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 inflic tion, 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 degree, and hence the surrounding healthy skin is drawn from all sides over the situation 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, &c. 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 are wounded. The mildest dressings and treatment 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, alarm. ing symptoms usually arise; riz. swelling, heat and pain of the limb; small and weak pulse; head-ache 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. Hydrophobia arises from the bite of a mad-dog, or other rabid animal. The 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 intolerable 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. Polypi 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 elevating the os nasi; destroy the other bones; and produce, succesively, fistula lachrymalis, inflammation and ulceration of t'e 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." Ulcers are consequences of wounds that have not united by the first intention; or 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 granulations, 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. at tended with pain, a thin and discoloured secretion from its surface, ragged edge, no distinct granulations, &c. Here decoction of poppy heads, used as a fomentation, emollient poultices, solution of opium (3iss to bj 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 plaister, 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 im provement in the surgical treatment of ulcerated legs, as it does not require the pati ent to be confined. There are various ulcers, not included under this arrangement, having peculiarities 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 appearances; 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 taken to remove the whole cyst in an intire 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 painful tumour, termed a schirrus, which ulcerating forms cancer. As several other swellings are both hard and painful, discrimination becomes particularly necessary. Schirrus has an uneven feel, is attended and swelling is irregular, the skin livid; 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. 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 cuttery has been wounded in phlebotomy, and 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 occurred, the disease often recurs. Cicuta, belladonna, digitalis, mercury, arsenic, &c. have been tried internally without success. Opium is necessary as a palliative. Caustics composed of arsenic have often been used, in order to destroy the tumour by sloughing, probably never with success in a true schirrus. 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 dema, 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 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 be operated on, from the axillary above the clavicle, the external iliac above the crural arch, and the carotid by the side of the trachea, down to their respective ramifications. The false aneurism should be opened opposite to the wounded part of the vessel, the tourniquet being previously applied; the coagula removed, and two ligatures placed on the artery as in the preceding kind. Varices are dilatations of the veins, occurring in parts where the return of the blood is contrary to gravity, or where pressure is made on the trunks so as to obstruct that return: hence they are most frequent in the legs. The affected vessels swell into irregular knots, in which the blood is at first fluid, but afterwards coagulated. The complaint at first is not painful, but afterwards he comes so, and gives rise to troublesome ulcerations. The vessel sometimes bursts, and considerable bleedings follow. The cause shoul! be removed, and a tight bandage applied, the horizontal position being preserved. When this treatment does not succeed, the trunk of the vein may be tied with two ligatures, and divided between. Hemorrhoids, or piles, are varices, often attended with hemorrhage. Leeches, cold applications, attention to regimen, open state of bowels, and balsam copaivæ, are means of temporary palliation. A radical cure may be effected by cutting off the excrescences with scissars, or tying them. Scrophula attacks particularly the lymphatic glands and bones, occasioning a soft indolent swelling in the former, and a softening, together with a carious affection, of the latter. After remaining enlarged for a long time, the skin, covering a scrofulous tumour, becomes of a light purple, and bursts, discharging an unhealthy matter, and leaving an ill-conditioned sore. Such attacks take place in several parts. They generally occur in peculiar constitutions, and the affection is considered hereditary. In the treatment we endeavour to give strength to the constitution; bark, sea-air, and sea-bathing are particularly serviceable. Attention to the digestive organs is particularly necessary. Alkalies have generally been relied on, but without due grounds; acids deserve a preference. The local treatment is not of much importance. The suppurations should not be opened. The scrofulous affections of the bones will be considered under Joints. Cow pox (variolæ vaccinæ, vaccina, &c.). This is an universal poison, derived from certain specific sores on the teats and ndders of cows, and capable of being communicated by accidental contact, where the cuticle has been removed, or by means of inoculation, to the human subject. A person who has been thus affected, is rendered for ever after incapable of receiving the small-pox infection. That subjects, who had taken the vaccine disease accidentally, were thereby secured from the small-pox, was popularly known in several of the dairy counties of England. But it was reserved for Jenner to show that the cow-pox could be propagated by inoculation, and that the inoculated disease possessed the same prophylactic power as the original disorder. It is not a merely local affection, but produces a general, though extremely mild disturbance of the constitution, which is ordinarily so trivial as not to excite any alarm in the very youngest subjects. It seems probable, at present, that it is not an infallible security against the small-pox, although the number of failures is very small, when due allowance has been made for the mistakes of the ignorant, and the misrepresentations of the designing. A small inflamed spot, distinguishable about the third day, shows that the inoculation has succeeded. This increases in size, becomes hard, and rises above the level of the skin. A small quantity of fluid can be discerned in the centre on the sixth day, and the pustule increases until the tenth day. This fluid will communicate the disease by inoculation. On the eighth day, when the pustule is fully formed, the constitutional effects begin to appear, and manifest themselves by slight pain in the part and axilla, headacb, shivering, loss of appetite, &c. These subside spontaneously in one or two days. During the general indisposition the pustule becomes surrounded with a broad circular inflamed margin, called the areola. Afterwards the fluid dries up, and a dark brown scab forms, which remains for about a fortnight. Venereal disease. This arises from the application of a peculiar morbid poison to the body, which affects various parts in succession. It first attacks the genitals of either sex, where it appears in the form of a circular ulcer or ulcers, with a white dirty concave surface, and thickened edge and basis, called chancres. These characters distinguish them from various other - ulcerations and excoriations, to which the same parts are exposed. The matter absorbed from these causes swellings of the lymphatic glands, named buboes. After a certain length of time, an ulcerated sore throat appears, attended with a peculiar copper-coloured eruption on the skin. The ulcer of the throat is excavated, and the chasm appears foul on the surface, with an appearance like a white slough, and a defined edge. The eruptions vary considerably; they have generally a reddish colour; the cuticle pcels off and forms again suc cessively; at last a true scab appears, under which ulceration takes place. After some time swellings of the bones, called nodes, appear, and gradually suppurate. These are very painful, particularly at night. The affections of the throat, skin, and bones, form what are called the constitutional symptoms of the disease, or lues venerea. The treatment of this disorder, in all its stages, consists in the exhibition of mercury, until it produces its peculiar effects on the constitution: these are universal irritability, quick pulse, &c. together with increased secretion of saliva, soreness of the gums and mouth, &c. This action excited by mercury destroys the action of the disease in all its forms, and may be considered' as a specific and certain cure of the disor der. The remedy is most frequently introduced by friction on the thighs; half a drachm being first employed for half an hour every night, and increased to two or three drachms. The pil, hydrarg, is the most common preparation for internal use; it may be taken at first in doses of five grains, morning and night. Hydrarg. calcin. gr. j. sible. The constitution of the patient which is frequently of the scrofulous kind demands the greatest care: bark, sea-air, &c. are therefore particularly proper in such cases. Where the joint is too thoroughly diseased, and the constitution is sinking, amputation must be performed. Loose cartilaginous substances are most frequent in the knee, where they excite in they get between the ends of the bones. They must be removed by means of an incision over the inner surface of the internal condyle, where they can be easily fixed by an assistant; the wound should be closed instantly, and every attention paid to keep off inflammation. with opium, and corrosive sublimate, are less frequent modes of exhibiting mercury. Lastly, mercurial fumigations have been employed, by exposing the patient naked, in a wooden box, to the fumes of the pulvis hydrarg. cinereus, thrown on a heated iron. The effect of mercury on the salivary secretion and gums, is considered as the criterion of its action on the system at large; this should not be allowed to be-_flammation, and are very troublesome, when come considerable, as the effects on the constitution are very pernicious. A very slight affection of the gums, continued from six to twelve weeks, will be adequate to the cure of most venereal complaints. The action of the remedy is usually maintained for a fortnight after the symptoms have disappeared, for the sake of security. Violent and long continued - salivation often aggravates the complaint, and becomes the source of other disorders. Decoction of sarsaparilla, mezereon, guaiacum, &c. nitrous acid, opium, and other remedies, have been employed in venereal cases; but the most that can be said of them is, that they are useful restoratives after the long employment of mercury. This is particularly the case with the nitrous acid. There is not much to be said on the local treatment of the different venereal symp. toms. Chancres, when very small, have been destroyed by lunar caustic, or excision; they may be dressed with mercurial ointment, or any solution of metallic salts; or with solution of opium if irritable. Buboes may be poulticed, if painful. AFFECTIONS OF JOINTS. White swelling attacks the larger articulations most frequently. It consists in an indolent tumour of the part, without affection of the skin, impairing the motions of the joint; arising from a diseased state of the bones and ligaments, which causes a general thickening of the superincumbent parts. The enlargement proceeds, the joint becomes painful, and abscesses form; the patient at last dying hectic. The treatment consists in subduing completely all increased action in the part by leeches, cupping, cold washes, &c. continued while there is any remains of pain or heat; and afterwards in keeping up a drain from the skin by means of caustic issues, or, what seems to be more advantageous, by Mr. Crowther's plan of blistering, and dressing the surface with unguentum sabinæ. These drains should be continued for six, twelve, or eighteen months. Perfect rest is indispen Hydrops articuli occurs after inflammation or injury, and may be dispersed by blisters and savine ointment; or by friction with camphorated liniments or mercurial ointment, united with mercurial purges. DISEASES OF BONES. Necrosis is the death of the whole of a bony cylinder, excepting its articular portions; and is most frequent in the thigh and tibia. The periosteum separates from the affected bones, becomes thickened and vascular, and forms a new case surrounding the old bone, and at last absorbing it. This process occupies many years; is attended with great pain and swelling of the limb at first, and subsequently with abscesses, which lead down to the old bone, and afford issue to copious fetid suppurations. In some instances the old bone, which is called the sequestra, has been removed by a surgical operation, particularly in the tibia. Where this cannot be admitted, blisters dressed with savine, or issues, will remedy the irritation, and prevent suppuration, while the absorption of the old bone is going on. Leeches, cupping, &c. may be required, if inflammatory symptoms manifest themselves. Sometimes amputation is necessary, particularly in poor persons, whose circumstances will not admit of delay. Exfoliation is the term applied to the death of a small portion of bone; in which generally the surgeon must wait until nature has separated the dead part. Caries is a disease of the substance of a bone, causing foul, ill-conditioned ulcers, and attended with occasional exfoliations. Means which reduce inflammation are proper at first; followed by counter irritation. Rickets is a disorder consisting in a flexibility of the bones, and, consequently, a deformity of the part affected, occurring ge |