likely to happen, unless there 
 were some cause retarding the descent 
 of the urine through those tubes. The 
 common belief is, that all calculi, found in 
 the ureter, are first produced in the infun- 
 dibula and pelvis of the kidney, from which 
 they afterward descend with the urine. 
 
 The generality of calculi, however, which 
 leave the kidney, are of small size, and 
 consequently, after a time, and exciting 
 some pain and inconvenience, they usually 
 pass into the cavity of the bladder. Indeed, 
 as Dr. Marcet remarks, the bladder is the 
 most frequent seat of calculi ; not only be- 
 cause all urinary concretions, or their nuclei, 
 formed in the kidneys, tend to fall into that 
 organ ; but also because a stone may be, and 
 probably often is, originally formed in the 
 bladder itself. 
 
 Rena! concretions vary considerably in 
 their number, size, and shape. In some 
 eases, a single small calculus has been 
 
 547 
 
 found occupying one of the foregoing situa- 
 tions ; while in other instances, an innume- 
 rable collection of calculous substances are 
 observed filling the whole of the cavity of 
 the pelvis and infundibula of the kidney, 
 distending its parietes, and even obstructing 
 the passage of the urine out of this viscus. 
 which is converted into a sort of membra- 
 nous cyst. Lastly, a single stone in the kid 
 ney tnay acquire a very large size there ; or 
 a great number of small caiculi, in the same 
 situation, may become cemented together, so 
 as to form one mass of enormous dimensions, 
 and the shape of which invariably corres 
 ponds to the space in which it is, as it were, 
 moulded. Hence, renal calculi often present 
 a variety of odd, irregular figures, resembling 
 those commonly observed in specimens of 
 coral. 
 
 It has been already remarked, that urina- 
 ry concretions of large size very often exist 
 in the kidney, without their presence being 
 indicated by any external circumstances, or 
 attended with any symptoms, sufficiently 
 unequivocal to constitute a ground for sus- 
 pecting the importance of their cause. On 
 the other hand, it is very usual for renal ca! 
 culi, of middling dimensions, to excite seri 
 ous and alarming complaints. The reason 
 of this difference becomes obvious, when 
 it is recollecied, that smallish concretions 
 are readily carried with the urine into the 
 ureter, and become fixed in the narrow por 
 tion of the tube. But very large calculi can 
 he contained only in the upper part of this 
 canal, where its parietes are more yielding, 
 and the space in them more capacious. 
 
 Calculi, of middling size, in their passage 
 through the ureter, cause at first, a feeling 
 of heaviness, or an indeterminate sense of 
 uneasiness, and an obtuse pain in the region 
 of the corresponding kidney. These com- 
 plaints occur at intervals of greater or less 
 duration. At length the pain grows more 
 urgent and annoying, attended with flatu 
 lence, heart-burn, frequent vomiting, pain- 
 ful retraction of, the testicle, and sometimes 
 acute fever. The patient makes water fre- 
 quently, and in small quantities at a time ; 
 and the urine is high-coloured and bloody 
 The patient cannot sit upright, his body being 
 bent forwards towards the affected side. 
 These symptoms may have more or less du- 
 ration, and then suddenly cease. They may 
 also subside, and recur several times suc- 
 cessively, with intervals of some day3. In 
 the latter case, the pain is fell at each at 
 tack to be situated lower in the track of the 
 ureter. Lastly, when the symptoms have 
 entirely disappeared, the urine is more 
 abundant, not so high-coloured, and easily 
 discharged, the stream sometimes bringing 
 out with it the urinary concretion, after its 
 entrance into the bladder. 
 
 Suppuration of the kidney, and an abscess 
 in the lumbar region, in consequence of re- 
 nal calculi, are not very common events 
 However, these are the only cases of the kind, 
 in which the interposition of surgery can be 
 useful. By adverting to previous cireum 
 stances, and irregularity of the pain about 
 
URINARY CALCULI 
 
 •>'18 
 
 The kidney, tiie pracl it ioner may suspect the 
 nature of a phlegmonous tumour in the 
 situation of this viscus. Whatever may be 
 his conjectures, however, he must carefully 
 abstain from the use of his lancet, until pu- 
 rulent matter is plainly under the integu- 
 ments. He may then safely make an open- 
 ing, from which urine and pus will be dis- 
 charged, and through which the calculi 
 themselves may sometimes be felt and ex- 
 tracted. If they should not be readily 
 touched with a probe, let not the surgeon 
 rashly conceive, that he is justified in en- 
 deavouring to discover them with his knife. 
 Their situation may be such as to baffle all 
 his endeavours, and the operation itself 
 might cause a most dangerous hemorrhage, 
 and other fatal mischief. The opening of 
 an abscess of the kidney may remain a long 
 while fistulous, and the circumstance indeed 
 warrant the conclusion, that the fiealing is 
 prevented by the presence of some extrane- 
 ous substances ; but a prudent practitioner 
 will never think of performing any opera- 
 tion for their extraction, unless they can be 
 distinctly felt, and nature has brought them 
 tolerably near to the surface. (See Nephro- 
 tomy.) 
 
 Urinary calculi, which form upon foreign 
 bodies, accidentally introduced into the blad- 
 der, and acting as nuclei, are a!-.\ ays single, 
 unless the number of foreign bodies them- 
 selves happen to be greater. It is curious 
 also to find, from the observations of Mr. 
 Murray Forbes, (On Gravel and Gout, p. 74, 
 8 ro. Lond. 1793,) and Dr. Marcet, that in 
 such instances the deposition most frequent- 
 ly, if not always, consists of the earthy phos- 
 phates, and especially of the fusibie calculus. 
 Thus, in the collection of Mr. R. Smith, of 
 Bristol, there is a pin, a piece of bougie, and 
 four pieces of stick, coated with fusible mat- 
 ter. (See Med. Chir. Trans. Vol 11, jo. 11.) 
 But when calculi originate from a particular 
 diathesis, there may be many of litem lodged 
 in the bladder at the same time. Several 
 distinct nuclei may descend successively 
 from the kidneys, and each may increase in 
 a separate manner. Sometimes, however, 
 calculi in the bladder, which are at 'first dis- 
 tinct and unconnected, become afterward 
 cemented together, so as to make only one 
 mass. 
 
 The magnitude of calculi in the bladder 
 is generally in an inverse ratio to their num- 
 ber. Sortie hundreds have been found in 
 one bladder; but they were not larger than 
 a pea. It is observed Uy Sir AstUjy Cooper, 
 that when a great number of calculi are 
 found in the bladdery the circumstance is ge- 
 nerally attended vvitn an enlargement of the 
 prostate gland, directly behind which a cal- 
 culus is formed. In cases of diseased pros- 
 tate gland, the bladder can seldom be com- 
 pletely emptied, and this partial stagnation 
 of the urine in the sac, here alluded to, is 
 supposed to facilitate the production of cal- 
 culi. From their number and collision 
 against each other, their surfaces are gene- 
 rally smooth, and their shape is commonly 
 roundish, (bjee Med. > Chir. Trans. Vo! 11 , 
 
 p. 359, and art. Prostate Gland.) Other cal- 
 culi have been met with of so large a size, 
 that they were more than six inches in dia 
 meter. In Fourcroy’s museum, and in that 
 of the Ecole de Medeeine, at Paris, may be 
 seen some calculi, which filled the whole ca- 
 vity of the bladder ; and in the Phil. Trans, 
 fur 18G9. the late Sir James Earle described 
 an enormous stone, which he extracted after 
 death from the bladder of the late Sir David 
 Ogilvie, who had been unsuccessfully cut for 
 it. This calculus, which was of the fusible 
 kind, weighed forty-four ounces, and was 
 of an oval shape, its long axis measuring 
 sixteen inches, and the shorter fourteen. 
 The average size of vesical calculi may be 
 compared with that of a chesnut, walnut, 
 or a small hen’s egg. The size depends 
 very much upon their composition, the 
 largest being of the fusible kind. Their 
 weight differs from a few grains to upwards 
 of fifty ounces ; but on an average, it is 
 from two to six ounces. Their weight is 
 not always proportioned to their size; for 
 substances of different qualities enter into 
 their composition, and diversify their hea- 
 viness. 
 
 The urinary salts, in calculous patients, 
 are not continually precipitated in the same 
 quantities: in some cases, indeed, the pro- 
 cess appears to be even suspended for a 
 considerable time. Hence a stone of mid- 
 dling size, already formed, may increase but 
 very slowly, and it has actually happened, 
 that a calculus, which could be plainly felt 
 with a sound, has remained more than ten 
 years in the bladder, and yet, after all this 
 time, been only of a moderate size. 
 
 According to Dr. Marcet, the form of 
 urinary calculi is mostly spheroidal, some- 
 times egg-shaped, but often (lattened on two 
 sides, like an almond. (P. 50.) Sometimes 
 the calculous matter, which descends from 
 the kidneys, is in the form of minute sphe- 
 rical grains, which have a singular tendency 
 to unite either to each other, or to calculi 
 already lodged in the bladder. 
 
 When there are several loose calculi in 
 the bladder together, they seldom lie long 
 in contact with each other, while their size 
 is diminutive, but are incessantly changing 
 their situation as the patient moves about, 
 or alters the position of bis body. Hence 
 their increase is at first regular and uniform : 
 but when they have attained a more consi- 
 derable size, or by their numbers compose 
 a large mass, their relative situation is more 
 permanent, and many of their surfaces be- 
 ing in this manner usually covered, no 
 longer receive any additional depositions. 
 Every other part of these calculi, however, 
 goes on increasing. It is thus that stones, 
 with surfaces corresponding to those oi 
 other stones, are produced, and which are 
 aptly denominated by the French writers, 
 “ pier res h face lies." 
 
 Dr. Marcet lias likewise taken notice oi 
 the angular shape of certain calculi, and re- 
 marked the rare occurrence ot their being 
 sometimes almost cubic. His work con 
 tains the engraving of a species of calculus. 
 
URINARY CALCULI 
 
 549 
 
 which somewhat resembles a pear, with a 
 circular protuberance at its broader end, 
 apparently moulded in the neck of the blad- 
 der. 
 
 The same intelligent writer has also par- 
 ticularly considered the variety in the co- 
 lours and surfaces of calculi, which often 
 alford indications of their chymical nature. 
 “ When they have a brownish, or fawn 
 colour, somewhat like mahogany wood, 
 with a smooth, though sometimes finely tu- 
 berculated surface, they almost always con- 
 sist of lithic acid. When cut open, they 
 appear to be formed of concentric layers, 
 sometimes homogeneous, sometimes alter- 
 nating with other substances. The colour, 
 however, cannot be considered as a .certain 
 criterion, since other kinds of calculi may 
 often be coloured in the bladder, in a simi- 
 lar manner, by bloody mucus, or other vi- 
 tiated seerelions. 
 
 :i When calculi are white, or gravish- 
 white, they always consist of earthy phos- 
 phates. This is particularly the case with 
 the species called fusible. And when they 
 are dark brown, or almost black, hard in 
 their texture, and covered with tubercles, 
 or protuberances, they are generally of the 
 species which has been distinguished by the 
 name of mulberry , and consists of oxalate of 
 lime. 
 
 “ Calculi have sometimes an uneven, 
 crystalline surface, studded with shining, 
 transparent particles. This appearance al- 
 ways denotes the presence of the ammo- 
 niaco-magnesian phosphate.” ( Marcet , p. 
 52.) 
 
 A large calculus, especially when it has a 
 rough irregular surface, produces a great 
 deai of irritation of the bladder, which con- 
 tracts more clasely round it. The contact, 
 however, is remarked to be particularly ex- 
 act at the transverse line, which extends 
 between the terminations of the two ureters 
 in the bladder ; a part of this organ which 
 generally becomes more thickened than the 
 rest. Sometimes, indeed, the cavity of the 
 bladder is nearly effaced, and the urine can 
 be retained only a very short time, or if it 
 be not evacuated, it spreads uniformly round 
 the calculus, especially above and below 
 the above-described transverse projection, 
 which is less yielding than other parts of 
 this organ. Hence, the surface of the stone, 
 towards the orifices of the ureters, does not 
 enlarge so fast as the other sides of it, and 
 a circular groove is produced, giving the 
 foreign body the shape of a calabash. Such 
 calculi are generally very large, and some- 
 times even of enormous size. In the latter 
 circumstance, the foreign body fills the ca- 
 vity of the bladder so completely, that there 
 is no space left for the lodgement of t lie 
 urine there, which fluid then generally passes 
 along a sort of groove, situated in a line 
 reaching from the lower termination of the 
 ureter to the neck of the bladder. This' 
 state is of course accompanied with a com- 
 plete incontinence. 
 
 Urinary calculi are not always loose and 
 moveable in the cavity of the bladder : be- 
 
 ing sometimes fixed in various ways to cer- 
 tain points of the circumference of this 
 organ ; a subject, w hich has been noticed in 
 the article Lithotomy . 
 
 When the bladder protrudes from the ab- 
 domen, so as to form a hernia, a stone is 
 occasionally situated in the displaced por- 
 tion of it. This circumstance has the same 
 effect as the encysted state of a calculus : 
 for the foreign body is thereby fixed, and it 
 cannot be propelled towards the neck of the 
 bladder at the period when the urine is dis- 
 charged. Also, in cases of prolapsus uteri T 
 when the bladder is drawn downwards, a 
 stone has sometimes been found lodged at 
 the low est part of it. The possibility of the 
 complication of a calculus, with such dis- 
 placements of the bladder, ought to be well 
 remembered, since, if the nature of the case 
 be detected, its treatment becomes mate- 
 rially simplified. 
 
 The symptoms of a stone in the bladder 
 have been detailed in the article Lithotomy ? 
 and therefore need not here be repeated. 
 They are all so equivocal, and bear so great 
 a resemblance to the effects of several 
 other disorders, that they cannot be depend- 
 ed upon, and consequently no well-informed 
 surgeon will venture to pronounce positive- 
 ly, that there is a calculus in the bladder, 
 unless he can distinctly feel it with a sound. 
 (See Lithotomy and Sounding.) As for the 
 operation, if the surgeon cannot plainly feel 
 the calculus immediately before he com- 
 mences the incisions, it ought to be post- 
 poned. 
 
 Notwithstanding the laudable zeal, With 
 which various distinguished physicians and 
 surgeons of the present day, have applied 
 themselves to the consideration of the 
 causes of urinary calculi, the subject is yet 
 in great obscurity. The conjectures which 
 have been started, respecting the influence 
 of particular kinds of food, drink, air, and 
 habits of life, are all Of them liable to such 
 objections, as throw" considerable doubts on 
 their correctness, and sometimes amount to 
 a decided refutation of them. 
 
 If a foreign body be introduced into a 
 cavity, to which the urine has access, what- 
 ever may be the nature of the immersed 
 substance, it always becomes after a time 
 incrusted with calculous matter, though it 
 undergoes no chymical change in its com 
 position. In such cases, it is found (See 
 Forbes on Gravel and Gout, 8 vo Lond. 1793, 
 and Marcet on the Chymical Hist., tyc. of 
 Calculous Disorders, 8 vo. Lond. IS 1 7.) that 
 the concretion mostly, if not always, con- 
 sists of the earthy phosphates. Mere, the 
 operation of any particular diathesis is be- 
 yond all suspicion, because theforeign body , 
 which forms the nucleus, would lead to the 
 production of a calculus in all descriptions 
 of patients. 
 
 There are some countries, where patients 
 with calculi are tolerably numerous; and 
 other parts of the world, where the disease 
 is rare, or never met with ; and yet the dif- 
 ference cannot always be accounted for by 
 any geographical circumstance, which is 
 
URINARY CALCULI, 
 
 550 
 
 constant, ov any definable peculiarity of 
 constitution, climate, diet, or mode of life. 
 One fact, however, I believe is certain, viz. 
 tiie uniform rarity of the disease in very hot 
 countries. In tropical climates, urinary cal- 
 culi are almost unknown, and, as Dr. Mar- 
 cet observes, the testimony of Dr. Scott on 
 this point, who long resided in India, must 
 be considered valuable. Dr. Scott affirms* 
 that, between the tropics, he never met 
 with a single instance of the formation of a 
 stone in the urinary bladder, although he 
 knew of some cases which had been im- 
 ported, and were not cured by climate. 
 (See Marcel on the Chymical History and 
 Med. Treatment of Calculous Disorders, Chap. 
 2, 8t’o. Load. 1817.) Yet, as calculi fre- 
 quently form on various nuclei, bullets, 
 pieces of bougies &c. I conceive, that, even 
 in India, calculi will some day or another 
 be found to originate from this cause, though 
 not perhaps from diathesis. 
 
 Urinary calculi are said also to be very un- 
 common in Spain and Africa, though pa- 
 tients with gravel are numerous in Majorca, 
 which lies between them. ( Magendie . Re- 
 cherces sur les Causes, fyc. de la Gravelle, p. 
 31, 8vo. Paris , 1818.) The usual belief is, 
 that calculi are most frequent in damp, cold 
 countries, like England and Holland, but, 
 that in such other parts of the. world, as are 
 either very hot or cold, the disease is rare. 
 However, in every estimate of this kind, the 
 number of the inhabitants of the countries, 
 or districts in question, is always an essential 
 thing for consideration, because the propor- 
 tion of stone-patients, in a given number of 
 individuals, is invariably rather small ; and, 
 therefore, in referring to the rarity of such 
 patients in very cold countries, it is to be 
 considered, whether the fact may not be, in 
 some measure, ascribable to the fewness of 
 the inhabitants. The state of medicine and 
 surgery, in the countries from which the in- 
 formation is transmitted, is likewise another 
 thing for contemplation, inasmuch as pa- 
 tients are not likely to be reported as suf- 
 fering from, or dying of stone, where the 
 nature of diseases is not scientifically ob- 
 served, morbid anatomy is uncultivated, and 
 the operation of sounding never attempted 
 However, as our East India native regi 
 meats are furnished with excellent surgeons, 
 I consider it well proved that in those regi- 
 ments the disease is uncommon, for other- 
 wise the statement would no doubt have 
 been contradicted by them. The fact seems 
 therefore well established, in relation to the 
 East Indies. At the same time, the ages of 
 the individuals, to whom any calculation 
 applies, is always to be taken into consider- 
 ation, before any inference be drawn re- 
 specting tile cause of the rarity of calcuii, 
 because, if the disease be rare among sol- 
 diers in India, it is also rare among soldiers 
 xn Europe, and therefore climate would not 
 explain the fact in both parts of the world. 
 But, probably, the recollection, that com- 
 mon soldiers are neither children, nor men, 
 above the middle period of life, and that the 
 first, formation of stone in yoylhs, adults. 
 
 and middle-aged persons, is uncommon, 
 unless some extraneous substance happen 
 to enter the bladder and form the nucleus, 
 may furnish a reason for the infrequency of 
 the disease among soldiers, applicable per- 
 haps to siich individuals in every country. 
 And that the children of soldiers, like those 
 of other persons, are not exempt from the 
 disease, I know very well, having had oc- 
 casion myself to operate upon a patient of 
 this kind during my service with the army 
 The preceding consideration also of the 
 general age of sailors in the royal navy, and 
 of the little chance there must be of a boy 
 with s'one beii.g sent to sea, or of any sailor 
 being admitted on board of a King’s ship 
 with that disorder, unless it be wilfully con- 
 cealed by the man himself, furnish to my 
 mind a better explanation of the cause of 
 so few cases of stone having been met with 
 among seafaring persons, than any of the 
 references to the habits or mode of life of a 
 sailor, made by Mr. C. Hutchison in his in- 
 genious paper. (See Med. Chir. Trans Vol 
 9, p. 448, fyr.) From this gentleman’s ac- 
 count it seems, that out of 86,00< patients, 
 admitted into the Naval Hospital at Haslar. 
 Plymouth, and Deal, in the space of sixteen 
 years, there has only been eight calculous 
 cases, or one in 10,750 patients. Two of 
 these cases were boys, about fourtten years of 
 age, “ who had laboured under symptoms of 
 stone for some years previously to their admis 
 sion into the service, and into which they had 
 recently entered , expressly for the purpose of 
 deriving benefit from our magnificent institu- 
 tions ; one was a marine who had been at 
 sea a few months only ; three were adult 
 seamen, and the seventh a marine ; but tlieir 
 length of service afloat could not be at all as- 
 cer tamed .- the eighth, and last case, was a 
 warrant officer, advanced in years , who had 
 been serving in ordinary, that is, in a ship 
 in harbour for a considerable time previ- 
 ously to the operation.” Subsequently to 
 the period, embraced by the returns col- 
 lected by Mr. C Hutchison, a boy has also 
 been operated upon in Haslar Hospital. 
 ( Vol. cit. p. 449.) Mr. R. Smith, of Bristol, 
 has published an interesting statistical in- 
 quiry into the frequency of stone in the 
 bladder in Great Britain and Ireland, though 
 strictly it is a comparative estimate of the 
 number of operations for stone in different 
 parts of the kingdom in given spaces of 
 time, and not of the number of calculous 
 patients. (See Med. Chir. Trans. Vol. 11.) 
 As far as I can judge from the facts sta- 
 ted in Mr. Smith’s paper, and from what 
 I know about the average number of ope- 
 rations for stone in London, not more 
 than 180 can be fairly reckoned as the an 
 iiu ah total in Great Britain and Ireland, 
 which is about 1 for each 100,000 of the 
 population, taken at 18 millions. Now, if 
 this fact be recollected, in computing the 
 rarity of stone operations in the navy, and 
 the other circumstances of there being few 
 children and old men in that service, and 
 of every man btiing examined by a surgeon, 
 to the state of his health, before, be is rn 
 
i;kinaky calculi 
 
 tered, 1 think the reason of the infrequency 
 of stone in the navy will be tolerably clear. 
 However, as sailors live partly in very hot 
 and partly in very cold climates, even if 
 they were of the ages most subject to cal- 
 culi. they may perhaps be rather less dis 
 posed to the complaint, than individuals of 
 the same periods of life, constantly resident 
 in England In the cold country of Swe- 
 den, urinary calculi are said to be infre- 
 quent. (Riche rand, Nosogr. Chir T. 8, p. 
 528, Ed. 4. ;) and, as surgery is there highly 
 cultivated, the uncontradicted statement 
 weighs considerably in favour of the truth 
 of the general belief in the rarity of this 
 disorder in very cold countries. But, as I 
 have already said, the number of inhabit- 
 ants, to which any particular evidence on 
 this point relates, is an essential inquiry, 
 before a safe inference can be drawn. 
 
 It is perfectly well ascertained, that the 
 greater number of urinary calculi are com- 
 posed chiefly of lithic, or uric acid, which is 
 naturally contained either in a free or com- 
 bined state in the urine of man, and all 
 other animals, which consume a great deal 
 of food abounding in azote, as flesh ojf every 
 kind, fish, shellfish, eggs, &ic. Whenever 
 the urine will redden the tincture ot turnsol, 
 Magendie infers with the generality of chy- 
 mists, that it contains lithic acid, the pro- 
 portion of which, he says, varies according 
 to the quantity of substances abounding in 
 azote, taken as food. And Magendie further 
 observes, that when animals live altogether 
 on flesh, their urine is full of uric acid, and 
 even may be entirely composed of it, as is 
 proved with respect to birds, by the experi- 
 ments both of Dr. Wollaston and Vauquelin. 
 Here Magendie cannot mean free uric acid, 
 but this acid in a state of combination ; for, 
 as Dr. Prout has observed, there is no in- 
 stance known, in which lithic, or uric acid 
 is secreted in a pure state ; birds, serpents, 
 &,c. always secrete it in combination with 
 ammonia ; in the gouty chalk-stone, it is 
 secreted in combination with soda. (On the 
 Nature, fyc. of Gravel and Calculus, p. 13.) 
 On the contrary, if animals live on vegeta- 
 bles, as is the case with the herbivorous 
 class, Magendie states that there is no ap- 
 pearance of lithic acid in their urine. In a 
 series of experiments, communicated by 
 Magendie to the Academy of Sciences in 
 1816, this distinguished physiologist exem- 
 plified, that if a carnivorous animal be de- 
 prived of all nutriment, containing azote, 
 and be fed with sugar, gum, oil, and other 
 substances considered to be nutritious, and 
 having no azote in their composition, the 
 urine, in three or four weeks, will contain 
 no lithic acid. (See Mem. sur les Proprteles 
 nutritives des Substances, qui nc contiennent 
 pas d'azote. Paris, 1817.) A dog, allow-ed 
 only sugar, and distilled water, soon began 
 to grow lean, and died apparently starved 
 on the 32d day from the commencement of 
 his diet. The inference which Magendie 
 draws from his experiments, aud from some 
 cases which he has detailed, is, that the 
 quantity of uric acid in the urine, and of 
 
 «i51 
 
 course, the tendency to gravel and calculous 
 disorders, depend very much upon the kind 
 of food. However, he takes into consider- 
 ation the relative propoition of the uric acid 
 to the urine itself, because if this be also 
 abundant, the liability to calculi is counter 
 .acted. It would appear also from his obser- 
 vations, that the urine not only becomes 
 impregnated with a great proportion of uric 
 acid in animals, which eat a large quantity 
 of flesh, but is also scanty ; arid that, on the 
 other band, a vegetable diet always pro- 
 motes the secretion of a large quantity of 
 fluid from the kindneys, as well as check- 
 tbe formation of the acid in question. Ma- 
 gendie is also disposed to believe, that the 
 rarity of calculi in hot climates may be 
 partly traced to the kind of food employed. 
 In fact, it is well known, that, in a consider- 
 able part of Asia, many millions of the inha- 
 bitants never eat flesh. But, though this 
 circumstance must be allowed to have full 
 weight, with respect to the sects which re- 
 ligiously decline animal food, the influence 
 ot climate cannot be rejected, because cal- 
 culi are rare in all hot countries, w r hethev 
 meat be freely eaten or not. At the same 
 time, the tenor of this gentleman’s reason- 
 ing may be true, that, setting out of the 
 question the influence of climate, a vege 
 table diet tends to prevent the formation of 
 lithic acid calculi, while eating large quan- 
 tities of such food as contains a greal deal 
 of azote, has the opposite effect. 
 
 However, Magendie himself is not so par 
 tiat to his theory, as not to confess that it is 
 liable to objections ; for, says he, individu- 
 als are met with every day, who from their 
 age, manner of living, and habits, appear to 
 be subjected to every condition, calculated 
 to produce the gravel, and yet they remain 
 free from it. Hence he infers, that there 
 must be some unknown causes which some 
 times keep the uric acid dissolved, even 
 where its quantity in the urine is copious. 
 On the other hand, he admits that certain 
 persons are met with, whose regimen and 
 mode of life ought to exempt them from 
 gravel, and still they are afflicted. In proof 
 of this fact, he adverts to^ the poor inhabit- 
 ants of a district in Sussex, mentioned by 
 Dr. Scudamore, (On the Nature and Cure of 
 Gout, fy-c. Svo. Land. 1817.) who live almost 
 entirely on vegetable matter and hard beer, 
 aud many of whom are much troubled with 
 gravel. Magendie might also have recol 
 lected, that some birds which live entirely on 
 vegetable matter, as several singing birds 
 kept in cages, void a good deal of the lithate 
 of ammonia. Magendie refers to examples 
 of gravel being always produced in certain 
 individuals after any unusual exertion, and 
 in other apparently healthy subjects, after 
 any difficulty of digestion, flatulence, the 
 eating of salad, raw fruit, &c. With regard 
 to the dyspepsia, frequently attendant on 
 calculous disorders, and other chronic dis- 
 eases, Magendie sets down the complaints 
 of the stomach and of the urinary organs, as 
 probably only two effects of the same cause, 
 and not. mutually productive of each other 
 
URINARY CALCULI 
 
 (See Rechercius , «V" • sar ' es Causes, fye. dc la 
 Gravelle ■ 8 to. Paris, 1818 .) 
 
 It should he observed, that Mageudie’s 
 observations are meant to apply only to ca- 
 ses of gravel, and where the substance void- 
 ed is 1 it hie acid. And as for other instances, 
 in which the calculous matter is formed of 
 phosphate of lime, oxalate of lime, cystic 
 oxide, &x. he deems the causes entirely un- 
 known. One thing is certain, that Magen- 
 die’s theory will not account for the origin 
 of calculi, unless a predisposition to the dis- 
 ease from other unknown or conjectured 
 causes be taken as a matter of fact. Indeed, 
 this admission he makes himself; and he 
 enumerates various circumstances conducive 
 to gravel, besides a diet of food abounding 
 in azote ; as advanced age, a sedentary life, 
 and hard study, long retention of the urine 
 in the bladder, strong wines and liquors. In 
 fact, without the predisposition, arising from 
 unknown causes, and particular periods of 
 life, a meat diet will not render the occur- 
 rence of calculi frequent, as is exemplified 
 in sailors, who eat a great deal of salt beef 
 and pork. And, on the contrary, that the 
 eatmg of little.' or no animal food will not 
 always prevent the formation of calculi, 
 when there is tendency to it from time of 
 life, diathesis, or other causes, is sufficiently 
 proved by the frequency of the disease in 
 infants, in whose food there is a much 
 smaller proportion of meat and azotic sub- 
 stances than in the usual. diet of an adult. 
 
 With respect to amorfdious sediments, the 
 circumstances which Dr. Prout has observed 
 to produce a lithic acid diathesis in per- 
 sons, subject to slight dyspepsia, but in other 
 respects healthy, are, 1, Simple errors in 
 diet. 2, Unusual, or unnatural exercise, 
 either bodily Or mental, particularly after 
 eating, and the want of proper exercise at 
 all other times. 3, Debilitating circumstan- 
 ces. (On Gravel , Calculus, tyc. p. 113.) An 
 unusually heavy meal, especially of animal 
 food, or bread, he says, is invariably follow- 
 ed by a deposition of the lithate of ammo 
 nia from the urine. Heavy, unfermented 
 bread, and compact, hard boiled, fat dump- 
 lings, or puddings, he finds particularly apt 
 to produce such an effect. 
 
 Crystallized sediments, or gravel, consist- 
 ing of nearly pure lithic acid, Dr. Prout as- 
 cribes to a free acid being sometimes gene- 
 rated in the kidneys, and combining with 
 the ammonia, with which the lithic acid is 
 previously united, so as to precipitate the 
 latter in a pure crystallized state. Accord- 
 ing to the investigations of Dr. Prout, the 
 precipitating acid is not constantly the 
 same, though generally the phosphoric, and 
 sometimes the sulphuric. (P. 1 :7, 128.) 
 
 The same intelligent writer represents, the 
 circumstances, which promote the formation 
 of urinary sediments in general, as being 
 either natural or acquired. - £ With respect 
 to those of the first description, (says he) 
 it cannot « think be doubtmi, that certain 
 individuals are much more liable to these 
 sediments than others. This tendency is 
 not infrequently inherited 'thus, I know a 
 
 family, where the grandfather ;fnd father 
 have actually lithic calculi in the bladder ; 
 and where the grandson, a youth of twelve, 
 or thirteen years of age, has a very strong 
 tendency to the same disease ; his urine de 
 positing frequently very large quantities of 
 lithic acid, both in the form of amorphous 
 and crystalline sediments. On the other 
 hand, the disposition to generate these sedi- 
 ments in excess is, like gout, or rather si- 
 multaneously with gout, but too frequently 
 acquired by indolent habits, and excess in 
 eating and drinking. Most frequently, how- 
 ever, the tendency to these diseases is con 
 nected with some unknown causes, peculiar 
 to certain districts or countries,” as, for ex- 
 ample, the district, of which Norwich may 
 be considered as the centre ; in which more 
 calculous cases occur than in the whole of 
 Ireland or Scotland. In such instances the 
 water, diet, temperature, &c. of the district 
 has been each accused, in its turn, of being 
 the exciting cause ; bnt, (says Dr. Prout) 
 the circumstance, I believe, still remains 
 unexplained. I have in one or two instan- 
 ces seen a fit of lithic gravel iuduced in the 
 predisposed by sitting on a damp cold seat 
 for some hours. Sometimes also a tenden- 
 cy to lithic calculus is evidently connected 
 with lo.^al injury, or disease of the kidney.” 
 (P. 133.) 
 
 The difficulty of tracing the causes of the 
 formation of calculi is rather increased, than 
 facilitated, by the fact, that, except when the 
 urinary organs are much diseased, the pa- 
 tient may appear to be in perfect health. 
 Indeed, persons of the strongest constitu 
 tions are often troubled with the stone, 
 quite independently of the entrance of any 
 foreign body, as a nucleus, into the bladder ; 
 and if is now universally admitted, that lithic 
 acid itself constitutes by far the most com - 
 mon nucleus, even when other calculou; 
 matter is deposited round it. (See Prout on 
 Grarcl, p. 95.) It is sometimes conjectured 
 that the female is less liable than the male 
 sex, to calculi ; but whether this is the fact, 
 or whether the circumstance can be satis- 
 factorily explained on another " principle, 
 viz. the facility with which any calculi of 
 moderate size are generally discharged 
 through the short and capacious meatus 
 urinarius,are questions perhaps not yet com- 
 pletely settled 
 
 Infants and children to the age of twelve, 
 or fourteen, are very liable to stone. How- 
 ever, it is asserted by Delpech, that at this 
 period of life, relapses are infrequent; that 
 is to say, an entirely fresh stone is hardly 
 ever formed again ; arid, if a return of the 
 complaint happens, the quickness of its re- 
 currence, and an attentive examination of 
 the calculus, will mostly' prove, either that 
 the second stone has formed round a frag- 
 ment of the first left behind, or that it ex- 
 isted when the former one was taken out, 
 but was not discovered. I am not inclined 
 myself to put much faith in this statement, 
 because it is hardly credible, that the calcu- 
 lous diathesis of childhood can be at all 
 diminished bv the circumstance of there 
 
UKINAItV CALCULI 
 
 having already been one calculus, and of 
 the patient having had the bladder opened 
 for its removal. 
 
 Dr. Marcet thinks, that the disorder is 
 frequent only among the children of the 
 poor classes; and that in those of the high- 
 er ranks, or even of the lowest classes, pro- 
 vided they arc well fed , the same frequency 
 is not observed. “ In the Foundling Hos- 
 pital, for instance, within the last 27 years, 
 during which 1151 children have been ad- 
 mitted, only 3 cases of stone have occurred, 
 all of which were among children while at 
 nurse in the country. And, in the Military 
 Asylum at Chelsea, which contains about 
 1250 children, and into which upwards of 
 6000 of them have been already admitted, 
 no more than one single case of stone has 
 occurred ” (See MarceVs Essay on Calcu- 
 lous Disorders, p. 36 ) However, supposing 
 that the foregoing statement refers to ope- 
 rations for stone, and that the average 
 number of operations for the population oi 
 Great Britain and Ireland, is annually about 
 1 for each 100,000 inhabitants, the inference 
 drawn by Dr. Marcet, which also does not 
 agree with later statistical reports, cannot be 
 received, because in the total number of 
 children, specified as having been admitted 
 into the above charities, even when every 
 allowance is made for the time comprised 
 in the calculation, the proportion of opera- 
 tions is far beyond the average, with refer- 
 ence to the population in general. And, 
 that stone cases are more numerous in the 
 children of the poor, than in those of the 
 higher classes, is a fact, which perhaps may 
 be explained by the recollection, that the 
 mass of the population consists of the poor 
 and laborious classes. 
 
 In the period of life, between the age of 
 twelve, or fourteen, and that of forty, the 
 liability to stone in the bladder, is much less 
 than in infancy, childhood, or old age. 
 And no doubt, many of the cases, which do 
 present themselves in adults, or middle aged 
 individuals, either began at an earlier period 
 of life, or are owing to some extraneous 
 nucleus. 
 
 According to Delpech, in old men, who 
 are particularly subject to calculi, the dispo- 
 sition to the return of the disease always 
 continues during life ; and hence in them, 
 relapses are frequent. {Pricisdts Mai. Chir. 
 T. 2, p. 193, fyc.) 
 
 The following table, collected by Dr. 
 Prout, exhibits the proportion of stone cases 
 before and after puberty, and of their occur- 
 rence in the different sexes : 
 
 isting of. 
 |Females 
 
 44 
 
 C/l , 
 
 
 
 a m 
 
 o o 
 
 
 
 u ^ 
 
 
 o 
 
 5 
 
 
 
 
 O) Ox 
 
 
 
 © 
 
 
 H 
 
 i C iO 
 
 
 -d 
 
 
 
 a 
 
 
 
 
 U3 — 1 
 
 . ©> 
 
 
 03 f' 
 
 o 
 
 o 
 
 Cl Cl 
 
 o 
 
 'Z. 
 
 
 
 
 
 
 
 ©> -1 
 
 r~- 
 
 O 
 
 Oi © 
 
 Cj 
 
 
 
 
 — ; 
 
 
 
 
 CO i'- 
 
 to 
 
 
 i - r- 
 
 to 
 
 
 
 03 
 
 23 
 
 
 
 o 
 
 ,c ~ 
 
 3 tft 
 
 —l * 
 
 m — « 
 
 a o 
 cj > 
 
 Thus, nearly one half of the whole number 
 of stone cases occur before the completion of 
 the 14 th year ; and it appears also from Mr. 
 Smith’s valuable reports, that there is an 
 evident increase in the number of cases, about 
 the age of 40 years. (See Prout on Gravel, 
 tyc. p. 210; and R. Smith , in Med. Chir. 
 Trans. Vol. 10.) 
 
 Dr. Marcet has estimated the comparative 
 frequency of the disease in various coun- 
 tries, and in the different stations of life, 
 and tried to ascertain, w'bether its frequency 
 be influenced by varieties of climate, or 
 situation, or by peculiarities in our habits 
 and occupations. He instituted inquiries at 
 all the great hospitals of the metropolis, in 
 the hope of getting at some useful records 
 concerning the vast number of patients, on 
 whom lithotomy had been performed in 
 those establishments. In London, he found 
 it impossible to obtain all the particulars of 
 such cases, as no entry of them had been 
 preserved. The Norwuch hospital, however, 
 afforded him some details, udiich are inter- 
 esting. All the calculi, w'hich have been 
 exracted in that hospital for 44 years, viz. 
 from 1772, to 1816, and which amount to 
 506, have been carefully preserved, with 
 the circumstances annexed to each stone, 
 and the event of the operation distinctly 
 recorded. Dr. Marcet has given the results 
 of these records in the following table : 
 
 Vofc, II 
 
 0 
 
URINARY CALCULI. 
 
 CO 00 
 f- Gl 
 
 — o 
 
 Oi 
 
 Ci 
 
 tr 1X1 
 
 CJ 
 
 2fa 
 
 It appears, says Dr. Marcet. from the 
 above table, that the mean annual number 
 of cases of lithotomy in the Norwich Hos- 
 pital, during the last 44 years, has been 
 11 1-2, or 23 in every two years ; and that 
 the total number of fatal cases, in the 506 
 operations- is 70, or 1 in 7 1-4, or 4 in 29. 
 The proportion of females, who have under- 
 gone the operation, is to that of males, as 
 58 to 1000, or about 1 to 17 ; that the mor- 
 tality from the operation in children was 
 oniy about 1 in 18; while, in adults, it was 
 4 in 19, or nearly quadruple. 
 
 According to Mr. Smith,, the mortality 
 from lithotomy at the Bristol Infirmary, has 
 been in the following proportions: 
 
 Age. 
 
 10 years of age and under 
 
 Between 10 and 20 
 
 20 
 30 
 40 
 50 
 60 
 70 
 
 30 
 
 40 
 
 50 
 
 60 
 
 70 
 
 SO 
 
 Mean at all Ages 
 
 Rate of Mor- 
 tality. 
 
 1 in 4 1-2 
 1 — 5 
 1 — 7 
 1 — 5 
 1-3 1-8 
 1 — 4 2-3 
 1-2 1-2 
 1 —2 
 
 I in 4 1-4 
 
 The following table is also from Mr. 
 Smith’s paper, and refers to the Leeds Hos- 
 pital. (See Med. Chir. Trans. Vol. 10.) 
 
 ] Cases of 
 | Lithotomy. 
 From 1767 to 1777124 of whicli 
 1777 1787162 
 
 1787 1797123 
 
 1797 1807 42 
 
 1807 1817146 
 
 Mean at all ages, 
 
 died 
 
 >r I in 12 
 1 7 3-4 
 
 1 7 2-3 
 
 1 6 
 1 5 3-4 
 
 1 in 7 4-5 
 
 In the Norfolk Infirmary the mortality has 
 been much less in children, than in adults. 
 But at St. Bartholomew’s, the proportion of 
 deaths in children, during the 20 years that 
 I frequently attended operations for stone 
 there, was very great. In the Bristol Infir- 
 mary, the risk in children seems to have 
 been about equal to what it has been in 
 adults. In all calculations of this kind, how- 
 ever, it is to be recollected, that as opera- 
 tions for the stone are done, not oniy by 
 surgeons of various degrees of skill, but in 
 dilferent ways, and even with instruments 
 of great diversity, such computations do not 
 give the fair average of any one method of 
 operating. 
 
 Now, where the patients are equally 
 favourable, but the results of any given 
 number of operations on them are consider- 
 ably dilferent, the skill of the surgeons, the 
 particular methods of operating pursued, the 
 kinds of instruments used, the general health- 
 iness of the hospital itself, and the treatment 
 after the patients are put to bed, are consi- 
 derations, by which questions, apparently in- 
 explicable, might sometimes he solved. 
 
 From the year 1772 !o 1816, the Norwich 
 Hospital received 18,859 patients of all 
 kinds, making an average of 428 annual ad- 
 missions ; and Dr. Marcet observes, that 
 the proportion of 50.6 operations of lithoto- 
 my, out of 18,859 patients, which corres- 
 ponds to about 1 in 38, exceeds in an as- 
 tonishing degree, that obtained from any of 
 the other public institutions, whose records 
 he examined. 
 
 Next to the records of the Norwich Hos- 
 pital, Dr. Marcet derived the most distinct 
 information of this kind from Cheselden, 
 who mentions in his work on anatomy, that 
 during the course of his public practice in 
 St. Thomas’s Hospital, a period of about 20 
 years, he had performed th’e operation of 
 the stone 213 times, and lost only 20 patients. 
 This was about 2 cases in 21, which is much 
 less than the common average. 
 
 In St. Thomas’s Hospital, during the last 
 ten years, the operation of lithotomy seems 
 to have been done, on an average, 11 times 
 in each two years ; and one case of stone 
 has occurred in eacli 528 patients admitted. 
 
 In St. Bartholomew’s, lithotomy was per- 
 formed 56 times in the years 1812, 1813, 
 1814, 1815, and 1816 The annual average 
 about 11, or 1 in each 340 patients of all 
 descriptions. 
 
 In Guy’s Hospital, lithotomy has been 
 performed, on an average, about 9 or 10 
 times annually, during the last 20, or 30 
 years. The proportion of calculous patients 
 there is also estimated as 1 in about 300 
 cases of all kinds. 
 
 Dr. Marcet’s inquiries incline him to think, 
 that on the whole, lithotomy in the London 
 Hospitals for some years, has been gradually 
 becoming less frequent ; and this lie con- 
 ceives may be owing, partly to a real reduc- 
 tion in the frequency of the stone, from 
 some . Iteration in the diet, or habits of the 
 people ; partly to* the use of appropriate 
 medicines ; and partly to the circumstance 
 
URINARY CALCULI. 
 
 t>5 6 
 
 of calculous patients not resorting so exclu- 
 sively, as was formerly the case, to the 
 great London hospitals for -the operation. 
 
 In the Royal Infirmary at Edinburgh, the 
 average number of stone cases annually, 
 during the last six years, is said not to have 
 exceeded 2, although about 2000 patients 
 are admitted there every year. 
 
 Dr. Marcet has been informed by M. 
 Roux, that, in La Charite at Paris, ten or 
 twelve cases of stone occur every year, out 
 of about 2600 patients, and that the propor- 
 tion of deaths from the operation there is 1 
 in 6 or 6. 
 
 In the HOpital des Enfans Malades, in 
 the same city. Dr. Marcet. states, on the 
 authority of Dr. Biett, that about 6 cases 
 of stone are received every year into that 
 establishment, where about 3000 children 
 of both sexes are annually admitted. There 
 have been only 3 cases in females, and 
 what is remarkable, only two deaths from 
 the operation in the course of the last se- 
 ven years. 
 
 Dr. Marcet was acquainted, that lithotomy 
 is comparatively rare at Vienna, not on ac- 
 count of the want. of good surgeons, or the 
 unfrequent occurrence of stone cases in that 
 part of the continent ; but in consequence of 
 the little attention paidjo this disease by the 
 most eminentsurgeonsofthe Austrian capital. 
 
 At Geneva, says Dr Marcet, in a popula- 
 tion of 30,000, lithotomy has been perform- 
 ed only thirteen times in the last twenty 
 years, though good surgeons are never 
 wanting in that town to perform the opera- 
 tion whenever an opportunity presents 
 itself. Out of these thirteen patients, seven 
 were not strictly Genevese, though belong- 
 ing to the neighbouring districts, and one 
 was an Englishman ; so that the disease 
 would, at first sight, appear to^be a rare oc- 
 currence at Geneva. But, continues Dr. 
 Marcet, if the smallness of the Genevese po- 
 pulation be taken into account, this propor- 
 tion of calculous cases may not fall very 
 short of that observed in other places. At 
 Lyons, a populous town, not more than 
 eighty miles distant from Geneva, the dis- 
 ease is stated to be rather frequent. 
 
 With regard to the chymical nature of 
 urinary calculi, there was nothing known 
 until 1776, when Sc'neele published on the 
 subject in the Stockholm Transactions. He 
 there stated, that all the urinary calculi, 
 which he had examined, consisted of a pe- 
 culiar concrete substance, now well known 
 by the name of lithic, or uric acid, which 
 he also showed was soluble in alkaline lixi- 
 via. Scheele further discovered, that the 
 lithic matter was, in some degree, capable 
 of being dissolved in cold water; that this 
 solution possessed acid properties, and, in 
 particular, that of reddening litmus; that it 
 was acted upon in a peculiar manner when 
 boiled in nitric acid ; and lastly, that hu- 
 man urine always contained this substance 
 in greater or less quantity, and often let it 
 separate in the form of a brick-coloured 
 sediment, by the mere, effect of cooling. 
 
 The disooverv made by Scheele was con- 
 
 firmed by Bergmann and Morveau,and the 
 investigation of the subject was afterward 
 prosecuted by others with redoubled ardour 
 As Professor Murray observes, experiments 
 continued to be repeated and diversified on 
 these concretions, anti on their solvents. 
 At length it was fully ascertained, that 
 there existed others, besides those compo- 
 sed of uric acid; and, latterly, our know- 
 ledge of them has been much extended by 
 the researches of Pearson, Wollaston, Four- 
 croy, and Vauquelin. Several important 
 facts have also been- established by the ta- 
 lents and industry of some other distinguish- 
 ed men ; viz. Dr. Henry, of Manchester ; 
 Professor Brande, of the Royal Institution 
 of London ; Dr. Marcet late of Guy’s Hos- 
 pital ; and Dr. Proul, of London. The facts 
 and considerations of the latter writer ren- 
 der it probable, however, that, the common 
 opinion of pure lithic acid being contained 
 in the urine is not exactly correct ; but that 
 this acid <£ in healthy urine exists in a state 
 of combination with ammonia, and that, in 
 reality, this fluid contains no uncombined 
 acid at all.” (On the jYaturc, fyc. of Gravel 
 and Calculus , c. 13.) 
 
 The credit which is due to Dr. Wollaston 
 for his valuable and original discoveries, 
 respecting urinary calculi, is very consider- 
 able; a truth which I have particular plea- 
 sure in recording here, since his merits have 
 not been faifiy appreciated by the French 
 ehvmists. Indeed, as Dr. Marcet observes, 
 it is the more desirable that his claims 
 should be placed in the clearest point oi 
 view, as the late celebrated M. Fourcror, 
 both in his “ Systerae des Connoissances 
 Chimiques,” and in his various papers on 
 this particular subject, has, in a most unac- 
 countable manner, overlooked Dr. Wollas- 
 ton's labours, and, in describing results, ex- 
 actly similar to those previously obtained 
 and published by the English chymist, has 
 claimed them as his own discoveries. Yet. 
 Dr. Wollaston’s was printed in our Philoso 
 phical Transactions, two years before Four- 
 croy published his Memoir in the w Annales 
 de Chimie.” and three years before he gave 
 to the world his “ Systeme des Connoissan- 
 ces Chimiques;” and he discussed in these 
 works a paper of Dr. Pearson on the lithic 
 acid, published in a volume of the Philoso- 
 phical Transactions (for 171)8) subsequent- 
 to that which contained the account of Dr. 
 Wollaston’s discoveries! (See Marcel's 
 Essay on Calculous Disorders, p 60. Also 
 Murray’s Syst. of Chyw . vol. 4, p. 6)6, edit, 
 of 1S09.) 
 
 It would appear then, that Scheele fir. 
 discovered the nature of those urinary cal- 
 culi which consist of lithic acid ; but that 
 Dr. Wollaston first ascertained the nature 
 of several other kinds, some of which have 
 also been described at a later period by 
 Fourcroy and Vauquelin. On the whole, 
 there are five species of concretions, whose 
 chymical properties were first pointed out. 
 by Dr. Wollaston, and no less than four be- 
 long to the urinary organs. These are, 1st. 
 Gouty concretions. 2dly. The fusible (■■■'■ 
 
cuius. 3dly. The mulberry calculus. 4thly. 
 •The calculus of the prostate gland. Gthly. 
 The cystic oxide, discovered in 1810. 
 
 1. Lithic Acid Calculus. Dr. Front be- 
 lieves that, at least two-thirds of the whole 
 number of calculi originate from lithic acid ; 
 for, as it forms by far the most common nu- 
 cleus, round which other calculous matter 
 is subsequently deposited, if such huclei had 
 not been formed and detained, two persons 
 at least out of three who suffer from stone, 
 would never have been troubled with the 
 disorder. (On Gravely Calculus, fyc. p. 95.) 
 
 Lithic Acid forms a hard, inodorous con- 
 cretion, of a yellowish, or brown colour, 
 similar to that of wood of various shades. 
 According to Professor Murray, calculi of 
 th is kind are in fine, close layers, fibrous, 
 or radiated, (and generally smooth on their 
 surface, though sometimes a little rough. 
 They arc rather brittle, and have a specific 
 gravity, varying from 1,276 to 1,786, but 
 usually above 1,500. One part of lithic 
 acid is said to dissolve in 1720 parts of cold 
 water, and 1150 parts of boiling water; 
 ( Marcel , p. 65.) and this solution turns ve- 
 getable blues to a red colour. When it has 
 been dissolved in boiling water, small yel- 
 lowish ((crystals are deposited as the fluid 
 becomes cold. Lithic acid calculi blacken, 
 but are not melted by the blowpipe, emit- 
 ting a peculiar animal smell, and gradually 
 evaporating, until a small quantity of white 
 ash remains, which is alkaline. By distilla- 
 tion, they yield ammonia and prussic acid. 
 They are soluble in the cold, in a solution 
 of pure potassa, ovsoda, and from the solu- 
 tion a precipitate of a fine white powder is 
 thrown down by the acid. Lime-water 
 likewise dissolves them, but more sparingly. 
 According to Scheele they remain unchan- 
 ged in solutions of the alkaline carbonates ; 
 a statement which agrees with that of Dr. 
 Prout, who accounts for the effect said to 
 be produced by the alkaline carbonates 
 upon calculi in the bladder, by their pro- 
 perty of dissolving the lithate of ammonia. 
 (Egan in Trans, of Irish Acad. 1805, Prout 
 on Gravel, tyc. p. 84.) They are not much 
 acted upon by ammonia. They are not 
 soluble either in the muriatic or sulphuric 
 acid ; though they are so in the nitric when 
 assisted by heat, and the residue of this so- 
 lution, when evaporated to dryness, as- 
 sumes a remarkably bright pink colour, 
 which disappears on adding either an acid 
 or an alkali. In many of these calculi, the 
 lithic acid is nearly pure ; in others, there 
 is an intermixture of other ingredients, par- 
 ticularly of phosphate of lime, and phosphate 
 of ammonia and magnesia ; and, in almost 
 all of them, there is a portion of animal 
 matter, which occasions the smell when 
 they are burnt, and the loss in their analy- 
 sis. (See Murray's Chymisiry, vol. 4, p. 
 640 ; and Marcel s Essay on the Chym. and 
 Med. Hist. »f Calculous Disorders, Svo. Load. 
 1817.) 
 
 A great quantity of uric acid is formed in 
 gpiiiy constitutions, and deposited in the 
 joints, or soft parts, in the state of lithate of 
 
 ammonia. Sir Everard Home removed a 
 tumour weighing four ounces from the 
 heel of a gentleman, a martyr to the gout ; 
 and when anatysed by Professor Brande, it 
 was found to be principally composed of 
 uric acid. (On Strictures, vol. 3, p. 313.) 
 
 2. Lithate of Ammonia Calculus, accord- 
 ing to Dr. Prout, is generally of the colour 
 of clay, f ts surface is sometimes smooth ; 
 sometimes tuberculated. If is composed of 
 concentric layers, and its fracture resem- 
 bles that of compact limestone. It is ge- 
 nerally of small size, and rather uncom- 
 mon ; but the lithate of ammonia very fre- 
 quently occurs, mixed with lithic acid, 
 forming a mixed variety of calculus. Under 
 the flame of the blowpipe it usually decre- 
 pitates strongly. It is much more soluble 
 in water than the lithic acid calculus ; and 
 always gives off a strong smell of ammonia 
 on being heated with caustic potash. The 
 liihale of ammonia is also readily soluble in 
 the alkaline subcarbonates, which pure lithic 
 acid is not. (Prout on Gravel , fyc. p. 83.) 
 
 3. Bone Earth, Phosphate of Lime Calcu- 
 lus. The presence of phosphate of limp in 
 urinary calculi had been mentioned by 
 Bergmaun and others, when Dr. Wollaston 
 first ascertained, that some calculi are en- 
 tirely composed of it. From the investiga- 
 tions of Dr. Wollaston, it appears that this 
 substance sometimes, though rarely, com- 
 poses the entire calculus, but that in general 
 it is mixed with other ingredients, particu- 
 larly with uric acid, and phosphate of mag- 
 nesia and ammonia. In the first case, the 
 calculus is described as being of a pale 
 brown colour, and so smooth as to appear 
 polished. When sawn through, it is found 
 very regularly laminated, and the laminae in 
 general, adhere so slightly to each other, as 
 to separate with ease into concentric crusts. 
 It dissolves entirely, though slowly, in mu- 
 riatic or nitric acid. Exposed to the flame 
 of the blowpipe, it is at first slightly char- 
 red, but soon becomes perfectly white, re- 
 taining its form, until urged with the utmost 
 heat from a common blowpipe, when it 
 :nav be completely fused. It appears to be 
 more fusible than the phosphate of lime, 
 which forms the basis of bone; a circum- 
 stance which Dr. Wollaston ascribes to the 
 latter containing a larger quantity of lime. 
 (Phil. Trans. 1797.) 
 
 4. Triple Phosphate of Magnesia and Am- 
 monia Calculus . The existence of this cal- 
 culus in the intestines of. animals was first 
 pointed out byFourcroy; but its being a 
 constituent part of some urinary calculi of 
 the human subject, was originally discover- 
 ed by Dr. Wollaston. (Phil. Trans. 1797.) 
 According to Dr. Prout, t his species of cal- 
 culus is always nearly white : its surface is 
 commonly uneven, and covered with minute 
 shining crystals. Its texture is not lamina- 
 ted, and it is easily broken and reduced to 
 powder. In some rare instances, however, 
 it is hard and compact, and when broken, 
 exhibits a crystalline texture, and is more or 
 less transparent. Calculi composed entire- 
 ly of the phosphate of magnesia and ammo. 
 
URINARY CALCULI 
 
 uia are rare, but specimens, m which they 
 constitute the predominant ingredient are 
 by no means uncommon. ( Prout , p. S6.) 
 When the blow-pipe is applied, an ammonia- 
 cal smell is perceived, the fragment dimi- 
 nishes in size, and it the heat be strongly 
 urged, it ultimately undergoes an imperfect 
 fusion, being reduced to the state ot phos- 
 phate of magnesia. ( P . 69.) Ur. Wollaston 
 describes the form of the crystals of this salt, 
 as being a short trilateral prism, having one 
 angle a right angle, and the other two equal, 
 terminated by a pyramid of three or six 
 sides. These crystals, as Dr. Marcet has ex- 
 plained, are but very sparingly soluble in 
 water, but very readily in most, if not all 
 the acids, and on precipitation, they reas- 
 sume the crystalline form. From the solu- 
 tions of these crystals in muriatic acid, sal 
 ammoniac may be obtained by sublimation. 
 Solutions of caustic alkalies disengage am- 
 monia from the triple salt, the alkali com- 
 bining with a portion of the phosphoric 
 acid. 
 
 5. Fusible Calculus. Mr. Tennant first 
 discovered, that this substance was different 
 from the lithic acid, and that, when urged 
 by the blowpipe, instead of being nearly 
 consumed, a large part of it melted into a 
 white vitreous globule. The nature of the 
 fusible calculus was afterward more fully 
 investigated and explained by Dr. Wollas- 
 ton. {Phil. Trans. 1797.) According to 
 the excellent description lately given ot this 
 calculus by Dr. Marcet, it is commonly 
 whiter and more friable than any other spe- 
 cies. It sometimes resembles a mass of 
 chalk, leaving a white dust on the fingers, 
 and separates easily into layers, or laminae, 
 the interstices of which are often studded 
 with sparkling crystals of the triple phos- 
 phate. At other times it appears in the 
 form of a spongy and very friable whitish 
 mass, in which the laminated structure is 
 not obvious. Calculi of this kind often ac- 
 quire a very large size, and they are apt to 
 mould themselves in the contracted cavity 
 of the bladder, assuming a peculiarity of 
 form which Dr. Marcet has never observed 
 in any of the other species of calculi, and 
 which consists in the stone terminating, at 
 its broader end, in a kind of peduncle, cor- 
 responding to the neck of the bladder. The 
 chymical composition of the fusible calcu- 
 lus is a mixture of the triple phosphate of 
 magnesia and ammonia, and of the phos- 
 phate of lime. These two salts, which, 
 when separate, are infusible, or nearly so, 
 xvhen mixed together and urged by the 
 blowpipe, easily run into a vitreous globule. 
 The composition ot this substance, says Dr. 
 Marcet, may be shown in various ways. 
 Thus, if it be pulverized, and acetic acid 
 poured upon it, the triple crystals will be 
 readily dissolved, while the phosphate of 
 lime will scarcely be acted upon ; after 
 which the muriatic acid will readily dissolve 
 the latter phosphate, leaving a small resi- 
 due, consisting of lithic acid, a portion of 
 which is always found mixed with the fusi- 
 ble calculus 
 
 5 At 
 
 It is also remarked [by Dr. Marcet, that 
 many of the calculi, which form round ex- 
 traneous bodies in the bladder, are of the 
 fusible kind. And the calculous matter 
 sometimes deposited between the prepuce 
 and glans is found to be of the same nature. 
 
 6. Mulberry Calculus , or Oxalate of Lime 
 is mostly of a dark brown colour, its inte- 
 rior being often gray. Its surface is usually 
 uneven, presenting tubercles more or less 
 prominent, frequently rounded, sometimes 
 pointed, and either rough or polished. It is 
 very hard, difficult to saw, and appears to 
 consist of successive unequal layers : ex- 
 cepting the few stones, which contain a 
 proportion of silica, it is the heaviest of the 
 urinary concretions. Though this calculus 
 has been named mulberry from its resem- 
 blance to that fruit, yet, as Dr. Marcet has 
 observed, there are many concretions of 
 this class, which, far from having the mul- 
 berry appearance, are remarkably smooth 
 and pale-coloured, as may be seen in plate 
 8, fig. 6, of that gentleman’s essay. Accor- 
 ding to Mr. Brande. persons who have void- 
 ed this species of calculus, are much less 
 liable to a return of the complaint, than 
 other patients, who discharge lithic calculi. 
 {Phil. Trans. 1808.) 
 
 With regard to chymical characters (says 
 Professor Murray,) it is less affected by the 
 application of the usual reagents, than any 
 other calculus. The pure alkaline solutions 
 have no effect upon it, and the acids dissolve 
 it with great difficulty. When it is reduced 
 however to fine powder, both muriatic and 
 nitric acid dissolve it slowly. The solutions 
 of the alkaline carbonates decompose it, as 
 Fourcroy and Vauquelin have observed ; 
 and this affords us the easiest method of 
 analysing it. The calculus in powder being- 
 digested in the solution, carbonate of lime 
 is soon formed, which remains insoluble, 
 and is easily distinguished by the efferves- 
 cence produced by the addition of weak 
 acetic acid, while there is obtained in solu- 
 tion the compound of oxalic acid with the 
 alkali of the alkaline carbonate. From this 
 the oxalic acid may be precipitated by the 
 acetate of lead, or of barytes ; and this 
 oxalate, thus formed, may be afterward de- 
 composed by sulphuric acid. Another me- 
 thod of analysing this calculus is by expo- 
 sure to heat : its acid is decomposed, and by- 
 raising the heat sufficiently, pure lime is 
 obtained, amounting to about a third of the 
 weight of the calculus. According to Four- 
 croy and Vauquelin, the oxalate of lime 
 calculus contains more animal matter, than 
 any other. This animal matter appeared to 
 them to be a mixture of albumen and uree. 
 '1 he composition of a calculus of this species 
 analysed by Mr. Brande, was; oxalate of 
 lime 65 grains; uric acid 16 grains ; phos- 
 phate ot lime 15 grains; animal matter lour 
 grains. 
 
 7. The Cystic Oxide Calculus is small, and 
 very rare. It was first described by Dr. 
 Wollaston. {Phil. Trans, for 1810.) In 
 external appearance, it bears a greater re- 
 semblance lo the triple phosphate of ma?- 
 
558 
 
 URINARY CALCULI. 
 
 nesia, than any other sort of calculus. 
 However, it is more compact, and does not 
 consist of distinct lamina?, but appears as 
 one mas»<;onfusedly crystallized throughout 
 its substance. It has a yellowish semi- 
 transparency, and a peculiar glistening lus- 
 tre. Under the blowpipe, it gives a singu- 
 larly fetid smell, quite different from that of 
 lithic acid, or the smell of prussic acid. In 
 consequence of the readiness, with which 
 this species of calculus unites both with acids 
 and alkalies, in common with other oxides, 
 and the fact of its also containing oxygen (as 
 is proved by the formation of carbonic acid 
 by distillation,) Dr. Wollaston named it an 
 oxide, and the term cystic was added from 
 its having been originally found only in the 
 bladder in two examples. Dr. Marqet, 
 however, has subsequently met with no less 
 than three instances of calculi formed of 
 cystic oxide, all of which were unquestiona- 
 bly of renal origin. 
 
 8. Alternating Calculus. Lithic strata fre- 
 quently alternate wkh layers of oxalate of 
 lime, or with the phosphates. Sometimes 
 also the mulberry alternates with the phos- 
 phates, and in a few' instances, three, or 
 even four species of calculi occur in the 
 same stone, disposed in distinct concentric 
 laminae. On the comparative frequency 
 of these and other varieties of calculi. 
 Dr. Prout’s work contains valuable infor- 
 mation. 
 
 9. Compound Calculi , with their Ingredients 
 intimately mixed. Under this title Dr. Mar- 
 cet comprehends certain calculi, which have 
 no characteristic feature, by which they can 
 be considered as distinctly belonging to any 
 of the other classes. He observes, that 
 they may sometimes be recognized by their 
 more or less irregular figure, and their less 
 determinate colour; by their being less dis- 
 tinctly, if at all divisible into strata ; and 
 by their often possessing a considerable 
 hardness. By chvmical analysis confused 
 results are obtained. (See Essay on the 
 Ckym. and Med. Hist, of Calculous Disorders, 
 p. 90.) 
 
 10. Calculi of the Prostate Gland. The 
 composition of those calculi is said to have 
 been first explained by Dr. Wollaston. (See 
 Phil. Trans, for 1797.) They all consist ot 
 ohospbate of lime, the earth not being re- 
 dundant as in bones. Their size varies from 
 that of a pin’s head to that of a hazel nut. 
 Their form is more or less spheroidal ; and 
 they are of a yellowish brown colour. 
 
 Fourcroy has described a species of uri- 
 nary calculus, which is characterized by its 
 being composed of the urate or lit hate of 
 ammonia. Dr. Wollaston, Mr. Brande, and 
 Dr. Marcet did not, however, satisfactorily 
 ascertain the presence of this substance in 
 any of the concretions, which they examin- 
 ed. As also urea and the triple phosphate, 
 both of which afford ammonia, are frequent- 
 ly present in lithic calculi, it is conjectured, 
 that these circumstances may have given 
 rise to the analytical results, from which the 
 existence of nratex>f ammonia has been in- 
 
 ferred. {Brande in Phil. Trans. 1808. Mar- 
 cet’s Essay, p. 93.) 
 
 The recent investigations of Dr. Prout, 
 however, tend to establish the reality of the 
 lithate of ammonia calculus. 
 
 Dr. Marcet has met with two specimens 
 of urinary calculi entirely different from any 
 which have hitherto been noticed. One of 
 these he proposes to name Xanlhic oxide, 
 from gavBoe, yellow , because one of its most 
 characteristic properties is that of forming 
 a lemon-coloured compound, when acted 
 upon by nitric acid. The chymical proper- 
 ties of the other new calculus, mentioned 
 by Dr. Marcet, correspond to those of fibrine, 
 and he therefore suggests the propriety of 
 distinguishing it by the term fibrinous. For 
 a particular description of these new sub- 
 stances, I must refer to this gentleman’s Es- 
 say. 
 
 11. Carbonate of Lime Calculus. This 
 substance is not enumerated by Dr. Marcet, 
 as entering into the composition of urinary 
 calculi. But, according to Mr. R. Smith, 
 there can be no doubt of the fact. Dr. W. 
 H. Gilby of Clifton, he says, detected it de- 
 cidedly in four instances. “ A notice of it 
 will be found in Mr. Tillock’s Journ. for 
 1817, vol. 49, p. 188, in the account of a 
 curious calculus, given to me by Mr. G. M. 
 Burroughs, of Clifton ; the nucleus of which 
 is a common cinder, an inch and a half 
 long, and one broad. Since the publication 
 of that paper (continues Mr. Smith,) Mr. 
 H. Sully, of Wiveliscombe, sent me three 
 oddly shaped calculi, which he removed 
 from a lad, together with 15 pea-sized ones 
 previously voided by the urethra, which are 
 entirely carbonate of lime, held together 
 by animal mucus.” (See Med. Chir. Trans, 
 vol. l\,p. 14.) Dr. Prout has also seen some 
 small calculi, composed almost entirely of 
 carbonate of lime. {On Gravel , fyc. p. 89.) 
 
 Dr. Prout has investigated with considera- 
 ble talent the comparative prevalency of the 
 different forms of urinary deposite, and the 
 order of their succession. His data are 
 taken from the examinations, made by Pro- 
 fessor Brande, of the calculi in the Hunterian 
 Collection ; by Dr. Marcet, of those at Nor- 
 wich and Guy’s Hospital ; by Dr. Henry, of 
 those at Manchester ; and by Mr. Smith, of 
 others preserved at the Bristol Infirmary. 
 The whole number of calculi examined was 
 S23 ; of these, 294 were classed under the 
 name of lithic acid. 98 of which were nearly 
 pure; 151 were mixed with a little of the 
 oxalate of lime ; and 45 with a little of the 
 phosphates. 113 consisted of oxalate of 
 lime. Three were of cystic oxide. 202 
 were phosphates ; of which 16 were nearly 
 pure ; 84 mixed with a small proportion of 
 lithic acid ; eight consisted of phosphate 
 of lime nearly pure ; three of triple phos- 
 phate nearly pure ; and 91 of the tusible or 
 mixed calculi 186 were alternating calculi, 
 or those whose lamina? varied, but consisted 
 of lithic acid, oxalate of lime, and phos- 
 phates: of these. 15 consisted of lithic acid 
 and oxalate of lime, the first being in the 
 creates t proportion : 40 of the oxalate of 
 
URINARY CALCULI 
 
 inne in the greatest proportion, and lithic 
 acid in the least ; 51 of the litbic acid and 
 the phosphates ; 49 of the oxalate of lime, 
 and the phosphates ; 12 of the oxalate of 
 lime, litbic acid, and the phosphates ; one 
 of fusible and litbic ; two of fusible, and 
 oxalate of lime ; and 16, the composition 
 of which was not mentioned. 
 
 Of compound calculi, whose composition 
 was not specified, there were 25. (See W. 
 Front's Inquiry into the JVature and Treat- 
 ment of Gravel and Calculus, p. 94.) 
 
 The proportion of Hi hie acid calculi is 
 somewhat more than one-third of the whole 
 number. But as this acid is the common 
 nucleus, round which other calculous matter 
 is deposited, Dr. Prout computes the pro- 
 portion of calculi originating from it, to be 
 at least two-thirds of the whole number. 
 According to the experiments of the same 
 physician, the red crystalline calculus is 
 composed of nearly pure lithic acid ; and 
 the earthy, amorphous one, consists of lithic 
 acid, more or less ammonia, generally a lit- 
 tle of the phosphates, and sometimes a small 
 portion of the oxalate of lime. The lighter 
 the colour, the greater in geheral the pro- 
 portion of lithate of ammonia and the phos- 
 phates. (P. 97.) 
 
 Oxalate of lime calculi form one-seventh 
 of the whole number, without any regularity, 
 however, in different museums. 
 
 Cystic oxide calculi are so rare, that the 
 proportion found was only one in 274. 
 
 Calculi composed of the phosphates , made 
 about one-fourth of the whole number. 
 
 Alternating Calculi amounted to between 
 one-fourth and one-fifth ; but, Dr. Prout 
 oilers good reasons for believing, that the 
 data, from which the estimate is drawn, 
 cannot be depended upon. For additional 
 information on this branch of the subject, 
 I must refer to Dr. Prout’s valuable work. 
 
 The stone being a severe affliction, and 
 the operation extremely hazardous and pain- 
 ful, a variety of experiments have been in- 
 stituted for the purpose, of discovering a 
 solvent for urinary calculi. Hitherto, how- 
 ever, all the remedies and plans which have 
 been tried, have been attended with very 
 limited, and by no means, unequivocal 
 •'iiccess, notwithstanding many persons may 
 have been deceived into a contrary opinion. 
 
 The dissolution of stones in the bladder 
 has been attempted by lilhontriptic medicines, 
 as they are termed, and by fluids injected 
 into this viscus. At the present day, prac- 
 titioners direct their endeavours very much 
 to the correction of those particular diathe- 
 ses, or states of the constitution, on which 
 the formation of various calculi depend, and 
 more confidence seems to be placed in this 
 aim, than in any schemes for the dissolution 
 of urinary concretions. It is certain, that 
 in the latter project many difficulties present 
 themselves, and among these, some of the 
 most serious are the great variety in the 
 composition of calculi ; the impossibility of 
 knowing tbe exact ingredients of a stone, 
 while it is concealed in the bladder, though 
 many useful suggestions for assisting the 
 judgment on this point have been recently 
 
 559 
 
 .otFered by Dr. Prout ; and lastly, if the right 
 solvent were ascertained, as calculated upon 
 chymical principles applied to urinary con- 
 cretions out of the body, it is obvious, that 
 any medicines, taken by the mouth, are lia- 
 ble to so many changes in the alimentary 
 canal, and in the lymphatic and vascular 
 systems, that it must be exceedingly difficult 
 to get them in an unaltered state and effect- 
 ive quantity into the bladder; while, if this 
 were possible (as it is in the way of injection 
 through a catheter,) the bladder itself might 
 be incapable of bearing the application, and 
 the patient lose his life in the experiment. 
 
 As Dr. Prout well observes, a calculus in 
 the bladder may be considered a substance 
 placed in a solution of various principles in 
 a certain quantity of water. If any of the 
 more insoluble of these principles exist in 
 this solution in a state of supersaturation , 
 the calculus will afford a nucleus, round 
 which the excess will be deposited. But, if 
 none exist in a state of excess, of course 
 none can be deposited, and the calculus 
 will not increase in bulk. 
 
 Whoever studies the chymical properties 
 of the urine, says Dr. Marcet, will learn, 
 that “ if any alkali (a few drops of ammonia 
 for instance.) be added to recent urine, a 
 white cloud appears, and a sediment, con- 
 sisting of phosphate of lime, with some am- 
 moniaco-magnesian phosphate, subsidesln 
 the proportion of about two grains of the 
 precipitate from four ounces of urine. Lime 
 water produces a precipitate of a similar 
 kind, which is still more copious ; for the 
 lime, in combining with the excess of phos- 
 phoric, and perhaps also of lactic acid, not 
 only precipitates tbe phosphate of lime, 
 which these aeids held in solution, but it 
 decomposes the other phosphates, thus ge- 
 nerating an additional quantity of the phos- 
 phate of lime, which is also deposited. 
 
 “ It, on the contrary (observes the same 
 author,) a small quantity of any acid, either 
 the phosphoric, the muriatic, or indeed 
 even common vinegar, be added to recent 
 healthy urine, and the mixture be allowed 
 to stand for one or two .ays, small reddish 
 crystalline particles of lithic acid will be 
 gradually deposited on the inner surface of 
 the vessel. 
 
 ‘ It is on these two general facts that our 
 principles of chymical treatment ultimately 
 rest. Whenever the litbic secretion predo- 
 minates, the alkalies are the appropriate 
 remedies ; and the acids, particularly the 
 muriatic, are the agents to be resorted to 
 when the calcareous or magnesian salts 
 prevail in the deposite.” ( P . 147, 148.) 
 
 The alkalies taken into the stomach cer 
 tainly reach the urinary passages through 
 the medium of the circulation ; and it is 
 aiso strongly suspected that the acids like- 
 wise do so, though this circumstance is still 
 a question. Unfortunately, the quantity of 
 either alkalies or acids, which thus mixes 
 with the urine, is so small, that no impres- 
 sion is made upon calculi of magnitude. 
 The experience of Dr. Marcet, Dr. Prout, 
 and others, however, has clearly ascer- 
 tained that such medicines are often capable 
 
UIUJNAKY CALCULI. 
 
 ' »jbU 
 
 of checking a tendency to the formation of 
 stone, and sometimes of bringiug on a cal- 
 culous deposite depending upon the altered 
 state of the system. Indeed Dr. Marcet ex- 
 presses his decided opinion, that, even sup- 
 posing not an atom of alkali or acid ever 
 reached the bladder, still it would not be 
 unreasonable to expect that these remedies 
 may respectively produce the desired 
 changes during the first stages of assimila- 
 tion ; in one case, by neutralizing any mor- 
 bid excess of acid in the primte vi<e ; and in 
 the other, by checking a tendency to alka- 
 lescence, or otherwise disturbing those 
 affinities, which, in the subsequent processes 
 of assimilation and secretion, give rise to 
 calculous affections. (P. 153.) 
 
 When muriatic acid is prescribed, from 6 
 to 25 drops may be given two or three 
 times a day, diluted with a sufficient quan- 
 tity of water. 
 
 The best way of taking the alkalies is by 
 drinking soda water as a common beve- 
 rage. It is asserted, however, on the au- 
 thority of Sir G. Blane, that when the 
 alkalies are combined with nitric acid, as 
 in the ordinary saline draught, they also 
 have the effect of depriving the urine of its 
 acid properties. 
 
 Dr. Marcet, with every appearance of 
 probability, refers to carbonic acid itself no 
 solvent power; and he does not even adopt 
 Mr. Brande’s opinion, that this acid passes 
 into the urine, when patients drink fluids 
 impregnated with it. 
 
 . But, it may be inquired, if no known in- 
 ternal medicine will dissolve a stone already 
 formed, what is the good of merely altering 
 the diathesis, and checking the increase of 
 the calculus, as lithotomy must still be ne- 
 cessary? The reasons for persevering in 
 the aim of correcting any particular state of 
 the system, and the urinary secretion, on 
 which state the increase of a calculus de- 
 pends, are very important; for it is found, 
 that, though medicines may be quite inca- 
 pable of dissolving a calculus, they relieve 
 a great deal of the distress and suffering 
 apparently the effect of the diathesis itself, 
 as will be presently noticed, and sometimes 
 afford such ease that the operation may be 
 postponed until the health is improved, or, 
 in a very old subject, even be dispensed 
 with altogether. The aim is also of high 
 importance, with the view of preventing 
 relapses. 
 
 As the lithic acid diathesis seems to be 
 concerned in the production of about two- 
 thirds of the whole number of the urinary 
 calculi, the correction of it has been a chief 
 aim among modern practitioners. For 
 this purpose, Magendie, whose experiments 
 tend to prove that the lithic acid diathesis 
 maybe lessened and removed by abstinence 
 from animal food, arid other nutriments 
 abounding in azote, founds his practice very 
 much upon this alleged fact. His indica- 
 ions, however, are four in number, viz. 1. 
 ro lessen the quantity of uric acid produced 
 by the kidneys; 2. to augment the secretiori 
 ,->f urine ;. a maxim, which leads iiim to con- 
 
 sider cutaneous perspiration injurious ; a 
 statement which I think must be rejected, 
 considering the rarity of calculi in hot cli- 
 mates, independently of the sentiments of 
 Dr. Wilson Philip, that the precipitating 
 acid (if such be the cause) is thrown off by 
 the skin, and consequently that insuring a 
 due performance of the cutaneous func- 
 tions, must, in these cases, be beneficial 
 (See Medical Trans, of the College of Phy- 
 sicians, Vol. 6.) 3. To prevent the lithic 
 
 acid from assuming a solid form, by satu- 
 rating it. 4. When gravel and calculi are 
 formed, to promote their discharge and at- 
 tempt their dissolution. ( Richerches , fyc. sur 
 la Gravelle, p. 42.) 
 
 For correcting the lithic acid diathesis, 
 Dr. Prout particularly enjoins the avoidance 
 of errors in diet, exercise, kc. The error of 
 quantity of food, he deems worse than the 
 error of quality. Patients, he say9, should 
 abstain altogether from things which mani- 
 festly disagree with them, and which must 
 be unwholesome to all, such as heavy un- 
 fermented bread, hard boiled and fat pud- 
 dings, salted and dried meats, acescent 
 fruits, and (if the digestive organs be debili- 
 tated) soups of every kind. In general also 
 wine, and particularly those of an acescent 
 quality, should be avoided. The wearing of 
 flannel, the preserving a regular state of the 
 bowels, and the occasional use of alterative 
 medicines, are likewise commended. (Prout 
 on Gravel, <^c. p. 135.) 
 
 According to the same author, the treat- 
 ment of calculous affections is either of a 
 local or general description. The local 
 treatment is nearly the same in all the spe- 
 cies ; the general treatment wall" depend 
 upon the nature of the calculous diathesis. 
 
 What Dr. Prout calls the local treatment 
 consists chiefly in prescribing hyosciamus 
 and opium, either alone or combined with, 
 uva ursi. The hyosciamus, he says, is ge- 
 nerally preferable in the lithic acid diathe- 
 sis, and opium in the phosphatic. He also 
 recommends the use of opium in the form 
 of injection and embrocation, andespecially 
 in that of a suppository. The warm bath, 
 fomentations, and sitting over hot water, 
 are spoken of as other means of relief. 
 
 According to the observations of the same 
 well-informed writer, the distressing symp- 
 toms produced by lithic aci4 calculi have a 
 very constant relation to the severity of the 
 diathesis present ; a circumstance, which 
 he says is also more or less true with re- 
 spect to all the other kinds of calculi : that 
 is to say, in proportion as the urine is unna- 
 tural, and loaded with gravel and amor- 
 phous sediments, in the same proportion, 
 are the patient’s sufferings. Hence our first 
 object should be to restore the urine to its 
 natural state. The first means to be recom- 
 mended, in ordinary cases, is usually a dose 
 of calomel and antimonial powder, the 
 Plummer’s pill, or some other alterative 
 purgative, taken at night, to be followed up 
 the next morning by an alkaline diuretic 
 purgative, composed, for example, ot Bo 
 chelle salts and magnesia, or subcarbona'e 
 
URINARY CALCULI 
 
 oi soda During the day, a strong infusion 
 of uva ursi. combined with hyosciamus and 
 the liquor potassae, may be taken. These 
 means ere to be persisted in for a greater or 
 less time, according to the circumstances, 
 and till the urine begins to be natural : they 
 may then be gradually left off or varied, as 
 occasion may require ; and, under this plan, 
 it will be found, that, in the majority of 
 cases, not only the urine will assume its natu- 
 ral state, but most, or all the distressing symp- 
 toms of calculus in the bladder, will be very 
 ihitch diminished, and in many instances dis- 
 appear. It is obvious also that, while the 
 urine is in its natural state, the calculus 
 cannot increase in size. 
 
 “ After the diathesis is once fairly broken 
 by these means, it may in general be easily 
 prevented from recurring by attention to 
 the diet, and other circumstances, formerly 
 mentioned as inducing this diathesis, and 
 by the occasional use of medicines ; and the 
 patient will scarcely know that he has a 
 calculus in the bladder, at least from the 
 pain that it gives him. I state this with 
 confidence ; but at the same time, I wish to 
 be understood to mean, that the freedom 
 from pain, &c. depend, in no inconsiderable 
 degree, upon the size of the calculus, its 
 smoothness, upon the exercise a patient is 
 •obliged to take, &,c. all of which are pre- 
 sumed to be favourable ; for it must be suf- 
 ficiently obvious that a foreign substance in 
 the bladder cannot be prevented from act- 
 ing mechanically, and from occasionally 
 producing bloody urine, or a temporary 
 stoppage of the discharge of that secretion 
 from the bladder, and similar symptoms, if 
 the patient is obliged to take severe exer- 
 cise.” ( Prout on Gravel, fyc. p. 202 — 204.) 
 
 At the beginning of the eighteenth cen- 
 tury, lime and the alkalies were known to 
 be frequently productive of relief in cases of 
 stone, and in particular the nostrum of a 
 Mrs. Steevens, the active ingredients of 
 which were calcined egg-shells and soap, 
 acquired such celebrity for the cures which 
 it effected, that much anxiety was expressed 
 that her formula should be made public. 
 The consequence was, that, in the year 
 1739, parliament appointed a committee of 
 22 respectable men to investigate the merits 
 of the remedy in question ; and, on their 
 very favourable report, the secret was pur- 
 chased for the sum of 5000/. These pro 
 ceedings naturally interested our neigh- 
 bours, and in the year 1740 and 1741, Mo- 
 rand communicated to the Academy of 
 Sciences two memoirs, in which are report- 
 ed numerous cases where the new remedy 
 was tried, and mostly with success ; the 
 greater number of the patients being de- 
 scribed as either benefited or actually 
 cured. 
 
 In many instances, stones which had been 
 unquestionably felt, were no longer to be 
 discovered ; and as the same persons w^ere 
 examined by surgeons of the greatest skill 
 an i eminence, both before and after the ex- 
 hibition of the medicines, it is no wonder 
 that the conclusion was drawn that the 
 Vor,. II 71 
 
 oO J 
 
 stones had .been really • dissolved. Front 
 the cessation of this success, however, and 
 from its now being known that-stones occa- 
 sionally become lodged in a kind of cyst, 
 on the outside of the general cavity of the 
 bladder, so as to cause no longer any mate- 
 rial suffering, surgeons of the present da) 
 are inclined to suspect, that this must have 
 happened in Mrs. Stevens’s cases. Ihis 
 was certainly what happened to one of the 
 persons, on whom the above medicine was 
 tried, as Dr. W. Hunter informs us. It is 
 evident, that a stone, so situated, would 
 not in general produce a great deal ol 
 irritation, nor admit of being felt with a 
 sound ; though, as l have stated in the 
 article Lithotomy, there have been a tew 
 exceptions to this observation. 
 
 Mrs. Steevens first gave calcined egg-shell • 
 alone; but, finding costiveness produced, 
 she added soap. In time,, she rendered her 
 process more complicated, adding snails 
 burnt to blackness, a decoction of camomile 
 flowers, parsley, sweet fennel, and the 
 greater burdock. 
 
 That, in the lithic acid diathesis, the car- 
 bonated fixed alkalies, taken in large doses, 
 have the effect of passing into the urine, and 
 saturating the redundant lithic acid in the 
 unhealthy state of that fluid, is a' fact deci- 
 dedly proved. If there were any doub 
 yet remaining upon this point, it would be 
 immediately removed by the perusal oi the 
 case of the celebrated Mascagni as detailed, 
 by himself. (See Mem. della Soc. Ital. 1804.y 
 This eminent anatomist being much afflicted 
 with gravel, derived benefit from drinking 
 the aqua alcalina mephitica, or Selzer Water , 
 but, conceiving, that more good might result 
 from a trial of carbonate of potash, he took, 
 at first half a dram of this substance in the 
 morning, and as much in the evening, dis- 
 solved in ten ounces of water. The second 
 dav, the dose was augmented to two drains, 
 and on the third to three, which quantity dis- 
 solved in 20 ounces of water, was continued 
 for ten days. “ Before taking the carbonate 
 of potash (says Mascagni) my urine was 
 very acid, arid immediately reddened litmus 
 paper: as soon as the medicine was begun, 
 I made the same experiment with the urine, 
 then voided, and found the intensity o.u 
 the colour of the paper less. The second day, 
 the paper was very little altered, and on le 
 third, the urine did not redden it at all . -tup 
 acid in my urine, therefore, was saturated, 
 and, at the same time, the pain in my loins 
 diminished, and no more gravel was voided 
 with my urine. Afterward the pain ceased 
 entirely, the urine became dearer, and I per- 
 ceived that it contained an excess of potash. 
 Being attacked again at a subsequent period 
 with the gravel, Mascagni adopted the same 
 treatment, and experienced equal benefit 
 from it. 
 
 In the lithic acid diathesis, the cauatic 
 alkali, in the form of the liquor potassae. has 
 sometimes been thought to have more em- 
 cacy, than the carbonate. 
 
 Sir E. Home and Mr. Hatchet first suggest- 
 ed the utility of giving magnesia in cases 
 
f KLNARJfc CALCULI. 
 
 of stone : aim ihe proposal was communica- 
 led to the public by Mr. Brande (Phil. Trans . 
 1810.) As Dr. Marcet observes, magnesia is 
 often found advantageous in long-protracted 
 cases, in which the constant use of the sub- 
 carbonated, or caustic alkalies, would injure 
 t he stomach. But, he properly remarks, that, 
 if magnesia is sometimes beneficial, it has 
 of late years often done harm. For, as this 
 earth is the base of one of the most common 
 species of calculi, viz. that containing the 
 phosphate of ammonia and magnesia, there 
 is nearly an even chance, when magnesia is 
 prescribed, without any previous knowledge 
 of the nature of the calculus, that it will 
 prove injurious. Magnesia, also, when long 
 and profusely administered, sometimes forms 
 large masses in the intestinal canal, causing 
 serious distress, and even fatal consequences. 
 
 According to Dr. Prout, purgatives wiil 
 sometimes stop calculous depositions, espe- 
 cially in children ; and Dr. Henry, of Man- 
 chester, has observed that a quack medicine, 
 composed of turpentine and opium, will oc- 
 casionally produce a plentiful discharge of 
 lithic acid from the bladder. 
 
 On the whole, I believe, reason and expe- 
 rience will aliow us to consider lirnewater, 
 soap, acidulous soda water, the carbonate of 
 potassa, the liquor potassa?, and magnesia, 
 only as palliative remedies, by which the 
 pain of the disorder may sometimes be 
 diminished, and the urinary secretion im- 
 proved, it being more rational to impute 
 the few supposed instances of greater suc- 
 cess to the calculi becoming encysted. 
 
 As medicines, taken into the stomach, 
 wiil not dissolve urinary calculi, solvent in- 
 jections have been introduced through a ca- 
 theter directly into the bladder. Fourcroy 
 and Vauquelin ascertained, that a ley of 
 potassa, or soda, not too strong to be swal- 
 lowed, softens and dissolves small calculi* 
 composed of the uric acid and urate of am- 
 monia, when they are left in the liquid a 
 few days. They proved, that a beverage, 
 merely acidulated with nitric or muriatic 
 acid, dissolves with still greater quickness, 
 calculi,, formed of the phosphate of lime, 
 and of the triple phosphate of ammonia and 
 magnesia. They also ascertained, that cal- 
 culi, composed of the oxalate of time, which 
 are the most difficult of solution, may be 
 softened, and almost quite dissolved, in nitric ■ 
 acid, greatly diluted, provided they are kept 
 in the mixture a sufficient time. 
 
 Liquids are then known which will dissolve 
 calculi of various compositions ; but, as I 
 have already hinted, much difficulty occurs 
 in employing, tliem effectually in practice, 
 -.'or, although they can be easily injected 
 into the bladder, this organ is so extremely 
 tender and irritable, that the action of such 
 liquidsupon it, as would be requisite for dis- 
 solving a stone, would produce sufferings 
 which no man could endure, and the most 
 dangerous and fatal effects on the bladder 
 i i self. Another objection to this practice also 
 arises from the surgeon never knowing what 
 il e exact composition of a calculus-is, be- 
 ar this body is extracted, and his conse- 
 
 quent inability to determine what solvent 
 ought to be tried. 
 
 Until the complete success of lithontriptics 
 is established, therefore, the operation of 
 lithotomy, severe and hazardous as it is, 
 must continue an indispensable practice, 
 whenever the patient s sufferings are great, 
 and the calculus too large to be voided, or 
 extracted through the urethra. In the early 
 stage, however, before calculi have exceed- 
 ed a certain size, if they cannot be expelled 
 with the urine, they may sometimes be taken 
 out by means of an instrument, invented by 
 Mr. Weiss, of the Strand, shaped like a 
 sound, but the end of which, after its introduc- 
 tion into the bladder, admits of being opened 
 and rnaife to grasp the calculus, which is 
 then to be drawn through the urethra. The 
 urine is first to be discharged through a ca- 
 theter. (See an Account of a Case , in which 
 numerous Calculi were extracted, without cut- 
 ting Instruments , by Sir. A. Cooper, in Med- 
 Chir. Trans. Vol. 11, p.349.) 
 
 Consult T. Lobb, a Treatise on Dissolvents 
 of the Stone, 8 vo. Loud. 1/39. Stephen Hales , 
 Experiments and Observations on Mrs. Stee 
 veils' s Medicines , 8 vo. Lond. 1741. Morand , 
 ■in Mem. de l’ Acad, des Sciences, 1740, and 
 1741. J. Rutty, New Experiments on Joanna, 
 Sieevens's Medicines , 8 vo. Loud 1742 R 
 Why It, an Essay on the Virtues of Lime Wa-% 
 ter and Soap, in the Cure of Stone, 8 vo 
 Edinb. 1761. D. Hartley, a Vieiv of tliepre 
 sent Evidence for and against Mrs. Sieevens's 
 Medicine, 8 vo. Lond. 1739 ; and Supplement . 
 1740. N. Hulme, a safe and easy Remedy for 
 the Stone, fyc.Ato. Lond. 1778 Wm. Butler , 
 Method of Cure for the Stone, chiefly by injec- 
 tions, 12 mo. Edinb. 1754. B. Langrisk, Phy- 
 sical Experiments upon Brutes, in order to 
 discover a safe Method of dissolving Stones in 
 the. Bladder by Injections, 8vo. Lond. 1746. J 
 Jurin , Effects of Soap-ley, taken internal hj 
 for the Stone, ‘Id Edit, with an Appendix . 
 12 mo. Ixmd. 1745. J. F. Schreiber, De Me - 
 dicamentosa J. Stcevens , contra calculum divul- 
 gato inefficaci et noxio, Gi)tt. 1744. Murray 
 Forbes, a Treatise upon Gravel and Gout , 
 with an Examination of Dr. Austin's Theory of 
 Stone, an Inquiry into the Operation of Sol- 
 vents, fyc. 8 vo. Lond. 1793. W. Austin, a 
 Treatise on the origin and component Parts of 
 the Stone, fyc. 8 vo. Lond. 1791. T. Beddoes , 
 on the Nature and Cure of Calculus , fyc. 8 vo. 
 Loud. 1793. J. S. Dorsey, an Essay on the 
 Lithontriplic Virtues of the Gastric Liquor. 
 
 8 vo. Philadelphia , 1802. M. Girardi, Dr. 
 Ur a Ursina, ejusque el aqiue calcis vi lilhon - 
 triplica, fyc. Patav. 1764. Schbele, in Stock- 
 holm Trans. Fourcroy, in Systeme des Con- 
 noissanccs. Ciiimiques . Wollaston, Pearson , 
 and Brande, in Phil. Trans, and Journal of 
 Science and Arts, Vols. 6 and 8, fyc. A. Marcet, 
 on Vie Chymical History and Medical Treat - 
 menl of Calculous Disorders, 8vo. Lond. 1 S 1 7 
 a work full of valuable information. Wilson 
 Philip, in Medical Trans. Vol. 6. Dr. Henry , 
 in Med. Chir. Trans. Vol. 10. C. Scudamore , 
 on Gout, fyc. Edit. 3. F. Magcndie, Recher- 
 ches Physiologiqucs et Medicates sur les Causes . 
 fyc. dr la GraveV-r, 8vo, Paris, I^IK, A 
 
URINARY li'lSTUL/L 
 
 
 Upland Hutchison, on the Comparative In- 
 frequency of Urinary Calculi among Seafaring 
 People , vid. Med. Chir. Trans. Vol. 9. A*. 
 
 Smith , a Statistical Inquiry into the Frequency 
 of Stone in the Bladder, in Great- Britain and 
 Ireland, vid. Med. Chir. Trans. Pol. 11. IV. 
 Front , an Inquiry into the Nature and Treat- 
 ment. of Gravel, Calculus, fyc. 8 vo. Loud. 1821 ; 
 a work abounding in original valuable observa- 
 tions J. Wilson , on the Structure and Physio- 
 logy of the Male Urinary and Genital Organ , 
 and the Nature and Treatment of their Dis- 
 eases, 8 vo. Loud. 1S21 ; this publication con- 
 tains an excellent summary of the latest 
 observations on the subject. 
 
 URINARY FISTULiE. By an urinary 
 fistula, strictly speaking, is implied a deep, 
 narrow ulcer, which leads into some of the 
 urinary passages : but, this name is likewise 
 applied to sinuses, which, without having any 
 communication with these passages, termi- 
 nate near some point of their course. Thus, 
 in Desault’s works, T. 3, p. 287,) three kinds 
 of fistula?, in respect to the urinary passages, 
 are noticed. The first Sort is called a blind 
 external fistula, because it opens only exter- 
 nally ; the second plind internal, because it 
 has only one opening into the urinary pas- 
 sages ; the third, is termed complete, being 
 attended both with an internal opening into 
 the urinary organs, and one or more external 
 apertures. 
 
 Among the blind external fistula?, only 
 such as terminate near the canal of the ure- 
 thra are particularly noticed in Desault’s 
 works. All fistulas of this kind are originally 
 owing to an abscess, that has formed in 
 the vicinity of the urethra ; and. in the arti- 
 cle Urinary abscesses, it has been explained, 
 that these suppurations frequently originate 
 from disease of that canal. Whatever may 
 be the cause of these fistulas, however, it 
 is not unusual to find, that, after the pus 
 has made its way towards the scrotum or 
 perineum, and discharged itself outwardly, 
 the ulcer is converted into a sinus, which 
 resists all the efforts of nature to heal it. 
 One of the chief circumstances, tending to 
 evince, that the sinus has no communication 
 with the urethra, is, that no urine has ever 
 escaped through the opening ; for, with re- 
 spect to the' judgment formed from the im- 
 possibility of making a probe touch a catheter 
 in the passage, it must be exceedingly falla- 
 cious, because the winding course of the 
 sinus, or the small size of its communication 
 with the urethra, may prevent the instru- 
 ments from touching each other. 
 
 According to Desault, the indications in 
 the treatment of these blind fistula? depend 
 upon the nature of their complications. 
 When the sinuses are kept up by a separa- 
 tion of the scrotum. from the parie es of the 
 urethra, Desault recommends exact com- 
 pression to be made over the part, which 
 method, he says, is sometimes sufficient to 
 accomplish a cure. When this plan fails, 
 he states, that the healing ot the sinus may 
 be promoted by practising an incision on 
 one side of the scrotum, and carrying it as 
 far as the denuded portion of the urethra. 
 
 When sinuses exist, and they depend upon 
 the smallness of the opening, or its un- 
 favourable situation for the discharge of the 
 matter, the aperture should be enlarged, by 
 making an incision into the main collection 
 of pus. When there are callosities, which 
 resist cataplasms, and the most active re- 
 solvents, Desault advises us to introduce into 
 the fistula, trochees of minium, for the pur- 
 pose of destroying the indurated parts. 
 When the bones are diseased, exfoliation 
 must be awaited ; and, in every instance, 
 the treatment should vary, according to the 
 cause, upon which the fistula depends. 
 
 Blind internal fistulae, or such as communi 
 cate with the urethra, but have no external 
 opening, are sometimes produced in conse- 
 quence of the bursting of an abscess into 
 this canal ; the ulceration, from a retention 
 of urine ; a false passage . and the healing of 
 the external part of the wound made in 
 lithotomy, while the internal part is not 
 united. 
 
 In these cases, there is a discharge of pus 
 from the urethra, before, and sometimes 
 after, the issue of the urine ; and one may 
 feel, in the ^ourse of the urethra, a tumour, 
 which increases while the patient is making 
 water, and afterward disappears on pressure 
 attended with a fresh discharge from the 
 penis of a mixture of pus and urine. 
 
 These internal urinary fistulae cannot be 
 cured, except by preventing the urine from 
 passing into them and lodging there. The 
 catheters employed should be neither too 
 large nor too small. If too large, they would 
 exactly fill the canal, and the pus and urine 
 contained in the fistula? could not be dis- 
 charged. If too small, the urine would in- 
 sinuate itself between them and the sides ot 
 the urethra, and enter the fistula?. Their use 
 must be continued till the ulcef is entirely 
 healed. 
 
 The most frequent urinary fistula? are those 
 which are termed complete. Their origin 
 may be in the ureters, bladder, or urethra. 
 Those which arise in the ureters, sometimes 
 terminate in the colon, and the urine is dis- 
 charged per ahum mixed with the feces. 
 But most commonly, these fistula? make 
 their appearance* externally, either in the 
 lumbar or inguinal regions. Those whicii 
 communicate with the bladder, have also dif- 
 ferent terminations. When they proceed 
 from the upper and interior part of this or- 
 gan, they ordinarily pierce the parietes of the 
 abdomen above the pubes, and towards the 
 navel. They also sometimes terminate in the 
 groins. When they originate in the poste- 
 rior parietes of the bladder^ they sometimes 
 tend into the cavity of the abdomen, where 
 they almost always prove mortal ; and some- 
 times into the intestines, if there should be 
 adhesions between these and the bladder, so 
 as to favour this communication. When the 
 opening in the bladder is near the bottom of 
 this viscus, the fistula sometimes terminates 
 in the rectum of ihe male, and the vagina of 
 the female subject; but most frequently it 
 ends in the perineum, in both sexes. With 
 regard to the fistula? which originate in the 
 
564 
 
 URINARY FISTULA. 
 
 urethra, they usually open externally in the 
 perimnurn, the scrotum, or the penis, and 
 sometimes alsto in the rectum. It is not un- 
 common to see the external opening of these 
 fistula? at a great distance from the internal 
 one, and to find it in the middle, and even 
 the lower part of the thighs, the groins, pa- 
 rietes of the abdomen, and as high as the 
 sides of the chest. Often there is only one 
 opening in the urethra, while there are seve- 
 ral situated externally, more or less distant 
 from one another. 
 
 Most of these fistula? are the consequences 
 of a retention ot urine, and are owing to 
 the same causes as the diseases of Which 
 they are a symptom. Those which cornvnu- 
 ni< ate with the rectum, in the male subject, 
 sometimes depend upon this intestine having 
 been wounded in the operation ot lithoto- 
 my ; and those which open into the vagina 
 are often the effect of a violent contusion, 
 caused by the head of the child in difficult 
 labours, or of ulceration produced by pessa- 
 ries, which are too large, and ihe margins of 
 which are too sharp and irregular. Carcino- 
 ma of the rectum aud vagina also give rise 
 to fistula?, by extending into the bladder. 
 
 The discharge of urine from the external 
 orifice of the fistula, is an unequivocal proof 
 of its communication with the urinary pas- 
 sage ; when the fistula is narrow, arid there is 
 no obstruction in the urethra, the urine some- 
 times escapes more readily the latter way 
 than through the fistula. It may also be dif- 
 ficult, or even impossible, to find out the in- 
 ternal orifice of the fistula with a probe. 
 When the fistula communicates with the rec- 
 tum or vagina, a staff introduced through 
 the urethra may sometimes be fell in those 
 parts. 
 
 When fistula of the bladder or urethra are 
 the consequences of a retention of urine, 
 produced by strictures, which still exist, or 
 have even increased since the formation of 
 the fistula, the circumstance may render the 
 introduction of the catheter difficult. In this 
 sort of case, if the catheter cannot be pass- 
 ed, the surgeon must endeavour to remove 
 the stricture with bougies, on the principles) 
 explained in the article Urethra , Strictures 
 of. “ In general, (as Sir Everard Home ob- 
 serves,) where fistula? take place in perina?o, 
 in consequence of a stricture, the removal 
 of the stricture is sufficient to give the fistula 
 a disposition to heal. There are, however, 
 cases which require more being done for that 
 purpose, and simply laying them open is not 
 sufficient.” (See Fistula in Perinceo.) Un- 
 der such circumstances, Sir Everard Home 
 finds the actual cautery the surest means of 
 making the part heal In one case, he pass- 
 ed a bougie into the urethra, and seared the 
 edge of the fistula with a hot wire, introdu- 
 ced as far as to touch the bougie. In another 
 instance, a full-sized silver sound was passed 
 into the bladder, and the direction of the 
 fistula having been ascertained with a probe, 
 a female steel sound was heated to redness, 
 and “ at the moment at which it passed from 
 a red to. a black heat, it was hurried down 
 through the fistula (about two inches and a 
 
 half) to the sound in the urethra. In both 
 these cases a cure was effected. ( Home on 
 Strictures , Vol. 3 , p. 262, fyc.) ■ 
 
 When fistulae terminate in the lower part 
 of the bladder, Desault advises the utmost 
 care to be taken to prevent the catheter from 
 being stopped up, and to hinder the instru- 
 ment from becoming displaced, or slipping 
 out of the bladder ; for which last purpose, 
 the catheter bracelet described by Sir E. 
 Home seems well calculated. However, 
 when the fistula communicates with the ure- 
 thra, Desault believes that no advantage 
 would be derived from keeping the catheter 
 open. In both cases, Desault recommends 
 us to continue the catheter, not only until 
 the fistula is cured, but also until the obsta- 
 cles which binder the urine from passing the 
 natural way are removed. 
 
 Fistulae of the bladder, communicating 
 with the vagina, and produced by difficult 
 labours, are almost always attended with loss 
 of substance. The forcible contusion, occa- 
 sioned by the child’s head, on the anterior 
 parietes of the vagina and bottom of the 
 bladder, gives rise to the formation of sloughs, 
 the separation of which • sometimes ieaves 
 apertures large enough to admit the finger, 
 and hence the difficulty of the cure. In 
 treating such fistulae, there are two indica- 
 tions to be fulfilled : 1st, to hinder the urine 
 from passing into the vagina : 2dly, to keep 
 the edges of the division as closely as possi- 
 ble together, so as to give them an opportu- 
 nity of uniting. 
 
 In women, the introduction of the cathe- 
 ter is easy ; but the instrument is more diffi- 
 cult to be fixed than in men. Desault con- 
 tends, however, that it is very essential to 
 have it so fixed in the bladder that the urine 
 may escape. He found that the only effect- 
 ual plan was to fasten the catheter to a point 
 that always retained the same position, with 
 respect to the meatus urinarius. He used a 
 kind of machine, made after the manner of 
 a truss, the circle of which was long enough 
 to embrace the upper part of the pelvis, and 
 had in its middle an oval plate, intended to 
 be placed upon the pubes. In the centre of 
 this plate was a groove, to which a piece of 
 silver was fitted, curved so that one of its 
 ends, with an aperture in it, came over the 
 vulva, on a level with the meatus urinarius. 
 This piece of silver admitted of being fas- 
 tened to the plate with a screw. After the 
 catheter had been introduced and arranged 
 in the bladder, so that its beak and eyes were 
 situated at the lowest part of tin's viscus, the 
 end of the instrument was put through the 
 aperture of the piece of silver which slided 
 into the groove of the plate, and it was af- 
 terward fixed in the way already explained 
 By means of this machine, the catheter was 
 securely fixed, without incommoding the pa- 
 tient, even when she was walking. 
 
 In these last cases, large catheters, with 
 full-sized apertures, should be employed, so 
 that the urine may more readily escape 
 through the instrument, than tall into the 
 vagina. In the early part of the treatment, 
 
URINARY FISTULA:. 
 
 otio 
 
 the catheters should also be left constantly 
 open. 
 
 In order to keep the edges of the division 
 as near together as possible, Desault intro- 
 duced into the vagina a soft kind of pessary, 
 large enough to fill the vagina, without dis- 
 tending it. By this means, the form of the 
 fistula was changed from round to oval, 
 whichis the most favourable to its reunion; 
 and the advantage was gained of closing the 
 fistula, and hindering the urine from falling 
 into the vagina. 
 
 When the rectum is wounded in lithotomy, 
 Desault advised dividing the parts compre- 
 hended between the wound of the operation, 
 the opening in the rectum, and the margin 
 of the anus. That such an operation may 
 become necessary in some instances. I will 
 not say ; but it can never be proper until it 
 is seen whether the wound of the rectum 
 will hot heal up favourably without such 
 treatment. I have seen two cases, in which 
 the rectum was cut in lithotomy, yet no fis- 
 tula ensued ; and other similar facts iiave 
 been mentioned to me by professional friends. 
 The success also with which the wound has 
 generally been healed after lithotomy, done 
 through the rectum, is another fact tending 
 to prove, that the inconveniences of a wound 
 of the latter bowel in the operation have 
 been rather exaggerated. 
 
 In a case of urinary fistula, co nmuni- 
 cating with the rectum, and which could 
 not be healed with the catheter. Sir A. 
 Cooper introduced a catheter into the blad- 
 der, and his finger into the rectum, and then 
 made an incision, as in the operation for the 
 stone, in the left side of the raphe, until he 
 felt the staff through the bulb. He then di- 
 rected a double-edged knife across the peri- 
 neum, between the prostate gland and the 
 rectum, with the intension of dividing the 
 fistulous communication between the urethra 
 and the bowel. A piece of lint was intro- 
 duced into the wound, and a poultice applied. 
 When the lint was removed, the urine was 
 found to take its course through the opening 
 in periiujeo ; the aperture in the rectum gra- 
 dually healed ; and that in the perineum 
 quickly closed ; the urine being all now dis- 
 charged in she natural way {A. Cooper , 
 Surgical Essays, Part 1 ,p. 215.) 
 
 As the same gentleman has observed, aper- 
 tures in the urethra, attended with loss of 
 substance, are extremely difficult to heal. 
 He relates a case where the urethra had 
 sloughed at the junction of the scrotum with 
 the penis; the opening healed at its margin, 
 but a large fistulous orifice still remained. 
 Bougies, the plans ol excoriating the edges 
 of the opening with blistering plaster, and 
 even paring them off, and bringing the fresh 
 cut surfaces together with the twisted »u;ure, 
 had all been tried in vain. In this example 
 a cure was affected by applying the nitrous 
 acid to the edge of the fistulous orifice, and 
 to the skin, three quarters of an inch around 
 it, the principle on which Sir A. Cooper rest- 
 ed his hopes ot success, being the contrac- 
 tion of the skin in cicatrization. The fir.-t 
 application having produced considerable 
 
 amendment, the plan was repeated several 
 times in the course of about nine months, ai 
 the end of which time the fistula was closed 
 But Sir A. Cooper is ol opinion, that such 
 practice will only succeed in cases where 
 the skin is very loose, and the scrotum forms 
 a part of the fistulous orifice. If the skin be 
 much confined, he suggests raising a piece of 
 skin from the scrotum, paring off tiie edges 
 of the fistulous orifice, and removing the 
 skin to a small extent around it. The skin 
 thu - raised is to be turned half round, so that 
 its raw surface may be .applied to the open- 
 ing. and unite. An elastic catheter is first 
 to be introduced. In the successful opera 
 tion of this kind, which was actually done, 
 the flap was held by four sutures; and small 
 slips of adhesive plaster, and a bandage to 
 support the scrotum, were employed. In 
 the course of the treatment, pressure Was 
 found necessary to prevent the occasional 
 passage of urine through the wound. (A 
 Cooper , Surgical Essays , Part 2 ,p. 221, fyc.) 
 
 Mr. Earle met with a case, in which the 
 integuments in the perineum, and above an 
 inch of the canal of the urethra, had slough 
 ed away in consequence of external violence. 
 At the man’s entrance into St. Bartholomew’s 
 Hospital, a large smooth cicatrix occupied 
 the place of the urethra, no vestige of which 
 remained in that part. The integuments on 
 the right side had suffered less extensively 
 than those on the left ; so that when the 
 catheter was introduced, that portion of the 
 instrument which pass.-d over the cicatrix 
 could be about half covered, by drawing 
 the skin and healed part from the right to 
 wards the opposite side. The treatment was 
 therefore begun by confining the knees to- 
 gether over a pillow, a.m applying a kind of 
 truss, which kept the skin constantly pressed 
 towards the left side. While these measures 
 were going on, the opportunity was taken of 
 dilating the anterior portion of the urethra 
 with bougies. Afterward the following ope- 
 ration, which I had the pleasure of seeing, 
 was performed ; a portion of the integuments 
 was removed, about an inch and a half long, 
 and one-third of an inch in width, on the 
 left side of the cicatrix. The groove thus 
 formed was intended for the reception of 
 the edge ot the skin to be detached from ihe 
 opposite side. An i. eision was then made 
 across the perineum, above and below, so as 
 to pare away the callous edges of the ure- 
 thra. The skin was next dis-ected off from 
 a portion of integument on the riglu side of 
 the perineum, about an inch and - halt in 
 length, and half an inch broad, leaving a 
 smooth space of rather more than an inch be 
 tween the cut surfaces. Ihe integuments on 
 the right ^-ide were now dissected up, turned 
 over a catheter, arid brought in contact with 
 the opposite groove. The detached portion 
 of cicatrix bled little during the operation, 
 and before it could be applied to the groove, 
 its edge bad so iivid an appearance, as to 
 create an apprehension that it must perish. 
 Two sutures were employed to assist in re- 
 taining it in the desired position, and some 
 straps of adhesive plaster and a bandage 
 
URINE, INCONTINENCE Ui 
 
 > 00 ‘ 
 
 completed the dressings. The day after the 
 operation, it was evident that some urine 
 had escaped by the side of the catheter; and 
 on the third day, when the dressings were 
 removed, it was found that the portion of 
 flesh which had been deprived of skin, had 
 sloughed, but that a sufficient quantity had 
 united above and below to form a canal, 
 open at one side, and large enough to in- 
 clude the whole catheter. After the parts 
 had healed, some urine could be made to 
 passthrough the urethra, when pressure was 
 applied to the left sicie of the remaining fis- 
 tula. Various attempts were afterward made 
 to excoriate its edges, and unite them, but 
 without success. 
 
 A second operation was therefore done 
 in the summer of 1820, and integuments 
 were now borrowed from the opposite side 
 to that from which they had been taken in 
 the first operation. A deep groove was. 
 made on the right side, the surface was de- 
 nuded of its cutis to some extent, a consi- 
 derable portion of integument was then de- 
 tached from the left side: and in order to 
 obtain healthy skin (says Mr. Earle) I en- 
 croached a little on the thigh, and laid bare 
 the edge of the fascia lata. Instead of pass- 
 ing any ligature through the detached por- 
 tion, the "old quill-suture was employed, 
 which was passed from the two outer cut 
 surfaces. A pad of adhesive plaster was in- 
 terposed between the ligatures and the llap 
 of skin. 5 ’ The catheter was not left in the 
 urethra, but introduced about three times in 
 24 hours. By this operation much more 
 was gained, and about two-thirds of the de- 
 ficient part of the canal were restored ; but 
 still a small aperture remained at the upper 
 part. This opening could not be closed by 
 touching it with escharotics, and conse- 
 quently, a third operation on a smaller scale 
 was done, which so nearly completed the 
 cure, as to leave only an orifice large enough 
 to admit a bristle, and this opening subse- 
 quently closed, arid the patient remained 
 quite well in March 1821. (S ee Phil Trans, 
 for 1821.) 
 
 Here we see the same art by which new 
 noses and under-lips are formed, extending 
 itself to cases where it may be the means of 
 extricating some individuals from a state in 
 which life is hardly desirable, i'he surgeon 
 of judgment, however, will never forget, 
 that such an operation is only indicated 
 where the fistula is large, the urethra lree 
 from obstruction, and bougies ancl the ca- 
 theter insufficient. 
 
 URINE, INCONTINENC E OF. This 
 complaint is quite the reverse of retention 
 of urine ; for, as in the latter affection, the 
 urine is continually flowing into the blad- 
 der, without the patient having the power 
 to expel it; so, in the former it Hows out, 
 without the patient being able to retain it. 
 
 According to Desault, children are parti- 
 cularly liable to the disorder ; adults are less 
 frequently afflicted with it ; and persons of 
 advanced years appear to be still less liable 
 to it. The last observation may seem an 
 error to such practitioners as have met with 
 
 numerous examples, where patients, advan- 
 ced in years, were incapable of retaining 
 their urine. The fact is, that the overflow 
 of this fluid, or, in other words, its dribbling 
 away through the urethra, in somecasesof re- 
 tention, of which it is only a symptom, has 
 been too commonly confounded with an 
 incontinence of urine, though the cases are 
 as different in their nature as possible, and 
 require very opposite modes of treatment. 
 In retentions , depending upon weakness and 
 paralysis of the bladder , the involuntary drib- 
 bling of the urine is generally only an effect 
 of the other disease, and they prevail to- 
 gether. The distended bladder reacts upon 
 the urine, and forces some of it out of the 
 urethra, until the resistance of the sphincter 
 and of the urethra are precisely equal to the 
 expelling power. Sometimes the urine even 
 dribbles away incessantly, as is found to 
 happen when the action of the bladder is 
 entirely destroyed; for being then con- 
 stantly full, it cannot hold any more of the 
 urine descending to it through the ureters, 
 unless as much be voided through the ure- 
 thra as is received from the kidneys, and as 
 unremittingly as the addition from the lat- 
 ter organs continues to be made. Such case 
 rather belongs to the article Urine , Reten- 
 tion of than the present subject. v 
 
 It is correctly remarked by Desault, that 
 the causes of an incontinence of urine, strict- 
 ly so called, are the very reverse of those 
 of a retention. The latter case -happens 
 whenever the action of the bladder is weak- 
 ened, and the resistance in the urethra in- 
 creased. On the contrary, an incontinence 
 originates, either from the expelling power 
 of the bladder being augmented, while the 
 resistance in the urethra is not proportion- 
 ately increased ; or from the resistance be- 
 ing lessened, while the expelling force 
 continues the same. On these principles, 
 Desault thought it easy to explain why the 
 disorder should be most common in chil 
 dren ; and one reason which he gives for 
 the circumstance is, that in childhood there 
 is more irritability than at any other period 
 of life. The expulsion of . the urine, he ob- 
 serves, is entirely effected by muscular ac- 
 tion while the resistance is merely owing 
 to the sphincter vesicoe, the levatores ani, 
 and perhaps to a few other inconsiderable 
 fasciculi of muscular fibres ; for the different 
 curvatures of the urethra, and the contrac- 
 tile power of this tube itself, he thought, 
 could make only a feeble resistance to the 
 discharge of the urine. An incontinence 
 happens in children, because the bladder 
 contracts so suddenly and forcibly, that its 
 contents are voided almost before these 
 young subjects are aware of the occasion to 
 make water, and without their being able to 
 restrain the evacuation. There are also ma- 
 ny children, who, from indolence, or care- 
 lessness, do not make water immediately 
 the first calls of nature invite them, and who 
 afterward, beingurgently pressed, wet their 
 clothes. In other young subjects, the sen- 
 sation which makes the bladder contract 
 and accompanies the expulsion of the urine. 
 
URINE, INCONTINENCE 01 oi>7 
 
 t* so slight, that the lu notion is performed 
 without any formal act of the will, — with- 
 out even exciting an impression sufficiently 
 strong to disturb sleep. This is the case 
 wit h such children as are troubled only with 
 an incontinence of urine in the night-time. 
 Increasing years, by diminishing the irrita- 
 bility of tile bladder, and making man more 
 attentive to his necessities, usually bring 
 about a cure of the infirmity, w hich seldom 
 continues till the patient has attained the 
 adult state. 
 
 It was not, however, the doctrine of De- 
 sault, that no period of life, excepting child- 
 hood, is subject to incontinence of urfne.. 
 On the contrary, he admits, that other ages 
 are subject to it but then it depends almost 
 alw'ays upon a want of resistance to the es- 
 cape of the urine. Thus, it may be occa- 
 sioned by weakness, or paralysis of the 
 sphincter vesica?, or levatores ani : some- 
 times also by a forcible dilatation of the 
 urethra, and loss of its elasticity, and, las 
 Desault might have added) its muscular 
 pow r er of contraction, since the microscopi- 
 cal observations of Mr. Bauer, tend to con- 
 firm the existence of muscular fibres on the 
 outside of the membrane of the canal, 
 though, as is elsew here mentioned, their ar- 
 rangement and mode of action are now' re- 
 presented to be quite different from w hat 
 was formerly supposed. (See Urethra , Stric- 
 tures of the.) 
 
 A calculus, a fungus, or any other extra- 
 neous body of an irregular shape, may lodge 
 in the neck of the bladder, but not accu- 
 rately filling it, may allow the urine to es- 
 cape at the sides ; or there may even be in 
 the calculhs grooves through which the 
 urine may pass into the urethra. 
 
 A violent contusion, or forcible distention 
 of the sphincter, is often follow ed by an in- 
 continence of urihe. F ormerly , the complaint 
 used to be very common after the mode of 
 lithotomy called the apparatus major, and 
 it is even at present not an unusual conse- 
 quence of the extraction of calculi from fe 
 males, either by dilatation or division of the 
 meatus urinarius, and neck of the bladder. 
 
 Women, after difficult labours, and in 
 "whom the child’s head has seriously contu- 
 sed and weakened the neck of the bladder, 
 are also subject to a species of incontinence 
 of urine ; which, however, is in general ex- 
 perienced only when they laugh, or make 
 exertions. 
 
 Incontinence of urine is stated by many 
 writers to be an attendant on paisy and 
 apoplexy. Here they mistake, what the 
 French surgeons aptly call the “ retention 
 d'urinc avec regorgeme?it ,” for an inconti 
 nence. In such cases, the involuntary dis- 
 charge of urine has been referred to paraly- 
 sis of the sphincter of the bladder; but it 
 is forgot, that the bladder itself aiso partici- 
 pates in the paralytic affection ; for the 
 sphincter now being a particular muscle, 
 but only a fasciculus of fleshy fibres, form- 
 ed, as Desault observes, by the junction of 
 those which compose the inner layer of 
 the muscular coat of the bladder, if can only 
 
 be weakened in the same degree, and at the 
 same time, as the rest of this organ. Be- 
 sides, says Desault, it is proved, and all phy - 
 siologists admit the fact, that the action of 
 the bladder is absolutely necessary for the 
 expulsion of the urine, and that when this 
 organ cannot act, a retention alw ays ensues 
 Although much less danger attends an in- 
 continence than a retention of urine, the in- 
 firmity is a serious affliction ; for as the pa- 
 tient’s clothes are continually wet with a 
 fluid that readily putrefies, the stench which 
 he carries about w ? ith him, is offensive to 
 himself, and every body who approaches 
 him. 
 
 In children, the disorder usually gets well 
 of itself, as they grow up and acquire 
 strength. When they wet their beds really 
 from idleness and carelessness, moderate 
 chastisement may be proper, inasmuch as 
 the fear of correction w ill make them pay 
 more attention to the earliest call to make 
 make water. However, it has always been 
 my own belief, that this doctrine is carried 
 to an unjustifiable extent particularly in 
 schools, and been a pretext for the most ab - 
 surd kind of severity. Nor is it doubted by 
 any man who understands the subject, that 
 in almost all cases, the disorder is a true in- 
 firmity, arising from the causes already in • 
 dicated, and not from indolence ; the sup - 
 posed crime taking place, in fact, w hen the 
 child is asleep, and unconscious of what i? 
 happening. 
 
 If excessive irritability, and constitutional 
 weakness, be the cause of incontinence of 
 urine, and a very small quantity of urine 
 forces the bladder to contract, the resist- 
 ance of the urethra being involuntarily 
 overcome, an endeavour should be made to 
 lessen such irritability by the use of the 
 warm, or cold bath, sea-batbing, tonics, 
 chalybeates, good air &c. And in order 
 to prevent the accident from taking place 
 in the night-time, the child should not lake 
 any drink for some time before being put 
 to bed ; the bladder should be always emp- 
 tied before sleep and if necessary, the 
 child ought to be taken up in the night for 
 the same purpose. 
 
 li the infirmity arises from a want of ac- 
 tion in the parts, causing the resistance in 
 the urethra, tonics may be externally and 
 internally employed. However, when tho 
 disorder has been "of long standing, Desault 
 found that they rarely succeeded. 
 
 Palliative means are then the only re- 
 source ; viz. instruments calculated either 
 to compress the urethra, and intercept the 
 passage of the urine, or to receive the fluid 
 immediately it ss voided. The first of these 
 plans is more difficult to accomplish in wo- 
 men than men ; but if may be executed by 
 means of an elastic hoop, which goes round 
 the pelvis, and from the middle of which, 
 in front, a curved elastic piece of steel de- 
 scends, and terminates in a small compress, 
 which is contrived to cover accurately the 
 meatus urinarius. (See CUvvres Chir. uc De- 
 sault par Bichat T 3, p. 95, ) 
 
 Large blisters: applied over the os sacrum? 
 
URINE; RETENTION Oi 
 
 &G8 
 
 Ixavc often cured an incontinence of urine, 
 both when the complaint seemingly arose 
 from excessive irritability of the bladder, 
 and from paralysis and loss of tone in this 
 organ and the parts, which naturally resist 
 the expulsion of the urine from it, the case 
 being in fact a retention “ par regorge me nt,” 
 or, as one might call it in plain English, a 
 retention, combined with incontinence of 
 urine. (See Med. Obs. and Inq.) As, in 
 some of these cases, the blisters removed 
 also a paralysis of the lower extremities, 
 they might have furnished a hint to the prac- 
 tice of making issues for the relief of the 
 palsy of the legs, connected with the dis- 
 eased vertebrae 
 
 URINE, RETENTION OF. It is ob- 
 served by the experienced Mr. Hey, that a 
 retention of urine in the bladder, when the 
 natural efforts, are incapable of affording 
 relief, is, in male subjects, a disease of great 
 urgency and danger. Persons advanced in 
 years, re more subject to this complaint, 
 than she young or nii> idle-aged. Is is of- 
 ten brought on by an incautious resistance 
 to the calls of nature ; and if not speedily 
 relieved, generally excites some degree of 
 fever. 
 
 The distinction, says Mr. Hev, which has 
 sometimes been made between a suppression 
 and retention of urine, is practical and judi- 
 cious Tue. former most properly points out. 
 a defect in the secretion of the kidneys ; the 
 latter, an inability of expelling the urine 
 when secreted. 
 
 The retention of urine is an inability, 
 whether total or partial, of expelling, by the 
 natural efforts, the urine contained in the 
 bladder. The characteristic symptom of 
 Ibis disease, previous to the introduction of 
 the catheter, is a distention of the bladder 
 (to be perceived by an examination of the 
 hypogastrium,) after the patient has dis- 
 charged all the urine, which he is capable of 
 expelling. 
 
 As this complaint may subsist, when the 
 flow of urine from the bladder is by no means 
 totally suppressed, great caution is required 
 to avoid mistakes. 
 
 Violent efforts to make water are often 
 excited at intervals, and during these strain 
 ings, small quantities of urine are expelled. 
 Such a case may be mistaken for strangury. 
 
 At other times a morbid retention of urine 
 subsists, when the palient can make water 
 with a stream, and discharge a quantity 
 equal to that which is commonly discharged 
 by a person in health. Under this circum- 
 stance, Mr. Hey has k own the pain in the 
 hypogastrium, and distention of the bladder, 
 continue till the patient was relieved by the 
 catheter. 
 
 And lastly, it sometimes happens, that 
 when the bladder has offered its utmost 
 distention, the urine runs off by the urethra, 
 as ta>t as it is brought into the blad- 
 der by the ureters. Mr. Hey has repeat- 
 edly known this circumstance cause a seri- 
 ous misapprehension of the true nature of 
 the disease. 
 
 In forming a correct judgment of all 
 
 these cases, it is very necessary to recollect 
 the important division of retentions of 
 urine into the complete and incomplete 
 forms; a distinction which will at once put 
 the surgeon on his guard against a variety of 
 errors. 
 
 In every case of retention of urine which 
 'he iate Mr. Hey attended, the disease could 
 be ascertained by an examination of the hy- 
 pogastrium, taken in connexion with the 
 other symptoms. The distended bladder 
 torms there a hard and circumscribed tumour, 
 giving pain to the patient when pressed with 
 the hand. Some obscurity may arise upon 
 the«exarnination of a very corpulent person ; 
 but in all doubtful cases, the catheter should 
 be introduced. 
 
 Mr. Hey has not adverted to the swelling 
 in the rectum, or vagina; nor to cases of 
 contracted bladder, where, of course, the 
 information, derived in ordinary instances 
 from the tumour above the pubes, cannot 
 be had; but in other respects, his observa- 
 tions on the diagnosis are practical and 
 correct. 
 
 Mr Hey had seen only a few cases of is- 
 churia reualis, or complete suppression of 
 the secretion of urine. The disease proved 
 faial in all his patients except one, in whom 
 it was brought on by the effect of lead, 
 taken into the body by working in a pottery. 
 It subsisted three days, during a violent at- 
 tack ot the colica pictonum, and was then 
 removed, together with the original disease. 
 Mr. Hey tound no difficulty in distinguish- 
 ing this disorder, in any of the cases, from 
 the ischuria vesicalis, though, for the satisfac- 
 tion ot some ot his patients, he introduced 
 the catheter. ( Practical Obs. in Surzery, p. 
 374 , fyc.) 
 
 Re tention of urine, may be the effect of a 
 great many different causes; as paralysis of 
 the bladder; inflammation of its neck; the 
 presence of foreign bodies in it ; pressure 
 made on its cervix by the gravid uterus ; en 
 largemerit of the prostate gland; strictures in 
 the urethra; fee. . 
 
 Every case of retention of urine demands 
 prompt assistance, but where the disorder 
 presents Itself in its complete form, the mis 
 chief of delay is of the most serious nature ; 
 for if the bladder remain preternaturally dis- 
 tended, it not only loses its contractile pow- 
 er, but is quickly attacked with inflammation 
 and sloughing. At length some (joint of it 
 bursts, and the urine is extravasated in the 
 cellular membrane of the pelvis ; spreading 
 behind the peritoneum as far up as the loins, 
 and in other directions, into the perineum, 
 scrotum, and the integuments of the penis, 
 and upper part ot the tiiigbs. The common 
 result then of the rupture of the bladder, and 
 the effusion of its contents, is the speedy 
 death » f the patient, from the effects of this 
 irritating fluid upo all the parts with which 
 it comes in contact, among which effects 
 is inflammation ot the peritoneum und bowels. 
 It appears also from '.he observations, both of 
 Desault and Sir Evrard Home, that a com- 
 plete retention ot urine alter a lime basilic 
 effect of putting a mechanical stoppage to 
 
URINE, RETENTION OF 
 
 u69 
 
 the further secretion of this fluid in the kid- 
 neys ; a circumstance which sometimes has 
 a principal share in producing death, parti- 
 cularly where this event happens before the 
 urine becomes extravasated. 
 
 In all cases of retention of urine, the indi- 
 cations are sufficiently manifest; viz. 1st, to 
 adopt such treatment as seems best calcula- 
 ted to procure a discharge of the urine 
 through the natural passage, which object is 
 performed, sometimes by means of fomenta- 
 tions, the warm bath, bleeding, opium, 
 and other medicines : sometimes bv the 
 removal of mechanical obstacles to the 
 flow of the urine ; hut more frequently b}' 
 the use of the catheter, than any other 
 means. When ell these plans fail, it then 
 becomes necessary to puncture the bladder. 
 2dly. The second indication, or that which 
 presents itself after the immediate dangers 
 of the distention of the bladder, are thus 
 guarded against, is to remove whatever dis- 
 ease, or other circumstance, constitutes the 
 still existing impediment to the natural ex- 
 pulsion of the urine. 
 
 With respect to the fit manner and time of 
 employing the several means for fulfilling 
 the above indications, and the selection 
 which should be made of them, these are 
 important considerations, which vary in dif- 
 ferent cases, and actually cannot be under- 
 stood, without due reference to the causes 
 and circumstances of each individual case. 
 A part of this subject belongs also to other 
 parts of this work, to which, in order to avoid 
 the necessity of repetition, I here refer. (See 
 . Catheter ; Bladder , Puncture of; Prostate 
 Gland, Diseases of; Urethra , Strictures of; 
 *?c.) 
 
 With respect to catheters, we shall find 
 that some cases require the urine to be 
 drawn off two or three times a day, and the 
 instrument to be taken out after each evacua- 
 tion ; while in other instances, it is prudent 
 to keep the tube continually introduced. 
 Here one general caution may be conveni- 
 ently offered, which is, never to let a 
 silver catheter remain in the passage more 
 than a week or ten days, without taking it 
 out and cleaning it ; for if this he not done, 
 the instrument becomes coated with deposits 
 from the urine, so as afterward not to admit 
 of being withdrawn through the urethra, 
 without great suffering and irritation. The 
 eye in the beak is also apt to become com- 
 pletely blocked up ; and sometimes the pres- 
 sure which the catheter makes on the part of 
 the urethra, corresponding to the root of the 
 penis, in front of the scrotum, causes in this 
 situation inflammation, followed by a slough 
 as large as a crown piece, and an opening, 
 formed by the loss of substance is left, which 
 may even continue fistulous during the pa- 
 tient’s life. These remarks particularly ap- 
 ply to metalic catheters ; but such as are 
 supposed to be made of elastic gum, espe- 
 cially those ordinarily met with in the shops, 
 are apt to spoil and become blocked up with 
 mucus, if not taken out and cleaned, or 
 changed, every five or six days. However, 
 as I have mentioned in the article Prostate 
 Vol. If. 73 
 
 Gland , Diseases of, Mr. Weiss lias succeeded 
 in constructing elastic catheters, which will 
 bear being retained more than a fortnight in 
 the urethra, without becoming obstructed, 
 besides having the advantage of always re- 
 taining a due curve. 
 
 1. Of the Retention of Urine, to which per 
 sons of advanced age are liable. -- This disor- 
 der is so common in elderly persons, that it 
 is generally allowed to be "one of the grie- 
 vances to which their period of life is par- 
 ticularly exposed. In them the bladder is 
 less irritable than in younger subjects, and 
 hence, it is not so soon stimulated by the 
 presence of the urine. In fact, it is notun- 
 til a painful sensation arises from the disten- 
 tion of the coats of the bladder, that the pa- 
 tient is aware of the occasion to discharge 
 the urine. The bladder then contracts; but 
 still would not be able to expel its contents, 
 were it not for the powerful action of the 
 abdominal muscles- Nor is the expulsion of 
 the urine even now complete : since the 
 bladder no longer retains the power of effa- 
 cing the whole of its cavity. On the con- 
 trary, alter each evacuation, some urine is 
 still left undischarged, and already consti- 
 tutes an incipient retention. The quantity 
 daily augments, and at length, not more than 
 half the fluid contained in the bladder is 
 voided at each evacuation. 
 
 According to Desault, the complaint par- 
 ticularly attacks old subjects of a plethoric 
 state of body, and of sedentary and studi- 
 ous habits. It also especially afflicts those 
 who, from carelessness or indolence, do not 
 take time enough to expel the last drops of 
 urine ; and others, who are accustomed to 
 discharge their urine into a pot, as they lie 
 in bed, instead of rising for the purpose. 
 
 In these cases, the urethra and neighbour- 
 ing parts seem to be free from every disease, 
 capable of preventing the issue of the urine ; 
 which has always come aw r ay freely, and in 
 a full stream, although it could not be dis- 
 charged with the same force, nor to the 
 same distance, as formerly. At length, in- 
 stead of describing an arch as it flows out, 
 it falls down perpendicularly between the 
 legs. Towards the close of the evacuation, 
 the patient is also not sensible of the final 
 contractile effort of the badder, of which 
 he used to be conscious in his younger days. 
 When he is about to make water, he is 
 obliged to wait some time before the eva- 
 cuation commences; and as the disorder 
 increases, he cannot make water without 
 considerable efforts ; the quantity of urine, 
 voided each time, manifestly decreases ; 
 the desire to empty the bladder becomes 
 more and more frequent ; and lastly, the 
 urine only comes away by drops, and an 
 incontinence succeeds a retention. 
 
 In this state, the patient’s sufferings are 
 not very great. The tumour, formed by 
 the bladder above the pubes, is indolent, 
 and, if it be pressed upon with some force, 
 a certain quantity of urine is discharged 
 from the urethra. 
 
 The retention of urine arising from old 
 age is seldom complete the urine, after 
 
UKLNE, RETENTION 01 
 
 5.70' 
 
 having filled anti distended the bladder, 
 dribbles oat of the urethra, so that the pa- 
 tient voids as much of this fluid in a given 
 lime, as he does in a state of health. Nor 
 is this species of retention of urine com- 
 monly attended with very urgent symp- 
 toms. It does not occasion, like complete 
 intention, a suppression of the urinary se- 
 cretion in the kidneys ; and as the urine 
 escapes through the urethra, after the blad- 
 der is distended to a certain degree, the 
 disorder is less apt to produce a rupture of 
 this organ, and dangerous extravasations of 
 the urine. The swelling of the bladder 
 then continues without any particular suf- 
 fering, except a sense of weight about the 
 pubes and perineum. These circumstances 
 have often led to serious mistakes, and the 
 disease has been set down as an abscess or 
 dropsy. 
 
 The indications are to evacuate the urine, 
 and restore the tone of the bladder. When 
 the retention is incipient, the proper action 
 of the bladder will sometimes return after 
 cold applications are made to the hypogas- 
 tric region, or thighs, and the patient goes 
 from a warm into a cool place. in order to 
 make water. 
 
 The patient must also be strictly careful 
 to make water immediately the least incli- 
 nation to do so is felt ; for, if this precau- 
 tion be neglected, the bladder grows more 
 and more inert ; the desire to make water 
 subsides; and the retention, which at first 
 consisted of only a few drops, very soon 
 becomes complete. It would then be in 
 vain, as Desault observes, to try the expe- 
 dients above recommended. No stimulus 
 will now make the bladder contract suffi- 
 ciently to expel the whole of the urine, and 
 the catheter is the only thing, by which this 
 fluid can be discharged. This artificial 
 mode of evacuation, however, only affords 
 temporary relief; for as the bladder is slow 
 in recovering its tone, a relapse would be 
 inevitable, if the employment of the cathe- 
 ter were not continued. Hence this instru- 
 ment must either be left in the bladder, or in- 
 troduced as often as the patient lias occa- 
 ion to make water. When a skilful surgeon 
 is constantly at hand, or when the patient 
 knows how to pass the catheter himself, 
 Desault thinks it better to introduce the in- 
 strument only when the bladder is to be 
 emptied, by which means the inconvenience 
 arising from the continual presence of a fo- 
 reign body, will be avoided. In this case, 
 either a silver catheter, or an elastic gum 
 one, may be used with equal advantage ; 
 Hut if the instrument is to-be kept in tiie 
 bladder, one made of elastic gum, and pro- 
 vided with a curved stilet, is to be prefered. 
 As in old subjects, the urethra is flaccid, a 
 large catheter is generally found to enter 
 more easily, than one of smaller diameter. 
 
 As the treatment must be continued for a 
 long while, and the bladder seldom perfectly 
 regains its tone in old age, the patient should 
 be instructed how to introduce the catheter 
 himself, and he is to pass it whenever lie 
 wants to make wafer. After a certain time. 
 
 however, he may try if tie can empty ike 
 bladder without this instrument. When he 
 finds that he can expel the urine, he should 
 certify himself by means of the catheter, 
 that the last drops of this fluid are duly 
 voided. Should they not be so, he must 
 persevere in the use of the instrument. 
 
 In this sort of retention of urine, it has 
 been proposed to throw into the bladder as- 
 tringent injections : Desault tried them ; but, 
 he does not give a favourable report of the 
 practice. 
 
 Warm balsamic, diuretic medicines; cold 
 bathing ; and liniments containing the tinc- 
 tura lyttee ; have likewise been praised ; but 
 according to Desault, these means frequent- 
 ly prove hurtful to persons of advanced 
 years, and are seldom useful. He restricted 
 his own practice to the use of the catheter 
 which, when skilfully employed, often re- 
 stored the tone of the bladder, and when it 
 failed, other means also were ineffectual. 
 A blister over the sacrum may deserve a 
 trial. 
 
 Passing over (he cases of retention of 
 urine, referred by Desault to the effects of 
 intemperance with .women, and the immo- 
 derate use of diuretic drinks ; cases which 
 considerably resemble in their nature and 
 treatment the retention, from the weakened 
 state of the bladder in elderly persons, I 
 proceed to another example of the disorder 
 still more interesting to the practical sur- 
 geon. 
 
 2. Retention of Urine from an Affection oj' 
 the Nerves of the Bladder . — These nerves 
 may be affected either at their origin, or in 
 the course of their distribution. Injuries of 
 the brain are seldom followed by a retention 
 of urine, but the complaint often aceom 
 panies those of the spinal marrow. A con 
 cussion of this medullary substance, from 
 blows, or falls upon the vertebral column ; 
 the injury which it suffers in fractures and 
 dislocations of the vertebra?, or from a vio- 
 lent strain of the back ; its compression by 
 blood, purulent matter, or other fluid effu- 
 sed in the vertebral canal, and the effects, 
 which a caries of the spine has upon it ; 
 may all operate as so many causes of a re - 
 tention of urine. This form of the com- 
 plaint may also be the consequence of tu 
 mours situated in the track of the nerves, 
 which are distributed to the bladder. 
 Whether the retention of urine, common in 
 typhus fever, arises from an affection of the 
 nerves of the bladder, or from the general 
 debility extending itself to the expelling 
 powers, may be a question ; but the liabili- 
 ty of patients in fevers to this disorder 
 should never be out of the practitioner’s 
 recollection. 
 
 When a retention of m ine arises from in- 
 jury or disease of the spinal marrow, an in- 
 sensibility and weakness of the lower ex- 
 tremities are almost always concomitant 
 symptoms. The patients suffer very little ; 
 most of them are ignorant of their condi- 
 tion ; and do not complain of any thing 
 being wrong in the functions of the urinary 
 organs. The surgeon, aware that a r©teu- 
 
URINE, RETENTION OF 
 
 vioii of urine is common in these cases, 
 shoulil examine, whether there is any inter- 
 ruption of the evacuation, either by feeling 
 the state of the abdomen just above the 
 pubes, or by. introducing a catheter. 
 
 As this species of retention of urine is 
 only symptomatic, and not dependent upon 
 any prev ious defect in the bladder, it is not 
 in itself alarming; but with reference to its 
 cause, it is exceedingly dangerous. Affec- 
 tions of the spine, complicated with injury 
 of the spinal marrow, are often fatal. By 
 means of a catheter, it is always easy to re- 
 lieve the inconveniences, arising from the 
 bladder not contracting, and thus fulfil the 
 only indication, which this sort of retention 
 of urine presents ; viz. the evacuation of 
 the urine. But this proceeding is merely 
 palliative ; and the bladder will not recover 
 ifs contractile power, until the causes of its 
 x weakness are removed. The last then is 
 the main object in the treatment, which 
 must vary according to the nature and ex- 
 tent of the disorder. 
 
 The consideration in detail of all the 
 means, which may be requisite for the relief 
 of the different accidents and diseases of 
 the spine, belongs to other parts of this 
 work. (See Dislocations and Fractures of 
 the Vertebrae; Vertebrae , Disease of.) In 
 shocks and concussions of the spinal mar- 
 row, Desault had a high opinion of the be- 
 nefit resulting from cupping. This was done 
 on, or near the part of the back, which had 
 been struck, and the number of scarifica 
 lions was proportioned to the strength of 
 the patient. The plan was sometimes re- 
 peated the same day, and for several days in 
 succession ; and when the patient could not 
 bear the loss of more blood, dry cupping 
 was employed, which in this country, would 
 be deemed less efficacious, than stimulating 
 liniments or blisters. In diseases of the 
 spine, Desault also preferred the moxa, to 
 caustic issues. 
 
 3. Retention of Urine from Distention of 
 the Bladder. — Desault thought that this form 
 of the disorder might very properly be call- 
 ed secondary , because it is invariably pre- 
 ceded and produced by a 'primary retention. 
 Of course, its remote causes are all those cir- 
 cumstances, which may bring on the other 
 forms of the complaint; but its immediate 
 cause depends altogether upon the weakness 
 and loss of irritability in the bladder, occa-* 
 sioned by the immoderate distention of its 
 coats. The disorder frequently occurs in 
 persons, who from bashfulness, indolence, 
 or intense occupation, neglect to make 
 water, when they first have the desire ; or 
 who cannot fora time empty the bladder, 
 in consequence of some temporary obstruc- 
 tion in the urethra Although the impedi- 
 ment to the escape of the urine no longer 
 exists, and the bladder is in other respects 
 sound, yet as this organ has been weakened 
 by the excessive distention of its coats, it 
 cannot now contract sufficiently to oblite- 
 rate the whole of its cavity, and expel the 
 last portion of urine. 
 
 The indication is simple : for there is not 
 
 here, as in other retentions of urine, another 
 disease to be remedied. The catheter, 
 when left in the bladder, generally proves 
 adequate to the restoration of the tone of 
 this viscus. I do. not conceive, however, 
 that English surgeons will place any confi- 
 dence in warm diuretics which were com- 
 mended by Desault, though they may join 
 him in the approval of a tonic plan of treat- 
 ment in general. When the urine flows 
 from the catheter in a rapid stream, and is 
 projected to some distance, and when it also 
 passes out between the catheter and the 
 urethra, it is a sign that the bladder has re- 
 gained its power of contraction, and that 
 it can empty itself, without the aid of the 
 instrument. In this circumstance, the ca- 
 theter is to be discontinued, and the patient; 
 may gradually resume his usual mode of 
 life. But When the urine passes through the 
 catheter only in a slow stream, the catheter 
 cannot be m>id aside, without the bladder 
 becoming distended again, and losing 
 whatever degree of tone it may have re- 
 covered. , 
 
 The time which the badder takes to re- 
 gain its power of contracting, varies consi- 
 derably in different cases. When the dis- 
 ease is accidental and sudden, it frequently 
 goes off in a few days. When it has come 
 on in a slow manner, it usually lasts about 
 six weeks. However, the cure is not to be 
 despaired of, if the paralytic affection of the 
 bladder should continue much longer. 
 Sabatier says that he has seen patients 
 wear a catheter upwards of ninety days, 
 and yet ultimately get completely well. 
 When there is reason for believing, that the 
 urine will come away of itself, the use ot 
 the catheter may be discontinued. When 
 he makes water very slowly; when he is 
 obliged to make frequent attempts: and 
 when he feels a sense of weight about the 
 neck of the bladder ; this organ lias not- 
 completeiy recovered its tone, and the em- 
 ployment of the catheter is still necessary. 
 When the patient could make water tolera- 
 bly well in the day, but not during.the rest 
 of the 24 hours, Sabatier has often seen be- 
 nefit arise from the catheter being worn 
 only in the night-time. 
 
 When three or four months elapse with- 
 out amendment, Sabatier states bis convic- 
 tion, that the tone of the bladder is lost for 
 ever. In this unfortunate case, the patient 
 should continue the flexible catheter, which 
 he should be taught to introduce himself, as 
 often as necessary. (See De la Mcdecine 
 Operatoirc. T. 2.) 
 
 Among the means deserving of trial, 
 when the contractile power of the bladder 
 does not return with the use of the catheter. 
 I have to mention the tincture of cantha- 
 rides ; blisters applied to the sacrum, and 
 kept open with the savine ointment ; and 
 cold washes to the hypogastric region. 
 
 In all cases, where the incapacity of the 
 bladder to contract, whether from weakness, 
 or paralysis, is the cause of retention, arid 
 where, though the bladder continues dis 
 tended, a certain quantity of urine feFmde’d 
 
URINE. RETENTION OF. 
 
 f> 72 
 
 daily, mistakes are particularly liable to be 
 made. Thus, besides the chance of the 
 disease being mistaken for an abscess, as 
 Colot states was not uncommon in his time, 
 other errors may take place. Sabatier was' 
 consulted about a woman, who had been 
 advised to repair to some distant mineral 
 waters, with the view of dispersing a tumour, 
 which remained after a difficult labour, and 
 was supposed to be in the uterus itself. 
 However, the swelling turned out to be 
 only a retention of urine, as it disappeared 
 as soon as the catheter was introduced. 
 Here no suspicion had been entertained pf 
 the real nature of the case, because the pa- 
 tient had voided her urine in a voluntary 
 manner, and in reasonable quantity, for the 
 live, or six weeks, during which the swelling 
 existed. 
 
 In a thesis by Murray, a case is recorded, 
 in which the swelling of the bladder was so 
 considerable, that it was mistaken for drop- 
 sy. The abdomen of a delicate woman 
 began to enlarge, without any particular 
 pain, and the cause was at first supposed to 
 be pregnancy. This idea however, was re- 
 moved by the enlargement increasing too 
 rapidly, attended with a great deal of ana- 
 sarca of the lower extremities, arms, and 
 face. The patient was now considered to 
 be dropsical ; and a surgeon was sent for to 
 tap the abdomen. The fluctuation in the 
 belly was quite evident. Fortunately, be- 
 fore the operation was done, atrial of diu- 
 retic medicines was determined upon ; and 
 while this plan was going on, the patient 
 was attacked with a total retention of urine 
 for three days ; a symptom, which she had 
 not previously suffered. It was now judged 
 prudent to pass a catheter, before the tro- 
 car was employed. Eighteen pints of urine 
 were drawn olF, and the swelling of the abdo- 
 men subsided. The next day, twelve more 
 pints of urine were drawn off. The anasarca, 
 which was entirely symptomatic, disappear- 
 ed. The application of cold water re-esta- 
 blished the tone of the bladder, so that when 
 three pints of urine had been drawn oft’ by 
 means of the catheter, the patient herself 
 could spontaneously expel three or four 
 others, with the aid of pressure on the hy- 
 pogastric region. 
 
 The retention of urine caused by weak- 
 ness, or paralysis of the bladder, and the 
 swelling above the pubes, may continue a 
 long while, without any inconvenience, ex- 
 cepting a sense of weight about the hypo- 
 gastric region, and frequent inclination to 
 make water Sabatier has known patients 
 labour under the complaint more than six 
 months. 
 
 4. Retention of Urine from Inflammation 
 of the Bladder . — According to Desault, 
 writers have ascribed different effects to an 
 inflammation of the neck of the bladder, 
 and to the same affection of the body of 
 this viscus. They have in fact regarded the 
 first case as a cause of retention ; and the 
 tyst as a cause of incontinence of urine. 
 An inflamed, highly sensible bladder, instead 
 of being weakened, has been supposed to 
 
 acquire an increase of energy, and to con- 
 tract with greater vigour. But if there had 
 not been retentions of urine, which could 
 be referred to nothing but inflammation o 
 the bladder, still analogy might have unde- 
 ceived us ; for an inflamed muscle is never 
 found disposed to contract, and if it be 
 compelled to act, its action is always fee- 
 ble. 
 
 Plethoric, bilious subjects, are said to be 
 particularly liable to this species of reten- 
 tion. It is also frequently occasioned by 
 the abuse of wine, or other spirituous liquors, 
 heating diuretic drinks, or the external, or 
 internal employment of lyttae. This form 
 of the complaint makes its attack suddenly, 
 and may be known by the frequent desire 
 to make water ; the acute .pain, in the re- 
 gion of the bladder; pain, which is increased 
 by the efforts to make water, and which 
 shoots up to the loins, and along the urethra 
 to the end of the glans ; by the frequency 
 and hardness of the pulse, and other symp- 
 toms of fever ; by the aggravation of the 
 pain, when the hypogastric region is press- 
 ed ; by the easy passage of a catheter into 
 the bladder; by the acute pain, which is 
 excited by the instrument touching the in 
 side of this organ ; and by the red, inflam 
 matory colour of (he urine. 
 
 In this case, the most prompt assistance 
 is necessary. The urine, which is a source 
 of additional irritation, should be drawn oft’. 
 The catheter should be introduced with 
 great gentleness, and merely far enough to 
 let its eye pass beyond the neck of the blad- 
 der. 
 
 The inflammation itself is to be counter- 
 acted by the most powerful antiphlogistic 
 remedies, large and repeated venesections ; 
 the application of leeches to the perineum 
 and hypogastric regions; the warm bath 
 glysters; fomentations on the abdomen; 
 and cold mucilaginous beverages. When 
 the inflammation extends to the other ab- 
 dominal viscera, attended with hiccough, 
 and vomiting, and continues beyond the 
 sixth day, the patient’s life is in extreme 
 danger. 
 
 5. Retention of Urine from Hernia of the 
 Bladder . — An inability to discharge the 
 urine is a symptom generally attending her- 
 nia of the bladder. But the weakness of 
 this organ is not always the sole cause of 
 the infirmity ; for the urethra itself makes 
 greater resistance than natural to the issue 
 of the urine. As the neck of the bladder is 
 drawn out of its right position by the por- 
 tion of this organ which actually protrudes, 
 the beginning of the urethra also undergoes 
 an elongation, and a change of its curvature, 
 by being pressed towards the symphysis of 
 the pubes, and its diameter is likewise di- 
 minished. ’fhe urine may also be detained 
 in the pouch composing the hernia, in con 
 sequence of the communication 'between 
 this and the rest of the bladder being too 
 small, or indirect, or perhaps from the her- 
 nial portion not being compressed by r tho 
 action of the abdominal muscle, or capable 
 of any contraction itself. However, the 
 
URINE, RETENTION OF. 
 
 oT4 
 
 rest of this organ, within the pelvis, can it- 
 self rarely expel the last drops of the urine. 
 Its complete contraction cannot be accom- 
 plished without great difficulty ; and in the 
 end it almost invariably follows, that the 
 urine is retained both in the protruded and 
 unprotruded portions. 
 
 When a retention, arising from a hernia 
 of the bladder, is complete, and occurs in 
 both parts of this organ, there is, in addition 
 to the symptoms common to other reten- 
 tions produced by weakness of the bladder, 
 a more or less considerable swelling in the 
 situation of the hernia. Ihe tumour is un- 
 attended with any change of the colour of 
 the skin ; is not very tender; and it presents 
 a feeling of fluctuation, sometimes obscure, 
 sometimes very distinct. When the swell- 
 ing is pressed upon, the desire to make wa- 
 ter is excited, or increased, and occasionally 
 a few. drops escape from the urethra. As 
 soon as the urine has been drawn off with 
 a catheter, and the patient is put in a pos- 
 ture in which the protruded portion of the 
 bladder is higher than the rest of this organ 
 within the pelvis, the tumour subsides, and 
 it is some time before it becomes large 
 again. 
 
 When the hernia is recent, and the pro- 
 truded portion of the bladder small and re- 
 ducible, the part ought to be returned and 
 kept up with a truss. When the part is ad- 
 herent and irreducible, the swelling ought 
 to be emptied by pressure, and supported 
 with a suspensory bandage. If the hernia 
 could in this manner be made gradually to 
 return into the abdominal ring again, a truss 
 would afterward be requisite. Proposals 
 have been made to endeavour to excite ad- 
 hesive inflammation in the cavity of the 
 protruded part of the bladder by compres- 
 sion, gradually increased, and thus oblite- 
 rate the pouch, in which the urine lodges. 
 Although Desault thought the attempt cau- 
 tiously made justifiable, be deemed the re- 
 sult very uncertain. 
 
 Were the retention of urine accompanied 
 with a strangulated state of the protruded 
 bladder, and the contents could not be 
 pressed into the other part of this organ, a 
 puncture of the swelling with a trocar has 
 been advised. But if there were an entero- 
 cele also present, as often happens, this ope- 
 ration would be attended with risk of inju- 
 ring the intestine. Hence, Desault prefer- 
 red opening the tumour by a careful irtci- 
 sion and he even approved of cuttingaway 
 the protruded cyst, if the communication 
 betwixt it and the rest of the bladder were 
 obliterated. For additional observations, I 
 refer to the 2d vol. of the First Lines of 
 Surgery, Ed. 4. 
 
 6. i Retention of Urine , caused by displace- 
 ments of the Viscera of the Pelvis. — The. dis- 
 placements, here signified, are. a retrover- 
 sion, prolapsus, and inversion of the uterus, 
 and a prolapsus of the vagina, or rectum. 
 When the intimate connexions of the blad- 
 der with the uterus and vagina in the fe- 
 male, and with the rectum in the male sub- 
 ject. are considered, it is obvious, that the 
 
 latter parts cannot be displaced, without 
 drawing along with them the bladder; and 
 that, in this state, whatever may be its con- 
 tractile power, it cannot contract so per- 
 fectly as to expel the whole of the urine. 
 To this deficient action of the bladder is 
 necessarily joined an increase of resistance 
 on the part of the urethra ; for, the begin- 
 ning of this canal being drawn by the blad- 
 der, changes its accustomed direction, and 
 such alteration cannot be made without the 
 sides of the tube being pressed together. 
 Thus the retroverted uterus draws the os 
 tinc.se above tiie pubes, and the posterior 
 part of the bladder is displaced,, which, in 
 its turn, draws along with it the commence- 
 ment of the urethra, pulls it upwards, and 
 increases the curvature, which this canal de- 
 scribes under the symphysis of the pubes, 
 against which it is forcibly applied. 
 
 In a prolapsus, or inversion of the womb, 
 vagina, and rectum, the back part of the 
 bladder, instead of being drawn upward and 
 forward, is pulled downward and backward, 
 and the curvature of the urethra is totally 
 altered. Below the pubes the bladder form ; 
 a convexity, and not a large concavity, as 
 in the instance of a retroversion of the 
 womb. This position of the parts should 
 alw r ays be recollected in passing the cathe 
 ter, as it shows what curvature and direc 
 lion should be given to the instrument, in 
 order to facilitate its introduction. 
 
 These retentions of urine are not often 
 followed by any very bad consequences. 
 It is generally sufficient to rectify the wrong 
 position of the bladder, and the commence - 
 ment of the urethra, by the reduction of the 
 displaced viscera, and a cure is then a mat- 
 ter of course, unless the excessive disten- 
 tion should have induced considerable 
 weakness of the bladder, in which event, 
 recourse must be had to the means previ- 
 ously recommended for this state of the 
 organ. The reduction of the viscera gene- 
 rally forms the first indication, and the 
 manner of accomplishing it is described un- 
 der the head of Uterus. When the reduc- 
 tion is not immediately practicable, or when 
 it fails to remove at once the retention of 
 urine, the catheter is to be used. Frequent- 
 ly, when the urine has been d'-awm off, the 
 reduction becomes more easy; but, some- 
 times, the altered direction of the urethra 
 renders the introduction of the catheter dif- 
 ficult ; nor will the instrument pass, unless 
 it be accommodated to the preternatural 
 state of that canal. Thus, in the retrover- 
 sion of the uterus, a catheter, very much 
 curved, answers better than one nearly 
 straight, like that commonly used for fe 
 males. 
 
 A curved catheter, says Desault, also an- 
 swers in cases of prolapsus uteri, he. ; but 
 with this difference, that, in a retroversion, 
 the concavity of the instrument must be 
 turned towards the pubes, but, in the pro- 
 lapsus, towards the anus. Sometimes the 
 catheter will not pass unless it be rotated, 
 as it were, and sometimes, when a silver 
 
URINE, RETENTION OF. 
 
 754 
 
 catheter cannot in any manner be intro- 
 duced, an elastic one will readily enter. 
 
 Were every effort to reduce the viscera, 
 and pass a catheter unavailing, and the ha- 
 zard of the bladder giving way urgent, the 
 surgeon would be called upon to let out the 
 urine with a trocar. (See Bladder , Punc- 
 ture of.) 
 
 7. Retention of Urine from Ike pressure of 
 the Uterus , or Vagina, on the Keck of the 
 Bladder. Besides the distention of the ute- 
 rus and vagina in pregnancy and parturition 
 (which cases I mean to pass over as be- 
 longing more properly to midwifery,) there 
 are other conditions of these organs which 
 may give rise to a retention of urine. I bus 
 It sometimes arises from the presence of 
 various kinds of tumours, or collections of 
 bu)od, or other fluid in the uterus, or ovary ; 
 or the distention of the vagina with the 
 menses, pessaries, &c. 
 
 In such cases, the retention of urine being 
 only symptomatic, the prognosis must de- 
 pend upon the nature of the cause, of which 
 the interruption of the urinary evacuation 
 is only an effect. The latter complaint is 
 here not very dangerous, because its incon- 
 venience may be obviated by means of the 
 catueter. But when the cause of the reten- 
 tion of urine is easily removed, and the 
 tone of the bladder is not impaired, even 
 the catheter is not always necessary, as 
 when the complaint is induced by a pessary, 
 or collection of blood in the vagina. In 
 other examples, in which the cause of the 
 difficulty of making water cannot be imme- 
 diately obviated, as in cases of tumours, the 
 catheter must be employed. In scirrhous 
 and cancerous diseases of the uterus, also, 
 this instrument is the only means of re- 
 lieving the retention of urine, as nature and 
 art can do little for the removal of the cause. 
 It ought to be known, however, that as 
 these last diseases increase, an incontinence 
 often succeeds to a retention of urine, in 
 consequence of ulceration taking place be - 
 tween the upper surface of the vagina and 
 the lower part of the bl&dder. 
 
 8. Retention of Urine from pressure of the 
 Rectum upon the Keck of the Bladder. Ab- 
 scesses in the vicinity of this intestine, he- 
 morrhoidal tumours, alvine concretions, and 
 the scirrho-contracted state of the gut, he. 
 may bring on a retention of the urine by 
 pressure on the neck of the bladder. I he 
 irritation, also, existing in these cases, may 
 tend to produce the complaint by exciting 
 a spasmodic contraction of the adjacent part 
 of the urethra. Here the relief of the re- 
 tention of the urine is to be effected by re- 
 moving. or curing the other disorder, which 
 operates as its cause, if this cannot be im- 
 mediately accomplished, the catheter must 
 be used, though, in several instances, it will 
 be better to, avoid even the irritation of the 
 catheter, and try the effects of bleeding, 
 the warm bath, and opium, which will fre- 
 quently enable the patient to make water. 
 The last means, however, will not suffice, 
 when the cause of the retention is likely to 
 continue a long time 
 
 9. Retention of Urine from Foreign bodies 
 in the Bladder. Without stopping to con- 
 sider the uncommon kinds of retention pro- 
 duced by carcinoma, fungous diseases, and 
 hydatids in the bladder, let us pass on to 
 the case, in which the urine is obstructed by 
 a calculus a t the neck of the bladder. Here 
 the patient, by altering his position, fre- 
 quently changes the situation of the stone, 
 and is immediately able to make water 
 again. However, this expedient will only 
 procure relief while the calculus is loose 
 in the cavity of the bladder; for, after it 
 has become fixed in the commencement of 
 the urethra, it must either be pushed back 
 with a catheter, taken hold of and brought 
 out with the urethra-forceps used by Sir A 
 Cooper, or extracted by a kind of operation 
 resembling the apparatus minor. See Li- 
 thotomy. 
 
 Many instances of various kinds of worms 
 in the bladder are upon record. On this 
 subject, an interesting paper w 7 as published 
 a few' years ago, by my friend Mr. Law- 
 rence, who met with an example, in which 
 an undescribed species of worms was abun- 
 dantly voided from the bladder. “ The ori- 
 gin of those animals (says Mr. Lawrence) 
 w hich inhabit the internal parts of living 
 bodies, is involved in much obscurity. Al- 
 though the intestinal w orms appear manifest- 
 ly , from their peculiar form, consistence, and 
 organs, to be particularly designed for those 
 situations in w hich they are found ; although 
 they have generative organs, and no similar 
 animals are know r n to exist out of living 
 bodies, yet it has been generally conceived, 
 thatthe germs, from which they spring, enter 
 from the mouth. The production of hyda- 
 tids in various parts of the body, cannot 
 however, be accounted for on such a suppo- 
 sition ; neither can w f e very easily conceive 
 that ova should enter from without into the 
 urinary organs.” The following facts, also 
 stated by Goeze (as Mr Lawrence observes,) 
 entirely overturn this opinion. Professor 
 Brendel, of Gottingen, found ascarides in 
 the rectum of an immature embryo. Blit 
 menbach discovered tmniae in the intestinal 
 canal of young dogs a few hours alter birth, 
 he. ( Vermch einer Katurgeschichte der Ein - 
 geiveidewurmer , p. 55.) The case, w 7 hich 
 Mr. Lawrence has recorded, exhibits an un- 
 questionable instance of peculiar and unde 
 scribed worms, voided from the urinary 
 passages. This gentleman says, that he 
 knows cf no other case, in which a distinct 
 species of w r orm has been clearly proved to 
 come from the bladder. Most of the cases 
 published were instances of common intes- 
 tinal round worms, which sometimes perfo- 
 rate the intestines and are discharged by 
 abscesses, or get into the bladder, after the 
 formation of adhesions betwixt this organ 
 and the bowels. In other instances, coag 
 ula of blood, mucus, or portions of the mu- 
 cous coat of the bladder, have been mista- 
 ken for worms ; and as Mr Lawrence fur- 
 ther observes, some of the descriptions can 
 apply only to larva* of insects. Two spe 
 cjmens of this last sort, he has seen himself. 
 
URINE* RETE 
 
 which were sent trorn the country as worms 
 voided from the bladder. (See Medico- 
 Chir. Trans, vol. 2, p. 382, fyc.) 
 
 In whatever way these animals get into 
 the bladder, a retention of urine may be 
 produced, either when they are numerous, 
 or when there is only one present, but large 
 enough to obstruct the vesical orifice ot the 
 urethra. In the very curious example rela- 
 ted by Mr. Lawrence, the passage of the 
 urine was obstructed, and the use of the ca- 
 theter continually necessary. 'Jhe oil of 
 turpentine was given internally, with some 
 appearance of benefit at first ; but, it after- 
 ward brought on febrile symptoms and ery- 
 sipelas, and its exhibition could not be kept 
 up. It was then injected into the bladder, 
 with an equal part of water. This . rather 
 accelerated the discharge of the worms ; but 
 they came away at times, whether the 
 injection was used or not, and as this means 
 produced the erysipelatous indisposition 
 again, it was left off. Olive oil was after- 
 ward injected ; the irritation after it was 
 less, and the fits of pain about the bladder 
 less violent. It was calculated that at the 
 time when Mr. Lawrence was writing the 
 particulars of the case, from 800 to 1000 
 worms had been discharged. For a detail 
 of the symptoms, and a particular descrip- 
 tion of the worms themselves, we must re- 
 fer to the above-mentioned publication. 
 
 According to the observations of Desault, 
 a retention of urine is frequently occasioned 
 by coagula of biood in the bladder. The 
 blood is said sometimes to come from the 
 kidneys, sometimes from the bladder, and 
 sometimes it even regurgitates from the ure- 
 thra. While fluid, it may be expelled with 
 the urine ; but, when coagulated, it is no 
 longer capable of being discharged. It is 
 the blood, w hich passes into the bladder, af- 
 ter w r ounds, or the operation of lithotomy, 
 that is most disposed to coagulate. If the 
 clots were too large to pass through a cathe- 
 ter, the best plan would be to inject into 
 the bladder lukewarm water, for the purpose 
 of loosening and dissolving them. 
 
 A retention of urine, has sometimes arisen 
 from the entrance of a piece of bougie into 
 the bladder. Even whole bougies, which 
 had not been properly secured, have been 
 knownto glide into the cavity of that organ. 
 
 As Desault observes, the urethra appears to 
 possess a kind of antiperistaltic action, by 
 which it tends to draw into the bladder 
 whatever substances it includes ; for, says 
 he, it is constantly noticed, that when these 
 substances are once within the urethra, if 
 they be not expelled by the urine, they al- 
 ways advance towards the bladder ; a cir- 
 cumstance which cannot be accounted for 
 by their weight. 
 
 The insinuation of these foreign bodies 
 into the bladder is a serious occurrence 
 both for the patient and surgeon. The for- 
 mer cannot avoid the consequence which 
 will sooner or later originate from the ex- 
 traneous substance, except bv submitting to 
 a dangerous and painful operation : the lat- 
 ter will be accused of being the author of 
 
 NT ION OF. S7 
 
 all the evil, and will find ii uitticull to excul 
 pate himself. In order to obviate the neces 
 sity of cutting into the bladder, in such cases, 
 Desault,. proposed the use of small spring 
 forceps, passed into the bladder through a 
 cannula, hut, although the instrument seem- 
 ed to answer on the dead subject, no instan 
 ces of its doing so on living patients are 
 on record. Were any instrument likely to 
 succeed, 1 think it would be the urethra- 
 forceps, shaped like a sound, employed by 
 Sir A. Cooper for the extraction of small 
 calcuii from the bladder. (See Lithotomy 
 and Urinary Calculi. 
 
 10 . Retention of urine from Inflammation 
 of the Urethra. In order to comprehend 
 the mechanism of this case, it is neces 
 sary to remember, that inflammation never 
 exists, without swelling, and that every 
 tumefaction of the lining of the urethra, 
 must necessarily lessen its diameter. In- 
 flammation of the urethra is most common- 
 ly produced by the external application, or 
 internal exhibition, of lyttae ; by gonorrhoea ; 
 the unskilful use of the catheter; the em- 
 ployment stimulating injections; bougies; 
 & c. Together with the lessening of the ca- 
 nal by the effect of swelling, there can also 
 be no doubt, that, in many of these instan 
 ces, a spasmodic contraction of the urethra 
 and neck of the bladder also contributes to 
 the retention of urine. Although Desault 
 believed that inflamed parts, endued with a 
 contractile power, were not disposed to con- 
 tract in that state, yet, it should be recollect- 
 ed, that even admitting this to be true, the 
 whole length of the urethra is seldom in- 
 flamed, and a part of it may therefore be af- 
 fected with a spasmodic, action, without the 
 theory espoused by Desault being at all im- 
 plicated. The effects of opium, tobacco, 
 and other antispasrnodics, often evinced in 
 immediately relieving these kinds of reten- 
 tion of urine, seem indeed to leave no doubt 
 respecting the existence of a sort of spasm 
 in the passage. Whatever may be the cause 
 of inflammation of the urethra, the diagno- 
 sis is free from all obscurity. Besides the 
 general symptoms of inflammation, the pa- 
 tient complains of a scalding sensation in 
 the passage : he experiences a great deal of 
 smarting, which is sometimes insupportable, 
 when he makes water; the penis becomes 
 ,in some degree swollen, and more tender; 
 and a very little pressure on the urethra 
 gives acute pain. In the mean time, the 
 stream of urine becomes lessened ; and, at 
 length, this fluid can only be voided in a 
 very narrow current, or only by drops, and 
 often not at all. 
 
 The disorder is to be treated on antiphlo - 
 gistic principles. Diluting, cooling, mucila- 
 ginous, beverages ; venesection ; leeches to 
 the perinauim ; the warm bath ; opium, 
 particularly in the torm of clysters, and fo- 
 mentations, are the means which usually 
 give relief. When inflammation exists in 
 the urethra, it is always desirable to avoid, 
 as long as possible, the employment of ca- 
 theters, which create irritation, and of course 
 increase the cause of the retention, It is 
 
URINE, RETENTION Oi 
 
 o7cl 
 
 particularly, in cases of this description, 
 ati<} in the retentions of urine, arising irom 
 strictures, that Mr. Earle has suggested the 
 use of tobacco in the form of clysters ; a 
 method, deserving adoption when the means 
 above enumerated are unavailing, and it is 
 preferable to the catheter, because it does 
 not cause any increase of irritation and in* 
 flammatioq in the urethra. (See Med. Chir. 
 Trans, vol. G,p- 82, fyc-) 
 
 11. Retention of Urine from Laceration of 
 the Urethra, The urethra is sometime' rup- 
 tured bv violent contusions on the perinaeum , 
 and the rough and unskiuul use of bougies and 
 catheters. The consequences usually are, 
 an extravasation of urine in the cellul r mem- 
 brane of the scrotum and penis ; a conside- 
 rable dark-coloured swelling ot these parts, 
 often followed by sloughing; and retention 
 of urine. The treatment consists in in re- 
 ducing an elastic gum catheter into the blad- 
 der. with as little delay as possible, and 
 keening it there until the breach in the canal 
 j 3 repaired. At the «ame time, the evils 
 threatened from the effusion of the urine are 
 to be lessened as much as possible, by ma- 
 king two or three free incisions in a depend- 
 ing part of the swelling, and the employ- 
 ment of fomentations, and antiphlogistic re- 
 medies. 
 
 12. Retention of Urine from Tumours silu- 
 ated in the Perinaeum, Scrotum, or Penis. A 
 retention of urine has been known to arise 
 from phlegmonous swellings and abscesses ; 
 extravasations of blood; and urinary tu- 
 mours and calculi formed in the perineum and 
 scrotum ; also from the pressure of a sarco- 
 cele ; hydrocele : a very large scrota! her- 
 nia : an aneurism of the corpus cavernosum ; 
 a ligature on the penis ; &c. 
 
 The radical cure of all such retentions oi 
 urine can only be accomplished by curing 
 the disease, on which they are dependent. 
 However, until the cause can be obviated, 
 the urine must be drawn off with a catheter. 
 Elastic gum-catheters usually enter more 
 eas iiy than those made of silver, as by their 
 flexibility they accommodate themselves bet- 
 ter lo any deviation of the urethra from its 
 ordinary direction. Desault particularly re- 
 commended a catheter of middling size to 
 be selected, and introduced, armed with its 
 stilet, until is stops in the canal ; when he 
 advised withdrawing the stilet for about an 
 inch in order to leave the beak of the instill- 
 ment quite free, so that it may follow the 
 curve of the urethra. Then the tube and the 
 stilet are to be pushed further into the canal, 
 care being taken, however, to keep the stilet 
 drawn back some distance irom the extremi- 
 ty of the instrument. By these precautions, 
 says Desault, the catheter may always be 
 pot into the bladder. Should the introduc- 
 tion prove neither painful nor difficult, De- 
 sault thought it belter not to annoy the pa- 
 tient by making him continually wear the 
 
 instrument 
 
 13 Retention of Uyfne from Disease of the 
 Prostate Gland. As a great deal lias been 
 mu} concerning this case in aforegoing arti- 
 
 cle, (see Prostate Gland,) 1 shall not here tie 
 tain the reader long upon the subject. 
 
 When the swelling of the prostate gland 
 is of an inflammatory kind, the retention of f 
 urine makes its appearance with the same 
 kind of symptoms as attend inflammation 
 about the neck of the bladder. 
 
 Here similar treatment to that commonly 
 adopted for the retention of urine produced 
 in the latter ca-se, is indicated ; particularly 
 bleeding, fomentations, the warm bath open- 
 ing medicines, anodyne clysters, the tinctura 
 ferri muriati, and in very obstinate urgent 
 cases, an enema of lobacco. If these means 
 fail, the surgeon may gently endeavour to 
 introduce an elastic gum catheter. 
 
 The symptoms of the retention of urine, 
 caused by chronic enlargement of the pros- 
 tate gland, and the reason of the impediment 
 to the discharge of that fluid in such a case, 
 are explained in another part of this work. 
 (See p. 378, fyc. Vol. 2.) From the remarks 
 there introduced, it appears, that when the 
 regular evacuation of the urine begins to be 
 impeded, the catheter becomes indispen- 
 sable, though the surgeon will often be 
 foiled in his endeavour to draw off the urine 
 with it unless he be duly acquainted with 
 the morbid changes produced in the parts. 
 And, as Sabatier long ago very correctly- 
 observed, the urine may not be discharged 
 though the instrument enter a considerable 
 way, either because its beak becomes en- 
 tangled in the prostate gland, or between a 
 swollen portion of ilvs gland and the neck of 
 the bladder . and does not reach the urine. 
 Hence Sabatier recommended the employ- 
 ment of a catheter with a very long beak, 
 which should also be bent considerably up- 
 wards. When, however, all efforts to pass 
 a catheter fail, the only resources are to 
 force a passage with a conical catheter, as 
 explained in Vol. 1, or to puncture the blad- 
 der above the pubes. (See Bladder , Punc- 
 ture of.) In this case, the operation should 
 never be done through the perinamm or 
 rectum, as the great size which the diseased 
 prostate gland 'sometimes attains, would be 
 an obstacle to making a puncture in either 
 of these situations. Puncturing the bladder, 
 however, is only a temporary means of re- 
 lief; and until a catheter can be passed 
 quite into the bladder, the cannula of the 
 trocar should not be withdrawn. 
 
 The objections to leaving the cannula in 
 the wound any considerable time, are the 
 irritation of the extraneous body ; the fear 
 of calculous incrustations lorming both on 
 the outside and inside of the cannula ; and 
 the hazard of not being able to find the 
 track into the bladder again, if the instru- 
 ment were taken out for the purpose ol 
 being cleaned. However, Sabatier approves 
 of the practice under the foregoing circum- 
 stances. And Colot adduces two instances 
 in which it proved very serviceable Sa- 
 batier also refers to another example of simi- 
 lar success, related in the thesis by Murray. 
 When Dr. Murray saw the patient, the can- 
 nula had been worn more than a year, lhc 
 patient was sixty years of age. and enjoyed 
 
URINE, RETENTION OF. 
 
 677 
 
 very good health. He was in the habit of 
 taking a stopper out of the cannula every 
 four hours. The wound had healed very 
 well all round the tube, and was quite free 
 from redness. ( Sabatier , Medecine Opkra- 
 toire, T. 2, p. 140.) For further observa- 
 tions, see Catheter and Prostate Gland. 
 
 14. Of the Retention of Urine produced 
 hy Strictures in the Urethra. From the ac- 
 count, which is given of strictures in ano- 
 ther part of this Dictionary, (see Urethra , 
 Strictures of,\ it appears that almost every 
 stricture, bad as it may be, is capable of 
 being rendered still worse, and the morbid 
 part of the urethra more impervious by a 
 spasmodic affection. Going out of a warm 
 into a cold situation, drinking, and other 
 kinds of intemperance, will often bring on 
 an irritable state of the canal, attended with 
 a spasmodic action of the strictured part, 
 an increased difficulty of voiding the urine, 
 and even a total retention of this fluid. 
 The patient makes repeated efforts to re- 
 lieve himself ; but hardly a drop of urine is 
 discharged. In the meanwhile the bladder 
 becomes filled, and ascends above the 
 pubes ; the abdomen grows tense and pain- 
 ful ; fever comes on; the countenance 
 looks red ; the brain becomes affected ; and 
 circumstances assume an extremely urgent 
 appearance. 
 
 In this case, antiphlogistic means should 
 be adopted without delay. The patient 
 ought to be bled, if nothing in his constitu- 
 tion and age prohibit this evacuation, which 
 it may even be proper to repeat. He should 
 also be put into the warm bath, and fomen- 
 tations should be continually applied to the 
 hypogastric region. Slightly diuretic beve- 
 rages may be prescribed, and leeches put 
 on the perinaeum. The principal means, 
 however, from which the greatest benefit 
 may be expected, is a liberal dose of the 
 tinctura opii, together with an anodyne 
 glyster. This is also another example, for 
 which Mr. Earle has particularly recom- 
 mended the exhibition of tobacco in the 
 form of a clyster ; and he has related a 
 case in illustration of the efficacy of the 
 plan. (See Medico- Chir. Trans. Vol. 6, p. 
 88.) The tinctura ferri muriati, which, ac- 
 cording to Mr. Cline, has a specific effect in 
 overcoming spasm of the urethra, seems 
 also worthy of trial. Indeed it should al- 
 ways be tried before tobacco, which being 
 sometimes violent in its effects, ought per- 
 haps to be the last resource in the way of 
 medicines. When such measures fail in 
 enabling the patient to empty his bladder, 
 and this viscus is becoming more and more 
 distended, an immediate attempt should be 
 made to introduce a small flexible elastic 
 gum-catheter through the stricture or stric- 
 tures into the bladder, which object may 
 be frequently accomplished, when due care, 
 perseverance, and geritleness, are not ne- 
 glected. 
 
 Sometimes when a small flexible catheter 
 cannot be introduced, a fine bougie admits 
 of being passed into the bladder, and on 
 Vol, II ' 73 
 
 being withdrawn, the urine follows, and is 
 discharged. 
 
 VVhen all the preceding plans prove un- 
 availing, and the danger arising from the 
 retention of urine continues to increase, 
 either the stricture must be forced with the 
 conical sound, an incision practised behind 
 the obstruction, or the bladder punctured 
 Ihe cannula of the trocar should then be 
 left in the wound till the strictures are 
 either cured, or at least till the urine re- 
 sumes its natural course. 
 
 15. Retention of Urine from the Lodgment 
 of Foreign Bodies in the Urethra. That such 
 accident must obstruct the discharge of 
 urine is too plain to heed any particular ex- 
 planation. Calculi are the most common 
 substances which bring on this kind of case ; 
 but articles, introduced into the urethra 
 from without, such as bougies, large pins, 
 &c. are occasionally lodged in the passage ; 
 and I opce extracted from a man’s urethra 
 a long black pin, with which he had been 
 examining the passage. The head of it was 
 towards the perinajuin, and the point about 
 two inches from the orifice of the glans. 1 
 passed the point through the lower surface 
 of the urethra, and then taking hold of it, 
 drew it further out, turned the head towards 
 Ihe glans, from the orifice of which it was 
 then easily removed. When substances 
 like calculi lodge, oily injections are some- 
 times tried with the view of rendering the 
 passage more slippery ; and occasionally 
 the dilatation of the canal with bougies or 
 catheters, followed by a very forcible ex- 
 pulsion of the urine, has answered. The 
 ancients sometimes tried the effect of suc- 
 tion. When the foreign body is closely 
 embraced by the urethra, and it cannot be 
 pushed forward with the fingers, Desault re- 
 commends endeavouring to extract it with 
 the forceps, invented for the purpose by 
 Mr. Hunter, and wffiich are contained in a 
 cannula ; or the urethra forceps, spoken of 
 in the articles Lithotomy and Urinary Calculi 
 might be employed. When, however, the 
 foreign body is too large to be taken out its 
 this manner, it must be extracted by an in- 
 cision. If an elastic catheter be now kept 
 in the urethra, so as to prevent the urine 
 from coming into contact with the cut part, 
 the wound will heal very well. Some time 
 ago there was published a case of calculus 
 in the urethra, attended with dysury, where 
 almost instantaneous relief was obtained 
 from the exhibition of a tobacco clyster. 
 The patient soon felt a strong desire to void 
 his urine; and “ upon making the attempt, 
 a large calculus came rolling along the 
 urethra, with complete relief of all his com- 
 plaints.” (See Edinb. Med. and Surg. Jour- 
 nal. Vol. 12, p. 373.) 
 
 Fr. M. Colot, Trait6 de V Operation de la 
 Taille ; avec dts Obs. sur la Formation de la 
 Pierre , et les Suppressions de V Urine, fyc. 
 12 mo. Paris, 1727- Sabatier, De la M6de- 
 cine OpAratoire, T. 2. C. B. Trye, Remarks 
 on Morbid Retentions of Urine, 2d Ed. <vo. 
 Gloucester, 1784. Hey’s Practical Observa- 
 tions in Surgery. Schreger Chirurgische Ver* 
 
07S ! UTERUS, INVERSION 01 
 
 s uche, p. 187, tyc. der Ischuria Calculosa , 
 8vo. JV urnberg, 1811. Desault's Parisian 
 Chirurgical Journal. S. T. Summering, Ab- 
 handlung iiber die schnell und larigsam todl- 
 lichen Kranhheiten der Harnblase und Ham - 
 rohre hey Mamurn in hohen Alter. 4td. 
 Frank. 1809. Richter , Anfangsrunde der 
 JVundarzneykunst , B. 6, p. 210, fyc. (Envies 
 Chir. de Desault par Bichat, T. 3. Desault 
 et Chop art, Trait6 des Maladies des Voies 
 Urinaires, 8 vo. 1796. JVauche, JVouvelles lie- 
 cherches sur les Retentions d' Urine par Retre- 
 cissement de VUretre, el par Paralysie de la 
 Vessie, tyc. 8 vo. Paris, 1806. Home's Prac- 
 tical Observations »n the Treatment of Stric- 
 tures, tyc. 3 vols. and on Diseases of the Pros- 
 tate Gland, 2 vols. 8ro. Land. 1811 — 1818. 
 H. Earle, in Medico- Chir. Trans. Vol. 6, p. 
 82, fyc. 
 
 UTERUS, INVERSION OF. This case 
 may either be complete or incomplete. 
 When it is incomplete, only the fundus of 
 the uterus passes through the os tincse. 
 When the inversion is complete, 4he uterus 
 becomes entirely turned inside out, passing 
 through the opening in its cervix, dragging 
 along with it a part of the vagina, and de- 
 scending more or less far down, sometimes 
 even between the patient’s thighs. 
 
 The inversion of the uterus mostly arises 
 from the manner in which the placenta is 
 extracted after delivery. Immediately after 
 parturition, the uterus is not yet contracted, 
 and its cervix is in a widened state. When 
 things are thus disposed, the uterus may 
 easily follow the after-birth, which is attach- 
 ed to it, and thus become inverted. The 
 event is particularly liable to happen. 1st, 
 When a premature attempt is made to ex- 
 tract the placenta. 2dly, When the funis is 
 pulled outward, without due care being ta- 
 ken to support the uterus with the fingers of 
 the left band. 3dly, When the operator 
 draws out the after birth too roughly and 
 violently. Though the placenta is some- 
 times so adherent that its extraction is diffi- 
 cult, and a risk must be encountered of 
 dragging down the uterus with it, this dis- 
 agreeable accident may generally be avoided 
 by performing the necessary separation of 
 the parts with the fingers introduced into 
 the cavity of the uterus. 
 
 The inversion, following delivery, does 
 not always proceed from unskilfulness ; but 
 sometimes happens, notwithstanding every 
 precaution, either because the patients 
 themselves make too violent efforts, or be- 
 cause the uterus is enlarged and heavy ; or 
 else in consequence of some predisposition, 
 some unusual laxity of the organ, which can 
 neither be foreseen nor prevented. Ruysch 
 saw an inversion of the uterus take place, 
 after the expulsion of the placenta, although 
 delivery had occurred in the most favour- 
 able way. 
 
 Mr. Windsor believes, that where the 
 Vii crus and vagina are in a relaxed state, 
 and the female has been subject to prolapsus 
 uteri, there is a greater disposition to the 
 occurrence of inversion, at the lime »*f la- 
 
 bour, than when such condition of the part? 
 does not exist. (Med. Chir. Trans. Vol. 10, 
 
 p. 360.) 
 
 A tendency to the accident is very com 
 mon in women who have once been afflict- 
 ed with it. Amaud mentions a woman, 
 who had an inversion of the uterus after her 
 first delivery, but the part was reduced. 
 She was attended by Amand again in her 
 next confinement ; and another inversion 
 of the uterus, quite as bad as the first, would 
 have happened, had not he, on perceiving 
 the disposition to the accident,* introduced 
 his finger into the cavity of the uterus, and 
 separated the placenta from its attachments, 
 before making any attempt to extract it. 
 
 Besides causes, connected with parturi- 
 tion, there are others of a different nature 
 Ruysch, Mauriceau and Lamotte, supposed 
 an inversion of the uterus could only happen 
 at the time when the placenta was extract- 
 ed, or a little while afterward. The acci 
 dent seemed to them impossible at any 
 other period, both on account of the thick- 
 ness of the uterus, and the smallness of the 
 os tincae. However, many facts prove that 
 the case may also depend on internal 
 causes, and affect women who have never 
 had children, as well as others who have 
 had them. Thus polypi of the uterus may 
 bring on inversion of the part. As their 
 pedicle is attached to the fundus of the 
 uterus, they may easily drag it downward 
 when its texture is lax and soft, particular- 
 ly as the operation of their weight is conti- 
 nual. (See Denman s Plates of a Polypus 
 with an Inversion of the Uterus. Fol. 1801.) 
 Uterine hemorrhages may also be conducive 
 to the accident, both because they relax the 
 texture of the uterus, and because they are 
 usually attend'd with acute pain, which 
 makes the diaphragm and abdominal mus- 
 cles act upon the uterus with all then- 
 power. 
 
 Levret speaks of a case of inversion of 
 the uterus, where the displacement was not 
 noticed until five years after delivery. In 
 this example, it is conjectured that the very 
 gradual and slow formation of the disease 
 must have been the reason of its not having 
 attracted earlier attention. (Did. des Sci- 
 ences Mid T. 23, p. 288. Also Baudelocqve, 
 in Brogniard, Bulletin des Sciences, 2, JV. 1.) 
 
 When an inversion of the uterus takes 
 place after delivery, there are certain symp- 
 toms by which it may easily be known 
 The uterus, in its natural situation, thicken- 
 ed and swelled as it is at this period, pre- 
 sents itself in the hypogastric region in the 
 form of a round circumscribed tumour ; but 
 when it has fallen downward, and become 
 inverted, a vacancy is felt in the situation 
 which it ought to' occupy. When the in- 
 version is incomplete, an examination with 
 the fingers detects in the vagina a tumour, 
 shapen like the segment of a sphere, having 
 a smooth surface, and being surrounded 
 with the cervix uteri, as with a kind of col- 
 lar, round which the finger may easily be 
 passed, either between it and the utems, or 
 between it and the vagina When the in- 
 
UTERUS, INVERSION OF 
 
 version is complete, which case is more 
 rare than the preceding, a tfcmour may be 
 felt in the vagina, from which it sometimes 
 even protrudes, apt to bleed, of an irregu- 
 larly round shape, hanging by a neck, the 
 lower part of which is surrounded by the 
 above circular, thick, fles.hy substance, con- 
 sisting of the os uteri itself. The slightest 
 touch makes the swelling bleed. The part 
 has a red colour, which, however, generally 
 diminishes in proportion to the duration of 
 the displacement. In lime, indeed, its sur- 
 face becomes less sensible to external im- 
 pressions, and only bleeds at the menstrual 
 periods, the blood oozing from every point 
 of the swelling, and not issuing from a sin- 
 gle aperture at the lower part of the tumour, 
 as in cases of prolapsus uteri. 
 
 In the incomplete inversion, patients feel 
 acute pain in the groins and kidneys, an 
 oppressive sense of heaviness in the hypo- 
 gastric region, and a tenesmus, which, com- 
 pelling them to make violent efforts, forces 
 the uterus further down, and'sometimes pro 
 duces a total inversion of it. Besides these 
 symptoms, more or less copious hemor- 
 rhages also occur. When the inversion is 
 complete, the pain is more acute, the loss 
 of blood more considerable, and the patient 
 often affected with peculiar weakness, fol- 
 lowed by cold sweats, convulsions, and de- 
 lirium. 
 
 In both forms of the disease, if the reduc- 
 tion be not almost immediately effected, 
 fatal consequences frequently ensue, either 
 very soon after the accident, from the vio- 
 lence of the hemorrhage, or at a more or less 
 remote period, partly from repeated losses 
 of blood, and partly from the constitutional 
 irritation and disturbance incessantly kept 
 up. 
 
 Happily, as Mr. Windsor observes, the 
 accident admits of remedy, if an intelli- 
 gent person be present to replace the uterus; 
 for if this be done immediately, and the 
 hand of the accoucheur be retained in the 
 cavity of this organ, until it has contracted, 
 and the patient afterward confined to the 
 recumbent posture, she will generally do 
 well. An unsettled point appears to be,' 
 whether the placenta, if still remaining, 
 should be extracted before, or after the re- 
 duction. Mr. Windsor,. w ho appears inclin- 
 ed to prefer the latter method, refers to two 
 examples, in which each plan was followed 
 by a recovery. (See Med Chir. Trans. Vol. 
 10 , p. 360 .) 
 
 And, in all cases, as the same author re- 
 marks, th^ accoucheur, after the expulsion 
 of the placenta, should assure himself by 
 manual examination, that the os internum is 
 free, while an endeavour is made to feel the 
 uterus with the hand placed upon the abdo- 
 men. “In consequence of the neglect of 
 this practice (says Mr. Windsor) it is to be 
 feared, that many lives have been lost ; the 
 true cause of the succeeding hemorrhage 
 not being ascertained till too late, as hap- 
 pened in the fatal case that occurred to a mid- 
 wife here (Manchester) last winter.” Some 
 women perish at once, or within a few 
 
 hours, and, when they live longer, the re- 
 duction is exceedingly difficult, because the 
 uterus and its cervix are becoming more 
 and more contracted. 
 
 In the reduction, Sabatier regards the in- 
 terposition of linen, between the hands and 
 the uterus, as unnecessary and even disad- 
 vantageous, because it prevents the practi- 
 tioner from having the assistance of a correct 
 feel of the part. The trial should be conti- 
 nued as long as the patient’s strength will 
 allow. However, if the tumour were in an 
 inflamed state, it would be prudent to put 
 the patient in the warm bath, use emollient 
 applications, and exhibit anodyne and laxa- 
 tive medicines, &ic. 
 
 When the reduction cannot be accom- 
 plished, many die, while others survive, 
 subject to an oppressive sensfe of weight, 
 and frequent hemorrhages, which bring on 
 great emaciation. Sabatier attended two 
 patients, who bad an inversion of the ute- 
 rus, six months, and yet they were able to 
 go about their family affairs. The same 
 author had heard of other women, who 
 had been afflicted with an inversion of dhe 
 uterus several years. 
 
 If the reduction cannot be performed, 
 and the patient survive the immediate ef- 
 fects of the injury, “some degree of in- 
 flammatory symptoms, accompanied with 
 fever, ensues. The abdomen becomes full, 
 tender to the touch, and, at its lower part, 
 sometimes rather hard There is costiveness 
 of the bowels, and sometimes retention of 
 urine, requiring for . a time the use of the 
 catheter. By the use of fomentations, 'ene- 
 mata, laxatives, and an antiphlogistic regi- 
 men. the symptoms abate, the power of 
 expelling the urine, especially if the uterus 
 is first raised a little in the vagina, is regain- 
 ed, and the patient gradually recovers the 
 full power of this function. Afterward she 
 becomes able to walk about, suckles her 
 infant, and perhaps enjoys apparently even 
 a tolerable state of health ; yet, the sangui- 
 neous discharges generally after a time,” 
 return profusely, and her pale countenance, 
 and emaciated appearance indicate the 
 greatest debility. 
 
 “ About the time, when she relinquishes 
 the office of suckling, the menses return 
 more regularly, the discharges of blood are 
 very considerable in quantity, or of long 
 duration ; the mucous discharges are gene- 
 rally copious at other times ; and the con- 
 stitution begins to sink under the reiterated 
 losses it sustains. The pulse becomes fre- 
 quent, the appetite is impaired, a cough, 
 with hectic symptoms sometimes occurs, 
 and the patient is quite unable to pursue her 
 usual domestic duties. In this state pallia- 
 tive means, as the use of astringent add 
 other remedies, become inadequate to check 
 the exhausted progress of the complaint, 
 and the unfortunate sufferer must soon 
 perish, unless some decisive means be devi- 
 sed for her relief. In this painful extremity, 
 the extirpation of the uterus itself has been 
 proposed - as thcjjjatost efficient means of re- 
 lief. a«nil^^||^nle as the operation at first 
 
UTERUS, INVERSION OF. 
 
 , ' 
 
 view seems, it is known to have been al- 
 ready performed with success.” Windsor , 
 in Med. Chir. Trans. VoL 10, p. 36 i — 63.) 
 
 One of the most afflicting consequences 
 of an inversion of the uterus, is so consi- 
 derable an inflammation of the part, as to 
 induce a danger of its mortifying. In this 
 circumstance, the extirpation of the uterus 
 lias been also suggested, and even practised ; 
 an operation that has had but little success, 
 the majority of patients on whom it has 
 been practised under such circumstances 
 having died. 
 
 The practice, of extirpating the inverted 
 uterus, through apprehension of the part 
 mortifying, cannot be too strongly repro- 
 bated ; for unless mortification das really 
 happened, the uterus may possibly be 
 brought into a state again, in which the 
 inconveniences arising from its inversion 
 would be very supportable, and the opera- 
 tion altogether avoided. Even supposing 
 mortification were to take place, the indica- 
 tion would be to appease the bad symptoms, 
 and promote the separation of the sloughs 
 by suitable applications, without doing any 
 injury to the living parts. One example, in 
 which the latter practice was successfully 
 adopted, is recorded by Rousset. That the 
 extirpation of the uterus, when this organ is 
 completely or incompletely inverted, totally 
 irreducible, and attended with the suffer- 
 ings and reduced health, so well described 
 by Mr. Windsor, may sometimes be advisea- 
 ble, cannot now be doubted. The unequi- 
 vocal examples on record of the removal of 
 the cancerous uterus by Osiander,Dupuy4reii, 
 Langenbeck, and others, and the cases, 
 published by Mr. Newnham and Mr. Wind- 
 sor, wdiere the inverted and irreducible 
 uterus urns successfully extirpated, furnish 
 sufficient evidence in favour of the practice 
 without referring to numerous other cases 
 reported on older authorities, the correct- 
 ness of some of which may be question- 
 able. 
 
 In fact, polypi, growing from the uterus, 
 frequently attain so considerable a size, that 
 they protrude out of the vagina, and are oc- 
 casionally mistaken for the uterus itself. 
 The surgeon extirpates the tumour with a li- 
 gature ; the operation does not undeceive 
 him about the nature of the part ; his patient 
 has a favourable recovery ; and the case is 
 published as an instance of the successful 
 extirpation of the uterus itself. 
 
 Although it is easy to distinguish the in- 
 version of the uterus, which happens soon 
 after delivery, it is not so to make out the 
 nature of such cases, as happen in other 
 circumstances, notwithstandingthe presence 
 of the same kind of symptoms. As cases of 
 the latter kind are uncommon, apd, conse- 
 quently, not expected, mistakes are the 
 more liable to be made. A polypus has 
 often been mistaken for an inversion of the 
 uterus, but, it should be recollected, that 
 the upper part of a polypus is always nar- 
 row ; and the tumour, which is not very 
 sensible, is irreducible ; wEereas^the uterus, 
 in a state of irtcomplet^j^Wl^, forms 
 
 a semi-spherical swelling, sometimes a little 
 oblong, but always broader above than be 
 low. It is very sensible, and may generally 
 be reduced. And, when the itiversion is 
 complete, the tumour has a greater resem- 
 blance to a polypus, inasmuch as it seems 
 to have a pedicle, but the impossibility of in- 
 troducing a probe far at the circumference 
 of such pedicle, as can be done in cases of 
 polypi, will generally serve at once as a 
 criterion of the nature ot the disease. 
 
 The greatest obscurity in the diagnosis is 
 said to prevail when the inversion is partial 
 and chronic, because the os uteri tl^en encir- 
 cles the summit of the tumour, justasit does 
 a polypus, and, in both cases, the finger will 
 pass all round between the parts. (See 
 Newnham' s Essay on Inversio Uteri, with a 
 History of the successful Extirpation of that 
 Organ , p. 82, 8 vo. Load. 1818.) However, 
 as I do not believe with this gentleman, that 
 the neck of the polypus is frequently as large, 
 and sometimes larger, than its inferior por- 
 tion, 1 should yet expect, that the difference 
 in the form of the two swellings, perceptible 
 on manual examination, would here be an 
 important criterion. In general, also, the 
 fact, that inversion of the uterus first hap- 
 pens, at or soon after delivery, is a conside- 
 ration, that would tend to a right discrimi- 
 nation of the cases, inasmuch as the first 
 protrusion of a polypus directly after delive- 
 ry, is rare, and, when it does happen, under 
 these circumstances, is probably always com- 
 plete, and not partial. 
 
 Reduction is the only plan, whether the 
 case has arisen from the w eight of a polypus 
 or trorn uterine hemorrhage. However, this 
 proceeding is generally useless, when the 
 disease originates from obesity. In the 
 latter case, as the cause still continues in 
 full force, the uterus is soon displaced again, 
 and a pessary is the only means to which 
 the patient can resort. 
 
 Having delivered many additional obser- 
 vations on the subject of inversion of the 
 womb, in the 2d vol. of the First Lines of 
 Surgery, Ed. 4, I shall here conclude with 
 referring to some works, in which the 
 reader will find valuable instruction on the 
 subject. F. B. Wachter , de Prolapsu et 
 Inversione Uteri, Tlalae, 1745. Act. JVaturw 
 Cur. Vol. 6, Obs. 107,‘ uterus feliciter extir - 
 patus. Nauche , des Maladies de i Uterus, 8vo. 
 Paris, 1816. Osiander, Ncuc Denkwitrdig- 
 keiten, 1 B. p. 307. Sabatier. Midecine 
 Op6raloire, T. 2. Diet, des Sciences Med. 
 T. 23, p. 287. W. Newnham , on the Symp- 
 toms, Causes, and Treatment of Inversio 
 Uteri , with a History of the successful Extir- 
 pation of that Organ , during the Chronic 
 Stage of the Disease, 8 vo Land. 1818. J. 
 Windsor, Obs. on Inversion of the Uterus, with 
 a Case of successful Extirpation of that Organ, 
 Med. Chir. Trans. Vol 10, p. 358. §c. Den- 
 man's Plates of a Polypus, with an Inversion 
 of the Uterus', 1801. Dr. Bail lie's Series of 
 Engravings, tyc. Fuse. 9, Tab. 5. C leghorn 
 in J\1cd. Communications , Vol. 2 ; a, chronif 
 
UTERUS, PROLAPSUS OF 
 
 581 
 
 case. E. B. Herzog de Inversionc Uteri, 4 to. When, in the course of time, a prolapsus 
 
 Wirceb. 1817. uteri changes from the incomplete to the 
 
 UTERUS, POLYPI OF. (Sc e Polypus.) complete state, all the inconveniences de 
 UTERUS, PROLAPSUS OF. The pending upon the pressure of the part upon 
 womb, situated in the upper and middle the rectum and bladder subside : that is to 
 part of the pelvis, is but imperfectly se- say, the feces and urine are now freely void 
 cured in its natural place by means of its ed. But, on the other hand, the symptoms 
 broad and round ligaments. Hence it some- arising from the stretching of the peritonae 
 times descends into the lesser cavity of the um become considerably worse. The ute- 
 pelvis, so as to pass more or less down the rus dra^s down with it the vagina, which 
 vagina, or even protrude beyond the labia, becomes doubled on itself, and a part of the 
 The first case is the incomplete ; the second, bladder, connected with the upper part of 
 the complete prolapsus uteri. the latter tube, is also drawn down. Some 
 
 In the first form of the disease, where the of the abdominal viscera may even fall into 
 
 uterus has not passed down so low as to 
 protrude externally, some of the complaints 
 which the patient experiences depend upon 
 the pressure of the d isplaced viscusupon the 
 parts unaccustomed to it, particularly the 
 bladder and rectum ; while other inconve- 
 niences arise from the tension of the liga- 
 ments, destined to retain the organ in its 
 natural position. These last grievances are 
 chiefly a sense of heaviness in the pelvis, 
 and a dragging pain in the loins ; symptoms 
 which are aggravated when the patient sits 
 up, or walks about ; but diminish when she 
 remains in bed, though as the disease, when 
 neglected, scarcely ever fails to grow worse, 
 they rarely subside altogether. However, 
 such amendment actually sometimes hap- 
 pens in consequence of the parts becoming 
 gradually habituated to their change of si- 
 tuation. When the disease comes on with 
 great suddenness, the symptoms are re- 
 marked to be much more severe than when 
 it takes place slowly. In the first case, long- 
 continued syncope, pain over the whole 
 abdomen, tenesmus, uterine hemorrhage, in- 
 flammation of the peritonseum, and severe 
 febrile symptoms may be excited. 
 
 With regard to the effects, caused by the 
 pressure of the tumour on the bladder and 
 rectum, they consist of more or less diffi- 
 culty in voiding the urine and feces. The 
 dysury and constipation increase in propor- 
 tion as the patient continues in an upright 
 posture, and the uterus descends nearer to 
 the inferior orifice of the vagina. Some- 
 times the irritation brings on a consi- 
 derable mucous discharge, which, when the 
 patient suffers little other inconvenience 
 from the prolapsus, is apt to be mistaken 
 for fluor albus, or gonorrhoea 
 
 A woman may become pregnant, not- 
 withstanding an incomplete prolapsus of the 
 womb. The displacement may even take 
 place at a more or less advanced period of 
 gestation, {Portal des Accouchemens) while, 
 in other still more uncommon instances, the 
 prolapsus has been remarked to disappear 
 when the period of labour drew near. Cases 
 exemplifying both these facts, are related 
 by Loder, ( Journ . fiir die Chir. B. 2, p. 13,) 
 by Saviard, Portal, (Mem. de VAcad. de 
 Chir. T. 3,) in the Journ. de Medecine T. 
 45 , and by Chopart. (Traite des Maladies 
 des Voies Urinaires.) A prolapsus uteri may 
 also happen during parturition. {Garin, 
 Journ. de Med. continue, T. 4, p. 265 ; Du- 
 creux, Mem. de l’ Acad, de Chir. T. 8, p. 393.) 
 
 the cul-de-sac, formed by the vagina, and 
 considerably increase the size of the tu- 
 mour. The swelling, protruding between 
 the thighs, is of an oblong, nearly cylindri- 
 cal form, and terminates below in a narrow 
 extremity, in which a transverse opening, 
 the os tinea?, may be discerned, from which 
 the menses are discharged at the periods 
 prescribed by nature. However, the cylin- 
 drical shape of the tumour may lead to mis- 
 takes, for the vagina, being doubled on 
 itself, and exposed to the effects of the air, 
 sometimes looks like skin. Hence women, 
 thus afflicted, have occasionally been sup- 
 posed to be hermaphrodites, the tumour be- 
 ing mistaken for a penis. ’ Such a case is 
 recorded by Saviard. 
 
 The patient is generally troubled with 
 tenesmus, and sometimes feels acute pain 
 in the tumour itself, which is subject to in- 
 flame and ulcerate, in consequence of its 
 depending posture, the friction to which it 
 is exposed, and the irritation of the urine. 
 
 The direction both of the bladder and 
 the urethra becomes horizontal, so tbat the 
 urine is thrown forwards, or even upwards, 
 in which latter case it wets the abdomen 
 Frequently the bladder cannot be emptied 
 without the assistance of the catheter ; and 
 sometimes the displaced uterus becomes 
 affected with inflammation and swelling. In 
 many cases there are profuse hemorrhages. 
 However, some women become so habitua- 
 ted to the disease that they hardly seem to 
 experience any annoyance from it : when 
 ever they are in the erect posture, and walk 
 about, the womb falls down, bringing with 
 it the vagina ; and, as soon as they lie dovvn 
 on their backs, the parts as readily return 
 into their natural position again. 
 
 The incomplete prolapsus is alone sub- 
 ject to any obscurity, which, however, may 
 be dispelled by manual examination. In 
 this, however, some precautions are neces- 
 sary. For instance, as the womb generally 
 returns into Its natural situation when the 
 patient lies down, the examination should 
 always be made as she is standing up. For 
 the same reason, if she is in the habit of 
 lying long in bed, the morning is not the 
 best period of the day for the examination. 
 The practitioner may also be deceived if fie 
 examine the parts when the rectum and 
 bladder are distended with their contents, 
 in which state the uterus may be hindered 
 from descending as low as at other periods. 
 If attention be paid to these circurastan 
 
UTERUS, PROLAPSUS OF 
 
 fibii 
 
 ces, an incomplete prolapsus may always 
 be distinguished without risk of error. 
 However, the records of surgery prove that 
 the case has sometimes been mistaken by 
 the inexperienced, or ignorant, for a poly- 
 pus, and the part extirpated under this sup- 
 position. So serious a blunder will be 
 avoided, if care be taken to remember that 
 polypi are generally softer and less sensible 
 than the uterus ; that, in a case of prolapsus, 
 the os tincae is situated at the lower part of 
 the swelling ; and, that if by chance any 
 resembling aperture should be met with 
 upon the corresponding portion of a poly- 
 pus, the prolapsus may still be known by 
 the greater depth to which a prohe will en- 
 ter such opening. A polypus of the uterus, 
 I believe, is always broadest at that extre- 
 mity, which is nearest the vulva ; but the 
 womb, in a state of incomplete prolapsus, 
 forms a tumour which is narrower below 
 than above. With very few exceptions, the 
 womb is likewise reducible, and the patient 
 directly afterward feels great relief; whereas 
 a polypus cannot be pushed ba'qk, and the 
 attempt, instead of giving relief, only in- 
 creases the, patient’s sufferings. 
 
 In a complete prolapsus, no doubt can 
 ever prevail about the real nature of the 
 case, for whatever uncertainty the feel of 
 the parts may create, none can ever remain 
 when the swelling is distinctly visible. 
 
 Although Mauriceau, Saviard, and Monro 
 have recorded instances of prolapsus uteri 
 in maidens, such cases are exceedingly rare. 
 The disease is hardly ever met with, except 
 in women who have had children, and ge- 
 nerally in those who have borne a great 
 many. This particularity is ascribed by 
 writers to the elongation of the ligaments of 
 the uterus it) women, in whom this organ 
 has been repeatedly gravid. The same con- 
 sideration may also account for the fre- 
 quency of prolapsus uteri during the first 
 months subsequent to parturition, especially 
 as the womb remains for some time after 
 labour more enlarged and heavy than natu- 
 ral. The disease is more common in thin 
 than fat women, and is said often to take 
 place in females when they suddenly change 
 from a fat to a very emaciated state. The 
 displacement is facilitated by jo. capacious 
 vagina, by a great width of the lesser ca- 
 vity of the pelvis, and the effects of tedious 
 and profuse attacks of fiuor albus. Prolap- 
 sus uteri has also been brought on by vio- 
 lent concussions of the body ; the protract ed 
 efforts of vomiting, coughing, or crying, 
 hard labour, and lifting, or carrying heavy 
 burdens. In what has been stated, one may 
 discern the reason why the affliction is so 
 frequent among the lower classes of society, 
 and why women, for a certain time after 
 parturition, should avoid an erect posture, 
 and every kind of exertion. In the treat- 
 ment of prolapsus uteri, there are two indi- 
 cations ; the first is to reduce the part ; and 
 the second is to keep it from falling down 
 again. 
 
 In the incomplete prolapsus, the first in- 
 dication is very easy of accomplishment ; 
 
 and, indeed, when the patient is placed on 
 her back, with her pelvis raised somewhat 
 higher than her chest, the utprus often re 
 turns of itself into its natural situation again. 
 At all events, the reduction may be imme- 
 diately effected by pushing the uterus up 
 into the pelvis with the fingers. 
 
 More difficulty generally attends the re- 
 duction of a complete prolapsus Here the 
 same posture is to be chosen as in the for- 
 mer case ; but the legs and thighs should be 
 bent. The rectum should also be first emp- 
 tied with clysters. Sometimes, indeed, 
 every attempt at reduction fails, notwith- 
 standing the adoption of the most vigorous 
 measures, the use of the warm bath, purga- 
 tives, venesection, low diet, fomentations, 
 &lc. Occasionally, the part is returnecLafter 
 a great deal of trouble; but, owing to the 
 long altered state of parts, the reduction 
 brings on worse symptoms than resulted 
 from the continuance of the prolapsus. 
 S?jch a case is recorded by Richter. (Bibl. 
 der. Chir. B. 3, p, 141.) The patient’s suf- 
 ferings were so much increased by the re- 
 duction, and so- obstinate a constipation 
 came on, that it became absolutely neces- 
 sary to let the uterus descend again In any 
 irreducible case, all that can be done is to 
 support the swelling, and prevent its in- 
 crease with asu«pensory bandage, and draw 
 off the urine with a catheter whenever re- 
 quisite. In these cases, the altered course 
 of the meatus urinarius is to be remember- 
 ed, and the catheter directed horizontally 
 towards the rectum 
 
 When the displaced uterus is inflamed, 
 and considerably swelled, the attempt at 
 reduction should be preceded by antiphlo- 
 gistic remedies, the patient should be kept 
 in bed, be put on a low regimen, be bled., 
 take purgative medicines, use the warm 
 bath, and drink diluent beverages, while 
 emollient applications are made to the part 
 itself. This plan of treatment has often 
 been attended with complete success, in 
 cases of prolapsus uteri, of long standing and 
 considerable size. Ruysch disapproved of 
 making any attempt to reduce the uterus 
 while it was inflamed and swelled. He also 
 thought that the operation should be post- 
 poned when the uterus was in an ulcerated 
 state. However, Sabatier rightLy observes, 
 that, as this complication is only accidental, 
 and merely arises from the friction to which 
 the tumour is exposed, and the irritation of 
 the urine, the plan of immediately replacing 
 the part cannot be attended with any dan- 
 ger. Off the contrary, since the cause 
 which produces and keeps up the ulceration 
 will cease, as soon as- the reduction is ac- 
 complished, the sores will heal after the 
 uterus is put into its natural situation again. 
 
 When a prolapsus uteri occurs in the 
 early stage of pregnancy, this state should 
 not let the practitioner neglecl to reduce the 
 part. Several instances are recorded, in 
 which the reduction was successfully ac- 
 complished in pregnant women ; and one 
 case of this kind is reported by Giraud. 
 ( Journ . de Mrdecine. T 45.) When preg- 
 
UTERUS, RETROVERSION OF 
 
 583 
 
 nancy is tar advanced, or the disease is of 
 long standing, the reduction is difficult. 
 Perhaps, says Sabatier, it may be more pru 
 dent, in these circumstances, to let the ute- 
 rus continue protruded, than to disturb the 
 mother and foetus with reiterated attempts 
 to reduce the part. The uterus, however, 
 should not be left to itself, but be well sup- 
 ported with a suitable bandage, and the pa- 
 tient kept in bed. When the prolapsus 
 uteri occurs at the period of delivery, every 
 attempt at reduction is both useless and 
 dangerous. In this case, the delivery of 
 the foetus-should be expedited by gradually 
 dilating the os tinea?, which, at the same 
 time, should be carefully supported. The 
 extraction of the placenta also requires a 
 great deal of caution, and it should be ac- 
 complished by introducing one hand into 
 the uterus, with the palm turned away from 
 the cavity of this viscus, towards the out- 
 side of the placenta, which is to be gradu- 
 ally separated from its edges towards its 
 centre. 
 
 In cases of complete prolapsus uteri, 
 Ruysch was an advocate for leaving the 
 expulsion of'the foetus, if alive, to be effect- 
 ed by nature ; and the same writer advises 
 us to be content with supporting the os 
 tinea?. But when the child is dead, he 
 recommends extracting it with one hand, 
 while the uterus is supported with theother. 
 Sabatier, however, entertains different sen- 
 timents. The expulsion of the child, he 
 says, is not less the effect of the contraction 
 of the diaphragm and abdominal muscles, 
 than of the womb itself. Hence, when 
 eitberof these agents fails to co-operate, the 
 delivery becomes either very difficult, or 
 impossible. This is exactly what happens 
 in the present case ; for the uterus having 
 fallen down, cannot be compressed. by the 
 diaphragm and abdominal muscles. Nor 
 can Sabatier discern the reason why Ruysch 
 should recommend the line of conduct to 
 differ, according to the different state of the 
 child. This is quite passive in parturition, 
 and contributes not in the least to its own 
 expulsion. 
 
 The second indication, or that of keeping 
 the uterus reduced, demands the employ 
 merit of astringent injections and pessaries. 
 
 The uterus, in a state of prolapsus, is 
 sometimes also affected with -cirrhus and 
 cancer. A case of this description was met 
 with by Ruysch ; and, very recently, a wo- 
 man wdiose uterus was cancerous, and in a 
 state of complete prolapsus, without any 
 inversion, was attended by Lai.genbeck, 
 who succeeded in removing the diseased , 
 organ with' a knife, and the patient recover- 
 ed According to this author’s description, 
 after the vagina had been separated from 
 the uterus, the latter organ was detached 
 from the peritoneum, without the latter 
 membrane being opened, a small portion of 
 the fundus uteri being left, however, as it 
 appeared quite sijund. The bleeding was 
 very profuse, and required the use of the 
 needle and ligatures. The ovaries and di- 
 vided ligamenta rotunda were found con- 
 
 nected with the removed portion of the 
 uterus. (Bibl. filr die Chir. B. 1, p. 551, 
 12mo. Hannover, 1818. Saviard , Obserr 
 
 Chir. 12 mo. Paris, 1702. J. G. Preund, De 
 Novo arlificio curandi procidentiam Uteri, 
 Franco f ad Viadn. 1710. Levret , in Journ , 
 de MM. T. 40, et Obs. snr la Cure Radicate 
 des plusiturs Polypes, fyc. Morgagni, de 
 Sedibus et Causis Morbotum , Episl. 45, 
 Kulmus, de Ulen Delapsv . , Suppressions Uri- 
 nre, et subsequent is Mortis * Causa, Gedani, 
 1782. White, in Med. Obs. and Inq. Vol. 2. 
 Shaw, in Mem. of the Medical Society of 
 London , Vol. 1. Portal, (.'ours d' Anatomic 
 Med. T. 5, p. 538, et M6m. de VAcad. de 
 Chir. T. 3. Sabatier , in Mem. de VAcad. de 
 Chir. T. 3, p. 361, and Medecine Operatoire , 
 T. 2. Ducreux, in M6m. de l' Acad, de Chir. T. 
 S, p. 493 Osiandtr, Annalen, B. 1, p. 175. 
 Diet, des Scietices M6d. T. 23, art. liysler op- 
 to sc. 
 
 UTERUS, RETROVERSION OF. Re- 
 troversion of the uterus is said to happen, 
 when its fundus is forced downward and 
 backwards betw een the sacrum and the pos- 
 terior part of the vagina, while its cervix 
 inclines towards the symphysis pubis. The 
 ancients are thought to have had some im- 
 perfect notipns of this case, and, in proof of 
 this opinion, certain passages are referred to 
 in (Elius, (Telrab. 4, Serm. 4, C. 77.) Mercu- 
 rial is, Mercatus, and others, (See Diet, des 
 Sciences M6d. T. 28, p. 273.) Be this as it, 
 may, it is generally confessed, that the sub- 
 ject had fallen into* oblivion, when Dr. Win. 
 Hunter called the attention of his pupils to 
 the subject, in 1754, and afterward drew up 
 an interesting paper concerning it. (Med 
 Obs. and. Inquiries, Vol. 4. 8 to. I.ond. 1771.) 
 Subsequently, the knowledge of the sub- 
 ject was extended by the observations of 
 Wlzezeck, (De Ulero retrojlexo. Prag. 1777,) 
 the remarks of Richter, (Chir. Bibl. B. 5 ,p. 
 521, fy B. 9,;/. 182.) and those of Wall, (Hiss, 
 de Uteri retroversions, Hal. 1782,) and by the 
 memoir of Desgranges, t 9 which the prize of 
 the Royql Academy of Surgeryat Paris was 
 adjudged, in the year 1785. According to 
 Sabatier, retroversion of the womb was a 
 case mentioned by Gregoift? in his private 
 lectures on midwifery at Paris.’ 
 
 Walter Wall, an English surgeon, who had 
 attended Gregoire, suspected Jbat *he had 
 met with a retroversio uteri in a woman, 
 some months advanced in pregnancy, and he 
 called in Dr. Hunter, in order to have the 
 advantage of his advice. The woman was 
 attacked with an obstinate constipation, and 
 retention of urine, and died in about a week. 
 A large tumo r w'hs found occupying the 
 whole of the pelvis, and pushirTg the vagina 
 against the os pubis. It had been found im- 
 practicable to push the swelling back into the 
 abdiunep, although the patient had been put 
 on her knees and elbows, while one hand 
 had been introduced into' the vagina, and 
 two fingers of .the other hand into the rectum. 
 Great curiosity existed about what informa- 
 tion would be afforded by dissection. On 
 opening the body, the bladder, which was 
 exceedingfy full of urine, filled almost the 
 
UTERUS, RETROVERSION OF. 
 
 484 
 
 whole anterior part of the abdomen, in the 
 panic manner as the uterus does in the last 
 month of pregnancy. When it had been 
 emptied, that part of it, in which the 
 ureters terminate, and which is connected 
 with the vagina and cervix uteri, was found 
 raised up, as high as the upper aperture of 
 the pelvis, by a large tumour, which filled 
 the r. hole cavity of the pelvis, and was 
 found to be the uterus. A catheter, when 
 passed into the vagina, couid ; .e made to lift 
 up the latter viscusand the upper part of the 
 tumour. This portion of the swelling, on 
 which the bladder lay, consisted of the cer- 
 vix uteri, while the fundus of this organ was 
 situated downwards .toward the os coccygis 
 and anus. The uterus was so large that it 
 could not be taken out of Ihe pelvis, before 
 the 'symphysis pubis was divided, and the 
 two ossa innominata were pulled asunder It 
 was found impossible to assign any cause for 
 ihe displacement of the uterus, as the pa- 
 tient had been making no exertion, and had 
 met with no tall, though she is said to have 
 been frightened at something just before the 
 complaint commenced. 
 
 Dr. Hunter, struck with the singular na- 
 ture of the case, i nought it deserving of the 
 attention of medical men, and he made it 
 the subject of a lecture which he delivered 
 in 1754. Fie was afterward consulted by 
 ,-evera! persons, who were afflicted with the 
 Tetroversio uteri ; but, not in so acute a way, 
 as in the above instance All the patients 
 were in the third month of pregnancy and 
 first suffered a difficulty of making water, 
 succeeded by retention of urine, and after- 
 ward by constipation. Dr. Hunter always 
 emptied the bladder by means of a cathe- 
 ter and glysters, which measures sometimes 
 effected a cure, the uterus spontaneously re- 
 suming its natural position. In every in- 
 stance, the accident disappeared, when preg- 
 nancy was more advanced, aifd the uterus 
 had acquired larger dimensions, in some 
 cases, in which Dr Hunter was consulted too 
 late, the trials to replace the uterus proved 
 fruitless, and the women died. Dr. Hunter 
 was so firmly convinced of the impossibility 
 of saving patietfcs circumscribed in the 
 above manner, unless extraordinary means 
 were resorted to, that he thought one should 
 endeavouc to diminish the size of the uterus, 
 by introducing a trocar into the body of this 
 yiscus, through the posterior parietes of the 
 vagina, so as to let out the water of the 
 amnios, the relative quantity of which is 
 known to be greater in the early, than in the 
 advanced stage of pregnancy. (See Jourel 
 in Bulletin de la Faculti de Mid. p. 173, an. 
 (1812.) 
 
 Such a puncture might certainly be the 
 means of the uterus resuming its natural 
 position ; but there would be considerable 
 danger of its exciting the conlraction'ol the 
 uterus, and causing abortion. No risk of 
 this kind would be encountered by punctur- 
 ing the bladder above the pubes. In this 
 manner, a free passage would be afforded for 
 the escape of the urine, and the reduction of 
 the uterus might be effected 
 
 Mr. Lynn, a surgeon in Suffolk, knew an 
 instance of the bladder bursting, and the 
 urine becoming exlravasated in the abdo- 
 men, in a case of retroversion of the uterus, 
 in consequence of the patient’s refusal to 
 submit to the preceding operation. The 
 woman was forty years of age, of a relaxed 
 habit, mother of several children, and had 
 been pregnant four months. She had also 
 been for sometime afflicted with a prolapsus 
 of the vagina. The swelling had been a few 
 days reduced, when in consequence of trip- 
 ping, she felt something become displaced in 
 her abdomen, and fall toward the lower part 
 of her back. She was immediately attacked 
 with constipation, retention of urine, nausea, 
 and pain in her belly. The means which 
 were employed, not proving effectual, Mr. 
 Lynn suspected a retroversio uteri, and in- 
 troduced his fingers into the vagina, in order 
 to ascertain the fact. Flis fingers were stop- 
 ped by a tumour, as large as a child’s head. 
 The swelling occupied the back part of this 
 passage, and descended as low as the peri- 
 naeum. Being certain, that the uterus was 
 displaced, he attempted to reduce it. The 
 patient was put into various positions, and 
 the fingers of one hand were introduced into 
 the vagina, while those of the other were 
 passed into the rectum. The use of the 
 catheter was not forgotten ; but it could not 
 be introduced far enough to reach the urine 
 Glysters were stopped at the very beginning 
 of the rectum. The abdomen was exceed- 
 ingly tense, especially in the hypogastric re- 
 gion. A proposal was made to puncture the 
 bladder ; but the patient refused to submit, 
 and preferred being left to her fate. On the 
 seventh day of her illness, she was very 
 much reduced ; and became affected with 
 nausea, and hiccough, the forerunners of 
 mortification. At length, she felt something 
 give way in her abdomen, and the ease, 
 which succeeded, revived her hopes. These, 
 however, were’ not of long duration, for, 
 after being delivered, she sunk, and died the 
 next morning. On opening the body, the 
 bladder was found to have sloughed, and 
 burst at several points, and two parts ot 
 urine were consequently extravasated in the 
 abdomen. 
 
 Retroversio uteri is a dangerous affection , 
 but it is not invariably fatal, particularly 
 when the patient receives succour, before 
 the disorder has made much progress 
 Though Callisen met with a case after deli- 
 very, and Desault knew an instance in 
 which the displacement was produced by a 
 polypus, retroversio uteri scarcely ever 
 occurs, except in the early months of preg- 
 * nancy, and in women whose pelvis is very 
 wide, while its brim, is very contracted. U 
 the uterus, in a pelvis of this conformation, 
 be pushed back by a distended bladder, and 
 pressed against (lie sacrum, while the soft 
 parts yield, the womb becomes,, as "it were, 
 wedged, and is incapable of changing its 
 position. In this immoveable state, it presses 
 upon the surrounding parts, and the^e upon 
 it, so that a very serious train of bad symp- 
 toms are the consequence. 
 
VAGINA IMPERFORATE 
 
 63G 
 
 The lirst care oi a practitioner, consult-: 
 «d in a case of retroversio uteri, should be 
 to empty the bladder and large intestines, 
 and to relax the parts by every possible 
 means. Then lie should immediately pro- 
 ceed to replace the uterus, by placing the pa- 
 tient in a suitable posture, and making me- 
 thodical pressure in the rectum and vagina. 
 Should he be so fortunate as to succeed, 
 the patient is to be confined in bed, her 
 bowels are to be kept open, and she is to be 
 advised always to obey the calls of nature 
 the first moment she feels any inclination to 
 make water. She is also to be enjoined to 
 avoid all kinds of exertion, and wait till the 
 gradual enlargement of the uterus removes 
 the possibility of this viscus descending into 
 the pelvis. ( Sabatier , Mddecine Opiraioirc, 
 T. 2.) 
 
 Some practitioners, of considerable emi- 
 nence, rather discourage the manual interfe- 
 rence to reduce the uterus, believing that 
 drawing off the urine will generally render 
 such interference unnecessary. ( Croft , in 
 Lond. Med. Journ. Vol. 9, p. 53. Denman’s In- 
 troduction to Midwif 'ery , 4 to. Lond. 1801. S. 
 Merriman , on Retroversion of the Womb, 8 vo. 
 Lond. 1810.) 
 
 (See Lynn , IV. Hunter, Garthshore , Bird, 
 and Hooper, in Med. Obs. and fnq. Vo Is. 4, 5, 
 and 6, Ckeston and C leghorn, in Med. Com- 
 munications, Vol. 2. John Clarke, Practical 
 Essays on the Management of Pregnancy and 
 Labour , Lond. 1793. Murray, in Uteri Retro- 
 versionem Animadversiones, Upsal. 1797. 
 Denman’s Introduction to Midwifery, Load. 
 1810. S'. Merriman, on Retroversion of the 
 
 Womb, fyc. 8 vo. Lond. 1810. Joltr., De Utero 
 Retroverso,Jen. 1 87. Desgranges, in Journ. 
 de Med. T. 66, p. 85. Klein, Chir. Bemerkun- 
 gen, p. 235. Baudelocque sur le Renverse- 
 ment de la Matrice , fyc. Paris , 1803. Cockell , 
 Essay on Retroversion of the Uterus. Lond. 
 1785. Richter, Chir. Bibl. B. 4. p. 61, — 70 
 —235—555: B. 5, p. 132—548; B. 7, p. 
 
 292; B. 8,p. 715; B. 9, p. 182; B. 11, p. 
 310 — 328 ; B. 12, p. 45 — 50.) 
 
 UVA URSl, which was first brought into 
 notice by De Haen, was once considered a 
 powerful remedy in calculus ; but though its 
 virtue in lessening the irritation of the blad- 
 der, is still acknowledged, its claim to utility 
 on any other principle, is quite ' rejected. 
 Dr. Austin recommended it for lessening the 
 irritability of the bladder, and diminishing 
 The secretion of diseased mucus, which, he 
 supposed, greatly contributed to the aug- 
 mentation of the stone. 
 
 Mr. 15. Bell also strongly recommended it 
 in gonorrhoea, where the irritability of the 
 bladder was excited in a high degree, and 
 where the urine was loaded with viscid 
 matter, fn these cases, he directed a scru- 
 ple, or half a dram of the powder, three 
 times a day. 
 
 Dr. Saunders orders three drams of uva 
 ursi to be macerated in a pint of hot water, 
 and two or three ounces of the strained 
 liquor to be given three times a day. (Charm. 
 Chirurg.) 
 
 UVULA, AMPUTATION OF. The uvula 
 is subject to several kinds of enlargement, 
 in which it becomes both longer and more 
 bulky than natural, or is simply lengthened. 
 In consequence of such changes, it becomes 
 troublesome in deglutition and speaking, and 
 causes a disagreeable tickling at the root of 
 the tongue, frequent retchings, and an an- 
 noying cough. 
 
 When things"have attained this state, me- 
 dicines are often ineffectual, and the only 
 plan of relief consists in amputating a por 
 tion of the uvula. 
 
 The ancients used to take hold of the 
 uvula with a pair of forceps, and cut off a 
 piece of it below the blades of the instru 
 ment. Fabriciusab Aquapendente objected 
 to this method, because it employed both 
 hands, and a third was needed for holding 
 the tongue and lower jaw. He preferred 
 scissors, and having the left hand at libertv. 
 
 When the size of the uvula was considera- 
 ble, and bleeding apprehended, Pare recon, 
 mended the application of a ligature to the 
 part, by means of an instrument, composed 
 of a ring, mounted on a slender handle, and 
 formed with a groove upou its convexity. A 
 ligature is put round the ring with a slip- 
 knot, which is to be tightened by means of 
 another ring, of much smaller size, mounted 
 like the preceding one, upon a long slender 
 handle. The ligature is tcy be left in the 
 mouth, and when it does not make suffi- 
 cient constriction, it is to be tightened. 
 
 Fabricius Hildanus subsequently descri- 
 bed an instrument constructed on the same 
 principles. Sabatier takes hold of the uvula 
 with a pair of forceps, made with holes in 
 the blades, like those used for the extraction 
 of polypi. He then divides the uvula with a 
 pair of scissors, made with concave cutting 
 edges. 
 
 Sabatier never saw any bleeding of con 
 sequence follow this trivial operation. (See 
 Midec.ine Opiratoire, T. 3.) 
 
 y. 
 
 V " AGIN A IMPERFORATE. Female in- 
 fants are often born with different im- 
 perforations of the vagina. Sometimes this 
 passage is not completely shut up, so that 
 the usual evacuations happen in an uninter- 
 rupted manner, and it i« a considerable time 
 Vot.1L. 74 
 
 before the malformation is discovered. 
 Some females are even stated to .have be- 
 come pregnant, notwithstanding such ob- 
 struction ; and in these cases, the membrane 
 which shut up a part of the mouth of the 
 vagina, either was torn by the effects of 
 
586 
 
 VAGINA, PROLAPSUS OF. 
 
 labour, or divided as much as was necessa- 
 ry for delivery. 
 
 Two membranes, one placed beyond the 
 other, and obstructing the vagina, have also 
 been found. That which is commonly met 
 with is only the hymen, thicker and strong- 
 er than natural. Ruysch describes the case 
 of a woman who bad been in labour three 
 days, and could not be delivered The head 
 presented itself, but was prevented from 
 coming out by the hymen, which shut up 
 the vagina, and was very tense. Ruysch 
 made an incision into the membrane ; but 
 to no purpose, since there was another mem- 
 brane, of a thicker texture, situated more 
 deeply in the passage. As soon as this se- 
 cond membrane was divided, the child was 
 expelled, and the case ended well. 
 
 When the vagina is completely imperfo- 
 rate, and the time of the menses commence, 
 many complaints occur, which afflict the 
 patient with more severity, in proportion as 
 the blood accumulates in the passage, and 
 they may even lead to a fatal termination 
 when the cause is not understood, or riot 
 detected till it is too late. These complaints 
 are very similar to those of pregnancy ; for 
 instance, rumbling noises in the bowels, loss 
 of appetite, nausea, vomiting, enlargement 
 of the mararaffi, spasms, convulsions, swell- 
 ing of the abdomen, &,c. Hence, girls in 
 this situation have often been supposed to 
 be pregnant, although they were not in a 
 state even to become so ; and some young 
 women have been known to die, after dread- 
 ful sufferings. 
 
 When the malformation consists altoge- 
 ther in the orifice of the vagina being shut 
 up by a membrane, the patient may be ea- 
 sily relieved by a crucial incision, or a sin- 
 gle cut, the edges of which are kept apart 
 by a tent of suitable shape and size. In- 
 stances of the success of such an operation 
 are to be found in numerous writers. Fa- 
 bricius ab Aquapendente informs us, that a 
 female child was born with a membrane 
 which completely shut up the vagina. The 
 girl experienced no inconvenience from it 
 till she was about thirteen, when the period 
 of her menses began. As the blood was re- 
 tained, she became afflicted with severe 
 pains in the loins, the lower part of the ab- 
 domen, and about the upper part of the 
 thighs. She was supposed to be attacked 
 with sciatica, and treated accordingly. Me- 
 dicines were prescribed which did no good ; 
 and at length she became hectic, and redu- 
 ced to a complete state of marasmus, in 
 which she passed restless nights, lost her ap- 
 petite, and was delirious. A painful, very 
 elastic tumour afterward presented itself 
 in that part of the abdomen which corres- 
 ponds to the uterus. The pains were aggra- 
 vated every month, at the period when the 
 patient ought to have menstruated. She was 
 in a dying condition when Fabricius ab 
 Aquapendente was consulted, who, after as- 
 certainin'; the real nature of the case, per- 
 formed the requisite operation. A prodi- 
 gious quantity of black putrid blood was 
 discharged from the vagina ; the bad symp- 
 
 toms gradually subsided, and the patient re- 
 covered. (See also J. C. Loder , Obs. Imper j 
 J'orationis Vagina. Jcone illusirota, 4to. Jena , 
 1800 ; and numerous ol her cases on record. ) 
 
 When the malformation is produced by 
 an extensive accretion of the sides of this 
 passage to each other, the cure is Sometimes 
 difficult. The result of the operation is 
 doubtful, because it is impossible to reach 
 the situation of the blood without cutting 
 through a considerable thickness of parts, 
 in doing which there is some danger of 
 wounding the rectum, or bladder. A lady, 
 twenty-four years of age, after having tried, 
 for eight years, such remedies as seemed 
 best calculated for exciting the menstrual 
 discharge, became affected with a large hard 
 swelling of the abdomen, and a kind of her- 
 petic affection round the body near the na- 
 vel. At length it was discovered, that the 
 impefforation of the vagina was the sole 
 cause of all the bad symptoms which the 
 patient had long endured. An incision was 
 made, which enabled the operator to intro- 
 duce his finger into a large cavity, and which 
 gave vent to a considerable quantity of 
 blood. It was thought that an opening had 
 been made into the vagina ; but the patient 
 having died three days afterward, it was 
 seen that a mistake had been made, as the 
 cavity, in which the finger had been intro- 
 duced, was that of the bladder. The vagina 
 was closed below by a substance of an inch 
 in diameter, and half an inch thick. The up- 
 per part of this passage, the uterus, and the 
 Fallopian tubes, were exceedingly enlarged, 
 and filled with a dark brown, sanious fluid. 
 A similar fluid was extravasated in the ab- 
 domen, and it was discovered to have pass- 
 ed there through a rupture which had taken 
 place in the Fallopian tube. The ovaries 
 were in a natural state. De Haen, who has 
 related this case in the sixth part of his 
 work, entitled Ratio Medendi , was of opi- 
 nion, that in Order to avoid opening the 
 rectum, or bladder, only one oblique cut 
 should be made in the membrane which 
 stops up the vagina, just as was advised by 
 Meeckren. (Sabatier de la Midecine Optra- 
 toire, T. 1.) 
 
 VAGINA, PROLAPSUS, OR INVER- 
 SION OF. According to Sabatier and Lev- 
 ret, the displaced part does not consist of 
 all the coals of the vagina, in the same 
 manner as the inverted uterus is formed of 
 the whole substance of this viscus. These 
 writers contend that the lining of the vagina 
 is alone displaced, in consequence of the 
 swelling and thickening with which it is af- 
 fected. Upon this point, however, Richter 
 does not accede to the opinion of Sabatier 
 and Levret, but describes the vagina as be- 
 ing liable to two kinds of prolapsus. In one 
 case, all its tunics are stated to be included 
 in the protrusion, the part becoming invert- 
 ed at the same time that it falls down, lti 
 the other example, it is only the relaxed 
 lining of the vagina which descends, and 
 makes the protrusion. 
 
 The possibility of a prolapsus of the whole 
 of the vagina, together with all its coats. 
 
V ACilNA, PROLAPSUS Ol 
 
 537 
 
 says Richter, has been doubted by Sabatier 
 and Levret; but without any real founda- 
 tion. If it be possible for the inner coat of 
 the vagina to separate from the external, 
 with which it is intimately connected, (an 
 event which every body admits as happen- 
 ing in the second kind of prolapsus of the 
 vagina,) why, asks Richter, should it be im- 
 possible for the whole of this tube, together 
 with all its coats, to be separated from the 
 surrounding parts, to which it is Ies3 closely 
 adherent ? Sometimes the rectum, inclu- 
 sive of all its coats, forms what is termed a 
 prolapsus ani, and why may not the vagina 
 be displaced in a similar manner, since it 
 must be much more liable than the rectum 
 to be propelled downwards in the violent 
 straining at the time of delivery ? Richter 
 asks, whether every prolapsus uteri is not 
 accompanied with such a displacement of 
 the vagina ? Cases are upon record, where 
 the prolapsus of the vagina happened all on 
 a sudden, in consequence of falls, the start- 
 ing of a horse, &c. ( Hoin , Levret, Journ. de 
 T. 40.) Here it cannot be supposed, 
 that the case w as merely a protrusion of the 
 inner coat, which can only be gradually re- 
 laxed and elongated. Lastly, some instances, 
 in which the prolapsus of the vagina was 
 several inches in length, have been gradual- 
 ly reduced by means of external pressure. 
 (Hoin.) How can it be imagined, says Rich- 
 ter, that such cases could proceed from any 
 degree of relaxation to which the membra- 
 nous lining of the vagina is liable ? 
 
 Richter acknowledges, however, that a 
 prolapsus of all the coats of the vagina is 
 much less common than that arising from 
 relaxation of the membranous lining of this 
 passage ; he states, that when it occurs, it is 
 generally a consequence of a prolapsus of 
 the uterus ; and that it cannot easily hap- 
 pen at all, except about the period of deli- 
 very. (See Jlnfangsgr. der Wundarzn. B. 7, 
 Kapitel 4.) 
 
 According to Sabatier, the prolapsus, or 
 inversion of the vagina, appears like a thick, 
 circular substance, irregularly plaited in the 
 middle, and at the bottom of which the 
 cervix uteri is situated, having descended 
 further down than natural. The displaced 
 portion of the vagina increases, or dimi- 
 nishes, according as the patient sits up, or 
 keeps in bed a certain time. The complaint 
 is accompanied with a sense of heaviness 
 in the hypogastric region ; tenesmus ; and 
 a difficulty of making water, in consequence 
 of the alteration produced in the direction 
 of the meatus urinarius. 
 
 Such is the prolapsus of the vagina in an 
 early state ; but when it has been of long 
 standing, and the patients have remained 
 for a long while without any assistance, the 
 membranous lining of the passage becomes 
 more and more thickened; and the tumour, 
 which it forms, becomes more considera- 
 ble, elongated, and hardened. In this state 
 there still continues, at the lower part of the 
 swelling, an opening, out of which the usual 
 evacuations are made. The grievances suf- 
 fered are similar to those arising from a pro- 
 
 lapsus uteri, to which, indeed, the present 
 case bears a great resemblance. The pro- 
 lapsus vaginas, however, differs, inasmuch 
 as the tumour formed by a descent of the 
 uterus is very firm, and terminates in a nar- 
 row end, where may be observed the oblong 
 transverse opening, named the os tineas; 
 while the tumour, arising from a prolapsus 
 of the vagina, is soft, thicker below than 
 elsewhere, and ends in an irregular aper- 
 ture. 
 
 Occasionally, a prolapsus of a very limit- 
 ed portion of the vagina is observed. This 
 case is generally the consequence of an un- 
 common sort of rupture, termed the vaginal 
 hernia (see Hernia ;) but it should also be 
 known, that in some cases of dropsy, a cir- 
 cumscribed protrusion of the vagina, in the 
 form of a cyst, or pouch, filled with fluid, 
 is sometimes noticed. ( Richter , Op. et loco 
 citato.) 
 
 When the prolapsus vaginae is recent, the 
 partway be easily reduced, and kept up 
 with a pessary. The use of astringent lo- 
 tions will also tend to prevent a relapse- 
 But when the case has been of long stand- 
 ing, it is neither easy to effect the reduction, 
 nor to prevent a recurrence of the disor£,j\ 
 Softening, relaxing remedies, in this cir- 
 cumstance, are recommended, and the pa- 
 tient should, in particular, confine herself 
 to her bed, and wear a T bandage, which 
 should be made to press upon, and support 
 a piece of sponge in the orifice of the va- 
 gina. 
 
 It is reasonable to expect, that after a 
 prolapsus vaginae has continued a long while, 
 the reduction must be difficult ; because the 
 vagina in this stale becomes affected with 
 swelling and induration. According to the 
 reports of Hoin and Levret, a large protru- 
 sion of this kind, ten inches in length, was 
 so diminished by keeping the patient inva 
 riably confined in bed upon her back, that 
 in the course of a month, the rest of the tu- 
 mour admitted of being reduced. Indeed, 
 as Richter observes, there can be little 
 doubt, that the treatment which has been 
 advised by some authors, for the diminution 
 of very old, enormous, omental ruptures, 
 would here be equally applicable ; viz. long 
 confinement in bed upon the back, with the 
 buttocks somewhat elevated ; unremitting, 
 well directed external pressure ; a very low 
 diet ; and repeated mercurial purges. 
 
 During pregnancy, a prolapsus of the 
 whole substance of the vagina may cause, 
 much embarrassment and even danger. Irv 
 one case of this description, where the pro- 
 trusion was five inches in length, it became 
 necessary to turn the child, and the displaced 
 vagina was lacerated. The woman, howe 
 ver, recovered. ( Pietsch , Journal de Med. 
 T. 34.) In another instance, where the pro- 
 lapsus became, at each return of the labour- 
 pains, as large as a man’s head, the practi- 
 tioner succeeded in holding the parts back, 
 while delivery w r as effected with the aid ot 
 the forceps. (See Loder’s Journ. 1 B. p. 
 490.) When this is impracticable, it is ne- 
 cessary, according to Richter, to make an 
 
VAR 
 
 VAR 
 
 588 
 
 iqcision through both sides of the prolapsus ; 
 a measure, says he, to which the practitioner 
 may the more readily make up his mind, 
 inasmuch as the parts have, in some cases, 
 been lacerated, without any ill consequen- 
 ces. 
 
 A prolapsus of the inner membrane of the 
 vagina, while small and recent, might per- 
 haps be removed by astringent applications. 
 When, however, it is of long standing, indu- 
 rated, and of large size, much expectation 
 ol success .from this treatment cannot be en- 
 tertained. Richter sees no reason why, in such 
 a case, the superfluous relaxed part should 
 not be cut away, especially if the disease be 
 accompanied with ulceration, and other se- 
 rious complaints. As he observes, there can 
 be no doubt, that a prolapsus of the inner 
 membrane of the vagina, when limited to 
 one part ol this canal, may always be safely 
 extirpated, either with a knife, or a ligature. 
 (Anfangsgr. der Wundarsn . B. 7, Chap. 4.) 
 
 As the swelling of the membranous lining 
 of this passage is folded back on itself, it 
 sometimes increases in such a degree, that 
 the tumour falls into a state of mortification. 
 In this event, some writers have advised the 
 ej^Arpation of the swelling, justifying the 
 practice on the authority of some distinguish- 
 ed practitioners, and the little danger atten- 
 dant on the operation. 
 
 Even Sabatier only objects to this pro- 
 ceeding, on the ground of the danger of mis- 
 taking a prolapsus of the uterus, for one of 
 the vagina. However, no modern surgeons 
 in this country would hesitate about reject- 
 ing such an operation, and leaving the sloughs 
 to separate of themselves. 
 
 The prolapsus, arising from a hernia in 
 the vagina, can only be ascertained by at- 
 tending to the symptoms which characterize 
 this sort of rupture. See Hernia. 
 
 Consult particularly Sabatier, Medecine 
 Op6ratoire, T. 2, p. 486, fyc. Edit. 2. Rich- 
 ter, Ansfangsgrtinde der Wundarzneykunst , B. 
 7, Kap. 4. 
 
 VARICOCELE. (from varix, a distended 
 vein, and kuav, .a tumour.) Many writers 
 mean by the term varicocele, a varicose en- 
 largement of the spermatic veins, which lat- 
 ter affection I have, with Celsus and Pott, 
 treated of under the name of Cirsocele. 
 
 Pott remarks, that the varicocele (which 
 is an enlargement and distention of the 
 blood-vessels of the scrotum) is very seldom 
 an original disease, independent of any other, 
 and when it is, is hardly an object of surge- 
 ry. The blood-vessels of the scrotum are 
 of different size in different people ; and like 
 the vessels in other parts of the body, are 
 liable to become varicose; but they are 
 seldom so much enlarged as to be irouble- 
 -sorae, unless such enlargement is the conse- 
 quence of a disease, either of the testicle, 
 or spermatic chord. When this is the case, 
 the original disease is what engages our at- 
 tention, and not this simple effect of it ; and, 
 therefore, considered abstractedly, the vari- 
 cocele is a disease of no importance, ( Poll's 
 Chirurgical Works , Vol , 2.) 
 
 VARICOSE ULCER. See Ulcer, and 1 
 Varicose Veins. . 
 
 ^VARICOSE VEINS. The term varix , 
 is applied by surgeons to the permanently' 
 dilated state of a vein, attended with an ac- 
 cumulation of dark-coloured blood, the cir- 
 culation of which is materially retarded in 
 the affected vessel. When veins are vari- 
 cose, they are not only dilated, they are also 
 evidently elongated ; for besides being irre- 
 gular, and in several places studded with 
 knots, they make a variety of windings, and 
 coiling themselves, form actual tumours from 
 the assemblage of their convolutions in one 
 particular place. When the branches of a 
 vein, thus dilated and elongated, are nume- 
 rous, and confined to a certain part of the 
 body, they constitute a very distinct swell- 
 ing. Indeed, when the diseased vessels are 
 situated near the integuments, the surgeon 
 can feel, and even see their tortuous course 
 These things, for instance, are remarkably 
 obvious in the vena saphena interna, in 
 which the affection is particularly common. 
 This vessel may be observed to form in its 
 course several ol these swellings, in the inter- 
 spacesof which it runs in a very serpentine 
 manner. 
 
 Varices are most commonly observed in 
 t l /Q lower extremities, reaching sometimes 
 even as far up as the abdomen. They have, 
 hovVever, been noticed in the upper extremi- 
 ties, and it is probable that the whole venous 
 system is susceptible of the affection.. As a 
 well-informed writer observes ; “ The great 
 venous trunks sometimes become varicose. 
 When the disease is situated near the heart, 
 it. is attended with pulsation, which renders 
 it liable to be mistaken tor aneurism. Mor- 
 gagni observed, that the jugular veins were 
 occasionally very much dilated, and pos- 
 sessed a pulsation. (Letter 8, art. 9, 10, U.) 
 He also relates a case in which the vena 
 azygos, for the length of a span, was so 
 much dilated, that it might be compared with 
 the vena cava. The patient died suddenly in 
 consequence of the rupture of this varix into 
 the right side. of the chest. (Letter 26, art. 29.) 
 A similar case is related by Portal, w ho also 
 mentions an instance in which the right sub- 
 clavian vein was excessively dilated, and 
 burst iuto she cbest- (C 'ours d' Anatomic 
 Medicate, tom. 3, p. 354, 373.) Mr. Clme 
 described in his lectures the case of a wo- 
 man who had a large pulsating tumour in her 
 neck, which burst and proved fatal by be- 
 morrhage. A sac proceeded from the inter- 
 nal jugular vein ; the carotid artery was 
 lodged in a groove at the posterior part of 
 this sac. The veins of the upper extremity 
 very rarely become varicose. Excepting 
 cases of aneurismal varix, the only instance 
 of this disease w ith which I am acquainted, 
 is mentioned by Petit. ( Trait 6 des Maladies 
 Chir. Tom. 2, p 49.) In this case, a varix 
 was situated at the bend of the arm : the pa- 
 tient was so fat that no other vein could be 
 found for the purpose of venesection, which 
 operation Petit repeatedly performed by 
 puncturing this varix. The superficial epi- 
 gastric veins sometimes become varicose. 
 
VARICOSE VEINS. 
 
 589 
 
 out the most frequent seats of this disease 
 are the venae saphenae, the spermatic, and 
 hemorrhoidal veins.” (See Hodgson's Trea- 
 tise on the Diseases of Arteries and Veins, p. 
 538, 539.) The deep-seated veins of the 
 extremities seldom become varicose. The 
 disease rarely occurs before the adult period 
 of life, and its progress is extremely slow. 
 It is very frequently remarked in pregnant 
 women, who have passed a certain age; 
 but it is particularly unusual for it to happen 
 in young women, even during a series of 
 repeated pregnancies. Surgeons have not 
 hitherto made out any very precise infor- 
 mation, respecting the kinds of constitution 
 which promote the occurrence of a varicose 
 enlargement of the veins. Nor has it been 
 well proved, that the disease often proceeds 
 from swellings of the abdominal viscera, or 
 any other species of tumour capable of me- 
 chanically obstructing the venous circula- 
 tion. One or more veins of the same limb 
 are at first most commonly affected with a 
 slight degree of dilatation, without pain or 
 any sensation of uneasiness. This beginning 
 change ordinarily advances with great slow- 
 ness, except in cases Where it accompanies 
 pregnancy, in which circumstance, one, or 
 both the lower extremities, as early as the 
 first months, are frequently seen covered with 
 largely dilated veins, or even with tumours 
 formed by an assemblage of varices. The 
 veins gradually become more ami more dis- 
 tended, lengthened, coiled up, and tortuous. 
 The patient then begins to complain of a 
 sense of heaviness, numbness, and sometimes 
 of very acute wandering pain, through the 
 whole of the affected limb. In a more ad- 
 vanced stage, in proportion as the varices 
 increase, and especially when the dilated 
 veins actually form tumours, the limb swells 
 and becomes more or less cedematous, ac- 
 cording to the extent of the disease, and the 
 time which it has existed. Delpech thinks, 
 however, that the cederna in this ca3e, is not 
 such as to justify the conclusion, that the in- 
 creased size of the veins, and the way in 
 which they distend the integuments, produce 
 a mechanical interruption of the function 
 of the absorbent systopi. For, says he, 
 enormous varices are sometimes, though not 
 often' met with, which are not attended with 
 any swelling of the cellular substance ; and 
 cases are slid more frequently seen, in which 
 there is a considerable degree of cederna, 
 while the varices are scarcely remarkable. 
 When the latter have prevailed a long while, 
 and made much progress, the coats of the 
 affected veins are not unfrequently thicken- 
 ed, swelled, and indurated, forming a sort of 
 half-canal, or solid tube. As Mr. Hodgson 
 remarks, *• the blood occasionally deposits 
 strings of coagulum in varicose veins : when 
 this is the case, the vessel is incapable of 
 being emptied by pressure, and is firm to 
 the Joueh. The deposition does not in ge- 
 neral fill the vessel, but by diminishing its 
 calibre, it retards the flow of blood, and 
 causes the dilatation to increase in the inferior 
 portion of fhe vein, and in the branches 
 which open into it.” (On, the Diseases of 
 
 Arteries and Veins, p. 541.) 'Ibis gentleman 
 has seen four cases, in which the coagulum 
 accumulated to such an extent, that the ca- 
 nals of the dilated vessels were obliterated., 
 and a spontaneous cure was the consequence 
 The excessive distention of the coats of n 
 superficial vein produces an inflammatory 
 irritation, at first in the adjoining cellular 
 membrane, and afterward in the integu- 
 ments. These organs become at first con- 
 nected together by the adhesive inflamma- 
 tion ; and if the distention continues to ope- 
 rate, they may at length ulcerate and burst, 
 and hemorrhage be the consequence. In 
 such cases, the effusion of blood is some- 
 times considerable ; but, says Delpech, we 
 have no example of its having proved dan- 
 gerous. The syncope following it ; or a 
 moderate compression, suffices for its stop- 
 page. A more common occurrence than 
 bleeding, is the coagulation of the blood in 
 the cavity of a varicose vein. The vessel 
 then becomes hard and incompressible, and 
 it loses tiiat elastic yielding softness, which 
 renders it capable of being diminished by 
 gentle pressure. If the parts be already in- 
 flamed, Delpech conceives, that the clot in 
 the diseased vein may act as an extraneous 
 body, and bring on ulceration, by the effects 
 of which it is at last brought into view. It^ 
 this sort of case, it is extremely uncommon 
 for hemorrhage to occur ; for in general, the 
 vessel is already obliterated by the preceding 
 inflammation. But the ulcer itself is very 
 difficult to heal, and may be kept up a long 
 while by the cedpmatous swelling of the 
 limb. Varices, or rather the oedema, which 
 is the consequence of them, has the same 
 effect upon every other species of ulcer, 
 and even upon the most simple solution of 
 continuity. While the swelling of the limb 
 cannot be dispersed ; while the edges of a 
 solution of continuity are kept asunder by 
 the tense state of the skin; and while the 
 divided parts are irritated by this painful 
 tension ; every thing is unfavourable to cica- 
 trization. Thus we see the most simple 
 wounds, which have been allowed to suppu- 
 rate, and ulcers which should have healed 
 rapidly, continue uncured a great many 
 years, merely because the limbs on which 
 they are situated, are affected with an oede- 
 matous swelling, the consequence of vari- 
 ces. Such is the condition of things in the 
 case which has been improperly named the 
 varicose ulcer. ( Delpech , Pricis des Mala- 
 dies Chir. Tom. 3, sect. 8, art. 3.) 
 
 In the investigation of the causes of vari- 
 ces, it is usual to dwell very much upon the 
 mechanical obstructions which may affect 
 the circulation of the blood in the veins. 
 Surgeons have thought themselves justified 
 iu regarding this as the only cause, because 
 a circular, moderate compression, incontes- 
 tably retards the course of the blood iu 
 these vessels, and produces a temporary dila- 
 tation of them, i'he opinion seems also to 
 derive confirmation from the knotty appear 
 ance of varicose veins, a circumstance which 
 has been accounted for by supposing that 
 the distention is greatest in the situation of 
 
V ARICOSE VEINS 
 
 <>90 
 
 the valves. Lastly, the idea is further sup- 
 ported by the well-known fact of the fre- 
 quent occurrence of varices during the state 
 of pregnancy. But it has not been remem- 
 bered, that the use of garters, for example, 
 is extremely common ; yet varices of the 
 legs are infinitely less frequent ; that very 
 large varices are met with in persons, who 
 have never employed anj r kind of ligatures, 
 to which the origin of the complaint can 
 be imputed ; that when the dilatation of the 
 veins extends to the thighs and parietes of 
 the abdomen, no causes of this description 
 even admit of suspicion; that varicose veins 
 are observable round several kinds of tu- 
 mours, especially scirrhi, when there is no 
 possibility of pointing out any mechanical 
 obstruction to the circulation of the blood ; 
 that varices sometimes make their appear- 
 ance at the commencement of pregnancy, 
 and long before the enlargement ot the 
 womb can impede the free return of the 
 blood through the veins in the pelvis ; that 
 nothing is more unusual, than a varicose di- 
 latation of the veins of the lower extremi- 
 ties in consequence of swellings of the ab- 
 dominal viscera ; and lastly, it has been for- 
 gotten, that the knots of the dilated veins 
 are far too numerous to admit of being as- 
 cribed to the resistance of the valves. It 
 cannot be denied, that pressure applied in 
 the track of the vessels tends to promote 
 their dilatation : but it can neither be con- 
 sidered as tiie only cause, nor as the princi- 
 pal one. The foregoing observations, made 
 by Delpech, render it probable, that some 
 unknown general cause is concerned in pro- 
 ducing varices, the formation of which may 
 also be facilitated by the impediments to the 
 free return cf the blood, occasioned by 
 certain attitudes, and particular articles of 
 clothing. 
 
 Mr. Hodgson conceives it probable, that, 
 in some instances, the valves are ruptured in 
 consequence of muscular exertions or ex- 
 ternal violence, in which cases the pressure 
 of the column of blood is the first cause of 
 the dilatation of the veins. Sometimes also 
 the disease appears to arise from preternatu- 
 ral weakness in the coats of the veins, as, 
 in those instances, in which, without any 
 evident cause, it exists in various parts of the 
 same person. ( Treatise on the Diseases of 
 Arteries and Veins , p. 537.) 
 
 Experience proves, says Delpech, that 
 there is no ceriain mode of curing varices , 
 strictly so called, which he thinks cannot be 
 wondered at, since the nature and causes of 
 the disease are completely unknown. The 
 same source of knowledge, however, also 
 proves, that the increase in the dilatation of 
 varicose veins may be retarded, and that the 
 oedematous swelling, attendant on the com- 
 plaint, may be beneficially opposed by me- 
 thodical and permanent compression. When 
 the whole of a limb, affected with varices, is 
 subjected to this last mode of treatment, the 
 dilated veins subside, the circulation is more 
 regularly performed, and the ccdema and pain 
 '.ease There is not (says Delpech) any bet- 
 ter method cf healing the solutions of con- 
 
 tinuity in the soft parts, produced or kept up 
 by the varicose state of the limb, and its 
 consequences. But sometimes, as soon as 
 the compression is discontinued, the varices 
 make their appearance again, the pain recurs, 
 the oedema returns, and the ulcers which 
 were healed break out afresh. 
 
 Inflammation of the integuments covering 
 a varix, or varicose tumour, cannot invaria- 
 bly be prevented by compression ; nor will 
 this treatment always succeed even in remo- 
 ving the intolerable pain which sometimes 
 attends numerous clusters of varicose veins. 
 In the first case, rest and relaxing applica 
 tions will often succeed ; and in the second, 
 the topical use of sedatives frequently gives 
 relief. It has been proposed to puncture and 
 empty varicose veins; but if a temporary 
 emptiness and relaxation of these vessels 
 were to remove the pain for a time, things 
 would fall into the old state again in the 
 course of a few days. If the plan were 
 adopted, it would be necessary to make a 
 free opening in the dilated vein, and extract 
 the coagulum. The vessel would then need 
 no ligature above and below the opening, 
 for the slightest compression would afterward 
 stop the bleeding, and the vessel be oblitera 
 ted by the subsequent inflammation. 
 
 We learn from Celsus, that the ancients 
 were accustomed to remove varices by exci- 
 sion, or destroy them with the oautery. ( De 
 Re Medicd, lib. 7, cap . 3.) When the vein 
 was much convoluted, extirpation with the 
 knife was preferred ; but in other cases, the 
 dilated vessel was exposed by an incision, 
 and then cauterized. Petit, Boyer, and many 
 British surgeons, have also sometimes cut out 
 clusters of varicose veins. 
 
 Delpech remarks, that the extirpation of 
 tumours composed of numerous varices has 
 been practised, either for the purpose of re 
 moving the pain in the situation of the dis- 
 ease, or other inconveniences. This opera- 
 tion has been successfully performed ; but it 
 appears not to have constantly had the effect 
 of preventing the formation of new varices, 
 and it has sometimes proved tedious, diffi- 
 cult, and severely painful in its execution. 
 In fact, an erroneous judgment must neces- 
 sarily be formed of the extent of these swell- 
 ings, when they are judged of only from the 
 appearance which they present under the 
 skin. Varices are not always confined to the 
 superficial veins, and when they extend 
 deeply, the operation must be ineffectual. 
 The opinion of Delpech is, that it should 
 never be undertaken, unless the disease be 
 accompanied with perilous symptoms, or the 
 patient nearly deprived of the use of his 
 limb. 
 
 It has been thought, that one of the esta- 
 blished principles in the treatment of aneu- 
 risms might be advantageously extended to 
 the cure of varicose veins. By tying the 
 principal venous trunk above the point to 
 which the varicose affection reaches, it is 
 said, that the course of the blood in the mor- 
 bid vessels may be totally stopped ; the co- 
 lumn of this fluid made to coagulate ; and 
 
VARICOSE VEINS. 
 
 ' 1 j i 
 
 .he consequent obliteration of the vessels 
 themselves accomplished. 
 
 The practice of tying veins for the cure 
 of varices, appears to have been employed 
 in the . days of Pare and Dionis, (Cours d' Ope- 
 rations de Chirurgic, p. 610,) who have ac- 
 curately described the operation of tying and 
 dividing the vein between the two ligatures. 
 Sir Everard Home has related many cases 
 of varicose, veins in the lee, some of them 
 accompanied with tedious ulcers, which, af- 
 ter the vena saphena major had been tied, as 
 it passes over the inside of the knee, were 
 readily healed, and the dilatation of the veins 
 of the leg relieved. 
 
 This practice has sometimes answered ; 
 but it bas also had its failures. 
 
 Among other evils, an inflammation of the 
 lied vein has been observed extending very 
 far in (he vessel, and succeeded by great con- 
 stitutional disorder, symptoms very anala- 
 gous to those of typhus fever, and death. In 
 some of these cases, previously to their ter- 
 mination, abscesses form in the direction of 
 the vessel below or above the ligature ; in 
 others, such collections of matter are not 
 observed. (See Travers on Wounds and 
 Ligatures of Veins. Surgical Essays, Part 
 1,p. 216, ard Oldknoiv, in Edinb. .Med. and 
 Surg. Journ. Vol. 5. R. Carmichael , in Trans, 
 of the King's and Queen's College of Physi- 
 cians, Vol. 2, p. 345, $-c.) Indeed, the dan- 
 gers arising from an inflammation of the in- 
 ternal coat of the veins are now generally 
 acknowledged, and every endeavour should 
 be made to avoid them. A case which hap- 
 pened in Guy’s Hospital, in 1S16, fully proves 
 them : the femoral vein happened to be 
 pricked in an operation for aneurism, and a 
 ligature was applied round the aperture. In- 
 flammation of its internal coat took place, 
 extending up into the vena cava, and the pa- 
 tient is supposed to have died of the indis- 
 position resulting from it. (See Travers's 
 Surgical Essays, Part 1, p. 222.) 
 
 Hence arises one of the most weighty ob- 
 jections to the practice of tying the trunks 
 of varicose veins, with the view of curing 
 their morbid dilatation, and its effects upon 
 the limb. 
 
 As Mr. Brodie observes, it seems to be 
 now established by the experience of mo- 
 dern surgeons, that a mechanical injury, in- 
 flicted on the trunk of one of (lie larger 
 veins, is liable to be followed by inflamma- 
 tion of its internal membrane, and a fever 
 of a very serious nature ; and (he occasional 
 occurrence of these symptoms, after the liga- 
 ture, or even the simple division of the vena 
 saphaena, has made surgeons less confident 
 than formerly of the propriety of attempt- 
 ing such operations for the relief of a vari- 
 cose state of the branches of that vessel in 
 the leg. Certain reflections, however, indu- 
 ced Mr. Brodie to think, that the same ill 
 effects would not follow a similar operation 
 performed on the branches themselves. 
 
 Where the whole of the veins of the leg 
 are in a state of morbid dilatation, and the 
 distress produced by the disease is not refer- 
 red to any particular part, there seem to he 
 
 no reasonable expectations of benelit, except 
 from the uniform pressure of a well-applied 
 bandage. But not unfrequehtly we find an 
 ulcer which is irritable, and difficult to heal 
 on account of its connexion with some Vari- 
 cose vessels ; or without being accompanied 
 by an ulcer, there is a varix in one part of 
 the leg, painful, and perhaps liable to bleed, 
 while the veins in other parts are nearly in a 
 natural stale, or, at any rate, are not the 
 source of particular uneasiness. In some of 
 these cases, I formerly applied the caustic 
 potash, so as to make a slough of the skin 
 and veins beneath it ; but I found the relief 
 which the patient experienced from the cure 
 of the varix, to afford but an inadequate com 
 pensation for the pain to which he was sub- 
 jected by the use of the caustic, and the in 
 convenience arising from the tedious healing 
 of the ulcer, which remained after the sc 
 paration of the slough. 
 
 “ In other cases, 1 made an incision with 
 a scalpel through the varix and skin over it. 
 This destroyed the varix as completely as it 
 was destroyed by the caustic, and I found it 
 to be preferable to the use of the caustic, as 
 the operation occasioned less pain, and as, 
 in consequence of there being no loss of sub- 
 stance, the wound was cicatrized in a much 
 shorter space of time. 1 employed the ope- 
 ration, Such as I have described it, with ad- 
 vantage in several instances ; but some 
 months ago I made an improvement in the 
 method of performing it, by which it is much 
 simplified; rendered less formidable, not 
 only in appearance, but also in reality ; and 
 followed by an equally certain, but more 
 speedy cure. 
 
 “ It is evident, (says Mr. Brodie,) that the 
 extensive division of the skin over a varix can 
 be attended with no advantage. On the con- 
 trary, there must be a disadvantage in it, as a 
 certain time will necessarily be required for 
 the cicatrization of the external wound. The 
 improvement to which 1 allude, consists in 
 this : the varicose vessels are completely di- 
 vided, while the skin over them is preserved 
 entire, with the exception of a moderate punc- 
 ture, which is necessary for the introduction 
 of the instrument with which the incision of 
 the veins is effected. Thus the wound of 
 the internal parts is placed under the most 
 favourable circumstances for being healed, 
 and the patient avoids the more tedious pro- 
 cess which is necessary for the cicatrization 
 of a wound in the skin above. 
 
 “ For this operation, I have generally em- 
 ployed a narrow, sharp-pointed bistoury, 
 slightly curved, with its cutting edge on the 
 convex side. Having ascertained the pre- 
 cise situation of the vein, cr cluster of 
 veins, from which the distress of the patient 
 appears principally to arise, I introduce the 
 point of the bistoury through the skin on 
 one side of the varix, and pas; it on between 
 the skin and the vein, with one of the flat surfa- 
 ces turned forwards, and the other backwards, 
 until it reaches the opposite side. I then 
 turn the cutting edge of the bistoury back- 
 wards, and in withdrawing the instrument, 
 the division of the varix 19 effected. The 
 
VEINS, DISEASES 01 
 
 592 
 
 patient experiences pain, which is occasion- 
 ally severe, but subsides in the course of a 
 short time. There is always hemorrhage, 
 which would be often profuse if neglected, 
 but which is readily stopped by a moderate 
 pressure, made by means of a compress and 
 bandage carefully applied.” 
 
 Mr. Brodie particularly enjoins the ne- 
 cessity of keeping the patient quietly in bed 
 for four or five days after the ope ation, and 
 removing the bandage and first dressings 
 with the utmost care and gentleness. He 
 also cautions surgeons not to make the in- 
 cision more deep than absolutely necessary. 
 Inflammation of the coats of the veins has 
 not occurred in any of the cases, in which 
 Mr. Brodie has adopted this method of treat- 
 ment. This gentleman wishes it to be un- 
 derstood, however, that he does not recom- 
 mend the practice indiscriminately, but with 
 a due attention to the circumstances of each 
 individual case. “ The cases for which it is 
 fitted, "are not those in which the veins of 
 the leg generally are varicose, or in which 
 the patient has little or no inconvenience 
 from the complaint; but those in which 
 there is considerable pain referred to a par- 
 ticular varix ; or in which hemorrhage is 
 liable to take place from the giving way of 
 the dilated vessels ; or in which they occa- 
 sion an irritable and obstinate varicose ul- 
 cer.” (See Mdd. Chir. Trans. Vol. 7, p. 
 195, et seq ) 
 
 On the subject of cutting through veins 
 affected with varix, it is proper to observe, 
 that even this plan has been known to bring 
 on severe and fatal symptoms. Cases, con- 
 firming this fact, are recorded in a valuable 
 modern work, which should be in the hands 
 of every practical surgeon. (See Hodgson's 
 Treatise on the Diseases of Arteries and Veins, 
 p. 555, et seq.) It is but justice to state, 
 .however, that, in these examples, Mr. Bro- 
 die’s manner of doing the operation was not 
 adopted. On the contrary, his method, as 
 far as l have yet heard, receives very gene- 
 ral approbation. Some cases and observa- 
 tions highly in favour of it, are detailed by 
 Mr. Carmichael. (See Tram, of the King’s 
 mid Queen’s College of Physicians, Vol. 2, 
 p. 369, fyc.) 
 
 Cases of spontaneous varix in the veins of 
 the arm are rarely observed. When these 
 vessels become varicose, it is almost always 
 in consequence of a communication being 
 formed, in the operation of venesection, 
 between the brachial artery and one of the 
 veins at the bend of the arm. The super- 
 ficial veins in this situation then become 
 more or less dilated, by the impulse of the 
 .stream of arterial blood which is thrown 
 into them. There is, however, a good deal 
 of difference between these accidental va- 
 rices, actually induced by a mechanical 
 cause, and those which originate sponta- 
 neously, or from causes not very clearly 
 understood. The former never acquire the 
 size which the latter often attain ; they 
 never exceed a certain magnitude, whether 
 pressure be employed or not ; they never 
 form tumours composed of an assemblage 
 
 of varicose veins ; they are never filled wuh 
 tough coagula of blood ; their coats are 
 never thickened, nor constitute the solid 
 half-canal remarked in the other species of 
 varices; the skin, which covers them, is 
 not disposed to inflame and ulcerate ; they 
 are not subject to occasional hemorrhage ; 
 and the limb is not affected with any cede- 
 matous swelling. ( Delpech , Traiti des Ma- 
 ladies Chir. T. 3, p. 261.) These circum- 
 stances render it evident, that here all sur- 
 gical interference would be unnecessary. 
 
 See Aneurism, where the aneurismal va- 
 rix is described ; Cirsocele, where the varix 
 of the spermatic chord is treated of; He- 
 morrhoids, where the diseased and enlarged 
 veins of the rectum are considered ; Vari- 
 cocele, where those of the scrotum are no- 
 ticed. 
 
 VA'RIX. (from varius, unequal.) The 
 term varices is applied to a kind of knotty, 
 unequal, dark-coloured swelling. arising from 
 a morbid dilatation of veins. (See Varicose 
 Veins.) 
 
 VEINS, DISEASES OF. To the obser- 
 vations and references made in the prece- 
 ding article ( Varicose Veins,) I here annex a 
 few remarks on the principal diseases of the 
 venous system, in order to render what has- 
 been already stated, in other parts of the 
 work, more complete. 
 
 It is justly observed by Mr Hodgson, that 
 11 the veins are liable to all those morbid 
 changes which are common to soft parts in 
 general ; but the membranous lining of these 
 vessels is peculiarly susceptible of inflam- 
 mation. When a vein is wounded, the in- 
 flammation, which is the effect of the injury, 
 sometimes extends along the lining of the 
 vessel into the principal venous trunks, and 
 in some instances, even to the membrane 
 which lines the cavities of the heart. This 
 inflammation sometimes produces an effu- 
 sion of coagulating lymph, by which the 
 opposite sides of the vein are united, so as 
 to obliterate the tube ; in this manner a 
 great extent of the vessel is occasionally 
 converted into a solid cord. In some in- 
 stances, the secretion of pus into the cavity 
 of the vessel is the consequence of inflam- 
 mation of the membranous lining of veins : 
 under these circumstances, the matter is 
 either mixed with the circulating blood, or, 
 the inflammation having produced rfdhcsion 
 of the sides of the vessel at certain intervals, 
 boundaries are formed to the collection ot 
 pus, which in this manner form a chain ot 
 abscesses in the course of the vessel. 
 
 “ When the inflammation of veins is not 
 very extensive, its symptoms are the same 
 as those of local inflammation in general : 
 but when the inflammation extends into the 
 principal venous trunks, and pus is secreted 
 into the vessel, it is accompanied with a 
 high degree of constitutional irritation, and 
 with symptoms which bear a striking re- 
 semblance to those of typhus fever. (See 
 Hodgson’s Treatise on the Diseases of Arteries 
 and Veins, p. 611, 512.) 
 
 Besides the example of inflammation ot 
 femoral and other large veins, brought on 
 
VENEREAL DISEASE. 
 
 o9J 
 
 by u ligature round a small aperture, acci- 
 dentally made in the femoral vein, in the 
 operation for popliteal aneurism, as men- 
 tioned in a foregoing article, (Varicose Veins.) 
 Mr. Travers reports another case, in which 
 a fatal inflammation of the femoral and ex- 
 ternal iliac veins, with marks of diffused in- 
 flammation up to the right auricle, was ap- 
 parently caused by the application of a liga- 
 ture to the mouth of the femoral vein, after 
 an amputation. (P. 227.) And the same 
 catastrophe would appear to be occasionally 
 the result of venous inflammation after am- 
 putation, even where the femoral vein is 
 not tied. (See Carmichael, in Trans, of 
 King's and Queen's College of Physicians, 
 Val. 2, p. 365.) In short, Mr. Travers’s ob- 
 servations, as well as those of Mr. Hodgson 
 and Mr. Carmichael, tend to prove, “ that 
 the inflammation of the interior tunic of a 
 vein sometimes follows a puncture, some- 
 times a division, a ligature encircling the 
 tube, or including only a part of it, or arises 
 spontaneously from an inflamed surface, of 
 which the vein forms a part.” (P. 238.) 
 Mr. Carmichael relates an instance, in which 
 the appearances after death seem to evince 
 that the patient died subsequently to an op- 
 eration .for femoral aneurism, of inflamma- 
 tion and suppuration within the femoral 
 vein, and extending both down the saphena, 
 and upwards through the common iliac vein. 
 The femoral vein had been pricked in the 
 operation, but not tied. (Trans, of the 
 King's and Queen's College of Physicians, 
 Ireland, Vol. 2. p. 350, fyc.) In order to 
 avoid the danger of wounding the femoral 
 vein, above the edge of the sartorius, Mr. 
 Carmichael recommends “ introducing the 
 needle on the pubal side of the artery 
 (P. 357) a direction which should have been 
 considered in the article .Aneurism. 
 
 Inflammation frequently produces a thick- 
 ening of the coats of the veins, as well as 
 adhesion of their sides, and obliteration of 
 their cavities. Indeed, in some instances, 
 these vessels have been found to resemble 
 arteries in the thickness of their coats, and 
 in retaining a circular form when cut across. 
 ( Hodgson , up. cit. p. 513.) 
 
 Ulceration sometimes extends to the coats 
 of veins, and, by exposing their cavities, 
 gives rise to hemorrhage. In certain exam- 
 ples, it commences in the membranous li- 
 ning, and destroys the other coats. In ge- 
 neral, however, the adhesive inflammation 
 precedes the ulcerative, and by obliterating 
 the cavities of these vessels, prevents the oc- 
 currence of hemorrhage. When sphacela- 
 tion takes place in the vicinity of veins, 
 their cavities, like, those of arteries under 
 similar circumstances, are filled with exten- 
 sive plugs of coaguium, which prevent he- 
 morrhage upon the separation of the mor- 
 tified part. 
 
 Veins are sometimes Ruptured, without 
 any previous morbid alteration in their 
 structure, and the accident may be induced 
 by muscular exertions, external violence, 
 the sudden effects of the cold bath, &,c. 
 
 Although a deposition of calcareous mat- 
 R Vot,. If, 75 
 
 ter almost invariably takes place in the ar- 
 teries of persons advanced in life, it is an 
 extremely rare occurrence -in the coats of 
 veins 
 
 Loose calculi have been found in the ca- 
 vities of veins ; and tumours sometimes 
 grow from their lining. In a case of scir- 
 rhous pylorus, Mr. Hodgson found a turnout*) 
 larger than a hazel nut, growing from the 
 lining of the splenic vein,’ and resembling in 
 its appearance and consistence the disease 
 which existed at the pylorus. (P. 524.) 
 
 The venous, like the arterial system, ap- 
 pears to be capable of carrying on a colla- 
 teral circulation, when any part of it is im- 
 pervious. Even after the obliteration of 
 the vena cava inferior, the blood lias been 
 known to be conveyed with facility loibe 
 heart through the lumbar veins and vena 
 azygos. In the case recorded by Dr. Baillie, 
 ( Trans, for the Improvement of Medical and 
 Chir. Knowledge, Vol. 1, p. 127.) it is. re- 
 markable, that the vena cava inferior was 
 obliterated at the point where the venae 
 cavee hepaticee opened Into it, so that not 
 only the blood from the lower extremities, 
 but also that from the liver, must have pass- 
 ed through collateral channels to the heart. 
 
 Want oi : room having prevented me from 
 introducing further observations on the dis- 
 eases of veins, I must refer to the following 
 works for additional , information. J. Hun- 
 ter, in Trans, for the Improvement of Med. 
 and Chir. Knowledge, Vol. J. Abernethy's 
 Works. J. Hodgson on the Diseases of Arte- 
 ries and Veins. Longuet , Dis. sur 1' Inflam- 
 mation des Veins, Paris, 1815. B. Tracers, 
 in Surgical Essays, Part 1, 8ro. Lond. 1818. 
 F. A. B. Puch el t , Das Venensystem in Seinen 
 Krankhaflen Verhaltnissen. Sro. Leipz 1818. 
 R. Carmichael, in Trans, of the Association of 
 Fellows, fyc. of the King's and Queen's Col- 
 lege of Physicians in Ireland, Vol. 2, Svo. 
 Dublin, ISIS. 
 
 VENEREAL DISEASE. (Lues Venerea 
 Morbus Gallicus. Syphilis.) About the year 
 1494, or 1495, the venereal disease is said 
 to have made its first appearance in Europe. 
 Some writers believe, that it originally broke 
 out at the siege of Naples ; but most of them 
 suppose that, as Columbus returned from 
 his first expedition to the West Indies about 
 the above period, his followers brought the 
 disorder with them from the new to the old 
 world. Other authors, however, among 
 whom is Mr. B. Bell, maintain the opinion, 
 that the venereal disease was well known 
 upon the old continent, arid that it pre- 
 vailed among the Jews, Greeks, and Ro- 
 mans, and their descendants, long before 
 the discovery of America. 
 
 Although many considerations lead me 
 to reject the common history of syphilis as 
 fabulous, I mean that account which refers 
 its origin to America, or the French array 
 in Italy, it does not appear to me. that any 
 utility would be likely to result from agita- 
 ting this question in modern tunes, because, 
 if it be true, as the most candiAwid intelli- 
 gent surgeons of the present rally 
 
 acknowledge, that they cannot precisely 
 
 A 
 
V IbNEltEAL DISEASE 
 
 b94 
 
 define what the venereal disease is, nor al- 
 ways point out the exact circumstances, in 
 which it differs from some other anomalous 
 complaints, even when the cases are before 
 their eyes, how can such discrimination be 
 attempted from a mere review of old de- 
 scriptions, unaccompanied with the advan- 
 tage of letting the reader judge from the 
 living patients themselves P But, as far as 
 the nature of the venereal disease has been 
 unravelled, and it is allowable to judge from 
 such comparisons, I may be permitted to 
 remark, that, in degree of severity, the 
 acuteness of symptoms, rapidity of propa- 
 gation, and extent and quickness of fatality, 
 no forms of disease, now ever conjectured 
 to be venereal, bear the least resemblance 
 to the destructive malady, with which the 
 army before Naples, at the close of the fif- 
 teenth century, was afflicted : nor will any 
 ignorance of the uses of mercury, as will be 
 presently noticed, explain differences so 
 strongly marked. 
 
 The venereal disease is supposed to arise 
 from a specific morbid poison, w hich, when 
 applied to the human body, has the power 
 of propagating or multiplying itself, and is 
 capable of acting both locally and constitu- 
 tionally. 
 
 Mr. Hunter was of opinion, that the ef- 
 fects produced by the foison arise from its 
 peculiar or specific irritation, joined with 
 the aptness of the living principle to be irri- 
 tated by such a cause, and the parts so irri- 
 tated acting accordingly. Hence, he con- 
 sidered. that the venereal virus irritated the 
 living parts in a manner peculiar to itself, 
 and produced an inflammation, peculiar to 
 that irritation, froiri which a matter is pro- 
 duced, peculiar to the inflammation. 
 
 The venereal poison is capable of aflat: t- 
 ing the human body in two different ways : 
 locally, that is, in those parts only to which 
 it is first applied ; and constitutionally, that 
 is, in consequence oi its absorption. 
 
 In whatever manner the venereal disease 
 was first produced, it began, says Mr. Hun- 
 ter, in the human race, as no other animal 
 seems capable of being affected by it. He 
 conceives also, that the parts of generation 
 were those first affected ; for, if the disease 
 had taken place on any other part, it would 
 not have gone further than tne person in 
 whom it first arose. On the contrary, if 
 the disease, in the first instance ot its for- 
 mation, be presumed to have attacked the 
 parts of generation, where the only natural 
 connexion takes place, between one human 
 being and another, except that between the 
 mother arid child, it was in the most favour- 
 able situation for being propagated ; and 
 Mr. Hunter infers, also, that the first effects 
 of the 'disease must have been local, in con- 
 sequence ol ijie fact, now well established, 
 that none of the constitutional effects are 
 communicable to other persons, ihat is to 
 say, infectious^ 
 
 Thus, the Atfinberless cases of the vene- 
 real diseasaJpicting generation after gene- 
 ration, ijyjdjBbservable in all the known 
 parts effme world, are. supposed to be 
 
 originally derived from the amours oi some' 
 unfortunate individual, in whom the poison 
 was first formpd, from causes beyond the 
 reach of human investigation. But, that any 
 statement of this kind is more valuable than 
 unsupported conjecture, is a proposition to 
 which my mind is not prepared to assent, 
 particularly when it is considered, that sores 
 on the genitals, giving rise to such constitu- 
 tional symptoms as puzzle the most discern- 
 ing practitioners of the present enlightened 
 days of medical science, are often of a very 
 diversified character, so as hardly to admit, 
 of reference to one common origin. And, 
 as l have already hinted, every modern spe - 
 culation, about the first origin of the distem- 
 per, promises but little instruction orsuccess, 
 because the question relates to a disease, 
 the diagnosis of which is still very unsettled, 
 and the complete definition of which has 
 hitherto baffled men of the greatest genius 
 and experience. 
 
 According to Mr. Hunter, the venereal 
 poison is commonly in the form of pus, or 
 some other secretion. In most cases, it ex 
 cites an inflammation, which (to use the 
 same author's language,) is attended with a 
 specific mode of action, different from an 
 other actions attending inflammation, and 
 accounting for the specific quality in the 
 matter. 
 
 The formation of matter, though a general;, 
 is not a constant attendant on this disease , 
 for inflammation, produced by the venereal 
 poison, sometimes does not terminate in 
 suppuration. But, if Mr. Hunter’s senti- 
 ments are correct, it is the matter produced, 
 whether with or without inflammation, 
 which alone contains the poison. Hence a 
 person, having the venereal irritation in any 
 form, not attended with a discharge, cannot 
 communicate the disease to another. In 
 proof of this doctrine, he states, that though 
 married men often contract the disease, and 
 continue to cohabit with their wives, even 
 for weeks, yet, in the whole of his practice, 
 he never once found, that the complaint w as 
 communicated under such circumstances, 
 except when connexion had been continu- 
 ed after the appearance of the discharge. 
 
 The late Mr. Hey, of Leeds, however, 
 gave it as his opinion, that a man might com 
 municate lues venerea, after all the symp- 
 toms of the disease had been removed, and 
 he was apparently in perfect health. (Sec 
 I, fed. Chir. Trans. Vol. 7, p. 547.) This senti- 
 ment is not only repugnant to the authority 
 of Mr. Hunter, but to common observation 
 and all sound reasoning. The very case, 
 which Mr. Hey adduced, in proof of the 
 occurrence, is decidedly inadequate to the 
 intended purpose, in consequence oi the im- 
 possibility of trusting to the accounts which 
 patients, under circumstances involving 
 their honour, are apt to give ot themselves. In 
 the case, recited by Mr Hey, the gentleman 
 might have had some venereal affection, at 
 the period of, or subsequently to, his mar- 
 riage ; and yet his feelings, and a sense of 
 the disgrace of infecting a virtuous woman, 
 might compel him to conceal the real truth 
 
VENEREAL DISEASE. 
 
 > wm his surgeon. Again, it is to be remem- 
 bered, that the lady herself might have de- 
 viated from the path of chastity, and ex- 
 posed herself to infection ; and, if she had 
 done so, she would neither have informed 
 her husband, nor Mr. Hey. I confess, that 
 it is at all times painful to suspect the vera- 
 city of individuals, whose situations in life 
 are respectable ; but, whenever an occur- 
 rence takes place, decidedly contrary to the 
 evidence of general experience, every pos- 
 sibility is to be recollected, in order to avoid 
 the necessity of admitting doctrines not 
 founded upon truth. 
 
 Mr. Hey, with much more reason, joins in 
 the belief of the possibility of the venereal 
 disease being communicated to the fetus in 
 utero, though in wbat manner the infection 
 is transmitted is a question not yet elucida- 
 ted. An universal desquamation of the 
 cuticle ; a hoarse squeaking voice ; copper- 
 coioured blotches ; a scaly eruption upon 
 the chin ; and an unnatural redness of the 
 anus ; are the common symptoms which Mr. 
 Hey sets down as proofs of syphilis in very 
 young infants. As these complaints yield to 
 snjalllffoses of the submuriate of mercury, 
 or the hVdrargyrus cum creta, arid either the 
 nurse or parent has had some venereal or 
 syphiloid disease at no very distant period, 
 the cases are often regarded as decided spe- 
 cimens of one of these disorders. 
 
 The venereal poison would appear to be 
 very irregular in its effects, different persons 
 being variously affected by it and hence, 
 probably, one cause of a great deal of the 
 uncertainly, yet prevailing about its distin- 
 guishing characters. Thus, as Mr. Hunter 
 mentions, two men sometimes have connex- 
 ion with the same woman ; both catch the 
 disease ; but one may have very severe, the 
 other exceedingly mild, symptoms. He 
 knew of an instance, in which one man 
 gave the disease to different women, some 
 of whom had it with great severity, while 
 the others suffered but slightly. On the 
 same point, 1 find an interesting statement, 
 made by Dr. Hennen, in his Report of Ob- 
 servations on Syphilis in the Military Hospi- 
 tals in Scotland : — “ We have had (says he) 
 frequent opportunities of remarking two or 
 more sores, of different kinds, existing at the 
 same time : an irregularly-shaped diffused 
 sore ; an elevated sore, covered with a light 
 coloured slough, as if a bit of shamoy leather 
 had been stuck on by some tenacious sub- 
 stance ; a groove, or streak along the glans, 
 as if made by a scraping instrument, filled 
 with purulent matter; and the true and per- 
 fect chancre, according to Mr. Hunter’s difi- 
 nition ; or the true syphilitic ulcer, according 
 to Mr. Carmichael. This last has, in some 
 cases, occupied the glans ; in some, the 
 prepuce ; while the sores of another des- 
 cription have been on the same part close 
 beside it, or on another part at a distance. 
 Three of these cases I particularly selected 
 for examination and public demonstration, 
 at the Castle Hospital ; in one, the Hunte- 
 rian chancre vva-s on the glans, and a sore, 
 without any hardness on the prepuce ; in an- 
 other, it was on the prepace, and a simple 
 
 ulcer on the glans in the third, a most per 
 iectspecimen of Hunterian chancre occupied 
 the internal prepuce, close to the corona 
 glandis ; and, at about half an inch from it, 
 nearer the frftnum, but farther from the 
 glans, was an elevated ulcer. In all these 
 cases, the Hunterian chancre healed (without 
 mercury) several days before the others. 
 
 “ Soldiers (says Dr. Hennen) arc gregari- 
 ous in their amours, arid we have frequently 
 several men at the same time in hospital, in- 
 fected by the same woman, with whom they 
 have had connexion in very rapid succession : 
 some of them have had one kind of sore, some 
 another, and some both. (Principles of Mili- 
 tary Surgery, Ed. 2, p. 52o.) But, if there 
 facts, which agree with my own observa- 
 tions, lie rather adverse to the theory of a 
 plurality of venereal poisons (See Carmi- 
 chaels Essays on the Venereal Disease, fyc.,) 
 they still leave difficulties, which cannot be 
 entirely solved by reference to peculiarities 
 of constitution, and different states of the 
 health, because no explanation, on this prin- 
 ciple, would account for a man having, at 
 the same time, upon the penis, two or til rte 
 different kinds of ulcers, apparently excitod 
 by one cause. Neither* will any difference 
 of texture afford the needed explanation, 
 though the utmost latitude be given to the 
 doctrine, that the appearance and progress of 
 sores are considerably modified by the na- 
 ture of the parts. It is only necessary to 
 consider the above passage from Dr. Hen- 
 nen’s work, to perceive that the particular 
 texture, whether prepuce, skin, glans, or 
 corona glandis, does not always communi- 
 cate to sores one invariable character, even 
 when they arise, as the evidence would dis- 
 pose one to suppose, as nearly as possible 
 under the same circumstances, and from the 
 same source of infection. 
 
 But, though in such examples, no data, 
 with which 1 am acquainted, lead to any safe 
 inference, respecting the exact cause of the 
 diversity, of effect, produced in different 
 persons, and even on different parts of the 
 same individual, by one kind of virus, not a 
 doubt can be entertained, that generally 
 climate and constitution have vast influence 
 over the venereal disease. In all warm 
 countries, the disorder, as far as regards the 
 natives, and those who have been long set- 
 tled there, is not ofily much milder in its 
 symptoms, but much more easy of cure. In 
 the West Indies, the Brazils, &c. it has fora 
 long period of time been very commonly 
 cured by means of sarsaparilla, guaiacum, 
 mezereon, &c. without a grain of mercury 
 It is alleged, however, that this mildness of 
 syphilitic complaints, and their facility of 
 cure, in warm climates, do not extend to 
 strangers, recently arrived there, who are 
 said even to suffer more from the virulence 
 of the disease, than in their native climate. 
 In Portugal, during the fate war, the dread- 
 ful ravages of the venereal disease among 
 the British soldiers, and its comparatively 
 milder phenomena among the inhabitants of 
 the country, were particularly noticed. “In 
 the British army, (says Mr. Fergusson) it is 
 probable, that more men have sustained the 
 
VENEREAL DISEASE 
 
 mos* piduneholy of all mutilations, during 
 tfie four years that it lias been in Portugal, 
 through this disease, than the registers of all 
 1 lie hospitals in England could produce for 
 the lust century ; while venereal ulceration 
 has not only been more intractable to the 
 operation of mercury, than under similar 
 circumstances at home; hut the constitution, 
 while strongly under the influence of the 
 lemedy, has become affected with the se- 
 condary symptoms in a proportion that 
 could not have been expected.' With the 
 natives, on the contrary, the disease is very 
 mild ; curable, for the most part, by topical 
 Treatment alone, or wearing itself out when 
 received into the constitution, after running 
 a certain course, not always a very destruc- 
 tive one, without the use of any adequate 
 mercurial remedy, &ic. The bulk of the 
 people, and of all the military at the hospitals, 
 even though a general order has been given 
 out, enjoining the use of mercury, cure 
 themselves, or get cured, by other means. I 
 have now been upwards of two years at the 
 head of their hospital department, and I 
 can declare, that it never occurred to me, 
 among all the venereal patients, whom in 
 that time I have seen pass through the hos- 
 pitals, to meet a single one under the in- 
 fluence of mercury, excepting those cases, 
 wherein I myself have personally superin- 
 tended its administration. They go out 
 cured by topical remedies gdone : and I have 
 lived long enough among them to ascertain, 
 that their return to hospital under such cir- 
 cumstances for secondary symptoms, is far 
 from being an universal, or even a frequent 
 occurrence. ( Fergusson , in Med. and Chir. 
 Trans. VoL 4,p. 1,2.) 
 
 The inference, at which Mr. Fergusson 
 arrives, is, that in Portngal, the disease is 
 exhausted, and has lost much of its virulence, 
 in the some manner as the natural small pox, 
 unresisted by inoculation appears to have 
 changed, in the same country, into a very 
 mild disease, which does well under any 
 mode of treatment. 
 
 u Yet (says Mr. Fergusson) 1 have no 
 doubt, that were this mild disease, or the 
 mildest that was ever produced from the 
 improved inoculation of England, communi- 
 cated to a tribe of Indians, or to a plantation 
 of negroes, or any other class of people, 
 who had never before known the small pox, 
 it would desolate, with all the fury of pesti- 
 lence, destroying wherever it? could find 
 victims, and never ceasing until it had des- 
 troyed the whole.” And, on the same prin- 
 < spies, Mr. Fergusson attempts to explain 
 the severe effects of the inoculation of the 
 e xhausted syphilitic virus of Portugal into the 
 constitution of the British, or other stanger, 
 ;snd the impossibility of curing the disease 
 by the same treatment, which answers for 
 the natives themselves. (Med. Chir. Trans. 
 Vol. 4, p. 7, 10.) On the other hand, Mr. 
 Guthrie does not admit, that the disease 
 which the*-troops contracted in Portugal was 
 more violent, than the same complaint in 
 England ; <>r rather he admits the fact, but 
 gives a different explanation of it from that 
 erf Mr. Fergusson : and refers the severe 
 
 effect of the disease upon the soldiers in 
 Portugal to the operation of the climate 
 upon their northern constitutions, and to 
 their irregularity and intemperance, vices, 
 to which the natives are not addicted. (See 
 Med. Chir. Trans. Vol. 8, p. 563.) 
 
 It has been a contested question, whether 
 the venereal disease and gonorrhoea arise 
 from the same poison ? Mr. Hunter ac- 
 knowledges,. that the opinion, of their ori- 
 ginating from two distinct poisons, seems to 
 have some foundation, when the difference 
 in the symptoms, and method of cure, is 
 considered. But he asserts, that if this 
 question be taken up upon other grounds, 
 and experiments be made, the result of 
 which can be safely depended upon, this no- 
 tion will be found to be erroneous. As the 
 arguments of Mr. Hunter, in support of the 
 doctrine that both diseases are produced by 
 the same virus, are noticed in the article 
 Gonorrhoea , I shall not here repeat them. 
 
 On the other hand, Mr. Bell relates some 
 experiments, from which the conclusion is 
 made, that the poisops of the venereal dis- 
 ease, and gonorrhoea, are entirely different 
 and distinct. 
 
 Matter was taken upon the point of a 
 probe, from a chancre on (he glans penis, 
 before any application was made to it, and 
 completely introduced into the urethra. 
 For the first eight days, the gentleman who 
 made this experiment, felt no kind of unea- 
 siness ; but about this period, he was attack - 
 ed with pain in making Water. On dilating 
 the urethra, as much as possible, nearly the 
 whole of a large chancre was discovered, 
 and in a few days a bubo formed in each 
 groin. No discharge took place from the 
 urethra, during the whole course of the 
 disease ; but another chancre was soon per- 
 ceived in the opposite side of the urethra, 
 and red precipitate was applied to it, as well 
 as to the other, by means of a probe pre- 
 viously moistened for the purpose. Mercu- 
 rial ointment was at the same time rubbed 
 ou the outside of each thigh, by which a 
 profuse salivation was excited. The buboes, 
 which till then, had continued to increase, 
 became stationary, and at last, disappeared 
 entirely ; the chancres became clean, and 
 by a due continuance of mercury, a com- 
 plete cure was at last obtained. If this 
 case, and another to which 1 shall present- 
 ly advert, could be entirely depended upon,, 
 they would tend to disprove the part of Mr. 
 Hunter’s theory, accounting for the different 
 effect's of the same poison by its application 
 in the case of chancre to a non-secreting 
 surface, covered with cuticle, and in that of 
 gonorrhoea to. a secreting mucous membrane. 
 However this may be, l have never seen a 
 chancre within the urethra. 
 
 The next experiment was made with the 
 matter of gonorrhoea, a portion of which 
 was introduced between the prepuce and 
 glans, and allowed to remain there without 
 being disturbed. In the course of the 
 second day, a slight degree of inflammation 
 was produced, succeeded by a discharge of 
 matter, which in the course of two or three 
 days, disappeared. 
 
VENEREAL DISEASE. 
 
 The same experiment was repeated ; but 
 no chancre ever ensued from it. 
 
 Two medical students were anxious to 
 ascertain the point in question ; and with 
 this view, they made the following experi- 
 ments, at a time, when neither of them had 
 ever laboured under either gonorrhoea, or 
 syphilis, aud both in these and in the pre- 
 ceding experiments, the matter of infection 
 was taken from patients who had never 
 made use of mercury. 
 
 A small dossil of lint, soaked in the mat- 
 ter of gonorrhoea, was by each of them in- 
 serted between the prepuce and the glans, 
 and allowed to remain on the same spot for 
 the space of twenty-four hours. From this 
 it was expected, that chancres would be pro 
 duced ; but in one, a very severe degree of 
 inflammation ensued over the whole glans 
 and pra>putium, giving all the appearance 
 of what is usually termed, gonorrhoea, spuria. 
 A considerable quantity of fetid matter was 
 discharged from the surface of the inflamed 
 parts, and for several days, there was rea- 
 son to fear, that an operation would be ne- 
 cessary for the removal of a paraphymosis. 
 By the use of saturnine poultices, laxatives., 
 and low diet, however, the inflammation 
 abated, the discharge ceased, no chancre 
 took place, and the case got entirely well. 
 In the other gentleman, says Mr. B Bell, 
 the external inflammation was slight, but in 
 consequence of the matter finding access to 
 the urethra, he was attacked on the second 
 day with a severe gonorrhoea, with which 
 lie was troubled for more than a year. 
 
 The next experiment was made by the 
 friend of the latter student ; he inserted the 
 matter of gonorrhcea, with a lancet, beneath 
 the skin of the prasputium, and likewise, 
 into the substance of the glans ; but although 
 this was repeated three different times, no 
 chancres ensued. A slight degree of inflam- 
 mation was excited : but it soon disappear- 
 ed, without any thing being done for it. 
 His last experiment was attended with more 
 serious consequences. The matter of a 
 chancre was inserted on the point of a probe 
 to the depth of a quarter of an inch, or 
 more in the urethra. No syifiptorns of go- 
 norrhoea ensued ; but in the course of five, 
 or six days, a painful inflammatory chancre 
 was perceived on the spot, to which the 
 matter was applied. To this succeeded a 
 bubo, which ended in suppuration, notwith- 
 standing the immediate application of mer- 
 cury; and the sore, that was produced, 
 proved both painful and tedious. Ulcers 
 were at last perceived in the throat, nor was 
 a cure obtained, till a very large quantity of 
 mercury bad been given, and the patient 
 kept in close confinement for thirteen weeks. 
 (On Gonorrhoea Virulenta and Lues Venerea, 
 Vol. 1, Edit. 2 ,p. 43S, fyc.) Mr. Evans, it 
 appears, has also several times inoculated 
 with the matter of gonorrhoea, but in every 
 case, it failed to produce any effect. (On 
 Ulceration of the Genital Organs, p. 81, 8to. 
 Lond. 1819.) 
 
 Some other facts 6n record however, 
 ♦end rather to support. Mr. Hunter’s infer- 
 
 enco, if any conclusion can bo ventured 
 upon without the aid of the most minute 
 details. Thus, Vigarous mentions an in- 
 stance, in which six young Frenchmen had 
 connexion with the same woman, one after 
 the other. The first and fourth in the order 
 of connexion, had chancres and buboes, the 
 second and third gonorrbma, the fifth chan- 
 cre, and the sixth bubo. (CEuvres de Chir. 
 Practique Montp. 1812, p. 8.) And Dr. 
 Hennen, who refers to this case, mentions a 
 similar one, in which the first person esca- 
 ped, the second had true chancres and eleva- 
 ted sores, and the third gonorrhoea. The 
 connexion took place within an hour. (Mi- 
 litary Surgery, Edit. 7. p 52G.) These facts 
 would indeed be much more interesting, if 
 the disease, with which the women were 
 affected, had been ascertained, and one 
 could securely calculate upon the men not 
 having exposed themselves, within a given 
 time, to any other sources of infection. In 
 short, without a perfect history and descrip 
 tion of cases of this kind, from their begin 
 Ring to their end, no light is thrown by 
 them on the question about the venereal 
 and gonorrhoeal poisons. Nor does Dr. 
 Hennen quote them with this view ; but for 
 the purpose of exemplifying the variety of 
 effects, produced on different individuals 
 apparently , by the same infection, though 
 the same consideration, which prevents any 
 certain inference from such observations, in 
 regard to the identity of the venereal and 
 gonorrhoeal poisons, seems also to interfere 
 with the other conclusion. In the experi- 
 ments, detailed both by Hunter and B Bell, 
 there is also one point assumed by both 
 parties, though it is far from being deter- 
 mined ; viz. that the matter discharged from 
 the urethra is always of one kind, in respect 
 to its infectious principle whatever this may 
 be, and that the secretion from every chan- 
 cre contains one, and only one species of 
 infectious matter. From the candid and 
 very practiqal work of Mr Evans, it would 
 appear, that some ulcerations on the penis, 
 such as would usually be called chancres, 
 though they have of late years been some- 
 times named elevated ulcers, arise from an 
 altered secretion, without any breach of sur- 
 face , or discernible disease in the female or- 
 gans. The same gentleman was also fre- 
 quently present at the examinations of the 
 public women in Valenciennes, and always 
 surprised at the small portion of disease to 
 be found among them : “ At one which 1 
 attended, (says he,) no less than 200 women 
 of the lowest description, and of course, 
 the most frequented by soldiers, were exa- 
 mined, and not one case of disease was 
 found among them ; nevertheless the mili- 
 tary hospitals had, and continued to have, 
 their usual number of venereal cases (ulcer- 
 ations.) 
 
 le At an inspection I have since attended, 
 where 100 women -were examined, only two 
 were found with ulcerations : 1 noticed 
 several with increased secretions, and one 
 with purulent discharge, but these were 
 taken no notice of by the attending 
 
VENEREAL DISEASE. 
 
 .m 
 
 geons, as they uiu not come sufEicietitly under 
 the head of virulent gonorrhoea. 
 
 “ That the two women, above mentioned 
 as having ulcers, infected the whole of the 
 men diseased in garrison, during the prece- 
 ding fifteen days, no one can for a moment 
 admit even as likely ; but if it be allowed, 
 that an altered secretion be sufficient for the 
 production of this disease, (the ulcus eleva- 
 tum) we shall at once have an explanation 
 of how it happened, that the military hos- 
 pitals continued to have their usual number 
 of venereal cases, he.” ( Evans on Ulcera- 
 tions of the Genital Organs, p. 72, 73, fyc.) 
 From the investigations of the same author, 
 the ulcus elevatum is the most frequent of 
 nil the sores met with on the genitals, and 
 besides being excited by diseased secretions, 
 and gonorrhoeal matter, is capable of being 
 transferred bp inoculation, and even of ori- 
 ginating spontaneously. (P. 67 — SI, fyc.) 
 
 Lagneau admits, that gonorrhoea may not 
 always proceed from the same poison as 
 the venereal disease ; but he believes, that 
 in the greater number of instances, the 
 virus is of the same quality. He is led to 
 this opinion by the consideration of several 
 women having been infected by the same 
 man with both complaints, and of the two 
 diseases having been communicated to 
 several men who had cohabited with one- 
 woman, and as is presumed with her alone, 
 at least, inasmuch as may relate to the pos- 
 sibility of any other infection weakening 
 the conclusion attempted to be drawn from 
 the case; a point, which has only been as- 
 sumed, and by no means ascertained. How- 
 ever, be this and other similar narrations 
 true, or not, in every particular, I agree with 
 Mr. Guthrie in believing, that the evidence, 
 adduced on the point under consideration, 
 justifies the opinion, “ that ulcers will arise 
 on the penis from the matter of gonorrhoea ; 
 that gonorrhoea will, in itsturn, be caused by 
 the matter of these same ulcers, and that both 
 occur in consequence of promiscuous, or 
 uncleanly intercourse. That many of the 
 ulcers , produced in this manner, will occasion- 
 ally assume every character of chancre, and 
 cannot be distinguished from it, I am perfect- 
 ly satisfied of from repeated observation ; 
 but I am equally certain, that a gonorrhoea 
 in men, with the worst appearances and 
 symptoms, can, and often does, arise from 
 irritating causes common to parts free from 
 any specific disease, or poison, is not distin- 
 guishable from one that has arisen from 
 promiscuous intercourse, and that both 
 complaints are curable in the same way, 
 and without mercury.” On the question, 
 whether gonorrhoea, or the ulcers resulting 
 from the matter of gonorrhoea, can produce 
 constitutional symptoms, Mr. Guthrie be- 
 lieves, that they generally do not, although 
 he does not affirm, that they cannot under 
 particular circumstances of constitution ; 
 and he is further of opinion, that if such 
 symptoms ever really arise, they become 
 serious only in consequence of the exhibi- 
 tion of mercury. fSee Med. C-iiir. Trans. 
 Vol. 8, p. 564 
 
 From what has been already observed, it 
 must be evident, that one of the greatest 
 obstacles to our arrival at a satisfactory 
 knowledge of the nature of lues venerea, is 
 the fact, that under this denomination, many 
 various diseases are comprised and con- 
 founded, and the particular distinctions of 
 each of which are not yet sufficiently made 
 out, to enable surgeons to form a well- 
 founded, and practical classification of them, 
 satisfactory to every impartial observer, 
 and agreeing with general experience. 
 But though such progress has not yet been 
 made, the attention of modern practitioners, 
 and especially that of Mr.'Carmichael, has 
 been directed to the subject. In fact, not- 
 withstanding some mysterious circumstan 
 ces in particular syphilitic cases may not 
 admit of complete and satisfactory explana 
 lion by the doctrine of a plurality of poisons, 
 no intelligent surgeons, I believe, now sup- 
 pose that the diseases, frequently Communi- 
 cated by sexual intercourse, always proceed 1 
 from one peculiar poison. As Mr. Rose has 
 observed, long before syphilis is supposed to 
 have commenced its career in the world, 
 some of these diseases were frequently met 
 with, and Mr. Pearson thinks, that, in addi- 
 tion to those formerly known, new forms of 
 disease have occasionally arisen, “ which 
 are succeeded by a regular series of symp- 
 toms nearly resembling the progress of lues 
 venerea.” ( Obs . on the Effects of various 
 articles of the Materia Medica in the Cure of 
 Lues Venerea, 2 d Ed. Introd. p, 53; and 
 Rose in Med. Chir. Trans. Vol. 8, p. 418b 
 Mr. Hunter also, in the seventh chapter of 
 his Treatise on the Venereal Disease, speaks 
 of many examples of new-formed diseases, 
 arising from peculiar poisons, quite different 
 he supposes, from every other virus pre- 
 viously known, or judged of b)' its effects. 
 But, though Mr. Rose appears to join in the 
 belief of a plurality of poisons, he is very 
 far from considering it settled, how far the 
 variety in the symptoms of venereal cases 
 is to be attributed to different poisons, or 
 how far the symptoms of the same poison 
 may be modified, and altered by constitu- 
 tion, climate, 4 and habits' of life. He re- 
 marks, that we seldom have an opportunity 
 of tracing different cases to the same source 
 of infection, and of comparing their pro- 
 gress with each other. (Vol. cit.p. 419.) 
 And, 1 may add, that as far as observations 
 of this nature have been made, and can be 
 trusted, they rathertend to prove, as al read} 
 noticed in the foregoing columns, that dif 
 rerent individuals, when infected nearly at 
 the same time, and by the same woman, arc 
 very far from having any uniformity in their 
 complaints ; some having one kind of sore : 
 some another; and others claps, he. And 
 the tenor of the remarks, made likewise by 
 Mr. Evans, as far as he has yet entered into 
 the subject, lead equally to ihe conclusion, 
 that one primary complaint, when it pro- 
 duces another, does not always occasion 
 one resembling itself. Thus, the ulcus 
 elevatum on the penis, though capable of 
 being communicated by inoculation, appear- 
 
V ENEivEAL DISEASE 
 
 od sometimes 10 be the effect of one kind 
 of infection, sometimes of another, and 
 sometimes even to have a spontaneous ori- 
 gin. Who shall unravel all these intricacies, 
 1 know not, whether he bring to his assist- 
 ance plurality of poisons, or states of the 
 parts and constitution, climate, neglect, 
 wrong treatment, or any other circumstance, 
 which can possibly be conceived to have 
 influence over the appearances, progress, 
 and consequences of the disease? Nay, it 
 would appear from some of the curious and 
 perplexing histories mentioned in the pre- 
 ceding pages, that one kind of primary com- 
 plaint in an individual may impart to other 
 persons primary complaints of a different 
 nature, so that even the hope of elucidating 
 parts of this abstruse subject, by adverting 
 to a plurality of infections, and a vigilant 
 observation of their characteristic effects, 
 meets with discouragement almost at its 
 very birth ; and though the doctrine of se- 
 veral kinds of poisons being concerned in 
 the production of syphilis and syphiloid 
 diseases still maintains its ground, an abso- 
 lute proof of its correctness can hardly be 
 said to have been yet afforded ; nor, indeed,- 
 could it be obtained, unless the inoculation 
 of healthy individuals with the matter of 
 the different forms of disease were justifia- 
 ble for the elucidation of the question. 
 And, as this is not the case, I think, with 
 Mr. Carmichael, that it might be a benefit 
 to society, if criminals were sometimes per- 
 mitted to commute a heavier punishment 
 by submitting to such experiments, without 
 which the inquiry into the reality, number, 
 nature, and etfects of the morbid poisons 
 under consideration, can perhaps never be 
 brought 4o a satisfactory termination. “ I 
 am perfectly aware (says Mr. Carmichael,) 
 how much the state of the human constitu 
 tion will modify local diseases, and am 
 willing to attribute to a certain extent, the 
 great variety of appearances, we witness 
 daily in venereal complaints, to this cause 
 alone. But, we observe that many of those 
 primary ulcers evince, from their very com- 
 mencement, such peculiar and distinct cha- 
 racters, that it would be quite an absurdity to 
 believe, that the virus is always the same, 
 and the variety of characters dependant 
 alone upon constitution. Thus nothing can 
 be more opposite, from the commencement, 
 than the common chancre, with its hardened 
 base, like a piece of cartilage under the skin, 
 and the sloughing ulcer. The first is slow 
 and chronic ; the latter begins with a morti-, 
 lied spot, extends by alternate sloughing and 
 phagedenic ulceration, and makes more pro- 
 gress in tnree days, than the- former in as 
 many Weeks. 
 
 “ The phagedenic ulcer is equally distinct 
 from chancre, as it does not evince, at any 
 period, a hardened base, but gradually creeps 
 from one part to another of the penis, leav- 
 ing those parts to heal, which, in thp first in- 
 stance, it attacked ; so that, when the disease 
 has existed for some months, the gltuis is 
 seen to exhibit its entire Surface furrowed 
 over with ulcerations and cicatrices. 
 
 byb 
 
 “ There is a raised ulcer, also, with elcva 
 ted edges, approaching the nature ot the 
 phagedenic ulcer, yet, whose characters are 
 sufficiently distinct to be considered as a 
 separate species. But, the most common 
 venereal primary ulceration presents such 
 various appearances in different individuals, 
 that, until a more exact knowledge is ob- 
 tained ; it is better described by its negative, 
 than its positive qualities, and it may be de- 
 signated an ulcer without induration, raised 
 edges, or phagedenic surface. 
 
 “ If (continues Mr. Carmichael) the plura- 
 lity of venereal poisons is supported by the 
 variety of primary ulcers, it is equally so by 
 the multiplicity of constitutional eruptions. 
 A primary ulcer, which was not phagedenic, 
 or sloughing, at first, may afterward, like 
 any other ulcer, become so by irritation, 
 neglect, or inflammation. But 1 do not 
 conceive, that we have grounds for suppo- 
 sing, that the state of the constitution can so 
 modify morbid poisons, as to cause the same 
 virus to produce in one person the chronic 
 scaly lepra, and psoriasis, and to assume in 
 another a decided pustular form, each pus- 
 tule spreading rapidly into a deep ulcer. 
 (On the Symptoms and Specific Distinctions of 
 Vtncrtal Diseases, p.6, fyc. 8 vo. Lund. 1818.) 
 
 The same gentleman, in his Essays on this 
 subject, published some years previously to 
 the above date, gives his reasons for believ- 
 ing that certain primary appearances are fol- 
 lowed by a corresponding train of constitu- 
 tional symptoms. 1st. That the syphilitic 
 chancre gives rise to scaly eruptions, lepra, 
 and psoriasis, an excavated ulcer of the ton- 
 sils, and pains and nodes of the bones. 2dly. 
 That the ulcer, without induration, raised 
 edges, or phagedenic surface, gonorrhoea 
 virulenta, and excoriation of the glans and 
 prepuce, are followed by a papular eruption, 
 which ends in desquamation, pains in the 
 joints resembling those of rheumatism, sore- 
 ness of the fauces, and frequently swelling 
 of the lymphatic glands of the neck ; but 
 without any nodes of tue bones 3dly. 
 That the ulcer, with elevated edges, in the 
 few instances in which it was traced by Mr 
 Carmichael to its constitutional symptoms, 
 was followed by a pustular eruption, which 
 terminated in mild ulcers, pains in the joints, 
 and ulcers in the throat, but no appearance 
 of nodes. 4;hly. That the phagedenic and 
 sloughing ulcers are generally attended with 
 constitutional symptoms of peculiar obsti 
 nacy and malignancy : \oz. pustular spots 
 and tubercles, which form ulcers, generally 
 spreading with a phagedenic edge, and heai- 
 ine from the centre Extensive ulceration 
 of the fauces, particularly of the back of the 
 pharynx, obstinate pains of the knees, and 
 other joints, w hile nodes are frequently pre- 
 sent, and the bones of the nose are occasion - 
 ally affected. (See. Carmichael's Essays and 
 his 0$s. on the Symptoms, i \-c, of Ven. Dis- 
 eases, p. 9.) 
 
 The observations of other modern writers 
 seem generally to coincide with those of 
 Mr. Carmichael, respecting the great variety 
 of character in primary venereal sores, and 
 
VENEREAL DISEASE. 
 
 GGU 
 
 partly also with regard to iiie hypothesis of 
 (here being various kinds of poisons, or in- 
 fectious matter, But, on some other great 
 questions, immediately connected with 
 these points, little similarity of opinion pre- 
 vails between him and other gentlemen, 
 who have laudably arid impartially entered 
 into the disquisition. And, in the first place, 
 without adverting again to certain state- 
 ments, already premised, which render it 
 probable, that differences of the virus, or, at 
 all events, differences in the forms of the 
 primary complaints in the contaminating 
 individuals, would nbt always explain the 
 reason of the diversified appearances and 
 nature ot the primary forms of disease in the 
 contaminated, I shall Iav.’before the reader 
 other evidence, having an immediate rela- 
 tion to Mr. Carmichael’s sentiment, that 
 each kind of primary veneral sore is follow- 
 ed by a peculiar and corresponding train of 
 constitutional symptoms. In the cases re- 
 cited by Mr. Rose, “ most of the papular 
 eruptions followed ulcers, which were not 
 very deep, and which healed without much 
 difficulty. Several of them had a thickened, 
 but not a particular indurated margin. This 
 corresponds with the observations cf Mr. 
 Carmichael , — I could not , howtvcr, discover 
 any decidedly uniform character in such sores ; 
 and the 16th case I should have considered 
 as a well-marked instance of chancre.” 
 (Med. Chir. Trans. Vol. 8, p. 399.) In 
 another place, it is staled, that the appear- 
 ances of sores can seldom be relied on in 
 parts of such vascular structure, and in 
 the midst of sebaceous glands. (P. 419.) 
 With respect to the phagedenic ulcer, Mr. 
 Rose expresses his belief, that it is rarely 
 followed by secondary symptoms, though he 
 inclines to the opinion, that it arises from 
 the application of some morbific matter, ac- 
 knowledging, however, (he great difficulty 
 of deciding, “ whether the great degree of 
 erethismus, excited by the local affection, 
 should be attributed to any peculiarity in 
 that matter, or is owing to the peculiar state 
 of the constitution.” (Med. Chir. Trans. 
 Vol. 8, p. 372.) And he then refers to the 
 ease, reported by Mr. Fergusson, where 
 • the infection was communicated by an 
 opera dancer at Lisbon, apparently in per- 
 fect health, who continued on the stage for 
 several months afterward, occasionally in 
 fecting others, without any thing extraordi- 
 nary, as far as he could learn, in the nature 
 of the symptoms.” (Op. cit. Vol.4,p. IE) 
 And, on the same subject, Mr. Guthrie does 
 not think, ‘‘ that Mr. Carmichael’s opinion, 
 as to the secondary symptoms, peculiar to 
 the phagedenic and sloughing ulcer, re- 
 ceives any support from what occurred to 
 the troops in Portugal ; because it did not 
 appear, that either of (hem, following sexual 
 intercourse, were dependent on the cause 
 which produced the ulcer. Where many 
 men have had intercourse with the same 
 woman (and with no others ?) they have not 
 all had the same complaint, although one of 
 th ? ulcers, so originating, has become pha- 
 gedenic. or sloughed ; neither has the same 
 
 woman herself suffered from this distemper 
 indeed, the nature of an ulcer of either kind 
 must, after a short time, effectually prevent 
 any intercourse, and we often find, that their 
 peculiar characters only appear after the 
 ulcer has existed for several days. I firmly 
 believe also, that in the greater number of 
 cases of sloughing ulcer, where mercury is 
 not given, no secondary symptoms would ap- 
 pear : and, in thost cases in which they did 
 appear, I apprehend, they would be equally 
 dependent on the state of the constitution, 
 as to the mode of cure, arid their destructive 
 characters. In other words, my observations 
 lead me to conclude, that these ulcers do not 
 depend upon a specific poison, but on the stale 
 of the constitution , under particular excite- 
 ment, and that, when, secondary symptoms 
 occur , they are not dependent on the stale of 
 the ulcer ; although 1 am ready to admit, that 
 in a constitution where an ulcer will readily 
 become phagedenic, the secondary symp- 
 toms, when they occur, may be different to 
 a certain extent from those that follow more 
 simple ulcers, in a healthier habit of body.” 
 (Guthrie in Med. Chir. Trans. Vol. 8 ,p. 664.) 
 My observations lead me to believe, with 
 Mr. Guthrie, that primary sloughing ulcers 
 do not depend upon any peculiar poison, 
 and I am also disposed to join him in the 
 opinion, that when hurtful local treatment 
 is out of the question, they are chiefly owing 
 to the stale of the constitution. According 
 to my experience, all kinds of ulcers on the 
 genitals may, from particularity of constitu- 
 tion, impairment of health, and sometimes 
 from the pernicious effects of the immode- 
 rate and indiscriminate einploymentof mer- 
 cury, assume in their progress a sloughing 
 disposition, and even have it from their 
 very commencement. Mr. Rose mentions 
 a case in which a healthy young man was 
 affected with a sloughing sore on the penis, 
 in consequence of a suspicious connexion. 
 It was not attended with any constitutional 
 disturbance, and yielded readily to mercury. 
 The same patient, twice afterward, at a very 
 considerable interval, had a fresh infection, 
 and the sores each time had precisely the 
 same character as the first. This, says Mr 
 Rose, is no uncommon occurrence, and it is 
 not probable that the sloughing and appear- 
 ance of the sores arose from the peculiarity 
 of the poison. (Med. Chir. Trans. Vol. S, 
 p. 420.) And another intelligent and expe- 
 rienced surgeon, who has particularly at- 
 tended to this investigation, declares his 
 conviction, that many varieties of sore, 
 independently of the sloughy chancre, men - 
 tioned by Mr. Carmichael, lead to constitu- 
 tional symptoms, differing in no respect from 
 those he has described, and admitting' of the 
 same mode of cure.” Nor does he believe, 
 with Mr. Carmichael, that only one particu 
 lar species of sore is capable of producing 
 the true secondary symptoms of lues. ( J 
 Baud, on Syphilis, p. 51 ) 
 
 From these observations, I think we may 
 safely infer, that with respect to the slough- 
 ing ulcer, it neither arises from the applica- 
 tion of any one specific poison to the part. 
 
venereal disease 
 
 col 
 
 nor is it connected with any regular train 
 secondary symptoms. 
 
 Dr. Hennen assures us, that he has fre- 
 quently had occasion to observe, that erup- 
 tions of the same nature and character have 
 succeeded to the foul, indurated, excavated 
 ulcer, and to the simple excoriation. “ In 
 fifteen cases of eruptions, unaccompanied 
 by any other symptoms, which succeeded 
 the Hunterian sore, six were tubercular, 
 five exanthematous, two pustular, one tu- 
 bercular and scaly, and one tubercular and 
 vesicular. 
 
 “In four cases following the same sore, 
 but in which the eruptions were complica- 
 ted with sore throat, two were tubercular, 
 one was tubercular and scaly, and one was 
 tubercular and axanthematous. 
 
 “ In twelve cases following the non Hunte- 
 rian sore, and in which eruptions were the 
 only symptoms, six were pustular, three 
 were exanthematous, and one was tubercu- 
 lar and scaly. 
 
 11 In seven cases where the eruption was 
 accompanied with sore throat, three were 
 exanthematous, two were tubercular, one 
 was papular, scaly, and tubercular,” and 
 one was pustular and tubercular. Dr. Hen- 
 nen also recites an instance in which a 
 Hunterian chancre was, at the distance of 
 ten weeks, succeeded by a papular eruption , 
 which, in the course of a month, was remo- 
 ved by low diet, purgatives, and the decoc- 
 tion of sarsaparilla. In two months after- 
 ward, an eruption of a similar nature ap- 
 peared without any fresh infection. This 
 Was treated with mercury, which was admi- 
 nistered five weeks, so as to excite a mode- 
 rate salivation. Under this treatment the 
 eruption faded, having, during its progress, 
 assumed the appearance of vesicles and pus- 
 tules, and at length falling off in amber- 
 coloured scales , with livid bases. Notwith- 
 standing this mercurial course, the patient 
 was h third time admitted, ten weeks after- 
 ward, (without any intervening primary 
 affection) with a pustular eruption, which 
 was finally cured without mercury, and the 
 pustules falling off in squamulae. In ano- 
 ther month, without any fresh infection, he 
 Was a fourth time taken into hospital, 
 with a very thickly dispersed pustular erup- 
 tion, somewhat different from the former, 
 the pustules being more nunaerous, smaller, 
 and acuminated. They yielded to non- 
 mercurial treatment. During all these 
 attacks, there was apththous sore throat, 
 and occasional flying pains in the joints. 
 The inference drawn from this case is, that 
 even a full and judiciously conducted mer- 
 curial course does not prevent the reappear- 
 ance of venereal eruptions, and that they 
 assume at different times different charac- 
 ters, notwithstanding the interruption they 
 receive in their natural progress by the use 
 of that remedy. (On Military Surgery, Ed. 
 2, p. 528—530.) After these accounts, I 
 can have no hesitation in coming to another 
 conclusion, which is, that, with the excep- 
 tion of the partial confirmation of Mr. Car- 
 michael’s doctrine by Mr. Rose, as far as 
 Vol. IE. “ 75 
 
 of relates to the frequency of papular erup 
 tions after superficial primary ulcers, the 
 regular connexion of particular forms of 
 secondary symptoms with any given de- 
 scriptions of primary sores, is so far from 
 being supported by the testimony of other 
 observers, that one kind of primary ulcer 
 may lead, in the same patient, to eruptions 
 of several different sorts, either existing to- 
 gether on various parts of the body, or 
 breaking out in succession ; and no regular 
 connexion can be traced between any one 
 species of primary sore, and any determi- 
 nate class of secondary symptoms. These 
 truths, 1 believe, must be admitted, disad- 
 vantageous as they are to the prospect of 
 bringing the diagnosis of syphilis to a final 
 settlement, so as to enable the writer to de- 
 scribe the disease with accuracy, and the 
 practitioner to recognize and treat it with 
 certainty. The first essential step to the 
 elucidation of this subject, however, is un- 
 doubtedly the subversion of every doctrine 
 relative to it, which is repugnant to gene- 
 ral experience. The same facts, which may 
 render it necessary for Mr. Carmichael to 
 retract some of his inferences, and which 
 have now been established beyond all 
 doubt or possibility of successful contradic- 
 tion, by the very impartial, disinterested, 
 and extensive investigations, made in the 
 army hospitals, would have obliged even 
 Hunter himself, had he been alive, to con- 
 fess the mistaken views which he some- 
 times took of the nature of the venereal dis- 
 ease. 
 
 Among other doctrines, Mr. Hunter incul- 
 cates, that “ the venereal matter, when 
 taken into the constitution, produces an 
 irritation which is capable of being continu- 
 ed, independent of a continuance of ab- 
 sorption, and the constitution has no poiver 
 of relief ; therefore, a lues venerea continues 
 to increase." The same criterion was pro- 
 posed by Mr. Abernethy, who states, that 
 the “ constitutional symptoms of the vene- 
 real disease are generally progressive, and 
 never disappear unless medicine be employ- 
 ed.” ( Surgical Observations , p. 137.) And* 
 notwithstanding some dissent may be tra- 
 ced in both old and modern writers from 
 the belief that mercury was absolutely es 
 sential to the cure of the venereal disease,, 
 and an opposite conclusion might easily 
 have been drawn from the whole history of 
 this subject, including the practice of for- 
 mer and present times, the contrary hypo- 
 thesis was that always taughtin all the great 
 medical schools of this country, even down 
 to so late a period as eight or ten years ago. 
 But the error no longer prevails, and no 
 facts are more completely established than 
 that mercury, however useful it may fre- 
 quently be in the treatment of the venereal 
 disease, is not absolutely necessary for the 
 cure either of the primary or secondary 
 symptoms, and that the disease, so far from 
 always growing worse, unless mercury be 
 administered, alternately gets well, without 
 the aid of this, or any other medicine. If 
 any man yet doubt the general truth of this 
 
VENEREAL DISEASE 
 
 602 
 
 statement, let him impartially consider the 
 many facts and arguments brought forward 
 in proof of it in the writings of Mr. Fergus- 
 son, Mr. Rose, Dr. Hennen, Dr. Thomson, 
 Mr. Guthrie, Mr. Bacot, and other modern 
 practitioners. In short, if there be such a 
 sceptic now living in this country, let him 
 peruse the returns made by the surgeons of 
 the whole British army, documents which 
 will be noticed in the sequel of this article ; 
 let him consider the evidence of the sur- 
 geons of other countries, especially that of 
 Cullerier, who annually demonstrates to his 
 class of pupils the cure of venereal ulcers 
 without mercury ; and the testimony and 
 practice of the German surgeons, who were 
 attached during the war to regiments of 
 their countrymen in the British service. 
 The fact is therefore indisputable, that the 
 venereal disease, in all its ordinary and di- 
 versified forms, is capable of a spontaneous 
 cure, and consequently, that the question, 
 whether the disease is syphilitic or not, can 
 never be determined by the circumstance 
 of the complaint yielding, and being perma- 
 nently cured, without the aid of mercury. 
 Yet, as Mr. Rose has observed, the supposi- 
 tion, that syphilis did not admit of a natural 
 cure, and that mercury was the only reme- 
 dy that had the power of destroying its 
 virus, was of late so much relied upon, that 
 where a disease had been cured without the 
 use of that medicine, and did not afterward 
 return, such fact alone, whatever might have 
 been the symptoms, was regarded as suffi- 
 cient proof that it was not a case of syphi- 
 lis. And, as the same writer very judi- 
 ciously remarks, the refutation of these no- 
 tions is of considerable importance, “ not 
 so much in reference to the treatment of 
 syphilis under common circumstances, for 
 the strikingly good effects of mercury will 
 probably not render it adviseable in general 
 to give up the use of that remedy, but from 
 the change it will produce in our views of the 
 diagnosis of the disease. The distinction 
 which has engaged such a share of attention 
 of late years, and which is evidently so im- 
 portant between syphilis and syphiloid dis- 
 eases, has been made to depend so much on 
 the former admitting of no cure, except by 
 mercury, that if this principle should be 
 found to be erroneous, the difficulties which 
 have attended it will in a great measure be 
 explained.” (Med. Chir. Trans. Vol. 8, p. 
 350, 351.) That it is erroneous will appear 
 more clearly when the treatment of syphi- 
 lis falls under consideration. 
 
 Excluding from present attention works 
 of ancient date, it is curious to find how 
 very near several writers, within the last 
 twenty or thirty years, arrived at the same 
 point to which recent investigations have 
 led. Thus, Mr. B. Bell observes, a chancre 
 might frequently be cured with external 
 applications alone, and as we know from 
 experience that the virus is not always ab- 
 sorbed, the cure would in a few instances 
 prove permanent ; but as we can never with 
 certainty know whether this would happen 
 or not, while, in a great proportion, of cases. 
 
 there would be reason to think that absorp- 
 tion would take place, we ought not in any 
 case to trust to it.” (On Gonorrhoea Virulen - 
 ta, tyc. Vol. 2, Ed. 2, p. 325, 8 vo. Edinb. 
 1797.) And, in some reflections upon a 
 case of doubtful nature, Dr. Clutterbuck 
 long ago remarked : “ Supposing even that 
 the diseased appearances had after a time 
 got well ot themselves, I should deem even 
 this no absolute proof of their not being of a 
 venereal nature. I have seen cases which 
 induce me to believe, that the venereal dis- 
 ease , in some of its stages, and in certain 
 circumstances, may get well without mereury 
 or any other remedy. But this is contrary to 
 the doctrine of Mr. Hunter, who supposed 
 that venereal actions go on increasing, with- 
 out any tendency to wear themselves oat 
 That lues venerea is much modified by cli- 
 mate, and other circumstances, is generally 
 allowed ; that it has been cured by other 
 means than mercury, we have also very 
 sufficient evidence in the older writers on. 
 the subject : not to mention the late suc- 
 cessful trials with acids and other substan- 
 ces. Many of the appearances on the skin go 
 off spontaneously. ‘ When purple spots ap- 
 pear on the skin,” (Mr. Hunter observes, p, 
 319,) “ giving it a mottled appearance in 
 this disease, many of the spots disappear, 
 whilst others continue and increase.” (U. 
 Clutterbuck , Remarks on some of the Opinions 
 of the late Mr. John Hunter, p. 27, Sto. 
 Lond. 1799.) If Dr. Clutterbuck had ad* 
 vanced one step further, and declared that 
 the venereal disease might be eured without 
 mercury, or any other remedy, in all, or 
 nearly all its forms, and not merely in some 
 of them, he would actually have anticipa- 
 ted the most important fact, recently esta- 
 blished chiefly by the meritorious labours 
 of the army surgeons, whose opportunities 
 of making the investigation were better on 
 several accounts than those of private prac- 
 titioners, who generally soon lose sight of 
 their patients, and never have them suffi- 
 ciently under their control and observation 
 to render a full perseverance in any method 
 a matter of certainty. At all events, Dr. 
 Clutterbuck may justly claim the merit of 
 having distinctly marked the fact, that the 
 circumstance of a disease giving way, and 
 being cured without mercury, is no proof that 
 the case is not venereal. 
 
 One of the most ingenious theories ever 
 devised for explaining all the perplexities 
 and irregularities of syphilis, is unquestion- 
 ably that of the late Mr. Hunter . for, it 
 accommodated itself almost to every thing, 
 and every believer in it fancied he could 
 account satisfactorily for many puzzling 
 occurrences which admitted of no good ex- 
 planation on other principles. Mr. Hunter 
 inculcated, that the parts contaminated by 
 the absorption of the venereal poison, do 
 not immediately begin to be palpably dis- 
 eased, but only acquire a disposition to take 
 on the venereal action. He further believed, 
 that when this disposition was once formed 
 in a part, it necessarily changed into action, 
 or manifest disease, at some future period. 
 
VENEREAL DISEASE 
 
 603 
 
 .That mercury can cure the disease, when 
 positively formed, but uot the disposition to 
 it. That although mercury cannot destroy 
 the disposition already contracted, yet that 
 it can prevent it from being formed at all. 
 That the disposition never becomes the real 
 disease, or, in Mr. Hunter’s language, goes 
 into action during the use of mercury. That 
 the action having oncetaken place, always 
 increases, never wearing itself out. That 
 parts, once cured, never become again con- 
 taminated from the same stock of infection. 
 And, that the matter of secondary ulcers, 
 or those which break out in consequence 
 of absorption, is not infectious. What Mr. 
 Hunter meant by the term disposition , I 
 think is better explained than the grounds 
 for the adoption of the theories connected 
 with it, viz. the presumption of its being 
 formed in all the parts capable of contami- 
 nation ; the certainty of its future change 
 into actual disease ; the impossibility of 
 curing it by mercury previously to such a 
 a change ; but the possibility of preventing 
 its formation at all by the timely use of that 
 remedy. 
 
 Dr. Clutterbuck has well observed, that 
 the only foundation for all these hypothe- 
 ses, connected with the phrase disposition, 
 is the fact, that secondary symptoms some- 
 times arise, notwithstanding a fall use of 
 mercury. If, says this gentleman, we were 
 to suppose, with Mr. Hunter, that all the 
 parts which are susceptible become at once 
 contaminated, and mercury has no influence 
 over them in this state, the constitution 
 should become affected in almost all cases, 
 for absorption probably always precedes 
 the application of remedies. Either, there- 
 fore, mercury does prevent the future action, 
 or a more frequent absence of susceptibility 
 to the disease must be supposed, than there 
 are grounds for imagining. ( Remarks on 
 the Opinions of Mr. Hunter , p. 9 — 12.) But, 
 surgeons of the present day, enlightened by 
 many new facts unequivocally determined 
 since Mr. Hunter’s time, know very well 
 that a disposition to the disease is in many 
 instances not produced at all, even though 
 the matter of a chancre be supposed to be 
 absorbed, since in a large proportion of 
 cases of chancres, which had all the charac- 
 teristic appearances of such ulcers, accord- 
 ing to Mr. Hunter’s own description, no 
 secondary symptoms followed, though the 
 patients were treated and cured without any 
 mercury. Yet, if Mr. Hunter’s theory were 
 true, the disposition must have been pro- 
 duced, the action or disease itself in the 
 form of secondary symptoms must have 
 ensued, sooner or later, and no cure could 
 have been ultimately effected without mer- 
 cury. Fortunately fur mankind, unsound 
 as some of the theories seem, which are 
 attached by Mr. Hunter to the supposed 
 disposition to the venereal disease, or its latent 
 form, there w r as one piece of advice given 
 by him, which may be said to have had a 
 beneficial effect in practice, though founded 
 upon these very doctrines ; and it was this, 
 that we should push our medicine no 
 
 farther than the cure of the visible effects of 
 the poison, and allow whatever parts may 
 be contaminated to come into action after- 
 ward.” (On the Venereal Disease, p 334.) 
 This maxim, I know, has been regarded by 
 some admirers of long salivations as the 
 cause of many relapses and imperfect cures ; 
 but when 1 advert to the dreadful mischief, 
 which formerly attended protracted courses 
 of mercury for latent and imaginary com- 
 plaints, my mind regrets that Mr. Hunter 
 himself should not have adhered strictly in 
 practice to his own principle, Irom which 
 he undoubtedly deviated with his patients, 
 and even in certain other parts of his wri- 
 tings. However, the effect has been to 
 discourage long courses of mercury j and, 
 perhaps, in this way, the world has been 
 benefited by the counsel, though not rigor- 
 ously adopted by him who gave it. Con- 
 fessing my own inability to reconcile the 
 various theories, about the nature and 
 effects of the venereal poison, to many 
 facts, which are disclosed in practice, I 
 shall now proceed to offer a few remarks 
 on each of the primary and secondary 
 symptoms. 
 
 Chancres. The penis, as Mr. Hunter has 
 observed, which in men is the common seat 
 of a chancre, is, like every other part of the 
 body, liable to diseases of the ulcerative 
 kind, and, on some accounts, is rather more 
 so than other parts. When attention is not 
 paid to cleanliness, excoriations or superfi- 
 cial ulcers often originate. The genitals, 
 also, like almost every other part that has 
 been injured, when once they have suffered 
 from the venereal disease, are very liable to 
 ulcerate again. Since therefore the penis 
 is not exempted from common diseases, 
 every judgment of the nature of ulcers upon 
 it, as Mr. Hunter truly remarks, should be 
 formed with great attention, particularly as 
 all diseases upon this part are suspected to 
 be venereal. But for a particular descrip- 
 tion of the many ordinary complaints, which 
 are apt to occur on the genitals, either pre- 
 ceded or unpreceded by sexual intercourse, 
 I refer to Mr. Evans’s treatise. (See Patho- 
 logical and Practical Remarks on Ulcerations 
 of the Genital Organs, 8 vo. Lond. 1819.) 
 From facts already mentioned in this ar- 
 ticle, however, it would appear that primary 
 syphilitic ulcers or chancres, by which I 
 imply sores capable of giving rise to the 
 secondary symptoms of the venereal dis- 
 ease, have no determinate external charac- 
 ter, are extremely diversified in their 
 appearance, and absolutely cannot be 
 distinguished by their mere look from sores 
 which are of a common, or at least a verv 
 different nature. This is another important 
 fact, for which every man in the profession 
 who seeks only truth, and the expulsion of 
 errors from the doctrines of surgery, must 
 feel obliged to the army surgeons. Nor is 
 their merit lessened by the consideration, 
 t ,a< the detection of mistake on this point, 
 like the discovery of the error, concerning 
 the invariable progress of the venereal 
 disease from bad to worse, unless medicU>e 
 
VENEREAL DISEASE. 
 
 
 be given, Las taken place in opposition to 
 the tenets of Mr. Hunter. “ Venereal ulcers 
 (says he,) commonly have one character , 
 which, however, is not entirely peculiar to 
 them ; for many sores that have no dispo- 
 sition to heal ( which is the case with a 
 chancre ,) have so far the same character. 
 Jl chancre has commonly a thickened base ; 
 and, although in some, the common inflam- 
 mation spreads much further, yet the specific 
 is confined to this base." (P. 215.) And 
 elsewhere, he observes, a chancre first be- 
 gins with an itching in the part. When the 
 inflammation is on the glans penis, a small 
 pimple, full of matter, generally arises, 
 without much hardness or seeming inflam- 
 mation, and with very little tumefaction ; 
 lor the glans penis is not so apt to swell 
 in consequence of inflammation as many 
 other parts are, especially the prepuce. 
 Mr. Hunter also explains, that chancres, 
 situated on the glans, are not attended with 
 so much pain and inconvenience as sores of 
 this nature on the prepuce. When chancres 
 occur on the fraenum, or particularly on the 
 prepuce, a much more considerable degree 
 of inflammation soon follows, attended 
 with effects more extensive and visible. 
 These latter parts, being composed of very 
 loose cellular membrane, afford a ready 
 passage for the extravasated fluids. The 
 itching is gradually converted into pain : in 
 some cases the sdrface of the prepuce is 
 excoriated, and afterward ulcerates; while, 
 in other examples, a small pimple or ab- 
 scess appears on the glans, and then turns 
 into an ulcer. The parts become affected 
 with a thickening , which at first, while of the 
 true venereal kind , is very circumscribed ; not 
 diffusing itself, as Mr. Hunter observes, gra 
 dually and imperceptibly into the surround- 
 ing parts ; but terminating rather abruptly. 
 Its base is hard , and the e.dges a little promi- 
 nent. When it begins on the fraenum, or 
 near it., that part is very commonly wholly 
 destroyed, or a hole is often made through 
 it by ulceration. Mr. Hunter thought it 
 better, in general, under the latter circum- 
 stance, to divide the part at once. 
 
 When the venereal matter is applied to 
 the body of the penis, or front of the scro- 
 tum, where the cuticle is thicker than that 
 of the glans penis and prepuce, the chancre 
 generally makes its appearance in the form 
 of a pimple, w hich commonly forms a scab, 
 in consequence of evaporation. The first 
 scab is generally rubbed oil';, after which a 
 second, still larger one, is produced. 
 
 When the disease is more advanced, it is 
 often attended with inflammation peculiar 
 to the habit, becoming in many instances 
 more diffused, and often producing phymo- 
 sis and paraphvmosis. However, says Mr 
 Hunter, there is yet a hardness around the 
 sores, which is peculiar to such as are caused 
 by the venereal virus, particularly those on 
 the prepuce. 
 
 Mr. Carmichael, also, in his arrangement 
 of primary ulcers on the penis, considers 
 the true chancre as being particularly dis- 
 tinguished by its hardened base, which he 
 
 compares to a piece of cartilage under the 
 skin. It is to be observed, however, that 
 Mr. Carmichael, by the true chancre, or 
 primary syphilitic ulcer, does not signify 
 that it is the only sore from which second- 
 ary symptoms may arise ; but his observa- 
 tions lead him to regard it as the cause of 
 such constitutional effects as belong to w hat 
 he deems the true form of syphilis, or that 
 in which the use of mercury is the most de- 
 cidedly indicated. It would give me sincere 
 pleasure to find any agreement on this part 
 of the subject among other observers. 
 The reader, indeed, must already know r , 
 that the hardened base, which both Hunter 
 and Carmichael have regarded as a distin- 
 guishing character of a true chancre, is not 
 found to be so by other gentlemen, who 
 have most impartially investigated this 
 point. Thus, Dr. Hennen observes, “ we 
 are not in possession of the knowledge of 
 any invariable characteristic symptoms, by 
 w^hich to discriminate the real nature of the 
 primary sore, and w e are equally at a loss 
 in many of the secondary symptoms. I am 
 well aware that some practitioners have 
 assumed to themselves the possession of a 
 “ tactus eruditus,” by which they can at 
 once distinguish a chancre, or a venereal 
 ulcer, or eruption, in w hich mercury is in- 
 dispensable, from one of a different nature ; 
 but I have seen too many instances of self- 
 deception to give them all the credit that 
 they lay claim to. It would be by no 
 means difficult to show that the high round 
 edge, the scooped or excavated sore, the 
 preceding pimple, the loss of substance, the 
 hardened base and edge , whether circumscri- 
 bed or diffused, and the tenaciously adhesive 
 discharge of a very fetid odour, are all ob- 
 servable in certain states and varieties of 
 sores, unconnected with a venereal origin. 
 The hardened edge apd base, particularly, 
 can be produced artificially by the applica- 
 tion of escharotics to the glans or penis of 
 a sound person ; and if any ulceration, or 
 warty excrescence, previously exists on 
 these parts, this effect is still more easily 
 produced.” (On Military Surgery, Ed. 2, p. 
 517.) Now, if it be asked, whether the 
 chancre with a hardened base, and promi- 
 nent edge, is distinguished by its not admit- 
 ting of cure without mercury ? and by any 
 regularity or peculiarity in the nature of 
 secondary symptoms, when they originate 
 from such an ulcer? modern experience 
 denies the validity of both these criteria. 
 If Mr. Rose’s excellent paper be consulted, 
 the reader will see that this gentleman has 
 certainly cured, without the aid of mercury, 
 ulcers, which had a decidedly marked indu- 
 ration of the margins and bases, by which 
 the syphilitic chancre, according to Mr. 
 Carmichael, is easily distinguished. (Med. 
 Chir. Trans. Vol. 8 ,p. 42 R fyc. ; also Guth- 
 rie, Vol. cit. p. 576.) And, us for the other 
 points, sufficient evidence has already been 
 detailed in the foregoing columns to satisfy 
 any impartial mind, that, as far ns the eye 
 can teach us, no kind of primary sore has 
 yet been satisfactorily proved to be the 
 
VENEREAL DISEASE 
 
 cause of only one set of peculiar constitu- 
 tional symptoms ; but, on the contrary, that 
 a great variety of appearances in the skin, 
 throat, &.c. may follow sores, which, as far 
 as external characters are concerned, seem 
 exactly alike. The only partial exception 
 to this remark is the great frequency of pa- 
 pular eruptions alter superficial sores ; a 
 point on which both Mr. Carmichael and 
 JMr. Rose agree, though the latter gentleman 
 does not represent even this connexion as 
 constant. Mr. Hunter computed, that claps 
 occur more frequently than chancres, in the 
 proportion of four or five to one. 1 am not 
 prepared to offer any opinion on this calcu- 
 lation, in reference either to chancres, as 
 defined by that interesting writer, or under 
 the more comprehensive view of them, to 
 which the results of modern investigations 
 would lead. One intelligent writer, how- 
 ever, has observed, that presftnt experience 
 does not justify Mr. Hunter’s conclusion re- 
 specting the infrequency of chancre com- 
 pared with gonorrhoea. (J. Bacot, Obs. on 
 Syphilis, p. 54.) Yet, in Dublin, if Mr. Car- 
 michael’s statement be correct, the fre- 
 quency of gonorrhoea, as compared with 
 that of what is sometimes termed the true 
 venereal chancre, must be so great as to 
 defy all computation ; for he informs us, 
 that since the descriptions of the success of 
 the non-mercurial practice fell into his 
 hands, he has been anxious to ascertain, by 
 personal observation, whether true syphili- 
 tic chancres did really admit of being cured 
 without mercury ; but, says he, “ this dis- 
 ease, as described by Hunter, has diminish- 
 ed in so extraordinary a degree in this 
 country, that, strange to say, I have from 
 that period met with only one case of true 
 chancre.” ( Observations on the Symptoms, 
 fyc. of Venereal Diseases, p. 14.) As this 
 chancre remained stationary a month, it 
 was thought proper to employ mercurial 
 frictions, and it then soon healed, leaving a 
 callosity which continued two months 
 longer. However, after the above passage 
 wus written, Mr. Carmichael met with two 
 cases of “ well marked chancre,” each of 
 which w r as attended with psoriasis syphili- 
 tica, scaly from its commencement. No 
 mercury was given. For five weeks, the 
 disease gained ground ; but, in the end, both 
 cases were cured, merely sarsaparilla hav- 
 ing been administered. The following 
 observations, contained in the appendix to 
 Mr. Carmichael’s work, do him infinite cre- 
 dit. “ Although, (says he,) these two cases 
 cannot fail to make a due impression, yet, 
 if they stood alone, their evidence could 
 not be deemed sufficient to establish a be- 
 lief, that true syphilis, like the papular 
 disease, is capable of yielding to the powers 
 of the constitution, or to remedies in which 
 mercury does not form an ingredient. But 
 this deficiency seems to be, in a great mea- 
 sure, supplied by the testimony, of Mr. Rose, 
 Mr. Hennen, and other equally intelligent 
 surgeons, who had the advantage of serving 
 with our army on the continent ; and, if in 
 the preceding pages I appear to he sceptical 
 
 dOui 
 
 with respect to the accuracy of their observa 
 tions,and doubted that it wastrue chancre, and 
 true syphilitic eruption, which yielded to their 
 prescriptions, unaided by mercury, these two 
 cases have satisfied me that every attention 
 is due to the exactness and discernment of 
 these respectable individuals ; and if 1 hesi- 
 tated until 1 saw with my own eyes, and 
 judged with m> own understanding, I claim 
 for my own observations no larger a mea- 
 sure of faith from others.” And he after- 
 ward adds, “ In thus relinquishing my opi- 
 nion, that true syphilis differs from oiher 
 venereal complaints, by always requiring 
 mercury for its cure, it is necessary to 
 reduce the doctrine I hold to this propo- 
 sition : that with respect to the use of that 
 medicine, it differs from them only in not 
 being injured, but decidedly benefited by 
 it in all its symptoms and stages.” (P. 216, 
 219.) 
 
 According to Mr. Hunter, there are three 
 ways in which chancres may be produced ; 
 first, by the poison being inserted into a 
 wound ; secondly, by being applied to a 
 non-secreting surface; and, thirdly, by be- 
 ing applied to a common sore. A wound, it 
 seems, is much more readily infected than 
 a sore. To whichever of these three differ- 
 ent surfaces the pus is applied, it produces 
 its specific inflammation and ulceration, at- 
 tended with a secretion of pus. The mat- 
 ter produced in consequence of these dffer- 
 ent modes of application, he says, partakes 
 of the same nature as the matter which was 
 applied, because, be observes, the irritations 
 are alike. How the alleged examples of 
 very different primary sores being sometimes 
 communicated by the application of the 
 maiter of chancre, are to be reconciled 
 with the Hunterian doctrines, it is difficult 
 to suggest, unless Mr. Carmichael’s obser 
 vation about the present excessive rarity of 
 the true syphilitic chancre, can furnish the 
 explanation. However, as far as I can be- 
 lieve my own eyes and judgment, I now see 
 in London the same forms of chancre, 
 which used to prevail during my apprentice- 
 ship at St. Bartholomew’s Hospital more 
 than twenty years ago. And if any differ- 
 ence can be particularized, it is only that 
 which depends upon their being less rarely 
 converted into worse diseases than mere 
 syphilitic ulceration, by the dreadful effects 
 of immoderate courses of mercury. 
 
 With respect to the three modes, in which 
 Mr. Hunter speaks of the venereal poison 
 being applied and taking effect, I know not 
 why he should have altogether excluded se- 
 creting surfaces; for of this nature (as a late 
 writer remarks) are the glans penis and co- 
 rona glandis, ( Bacot on Syphilis, p. 55,) and 
 of a similar kind, are the insides of the labia, 
 the surfaces of the nymphae, &ic. where sores 
 are common enough. Whatever may be 
 the truth of the impossibility of the forma- 
 tion of chancres within the urethra, the 
 latter considerations certainly tend to prove 
 that the secreting nature of its membrane, 
 is not the only reason for the alleged fact. 
 
 I shall not here detain the reader with 
 
VENEREAL DISEASE. 
 
 <K)0 
 
 descriptions ot the primary ulcer with eleva- 
 ted edges, the phagedenic, and the sloughing 
 chancre. Such descriptions I have embo- 
 died in the last edition of the First Lines of 
 Surgery, with the sentiments of Mr. Carmi- 
 chael, respecting the train of constitutional 
 symptoms, appertaining, as he believes, to 
 each form of ulcer. It is an interesting dis- 
 quisition, but as far as my observations and 
 inquiries go, it has not yet reached any de- 
 gree of certainty or precision ; and as I have 
 already explained, the reports published by 
 other gentlemen engaged in this investiga- 
 tion, do not by any means confirm the much 
 desired intelligence, that such progress has 
 been made in the knowledge of all the diver- 
 sified symptoms of the venereal disease, that 
 its varieties can now be classed both in re- 
 gard to the primary ulcers, and the secondary 
 symptoms connected with each description 
 of chancre. 
 
 I firmly believe, that with respect to all 
 the appearances of this disease, both in its 
 primary and secondary forms, a vast deal 
 depends upon constitution, independent- 
 ly of the nature ot the virus. And I adopt 
 this opinion, at the same lime that many re- 
 flections, already hinted at in this article, 
 lead me to join in the belief, that syphilitic 
 diseases may depend upon a variety of poi- 
 sons, whereby some of the perplexity of these 
 cases may be explained. 
 
 The local, or immediate effects of the ve- 
 nereal disease, are seldom wholly specific; 
 but are usually attended both with the 
 specific and constitutional inflammation. 
 Hence, Mr. Hunter advises particular atten- 
 tion to be paid to the manner in which a 
 chancre first appears, and to its progress. 
 If the inflammation spreads in a quick and 
 considerable way, the constitution must be 
 more disposed to inflammation, than natural. 
 When the pain issevere, Mr. Hunter remarks, 
 there is a strong disposition to irritation. 
 Chancres, also, sometimes soon begin to 
 slough, there being a strong tendency to 
 mortification. 
 
 It is also observed by Mr. Hunter, that 
 when there is a considerable loss of sub- 
 stance, either from sloughing or ulceration, 
 a profuse bleeding is no uncommon circum- 
 stance, more especially, when the ulcer is on 
 the glans. The adhesive inflammation does 
 not appear to take place sufficiently to unite 
 the veins of this part of the penis, so as to 
 prevent their cavity from being exposed, 
 and the blood escapes from the corpus spon- 
 giosum urethrae. The ulcers, or sloughs, often 
 extend as deeply as the corpus cavernosum 
 penis, and similar bleedings are the conse- 
 quence. 
 
 With respect to chancres in women, the 
 labia and nymphae, like the glans penis in 
 ruen, are subject to ulceration, and the ulce- 
 rations are generally more numerous in fe- 
 males than males, in consequence of the 
 surface on which the sores are liable to 
 form being much larger. As Mr. Hunter 
 observes, chancres are occasionally situated 
 ou the edge of the labia ; sometimes on the 
 outside of these parts ; and even on the pe- 
 
 rinaeum. When the sores are formed or; the 
 inside of the labia or nymphae, they can 
 never dry or scab ; but when they are ex- 
 ternally situated, the matter may dry on 
 them, and produce a scab, just as hap- 
 pens with respect to chancres situated on 
 the scrotum, or body of the penis. 
 
 Mr. Hunter remarks, that the venereal 
 matter from these sores is apt to run down 
 the perinagum to the anus, and excoriate the 
 parts, especially about the anus, where the 
 skin is thin, and where chancres may be 
 thus occasioned. 
 
 Chancres have been noticed in the vagi- 
 na ; but Mr. Hunter suspected that they 
 were not original ones; but that they had 
 spread to this situation from the inside of the 
 labia. 
 
 Before any of the virus has been taken up 
 by the absorbents, and conveyed into the 
 circulation, a chancre is entirely a local af- 
 fection. From the Hunterian doctrines, 
 however, it would appear that absorption 
 must generally soon follow the occurrence 
 of the sore ; and all the modern opinions 
 concerning the nature of ulceration itself, 
 would lead to the same inference. When 
 no secondary symptoms take place after the 
 cure of chancre without mercury, I believe 
 few surgeons of the present day would at- 
 tempt to account for the fact by the hypo- 
 thesis of the matter not having been absorb- 
 ed ; and this observation is made with every 
 disposition on my part to express my assent 
 to the truth of another circumstance, viz* 
 that some persons appear much more sus- 
 ceptible of the effects of the venereal disease 
 than other individuals. It is remarked by 
 Mr. Hunter, that the interval between the 
 application of the poison, and its effects 
 upon the parts is uncertain ; but that on the 
 whole, a chancre is longer in appearing, 
 than a gonorrhoea. However, the nature of 
 the parts affected makes some difference. 
 When a chancre occurs on the fraenum, or 
 at the termination of the prepuce in the 
 glans, the disease in general comes on earlier; 
 these parts being more easily affected than 
 either the glans penis, common skin of this 
 organ, or the scrotum. He adds, that in 
 some cases, in which both the glans and 
 prepuce were contaminated from the same 
 application of the poison, the chancre made 
 its appearance earlier on the latter part. 
 Mr. Hunter knew of some instances in which 
 chancres appeared twenty-four hours after 
 the application of the matter; and others, in 
 which an interval of seven weeks, and even 
 two months elapsed between the time of 
 contamination, and that when the chancre 
 commenced. However, here, os in almost 
 all other statements about this perplexing 
 subject, we never know with certainty that 
 the writer has sufficient grounds for the as- 
 sumed fact, that it is only one kind of poison 
 which is spoken of. 
 
 TREATMENT OF CHANCRES. 
 
 It was one of Mr. Hunter’s opinions, that 
 the ulceration arising from venereal inllam- 
 
venereal disease. 
 
 m 
 
 yaation, generally, if not always, continues 
 till cured by art, and his theoretical reason 
 for this circumstance was, that as the in- 
 flammation in the chancre spreads, it is al- 
 ways attacking new ground, so as to produce 
 a succession of irritations, and hinder the 
 disease from curing itself. 
 
 It was no doubt the foregoing opinion of 
 Mr. Hunter, which formed the authority for 
 the position which was always forcibly in- 
 sisted upon in the surgical lectures which I 
 attended some years ago in London, viz. 
 that all venereal complaints, when not coun- 
 teracted by remedies, invariably grow pro- 
 gressively worse and worse. But modern 
 experience apprizes us, that this doctrine is 
 far from being correct. As I have noticed 
 in the foregoing pages, Mr. Fergusson assures 
 us, that in Portugal, the disease in its prima- 
 ry state among the natives is curable without 
 mercury, and by simple topical treatment j 
 that the antisyphilitic woods, combined with 
 sudorifics, are an adequate remedy for con- 
 stitutional symptoms ; and that the viruieuce 
 of the disease has there been so much miti- 
 gated, that after running a certain course 
 (commonly a mild one) through the respec- 
 tive orders of parts, according to the known 
 laws of its progress, itexhauslsilself and ceases 
 spontaneously. (See Med. and Chir. Trans. 
 Vol. 4, p. 2 — 6.) • Iri the third edition of the 
 First Lines of the Practice of Surgery, it was 
 sufficiently proved, from several conclusions 
 drawn from the writings of Mr. Pearson, 
 ( Obs . on the Effects of Various Articles in the 
 Cure of Lues Venerea,) that venerea! sores 
 might be benefited, and even healed under 
 the useof several inert insignificant medicines 
 And as I have previously explained, the 
 possibility of curing chancres and other ve- 
 nereal complaints, without mercury, was 
 Jong since remarked by Dr. Clutterbuck, 
 who thence very justly inferred, that the 
 healing of a sore without this remedy was 
 no test that it was not venereal. (See Re- 
 marks on the Opinions of the late John Hun- 
 ter, 1799.) 
 
 But although the whole history of the 
 venereal disease, and of the various articles 
 of the materia medica, if carefully reflected 
 upon, must have led to the same conclusion, 
 the truth was never placed in such a view as 
 to command the general belief of all the 
 most experienced surgeons in this and other 
 countries of Europe. I do not mean to say, 
 thnt the truth was not seen arid remarked by 
 several of the older writers ; for that it was 
 so any man may convince himself by refer- 
 ring to several works, quoted in the course 
 of this article. But it is to be understood, 
 all indecision could never be renounced, as 
 long as prejudices interfered with the only 
 rational plan which could be adopted, with 
 the view of bringing the question to a final 
 settlement ; I mean experiments on a large 
 and impartial scale, open to the observation 
 of numerous judges, yet under such control 
 as insured the rigorous trial of the practice. 
 Nor could such investigation be so well 
 made by any class of practitioners as the 
 army surgeon?, whose patients are nume- 
 
 rons, obliged to follow strictly the treatment 
 prescribed, w itbout any power of going from 
 hospital to hospital, or from one surgeon to 
 another, as caprice may dictate, or of eluding 
 the observation of the medical attendants 
 after a seeming recovery. And here I must 
 take the opportunity of stating, that as far 
 as my judgment extends, the most important 
 and cautions document yet extant on the two 
 questions of the possibility and expediency of 
 curing the venereal disease without mercury, 
 is the paper of Mr. Rose. For let it not be 
 presumed, that because the army surgeons 
 find the venereal disease curable without 
 mercury, they mean to recommend the total 
 abandonment of that remedy for the distem- 
 per, any more than they would argue that 
 possibility and expediency are synonymous 
 terms. At the time when Mr. Rose publish- 
 ed his observations, he had tried the non- 
 mercurial treatment in the Coldstream 
 Regiment of Guards, during a year and 
 three quarters, and had thus succeeded in 
 curing all the ulcers on the parts of genera 
 tion which he met with in that period , to - 
 gether with the constitutional symptoms to 
 which they gave rise. “ I may not be war- 
 ranted in asserting, (says this gentleman,) 
 that many of these were venereal, but un- 
 doubtedly a considerable number of them 
 had all the appearances of primary sores, 
 produced by the venereal virus, and arose 
 under circumstances, where there had been 
 at least a possibility of that virus having been 
 applied. Admitting that there is nothing so 
 characteristic in a chancre, as to furnish in - 
 controvertible proof of its nature, it will yet 
 be allowed, that there are many symptoms 
 common to such sores, although not en- 
 tirely peculiar to them, and whenever these 
 are met with, there are strong grounds 
 to suspect, that they are the effects of 
 the syphilitic virus. In a sore, for in- 
 stance, appearing shortly after suspicious 
 connexion, where there is loss of substance, 
 a want of disposition to granulate, and an 
 indurated margin and base, there is certain- 
 ly a probability of that poison being present. 
 Among a number of cases of such a descrip- 
 tion, taken indiscriminately, the probability 
 of some being venereal is materially increas- 
 ed, and must at last approach nearly to a 
 certainty. On this principle some of the 
 sores here referred to, must have been 
 venereal. They were also seen by different 
 surgeons, on whose judgment I would rely, 
 who agreed in considering many of them 
 as well marked cases of true chancre.” 
 ( Rose in Med. Chir. Trans. Vol. 8 ,p. 357, fyc.) 
 The men thus treated, were examined almost 
 every week, for a considerable time after 
 their apparent cure, “both that the first ap- 
 proach of constitutional symptoms might be 
 observed, and that any deception from an 
 underhand use of mercury might be guarded 
 against.” (P. 359.) Sixty cases of ulcers on 
 the penis were also cured by, Mr. Dense, in 
 the York Hospital, by means of simple dress- 
 ings, the only general remedy being occasion 
 al purgatives. The practice was likewise ex 
 tepsivelv tried by Mr. Why tr per and .**■ 
 
VENEREAL DISEASE. 
 
 608 
 
 Good, surgeons of the Guards, with the same 
 kind of success. In Mr. Rose’s practice, all 
 idea of specific remedies were entirely laid 
 aside. The patients were usually confined to 
 their beds, and such local applications were 
 employed, as the appearances of the sores 
 seemed to indicate. Aperient medicines, 
 antimony, hark, vitriolic acid, and occasion 
 ally sarsaparilla, were administered. (P. 
 363.) Upon an average (says Mr. Rose) 
 one out of every three of the sores thus treat- 
 ed , was followed, by some form or other 
 of constitutional affection: this was in most 
 instances mild, and sometimes so slight, that 
 it would have escaped notice, if it had not 
 been carefully sought for. The constitu- 
 tional symptoms were evidently not 3uch as 
 could be regarded as venereal, if we give 
 credit to the commonly received ideas on 
 the subject. Caries of the bones , and some of 
 the least unequivocal symptoms, did not oc- 
 cur. In no instance was there that uniform 
 progress, with unrelenting fury, from one 
 order of symptoms and parts affected to an- 
 other, which is considered as an essential 
 characteristic of true syphilis.” (Med. Chir. 
 Trans. Vol. 8, p. 422.) The constitutional 
 symptoms also yielded, without the aid of 
 mercury, and frequently primary sores, cor- 
 responding to what had been called the 
 true chancre, with indurated base, were 
 cured in this manner, yet were followed by 
 no secondary symptoms. We are also in- 
 formed, that “ several cases occurred of a 
 cluster of ill-conditioned sores over the 
 whole inner surface of the prepuce, and 
 behind the corona glandis; and also of a 
 circle of small irritable sores, situated on 
 the thickened and contracted ring at the ex- 
 treme margin of the prepuce. These occa- 
 sionally produced buboes.” None of the sores 
 of this description met with by Mr. Rose , were 
 followed by any constitutional affection. ( Vol. 
 cit. p. 370.) He bears testimony to the ill 
 effects of mercury and stimulants in cases 
 of phagedenic ulcers, and confirms a not 
 uncommon opinion, that they are seldom 
 followed by secondary symptoms, which 
 opinion should be qualified with the condi- 
 tion mentioned by Mr. Guthrie, (Med. Chir. 
 Trans. Vol. 8, p. 565.) that no mercury be 
 given. Lastly, as I have already stated, 
 Mr. Rose observed, that most of the cases of 
 papular eruptions followed ulcers, which 
 were not very deep, and healed without 
 much difficulty. (P. 399.) 
 
 Although the fact of the possibility of 
 curing every kind of ulcer on the genitals, 
 without mercuiy, is now so fully confirmed 
 by the statements of Mr. Guthrie, (Med. 
 Chir. Trans. Vol. 8, p. 558, and 676.) ; Dr. 
 I. Thomson, (Edinb. Med. and Surg. Journ. 
 for January , 1818;) Dr. Hennen, (Op. cit. 
 Nos. 54 and 55, and Principles of Military 
 Surgery , Ed. 2.) ; Mr. Bacot, (On Syphilis, 
 p. 26, fyc.) ; and many other careful obser- 
 vers, and it is of great importance in rela- 
 tion to the removal of an erroneous doc- 
 trine concerning the diagnosis, the expedien- 
 cy of the practice must evidently be deter- 
 mined by other considerations, the princi- 
 
 pal of which are the comparative quickness 
 of the cures effected with, and without mer- 
 cury ; the comparative severity and frequen- 
 cyof secondary symptoms ; and the generally 
 acknowledged fact, that a syphilitic primary 
 sore is not indicated with any degree of cer- 
 tainty by its mere external character, or in- 
 deed any other criterion, that I know of. 
 
 Respecting the comparative quickness of 
 the cures of chancres, or reputed chancres, 
 without the aid of mercury, much disagree- 
 ment prevails in the different reports, even 
 those collected by the same individuals, 
 whose statements must therefore be deem- 
 ed perfectly impartial, though inconclusive. 
 (See Hennen's Military Surgery , Ed. 2, p. 
 536, fyc.) Some of Mr. Rose’s best marked 
 cases of chancre, that is to say, such as were 
 distinguished by the indurated base and cir- 
 cumference, healed in a very short time. 
 But even respecting these, or any other 
 kinds of chancre, no regularity on this point 
 can be found. Mr. Guthrie observes, if the 
 “ ulcers were not without any marked ap- 
 pearance, and did not amend in the first fort- 
 night, or three weeks, they generallyremain- 
 ed for five, or seven weeks longer ; and the 
 only difference in this respect between them 
 and the raised ulcer of the prepuce was, 
 that this often remained fora longer period, 
 and that ulcers, possessing^the true charac- 
 ters of chancre, required in general a still 
 longer period for their cure, that is, from 
 six, eight, to ten, twenty, and even in one 
 case, twenty-six weeks, healing up and ul- 
 cerating again on a hardened base. Those 
 that required the greatest length of time had 
 nothing particular in their appearance, that 
 would lead us to distinguish them from 
 others of the same kind, that were healed 
 in a shorter time.” (Med. Chir. Trans. Vol. 
 8, p. 558.) The same writer afterward ex- 
 presses his belief, that almost all the pro- 
 tracted cases would have been cured in one 
 half, or even one-third of the time, if a 
 moderate course of mercury had been re- 
 sorted to. 
 
 In relation to the question before us, one 
 of the most important documents which I 
 met with, is an official circular, signed by 
 Sir James M‘Grigor and Dr. Franklin, from 
 which it appears, that in 1940 cases of pri- 
 mary venereal ulcerations on the penis, 
 cured without mercury . between December, 
 1816, and December, 1818, (including not 
 only the more simple sores, but also a re- 
 gular proportion of those with the most 
 marked character of syphilitic chancre) the 
 average period taken up by the treatment, 
 when bubo did not exist, was 21 days, ; with 
 bubo, 45 days. (See H ennen's Military Sur- 
 gery, Ed. 2, p. 545.) And it further appears, 
 that during the period above specified, 2827 
 chancres, a more considerable proportion 
 of which were probably Hunterian chan- 
 cres, were treated with mercury, and that 
 the average period required for the cure, 
 when there was no bubo, was 33 days ; 
 with bubo, 50. As far therefore as a judg- 
 ment can be formed from this official esti- 
 mate, and no calculation is ever likely to be 
 
VENEREAL DISEASE. 
 
 <509 
 
 furnished on a larger, or more impartial 
 scale, the evidence tends to prove, that pri- 
 mary sores may generally be cured rather 
 sooner without, than with, the administra- 
 tion of mercury. But, as practitioners are 
 not obliged to restrict themselves either to 
 the mercurial, or non-mercurial practice, 
 I am of opinion, that the total rejection of 
 mercury is by no means justified by any 
 facts, yet before the public, concerning the 
 time requisite for the cure on either plan, 
 because, as it is universally admitted, that 
 some cases are very tedious, unless mercury 
 be given, neither reason nor experience will 
 sanction the exclusive adoption of only one 
 mode of practice, whether the backward- 
 ness to heal exist, or not. On the contrary, 
 as far as the consideration of time has 
 weight, prudence and common sense teach 
 us to diversify the treatment according to 
 circumstances But it may be inquired, 
 since the backward disposition of a sore to 
 heal cannot be known at first by its mere 
 appearance, should the treatment begin with 
 mercury, or not? Now, although late writers 
 dwell very much on the impossibility of 
 judging of the nature of a sore by its look 
 alone, one fact is certain, thatsome ulcers on 
 the penis have a clean appearance from their 
 very commencement; some cases are simple 
 excoriations ; and others, though ill-condi- 
 tioned, are so small, that a fair chance 
 offers itself of destroying every part of the 
 disease with caustic. In all such cases, I 
 should never commence with mercury. 
 With respect to phagedenic and sloughing 
 chancres, repeated experience has con- 
 vinced me that they are cases, in the first 
 stage of which, at all events, mercury should 
 always be avoided ; and I believe with Mr. 
 Guthrie, that when this is strictly done, 
 secondary symptoms are rare. One sore of 
 this kind was long ago pointed out by Mr. 
 Pearson as not requiring mercury ; and the 
 attention of surgeons has been of late par- 
 ticularly directed to it by Mr. Bacot. “ It 
 is characterized by a great derangement of 
 the general health, by a high state of in- 
 flammation of the part, by great local pain, 
 and proceeds rapidly to the destruction of 
 the parts. The situation of this sore is most 
 commonly in the angle between the pre- 
 puce and glans penis ; and those of a full 
 habit of body, the young and the vigorous, 
 are most liable to its attack. The most 
 prompt and vigorous antiphlogistic means 
 are necessary to arrest the progress of this 
 sore ; and the blood, taken away in these 
 cases, presents the usual inflammatory ap- 
 pearances, frequently in a very high degree. 
 The exhibition of mercury in this species of 
 sore is highly mischievous, and productive 
 of the worst consequences ; nor does it 
 often happen that secondary symptoms 
 succeed, &,c. (On Syphilis, p. 57.) Here, 
 according to Mr. Pearson’s observations, 
 made many years ago, mercury is not per- 
 haps necessary for the security of the con- 
 stitution ; but, I conceive, it might be more 
 correct to say, that the safety of the consti- 
 tution actually requires that mercury should 
 v ot , n, 5 77 
 
 be strictly avoided, because there Is some 
 ground for believing, that in these in- 
 stances, it is not only injurious to the local 
 disease, but conducive to secondary symp- 
 toms. However, if the latter symptoms 
 should arise, notwithstanding mercury has 
 not been administered during the cure of 
 the ulcer, alterative doses of that medicine 
 may still be useful, as Mr. Carmichael ob- 
 serves, when the disease is in the wane, 
 but not until then ; previously to which pe 
 riod, the best internal remedies are antimo- 
 nials, sarsaparilla, guaiacum, compound 
 powder of ipecacuanha, arseniate of kali, 
 the nitrous acid, and nitro-muriatic bath. 
 (See Obs. on the Symptoms , fyc. of the Vene- 
 real Disease, p. 209.) 
 
 With respect to chancres, with a hardened 
 base and margin, it certainly appears that 
 many of them have healed tolerably fast 
 without mercury; but a large proportion of 
 them seem to be tedious when that medi- 
 cine is not employed. (See three cases 
 recorded in the work last quoted.) It may 
 be thought, however, that the official docu- 
 ment, circulated by Sir James M'Grigor and 
 Dr. Franklin, tends to prove, that, at all 
 events, these sores heal sooner without than 
 with mercury. But this deduction seems 
 hardly allowable ; because, as these faithful 
 and impartial reporters have sensibly re- 
 marked, the 2827 sores, treated with mer- 
 cury, may be fairly presumed to have 
 partaken of the character of Hunter’s chan- 
 cre, in a greater proportion than the 1940 
 primary sores treated without mercury. (See 
 Hennen's Military Surgery , p. 545.) Con- 
 sequently, though the sores treated with 
 mercury seem, on the average, to have heal- 
 ed more slowly than others treated with it ; 
 yet it is to be taken into the account, that a 
 larger number of the first cases were ulcers 
 with a hardened base and margin, and that 
 if they had not had the mercurial treatment 
 extended to them, it is possible their com- 
 plete cure might generally have been still 
 more tedious. As the evidence now stands, 
 therefore, 1 conceive it right to employ mer- 
 cury with moderation for all sores on the 
 penis, having the characters of the Hunterian 
 chancre, and appearing after a suspicious 
 connexion. 
 
 A consideration, however, which ought to 
 have greater influence than the slowness or 
 quickness of the treatment of primary sores, 
 with and without mercury, is the question, 
 whether, upon the average, secondary symp- 
 toms are more frequent after the non-mercu- 
 rial practice, than the other ? On this most 
 interesting point, the reports vary, as indeed 
 they do on almost every matter in the inves- 
 tigation, excepting the facts of the possibility 
 of curing all forms of the venereal disease 
 without mercury, the great rarity of any af- 
 fection of the bones, and the general mild- 
 ness of the secondary symptoms, when that 
 medicine is not employed. On all these 
 points, the testimonies are strong and con- 
 vincing. But while Mr. Rose found secon- 
 dary symptoms take place in one-third of his 
 cases treated without mercury, (Med. Ckir. 
 
610 
 
 VENEREAL DISEASE. 
 
 Trans. Vol. 8, p. 222,) the proportion in the 
 York, and some other hospitals, was only 
 about one-tenth. (Vol. cit. p. 559.) In the 
 1940 cases of primary sores on the penis, 
 treated without mercury in the army hospi- 
 tals, between D-*c. 1816, and Dec. 1818, 
 there were only 96 instances of secondary 
 symptoms of different sorts, or not more ihan 
 one-twentieth. But the proportion of cases 
 of secondary symptoms in the case of pri- 
 mary ulcers, treated with mercury, was still 
 smaller, and this in an important degree, be- 
 ing only 51 out of 2827 cases, or about orie- 
 fifty- fifth. Were it not necessary here to 
 make a considerable allowance for the pro- 
 bable circumstance of the Hunterian chancre 
 prevailing most in the cases treated with 
 mercury, a point admitted by Sir James 
 M‘Grigor and Dr. Franklin, we should here 
 have a powerful and decisive evidence in 
 favour of the general superiority of mercury 
 for the prevention of secondary symptoms. 
 Nor am 1 certain that the conclusion can be 
 much weakened by the probability of the 
 difference here alluded to, because, from the 
 evidence of late brought to light respecting 
 the nature of the class of diseases which go 
 under the name of syphilis, we have no right 
 to infer, that what has been called the frue, 
 or Hunterian chancre, is more disposed than 
 some other primary sores to occasion se- 
 condary symptoms. Indeed, Mr. Guthrie 
 declares, in the cases referred to in his paper, 
 that where mercury was not used, these 
 symptoms more frequently followed the 
 raised ulcer of the prepuce, than the true 
 characteristic chancre of syphilis affecting 
 the glans penis. (Med. Chir. Trans. Vol. 8, 
 p. 577.) On the whole, as the reports now 
 stand, and as far as I can judge from cases 
 which I have seen myself, the secondary 
 symptoms are more frequent when primary 
 ulcers are promiscuously treated without 
 mercury. But it by no means follows from 
 this fact, that the w r ay to have the smallest 
 possible number of cases of secondary symp- 
 toms, is to employ mercury in all instances 
 of sores on the genitals. This both reason 
 and experience contradict, inasmuch as mer- 
 cury, given in cases which do not require it 
 for the security of the constitution, is fre- 
 quently itself a source of cutaneous diseases, 
 sore throats, and nodes, which, without its 
 baneful influence, would never have occur- 
 red. The prudent course seems here to be, 
 to exercise our judgment and discretion, and 
 to be guided in some measure by the ap- 
 pearance and progress of the sore, according 
 to principles already suggested; for though 
 the look of a sore may not, in the present 
 state ot our knowledge, always enable us to 
 form a certain inference respecting the risk 
 of secondary symptoms, if mercury be omit- 
 ted, it cannot be said, that the danger would 
 be positively obviated by having recourse at 
 once to mercury in every kind of primary 
 sore, and notwithstanding every thing which 
 has been lately published, I still flatter my- 
 self, that surgeons, accustomed to see much 
 of venereal cases, can yet distinguish exco- 
 riations, boils, simple healthy sores, and 
 
 some other similar ailments, («ep Evans on 
 Ulcerations of the Genital Organs, 8 vo. Lond. 
 1819,) from ulcers, by which the constitution! 
 is liable to be affected. Until further data 
 exist, I cannot venture to lay do vn other 
 directions about (he treatment of primary 
 sores. It is with pleasure, however, that [ 
 subjoin the advice of other gentlemen, whose 
 sentiments and talenf« deserve respect, 
 though their opinions may not exactly agree 
 with my own. “ In every primary ulcer, 
 (says Dr. Hennen,) I would give up the idea 
 of using mercury at first, treating it as if it 
 were a simple ulceration, by cleanliness, 
 rest, and abstinence, and applying to it the 
 most simple, and mildest dressings. If the 
 sore did not put on a healing appearance in 
 a reasonable time, the extent of which must 
 depend upon the circumstances of the pa- 
 tient, I should make use of more active 
 dressings. But if, beyond all calculation, it 
 remained open, 1 should certainly not sacri- 
 fice every consideration to a dislike of mer- 
 cury, knowing how many persons have been 
 seriously benefited by a judicious and mild 
 administration of that remedy.” (On Mili- 
 tary Surgery, Ed. 2, p. 518.) When primary 
 ulcers resist common means » certain lime, 
 Mr. Barot would also have recourse to mer- 
 cury. (On Syphilis, p. 69 ) Like me, how- 
 ever, the latter author does not approve of 
 invariably postponing that remedy, until the 
 latter criterion, viz. the backwardness of the 
 sore to be healed by other methods, is af- 
 forded. 
 
 Whenever the employment of mercury in 
 this work is recommended, I am very far 
 from wishing to be thought an advocate for 
 pushing that medicine, as the phrase is. On 
 the contrary, experience has fully convinced 
 me, that in no forms of chan' re, nor in any 
 other stages of the venereal disease, is it 
 proper to exhibit mercury in the unmerciful 
 quantity, and for the prodigious length of 
 time, which custom, ignorance, and preju- 
 dice, used t»* sanction in former days. Vio- 
 lent salivations, at all events, ought to be for 
 ever exploded. 
 
 When I was an apprentice at St. Bartho- 
 lomew’s Hospital, mo^t of the venereal pa- 
 tients in that establishment were seen with 
 their ulcerated tongues hanging out of their 
 mouths; their faces prodigiously swelled; 
 and their saliva flowing out in streams. The 
 wards were not sufficiently ventilated, and 
 the stench was so great, that the places well 
 deserved the appellation of foul. Yet, not- 
 withstanding mercury was thus pushed, (as 
 the favourite expression was,) it was then 
 common to see many patients suffer the most 
 dreadful of mutilations, in consequence of 
 sloughing ulcers of the penis; other patients 
 whose noses and palates were lost ; others 
 who were covered with nodes and dreadful 
 phagedenic sores. 
 
 Happily, at the present day, this attach- 
 ment to violent salivations no longer pre- 
 vails; simple excoriations and common ul- 
 cers are more attentively discriminated ; and 
 even in what are reputed to be true syphili- 
 tic chancres, mercury is seldom given, except 
 
VENEREAL DISEASE 
 
 611 
 
 m very moderate doses, or such quantities 
 as only gently affect the gums and salivary 
 glands. The surgeon, now no longer blind- 
 ed with the conti ual tear of the rapid and 
 furious progress of syphilis when not duly 
 unresisted by mereury, avoids the very mode 
 ot practice which was itself the cause of all 
 the aggravated forms of the disease. The 
 consequence is, that very bad instances of 
 the ravages of lues vener* a are now hardly 
 ever observed in the above hospital, and the 
 few aggravated cases which are met w ith, 
 are geneially in lhat state previously to their 
 admission. Another benefit, also resulting 
 from modern investigations, which proves 
 that chancres, and all other varieties ol the 
 venereal disease, do not absolutely require 
 mercury for their cure, is the safety with 
 which it is now knowm thai the u-e of such 
 medicine may be postponed, where the pa- 
 tient’s present state of health would not well 
 bear its exhibition. And ! know, tha« an ig- 
 norance of this fact has formerly caused the 
 death of many a poor sutferer. 
 
 The greater present mildness of syphilitic 
 diseases in England, I ascribe chiefly to the 
 more judicious treatment now’ adopted, and 
 not to any change or modification in the na- 
 ture of the disorder. There are others, how- 
 ever, who mrtj think as Mr. Fergusson does 
 with regard to syphilis in Portugal, that the 
 disease has exhausted a great deal of its vi > 
 rulence from long continuance among us. 
 But before we are altogether justified in 
 drawing such a conclusion, we must forget 
 all the* bad practice wnich prevailed in for- 
 mer days, and hich, in my opinion, is suffi- 
 cient to account tor the more severe forms 
 in which syphilis then presented itself. 
 
 According to Mr. Hunter’s ideas, the most 
 simple method of treating a chancre is to 
 extirpate it with caustic, or the knife, where- 
 by it is reduced to the state of a common 
 sore, or w’ound, and heal$ up as such. How- 
 ever, he sanctions this practice only on the 
 first appearance of the chancre, when the 
 surrounding parts are not yet contaminated ; 
 for, he says, it is absolutely ecessary to re- 
 move the w’hole of the diseased part, and this 
 object is exceedingly difficult of accomplish- 
 ment, when the disease has spread considera- 
 bly. When the chancre is situated on the glans 
 penis, he thought touching the sore with the 
 lunar caustic preferable to cuttim: it aw'ay, 
 because the hemorrhage from the cells of 
 the glans u 7 ould be considerable after the use 
 of the knife 
 
 The caustic should be pointed at the end 
 like a pencil, in order that it may only touch 
 9uch parts as are really disease ; and its ap- 
 plication should be repeated till the surface 
 of the sore, after the separation of the last 
 sloughs, assumes a red ancLhealthy appear- 
 ance, w r hen it will heal, litce any other sore 
 made with caustic. 
 
 When tiie sore is on the prepuce, or the 
 common skin of the penis, and in art incipient 
 state, the same practice may be adopted w ith 
 success When the chancre is large, how- 
 ever, it cannot be destroyed with the argen- 
 tum nitratura, which does cot extirpate the 
 
 increasing sore deeply enough. In sucli 
 cases, Mr. Hunter thought that the potassa 
 cum calce might answer belter. When the 
 caustic could not lie conveniently employed, 
 this author sometimes recommended the ex- 
 cision of chancres, a plan which he had 
 adopted himself, and the part afterward 
 healed with common dressings. However, 
 says he. as our knowledge of the extent 
 of the disease is not always certain ; a :d as 
 this uncer amty increase; with the size of 
 the chancre, the cure must he in some mea- 
 sure promoted by proper dressings, and it 
 will t»e prudent to dress the sore w ith mercu- 
 rial ointment. When a chancre is destroyed 
 almost immediately on its first appearance, 
 Mr. Hunter believes lhat there is I i t tie dan- 
 ger of the constitution being infected, as it 
 is reasonable to conclude lhat there has not 
 been time for absorption to take place. 
 However, on account of the impossibility 
 of being certain on this point, he recom- 
 mends mercury to be given from motives 
 of prudence, the quantity of which medicine, 
 be says, should he proportioned to the dura- 
 tion a, id progress of the sore. When the 
 chancre is large, Mr. Hunter deems mercury 
 absolutely necessary, and he conceives that 
 very little good is to be done by the extirpa- 
 tion. 
 
 With respect to dressings for chancres, Mr. 
 Hunter seems to have placed a good deal of 
 confidence in those which contain mercury ; 
 but I do not believe that the same attach- 
 ment to them prevails non which existed 
 twenty years ago. And the established fact 
 of mercury not being absolutely necessary i i 
 any way for the. cure of different venereal 
 sores, must have the effect of removing some 
 prejudices on this [mrt of the subject. As 
 common mercurial ointment is always more 
 or less rancid, I have found it in many cases 
 a bad kind of dres ing ; and now never ap- 
 ply it to ulcerated surfaces. In ordinary 
 cases, I believe astringent lotions made w ith 
 the sulphate of copper, acetate of lead, alum, 
 &,c. answer the best. Some chancres are in- 
 dolent, and require stimulants, like the hy- 
 drargyri nitrico oxydurn blended with oint- 
 ment, the unguentura hydrargyri nitrati more 
 or less weakened, ora solution of the nitrate 
 of silver. Mr. Hunter, always partial, even 
 in cases of indolent chancres, to mercurial 
 dressings expresses his preference to a salve 
 containing calomel, as being more active 
 than common mercurial ointment. In phage- 
 denic and sloughing chancres, the carrot and 
 fermenting poultices, solutions of the extracts 
 of hemlock and opium ; hut particularly 
 bread and water poultices with opium, and 
 lotions of the arsemate of kali, nitrous acid, 
 and nitrate of sliver, merit tiial. 
 
 In general, Mr. Hunter was an advocate 
 for changingthe dressings very often, because 
 the matter separates them from the sore, 
 so as to diminish their effects. He states, 
 that changing the appli* at ions thrice a day, 
 will not be found too often, particularly 
 when they are in the form of an ointment. 
 
 When the venereal nature of a chancre is 
 removed, the sore frequently becomes eta- 
 
VENEREAL DISEASE 
 
 612 
 
 tionary, in which case Mr. Hunter observes, 
 that new dispositions have been acquired, 
 and the quantity of disease in the part ha£ 
 been increased When chancres are only 
 stationary, Mr. Hunter says, they may often 
 be cured by touching them slightly with 
 the lunar caustic. In these cases, no cica 
 trization seems possible, till the contamina- 
 ted surface, or the new tiesh which grows 
 on that surface, has either been destroyed 
 or altered. When sores are situated under 
 the prepuce, where they are concealed by 
 a phymosis, some emollient, or gently as- 
 tringent lotion, should frequently be injected 
 under the fore-skin, so as to wash out any 
 matter which might otherwise lodge there, 
 and cause additional irritation. 
 
 Contrary to the doctrines, which the facts 
 of modern experience have now fully esta- 
 blished, Mr. Hunter believed, that mercury 
 should be given in every case of chancre , hovv- 
 ever slight, and even when it has been de- 
 stroyed by caustic, or other means, on its 
 very first appearance. The remedy, he says, 
 should be continued for some time after the 
 chancre has healed , in order to hinder the ve- 
 nereal disposition from forming. Here we 
 find even Hunter himself falling into some 
 inconsistencies ; for, in other parts of his 
 work, he seems to approve of the principle 
 of giving mercury only when actual and 
 visible disease exists, becau-e it cannot cure 
 the disposition to it, even if it exists. Now, 
 though the chancre is cured, no further ab- 
 sorption of the virus from it is possible, and 
 whatever disposition to the disease can arise 
 from absorption, must have already been 
 formed, and therefore cannot be prevented, 
 and, according to Mr. Hunter’s own theory, 
 the virus has been long ago expelled from 
 the system, together with some of the ex- 
 cretions, mercury is recommended with the 
 view of protecting the constitution. How- 
 ever, if Mr. Hunter’s explanations are not 
 altogether satisfactory on this part of the 
 subject, I believe the fault is in his theory, 
 because, in cases where mercury is deemed 
 adviseable, general experience appears to 
 sanction the practice of continuing its use 
 for some time after the chancre is perfectly 
 healed. Yet many exceptions to this rule 
 present themselves ; for, if a chancre is 
 large, and very long in healing, its syphilitic 
 character is generally extinct a good while 
 before cicatrization is completed, and per- 
 severance in mercury under these circum- 
 stances would be both an absurd, and a 
 dangerous practice. 
 
 Hence, in a great measure, the cause of 
 the numerous instances of the mercurial dis- 
 ease, as Mr. Mathias has named it, and 
 which, in former days, did far more mis- 
 chief than syphilis itself. (See An Inquiry 
 into the History and Nature of the Disease, 
 produced in the Human Constitution by the 
 Use of Mercury, 3d Ed 8 vo. Land. 1816.) 
 This part of (lie subject is noticed by Mr. 
 Hunter, who states, that in very large chan- 
 cres, it may not always be necessary to 
 continue cither the external or internal ad- 
 ministration of mercury till the sore is 
 
 healed ; for the venereal action is just as 
 soon destroyed in a large chancre, as it is in 
 a small one, since every part of the sore is 
 equally affected by the medicine, and, of 
 course, cured with equal expedition. But, 
 in regard to cicatrization, circumstances are 
 different, because a large sore is longer than 
 a small one in becoming covered with skin. 
 Hence, according to Mr. Hunter, a large 
 chancre may be deprived of its venereal 
 action, long before it has healed ; while, on 
 the other hand, a small one may heal before 
 the syphilitic affection has been destroyed. 
 In the latter case, he represents it as most 
 prudent, both on account of the chancre 
 and constitution, to continue the employment 
 of mercury a little vjhile after the sore is 
 healed; advice which, as 1 have already 
 stated, is at variance with certain parts of 
 his own theory, however well justified it 
 may be by experience. 
 
 As Mr. Hunter has explained, chancres 
 both in men and women often acquire, du- 
 ring the treatment, new dispositions, w hich 
 are of various kinds, some retarding the 
 cure, and leaving the parts in an indolent 
 thickened state, after the cure is accom- 
 plished. In other instances, a new disposi- 
 tion arises, which utterly prevents the parts 
 from healing, and often produces a much 
 worse disease than that from- much it ori- 
 ginated. Such new dispositions may lead 
 to the growth of tumours. They are more 
 frequent in. men than women, and generally 
 occur only when the inllammation has been 
 violent from some peculiarity of the parts, 
 or constitution. They have sometimes been 
 considered as cancerous. 
 
 Among the diseases in question, Mr. Hun- 
 ter notices those continued, and often in- 
 creased inflammations, suppurations, and 
 ulcerations, which become diffused through 
 the whole prepuce, and also, along tile 
 common skin of the penis, which becomes 
 of a purple hue, attended with such a gene- 
 ral thickening of the cellular membrane, as 
 makes the w'hole organ appear considerably 
 enlarged. The same writer observes, that 
 the ulceration on the inside of the prepuce 
 will sometimes increase, and run between 
 the skin and the body of the penis, and eat 
 holes through different places, till the whole 
 is reduced to a number of ragged sores. 
 The glans often shares the same fate, till 
 more or less of it is gone. Frequently, the 
 urethra in this situation is wholly destroyed 
 by ulceration, and the urine is discharged 
 some way farther back. The ulceration, if 
 unchecked, at length destroys all the parts. 
 In this acute case, prompt relief is demand- 
 ed ; but often the proper mode of treatment 
 cannot be at once determined, owing to our 
 ignorance in r^pect to the exact nature of 
 the peculiar cause of the disease. Mr 
 Hunter states, that the decoction of sarsa- 
 parilla is often of service, when given in 
 large quantities ; and that the extract of 
 hemlock, and sea bathing, are sometimes 
 capable of effecting a cure. According to 
 my own experience, the omission of mer 
 cury is here the most essential thing. 
 
VENEREAL DISEASE 
 
 Glo 
 
 Sometimes alter a chancre has healed, 
 the cicatrix breaks out again, and puts on 
 the appearances of the preceding sore. 
 Occasionally, similar diseases break out in 
 different places from that of the cicatrix. 
 Mr. Hunter believes, that they differ from a 
 chancre in generally not spreading so fast, 
 nor so far; in not being so painful, nor so 
 much inflamed ; in not having such hard 
 bases as venereal sores have ; and in not 
 producing buboes. This writer is of opi- 
 nion, that- they are not venereal, and he 
 states, that they' are very apt to recur. 
 
 Mr. Hunter does not specify any particular 
 mode of cure for all these cases ; but he 
 mentions one instance, which seemed to be 
 cured by giving forty drops of the liquor 
 potassae, every evening and morning, in a 
 basin of, broth ; and he adverts to another 
 case, which was permanently cured by sea- 
 bathing. 
 
 In some instances, after a chancre has 
 healed, the parts, as Mr. Hunter remarks, 
 do not ulcerate ; but appear to become 
 thickened and indurated. Both the glans 
 and prepuce seem to swell, so as to form on 
 the end of the penis a tumour, or excres- 
 cence, shaped very much like a cauliflower, 
 and when cut into, showing radii, running 
 from its base, or origin, towards the exter- 
 nal surface. It is extremely indolent, and 
 not always a consequence of the venereal 
 disease; for Mr. Hunter has seen it arise 
 spontaneously'. 
 
 No medicine seems to be at all likely to 
 cure the disease ; the only successful means 
 is to amputate a considerable part of the 
 penis, and then to keep a proper catheter 
 introduced in the urethra. 
 
 Another disposition, induced by the pre- 
 vious occurrence of chancres, is that to ex- 
 crescences, or cutaneous tumours, called 
 warts. These are frequently considered not 
 simply as a consequence of the venereal 
 poison, but as possessed of its specific dis- 
 position, and therefore, says Mr. Hunter, 
 surgeons have recourse to mercury for the 
 cure of them ; and it is said, that such treat- 
 ment often removes them. This eminent 
 practitioner never saw mercury produce 
 this effect, although the medicine was given 
 in sufficient quantity to cure recent chan- 
 cres, and a lues venerea, in the same person. 
 (See Wart.) 
 
 Mr. Hunter takes notice of sloughs, which 
 occur in the tonsils, from the effect of mer- 
 cury on the throat, and are apt to be mis- 
 taken for venereal complaints. He also 
 mentions that, sometimes, when the original 
 chancre has been doing well, and been 
 nearly healed, he has seen new sores break 
 out on the prepuce, near the first, and as- 
 sume all the appearance of chancres. 
 
 When, in the treatment of chancres, a 
 bubo arises, while the constitution is under 
 the influence of a sufficient quantity of 
 mercury to cure such sores, which medicine 
 has also been rubbed into the lower extre- 
 mity, on the same side as the bubo, Mr. 
 Hunter suspects, that the swelling in the 
 groin is not venereal, butis produced by' the 
 
 mercury. In these cases, he always pre- 
 ferred conveying mercury into the system 
 in some other manner. 
 
 With respect to the treatment of chancres 
 in women, since it is difficult to keep dress- 
 ings on the parts, Mr Hunter advises the 
 sores to be frequently washed with some 
 mercurial soluti n, and speaks of one made 
 with oxymuriate of mercury, as perhaps 
 being the best, since it will act as a specific, 
 and stimulant also, when this is requisite. 
 When the chancres, however, are irritable, 
 they are to be treated in the same manner 
 as similar complaints in men. When the 
 sores extend into the vagina, this passage 
 must be kept from becoming constricted, or 
 closed by the introduction of lint. 
 
 Sometimes, after a chancre and all vene- 
 real disease are cured, the prepuce continues 
 thickened and elongated, so that the glans 
 cannot be uncovered. Perhaps, the case is 
 often without remedy. Mr. Hunter, how- 
 ever, very properly recommends trying 
 every possible means, and he informs us, 
 that the steam of warm water, hemlock 
 fomentations, and cinnabar fumigations, are 
 frequently of singular service. 
 
 When the thickeniug and enlargement of 
 the prepuce cannot be removed by appli- 
 cations, all the portion, anterior* to the 
 glans penis, may be cut away. (See Phy- 
 mosis .) 
 
 Bubo. The immediate consequence of a 
 chancre, which is called a bubo, and also 
 the remote effects, implied by the constitu- 
 tional, , or secondary symptoms , arise from the 
 absorption of recent venereal matter from 
 some surface, where it has either been ap- 
 plied or formed. 
 
 We are already aware, that Mr. Hunter 
 believed the matter of gonorrhoea to be ca- 
 pable of communicating the venereal dis- 
 ease. Hence, he explains in the following 
 terms, the three ways in which he thought a 
 bubo might arise in consequence of absorp- 
 tion. He observes, that the first and most 
 simple manner, is when the matter, either 
 of a gonorrhoea, or chancre, has only been 
 applied to some sound surface, without 
 having produced any local effect on the 
 part; but has been absorbed, immediately 
 after its application. Mr. Hunter affirms, 
 that he has seen instances of this kina, 
 though he confesses that they' are very rare, 
 and that, in most cases apparently of this 
 nature, a small chancre may be found to 
 have existed. 
 
 The second mode of absorption, or that 
 taking place in a gonorrhoea, Mr. Hunter 
 represents as more frequent. That second 
 ary symptoms do occasionally follow go- 
 norrhoea is yet commonly admitted, though 
 whether they differ essentially from those 
 which follow true chancres, is a point not 
 yet completely settled. However, as far 
 as Mr Carmichael’s experience goes, there 
 is a difference, a part of which consists in 
 the eruption being of the papular kind, as it 
 is also after many instances of simple pri- 
 mary ulcers. (See Obs. on the Symptoms, 
 be. of Venereal Diseases , 8vo. Land. 1818.' 
 
014 
 
 VENEREAL DISEASE 
 
 The thira mode is (he absorption of mat- 
 ter from an ulcer, which may either be a 
 chancre, or a bubo. This mode is by far 
 the most common, and it proves, with many 
 other circumstances, that a sore, or ulcer, 
 Is the most favourable for absorption. Mr. 
 Hunter believed, that absorption was more 
 apt to take place from sores on the prepuce, 
 than those on the glans. 
 
 A fourth mode of absorption from a 
 wound is also an occasional occurrence. 
 
 Mr. Hunter notices, that what is now 
 commonly understood by a bubo, is a swell- 
 ing, taking place in the absorbing system, 
 especially in the glands, and arising from 
 the absorption of some poison, or other 
 irritating matter. When such swellings 
 take place in the groin, they are calle^l bu- 
 boes, whether they proceed from absorption 
 or not. 
 
 Mr. Hunter regards every abscess in the 
 absorbing system as a bubo, whether in the 
 vessels, or the glands, when it originates 
 from the absorption of venereal matter. 
 
 The matter is taken up by the absorbent 
 vessels, and is conveyed by them into the 
 circulation. In its passage through these 
 vessels, it often affects them with the spe- 
 cific inflammation. The consequence is 
 the formation of buboes, which are vene- 
 real abscesses. These are exactly similar 
 to a chancre in their nature and effects, the 
 only difference being in resard to size. As 
 the lymphatic vessels and glands are irrita- 
 ted by the specific matter, before it has un- 
 dergone any change in its passage, the 
 Inflammation produced, and the matter se- 
 creted, partake of the specific quality. 
 
 Inflammation of the absorbent vessels 
 themselves is not nearly so frequent, as that 
 of the glands. In men, such inflammations, 
 in consequence of chancres upon the glans, 
 or prepuce, generally appear like a cord, 
 leading along the back of the penis from the 
 sores. Sometimes, the absorbents inflame, 
 in consequence of the thickening and exco- 
 riation of the prepuce in gonorrhoea. The 
 indurated lymphatics often terminate insen- 
 sibly near the root of the penis, or near the 
 pubes; while, in other instances, they ex- 
 tend further to a lymphatic gland in the 
 groin. Mr. Hunter believed, that this affec- 
 tion of the absorbent vessels is truly venereal. 
 The formation of a hard cord, he conceived, 
 arose from a thickening of the coats of the 
 absorbents, and from an extravasation of coa- 
 gulable lymph on their inner surface. 
 
 A cord, of the above kind, often suppu- 
 rates, sometimes in more places than one, 
 so as to form one, two, or three buboes, or 
 small abscesses in the body of the penis. 
 
 Inflammation much more frequently aftects 
 the absorbent glands, than the vessels. The 
 structure of the former parts appear to con- 
 sist of the ramifications and reunion of the 
 absorbent vessels. From this structure, ob- 
 serves Mr. Hunter, we may reasonably sup- 
 pose, that the fluid absorbed is in some mea- 
 sure detained in the glands, and thus has a 
 greater opportunity of communicating the 
 / disease to them- than to the distinct vessel?. 
 
 * Swellings of the absorbent glands may 
 originate from other diseases, and should be 
 carefully discriminated from those which 
 arise from the venereal poison. With this 
 view, Mr. Hunter advises us first to inquire 
 into the cause, in order to ascertain whether 
 there is any venereal complaint at some 
 greater distance from the heart, such as 
 chancres on the penis, or any preceding^dis- 
 ease in this situation. He recommends us to 
 inquire, whether any mercurial ointment 
 has been at all applied 10 the leg and tnigh 
 on the diseased side ; for mercury applied to 
 those parts for the cure of a chancre, will 
 sometimes cause glandular enlargements, 
 which are occasionally mistaken for vene- 
 real buboes. This irritation of the inguinal 
 glands by the mechanical action of mer- 
 curial ointment, has also been particularly 
 noticed by Professor Assalini, who states, 
 that he has had frequent opportunities 
 of convincing himself of the fact. (See 
 Manuale di Chirurgia, p. 67.) Mr. Hunter 
 reminds us to observe, whether there has 
 been any preceding disease in the constitu- 
 tion, such as a cold, fever, &ic. The quick 
 or slow progress of the swelling is likewise to 
 be marked, and the tumour must be distin- 
 guished from femoral hernia, lumbar ab- 
 scesses, and aneurisms of the crural artery. 
 In particular cases, it would appear, that 
 some time elapses ; before (he venereal mat- 
 ter produces its effec ts on the absorbent 
 glands after its absorption. Mr. Hunter no- 
 tices, that, sometimes, at least, six days 
 transpire first ; a circumstance, which can 
 only be known by the chancres having 
 healed six days before the bubo began to 
 appear. However, as the last matter of a 
 chancre is probably not venereal, he infers, 
 that in cases of this kind, absorption must 
 have taken place earl ier than other considera- 
 tions would lead one to suppose. Accord- 
 ing to Mr. Hunter, in general, only the 
 glands nearest to the seat of absorption are 
 attacked. Thus, when the matter is taken 
 up from the penis in men, the inguinal 
 glands are affected ; and when from the 
 vulva in women, those glands swell which 
 are situated between the labium and thigh, 
 and the round ligaments. 
 
 It was one of Mr. Hunter’s opinions, that 
 only one gland at a time is commonly affect- 
 ed by the absorption of venereal matter. If 
 this sentiment be correct, the circumstance 
 may be considered as a kind of criterion be- 
 tween venereal and other buboes. The 
 second order of lymphatic vessels and glands 
 are never affected ; as, for instance, those 
 along the iliac vessels, or back. Mr. Hunter 
 informs us, that he also observed, that 
 when the disease was contracted by a sore, 
 or cut upon the finger, the bubo occurred a 
 little above the bend of the arm, by the 
 side of the biceps muscle, and no swelling 
 of this sort formed in the arm-pit. How- 
 ever, he had heard of a fevv rare cases, 
 in which a swelling in the axilla was also 
 produced. 
 
 When buboes arise from a venereal dis- 
 ease on the penis? they are situated in the 
 
VENEREAL DISEASE 
 
 GIG 
 
 glands of the groin. When a bubo arises 
 from a gonorrhoea, either groin may be 
 attacked. But when the disease originates 
 from a chancre, the bubo most frequently 
 takes place in the nearest groin. 
 
 The situation of the absorbent glands, how- 
 ever, is not always exactly the same, and 
 the course of the lymphatics therefore is sub- 
 ject to some variety. Hence, Mr. Hunter 
 has seen a venereal bubo, produced by a 
 chancre on the penis, situated a considerable 
 way down the thigh ; he has also often seen 
 buboes as high as the lower part of the belly, 
 before Poupart’s ligament . and sometimes 
 near the pubes. At the present day, swell- 
 ings of the femoral glands are never consi- 
 dered venereal. 
 
 The seat of absorption is more extensive 
 in the female sex, and the course of some 
 of the absorbents is also different. Hence, 
 buboes in women may occur in three situa- 
 tions, two of which are totally different from 
 those in men 
 
 When chancres are situated forwards, 
 near the meatus urinarius, nympha?, clitoris, 
 labia, or mons veneris, the absorbed matter 
 is generally conveyed along one, or both of 
 the round ligaments, and the buboes are 
 formed in those ligaments, just before they 
 enter the abdomen. Mr. Hunter suspected 
 such buboes not to be glandular ones, but 
 only inflamed absorbents. 
 
 When chancres are situated far back, near 
 or on the perinaeum, the absorbed matter is 
 carried forward along the angle, between the 
 labium and the thigh, to the glands in the 
 groin, and often, in this course, small buboes 
 are formed in the absorbents similar to those 
 abscesses which occur on the penis in men. 
 
 When the effects of the poison do not rest 
 iiere, a bubo in the groin may be occasioned 
 in the same manner as in men 
 ( Owing to the difficulty of being sure, that 
 women are quite free from infection, it is 
 often more difficult to decide in them, than 
 in men, whether a bubo is venereal, or not. 
 In men, who have had no local complaint, 
 the bubo can only be venereal, when direct 
 absorption from the surface of the skin has 
 taken place. 
 
 A bubo, says Mr. Hunter, commonly be- 
 gins with a sense of pain, which leads the 
 patient to examine the part, where a small 
 hard tumour is to be felt. This increases, 
 like every other inflammation, that has a 
 tendency to suppuration, and unless check- 
 ed, pus forms, and ulceration follows, the 
 matter making its way to the skin very fast. 
 
 The above celebrated writer remarks, 
 however, that there are some cases, which 
 are slow in their progress. This circum- 
 stance he imputes either to the inflammatory 
 process being kept back by mercury, or 
 other means, or to its being retarded by a 
 scrofulous tendency. 
 
 The inflammation, he says, is at first con- 
 fined to the gland, which may be moved 
 about in the cellular membrane ; but when 
 the part has become enlarged, or when the 
 inflammation, and suppuration, are more 
 advanced, the surrounding parts become 
 
 more inflamed, and the tumour is more dif- 
 fused. Some buboes become complicated 
 with an erysipelatous and cedematous affec- 
 tion, by which they are rendered more dif- 
 fused, and less disposed to suppurate. 
 
 Mr. Hunter allows, that to distinguish, 
 with certainty, the true venereal bubo from 
 other swellings of the glands in the groin, 
 may be very difficult. He represents the 
 true venereal bubo, in consequence of a 
 chancre, as being most commonly confined 
 to one gland. It preserves Us specific dis- 
 tance till suppuration has taken place, and 
 then becomes mure diffused. It is rapid in 
 its progress from inflammation to suppura- 
 tion and ulceration. The suppuration is 
 commonly large, considering the size of the 
 gland, and there is <»nly one abscess. The 
 pain is very acute, and the inflamed part of 
 the skin is of a florid red colour. 
 
 Mr. Hunter describes such buboes as 
 arise without any visible cause, as being 
 of two kinds. One sort inflame and suppu- 
 rate briskly. These he always suspected 
 to be venereal, although he allows there 
 was no proof of it, and only a presump- 
 tion deduced from the quick progress of the 
 disease. 
 
 The second kind are generally preceded, 
 and attended with slight fever, or the com- 
 mon symptoms of a cold, and they are 
 generally indolent and slow in their progress. 
 If they are quicker than ordinary, they 
 become more diffused than venereal buboes, 
 and they are often not confined to one 
 gland. When very slow, they give but 
 little sensation ; but, when quicker, the sen- 
 sation is more, acute, though not so much so 
 as in venereal cases. They usually do not sup- 
 purate. and often become stationary. When 
 they do suppurate, it is in a slow manner, and 
 frequently in more glands than one, while 
 the inflammation is more diffused, and not 
 considerable, in relation to the swelling. 
 The matter makes its way to the skin slowly, 
 and the part affected is of a more purple 
 colour. Sometimes, the abscesses are very 
 large, yet not painful. 
 
 In considering whether the swellings of 
 the inguinal elands are, or are not venereal, 
 the first thing to be attended to is, whether, 
 or not, there are any venereal complaints. 
 If there are none, Mr. Hunter observes, that 
 there is a strong presumptive proof, that the 
 swellings are not venereal. When the 
 swelling is only in one gland, very slow in 
 its progress, and gives but little, or no pain, 
 it is probably merely scrofulous. However, 
 when the swelling is considerable, diffused, 
 and attended with some inflammation and 
 pain, the constitution is most probably af- 
 fected with slight fever, the symptoms of 
 which are lassitude, loss of appetite, want of 
 sleep, small quick pulse, and an appearance 
 of approaching hectic. Such swellings are 
 long in getting well, and do not seem to be 
 affected by mercury, even when very early 
 applied. 
 
 Mr. Hunter mentions his having seen the 
 above affection of the groin, together with 
 the constitutional indisposition, take place 
 
VENEREAL DISEASE. 
 
 *ilO 
 
 where there were chancres ; and he was 
 puzzled to determine, whether the disease 
 in the groin was sympathetic, from derange- 
 ment of the constitution, or whether it arose 
 from the absorption of matter. He had 
 long suspected, that there was a mixed 
 case, and was at last certain, that such a 
 case might prevail. He had seen instances, 
 in which the venereal matter, like a cold, or 
 fever, only irritated the glands to disease, 
 producing in them scrofula, to which they 
 were disposed. 
 
 In such cases, says Mr. Hunter, the swell- 
 ings commonly arise slowly, give but little 
 pain, and if mercury be given to destroy the 
 venereal disposition, their progress is acce- 
 lerated. Some suppurate while under this 
 resolving course ; and others, which proba- 
 bly had a venereal taint at first, become so 
 indolent, that mercury has no effect upon 
 them, and in the end, they either get well 
 of themselves, or by other means. 
 
 According to Mr. Hunter, buboes are 
 local complaints. 
 
 TREATMENT OF BUBOES. 
 
 When a bubo is judged to be venereal, 
 and only in an inflamed state, an attempt is 
 to be made to resolve the swelling. The 
 propriety of the attempt, however, depends 
 on the progress which the disease has made. 
 If the bubo be very large, and suppuration 
 appears to be near at hand, resolution is not 
 likely to be effected. When suppuration 
 has already taken place, Mr. Hunter much 
 doubted the probability of any success at- 
 tendingthe endeavour, which now may only 
 retard the suppuration, and protract the 
 cure. 
 
 The resolution of these inflammations, says 
 Blr. Hunter, depends principally on mercury , 
 and almost absolutely on the quantity , which 
 can be made to pass through them. When 
 suppuration has taken place , the cure also de- 
 pends on the same circumstances. Hence, he 
 recommended the mercury to be applied to 
 such surfaces as allow the remedy, when 
 absorbed, to pass through the diseased gland. 
 In this manner, he conceived, that the dis- 
 ease in the groin might be subdued, and that 
 the constitution would be less likely to be 
 contaminated. At the same time, he admit- 
 ted, that the situation of many buboes is 
 such, as not to have much surface for ab- 
 sorption beyond them ; for instance, the bu- 
 boes on the body of the penis, arising from 
 chancres on the glans, or prepuce. 
 
 As venereal buboes are an effect, or conse- 
 quence of chancres, or venereal sores, and 
 glandular swellings in the groin may take 
 place from other kinds of sores, or local ir- 
 ritations, and even from various constitution- 
 al causes, while modern surgeons profess 
 their incapacity always to pronounce the 
 character either of a primary sore, or a 
 bubo, by its first appearance, and progress, 
 it is evident, that the same difficulties pre- 
 sent themselves here, as in cases of primary 
 sores, respecting the principles, by which 
 rhe treatment should be guided. It is like- 
 
 wise to be remembered, that buboes, when 
 supposed to be decidedly syphilitic, are not , 
 as Mr. Hunter imagined, absolutely incurable 
 without mercury. The firm confidence also, 
 which Mr. Hunter had in the doctrine of the 
 benefit derived from the practice of rubbing 
 mercury into surfaces, from which it would 
 be conveyed directly to the diseased glands, 
 so as both to resolve the swelling and pre- 
 serve the constitution, is not now regarded 
 as an unquestionable subject. As Mr. Bacot 
 has judiciously remarked, there is some in- 
 consistence in Mr. Hunter’s own statements 
 upon this point •, for, in one place he affirms, 
 that mercury, applied to the legs and thighs 
 for the cure of a chancre, will sometimes 
 cause, instead of disperse, a bubo. (P.404.) 
 And Mr. Bacot believes himself, that mer- 
 cury as frequently promotes the suppuration 
 of buboes, as their dispersion. (On Syphilis , 
 p 74.) And, respecting the practice of try- 
 ing to make the mercury pass through the 
 diseased glands, Mr. Hunter rather contra- 
 dicts himself in another page, where he con- 
 fesses his own doubts of its utility in suppu» 
 rated buboes. However, Mr. Hunter ad- 
 mits, that mercury alone is not always capa- 
 ble of effecting the cure of such buboes as 
 are deemed venereal ; and when the inflam- 
 mation rises very high, he approves of bleed- 
 ing, purging, and fomentations. When the 
 inflammation is erysipelatous, he has a high 
 opinion of bark; and, when it is scrofulous, 
 he praises hemlock, and poultices made with 
 sea-water. He was also aware of the fact 
 of emetics sometimes occasioning the ab- 
 sorption of the matter of buboes, after it is 
 distinctly formed. 
 
 If there is generally great difficulty in 
 pronouncing at first the nature of a primary 
 sore, as to the question of its being syphilitic 
 or not, the same difficulty must occur with 
 respect to judging of the glandularswellings, 
 excited by it. And, on this account, and 
 from the encouraging circumstances, that 
 all buboes may be cured without mercury, 
 and that the course of the venereal disease, 
 unresisted by that mineral, is not so terrible 
 and incurable, as used to be supposed, some 
 surgeons, instead of having immediate re- 
 course to mercury, prefer a little delay, in 
 order to see, whether the swelling will sub- 
 side, or not, under the use of common an- 
 tiphlogistic means. Thus, Dr. Hennen dis- 
 approves of using mercury immediately a 
 bubo presents itself ; and he states, that the 
 same principles, which guide him in the pri- 
 mary ulcers, would have the same, if not 
 greater force, in the case of buboes. “ In 
 their irritable state (says he) I consider mer- 
 cury altogether inadmissible.” (On Military 
 Surgery, Ed. 2 ,p. 518.) 
 
 Although the correctness of some of the 
 principles, by which Mr. Hunter regulated 
 his practice in buboes, must now be ques- 
 tionable, inasmuch as he calculates too much 
 on the absolute necessity for mercury, and 
 on the usefulness of making it pass through 
 the diseased glands, I conceive, that some 
 of his directions are yet too important to 
 excluded from this work. He sayr : 
 
VENEREAL DISEASE. 
 
 017 
 
 'quantity of mercury, necessary for the reso- 
 lution of a bubo, must be proportioned to 
 the obstinacy of the complaint ; but that care 
 must be taken not to extend the employment of 
 the medicine so far as to produce certain effects 
 on the constitution. When the bubo is in a 
 situation, which admits of a large quantity 
 of mercury being rubbed in, so as to pass 
 through the swelling, and when the com- 
 plaint readily yields to the use of half a 
 drachm of mercurial ointment, every night, 
 the mouth not becoming sore, or at most, 
 only tender, Mr. Hunter thinks it sufficient 
 to pursue this course, till the gland is redu- 
 ced to its natural size. In this manner, the 
 constitution will probably be safe, provided 
 thfe chancre, which may have caused the 
 bubo, heals at the same time. When . the 
 mouth is not affected in six, or eight days, 
 and the gland does not readily resolve, then 
 two scruples, or a drachm, may be applied 
 every night ; and, continues Mr. Hunter, if 
 there should still be no amendment, even 
 more must be rubbed in. In short (says he) 
 if the reduction is obstinate, the mercury 
 must be pushed as far as can be done with- 
 out a salivation. 
 
 When there is a bubo on ea^li side, so 
 much mercury cannot be made to pass through 
 each, as the constitution in general will not 
 bear this method. However, Mr. Hunter 
 sanctions the plan of minding the soreness 
 of the mouth less in this kind of case ; 
 though, he adds, that it is belter to let the bu- 
 boes proceed to suppuration , than to load the 
 system with too much merewry. 
 
 When the situation of buboes will not al- 
 low an adequate quantity of absorbed mer- 
 cury to pass through them, the frictions 
 must be continued in order to affect the con- 
 stitution ; but, according to Mr Hunter in 
 this case, more mercury will be requisite, 
 than when the remedy can be made to pass 
 directly through the diseased gland ; an as- 
 sertion, which may now be doubted. 
 
 Many buboes remain, without either co- 
 ming to resolution, or suppuration ; and, 
 notwithstanding every attempt to promote 
 these changes, the glands become hard and 
 scirrhous. Mr. Hunter conceived, that these 
 cases are either scrofulous at first, or be- 
 come so as soon as the venereal disposition 
 is removed. He advises the use of hemlock, 
 sea-water, poultices, and sea-bathing. 
 
 According to a modern surgeon, of judg- 
 ment and considerable experience, when 
 buboes are in a chronic stationary state, the 
 application of blisters to the swelling is at- 
 tended with the most beneficial effects. And, 
 lie rightly observes, that when such tumours 
 are extremely hard and indolent, it is more 
 advantageous to let the patient have the be- 
 nefit of the open air, exercise, and his ac- 
 customed mode of living, than to confine 
 him in an hospital. ( Jlssalini , in Manuals di 
 Chirurgia , p. 64 ; Milano, 1812.) Stimula- 
 ting the skin with the antimonial ointment, 
 is also sometimes a good practice. 
 
 The suppuration of buboes frequently can- 
 not be prevented by any known means. 
 They are then to be treated, in some re- 
 Vot, II ' 7* 
 
 spects, like any other abscess. Before open- 
 ing buboes, Mr. Hunter conceived it advan- 
 tageous to let the skin become as thin as 
 possible, because a large opening would 
 then be unnecessary, and no measures re- 
 quisite for keeping the skin from closing, 
 before the bottom of the sore had healed. 
 
 Mr. Hunter was doubtful , whether the ap- 
 plication of mercury should be continued 
 through the whole suppuration. He was in- 
 clined to continue it ; but, in a smaller quan- 
 tity. 
 
 There has been much dispute, whether a 
 bubo should be opened, or allowed to burst 
 of itself, and whether the opening should be 
 made with a cutting instrument, or caustic. 
 On this subject, Mr. Hunter remarks, that 
 there is no peculiarity in a venereal abscess 
 to make one practice more eligible than 
 another. The surgeon, he says, should be 
 guided in some degree, by the patient. Some 
 patients are afraid of caustics ; others, of 
 cutting instruments. But, when the surgeon 
 has the choice, Mr. Hunter expresses a pre- 
 ference to opening the bubo with a lancet, 
 in which method, no skin is lost. But he 
 observes, that w r hen a bubo is very large, 
 and there will be a great deal of loose skin, 
 after the discharge of the matter, he thinks, 
 that caustic may,' perhaps, be better, as it 
 will destroy some of the redundant skin, and 
 occasion less inflammation, than what is 
 caused by an incision. The potassa cum 
 calce is the caustic commonly employed. 
 
 After the bubo has been opened, surgeons 
 usually poultice it, as long as the discharge 
 and inflammation are considerable, and then 
 they employ dressings, which must be of a 
 quality, adapted to circumstances. In the 
 mean while, mercury is continued, both to 
 make the bubo heal, and prevent the bad 
 effects, which might otherwise arise from 
 the matter being continually absorbed. 
 
 The mercurial course is to be pursued, till 
 the sore is no longer venereal. But, in ge- 
 neral, since this point is difficult to ascer- 
 tain, Mr. Hunter advises the continuance of 
 mercury till the part has healed, and even 
 somewhat longer, if the bubo has healed 
 very quickly ; for, the constitution is apt to 
 become contaminated. However, he did 
 not approve of this long use of mercury in 
 all cases; because buboes often assume, be- 
 sides the venereal, other dispositions, which 
 mercury cannot cure, and will even exas- 
 perate. 
 
 Sometimes thesores, whentheyarelosing, 
 or entirely deprived of the venereal disposi- 
 tion, become changed into ulcers of another 
 kind, and, most probably of various kinds. 
 How far it is a disease arising from a vene- 
 real taint, and the effects of a mercurial 
 course jointly, says Mr. Hunter, is not cer- 
 tain. He suspected, however, that the na- 
 ture of the part, or constitution, had a prin- 
 cipal share in the case, and, I believe, few 
 surgeons of the present time entertain any 
 doubt of the abuse of mercury being a very 
 frequent cause, independently of any other 
 circumstance. (See Mathias on the Mercuri- 
 al Disease. Ed. 3.) 
 
VENEREAL DISEASE. 
 
 CIS 
 
 Mi'.v Hunter observes, Ilia! sue]) diseases 
 make the cure of the venereal affection much 
 more uncertain, because, when the sore be- 
 comes stationary, or the mercury begins to 
 disagree, we are ready to suspect that the 
 virus is gone ; but, this (he supposes) is not 
 always the case. He had seen some buboes 
 exceedingly painful and tender to almost 
 every thing that touched them, and the 
 more mild the dressings were, the more pain- 
 ful the parts became. 
 
 In some instances, the skin alone becomes 
 diseased. The ulceration spreads to the 
 surrounding integuments, while a new skin 
 forms in the centre, and keeps pace with 
 the ulceration, so that an irregular sore, 
 which Mr. Hunter compares with a worm- 
 eaten groove, is formed all round. It ap- 
 pears only to have the powerof contamina- 
 ting the parts, which have not yet been af- 
 fected ; and those which have, readily heal. 
 According to the same author, when buboes 
 become stationary, and are little inclined to 
 spread, attended with a sinus, or two, hem- 
 lock, joined with bark, is the medicine most 
 frequently serviceable. It is to be used both 
 externally and internally. Mr. Hunter also 
 speaks favourably of sarsaparilla, sea-bath- 
 ing, and sea-water poultices. He states, 
 that at the Lock Hospital, gold refiners’ wa- 
 ter has been found an useful application ; 
 and that in some cases, benefit has arisen 
 from drinking large quantities of orange- 
 juice, and from the use of mezereon. 
 
 Lues venerea. Surgeons imply, that a 
 lues venerea has taken place, when the vene- 
 rea! virus has been absorbed into the circu- 
 lation. Mr. Hunter does not think the epi- 
 thet constitutional strictly proper in its ap- 
 plication to this form of the venereal disease. 
 By constitutional disease, he observes, he 
 should understand that, in which every part 
 of the body is acting in one way, as in fevers 
 of all kinds ; but, the venereal poison seems 
 to be only diffused through the circulating 
 fluids, and, as it were, to force certain parts 
 of the body to assume the venereal action, 
 which action is perfectly local. To use Mr. 
 Hunter’s phrase, it takes place in different 
 parts in a regular succession of susceptibili- 
 ties. Only a few parts are acting at the 
 same time ; and a person may be constitu- 
 tionally affected in this way, and yet almost 
 every function may be perfect. 
 
 The venereal poison is generally conveyed 
 into the system from a chancre. It may, 
 also, according to Mr. Hunter’s doctrine, be 
 absorbed from a gonorrhoea. There is like- 
 wise a possibility of its getting into the cir- 
 culation from the surface of the body, with- 
 out any previous ulceration. According to 
 his doctrine, it may bo absorbed from com- 
 mon ulcers, without necessarily rendering 
 them venereal ; and it may be taken up from 
 wounds, in which cases, it generally first 
 causes ulceration. 
 
 Venereal ulcers. In consequence of the 
 blood being contaminated with real venereal 
 pus, it might be expected that the local 
 effects thi s produced, would be similar in 
 their nature to those producing them. Mr. 
 
 Hunter believed, that this is not the case, 
 lie notices, that the local effects from a 
 constitutional contamination, are all of one 
 kind, viz. ulcers, let the effects make their 
 appearance on any surface whatever, either 
 the throat or common skin. But Mr. Hun- 
 ter conceived, that if the matter, when in 
 the constitution, were to act upon the same 
 specific principles, as that which is exter- 
 nally applied, a gonorrhoea would arise, 
 when it affected a canal, and only sores, or 
 chancres, when it attacked other surfaces. 
 
 Mr. Hunter found, that even the sores 
 which are caused in the throat are very dif- 
 ferent from chancres. He says, lhat the 
 true chancre produces considerable inflam- 
 mation, often attended with a great deal of 
 pain, and quickly followed by suppuration. 
 But the local effects, arising from the virus 
 in the constitution, are slow in their pro- 
 gress, attended with little inflammation, 
 and are seldom or never painful, except in 
 particular parts. However, Mr. Hunter 
 allows that this sluggishness in the effects of 
 the poison depends on the nature of the 
 parts diseased ; and he owns that, when 
 the tonsils, uvula, or nose, are affected, the 
 progress of the morbid mischief is rapid, and 
 bears a greater resemblance to a chancre 
 than when it occurs on the skin. Even in 
 those parts Mr. Hunter thought that the 
 ulcers were attended with less inflamma- 
 tion than chancres which were spreading 
 with equal celerity. 
 
 Before the time of Mr. Hunter, the matter, 
 secreted by sores which arise from a consti- 
 tutional infection, was always considered 
 to be of a poisonous quality, like the matter 
 of a chancre. At first, one would expect 
 that this must actually be the case, because 
 venereal matter is the cause, and mercury 
 cures chancres, and also ulcers proceeding 
 from a lues venerea. Mr. Hunter remarks, 
 however, that the latter circumstance is not 
 a decisive proof, since mercury is capable of 
 curing many diseases , besides the venereal. 
 He also takes notice, that when pus is ab- 
 sorbed from a chancre, if generally produ- 
 ces a bubo ; but that a bubo is never occa- 
 sioned by the absorption of matter from a 
 venereal sore, arising from the virus diffu- 
 sed in the circulation. For instance, when 
 there is a venereal ulcer in the throat, no 
 buboes occur in the glands of the neck ; 
 when there are syphilitic sores on the arms, 
 or even suppurating nodes on the ulna, no 
 swellings form in the glands of the armpit, 
 although these complainis occur when fresh 
 venereal matter is applied to a common 
 sore on the arm, hand, or fingers. No swell- 
 ing is produced in 1 lie groin in consequence 
 of nodes, or blotches on the legs and 
 thighs. 
 
 Some very important experiments arc 
 related in Mr. Hunter’s Treatise on the Ve- 
 nereal Disease, in order to prove that the 
 matter from a gonorrhoea, or clmncrc, is 
 capable of affecting a man locally, who is 
 already labouring under a lues venerea, and 
 that the matter from secondary syphilitic 
 sores has not the same power. The parti- 
 
’ VENEREAL DISEASE 
 
 610 
 
 culars, however, are too long to be inserted 
 in this book. 
 
 Parts most susceptible of the Lues Venerea, 
 fyc. Some parts of the body seem to be 
 much less susceptible of the lues venerea 
 than others ; indeed, Mr. Hunter observes, 
 that, as far as our knowledge extends, cer- 
 tain parts cannot be affected at all. The 
 brain, heart, stomach, liver, kidneys, and 
 several other viscera, have never been 
 known to be attacked by syphilis. 
 
 The first order of parts, or those which 
 become affected in the early stage of the 
 lues venerea, are the skin, tonsils, nose, 
 throat, inside of the mouth, and sometimes 
 the tongue. 
 
 The second order of parts, or those which 
 are affected at a later period, arc the peri- 
 osteum, fasciae, and bones. 
 
 Mr. Hunter conceived, that one great rea- 
 son of the superficial parts of the body suf- 
 fering the effects of the lues venerea sooner 
 than the deep-seated ones, depends on the 
 former being more exposed to external cold. 
 He remarked, that even the second order 
 of parts do not all become diseased at the 
 same time, nor every where at once. 
 But. on tlfe contrary, such as are nearest the 
 external surface of the body are first disea- 
 sed, as, for instance, the periosteum, bones 
 of the head, the tibia, ulna, bones of the 
 nose, &c. Neither does the disease affect 
 these bones equally on all sides ; but first 
 on that side which is next to the external 
 surface. It was Mr. Hunter’s belief, how- 
 ever, that the susceptibility of particular 
 bones did not altogether depend upon their 
 nearness to the skin ; but upon this cir- 
 cumstance and their hardness together. 
 
 The foregoing account by no means 
 agrees with the results of modern inquiries 
 into the nature of the venereal disease ; for, 
 unless mercury be given, it appears that the 
 bones are very seldom affected by it. Thus 
 in the cases which were treated by Mr. 
 Rose without mercury, he observes, that 
 u the constitutional symptoms were evi- 
 dently not such as could be regarded as ve- 
 nereal, if we give credit to the commonly 
 received ideas on the subject. Caries of 
 the bones, and some of the least equivocal 
 symptoms, did not occur. In no instance 
 was there that uniform progress, with un- 
 relenting fury, from one order of symptoms 
 and parts affected to another, which is con- 
 sidered as an essential characteristic of true 
 syphilis.” (Med. Chir. Trans. Vol. 8, p. 423.) 
 We learn also from Mr. Guthrie, that the 
 bones were not affected in any of the cases, 
 cured entirely without mercury in the York 
 Hospital, though there were several other 
 cases admitted, “ in which a few mercurial 
 pills had been taken, and the mouth not 
 affected, and in which the primary symp- 
 toms were followed by eruptions both pa- 
 pular and scaly, by ulcers in the throat, by 
 nodes , and, in one case, by inflammation of 
 the periosteum covering the bones of the 
 nose, and ulceration of the septum nasi, 
 although mercury was resorted to for its 
 cure.” ( Vol. cit. p. 560.) 
 
 In the examples treated without mercury, 
 under the superintendence of Dr. Henncn, 
 this gentleman did not see “ a single case 
 in which the bones of the nose were affected : 
 some cases of periostitis, and of pains and 
 swellings of the bones of the cranium and 
 ext renAties were met with ; but, except in 
 two, he never remarked any nodes which 
 could be regarded as unequivocally syphili- 
 tic One of these yielded to blisters and 
 sarsaparilla ; the other, after resisting guaia- 
 cura and sudorifies, was dispersed by mer- 
 cury (On Military Surgery , Ed. 2, p. 581.) 
 Dr. Hcnnen’s statement on this subject 
 would have been more satisfactory had it 
 comprised his opinion of the characters of 
 an unequivocally syphilitic node. On the 
 whole, it appears tolerably certain that 
 mercury, especially when employed unmer- 
 cifully, and even when employed in mode- 
 ration, and the patient exposes himself to 
 damp and cold, tends to promote the fre- 
 quency of nodes, as a sequel of the venereal 
 disease, though as the long and abundant 
 use of the same mineral does not cause the 
 same consequence after other complaints, 
 and venereal ulcers, treated altogether with- 
 out mercury, rarely lead to nodes, it would 
 seem as if these swellings were the product 
 of the combined action of syphilis and mer- 
 cury together. The infrequency of nodes 
 in the strictly non-mercurial practice, is 
 one of the most important facts yet esta- 
 blished in its favour, and it is curious to find 
 from some quotations made by Dr. Herinen, 
 that it was well known in former days. 
 Fallopius, in his 86th chap. De Ossium Cor- 
 ruptione, speaking of the loss of the bones 
 of the nose and palate, says “ et sciatis 
 quod non in omrii iuveterato gallico hoc 
 fit, sed tantum in illis, in quibus inunclio 
 facta est cum hydrargyro And Fernelius, 
 in speaking of the injurious effects of mer- 
 cury, observes, “ recidiva raro similis est 
 radici, neque iisdem symptomatis exercet, 
 sed fere distillatione, arthritide tophis, vel 
 ossium carie.” (Jlphrodisiacus. Vol.3,p 146.) 
 And Palmarius, in considering the affection 
 of the bones, as Dr. Hennen has noticed, 
 uses the following remarkable words : u sed 
 hoc ils duntaxat contingit, qui olim a lue 
 venerea hydrargyrosi vindicati putareutur, 
 non qui decocto guaiacino etalexipharmaco 
 curati fuissent.” (De Morb. Contagiosis 9 
 Cap. 7, lib. 2, p. 124; Parisiis, 1578.) Dr. 
 Hennen expresses his own conviction, 
 in which I entirely agree, that the carious 
 affections of the bones, which are so com- 
 mon in persons treated by long mercurial 
 courses, proceed not from the disease, but 
 from the remedy rapidly and irregularly 
 thrown in while periostitis exists ; and ho 
 has not seen a single case of carious bone 
 in the military hospitals, since the non- 
 mercurial treatment was adopted, except 
 where mercury has formerly been used. (On 
 Military Surgery, Ed. 2, p. 505, 506.) 
 
 Nor will the results of modern experi- 
 ence and inquiries, made on a very expen- 
 sive and impartial scale, allow us to consi- 
 der the venereal disease as regularly and 
 
VENEREAL DISEASE. 
 
 020 
 
 unavoidably leading to any secondary 
 symptoms, even though no medicine at all 
 be employed for their prevention. This is 
 fully exemplified in the official reports of 
 the army hospitals. The particulars of 5000 
 cases, spoken of by Sir James M‘Grigor and 
 Dr. Franklin, lead to the opinion, tint “the 
 frequency or rarity of secondary symptoms 
 wotrld seem 1o depend on circumstances 
 not yet sufficiently understood or explained, 
 although the following fact would tend to 
 the belief, that either the constitutions of the 
 men, or the mode of conducting the treat- 
 ment without mercury, are the causes that 
 possess the greatest influence in their pro- 
 duction. In one regiment, 4 secondary 
 cases out of 24, treated without mercury, su- 
 pervened.” In another regiment, 68 cases 
 were treated without mercury, all bearing 
 marks of true venereal disease, (and 28 of 
 them especially selected for their decided 
 characters of chancre) yet no secondary 
 symptoms of any kind had taken place fif- 
 teen months after the treatment had ceased. 
 The same document, founded on the above 
 large number of cases, confirms another 
 fact, that no peculiar secondary symptoms 
 follow peculiar primary sores; a conclusion 
 which is directly adverse to Mr. Carmi- 
 chael’s opinions, of which I have taken 
 more notice in another work. (See First 
 Lines of the Practice of Surgery , Vol. 1, 
 Ed. 4.) 
 
 According to Mr. Hunter, the time neces- 
 sary for the appearance or production of 
 the local effects, in parts most susceptible 
 of the disease, after the virus has passed 
 into the constitution, is generally about six 
 weeks ; but in many cases the period is 
 much longer, while in other instances it is 
 shorter. Sometimes the local effects make 
 their appearance within a fortnight after the 
 possibility of absorption. 
 
 The effects on other parts of the body, 
 which are less susceptible of the venereal 
 irritation, or slower in their action, says Mr. 
 Hunter, are much later in making their ap- 
 pearance. And when the first and second 
 order of parts are both contaminated, the 
 effects generally do not begin to appear in 
 the latter till after a considerable time, and 
 sometimes not till those affecting the for- 
 mer parts have been cured. 
 
 Mr. Hunter, however, refers to instances 
 in which the periosteum, or bone, was 
 affected before any of the first order of parts ; 
 but he was uncertain whether the skin or 
 throat would afterward have become dis- 
 eased, as the disorder was not allowed to 
 go on. 
 
 Venereal Eruptions. The whole tenor of 
 Various facts, specified in the foregoing co- 
 lumns, tends to prove, that what is usually 
 called the venereal disease is in reality seve- 
 ral diseases, modified also by constitution, 
 climate, regimen, and mode of treatment. 
 And hence,* perhaps, the chief source of all 
 the perplexity and uncertainty, which are 
 yet so manifest as fully to justify the doubt 
 sometimes entertained, whether any dis- 
 ease, corresponding to the former notions 
 
 of syphilis, really exists. Were any proof" 
 of the truth of this reflection needed, in 
 addition to the many other proofs of it 
 already premised, the subject of venereal 
 eruptions would at once furnish it ; for here 
 no kind of regularity can be traced, either 
 in the appearances on the skin abstractedly 
 considered, nor in the connexion between 
 certain kinds of primary ulcers and particu- 
 lar forms of cutaneous disease. Nay, as I 
 have noticed in the preceding pages, some- 
 times, in consequence of a primary vene- 
 real sore, different kinds of eruptions form 
 together, or successively on one individual; 
 and, as far as one can judge by the eye, ex- 
 actly the' same kind of chancre may produce 
 very different breakings out in different per- 
 sons, even though treated on precisely the 
 same plan. These circumstances are truly 
 confusing. In Mr. Rose’s paper, however, 
 there is a partial confirmation of one part 
 of Mr. Carmichael’s theory, viz. the fre- 
 quency of papular eruptions after simple 
 primary ulcers, or superficial sores, which 
 readily heal. According to the latter gen- 
 tleman, this form of eruption may also fol- 
 low gonorrhoea, and is generally preceded 
 by fever, and ends in desquamation. What- 
 ever may be the degree of truth respecting 
 the relation between this kind of eruption 
 and the alleged primary complaints, the 
 practice recommended by Mr. Carmichael 
 for such cases is judicious. General blood- 
 letting is recommended when there is fever, 
 and the medicines praised are antimonials 
 and sarsaparilla. Afterward, when the fever 
 subsides, and the eruption desquamates, an 
 alterative course of antimony and calomel, 
 it is said, will accelerate the cure, though 
 not absolutely necessary. In cases of vene- 
 real pustular eruptions, supposed by Mr. 
 Carmichael to be most frequent after chan- 
 cres with elevated edges, '.vithout indura- 
 tion, bloodletting is also advised during the 
 febrile stage, followed by antimonials, sar- 
 saparilla, guaiacum, tar-ointment, baths of 
 sulphurated kali, or the nitro-muriatic bath ; 
 and after the pustules have terminated in 
 scaly blotches, alterative doses of mercury, 
 conjoined with sarsaparilla or guaiacum. 
 An eruptioq of tubercles, or spots of a pus- 
 tular tendency, or of both intermixed, pre- 
 ceded by fever, and terminating in ulcers 
 covered with thick crusts, complaints which 
 Mr. Carmichael considers a sequel rather of 
 the phagedenic than other chancres, he 
 treats at first by bloodletting, followed by 
 antimonials, sarsaparilla, guaiacum, com- 
 pound powder of ipecacuanha, arseniate of 
 kali, nitrous acid, and nitro-muriatic bath. 
 Mercury is said to be hurtful, except in the 
 last stage. To scaly blotches, which he 
 conceives to be a sequel of the true chan- 
 cre, or callous ulcer, he applies the same 
 local treatment as to pustular eruptions, and 
 he deems the question, whether sarsaparilla 
 and guaiacum might here be substituted for 
 mercury, yet unsettled. (See Obs. on the 
 Symptoms, tyc. of Venereal Diseases , Synop- 
 sis, p. 205, fyc.) The investigations made 
 in the military hospitals decidedly prove. 
 
venereal disease. 
 
 that all kinds of eruptions, supposed to be 
 venereal, may be cured without mercury ; 
 but, I believe, the great and superior useful- 
 ness of moderate quantities of mercury for 
 the removal of the scaly, copper-coloured 
 blotches, is still generally acknowledged. 
 But, even in these cases of copper-coloured 
 spots, Mr. Bacot’s advice may be good, viz. 
 when the general health is much deranged, 
 the tongue loaded and furred, and the appe- 
 tite gone, to defer mercury “ until, by pro- 
 per evacuations and attention to the gfeneral 
 health,’' the patient has had the benefit of 
 a delay, “ which will, in many instances, 
 render all farther medical treatment unne- 
 cessary. It is undoubtedly true that, what- 
 ever plan be pursued, these eruptive symp- 
 toms will eventually disappear ; still, where 
 they continue to linger for a long time, and 
 are attended with^ their usual accompani- 
 ments of great languor, debility, and dis- 
 turbed rest, I neither know, nor can I un- 
 derstand, the advantage of delaying that 
 remedy, which repeated experience has 
 taught me to rely upon,” &c ( Bacot on 
 Syphilis, p. 99.) Although Mr. Carmichael’s 
 practice seems good, his theory, about the 
 connexion of certain sores with particular 
 eruptions, and other peculiar secondary 
 symptoms, appears to be nearly refuted by 
 the late investigations made in the military 
 hospitals. To some facts, relating to this 
 question, I have already adverted. 
 
 There is as little certainty, about the 
 essential characters of a syphilitic erup- 
 tion, as about the test of every other 
 symptom of the venereal disease, or, rather 
 diseases. While Mr. Hunter describes 
 the eruption as generally occurring over 
 the whole body, Dr. Bateman states, that 
 syphilitic affections of the skin com- 
 monly make their first appearance on the 
 face, where they are usually copious, and 
 on the hands and wrists. ( Pract . Synopsis of 
 Cutaneous Diseases, p. 332, edit. 3.) Their 
 colour, he says, is in general less livid, than 
 that of ordinary eruptions, being of a brown- 
 ish red of different shades ; but that this is 
 not universal ; for some of the syphilitic 
 ecthymafa have a bright red base in the be- 
 ginning. Exposure to cold accelerates their 
 progress, and increases their extent ; while, 
 on the other hand, warmth retards and 
 meliorates them. (P. 333.) According to 
 Hunter, the discolourations make the skin 
 appear mottled, and many of the eruptions 
 disappear, while others continue, and in- 
 crease with the disease. 
 
 In other cases, the eruption comes on in 
 distinct blotches, which are often not ob- 
 served, till the scurf has begun to form. 
 At other times, the eruption assumes the 
 appearance of small distinct inflammations, 
 containing matter, and resembling pimples, 
 not being however, so pyramidal, nor so red 
 at the base. Mr. Hunter also observes, that 
 venereal blotches, on their first, coming out, 
 are often attended with inflammation, which 
 gives them a degree of transparency, which 
 is generally greater in the summer, than the 
 winter, especially, if the patient be kept 
 
 02 1 
 
 warm. In a little time, this inflammation 
 disappears, and the cuticle peels off in the 
 form of a scurf. The latter occurrence 
 often misleads the patient and the surgeon, 
 who look upon this dying away of the in- 
 flammation, as a decay of the disease, till a 
 succession of scurfs undeceives them. 
 
 The parts affected next begin to form a 
 copper-coloured, dry, inelastic cuticle, call- 
 ed a scurf, or scale. This is throw n off, and 
 new ones are formed, which spread to the 
 breadth of a sixpence or shilling ; but, sel- 
 dom more extensively, at least, for a consi- 
 derable time. In the mean while, every 
 succeeding scale becomes thicker and thick- 
 er, till at last it becomes a common scab. 
 Then the disposition to the formation of 
 matter takes place in the cuti^ underneath, 
 and a true ulcer is produced, which com- 
 monly spreads, although in a slow way. 
 
 When the affected part of the skin is op- 
 posed by another portion of skin, which 
 keeps it in some degree more moist, as be- 
 tween the nates, about the arms, between 
 the scrotum and the thigh, in the angle be- 
 tween the two thighs, on the red part of the 
 lip, or in the arm-pits, the eruptions, instead 
 of being attended with scurfs and scabs, are 
 accompanied with an elevation of the skin, 
 which is swollen with extravasated lymph 
 into a white, soft, moist, flat surface, w r hich 
 discharges a white matter. {Hunter.) 
 
 Mr. Carlisle has pointed out what he 
 terms an herpetic abrasion of the cuticle ori 
 the breast, or abdomen, having the appear- 
 ance of venereal blotches. He states, that 
 it is less deep in the skin ; that it has less of 
 an inflammatory base ; and that it is not so 
 distinctly pircumscribed, as the true vene- 
 real blotch. It never forms a purulent crust ; 
 but is simply a furfuraceous scaling of the 
 cuticle. This form of disease seems to him 
 to be produced by a disordered stomach and 
 liver. (See Loud. Med. Deposit. Vol. 7, p. 
 92.) 
 
 A venereal eruption often attacks that part 
 of the fingers, on which the nail is formed. 
 Here, the disease renders that surface red, 
 which is seen shining through the nail ; and 
 if allowed to continue, a separation of the 
 nail takes place. 
 
 When surfaces of the bod} r , covered with 
 hair, are attacked, the hair separates, and 
 cannot be re-produced as long as the dis- 
 ease lasts. 
 
 It must be allowed, that it is frequently 
 very difficult to say, whether an eruption is 
 syphilitic or not, and an opinion should 
 rather be formed from the history of the 
 case, than from any particular appearance 
 of the eruption itself. As Dr. Bateman has 
 remarked, the cutaneous eruptions, which 
 are the result of the venereal poison, are 
 often the source of considerable embarrass- 
 ment to the practitioner. They assume 
 such a variety of forms, that they bid defi- 
 ance to any arrangement founded upon their 
 external character ; and in fact, they possess 
 no common, or exclusive marks, by which 
 their nature and origin are indicated. There 
 is perhaps, no order of cutaneous appearan 
 
VENEREAL DISEASE. 
 
 ces, and scarcely any genus, or species of 
 tbe chronic eruptions, which these secon- 
 dary symptoms of syphilis do not occasion- 
 ally resemble. Dr. Bateman admits, how- 
 ever, that in many cases, there is a differ- 
 ence, which a practised eye will recognise, 
 between the ordinary diseases of the skin 
 and the syphilitic eruptions, to which the 
 same generic appellation might be given. 
 This, says he, is often observable in the shade 
 of colour , in the situation occupied by the 
 eruption, in the mode of its distribution , and 
 in the general complexion of the patient. 
 Hence, to a person conversant with those 
 ordinary diseases, a degree of anomaly in 
 these respects will immediately excite a sus- 
 picion, which will lead him to investigate 
 the history of the progress of such an erup- 
 tion, and of its concomitant symptoms. 
 (See Bateman's Practical Synopsis of Cuta- 
 neous Diseases, p. 331, 332, Edit. 3.) 
 
 Dr. Hennen in his valuable book, does not 
 pretend to be able to discriminate the true 
 syphilitic eruptions from others, and indeed, 
 by what criterion they are to be known, I 
 am myself entirely puzzled to comprehend, 
 after the numerous facts, so fully established 
 by recent experimental inquiries. Dr. 
 Hennen generally approves of delaying 
 mercury at first, in order to see whether 
 these cutaneous affections will yield to other 
 means ; “ but (says he) I should not very 
 long postpone the employment of the mild- 
 est mercurial alteratives, aided by warm 
 bathing, and sudorifics. (On Military Sur- 
 gery. Ed. 2, p. 518.) 
 
 Venereal Disease of the Throat, Mouth, 
 and Tongue . — In the throat, tonsils, and in- 
 side of the mouth, the disease is said by Mr. 
 Hunter generally to make its appearance at 
 once in the form of an ulcer, without much 
 previous tumefaction. Consequently the 
 tonsils are not much enlarged. 
 
 A venereal ulcer in the throat 'was suppo- 
 sed by the same author to be in general 
 tolerably well marked, though he confesses, 
 that it may not in every instance be distin- 
 guishable from an ulcer of a different na- 
 ture. Several diseases of the throat, he re- 
 marks, do not produce ulceration on the 
 surface. One of these is common inflam- 
 mation of the tonsils. The inflamed place 
 often suppurates in the centre, so as to form 
 an abscess, which bursts by a small opening ; 
 but never looks like an ulcer that has begun 
 superficially, like a true venereal sore. The 
 case is always attended with too much in- 
 flammation, pain, and tumefaction of the 
 parts, to be venereal. Also when it suppu- 
 rates and bursts, it subsides directly, and it 
 is generally attended with other inflamma- 
 tory symptoms in the constitution. 
 
 Mr. Hunter then notices an indolent tu- 
 mefaction of the tonsils, peculiar to many 
 persons whose constitutions are disposed 
 to scrofula. The complaint produces a 
 thickness in the speech. Sometimes coagu- 
 lable lymph is thrown out on the surface of 
 the parts affected, and occasions appearan- 
 ces, which ♦are by some called ulcers; by 
 some sloughs; and, by others putrid sore- 
 
 throats. The case is attended with too 
 much swelling to be venereal, and with a 
 little care, it may easily be distinguished 
 from an ulcer, or loss of substance. How- 
 ever, when this difference is not obvious at 
 first sight, it is proper to endeavour to 
 remove some of tbe lymph, and if the 
 surface of the tonsil underneath should 
 appear to be free from ulceration, we may 
 conclude with certainty, that the disease is 
 not venereal. Mr. Hunter states, that he 
 has seen a chink filled with coagulable 
 lymph, so as to appear very much like an 
 ulcer; but on removing that substance, the 
 tonsil underneath was found perfectly sound. 
 He adds, that he has seen cases of a swelled 
 tonsil, having a slough in its centre, which 
 slough before its detachment, looked very 
 like a foul ulcer. The stage of the com- 
 plaint, he says, is even more puzzling when 
 the slough has come out ; for then the dis- 
 ease has most of the characters of the vene- 
 real ulcer. Whenever he met with the dis- 
 ease in its first stage, he always treated it 
 as if it had been of the nature of erysipelas, 
 or a carbuncle. When the complaint is in 
 its second stage, without any preceding 
 local symptoms, he recommends the prac- 
 titioner to suspend his judgment, and to 
 wait a little, in order to see how far nature 
 is able to relieve herself. If there should 
 have been any preceding fever, the case is 
 still less likely to be venereal. Mr. Hunter 
 informs us, that, he has seen a sore-throat of 
 this kind mistaken for a venereal case, and 
 mercury given till it affected the mouth, 
 when the medicine brought on a mortifica- 
 tion of all the parts concerned in the first 
 disease. 
 
 Another complaint of these parts, which 
 Pdr. Hunter represents as being often taken 
 for a venereal one, is an ulcerous excoria- 
 tion, which runs along their surface, be- 
 coming very broad and sometimes foul, 
 having a regular termination, but never 
 going deeply into the substance of the parts, 
 as Mr. Hunter believes the venereal ulcer 
 does. No part, of the inside of the mouth 
 is exempt from this ulcerous excoriation ; 
 but, according to Mr. Hunter, the disease 
 most frequently occurs about the root of 
 the uvula, and spreads forward along the 
 palatum molle. He remarks, that the 
 complaint is evidently not venereal, since it 
 does not yield to mercury. He has seen these 
 ulcerous excoriations continue for weeks, 
 without undergoing any change, and a true 
 venereal ulcer make its appearance on the 
 surface, of the excoriated part. He says, 
 that such excoriations were cured by bark, 
 after the end of the mercurial course, by 
 which the syphilitic sore was cured. 
 
 This author describes the true venereal 
 ulcer in the throat, as a fair loss of substance , 
 part being dug out, as it were, from the body 
 of the tonsil : it has a determinate edge, aiul 
 is commonly very foul, having thick while 
 matter, like a slough, adhering to it, and not 
 admitting of being washed away. 
 
 Here, however, as in most other supposed 
 forms of syphilis, some test is wanting, by 
 
VENEREAL DISEASE. 
 
 023 
 
 which the case may be certainly distinguish- 
 ed from other diseases of the throat, present- 
 ing similar appearances ; for, as Mr. Rose 
 has very truly remarked, “ the excavated 
 ulcer of the tonsils, as described by Mr. 
 Hunter, is not, as Mr. Carmichael seems to 
 think, a peculiar symptom of the presence of 
 the syphilitic virus. I have repeatedly seen 
 it, as well as the scaly blotch, in cases where 
 mercury had beeu freely employed for the 
 primary sores, and in which I considered 
 the virus as eradicated, and both have dis- 
 appeared under the use of sarsaparilla.” 
 (Med. Chir. Trans. Vol. 8 , p. 421.) In a re- 
 cent work, Mr. Carmichael himself acknow- 
 ledges the justice of the preceding observa- 
 tion, and owns, that since the publication of 
 his Essays, he has often noticed the exca- 
 vated ulcer of the tonsils, either attending 
 the primary phagedenic ulcer, or the train of 
 constitutional symptoms which arise from it. 
 ( On the Symptoms , <^c. of Venereal Diseases, 
 P- 17.) In affections of the throat, Dr. Hen- 
 nen states, that he “ w ould be more guarded 
 than in any others, in the employment of 
 mercury, until all inflammatory disposition 
 was removed.” Afterward he has seen 
 them yield, u as if by magic, so soon as the 
 local effects of mercury on the parts within 
 the mouth became obvious.” But when 
 mercury was given earlier, he has seen a vast 
 number of instances in which irremediable 
 mischief was done. (On Military Surgery, 
 Ed. 2, p. 518.) 
 
 According to Hunter lues venerea some- 
 times produces a thickening and hardening 
 of the tongue, but frequently ulceration, as 
 in other parts of the mouth. He describes 
 venereal sores on the tongue, as generally 
 more painful than those on the skin ; but less 
 so than common sore throats from inflamed 
 tonsils. They oblige the patient to speak 
 thick, as if his tongue were too large for his 
 mouth; with a sits all degree of snuffling. 
 
 Mr. Hunter doubted the reality of a vene- 
 real. ophthalmy, though he owns that there 
 are inflammations of the eyes, which yield 
 to mercury See the subject of iritis in the 
 article Ophthalmy. 
 
 Symptoms of the second stage of Lues Ve- 
 nerea. — The periosteum, fascia, tendons, 
 ligaments, and bones, are the parts which 
 Mr. Hunter enumerates, as liable to be af- 
 fected ir» the second stage of lues venerea. 
 This observation in its full extent, however, 
 seems to be rendered rather questionable ; 
 for it would appear from the evidence both 
 of ancient and modern writers, that true 
 nodes , or venereal swellings of the bones, and 
 particularly caries, rarely take place from 
 syphilis, unless mercury be employed, it is 
 an observation of Mr. Hunter’s, that we can- 
 not always know with certainty what parts 
 may become affected in this stage of the 
 disease. He says he has known the dis- 
 temper produce a total deafness, some- 
 times followed by suppuration, and great 
 pain in the ear, and side of the head. I 
 have already explained, that it was one of 
 this gentleman’s doctrines, that the second 
 order of parts were generally deep-seated. 
 
 When these become irritated by the poison, 
 he observes that the progress of the disease 
 is more gradual, than in the first order of 
 parts. It assumes very much the character 
 of scrofulous swellings, or chronic rheuma- 
 tism ; only it affects the joints less frequently 
 than the latter affection does. A swelling 
 sometimes makes its appearance on a bone, 
 when there has been no possible means of 
 catching the infection for many months ; 
 and in consequence of the little pain expe- 
 rienced, the tumour rflay be of some consi- 
 derable size, before it is noticed. Some- 
 times a great deal of pain is felt ; but no 
 swelling comes on, till after a long while. 
 According to Mr. Hunter, these remarks are 
 also applicable to swellings of the tendons, 
 and fasciae. As tumours of this kind only 
 increase by slow degrees, they are not at- 
 tended with symptoms of much inflamma- 
 tion. When they attack the periosteum, 
 they seem like an enlargement of the 
 bone itself, in consequence of being very 
 firm, and closely connected with the latter 
 part. Mr. Hunter also further observes, that 
 in these advanced stages of the disease, the 
 inflammation can hardly gel beyond the 
 adhesive kind, in which state, it contiuues 
 to become worse and worse, and when 
 matter is formed, it is not true pus, but of a 
 slimy description. Some nodes, be says, 
 both of the tendons and bones, last for 
 years, before they form any matter at all. 
 These cases, he considered, as not being 
 certainly venereal, though commonly consi- 
 dered as such. Mr. Hunter found it difficult 
 to explain the reason why, when lues venerea 
 attacks the bones, or the periosteum, the pain 
 should sometimes be very considerable, and 
 sometimes very trivial. Venereal pains in fhe 
 bones Bre described by Mr. Hunter as being 
 of a periodical kind, generally most severe 
 in the night-time. 
 
 At the present day, when many cases 
 formerly supposed to be syphilitic, are 
 treated without any mercury, and even 
 those which are reputed to be venereal, are 
 cured by much smaller doses of that medi- 
 cine than were given in Mr. Hunter’s time, 
 nodes have become much less frequent, and 
 I have already in a previous part ot this 
 article expressed my decided belief in the 
 justness of the opinion given by Fallopius 
 and others, that a disposition to nodes is 
 often occasioned by the abuse of mercury. 
 
 Treatment of Lues Venerea.— In Mr. Hun- 
 ter’s opinion, the first order of parts, or (hose 
 which are most suscept ible of being affected 
 in lues venerea, are also the most easy of 
 cure ; while the second order of parts take 
 more time to be remedied. 
 
 In the class of complaints, arising in the 
 second stage of the lues venerea, Mr. Hun- 
 ter believed, that it was unnecessary to con- 
 tinue the employment of mercury, till all 
 the swelling had disappeared. For it is ob- 
 served by this distinguished writer, that 
 since these local complaints cannot conta- 
 minate the constitution by re-absorption, and 
 since the venereal disposition and action 
 from the constitution can be cured, while 
 
VENEREAL DISEASE. 
 
 B24 
 
 the local effects still remain, and this even 
 when the tumefaction, forming nodes on 
 the bones, fasciae, kc. has proceeded to sup- 
 puration, there can be no occasion for con- 
 tinuing the course, after the venereal action 
 has been destroyed. Whatever may be 
 hereafter decided concerning the superiority 
 of mercury as a remedy for many seconda- 
 ry symptoms, one thing appears already 
 well made out, viz. that it should always be 
 employed with moderation, lest it produce 
 worse effects, and moYe terrible diseases, 
 than those which it is designed to relieve. 
 For an account of the various ways of exhi- 
 biting it, I must refer to the article Mercury. 
 
 To the following ingenious reasoning on 
 the operation of mercury, and the principles 
 by which its administration should be regula- 
 ted, surgeons of the present day will not give 
 more credit than facts warrant, because some 
 of Mr. Hunter’s opinions are manifestly in- 
 fluenced by the supposition, that mercury is 
 absolutely necessary for the cure of the ve- 
 nereal disease. 
 
 In curing the lues venerea, mercury can 
 only have two modes of action ; one on the 
 poison : the other on the constitution. If, 
 says Mr. Hunter, mercury acted on the poi- 
 son only one might conceive it did so, 
 either by destroying its qualities, by decom- 
 posing it, or else by attracting it and carrying 
 it out of the circulation. If mercury acted 
 in the first of these ways, one would expect, 
 that the cure would depend on the quantity 
 of the medicine taken into the system. If 
 it acted in the second manner, one would 
 Infer, that the progress of the cure would 
 be proportionate to the quantity of evacu- 
 ation. But, observes Mr. Hunter, if it act 
 upon the principle of destroying the diseased 
 action of the living parts, and of counteract- 
 ing the venereal irritation, by producing one 
 of a different kind, then, neither quantity 
 alone, nor evacuations, will avail much. He 
 states, that the quickness of the cure depends 
 on quantity, joined with visible effects. 
 However, it is added, that although the ef- 
 fects which mercury has upon the venereal 
 disease, are in some degree proponioned to 
 the local effects of the medicine on some o t 
 the glands, or particular parts of the body, 
 as the mouth, skin, kidneys, and inte. lines, 
 yet such effects are not altogether propor- 
 tioned to these other circumstances. When 
 mercury disagrees with the constitution, so 
 as to produce great irritability and hectic 
 symptoms, this action of irritation, as Mr. 
 Hunter explains, is not a counter-irritation 
 to the venereal disease. 
 
 It was also noticed by the same author, 
 that the effects of mercury on lues venerea 
 are always in proportion to the quantity of 
 the remedy exhibited in a given lime, and the 
 susceptibility of the constitution to the mer- 
 curial irritation. He says that these circum- 
 stances require the most minute attention, 
 and that, in order to obtain the greatest ac- 
 tion of mercury with safety, and in the most 
 effectual manner, the medicine must be 
 given till it produces effects somewhere. 
 However, it must not be exhibited too 
 
 quickly, in order that a sufficient quantity 
 may be given, before we are obliged to stop, 
 in consequence of the effects. Mr. Hunter 
 thinks, that when the local effects are pro- 
 duced too quickly, they prevent a sufficient 
 quantity of the remedy from being taken into 
 the system to counteract the venereal irrita- 
 tion at large. 
 
 Mr. Hunter mentions his having seen some 
 cases, in which mercury acted very readily 
 locally, and yet the constitution was hardly 
 affected by it, for the disease would not give 
 way. He states, that he has met with other 
 cases, in which the mere quantity of mercury 
 did not answer, till it was given so quickly 
 as to affect the constitution in such a manner 
 as to produce local irritation, and, conse- 
 quently, sensible evacuations. This, be ob- 
 serves, is a proof that the local affects of 
 mercury are often the sign of its specific 
 effects on the constitution at large, and it 
 shows that the susceptibility of the diseased 
 parts to be affected by the medicine, is in 
 proportion to its effects on the mouth. Its 
 effects, he contends, are not to be imputed 
 to evacuation; but to its irritation. Hence, 
 he inculcates, that mercury should be given, 
 if possible, in such a manner as to produce 
 sensible effects upon some parts of the body, 
 and in the largest quantity that can be 
 given, to produce these effects within cer- 
 tain bounds. Mr. Hunter also remarks, that 
 these sensible effects should be the means of 
 determining how far the medicine maybe 
 pushed, so as to have the greatest effect on 
 the disease, without endangering ihe consti- 
 tution. The practice must vary according 
 to circumstances ; and if the disease is in a 
 violent degree, less regard must be had to 
 the constitution, and mercury must be thrown 
 into the system in larger quantities ; a very 
 dangerous precept, as far as 1 can judge, 
 from many cases in which I have seen it 
 acted upon. 
 
 Mr. Hunter likewise acquaints us, that 
 when the disease is in the first order of parts, 
 a smaller quantity of mercury is necessary, 
 than when the second order of parts are 
 affected, and the disease has been oi long 
 standing, its first appearances alone being 
 cured, and the venereal disposition still re- 
 maining in the secondary parts. For the 
 purpose of curing the venereal disease, 
 whether in the form of chancre, bubo, or 
 lues venerea, Mr. Hunter was of 'opinion, 
 that probably the same quantity of mercury 
 is necessary. He represents, that one sore 
 requires as much mercury as fifty sores in 
 the same person, and a small sore as 
 much ns a large one He thought that 
 the only difference, if there is any, must 
 depend upon th** nature of the parts affected, 
 that is, on. their being naturally active or in- 
 dolent. He conceived, however, that on the 
 whole, recent venereal complaints are gene- 
 rally more difficult ol cure, than the symp- 
 tom? of lues venerea, and that this may 
 make a difference, in regard to the quantity 
 of mercurv necessary. 
 
 Havingnow delivered the principal gene- 
 ral instructions, relative to the exhibition ot 
 
VENEREAL DISEASE. 
 
 62 o 
 
 mercury in the treatment of the venerea! 
 disease, as given by Mr. Hunter, I must not 
 quit this subject without remarking, that 
 even this eminent surgeon appears on the 
 whole too partial to the long use of mercu- 
 ry, and sometimes to the introduction of 
 immoderate quantities of it into the system. 
 In general, however, his observations tend 
 to condemn all violent salivations. It is to 
 be recollected, that in his days, nobody had 
 a suspicion that truly syphilitic sores (if this 
 expression be allowable, while they cannot 
 be defined, nor distinguished by their ap- 
 pearances) would in the end spontaneously 
 heal, and he himself had no dependence 
 upon any medicine, except mercury, for the 
 cure of the true venereal disease. But mo- 
 dern experience evinces, that the disorder 
 seldom now presents itself in forms so bad 
 and intractable as formerly ; that it is even 
 capable of spontaneously ceasing ; and that 
 Ave hardly ever see cases in which it is re- 
 quisite to give mercury, except in very 
 moderate quantities. Indeed, such is the 
 change, that many surgeons suspect that the 
 very nature of the disease must have under- 
 gone a material alteration or modification. 
 In England, in rny opinion, every thing is 
 to be referred to the improved manner of 
 employing mercury only in moderate doses, 
 and never pushing its exhibition, till the 
 constitution is so impaired, that undescriba- 
 ble forms of diseases ensue, which are 
 sometimes the compound effect of mercury 
 and syphilis together ; and, in other in- 
 stances of that description, which surgeons 
 now frequently call syphiloid , or pseudo- 
 syphilitic , not depending upon the venereal 
 poison at all, but upon a state of the system, 
 which mercury is known to aggravate in 
 the Avorst degree. For additional informa- 
 tion concerning internal remedies for the 
 venereal disease, see Mercury, Guaiacum, 
 Mezereon, Muriatic Acid , Nitrous Acid , Sar- 
 saparilla, Sulphuric Acid, fyc. 
 
 With respect to the local treatment of 
 the symptoms of lues venerea, Mr. Hunter 
 thought that none would in general be ne- 
 cessary, since the constitutional treatment 
 Avould commonly effect a cure. However, 
 he admits, that sometimes the local effects 
 will not give way, and the parts remain 
 swollen in an indolent inactive state, even 
 after there is every reason to believe that 
 the constitution is perfectly cured. In such 
 cases, he recommends assisting the consti- 
 tutional treatmeat by local applications of 
 mercury to the part, either in the form of 
 a plaster or ointment. The latter applica- 
 tion, he says, is the best. When these are 
 not sufficient, he advises an attempt to he 
 made to excite inflammation of another 
 kind. He says he has seen a venereal node, 
 which gave excruciating pain, cured by mere- 
 ly making an incision down to the bone, the 
 whole length of the node. The pain ceased , 
 the swelling decreased, and the sore healed 
 up kindly, without the assistance of a grain 
 of mercury. He mentions, that blisters have 
 been applied to nodes with success, remo- 
 ving the pain, end taking away the swelling. 
 
 Von. !!. TO 
 
 With regard to these last cases I may add, 
 that, for many years past, the idea of com- 
 pletely dispersing nodes by mercury has 
 been entirely abandoned in St. Bartholo- 
 mew’s hospital. In this institution, long 
 protracted mercurial courses for the cure 
 of such swellings are totally relinquished. 
 When small moderate quantities of mercury 
 have had their full effect, a blister is ap- 
 plied o\ T er the swelling, and kept open, 
 under which plan the tumour generally sub- 
 sides as far as its nature will allow. 
 
 Diseases resembling the Venereal. Pseudo- 
 syphilis. — Sores on the glans penis, prepuce, 
 &,c. in the form of chancres, as Mr. Hunter 
 notices, may and do arise without any vene- 
 real infection, and sometimes they are a 
 consequence of former venereal sores, 
 Avhich have been cured. 
 
 The symptoms, produced by the \ r enereal 
 poison in the constitution, sire such as are 
 common to many other diseases. For in- 
 stance, Mr. Hunter remarks, that blotches 
 on the skin are common to what is called a 
 scorbutic habit ; pains are common to rheu- 
 matism ; swellings of the bones, perios- 
 teum, fasciae, &c. to many bad habits, 
 perhaps, of the scrofulous and rheumatic 
 kind. Thus, says he, most of the symptoms 
 of the venereal disease, in all its forms, are 
 to be found in many other diseases. Hence , 
 the original cause, and many leading circum- 
 stances , such as dates, effects of the disorder 
 upon others, from connexion, when only local , 
 the previous and present symptoms, fyc. must 
 be considered, before we can determine abso- 
 lutely what the disease truly is. All the cir- 
 cumstances and symptoms, taken together, 
 may be such as will attend no other disease. 
 However, Mr. Hunter confesses, that with 
 all our knowledge, and with all the appli- 
 cation of that knowledge to suspicious 
 symptoms of this disease, we are often mis- 
 taken, calling distempers venereal , which arc. 
 not so, and sometimes supposing really syphi- 
 litic affections to be of another nature. 
 
 Mr. Hunter takes notice, that in some 
 constitutions, rheumatism, in many of its 
 symptoms, resembles the lues venerea. 
 The nocturnal pains, swelling of the ten- 
 dons, ligaments, and periosteum, and pain 
 in those swellings, are symptoms both of 
 the rheumatism, and also of the venereal 
 disease, when it attacks such parts. Mr. 
 Hunter, however, did not know that he had 
 ever seen the lues venerea attack the joints , 
 though many rheumatic complaints of such 
 parts are cured by mercury, and therefore 
 supposed to be venereal. 
 
 Mercury, given Avithout caution, often 
 produces the same symptoms as rheuma- 
 tism. Such complaints Mr. Hunter had 
 seen mistaken for venereal ones, and mer- 
 cury continued. He explains, that some 
 diseases not only resemble the venereal iri 
 appearance, but in the mode of contamina- 
 tion, proving themselves to be poisons by 
 affecting the part of contact ; then produ- 
 cing immediate consequences similar to 
 buboes ; and also remote consequences si- 
 milar to the lues venerea. 
 
VENEREAL DISEASE 
 
 <>■20 
 
 Mr. Hunter observes, that it is nearly as 
 dangerous, in some constitutions, to give 
 mercury, when the disease is not venereal, 
 as to omit it in other cases, which are 
 really syphilitic; and had he been ac- 
 quainted with recent investigations, he 
 would undoubtedly have gone further, and 
 declared that it is in reality far more dan- 
 gerous. Many of the constitutions, which 
 put on some of the venereal symptoms, 
 when the disease is not really present, he 
 says, are those with which mercury seldom 
 agrees, and commonly does harm. He had 
 seen mercury, which was exhibited for a 
 supposed Venereal ulcer of the tonsils, pro- 
 duce a mortification of those glands, and 
 the patient was nearly destroyed. 
 
 Mr. Abernetby, in his Surgical Observa- 
 tions, 1804, has treated at some length of 
 diseases resembling syphilis, and has ad- 
 duced several very interesting cases, which 
 i advise every surgical practitioner to read 
 with the greatest attention, as in fact they 
 confirm the views of the subject lately so 
 fully established. 
 
 “ A gentleman (says he) thought that he 
 had infected a slight cut on his hand 
 (which was situated in front of, and just 
 below the little finger,) with the discharge 
 from a bubo in the groin, that he had occa- 
 sion to open. The wound fretted out into 
 a sore about the size of a sixpence, which 
 he showed me, and which 1 affirmed had 
 not the thickened edge and base, and other 
 characters of a venereal chancre. 1 there- 
 fore recommended him to try the effect of 
 local means, and not to use mercury. 
 
 “ In about a month, the sore, which had 
 spread a little, became again contracted in 
 its dimensions, and assumed an healing ap- 
 pearance. At this time pain was felt ex- 
 tending up the arm, and suddenly a consi- 
 derable tumour arose over the absorbing 
 vessels, which proceed along the inner edge 
 of the biceps muscle. This tumour became 
 nearly as big as a small orange. As the 
 original sore seemed now disposed to heal, 
 and as there was no surrounding indura- 
 tion, I could not believe it venereal, and 
 therefore recommended him still to abstain 
 from mercury, and apply leeches and linen 
 moistened in the aq. litbarg. acet. comp, to 
 the tumour formed over the inflamed ab- 
 sorbents. For it seemed to me, that if the 
 venereal poison had been imbibed from the 
 sore, it would have passed on to one of the 
 axillary glands, and would have caused in- 
 duration and inflammation to take place 
 there more slowly than had occurred on 
 the present occasion. 
 
 “ Under this treatment the tumour was 
 discussed, and the sore at the same time 
 healed. About three weeks afterward, the 
 patient called on ine, and said that there 
 were venereal ulcers in his throat; and in 
 each tonsil there was an ulcer deeply exca- 
 vated, with irregular edges, and with a sur- 
 face covered by adhering matter ; ulcers, 
 in short, which every surgeon, who de- 
 pends on his sight as his guide, would have 
 pronounced to be venereal. Shortly after 
 
 also some copper-coloured eruptions aj> 
 peared on his face and breast. He*showed 
 his diseases to several surgeons, on whose 
 opinion he relied, who, without hesitation, 
 affirmed that they were venereal, and that 
 the mercurial course had been improperly 
 delayed. 
 
 “ While the patient was looking out for 
 lodgings, in order that he might go through 
 the mercurial process, a circumscribed 
 thickening and elevation of the pericra- 
 nium, covering the frontal bone, appeared ; 
 it was of the circumference of a half-crown 
 piece ; and was, in short, what every sur- 
 geon, who. is guided only by his sight and 
 touch, would, without hesitation, have 
 called a fair corona veneris. I now told 
 the patient that I was more inclined to be- 
 lieve his disease was not syphilitic, from 
 the sudden and simultaneous occurrence of 
 this node, with the sore throat, &.c. Other 
 surgeons thought differently ; and I believe 
 this very sensible and amiable young roan 
 imagined that his health would become a 
 sacrifice, if he any longer attended to my 
 opinion. He was preparing to submit fo a 
 mercurial course, when very important 
 concerns called him instantly into the 
 country. He went with great reluctance, 
 taking with him mercurial ointment, &tc. ; 
 and after a fortnight, I received a letter 
 from him, saying that he found his com- 
 plaints benefited by his journey, that busi- 
 ness had prevented him from beginning the 
 use of mercury for a few days ; that he now 
 found it was unnecessary, for his symptoms 
 had almost disappeared ; and shortly after- 
 ward he became perfectly well.” 
 
 Mr. Abernethy considers this case as the 
 most unequivocal instance extant of a dis- 
 ease occurring, which could not from ap- 
 pearance be distinguished by surgeons of the 
 greatest experience from syphilis, and 
 which, however, was undoubtedly of a 
 different nature ; (that is to say, it was of a 
 different nature, according to certain cri- 
 teria, then generally believed, but which 
 recent investigations have proved to be 
 destitute qf foundation.) All the tests here 
 alluded to having been spoken of in the 
 foregoing columns, I shall not here repeat 
 them. 
 
 Some years ago the nitric acid was intro- 
 duced as a remedy for syphilis. (See Ni- 
 trous Jicid.) To the position of its efficacy 
 being as great in venereal cases as was first 
 alleged, many surgeons have not acceded, 
 though, as a sensible writer has observed, 
 it has certainly been allowed, with some 
 other medicines, to remain in a kind of 
 copartnership with mercury, and admitted 
 to be useful in venereal cases under certain 
 circumstances. A great deal of this want 
 of agreement, on the effects of remedies in 
 syphilitic cases, is now explained by the 
 imperfection of the diagnosis, and the im- 
 portant fact, that the disease may generally 
 be cured iu lime, without any medicines 
 whatsoever, though this time is sometimes 
 long. Dr. Scott, who first suggested the use 
 of nitrous acid, has attempted to Recount 
 
VENEREAL DISEASE 
 
 627 
 
 for its alleged occasional failures, by ob- 
 serving that the acid, which he employed, 
 was not pure nitric acid, but an impure 
 acid, containing an admixture of muriatic 
 acid. He therefore, some time ago, re- 
 commended the use of a compound acid, 
 containing three parts of nitric acid, and one 
 of muriatic, which he administered inter- 
 nally, and also applied externally, largely 
 diluted, as a bath, until the gums were af- 
 fected and ptyalism pVoduced ; and he con- 
 ceived every trial as quite inconclusive, 
 unless these constitutional effects occurred. 
 
 “ The acid that I have used of late (says 
 Dr. Scott) is the nitro muriatic ; and it is 
 formed by mixing together equal parts of 
 the nitrous, or nitric acid, and muriatic acid. 
 If these acids be in the state of concentra- 
 tion, that they usually possess in the shops, 
 and if the quantities be considerable, a 
 great volume of gas is evolved on their 
 coming into contact, which taints every 
 part of a house, is extremely hurtful to the 
 lungs, and disagreeable to the smell. To 
 avoid this inconvenience, I put a quantity 
 of water, at least equal in bulk to both the 
 acids, into a bottle, and I add the acids to 
 it separately. This method does not only 
 prevent the unpleasant odour, but it tends 
 to retain the chlorine, on which its effects 
 depend, it is well known, that the nitro- 
 muriatic acid acts very readily on the 
 metals and earth ; nothing therefore but 
 glass, or extremely well glazed vessels of 
 porcelain, should be used to contain it. 
 Wooden tubs for bathing answer very well, 
 and they should always be made as small as 
 ; possible , compatible with their holding the 
 body, or the limbs that we wish to expose 
 to the bath. From their being small, we 
 save acid, and are able to heat the bath with 
 ease. In India, I have often exposed the 
 whole body below the head to this bath ; 
 but here I have been satisfied, in general, 
 with keeping the legs and feet exposed to 
 it. In order to warm the bath, after the 
 first time, I have commonly made a third 
 or a fourth part of it to be thrown away, and 
 the loss replaced by boiling water and a 
 proportional quantity of acid. To save the 
 expenditure of acid, I have occasionally 
 warmed a portion of the bath in porcelain 
 vessels, placed near the fire, but l fear this 
 may diminish its effects. 
 
 u It is no easy matter (continues Dr. 
 Scott,) to give directions, with regard to 
 the degree of acidity of the bath. I have 
 commonly made it about as strong as very 
 weak vinegar, trusting to the taste alone. 
 The strength should be regulated by the 
 degree of irritability of the patient’s skin. 
 1 may say, that although I like to know that 
 it is strong enough to prick the skin a very 
 little, after being exposed to it from fifteen 
 to thirty minutes, yet I believe that even 
 such an effect as this is unnecessary. 
 
 1 ‘ The time too of remaining in the bath, 
 in order to produce the greatest effect, is a 
 matter of doubt. I have kept the legs and 
 feet exposed to it for half an hour or more ; 
 but, with more delicate people, not above 
 
 one-half, or one-third of that time. I have 
 repeated these baths daily, or even twice, 
 or thrice a day. (See Med. Chir. Trans. 
 Vol. S, p. 181.) Dr. Scott adds, that the 
 mere sponging the skin with nitro-muriatio 
 acid, sufficiently diluted witli water, gives 
 rise to the very same effects f.s bathing? and 
 is more easily adopted. Fifteen or twenty 
 minutes may be employed in the sponging, 
 though a much less time produces very ma- 
 terial effects. 
 
 Dr. Scott has found the nitro-muriatic 
 acid particularly useful, even in this coun- 
 try, in that description of syphilis, which is 
 termed pseudo-syphilis ; and he attributes 
 the beneficial effects to the chlorine, which 
 is loosely combined in this compound. 
 (See Journal of Science and the Arts, Vol. 1, 
 p. 205 — 211. Lond. Med. Reposil. Vol. 7, p. 
 59 ; and Med. and Chir. Trans., Vol. 8, p. 
 173, et seq.) 
 
 The only important conclusion which l 
 venture to draw from Dr. Scott’s observa- 
 tions, is a confirmation of the fact of the 
 generally curable nature of syphilitic dis- 
 eases, without the aid of mercury. And I 
 further believe, that though the nitro-muri- 
 atie bath may sometimes be useful, the 
 surest way of bringing it into discredit is 
 to represent it as applicable to all forms of 
 syphilis, for which neither this remedy, nor 
 even mercury itself, will ever suffice. 
 
 J. de Vigo, De Arte Chirurgica, fol. Lugd. 
 1518. N. Montesaurus . De Disposition^ us, 
 quas vulgo Mai Fransos appellant, 1497. Ki- 
 col. Massa de Morbo Gallico, Liber, 4lo. Te- 
 net. 1532, et 1536, auctior, 1563. Nic. Lco- 
 nicerus Liber de Epidemia quam ltali morurm 
 Gallicum, Galli ero Xeapolitanum vacant, 
 Fol. Papice . 1506. Gabr. Fallopius, de Tor- 
 bo Gallieof^to. Patav. 1563. Kic.de Blegny, 
 Zodiacus Medico- Gallicus, 4to. Geneves, 1680. 
 Hieron. Fracaslorius, Syphilis Poema; et, 
 Tractatus de: Syphilide ; Veronce., 1530. Also, 
 De Contagionc et Contagiosis Morbis, Venet. 
 1546, Casp. Torella, Tractatus cum Consiliis 
 contra Pudendagram, Romes, 1497. Also , 
 Dialogus de Dolore et de Ulceribus in Pu- 
 dendagra ; Romes, 1500. Ant. Francantia - 
 nus, de Morbo Gallico, 8 to. Patav. 1563. 
 Jul. Palmarius , De Morbis Contagiosis, 4 io. 
 Paris , 1578. Guil. Rondeletius, de Morbo 
 Gallico, 1576. J. Fernelius, Universa Me- 
 dicina, 4 to. Venet. 1564, p. 584, 593, 
 
 Ulric de Hulten, de Morbo Gallico . Mogun! 
 1531. R. Rostinio, Trattato di Mai. Fran - 
 cess, \2mo. Venet, 1556. Al. Luisinus, Aphro- 
 disiacus, Venet. 1566, et in 2 Tom. fol. Lugd. 
 Bat. 1728, one of the most valuable collections 
 of the Works of ancient writers on Syphilis. 
 Diaz de Isla, Tratado contra las Bubas. 1527. 
 Wm. Clowes, a new and approved Treatise , 
 concerning the Cure of^the French Poclces, by 
 the Unctions, 8va. Lond. 1575 ; said to be the 
 earliest English book on Syphilis. J. Aslruc, 
 de Morbis Venereis ; Lutet. Paris , 1740. Le 
 Blond, (Jbs. sur la Fitvre Jaunt, Chap. 4. 
 Leo Africanus, Descriptio A f rices, L. 1 , p. 86. 
 The last two authors mention: the fad of the 
 nature of the Venereal Di&af j If get wet! 
 spontaneously in hot climates. I?r. Ah,- 
 
VENEREAL DISEASE. 
 
 62S 
 
 cromby , Tula or. effienx Luis Venerece , scepe 
 absque. Mercurio, ac ( semper absque Saliva- 
 Hone Mercurial! Ciirandw Methodus, Land. 
 \2rno. 1084. J. Sinteiaer, The Scourge of 
 Venus and Mercury , represenled in a Treatise 
 an the Venereal Disease, giving a succinct Ac- 
 count of that Dreadful Distemper, and the 
 fatal Consequences arising from mercurial 
 Cures , <y c. iciih the true Way of curing the 
 Mercurial Pox, found to be. more dangerous 
 than Pox itself Lond. 1709. Morgagni, de 
 Sedibus , tyc. Morborum. John Douglas, Dis- 
 sertation on the Venereal Disease, wherein a 
 Method of curing all the Stages of that Dis- 
 temper will be communicated, without the help 
 of any mercurial drenches, vomits, or fumiga- 
 tions, fyc. and, above all, a Salivation in all 
 cases will be avoided , 8 vo. Lond. 1737. Lu- 
 dolff \ Demonstrate, quod alrocissimce Luis 
 Vencrecc symptomata non sinl affect us morbi, 
 sed cure ntercurialibus institute , Erf. 1747. 
 C. Willoughby, The Practice of Salivation 
 shown to be of no Use, Lond. 1723. J. Profly , 
 an Easy and Exact Method of Curing the Ve- 
 nereal Disease, fyc. ; to which are added Ex- 
 periments publicly made of an effectual Me- 
 thod of Cure without Salivation or Confine- 
 ment, 8vo. Lond. 1748. Wm. Browfield, Ac- 
 count of the English Night Shade, <?/c. and 
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 John Hunter, a Treatise on the Venereal Dis- 
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02a 
 
 vertebrae, disease of 
 
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 Opinion about the Venereal Disease, rid. 
 Land. Med. Reposit. Vol. 7, p. 89. R. Car- 
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 Svo. Lond. 1818. T. Rose, Obs. on the 
 Treatment of Syphilis, with an Account of 
 several Cases, in which a Cure was effected, 
 without the Use of Mercury , in Med. Chir. 
 Trans. Vol. 8. G. J. Guthrie , on the Treat- 
 ment of the Venereal Disease, without Mercu- 
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 and J. Henntn , in Edinb. Med. and Surgical 
 Journ. Vol. 14 ; also, J. Hennen, in Princi- 
 ples of Military Surgery, Edit. 2, 8vo. Edinb. 
 1820. J.Bacol, Obs. on Syphilis, principally 
 with reference to the use of Mercury, Sr o. 
 Lond. 1821. James Evans, Pathological and 
 Practical Remarks on Ulcerations of the Geni- 
 tal Organs, 8 vo. Lond. 1S19. F. G. Sarfass, 
 De Methodis alque mtdicamenlis antisyphiliti- 
 cis , 4 to. Berol. 1816. Anonym, sur la Non- 
 existence de la Maladie Venerienne, <£*c. Svo. 
 Paris, 1811. 
 
 VENESECTION, (from vena, a vein, 
 and sectio, a division.) The operation of 
 opening a vein. Phlebotomy. See Bleed- 
 ing. 
 
 VERRUCA. A Wart. See Wart. 
 
 VERTEBRAE, DISEASE OF. The case, 
 here to be considered, is a disease of the 
 spine, sometimes originating in an ulceration 
 of the intervertebral cartilages, sometimes in 
 a morbid condition of the cancellous struc- 
 ture of the bodies of the vertebrae ( Brodit on 
 Diseases of the Joints, p. 259,) followed by a 
 more or less complete loss of the power of 
 using the legs. 
 
 Formerly, the affection of the limbs was 
 generally called a palsy, and treated as a 
 paralytic affection ; to vvhicli it is in almost 
 every respect perfectly unlike. 
 
 In the true paralysis, (says Mr. Pott) from 
 whatever cause, the muscles of the affected 
 limb are soft, flabby, unresisting, and inca- 
 pable of being put into even a tonic state ; 
 the limb itself may be placed in almost any 
 position, or posture ; if it be lifted up, and 
 then let go, it falls down, and it is not in the 
 power of the patient to prevent, or even to 
 retard, its fall ; the joints are perfectly and 
 easily moveable in any direction ; if the af- 
 fection be of the lower limbs, neither hips, 
 knees, rior ankles, have any degree of ri- 
 gidity, or stiffness ; but permit the limb to be 
 turned, or twisted, in almost any manner. 
 
 In the present case, the muscles are in- 
 deed lessened, hut they are rigid, and al- 
 ways at least in a tonic state, by which the 
 knees and ankles acquire a stiffness not very 
 easy to overcome. By means of this stiff- 
 ness, mixed with a kind of spasm, the legs 
 of the patient are either constantly kept 
 stretched out straight, in which case consi- 
 derable force is required to bend the knees, 
 or they are, by the action of the stronger 
 muscles, drawn across each other, in such 
 
 manner as to require as much to separate 
 them. When the leg is in a straight position, 
 the extensor muscles act so powerfully, as 
 to require a considerable degree of force to 
 bend the joints of the knees j and, when they 
 have been bent, the legs are immediately, 
 and strongly, drawn up with the heels to- 
 ward the buttocks. By the rigidity of the 
 ankle joints, joined to the spasmodic action 
 of the gastrocnemii muscles, the patient’s 
 toes are pointed downward, in such manner 
 as to render it impossible for him to put his 
 foot flat to the ground : which makes one of 
 the decisive characteristics of the distemper. 
 
 The majority of those who labour under 
 this disease, are infants, or young children : 
 adults are by no means exempt from it ; but 
 Mr. Pott never saw it at an age beyond 
 forty ; and Mr. Baynton never met with 
 more than three instances, which approach- 
 ed that period of life. (On Diseases of the 
 Spine, p. 4.) 
 
 In one case, however, recited by Mr. Bro- 
 die, the patient was forty-five years old. 
 (On Diseases of Joints, p. 268.) By Pott, 
 Baynton, and several other writers, a belief 
 is entertained, that the disease is most dis- 
 posed to happen in scrofulous subjects, in 
 which opinion I am also disposed to join. 
 There can also be no doubt of the fact, sta- 
 ted by Mr. Pott, that it most frequently hap- 
 pens in weak and delicate children. 
 
 According to Mr. Pott, if the patient be a 
 child, the account, most frequently given is, 
 that for some time previous to the incapa- 
 city of using its limbs, it bad been observed 
 to be languid, listless, and very soon tired ; 
 that it was unwilling to move much, or 
 briskly ; that it had been observed fre- 
 qucnly to trip and stumble, although no im- 
 pediment lay in its way ; that when it mov- 
 ed hastily, or unguardedly, its legs would 
 cross each other involuntarily by which it 
 was often and suddenly thrown down ; that 
 if it endeavoured to stand still, and upright, 
 unsupported by another person, its knees 
 would totter and bend under it ; that it could 
 not, with any degree of precision or certain- 
 ty, steadily direct either of its feet to any 
 particular point, but, that in attempting so to 
 do, they would be suddenly, and involunta- 
 rily, brought across each other ; that soon 
 after this, it complained of frequent pains 
 and twifebings in its thigh s, particularly 
 when in bed, and of an uneasy sensation at 
 the pit of the stomach ; that when it sat on 
 a chair, or a stool, its legs were almost al- 
 ways found across each other, and drawn 
 up under the seat ; and that in a little time 
 after these particulars had been observed, it 
 totally lost the power of walking. 
 
 The same author observes, that if the in- 
 curvation be of the neck, and to a consider- 
 able degree, by affecting several vertebrae, 
 the child finds it inconvenient and painful to 
 support its own head, and is always desirous 
 of laying it on a table or pillow, or any thing 
 to take off the weight. If the affection be of 
 the dorsal vertebrae, it is soon attended with 
 loss of appetite, hard dry cough, laborious 
 
630 YERTKBR/E, 
 
 respiration, quick pulse, and disposition to 
 hectic. 
 
 Mr. Pott states, that an adult, in a case 
 where no violence has been committed or 
 received, will tell you that his first intima- 
 tion was a sense of weakness in his back- 
 bone, accompanied with what he will call a 
 heavy dull kind of pain, attended with such 
 a lassitude as rendered a small degree of 
 exercise fatiguing ; that this was soon fol- 
 lowed by an unusual sense of coldness in his 
 thighs, not accountable for from the weather, 
 and a palpable diminution of their sensibili- 
 ty. That, in a little time more, his limbs 
 were frequently convulsed by involuntary 
 twitchings, particularly troublesome in the 
 night; that soon after this, he not only be- 
 came incapable of walking, but that his 
 power either of retaining or discharging his 
 urine and feces was considerably impaired, 
 and his penis became incapable of erection. 
 
 The adult also finds all the offices of his 
 digestive and respiratory organs much af- 
 fected, and complains constantly of pain 
 and tightness at his stomach. 
 
 The true cause of the disease is a morbid 
 state of the spine, and of some of the parts 
 connected with it ; which distempered state of 
 parts will , upon careful inquiry , he always 
 found to have preceded the deformity some 
 length of time ; in infants, this is the sole 
 cause, and external violence has nothing to 
 do with it. “ In the adult (says Mr. Pott) I 
 will not assert, that external mischief is al- 
 ways and totally out of the question ; but I 
 will venture to affirm, what is equal, as far 
 as regards the true nature of the case, which 
 is, that although accident and violence may, 
 in some few instances, be allowed to have 
 contributed to its more immediate appear- 
 ance, yet the part in which it shows itself, 
 must have been previously in a morbid 
 state, and thereby predisposed for the pro- 
 duction of it. I do not by this mean to say, 
 that a violent exertion cannot injure the' 
 spine, nor produce a paralytic complaint : 
 that would be to say more than I know ; 
 but I will venture to assert, thal no degree 
 of violence whatever is capable of produ- 
 cing such an appearance as lam now speak- 
 ing of, unless the bodies of the vertebrae 
 were by previous distemper disposed to give 
 way; and that no supposable dislocation, 
 caused by mere violence done to the bones 
 of the back, which bones were, before the 
 receipt of the injury, in a sound state, can 
 possibly be attended with the peculiar symp- 
 toms of a curved spine.” 
 
 For some observations, connected with 
 this point, I refer the reader to C. Bell’s 
 Surgical Observations, Vol. 1. 
 
 Mr. Brodie agrees with Mr. Pott, and 
 other writers on the fact, that the actual 
 curvature must be preceded by a disease of 
 the parts, unaccompanied with any visible 
 deformity, and “ cannot take place until the 
 caries has made considerable progress.” In 
 the early stage of the case, therefore, when, 
 as Mr. Brodie justly observes, the diagnosis 
 is of the most importance, no information 
 can be obtained from the appearance of the 
 
 DISEASE OF. 
 
 spine itself, the shape of which is yet un 
 changed; and frequently the symptoms, 
 which do take place early, are not unequi- 
 vocal ; they are, according to this writer, 
 “ a pain, and some degree of tenderness in 
 thal part of the spine where the disease has 
 begun; a sense of constriction of the chest; 
 an uneasy feeling at the pit of the stomach, 
 and of the whole abdomen ; a disturbed 
 state of the functions of the alimentary ca- 
 nal, and of the urinary bladder; a sense of 
 weakness and aching, and occasional cramps 
 of the muscles of the extremities.” But, as 
 Mr. Brodie confesses, very similar symptoms 
 may arise from other causes, and sometimes 
 no particular complaints are made previ- 
 ously to the actual discovery of the curva- 
 ture. (On Diseases of Joints, p. 279, 280.) 
 
 I have already mentioned Mr. ^rodie’s 
 opinion, deduced from dissection, that, in 
 many instances, caries of the spine has its 
 origin in an ulceration of the intervertebral 
 cartilages, beginning in tbeir centre, and ex- 
 tending to their circumference, and after- 
 ward affecting the bodies of the contiguous 
 vertebra ; but that, in other cases, the dis- 
 ease has its origin in the bodies of the verte- 
 bra themselves, which are liable to the same 
 peculiar disease of the cancellous structure, 
 which is noticed in the articulating extremi- 
 ties of other bones. (Brodie on Diseases of 
 Joints , p. 267.) This gentleman suspects 
 that the disease, which begins in the cancel- 
 lous structure of the vertebra, is more im- 
 mediately followed by suppuration, than 
 that which commences in the intervertebral 
 cartilages ; and that the first form of the dis- 
 ease seldom occasions so extensive a des- 
 truction of the vertebrae, as the last. “ But 
 (says Mr. Brodie) farther than this, nothing 
 which I have hitherto observed, enables me 
 to point out any circumstances, in which 
 the symptoms of these different diseases 
 differ.” (P.276.) Respecting another state- 
 ment, that when the lumbar vertebra are 
 alone affected, the symptoms dependent 
 on pressure, or irritation, of the spinal mar- 
 row, are absent, 1 cannot say tbatit accords 
 with several cases which have fallen under 
 my own notice, that is to say, if the affection 
 of the lower limbs is to be received as a test 
 of such irritation or pressure. 
 
 According to Mr. Pott, the true curvature 
 is invariably uniform, in being from within 
 outward ; but it varies in situation, in extent, 
 and in degrees ; it affects the neck, the back, 
 or the loins ; it comprehends one vertebra 
 only, or two, or more ; and as few or more 
 are affected, or as these are more or less 
 morbid, and consequently give way more or 
 less, the curve must be different. 
 
 In these cases, as Mr. Brodie remarks, “the 
 distortion of the spine is usually of a pecu- 
 liar kind, and such as nothing can produce, 
 except the destruction of the bodies of one 
 or more vertebra. Tbe spine is bent for 
 ward, so as to form an angle posteriorly ; 
 and although the destruction of the vertebra? 
 may be the same, it is more obvious in some 
 parts of the spine than it is in others. For 
 example- the spinous processes in the middle 
 
VERTEBRAE, DISEASE OF. 
 
 631 
 
 of the back being long, and projecting 
 downwards, the elevation of one of these 
 must occasion a greater prominence than 
 that of one of the spinous processes of the 
 neck, which are short, and stand directly 
 backwards. 
 
 “ Curvature of the spine, in the direction 
 forwards, may arise from other causes, as a 
 "weak condition of the muscles, or a rickety 
 affection of the bones. In general, in such 
 cases, the curvature occupies the whole 
 spine, which assumes the form of a segment 
 of a circle. At other times, however, it 
 occupies only a portion of the spine, usually 
 that which is formed by the superior lumbar 
 and inferior dorsal vertebrae.” But here, 
 as Mr. Brodie has found, the curvature is 
 always gradual, and never angular ; a cir- 
 cumstance by which it is distinguishable 
 from the curvature produced by caries. 
 The cases, however, he thinks, have often 
 been confounded, and some speedy and 
 complete cures of carious spine on record, 
 he infers, must have been cases of an entire- 
 ly different nature. (On Diseases of Joints, 
 p. 282, <$/•<:. and Earle , in Edinb. Med. Journ. 
 Jan. 1815.) 
 
 Lateral curvatures of the spine are alleged 
 generally to incline to the right side ; and 
 the fact is referred (with what correctness 
 I know not,) to the undue power, which is 
 acquired by the more general use of the 
 right arm, and of other muscles, in the per- 
 formance of the voluntary actions.” (Boyn- 
 ton on Diseases of the Spine, p. 43.) It is 
 admitted, however, that exceptions are met 
 with, and that the lateral curvature some- 
 times tends to the left, and occasionally 
 resembles the letter S reversed. On this 
 subject, I have also another rare exception 
 to specify, which is explained by Mr. Bro- 
 die, viz. that though lateral distortions of 
 the spine generally arise from causes inde- 
 pendent of caries, a slight degree of lateral 
 curvature is, in some instances, produced 
 by the bodies of ihe vertebras having been 
 destroyed on one side by caries in a greater 
 degree than on the other. (Brodie on Joints, 
 p. 284.) 
 
 In general, the lower limbs alone usually 
 feel the effect. Mr. Pott, however, had 
 seen two cases, in one of which the arms 
 only were affected ; in the other, both legs 
 and arms. Mr. Ford showed him a lad, 
 who hadfost the use of both arms and legs 
 from a eif.Vature. An account of two simi- 
 lar examples was also communicated to Mr. 
 Pott by Mr. Parke, of Liverpool. 
 
 Mr. Brodie has never known the paralysis 
 affect the muscles of the arms, when the 
 disease was at the lower or middle part of 
 the spine ; but he agrees with Mr. Cope- 
 land, that the symptoms are not always 
 confined to parts below the disease, and 
 that it is not uncommon for pains in the 
 upper extremities to accompany the para- 
 lytic affection of the legs and thighs. (Bro- 
 die, p. 285. Copeland, Obs. on Diseased 
 Spine, fyc.) 
 
 Very soon after tue curvature, some pa- 
 tfrhts are rendered totally and absolutely 
 
 incapable not only of walking, but of using 
 their legs in any manner ; others can make 
 shift to move about with the help of crutch- 
 es, or by grasping their thighs just above 
 the knees with both hands ; some can sit 
 in an armed chair, without much trouble 
 or fatigue ; others cannot sit up with any 
 help; some retain such a degree of power 
 of using their legs as to be able to shift, 
 their posture when in bed; others have no 
 such power, and are obliged to be moved 
 upon all occasions. 
 
 I have been present at the dissection of 
 persons who died of lumbar abscesses, and 
 who, while they lived, never suffered the 
 peculiar loss of the use of the lower ex- 
 tremities, so well described by Mr. Pott,, 
 though the vertebrae were found to be dis- 
 eased. However, in other instances of 
 such abscesses, attended with caries of the 
 spine, the legs are deprived of their power. 
 But, whether the difference is to be ex- 
 plained by the consideration, that, in some 
 cases, the disease of the bone may be se- 
 condary and the abscess itself the primary 
 complaint, I cannot determine. At all 
 events, suppuration is frequently only an 
 effect, the curvature existing long before 
 the abscess; and, in such cases, the legs 
 are effected. A few weeks ago, Mr. Dunn, 
 of Scarborough, consulted me about a case 
 in which the latter facts were exemplified. 
 Mr. Brodie’s opinion, that suppuration takes 
 place at an earlier period in cases where 
 the disease begins in the cancellous struc- 
 ture of the bones, has been already noticed. 
 In having a tendency to excite suppuration, 
 and in producing the weakness of the 
 lower extremities, the present disease of 
 the spine appears to be materially different 
 from the absorption of the vertebras, some- 
 times caused by the pressure of aneurisms, 
 and other tumours. (Hodgson on Diseases of 
 Arteries, fyc. p. 80.) 
 
 Mr. Pott observes : — When a child ap- 
 pears to be what the common people call 
 naturally weakly, whatever complaints it 
 may have are supposed to be caused by its 
 weak state, and it is generally believed, that 
 time and common care will remove them ; 
 but when a curvature has made its appear 
 ance, all these marks bf ill health, such as 
 laborious respiration, hard cough, quick 
 pulse, hectical heat and flushing, pain and 
 tightness of the stomach, fcc. are more at- 
 tentively regarded, and set to the account 
 of the deformity consequent to the curve, 
 more especially if the curvature be of the 
 dorsal vertebra?, in which case the deformi- 
 ty is always greatest ; but whoever will 
 carefully attend to all the circumstances of 
 this disorder, will be convinced, that most, 
 if not all the complaints of children, labour 
 ing under this’infirmity, precede the curva- 
 ture, and that a morbid state of the spine, 
 and of the parts connected with it, is the 
 original and primary cause of both. 
 
 Among many other reasons for thinking, 
 that an effect was mistaken for a cause, Mr 
 Pott enumerates the following : 
 
 I That he did not remember ever 
 
VERTEBKyE, DldEASE 01'. 
 
 o3 2 
 
 have seen this useless state of the limbs 
 from a mere malformation of the spine, 
 however crooked such malformation might 
 have made it. 
 
 2. “ That none of those deviations from 
 right shape, which growing girls are so liable 
 to, however great the deformity might be, 
 was ever attended with this effect.” 
 
 With respect to the treatment of diseased 
 spine, I think one principle laid down by 
 Mr. Pott, must receive approbation ; viz. 
 that the primary and sole cause of all the 
 symptoms is a distempered state of the 
 parts, composing, or in immediate connex- 
 ion with the spine, tending to, and most 
 frequently ending in a caries of the verte- 
 bra?. Hence, says he, all the ills, whether 
 general or local, apparent or concealed ; 
 the ill health of the patient, and in time the 
 curvature. As the disease does not origi- 
 nate in the limbs, no application to them 
 can be of any use, and the great indication 
 must be to stop the progress of the disease 
 in the affected part of the spine. 
 
 The first suggestion of the probability that 
 issues might prove serviceable in this dis- 
 ease, appears to have been made to Mr. 
 Pott by Dr. Cameron, of Worcester, who 
 told him, that having remarked in Hippo- 
 crates, an account of paralysis of the lower 
 limbs, cured by an abscess in the back, he 
 had in a case of useless limbs, attended with 
 a curvature of the spine, endeavoured to 
 imitate this act of nature, by exciting a pu- 
 rulent discharge, and that it had proved very 
 beneficial : which was confirmed to Mr. 
 Pott by Mr. Jeffreys, of Worcester, who 
 had made the experiment with the same 
 success. 
 
 The practice which Pott recommends, 
 consists merely in procuring a large dis- 
 charge of matter from the integuments on 
 each side of the distempered bones forming 
 the curvature, and in maintaining such dis- 
 charge until the patient shall have recovered 
 his health and the use of his limbs. They 
 who are little conversant with matters of 
 this sort (says Mr. Pott) will suppose the 
 means very inadequate to the proposed 
 end ; but they who have been experimen- 
 tally acquainted with the very wonderful 
 effects of purulent drains, made from the 
 immediate neighbourhood of diseases, will 
 not be so much surprised at this particular 
 one ; and will immediately see how such 
 kind of discharge, made and continued 
 from the distempered part, checks the fur- 
 ther progress of the caries, gives nature an 
 opportunity of exerting her own powers of 
 throwing off the diseased parts, and of pro- 
 ducing, by incarnation, an union of the 
 bones (now rendered sound,) and thereby 
 establishing a cure. 
 
 Mr. Pott considers it a matter of very 
 little importance towards the cure, by what 
 means the discharge be procured, provided 
 it be large, that it come from a sufficient 
 depth, and that it be continued for a suffi- 
 cient length of time. He tried setons, 
 issues by incision, and issues by caustic, and 
 found the last in general preferable, being 
 
 least painful, most cleanly, most easily ma- 
 nageable, and capable of being longest con 
 tinued. 
 
 The caustics, he observes, should be ap- 
 plied on each side of the curvature in such 
 a manner as to leave the portion of skin, 
 covering the spinal processes of the protru- 
 ding bones entire and unhurt, and so large, 
 that the sores upon the separation of the 
 eschars, may easily hold each three or four 
 peas, in the case of the smallest curvature ; 
 but in large curves, at least as many more. 
 
 The issues which modern surgeons usually 
 make, for the relief of the symptoms arising 
 from diseased vertebra?, are larger than such 
 as Mr. Pott himself was in the habit of 
 forming. They now commonly prefer 
 making an issue on each side of the spinous 
 processes, about three or four inches long, 
 and half an inch broad. 
 
 The size of the issue intended to be made 
 being determined, the place where it is to be 
 made should be accurately marked out with 
 ink. All the skin immediately around should 
 then be covered with adhesive plaster, in or- 
 der that it may be protected from the action 
 of the caustic. Let the surgeon next take a 
 piece of caustic potassa, or of potassa cum 
 calce, and wrap a little tow round one end 
 of it, so that he may take hold of it with 
 safety and convenience. The other end of 
 the caustic should then be moistened a little, 
 and rubbed very quickly on the portion of 
 the integuments, which is to be converted 
 into an eschar. The caustic is to be rubbed 
 in this manner, till the part turns of a dull 
 brown colour, when the caustic should be 
 carefully washed off with a little wet tow, 
 and a poultice applied. 
 
 As soon as the eschars admit of being re- 
 moved, a row of peas, or beans, connected 
 together with thread, should be laid on the 
 sore, and confined there with sticking plas- 
 ter. A compress, containing a piece of 
 pasteboard, or sheet-lead, is then to be bound 
 over the peas or beans with a roller. In 
 consequence of the continued pressure, the 
 peas or beans soon form little hollows for 
 themselves, in which they should be regu- 
 larly placed every day. When the pressure 
 is not duly maintained, the granulations are 
 apt to rise so high, that the peas cannot be 
 well kept on the part. In this circumstance, 
 the surgeon must try to repress the high 
 surface of the sore, by sprinklin'* on it a 
 little savine powder and subacetat? of cop- 
 per, mixed together in equal proportions. 
 When this plan is unavailing, the reappli- 
 cation of the caustic becomes indispensable. 
 
 Whatever time may be requisite to restore 
 the health, as well as the use of the limbs, 
 Mr. Pott thinks, that the issues should be 
 kept open until these objects are completely 
 fulfilled; and even longer, especially in 
 growingchildren. Heownsthat nothing can 
 be more uncertain, than the time required 
 for the cure. He has seen it perfected in 
 two or three months ; and he has known it 
 require two years ; two-thirds of which time 
 passed before there was any visible amend- 
 ment 
 
VERTEBRA, DISEASE 01 
 
 03o 
 
 Alter the discharge has been made some 
 time, the patient is found to be better, in all 
 general respects, and if of age to distinguish, 
 will acknowledge, that he feels himself to 
 be better in health ; he begins to recover 
 his appetite, gets refreshing sleep, and has a 
 more quiet and less hectical pulse ; but the 
 relief which lie feels above all others* is 
 from having got rid of that distressing sen- 
 sation of tightness about the stomach ; in a 
 little time more a degree of warmth, and a 
 sensibility are felt in the thighs* which they 
 had been strangers to for some time ; and 
 generally much about the same time the 
 power of retaining and discharging the urine 
 and feces begins to be in some degree exerted. 
 
 The first return of the power of motion 
 in the limbs, says Mr. Pott, is rather disa- 
 greeable ; the motions being involuntary, 
 and of the spasmodic kind, principally in 
 the night; and generally attended with a 
 sense of pain in all the muscles concerned. 
 
 At this point of amendment, if it may be 
 so called, it is no uncommon thing, espe- 
 cially in bad cases, for the patient to stand 
 some time without making any farther pro- 
 gress ; this, in adults, occasions impa- 
 tience, and in parents, despair; but in the 
 milder kind of case, the power of voluntary 
 motion generally soon follows the involun- 
 tary. 
 
 The knees and ankles, by degrees, lose 
 their stiffness, and the relaxation of the 
 latter enables the patient to set his feet flat 
 upon the ground, the certain mark that the 
 power of walking will soon follow ; but 
 those joints having lost their rigidity, be- 
 come exceedingly weak, and are not for 
 sometime capable of serving the purpose of 
 progression. 
 
 An attentive examination of the morbid 
 appearances, and their effects in different 
 subjects, led Mr. Pott to conclude, among 
 other things, that the disease which produ- 
 ces these effects on the spine, and the parts 
 in its vicinity, is what is in general called 
 scrofula. 
 
 That ulceration or caries of the bodies of 
 the vertebras affected, is the common morbid 
 change, and not enlargement. 
 
 That when the attack is made upon the 
 dorsal vertebrae, the sternum and ribs, for 
 want of proper support, necessarily give 
 way, and deformity, additional to the curve, 
 is produced. 
 
 That this kind of caries is. always confined 
 to the bodies of the vertebae, seldom or 
 never affecting the articular processes. 
 Two cases were seen by Pott, in which the 
 bodies of the vertebrae were completely de- 
 tached from their processes, so as to leave 
 the membrane of the spinal marrow per- 
 fectly bare. 
 
 That without this destruction of the bodies 
 of the vertebrae, there can be no curvature 
 of the kind here treated of ; or in other 
 words, that erosion is the sine qud non of 
 this disease ; that although there can be no 
 true curve without caries, yet there is, and 
 that not infrequently, caries without curve. 
 
 That the caries with curvature and useless 
 fVoL.1T. SO 
 
 limbs, is most frequently of the cervical or 
 dorsal vertebrae, the caries without curve, 
 of the lumbal, though this is by no means 
 constant or necessary. 
 
 That in the case of carious spine without 
 curvature,. it most frequently happens, that 
 internal abscesses, and collections of matter 
 are formed, which matter makes its way 
 outward, and appears in the hip, groin, or 
 thigh ; or being detained within the body, 
 destroys the patient : the real and immedi- 
 ate cause of whose death is seldom known, 
 or even rightly guessed at, unless the dead 
 body be examined. 
 
 That what are commonly called lumbal 
 and psoas abscesses, are not infrequently 
 produced in this manner, and therefore, 
 when we use these terms, we should be 
 understood to mean only a description of 
 the course, which such matter has pursued 
 in its way outward, or the place where it 
 makes its appearance externally, the terms 
 really meaning nothing more, nor convey- 
 ing any precise idea of the nature, seat, or 
 origin of a distemper subject to great varie- 
 ty, and from which variety its very different 
 symptoms and events in different subjects, 
 can alone be accounted for. 
 
 That contrary to the general opinion, a 
 caries of the spine is more frequently a 
 cause, than an effect of these abscesses. 
 
 That the true curvature of the spine from 
 within outward, of \yhich the paralytic, or 
 useless state of the lower limbs, is a too fre- 
 quent consequence, is itself but one effect of 
 a distempered spine ; such case being al- 
 ways attended with a number of complaints, 
 which arise from the same cause : the gene- 
 rally received opinion, therefore, that all the 
 attending symptoms are derived from the 
 curvature, considered abstractedly, is by no 
 means founded in truth, and may be pro- 
 ductive of very erroneous conduct. 
 
 That when two or more vertebrae are af- 
 fected, forming a large curve, however per- 
 fect the success of the treatment may be 
 with regard to the restoration of health and 
 limbs, yet the curvature will and must re- 
 main, in consequence of the union of the 
 bones with each other. 
 
 That the useless state of the limbs is by no 
 means a consequence of the altered figure 
 of the spine, or of the disposition of the 
 bones with regard to each other, but merely 
 of the caries : of this truth there needs no 
 other proof, than what may be drawn from? 
 the cure of a large and extensive curvature, 
 in which three or more vertebras were con- 
 cerned : in this the deformity always remains 
 unaltered and unalterable, notwithstanding 
 the patient recovers both health and limbs. 
 
 Pott contends, that a morbid state of the 
 parts, previous to deformity, caries, or curve, 
 must be allowed. All the general complaints 
 of persons afflicted with this disorder, he 
 says, will, upon careful inquiry, be found to 
 have preceded any degree of deformity, to 
 hatfe increased as the curve became appa- 
 rent, and to have decreased as the means 
 used for relief took place; the pain and 
 tightness about the stomach, the indigestion 
 
VERTEBR/E, DISEASE OF. 
 
 cm 
 
 (he want of appetite, the disturbed sleep, &c. 
 &c. gradually disappear, and the marks of 
 returning health become observable before 
 the limbs recover the smallest degree of their 
 power of moving. 
 
 On the other hand, is admitted to be as 
 true, that when from extent, or degree, or 
 inveteracy of the caries, the issues are found 
 to be unequal to the wished-for effect, the 
 general complaints receive no amendment ; 
 but increase until the patient sinks under 
 them. 
 
 If all this be true, says Mr. Pott, and it 
 be found that the issues are capable of ef- 
 fecting a perfect cure, even after a caries 
 has taken place, and that to a considerable 
 degree, is it not reasonable to conclude, that 
 the same means, made use of in due time, 
 might prove a preventive ? 
 
 Besides the forms of disease of the spine 
 treated of in this article, the observations of 
 Mr. Wilson prove, that the distemper may 
 sometimes begin within the theca vertebralis, 
 and thence extend to the bones. He also 
 demonstrated, at the College of Surgeons, 
 scrofulous tumours in the spinal marrow. 
 Such diseases would create a loss of power 
 in the parts below them, without any curva- 
 ture of the spine. {Lectures on the Skeleton , 
 fyc.p. 397.) 
 
 In France, the same indication is followed 
 as that on which Mr. Pott lays stress, viz. to 
 endeavour to arrest the disease of the spine 
 hy means applied in the vicinity of the mor- 
 bid parts. But instead of employing caustic 
 issues, the tnoxa is used, and sometimes re- 
 peated cupping near the affected bones ; 
 both which means were particularly re- 
 commended by Desault. 
 
 Another practice, which yet lias partisans, 
 though it was strongly disapproved of by 
 Pott, is that of supporting the spine with ma- 
 chinery. Perhaps the latter author may have 
 carried his objections to this method beyond 
 all reason, and with the exception of Dr. 
 Harrison, (see Lond. Med. and Physical 
 Journ. JYov. 1820,) I believe no modern 
 practitioner now ever advises it on t »e sup- 
 position of there being any dislocation; an 
 error which formerly prevailed. As Mr. 
 Biodie observes, certainly no machines ought 
 ever to be employed for the purpose of elon 
 gating the spine and correcting the deformi- 
 ty : but if they be used simply to take off 
 the weight of the head, chest, and upper ex- 
 tremities, from the diseased part of the spine, 
 they may sometimes be of service. The 
 late Sir James Earle had a very favourable 
 opinion of their utility. I believe, with Mr. 
 Brodie, that they ought never in the iirst in- 
 stance to supersede the constant mainte- 
 nance of the horizontal position ; but that 
 they may be advantageous, when circum- 
 stances make it desirable that the patient be- 
 gin to sit up a part of the day. (On Diseases 
 cf the Joints, p. 291.) 
 
 From Mr. Poll’s own account, it will be 
 seen, that he never pretended that issues, 
 kept open in the vicinity of the disease, were 
 infallible; and a late eminent surgeon has 
 actually referred the good which Pott 
 
 thought accrued from them, to the Song ob 
 servance of the horizontal posture. Mr, 
 Baynton, the gentleman to whom I allude, 
 also mentions, that M. David is the only 
 writer who has suggested that rest would 
 affect the cure of diseases of the spine. On 
 this point, however, Mr. Baynton was en- 
 tirely mistaken, as, about eighteen years 
 ago, Loder wrote some remarks, particularly 
 directed to the object of recommending quie- 
 tude in the present disease, as the best means 
 of promoting anchylosis. (See Med. Chir . 
 Beobachlungen, p. 251 ; 8 vo. Weimar , 1794.) 
 
 Now, although I fully concur in the pro- 
 priety of keeping the patient as quiet as pos- 
 sible in the recumbent position, inasmuch 
 as motion must be hurtful to t he diseased 
 part of the spine, it does not follow, that be- 
 cause this admission is made, that issues 
 should be rejected, and that rest must do 
 every thing. In one part of Mr. Baynton’s 
 reasoning, an error prevails, which I shall 
 here notice, as it seems greatly to have influ 
 enced his opinions; and as far as I know it 
 has not been remarked by the critical exa- 
 miners of that gentleman’s book. The mis 
 take is in supposing, that the process by 
 which the diseased part of the spine is to be 
 restored and united, should be conducted 
 exactly on the same principles as the union 
 of bones free from disease. In fact, there is 
 an additional indication, which is to stop the 
 progress of the disease, for which purpose, 
 experience proves that issues, aided by rest , 
 are the means affording the best chances of 
 success. I have attended several children 
 myself, who, from the effect of issues, reco- 
 vered the use of their lower extremities, 
 even though they could not be kept constant- 
 ly at rest. 1 must also give my testimony 
 to the truth of Mr. Brodie's statement, that 
 many patients are benefited almost immedi- 
 ately the issues are made, or uniformly -find 
 themselves better after each application of 
 the caustic. {On Diseases of Joints, p. 282.) 
 In some cases, however, caustic issues fail 
 to affosd relief; and when they are of no 
 use, rest in the horizontal posture, below 
 ground, I believe must soon be the patient’s 
 doom. Whether the occasional failure of 
 issues. is to be ascribed to the advanced pro- 
 gress which the disease has made, or to its 
 having begun in the cancellous structure of 
 the vertebrae, as suggested by Mr. Brodie, 
 future observation must decide. 
 
 Consult Pott's Chirurgical Works, Vol. 8. 
 G. Gebb, Select Cases of the Disorder , com- 
 monly termed Paralysis of the Lover Extre- 
 mities, 8 vo. Lond. 1782. C. H. Wilkinson , 
 Essays on Distortion of the Spine , fyc. 8 vo. 
 Lond. 179S. Loder , Med. Chir. Beobachlun- 
 gen , B. 1 ,p. 247, fyc. 8 vo. Weimar, 1794. J. 
 C. Frank, Oralio de Vertebralis Columnar in 
 Morbis Dignilale ; Pavia, 1791. C. Van 
 Boy, De Scoliasi, Alo. Lugd. 1774. Sir J 
 Earle, Observations on the Cure of Curved 
 Spine ; in which the effect of Mechanical As- 
 sistance is considered, Svo. Loud. 1803. Gius- 
 eppe Bergamaschi, Osservazioni sulla Injlam- 
 mazione dello Spinale Medollo e dellc sue 
 Membrane ; 4to Par. 1810. T. Baynton. Jh- 
 
WAR 
 
 win 
 
 <>35 
 
 Account of a Successful Method of Treating 
 Diseases of the Spine ; Sro. Bristol , 1813. 
 11. Earle , in Edinb . Med. and Surg. Jo urn. 
 for January , 1815. J. L. Chbulant , Decas 
 Pelvium Spinarumquc Deformatarum ; 4/o. 
 
 1818. G. Malseh, de nova Machina 
 Graefiana Distortiones Spince Dorsi ad Sanan- 
 das, necnon Disquisitio DeformHatum ista- 
 rum ; 4to. Berol. 1818. Abercrombie , in 
 Edinb . Med. and Surg. JournJ for January , 
 1818. Kapeler,iu Annuaire Mcd.Ckir. dcs 
 Hdpitaux de Paris, T. i , p. 390 ; 4 to. Paris, 
 3819. T. Copeland, Obs. on the Symptoms 
 and Treatment of Diseased Spine ; Svo. B. C. 
 Brodie, Pathological and Surgical Observa- 
 tions on the Joints p. 257, fyc. Svo. Bond. 
 
 1818. James Wilson , Lectures on the Struc- 
 ture and Physiology of the Skeleton, and on 
 the Diseases of the Bones and Joints ; p. 395, 
 8 vo. Bond. 1820. 
 
 VINEGAR. (Sec Acetic Acid.) 
 
 ^ VINUM 0111. Take of extract of opium 
 ^i, cinnamon bark bruised, cloves bruised, 
 of each 3j ; wine a pint. Macerate for 
 eight days, and filter. The thebaic tincture, 
 or liquid laudanum of Sydenham, in sur- 
 gery, it is often preferred to the common 
 tincture of opium, as an application to tiie 
 eye. 
 
 VIPER, BITE OF. See Wounds. 
 
 VOLVULUS, (from voivo. to roll up.'* 
 See Intussusception. 
 
 w. 
 
 ~Wf ART. Mr. Hunter observes, that a 
 
 V ▼ wart appears to be an excrescence 
 from the cutis, or a tumour formed upon it, 
 by which means it becomes covered with a 
 cuticle, which is either strong and hard, or 
 thin and soft ; just as the cuticle is which 
 covers the parts, from which the excres- 
 cence arises. Warts are radiated from their 
 basis to their circumference. The surface 
 of the radii appears to be pointed, or granu- 
 lated, like the surface of healthy granula- 
 tions, with the exception of being harder, 
 and rising higher. The surface on which 
 the wart is formed, seems only to be capa- 
 ble of producing one; for the surrounding 
 and connecting surface does not throw out 
 a similar substance. Thus, when a wart has 
 once begun to grow, it rises higher and 
 higher, without becoming larger at its basis. 
 Such excrescences seem to have within 
 themselves the power of growing ; for, as 
 Hunter remarks, after they have risen above 
 the surface of the skin, on which their basis 
 cannot grow larger, they swell out into a 
 round thick substance, which becomes 
 rougher and rougher. 
 
 In consequence of this structure, warts 
 are very liable to be hurt by bodies rubbing 
 against them, and from such a cause, they 
 often bleed very profusely, and are rendered, 
 sore and painful. (On the Venereal Disease, 
 p. 250, Edit. 2.) 
 
 As warts are adventitious substances, and 
 not any part of the original structure of the 
 body, their powers of life are weak. Hence 
 when stimulated, they generally become 
 smaller, and at length altogether disappear, 
 or drop off. 
 
 On this principle, warts may frequently 
 be cured by the application of the sulphate 
 of copper, or a powder, composed of the 
 powders of savine leaves, and the subace- 
 tate of copper, in equal proportions. 
 
 However, the employment of stronger 
 escharotics, like the nitrate of silver, or the 
 concentrated acetic acid ; the removal of 
 such excrescences with a knife, or pair of 
 scissors; or tying their necks with a liga- 
 
 ture, is a mode frequently preferred, be- 
 cause the cure is sooner accomplished. 
 
 The two last methods are eligible, when 
 the wart has a narrow neck; but after the 
 removal of the excrescence, it is still proper 
 to touch the root with the caustic, or the 
 acetic acid; for unless the whole be com- 
 pletely destroyed, the wart will inevitably 
 grow again. 
 
 Warts on the pudenda, and about the 
 anus, scarcely ever withstand the effect of 
 the powder of savine, and subacetate of 
 copper, though they will sometimes resist 
 a course of mercury, adequate to cure lues 
 venerea ; a consideration, which led Mr. 
 Hunter to believe them not to be syphilitic. 
 In this opinion, I believe all the best sur- 
 geons of the present day concur.* 
 
 WHITLOW. ( Panaris , Onychia, Pana- 
 ritium, Paronychia.) A whitlow is an in- 
 flammation, about the end of the finger, 
 exceedingly painful, and very much disposed 
 to suppurate. The toes are also sometimes 
 the seat of the disease. 
 
 Writers usually divide Whitlows into four 
 kinds. In the first, or mildest, a vesicle, 
 filled with matter, commonly arises near the 
 root, or side of the nail, after a superficial 
 inflammation of trivial extent. The matter 
 is situated immediately under the cuticle. 
 Sometimes the abscess takes place under the 
 nail, in which case, the pain is severe, and 
 not unfrequently shoots upward, as far as 
 the external condyle. 
 
 * The ligature is as effectual and convenient as any 
 method recommended, for the removal of warts. 
 But as warts have seldom necks sufficient to retain the 
 thread, I have been in the habit of resorting to a plan 
 which 1 have always found successful, to the entire 
 removal of warts. Take a fine sewing needle, armed 
 with strong silk, and pass it through, the centre of the 
 tumour at its base, taking care to go deep enough, that 
 the whole disease may be included, then by tying this 
 at each side, of sufficient tightness to interrupt the cir- 
 culation, the wart will dropoff within the w'eek, without 
 inconvenience to the patient. From the manner in 
 which the ligatures are applied, there is no possibility 
 of their coming off, until the disease come with it. In 
 this way, I have freed a hand from a dozen at one 
 time, to the great satisfaction of the individual ; and 
 when removed in this manner, I have never found 
 them recur- Am. Ed. 
 
636 
 
 WHITLOW 
 
 The second kind of whitlow is chieGy situ- 
 ated in the cellular substance under the 
 cutis, and, for the most part, occurs at the 
 very end of the finger. In this sort of case, 
 the inflammatory symptoms, especially the 
 pain, are far more violent than in other 
 common inflammations of net greater extent. 
 However, although the pain is thus severe, 
 it does not in general extend far from the 
 part affected. Writers usually impute the 
 violence of the pain, and the considerable 
 degree of inflammation attending the com- 
 plaint, to the hard and unyielding nature of 
 the skin on the finger. To the same cause 
 they also ascribe the difficulty of perceiving 
 any fluctuation after matter is formed ; and 
 the slowness with which the pus makes its 
 Way outward. 
 
 The third kind of whitlow is distinguish- 
 able from the others by the following cir- 
 cumstances. With the most excruciating 
 pain, there is very little swelling in the 
 affected finger, but a vast deal in the hand, 
 particularly about the wrist, and over the 
 whole fore-arm. The pain extends to the 
 hand, wrist, elbow, and even the shoulder. 
 When suppuration takes place, a fluctuation 
 can never be felt in the finger, though it 
 may very often be distinctly perceived in 
 the hand, at the wrist, or even somewhere 
 in the fore-nrrn. The case is frequently ac- 
 companied with considerable fever. The 
 disease is seated in the tendons and their 
 sheaths, and the power of moving the fin- 
 gers, and even the whole hand, is lost. 
 
 Authors describe the fourth kind of whit- 
 low as arising principally from an inflamma- 
 tion of the periosteum. The case is attend- 
 ed with one peculiarity, which is, that, how- 
 ever violent the pain may be, it never ex- 
 tends to the hand and fore-arm, nor is 
 there any external swelling of the affected 
 finger. Suppuration generally follows very 
 soon, the usual consequence of which is a 
 caries, or rather a necrosis, of the subjacent 
 finger-bones. 
 
 Whitlows commonly begin on the inside 
 of the fingers ; but they do occasionally 
 Commence on the back of these parts, and 
 even on that of the hand. Though pain 
 about the wrist is usually the effect of in- 
 flammation in the finger, Acrel mentions a 
 case in which the disorder was altogether 
 confined to the hand itself. ( Vorfalle , 2 
 B. p. 191.) 
 
 Mr. Wardrop has favoured the public 
 with an account of a particular species of 
 whitlow, which, from its malignant cha- 
 racter, he has denominated the onychia ma- 
 ligna. “The commencement of this dis- 
 ease is marked by a degree of swelling, of 
 a deep red colour, in the soft parts at the 
 root of the nail. An oozing of a thin ichor 
 afterward takes place at the cleft formed 
 between the root of the nail and soft parts, 
 and at last the soft parts begin to ulcerate. 
 The ulcer appears on the circular edge of 
 the soft parts at the root of the nail ; it is ac- 
 companied with a good deal of swelling, 
 and the skin, particularly that adjacent to 
 the nicer, ha® a deep purple colour. The 
 
 appearance of the ulcer is very unhealthy, 
 the edges being thin and acute, and its sur- 
 face covered with a dull yellow, or brown- 
 coloured lymph, 'and attended with au ichor- 
 ous and very fetid discharge. The growth 
 ol the nail is interrupted, and loses its na- 
 tural colour, and at some places appears to 
 have but little connexion with the soft parts. 
 In this state (says Mr. Wardrop) l have 
 seen the disease continue for several years, 
 so that the toe, or finger, became a deform- 
 ed bulbous mass. The pain is sometimes 
 very acute ; but the disease is more com- 
 monly indolent, and accompanied with lit- 
 tle uneasiness. The disease affects both the 
 toes and the fingers. I have only observed 
 it on the great toe, and more frequently on 
 the thumb, than any of the fingers. It occurs, 
 too, chiefly in young people •, but I have 
 also seen adults affected with it.” (IVar- 
 drop , in Med. Chir. Trans. Vol. 5, />. 135, 
 136.) 
 
 The causes of whitlows are generally of a 
 local nature. Writers enumerate the fol- 
 lowing as the most common : a contusion ; 
 suddenly warming the finger when it is ex- 
 ceedingly cold ; pricks with needles, . or 
 other sharp instruments ; and the insinua- 
 tion of irritating matter into scratches on the 
 finger. A surgeon, in operating lor a fistula 
 in ano, has been known to cut his finger, 
 and have, in consequence of the accident, 
 a very severe and dangerous kind of whit- 
 low. Richter also mentions a person who 
 had a most obstinate whitlow, in conse- 
 quence of a slight wound on the finger, in 
 examining the head of a horse that had the 
 glanders. Sometimes the cause of a whit- 
 low depends on a splinter, or thorn, which 
 continues lodged in the part. Very often, 
 no particular cause whatever can he assign- 
 ed for the complaint. 
 
 The first case, which occurs about the 
 root of the n§il, ought to be opened as 
 soon as possible. When this plan is not 
 adopted, the matter is apt to penetrate more 
 deeply, reach the root of the nail, and occa- 
 sion a loss of this part. When an effectual 
 opening is not made, the matter collects 
 again. In general, a detachment of the cu- 
 ticle takes place as far as the abscess extends. 
 When the inflammation has been very vio- 
 lent, and the matter has made its way as far 
 as the root of the nail, the nail itself is in 
 general gradually detached, while the denu- 
 ded portion of the root of the nail acts on 
 the sore as a foreign body, and hinders it 
 from healing. Hence the surgeon should 
 repeatedly cut away as much of the lower 
 edge of the nail as he can, and insinuate a 
 little soft lint between the margin of the 
 nail and the sore, in order to keep the latter 
 from being irritated by the former. In pro- 
 portion as the old nail gradually separates, 
 a new one makes its appearance. 
 
 When matter lies under the nail, an open- 
 ing should be made through the part as 
 speedily us possible, for the discharge of the 
 abscess. In order to perform this operation, 
 Richter advises the surgeon to scrape the 
 naj! with a piece of glass, till it is as thin ns 
 
whitlow. 
 
 637 
 
 a can well be, when it may be cut through 
 with a bistoury. 
 
 In the secoml species of whitlow, suppu- 
 ration may sometimes be prevented, and 
 the inflammation be resolved, by the timely 
 employment of proper means. When the 
 pain is violent, and acute fever prevails, it 
 may be adviseable to bleed the patient. In 
 a few severe cases, the application of three 
 or four leeches to the affected finger has 
 been known to procure prompt relief. 
 
 ( Schmucker .) Theden thinks, that applying 
 a roller round the finger, hand, and arm, 
 and frequently wetting the first two parts 
 with a lotion, the most certain means of 
 resolving the inflammation. Platner advi- 
 ses the finger to be for some time immersed 
 in water as warm as the patient can bear. 
 Some recommend the external use of cam- 
 phorated spirit, or the volatile alkali : while 
 others advise the affected finger to be plun- 
 ged in a warm solution of soap, or kali. 
 When the whitlow is occasioned by a prick, 
 particular care must be taken that no extra- 
 neous substance remain in the puncture. 
 
 When the symptoms do not lessen by the 
 fourth day, Richter recommends an open- 
 ing to be made. Even when no fluctuation 
 is discovered, he approves of making a cru- 
 cial incision in the seat of the pain, and he 
 states, that although no matter may be dis- 
 charged, the patient always derives infinite 
 relief from the operation. The benefit, he 
 says, may either be imputed to the bleeding, 
 or to the division of the hard tense skin 
 which compresses the subjacent inflamed 
 parts. Sometimes the collection of matter 
 can be plainly felt, and, in this case, there 
 can be no hesitation about the place where 
 the opening should be made. However, it 
 may lie proper to remark, that the opening 
 should always be made sufficiently large. 
 When the surgeon makes a small puncture, 
 it soon closes again, and a repetition of the 
 operation become^ necessary. When open- 
 ing the abscess is delayed, the theca of the 
 flexor tendons easily becomes affected, or 
 the matter may spread to a considerable exr 
 tent under the skin. Sometimes it makes 
 its way through the cutis by ulceration, and 
 raises up the cuticle. In this case, as soon 
 as the cuticle has been opened, a director 
 should he introduced into the aperture in 
 the skin, and the latter opening be enlarged 
 with a bistoury. 
 
 The third species of whitlow seldom 
 affects the last phalanx of the fingers; but, 
 generally, the second or third. In this case, 
 Richter enjoins us never to defer making an 
 opening longer than the third day. If we 
 wait till suppuration happens, we shall wait 
 till the tendons are destroyed, and the use 
 of the finger lost. In the case under consi- 
 deration, the matter is always of bad qua- 
 lity, and very small in quantity. A fluctua- 
 tion in the finger can seldom be felt. How- 
 ever, in a few instances, the matter is per- 
 ceptible at the extremity of the finger, or 
 about the finger-joints, but, more often, in 
 the palm of the hand, or near the wrist. 
 In these circumstances, the tendons are in 
 
 general already destroyed, and a stiffness 
 of the finger and hand is to be apprehended 
 When the complaint is the consequence of 
 a puncture, the best plan, according to 
 Richter, is at once to enlarge the wound; 
 for, in this sort of case, all other methods 
 are unavailing. It is not enough, however, 
 to cut through the skin ; the tendinous theca 
 itself must be laid. open. 
 
 When a collection of matter forms to- 
 wards the wrist, attended with violent pain 
 in that situation, an opening must also be 
 made there. If an opening should have 
 been already made in the hand, a probe 
 may be introduced into the wound, and ano- 
 ther aperture made in an eligible situation, 
 by cutting on the end of the instrument. 
 In the same way, Richter advises an open- 
 ing to be made in any part of the fore-arm, 
 where great pain, or the symptoms of sup- 
 puration, may indicate its propriety. 
 
 In the fourth kind of whitlow, early inci- 
 sions, made down to the bone, are the most 
 certain means of obviating the danger. 
 When such incisions are not made early 
 enough, suppuration takes place, and the 
 bone becomes carious. The cut is to be 
 made iu the place where the pain is most 
 severe. When the first phalanx is affected, 
 the incision may be made in front of the 
 finger : but when the second or third is the 
 seat of the complaint, the opening should be 
 made on one side. However, in order that 
 the opening may be useful, it is absolutely 
 necessary to make it down to the bone. 
 When the incision is delayed too long, a 
 small quantity of unhealthy matter is usually 
 detected, and the bone is found in the state 
 of necrosis. As $an exfoliation can hardly 
 be expected in this situation, it is best to 
 remove at once the diseased piece of bone. 
 When the last phalanx alone is affected, the 
 finger retains its form, with the exception of 
 its end being a little shorter and flatter. 
 When the disease, however, is situated in 
 the third phalanx, Richter thinks it better 
 to amputate the finger than remove the 
 diseased bone, as the finger, if left, would 
 always remain stiff and unserviceable. 
 fSce Anfangsgr. dcr IVundarmeykunst , 
 Pol. 7.) 
 
 With regard to the treatment of the spe- 
 cies of whitlow, named by Mr. Wardrop, 
 onychia maligna , all local applications have, 
 in many instances, proved quite ineffectual, 
 and the part , been amputated. The only 
 local treatment, which Mr. Wardrop has 
 ever seen relieve this complaint has been 
 the evulsion of the nail, and afterward the 
 occasional application of escharotics to the 
 ulcerated surface. I have myself Seen a 
 similar plan occasionally succeed, and the 
 applications which appeared to answer best 
 were arsenical lotions, Plunket’s caustic, or 
 a veiy strong solution of the nitrate of sil- 
 ver. Nothing, however, will avail, till the 
 nail is removed, and its total separation 
 sometimes takes up a good deal of time, 
 unless the patient submit to the great pain 
 of having it cut away. 
 
 Mr. Wardrop tried with success the exhi 
 
cm WOUNDS. 
 
 Coition of mercury in four cases of the ony- 
 chia maligna. The medicine was given in 
 small doses at first, and afterward increa- 
 sed, so as to affect the gums in about twelve 
 or fourteen days. When the system was in 
 this state, the sores in general soon assumed 
 a healing appearance, and the bulbous 
 swelling gradually disappeared. (See Med. 
 C/nr. Trans. Vol. 5, p. 138.) 
 
 WOUNDS. A great deal of the subject 
 of wounds has been already considered in 
 the articles, Gunshot Wounds ; Head, Inju- 
 ries of ; Hemorrhage; Hydrophobia; Paro- 
 tid Duct ; Sutures ; Tetanus ; Throat >' he. 
 
 A wound may be defined to be a recent 
 solution of continuity in the soft parts, sud- 
 denly occasioned by external causes, and 
 generally attended at first with a greater or 
 lesser degree of hemorrhage. 
 
 Wounds in general are subject to a consi- 
 derable variety in their nature, degree of 
 danger, facility of cure, and the consequen- 
 ces which are to be apprehended from 
 them. Some wounds are perfectly trivial, 
 not extending more deeply than the skin 
 and cellular membrane ; while others are 
 more serious, penetrating the muscles, ten- 
 dons, large blood-vessels, and nerves, of im- 
 portance. There are also certain wounds 
 which are not confined to the soft parts, 
 but injure even the bones; such are many 
 sabre-wounds, which frequently separate 
 at once both a portion of the scalp and the 
 subjacent part of the skull. Many wounds 
 of the head, chest, and abdomen, injure the 
 organs contained in those cavitjes. in short, 
 the varieties, and the degree of danger, at- 
 tending wounds in general, depend very 
 much upon some of the following circum- 
 stances. The extent of the injury ; the kind 
 of instrument with which it has been inflict- 
 ed ; the violence which the fibres of the 
 part have suffered in addition to their divi- 
 sion ; the size and importance of the blood- 
 vessels and nerves which happen to be in- 
 jured ; the nature of the wounded part in 
 respect to its general power of healing 
 favourably or not ; whether the operations 
 of the system at large, “and life itself, can 
 be well supported or not, while the func- 
 tions of the wounded part are disturbed, 
 interrupted, or suspended by the accident ; 
 the youth or old age of the patient ; the 
 goodness or badness of his constitution ; and 
 the opportunities which there may be of 
 administering proper surgical aid, and assist- 
 ance of every kind. 
 
 Wounds are distinguished by surgical wri- 
 ters into several kinds ; viz. incised, punc- 
 tured, contused, lacerated, poisoned, and gun- 
 shot wounds. They also make another equal- 
 ly important, division into Wounds of the 
 Head, Thorax, Abdomen, fyc. 
 
 Of gunshot wounds, and wounds of the 
 bead, an account has already been given. 
 (See Gunshot Wounds, and Head, Injuries 
 of.) The other cases I shall now proceed to 
 consider. 
 
 Incised Wounds. As a general observa- 
 tion, it may be stated, that, center is paribus, a 
 wound, which is made with a sharp cutting 
 
 instrument, which is, in short, a mere inci 
 sion, is attended with less hazard of danger- 
 ous consequences, than any other kind of 
 wound whatever. The fibres have only been 
 simply divided ; they have suffered no con- 
 tusion nor laceration ; consequently, they 
 are less likely to inflame severely, or to sup- 
 purate, or slough ; and they commonly ad- 
 mit of being united again in a very expedb 
 tious manner. 
 
 Generally simple incised wounds bleed 
 more freely, then contused and lacerated 
 ones, which at first sometimes scarcely pour 
 out any blood at all, although considerable 
 blood-vessels may be injured. But this cir- 
 cumstance, apparently diminishing the dan- 
 ger of contused and ' lacerated wounds, is 
 deceitful, and serves rather to render the 
 case in reality more perilous, by inducing 
 the inexperienced practitioner to be off his 
 guard against hemorrhage. Thus, in gun- 
 shot wounds, it often happens, that on their 
 first occurrence, the bleeding is trivial ; but 
 the side of some large artery having suffer- 
 ed great violence at the time of the accident, 
 it may ulcerate or siough, a week or ten days 
 afterward, and an alarming and even fatal 
 effusion of blood be the result. 
 
 In cases of simple incised wounds, the 
 bleeding which at onre takes place from all 
 the divided vessels, is a source of very use- 
 ful information to the surgeon, inasmuch as 
 it enables him to judge, what danger is to 
 be apprehended from the hemorrhage, whe- 
 ther the cut vessels are large enough to de- 
 mand the ligature, or, on the contrary, whe- 
 ther they are such as will cease to bleed, 
 either by slight pressure, or of their own 
 accord. 
 
 In a recent simple incised wound, ihere 
 are three objects which the surgeon should 
 endeavour to accomplish, without the least 
 delay. The first, and that which requires 
 his immediate interference, is the bleeding, 
 which must be checked. The sbeond is 
 the removal of all extraneous matter from 
 the surface of the wound. The third is 
 the reunion of the opposite sides of the 
 injury. 
 
 When the divided vessels are not above a 
 certain size, the bleeding soon spontaneous- 
 ly ceases, and no surgical measures need be 
 taken on this particular account. When the 
 wounded vessels are even - somewhat larger, 
 and their situation is favourable for com- 
 pression with a bandage, it is often ndvisea- 
 ble to close the wound and apply compresses 
 and a roller, rather than have recourse to 
 ligatures, which always create a certain de- 
 gree of irritation and suppuration. However, 
 though l have made this observation, I 
 should be exceedingly sorry to appear at all 
 against the general preference lo ligatures, 
 whenever the wounded arteries are above a 
 certain .magnitude. In this circumstance, 
 tying the bleeding vessels is the only safe 
 mode of proceeding. When the artery is ot 
 considerable size, and its mouth can be 
 readily seen, the most proper instrument for 
 taking hold of it is a pair of forceps. In 
 applying the ligature, the surgeon must take 
 
WOUNDS. 639 
 
 care lo puli its cuds in such a manner, that 
 the noose will not rise above the mouth of 
 the vessel, and for the purpose of altering 
 the direction of the force employed in 
 tightening the ligature, the ends of the 
 thumbs are generally made use of. The 
 tenaculum is commonly employed for ta- 
 king up arteries, which are not large and 
 distinct. 
 
 Very fine ligatures, of sufficient strength, 
 are at present often applied, as \vell to large 
 as small vessels. One half of each ligature 
 should always be cut off, before the wound 
 is closed, and there are some surgeons, who 
 prefer the method of cutting off’ all the liga- 
 ture, except what forms the noose immedi- 
 ately round the artery. (Delpech, M6m . sur la 
 Pourriture d' Hdpital, p. 29; Lawrence in Med. 
 Chir. Trans. Vol. 6, p. 156.) To the latter 
 plan, however, a lew surgeons have addu- 
 ced objections, particularly Mr. Guthrie, 
 who only admits the utility of it in cases 
 where the wound will not unite by the 
 first intention; ( On Gunshot Wounds, 4 p. 
 94.) and Mr. Cross, of Norwich. (Bee the 
 London Medical Repository , Vol. 7, p. 353.) 
 The experiments of Mr. Cross lend to the 
 following conclusions : 
 
 First, If the wounds do not unite by the 
 first intention, the ligatures may escape with 
 the discharge, without any inconvenience. 
 
 Secondly, If common ligatures of twine 
 are cut short, the wound may unite over 
 them, and they may be found in abscesses 
 after an interval of many weeks. 
 
 Thirdly, If the finest dentist’s silk be em- 
 ployed in the same way, and the wound 
 unite over it, the ligature may be detached 
 from the vessel, and remain buried in an ab- 
 scess, where it will be found at different pe- 
 riods, from one to seven months; and this 
 may happen, whether the vessel be firmly 
 compressed with a single ligature, or divided 
 between two ligatures, so as to imitate the 
 circumstances under which vessels are tied 
 after operations. 
 
 Fourthly, If Indian silk, fine as hair, be 
 put round a vessel so as to diminish its dia- 
 meter, or to effect its obliteration, by just 
 compressing its sides together, it may remain 
 in this situation, without exciting abscess, or 
 producing any inconvenience. The ligature 
 may be thus applied to compress an artery 
 for the cure of aneurism ; but not to secure 
 vessels divided in operations. If a thin liga- 
 ture be drawn sufficiently tight upon a ves- 
 sel on the face of a stump to be secure, Mr. 
 Cross is persuaded, that the extremity of the 
 vessel which becomes insulated, as it were, 
 must die. (See Lond. Med. Reposit. Vol. .7, pi 
 363.) Jt deserves attention, that the preced- 
 ing inferences are chiefly founded on experi- 
 ments mode upon asses and dogs. For fur- 
 ther observations, s oo. Aneurism, Hemorrhage, 
 Ligature, Surgery, 4"C. 
 
 The bleeding having been suppressed, the 
 next object is to remove any extraneous 
 matter, such as dirt, bits of glass, clots of 
 blood. &.c. from the surface of the wound. 
 Were this circumstance neglected, the plan 
 o f uniting the opposite sides of the cut by 
 
 the adhesive inflammation, or by wbat is 
 more frequently termed, union by the first in - 
 tention, would in general be frustrated. 
 
 As soon as attention has been paid to the 
 foregoing indications, the surgeon must put 
 the lips of the wound in contact, and take 
 measures for keeping them in this state, 
 until they have grown firmly together. The 
 sides of incised wounds are kept in a state 
 of apposition by means of adhesive plaster, 
 a proper position, the pressure of a roller, 
 and in a few particular instances, by the em- 
 ployment cf sutures. 
 
 With respect to sutures, as they create 
 pain, irritation, and some degree of suppu- 
 ration, they ought never to be employed 
 when the parts can be kept in contact with- 
 out them. However, certain cases require 
 them, and it is admitted by many experienced 
 surgeons, that in sabre-wounds of the ears, 
 eyelids, nose, and lips, it is proper to use 
 them. (See Assalini's Manuale di Chir, 
 Parte Seconda, p. 10.) An account of the 
 several kinds of sutures, with remarks on 
 their employment, will be found in the arti- 
 cle Sutures. 
 
 The best and most common method of 
 keeping the surfaces of divided parts in con- 
 tact is by means of strips of adhesive plaster. 
 When they are to be applied, the surgeon 
 should pul the wounded limb or parts in the 
 position, which is most favourable to bring- 
 ing the lips of the wound together. With this 
 view, a position should generally be chosen 
 which relaxes the skin and subjacent mus- 
 cles. An assistant should tiien place the 
 edges of the wound as evenly together as 
 possible, and hold them in this state, until 
 the surgeon has secured them in this condi 
 tion by strips of adhesive plaster, applied 
 across the line of the wound. In general.it 
 is deemed adviseable to leave a small inter- 
 space of about a quarter of an inch between 
 each two strips of plaster, by which 
 means the matter cannot be confined in case 
 of suppuration. Over these first strips, lint is 
 to be applied, and kept in its place with 
 oilier pieces of adhesive plaster. Then, if 
 necessary, a pledget and compresses are to be 
 put on the part, and, lastly, the bandage, or 
 roller is to be applied. 
 
 In this manner, the fresh-cut surfaces are 
 brought into contact, and to preserve them 
 quietly in this state, is the next great aim 
 which the surgeon should have in view. 
 The wounded part should be laid in the pos 
 lure which was found the most favourable 
 for approximating the sides of the cut at the 
 time of applying the dressings, and the patient 
 should be directed to keen the part in a per 
 fectly quiet state. 
 
 When attention is paid to these circuit 
 stances, it often happens that the two oppo 
 site surfaces of the wound grow together 
 again in the course of forty-eight hours, 
 without any degree of suppuration. The 
 process by which this desirable event is ac- 
 complished, is well known among surgeons, 
 by the name of union by the first intention. 
 Besides the advantage of the cure bein'-- 
 effected in this way with the greatest exn <?■ 
 
WOUND# 
 
 t349 
 
 dition possible, there is still another thing 
 much in favour of constantly promoting this 
 method of healing wounds, which is, that 
 the scar is much less than after any other 
 mode of cicatrization, and the part is cover- 
 ed with original skin, which is always much 
 stronger than any which can be formed as a 
 substitute for it. 
 
 It is wonderful with what celerity union 
 by the first intention takes place under 
 favourable circumstances. In the course 
 of three days, the large wound made in the 
 operation of amputation, is frequently all 
 healed, except just where the ligatures are 
 Situated. 
 
 When the two sides of the wound have 
 been brought together, before the oozing of 
 blood has entirely ceased, Mr. Hunter con- 
 ceives that blood itself becomes the first 
 bond of union ; but on this point, Professor 
 Thomson, of Edinburgh, entertains a doubt ; 
 and all practical surgeons agree, that the 
 lodgment of blood on the surface of a 
 wound, is more likely to prevent than pro- 
 mote. the union of the parts. In all com- 
 mon instances, what Mr. Hunter calls the 
 adhesive inflammation takes place. In this 
 process, coagulating lymph either issues 
 from the half closed mouths of the vessels, 
 or from the surface of the opened cells of the 
 cellular substance. This becomes the first 
 uniting medium, and very soon afterward, in 
 some inexplicable manner, a vascular inter- 
 course is established between the opposite 
 sides of the wound. 
 
 The power which parts of the animal 
 body have, of thus growing together, is stri- 
 kingly evinced by the possibility of remo- 
 ving a part of one body, and then uniting it 
 to some part of another. In this latter case 
 there can be no assistance given to the 
 union on one side, since the detached part, 
 as Mr. Hunter observes, can hardly do more 
 than just preserve its own living principle, 
 and accept of union. In this way, says the 
 same writer, the spurs of the young cock 
 can be made to grow on his comb, or on 
 that of another cock ; and its testicles, 
 after having been removed, may be made 
 to unite to the inside of any cavity of an 
 animal. 
 
 Every one initiated in surgery has heard 
 of the feats of Taliacotius, Garengeot, and 
 others, who are said to have succeeded in 
 effecting the union of parts, which were 
 completely severed from the body. Several 
 other not less extraordinary performances by 
 modern surgeons are recorded. (See Obser- 
 7 : aliom on Adhesion, with two Cases , demon - 
 slralive of the Powers of Nature to reunite 
 parts, which have been by accident totally sepa- 
 rated from the animal System, by fVm. Bal- 
 four , S vo. Edinb. 1814.) Indeed the well- 
 known practice of transplanting the teeth, 
 the experiments of Duhamel and Hunter; 
 and the number and respectable character of 
 the testimonies upon this subject, fully con- 
 vince me of the occasional success, which 
 may attend the endeavour to bring about 
 such an union. Experience also fully proves 
 *he frequent success which attends an en- 
 
 deavour to unite a part, which retains only 
 the slight connexion of a small piece of flesh, 
 or even a tew fibres. My friend, Mr. Lav;- 
 rence, lately had a case which illustrates the 
 truth of this statement. A man on the top 
 of a stage-coach, was carried underagateway 
 which did not leave sufficient room for him 
 to pass without injury, and bis head was so 
 much wounded, that one of his ears was entire- 
 ly separated, with the exception of an attach- 
 ment by a trivial piece of integuments. 
 Mr. Lawrence assented to the man’s wish of 
 not having the separation completed, and 
 fixed the part in its situation with a few su j 
 tures. The consequence was that the ear 
 soon united again, and the patient escaped 
 all disfigurement. Of the knowledge of the 
 disposition of living cut surfaces to grow 
 together with considerable expedition, sur- 
 geons, both of ancient and modern times, 
 have availed themselves not only in the 
 treatment of accidental wounds, but also in 
 the removal of deformity, as exemplified in 
 the cure of fissures in the palate or lips, (see 
 Harelip ,) but most particularly in the curi- 
 ous and interesting art of forming new 
 under-lips and noses, and closing largo defi- 
 ciences in the urethra with flaps of flesh, 
 raised from the adjacent parts, shaped ac- 
 cording to circumstances, and laid directly 
 down upon a fresh-cut surface purposely- 
 prepared, where it is steadily confined for a 
 certain time with sutures, or simple adhesive 
 plaster and pressure, as the nature of the 
 case may indicate. Nay, sometimes, the 
 flesh for the formation of the organ to be 
 restored has even been taken from a distant 
 part, as for instance, from the arm for the 
 restoration of parts of the face. When this 
 was done, the limb was confined in close 
 contact with the raw surface formed on the 
 face, until a union between them had been 
 effected ; a division was now performed 
 with the scalpel, and the opportunity taken 
 to shape the portion of the limb which was 
 to be left behind, according as the part to be 
 restored might he the ear, nose, or lip. At 
 the present day, the flesh is usually taken 
 from the adjacent parts; a connexion of 
 the flap with the rest of the body is retained, 
 so as to ensure some circulation of blood in 
 it, and it is turned into any position which 
 the circumstances may demand. (See Gas- 
 par Taliacotius , Chirurgia Nova de Narium , 
 Aurium, Labiorumque Defectu,per insilionem 
 cutis ex humero sarciendo, fye. 8 vo. Francof. 
 1598. J. C. Carpue, an Account of Two 
 successful Operations for restoring a lost Nose 
 from the Integuments of the Forehead, 4to. 
 Lond. 1816. Giuseppe Baronio, Degli Inncsti 
 Animali, 8 vo. Milan. C. F. Graefe, De Rhi~ 
 noplastice, site Arte curtum Nasum ad Vivum 
 restituendi, cemmentaiio , quA prisca illius ratio 
 iterum experimenlis illustratur novisque me- 
 thodis ad majorem pcrfeclionem perducilur , 
 4/o. Berol. 1818. Sir A. Cooper, on Unnatural 
 Apertures in the Urethra; Surgical Essays, Part 
 2. H. Earle, on the Re-establishment of a Canal 
 in the place of a portion of the Urethra, in Phil. 
 Trans, for 1821. A Case of restored Nose, by 
 Mr. C. Hutchison. A Case of artificial Anus 
 
WOUNDS. 
 
 o*U 
 
 cured by U. F. Collier, in Med. and Physical 
 Journ. for June, 1820. 
 
 Mr. John Bell describes the process of 
 adhesion to be this : either the arteries of 
 the opposite surfaces inosculate mouth to 
 mouth, orjrather each cut-surface throws out 
 a gluten ; the gluten fills up the intermediate 
 space ; into that gluten the lesser arteries 
 of each cut-surface extend themselves, and 
 it is thus, perhaps, by the generation of a 
 new intermediate substance, that the con- 
 tinuity and entireness of the part are so 
 quickly restored. If any one point fail to 
 adhere, there the wound must run into 
 suppuration ; because, says Mr. J. Bell, at 
 that point there is a separation of parts, 
 which is equivalent to a loss of substance. 
 
 The same writer observes, that there are, 
 no doubt, accidents, both of the constitution 
 and the wound, which will prevent adhesion. 
 If the patient be of a bad habit of body ; if 
 he be lying in afoul hospital, in the midst of 
 putrid sores, and breathing a contagious air ; 
 if he be ill of a fever, or flux, or any general 
 disease ; then the properties of the body 
 being less perfect, the wound will not ad- 
 here. Mr. J. Bell also notices, that, if the 
 wound be foul, made with a poisoned 
 weapon, or left with foreign bodies lodged 
 in it ; or if a considerable quantity of blood 
 be poured out into the cavity of the wound, 
 or if there be a wounded lymphatic, or a 
 wounded salivary duct, a. wounded intestine, 
 or a bleeding artery or vein, the immediate 
 adhesion of the whole of the wound may be 
 prevented. However, I cannot help re- 
 marking, that, though Mr. John Bell, in 
 imitation of most surgical writers, sets do wn 
 the wound of a lymphatic as preventive of 
 the union of w ounds, I eannot say, that I 
 ever saw such an effect imputable to the 
 cause just mentioned. Also, when an artery 
 or vein is cut, and requires to be tied, the 
 adhesion of the wound would be prevented 
 only just wdiere the ligature lies, and at no 
 other point. 
 
 There is no wound, observes Mr. John 
 Bell, in wdiich we may not try with perfect 
 safety to procure this adhesion ; for nothing 
 can agree better with one surface of the 
 wound, than the opposite one, which has 
 been just separated from it. They may 
 immediately adhere together, and even if 
 they should not do so, no harm is done, and 
 the wound will yet suppurate as favourably, 
 as if it had been roughly dressed with dry 
 caddis, or some vulnerary balsam, or acrid 
 ointment. If one part should suppurate, 
 while one half adheres, then, says Mr. John 
 Bell, one half of our business is done. In 
 short, this simple duty of immediately 
 closing a wound is both natural and safe. 
 (Discourses an the Nature and Cure of Wounds , 
 Vol. 1.) 
 
 Upon this interesting topic of the advan- 
 tages of union by the first intention, the 
 most enlightened surgeons of all Europe 
 now begin to entertain only one opinion. 
 The practice is generally adopted both in 
 the treatment of accidental cuts, and of the 
 wou,nds resulting from surgical operations. 
 
 Vol.IL * 81 
 
 Thus Assalini, one of the best modern sur 
 geons in Italy, begins his Manual of Surgery 
 with the following axiom : “ Wounds and 
 injuries of the soft parts, produced by cut- 
 ting instruments, from the trilling wouq^jf 
 a vein, made for the purpose of discharging 
 a few ounces of blood, to the incision in the 
 uterus for the extraction of the foetus, inclu- 
 sively, should all be united by the first inten- 
 tion. (See Manual e di Chirurgia ; Discorso 
 Primo. Milano , 1812.) 
 
 British surgeons have, indeed, been ac- 
 cused by M. Roux of indiscriminate par- 
 tiality to the plan of uniting all incised 
 wounds by the first intention, and his coun- 
 tryman Baron Larrey has wished the me- 
 thod to be discontinued after amputation, in 
 order (as he states) to lessen the chance of 
 tetanus. But the exceptions which these 
 surgeons wish to make, are few T , and few as 
 they are, they are not likely to be establish- 
 ed, since several of the circumstances, al- 
 leged as reasons for limiting so beneficial 
 a practice, are hypothetical, and far from 
 being clearly proved. (See Roux , Mtmoire 
 el Obs. sur la Reunion immediate de la Plaie 
 apr&s V Amputation circulaire des Membres, 
 8t •£>. Paris, 1814. Larrey, M6m. de Chir. Mil- 
 Tome 4, 8 to. 1812—17.) 
 
 Sometimes the attempt to procure union 
 by the first intention fails, even in cases of 
 incised wounds : but, in this circumstance, 
 no harm arises from the kind of practice 
 which has beeirfollowed. The case, in fact, 
 now falls into nearly the same state, as 
 would have occurred, had no attempt at 
 union been made at all. The patient has 
 taken the chance of a quicker mode of cure ; 
 but he has not been successful, and he must 
 now be cured by a process, w hich on ac- 
 count of its slowness he at first wished to 
 avoid. It is to be observed also, that union 
 by the first intention, if not spoiled by sutures, 
 rarely fails so completely, that there is not 
 a partial adhesion of some points of the 
 wound. The moment when we observe 
 pain, inflammation, and swelling of the 
 wound, a separation or gaping of its lips, the 
 stitches tense (when these have been used,) 
 and the points where the stitches pass parti- 
 cularly inflamed, Mr. John Bell advises us 
 to undo the bandages, draw out the sutures, 
 and take away every thing, w^hich acts like 
 a stricture on the w'ound. These prudent 
 measures, he observes, may abate the rising 
 inflammation, and prevent the total separa- 
 tion of the skin, while an endeavour may 
 still be made to keep the edges of the 
 wound tolerably near each other by the 
 more gentle operation of sticking-plasters. 
 
 However, when the inflammation rises 
 still higher, and it is evident, that a total 
 separation of the sides of the wound cannot 
 be avoided, Mr. John Bell wisely recom- 
 mends leaving the parts quite loose, and ap- 
 plying a large soft poultice ; for, says he, 
 should you in this critical juncture, persist in 
 keeping the parts together with sutures, the 
 inflammation, in the form oferysipelas, would 
 extend over the whole limb, attended with a 
 fetid and bloody suppuration the 
 
WOlviND.S. 
 
 u.4-2 
 
 \vound has been brought into a favourable 
 state, '•another attempt may be made to 
 bring the edges near each other, not with 
 sdfltres, but strips of adhesive plaster, or the 
 gentle application of a bandage. 
 
 Mr. John Bell concludes with remarking, 
 that the suppuration, production of granula- 
 tions, and all that follows, are the work of 
 nature. The only thing that the surgeon 
 can usefully do, is to take care of the health. 
 When the wound does not suppurate favour- 
 ably, the discharge generally becomes pro- 
 fuse, thin, and gleety. This state is to be 
 amended by bark, wine, rich diet, and good 
 air. 
 
 1 shall conclude this subject of union by 
 the first intention, with an extract from 
 the writings of Mr. Hunter, who observes, 
 that 
 
 et It is with a view to this principle of 
 union, that it has been recommended to 
 bring the sides (or lips) of wonnds together ; 
 but, as the natural elasticity of the parts 
 makes them recede, it has been found ne- 
 cessary to employ art for that purpose. This 
 necessity first suggested the practice of sew- 
 ing wounds, and afterward gave rise to va- 
 rious inventions in order to answer this end, 
 such as bandages, sticking-plasters, and liga- 
 tures. Among these, the bandage common- 
 ly called the uniting bandage is preferable to 
 all the rest, where it can be employed ; but 
 its application is very confined, from being 
 only adapted to parts w T here a roller can be 
 used. A piece of sticking-plaster, which has 
 been called the dry suture, is more general 
 in its application than the uniting bandage, 
 and is therefore preferable to it on many oc- 
 casions. 
 
 “ I can hardly suppose (says Mr. Hunter,) 
 a wound, in any situation, where it may not 
 be applied, excepting penetrating wounds, 
 where we wish the inner portion of the 
 wound to be closed equally with the outer, 
 as in the case of hare-lip. But even in such 
 wounds, if the parts are thick, and the wound 
 not large, the sides will seldom recede so 
 far as to make any other means necessary. 
 The dry suture has an advantage overstitches 
 by bringing a larger surface of the wound to- 
 gether, by not inflaming the parts to which 
 it is applied, and by neither producing in 
 them suppuration nor ulceration, which 
 stitches always do. When parts, therefore, 
 can be brought together, and especially 
 where some force is required for that purpose, 
 from the skin not being in large quantity, 
 the sticking-plaster is certainly the best ap- 
 plication. This happens frequently to be 
 the case after the removal of tumours, in 
 amputation, or where the sides of the wound 
 are only to be brought together at one end, 
 as in the hare-lip ; and I think the difference 
 between Mr. Sharp’s cross-stitch, after ampu- 
 lion, as recommended in his Critical Inquiry, 
 and Mr. Allanson’s practice, shows strongly 
 he superiority of the sticking-plaster (or dry 
 suture,) In those parts of the body where 
 t.ue skin recedes more than in others, this 
 ''routine nt becomes most necessary ; and as 
 !*><• y-*vlp probably recedes as little a-s rtu.y, *t 
 
 is therefore seldom iieceasary to app^y any 
 thing in wounds of that part ; the practice 
 will certainly answer best in superficial 
 wounds, because the bottom is in these more 
 within its influence. 
 
 “ The sticking-plasters should be laid on 
 in strips, and these should be at small dis- 
 tances from each other, viz. about a quarter 
 of an inch at most, if the part requires close 
 confinement ; but when it does not, they 
 may be at greater distances. This precaution 
 becomes more necessary if the bleeding is 
 not quite stopped ; there should be passages 
 left for the exit of blood, as its accumula- 
 tion might prevent the union, although this 
 does not always happen. If any extraneous 
 body, such as a ligature, should have been 
 left in the wound, suppuration will take 
 place, and the matter should be allowed to 
 vent at some of these openings, or spaces, 
 between the slips of plaster. 1 have known 
 a very considerable abscess formed in con - 
 sequence of this precaution being neglected, 
 by which the whole of the recently united 
 parts has been separated. 
 
 “ The interrupted suture, which has gene- 
 rally been recommended in large wounds, 
 is still in use, but seldom proves equal to 
 the intention. This we may reckon to be 
 the only one that deserves the name of su- 
 ture ; it was formerly used, but is now in a 
 great measure laid aside in practice, not 
 from (he impropriety of uniting parts by 
 this process, but from the ineffectual mode 
 of attempting it. In what manner better 
 methods could be contrived^ 1 have not been 
 able to suggest. It is to be understood, that 
 the above methods ofsbringing wounded 
 parts together, in order to unite them, are 
 only to be put in practice in such cases as 
 will admit of it} for if there was a method 
 known, which in all cases would bring the 
 wounded surfaces into contact, it would, in 
 many instances, be improper, as some 
 wounds are attended with contusion, by 
 which the parts have been more or less 
 deadened ; in such cases, as was formerly 
 observed, union ^cannot take place accord- 
 ing to our first principle, and therefore it is 
 improper to attempt it. 
 
 “In many wounds, which are not attend- 
 ed willi contusion, when we either know, 
 or suspect, that extraneous bodies have been 
 introduced into the wound, union by the 
 first intention should not be attempted, but 
 they should be allowed to suppurate, in or- 
 der that the extraneous matter may be ex- 
 pelled. Wounds which are attended with 
 laceration, although free from contusiou, 
 cannot always be united by the first inten- 
 tion, because it must frequently be impossi- 
 ble to bring the external parts, or skin, so 
 much in contact, as to prevent that inflam- 
 mation which is naturally produced by ex- 
 posure. But even in cases of simple lacera 
 tion, where the external influence is but 
 slight, or can be prevented (as we observed 
 in treating of the compound fracture,) we 
 find that union by the first intention often 
 takes place ; the blood, which fills up the 
 hiterstvw of the lacerated parts, having prf • 
 
WOfcJNliS 
 
 ■'vented the siiuiuius ot imperfection in them, 
 and prevented suppuration, muy afterward 
 be absorbed. 
 
 te Many operations may be so performed 
 as to admit of parts uniting by the first in* 
 tention ; but the practice should be adopted 
 with great circumspection : the mode of 
 operating with that view, should in all cases 
 be a secondary, and not a first considera- 
 tion, which it has unluckily been too often 
 among surgeons. In cases of cancer, it is 
 a most dangerous attempt at refinement in 
 surgery. 
 
 “ In the union of wounded parts by the 
 first intention, it is hardly or never possible 
 to bring them so close together at the expo- 
 sed edges, as to unite them perfectly by 
 these means; such edges are therefore 
 obliged to take another method of heuiing. 
 If kept moist, they will inflame as deep be- 
 tween the cut surfaces as the blood fails in 
 the union, and there suppurate and granu- 
 late ; but if the blood be allowed to dry and 
 form a scab between, and along the cut 
 edges, then inflammation and suppuration 
 of those edges will be prevented, and (his 
 \vill complete the union, as will be descri- 
 bed by and by. 
 
 “ As those effects of accidental injury, 
 which can be cured by the first inteution, 
 call up none of the powers of the constitu- 
 tion to assist in the reparation, it is not the 
 least affected or disturbed by them ; the 
 parts are united by the extravasated blood 
 alone, which was thrown out by the injury, 
 either from the divided vessels, or in conse- 
 quence of inflammation, without a single 
 action taking place, even in the part itself, 
 except the closing or inosculation of the 
 vessels : for the flowing of the blood is to 
 be considered as entirely mechanical. Even 
 in cases where a small degree of inflamma- 
 tion comes on, it is merely a local action, 
 and so inconsiderable, that the constitution 
 is not affected by it ; because it is an opera- 
 tion, to which the powers belonging to the 
 parts themselves are fully equal. The in- 
 flammation may produce a small degree of 
 pain, but the operation of union gives no 
 sensation of any kind whatever.’ 1 ( Hunter 
 on the Blood , Inflammation, and Gunshot 
 Wounds .) 
 
 Contused and Lacerated Wounds. — Lace- 
 rated wounds are those, in which the fibres, 
 instead of being divided by a cutting instru- 
 ment, have been torn asunder by some vio- 
 lence, capable of overcoming their force of 
 adhesion. The edges of such wounds, in- 
 stead of being straight and regular, are jag- 
 ged and unequal. 
 
 The term contused is applied to those 
 wounds which are occasioned by some blunt 
 instrument, or surface, which has violently 
 struck a part of the body. 
 
 These two species of wounds greatly re- 
 semble each other, and astheyrequire nearly 
 the same kind of treatment, writers usually 
 treat of them together. 
 
 Lacerated and contused wounds differ 
 from simple incised ones, in appearing, at 
 first view, much less alarming than the tat- 
 
 bd3 
 
 ter, while, in reality, they are infinitely 
 more dangerous. In simple cut wounds, the 
 retraction of the parts, and the hemorrhage, 
 are generally much more considerable than 
 in a lacerated wound of the same size. 
 However, notwithstanding these circum 
 stances, they commonly admit of being 
 healed with far greater ease. It is worthy 
 of particular notice, that lacerated and con- 
 tused wounds are not in general attended 
 with any serious effusion of blood, even 
 though large blood-vessels may be injured. 
 
 I say in general, because in the year 1813, 
 
 I saw a soldier, whose death was occasioned 
 by a sudden effusion of a very large quan- 
 tity of blood from the internal jugular vein, 
 which vessel had been injured by a muskel- 
 ba.Il, that first entered the integuments be- 
 hind the mastoid process, and passed ob- 
 liquely downwards and forwards towards 
 the sternum. The blood did not issue ex- 
 ternally; but formed betwixt the integu- 
 ments and the trachea, a large dark-coloured 
 swelling, which produced almost immediate 
 suffocation. At the memorable siege of 
 Saragossa, Professor Assalini saw a surgeon 
 whose left carotid artery had been injured 
 by a musket-bail, perish of hemorrhage in 
 a few seconds. (See Assalini’s Manuale di 
 Chirurgia, p. 32, Milano, 1812.) 
 
 In most cases, however, there is little or 
 no hemorrhage from lacerated and contused 
 wounds, and it is a circumstance, which 
 often leads inexperienced practitioners to 
 commit great mistakes, by inducing them 
 to promise too much in the prognosis which 
 they make. Surgeons versed in practice, 
 however, do not allow themselves to be de- 
 ceived by the absence of hemorrhage, and, 
 in proportion as there is little bleeding, they 
 apprehend that the violence done to the 
 fibres and vessels has been considerable. 
 What is it, but the contused and lacerated 
 nature of the wound, that prevents hemor 
 rhage from the umbilical arteries, u'hen ani 
 mals divide the navel-string with their teeth ? 
 Whole limbs have frequently been torn from 
 the body, without any hemorrhage of con- 
 sequence taking place. 
 
 In the Phil. Trans. Cheselden has recorded 
 a very remarkable case, in which a man’s 
 arm was suddenly torn from his body. 
 Samuel Wood, a miller, had round his arm 
 a rope, which got entangled with the wheel 
 of the mill. He was lifted off the ground, 
 and then stopped by a beam, which pre 
 vented his trunk from passing further ; at 
 this instant, the wheel, which was moving 
 with immense force, completely tore, and 
 carried away, his arm and scapula from his 
 body. The appearance of a wound, occa- 
 sioned in this manner, must of course be 
 horrible, and the first idea, thence arising, 
 must naturally be that the patient cannot 
 possibly survive. Samuel Wood, however, 
 escaped with his life. The limb had been 
 torn off with such velocity, that he was un- 
 aware of the accident, till he saw his arm 
 moving round on the wheel. He immedi- 
 ately descended by a narrow ladder from 
 the mill, and even walked some pacers, with 
 
WOUNDS. 
 
 I >tt d 
 
 a view of seeking assistance. He now fell 
 ^lowii from weakness. The persons who 
 first came to his assistance, covered the 
 wound with powdered sugar. A surgeon, 
 \vno afterward arrived, observing that there 
 was no hemorrhage, was content with 
 bringing down the skin, which was very 
 loose, so as to make it cover the surface of 
 the wound. For this purpose he used two 
 cross stitches. The patient was conveyed 
 the next day to St. Thomas’s Hospital, and 
 put under the care of Mr. Fern. This prac- 
 titioner employed the usual means for pre- 
 venting the bad symptoms most to be ex- 
 pected in this sort of case. The first dress- 
 ings came away without any bleeding; no 
 alarming consequences ensued ; and the 
 patient, in two months, completely reco- 
 vered. 
 
 When the arm was examined, it was 
 found, that the muscles, inserted into the 
 scapula, were torn through near their inser- 
 tions ; while other muscles, arising from 
 this bone, were carried away w ith it. The 
 skin, covering the scapula, had remained in 
 its natural situation, and seemed as if it had 
 been divided precisely at the insertion of 
 the deltoid muscle. 
 
 In La Motte’s Trait6 des Accouchemtns, 
 may be found an account of a little boy, 
 who, while playing near the wheel of a 
 mill, got his hand, fore-arm, and arm, suc- 
 cessively entangled in the machinery, and 
 the limb was violently torn away at the 
 shoulder joint, in consequence of the lad’s 
 body not being able to pass in the direction 
 Id which the arm w as drawn. The bleed- 
 ing was so trivial, that it was stopped with 
 a Tittle lint, and tiie boy very soon reco- 
 vered. 
 
 In the fifth vol. of the Edinb. Med. Com- 
 mentaries, may also be perused the history 
 of a child, three years and a half old, whose 
 arm was torn off by the wheel of a mill. 
 Mr. Carmichael, who saw the child about 
 an hour after the accident, found it almost 
 in a dying state, with cold extremities, small 
 faltering pulse, and all the right side of the 
 body convulsed. However, there was 
 hardly any bleeding. The arm was broken 
 about an inch and a half above the elbow ; 
 the stump had a dreadful appearance ; all 
 the soft parts were in a contused and lace- 
 rated stale, and the humerus was laid bare 
 as high as the articulation, which was itself 
 exposed. The skin and muscles were lace- 
 rated to a much greater extent, and in dif- 
 ferent directions. The remainder of the 
 humerus was removed from the shoulder- 
 joint by amputation, only as much skin and 
 tnuscle being left as was sufficient to cover 
 the wound. In two months the child was 
 well. 
 
 In the M6m. de VAtad. de Chir. T. 2, is 
 an account of a leg being torn away at 
 the knee-joint by a cart wheel. The pa- 
 tient was a boy, about nine or ten years of 
 age. This accident, like the foregoing ones, 
 was accompanied with no hemorrhage. 
 The lower portion of the os femoris, whieh 
 was exposed, was amputated, together with 
 
 such portion ot the soil parts, as was in a 
 contused and lacerated state. The patien; 
 experienced a perfect recovery. 
 
 The preceding cases strikingly confirm 
 the observation, which I have already made, 
 in regard to the little bleeding, which usu- 
 ally arises from contused and lacerated 
 wounds. 
 
 In these instances, the pain is also in an 
 inverse ratio to the cause of the accident; 
 it is generally very severe, when the wound 
 is only moderately contused : and, on the 
 other hand, the patient scarcely suffers any 
 pain at all, where there has been so violent 
 a degree of contusion, as at once to destroy 
 the organization of the part. 
 
 When the bruised fibres have not been 
 injured above a certain degree, the part 
 suppurates ; but such portions of the wound 
 as have suffered greater violence, inevitably 
 die, and are cast off in the form of sloughs. 
 Granulations are afterward formed, arid 
 the breach of continuity is repaired by the 
 process of cicatrization. (See this word.) 
 
 When a still greater degree of violence 
 has been done, and, especially, when arte- 
 ries of a certain magnitude have been in 
 jured, a mortification is too frequently the 
 consequence. However, if the constitution 
 be good, and the mischief not too extensive, 
 the case may still end well. But, in other 
 instances, the event is alarmingly dubious ; 
 for the mischief is then not limited to the 
 wounded parts, which have suffered the 
 greatest degree of contusion ; but, too fre- 
 quently, extends over such parts as were 
 not at all interested by the wound itself. 
 
 The mortification arising directly from the 
 impaired organization of parts, is not what 
 is the most alarming circumstance. A still 
 more dangerous kind of mortification, is that 
 which is apt to originate from the violent in- 
 flammation occasioned by the accident. This 
 consequence demands the utmost attention 
 on the part of the surgeon, who must let no 
 u«eful means be neglected, with a view of 
 diminishing the inflammation before it has 
 attained too high a degree, and very danger- 
 ous symptoms have commenced. In the 
 first instance, he should not be afraid of let- 
 ting the wound bleed a little, if it should be 
 disposed t:* do so. The ediies of the wound 
 should then be gently drawn towards each 
 other with a few strips of sticking-plaster, so 
 as to lessen the extent of the exposed sur- 
 face . hut no sutures are proper. Indeed, 
 the plan of diminishing the exposed surface 
 of a contused wound with strips of adhe- 
 sive plaster, is not invariably right ; because 
 their application creates a hurtiul degree ot 
 irritation. The method is chiefly advisenble 
 when there is a large loose flap of skin, 
 which can be conveniently brought over the 
 wound. In other cases, it is best to leave 
 the parts free, uncompressed, and unconfined 
 With any adhesive plaster, because if it were 
 applied its irritation would do barm, and 
 could not possibly procure any union of The 
 parts. Under the most favourable circum- 
 stances, hardly any part of the wound can 
 be expected to unite by the first intention 
 
WOUNDS. 
 
 Ine whole or the greater part of it will neces- 
 sarily suppurate, after the detachment of the 
 sloughs. The surface will then granulate, 
 new skin will be formed, and the part heal 
 just like a common wound. Perhaps, until 
 the sloughs separate, the best application is 
 a soft poultice, which should be put on 
 cold, lest it bring on too great an oozing of 
 blood. 
 
 Nothing, indeed, is so proper for checking 
 any tendency to hemorrhage as cold applica- 
 tions, which are also the most effectual in 
 preventing and diminishing the great degree 
 of inflammation, which is one of the most 
 dangerous consequences of this description 
 of wounds. 
 
 No surgical writer, I think, has given 
 more rational advice, respecting contused 
 wounds, than that published by Professor 
 Assalini. In general, says he, the treatment 
 of contused wounds, whether they be simple 
 and slight, or complicated and severe, re- 
 quires the active employment of debilitating 
 means in order to prevent inflammation. 
 Cold water, and ice ; and general and topi- 
 cal bleeding, are the things usually resorted 
 to with success. Vulnerary lotions, campho- 
 rated spirit, and other spirituous applications, 
 are improper, and if their pernicious effects 
 are not always very evident, it is only be- 
 cause the contused injuries have been trifling, 
 and in their nature perfectly easy of cure. In 
 these cases, as well as in those of extravasa- 
 tions and glandular swellings, Assalini gives 
 a preference to cold applications. The in- 
 ternal remedies and regimen, (says he) 
 should also be adapted to the condition of 
 the patient. A cannon-ball, at the end of 
 its course, may come into contact with a 
 limb, and fracture the bones, while the inte- 
 guments have the appearance of being unin- 
 jured. Such cases are often attended with 
 dreadful mischief in the soft parts around 
 the bone, which generally sphacelate. This 
 is an accident for which immediate amputa- 
 tion is mostly indispensable (see Gunshot 
 Wounds;) but if any thing be capable of pre- 
 venting inflammation and gangrene, it is an 
 active debilitating plan of treatment, assisted 
 with cold applications to the injured part. 
 In such cases, the internal and external use 
 of stimulants is approved of by many sur- 
 geons. But, Assalini prefers considering the 
 state of the injured limb, just like what it is 
 when affected with frost ; and he thinks that 
 the employment of stimulants will neces- 
 sarily produce the same effect as caloric 
 prematurely applied to parts deadened with 
 cold. On the contrary, from the outward 
 employment of ice and cold lotions in tb.ese 
 cases, and in contused injuries in general, he 
 has seen the greatest benefit derived. 
 
 Assalini conceives, that reason will be 
 found to support this practice. The opera- 
 tion of cold, he says, retards the course of 
 the blood, which meeting with only dama- 
 ged vessels, augments the extravasation as 
 it continues to flow. By lessening the tem- 
 perature of the part, cold applications like- 
 wise diminish the danger of inflammation 
 and sphacelus, at the same time that they 
 
 o4o 
 
 have the good effect Of rendering the suppu 
 ration, which must qnsue, less profuse, than 
 it would be, were not extravasation of blood, 
 and violence of the inflammation, lessened 
 by such applications, and a lowering plan of 
 treatment. 
 
 Why, says Assalini, should not this me- 
 thod, which is generally adopted to prevent 
 the effects of concussion of the brain after 
 blows on the head, be, for analogous reasons, 
 employed in examples of extravasation and 
 commotion in other parts of the body ? 
 
 ( Manuale de Chirurgia, Parte Prima t p 17.) 
 Cold applications, however, in cases of con- 
 tused wounds, are chiefly to be preferred, for 
 the first day or two, in order to check the 
 increase of extravasation and inflammation. 
 After this period, l give a decided preference 
 to an emollient linseed poultice, which will 
 be found the most easy dressing during those 
 processes, by which the slougii3 are detached, 
 the surface of the wound cleansed, and the 
 origin of granulations established. When 
 these changes have happened, the remaining 
 sore is to be treated on the same principles 
 as ulcers in general. See Ulcers. 
 
 Punctured Wounds. — A punctured wound 
 signifies one, made with a narrow-pointed 
 instrument, the external orifice of the injury 
 being small and contracted, instead of being 
 ofasize proportionate to its depth. A wound, 
 produced by a thrust of a sword, or bayonet, 
 affords us an example of a punctured wound. 
 
 Wounds of this description are in general 
 infinitely more dangerous than cuts, notwith- 
 standing the latter have the appearance of 
 being by far the most extensive. In cases 
 of stabs, the greatest degree of danger al- 
 ways depends on the injury, and rough vio- 
 lence which the fibres have suffered, in ad- 
 dition to their mere division. Many of the 
 disagreeable consequences are also to be 
 imputed to the considerable depth, to which 
 these wounds extend, whereby important 
 parts and organs are frequently injured. 
 Sometimes the 'treatment is rendered per- 
 plexing, by the difficulty of removing ex- 
 traneous substances, as forinstancea piece of 
 the weapon, which has been left in the 
 wound. Lastly, experience proves, that 
 punctured wounds and stabs are particularly 
 liable to be followed by a great deal of in- 
 flammation, fever, deep seated abscesses, si- 
 nuses, fee. 
 
 A strange notion seems to pervade the 
 writings of many systematic authors, that all 
 the danger and disagreeable consequences 
 of punctured wounds are entirely owing to 
 the narrowness of their orifices, which pre- 
 vents suitable applications from being made 
 to their bottom. Hence, it is absurdly re- 
 commended to dilate th* opening of every 
 slab, with the view, as is generally added, 
 of converting the accident into a simple inci- 
 sed wound. Some of these writers are advo- 
 cates for making the dilatation with a cutting 
 instrument, while others, with equal absurdi- 
 ty, propose to enlarge the opening with tents. 
 
 Certain authors regard a punctured 'wound, 
 as a recent sinus, and in order to make the 
 inner surfaces unite, they recommend ex- 
 
IYOUjSUs. 
 
 <>4i> 
 
 citing a degree of inflammation in them, 
 either l>y means of setons, or injections. 
 
 In the earliest edition of The First Lines of 
 the Practice of Surgery, I have taken parti- 
 cular pains to expose the folly and errors, 
 which prevail in most writings on this part 
 of practice. In the above work, I have re- 
 marked, that if the notion were true, that 
 an important punctured wound, such as the 
 stab of a bayonet, could be actually chan- 
 ged into a wound, partaking of the mild 
 nature of an incision, by the mere enlarge- 
 ment of its orifice, the corresponding prac- 
 tice would certainly be highly commenda- 
 ble, however painful. But the fact is other- 
 wise : the rough violence, done to the fibres 
 of the body by the generality of stabs, is 
 little likely to be suddenly removed by an 
 enlargement of the wound. Nor can the 
 distance, to which a punctured wound fre- 
 quently' penetrates, and the number and na- 
 ture of the parts injured by it, be at all 
 altered by such a proceeding. These, which 
 are the grand causes of the collections of 
 matter, that often take place in the cases 
 under consideration, must exist, whether the 
 mouth and canal of the wound be enlarged 
 or not. The time when incisions are pro- 
 per, is w’hen there are foreign bodies to be 
 removed, abscesses to be opened, or sinuses 
 to be divided. To make painful incisions 
 sooner than they can answer any end, is 
 both injudicious and hurtful. They are 
 sometimes rendered quite unnecessary, by 
 the union of the wound throughout its 
 whole extent, without any suppuration at 
 all. 
 
 Making a free ineision in the early stage 
 of these cases, undoubtedly seems a reasona- 
 ble method of preventing the formation of 
 sinuses, by preventing the confinement of 
 matter, and were sinuses an inevitable con- 
 sequence of all punctured wounds, for 
 which no incisions had been practised at the 
 moment of their occurrence, it would un- 
 doubtedly be unpardonable to omit them. 
 Fair, however, as this reason may appear, it 
 is only superficially plausible, and a small 
 degree of reflection soon discovers its want 
 of real solidity. Under what circumstances 
 do sinuses form ? Do they not form only 
 where there is some cause existing to pre- 
 vent the healing of an abscess ? This cause 
 may either be the indirect way, in which 
 the abscess communicates externally, so 
 that the pus does not readily escape ; or it 
 maybe the presence of some foreign body, 
 or carious bone ; or lastly, it may he an in- 
 disposition of the inner surface of the ab- 
 scess to form granulations, arising from its 
 long duration, but removable by laying the 
 cyst completely open to the influence of 
 the air. Thus it becomes manifest, that the 
 occurrence of suppuration in punctured 
 wounds is followed by sinuses only when 
 the surgeon neglects to procure a free issue 
 for the matter, after its accumulation ; or 
 when he neglects to remove any extraneous 
 bodies. But as dilating the wound at first 
 can only tend to augment the inflammation, 
 nnd render the suppuration more extensive. 
 
 it ought never to be practised in tnese casev. 
 except for the direct objects of giving free 
 exit to matter already collected, and of 
 being able to remove extraneous bodies 
 palpably lodged. I shall once more repeat, 
 that it is an erroneous idea to suppose the 
 narrowness of punctured wounds so princi- 
 pal a cause of the bad symptoms, with 
 which they are often attended, that the 
 treatment ought invariably to aim at its, re- 
 moval. 
 
 Recent punctured wounds have absurdly 
 had the same plan of treatment applied to 
 them as old and callous fistuhe. Setons and 
 stimulating injections, which in the latter 
 cases, sometimes act beneficially, by exci- 
 ting such inflammation as is productive of 
 the effusion of coagulating lymph, and of 
 the granulating process, never prove ser- 
 viceable when the indication is to moderate 
 an inflammation, which is too apt to rise to 
 an improper height. The counter-opening, 
 that must be formed in adopting the use oi 
 a seton, is also an objection. However, 
 what good can possibly arise from a setou 
 in these cases? Will it promote the dis- 
 charge of foreign bodies, if any are present : 
 By occupying the external openings of the 
 wound, will it not be more likely to prevent 
 it ? In fact, will it not itself act with all the 
 inconveniences and irritation of an extra- 
 neous substance in the wound ? Is it a likely 
 means of diminishing the immoderate pain, 
 swelling, and extensive suppuration, so often 
 attending punctured wounds ? It will un- 
 doubtedly prevent the external openings 
 from healing too soon ; but cannot this ob- 
 ject be effected in a better way? If the sur- 
 geon observes to insinuate a piece of lint 
 into the sinus, and pass a probe through its 
 track once a day, the danger of its closing 
 too soon will be removed. 
 
 The practice of enlarging punctured 
 wounds by incisions, and of introducing se- 
 tons, is often forbidden by the particular 
 situation of these injuries. 
 
 In the first stage of a punctured wound, 
 the indication is to guard against the attack 
 of violent inflammation. When no con- 
 siderable quantity of blood has been lost, 
 general and topical bleeding should be prac 
 tised. In short, the antiphlogistic plan is tu 
 be followed. As no man can pronounce, 
 whether such wounds will unite or not, and 
 as no harm can result from the attempt, the 
 orifice ought to be closed, and covered with 
 simple dressings. In such cases, cold appli- 
 cations are also highly commendable. Whe- 
 ther gentle compression might be made to 
 promote the adhesive inflammation or not, 
 may be doubtful : l confess, that I should 
 not haVe any reliance upon its usefulness. 
 Perfect quietude is to be observed. When 
 the pain is severe, opium is to be adminis- 
 tered. 
 
 Sometimes under this treatment, the sur 
 geon is agreeably surprised to find the con- 
 sequent inflammation mild, and the wound 
 speedily united by the first intention. u Nu- 
 merous are the examples ol wounds, which 
 penetrate the lapge ravifies. being healed by 
 

 wu 
 
 the iVrkt intention, tiial is, ui-tiiout any sup- 
 puration. Even wounds of the chest itself, 
 with injury of the lungs (continues an ex- 
 perienced military surgeon and professor,) 
 ought to be united by the first intention. 
 (Jlssalini, in Mnnuale di Chirurgia, parte 
 Scconda , p. 13.) More frequently, however, 
 in cases of deep stabs, the pain is intolera- 
 ble; and the inflammatory symptoms run 
 so high as to leave no hope of avoiding sup- 
 puration. In this condition, an emollient 
 poultice is the best local application ; and 
 when the matter is formed, the treatment is 
 like that of abscesses in general. See Sup- 
 puration. 
 
 Poisoned IVounds: Bite of ike Viper . — If 
 we exclude from present consideration the 
 bites of mad dogs, and other rabid animals, 
 which subject is fully treated ot in the ar- 
 ticle Hydrophobia, wounds of this descrip- 
 tion are not very eommon in these islands. 
 In dissections, pricks of the hand sometimes 
 occur, and they are in reality a species of 
 poisoned wound, frequently causing consi- 
 derable pain and irritation in the course of 
 the absorbents ; swelling and suppuration 
 of the lymphatic glands of the arm or axilla; 
 and severe fever and constitutional irrita- 
 tion. An instance of the fatal consequences 
 of such an injury must still be fresh in the 
 recollection of the profession ; and some 
 others of yet more reoent date have taken 
 place in this metropolis. (See London Me- 
 dical Repository, Vol. 7, p ■ 288.) 
 
 In many instances, however, surgeons 
 wound their fingers in dissecting bodies, 
 and no particular ill consequences ensue. 
 The healthy and robust are said to suffer 
 less frequently after such accidents, than 
 persons, whose constitutions have been 
 weakened by hard study, excesses, pleasure, 
 or previous disease. It is remarked, also, 
 that pricks of the lingers, met with in open- 
 ing the bodies of persons who have died of 
 contagious diseases, and where a virus or 
 infectious matter might be expected to exist 
 in such bodies, do not communicate the in- 
 fection. Doubtless (observes Richerand) 
 the activity of certain animal poisons, from 
 which the venereal and several other dis- 
 eases arise, is extinguished with life. (JVb- 
 sographie Chir. T. 1 ,p. 102, 103. Edit. 4.) 
 
 With regard to the treatment of the 
 pricks of dissecting scalpels, the surgeons of 
 the continent recommend the immediate 
 cauterization of the little wounds with a 
 grain of caust ic potassa, or the liquid muri- 
 ate of ammonia. Tonic remedies, particu- 
 larly wine, is prescribed, and great atten- 
 tion paid to emptying the bowels. 
 
 The stings of bees, wasps, and hornets, 
 are also poisoned wounds, though ^ftey are 
 .seldom important enough to require the 
 assistance of a surgeon. The hornet is not 
 found in Scotland; but it is an inhabitant of 
 several of the woods in England. Its sting, 
 which is more painful than that of a bee, 
 or wasp, is not, however, often the occa- 
 sion of any serious consequences. 1'he 
 stings of all these insects are attended with 
 a vhn-ro pain in the part, very muckly suc- 
 
 ceeded by an inflammatory swelling, which, 
 after a short time, generally subsides of it- 
 self. When the eye is stung, as sometimes 
 has happened, the e fleets may be very se- 
 vere, as is elsewhere noticed. (See Ophthal’ 
 my.) It has been lately observed, that the 
 pain of the stings of venomous insects, like 
 the bee, depends less upon the introduction 
 of the sting into the part, than upon that of 
 the venomous fluid. The experiments of 
 Professor Dumeril tend to prove, that when 
 the little poison bladder, situated at the 
 base of the sting, has been cut off, a wound 
 with the sting then produces no pain. The 
 poison flows from the vesicle through the 
 sting at the instant when this passes into the 
 flesh. The exact nature of this venomous 
 fluid is not known. When applied to mu- 
 cous surfaces, or even to the surface of the 
 conjunctiva of the eye, it causes no dis- 
 agreeable sensation ; but when it is intro- 
 duced into the skin, by means of a needle, 
 it immediately excites very acute pain. 
 
 Oil, honey, spirits of wine, the juice of 
 the plantain, and a variety of other local 
 applications, have been extolled as specifics 
 lor the relief of the stings of insects. Mo- 
 dern experience, however, does not sanc- 
 tion their claim to this character. In fact, 
 none of these applications either neutralize 
 the poison, or appease with superior efficacy 
 the pain of the sting 
 
 These cases should all be treated on com- 
 mon antiphlogistic principles, and the most 
 rational plan is to extract the sting, taking 
 care, in the first instance, to cut oft* the little 
 poison vesicle with scissors, lest in the at- 
 tempts to withdraw the sting more of the 
 virus be compressed into the part. The 
 stung part should then be immersed for a 
 time in ice-cold water, anc! afterward co- 
 vered with linen, wet with the liquor plumbi 
 acetatis dilutus. Were the inflammation to 
 exceed the usual degree, leeches and aperi- 
 ent medicines would be proper. In short, 
 as there is no specific for the cure of these 
 cases, they are to be treated with common 
 antiphlogistic means. 
 
 With regard to the bites of serpents, 
 those inflicted by the rattle-snake of Ame- 
 rica, and the cobra di capello of the East 
 Indies, are the most speedily mortal. In- 
 deed, this is so much the case, that some- 
 times there is scarcely an opportunity of 
 trying any remedies ; and even when the 
 patient is not destroyed thus rapidly, there 
 is such general disorder of the nervous sys- 
 tem, with repeated faintings arid sickness, 
 that medicines cannot well be retained in 
 the stomach, at least for some time. 
 
 Mr. Catesby, in the Preface to his Natural 
 History of Carolina, informs us, that the 
 Indians, who, by their constant wanderings 
 hi the woods, are liable to be bit by snakes, 
 know, as soon as they receive the injury, 
 whether it will prove mortal or not. If it 
 be on any part at a dislance from largo 
 blood-vessels, or where the circulation is 
 not vigorous, they apply their remedies ; 
 but if any vein of considerable magnitude 
 be hurt, they qnietlv resign themselves to 
 
WB WOUNDS. 
 
 their fate, knowing that nothing can then 
 be of service. Among the remedies on 
 which they chiefly depend are seneka root, 
 volatile alkali, and particularly strong doses 
 of arsenic, as will be presently noticed 
 again. 
 
 If we put out of consideration animals 
 affected with rabies, the viper inflicts the 
 'worst poisoned wound ever met with in 
 these islands. In fact it is an animal which 
 inserts into the part w hich it bites a poison 
 capable of exciting very serious conse- 
 quences. The jaws of the viper are fur- 
 nished with teeth, two of which in the 
 upper jaw are very different from the rest. 
 These, w hich are about three lines long, are 
 covered for about two-thirds of their length, 
 with a membranous coat or sheath, are of a 
 curved shape, and articulated with the jaw- 
 bone. When the animal is tranquil, and 
 his mouth shut, they lie dowm with their 
 points turned backwards 3 but they instantly 
 project forwards when it is irritated, and 
 about to bite. In them are canals, which 
 terminate by a very narrow fissure on their 
 convex sides, a little way from their points. 
 The rest of these fangs is very hard and 
 solid ; and the canal is usually filled with a 
 transparent, yellowish fluid, the poison of 
 the viper. 
 
 This venomous fluid is secreted by two 
 glands, or rather by two clusters of glands, 
 one on each side of the head, placed on the 
 front of the forehead, directly behind the 
 eye-ball, under the muscle, which serves to 
 depress the upper jaw. Thus the muscle 
 cannot act without pressing upon them, and 
 promoting the secretion of the fluid, which 
 they are destined to prepare. A little bag, 
 or vesicle, connected to the base of the first 
 bone of the upper jaw, as well as to the end 
 of the second, covers also the roots of the 
 curved fangs, and forms a receptacle for the 
 venom. 
 
 The viper is chiefly found in hilly, stony, 
 and w r oody districts, and seldom in flat or 
 marshy places. It is not its nature to at- 
 tack man, or large animals, except when 
 provoked. Its venom is only employed for 
 the destruction of smaller animals, such as 
 mice, frogs, k.c. which are usually swallow- 
 ed w hole, and to the digestion of which the 
 venomous secretion is by some writers sup- 
 posed to contribute. When, however, a 
 viper is pursued, trod upon, taken hold of, 
 or hurt, it immediately bites, and were it 
 only on account of the shape of the fangs, 
 the wound might be attended w ith very un- 
 pleasant effects; but it is certain of being 
 so, by reason of the species of inoculation 
 which complicates it, and of which the 
 mechanism is as follows : 
 
 When a viper is about to bite, it opens its 
 mouth very wide. The two curved fangs, 
 which had previously lain flat down in the 
 cavity of the membrane attached to their 
 base, now project, and become perpendicu- 
 lar to the low er jaw. When the bite takes 
 place, the poison is propelled through the 
 fangs, by t lie contraction of the muscles, 
 and the closure of the mouth, and is in- 
 
 jected into the wound with a force propor- 
 tioned to its accidental quantity at the 
 time, and the vigour of the animal. 
 
 The bite of a viper is quickly followed by 
 severe effects, some of w'hich are local, and 
 the others general ; but it is with the former 
 that the disorder invariably commences. 
 At the instant of the bite, the bitten part is 
 seized with an acute pain, which rapidly 
 shoots over the whole limb, and even affects 
 the viscera and internal organs. Soon after- 
 ward the w’ounded part swells and reddens. 
 Sometimes the tumefaction is confined to 
 the circumference of the injury ; but most 
 frequently it spreads extensively, quickly 
 affecting every part of the limb, and even 
 the trunk itself. A sanious fluid is often 
 discharged from the wound, around which 
 phlyctenas arise, similar to those of a burn. 
 After a short time, however, the pain abates 
 considerably ; the inflammatory tension 
 changes into a doughy, or oedematous soft- 
 ness ; the part grow's cold; and the skin 
 exhibits large livid spots, like those of gan- 
 grene. The general symptoms also come 
 on with celerity ; the patient is troubled 
 with anxiety, prostration of strength, diffi- 
 culty of breathing, and cold profuse sweats 
 Vomiting frequently occurs, and sometimes 
 copious bilious evacuations from the bowels 
 These symptoms are almost constantly at- 
 tended with an universal yellowness, and 
 excruciating pain about the navel. 
 
 The effects occur in the same way in 
 nearly all subjects, with some differences 
 depending upon the particular irritability 
 and constitution of the patient ; the high or 
 low temperature of the atmosphere ; the 
 greater or lesser anger of the viper ; the 
 number of its bites; the size of the reptile 
 itself ; the depth to which the fangs have 
 penetrated ; and whether the bitten part 
 happens to be one of great sensibility, or 
 w as naked or not at the time of the acci- 
 dent. In general, weak, pusillanimous 
 persons, of bad constitutions, and loaded 
 stomachs, suffer more sudden and alarming 
 ill consequences, than strong, healthy sub 
 jects, wdio view 7 the danger without fear 
 Several bites are, of course, more danger- 
 ous than a single one ; and, lastly, it has 
 been remarked, that the venom of the viper 
 is more active in summer than the spring. 
 
 A year or two ago, however, the news 
 papers recorded the death of a servant, 
 from the inadvertent application of the poi- 
 son to a scratch on his hand, as he was exa- 
 mining the fangs and venomous organs of a 
 viper perfectly torpid in the winter season. 
 
 Severe, however, as the effects of the 
 bite of a viper may be, they are far from 
 being so perilous as they are commonly 
 supposed to be. Indeed, the injury rarely 
 proves fatal to an adult, even when inflicted 
 by a viper in the middle of summer, the 
 period when the animal is mo3t active and 
 vigorous. Exceptions to this common be- 
 lief, however are upon record. Thus in 
 the year 1816, a vvomaD, in France, aged 
 sixty-four, was bit ou the thigh by a viper, 
 and. died in thirty-seven hours, notwith- 
 
WOUNDS. 
 
 standing the internal use of the liquor am- 
 monite, and the enlargement of the wound, 
 and cauterization of it with this fluid. In 
 this case, it is to be observed, that an hour 
 elapsed before any thing was done. (See 
 Annalts du Cercle Medicate , T. 1, P- 43, S vo. 
 Paris, 1820.) 
 
 Fontana, therefore, was not exactly cor- 
 rect in concluding, that the bite of an ordi- 
 nary viper will not prove fatal to a full- 
 grown person, nor even to a large dog, 
 though it does so to smaller animals. Five 
 bites from three strong and healthy vipers 
 were not able to kill a dog weighing sixty 
 pounds; and as this dog was little more 
 than a third part of the weight of an ordi- 
 nary man, Fontana supposed that a single 
 bite could never be fatal to an adult. He 
 says, that he had seen a dozen cases himself, 
 and had heard of fifty more, only two of 
 which ended fatally. Concerning one of 
 these cases, he could get no information ; 
 the other patient perished of gangrene, 
 twenty days after the bite. The mortifica- 
 tion began three days after the accident, 
 the bitten place having been deeply scarified 
 almost as soon as the injury was received. 
 Fontana believes, that much of the faint- 
 ness, &.c. which ensues upon the bite of a 
 viper, are the mere effects of terror. “ Upon 
 a person’s being bit (says he; the fear of 
 its proving fatal terrifies himself and the 
 whole family. From the persuasion of the 
 disease being mortal, and that not a mo- 
 ment is to be lost, they apply violent or 
 hurtful remedies. The fear increases the 
 complaint. I have known a person that 
 was imperceptibly bit in the hands or feet, 
 and who, after seeing the blood, and ob- 
 serving a viper near him, suddenly fainted 
 away ; one, in particular, continued in a 
 swoon for upwards of an hour, until he was 
 accidentally observed, and recovered out 
 of it by being suddenly drenched in cold 
 water. We know that death itself may be 
 brought on by very violent affections of the 
 mind, without any internal disease. Why 
 may not people, that are bit, die from a dis- 
 ease, produced entirely from fear, and who 
 would not otherwise have died from any 
 complaint produced by the venom ?” Al- 
 though it must be owned, that Fontana be- 
 stowed a great deal of attention upon this 
 subject, the above reasoning is hypothetical 
 and inconclusive. If it were to be granted, 
 that some very timid, delicate, or nervous 
 people, die from fear alone, it could not be 
 admitted, that the generality of people, bit 
 by snakes, perish also from the violent 
 effect of mental alarm. 
 
 Whenever the patient dies, the catastro- 
 phe is always ascribable to the quantity of 
 venom inserted in the wound ; the number 
 of bites ; their situation near important or- 
 gans ; and the neglect of proper means of 
 relief. In ordinary cases of a single bite 
 upon the extremities, the patients would get 
 well even without any assistance ; but the 
 symptoms would probably be more severe, 
 and the cure slower. 
 
 Vox.. IF 
 
 649 
 
 From some facts, recorded by Sir Everard 
 Home, and observations made on the opera 
 tiou of the poisons of the black spotted 
 snake of St. Lucia, the cobra di Capello, and 
 the rattlesnake, it appears, that u the effects 
 of the bite of a snake, vary according to the 
 intensity of the poison. When the poison 
 is very active, the local irritation is so sud- 
 den, and so violent, and its effects on the 
 genera! system are so great, that death soon 
 takes place. When the body is afterward 
 inspected, the only alteration of structure 
 met with, is in the parts close to the bite, 
 where the cellular membrane is completely 
 destroyed, and the neighbouring muscles 
 very considerably inflamed. • When the poi- 
 son is less intense, the shock to the general 
 system does not prove fatal. It brings on a 
 slight degree of' delirium, and the pain in the 
 part bitten is very severe : in about half an 
 hour, swelling takes place from an effusion of 
 serum in the cellular membrane, which con- 
 tinues to increase, with greater or less ra- 
 pidity, for about twelve hours, extending, 
 during that period, into the neighbourhood 
 of the bite. The blood ceases to flow in the 
 small vessels of the swollen parts ; the skin over 
 them becomes quite cold ; the action of the 
 heart is so weak, that the pulse is scarcely per- 
 ceptible, and the stomach is so irritable that 
 nothing is retained by it. In about sixty hours , 
 these symptoms go off ; inflammation and sup- 
 puration take place in the injured parts; and 
 when the abscess formed is very great, it 
 proves fatal. When the bite has been in 
 the finger, that part has immediately mortified. 
 When deaih has taken place, under such cir- 
 cumstances, the absorbent vessels, and their 
 glands have undergone no change, similar to 
 the effects of morbid poisons, nor has any part 
 lost its natural appearance, except those im- 
 mediately connected with the abscess. In 
 those patients, who recover with difficulty 
 from the bite, the symptoms, produced by 
 it, go off more readily, and more complete- 
 ly, than those produced by a morbid poi 
 son, which has been received into the sys- 
 tem.'’ ( Sir E. Home, Case of a Man who died 
 in Consequence of the Bite of a Rattle Snake, 
 in Phil. Trans. 1810.) 
 
 Numerous remedies for the bites of com 
 mon vipers have obtained celebrity. Ac 
 cording to certain writers, each of these re 
 medies has effected wonderful cures ; and 
 yet, as Boyer well remarks, every one of 
 them has been in its turn relinquished for 
 another, the sole recommendation of which 
 has frequently consisted in its novelty. Any 
 of these boasted medicines, though of oppo 
 site qualities, cured, or at least seemed to 
 cure, the patients, and the partisans of each 
 considered, that he had a right to extol his 
 own remedy as a specific, when the patient, 
 to whom he administered it, was seen to re- 
 cover perfectly, after suffering a train of se- 
 vere symptoms. But the reason of this pre- 
 tended efficacy becomes obvious, when one 
 knows that the bite of a viper is of itself 
 rarely mortal to the human subject, and that 
 the severity of the symptoms materially de- 
 pends upon the quantity of the venom in the 
 
 82 
 
WOUNDS 
 
 
 wound. {Boyer, TraiU des .Maladies Chir. 
 T. 1 ,p. 428.) 
 
 The treatment of the bite of a viper is di- 
 vided into local and general means. . 
 
 The local treatment has for its principal 
 object the destruction of the venom ; the 
 prevention of its entrance into the vessels, 
 or the removal of it from the wound. 
 
 Ot scarifying the wound, I shall only say, 
 that it promises no utility, if it be practised 
 with a view of letting such dressings be ap- 
 plied, as are extolled as specifics ; for we 
 know, that there is no local application, 
 which is entitled to this character. Fontana 
 was an advocate for applying a ligature 
 round the lirnb,*in order to check the ingress 
 of the venom into the circulation ; and he 
 thought, that he had seen much good result 
 from this practice. Sir Everard Home is 
 also of opinion, that “ the only rational lo- 
 cal treatment,to prevent the secondary mis- 
 chief, is making ligatures above the tumefied 
 part, to compress the cellular membrane, 
 and set bounds to the swelling, which only 
 spreads in the loose parts under the skin ; and 
 scarifying freely the parts already swoln, 
 that the effused serum may escape, and the 
 matter be discharged as soon as it is formed. 
 Ligatures (he says) are employed in Ameri- 
 ca, but with a different view, viz. to prevent 
 the poison being absorbed into the system.” 
 (Phil. Trans, for 1810, p. 87.) At all events, 
 if compression be employed, it should be 
 so regulated as not to create any risk of 
 gangrenous mischief, by its interruption of 
 the circulation. 
 
 Suction of the wound has been proposed, 
 and seems founded on reason ; but experi- 
 ence, I believe, has determined little in its 
 favour. A cupping-^lass might be employed, 
 but, probably, no mode of suction would 
 succeed in extracting the whole of the poi- 
 son. 
 
 The most certain method of removing the 
 virus consists in the excision of the bitten 
 part. This operation, however, would hardly 
 be proper, unless done immediately after the 
 injury, before much inflammation had come 
 on. It is likewise a practice to which many 
 patients would not assent, and even some 
 surgeons may deem the proceeding too se- 
 vere, in relation to the bite of the viper of 
 this country. The bite might also be incon- 
 veniently situated for the excision of the 
 parts. 
 
 Another plan, more commonly preferred 
 is, that of destroying the envenomed part 
 with caustic, or the actual cautery. When 
 this is done in time, the poison is prevented 
 from extending its irritation over the ner- 
 vous system, through the medium of which 
 all the worst symptoms are usually excited. 
 The caustic and cautery may also have the 
 effect of chymically destroying the venom 
 itself, while they must tend to hinder its 
 passage into the circulation, inasmuch as 
 they destroy the neighbouring absorbent 
 vessels. The caustic, which Fontana pre- 
 ferred, was potassa. But, as Boyer sensibly 
 ' remarks, every caustic, of equal strength, 
 must infallibly have the same, effect, n« its 
 
 mode of operating is that of destroying the 
 point of irritation, viz. the seat of the ve 
 nom. In France, liquid caustics are pre- 
 ferred, the fluid muriate of antimony, the 
 liquor ammonia?, or-dhe sulphuric, or nitric 
 acid, because their action is quicker, and 
 they more certainly penetrate to the bottom 
 of the wound. {Traits des Mai. Chir. T. 1, 
 p. 429.) Either of these liquids may be 
 applied by means of a slender pointed bit of 
 wood, which is to be dipped in it, and then 
 introduced into the punctures, made by the 
 fangs of the reptile. The piece of wood 
 should be withdrawn, w r et once more, and 
 applied again. If a drop of the caustic can 
 be inserted, so much the better. When the 
 bite is very narrow and deep, the caustic can- 
 not well be introduced, before the mouth of 
 the wound is somewhat enlarged with a lan- 
 cet. A little bit of lint may then be wet in 
 one of the above fluids, and be pressed deep- 
 ly into the wound. 
 
 After the caustic has produced an eschar 4 
 the best application is an emollient poul- 
 tice. 
 
 It is not, however, every bite of a viper, 
 that requires local treatment, even of this 
 degree of severity. As Boyer observes, 
 when the wound is superficial, the viper 
 benumbed with cold; its poison considera- 
 bly exhausted by its having previously bit- 
 ten other animals ; the swelling inconsider- 
 able ; and the patient neither affected with 
 prostration of strength, nor pain about the 
 praecordia ; a few drops of ammonia may be 
 introduced into the wound, and a small 
 compress wet with the same fluid applied. 
 Formerly, olive oil was considered, in Eng- 
 land, one of the best applications for the 
 bites of snakes, and its virtues were after 
 ward extolled in France by Pouteau ; but, 
 says Boyer, it possesses no specific efficacy, 
 as the experiments of Hunaud and G6otfroi 
 have decidedly proved. ( Traitd des Mala- 
 dies Chir. T. l,p. 431.) 
 
 With respect to the general treatment, if 
 we exclude emetics, of which Dr. Mead had 
 a high opinion, when the patient was much 
 jaundiced the favourite medicines are cor- 
 dials, ammonia, and arsenic. The ancients 
 employed theriaca, Mithridates, salt, and 
 the carbonate of ammonia. Of all stimulants, 
 however, the liquor ammonia? is that which 
 now obtains the greatest confidence ; or 
 else, the eau de luce , which only differs from 
 the fluid ammonia, in containing a small 
 quantity of the oleum succinatum. In 
 France, this remedy is even at the present 
 time regarded, as having the best claim to 
 the title of a specific for the bite of a viper 
 {Boyer, op. cit.) 
 
 In France, Bernard de Jussieu first tried 
 ammonia in the year 1747 (see Hist, de 
 VAcad. des Sciences , 1747 ;) since which time 
 it has been extensively employed for the 
 cure of the bites of vipers, both as an inter- 
 nal and external remedy. It had, however, 
 been highly praised by Dr. Mead at a much 
 earlier period. 
 
 A few drops of the remedy are to be ex- 
 hibited every two hours : but. as it is very 
 
W0Li\b& 
 
 boi 
 
 powerful, it must always be diluted with tea, 
 or some other drink, or the mistura cam 
 phora?. The dose, however, must depend 
 upon the age and constitution of the patient, 
 and the intensity of the symptoms. Four 
 or five drops suffice for a person of weak, 
 delicate, irritable habit ; but twelve- or fif- 
 teen may be given to stronger subjects, 
 when the symptoms are violent. With am- 
 monia, some practitioners order wine. 
 
 In St. George’s Hospital, the man who 
 was bit by the rattle-snake, kept for exhibi- 
 tion, took aperient medicines, the liquor 
 ammonias, aither, the spiritus ammonias, 
 comp, opium, and other stimulants ; but 
 without any apparent benefit. The disease 
 followed that course which Sir E. Home 
 has described as usual when the shock on 
 the system is not directly fatal, and the 
 mischief in the arm ultimately produced the 
 man’s death. (See Phil. Trans. 1810.) 
 
 From the following passage, in relation 
 to the' bites of snakes in general, it seems 
 that Sir Everard Home, in 1810, had no 
 confidence in any medicines which had then 
 been duly tried. The violent effects, 
 which the poison produces on the part bit 
 ten, and on the general system, and the 
 shortness of their duration, where they do 
 not terminate fatally, (says he) have fre- 
 quently induced the belief, that the recove- 
 ry depended on the medicines employed ; 
 and, in the East Indies, eau de luce is con- 
 sidered as a specific. 
 
 There does not appear to be any founda- 
 tion for such an opinion ; for when the poi- 
 son is so intense as to give a sufficient shock 
 to the constitution, death immediately takes 
 place, and where the poison produces a lo- 
 cal injury of sufficient extent, the patient 
 also dies, while all slighter cases reco- 
 ver. The effect of the poison on the con- 
 stitution is so immediate, and the irritability 
 of the stomach so great, that there is no op- 
 portunity of exhibiting medicines till it has 
 fairly taken place, and then there is little 
 chance of beneficial effects being produced. 
 (Sir E. Home, in Phil. Trans. 1810.) 
 
 Fontana also had little faith in reputed 
 antidotes; but it is to be noticed, that his 
 observations refer only to the bites of*vipers. 
 u In no country (says he) through which I 
 passed, could I ever find any two people or 
 persons, bit by the viper, either in the moun- 
 tains or valleys, that used the same reme- 
 dies. Some used theriaea alone, either ex- 
 ternally or internally applied ; others com- 
 mon oil ; a third set used stimulants, such 
 as the strongest spirituous liquors ; whilst 
 others, on the contrary, tried every different 
 kind of sedative. In short, there is hardly 
 any active kind of medicine that has not 
 been tried as a cure in this disease ; while, 
 at the same time, it is certain that, under all 
 the varieties of application, none of the pa- 
 tients died.” Hence Fontana concluded, 
 that none of the remedies had any effect in 
 curing the disease. 
 
 Later observations, however, tend to 
 raise our hopes, that a medicine is now 
 known which really seems to possess consi- 
 
 derable efficacy against Uie bite, even of a 
 very formidable kind of snake. From some 
 facts recorded in Dr. Russell’s History oi In- 
 dian Serpents, on the authorities of Mr. Duf- 
 fin and Mr. Ramsay, it appears that the Tan - 
 jure pill, of which arsenic is the chiefingre- 
 dient, is exhibited with considerable success 
 in India after the bites of venomous serpents 
 this information led Mr. Chevalier to pro- 
 pose the fair trial of arsenic. 
 
 Mr. Ireland, surgeon to the 60th regt. had 
 formerly heard Mr. Chevalier recommend 
 the trial of arsenic, and he was resolved to 
 make the experiment whenever an oppor- 
 tunity offered. On his arrival in the island 
 of St. Lucia, he was informed that an officer, 
 and several men, belonging to the 6Sth re- 
 giment, had died from the bites of serpents, 
 supposed to be the coluber earinatusof Lia- 
 na?^. 
 
 The reader will find some interesting ac 
 count of the serpent here alluded to, in a 
 tract, which I have lately read, entitled Mo- 
 nographic du Trigonocephale des Antilles , on 
 Grand Vipere Fcr-de- Lance de la Martinique, 
 par A. Moreau de Jonnes, 8 vo. Paris, 1816. 
 
 Mr. Ireland also learnt, that every thing 
 had been tried by the attending medical men 
 to no purpose, as all the patients had died, 
 some in six, and others in about twelve 
 hours from their receiving the wound. 
 
 A case, however, soon came under Ml'. 
 Ireland’s own observation, and as nothing 
 that had been done before, seemed to have 
 been of any service, he was determined to 
 give arsenic a full trial. 
 
 “ Jacob Course, a soldier in the York light 
 infantry volunteers, was bitten in the left 
 hand, and the middle finger was so much 
 lacerated, that I found it necessary to am- 
 putate it immediately at the joint with the 
 metacarpal bone. 
 
 “ I first saw him about ten minutes after 
 he had received the wound, and found him 
 in a torpid, senseless state ; the hand, arm, 
 and breast of the same side were much 
 swelled and mottled, and of a dark purple, 
 and livid colour. He was vomiting, and ap- 
 peared as if much intoxicated. Pulse quick 
 and hard : he felt little or no paini during 
 the operation. 
 
 u The wound being dressed, and the pa- 
 tient put to bed, I ordered a cathartic clys- 
 ter, and the following medicine to be taken 
 immediately. Liquor Arsenic. 3ij. Tinct. 
 Opii, gt. x. Aq. Menth. Pip. j§iss. which was 
 added to half an ounce of lime-juice, and 
 as it produced a slight effervescence, it was 
 given in that state ; this remained on his 
 stomach, and was repeated every half hour 
 for four successive hours. In the mean 
 time, the parts were frequently fomented 
 with common fomentations, and rubbed 
 with a liniment composed of 01. Terebinth, 
 ^ss. Liquor Ammon. |ss. and 01. Oliv. Jiss\ 
 The cathartic clyster was repeated twice, 
 when the patient began to be purged ; and 
 the arsenical medicine was now disconti- 
 nued. He had become more sensible when 
 touched, and from that time he gradually 
 
WOUNDS 
 
 C&2 
 
 recovered his faculties ; he took some nou- ner two cavities aye formed, which have rid' 
 vishment, and had several hours sleep. sort of communication with each other 
 
 “ The next day he appeared very weak, By the two pleura 1 , touching and lying 
 and fatigued ; the fomentation and liniment against each other, a middle partition is 
 were repeated. The swelling diminished formed, called the mediastinum. These two 
 gradually ; the natural colour and feeling membranes are intimately adherent to each 
 returned, and by proper dressings to the other, in front, the whole length of the ster- 
 wound, and attention to the state of his num; but behind, where they approach the 
 bowels, he soon recovered and returned to vertebrae, they separate from each other, 
 his duty.” so as to leave room for the aorta, cesopha- 
 
 Mr. Ireland recites about four other ex- gus, &z.c. The heart, enclosed in the peri- 
 amples, in which arsenic was exhibited with cardium, occupies a considerable space on 
 similar success. the left of the mediastinum, and all the rest 
 
 It deserves particular notice, that the li- of the chest is filled with the lungs, except 
 quor arsenici employed by Mr. Ireland, was behind, w here the large blood-vessels, 
 prepared according to Dr. Fowler’s pre- nerves, tbpracic duct, and (Esophagus, are 
 scription, which directs sixty four grains of situated. In the perfectly healthy state, the 
 arsenic, and as many of the fixed vegetable lungs do not adhere to the pleura ; but in 
 alkali, to be dissolved in a sand heat, and ‘the majority of subjects, at least in this 
 the solution to be made an exact pint, so climate, who are examined after death, such 
 that two drachms contain one grain of arse- adhesions are found in a greater or lesser 
 jiie in solution. (See Med. Chir. Trans. Vol. degree. The disease may probably be oc- 
 2, p. 393, fyc.) casioned by very slight inflammation ; and 
 
 IVounds of the Thorax . — The thorax is a as the surface of the lungs is naturally des- 
 cavity of an irregularly oval figure, bounded tined to be always in close contact with the 
 in front by the sternum, laterally by the pleura, and patients are frequently not sus- 
 ribs, posteriorly by the vertebrae of the back, pected to have any thing wrong in the tho 
 above by the clavicles, and below by the rax, this morbid change being often acci 
 diaphragm, a very powerful muscle, which dentally discovered after death, in lookingfoi 
 forms a kind of partition between the cavity something else ; it may be concluded, tha' 
 of the thorax, and that of the abdomen. it does not produce any serious effects. 
 
 The diaphragm is not stretched across, in The thorax is subject to all kinds of 
 a straight direction, from one side of the wounds ; but their importance particularly 
 chest to the other ; but on the contrary, depends on their depth. Those which do 
 descends much further in some places than not reach beyond the integuments do not 
 in others. If the cavity of the thorax be differ from common wounds, and, when 
 opened by a transverse section, about the properly treated, are seldom followed by 
 middle of the sternum, the diaphragm ap- any bad consequences. On the contrary, 
 pears, on examination, to be very promi- those which penetrate the cavity of the 
 nent and convex towards its centre, while pleura, even by the slightest opening, may 
 it sinks downward at its edges, towards all give rise to alarming symptoms. Lastly, 
 the points to which the muscle is attached, wounds injuring any of the thoracic viscera, 
 At its anterior, and most elevated pajt, it is are always to be considered as placing the 
 fixed to the ensiform cartilage, whence, de- patient in a state of considerable danger, 
 scending obliquely to the right and left, it is From what has been said, it appears that 
 inserted, on both sides, into the seventh rib, wounds of the thorax are very properly di- 
 all the lower ribs, and lastly, into the lower visible into three kinds; viz. 1. such as 
 dorsal vertebrae. According to this descrip- affect only the skin and muscles; 2. such 
 tion, it is obvious, that the cavity of the as enter the cavity of the chest, but injure 
 thorax has much greater depth and capacity none of the viscera ; 3. others, which in 
 behind, than in front; a circumstance which jure the lungs, or some other viscus. 
 surgeons ought to be well aware pf, or else Superficial Wounds of the Thorax. — Im- 
 they will be liable to give most erroneous mediately a surgeon is called to a recent 
 opinions concerning wounds of the chest, wound of the chest, his first care should be 
 For instance, a practitioner deficient in ana- to ascertain, whether the w eapon has pene- 
 tomical knowledge, might imagine that a trated the pleura or not. In order to form 
 weapon, pushed from above downward into a judgment on this circumstance, surgical 
 the front of the chest, could never reach the writers recommend, 1. Placing the wound- 
 lungs, after having penetrated the cavity of ed person in the same posture in which he 
 the abdomen. It is a fact, however, that was when he received the wound, and then 
 no instrument could pass in this direction, carefully examining with a finger, or probe, 
 even some inches below the highest part of the direction and depth of the stab. 2. The 
 the abdomen, without entering the chest. examination, if possible, of the weapon, so 
 The whole cavity of the thorax is lined as to see how much of it is stained with 
 with a membrane named the pleura, which blood. 3. The injection of fluid into the 
 is every where adherent to the bones which wound, and attention to whether it regur 
 form the parietes of this cavity, and to the gitates immediately, or lodges in the part 
 diaphragm. Each side of the thorax has a 4. The colour and quantity of the blood, 
 distinct pleura. The two membranes meet discharged from the wound, are to be no- 
 in the middle of the chest, and extend from ticed, and whether any is coughed up. 6. 
 the sternum to the vertebrae. In this man- We are to examine . whether air escape* 
 
WOUNDS. 
 
 boo 
 
 from (lie wound in respiration, and whether 
 there is any emphysema. 6. Lastly, the 
 state of the pulse and breathing must be 
 considered. 
 
 In wounds of the chest, however, sur- 
 geons should not be too officious with their 
 probes, merely for the sake of gratifying 
 their curiosity, or appearing to be doing 
 something. No judicious surgeon can 
 doubt that authors have dwelt too much on 
 the subject of probing wounds of the abdo- 
 men and thorax ; for they would really lead 
 their readers to believe, that, until the 
 wound has been traced with the finger or 
 probe, to its very bottom and termination, 
 surgeons are not qualified to institute any 
 mode of treatment. The only advantage 
 of knowing that a wound penetrates the 
 chest, is, that the practitioner immediately 
 feels himself justified in having recourse to 
 bleeding and other antiphlogistic means, 
 with the view of preventing inflammation 
 of the pleura and lungs, which affection, if 
 not controlled in time, often proves fatal. 
 However, there can be little doubt, that if 
 the nature and depth of the wound cannot 
 be readily detected with the eye, the finger, 
 or a probe, or by the discharge of air, or 
 blood, it is much safer to bleed the patient 
 than to put him to useless pain with the 
 probe, and waste opportunities of doing 
 good, which too frequently can never be 
 recalled In short, generally speaking, it is 
 better, and more advantageous for all pa- 
 tients, that some of them should lose blood, 
 perhaps unnecessarily, than that any of 
 them should die in consequence of the eva 
 euation being omitted or delayed. 
 
 Almost all writers, who have taken pains 
 to direct how wounds of the thorax should 
 be probed, conclude with remarking, that, 
 however advantageous a knowledge of the 
 direction and depth of the wound may be, 
 much harm has' frequently been done by 
 pushing the attempts to gain such informa- 
 tion too far. It is, perhaps, of greater im- 
 portance to learn, by some kind of exami- 
 nation, the extent of a wound, which does 
 not reach beyond the integuments, or in- 
 tercostals, than to know whether the w ound 
 extends into the cavity of the chest. For, 
 even when the pleura is found to be divided, 
 if the xvound be attended with no urgent 
 symptoms, the information is of no practical 
 use, if we make it a rule to adopt, without 
 the least delay, a strict antiphlogistic plan of 
 treatment, in all cases in which there is 
 any doubt or chance of the parts within the 
 chest being wounded, and likely to inflame. 
 Besides, frequently, the symptoms are more 
 urgent and alarming than they could be 
 were only parts on the outside of the thorax 
 injured ; and, under such circumstances, 
 it is manifest that a probe cannot be neces- 
 sary for discovering that the wound extends 
 into the chest. 
 
 With respect to the injection of luke- 
 warm water, or any other fluid, and the cir- 
 cumstance of its regurgitation, as a criterion 
 of the wound being only superficial, the 
 plan i? more objectionable than the employ- 
 
 ment of a probe ; for, if the liquid be pro- 
 pelled with force, it may be injected into 
 the cellular substance, and seem to be pass- 
 ing through the track of the w ound into the 
 chest, w hile, in reality, not a drop does so. 
 Besides, is it a warrantable proceeding to 
 try to insinuate any quantity or kind of 
 liquid whatever between the pleura and 
 lungs, into a situation in which it must neces- 
 sarily obstruct the important function of 
 respiration, and cause serious inconve- 
 nience ? 
 
 When air issues from the wound in expira- 
 tion, there is ground for suspecting that the 
 lungs are wounded. But I believe, that 
 such authors as represent this circumstance 
 as an infallible criterion of the nature of the 
 accident, labour under a mistake ; for when 
 there is simply an opening in the chest, with- 
 out any injury of the lungs whatever, the 
 same symptom may occur. The air, which 
 is discharged through the wound in expira- 
 tion, has previously entered the bag of the 
 pleura through the same wound in inspira- 
 tion. In order to remove all doubt, the pa- 
 tient should be requested to expire, as strong- 
 ly as he can, so as to force out whatever air 
 may have accumulated in the chest. At the 
 end of each expiration of this kind, care 
 must be taken to bring the skin closely over 
 the orifice of the w ound, and to keep it thus 
 applied, during each following inspiration, 
 for the purpose of preventing the external 
 air from entering. In this way, if there be 
 no wound of the lungs, all the air will soon 
 be expelled ; but if it still continues to be dis- 
 charged in expiration, the lungs must be 
 wounded. 
 
 Sometimes, an emphysematous swelling 
 takes place round wounds of the thorax, in 
 consequence of a quantity of air diffusing it- 
 self in the cellular substance. In wounds, 
 which are straight and ample, this symptom 
 is very uncommon ; but, in cases of narrow 
 oblique stabs, and where the lungs are 
 wounded by the points of broken ribs, it is 
 by no means unfrequent. (See Emphysema.) 
 When a considerable quantity of blood 
 flows from the wound, there is reason for 
 conjecturing, not only that the w'eapon 
 has penetrated the cavity of the thorax, but 
 that some of the thoracic viscera are injured. 
 Excepting the intercostal arteries, which 
 run along the lower edges of the ribs, and 
 the trunks of the thoracic arteries, all the 
 other vessels, on the outside of the chest, 
 are very inconsiderable. The effects of com- 
 pression will indicate, whether the blood 
 escapes from an artery on the outside of the 
 cavity of the pleura ; and sometimes, the 
 situation and direction of a wound at once 
 denotes, that the hemorrhage cannot pro- 
 ceed from the trunks of the thoracic ar- 
 teries. 
 
 Even the appearance of the blood, which 
 comes from the wound, may lead to some 
 conjectures, concerning the depth of the 
 injury. The blood, which flow s from wounds 
 of the lungs, is of a brighter scarlet colour, 
 and more frothy, than that which is dis 
 
WOUNDS. 
 
 664 
 
 charged from the vessels of any other 
 part. 
 
 There can be no doubt of the lungs being 
 wounded, when the patient is observed to 
 spit up blood ; but, the absence of this symp- 
 tom is not a positive proof of their being 
 untouched, though unquestionably, a very 
 important circumstance in the diagnosis, 
 and, generally speaking, a correct criterion 
 of the lungs having escaped injury. At all 
 events, when no blood is spit, or coughed 
 up, the lungs can never be deeply pene- 
 trated. 
 
 The state of the pulse, and that of respira- 
 tion ought to be particularly attended to by 
 the practitioner. Neither one, nor the other, 
 seems altered, at least at first, when wounds 
 do not reach more deeply than the integu- 
 ments; but those which penetrate the cavity 
 of the thorax, and especially such as injure 
 the viscera, may frequently be distinguished, 
 from the very first moment of their occur- 
 rence, by their effects on the sanguiferous 
 system, and the function of respiration. 
 When the lungs are wounded, at a point 
 where they adhere to the pleura, no air can 
 be effused in the thorax, and the functions of 
 those organs may, on this account, suffer 
 less disturbance than would be the conse- 
 quence of an equal degree of injury at some 
 other unadherent portion of the lungs. 
 Experience proves, that when either air or 
 blood insinuates itself between the lungs 
 and the pleura, the lungs become immedi- 
 ately oppressed, the breathing is attended 
 with great difficulty, the pulse is weak, con- 
 tracted, and intermittent. 
 
 Wounds of the integuments and muscles 
 of the thorax, are not attended with any 
 particular danger ; they heal with the same 
 readiness, and by the same means, as com- 
 mon superficial wounds in any other part of 
 the body. 
 
 When the case is a punctured, or a gun- 
 shot wound, some writers are advocates for 
 laying open the track of the injury from 
 one end to the other, if its course should not 
 be too extensive, and they then recommend 
 dressing the cavity down to its bottom. 
 When the track of the wound was too exten- 
 sive, a seton was sometimes introduced. 
 The aim of such exploded practices was to 
 prevent the outer part of the wound from 
 healing too soon, and. thus give time for the 
 xvhole of it to heal in an equal degree. 
 When a seton was used, the thickness of the 
 skein was gradually diminished, and, after 
 the whole of it had been removed, a slight 
 compression was kept up for a few days, 
 with the view of completing the cure. 
 
 The French surgeons have the discredit of 
 having brought setons into fashion in this 
 branch of surgery, and I am particularly 
 glad, that a late writer has well exposed the 
 absurdity of the practice. “We find (says 
 Mr. John Bell) the history of it to he plainly 
 this : that as Guy de Chauliac, JPar6, and ail 
 the older surgeons, did not know how to 
 dilate gunshot wounds, they found these 
 same setons useful in bringing the eschar 
 sooner away, and in preserving an open 
 
 wound ; and, as they believed the wounds to 
 be poisoned, they took the opportunity of 
 conducting, by these setons, whatever acrid 
 medicines might, according to the prevailing 
 doctrines of that .time, have any chance of 
 correcting the-poison.” Mr. J. Bell notices, 
 howsurprisingitistoseethe cruelty, and per- 
 severance, with which some modern prac- 
 titioners, particularly French, draw these 
 cords through wounded limbs ; and when 
 the ^roughness of such a cord, or the acri- 
 mony of the drugs conveyed by it, produces 
 a copious suppuration, these men are de- 
 lighted with such proofs of their success. 
 The setons have been introduced by the 
 French surgeons, across the thickest parts of 
 the limbs, along the whole length of the 
 fore-arm, and, at the same time, frequently' 
 through the wrist-joint. The setons have 
 also been covered with stimulating applica- 
 tions. Profuse suppurations, and dreadful 
 swellings of course ensued ; still, as Mr. J 
 Beil has remarked, these cruelties were con- 
 tinued, till the wound healed almost in spite 
 of the pain ; or till the coming on of very 
 dreadful pain, great suppurations, convul- 
 sions, &,c. made the surgeon discontinue the 
 method, or even amputate the limb. The 
 French have become so familiarized to 
 setons, that they do not restrict their use to 
 flesh wounds, they pass them quite across the 
 thorax, across the abdomen, and even 
 through wounds of the knee-joint. 
 
 When we wish to excite inflammation, 
 in the cavity of the tunica vaginalis, for 
 the purpose of radically curing a hydro- 
 cele, we either pass a seton through the 
 part ; lay it open with an extensive inci- 
 sion ; cram a tent into it ; or injgct some 
 irritating fluid into it. While the animal 
 machine continues the same, says Mr. John 
 Bell, the same stimuli will produce the same 
 effects, arid a seton, injection, or long tent, 
 if they produce pain and inflammation in 
 the scrotum, will not be easy in the chest : 
 and, unless we can use them in the chest, 
 with the same intentions with which we use 
 them in the. hydrocele, (in other words) un- 
 less we are justified in inflaming the chest, 
 and causing an adhesion of all the parts, we 
 cannot use them with any consistency or 
 good sense. 
 
 With regard to the cases which the 
 French adduce in confirmation ot the good! 
 effects of their plans, 1 am entirely of 
 opinion with Mr. J. Bell, that the facts only 
 prove, that ike patients recovered in spite of 
 the setons. “ It is like (adds this author) 
 what happened to a surgeon, who was dab- 
 bing in the thorax with a piece of caustic 
 which fell directly into the cavity oi the 
 ciiest, where it caused very large suppura- 
 tions, and yet the patient was saved, l'he 
 patient recovered, in spite of the caustic, 
 just as M. Guerin’s patient, and many other 
 poor unhappy souls, who lived in spite ot 
 the setons. One would think, that people 
 took a pleasure in passing setons across the 
 eyeball, the chest, the knee-joint, &c. 
 merely to make tools stare, when the bust- 
 
WOUNDS. 
 
 troll 
 
 fciess might be as effectually done with an 
 abscess lancet.” 
 
 Mr. John Bell, in his usual lively style, 
 makes the employment of tents, in wounds 
 of the chest, seem equally ridiculous and 
 improper. Indeed, he says, he knows of' no 
 occasion in all surgery, in which tents can be 
 useful, except in the single one of a narrow 
 opening, which we desire t<> dilate, in order to 
 g t at the bottom of the. wound ; and where 
 either, on account of some'great artery , or the 
 fearful temper of our patient, ive dare not use 
 the knife. (See J. Bell on Wounds. Dis- 
 course 2, Vol. 2.) 
 
 Having hitherto been engaged, rather in 
 pointing out what ought not to be done, 
 than what ought, I shall next make some re- 
 marks on the line of conduct, which should 
 be adopted, in cases of wounds of the pa- 
 rietes of the chest. 
 
 When the wound is a common cut, the 
 sides of the division are to be brought into 
 contact, and maintained in this position 
 with strips of adhesive plaster, compresses, 
 and a bandage, until they have grown toge- 
 ther. If the surgeon take care to relax such 
 muscles as happen to be cut, or to be situated 
 immediately under the wound of the integu- 
 ments, there will rarely be any need of 
 sutures. 
 
 As cut wounds seldom or never .penetrate 
 the chest, and there is generally no reason 
 why they should not unite by the first inten- 
 tion, without being followed by extensive 
 inflammation and abscesses, antiphlogistic 
 means should be employed with moderation. 
 Bleeding will not often be requisite. The 
 grand objects are, to keep the patient in a 
 quiet state, on rather a low diet, and to hin- 
 der him from taking wine, porter, spirits, or 
 any other stimulating beverages. 
 
 If the wound, instead of healing favoura- 
 bly, should inflame, the treament should be 
 regulated by the principles laid down in the 
 article Inflammation. If it suppurate over 
 its whole surface, but without a great deal of 
 surrounding swelling and inflammation, one 
 or two strips of sticking-plaster, may still be 
 used with advantage ; for, in this way, the 
 cavity, which must now 1 be filled^up by gra- 
 nulations, will be rendered much smaller 
 than it otherwise would be. Some very soft 
 lint may be laid in the cavity of the wound, 
 which the sticking-plaster does not entirely 
 remove, and over the whole a pledget of 
 some mild, unirritating ointment. No pres- 
 sure is now proper, until the inflammation 
 diminishes ; and if the discharge should be 
 profuse, or the surrounding inflammation 
 considerable, the best application would be 
 an emollient poultice. In this state of things, 
 the patient should also be bled, and leeches 
 be applied near the inflamed parts. 
 
 When the case is a stab, or punctured 
 wound, the fibres of the divided parts are 
 not simply cut, they are also considerably 
 stretched, bruised, and otherwise injured. 
 Hence, generally they will not admit of 
 being united so readily, as the sides of a 
 clean incision, made with a sharp instru- 
 ment, However, the possibility of uniting 
 
 the opposite sides of punctured wounds must 
 depend very much on the shape of the 
 weapon r and the suddenness, roughness, and 
 violence, with which it was driven into the 
 part. \ prick with a needle is a punctured 
 wound ; so is that often made by surgeons 
 with their lancets ; yet, these injuries do not 
 frequently bring on violent inflammation,, 
 and abscesses, as other wounds frequently 
 do, which are inflicted with bayonets, and 
 pikes. 
 
 Let us suppose a man to have received 
 a thrust of a bayonet, which has run into 
 the skin and muscles, covering one side 
 of the thorax : what plan can the surgeon 
 follow, with the greatest .advantage to his 
 patient ? 
 
 Instead of laying open the whole track of 
 such a wound with a knife, as is barbarously 
 recommended in many of the principal 
 works on surgery ; instead of drawing a 
 seton through its whole course, or of cram- 
 ming into the part a hard, irritating tent ; 
 the practitioner should take whatever chance 
 there may be of uniting the wound without 
 suppuration. For this purpose, he should 
 recollect that the great degree of violence 
 done to the parts in punctured wounds is 
 the reason why they are so apt to inflame 
 and suppurate. Hence- the expected inflam - 
 mation is to be counteracted in the very first 
 instance ; and immediately the wound is 
 dressed, the patient should be freely bled, 
 and take some saline purgative medicines. 
 With regard to the dressings, the orifice of 
 the wound may be lightly closed with sticking- 
 plaster, or covered with any mild superficial 
 applications. Over and around these, the 
 surgeon may apply linen, kept continually 
 wet with cold water, or the liquor plumbi 
 acetalis dilutes. As, however, many pa- 
 tients have a strong dislike to cold applica- 
 tions to any wounds upon their bodies, it 
 is often necessary {^dispense with this prac- 
 tice. The dressings are to be retained 
 with a roller ; but it is not to be tight, 
 as pressure is more likely to do harm, 
 than good. Thus the inflammation of the 
 wound will be moderated ; the extravasa- 
 tion of blood prevented-, the chance ofunkm 
 by the first intention taken ; and all p^rfM 
 operations avoided. And, nothing is morlf 
 certain than the fact, that, if antiphlogistic 
 means be strictly employed, many stabs heal 
 without abscesses, or any very severe symp- 
 toms, when no hope could be entertained of 
 their doing so under other treatment. But, 
 if suppuration should happen, and a col- 
 lection of matter take place, would the 
 patient suffer more, or -be put into greater 
 danger, by having a proper depending 
 opening, of just sufficienffsize, now made 
 into the abscess in an eligible place, than 
 if he had submitted to have the formidable 
 operation of laying open the whole extent 
 of a stab, performed in the first instance ? In 
 short, will he suffer half so much, be half so 
 long in getting well, or have to encounter 
 half the danger ? With all this advantage, he 
 will have taken a certain chance, which 
 attends all these cases, if the wonnd be- 
 
WOUNDS. 
 
 050 
 
 coming united by what is called the first 
 intention, that is to say without any suppu- 
 ration. I need not enlarge upon this subject, 
 but refer the reader to what has been said in 
 the preceding columns on the subject of 
 Punctured Wounds, and to the treatment of 
 abscesses, in the article Suppuration. Gun- 
 shot wounds, merely injuring the parietes 
 of the chest, are to be treated according to 
 principles elsewhere explained. (See Gun- 
 shot Wounds.) 
 
 Of Wounds penetrating the Cavity of the 
 Thorax . — Penetrating wounds of the- chest 
 are always dangerous, and claim the utmost 
 attention of the practitioner. I shall first 
 treat of such wounds as enter the cavity of 
 the thorax, but without injuring the viscera. 
 
 In the healthy state, the lungs so complete- 
 ly fill the thorax, that, both in inspiration and 
 expiration, they are always in close contact 
 w«h the pleura ; and whenever air, blood, 
 or any other matter, insinuates itself between 
 the pleura costalis and pleura pulmonalis, 
 more or less oppression and difficulty of 
 breathing immediately take place. In all 
 wounds attended with a division of the 
 pleura costalis, and occurring in a situation 
 where there happens to be no adhesion be- 
 tween this membrane and the lungs, some of 
 the external air, ora small quantity of blood, 
 or both, can hardly fail to get into the cavity 
 of the thorax. If one of the intercostal ar- 
 teries be wounded, and the external orifice 
 be very narrow, the blood furnished by this 
 vessel may pass into the chest, and immedi- 
 ately produce oppression of the breathing, 
 and other symptoms of pressure on the lungs. 
 Of what is to he done in this case, l shall 
 presently speak. 
 
 When a wound is known to have entered 
 the pleura, and there is no symptom leading 
 to a suspicion that the lungs, or any large 
 vessel, is wounded, the injury is to be dress- 
 ed according to common principles, and the 
 more superficially the better. Authors also 
 usually direct us, just before we close the 
 opening, to tell the patient to make a deep 
 inspiration, for the purpose of expelling as 
 much of the air as possible, which may have 
 passed into the cavity of the pleura. At the 
 end of such inspiration, the edges of the 
 wound in the skin are to be brought together, 
 and kept so with sticking-plaster, com- 
 presses, and a roller. The other indications 
 are to prevent inflammation of the pleura 
 and lungs by rigorous antiphlogistic reme- 
 dies, particularly bleeding, which should be 
 copious, and repeated as circumstances may 
 require. 
 
 Penetrating wounds of the chest may be 
 complicated with some of the following cir- 
 cumstances: 1. Foreign bodies. 2. Injury 
 of one of the intercostal arteries. 3. Pro- 
 trusion of a portion of the lungs. 4. Em- 
 physema. 5. Extravasation of blood in the 
 thorax. 
 
 1. Almost all these wounds occasion pain 
 and difficulty of breathing. Many of them 
 are also followed by an emphysematous 
 swelling around the w ound ; the patient fre- 
 quently coughs up blood : and after having 
 
 had for some time a small, contracted, irre- 
 gular pulse, with a pallid countenance and 
 cold extremities, he is too often seized with 
 severe fehrile symptoms, the effect of inflam 
 mation of the lung3 and parts within the 
 chest. These symptoms should be counter 
 acted by bleeding, a very low regimen, open 
 ing saline medicines, the use of leeches, or 
 cupping, and the strict observance of qui- 
 etude. If such indisposition should con- 
 tinue longer than a few days, without dimi 
 nation, writers inform us, that there is ground 
 for suspecting that they depend upon the 
 presence of some foreign body. However, 
 it may be doubted whether Sabatier’s advice, 
 iramediaiely to make search after the extra- 
 neous substance, is proper under these, cir- 
 cumstances. For tny ow r n part, I cannot 
 think the symptoms above related by any 
 means unequivocal, and even were they so, 
 the practice would -dill be questionable. 
 (See Medecine Opiratoire, Tom. 2, p. 244.) 
 
 Sabatier has quoted the two following 
 ca^es, for the purpose of showing what may 
 be attempted in these cases. — “ A man, twen- 
 ty-seven years of age, was struck very vio- 
 lently with a knife on the outer part of the 
 fourth true rib. Simple dressings were ap- 
 plied tor the first few 7 days; but a considera- 
 ble coughing and spitting of blood ensuing 
 M Gerard was consulted, wdio found, that 
 the symptoms depended on the presence of 
 a piece of the knife, which had pierced the 
 rib, and was projecting some way into the 
 thorax. So little of the foreign body w 7 as on 
 the outside of the rib, and it was so fixed in 
 the bone, that it could neither be extracted 
 with any kind of forceps, nor even moved 
 in the least with a leader, mallet, he. Al- 
 though the only expedient seemed now to 
 be that of sawing orcutting out the portion of 
 the rth, Gerard conceived that an attempt 
 might first be made to extract the foreign 
 body, by pushing it from within outward. 
 For this purpose, having put a steel thimble 
 on his index finger, he introduced it into the 
 cavity of the thorax, and thus succeeded in 
 pushing out the piece of the knife. 
 
 A spicula of the bone was afterward felt , 
 but it wa^too firmly connected with the rest 
 of the i ib to admit of being completely taken 
 out. Gerard was absurd enough to surround 
 the whole rib at the splintered part with a li- 
 gature . . To these ingenious proceedings, as 
 the French term them, was imputed, not only 
 the cessation of all the bad symptoms, but 
 a speedy recovery. (See la Faye's Notes to 
 the Trait 6 des Operations de Dionis.) 
 
 An officer was shot in the left side of the 
 chest. The ball entered about where the 
 bone and cartilage of the seventh true rib 
 unite, and came out in the situation of the 
 angle of the same bone, which was broken 
 in tw 7 o places. The posterior part of the 
 first false rib was also broken Incisions 
 were made, which enabled the surgeon to 
 take away several splinters of bone, and fa- 
 cilitated (that mischievous French practice) 
 the introduction of a seton. Soft mild dress 
 ings were applied. The patient was bled 
 twenty-six times, with the view of relieving 
 
WOUNDS. 
 
 the fever, difficulty of breathing, and spitting 
 of blood. On the fifth day, suppuration 
 commenced, and the seton could be easily 
 drawn. In about a fortnight, the patient’s 
 sufferings considerably abated, and he passed 
 som* of the ensuing days in a tolerably easy 
 state. Circumstance*, however, made it 
 necessary to move him to another place, and 
 on the twenty-fourth day, he had a bad 
 night ; febrile symptoms came on ; and the 
 discharge was not of its usual consistence. 
 He was bled twice more, and hia critical 
 state led the surgeon to examine the wounds 
 again. On passing a finger into the posterior 
 wound, a foreign body was felt, an i easily 
 extracted. It was a piece of the patient’s 
 coat. A spicula of bone was also felt more 
 deeply lodged, which required the wound to 
 be dilated. Partial relief followed the re- 
 moval of these extraneous substances. 
 
 On the thirtieth day, the bad symptoms 
 recurred, two more bleedings were practised, 
 and as fears were entertained that ike seton 
 zvas doing harm , it was suppressed. The pa- 
 tient now first made complaint ot feeling 
 something which pricked him, in a deep situ- 
 ation between the two openings of the 
 wound. It was therefore determined to di- 
 vide all the parts intervening between the 
 two orifices, and occupying an extent of 
 seven or eight inches. Guerin cut the parts 
 between the two ribs, from within outward, 
 under the guidance of his finger introduced 
 into the posterior wound, care being taken 
 not to cut near the lower edge of the upper 
 rib. In this way, the whole track of the 
 ball was laid open, and in the middle of it. a 
 very sharp splinter was found, projecting 
 into the substance of the lungs. It was re- 
 moved, and the wound dressed with simple 
 applications. From this day all the bad 
 symptoms ceased. (06s. de Guerin in Mem. 
 de I’Acad. de Chir. T. 2 ; 41c.) 
 
 Mr. John Bell has taken notice of the pre- 
 ceding case ; he observes, that some of Gue- 
 rin’s steps were bold and good, as well as 
 successful; but that the employment of the 
 seton was wrong. The example teaches us 
 several important circumstances : 1. The 
 propriety of making very free dilatations for 
 the extraction of splinters of bone. 2. The 
 utility of repeated copious bleedings, which 
 in the above case, indeed, had the greatest 
 effect both in preventing such hemorrhage in 
 the chest as would probably have produced 
 suffocation, and also in averting a degree of 
 pulmonary inflammation, which would have 
 proved fatal. 
 
 Mr. John Bell judiciously condemns the 
 seton : “ Had M. Guerin (says he) been 
 asked what good it was to do, it would have 
 been difficult for him to have invented even 
 a plausible apology for the practice which, 
 if it was not doing good, could not fail to do 
 harm. Was this seton nece sary for keeping 
 the wound open ? No, ureiy ; for the wound 
 could not have closed while il was irritated 
 and kept-in suppuration by splinters of bone, 
 and a piece of cloth within the breast. Was 
 it to draw the piece of cloth out ? Surely, in 
 the course of twentr days, a piece of cloth 
 Vo;,. II ' S3 
 
 657 
 
 would have had some chance at least of be- 
 ing floated towards the wound, either by the 
 natural flux of the matter, or by the help of 
 a mild injection. Was it uspful in support- 
 ing the discharge ? This would have been a 
 sore question lor M Guerin ; for it support- 
 ed the suppuration only by inflaming the 
 chest ; and where inflammation of the chest, 
 or high cough, or bloody expectoration, or 
 a profuse discharge, were the chief dangers, 
 a great seton could hardly be a comfortable 
 inmate in the breast. 1 think one might 
 very boldly promise to produce bloody ex- 
 pectoration and terrible cough, profuse sup- 
 purations, and oppression, to any degree, by 
 drawing such a cord across a sound thorax.” 
 
 Mr. John Bell next censures M. Guerin for 
 not having discovered the pricking piece of 
 bone before the thirty-eighth day; a disadvan- 
 tage which he partly ascribes to the seton, 
 the pain of drawing which across the chest 
 deadened every lesser pain, and, consequent- 
 ly, the patient could not feel the trilling 
 pricking of the bone, (ill his greater suffer- 
 ings from the seton were allayed. “ In short, 
 (says Mr. John Bell,) M. Guerin passes a 
 a great strap of coarse linen across the cavi- 
 ty of the chest, and when it causes inflam- 
 mation, he thinks to subdue it by bleeding ; 
 when M. Guerin continued for thirty days 
 drawing a coarse seton through the breast 
 every morning, and bleemng for the cough 
 every night, what did he do but raise inflam- 
 mation with his left hand, to show how well 
 he could cure it w ith his right ?” (See John 
 Bell on Wounds , Vol. 2, p. .36 — 38.) 
 
 The liability of wounds of the chest to be 
 complicated with the lodgement of foreign 
 bodies, is a circumstance of which the prac- 
 titioner should ever be mindful. u In the 
 examinations of the bodies of soldiers who 
 have died from these injuries, (says Dr. 
 Hennen,) I have frequently found pieces of 
 wadding or clothes, spiculae of bone, and 
 balls, and, in one case, some charpie used as 
 a dressing ; either loose in various parts of 
 the lungs, or lying in sacs, which the exer- 
 tions of the constitution to free itself had 
 thrown round them by the medium of the 
 coagulating lymph. Iu the more fortunate 
 few who have recovered, these matters have 
 been discharged from the wounds, or ex- 
 tracted from them by the surgeon. In some 
 lucky cases, they have been ejected by the 
 convulsive efforts to cough, which their irri- 
 tation has occasioned.” ( On Military Sur- 
 gery , Ed. 2, p. 367 ) For an account of the 
 dexterity with which Larrey has sometimes 
 traced balls in ihe chest, and extracted them 
 by bold operations, I must refer to his valua- 
 ble writings. (See Mem. de Chir. Mil . T. 4 ,p. 
 250, fyc.) Balls have sometimes lodged and 
 remained encysted in the lungs for upwards 
 of twenty years, without the health beins; at 
 all disturbed by their presence (See Percy, 
 Manuel , fyc p. 125 ; Boyer , Trait 6 des Mai. 
 Chir. T. 7,p. 310, fyc.) 
 
 2. When one of the intercostal arteries is 
 wounded by a narrow oblique stab, the ac- 
 cident cannot at first be known. In this 
 case, the blood commocly make? its way 
 
WOUNDS. 
 
 6-58 
 
 into the cavity of the chest, where it causes 
 a more or less considerable extravasation. 
 But when the wound is ample, and direct, 
 the effused blood, which has all the charac- 
 ters of arterial blood, leaves no doubt con- 
 cerning the injury of an intercostal artery. 
 However, if any uncertainty prevail, it may 
 easily be dispelled, by introducing a finger 
 into the wound, and making pressure with 
 it on the lower edge of the rib, which cor- 
 responds to the vessel suspected to be in- 
 jured. 
 
 Gerard proposed to stop hemorrhage from 
 the intercostal artery, by means of a liga- 
 ture. His plan was to enlarge the external 
 wound, as far as the upper edge of the rib, 
 corresponding to the wounded intercostal 
 artery, and then to introduce into the chest 
 a common curved needle, armed with a 
 ligature, to which was attached a dossil of 
 lint. The needle was passed behind the 
 rib, rather higher than the superior edge of 
 the bone. The point of the instrument was 
 then pushed from within outward, and 
 brought out through the external wound, 
 together with the ligature. When the dossil 
 had come into contact with the artery, the 
 two ends of the ligature were tied over a 
 thick compress, placed on the outside of the 
 rib. In this manner, the bone was sur- 
 rounded with the ligature, and the artery 
 compressed. 
 
 Goulard, of Montpelier, having found dif- 
 ficulty in passing a common needle, whose 
 shape little corresponded to the track, 
 through which it had to pass, being curved 
 towards its point, and straight towards the 
 eye, invented one expressly for this opera- 
 tion. He also objected to the common 
 bent needles, as he conceived that they 
 might wound the lungs with their sharp 
 points and edges. Goulard’s needle formed 
 three-fourths of a circle, and was fixed on a 
 long handle, which facilitated its introduc- 
 tion. The eye, in which the ligature was 
 put, was situated near the point, which was 
 a little blunted, and the ligature lay in a 
 groove, in the convexity of the instrument. 
 When the needle had passed through the 
 intercostal muscles, and its point had made 
 its appearance over the rib, which was 
 above the artery, the ligature was untied, 
 and held, while the needle was withdrawn 
 at the place where it had entered. The 
 ligature was then tied, as in Gerard’s me- 
 thod. 
 
 It was afterward thought, that com- 
 pression might answer better than the fore- 
 going use of the ligature. Lottery, professor 
 of anatomy in the university of Turin, con- 
 structed, for this purpose, a steel plate, 
 which is described, and engraved in the 
 second volume, 4to. of the Metnpires de 
 1’Acad. de Chir. This plate was narrow at 
 one end ; broad at the other ; and curved 
 in two directions at its narrow part, where 
 there were some holes, by means of which 
 a compress for the artery was fastened ori 
 the instrument. The broad end of the plate 
 bad two long parallel slits, through which a 
 
 riband was passed, with which the instru- 
 ment was secured. 
 
 When the wound, corresponding to the 
 intercostal artery, was sufficiently extensive 
 in the transverse direction, the narrow, bent 
 end of the instrument was so introduced, 
 that the lower edge of the rib above was 
 placed in the concavity of the curvature, 
 while the compress acted on the edge of 
 the bone, and, of course, 011 the artery. 
 The rest of the instrument appiied itself to 
 the side of the thorax, in which situation it 
 was fastened. When the wound was not 
 ample enough, a sufficient dilatation of it 
 was first made for the introduction of the 
 instrument. 
 
 Quesnay employed a piece of ivory, which 
 he covered with lint, Lc. and then intro- 
 duced within the chest. The instrument 
 was then drawn from within outward, by 
 means of a riband, and thus the necessary 
 compression was produced. 
 
 Quesnay’s plan is somewhat like that in- 
 vented by Lottery. But, to have introduced 
 the compress entirely into the thorax, to- 
 gether with the ivory, which was the basis 
 of it, and then to have drawn the contri- 
 vance from within outward, as was probably 
 intended, a very large wound would have 
 been indispensable. This was also one of 
 the many strong objections to Lbttery’s 
 instrument, which, in fact, could only be 
 employed when there was a free and ample 
 opening. 
 
 Belloque, seeing the inefficacy of all the 
 compressing means used before his time, 
 and their inconveniefices, invented an in- 
 strument, which, he says, is calculated for 
 making proper pressure, and following the 
 motion of the ribs, without hindering the 
 escape of extravasated blood. The machine 
 is engraved, and described, in 2 T. of Mem. 
 de 1’Acad. de Chir. 4to. It is composed of 
 two plates, which are wadded, and capable 
 of being brought towards each other by 
 means of a screw. This instrument, as Sa- 
 batier observes, may indeed answer ; but it 
 is complicated and awkward, and its utility 
 is founded on the supposition of the wound 
 being larger, than wounds are, which are 
 made with common weapons. 
 
 Justly averse to any unnecessary multi- 
 plication of surgical instruments, modern 
 practitioners reject all particular contrivan- 
 ces for stopping hemorrhage from the inter- 
 costal arteries. Indeed, as the accident is 
 very rare, it is probable, that, if the best in- 
 strument possible were devised, it would 
 hardly ever be at hand, when required. 
 
 A common dossil of lint (says Sabatier,) 
 fastened to a strong ligature, and introduced 
 between the two ribs, or even quite into 
 the chest, and then drawn, from within out- 
 ward, like Quesnay’s compress, would fulfil 
 every desirable purpose. The ■ external 
 wound should then be covered with simple 
 dressings, and a bandage applied round the 
 body. The patient should be freely and 
 repeatedly bled, and treated on the most 
 rigorous antiphlogistic plan. 
 
 Professor Assalini joins all the best, mo- 
 
WOUNDS. 
 
 659 
 
 dern surgeons in reprobating the introduc- 
 tion of the preceding contrivances and ex- 
 traneous substances into the chest, in order 
 to stop hemorrhage from the intercostal ar- 
 tery. All these methods, he remarks, .are 
 calculated to excite a dangerous degree of 
 inflammation in the chest. Hence he pre- 
 fers simply cutting the artery across, so as 
 to allow it to retract, and if this plan fail, he 
 recommends the wound to be elosed. 
 Should the blood find its way into the chest, 
 it is true, the consequences will be serious, 
 but not fatal ; and, if the symptoms require 
 it, the operation of empyema may after- 
 ward be done. A small quantity of effused 
 blood, however, may be absorbed, and no 
 such proceeding be requisite. ( Manuale di 
 Chirurgia , p. 58, 59.) 
 
 Dr. Hennen conceives, that whenever the 
 tenaculum can be used for an injured inter- 
 costal artery, the practice should be adopted. 
 He states, that cases are reported in which 
 the vessel was thus secured ; but that he has 
 never seen the method adopted himself. 
 “ Unfortunately, (says he) we but too often 
 are disappointed in finding the source of the 
 hemorrhage, and here judicious pressure is 
 our only resource. In some very slight 
 cases, I have used the graduated compress 
 with success; but if the sloughing is exten- 
 sive, nothing but the finger of an assistant, 
 relieved as often as occasion may require, 
 aud pressure direct upon a compress placed 
 along the course of the vessel, or so dispo- 
 sed as to operate upon its bleeding orifice, 
 will be of any avail. (, Military Surgery, Ed. 
 2, p. 377.) 
 
 3. The protrusion of a portion of the 
 lungs, in consequence of wounds penetra- 
 ting the tfhest, is a very unusual case : but 
 there are some instances recorded by wri- 
 ters : and one case l attended myself after 
 the battle of Waterloo. Sehenckius relates 
 an example, taken from Rolandus, The 
 latter was called to a man, who had been 
 wounded in the thorax, six days before. A 
 portion of the lungs protruded in a state of 
 mortification. Rolandus extirpated it, and 
 the patient soon recovered. 
 
 Tulpius has recorded a similar fact. A 
 man received an extensive wound, just be- 
 low his left nipple. His naturally gay dis- 
 position, however, led him to neglect the 
 injury; and on the third day a piece of the 
 lung3, three inches in length, protruded. 
 The patient went to Amsterdam, whence he 
 was distant two days’ journey, for the pur- 
 pose of receiving succour in one of the hos- 
 pitals of that city. The protruded piece of 
 lung, which was already mortifying, was 
 tied, and cut off with scissors. It weighed 
 three ounces. The wound healed in a fort- 
 night, and the patient experienced no com- 
 plaint afterward, except a slight cough, with 
 which he was occasionally troubled. He 
 survived the accident six years, leading a 
 wandering, drunken life. After death, no- 
 thing particular was observed in the thorax, 
 except that the lungs had become adherent 
 to the pleura, in the situation of the wound, 
 Hildanus relates another case : a man wa? 
 
 wounded with a knife, between the fifth 
 and sixth ribs, near the sternum. As a piece 
 of lung protruded through the opening, and 
 had a livid colour, it was extirpated with 
 the actual cautery. The wound was then 
 dilated, and the ribs kept apart, with a 
 wooden wedge, under which plan, the por- 
 tion of lung, girt by the opening, shrunk 
 within the chest. The patient was soon 
 completely well. 
 
 A fourth example of a protrusion of a 
 piece of lung through a wound in the tho- 
 rax, is among the cases recorded by Ruysch. 
 The servant of a seafaring man was wound- 
 ed in the anterior and inferior part of the 
 chest, and was immediately attended by a 
 surgeon, who mistook the protruded piece 
 of lung for a portion of omentum, and ap- 
 plied a tight ligature round it. Ruysch, who 
 was consulted, soon detected the mistake 
 which had been made, but he delivered his 
 opinion, that the wound would heal very 
 well, as soon as the tied piece of lung was 
 detached. The event justified his prognosis, 
 and the patient recovered. 
 
 When the protruded portion of lung is 
 sound, the reduction ought to be made 
 without the least delay. It should be done 
 on the same principles as those on which 
 protruded pieces of intestine, or omentum, 
 are reduced. (See Wounds of the Abdomen .) 
 A recurrence of the accident is to be pre- 
 vented by closing the wound, and placing 
 a compress over it. But when the piece of 
 lung is already in a mortified state, in con- 
 sequence of the constriction which it has 
 suffered, or when its large size prevents re 
 duction, Sabatier is of opinion, that the only 
 resource is to extirpate the part, after apply- 
 ing a ligature round its base. If the latter 
 step were not taken, a dangerous hemor- 
 rhage might follow, or even an extravasa- 
 tion in the thorax. (Midecine Optratoire , 
 Tom. 2, p. 224.) However, the practice 
 recommended by Sabatier appears ques- 
 tionable in the instance of mortification, be- 
 cause the dead part will naturally be thrown 
 off by a spontaneous process ; and when 
 the wound is too small to allow the part to 
 be returned, its dilatation might be more 
 adviseable than the removal of a consider- 
 able portion, or even any, of the lung. 
 
 After the battle of Waterloo, I had a pa- 
 tient with a protrusion of a piece of lung, 
 four or five inches in length. The part was 
 much bruised, and coitld not be easily re- 
 duced. I therefore applied a ligature round 
 its base, and cut it off. Previously, how- 
 ever, I made an incision in it, in order to 
 ascertain ^whether it would bleed freely, 
 which being the case, induced me to use a 
 ligature. I was afterward informed by my 
 friend Mr. Collier, that the man died. 
 
 4. Emphysema is another symptom with 
 which penetrating wounds of the chest are 
 frequently complicated, especially when 
 they are small, and indirect. When such 
 wounds are small, and not straight in their 
 course ; when their track is rendered im- 
 pervious either by change in the situation 
 of the muscles, the swelling of the parts. 
 
WOUNDS. 
 
 liOU 
 
 clots of blood, or any extraneous substan- 
 ces ; air may insinuate itself into the cellu- 
 lar substance, so as to cause a great deal of 
 tumour and distention. Emphysema is 
 easily distinguishable by the tumefaction of 
 the part affected, without any pain, or 
 change of colour in the skin, and by the 
 crepitation which is perceptible on pressing 
 the air from one part of the cellular sub- 
 stance into another. Emphysema may take 
 place, where the lungs are not wounded, 
 but in this case it can never be of much ex- 
 tent. Here the emphysematous swelling is 
 caused by the air, which insinuates itself 
 into the cavity of the thorax through the 
 wound, during the first inspirations which 
 follow the accident, and the same air is 
 expelled in the subsequent acts of expira- 
 tion. But when the lungs are wounded, the 
 emphysema arises from the escape of air 
 from those organs, during inspiration, first 
 into the cavity of the thorax, and thence, 
 through the inner opening of the external 
 wound, into the cellular substance. 
 
 I should have deemed it unnecessary to 
 have said any thing in this part of the work, 
 on the present subject, and have contented 
 myself with referring to the article Emphy- 
 sema, were not the cause of this symptom 
 rather perplexing, and did I not hope that 
 the following extract from Sir A. Halliday’s 
 publication will tend to facilitate the com- 
 prehension of these cases. This gentleman 
 menlions the following circumstances, under 
 which air may escape from the lungs, or 
 emphysema arise. 
 
 1st. u An injury or disease of the pleura 
 pulmonalis, causing a wound or ulceration 
 of that membrane, and thus allowing the air 
 to escape from the lungs, as in oblique ex- 
 ternal wounds, where the outer opening, 
 and that of the pleura costalis have healed, 
 or closed up, and in ulcers of the surface of 
 the lungs. 
 
 2dly. “ The pleura pulmonalis, and pleura 
 costalis, may be wounded or ulcerated when 
 there is no external opening, as when the 
 ends of fractured ribs penetrate through both 
 into the substance of the lungs; and it is 
 from this accident, fcc. that emphysema most 
 commonly takes place. 
 
 3d!y. “The common- integuments of the 
 parietes of the chest, the intercostal muscles, 
 and the pleura costalis may be wounded, 
 while the plura pulmonalis and the lungs 
 remain uninjured, so that the air admitted 
 from without, and collected in the cavity of 
 the thorax, may be pressed into the cellular 
 membrane, so as to occasion emphysema.” 
 
 The same writer remarks, “ that the lungs 
 in the thorax have often, and not unaptly, 
 been compared to a bladder in a close pair 
 of bellows; but if we suppose the bellows 
 to be divided into two compartments, and 
 each of these to contain a bladder, which 
 mutually communicate with each other, and 
 with the external air, by means of a tube 
 which is exactly adapted to the nozzle of 
 the bellows, arid which admits the air only 
 into the cavity of the bladders, and not into 
 the space betwixt the bladders and bellows. 
 
 we shall then have a perfect representation 
 of the mechanical structure of the thorax 
 The bellows will represent the thorax, divi- 
 ded in the middle by the mediastinum ; the 
 bladders will represent the lungs of the right 
 and left sides; and the tube, which com- 
 municates with the bladders and with the 
 external air, will represent the trachea. The 
 only thing which is wanting to render this 
 mechanical representation perfect* is, that 
 the bladders should exactly fill (he bellows, 
 so as to leave no air betwixt them and the 
 bellows.” 
 
 It is explained by Sir A. Halliday, that 
 when the handle of the bellows is lifted up, 
 the bladders become filled by the external 
 air, which rushes in through the tube which 
 communicates with both of them. When the 
 handle is depressed, the air is expelled again. 
 In the like manner the lungs are filled with 
 air, and emptied again when the capacity of 
 the chest is enlarged by the inspiratory rnus° 
 cles, and then diminished by the expiratory 
 ones. 
 
 When emphysema arises from a wound, 
 or ulceration of the pleura pulmonalis, on 
 one side of the thorax, the case is nearly the 
 same as if an opening were made in one of 
 the bladders, which opening would form a 
 communication, as the same gentleman ob- 
 serves, with the bellows and bladder on one 
 side. It this should happen while the handle 
 of the bellows is depressed, no sooner is the 
 handle raised, than air rushes into the 
 space betwixt the bladder and bellows, and 
 on keeping up the handle a little while, the 
 bladder will become quite collapsed, and the 
 place which it occupied, while distended, 
 will now be occupied by the air. If now, 
 says Sir A. Halliday, u we attempt to force 
 out the air, by depressing the handle of the 
 bellows, we shall find that this cannot be 
 done ; for there is no direct communication 
 between the bellows and the external air ; 
 and as the effused air presses equally on all 
 parts of the collapsed bladder, it cannot es 
 cape through it.” 
 
 When the thorax is expanded in inspira- 
 tion, the pressure is taken off the surface of 
 the wounded lung, and the air which now 
 enters this organ, instead of distending its 
 cells, passes through its wound into the 
 space between the pleura pulmonalis, and 
 pleura costalis. The lung will, indeed, be 
 partially expanded, as long as inspiration on 
 that side goes on ; the more so, the smaller 
 its wound is. At every expiration, however, 
 when the thorax is diminished, the effused 
 air will be compressed against the wounded 
 lung; but none of the air which has escaped 
 can re-enter the lung again ; “ because (as 
 the preceding writer accurately remarks) the 
 whole of the air contained in the lung, must 
 be forced out, and then (lie pressure (of the 
 air) against every part of the collapsed lung 
 being 6qual, will prevent its separating any 
 part, so as to make a passage for itself into 
 the trachea.” Thus fresh air accumulates at 
 every inspiration in the space between the 
 pleura?, while none can escape from the same 
 situation during expiration, and the quantity 
 
W#UNDS 
 
 661 
 
 accumulated will, at last, eqaal that which is 
 received into the other lung, during the most 
 powerful inspiration. 
 
 When the pleura pulmonalis, and pleura 
 costalis are both wounded, the same effusion 
 of air between them continues from the 
 above-mentioned causes, till the lung collap- 
 ses. Vyben an attempt is now made to ex- 
 pire, the injufed side of the thorax must con- 
 tinue distended, notwithstanding every el- 
 fort of the patient. In this expiratory act, 
 however, if the capacity of the thorax be 
 diminished, and the air compressed, a part 
 of it finds its way through the wound in the 
 pleura costalis, into the common cellular, 
 substance of the parietes of the chest. 
 
 The passage of air into the cavity of the 
 thorax during the inspiration is, as Sir A. 
 HaUiday observes, now more easy than the 
 return of that already effused in the cellular 
 membrane, and consequently, the subcuta 
 neons emphysema continues to increase with 
 a rapidity which is remarkable, as long as 
 the patient lives. 
 
 To explain the origin of emphysema, in 
 cases of wounds, which only enter the chest, 
 and do not injure the lungs at all, this writer 
 has recourse to the simile of the bellows and 
 bladders. Were an opening made into the 
 bellows, without injuring the contained 
 bladders, and the access of air by this open- 
 ing more free than that by the nozzle, com- 
 municating with the cavity of the bladder, 
 more air would enter by the opening, than 
 by the pipe, on the handle being raised, so 
 that the bladder would not rise as usual, 
 when no opening in the side of the bellows 
 existed. If the latter opening be smaller than 
 that of the pipe, the bladder will only be par- 
 tially filled, and on depressing the handle of 
 the bellows, the air contained in the bladder, 
 and that between the bladder and the bel- 
 lows, will be expelled in the same propor- 
 tion to each other, as that in which they 
 were formerly filled. This process would 
 continue to go on in the same way, did not 
 the bladder naturally collapse more and 
 more from its gravitation. Let us now stop 
 the mouth of the pipe, while the handle of 
 the bellows is raised, and the bladder par- 
 tially filled. On trying next to depress the 
 handle, it results, that as no air can escape 
 from the pipe, the air contained between 
 the bladder and the bellows must be first 
 evacuated, while that contained in the blad- 
 der of the sound side, will be forced into 
 the bladder on the injured side, and either 
 distend it, so as to rupture it, or cause it to 
 protrude. 
 
 Hence, in the case of a wound penetra- 
 ting the chest, without injuring the lungs, if 
 the air can enter more freely by the 
 wound than by the trachea, more of it 
 will enter, in the act of inspiration, into 
 the cavity of the thorax, than into the lungs. 
 On the contrary, when the opening of the 
 wound is not so large as that of the tra- 
 j chea, less air will enter the thorax than the 
 lungs. 
 
 In the expiration, the air will be forced 
 from the two different situations, in pro- 
 
 portion to the quantity which enters each 
 of them in inspiration, and no air at all 
 would accumulate in the thorax, did not 
 the lungs always tend to collapse from their 
 gravitation. Should, however, the patient, 
 in making an effort to expire, contract 
 the glottis, the air contained in the lungs 
 of the sound side, may be propelled into the 
 bronchia and air-cells of the lungs, on 
 the same side as the wound, so as to distend 
 them, and even make them protrude at the 
 wound. 
 
 Dr. HaUiday remarks, that such a pro- 
 trusion often happens, when wounds are 
 made in dogs, and has been erroneously 
 adduced as an argument against the col- 
 lapse of the lungs, when an opening is made 
 into the thorax of the human subject. (See 
 Obs. on Emphysema , by Sir A. HaUiday, 
 1807.) 
 
 For information concerning the treatment 
 of this affection, see Emphysema. 
 
 5. I have already noticed, that wounds of 
 the thorax may injure one of the intercostal 
 arteries, and when the blood cannot flow 
 outward, it may be extravasated in the 
 chest. The same consequence may follow 
 wounds of the pulmonary vessels, those of 
 the heart, or of the heart itself. And here I 
 may take the opportunity of remarking, that 
 sometimes wounds of the heart do not 
 prove instantaneously fatal. A case in which 
 a bayonet passed through the colon, sto- 
 mach, diaphragm, part of the lungs, and the 
 right ventricle of the heart, and yet the pa- 
 tient lived nine hours after the receipt of the 
 injury, is recorded by Dr. Babbington. (See 
 Med. Records and Researches , Lond. 1798 ; 
 also a case by Ckastenet in Jour, de Med. 
 Mil. T. 2.) In almost all cases, however, 
 such injuries prove instantly fatal ; and the 
 same remark will extend to cases of hemor- 
 rhage from vessels above a certain size, 
 but when they are less considerable, the pa- 
 tient may live for a greater or less time, and 
 receive the aid of surgery. 
 
 The following are the symptoms which 
 denote an extravasation of blood in the 
 thorax. The patient feels great oppression, 
 and such uneasiness as will not let him long 
 continue in one position. Unless he bend 
 his body very much forward, in which posi- 
 tion, the diaphragm is relaxed, and not so 
 much dragged by the weight of the extrava- 
 sated fluid, he feels great difficulty in stand- 
 ing or sitting up. When the thighs are 
 bent, the patient can lie with tolerable 
 ease on his back ; be is also not averse to 
 lying on the side, on which the wound is 
 situated ; but he cannot place himself on the 
 opposite side, without feeling very acute pain 
 in the situation of the mediastinum. 
 
 His respiration is short, frequent, and in- 
 terrupted by sighs ; his veins become emp- 
 ty ; a cadaverous paleness spreads over his 
 countenance ; his extremities become cold ; 
 a viscid perspiration covers his neck and 
 temples; his teeth chatter; his pulse be- 
 comes weak ; and if, as most frequently 
 happens, the lungs are wounded, he spit?- 
 
WOUNDS. 
 
 
 up frothy blood, end air issues from the 
 wound. 
 
 Though one might suppose (he above 
 class of symptoms always attendant on a 
 considerable effusion of blood in the thorax, 
 this is not the case. Wounded persons 
 have been known to die of such an extrava- 
 sation, whose respiration was tolerably free, 
 and who did not complain of suffering more 
 inconvenience in one posture than another. 
 Sabatier says, that several facts of this kind 
 have fallen under his own observation. 
 Olher wounded persons, also, who suffered 
 most of the complaints ascribable to extra- 
 vasations of blood in the thorax, have been 
 cured by ordinary means. Mery gives an 
 account of a young man, wounded in the 
 anterior and superior part of the chest, about 
 two o’clock in the morning, who had such 
 difficulty of breathing, and fever, five hours 
 afterward, that an extravasation was sup- 
 posed to exist, and Mery was thinking of 
 making an opening for its, evacuation. A 
 tumour near the great pectoral muscle, pre- 
 senting neither t lie feel of fluctuation, nor 
 that of emphysema, made him suspend his 
 decision. The tumour was dispersed by 
 bleeding, and the application of compresses, 
 dipped in a mixture of spirit of wine and 
 water. 
 
 However, even the assemblage of the 
 above symptoms did not deceive Petit. 
 Having been requested to assist at an ope- 
 ration, which was about to be done on a 
 wounded man, about whose armpit, pecto- 
 ralis major, and latissimus dorsi muscles a 
 prodigious emphysematous swelling had ta- 
 ken place ; whose respiration was painful 
 and difficult ; and who spit up frothy blood ; 
 Petit gave it as his opinion, ihat it was unne- 
 cessary to make an opening into the chest. 
 He thought it would be sufficient to enlarge 
 the wound, which was at a little distance 
 from the armpit, near the edge of the latis- 
 simus dorsi, so as to give vent to the effused 
 air. This advice was followed, th§ emphy- 
 sema soon disappeared, and the patient re- 
 covered. 
 
 The equivocal nature of the symptoms of 
 extravasations of blood in the thorax, has 
 induced practitioners to pay the most scru- 
 pulous attention to every circumstance at- 
 tendant on these cases. In several instan- 
 ces, Valentin remarked, that an ecchymosis 
 occurred, at the angle of the false ribs, and 
 spread towards the loins. The ecchymosis 
 is described as being of a clear purple 
 colour, like the spots which sometimes 
 form on the abdomen, a little while after 
 death. In a case, in which most of the 
 symptoms of extravasation were combined 
 with the above sort of ecchymosis, Valen- 
 tin advised a counter-opening to be made. 
 The advice was overruled, and the patient 
 soon afterward died : more than six pints 
 of blood were found extravasated in the 
 thorax. 
 
 Sabatier remarks, that we cannot too 
 highly applaud the zeal of those practi- 
 tioners, who endeavour to dispel the doubts 
 which still prevail in several parts of sur- 
 
 gery. At the same time, he thinks, that ail 
 who take interest in the improvement of 
 this science, should endeavour to ascertain 
 the truth of any new observations which 
 are offered. Hence, he deems it proper to 
 relate a case which was communicated to 
 him by M. Saucerotte (the father,) an emi- 
 nent military surgeon, and which shows 
 that the ecchymosis, observed by Valentin, 
 is, at least, not invariably attendant on ex- 
 travasations of blood in the chest. A light- 
 horseman, who had received a thrust with 
 a sabre in the right side of the thorax, 
 above the tendon of the pectoralis major, 
 appeared to be going on very well for the 
 first four days after the accident. On the 
 fifth, he complained of difficulty of breath- 
 ing, uneasiness, and an inability of lying on 
 the left side, without aggravating his com- 
 plaints. He complained of a great deal of 
 pain in the region of the liver, and at the 
 top of the shoulder. His pulse was small 
 and contracted, and rather hard than weak. 
 The right side of the chest seemed larger 
 than the left. On the eight and ninth day, 
 the symptoms became more urgent, and the 
 patient found no ease, except in leaning on 
 his right side, and supporting himself on a 
 chair, placed across his bed. This assem- 
 blage of symptoms indicated an extravasa- 
 tion of blood in the right cavity of the 
 thorax ; but as the ecchymosis, which Va- 
 lentin has described, was not apparent, 
 doubts were entertained about the real na- 
 ture of the case. When a counter-opening 
 was made on the dead body, a pint of pu- 
 trid blood flowed out. 
 
 When the surgeon feels assured, that an 
 extravasation of blood in the thorax has 
 really occurred, and the symptoms are very 
 urgent, the discharge of the confined fluid 
 appears to promise benefit. However, be- 
 fore the operation is done, the revived state 
 of the pulse, the return of warmth in the 
 extremities, and the cessation of great faint- 
 ness, ought to denote, that the hemorrhage 
 no longer continues from the vessels ; for, 
 if this be not the case, a fresh quantity of 
 blood must soon be extravasated again, and 
 the patient die exhausted. 
 
 Authors mention five methods of dis- 
 charging blood from the thorax ; viz. 1st. 
 By placing the patient in a posture, which 
 favours the escape of the blood. 2dly. By 
 introducing a syringe for the purpose of 
 sucking it out, or a mere cannula, through 
 which it is to flow. 3dly. By enlarging the 
 wound. 4thly. By employing injections. 
 Stilly By making an opening in a depend- 
 ing part of the thorax. 
 
 1. Success cannot be expected from 
 merely placing the patient in a posture, 
 which is favourable to the escape of the ex- 
 travasated blood, except when the wound 
 is situated at the inferior part of the chest, 
 and is large and direct in its course. Parc 
 successfully adopted this method in the 
 case of a soldier, who was stabbed in three 
 places with a sword ; one of the wounds, 
 which entered the chest, being situated 
 under the right nipple. The man was fire* 
 
WOUNDS 
 
 Otje 
 
 dressed by a surgeon, who made several 
 sutures. The patient was soon afterward 
 attacked with considerable difficulty of 
 breathing, fever, coughing, spitting of blood, 
 and acute pain in the side. Par6, who was 
 consulted the next day, suspected that an 
 extravasation had happened ; consequently 
 he cut out the sutures, and placed the pa- 
 tient in a position, in which his feet were 
 much more raised than the head. Pare also 
 recommended him to hold his breath, and 
 then introduced his finger into the wound, 
 in order to take away some clots of blood, 
 which appeared at its orifice. By these 
 steps, the discharge of seven or eight ounces 
 of fetid coagulated blood was effected. 
 
 2. The idea of drawing out of the thorax 
 extravasated blood with a syringe is rather 
 ancient. The pipes of all syringes, for this 
 purpose, should have blunt ends, lest they 
 injure the lungs. Mere tubes, containing a 
 stilet, have also frequently been employed. 
 Scultetus relates a case, in which an instru- 
 ment of the latter sort was successfully 
 employed. No syringe, nor any suction 
 with the mouth/ was requisite. It was 
 found necessary merely to introduce the 
 tube, and then withdraw the stilet. 
 
 Lamotte used only a simple cannula, 
 which he introduced into the centre of the 
 extravasation. Then having placed the 
 patient in what he conceived to be the most 
 favourable posture, and requested him to 
 hold his breath, he drew &ff the collection 
 of fluid. The cases numbered 216, 217, 218, 
 show the success which attended this me 
 thod. Although it might also have answered 
 very well in case 219, Lamotte saw that the 
 high situation of the wound w ould not have 
 allowed all the blood to be discharged, and 
 therefore he made a counter-opening. 
 Thus the thorax was completely emptied, 
 and a recovery ensued. When a cannula 
 is employed, authors recommend it to be 
 introduced every day till the bad symptoms 
 cease, and no more fluid escapes through 
 the cavity of the instrument Alter having 
 given vent to blood, it allow's a bloody se- 
 rous fluid to escape, and at a later period 
 pus, w hich becomes of a thicker and thicker 
 consistence, the nearer the patient is to a 
 recovery. 
 
 3. The cases in which a wound, compli- 
 cated with an extravasation in the chest, 
 should be dilated, are those in which the 
 situation of the opening is favourable to 
 the escape of the blood. The operation is 
 performed with a curved bistoury, and a 
 director. The integuments, and external 
 muscles, are to be divided in a perpendicu- 
 lar direction, and the intercostal muscles 
 in a line parallel to the ribs. Care is also 
 to be taken not to cut loo near the lower 
 edge of the upper rib, lest the intercostal 
 artery be wounded. Dionis practised such 
 an operation on a soldier, who was wound- 
 ed at Befort, in 1703, with a sword below 
 the right nipple, whereby a direct opening 
 was made into the thorax. When the ex- 
 travasated fluid had been let out, Dionis 
 made the patient lie on the wounded side 
 
 during the night, and in proportion as the 
 blood continued to be thus evacuated, the 
 breathing became free from oppression. 
 
 4. The methods, above explained, may be 
 of use when the blood retains its natural 
 state of fluidity; but, when it is coagulated, 
 as often happens, they can be of no avail. 
 In tins circumstance, most authors direct a 
 proper opening to oe made, and tepid water 
 then to be thrown into the chest, with the 
 view of loosening and dissolving the coa- 
 gula and washing them out Of the wound. 
 The French writers, even the modern ones, 
 ( Sabatier ) most absurdly recommend the 
 injection of various detergent vulnerary de- 
 coctions, and of solutions of honey of roses, 
 soap, salt, fcc. What idea these authors can 
 entertain of the great tendency to inflam 
 mation of the lungs and pleura, or what 
 good they can expect from such applica- 
 tions, is difficult of conception. 1 am firmly 
 convinced, that the meanest scribbler on 
 surgery, in this country, would be ashamed 
 of offering such advice. 
 
 5. When the wound is narrow, and situ- 
 ated at the upper part of the chest, the ex- 
 travasated blood cannot be discharged, un- 
 less a counter-opening be made at the lower 
 part of this cavity. The best place for mak- 
 ing the opening, and the proper manner of 
 executing the operation, are described 
 under the head of Paracentesis. As soon as 
 the opening has been made, the blood flows 
 out. Its discharge is then to be promoted 
 by such a posture as will render the open - 
 ing depending. 
 
 The old surgeons, who had much more 
 fear than the moderns of letting the opening 
 heal up, sometimes employed tents for the 
 purpose of preventing this event, until all 
 danger of another collection of blood or 
 matter seemed to be over. However, as 
 in these cases tents are apt to bring on in- 
 flammation of the pleura and lungs, hinder 
 the escape of whatever fluid is contained in 
 the chest, and cause great irritation, pain, 
 and even exfoliations from (be ribs, their 
 use is now relinquished. 
 
 As large tents had the effect of hindering 
 the discharge of blood, or matter from the 
 cavity of the chest, some of the old French 
 surgeons employed a kind of wick ; but, in 
 the present state of surgery, I do not con- 
 sider that it would be at all edifying to enter 
 into a comparison of these contrivances. 
 If any means be ever requisite for keeping 
 the opening from closing, there cannot be a 
 better thing for the purpose than a short 
 cannula, with a rim to keep it from slipping 
 into the thorax, and two little rings for con’- 
 fining it in its situation with a riband. 
 This should only just enter deeply enough 
 to have its inner orifice on a level, or a very- 
 little further inward than the pleura costa- 
 lis, so that it may not irritate the lungs. 
 
 When the patient has been dressed, he is 
 to be kept in bed, with his head and chest 
 somewhat elevated, and his thighs bent, in 
 which position the breathing will be least 
 oppressed. It is usual also to recommend 
 him to lie, as much as possible, on the siffe 
 
WOUNDS. 
 
 Bu4 
 
 on which the operation has been done. He 
 is to keep himself in as quiet a condition as 
 he can. He is to be put on very low diet, 
 and., if his strength allows, he is to be bled 
 from the arm ; and this evacuation must be 
 repeated, with other antiphlogistic means, 
 as often as the urgency of the fever and in- 
 flammatory symptoms indicates, and the 
 strength allows. Bleeding from the arm, 
 besides counter-acting inflammation in the 
 chest, which is a principal source of danger, 
 does good by lessening the force of the cir- 
 culation in the wounded vessels, and thus 
 diminishing the tendency to internal hemor- 
 rhage. 
 
 The old practice of keeping open wounds 
 of the chest is now nearly exploded ; but, if 
 it ever be adviseable, particular caution must 
 be used not to let the tents, and pieces of 
 the dressings, glide into the cavity of the 
 pleura. Tulpius speaks of a Danish gentle- 
 man who had been under a careless sur- 
 geon, on account of a wound in the thorax, 
 and who coughed up, six months afterward, 
 a large tent. A similar fact is recorded by 
 Hildanus. A man was stabbed in the right 
 side of the chest, near the axilla, between 
 the second and third ribs. Fora fortnight, 
 a great deal of blood was discharged both 
 from the wound and the mouth. The 
 wound healed ; but the patient continued 
 to be afflicted with considerable difficulty of 
 breathing, an incessant cough, and to spit 
 up a greenish, fetid matter. Three months 
 afterward he coughed up two tents, which 
 had slipped into the cavity of the thorax. 
 
 A relaxation of the antiphlogistic regimen 
 must be made with very great circumspec- 
 tion. Too much nourishment, talking too 
 frequently, and any exertion, are circum- 
 stances which may induce a renewal of 
 the hemorrhage, and extravasation. Vesa- 
 lius saw an accident of this nature happen 
 a fortnight after the wound, and eleven 
 days after the operation for empyema. A 
 soldier, who had been stabbed in two places 
 with a sword above the right nipple, was 
 attacked with fever, difficulty of breathing, 
 restlessness, and acute pain at the bottom of 
 the chest. These symptoms induced Vesa- 
 lius to infer, that an extravasation had taken 
 place ; but he was afraid of making an open- 
 ing in the chest for fear the hemorrhage 
 should still continue from the wounded 
 vessels. However, as the patient remained 
 in the same state the fourth day after the 
 receipt of the wounds, and he still had 
 strength enough, Vesalius undertook the 
 operation, by which a considerable quan- 
 tity of extravasated blood was discharged. 
 The patient felt great relief at the instant. 
 The oozing of blood continued for a few 
 days, after which a favourable suppuration 
 took place in all the three wounds, and the 
 case was expected to end well. But the 
 patient having regained his strength, and 
 taken too much food, the recurrence of he- 
 morrhage caused his death. Lombard saw' 
 a soldier die instantaneously of internal 
 hemorrhage, brought on by throwing a 
 
 bowl at some nine pins, two months after 
 he had been cured of a wound of the lungs . 
 
 When the edges of a penetrating wound 
 of the chest are to be brought together, 
 writers state, that the patient should be re- 
 quested to make a strong inspiration, with 
 the wound closed, and then a long, slow 
 expiration with it open, and so on, till as 
 much of the air is discharged from the tho- 
 rax as possible, and then the wound is to 
 be accurately closed w ith sticking-plaster. 
 From what has been observed, however, in 
 the article Emphysema , it will appear, that 
 when there is a direct opening into the 
 thorax, so as to admit the external air, the 
 lungs on one side coilapse, and remain so 
 till the wound is healed, and the air absorb- 
 ed. When one of these organs is wounded, 
 a collapsed state is indeed the best condi- 
 tion in which it can possibly be for a cer- 
 tain time, that is, till the breach of conti- 
 nuity in it is healed. Schemes for making 
 the lung expand, by exhausting the air from 
 the cavity of the pleura, may be amusing 
 on paper, but, 1 apprehend, they will never 
 be of real use in practice. 
 
 Fistulse sometimes continue a long while 
 after w ounds of the thorax. Platner men- 
 tions an instance in which there was a fistu- 
 lous opening, out of which the air rushed 
 with sufficient force to blow out a candle. 
 The patient lived a long while in this state 
 without suffering any particular inconve- 
 nience. 
 
 Another occasional consequence of a 
 wound of the chest, is a hernia of the lungs,, 
 an affection of which Sabatier met with an 
 example. A soldier, thirty years of age, 
 W'as wounded with a bayonet in the right 
 side of the chest, between the middle part 
 of the fifth and sixth true ribs. The wound 
 healed ; but, as the intercostal muscles had 
 been divided to a great extent, and could 
 not be approximated with precision, an 
 empty space was left under the integuments, 
 which a!low r ed a piece of the lungs, as large 
 as a walnut, to protrude between the ribs. 
 The swelling enlarged at the time of inspi- 
 ration, and grew smaller when expiration 
 took place, occasioning merely a slight pain 
 without any oppression in the chest. 
 
 Though so much has been written on the 
 subject of discharging blood from the chest, 
 in cases of extravasation within that cavity, 
 the operation is very rare. During the last 
 twenty-four years, I have never heard of its 
 being done by any of the surgeons in Lon- 
 don. In military surgery, however, the 
 practice is occasionally exemplified. (Lar- 
 rey, M6m. dc Chir. Mil. T. 2, p. 158, 8pc.) 
 No doubt, the true reason of the operation 
 being uncommon, is the obscurity in the 
 diagnosis, the symptoms being all of an 
 equivocal nature Even Larrey, generally 
 so partial to operations, recommends the 
 immediate closure of all wounds of the 
 chest, excepting such as are complicated 
 with injury of the intercostal artery, be- 
 cause, (says he) unless very considerable 
 vessels of the lungs are injured, (in which 
 case nothing cam bo of any use) either no 
 
WOUNDS 
 
 C(*j 
 
 extravasation, or only a trivial one, happens, 
 which, under the employment of rigorous 
 ♦antiphlogistic treatment, may be dispersed 
 by absorption. (P. 127.) In the general 
 propriety of closing all wounds of the chest, 
 I entirely concur with Larrey, Pelletan^ 
 t Boyer, and Dr. Hennen. ( On Military 
 L Surgery, ed. 2, p. 373.) 
 
 Consult Sabatier, De la MMecine Opera- 
 toire, T. 2. Joum. de Med. Militaire, 7 
 Tomes. Schmucker, Wahrnehmungen, 2 B. 
 Berlin, 1774 — 89. J. Bell , on the JVa'ure 
 I and Cure of Wounds, Ed. 3. D. J Larrey, 
 Mdm. de Chir. Militaire, 8 vo. Paris, 1812 — 
 1817, in various places. John Hennen, 
 Principles of Military Surgery, Ed. 2, 8 vo. 
 Edinb. 1820. Wm. Maiden, an Account of 
 a Case of Recovery, after an extraordinary 
 Accident, 4/o. Lond. 1812. The injury here 
 referred to is one of the most extraordinary on 
 record ; the shaft of a gig having been driven 
 with the greatest violence between the sternum 
 and lungs. Sir A. Halliday, in Edinb. Med. 
 and Surg. Joum. Vol, 1 1, p. 140 ; a Recovery 
 from a Gunshot Injury, in which a great part 
 of the Shoulder was carried away , and the 
 Lungs and Pericardium were exposed : to 
 the authenticity of this Case / can bear wit- 
 ness myself, having been at the Field Hospital, 
 when the Soldier arrived from the Trenches, 
 near Antwerp. 
 
 Wounds of the Abdomen. — Here one of the 
 chief causes of danger is the tendency of 
 the peritoneum to inflame. Every pene- 
 trating wound of the belly is apt to excite 
 this inflammation, which too often extends 
 itself over all the viscera, and terminates in 
 the death of the patient. 
 
 There are (says Mr. John Bell) a thousand 
 occasions, on which the delicacy of the 
 peritoneum may be observed. The wound 
 of the small sword, and the stab of the sti- 
 letto, explain to us, how quickly the perito- 
 neum, and all its contained bowels, inflame 
 from the most minute wound, although the 
 injury be almost too small to be visible on 
 the outside, and scarcely within ; for often, 
 upon dissection, no intestines are discover- 
 ed wounded, and no feces have escaped into 
 the abdomen. In subjects who die after 
 lithotomy, we find the cavity of the perito- 
 neum universally inflamed. The operation 
 of the Caesarean section is fatal, not from 
 any loss of blood, for there is little bleed- 
 ing; nor from the parts being exposed to 
 the air, for patients also die in whom the 
 womb bursts, and where the air has no pos- 
 sible opportunity of insinuating itself ; but 
 the case proves fatal from the inflamma- 
 tion which is always disposed to originate 
 from wounds of the peritoneum, small as 
 I well as great. ( Discourses on the Nature and 
 ♦ Cure of Wounds, p. 310, edit. 3.) 
 
 But although there can be no doubt that 
 the wound, abstractedly considered, is the 
 most frequent occasion of this dreaded in- 
 flammation ; yet it sometimes happens that 
 the inflammatory consequences must be 
 ascribed to another kind of cause. If an 
 intestine be wounded, its contents may, 
 under certain circumstances, be effused in 
 Voi.. IT. 84 
 
 the abdomen ; it the fiver, spleen, kidney, 
 or any large vessel be injured, blood may 
 be poured out among the viscera ; if the 
 gall-bladder be wounded, bile may be effu- 
 sed ; and if the bladder be pierced, the 
 urine may escape into the abdomen. Now 
 all these fluids are extraneous substances 
 with respect to the surfaces, with which 
 they often come into contact, and, as such, 
 they give rise to inflammation of the peri- 
 toneum and viscera. 
 
 Wounds of the belly are divided, by almost 
 all writers, into such as penetrate the cavity 
 of the abdomen, and into others, which 
 only interest the skin and muscles. 
 
 The former differ very much in their na- 
 ture, and degree of danger, according as 
 they do, or do not, injure parts of impor- 
 tance, contained in the peritoneum. The 
 latter are not remarkably different from the 
 generality of other superficial wounds. 
 The chief indications are to lower inflam- 
 mation, and to prevent collections of mat- 
 ter. A few particularities, however, in the 
 treatment of superficial wounds of the ab- 
 domen, merit attention. 
 
 Superficial Wounds . — The most ancient 
 surgeons, and their successors, down to the 
 present day, have recorded, that wounds of 
 tendinous parts frequently give rise to very 
 unpleasant consequences. Almost the 
 whole front of the abdomen is covered with 
 tendinous expansions, and, on this account, 
 -it is not unusual to see punctured wounds 
 in this situation followed by extensive in- 
 flammation, and the formation of abscesses. 
 At the same time, the patient is affected 
 with a great deal of inflammatory fever. 
 He suffers aedte pain, sickness, hiccough, 
 and considerable disturbance of the ner- 
 vous system. ( Callisen , Syst. Chirurg. Ho- 
 diernce , Vol. 1 ,p. 698, Hafniee, 1798.) When 
 the tension and swelling of the abdomen 
 abate, shiverings sometimes occur, and in- 
 dicate the occurrence of suppuration. The 
 matter sometimes accumulates in the tendi- 
 nous sheath of the rectus muscle, and, when 
 the collection in this situation remains un- 
 discovered until a pointing appears, no 
 sooner does the abscess burst, or it is open- 
 ed, than an extraordinary quant ity of matter 
 is discharged. The surgeon ^should care- 
 fully remember the nature of this kind of 
 case, as there is frequently not sufficient 
 alteration in the appearance of the integu- 
 ments to denote either the existence or the 
 extent of the suppuration. 
 
 Such an abscess forms one remarkable 
 exception to the excellent general rule of 
 allowing acute phlegmonous abscesses to 
 burst of their own accord. In the present 
 instance, there is an aponeurotic expansion, 
 intervening between the abscess and the 
 skin, and nothing retards the natural pro- 
 gress of the matter to the surface of the 
 body so powerfully as the interposition of a 
 tendinous fascia. But, even in this circum- 
 stance, the propensity of pus to make its 
 way outward is often seen to have immense 
 influence. Though there is only a thin 
 membrane (viz. the peritoneum^ between 
 
666 
 
 WOUNDS. 
 
 matter so situated* and the cavity of the 
 abdomen, the abscess after a time mostly 
 points externally. 
 
 Tiie proper treatment of this case is to 
 prevent the surprising accumulation of mat- 
 ter, and rapid increase of mischief, by 
 making a depending opening, sometimes at 
 the very lowest part of the sheath of the 
 rectus muscle, and this, as soon as the lodge- 
 ment of matter is clearly ascertained. 
 
 If ever there be a case in which it is ad- 
 vantageous and justifiable to make an early, 
 dilatation of a punctured wound, in order 
 to prevent the above-described ill conse- 
 quences, it is unquestionably the present 
 one. Such practice, indeed, is particularly 
 recommended by Callisen, in addition to 
 the strictest antiphlogistic means. (See 
 Syst. Cliir. Hodiernce, Vvl.1,p. 698, edit. 
 1798.) 
 
 Sometimes the matter is formed between 
 the external and internal oblique muscles, 
 and spreads to a great extent. The pus 
 may even insinuate itself into the abdomen, 
 and the case end fatally. Such an example 
 is recorded by Dr. Crowther, of Wakefield. 
 In this instance, however, the disease pro- 
 ceeded from a contusion, not a wound. 
 (See Edinb. Med. and Surgical Journal t Vol. 
 2 ,p. 129.) 
 
 Superficial wounds of the abdomen are 
 to be treated on the same principles as simi- 
 lar wounds in other situations. The indica- 
 tions are to prevent inflammation as much 
 as possible, and, if suppuration should be 
 inevitable, to let out the matter by a de- 
 pending opening as soon as the abscess is 
 known to exist. The inflammation is to be 
 checked by general and topical bleeding, 
 low diet, emollient clysters, diluent beve- 
 rages, quietude, opening medicines, cold 
 applications, or fomentations and poultices, 
 and the mildest and most simple dressings. 
 (See Inflammation.) 
 
 Whenever the abdominal muscles are 
 wounded, they should be relaxed, and the 
 patient kept quiet in bed. A very impor- 
 tant point in the treatment of wounds of 
 the parietes of the abdomen, is to afford a 
 degree of support to the wounded parts, so 
 that the pressure of the viscera may be re- 
 sisted. The sides of the abdomen are almost 
 wholly composed of soft parts, which easily 
 yield. No part of the front, or sides of the 
 abdomen, is supported by a bony structure, 
 and as the viscera are for the most part, 
 more or less moveable, and closely com- 
 pressed by the abdominal muscles, and dia- 
 phragm, they are liable to protrude, when- 
 ever the resistance of the containing part3 is 
 not sufficiently powerful. Hence all wounds 
 of the abdomen, especially those, in which 
 both the integuments and muscles have been 
 cut, demand strict attention to the precau- 
 tion of supporting the wounded part, and 
 this, though the peritoneum itself should 
 not happen to be divided. The patient 
 ought to keep as much as possible in a 
 horizontal position, and suitable compresses 
 and bandages should be applied. And, in 
 order to guard against hernia?, the parts 
 
 should be supported, in this way, a consi- 
 derable time after the wound is healed. 
 
 ’I'he peritoneum being connected by means 
 of cellular substance with the inner surface 
 of the abdominal muscles, there is always 
 some risk of the inflammation of these 
 parts extending to that membrane. The 
 danger must be averted by the rigorous em- 
 ployment of antiphlogistic treatment. What 
 renders the event still more dangerous, is, 
 that when one point of the peritoneum is 
 affected, the inflammation usually spreads 
 with immense rapidity over its whole ex- 
 tent, and too often proves fatal. 
 
 As superficial wounds of the abdomen are 
 to be treated on the general principles, ap- 
 plicable to all resembling w r ounds in other 
 situations, it is hardly necessary to state, 
 that union by the first intention, if possible, 
 is always to be attempted. 
 
 Of Wounds penetrating the Cavity of the 
 Abdomen — The first thing which the surgeon 
 is generally anxious to know, when he is 
 called to a wound of the belly is, whether 
 the wound penetrates the cavity of the ab- 
 domen, and whether any of the viscera are 
 injured. 
 
 When the wound is extensive, and the 
 bowels protrude, the first part of the ques- 
 tion is at once decided. But when the 
 wound is narrow, and the viscera do not 
 protrude, it is more difficult to know, whe- 
 ther the cavity of the abdomen is penetra- 
 ted or not. An opinion, however, may be 
 formed, by carefully examining the wound 
 with a linger or a probe ; by observing, if 
 possible, how ranch of the weapon is stain- 
 ed with blood -, considering the direction in 
 which it was pushed ; the quantity of blood 
 lost, the state of the pulse, and whether any 
 bile, feces, or other fluids, known to be na- 
 turally contained in some of the abdominal 
 viscera, have been discharged from the ori- 
 fice of the injury. 
 
 When the wound is sufficiently large to 
 admit the finger, a surgeon can always learn, 
 whether the injury extends into the abdo- 
 men, because the smooth lining of that 
 cavity, and the contained bowels, may be 
 easily felt. There is one chance of decep- 
 tion, however, arising from the possibility 
 of mistaking the inside of the sheath of the 
 rectus muscle for the cavity of the perito- 
 neum ; and when the examination is made 
 with a probe, particular caution should be 
 used in forming a judgment of the nature of 
 the case ; for the parts are so soft and yield- 
 ing, that a very little force will make the 
 instrument pass a considerable way inward. 
 Every examination of this kind should 
 always be undertaken, if possible, when the 
 patient is exactly in the same position, iu 
 which he was at the time of receiving the 
 wound. Formerly, injections were some- 
 times employed as tests of the penetration 
 of the cavity of the abdomen. This absurd 
 experiment is now very rightly exploded. 
 It is well known to the moderns, that the 
 space, termed the cavity of the abdomen, 
 is, in fact, completely filled with the various 
 viscera, and that in general, an injected 
 
WOUND; 
 
 067 
 
 fluid would not so easily find its way into 
 the bog of the peritoneum, as an unreflect- 
 ing person might suppose. And if it were 
 propelled with much force, it would be quite 
 us likely to insinuate itself into the cellular 
 substance of the parietes of the abdomen, 
 or perhaps, into the sheath of the rectus 
 muscle. The least tortuosity of the wound, 
 or a piece of bowel, or omentum, lyiug 
 against the internal orifice of the injury, 
 would also completely prevent an injection 
 from passing into the abdomen. 
 
 When a considerable quantity of blood 
 issues from a wound of the abdomen, we 
 may pronounce, almost with certainty, that 
 some large vessel, within its cavity, is inju- 
 red. Excepting the epigastric artery, which 
 runs on the forepart of the abdomen, along 
 the inner surface of the rectus muscle, no 
 large vessel is distributed to the muscles 
 and integuments. At the same time, it is 
 deserving of particular notice, that a large 
 artery may be opened in the abdomen, and 
 not a drop of blood be discharged from the 
 wound. 
 
 In such cases, the consequent symptoms 
 quickly lead to a suspicion of what has hap- 
 pened. The patient complains of extreme 
 debility and faintness ; his pulse falters ; 
 he has cold sweats; and if the bleeding 
 should not speedily cease, these symptoms 
 are soon followed by death. 
 
 Sometimes, the extension of the wound 
 into the cavity of the abdomen, is from the 
 first quite manifest, being indicated by the 
 escape of chyle, bilious matter, feces, or 
 other fluids. The vomiting up of a consi- 
 derable quantity of blood, or its discharge 
 by stool, affords also the same information. 
 The urine however, may flow from a wound, 
 which does not actually penetrate the abdo- 
 men, for the kidneys, ureter, and bladder 
 may be said to be out of the abdomen, be- 
 cause they are really on the outside of the 
 cavity of the peritoneum. 
 
 When none of the above symptoms occur : 
 when neither the finger nor probe can be 
 introduced ; when none of the fluids, known 
 to be contained in the various receptacles 
 in the abdomen, are discharged from the 
 wound; when the pulse remains natural, 
 and the pain is not excessive ; there is rea- 
 son to hope, that the wound has not injured 
 parts of greater consequence, than the in- 
 teguments and muscles. (Encyclopedic 
 Mtthodique, Partie Chir. Art. Abdomen.) 
 
 I have now taken a survey of the criteria, 
 commonly noticed by writers, for the pur- 
 pose of enabling surgeons to discriminate 
 a wound, which penetrates the abdomen, 
 from one which is more superficial. My 
 next duty is to warn the practitioner, that 
 too much solicitude to determine this point, 
 is very frequently productive of serious 
 harm. It may be set down, as an axiom in 
 surgery, that in general , whenever the probing 
 of a wound is not rendered absolutely neces- 
 sary by some particular object in view, it may 
 be judiciously omitted. A narrow, oblique 
 wound may enter the cavity of the abdo- 
 men, without there being any particular 
 
 method of ascertaining, whether it has done 
 so, or not. However, this want of positive 
 information is of no practical importance; 
 for, when there are no urgent symptoms, 
 evincing the nature of the case, the treat- 
 ment ought obviously to resemble that of a 
 simple wound ; and whether the wound be 
 deep, or superficial, antiphlogistic remedies 
 are indicated. 
 
 The edges of a wound, penetrating the 
 abdomen, but unattended with injury of the 
 viscera, arc to be brought together with 
 sticking-plaster, in the same way as commoa 
 wounds. Sutures are not generally neces- 
 sary. Numerous cases may be found in the 
 records of surgery, proving that wounds of 
 the abdomen may be easily united without 
 sutures, provided the surgeon take care to 
 avail himself of the assistance, which may 
 be derived from a suitable position and a 
 proper bandage. But such cases are less 
 decisive, than relations of the Ca?sarean 
 operation, the extensive wound of which 
 admits of being healed by the same simple 
 means. It is not my intention to assert, 
 that in the majority of these examples, 
 sutures were altogether dispensed with; 
 but, the ligatures frequently cut their way 
 through the skin and muscles, and the ap- 
 plication of others was impossible, either 
 on account of the particular state of the 
 case, or the patient’s aversion to them. Still 
 the union of such wounds was accomplish- 
 ed. A bandage, made on the same plan, as 
 that with eighteen tails, would be extremely 
 convenient for longitudinal wounds of the 
 abdomen. (See Pibrac in Mtm. de VAcad. 
 de Chir. T. 3, 4/o.) 
 
 In the treatment of wounds of the abdo- 
 men, sutures may generally be relinquished, 
 not only without harm, but with benefit; 
 for their employment is sometimes the cause 
 of bad symptoms. In one instance, the hic- 
 cough and vomitihg could not be appeased 
 by any remedy which was tried. On the 
 fourth day, the wound was inflamed and 
 painful, and it was judged proper to cut 
 away two sutures, and employ only simple 
 dressings, with the view of diminishing the 
 pain and swelling. The symptoms quickly 
 abated, and in a week, were entirely cured, 
 the wound healing up very well. (Op. cit.) 
 
 However, there are circumstances, in 
 which it would be impossible to dispense 
 with sutures. If, for instance, the belly 
 were torn open from one side to the other 
 with a bullock’s horn ; or if it were exten- 
 sively divided with the tusks of a wild boar, 
 a stag’s horn, a razor, &c. and the inflated 
 intestine could not be kept from protru- 
 ding ; some stitches would be absolutely 
 necessary, but even then, they should be as 
 few as possible. (Sabatier, Mtdecine Optra- 
 toire, T.l, p. 214, edit. 2.) 
 
 “ Oufgood old surgeon Wiseman (observes 
 Mr. John Bell) has said with great simplici- 
 ty, as a great many have said after him, it 
 frequently happenetb, that a sword passetli 
 through the body, without wounding any 
 considerable part.’ He means, that a rapier, 
 or ball, often passes quite across the belly, 
 
WOUNDS. 
 
 60S 
 
 in at the navel, anti out at the back, and that 
 without one bad sign, the patient recovers, 
 and as has very often happened, walks 
 abroad in good health, in eight days; which 
 speedy cure has been supposed to imply a 
 simple wound, in which all the bowels have 
 escaped. But we see now, how this is to be 
 explained ; for we know, that in a thrust 
 across the abdomen, six turns of intestine 
 may be wounded, — each wound may ad- 
 here ; adhesion, we know, is begun in a 
 few hours, and is perfected in a few days ; 
 and when it is perfect, all danger of inflam- 
 mation is over; and when the danger of in- 
 flammation is over, the patient may walk 
 abroad ; so that we may do, just as old 
 Wiseman did in the case here alluded to, 
 ( P . 98, the case of a man, who was wound- 
 ed across the belly, and well and abroad in 
 seven days,) ‘ Bleed him, and advise him to 
 keep his bed and be quiet.’ In short, a man, 
 thus wounded, if he be kept low, has his 
 chance of escaping by an adhesion of the 
 internal wounds.” ( Discourses on the Nature 
 and Cure of Wounds , p. 329, 330, edit. 3.) 
 
 The truth of these observations is well 
 illustrated in a case mentioned by Dr. Hen* 
 nen, in which a soldier recovered, whose 
 abdomen u T as pierced with a ramrod, which 
 stuck so fast in the vertebrae, that some 
 force 'was required to disengage it. ( On 
 Military Surgery , p. 402, ed. 2.) 
 
 When a man is stabbed or shot in the belly, 
 and none of the bowels protrude, the wisest 
 plan is to keep the patient as quiet as possible, 
 have recourse to copious and repeated bleed- 
 ing, prescribe anodynes, and the lowest fluid 
 diet, and apply light superficial unirritating 
 dressings. In the event of severe pain and 
 swelling of the belly coming on, leeches, 
 fomentations, the warm bath, and emollient 
 poultices, will be necessary, and nothing 
 will now avail, except the most rigorous 
 employment of antiphlogistic remedies. As 
 Dr. Hennen observes, the best means of 
 emptying the bowels are oleaginous clysters, 
 and if any internal medicine be given, as a 
 purgative, it should be of the mildest nature. 
 (On Military Surgery, p. 402, ed. 2.) Castor 
 oil is perhaps the best; but, on the whole, 
 for some few days, I would hardly venture 
 beyond the use of clysters for procuring 
 evacuations from the bowels. 
 
 Suppuraiionin the Abdomen, in consequence 
 of Wounds. — Abscesses within the bag of 
 the peritoneum are far from being common. 
 As a late writer well observes, "the con- 
 taining and contained parts of the abdomen 
 present to each other an uniform and con- 
 tinuous surface of membrane. This mem- 
 brane is of the serous class, and the species 
 of inflammation, to wdiich it is especially 
 subject, is that, which has been denominated 
 the adhesive. The membrane, lining the 
 intestinal canal, is of the mucous elffs, and 
 the ulcerative inflammation is the species, 
 to which this class is liable. This benefi- 
 cent provision is an irresistible evidence of 
 the operation of a salutary principle in dis- 
 ease. If the inflamed peritonfeurn had run 
 directly into suppuration : ulceration of the 
 
 surrounding parts would have been required 
 for an outlet ; and if the inlernal surface of 
 the irritated bowel had tended to form ad- 
 hesions, the canal would have been in con- 
 stant danger of obliteration.” (Travers on 
 Injuries of the Intestines, Ipc. p. 10.) 
 
 That collections of matter, however, do 
 sometimes take place in the cavity of the 
 abdomen, in consequence of wounds, is a 
 fact, of which there are too many proofs on 
 record for the possibility of the case to be 
 doubted. At this moment, be it sufficient to 
 refer to two examples of the occurrence, as 
 related by Mr. B. Bell. (System of Surgery , 
 Vol. 5, p. 256.) 
 
 If the abscess were in any other part of 
 the body, and did not readily point, the 
 wisest practice would undoubtedly be to 
 make an opening sufficient for the evacua- 
 tion of the matter. But suppuration in the 
 abdomen can seldom be known with cer- 
 tainty in an early stage of the case : for the 
 abscess is so deep, that no fluctuation, nor 
 swelling, is perceptible, until the quantity 
 of pus is considerable. Nor would it be 
 judicious to expose the patient to the hazard, 
 which might arise from making an opening 
 into the abdomen, merely for the sake of 
 discharging a small quantity of matter. 
 
 Many writers impute much of the danger 
 of wounds of the abdomen to the entrance 
 of air into the cavity of the peritoneum, 
 in inculcating such opinions, however, they 
 betray an inaccuracy of observation, which 
 a very little reflection would have set right. 
 Too much stress has long been laid on the 
 introduction of air into the abdomen, as 
 being a cause of inflammation. The fact 
 is, the cavity of the belly is always so com- 
 pletely occupied by the several viscera, that 
 the whole inner surface of the peritoneum 
 is invariably in close contact with them, 
 and therefore, air cannot easily diffuse itself 
 from the wound, throughout the abdomen 
 After tapping, in dropsical cases, inflamma- 
 tion seldom arises, though here the air has 
 quite as good an opportunity of entering 
 the abdomen, as in any case of wound. 
 The peritoneum in animals has been infla- 
 ted, without any inflammation being exci- 
 ted. In cases of tympanitis, the peritoneum 
 is distended with air, and yet both this 
 membrane and the bowels are quite unin- 
 flamed. In the human subject, it seems 
 probable, that if a wound were made in a 
 vacuum, the breach of continuity itself 
 would be an adequate cause of inflamma- 
 tion. It may also be remarked, that collec- 
 tions of matter in the abdomen are almost 
 always completely circumscribed, and sepa- 
 rated from the general cavity of the perito- 
 neum, by the adhesion of the viscera to each 
 other, and to the inside of the'peritoneum. 
 
 1 am of opinion, that no surgical writer 
 has succeeded so well, as Mr. John Bell, in 
 exposing the absurd apprehensions, not un - 
 commonly entertained by practitioners, re- 
 specting the entrance of air into the abdo- 
 men and oilier cavities of the body. Ho 
 inquires, 1st. Whether air can really get into 
 the cavity of the abdomen ? and, 2dly. 
 
WOUNDS. 069 
 
 "Whether, it it were there, it would produce bowels are exposed to the air. ' ( Discourses 
 
 the dreadful effects ascribed to it ? on the Nature of Wounds , p. 343, 344.) 
 
 Upon the first question, his arguments run In adverting to the question, whether ait’ 
 thus: — “ Suppose a wound of an inch in is so irritating to the cavities of the body as 
 length : — suppose the bowel to have sunk, many have supposed, Mr. John Bell critici- 
 in some strange way, into the pelvis, for ses with much spirit and success, the opi- 
 example, so as to have left a mere vacuum ; nions, published on this subject by Mr. A. 
 what should happen with the flexible pa- Monro, in his account of the Bursae Muco- 
 rietes of the abdomen ? Should they stand sa?, as the annexed quotations will show, 
 rigid, while the air rushed into the cavity “ That the vulgar should believe, the first 
 to fill it ? No, surely. But, on the contrary, superficial impression that strikes them, of 
 
 the walls of the abdomen would fall toge- 
 ther, and the pressure of the outward air, far 
 from making the air rush in by the outward 
 wound, would, at once, lay the belly flat, 
 and close the wound. But, since the walls 
 of the abdomen are not flaccid, nor the ca- 
 vity empty, but the abdomen full, and the 
 flat muscles, which cover it, acting strongly, 
 the effect must be much more particular ; 
 for, the moment that the belly is wounded, 
 the action of the muscles w'ould force out 
 part of the bowels ; the continuance of that 
 action is necessary to respiration : the re- 
 spiration continues as regular after the 
 wound as before ; and the continual pres- 
 sure of the abdominal muscles, and the 
 diaphragm, against all the viscera of the ab- 
 domen, prevents the access of air so effec- 
 tually, that though we should hold such a 
 wound open with our fingers, no air could 
 pass into the abdomen, further than to that 
 piece of gut which is first touched with the 
 finger, when we thrust it into the abdomen. 
 Nothing is absolutely exposed to the air, ex- 
 cept that piece of intestine which is without 
 the abdomen, or that, which we see, when 
 we expose a small piece of the bowels, by 
 holding aside the lips of the wound. The 
 pressing forward of that piece, and the pro- 
 trusion of a portion of the gut, proportioned 
 always to the size of the wound ; the pres- 
 sure from behind keeping that piece pro- 
 truded, so that it is with difficulty we can 
 push it back with our finger; this incessant 
 pressure, in all directions, is an absolute se- 
 curity against the access of air. The intes- 
 tine comes out, not like water out of a bottle, 
 the place of which must be supplied by air 
 entering into the bottle, in proportion as the 
 water comes out ; but, the gut is pushed 
 down by the action of the muscular walls 
 of the abdomen, and that action follows the 
 intestine, and keeps it down, and prevents 
 all access of the air, whether the gut con- 
 tinue thus protruding, or w hether it be re- 
 duced ; for, if it be reduced, the walls of the 
 abdomen yield, allowing it to be thrust back, 
 but admitting no air. Those, who want to 
 know the effect of air, diffused within the 
 cavity of the abdomen, must make other 
 experiments, than merely cutting open pigs’ 
 bellies ; — they must give us a fair case, 
 without this unnecessary wound. We will 
 not allow them to say, when they cut open 
 the belly of any creature, with a long inci- 
 sion, that the inflammation arises from the 
 air; much less shall we allow them to say, 
 when they open the belly with a smaller 
 incision, that, by that little incision, the air 
 gets into the abdomen, and that all the 
 
 air hurting a wound or sore, is by no means 
 surprising ; but it is not natural that men, 
 bred to philosophy, should allow so strange 
 an assertion as this, without some kind of 
 proof. ThM the air which we breaihe, and 
 which we feel upon the surface so bland and 
 delightful, should have so opposite a relation 
 to the internal parts, that it should there be 
 a stimulus, more acrid and more dangerous 
 than the urine, is- not to be believed upon 
 slight grounds. I do affirm (says Mr. John 
 Bell) that it remains to be proved, that this 
 fluid, which seems so bland and pleasant to 
 all our senses, and to the outward surface, 
 is yet a horrible stimulus when admitted, as 
 a celebrated author grandly expresses it, 
 
 ‘ into the deep recesses of our body.’ 
 
 ( Monro's Bursae Mucosae.) 
 
 With how much reason Mr. John Bell 
 objects, that this, doctrine is unfounded, will 
 be manifest to every man of any discern- 
 ment, or impartiality. 
 
 “ The air, for instance, escapes from the 
 lungs, in a fractured rib, and first goes abroad 
 into the thorax ; then into the cellular sub- 
 stance ; then the emphysematous tumour 
 appears; but often without any scarifica- 
 tions, with very little care and assistance on 
 our part, the air is absorbed, the tumour 
 disappears, and, without inflammation of 
 the chest or any particular danger, the man 
 gets well. Here then is the air, within the 
 cavity of a shut sac, filling the thorax, and 
 oppressing the lungs, without any danger- 
 ous inflammation ensuing. | 
 
 u That the air may be pushed under the 
 cellular substance all over the body, without 
 causing inflammation, is very plain, from the 
 more desperate cases of emphysema, where 
 the patients, after living eight or ten days, 
 have died, not from inflammation, but from 
 oppression merely, the body being so cram- 
 med with air, that even the eyeballs have, 
 upon dissection, been found as tense as 
 blown bladders. We have also many ludi- 
 crous cases of this kind, which prove this 
 to our perfect satisfaction. Soldiers and 
 sailors sometimes touch the scrotum with 
 a lancet, introduce a blowpipe, and blow 
 it up to an enormous size, imitating her- 
 nia?, by which they hope to escape from 
 the service. The old story of a man, who 
 was so wicked as to make a hole in his child’s 
 head, and blow it up, that he might show 
 the child in the streets of Paris for a mon- 
 ster, is well authenticated ; and I have lit- 
 tle doubt, that a fellow who knew how to 
 do this, w'ould blow it up every morning, 
 and squeeze it out when he put the child to 
 bed at night. Some villanous butchers, hav* 
 
WOUNDS. 
 
 oru 
 
 ing a grudge at a soldier, found him lying 
 drunk under a hedge ; they made a little 
 hole in his neck, and blew it up, till he was 
 like a bladder, or, as Dr Hunter describes the 
 disease of emphysema, like a stuffed skin." 
 (P. 3S8, 389.). 
 
 After many other pertinent observations, 
 blended with appropriate satire on the ex- 
 travagant notions professed by Monro, on 
 the bad effects of the air in lithotomy, 
 operations for hernia and hydrocele, the 
 Caesarian section, Lc. Mr. John Bell most 
 justly holds up to ridicule the propositions 
 of Dr. Aitk to perform this last operation 
 wider the cover of a warm bath , in order to 
 exclude the air. “ This, though It may seem 
 to be a scurvy piece of wit, was really pro- 
 posed in sober serious earnest. But (adds 
 Mr. John Beil) the admission of atmospheric 
 air, as a stimulus, when compared with the 
 great incisions of lithotomy, of hernia, of hy- 
 drocele, of Caesarean section, of the trepan, 
 is no more than the drop of the bucket to 
 the waters of the ocean. And it is just as 
 p.oor logic to say, that after such desperate 
 operations, these cavities are inflamed by 
 the admission of air, as it would be to say, 
 (as Monro did) that when a man is run 
 through the pericardium with a red-hot po- 
 ker, that the heart and pericardium are in- 
 flamed by the admission of the air.” (P. 847, 
 Edit. 3.) 
 
 Enough, I conceive, has been said, to dis- 
 pel all the idle fear and prejudices, which 
 have prevailed concerning the bad effects 
 of the air in wounds of the abdomen, as well 
 as several other cases. When so justly emi- 
 nent a man as Dr. Alexander Monro, senior, 
 \vas disturbed by such apprehensions, it is 
 not wonderful that many a poor ordinary 
 member of the profession should have been 
 terrified nearly oui of his wits upon the sub- 
 ject; and for quieting this alarm, and expo- 
 sing its absurdities, I really think Mr. John 
 Bell deserving particular praise. 
 
 In general, 14 all cases of wounds of the 
 abdomen, it is an excellent rule never to be 
 officious about abscesses which may take 
 place, nor to exhibit a partiality to such ex- 
 periments as have been devised for learning 
 precisely what bowel is wounded. It is 
 quite time enough to interfere, when the 
 urgency of the symptoms confirm any sus- 
 picions which may be entertained. A great 
 deal of harm is frequently done by hand- 
 ling and disturbing the wounded parts more 
 than is necessary, and it is well known that 
 wounds, at first attended with alarming 
 symptoms, frequently have a favourable ter- 
 mination. Swords, balls, and other wea- 
 pons, sometimes pass completely through 
 the body, without the patient suffering after- 
 ward any threatening symptom, or, indeed, 
 any effects which, abstractedly considered, 
 would authorize the inference, that the vis- 
 cera had been at all injured. Severe inflam- 
 mations may not end in suppuration, and 
 when pus is formed, it is sometimes absorb- 
 ed again. Nothing then indicates the ne- 
 cessity for the discharge of purulent matter 
 n. the abdomen , unless the fluctuation and 
 
 situation of the abscess be very distinct, 
 and the quantity and pressure of the matter 
 clearly productive of inconveniences. Un- 
 der these circumstances, the surgeon should 
 make a cautious puncture with a lancet. 
 
 Protrusion of the Viscera. — The omentum 
 and small intestines are the parts most liable 
 to protrusion ; but, in large wounds, the 
 great intestines, the stomach, and even the 
 liver and spleen, may project through the 
 opening. The general symptoms, indicating 
 a protrusion of the parts, are sufficiently ob- 
 vious ; but, it deserves attention, that, in fat 
 subjects, the adipose membrane may project 
 from the wound, and put on somewhat of 
 the appearance of omentum. The special 
 symptoms are to be collected from a know- 
 ledge of the natural situation of the parts, 
 and reflecting what region of the abdomen is 
 wounded. ( Callisen , Syst. Chir. Hodiemce , 
 T. 1 ,p. 702 and 703, edit. 1798.) 
 
 From penetrating wounds considerable 
 porjjons of the bowels, or omentum, some- 
 times protrude, and though these viscera may 
 not have received injury, yet their being 
 displaced, is sometimes productive of fatal 
 consequences. 
 
 The best mode of preventing such mis- 
 chief, is to return the viscera into the cavity 
 of the abdomen as speedily as possible. 
 Almost all authors recommend fomenting 
 the displaced parts, previously to the attempt 
 at reduction ; but in giving this advice, they 
 seem to forget, that while time is lost in this 
 preparatory measure, the protruded bowels 
 suffer much more harm from exposure, that 
 is to say, from the very circumstance of 
 their being out of their natural situation, 
 than they can possibly receive good from 
 any application made to them. No kind of 
 fomentation can be half so beneficial, as the 
 natural warmth and moisture of the cavity 
 of the abdomen. In order to facilitate the 
 return of a protruded piece of intestine, or 
 omentum, the abdominal muscles should be 
 relaxed by placing the patient in a suitable 
 posture, and the large intestines emptied 
 with a glyster. In mentioning the last 
 measure, it is not meant, that the surgeon 
 should delay the attempt to reduce the part, 
 until the glyster has operated. No, this 
 means is only enumerated as one that may 
 become serviceable, in case the surgeon can- 
 not immediately accomplish the object in 
 view. — The mesentery Ought always to be 
 reduced before the intestine ; the intestine 
 before the omentum ; but, the last protruded 
 portion of each of these parts ought to be 
 the first reduced. 
 
 It is only w T hen the intestine and omen- 
 tum are free from gangrene and mortifica- 
 tion, that they are invariably to be returned 
 into the cavity of the belly, without hesita- 
 tion. Also, when the protruded parts are 
 covered with sand, dust, or other extraneous 
 matter, they should be tenderly washed with 
 a little tepid water. 
 
 For the reduction of the parts, the fore- 
 fingers are the most convenient, and it is a 
 rule to keep the portion first returned, from 
 protruding again, by one finger, until it has 
 
WOUNDS. 
 
 i 
 
 been followed by another portion, introdu- 
 ced by the other finger. The second piece 
 is to be kept up, in the same way, by the 
 finger used to return it; and so on, till the 
 displaced parts have all been put into their 
 natural situation. 
 
 In attempting to reduce a piece of pro- 
 truded intestine, the patient should be 
 placed in the most favourable posture : the 
 head and chest should be elevated, and the 
 pelvis raised with pillows. Nothing can be 
 more absurd, than the advice to put the 
 thorax rather lower than the pelvis, in order 
 that the weight of the viscera may tend to 
 draw inward the protruded parts. This is 
 another erroneous idea, arising from the 
 ridiculous supposition, that a great part of 
 the abdomen is actually an empty cavity. 
 The relaxation of the abdominal muscles is 
 a much more rational and useful object. 
 When this is properly attended to, and the 
 above directions observed, and the wound 
 is not exceedingly small, in relation to the 
 bulk of the protruded viscera, the parts 
 may generally be reduced. But in addition 
 to what has been already stated, it is neces> 
 sary to remark, that the pressure should be 
 made in a straight direction into the abdo- 
 men ; for when made obliquely, towards 
 the edges of the wound, the parts are liable 
 to suffer contusion, without being reduced, 
 and even to glide between the layers of the 
 abdominal muscles, and become strangula- 
 ted. When the wound is in the front of the 
 abdomen, pressure made in this unskilful 
 way may force the viscera into the sheath 
 of the rectus muscle, and cause the same 
 perilous symptoms as arise from an incarce- 
 rated hernia. (See Hernia.) 
 
 When the reduction seems complete, the 
 surgeon should assure himself of it, by in- 
 troducing his finger into the cavity of (he 
 abdomen so as to feel that the parts are all 
 actually reduced, and sutler no constriction 
 between the edges of the wound and the 
 viscera in the abdomen. 
 
 A difficulty of reduction may arise from 
 the protruded intestines being distended 
 with feces or air. In this circumstance, 
 the contents of the gut may frequently be 
 made to pass by degrees into that portion of 
 the intestinal canal, which is within the 
 abdomen. In order to accomplish this pur- 
 pose, the surgeon must press the contents 
 of the bowel toward the wound ; and, if be 
 succeeds in emptying the part, he will com- 
 monly experience equal success in his next 
 attempt to replace it in the abdomen. 
 
 Sometimes, in cases of narrow stabs, 
 considerable pieces of intestine protrude, 
 and cannot be reduced without doing im- 
 prudent violence to the bowel. Under 
 these circumstances, the dilatation of the 
 wound is indispensable. However, when 
 the reduction seems almost a matter of im- 
 possibility, on account of the smallness of 
 the wound, if the surgeon be careful to re- 
 lax the abdominal muscles, draw a little 
 more intestine out of the wound, and gently 
 press the contents of the bowel through the 
 constriction into the abdomen, he will fre- 
 
 quently succeed in reducing the parts, with- 
 out using the knife. 
 
 Whfen such operation is unavoidable, the 
 dilatation should be made in a direction 
 which will not endanger the epigastric ar- 
 tery, and, if possible, in the same line as 
 the muscular fibres. 
 
 We are also advised to make the incisiou 
 upward rather than downward, when it 
 can be done with equal convenience, be- 
 cause it is supposed the first direction will 
 be followed by less danger of hernia. ( Sa- 
 batier , Medecine Opiratoire, T. 1, p. 220, 
 Ed. 2. Callisen , Syst. Chir. Hod. T. 1, p. 
 705.) If, however, the upper angle of the 
 wound correspond to the direction of the 
 suspensory ligament of the liver, writers 
 advise making the dilatation at the lower 
 angle, in order to incur no risk of hemor- 
 rhage from the umbilical vein. In the. 
 adult, this vessel is generally obliterated, 
 and turned into a ligamentous substance ; 
 though it would appear that, in a few in- 
 stances, it remains pervious to the navel, 
 Hildanus saw a young man die instantly in 
 consequence of a stab in the belly between 
 the false ribs and the umbilicus ; and, on 
 opening the body, he found blood effused 
 from a wound of the umbilical vein. It has 
 been feared, also, that cutting the suspen- 
 sory ligament of the liver might give rise to 
 such a displacement of that viscus as would 
 interrupt the freedom of respiration, or 
 obstruct the circulation of the blood in the 
 vena cava. But the apprehension is un- 
 founded ; for Riolan found this ligament 
 ruptured and retracted towards the liver in 
 a nimble Ethiopian female dancer, whose 
 respiration had not suffered any particular 
 disturbance during her lifetime. ( Sabatier , 
 Mid. Opiratoire, T.l,p. 220, 221, Ed. 2.) 
 
 The incision should never be larger than 
 absolutely requisite, as hernia is much dis- 
 posed to occur wherever the peritoneum 
 has been divided. The operation may be 
 done with a curved bistoury and a director, 
 much in the same way as is done in cases of 
 strangulated ruptures. (See Hernia.) 
 
 After the battle of Waterloo, many cases 
 presented themselves in which the bowels 
 and omentum protruded, and in several of 
 these examples the reduction could not be 
 effected before the wounds had been en- 
 larged. So tightly also were the parts girt, 
 that the operation was sometimes far from 
 being easy. 
 
 Instead of enlarging wounds of the abdo- 
 men, it has been proposed to let out the air 
 from the protruded intestines, by making 
 small punctures with a needle, so as to 
 lessen their volume sufficiently to make 
 them reducible. The suggestion first origi- 
 nated with Par6, who declares that he has 
 practised the method with success. Rousset, 
 his contemporary, also informs us that the 
 plan was adopted by another surgeon in an 
 instance where the epigastric region was 
 wounded, and a large portion of the intes- 
 tines protruded in a strangulated state. Pe- 
 ter Eowe, an English surgeon, likewise 
 assures us, that he frequently adopted the 
 
WOUNDS 
 
 672 
 
 practice, when other means failed. Garen- 
 geot, Sharp, and Van Swieten, are all ad- 
 vocates for Fare’s proposal ; but they 
 recommend the employment of a round 
 needle, which will merely separate the fibres 
 of the intestinal canal, without cutting them, 
 as a flat, triangular, sharp-edged needle 
 would unavoidably do. These last writers, 
 however, only sanction the practice when 
 the quantity of protruded intestine is great, 
 and the bowel is so enormously distended 
 with air, that it would be impossible to re- 
 duce the part, though the wound were en- 
 larged, and every thing else put in practice, 
 likely to bring about the reduction. Bui, as 
 Sabatier remarks, the punctures must be 
 entirely useless, if made with a fine needle, 
 since they will be immediately stopped up 
 with the mucous secretion, with which the 
 inside of the bowels is constantly covered ; 
 and if the punctures are made with a broad 
 triangular needle, or a very large round 
 one, as Desault and Chopart advise, they 
 must be highly dangerous, inasmuch as they 
 are likely to give rise to inflammation, and 
 even to extravasation, within the abdomen. 
 (Medecine Opiraloire, T. 1 , p. 10.) 
 
 That small punctures in the bowel would 
 not answer the purpose, but be obstructed 
 by the villous or mucous coat, is a fact, 
 which has been for a long time well known 
 to surgeons. Callisen, among "others, has 
 particularly noticed it: 11 Acu puncturae 
 
 enim flatibus exitum parare nequeunt, siqui- 
 dem tunica villosa foraminula obstruit,” &c. 
 (Sys. Chir. Hod . T 2, p. 704.) 
 
 It was the circumstance of small punc- 
 tures being unavailing, that led Desault and 
 Chopart to recommend the use of a large 
 round needle : “ pour que louverture ne soit 
 point bouchie par les mucositis dont les intes- 
 tines sont enduils” But they were also 
 aware of the danger of employing such an 
 instrument, since they give us directions 
 how to proceed in order to prevent extra- 
 vasation and inflammation : On prd vien- 
 
 dra V epanchement des matilres stercorales en 
 passant, avant de reduire iintestin , line anse 
 de fil dans la portion dc mesentere qui repond 
 a la piqure pour la fixer contre les bords de 
 la plait exttriture, et Von combuttra par Its 
 remedes giniraux Vinfiammation que cet pi- 
 qure peut attirer .” ( Traiti des Maladies 
 
 Chirurg. T. 2, p. 135.) Richerand is still 
 an advocate for puncturing the bowel, for 
 which operation he boldly recommends a 
 small hydrocele trocar. ( JVosogr . Chir. T. 
 3 ,p. 336, Ed. 4.) 
 
 Mr. Travers, one of the latest and best 
 writers upon this subject, most properly 
 joins in the condemnation of the plan of 
 pricking the protruded bowels. Blancard 
 and others protested against this practice 
 on the very sufficient ground of its ineffi- 
 cacy. La Faye very truly says, it is a use- 
 less as well as dangerous practice ; for the 
 openings made by a round needle cannot 
 give issue to the contained air.” Mr. Tra- 
 vers then cites two cases, showing that even 
 small stabs in a bowel will not prevent its 
 becoming distended w ith air. 
 
 “ A man was brought to St. Thomas'? 
 hospital, on Saturday, the 30th of June last, 
 (1811) who had been stabbed in the direc 
 tion of the epigastric artery, oy the left side 
 of the abdomen, by a case knife. He died 
 in eighteen hours, apparently from the sud- 
 den and copious hemorrhage, which had 
 taken place within the belly, <\bout half a 
 yard of ileon was protruded. The gut was 
 highly discoloured, and so much distended, 
 notwithstanding it was pierced in three 
 places, that the wound of the integuments 
 required to be freely dilated before it could 
 be returned. The apertures were in fact 
 obliterated by the mucous coat” 
 
 “ It appeared upon the trial of Captain 
 Sutherland (Ann. Reg. June 1809), for the 
 murder of his cabin boy, that the intestines 
 had been extensively protruded through a 
 wound near the left groin, and had lain ex- 
 posed for four or five hours ; that the dirk 
 had pierced through one fold of intestine, 
 and entered another ; that the w r ound of 
 the intestine was half an inch long ; that 
 the reduction could not be accomplished 
 until the parietal wound was dilated ; and 
 that the intestine was then returned, and 
 the integuments sewed up.” (Travers on 
 Injuries of the Intestines, p. 174, 176.) 
 
 With respect to this last case, however, I 
 must observe, that it does not satisfactorily 
 prove what the author intends, namely, 
 that the bowel was distended with air, though 
 there was a wound in it half an inch long, 
 for the evidence does not inform us that the 
 difficulty of reduction was owing to this 
 cause. I have seen a very small portion of 
 omentum protrude through a wound, and 
 baffle all endeavours to reduce it for nearly 
 an hour. The first case adduced by Mr. 
 Travers, however, is more explicit and in- 
 teresting ; and we are to infer from it, and 
 the observations of Haller, Callisen, &.c. 
 that the punctures made in an intestine are 
 not closed by mucus, as Sabatier and De- 
 sault have asserted, but by the mucous coat 
 itself. 
 
 As the above expedient had been recom- 
 mended by writers of some weight, I 
 thought that the subject should not be passed 
 over in silence, and without a caution to 
 the reader, never to put any confidence in 
 the method. The plan does not facilitate 
 the business of the operator. There is not 
 even this solitary reason in favour of the 
 practice ; and though it may have answered 
 when large needles were used, and some 
 patients so treated may have recovered, 
 every person, who has the least knowledge 
 of the animal economy, will easily compre- 
 hend how even the smallest opening, made 
 in parts so irritable and prone to inflamma- 
 tion as the bowels, must be attended with 
 greater danger than would result from en- 
 larging a wound of the skin and muscles. 
 Besides, the air may frequently be pressed 
 out of the intestine in a safer way, as I have 
 already described. 
 
 A wound of the abdomen, attended with 
 one of the most considerable protrusions ot 
 the viscera that 1 have ever read of, is re- 
 
wounds. 
 
 horded by Mr. Hague, surgeon at Rippfcn : 
 “ August 30th, 1808 (says this gentleman) 
 I went to Norton Mills, about four miles 
 from hence, to see John Brown, ret. 12 
 years, who had received a wound in the 
 abdomen by a wool shears. OnHny arrival, 
 which was little more than an hour after 
 the accident, I found the poor lad in a very 
 distressing situation ; the great arch of the 
 stomach, and the whole of the intestinal ca- 
 nal, (duodenum excepted,) contained with- 
 in the abdomen, having protruded through 
 the wound. The incision was on the left 
 side of the body, commencing at about two 
 inches below the scrobiculus cordis, and 
 extending in a straight line near four inches 
 in length, distant from the navel two inches, 
 and he was uuite sensible, and had vomited 
 so as to empty the stomach ; very little 
 blood was lost. I immediately proceeded 
 very carefully to examine the protruded 
 viscera, none of which were wounded, and 
 reduced them as quickly as possible, begin- 
 ning with the stomach, and following the 
 regular course of the intestines, in the latter 
 portion of which 1 distinctly felt feces of 
 father firm consistence. He complained of 
 some pain during the reduction, though not 
 much ; and expressed great relief when the 
 parts were completely returned. I now 
 desired an assistant to lay the palm of his 
 hand over the wound, and make some 
 pressure upon it ; for l found, that, without 
 this, the parts would soon have protruded 
 again by the action of respiration, which 
 was oppressed and laborious. 1 brought 
 the sides of the wound together by five su- 
 tures, beginning from above downwards, 
 and passed the needle on each side, quite 
 through the integuments with the perito- 
 neum, &Z.C. The wound was also dressed 
 with adhesive plaster, and covered with a 
 bandage.” (Vide Edinburgh Medical and 
 Surgical Journal , Vol. 5, p. 129, <$/-c.) 
 
 This case is interesting ; for notwith- 
 standing so unlimited a protrusion of the 
 viscera, and the circumstance of the parts 
 being left unreduced for more than an hour, 
 a recovery ensued, under the judicious em- 
 ployment of bleeding, purging, anodynes, 
 &c. 
 
 In la Caserne de St. Elizabeth at Brussels, 
 after the battle of Waterloo, the number of 
 protrusions of the viscera, which fell under 
 my notice, were much more considera- 
 ble, than what I previously had any idea of 
 ever meeting with. I well remember, in my 
 own part of the hospital, two protrusions of 
 a large portion of the stomach ; three of the 
 bladder ; and ten or twelve of the mesente- 
 ry, omentum, or intestines. 
 
 Whether a suture should be used, when the 
 protruded intestine is wounded, is a subject 
 which will be noticed in considering wounds 
 of the intestines. 
 
 Some of the exposed intestine may have 
 mortified before the arrival of surgical assist- 
 ance. In eases of wounds, this event is/are ; 
 but in those of stranzulated hernias it is not 
 Vos. II „ 85 
 
 U73 
 
 uncommon. The treatment is explained in 
 the article Hernia. 
 
 When the protruded intestine is in a state 
 of inflammation, its immediate reduction is r 
 beyond all dispute, the means most likely to 
 set every thing right. Even when tiie in- 
 flammation is considerable, a timely reduc- 
 tion of the displaced part, and the employ- 
 ment of antiphlogistic means, will often pre- 
 vent gangrenous mischief. The dull, brown, 
 dark red colour of the intestine may induce 
 the practitioner to suppose, either that the 
 part is already mortified, or must inevitably 
 become so, and consequently, he may delay 
 returning it into its natural situation. But 
 notwithstanding this suspicious colour of the 
 intestine, its firmness will evince, that it is 
 not in a state of gangrene. The ultimate 
 recovery of a portion of intestine, so cir- 
 cumstanced, is always a matter of uncer- 
 tainty ; but the propriety of speedily repla- 
 cing the part in its natural situation, is a 
 thing most certain. “ Partes egressre sanee 
 (observes Callisen) eitissime sunt reponendre, 
 neque obstat mutatio coloris nativi in rubrum 
 subfuscum.” (Sysl. Chir. Hod. T. \,p. 703, 
 edit. 1798.) In case the bowel mortify after 
 its reduction, all hopes of the preservation of 
 life are not to be abandoned ; as I have no 
 ticed in the articles Anus, artificial, ami Her- 
 nia, in which last part of the book, many 
 things, necessary to be known, concerning 
 the mode of reducing protruded omentum, 
 will also be found. 
 
 When a piece of intestine cannot be re- 
 duced, granulations and new skin sometimes 
 grow over it, and a cure follows, as the ex- 
 perience of Callisen confirms. (Op. cit. p. 
 706.) 
 
 The protruded viscera having been re- 
 duced, the next object is to retain them in 
 the abdomen, until the wound is completely 
 healed. When the wound is small, this is a 
 matter of no difficulty ; for it is enough to 
 put the patient in a position which will re- 
 lax the fibres of the wounded muscles, while 
 the edges of the wound are maintained in 
 contact with sticking-plaster, and supported 
 by a compress and bandage. Costiveness is 
 to be removed by the mildest purgatives, 
 such as the oleum ricini, or by laxative clys- 
 ters, which are still preferable. But in cases 
 of extensive wounds, even when the treat- 
 ment is conducted with all possible judg- 
 ment, it is occasionally difficult, and even 
 impossible, to hinder the protrusion of the 
 bowels by common dressings and a ban- 
 dage. In this circumstance the edges of 
 the wound must be sewed together. (See 
 Gastroraphe.) In modern times, however, su- 
 tures are much more seldom employed than 
 formerly, and in the above article, some re- 
 marks are offered, proving that the generality 
 of wounds of the abdomen do not require the 
 practice. 
 
 When the omentum protrudes, and is 
 strangulated by the narrowness of the open- 
 ing, it soon contracts adhesions to it, unless 
 speedily reduced. Should such connexion 
 be already formed, when the surgeon is first 
 consulted*, we are advised to cut off the por- 
 
674 
 
 WO USD'S. 
 
 tion which exceeds the level of the integu- 
 ments, and to leave the rest in the wound. 
 The latter will block up the opening, 
 and have the good effect of preventing 
 hernia. (Richer and, JYosogr. Ch%r. T. 3, p. 
 339, edit. 4.) When the protruded omen- 
 tum is sound and free from adhesions, it 
 ought to be reduced without delay. But, 
 when the protrusion is large, and there is 
 reason to fear, from the vomiting and the 
 pains shooting frdrn the wound to the epigas- 
 tric region, that the stomach is dragged, the 
 displac ed part must be made free, and if 
 sound, reduced. Should it be in a mortified 
 state, the dead part must be previously cut 
 away, and any vessels which bleed, tied 
 separately with a piece of fine thread, or silk, 
 both ends of which may either be cut off 
 close to the knot, and the part then reduced; 
 or one end of the silk may be left out of the 
 w r ound, and the other cut away. Practition- 
 ers who apprehend ill effects from leaving 
 within the abdomen so small a particle of 
 extraneous matter, as the little knot of fine 
 thread, will prefer the last method, and wilh- 
 dravv the ligature altogether, as soon as it 
 becomes loose. 
 
 Extravasation in the Abdomen. — Wounds 
 of the abdomen may be complicated with 
 extravasations of blood, chyle, excrement, 
 bile, or * urine. None of these complica- 
 tions, however, are half so frequent, as an 
 inexperienced practitioner would apprehend. 
 The employment of the phrase cavity of 
 the abdomen has paved the way to much er- 
 roneous supposition upon this subject, and 
 has induced many absurd notions, which 
 even the sensible observations, long ago pub- 
 lished by J. L. Petit, have scarcely yet dis- 
 pelled. 
 
 As a modern writer has observed : “ There 
 is not truly any cavity in the human body, 
 but all the hollow bowels are filled with 
 their contents, all the cavities filled with 
 their hollow bowels, and the whole is equal- 
 ly and fairly pressed. Thus, in the abdomen, 
 all the viscera are moved by the diaphragm 
 and the abdominal muscles upwards and 
 downwards, with an equable coutinuai pres- 
 sure, which has no interval ; and one would 
 be apt to add, the intestines have no repose, 
 being kept thus in continual motion ; but 
 though the action of the diaphragm, and the 
 reaction of the abdominal muscles are alter- 
 nate, the pressure is continual; the motion 
 which it. produces, (they produce) is like 
 that which the bowels have, when we move 
 them forwards in walking, having a motion, 
 with respect to space, but none with regard 
 to each other, or to the part of the belly 
 which covers them ; the whole mass of the 
 bowels is alternately pressed, to use a course 
 illustration, as if betwixt two broad boards, 
 which keep each turn or intestine in its right 
 place, while the whole mass is regularly 
 moved. When the bowels are forced down 
 by the diaphragm, the abdominal muscles 
 recede : when tbe bowels are pushed back 
 again, it is the reaction of the abdominal mus- 
 cles, lhatforces thembackand follows them ; 
 there is never an instant of interruption of this 
 
 pressure, never a moment, in which the bow 
 els do not press against the peritoneum ; nor 
 is there the smallest reason to doubt that the 
 same points in each are continually opposed 
 We see that the intestines do not move, or, 
 at least, do not need to move in performing 
 fheir functions; for in hernia, where large 
 turns of intestines are cutoff by gangrene, 
 the remaining part of the same intestines is 
 closely fixed to the groin, and yet the bow- 
 els are easy, and their functions legular. 
 We find the bowels regular, when they lie 
 out of the belly, in hernia, as v\ hen a certain 
 turn of intestine lies in the scrotum or thigh, 
 or in a hernia of the navel ; and where yet 
 they are so absolutely fixed, that the piece 
 of intestine is marked by the straitness of 
 the rings. We find a person, after a wound 
 of the intestine, having free stools for many 
 days ; ant) what is it that prevents the feces 
 from escaping but merely this regular and 
 universal pressure ? We find a person, on 
 the fourth or fifth day, with feces coming 
 from the wound ! a proof, surely, that the 
 wound of the intestine is still opposite or 
 nearly opposite to the external wound. We 
 find the same patient recovering without one 
 bad sign ! What better proof than this could 
 we desire, that none of the feces have exu- 
 ded into the abdomen ? 
 
 “ If in a wound of the stomach, the food 
 could get easily out by that wound, tbe sto- 
 mach would unload itself that way, there 
 would be no vomiting, the patient must die; 
 but so regular and continual is this pressure, 
 that the instant a man is wounded in the 
 stomach, he vomits, he continues vomiting 
 for many days, while not one particle es- 
 capes into the cavity of the abdomen. The 
 outward wound is commonly opposite to that 
 of the stomach, and by that passage, some 
 part of the food comes out ; but when any 
 accident removes the inward wound of the 
 stomach from the outward wound, the ab- 
 dominal muscles press upon the stomach, 
 and follow it so closely, that if there be not 
 a mere laceration extremely wide, this pres- 
 sure closes the hole, keeps the food in, ena- 
 bles the patient to vomit, and not a particle, 
 even of jellies, or soups, is ever lost, or goes 
 out into the cavity of the belly. 
 
 i: How (proceeds Mr. J. Bell) without this 
 universal and continual pressure, could the 
 viscera be supported ? Could its ligaments, 
 as we call them, support the weight of the 
 liver ? Or what could support the weight of 
 the stomach when filled ? Could the mesen- 
 tery, or omentum, support tbe intestines ; or 
 could its own ligaments, as we still name 
 them, support the womb ? How, without 
 this uniform pressure, could these viscera fail 
 to give way and burst ? How could the cir- 
 culation of the abdomen go on ? How could 
 the liver and spleen, so turgid as they ate 
 with blood, fail to burst ? Or what possibly 
 could support the loose veins and arteries of 
 tbe abdomen, since many ot them. e g. the 
 splenic vein, is (are) two feet in length, is 
 (are) of tbe diameter of tbfe thumb, and has 
 (have) no other than the common pellucid 
 and delicate coats of the veins ? How could 
 
WOUNDS. 
 
 675 
 
 (be viscera of Ibe abdomen bear shocks and 
 falls, if hot supported by the universal pres- 
 sure of surrounding parts ? In short, the acci- 
 dent of hernia being forced out by any blow 
 upon the belly, or by any sudden strain, ex- 
 plains to us how perfectly full the abdomen 
 is, and how ill it is able to bear any pressure, 
 even from its own muscles, without some 
 point yielding, and some one of its bowels 
 being thrown out. And the sickness and 
 faintness, which immediately follow the 
 drawing off of the waters of a dropsy ,«explain 
 to us, what are the consequences of such 
 pressure being even for a moment relaxed. 
 But, perhaps, one of the strongest proofs is 
 this, that the principle must be acknowledged, 
 in order to explain what happens daily in 
 wounds ; for though in theory ive should be 
 inclined to make this distinction, that the 
 hernia, or abscess of the intestines will ad- 
 here and be safe, but that wounded intes- 
 tines, not having time to adhere, will be- 
 come flaccid, as we see them do in dissec- 
 tions, and so, falling away from the external 
 wound, will pour out their feces into the ab- 
 domen, and prove fatal ; though we should 
 settle this, as a fair and good distinction in 
 theory, we find that it will never answer in 
 practice. Soldiers recover daily from the 
 most desperate wounds ; and the most likely 
 reasons, that we can assign for it, are the 
 fulness of the abdomen, the universal, equa- 
 ble, and gentle pressure ; and the active dis- 
 position of the peritoneum, ready to inflame 
 with the slightest touch. The wounded in- 
 testine is, by the universal pressure, kept 
 close to the external wound, and the perito- 
 neum and the intestine are equally inclined 
 to adhere. In a few hours, that adhesion is 
 begun, which is to save ‘he patient’s life, and 
 the lips of the w r ounded intestine are glued 
 to the lips of the external wound. Thus is 
 the side of the intestine united to the inner 
 surface of the abdomen ; and though the gut 
 casts out its feces, while the wound is open ; 
 though it often casts them out more freely, 
 while the first inflammation lasts; yet the 
 feces resume their regular course, whene- 
 ver the wound is disposed to close.” (John 
 Bell's Discourses on Wounds, p. 323, 327, 
 Edit. 3.) 
 
 The loregoing extract, though drawn up 
 in a careless style, contains such observa- 
 tions as are well calculated to make the 
 reader understand, that the abdomen is in 
 reality not a cavity, but a compact mass of 
 containing and contained parts ; that the 
 close manner, in which the various surfaces 
 are constantly in contact most powerfully 
 oppose extravasations ; and that, in fact, it 
 often entirely prevents them. The passage 
 cited impresses us with the utility of that 
 quick propensity to the adhesive inflamma- 
 tion, which prevails throughout every peri- 
 toneal surface, and which not only often has 
 the effect of permanently hindering effusion of 
 the contents of the viscera, by agglutinating 
 the parts together, but which, even when 
 an extravasation has happened, beneficially 
 confines the effused blood in one mass, and 
 surrounds it with such adhesions of the 
 
 parts to each other, as are rapid in their 
 formations, and effectual for the purposes 
 of limiting the extent qf the effusion, and 
 preventing the irritation of the extravasa- 
 ted matter from affecting the rest of the ab- 
 domen. 
 
 It is to Petit that surgeons are indebted 
 for more correct modes of thinking upon the 
 foregoing subject, and it is with great plea- 
 sure that I here refer to his valuable obser- 
 vations. (See Mem. de I'Acad. de Chir.) 
 
 But notwithstanding the reciprocal pres- 
 sure of the containing and contained parts 
 against each other, and the useful effect of 
 the quickly arising adhesive inflammation, 
 in all penetrating wounds of the belly, com- 
 plicated with injuries of the viscera, we are 
 not to suppose, that extravasation never 
 happens ; but only that it is much less fre- 
 quent than has been commonly supposed. 
 Mr. Travers, with much laudable industry, 
 has endeavoured to trace more minutely, 
 than any preceding writer, the particular 
 circumstances, under which effusions in the 
 abdomen are likely or unlikely to hap- 
 pen.” It being admitted (says he) tbat 
 there are cases in which effusion does 
 take place, it is easy to conceive circum- 
 stances which must considerably influence 
 this event. If, for example, the stomach and 
 bowels be in a state of emptiness, the nausea 
 which follows the injury will maintain that 
 state. If the extent of the wound be con- 
 siderable, the matter will more readily pass 
 through the wound, than along the canal. 
 A wound of the same dimensions in the 
 small and large intestines, will more readily 
 evacuate the former than the latter, because 
 it bears a larger proportion to the calibre. 
 Incised and puntured wounds admit of the 
 adhesion of the cut edges, or the eversion of 
 the internal coat of the gut, so as to be in 
 many instances actually obliterated ; where- 
 as lacerated, or ulcerated openings, do not 
 admit of these salutary processes. Again, in 
 a transverse section of the bowel, contrac- 
 tion of the circular fibre closes the wound, 
 whereas in a longitudinal section, the con- 
 traction of the fibre enlarges it. Such (says 
 Mr. Travers) are the circumstances, which 
 combined, in a greater or less degree, in- 
 crease or diminish the tendency to effu- 
 sion.” (On Injuries of Intestines , §*c. p. 
 13, 14.) 
 
 After the details of some experiments and 
 cases, the preceding author makes, among 
 other conclusions, the following : 
 
 1. That effusion is not an ordinary conse- 
 quence of penetrating wounds. 
 
 2. That if the gut be full and the wound 
 extensive, the surrounding pressure is over- 
 come, by the natural action of the bowel 
 tending to the expulsion of its contents. 
 
 3. That, if food has not recently been 
 taken, and the wound amounts to a division 
 of the gut, or nearly so, the eversion and 
 contraction of the orifice of the tube prevent 
 effusion. 
 
 4. That if the canal be empty at the lime 
 of the wound, no ^subsequent state of the 
 bowel will cause effusion, because the super- 
 
VJTOUA'DS. 
 
 
 vening inflammation agglutinates the sur- 
 rounding surfaces, and forms a circumscribed 
 sac ; nor can effusion take place from a 
 bowel at the moment full, provided it retains 
 a certain portion of its cylinder entire, the 
 wound not amounting nearly to a semidivi- 
 sion of the tube, for then the eversion and 
 contraction are too partial to prevent an 
 extravasation. 
 
 5. That, when however air has escaped 
 from the bowel, or blood has been extrava- 
 sated in quantity within the abdomen at the 
 time of the injury, the resistance, made to 
 effusion, will be less effectual, although the 
 parietal pressure is the same, as such fluids 
 will yield more readily, than the solids na- 
 turally in contact. (P. 25, 26, 100.) 
 
 “ That, though extravasation is not com- 
 mon in penetrating wounds, it follows more 
 generally in cases, where the bowel is 
 ruptured by blows, or falls upon the belly, 
 while the integuments continue upwounded. 
 (P. 36.) 
 
 7. That when the bowels are perforated 
 by ulceration, there is more tendency to 
 effusion, than in cases of wounds. (P. 
 38, fee.) 
 
 Mr. Travers attempts to explain the reason 
 of the greater tendency to effusion, in cases 
 of intestine burst by violence, than in those 
 of ulceration, “by the difference in the na- 
 ture of the injury, which the bowel sustains, 
 when perforated by a sword or bullet, as in 
 the one case, or burst or ulcerated in the 
 other. A rupture by concussion could only 
 take place under a distended state of the 
 bowel, a condition most favourably to effu- 
 sion, and from the texture of the part, a rup- 
 ture so produced would seldom be of limited 
 extent. The process of ulceration, by which 
 an aperture is formed, commences in the in- 
 ternal coat of the bowel, which has always 
 incurred a more extensive lesion, than the 
 peritoneal covering. The puncture, or cut, 
 is merely a solution of continuity in a point, 
 or line ; the ulcerated wound is an actual 
 loss of substance. The consequence of this 
 difference is, that, while the former, if small, 
 is glued up by the effusion from the cut ves- 
 sels, or, if large, is nearly obliterated by the 
 full eversion of the villous coat, the latter is 
 a permanent orifice ” (P. 46.) 
 
 How much Mr. Travers and Mr. John 
 Bell differ in opinion, upon these latter 
 points, will appear from th^s following^as- 
 sage : after adverting to the adhesion, which 
 takes place between the viscera and the 
 peritoneum, under a variety of circumstances 
 attending disease, Mr. John Bell observes : 
 “ This it is, which makes the chief difference, 
 in point of danger, betwixt an ulcerated and 
 a wounded intestine ; for, in a wound, there 
 is, as we should suppose, no time for adhe- 
 sion, nothing to keep the parts in contact, no 
 cause, by which the adhesion might be pro- 
 duced. But, in an ulcer, there is a slow dis- 
 ease, tedious inflammation, adhesion at first, 
 and abscess, and bursting afterward j some- 
 times a fistula remains discharging feces, and 
 sometimes there is a perfect cure. If a nut- 
 shell, a large coin, a bone, or any dangerous 
 
 thiqg be swallowed, i( stops in the stomach, 
 cadsing swelling and dreadful pain ; at last, 
 a hard firm tumour appears, and then it sup- 
 purates, bursts, the bowel opens, the food is 
 discharged at every meal, till the fistula 
 gradually lessens, and heals at last. But 
 where the stomach is cut with abroad wound 
 of a sabre, the blood from the wounded 
 epiploic vessqjs, or the food itself, too often 
 pours out into the abdomen, and the patient 
 dies,'&ic.” ( Discourses on Wounds, p. 321, 
 edit. 3.) The author afterward proceeds to 
 explain, how in cases of penetrating wounds, 
 the compact state of the containing and con- 
 tained parts, and the incessant and equable 
 pressure, which the viscera sustain, fre- 
 quently hinder effusion. 
 
 Which of these gentlemen is most correct, 
 I cannot pretend to determine, and whether 
 Mr. Travers’s cases are deviations from what 
 is most comraoh, can only be decided by a 
 comparative examination of a greater num- 
 ber of facts. When the intestines ulcerate, 
 and thus rid themselves of foreign bodies, 
 the general tenor of the cases on record un- 
 doubtedly affords us little reason to be ap- 
 prehensive of extravasation. Yet, with re- 
 spect to ulceration of the intestines from 
 other causes, circumstances may be very 
 different. And it is but justice to state, That 
 Mr. Travers’s opinions have received some 
 confirmation from an interesting case, pub- 
 lished by Dr. J. Crampton, of Dublin. It is 
 an instance of rupture of the stomach, and 
 fatal effusion of its contents into the cavity 
 of the abdomen. The patient was a young 
 lady, aged 29. She was suddenly'fhken ill 
 with spasm in her stomach, and other severe 
 symptoms, and died in about twelve hours. 
 “ On opening the abdomen, the stomach was 
 observed to be pale, flaccid, and empty. Its 
 contents, among which were recognized oat- 
 meal and castor oil, had escaped into the 
 cavity of the abdomen, through a round 
 aperture situated on its anterior surface, 
 at the union of the cordiac and pyloric 
 portions. This perforation of the stomach 
 was perfectly circular, about the size of a 
 pea, and appeared to be the result of an 
 ulcer on the mucous surface, which had 
 gradually penetrated the other coats. This 
 ulcer was hollow and circular, nearly the 
 size of a shilling, and had the appearance, as 
 if it had been made with caustic, with the 
 orifice in its centre.” (J. Crampton , Med. 
 Chir. Trans. Vol. 8, p. 230.) To the prece- 
 ding, Mr.Travers has annexed some addition- 
 al facts : one is an example of a rapidly fatal 
 effusion of the intestinal contents, through 
 an ulcerated opening nbout a finger’s 
 breadth below the pylorus. The foramen 
 had a peritoneal margin, and proved to bo 
 the centre of an irregular superficial ulcer of 
 the mucous coat. Another case is that of a 
 similar ulceration of ( the small intestines, and 
 fatal extravasation of their contents. In 
 another example, a circular aperture ot the 
 peritoneum, large enough to admit a crow’s 
 quill, was found after death at the junction 
 of the duodenum and stomach. It also was 
 the centre of an ulcer, that had destroyed 
 
Ike villous and muscular coals oi the bowel 
 to ..the extent of half an Inch, lor many 
 other ingenious observations, I must refer 
 the reader to Mr. Travers’s paper, who con- 
 cludes with remarking, that the chief diag- 
 nostic symptoms of these hopeless cases ap- 
 pear to be : 
 
 1. Sudden, most acute, and unremitting 
 pain, radiating from the scrobiculus cordis, 
 or the navel, to the circumference of the 
 trunk, and even to the limbs. A peculiar 
 pain, the intensity of which, like that of par- 
 turition, absorbs the whole mind of the pa- 
 tient, who, within an hour from the enjoy- 
 ment of perfect health, expresses his serious 
 •i and decided conviction, that if the pain be 
 v not speedily alleviated, he must die. 
 
 ^ Coeval with the attack of pain, remark - 
 f able rigidity and hardness of the belly, from 
 a fixed and spastic contraction of the abdo- 
 
 i minal muscles. 
 
 3. A natural pulse for some hours, until 
 the symptoms are merged in those of acute 
 peritonitis, and its fatal termination in the 
 adhesive stage. (Med. Chir. Trans. Vol. 8, 
 p. 231, et seq.) 
 
 * Blood is more frequently extrayasated in 
 the abdomen, than any other fluid, but, it 
 does not always take place, Unless the 
 
 | wounded vessels be above a certain rnagni- 
 | tndfr. The compact state of the abdominal 
 ■' viscera, in regard to each other, and their 
 f action on each other, oppose this effect. 
 
 I The action alluded to, which depends on 
 the abdominal muscles and diaphragm i3 
 rendered very manifest by what happens in 
 consequence of operations for hernias, at- 
 tended with alteration of the intestines, or 
 omentum If these viscera burst, or suppu- 
 rate, after being reduced, the matter which 
 escapes from them, or the pus which they 
 secrete, is not lost in the abdomen -, but is 
 propelled towards the wound in the skin, 
 and there makes its exit The intestinal mat- 
 ter effused from a mortified bowel, has been 
 known to remain lodged the whole inter- 
 val, between one time ot dressing the wound 
 and another, in consequence of the surgeon 
 stopping up the external wound with a large 
 tent. When the above-mentioned action or 
 pressure of the muscles, is not sufficient to 
 keep the blood from making its escape from 
 the vessels, still it may hinder it from be- 
 coming diffused among the convolutions of 
 the viscera, and thus theSextravasation is 
 confined in one mass. The blood, effused 
 and accumulated in this way, is commonly 
 lodged at the inferior and anterior part of 
 the abdomen, above the lateral part of the 
 pubes, and by the side of one of the recti 
 ' muscles. The weight of the blood may 
 l propel it into this situation, or perhaps, there 
 may be less resistance in this direction, than 
 ! in others. In opening the bodies of persons, 
 x«ho have died with such extravasations, 
 things may put on a different aspect, and 
 j the blood seem to be promiscuously extra- 
 1 vasated over every part of the abdomen. 
 But, when such bodies are examined with 
 care, it will be found, that the blood does 
 i not insinuate itself among the viscera, till 
 
 the moment when the abdomen is opened, 
 and the masy previously lies in a kind ot’ 
 pouch. This pouch is frequently circum- 
 scribed, and bounded by thick membranes, 
 especially when the extravasation has been 
 of some standing. (Sabatier Medecine Opt' 
 ratoire , T. l,p. 28 — 30.) 
 
 Every practical surgeon should remember 
 well that all the abdominal viscera closely 
 touch either each other, or the inner surface 
 of the peritoneum. This is one grand reason, 
 why extravasations are seldom extensively 
 diffused ; but, commonly lie in one mass, as 
 Petit, Sabatier, and all the best moderns have 
 noticed. The pressure of the elastic bowels, 
 diaphragm, and abdominal muscles, not only 
 frequently presents an obstacle to the diffu- • 
 sion of extravasaied matter, but often serves 
 to propel it towards the mouth of the wound. 
 The records of surgery furnish numerous 
 instances, in which persons have been stab- 
 bed through the body, without fatal conse- 
 quences, and sometimes without the symp- 
 toms being even severe. In Mr. Travers’s 
 publication many ( cases, exemplifying this ob- 
 servation, are quoted from a Variety of 
 sources: Fab. Ilildan. Obs. Chirurg. Cent, 
 5. Obs. 74. CEuvres de Pare, liv. 10. Chap. 
 35. Wiseman’s Surgery, p. 371. La Motte’s 
 Traite Complet de Chirurgie, &c. &.c. In 
 such cases, the bowels have been supposed 
 to have eluded the point of the weapon, and, 
 perhaps, in a few instances, this may actually 
 have been the fact ; but, in the generality of 
 such examples, the bowels must have been 
 punctured, and the extravasation of intes- 
 tinal matter prevented by the pressure of the 
 viscera against each other. 
 
 The pouch, or cyst, in which the extrava- 
 sated blood, or matter, lies, as mentioned by- 
 Sabatier, is formed by the same process, 
 which circumscribes the maiter of abscesses. 
 (See Suppuration.) It is, in short, the adhe- 
 sive inflammation. All the surfaces in con* 
 tact with each other,' and surrounding the 
 extravasation, and traffk of the wound, ge- 
 nerally become so intimately connected to- 
 gether by the adhesive inflammation, that 
 the place, in which the extravasation is 
 lodged, is a cavity entirely destitute of ail 
 communication with the cavity of the peri- 
 toneum. The track of the wound leads to 
 the seat of the effused fldld, but has no 
 distinct opening into the general cavity of 
 the abdomen. The rapidity, vith which the 
 above adhesions frequently form, is almost 
 incredible. 
 
 It should be known, however, that extra- 
 vasations are occasionally diffused in various 
 degrees among the viscera, owing to the 
 patient being subjected to a great deal of 
 motion, or affected with violent spasmodic 
 contractions of the intestines. Urine and 
 bile are also generally dispersed to a great 
 extent. As for blood, its disposition to 
 coagulate must often tend both to stop fur- 
 ther hemorrhage, and confine the extravasa- 
 tion in one mass. 
 
 Symptoms and Treatment of Extravasations 
 in the Abdomen. 1. Blood - — Wounds of the 
 ,spleen, and of very large veins and arteries 
 
WOUNDS- 
 
 4 S 
 
 in the abdomen, almost always soon prove 
 fatal from internal hemorrhage. The blood 
 generally makes its way downwards, and 
 accumulates at the inferior part of the ab- 
 domen, unless the presence of adhesions 
 happen to oppose the descent of the fluid 
 to the most depending situation. The bidly 
 swells, and a fluctuation is perceptible. The 
 patient grows pale, loses his strength, is 
 affected with syncope, and his pulse be- 
 comes weak, and scarcely distinguishable. 
 In short, the symptoms usually attendant on 
 profuse hemorrhage are observable. As 
 the viscera and vessels in the abdomen are 
 compressed on all sides by the surrounding 
 parts, the blood cannot be effused without 
 * overcoming a certain degree of resistauce ; 
 and unless a vessel of the first magnitude, 
 like the aforta, the vena cafa, or one of 
 their principal branches, has been wounded, 
 the blood escapes from the vessel slowly, 
 and several days elapse, before any consi- 
 derable quantity accumulates. 
 
 In these cases, the symptoms, which per- 
 haps bad disappeared under the employ- 
 ment of bleeding and anodyne medicines, 
 now recur. A soft fluctuating tumour may 
 be felt at the lower part of the abdomen ; 
 sometimes on the right side ; sometimes on 
 the left ; but occasionally on both sides. 
 The pressure made by the effused blood, on 
 the urinary bladder, excites distressing incli- 
 nations to make water ; while the pressure, 
 which the sigmoid flexure of the colon 
 suffers, is the cause of obstinate constipa- 
 tion. In the mean time, as the quantity of 
 extravasated blood increases, the. perito- 
 neum inflames. The pulse grows weaker ; 
 debility ensues ; -the countenance becomes 
 moistened with cold perspirations ; and 
 according to some w riters, unless the sur- 
 geon practise an incision for the discharge 
 of the fluid, the patient falls a victim to the 
 accident 
 
 In the year 1733, Vacher adopted this 
 treatment with success. Petit afterward 
 tried the same plan, though it did not an- 
 swer, (as is alleged) in consequence of the 
 inflammation having advanced too far before 
 the operation w'as performed. Long before 
 the time of Vacher and Petit, a successful 
 instance of similar practice was recorded by 
 Cabrole, in a work which this author pub- 
 lished, under the title of A\y*(Znrov ctvetro/ui- 
 xsv, id est, Anatbmes elenchus accuratissi- 
 mus, omnes humani corporis partes ea qui 
 solent secari methodo, delineans. Accessere 
 osteologia, observationesque Medicis ac 
 Chirurgicis perutiles. Geneva* 1604. The 
 method pursued by Vacher, was therefore 
 not so new as Petit imagined. 
 
 Indeed, w^hen the symptoms leave no 
 doubt, of there being a large quantity of 
 blood extravasated in the abdomen ; when 
 the patient’s complaints are of a very serious 
 nature, and are evidently ow ing to the irri- 
 tation and pressure of the blood on the 
 surrounding viscera ; and when a local 
 swelling denotes the seat of the extravasa- 
 tion-, there cannot he two opinions about, the 
 
 propriety of making an incision for its eva= 
 cuation. 
 
 Surgeons should recollect, however, that 
 if no opening be made, a small extravasation 
 of blood may not produce any considerable 
 irritation. On the contrary, when the cyst 
 including the blood is opened, the air then 
 has access, and that part of the fluid which 
 cannot be discharged, putrifies and becomes 
 so irritating, as to be a true cause of inflam- 
 mation. The bad symptoms are also some- 
 times chiefly owing to the injury done to 
 parts within the abdomen, and still more 
 commonly to inflammation within that ca- 
 vity, arising rather from the wound than 
 from the presence of effused blood. On the 
 whole, I am disposed to join a late waiter 
 in the belief, that the practice of discharging 
 extravasated blood from the abdomen can 
 rarely be adviseable — (See Htnneris Mil, 
 Surgery , P. 412, erf. 2.) 
 
 2. Chyle and Feces. — These are not so 
 easily extravasated in the abdomen as blood, 
 because they do not require so much resist- 
 auce, on the outside of the stomach and 
 intestines, to make them continue their na- 
 tural route through the alimentary canal, as 
 blood requires to keep it in the vessels. 
 However, when the wound is large, aud 
 the bowel distended at the moment of the 
 injury, or when, as Mr. Travers has explain- 
 ed, air is extravasated, or blood effused in 
 the abdomen, which fluids are incapable of 
 making effectual resistance to the escape of 
 the intestinal matter, the latter may be ef- 
 fused. (See an Inquiry into the Process of 
 JYature in repairing Injuries of the Intestines , 
 fyc.p. 26.) Nothing is a better proof of the 
 difficulty, with which chyle and feces are 
 extravasated, than the operation of an 
 emetic, when the stomach is wounded and 
 full of aliment. In this instance, if the re- 
 sistance to the extravasation of the contents 
 of the stomach were not considerable, they 
 would be effused in the abdomen, instead of 
 being vomited up. A peculiarity in wounds 
 of the stomach and intestines is, that the 
 opening, which allows their contents to 
 escape, may also allow them to return into 
 the wounded viscus. 
 
 Extravasation of intestinal matter in the 
 abdomen is attended with severe febrile 
 symptoms; considerable pain and swelling 
 of the belly ; convulsive startings ; and hic- 
 cough and vomiting, with which the patients 
 are generally attacked the day after the re- 
 ceipt of the wound. ( Sabatier , Mtd. Optra- 
 toirc , T. 1 ,p. 34.) 
 
 In these cases, only general means can 
 be employed ; venesection, leeches, fomen- 
 tations, low diet, perfect rest, anodynes, he. 
 All solid food must be strictly prohibited. 
 If pressure can be borne without inconve- 
 nience, as is sometimes the case in the early 
 stage, the close state of the viscera may bo 
 increased by the application of a bandage 
 round the body. 
 
 If the symptoms arc not speedily assua- 
 ged, the inflammation spreadsover the whole 
 cavity of thc;)bdomcn, gangrenous Mischief 
 

 WOUNDS. 
 
 
 : akes place, and the patients die in the course 
 of a lew days. 
 
 3. Bile — Bile, on account of its great 
 fluidity, is more apt to be widely extravasa- 
 ted in the abdomen, than either blood, or the 
 ( contents of the stomach aud intestines. 
 However, on account of the small size of 
 the gad bladder, and its deep guarded situa- 
 tion, between the concave surface of the 
 i liver, and upper part of the transverse arch 
 of the colon, wounds of it are uncommon. 
 
 Sabatier informs us, that he has only been 
 able to find one example on record. This 
 case was communicated to the Royal Socie- 
 ty of London, by Dr. Stewart (No. 414, 
 
 | pag. 341. Abridgm. Vol. 7, pag. 571 — 572,) 
 A wound penetrated the cavity of the abdo- 
 men, and entered the fundus of the gall 
 p bladder, without doing any material injury 
 [ to the adjacent parts. The abdomen was 
 I immediately distended, as if the patient had 
 | been afflicted with an ascites, or tympanitis ; 
 
 ? nor did the swelling either increase or di- 
 minish, till the patient’s death, which hap- 
 | pened in a week. 
 
 i Though there was a great deal of tension, 
 I there was no rumbling noise in the abdomen. 
 
 ! No stools, and very little urine were dis- 
 I charged, notwithstanding purgatives and 
 I clysters and a good deal of liquid nourish- 
 f ment, were given. Anodynes failed to 
 i; 1 procure one instant of sound sleep, and tile 
 patient was incessantly in a most restless 
 state. There was no appearance of fever, 
 
 ' and the pulse was always natural till the last 
 | day of the patient’s life, when it became 
 1 intermittent. After death, the intestines 
 ® were found much distended, the gall bladder 
 v quite empty, and a large quautity of bile 
 5 extravasated. 
 
 Sabatier had an opportunity of noticing 
 the symptoms of an extravasation of bile, 
 in consequence of a wound of the gall blad- 
 der. The patient’s abdomen swelled very 
 quickly ; his respiration became difficult, 
 and he soon afterward complained of tension 
 and pain in the right hypochondrium. His 
 pulse was small, frequent, and contracted ; 
 his extremities were cold, and his counte- 
 nance very pale. The bleedings which 
 were practised the first day, gave him a little 
 relief ; but the tension of the abdomen, 
 and the difficulty of breathing, still continu- 
 ed. A third bleeding threw the patient into 
 the lowest state of weakness, and he vomit- 
 ed up a greenish matter. On the third day, 
 
 ; the lower part of the belly was observed to 
 be more prominent, and there was no doubt 
 of an extravasation. Sabatier introduced a 
 trocar, and gave vent to a green blackish 
 ' fluid, which had no smell, and was pure bile 
 ! that had escaped from the wound of the 
 gall bladder. After the operation, the pa- 
 tient grew weaker and weaker, and died in 
 I a few hours. On opening the body, a large 
 quantity of yellow bile was found between 
 the peritoneum and intestines ; but it had 
 not insinuated itself among the convolutions 
 1 of the viscera. A thick gluten connected 
 the bowels together, and they were prodi- 
 ji giously distended. The gall bladder was 
 
 shrivelled, and almost empty. Towards its 
 fundus, there was a wound, about a line and 
 a half long, corresponding to a similar 
 wound in the peritoneum. The wound 
 which had occurred at the middle and lower 
 part of the right hypochondrium, between 
 the third and fourth false ribs, had glided 
 from behind forward, and from above 
 downward, between the cartilages of the 
 ribs, until it reached the fundus of the gall 
 bladder. 
 
 Sabatier takes notice, that the symptoms 
 of the two cases, which have just now been 
 related, were very similar. Both the patients 1 
 were affected with an exceedingly tense 
 swelling of the belly, unattended with pain, 
 or borborygmus, and they were both obsti- 
 nately constipated. Their pulse was ex- 
 tremely weak the latter days of their indis- 
 position, and they were afflicted with hic- 
 cough, nausea, and vomiting. 
 
 Sabatier seems to think one thing certain, 
 viz. that wounds of the gall bladder attended 
 with effusion of bile, are absolutely mortal, 
 and that no operation can be of any avail. 
 
 ( Mddecine Operatoire, T. 1 ,p. 34 — 37.) 
 
 A contrary inference, however, may be 
 drawn from a case, detailed by Parois^g, in. 
 which a bullet had lodged in the gall bladder 
 two years. (Opuscules de Chir. p. 255.) The 
 recovery published by Mr. Fryer, of Stam- 
 ford, tends also to prove, that every effusion 
 of bile is not unavoidably fatal. A boy, 
 about thirteen years old, received a violent 
 blow from one of the shafts of a cart, on 
 the region of the liver. The injury was 
 succeeded by pain, frequent vomiting of 
 bilious matter, great sinking, coldness of the 
 extremities, and a weak, small, fluttering 
 pulse. The belly was fomented, and pur- 
 ging clysters thrown up. On the third day, 
 symptoms of inflammation began, attended 
 with considerable pain about the liver, great 
 tension and soreness of the abdomen, and 
 frequent vomiting. The pulse was quick, 
 small, and weak ; the skin hot and dry; the 
 tongue mucii furred ; the urine high-colour- 
 ed ; and there was some difficulty of breath- 
 ing ; and great thirst. Eigh^ ounces of 
 blood were taken away, the fomentations 
 continued, and a few grains of calomel were 
 directed to be given every four hours until 
 the bowels were properly opened. After- 
 ward, the effervescing mixture, with ten 
 drops of laudanum, was exhibited every 
 four hours. 
 
 On the following day, the patient had 
 some motions, and was much better; but, 
 as his sickness continued, he was ordered a 
 grain of opium every four hours. About a 
 week afterward, he complained of a great 
 increase of pain, which was Bomewhat re- 
 lieved by a blister. He was now completely 
 jaundiced, and his stools were white, but 
 the tension, pain, and sickness were abated. 
 
 Two days afterward, a fluctuation was 
 perceived in the abdomen, which, in another 
 week, became considerably distended with 
 fluid. The patient did not now complain of 
 much pain ; but appeared to be sinking fast ; 
 a puncture was made in the swelling, and 
 
woL\m- 
 
 ti&Q 
 
 thirteen pints of what appeared to be pure 
 bile were evacuated. The bowels then soon 
 became regular, and the appetite good. In 
 twelve days, the operation was repeated, 
 and fifteen pints of the same bilious fluid 
 were drawn oft'. Nine days afterward, an- 
 other punctune was made, and thirteen pints 
 more let out ; and six were discharged in an- 
 other fortnight. From this period the boy 
 went on well, and perfectly recovered un- 
 der the use of light tonic medicines. (See 
 Med. Chir. Trans. Vol. 4, p. 330.) 
 
 A previous accidental adhesion of the 
 galWuadder to the peritoneum might also 
 prevent the extravasation of bile, and its 
 tiangerous effects. ( Callisen , Syst. Chir. 
 
 Homtrnoe. T. 1.^.718.) 
 
 According to Dr. Hennen, a deep wound 
 of the liver is as fatal as if the heart itself 
 was engaged. The slighter injuries are re- 
 coverable. He states, that the usual symp- 
 toms of a wound of the liver are yellowness 
 of the skin and urine ; derangement of the 
 alimentary canal, and great and distressing 
 itching of the skin. The discharge from 
 the wound is generally yellow and glutin- 
 ous . though sometimes either serous, or 
 like^, unraixed bile. (On Militai'y Surgery, 
 Ed72^p. 429.) For some other interesting 
 observations on wounds of the liver, I have 
 great pleasure in referring to the latter work. 
 (See akfo Wedekind de Vulnere Hcpatis C'ura- 
 io, Jence, 1735 ; and Thomson's Report of 
 Obs . made in the Military Hospitals in Bel- 
 gium , 8ro. 1816.) 
 
 4. Urine. — Urine being of a very fluid 
 nature, may, like the bile, be extensively 
 diffused in the abdomen, when the bladder 
 is wounded at any part, connected with the 
 peritoneum. If, in this kind of case, the 
 urine be not drawn off with a catheter, so 
 as to prevent its extravasation, the patient 
 soon perishes. Many instances are recorded 
 of the bladder being injured even by gun- 
 shot wounds, which were not mortal. 
 
 Wounds of the bladder are attended with 
 a discharge of bloody urine and difficulty 
 of making water. They are always dan- 
 gerous cases, both on account of the risk 
 of the effusion of so irritating a fluid in the 
 abdomen, and of the chance of extravasa- 
 tion in the cellular membrane. Under 
 proper treatment, however, they often ad- 
 mit of cure. (See Gunshot Wounds.) If 
 possible, the elfused fluid should be dischar- 
 ged by a depending posture, or suitable 
 punctures, or incisions, and the recurrence 
 of extravasation prevented by the introduc- 
 tion of a catheter, which is to be left in the 
 urethra. The patient must also be allowed 
 little drink. As for the tension and pain of 
 the belly, the common attendants of a 
 wounded bladder, they may be greatly re- 
 lieved by the use of the warm bath, ( Calli - 
 sen, T. 1, p. 719.) bleeding, low diet, and 
 other antiphlogistic means not being omit- 
 ted. 
 
 Wounds of the Stomach. — As Dr. Hennen 
 has observed, these cases are extremely 
 dangerous, though not always mortal. 
 91 Baron Percy calculates, that of twenty 
 
 cases, four or live onTy have escaped ; this.* 
 however, is a most favourable average.' * 
 Two cures of wounds of the stomach are 
 reported by Dr. Thomson. (Obs. made in 
 the Military Hospitals in Belgium, fyc.) With 
 respect to the chances of recovery, Dr. 
 Hennen justly remarks, that, in the histories 
 of the Bohemian, Prussian (D. Beckher de 
 Cultriroro Prussiaco, 12wo. Lugd. 1638,) and 
 English u Cultri-sores,” in some of whom 
 the knives have been cut out, and in others, 
 discharged spontaneously through the coats 
 of the stomach and parietes of the abdomen, 
 are very encouraging. Hevin has collected^ 
 many instances of recovery both from in- 
 cised and gunshot wounds of the stomach. 
 (Mem. de VAcad. de Chir. T. 1.) But, ac- 
 cording to Dr. Hennen, Ploucquet, in the 
 articles “ Ventriculus” and “ Pantophagi,” 
 has brought together the largest number of 
 cases. Dr. Hennen, also refers to Loie * 
 thorpe's Abridgment of the Phil. Trans. Vol. 
 6, p. 192, for instances, in which the sto- 
 mach of a horse was wounded and sewed 
 up, and the same practice extended to the 
 human subject, with success. It appears | 
 also from the “ Annales de Literature,” &c. 
 T. 2, by Kluyskens, from Sehlichting’s 
 “ Iraumatologia,” and the “ Bulletin de la 
 Faculty," fyc. Tom. 5 ,p. 386, that wounds of 
 the human stomach have been stitched with 
 success in various cases of recent date. 
 (See Hennen' s Military Surgery, Ed. 2, p. 
 438 ) As the latter author observes, wounds 
 of the stomach not unfrequently become 
 fistulous and remain open. In a case, re- 
 corded by Richerand. the fistula continued 
 open nine years ; and in another instance, 
 related by Ettmuller, ten years. (De Vul- 
 nere Ventriculi Programme, l dp. 1730.) And 
 Wencker has detailed a case, in which the 
 opening continued twenty-seven years. 
 (See Halteri Dissert. Chir. Vol. 5, art. 19. V 
 For farther information, connected witn 
 this subject, the reader may also consult, 
 Jungen, de Lethalitate Vulnerum Ventriculi, 
 Helmsl. 1751 ; and Ludov. Horn, de Ventri- 
 culi Ruptura, 8 vo Berol. 1817. Also Med, 
 Chir. Journ. Vol. 5, p. 72. 
 
 Wounds of the Intestines. — The vomiting 
 of blood, or discharge of it by stool ; the 
 escape of fetid air, or of intestinal matter, 
 from the mouth of the wound ; an empty 
 collapsed state of a portion of bowel, pro- 
 truded at the opening in the skin, are the 
 common symptoms attending a wound of 
 this kind. When the wound is situated in 
 the prolruded portion, it is obvious to the 
 surgeon’s eye ; but when it affects apart of 
 the intestinal canal within the abdomen, the 
 nature of the case can be known only by a 
 consideration of other symptoms. In addi- 
 tion to such as I have already described, 
 there are some others, whicli ordinarily 
 accompany wounds of the bow’els ; as, for 
 instance, oppression about the proecordia, 
 acute or griping pain in the belly, cold 
 sweats, syncope, &.c. But, unless the 
 wounded intestine protrude, there is no 
 ractical good in knowing whether the 
 owel is Injured or not, since, if it be in. the 
 
WOUNDS 
 
 ’abdomen, the treatment ought not to be 
 materially different from that of a simple 
 penetrating wound of the belly, unattended 
 with a wound of any of the viscera. Large 
 wounds of the small intestines, particularly 
 of the duodenum and jejunum, are attended 
 with acute fever, anxiety, paleness of the 
 countenance, syncope, cold perspirations, a 
 small, intermitting, tremulous pulse, and 
 they frequently prove fatal. Injuries of the 
 small intestines are also more otten, than 
 those of the large ones, followed by extra- 
 vasation. A total division of the upper part 
 of the intestinal canal, towards the pylorus, 
 will deprive the body of the nourishment 
 requisite for its support. If the chyle 
 escape from the wound, the patient will die 
 of a slow marasmus ; and if it become ex- 
 travasated, it will be likely to excite such 
 irritation as will prove fatal. The escape of 
 excrement, or of fetid air from the wound, 
 indicates an injury of one of the large in- 
 testines. In these cases, the symptoms are 
 generally milder, and the passage of the 
 intestinal contents outward through the 
 wound more easy, on account of the bowel 
 being less moveable. For the same reason, 
 the wounded intestine more readily con- 
 tracts an adhesion to the adjacent parts. 
 (Callisen, Sysl. Chirurgice Hoditrnte, T. 1, p. 
 717.) 
 
 A wounded intestine is said to present 
 some particular appearances, to which the 
 generality of writers have paid no attention : 
 u If a gut be punctured, the elasticity of the 
 peritoneum, and the contraction of the 
 muscular fibres, open the wound, and the 
 villous, or mucous coat, forms a sort of her- 
 nial protrusion, and obliterates the aperture. 
 If an incised wound be made, the edges are 
 drawn asunder, and reverted so that the 
 mucous coat is elevated in the form of & 
 fleshy lip. If the section be transverse, the 
 lip is broad and bulbous, and acquires tume- 
 faction and redness from the contraction of 
 the circular fibres behind it, which produces, 
 icelatively to the everted portion, the ap- 
 pearance of a cervix. If the incision be 
 according to the length of the cylinder, the 
 lip is narrow, and the contraction of the ad- 
 jacent longitudinal fibres, resisting that of 
 the circular fibres, gives the orifice an oval 
 form. This eversion and contraction are 
 produced by that series of motions, which 
 constitutes the peristaltic action of the in- 
 testines.” ( Travers on Injuries of the Intes- 
 tines, p. 85.) 
 
 According to this gentleman, some of 
 these appearances were described by Haller, 
 in Element. Physiol, lib. 24, sect. 2 ; and 
 Opera Minora , T. 1, sect. 15. 
 
 Having witnessed the facility, with which 
 considerable injuries of the intestinal tube 
 were repaired, Mr. Travers was desirous of 
 ascertaining more fully the powers of na- 
 ture in the process of spontaneous repara- 
 tion, and of determining, under how great 
 a degree of injury it would commence, as 
 well as the mode of its accomplishment. 
 For these purposes, he divided the small 
 intestine of several dogs as far as the mesen- 
 Voji. II. 86 
 
 lory. All these animals died, in corise 
 quence of the intestinal matter being extra 
 vasated, if they had been lately fed, or if 
 they had been fasting in consequence of in- 
 flammation, attended with a separation of 
 the ends of the divided bowel, eversion of 
 the mucous coat, and obliteration of the 
 cavity, partly by this eversion, and partly 
 by a plug of coagulated chyle. 
 
 In one particular instance, in which Mr. 
 Travers made a division of the bowel, half 
 through its diameter, a sort of pouch was 
 formed round the injured intestine. “A 
 pouch, resembling somewhat the diverti- 
 culum in these animals, was formed opposite 
 to the external wound, on the side of the pa- 
 rietes, by the lining peritoneum, on the other 
 side, by the mesentery of the injured intes- 
 tine, that iqtestineitself,and an adjacentfold, 
 which had contracted with it a close adhe- 
 sion. The pouch, thus formed and insula- 
 ted, included the opposed sections of the 
 gut, and had received its contents, he. The 
 tube, at the orifices, was narrowed by the 
 half eversion, but ottered no impediment to 
 the passage of fluids.” (P. 96.) Whether, 
 under these circumstances, the functions of 
 the alimentary canal could have been con- 
 tinued, Mr. Travers professes himself inca- 
 pable of deciding. Among the inferences, 
 which this gentleman has drawn from the 
 experiments, detailed in bis publication, the 
 tendency of the two portions of a divided 
 bowel to recede from each other, instead 
 coalescing to repair the injury, merits no- 
 tice, inasmuch as it tends to show, that the 
 only means of spontaneous reparation con- 
 sist in the formation of an adventitious 
 canal, by the encircling bowels and their 
 appendages. The everted mucous coat, 
 which is the part opposed to the surround- 
 ing peritoneum, is also indisposed to the ad- 
 hesive inflammation. 
 
 When, however, the wound of the intes- 
 tine is smaller, the obstacles to reparation 
 are not absolutely insurmountable. Here, 
 retraction is prevented, and the processes of 
 eversion and contraction modified by the 
 limited extent of the injury. If, therefore, 
 the adhesive inflammation unite the con- 
 tiguous surfaces, effusion will be prevented, 
 and the animal escape immediate destruc- 
 tion. But, union can only take place 
 through the medium of the surrounding 
 parts. 
 
 According to Mr. Travers, it is the re- 
 traction, immediately following the wound, 
 that is a chief obstacle to the reparation of 
 the injury ; for, if the division be performed 
 in such a way as to prevent retraction, the 
 canal will be restored ia so short a time, as 
 but slightly to interrupt the digestive func- 
 tion. In confirmation of this statement, a 
 ligature was tightly applied round the duo- 
 denum of a dog, which became ill, but en- 
 tirely recovered, and was killed. “ A liga- 
 ture, fastened around the intestine, divides 
 the interior coats of the gut, in this effect 
 resembling the operation of a ligature upon 
 an arfery. The peritoneal tunic alone 
 maintains its integrity. The inflammation, 
 
WOUNDS 
 
 
 which the ligature induces on either side of 
 it, is terminated by the deposition of a coat 
 of lymph, which is exterior to the ligature, 
 and quickly becomes organized. When the 
 ligature, thus enclosed, is liberated by the 
 ulcerative process, it falls of necessity into 
 the canal, and passes oft' with its contents.” 
 (P. 103, 104.) 
 
 It appears also from Mr. Travers’s experi- 
 ments and observations, that longitudinal 
 wounds of the bowels are more easily repair- 
 ed, than such as are transverse. In a dog, a 
 longitudinal wound, of the extent of an inch 
 and a half, was repaired by the adhesive 
 inflammation. Here the process of eversion 
 is very limited ; the aperture bears a smaller 
 proportion to the cylinder of the bowel ; 
 and the entire longitudinal fibres resist the 
 action of the circular, which ane divided, 
 and can now only slightly lessen the area 
 of the canal. (P. 108.) 
 
 We come now to the consideration of the 
 treatment of wounds of the intestines; a 
 subject, in which much difference of opinion 
 has prevailed ; principally, however, con- 
 cerning the circumstances in which sutures 
 are necessary, . and the most advantageous 
 way of applying them. 
 
 When the wounded bowel lies within the 
 cavity of the abdomen, no surgeon of the 
 present day would have the rashness to 
 think of attempting to expose the injured 
 intestine, for the purpose of sewing up the 
 breach of continuity in it. In fact, the sur- 
 geon seldom knows at first what has hap- 
 pened ; and when the nature of the case is 
 afterward manifested, by the discharge of 
 blood per anum, an extravasation of intes- 
 tinal matter, Sic. it would be impossible to 
 get at the injured part of the bowel, not 
 only because its exact situation is unknown, 
 but more particularly on account of the ad- 
 hesions, which are always formed with sur- 
 prising rapidity. But, even if the surgeon 
 knew to a certainty, in the first instance, 
 that one of the bowels was wounded, and 
 the precise situation of the injury, no suture 
 could be applied, without considerably en- 
 larging the external wound, drawing (he 
 wounded intestine out of the cavity of the 
 abdomen, and handling and disturbing all 
 the adjacent viscera. Nothing would be 
 mure likely, than such proceedings, to ren- 
 der the accident, which may originally be 
 curable, unavoidably fatal. 1 entirely agree 
 upon this point with Mr. John Bell, who 
 says, “ When there is a wounded intestine, 
 which we are warned of only by the pass- 
 ing out of the feces, we must not pretend 
 to search for it, nor put in our finger, nor 
 expect to sew it to the wound ; but we may 
 trust that the universal pressure, which 
 prevents great effusion of blood, and col- 
 lects the blood into one place, that very 
 pressure, which always causes the wounded 
 bowel and no other to protrude, will make 
 the two wounds, the outward wound and 
 the inward wound of the intestine, opposite 
 each other, point to point ; and if all be 
 kept there qyiet, though but for one day, so 
 lively is the tendency to inflame, that the 
 
 adhesion will be begun, which is to save the 
 patient’s life.” (Discourses on Wounds v 
 361, Edit. 3.) 
 
 When the extravasation, and other symp- 
 toms, a few days after the accident, show 
 the nature of the case, a suture can be of 
 no use whatever, as the adhesive inflamma- 
 tion has already fixed the part in its situ- 
 ation, and the space in which the extrava- 
 sation lies is completely separated from the 
 general cavity of the abdomen by the sur- 
 rounding adhesions. 
 
 When the bowel does .not protrude, and 
 the opening in it is situated closely behind 
 the wound in the peritoneum, a suture is 
 riot requisite ; for the contents of the gut 
 not passing onward, will be discharged 
 from the outer wound, and not be diffused 
 among the viscera, if care be taken to keep 
 the external wound open. There is no dan- 
 ger of the wounded bowel changing its 
 situation, and becoming distant from the 
 wound in the peritoneum, for the situation 
 which it now occupies is its natural one. 
 Nothing but violent motion or exertions 
 could cause so unfavourable an occurrence., 
 and these should always be avoided. The 
 adhesions, which take place in the course 
 of a day or two, at length render it impos- 
 sible for the bowel to shift its situation. 
 
 Things, however, are far different when 
 the wounded part of the bowel happens to 
 protrude. Here we have the authority of 
 all writers in sanction of the employment of 
 a suture. No enlargement of the outer 
 wound is requisite to enable the practitioner 
 to adopt such practice ; there is no disturb- 
 ance of the adjacent parts; there is no 
 doubt concerning the actual existence of the 
 injury . no difficulty in immediately finding 
 out its situation. 
 
 But, though authors are so generally 
 agreed about the propriety of using a suture 
 in the case of a wounded and protruded 
 bowel, they dift’er exceedingly both as to 
 the right object of the method, and the 
 most advantageous mode of sewing the in- 
 jured part ot the intestine. Some have 
 little apprehension of extravasation, advise 
 only one stitch to be made, and use the li- 
 gature chiefly with a view of confining the 
 injured bowel neat* the external wound, so 
 that in the event of an extravasation the 
 eft'used matter may find its way outward. 
 Other writers wish to remove the possibi- 
 lity of extravasation, by applying numerous 
 stitches, and attach little importance to the 
 plan of using the ligature principally for the 
 purpose of keeping the intestine near the 
 superficial wound. 
 
 When the wound of a bowel is so small 
 that it is closed by the protrusion of the 
 villous coat, the application of a suture 
 must evidently be altogether needless ; and 
 since the ligature would not fail to cause 
 irritation, as an extraneous substance, the 
 employment of it ought unquestionably to 
 be dispensed with. 
 
 Supposing, however, the breach in the 
 intestine to be small, yef sufficient to let the 
 feces escape, what method ought to be 
 
VYOI/NDS. 
 
 adopted V The following practice seems 
 rational. As Sir Astley Cooper was ope- 
 rating on a strangulnted hernia, at Guy’s 
 hospital, an aperture giving issue to the in- 
 testinal contents was discovered in a portion 
 of the sound bowel, just when the part, was 
 about to be reduced. The operator, inclu- 
 ding the aperture in his forceps, caused. a tine 
 silk ligature to be carried beneath the point 
 of the instrument, firmly tied upon the gut, 
 and the ends cutoff close to the intestine. 
 The part was then replaced, and the patient 
 did well. Mr. Travers, who has related this 
 fact, approves of the plan of cutting away 
 the extremities of the ligature, instead of 
 leaving them hanging out of the external 
 wound. It appears, that, when the first 
 practice is followed, the remnant always 
 makes its way into the intestine, and is 
 discharged with the stools without any in- 
 convenience. But when the long ends are 
 drawn through the outer wound, and left in 
 it, they materially retard the process of heal- 
 ing. (On Injuries of the Intestines, fyc. p. 
 1 12, 113.) 
 
 Let us now inquire what ought to be the 
 conduct of a surgeon, should he be called 
 to a patient, whose bowel is divided through 
 Its whole cylinder, and protruded out of the 
 external wound. 
 
 Various have been the schemes and pro- 
 posals for the treatment of this sort of acci- 
 dent; and since experience has furnished 
 few practitioners with an opportunity of 
 seeing such a case in the human subject, a 
 variety of experiments have been made on 
 animals, in order to determine what treat- 
 ment would be the most successful. Ram- 
 dohr, indeed, is stated by Moebius to have 
 had occasion to try on the human subject a 
 plan, of which a vast deal has been said and 
 written. He cut off a large part of a mor- 
 tified intestine, and joined the two sound 
 ends together, by inserting the upper within 
 the lower one, and fixing them in this posi- 
 tion with a suture, the ligature being also 
 employed to keep them at the same time 
 near the external wound. The patient re- 
 covered, and the feces continued to pass 
 entirely by the rectum in the natural way. 
 (See Halleri Disput. Anat. Vol. 6, Obs. Med. 
 Miscdlan. 18.) 
 
 About a year after the operation, the 
 patient died, when the anatomical prepara- 
 tion of the parts was sent to Ramdohr by 
 Heister. They were preserved in spirits of 
 wine, and exhibited, according to the latter 
 author, an union of the two ends of the 
 bowel together, and their consolidation ivilh 
 a part of the abdomen. Now it has been 
 questioned by a late writer, whether the 
 union here spoken of ever really happened. 
 When the upper end of the bowel is intro- 
 duced into the lower, the external surface 
 of the former is put in contact with the 
 inner one of the latter; a serous membrane 
 is placed in contact with a mucous one. 
 These heterogeneous structures, he alleges, 
 are not disposed to unite. The mucous 
 membrane, when inflamed, more readily 
 secretes h kind of mucus, which would be 
 
 an invincible obstacle to adhesion. He 
 thinks it therefore more than probable, that,, 
 in the case related by Heister, the invagi- 
 nation was maintained by the union of the 
 intestine with the corresponding part of the 
 abdominal parietes. Several experiments 
 on living animals have convinced him that 
 this happens, ana that the mucous mem- 
 brane will not unite with the external peri- 
 toneal coat. This impossibility of produ- 
 cing an immediate union between the mu- 
 cous and serous membranes may of course 
 be urged as an objection to Ramdohr’s 
 practice. (Richer and, Nosographie Chir. T. 
 3, p. 344, 345, Edit. 4.) Another equally 
 strong objection is, that the upper end of 
 the bowel cannot be put into the lower 
 one, unless it be separated from a part of 
 the mesentery. Here the division of the 
 mesenteric arteries may cause a dangerous 
 bleeding. In vain did Boyer tie seven or 
 eight of these vessels : his patient died with 
 an extravasation in the abdomen. ( Riche- 
 rand ’, T 3, p. 343, Edit. 4.) 
 
 Moebius attempted to repeat Ramdohr’s 
 operation upon a dog; but he could not 
 succeed in insinuating the upper part of tho 
 divided bowel into the lower one, on ac- 
 count of the contraction of the two ends of 
 the intestinal tube, and the smallness of the 
 canal. Moebius, therefore, was obliged to 
 be content with merely bringing the ends of 
 the bowel together with a suture : the ani- 
 mal soon afterward died of an extravasa- 
 tion of the feces. 
 
 Dr. Smith, of Philadelphia, also tried to 
 repeat Ramdohr’s method, but could not 
 succeed. He divided the intestine of a dog 
 transversely, and having inserted a piece of 
 candle into that portion of the bowel, which 
 was supposed to be uppermost, he endea- 
 voured to introduce the superior within the 
 inferior; but the ends became so inverted, 
 that it was found utterly impossible to suc- 
 ceed. The scheme was therefore given up, 
 and only one stitch made, the ligature 
 being then attached to the external Wound, 
 in the manner advised by Mr. John Bell. 
 The dog died, and on examination there 
 was found a considerable quantity of feces 
 and water in the abdominal cavity. 
 
 Two more trials were made of Mr. John 
 Beil’s plan, by Dr. Smith, on the intestines 
 of dogs. In both instances the animals 
 died, the intestines being much inflamed, 
 and feces effused in the abdomen. (See 
 Dr. Smith's Thesis.) 
 
 Mr. Travers likewise tried the same ex- 
 periment. <{ 1 divided the small intestine of 
 a dog, whTch had been for some hours fast- 
 ing, and carried a fine stitch through the 
 everted edges, at the point opposite to their 
 connexion with the mesentery. The gut 
 was then allowed to slip back, and the 
 wound was closed. The animal survived 
 only a few hours. Examination. The pe - 
 ritoneum appeared highly inflamed. Adhe- 
 sions were formed among the neighbouring 
 folds, and lymph was deposited in masses 
 upon the sides of the wounded gut. This 
 presented two large circular orifices. Among 
 
684 
 
 WOUNDS. 
 
 the viscera were found a quantity of bilious 
 fluid, and some extraneous substances, and 
 a worm was depending from one of the 
 apertures. By the artificial connexion of 
 the edges in a single point of their circum- 
 ference, and their natural connexion at the 
 mesentery, they could recede only in the 
 intervals, and here they had receded to the 
 utmost.” In another experiment, Mr. Tra- 
 vers increased the number of points of 
 contact, by placing three single stitches 
 upon a divided intestine, cutting away the 
 threads, and returning the gut. The animal 
 died on the second day. Examination. 
 Similar marks of inflammation presented 
 themselves. The omentum was partially 
 wrapped about the wound ; but one of the 
 spaces between the sutures was uncovered, 
 and from this the intestinal fluids had esca- 
 ped. On cautiously raising the adhering 
 omentum, the remaining stitches came into 
 view. Here again the retraction was con- 
 siderable, and the intervening elliptical 
 aperture proportionally large. On the side, 
 next to the peritoneum, however, the edges 
 were in contact and adhered, so as to unite 
 the sections at an angle. 
 
 From such experiments, the conclusion 
 drawn by Mr. Travers is, that apposition at 
 a point or points, is, as respects effusion, 
 more disadvantageous than no apposition at 
 all ; for it admits of retraction and prevents 
 contraction, so that each stitch becomes the 
 extremity of an aperture, the area of which 
 is determined by the distance of the stitches. 
 (P. 116, 119.) This gentleman therefore 
 maintains, that the absolute contact of the 
 everted surfaces of a divided intestine, in 
 their entire circumference, is requisite to secure 
 the animal from the danger of abdominal 
 effusion. (P. 121.) The species of suture 
 employed (says Mr. Travers) is of second- 
 ary importance, if it secures this contact. 
 (P. 134.) And among other observations, 
 I find “ wounds amounting to a direct divi- 
 sion of the canal are irreparable, and there- 
 fore invariably fatal.” (P. 133.) 
 
 These inferences do not appear to me 
 satisfactorily established. We are told, that 
 apposition at a point or points is, as respects 
 effusion, more disadvantageous than no ap- 
 position at all, and that the absolute con- 
 tact of the divided surfaces, in their entire 
 circumference, is requisite to secure the 
 animal from the danger of abdominal effu- 
 sion. The foundation of these unqualified 
 conclusions is five experiments made on 
 dogs, in four of which experiments the di- 
 vided bowel was brought together with one 
 stitch, on Mr. John Bell’s plan, while in 
 another three stitches were made ; and yet, 
 in all these instances, the animals died with 
 the contents of the bowels effused. So far 
 the inferences seem established. Unfortu- 
 nately for their stability, however, Mr. 
 Travers immediately afterward proceeds to 
 relate other experiments, instituted by Sir 
 Astley Cooper, Dr. Thomson, and Dr. 
 Smith, which, though Mr. Travers seems 
 unaware of the fact, tend Piost completelv 
 
 to overturn the conclusions, which he had 
 been previously making. 
 
 “ Sir A. Cooper repeated the experiments 
 of Duverger, who had succeeded in uniting 
 by suture, the divided intestine of a dog, in- 
 cluding in it a portion of the trachea of a calf. 
 In place of the uninterrupted suture, three 
 distinct stitches were inserted. On the six- 
 teenth day the animal was killed, and the 
 union was complete.” (P. 123.) 
 
 Here are two facts, proving diat a wound- 
 ed intestine may be united, though the suture 
 was not such as to maintain the divided sur- 
 faces in contact, in the whole of their cir- 
 cumference. 
 
 Sir Astley Cooper then made the experi- 
 ment, without including the foreign sub- 
 stance. The animal recovered, being a 
 third fact, tending to prove, that the absolute 
 contact of every point of the ends of the 
 divided bowel is not essential to the cure. 
 (See A. Cooper on Inguinal and Congenital 
 Hernia, Chap. 2.) 
 
 After dividing the small intestine of a dog. 
 Dr. John Thomson, of Edinburgh, applied 
 five interrupted stitches, at equal intervals, 
 the ends of the ligatures were cut off, and 
 the external wound was closed with a su- 
 ture. This animal did not die of the opera- 
 tion, and when he was afterward killed, it 
 appeared that the threads had made their 
 way into the interior of the intestinal canal. 
 Dr. Thomson repeated this experiment, and 
 did not kill the animal till six weeks after- 
 ward, when the same tendency of ligatures 
 to pass into the bowels, and be thus dischar- 
 ged, was exemplified. 
 
 These two last cases make five, in proof 
 that the absolute contact of every part of 
 the ends of a divided bowel is not essentia? 
 to prevent effusion, or the cen§equences of 
 the wound from proving fatal ; and several 
 other experiments were made by Dr. Smith, 
 of Philadelphia, who employed four stitches 
 with similar success. 
 
 As far then as the majority of such facts 
 ought to have weight, we are bound to re- 
 ceive the conclusions of Mr. Travers as in- 
 correct, and unestablished. I am only sur- 
 prised, that Mr. Travers himself, who has 
 cited the particulars of all these last experi- 
 ments, did not perceive, that they struck di- 
 rectly at his own inferences. They are not 
 only irresistible arguments against Mr. Tra- 
 vers’s conclusion, that the union of a divided 
 bowel requires the contact of the cut extre- 
 mities in their entire circumference; but 
 they are a plain denial of another position 
 advanced by this author, viz. that wounds 
 amounting to a direct division of the canal, 
 are irreparable, and, therefore, invariably 
 fatal. 
 
 With respect to the species of suture be- 
 ing of secondary importance, provided it 
 secure the complete contact of every part 
 of the everted ends of the divided bowel, I 
 regret, that Mr. Travers has omitted to insti- 
 tute experiments, in order to show that any 
 such suture can be practised, and if he has 
 the ingenuity to apply it, whether the result 
 would be for or against the conclusions 
 
WOUNDS, 
 
 which he has formed. The lact of the su- 
 tures always making I heir way into the cavi- 
 ty of the bowel, and being thus got rid of, 
 appears to me highly interesting, since it 
 shows the safety of cutting away the ends 
 instead of leaving them hanging out of the 
 external wound, so as to creale the usual ir- 
 ritation and inconveniences of extraneous 
 substances. It seems that Mr. Benjamin Bell 
 first recommended cutting the ends of the li- 
 gatures away, and reducing the bowel in this 
 state into the abdomen, as, he says, a con- 
 siderable part of the remainder of the liga- 
 ture will fall into the cavity of the gut. ( Sys- 
 tem of Surgery, Vol. 2, p. 128, edit. 7.) We 
 have seen that the experiments of Dr. Thom- 
 son confirm the observation, and those insti- 
 tuted by Mr. Travers, tend to the same con- 
 clusion. 
 
 According to the latter writer, the follow- 
 ing is the process, by which a divided intes- 
 tine is healed, when sutures are employed. 
 “ It commences with the agglutination of 
 the contiguous mucous surfaces, probably by 
 the exudation of a fluid, similar to that which 
 glues together the sides of a recent flesh 
 wound, when supported in contact. The 
 adhesive inflammation supervenes, and hinds 
 down the everted edges of the peritoneal 
 coat, from the whole circumference of which 
 a layer of coagulable lymph is effused, so as 
 to envelope the wounded bowel. The ac- 
 tion of the longitudinal fibres, being oppo- 
 sed to the artificial connexion, the sections 
 mutually recede, as the sutures loosen by 
 the process of ulcerative absorption. During 
 this time, the lymph deposited becomes or- 
 ganized, by which further retraction is pre- 
 vented, and the original cylinder, with the 
 threads attached to it, is encompassed by the 
 new tunic. 
 
 “ The gut ulcerates at the points of the 
 ligatures, and these fall into its canal. The 
 fissures left by the ligatures, are gradually 
 healed up; but the opposed villous surfaces, 
 so far as my observation goes, neither ad- 
 here, nor become consolidated by granula- 
 tion, so that the interstice, making the divi- 
 sion internally, is probably never obliterated.” 
 (Travers on Injuries of the Intestines , fyc. p. 
 12S.) 
 
 Notwithstanding I have carefully read all 
 the arguments adduced by Mr. Travers in 
 favour of stitching a divided bowel at as 
 many points as possible, I still remain un- 
 convinced of the advantage of such practice, 
 for reasons already suggested. If a case 
 were to present itself to me, in which a 
 bowel, partly cut through, protruded, l 
 should apply only a single suture, made with 
 a small sewing-needle, and a piece of fine 
 silk. If the bowel were completely cut 
 across, I should have no objection to attach 
 its ends together by means of two or three 
 stitches of the same kind. I coincide with 
 Mr. Travers, respecting the advantage of 
 cutting off the ends of the ligature, instead 
 of leaving them in the wound, as I believe 
 he is right, in regard to the little chance there 
 is of the injured intestine receding far from 
 the wound, and if the ends of the ligature 
 
 && 
 
 are then of no use in keeping the bowel in 
 this position, they must be objectionable, as 
 extraneous substances. 
 
 As confirming some of the foregoing ob- 
 servations, I would refer to the valuable wri- 
 tings of Scarpa, and those of Dr. Hennen. 
 The parts of the former, to which I allude, 
 being contained in the last edition of the 
 First Lines of Surgery, need not here be re- 
 peated. u The older practitioners, (says Dr. 
 Hennen,) were very much averse from leav- 
 ing any thing to nature in cases of abdomi- 
 nal injuries, although their universal em- 
 ployment of sutures ought to have convinced 
 them, bow much she could bear with impu- 
 nity; for there can be very little doubt, that 
 their uniform performance of the operation 
 of gastroraphe was at least superfluous, if not 
 positively hurtful. In the course of a very 
 extensive, practice, two cases only have come 
 under my notice, where if was required to a 
 wounded intestine, though frequently it may 
 be needed for injuries to the parietes.” (On 
 Military Surg. ed 2, p 411.) 
 
 When the protruded intestine is mortified, 
 which must be a very rare occurrence in 
 cases of wounds, the treatment should be the 
 same as (hat of a mortified enterocele. (See 
 Hernia.) 
 
 As Dr. Hennen observes, in the treatment 
 of wounds of the abdomen, the violence of 
 sypmtom • is to be combated more by gene- 
 ra! means, than by any of the mechanical 
 aids of surgery. The search for extraneous 
 bodies, unless superficially situated, or they 
 can be felt with a probe, is entirely out of 
 the question. “ Enlargement, or contrac- 
 tion of the wound, as the case may require, 
 for returning protruded intestine, securing 
 the intestine itself, and promoting the ad- 
 hesion of the parts, is all that the surgeon 
 must do in the way of operation ; and 
 even in this, the less he interferes the 
 better.” (On Military Surgery, ed. 2 p 
 401.) 
 
 The principal indicat ion is to prevent n 
 dangerous degree of inflammation. Hence 
 bleeding and the antiphlogistic treatment 
 are highly indispensable. Let not the sur 
 geon be deterred from such practice by the 
 apparent debility of the patient, hi^ smalt 
 concentrated pulse, and the coldness of bis 
 extremities, symptoms common in acute in- 
 flammation of the bowels, and, in fact, them- 
 selves, indicating the propriety of repeated 
 venesection. Wounds of the small intes- 
 tines are attended with more dangerous 
 symptoms than those of the large ones. AH 
 flatulent, stimulating, and solid food, is to 
 be prohibited. The bowels are to be daily- 
 emptied with glysters, by which means, no 
 matter will be suffered to accumulate in the 
 intestinal canal, so as to creale irritation and 
 distention. 
 
 When excrementitious matter is discharged 
 from the outer wound, it is highly necessarv 
 to clean and dress the part very frequentl)* 
 Gentle pressure should also be made with 
 the fingers, at the circumference of (ha 
 vvouud, at each time of applying the dress- 
 ings, for the purpose of promoting the es* 
 
WOUNDS. 
 
 &80 
 
 cape of any exlravasated matter. For (be 
 same reason, the patient should always lie, 
 if convenient, in a posture that will render 
 the external opening depending. 
 
 After a day or two, the surgeon need not 
 be afraid of letting the outward wound heal 
 up; for the adhesive inflammation, all around 
 the course of the wound, will now prevent 
 any extravasated matter from becoming dif- 
 fused among the viscera. If the case should 
 ond well, the intestine generally undergoes 
 a diminution in its diameter at the place 
 where the wound was situated. When this 
 contraction is considerable, the patient oc- 
 casionally experiences colic pains at the part, 
 especially after eating such food as tends to 
 produce flatulence. As these pains usually 
 go entirely off after a certain time, and no 
 inconvenience whatsoever remains, the in- 
 testine may possibly regain its wonted capa- 
 city again. A more considerable constric- 
 tion of the above sort has been known to 
 occasion a fatal miserere. Even the intes- 
 tine itself has been known to burst in this 
 situation, after its contents had accumulated 
 behind the contracted part. Patients who 
 have recovered from wounds in the intes- 
 tines, should ever afterward be particularly 
 careful not to swallow any hard substances, 
 or indigestible flatulent food. On this sub- 
 ject the writings of Scarpa are particularly 
 interesting. 
 
 In some instances, intestinal matter con- 
 tinues to be discharged from the outer 
 wound, either in part, or entirely, so that 
 either a fistula, or an artificial anus, is the 
 consequence. A fistula is more apt to fol- 
 low, when an intestine has been injured by 
 a ball, has been quite cut through, or has 
 mortified. But numerous cases prove, that 
 this is not invariably the consequence, and 
 that a perfect cure has frequency followed 
 each of these occurrences. (See Amis, Arti- 
 ficial.) 
 
 When an intestine is completely cut 
 through, and the lower portion of the canal 
 lies inaccessibly concealed in the abdomen, 
 writers insist upon the necessity of promoting 
 the formation of an artificial anus. In this 
 particular case, they recommend fixing the 
 extremity of the intestine with a fine suture, 
 to the edges of the outer wound. In order 
 to distinguish the upper end of the intestine 
 from the lower, the proposal is sometimes 
 made to give the patient a little milk, and to 
 observe whether the fluid, after a time, issues 
 from the mouth of the protruded gut. In 
 the mean while fomentations are employed. 
 If the upper end of ihe intestine be in the 
 abdomen, these speculative authors even 
 deem it justifiable, when the accident is 
 quite recent, to dilate the outer wound, 
 search for the hidden continuation of the 
 bowel, and then sew the two ends together. 
 
 Practical surgeons, I believe, are right in 
 attaching little value to such directions. 
 “ Indeed, (says a modern writer,) the surgi- 
 cal world have long since dismissed their 
 feurs about the intestine falling inwards, and 
 about the difficulties of distinguishing be- 
 i ween the right and the wrong end of it 
 
 The apprehensions of abdominal effusion? 
 are now all pretty well subdued. The occur 
 rence is extremely rare, and when it does 
 happen, we leave the poor wretch to die in 
 peace, without searching after effused fluids, 
 the nature of which cannot be known, or if 
 known, the information canno‘ in the most 
 remote degree lead to recovery. I have 
 never witnessed a case where any possible 
 good effects could follow the paracentesis; 
 for peritonitis, in its most exquisite form, 
 has always preceded the symptoms which 
 would lead to the performance of that ope- 
 ration.” ( Hennen on Military Surgery, Ed, 
 
 2, MU ) 
 
 In some instances, musket-balls pass into 
 the abdomen, lodge there a considerable 
 time, and are tiien voided through the in- 
 testinal canal ; while, in other examples, 
 they become encysted, and continue lodg- 
 ed (he rest of the patient’s life, without 
 producing much, or, indeed, any inconve- 
 nience. 
 
 Contusions and other Injuries of the Ab- 
 domen. — A violent contusion of the abdo- 
 men may injure the contained viscera, with- 
 out the occurrence of any external wound. 
 It was in this way, that the liver or gall- 
 bladder was ruptured in the boy mentioned 
 by Mr. Fryer, (Med. Chir. Trans. Vol. 4 ;) 
 and that the vena cava was lacerated in 
 the case which fell under the observation of 
 Richerand, where a cart-wheel passed over 
 child’s belly. (Koso^raphie Chir. T. 3, p. 
 353.) In other instances, the mischief is 
 done to the intestines ; and still more fre- 
 quently, the viscera, as well as the parietes 
 of the abdomen, have only suffered a more 
 or less forcible contusion. The effects of 
 such violence, are inflammation of the in- 
 jured bowels, and their adhesion to the in- 
 side of the peritoneum. Thus the stomach 
 and intestines, the liver, and the gall-blad- 
 der, w T hen inflamed from a blow upon the 
 front of the belly, contract adhesions to Ihe 
 corresponding portion of the parietes, which 
 has been also bruised, and is itself inflamed. 
 When such inflammations suppurate, (and, 
 according to Richerand, it is their most usu- 
 al course,) on opening the abscess, the pus is 
 found blended with the matter, which the 
 viscera contain or secrete. Thus the alimen- 
 tary matter, and even intestinal worms have 
 been discharged with the pus on opening 
 certain abscesses, which communicated with 
 the cavity of the stomach or bowels ; and 
 bile has been found blended with the mat- 
 ter of abscesses in the right hypochondri- 
 um. 
 
 When in consequence of a blow upon the 
 anterior part of the belly, the patient expe- 
 riences in the situation of the injury a deeply- 
 seated pain ; wdien a tumour forms, and the 
 symptoms indicate violence done to some of 
 the adjacent viscera ; the inflammation is to 
 be opposed by every possible antiphlogistic 
 means. But when, notwithstanding such 
 treatment, the swelling increases and suppu- 
 rates, the abscess is not to be opened until it 
 is perfectly mature. The inflammatory symp- 
 toms, which preceded its formation, indicate 
 
WOUJN’DH. 
 
 63 
 
 vhat there is an adhesion between the in- 
 jured organ and the parietes of the abdomen. 
 Without this adhesion, opening the abscess 
 would be attended with more risk, because 
 the pus, or other matter, might become ex- 
 travnsated in the cavity of the peritoneum. 
 For the same reason, in the examples of tu- 
 mours, caused by bile in the gall bladder, J. 
 L. Petit recommends deferring the opera- 
 tion of opening them, until the inflammatory 
 symptoms evince, that an adhesion has taken 
 place between the fundus of the gall bladder, 
 and the corresponding point of the parietes 
 of the abdomen. 
 
 An adhesion of the abdominal viscera to 
 the inner surface of the peritoneum may be 
 induced by other causes, besides the action 
 of contusing bodies. A knife, a fork, a 
 shoemaker's awl, a needle, and other extra- 
 neous substances incapableof passing through- 
 out the alimentary canal, have been known 
 to irritate the stomach, or bowel, and to 
 bring on adhesion of them to the parietes of 
 the abdomen, where a tumour has formed, 
 which, on being opened, has discharged the 
 foreign body. The records of surgery 
 abound in facts of this kind. A fistula suc- 
 ceeds the opening of the abscess ; the ali- 
 mentary matter escapes ; and if the aper- 
 ture admit not of beiug healed by methodi- 
 cal compression, the intestinal canal between 
 the fistula and the anus contracts ; most of 
 the contents of the bowels pass out at the 
 preternatural opening, and the patient falls 
 into a state of marasmus, the more quickly 
 fatal, the nearer the injury of the intestinal 
 canal is to the stomach. 
 
 A long-continued pressure on the epigas- 
 tric region may cause an adhesion of the 
 stomach to the peritoneum, and suppuration 
 taking place at the part, a fistula, communi- 
 cating with the cavity of that organ, may be 
 formed, and allow the victuals to escape ex- 
 ternally. (See Richer and, Physiologic, T. 1. 
 Chymijication : A osographie Chirurg. T. 3 ,p. 
 353 — 356, Ed. 4.) 
 
 I shall conclude, with repeating, that in 
 the generality of injuries of the abdomen 
 from external violence, whether wounds or 
 contusions, the principal danger depends 
 upon inflammation of the peritoneum. In 
 the treatment, therefore, the most necessary 
 thing is to prevent and oppose this perilous 
 affection. Copious and repeated venesec- 
 tion, the application of leeches, mild ape- 
 rient clysters, a low fluid diet, perfect rest, 
 fomentations, and the warm bath, are among 
 the most effectual antiphlogistic remedies, 
 which, in such cases, are entitled to praise 
 and confidence. 
 
 For information on wounds of the abdo 
 men, see Flajani, Osservazioni, fyc. T. 3. A. 
 Malaval Qucestio, fyc. an tenuium inlesti- 
 norum vuluus letkale ? Paris, 1734. fVcncker , 
 Virginis per viginti septem annos ventriculum 
 perforatum habentis, Hisloria et Sedio, Ar- 
 gent. 1743. Haller, Disp. Chir 6 — 19. 
 Callisen's Systema Chirurgice Hodiernee, T. I, 
 p. 697, fyc. Edit. 1798, Hafnice. Richerand, 
 Nosogr. Chir. T. 3, p. 327, fyc. Edit. 4. 
 Med Chir. Trans. Vof. 4,p. 330. J. Cromp- 
 
 ton's Case of Rupture of the Stomach and 
 Escape of its Contents, fyc. with Obs. by B. 
 Travers , in Med. and Chir. Trans. Vol. 8, p. 
 228, fyc. Richter, Anfangsgriinde der IV un - 
 darzneykunst, B. 5, Kap. 1. Discourses on 
 tht Nature and Cure of Wounds, by John 
 Bell , Edit. 3. L. Nahnoni , De Simiiium par- 
 tium humanum corpus consiituteniium rege- 
 nera tiont, Mediolani. 1782. Encyclopidie 
 Methodique, Partie Chir. Art. Abdomen et 
 Intestins. Dr. Smith’s Inaugural Thesis. 
 B. Travers, an Inquiry into the Process of 
 Nature. in repairing Injuries of the Intes- 
 tines, 8 vo. 1812. J. Hunter on Gunshot Wounds. 
 Sir A. Cooper’s work on Inguinal and Conge- 
 nital Hernia, Chap. 2, fol. 1804. Sabatier, 
 Midecine Op&ratoire, T. 1. Petit, Essai sv.r 
 Its Epanchemens, fy Suite de V Essai sur les 
 Epanchemens, in M6m. de I’Acad. de Chir. 
 
 For information on wounds in general, sec 
 Coes. Magatus, De Rara Medicalione Vul- 
 nerum, seu de Vulneribus raro tractandis , fol. 
 Ven. 1616. A. Read, his Works, containing , 
 1. Lectures on Tumours and Ulcers. 2. A 
 Treatise of the first Part of Chirurgery, which 
 teacheth the reunilion of the parts of the Body 
 disjointed, arid the methodical doctrine of 
 Wounds, fyc. 2d Edit. 8vo. Loud. 1650. Wer- 
 ner, De Vulneribus absolute et per accident le- 
 thalibus, Regiom. 1650. J. Bohn, De rtnun- 
 ciatione Vulnerum ; seu Vulnemm Lethalium 
 Examen , 12mo. Lips. 1689. P. Ammannus , 
 Praxis Vulnerum lethalium, fyc. 12 mo. Fran - 
 cof. 1690. ./. Colbatch, New Light of Sur- 
 gery, showing a more safe and speedy way of 
 curing Wounds, thati has hitherto been prac- 
 tised, 12 mo. Lond. 1695. Ph. Com. Fabri ♦ 
 civs, Programma quo causae injr^quentice vul- 
 nerum lethalium, pree minus lethiferi sexfab- 
 rica corporis human! anatomica , el situpartium 
 praecipue eruuntur, Ilelmstad. 1753. John 
 Hunter, a Treatise on the Blood, Inf animation, 
 fyc. John Bell’s Principles of Surgery, and 
 his Discourses on Wounds. W. Balfour, Ob- 
 servations on Adhesion , with two Cases, de- 
 monstrative of the Powers of Nature to re- 
 unite parts , which have been totally separated 
 from the animal System, 8 vo. Edinb. 1814. 
 Larrey , M6moires de Chirurgie Militaire, 
 Memoir es et i rix de V Academic Royale de. 
 Chirurgie. Sabatier, Mcdecine Oplraloire. 
 Assalini, Manuale di Chirurgia ; Milano , 
 1812. Richerand, Nosogr. Chir. Ed. 4. Boyer , 
 Trait 6 des Maladies Chir. T. 1. Delpech , 
 Precis des Maladies Reputtes Chirurgicales , 
 T. 1. Sclimucker , Wahrnehmungen und Chi- 
 rurgische Schriften. Lombard, Instruction Som 
 maire sur VArl des Pansemens, 8ro. Stras- 
 bourg. 1797. Also, Clinique Chirurgicale 
 relative aux plaies, 8vo. Strusb. an. 6. Guth- 
 rie. oi. Gunshot Wounds. 2d Edit. Jones, on 
 Hemorrhage. Schreger, Chirurgische l er- 
 siiche, B 2. p. 260, fyc. 8 vo. Nurnberg. 1818. 
 Thomson's Lectures on Inflammation, 8 vo. 
 1813; and his Report and Obs. made in the 
 Military Hospitals in Belgium, Sro. 1816. J. 
 Hennen’s Military Surgery, Ed. 2, 8ro. Ed in. 
 1820; and the various Works cited in the 
 course of this article, and at the conclusion of 
 that on Gunshot Wounds. For information 
 on poisoned wounds, consult F. Re&, Osser* 
 
BOUNDS 
 
 ■tibS 
 
 vasioni inlorno alle Vipere. Firenze, 1664. 
 M. Charas, Nouvelles Experiences sur la 
 Vipere , 4 to. Paris, 1669. Also, a Reply to 
 Redi's Letter, concerning Vipers. 12 mo. Lond. 
 1673. Stanford Wolf erstan. Inquiry into the 
 Causes of Diseases in General , fyc. Also, of 
 the Venom of Vipers, 12 mo. Lond. 1692. A. 
 Moureau de Jonn6s Monographic dn Trigono- 
 ciphale. des Antilles ou Grand Vipere Fer-de 
 Lance de la Martinique, Par 8 vo. 1816. A. 
 Vater. et F Gensler, de Antidolo JYovo ad- 
 verms viper arum morsum, prcesentissimo in 
 Anglia hand ita pridem delecto ; Witlemb. 
 1736. ( Haller , Disp. ad Morb. 6, 693.) J. E. 
 Bertin et J. F. C. Morand, Thesis in here 
 verba , ergo Specijicum Viperce Morsus antido- 
 tum Alkali Volatile, in Haller's Disp. ad 
 Morb. 6,611, Paris. 1 749. Catesby's Hist, 
 of Carolina. Mead on Poisons. Fontana , on 
 the Venom of the Viper. Acrel de Morsura 
 Serpentum, 4 to. Upsal. 1762. Russell , on 
 Indian Serpents Ireland, in Med. Chir. 
 Trans. Vol.2. Sir E. Home, in Phil. Trans. 
 1810. 
 
 WRY-NECK. ( Caput Obslipum ; Torti- 
 collis.) An involuntary and fixed inclina- 
 tion of the head towards one of the 
 shoulders ; a disorder not spoken of by the 
 ancients. It should not be confounded 
 with a mere rheumatic tension and stiffness 
 of the neck, nor with the faulty position of 
 the head, arising from deformity of the cer- 
 vical vertebrae. 
 
 Tulpius, a learned physician at Amster- 
 dam, about the middle of the seventeenth 
 century, has recorded the cure of a boy, 
 twelve years old, who, from his earliest 
 infancy, had had his head drawn down to- 
 wards the left shoulder, by a contraction of 
 the scalenus muscle. Fomentations were 
 applied in vain. The head could not be 
 brought into the right posture, even with 
 the aid of steel collars A consultation was 
 therefore held, in which it was decided to 
 put the boy under the care of Minnius, a 
 surgeon who had performed several opera- 
 tions with success in similar cases. A large 
 eschar was first made with caustic ; and tiie 
 muscle, which drew the htad to one side, 
 was then divided with a knife. Tulpius, 
 who has left a very confused account of the 
 operation, observes that it was performed 
 with great slowness and circumspection, 
 for fear of wounding the carotid artery and 
 jugular vein. However, he offers one good 
 piece of advice, which is, not to make any 
 preliminary application of caustic, as it 
 only causes useless pain, and cannot be of 
 any service. He also recommends the ope- 
 ration not to be done by little and little, at 
 repeated times ; and says, that the surgeon 
 should make a complete division of the 
 muscle at once, with the necessary degree 
 of caution. 
 
 Job k Meckren also treats of the opera- 
 tion for the cure of a wry-neck. He states, 
 that he had seen it performed on a boy, 
 fourteen years old. The tendon of the 
 sterno-cleido-mastoideus muscle was skill- 
 fully divided with one stroke of a sharp pair 
 
 of scissors, by a surgeon named Flurianu 
 and as soon as the incision was made, the 
 head resumed its right position. ( Obs . Med. 
 Chir. C. 33.) Mr. S. Sharp believed, that 
 the wry-neck mostly arose from a contrac- 
 tion of the sterno-cleido-mastoideus muscle, 
 which he proposed the division of, when- 
 ever the disorder seemed to proceed from 
 this kind of cause. However, he made an 
 exception of cases, in which the disorder 
 had existed a considerable time, or from in- 
 fancy. He remarks, that, if the cervical 
 vertebrae have grown in a distorted direc- 
 tion, the position of the head cannot be 
 rectified. With these restrictions, the fol- 
 lowing is the operation, which he recom- 
 mends : A transverse incision is to be 
 
 made through the skin and fat, of a size 
 somewhat more extensive than the breadth 
 of the muscle, and about one third of its 
 length from the clavicle. A probed razor 
 is then to be passed underneath the muscle, 
 and to be drawn out, so as to make the re- 
 quisite division of the part. After the inci- 
 sion has been made, Mr. Sharp recommends 
 the wound to be filled with dry lint, and to 
 be always dressed in a way best calculated 
 to keep the extremities of the muscle from 
 growing together again. For this purpose, 
 he directs the cut ends to be separated from 
 each other as much as possible, with the 
 assistance of a bandage to support the head, 
 duringthe w'hole time of the cure, which, he 
 says, will generally be about a month (On 
 the Operations of Surgery, Chap 35.) 
 
 According to Mr Sharp’s account, this 
 operation ought to be common. However, 
 if attention be paid to the nature and 
 causes of the disease, and to the differ- 
 ences resulting from whether the disorder 
 be recent, or of long standing ; constant, 
 or periodical ; idiophatic, or sympathetic ; 
 dependent on spasm, or merely on paraly- 
 sis of the antagonist muscles; and, lastly, 
 if it be recollected, that the affection may 
 be produced by other muscles, besides the 
 sterno-cleido mastoideus ; it will appear, 
 that cases, in which the foregoing opera- 
 tion can be judiciously undertaken, are 
 not frequent. 
 
 With regard to the manner in which Mr, 
 Sharp operated, Mr. B. Bell conceived, 
 that it was attended with hazard of wound- 
 ing the large blood vessels. But, though it 
 seems to me better to use a probe-pointed 
 bistoury and a director, than the kind of 
 razor which Mr. Sharp employed, I do not 
 coincide with Mr. B Bell in thinking, 
 that the latter surgeon’s plan was at all 
 objectionable on the score of danger, in re- 
 spect to wounding the vessels. Some 
 practitioners may even think Mr. B. Bell’s 
 method most likely to injure the large ves- 
 sels; for be advises the operator to cut the 
 muscle from without gradually inward, as 
 deeply as necessary. 
 
 Perhaps, the most prudent method of 
 operating, is to divide the clavicular portion 
 of the contracted muscle, near the clavicle, 
 and even to cut out a sufficient piece, to re 
 move all chance, of the twe ends uniting 
 
WRY-NECK. 
 
 689 
 
 again, This step would weaken the muscle 
 considerably, and perhaps, might answer 
 every purpose. It could easily be accom- 
 plished, by means of a director, and curved 
 bistoury, after making the requisite division 
 of the skin with a common scalpel. Were 
 this proceeding to produce only partial 
 amendment, the sternal port ion of the mus- 
 cle might afterward be divided. A director 
 should be passed under it, and the division 
 made with a probe-pointed curved knife. 
 
 Any cause, destroying the equilibrium be- 
 tween the two sterno-cleido-mastoidei mus- 
 cles, will produce a wry-neck. Thus, when 
 one of them is affected with spasm, and acts 
 more forcibly than Uie other, it draws the 
 head towards the shoulder of its own side ; 
 but, when one sterno-cleido-mastoideus is 
 paralytic, while the other retains only its 
 natural power, the balance of action is 
 equally destroyed, and the sound muscle in- 
 clines the head toward the nearest shoulder. 
 Jn paralytic cases, electricity, (Phil. Trans. 
 Vol. 68, p. 97 ; Gilby. in London Med. Journ. 
 Vol. 4, 1790.) blisters, stimulating liniments, 
 the shower bath, seh-bathing, issues, setons, 
 the application of moxa, and attention to the 
 health in general, are the means affording 
 the best chances of relief. 
 
 Although the wry-neck may occasionally 
 depend on the state of the sterno-cleido- 
 mastoidei muscles, the case is far from being 
 frequent The deformity is much oftener 
 owing to some affection of the integuments. 
 Louis often successfully divided contractions 
 of the skin, which had kept the head drawn 
 to one side for many years, and had been 
 occasioned by burns. Some of these con- 
 tractions, he says, might easily have been 
 mistaken fora part of the sterno-cleido-mas- 
 toideus itself. 
 
 Mr. Gooch relates a case of wry-neck, 
 which was caused by a contraction of the 
 platysma myoides muscle. The patient was 
 a young gentleman, fourteen years of age, 
 who had always enjoyed very good health 
 in every other respect. For several months, 
 his head had been strongly drawn to one 
 side by a constant contraction of the platys- 
 ma myoides muscle, which was exceedingly 
 rigid, especially about its insertion at the 
 basis of the jaw, and from the angle of the 
 os maxillare inferius to the chin, the skin 
 presented an appearance like that of the 
 cicatrix of a burn. The same side of the 
 face, quite from the point of the chin, Was 
 much shrunk, and distorted by the contrac- 
 tion of the muscle, and the corner of the 
 mouth, in particular, was so drawn to one 
 side and downward, when the patient turn- 
 ed his head, that a vast deal of deformity 
 was the consequence. From the inferior 
 part of the eyebrow, at the internal angle of 
 the eye, to near the top of the head, there 
 was a kind of furrow upon the skin, about 
 half an inch broad, with a shining, polished 
 appearance, like the cicatrix of a wound, 
 and destitute of hair, which had fallen off. 
 From the corner of the eye downwards, 
 there was the same kind of appearance in a 
 less degree. The patient wag subject to re- 
 Vol. IF ' 87 
 
 peated attacks of spasms, whicn began at 
 the insertion of the muscle, and terminated 
 at the eye, attended with a great deal of 
 pain. The ear, and also the temporal and 
 frontal muscles, were sometimes affected in 
 a similar manner. The parts, in the course 
 of the insertion of the muscle into the jaw- 
 .bone, were considerably thickened, without 
 being in the least inflamed externally, and 
 when touched, but not stretched, they were 
 little painful. The subjacent muscles did 
 not seem at all affected. 
 
 It appears from the account given by Mr. 
 Gooch, that in the treatment of this affec- 
 tion, every known means had been tried, 
 by the advice of the most eminent practi- 
 tioners ; but without effect. Mr. Gooch de* 
 termined to try what benefit would be pro- 
 duced by the division of the muscle. He 
 first divided the integuments a little below 
 the jaw, and thus exposed the whole brea. th 
 of the platysma myoides muscle, the fibres 
 of which seemed to be in a state of violent 
 extension, especially when the patient’s 
 head was inclined towards the opposite side 
 Mr. Gooch then divided the muscle com- 
 pletely across by a very careful dissection, 
 until the fascia? of the subjacent muscles 
 were exposed. The patient was then di- 
 rected to turn his head towards the opposite 
 side, and Mr. Gooch had the satisfaction of 
 observing that the palient could perform 
 this motion, without the face and corner of 
 the mouth being affected, as they used pre- 
 viously to be. The wound was treated in 
 the ordinary way, and no particular symp- 
 toms arose. As soon as the inflammation 
 had subsided, the patient was directed fre- 
 quently to move his head about in order to 
 prevent any kind of stiffness which mi tit 
 ensue from the contraction of the muscular 
 fibres, and the inelasticity of the cicatrix. 
 
 The patient was perfectly relieved by the 
 foregoing operation, and had no return of 
 the painful spasms, to which he had been 
 previously subject. The side of his face, 
 however, never recovered its proper degree 
 of plumpness. ( Chir . Works of B. Gooch , 
 Vol. 2 ,p. 81.) 
 
 Whenever an attempt is made to cure a 
 wry-neck, by dividing any of the muscles, 
 or merely the integuments, it becomes ne- 
 cessary to take some measures for keeping 
 the head in a proper position, during the 
 treatment of the wound, lest, in conse- 
 quence of the head inclining in the direc- 
 tion in which it was before the operation, 
 the divided parts grow together again, and 
 bring the patient into the same condition, 
 in which he was before any thing had 
 been done. With a view of preventing this 
 unpleasant circumstance, Mr. Sharp recom- 
 mends filling the wound with lint, and ma- 
 king it suppurate. Mr. B. Bell, on the other 
 hand, advises the employment of a proper 
 machine for keeping the head in a due po- 
 sition. Some writers think the use of a 
 bandage quite sufficient for the purpose. 
 When the sterno-cleido-mastoideus is af- 
 fected, perhaps the excision of a small por 
 tion of if would be prudent 
 
ZINC. 
 
 690 
 
 Boyer met with a case of paralysis of the 
 extensor muscles of the head, attended with 
 a constant approximation of the chin to the 
 sternum. The disease resisted every plan 
 of treatment, and an apparatus for support- 
 ing the head was the only thing found of any 
 use. (See Trait# des Mai Chir. T. 7 ,p. 61, 
 8 vo. Paris , 1821.) Sharp's Treatise on the 
 Operations of Surgery, chap. 35. Blasius, 
 Ohs. Med. Rar. p. 2, No 1. Cure effected hy 
 operation. Mauchart, De Capile Obstipo, 
 
 Tub . 1737. Chirurgical Worlds of B. Goochs 
 Vol. 2, p. 81. B. Bell's System of Surgery 
 Roonhuysen , Heylcuren, p. 1, No. 22 and 33 
 successful operation. Encyclopedic M6tho- 
 dique , Partie Chirurgicale T. 2, Art. Torti- 
 collis. Joh. Christ. G.ottfr. Jorg. itber die 
 Verrkriimmungen des MenschlicHen Harpers , 
 und eme rationelle und sichere Heilart der- 
 selbcn ; Leipzig, 1810. Baron Boyer, Trait 6 
 des Mai. Chir T. 7, p. 48, fyc., 8 vo. Paris, 
 1821. 
 
 z. 
 
 Z INC. The preparations of this metal 
 are of considerable use in surgery. 
 With respect to the sulphate of zinc , it may 
 be said to be generally the best emetic, in 
 cases where it is desirable to empty the sto- 
 mach without the least delay, as in cases of 
 poison, for which purpose, the common dose 
 is 3j. “ As an external application, this 
 
 salt dissolved in rose-water, in the propor- 
 tion of gr. iss to %j. of rose-water, forms an 
 excellent collyrium in the latter stage of 
 ophthalmia, after the inflammatory action 
 has subsided ; it is a good injection in a si- 
 milar stage of gonorrhoea ; and a lotion in 
 
 some kinds of superficial inflammations. Oi 
 double strength, this solution is the best ap- 
 plication that can be used in scrofulous tu- 
 mours, after they have suppurated, and the 
 abscess been discharged.” (A. T. Thomson , 
 London Dispensatory, Ed. 2, p. 559.) The 
 unguentum zinci , composed of an ounce 
 of the oxide of zinc, and six ounces of pre- 
 pared lard, is an useful astringent, mildly 
 stimulant application ; and is frequently em- 
 ployed in various cases of cutaneous dis- 
 eases, ringworm, sore nipples, and chronic 
 inflammation of the conjunctiva of the 
 eyelids 
 
APPENDIX. 
 
 HYDROPHOBrA. Our author, after 
 a most laborious research into the annals 
 of surgery, in orderto ascertain the patho- 
 logy of this disease, and without being 
 able to decide upon any of the at present 
 promulgated opinions, is constrained, be- 
 ing in doubt, at length to ask, “ Does the 
 infectious principle of ixibies reside in the 
 salivary secretion , or in the mucus of the 
 trachea and bronchia and immediately 
 adds, “ The common belief is . that, in hy- 
 drophobia , the salivary glands arc consi- 
 derably affected By this b shon n, that, 
 notwithstanding the mystery in which 
 the pathology of this disease is invol- 
 ved, the mind of the inquirer has been led 
 to the site of the salivary organs, to 
 search for a cause which he deleares 
 himself satisfied existed in no other situa- 
 tion. 
 
 It is for me now to record a com- 
 munication from a most respectable 
 physician at St. Petersburg, Dr. Maro- 
 chetti, handed me by the Honourable S. 
 L. Mitchill, M. D., in the hope that the 
 medical community of this country will 
 exert itself, as frequently as oppor- 
 tunity may offer, either to substantiate 
 the doctrine of the salivary glands being 
 the particular and primary localit y of hy- 
 drophobia ; or disprove the assertion, 
 by an evidence which shall direct the 
 mind to another source. 
 
 • St. Petersburgh, 17th (29th) Nov. 1821. 
 
 Sir — I did myself the honour of en- 
 closing you, about a month since, a ma- 
 nuscript copy of a report read October, 
 1820, to the Medico-Physical Society of 
 Moscow, by Dr. Michel Marochetti, upon 
 hydrophobic virus, and the means of dis- 
 covering its presence and destroying its 
 activity in an infected subject. Appre- 
 hending that my letter may have mis- 
 carried, I trouble you with the duplicate, 
 accompanied by the same memoir in a 
 printed form, which it has received since 
 my first letter. 
 
 The art of inoculating for small-pox, 
 and thereby mitigating the violence of 
 the disease, having been first known and 
 practised in the East, encourages a hope 
 that the discovery from the same quar- 
 ter, of a mode of curing the incipient 
 symptoms of hydrophobia, by a process 
 in some degree analogous, may be the 
 
 means of rescuing numbers of victims 
 from encountering death in one of its 
 most horrid forms. 
 
 Desiring to give a wide circulation to 
 the paper of Dr. Marochetti, in order 
 that our country may have the early be- 
 nefit of his discovery, I have thought I 
 could not address myself better than to 
 the President of the Medical Society of 
 New-York, who will not fail to give his 
 recommendation so far as it may be me- 
 •rited. 
 
 S have the honour to be, Sir, respect 
 fully*, your obedient servant, 
 
 HENRY M1DDEL ON. 
 Hon. S. L. Mitchill. 
 
 Observations on Hydrophobia : contain- 
 ing certain indications for ascertaining 
 the existence of the hydrophobic poison 
 in an individual , and the means of pre- 
 venting its developement by destroying 
 Us germ. In a memorial read before the 
 Medico- Physical Society of Moscoiv, on 
 the 4 ih of October, 1820; by Michel 
 Marochetti, Attending Physician at the 
 Gallitzin Hospital , and member of the 
 said Society. Printed in St. Peters- 
 burgh, at the Press of Public Instruc- 
 tion, 1821. 
 
 Among the fatal accidents to which 
 man is exposed, the hydrophobia, a ter- 
 rible consequence of the bite of rabid 
 animals, is a disease whose cruelty is ag- 
 gravated by the insufficiency of all the 
 means hitherto employed to save its vic- 
 tims, and by the acknowledgment of all 
 practical men, that there is no specific 
 against the hydrophobic virus, after ab- 
 sorption has taken place, and the symp- 
 toms have appeared. I shall not under- 
 take a refutation of this truth. I shall 
 only say, that, with a knowledge of the 
 cause, it is possible, by means of help duly- 
 afforded, to prevent the mischief, and 
 consequently to save from certain death, 
 those persons who, before the discovery 
 which I have the honour to announce, 
 had no chance of safety. 
 
 Hitherto, the professors of the healing 
 art have been ignorant of the true seat of 
 the disease. A crowd of remedies have 
 been administered ; some because they 
 had doubtlessly been employed with suc- 
 cess in' cases where there was no hydro- 
 hobia, and others for the purposes of 
 enevolenee and prevention. But a very 
 
APPENDIX 
 
 important point in medicine, and one 
 that has been sought in vain, is.the cause 
 of this malady. Its effects are, unfortu- 
 nately, but too well known. I shall there- 
 fore, on this occasion, endeavour to state, 
 1st, the knowledge 1 have derived from 
 observation ; 2d, the origin of the dis- 
 covery ; and 3d, the different patholo- 
 logical occurrences I have been able to 
 collect, with my own remarks upon them. 
 
 Having spent almost eight years of my 
 life in the southern governments of Rus- 
 sia, where there is a great number of 
 dogs, some of them often run mad, and 
 produce frequent accidents. Repeatedly 
 I have endured the distress of beholding 
 the deaths of these victims. 1 necessa- 
 rily made inquiries concerning hydro- 
 phobia, and tried all the known methods 
 of treating it. Confined to a village in 
 the midst of the wretched creatures, 
 some of whom had been bitten by mad 
 dogs, and others by mad wolves, nobody 
 possessed better opportunities than my- 
 self to follow and to watch the course 
 and progress of this horrible disorder. 
 
 I now state the conclusions I have 
 drawn from the most scri/pulous atten- 
 tion to hydrophobia. 
 
 In the. first place, I am convinced by 
 experience, that if several persons are 
 bitten in succession by a rabid animal, 
 the first bitten exhibits in the develope- 
 rnent of the disease, more serious and 
 violent symptoms than the second, this 
 more than the third, and so on ; the poi- 
 son acting always in an inverse ratio to 
 the numbers, in such a manner that the 
 eighteenth or twentieth person may be 
 considered out of danger. Such a case 
 sometimes happens. 
 
 Secondly, the hydrophobic virus does 
 not constantly reside in tile mouth of the 
 mad animal. — It gathers there only at 
 the end of a certain time. The bite, in 
 this interval, is not to be considered as 
 venomous. Here is another case in which 
 the rabies is not communicated. 
 
 Thirdly, the hydrophobic virus does 
 not lose, like the pestilential miasma , , any 
 of its intensity in being communicated 
 from one body to another — but it acts 
 with more or iess violence in proportion 
 to its quantity. Unfortunately, the effect 
 is not the less fatal, by reason of its 
 quicker or slower operation. 
 
 Fourthly, it is evident that this virus 
 does not continue in the wounds ; but is 
 conveyed in its full force to a part of the 
 body presently to be described. In this 
 part, it instantly acts as a most powerful 
 astringent, and, by accumulation, inflames 
 and shuts the passages, by which nature 
 endeavours to expel it from the animal 
 economy. 
 
 Fifthly, there is one, and only one way, 
 to prevent the developement of hydro- 
 phobia in a person who is threatened with 
 
 it. I declare boldly, and experience will 
 bear me out in the assertion, that this is 
 to evacuate the hydrophobic virus when 
 itappears. Where does this reside ? and 
 how can it be evacuated ? 
 
 Sixthly, the sub-lingual glands are two 
 in number, one on each side, under the 
 tongue, between the genio-glossi muscles, 
 the lower jaw, and the inner membrane 
 of the mouth, which immediately covers 
 them. From these glands proceed two 
 or three secretory ducts, which open in- 
 to the ducts of the sub maxillary glands, 
 and those latter open one on the one side, 
 and the* other on the other side of the 
 frajnum of the tongue — it is precisely to 
 the extremities of these ducts, that the 
 hydrophobic virus is conveyed after a 
 bite indicted by a rabid animal, and there 
 it is temporarily detained, forming, at the 
 two spots just described, one or two small 
 tumours of unequal size. By touching, 
 which may be done with a probe, it is 
 found that there is contained a fluctua- 
 ting humour, which is, as absorption 
 proves, the hydrophobic poison itself. 
 It is there that nature delivers to us her 
 enemy, it is from this hold that the sur- 
 geon ought to expel him. 
 
 Seventhly, the time cannot be exactly 
 defined at which these small tumours 
 will show themselves. If the virus is not 
 evacuated in twenty- four hours it disap- 
 pears by re-absorption . Then no trace 
 is left of its pre-existence. There takes 
 place a double metastasis towards the 
 brain. The most frightful symptoms of 
 hydrophobia commence, and the patient 
 sinks under one of its paroxysms. — On 
 opening the body, nothing remarkable is 
 observed ; pathological anatomy, after 
 all its explorations, has not discovered 
 any indication capable of fixing the atten- 
 tion of physicians, and of rendering an 
 explanation of the causes, because they 
 did not understand the re-absorption of 
 this virus. 
 
 Eighthly, the first thing to be observed 
 when a person believes he has been bit- 
 ten by a mad animal, is the lower side of 
 the tongue, which ought to be examined 
 for six weeks, once, or even twice a daj r , 
 for more perfect precaution. If at the 
 end of this term there is no appearance 
 of the small swellings already described, 
 we may rest assured that the individual 
 is not to be infected with hydrophobic 
 virus, During these examinations, if the 
 tumours appear, they must be instantly 
 cauterized , or, what is better, opened with 
 a small, sharp lancet. This operation is 
 performed by raising the tongue with one 
 hand, covered with a suitable cloth, to- 
 wards the palate, and somewhat side 
 ways, to the end that the small button® 
 or tumours may be easily touched. For 
 greater convenience the tongue ought to 
 be supported by an assistant: so that 
 
APPENDIX. 
 
 093 
 
 There uiay be made as many longitudinal eyewitness. Leave was obtained from 
 incisions as there are lumps. From these the master of the village; and my per - 
 latter there will proceed some drops of mission w as additionally granted, that 
 a sanious lymph, somewhat greenish , the peasant should take charge of the 
 which, the patient operated upon, will patients. I however imposed two condi • 
 spit out. As soon as the operation is tions; the first of which was, that I 
 over, the patient must wash his mouth should be present at every thing he did ; 
 with a strong decoction of the tops and and the second, that to be sure that the dog 
 flowers of the Genista lateo-iindoria , that had bitten them was really mad. and 
 (Dya’s Broom.) It is almost superfluous hydrophobic, I should practise upon one 
 to observe, that this decoction must be of the patients in my own way. I se- 
 prepared in advance, for it must be regu- lected from among them a girl, six years 
 larly taken during the six weeks that the old, whom 1 subjected to medical treat- 
 patient is under examination, as a com- ment. The others began to take the de- 
 mon drink. The dose is a pound and a coction of the genista lateodindoria , 
 half per day, in decoction ; or four which the peasant prepared in my pre- 
 drachms a day in pow der, in doses of one sence. 
 
 drachm each. The prescriber, however, As I passed the greater part of my 
 will always take into consideration the time near these unfortunate persons, 1 
 age and constitution of the patient. administered my own remedies for the 
 
 Ninthly, 1 observe that the operation girl I had taken for my own patient. I 
 which consists, in opening the small tu- had engaged a surgeon, with orders not 
 mours, has the great advantage of being to let the peasant do any thing in ray 
 so simple, and so easy to execute, that absence. This plain man began by exa- 
 not only professional men, but every in- mining the tongue of each individual,, 
 dividual who has seen it performed two one after the other, on its low ? er part, or 
 or three times, can perform it himself, under side, every morning and evening. 
 This is very important for the small As the tumours appeared, he showed 
 towns and villages, where, as yet, there them to me; and he opened them, and 
 are no settled and established surgeons, cauterized them with a sort of large 
 I offer myself, on the occurrence of the needle, heated red hot in the candle,, 
 first accident of this kind, to perform the After the operation, he caused them to 
 operation in the presence of any person rinse their mouths with the same decoc- 
 whom the government may be pleased tion which has been mentioned for inter- 
 to appoint. nal use. 
 
 I inhabited the Ukraine, during 1813, The girl of six years old, whose trpat- 
 in the capacity of physician to his excel- ment bad been continued w ith the great- 
 lency the count Morzezensky. In one. est care, and conformably to the rules of 
 of his villages, called Kijawka, during an established, practice, became the victim 
 evening of the autumn, at the hour when of the experiment ! for, on the morning 
 the peasants return home from their la- of the seventh day after the bite, she was 
 bour, a huge hydrophobic dog of a neigh- suddenly seized with symptoms of hy- 
 houring village, bit fifteen persons of dif- drophobia, and at the end of eight hours 
 ferent ages and sexes. As 1 lived at the expired in my presence, during a parox- 
 distance of five versts, 1 received no intel- ysm of the most frightful symptoms. 
 Iigence until the next morning Proceed- Of the fourteen remaining persons, 
 ing then with all possible speed to the twelve underwent the opt ration of open- 
 place, 1 procured for these unfortunate ing their tumours, and w ere saved. The 
 persons a house, spacious enough to con- two others, w ho had been bitten last, had 
 tain them all, and I placed near them at- no tumours. These fourteen persons, 
 teridants to .nurse and attend them. after hav ing for six weeks made use of 
 
 While these arrangements were ma- the decoction of Genista , were dischar- 
 king, a deputation of old men waited up- ged Vured. 
 
 on me, praying that the bitten persons Having remained there more than 
 might be treated by a Peasant of the three years after this occurrence, 1 saw, 
 neighbourhood, w ho had for a number of a number of times, all the individ jals, 
 years made a business of attending such and can attest that their recovery was 
 cases, and with constant success. They complete. 
 
 all assured me they would bear w itness l state more facts. Being in Podolia 
 in favour of this man, who. according to during 1818, 1 resided in a small tows 
 their declaration, had already served called Meskowka, within the district of 
 several hundred persons in that govern- Olgapal. In the month of February, 
 ment.' twenty six persons, partly Christians and 
 
 I had previously heard of this man. I partly Jews, of different ages and sexes, 
 was desirous of satisfying myself as to were bitten by a hydrophobic dog. This 
 the efficacy of a means so very important dog made incursions into the town, and 
 to humanity, and of which I had wished having bitten all the persons he met, had 
 to have an opportunity to become an disappeared. The inhabitants, however. 
 
(.94 
 
 APPENDIX. 
 
 rallied ; and in their search for him, in 
 the place of his usual retreat, found him 
 dead near a heap of wheat. 
 
 Though I took great pains to ascertain 
 the successive order of the bites, I was 
 unable to determine the exact series in 
 these twenty- x individuals. 
 
 So con. durable a number of the bitten 
 and calamitous beings could not be ac- 
 commodated in any house that could he 
 procured. I was therefore obliged to 
 separate them into three divisions ; and 
 send each division to a distinct house. 
 I attached to the first division, nine men; 
 to the second, eleven women ; and to the 
 third, six children. Iri each of the 
 houses I stationed a Hebrew surgeon, to 
 prepare the decoction of the Genista 
 lateo -tinctoria, to administer it to them 
 regularly, and to report to me every 
 thing that happened. 
 
 The result was, that, in the first divi- 
 sion, five persons had swellings under 
 the tongue ; in the second, all had them ; 
 and in the third, only three of the child- 
 ren. 
 
 Among these individuals, they who 
 had the deepest and most numerous 
 wounds, experienced the tumours on the 
 third day. The rest on the fifth, seventh, 
 and ninth days. In one woman, these 
 sub lingual swellings did not manifest 
 themselves until the twenty- first day after 
 the bite. This woman had received a 
 slight bite in the right leg. 
 
 The seven persons who had no tu- 
 mours nevertheless drank the decoction 
 for six weeks, and were then set at liberty 
 with the. res # t, excepting those whose 
 wounds were* not healed. They remain- 
 ed in charge until their entire restoration 
 to health. I have employed, as an excel- 
 lent detergent, the residue of the decoc- 
 tion of the herb Genista, as an applica- 
 tion to the wounds, in the form of a poul- 
 tice. 
 
 It is not uhfrequently necessary, to 
 give a gentle purgative, once a week, or 
 at least a simple clyster prepared from 
 a decoction of the marsh-mallows of the 
 shops, in which a small quantity of 
 Aslrakan salt is dissolved. By either of 
 these means, costiveness is prevented. 
 
 There is a matter which merits the 
 greatest attention This is t he succession 
 of forerunning symptoms, observable 
 during the formation of the small pus- 
 tules, whose discovery is the offspring of 
 a most lucky observation. Towards that 
 stage, the pupil of the eye is dilated and 
 fixed ; the look is sad ; uneasiness is 
 complained of; and there is a small pain 
 in the head. These are the only symp- 
 toms I have been able to detect. The 
 simple and easy method of treating per- 
 sons threatened with hydrophobia, is 
 that which has been practised upon about 
 forty individuals with complete success. 
 
 The little girl, who fell a sacrifice to my 
 experiment, affords a piece of evidence 
 quite as strong. Henceforward a regi- 
 on can be adopted, of which I will war 
 rant the salutary result. 
 
 Byway of conclusion, I remark, that 
 at different times and places, 1 have 
 treated six persons in the same manner ; 
 among others, a peasant who had been 
 bitten by a mad wolf, as he was going 
 from one village to another. His cries 
 brought other men, who assisted iri killing 
 the ferocious beast, who had been already 
 marked as hydrophobic. The only dif- 
 ference between this and the radical cure, 
 was, that this man, among other wounds, 
 had been bitten on the forepart of the 
 ankle; and that the tendons and liga- 
 ments were so lacerated, that all the sur- 
 gical means which were applied, could 
 not prevent a great deformity of the foot. 
 He was confined to hi§ bed for two 
 months. 
 
 After the disclosures I have made con- 
 cerning the hydrophobic virus, 1 consider 
 the disease as a local evil , of which it is 
 possible to prevent the consequences, by 
 a seasonable removal of the morbific 
 matter. For after the reabsorption has 
 been made, there are no means of arrest- 
 ing its terrific effects. I think it may be 
 thence concluded, that the known symp- 
 toms of hydrophobia, such as constriction 
 of the breast, violent pain in the head, 
 dilatation of the pupil, occasional palsy of 
 the tongue, convulsions, dread of liquids, 
 all nervous symptoms, are produced by 
 the reabsorption of the hydrophobic poi- 
 son. The nerves from the fifth pair, 
 those which go to the tongue, the inter- 
 costal and corvical nerves, furnish direct 
 evidence of the manner in which the \ irus 
 exerts its deleterious action through the 
 medium of the nerves leading from the 
 sublingual and submaxillary glands. 
 Without taking into consideration the 
 complicated distribution of these nerves, 
 their connexions and sympathies, 1 en- 
 tertain the hope, that Physiology will, 
 one day, give us more satisfactory details 
 on this subject. It only remains for me, 
 gentlemen, to state my sole and particu- 
 lar desire for the publication of a me- 
 moir, useful to humanity, and the chief 
 object of my researches and of my exer- 
 tions. 
 
 Accept, respectable president, and 
 members, who have had the goodness to 
 receive me as a colleague and fellow- 
 labourer, the observations which I offer 
 you, in the most philanthropic spirit ; add 
 thereto your own intelligence, and aid me 
 with your practical experience. I shall 
 be overjoyed if I should be happy enough 
 to limit the disasters caused by hydro- 
 phobia. 
 
 ( Signed) M A HOC H ETTf 
 

 APPENDIX. 
 
 
 Since the receipt of the foregoing, the teeth in it. Tn the evening f gave him 
 Doctor has had forwarded to him a some more milk and water, and mutton 
 communication, which, when read, will be broth, which he took freely and went to 
 
 found in affinity with the preceding 
 
 Remarks on Hydrophobia , more particu- 
 larly as it occurs in Dogs ; in « letter 
 from a gentleman of observation and 
 exverience in New- Jersey* dated March 
 15, 1822. 
 
 Sir— 1 lately read with much plea- 
 sure, in the New-York Spectator oi the 
 1st instant, Mr. Middleton’s letter to you 
 accompanying Dr. Marochetti’s very 
 interesting report on the symptoms and 
 cures of hydrophobia. 
 
 As I consider it the duty of every 
 member of the human race, to commu- 
 nicate any thing that may in any way 
 tend to elucidate or corroborate tiiis 
 wonderful discovery, (the greatest th;*t 
 has yet been made in medical science,! 1 
 beg leave to submit to your considera- 
 tion two cases, which within these 
 eighteen months have fallen within my 
 personal knowledge and information, and 
 may be depended on. 
 
 On the morning of the eighteenth of 
 December, 1820, while living in Canada, 
 a favourite dog, belonging to me, of the 
 Setter breed, showed what 1 imagined 
 to be symptoms of madness, on which 1 
 immediately directed my servant to tie 
 him up in an out-house, and to give him 
 some salt and water, as he appeared 
 from scratching his neck and throat until 
 it absolutely bled , to have something 
 sticking in it ; this made him in a short 
 time throw up a quantity of yellow 
 frothy matter, and seemed to relieve him 
 very much, so that at 12 o’clock he ap- 
 peared free from every species of com- 
 plaint. Soon after, the servant gave him 
 some water, which he lapped freely, and 
 immediately threw up a large quantity of 
 the same yellow frothy matter, some of 
 it in large lumps. From these symp- 
 toms, l was induced to think .that he had 
 swallowed some poisonous substance, on 
 which account I gave him some milk 
 and water and fat mutton broth, which 
 lie took freely, and appeared as if sensi- 
 ble of the attention paid him, and as 
 usual wagged his tail, and readily obeyed 
 every order I gave him. 
 
 Next day his appearance was more 
 unfavourable : his eyes appeared glazed 
 and heavy, his tail drooped, his stomach 
 and bowels were contracted, his back 
 raised in a circular form, and his neck 
 raw from continual scratching. At this 
 time ! had him and the barrow in which 
 he lay removed to a warmer place, which 
 I did witiiout any difficulty, as he knew 
 and obeyed me as usual; yet, soon. after, 
 when I held out my stick towards him, 
 he laid hold, and left the marks of his 
 
 rest. 
 
 Ahout midnight 1 was awakened by 
 his incessant and apparently painful 
 barking, which he continued without in- 
 termission until daylight, when he exhi- 
 bited what appeared to me such un- 
 doubted signs of violent madness, that f 
 was under the painful necessity of shoot- 
 ing him. My servant then told me, that 
 the day I desired him to be tied up, he 
 made a snap at his thigh, and gave it a 
 pinch, but having on thick pantaloons,, 
 and drawers, he did not break the skin, 
 and no bad consequences have ensued 
 from it. 
 
 When staying last August with my 
 friend, Mr. Grant, at Montreal, I happen- . 
 
 < d to mention all these circumstances to 
 him, when he, pointing to a favourite 
 dog, lying at his feet, told me, that about 
 two years ago he was in so similar a 
 situation, that he left orders with his 
 servant to shoot him, and as he could not 
 do it himself, or be in the way when it 
 was done, he went into the country for 
 some h'*urs. On his return home, the 
 first question he asked was, ‘ l have you 
 disposed of the dog ?” to which, to his 
 great surprise , the servant answered, 
 
 “ No, sir, l could not find in my heart 
 to kill the poor dumb brute, and as he 
 seemed by his violent scratching to have 
 something in his throat, or mouth, that 
 caused his illness, I got a friend to assist 
 me, who held him down while I opened 
 his mouth for the purpose of examining 
 it, and his throat, when under his tongue ,, 
 
 I observed a large Blob or Tumour , which 
 I opened with a penknife, and out of it 
 came a great deal of nasty matter, which 
 the dog threw out of his mouth, imme- 
 diately leaped up, frisked about the room 
 as if sensible of the cure that had been 
 effected on him, and he is now as well as 
 ever he was.” Mr. Grant could hardly 
 believe the story ; but the entrance of 
 the dog into the room, in his usual man- 
 ner, to his great joy, confirmed the truth 
 of it. 
 
 On Mr. G’s relating these circum- 
 stances to me, I mentioned to him, that; 
 I thought the matter of so great conse • 
 quence, that he ought to draw up a state - 
 ment, and communicate it to some medi - 
 cal friend, as it might, perhaps, be the 
 means of finding out a cure for the dis- 
 temper in dogs, which I then thought it 
 was, though was convinced, from Dr. 
 M.’s report, that it was the real hydro- 
 phobia. 
 
 As I soon after left, that country, 1 do 
 not know whether or not Mr. G. follow- 
 ed my advice ; but in case he has not, I 
 now give you all the circumstances of 
 both cases, well convinced that they can- 
 
 & 
 
APPENfo/X 
 
 €96 
 
 not be placed in better hands; leaving 
 you at liberty to make such use as you 
 may think proper of this information. 
 
 As Dr. M. mentions having the hands 
 properly covered when examining the 
 mouths of patients, I would beg leave to 
 suggest your publishing what material 
 you deem a proper and necessary cover- 
 ing for the hand ; with which, and a lan- 
 cet, at least one person in each village, or 
 large family, ought, in case of accidents , 
 to be provided, as there are many parts 
 of this extensive country, where medical 
 aid cannot be procured, or the patient 
 unable to pay the expense of the long 
 attendance necessary. And I would also 
 beg leave to suggest the propriety of 
 having this report of Dr. M.’s promulga- 
 ted throughout the country in general, 
 through the medium of newspapers or 
 cheap pamphlets, with the addition of 
 such remarks as you may think proper 
 or necessary to make to it. 
 
 When 1 was a boy, at school in the 
 North of England, 1 learnt to worm dogs, 
 which, it was said , did not prevent their 
 going mad ; but in case they were infect- 
 ed, occasioned a relaxation or paralysis 
 in the lower jaw, which disabled them 
 from biting any thing, and under that 
 idea, t afterward wormed a number of 
 dogs, but cannot, at this distant period, 
 say what were the consequences or 
 effects of it ; but as the custom was ge- 
 neral, there must have been something 
 in it, and perhaps might have proceeded 
 from the idea that the tongue was some- 
 how afflicted. That the saliva of a mad 
 dog will not communicate the disease, 
 unless carried into the circulation through 
 a wound in the skin, I am perfectly con- 
 vinced, as a lady, a friend of mine, had 
 her face licked all over by a favourite 
 gray hound, which had been tied up on 
 account of being supposed to be infected, 
 but got loose, and immediately after be- 
 ing again tied up, got loose a second 
 time, and ran off, and, before he was 
 killed, bit a number of dogs and cattle, 
 all of which went mad, yet the lady 
 never felt any bad consequences from it. 
 
 With real esteem, I have the honour 
 to be, 
 
 Sir, your most obedient, 
 
 Humble Servant, 
 
 W. ARMSTRONG. 
 S. L. Mitchill, M. D. 
 
 March 26, 1822. 
 
 LITHOTOMY. What I have to say 
 at present upon this article, is founded 
 upon two lately-discovered anatomical 
 facts, which, in my opinion, will become 
 of the first consideration in regulating the 
 operation of lithotomy. The first of 
 them has reference to the particular ex- 
 tent, thickness, and connexion of the 
 triangular ligament of the urethra : and 
 
 the second to the pelvic partition, or that 
 extension of the fascia iliaca, which 
 passes over the brim of the pelvis to be- 
 come attached to the side of the urinary 
 bladder, and called ileo-vescial-fascia. 
 
 “ The triangular ligament of the urethra 
 is stretched across the arch, between the 
 rami of the pubes at the anterior edges of 
 these bones. It is connected above, to 
 the middle of the lower edge of the pubic 
 ligament, by which a space is left on each 
 side, for the passage of the internal pu- 
 pendal arteries to the penis. 
 
 This ligament is about an inch and a 
 half in depth, having its lower edge semi- 
 lunated, and formed into two arches, both 
 sprung from a central projecting portion 
 of the ligament, which will be afterward 
 mentioned as the centre of union of the 
 muscles of the perineum. These arches 
 are concave facing the coccyx, and go 
 towards the tuberosities of the ischia, by 
 processes firmly attached to the inner 
 edge of the bone, and that terminate by 
 being incorporated with the anterior sa~ 
 cro-sciatic ligaments. 
 
 This branch of the triangular ligament, 
 moreover, assists the sacro-sciatic on each 
 side, in sending up, within the pelvis, the 
 aponeurosis to the obturator in-ternus 
 muscle. 
 
 The central projecting point, at the 
 lower edge of the triangular ligament, is 
 kept in its place, in giving form to these 
 arches, by the action of the sphincter 
 ani, and transversales perinei muscles. 
 
 At about the middle of the triangular 
 ligament is a hole, for the urethra, in its 
 passage from the bulb. 
 
 The triangular ligament is composed 
 of two very distinct lamina;, which are 
 naturally separated at some distance from 
 each other, in consequence of having 
 between them, the glandulse antepros- 
 tatae, or Cowper’s glands.” — Surg. Anal. 
 
 By this description, I wish it to be un- 
 derstood, that the triangular ligament of 
 the urethra is closing the outlet of the 
 pelvis for a great extent under the arch 
 of the pubis ; and that, at its upper part, 
 it is full half an inch thick, getting gra- 
 dually thinner towards its arched edge, 
 at its under part. 
 
 Now, in almost every book which con- 
 tains directions for the operation of 
 lithotomy, we are told to “ cut through 
 the common integuments by the side of 
 the rapha of the perineum, against the 
 groove of the staff, which is to be 
 the fir^t incision ; thpn to divide the 
 transversales perinei muscles, which is 
 the second incision; and after this, to 
 feel for the groove of the staff, in the 
 membranous part of the urethra, to cut 
 upon it, and to introduce the beak of 
 the instrument, that is to divide the 
 prostate gland. Hence we find surgeons 
 getting into the bulb of the urethra in- 
 
APPENDIX 
 
 stead oft Up membranous part ; from their 
 attention not having been directed to the 
 presence of the thick triangular ligament. 
 After this, by carrying the beak of their 
 instrument on, they cut the bladder and 
 prostate, and prepare to introduce the 
 forceps for the extraction of the stone, 
 without having made sufficient room for 
 its exit. The bare hint at this circum- 
 stance. will sufficiently account for the 
 pulling and twisting we every da)’ see and 
 hear tell of, during the effort to extract 
 even very small stones by the lateral ope- 
 ration. [ have seen a patient, under such 
 circumstances, sent from the operating 
 table of a large hospital, who died, soon 
 after two hours had been spent in vain 
 efforts to extract not a very large stone, 
 from the urinary bladder. 
 
 The French surgeons, from having 
 often met with these difficulties, choose 
 at length to dignify the accident by a 
 particular epithet ; not however for the 
 purpose of guarding against it, hut that 
 the world might know they had in- 
 vented a new operation for lithotomy, 
 which they called 1’operation par deux 
 temps : that is, wherein’ the patient, 
 found exhausted by the laborious efforts 
 to extract the stone by the forceps, at 
 the time of the operation, was put to 
 bed, in order to recruit for another trial 
 the following day. 1? operation par deux 
 temps ! 
 
 The Pelvic Partition. I believe nine 
 out of ten of the cases of death after 
 lithotomy, are to be attributed to perito- 
 neal inflammation, caused by extrava- 
 sated urine retained in some quantity 
 against the under surface of the perito- 
 neum, as it passes from the bladder to 
 the rectum and side of the pelvis. 
 
 1 have taken some pains, in the first 
 part of a System of Surgical Anatomy, 
 published this year, to describe the par- 
 ticular connexions of the iliac fascia with 
 the side of the urinary bladder, and to 
 show that a complete septum is formed 
 by this membrane at each side, which 
 is impenetrable by any aqueous fluid ; 
 and by its peculiar attachments, a pit 
 exists at the side of the back part of the 
 bladder, which is bounded below by this 
 fascia, and above and behind by the peri- 
 toneum, as it goes from the bladder to 
 the side of the pelvis. That this pit is 
 likely to be filled with urine, during the 
 incision into the bladder in the operation 
 for stone : and that, when urine is here 
 placed, it has no possible way of escape 
 but by absorption. When urine is in this 
 situation, therefore, it is in constant con- 
 tact with a considerable extent of sur- 
 face of peritoneum; and that, under such 
 circumstances, it is equal to produce ery- 
 sipelatous inflammation of the mem- 
 brane, no one will deny. 
 
 .1 think it can be demonstrated by fair 
 Voi, If '08 
 
 induction, that, from the time of Celsus 
 to the present day, the different opera- 
 tions of lithotomy were successful in pro- 
 portion as this pelvic partition remained 
 uncut. The fatality attending Mr. Chc- 
 selden’s first operation, is to he ascribed 
 to the urinal infiltration, consequent upon 
 the manner in which he divided the blad- 
 der. He cut upwards, and necessarily 
 wounded this partition. We are permit- 
 ted to draw this inference, especially as 
 Mr. Cheselden has not accounted for 
 such events in any other way. The 
 high operation has been laid aside from 
 being so often unsuccessful ; and, in all 
 the descriptions given of that perform- 
 ance, we are left in the dark as to the 
 cause ; being only presented with ac- 
 counts of its comparative ill success. The 
 operation by the apparatus major, I have 
 no doubt, was instituted in its day from 
 a consciousness that something was cut 
 in other operations, that ought not to 
 be cut. Hence the method by dilatation 
 was thought more adviseable. 
 
 [Surg. Anat. Pari /.] 
 The result of my observations upon the 
 structure of the parts within the pelvis, 
 in reference to the division of the bladder 
 and prostate in the operation of lithotomy, 
 is this ; that there is a line for this inci- 
 sion, which, when observed, the prostate 
 gland can be completely divided, and the 
 neck of the bladder beyond it, for the ex- 
 tent of two inches, with all safety to the 
 patient, and without opening the pelvic 
 partition, or wounding the peritoneum or 
 vesicula seminalis ; which line w ill he 
 obtained by observing the following rule. 
 The patient is to be placed on the table in 
 the usual manner, tied hands and feet, 
 and in that exact position in which he is 
 ordinarily placed for the operation. Then 
 let the knife, having entered the groove of 
 the staff', be carried into the bladder, and 
 the bladder and prostate divided, while the 
 instrument is held in a line with the ho- 
 rizontal table on which the patient lies, 
 that will give an angle of forty-five de- 
 grees. 
 
 NEEDLE, surgeons’. Every prac- 
 titioner must have felt, even at the ends 
 of his fingers, the inconvenience and diffi 
 culty attending the introduction through 
 the skin of Ihe common curved needle. 
 The young student is almost sure to prick 
 his fingers, in his first attempts at sew’ing 
 up the dead body; although a large 
 needle is then generally made use of. 
 And in the living subject, when bringing 
 arts together by suture, as in case of 
 arelip, it is not always easy to intro- 
 duce the common needle in the course 
 we wish it, or do it at all, in any thing like 
 a graceful manner. The needle is small, 
 rolls between the fingers, and has its 
 point coming out sometimes at a dart 
 at which we feast expect if. 
 
APPEND 1 &. 
 
 'SJfr 
 
 Dr. Miller, of Franklin, Massachu- 
 setts, has contrived a delicate instrument, 
 which I think in every instance will be 
 more efficient than the ordinary needle. 
 
 It is a curved needle, with an eye about 
 the eighth of an inch from its point, fixed 
 into a straight handle, by which full 
 power is had over the instrument. It is 
 first introduced through both lips of in- 
 tegument, and then armed with silken 
 ligature, when the thread takes the place 
 of the needle as the latter is withdrawn. 
 
 OSTEO SARCOMA The following 
 is an account of three cases in which ex- 
 tensive portions of the lower jaw were 
 taken away for the removal of this dis- 
 ease ; after previously tying the carotid 
 artery, in each individual, by Professor 
 Valentine Mott. Two of these cases were 
 of successful issue, but the third was lost; 
 from circumstances, however, which 
 could not be fairly referred to the opera- 
 tion. 
 
 On the 12th Nov. 1821, being asked by 
 Dr. Mott to see a patient of his with a 
 curious disease on the right side of the 
 lower jaw, 1 was shown an interesting 
 young woman, by name Catharine 
 Bucklew, of about 17 years of age, of 
 healthy appearance, good constitution, 
 and who gave of herself the following 
 account. 
 
 She stated that at about two years pre- 
 vious, a swelling commenced behind the 
 last molar tooth, attended with acute 
 pain about the angle of the jaw, that con- 
 tinued for three weeks ; at which time the 
 inflammation left her, without any evi- 
 dent resolution. During this attack there 
 was no inflammation of the integument, 
 nor could any pus be discovered, either 
 on the cheek or about the bone within 
 the mouth. That some domestic appli- 
 cations were made use of to the cheek, 
 hut the swelling remained, assuming the 
 appearance of smooth and hard bone. 
 That, at about twelve months after its 
 commencement, she applied to a physi- 
 cian in New- Jersey, (it being her resi- 
 dence,) who advised blisters to the cheek, 
 with the topical application of caustic to 
 the tumour, together with a general anti- 
 phlogistic constitutional treatment: and 
 that this was persisted in for two months 
 without any benefit. 
 
 Soon after this she came to the city, 
 and put herself under the care of Dr. 
 Mott, in the New-York Hospital, when 
 the tumour had extended from the root 
 f the coronoid process to the second 
 bieuspis tooth, being elevated nearly an 
 inch above the level of the teeth, and 
 spreading considerably wider than the 
 alveolar processes. Its appearance was 
 smooth, and to the touch somewhat elas- 
 tic, though firm. Dr. Mott made an in- 
 cision on each side the alveolar margin, 
 
 with a scalpel, by which he was enabled 
 pretty readily to remove the tumour to a 
 level with the jaw bone. The tumour, 
 upon examination after removal, was 
 found to contain many cartilaginous and 
 osseous spiculae ; and in its substance 
 one of the molar teeth was imbedded, 
 in a perfectly sound state. About three 
 months after this a small sprout, which 
 had grown rapidly, was taken off ; she 
 upon this removed to the country, where 
 she remained in a very comfortable state 
 for several months. 
 
 At the time I saw her, she further 
 stated, that the first molar tooth came 
 away early in the disease ; that the se- 
 cond soon followed; after which, three 
 or four of the other teeth at that side of 
 the jaw ; and that previously to this dis - 
 ease, she had never a decayed tooth : 
 and further, that no fluctuation was to be 
 felt at any time in the tumour ; had 
 no constitutional symptoms as the ef- 
 fects of this disease, nor any inordinate 
 headach on that side. The lymphatic 
 glands of the neck were, however, swol- 
 len during the continuance of the inflam- 
 mation, in the early period of the disease, 
 but disappeared when the pain subsided. 
 
 When 1 saw her, at the date mention- 
 ed, the tumour had the same firm and 
 slightly elastic feel, which was said to 
 characterize it in its early stage, and in- 
 volved all the right side of the inferior 
 maxillary bone. Projecting outwards, it 
 formed a great convexity of the cheek ; 
 upwards it was divided into two por- 
 tions by a furrow made by the pressure 
 of the teeth of the upper jaw ; this was 
 attended with a constant abrasion of sur- 
 face and discharge, which, though offen- 
 sive, did not appear to be acrid or irrita- 
 ting : downwards, it was nearly in con- 
 tact with the thyroid cartilage ; and in- 
 wards, it extended beyond the middle 
 line of the mouth, pushing the tongue 
 and uvula much to the left side. 
 
 The tumour, at the back part of the 
 mouth, had encroached so much upon 
 the passage leading to the fauces, and 
 the pressure of the lower part on the 
 pharynx was so considerable, that deglu- 
 tition became difficult ; and from the 
 great inconvenience attending mastica- 
 tion, she had been compelled for some 
 time to subsist upon liquid aliment. Her 
 speech was much interfered with, in con- 
 sequence of the displacement of the 
 tongue ; but she had no pain in any part 
 of the tumour. 
 
 Under all these circumstances, she was 
 very desirous to be made acquainted if 
 an operation could not be performed, 
 which might extend to her some chance 
 of life; observing, that if she continued 
 in the present state much longer, she 
 would soon be unable to swallow anr 
 
APPENDIX. 
 
 
 tiling, judging from the vapid growth that 
 the tumour had shown for the few weeks 
 previous ; and fully aware of the danger- 
 ous nature of the novel operation her ease 
 would reouire, she expressed herself 
 determin* a to submit to it, and hazard 
 the consequences. The uncertain result 
 of the operation was fully explained to 
 her by Dr. Mott, and moreover that she 
 might die under its performance ; but 
 that it was believed both practicable and 
 proper. 
 
 After preparing the sj'stem for about a 
 Week, with a light diet and a few doses 
 of neutral salts, the operation was com- 
 menced on the morning of the 17th. As 
 it was thought prudent to begin by pla- 
 cing a ligature on the common carotid, 
 this vessel was sought for at the middle 
 of the neck, and one ligature placed 
 around it. Very little blood was lost, 
 and only one subcutaneous branch at the 
 lower end of the wound required tying. 
 Although she submitted to this part of 
 the operation with firmness, yet imme- 
 diately afterward she became pale and 
 almost pulseless, with the presentiment 
 that she should die if the operation of 
 extracting the tumour was persisted in. 
 In this her state of mental perturbation, 
 it was resolved not to proceed ; she was 
 therefore put to bed. 
 
 After she recovered a little, she was 
 apprized that what had been done, was 
 only preparatory to the most important 
 part of the operation ; and that that 
 would prove of little or no benefit to her 
 if it was not further proceeded in. She 
 was then urged to give the thing full con- 
 sideration, and, if possible, to make up 
 her mind to submit to the performance 
 of the remaining part, which on no ac- 
 count should be deferred longer than the 
 following day. 
 
 13 tk, 7 A. M. — Found her this morn- 
 ing much composed, having slept well, 
 and free from fever. Upon putting the 
 question, would she submit to the rest of 
 the operation ? she answered, with much 
 decision, that she was determined to un- 
 dergo it. She was, therefore, being 
 cheerful and resolute, at ten o’clock pla- 
 ced again upon the table, when Dr. Mott 
 proceeded with the operation in the fol- 
 lowing manner. 
 
 Feeling for the condyloid process, the 
 incision was begun upon it opposite the 
 lobe of the ear, and carried downwards 
 opposite the ear, over the angle of the 
 'aw, in a semicircular direction along the 
 ower part of the tumour as it rested upon 
 the thyroid cartilage, ending at about 
 half an inch beyond the angle of the 
 mouth, upon the chin. After this the se- 
 cond incisor tooth of the right side was ex- 
 tracted, which was from a sound part of 
 the bone ; and upon further separating 
 the soft parts from tire side of the jaw 
 
 near tire chin, a narrow saw, similar to a 
 key-hole saw, was introduced into the 
 mouth from the wound, by which was 
 divided the jaw-bone in a perpendicular 
 direction, commencing where the incisor 
 tooth had been extracted. The lower 
 part of the tumour was then laid bare by 
 cutting through the mylo-hyoid muscle ; 
 when the flap of the cheek was carefully 
 separated and turned up over the eye. 
 This exposed fully to view the whole ex- 
 tent of the tumour, as it rose towards the 
 os make. Now, after the integuments 
 were cautiously dissected from the paro- 
 tid gland, the masseter muscle was detach- 
 ed at its insertion, until the edge of this 
 gland ; then separating a few more fibres 
 of the muscle under the gland, the paro- 
 tid was readily raised without injury. 
 The maxilla was next laid bare for some 
 way above its angle, where it was seen 
 sound and in a healthy state. To facili- 
 tate the sawing of the bone in this second 
 situation, it was necessary to make a fur- 
 ther incision through integument for 
 about an inch close to the lobe of the ear, 
 and over against the mastoid muscle. 
 Then with a fine saw made for the pur- 
 pose, smaller and more convex than 
 Hey’s, the bone was divided obliquely 
 downward and backward, at a part about 
 midway between the angle and condy- 
 loid process. This part of the sawing 
 was necessarily performed with much 
 caution, to avoid wounding the great ves- 
 sels, and the inferior maxillary nerve. 
 After the bone was sawed through, the 
 action of the temporal muscle separated 
 the coronoid from the eondyloid process, 
 and drew it up under the zygomatic arch. 
 
 An elevator was now introduced, where 
 the bone was divided at the chin, by 
 which the whole diseased mass was rais- 
 ed ; and, with a scalpel passed into the 
 mouth, the tumour was separated from 
 the side of the tongue, as far back as the 
 posterior fauces. The tumour could 
 now be turned against the side of the 
 neck, to assist its separation, from the 
 parts below the base of the jaw, and 
 from the pharynx. The pterygoid mus- 
 cles were next detached, and the third 
 branch of the fifth pair of nerves divided 
 a little above the foramen at which it 
 enters the hone, observing much caution 
 to secure the safety of the trunk of the 
 internal carotid, and deep-seated jugular 
 both of which were exposed. 
 
 At the several periods of this operation, 
 the curved spatulas of Colles were found 
 of infinite service, as in elevating the pa- 
 rotid gland, keeping the tongue steady, 
 &tc. 
 
 Very little blood was lost in this ope- 
 ration ; three arteries only, of any size, 
 required a ligature : viz. the facial, lingua), 
 and a little branch behind and under- 
 neath the angle of the jaw. 
 
APPEJNDIX. 
 
 luo 
 
 After waiting for a little time to ob- 
 serve if any hemorrhage should ensue 
 upon the reaction of the system : the 
 dap of the cheek was brought down and 
 closely approximated to the divided inte- 
 guments below by three interrupted 
 sutures; after which, adhesive straps, lint, 
 compress, and a double-headed roller, 
 being applied, the patient was made, as 
 comfortable as possible, and directed to 
 be continued upon the table for a few 
 hours to recruit. 
 
 At eight o’clock in the evening she had 
 been removed to her bed, and signified 
 that she was comfortable. Some reaction 
 of the circulation had taken place ; but 
 there had been no hemorrhage. The 
 pain from the operation she said was less 
 than she had expected. For the first time 
 since the operation she sipped three tea- 
 spoonsful of cold water, and gave evi- 
 dence by a nod that she could swallow. 
 One hundred drops of tinct. opii was di- 
 rected to be given if any twitching, more 
 pain, or restlessness, should come on. 
 She was recommended to make no effort 
 to speak. 
 
 19 ih, 7 A. M. — She w’as found quite 
 free of fever and irritation, and in every 
 respect comfortable : she swallowed cold 
 water by the tea-spoonful with but little 
 inconvenience : she slept several hours 
 during the, night. 
 
 12 at noon. — She was found comforta- 
 ble ; skin moist; pulse less frequent, and 
 soft : an enema was directed to be admi- 
 nistered of soft soap and water; she had 
 a little more difficulty in swallowing, but 
 none in breathing. 
 
 9 P. M. — She was as well as in the 
 morning ; the enema had operated three 
 times, and relieved her ; pulse frequent, 
 but not tense : she had taken about two 
 ounces of cold water by the spoon since 
 daylight. 
 
 20/A, 7 A. M. — She had had a very 
 comfortable night ; instead of nodding, 
 she answered yes and no to the several 
 questions, in an audible whisper. 
 
 9 P. M. — She was much as in the 
 morning. 
 
 21s/, 9 A. M. — Was as comfortable as 
 yesterday morning. 
 
 9 P. M. — There was no material alter- 
 ation. 
 
 22 d, 9 A. M. — An enema was directed 
 to be administered as before. She was 
 allowed to take, in addition to her cold 
 water and teas, some thin chicken soup ; 
 and was, in every respect, doing well. 
 
 9 P. M.— Tumefaction of the lips and 
 cheek very trifling, not enough to effect 
 the least change in the lids of the right 
 eye. 
 
 — Was in every respect comforta- 
 ble. 
 
 24 tk, 1 1 A. M. — Has made no com- 
 
 plaint. The wounds were dressed, and 
 union by adhesion had taken place in 
 their whole extent, excepting about the 
 ligatures and sutures. Suppuration hav- 
 ing come on about two of the sutures, 
 were removed. Pulse about 120. — 
 The adhesive straps were renewed, with 
 lint interposed between them and the 
 double-headed roller. 
 
 25 th. — Was every way comfortable. 
 Pulse 120. 
 
 26/A. — She said she had no complaint 
 to make. Pulse 80. She was directed 
 to take a small dose of sulphate of mag- 
 nesia. 
 
 27/A. — Spoke audibly, and said she was 
 very well. Pulse about 84 
 
 28 Ih. — Was as well as before ; the 
 wounds were dressed ; the two sutures 
 at the upper part, near the ear, were 
 removed ; wounds appeared heated, at 
 every part except where the ligatures re 
 main upon the arteries. Pulse 80. 
 
 .2 9th. — Felt very well ; spoke dis- 
 tinctly ; took freely of soup and other 
 thin food. Pulse 100. 
 
 Dec. 8 d . — Ligature from the carotid 
 came away with the other three ligatures 
 from the upper wound. A small collec- 
 tion of matter was evacuated from under 
 the integuments in the lower wound, 
 which had been produced by the irrita- 
 tion of the ligature. 
 
 4 th. — Spoke and swallowed very well ; 
 wounds almost healed. Hits used for 
 some days a wash of spirits and water to 
 the mouth, with a view to correct some 
 feetor of the saliva, and cleanse the 
 mouth. 
 
 6 th. — She was found dressed, and sit- 
 ting in an adjoining room, reading by 
 the fire. She* looked and said she felt 
 very w ell. The bandages being all left 
 oft', the only deformity apparent was a 
 little more tumefaction of the right 
 cheek than the left ; wounds almost well : 
 moved very readily the sound half of 
 the under jaw. She was permitted to 
 chew’ some animal food. 
 
 10/A. — Wounds all healed; made no 
 complaint. 
 
 March , 1822. — There was scarcely any 
 perceptible deformity: the right cheek 
 appeared, upon close examination, to be 
 a little more depressed than the left; and 
 some osseous deposit had commenced at 
 the two situations at w hich the bone had 
 bee n d i vi d ed . H er hea 1 1 h , i n e v t* ry respec t , 
 was perfectly good, and she enjoyed the 
 free use of the left side of the lower jaw. 
 
 Maky Roe, a married woman, aged 
 22 years, came to New- York from Long- 
 Island, on the 25th of March, 1822, to 
 consult Dr. Mott concerning a tumefac- 
 tion of the left side of her lower jaw-bone. 
 
 She stated, that about one year from 
 date there appeared an enlargement of 
 the bone, at a point from which one of 
 
APPENDIX. m 
 
 the molar teeth some time before had 
 been extracted. That it continued to in- 
 crease gradually ; but being at that time 
 pregnant with her second child, and 
 feeling little pain in the swelling, she 
 took no particular notice of it. Since her 
 delivery, however, which took place 
 about six months before she came to the 
 city, it has increased much more rapidly, 
 but the pain remained as at first, and has 
 been only felt occasionally to shoot 
 through the part. 
 
 This disease was much less extensive 
 than that in the preceding case, but it 
 reached from the base of the coronoid 
 process to the first bicuspis tooth, ex- 
 tending on each side of the bone to near 
 the base, and as far back as the angle, at 
 which part the base was comprehended 
 in the disease. Several of the teeth had 
 been thrust out by the growth of the tu- 
 mour, and those which remained were 
 very much displaced. The tumour had 
 the same appearance and elastic feel of 
 that in the former case. 
 
 On the SOth March, at 12 o’clock, Dr. 
 Mott, assisted by Drs. Post, Burro we-, and 
 myself, tied the ieft carotid artery through 
 an opening of about two inches in length 
 opposite the thyroid cartilage ; and so lit- 
 tle was the constitutional effect of this, 
 that it was determined to proceed with 
 the rest of the operation immediately. 
 
 An incision through the integuments 
 was now made, as in the former case, be- 
 ginning over the condyloid process above 
 the meatus auditorius, and carried in a 
 semicircular direction below the base of 
 the jaw, to terminate upon the chin a lit- 
 tle under the lip. The flap of the cheek 
 being dissected up, the first bicuspis 
 tooth was extracted to prepare the way 
 for the saw ; which instrument was 
 then applied, and the bone divided in a 
 perpendicular direction front that situa- 
 tion. The masseter muscle was separa- 
 ted from the angle of the jaw, and the 
 parotid gland carefully elevated anteri- 
 orly, in order to exhibit the hone a little 
 above the angle, that room might be made 
 for the saw. The bone was now cut 
 through midway between the processes 
 and angle, in aline parallel with the zygo- 
 matic arch. 
 
 The bone was now raised at the chin 
 by the finger and thumb, then detached 
 from the parts within the mouth by a 
 scalpel, until the diseased mass was com- 
 pletely removed. 
 
 During the elevation of the flap, and 
 removal of the bone, the hemorrhage was 
 profuse. At least a dozen ligatures were 
 applied to bleeding arteries ; some of the 
 vessels bleeding equally free from both 
 their extremities. 
 
 The patient bore the operation with 
 undaunted firmness, the flaps of integu- 
 ment were brought together by several 
 
 interrupted sutures, accompanied by ad- 
 hesive straps and proper bandaging. 
 
 The operation occupied one hour and 
 fifty minutes. 
 
 7 o’clock, P. M.— Pulse 30 ; nodded 
 that she was comfortable ; had slept lb 
 minutes, and was refreshed, but was sick 
 at stomach, and had made an effort to 
 vomit ; ordered not to attempt to speak. 
 
 10 P. M. — Had coughed some, which 
 was followed by a discharge of fresh 
 blood from ttie mouth, as well as from 
 the wound, so as to come through the 
 bandage, and run upon the neck. Pulse 
 88 : had taken a little cold water by tea- 
 spoonsful 
 
 31 st, to X. M» — Had a good night, but 
 coughed hard several times, yet no more 
 bleeding ; felt much refreshed from deep ; 
 pulse y2; skin natural; took 10 drops 
 tinct. opii to allay cough, but nausea be- 
 ing the effect, was not repeated : to have 
 cold barley water instead of common wa- 
 ter, by the tea-spoonful. 
 
 April ls£. — Passed an uncomfortable 
 night, owing to cough ; pulse 02 ; was 
 ordered enema communis , which was re- 
 peated in the afternoon with good effect. 
 Five P. M. pulse 120 to 135; articulates 
 a little, though indistinctly ; was ordered 
 a cough mixture. 
 
 2 d — More comfortable ; pulse 88 ; all 
 symptoms favourable. No tumefaction 
 about the eyelids ; cough less. 
 
 3d.— Felt refreshed ; countenance good ; 
 no tumefaction of the face ; articulated 
 distinctly ; pulse 88 ; complained of hun- 
 ger. 8 P. M. pulse 80; cough was trou- 
 blesome forepart of the day. mixt. ex- 
 pect. cont. 
 
 4th. — Said with a distinct and audible 
 voice that she was better than at any 
 other time since the. operation ; felt no 
 pain in the wound; coughed less; but 
 from the state of the bandages, the wound 
 was cleaned and dressed. The parts 
 were found to look well; pulse 92; felt 
 hungry ; was ordered some thin broth. 
 
 5th. — Had a comfortable night; took 
 some chicken tea with much relish ; pulse 
 104; no appearance of tumefaction. Had 
 an enema this morning which operated 
 well ; cough much relieved. 
 
 6th. — Dressed ; removed from the up- 
 per wound the sutures, and all the liga- 
 tures except one ; parts looked well. 
 The lower wound looked well ; but there 
 was little union there by adhesion, proba- 
 bly ow'ing to cough ; pulsq 80. 
 
 7th. — Has been sitting up in bed a lit- 
 tle ; pulse 32 ; was ordered sulphate of 
 soda in divided doses. 
 
 8th. — Improving daily; wounds doing 
 well ; the last ligature from the upper 
 wound was removed ; pulse 120. The 
 increase of pulse probably owing to the 
 operation of salts, which had just then 
 taken place. 
 
APPENDIX. 
 
 
 \<Zth. — 'W hile the wound was dressing; 
 this day the ligature from the carotid 
 came away ; patient doing well ; pulse 
 104. 
 
 1 Oth. — The fcetorand disagreeable taste 
 in the mouth very much gone, from the 
 daily use of a w dak spirit and water lo- 
 tion. She w'ns permitted to nurse her 
 babe a little to-day, for the first time 
 since the operation. 
 
 16th. — YVounds almost closed. 
 
 17 th. — She felt satisfied that the wound 
 within the mouth was completely healed. 
 
 2,0th . — Had been down stairs. 
 
 23d . — Was permitted to chew some 
 animal food on the right side of the 
 mouth. 
 
 28 th, Mid-day.— Suppuration was ob- 
 served in the course of the cicatrix of the 
 upper wound. Upon opening the part 
 with a lancet, the noose of one of the li- 
 gatures came away which had been left 
 in the wound, the thread having been 
 taken off before close to the knot.* 
 
 May 6. — Left the city this day, com- 
 pletely recovered, for her residence on 
 Long- Island. 
 
 The last case, though not by any 
 means the least, 1 have now to commu- 
 nicate. 
 
 Prince, a coloured lad, aged 18 years, 
 was sent to Dr. Mott, from Middletown 
 Point, Now-Jersey, having an osteo-sar- 
 comatous tumour, embracing the lower 
 jaw-bone from the articulation of the 
 right side, as far round as the alveolar 
 socket, supporting the first molar tooth 
 on the left, presenting in size an appear- 
 ance equal to that of his head. 
 
 In giving his history, he stated that, at 
 the age of twelve, an enlargement of the 
 bone showed itself at the right side, op- 
 posite the situation of the second molar 
 tooth, which was at first considered a 
 gum-bile, but, gradually increasing, dis- 
 Jodged, one after another, the teeth in its 
 neighbourhood. 
 
 When it had arrived to the size of a 
 walnut, a lancet was put into it, but no 
 pus or fluid issued In 1818, (then as 
 large as a goose’s egg) it was again open- 
 ed, and a small quantity of blood and 
 matter w r as discharged. Lately, two or 
 three small openings had taken place 
 within the mouth, attended with a dis- 
 charge of pus and ichor, at which places 
 also were denuded several bony spiculse, 
 clearly characterizing the disease. Ex- 
 ternally, and near the most depending 
 part, an ulceration of the skin had shown 
 itself, from which the tumour afforded 
 a daily discharge of an ounce or two of 
 matter ; and this had been kept up for 
 the several last weeks. By this opening, 
 a probe could be passed tor some dis- 
 
 * The reader may apply this fact to what has been 
 said in ihe Appendix of s'ol 1 upon leaving ligatures 
 under the shin for absorption, after amputation. 
 
 tance into the substance of the enlarge- 
 ment. 
 
 From the great emanation which was 
 
 f iresent in this lad’s case, there could be 
 ittle hope entertained from the formida- 
 ble operation which would be required to 
 relieve him from such a mass of disease. 
 Still, as he was about to perish, and being 
 on his own part very desirous to take 
 what little chance the means might pro- 
 mise, it was thought right to operate. 
 
 Having assisted Dr. Mott in this opera- 
 tion also, 1 had opportunity to observe 
 the different steps of the performance. 
 
 May 15 th, 1822. — At noon this day the 
 doctor commenced by tying the right ca- 
 rotid artery, a little above the clavicle. 
 This the patient bore well, being little 
 exhausted ; and after resting and refresh- 
 ing himself with a little wine, he express- 
 ed his wish that the operation might be 
 continued. 
 
 An incison was now ? begun opposite the 
 jugum temporale , carried in a semicircu- 
 lar course over the most prominent part 
 of the swelling, and terminated opposite 
 the first molar tooth of the left side. 
 Another cut of the same form, but of less 
 extent, below this, left insulated a large 
 piece of integument, in which was situated 
 the ulceration. The flaps being then dis- 
 sected from the tumour, the second 
 bicuspis tooth of the left side was extract- 
 ed, and the bone sawed through at this 
 sound part, by the same instrument which 
 had been devised for the other cases. 
 Now raising with an elevator, and then 
 by the thumb and finger, the bone, where 
 sawn through, the diseased mass was 
 cautiously di-sected from the tongue, 
 palate, and pharynx, until the joint upon 
 the right side was exposed. The capsu- 
 lar ligament was then cut into, at the in- 
 ner side of the joint ; after which, the 
 bone was easily removed from its articu- 
 lation. In the course of this operation, 
 very little blood was lost, it being neces- 
 sary only to apply four ligatures. 
 
 The patient was much exhausted, as 
 the operation, from the great extent «ff 
 the disease, necessarily occupied a con- 
 siderable time ; and this was also favoured 
 by his previous state of debility. 
 
 After he recruited a little, the flaps of 
 the parts were brought together by seve- 
 ral interrupted sutures, and upon apply- 
 ing adhesive straps with the double-head- 
 ed roller, he was sent to bed. 
 
 This tumour weighed twenty ounces. 
 3 P. M. — Has continued to recover 
 gradually from the shock of the opera- 
 tion. 
 
 5 o’clock.— Had a sleep of half an 
 hour; awakened relieved; pulse regu- 
 lar and distinct. 
 
 8 o'clock.— Pulse 140, rind regular; 
 skin cool and moist ; .signified by a nod 
 
APPENDIX 
 
 703* 
 
 that he was more comfortable than he 
 expected to be ; had spoken pretty dis- 
 tinctly for several things, contrary to par- 
 ticular orders ; swallowed some water 
 from the spout of a teapot, but taken with 
 much difficulty. 
 
 16/Ji, 10 A. M.— Has slept quietly for 
 the most of the night, and only took a 
 little cold water once; skin of natural 
 temperature; pulse 120, and stronger 
 than last evening ; nodded that he felt 
 comfortable; was ordered a little cold 
 water occasionally, but to take it as sel- 
 dom as possible. 
 
 10 P. M. — Pulse 124, and fuller; skin 
 pleasantly warm; articulated that he 
 felt refreshed from sleep ; swallows well, 
 the fluid being conveyed into the poste- 
 rior fauces by means of an elastic tube 
 and bottle. Contrary to orders, rose from 
 his bed to have an evacuation from his 
 bowels, and pass urine ; all which he ac- 
 complished without difficulty. 
 
 \7th, 10 A. M. — Had a good night. 
 Pulse 120 ; skin natural ; swallows with 
 more difficulty ; and some of the liquid 
 passes through the wound. Bandage 
 was removed, and all the dressings ad- 
 justed anew ; slight cough. 
 
 9 P. M. — Said he was as comfortable 
 as in the morning. Pulse 124. Has slept 
 considerably during the day 7 , and ex- 
 pressed himself as much strengthened by 
 it. 
 
 18 th, 10 A. M. — Passed a good night ; 
 is quite as well as yesterday ; swallowed 
 better; pulse 130. 
 
 10 P. M. — Was not so well as in the 
 morning. Pulse from 13:) to 140. 
 Coughed more frequently, with hurried 
 respiration ; was restless, and felt faint 
 at times ; in the course of the afternoon , 
 during a very heavy lightning-storm , he 
 suddenly fainted, and appeared threaten- 
 ed with immediate dissolution : but after 
 a short interval, revived by the use of 
 volatiles and fanning ; said he felt consi- 
 derable pain in his left side, which pre- 
 vented him from taking a full inspiration ; 
 he described every breath as painful to 
 him, which was also evinced by the dis- 
 tress of his countenance; w;is ordered a 
 blister immediately to his side. 
 
 VHh, 10 A M — Relieved by the blis- 
 ter; slept considerably during the night; 
 had fainted once during the night. Dress- 
 ed the wound ; more than two-thirds of 
 it had united by adhesion. Breathing 
 better. Pulse from 132 to 140. Cough 
 less troublesome ; swallowed some cho 
 colate. 
 
 In the course of this day, however, his 
 breathing became more troublesome, 
 with great anxiety and restlessness ; and 
 4 o’clock in the afternoon, after two 
 or three faint turns, he expired. 
 
 Anxious to be satisfied of the cause of 
 his sudden death? 1 examined the body. 
 
 1 found the wounds, the result of the 
 operation, healthy, and united by adhe- 
 sion throughout the most of their course. 
 
 Upon raising the sternum, I found in 
 the anterior mediastinum a massy depo- 
 sit of coagulahle lymph, seemingly of 
 recent exudation ; this was of a yellowish 
 hue, having the exact appearance of pus, 
 but wanting fluidity. In the cavity 
 of the pericardium was contained a pint 
 of yeliow serum ; and each lung exhibited 
 marks of high inflammation ; the surface 
 of both lungs w as of a florid, arid in some 
 places a deep purple hue. There was, 
 however, in no place any adhesion be- 
 tween the lung and the side of the chest. 
 
 The conclusion I have, drawn from this 
 examination, coupled w ith my acquaint- 
 ance with the more particular circum- 
 stances of this man’s case is, that his 
 death was to be attributed to inflamma- 
 tion of both lungs, caused hy lightning. 
 
 As I am informed these cases are yet 
 to appear before the public in a more de- 
 tailed state, I shall content myself with 
 this one remark : — 1 believe an important 
 practical fact has been confirmed by these 
 operations ; namely, that the tying of the 
 common carotid previously to any other 
 part of the operation in these individual 
 cases, did prevent hemorrhages during 
 the performance, which would have so 
 interrupted the surgeon that he might 
 have been unable to proceed. But more- 
 over, that tying these arteries low dow r n in , 
 the neck before the other part of the ope- 
 ration, and not their branches, as they 
 might have been from time to time cut 
 in the course of the operation, did prevent 
 an excess of inflammation during the 
 cure; which, as can be imagined, might 
 have extended to the brain and its mem- 
 branes, and been the cause of death. 
 At all events, might have protracted the 
 cure, by effecting a long-continued puru - 
 lent discharge, w ith emaciation, and much 
 loss of strength to the patients. 
 
 Aboutthree weeks after Prince’s death, 
 an old gentleman came from Westches- 
 ter, with a similar disease of the right 
 side of the jaw, of considerable extent ; 
 but as he w as of an irritable constitution, 
 bad habit, and upwards of sixty years of 
 age, he was advised to go home, and not 
 think of an operation. 
 
 I have been (yesterday, December 11,) 
 shown another case b} Dr. Mott, in a fine- 
 looking boy of about nine years of age, 
 from the neighbourhood of Corlaer’s 
 Hook, on whom it is purposed to operate 
 in the course of the week. The disease 
 is of three years’ growth, and extends 
 from the angle at the left side of the jaw 
 to the chin. 
 
 it is probable, that had it not been for 
 the successful issue ot Catharine Buck- 
 lew’s case, vve should never have heard 
 of the remaining four ; proving that osteo- 
 
APPENDIX 
 
 %M 
 
 sarcoma in that situation, is not a novel 
 disease ; nor so rare as may have been 
 hitherto supposed. 
 
 PESSARY. I have lately had pre- 
 sented me, by Dr. Barker of this city, a 
 newly-constructed pessary for prolapsus 
 uteri; for which he has just now ob- 
 tained a patent. 
 
 That there was room for improvement 
 in these instruments, no practitioner, to 
 whose lot it has fallen to direct ihe ap- 
 plication of those hitherto in use, can 
 deny; and it will be admitted, that the 
 common boxwood pessary, to say the 
 least against it, is calculated to excite and 
 keep up a debilitating discharge from the 
 vagina. 
 
 Dr. Barker s instrument is a pyriform 
 gum-elastic bag: h ving connected with 
 its neck a valvular m* < lamsm of ivory, 
 for retaining such r- as might be intro- 
 duced to fill it, alter it had been passed 
 up the vagina. The pressure induced 
 by such an instrument must be one as 
 will most effectually answer the com- 
 manding indication ; and can never be 
 unpleasant or injurious to the patient. 
 
 There is attached to it a contrivance, 
 by which the patient herself can fill it 
 with air, and by which also she may 
 empty it when it may be her wish to 
 have it withdrawn. That this part of it, 
 however, may not be improved upon, 1 
 am not so well convinced ; but, as re- 
 gards the. instrument itself, it is undoubt- 
 edly the best, under the name of pessary, 
 that has yei been submitted to the pub- 
 lic ; proved by the assurances of the nu- 
 merous patients w r ho have already put it 
 to test. 
 
 PROSTATE GLAND. Whatlhave 
 to say upon this article, is, that 1 have 
 never seen any thing like a third lobe, as 
 described by Sir Everard Home to this 
 gland in its healthy state: yet 1 have 
 seen something like it behind the veru- 
 montanum, while the prostate was gene- 
 rally enlarged, although not tumefied in 
 any other particular situation. And I will 
 venture this explanation for the occur- 
 rence. 
 
 The prostate gland is surrounded by a 
 tunic, derived from the posterior surface 
 of the triangular ligament, and which, 
 after strengthening the urethra at the 
 membranous part, passes on to this gland, 
 affording a covering equally dense with 
 the tunica albuginea of the testis. But 
 the prostate is not lined with any thing 
 like this where it is pierced by the ure- 
 thra : yet the verumontanum gives 
 
 firmness to the anterior part of that 
 roove. As (he effect of a general in- 
 animation of this gland, its whole sub- 
 stance will at first become gradually en- 
 larged, and then, if the disease continues, 
 a special tumefaction or elevation will 
 show itself, projecting towards the cavity 
 
 of the bladder behind the verurnontanua^ 
 or in other words, at that part of the 
 prostate tvhich is tvanting support from 
 the dense tunic just spoken of. And 
 when inflammation exists in that part of 
 the gland exclusively, this peculiar eleva- 
 tion, or third lobe , may show itself without 
 any general enlargement of the prostate 
 gland, 
 
 TIC DOULOUREUX. Upon the 
 operation lor this disease I have had fre- 
 quent conversations with my friend Pro- 
 fessor Mott, who, as far as 1 can learn, 
 has had more to do with it than any me- 
 dical man in the country. He informed 
 me that he had operated for neuralgia 
 about fifty different times, with varied 
 success ; and has among other facts ob- 
 served, that in cases wherein he had 
 operated more than once, the interval of 
 relief became less, in proportion as the 
 operation had been often performed. 
 
 The inaugural dissertation of the late 
 J. W. B. Murray, M D., which contains 
 a summary of Dr. Mott’s experience up 
 to 1816, the time of its publication, hav- 
 ing fallen into my hands, 1 shall copy as 
 much of it, as has reference to the opera- 
 tion for tic douloureux. 
 
 “The most strenuous advocate for the 
 operation, in this country, is Professor 
 Mott. His success has been so unequi- 
 vocal, and his opportunities of witnessing 
 the disease so comparatively numerous, 
 that his unqualified opinion in all cases of 
 Neuralgia, is ‘divide the nerve f then, if 
 necessary, employ the other remedies to 
 destroy or diminish the susceptibility to 
 return, which will be accomplished most 
 certainly by hemlock and other narco- 
 tics. Dr. Mott has operated on five pa- 
 tients. He has divided different nerves 
 on Dr. Jones’s face eleven times, but the 
 disease seems so rooted in the old gen- 
 tleman’s constitution, as to require fre- 
 quent repetition of the operation. He 
 has become so accustomed to it, that 
 whenever the inveterate tormentor deve- 
 lopes itself, he sends for his surgeon with- 
 out delay, knowing that from his hands 
 he shall receive relief. Mr. George G. 
 Graham, practitioner in Orange County, 
 while a student of medicine, divided the 
 infra orbitar nerve with success; and Dr 
 Post, associated with Dr. Mott, operated 
 lately on a gentleman, whose left cheek 
 was diseased, and he instantly arrested 
 the spasms. 
 
 The d< gree of certainty promised by 
 the operation, as resulting from the phy- 
 siology of nervous reunion, becomes an 
 interesting question. Dr. Haighton’s 
 masterly and conclusive experiments on 
 the reunion of divided nerves, have com- 
 pletely established that point: and it is a 
 settled dogma in physiology, that by the 
 growth of Iresh matter, or by the ap- 
 proximation of the divided ends, the 
 
APPENDIX 
 
 functions of a nerve are restored. Mr. 
 Abernethy, however, arguing from the 
 renewed sensibility and mobility of the 
 ring finger, on which he operated, thought 
 that the anastomosing branches had be- 
 come enlarged, and, officiating in lieu of 
 the original trunk, rendered a complete 
 cure impracticable. Had that learned 
 surgeon removed a portion of the trunk 
 of the ulnar nerve, and then been baf- 
 fled in his anticipated cure, his apprehen- 
 sion would be well founded. There is 
 some difference between the effects of a 
 divided trunk and of its branches. Ner- 
 vous influence can readily be reeommu- 
 nicated by the preservation of the for- 
 mer, should the latter be effectually ope- 
 rated upon. Moreover, as the nerve of 
 the opposite side of the finger was deri- 
 ved from the radial nerve, the difficulty 
 of solving the mystery is diminished. 
 
 In opposition to the utility of operating, 
 the uncertainty of immediate relief from 
 a division of the nerve has been particu- 
 larly urged. For, say they, the reunion 
 5s so speedy and so certain, that nature 
 will commence her countervailing pro- 
 cess before the desired object is com- 
 pletely attained; thus tantalizing the pa- 
 tient still more, and adding unnecessa- 
 rily to his sufferings. The author of a 
 thesis* supported before the Faculty of 
 Medicine of Paris, expresses his doubts 
 of the success of the operation ; he pre- 
 tends that it was repeated five times on 
 one patient, and asserts that he finally 
 owed his cure to the warm baths of Plom- 
 bieres. 
 
 In the same dissertation are the histo- 
 ries of two other patients, on whom a 
 Parisian surgeon practised without suc- 
 cess the division, and afterward the cau- 
 tery on the supra and infra-orbitar nerves, 
 the malar branches of the portio dura, 
 and the mental nerve. f The preceding 
 remarks on the success of the operation 
 are a full reply to such objections. 
 
 Wherever a considerable portion of the 
 nerve can be abstracted, a greater dura- 
 tion will assuredly be given to the cure. 
 This cannot be attempted on many of 
 the nerves of the face ; because the ra- 
 mification is so immediate and extensive, 
 as to preclude a successful endeavour to 
 remove much of the frontal, infra-orbital, 
 or mental nerves. The branches of the 
 pes anserinus are intimately connected 
 with the parotid gland and duct ; also by 
 some very beautiful and extraordinary 
 anastomoses with the other facial nerves, 
 so that a similar hinderance occurs here. 
 The only nerve about the head which 
 affords the slightest chance for effectual 
 and final division is the portio dura, in 
 
 * Utrura in pcrtinacibus capitis et faciei doloribus 
 aliquld prodesse possit, sectio ramorum nervi quinti 
 paris ? proponebat Veillart, 1763 , conclusio negative. 
 t Richerand Nosorraotue Obirumcale, T. II. P- 201* 
 Vol. II. ' ' *0 
 
 iOo 
 
 its passage between file stylo-mastoid 
 hole, and the angle of the lower jaw. 
 When the disease is in any other part of 
 the system, if half an inch of the princi- 
 pal trunk supplying the affected spot 
 could be removed, there would be little 
 dread of its return. A repetition of in- 
 cisions through a nerve, by insulating se- 
 veral portions, would be another means 
 of protracting a renewal of the disease ; 
 and in the sub-orbitar nerve, this has 
 been done by Dr. Mott, when operating 
 on Dr. Jones.J This improvement, I be- 
 lieve, is attributable to Dr. Mott, and its 
 application must be productive of dec!-* 
 ded and happy consequences. 
 
 It is a curious circumstance connected 
 with the operation, that although the 
 nerve shall be completely divided, from 
 some cause, the chain of morbid actions 
 will not be interrupted for several, per - 
 haps twelve or fourteen, days. This has 
 induced some to pronounce hastily, that 
 the operation has failed. Any attempt 
 satisfactorily to explain this occurrence, 
 
 1 think would be fruitless. 
 
 Operation on the infra-orbitar nerve.— 
 The participation of this nerve in neural- 
 gia, may be detected by the course of 
 the pain up the side of the nose, some - 
 times following an arched direction be- 
 tween the eyebrow and upper lid, or in 
 either the brow or lid, and extending 
 along the zygomatick arch : or it may be 
 confined to the muscles passing between 
 the os mala? and the angle of the mouth, 
 involving the buccinator and masseter. 
 Pressure may be applied to the infra-oi- 
 hitar foramen, during which the pain will 
 be arrested, provided the disease depends 
 on that nerve. A tremulous motion of 
 the upper lip on one side, most commonly 
 attends this variety of neuralgia. 
 
 To Dr. Haighton we, are indebted for 
 an excellent view of this nerve, and a. 
 delineation of the point for division. 
 
 “ He measured the space between the 
 inferior edge of the orbit and the superior 
 edge of the foramen in thirty skulls, and 
 found the distance in sixteen skulls 1-4 
 of an inch, which he considers the me- 
 dium distance from the upper part of the 
 foramen ; and if we allow 1-3 of an incii 
 for the breadth of the foramen, and 1-ff 
 below its inferior part, half an inch from 
 the lower edge of the orbit will be a pro- 
 per place for performing the operation. 
 Having endeavoured to establish a rule 
 for determining its distance from the 
 orbit, it may be proper to ascertain its 
 situation with respect to a line drawn 
 from the inferior part of the internal an- 
 gular process of the os frontis , obliquely' 
 across the orbit, to the centre of the os 
 males. The measurement of this line i« 
 tnirty skulls, did not vary more than 1-a 
 
 X Medical Repos fOry. (». series } Vol. TT. Nrfc " 
 
7 U.o 
 
 APPENDIX* 
 
 of an inch, anil it was found that a line 
 drawn downward perpendicular to this 
 oblique line, at the distance of 7-3 of an 
 inch from the internal angle of the eye, 
 passed across the orifice of the sub-orbi- 
 tar foramen.’’ 
 
 This point being settled, Dr. Haighton’s 
 direction, for operating, is “ to make an 
 incision of 3-4 of an inch in length, car- 
 ried obliquely downwards, (on account 
 of the oblique course which many of 
 these nerves take, in their passage from 
 the foramen to the ala nasi,) the centre 
 of which must correspond with the fora- 
 men, only 1-4 of an inch below it. The 
 incision must be made down to the bone, 
 otherwise we cannot be certain of divi- 
 ding the nerves, as they are situated very 
 deep.” 
 
 The deformity produced by a large 
 cicatrix, in this method of operating, ex- 
 poses it to objection. Professors Post 
 and Mott have employed the following 
 mode with the happiest success, and per- 
 fect facility. 
 
 The only instrument required is a 
 sharp-pointed bistoury, or phymosis 
 knife, either in a stiff handle, or well 
 secured. 
 
 Having ascertained the situation of the 
 infra-orhitary foramen, by Dr. Haighton’s 
 rule, and also by the depression which 
 can be distinguished in most subjects, let 
 the nose be held aside by the assistant 
 who secures the patient’s head. Intro- 
 duce the bistoury about midway between 
 the nose and the nasal, margin of the 
 foramen ; carry it down to the bone, and 
 pass the point close to the hone, in order 
 to get it under the nerve. The point 
 must then he elevated a little, though it 
 must not pass through the skin from be- 
 neath ; by a littie rubbing motion with 
 one finger upon the point of the knife, at 
 the same time cutting gently with the 
 knife, the nerve will he divided. 
 
 As a considerable branch of the inter- 
 nal maxillary artery accompanies the in- 
 fra-orbital nerve, its division will be shown 
 by a copious arterial hemorrhage ; and a 
 peculiar acute pain accompanies the sec- 
 tion of the nerve, in addition to the dif- 
 ference, perceptible to the operator, be- 
 tween cutting a nerve, .and any other soft 
 solid. The upper lip must now he exa- 
 mined by touch. If the patient acknow- 
 ledge a destruction of sensibility, the sur- 
 geon may withdraw his bistoury ; other- 
 wise, the cutting must be repeated, until 
 from numbness, he is satisfied that the 
 nerve is divided. By asking the question 
 previously to withdrawing the knife, the 
 patient has no reason to conceive that 
 any disappointment attended the first at- 
 tempt, and the repetition of incisions he 
 may suppose to belong regularly to the 
 operation. 
 
 Being certain that the nerve is tho- 
 
 roughly divided at the first point of sec- 
 tion, make two or three incisions through 
 it lower down ; and thus endeavour, as 
 Dr. Jones expresses it, to “insulate a 
 portion of it, (included as it were in a pa- 
 renthesis,) with respect to the common 
 sensorium.” Since the in fra- or bitary 
 nerve as it leaves the foramen expands 
 immediately like a fan, and distributes its 
 branches to the surrounding parts, the 
 incisions last mentioned may be exten- 
 sive, retaining the knife still underneath 
 the skin. The knife is then to be with- 
 drawn through the first opening, and the 
 lips of this diminutive external wound 
 can be drawn together, and secured by 
 adhesive plaster. 
 
 The only obstacle to a free section to 
 wards the nose, is the facial vein, Which, 
 beginning at the inner angle of the eye, 
 holds a diagonal course towards the angle 
 of the jaw. A wound of this, however, 
 will not be attended with any serious con- 
 sequences: it will only add to the ecchy- 
 mosis already arising from the artery, 
 and can be compressed by a slight force 
 applied to the spot. The suffusion of 
 blood will be removed by absorption in a 
 few days, and its removal may be aided 
 by any moderately stimulating lotion. 
 
 The great advantage of this method 
 over Dr. Haighton’s, will be apparent 
 from the impossibility of any large cica 
 trix being the consequence. 
 
 Operation on the Frontal nerve . — This 
 final distribution of a highly useful and 
 important branch of the trigemini, after 
 it has entered the orbit through the fora 
 men lacerum, appears to cling to the roof 
 of the orbit, passing between the bone and 
 the periosteum,* of course above the le 
 vator muscle of the upper eyelid. It 
 leaves the oi bit through the supra-orbitav 
 foramen, w hich in many skulls is only a 
 notch, closed below by a ligament. The 
 situation of this hole or notch may be 
 ascertained, w ith tolerable precision, by 
 finding the sub-orbitar foramen ; as it is 
 about 1-4 of an inch within a perpendi- 
 cular line drawn from the latter, and con- 
 tinued up the forehead. 
 
 Pass a bistoury or knife about S-4 of 
 an inch within the orbit, immediately 
 beneath the superciliary ridge of the os 
 frontis, and divide the her\e outwardly. 
 A numbness must be felt on the forehead 
 and eyebrow, and down the nose, before 
 the knife is withdrawn. The connexion 
 between the nerve and the bone is suffi- 
 cient to impress the necessity of keeping 
 the point of t he bistoury as close as pos- 
 sible to the bone, and the dense perioste- 
 um affords additional resistance w hile di 
 viding the nerve. The ophthalmic artery 
 will bleed profusely for a few minutes. 
 
 Meckel. Traclatua AnaUnnico-pliysiologicu? dr 
 quin to pare nervorum cerebri- See. j'nkK. 
 
appendix 
 
 and when its flow outwardly is repress- 
 ed, it will produce so much ecchymosis 
 as to blacken the eye to a considerable 
 extent. 
 
 Operation on the Menial nei've . — The 
 foramen through which emerges the in- 
 ferior-maxillary branch of the fifth pair, 
 is situated generally about midway be- 
 tween the alveolar processes of the jaw 
 and its base, in a line between the cuspi- 
 dal us and anterior bicuspid teeth. The 
 nerve rnay be divided by turning down 
 the lip, and introducing the bistoury 
 about the first bicuspid tooth, with the 
 back towards the angle of the jaw. K« ep 
 the knife close to the bone, and by fol- 
 lowing the excavation of the jaw, the 
 nerve will he divided by a cutting mo- 
 tion rather from the hone. 
 
 In the aged edentulous subject, from 
 the absorption of the alveolar processes, 
 no reference can he made to the teeth, 
 in finding the mental foramen. It is 
 situated generally in the same line with 
 the supra orbitary hole, and consequently 
 can easily be discovered. 
 
 Operation on the Portio Dura. — A 
 mere description of the complicated and 
 extensive distribution of this nerve, will 
 be sufficient to justify a doubt of any 
 operation being so devoid of danger, or 
 troublesome consequences, as to author- 
 ize its performance. 
 
 When neuralgic sensations are traced 
 from just above the angle of the jaw, in 
 transverse lines across the face, upwards 
 through the temples, downwards along 
 the base to the symphysis of the chin 
 backwards behind the ear ; exciting es- 
 pecially a profuse discharge of saliva," 
 and frequently, from their severity, ab- 
 sorbing all perception of distinct linear 
 direction, but communicating the idea of 
 the whole cheek being in a paroxysm of 
 neuralgia, a surgeon may pronounce the 
 portio dura tu he the affected nerve. 
 
 A brief display of the organs contained 
 in the side of the face, seems necessary 
 for the purpose of conveying a distinct 
 view of the embarrassment and difficulty 
 attending any projected operation on the 
 portio dura. 
 
 The parotid gland, whose agency in 
 furnishing saliva is superior to any other 
 destined for that use, occupies the w hole 
 space from the mastoid process of the 
 temporal bone, penetrating to the ‘‘very 
 root of the external auditory sinus, almost 
 to the internal carotid artery and jugular 
 vein ;”f it is sunk behind the lower jaw, 
 and adheres to the pterygoideus internus 
 muscle, while it reaches forwardly, by 
 
 * I have not noticed this in any description of Neu- 
 ralgia 5 but a moment’s reflection, I think, will show, 
 that a diseased nerve passing through the parotid 
 gland, imbedded in its substance, must affect the flow 
 of saliva from that gland. 
 
 t Surgical Anatomy of the ITead and Nock, by Mr. 
 Mian Tlurns of Glasgow. 
 
 means of the socia parolidis, nearly to the 
 anterior edge of the masseter muscle, and 
 upwards to the zygoma. The ducts from 
 its numerous lobuli unite, and are conti- 
 nued in one trunk to the buccinator mus- 
 cle, which it perforates nearly opposite 
 the second or third dens molaris. “ Its 
 course will generally he defined, by a line- 
 extended from the junction of the lobe of 
 the ear and figured portion, to midway 
 between the root of the nose, and the 
 angle of the mouth.” 
 
 The arteria transversalis faciei “is 
 generally placed midway between the 
 parotid duct and the zygoma. At this 
 part it lies between the socia parolidis 
 and the masseur muscle.” 
 
 “The portio dura, when passingdrom 
 the foramen stylo-mastoideum, lies be 
 hind the parotid gland ; but it immedi- 
 ately dips into its substance. It conti- 
 nues a single and undivided trunk, for 
 about half an inch of its course. This 
 part of the nerve runs in a slanting di- 
 rection, downward and forward, imbed- 
 ded in the gland. Where the portio 
 dura is escaping from the skull, it is deep- 
 seated, and nearly in contact with tne 
 arteria posterior auris, and where that 
 artery and the occipital arise by a com- 
 mon trunk, the latter vessel is quite in 
 the vicinity of the portio dura. By the 
 styloid process,” (which is the bar- 
 rier between the external and internal 
 carotids,) “the nerve is separated from 
 the internal carotid artery, and jugular 
 vein. About midway between the 
 ascending plate of the jaw-hone and the 
 mastoid process, the portio dura is nearly 
 opposite to the posterior facial vein, and 
 the external carotid artery. 
 
 “ It is at this point, at a place where 
 the nerve is still deeply covered by the 
 glandular substance, that it divides into 
 its branches, which separately perforate 
 the gland, to reach the cheek, and other 
 parts on which they are to be distributed. 
 The largest of these branches inclines 
 upward and forward, and while still im- 
 bedded in the gland, it subdivides into a 
 numerous set of twigs, which cover as 
 with a net- work, the zygoma and the ar- 
 teria transversalis faciei. The largest of 
 these twigs runs nearly midway between 
 the zygoma and the parotid duct. The 
 other divisions of this nerve ramify over 
 the face, and about the throat. 
 
 ‘‘ The trunk of the nerve can be reach - 
 ed, with safety, only by an incision be- 
 ginning at the very root of the mastoid 
 process, and continued downward and 
 forward, along the anterior margin of the 
 sterno-mastoid muscle. The dissection 
 no doubt will require to be deep; but in 
 performing it the surgeon will not expe- 
 rience much difficulty The lobe of the 
 ear will require to be pulled upward, and 
 held forward, while prosecuting this dis- 
 
APPEiNDIK- 
 
 ':ob 
 
 section, In performing the dissection, 
 'he nei*vu3 superficialis colli will necessa- 
 rily be divided, where entering the lower 
 angle of the parotid. Tlfe glandular 
 substance itself will be injured, and the 
 arteria posterior auris w ill be cut across.”* 
 
 In this manner, Mr. Burns has been in 
 the habit of removing half an inch of the 
 nerve on the dead subject ; and Professor 
 Mott, since the inestimable Surgical 
 Anatomy of the Head and Neck made its 
 appearance, has exhibited to his class of 
 surgery the mode of performing the ope- 
 ration. It has never been attempted in 
 this complete and radical manner on the 
 living subject ; although many incisions 
 have been made in the cheek, for the 
 purpose of dividing the branches of the 
 pes anserinus: The outline that has been 
 given of the anatomy of the face, exhibits 
 the difficulty attending that procedure, 
 and the infallible consequence must be 
 troublesome, perhaps perpetual, salivary 
 fistulas. 
 
 Should it be necessary, however, to 
 divide any of the facial branches of the 
 portio dura, it has been suggested by 
 Dr. Mott, that it might by effected by in- 
 troducing a bistoury, as in the other ope- 
 rations, and making the incisions in vari- 
 ous directions beneath the skin. The 
 prospect of an unpleasant result will be 
 thus considerably diminished, and the 
 fistula would probably admit of a more 
 rapid cure. 
 
 A few observations on the propriety of 
 employing caustic applications, will close 
 the subject. If the object, be to destroy 
 every prospect of a recurrence of neural- 
 gia, and if the patient will consent to an 
 experiment, which, if successful, must 
 effectually annihilate the nerve, the pre- 
 cedents afforded by the French surgeons 
 will authorize the attempt. It has been 
 objected, that the proximity of some of 
 • he nerves to the bone must necessarily 
 involve exfoliation. This consequence 
 depends, very probably, on the manage- 
 ment of the caustic, which should not be 
 left so long in contact with the bone as 
 to endanger its continuity. 
 
 After the nerve has been divided by 
 the operation, it may answer a good pur- 
 pose to interpose caustic between the 
 extremities of the nerve, and thus com- 
 bine both expedients. The tediousness 
 of reaching the nerve from the surface by 
 caustic, besides the torture it would in- 
 dict, possibly producing tetanus, seem to 
 interdict any proceeding different from 
 that proposed Dr. Jones declined the 
 use of caustic, from dread of tetanus, nor 
 was his fear without foundation. VVe 
 should, however, repose some confidence 
 in the practice of the French, and admit 
 this method of destroying a nerve to an 
 
 equal rank with the knife, in those eases 
 where its employment is feasible, and 
 unattended with danger to the bone. 
 
 Following this is a letter by the Pro- 
 fessor to Dr. Murray, from which some 
 additional information can be collected. 
 
 Esteemed Pupil , — Since a doubt has 
 been expressed by some, as to the even- 
 tual result of the operation of dividing 
 the nerve in Neuralgia, allow me to avail 
 myself of this opportunity, to state the 
 success which has attended it in my 
 practice. 
 
 In a confirmed case of neuralgia, in a 
 lady about 60 years old, in 1810, i divi- 
 ded the infra orbital nerve on the, right 
 side; the relief was instantaneous. Be- 
 fore the knife w r as withdrawn, she ex- 
 claimed, “ I am relieved, I can nov/ 
 speak, blow my nose, and swallow,’ 
 which had been almost impossible for 
 some days, owing to the unspeakable 
 agorijr of the disease. There were slight 
 neuralgic symptoms for about ten days, 
 then she became perfectly free from the 
 slightest trace of it, and has never since 
 had a return severe enough to induce her 
 to resort to the operation, the pain of 
 which she by no means dreads : for all 
 attest that a single paroxysm far sur- 
 passes the smart from the incision. For 
 about four months she was entirely free 
 from the disease. 
 
 A gentleman, aged about fifty, having 
 had neuralgia for four years, applied to 
 me, in the beginning of the year'1811, 
 for surgical relief. Palliative means 
 having failed, and the disease increasing 
 in violence, I recommended the opera- 
 tion as the best and only remaining re- 
 source. 1 divided the infra-orbital nerve 
 of his right cheek. The paroxysms con - 
 tinued for a day or two as frequent and 
 violent as before the operation : but in a 
 week it entirely left him. In about four 
 months, the pain began to return, and 
 increased in violence from time to time, 
 but did not equal its former severity 
 till about six months since, when it be- 
 came more severe than ever. About 
 three months ago I repeated the opera- 
 tion on the same nerve; the pain went 
 off gradually in about a week, and he 
 says the last operation is by far the most 
 successful. 
 
 In 1811 , I divided the right infra-orbi- 
 tary nerve for a lady, who had been 
 labouring under severe neuralgia for two 
 or three years. She experienced no 
 immediate relief ; on the contrary, the 
 paroxysms appeared to be increased in 
 frequency, and aggravated in violence, 
 for several days: they then began to de- 
 cline, and had entirely left, hei about the 
 twelfth day. I believe the disease has 
 never returned . 
 
 * Surgical Atfatonv’ of tine H®nrt amt Norti- 
 
APPENDIX. 
 
 309 
 
 On that highly respectable physician, 
 and victim to neuralgia, Dr. Jones, of this 
 city, I have operated about eleven times, 
 and in every instance with the most per- 
 fect success. 
 
 After having been afflicted with this 
 horrible disease for seven or eight years, 
 apd having exhausted all the resources of 
 the Materia Medica to no purpose, the 
 doctor at last yielded to my frequent and 
 earnest importunities, and allowed me to 
 divide the right infra-orbital nerve, at the 
 advanced age of sixty-seven years. His 
 pains were increased for several days, 
 but about the twelfth they abated gradu- 
 ally, and in a few days completely left 
 him. He continued for four or five months 
 free from pain ; but after exposure to 
 cold, he felt now' and then alarming 
 touches of the disease, which at length 
 became very violent. Every subsequent 
 operation on the infra-orbital and mental 
 nerves, has been followed with complete 
 relief ; but the intervals have been mostly 
 shorter than the first; they do not, how- 
 ever, gradually shorten ; several of the 
 last operations have varied very little in 
 the interval of ease, it being of from three 
 to four months duration. 
 
 The violence of the paroxysms has se- 
 veral times been augmented for a day or 
 two after the operation, and as the addi- 
 tional irritation of the division of the 
 nerves subsides, the pain gradually dimi- 
 nishes. The disease always leaves him 
 in from seven to twelve days after the 
 operation. From the last division, how- 
 ever, of the infra-orbitary, about three 
 weeks since, he received immediate ease, 
 having scarcely a single pain afterward. 
 
 Last winter, I divided the right infra- 
 orbital nerve for Major B , aged about 
 
 fifty, who had been labouring under a 
 regularly increasing neuralgia for about 
 four years. The operation increased his 
 disease in every respect for several days ; 
 it then abated, and gradually went com- 
 pletely off in about the usual period of 
 twelve days. Four months and more 
 have now’ elapsed, and the disease has 
 not returned. 
 
 About three weeks since, I attended, 
 in conjunction with Dr. Post, a Colonel 
 
 K , aged about sixty, who for five 
 
 years had been afflicted with severe neu- 
 ralgia of the left infra-orbital nerve. Dr. 
 P. divided this nerve, and it was fol- 
 lowed with immediate relief. He expe- 
 rienced little or no pain afterward. 
 
 Hoping that all the miserable victims 
 of neuralgia may be encouraged to resort 
 to a surgical operation, either in the form 
 of a simple or double division ; by a sin- 
 gle external incision, or, where practica- 
 ble, the removal of a portion of the nerves, 
 
 1 am, with sentiments of high regard 
 and esteem, 
 
 VALENTINE MOTT, 
 
 fj mo. (May) 1st 1816. 
 
 TOURNIQUET. Notwithstanding 
 all the encomium justly paid to the screw 
 tourniquet of M. Petit, that instrument 
 seems superseded by one of American 
 invention. I could never bring myself to 
 believe, that a sufficient pressure could 
 be obtained against the artery by the pad 
 of that instrument, while applied as di- 
 rected in the text ; viz. the tourniquet 
 itself being upon the extremity in an op- 
 posite direction, w ithout pioducing much 
 more general constriction of the limb 
 than was to he desired. On this account, 
 
 1 have been in the habit of dispensing 
 with the ordinar) pad, and substituting 
 a small and firm single headed roller 
 undpr the base of the instrument, and 
 placing the whole over the artery. Whe- 
 ther it was merely ideal or not, 1 will not 
 pretend to answer ; hut certainly patients 
 were much better satisfied by this method 
 of applying the instrument. 
 
 The tourniquet invented by Dr. Moore, 
 of Massachusetts, appears to answ er in a 
 most excellent manner this design. It is 
 made of brass, and intended to be ap- 
 plied over the artery. It has a pad of 
 metal, of an oval convex form, that can 
 be projected from the under part of the 
 instrument by the operation of a male 
 and female screw, which 's morticed in a 
 frame, also of brass, for the purpose of 
 its support, and forgiving it a proper di- 
 rection. There may be a linen compress 
 between this pad and the limb, or the 
 brass pad may be covered by a piece of 
 shamois leather, gathered around it for 
 the time, after the manner that tailors 
 cover buttons. The strap of this instru- 
 ment is intended to buckle on the outside 
 of the limb ; and to prevent the skin from 
 any unpleasant sensation, there is a piece 
 of leather placed under the buckle analo - 
 gous to that for the under part of Petit’s 
 screw tourniquet. 
 
 TRUSS. I am at a loss to divine w ; hy 
 Mr. Cooper has altogether omitted the 
 mention of the truss of Messrs. Salmon,- 
 < >ddy , & Co. of London, w hich does ap 
 pear to me as infinitely sup* rior to any 
 now in use, or likely to be contrived. 
 
 There are tt\o very formidable objec- 
 tions that I think must obtain against all 
 the trusses, with that exception, and they 
 are the follow ing : V hen the pad is firm- 
 ly connected with the steel strap, it is 
 clear, that in the different positions of the 
 body, and constantly during progressive 
 motion, pressure is made alternately by 
 the one edge of the pad. then by the cen- 
 tre, or the other odge ; and in proportion 
 as the truss has been at first well applied, 
 that is, with the more convex part of 
 the pad against the ring, so the same 
 centre of the pad n ay be the cause of 
 strangulation of a portion of intestine or 
 omentum, that should have been pei mil- 
 ted to peep through the opening in the 
 abdominal pnrietes.at a time when prer 
 
APPENDIX. 
 
 •<io 
 
 sure was made by the edge of the truss. 
 In this way I would explain the evils at- 
 tributed to trusses. The truss I speak 
 of provides against this accident, by ha- 
 ving a hall and socket joint between the 
 pad and steel strap, by which contrivance 
 no other part of the pad can at any time 
 make pressure but the very centre ; and 
 which, if in the first instance properly ap- 
 plied to the ring, must continue to make 
 a fair and an equable pressure. 
 
 The other objection applicable to 
 trusses in general, is derived from the cir- 
 cumstance of the strap which passes by 
 the. pelvis being in close contact with the 
 body at that part ; so that in progressive 
 motion, when the muscles at the upper 
 part of the thigh and outer part of the 
 pelvis contract, the parts become for a 
 time swollen, so that the pad is neces- 
 sarily drawn from immediately over the 
 ring. The consequence of this is, a pro- 
 trusion of the hernia ; against which the 
 ball and socket joint, I have just alluded 
 to, will not protect. 
 
 The truss, however, I would recom- 
 mend, has a provision by which this 
 occurrence cannot take place. The strap 
 is not in contact with the pelvis, but takes 
 a free course by its side, and can, for 
 convenience sake, be laid against the soft 
 abdominal muscles above the spine of the 
 ilium ; while from having a free motion 
 with the pads by virtue of the ball and 
 
 socket joint, it preserves at the same time 
 a sufficient and most uniform pressure. 
 
 VARICOSE VEINS. From what 1 
 have seen in this country, the practice of 
 Mr. Brodie seems to have been impro- 
 ved upon, by one more in conformity 
 with that of the ancients. 
 
 I have reference to the excision of 
 about an inch of the trunk of the princi- 
 pal superficial vein, which receives the 
 blood from those in the varicose state. 
 Last year, I witnessed this operation at 
 the Philadelphia Hospital, on a man with 
 extensive varices of the superficial veins 
 below the knee. The vein in the ham, 
 or the branch ir> that situation which was 
 to become the saphena, was cut upon 
 with a scalpel, and about an inch of its 
 length extracted. The integuments were 
 brought together by adhesive plaster, 
 and in about three weeks all the varices 
 disappeared. 
 
 I have been in the habit of puncturing 
 these veins with a lancet, in several situa- 
 tions at the same time ; and after they 
 had bled freely, of dressing the limb with 
 a compress and bandage, very systemati- 
 cally applied, moistening the whole three 
 or four times within the first twenty-four 
 hours with the rectified spirits of w ine. 
 By this treatment, the disease was very 
 generally removed, provided it was not 
 dependent upon constitutional circum- 
 stances. 
 
 T' 5 V» OP THR SBCONfc VOT.UMK, 
 
 life LIBRARY OF THE 
 JUL 1 u 1933 
 
 WajVWiSJtV fif IWMMM3. 
 

 
b 
 
 
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