Part 22

In the pustular form of eruption the general treatment is the same as in the papular. Mercury is hurtful, and increases the tendency to burrow. When the surface is nearly covered with pustules and ulcers in all stages, desquamation may be hastened by fumigations of sulphur, the general sulphur baths, lotions of sulphuret of potass, nitro-muriatic baths, vapour baths, or by smearing the affected surface with equal parts of tar and sulphur ointment.

In phagedena the patient ought to be, if possible, placed in an airy and healthful situation. In most cases free bloodletting may be necessary at the commencement, and will be advantageously followed by purgatives and antimonials. The patient ought to be strictly confined to his room, and ordered low diet with diluents. Afterwards, the internal use of nitric acid, the decoction of sarsaparilla, and an occasional dose of Dover’s powder at night, will be beneficial, particularly if sleep be disturbed with pain of the bones and joints. Mercury, even in small quantities, protracts the disease, and in large doses it hastens the ulceration and sloughing. When all febrile symptoms have subsided, when the ulcers are nearly healed, when no fresh pustules appear, and when desquamation is begun, alterative doses of mercury, as a blue pill or grey powder every second night, may sometimes be ventured upon, will tend to hasten the cure, and will not, possibly, be followed by any unpleasant symptoms. The safe course is to promote the secretions by some safe substitute—preparations of sarsaparilla, ipecacuan, taraxacum, &c.

In fact, in all scaly eruptions, whether scaly from their commencement, or having become so in their latter stages and previously to their disappearance, mercury, prudently administered, will be useful by expediting the cure, and not injurious by deranging the system. The tar or citrine ointments may be applied to the eruptions and cutaneous ulcers.

For the ulcers of the throat, unless in a sloughing state, the lunar stone appears to be almost a specific, removing the irritability of the sores, and protecting them from further irritation by coagulating the discharge, which then more effectually covers and protects them. The application requires to be repeated every second or third day, as, by the frequent and necessary motions of the parts, the crust loosens and separates, leaving the surface exposed and irritable. At the same time the sore will contract very considerably under each successive crust. The lunar stone may also be applied in solution; or a solution of the bichloride of mercury in spirits or laudanum may be used, in the proportion of from four to six grains to the ounce, or stronger. The solution of the nitrate of mercury is sometimes employed with advantage. Fumigation of the throat with the red sulphuret of mercury has been extolled as a powerful means of checking the alternating sloughing and ulceration which often accompany the ulcers of these parts, but the propriety of its employment is doubtful; the system is thereby rapidly put under the influence of the mineral, which, as already remarked, generally aggravates the violent disturbance under which the constitution labours. More permanent good may be expected from means taken to remedy the constitutional evils than from such violent remedies as are directed against the affected part, but which also produce a baneful effect on the system. In ulcers of the nostrils, with fetid discharge, snivelling, exfoliation of the inferior spongy bones, affections of the palate, &c., the nitrate of silver is also very efficacious; or the affected parts may be occasionally touched with a hair pencil, dipped in a liniment composed of lime-water, olive oil, and the golden ointment. They ought to be frequently washed with tepid water, and all sources of irritation must be removed. If the patient be in the habit of taking snuff, the practice must be abandoned, and the powder already impacted in the nostrils removed. If there be carious teeth or stumps in the upper jaw, the sores can scarcely be expected to heal till these be extracted, as constant irritation is kept up by them. When the affection proves obstinate, a recourse to mercury is recommended by some writers; but this will make bad worse. Sarsaparilla in these cases, with attention to diet and air, will always prove a better alterative than any form of mercury. It may be combined, according to circumstances, with the nitric or nitro-muriatic acids, or with the hydriodate of potass, in which many practical men have great faith. This medicine is employed in cachexia, following or not the use of mercury, and is directed against eruptions, sore throat, and pains in the limbs.

The constitutional symptoms of the scaly disease, or true pox, when they occur, which is now but seldom, are decidedly benefited by a prudent employment of mercury. It may be administered externally or internally, though the latter method is the one generally adopted. It may be introduced into the system under various forms, according to the particular circumstances of the case, or the ideas of the practitioner. The most common form, and the simplest, is the pil. hydrargyri; but for this may be substituted hydrargyrum cum creta, Plummer’s pill, or calomel with antimony. In painful affections of the bones, with or without swelling, the muriate of mercury (bichloride) is the form which I have found most efficacious; one-eighth of a grain of the muriate being given thrice a day in a pill; or the medicine may be given in solution. The iodide of mercury is also a very useful medicine in some cases. It is impossible, and would be absurd, to lay down any precise rules as to the quantity of mercury which is necessary for the cure of pox: in some patients the system is with difficulty put under its influence, whilst in others a single grain will produce salivation, constitutional disturbance, and eczema. When the mouth becomes affected the mercury ought to be discontinued: much harm and no good resulting from the medicine being pushed to profuse salivation; the tongue swells hideously, the teeth loosen, and portions of the jaw die and exfoliate. It is sufficient that the system be under the influence of mercury; and that circumstance is marked by the tenderness of the gums. If, after the medicine has been disused, the disease does not appear to recede, it may be resumed in the same moderate way as before; but there certainly can be no use in continuing mercury after the symptoms of venereal affection have ceased. Nodes may still exist, portions of bone may be dying, abscesses forming, and various other changes of structure going on, but these are no reasons for a continuance of the mercury. If they have originated from the venereal affection, that cause has been removed, and the diseased actions will now proceed altogether independently of their original cause. Mercury proved beneficial in removing a disease of which they are not a part but a consequence; and, if that medicine be now blindly persevered in, the only effect will be to ruin the constitution, and thereby greatly retard the cure of those affections which, if the natural powers of the system had been merely supported, or in a great measure left to themselves, would have soon ceased to annoy the patient or alarm the antisyphilitic mercurialist.

Slight swellings and pains of the bones often yield to local abstraction of blood, friction, and the internal use of the compound decoction of sarsaparilla. Nodes, however, sometimes continue to enlarge, and occasion much pain, notwithstanding these means; and in such circumstances much relief will be afforded by a free incision over the affected part, from whatever cause the swelling may proceed. When the pain has subsided, and the swelling remains stationary, a decrease of it may be sometimes effected by a blister.

Of the bad effects of mercury on the constitution much might be said. Treatises have been written on mercurial pox, a species reported to be much the most violent; and others have detailed an accumulation of evils, under the title of mercurial disease. There is no doubt that extensive, deep, and sloughy ulcers of the throat are produced by mercury; and of this I witnessed the following unexceptionable instance:—The fauces presented one extensive mass of ulceration, sloughing at its margins, and the uvula was almost detached. The patient was an old and emaciated woman, who neither had, nor could be supposed to have, any venereal complaints. She employed herself in coating mirrors with quicksilver, and to that she ascribed her malady. In fact, her system had been long under the influence of mercury, in consequence of her occupation. When I visited her, her daughter and husband, the latter of whom was paralytic, and almost bedridden, were affected, from the same cause, with a pustular eruption of the face, with disease of the nostrils, and snivelling. Another old woman had numerous and deep ulcers of the fauces, tongue, and lips, having been kept unmercifully under mercury for nine continuous months. She had, besides, taken it from time to time, for upwards of four years, though her sole complaint was slight sore throat. Pains of the joints, too, I believe, are attributable to the use of mercury. That medicine has no power to prevent the occurrence of nodes, for these often form during its action. Affections of the periosteum are very frequent in horses and other lower animals, and also easily excited in some human subjects who have neither had pox nor been put under mercury; but in no instance of venereal disease have I observed serious affections of the bones where mercury had not been given. Even the advocates for mercurialising speak of mercurial nodes. It has been asserted that nodes do not occur when mercury has been given for liver or other complaints; but they do form under such circumstances, though not so frequently as when the medicine has been exhibited during venereal symptoms. A cachectic state is often induced by a continued use of mercurial preparations, or at least by mercury and disease together, in constitutions not originally strong. It is marked by pale lips; bloodless conjunctiva; a rough anserine skin; a relaxed state of the mucous membranes; hemorrhages from these, particularly from the gums, which may prove fatal, as I have myself witnessed; exfoliations of the alveolar processes; slimy stools; pale urine; pains of the limbs; sores, showing great indolence, or even assuming malignant action; dropsical symptoms, and other evils, of which a lengthened catalogue might be made out. Such symptoms were often met with when mercury was exhibited for every trifling or suspected sign of disease arising from carnal conjunction. On this subject, Mr. Samuel Cooper has well remarked: “Experience has fully convinced me, that in no forms of chancre, nor in any other stages of the venereal disease, is it proper to exhibit mercury in the unmerciful quantity, and for the prodigious length of time, which custom, ignorance, and prejudice, used to sanction in former days. Violent salivations ought, at all events, to be for ever exploded. When I was an apprentice at St. Bartholomew’s Hospital, most of the venereal patients in that establishment were seen with their ulcerated tongues hanging out of their mouths, their faces prodigiously swelled, and their saliva flowing out in streams. The wards were not sufficiently ventilated, and the stench was so great, that the places well deserved the appellation of foul. Yet, notwithstanding mercury was thus pushed (as the favourite expression was), it was then common to see many patients suffer the most dreadful mutilations, in consequence of sloughing ulcers of the penis; other patients, whose noses and palates were gone; others who were covered with nodes and dreadful phagedenic sores.” This woful picture is not exaggerated, and cannot be too strongly impressed on the minds of young practitioners. A small quantity of mercury will affect violently some constitutions; as of those who have been in warm climates, or who have taken much of the drug, even in this country.

Eczema Rubrum, a disease resulting from external causes, but which may also be produced by mercury, often arises from but a very small quantity of that medicine even applied externally. It most frequently affects the scrotum and upper and inner parts of the thighs. It is preceded by heat and itching in the part; a diffused redness appears, and the affected surface is rendered rough by the eruption of numerous minute vesicles. In a short time, these vesicles, if not ruptured, attain the size of a pin’s head, and the included serum becomes opaque and milky. The affection soon extends over the rest of the body in successive large patches, and is accompanied with considerable swelling of the integuments, tenderness of the skin, and itching. The vesicles burst, and discharge a thin acrid fluid, which renders the surrounding surface painful, inflamed, and excoriated. The discharge becomes thicker, adhesive, and fetid, and by its drying, partial yellowish incrustations are formed. The disease terminates in desquamation, and in some cases, the hair and nails are also lost. It is preceded and accompanied with smart fever, and general disorder of the system.

Erethismus is another occasional consequence of mercury, characterised by remarkable depression of strength; small, quick, and often unequal pulse; anxiety, sighing, and trembling; a pale contracted countenance, and occasional vomiting. While in this state, sudden exertions are apt to prove fatal.

OF SCALDS AND BURNS.

Different degrees of injury are inflicted on the surface from the application of heated solids or fluids. The term scald is generally confined to the effects of heated fluids, whilst burn denotes the consequences of the application of a heated solid, or of ignited combustible matter; the latter class of accidents is, in general, the more serious, yet the former, though not injuring the skin deeply, gives rise to the most alarming symptoms when a large extent of surface is affected. A slight degree of heat is productive only of redness of the surface, with a sharp hot pain, and these symptoms may subside with or without vesication. However, effusion of serum under the cuticle often takes place almost immediately after the contact of the heated body—the cuticle may be destroyed by the intensity of the injury—or the true skin may die, either partially or throughout its whole thickness, and the subjacent parts be at the same time injured to a greater or less depth. But parts, not severely injured at first, may afterwards perish, violent inflammatory action being excited, which terminates in sloughing. The neighbouring parts have their vitality much diminished, by the direct influence of the injury; and hence, when these parts come to be the seat of increased action, sloughing almost inevitably ensues, from the want of corresponding power. From the same cause, subsequent sores are tedious in healing, being so far debilitated as to be unable to assume full vigour; even slight ulcerations following vesication contract very slowly; the granulations are flabby, and the discharge profuse and thin. The inflammation is often at first very violent, and kept within bounds with difficulty. Burns of the trunk, particularly of the genital organs, are to be considered as attended with much danger. And extensive burns and scalds, wherever situated, are always to be dreaded. Violent constitutional irritation takes place, dyspnœa is apt to occur, with effusion into the chest of serum, or a sero-purulent fluid; and the nervous system ultimately becomes oppressed. Great sinking of the vital powers is generally the immediate consequence of extensive and severe burns; there is shivering, weakness of the pulse, cold extremities, anxiety, and vomiting, requiring the exhibition of warm drinks, and even sometimes of cordials, opium, or strong stimulants. These must, however, be given with a sparing hand, or the depression following the excitement is with difficulty got over. Nor can it be matter of surprise that such serious effects occur, when we reflect on the extreme sensibility, and highly organised state of the affected part, and the important functions which it is intended to perform, as well as those sympathies which it holds with internal parts, on which life principally depends.

In trifling burns cold applications are generally used—as immersing the part in cold or iced water. A great variety of remedies are employed, spiritous, watery, acid, alkaline, cold or hot; some apply a coat of cotton or flour, some of tar or pitch, and they state that when these artificial crusts separate, the skin is found healed beneath; in fact, every practitioner, and almost every individual, possesses a favourite application for this very common accident. Some have recommended holding the part to the fire, or plunging it into hot liquid; but this practice, and all similar, are too severe ever to become general, when milder means prove equally effectual. Perhaps the most common applications are, a mixture of lime-water and olive oil, or the ceratum acetatis plumbi. The vesicles, when left to themselves, burst, expose an irritable surface, and the acrid discharge from them excoriates the surrounding skin. Their contents ought to be evacuated by a small puncture, and the cuticle being left carefully undisturbed, a scab soon forms, by which the part is protected while healing. In extensive injuries of the skin, where the cuticle has been altogether destroyed, finely carded cotton is sometimes applied; it is of use in somewhat the same way as the cuticle in the former instance, and being a sort of cushion over the part, prevents it from being irritated by bed or body clothes, or by the patient’s resting on it. It soon becomes soaked with the discharge, and must either be frequently changed, or become a receptacle for pus to putrefy in, and maggots to breed; on account of these circumstances it is objectionable. Dusting the part with common flour, starch, or hair powder, is equally advantageous, and much more convenient; relief is afforded by its immediate application; the parts are cooled; the flour, absorbing the discharge, is soon formed into crusts, which effectually protect the surface; and the after-secretion readily escapes from beneath this, no more moisture being imbibed than is merely sufficient for the encrustation. The artificial covering ought not to be removed until completely detached, by purulent matter accumulating beneath it; then its presence can be of no service, and its removal is accomplished by fomentation or poultice, and without pain to the patient; whereas, by pulling off the crusts shortly after their formation, as some do, whilst they are adherent to the surface, and protecting it from injury, much pain is given to the patient, the raw surface is irritated, and made liable to over-action; a useful application is taken away to make room for another, and, perhaps, not so congenial. After the spontaneous separation, fresh flour may be again sprinkled over the suppurating surface, and, if the affected part is small, it may heal under this application. But when, in burns of considerable extent, suppuration is fully established, and granulations have begun to arise, tepid-water dressing, and lotions, are to be applied as to any other granulating sore; for the reasons already assigned, the applications require to be of a gently stimulating nature.

In severe cases, there is first extreme depression of the powers of life, under which patients sometimes sink; but most frequently this state is obviated by the employment of cordials or stimulants. But these ought to be administered with caution, for reaction soon commences, and often increases to well-marked inflammation, requiring for counteraction low diet, and even bleeding. In such cases gentle laxatives are preferable to purgatives, as by the latter the patient is obliged to make frequent movements, and those are always painful. Stimulants have been strongly recommended, at first powerful, and afterwards gradually weaker, so as, it was said, to restore the balance between the affected parts and the system; and the latter is again to be excited, in order to meet the increased action which the parts assume. The practice is founded on fancy, and cannot become general, being in its first part cruel, and in its second absurd. Whilst debility exists, stimulate cautiously; when over-action ensues, adopt those measures which are best calculated to subdue excitement; this is common sense, and the common practice.

During the process of healing, position of the parts ought to be carefully attended to; contraction of the cicatrices, and cohesion of opposed surfaces often causing unseemly deformities. Surfaces opposed to each other, and naturally separate, may be prevented from uniting by dressing interposed; and contraction of joints is to be guarded against by keeping the limb extended by splints and bandages. Where deformity has occurred, the hardened cicatrix which is in fault may be either divided or excised, and by paying attention to position in the after-treatment, the evil may be greatly lessened. In the case of contracted joints, it is not necessary to excise the whole or greater part of the callous web; simple division is sufficient, if carried deep enough, through the altered and condensed cutaneous tissue. A horrid case of deformity is sketched on the next page, and from a very horrid and atrocious scoundrel, the companion and assistant of Messrs. Burke, Hare, and Co., the Thugs of the Modern Athens. In such a deformity the art of surgery could not avail. In others, however, the cicatrix is not so extensive; it is separated into bands, by the division of which the position of the head and lip is improved, and the comfort of the patient much enhanced. In one case, in which I operated with success very lately, the scar, though extensive, was remarkably soft and pliable, as much so as the finest kid leather.

PART SECOND.

OF PARTICULAR SURGICAL SUBJECTS.

INJURIES OF THE HEAD.

Wounds of the Scalp are attended and followed by more dangerous symptoms than wounds of the integuments on any other part of the body. This is in a great measure attributable to the nature and connections of the parts. The subcutaneous fatty matter is condensed, and closely attached to a firm and unyielding tendinous expansion; and betwixt these tissues and the pericranium, a loose cellular tissue is interposed, so as to allow of free motion of the parts. They are highly vascular, with the exception of the occipito-frontalis fascia, and between them and the internal parts, as is well known, a free communication exists. Injuries of these coverings, though at first apparently trifling, and consequently looked upon as of no importance, and unattended with danger, often assume a very alarming character. No injury of the head, in fact, is too slight to be despised, or too severe to be despaired of.

Punctured and lacerated wounds, more especially those penetrating all the layers of covering, are frequently followed by violent and extensive inflammation of all the tissues, with severe constitutional disturbance, and with delirium and other symptoms denoting functional derangement of the brain. The swelling is often extensive, involving the whole scalp, together with the integuments of the face, and completely shutting the eyelids. In some cases resolution may be accomplished, but the most frequent termination is extensive infiltration of purulent matter into the cellular, or even into the more deep structures, with sloughing of the tendinous expansion. Collections of matter frequently form in the loose cellular tissue of the eyelids, when the parts are affected with inflammation, whether superficial or deeply seated.

As to treatment, after the infliction of an injury, the scalp ought to be shaved, and the wound cleansed of coagula and foreign substances. If a large flap of integument is detached, it should be replaced, and retained as nearly as possible in its natural situation; and if, for this latter purpose, slips of uninitiating adhesive plaster and methodical compression prove insufficient, it will be necessary to employ a very few points of interrupted suture: these, however, must be removed at an early period, that is, when either adhesion or suppuration has commenced, and ought, if possible, to be altogether dispensed with, being apt in this situation to produce injurious effects by their irritation. Light dressing is afterwards applied. On the accession of swelling, heat, and pain, the parts are to be well fomented with a hot decoction of chamomile flowers, or hops, and afterwards covered with a warm and soft poultice; and should these symptoms continue, the fomentation ought to be frequently repeated. Fomentation and poultice are also the best applications when a day or two has elapsed between the receipt of the injury and the patient’s application for cure. The constitutional symptoms are to be moderated, and may in many instances be averted, by the exhibition of antimonials and purgatives; and by general bloodletting, when demanded and authorised by the symptoms, and the state of the constitution. Punctures or incisions are to be employed according to circumstances, in order to lessen the vascular congestion of the part, and prevent the formation of matter, to evacuate it if already secreted, or to relieve inflammatory tension and promote the formation of pus at the incised parts, where erysipelatous inflammation is threatened, healthy suppuration in such circumstances often appearing to be critical. In many unpromising cases of lacerated scalp, when a great part of the cranium has been exposed, and partially deprived of its periosteum, a rapid cure has taken place without the formation of much matter. The detached scalp, though much torn and bruised, ought not at first to be removed, it being more prudent to leave nature to determine how much must be destroyed. After the sloughs, if any, have separated, and granulation has commenced, the loss of substance is rapidly repaired in this region, more especially when the patient is young and healthy. General or partial support, by bandaging, is required in many cases, as by a handkerchief, split cloths, or a roller applied in various forms.

Wounds of the Temporal Artery are either the result of accident, or made intentionally for the purpose of abstracting blood; and it may be here proper to make a few remarks regarding this latter circumstance. When it is wished to take away blood from the head, no one thinks of opening the trunk of the temporal artery; its anterior branch is generally chosen. By some the vessel is first exposed by means of a scalpel, and then opened with a lancet. But preliminary incisions are altogether unnecessary. The vessel ought not to be cut entirely through, and the incision should extend obliquely across its course; and care is to be taken that the external aperture shall be larger than that in the cellular tissue involving the artery, as thus the blood escapes freely, and no risk is incurred of its becoming infiltrated into the surrounding parts. When the branch is of the ordinary size, a sufficient quantity of blood is readily obtained from it; but if, from its small size, or a faulty form of incision, blood does not flow freely and quickly, a cupping-glass may be applied, and its lower edge slightly raised. This latter precaution is absolutely necessary, for if neglected, little or no blood can escape, the artery being firmly compressed against the cranium by the edge of the exhausted glass. No other mode of cupping ought to be practised on the temples, for the cupping by scarification is here both unwarrantable and unnecessary—unwarrantable, because the cicatrised scarifications leave an unseemly and permanent mark on a prominent part of the countenance,—and unnecessary, since there can be no occasion for six or eight incisions when one is fully sufficient. The bleeding may be readily stopped, after the requisite quantity has flowed, by a small graduated compress placed over the wound, and retained by bandages, which surround the head, and are afterwards twisted and brought under the chin in order to increase the security. If by these means the bleeding is not readily restrained, the vessel may be divided throughout its whole circumference, by entering the lancet at the original wound, and moving its point laterally. Then compression is to be again employed, by the assistance of which the natural processes for closing the divided extremities are speedily accomplished.

When this artery has been injured by external violence, the wound of the integuments is generally large, and the bleeding profuse. In such cases, both ends of the vessel must be pulled out by means of forceps, and tied separately; afterwards the integuments are to be approximated and supported.

Unpleasant consequences sometimes result from the simple operation of opening the temporal artery, and occasionally also from accidental wounds of that vessel. The integuments unite, and may soon heal; but, from the compression not being sufficient, a small quantity of blood is insinuated into the cellular tissue, which becomes condensed for a considerable extent around the wound, and ultimately a sac is formed, which communicates with the ununited opening in the artery, and is consequently filled with sanguineous clots; in short, an aneurismal tumour is formed. For the cure of this untoward occurrence, the artery may be tied between the heart and tumour, as in the case of spontaneous aneurism; but in consequence of the free inosculation which exists between the numerous ramifications of the artery, this measure may not prove successful, and it will be found necessary, either then or afterwards, to secure the vessel beyond the tumour. But there is another mode of procedure. From the tumour being generally small and circumscribed, excision of the whole of it can be effected easily, and so as to leave but a slight scar: this operation is not liable to failure, and is not more severe than the first mentioned. After the removal of the diseased part by elliptical incisions, the two ends of the artery are to be included in separate ligatures, and the edges of the wound kept together.

A more troublesome accident sometimes takes place,—ulceration of, and over, the vessel, with effusion of serous and purulent fluids into the surrounding cellular tissue, often to a great extent. A profuse flow of blood bursts from the ulcerated surface, perhaps twelve, fifteen, or twenty days after the vessel had been opened, and, if active means are not speedily adopted, the hemorrhage by its recurrence may prove very dangerous. In such cases compression is of no avail; the bleeding may be staid for a time by this means, but upon the circulation becoming again active, fresh hemorrhage must and does take place; the parts around are separated and engorged more and more, the blood escapes in alarming quantities, and the patient is saved only by the occurrence of syncope. To search for, and make a clean dissection of the wounded part of the vessel in such cases, is impossible. A long and deep incision must be made through the swollen and diseased parts in the course of the arterial branch, and a ligature passed under it, on each side of the ulcerated point, by means of the common curved suture-needle, or of one in a fixed handle. The ligatures should be at a considerable distance from each other, in order that they may surround healthy parts of the vessel; after they have been firmly tied, all risk of further hemorrhage is gone. Of course the ligatures should enclose as little as possible of the parts surrounding the artery. A poultice is perhaps the best application for a few days, and under its soothing influence the effects of the continued compression, which had been previously employed, soon subside. The after applications must be varied according to the appearances which the part presents.

Laceration of a large or small bloodvessel is a frequent consequence of bruise of the scalp.—Blood is effused, and the surrounding parts are thereby separated to a greater or less extent; and thus a tumour is formed, either rapidly or slowly, according to the size of the injured vessel. The swelling is in general large, soft in the centre, and hard towards its circumference; the blood in the latter situation being coagulated, and firmly impacted in the condensed cellular tissue; whilst in the centre it is fluid, or at least partially so, and occupies a free cavity. These characters of the tumour are apt to mislead a careless or inexperienced examiner, the feel being in some degree similar to that attending fracture with depression, but still easily distinguishable from it by attentive and experienced manipulation. By pressing the finger or thumb firmly on the centre of the tumour, the blood is displaced, and the bone felt distinctly. In slight cases of this affection, no treatment is required, as the tumour is of no importance, and soon disappears, by the effused blood being absorbed. When, however, the swelling is accompanied with unpleasant symptoms, cold applications are to be made to the part, and low diet, with occasional purgatives, enjoined. If inflammatory symptoms occur, local abstraction of blood may be necessary, followed by hot fomentations to the part. When the pain has ceased, and the swelling is not speedily removed, absorption is promoted by stimulating applications, such as fomentation with a solution of the muriate of ammonia in a decoction of the anthemis nobilis, in the proportions of ℥ss. to ℔ii.; a spirit lotion containing the tincture of arnica montana, in the proportion of one part to fifteen or twenty of water, will be found a good application in many such cases.

Such tumours may ultimately require to be laid open, in consequence of the blood putrefying and becoming mixed with purulent secretion. Under no other circumstances is incision warrantable, as unhealthy, troublesome, and tedious suppurations are sure to follow.

Of Concussion.—Concussion, in a greater or less degree, attends most injuries of the head. The functions of the brain are either disturbed or suspended; there is loss of sensibility, of volition, and frequently of the power of motion. The confusion of intellect or stunning may disappear in a short time, or may continue, though diminished in intensity, for many days, and even for weeks; it is seldom, however, that the functional disorder exceeds in duration two or three days, and in general it disappears before that length of time has elapsed. The stupor is seldom complete; the patient can perhaps be roused, though with difficulty, so as to answer questions by a hurried monosyllable, or make signs in regard to the seat of pain, or for such things as he may suppose himself to be in need of. At first the circulation is weak; the pulse is fluttering, often intermitting, and scarcely to be felt in the extremities; the countenance is pale, and the surface cold; there is occasional vomiting, a symptom which seldom occurs when compression of the brain exists, and the breathing is difficult, though scarcely ever stertorous. The pupils are generally contracted, but not uniformly so; one pupil may be contracted and the other dilated; at first, they are insensible to light, neither dilating when in darkness, nor contracting further when the light is suddenly increased; not unfrequently a considerable degree of squinting exists. The muscles are neither much relaxed, nor spasmodically contracted. After a time, the circulation is restored, and the heat of the surface returns, with more or less of regained sensibility. The pulse either becomes altogether natural, or else more slow or more rapid than in health. The circulation is then easily excited; by even raising the patient in bed, the pulsations of the carotids are increased, in some cases, by fifteen or twenty beats. Sensibility returns, always very gradually, and in some cases more slowly than in others; frequently the patient becomes quite collected after the lapse of some hours or a few days, but in other instances a degree of mental confusion remains for many weeks; occasionally the intellect continues weak for a lengthened period, and sometimes even for the remainder of life.

When the insensibility has begun to diminish, the patient can be roused with less difficulty; if pinched, he complains of it by uttering some inarticulate sounds, or by attempting to move himself further from the quarter whence he supposes the injury to come; he answers, though with unwillingness, loud questions regarding the pain which he suffers, and points to the part where it is chiefly felt. As the stupor goes off, symptoms of inflammatory action, or a threatening of it in a greater or less degree, manifest themselves. The pulse becomes more rapid and sharp, the skin is hot and dry, the face is flushed, the conjunctiva is redder than usual, and the pupils are often much contracted: the patient is restless, and tosses about in bed; mutters confusedly to himself; often attempts to enact a part in some fanciful scene which he supposes to be passing around him, or talks rapidly and incoherently concerning circumstances which have formerly occurred. His flitting ideas are often of an alarming nature; he endeavours to get out of bed, and struggles violently if opposed. He frequently puts his hand towards his head, and gives other indications of suffering acute pain in that region, much increased by any movement of the part.