There are few accidents or diseases, to which the human body is liable, which are not preceded or followed by incited action, increased circulation, and accumulation of blood in the capillary vessels of the part affected; and these phenomena require to be very attentively studied, and correctly understood, by all who propose practising the healing art. As all the salutary as well as diseased processes which occur in the human body are more or less attended or affected by this action, and as its regulation forms a principal part of the duty of the surgical practitioner, this work cannot be more properly commenced than by treating of its nature, consequences, and management. Inflammation may be defined to be, an unnatural or perverted action of the capillary blood vessels of an organ or part of the body, attended with redness, throbbing, swelling, pain, heat, and disorder of function, as well as with more or less disturbance of the system. Every part of the body is liable to inflammation; and some writers have divided this action into different kinds, according to the particular tissue which it chiefly involves. But it appears to be always of the same character, though modified by various circumstances, such as the tissue in which it occurs, the state of the constitution, the exciting cause, and the intensity of the action. The usual division of the subject, into Acute and Chronic, is that which it is here proposed to adopt. The term Chronic Inflammation is more properly applicable to a consequence of the Acute: but it is at the same time true, that morbid actions proceed more slowly in some constitutions, and in some parts of the body, than in others; and that changes of structure and morbid products, such as generally result from inflammatory action, even occasionally occur, without the prominent symptoms of inflammation being experienced by the patient or detected by the practitioner. The term Morbid is used in contradistinction to what is called Healthy Inflammation; but inflammatory action is generally connected, more or less, with a diseased or disordered state of some part Redness is the first sign of inflammation to be considered; this is observed, in the living body, on the surface, or at the extremities of those canals which terminate externally. The inflamed conjunctiva affords a conspicuous example of this appearance. In a subject that has suffered from an internal inflammatory attack, a good opportunity is frequently afforded of observing the enlarged and injected state of the vessels on which the red colour depends. But inflammation may have existed to a certain degree, and yet the parts may be pale, from the capillaries having emptied themselves into the veins immediately after the patient’s death. The paleness may be also in part caused by the influx of the red globules being impeded immediately after death, or when the patient is in articulo mortis, in consequence of the contraction of the vessels, which is well known to occur at that period. It has been said that redness is not essential to inflammation; for serous vessels may be altered in size and function by this action, and yet not be sufficiently dilated to receive the red globules of the blood. And, again, that serous vessels may be enlarged so as to admit the red globules; and a part that is colourless when in the healthy state may, in consequence, assume a highly red hue when in an inflamed condition. This may be observed in the cornea lucida, which, when violently inflamed, is pervaded by numerous vessels, visible to the naked eye, distended with red blood, ramifying over the whole of it, and freely inosculating with each other. Some have even supposed that these vessels are newly formed, in consequence of inflammatory action. This opinion is, however, erroneous; as the vessels existed in the cornea previously, and are only increased in size, so as to admit of the accumulation of a sufficient number of red particles to render the vessels visible. The speedy, and, in many cases, instantaneous, appearance of red vessels where they could not previously be observed, decidedly overturns the opinion that new vessels are in such a case formed. New vessels are seldom formed, unless after a breach of structure, or in cases where morbid deposits become vascular. There is no proof of the existence of mere serous vessels in the human body, as any one may ascertain who is accustomed to examine the capillaries with a good microscope. Vessels which are so small as to admit only a very few, say one, or at most two rows of globules, would, of course, appear colourless, and these are what have been called serous vessels. The globules of blood are so small as to be invisible to the naked eye; and vessels carrying only one series of Throbbing, to a greater or less degree, is always felt in an inflamed part by the patient; and it is frequently so distinct as to be readily perceived by an attentive examination. This arises, probably, from the stagnation of blood in the vessels of the part over-excited, and principally affected by the disease or injury, causing an increase in the collateral circulation; and it is this rapidly increased action around that gives rise to the signs and symptoms, and constitutes, in point of fact, what is known and recognised as inflammation. The sensation of throbbing is not, however, produced entirely by the action of the capillary vessels, but in consequence, also, of the larger trunks in the neighbourhood sympathising with these capillaries, and so having their action increased also. The obstruction of the capillaries in the early stage of inflammation must necessarily cause a greater force of the heart to be expended on the trunks leading to such capillaries; hence the greater impulse and velocity of blood in the circumferential and patent vessels. In fact, when the inflammatory action is extensive or severe, or when the part affected is of much importance to life, the whole circulating system is disturbed, and thus arises the sympathetic excitement of the constitution. The incited action of those vessels in the more immediate vicinity of the inflamed part is well marked in cases of Paronychia. There the digital, the radial, and ulnar arteries, with their branches, beat more violently than usual; and with much greater force, though not more rapidly, than the vessels in other parts of the body. Swelling is caused by the enlarged and overloaded vessels relieving themselves by effusion of part of their contents into the surrounding cellular texture. The effusion varies in extent and consistence, according to the degree of inflammatory action, and the species of resistance offered; at first it is serous, then mixed with fibrin, and consequently spontaneously coagulable. CÆteris paribus, the greater The nature of the effused fluid varies according to the degree of violence and advancement of the action, and is also modified by the texture in which that action occurs. It may consist of serum, lymph, blood, or pus. In inflammation, in short, exhalation, though at first diminished, is soon much increased, whilst the powers of the absorbent vessels are diminished, or at least do not maintain their usual relation to those of the exhalants. Pain is the next symptom enumerated. Here the very common error of supposing that where there is pain there must always be inflammation may be noticed. Some diseases attended with the most acute pain, as Tic Douloureux and Cramp, are generally unattended with inflammation. Many chronic diseases, too, are accompanied with violent and long-continued paroxysms of pain, without excited circulation of the part. This erroneous opinion often gives rise to highly prejudicial proceedings, as—the exhausting, by copious depletions, the vital powers of patients, already enfeebled by continued disease or treatment—the consequent aggravation of the urgent symptoms—and, the then only termination of the disease and of the practice, death. Again, it is true that we must bleed, in some cases, with the view of preventing the occurrence of inflammation; yet the prophylactic treatment may be carried too far, as in cases of violent injuries, or after severe operations. In these instances, the immediate abstraction of blood, so far from being beneficial, expedites the dissolution of the patient, or at least greatly retards the cure. Pains arising from local irritations are often treated in a similar way, whilst the removal of the cause would be much more likely to restore the natural action of the parts. Though inflammation does not always accompany the sensation of pain, yet the latter, in a greater or less degree, attends inflammatory action; and, perhaps, it is fortunate that it does so. Because, were it not for the occurrence of pain, the patient’s attention would not be directed to the disease; he would continue to use the part as if in health, and the affection would thus be much aggravated. Whereas, according to the existing provision of nature, pain is felt at the commencement of the action, the presence of which the patient is thereby made aware of; and he is compelled to employ such measures for its removal as reason naturally dictates, of which none is more effectual than disusing the affected part. The nerves are thus the safeguards of the various parts of the body in health—their nurses in disease. A part deprived of sensation may be used, even to the de The presence of pain, as a symptom of inflammation, may be easily explained. The connexion of the vascular with the nervous system is very constant and intimate. Their ramifications accompany each other, and are contained in the same cellular sheath; and without the reciprocal influence of each, neither could perform its functions perfectly. By injecting a limb soon after its separation from an animal, and before its vital heat has departed, spasms of all muscles are sometimes produced; showing the intimate connexion between these two systems. This, however, is distinct from the contractions of the muscular fibre produced by the application of stimuli. In the former case, the contractions are universal, and induced through the medium of the nerves. In the latter, the irritability of the fibre is excited. When the circulation is excited, the nerves accompanying the affected vessels are unusually compressed, and over-stimulated by the circulating fluid, in which, probably, some change takes place, and in this manner unnatural impressions are produced; the nerves themselves are likewise the seat of disease, in consequence of the enlargement of the minute capillaries which permeate them. Over-distension of the coats of the vessels may also be supposed to give rise to painful feelings, independently of any affection of the accompanying nervous trunks. The degree of pain is generally in proportion to the sensibility of the part when in health; it also depends upon the distensibility of the parts affected, and on the intensity of the inflammatory action. When bones, tendons, &c., which in their uninflamed state are nearly insensible, become inflamed, the pain and suffering are most excruciating, owing to the resistance opposed to the dilatation of the vessels, and the prevention of the effusion by which they naturally relieve themselves. The kind of pain also varies, in consequence of different modifications in the action causing different impressions on the sensorium. Pain is not always increased in proportion to the natural sensibility of the part; for in some instances the sensibility is rendered much more intense, while in others it is much obtunded. The last, and, according to some writers, the only unequivocal symptom of inflammation, is Heat. In extravasation of blood into the cellular texture, as under the conjunctiva, there is redness, swell The signs, symptoms, and consequences of inflammation—and amongst others, heat—are modified by the distance of the affected part from the centre of circulation. All actions, healthy as well as morbid, proceed with more vigour in the superior extremities—in the head, the neck, and the trunk, than in the more remote parts of the body; for to the former the blood is transmitted more speedily, if not in greater quantity, and is not so liable to be impeded in its return. Hence an arm may bear up under a severe injury, which, to an inferior extremity, would prove inevitable destruction. The heat, however, of an inflamed part, is generally supposed to be much greater than it really is. The sensation of heat is considerable to the patient, as well as to any observer, whilst the absolute increase of temperature is very slight indeed. It has been proved by the most decided experiments of Mr. Hunter, on the mucous canals of animals, first when in health, and again after violent inflammation had been excited, that little or no variation of temperature can be observed. The elevation of temperature is probably constant, though only amounting to a degree, or even less. As the blood is the source of heat, wherever an increased quantity is circulated, there should, to some extent, be increased heat. The effects of an incited action of the vessels on the system at large must now be adverted to; or, in other words, that general disturbance in the system which attends inflammatory incitation, and which occurs in a degree proportioned to the power of the exciting cause, and the kind of texture primarily affected. The functions both of the sanguiferous and nervous systems are deranged, producing a state termed Symptomatic or Sympathetic Inflammatory Fever. From some observations of my friend Mr. Gulliver, it is probable that this During the paroxysm of inflammatory fever all the secretions and excretions are diminished or suppressed; and hence the hot dry state of the skin, the thirst with foul and dry tongue, the scanty and high coloured urine, and the constipation of the bowels. This last symptom, however, though it may arise partially from the diminished secretion of mucus, yet is often dependent on disturbance of the functions of the brain and nerves. The pulsations of the arteries become rapid and strong, the sanguiferous system being unable to relieve itself by effusion, in consequence of the obstruction of the exhalants. If the extreme vessels are in any way obstructed, and the general circulation in consequence much accelerated, the internal viscera become oppressed, and are interrupted in their functions; and relief is experienced only when relaxation occurs in the vessels upon the surface of the body. Thus, in any violent and continued exertion, there is a sense of oppression in the chest, and the functions of the encephalon are somewhat disordered, but as soon as perspiration breaks out the relief is instantaneous, and the animal can, without difficulty, persevere in its exertions. In inflammatory fever, the breathing is often difficult, and the appetite declines; the patient is restless and watchful, and when he does sleep, he is not thereby refreshed. In the more violent cases, the sensorial functions are much disturbed; even delirium supervenes, with violent muscular exertion and convulsions, and may be followed by coma, should the local affection not subside. The delirium attendant on violent diseases and accidents may often be considered a beneficent effect of nature’s operations; for the patient, frequently losing all consciousness of his situation, seems to be under the influence of the most pleasing hallucinations, and is freed from the more lamentable state of severe mental as well as bodily affliction. Writers on Inflammation have expatiated at great length on Sympathies; and these have been divided into, 1st, The Partial—the Remote, the Continuous, and the Contiguous;—Remote, when parts sympathise, though situated at a considerable distance from each other;—Contiguous, when the sympathetic action seems to be produced, in separate parts, merely from juxtaposition;—Continuous, when the action extends in parts which are of similar texture, and conjoined with that which is primarily affected.—2d, The system sympathises much more with some parts than with others; and we accordingly find that disorder in one part will give rise to alarming constitutional excitement, whilst in another, a much greater derangement in function and structure will apparently be almost entirely disregarded by the constitution. Irritation is an effect of sympathy, and differs from inflammation, inasmuch as the functions of the nervous system, and not those of the sanguiferous, are disturbed;—the latter frequently supervenes on the former. Irritation is local, or constitutional. As examples of the strictly local species, may be mentioned that peculiar and dreadfully annoying sensation produced in the alveoli by the presence of a diseased tooth, or the irritation caused by ascarides in the rectum, or by stone in the bladder. But, from this action being dependent on the nervous agency, irritation is frequently produced in a part remote from the source of the action. Thus, if an irritating cause of any kind be applied to the origin of a nerve, the effects of the irritation may be evinced in a part supplied by its extreme branches; while, if the cause is applied to the termination of a nerve, a similar action is produced at its commencement, and in parts supplied by nerves from the same origin. Thus, disease of the hip-joint causes pain in the knee, whilst dentition in children not unfrequently produces fatal effusion at the base of the brain; and again, irritation at the neck of the bladder frequently gives rise to pain in the feet. Local impressions, injuries, or irritations, though apparently of little importance, frequently produce irritation which affects the whole system, and is therefore termed constitutional. Syncope sometimes follows the passing of a bougie along the urethra. We meet with too many instances of constitutional irritation following severe injuries or operations, especially if attended with much hemorrhage. In general, there is considerable prostration of strength; the patient is anxious and restless; his sleep is disturbed; the pulse is weak and fluttering, occasionally intermittent; the tongue is white and loaded; the appetite is gone; the stomach rejects the little food which the patient is able to take; he is startled and annoyed by the slightest external impression. At this period of the disorder, rigors generally occur, and are followed by a sense of heat, and by perspiration; then the above symptoms gradually decrease, and the patient recovers; but in certain instances his breathing becomes quick and somewhat oppressed, attended with a peculiar spasmodic elevation of the nostrils; all the secretions are diminished, the intellectual functions become impaired, and there are occasional convulsive twitchings; coma supervenes, preceded by a low muttering delirium, and followed by death. This action, as well as every other, is much modified by the importance of the part which is the source of the action, and by the The Causes of Inflammation come next to be considered; and first, of the proximate cause or theory. The different states of the Vessels, in their healthy and in their incited condition, have given rise to much discussion. In the first place, considerable difference of opinion exists as to the relative share which the heart, the larger arteries, and the capillaries, have in propelling the circulating fluid in a state of health. Some physiologists are inclined to attribute the principal power to the heart, the blood being propelled and returned, according to them, almost entirely by the vis a tergo; while they suppose that the arteries possess merely a degree of elasticity or tonicity. Considering the arteries as elastic tubes, performing an indispensable part in the propulsion of the blood, we will now briefly consider their state in inflammation. Passing over the different theories of error loci, spasm, &c., which have at various times been entertained, let us first examine the condition of the capillary vessels, for these are primarily and principally concerned. In inflammation, the balance of the circulation is destroyed, but a diversity of opinion has existed as to the precise nature of the change which occurs. It has been supposed, and perhaps correctly, that the circulation is, in the first instance, much accelerated in the capillary vessels of an inflamed part; but it has been satisfactorily proved by experiment, that, after inflammation is fairly established, the blood circulates more slowly than in the healthy state of the vessels. There appears, in fact, to be, as insisted upon by some writers on the subject, a state of excitement, then of collapse, followed, if the life of the part is not destroyed, by reaction. When a part is stimulated, the circulation is accelerated, and a greater quantity of blood is transmitted by its vessels: if the excitement is speedily removed, they recover themselves, though perhaps a little dilated, and no inflammation ensues. If, for instance, a foreign body of any kind gets entangled betwixt the upper eyelid and the bulb of the eye, and it is permitted to remain a few moments only, redness of the whole surface of the conjunctiva takes place, but it is transitory, and disappears entirely some short time after the extraction of the foreign body. If, however, it is permitted to continue longer in contact with this sensible surface, the membrane reddens more and more, and becomes thickened. Violent pain, with discharge of tears, and alteration of the secretion from the mucous surface, take place, ophthalmia is, in fact, established. If the exciting cause is applied for a sufficient length of time, the extreme vessels lose their contractility, they are weakened, become dilated, and the contained blood circulates slowly. When inflammation is fairly established in a part, the capillaries become considerably dilated, and the blood is often completely stagnated in the inflammatory point. In the circumference of this focus, it is accelerated as formerly noticed: the blood is probably stagnated for two or three days in the capillaries and in the contiguous cellular tissue, when the action is at all violent. It, The blood globules are, perhaps, merely compressed; for whenever motion is produced in the fluid, they speedily reappear. Fresh globules also find their way into the affected capillaries from neighbouring vessels. The alteration in the component parts of the blood has been supposed to depend upon the previous state of the inflamed vessels in which it is contained: it is said soon to reassume its natural appearance, when brought into a healthy vessel, and reference is made to experiments on the web of the frog’s foot. When once altered, it is, however, questionable if the blood ever reassumes its natural appearance; of course the blood which takes the place of that which was stagnated in the capillaries will be natural. If there have been extensive inflammation, and therefore much altered blood, one of two things will happen, viz., inflammatory fever and its consequences, or the discharge of the offending matter (the altered blood) as pus. We may also conclude that the blood of an inflamed part undergoes chemical changes; for when the part becomes gangrenous, the blood then loses its red colour, and assumes a yellowish-brown hue, from the absorption of its colouring matter, which necessarily implies an alteration in its chemical constitution. It seems not unlikely, that the change which is early observed in the appearance of the blood of an inflamed part is the commencement of a chemical process, which, if the vessels do not regain their contractile power, terminates in the total destruction of the ordinary properties of that fluid. It is probable that the more modern speculators in medical science have paid too little attention to the state of the fluids, and to the fact that, when diseased action occurs in a part, its secretions and supplying fluid are very considerably changed. But the blood in inflammation also undergoes a change, observable In inflammation, as was formerly remarked, a greater quantity of blood not only flows into the capillary vessels, but it also escapes from them, or is extravasated. This may occur with or without rupture of the vessels, and to a greater or less extent, according to the violence of the action, and the texture of the part. When local inflammatory action exists to a considerable degree, the general circulation is more or less disturbed. The heart, and the larger vessels supplying the capillaries, which are more immediately concerned in the local action, subsequently sympathise with the part affected, and, acting with greater vigour than usual, propel the blood into the extreme branches; so that the inflammatory excitement may be said to be gradually communicated by the continuous sympathy, till the whole sanguiferous system becomes subject to its influence. The degree of this general excitement depends greatly on the texture and function of the part primarily affected. The term Passive Inflammation has been applied to that state in which the larger vessels are not excited, or have ceased to sympathise with the capillary branches. The term Chronic Inflammation is properly limited to the consequence of the acute inflammatory action, the part remaining turgid and swollen, the vessels over-distended with dark blood, but with little or no pain, and without heat or throbbing. Congestion is also employed to denote fulness of the vessels, large as well as small, when no sign of excited circulation, or of decided inflammatory action, has occurred. It is most fre It may here be mentioned, that some have denied the existence of vitality in the blood; and to some minds it may, perhaps, be difficult to conceive how a fluid should be possessed of this principle. But no one can either doubt or deny that the blood, in its distribution, in its manner of receiving increase, in the secretions furnished by it, and in its various morbid changes, is governed by certain laws and principles which cannot be explained by those of chemistry or mechanics, but must belong to some other power. It is allowed, and has been promulgated by all authors, that the blood is one of the most active agents in the animal economy—in repairing waste, in affording peculiar fluids necessary in that economy, in supplying organs with materials for carrying on their functions, &c.; and yet all this, according to some, is accomplished by a dead animal fluid; no one can plausibly object to the laws by which the blood is governed being referred to the power of life, and to their being called Vital Principles. Certain circumstances give rise to inflammation, and have been called its Exciting or Immediate Causes. Among the external applications producing inflammation, stimulants bear a conspicuous part; the effects of which, in causing this action, are well shown by many experiments that have been performed on the lower animals: by the application of ammonia, spirits of wine, or common salt, for example, to the diaphanous web of a frog’s foot. As stimulants usually causing inflammatory action, by their being applied to the surface of the body, may be enumerated acids, alkalies, certain salts, animal substances, such as cantharides, the juices of many plants, many poisons, an excessive degree of heat, &c. Any solid substance, though by no means acrimonious in its quality, may act as an exciting cause, as by pressure or friction. Wounds also, especially when of considerable size, and occurring whilst the constitution is in an unhealthy condition, give rise to local, and occasionally general, inflammatory action. This action is besides frequently produced by injury from an obtuse body causing a bruise or fracture; by the lodgement of extraneous substances, or of decayed portions of the system,—such as portions of bones, tendons, &c.; or by irritating matter generated in the system itself,—by concretions, tumours, vitiated secretions, &c. One of the most frequent causes of inflammation is cold; the action of which, however, cannot always be readily explained. In some instances, it appears to act directly on a part, as in inflammation of the mucous membrane lining the organs of respiration: in others, its action is indirect, probably by disturbing the equality of the circulation, the inflammation occurs in a part distant from the surface the Inflammation is said to terminate in Resolution, Suppuration, and Mortification. The application of the word termination, however, is injudicious; for in general the inflammatory action, though much abated, is not extinguished by the occurrence of suppuration or mortification, but often continues in the surrounding parts with unabated intensity; and not unfrequently several of the terminations occur combined with each other. Adhesion has also been mentioned as a termination of inflammation, but perhaps improperly; for, although in certain parts of the body, as in the serous cavities, adhesion is produced in consequence of inflammatory action, and during its progress, still the process of adhesion is altogether independent of this action in other textures, such as the cellular. In the uniting of a flesh wound, a certain degree of incited action of the blood vessels is necessary for the accomplishment of the adhesive process; but should that incited action reach the inflammatory pitch, the union by the first intention is interrupted, and the wound must heal by granulation with suppuration. The process of adhesion will be more properly attended to when treating of wounds. The various terminations of inflammation are salutary or destructive, according to circumstances; but resolution is, in general, the one most to be desired; complete resolution, however, perhaps seldom occurs; after the inflammatory action has attained a certain point, this cannot be expected to happen. Resolution takes place in consequence of the reËstablishment of the circulation in the capillaries, in which the blood had stagnated; hence the diminution of the increased action in the larger vessels—the effused fibrin, at the same time, if there was much swelling, is Again, it not unfrequently happens, when inflammation has occurred in the surface, and continued for a short period, that it spontaneously disappears, and does not again return; the action is said to terminate in Delitescence, and of course this is always a favourable occurrence. But if the inflammation, after having suddenly disappeared, attacks another part at a distance from that first affected, the change is termed Metastasis. If the inflammation leaves an internal viscus, and appears on the surface of the body, the circumstance is favourable; but if it leaves the latter to attack the former, the result is highly dangerous. Treatment.—In the treatment of inflammation, with a view of procuring resolution, our attention must be first directed to the exciting cause: it is, if possible, to be discovered, and removed. Thus, foreign bodies are to be extracted—fractures reduced—strictures divided—unnatural accumulations of fluid withdrawn, &c. In many cases, if the exciting cause is removed, nothing more is required; the inflammation speedily subsides. If the cause cannot be removed, or if, after its removal, the inflammation proceeds unabated, the arterial action must be reduced by general and local abstraction of blood. By general depletion, the action of the whole sanguiferous system is diminished, as well as of those vessels more immediately engaged in the morbid action; but the affected capillaries are still dilated, and less capable than the larger trunks of effective contraction to propel their contents; and are therefore only sufficiently depleted by the local abstraction of blood, by leeches, But bleeding is not to be had recourse to without due consideration of the age, strength, constitution, and idiosyncrasy of the patient; if employed, it must be modified according to these; and it has already been mentioned, that depletion is not always to be persevered in on account of the presence of the buffy coat. Bleeding is materially assisted in reducing the activity of the circulation, by the employment of saline purgatives, along with nauseating doses of antimony. Diaphoretics are of essential service in promoting the action of the exhalants, and thereby relieving the affected capillaries. The exhibition of opium is frequently advantageous, more especially after depletion, in allaying the painful sensations when severe, and averting reaction, and also in procuring refreshing sleep, when the patient is anxious and restless. Digitalis has been administered, with the view of reducing the arterial action; but it has been fully established, that this medicine acts at first as a direct stimulant, and that it is only after its use has been continued for some time that its effects become sedative. The local applications to an inflamed part are sometimes made hot, sometimes cold. The latter will perhaps be at first the more grateful to the sensations of the patient. They are, however, with greater propriety employed before inflammatory action is fairly established, and they act by constringing the superficial vessels with which those more deeply seated sympathise to a certain extent; but warm fomentations are more pleasant and useful when inflammation has really taken place; they relieve the pain more effectually, and at the same time promote the cutaneous transpiration; they relax the surface moreover, effusion is thus encouraged, the deeper vessels are so far relieved of their load, and the pressure upon, and stimulation of, the nerves are thus diminished. After the violence of the symptoms has abated somewhat, the vessels still, however, being loaded with blood, the inflammation in fact having become chronic, stimulants may with propriety be applied directly to the affected parts; these are employed, perhaps, with greatest advantage immediately after the bloodvessels are unloaded by leeching, scarification, or punctures; this practice is borne out by the result of experiment and observation. It is seen, that after the vessels have become dilated, and the blood has stagnated in them through the infliction of injury, or the application of some stimulating substance, that the employment of another and different stimulus immediately causes the contraction of the capillaries, and the renewal of active circulation. During an inflammatory attack, the patient should be allowed very little food, and what he does receive must contain little nutriment in proportion to its bulk. But in many cases it is unnecessary to enjoin such abstinence, as the patient has no appetite, and refuses food. In inflammation of deeply-seated parts, such as the apparatus of some articulations, it is a frequent mode of assisting the completion of resolution to excite inflammatory action in an external, and consequently less vital and important part. This is accomplished by the application of stimuli, caustics, cautery, setons, &c. It appears that the stimulating substance produces an incited action of the bloodvessels, or a revulsion, according to the older authors, in the part to which it is applied; and that, consequently, the neighbouring arterial trunks, in order to sustain that incited action, supply the part with a larger proportion of their contents than it usually receives; and the necessary consequence of the stimulated part receiving an additional supply of blood is, that the part originally inflamed receives less. The effect, indeed, seems analogous to that of topical bleeding, with this difference—that it is more permanent. Besides, it determines suppuration on the surface, and so renders it less necessary for the vessels to produce pus in a worse situation—the deeper seated parts. But it must be borne in mind, that this method is not to be resorted to in the commencement, or during the active state, of the inflammatory action, but only when that action has begun to decline, otherwise the disease may be much aggravated, instead of being relieved. If, notwithstanding all the means employed to procure resolution, the inflammatory action continues unabated, the result next to be desired and accelerated is Suppuration; and with this view, it becomes necessary to change the treatment, both local and general. Above all, disuse and a proper position of the affected part must not be neglected. Unless absolute repose is strictly enjoined and attended to, and the return of blood from the inflamed tissues is favoured, very great difficulty will, in the majority of cases, be experienced in removing any of the signs or symptoms of inflammatory action, even by the most energetic means, general or local. This will be more fully insisted upon in the progress of the work. OF SUPPURATION AS A CONSEQUENCE OF INFLAMMATORY ACTION.It has already been stated, that the blood is stagnated in the capillaries occupying the centre of the inflamed part, as well as extravasated in the contiguous cellular tissue. Pus has long been considered as a secretion; but, from the time of Mr. Hunter downwards, a great similarity between the globules of pus and those of blood has been recognised: the former, however, are spherical, larger, and rougher on the surface, and are not so regular in size as those of blood; their diameter is between 1/2000 and 1/3000 of an inch, although some of the globules may be occasionally seen a little larger or smaller than these measurements. Smaller particles are also detected, the molecules of In many constitutions, the slightest incited action of the vessels is followed by the formation of pus, and the appearance of a depÔt of purulent matter is often the first indication that such action has existed; but in the majority of instances, the deposition of pus is preceded by the usual characters of well-marked inflammatory action. Suppuration occasionally occurs without previous solution of continuity; for pus is frequently contained in the serous and mucous cavities, when no breach of continuity can be discovered, at least we find a fluid not distinguishable from purulent matter; it may be a vitiated secretion, but still it presents the usual characters of pus. But it occurs, generally, when there has been a previous lÆsion of structure, and in this case its progress is most distinctly marked. In exposed cellular texture, for example, particles of blood are effused; the serum is afterwards absorbed, and the lymph remains; this latter gives transmission to minute vessels which deposit the purulent fluid, whilst others secrete particles of organised matter to form granulations, in order to repair the loss of substance. This process is often unattended with any great degree of constitutional disturbance, because the fibrin effused sets a bound to the pus, and is the provision After purulent matter has begun to accumulate under the surface, the pressure thereby occasioned produces condensation of the neighbouring cellular tissue, which, along with the previously effused lymph, forms the parietes of the abscess; and in proportion as the matter accumulates, the cavity enlarges by the successive processes of ulceration of portions of its parietes, by continued effusion of lymph, and by farther condensation of the surrounding parts. Thinning of the parietes takes place by ulcerative absorption, particularly towards the surface—or, if that be difficult, towards a mucous outlet—as is exemplified by the bursting into the bowels or bronchiÆ of abscess of the liver. But in some instances, when no lymph is previously effused, and no cyst is formed, the matter is not confined, but pervades the cellular substance extensively, and is generally followed by more or less sloughing of that tissue, and by great constitutional disturbance. This most frequently occurs in patients of a debilitated habit, in whom the incited action has been so slight as not to cause the effusion of lymph, by which nature usually sets bounds to the suppurating process. M. Gendrin advanced the opinion that pus was nothing but transformed blood; but his experiments on frogs are at least doubtful, since Mr. Gulliver, on repeating them, could not by any means induce the process of suppuration in these animals. It has been rendered probable by this gentleman’s observations that suppuration is a sort of proximate analysis of the blood, the fibrin being added to the contiguous parts, as in causing them to swell, forming the cysts of abscesses; the blood globules altered into pus being discharged as useless and excrementitious matter. Pure pus is heavier than water, of a yellowish-white colour, somewhat of the consistence of cream. It is very little inclined to putrefaction, less so, perhaps, than any animal fluid not oily. It is composed of globules, and a clear transparent fluid, coagulable, it has been said, by the muriate of ammonia. When a solution of this salt produces any change, it is by rendering the pus more ropy; not coagulation, but a sort of gelatinisation follows. It is said also to be sweet and “mawkish to the taste.” In unhealthy pus, such as already noticed, or in vitiated muco-puriform secretion, the colour and consistence are different, and flakes, resembling portions of lymph, are seen floating in it: they consist of The symptoms attendant on suppuration vary much according to the nature of the parts involved. In general, it is accompanied with the subsidence of acute pain and fever; but, in unyielding textures, the increase of swelling, by the formation of purulent matter, is often attended with an aggravation of the symptoms, and with an increase of danger to the structures affected. The pain which accompanies suppuration is dull, and attended with a sensation of fulness and throbbing, and an increase of the tumour; ultimately the parietes of the abscess become absorbed, and the collection, being more superficial, the most careless observer must be convinced of its existence, by the less equivocal signs of fluctuation and pointing. In general, especially when the abscess is deeply seated, a greater or less degree of oedema surrounds it, producing a soft pitting tumour; but not unfrequently, when the degree of excitement is more intense, lymph, instead of serum, is effused, rendering the part more hard and resisting: in such cases it may be difficult to discover the existence of purulent matter, and the tactus eruditus, as it is called, will be found of material service; for, though pus is neither acrid nor corroding, still, if allowed to remain for any long period, much mischief may be caused—the bones may become diseased—muscles and tendons may slough—and the matter may discharge itself, by means of ulceration, into certain cavities and canals, and produce very serious consequences. Of the bad effects produced by the pressure and irritation of extensive and undisturbed collections of purulent matter, every practitioner must have seen numerous examples. Still, through prejudice, erroneously conceived opinions, or servile imitation, the greatest dread seems, with many, to exist of the practice of giving a free exit to the contents of such depÔts. The symptoms and sensible signs of suppuration are usually preceded by shivering, recurring at intervals, and commonly terminating in profuse perspiration. But this is by no means an unequivocal sign of the occurrence of suppuration; and this process very often takes place without any feeling of rigor. The older authors supposed that pus was derived from the solids—or that it was formed by the melting of dead animal matter—or Pus was formerly regarded as irritating and corroding, and was therefore carefully removed from every granulating sore; but purulent matter, though it may prove a source of irritation to the neighbouring parts, does not disturb the surface which secretes it, but, on the contrary, protects the tender granulations, and acts as a temporary cuticle. A crust is formed by the evaporation of the thinner part of the fluid; and we frequently see small sores healing rapidly when thus protected. In some instances, we adopt the hint given to us by nature, and produce a scab by the application of powders, lunar caustic, &c. The discharge does not always consist of laudable purulent matter. Pus formed in the diseased part itself has particular characters, according to the tissue involved; thin and greyish in bones, opaque and caseiform in cellular tissue, flocculent in serous, and greenish and thready in mucous membranes; it is said to be reddish in the liver, and yellowish-grey in muscles. Its sensible properties are various, often very offensive when proceeding from a cavity containing decayed bones, and it degenerates in consequence of disturbance of the constitution, or of the part affected. It is also frequently suppressed, in consequence of over-action in the vessels of the part, or from debility, partial or general. Suppression of a purulent discharge is to be regarded as an untoward symptom, fraught with considerable danger, being generally followed by the most violent constitutional disturbance. Certain cases would seem to warrant the belief that a species of metastasis occurs; that the matter is absorbed, and again deposited in some From the discharge varying according to the state of the system, the latter can in general be accurately ascertained by examination of the sores which afflict the patient. In collections of matter not far removed from the surface, the most superficial, and generally the most dependent, portion of the parietes appears inflamed; its inner surface is gradually absorbed; and, when it has thus become attenuated, a portion of the integument sloughs or ulcerates. A communication is established with the diseased parts, through the external surface, thus providing an aperture for the evacuation of the matter—of extraneous substances—or of parts of the body which have either mortified, or otherwise become useless to the system. In such collections, more especially if deeply seated, the matter generally seeks the surface, or extends in the course of the bloodvessels. Cold abscesses, as they are called, often contain as much flaky fibrinous matter as true pus: hence one of the signs of inflammation, swelling, is absent; the fibrin being discharged instead of having been added to the neighbouring parts. As formerly remarked, suppuration occurs much more readily in some constitutions than in others; and patients peculiarly liable to the formation of abscesses, without any great degree of previous excited action of the bloodvessels, are said to labour under Struma or Scrofula. These terms are by some used to denote a distinct or specific disease, while others consider them merely as a peculiar state of the constitution. The strumous diathesis is said to be marked by hair and irides of a very light colour, and by the skin being of a peculiar white hue; Constitutions, in every respects strong and originally vigorous, may, from various causes, become weak, and present many of the symptoms usually termed scrofulous. I recollect a young patient, born of healthy parents, who had enjoyed excellent health, becoming covered with ulcers and chronic abscesses, in consequence of exposure to cold during menstruation. To the continued irregular and imprudent exhibition of mercurial alteratives, as they are called, may be attributed the cachectic and scrofulous constitutions of many thousands of patients of all ages. The strumous diathesis is said to depend upon a want of balance, or proportion, between the solids and circulating fluids. Want of action and power in the organs forming and circulating the blood, disordered digestion, and various other circumstances which it is unnecessary to detail, have also been considered as causes of this state of the constitution. Many suppose that the diathesis, or a disposition to the diathesis, is always congenital; and this opinion is supported by the majority of cases. However, certain circumstances produce a scrofulous habit of body in patients who previously appeared to be vigorous and healthy, and untainted with any peculiar disposition to disease. Of these predisposing causes may be mentioned, a poor diet, an impure atmosphere, exposure to damp and cold, inattention to cleanliness, the latter circumstance acting sometimes by producing local irritation: in fact, whatever deranges the general health, seems, in many cases, to induce the strumous diathesis. Some constitutions are incapable of resisting any unusual incitement of the vascular system, or of repairing the consequences of the action, or of any injury, in whatever way inflicted. In such individuals, all the parts of the body are deficient in power—some, however, are more so than others, and, consequently, more readily give way; thus, the lymphatic system, the mucous membranes, the skin, the bones and their coverings, generally suffer in the first instance. Glandular swellings of all kinds, and in all situations, often followed by suppuration, are apt to occur from irritation of various descriptions, but more so in constitutions originally weak, or which have become debilitated by disease or any other cause. The larger glandular tumours are formed by congregation and agglutination of the smaller ones, and by the deposition of adventitious matter in the connecting cellular substance; separation of the smaller tumours composing these, naturally, or under the use of deobstruents exhibited internally, or applied to the surface, is a highly favourable sign, and equally encouraging to the surgeon and the patient. Dentition, the presence of carious teeth, of stumps of teeth; excoriations behind the ears, eruptions on the scalp, affections of the lining membranes of the eyelids, mouth, or nose, of the skin of the face, are Tumours formed by the enlargement of glands are frequently productive of dangerous consequences. If situated in the neck, they may render breathing and deglutition extremely difficult, and in the event of their suppurating, the purulent matter may be discharged into the trachea or gullet; fatal results have followed the giving way of an abscess into the former canal. The breathing is also seriously impeded by enlargement of the bronchial glands, by the pressure of which the lungs may be much condensed, and unfitted for their functions. The immediate effect of enlargement of the mesenteric glands, is interruption to the passage of the chyle, and a consequent decline of the powers of life. Such tumours in the abdomen have been mistaken for enlargement of the liver, spleen, ovarium, &c., and the most noxious treatment employed. Inflammatory glandular enlargements terminate either in resolution, in delitescence, or in suppuration; sometimes in death of the part. When the tumour, after having attained a certain size, gradually disappears, it is said to be resolved; when, however, it is rapidly discussed, it terminates in delitescence; the difference between the terms being the same as when used to express the corresponding terminations of inflammatory swelling in general. Suppuration is by far the most usual termination, and the matter is frequently evacuated through numerous small apertures, exposing the gland denuded and prominent in the middle of the chasm; in such cases, the gland proves the source of much irritation, and must be destroyed, otherwise the cure is extremely tedious. Though inflamed and swelled lymphatic glands very generally disappear by suppuration, it is to be remarked that the conglomerate glands, though often violently inflamed, seldom, if ever, have pus formed in them; in mumps, for instance, the action often runs very high, yet abscess of the parotid is rare. The submaxillary salivary glands are often supposed and said to be inflamed and enlarged; the conglobate glands superficial to them are in such cases only affected. Collections of pus in the lymphatic glands or cellular substance, in patients of a weak constitution, (whether naturally or in consequence of disease,) are attended with little or no pain, or inflammatory action; and although it is probable that inflammation does precede the formation of such purulent depÔts, still it is generally so slight as not to attract the attention of the patient or his attendant. The sensation is dull and uneasy, rather than painful; and, even after the accumu The skin, particularly that of the face, becomes, in very many cases, affected either primarily or secondarily with scrofulous ulceration, which commonly extends to the neighbouring textures. The disease has sometimes been mistaken for cancer, and other affections of a malignant nature, and has received various names accordingly. The integuments in the neighbourhood of the ulcer are of a purple hue, and become undermined, from the extension of the disease in the subjacent cellular tissue. The discharge is thin and gleety—the sore is of an unhealthy and debilitated character, and makes but little attempt at reparation; its surface is covered by a viscid fluid, and sloughing occasionally occurs in consequence of the extreme debility of the parts. Numerous sinuses frequently extend in a superficial direction, and render the cure more tedious and complicated. Those of a scrofulous constitution are most liable to be affected with caries, softening, and other diseases of the bones and their coverings; these, however, will afterwards be treated of, along with ulceration of cartilages, diseases of ligaments and synovial membranes, lumbar abscess, &c.; all of which affections, in the plurality of instances, are connected with the strumous diathesis. In the treatment of abscesses, the principal indications are, to remove any degree of inflammatory action with which the surrounding parts may be affected—to keep the part moist, clean, and at rest—to remove all source of local irritation—to promote and accelerate the progress of the matter to the surface—and, lastly, to give it free vent; for though it sometimes happens that collections of purulent matter disappear, still the occurrence is so rare, that to treat abscess generally when in an advanced stage with the expectation of resolution would be highly injudicious. By blistering and pressure, however, tumours containing a small quantity of purulent fluid can occasionally be discussed. Warm fomentations afford great relief, especially at the commencement, when there still remains a considerable degree of surrounding inflammation. These may be either what are termed anodyne, or not; in general, fomentation with chamomile flowers or hops, contained in a woollen bag, and wrung out of warm water, will be found the most convenient and efficient, and is well entitled to the term anodyne, which is usually applied to others of a complicated, and not more efficacious, character. Poultices are of material service, particularly when the collection is advancing to maturation; and their composition is of little importance, provided they are moist, warm, and soft. Stale bread soaked with hot water, or an equal quantity of grated bread and linseed meal, (if not adulterated with mustard, as is sometimes the case,) mixed with sufficient quantity of boiling water, form excellent and soothing cataplasms. Their use, however, may be persevered in too long; for, after an abscess has given way, the suppuration may be kept up in conse By the continued presence of purulent matter, absorption, ulceration, caries, and even death, of bone, is frequently produced, all which might have been prevented by its evacuation. If pus collect in the neighbourhood of cavities or canals, it is of the utmost importance that it be early discharged; and the evil effects of negligent and dilatory treatment are well exemplified in the following cases:—A patient had been allowed to suffer, for a long time, under an extensive abscess at the lower part of the neck, beneath the origins of the sterno-mastoid muscles. The abscess at length gave way externally; but the patient was at the same time seized with profuse expectoration of pus, and during expiration the air escaped through the external openings in the neck. It was evident that the abscess communicated with the trachea, and it also appeared to have extended deeply into the mediastinum. The patient soon perished, but there was no opportunity of examining the parts. In another case of extensive abscess at the root of the neck, an opening was proposed, but delayed. At length, the abscess gave way spontaneously; and from the circumstance of portions of solid as well as fluid ingesta escaping by the external opening, it was evident that the oesophagus had ulcerated. The cure was very tedious, but ultimately complete, and apparently much accelerated by free counter openings. In suppuration of the cellular substance in the neighbourhood of the anus, the matter may present itself externally, whilst it is making extensive progress internally; and if a free opening is not made, fistula ani is the result. The propriety of an early evacuation of purulent matter in important, or very sensible, organs, such as the eye and testicle, is very evident. The larger arterial and venous trunks appear not to suffer from suppuration, for in purulent depÔts we find them entire, and much thickened by copious effusion of lymph into their outer cellular coat and sheath; the nerves, however, are not so much protected, or do Illustration The most convenient and effectual mode of opening an abscess is with a sharp-pointed bistoury, and the incision should vary in extent according to the circumstances of the case. The straight instrument, used as described and represented in the “Practical Surgery,” p. 5 When the abscess has been deeply seated, and the incision made through a considerable thickness of healthy parts, it is sometimes, though very rarely, necessary to introduce a small piece of lint between the edges of the wound, otherwise they may speedily adhere, and the discharge of the matter be in this way prevented. In consequence of smart hemorrhage, also, it may be proper to stuff the wound with lint, and retain it for an hour or two; but in general the practice of stuffing abscesses, or the openings into them, is hurtful. After the incision, as already remarked, it is unnecessary and injurious to discharge the pus by forcibly squeezing the sides of the abscess; the application of a poultice will promote the evacuation of the matter, and allay the irritation. In chronic abscesses of large size, it is sometimes necessary to make a counter opening—that is, an opening in a part of the tumour opposite to the original opening, in order that the matter may be more completely discharged. Setons introduced into the cavity of phlegmonous abscesses some time after their evacuation, are highly injurious, as causing much irritation in parts which are already in a morbid state of excitement; but in chronic A too common result of abscess, when inertly treated, is the formation of a Sinus; that is, a canal, the circumference of which is condensed by deposited lymph, and which furnishes a discharge of unhealthy purulent matter, frequently thin and gleety. Several sinuses frequently unite, and evacuate their contents by one opening. Previously to treating a sinus, its extent must be carefully examined by the probe; this requires considerable caution, for the full extent of the canal may not be discovered, in consequence of its tortuous course, or from its diverging into collateral branches; or the probe, by being used too forcibly, may pass into parts altogether unconnected with the morbid cavity. Thus, in exploring a sinus at the lower part of the leg, or in the foot, the probe may be pushed to a considerable extent beneath the tendinous sheaths of the muscles, and induce the surgeon to adopt treatment unnecessarily severe. In the treatment, we may at first employ setons, injections, and graduated pressure, as formerly explained; and if these fail, the canal must be freely laid open by the knife—a mode of practice much more effectual; then there is formed a cavity similar to that of a recent abscess, and to be treated accordingly. Incision is most frequently necessary when the sinus exists in adipose substance, in tendinous structure, in parts possessed of little vitality, and in patients of a sluggish and The healing of an abscess which has been opened closely resembles the process of union by the second intention in a flesh wound; granulations arise, attended by the secretion of pus, the cavity gradually contracts; the surrounding effusion is absorbed along with a portion of the adipose matter; and on the granulations reaching the surface, new skin is formed, and the parts coalesce. After abscesses have been opened, the fomentations, poultices, or warm-water dressing, as recommended in the treatment of ulcers, are to be continued, but only for a limited time. The power of the system must be carefully supported by exposure to a pure atmosphere; by nourishing food; by the exhibition of wine, tonics, and such medicines as promote digestion. In cases where the system is unusually inert, it may be proper to administer stimulants. The most powerful stimulants are frequently necessary, and by steady perseverance in the use of them, patients have often been saved in very hopeless circumstances. Great attention must be paid to the bowels, and the secretions poured into them, for on the condition and quality of these the state of the constitution materially depends. The internal Use of cantharides is often advantageous in chronic suppurations and abscesses, but it is inadmissible in cases where enlarged glands occupy dangerous situations, either externally or internally; unless the tumours are in progress towards resolution, suppuration is certainly induced, and may be productive of the worst consequences. The glands not unfrequently become enlarged during the exhibition of this medicine; and such an occurrence must be watched attentively. In illustration of the good effects of stimuli in certain cases, it may be mentioned that the cavities of abscesses are often speedily effaced by granulations, and that obstinate sores frequently contract and cicatrise, after the occurrence of a febrile attack, though they had previously shown no disposition to heal. In glandular swellings, Deobstruents, as they have been called, are used; and with this view, mercury is often had recourse to; this medicine, however, instead of producing a salutary effect, very generally tends still farther to impair the constitution. Preparations of iodine, exhibited both externally and internally, appear to be sometimes of use when the swellings have become stationary, or are inclined to subside. Iodine may be given in combination or not with iron. It is a medicine exhibited very generally and indiscriminately, and is very much more trusted to than it deserves to be. When the tumours are irritable, fomentations may be employed, and advantage In the treatment of large indolent collections, it was proposed by Mr. Abernethy to make a small and indirect aperture, and to evacuate the contents of the abscess as often as the matter accumulated; but a degree of constitutional irritation frequently supervenes upon this proceeding, and the discharge becomes bloody, putrid, and mixed with a considerable quantity of gaseous fluid. The discharge of blood probably arises from the usual support being taken away from the vessels ramifying on the surface of the cavity, in the same way that blood is effused into the cavity of the abdomen, in consequence of the too rapid evacuation of the serum in ascites. Suppuration, more especially when extensive and long continued, is attended with a peculiar species of fever, termed Hectic. This fever is the remote consequence of local injury, or disease, whereas symptomatic inflammatory fever is the immediate one. The incessant and long-continued addition of pus to the blood may be the cause of hectic fever. In cases of pulmonary consumption, pus globules are almost uniformly detected in the blood. This fact has been noticed by Dr. Davy and Mr. Gulliver. The pus is probably carried along the capillaries, where it is always forming in chronic abscesses: in short, all the pus formed is not separated from the blood. Hectic probably arises from the never-ceasing addition of a little pus to the blood, inflammatory fever from the sudden addition of a large quantity. In long-continued disease, particularly internal, the hectic occasionally occurs before the existence of suppuration is indicated; and it does not always supervene upon suppuration, even though extensive. Hectic has been supposed to arise from the absorption of pus; but pus cannot well be absorbed without disintegration of its particles (and then it would be no longer pus), for their diameter exceeds that of the more minute bloodvessels and absorbents. Abscesses occasionally disappear, without this event being followed by any unpleasant symptom. Hectic fever is most apt to arise in constitutions originally weak; and usually either from some incurable disease of a vital organ, or from extensive affection of a part not essential to life; but it may also be induced without any local assignable cause. The general symptoms are those of a low and gradual fever, attended with great debility; the pulse is frequent, unequal, small, and sharp; the general surface is pale; there is flushing of the face, hands, and feet; the skin, at one period, is cold and clammy, sometimes dry and rough—at another, it is bathed in profuse perspiration, especially towards evening; chills alternate with flushing; the appetite is much impaired; diarrhoea supervenes; pale-coloured urine is voided in great quantity, often with a lateritious sediment; there is want of sleep, and great anxiety; the eyes are sunk, and of a glassy hue; the features become changed; there is great emaciation; the patient, gradually more and more weakened, falls into a state of coma, and expires. A condition, somewhat resembling sympathetic fever, occasionally In the treatment of hectic, the local disease giving rise to the symptoms, if it cannot be cured by other means, must be removed by operation. Thus, if hectic is consequent on long-continued, but not extensive, disease of bone, the affected portion is to be taken away; if from extensive chronic disease of an arm or leg, the limb must be amputated. In general, the removal of the hectic cause is followed by immediate melioration of the symptoms, even though the patient has been reduced to an almost moribund condition: the feeble hectic pulse of 120 or 130 sinks in a few hours to 90, and becomes more full and strong; anxiety and restlessness cease, and a patient sleeps soundly the first night after the operation, who for weeks had scarcely closed his eyes; the cold sweats and colliquative diarrhoea immediately subside, and the urine loses its sediment; in effect, all the hectic symptoms disappear, and are succeeded by such as indicate a marked improvement in the power and energy of the constitution; and the rapidity with which these changes take place is in many cases truly astonishing. Nourishing food, wine, tonics, &c., must be given, in the first instance sparingly, and afterwards gradually increased in quantity, according as the stomach can bear them; for it is not to be overlooked, that incautious and too liberal use of them may be productive of irretrievable evils, as the action of the system may be increased beyond its resources, in the same way as the imprudent application of stimulants to a part debilitated by an excessive degree of cold causes its sphacelation, in consequence of the arterial action induced being greater than what the power of the part can support. The mineral acids may be useful in checking the inordinate perspiration; opium, astringents, and absorbents, in arresting the diarrhoea; but all are of little avail unless the exciting cause is removed, and to this latter circumstance the attention of the practitioner ought therefore to be chiefly directed. It is not always quite safe, however, to free the patient at once of a great suppurating drain. Upon the healing up of extensive and long-continued ulcers, it is often necessary, in order to prevent oppression of and congestion in the viscera of the chest, abdomen, or head, to insert an issue or seton, and gradually withdraw it. In amputations also, more especially in patients above the middle period of life, to rid them of disease which has caused hectic and wasting, in consequence of profuse discharge, it is often advisable to keep part of the wound open, so that it may suppurate, heal, and dry up slowly. Mortification, or the death of a part, is also one of the results of inflammatory action, and the term has been subdivided into Mortification is not always a result of inflammation; it is sometimes preceded by incited action of the vessels, sometimes not. It follows as a matter of course that if inflammatory action is so violent as to cause stagnation of blood in most or all the vessels of a part, and this is continued, there must be a consequent failure of nutrition, which will terminate in mortification. Humid or traumatic gangrene frequently occurs without previous inflammation, the injury being so severe as at once to deprive the part of its vitality. Dry or chronic mortification is often unpreceded by inflammatory action, or at least it is slight and of very short duration. It is preceded by stagnation, or is at all events coincident with this stagnation, not in the smaller vessels only, but in the trunks leading to the affected part. In humid gangrene, swelling with erethismus generally precedes the death of the parts; whereas in the dry, whether the surface change colour immediately or not, they shrink immediately. In the former they quickly lose their vitality, and consequently retain a considerable portion of their fluids; in the latter the process is much slower, and they become dry and shrivelled. The most common remote cause of spontaneous mortification is a rigid state of the arteries, most frequently met with in the inferior extremities of elderly persons, in consequence of the deposition of calcareous matter between the internal and middle coat; this calcareous degeneration may be confined to a part of the limb, or may pervade the whole of it, and even extend throughout the arterial system. There are many cases in which disease of the arteries has existed, though no gangrene occurred; but this by no means invalidates the assertion, since, when arteries are thus affected, the part cannot withstand sphacelus when exposed to any of its immediate causes. An attempt has been made to connect mortification with an inflamed state of the arterial coats. This opinion is not confirmed by experience. Obstruction from coagulation of their contents, and inflammation of the venous trunks, sometimes precedes death of the extreme parts in old people, and seems to act as a direct cause. After wet seasons, spontaneous gangrene has prevailed as an endemial disease on the Continent, where rye is a principal article of food. The rye is subject to a disease called Ergot; the grains become large, black, and have a horny consistence; and the use of it, when thus diseased, is assigned as the cause of gangrene. The patients who have suffered from the use of this ergot or cockspur rye have experienced pain and heat, with swelling, generally in the lower limbs, Mortification, to a greater or less extent, may be produced in any constitution, and at any age, by the application of heated substances, caustics, acids, &c.; by the effusion of acrid matter into the cellular substances, as urine or putrid sanies; by the interruption of the circulation and nervous energy, as from ligatures or improperly applied bandages—or by natural strictures, as those in hernia and paraphymosis; by continued pressure, more especially in such patients as have, from long suffering and confinement, had the powers of the circulating system weakened; and by violent contusions, as in fractures, compound luxations, and gunshot injuries. A frequent source of mortification, in inclement seasons and climates, is exposure to extreme cold. In this case, the cold is not the direct, but the indirect cause; the power of the parts is very much weakened by exposure to the low temperature, and is thereby rendered incapable of resisting the incited action which follows the stimulus of sudden transition from cold to heat, even though the degree of increase in temperature should not exceed that of the natural standard. That cold is not the direct cause of mortification, has been undeniably proved by facts derived from military practice. No symptoms of inflammation or gangrene occur when the soldier is on duty, and continuously exposed to severe cold; but they speedily present themselves after a rapid thaw has commenced, or after the soldier has imprudently approached a fire. Soon after the half-frozen person has begun to feel a little more comfortable from sudden warmth, he becomes aware of pain, attended with a sensation of itching in the extremities, generally the lower, which are considerably swollen, and of a dull red colour; these, and other symptoms of inflammation, are of no long duration, the action speedily runs its course, and the part soon plainly indicates that gangrene has commenced. When gangrene follows the tight application of a ligature, the death of the part seems to depend more on obstruction to the circulation of the blood, than on any diminution of the nervous energy, for we do not observe that paralytic limbs are peculiarly liable to gangrene. The surgeon frequently takes advantage of the fact that a part soon dies when its supply of blood is cut off, or its return in the Mortification may be produced by the above-mentioned causes, either immediately or consecutively; and it will occur in some constitutions, or states of constitution, at some periods of life, in some structures, and in some parts of the body, more readily than in others. Inflammatory action is seldom so intense as to terminate in death of the part, unless the power of that part has been diminished by previous local or constitutional disease, or by injury; and the inflammation preceding gangrene is all along attended by symptoms of so well-marked debility, both local and general, that it is frequently designated the Inflammatio Debilis. Of inflammatory affections, the erysipelatous most frequently terminates in gangrene; in other words, the power of resisting incited action is not so great in the cellular tissue and skin as in other parts of the body. Illustration The period at which the symptoms of gangrene appear after an accident varies, in general, according to the severity of the injury. As was already observed, the part may be immediately deprived of its vitality—if not, symptoms of gangrene sometimes appear within a few hours after reaction has taken place; while in other cases, tension, pain, and heat occur, and may continue for a longer or shorter time, according to the degree of power remaining in the part. Tension often exists to a great extent after severe injuries, from extravasation of blood or serum; the functions of the vessels are thereby interrupted, and gangrene is inevitable. As the action proceeds, the pain and heat often subside—the parts become flaccid—dark-coloured serum is effused beneath the cuticle, forming what are termed PhlyctenÆ—the skin becomes dull and livid—dark streaks extend along the limb, perhaps from the colouring matter of the blood transuding, as in commencing putrefaction in the dead body—air is effused into the subcutaneous cellular tissue, causing a sense of crepitation when pressed by the finger—sloughs form, either black or of an ash colour—and the gangrene involves a greater or less extent of the limb. The mortification is here represented as attacking a limb that had suffered from compound fracture. The dark part around and above the protruded bone was in a state of sphacelus. The dorsum of the foot and the integument towards the knee were only gangrenous. The patient was advanced in life, and the state of the constitution such as to induce a belief that there was a predisposition to mortification. The removal of the limb was, under the circumstances, reckoned inexpedient. In some instances, the mortifica In compound fractures, dislocations, or severe bruises of the soft parts, dark-coloured, prominent points occasionally appear, in consequence of the effusion of bloody serum beneath the cuticle; in these, however, the fluid is speedily absorbed, and the surface resumes its natural aspect, the cuticle exfoliating and being reproduced; and it is of consequence to know their real nature, for, if mistaken for the gangrenous phlyctenÆ, the inexperienced practitioner may be alarmed, and, consequently, have recourse to very injudicious practice. When the process of gangrene is checked, the skin immediately beyond the mortified part becomes of a brighter hue, and is affected by a more healthy species of inflammation, which ultimately terminates in ulceration, with purulent discharge, and thereby forms what is called the line of demarcation between the dead and the living parts; the process, commencing in the integuments, gradually extends to the deeply seated parts, so that the mortified portion is ultimately attached to the living merely through the medium of bone or ligament. Arteries appear more than any other texture to resist sloughing; and those leading to a mortified part are found contracted and filled with coagulated blood, so that the spontaneous separation of the sloughs, and even incisions for their removal, made in sound parts, are followed by little or no bleeding. This salutary change in the arteries may be accounted for by supposing, that the inflammatory action which leads to the separation of the dead substance from the living affects the arteries at that point as well as the other structures, causing adhesion of their internal surface, and obliteration of their cavities; and the natural result is, that the calibre of the artery above the obliterated point gradually diminishes in size, and the blood coagulates up to the nearest collateral branch: but in consequence of extension of the inflammatory action, the collateral branches may also be obliterated to a considerable extent upwards, and thus the contraction and coagulation in the larger trunk will also extend in proportion. Besides, before the line of separation has commenced, arteries cannot transmit their contents into the sphacelated part, any more than into an extraneous body; so that the circulation of the blood in them is as effectually obstructed as if a ligature were tightly applied; in this way, also, the contraction and coagulation may be accounted for. Mortification is accompanied with great anxiety; coldness and clamminess of the face and extremities; weak, irregular, and hurried circulation; quick, short breathing; a cadaverous expression of countenance; hiccup (which, however, often occurs in very slight sloughing, or when no sloughing has taken place, in external or internal inflammations, extravasations, &c.); by diarrhoea, vomiting, and in hopeless cases, more especially of traumatic gangrene, by delirium and coma; in fact, almost all the symptoms of severe con In the treatment of mortification, no one would think of using any means, local or general, so long as the cause remained; and it therefore must in the first place be removed, otherwise the mischief may speedily become irreparable; thus, a stricture must be divided, irritating fluids evacuated, foreign bodies extracted, &c. In chronic gangrene the cause is constitutional, and the means employed must be directed accordingly. In general, the power of the constitution requires support, though, in cases where much fever is present, it may often be necessary to keep the patient on low diet: exhibit salines and mild purgatives in the first instance. The effects of food should be attentively watched, and its quantity increased or diminished accordingly. On the subsidence of the fever, and when sphacelus has occurred, wine and animal food must be given abundantly. Stimulants, strictly so called, are not admissible until the line of separation be formed, and their exhibition must then be regulated by the circumstances of the case. Opium and other anodynes are found necessary during the progress of the disease, to allay irritation and produce sleep; opium has been recommended on very high authority, that of Mr. Pott, in mortification of the lower limbs. The bowels must be attended to. Peruvian bark was at one time supposed to be a specific in this disease, but experience has not born out the opinion; it seldom agrees in substance, and the decoction, with or without the compound tincture or sulphate of quina, will be found much more useful in supporting the power and tone of the digestive organs. After the line of separation has been formed, and not till then, the surgeon may interfere, and assist nature in her work, dividing the exposed bones or ligaments by which the dead parts still adhere to the living; or he may perform amputation immediately below the line of demarcation. Amputation in the sound parts cannot be recommended: for vitality is impaired throughout the system, and more particularly near and above the line of demarcation, In order to prevent the occurrence of gangrene after exposure to intense cold, the frigid part must be cautiously and slowly restored to its natural temperature; first by being either placed in very cold water, or rubbed with snow; afterwards, by the degree of warmth in the applications, and surrounding atmosphere, being gradually increased. In acute gangrene, and in robust constitutions, when the affection arises from over-action, abstraction of blood is had recourse to with marked advantage. In some cases it may be employed, but with due caution, even after sphacelus to a slight extent has occurred. In gangrene, purging and bleeding must not be had recourse to but with the greatest circumspection; for it ought always to be remembered, that however strongly they may be indicated, the time is not far distant when they will be totally inadmissible, and when the weakening effects of depletion will prove highly prejudicial, particularly in cases where the mischief is proceeding rapidly. The loss of blood is frequently beneficial in sloughing phagedena, as is exemplified on the occurrence of spontaneous hemorrhage in such cases. When a portion of a limb, throughout the greater part of its substance, is so injured that it evidently cannot recover, it ought to be removed instantly, and before the constitution has suffered. When gangrene follows inflammatory action, this is first to be moderated, and then the strength by all possible means supported. When only a portion of the soft parts of a limb is destroyed by mortification, and it is likely that the member may be saved and prove useful to the patient, measures should be adopted to hasten separation of the dead parts, and reparation of the breach in the living. After the separation of sloughs has commenced, the attention of the surgeon is chiefly to be directed towards the constitution; it must be supported and strengthened by nourishing food, wine, and tonics, or by stimulants, if necessary. Bark in substance, acids, and other supposed antiseptics, are of but little use. The local applications which have been employed are numerous; poultices of all kinds, charcoal, carrot, and effervescing; various lotions to the surrounding parts, spirituous applications, such as several of the tinctures, liniment of turpentine, balsams, &c., with the view of correcting the fetor. But it is evident that such applications to a dead part can be productive of no effect; the only beneficial result that can be expected from such means is removal of the fetid smell, which can be effected, if need be, by sprinkling a solution of the chloride of soda on the body-linens and bed-clothes. Scarifications are sometimes used; when these are made merely into the sphacelated part, they can be productive of good only by allowing the escape of matter; when they extend more deeply, they are injurious. When the sloughs become loose, they must be removed bit by bit with scissors; and when the sphacelated part has separated entirely, the healing of the breach is to be promoted by judicious dressing, bandaging, and by proper position. In mortification of an extremity, in consequence of injury, removal of the part by incision in the sound substance was formerly as much dreaded as in chronic cases before the separation had commenced; but such fears have now subsided, and the practice of delay has been in a great measure relinquished,—amputation being performed in the sound part, at a considerable distance from the mortified or even gangrenous tissues, and during the progress of the disease, occasionally with a favourable result. If the surgeon defer the operation until a line of separation have begun to form, he will soon discover the danger of his delay; the constitution will, in the majority of cases, rapidly sink under the malady before the progress of the disease is in any measure checked, or any attempt is made to throw off the mortified parts. Two cases which lately occurred in my hospital practice, are here introduced from the “Lancet,” to show how different the progress is, and how opposite the practice ought to be. Both the patients made excellent and rapid recoveries. “Sarah Arnold, Æt. 75, was admitted on the 26th of January. She has been a person of great mental and bodily activity, and has enjoyed excellent health from her infancy, until her present illness, although necessarily exposed, from the nature of her occupation, a gatherer and hawker of watercresses, to all varieties of weather. Illustration “27. She continues much the same as yesterday; slept little, bowels moved twice; tongue clean and moist; appetite very good; pulse as before; heat of skin natural; intellect clear; no expression of anxiety in the countenance. ?. Haust. Con. Vin. Full diet. “28. The suppuration on the inner side of the arm is more copious, and the discharge is more fetid. The livid spots on the outer side of the arm have not extended, and there is some slight redness around them. Pulse 104, of good strength; tongue clean and moist; heat of skin still natural; appetite good; bowels moved once since the last “29. The dry and shrivelled state of the extremity has extended as high as the middle of the forearm. The discharge is much the same as before in quantity, but is more fetid. The separation between the gangrenous and the sound parts, which had begun on the outer side of the arm when she was admitted, is extending a little, both towards the inner and the outer side. Pulse 90, of moderate strength; skin natural; tongue clean and moist; bowels open; appetite excellent. “30. Much the same as yesterday; sleeps a little better. “31. The suppuration is more copious; the discharge extremely fetid. The dead parts on the inner side of the humerus are gradually becoming more detached. No change in the appearance of the livid spots beyond the line of separation; pulse 102, of pretty good strength; bowels continue regular, and the appetite is good. Cont. vinum et haust. “Feb. 2. The separation of the gangrenous parts on the inner side of the arm has advanced a little more since last referred to. The livid spots have disappeared, with the exception of the largest, where a small superficial slough has formed. The diseased parts were removed to-day, the line of separation being fairly established, and suppuration having taken place in a great part of its extent. The soft parts were divided by means of a pair of scissors, cutting as near to the living parts as could be done with safety; the bone was then denuded as high up as possible, by passing a bistoury round it, and it was then divided by the saw. There was no bleeding from the soft parts, and only slight oozing from the bone, which was found to be alive where it was divided. Cont. vinum et haust. “3. Continues in much the same state as yesterday; pulse 104, of good strength; tongue clean and moist; bowels moved once; skin natural; appetite good; suppuration very free. Cont. “5. Suppuration copious; a portion of the dead parts left have separated, and left a healthy florid granulating surface. Continues much the same. “6. Discharge copious, and much less fetid; bowels regular; pulse 100, of good strength; tongue clean; appetite good; wishes for more food. To have an additional chop. Cont. alia. “8. The greater part of the sloughs have separated, and have left a healthy florid granulating surface; no change in the general symptoms. Continue. “9. The stump looks well, and the posterior part of the cut end of the bone is covered by healthy granulations. “In some notes of this case, kindly furnished me by the late Professor Fergus of King’s College, who had an opportunity of watching the appearances for some time before the admission of the patient here, it is mentioned that the flow of blood in the veins was exceedingly slow, and that hard knotty tumours could be felt in the parts before they became sphacelated. These swellings all along preceded the mortification. It is mentioned, besides, that the patient had a sort of fit, but that it could not exactly be ascertained whether or not “S.W., aged 16, was admitted March 12, under the care of Mr. LISTON. She is a servant girl, of sanguine temperament and good constitution. On Friday, March 9, she was cleaning the outside of a parlour window, and stood on the sill. The window-sash, upon which she was depending for support, being suddenly drawn down by a person inside, she was precipitated into an area, a distance of fifteen feet. She was immediately picked up, and conveyed to the hospital. The house-surgeon detected a compound fracture of the ulna, and a fracture of the radius, both fractures being a little above the wrist-joint of the right arm. The fracture was adjusted, and the wound, which was inferiorly to, and behind, the wrist, dressed in the usual manner. A dose of house-medicine was administered; suitable directions were given in case of the occurrence of pain or swelling; she was sent home, and desired to remain quiet. The following morning (Saturday) she was visited by the house-surgeon, who found her comfortable, but she had passed a sleepless night. On Sunday morning the affected part became so intolerably painful that she tore off the splints and bandages, which one of the dressers of the hospital had a short time before readjusted; in the evening she was in great pain, and the arm was much swollen. “12. To-day (Monday) she was admitted into the hospital; water-dressing was applied to the wound. The bandages were reapplied, and an anodyne administered in the evening, with the effect of producing some rest. “13. The pain and swelling were so great during the night that the house-surgeon was called up to see her, and ordered the application of fomentations; this morning she is much more comfortable. “14. On removing the whole of the apparatus this morning early, mortification was found to have taken place in the limb; at the time of Mr. Liston’s visit in the middle of the day, the limb was very swollen, the fingers were of a black colour, the forearm livid, there were vesications near the elbow with fetid discharge. There was a good deal of fever with slight delirium; pulse irregular, quick. Mr. Liston considered the only chance the patient had was the immediate amputation of the limb at the shoulder. The patient’s consent having been readily obtained, Mr. Liston proceeded at once to the “Operation.—He first introduced a long double-pointed knife under the acromion, and brought the point out at the lower and pos “15. Passed a good night; has had little pain; feels very comfortable this morning; she is cheerful, and has little fever; pulse 86, regular. The wound looks healthy. “April 2. Since the above date, the patient has been gradually improving in her health and strength, and she is now able to walk about the ward.” In gangrene occurring after exposure to cold, amputation should not be had recourse to till after the line of separation has formed; and in this case the constitutional symptoms are much less urgent, and the object of the operation might be frustrated by its being performed in parts, which would speedily become sphacelated. The amputation may be performed either at the line of separation by cutting the ligaments or bones, as was done in the case from which the accompanying sketch was taken, and when the line of separation is well declared; or, if by these means a good covering is not likely to be had for the exposed surface, the incisions may, in these cases, be with safety and propriety made in the living tissues, at the most convenient point. Illustration In gangrene arising from obstruction or injury of blood vessels, in healthy constitutions, amputation must be performed early—for thus the chance of ultimate success is increased, while the danger of delay is the same as in cases of gangrene caused by severe injury. OF ERYSIPELAS.Erysipelas is an inflammation of the external surface, accompanied with peculiar symptoms and appearances, the morbid action being modified by the texture in which it occurs. According to the various circumstances attending the disease, it has been divided into several species: phlegmonous, bilious, oedematous, gangrenous, acute, malignant, &c. The term Erythema is applied to cases of rash or efflorescence, unaccompanied with fever, swelling, or vesication. Inflammation of the skin only, is marked by bright redness, not circumscribed, and disappearing when pressed. By pressure, the bloodvessels are emptied for a time, the part sinks and becomes pale; but, on removing the pressure, it soon regains its former colour and relative situation; when these circumstances concur, the part is said to pit. There is no tension,—the pain is not throbbing, but of a burning or itching kind, and there is often a degree of oedematous swelling. Swelling does not occur to any great extent, however, during the existence of the inflammation in the skin and rete mucosum; but the parts sometimes become much swollen after subsidence of the inflammatory action, the vessels having relieved themselves by effusion of serum; and afterwards the oedematous surface often assumes a yellowish hue. In some cases, the serous effusion is from the first, more extensive than in others, and hence the term oedematous erysipelas, or inflammatory oedema. Upon the decline of inflammation, a serous fluid is often effused also in great quantity under the cuticle, giving rise to vesications, resembling the blisters produced by the application of boiling water to the skin; and from this circumstance, erysipelas has been classed amongst cutaneous affections in the order bullÆ. The erysipelatous redness does not terminate abruptly, and is not defined by a distinct boundary, as some have asserted, but becomes gradually lost in the surrounding parts. It frequently involves the contiguous parts one after another, and extends with great rapidity. It often leaves one part suddenly, and attacks another, either in the neighbourhood, or situated at a considerable distance; in other words, metastasis takes place. The disease takes on this erratic character without our being able to assign any good reason for it; and this form of the disease is frequently attended by symptoms of typhoid fever. When it disappears suddenly, or is repelled by cold applications, affections of the internal organs sometimes supervene, as of the bowels, lungs, or brain; the diseased action leaving the external surface, and attacking the deeply-seated organs; thus, in a case of erysipelas of the ankle and foot, the external symptoms disappeared suddenly, and an affection of the lungs supervened, under which the patient sunk; and in erysipelas of the face and scalp, the sudden disappearance of the redness is frequently followed by delirium and coma. Again, in acute disease of an internal part, the symptoms are much meliorated, and often entirely removed, by inflammation of the skin being induced artificially, or occurring spontaneously. The integuments of the face and head are frequently attacked by erysipelas, in consequence of wounds and bruises of the face or scalp, even though very slight, and it often takes place here spontaneously, as in other parts of the body. Erysipelas commonly arises from constitutional derangement, as is shown by the symptoms which precede it, and also by the efficacy of internal remedies in checking its progress; in such instances, external applications, unaccompanied with constitutional treatment, produce little or no effect. It is often produced around a wound by the employment of improper dressing, rancid ointments, or irritating plasters, by a too free use of the part, or by the friction and irritation of the patient’s clothes. It occurs most readily in those who live freely, indulging in the imprudent use of spirituous liquors, and whose constitutional powers are thereby considerably weakened. It is also said to be sometimes caused by violent passions, as anger or grief; and by exposure to cold, or to heat,—the former acting only as a remote, the latter as an immediate cause. As an example of its occurring in consequence of heat, it is a common remark, that cooks, who are necessarily much exposed to the fire, are frequently the subjects of erysipelas of the face; but in the majority of such cases, there may be other causes in operation,—the abuse of ardent spirits, and habitual overcharging of the system with stimulating food. It is more commonly met with in summer than in winter. And in certain states of the atmosphere, even in healthy situations, a degree of erysipelas is apt to occur after wounds by operation or accident. It is often periodical, especially in females who have ceased to menstruate, always recurring at regular intervals; it attacks parts of the body, most generally the face, and in some cases monthly, in some once in the year, and in others once every two years. It sometimes appears to occur as a natural means of relief from impending affections of more serious nature, as of the system or of internal organs. Those who have once been afflicted with the disease become more liable to its attacks. Erysipelas is generally preceded and accompanied with more or less disturbance of the digestive organs. In Bilious Erysipelas, the portion of skin affected is said to present a more yellow colour than in the phlegmonous, the derangement of the digestive organs is greater, and hence the origin of the distinctive term; fits of shivering occur, the patient complains of a bitter taste in his mouth, and the tongue is furred and of a brown colour. In the Phlegmonous, in which other textures than the skin are often affected, viz., the subcutaneous and intermuscular cellular tissue and the fasciÆ, the pain is more intense, and of a throbbing kind; the swelling is hard, more deeply seated, and more extensive; there is considerable tension; and the redness is of a darker hue. Nausea and a bitter taste in the mouth do not precede the erysipelatous appearance, but the skin and tongue are dry, and there is great thirst. When the disease begins to subside, then the foul tongue supervenes, with the bitter taste and nausea. Erysipelas, of a contagious and violent character, frequently occurs, and is apt to spread extensively, in badly aired situations, where a Hospital Erysipelas, as this species is termed, is nearly allied to that dreadful disease, Hospital Gangrene, and the two affections are often blended. It comes on after operations, or in patients who have sustained an external injury by accident. In unhealthy hospitals it not unfrequently appears in previously sound parts, and without any assignable cause; and, from its following the slightest wound, recourse cannot be had with safety even to venesection, cupping or leeching. It is a dreadful scourge in many hospitals, more especially during particular seasons of the year—during hot, damp weather, and in spring and autumn, attacking the patients indiscriminately. Of late years Erysipelas appeared in the Royal Infirmary of Edinburgh, during the wet and changeable summers which prevailed; some of the cases were very severe, and a few terminated fatally. It was very satisfactory, however, to observe that it did not spread as it used to do formerly, that patients occupying the beds immediately around those affected, though afflicted with sores and in indifferent health, remained exempt from the disease; and that many of the most severe cases did not originate in the house, but were brought from the crowded and unhealthy parts of the city. The same may be said of the disease as it has shown itself in the North London Hospital since it was opened for the reception of patients up to the present time. Hospital Erysipelas is for the most part preceded by violent constitutional symptoms, derangement of the chylopoietic viscera, shivering, brown tongue, and a bitter taste in the mouth; if there is a sore on the body, it assumes a sloughy aspect; the surrounding skin becomes of a dark red colour, and there is a feeling of tension, accompanied with a burning pain. The erysipelas extends rapidly, and generally terminates in suppuration and sloughing of the cellular substance, or, if inertly treated, in immediate gangrene of the parts. The concomitant fever is generally low, and though, in the first instance, the circulation may be vigorous, symptoms of debility will speedily appear. It will be more fully dwelt upon, along with Hospital Gangrene. In all cases of erysipelas there is more or less concomitant fever, modified by the extent of the local affection—by the age of the patient—by the previous habits and state of health—by the constitution—and by other circumstances. The pulse is accelerated, and is either of a sthenic or asthenic character, according to the state of the system and type of the prevailing fever. There is headache, languor, thirst, restlessness, and even delirium, especially when the face or scalp is the seat of the disease. Erysipelas may terminate in resolution. If this takes place in the first stage of the disease, the redness gradually declines, along with the swelling, the cuticle exfoliates, and the part regains its usual appearance, the skin remaining loose and shrivelled. If it occurs after vesications have formed, the effused fluid is absorbed, a scab forms, and desquamates along with portions of the cuticle. It may terminate in suppuration, when the inflammation has ex Acrid sanious matter is often infiltrated extensively into the subcutaneous cellular tissue round a wound or sore. The superimposed integuments are of a dark brown colour, and the part is boggy. Sloughing of the cellular membrane here takes place in consequence of the infiltration, and not from inflammatory action having been established. The affection has been termed Diffuse Cellular Inflammation, but a more proper appellation is Diffuse Cellular Infiltration; the cellular tissue, even where treatment is adopted at an early period, can scarcely be prevented from perishing. Erysipelas, if properly treated from its commencement, will seldom terminate in gangrene of the skin. This termination is occasionally observed, however, in patients whose constitutions have been extremely debilitated. In mild cases of erysipelas, attention to the state of the bowels, and regulation of diet, will often be sufficient to remove the disease. When there is much disorder of the digestive organs, and particularly of the biliary secretions, emetics may be given at the commencement; these are productive of but little good in the more advanced stage, and their place is advantageously supplied by nauseating doses of antimony, combined or not with purgatives. One-eighth of a grain of tartarised antimony may be given in solution every hour, with or without a due quantity of the tart. potassÆ and sodÆ, or Rochelle salt. The hydrargyrum cum creta is often given with great benefit when the tongue is dry and covered with a brown crust: it may be combined sometimes advantageously with the compound powder of ipecacuanha. With the same view calomel with antimonial powder may be exhibited. The exhibition of saline purges is attended with great good in some severe cases. Such medicines tend to subdue any arterial excitement that may exist, evacuate the bowels, promote perspiration, remove the superabundant bilious matter, and serve to restore the healthy functions of the liver. In severe cases, more especially of phlegmonous erysipelas, in which there is acceleration of the pulse, and a degree of febrile excitement, general bleeding may be had recourse to; but it must be employed with caution, for the symptoms of increased vascular action may arise from constitutional irritation, and not be meliorated by the depletion. The practice is superseded by the timeous and free local bleeding from incisions, as will be noticed by and by. The exhibition of the extract of aconite in this and other inflammatory affections, is often followed by great abatement of vascular excitement, so that the necessity for abstrac In erythema, the mere outer surface of the skin only being slightly affected, and not to any very great extent, advantage sometimes results from the application of nitrate of silver. A strong solution may be pencilled upon the part, or, after being wetted, the affected surface may be gently rubbed over with the solid caustic. The pain and uneasy sensations in the part being thereby diminished or removed, and extension of the disease seeming to be arrested. Discoloration caused by such practice is of little consequence, as desquamation must follow. It is questionable how far it may be safe to apply lunar caustic to any extensively inflamed surface, more especially of the head and face, lest metastasis should occur. The inflammatory action in the skin is subdued by the application, whilst it may advance, in the cellular tissue, to suppuration and sloughing, if other means are not adopted; and from the hard and blackened state of the cuticle, the condition of the subjacent parts is not readily perceived. The remedy is only applicable to erythema, and most advantageously as a means of bounding it. The line should be drawn at some distance from the affected tissues; and if so, it is seldom that the disease oversteps it. Local abstraction of blood, by puncture or incision, proves exceedingly beneficial in cases of erysipelas, whatever its degree. It must be borne in mind by the practitioner, when called to treat the disease, that the state of parts is very various, and this may depend upon the original nature of the disease, upon its site or duration. The surface of the skin only may be affected—that and the subjacent cellular tissue may be involved, gorged with serous, lymphatic, or purulent infiltration—there may exist great tension of the parts, with a sloughy state of the cellular tissue, established in addition to suppuration—and again, there may be infiltration of the subfascial and intermuscular tissues, leading ultimately to exposure and exfoliation of bones or disease of articulations. From inattention to these circumstances, the treatment being often directed to the name of the disease, great discrepancy of opinion, as to the most proper local management, has arisen; there has accordingly been a controversy as to whether the blood should be drawn from mere punctures from limited incisions, or from long gashes extending from one joint to another. In cases not very severe or extensive, when the skin only is af Some surgeons have disapproved of long incisions, alleging that they are tedious in healing, and prefer making numerous small ones; but it is difficult to understand how the cure should be more tedious in the one case than in the other, when the actual extent of divided surface is the same. According to my experience, several free incisions are made with less pain than a number of trifling scratches, and heal as soon, whilst by the former the purpose of the practitioner is much better fulfilled: the same good effects result from them as from punctures in the more slight cases, if they are made at the commencement of the disease; and if the affection is in its advanced stage, the effused fluid, and the sloughs, are discharged, and the infiltration of pus, and destruction of parts in consequence of the matter being confined, are prevented by its being allowed a free exit as soon as it is formed. Incisions then are made both in the early stage of the disease, and after effusion has occurred: in the former case, they are justifiable, because they arrest its progress; in the latter, they are absolutely necessary, to prevent its injurious effects. The parts are to be fomented, and afterwards covered with a common poultice, containing no oil or grease, or with soft lint saturated with tepid water, and covered with oiled silk, to prevent evaporation. When the erysipelas has gone off, the incisions are treated as common wounds, by dressing and bandage. After punctures, or incisions, more or less blood is allowed to flow, according to circumstances. It often escapes from the vessels of the part in great profusion; this, in many cases, may be prejudicial or excessively dan Powders, such as flour, chalk, and camphor, &c., have been applied to the erysipelatous surface, but are of little use, and, by their irritation, frequently prove injurious on the bursting of the vesicles. They are applied, according to some, with the view of cooling the surface, and after all the part may be seen enveloped in folds of flannel. Cold application, such as the spirituous and evaporating lotions, containing vinegar and spirits, liquor acet. ammoniÆ, Goulard’s extract, &c., may, in many cases, afford temporary relief, but their use is fraught with the utmost danger; for their direct tendency is to produce metastasis, and if that be to an internal organ of importance, the result is too generally fatal. Or if the erysipelas, on leaving the part originally affected, attack another also superficial, the local treatment has to be commenced anew. If these lotions are to be employed at all in this disease, they must be made tepid. In case of the translation of erysipelas to any important part, blisters may be applied to the surface which it has left, or to any other in the neighbourhood, with the view of recalling the disease to its original and less dangerous situation: In Hospital Erysipelas, purging cannot be carried to any great extent with safety, and general bleeding is seldom if ever admissible unless the patients previously robust and in good health, in whom the disease has occurred in consequence of their being conveyed to a distance and during hot weather, after an accident or wound, and in whom the fever is of a violent inflammatory nature. In civil hospitals, the patients are generally in a weak state before the accession of this disease; and in their case, after the stomach and bowels are regulated, stimulants are more requisite. Great attention must be paid to cleanliness, the sores must be frequently dressed, and the same sponges must not be used for different individuals: in order to prevent contamination by the promiscuous use of sponges, it is better to clean the parts around sores with lint or tow, and to destroy immediately such dressings as have been used. The apartments must be well ventilated, and those who are affected with the disease should be separated from the rest of the patients. The local applications will vary according to the particular circumstances of each case. Strong escharotics may be required to clean the surface of the sores, and put a stop to the sloughing. The nitric acid will answer the purpose well, and is less objectionable than some remedies that have been used; such as the arsenical solution, or the red hot iron. OF FURUNCULUS AND ANTHRAX.Furunculi, or Boils, most generally occur in unhealthy constitutions, particularly in those individuals who are habitually addicted to the use of ardent liquors: they seem to arise from, at least they follow, disorder of the digestive organs. Their seat is in the skin and subjacent cellular tissue. They generally occur in those parts which are possessed of little vitality, as in the back, buttocks, shoulders, the posterior part of the neck, &c. They are seldom single, are often numerous, and vary in size from a pea to a pigeon’s egg. A boil is of a conical form, elevated above the surface of the body; its base is hard and firm, whilst its apex is acute, soft, of a white colour, and exceedingly painful; the pain experienced in the tumour In this unhealthy species of inflammation, resolution cannot be expected; on the contrary, suppuration is the natural termination of the disease, and must be hastened by poultices and fomentations. A simple or crucial opening, according to circumstances, must afterwards be made in the apex of the tumour, so that the sloughs of the cellular tissue may be permitted to escape readily. In the advanced stage, the sloughs are the irritating cause by which the inflammatory action is prolonged, and on their removal the cavity contracts speedily. If there is much derangement of the digestive organ, it may frequently be found necessary to administer an emetic. If the bowels are slow and the liver torpid, calomel and antimony are highly useful, or other mercurial preparations may be given, in combination with active purgatives; if the state of the secretions is more natural, these medicines may be administered in alterative doses. The mineral acids are often usefully administered, with the view of removing the disposition to the formation of boils. Twenty minims of the aromatic sulphuric acid may be given twice or thrice a day in any convenient vehicle. Anodynes are occasionally required. Anthrax or Carbuncle maybe considered as a severe form of boils. It occurs in the plague, and is a characteristic symptom. It appears in the same parts, and apparently from the same causes, as the boil. The tumour is of a more flattened form, slightly elevated above the It seldom occurs in the face or head, and when it does, it generally proves fatal. In a male patient in the Edinburgh Royal Infirmary, aged forty-eight, a carbuncle of the size of a very large orange was situated in the centre of the forehead; by active local and constitutional treatment, he soon got well. The affection is sometimes attended with typhoid symptoms, rigors, profuse perspiration, nausea, vomiting, disordered bowels, loss of appetite, anxiety, restlessness, difficult respiration, palpitations, faintings, pale-white tongue, low pulse, pale or turbid urine, headache, giddiness, drowsiness, and, in severe cases, with delirium. In old or exhausted patients, the prognosis is unfavourable. An early and free incision must be made into the tumour; if the swelling is large or extensive, the preferable form of incision is the crucial; the ill-formed matter is thus evacuated, the slough exposed, and more readily allowed to escape. If the mortification of the cellular tissue be extensive, and the sloughs prove firmly adherent, the free employment of the caustic potass will be found of much service, the half-dead cellular substance being thereby completely destroyed, and the surrounding parts stimulated to a new and superior degree of action, necessary for the removal of the mortified parts, and reparation of the breach of surface. Poultices and fomentations may afterwards be employed, followed by the warm-water dressing, medicated or not. The stomach and bowels must be put into proper order by the exhibition of suitable medicines; and the vis vitÆ may be still farther supported by the administration of tonics and stimulants. If, after the separation of the sloughs, the exposed surface shall assume an indolent or debilitated action, stimulating dressings, such as turpentine liniment, or elemi ointment may be employed. Such practice will be found sufficient to procure a speedy and favourable termination of the disease, in this country, where we have not to combat any of those malignant diseases with which carbuncle is accompanied in other climates. OF INFLAMMATION OF THE MUCOUS MEMBRANES.Mucous Membranes and the skin are analogous in structure, somewhat similar in function, and sympathise closely with each other in health and in disease. Both are endowed with that peculiar degree of sensibility which enables them to bear with impunity the impressions of foreign bodies; and both are protected from the influence of these bodies by an inorganic covering; the cutis and rete mucosum by the epidermis; the corium of mucous membranes by a laminated epithelium. They are the seat of all excretions, and by them all substances are introduced from without into the system. The capillary portion of the vascular system appears to have somewhat the same arrangement in both; the distribution of blood to the mucous membranes being, however, more copious. At the commencement and extremity of the alimentary canal, they insensibly pass into each other by means of an intermediate structure, of which the prolabium may serve as an example. In particular circumstances, they change into each other, both in appearance and in function. Thus, in prolapsus of the gut or of the vagina, the discharge from the protruded mucous surface after a time subsides, the rugÆ disappears, the membrane becomes thickened and indurated, and gradually assumes an appearance exactly resembling that of the skin. In natural paraphymosis, the delicate membrane which, in the healthy state of parts, lines the internal surface of the prepuce, becomes converted into a cuticular covering. In neglected and long-continued excoriation of the nates, the raw surface, which was at first tender and irritable, and discharged a serous fluid, becomes villous, less sensible, and discharges a fluid similar to a mucous secretion. In sinuses also of long duration, the secreting surface becomes changed, so as to resemble a mucous membrane, and the discharge, from being purulent or gleety, becomes mucous, or at least resembles a mucous fluid, A mucous surface, when inflamed, has for a short time, perhaps, at first, its functions suspended; it then furnishes a secretion, increased in quantity, and but little changed in appearance from the healthy fluid; afterwards the discharge resembles purulent matter, and is termed muco-purulent. When, however, the inflammation is violent, the discharge becomes bloody, or is altogether suppressed, and the membrane is thickened. Inflammation of a mucous membrane is very apt to spread with great rapidity, in this respect resembling the corresponding affection of the skin. It is attended with a sense of itching, and a burning pain. This pain is much increased by the muscles surrounding the parts being thrown into action, as in expelling their contents, more especially if these be of an acrid quality. The membrane is thickened, and of a spongy appearance; its surface is red, and sometimes covered with flakes of lymph; occasionally it is much softened, and coated with a viscid adherent mucus; and it would appear, in many instances, that, in acute inflammation, the membrane is generally softened, whilst it becomes indurated from chronic inflammatory action. When the inflammation is violent, and In inflammation of this tissue, metastasis is also apt to occur, from one part of the membrane to another, and from the membrane to the external surface. Cynanche, for instance, often follows upon erysipelas of the face and scalp, and vice versÂ. The passages, the internal surfaces of which are invested by a mucous membrane, are those subservient to respiration, nutrition, generation, and the urinary secretions; in other words, the mucous surfaces are the Pneumogastric and the Genito-urinary. Their particular diseases will be treated of hereafter. OF INFLAMMATION OF THE SEROUS MEMBRANES.On such an extensive subject it is unnecessary to enter fully; not that the inquiry is uninteresting, or that a knowledge of the diseases of the internal cavities, and the mode of treating them, is not required of the surgical practitioner before he can enter into practice, with safety to his patients and comfort and satisfaction to himself, but we have a very important class of diseases to bring under review in a limited space, and it is properly the province of others to treat of internal disorders, and to describe the best mode of alleviating or curing them. It is, however, the duty of the surgeon to treat the inflammatory affections of some of the serous membranes, and the consequences of inflammatory action in most of them; and it is therefore highly necessary that he understand the symptoms, progress, and consequences of such actions. The affections of the serous membranes are principally under the management of the physician; but they not unfrequently follow wounds and surgical operations, and the diseases of several of them are purely surgical. Inflammation of a serous membrane is attended with heat and pain, aggravated by motion of the parts and by pressure; the natural secretion is increased in quantity, the process of exhalation being incited, and that of absorption weakened; the serous fluid accumulates. The secretion becomes altered in quality, and assumes a milky appearance; lymph is effused, generally mixed with purulent matter, and floats in the fluid, or adheres to the surface of the membrane, which is rough and flocculent. The adherent lymph becomes organised, being penetrated by numerous bloodvessels; and thus the original membrane is, in many instances, much thickened, chiefly from the addition of new matter, though also from enlargement of its bloodvessels and opening out of the primitive tissues, principally the subserous cellular. When inflamed serous surfaces, which have been altered, both in texture and function, in consequence of inflammatory action, remain for a short time in contact with each other, lymph is effused and penetrated by bloodvessels from each surface; thus the new deposit is organised, and forms a medium of connection. By this process the parts are inti OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS.Inflammation of the synovial surface occurs in consequence of wounds, bruises, or sprains, and often from exposure to cold; from the latter cause, the knee and elbow joints most frequently suffer, as they are generally more exposed to its influence, and not so well covered with muscular substance as the others. Constitutional diseases, such as certain fevers, are followed sometimes by effusion of serous fluid into joints. Purulent matter is also deposited in joints during certain forms of suppurative fever; and this is attended by rapid change of structure. There is heat, throbbing, pain, and swelling of the part, sometimes redness of the surface, and great constitutional disturbance; the symptoms and appearances, however, vary much, according to the extent of the joint which is involved. When part of the capsule is affected, the inflammation spreads rapidly over all the surface; the When the action is more violent, and is not actively opposed, lymph is effused on the inner surface of the membrane, or is deposited amongst the ligamentous and cellular tissues external to the joint, in consequence of which, the membrane and external ligaments become thickened, and of an almost cartilaginous consistence. Serum is effused into the more superficial cellular tissue, filling up the hollows around the joint, concealing the protuberances of the bones, and producing a globular swelling. The articulating surfaces become ulcerated, and matter forms within the capsular ligament; or the pus is deposited exteriorly to the joint, and gradually approaches the surface. But although ulceration is so prone to occur in the cartilages, the synovial membranes do not readily take on this action, unless from the progress of matter, formed within the joint, towards the surface. The synovial lining of the bursÆ and sheaths of the tendons are extremely indisposed to ulcerate; and it may be remarked, that, while suppuration without ulceration is common in the synovial membranes, the cartilages, on the other hand, afford frequent instances of ulceration without suppuration, of which more particular mention will be made in the sequel. The cartilage is occasionally swelled and softened where the disease has long existed. Along with ulceration of the cartilage, a portion of it may become dead, or either state may occur separately; and in many cases, the substance of the bone also becomes affected, of which two classes of cases may occur, viz., great inflammation on the articular surface of the bone, with separation of the cartilage by the ulcerative process in this situation; and inflammation of the medullary web, leading to atrophy of the cancelli, collections of pus therein, or even death of a portion of the spongy texture of the bone, as will be more particularly treated of in the chapter on diseases of the osseous tissue. These changes often compose the primary disease, and to them the affections of the synovial membrane and other parts succeed. Such occurrences are attended with alarming disturbance of the constitution, with fever, and even with the most threatening and dangerous symptoms, such as delirium and coma. If the patient An opinion has been broached lately by Mr. Key, that the ulceration of cartilage was consequent upon the increased vascularity and thickening of the synovial membrane, that the cartilage, in fact, was removed by the action of the vessels ramifying in the membrane, and the prolongations or fringes from it in its diseased condition. Occasionally these fringes correspond, in a remarkable manner, to the breach of surface in the cartilage; but again, ulceration is frequently met with far removed from the membrane. It is also seen, in cases where an opportunity is afforded of making the examination in the earlier stage of disease, that ulceration exists to some extent whilst the synovial membrane is unaffected. And certain cases, in which the cartilage is affected with hypertrophy, and the common form of atrophy of this part in old people, are altogether adverse to Mr. Key’s views. When ulceration takes place at a point removed from the attachments of the synovial membrane, it appears to proceed more frequently from the attached than from the free surface of the cartilage; then the adventitious membrane occupying the rugged spaces, and which under the microscope appears highly vascular, is connected apparently with the medullary web. In acute inflammation of the synovial membrane, and in cases where the cartilage is ulcerated, the pain is very intense, and the spasms of the limb most distressing. This happens when the surface is ulcerated, and perhaps to no great extent. We know that in the horse an ulcerated hollow in the cartilaginous covering of the navicular bone, not so large as to contain a grain of barley, will cause such lameness and suffering as to render the animal so affected perfectly useless. If he is not destroyed at this stage, as many valuable animals have been, the mischief extends, and terminates in extensive disease of that and the neighbouring bones and articulations. It is different if the disease commence, as it sometimes does, in the human subject, in the cancelli of the bone, and on the attached surface of the cartilage, the free surface remaining some time entire and smooth. When the synovial membrane is primarily affected by chronic disease, the pain is in general trifling, often not complained of, and swelling of the part, from effusion, into the joint or neighbouring bursÆ, first attracts attention, after it has existed, perhaps, in a slight degree, for a considerable time. The joint is stiff, and pain is experienced from extensive motion; on this account the patient is disinclined to use it, and it is soon tired by the slightest exertion. The swelling becomes more solid, though still remaining elastic, and the feeling of fluctuation diminishes. Effusion of lymph follows that of serum, the latter having been absorbed; the motion of the joint is still further impeded, and the articulation is distorted; the patient keeps the limb in the most easy position, generally that of partial flexion, in which it becomes almost immovably fixed. The cause of the flexed position, which is almost pathognomonic of knee disease, being preserved, seems to be that the limb is insensibly brought into it in order to take the pressure off the interarticular apparatus, the ligamenta mucosa and alaria,—these swell—the The swelling is often irregular, being more protuberant at one part than another, from the fluid or the addition of solid matter being accumulated where the least resistance is afforded; but the slighter inequalities are generally filled up by oedema of the cellular texture. As the disease proceeds, matter forms in the joint, and is often attended with great pain and fever; or the pus is effused into the bursÆ, into the surrounding cellular tissue, or into the filamentous tissue amongst the tendinous sheaths of the muscles in the neighbourhood; being allowed to remain without an outlet, it at length communicates with the cavity of the joint. Portions of the cartilages are absorbed, though this, as already noticed, may occur at the very commencement of the disease; the subjacent bone becomes affected by ulceration, or perhaps its vitality is partially destroyed. When matter has accumulated, a portion of the capsular ligament generally ulcerates, the pus escapes, and is ultimately discharged externally. When the disease begins with swelling, which is of a chronic character, and produces but little inconvenience, and when the more urgent symptoms supervene after the swelling has continued for a considerable time, there is every reason to suppose that the disease has originated in the synovial membrane, or perhaps in the osseous cancelli, and this is generally met with in poorly fed and strumous subjects. But when the first symptoms have been pain and stiffness of the joint, without change of its appearance, and when the swelling has occurred after these symptoms have been of some duration, then it is probable that the cartilages are the primary seat of mischief. For the most part, however, the symptoms have a general resemblance in most chronic affections of the joints, and all the apparatus is sooner or later involved. When the cartilage has been extensively Purulent matter not unfrequently collects in the substance of the bones, which in all cases ultimately become softened in a remarkable manner. In many subjects, without actual disease of the osseous tissue, the heads of the bones are so altered in consistence, are so deficient of earthy matter, as to be easily cut with a knife. It has been a matter of dispute, whether, in this affection, the articulating extremities of the bones are enlarged or not; and the supposition that they are always more or less increased in size, or hypertrophied, has arisen from the extensive effusion and indurated state of the soft parts being mistaken for this enlargement. In the first stages of the disease, they are seldom, if ever, enlarged; but when ulceration of the bone has occurred, new osseous matter is deposited to a greater or less degree in the neighbourhood of the ulcer,—an attempt by nature towards a cure, but too often an ineffectual one. The bones, in strumous subjects, are often much enlarged, from collection of purulent matter in their substance giving rise to a sort of spina ventosa. I removed the upper extremity of a boy lately on account of extensive disease about the elbow. The ulna to near the wrist was swollen enormously by purulent collections in its medullary canal. In cases when the whole of the articulating extremity of the bone is not enlarged, still that portion which is more immediately concerned in the articulation is often considerably expanded. Frequently when the knee is the seat of the disease, the lymphatic glands in the groin are enlarged; and when the elbow or wrist joints are affected, there is often a similar enlargement of the glands in the axilla: such glandular tumours have not rarely been confounded with those accompanying malignant disease, and measures which were absolutely necessary for the salvation of the patient, have thus been delayed or neglected. When the disease is extensive, and has endured for a considerable period, hectic fever supervenes, and is aggravated after the abscesses give way. The patient becomes much weakened and emaciated, and loses his appetite; the pulse is rapid, with night sweats, diarrhoea, &c.; and from a continuation of the hectic cause, the life is endangered. In some cases, however, the health is restored, and the disease abates spontaneously; in others, the disease is arrested, and a complete cure accomplished, by the careful employment of such means as will be afterwards mentioned. The appearances produced by inflammation and consequent disease of the synovial membrane, are the following. In the first stage, the internal surface of the capsular ligament, and the rest of the synovial membrane, is found of a red hue, its formerly colourless vessels being now made apparent, from enlargement and consequent injection with a greater quantity of red blood; and the serum within the cavity of The interarticular adipose tissue also seems to be increased in volume, from being infiltrated with a serous fluid, by the discharge of which the diseased bloodvessels may have attempted to relieve themselves. When the inflammation has been intense, or of long duration, lymph is secreted, and deposited on the external surface of the membrane, forming an intimate union between it and the ligaments, and producing thickening of the external apparatus. Or the lymph is also effused on the inner surface of the membrane, to which it adheres and becomes organised; this is generally accompanied by the formation of purulent matter; the organised effusion is often so extensive as to conceal almost the whole of the synovial membrane, excepting portions of its delicate reflexions which invest the articulating cartilages. By the lymphatic deposit, to a less degree, the folds also of the synovial membrane adhere to each other, whereby the motion is still farther impeded, and the pain, when attempted, increased. Occasionally the synovial membrane is found enormously thickened, much softened in texture, and of a brown hue, when the disease has been of a very chronic character. Along with these appearances, serum is generally found effused, in a greater or less quantity, into the cellular tissue exterior to the ligamentous covering. In cases in which the matter has formed and remained long within the cavity of the articulation, the synovial membrane and the ligaments become blended into one soft mass, the internal surface of which is lined with a thick coating of lymph, as in the case of common abscess. If purulent matter is effused externally, and communicate with the joint, the capsular ligament will be found to have ulcerated and given way at certain points, forming apertures, usually of small size, and with ragged margins. All these appearances may exist without disease of the cartilages Illustration or extremities of the bones; but generally they are also affected at the same time. At first the surface of the cartilage is slightly irregular and rough, and the change is not observed, unless on minute inspection. Afterwards the surface is marked with small depressions, which may be numerous, and are surrounded with irregular and somewhat serrated margins. They gradually increase in depth and extent, and the subjacent bone is ultimately exposed at one or more points, as here shown. Often the greater part of the cartilage is removed by absorption; the bone is exposed, opened out in its texture, softened, of an irregular surface, and in some places excavated, containing a thin ichorous fluid; the process of ulceration has also extended to the osseous tissue. Sometimes scales of cartilage of considerable size are either completely detached, having become dead, and been The incipient stage of such disease may exist without the synovial membrane being much, if at all, affected; but when the ulceration has made farther progress, all the articulating apparatus is more or less diseased. It may be here remarked, that the synovial membrane may be affected for a long period, thickened portions may extend over the cartilages, and these may have lymph upon them and yet remain intact. Illustration The cure, resorted to by nature, and in which she may be much assisted by the surgeon, is Anchylosis, ligamentous or osseous. New bone is deposited in the neighbourhood of the disease, and the ulcers become, as it were, cicatrised; the articulating extremities of the bones are joined to each other by a firm osseous matter, either universally disposed or consisting of processes extended between the bones at various points: or again, in consequence of the effusion of lymph into the cellular tissue, and the consequent thickening and induration of that and of the fibrous tissue exterior to the joint, this connecting medium is so strengthened and concentrated as to retain the articulating surfaces in exact apposition; from one, and usually from both, of these changes, the joint is securely fixed and rendered immovable, or nearly so. In complete anchylosis, the cancellous texture of the two bones, after some time, becomes perfectly continuous, so that they in fact constitute but one bone, as seen in cut, p. 84. A very perfect specimen of anchylosed knee joint is also delineated in the cut above. But even after this happens, the disease is still apt to recur from slight causes, the bony or ligamentous union being The joints are often affected by rheumatic and gouty inflammation; and there are three species of disease, tolerably distinct in their pathological characters, generally attributed to these causes. In one there is a deposit of chalky-looking matter, composed chiefly of super-lithate of soda, on the articular surfaces of the synovial membrane and cartilage, but most abundantly in the cellular tissue outside the joint, an affection in which the cartilage is seldom known to ulcerate. In the second, the cartilages are atrophied, as if Illustration worn away by attrition, the articular surfaces of the bone being much modified in shape, more or less denuded of cartilage, and remarkably polished and hard, so as to have been compared to porcelain, as will be described in another section. In the third, the fibrous tissue in the neighbourhood of a joint is primarily affected, the synovial membrane and cartilages not becoming involved till the disease is much advanced. It is not uncommon in the elbow of middle-aged persons who have been much exposed to the atmospherical vicissitudes, and is sometimes attributed to the effect of mercury or syphilis. The periosteum around the articular ends of the bones becomes swelled and painful; the affection is very slow in its progress; abundant deposition of adventitious bone takes place, often in short spiculÆ, gradually encroaching around the joint, which ultimately becomes involved. A good specimen is here given. The disease was of twelve months’ duration, and was attributable to rheumatic inflammation supervening upon sprain. The affection involves extensively all the bones composing the articulation. Although wounds penetrating the larger joints are attended with danger, the synovial membranes are possessed of considerable powers of reparation, and often heal readily after severe injuries. An occasional result of inflammation is adhesion between the layers of the membrane, but this is by no means so frequent as in the serous tissues. The reparative power of cartilage is so low that the best termination that can be expected from the ordinary forms of ulceration, is union between the abraded surfaces. In experiments which have been made on the lower animals, portions of cartilage which had ON HYPERTROPHY AND ATROPHY OF THE ARTICULAR CARTILAGES, WITH EBURNATION OF THE SURFACES OF THE BONES.It has been already observed (at page 68), that the cartilages are occasionally swelled and softened in cases of chronic inflammation; and it now remains to notice instances in which they become hypertrophied or atrophied, apparently without inflammatory action. Although these affections are not likely to come often under the treatment of the surgeon in civil life, yet they are of much importance to the naval or military practitioner, since an accurate knowledge of them will lead him to institute a careful inquiry when a man complains of inability to sustain the fatigue of marching with the burden of a heavy knapsack; and they are of considerable interest in a physiological point of view, because they tend to show the inherent vitality of cartilage, and that it is liable to serious organic changes quite independently of diseased action in the surrounding tissues. Some examples of hypertrophy of cartilage, principally affecting that of the patella, have been described by Mr. Gulliver, and figured in the third fasciculus of drawings from the Army Anatomical Museum. In these the cartilage is swelled so as to form a ridge across the articular surface of the bone, the hypertrophied part being perfectly smooth, except where its continuity is interrupted by irregular fissures, as if the perpendicular cartilaginous fibres were split into bundles of variable size and shape. These cases occurred in young and middle-aged men who died of pulmonary consumption; and it is probable that the disease would be more frequently found, if it were more frequently looked for, since it does not seem to have been accompanied by any change in the surrounding parts, and would perhaps only be indicated by weakness of a joint rendering it unfit for severe work. The atrophy, or absorption of cartilage, is so frequently seen in the joints of old subjects, that some authors have been disposed to regard it rather as a physiological than a pathological condition. It is, however, unquestionably a disease; and in the drawings above mentioned, are some specimens of it from a soldier under the middle age. The cartilage seems in the first instance to be opened out in its texture, and numerous little villous processes appear on its surface, often as if its fibres were enlarged after absorption of the substance which connected them. The thinning sometimes takes place in patches, occasionally in grooves, corresponding to the motions of the articular surfaces; the subjacent bone becomes at length completely denuded, and soon presents a polished porcelain-like surface, which is so re The hard, polished, and ivory-like appearance of the articular surface, would lead us to suppose that it contained an unusual quantity of earthy matter, yet an analysis by Dr. Davy, here given, shows the contrary.
In many instances where the disease is of long standing, a deposit of adventitious bone takes place around the articular surfaces, and this may occur to such an extent as to produce anchylosis of the joint, the articular extremities of the bone often presenting several irregular depressions, and becoming variously altered in shapes, as shown in the cuts, p. 86. It is curious that the atrophy of cartilage is generally seen in its early stage to attack the joints in pairs, and to occur also in corresponding parts of the articular surfaces; a fact which coincides with the disposition of caries to appear simultaneously or successively in corresponding molar teeth. Of the causes of the disease but little is known, although it is generally attributed, like some other obscure affections, to the effect of rheumatism. It often follows in old people upon long disuse and confinement of a limb to one position, as during the cure of fractures. A very valuable specimen was presented to me lately by my friend Mr. Busk, of the Dreadnought hospital ship. The elbow had been apparently subjected to great injury. The radius and ulna had been fractured: the former had united, whilst a false joint had been formed betwixt the portions of the ulna. There is profuse deposit of bone around the elbow-joint, which must have been quite stiff, or nearly so, as regarded flexion and extension; but the end of the radius and corresponding articulation of the humerus are beautifully polished. This polish is not unfrequently seen also upon disunited fractures, as in the neck of the femur. Atrophy of the cartilages has been seen where no rheumatism was ever known to have troubled the patients; and they are more generally disposed to ascribe it to the effect of incessant hard work. At all events it is comparatively rare among women, and in the upper ranks of society; and the wasting often presents very much the appearance which would result from the The symptoms of the disease are generally obvious enough in the more advanced stages by the crackling which may be heard when the joint is moved; and in the early stage a grating may be felt by a careful manipulation. SCROFULOUS DISEASE OF JOINTS.Affections of the membranes, ligaments, and bones, often occur in persons of weak constitutions, and proceed very gradually. They have been all classed under the general term of white swelling. They most frequently present themselves without any assignable cause, or are attributed to the slightest injuries. The disease generally commences in the cancellated texture of the bones: these are soft and light, and contain in their cells a quantity of caseous or tubercular matter. The softness is attributable to an interstitial atrophy of the bony tissue, as well as to an alteration in the proportion of its constituents; the animal matter being in excess, with a corresponding deficiency of the phosphate of lime. There is an increased vascularity of the medullary membrane, and the cancellated texture contains thin brownish-looking fluid instead of marrow. In cases of disease which has commenced in the cancellated texture, there is hardly any pain at first, and the progress of the disease is remarkably insidious. When the lower extremity is affected, the child is observed to limp; the limb wastes; it appears to be longer, partly from atrophy of the muscles, partly from relaxation of the ligaments and effusion into the joint. The term white-swelling, which ought to be discarded from surgery, was at one time made to include all the different affections to which joints are liable in weak constitutions—thickening of the parts, with an external colourless swelling—collections of matter about articulations, with or without an external aperture—effusion of fluids into the cavities of joints, or into the bursÆ—destruction of cartilage by ulceration, or in consequence of portions becoming dead—absorption, ulceration, caries, or intractable ulceration of the bone adjoining the articulation. Those under twenty years of age are most liable to chronic affections of the joints, and they occur very frequently in children. Great anxiety is often shown by friends of patients to account for chronic disease of a joint, so as to save their whole generation from the imputation of being tainted with scrofula. It is attributed, sometimes correctly enough, to some injury perhaps trifling; to a sprain, or twist, or squeeze from a tight shoe, or to a bruise from falling; and it is no doubt true, that young or old people of the most healthy con Such affections advance slowly; all the articulations are liable to them; but those which are most subject to the disease are the hip, knee, ankle, and elbow. Of these, the knee-joint is most frequently affected, probably from the greater extent of cancellated and articulating surface. In young persons of unhealthy constitutions, the joints not unfrequently become affected one after another, and superficial abscesses form, terminating in open sores. I was obliged to amputate the upper extremity of a young lady a few days ago, in which a metacarpal bone and its articulation, the entire chain of carpal bones, the wrist and elbow joints, were all thoroughly involved in disease. NEURALGIC AFFECTIONS OF JOINTS.The joints, like other parts of the body, are very often the seat of painful affections, without organic disease existing. These neuralgic affections are often connected with, or followed by, hysterical symptoms. They frequently also depend upon derangement of the digestive organs,—upon the lodgement of irritating matters, sordes, or worms in the intestinal tube; and when we reflect upon the extent of the lining membrane, the expansion of nervous filaments, and upon the sympathy which they hold with the whole system, we cannot be astonished at the circumstance. Many cases of supposed hip-disease in children, with the symptoms and some of the signs of it, have come under my notice, which have yielded at once to the expulsion of offending matters or worms. Some affections of joints seem to depend upon gouty diathesis; others are intermittent: at one time the joint complained of is hot, and somewhat swollen; at another cold, and bluish on the surface. In these affections of joints the pain, indeed, is seldom constant: the patient’s rest is not broken; there are none of the violent spasms during sleep, which attend upon certain alterations of structure. The pain is equally complained of when the part is touched with the utmost gentleness, or when a thorough and searching examination is made, when the joint is freely moved, and the articulating surfaces of the bones are forcibly squeezed against each other. The pinching of the skin causes pain. There is seldom throbbing, or heat, or swelling; though, after long continuance of the diseased state, these may supervene to a slight extent. The pain complained of is seldom referred to one point, but to a large extent of the limb; and if the attention is diverted, the examination may be carried to any extent, without complaint being made. Sir B. Brodie, who has done a great service to the profession by directing attention to these nervous affections in his excellent work, and in his lectures, notices that the knee, when the seat of pain, is generally kept in the extended position, and this is very different from This class of diseases generally affects females of delicate organisation about the age of puberty, and in whom the menstruation is irregular. Males in delicate health are also subject to similar affections. ON GROWTHS FROM THE SYNOVIAL MEMBRANE, AND LOOSE SUBSTANCES IN THE JOINTS.The synovial membrane is sometimes studded on its inner aspect with loose fleshy or semicartilaginous substances projecting into the cavity of the joint. The entire surface of the membrane is occasionally covered with these bodies, which are of a white or yellowish colour, and very variable in size and shape; the smallest presenting the form of villi not much larger than those of the jejunum, the largest having somewhat the magnitude and appearance of the appendices epiploicÆ of the large intestine, while many of an intermediate size approach in appearance to a lemon-seed. In some instances the membrane is only partially pervaded by them, and they are not unfrequently arranged like a fringe around the edge of the articular surfaces. They are generally very smooth on the surface, which appears to be perfectly continuous, if not identical, with the synovial membrane. Their attachment is frequently broad, and occasionally very narrow and pedunculated, often merely filamentous, so that a little further thinning of the part, or slight force acting on the body, would remove it from the capsule, and throw it loose into the cavity of the articulation. The disease has been most frequently seen in the knee, and sometimes in the elbow. The affection is obscure in its nature; it is slow in its progress; the joint is the seat of pain after and during exercise, probably from the morbid processes interfering with the motions of the articular surfaces. As the disease advances, the joint becomes swelled and elastic, unattended generally by ulceration of the tissues within or around it. In examining the part, when the articular surfaces are moved on each other, it will be found that their motion is more or less interfered with; and considerable irregularity in their action may be felt by the hand placed firmly on the joint during the procedure. Loose bodies may be found in the articulations, particularly in the knee and elbow, under the circumstances just described; but we often find others of a different structure loose within the capsule, which may be throughout smooth and apparently healthy. These bodies are extremely variable in size, generally rounded or oval, with a polished surface; many of the smallest present the character of fibro-cartilage or cartilage; the larger are often more or less modulated, very firm and gristly, and sometimes contain a considerable nucleus of bony matter. The articular ends of the bones are occasionally The disease is common in the knee; and patients frequently go about for years, who will tell you that they have something rolling within the joint, which will often be found on examination to be actually the case. It is obvious that loose bodies in the joint must prove an obstacle to easy progression; and the smaller ones seem to be particularly so, probably from becoming easily entangled by different parts of the articular apparatus. However difficult it may be to account for the cause of these formations, the means by which they may get within the articulation seems obvious enough. If a small knob of coagulated lymph should form on the inner aspect of the membrane, the point of attachment, as has already been noticed, might gradually become narrower, from the motions of the joint or other causes, till the connection were severed. But there is reason to believe that many of the substances found loose in the joints are formed altogether in the cellular tissue without the capsule; for it is difficult to conceive that they can increase in size, or take on the ossific action in their centre, by an act of independent vitality, after they have been separated from the surrounding parts. Accordingly, dissection has occasionally disclosed loose bodies within the knee-joint, and others of just the same structure outside the synovial membrane, which was however protruded by their pressure, and appeared to connect some of them by a pedicle only, ready to break and allow the foreign body, with its covering of the membrane, to fall into the cavity of the articulation. AFFECTIONS OF SYNOVIAL POUCHES OR BURSÆ.BursÆ are lined by a membrane, greatly resembling the synovial in appearance, function, and disease. They are frequently the seat of inflammation of an acute character; but in most instances the action is of short duration, and generally terminates in an increase and accumulation of the secreted fluid. The attendant pain is very severe, and much increased by any motion of the neighbouring parts. Occasionally a portion of the cellular substance, which is exposed to pressure of motion, as over a prominent portion of bone, assumes the appearance of a bursa, secretes a similar fluid, and is similarly affected in consequence of inflammation. These adventitious bursÆ are met with in various situations. Bunion is a good example of such a bursa thickened from long-continued pressure. They are seen on the outer ankles of tailors, on the shins of boot-closers, on the forehead, point of the elbow, &c. Disease of the bursÆ may occur from external injury, and they often become affected subsequently to disease of the neighbouring joint. If the action is violent, lymph is effused on the inner surface, or external to its cavity, causing considerable thickening. The sac is thus sometimes all but obliterated. Tumours, originally house When inflammatory action has commenced in a bursa, it must be subdued by copious topical bleeding, along with the exhibition of purgatives; in most cases general bloodletting will not be required. After the inflammation has subsided, the parts remain swollen, from the effusion either of serum or lymph; stimulating applications may then be employed with advantage. In general, the ammoniacal plaster, or the brushing over the surface with tincture of iodine will answer. Blisters are sometimes employed with the same view. In obstinate cases, when the tumour is of no large size, a seton may be passed, retained till suppuration has taken place, and gradually withdrawn. Great risk attends interference with bursÆ of large size near joints or cysts containing serous or glairy fluid in any situation. Even trifling punctures into such have been sometimes followed by inflammation of the inner secreting surface and violent constitutional disturbance. When suppuration has occurred, it will in many instances be prudent to evacuate the matter by one or more incisions, in order to prevent farther mischief, especially if the bursa, a superficial one, is in the neighbourhood of a joint. After the matter has been evacuated, the cavity gradually contracts, and ultimately the bursa is completely obliterated. Diseased bursÆ, near the surface, and unconnected with important parts, have been dissected out. The operation is not often necessary, and in some situations attended with considerable risk. Tumours, solid or nearly so, arising from diseased bursa of long standing, may sometimes require to be so treated. OF COXALGIA, MORBUS COXARIUS, OR HIP-JOINT DISEASE.This disease has been supposed to commence in the cartilages; it appears, however, to originate indiscriminately in the cartilage and the bone, as well as in the membrane lining the capsule and investing the cartilage and the ligaments; but whether it begins in one or other of these tissues, it soon, if neglected, involves them all. It affects patients of all ages, though children under twelve are most generally its victims; and in these it often makes considerable progress without its existence being suspected. The patient is observed to be a little lame, and to be awkward in the use of the affected limb, but he experiences little or no pain in the first instance; and if he Again, and particularly in adults, the limb is easy only in certain positions, and cannot be moved without great suffering; pain is also complained of in the groin, and often immediately behind the trochanter major. If an examination is made when the patient is thus halting, and even though he complains of no pain, the limb is found shrunk, wasted, and lengthened. The elongation of the limb occurs mainly in consequence of the inclination of the pelvis towards that side. When the disease Illustration has made progress, it has been supposed that swelling of the apparatus of the joint, and effusion into its cavity, might separate the head of the bone from the acetabulum, when pressure from the trunk was not applied. The lengthening is often great, and its extent and cause are ascertained by accurate comparison of the two limbs, laid in contact when the patient is in the recumbent posture. The degree of lengthening is here carefully represented from a recent case. But occasionally, even in the first stage, before destructive ulceration has set in, in consequence of the pain and spasms, the limb becomes remarkably shortened and retracted. This also will be found, on careful examination, to depend upon the relative positions of the two ossa innominata. When the patient stands, the affected limb is considerably advanced before the other, on which the weight of the trunk is chiefly, or entirely, supported; the knee is generally bent, and the toes only rest on the ground. In the advanced stages of the disease, and when there is reason to suppose that ulceration of the cartilages has set in, the patient, during progression, moves the affected limb with the hands grasped round the thigh, and in bed it is moved by the aid of the sound one. The spine is frequently affected, becoming bent in different directions, to preserve the equilibrium of the body; and a deformity of the trunk to a certain degree occurs, which, however, may be in general easily remedied. The The circumstances attending the first stage of the disease in childhood, in which the limb is lengthened, and there is no decrease, but rather an enlargement of the parts composing the joint, have been already described and illustrated. When, however, absorption occurs, and the articulation begins to be destroyed, the second stage of the disease commences, and the limb becomes then sensibly shortened; the toes are turned inwards or outwards; in many cases there is every Illustration appearance of dislocation of the thigh upward and backward; and in others the limb is much bent, the toes only reaching the ground. The ultimate position of the limb and degree of shortening will depend much upon the extent to which the head and neck of the femur is destroyed, upon the inclination of the pelvis, and also upon the portion of the acetabulum which is most diseased. The joint becomes tender, the slightest motion causing much pain, and the parts around appear swollen. The patient retains the limb in the most comfortable position, and it is generally bent upon the pelvis and inverted. This may arise from relief being afforded when the psoas is relaxed, and the pressure thus removed from the fore part of the joint. In many cases matter forms behind, or rather below, the trochanter major, and the collection often attains a large size. When the presence of matter has been ascertained in this situation, it has been The formation of matter is preceded by great pain, and frequent startings of the limb during sleep, accompanied with fever, and other symptoms of severe constitutional disturbance. On the escape of matter by the natural process from the capsule the painful feelings usually subside. The abscess may appear, as already stated, near the trochanter major, or in the back part of the thigh. Matter sometimes makes its way into the pelvis, through a perforation in the acetabulum, thence it may fall through the sacro-ischiatic notch into the thigh, and find its way under the fascia, nearly to the knee; or again, it may present to the side of the rectum, or even, as I have seen, burst into the bowel and continue to be discharged thus for a long period. If the treatment is neglected, abscess succeeds abscess; and in consequence of the profuse discharge, which may be evacuated from one or many openings round the joint, the patient is at length exhausted, and sinks. In some instances the spontaneous cure by anchylosis occurs, as in the instances from which these sketches are taken. In the one, the head and neck of the bone had In many cases, the appearance which the various parts of the diseased joint present, are similar to those which have been already described when treating of affections of the joints generally. Frequently, however, the osseous tissue in this situation is much more extensively affected. Often the whole cartilage on the head of the femur is Illustration completely removed, exposing the bone in an ulcerated condition; and when the system has long borne up under the disease, the greater portion of the head, neck, and even of the trochanter, is destroyed, the extremity of the bone being completely altered in form, and composed of a loose and spongy structure. A similar disorganisation occurs in the acetabulum; the mucous gland is destroyed, the cartilage is often wholly removed, and the margins of the acetabulum absorbed, a large and flat ulcerated depression merely being left for the reception of the diseased femur; in other instances the margins remain unaffected, whilst the ulceration proceeds in the centre, and the cavity is thereby much deepened. Not unfrequently the ulceration proceeds farther, and an aperture is formed in the acetabulum, so that matter accumulates within the pelvis. The opening is sometimes so large that the femur is protruded through it. When matter has formed in the soft parts round the joint, portions of the bones of the pelvis, in contact with the pus, are ulcerated to a greater or less extent, and sometimes these ulcers are surrounded by deposits of new bony matter. From such changes in the osseous parts of the articulation the limb is shortened, sometimes to a great degree, though no dislocation has occurred. Indeed, dislocation is by no means so frequent a cause of the shortening as is generally believed. If the head of the femur has been dislocated, and if the disease in the joint has afterwards subsided, the acetabulum is found to be much contracted, with its margins smooth and little elevated, and, if the patient survive for a number of years, it will be almost wholly obliterated. But a portion of the dorsum of the ilium, upward and backward, which is the most frequent dislocation in this disease, is gradually ON CERTAIN ALTERATIONS OF FORM IN THE HEAD AND NECK OF THE THIGH BONE.Illustration When treating of atrophy of the articular cartilages, it was observed that, in the latter stages of the disease, the subjacent bone was liable to become denuded, and its articular extremity more or less deformed. Now one of the most interesting of these changes occurs in the head of the thigh bone, which becomes polished on its surface, flattened But there is another affection in which the femur may be shortened in a comparatively brief space of time from absorption of the intra-capsular portion of its neck, generally succeeding to a fall on the trochanter, Illustration and sometimes occurring in young and middle-aged subjects. In treating of fractures of the cervix femoris, it will be observed that retraction of the limb is occasionally delayed for a while: hence the importance of an accurate knowledge of those cases in which shortening of the neck of the thigh bone may succeed to an injury short of fracture. The deficiency of accurate anatomical details concerning such cases led to a doubt as to their existence; but this question has been completely put at rest since the history and dissection of two unequivocal examples by Mr. Gulliver; and the annexed cut represents the changes of form in the head of the bone, the shortening of the neck and comparative length of the femora, in a young man from whom these bones were obtained, and who walked about as many others have done, during the progress of the disease. In the above, and in many other cases, the shortening of the neck In old subjects, particularly in fat women, the neck of the femur is often shortened, and becomes more transverse and brittle than natural, from a true interstitial absorption or atrophy of the osseous tissue. This has sometimes been described as a natural effect of age, but it is undoubtedly disease, for in the greater number of old people the neck of the thigh-bone presents its usual length and obliquity. The affection is obviously a very serious one, as predisposing to fracture of the part, under circumstances which render its reunion almost hopeless. Treatment of Affections of the Joints.—After the infliction of a wound, accidental or not, in order to prevent inflammation of a joint from becoming violent, it is of the utmost importance to bring the edges of the wound into close apposition. Sometimes neither local action, nor disturbance of the constitution, supervene on an opening, even of considerable size, being made into a joint, while the slightest puncture often gives rise to the most dreadful symptoms, both local and general. An incised wound, of no great extent, will be sufficiently closed by the careful application of adhesive plaster, and attention to the position of the limb; but if it is extensive stitches become indispensable. The parts must be kept in a state of complete relaxation and rest; cold cloths or iced water, allowed to drop or run over the The employment of the bichloride of mercury, though a most efficient escharotic, appears not to be unattended with danger, as in many instances violent purging, with tenesmus and bloody stools, follow its application. When swelling exists without pain, considerable advantage may be derived from frictions and liniments of various kinds, with careful bandaging. No applications can be of the least avail unless the joint be kept completely at rest. When there is no pain in the joint, when swelling exists, with or without fluctuation, and there is every reason to believe that the extremities of the bones are not much diseased, a cure may be, in general, obtained by the employment of rest, support, and slight superficial excitement. A practice which has been extensively and rather indiscriminately pursued in diseases of joints and of other parts, in affections of synovial membrane, ulceration of cartilage, disease of bone, and even in cases of necrosis, is here detailed. It is useful in proper cases, very hurtful in others. The joint is well washed with It is seldom that local abstraction of blood is at all required, and its employment in cases of morbus coxarius in weak constitutions, which it generally seizes upon, is very questionable. Neither is counter-irritation called for; and it is only in extreme cases, when the suffering is intense, that small blisters over the fore part of the joint, or a slight drain in that situation, or behind the trochanter, is admissible. The nitrate of silver rubbed on the surface causes vesication and discharge; and its early repetition is often followed by good effects. The tincture of iodine, or a liniment containing sulphuric acid, may sometimes be applied with the same view. There is no doubt whatever, that much of the benefit that attends upon counter-irritation, both in the human body and in the lower animals, is to be attributed to the rest that is at the same time enjoined, and often indispensable. It is thus that the firing and blistering of horses does good in the majority of the diseases of tendons, bursÆ, bones, and joints. In some instances, it may be necessary to have recourse to soothing applications, as fomentations to affected joints, and to employ general antiphlogistic means suited to the age, strength, and constitution of the patient. In the greater number of cases in young subjects, after the stomach and bowels are unloaded, the system must be supported by tonics and nutritious food; none are more beneficial than the preparations of iron. When the occurrence of anchylosis affords the only hope, this process ought to be encouraged by rest, and the limb at the same time kept in that position which will be most useful in after life; this will be effected here also by the employment of splints. In cases of disease of the knee, ankle, elbow, or wrist joints, notwithstanding everything that can be done, the disease often runs its course, abscesses form and give way, the patient’s health declines, and he becomes emaciated and hectic. In such cases amputation, when not contraindicated by internal disease, must be had recourse to, as the only remedy. In some few instances, the excision of the diseased extremities of the bones may supersede this operation; but Hydrops articuli will in general be got rid of by the use of friction, either dry or with liniments; by stimulating plasters or by blisters; and by the proper application of bandages. Mercurial ointments are used in this affection, and often with very great benefit. Electricity has been recommended. In neuralgic affections of joints, it is clear that the symptoms are to be combated by general and not by local means, at least of a severe nature. The patient must be amused and occupied, exercise in the open air must be enjoined, and attention paid to diet. The state of the digestive organs and secretions should be looked to, and corrected if need be. Medicines directed to the regulation of the functions of the uterus are essential in the majority of cases. When there is reason to suspect the lodgement of sordes or worms in the intestinal canal of children so affected, the balsam of copaiba, in doses of ?ss., or more, on an empty stomach, followed, if need be, by brisk purgatives, will be found to answer admirably. Tonics, such as preparations of iron, of quina, &c., are then given with advantage: many apparently bad cases yield at once to such treatment. As local applications, anodynes, fomentations, or cold lotions are employed, according to circumstances. Frictions with gently stimulating liniments, belladonna, veratria, &c., may be used as occasion demands. The patient must be encouraged to use the affected limb as much as possible; and the use of all severe and heroic remedies, as bleeding, blistering, counter-irritation, setons, issues, or moxas, discountenanced. OF INFLAMMATION OF BONE, AND DISEASES THENCE ARISING.Bones grow and are nourished by the same means, and are subject to the same laws, with other parts of the system. Like all the tissues of a white colour, particularly when their growth is completed, they are less freely supplied with bloodvessels and nerves than other parts. When incited action of the bloodvessels occurs in the harder textures, sensibility is roused to an exquisite degree, and the healthy and perverted processes often advance with great vigour and amazing rapidity. Inflammation of bone often arises from external injury, and in some constitutions from very slight causes. Its occurrence is supposed to be favoured by a syphilitic taint, but the inflammatory disposition is much more frequently produced in a system vitiated by the abuse of mercury. From the unyielding nature of the tissue, the pain attendant on inflammatory action is dreadfully excruciating; it is also most violent during the night, even in chronic cases, a circumstance which does not admit of satisfactory explanation. The integuments over the inflamed bone are swollen, and the tumour is oedematous; whilst a hard and solid tumefaction exists in the more deeply-seated parts, caused partly by enlargement of the osseous tissue and partly by effusion of lymph into the cellular substance. The bone is imbedded in a gelatinous or lymphatic effusion, situated mostly beneath the periosteum. This membrane is more vascular than in its natural condition, thickened, Illustration and at the same time opened out in texture. The bloodvessels of the affected bone are much increased, both in activity and in size; and, in consequence of enlargement of the vessels, and thickening of the naturally delicate membrane on which the vessels ramify, the bone is swollen and increased in size; its texture, as shown in the annexed cut, is loose, somewhat resembling the cancellated structure, and its surface is occupied by numerous foramina, which are enlarged in proportion to the size of the vessels which they contain. The limb is often enormously swollen and indurated. The gelatinous effusion beneath the periosteum speedily becomes organised, nodules of osseous matter project into it, and adhere to the surface of the bone frequently by a narrow neck; these increase in number, gradually assume a solid appearance: the bone is thus thickened, often to a very great extent. It has been supposed that the new osseous matter is deposited by the vessels of the soft parts and of the periosteum; but there can be little doubt but that it is secreted principally by the vessels which ramify within the substance of the bone, and by the vessels of the periosteum after they have entered the osseous tissue. Thus, in the When bone is extensively affected with inflammation, motion is impaired; the muscles being displaced and retarded in their action by the swelling and irregularity of the bone, by effusion of lymph into their tissue and intermuscular spaces, and, perhaps, also, by their partaking, in some measure, of the inflammatory action. Any attempt to move the parts very much aggravates the patient’s suffering. Occasionally inflammation attacks almost all the bones in the body, and causes great constitutional disturbance, by exhausting the powers of life: it sometimes terminates fatally. Bones become inflamed from various causes. However it originates, the action ends, as in the other tissues, in resolution, suppuration, or mortification. The effusion by which the diseased vessels naturally relieve themselves in softer textures cannot here take place so readily, or to such an extent as to prove beneficial: the intensity of the action is with difficulty subdued, and, consequently, resolution is comparatively rare. When it does occur, the parts do not soon regain their natural condition, but often remain considerably swollen and indurated, as is seen in nodes, which continue during the life of the patient, without causing pain or much inconvenience. Suppuration on the surface, or in the centre, and partial or total death of a portion of bone are the most frequent consequences of external injury and incited vascular action; but suppuration in the cancellated texture frequently follows very slight incited action in those of a scrofulous habit. Tubercular matter exists, in all probability, previously, and it leads very often to long continued disease, curable only by operation. The matter may find its way to the surface after long suffering and great constitutional disturbance. Again, it may be confined for months, or even years, the patient suffering from time to time the most excruciating agony. The bone becomes thickened towards the surface by new deposit, as the cavity is increased by ulcerative absorption, and relief is only afforded, a correct diagnosis having been formed, by artificial evacuation of the matter. In many cases small sequestra lie in the cavity; and though the matter escapes naturally, or is evacuated, the patient’s strength becomes worn out, and he perishes, unless the limb is removed. So long as dead portions of bone remain, the discharge cannot cease permanently. Fresh collections are apt to form in the soft parts if the original openings close. It is no easy matter to discover or remove sequestra from deeply seated bones. A section of the femur is represented on the next page, showing a cloaca leading to the cavity of an abscess in the medullary canal. The bone is very dense in consistence, and irregular on its surface. SUPPURATION IN BONESuppuration in bones is necessarily connected with loss of substance, and condensation of the surrounding parts; and purulent collections exteriorly, if allowed to press long, or if bound down by unyielding sheaths, will sooner or later produce a breach of continuity, by Illustration causing absorption of the outer lamella and the subjacent cancellated texture. A similar effect is produced by aneurismal and some other tumours. Such loss of substance is, in some instances, speedily repaired, after removal of the cause, by effusion of new matter from the surrounding bloodvessels of the bone; thus, in disease in consequence of pressure from large aneurism, there is reason to suppose that the healing process commences as soon as the aneurismal sac begins to diminish, as after operation. But, as has been already observed, the healthy actions are more vigorous in the softer tissues than in bone; and when ulceration has occurred in the latter, it is generally attended with weak action, and presents the same general characters as an ulcer in the soft parts, connected with a feeble action of the bloodvessels; the discharge is thin and fetid, absorption gradually proceeds, and there is little or no effort towards reparation. Cavities in bones are necessarily slower in healing than those in the soft parts; the vitality and power of reparation are lower; and there being no elasticity in the parts, the walls cannot come rapidly together, contract and coalesce. It may tend to prevent confusion of the two different morbid states, if we confine the term ulceration to suppuration in, and absorption of, bone, whilst the vessels retain a considerable power of action, throw out new matter, and procure a reparation of the breach; and this condition of the osseous tissue exists when the disease is situated in the surface of the bone, and when it has been produced by an external cause. On the contrary, the term caries will denote that peculiar kind of ulceration in which reparation is hardly attempted by nature, and is with difficulty obtained by the most active interference; and this disease will most generally be found to affect the cancellated structure. The comparative frequency of one or other of the terminations of inflammation depends much on the kind of bone implicated. CARIESCaries most frequently occurs in the heads of long and in the cancellated structure of the short bones, as unhealthy suppuration most frequently takes place in the loose, fatty, and cellular tissues of the soft parts. The formation of abscess in the cancelli is generally preceded by deposit of tubercular matter, isolated or collected in masses, and by the softening of this cheesy substance. When pus has formed in the substance of a bone, the outer lamella, in the end, becomes absorbed, and the effusion undermines the periosteum, which, from the distension, also ulcerates: the matter then spreads into the neighbouring cellular tissue, or makes its way to the surface, and is evacuated, or, what is still worse, it escapes into an It was formerly remarked that bones become highly sensible from incited action; hence, during the progress of this disease, which is attended with more or less inflammation, the patient generally suffers most excruciating agony—so great, in general, as to prevent him, perhaps for weeks, from enjoying the least repose. The affected part is considerably swollen, but the enlargement is seldom so general, or so great as in the diseased state of the ligaments and other apparatus of a joint. White swelling, however, may be the precursor of caries; or, in other words, a disease commencing in the bursÆ, ligaments, synovial membrane, or cartilage, may extend to the bone; and breach of continuity, attended with weak action, be the consequence. In caries the affected portion appears neither to possess vitality enough to enable it to repair the breach, nor to be sufficiently deprived of vitality to be thrown off by the surrounding parts. Considerable portions of dead bone are occasionally found in carious cavities, in the heads of bones, and even in the vertebral column. Small portions are also detached piecemeal in the progress of ulceration, and discharged; but it is seldom that the whole surface is thrown off, so as to give place to a healthy and reparative action. When the parietes of the cavity have remained a considerable time in this inactive state, the surrounding vessels become more active, and the surface of the bone in the vicinity is studded with nodules of new osseous matter. The disease here delineated affected only a small portion of the cancellated texture of the condyle. An ashy looking substance fills the cavity, and this again was concealed in the recent state by lardaceous Illustration matter. The elbow joint is unaffected, excepting only that, from the deposit of new bone in spiculÆ and nodules, and the condensation of the soft parts, almost complete anchylosis had taken place. This deposit is not always limited to the affected bone, if one only be the seat of the disease, but frequently extends to those articulated with it. The soft parts are commonly more or less thickened, and rendered exceedingly dense by effusion of lymph into the cellular texture; and so great is this thickening sometimes, that the knife is resisted as if by cartilage. The discharge which proceeds from the carious part is generally highly fetid, very profuse, is often poured through several openings, and the surrounding skin is excoriated and generally of a livid colour. The ichorous discharge occasionally dries up for a short period and again breaks out more violently. The surface of the ulcer is, in some cases, occupied by soft unhealthy granulations; in others the earthy part of the bone is most prominent. When the parts have been macerated and dried, the disease is often found to have proceeded more in width Interstitial absorption of those bones which are in the neighbourhood of the carious ulceration often occurs in the tarsus and carpus. The superincumbent integuments are livid and cold, and pain is felt in the situation of the bones; yet they are not affected with continuous ulceration, but portions of their substance are gradually removed by absorption, so that they are much loosened in texture, and may be altogether destroyed, or come to consist merely of a thin and reticulated osseous shell, whilst at the same time their cartilaginous surfaces often remain in their healthy condition. The constitutional disorder attendant on caries is at first very great; the sympathetic fever is followed by hectic, under which, and the discharge, many patients sink. The general affection in some degree keeps pace with the local in violence and duration. The irritation is in some cases so great as to destroy the patient in a very few months or weeks; but not unfrequently a constitution, by no means strong, will be enabled to bear up for a long period under very extensive disease of a bone. The paroxysms of pain and inflammation occasion fresh attacks of constitutional derangement: this occurs till the patient’s health and strength are exhausted, and he sinks under the disease, or is relieved by the spontaneous or artificial removal of the cause. A natural cure of caries may occur in consequence of the diseased parts so far recovering their natural degree of vascular action as to form granulations and repair the breach; but most frequently it is necessary, for the accomplishment of this purpose, that incited action occur to a very considerable degree; and the diseased parts, already extremely weak, have not sufficient power to withstand the action, but perish; whilst the action of the surrounding parts, not being increased to such a degree as to overcome their powers, throws off the dead, secretes a more bland discharge, and deposits healthy granulations, which gradually fill up the cavity. Treatment.—In inflammation of bone, resolution must be brought about, if possible; the other terminations are to be prevented by all In inflammation of the short bones or heads of the long bones, if the action does not yield to topical bleeding and becomes chronic, counter-irritants must be employed. Blisters repeated are often useful in subduing the remaining action, and in obstinate cases small caustic issues are sometimes of service. During the adhesion of the eschar, the best application is a common poultice or water dressing, which, on the separation of the dead part, may be exchanged for any simple ointment, it not being at all desirable in general to check the discharge and heal up the breach of surface. Moxa is sometimes employed to make an issue in these and other cases, but it is not superior in any respect to the potential cautery, whilst its employment is generally very alarming to the patient. The sores following the use of In cases of atrophy of bone, and where there is reason to suspect the scrofulous or tubercular deposit to be going on, the affected part should not be much used, and means taken to give tone to the system. Preparations of iron are often exhibited with advantage. The combination of iodine with iron may sometimes answer. Abscesses should be opened early, so as to prevent extension of the mischief. In abscess in the shafts of the long bones, it is occasionally necessary to make an opening through the outer lamella by the trephine, so as to evacuate its contents. Some instructive cases have been given by Sir B. Brodie, illustrative of the good effects of this practice. I subjoin one out of many from my own hospital practice. “W. A., aged 22, was admitted Oct. 26, 1837, under the care of Mr. Liston. He is a policeman of weak conformation. He states that when about six or seven years of age he was first attacked with an aching pain in the right leg, near its middle, and since that period has been subject to three or four attacks every year. These usually were experienced in the spring, during rough, windy, and cold weather, and continued from one to three weeks. The pain was always aggravated at night, and so trifling in the day that he was always able to go about. These attacks ceased to occur when he was between 15 and 16 years of age, and since that time, until last May, he has been free from them. He states that up to about his 16th year the bone of the leg gradually enlarged in its middle portion, but then became stationary, and at the period of entering the police the difference between the bones of both legs was not great; this was about two years ago. Since then he has been accustomed to walk for a considerable length of time daily. During some months he was obliged to do the night work, and then he was much exposed to cold and wet. Last May, while thus engaged, he experienced again an aching pain in the middle of the right tibia; this was aggravated at night; and after a fortnight’s duration, during which it became gradually worse, he was obliged to give up his duties in the police, being unable to continue them any longer. At this time he consulted the surgeon of the subdivision with which he was connected; his treatment was fomentations to the leg and aperient medicine occasionally. Not being much relieved by this, he afterwards ordered the application of leeches on three several occasions, and mercury to salivation. At the end of three weeks he returned to his duty. In the latter part of September he was again attacked with pain during night duty; this pain increased rapidly in severity, and after three nights he was again obliged to leave duty. He was now treated again with the frequent and copious application of leeches at different intervals, and likewise took some pills, which did not affect his mouth. This treatment, with frequent fomentations, was persevered in for a month, but without permanent benefit, and then he was brought to this hospital. Has never had any syphilitic complaint. “Present state.—Has an enlargement of the tibia about its middle third, of a diffused character, and which seems to extend a good deal “Nov. 4. The leeches were repeated; much the same. “8. Symptoms as before. As he complains of pain over the eyebrow, with nausea, let the mercury be left off. A variety of constitutional and local treatment has been pursued during Mr. Liston’s absence from the hospital, but without affording any relief; the patient’s nights were passed in great agony, and his general health began to suffer. On the 27th, after consultation with Mr. Fisher, the surgeon to the Police Force, Mr. Liston had the patient carried into the operating theatre. He made an incision along the spine of the tibia of about three inches in extent; another shorter one was made to fall on this at right angles from the inner side. The surface of the bone thus exposed was perforated to the depth of fully half an inch by a small trephine. A very dense circle was removed from the perforation; still the fluid, which was suspected to exist, did not appear. Mr. Liston, encouraged by the intense pain complained of as the process of perforation proceeded, again applied the crown of the instrument, and after a few more turns, brought out a further circle of considerable thickness, and this was forthwith followed by a flow of well-digested purulent matter. “28. Complains of no pain comparatively; slept well last night after an anodyne draught; has felt much relieved since the operation; a good deal of matter was discharged from the sore during the night; water-dressing to be applied to the wound. “30. Slept well without any anodyne the last two nights. The relief afforded by the operation is felt more now than it was at first. “Dec. 2. The wound looks florid and clean; granulations are springing up; general health very much improved. “4. The edges of the wound are thickened by the granulations; the discharge from the wound still considerable; feels quite well in health. “12. The wound continues much the same; the rollers have been discontinued. “14. Feels himself gaining strength daily; can walk without pain; wound is contracting and hard; granulations seem to lessen the depth of the opening in the bone; there appears to be no sequestrum.” When caries is fairly established, and the integuments have given way, the best and most successful proceeding is that pointed out by nature—destruction of the diseased portion; and the means must vary according to the particular circumstances. In many cases, nature seems to wait but for the separation of the sickly parts, either by accident, or by the interference of art. The means are to remove, partially or wholly, the diseased part, or to effect such a change of action as will throw it off. The first indication will be accomplished by trephines, scoops, saws, and forceps; the second by active escharotics; frequently both are required. If there be extensive disease in the medullary canal of a bone, several perforations may require to be made, and these may be connected by the use of a small saw, or the cutting forceps. The diseased cancelli, thus exposed, can be readily removed by the scoop or graver, as recommended by Mr. Hey, primus, in his excellent work. If, with the probe, it is ascertained that a portion of the cancellated texture has become dead and loose, it is to be removed after dilatation of the external opening. It may frequently be difficult to distinguish in the effused blood, between what is diseased and what is not; it will often be necessary afterwards to cauterise freely the exposed surface, and for this purpose the oxidum hydrargyri rubrum ought generally to be preferred. The slough will soon be thrown off, and healthy granulations fill up the breach. The application of the actual cautery may be by some considered necessary: at one time I employed this remedy very extensively in caries, and occasionally with very good success; I have since, however, been led to change my opinion, and am now inclined to prefer the potential cautery already mentioned. By the application of the red-hot iron, the diseased portion is destroyed effectually, but at the same time the vitality of the surrounding parts is often very much weakened and their power of reparation diminished, so that they are incapable of assuming a sufficient degree of action for throwing off the dead part; their action being increased whilst their power is diminished, they may become affected with caries, and thus, instead of being arrested, the original disease will either be increased, or extensive necrosis may take place. The red oxide of mercury is not calculated to produce such bad effects; it does not spread or insinuate itself into the bony tissue, In operating on the carpal and tarsal bones for removal of caries, the surgeon must be well acquainted with the connexions and relations of the parts. If one bone is diseased, its removal will be sufficient; if several, the operation becomes more painful and difficult. When one only of the tarsal or carpal bones is almost completely destroyed, and the surfaces of those articulated with it are also more or less affected, it is not sufficient or safe merely to remove the loosely attached portions of the one primarily attacked; the diseased parts of those surrounding it must also be taken away, and it will often be necessary to apply the caustic afterwards. In caries of the distal range of bones, the bases of those supported by them are in general involved, and must also be removed. If one only is diseased, with the base of the metacarpal or metatarsal bone attached to it, the removal of these will be enough, and can be accomplished without difficulty. Some have recommended the total extirpation of a metacarpal or metatarsal bone, leaving the finger or toe appended; but the member, when thus left unsupported, can never become of any service to the patient, and may be productive of much inconvenience; whilst removal of them, along with the diseased bone, renders the operation much more easy of execution. If the whole disease can be extirpated, leaving the surfaces of the surrounding bones covered with healthy cartilage, the use of the caustic is not required, and would be productive of harm; but wherever it is impossible to avoid encroaching on the cancellated texture, such as of the os calcis, which it would be unsafe or imprudent to take away entirely, its use is then indispensable. After the removal of carious bones, the symptoms soon disappear, and the patient obtains a rapid, and often permanent cure. The instruments for these operations, and the method of performing them, will be afterwards mentioned. In conclusion, it may be remarked that the temporary cicatrix of a sore leading to a diseased bone has a very different appearance from the sound scar which is formed after its removal. The former is bluish, soft, on a level with the surrounding parts, and moveable; the latter is depressed, white, and firmly adherent to the bone. NECROSISDeath of bone, or Necrosis, is an effect of violent inflammation, particularly of the medullary web, or external injury; a termination of inflammatory action in bone corresponding to sphacelation in the softer tissues. It has been observed, that the bones are not extensively supplied with bloodvessels, and that their natural powers are inferior to those of the softer parts; and from this circumstance the frequency of necrosis can be readily accounted for. The short bones Illustration The progress of necrosis is, as has been said, similar to that of sphacelation. The affected bone gradually changes its colour, and loses its sensibility; a line of demarcation is formed, and ultimately the dead portion is completely detached from the living. Previous to its separation, the surrounding parts, the portions of bone which are not doomed to perish, have commenced forming new osseous matter, which is secreted in nodules, and from continued deposition soon becomes consolidated. The commencement of the process is well seen in the following sketches from specimens in my collection. The disease, as represented in the two first cuts, was of the most acute kind, and a great part of the shaft of the tibia had perished. This is seen at various points through the sort of cortical deposit of new bone. The new bone, in its turn, secretes a texture similar to itself, The separation of the dead part from the living is accomplished with greater or less ease, according to the bone which is affected, the state of the constitution, and the general health; in the bones of the superior extremity, this, as well as every other action, proceeds more rapidly than in those of the inferior. It occurs in consequence of absorption of the living part of the bone, which is in close proximity to the dead. The sequestrum, if large, is not pushed off, as some have supposed, by granulations, deposited on the living margin of the bone. A small portion of the inner shell, when completely detached, may sometimes be observed to be extruded from a cloaca by granulations from the living bone. During its progress, matter forms, makes its way to the surface, and is discharged through minute, and often numerous apertures, which afterwards become fistulous. The soft parts are thickened and indurated, and the integuments are red, and sometimes of a livid colour. Formation of matter upon the bone is occasionally the cause of necrosis, the periosteum being destroyed or separated from its connections by the pressure or insinuation of the pus. I have seen several instances in which it followed neglected erysipelas of the lower extremity. The matter is in general thick and laudable; at first it is secreted profusely, but afterwards in smaller quantity. The external openings, or papillÆ, through which it is discharged, are found to lead to cloacÆ, or apertures in the new and living bone, which encase the dead, and through these the dead portions can be discovered by the probe; and it will thus be ascertained whether the sequestrum is fixed or detached: when loose, it can sometimes be moved upward and downward in the cavity. When the shaft of a bone is much affected, the whole limb is enlarged, by the inflammation having extended to a considerable distance above and below the portion about to become necrosed. The unshapely appearance of the limb continues until the sequestra are discharged; for by their presence incited action is still continued, and subsides only after their removal. Some time before any portion of bone has become dead, or begun to be separated, great effusion of new bone has, in general, occurred; thus a preparation has been made for the strengthening of the limb, which, after a considerable portion of the bone has been detached, would otherwise be incapable of supporting the weight of the body. The unnatural bulk of the limb is afterwards much diminished, for the new bone gradually becomes consolidated, and smooth on the surface by the action of the absorbents. Nature seems to construct her In external necrosis, or death of the outer lamella, reparation is chiefly made by the subjacent parts; and this species of necrosis occurs most frequently in the flat bones. In necrosis involving a greater thickness of the bone, the new matter is also furnished by the subjacent parts, which, however, are materially assisted in the process by the living bone, which forms the margins of the void caused by the absorbent process for the detachment of the dead portion. The bony matter is deposited with great activity, and frequently columns of the new deposit cross over the sequestrum, binding it firmly down, and rendering it almost immovable, although it may be completely detached from the living parts. It has already been stated, that those vessels which ramify within the substance of the periosteum have no share in the reproduction of bone, but plastic matter is effused by the ramifications extending from the membrane to the bone: this effusion becomes organised, and greatly assists in forming the substitute. It has been formerly remarked, that a limited, and, on after examination, an apparently trifling necrosis of the cancellated structure, may produce the most violent local symptoms; the painful feelings, the discharge, and the thickening of the bone, continue, as long as the cancellated sequestrum remains; severe symptomatic fever is induced, endangering the life of the patient, and often rendering removal of the limb absolutely necessary. Occasionally abscesses form at a considerable distance from the necrosed part, and terminate in sinuses, which communicate with the diseased bone, and are consequently long and tortuous, so that examination by the probe is rendered difficult. When necrosis is extensive, there is a risk of fracture occurring, if motion of the limb be permitted before a sufficient quantity of matter has been effused, before nature has had sufficient time for the consolidation of her substitute, and consequently before the new bone has come to resemble the old in thickness and cohesion. Violent inflammatory fever attends the incited action of the vessels of the bone and periosteum which precedes necrosis. But after the abscesses have given way the painful symptoms subside, and the health seldom suffers to any great extent, the system becoming gradually accustomed, as it were, to the new condition of the parts. Hectic supervenes only when the disease is very extensive, and joints become involved. Frequently fresh collections of matter form as each piece of bone approaches the surface. When the effusion of new bone has extended to the neighbourhood of a joint, its motion may be very much impeded, and, from the limb being kept in a state of rest for the cure of the necrosis, anchylosis may even occur. Treatment.—The means of preventing inflammatory action from running high and ending in death of bone have been already alluded to—abstraction of blood, rest, purgatives, and antimonials. When necrosis has occurred, no interference with the bone is allowable, unless the sequestrum is quite loose, or unless the patient’s health is The treatment may be summed up in a very few words. Prevent the necrosis, if possible; open abscesses whenever they appear; encourage the patient to move the neighbouring joints; support the strength; remove sequestra when loose, but do not interfere till they are ascertained to be so; give the limb proper support and rest, when It is almost superfluous to remark, that leeching and blistering are worse than useless after necrosis has occurred, however useful they may be in preventing it; and that the adoption of measures to promote the dissolution and absorption of the sequestra are glaringly absurd. Necrosis, after amputation, was formerly frequent; but in the present improved state of this operation it is so rare as scarcely to demand separate consideration. Such specimens as here depicted are common enough in the collections of those who have practised the old round-about operation; in fact, it is only by this painful and tedious interference of nature that a tolerable stump is formed in many of these cases. Death of a small portion will sometimes, though very rarely, follow even a very well Illustration performed amputation, if through any mischance the recovery is slow, and wasting discharge takes place with emaciation. It happens sometimes, as when secondary hemorrhage (that is to say, bleeding after the fourth day) has taken place, that the flaps are separated by the coagula, and it may be impossible to bring the parts together and give them due support; then the muscles, wasted and shrunk, may leave the bone a little, but the exfoliation is but very trifling. The inner shell of bone, as may be seen in the above sketch, perishes more extensively than the outer; and this arises probably from inflammation of the medullary membrane, in consequence of exposure, or, perhaps, from its being sometimes injured by the operator or assistants seizing the bone rudely to steady the stump, in order to facilitate the ligature of the vessels. In experiments on animals, the disturbance and injury of the medullary membrane is followed by internal necrosis, thickening of the outer living shell, and effusion betwixt the periosteum and bone. New bone is also furnished from the medullary canal, as is also shown in the sketch. FRAGILITAS OSSIUMOccurs chiefly in old people, whose bones contain an undue proportion of earthy matter, are endowed with little vascularity, and filled with an oleaginous fluid. They contain an undue quantity of phosphate of lime compared to the gelatin; and the liability to fracture is further increased by the interstitial absorption of the outer shell. They are in an atrophied state, and this is often in part attributable to disuse of the limbs. This state of the osseous system very often follows upon an attack of rheumatic fever, and is met with in patients who have laboured under cancerous affections. The bones, when in this condition, often break from the slightest force applied; as from the action of the muscles when the patient turns himself in bed, whilst walking across the room, or when endeavouring to attain the erect posture when seated on a chair. After fracture the process of reunion is extremely slow, and it does not take place at all in patients very old and of worn-out constitution. With a view to prevent the occurrence of fracture when the bones are in this condition, for it is impossible by any treatment to prevent the change in the texture of the bones, the only rational indications seem to be to keep the patient on a generous diet, and to prohibit him from making any great muscular exertion—to avoid, in fact, all circumstances likely to produce a sudden action of any particular set of muscles. OF MOLLITIES OSSIUM, RACHITIS, ETC.These affections differ only in this, that in the latter the earthy matter is not deposited originally, whilst in the former it is absorbed after having been deposited; in both the result is the same. The latter is peculiar to the very young, the former to those of an advanced age. Rickets and mollities ossium seem to differ also in this. In the latter there is seldom, if ever, any reparative action. The diseased process of deposit continues in the bone, the softening increases, and Illustration Softening of the bones is met with at all ages, and in different degrees. It seems sometimes to be congenital, and combined with hydrocephalus. It often follows dentition, measles, hooping-cough, or other infantile diseases inducing debility. In females it seems to be produced, or at least often accompanied, by the debilitating effects of leucorrhoea, miscarriages, and floodings. Loss of blood, in any way, predisposes to it. Mercury, given in immoderate quantities, produces a softening of the bones; and, in some most remarkable instances on record, the free use of common salt was the only cause assigned. When the disease affects children, all the bones generally suffer, those of the extremities as well as those of the trunk; the limbs become bent in an extraordinary manner, and the heads of the bones are swollen, and appear to be much more so in consequence of the wasted and flabby state of the muscles. The child walks with diffi The bones of rickety subjects are soft, cellular, and of a brown colour, contain a dark fluid, and are very deficient in earthy matter. As a simple proof of the latter circumstance, it may be mentioned that distortions of the pelvis can be, and often are, accurately imitated by soaking the bones for some time in acid, whereby the earthy matter is extracted. In many instances this component of the bones is almost entirely removed, and soft matter deposited instead; they then consist merely of an extremely thin external osseous shell, covered by thickened periosteum, and containing a pulpy substance resembling fatty matter. During the progress of the disease, the urine deposits, often in great quantity, a white sediment, which, on analysis, is found to be the phosphate of lime. In rickets the head is generally enlarged to a greater or less degree, and the bones of the cranium are thickened and spongy; not unfrequently the intellectual faculties remain acute. In adolescents and adults the limbs seldom become affected; the bones composing the spinal column are the seat of the disease, and, along with the distortion of the spine, the position of the ribs is necessarily altered. Certain rare cases have occurred, in which all the bones of the adult were softened to a very great degree. In one remarkable instance, the patient complained of an annoying sense of tightness in the limb most affected, and, on examination, the softened bone was found greatly depressed at that point, as if a strong ligature had been drawn tightly round it. Mr. Howship, who attended the patient, was so kind as to present me some years ago with a portion of the altered femur, which consists of a fatty-looking substance, and appears to contain little or no earthy matter. Though incurvation of the spine occurs in boys, and even in adults, still it is most frequently met with in young females; and in them it is often induced by their having assumed a bad habit by sitting long in one constrained and awkward posture, as in writing or drawing, without, perhaps, the bones being unnaturally soft in the first instance. It often follows affections of the lower limbs, as of the knee or hip-joint; and is also caused by shortening of a limb, which has been negligently or ineffectually treated after fracture during child Illustration At first, during slight curvature from such causes, the spine can be brought into its original straight position by the voluntary action of its muscles. After some time, however, the curve cannot be remedied by any effort; interstitial absorption of the bodies of the vertebrÆ towards the concavity of the curve occurs; they become changed in form, and accommodated to their altered position, as shown in the accompanying sketch; the muscles also accommodate themselves to the new position, as do also the various ligaments connected with the spinal column. When the curvature is seated in the dorsal vertebrÆ it is generally to the right side; this shoulder is raised, and the chest is protruded, whilst the opposite side is depressed and flattened. The clothes hang loose, or fall off on the left side—the patient rests the weight of his body chiefly on the left leg—on stooping the right The bones of the pelvis become distorted, and are twisted to one side; or, when the softening is great, and the patient confined to the recumbent position, the introitus of the cavity becomes diminished in the antero-posterior diameter; and, if the patient walk about, the ossa pubis are squeezed together, in consequence of the pressure of the ossa femora against the acetabula. The crests of the ilia are often bent inwards, in consequence of the pressure of steel apparatus injudiciously applied with a view of removing deformity. When the bones become consolidated after such distortion, they present most serious obstacles to parturition; and, most unfortunately, crooked and deformed women possess, it is said, “great aptitude for conception.” When, in such females, the untoward circumstance of pregnancy has occurred, it has been necessary, in some, to have recourse to the CÆsarean operation, and others have been delivered with the greatest difficulty and danger; notwithstanding which, many of these latter have, after recovering from a long and tedious illness, again become pregnant. In some cases the softened ribs not only compress the organs of the chest, but are also pressed down upon the abdominal viscera, or even into the pelvis. The symptoms arising from such displacement are at first urgent, as can readily be imagined, and are often treated as inflammatory, to the detriment of the patient. After some time, as the state of the patient’s health improves, the bones in some degree regain their original firmness, and the curvatures are rendered permanent. New bone is deposited in the concavity of the curve, at first in irregular masses, but afterwards becoming condensed, and assuming a more regular form, the column is thereby supported and strengthened. Bending of the spine backward, with depression of the spinous processes, is extremely rare. But curvature forward, with projection of these processes, is by no means uncommon, and is generally supposed to be caused by caries of the bodies of the vertebrÆ; in many instances, however, it arises from interstitial absorption only. Curvature from caries of the vertebrÆ, though not so frequent as the curvature from other causes, is met with pretty often. In adults, the curvature from ulcerative absorption is more common than that from softening of the bones. It is attended with the formation of purulent matter, which presents in the loins, at the top of the thigh, or near the anus; the bones may become affected secondarily, though much less frequently, in consequence of the formation and accumulation of purulent matter in their neighbourhood. There is pain in the loins; the patient walks in a stooping posture, and often complains of pain in the knee or thigh. The lower limbs sometimes become paralytic, as also the sphincters and extremities of the hollow viscera; In the treatment of Rachitis, the chief indication to be fulfilled is to support and increase the powers of the system; and this may be accomplished by affording the patient a generous diet, keeping the bowels in good order, enjoining gentle exercise and exposure to pure air, by the assiduous use of frictions, and by supporting the softened bones by properly applied and light machinery. Much mischief may be done by clumsy and heavy apparatus which confine the movements of the patient; the muscles are wasted, consequently the spinal column is weakened, the general health is impaired, and the disease is aggravated. Some have recommended the internal administration of the phosphate and muriate of lime, but their efficacy is extremely doubtful. Preparations of iron seem to answer much better in the greater number of cases. In cases of curved spine, apparently arising from bad habit, the patient should be in no degree confined at writing, or drawing, or music; her posture while at work or play ought to be attended to, as well as her mode of walking or standing; and, if awkward, prohibited. Gymnastic exercises of the more gentle kinds ought to be enjoined, such as those with poles and light wooden clubs, the turning of a wheel, the exercise with balls, &c. Carrying weights on the head can only be applicable in certain cases. The shoulders, in some instances, ought to be kept back by means of a light back-board; and in aggravated cases the weight of the shoulders, and sometimes also of the head, must be taken off the spine by a light and well-contrived apparatus. Sea-bathing, good air, out-of-door exercise, and attention to diet, are of material importance. Frequently advantage will result from the patient’s sleeping on a hard mattress; and, in bad cases, from lying down, when tired, on an inclined plane. In great softening, it will be necessary to confine the patient entirely to the recumbent position, and to support the head and shoulders by a light and firm machine. The causes, symptoms, appearances, and treatment of caries of the spine, in its different regions, with or without curvature, will be afterwards considered. OF INFLAMMATORY AND OTHER AFFECTIONS OF THE ARTERIAL SYSTEM.During inflammation of arteries, the actions of the vessels are accelerated and attended with pain; the internal coat is found to be of a red colour, from increase of its vascularity, and not from its being merely tinged with the colouring part of the blood; or it is of a yellowish hue and rough, from the deposition of lymph on its surface, Inflammation is supposed to precede degeneration of the arterial coats. As a person advances in life the arteries lose elasticity, and the heart its balance with them; either the one or the other becomes dilated, their parietes are thickened, and the valves are altered in structure; the enlargement of the vessels is generally greatest towards their origin. The dilatation of arteries, more especially of the internal ones, is often very great; ultimately the internal coat gives way, and the external, with the surrounding tissues, yields in proportion as the blood diffuses itself. The internal tunic is occasionally burst in consequence of violent and sudden muscular exertion; and, even when the vessels are pretty limber and sound, effusion of lymph, and obliteration of the vessel ensue, or, more frequently, aneurism. Previously to the rupture of the internal tunic, however, there is, in most cases, a morbid alteration in the texture of the vessel. The internal coat becomes dry; its textures is more dense and less elastic, and consequently more brittle. Morbid matter is deposited between the middle and internal coats, and this, by stretching the latter still further, diminishes the elasticity and cohesion of their texture. The deposit is at first to a slight extent and of soft consistence, somewhat resembling condensed fatty matter. Afterwards it increases in quantity and consistence, becoming, instead of soft and yielding, dense, hard, and incompressible; in short, calcareous. Though the morbid deposit is at first confined, as above related, its limits are afterwards extended; calcareous matter is insinuated, either in minute particles or in broad laminÆ, amongst the fibres of the middle coat, is also found external to it, and occasionally situated in Illustration the cellular coat. In fine, the various component parts of the parietes of the vessel degenerate, according to the degree of advancement which the disease has attained; and such a condition is the predisposing cause to ulceration of the internal coat, and subsequent effusion of blood. The steatomatous, ulcerated, earthy degeneration of the proper coats of an artery, as Scarpa, the celebrated professor of Pavia, has it, are well exhibited in the accompanying sketch. ANEURISMDuring violent and sudden exertions The blood contained within the aneurismal sac, being comparatively motionless, coagulates, and the coagulum is attached to the In some rare cases the deposition of fibrin has gone on gradually accumulating, filled completely the aneurismal cavity, and thus effected a spontaneous cure, the remaining solid tumour imperceptibly diminishing by the action of the absorbents. After obliteration of the aneurismal cavity, the fibrin is generally deposited in so great quantity as to occupy the calibre of the vessel above and below the tumour, obstructing the progress of the blood, causing it to flow by the smaller and collateral branches, and effecting a spontaneous cure, somewhat similar to that produced by the artificial application of a ligature. Coagula are seldom formed in the dilated vessel, to whatever size it may be enlarged, unless there is fissure of the internal coat; for in no other way can a portion of the blood readily become stagnant, while the calibre of the vessel remains pervious. There is in my collection a preparation of dilated aorta, to the coats of which adheres a large firm coagulum. Occasionally, though rarely, a dilatation of the internal coats is met with accompanied by thinning of the external ones. Of this sort of diverticulum, there is also a good specimen in the collection here alluded to. A spontaneous cure may also be accomplished from the original aneurism being compressed by one of a more recent origin, causing ultimate obliteration of the canal. Of this I recollect one remarkable instance; the patient was afflicted with an aneurism of the axillary artery, which had attained a large size, and the cure for the disease in this situation being then unknown or unattempted, the patient was considered as lost; but some time after the tumour began to diminish, and disappeared. The patient died; and the cause of death was found to be the giving way of an aneurismal tumour of the arteria anonyma, which was situated so closely to the aneurism of the subclavian as to have acted as a mechanical compress, causing obliteration of the vessel at that point. When a cure has been effected, the vessel is found to be converted into a dense and impervious cord at the site of the tumour. The canal above is dilated; the coats are thickened, especially the middle; and from the thickening and increased action of the fibres, the internal coat becomes somewhat rugous, the rugÆ being in a transverse direction. The aneurismal tumour in general increases, and approaches the surface, involving and destroying all the intervening textures. If resisted in its enlargement by bone, even this is not sufficient to impede its progress; the bone is absorbed, and perhaps ulcerated, at Illustration An aneurism of the descending aorta, in a great measure one from dilatation, is here represented: the patient also laboured under popliteal aneurism of one limb, and inguinal of the other. He died suddenly, in consequence of the giving way of the internal tumour. The escape of blood into the cellular tissue may even take place to such an extent as to prove fatal in a few hours. The disease may also prove fatal by mere compression, as of the trachea, impeding breathing, and inducing disease of the respiratory organs; or by pressure on the gullet preventing the passage of food: in the latter case, however, the dissolution is generally more sudden, in consequence of the compressing part of the tumour giving way, and the contents being evacuated into the stomach or mouth. If the aneurism compress a plexus of nerves, or the spinal chord itself, the anterior part of the vertebrÆ having been previously absorbed, paralysis is produced. In consequence of aneurism, the circulation of blood in the vessel is obstructed; hence the collateral branches above the tumour become enlarged, and through them the circulation is continued; by their anastomosis with collateral branches which arise below the seat of the tumour, a portion of the fluid is brought back into the canal of the original artery. The circumstance of collateral enlargement used to be distinctly enough demonstrated in amputation, one of the old cures for the disease. The tumour may be suddenly increased by a portion of the parietes giving way, and the blood being propelled into the cellular tissue, which becomes thereby condensed, and supplies the deficiency in the original sac; diffuse is thus superadded to the true or encysted aneurism. The disease is generally accompanied with great pain, the neighbouring nerves being much stretched by the enlargement of the tumour, as in the axilla or ham; in these situations also the limb below the aneurism is much swollen from the compression of the absorbents and veins and consequent infiltration into the cellular tissue. Diffused aneurism from wounds, and the other species of the disease, will be afterwards treated of. The peculiar degeneration of the coats of the vessels has been already stated to be the predisposing cause of aneurism; and the disease may be directly caused by over-excitement of the circulation, or by an over-exertion of the muscles. It is more frequent in males Treatment.—In internal aneurism the only indication which can be followed, with any chance of success, is to favour the occurrence of a spontaneous cure, by abstracting all stimuli, mental and corporeal, by enjoining complete rest, by keeping the patient on low diet, and by repeated bleeding. Thus the force of the circulation is diminished, and coagulation, it is said, promoted; by this practice aneurisms, the progress of which defies external means, are occasionally, though very rarely, cured. Ice and other cold applications to external aneurisms, or those which have made their way to the surface, have been recommended to induce coagulation, but their use is not unattended with danger; for they may, in some stages, so far diminish the vitality of the coverings as to cause sloughing, and fatal hemorrhage. In the treatment of aneurisms exterior to the great cavities, important improvements have been made in modern times. No success can be expected to follow palliative and temporizing measures, and a cure can result only from operation. Formerly it was the practice to lay open the aneurismal tumour, to search for the extremities of the artery opening into the cavity, and to secure them by a ligature, or close them by pressure, styptics, or both. In some few instances this method had permanent success; but in the majority the operation proved wholly abortive, and not unfrequently fatal. It was necessarily tedious in its performance, and attended with much danger, the blood being discharged in great profusion immediately after the opening of the sac, and the extremities of the vessels being with great difficulty detected and secured. Besides, the vessels in the immediate neighbourhood of the tumour having generally undergone the degeneration already mentioned, were incapable of taking on any healthy action; the application of ligature on a vessel thus circumstanced could consequently be productive of no advantage. From this method having almost invariably proved unsuccessful, practitioners in those days generally preferred amputation, when the tumour was so situated as to allow it; and when the disease occupied a situation in the limb so high as to prevent amputation, the case was deemed incurable, and the patient abandoned to his fate. But amputation was accompanied with circumstances almost equally alarming with those attendant on division of the sac: the hemorrhage was very great; for as a consequence of obstruction to the free passage of the blood in the aneurismal vessel, the circulation was chiefly carried on by the collateral anastomosing branches, which were there The operation of applying a ligature on the vessel at a distance from the tumour, and thus intercepting or weakening the flow of blood into the cavity, so as to allow complete coagulation to take place, is of comparatively modern invention, and is the one now practised with almost invariable success. To John Hunter without doubt belongs the merit of proposing and putting it in practice; it has been claimed also for the celebrated Desault. This operation has been variously modified. Some have advocated the temporary application of a ligature, conceiving that the effects produced will be as complete and permanent when it has been allowed to remain only for a certain time, as when it is left undisturbed and ultimately separated by nature. Such a theory, however, has proved to be incorrect in most of the instances in which it has been reduced to practice on the human subject; and the operation is at best very uncertain, and not to be relied on. Others have employed a double ligature, and some of the Continental surgeons have applied a great many; some were tightened, others left loose, and looked upon as ligatures of reserve to be tightened, should hemorrhage take place, an occurrence likely enough to follow their clumsy and unsurgical proceedings. A thick broad ligature like tape has also been used, from an ill-grounded apprehension that all the coats of the artery would be cut completely through by the tight application of a thin and firm one. With the same view, a roll of linen or plaster has been interposed betwixt the noose and the vessel, and this practice has been advocated even by good surgeons—as Scarpa. Such complications can do no good, and may do much mischief. The artery must be greatly detached from its surrounding connections before the numerous and flat ligatures can be applied, in consequence of which its coats will be apt to slough or ulcerate, and hemorrhage occur. When, from any cause, the vessel has been detached to a greater extent than is sufficient for the passing of one ligature, two ought undoubtedly to be used, and one applied close to each extremity where it is attached to the surrounding parts. Again, it has been proposed, after the application of a double ligature, that the vessel should be cut through betwixt the two deligated points; it being supposed that in this way the closure of each extremity will be more rapid, the cut ends retracting, and being, in fact, in the same circumstances as the extremities of arteries which have been tied on the face of a stump. Mechanical contrivances have also been invented for the compression of the artery,—such as the serrenoeud and presse artere; these, however, are clumsy, insufficient, and often injurious. The single ligature, when properly applied, is the most safe, and preferable to any other, for arresting permanently the flow of blood Ligatures composed of animal substance, such as catgut, have been proposed as preferable to all others, on the supposition that they would be absorbed, and occasion less irritation; the fallacy of any such theory has already been adverted to. After the ligature has been applied for some time, it induces ulceration of the external coat which it envelopes, by which means it becomes detached from the vessel; acting as a foreign body, and causing a slight degree of suppuration, it makes its way by nature to the surface and is discharged. The period at which it separates may be said to be from the tenth to the twentieth day; sometimes sooner, seldom later. If, however, much of the surrounding parts have been extensively included along with the vessel, a longer period will probably elapse before the separation of the ligature. One end only of the ligature should be cut away close to the artery, the other being left hanging from the external wound; perhaps it is even safer to leave both, unless a third The operation ought to be performed at as early a period of the disease as possible. Some recommend that it should be delayed in recent cases, with the view of allowing sufficient time for the anastomosing vessels to enlarge, in order that the circulation may be more vigorous in the smaller branches after obstruction of the principal vessel. Such delay prolongs the patient’s sufferings, which are in many cases extremely acute, and the precaution is altogether unnecessary, as has been amply proved by experience. On the same principle, the previous application of pressure to the vessel has been recommended; but few surgeons, if any, are now afraid of trusting to the resources of Nature when the principal vessel of a limb is obliterated, and that suddenly, without previous dilatation of the anastomoses. Cases are on record, in which the abdominal aorta has been completely obstructed by a natural process, without much impeding the inferior circulation; and in one remarkable instance of this description, the inconvenience was so slight that the disease was not suspected during the life of the patient, the lower limbs retaining their usual size and activity. In plethoric habits it may sometimes be prudent to abstract blood, even more than once, previously to the operation. When the ligature is placed immediately below a collateral branch of considerable size, a bloody coagulum is not formed, though adhesion may occur; but if the excited action should extend to the collateral branch, and its canal become thereby obliterated, a coagulum is speedily deposited. In consequence of the enlargement of the anastomosing branches, and the increasing circulation in them, pulsation generally returns in the tumour, to a slight degree, some days after the operation. This, however, is by no means a sign that the operation has been ineffectual; for the renewed pulsation almost always disappears in the course of a very short time. In one instance only have I found it assume a more permanent and troublesome aspect; in that case, it recurred about ten months after the performance of the operation, but speedily disappeared under the careful use of a compress and bandage. On account of the aneurismal diathesis, it occasionally happens, that after the cure of one aneurism, another appears in a different situation; in two instances, I operated on both thighs, at a considerable interval, successively and successfully, for popliteal aneurism, in the same patients. When the tumour is so situated as not to admit of the application of a ligature between it and the heart, it has been proposed to place the ligature on the distal side of the aneurism, upon the supposition that coagulation will occur within the sac in this case as after the common operation. The appearance of the vessel after the application of a ligature above the tumour has been already shown. The obliteration of the sac proceeds, in some cases, very rapidly; it assumes a harder feel, decreases, and disappears; being connected with the vessel by means of a dense impervious chord, to which condition that portion of the artery has been reduced. The anastomosing vessels enlarge more and more, carry blood freely from above to below the ligature, and thence to below the tumour; some even passing to the latter situation directly from above the ligature. Along with the muscular and other Immediately after the operation, the circulation in the limb cannot be so vigorous as before; its temperature is consequently diminished, and it possesses less power of resisting the influence of stimuli. The limb ought to be kept only moderately warm; for if too much heat be applied, there is a risk of gangrene. The temperature afterwards rises, and soon gets above the natural standard; the blood, from obstruction in the internal parts, being chiefly determined to the surface. After the collateral circulation has been completely established, the limb regains its natural temperature. Secondary hemorrhage is occasionally a consequence of this operation; nor is it to be wondered at, should one ligature only be used, seeing that this is often clumsily applied; the cellular tissue being lacerated, and the vessel detached from its connections by the use of blunt instruments, directors, and silver knives. When many ligatures are employed and foreign substances placed in the wound, the patient can scarcely be expected to escape profuse bleeding. If, however, the operation by single ligature be properly performed, and the coats of the artery be sound at the deligated point, the occurrence of secondary hemorrhage must be rare. It generally supervenes when the ligature is about to separate: at first there is a thin bloody discharge, afterwards the quantity of blood is more copious; it is evacuated at first in a gentle and continued stream, but afterwards per saltum, and in profusion. The discharge not unfrequently stops for a short time, but, on the circulation being excited, it again returns; and the patient soon dies, unless active measures be practicable, and immediately resorted to. Compression can be of no use; nor can astringents, nor venesection, which I have actually seen practised in such cases. The application of a ligature betwixt the heart and the open point of the vessel affords the only chance of saving the patient; the surgeon must interfere, and do what is in his power—he cannot look on and see the patient bleed to death. Occasionally the aneurismal sac deviates from its usual structure and appearance. Sometimes osseous or calcareous matter is found deposited, to a greater or less extent, in the substance of the parietes of the sac, or between the laminÆ of fibrin which it contains. The tumour may also occupy unexpected situations, occurring after fracture of the bones and laceration of an artery, and perhaps from more slight external injuries. A disease of bone, somewhat resembling aneurism in that tissue, will be afterwards noticed. OF ANEURISM BY ANASTOMOSIS.This disease is generally seated in the external cellular tissue. It has been supposed to attack occasionally the internal organs; and a case is related in which it was situated in the cellular tissue, between In very slight cases of erectile tumour, or in nÆvus threatening to assume an aneurismal action, cold and pressure are sometimes, though very rarely indeed, sufficient for the prevention or removal of the disease. The most effectual remedy is excision, though this can very rarely indeed be had recourse to with safety; for when the disease is extensive, the vessels in its neighbourhood are much enlarged, and their action increased; so that any attempt to remove the tumour by the knife is followed by profuse, and often an uncontrollable, flow of blood. When excision is practicable, it ought to be accomplished by cutting very clear of the disease; the tumour, like every other, must be cut out, not cut into. If the incisions encroach on the substance of the tumour, or are made in the immediate neighbourhood of the diseased part, the tremendous bleeding which invariably ensues will convince the practitioner of the impropriety of his conduct, and rashness of the proceeding. Attempts have been made to arrest the progress of the diseased action, by tying the principal arterial trunks entering the tumour; but these have proved ineffectual, as might be expected, considering the unusually free and numerous inosculations which then exist. In a few instances, ligature of the carotid artery, on the same side with a tumour on the face or head, has put a stop to the disease; in the others, it has been unavailing. When the tumour is so situated, or of such a size, as to render the expediency of excision doubtful, it may often be safely and expeditiously removed by ligature. In some cases the tumour is prominent, so that it readily allows of the application of a ligature around its base; in others, it is flat and broad; in which case, a long needle, or needles, armed with a double ligature, can be passed beneath it, and the ligatures can then be separated, and so disposed as to cause sufficient constriction of the entire mass.—Vide Practical Surgery, p. 331, 336. In many cases, incisions may be made with great advantage, either before or after introducing the ligatures; the diseased mass is thus more effectually included and strangled, and much pain and deformity are avoided. The disease, however, occasionally occupies such situations as are totally beyond reach. The application of potass has been recommended; and this caustic is certainly sufficiently powerful to destroy the diseased parts; but its use is attended with danger from profuse hemorrhage. Superficial nÆvi may occasionally be got rid of by the application of nitric acid, but it requires to be applied over and over again; and, after all, some more effectual means must probably be resorted to. Stimulating injections into the substance of the growth have been sometimes employed. Cures, it is said, have followed the use of setons, or the repeated puncturing and breaking up of the tissue with a needle. None of these means are to be depended upon. The cases are innumerable in which I have been obliged to employ the ligature in an effectual manner, combined or not with incision, where caustics, injections, puncturings, setons, and even imperfectly applied ligatures, had been previously resorted to in vain. Besides, in children there is as much resistance and crying, and as much anxiety in parents, produced by a slight operation, as by a more effectual one. OF INFLAMMATION OF VEINS.Veins are very susceptible of inflammation, and the action is very apt to extend along the coats rapidly; in some cases it reaches the Inflammation in the venous, as in the other tissues, may terminate in resolution. Otherwise, lymph is secreted, whereby the coats of the vessel become thickened, and its internal surface agglutinated, causing obliteration of the canal to a greater or less extent. Suppuration also occurs, and the pus may be deposited in a cyst formed amongst the coats of the vessels; or, as is most frequently the case, it is secreted from the internal coat, and occupies the canal of the vein. It then generally accumulates, its passage into the circulation being prevented by a deposition of lymph sufficient to occupy the calibre of the vessel betwixt the heart and the seat of the purulent matter. The termination in purulent secretion is accompanied with a high degree of constitutional irritation, and typhoid symptoms, more especially if any pus finds its way into the circulation. The integuments in the course of the inflamed vessel or vessels are of a dark red colour, and great pain is caused by pressure. Often there is a considerable oedematous swelling of the limb, occasionally followed by the formation of unhealthy pus, diffused in the cellular membrane, causing sloughing of that tissue, or of the soft parts more deeply seated. This disease generally follows an accidental wound or operation, as venesection or amputation; it is also of frequent occurrence after the application of a ligature to the extremity of a vein. Many patients have died of this disease, induced by the application of a ligature to the vena saphena major, for the cure of varix. Wounding of large veins ought to be studiously avoided; and if wounded, the bleeding from them should, if possible, be arrested by pressure. When from any cause the extremity of a large vein in a wound is not closed, when it is not plugged up by plastic matter, pus seems to enter it readily, and by mixing with the circulating fluid causes dreadful mischief; great constitutional disturbance accompanies the purulent deposits which follow in the solid viscera and in the joints. Inflammation of veins is a very unmanageable disease; the exhibition of purgatives and antimonials will be prudent, in order to evacuate the bowels, produce diaphoresis, and diminish the force of the circulation; the pain will also be much relieved by the application of warm fomentations to the affected part. General depletion is not admissible unless at the very commencement of the disease, and local bleeding must be had recourse to with very great caution; for by copious abstraction of blood, gangrene may be induced, or at least hastened. The limb must be altogether disused and elevated, the patient being kept in a state of complete rest, and not exposed to any excitement or anxiety. Blisters have been employed, but with no good effect. If the vein is much distended, and it is evident that it contains a confined accumulation of pus, it ought to be treated as a common abscess, the matter evacuated by an incision, and various dressings employed, according to circumstances. Such practice I have found successful, and not followed by any untoward symptoms. The abscess is often limited at each extremity by the deposition of lymph in the canal of the vessel; and after the evacuation of its contents, the cavity contracts, and the portion of the vessel which has been the seat of suppuration becomes completely impervious. Inflammation of a vein is also occasionally followed by the sudden appearance of a purulent depÔt in some part of the body, external or internal, at a distance from the inflamed part. Thus, in inflammation of a vein in the forearm, it is not unusual to find an abscess formed suddenly in the axilla on the opposite side; after amputation, or other capital operation, the patient is often suddenly affected with violent symptoms of disease in the chest, and, on examination, abscesses will probably be discovered in the substance of the lungs, the existence of which had only been suspected a short time previous to death. Possibly some pus globules, the seeds of disease, may be arrested in their course through the capillaries of these organs, and thus a foundation be laid for mischief. A very satisfactory explanation of these phenomena cannot readily be given. It has already been noticed, that the softening of coagulated fibrin must not be confounded with suppuration. The fibrinous pulp has commonly been called pus, though erroneously; and when occurring in the veins, as it frequently does, has been generally described as inflammation and suppuration of the vessel. The distinction is important; first, because many of the so-called cases of phlebitis are Illustration shown to be of a different nature, and secondly, as to the theory of suppuration, on which subject many writers in this country have been engaged in making commentaries on, and compilations of, the French doctrines, which are not deserving of much regard. There exists without doubt a capillary phlebitis, and the vast importance of inflammation, and its consequence in these vessels, will be estimated when their great extent and functions are recollected. It is probably in this class of cases especially that the blood becomes contaminated with pus. Veins frequently become dilated or varicose; they assume a tortuous course, appear much enlarged, and present an elastic, soft feel, except in the situation of the valves, where they are more hard and incompressible: occasionally the tortuous windings form a bluish tumour of considerable size. The dilatation of the superficial branches is increased by heat, the skin being thus relaxed, so as to give less support. The limb is swollen and oedematous. The dilatation is generally supposed to be confined to the vessels near the surface, but it appears that the deep-seated ramifications The cause of this affection is obstruction to a free return of the blood; as by tumours, either natural or adventitious, from pregnancy, constipation, &c.; or by the tight application of a ligature round the limb, as of a garter. It often occurs in those who have been in the habit of great muscular exertion, the blood being thereby forced from the deep-seated veins into the superficial. This even occurs, though very rarely, in the upper extremity, and I have witnessed more than one instance of it. Here it is more readily got rid of. Dilatation of venous branches is met with in the scrotum, labium pudendi, lower part of the abdomen, in the neighbourhood of the anus, and at the lower part of the neck. The lower limb is, however, the most common seat of the disease: when the veins in this situation are dilated, the valves are insufficient to obstruct the calibre of the vessels, and consequently the lower and smaller ramifications have to sustain the column of blood in the superficial veins of the whole limb, its weight not being diminished by the support which, in the natural state of parts, is afforded by the valves; the disease is thus more and more aggravated. The left limb is generally the one affected; and this circumstance may probably be explained by the pressure of the sigmoid flexure of the colon on the left iliac vein. In the majority of cases, the palliative treatment can only be adopted. The limb must be used as little as possible, and, if practicable, be kept in a state of complete rest; the veins must also be supported by the application of a bandage, or the wearing of a laced stocking. The Indian rubber bandage worn over the stocking or drawers answers fully as well as any other method. In some instances, the application of cold has been of advantage, by promoting the contraction of the dilated vessels. When pregnancy is the cause, it is needless to commence any method of cure, until the cause be removed; and the same remark is applicable when the affection arises from habitual constipation. The varices occasionally become inflamed, painful, and much swollen, with considerable oedema of the whole limb. Their contents become coagulated, and their coats thickened; in the end, the swelling abates and the vessels are closed. In certain cases, this spontaneous cure, a radical one, may be imitated by the surgeon; an escharotic being applied over the trunk of the vein at a healthy point, whereby inflammation is produced in the coats of the vessel, and obliteration of its cavity accomplished: the A much preferable method, as being less painful and unattended with risk, is that of passing needles under the vessel, and twisting a piece of thick and strong silk round them. Two needles should be applied together, at an interval of about half an inch, at whatever points it is thought right to close the vein. Coagulation takes place in the included part, and also frequently for some distance below it; the coats of the vessel are thickened, and its canal closed. The needles are withdrawn before they begin to cut their way out by ulceration,—say at the end of from three to five days,—according as the parts become condensed. The needles suited to the purpose are soft, but tempered at the point, which is spear-shaped; the ends are cut off with pliers after the thread is fixed. Other operations have been performed on the veins, to procure a radical cure of varix; one or more ligatures have been passed round the vessel, as in the operation for aneurism; and the vessel has been divided, or a portion of it dissected out, and its cut extremities afterwards either compressed or secured. Such proceedings are now almost entirely abandoned. OF TUMOURS.A tumour is a swelling or new production, and not a part of the original composition of the body. Blood may have been effused, and the coagulated part, becoming organised, is increased in size by deposits from the vessels which enter it; or perhaps the blood, the coloured part of it at all events, is taken up and lymph is deposited, which, if not also removed, “undergoes further changes of a secondary nature, and remains a parasite or new structure.” Its structure and growth are modified according to the action which its own vessels assume, independently of the surrounding vascular system. The bloodvessels may enter this new growth by a narrow Tumours are divided into Solid and Encysted. The solid are generally enveloped by a dense cellular sheath of the surrounding cellular substance, yielding and becoming condensed in proportion as the tumour increases in size; this covering appears as a barrier between the healthy and diseased parts, shutting out the latter, as much as possible, from connection with the rest of the body, and preventing the former from participating in the injurious tendencies of the latter. Some tumours have no such limit, but extend in the direction where there is the least resistance, hold a free intercourse with the surrounding parts, and impart to them their morbid disposition and action; others are limited in their situation and communications, but prove dangerous or annoying from their bulk. Some grow rapidly, and prove troublesome in a few weeks or months; others remain without much increase for years, and produce little or no inconvenience. Occasionally tumours partly resemble the texture in which they grow; those of a fatty nature are frequently found to have their nidus in the adipose tissue; cartilaginous tumours project from the surfaces of bones or of a joint, are subsequently detached, and lie loose in its cavity; growths of a cellular structure internally, and invested by an apparently mucous lining, protrude from the surface of mucous membranes. Others differ, not only from the texture in which they are situated, and from which they derive their nutritive vessels, but also from every other part of the healthy structure. In one instance, a congenital tumour was found to be composed of an aggregation of numerous materials, many of them resembling the healthy textures of the body. But again, tumours are constantly met with, composed of matter which in no respect resembles any of the natural tissues of the body: those are what have been called heterologous formations. The simple tumour is mere enlargement of a part, from the infiltration of solid matter deposited by its bloodvessels. There can This species of tumour, or rather this enlargement which precedes the formation of a tumour, is chiefly met with in the cellular and glandular structures. Sometimes it is described under the term of oedema solidum. In the scrotum, where the cellular tissue is remarkably loose and extensile, such tumours attain a very large size. They are found in this country, though more frequently in warm climates. I removed one from this situation successfully, which weighed upwards of 44-1/2 lbs.; it had been of twelve years’ duration, and caused much inconvenience to the patient. It is sketched in the Practical Surgery, p. 341. It occurs in the mamma, apparently in consequence of suppression of the menstrual discharge; the gland becomes enlarged, there is no pain in the tumour, and it feels soft and doughy. When the subcutaneous cellular tissue is the seat of the disease, the tumour is often of considerable extent, but rarely forms a great protuberance. It sometimes is situated in the coverings of the nose, which, as they become enlarged, lose their natural colour, and assume a purple hue; the mucous follicles also are often much enlarged, and occasionally emit a profuse discharge of their secre It has been already observed, that when simple enlargement exists for some time the structure changes. It becomes more dense, and assumes a peculiar action, independent of that of the surrounding parts. It has a harder and more firm feel, and all traces of the texture in which it was formed are destroyed. It may be considered as the next in order to the one already mentioned, both as to the simplicity of its structure and action; but in consequence of its action being independent of those of the neighbouring parts, and liable to change from even slight causes, it is very apt to degenerate into those tumours which are more complex and injurious. ADIPOSE TUMOURS.Another species of tumour seems to be composed almost entirely of fatty matter insinuated amongst extended and delicate cellular substance, and has been therefore termed adipose. It is surrounded by a cyst of dense cellular tissue, and to this it loosely adheres; its bloodvessels are few, and it is of an inactive and innocuous character. It is generally lobulated, and often attains a large size. It is not only irregularly prominent on its outer surface, but in its whole circumference, and its lobuli often insinuate themselves to a great depth amongst nerves, bloodvessels, and other important parts; owing to this circumstance they frequently prove a source of the greatest inconvenience from their bulk, for of themselves they are neither hurtful, nor possess any disposition to involve those parts with which they are in contact. This tumour is found only in the cellular and adipose tissues. From its loose connection with its envelope, it admits of ready removal by operation. A tumour of this kind is here represented, which, but for this circumstance, owing to its awkward situation under the tongue, could not by any possibility have been extirpated. It is fully larger Illustration than an orange, and had caused very great suffering. It is not so much lobulated as fatty tumours generally are. The adhesions of adipose tumours are, however, rendered firm and more numerous by pressure or external stimulants—in fact, by whatever induces inflammatory action in its substance or in its surrounding connections; and from this cause the extraction is often rendered exceedingly difficult. The skin becomes thickened and of a red hue, and the tumour itself is much more vascular. From this cause it is apt to assume a The patient does not complain of any pain or uneasiness in the tumour, unless inflammation be excited in it; then the pain and other symptoms are such as attend incited action, and the sensations which are afterwards experienced vary according to the character which the tumour assumes. Certain changes may occur in its texture, though not in its general character or disposition; thus osseous or earthy matter is occasionally deposited in some part of the tumour, while the surrounding adipose substance retains its appearance and density. Suppuration, it is said, has followed inflammatory action, excited in an adipose sarcoma. OF FIBROUS TUMOURS.Illustration Fibrous tumours are not uncommon, and are formed in various textures. In general they are composed of a substance of a dirty Besides those tumours which have been described, there is a number of others not of a malignant disposition, which are so various in their structure as to baffle all attempts to reduce them to a scientific classification. Some are composed of a homogeneous substance of almost cartilaginous consistence and a whitish colour; some consist of cartilaginous matter, mixed with substance of less density and of a different appearance; in some, fibrous matter is mixed with a homogeneous glandular-looking substance, partially softened. Some are almost entirely composed of osseous matter; others contain it in small proportion. It would be endless to enter into a minute detail of the structure of such tumours, for it may be said that their appearances vary with their number. In almost all tumours cysts are found, and the internal structure of some tumours consists almost entirely of cysts, or hydatids, as they have been called; in others, these only occupy certain parts, and compose but a minor feature in the structure. The sacs are generally lined with a delicate and smooth membrane, which is often vascular at various points; some contain a transparent and glairy fluid, albuminous or gelatinous; some bloody serum; some purulent, some curdy matter, or this mixed with a serous or purulent fluid; some pure blood; some a fluid like printer’s ink; and not a few are occupied by a dense elastic substance, which, on a section being made of the tumour, rises irregular and ragged above the cut surface. Some tumours are smooth; others lobulated or tuberculated. OF ENCEPHALOID TUMOURS.The tumour which comes next to be described is decidedly malignant. It is the Encephaloid, or Medullary Sarcoma. Although these tumours have been called encephaloid and medullary, it must not be understood that their intimate structure has any relation to that of the brain or marrow; for this reason the old term fungoid is perhaps a preferable one, since it leads to no false notion as to their nature, while it expresses a condition which at one time or other is remarka Illustration The mamma and testicle, and the contents of the orbit in children, are the most frequent seats of this disease; it not unfrequently occurs in the lymphatic glands, and few textures can be considered as exempt from it. The part at first enlarges slowly: but afterwards the disease advances with great rapidity, involving the adjacent parts. In general, the affection is not attended with much pain; the part has a spongy and elastic feel, and frequently presents an obscure sense of fluctuation, indicating that softening is more or less begun. The skin is tense, generally brownish, and is pervaded by large venous branches. This venous enlargement is always observable in the advanced stage of the disease, before or after ulceration has taken place; it is peculiarly evident in the eyelids, when the contents of the orbit are involved, and is to be attributed to obstruction of the circulation in the deeper vessels. The tumour is increased by the surrounding parts assuming a similar action, and being converted into a similar mass; and the disease also seems to be propagated by means of the absorbent system, and by the irritation conveyed along the vessels which emanate from the tumour, or from its immediate vicinity. Thus, when the testicle or mamma is affected, the lymphatic glands, both above and below the tumour, and the course of the absorbent vessels, are converted into an encephaloid mass, all traces of their glandular structure being completely destroyed. The same brain-like or cancerous matter is also found in the bloodvessels, large and small. When the disease has been of long duration, the superincumbent integuments appear tense, assume a purple colour, and ultimately ulcerate; a portion of the pulpy mass then protrudes, of a fungous Along with these local symptoms, there is a complete subversion of the system,—there being at first symptoms of constitutional irritation, afterwards those of hectic and extreme exhaustion. When the lympathic glands are diseased, the limb beneath is much swollen from oedematous effusion, the return of the blood and lymph being prevented; violent and excruciating pains are experienced in the course of the nerves of a limb; it also frequently loses its sensation, from those organs being either involved in the disease, or pressed on by the tumour. The vessels in the neighbourhood of the affected parts are materially altered, though they are seldom converted into encephaloid matter; the arteries are often completely obstructed by coagulating lymph for a considerable extent, and the coagulum not only occupies the principal trunk, but extends into the minute ramifications; and this explains why hemorrhage seldom occurs, even after ulceration of the tumour is far advanced; the veins also are frequently obstructed in a similar way; but in many cases they contain a soft and pulpy matter, exactly resembling the substance of the tumour. The fungus which protrudes after ulceration of the integuments sometimes bleeds, when it would appear that the hemorrhage proceeds from those bloody collections in the substance of the tumour already mentioned. According to my experience, when bloody points, or cysts containing bloody fluid, exist in a medullary or other tumour which has been removed, and if the diseased matter be reproduced, a bleeding fungus will almost certainly follow. This species of tumour occurs in all ages and in all situations, and during its progress evinces strong proofs of inveterate malignancy: if removed early, the disease may be arrested; but if the operation be long delayed, a tumour of a similar nature, and more extensive, will almost invariably be produced. In several instances I have removed encephaloid tumours, from the situation both of the mamma and testicle, and the disease did not return; but in the other cases the result has been as above stated. Encephaloid disease of the internal organs frequently supervenes on that of the external parts, and accelerates the patient’s dissolution; when in such situations they are beyond the reach of surgical art, and their existence is only, if at all, ascertained, in order to enhance the unfavourable nature of the surgeon’s prognosis. OF MELANOID TUMORS.The Melanoid tumour is rather of rare occurrence in the human subject; it originates in the cellular tissue, and most frequently attacks the internal viscera; sometimes it occurs in the eyeball, where it has been seen with the encephaloid disease, and occasionally melanotic matter is diffused amongst the cellular tissue throughout the whole body, even in that of the bones. The external surface of the tumour is generally of a shining and mottled appearance; internally it consists of a homogeneous black matter infiltrated into the cellular tissue, which is condensed, and in some cases distinctly increased in vascularity. The tumour, seldom of a large size, extends chiefly in a lateral direction. Occasionally it is pretty firm; in other instances it is soft, broken down, and semifluid. The melanotic matter is not always so deposited as to form a distinct tumour, but frequently seems to be sparsely infiltrated into the cellular tissue; and occasionally it is diffused in so minute a quantity as merely to tinge the part, or form dark streaks. Sometimes it is infiltrated in the substance of an organ, and sometimes it is effused on its surface; occasionally it is surrounded by a distinct delicate sheath; usually it is confined by no envelope, excepting the partial condensation of surrounding parts. In the skin it sometimes presents in a tubercular form. The tumour is said to be chiefly composed of albumen, mixed with a peculiar colouring matter. The disease mostly occurs in the trunk, seldom in the extremities; it is not uncommon in the orbit, and in the internal organs the melanotic deposits are generally both numerous and extensive. There is seldom pain, and the patient seems to suffer chiefly from lassitude and extreme debility, which gradually increase; anasarca frequently supervenes; the functions of the organs affected are much impeded, or even altogether destroyed, and thereby the sinking of the powers of life is accelerated according to the viscera affected and the extent of the disease. Melanosis occurs most frequently in advanced life, though it is not confined to it; whereas encephaloid attacks indiscriminately all ages. OF CARCINOMATOUS TUMOURS.The most malignant and intractable of tumours is the Carcinomatous. This term is applied to the disease in its occult state, whilst Cancer, a term pretty indiscriminately employed, may denote its condition after ulceration. The word scirrhus is often used synonymously with carcinoma; but the former has been, and still is, improperly employed to denote indurations and enlargements of structures in all situations, and has been altogether so much abused as to warrant its being erased from the nomenclature of diseases. Carcinoma seldom occurs before the age of thirty, and generally not till a later period of life; there are instances, however, of its appearance at The cancerous tumour afterwards presents a stony hardness, is generally of a globular form, and irregular and unequal in its surface. At a still later period it gradually enlarges, in the way already mentioned, remains moveable for some time, but ultimately becomes fixed by the increased extent of its connections. By these circumstances it may, in general, be distinguished from the tumours which, from the first, occupy a wide space, and are firmly fixed by intimate connections with the surrounding parts. When the tumour has once been developed, its progress is slow and steady, being arrested, or made to recede, neither by the efforts of nature nor by the interference of art. Pain is generally complained of in the region of the tumour, and is of a lancinating kind, compared by the patient to the passing of sharp instruments through the part; occasionally, however, there is no pain in the new formation, and little inconvenience is Along with these local symptoms and appearances, it can be readily understood that the constitution is, from the first, materially affected. The alimentary organs are deranged in function, the patient has a wan and sallow countenance, and is in general weak and much Illustration emaciated. After ulceration, the system is still more reduced by the discharge, the patient becomes hectic, and is often afflicted with diarrhoea; along with the other symptoms of extreme debility, the patient may become anasarcous, is affected with cough and dyspnoea, or by other symptoms indicating disease of some internal organ, and is ultimately carried off in a state of exhaustion. The disease attacks various textures, but perhaps most frequently the mammary gland. The mamma generally diminishes in size from absorption of the fatty matter; the nipple is retracted, often to a great degree, and the surrounding integuments are of a purplish hue, and exude a sanious fluid; at length the nipple is completely destroyed by ulceration. In other Ulcers or swellings, at first simple, may assume a malignant action, either carcinomatous or of another kind; thus, in one instance, a simple ulcer, produced by a burn, assumed a foul and unhealthy aspect; and ultimately degenerated into a most malignant sore. Various malignant actions commence in glands of the conglobate or conglomerate kind, at first simply enlarged from irritation or injury. The female breast often becomes indurated from a blow, or from milk abscess, and remains for a series of years, half a lifetime perhaps, without any perceptible change in the enlargement and induration; but the tumour frequently is roused into activity at the critical time of life, and malignant action ultimately commences. The menstrual period ought to be particularly attended to in affections of the mamma more especially, but also in all tumours and ulcers; for both during and before it tumours become larger and more painful, the whole system appears to be excited, then relaxed, and all morbid actions seem to possess increased activity. In this disease, as in soft cancer, as it has been called, (and they occasionally pass into each other,) the bloody masses, or sacs containing bloody fluid, are to be dreaded, and when they exist are to be considered as very unfavourable; for if, on the removal of a carcinomatous tumour, such appearances be found, the disease will certainly return; a new tumour, of even a worse character than the preceding, will be formed; a fungus will be protruded, and from this hemorrhage will occur. The lymphatic glands, both above and below the tumour, generally enlarge early in the disease, become hard, and cut like cartilage, and with a grating noise. Frequently they become converted into a dense and fibrous substance, resembling carcinoma; sometimes they are softened and broken down at several points, and contain a purulent or bloody fluid. They enlarge, coalesce, and form irregular masses, which rise more and more above the surface; the superimposed integuments give way, and then occur those destructive ravages by ulceration and sloughing already described. The lymphatic vessels entering these tumours and emerging from them feel hard and wiry, as if thickened. The integuments in the neighbourhood of the tumours, and in the course of these absorbents, are of a blue colour, and the veins enlarged and tortuous; the limb below the enlargement swells and is oedematous. The absorbents often become affected months or even years after the removal of the original and exciting tumour; the immediate cause being taken away, yet the inherent disposition to malignant action is too often left, not to be eradicated. In fact, the disease generally returns, either in the original integuments, Cancer seizes either the mucous or the cutaneous surface, with hardness and a warty excrescence; this ulcerates, and is surrounded by a hardened base. The process of destruction advances, and the ulcerated part presents the same appearances as those of a sore arising from a similar action in a deeply-seated carcinomatous tumour. The glands also enlarge, and assume the same aspect as if they had been the original seat of the disease. Some pathologists seem disposed to deny this, but apparently on no very sufficient grounds. FUNGUS HÆMATODESHas been much confounded with medullary sarcoma, but the two diseases are materially different. Fungus hÆmatodes almost always supervenes on other morbid formations, when they have been ulcerated and exposed; and the particular formation which most frequently precedes is the medullo-sarcomatous; a bleeding fungus, however, occasionally protrudes from tumours of a different character, which, though they may have been at first simple, have degenerated, ulcerated, and assumed a malignant action. The disease certainly does not occur so frequently as some have asserted; for many, instead of limiting the application of the term to those fungous protrusions which bleed, honour with the appellation of fungus hÆmatodes every growth which protrudes after the ulceration of a tumour, and every tumour which is unusually prominent, of soft consistence, and of a somewhat fungous appearance, although such have never shown any disposition to bleed, either spontaneously, or from irritation. But fungus hÆmatodes, as the name implies, is truly a fungus which resembles blood; and as bloody or blood-like tumours are formed from the rupture of some vessel of rather a large size, and as they almost invariably evince a tendency to profuse hemorrhage, as a necessary consequence of the mode of their formation, the term is correctly applied only to those fungous growths which either have at one time emitted a discharge of blood, and exhibit symptoms of a recurrence of the hemorrhage, or which frequently pour out a quantity of blood, sometimes inconsiderable, but often profuse, and generally altogether uncontrollable. In short, the circumstances necessary to entitle a morbid formation to the appellation of fungus hÆmatodes are a fungous structure and appearance, and hemorrhage proceeding from it to a greater or less degree, and with more or less frequency. Fungi are frequently met with, but there are certainly few hÆmatoid fungi. The excrescence is generally of a dark colour, resembling a mass of coagulated blood, but of more soft consistence, and its extremity In consequence of the repeated and profuse loss of blood, the patient is gradually worn out, becomes hectic, is affected with nausea, vomiting, and indistinct articulation, with all the symptoms of extreme debility, and he generally sinks exhausted, or may be suddenly carried off by profuse hemorrhage. The size of the bleeding fungus is extremely various, but it is rarely large; in fact, we frequently find that the most violent hemorrhage occurs from those of a small size; and in illustration of this, I shall briefly relate the following case. A man, aged forty, had been afflicted for some time with ulceration in the ham, and exfoliation of the posterior part of the femur. The sore healed; but about two years afterwards the cicatrix became ulcerated, and produced a very small fungus, resembling, in fact, a minute cluster of exuberant granulations: from this blood was effused in small quantity, and was easily restrained by the application of a bandage; but the hemorrhage returned at various intervals for upwards of a week, became extremely profuse and altogether uncontrollable. By this the patient was greatly exhausted, and amputation was rendered absolutely necessary. On examining the limb, the lower portion of the femur was found somewhat enlarged, its internal structure completely destroyed, and the periosteum on the inner side much thickened. On the posterior and inner part of the bone, about three inches above its articulation, there was a small fungous tumour of an irregular surface, and of soft consistence, resembling congealed tallow. From this excrescence the blood had been effused into a cyst formed amongst the muscles, and afterwards discharged externally. He recovered from the amputation, and remained well. THE PAINFUL TUBERCLE.Though of small size, and not possessed of malignant action or disposition, is a tumour of very great interest, on account of the excruciating pain with which it is accompanied. It is mostly situated in the subcutaneous cellular tissue, but not unfrequently in the intermuscular cellular substance; one tumour of this species which I have removed was so deep as to be in immediate contact with the sheath of the posterior tibial nerve. The tumour, generally of the size of a garden pea, rarely exceeds that of a cherry. It is invested by a dense ligamentous cyst, to which it intimately adheres; but occasionally the capsule is thin and cellular: in many instances its surface is perfectly smooth, in others it is slightly nodulated. It is not connected with any large nervous trunk; but minute nervous fibrillÆ can occasionally be traced expanding on its surface, and apparently entering its substance. Internally it is composed of numerous whitish fibres, of considerable density, ramifying irregularly throughout its structure; and betwixt these is insinuated a firm substance, generally of a grey colour, and frequently of an almost cartilaginous consistence. Such is the structure most frequently observed; but in this morbid formation, as in all others, the appearances may be said to vary in almost every instance. Sometimes the fibres are indistinct, and of a yellowish or dirty grey colour; and the interfibrous matter is often found to vary in density and colour in different tumours, being at one time dense and almost transparent, at another opaque and cartilaginous, and sometimes rather soft, brownish, and occasionally tinged with blood. The larger nervous trunks sometimes become diseased, being affected with an enlargement resembling the structure and appearance of the preceding tumour, and such enlargements are termed Neuromata. Occasionally a portion of a nervous trunk is thus enlarged, from a blow or wound; and sometimes there can be no cause assigned. Nerves when divided, become bulbous on that extremity towards their centre. In stumps this is well seen; whilst all the tissues entering into it, after a time shrink, and become more or less atrophied (bone, muscles, vessels, &c.), the extremities of the nerves swell out and present a bulbous appearance. When these tumours are connected to, and only covered by, integument, or when they are adherent to the ligamentous substance covering the bone, and become exposed to pressure, as in badly made stumps, the patient often suffers excruciating agony. The nervous trunk above is, in general, slightly enlarged, sometimes has a tortuous course; and in some instances the neurilemmal bloodvessels are considerably increased in size. The same symptoms exist, though in a less acute form, as in the painful tubercle. OF POLYPUS.A common species of tumour is that which is attached to a mucous surface, and is called POLYPUS. Polypi vary in structure and disposition; some are simple and benign, others are most malig OF ENCYSTED TUMOURS.Along with these have been classed the enlargements of bursÆ, sheaths of tendons, &c., but with equal propriety might we include hydrocele and other collections in natural cavities. Encysted tumours are almost always situated superficially. The skin is distended, seldom inflamed, and often contains enlarged bloodvessels, which give it a streaked appearance. They consist of an external cyst, which is in some instances extremely thin and delicate, in others dense, of considerable thickness, and composed of fibrous looking substance, occasionally it is almost cartilaginous; the internal structure may be said to be almost always more or less fluid, but varies much in consistence. The tumour is surrounded with condensed cellular substance, which is of greater or less thickness and strength according to the size of the tumour. Some of these tumours are supposed, and on good grounds, to be mere enlargements of the natural mucous follicles, in consequence of obstruction in their ducts, by hardened and vitiated secretion; the cyst, therefore, will be at first thin and delicate; its contents will resemble the natural secretion of the follicle, and in many cases may be readily squeezed out. There is a black point on the most prominent part, marking the obstructed orifice of the follicle, and the sac is found at this point to adhere firmly to the skin. Even after all other marks of its original formation have disappeared, the situation of the orifice is sometimes indicated by small dark spots, by depression, or by a minute ulcer. Encysted tumours, or wens, as they have been called, often appear to be hereditary; seldom occur single, and are met with under the surface of all parts of the body. They have been divided into different classes, according to the nature of their contents: Atheroma Sometimes, though rarely, the most prominent parts of the tumour ulcerate, and on the exposed surface is deposited a substance of semifluid consistence and gelatinous appearance, which afterwards increases in density, and ultimately assumes all the characters of horn. This hard excrescence in some instances increases only to a slight degree, and afterwards remains stationary; in others it attains a large size, and occasionally assumes a curved or tortuous form, like that of the horns of inferior animals. Horns are generally met with on the forehead, and the scalp may be said to be their seat. The largest which I have seen, measured seven inches in length, and two in circumference; but others have been removed still larger. In many encysted tumours, hairs grow from the internal membrane of the cyst, often numerous, and are generally found in those situated on the eyelids; in some the hairs are destitute of bulbs, lie loose within the tumour, and are often rolled into a globular form. The adhesions of these tumours are in general very slight and easily broken up, but when seated amongst tendons, or in unyielding parts, they are often extremely firm. Violent inflammatory action may follow injuries of the tumours, or the making of even minute openings into them; suppuration occurs, the discharge is thin, fetid, and often bloody; there is much pain, and frequently severe constitutional irritation. Occasionally a fungus, bleeding or not, is protruded through the aperture; more frequently, however, the opening heals, and the tumour remains as before. External injuries sometimes appear to OF TUMOURS OF BONES.The vascular action of bones, in their healthy state, is feeble, but, as in other feeble parts, it is easily excited, and disease of an obstinate and unyielding nature is apt to follow. The morbid growths vary much in texture. The most frequent are the osseous, or those of the same structure with the original bone; but even these differ much in the density and arrangement of their particles: they have been termed exostoses. They may be of great density, and are then called the hard, or ivory; these never attain a large size, seldom exceed that of a bean, have a smooth and polished surface, and are of a flattened and hemispheroidal form, their greatest circumference being at the base; they occur in many of the bones, but generally in those of the cranium and face. Others, being of a more loose and spongy texture, have been called cancellated. These are commonly formed by the bones of the extremities, and often attain a very considerable size; they grow from the periosteum, or from the outer surface of the bone, and are then covered by an expansion of this membrane. Sometimes they adhere by a narrow neck, and expand into a bulbous form, so that they can be very readily removed by operation, and are very apt to be broken off by external injury. Others have a broad and firmer attachment, and are of an irregular shape, often projecting in the form of a large spicula, and at other times assuming a somewhat stalactical appearance. Such frequently prove the source of much inconvenience, by impeding the motions of the muscles, or disturbing the functions of any adjoining organ. They possess no malignant disposition, but are under the same laws, though perhaps in a less degree, with their parent trunk. On making sections of exostoses, and of the bones from which they arise, some appear to be mere enlargements or processes of the parent bone, the cancellated tissue extending itself so as to form the interior of the exostoses, whilst the exterior resembles a proportionate extension of the outer lamina. Others are evidently formed by the deposition of osseous matter externally to the outer lamina, many being dense and compact throughout, others containing an internal cancellated structure, but which is not continuous with that of the bone, as it is separated by the natural outer lamina. Their formation appears similar to that of the foetal bones: a glutinous matter is effused, becomes dense, and is converted into cartilage; bloodvessels shoot into it, ramify throughout its whole structure in a radiated form, and Frequently a bone is much enlarged throughout its whole extent, or the greater part of it, and presents a cancellated texture: sometimes, also, it is much thickened, and, at the same time, of great solidity; but such enlargements cannot be considered as tumours of bones, or exostoses, any more than those nodules of new osseous matter, which are effused in consequence of inflammation of the osseous tissue. The most frequent cause of exostoses appears to be external injury; their progress is slow, attended with slight dull pain, and often accompanied with no inconvenience; their existence can be readily ascertained, a hard and immoveable body being felt where no bone exists in the natural state of parts; but when the tumour projects into an internal cavity, the diagnosis is rendered obscure. Most frequently, they remain stationary, after having attained a certain size, and are productive of little inconvenience, the surrounding parts having accommodated themselves to the new formation. Occasionally, suppuration occurs in the soft parts, the matter comes to the surface, and a troublesome abscess is formed. To this class of tumours would I confine the term exostosis, not including those consisting of softer materials, and possessed of a less benign action. OF OSTEOSARCOMA.By this term is meant, an enlargement and alteration in the structure of a bone, accompanied with the deposition of a morbid sarcomatous substance internally. This morbid change appears to be the consequence of inflammation, and its origin is frequently attributed to some mechanical injury or local irritation. In the commencement of the disease, the bone is slightly enlarged, perhaps somewhat thickened in its outer laminÆ; and on a section of it being made, is found to contain a brown fleshy substance instead of its cancelli. This appears to be formed in consequence of a morbid action, perhaps inflammatory, of its internal structure. By the pressure of the new formation, the parietes of the bone are pushed outwards, in some cases attenuated, in others thickened by deposition of new osseous matter, inflammatory action having been induced by the pressure. As the internal formation increases, the parietes are extended, and are generally much attenuated, becoming in some places thin as paper, and diaphanous; they also would seem to lose a portion of their earthy matter, for they are flexible, somewhat elastic, and not There are other tumours of bones in some degree resembling, which do not strictly come under the term Osteosarcoma. Some are wholly cartilaginous, the disease commencing in their centre, and involving their entire substance, emitting a gelatinous fluid when cut, but containing no cells; others are not uncommon, partly osseous, and partly cartilaginous, containing cells filled with a glairy fluid; others are composed of cartilage, intersected with dense fibrous matter, in a greater or less proportion. In fact, the individual tumours of bones vary as much from one another as those of the softer tissues; scarcely two are alike in their progress, action, or anatomical characters. Irregular spicula of bone are found in many parts of their structure; in the same way that portions of bone often exist in tumours having no connection with the bones; in many places they are softened and broken down, the partitions between the cells are destroyed, and these contain a pulpy mass of a dark sanious appearance. On making a section, they are observed to be continuous with the interior of the bone, which is converted into a substance similar to themselves, or is of a more soft and medullary character. The external surface becomes tuberculated, the integuments are painful, and changed in appearance; they ulcerate, the tubercles burst, the discharge is thin and bloody, the ulceration SPINA VENTOSA.By this term is understood a mere expansion of a bone from a collection of matter in its substance. The disease may be produced by external injury, exciting inflammation, and consequent suppuration, in the cancellated tissue; or in a weakened and unhealthy constitution, the action may be of a chronic nature. The fluid accumulates, the cancelli are broken down, and the much-attenuated parietes of the bone are pressed outwards. Occasionally inflammatory action is excited on the external surface, from the pressure of the contained fluid, and minute nodules of bony matter are effused, as if nature endeavoured to strengthen those walls which are daily becoming thinner, and more incapable of supporting the weight of those parts which they encircle. The disease differs from Osteosarcoma in the contents being uniformly fluid, generally purulent, though often mixed with more liquid and dark-coloured matter, or with a curdy substance—in the gradual extension of the bone—in no fungus protruding after a portion of the attenuated bone has given way, matter being discharged as from a common abscess; and in the tumour not possessing a malignant disposition. At first there is considerable pain in the part whilst the matter is forming, but afterwards it becomes much less acute, and in many instances there is no inconvenience, except from the bulk of the tumour. Often after having reached no very large size, it becomes stationary, neither recedes or enlarges, and all painful sensations cease; in other cases it enlarges gradually, attains an enormous size, and produces much disturbance of the constitution; but in such instances the patient is generally weak and cachectic. The largest tumour of this species which I have seen, occurred in the lower part of the femur. It measured, in breadth, seven inches, in length, seven and one-fourth. The parietes were composed of an extremely thin lamina of bone, and in this there were numerous deficiencies supplied by delicate ligamentous matter; its cavity was divided into several compartments by thin septa, partly osseous and partly membranous. A representation of the femur so affected is given in the Practical Surgery, p. 350. The patient was a boy of twelve years of age; amputation of the limb was earnestly advised, the friends objected, he died hectic. ANEURISMAL TUMOURS.Besides these tumours a species of an anomalous character is sometimes met with, appearing to arise from an aneurismal or varicose state of the venous radicles or capillaries, and partaking somewhat also of the nature of fungus hÆmatodes. The sac of the tumour was composed of bony matter, containing little earth, and arranged in strata of short fibres pointing to the cavity. Its outer surface was smooth, and covered by a dense membrane; whereas the inner, to which so equable a resistance was not afforded, was studded with projecting spicula. The lower part of the scapula, partially absorbed, lay in the middle of the sac, covered by the remains of its muscles and coagula. Very large vessels were perceived ramifying on the surface of the tumour. The patient made a rapid recovery, and the wound all but healed. A fungus, however, began to appear in about six weeks, which grew rapidly. This was removed, and the bone cauterized with little good effect. The tumour was soon reproduced. It was proposed to remove the remainder of the scapula with the extremity, as the only chance, though perhaps a slight one. This was objected to, and he died about five months after the operation, worn out by hemorrhage and profuse discharge. The diseased parts presented the following appearances. Portions of the acromion process, superior costa, and spine of the scapula, were of their natural appearance. But the coracoid process, the glenoid cavity, and the cervix, were entirely destroyed, and their situation occupied by an irregular broken-down tumour, consisting of osseous spiculÆ, and cancelli, irregularly disposed, and forming cavities which were filled with blood, partly fluid and partly coagulated. The head of the humerus was extensively absorbed. The articulating cartilage was almost entirely destroyed, particularly on the inner side, where a large portion of the bony matter had also been removed. The ulcerated surfaces were of a dark, bloody colour. HYDATIC TUMORS.Another disease of the bones which ought to be introduced here is the development of hydatids, which I described twelve years ago under the name of osteo-hydatidic tumours. The seat of this affection is not confined to any particular class of bones; though the long are perhaps most prone to it. Its precise nature and origin have not yet been determined; nor are its symptoms such as to enable us, in the present state of our knowledge, to distinguish it from exostosis, osteosarcoma, and other maladies. Its progress is commonly slow, the surface of the tumour is smooth and regular, the skin exhibits no unusual appearance, and the adjacent textures rarely participate in the morbid action. The hydatids, usually of a globular figure, vary greatly in size and number, and are generally filled with a thin, limpid fluid. They appear to be of the nature of acephalocysts. The prognosis unfavourable, owing to the difficulty of destroying these parasites, and their constant tendency, when interfered with, to reappear. As soon as the true nature of this tumour is ascertained it should be laid freely open, its contents turned out, and the sac destroyed. For this purpose the sides of the cavity should be seared with the actual cautery, or touched with some of the more powerful escharotics, as the nitrate of silver, or the caustic potash. If these measures fail, and the disease involve the whole circumference of the bone, nothing short of amputation will suffice. This was successfully resorted to in one of the cases which came under the observation of Mr. Lucas of London.] TREATMENT OF TUMOURS.It may be observed generally, that no benefit can be derived from external applications to tumours, such as friction with liniments or ointments containing iodine, mercury, &c.; and that, therefore, it is injudicious to employ such temporising measures; for though a tumour at its commencement appear to be of a very harmless nature, yet it may soon assume a most malignant character. If an apparently simple tumour increase, and exhibit symptoms of inflammation, it will perhaps be advantageous to apply leeches, to arrest that incited action which affords the accession of new materials; this, however, cannot check the morbid activity inherent in the new formation, though it may hold the growth in check a little. If a tumour is to be removed by external applications, it is evident that these must be such as shall prevent the deposit of new matter, and allow the absorbents to remove that which already exists; for absorption is always going on in a tumour, though it leaves no evidence of its progress, on account of the deposition of new matter exceeding the removal of the old. I must say that I am unacquainted with any remedies capable Many of the tumours first described have no malignant disposition originally, and only require surgical interference when they produce deformity or inconvenience from their bulk. Yet even these ought not to be allowed to attain any great size, however indolent they may appear at first, and however little pain they may produce; for there is always a danger of their assuming a malignant tendency, or forming connections with important parts, so as to render their removal either altogether impracticable, or at least attended with much difficulty. Tumours of every kind, when seated near important organs, must be early removed. Glandular tumours, however, even when of great size and long continuance, are not to be rashly interfered with, when they arise from irritation in the neighbourhood. Those in which it is feared that malignant action has commenced cannot be trifled with; and the only means which afford a chance of the patient’s being effectually delivered from them is an operation. With a view to their complete extirpation, the external incisions ought always to be free, so as to admit of the after-dissection being easily and rapidly performed: they ought also to be made in the direction of the muscular fibres, whether these lie above or beneath the tumour. In this way the margins of the wound are easily brought into apposition, and there retained; whereas, if the fibres be divided transversely, the wound will gape, and union by the first intention be rendered absolutely impossible. If there is no reason to suppose that the tumour is malignant, little or no integument ought to be removed, unless the growth is of a large size; but, when malignity is dreaded, all the discoloured, tense, and adherent integument, all that is permeated by dilated and tortuous vessels, ought to be taken away, and the incisions made at a distance from the disease. In all cases they ought to commence at the point where the principal vessels enter; these are thus divided at the outset, can be readily secured by ligature, or by the fingers of an assistant, and the dissection is proceeded in without risk or interruption from farther hemorrhage. If the opposite course be pursued, the vessels will be divided two or more times during the operation, and thus the performance of it will either be delayed by the application of numerous ligatures, or will be attended with a considerable loss of blood. After the tumour has been exposed it ought to be principally detached in one direction, as in this way its removal will be sooner accomplished, and not first cut on one side and then on another. If malignant, great care should be taken that all the diseased mass be removed, for a minute portion remaining will form a nucleus in which similar diseased actions are certain to arise; in most instances, it will be prudent not only to remove the parts actually diseased, but those also which are in immediate connection with the tumour, though at the time they appear healthy. All important parts must be carefully avoided. After removal of the mass, and the complete cessation of bleeding, the edges of the wound Exostoses need not to be interfered with, unless they are the source of much inconvenience, either from their size and form, or from their having been detached, and lodged amongst the adjacent soft parts. If loose, they can be removed in the same way as any other extraneous body; if firm, their attachment must be divided by a saw, or by cutting pliers, close to the bone from which they spring. Sometimes, as in the scapula or other flat bone, a portion of the original bony tissue can be cut out along with the new growth, and this renders the chance of any return of disease much less likely. Osteo-sarcomatous tumours are to be taken away, along with the part of the bone in which they are imbedded, and, if possible, before the integuments have ulcerated. The incisions must be made, and the bone sawn, at a healthy part. The removal of the entire bone in which the disease has commenced, when practicable, will afford a still better chance of immunity from farther disease. In spina ventosa more is seldom required than to lay open the cavity, give vent to the matter, and then treat the case on the same principles as in abscess of the soft parts. The cellular tumours, partly cartilaginous, partly osseous, ought not to be permitted to remain; the operation can generally be done without much difficulty; and thus the danger of their degenerating avoided. Frequently, however, a considerable part of the bone must be removed along with the tumour, since the neighbouring tissue is generally softened, and intimately adherent to the diseased part, which it somewhat resembles in structure. In general, regular dissection is unnecessary in the removal of encysted tumours. An incision is made, or an elliptical portion cut out; the contents escape, and the cysts, being then laid hold of by dissecting forceps, is readily separated. In some situations, as on the eyelids, under the tongue, or amongst tendons, the sac, which is thin, is not so easy of extraction; it is then inseparable, either naturally, or from previous inflammation. Caustic is used with safety to destroy those parts which cannot be detached, and for this purpose the potass is to be preferred. When, however, the tumour is large, a part of the integuments covering it must be removed, otherwise a large cavity will be left, in which pus might accumulate. In this case, the base of the tumour is to be surrounded by two elliptical incisions, and the cyst dissected out entire, leaving only integument sufficient to cover the exposed surface. In the smaller tumours, it is vain to attempt regular dissection; a portion of the cyst will be left, and the disease OF WOUNDS.These vary in extent and nature. The instrument by which they are inflicted, the violence attending the injury, and the nature and importance of the parts divided, or in the neighbourhood of the wound, must all be attended to, for, from an accurate knowledge of these circumstances, the treatment of the case comes to be conducted accordingly. Wounds are divided into incised, punctured, bruised, and lacerated; that is, into such as are inflicted by a sharp-edged, sharp-pointed, or an obtuse body. In the first kind, there is greater or less effusion of blood, according to the size and number of the vessels divided. Some extend but a little way beyond the subcutaneous cellular tissue, and are consequently attended with but slight bleeding; others penetrate to a greater depth, and occasion hemorrhage from a large vessel, or other alarming symptoms, by having reached some important organ; others, though not of so great a depth as the former, may still, on account of their mere extent, be accompanied with very considerable loss of blood from a number of small branches. It is seldom that fatal effects immediately follow external wounds; but they may and do occur when bloodvessels of the first class only are cut. They are most likely to prove suddenly fatal when the arteries are only partially divided, and when the large veins accompanying them are also involved. When the artery is cut through, its extremities retract, effusion takes place into the sheath and compresses the orifice; the formation of a coagulum within the vessel is thus promoted, and the hemorrhage arrested. But, when a portion only of the circumference is divided, the blood continues to flow through the aperture and onwards, as if into a smaller ramification of itself, no retraction or contraction of the vessel can occur, coagulation is slow, and the bleeding profuse. I have seen a wound of so small a vessel as the internal mammary prove almost instantaneously fatal. Wounds of the large internal vessels for the most part prove immediately fatal; as wounds of the heart, or the large vessels passing to and from its cavities, at the root of the lungs, or at the upper part of the liver. When the heart, or the vessels within the pericardium, have been divided, it can be readily understood how life should be immediately destroyed, since the blood effused into the cavity of the pericardium by its pressure completely arrests the action of the heart. But occasionally punctured wounds, in such situations, have not been followed by instant death. In such cases, alarming symptoms occur at the time, but subside, and the patient may for some time suffer no uneasiness, but afterwards expires suddenly during muscular exertion, or perhaps in a fit of violent passion. Blood must have been effused into the pericardium at the first, causing When an artery is divided, its extremity retracts within the sheath, it also contracts, and coagulation occurs; thus the orifice is obstructed, and a temporary barrier formed to further hemorrhage. The tube, however, is permanently closed by effusion of lymph from its orifice, and consolidation of the surrounding parts. The circumstances which follow division of an artery are these:—The immediate effect is retraction of its ends within the investing sheath, and a simultaneous contraction of the coats, so as to diminish the calibre. From the superior orifice there is necessarily a profuse flow of blood, which is discharged through the sheath that formerly enclosed that part of the vessel which has retracted. After considerable effusion of blood, the flow becomes slower and less profuse; particles of blood adhere to those filaments which previously connected the artery to the sheath, but which were lacerated by the sudden retraction of the divided extremity; these particles coagulate, and lessen the canal through which the blood is discharged, whilst they present an irregular surface, on which the blood continues to be deposited and to coagulate; and thus the aperture in the sheath is ultimately closed. This external coagulum is found to commence at the extremity of the artery, where it is of a cylindrical form, and shuts up the mouth of the vessel; it then extends along the canal in the sheath, frequently assuming a conical form; and, if a free discharge has been allowed for the blood, it will terminate at the cut margin of the sheath, otherwise it will be found continuous with the coagulum blocking up the external wound. Also, when hemorrhage has been resisted by the shutting of the external wound, blood is infiltrated into the cellular tissue around the bleeding point, and there coagulates; but this circumstance can be productive of little or no pressure on the parietes of the vessel, so as to assist those other natural means which obstruct it. The flow of blood through the divided vessel being prevented, the circulating fluid necessarily passes through the nearest collateral branches, leaving the blood in the extremity of the larger trunk in a state of comparative rest; consequently, coagulation occurs in this situation. The internal coagulum, however, is small, and not sufficient to occupy completely the cavity of the vessel; it is of a conical form, its apex being towards the heart, and opposite to the first collateral branch, and its base resting on the external coagulum, and there adhering to the internal surface of the If the hemorrhage is suppressed artificially, either by ligature, or by otherwise well-applied pressure, no external coagulum is formed; there appears only the internal bloody coagulum, the lymphatic effusion, and consolidation of the compressed part. The natural contraction and retraction cannot occur in vessels partially divided; hemorrhage, therefore, is more violent and dangerous from a partial than from a complete section. Again, transverse wounds are more dangerous than longitudinal; in the latter, the edges of the wound are spontaneously approximated on account of the structure of the vessels, whilst, from the same cause, the margins of the latter continue separate, and, in fact, the aperture is a complete circle; the lips of an oblique wound will be more or less apart, in proportion as it approaches to the transverse direction. When an artery has been punctured, the wound in the sheath perhaps does not correspond with that in the vessel; blood, therefore, accumulates between the vessel and its sheath, and there coagulates. The wound is thus compressed, its edges kept in contact, and the farther escape of blood prevented; the lips of the incision are then agglutinated by effused lymph, and cicatrisation occurs. This, however, cannot be expected to take place unless methodical pressure has been applied from the first. Even from small punctures blood is effused under the sheath and into the neighbouring cellular tissue, rapidly, and in such quantity as to prevent adhesion. The effusion continues, and a false aneurism is formed. If a considerable part of the circumference has been divided, the lymph may be, and generally is, superabundant, From wounds of veins the blood flows, not in a sub-saltatory but in a uniform stream: its colour is dark, and the flow is easily suppressed. The common opinion is, that to place a ligature on a vein is dangerous, and to be scrupulously avoided. The process of reparation, besides, in a wounded vein, is different from that in an artery. Veins are less disposed to the secreting action by which adhesion is perfected; and, when inflamed, the inflammation is extremely apt to extend along the coats of the vessel; which latter circumstance has been ascribed to the great proportion of cellular tissue in their coats. When punctured longitudinally, the lips of the wound remain in contact, and cicatrisation, by means of effused lymph, is soon effected; in fact, the wound heals by the first intention. But if opened obliquely or transversely, not to a great extent, the immediate result is discharge of blood, and, when this has ceased, a coagulum forms in the wound, the margins of which remain separate; and this coagulum generally communicates with blood effused into the sheath of the vessel. After some time, the lips of the wound, encircling the coagulum which occupies the aperture, and which has temporarily averted the hemorrhage, become somewhat turgid, and increased in vascularity; they then appear to assume a secreting action, by which a membranous substance, of extreme delicacy, is produced; and the extent of this membrane is increased until it form an expansion, investing the outer surface of the clot; it then becomes thickened, by In many, nay in most, instances of hemorrhage from a wounded artery, the surgeon cannot wait for the natural processes by which the flow of blood is arrested, but must have recourse to immediate and certain means. In division of the smaller arteries, or in minute wounds of the larger, pressure, well applied, will often be sufficient. In both cases it immediately stops the flow: in the former, it prevents the blood from penetrating into that portion of the sheath which has been vacated by the retracted artery; and it being thereby confined, and kept in a state of rest, coagulation soon takes place. At the same time, the compression brings the divided margins of the vessel into close apposition, and thereby permanent closure, by adhesion, is quickly accomplished. In the latter, the mere circumstance of the escape of blood being prevented, naturally hastens the closure of the minute aperture by the natural process; and, if the compression be accurate and very firm, the opposite surfaces of the vessel, being brought in contact, may adhere, and the canal be obliterated at the wounded point. It is obvious that, in this latter class, pressure can only be of advantage immediately after the infliction of the wound, and not when blood is extravasated to a great extent. Pressure may be used along with styptics, or along with escharotics, actual or potential. They may be often employed when pressure ought not; styptics promote the contraction and retraction of the divided extremities, and thereby expedite the formation of a coagulum. Escharotics form a slough, which, adhering to the extremity of the vessel, stops the flow of blood, and the cut margins of the vessel, being stimulated by the application, soon cohere. Active stimulating applications merely cause effusion quickly of coagulated lymph, and thus often arrest hemorrhage from very vascular surfaces better than the so-called styptics. Not unfrequently, after the separation of the slough, it is found that union has not taken place, and hemorrhage is renewed; from this circumstance, the remedy cannot be trusted to, except when the divided vessels or vessel are of small size. It may be stated, generally, that these means are of little avail without methodical pressure. In oozing from small vessels, pressure may be applied by means of agaric, sponge, or lint. In bleeding from small vessels, where there is general oozing from the surface, and pressure cannot readily be made, applications tending to produce A ligature, well applied, is the only means that can be relied on. The immediate effect of a tightly-drawn ligature is to avert the flow of blood, to divide the internal and middle coats at the deligated point, the cellular coat remaining entire, and to narrow the canal for some extent above the point at which it is applied. Coagulation then occurs within the vessel above the ligature, provided there is no collateral branch in the immediate vicinity. The ruptured margins of the internal coat effuse lymph and cohere; lymph is effused also in the cellular tissue, exterior to the artery and to the ligature; by the compression of the ligature, ulceration occurs in those parts which it envelopes, and the foreign body is discharged; but before this occurs the canal of the vessel has been obliterated by an internal coagulum, and by the effused lymph. Afterwards, the same absorption and consolidation occur as in a divided artery, the orifice of which has closed permanently and spontaneously. When from a punctured wound profuse hemorrhage ensues, there is reason to suspect that an important vessel has been hurt, and the bleeding point must be sought for. After the artery giving out the blood has been discovered, the external wound must be enlarged, so as to expose the vessel, and admit of the convenient application of a ligature. It will not be sufficient to include the vessel above the wounded point, for the lower part will, after some time, be supplied with blood by the collateral branches almost as freely as by the large trunk, and, consequently, bleeding will be renewed. Two ligatures are to be employed, one above, the other below, the wound. The wounded vessel must be exposed, as already stated, but not detached more than is sufficient for the application of the ligature; and at the same time the ligatures ought to enclose nothing but the vessel. Neither ought the ligatures to be placed at any considerable distance, Illustration When no assistant is at hand, and in cases of emergency, the surgeon provided with this little instrument can tie vessels without the least difficulty; and in operation, when many vessels spring, several of these forceps can be applied; there is besides this great advantage in their employment, that a clumsy assistant can scarcely include the point of the instrument with the vessel. Hemorrhage from the smaller vessels soon ceases; and, before reaction occurs, their orifices have generally become so obstructed as to resist the effusion of blood. The effects of ligature on a vein are somewhat different from those on an artery. The inner coat of the former is more dense and elastic, and remains entire, whilst the external and middle are divided. It is puckered by the ligature, and its opposite surfaces are placed in immediate contact; but there is no breach of surface, and adhesion The edges of the wound, in the soft parts, ought not to be approximated till the bleeding has entirely ceased, and the surface become glazed, for the interposition of the slightest quantity of blood prevents union by the first intention. When bleeding has ceased, the divided edges are to be brought together as accurately as possible, and adhesion promoted. The minute vessels assume an action greater than in the healthy state, though not equal to inflammatory action; they effuse coagulating lymph, by which the opposed surfaces are agglutinated, though the union is at first feeble and easily broken up. Soon the lymph is firmly attached, by newly-formed vessels, to the surface from which it was secreted; in effect, it becomes organised, and rendered capable of undergoing, through its inherent powers, the changes necessary for its perfection and stability. Similar processes go on in it as in any sound part of the body; new matter is deposited, and the superfluous is absorbed. The process of nutrition, however, is not the same in all parts of its substance, that is, the new matter deposited is not exactly similar at all points; but, according as the new secreting vessels proceed from the different tissues of which the margins of the recent wound are composed, so, in various parts of the new formation, these vessels assume peculiar modes of action, one set forming muscular, another cellular tissue, and a third a substitute for skin, formations corresponding to the primary tissues from which the secreting vessels proceed. Thus the vasa vasorum, ramifying on the divided ends of the minute vessels, secrete a substance which is transformed into a set of minute capillaries, and these also, assuming a secretive action, produce an arterial or venous tube, similar to that nourished by the original vasa vasorum. By this process the lymph becomes well supplied with bloodvessels, those from the opposite surfaces meeting, and freely inosculating with each other. These bloodvessels, as already stated, have been produced from arteries possessing different powers, and hence the newly-formed assume actions similar to those of the primary, and thereby interstitial matter is deposited of its proper kind and in its proper place, a cuticular membrane superficially, then cellular tissue, afterwards muscular, and so on according to the primary tissues which had been divided; these parts do not at first resemble exactly the corresponding natural tissues, but, by the continued action of the new vessels and capillaries, they are moulded and prepared for the due performance of their respective functions. If the degree of action necessary for the accomplishment of these processes increase to inflammation, adhesion is interrupted till the action be lowered to its previous standard. From this view it is evident, that, besides a certain excitement of the bloodvessels, it is necessary that the raw margins be in close apposition, and carefully retained so, for, by ever so slight movement Of late, I have greatly dispensed with stitches and the common adhesive plaster, using, instead of the latter, slips of glazed riband smeared with a saturated solution of isinglass in brandy, which is much less irritating and more tenacious than the common adhesive compost. The parts are fixed temporarily with a single stitch, or two at most, and cloths dipped in cold water are placed over the wound; the ribands are not applied till the adhesive substance has partly congealed, and the oozing of blood ceased. The divided margins being approximated by the fingers of an assistant, the ribands are laid gently over, and held for a few seconds. Soon after a sufficient number have been applied the stitches are withdrawn, being no longer necessary. No other dressing is required unless suppuration occur; the ribands will adhere firmly till the completion of the cure, and thus the pain and irritation caused by frequent dressing is avoided. Even the largest wounds, as after amputation, are treated in this manner with the most satisfactory results. Of late years a plaster, made by coating oiled silk with a solution of isinglass, has If at any part adhesion fail, suppuration and granulation must follow. The adhesion may be prevented by any of the circumstances already mentioned, or by an unfavourable state of the constitution, the nature of the wound, exposure to bad air, the occurrence of fever, or of a flux natural or not. The wound may contain foreign matter; blood or the contents of canals may be effused into it, and many other obstacles may exist to retard, or prevent adhesion. Notwithstanding, in all cases, though the chance of union be but small, the parts should be approximated. A great point is gained if certain parts only are brought to adhere, for by their natural attachments the opposite surfaces are preserved in more direct contact than they could otherwise be, and thereby but little space remains to be filled up with granulations. If, on the contrary, the surfaces are not approximated, the flap is diminished in size, and when afterwards placed in contact with the surface from which it was detached, it is found not to correspond, leaving considerable deficiency to be repaired by the comparatively slow process of granulation. Whereas, if it had been early replaced, partial attachments would probably have been formed by adhesion, the flap thereby retained in situ, and prevented from shrinking, so that but little new matter would be required. Sometimes union does occur, and that speedily, after the flap has remained separate for a considerable time; and in such cases it may be doubted, whether union is accomplished by adhesion, strictly so called. Most probably it is by this process that the rapid union occurs in such circumstances: the divided parts have assumed an excited action, and effused lymph; during their state of separation, the lymph will become organised when it is connected with the original parts, just as well as if the surfaces had been in contact; and when they are at length so placed, they will be agglutinated to each other by the outer part of the effused lymph, which still continues soft and unorganised. If motion be then prevented, organisation, which has already commenced in the connecting medium, will proceed undisturbed, converting the agglutination of soft unorganised lymph into firm and permanent union by means of organised tissue. In these circumstances, it is not to be wondered at if adhesion should be completed in a shorter time than when the surfaces are brought together immediately after their division; in each instance the process is the same, only in the one it has to proceed from its very commencement, whilst in the other it is previously all but perfected, and after the parts have been put together, the last stage only requires completion. It is only in a particular stage of a granulating surface, that adhesion will take place speedily, when the discharge is diminished, but healthy, and the granulations florid and firm. When a wound is to heal by granulation, the exposed surface at first is dry, painful, and slightly swelled, and afterwards a thin discharge of bloody serum is poured out, with relief to the painful sensations; the surface is at this time covered by a thin layer of coagulated lymph, and the parts, if approximated, are in the most If union by the first intention does not take place, then all the application to procure it must be abandoned, all sutures, plasters, compresses, &c., must be dismissed, for they now can do no good, and may be productive of harm; the attention, on the contrary, must be directed to effecting union by granulation; with this view, other means are to be chosen, so that to continue those which were formerly used to promote adhesion would be absurd, when adhesion From bruised and lacerated wounds there is little or no hemorrhage, but in proportion to the severity of the bruise, is the bleeding slight, and the danger great. The bloodvessels are so torn and twisted as to permit the spontaneous and temporary suppression of hemorrhage to occur almost immediately; and the larger arteries may escape entirely, owing to their elasticity. Sometimes after bruised wounds, such as those inflicted by gunshot, the large vessels bleed instantly and violently; often, however, hemorrhage occurs only after the sloughs separate, many days after the infliction of the injury, and then it is generally very profuse; in some instances, limbs are torn, bruised, or shot away, without hemorrhage occurring to any great degree, or at any period. Frequently the vitality of the parts surrounding the wound is much diminished; and the whole limb is apt to become gangrenous, either immediately, on account of the extreme violence of the injury, or consecutively, from greatly excited action going on in parts whose power of resistance has been much impaired: it often arises also from constitutional peculiarity. The gangrene extends often rapidly, in consequence of the infiltration of putrid serosity into the cellular tissue. In the treatment of bruised wounds, the position of the parts must be carefully attended to; they must be placed in a state of relaxation. In general, it is unnecessary to retain the margins of the wound in contact, for adhesion cannot occur—suppuration must ensue, and is to be desired—and the dead and dying parts must be loosened and discharged before union can take place. Sometimes, as when a large flap has been detached, and the parts not much injured otherwise, approximation Punctured wounds are dangerous, from the deep and internal effusion of blood and serum which usually attends them. The effusion, which in open wounds is poured out externally, and moderates and prevents the excited action from exceeding what is salutary, is, in punctured wounds, poured into the substance of the limb to its detriment. It is followed by severe inflammatory action and profuse suppuration. In order to prevent these untoward results, it was formerly the practice immediately to dilate the wound; but this is hurtful, for if the wound be deep, as it generally is, dilatation of its whole extent is a proceeding severe in itself, and in its consequences; whilst, if the external part only of the wound is dilated, the operation will entirely fail to effect what is intended. The knife will be used in great good time where a foreign body is found to be lodged in the wound, when tension has occurred, or matter has formed. Sometimes the wound heals throughout its whole track by adhesion, without any bad symptoms being so much as threatened. Setons, recommended in this class of wounds, are of no service. It is not the narrowness of the external opening, as is sometimes supposed, that is the cause of all the mischief, but the injury and consequent inflammation of deep-seated parts. Poisoned wounds are rare in this country. Wounds by the stings of certain trifling insects produce considerable swelling in some constitutions, and when the injury has been inflicted on a loose texture. In some parts of this country, the bite of a small adder causes pain, swelling, and unhealthy suppuration of the part, with some constitutional disturbance, but the results are seldom serious, and never fatal. In warmer climates, the bites of some snakes are followed by the most violent symptoms; in some cases proving fatal in a few hours, Wounds received during dissection occasionally have unpleasant consequences from the absorption of animal matter. The absorbents leading from the wounded part become swelled and painful, and in slight cases there are shivering and general indisposition for some days. The more violent symptoms arise from examining bodies which are rather recent, and in which putrefaction is just commencing, and very frequently from inspecting the bodies of females who have died of puerperal diseases. The absorption may take place from punctures made by scissors, the point of a knife, or spiculÆ of bone, or from old scratches, or chops by the side of the nail or on the hand. There is little or no danger from an open and bleeding wound, as by the flow of blood the part is completely cleaned; it is generally from slight punctures that untoward symptoms need be apprehended. Effects similar to those resulting from wounds in dissection often occur in nurses and others who have pricked themselves with pins while washing foul clothes, or from handling poultices or dressings removed from bad, putrid, or sloughing surfaces. The symptoms already mentioned are soon followed by others more severe: shivering continues, and the patient is seized with vomiting; the part affected, and often the greater part of the arm, becomes red and much swollen; the cellular tissue is infiltrated with serum often dark and putrescent, abscesses form at various points along the limb to the axilla, and purulent matter is diffused throughout the unhealthy cellular tissue, which in many instances sloughs, and gives rise to extensive sores. Typhoid symptoms soon appear, and in the more aggravated cases speedily prove fatal. When such local and constitutional symptoms arise, it will generally be found that the patient was of a broken-up constitution previously to the infliction of the wound; did they solely depend on the inoculation of virus, they would be of very common occurrence, considering that wounds are so frequently received during dissection; but it is seldom comparatively that any unpleasant symptoms follow such an accident. In all cases, however, it is prudent to adopt measures in order to prevent absorption of the virus. With this view, the wound is made to bleed by means of pressure or suction, and by the latter method the exposed surface is most effectually purified; afterwards nitrate of silver maybe applied to deaden the surface, and protect it by an eschar. If such means be unavailing, the after symptoms must be encountered as they appear, local inflammation subdued, tension re We shall next treat briefly of gunshot wounds; under this head are included the contused and the lacerated, caused by splinters, &c. The vitality of the injured surface is generally destroyed at once, whence bleeding seldom occurs, even after whole limbs have been shot away; in some cases, however, hemorrhage is profuse, as when a large artery has been wounded by small shot. The effects on the system are extremely various; some persons are affected with tremors, anxiety, and depression from slight wounds; while the most severe injuries are often unaccompanied by any disturbance of the nerves. The shock is generally of short duration, disappearing soon, on the patient’s being reassured and encouraged, or after his taking a little wine or opium. In gunshot wounds, those inflicted from a distance or close at hand can in general be readily distinguished. In the latter, the wound is large and lacerated, portions of the wadding are impacted, and the skin around is marked with grains of gunpowder. In the former, the wound is small and clean. When a ball passes through a fleshy part, the opening at its entrance is small and depressed; whilst that by which it escaped is open, with everted edges. When it follows a superficial course, its track is marked by a wheal, or elevation of the skin with discoloration. At one time, it was believed that the most serious consequences resulted from a ball passing close past the body without even touching it—that in this way violent concussion of the brain, proving instantly fatal, was produced; but this notion has been disproved by experience; part of the head accoutrements, of the hair, of the nose, and of the ears, have been shot away by cannon-balls, and yet no disturbance of the brain has followed either immediately or consecutively. The opinion originated from the circumstance of soldiers having been found dead without any evidence of injury; but bones are often broken and comminuted by an indirect blow, or by a spent ball, without any breach of surface or external sign remaining; internal injuries indeed—rupture of viscera—more than sufficient to cause instant death, are thus inflicted without any apparent external lÆsion. The course of a ball in the body is often very strange, depending on the force with which it is projected, or the resistance which is opposed to it, and on the position of the struck part. Balls often pass under the integument almost completely round the head or chest, having first struck the bone at a very oblique angle. Frequently they remain, lodged along with part of the clothing which they thrust before them. In such cases, they may be immediately removed, their exact situation being previously ascertained by external examination, or by means of a probe. They can generally be extracted through the aperture by which they entered; but if situated superficially, and at a distance from the opening, this will be more readily accomplished through an incision made upon them; if allowed to remain, suppuration will occur in the neighbourhood, the surrounding cellular tissue Besides, the bones are often splintered by the force with which they are struck, and loose portions of them lodge amongst the muscles; then they are the cause of much mischief, for, on account of their long, sharp, and irregular form, they occasion great irritation, suppuration ensues in various parts, sinuses form, and the cure is rendered very tedious. In other cases, the bone is split in a longitudinal direction, and, in the cylindrical bones, these fissures are often of great extent. Considering the nature of the body which inflicts the injury in a gunshot wound, and the velocity with which it is impelled, it is evident that the cure must be in all cases tedious, in consequence of the sloughing and suppuration which is induced, particularly at the aperture through which the ball passed. The foreign body ought always to be removed as early as possible, provided it can be accomplished without much violence, or injury to the parts. Dilatation of gunshot wounds is now had recourse to only to facilitate the removal of balls, splinters, &c., and even with this view, it ought to be employed but to a very slight extent, if at all; for foreign substances, when deeply seated, can be much more easily taken out when the sloughs are separating, and the parts relaxed by suppuration; then, too, they can be more readily reached through a counter-opening, when their situation renders this expedient. In short, the surgeon is not justified in cutting for balls, unless they are easily felt, and not deeply lodged. In order to discover the foreign body, probes will sometimes be required; the finger often answers the purpose best, unless when the In severe injuries of the limbs, the surgeon must be guided by the state of the part, and of the constitution, by the circumstances in which he is placed, as to accommodation, and mode of transportation, &c., in deciding on the removal of the part by amputation,—or on making an attempt to save it, by trusting to, and assisting, the processes of nature. The question whether to amputate immediately, and on the spot, merely allowing the shock, if any exist, to pass away, or to delay till suppuration occur, is now scarcely a matter of dispute. When it is evident, from the extent, violence, and nature of the injury, that there is danger of speedy mortification, or of extensive and severe inflammation and suppuration, amputation is to be instantly performed,—delay is inadmissible. In comminution of the hard, with contusion and laceration of the soft parts—where limbs have been shattered and completely detached, or nearly so—in lacerations of parts, including the principal bloodvessels and nerves—fractures of the heads of bones, with openings into the joints—and in bad compound fractures, more especially of the thigh (for all compound fractures of the upper part of the thigh are dangerous), amputate at once. When the limb has been retained, and gangrene arises in consequence of the external injury, and when there is no reason to suppose that any internal cause is also in existence; or when the violence of inflammatory action has subsided, and the patient is become hectic, with profuse purulent discharge, and with disunited bones, then amputate. But, in this latter case, the chance of recovery is not so great, and the proportion of recoveries small; whereas, in the immediate or primary operations, the very reverse holds true. Such is the experience of the greater number of military surgeons. In civil practice, the results are somewhat different; a greater proportion of primary amputations are unsuccessful, and the secondary turn out more favourably than the statements of military surgeons would lead one to believe. In all cases, the judgment of the surgeon must guide him in his determination. The circumstances of the case, and the probable contingencies, must be all duly considered, and he must not proceed Paralysis occasionally follows wounds of the arm, forearm, face, &c., inflicted by accident or operation, and this arises from an important nerve, or set of nerves, being divided. In cases of simple division, without much separation of the parts, reunion of the nerves may take place, and their functions be restored. If the limb remains paralysed, after cicatrisation of the wound, tepid effusions, friction, dry or with liniment, stimulating applications, &c., may sometimes be advantageously employed. TETANUSIs a disease which occasionally follows a wound, but rarely in this country. It is a spasmodic contraction, with rigidity, of the voluntary muscles, in some cases involving the whole body, in others the upper part of it only, and in some it is confined to a certain class of muscles. When the extensors are affected, the disease is termed opisthotonos; when the flexors, emprosthotonos. Complete tetanus is said to exist when the flexor and extensor muscles exactly balance each other, and the body is thereby kept straight and rigid. But when the affection is confined to the muscles of deglutition, and chiefly to those moving the lower jaw, it is called trismus. The disease has besides been divided into acute and chronic, and into traumatic and idiopathic; the one following wounds, the other arising from internal causes, or circumstances not connected with the lÆsion of the surface. The disease supervenes at various periods; sometimes, though rarely, not long after the infliction of the injury, in other instances after the lapse of eight or ten days, and often when the wound is healing, or nearly cicatrized. In warm climates, where it is of very frequent occurrence, it occasionally seems to be caused by exposure to damp and changeable weather; in children, it supervenes on the slightest irritation. It is often induced by the presence of splinters, or rather bodies of an irritating nature, and by the partial division of nerves. Not unfrequently it occurs after clean wounds, as amputation or venesection; in the former it may perhaps arise from a nerve being included in the same ligature with an artery, in the latter, from a nervous twig being partially divided. The more prominent symptoms are, stiffness of the back of the neck, and contraction of the features; difficult deglutition supervenes, and the efforts to accomplish it are attended with violent spasms of the muscles of the pharynx and oesophagus. Spasms of the injured limb often precede those of the muscular system generally; the muscles of the lower jaw become rigid and spasmodically contracted, and by a continuance and increase of the spasmodic action, the mouth is at last completely and immovably shut. The muscles of the trunk and limbs become affected, and there are violent spasms of particular sets of them, most generally of those situated posteriorly; thus the body is bent violently backward, so that its whole weight is supported on two points only, the heels and the oc This disease is one of the most intractable with which the surgeon has to contend. In the acute form, time is scarcely allowed for remedies; and in the advanced stage, it is with much difficulty that medicine can be received internally. Of course all irritations must be removed, both local and general, as far as that can be accomplished. If the patient be robust, and if the tetanic symptoms be ushered in with arterial incitement, general depletion ought certainly to be practised; and if the symptoms be such as to render the propriety of general bleeding dubious, blood may be abstracted locally, from the back of the head, or along the spine; and this may be followed by such counter-irritants as act rapidly. At the same time, powerful purgatives must be given, so as to bring the bowels into a better state; for, as already observed, obstinate constipation is a constant attendant on this disease. But the most important indication is to alleviate and prevent, if possible, the spasms; and for this purpose, opium is to be administered in large doses, either by itself, or combined with camphor or other antispasmodics. By such means, the Some practitioners have used mercurial frictions along the spine, or on other parts of the surface; while others administer stimulants, and enemata with tobacco and turpentine. When there is reason to apprehend that the symptoms arise in consequence of laceration or partial division of a nervous trunk, it has been recommended to complete the division of it; and the practice is worthy of adoption, as in some cases it appears to have been successful. Little good can result from scarification of the wound. Amputation of the wounded member has also been proposed, particularly in chronic cases, and in one or two it has succeeded. I have made trial of it in but one instance, and in that it failed. Acute tetanus had followed a lacerated wound betwixt the thumb and forefinger; amputation of the forearm was performed, and immediately after the operation the spasms abated; but they soon returned, notwithstanding the free use of opium, and other remedies, and the patient died. In this case, the branch of the median nerve was found partially divided, and its cut extremities were thickened and inflamed. During the operation, I wished to abstract a considerable quantity of blood, but the arteries seemed to be so spasmodically contracted, as to permit the flow of a small quantity only. On examination after death, the median nerve was of its natural appearance, excepting at the bend of the arm, where it was of a bright-red colour. No change could be perceived in the brain or spinal chord, though the examination was conducted with the utmost care. OF ULCERS.By ulcer is generally understood a breach of continuity in the soft parts of the body, with secretion of purulent or other fluid. But as suppuration may be independent of ulceration, so may we occasionally see a loss of substance like an ulcer on the surface of parts, without the production of pus, or any other morbid secretion, of which some instances are noted in the remarks on Atrophy of Articular Cartilage. Mr. Burns, in his excellent volume on the Principles of Surgery, has extended the term to the reparative process, as well as the destructive; this, if adopted, would lead to confusion and misapprehension. Ulcers vary much in disposition and appearance, follow wounds, abscesses, sloughing, eruptions, &c., and often occur without any previous lÆsion of the surface. Those most generally met with are comprehended in the following classes:—1. The simple purulent ulcer, or healthy or healing sore. 2. The weak or sluggish ulcer,—a sore with undermined integuments and an unhealthy state of the cellular tissue. 3. The indolent ulcer,—a sore with hard elevated edges, and presenting little or no appearance of reparation. 4. The irritable ulcer,—a sore with over-action, and generally affecting only the mere surface of the true skin. Besides these, there are sores connected with diseases of the bones, and others arising from specific action; some are complicated with a varicose state of the veins: the former have been already treated of; the latter are reserved for consideration. Ulcers change their characters, as from simple to irritable, and from indolent to inflamed; the change depends on situation, on the state of the constitution, and on the treatment which they receive. I. The appearances of the first class were described when the healing of wounds by granulations was considered, p. 173. They heal more readily on the upper extremities, on the face, neck, and trunk, than on the lower limbs; for in the former parts the circulation is more vigorous, the natural processes of cure proceed more easily, and are less liable to interruption. The sore only requires rest, a clean condition of the surrounding parts, mild and light dressings, and moderate support; dry lint or lotions are preferable to ointments, since the latter are apt to irritate by their rancidity. When the sore is of considerable size, and there is a tendency in the granulations to rise above the level of the surrounding skin or cicatrix, the edges may be protected by very narrow slips of fine old linen or cambric, spread with fresh spermaceti ointment or cold cream; a pledget of dry lint is then laid on, and retained by a roller. The dressings thus arranged do not adhere, and the tender cicatrix is not ruffled and disturbed; or a piece of pierced linen spread thinly with unirritating ointment may be placed over the sore, and above that dry lint. When the sore has contracted to a small size, and some powder, as starch or calamine stone, or a piece of dry lint, may be applied, so as to allow a scab to form for the protection of the subjacent surface; but this will, in most cases, be better accomplished by touching the surface lightly with lunar caustic or blue stone; the fluids on the During the cure, the patient must be a good deal confined to the recumbent posture; when erect, a bandage or laced stocking must be applied to the limb; thus the return of blood is assisted, swelling is prevented, and the affected parts placed in a state of comparative rest. Much pressure ought to be avoided, as it is apt to produce bad effects upon the sore, causing absorption of the granulations, thin bloody discharge, and great tenderness of the surface. After cicatrisation, the scars may be absorbed, and sores reproduced, by external injuries, or an unhealthy state of the body; and so much does the state of a sore depend upon that of the general health, that the one is a good index of the other. II. In the second class of sores, or those with weak action, the granulations are flabby, of a pale colour, and possessed of little sensibility or vascularity; the discharge is gleety, and the surface is liable to be destroyed by ulceration or sloughing, upon the slightest excitement of the circulation in the part. The surrounding integuments are generally of a bluish colour, in consequence of their separation from the subjacent parts; and in several places of the neighbourhood, small, unhealthy, detached abscesses may exist; at some points of the sore, glairy fluid is seen to ooze out on pressure, and a probe can be passed pretty deeply into the cavity of an abscess in the soft parts beneath. These sores may arise from an unhealthy condition of the cellular tissue, taking place spontaneously, or following slight injury; they are attributable to the state of the constitution, and may result from an ulcer, originally of a healthy It is the business of the surgeon, in cases of this description, first to obtain a sound foundation, by destroying the unhealthy skin and cellular tissue; the free application of caustic potass will answer this end most readily and effectually. Its application is attended with considerable pain, but the practice is more successful and less severe than the removal of the unsound parts by the knife or other means. The small abscesses may be all freely laid open; the diseased cellular tissue may be cut into, or cut away; in short, incisions may be made in all directions, and in every portion of the affected part; but still it will be found that the granulations, as they appear, become pale and flabby, that they spring from a loose and powerless base; matter will again collect; the surrounding skin will again be undermined; no progress will be made towards soundness. But by attention to the state of the constitution, and the application of potass, the neighbouring sound parts have their actions roused, and the healing is carried on rapidly. After its application, a poultice may be applied for a few days, and followed by water dressing, and then stimulants, both internally and externally employed according to circumstances, the parts being all along well supported. The long continued use of warm fomentations, or poultices, is prejudicial, as tending to diminish still farther the action of the parts; ointments can be of little service, and will generally do harm. III. Indolent ulcers, which have long existed, are frequently met with on the lower limbs. Their margins are thick and insensible—their surfaces smooth, hollow, and of a pale colour—the discharge is scanty, and adheres to the surface. A sore, having been long open and neglected, degenerates into this state. Poultices are to be applied for a day or two, to clean the surface, promote the discharge, and soften the callous margins. This is the more necessary, if, as is often the case, the sore, or the surrounding integuments, are inflamed when the patient applies for relief. Afterwards, the applications must be of such a nature as to moderate the discharge and keep the granulations firm and healthy. In such cases only is adhesive plaster applicable, and in them it produces the most beneficial results. Supposing the ulcer to be situated on the fore and middle part of the leg, a bandage should first be firmly applied from the toes to a little below the sore; the ulcerated part of the limb is then encircled by narrow strips of adhesive plaster, tightly drawn, and with the extremities of each strip crossing immediately over the ulcer. A pledget of tow is placed on the plasters to absorb the discharge, and the bandage is brought over dressings, and continued for some way upward. By this application, the margins of the sore, it is supposed, are brought nearer to each other, and the ulcerated surface diminished; the sluggish granulations and the subjacent parts are stimulated, and a more vigorous action being excited, the process of reparation proceeds speedily and effectually; the surrounding parts, previously turgid and oedematous, are by the pressure brought to the same level with the newly-secreted matter, and new skin is quickly formed. In the previous state of matters, the old skin was much These sores are often connected with a varicose state of the veins. In all such cases, a degree of compression on the affected limb must be maintained, both during the continuance of the sore, and after it has healed. The usual situation of such sores is on the leg, and the varicose state of the veins does not, in general, extend above the knee; in such cases, a radical cure may be attained (provided the patient wishes to encounter the attendant risks, rather than submit to a continuance of the disease) by effecting an obliteration of the saphena major vein. The manner of doing this, and its effects, were mentioned while treating of diseased veins. In some cases, the saphena minor is also varicose to some extent, the varices on which must also be obliterated. Sometimes as many as eight or ten needles must be applied, in pairs, before the circulation of a limb can be brought into a right state. IV. In this fourth class of sores, or the irritable from over-action, the sore and its edges are of a jagged, irregular appearance, the discharge is thin and bloody, and considerable pain is experienced. This ulcer is very superficial, involving only the surface of the corium and the more sensible part of the integument, the papillÆ, and extremities of the nervous filaments. They often succeed to scaly eruptions, and present a remarkable character and appearance, cica Ulcers are occasionally prevented from healing by the presence of dead portions of tendon, fascia, or cellular tissue, and are accompanied in general with a bad state of constitution; in such it is necessary to clean the surface by a powerful escharotic, and the best is potass. Otherwise, granulations will be produced quickly, it is true, and in abundance, to supply the original substance; but then they are flabby and exuberant, new skin is formed slowly, if at all, and the sore does not contract; but by removing the dead or half-dead surface, a healthy and firm foundation is prepared, on which is securely and gradually raised the new matter for cicatrisation. But caustics are applied injudiciously to firm and healthy granulations which have not yet reached the level of the surrounding parts; they are only useful in repressing exuberant granulations, or in destroying half-dead parts, which interrupt or deteriorate the cure: and when employed, it should be effectually, and once for all. Along with the topical treatment of ulcers, internal means are, in most cases, indispensable. Thus, in indolent ulcers, the state of the constitution is often sluggish, and ought to be changed by the exhibition of alteratives or stimulants; with this view, much benefit is derived from a prudent and restrained use of mercury, from the lytta vesicatoria, from minute and occasional doses of arsenic, from the free exhibition of sarsaparilla, and from generous diet, porter, and wine. It is however, altogether impossible to lay down fixed rules for the management of sores; every one has some peculiarity in its nature and appearance, every one requires some peculiarity in the applications and mode of dressing, and what may suit well one day will often prove inert or injurious on the succeeding. Again, when any one application or internal remedy is found to agree with the sore, it ought not to be changed for fashion’s sake, from caprice or routine. In this department of surgery, one practitioner excels another, not by his supe OF HOSPITAL OR CONTAGIOUS GANGRENE, AND SLOUGHING PHAGÆDENA.This disease has been long known, and has proved very fatal in crowded and badly-aired hospitals. It may break out at any season, but hot, sultry, and damp weather is most favourable to it. No breach of surface, however small, is secure from its attack. The wound becomes painful and swollen, and loses its healthy, florid appearance; the granulations are flabby, and appear as if distended with air; vesicles form, containing serum or a bloody fluid; the pain is stinging; the secretions are suspended; and the wound is either altogether dry, or covered with slimy, tenacious, and peculiarly offensive matter. An ichorous discharge follows, the pain increases. The sore assumes a circular form, and its edges are everted; erysipelas attacks the surrounding integuments, often extending over the whole limb, and forming a principal feature of the disease. In fact, violent erysipelas and hospital gangrene are affections very closely allied to each other, often arising at the same time, and from the same causes. Both are accompanied with great constitutional disturbance; but in erysipelas, this generally precedes, whilst in hospital gangrene, it follows, the appearance of the malady. The lymphatic glands, in the neighbourhood of the gangrenous part, inflame and suppurate, the skin gives way, and the gangrene soon seizes the newly-formed sore. Fever supervenes, the pulse is often full and strong, and the surface hot; there is great nausea and thirst; the tongue is brown, and the bowels much disordered. The inflammation and ichorous discharge increase. A thick slough covers the sore, and its fetor is peculiar and intolerable. The burning pain is excruciating. Blood oozes out, and, in the Now, extensive mortification occurs, the strength fails, the pulse becomes tremulous and indistinct, the features collapse, the surface is bedewed with a cold sweat, diarrhoea and hiccough come on, and death puts an end to the patient’s suffering. Such is the progress of the disease in those who were previously in perfect health. Often, however, it is attended with typhoid symptoms almost from the beginning, in people whose constitutions are wasted, who have long laboured under disease, or who have been long confined in hospital. The important distinction between these cases must influence the treatment; what succeeds in the one will destroy in the other. It is not the name of the disease which is to be combated, but each symptom as soon as it presents itself. Those who have been once afflicted with hospital gangrene are extremely liable to its recurrence, and that too on the same sore; though the secondary disease is much less acute. This form has been termed Sloughing PhagÆdena, and may seize a sore not previously affected with gangrene. The wound, recovering from the first attack, and appearing to heal rapidly, with good discharge and healthy surface, presents, near its edge, a small dark spot or ulceration, of the size of a small bead or shot, of a circular form, with a ragged edge, excavated surface, and fetid discharge. Several such points may appear; they spread rapidly, unite, and the surface is soon destroyed. It is not uncommon to find one part of the sore of a healthy appearance, and even cicatrising, whilst in another part the surface is rapidly disappearing. The patient complains of a burning sensation in the part; suppuration occurs round the edges and beneath the slough, and the dead parts separate; but the same process again takes place, and another slough forms. The malady proceeds often with a rapid and alarming pace; the sloughs are soft, pulpy, and reddish, and separate one after another, exposing muscles, nerves, bloodvessels, and bones. Joints are opened into, and the vessels, having been exposed, perhaps for a day or two, give way, and fatal hemorrhage ensues, their cavities not being obstructed with coagula as in sphacelus. The patient is sick, has no appetite, and labours under other symptoms of deranged stomach; there is restlessness, with a small quick pulse, and all the symptoms of a weakened and sinking system. The ulceration becomes more rapid, the discharge is bloody and peculiarly offensive; all the symptoms increase in violence, and may proceed for fifteen or twenty days, or terminate in four or five, either in convalescence or death. Hospital gangrene is supposed to arise from a variety of causes: from the state of the atmosphere, moist and hot—from inattention to cleanliness, the parts around the sore being seldom wiped, the matter collecting amongst the dressings, and becoming acrid by putrescence—from irritating applications, as rancid ointments—from a too stimulating diet, and from the abuse of wine and spirits—from mechanical irritation, in moving the wounded over rough roads and in bad conveyances, as after great engagements—from specific contagion without immediate contact. After being once generated, it is In the treatment of this scourge, great attention must be paid to cleanliness in all circumstances. Free ventilation must be constantly preserved in the apartments of the sick, and fumigations assiduously employed. The infected ought to be separated from the others, and but few patients placed in the same ward. Stagnant drains and accumulations of filth out of doors are to be removed; otherwise, during hot weather, the atmosphere becomes much vitiated. Care must be taken, also, to destroy all the dressings which have been used; not to employ sponges, but to wipe the surface in the neighbourhood of the sore occasionally with tow, which is to be burnt immediately, being an article of little value, and easily procured. Too much attention cannot be paid to the cleaning of those instruments with which gangrenous sores have been treated, before they be applied to healthy wounds. As to the constitutional treatment, the alimentary canal must first be purged of its solid contents, and the secretions afterwards kept in as good a condition as possible. When the wound or sore is surrounded with intense inflammation, and when the skin is dry and the pulse strong and full, with all the other symptoms of an inflammatory diathesis, immediate recourse must be had to free abstraction of blood from the system, as thus only can the progress of the disease be efficiently arrested; and if inflammatory symptoms exist, when there is reason to expect the occurrence of the disease, though no symptom of it has yet appeared, then, too, venesection combined with purgatives is demanded, as being the most powerful preventives. Emetics are also recommended. When the affection is from its commencement accompanied with typhoid symptoms, depleting measures must do irreparable mischief: in such cases, the local pain and irritation will be relieved by the exhibition of opium or camphor, and it may also be of service to preserve a perspirable state of the surface by means of Dover’s powder, or other diaphoretics. Preparations of Peruvian bark, the decoction with or without the tincture and acid, or the sulphate of quina, are often given with great advantage—opium is also usefully exhibited. Vinegar, weak acids, the nitric and muriatic acids diluted, have been used as external applications, and nitrate of silver, the red oxide of mercury, and the actual cautery, have been applied with the view of removing the diseased parts, and procuring a healthy surface. Arsenic in solution, used so as to produce a slough, followed by hot dressings, has been supposed to be serviceable. A much safer and more powerful application is the strong nitric acid, which sometimes requires to be applied over the diseased surface very freely, and repeated if need be. THE MALIGNANT PUSTULEIs a gangrenous inflammation of the skin, rarely extending to the subcutaneous cellular tissue, and in this respect differs from carbuncle, The disease generally attacks the hands, neck, face, or shoulders of butchers and others, who carry, or in some way deal in carrion. It has also taken place in consequence of the hand being introduced into the rectum—a veterinary method of removing scybala—of an animal labouring under putrescent disease. A pustule appears on the part affected, containing a serous or a dark-coloured fluid; and the base ulcerates, extending through the skin to the subjacent parts; at first it is accompanied with a pricking sensation, afterwards the pustule enlarges and becomes brown, and the pain is burning and itching. The vesicle when opened, or when it has burst spontaneously, furnishes a few drops of red serum, and the pain is thereby relieved for a few hours. A hard, moveable, and circumscribed tubercle forms, without alteration of the surrounding skin. The bottom of the sore is yellow, greenish, or livid, and the sensation is that of acute heat and erosion. PhlyctenÆ spread around. The tubercle becomes black in the centre, and an eschar forms; the patient becomes irritable and languid. The gangrenous point begins to extend, and that alarmingly; great swelling takes place, elastic, red, and shining, more emphysematous than inflammatory or oedematous. The burning pain is aggravated; the patient has a feeling of weight and stupor; great constitutional disturbance follows, there is slow fever, with a small pulse, a dry and brown tongue, and unquenchable thirst; a low muttering delirium ensues, and under these symptoms the patient soon sinks. After death, the fetid body swells rapidly. The disease sometimes terminates fatally in twenty-four hours or less; but generally the patient’s sufferings are more OF ULCERS OF THE GENITAL ORGANS, AND THEIR CONSEQUENCES.It were unprofitable to enter here upon the History of Venereal Affections, as it is a subject of no practical utility, still involved in uncertainty, and mystified by disputation. It will suffice to describe the different forms of the disease, and state the treatment applicable to each. During the last century, and in the beginning of this, much greater ravages were produced by the disease than at the present time; and though this may be, perhaps, partly owing to a change in the poison itself, it is mainly attributable to the mildness of the measures by which it has been, and is, opposed. Every form of the affection, as soon as it appeared, was at one time opposed by a counter poison, mercury; and the practitioner, relying implicitly on this mineral as a specific, and not being fully aware of its dangerous properties, continued to gorge the system with the supposed remedy, subverting the constitution of his patient, making, in many cases, no impression on the disease, but still persevering in the use of a poison equal, if not more potent, than the one which it was intended to destroy. The change of treatment has been propitious to our science and to mankind. But let it not be inferred that mercury now is, or ought to be, entirely dismissed from the treatment of this disease, or from practice generally: often no other means are effectual; but it should always be prescribed most cautiously and sparingly. The effects of the venereal virus are divided into primary or local, and secondary or constitutional; and these present a great variety in their appearances, characters, and tendencies. They are sometimes modified by the constitution, or by the remedies ordered in the first stage; but there can be no doubt that different poisons exist, pro The most common kind of sore is the simple ulcer, at first excavated, in consequence of the process of ulceration continuing; afterwards the ulceration stops, and granulations, somewhat fungous, supply its place, so that the surface is raised above the level of the surrounding parts, and has a smooth, soft appearance; there is no hardness of the edges, and there is no tendency to slough or extend by ulceration. Sometimes it commences in the form of a pustule, which soon gives way, discharging its contents, and leaving an exposed surface, in which the process of ulceration quickly proceeds; but often it arises from simple abrasion of the surface. Different forms of sores may exist on the glans and prepuce at the same time; and it is maintained, that one sore may produce another of a different kind, and the same is asserted with regard to eruptions. The simple ulcer, as well as other sores, is produced by the contact of secretions, generally morbid, but often apparently healthy, with a susceptible surface. Sores, with eruption and sore throat, sometimes appear in one or both individuals immediately after marriage, and probably arise from the acrimony of the female secretions causing tenderness and ulceration of the parts. The application of gonorrhoeal matter readily produces the simple ulcer on the glans or prepuce, particularly if an abrasion or rawness existed; and if the matter be allowed to remain on an unbroken surface, a pustule will form, and ulceration follow. From this latter cause numerous sores are produced, separated from each other by sound parts, and not extending into one continuous ulcer; and this condition may have been preceded, on the glans, by a rawness of the surface and a profuse discharge, or by a herpetic eruption on the mucous lining of the prepuce. One man may be affected with gonorrhoea, and another with ulcer, from connection with the same female, the same day or hour; and it is doubtful whether the effect is not similar, in both cases, viz., ulceration; for it is supposed, that in gonorrhoea, the discharge, in some rare cases, proceeds from patchy ulceration of the mucous lining of the urethra, similar to the ulceration usually met with on the glans. In examining women who have communicated infection, very often no sores are found, and but little unhealthy discharge. In short, the simple elevated sore may arise from the application of secretions from an unbroken surface, from inoculation of matter from a similar sore, or spontaneously, from inattention to cleanliness. Sores with elevated surface, more extensive than those of the glans and prepuce, occur on the skin of the penis and scrotum, or in the folds of the thigh; and in women they are often met with in the perineum, or the cleft of the nates. Sores of different kinds arises at various periods after the application of their cause, from a day or two to some weeks, or longer, but the usual time may be said to be from four to eight days. The duration of the simple elevated sore may be modified by various circumstances—by the constitution of the patient, his mode of living, and the attention paid to the affected part. It seldom remains open above a few weeks, but occasionally it may be seen unhealed at the end of several months in those who lead careless and irregular lives. From the simple ulcer there arises a constitutional affection, in all respects resembling that which follows gonorrhoea (a disease which will be treated of under affections of particular mucous surfaces); but before attending to this, it will be proper to advert to another form of ulcer, which differs but slightly from the preceding in primary and secondary symptoms. It is a sore with a brown surface, either on a level with, or above the surrounding parts, with defined and elevated edges, with no cartilaginous hardness of base or margins, and with no tendency to spread either by sloughing or by ulceration. Such may occur in the same situation as the simple sores, but they often form on the outer surface of the prepuce, or on the scrotum; and are not unfrequently met with round the orifice of the prepuce, which is a most troublesome situation, as, in healing, they generally produce phymosis. Sores and fissures in this situation are very often kept up by the tense and irritable state of the aperture. The bubo which follows this differs from that caused by the simple sore, in having, after ulceration of the integument, a greater disposition to burrow; and this tendency is more marked where mercury has been employed. From either of these forms of ulcer, it sometimes happens that constitutional affections arise, either during the existence of the sore, or some weeks after it has cicatrised. The usual secondary symptoms are those attendant on a papular eruption. There is fever, with pains referred to the head, to the joints, chiefly the larger ones, and to the chest, which latter symptom is sometimes attended with dyspnoea. This indisposition is followed by the appearance of a papular eruption, termed lichen, on the face and trunk, the extremities being less thickly studded. The fever subsides in a great measure after the eruption appears and comes fully out; but fresh crops of papulÆ may appear, and, in this case, the fever continues little abated until the eruption begins to fade. The eruption consists, in the first instance, of simple elevations or pimples of a red colour, and these do not appear at once, but gradually: so that some have assumed the form of cones, with minute collections of matter in their apices, whilst others are mere elevations of the cuticle. When they fade the spots are of a copper tint, and become covered with thin scales, in consequence of the cuticle de Such is the usually mild character of this affection; but if its progress has been interrupted by any means, more particularly by mercury, it assumes a more complicated form, and a less tractable nature. If that mineral is administered in the usual style, and at the commencement, when the fever and other symptoms are high, the patient’s sufferings are all much aggravated. After the fever has subsided, the eruption will often be found to disappear under the use of mercury; but it is extremely apt to recur, as soon as the system has shaken itself free from the effects of that medicine. The mercury produces an irritation, which supersedes the eruption, but by frequent repetition its effects on the system diminish: it at last fails to create an irritation more powerful than the disease to which it is opposed, and, consequently, the eruption does not yield, but during its use is frequently reinforced by fresh crops of papulÆ. If the eruptive fever, and advanced stage of the disease, are imprudently and suddenly arrested by the use of mercury, by exposure to cold, or by other means, inflammation of the iris or joints often follows, of a very violent form, and not to be easily moderated. No one thinks of repelling measles or other eruptive diseases, and with good reason, for such practice would almost certainly induce serious affections of internal organs. For the same reason, every precaution must be used to allow this form of eruption to take its own course, while we merely regulate the constitutional symptoms as they obtrude. Another form of eruption, which occasionally, though much less frequently, results from either of the above mentioned sores, is the pustular. It is preceded by fever, and consists of rather large pustules, separated from one another, and not very numerous. After their apices give way, and the contained pus is discharged, a thin scab is formed, and on its separation a small ulcer is left, which in general soon heals from its margins, leaving a dark-coloured spot to mark its situation. The papular and pustular eruptions are sometimes blended; a few pustules appearing amongst numerous papulÆ, or vice versÂ. The pustular disease is not of frequent occurrence; and in proportion as it approaches the papular, with desquamation, it becomes milder and more easily removed. In it, as in the papular, mercury proves injurious. The phagedenic form of ulcer is the most dreadful and unmanageable of all; most uncertain in progress, and direful in event, and often rendered still more destructive by the mode of treatment adopted. Fortunately, it is now seldom seen, though not long ago it was well known, as a perpetrator of dreadful havoc, under the name of black pox. It is a corroding ulcer, without hardness of the surrounding parts, presenting no appearance of regeneration of the tissues which have been destroyed. It may follow either upon a pustule or an abrasion. Sometimes it destroys the prepuce and glans in a few days, or again, when chronic, it spreads deceitfully, healing at one part and destroying at another. The ulceration is often deep, penetrating the corpora cavernosa, or the corpus spongiosum urethrÆ: in such cases it is followed with violent hemorrhage, which often produces a great and sudden improvement in the sore. After slow cicatrisation it not unfrequently happens that the scar gives way, and the ulceration returns. Sometimes another character is given to the sore, by the rapid sloughing of the parts. In this modification, a small black spot is first observable, unattended with pain: it enlarges rapidly, and, after no long time, the mortified part separates, exposing an unhealthy surface, which is immediately attacked and progressively destroyed by phagedena. The part may again slough, and, by an alternation of mortification and phagedenic ulceration, the external organs of generation, male or female, may be wholly destroyed. In the present day, however, its ravages are much less extensive and more easily combated than formerly, and it seldom, if ever, proves fatal. One very troublesome case is in my recollection, where the patient suffered two attacks at the interval of two years. During the progress of the disease he was seized with delirium tremens; a bubo formed and ulcerated; a violent hemorrhage occurred from the sore; sloughing and phagedena alternated; and both prepuce and glans were entirely lost. An eruption followed, accompanied with ulceration of the throat and nostrils. He recovered much mutilated. Ulcers originally of a simple character may become affected with phagedena, or sloughing, from the state of the constitution, from mismanagement, or from exposure to an unhealthful atmosphere. But in such cases, after the separation of the slough, the exposed surface is found to be of a healthy granulating character, contrary to what is observed in the originally phagedenic disease. Buboes, when they occur, have the same malignant action as the primary sore: the breach of surface is extended either by sloughing or by phagedenic ulceration, and the edges of the sore are ragged and undermined. The secondary eruption which follows the phagedenic form is pustular, though differing from that which has been already noticed. The pustules soon give way, and ulcers remain, covered with thick scales or crusts, which sometimes increase, layer by layer, so as to become prominent, dense, and of a conical form,—the rupia prominens. After the separation of the crusts the ulcers are found, superficial, rather unhealthy, and showing a disposition to extend, chiefly Ulcers of the throat occur, of a very alarming kind, quickly destroying the parts attacked, spreading chiefly towards the posterior part of the fauces, rapidly extending to the pharynx and to the nostrils, and in some instances also involving the larynx. The pendulous velum of the palate and the tonsils are often wholly destroyed, the bones of the nose, more especially the turbinated, are deprived of their coverings, and exfoliate, the osseous and cartilaginous portions of the septum are discharged, and the nose becomes sunk, or is supported merely by the columna. The patient’s breath is fetid, respiration is in some degree obstructed, a foul ichorous discharge flows from the nares, and the surrounding parts are inflamed, swollen, and excoriated. The countenance is greatly disfigured. On looking into the throat, nothing is seen but an extensive ulcerated surface covered with white adherent matter, and exhaling an offensive fetor, particularly when the bones are affected. Respiration is nasal, and the speech indistinct. When the larynx becomes affected, the patient may be almost considered as lost: phthisis laryngea is established, the symptoms and treatment of which will be afterwards mentioned. The mutilating affection of the nose does not seem to be produced by any other form of the venereal disease, if not in any way aggravated. Along with the eruption and its after effects, severe pains in the articulations, particularly in the knee-joint, often occur, and are always much increased during the night. Nodes seem to be produced only in those cases in which mercury is exhibited; their most usual situation is on the fore part of the tibia; severe pain is felt in the part, which becomes slightly swollen, and of a bright red colour; the swelling feels dense and firm, being a simple enlargement of the bone. They often occur when the patient is The last distinct form of the venereal disease is the scaly—syphilis, or true pox. The primary sore, termed a chancre, “is somewhat of a circular form, excavated, without granulations, with matter adhering to the surface, and with a thickened edge and base. The hardness or thickening is very circumscribed, not diffusing itself gradually and imperceptibly into the surrounding parts, but terminating rather abruptly.” Such is the appearance generally presented by the sore when situated on the glans and prepuce. It generally commences in the form of a pimple, without much surrounding inflammation. Sometimes the ulcerated surface is very inconsiderable, but there is always the abrupt and remarkably dense thickness which serves as a distinguishing mark. The non-syphilitic ulcers may have surrounding hardness from the first, or in consequence of the application of stimulants and escharotics; but this is diffused into the neighbourhood, and is not, it is said, of that remarkable solidity peculiar to chancre. It is seldom that more than one chancre occurs: the usual situation is on the glans and lining of the prepuce; but they occasionally form on the outer surface of the prepuce, and on the dorsum penis. In the latter situation the sore assumes a somewhat different appearance: it is, in general, larger, the hardness of the base is not so great, the excavation is less, and the surface is of a livid hue. When allowed to proceed uninterrupted, the livid surface is alternated with that of a light brown or tawny colour. Chancre is an indolent ulcer when compared with the phagedenic or sloughing sore, the ulceration proceeds very slowly, and, in proportion as it advances, the surrounding hardness increases. It is also contumacious and obstinate in taking on any reparative action. Phymosis occasionally takes place, in consequence of chancre situated at the orifice of the prepuce, but not so frequently as when that situation is occupied by superficial sores of a more active nature. Bubo sometimes appears in both groins, or in one; sometimes on the same side with the sore, often on the opposite, and not unfrequently when the sore is healing, or after it has healed. It may suppurate and give way, or may subside without having advanced to suppuration. It differs in no respect from the swelling of the glands from other causes, either in its swelled or open state. Neither does the occurrence of a bubo render it more probable that constitutional symptoms will follow. Enlargement of the glands is often caused, or at least hastened, by the patient continuing to walk about and exert himself during the existence of a sore, and whilst the absorbents are in an irritable state; but a bubo may be caused by irritation or excoriation in any way produced; and it not unfrequently occurs without any apparent cause. In some cases of chancre or other ulcer, the absorbents along the dorsum penis become swollen, and occasionally suppurate. In former times, it was not uncommon for the surgeon to insist that all swellings in the groin were venereal, though no primary sore had ever The eruption which follows the chancrous form of primary sore is scaly from the commencement, and by this character is readily distinguished from every other venereal affection. It is generally preceded by an efflorescence or discoloration, rendering the skin of a mottled appearance. The scaly eruption is a form either of lepra or of psoriasis. The patches usually do not exceed a sixpence in size, are distinct and separate from each other; their base is of a dark red or coppery hue, the affected skin is not hard or rough, but soft and pliable, and seldom covered with crusts; as they extend, the edges are slightly elevated at the centre, which alone is covered with thin white scales, appears flattened and somewhat depressed; when they begin to fade, the margins shrink and become paler, and desquamation proceeds slowly; a circular, purplish-red discoloration, with a central depression, remains for some time after the blotches have declined: the depression is permanent, but the discoloration disappears. The smaller patches, which assume a variety of forms, continue for some time of a dark colour, extend towards the circumference, become pustular, and at length ulcerate superficially, enclosing an area of sound skin. When depressions of the skin, as the folds of the nates, are affected, a scaly eruption does not take place, but soft and moist elevations arise, discharging a whitish matter, varying in form and size, and accordingly receiving various appellations, as condylomata, fici, or marisci. From them a secondary form of disease is occasionally communicated. If no decided treatment is resorted to, and if the eruption is consequently permitted to follow its own course, thick crusts form, ulceration proceeds beneath them, the matter is confined, and the patch becomes prominent. Another secondary symptom of chancre is ulceration of the throat, sometimes extensive, but generally situated in the tonsils, or their immediate neighbourhood. The ulcer is not preceded by much pain or swelling: “it is a fair loss of substance, (part being dug out, as it were, from the body of the tonsil,) with a determined edge, and is commonly foul, with thick matter adhering to it, like a slough, which cannot be washed away.” Such ulceration may be simulated by excavated sores attending the phagedenic form of disease; and it ought to be more especially distinguished from an affection to which the tonsil is extremely liable, irregularity of its surface, enlargement, and effusion of lymph, in consequence of chronic inflammation. A more serious part of the secondary disease is affection of the deep-seated parts, ligaments, periosteum, and bones. The bones nearest the surface are principally affected: a swelling gradually forms on the tibia or ulna, without discoloration of the integuments, and without pain occurring till after a long time. The pain is most severe during the night. The inflammation of the periosteum is often very violent, the subjacent bone, as in the head or extremities, becomes dead, and exfoliates; but it remains to be seen whether this Such are the affections, local and constitutional, arising from a venereal cause; but the latter may be simulated. Many affections of the skin, mucous membranes, and bones, resembling the venereal disease, may be produced by disorder of the constitution, by a decay of the digestive organs, by unwholesome food, and exposure to inclement weather, by inattention to cleanliness, and many other circumstances. Morbid poisons, not venereal, but of various kinds, may exist, and cause much mischief. A disease resembling syphilis was produced by the cruel practice of transplanting teeth from sound people into the jaws of persons in the higher ranks of life, whose corresponding teeth were decayed. The latter were the affected party, and that justly. A very infectious disease was at one time common in the poorer parts of Scotland, and known under the name of sibbens, or sivvens, chiefly occurring amongst the poor, ill-fed, badly-clothed, and worse-housed people in the Highlands. It was communicable by very slight contact by kissing the lips of an infected person, smoking the same pipe, drinking out of the same cup, or using the same spoon. Cases of it are still occasionally seen. There are ulcers of the lips, mouth, throat, and nose; ulcerated patches and warty excrescences in the cleft of the thighs, in the axilla, and round the anus and pudenda. A pustular eruption appears, and terminates in hardened crusts. The same disease is known in Ireland, under the name of button-scurvy; and a similar one, called raddesyge, has been described as occurring on the sea-coasts of Norway and Sweden. In Canada, also, something of a like nature was at one time prevalent. The yaws, at one time common and destructive in the West India Islands, appear to be much of the same nature. Some of these diseases, more particularly sivvens, are very common amongst children. Even in these days children are not unfrequently born with copper-coloured blotches of the skin and desquamation of the cuticle; or they may come into the world with these appearances, along with affections of the mucous membrane, hoarse voice, redness round the anus, &c. These are forthwith attributed to a syphilitic taint existing in either of the parents; and one or both are put under mercury; but child after child comes into the world in the same plight. Again, the disease is communicated by children to the nurses, and vice versÂ. All these Some have believed mercury a certain test of syphilis; maintaining that the disease, still checked by the specific, is never overcome by the constitution; that it is unchangeable, and regularly and progressively grows worse, where no mercury is employed; that, opposed by that medicine, it is stationary, and is permanently cured by adequate mercurial influence on the constitution. Whatever were the appearances, if they went off under mercury, the advocates for this practice set them down as those of syphilis, lues, or pox. If they did not yield to that mineral, they were termed syphiloid, pseudo-syphilitic, or mercurial; for they did admit, now and then, that their favourite remedy produced unpleasant effects. Such theory and practice are now very happily exploded. As to the treatment of local venereal affections, it may be, in the first place, remarked, that prevention is better than cure. The means employed for accomplishing this end are very various: oily applications, alkaline and spirituous washes, &c., with the view either of preventing the matter from coming into contact with the genitals, or of completely removing it, when it has been but a short time applied. There is one certain method of avoiding disease, which it is unnecessary to mention. In all affections of the penis, it is of the utmost importance to keep its extremity bound up to the abdomen, in order to prevent congestion or inflammatory swelling. Celsus knew this well; “Sursumque coles ad ventrem deligandus est, quod in omni curatione ejus necessarium est;” rest and quiet must be strictly observed; the patient must be confined to the recumbent position, particularly when the sore is irritable, when swelling or bubo has occurred or is threatened; and when the system is excited, and the eruption has commenced, the bowels must be kept gently open, the patient’s diet must be low, and the parts surrounding the sore are to be kept carefully clean. Whatever the nature of the ulcer may be, it is safe and prudent, in the first instance, to change its action by the use of the nitrate of silver, or to destroy the surface by the free application of escharotics, as nitric acid, or solution of nitrate of mercury: the morbid poison is thus got rid of, and the surrounding parts stimulated to a proper degree of action. This is absolutely necessary in the phagedenic form of ulcer, whether of an acute or chronic nature. But, in most cases, the patient does not apply for medical assistance till the sore has been of so long duration as to preclude all hope of counteracting the virus by any local application. The simple superficial sores, and those with elevated margins, must be treated on the same principles as if they were totally unconnected with any specific cause; and the applications must be varied according to the peculiarities of the part affected, and the different appearances which the surface assumes during the progress of cure. Lotion is the form of application found preferable in most cases, and may consist of calomel and lime-water, with mucilage, called the black wash; of muriate of mercury, with lime-water, called the yellow wash; of a solution of sulphate Buboes are to be treated in the same way as any other inflammatory swellings; local means being taken at the commencement to subdue the inflammatory action, and resolve the swelling. Rest is indispensable. When they are stationary, the application of a blister will either cause resolution or suppuration, and so the enlargement will be got rid of, either in the one way or the other. The painting of a rubefacient solution of iodine occasionally on the swelling is also useful, and preferable to frictions with iodine ointment. When they have passed into a decidedly chronic state, absorption may be promoted by pressure, or, again, means must be taken to hasten suppuration, and the matter which forms is to be early evacuated. If suppuration occur in the cellular tissue, and not in the substance of the enlarged gland, neither cicatrisation, nor a permanent cure, can be expected until the prominent and indurated parts have been destroyed by the caustic potass. In phagedena, bread and water poultices or tepid-water dressing are, in the first place, to be applied, and the pain and irritation may be soothed by solutions of opium, or extract of poppy. If bands of skin intersect the ulcerated parts, they are to be divided, as being a source of irritation which prevents healing. If the frÆnum prÆputii be surrounded by ulceration and undermined, it must be incised for a similar reason. It is often advisable, also, to divide the prepuce. After the process of destruction has ceased, gently stimulating washes will promote contraction of the sore. It is an important fact, that the majority of primary ulcers can be made to heal without mercury. Cavillers object to the mercurial washes, supposing that they may act by affecting the constitution. The sores with hardened edges, chancres, heal as well as others, when mercury is not employed, but much more slowly. In some mercury is injurious: in chancres it promotes the cure. In any case, I would never think of ordering it, unless the progress were very tedious, the ulcer being indolent and contumacious; then mercury may be advantageously used, and moderately continued, until the callosity disappear. It is no easy matter to say, judging from the appearance of the ulcer, whether secondary syphilitic symptoms are likely to arise in consequence of it or not, or what their nature may be should they occur: they follow upon sores of all characters, and, again, do not appear, after what might be set down as the genuine Hunterian chancre. Whatever the nature and appearance of the ulcer may have been in the first instance, should it become stationary, and show no disposition to heal under local means, mercury may then be given cautiously, and with advantage. Considering that very obstinate sores are now seldom met with, it would seem that very little mercury is required in the treatment of primary venereal ulcers. During the progress of acute inflammatory action, this medicine should Constitutional symptoms do not often occur, taking place scarcely in one case out of a hundred of all the forms of sores which present themselves. In the papular form mercury is hurtful, as already remarked; it interferes with the natural and mild progress of the affection, frequently gives rise to iritis, and produces pains of the joints and bones. The powers of the constitution, aided by simple remedies, are sufficient: the cure may be tedious, but cannot be destructive. Whereas, if mercury be considered as the only specific, its use will be long continued; it will frequently be resumed after it has been dispensed with on the supposition that the virus is destroyed; and by the effects of excessive mercurial irritation, combined with those of the disease, tampered with and aggravated, the patient may ultimately perish. The fever, which precedes and attends the eruption, must be moderated by depletion, antimonial medicines, and purgatives; but depletion ought not to be carried far, lest the eruption be thus checked and disappear; and the patient ought to be carefully removed from external circumstances which might produce a similar effect. After the eruption has come fully out, and the febrile symptoms subsided, it will be sufficient to attend to the general health, and employ the decoction of sarsaparilla, a medicine which excites the secretions, and more especially promotes diaphoresis. In short, the treatment may be said to consist in allowing the disease, in a great measure, to follow its own course, taking measures to prevent it from being interrupted, and merely moderating such violent symptoms as may precede or accompany it. In the pustular form of eruption the general treatment is the same as in the papular. Mercury is hurtful, and increases the tendency to burrow. When the surface is nearly covered with pustules and ulcers in all stages, desquamation may be hastened by fumigations of sulphur, the general sulphur baths, lotions of sulphuret of potass, nitro-muriatic baths, vapour baths, or by smearing the affected surface with equal parts of tar and sulphur ointment. In phagedena the patient ought to be, if possible, placed in an airy and healthful situation. In most cases free bloodletting may be necessary at the commencement, and will be advantageously followed by purgatives and antimonials. The patient ought to be strictly confined to his room, and ordered low diet with diluents. Afterwards, the internal use of nitric acid, the decoction of sarsaparilla, and an occasional dose of Dover’s powder at night, will be beneficial, particularly if sleep be disturbed with pain of the bones and joints. Mercury, even in small quantities, protracts the disease, and in large doses it hastens the ulceration and sloughing. When all febrile symptoms have subsided, when the ulcers are nearly healed, when no fresh pustules appear, and when desquamation is begun, alterative doses of mercury, as a blue pill or grey powder every second night, may sometimes be ventured upon, will tend to hasten the cure, and will not, possibly, be followed by any unpleasant symptoms. The safe course is to promote the secretions by some safe substitute—preparations of sarsaparilla, ipecacuan, taraxacum, &c. In fact, in all scaly eruptions, whether scaly from their commencement, or having become so in their latter stages and previously to their disappearance, mercury, prudently administered, will be useful by expediting the cure, and not injurious by deranging the system. The tar or citrine ointments may be applied to the eruptions and cutaneous ulcers. For the ulcers of the throat, unless in a sloughing state, the lunar stone appears to be almost a specific, removing the irritability of the sores, and protecting them from further irritation by coagulating the discharge, which then more effectually covers and protects them. The application requires to be repeated every second or third day, as, by the frequent and necessary motions of the parts, the crust loosens and separates, leaving the surface exposed and irritable. At the same time the sore will contract very considerably under each successive crust. The lunar stone may also be applied in solution; or a solution of the bichloride of mercury in spirits or laudanum may be used, in the proportion of from four to six grains to the ounce, or stronger. The solution of the nitrate of mercury is sometimes employed with advantage. Fumigation of the throat with the red sulphuret of mercury has been extolled as a powerful means of checking the alternating sloughing and ulceration which often accompany the ulcers of these parts, but the propriety of its employment is doubtful; the system is thereby rapidly put under the influence of the mineral, which, as already remarked, generally aggravates the violent disturbance under which the constitution labours. More permanent good may be expected from means taken to remedy the constitutional evils than from such violent remedies as are directed against the affected part, but which also produce a baneful effect on the system. In ulcers of the nostrils, with fetid discharge, snivelling, exfoliation of the inferior spongy bones, affections of the palate, &c., the nitrate of silver is also very efficacious; or the affected parts may be occasionally touched with a hair pencil, dipped in a liniment composed of lime-water, olive oil, and the golden ointment. They ought to be frequently washed with tepid water, and all sources of irritation must be removed. If the patient be in the habit of taking snuff, the practice must be abandoned, and the powder already impacted in the nostrils removed. If there be carious teeth or stumps in the upper jaw, the sores can scarcely be expected to heal till these be extracted, as constant irritation is kept up by them. When the affection proves obstinate, a recourse to mercury is recommended by some writers; but this will make bad worse. Sarsaparilla in these cases, with attention to diet and air, will always prove a better alterative than any form of mercury. It may be combined, according to circumstances, with the nitric or nitro-muriatic acids, or with the hydriodate of potass, in which many practical men have great faith. This medicine is employed in cachexia, following or not the use of mercury, and is directed against eruptions, sore throat, and pains in the limbs. The constitutional symptoms of the scaly disease, or true pox, when they occur, which is now but seldom, are decidedly benefited by a prudent employment of mercury. It may be administered externally or internally, though the latter method is the one generally Slight swellings and pains of the bones often yield to local abstraction of blood, friction, and the internal use of the compound decoction of sarsaparilla. Nodes, however, sometimes continue to enlarge, and occasion much pain, notwithstanding these means; and in such circumstances much relief will be afforded by a free incision over the affected part, from whatever cause the swelling may proceed. When the pain has subsided, and the swelling remains stationary, a decrease of it may be sometimes effected by a blister. Of the bad effects of mercury on the constitution much might be said. Treatises have been written on mercurial pox, a species reported to be much the most violent; and others have detailed an accumulation of evils, under the title of mercurial disease. There is no doubt that extensive, deep, and sloughy ulcers of the throat are produced by mercury; and of this I witnessed the following unexceptionable instance:—The fauces presented one extensive mass of ulceration, sloughing at its margins, and the uvula was almost detached. The patient was an old and emaciated woman, who neither Eczema Rubrum, a disease resulting from external causes, but which may also be produced by mercury, often arises from but a very small quantity of that medicine even applied externally. It most frequently affects the scrotum and upper and inner parts of the thighs. It is preceded by heat and itching in the part; a diffused redness appears, and the affected surface is rendered rough by the eruption of numerous minute vesicles. In a short time, these vesicles, if not ruptured, attain the size of a pin’s head, and the included serum becomes opaque and milky. The affection soon extends over the rest of the body in successive large patches, and is accompanied with considerable swelling of the integuments, tenderness of the skin, and itching. The vesicles burst, and discharge a thin acrid fluid, which renders the surrounding surface painful, inflamed, and excoriated. The discharge becomes thicker, adhesive, and fetid, and by its drying, partial yellowish incrustations are formed. The disease terminates in desquamation, and in some cases, the hair and nails are also lost. It is preceded and accompanied with smart fever, and general disorder of the system. Erethismus is another occasional consequence of mercury, characterised by remarkable depression of strength; small, quick, and often unequal pulse; anxiety, sighing, and trembling; a pale contracted countenance, and occasional vomiting. While in this state, sudden exertions are apt to prove fatal. OF SCALDS AND BURNS.Different degrees of injury are inflicted on the surface from the application of heated solids or fluids. The term scald is generally confined to the effects of heated fluids, whilst burn denotes the consequences of the application of a heated solid, or of ignited combustible matter; the latter class of accidents is, in general, the more serious, yet the former, though not injuring the skin deeply, gives rise to the most alarming symptoms when a large extent of surface is affected. A slight degree of heat is productive only of redness of the surface, with a sharp hot pain, and these symptoms may subside with or without vesication. However, effusion of serum under the cuticle often takes place almost immediately after the contact of the heated body—the cuticle may be destroyed by the intensity of the injury—or the true skin may die, either partially or throughout its whole thickness, and the subjacent parts be at the same time injured to a greater or less depth. But parts, not severely injured at first, may afterwards perish, violent inflammatory action being excited, which terminates in sloughing. The neighbouring parts have their vitality much diminished, by the direct influence of the injury; and hence, when these parts come to be the seat of increased action, In trifling burns cold applications are generally used—as immersing the part in cold or iced water. A great variety of remedies are employed, spiritous, watery, acid, alkaline, cold or hot; some apply a coat of cotton or flour, some of tar or pitch, and they state that when these artificial crusts separate, the skin is found healed beneath; in fact, every practitioner, and almost every individual, possesses a favourite application for this very common accident. Some have recommended holding the part to the fire, or plunging it into hot liquid; but this practice, and all similar, are too severe ever to become general, when milder means prove equally effectual. Perhaps the most common applications are, a mixture of lime-water and olive oil, or the ceratum acetatis plumbi. The vesicles, when left to themselves, burst, expose an irritable surface, and the acrid discharge from them excoriates the surrounding skin. Their contents ought to be evacuated by a small puncture, and the cuticle being left carefully undisturbed, a scab soon forms, by which the part is protected while healing. In extensive injuries of the skin, where the cuticle has been altogether destroyed, finely carded cotton is sometimes applied; it is of use in somewhat the same way as the cuticle in the former instance, and being a sort of cushion over the part, prevents it from being irritated by bed or body clothes, or by the patient’s resting on it. It soon becomes soaked with the discharge, and must either be frequently changed, or become a receptacle for pus to putrefy in, and maggots to breed; on account of these circumstances it is objectionable. Dusting the part with common flour, starch, or hair powder, is equally advantageous, and much more convenient; relief is afforded by its immediate application; the parts are cooled; the flour, absorbing the discharge, is soon formed into crusts, which In severe cases, there is first extreme depression of the powers of life, under which patients sometimes sink; but most frequently this state is obviated by the employment of cordials or stimulants. But these ought to be administered with caution, for reaction soon commences, and often increases to well-marked inflammation, requiring for counteraction low diet, and even bleeding. In such cases gentle laxatives are preferable to purgatives, as by the latter the patient is obliged to make frequent movements, and those are always painful. Stimulants have been strongly recommended, at first powerful, and afterwards gradually weaker, so as, it was said, to restore the balance between the affected parts and the system; and the latter is again to be excited, in order to meet the increased action which the parts assume. The practice is founded on fancy, and cannot become general, being in its first part cruel, and in its second absurd. Whilst debility exists, stimulate cautiously; when over-action ensues, adopt those measures which are best calculated to subdue excitement; this is common sense, and the common practice. During the process of healing, position of the parts ought to be carefully attended to; contraction of the cicatrices, and cohesion of opposed surfaces often causing unseemly deformities. Surfaces opposed to each other, and naturally separate, may be prevented from uniting by dressing interposed; and contraction of joints is to be guarded against by keeping the limb extended by splints and bandages. Where deformity has occurred, the hardened cicatrix which is in fault may be either divided or excised, and by paying attention to position in the after-treatment, the evil may be greatly lessened. In the case of contracted joints, it is not necessary to excise the whole or greater part of the callous web; simple division is sufficient, if carried deep enough, through the altered and condensed cutaneous tissue. A horrid case of deformity is sketched on the next page, and from a very horrid and atrocious scoundrel, the companion and assistant of Messrs. Burke, Hare, and Co., the Thugs of the Modern Illustration |