626

SURGERY.

viz. either to the ends of fuch bones as compofe the joints having run into one another, so as to become firmly conjoined in confequence of the furrounding cartilages being abraded; or to the infpiffation, as it is termed, of the fynovia of the joints, whereby their cavities are entirely filled up, and no fpace left for the future motion of the bones. Both these opinions, however, are in general very ill founded: as the ftiffnefs almoft always proceeds from a contraction of the muf. cles and tendons. It may often be cured by a long continued use of emollients.

156. The beft emollient that can be used is pure olive oil applied warm; as much of it as can be easily rubbed in by an hour's gentle friction fhould be regularly done at least three times aday; and inftead of confining the friction aitogether to the rigid tendons, it should be extended over the whole mufcles, even to the infertions of their other extremities; but more efpecially on their fleshy mufcuiar parts, where the principal caufe of the continuance of fuch complaints is probably feated.

157. The omentum of a new-killed fheep, or of any other animal, applied over all the difeafed parts directly on being cut out of the animal is fometimes attended with advantage. The application fhould be renewed as frequently as poffible, once a day at leaft, or oftener when it can be done; for on being more than 4 or 5 hours ap. plied it becomes difagreeable; and after that time, indeed, as it commonly turns ftiff, it cannot then be of much service.

158. The diforder has hitherto been fuppofed not to be fo far advanced as to have occafioned the formation of matter; for when come that length, no confiderable advantages can be expected from any of the remedies as yet recommended: but even in that state of the complaint, if the patient's health does not abfolutely require i, amputation of the member should not be immediately had recourfe to, for by opening the different abfceffes foon after their formation, the matter may be prevented from destroying the capfular ligaments of the joints, which, if once effected, would no doubt render that operation neceffary. Even in point of fuccefs from the operation, it ought never to be advised till the complaint is pretty far advanced. For in this diforder, efpecially, a greater proportion of patients have recovered after amputation, who have previously been confiderably reduced by diarrhœas and other weakening fymptoms, than of fuch as have still remained in a full plethoric habit of body.

159. All the different obfervations, hitherto made upon the treatment, relate particularly to the rheumatic fpecies of the diforder; and when had recourfe to in time, and duly perfifted in, they will frequently be found of service: but when the difeate is fo far advanced as to have deftroyed the capfular ligaments of the joint, and perhaps even the cartilages and bones themfelves, amputation of the member is then no doubt the only refource.

160. In the fcrophulous white fwellings, when the difeafed parts of the bone begin to caft off, a cure may in that way, by affifting the efforts of

CHAP. III.

nature, be fometimes obtained in the fmall joints; it is not probable thas any other resource than but in all the large joints, as the knee, ankle, &c amputation will ever afford much relief. And even the effects of that operation can feldom be depended on as lafting; for when the general fcrophulous taint ftill fubfifts in the constitution, the disorder will moft probably appear again in fome other part; which, however, in the advanced ftages of the difcafe it is fometimes neceflary to run the risk of, the pain being often fo tormenthazard than to bear it longer. When, however, for ing as to make it more eligible to fubmit to any fome reaton or other, amputation is determined againft, as there being almoft a certainty of the complaint foon returning, from the scrophulous difpofition appearing very strong in the system, it then becomes neceffary to have recourse to palliatives, fo as to render the complaint as tolerable dofes, by moderating the pain and procuring reft as poffible: and with this view, opiates in large to the patient, wil in general be found the princines and articles of regimen as are found benecipal remedy. In other refpe&ts, all fuch medificial in fcrophula, may be had recourse to.

SECT. III. Of CANCERS.

lar parts of the body, where they are caused by 161. CANCERS commonly arife in the glanduany bruise or contufion, sometimes a very flight one; and hence they are more common in the lips, and in the breafts of women, than in any odiftinguished into occult and open. The OCCULT ther parts of the body. Cancers are generally are fuch hard fcirrhous fwellings as are attended with frequent shooting pains, and which at laft generally terminate in the latter.

fore which commonly fucceeds to hard swellings 162. The OPEN cancerous ulcer is that (pecies of of the glands; although fometimes it occurs without any previous hardnefs. The edges of the ulcer are hard, ragged, and unequal, very painful, and reverse in different ways, being fometimes turned upwards and backwards, and on other occafions inwards. the fore is commonly very unequal, there being The whole furface of in fome parts confiderable rifings, and in others deep excavations. The discharge is generally a thin dark-coloured fetid ichor; often poff-ffed of fuch acrimony as to excoriate, and even destroy, the neighbouring parts. ftages of the disease, by the erosion of blood-vefIn the more advanced are fometimes aifo difcharged. feis which occurs, confiderable quantities of blood

affections, universally complain of a burning heat 163. Patients labouring under real cancerous over the whole ulcerated surface; which, in general, is the moft tormenting fymptom of the diforder; and thofe fhooting lancinating pains, which were troublesome in the occuit state of the complaint, become now a great deal more fo. appearances are fo various, that it is almoft imThese are the most frequent fymptoms, but the poffible in any defcription to comprehend every thofe enumerated, concur together in the fame When two, three, or more, however, of ing of the cancerous kind. ulcer, we may always be pretty certain of its be

one.

hemorrhagies now frequently enfue; the pain becomes ftill more excruciating; and, unless proper affiftance be given, the patient is generally cut off in not many months after the breaking out of the cancer.

167. In early stages, the disease in general may be confidered as entirely a local affection, and a radical cure may be of course expected; but in proportion as the skin fhall afterwards be found difeafed and adhering to the gland, and that to the pectoral muscle, and the lymphatic glands near the mamma and in the arm-pit fwelled, the chance of a cure becomes more doubtful, as the cancerous matter may have been abforbed, and part of it carried into the fyftem. The most unfavourable ftate for an operation is when there are ulcerations in the breaft, large, deep, and of long ftanding; and particularly if thefe are attended with great pain, when the arm of the affected fide has become cedematous, and the health of the patient is much impaired. In this laft ftate very little is to be expected from a furgical operation. But arfenic has been prescribed with fuccefs, for cancer. See ARSENIC, § 8-10.

164. As to the causes of cancers, there have been many conjectures, but without any folid foundation. It is of fome moment, however, to determine whether they arife from fome general disorder in the system, or are only local. Many eminent practitioners have been of opinion that they arife from a general diforder of the fyftem; and hence confider them as totally incurable even by extirpation, as the latent feeds of the difeafe, in their opinion, will not fail to bring on a return of it fomewhere or other. Of this opinion the late Dr MONRO appears to have been; and in a paper on this fubject in the Edinburgh Medical Effays, declares, that "of near 60 cancers which he had been prefent at the extirpation of, only four patients remained free of the difeafe at the end of two years." From this bad fuccefs, and the violent progrefs of the difeafe, he finally concludes against the extirpation of cancers, and, propoies only the palliative method of cure. But later practitioners have been a great deal more fuccefsful; and a late publication by Mr HILL, furgeon at Dumfries, has put the usefulness of ex tirpation beyond a doubt, when the operation is performed in time; though, after the disease has 168. In extirpating the mamma, which we fhail continued long, and the virus been absorbed, the firft fuppofe is to be done where the skin is found, whole fyftem acquires a cancerous difpofition, and where the tumor has no uncommon adhesion and the difeafe almoft certainly recurs in fome o- to the pectoral mufcle, the patient ought to be ther part. From internal medicines we can ex- placed horizontally in a bed, or upon a table copect little or nothing in the cure of cancers; and vered with a mattrefs, &c. The operator is to be external applications can do no more than palli-feated, and to have proper affiftants. A longituate. Great expectations were formed from the powder and extract of cicuta; but it has fo univerfally failed, that few put much confidence in it at prefent. However, it has fometimes been of fervice in cafes of a fimple indurated gland; and even where the disease has been farther advanced, it has produced a better discharge, and diminished the fetor of the fore; but as it cannot be depended upon for a radical cure, a delay of the operation is never to be recommended.

165. No part of the body is more fubject to cancer than the breasts of women. Cancer of the mamma may arife at any period of life, though it feldom appears till about the time the menies usually disappear. Tumors arifing in the breast previous to this period have been confidered by fome practitioners as being only of a fcrophulous nature; and it is probably owing to that circumftance that feveral cures have been of late years made on tumors of the breaft by mercurial frictions and other remedies.

166. SCIRRHUS and CANCER of the breafts are diftinguished by the following marks: When the tumor is firft obferved, it is commonly in form of a fmall hard knot in the glandular part of the mamma, while the skin at the fame time is free from inflammation. It frequently continues in this ftate for feveral months: by degrees, however, it increases confiderably in fize, and at last a fharp pain is felt fhooting towards the axilla. The lymphatic glands at the under edge of the pecto ral muscle and in the axilla are often enlarged, and an occult cancer is now formed. By degrees the integuments over this part of the tumor in the mamma become difcoloured, and at laft an ulceration or open cancer breaks out. Violent

dinal incifion is then to be made with a common fcalpel through the fkin and cellular fubftance along the whole extent of the tumor, and at a little diftance from the nipple, which is to be faved. When the longest diameter of the tumor is acrofs the body, inftead of a longitudinal incifion, a tranfverfe one is to be made. The integuments being diffected from the mamma on both fides of the incifion, the patient's arm is to be extended to fave the pectoral mufcle; and the whole glandular part is to be detached from the mufcle, though a small portion only fhould be diseased, beginning at the upper fide, and separating downwards. If there be any indurated glands, they are to be carefully removed. If the patient be faint, a glass of wine, or fome other cordial, is to be given. After the difeafed parts are removed, the wound is to be cleaned with a fponge wrung out of warm water, which will generally render the fmall bleeding veffels more confpicuous. The integuments are next to be closely applied to the parts underneath, and retained there by the twifted future, and likewife by a few adhesive ftraps. A large pledget of fimple ointment is now to be laid over the whole; and this is to be covered with a thick comprefs of lint, tow, or foft linen; and the dreffings to be kept in their place, and moderate preffure made by the napkin and feapulary bandage. By this method the integuments will generally foon adhere, and a cure will be performed by the firft intention. But it feldom happen that the operation is performed while this favourable mode of practising it will answer.

169. In general, before extirpation of a breaft is recommended by the furgeon, or submitted to by the patient, a confiderable portion of the exKkkk 2 ternal

ternal integumin care fo much citeaded as to ren- common blitter. In extenfive burns, where the der it neceifary to feparate them along with the irritation is great, along with external applicaglandular part of the mamma. Sometimes the tions, opium (hould be preferibed, in dofes adetumor adheres to the pectoral mufcie, and that quate to the degree of pain. Even that ftupor again to the ribs. In either of these cales it be- with which patients in this fituation are fome comes neceffary to remove all the difeafed parts. times attacked, is found to be more readily reFor this purpote, two incitions of an oval form, moved by opium than by any other remedy. with fharp extremities, of a fufficient fize to in- With refpect to the blifters which arife upon clude the whole of the affected parts, become ne- burns, it has been difputed whether they ought to ceflary. But if, belides the difcafe of the breaft, be opened, or allowed to remain tili they diy up the lymphatic glands near it are indurat. d, or o- of themieives. But, according to the opinions of therwife difeafed, the firft incifion ought to ex- the lateft authors, they ought to be opened as foon tend at once over thefe; and after the other parts as any confiderable quantity of fluid is found in have been removed, and the vessels secured, the them. After the serum is discharged, a thin liniwhole of the difeafed glands fhould be extirpat- ment of wax and oil, with a little faccharum saed; and in performing this part of the operation, turni, fhould be applied to the part. confiderable affiftance may be given by fupporting them with a book, or a ligature pafled thro' them, till they are entirely removed. When they lie deep in the axilla, the points of the fingers, or the end of the handle, will fometimes be fafer than the edge of the knife. After having remov. ed all the glands which are in the fmalleft degree affected, the cut edges of the skin are to be brought as near to each other as the nature of the cafe will allow, fo as to heal as much as poffible by the first intention. After the wound is nearly, or entirely healed, an affue, inferted into the arm of the oppofite fide, will be the beft means of preventing a relapfe,

SECT. IV. Of BURNS.

170. THE immediate confequence of burns is a greater or lefs degree of inflammation; and the danger attending fuch accidents is in proportion to the extent of the injury. Burns which irritate the fkin only, without defroying the cuticle, act nearly in the way of a common bliftering plafter. When the cuticle is deftroyed, no blifter takes place; a mortified flough is obferved; and when this feparates, an ulcer is left. Where the cuticle is not deftroyed, relief may be procured by holding the part affected a confiderable time in very cold water, or fometimes by piunging it into water a little below the boiling point; but the coid water is the fpeediest and beft remedy, and gives complete relief, if continued for a fufficient time, Solutions of faccharum faturni, or acetite of lead, or the common white ointment, and other preparations of lead, alfo give speedy relief. Vinegar is a very effectual application, whether the fkin be found or bliftered. The part may be entirely immerfed in it, or linen rags dipt in the vinegar may be applied, and the parts kept conftantly moift, till the pain be removed. The fame application is ufeful where the fkin is rubbed off, or otherwife defroyed. In this cafe, indeed, the vinegar is apt to give additional pain on its firft application; but this foon ceafes, and the part becomes much cooler and cafier. If the patient will not fuffer the vinegar to be applied immedi. ately to the furface of the fore, a linen rag foaked in olive-cil may be previously laid on the part, covering the whole with the cloths dipped in vinegar; and thefe applications are to be occafionally repeated til the pain and inflammation be entirely removed; after which the parts are to be drefled in the fame manner as in the cafe of a

171. In cafes of very fevere burns, where, notwithstanding the above treatment, there is danger of a violent inflammation being induced, bloodletting, cooling purgatives, and other remedies adapted to the peculiar fymptems, muft be used. When, again, burns are from the first attended with lo's of fubftance, as commonly happens af ter the application of hot metallic bodies, we ought to have recourfe to the vinegar, or to a b niment which is now in very common ufe for fuch purposes, male of equal parts of ant-feed oil and time-water, which, when thaken together, forms a thick white fubftance, which often gives fpcedy relief; and it may be readily applied by daubing the parts frequently over with a fott pencil well foaked in it. Though this has been confidered as one of the belt applications in burns, yet, in fome cafes, more immediate relief has been procured from the application of Gou lard's cerate, or the unguentum nutritum; and a weak folution of faccharum faturni has alto been of fervice.

172. When burns are occafioned by the explo fion of gun-powder, fome of the grains of the powder are apt to be forced into the skin. At firft they produce much irritation; and if they are not removed, they commonly leave marks which remain during life. They fhould, there fore, be picked out as foon as poffible after the accident; and to prevent inflammation, as well as to diffolve any power which may remain, the parts afflicted fhould be covered, for a day or two, with emollient poultices. In other refpects, injuries of this fort are to be treated like any other kind of burns.-When burnt parts are conti guous to each other, they are apt to adhere. To prevent this, pledgets covered with any proper dreiling ought to be inferted between them dur ing the courte of the cure. Uicers arifing from burns are apt to become foft and fungous, and to rife above their natural level. When this is ob ferved, the emollient ointments, which have been previously used, should be laid afide, and thofe of a

moderately afringent nature applied. Gentle compreflion with a roiler is alfo of particular fer vice. Advantage is kewife derived from faturnine washes, &c. One of the best ointments, in fuch cafes, is the common calamine cerate. Thefe will commonly antwer the purpofe; but when they prove infufficient, burnt alum, blue vitriol, or even lunar cauftic, may be neceflary.

CHAP.

purgatives, and other remedies useful in inflam- the finger affected by leeches, 6 at a time. 2. Apmations, to be neglected. plying faturnine cataplafms; particularly 1 oz. cerufa acetata, diffolved in half a pound of pure vinegar, and mixed with 5 ib. of spring water, applied with bread crumb, in soft linen. 3. In desperate cafes, when the bone becomes carious, there is no cure but amputation. But to give a proper view of the difeafe, Mr MARTIN fhould publish his Effay. The writer of this article will only add, that he has known a cafe of whitloe, of long continuance, and so severe, that the finger was condemned to be cut off, and the young woman was juft going to the furgeon for that purpose, when the writer, meeting her on the itair, advised her firft to try repeated bathing with a mixture of strong spirits and iaudanum. This fhe did, and in lefs than a fortnight her finger was as well as ever.

182. Authors have an idea that little advantage can be derived from laying open the abfcets, on account of the great danger which may enfue from the admission of air. Mr BENJAMIN BELL, however, is of an oppofite opinion, and has always given vent to matter here as elsewhere, and no bad confequences have been obferved. The matter, when long lodged, has been found to deftroy the foft parts and bones, and fometimes to make its way into the cavity of the abdomen; all of which might be prevented by an early evacuation. For this purpose a trocar fhould be used, which was tried by Mr Bell in one cafe with complete fuccefs.

183. Some other cafes are lately related by au. thors, where, by the introduction of a feton, and drawing off the matter by flow degrees, and then by ufing comprefs, and fometimes injections of gently irritating fluids, a cure has been performed in the course of a few months. If the cafe is doubtful, an opening fhould be made with the knife in the fame manner as in hernia. If the flow of matter continue confiderable for 2 or 3 weeks, injections of a weak folution of faccharum faturni, lime water, or other gentle aftringents, may be employed.

SECT. V. Of PARONYCHIA, or WHITLOE, and

CHILBLAINS.

184. WHITLOE is a painful and inflammatory fwelling at the extremities of the fingers under the nails, terminating in an effufion of clear ferum below the skin, which is fometimes fo acrid as to corrode the periosteum, and render the bones carious. At other times the inflammation runs fo high that the whole of the arm fwells, particularly the lymphatics, and sometimes even the glands in the axilla.

185. When this affection arifes from external violence, the remedies employed for inflammation, in generai, will be of service. When it arifes from unknown causes, ardent fpirits and aftringents have been found ufeful. When an effufion of a ferous matter takes place, it is immediately to be discharged, as it is almoft impoffible to convert it into proper pus. When this ferum has continued fo long as to render the bone carious, a removal of the whole bone, or of the carious por. tion, becomes neceffary, in order to effect a complete cure.

186. We have been favoured by Mr P. MARTIN, furgeon, Dunning, with a very full and accurate Effay on Paronychia; but which, is by far too long to admit of infertion. The most important particulars of it, however, are the following: He very judiciously diftinguishes 3 fpecies of Paronychia to which he gives the names of, 1. Dermal, chiefly affecting the skin, and terminating with an effufion of clear acrid ferum below it. 2. Periosteal, connected with the periosteum, and terminating with an effufion of acrid ferum, in contact with the furface of the periosteum. 3. Offal, connected with the bone, and terminating in an effusion of acrid ferum between the perioftoum and the bone. For all these species he prefcribes various methods of cure; as, 1. B.e.ding

187. CHILBLAINS are inflammatory fwellings, of a purple colour, chiefly affecting the heels, and fometimes alfo the fingers, toes, arms, hands, or feet, or even the tips of the nofe and ears, attended with a flinging pain, and a degree of itching. The fwelling fometimes cracks, and discharges an acrid ferum; fometimes a mortification takes place, and an ulcer follows very difficult to heal. This diforder is owing to the weaker action of the fmall vellels moft remote from the heart, occafioned by cold or dampnefs, and occurs mot frequently in people of a delicate conftitution.

188. When the patient has been for fome time exposed to the cold, and the parts are froft bitten, they ought to be plunged into the coldest water, and rubbed with falt; when they are only benumbed, rubbing them with camphorated ipi rit of wine will answer equally well: but when cracks take place, and an oozing of acrid matter enfues, poultices may be applied, but not long, as they are apt to give rife to fungous excrefcen

ces.

SECT. VI. Of CONTUSIONS and SPRAINS.

189. CONTUSIONS of the integuments and mufcies produce pain, fwelling, and inflammation, and thefe, in fome cafes, may extend to a confiderable degree; but in general they are lefs violent than what take place in cafes of fprains of ligaments or tendons; for in thefe there is frequently a total lofs of motion for many weeks, and fometimes for years, if proper attention be not paid. An effufion of fluids always fucceeds the injury, which feems to be, for the most part, of a serous nature, as the kin ufually retains its natural colour; fometimes the tumefied parts are of a deep red, or leaden colour, owing to a rupture of some velfels conveying red blood.

190. In the treatment of contufions and sprains, two circumftancés require attention. 1. To endeavour to prevent the fwelling as far as is practicable; 2. To employ those remedies afterwards which are known to be moft powerful in preventing or removing inflammation. In contufions of the cellular fubftance, and even of the muscles, the effufed fluids are commonly foon absorbed; but in fprains of the tendons or ligaments, a very troublesome, painful thickness of the injured parts is apt to continue for a great length of time, and in fome inftances even for life.

1