tion and

tion.

tion.

44

Thefe different applications, under the reftrictions taken Suppuranotice of, being continued for a longer or shorter time, according to the fize of the tumor, its fituation, and other circumftances, a thorough fuppuration may in general at last be expected.

Inflamma increafe; and cfpecially if the tumor turns larger, and fomewhat foft, with an increase of throbbing pain; we may then Suppura- with tolerable certainty conclude, that fuppuration will take place; and fhould therefore immediately defift from fuch applications as were judged proper while a cure was thought Method of practicable by refolution, and endeavour to affift nature as promoting fuj:pura- much as poffible in the formation of pus, or what is called maturation of the tumor. For this purpose there is nothing better than to preserve a proper degree of heat in the parts. This is commonly done by the means of warm fomentations and cataplafms; and when thefe are regularly and frequent Jy renewed, nothing, it is probable, could more effectually answer the purpofe. But in the ordinary manner in which they are applied, by the cataplafms being renewed only once, or at moft twice a day, they must always, it is ima gined, do more harm than good. For fo foon as the degree of heat they were at firft poffeffed of is diffipated, the moil ture kept up by them, with the confequent évaporation which enfues, must always render the part a great deal colder than if it had been merely wrapped in flannel without the ufe of any fuch application.

In order to receive all the advantages of fuch remedies, the part affected should be well fomented with flannels preffed out of any warm emollient decoction, applied as warm as the patient can eafily bear them, continued at least half an hour at once, and repeated four times a day.

Immediately after the fomentation is over, a large emol lient poultice should likewise be applied warm, and renewed every fecond or third hour at fartheft. Of all the forms recommended for emollient cataplafms, a common milk-andbread poultice, with a proportion of butter or oil, is perhaps the most cligible; as it not only poffeffes all the advantages of the others, but can at all times be more cafily obtained.

Roafted onions, garlic, and other acrid fubftances, are frequently made ufe of as additions to maturating cataplafms. When there is not a due degree of inflammation in the tumor, and when it appears probable that the fuppuration would be quickened by having the inflammatory fymptoms fomewhat increased, the addition of fuch fubftances may then be of fervice; but when fimulants are necessary in fuch cafes, a fmall proportion of ftrained galbanum, or of any of the warm gums, diffolved in the yolk of an egg, and added to the poultices, is a more certain form of applying them. Whenever the inflammation, however, takes place to a proper degree, such stimulating fubftances never can be neceffary; and in many cafes, it is apprehended, they may even do mifchief.

In fuch tumors as, from their being poffeffed of little or no inflammation, are commonly faid to be of a cold nature, as they are generally indolent, and proceed very flowly to fuppuration, plafters compofed of the warm gums are often had recourse to with confiderable advantage. In fuch cafes, they are not only of ufe by the ftimulus and irritation they occafion, but by the heat which they tend to preferve in the part. They become particularly neceffary when the patient, by being obliged to go abroad, cannot have cataplafms frequently enough renewed, or fo conveniently applied; but when fome fuch objection does not occur, the latter, for very obvious reasons, fhould always be preferred.

Dry cupping, as it is termed, that is, cupping without the use of the fcarificator, upon or as near as poffible to the part affected, is frequently had recourfe to with advantage in promoting the fuppuration of tumors. It is only, however, in fuch as these last mentioned, where there feems to be a deficiency of inflammation, that it can ever either be neceffary or useful; but in all tumors of a real indolent na

46

Matter being fully formed in a tumor, is known by a re-Signs that miffion of all the fymptoms taking place; the throbbing marter is pain, which before was frequent, now goes off, and the pa.formed. tient complains of a more dull, conftant, heavy pain: the tumor points at fome particular part, generally near to its middle; where, if the matter is not encyfted, or deep feated, a whitish yellow appearance is obferved, inftead of a deep red that formerly took place; and fluctuation of a fluid underneath is, upon preffure, very evidently difcovered. Sometimes, indeed, when an abfcefs is thickly covered with muscular and other parts, though, from concurring circumftances, there can be little doubt of there being even a very confiderable collection of matter, yet the fluctuation cannot be readily diftinguished: it does not, however, often happen, that matter is so very deeply lodged as not to be dif covered upon proper examination.

This, however, is a circumftance of the greatest confequence in practice, and deserves more attention than is commonly given to it. In no part of the furgeon's employment is experience in former fimilar cafes of greater ufe to him than in the prefent; and however fimple it may appear, yet nothing, it is certain, more readily diftinguishes a man of obfervation and extenfive practice, than his being able eafily to detect collections of deep-feated matter; whilft nothing, on the contrary, fo materially affects the character of a furgeon, as his having, in such cafes, given an inaccurate or unjuft prognofis; as the event, in disorders of that nature, comes generally at last to be clearly demonftrated to all concerned.

Together with the feveral local fymptoms of the prefence. of pus already enumerated, may be mentioned the frequent fhiverings to which patients are liable on its first formation: thefe, however, feldom occur fo as to be diftinctly observed, unless the colle&ion is confiderable, or feated internally in fome of the viscera.

47

After the matter is fully formed, and the abfcefs brought of opening to maturity, the only remedy is to open it, and give vent to abscesses, the pus it contains. In many cafes, indeed, nature will do the work, and abfceffes, when fuperficially feated, will cer tainly burit of themfelves: but where the matter lies deep, we are by no means to wait for this fpontaneous opening; as the pus will acquire an acrimony before it can break through the integuments, which may prove very prejudicial to health. However, it is a general rule not to open abfceffes till a thorough fuppuration has taken place; for, when laid open long before that period, and while any confiderable hardness remains, they commonly prove more troublesome, and seldom heal fo kindly.

In fome cafes, however, it is neceffary to deviate from. this general rule, and to open them a good deal fooner; particularly in all fuch critical abfceffes as occur in malignant fevers. In like manner, in the plague, we are commonly advised to open fuch tumors, fo foon as they are at all tolerably, advanced, and not to wait till they are fully maturated; as, from experience in these disorders, it is found to be of more. confequence, for the removal of the original disease, to have a quick difcharge of matter produced, than any harm the patient can ever suffer from having a swelling somewhat prematurely laid open.

In abfceffes, alfo, fituated on any of the joints, or upon either

Gangrene. mation that is here particularly treated of, and in which no fuch varieties are ever obferved, it is not neceffary to carry the inquiry farther.

53

Proguofis.

54

Means of

La grene arifi g from

The prognofs in every cafe of gangrene is doubtful at first, as, even in the flighteft cafes, the patient may fuffer from the fpreading of the difeafe; but flight cafes, from external injuries, are more favourable than thofe which arife from internal causes, though no perfon can be confidered fafe till the difeafed parts are feparated, and even entirely caft off. When inflammation happens round a mortified part, more especially if pus be formed, we may pretty cer. tainly pronounce that the mortified part will be thrown off. When there is reafon to fufpect from the violence of the Preventing fever and great heat of the inflamed part, that it will terininate in gangrene, blood-letting, and whatever may have a inflamma tendency to moderate the inflammation, may check its progrefs. But as the patient, in fuch cafes, is fometimes apt to fink afterwards, nothing more ought to be done than is merely neceffary to moderate the prefent fymptoms. If an inflamed furface put on a gangrenous appearance when the patient is weak, and the pulfe low, we must have recourfe to whatever may invigorate the fyftem, viz. a nourishing diet, with the free ufe of wine. Peruvian bark likewife is to be given in as great quantities as the ftomach of the patient will permit. When the ftomach cannot bear enough in fubftance, which is the belt form of exhibiting it, it may be given either in form of tincture or joined with aromatics. External applications, fuch as are of a ftimulating nature, may likewise be useful.

tion.

55 Arifing From cold.

Scarifica

terna! ap

parts im. proper.

In the cafe of gangrene arising from cold, the part must be immerfed in very cold water, or rubbed with fnow; for if any thing warm be applied, or the patient brought near a fire, it certainly mortifies. If the whole body has become torpid with cold, the fame practice must be followed; the very cold water fhould be afterwards changed for fome that is a little warmer, and the patient gradually brought to a proper degree of heat. Rubbing with falt is fometimes found useful. If the whole body be benumbed, cordials are not to be adminiftered too fuddenly. A glass of cold wine Ahould first be given, afterwards warm wine by itself, or with fpices. If ftronger cordials be required, ardent spirits may be employed. Notwithstanding the greatest attention, however, a mortification fometimes takes place, and in fome inftances very fuddenly; as in the cafe of carbuncle, where, after an inflammation has continued for scarcely 24 hours, the parts become black, and end in real mortification.

In the treatment of mortified parts, a variety of extertions and ex-nal applications have been pointed out, and particularly thofe of the antifeptic kind; fuch as all the warm gums and plication to balfams, ardent spirits, and even alcohol: and to admit of mortified their nearer application to the found parts, with a view to the prefervation of thefe from putrefaction, deep fearifications through the diseased, and into the found parts, have been generally recommended. But although fuch articles may be of use in preserving dead animal-fubftances from corruption; yet that they will always prove ferviceable in the fame manner in living bodies, is probably very much to be doubted. And it is even apprehended, by the ftrong ir ritation they always occafion when applied to a living fibre, that, in fuch cafes as the prefent, they may rather do mifchief; it being only a very flight degree of inflammation that is required to bring on a fuppuration. The incifions, when carried into the found parts, with a view to facilitate the operation of such remedies, may likewife do harm; not only from the risk of wounding the blood-veffels, nerves, and tendons, that lie in the way, but also by allowing a free and farther entrance of the putrefcent fluids into the parts not yet affected and unless they are carried fo deep as freely to

reach the found parts, applications of the antifeptic kind Ulcers... can never have any effect in answering the purpose for which they were intended.

All the advantages commonly obferved from the great variety of applications recommended for gangrene, are chtained with more cafe, and generally with more certainty, from the ufe of any gentle ftimulating embrocation; which, by exciting a flight irritation upon the furface, and elpecially when affifted by a free use of the bark, at laft common. ly produces fuch a degree of inflammation as is wifhed for. With this view, a weak folution of fal ammoniac in vinegar and water has been known to anfwer exceedingly well a dram of the falt to two ounces of vinegar and fix of water, forms a mixture of a very proper ftrength for every purpose of this kind; but the degree of ftimulus can be easily either increased or diminished, according to circumftances, by using a larger or smaller proportion of the fält.

Although, for the reafons formerly advanced, incifions may not in general be proper; yet in fuch cafes where the mortification runs very deep, it is fometimes of fervice to make fcarifications into the difeafed parts, fo as to remove part of them; which, by taking off a confiderable load perhaps of putrid fiefh, not only leffens the fetor, which in fuch cafes is always confiderable, but often renders it more easy for the found parts to free themselves from the remainder. When with this view, however, incifions are had recourse te, care fhould always be taken that they be not carried the length of the found parts.

When by the ufe of external or internal remedies, a feparation of the mortified part has been effected, and a discharge of pus produced, the remaining fore is then to be confidered merely as a fimple purulent ulcer, and may be treated in the fame manner.

CHAP. IV. Of Ulcers, White Swellings, Cancers,

and Burns.

SECT. I. Of Ulcers

A SOLUTION of continuity in any of the fofter parts of the body, discharging either pus, fanies, or any other vitiated matter, is termed ulcer; and when the fame circumftances happen to the bones, the term caries or carious ulcer is adopted.

57

Ulcers are diftinguished by their particular diforders, Different though it feldom happens that the affections are not compli, kinds of cated; and when we lay down rules for the management of ulcers. one fpecies of ulcer, it is generally requifite to apply them to almost all others. However, the characters of moft eminence. are, the callous ulcer, the finuous ulcer, and the ulcer with caries of the adjacent bone: befides this there is the putrid, the corrofive, the varicofe ulcers, &c.; but as they have acquired their names from fome particular affection, we hall fpeak of the treatment of them under the general head of ulcers.

It will be often in vain to pursue the beft means of cure by topical application, unless we are affifted by internal remedies; for as many ulcers, are the effects of a particular indifpofition of body, it will be difficult to bring them into order while the caufe of them remains. Thofe which are cancerous and fcrophulous feem to gain the least advan tage from phyfic; for if in their beginnings they have fometimes been very much relieved, or cured, by falivation, or any other evacuation, they are allo often irritated and made worse by them..

58

When an ulcer becomes foul, and difcharges a nafty Of callous thin ichor, the edges of it, in procefs of time, tuck in, and, ulcers. growing fkinned and hard, give it the name of a callous ul

cer;

t

down the edges of the ulcer better than any other gentle White applications.

Ulcers. made moft frequently are thofe of compound fractures, and the breast: but the latter do oftener well without dilatation than the former; though it must be performed in both, if practicable, the whole length of the abfcefs, when after fome trial the matter does not leffen in quantity, and the fides of it grow-thinner; and if the finufes be fiftulous, no cure nced be expected without dilatation.

64

ulcers.

:

When an ulcer with loofe rotten flesh discharges more than the fize of it fhould yield, and the difcharge is oily and ftinking, in all probability the bone is carious; which may cafily be diftinguished by running the probe through the flesh and if fo, it is called a carious ulcer. The cure of these ulcers depends principally upon the removal of the rotten part of the bone, without which it cannot heal. Those caries which happen from the matter of abfceffes lying too long upon the bone, are moft likely to recover: those of lues venerea very often do well, because that dif temper fixes ordinarily upon the middle and outfide of the denfeft bones, which admit of exfoliation; but those produced by fcrophula, where the whole extremities of the fpongy parts of the bone are affected, are exceedingly dangerous. Of carious All enlarged bones are not neceffarily carious; and there are ulcers sometimes on the skin which covers them, which do not communicate with the bone, and confequently do well without exfoliation: nay, it fometimes happens, though the case be rare, that, in young fubjects particularly, the bones will be carious to fuch a degree, as to admit a probe almost through the whole fubftance of them; and yet afterwards admit of a cure, without any notable exfoliation. The method of treating an ulcer with caries, is by applying a cauftic of the fize of the fcale of the bone which is to be exfoliated; and after having laid it bare, to wait till the carious part can without violence be feparated, and then heal the wound. In order to quicken the exfoliation, there have been several applications devifed; but that which has been moft used in all ages, is the actual cautery, with which furgeons burn the naked bone every day, or every other day, to dry up, as they say, the moisture, and by that means procure the feparation: but as this practice is never of great fervice, and always cruel and painful, it is now pretty much exploded. Indeed, from confidering the appearance of a wound, when a scale of bone is taken out of it, there is little doubt that burning retards rather than haftens the feparation; for as every scale of a carious bone is flung off by new flesh generated between it and the found bone, whatever would prevent the growth of these granulations would also in a degree prevent the exfoliation; which muft certainly be the effect of a red-hot iron applied fo clofe to it,

6.5 Treatment.

}

SECT. II. Of White Swellings.

Swellings

66 There Rheumatic

THERE are two fpecies of white fwellings, Mr Benjamin Bell obferves; the one of a mild nature, and frequently admitting of a cure; which the other never does. The former, named by our author the rheumatic fpecies of white fwelling, begins with an acute pain, feemingly diffused over the whole joint, and frequently extending along the tendinous aponeuroses of the muscles which communicate with it. is, from the beginning, an uniform fwelling of the whole white iwel. furrounding integuments. Great tenfion generally prevails; ling. but at first there is feldom any external change of colour. From the commencement of the difeafe the motion of the joint is attended with exquifite pain, and the patient keeps it conftantly in a relaxed pofture, finding that the easiest. Hence the tendons become extremely stiff and rigid, till at laft the joints have the appearance of complete and real anchylofes. The fwelling now begins to augment, till the joint has acquired three or four times its natural fize; the cuticular veins become turgid and varicofe; at the fame time that the mufcular fubftance of the limb below decays, though it frequently acquires an equality in fize by becoming oedematous; the pain becomes intolerable, efpecially when the perfon is warm in bed or otherwise heated; abfceffes form in different parts, which, either breaking of themselves, or by being laid open, discharge confiderable quantities of matter, but without any remarkable effect in reducing the fize of the fwelling. The pus difcharged from these is at first of a tolerably good confiftence, but foon degenerates into a thin ill-conditioned fanies. ever, the orifices from whence it flows foon heal up, unless they are kept open by art; and new collections breaking out, they burft and heal up as before; fo that in long-continued diforders of this kind, the furrounding integuments are often entirely covered with cicatrices.

Some caries of the bones are fo very fhallow, that they crumble infenfibly away, and the wound fills up; but when the bone will neither exfoliate nor admit of granulations, it will be proper to scrape it with a rugine, or perforate it in many points with a convenient inftrument down to the quick. In fcrophulous cafes, the bones of the carpus and tarfus are often affected; and from their fponginefs they' are seldom cured: fo that when these, or indeed the extremities of any of the bones, are carious through their substance, it is advisable to amputate; though there are inftances in the fcrophula, but more especially in critical abfceffes, where, after long dreffing down, the splinters, and fometimes the whole fubftance, of the fmall bones, have worked away, and a healthy habit of body coming on, the ulcer has healed; but these are so rare, that no great dependence is to be laid on such an event. The dreffings of carious bones, if they are stinking, may be doffils dipped in the tincture of myrrh; otherwise those of dry lint are eafieft, and keep

་

How

In the mean time, the health of the patient gradually declines, from the violence of the pain, and the absorption of matter into the fyftem, which takes place in fome degree from its firft formation in the different abfceffes; but which never appears fo evidently till the different abfceffes have been laid open; after which a quick pulfe, night-fweats, and a weakening diarrhoea, are fure to occur, which generally carry off the patient, if the member is not either amputated, or the disease cured fome other way.

67

On diffecting limbs which have been amputated for white Apperance fwellings, the original difeafe appears to have been a mor- of the atbid thickening of the furrounding ligaments, without any tected limbs other affection of the joint whatever; the bones and carti- on diffe lages always remaining perfectly found, as likewife the tion. fynovia both in quantity and confiftence. In the more advanced stages of the diforder, the thickness of the ligaments is more confiderable, and is generally attended with an ef fufion, into the furrounding cellular fubftance, of a thick glairy matter, which gives to fwellings of this kind an elastic fpringy feel, independent of the collections of matter the fluctuation of which may alfo be perceived. Through this glairy matter the collections of pus run in various directions, without feeming, however, to mix with it. In fome inftances alto a great many fmall hydatides are obferved all which form a confufed mafs, incapable of further diffection.

;

1