191. It is neceffary, therefore, to obviate the fe fymptoms as foon as poffible; and for this purpofe, cold aftringent applications, as water, vinegar, &c. are moft commonly ufed. Others again, with a view to relax the parts fully, make ufe of water as hot as the patient can bear it. By immerfing the injured part in these immediately after the injury is received, the effufion will at least be fomewhat obviated. When the pain is exceffive, opiates become neceffary. After blood has been freely difcharged, a repetition of the remedies already mentioned will give great relief; care fhould be taken, at the fame time, that the injured parts be kept in a relaxed and easy pof

ture.

X CHAP. V. OF INDOLENT TUMORS. 192. THESE are fuch as are flow in their progrefs, and may continue for a long time without being attended with either pain or inflammation; though occafionally almost all of them may be inflamed, and fome of them, in that state, attended with confiderable pain. They are of different kinds according to the nature of their contents, and appear in various parts of the body. They are feated in the adipofe and cellular membrane; whence it often happens that they take place in the vifcera themselves, where they are frequently mortal. Sometimes they are filled with a fubftance of the confiftence of honey, and are thence called meliceratous tumors; fometimes they are filled with an harder fubftance, and are then calied atheromatous tumors; at other times they are filled with a substance of the confiftence of fat, and are then cailed STEATOMATOus. Sometimes, however, they are found to be replenished with a fluid lymph coagulable by heat, and are then called hydatids. One fet are filled with matter like the fynovia of the joints, and get the name of

GANGLIONS.

193. Tumors of this kind are eafily diftinguish. ed from all others, as having neither heat, pain, nor pulfation, as is to be obferved in those which incline to fuppurate; and they are diftinguished from each other, before they are laid open, by fluctuation being readily perceived in the meliceris: the atheroma is foft and compreffible, but has no fluctuation; while the fleatoma is commonly firm, and rolls under the skin. But thefe rules are liable to confiderable exceptions. The meliceris and atheroma are moft commonly found upon the head, and the steatoma upon the other parts of the body; while ganglions are fituated over the tendons of the mufcles. Thefe tumors must be either extirpated entirely, or laid open fo as to difpofe the cyft to flough off or granulate. If the matter be fluid, we may evacuate it by an opening made with a lancet, or by means of a feton; but as the matter is apt to collect again, it is better to remove the fac entirely. If large veffels or nerves prevent this from being done, then it is to be laid freely open and exposed to the air, fo that the bag may granulate, or be thrown off. When the tumor is to be extirpated, a longitudinal incifion is to be made through the integuments; after which the tumor may be frequently removed by the point of the finger, or by the end of a spatula, replacing the integuments with a

view to heal by the firft intention. In every pendulous tumor of this kind, with a narrow neck, we ought to divide the teguments near the bottom of the tumor, in an oval form, fo that the wound may be afterwards properly covered with the remaining integuments. After the tumor is removed, the fkin is to be replaced over the wound, and fixed with adhesive straps, covering it with a pledget of cerate, a small comprefs of linen, with a bandage above ali, to make a gentle preffure on the parts.

SECT. I. Of STEATOMATOUS and SARCOMATOUS

TUMORS.

194. STEATOMATOUS tumors have been rank ed by authors among those of the encyfted kinu, but they have no other cyft containing them than the common cellular fubftance, fomewhat condenfed; and the particles of fat compofing them are found of the fame fize with thofe in a found part of the body.

195. Authors formerly advised the difcuffion of fteatoma, or the prevention of their growth, by the application of preffure; but by fuch means the growth is rather promoted than retarded, nor have internal remedies been of any advantage. They can be removed therefore by an operation which is the fame with that for the extirpation of encysted tumors.

196. Sarcomatous tumors have nearly the fame external appearance with thofe of the steatomatous kind. The term has been applied, in a general way, to fcirrhi of the glands; but farcomatous tumors are likewife found in various other parts of the body, and are distinguished from fteatoma by being firmer to the touch; internally they are of a redder colour, approaching to that of mufcles, in confequence of the greater number of veffels entering into their fubftance. fhould be treated in the fame manner as fteatoms; but the operation ought to be performed early, as they are more apt to degenerate into

cancer.

Thefe

197. GANGLIONS of the tendons are alfo encyfted tumors, feated in the burfæ mucoiæ, or fheaths of the tendons which belong to the extremities. They are ofteneft met with over the tendons upon the back of the wrift, and about those of the ankle and other parts of the extremities. When preffed, they are found to poffets a confiderable degree of elafticity, from which, and from their fituation, they may generally be diftinguithed from other ercyfted tumors. They feldom arrive at any great bulk, are not often attended with pain, and commonly the fkin retains its natural appearance. On being laid open, they are found to contain a tough, vifcid, tranfparent fluid, refembling the white of an egg.

198. They are generally produced by sprains, or contufions of the joints, or by rheumatism. In many inftances, they go of infenfibly, without afliftance from art; but as this is often not the cafe, means ought to be used for removing them. Moderate friction often repeated, or gentle compreffien by thin plates of lead, &c. fometimes

ren.ove

remove them. They have also been removed by busters: but the moft certain method is, to make a fmali puncture into the fac, and to draw a cord through it; or, after the pun&ure is made, to prefs out the contents, and then inject fome gent. jy ftimulating Ruid, as port wine and water heated blood-warm. Sometimes, in tumors of this kind, bodies of a cartilaginous nature, and of different fhapes and sizes, are found; f m; quite fmouth, others with peduncles; whence they are fuppofed by Dr MONRO, in his work upon the burle mucofe, to have been attached to the burfe As these cannot be removed by any remedy yet known, it is proper to difcharge them. But as the parts fometimes fuffer from inflammation when the tumor is laid fu ly open, it may be punctured at each end; and, after preffing out the contents, a fmail cord may be introduced; after which gentle preffure may be applied with a comprefs and bandage over the courte of the tumor. The cord however thould not be continued so long as to induce any great degree of inflammation, for a flight degree of this fufficientby aufwers the purpose.

SECT. III. Of COLLECTIONS within the CAPSULAR LIGAMENTS of JOINTS, and of CARTILA GINOUS BODIES contained there.

199. COLLECTIONS in these parts may confist of ferum, blood, or pus and synovia combined. They are oftenet met with in the joints of the knee, and may be produced either by internal or external caufes. These collections may in gene. ral be distinguished from each other.

200. Watery effufions, or dropfical fwellings of the joints, arife chiefly from fevere rheumatic complaints; and when the tumor is not very large, the fluctuation of the fluid may be feit by pref fure. When a large effusion appears immediately after a violent bruife, it probably confifts chiefly of blood: but when it fucceeds a violent prain, attended with great pain, inflammation, and fwelling, terminating in an effufion, there is every reafon to think that the contained fluid confifts of pus mixed with fynovia.

201. Swellings of the joints are apt to be confounded with collections in the buriæ mucosæ, or with matter effufed in the adjacent cellular fubftance. From the first they are diftinguished by the contained fluid paffing readily from one fide of the joint to the other, and from its being diffafed over the whole of it; whereas, when it is contained in the burfæ, the tumor is confined to a particulr part, and is feldom attended with much pain.

202. When fuch collections can safely be allow. ed to remain, the capfular ligament ought never to be opened, as they can often be removed by Mifcutients. Even confiderable collections arifing from rheumatism may be difcuffed by friction, fomenting the parts with warm vapour, keeping them conitantly moift with faturnine folutions, overing them properly with flannel, and appiy12 blitters. When thefe fail, fupporting the part with a laced ftocking, or with a roller is often of fervice. But whether a rheumatic tumor can be discuffed or not, it ought not to be opened; for the inconvenience attending it is more intolerable

than the pain and inflammation which may enfue. But when matter would do mifchief by lodging, it thould be difcharged. Effused blood and matter which fucceed high degrees of inflammation are of this kind. Blood is often extravasated among foft parts with little detriment; but when in contact with cartilage or bone, it foon hurts them materialy. The matter ought to be difcharged so as most effectuaily to prevent the admiffion of air into the cavity of the joint. For this purpose the opening fhould be made with a trocar; and the skin, previously drawn tight to the upper part of the tumor, thould be pu led down immediately on with drawing the canuia. A piece of aehelive plafter fhould be directly laid over the open. ing, and the whole joint should be firmly supported by a flannel roller. If the patient be plethorc, he fhould be blooded to fuch an extent as his ftrength will bear; he should be put upon a ftrict antiphlogutic regimen, and in every respeż fhould be managed with caution; to prevent in flammation which is very apt to enfue.

203. Joints are fometimes rendered painful and ftiff by the formation of fubftances within the capfular ligaments. Thefe are fometimes loose, and membranous nature, fimilar to thofe of fwellings of as firm as cartilage; and fometimes of a fort the burfæ mucolæ. In fome cafes thefe fubitan ces, especially the last species, retain nearly the fame fituation, without being much affected either by preflure or by the motion of the joint: n that cafe the pain is conftant, but seldom severe. The firft fpecies, however, is commonly very moveable; and on being touched, they flip with fuch facility that it is difficult to fix them even with the fingers. Thefe are only painful in particular fituations.

204. Where these concretions appear, upon examination, to be perfectly loose and detached, if the pain which they excite is very fevere, we thould in a cautious manner take them out, by making an incifion into the joint. But if there is reaion to fufpect that they are connected with any part of the joint, the patient ought to be advif. to fubmit to the pain they induce, which in general will be rendered moderate by shunning ex:7cife; but if, notwithstanding this, it becomes infupportable, amputation is the only refource.

205. The limb being firmly secured by affiftants, in that pofture which admits of the body to be taken out being felt most diftin&tly, the furgeon fhould endeavour to fix it with his fingers towards the upper part of the joint, after an afliftant has drawn the skin as much as poffible upwards from the part where the incifion is to be made. The operator with a fcalpel is now to make an incifion through the teguments and capfular ligament, directly upon the fubftance itself, of such a fize as will admit of its being eafily taken out; which may be done either with the finger or with the end of a blunt probe. If it is found to be conner. ted by any fmail filaments either to the captur ligament or to the cartilages of the joint, they fhould be cautiously divided, either with a probepointed biftoury, or probe-pointed fciffars, att? drawing the fubftance itself as far out as it can be got. When more concretions than one are found. they fhould all be taken out at the fame opening.

when this can be done; but when it cannot it will be better to allow the firtt incifion to hear before attempting the fecond, fo as to avoid the exciting of inflammation.

206. After the concretion is removed, the fkin fhoud be immediately drawn over the wound in the capfular ligament; and the lips of the opening in the skin being laid together, they fhould be fecured in this fituation by pieces of adhetive plafter to prevent the air from finding accefs to the cavity of the joint. Till the wound be complete. by healed, the patient fhould not only be confined to bed, but the limb fhould be kept as much as poffible in one pofture, and a strict antiphlogiftic regimen fhould be observed.

SECT. IV. Of SPINA BIFIDA.

207. SPINA BIFIDA is a tumor which sometimes appears upon the lower part of the fpine in new. born children. A fluctuation is diftinctly perceived in it, and the fluid it contains can in fome meature be prefled in at an opening between the vertebræ. In fome cafes this opening is owing to a natural deficiency of bone; in others, to the feparation of the spinous proceffes of the vertebræ.

208. The difeafe proceeds from ferum collected within the coverings of the spinal marrow. It is always fatal. Children labouring under it bave been known to live for two or three years; but, in general, they linger and die in a few weeks. All that art has been able to do is to fupport the tumor by gentle preffure with a proper bandage. When a tumor of this kind is laid open or burits, the child dies in a few hours. A tumor nearly of the fame nature with this is fometimes met with upon duferent parts of the head in new-born children: it is formed by a fluid lodged beneath the membranes of the brain, which have been forced out at fome unoffified part of the fkull. The above obfervations are equally applicable to this.

SECT. V. Of SCROPHULOUS TUMORS. 209. HAVING treated of SCROPHULA in general under the article MEDICINE, we thali here only defcribe the treatment of Scrophalous tumours. Some practitioners have recommended poultices, &c. to bring fcrophulous tumors to fuppuration; but the best practitioners have laid them aside, because they increase the fift and fpongy ftate of the parts, by which they are kept from healing.

210. As external applications are ineffectual, it is better to allow fcrophulous tumors to be as much expofed as poible, as this frequently renders tin fubfequent uicer more eatily cured. The other methods recommended for difcuffing thefe tumors are, the internal ufe of cicuta, burat fponge, muriated barytes, a long continued ufe of the cold bath, paracularly of fea-bathing, and drinking mineral or fea water. Thefe, to produce any effect, should be begun early, while tumors are fmali, and long perifted in. When the tumors come to a state of fuppuration, if they are feated upon the thorax or abdomen, or any of the large joints, free vent ought always to be given to the matter to prevent its bunting into thefe cavities; and when the abicefs is large, this ibould be done with a trocar, or by patting a VOL. XXI. PART H.

cord thro' it to exclude the external air. When the tumors are not fituated upon great cavities, it is better to allow them to break of themfeives, as the fores commonly heal more readily, and the fear is pretty fimilar in both. The most proper applications to fcrophulous fores feem to be thofe of the faturine kind, as they diminifh inflammation, and in fome measure prevent the fore from fpreading. When the bones become carious, they are to be treated like carious bones from of ther caufes; but amputation cannot here be attended with advantage, as the difeafe proceeds from a fault in the conftitution. After the fores are healed up, the introduction of an iffue may atlift in preventing their return.

211. Mr P. MARTIN, furgeon at Dunning has discovered, that DIGITALIS, or Fox-glove, has a very powerful effect in refolving fcrophulous tumours when given in fmail dofes: either, 1. in the form of tincture; viz. one part of faturated tincture of digitalis to 2 of Spirit. Etheris Nitrofi; in dofes of 25 or 30 drops at first, and gradually increafed: or 2. in the form of Powder from half a gr. to a grain of digitalis, combined with from I to 2 gr. of Hydrarg. muriatus mitis; 5 gr. of magnefia ufta; and of ginger, q. s. being only intended to make the digitalis fit eafy on the ftomacli. This laft may be given once every ad night, and the digitalis afterwards gradually increated; with warm gruel, or other mild diluent after every dofe. This mode of cure Mr Martin fays, fully anfwered his expectations.

212. Tumors of a ferophulous nature are fome times apt to be mistaken for those of the scirrhous kind, and thus may be improperly extirpated. Scrophulous tumors deeply leated commonly have a degree of firmnels, which if they happen to be feated near a fufpicious part, as clofe by the fide of a woman's breait, may give occafion to such a mistake But they may generally be diftinguished by the foftnefs even of the firmest kind of them, when compared with feirrhus. They have always a smooth equal furface; whereas fcirrhus is fomewhat unequal or knotty, and feated in the real fubftance of the gland; and a shooting pain is commonly felt in it from time to time,' even from its first appearance. They are general¡y accompanied, too, with other symptoms of fcrophula, which is not neceffaruy the cate with fcirrhus.

SECT. VI. Of BRONCHOCELE.

213. THIS is a tumor on the fore part of the neck, feated between the trachea and skin, termed in French goitre. In this country it is very rare; but it is frequent among the inhabitants of the Alps, and other mountainous countries, and is fuppofed to be owing to the ufe of the fnowwater. It is feated most frequently in the thyroid gland; tho' in two cafes examined by Mr Benjamin Bell this gland was diminished from the compreflion of the tumor, which was chiefly formed of condensed cellular fubftance, with effutions in different parts of it of a vifcid brown matter. Dr PROSSER confiders bronchocele as a dropfical affection of the thyroid gland; and in corti mation of this he gives an account of a dullection of LIN

harm. When every other part of the difeafe is eradicated, the warts may generally be removed by wathing the morning and evening in lime-water, or in a weak folution of faccharum faturn. They may be removed a.fo by the knife, and the parts from whence they are cut afterwards touched with lunar cauftic, to prevent them from returning: but when this method is practifed, the operator ought to be certain that he has removed the wart entirely, for where part has been left the most formidable symptoms have fometimes enfued.

SECT. VII. Of POLYPI.

219. POLYPI are pentulous, fiefhy, indolent tumors, fo called from their fuppofed icfemblance to the animal of that name. They may be found ia different cavities of the body, and originate fon the uning membrane; but thofe which come under furgical treatment are found in the nose, mouth, throat, and outer paffage of the ear, and in the vagina and rectum. They are divided into two claffs: the one foft and compreffible, the other extremely firm. Both of them bleed on being fretted or roughly handled. The foft kind driveis and contracts in a dry atmosphere, (this 15 particularly the cafe with thofe of the nofe;) but the firm are not affected by the weather. Their colour is commonly pale and tranfparent, and fometimes a deep red.

220. The pain at the commencement of the diforder is always inconfiderable; but increases in thole of a hard nature as they increase in fize. Sometimes polypi of this kind become unequal, and form ulcers over the whole furface, discharging fetid matter in confiderable quantity. They are apt at this time, uniefs extirpated, to degene

rate into cancer.

221. Moft frequently they arife from local injury, or whatever tends to produce and support an inflamed ftate of the part. Scrophula and lues venerea, though confidered by fome authors as frequently giving rife to them, feem only to be exciting caufes; for in lues venerea in particular, poly. pi when prefent remain after the difcafe is cured. 222. The prognofis muft depend much upon their fituation and their confiftence. The foft kind being leidom painful, may be removed at any pericd with little danger; but the hard kind are generally not only painful, but more apt to degenerate into cancer, or to return after being removed. The foft kind therefore may be removed in general with fuccefs; but when polypi cf a harder nature exift, the prognofis will be much more unfavourable.

tual practice; and with this view the knife, fciffars, torceps, or ligature, are more generally recommended. The knife and feiffars may be used when the roots of the tumor can be readily come at; but polypi are seldom fo fituated as to render excifion practicable; and even when they are, the hemorrhagy may be attended with confiderabie danger. The removal of a polypus by tearing or twitting it with the forceps, Plate CCCXXIV, fig. 5. is occafionally practifed; but as ligatures are lefs painful, and fully as effectual, they are now more generally employed. The ligatures confift of wire, catgut, filk cord, &c. Different methods have been employed for palling thefe over polypi, according to their different fituations.

224. When the ligature is to be applied, it is to be pafled double over the tumor, and conducted to the root of it by means of the fingers, or by flit probes, as in Plate 324, fig. 6. or rings, fig. 7. as may be heft suited to the inape and fize of the paffige. The ends of the ligature are then to be introduced into a finge or double canuia, as in fig. 8. which is to be pushed along the oppofite hide of the polypus till the end of the canula each the root of it, when the ligature is to be drawn fomewhat tight, and faftened to the canula which is to be left in the paffage. The ligature is to be daily tightened till the tumor drop off. In this manner the largest polypus may be removed equalby well with thote of a fmailer fize. Should any part of it remain, it may be destroyed by caustic, and different inftruments are contrived for conducting this to the root of the tumor.

225. What has been faid of the treatment of polypi in general, readily applies to those seated in the nofe, outer pailage of the ear, the rectum, and the vagina. It likewife applies to thofe in the throat; only that inftead of paffing the ligature through the mouth, it is to be passed through one of the noftriis. The operator is then to introduce one or two of his fingers into the mouth, and open the doubling of the ligature, which he is to pafs over the polypus, and having preffed it down to the root of it, to proceed as before directed. CHAP. VI. OF DISEASES OF THE BONES. 226. THE bones as well as the fofter parts are liable to be swelied, either throughout their whole length, or to have tumors formed on particular parts of them.

227. EXOSTOSIS is one fpecies of tumor of the bone. According to Mr BROMEFIELD, no fweiling fhould be called fo, but an excrefcence cont!nued from a bone, like a branch from the trunk of a tree. Under this head therefore is ranked the benign node, which may be produced by external injury, fuch as contufions and fractures: it can hardly be called a disease, as pain feldom fucceeds, but rather a deformity.

228. There are rifings or tumors obfervable on the bones, which are often the confequents of ve~ nereal virus, and are termed tophi, gummi, or nodes. -TOPHUS is a foft tumor in the bone; and feems to be formed of a chalky substance, that is intermediate between the offeous fibres. These cretaceous extravafations are fometimes found on the ligaments and tendons, as well as on the bone; and may fometimes be taken out by the knife.