subsides. Cold washes, or poultices, to the part, as they seem to agree: the former are preferable, on the principle of checking the inflammation.

Carbuncle is a very violent unhealthy kind of inflammation, attended with a painful deep discoloration of the skin, a very remarkable thickening and induration of that part, and gangrenous suppu. ration under it, occurring usually at the back part of the trunk, and often constituting a symptom of the plague and other malignant fevers. Its size varies considerably. Openings form in the swelling, and give issue to a very offensive discharge; and in the end extensive mortification ensues. The fever, which is at first inflammatory, soon becomes typhoid; and strong marks of chylopoietic derangement are generally attendant.

The swelling must be completely laid open by a free incision through the brawny skin, so as to discharge all the matter and sloughs. Purgatives and emetics are proper for the disturbed digestive organs; and the debility which remains after the disorder has subsided demands strengthening medicines and food. Opium, when the pain is excessive.

Boils are similar to carbuncles, except that they are smaller, and require the same treatment; the state of the chylopoietic organs must be particularly regarded.

Edema is an unusual accumulation of water in the cellular substance, occasioning a general swelling of the part, without discoloration, that pits on pressure, is uneasy rather than painful, and increases in a depending position. It arises from constitutional or local weakness. In the latter case, which alone belongs to surgery, let the cause be removed; put the limb in a horizontal posture; employ frictions with flannel, and camphorated, or other slightly stimulating applications, and then apply a moderately tight roller.

Burns are attended with violent inflammation of the part, severe pain, and fever. The cuticle is raised into clear yellow blisters. The part may be destroyed at once, and converted into a dead black substance, or it may slough from the subsequent inflammation. vesications do not form, suppuration will probably not take place. Where the injury is very extensive, the breathing is much affected.

If

As burns are violent local inflammations, the antiphlogistic treatment, both locally and generally, was the usual surVOL. XI.

gcal practice, until Dr. Kentish, who then practised surgery at Newcastle, introduced the opposite, but, as subsequent experience has proved, much more successful plan of applying hot oil of turpentine, or alcohol, and then covering the part with a liniment composed of ung. resin. flav. and ol. tereb. on the principle of maintaining the action of the part by an adequate stimulus, which is to be gradually diminished. The first dressing remains for twenty-four hours; and in the second, warm proof-spirit, or laudanum, may be used before the plaster is applied; which alone suffices for the third. When suppuration commences, powdered chalk, and a plaster of cerat. lap. calam. Opium and good diet are to be allowed at the commencement of the treatment, with the topical stimulus.

Effects of cold. When a limb has been frozen, heat must be communicated to it very gradually. The sudden application of considerable warmth will inevitably cause mortification. Rub the part with snow, as persons in northern countries do their ears or noses when thus affected, or with cold water, until motion and sensibility return. Then camphorated spirit of wine may be used, and, ultimately, a moderate approach to the fire may be allowed; or else the patient may be put in a warm bed, and warm flannels may be applied locally; general perspiration being at the same time promoted. The same principles must be kept in view when the whole body is affected. Volatiles and sternutatories may be used when animation has returned; and warm wine or spirits should be introduced into the stomach as speedily as possible.

Chilblains are caused by exposure of parts to the vicissitudes of heat and cold, particularly in young persons, females, and such as are brought up tenderly. Before they are ulcerated, ice, cold water or snow may be applied two or three times a day; and the parts should be kept dry, and in an uniform temperature. In some cases, topical stimulants seem more beneficial, as spir. vin. camph. or tinct. myrrhæ rubbed in; also vinegar and alum lotion. Sp. vin. camph. and tinct. cantharid. in equal parts, have been very useful.

WOUNDS.

These vary so much, according to their extent, the degree of violence employed, the powers of the part, its importance to FP

life, complication with bleeding, fracture of bones, &c. that they must be consider. ed under various heads.

The size of the wound is a matter of consequence, as a very large cut may produce serious consequences, although no important parts are injured. The degree of violence done to the fibres is another material consideration: a wound, in which the parts have been bruised, stretched and lacerated, as well as divided, will often mortify from that cause only; hence contused and gun-shot wounds are particularly dangerous. Such injuries too as expose circumscribed cavities are alarming, on account of the inflammation which generally follows such exposure; hence the danger of even a slight wound in the belly, chest, or large joints. A slight wound of a part, whose functions are intimately connected with life, is often fatal.

Simple incised wounds require only that the sides should be brought into a state of apposition, and maintained in than condition, by means of adhesive plaster, as sisted perhaps by bandage.

Hemorrhage, which frequently attends these injuries, demands particular care, as it must be stopped before any thing else is done. If the blood flow from an artery, it is a florid red, and comes out in jets; if from a vein, the stream is uniform, and the colour dark purple. If the vessel be not large, the bleeding often stops of itself. The divided artery retracts; the surrounding cellular substance, becoming injected with blood, presses on its mouth; and, finally, the blood coagulates in the orifice. Thus the sides of the vessel grow together. But death would often take place before the bleeding stopped in this way, particu. Jarly if the vessel were large; or, at all events, great danger would arise from the bleeding. Hence it is always desirable to tie the mouth of the bleeding vessel, which secures us at once from all alarm on the subject of hemorrhage. A ligature, when properly applied, is found to cut through the two internal coats of an artery; the inflammation thus excited in the vessels of the part is attended with an effusion of coagulating lymph, which, together with the coagulation of the blood, effectually closes the tube, before the separation of the thread, which is seldom delayed beyond a fortnight. The ligature should include the artery only; or, when it is small, as little surrounding matter as possible; when the vessel is large, it may be drawn out with the for

ceps: in the latter case a tenaculum must be used. As much force may be employed in drawing the knot, as can conveniently be exerted by the hands.

The use of the ligature in hemorrhage is preferable to every other means: the tourniquet may be placed on the limb, until the vessel is found and secured.When the main arterial trunk of a part is compressed by the pad of this instrument, there is no immediate danger of bleeding.

The tourniquet in common use, for which we are indebted to a French surgeon, Petit, consists of a band and buckle, a pad, and a sort of brass bridge, capable of being elevated and depressed by means of a screw. The band is first buckled round the limb in such a manner that the pad, which is attached to the band, is placed exactly over the artery. The bridge, over which the band proceeds, is to be then raised, by turning the screw, and thus a due degree of pressure is produced. It affords, however, only a temporary security. When a tourniquet cannot be procured, pressure may be made by any simple ligature round the limb, twisted to the requisite tightness by means of a stick.

pressure;

Compresses and bandages will some. times stop bleedings by their mechanical If the bleeding vessel cannot be found, if but are inferior to the ligature. there be rather a general oozing than an sel, or if the artery lie against a bone, as hemorrhage from any considerable vesthose of the scalp, this method may be employed.

When a large artery has received a small wound, as the brachial in bleeding, the following plan may be tried. Apply a tourniquet so as to command the flow of blood into the vessel, bring the edges of the external wound into contact. Bind on firmly with a roller a graduated compress, with the apex placed exactly in the situation of the wound of the artery. A longitudinal compress has sometimes been added in the course of the vessel, above the wound; but it would probably impede the circulation too much. Then let the limb be kept perfectly quiet.

The use of agaric, of the actual and potential cautery, and of styptics, as means of arresting hemorrhage, are ba. nished from modern surgery.

When bleeding is stopped, and all foreign bodies, or coagula of blood, have been removed, the sides of the wound should be approximated by means

of sticking-plaster, assisted, if necessary, by the position of the part, by bandage, &c. In forty-eight hours the sides of a wound, healed in this way, will be agglu. tinated, and the process by which they are united is named "union by the first intention." Sutures were formerly employed in the treatment of such wounds, but their use is restricted now to the very few cases where the sticking plaster cannot be conveniently applied, as the hare lip, &c. They have fallen into disrepute as a general mode of treating wounds, principally because they tend to increase inflammation. The new wounds which they make, their irritation as extraneous bodies, the forcible manner in which they drag the living parts together, and their incapacity, in general, to accomplish any useful purpose, which position adhesive plaster and bandages cannot effect, are strong motives for reprobating their general employment. They often bring on such irritation as to render their removal necessary.

The sides of a wound, treated in the way now described, throw out coagulating lymph, which joins them together. This forms an uniting medium, through which new vessels shoot from the opposed surfaces. We cannot help admiring the celerity with which this uniting process is completed. The wound produced in amputating a thigh is often securely united in seventy-two hours; and the principles now detailed apply to the manage ment of all wounds made by surgical ope

ration.

Punctured wounds are often attended with more pain, inflammation, &c. than others. Enlarging their orifice is an unnecessary practice, unless abscesses, or extracting foreign bodies, should demand it. A soothing plan by means of emollient poultices, &c. is preferable.

Lacerated and contused wounds, on account of the violence attending their infliction, do not unite like simple cuts by the first intention. Yet they should be brought together, and inflammation obviated by the appropriate treatment.

If a wound does not unite by the first intention, it must granulate and cicatrize. Pus is secreted from its surface, which becomes red and uneven, rising into little protuberances, called granulations. These fill up the cavity of the wound to a level with the skin, which then grows over and covers them by a newly formed smooth pellicle, termed a cicatrix. When this process is completed, the newly formed part is absorbed to a great de

gree, and hence the surrounding healthy skin is drawn from all sides over the situ ation of the wound, presenting a puckered appearance.

Gunshot wounds are attended with great laceration and violence, insomuch that the parts in their track are killed, and must be thrown off in the form of sloughs. They are very often complicated with fractures, wounds of arteries, viscera, and with the introduction of foreign bodies, as balls, portions of clothing, &c.

Immediate amputation is often necessary in gunshot wounds of the limbs; and often there is much doubt whether this means should be adopted or no. It may be done immediately after the accident, before suppuration, fever, &c. have supervened; or when the violent inflammation, swelling, &c. have abated. By deferring it to the latter period, the surgeon has often a chance of saving the limb; and if he does not succeed, he operates under more favourable circumstances, as a patient habituated to disease bears an operation much better than a person in good health. Yet this is not meant as an argument against immediate amputation in any case; for by that practice a simple incised wound is substituted for a complicated lacerated, one; and the constitution escapes that hazard which repeated suppurations, painful incisions, &c. are inevitably attended with. Besides, after the constitution is nearly ruined by the processes of recovery, from a dreadful injury, the limb is often no better than a wooden one.

Incisions at the entrance and exit of the ball are not necessary, unless there is an object to be accomplished. Foreign bodies should be extracted, if it can be done easily; but tedious examinations and incisions are improper, particularly when the belly or chest is wounded. The mildest dressing and treatments should be employed. Fomentations and poultices, and dressings of white cerate, answer every end.

Poisoned wounds. The stings of bees, &c. the bites of gnats, and other insects, are treated by cold applications, and attention to the constitution, if the general irritation be great. In the bite of the viper, alarming symptoms usually arise, viz. swelling, heat, and pain of the limb; small and weak pulse; head-ach and vomiting, &c. Perhaps excision might be proper at the very first; or, at all events, the wound should be carefully cleansed. Emetics, and volatile alkali, have been commended as constitutional means.

The

Hydrophobia arises from the bite of a mad-dog, or other rabid animal. wound heals, but in about three weeks a dull pain is again felt in it. Dejection of spirits appears at the same time, followed soon by the dread of water, and intolera ble sense of suffocation and convulsions at any attempt to swallow fluids. Horror of the countenance, redness of the eyes, convulsive and violent movements, &c. continue to the time of death. Excision of the bitten part is the only preventive: it should be employed at any time previous to the accession of symptoms; the use of caustic, &c. is very uncertain. No remedy is of the least use when the symptoms have appeared.

Contusions, when slight, may be treated by cold applications, and quietude of the injured part. In other cases, topical bleeding, followed by discutient lotions, as sal ammoniac in vinegar and water, or fomentations of hot vinegar, and afterwards camphorated liniment, are required. Purging and venesection are sometimes necessary.

Polupi are fleshy excrescences, growing from a thin pedicle, and occurring most commonly in the nose and uterus.

Those of the nose are divided into the

fleshy, or benign, which are white, soft, and unattended with pain; and the malignant, which are hard and painful, and, according to some, of a carcinomatous nature. They grow most frequently from the spongy bones; occasion at first an obstruction of the nose, and gradually fill up the whole cavity; extend backwards to the throat; expand the nostril by ele. vating the os nasi; destroy the other bones; and produce, successively, fistula lachrymalis, inflammation and ulceration of the schneiderian membrane, caries of the bones, &c.: some often bleed. They must be extracted by means of forceps; by which the tumour is seized, and torn away from its root. This process must be repeated until the nostril is cleared. If any present in the throat, they may be removed in the same way from that part. If troublesome bleeding should follow, and not yield to a probe armed with lint, moistened in a strong solution of white vitriol, and applied to the part, a piece of lint may be drawn into the posterior opening of the nose, by means of a ligature introduced through the nostril, and drawn out at the mouth; the front aperture being also stopped.

Polypi of the uterus occasion at first an enlargement of that organ, and various other symptoms, as pain, hemorrhages,

&c. The tumour escapes from the uterus, and by its presence in the vagina irritates the rectum and bladder; causing still worse uterine affections, as bleedings, discharges of other kinds, &c. At last it descends through the external parts, with an aggravation of all the distressing symptoms. Now it must be carefully distinguished from the prolapsus, or inversic uteri. It should be removed by means of a ligature conveyed to its root in the uterus, by instruments designed for that purpose, as the double canula of Levret, or the improved instrument of Richter, represented in Cooper's "First Lines."

have not united by the first intention: or Ulcers are consequences of wounds that of a diseased process, named ulceration, in which a breach is made in the substance of the body by the absorbents A healthy ulcer has small florid and pointed granu. lations, which secrete a thick white pus. Here any simple dressing, confined by means of a roller, is sufficient.

But the ulcer may be irritable, i. e. attended with pain, a thin and discoloured secretion from its surface, ragged edge, no distinct granulations, &c. Here decoction of poppy-heads, used as a fomenta. tion,emollient poultices, solution of opium, (3iss. to lbj. of water) are proper; or it may be indolent, i. e. not painful, having thick edges, flabby colour, and imperfect granulations. Irritable ulcers are brought into this state by too long poulticing. Stimulating applications to the sore are proper here; as red precipitate, solution of lunar caustic, &c. combined with a roller, applied uniformly and firmly over the whole limb. But the most successful treatment is that proposed by Mr. Baynton, of Bristol, of surrounding the limb, for a considerable extent, with straps of adhesive plaster, applying a roller, and keeping wet cloths on the part, if there be pain. This practice indeed often succeeds, where the ulcer is of the irritable cast; the pressure of the roller is useful, and the cold water relieves the pain. It is most particularly beneficial in ulcers of the legs, attended with varicous veins : and, in short, is a very great improvement in the surgical treatment of ulcerated legs, as it does not require the patient to be confined.

There are various ulcers, not included under this arrangement, having peculiari ties in their appearance, discharges, &c. They are often connected with disordered chylopoietic organs.

Encysted tumours consist of a cyst of various thickness, containing a matter of very different consistence and appear. ances; according to which the tumour is called meliceris, the contents resembling honey; atheroma, when of a pappy nature; or steatoma, when of a fatty kind. They must be extirpated, care being ta ken to remove the whole cyst in an entire

state.

Sarcomatous tumours are fleshy masses organized throughout, produced by chronic inflammation, sometimes being newly formed; at others merely enlargements of originally existing parts, possessing a more or less defined cyst or capsule, which is formed by a condensation of the surrounding cellular substance. Their structure is very various, sometimes consisting entirely of fat, at others of a fleshy vascular mass, in which there may be cysts, or division into something like lobes, &c. In the rapidity of their growth, pain, &c. they differ very much; some also affect the lymphatics, which others do not. As they are produced by chronic inflammation, local bleeding and cold washes will generally arrest their growth, and often reduce their size. Topical stimuli may also be employed with the view of discussing them; but extirpation is the only plan to be relied on. The mode of operating will be explained in speaking of the amputation of the breast.

Carcinoma commences with a hard pain ful tumour, termed a scirrhus, which, ulcerating, forms cancer. As several other swellings are both hard and painful, discrimination becomes particularly necessary. Scirrhus has an uneven feel, is attend. ed with occasional darting pains, affects all the surrounding parts, so that the tumour becomes fixed to the muscles and skin, which latter has a dull leaden colour. When cut into, it exhibits a hard gristly appearance, with white ligamentous bands, extending into the surrounding fat. When it becomes a cancer, a large chasm is formed by ulceration and sloughing: the sore is unequal, with thick indurated edges, and copious discharge of fetid sanies, combined frequently with bleeding. A fungus often arises. Previously to this period the absorbent glands are generally swelled, and they afterwards take on the same disease. Extirpation in the earliest state is the only safe treatment: it may be performed after the glands are affected; but then those also should be removed. Here, however, as well as when ulceration has occured, the disease often recurs. Cicuta, belladonna, digita

lis, mercury, arsenic, &c. have been tried internally without success. Opium is necessary as a palliative. Caustics compos. ed of arsenics have often been used, in order to destroy the tumour by sloughing, probably never with success in a true scirrhus.

Ganglions are small hard tumours, not painful, containing in a cyst a fluid like white of egg, connected with a tendon, and occurring most frequently on the hands. Pressure, stimulating applications by means of friction, or extirpation by the knife, may be employed.

Aneurisms are swellings formed by the dilatation or rupture of arteries; the former being named true, and the latter spurious; but this distinction is of little use in practice. The tumour pulsates, except when the artery above is compressed; it is not painful; it may be made to disappear by means of pressure in an early stage. When it has grown to a great size, the pulsation is often diminished, for at first the blood does not coagulate in the bag, which is the case afterwards to a great extent. The size of the tumour becomes very inconvenient, its pressure causing adema, caries, &c." The skin at last grows thin and bursts, when the patient dies of bleeding. Aneurisms of this kind generally occur spontaneously, from a diseased state of the arterial coats; but sometimes a strain or blow gives rise to them.

When an artery is wounded, and the blood escapes into the cellular substance, a false aneurism is formed. This happens at the bend of the arm from bleeding. The swelling is irregular, the skin livid, and pulsation may or may not be present.

The varicous aneurism is where the artery has been wounded in phlebotomy, and the blood escapes from it into the vein, causing a varicous enlargement of that vessel, with pulsation, and a peculiar hissing noise. This is not dangerous, and requires no treatment.

The treatment of aneurism consists in preventing the flow of blood into the tumour, which then gradually diminishes. Hence it is obvious that those of the aorta can admit of no remedy. In the limbs, however, they may be cured by the operation of exposing the artery at a considerable distance from the tumour, nearer to the heart, passing a double ligature under it, tying these at the parts where the vessel is surrounded by its natural connections, and dividing it between them. A single ligature will be sufficient, but it is not so safe. In this way any artery may