UNITED STATES OF AMERICA
WASHINGTON,  D. C.
OPO  16—87244-1 
 
 
THE
          L  E  C  T  UR  E   S

                          0 F

SIR   ASTLEY  COOPER,  BART.   F.R.S
                     Ml
          SURGEON TO THE KINXJ,  &c,

                       ON  THE

      PRINCIPLES  AND  PRACTICE

                          O F

                 SURGERY;
  ADDITIONAL  NOTES  AND CASES.


         BY  FREDERICK  TYRRELL,  ESQ..,
Surgeon to St Thomas's Hospital, and to the London Opthalmic Infirmary,

                  THIRD AMERICAS
          FROM THE L4ST LONDON EDITION,
VOL.   II      H
s^v?
          BOSTON—LILLY AND  WAIT.
G. ■& C. .V: H. CARV1LL, AND E. BLISS, NEW-YORK ; CAREY & HART, PHI-
  LADELPHIA; W. & J. NEAL, BALTIMORE; LITTLE & CUMMINGS, AL-
  BANY ;  M.CARROLL,  N. ORLEANS; AND S.' COLMAN, PORTLAND,
                          1831. 
wo
C77CL
1831
 v.Z

  \-ktn2. 
PREFACE.
   The delay in the  publication of this volume has
been occasioned by a fire at the Printer's, which de-
stroyed the  impression  when it was  nearly  com-
pleted.

   I have  added a Paper by Sir Astley Cooper, on
the developement of the Nipple, which he  had the
the kindness to send me with the following Note:


   ' DEAR  SIR,

       ' I have looked over this Volume, and find it
contains a correct account of the subjects treated of
in my  Lectures.
    ' I have sent you a  few observations on the
swellings  which  form in the Nipple, and up on the
structure in which they are founded; this may  form
an Appendix to the diseases of  the breast which are
described  in this volume.

                    ' Yours very truly,

                         ' Astley Cooper.'
' Spring Gardens.' 
 
CONTENTS.
LECTURE		PAGE
XIII.	On Injuries of the Spine,	9
XIV.	On Aneurism,	25
XV.	On the Operation for Aneurism,	44
XVI.	On Hydrocele,	70
XVII.	On the Operations for the Cure of	
	Hydrocele,	81
XVIII.	On the Diseases of the Testicle,	94
XIX.	On the Simple Chronic Enlargement	
	of the Testis,	110
XX.	On Diseases of the Breast,	125
XXI.	On the Treatment of Scirrhous Tu-	
	bercle,	146
XXII.	On Urinary Calculi,	167
XXIII.	On the Operation of Lithotomy,	184
XXIV.	On Calculi in the Prostate Gland,	222
XXV.	Operations for Retention of Urine,	230
XXVI.	Of Fistula in Ano,	244
XXVII.	Of Polypus of the Nose,	260
XXVIII.	Paracentesis of the Abdomen,"	273
XXIX.	Of Hare Lip,	292
XXX.	On Amputation,	308
 
 
              WLtttUVtSit

                       c^c.



              LECTURE   XIII.

             ON INJURIES OF THE SPINE.

   The effects which arise from violence done to the
spine, are very similar to those which are produced
by injuries to the head; for example—concussion—
extravasation—fracture—fracture with depression—
suppuration and ulceration.

       OF CONCUSSION OF THE SPINAL MARROW.

   Effects of—When a  person  receives a severe
blow upon the spine,  or, from any  great violence,
has  it  suddenly bent, a paralysis  of the parts below
will  frequently succeed,  in a degree proportioned to
the  severity of the injury; and after such an event,
the person sometimes gradually recovers the motion
and sensation of the paralysed parts.
   Treatment.—If the part be tender to the touch, or
the patient complains of pain, blood should be taken
away, near to the part injured, by cupping or leeches,
and  the bowels should be kept freely open.  After
a week or ten days, if the patient be not much re-
lieved, a  blister should be  applied, and the surface
be afterwards  dressed with equal parts  of the un«
  VOL.  II.            1 
10
guent: lyttae and  cerat: sabinae.  The extremities
should be frequently rubbed with a liniment of a
slightly stimulating nature ; and as sensation returns,
electricity  or galvanism  may  be beneficially em-
ployed.
   Case.—A man was  admitted  into Guy's Hospital
(under the care  of Dr. Curry) who had received a
severe blow from a piece of wood falling upon his
loins.   When he was brought into the Hospital, his
lower extremities were in a  great degree deprived
of motion, and their sensation was much diminished.
When resting on his  back in bed,  he could with
much difficulty draw up his legs, but could not bend
them  at a right  angle with his body;  and a conside-
rable  time elapsed  before he could make the mus-
cles of his lower extremities  obey the efforts  of his
will.  As there  was still the  appearance of severe
contusion and much deep-seated tenderness at the
injured part, blood  was repeatedly taken away by
cupping, and his  bowels were  kept freely  open by
calomel and  saline medicines.   When the pain and
tenderness  had  been removed, a blister was  applied,
and a discharge  kept up  from the surface for  three
weeks.  The liniment: ammonias was rubbed on the
extremities.   In  six weeks the motion  and sensation
of the limbs had nearly returned, when he was sub-
mitted to the influence of electricity.   By this  treat-
ment, in ten weeks, he got perfectly well.

                OF EXTRAVASATION.

  Of effusion of  blood into the  spinal canal, I have
seen  but  very  few examples:  one I recollect wit-
nessing in  St. Thomas's  Hospital.  A man had re-
ceived a severe blow  upon  the dorsal  vertebras,
which produced complete paralysis  of the  lower
extremities,  and  shortly after his admission  into the 
11
Hospital he died.  Upon examination after death,
slight extravasation was found in the spinal canal.
   Case.—I  was consulted  about a very interesting
case which was under the  care  of  Mr. Heaviside ;
the particulars of which were as follow :  A young
gentleman was swinging, when  some of his compa-
nions caught him by the neck with a rope, during
the time that  the swing was in rapid motion; by
which the whole of the cervical portion of the spine
was  violently strained.  As, however,  the  line slipt
immediately off, he thought but little of it.   Subse-
quently to  the  accident, for some  months, he was
not  aware of  any pain  or inconvenience;  but his
school-fellows observed that he was less active than
usual; instead  of filling up his  time  by play, he
would be lying on the school forms, or leaning upon
a stile or gate, when in the fields.  From this time
he continued to decline, both in strength and power.
He was brought to  London for advice about the
middle  of  May.  His  complaints  were occasional
pains in his head, which were more severe and fre-
quent about the back part and the neck, extending
down the back.   The muscles at the posterior part
of the head and neck were "stiff,  indurated, and very
tender to external pressure : he  felt pain in moving
his head or  neck  in  any direction; added to  these
symptoms, there was a great deficiency in the volun-
tary  powers of motion, especially in the limbs.
  Two setons were placed in the neck, and he took
various medicines, without  experiencing any benefit.
His complaints,  especially the paralytic affection of
his limbs, got much worse; besides which,  he felt
an extremely painful  sensation of burning in the loins.
In a  short time this was succeeded by a sense of ex-
treme coldness  in  the same part.  The pulse and
heat were natural. 
12
  A consultation of Dr. Baillie, Dr. Pemberton, Mr.
Heaviside, and myself, was held,  and the application
of mercury was determined on.  The pilul: hydrarg:
was taken for  a few days ; but as it  produced vio-
lent action upon the bowels, mercurial frictions were
consequently employed.   He felt his limbs getting
every day weaker, but his neck was more free from
pain when moved, and he was more capable of mov-
ing it by his own natural  efforts.
  On the 7th of  June his respiration became labo-
rious;  all his  symptoms  rapidly increased, and on
the following day he expired.

                   EXAMINATION.

  The whole  contents of his  head  were carefully-
examined, and appeared perfectly healthy; but upon
sawing out the posterior  parts of the cervical ver-
tebras, the theca  vertebralis was found  overflowed
with blood, which had been effused between the the-
ca and the enclosing canal of  bone.  The dissection
being further  prosecuted, this effusion was found to
extend from  the first  vertebra of  the neck to  the
second vertebra of the loins, both included.
  The preparation, which is in the museum of  Mr.
Heaviside, only shews a small  portion of  the  effused
blood, which  had become coagulated on  the theca;
as much of it, being fluid, escaped during the exami-
nation.

           FRACTURE WITH DISPLACEMENT.

  The separation of one vertebra  from  another is
of very rare occurrence without fracture ;  and the
supposed dislocations of the spine are, in a very large
majority  of  cases, fractures  with  displacement.
When this happens, the  parts of the  body situated 
13
below the  seat of injury become paralysed.   Thus,
if it occur in the lumbar vertebrae, the person imme-
diately loses  all power of motion  and sensation  in
his lower extremities, his faeces pass off involuntarily,
the action of the sphincter ani being destroyed; and
his  urine is retained, the bladder  being unable  to
contract.
  Of the  dorsal.—When the dorsal  vertebrae are
the seat of this injury, all those  parts situated below
the fracture  are paralysed, as in the former case;
but in addition, the abdomen becomes distended with
air, which  escapes into the intestines in consequence
of the diminished powers of  the part;  this  gradu-
ally subsides after the patient's  bowels have been
freely opened.
  Of the lower  cervical.—If the fracture with dis-
placement takes place in any of the cervical verte-
brae below the fourth,  the same symptoms occur in
the body and lower extremities  as when the dorsal
vertebrae are injured;  and there is also a partial pa-
ralysis of the upper extremities, but seldom such as
to deprive the patient of all motion and sensation.
   Of the upper cervical.—When it happens above
the fourth cervical  vertebra, the person generally
dies on the instant; because the diaphragm is para-
lysed, which is the only agent in supporting respira-
tion after such  injury  of the  lower vertebrae of  the
neck; but when  the  fracture  with  displacement is
above the  origin of  the phrenic  nerve,  the dia-
phragm  loses  its power,  and dissolution almost im-
mediately results.
   Period of termination.—Patients  rarely  recover
from these injuries to  any part  of the spine, but the
period at which life is destroyed varies according to
the seat and violence of the accident.
   From injury  to the  lumbar  vertebras.—In the loins,
if the displacement be considerable, the person may 
14
die in  three weeks; but if slight,  the patient may
survive many  weeks.  I recollect  a  case  in which
the patient lived two years  after a supposed  frac-
ture with displacement of the lumbar vertebrae; but
the precise nature  of the  injury was  uncertain, as
the friends would not permit any examination of the
body after death, by which alone the  extent of the
mischief could have been decidedly ascertained.
   To  the dorsal.—The  patient  usually survives a
much  shorter period when the dorsal vertebrae are
injured: although  I  have  known a gentleman live
nine months  after  such an  accident  to this  part,
which  was occasioned by his horse falling, and rolling
upon him, after  leaping over a wide and deep  road,
to which he came unawares whilst riding  at speed.
   To  the lower  cervical.—After  the  occurrence of
such injury between the fourth and seventh cervical
vertebrae, the patient seldom lives  longer than four
or five days, and in  some cases dies  within eight-and-
forty hours after the accident.
  Fracture without displacement.—Fracture of a ver-
tebra may take  place without displacement; a curi-
ous instance of which occurred  in the cervical verte-
brae, at the time I lived with Mr. Cline, the particu-
lars of which were  as follow:
  Case.—A girl received a severe blow upon her
neck;  after which  it was observed, that whenever
she wanted to look  at  any object,  either  above or
below  her, she always supported  her head with her
hands,  and then gradually and carefully elevated or
depressed it, according as  she wished, towards the
object.   After any sudden  shock she used to run to
a table, and placing  her hands under her chin, rested
them against the table until the agitation occasioned
by the concussion  had  subsided.   Twelve months
after the accident  the child died ;  and on examina-
tion  after death Mr. Cline found a transverse  frac- 
J.0
ture of the atlas,  but  no displacement.  When the
head was depressed or elevated,  the dentiform pro-
cess of the second vertebra became displaced, carry-
ing with it  a portion of  the atlas, occasioning pres-
sure upon  the  spinal  marrow, which  was also pro-
duced by any violent agitation.
   Treatment.—In  the  treatment of fractures of the
spine, with displacement, no plan, hitherto adopted,
has been productive of any permanent benefit.
   Mr.  Cline's  operation.—Mr. Henry Cline,  who
was an excellent anatomist, and a very good surgeon,
first attempted to afford  relief  by  operation after
this accident, as he thought that cases of this kind
should be treated as those of fracture with depres-
sion of  the  skull; and he had made  numerous ex-
periments, the result  of which gave  him reason to
suppose that such an  operation might be successful.
He cut down upon the spine, at the part where the
displacement was  evident, and having exposed  the
spinous process and arch of the injured vertebra, he
sawed through the arch  near to  the transverse pro-
cess with a small trephine of his own  invention, and
then raising the depressed portion of  bone, he thus
took off the pressure from the spinal marrow.
   It is well known that  union of bone  has  taken
place after fracture with slight displacement of the
vertebrae.   Mr. Brooks has a preparation shewing a
union of this kind ;  and  in the museum at the Col-
lege of Surgeons is another portion of spine, present-
ed by Mr. Harold, of  Cheshunt,  in which union has
been produced after  an  accident  of this nature.
There can be no fear  then as to the  restoration of
the part, if the pressure  on the spinal  marrow could
be removed.
   In many cases of fracture with displacement of
the  spine,  the spinal  marrow is  either partially or
completely  torn through.   In such instances little 
10
good could result from  an operation;  but in others
the spinal marrow  is apparently but  little injured;
and  in  such cases  it was,  that  Mr. Cline thought
there might be hope from an  operation.   Mr. Tyr-
rell  has  performed the operation since  Mr. Cline,
but both cases terminated fatally :*—whether future

  * As this case has been published in a foreign  work, with
some inaccuracies, I take this opportunity of giving a correct
detail of it.
  John Buckley, aged twenty-five, a labouring man, about the
middle size, and of rather spare habit,  was brought into St.
Thomas's Hospital, on the  evening of  Tuesday,  the 15th of
October 1822, having received some injury to the  spine, which
was occasioned by his  slipping at the time he was carrying a
heavy load of cast metal: he fell about  five feet, but was not
aware that the metal struck  him.  The accident had happened
early in the morning of the 13th, since which time his urine
and faeces had  passed off involuntarily.   I saw  him a few hours
after his admission into the Hospital, and,  on examination, found
that he had lost all sensation  and power of motion, below Pou-
part's ligament anteriorly, and the lumbar vertebrae posteriorly;
in fact, the superior edge of the pelvis marked accurately the
line between  the  sensitive  and the  non-sensitive parts.  The
spinous  process of the twelfth  dorsal vertebra was depressed,
and he complained of acute pain when this part was touched.
The temperature of all parts was equal.  He had not passed
any urine since his admission,  but at  night he complained of its
accumulation giving him inconvenience,  when it was drawn off.
16th.  He was  much the same  in every respect; in the after-
noon, my colleague (Mr Green) was kind enough to see him
with me; when we decided  that an operation, similar to that
performed by Mr. H. Cline,  might probably be beneficial; but
as our consultation was late in the day, and the operation likely
to be very tedious, I deferred it until the next morning.   17th.
No  improvement or abatement of any of the symptoms : at half
past ten o'clock he was taken into the operating theatre on his
bed, being placed with  his  face downwards,  and some pillows
under the  lower part of the  abdomen, in order to elevate that
portion of the spinal column which had been injured.  My col-
leagues (Messrs. Travers and Green) being present, I perform-
ed  the following operation.   An incision, about six inches in
length, was made through the integuments, in the direction of
the  spinous processes, havincr that of  the last dorsal vertebra ir 
17
 trials will be more successful,  it  is difficult to say;
 we cannot speak decidedly on  the  subject,  as  the

 the middle, over the point of which was observed some slight
 extravasation of blood.  The muscles were then separated by
 the scalpel, from the sides of the  spinous processes, and from
 the arches of  the twelfth  dorsal and first lumbar vertebrae, as
 far as the transverse processes,  also partially from those above
 and below.  During this separation some arterial haemorrhage
 occurred, which vas very troublesome in obstructing my view
 of  the parts;  but it was not very copious.   An assistant then
 held aside the integuments and muscles with a broad bent piece
 of iron, so as to allow of the application of a small trephine on
 the arch of the first lumbar vertebra.  After using the trephine
 for some time ineffectually,  I cut  away the spinous process of
 the vertebrae with a chain saw, which enabled me to see much
 better the operation of the trephine; and finding  that 1 made
 very little progress with it,  I took, instead of it, one of Hey'a
 small saws, with which I sawed nearly through  the arch, close
 to the transverse process; and  after having done the same on
 the other side,  I soon succeeded in removing the larger part of
 the arch with a pair of strong tooth forceps, leaving but a thin
 portion,  covering  the  canal.  The arch of the twelfth dorsal
 (over which the extravasation had  been observed) was distinct-
 ly found  to be  loose:  I then  proceeded to remove it, as I had
 done the former, which I soon effected  completely, so as to ex-
 pose the ligamentum subflavum:  this  was found divided: on
 elevating it, the dura matral covering of the cord  was seen
 quite perfect, and  apparently free  from injury.   I then remov-
 ed the portion of the arch of the first lumbar, which 1 mention-
 ed as having left, together with the ligament, exposing near
 two inches of the sheath of the  cord, which appeared healthy;
 and under which the pulsations of the cord could be seen.  The
 patient could now feel distinctly,  on being pinched inside the
 thigh; which  immediate  return of sensation was beyond my
most sanguine  expectations.  The edges of the wound were
brought together by two sutures,  dressed lightly with strips of
adhesive plaster,  and  the patient removed to his ward, on the
same bed, and  in the same position.
  I am much indebted to my colleague, Mr. Green, for his assist-
ance, and am happy in having this opportunity of publicly thank-
ing him for his  kindness, not  only in this instance, but many
others in which I have had occasion to ask his advice or assist-
 ance.  The operation occupied nearly an hour and an  half, dur-
 ing which time  the patient scarcely uttered a complaint.  More
   VOL. II.             2 
18
 first operations have been unsuccessful.  The proposal
 is laudable, and the operation is not severe, nor does

 patience  is required in the performance of this operation than
 skill; as  it is extremely tedious, and requires much care  in
 using the saw;  also in elevating the bone  from the canal. The
 trephine is of no use ; the scalpel, Hey's saw, and the forceps,
 are all the instruments required, with the piece of bent iron to
 hold aside the muscles.  Mr. H. Cline used this last instrument,
 which answers the purpose much better than the fingers of an
 assistant could do, and is much less in the way.
   Soon after being placed in his ward,  he took thirty drops of
 the tincture of opium, as he expressed a wish for something to
 make him sleep.   I saw him again at  three o'clock, when he
 said he felt very comfortable ;  but did not appear to have more
 sensation than when removed to his ward  after the operation ;
 he had not slept, in consequence of which the tincture of opium
 was to be repeated in the evening. Being engaged out of town, I
 did not see him again  until about one o'clock in the morning of
 the 18th : he was  perfectly easy; had slept, and felt me pinch
 his toes : a very considerable oozing had taken place from  the
 wound, more of  a serous  than sanguineous nature;  his pulse
 was feeble ; in consequence of which  I  directed  him to take
 weak wine and water, when thirsty.  Ten  o'clock.  Had slept
 comfortably since I quitted him ; serous discharge still continues
 from the  wound, which looks  healthy;  the edges in several
 parts adhering;  pulse still weak; ordered his  wine and water
 to be made stronger.  One o'clock.  Complained of his bladder
 being distended,  when 1 introduced a  flexible catheter,  and
 drew off about a quart of high-coloured  urine.  The catheter
 was allowed to remain in the urethra,  and I desired that  the
 bladder might be kept empty, by frequently taking out the plug
 and letting the urine flow off.   Eight o'clock.  Very easy;  had
 passed but little  urine since ;  pulse had got up considerably,
 but was soft and regular.  Not  having passed  any faeces since
the operation, I ordered an injection of common salt and barley
 water (the enema  com: of the   Hospital) to be  thrown up;  he
 felt it pass, and it was retained :  wine  and water to be weak-
 ened.  19th.  Ten  o'clock.    Had  slept  well;  pulse good;
wound looking  very  healthy; slight suppuration ;  sensation
more general and distinct; had  not  had  any motion or return
 of the injection,  in consequence of which I directed him to
take  four grains of calomel  and a scruple of rhubarb immedi-
 ately.   His position (which  had not been altered since  the
•peration) being  uneasy, I had him  turned  a little to one side, 
19
it increase  the danger of the patient; time and ex-
periment can only determine its value.  If we could

propping him well with pillows.   His urine had been frequent-
ly allowed to flow off; but much had not passed. Eight o'clock.
Very comfortable; pulse  rather  full; to omit his wine.   20th.
Slept well;  pulse good ;  sensation more distinct;  wound look-
ing  well, with rather more suppuration ; his  position changed
to the other side ; has not had any motion ; enema to be repeat-
ed,  with the addition of  an ounce of castor oil.  21st. Bowels
freely open, but the passage of the faeces involuntary, although
he could tell when they passed.  He had not slept quite so well,
on account of the nurse  having loaded him with  bed clothes,
which occasioned very copious perspiration : pulse good; wound
healthy : sensation improving : during the night, a considerable
quantity of urine escaped into the bed, in consequence of the
nurse having taken the plug from the catheter; it was extreme-
ly ammoniacal, and caused excoriation in two or  three places
about the thighs ;  a  dry  sheet was drawn  under him, and pow-
dered chalk applied to the excoriations.   22d. Slept well, but
again perspired profusely ; pulse  weak ; wound healthy ; rath-
er more excoriation :  to take some diluted nitric acid, and to
eat a small quantity of  meat; position occasionally changed
from side to side ; sensation gradually  increasing.   23d. Slept
tolerably, perspired but very little, was rather restless; pulse
good ;  wound healthy ; the urine loaded with  mucus ;  in con-?
sequence of which I directed  that he should  omit the acid, and
take some  liquor potassae,  with a  few drops of  tincture  of
opium,  three or four times in the day.  Hitherto  he had been
lying on his abdomen, and now and then turned a little to either
side ; this  position was  very uncomfortable  to him,  and  the
pressure on the excoriated parts  very painful; I therefore or-
dered a clean bed to be made up, with the addition of two long
soft pillows, which were placed  lengthways on the bed, under
the sheet,  leaving a space between them ; he  was  then care-
fully moved into it, and placed on his back,  with the spine in
the space between the pillows:  he expressed much reiief from
this alteration, which  did not occasion the  slightest inconve-
nience.   24th. Slept well, and had turned a little to the side in
the  night;  wound healthy;  pulse good;  discharge of mucus
with the urine less in quantity.   The catheter had  been with-
drawn  the  evening before;  and,  during the night,  he  had
passed  small  quantities  of urine of  his own  accord;  but there
is  still  a dribbling:  he also  feels distinctly the  passage of
the  faxes,  but  cannot retain them.  The liquor potassae  had 
20
 save one life  in a hundred  by it,  we s*hould  deserve
 well of  mankind; and  if  any good  does ultimately

 been given him in  the  night, undiluted; by which his mouth
 was burnt,  and  he objected  to  take any more.   I, therefore,
 ordered a mixture of carbonate of soda,  carbonate of  magnesia,
 and mucilage, to be taken two  or three times  a day instead.
 Sensation pretty distinct to the toes.   25th.  Had not slept very
 well; pulse good ; and  wound  healthy; quantity of  mucus in
 the urine larger : to take soda water.  At eleven o'clock in the
 evening  I was sent for, in consequence of his  complaining of
 pain in the region of the bladder.  His  countenance  was rath-
 er anxious, and he was very restless; the pain was confined to
 the region of the bladder;  the  abdomen flaccid ; r.nd the bow-
 els freely open.   The  catheter  had' been  passed, by which a
 considerable quantity of mucus was drawn off—this had reliev-
 ed him a good deal;  pulse not in the least hard or thready; to
 foment the lower part of the  abdomen, and  to take thirty drops
 of opium every four hours; some mucilage, alkali, and opium,
 to be injected into the bladder.   26th. Had slept at  intervals;
 pulse pretty good; wound healthy; urine not sa much loaded
 with mucus; still considerable pain at the lower part of the
 abdomen.   Leeches to be applied  immediately; the  fomenta-
 tion continued, and opium to be taken every four hours.   27lh.
 Had been relieved by the application of the leeches, which I
 ordered to be repeated, as he still  complained of pain.  Slept
 a little ; much anxiety of countenance :  urine still loaded with
 mucus, and  tinged  with  blood;  pulse  rather quick,  but soft.
 The fomentation to be continued ; bowels freely open; the
 pain in the region of the bladdtr increased a little in the even-
 ing,  when 1 again ordered the leeches,  and constant fomenta-
 tion.  28th.  Appeared much  better; had slept  well, and had
very little pain in the abdomen, which was considerably distend-
 ed, but not tense, or painful on being pressed ; wound looking
 healthy;  pulse much the same as yesterday; urine not so much
loaded with  mucus, but still tinged with  blood; much troubled
 with flatulence :  in the evening he was much the same.   29th.
 Had slept tolerably for a few hours after I saw him;  but early
in the morning awoke with pain in the stomach, and immediate-
 ly began to vomit; the vomiting continued almost incessantly
 until I arrived at the Hospital in  the  morning,  when  it abated
 a little ; but he still continued at  intervals to throw up  quanti-
 ties of a dark green bilious-looking fluid, the same as he had
 ejected from  the first; it was not frothy, nor had it a foetid
 or sour smell: 1 ordered him to  take  the effervescent mixture 
21
result  from  it, Mr. Henry Cline has the merit of
proposing it.—Palmam qui meruit ferat.

(subcarb. of potash,  mint  water,  and lemon juice,) with  ten
drops of tincture of opium, evary half hour, and waited to see
the effect:  after taking two doses, he became much more tran-
quil, and went to sleep, in  which state I left him.  The vomit-
ing returned occasionally during the day,  but  was always re-
lieved by the effervescent  mixture.  In the night he was very
restless  ; and on one  occasion, when the nurse quitted  his bed-
side for a few moments, he nearly got out of bed, and was only
prevented  by her return; towards morning  he became more
quiet, but  was evidently sinking, and he died about six o'clock
on the 30th, having been perfectly sensible until within a short
time of  his  death.
  The attempt to get out  of bed is  mentioned  by Mr.  Charles
Bell as a common circumstance in the termination of fatal cases
of injury  to the  spine,  therefore cannot  be regarded as  any
proof of recovery of motion from the operation.

                         DISSECTION.

  I inspected the body between three and four o'clock the same
day, and the followiug is an account of the appearances :
  On opening the cavity of the abdomen a quantity of air es-
caped, which had little smell; the peritoneal covering of the
parietes adhered slightly to  the ilium and  caecum on the right
side of the pelvis, but was otherwise quite healthy ;  a small
quantity of dark-coloured fluid in the cavity of the pelvis.  The
liver, pancreas, and spleen quite healthy.   The stomach, view-
ed externally, appeared sound;  but  on opening it,  the vessels
of its mucous surface were found much injected with  red par-
ticles, which I considered  the effect of long-continued vomiting,
not of inflammation.   The folds of the small intestines imme-
diately in contact with the bladder, and on  the right side of the
pelvis, near the caecum, adhered together,  but, more particular-
ly near  the bladder;  on removing them, the bladder  was ex-
posed, much thickened, and of a bluish tint: I passed a catheter,
with a view of keeping it  from the pubis,  that  I might remove
it more  easily; but with a little pressure, the end of the instru-
ment broke through  its  parietes ;  when removed, the whole of
its coats were found  to be in a morbid state, but more  particu-
larly the mucous one, which was much thickened, and its in-
ternal surface very rough : much as I have seen  it in  patients
who have suffered a  length of time from irregular stone in the
bladder : it was altogether pulpy, and easily broken down.  The 
99
OF SUPPURATION AND  ULCERATION  OF THE  SPINAL MAR-
                          ROW.

   The  only case  in  which I  have had an opportu-
nity of  ascertaining  this disease by  dissection, was
the following :

alteration of structure extended to the membranous part of the
urethra.  The kidneys and ureters were perfectly healthy;  nor
was there any other diseased appearance either in the abdomi-
nal or thoracic  viscera.   The  fracture of the  body of the ver-
tebras was not discovered, until the  vessels,  &c.  covering it,
had been removed.   The surface  of the wound  made in the
operation was sloughy, but this did not extend deeper than the
newly-formed matter.  There  was a deposition of lymph exter-
nally on  that portion  of the dura  matral covering, which  had
been exposed in the operation, as may be seen by the prepara-
tion of the  parts, which are preserved  in the collection at St.
Thomas's Hospital; but both it and the  spinal cord itself were
otherwise apparently in  a sound and healthy state.

                         REMARKS.

  All attempts which have as yet been made to relieve patients
suffering  from injury to the spinal column, by operation, have
proved unsuccessful;  but, I  think, under such circumstances,
that, instead of deterring others from  undertaking similar ope-
rations, they rather tend to encourage them in  the performance.
  When  the above case occurred, I  was not aware that any one,
excepting Mr. Henry Cline, had performed this operation;  but
I have lately received some account of a case  in which Mr. W.
Wickham, junior, of Winchester, operated about six years ago;
and I understand that Mr. Attenburrow, of Nottingham, has  also
performed an operation of a similar nature; but 1 have not been
able to procure any particulars of the case.
  The patient upon whom Mr. Wickham operated, had receiv-
ed a severe blow upon the  back and  lower part  of the neck,
causing fracture with displacement of the seventh cervical ver-
tebra.  The body and the inferior extremities were completely
paralyzed, and there was also  partial  affection of  the superior
extremities.   Mr. Wickham did not see the patient until seve-
ral days after the accident; and had not  therefore an opportu-
nity of performing  the operation sooner than the eighth  day
subsequent  to its  occurrence,^' at which period he did it more 
23
   Case.—A  gentleman,  who  resided  about eight
 miles from London, had, by a fall, received a severe

 from the earnest solicitations of the patient and his friends, than
 from any conviction of its being likely to prove beneficial.
   The operation was easily performed,  and the patient was in
 a degree relieved by it;  his breathing became more free, and
 sensation returned  to a considerable extent, but he died on the
 second day after the  operation.
   Mr. Wickham (to whom I feel much  indebted for these par-
 ticulars) informs me, that the benefit afforded by the operation,
 even at the late period at which it was  performed in this case,
 was  such as  to induce him to think much more favourably of
 the probable  result of a similar operation, performed at an ear-
 lier period after the injury, than he did before the occurrence
 of the above  case.
   The friends of the patient would not permit Mr. Wickham to
 examine the injured  parts  after death, so that he was not able
 to ascertain the precise extent of mischief.
   In Mr. Henry Cline's case the spinal  marrow and its mem-
 branes had been completely torn  through, so that a favourable
 termination could not be  expected.
   My patient died of inflammation of his bladder, occasioned by
 the irritation of the  urine, which, I believe, might have been
 prevented; and I should  have taken steps for that purpose had
 I then known some circumstances, of which I have since been in-
 formed, connected  with Mr. Cline's experiments relative to in-
 juries of the spine.   He  invariably found, that when complete
 paraplegia was produced  by the injury which he inflicted on the
 spinal marrow of dogs, that the  bladder became affected from
 the action of the urine on its mucous coat.  This organ having
 lost its nervous power, it  appears that the urine becomes de-
 composed in it, as it does after it is voided in the usual manner,
 and it then acts as an irritant on the mucous surface; this might
 probably be  obviated  by frequently emptying the bladder by
 means of a  syringe, and by injecting a mucilaginous fluid to pro-
 tect  the mucous coat.
   The immediate,  although partial,  return of sensation in my
 patient, and  the after gradual increase of feeling,  are proofs
 that  the operation was in  a degree serviceable.  The patient
 also  lived long enough to shew that the  effects of the operation
 upon the parts immediately concerned in it, are not sufficient to
 afford any ground for objection to its performance.
   Every surgeon knows what the  termination of these cases
 without operation always is; therefore why not attempt to save
 the patient by an operation, easy in its performance, and not in
itself productive of any serious mischief.—T. 
24
 blow on his spine, which did not, however, produce
 any immediate ill effect.   Some time  after, having
 been much exposed  to changes of weather,  he was
 suddenly seized with pain in his  back, which was
 followed by  paraplegia,  retention of  urine, and in-
 voluntary discharge  of faeces.  I was  requested to
 see him on  account  of the retention  of urine, and
 attended him for a  length of time for the purpose
 of using the catheter.  For several weeks his symp-
 toms remained  unchanged, excepting  the appear^
 ance of a troublesome sore on the nates.   Towards
 the close of  his existence, he complained  of much
 uneasiness and distension at  the upper  part of his
 abdomen.  His appetite failed, he rejected his food,
 and he  had a great deal of fever, with quick pulse
 and profuse perspiration—he sunk gradually.

                    DISSECTION.

  Upon opening the spinal sheath, a milky fluid was
found within it, just above  the cauda equina; and
higher  up, about three  inches,  the spinal  marrow
was  ulcerated  to a considerable depth, and was in
that softened state which the brain assumes when it
is rendered semifluid by putrefaction.   All the other
parts of the body were healthy, excepting  the blad-
der, which  was considerably inflamed.

                   TREATMENT.

  In a case  like  this,  it will be required to take
 f>recautions to prevent inflammation, by cupping or
 eeches  : subsequently, counter irritation, by  blisters
or tartar emetic, will be  useful:   issues or setons
may also, in some cases, prove beneficial. 
2.)
               LECTURE  XIV.

                   ON ANEURISM.

   Definition.—An  aneurism is a pulsating  tumour
communicating with the interior of  the heart, or of
an artery, and containing blood.
   External and internal.—When an aneurism is seat-
ed in one of the  extremities, or upon any superficial
artery, it is generally called external; when situated
upon any of the arteries  of the cavities, as the abdo-
men or thorax, it  is termed internal.   In the first
case, there is usually but little difficulty in ascertain-
ing the nature  of the disease; in the  latter  case,
however,  much obscurity often exists, rendering the
diagnosis extremely doubtful.
   Three stages  of external aneurism.—In the forma-
tion  of external aneurisms, three stages may be ob-
served.   At first, a small tumour is perceived, which
pulsates very strongly;  it then contains only fluid
blood, and may be easily emptied by pressing upon
the artery which supplies  it, between  the swelling
and the heart,  thus stopping the flow of blood into
the sac.   When  in this  stage, the patient does not
experience much pain or inconvenience; sometimes
he is attacked with cramp or spasmodic contractions
of the muscles of the limb below the aneurism, more
particularly  when undressing to go to bed.
   In the second stage, the tumour is larger and more
solid, and the sac cannot be completely emptied as
in the former case.   The blood has in  part coagu-
lated in the  inlerior of the sac,  and its parietes have
become much thickened.  The size  of the swelling,
and its pressure on  the surrounding  parts, now  cre-
   vol. ir.              3 
26
ates  pain, and  retards the circulation.  The pulsa-
tion is still distinct,  but not so violent as in the first
stage.
  In the third stage, the size of the aneurism is still
further augmented, and it acquires much more soli-
dity.  The pulsation  is very indistinct, and only to
be felt at that part of the tumour which is opposite
to the orifice in the artery.   The sac is now almost
filled by  layers of fibrous matter, and contains but a
very small quantity of fluid blood.  The patient ex-
periences much severe pain, and great inconvenience
in moving the limb, particularly if the aneurism be
seated near a joint; the extreme parts of the limb
become oedematous, from the pressure of the tumour
impeding the functions of  the  veins and  absorbent
vessels;  sensation  is  also diminished from pressure
on the nerves.
   Mode in which life is destroyed.—After this the
aneurism continues slowly to  increase; the integu-
ment over  it becomes of a dark colour; inflamma-
tion of the cutis takes place, and  the  cuticle is par-
tially separated  by the formation  of vesicles.   A
gangrenous spot  next appears, and in a short time
an eschar is  formed and separates, by  which the sac
is opened;   some  blood  immediately escapes, but
rarely in sufficient quantity to destroy life.   The pa-
tient sinks  from  the repeated  loss of blood,  much
more frequently  than from one copious haemorrhage.
   At first, the opening  into the  aneurismal sac is
small, and the bleeding which takes place usually
slight, being easily stopped by pressure upon  the
wound;  but  as the sloughing  process  proceeds,  the
opening  becomes enlarged, and the haemorrhage re-
turns, and thus,  by the repeated  loss of blood, the
life of the patient is destroyed.   Sometimes an aneu-
rism commencing internally, but breaking externally,
causes death in  the same way, as for instance, an 
27
 aneurism in the thorax; but when  it opens inter-
 nally, the patient frequently dies instantaneously.
   Sometimes destroy life suddenly.—I have, however,
 known  the bursting of an  external aneurism cause
 immediate loss of life.  A  man had  an aneurism in
 the groin, which burst on his making an attempt to
 throw off his bed clothes and to raise himself in  bed,
 and he  died in a few moments.
   Not  always destructive.—An aneurism  does  not
 always  prove destructive to life, although  no opera-
 tion be  performed for  its cure.   I have seen  gan-
grene of the foot and lower part of  the leg produc-
ed by a popliteal aneurism; the  gangrenous parts
separated, and the patient recovered.
   Internal aneurism.—I shall now describe internal
aneurisms, which  differ in  some respects  from the
external.

              ANEURISM  OF THE HEART.

   An aneurism of the heart consists of a sac formed
externally to  the parietes of that organ, but having
on opening  in it, which communicates  with the in-
terior of one of the cavities.  It is a  very rare dis-
ease, and I have only seen three  specimens of it; for
the dilatations of the ventricles, which are not uncom-
mon, and which  are frequently called aneurisms, are
not really so.   We have  two  preparations of  this
disease  in the Museum  at St. Thomas's Hospital.
   Case.—One of  the  cases, in  which I had an op-
portunity of seeing the disease, was  under the care
of Mr.  Palmer,  assistant  surgeon in  the army.   A
soldier belonging to the regiment to  which Mr.  Pal-
mer was attached, received a severe flogging, and
during  the punishment he held his  breath;  he
shortly  after  this complained of  a violent pain  in
his chest,  which  was quickly followed by ascites
% 
2U
and oedema of his  inferior  extremities.   He died
suddenly, and upon  inspecting his body after death,
Mr.  Palmer found, that an  aneurism  which  had
been  formed on the  left ventricle,  had burst into
the cavity of the pleura on the left side.
  Case.—Another case occurred under  Mr. Postle-
thwaite, of Chichester.  The patient had symptoms
of organic disease  of his heart, with  ascites and
oedema, as in the former case.  The man died sud-
denly, and an aneurism of the left auricle was found
on examining his body. The aneurism was of the size
of a large  walnut, and a quantity of blood  was ef-
fused between the coats of the auricle.

        ANEURISM OF  THE ASCENDING  AORTA.

  The commencement of the  aorta, just  where it
is covered by the pericardium,  is not an uncommon
seat of aneurism.  We  have some preparations  in
the Museum at St. Thomas's Hospital, shewing the
disease situated at this part.   In one of  these speci-
mens  the  aneurism  had burst into the  pericardium,
which was found filled with blood.   The history of
the patient from whom this aneurism  was taken,
may  be useful, in order to make you cautious in such
cases.
  Case.—A man who had been admitted into Guy's
Hospital  under  my care, having a popliteal  aneu-
rism,  was  taken into the operating theatre, for the
purpose of having a ligature put upon  his femoral
artery.  He was placed upon a table  in the proper
position, and I had commenced  the operation, when
he stretched himself  on  his back, and I perceived
his urine flowing  from him.   This, I said,  is some-
thing  more than  common apprehension,  or expres-
sion of pain ; I  took out a lancet, and opened a vein
in his arm, but the  blood did not flow: I then tried 
29^
 to bleed him from the jugular vein; he gave a deep
 gasp,  and in a few minutes  was dead.   The next
 day I opened the bodv in the  presence of the  pupils,
 when  I found the pericardium distended with blood,
 which had escaped from an opening in an aneurism
 seated at  the  beginning of the  aorta, immediately
 above the  semilunar valves.  If I had finished the
 operation,  I  might have had the credit of  killing
 this patient.
   You should  be particularly  careful not  to perform
 an operation for an aneurism, until you are satisfied
 that no others exist, as it often happens  that  many
 aneurisms  form in several  parts of the same indivi-
 dual at once.   Mr. Cline was about to operate upon
 a man in St. Thomas's Hospital, who had a popliteal
 aneurism,  but deferred it on account  of the patient's
 complaining of pain in his abdomen.  A few days
 afterwards the man died suddenly, and, on examina-
 tion,  an aneurism was found between the two emul-
 gent arteries, which had burst into the abdomen.
  Aneurism producing absorption of bone, 8rc.—Ab-
 sorption of part of the sternum and of  the cartila-
 ges  of the ribs, sometimes  takes  place from the
  ressure of an aneurismal sac, situated between the
  eart  and  curvature of the  aorta.  We have a pre-
 paration in which three of the cartilages  of the ribs,
 and a considerable  portion of the sternum have been
 thus destroyed.
  Progress of this aneurism.—An aneurism  seated
 on this part of the aorta,  at first  usually  presses
 upon the  lung, producing  oppression in breathing
 and  cough, and is, at this stage,  often confounded
 with dyspnoea arising from other causes:  but  as the
 disease increases,  the  upper  part of the  chest be-
 comes enlarged, and a pulsation may be distinctly felt
 by pressing on  the  intercostal spaces.  The cartila-
ges of the  ribs are then absorbed, and subsequently
I 
30
 a portion of the pectoral  muscle; inflammation  is
 produced in the integument; an eschar forms in the
 centre of that inflammation, and as the eschar gra-
 dually separates, the patient loses his life  from nae-
 morrhage.
   Life may be prolonged.—In these cases the life of
 the  patient  may  be  often prolonged, even  after
 bleeding has commenced, by coating the wound, and
 forming an artificial sac ; and  two or three weeks
 may be thus added  to life,  and enable  the  patient
 to prepare for that "bourn from which no traveller
 returns."
   Case.—A woman  was  admitted  into Guy's Hos-
 pital,  having  an aneurism  of  the  ascending  aorta.
 The skin  became inflamed, an eschar formed and in
 part separated, so  as to allow of  the escape of  a
 quantity of  blood ; the haemorrhage stopped in con-
 sequence of a coagulum plugging up the orifice, and
 the wound was more completely closed, by the ap-
 plication of some lint, confined  by plaisters and ban-
 dages : no further bleeding occurred, but the patient
 died twenty-seven days after the first haemorrhage,
 in consequence of inflammation  of  the aneurismal*
 sac, and of the aorta.

   ANEURISM OF THE CURVATURE OF THE AORTA.

  These aneurisms  project  just above the sternum,
 and they destroy life in different modes; sometimes
 bursting externally, as in the former examples, some-
 times occasioning death by  their pressure.   I have
 an example, given me by Mr.  Davis, formerly sur-
gueon of the Custom House, in  which  death was
 produced  by its  bursting into the  trachea.   The
 man was rising  from his  bed,  when he was  seized
 with cough,  immediately expectorated  blood, and
 died  in a few  minutes from  suffocation and  loss of 
31
blood.   Upon dissection, an ulcerated opening about
the eighth of an inch  in diameter was  found in the
trachea from the aneurismal bag.
  Sometimes  resemble  carotid aneurism.—Aneurisms
beginning from the curvature of the aorta,  some-
times rise to the  middle of the neck, and assume
the appearance of carotid  aneurism.   A specimen
was  given  me by Mr.  Dyson, surgeon,  of Fore
Street, who sent to me to say, that he had a carotid
aneurism under his care, which he wished me to ex-
amine.  1 found a tumour in the side of the neck,
but  thought I  could trace  a small swelling  from it
to the  sternum, and, therefore, refused to operate.
The patient lived seven  months, and  Mr. Dyson
gave me the aneurism which sprung  from  the cur-
vature of the aorta : a large bag was  formed in the
neck, communicating  by a  narrow canal with  the
curvature of the aorta.
   Case.—Mr. Allan Burns,  formerly  a  most excel-
lent surgeon and anatomist at Glasgow, wrote to me
respecting  a pulsating tumour above the  clavicle,
upon which it was proposed to perform the opera-
tion for aneurism.  In my answer, I said, Take care
that the case which you  have described is not an
aneurism of the aorta.  The operation was not per-
formed ; the  patient died  of  the  disease,  which
proved, upon dissection, to  be an aneurism of the
aorta.   This case  is mentioned in Mr. Burn's excel-
lent work on the anatomy of the neck.
   Produce suffocation.—Aneurisms  of  the curvature
of the  aorta sometimes destroy, by their pressure on
the trachea producing suffocation;  sometimes they
occasion great difficulty in swallowing, by their pres-
sure on the  oesophagus; and when seated  at  the
lower  part  of the  curvature, they now and then ap-
pear at the back between the scapulae. 
:\-i
        ANEURISM OF THE ARTER1A  INNOM1NATA.

   This case will rarely allow of an operation.   Here
 is a specimen of it, and you will see that there is
 scarcely any space between the  aneurism and  the
 aorta;  and I think it one of the most.difficult opera-
 tions in surgery.   My friend,  Dr. Mott, of New
 York, is the only person who has  had the intrepidity
 to put a ligature on  this vessel:  the  patient, for a
 time, appeared to be doing well, but ultimately did
 not  recover.

 ANEURISM OF THE DESCENDING AORTA WITHIN THE THO-
                       RAX.

   On the aorta in the posterior mediastinum,  I have
 seen three small aneurisms.   When  they become
 large,  they sometimes  burst into the oesophagus.   I
 have an excellent preparation given me by Mr. Ar-
 miger, in which you may see a large aneurismal bag
 with an ulcerated opening into the oesophagus.  The
 patient died from profuse vomiting of blood.  In the
 morbid collection  at Guy's  Hospital,  you may see a
 similar  specimen  taken from a patient of Mr. Fos-
 ter's, who not only vomited blood, but  passed a con-
 siderable quantity by stool.

        ANEURISM OF THE ABDOMINAL AORTA.

   When an aneurism is seated  above  the caeliac ar-
tery its pulsation may be distinctly felt at  the scro-
biculus cordis :  and the pressure of the swelling on
the upper curvature of the stomach produces  so fre-
quent an inclination to vomit, that the patient is un-
der  the  necessity of observing  extreme abstinence,
to keep the stomach in a quiescent state. 
Xi
  Bursting into an intestine.—When the aneurism is
seated lower down, and on the fore part of the aor-
ta, it sometimes bursts into an intestine.   Dr. Scuda-
more brought a gentleman to my house,  who had a
pulsating tumour just  above the umbilicus. A few
weeks afterwards I was  sent for to this gentleman
at Henley, who had been seized with fainting, and a
discharge of blood by stool:  he revived a little, but
on the following morning the discharge of  blood re-
turned, and he died suddenly: in the aneurism which
I removed from him,  you may see that the jejunum
had adhered to the fore part of the aneurismal  bag,
and that the sac had ulcerated into the intestine.
  Producing absorption of the vertebrae.—When the
aneurism arises from the posterior part of  the aorta
in the  abdomen, it  presses upon the spine, and pro-
duces absorption of the vertebrce:  it then proceeds
until it appears between the last rib and spine of the
ilium in the loins.  In  a specimen taken from a pa-
tient  in  the other Hospital,  by Mr. Howden, the
aneurism projected into each loin.   As the aneurism,
when it  appears  in the loins, and has acquired any
magnitude, does not in general pulsate, you must be
upon your guard  that you do not mistake it for lum-
bar  abscess,  a circumstance 1 once saw  happen.  A
surgeon, in a hasty way, said,  " This is a lumbar ab-
scess," and  plunged a lancet into it, and then  with
something of a similar exclamation, he said, "God
bless me! this is blood;"  a piece of adhesive plaster
was  applied  covered  by a roller, and  the wound
healed, and the patient afterwards died of the burst-
ing of the aneurism internally.
  Appearing at the ischiatic notch.—1 have seen an
aneurism seated  in  the cavity of the  pelvis  pass
through the ischiatic notch under the gluteus maxi-
mus muscle, where it produced a large pulsating tu-
mour,  which J at first thought was an aneurism of
  VOL. II.           4 
34
the gluteal artery;  but feeling apprehensive that it
might have some communication with the vessels of
the interior of the pelvis, I would not operate;  and
the patient, before  he died, had  an  haemorrhage
from his bladder, which shewed that  the aneurism
was seated within the pelvis, and that it had pro-
truded into the ischiatic notch.

            OF  THE  SIZE OF  ANEURISMS.

  The  aneurism given me by Mr. Howden is  the
largest I have ever seen: it  began from  the poste-
rior part of  the aorta  by the emulgent arteries; on
the one side it  passed into  the loins,  and it  there
Contained many pounds of blood; on the other  side
it first  projected into the loin in the situation of the
left kidney; it  then descended over the psoas mus-
cle under the sigmoid  flexion of the colon, and  ter-
minated on the brim of the pelvis.

OF THE NUMBER  OF ANEURISMS  IN THE SAME INDIVI-
                      DUAL.

  The greatest  number of aneurisms which I have
seen in the same person  is seven : an Irish labour-
er  came  into  the other  Hospital, with an aneu-
rism at  the origin  of the  arteria profunda,  and
another  in the femoral  artery, near the middle of
the thigh.  I  tied the external iliac  artery  above
Poupart's ligament,  and the man, some time after-
wards, died of an aneurism at the bifurcation of the
aorta, which burst into the cavity of the abdomen:
I injected the limb, in which  you have an opportu-
nity of seeing beautifully the anastomosis of the  iliac
artery,  with  the vessels  of  the thigh.   Upon ex-
amination of this man's body, an aneurism was found
in each ham:  one at the  bifurcation  of the  aorta? 
35
one at the origin of the arteria profunda, one in the
middle of  the thigh, and  two  between  the popliteal
aneurism and the femoral, making in all seven aneu-
risms.*

  * The  following case is curious, perhaps,  on  account  of
the number  of aneurisms which existed in the same person ;
but I have introduced  it because, having received a useful les-
son from it myself, I think the history of it may be of service to
others.
  W. Wardle, aet. 47,  was admitted into  St. Thomas's Hospital,
on the 29th of May, 1823, on account of a large swelling, which
occupied the left ham, and  extended on  to the fore  part of the
thigh, just above the knee,  projecting chiefly on the inner side
over the vastus internus muscle.   The  integument was  florid,
and he had rigors,  with other symptoms of suppuration.  On
attentively examining the swelling,  1 found an evident sense of
fluctuation, and pressing my hand  firmly on  it,  I could feel a
thrill, which was also  felt by several gentlemen who were with
me at  the time.   His own history of the disease  was very un-
satisfactory, and certainly rather indicated the formation of  an
abscess than of an  aneurism.   There being considerable doubt
about  the precise nature  of  the swelling,  on the  following
morning I requested Mr. Green and  Mr. Key to see the patient
with me:  in examining the part, neither of them could feel the
thrill 1 before mentioned;  and, on consultation, we determined
that a small  puncture  should be made;  as little harm  could re-
sult from it, even if it proved to be an  aneurism.   1  therefore
carefully introduced a lancet near the boundary of the tumour,
on the upper part over the  rectus muscle, when a jet of arterial
blood at once convinced us of the  true nature of  the disease.
The  opening  was immediately closed  by the pressure of the
finger on it, and  the patient  was conveyed into the  operating
theatre, that a ligature might be placed on the femoral artery.
Whilst feeling in  the  course of the  artery, before commencing
the operation, 1 found a small  aneurism  near the part in  which
I had intended to secure the vessel; this led to a more minute
examination of the patient,  and at that period another aneurism
was found, just above the  tendon of the triceps, on  the same
side, making two femoral aneurisms and a popliteal on the left
side.   On the right side the artery felt dilated in several places,
but  a  little  below  Poupart's  ligament  an aneurism existed as
large as an egg.
   After further consultation, it was decided that I should  tie the
femoral artery between the two small aneurisms, as we  feared 
30
   Query—Had his  occupation,  which obliged him
to mount very high  ladders, been the  means of pro-
ducing this very extensive disease ?


            ANEURISMS LOCAL OR GENERAL.

   When they occur opposite  to a  joint,  a  partial
disease of the artery often  gives rise  to them; but,
when they are seated  in other  parts of the  body,
there is usually a disease in the arteries, which pro-
duces a general  disposition  to  their formation:  the
ultimate success of operations will depend very much
upon the disposition to the  disease being  partial or
general.

that a ligature  on the external iliac  would not command  the
haemorrhage from the aneurismal sac; and it  appeared proba-
ble, that the superior aneurism, which was small and situated
below the profunda, might  become obliterated (if  the circula-
tion through it  were  prevented) by coagula forming in it, as in
a healthy artery.  1 therefore exposed the vessel in the usual
manner, and placed a ligature on that portion which was situated
between the two aneurisms; this was about one or one and a
quarter inch in length, and appeared sound.
  Four days after the operation,  I left town  for three  weeks,
during which time  he  remained  under the  care  of my col-
leagues; the extremity  became gangrenous,  and the aneuris-
mal sac in the ham sloughed,  exposing the femur.  A consulta-
tion was held, at which Sir Astley Cooper attended,  about the
propriety of amputating; but it was not thought advisable,  on
account of the  diseased  state of the arteries.   The  ligature did
not separate from the wound until the sixth week;  and the pa-
tient lingered until the 28th of July.

                       DISSECTION.

  The popliteal and inferior femoral  aneurisms of the left side
had been destroyed by. sloughiDg; that above the ligature  was
not closed.  On the right side were found three femoral aneu-
risms, and a small popliteal, making in all seven ; besides some
dilatation of the aorta, immediately above the  bifurcation___T- 
37
   OF THE AGE AT WHICH ANEURISMS GENERALLY OCCUR.

   The  period of life at which they most frequent-
 ly occur is between thirty and fifty years;  at  that
 age, in  the  labouring  classes,  the  exertions of the
 body  are  considerable, and  its strength  often be-
 comes diminished :  in very old age  this complaint is
 less frequent,  as muscular  exertion  is less.   The
 greatest age at which  I have seen aneurism  has
 been eighty  years :  this was  in a man for  whom I
 tied the femoral artery in  Guy's  Hospital, for  pop-
 liteal aneurism;  and, notwithstanding his  advanced
 age, I never had  an operation succeed  better.   I
 also operated upon  a man of sixty-nine years, and
 that case also  did well.   A  boy, in  this  Hospital,
 had an aneurism of  the  anterior  tibial artery, who,
 I  was informed, was only eleven years of age.   The
 man of eighty was the oldest, and the boy of eleven
 the youngest,  which I  have  seen  with aneurism.
 Age, with  general good health, forms no  objection
 to the operation.

       OF THE SEX MOST DISPOSED TO ANEURISM.

   The male is much more subject  to this  disease
 than the female :  women are  rarely the subject of
 aneurisms in  the limbs; the reason for which is,  that
 they do not exert  themselves  so much  as the other
 sex.   In forty years' experience, taking the Hospi-
 tal and  private  practice, I  have seen only eight
 cases of  popliteal aneurism  in  the  female, but an
 immense number in the male.   The aneurisms which
 I have seen in  the female,  have been  the greater
number in  the ascending  aorta, or  the  carotid ar-
 teries. 
38
          OF  THE FORMATION OF ANEURISM.

  The first circumstance which occurs in an artery
which is about to produce an aneurismal  swelling is,
that it becomes opake and slightly inflamed; a small
yellow spot appears in the part where the aneurism
is afterwards formed,  and there is a  slight efflores-
cence surrounding it ;  a process of  absorption  next
thins the coat of the  artery, so  that  its  texture be-
comes like a fine web of cellular tissue :  at this time
nature sets up a process of  defence,  which is beau-
tifully exemplified  in a  preparation in St. Thomas's
Museum; it is an incipient aneurism  of  the  aorta;
the coat of the artery has  been  absorbed,  and op-
posite to the  parts absorbed you observe a layer of
adhesive matter, by which  a  defence is  produced,
and the  progress of the disease for  a  time resisted ;
a covering is  formed by the  adhesive inflammation,
which strengthens the artery and prevents  the im-
mediate escape of blood.  As the  coat of the artery
is absorbed,  the part  in the vicinity  of  the  artery
becomes united to its  surface  by  the  adhesive pro-
cess : thus, if it  be an  aneurism of  the ascending
aorta, the pleura is united with it, and forms a por-
tion of the aneurismal bag;  the pleura becomes ab-
sorbed and the lung  forms  a part  of the sac,  the
lung and pleura  costalis are absorbed in their turn,
and  the intercostal muscles and cartilages  of the
ribs form a part of the sac  ; these removed by ab-
sorption, the  pectoral  muscle becomes the sac, and
when this is  absorbed, the  skin, which   is  the only
covering for the blood, inflames, dies,  and sloughs in
the way I have already described,  and  the  person
loses his life  from haemorrhage.
  Former opinions.—Aneurisms we're formerly sup-
posed to be produced by the dilatation of the coats 
39
of an artery, and  those which arose from  wounds
or lacerations were called spurious; but Scarpa first
clearly described that aneurism arose from the ab-
sorption of the coats of an  artery, and that conse-
quently they are generally spurious.

               CAUSES OF ANEURISM.

  A diseased state of an artery.—The general cause
of aneurism is  a diseased  state  of the coats of an
artery, by which it becomes altered  in its  appear-
ance and thinner in its texture; but  this, although
the most frequent, is  not  the only cause of  the dis-
ease, for sometimes the  artery becomes dilated in
its whole  circumference.  Two excellent specimens
of this dilatation are  to  be seen in  our museum.
One, in which   the general dilatation exists  beyond
the curvature  of the aorta;  and the  other, in which
it occupies the whole of  the curvature.
   Laceration of an artery.—Aneurisms are also pro-
duced  by laceration of arteries, without any exter-
nal wound,  of  which the  two following instances
have occurred in  my practice:  A gentleman, who
was  shooting,  in leaping a ditch, slipped  from  the
top of the bank; at this  moment he felt something
snap in his ham, and  when  he attempted to walk,
he found himself lame from  the  accident;  he was
attended by Mr. Holt, surgeon, at Tottenham, and
was  afterwards  brought  to  town, when he under-
went the operation for popliteal aneurism :  in  this
case the aneurism  began to form  in a very short
time after the  accident,  and it  was  about a month
after it that  the  operation was  performed.  The
other  case  was as follows  :  A gentleman whom  I
was attending for a bad  stricture  in  his urethra, in
attempting to raise himself  in  bed upon his hands,
felt  something snap in the back of his right  hand : 
40
when I next visited him,  he told me the  circum-
stance, and desired me  to look  at  a swelling upon
his hand ; placing my finger upon it, 1 felt a pulsat-
ing  swelling;  I tried what could be  effected  by
pressure, but this did  not succeed,  and I  found it
necessary to open the tumour ;  it discharged a large
quantity of arterial  blood, in part coagulated, which
proceeded from the radial artery, under the exten-
sor tendons of the thumb; I tied that artery at the
place at which the  pulse is usually felt, and I tied
it beyond the extensor tendons,  between the thumb
and fore finger.  A punctured  wound  made into an
artery, or a  small incision, will  occasion an extrava-
sation of blood into the  cellular tissue,  which  will
render the  operation  for  aneurism  necessary for its-
cure.

          OF THE DISSECTION OF ANEURISM.

  When an  aneurismal  sac  is  opened and turned
back, the cavity in  which the blood is contained is
not   immediately exposed, but numerous layers of
fibrous matter line  the  inner part of  the  sac,  and
form laminae  within each other; within  which  the
fluid blood  is contained ;  these  laminae are  largest
towards the sac, and form a  portion of a lesser cir-
cle  as they approach the fluid  blood; these being
removed, and the  fluid or the  recently coagulated
blood, being spunged away, the orifice of the artery
into  the sac is  directly seen; sometimes this orifice
is small, and is formed by a portion of the circumfe-
rence of  the artery; and is sometimes large,  the
whole  circumference of  the artery  having given
way. 
41
                DIAGNOSIS OF ANEURISM.

    Aneurism  may be  distinguished  from  other  dis-
 eases by the  following  marks; if the aneurism  be
 small, press the artery which  leads  to it, and you
 will empty the  aneurismal bag; but if the aneurism
 has existed long, is very solid,  and  its pulsation not
 very strong, sit by  the  patient's side, observe care-
 fully the size of the  swelling;  press your finger on
 the artery  above, and the aneurism will sink under
 the pressure on the  artery;  upon  giving up  that
 pressure suddenly, a  jet of  blood rushes into  the
 aneurismal  bag, and raises it to  its former height.
   In a doubtful case of  aneurism of the groin, Mr.
 Brodie informed me every doubt vanished upon ap-
 plying the stethoscope.
   If a  tumour, not  aneurismal,  has an  artery  of
 large size passing over  it, a  pulsation is produced
 which is liable  to deceive.  1 was  asked to see a
 glandular tumour in the neck, over which the caro-
 tid artery took  its course, and which was easily dis-
 tinguished from aneurism by the  line of pulsation
 produced by the artery, whilst the  lateral parts  of
 the tumour had no pulsation.   When a tumour is
 situated  upon an artery,  and derives pulsation from
 it, it may be distinguished  from aneurism by elevat-
 ing the swelling from  the artery which deprives the
 tumour of its pulsation.
   Pulsating tumours in the neck are  common,  and
 may be distinguished from aneurism,  by desiring the
 patient to make an  effort to swallow.   Carotid aneu-
 risms generally  do not move  with the larynx or tra-
chea :  other pulsating  tumours  in the  neck are, for
the most  part, connected with the thyroid gland, and
obey the  motions of the  air tube in swallowing.
   vol. n.             5 
42
      ON THE SPONTANEOUS CURE OF ANEURISM.

   Patients should know that this disease, which i*
generally  hopeless  without  operation,  sometimes
undergoes a spontaneous cure, for it is a great con-
solation for  them  to  know this.    I  have  known
many examples of this change in aneurism, and will
relate  one  of the most striking:   George  Bowie
was admitted into Guy's Hospital, with-an aneurism
in the groin; when the aneurism  had  acquired con-
siderable magnitude, as he was sitting  by the fire in
his ward, he suddenly felt a snap in the swelling;
his leg and thigh became immediately swollen and
useless, and  the patients assisted him into bed.   The
pulsation in the  swelling continued  for  four days,.
and then ceased; the swelling of the limb gradually
subsided, and four months  afterwards  he was  able
to walk, with scarcely any lameness : I met him one
day in  the Square of the Hospital,  and asking him
how he was, he said,  " Sir, I am  pretty well of my
old complaint, but I have got something alive in my
inside;" and upon applying my hand to his abdomen,
I found a pulsating  tumour : he died  from the burst-
ing of this aneurism inlo the abdomen.  1 examined
him, and  we have the parts  preserved in the
Museum of  St. Thomas's Hospital.  The aneurism
of the thigh had burst  under the  fascia lata, and
the accumulated  blood pressed the aneurism on the
femoral artery,  so as  to interrupt the circulation.
Both the iliac and upper part of the  femoral  artery
were obliterated, and the blood found its course  by
the internal  iliac vessels.
   I have seen spontaneous cures of  aneurism pro-
duced without any circumstance which would readily
explain the cause:  one  case with Sir  William Bli-
zard, at Walworth; a case of popliteal  aneurism ; 
43
and another of popliteal aneurism in Guy's Hospital.
Mr. Ford  has published cases  of this description;
and  Dr. Baillie has met with  similar  instances.   I
once  saw, in  Guy's Hospital, a  man who  had an
aneurism  in the thigh,  which  had existed  several
years;  which  still retained its  pulsation, but  had
ceased to increase, although it had not diminished :
this  man died  of some  other disease ; and  upon
examination, I found it to be aneurism  produced by
the general dilatation  of the coats of the  artery.

         ON THE  TREATMENT OF ANEURISM.

   Little done  by medical treatment.—From  the me-
dical treatment of this disease, 1 must confess that I
have  seen but little advantage.   Mr. Brown, a sur-
geon, who had an aneurism  of  the aorta,  was ex-
ceedingly strict in his  diet,  and in his exercise;  but
he lived  only a very few  months.  A  gentleman,
who had an aneurism of his aorta, took four ounces
of food  three times  a  day, and refrained almost
entirely from exercise  ; and although he  began this
plan in August, almost  as  soon as the disease was
distinctly  discovered,  yet he  died in  the following
February.  The  result  of  my  observation  is,  that
two  measures only are useful;  the  one  abstraction
of blood from the arm, when the pulse is hard and
full,  from  which  I have  seen  undoubted  benefit
arise :  the other,  the  administration  of the  carbon-
ate of  soda,   in  considerable  doses,  which,  with
entire  rest, seem to  prevent the increase of  the
swelling;  but  the soda is  at  last  obliged to be
abandoned, on account of its producing  petechias:
the irritability of the  body  is often so  increased by
an antiphlogistic treatment, that the  quickness of
the pulse which follows, does as much  injury as the
natural force  of circulation. 
44
               LECTURE  XV.

         ON  THE OPERATION FOR ANEURISM.

 As aneurism leads to a gangrenous state of the limb,
 as  well as to the  bursting of the aneurismal bag,
 and subsequently haemorrhage; it therefore becomes
 necessary,  in order  to  preserve  the life  of the
 patient, that an  operation should be performed, to
 check the  progress of the disease.  The operation
 for it is one of the greatest triumphs of our science;
 it  is  founded upon a knowledge of anatomy, upon
 the best physiological principles,  and upon a tho-
 rough acquaintance with the  nature of the disease.
 To that stupendous genius Mr. Hunter, is mankind
 indebted for  it;  before his  time an operation had
 been  performed  so rarely successful,  that  surgeons
 doubted whether it  were best to  perform it, or to
 amputate ;  and  I  can recollect seeing a man, who
 regularly came  to  St. Thomas's Hospital to shew
 himself, because he was thought to be a curiosity in
 having recovered from  the operation for popliteal
 aneurism;  this was  forty years ago; the operation
 then  consisted  in  applying  a  tourniquet  upon the
limb,  in making an extensive incision into the aneu-
 rismal bag  in the direction of the artery:  in  remov-
 ing the  layers of fibrin accumulated in the sac with
 the hand,  and  in spunging the  bag  clean.    The
tourniquet  being then loosened, the  openings from
the artery  were seen ; a probe was passed into the
orifice towards the heart,  and a ligature  was tied
round that part  of the artery ;  a probe was carried
into the orifice  towards the foot, and a ligature was
made  to surround that portion  of the artery :  thus a 
45
 ligature was  applied  above and below the opening
 in  the sac, and  the wound  was attempted  to be
 healed as  any  other in which  ligatures  are  intro-
 duced: high  constitutional  irritation followed  this
 operation, extensive suppuration  succeeded, haemor-
 rhages were  frequent  consequences, and its  issue
 was generally unsuccessful.
   The plan of Mr. Hunter  had extensive scientific,
 and pathological  views; the principle of his opera-
 tion was,  to direct the blood into new channels; and,
 instead of  disturbing the  diseased  parts, to  leave
 them  to  be absorbed by the  processes  of nature.
 The whole of his operation, then, in principle, con-
 sisted  in tying the artery which led to the aneurism,
 in preventing it  any  longer from  receiving  blood
 from the heart, and  in directing the blood into new
 and anastomosing  channels.

    OF THE OPERATION FOR  POPLITEAL ANEURISM.

   It is proper  that  this operation should be per-
 formed before  the foot and  leg be much swollen.
 If the  patient be  of full habit, I find  there  is  no
 objection  to taking away blood  from  the  arm, two
 or three days  prior to the operation, arid the patient
 for a  week  before  should avoid  any stimulating
 food.
  Instruments  required.—The  instruments required
 are, a  common scalpel, a silver knife, a curved-eyed
 probe  of half  the  usual  length of probes, threaded
 with Dutch twine.
  Place of incision.—The  place of the  incision is
 one-third  of the length  of the thigh from the ante-
 rior  superior  spinous  process  of the ilium, to  the
internal condyle of the os femoris.   Mr. Hunter
 performed  it  just  above the tendon of the triceps
femoris; but the artery is more deeply seated there, 
46
 and has more vessels opening  from it which are m
 danger of injury.
   Position  of "the patient.—The patient  is  placed
 upon a table of convenient height, in the recumbent
 posture, with his shoulders a little elevated, and his
 leg slightly  bent to relax the sartorius muscle.
   Length of the first incision.—The incision is to be
 four inches long;  its direction that of the sartorius
 muscle, and just  upon its  inner  edge.   Any large
 branch of the  saphena vein is  to  be avoided, and
 the first incision is to expose the fibres of  the sarto-
 rius.
   The second  incision is to separate the inner edge
 of the  sartorius from the adductor longus femoris,
 and  this  merely divides the cellular tissue.   The
 sartorius  is  then  gently drawn  outwards, and the
 sheath  of vessels becomes exposed, in which  the ar-
 tery, being  more superficial  than the vein, may be
 felt  pulsating.   A third incision  opens  the sheath,
 and this must be done with caution, as the sheath is
 to be divided over the artery.   A septum is found
 between the  artery  and vein.   The point  of the
 silver knife  may be here most safely used, to farther
 open  the sheath,  and  to  admit  the  probe.   The
 probe  is  to  be introduced  under the  artery  with
great care, to avoid injury  to  the vein, and  to ex-
 clude any branch  of nerve, as I  have  known the
 saphenus nerve included in the ligature, and  numb-
 ness produced  in  the  course of the saphena vein.
 The probe  being brought out at the wound,  the  li-
 gature is then left under the artery.  All  this is to
 be effected  with as little  disturbance  to  the  artery
 as possible.  The ligature  is to be  then  tied,  first
 passed through twice, and then only once  in making
 the knot secure.   If  any small vessel  bleeds  in the
operation above the site of the ligature upon the ar-
 tery, let it be immediately secured by a  thread; as,
 from the interruption to the  circulation in the prin- 
47
eipal vessel, the smallest artery is apt to bleed free-
ly.   Directly  as the  ligature is  made secure,  the
pulsation in the  tumour  generally ceases ;  I say ge-
nerally, because I have known an obscure  pulsation
remain through  the influence of anastomosing ves-
sels.
  Dressing the wound.—When the ligature has been
securely tied, cut off one of its ends, and  leave  the
other hanging from the centre of the wound.  Bring
the edges of the skin  exactly together,  and secure
them by adhesive plaster, leaving  small  interstices
to permit the escape  of discharge.   Do  not  apply
any bandage, and let the  patient be carried to  bed
in the recumbent posture.   Place the limb in a slight-
ly-bent  position, rather  on its outer side,  and  the
foot is to be wrapped in flannel.
   Other modes of operating.—These  are the steps
of the operation;  attempts have been made by in-
genious surgeons to improve upon this mode of per-
forming it, and one of the best  proposals for  this
purpose was made by Mr. Cline.   As haemorrhage
sometimes  occurs at the time  the ligature separates,
he proposed to prevent ulceration of  the artery by
using a  broad ligature, tying it upon a piece of cork,
and removing it after  some days,  before ulceration
usually begins.   The  first operation succeeded ;  but
he afterwards found the introduction  of  an extrane-
ous body produced too much irritation.
  Mr. Crampton's.—Mr. Crampton, of Dublin, used
an ingenious instrument, which he called  the  presse
artere, with the same view.
  Dr. Jones's.—Dr. Jones (author of  an excellent
work on the natural  means of suppressing haemor-
rhage) having found that small  ligatures cut the in-
ner coat of an artery  without  injury to the external,
advised that the ligature should be tightly tied, and
then removed, the arlery being left to adhere when
it was exposed.   I tried this plan in two instances. 
48
   Experiments.—The first was in a case of popliteal
 aneurism in Guy's Hospital.   I put a ligature around
 the femoral  artery at the usual place ;  and tying  it
 very  tight,  after thirty hours I loosened  it.  The
 pulsation in the aneurism returned  after half a mi-
 nute with the same  force as prior to the operation;
 I, therefore, ac^in tightened the ligature, and suffer-
 ed it to remain forty-two hours longer ;  after seven-
 ty-two hours I removed the ligature, and the pulsa-
 tion did not return;  thirteen days after, as I entered
 the  square of the Hospital,  one of my dressers in-
 formed me, the man had haemorrhage  from the fe-
 moral artery.  I visited him immediately, and found
 it to be so ; a tourniquet was applied just above the
 wound, the haemorrhage did not return,  and the pa-
 tient recovered.
   The second  case  was an aneurism  of the radial
 artery, produced by a wound ;  I removed  the liga-
 ture twenty-four hours after it had been applied, but
 the  pulsation returned;  I made an  incision into  the
 tumour, applied  a  ligature upon the artery above
 and  below the  openings into  the sac, and the aneu-
 rism was  cured.
   Mr. Abernethy's.—Mr. Abernethy proposed a new
 and  very  ingenious  mode of  operating  for   this dis-
 ease, by placing two ligatures upon the  artery, and
 dividing the  vessel  between  them; thus  reducing
 the extremity of the vessel nearest to the heart, to
 the state  in which it is in a  stump.   I  have often
 performed this operation, and very successfullv ; and
 I think it ought to be adopted in all cases  in which
 the artery is  much disturbed in the operation,  and
 separated from the  surrounding cellular tissue; as
 the division of  the artery enables it to  retract into
the cellul.-ir membrane above ; it is liable, however.
to one  objection, viz. to the  ligature escaping from
 the artery soon after its application; this happened 
49
 to Mr. Cline, sen. in St. Thomas's Hospital, and to
 myself in Guy's  Hospital; both ligatures came off
 the artery as I divided it, but I immediately replac-
 ed them.
   Of cutting  off both ends of the  ligature.—It has
 been recommended to cut off both ends of the liga-
 ture close to the knot, in the hope  that the wound
 would heal  over it, and that it would remain without
 producing inflammation; but experience has shewn
 that it separates by ulceration, and  often produces a
 considerable degree of irritation.

     OF THE AFTER TREATMENT  OF THE PATIENT.

   Application of flannel,—A piece of flannel is to be
 placed around the  limb, or a warm stocking  to be
 worn, to preserve the  warmth of the limb,  for
 there is danger  of gangrene in cold  weather;  the
 heat of the  foot is generally two degrees more than
 that of the sound side; but if it be exposed to the
 influence of low temperature, it is  easily robbed of
 the heat which is necessary to its preservation.   Be-
 fore I learned this, I had  operated  upon a young
 gentleman  during the winter,  who, when I visited
 him  in  the  evening,  complained of great coldness,
 numbness, and a sense of weight in his foot; this in-
 duced me to look at the limb, and I found that  the
foot  was quite cold, and that the blood was stagnant
in it.   I sat  down by  the bedside of the patient,  and
rubbed his leg with a warm flannel till heat was re-
stored to the limb; and ever since that time I have
wrapped the  limb in a piece  of flannel, and some-
times put bottles filled with hot water to the ieet, if
the weather be  particularly cold.
  For a few days  after  the operation, a consider-
able  degree  of constitutional irritation  is produced ;
and I have in  two or  three instances  knswn  reten-
  vol. ii.              6 
5W
tion of urine occur, rendering the introduction of the
catheter necessary.  The  medicine  best  suited to
the patient is a simple saline draught with sulphate
of magnesia; and  opium  may be  administered,  if
there  be any  considerable  degree   of irritability.
Great care must be taken that the patient does not
rest too much upon his heel, as a gangrenous spot is
apt to form there, if that be permitted ; the patient
must make no effort  to use the limb, as any disturb-
ance of  the sartorious muscle prevents the ready
adhesion of the wound.   Every other day will be
sufiicient for the reapplication of the  dressings ;  and
for the first four days, at  least, they should  not be
disturbed.
   Separation of the ligature.—Between the eleventh
and fifteen day the ligature  usually separates, but I
have known a broad ligature twenty-seven days  in
ulcerating.  Nothing must be done  to assist  the se-
paration of the ligature, leave  it entirely to a natu-
ral process.  For three or four days after the  liga-
ture has separated, carefully guard the patient from
raising himself in bed, for the following  reason.
   Case.—A sailor endeavouring to push  his pocket
knife through  a cable, which  was placed between
his thighs, the knife slipped, and entered his femo-
ral artery; a profuse haemorrhage ensued; a tourni-
quet, made by a handkerchief and stick  at the mo-
ment, was put  around  the limb, and  he was brought
to Guy's  Hospital.   I put a ligature above  and be-
low the wound in the artery, and on  the  fourteenth
day these ligatures separated:  at twelve o'clock the
same day he was sitting in his bed washing his hands,
when a gush of blood took  place from  the wound.
A tourniquet  was directly  applied  by the dresser,
and I  was sent for.    The  haemorrhage  proceeded
from the  portion of the artery nearest the  heart,
upon  which I placed a ligature,  which rendered it 
51
necessary  for  the  man  to  keep his bed for there
Weeks  longer; but he  ultimately  recovered:  this
shews the necessity of perfect stillness  on the part
of  the patient, whilst the  ligature is separating and
the adhesion is remaining feeble.
  Mode in which  circulation is  carried on.—After
this operation the circulation is carried on  principal-
ly by the  arteria profunda; its  branches communi-
cate with the articular arteries of the popliteal, and
with  arteries sent to the knee  by the anterior and
posterior tibial;  large branches in the sciatic nerve,
sent off by the  arteria profunda, communicate very
freely with the popliteal artery, the articular of the
knee joint, and with branches of the posterior tibial
artery ;  the  freedom of anastomosis now  and then
leads to a reproduction of an aneurism, of which
you have  all had  an opportunity of seeing an  in-
stance during the present season in Guy's Hospital.
The femoral artery had been tied last year by  Mr.
Key,  and the man was discharged cured; but during
the  present  season he  has returned with a  very
painful tumour  in the ham, having an obscure pulsa-
tion in it, the flexor  muscles of the knee  were ex-
tremely rigid, and  the man's health was giving way
so rapidly, that I was obliged to amputate  the limb,
and a large artery  which passed  to  the tumour was
obliged to  be secured  nearly in the situation usually
occupied by the femoral artery.
  Subsequent gangrene.—1  have  known  the opera-
tion fail in three  or four instances from gangrene of
the leg which demanded amputation.
  Haemorrhage.—I  have also seen it several times
fail from haemorrhage, but  more  frequently former-
ly than  of late years; now the  principles of the
operation are so well understood.
  This,  however, occurs in some  instances, on ac-
count of the artery not being closed at the time the 
52
 ligature separated,  in consequence of which the pa-
 tient has been destroyed  bv haemorrhage;  this arose
 from  a  deficiency of power in  the  constitution,  so
 that the  necessary degree  of  inflammation  had not
 been produced,  or from a diseased state of the arte-
 ry itself.*

   * A case of this nature occurred to Mr. Bransby Cooper, of
 which the following are the particulars :
   On the 9th of June, 1823, Mr. Gaitskell,  of Rotherhithe, was
 requested to see J. C. Esq. aet. 49, on  account of the sudden ap-
 pearance  of a swelling on  the  upper part of the left  thigh,
 three inches  below Pouparfs ligament; which proved  to be a
 femoral aneurism.   Sir Astley Cooper was  consulted, and as
 but little pulsation existed  in the tumour,  he thought  a spon-
 taneous cure might  take place, and recommended that  the pa-
 tient should  adopt  those measures most likely to  assist the ef-
 forts of nature.  On the 21st of June, however, Mr.  C, whilst
 in the act of raising himself in bed, felt something give way in
 the thigh ; this was immediately  followed by a  rapid increase
 of the swelling1, which soon extended to  Poupart's  ligament.
 Sir A. Cooper was sent for,  but being out of town, his nephew
 (Mr. Bransby Cooper) attended for him, and after a consultation
 with Mr. J. H.  Green, a ligature was placed on the external
 iliac.   The operation  was performed with  great  facility in  the
 usual manner.
  Every thing went on  favourably  for eighteen days  after,
 when a slight arterial haemorrhage took place from the  wound,
 which returned at intervals  on the 19th, 20th, and 21st days;
 when it entirely ceased for forty-eight hours.  The wound  ap-
 peared healed, excepting near  the  ligature, around which a
 glassy  granulation  protruded.  On  the 24th, 25th,  and  26th
 days, the bleedings  returned oftener and more violently than
 before, but were checked for a time  by pressure  and cold  ap-
plications ; the  patient  became much  exhausted from the  re-
peated loss of  blood, and the  wound again opened.   On the
27th, a profuse  haemorrhage supervened, which separated the
ligature, and an hour after the patient  expired.

                        DISSECTION.

  The artery was completely divided,  and the extremities were
 above an inch apart.  The superior portion was slightly glued
to the psoas muscle by adhesive matter;  it contained a small 
53
   Case.—Mr.  Birch lost  a patient in  St. Thomas's
Hospital, from the femoral  artery being  tied  too
near to the arteria profunda to allow of adhesion of
the inner coats of the  artery, and consequently  to
prevent haemorrhage.

   OF  ANEURISM OF THE ANTERIOR  TIBJAL ARTERY.

   If this disease be placed at the  upper part of the
leg,  the same  operation  is  required for it as that
which is performed for  popliteal  aneurism.  Mr.
Lucas, sen. surgeon of  Guy's Hospital, had a patient
with  anterior  tibial  aneurism seated a  little below
the head of the fibula.   He  performed the  opera-
tion  of tying the  femoral artery, and the pulsation
in the aneurism ceased, and the swelling for a time
subsided.   The  case did not ultimately recover, for
a slough took  place of the aneurismal sac;  but the
failure arose not from  the operation being inappro-
priate, but from a very unhealthy  constitution.  Mr.
Henry Cline  had a  case of this  disease upon  the
upper part of the  foot, and  he  tied  the  anterior
tibial artery at the lower part of the leg,  but the
pulsation in the  aneurism continued  when  the boy
quitted the Hospital.   It will be, therefore, right to
tie the artery  by opening the sac, so as to  secure it
above and  below the  aperture, if the  aneurism be
seated low down in the limb, as the anastomosis with
the planter arteries is  exceedingly free.

loose coagulum, but there was not the slightest appearance of
any adhesive process internally. The inferior portion was also
open, but  did not contain any coagulum.   The coats of the ar-
tery were extremely thin  and semitransparent, having much
more the character of the coats of a vein than an artery.—T. 
H
   OF ANEURISM OF  THE POSTERIOR TIBIAL ARTERY.

   I have tied the femoral artery for  an aneurism,
 under the calf of the leg, in the' posterior tibial ar-
 tery, in a man of the name of Fox, aged sixty-nine
 years, who proceeded quite favourably.

              OF INGUINAL ANEURISM.

   The femoral artery sometimes forms an aneurism
 just opposite the hip-joint and below Poupart's liga-
 ment.   I have also seen it at the origin of the arte-
 ria profunda; but  if the  aneurism be  placed any
 where between  the groin  and the middle of the
 thigh, it  is best to tie

           THE  EXTERNAL ILIAC  ARTERY.

   Mode  of operating.—The operation  is performed
 as follows : The patient  being placed in the recum-
 bent  posture on a  table of convenient height,  the
 incision is begun just above the  abdominal ring, and
 is extended downwards in a semi-lunar direction to
 the upper edge of Poupart's ligament,  and again up-
 wards, to within an  inch of the anterior and superior
 spinous process of the ilium.   This incision  exposes
 the tendon of the external oblique muscle : in the
 same direction the above tendon is to be cut through,
 and  the  lower edges of the internal  oblique and
 transversalis  abdominis  muscles  are exposed;  the
centre of these muscles is then to be separated from
Poupart's ligament;  the opening by which the sper-
 matic cord quits the abdomen, is thus exposed, and
the finger passed through  this space is directly ap-
 plied upon the  iliac  artery above the origin of the
epigastric and circumflex  ilii  arteries.  The  iliac 
55
artery is placed  upon the  outer side of the  vein;
and the next step of the operation consists  in gently
separating the vein from the artery by the extremi-
ty of a director,  or by the end of the finger.   The
iron curved  aneurismal  needle is then passed  under
the artery, and between it and the vein from  with-
out inwards, carrying a ligature, which being brought
out at the wound, the needle is withdrawn, and the
ligature is then tied  around the  artery, as in  the
operation for popliteal aneurism.  One end of the liga-
ture being  cut away, the other is  suspended from
the wound,  the edges of which are brought togeth-
er by adhesive plaster,  and the wound is treated as
any other containing a ligature.
   Amid  the many cases of this operation which I
have  had occasion  to perform, two of  them  have
been in medical men, Mr. J.  of Stamford, and  Mr. C.
of Worcester, both of whom are now living.   One
unfortunate  case  only occurred,  in which  I lost the
patient from haemorrhage,  which took place on the
fifteenth day after the operation.  I applied another
ligature, but the man sunk  from the debility  conse-
quent on the loss of blood.

            THE INTERNAL ILIAC  ARTERY

   Has been tied by Mr. W. Stevens, surgeon,  in the
island of Santa Cruz, for the cure of a large aneu-
rism of the left glutceal artery.   The following ac-
count of the operation has been published  in the
fifth volume of the Medico-Chirurgical Transactions:
   Operation.—An incision, about five inches in length,
was made on the left side,  in the lower and lateral
part  of  the abdomen,  parallel  with the epigastric
artery, and  nearly half  an inch on  the outer side of
it.   The skin,  the superficial fascia, and the three
thin abdominal  muscles, were  successively divided: 
56
 the peritoneum was separated  from  its  loose con-
 nexion with the iliacus internus and psoas muscles;
 it was then turned  almost directly inwards, in a di-
 rection from the anterior superior spinous process of
 the ilium, to the division of the common iliac artery.
 In the cavity which I had now made I felt for the
 internal iliac, insinuated  the point of my  fore-finger
 behind it, and  then pressed the artery betwixt  my
 finger and thumb.  Dr. Lang now felt the aneurism
 behind;  the pulsation had entirely ceased,  and the
 tumour was disappearing.  I examined the  vessel in
 the pelvis;  it was healthy and free from its  neigh-
 bouring connexions; I then passed a ligature behind
 the artery,  and tied it  about  half an inch from its
 origin.  The tumour disappeared almost immediate-
 ly after the operation,  and  the wound healed kindly.
 About the  end of the  third week the  ligature came
 away, and  in ^six weeks  the woman was perfectly
 well.
   The case in  which I put a ligature  on  the aorta,
 has been published in  the  first part of the Surgical
 Essays.  I  shall, therefore, only give a short extract
 from it here.

             LIGATURE ON  THE AORTA.

   Case.—Charles Hutson,  a porter, aet. 38, was ad-
 mitted into Guy's Hospital,  on the 9th of April 1817,
 for an aneurism  in  the left groin,  situated  partly
 above and  partly below  Poupart's  ligament.   The
 swelling was very much diffused, and pressure upon
 it  gave considerable pain.  On  the  third day after
 he had been in the Hospital, the swelling increased
 to double its former size,  and extended from three
 to four inches above Poupart's  ligament to an equal
distance below  it, and was  of great magnitude. Just
 below the anterior and superior spinous  process of 
57
the ilium, a distinct  fluctuation could be felt in the
aneurismal sac, so that  the blood had not evidently
yet coagulated ; and the peritoneum was carried far
from the lower part of the abdomen,  in  such a man-
ner as  to reach the common iliac artery, and to ren-
der an operation  impracticable without  opening the
cavity of the peritoneum.  I therefore was extreme-
ly averse to perform  an operation, and determined
to wait and see  if  any efforts would be made to-
wards  a spontaneous cure.
   He  was  occasionally  bled, kept perfectly quiet,
and pressure was applied on the tumour.   June 19th,
a slough was observed  on the exterior part of the
swelling  below Poupart's ligament, which,  in  part,
separated on  the 20th,  and he had  some bleeding
from  the sac,  but  it was easily stopped  by a com-
press of lint, confined on the part  by adhesive  plas-
ter.  On the 22d, after some slight exertion, he bled
again, but not profusely.  24th, the  bleeding again
recurred,  but  stopped spontaneously.  25th, about
half-past  two  o'clock, in consequence of a sudden
mental agitation,  bled profusely, and became so much
exhausted, that  his -faeces passed off involuntarily;
but Mr. Key,  then my apprentice, succeeded in pre-
venting immediate dissolution by pressure.   At nine
o'clock the same  evening I saw him,  and found him
in so reduced a state, that he could not  survive ano-
ther haemorrhage, with which he was every moment
threatened.   Yet still anxious to avoid  opening the
abdomen, to secure the  aorta near to its bifurcation
I  made an  incision  into the aneurismal sac, above
Poupart's ligament, to ascertain if it  were practica-
ble to  pass a ligature around the artery from thence.
On introducing  my finger, I  found  that the artery
entered the sac above and quitted it  below, without
there  being any  intervening  portion of vessel; I
therefore, was obliged to abandon that mode of ope-
   vol. n.            7 
58
rating; and as the only chance  which remained ot
preventing his immediate dissolution,  by  haemor-
rhage, was by tying the aorta, I determined on doing
it.  The operation was performed as follows:
  Operation.—The patient's shoulders were slightly
elevated by pillow?, in order  to  relax,  as  much as
possible, the abdominal muscles; for I expected that
a protrusion of intestines would  produce embarrass-
ment in the operation, and was gratified to find that
this was  prevented by their empty state,  in conse-
quence of  the  involuntary evacuation of the faeces.
I then made  an incision,  three inches long,  into the
linea alba,  giving it a slight curve,  to avoid the  um-
bilicus: one inch and a half was above,  and the re-
mainder below the  navel.  Having divided the linea
alba, I  made a small  aperture into the peritoneum,
and  introduced my finger into  the abdomen ;  and
then  with  a probe-pointed  bistoury  enlarged  the
opening  into  the peritoneum  to nearly the same ex-
tent  as  that  of the  external wound.  During the
progress of the operation, only one small convolution
of intestine projected beyond the wound.
   Having  made a sufficient opening to  admit  my
finger into the  abdomen, I passed it between the in-
testines to the spine,  and felt the aorta greatly en-
larged, and beating with excessive force.  By means
of ray finger  nail, I scratched through the peritone-
um on the left side of the aorta, and  then  gradually
passed my finger between the aorta and spine, and
again penetrated the peritoneum,  on the right side
of the aorta.
   I had now my finger under the artery, and by its
side  I conveyed the blunt aneurismal needle,  armed
with a single ligature behind it;  and  Mr. Key drew
the ligature from the  eye of the needle  to the exter-
nal wound, when the  needle was withdrawn.
   The next circumstance, which required consider- 
59
able care, was the exclusion  of  the  intestine from
the ligature,  the ends of which were brought toge-
ther at the wound,  and the  finger was carried down
between  them, so as to remove every portion of the
intestine  from between the  threads : the  ligature
was then tied,  and  its ends were  left  hanging out of
the wound.
  During the operation  the faeces passed involunta-
rily, and the patient's  pulse, both  immediately and
for  an hour after the operation, was 144 in a minute.
I applied my hand  to his right  thigh, immediately
after the operation, and  he said that I touched his
foot, so that the sensibility  of the  leg was very im-
perfect.
  The omentum was drawn behind  the  opening as
far as the ligature would admit, so  as to facilitate
adhesion; and the edges of the wound were brought
together by means of  a quilled suture and adhesive
plaster.
   He remained very comfortable until the following
evening, when he vomited,  and his faeces passed off
involutarily.   27th, Seven o'clock A.M.  had passed
a restless night, and had vomited at intervals;  pulse
 104, weak and small;  pain  in his  head;  great anx-
iety of  countenance;  very restless,  and his  urine
dribbled from him.  He gradually  sunk, and died at
eighteen minutes after one  o'clock, having survived
the operation forty hours.

                    DISSECTION.

   No peritoneal inflammation, but at the edges of
 the wound, which were glued together by  adhesive
 matter, excepting at the part at which the  ligature
 protruded.   The thread had been  passed around
the aorta, about three quarters of  an inch above its
 bifurcation, and rather more than an inch below the 
60
part at which  the duodenum crosses the artery; it
had  not included any portion of omentum, or intes-
tine.   Upon carefully cutting open the aorta, a clot.
of more than an inch  in length,  was found to have
sealed the vessel  above the ligature; below the bi-
furcation, another, an inch in extent, occupied the
right iliac artery ; and the left was closed  by a third,
which reached as far as the aneurism: all were gra-
tified  to observe the artery so completely shut  in
forty hours.  The aneurismal sac,  which  was of a
most enormous size, reached from the common iliac
artery to below Poupart's ligament, and extended to
the  outer  part of the thigh.  The artery was de-
ficient from the upper to the lower part of the sac,
which was tilled with  an immense quantity of coagu-
lum.*

            ANEURISM OF THE CAROTID.

   1  have twice  performed the  operation of tying
the common carotid, on account  of the existence of
aneurism; and  as both these cases have been already
published in the  first  volume of the Medico-Chirur-
gical Transactions, it will be only necessary to give
a short account of them here, and  of  the mode  in
which this operation  is to be performed.
   Case.—The  first case is that  of Mary Edwards,
set. 44.  The  swelling occupied two-thirds of the
right side of the  neck, pulsated  very  strongly, and
the  integument at the  most prominent part  of the
tumour appeared  very thin.   It  had  existed  six

  * In an operation which I lately performed of tying the ex-
ternal iliac artery much  above Poupart's  ligament, I  think I
could with little difficulty have reached the aorta, by turning
up the peritoneum without dividing it; and should I again wish
to pnt a ligature on  the aorta,  1 should  prefer this method to
the one I have before adopted. 
61
mentis previous to the operation, which was per-
formed ^as follows:  On November 1,  1805,  I  made
an incision, two inches  long, on the  inner edge  of
the stemo-niasloid  muscle, from the inferior part of
the tumour to the clavicle, which laid bare the omo
and  sterno-hyoideus  muscles,  which  being  drawn
aside towards the trachea, exposed the jugular vein.
The motion of this  vein produced the only difficulty
in the operation ; as, under the different states  of
breathing, it sometimes  presented itself to the knife
tense and distended, and then as suddenly collapsed.
Passing my  finger  into the wound, to confine  that
vein, I  made  an incision upon the carotid artery,
and having laid it bare, I separated it  from the par
vagum,  and introduced a curved  aneurismal  needle
under it, taking care to exclude the recurrent nerve
on the  one  hand, and the par vagum  on  the other.
The two threads were  then tied about half an inch
asunder, being the  greatest  distance  to which they
could be separated  : on account of the short space,
I did not divide the artery.   As soon as the threads
were tied, all  pulsation in  the  tumour ceased, and
the wound was superficially  dressed.
  Immediately after  the operation she  was seized
w7ith a severe  fit of coughing, which  continued half
an hour, when  she  became more tranquil, and slept
six hours during the following night.   She continued
in a favourable state until  the  8th,  when it was
observed that her left arm  and leg were  paralytic :
she was restless, but had not any pain in the  head.
9th. Could  not swallow solids, and  felt  occasional
pricking pain in the wound.   11th. Power of motion
of the  left  arm  returned,  and she appeared going
on  favourably.   12th.  The  two ligatures  came
away with the intervening  portion of artery.  She
went on well until the  17th, the tumour reducing,
and the wound  healing;  when the wound  again 
62
opened,  the  tumour  increased, and  was  painful ;
she had a violent cough, great difficulty in  swallow-
ing, and  a hi^h degree of  constitutional  irritation.
From this time  she gradually got worse,  and  died
on the 21st.

                   DISSECTION.

   Inflammation  of the  aneurismal sac, which  con-
tained coagula and pus :  the inflammation  extended
nearly to the basis of the  skull, in the course of the
par vagum.   The glottis was almost closed, and the
internal surface of the trachea was  inflamed, fibrin
adhering to its mucous membrane.   Owing to the
pressure of the  tumour, the pharynx  would scarcely
admit a bougie of the size of a goose quill.   The
cause of her death then was the inflammation of the
aneurismal sac and  of the adjacent parts,  by which
the  size of the tumour became so increased as to
press on the  pharynx and prevent deglutition, and
upon the larynx, so  as to excite  coughing, and to
impede respiration.
  Case.—Humphrey  Humphreys, aet. 50, an  iron
porter, had an aneurismal tumour on the left side of
the  neck,  about  the size of a  walnut,  extending
from the angle  of the jaw to the thyroid cartilage.
He had  observed it about six  months  previous to
the operation, and it was accompanied with violent
 Cain in  the  head, and a sense of pulsation in  the
 rain.   When the sac was  emptied by pressure on
the artery below, the  tumour  regained its orio-inal
size by one contraction of the heart.
  The  operation was performed at Guy's Hospital,
on the 22d of June, 1808, iu the  same manner  as in 
                       63

the preceding case, only that the artery was divided
between the ligatures. The  pulsation in the tumour
did not,  however, entirely cease;  but the pain in
the head  subsided  immediately,  and did  not  again
return.
   The patient had scarcely an unpleasant symptom
following  the operation ;  the wound healed, as far
as the ligatures  would permit,  by adhesion ;  the
ligatures came away on the  14th  and 15th of July;
the  tumour  gradually diminished,  but an  obscure
pulsation existed in  it until the beginning cf Septem-
ber, when it could not be felt.   The wound closed
slowly, and the man returned to his employment on
the  I 4th of September.

               SUBCLAVIAN ANEURISM.

   The operation for tying the subclavian artery was
first successfully  performed  by Dr.  Post, of  New
York, and since by Mr. Lister, Mr. Todd, Mr. Gibbs,
Baron Dupuytren, Mr. Key, and others.  The  fol-
lowing were the steps of the  operation in Mr. Key's
case :
   The  patient being  laid  upon  an inclined plane,
formed by  the lithotomy  table, so that  the  light
from a large skylight could  be thrown into  the tri-
angular space in which the artery lies imbedded ; I
drew the  integuments down  over the  clavicle,  and
cut freely  upon  the  bone,  beginning the  incision
about half an inch over the clavicular portion of the
sterno-mastoid, and  continuing it outwards  for about
three inches.  The  integuments being relaxed, the
incision became raised about a third  of an inch above
the  clavicle, and  exposed  the platysma  myoides,
which  was  divided  to the  same extent.   Several
turgid veins were now exposed upon the  cervical
fascia, to avoid which was  impossible ; they  were 
64
therefore divided, and about three ounces of blood
lost; one, larger than the rest, Mr. Travers secured,
to prevent any obstruction in the aftersleps  of the
operation.   The outer laver of the  cervical fascia
was then divided  by the knife, and the  loose cellu-
lar texture, enveloping the glands of the  neck, being
detached by  the  finger, the omohyoideus  muscle
was  laid bare ;  a little farther dissection  then  dis-
covered  the artery to the  finger;  but the depth of
the angle, in which it was enclosed, rendering it im-
possible  to  pass a ligature  under it in so confined a
space ; about half an inch  of the sternomastoid was
divided,  which gave considerable room.   The arte-
ry was  then exposed by  means of a director,  and
the aneurismal needle was readily  conveyed  under
it, by passing it from  below upwards.  The method
I adopted  to  prevent any difficulty  in passing  the
ligature under the vessel, is detailed in the Medico-
Chirurgical  Transactions.  It is now a twelvemonth
since the operation was performed: the pulse in the
radial artery  is scarcely perceptible, although the
man enjoys  very good use of the limb, and is other-
wise in perfect health.

        ANEURISM OF  THE BRACHIAL ARTERY.

  I do not remember to have seen a case of aneurism
from disease in the  brachial artery; but 1 have seen
several at the elbow  joint, arising from  a  wound of
this artery; and as the treatment is the same in
each,  I will  describe  the operation  which  is  requir-
ed :—An  incision is made in the middle  of the  arm
between  the shoulder and  elbow, on  the inner e(Ve
of the biceps flexor cubiti,  of three  inches  in  leno-fh,
which directly exposes the brachial artery, its vena
comites, and  the median nerve : the artery is to be
a little dissected from the nerve and veinsj and then 
65
a probe is to be carried  under the  artery, armed
with  a ligature; the probe  is  to be  withdrawn,
leaving the ligature  under the vessel; the ligature
is then to be secured, as in the former operations,
with as little disturbance to the artery as  possible ;
one end of the thread is to be removed, whilst the
other is suffered to remain between the edges of the
wound, which are to be nicely adjusted with adhe-
sive  plaster.  It is better  not to  make an  incision
upon  the  artery  at the elbow joint, as most impor-
tant parts are divided, and constitutional  irritation
runs so high as to occasion the destruction of life,
as the following case  explains :
  Case.—One  of  our  young gentlemen  at  Guy's
Hospital,  in  bleeding a  patient,  recently  admitted
for  an accident,  had the misfortune  to prick the
artery ; the jet of blood, its arterial colour, and the
quantity  lost in  a short time  (being thirty-seven
ounces,) immediately  informed him of the  nature of
the injury.  He  bound up the arm as tightly as the
patient could bear, and succeeded  in suppressing the
haemorrhage; but, on the fourth day, the  tightness
of the bandage produced so much  pain, that the pa-
tient could bear it no longer, and  he  requested that
it might be  somewhat loosened ; but so soon as this
was done, the  bleeding was  renewed, and one of
the surgeons of  the Hospital was sent for; he made
an incision  upon the artery at  the  elbow joint,
where it  had been injured; the  operation was ex-
ceedingly tedious and difficult, but at last the artery
was secured  above and below the opening; violent
constitutional irritation succeeded,  and, on the eighth
day from his being bled, the man expired.   The
preparation taken from this man's arm is preserved
in St.  Thomas's Hospital.
  Old operation sometimes proper.—When this aneu-
rism  acquires very great magnitude, it is proper to
  VOL. II.              8 
66
 perform the old operation.  I lately saw Mr.  Mor-
 gan, surgeon of Guy's Hospital, perform this opera-
 tion easily and adroitly, in  a case of large aneurism.

           ANEURISM OF THE ULNA  ARTERY.

   I have seen only one case of aneurism of the ulna
 artery from disease ; it  was  in  a patient of Mr.
 Chandler's, in St. Thomas's Hospital; the aneurism
 was seated where the artery dips under  the prona-
 tor  radii,  teres, and  flexor muscles  of  the  hand.
 Mr. Chandler tied the artery above the swelling; it
 was an  extremely difficult and tedious  operation,
 and it  would have  been much  better to  have tied
 the brachial artery, either in the middle of the arm,
 or to have opened the aneurismal sac, and to have
 tied the  artery above  and  below its opening.   The
 patient died from the  constitutional irritation result-
 ing from this operation.
   In aneurism of the  ulna artery, situated at the
 wrist, it  is  right  to open  the sac,  to tie  the artery
 above and below the opening, taking care to exclude
 the ulna  nerve, which closely accompanies the artery.
   In aneurisms of the radial  artery  at  the  wrist,
 which  are frequently  occurring  by  wounds  from
 glass, the "aneurismal sac  must be  opened, and the
 artery tied above and  below the opening.   Mr. W.
 Cooper,  formerly surgeon at Guy's Hospital, in per-
forming  this operation, found the upper  portion of
the radial artery obliterated, and that the aneurism
was supported by regurgitation from the hand, from
the free  anastomosis with the ulna  artery.

            OF ANEURISM OF THE SCALP.

  Those which  I have  witnessed are as follows:—
an aneurism of the  posterior aural artery,  in  a pa- 
67
tent of  Mr. Fry, surgeon, at Dursley, kGloucester-
shire, which had been produced by a blow from her
husband.   I opened the  sac, and  was  compelled to
tie not  only the vessel which led  into the sac, but
numerous others, entering in all parts of the circum-
ference  of the swelling.
  I have seen several  cases of temporal aneurisms
from arteriotomy in that vessel.   One in Mr. Hen-
sleigh, a medical  student.  I opened the sac, secur-
ed the  temporal artery  at its lower part,  and was
then obliged to secure  many others entering the cir-
cumference of the sac, which had been excessively
dilated.   One case I  saw from   Mr.  Toulmin,  of
Hackney, produced by striking the temple against
the corner of a dining  table.
  A young lady,  whom Mr. Cline and myself have
visited in  consultation,  has a large pulsating tumour
in the forehead, above the  eyebrow, the  cause of
which is unknown.  In this  case I propose to make
a circular incision  around the sac to  the  bone, to
divide all  the  vessels which feed it,  and  then  to
make.use of pressure upon it.
  The  operation best  calculated to cure aneurisms
of the scalp  is  to cut  directly across  them, and to
make use of  pressure  to stop the bleeding,"5 to pre-
vent the course of the blood through  the  swelling,
and to produce adhesion  of the sides of the sac.
  Aneurisms are to be prevented  after arteriotomy
by the complete division of the vessel.

            OF  THE ANEURISMAL VAR1X.

  When the brachial  artery is punctured  with  the
lancet through the  vein in  bleeding, an adhesion  is
sometimes produced between the one and the other;
and the blood, flowing  from the artery into the vein,
causes an enlargement  of the latter, opposite the el- 
68
bow joint.   The swelling is called aneurismal varix,
from the enlargement of the vein, and from its con-
nexion with the artery.  The swelling of the vein
acquires the size of  a pigeon's egg, and then it usu-
ally  ceases to increase.   There is a pulsation in the
swelling, with  a  thrilling  sensation,  and a  hissing
noise.   If  the  artery  be  compressed above,  the
swelling becomes  flaccid and  can be emptied  of
its blood;  but if the arm be  compressed below  the
swelling, the pulsation continues, and the size of the
swelling remains  unaltered.   The  brachial  artery,
above  the varix, becomes enlarged,  owing to the
greater quantity of blood which it conveys.
  The  swelling of  the  vein  proceeds to the size
which I have mentioned, and  then  becomes station-
ary.   A woman, with this altered  state of the cir-
culation, used frequently to exhibit her  arm to the
students for many successive years,  and it seemed to
remain  annually the  same.
  No operation has  been required  for this disease,
in any case which I  have  seen of  it,  as it is not a
dangerous  state, either  to  the life  or even  to the
arm.  It renders the arm weaker, and nothing more
serious  arises from it.
  Case.—Mr. Atkinson,  a most respectable surgeon
at York, sent me an account of a case, in which an
operation had been performed for  this disease, and
it proved fatal.
  Treatment.—When the accident has recently  oc-
curred, it may  be cured  by the following plan.
  Case.—A young lady was brought to my house by
the  surgeon who  had the  misfortune  to  prick the
brachial artery in  bleeding.  The wound  had heal-
ed, but an aneurismal varix followed, of the size of
a pigeon's egg, attended  with strong pulsation, a
thrill, and  a hissing noise.  I ordered it to  be com-
pressed with a dossil of  lint and a roller; but it did 
69
not succeed in subduing it.   I then directed  that  a
circle of iron should be  put  round the  arm,  with  a
pad, which could be screwed down on the brachial
artery, in the middle of the arm, between the shoul-
der and elbow-joint.   This she  bore  without much
suffering, and gradually  the  swelling at the elbow
subsided, and pulsation in the brachial artery and in
the tumour could be no longer perceived.   As the
gentleman, who attended the case with me, was well
acquainted with Mr. Abernethy, he took the young
lady to Mr. Abernethy,  at my request, to shew him
the cure of this disease.

                                              «
                                              v 
70
               LECTURE XVI.

                  ON HYDROCELE.

  Definition.—Hydrocele is an accumulation of fluid
in the tunica vaginalis  testis,  producing a pyriform,
fluctuating, and  generally a transparent  swelling in
the scrotum.*
  Symptoms.—In this  disease the symptoms are as
follow:  a swelling begins about the testis, unattend-
ed with pain, and  is usually  observed  only by acci-
dent.   It  is at first flaccid, and  the fingers readily
sink through it,  so that  the  testis  can be distinctly
felt.  As  it  increases,  the swelling becomes  tense,
and conceals the testis.   It then assumes a pyriform
shape, the largest  part  of the swelling is opposite to
the testis, and as it rises towards the abdominal ring,
its diameter gradually lessens.  It  is generally unat-
tended with pain.   Some few of the vessels  of the
scrotum are enlarged, but  the skin  does not appear
to be inflamed, and the  patient suffers  no inconve-
nience but from its weight and  its magnitude : his
general  health being unaffected.
  Transparency.—Upon accurate examination of the
swelling, it is found to be transparent;  and, as some
surgeons  deny  the  truth  of this, it  must  arise
from their not  understanding the  mode of  making
the examination.  The  room  is to be darkened ; the
patient holds a candle, burning brightly, close to the
side of the scrotum, and the surgeon grasps the pos-

  *  The term Hydrocele applies to any watery tumour; but it
is now limited by surgeons to hydrocele of the tunica vaginalis,
and to hydrocele of the spermatic cord.
r 
71
terior part of the swelling,  so  as to  render its fore
part as tense as is possible ;  then the surgeon, looking
at the swelling from the side opposite to the candle,
and  placing his left hand on the  fore part of  the
scrotum,  immediately  discovers  transparency.    I
have seen surgeons place a candle on one side, raise
the scrotum, and look from the other, and say  the
swelling is not transparent;  and in this way it scarce-
ly ever will be.   The strong light of the sun, falling
directly on the part,  answers equally well, in shew-
ing its transparency.
   Fluctuation.—Hydrocele  has a distinct fluctuation,
which may be observed in  the most distant parts of
the swelling, by pressing with  the fingers  at remote
parts.   However, when it is excessively distended it
feels hard.
   Situation of the testicle.—The  testis is  generally
placed two thirds of  the swelling  downwards,  and
at the posterior part  of  the  scrotum ;  pressure at
that  part  gives the sensation of squeezing  the testis,
and when the swelling is transparent  the testis may
be seen there.
   Hydrocele  is  a  very  moveable  swelling;—if it
does not distend the part much in the course of  the
spermatic cord, it bends easily upon  the  abdomen,
and moves readily in all directions.
   Such is the usual character of the disease ;  but
sometimes, and not unfrequently, it  is the  result of
inflammation of  the testis,  Avhen it  is preceded by
pain, redness, hardness,  and  swelling of the part,
which assumes more the form  of the testis itself, and
is  less distinctly transparent.
   Nature  of the fluid.—The fluid which  hydrocele
contains resembles serum ;  like it, yellow  and trans-
parent ; like it, coagulable by  heat,  by acids, and by
alcohol : it coagulates in  Port  wine   and in solutions
of the sulphate  of  zinc, used as injections. 
72
              VARIETIES OF HYDROCELE.

   As this disease is subject to great varieties, it is
 necessary these should be particularly pointed out.
   On both sides.—The  disease sometimes  exists on
 both sides of the scrotum, and when  this happens
 the swellings must be cured in succession.
   Testicle on the fore part.—The testis varies  in its
 situation  in this disease; it is sometimes glued to the
 fore part of the tunica vaginalis,  and the  serum  is
 accumulated  on each side  of it.  I was  called to
 the following case :—A gentleman  consulted  a sur-
 geon for a swelling  in the scrotum,  which he pro-
 nounced to be hydrocele.  He put  a trocar into it;
 no water followed, and he said " I am mistaken; this
 is a solid  enlargement of the  testis, and  it must be
 removed."   The  patient, excessively alarmed at so
 severe a  sentence, said he should  require time to
 think  of  it,  and another surgeon  was consulted.
 When  his  clothes  were loosened,  venereal  spots
 were observed  upon the skin of the abdomen, and
 he had a node  upon  the tibia.   Mercury and sar-
 saparilla were given him, and  he  got  well of  those
 symptoms.  But the swelling remained  in  the scro-
 tum, and was clearly an hydrocele,  from its fluctua-
 tions and its  transparency; but with the testis  ad-
 hering to  the anterior part of the tunica vaginalis.
 It was injected from the side instead  of the  fore
 part, and  the  patient perfectly recovered.
   Result of inflammation.—When hydrocele  is the
 result of inflammation of  the  testis,  the water  is ac-
 cumulated (in consequence of  an unnatural adhesion
of the tunica vaginalis) above the  testis, or below it,
and upon either side.
   In our collection at St.  Thomas's,  we have a pre-
paration of the tunica vaginalis giving way posteri- 
 orly to the pressure  of the  water, and  forming a
 new and additional sac.
   Two swellings.—Hydrocele sometimes forms two
 swellings, one in the scrotum,  another at the abdomi-
 nal ring, with a smaller swelling of communication
 between them :—this has much the appearance  of
 hernia.
   Two distinct hydroceles are sometimes  formed
 upon the  same  side, of which  the following  is an
 example.
   Case.—Mr. Roberts,  surgeon, of Malmesbury, in
 Wiltshire, consulted Dr. Cheston, of Gloucester, re-
 specting a patient of his who had hydrocele; and it
 was agreed  that the water  should be drawn  off,
 which  Mr. Roberts did in Dr. Cheston's  presence;
 but they were both surprised to  see a  swelling re-
 maining, half as  large  as at first, and  which  could
 not be emptied through  the canula.  The canula
 was therefore  withdrawn, and  soon  after  he was
 sent to  London, where I saw him.  I  tapped the
 hydrocele, and a yellow serous fluid was discharged;
 but still half the swelling remained.  I then  dark-
 ened the room, ordered a candle, and examined the
 swelling, and which extended from  the upper part
 of the testis to the abdominal  ring:—it  was very
 transparent.  1 therefore tapped it, and drew off a
 fluid like  water, quite  free from  colour.   I after-
 wards  injected  the lower hydrocele, and repeatedly
tapped the upper swelling.   This additional swelling
was either  hydrocele of the  cord, or a  hernial sac
closed at its  orifice.
   We  have two preparations,  in  the  collection at
 St. Thomas's Hospital,  of a cyst growing between
 the tunica vaginalis and  the tunica  albuginea,  upon
 the surface of the testis.   I have  seen another ex-
 ample  of the same kind.
   Communicates with the abdomen.—Hydrocele some-
   vol. ir.               9 
74
times communicates with the abdomen:  1 have  se-
veral times seen this circumstance in children ;  oc-
casionally also in the adult.   The  following is an
interesting  case  of  the former.   Mr.  Dobson* of
Harlow, sent me a young gentleman with hydrocele,
which communicated with  the abdomen.  I wrote
to Mr. Dobson to  the  following effect:  " Our  first
step must  be  to apply a  truss,  and obliterate the
communication of  the  tunica vaginalis with the  ab-
domen,  and  then  we will inject the  hydrocele."
Many months afterwards, Mr. Dobson wrote  me
word that  the truss  had cured  the  hydrocele; for
that, when the  opening  of the tunica vaginalis was
obliterated  by its  pressure, the water became en-
tirely absorbed.   Where  hydrocele communicates
with the abdomen, and there is abdominal dropsy, it
is very convenient to tap  the  patient through  the
scrotum.
   Usual  quantity  of fluid.—The usual  quantity of
fluid in hydrocele  is from  six to eight  ounces;  but
the  largest  hydrocele I  have heard of was that of
Mr. Gibbon, the historian, from whom Mr.  Cline
drew off six quarts of fluid: my colleague, Mr. Mor-
gan, also mentioned  to  me a case  of very great ac-
cumulation of water in hydrocele.
   Varies in appearance.—The fluid also varies in its
appearance, although generally yellow, transparent,
and saltish to the  taste;  it  sometimes contains  a
quantity of white  flaky matter, produced by chronic
inflammation,  which I have seen more in the hydro-
cele of West Indians than in others.
   When produced under acute inflammation of the
testis, the  fluid is  sometimes of a red colour,  from
a mixture of red particles of the blood.
   I have  also seen  in the fluid of  hydrocele loose
cartilaginous bodies, of which we have  a  specimen
in our collection at St.  Thomas's Hospital.  When
hydrocele  has existed a great length of time, the 
75
 tunica vaginalis becomes thickened like parchment,
 and  consequently  opaque.    Mr. Warner  found a
 tunica vaginalis ossified.  There  is also one in that
 state in the collection at  Guy's Hospital;  and  Mr.
 Beavers, a pupil of Mr. Hey, of Leeds, gave me an
 example of one which he removed from the dead
 body.

              DIAGNOSIS OF HYDROCELE.

   Differs from diseased testicle.—Diseased  testis is
 distinguishable from hydrocele by the latter  being
 less heavy.   The diseased testis  is more flat on  the
 sides than hydrocele,  and  more solid;  pain is also
 produced by squeezing the testis;  the  epididymis is
 often capable of being felt as a distinct tumour;  the
 cord  may be  traced  with facility in  the diseased
 testis;  there  is great vascularity of the scrotum;
 pain is felt in the loins generally; there is often the
 appearance of loss of  health  in disease  of  the tes-
 ticle.   A person comes into my room, and says,
 " Sir, I have a disease in my  testicle."   Looking at
 him, I am wont to say, if I observe the appearance
 of good health, " I doubt that, Sir;" and upon exa-
 mination, usually find it to be  hydrocele.
  From hernia.—From hernia it may be distinguish-
 ed by the occasional return of  the hernial swelling
 into the  abdomen; by the dilatation of  hernia in
coughing; by hernia descending from the abdomen,
and  by  hydrocele  growing  from below upwards.
Hydrocele and  hernia  are,  however, occasionally
combined in the same  individual, when  the  hydro-
cele  is placed before the  hernia.  Hydrocele  is
sometimes met with below an adhering omental con-
genital  hernia.  Fluctuation   and  transparency are
also diagnostic marks of hydrocele.
  From varicocele.—Hydrocele may be distinguished 
 from varicocele by placing the patient in the recum-
 bent posture in which varicocele disappears.
   From hcematocc/c.—From haematocelc  it is  diffi-
 cult to distinguish it;  but  I will stale the difle.ences
 in the two diseases, when  speaking of hematocele :
 here it will only be necessary to say, that haemato-
 cele is generally the result of a blow.

            OF THE CAUSES OF HYDROCELE.

   Dropsy generally, and  this disease in  particular,
 is often said to arise from increased secretion or di-
 minished  absorption,  by which  the question of its
 cause  is really avoided :—for myself,  I  believe a di-
 minished  absorption is very rarely  the cause of true
 dropsy.   We do sometimes observe a leg or an arm
 swollen from enlargement  of the absorbent glands of
 the groin or axilla, but the swelling is very different
 to common oedema, being much more solid than drop-
 sy usually is.  But dropsical  swellings generally are
 the result of an increased secretion  from the arteries.
 The proofs of this are found in  the increased vascu-
 larity of the membranous  surface producing it,  seen
 in the living or injected in  the dead state; also in
 the changes in the membranes, produced  in long-
 continued dropsies; and in the quickness with which
 hydrocele  succeeds inflammation  of  the testis  and
 tunica vaginalis.  Certainly,  however, common  hy-
 drocele is rather the  result of relaxation of the arte-
ries, in which their mouths pour out more fluid, than
 it is the effect of inflammation.  The absorbent ves-
sels of the spermatic cord are very much  larger in
 hydrocele than on  the opposite and undiseased  side.
  Hydrocele is not unfrequently the effect of inflam-
mation of the testicle, which, as it subsides, leaves
the tunica vaginalis filled  with serum, of  a deeper
colour than  usual, and often slightly tinged with  red
particles. 
/"/
   Hydrocele  is  generally merely a  local disease;
but is sometimes connected with a general hydropic
disposition.

       OF THE NATURAL  CURE OF HYDROCELE.

   If  an  hydrocele be suffered to remain and to be-
come of large size;  if the patient be under the ne-
cessity of labour  to obtain subsistence, inflammation
of the tunica  vaginalis arid scrotum  will  arise from
excessive distention.  A  slough of the scrotum and
tunica vaginalis is produced, and, as it separates, the
water escapes : a suppurative inflammation succeeds,
granulations arise, and  the  patient  in this way re-
ceives his cure.
   Case.—Hydrocele is not always cured by a blow
which tears the tunica vaginalis.   I once attended a
gentleman, who consulted me for an hydrocele ; and
who,  whilst riding in the neighbourhood of Gibraltar,
was thrown forward upon the pommel of his saddle,
and received  a severe blow on the scrotum.  The
hydrocele disappeared, but in six months again form-
ed, and was,  he thought,  as  large as before.  I in-
jected it about two years from the accident.

    OF THE CURE  OF  HYDROCELE BY ABSORPTION.

  In children.—This disease is, in young people, very
generally curable  by absorption.  If  a child  be
brought  to me with hydrocele, I direct a little calo-
mel and rhubarb occasionally, and order a suspensory
bandage, which  is  to be kept wet with the muriate
of ammonia and liquor ammonias acetatis, in the pro-
portion of  3ij. of the former to gvj. of the latter.
This, after a short time, produces excoriation, and
leads  to the absorption  of the fluid.   The tinctura
lyttae  may be added, if the fluid does  not absorb
quickly. 
78
   When hydrocele is the result of inflammation of
 the testis, the same  mode of treatment  often  suc-
 ceeds in the adult, in  promoting absorption of the
 fluid, viz. giving submurias hydrargyri c extract:  co-
 locynth: comp: and applying an irritating lotion to
 the part.  These  applications  have,  however, no
  r>wer over the common hydrocele of the adult, and
  have tried continued blistering without benefit.

            OF TAPPING FOR HYDROCELE.

   When the general health forbids  an operation,
 which, although mild, is attended in some constitu-
 tions with risk, if a patient's fears prevent him from
 submitting to a more effectual treatment, or when it
 is inconvenient  to him  to undergo any other opera-
 tion ; the water is removed by tapping.
  Instruments.—The instruments required are a  tro-
 car  and  canula.  The canula  two inches long,  and
 the eighth of an inch in diameter.  A lancet only is
 sometimes employed;  but  it  is  an  inconvenient
 instrument,  leading to  difficulty in evacuating  the
 whole of the water,  and to bleeding into the tunica
 vaginalis after the operation.
  Mode  of operating.—The mode of performing  this
 operation is as follows: The  person is to stand  be-
 fore the  surgeon, who grasps  the scrotum and swell-
 ing with his  left hand,  and  introduces  the trocar
 two thirds of the length of the swelling downwards,
 and not directly horizontally,  but with a slight obli-
 quity upwards.  When the canula has entered  the
 tunica vaginalis, the  trocar is  withdrawn, and  the
 canula is then passed  further into the tunica vagina-
lis, and the water escapes.
  The swelling is grasped, that the fore part of the
scrotum  and  tunica vaginalis  may  be put  upon  the
stretch, when the trocar enters easily. 
79
  The trocar should be directed slightly upwards,
and then the testicle is not in danger of injury, which
it will be if the trocar be  entered horizontally; and
the canula  is  further  introduced when the trocar is
withdrawn, by which  a wound of the spermatic cord
or testicle will be effectually prevented.   When the
water  has  been  removed,  and the canula  is with-
drawn, a small  piece  of adhesive plaster  should be
laid  over the wound, and a suspensory bandage be
applied.
  Sometimes  succeeds in  curing.—This  operation
sometimes  succeeds in  preventing  a return of the
disease, although  very rarely; but to give the pa-
tient the best prospect of it, a strong stimulating lo-
tion may be immediately applied.
   Exercise sometimes  produces  inflammation.   I
have known  a  person who  had been  tapped in the
morning, get into  a  coach at night to  go to Man-
chester,  and have sufficient inflammation produced
to effect a  cure.
   Time in which  it forms again.—As in very few
cases inflammation succeeds, or a  cure is produced
by this operation, the patient returns in a few months
for its repetition; but the time of  reaccumulation is
very uncertain.
   If the disease very soon reappear, it is a proof of
an hydropic  disposition,  and it is right to give sub-
murias hydrargyri, with squills, at night, and tincture
of digitalis spiritus setheris nitrici  and mistura cam-
phorata twice  in the day.
   Not devoid  of danger.—This apparently  trifling
 operation is  not entirely unattended with danger, as
the follwing case proves :
   Case.—Mr. Somersett, an aged  gentleman, came
 to town from Wiltshire,  to undergo this operation;
 and on the evening of  the  day in which  it  was per-
 formed, he took a long walk.  On the following day 
80
 but one there was considerable inflammation in the
 scrotum, and his son, who was my dresser,  advised
 him  to rest and suspend the part.   The inflamma-
 tion, however, proceeded, and in a week he expired;
gangrene having been produced in the  scrotum to a
considerable  extent.   Well  may  it  be said  in our
profession,  " There are some you must not  touch,
there are others you cannot kill."   Mr. Green, of
Lewisham, has published  a case of a  similar kind,
which I had an opportunity of witnessing. 
81
              LECTURE  XVII.

  OF THE  OPERATIONS  FOR THE  CURE OF HYDROCELE.

   Various  have  been  the  operations advised  and
 resorted to for the cure of this  disease : some very
 severe, others  very uncertain in their issue.   The
 excision of  the  tunica  vaginalis  to greater or  less
 extent  was practised   by  surgeons forty  or fifty
 years ago :  an operation which  I have seen two or
 three times  performed, but which I hope  never to
 witness again ;  painful in  its performance,  and vio-
 lent in its consequences, beyond what this disease
 (which is little  more  than an  inconvenience)  will
 warrant.   A second  operation consisted in  passing a
 tent into  an opening in  the tunica  vaginalis, which
 produced inflammation, but, from the adhesion being
 partial, it often  did not  prevent  a return  of the dis-
 ease.  Thirdly, caustic  was used, potassa  fusa was
 applied to the scrotum, and rubbed upon  the part,
 until its influence reached  the tunica vaginalis, de-
 stroying its  life and texture; this, when well manag-
 ed, was a very successful operation; but  it required
 great attention in its  use, and I have known  it, in a
 diseased constitution, destroy life.
   Different  operations.—The  operations  to which I
 have occasionally  recourse, are  three :  1st,  Injec-
tion ; 2d,  Seton;  3d, Incision.   The object  of the
 two former is, to excite adhesive inflammation, and
 to change the action of the part, so as to  prevent
 further secretion ; in the  latter, to fill  the cavity
 with granulations.
   vol. h.               10 
82
   Injection.—For the  operation by injection we are
 indebted to Sir  James  Earle; and those who are
 old enough to remember the contrariety of  opinion
 on the  treatment of hydrocele; how  one surgeon
 advocated seton, another caustic,  a  third incision;
 well  know how to  appreciate the proposal of Sir
 James Earle, and  must  be  aware  how much our
 profession and mankind are indebted to him for his
 suggestion.
   Instruments required.—The  apparatus  which  is
 required for this operation is an elastic gum  bottle,
 to contain about six  ounces of fluid,  fitted  with a
 brass cylinder  to receive a stop cock, which can be
 attached at pleasure.   A trocar and a canula  two
 inches long are also  required.
   Fluids injected.—The  fluid which is used as an in-
jection is, either equal parts of port wine and  water,
 or sometimes, when a person has been  very unirri-
 table,  and the operation  has  failed, two thirds of
 wine and one third  of water, or 3J of zinci sulphas
 to lbj of water, or one  sixth of spin vini  to  five
 sixths  of water.  Cold  water  itself succeeds often
 very well, but I have known it fail.
   Mode of operating.—The patient  is  placed  in a
 recumbent posture upon a sopha or chairs, and the
 surgeon sits by his side;  the tumour is lightly  grasp-
 ed by the  left hand of the surgeon, and the  trocar
is thrust in gradually and obliquely.  It  should enter
 two thirds of the swelling downwards, and be direct-
ed not immediately  downwards to  the  testicle,  but
a little  upwards, so that if it  penetrated it  would
pass more  than  one third of the swelling   down-ft
wards.   The trocar  and canula having  entered the
tunica  vaginalis,  the trocar  is withdrawn,  and in
doing this the surgeon not only nips  the scrotum, but
the tunica  vaginalis around the canula,  to confine it
within the bag;  and when the  trocar is withdrawn, 
83
he pushes the canula to its  hilt within the tunic.
The water then escapes into a basin provided  for
the  purpose.   The surgeon  putting the stop cock
into the elastic bottle, introduces the stop cock on
the canula, and the contents of the  bottle are then
thrown into  the tunica vaginalis; great care being
taken  to nip the  tunic upon the canula; the bottle
is then removed, the stop cock remaining upon the
canufa.  The  patient soon feels pain in  his groin,
next in the spinous process of the ilium, and then in
the loins, sometimes the neck of the bladder suffers.
The fluid  is to  be withdrawn at  the  end  of five
minutes, and then the operation  is completed.
   Time the injection is to be retained.—Although, as
a general  rule, five minutes are occupied  in the re-
tention of the injection, yet it  may be observed, that
the suffering  is  sometimes  so considerable, that a
surgeon might be tempted to believe that the fluid
should be  sooner removed; but the succeeding in-
flammation is not at all commensurate with the pre-
vious   irritation :  those  who  suffer the most at the
time of injecting, have often the least inflammation,
and I am, therefore, disposed to continue it the same
in all adults.   In the  young, three  minutes will suf-
fice.
   Tunic not to be distended by the injection.—I never
distend the tunica vaginalis  with the injection, but
throw  in less  fluid than was  removed from the hy-
drocele, and move it in the tunica vaginalis, so as  to
make it apply itself  to every part  of the surface.
If much be injected, the ere master contracts,  and
forces  a part of it by  the side of the canula into the
cellular membrane  of the scrotum.
   Slight enlargement of the testicle.—If, when I have
drawn off the water,  I find the  testis somewhat en-
larged, it does  not  prevent my proceeding with the
operation; for I  find the excitement which it pro- 
84
duces often  diminishes the testis, and does not pre-
vent the success of  the operation.
  After-treatment.—When the operation is conclud-
ed, much depends upon the after-treatment  to ren-
der its issue Successful.   The suspensory bandage is
not to be reapplied, and the rules laid down for the
patient  are  these:   If you  are in much  pain, lie
down; if you suffer but little, take exercise; if you
be in much pain, eat very little and drink only dilu-
ents; if you suffer  but little, take your dinner  and
two or  three glasses of wine ; come to me  to-mor-
row ; if, then, there be redness in the scrotum, con-
siderable tenderness, and some swelling, you direct
the suspensory  bandage to be worn, the exercise to
be moderated, and  the diet to be light; but if there
be little appearance of inflammation, it is  right to
grasp the scrotum in one  hand, and with the  other
to gently tap it a few times  with  the fingers to pro-
duce slight pain.  Recommend exercise and a gene-
rous diet, until redness of the scrotum, swelling, and
pain in the part be  produced ; for the inflammatory
swelling from the injection should be nearly  as great
as that which  had  previously  existed from  the  dis-
ease.
   The  swelling continues increasing for a  week, is
stationary for a few days, and  then declines, so that
in three weeks  it has subsided; the operation rare-
ly requires a confinement of more than a few hours;
sometimes it does so for a week,  but, in general, I
say to my patients,  after four days you will be walk-
ing about  again; and then if they are not confined
at all, they are  much gratified.
   Operation fails.—This  operation sometimes fails
in producing sufficient inflammation to effect a cure.
I once  asked  Sir  James Earle if  he  did  not  fail
sometimes;  and he  said, scarcely ever;  this is quite
contrary to  my  experience; for I sometimes fail, 
85
and should very often, but for great care in the af-
ter-treatment, upon which, I  think, much  depends.
I sometimes, when water is reproduced  a few days
after the operation, tap it to remove the serum, and
to produce, by this operation, a larger  share of in-
flammation.
  From suppuration.—I have seen suppuration, after
injection, in very irritable tpersons; and in cases in
which  the  hydrocele  has been the  result of inflam-
mation, and the  inflammation of  the tunica vaginalis
had  not  completely subsided.  It  occasions  delay,
makes the  operation much more  painful, and renders
confinement necessary,  but it makes the cure more
certain.  A young man, about twenty years of age,
come  to  me in  Spring  Gardens, with an hydrocele
on each  side.  He resided  in  Long Lane in the
Borough, a distance of two miles from my  house.   I
injected one of  the  swellings with equal  parts  of
port wine  and  water,  and sent   him home.  I was
sent for  to him on account of a  high degree of in-
flammation, which proceeded to suppuration, and
which  I imputed to suffering him to go to a distance
directly after the  operation.   When he had recov-
ered from  this operation, I injected the other at his
own house, and directed  him to keep his  bed, and
used the same  strength of injection as before, yet
this hydrocele suppurated also.
  Case.—I was once  called  in consultation  a few
miles into the country respecting a gentleman, whose
hydrocele  had  been injected in London,  and  who
was  suffered to return  home afterwards, and the
tunica  vaginalis suppurated.
  When cysts  grow  between  the tunica  vaginalis
and tunica  albuginea, the operation will necessarily
occasionally fail.
  Danger  of injecting.—The  operation of injection
is not entirely without danger, and the danger con- 
86
 sists in throwing the injection into the cellular mem-
 brane of  the scrotum.  I have seen  many cases in
 which extensive sloughs were produced, and the fol-
 lowing is a case well worthy attention.
   Case.—A  man had been  under my care in Guy's
 Hospital for hydrocele, which  I injected, and failed
 in  producing a cure.  The  man, two  years after-
 wards, was admitted under  the care of one of my
 colleagues.   I spoke to the man, and examined him ;
 the case was decidedly hydrocele, in  the same side
 as  before.   About a fortnight  after,  as I  passed
 through the  same ward,  I said to one of the  gentle-
 men  by my side, " Mr. Godfrey, where is the man
 with  hydrocele?"—"Sir," said he, "he has  quitted
 the Hospital."—" Indeed," I said, "why?"  No an-
 swer  was made.   As  I was returning over  London
 Bridge, in my  way to the City, Mr. Godfrey joined
 me, and  said,  " Sir, I beg your  pardon for telling
 you the man  had  quitted the Hospital ;  but the fact
 is, that he is dead.   The  dresser of the surgeon un-
 der whose care he  was, attempted to inject the hy-
 drocele, by the permission of the surgeon: he threw
 in the fluid  with  great difficulty, and only after re-
 peated efforts;  the man  complained  violently,  and
 when the injection  was attempted to be withdrawn,
 it would  not escape; in  short,  it had  entered  the
 cellular membrane only;  violent inflammation  and
 gangrene  ensued,  and the  man died in a week."
 This  circumstance  happened from the canula  not
 being  passed into the tunica vaginalis,  so that  the
 injection  never  entered it; and even  if  the  canula
 has entered   the tunic, and is not confined there by
 pinching  the tunica vaginalis around  it, it is apt to
slip out.  This  was the reason why I mentioned the
 care which was necessary to push the canula home,
 and to pinch  the tunica vaginalis round it.
  Mode in which the cure is effected.—The mode in 
87
 which the cure is generally effected is,  by the effu-
 sion of serum  and fibrin into the  tunica vaginalis;
 the serum becomes absorbed,  and the fibrin glues
 the sides of the tunic together, and is also at length
 in a great degree absorbed;  but  this effusion is not
 necessary to the cure, which seems, in some cases,
 to be effected  by a change of action in the vessels.
   Case.—A captain in the coasting trade came to me
 with hydrocele, which I injected, and cured him. Some
 years afterwards I attended him with Mr. Holt, sur-
 geon, for a disease, of whioh  he died.   I requested
 of Mr. Holt to take away the testicle and tunica va-
 ginalis after death; which  he did,  and  it is now in
 the collection of St. Thomas's Hospital.  The tunic
 had adhered  very  partially, it was more  relaxed
 than usual, but did not contain  water;  so that from
 change of action, or effusion on the mouths  of  the
 vessels, it had ceased to be a secreting surface.

           OF THE OPERATION BY INCISION.

   When  some  obscurity hangs over the nature of
 the case as to its being  connected with  hernia, or
 some  enlargement or disease in   the testicle,  it is
 sometimes,  though  rarely, necessary to  open  the
 tunica vaginalis.
   Operation.—This is done by  beginning an incision
 at the upper part of the swelling, and extending it
 two  thirds downwards;  for if it  be made  to  the
lower part of  the tunica vaginalis, it leaves the tes-
tis too much exposed, and produces excessive inflam-
 mation in it.   The water being evacuated, and the
state of the testis learnt, as well as if there be any
disease connected  with  it (as cysts  on the testis,) a
little common  flour is sprinkled in,  and thus the sur-
face is forced  to granulate,  and  any return of the
disease is sure  to be prevented ; very seldom, how- 
88
ever, is such an operation required; and it ought
not to be had recourse to but in cases of great doubt
with respect to the disease, as it is one of great se-
verity.  After  this operation  a poultice only should
be applied,  and the cure  is effected by suppuration
and granulation.

     OF THE SETON FOR THE CURE  OF HYDROCELE.

  In cases in which  hydrocele will not yield to sti-
mulating lotions,  used with a view to produce ab-
sorption in very young persons, I prefer to the ope-
ration of injection the following plan:
  I pass a common curved needle and thread through
the hydrocele transversely, about half way from the
upper  to the lower  part of the  swelling,  including
about an inch and a half of integument, and one inch
of tunica  vaginalis.   I then  tie  the thread with a
knot, leaving it loosely hanging in the tunica vagina-
lis and scrotum.   No confinement  is necessary;  the
child  runs  about  as usual, until  the part reddens,
swells, and  becomes  hard, which is about a week;
and at the end of that time I withdraw the thread,
and the adhesive  inflammation produces the cure.
  I sometimes, in the adult,  adopt the  same plan «
when the injection has not  produced sufficient in-
flammation, and it prevents the necessity of any fur-
ther operation.
        HYDROCELE  OF  THE  SPERMATIC  CORD.

  This disease is rather of rare occurrence.   It may
be defined to be an accumulation of fluid in the tunica
vaginalis of the spermatic cord.
  How formed.—The complaint is founded upon the
following circumstance:  When the testis descends 
89
 from the abdomen, the spermatic cord is closely in-
 vested  by peritoneum, which adheres to its vessels;
 but the portion of peritoneum which descends with
 the testis from the lower part of the abdomen, does
 not, at  first, adhere  to the cord, but a channel, ad-
 mitting of a probe, is left between the two portions;
 so that the tunica vaginalis is, at  first,  open to the
 abdomen from  the testicle upwards.  But after  a
 time adhesion is  produced of  the tunica vaginalis
 from the  place  at which  the spermatic cord quits
 the  abdomen  nearly  to the testis,  and  the two por-
 tions appear as one.   Sometimes,  however, it  hap-
 pens, that in  some part of the cord  the  adhesion is
 not complete, and then a  space is left,  in which a
 slight secretion proceeds, and which, accumulated or
 increased,  produces at this part an hydrocele of  the
 cord.
   The  swelling, when seated below the abdominal
 ring, is easily distinguished from others.  It is globu-
 lar, and when grasped  and raised, it appears of a
 slight blue colour;  it is very transparent; extreme-
 ly firm to  the feel;  is  unattended  with pain; it
 rarely acquires any considerable  size,  and is merely
 an inconvenience to the patient from the impression
 it produces in his mind.
   Difficult  to distinguish from hernia.—When this
 swelling is  seated in  the spermatic cord above the
 abdominal  ring, it  it very difficult to distinguish it
from hernia; for  it  disappears  under pressure, is
very apparent in the  erect, and almost disappears
in the recumbent  posture;  but there  is no pain, no
gurgling, no interruption to the bowels from the tu-
mour.   The disease in this situation feels like a bul-
let  lodged  in the cord,—left to itself it  increases,
and at  last emerges at  the ring,  when its transpa-
rency decides its nature.
   Treatment.—In the  treatment  of this  disease it
   vol. ii.              U 
90
may be injected, or an incision be made into it, or a
seton introduced.
   I am of opinion it is best not to inject  them ;  for
it is with  difficulty done, and  the  disease is apt  to
return; this has happened to myself;  and the fol-
lowing  case,  which  had  been under  the  care  of
a very intelligent  surgeon, Mr. Pulley, of Bedford,
is a proof that it happened to another :
   Case.—Master-----, of Bedford, had a hydrocele
of the cord, of six years'  duration: it appeared  in
part above,  but the  greater  part  just  below the
ring ;  it was very transparent.   Mr. Pulley tapped
it, and  it formed again  immediately.   Mr. P. has
twice injected it—once five years ago, and secondly,
two years and a half since, but the disease returned.
I cured it by  making an incision,  and introducing
flour,  but  two abscesses formed during the cure.
  A seton made  by introducing a common  curved
needle carrying a single silk, is a more lenient cure.
  A hydrocele sometimes, I believe, forms on the
cord from a secretion, proceeding into a hernial sac
shut at its orifice to the abdomen.
                  ON HEMATOCELE.

   Haematocele is a collection of blood in the tunica
 vaginalis  testis.  The  tumour is pyriform  like hy-
 drocele, is not  painful,  does not affect  the general
 health, and is attended with slight fluctuation, but it
 is not in the least transparent.
   Distinguished from hydrocele.—It is distinguishable
 from hydrocele  by its  weight being greater, by its
 want of transparency,  by its obscure fluctuation, but    *
 most easily by its being usually the sudden result of
.a blow  upon the  part. 
91
  Case.—A man came  to  my house in the  country
with a pyriform swelling of the scrotum,  which, he
said, had  been  the  result of  his  being  thrown in
riding  upon the pommel of the saddle,  and  that, at
first, the scrotum had  been  also  severely  bruised,
and was of various colours  from extravasated blood.
I made an  incision into the tunica  vaginalis,  and dis-
charged a  large quantity  of brown-coloured  fluid
blood,  and large coagula changed in colour by long
retention;  I then ordered a poultice, to  produce
suppuration in the tunica vaginalis.
  Case.—Mr. W. was brought to  my house by  Mr.
Harris, surgeon, of Gracechurch Street, with a  pyri-
form swelling of the scrotum,  produced  by a  blow
fifteen years before ; and  it increased  progressively
to the  time  at  which I saw  him.  The  testis  and
epididymis could be felt at the lower  part  of the
swelling, and above it to the ring a solid  substance,
mixed  with a fluid, could be perceived; the  swelling
was not in  the  least  transparent, and he had never
suffered pain in  it.   1  opened the swelling at my
house, Sept. 23, 1822,  and  discharged a greenish
dark-coloured fluid blood,  and solid substance  of a
slightly yellow colour.  The  tunica  vaginalis  was
excessively  thickened,  looking  like   the  densest
parchment.  He went  home in a  coach, which was
about  three miles; and on the  same day,  when
imprudently  sitting  in  his counting house, he  was
seized  with a profuse haemorrhage from the tunica
vaginalis, and fainted :  he was  carried to bed, and
he had violent  constitutional irritation, with suppu-
ration  of the tunica vaginalis; but he did  well.
  Sometimes follows  hydrocele.—Haematocele   now
and  then  follows  tapping  in  hydrocele, more espe-
cially if a lancet be used.  Mr.  Sherwood, of Read-
ing,  informed me, that a  hydrocele being tapped,
some blood escaped  after the canula was withdrawn. 
92
The lips of the wound were  united, and some time
after a fresh hydrocele appeared to be formed, and
was  to  be operated  upon by injection;  but  upon
passing  the trocar, the tunica vaginalis was found
full of blood.   An incision was made into the tunica
vaginalis, the blood was discharged, and the patient
was cured.
   Case,—Mr.  Lewis,  surgeon, in Mark Lane, had a
patient  whom  he  had twice  tapped for hydrocele.
About two  months after the last operation,  he re-
turned  with the appearance of a renewed  disease,
only that the swelling was somewhat rounder.  Mr.
Lewis again  tapped, and drew off a pint of thick
bloody fluid.   In a fortnight the swelling re-appear-
ed, has  never  increased, but is gradually absorbing.
   Case.—Haematocele is sometimes founded on  hy-
drocele.  A man was brought into Guy's Hospital,
who had long  had a hydrocele, who had  received a
severe  blow upon it,  which suddenly increased  the
swelling, bruised the  scrotum, and produced great
pain  from distention.   I  made  an  incision  into it,
discharged a large quantity of water, and  of coagu-
lated blood, and found a rent in the tunica vaginalis
about two  inches long,  covered   with  coagulated
blood.
   Case.—Dr.  Saunders,  formerly teacher of medi-
cine at Guy's  Hospital,  had a hydrocele,  for which
he applied occasionally to Mr. Lucas, my colleague
at Guy's, to  have it tapped.  In stepping  upon a
chair to reach a book, he fell  against the back of
the  chair, and received a blow  upon the scrotum,
which led to  the  recurrence, as he thought, of his
hydrocele, and  in a few days he went to  Mr. Lucas
to have it tapped, but upon the introduction of the
trocar no water passed ;  the doctor then cousulted
several surgeons ; and at length Mr. Cline made an
incision into the part, and the tunica vaginalis  was 
93
found full of coagulated blood, which was discharg-
ed, a poultice  applied, and he soon recovered.
  Not always produced by a  blow.—Haeraatocele is
not always  produced by a blow.  I attended,  with
Mr. Hicks, in  Bond Street, a gentleman, who had a
large pyriform swelling in the left  tunica  vaginalis,
which had  never been  painful, and which had an
obscure  fluctuation.   I made  an incision into  the
swelling, in the  presence of  Mr.  Hicks, and  dis-
charged  near  a pint of fluid  blood.  This  swelling
had  not  succeeded a blow, but Mr. Hicks imputed
it to excessive exertions this gentleman had been in
the habit of making.
  We have in the collection  at St. Thomas's Hos-
pital  a haematocele, in which  the  testicle  was  re-
moved by  mistake.   The case  assumed the symp-
toms and feel  of a diseased testis, and  the surgeon
determined upon its removal.   I took it to St. Tho-
mas's to dissect, for the surgeon who had removed
it had not even the curiosity to examine the disease.
When I opened  the tunica vaginalis I found it most
excessively  thickened,  and filled with coagulated
blood of a brownish  red colour.  The  testicle  was
placed at  the  posterior  and  lower  part  of  the
swelling. 
94
              LECTURE  XVIII.

         ON THE DISEASES OF THE TESTICLE.

   That change to which the  testicle is sometimes,
but not very frequently subject, viz. the formation
of a  number  of cysts  or hydatids within its  sub-
stance, is the disease which I shall first describe.

        OF  THE HYDATID OR ENCYSTED  TESTIS.

   Age at which it occurs.—This change in the testi-
cle is usually observed  in the earlier periods of life,
generally from eighteen to thirty-five years, although
I have  seen it  occur at forty-nine  years.   It has
been  said to begin  in an enlargement  at the  end of
the epididymis ; but of the part in which it com-
mences I am by  no means certain, whether in the
testis or in the  epididymis; for the enlargement
is so  gradual  and imperceptible,  that it is  usually
discovered  by accident.  The   disease is generally
unattended with pain, nor does the  patient complain
of any  tenderness in  the part  when  it is handled.
It  does not seem to  be produced by or attended
with  any constitutional  disease, for the appearance
of the  person is  sometimes that of  robust  health.
There is no redness of the scrotum, but the  veins
of the spermatic cord  are, in some instances, very
much distended with  blood, so as to be  varicose.
The form  of the swelling  is that  of the testicle,
rounded upon  its fore  part, and flattened upon its
sides, rather than  pyriform like hydrocele.   The 
95
epididymis, under the greatest  enlargement, can be
distinguished in its swelling from the testis by a line
of separation between them.  The disease  is  at-
tended  with obscure  fluctuation, but it is  rather a
yielding  at the  part  compressed  with the  finger,
than an extensive fluctuation  from  one  extremity of
the swelling to the other.  If the  diseased part be
firmly compressed, it gives the sensation of squeez-
ing the testis; it gradually increases until it acquires
great size, and  then its weight becomes very incon-
venient,  and the disease  produces  considerable  un-
easiness in the loins, from  the testicle stretching  the
nerve of the spermatic plexus.   On  these accounts,
viz.  the  size it  acquires, and the  pain which its
weight produces, the patient  becomes anxious  for
its removal.
  I have never seen  this disease affect the sperma-
tic cord to the abdomen, or  extend its influence  be-
yond the testicle and epididymis.

        ON THE DISSECTION OF THIS DISEASE.

  On cutting into the  part after its removal, the tu-
nica vaginalis is found  to be a little thicker, and  the
tunica albuginea is much denser than natural.  The
testis is in  its interior, is  filled with  numerous cysts
of various sizes, some small  as the heads of pins,
others of the size of peas, and the largest about an
inch in diameter : as they vary in  size, so the fluid
which they contain differs in appearance—the small-
est contain a watery fluid, transparent,  and without
colour;  the larger  appear to be filled  with serum;
and the largest,  when  opened, discharge mucus with
some pus,  as they have undergone a partial suppu-
ration.  I  have seen  in  these cysts a  true hydatid
contained in  the  fluid, like that which  is frequei^'y
found in the liver.  The cysts are highly vascular, 
96
  and their appearance is very beautiful when the se-
  rum is seen through a highly vascular cyst.  The
  glandular structure  of the  testis  seems to  be in a
  great  measure destroyed.   The appearances  in the
  epididymis are of a similar kind, only that  the cysts
  do  not acquire the same magnitude.

      OF  THE DIAGNOSIS  OF  THE HYDATID TESTIS.

   Mistaken for hydrocele.—This disease is often mis-
  taken for hydrocele;  and it must be confessed, that
  they are with great difficulty distinguished from each
 other.   I do not  believe that  there is any surgeon,
 who is candid,  and who has had such opportunities
 as the surgeons of the large Hospitals  possess of wit-
 nessing disease, who will not confess he has mistaken
 this disease in the testicle for hydrocele, and plung-
 ed a lancet into it, and has  been  surprised to find,
 that a little water and blood only have followed.
   Marks of  distinction.—The  marks of distinction
 are  a  less extensive  fluctuation,  a much  heavier
 swelling,  rounded upon  the fore  part, and flattened
 upon the sides; the entire  absence  of transparency;
 the  sensation of  the  testis being  squeezed  under
 pressure; the varicose state  of the  vessels of the
 cord and  dilated veins of the scrotum; a division  of
 the  swelling  into  two,  viz,  testis  and  epididymis.
 Testis not felt as in hydrocele.

                       CASE I.

   Charles Demby, aged forty-nine, was admitted
into  Guy's Hospital,  23d  of May,   1804, with en-
largement of the testis.   It began two years before
in a  diminution of the  left testis,  accompanied  by a
sense of  weakness on the  left side;  it  afterwards
gradually  became larger than  the  other; and he ap- 
97
plied, three quarters of a year after discovering this
increase, to a surgeon of the first talent and respec-
tability in the neighbourhood of London, who intro-
duced  a trocar into the testis, and a little water was
observed  to issue, but  the quantity was very small.
He immediately pronounced it a case  of hydatid tes-
ticle :  as  it still continued to increase, the  patient
applied for admission into Guy's Hospital.  On the
29th of May I removed the testis,  and upon cutting
into it  I found a purulent fluid in some of the cysts,
and the  appearances  which I have described  in
others.  The wound quickly healed, and he was dis-
charged on the  16th of June, having  thus early en-
tirely recovered.

                      CASE II.

   Mr. Davie, surgeon, brought me  a testis from a
subject in the dissecting-room,  in which one of the
globular hydatids was  lodged.   It was enclosed in a
distinct cyst,  produced by  adhesive  inflammation;
the hydatid itself exactly resembled that which is  so
frequently met with in cysts of  the liver.

                      CASE III.

   Bartholomew Lupre, aged thirty, an Italian sailor,
was admitted  into Guy's Hospital  in Aprilr  1809,
with an enlarged  testis,  which he reported began
four or five months  previously; the cause was un-
known, but  he  supposed that  it arose from a  cold,
produced  by  his wearing wet  clothes; the veins  of
the scrotum  were much loaded  with blood, and
those  of  the spermatic  cord  were  very varicose.
This man suffered considerable pain in his loins from
the weight of the swelling.   I performed the opera-
   vol. ii.              12 
98
tion of removing the testicle, and found it, upon dis-
section, full of cysts of various magnitude.

                      CASE IV.

   A young  medical man called  upon  me with en-
largement of the testis, unattended with pain: its in-
crease was gradual, its weight was considerable, its
fluctuation obscure; the general health  was good.
Mr. Guthrie  removed  the testis,  which I examined,
and found to be of  the  hydatid  or encysted kind:
he gradually recovered.
   Cause.—The  cause of  this disease  is unknown,
and I shall not indulge in speculation, which would
probably be  unsatisfactory for want of  proof, and
useless in preventing the occurrence of the disease,
if clearly developed.
   The operation for the hydatid disease is required
from  the inconvenience resulting  from  its size, and
from the pain in the loins produced by  its weight.
A quantity of blood should be taken from the arm;
the patient briskly purged for a few days, and ani-
mal food refused for a week before the operation.
I  have  never known  a patient do otherwise than
well under the removal of the testicle for  this dis-
ease.
   No danger of return, if removed.—You may con-
fidently also assure  your patient, that there is no re-
mote danger  of returning disease; for in no instance
has there, within my knowledge, been any extension
of the complaint to the abdomen by the absorbent
vessels.
   It is right  to state,  however,  that I once saw in
Mr. Moorhouse, a medical gentleman who died of a
fungous testicle,  which extended  into the abdomen;
in some parts of the testicle numerous hydatid cysts
mixed with the morbid fungus or  medullary struc- 
99
ture; so it seems that the two diseases may be com-
bined in the same individual.

      OF THE MALIGNANT DISEASES OF THE TESTIS.

   The testicle is subject to two diseases of a malig-
nant character: viz. the fungus and the scirrhus dis-
ease : of which  the  former is by far the most fre-
quent.

OP THE FUNGUS, MEDULLARY,  OR PULPY DISEASE OF THE
                      TESTIS.

   Under these various  names has this disease been
described—fungus, because when it ulcerates, a large
fungus projection forms from it;  medullary, because
it has somewhat the appearance of the brain  in  a
putrid state; pulpy, because it  is  soft,  and easily
breaks down  to pressure.   It has  been often also
called the soft  cancer, on  account of some resem-
blance it bears to cancerous  affections,  although its
texture is of a much softer consistence.
   Symptoms.—The symptoms of this complaint are
as follow: It begins in an enlargement in the body
of the testicle, which is,  at first, accompanied  with
great hardness, and the form of the swelling is more
globular than that of the testis  in  its natural state.
The epididymis becomes soon affected after the dis-
ease has shewn itself in the testis;  the enlargement
proceeds generally rapidly,  although, in some cases,
it varies in  that respect.  The pain which  attends
 it, is at first only occasional, and not severe.  Slight
 causes, as a catarrh, or more than usual exertion, in-
 crease its size;  but by rest, the enlargement sub-
 sides nearly to its former state:  it  soon becomes  of
 the size of a small orange and of its globular shape:
 it feels very hard, but is free from tenderness when 
100
pressed;  it at length  forms adhesions to the sur-
rounding parts, so that  the scrotum, after  a time, is
only moveable over it at some points.  It is, at first,
regular on its surface ;  after a time the cord enlarges
above the abdominal ring, and at length it  contracts
adhesions to the  pubis.  At  first the scrotum is not
inflamed,  although the  vessels are somewhat larger.
A gland or glands become enlarged in the  groin, un-
attended with  pain after the testis has adhered to
the scrotum, and  which gradually increase.  An ab-
sorbent gland also generally enlarges on the opposite
side to that in  which  the disease begins.  The dis-
ease extends by absorption into the  abdomen, before
the testis adheres to  the tunica vaginalis  and scro-
tum, and produces a cord which may be traced upon
the psoas muscle  by  deep pressure  to the  region of
the kidney, where it produces, just  below the emul-
gent artery, a tumour, readily felt by  pressure, when
the abdominal  muscles  are  relaxed by bending the
body in the recumbent  posture.
   Constitutional affection.—At first  the  constitution
does not suffer, although the countenance of these
persons is generally sallow at the very dawn of the
disease, shewing  that  the general health is in  some
degree defective.  There is, sometimes, uneasiness
in the loins, and sharp pricking  pains in the thighs
and legs;  and as the disease advances, the leg, thigh,
and foot,  on the diseased side,  become cedematous,
and feel weak.   For  some  time before death the
patient loses his appetite, and gets but little sleep:
he has  profuse perspiration; the bowels  are gene-
rally very irregular,  as the tumour  on the  abdomen
increases, though  prior to that time  they are regular,
and there is sometimes an irritability of the bladder,
and  frequent inclination to make water.   The iliac
glands are also enlarged above  Poupart's  ligament.
  Period in which  it  proves  destructive.—I  have 
101
known the disease very rapid in its progress, termi-
nating the patient's existence in  a few months;  but I
have  also known it two years in one case, five years
in another,  and fourteen in  a   third.   The fact is,
that a simple chronic disease in  the  testicle will re-
main stationary  for a length A  time,  if the constitu-
tion be tolerably good; but if  it become deranged,
a  malignant  action  is  produced,  and  the  disease
assumes   the  character   of  the  complaint  I  am
describing.*   The testis  in  this disease has  often a
disposition to ulcerate; the scrotum adheres  to the

  * This is well illustrated by the following case: James Ver-
rall, aet. 26, employed as a musician at one of the theatres, in
the spring of 1823,  contracted a gonorrhoea, for the fourth time,
which, in three or four weeks, gave rise to an inflammation and
enlargement of the testicle ;  for this he applied evaporating lo-
tions, and kept at rest, and by these means reduced the inflam-
matory symptoms;  but the testicle still remained hard and much
larger  than in the natural state.  He then returned to his usual
mode of living, which was very irregular, and in the following
October the testicle became  farther enlarged, particularly at
the posterior part,  and it continued gradually to increase in size,
until his admission into St. Thomas's Hospital, on April the 8th,
1824.  The following is an  account  of the  symptoms and ap-
pearances  at that  time.  His  countenance  sallow, secretions
irregular,  and much general constitutional derangement, with
occasional severe  pain in the  affected part, extending to the
loins.   The testicle was about the size of a large orange, some-
what uneven on its surface,  feeling  extremely hard in some
parts,  and in others soft and fluctuating.   The usual  remedies
for chronic diseases were employed without producing any al-
teration in the disease, when,  by the  advice  of my colleagues
and myself, he consented to have it  excised.  This 1 did for
him in  the usual way : and on  examining the diseased testicle,
after its removal, I found the substance of the gland converted
into a soft,  pulpy, or medullary matter, in the centre of which
was a small abscess;  the epididymis presented a hard mass, like
scirrhus, and had numerous portions of cartilage deposited in it,
and at  its upper part was a bunch of hydatids.
   After the operation, he had a severe  attack of peritonitis,
which  was  subdued by active treatment, and he left the Hospital
much improved in health, with the wound quite closed. 
102
tunica vaginalis, and  assumes a livid  hue.   A sense
of fluctuation  is produced, so that it might be sup-
posed to contain a fluid;  ulceration  begins in the
scrotum, and  through the opening a fungous sub-
stance projects, which discharges a very large quan-
tity of a watery fluid; bleedings  occasionally ensue
from  this fungus.  If the testicle be pressed, a quan-
tity of matter which looks like putrid  brain issues;
the fungus sloughs,  then  the  part discharges pro-
fusely, bleeds, and again sloughs, until the patient is
exhausted by irritation and discharge.   Towards the
close  of life the pain is often excessively severe in
the part,  in the abdomen  it is occasional only; and
the patient has vomiting, and frequent attacks  of
diarrhoea.  I have known a person just before death
have  the following symptoms, vomiting,  hiccough,
violent pain in the abdomen,  swelling of the legs and
thighs, tumour in  the abdomen,  and pain with ten-
derness  on pressure over the abdominal muscles.

                    DISSECTION.

   The testicle in these cases varies  in its appear-
ance  according to the stage  of the disease.  A se-
cretion of a soft pulpy  matter,  looking something
like brain, is found deposited in the midst of the se-
meniferous tubes in its early stages;  and as the dis-
ease advances, and the testicle becomes enlarged, the
semeniferous tubes are absorbed, and  the peculiar
secretion of this disease  occupies their  natural situa-
tion.  I have  injected several of these diseases, and
we have beautiful specimens of them in the collec-
tion.  The secreted solid substance is very partially
vascular; in some parts  the vessels are very nume-
rous,  in others they do not enter the disease;  those
which do,  are so  tender  in their coats,  that they
readily give way to  very  slight  force; when ulcer- 
103
ated the fungus is found very vascular, other parts
of the tumour appear broken down, so as to have
lost their organization, and  resemble cream; por-
tions of the substance are solid like brain, but in se-
parate masses; some  have often also a woolly  or
floculent appearance.
  The true nature of the disease.—The  true  history
of the disease appears to consist in the part secret-
ing, not common fibrous or  adhesive  matter, but a
material of much softer consistence scarcely support-
ing vessels in some parts, whilst in others there is a
rapid growth  of  the blood vessels:  in  one case,
therefore,  it  falls readily into disorganization;  in
another, produces a  projecting fungus so soon as
ulceration allows the vessels a less limited growth;
but more of this hereafter.   In some parts we find
coagulated blood  mixed with the matter effused, and
in others small collections of serum.
  Disease in  the  spermatic  cord.—In the dissection
of the body the spermatic cord is tuberculated with
fungous tumours,  which contain a soft white  pulpy
mass;  and similar swellings adhere to  the  peritone-
um within the abdomen.  A tumour is found on the
loins,  reaching from thence upwards,  behind the  in-
testines, to the kidney. It covers .the aorta and ve-
na cava,  and the kidney adheres to it:  when cut  in-
to,  there issues from the  tumour  a  considerable
quantity  of matter which looks like thick cream,
mixed with a  small quantity of  the  colouring parts
of the blood.   The mesenteric glands are enlarged;
the liver has  tubercles in it; the thoracic duct  is
sometimes  obstructed  by a  fungus or medullary se-
cretion on it;  the duodenum passes over, adheres to
the tumour, and is narrowed by it, and the aorta and
cava  also adhere to it posteriorly.   The  coats of
the aorta and  vena cava become  diseased. 
104
        OF THE DIAGNOSIS  OF THIS BISEASE.

  Difference from hydrocele.—This is a difficult task.
From  hydrocele,  the  want of  transparency;  the
more globular form of the swelling ;  the pain which
occasionally attends it;  its yielding, rather than ex-
tensively fluctuating, and the appearance of want of
general health, become the means of distinguishing
it.
  From hydatid testicle.—But from the  hydatid tes-
ticle, when this disease arrives at the  pulpy state,
the distinction is much  more difficult, and  the  most
experienced  are liable  to err.   Pain in  the part oc-
curring at distant intervals; a sallow complexion, and
the appearance of deficient  general health are the
criteria, but still I  have  known  the  best surgeons
mistaken.  I really am decidedly of  opinion,  that in
hydrocele, hydatid, or fungus testis, no objection ex-
ists to  introducing a lancet to discover  the real na-
ture of the disease.   If it be hydrocele, the  rush of
water  directly  proves its nature.   If it  be the hy-
datid swelling, a little water,  mucus, and blood es-
cape ;  and if medullary,  blood  only ; sometimes  a
little brain-like substance  appears  upon the lancet,
which  immediately informs the surgeon of the true
form of the complaint.  It does no mischief in the
cases which it cannot relieve, and without it the sur-
geon's  reputation is endangered, if he gives  a  rash
opinion upon the nature of the disease.

           OF THE CAUSE  OF THIS DISEASE.

  Deranged   state  of constitution.—This  disease
arises  from a defective state of the  constitution :  it
generally occurs in persons naturally feeble,  and in
those  who are irritable,  both in body and mind. 
                         105

 They are subject to slight feverish  attacks,  to irre-
 gular secretions, to defective  digestion ; the former
 producing new  and disordered actions;  the latter
 leading  to an unhealthy state of blood in  which the
 quantity of serum is large,  and the fibrous  part of
 the blood small  in  quantity, and  loose  in  texture.
 But independent of the  state of constitution, there
 is also an altered local action : if the parts inflamed
 from this disease are cut into,  a fungous structure
 will be  produced from  the wound ;  but if the con-
 taminated parts  are entirely  removed,  the  wound
 heals as any other wound in the body without any
 such morbid appearance.

         OF THE TREATMENT OF THIS DISEASE.

   Medicines of no  service.—No  medicine  has been
 yet  discovered  which  has.  any  influence over this
 disease,  when it has been once formed.  The com-
 mon remedies used for  the preservation  of  the ge-
 neral health  may,  by  improving  the constitution,
 lessen or prevent the tendency to the  disease; but
 no medicine has any influence upon  it when  the  lo-
 cal disease has once appeared.  The pil: hydr: sub-
 muriatis  composita given at night, and  infus:  casca-
 rillae, soda, rhubarb, and  ammonia, given bis die, or
 hyd. c. creta, soda, and  rhubarb,  are the best medi-
 cines to improve  the constitution; yet  we ought to
look further, to try to discover, amidst the numerous
new articles which chemistry and the  extension of
botanical knowledge have given,  if some specific re-
medy cannot be discovered  for this disease.   The
local remedies hitherto employed have  been equal-
ly  inefficacious.   Leeches and evaporating lotions,
upon general principles, retard the  progress  of the
disease, but nothing has any specific  power in chang-
ing the action of  the  part; when  ulcerated,  solu-
  VOL. II.             13 
106
tions of alum, of sulphate of zinc and of copper, and
diluted  nitric and sulphuric acid are of some use.
All, then, that is left to  the surgeon  is to  improve
the constitution  first, next to effect the removal of
the disease by the  knife ; and when this  has been
done, to give such medicines, and rules of living, as
shall,  by  improving  and  preserving the  health,
change  the constitution,  and lessen the  disposition to
the return of this disease.
  Operation uncertain.—The removal of this disease
by operation is very often unsuccessful, as the disease
is very  apt to return in the part, or in some distant
organ of the body,  if a  constitutional treatment  is
not previously  and even afterwards pursued.  I re-
moved  in a patient of Mr. Sterry, in Bermondsey,  a
fungous ulcer from the  shoulder,  and the disease
soon afterwards shewed itself in the  eye, of  which
the patient died.  I removed, in a Mr. Bernard, an
eye affected with this disease, and in less than twelve
months the disease reappeared  in a very large swell-
ing above the groin.   In the removal of this disease
in the testicle, the  complaint  frequently returns  in
the loins and in the spermatic cord.   It is quite ne-
cessary that the operation  should be  performed  in
an early state of the  disease.   If, therefore,  a  pa-
tient applies with this disease, and I,put him  under
a course of mercury, and treat  him as  I shall direct-
ly describe I do a  simple  chronic inflammation  of
the testicle, and if it do not yield, I advise  its remo-
val ; for if the  spermatic cord  in  the least partici-
pates in the disease, the operation does not succeed :
so soon as the wound be healed, and  sooner  if the
wound  be slow  to heal, I give constitutional remedies
to improve the  general  health, and to  lessen the dis-
position to a return of the disease. 
107
      OF  THE TRUE SCIRRHUS OF THE TESTICLE.

   A very rare disease.—This  is an  extremely rare
 disease ; that which I have previously described be
 ing the most frequent;—indeed, for  a length of time
 I doubted if the testicle was subject to the disease
 to which  the breast is so prone;  viz. the  scirrhus,
 which,  in its progress, produces cancer.
   I  have seen few examples of that hard  swelling
 in the  testis which resembles  scirrhus, and I have
 never seen but one instance in  which that hardened
 testis ulcerated and destroyed the  part, resembling
 in its progress  the  cancerous  ulcer of the breast.
 Old persons are most liable to this  disease;  in the
 few examples in which I thought the disease  might
 be scirrhus, the  age has been between fifty  and sev-
 enty years.
   Symptoms.—The symptoms  have  been, a slow in-
 crease of the testicle, a  hardness  which rendered
 the part almost  impenetrable to pressure, occasional
 severe pain in the part extending towards the loins,
 the disease beginning in the testis; at length extend-
 ing to  the  epididymis; extremely  slow in  its pro-
 gress ; the surface of the testicle feeling tuberculat-
 ed, irregular, knotted, and  excessively hard;  the
 spermatic cord  becoming gradually thickened; the
 body bent forward, or the thigh advanced; the leg
 and thigh, upon  the  affected side, swollen and cede-
 matous ; some water  effused into the tunica vagina-
lis, so that the  testis  is felt through an hydrocele, a
tumour at last forms in the loins, but never acquires
 the magnitude of  that in the medullary disease, nor
 does the testis  become so large in scirrhus as in the
 complaint before described. The patient sinks from
 impaired digestion, violent pain in the abdomen, and
 irregular state of bowels.
i 
108
                    DISSECTION.

   When the testicle is cut open, the tunica vaginalis
 and tunica  albuginea are thickened; and, instead of
 the tubes which form the secreting structure of the
 testicle, a hard white  mass is  found, in lobes or tu-
 bercles, which are harder  than the other parts, and
 in which cartilaginous and  sometimes ossific matter
 are deposited.  The epididymis has the same ap-
 pearance, and some  tubercles are found in the cord.

                 SCIRRHOUS TESTIS.

   Case.—Thomas Cheston, aged 44, who had resid-
 ed at Tottenham, was admitted into Guy's Hospital,
 for an enlarged and hardened testis.  The  testis,
 when first  enlarged,  was impenetrably hard ;  water
 formed around  it, and the  hardened mass was felt
 through the surrounding water, which, being drawn
 off, was found -to amount to four Ounces.   His dis-
 ease  began in June  1808, and he  says,  he first ob-
 served a pain in the  loins, and,  a month afterwards,
 hardness and  uneasiness in the testicle: it gradually
 increased, but never  became very large.   The tes-
 ticle and epididymis, when he came to the  Hospital,
 were both affected,  but  the  spermatic cord was not
 enlarged.   He had much  pain in his loins, more es-
 pecially in stooping.   His countenance became then
 sallow ; his digestion  impaired ; his leg and  thigh
 (but first the latter)  became enlarged  and  cedema-
tous.  He  had  been a  strong  muscular man, and
thought he was in good health when the disease be-
gan.  The testis was removed in March 1809, and
the wound  slowly healed.  He was discharged  the
 Hospital  as soon as the wound  was closed ;  but the
swelling in  the thigh  and leg remained, and he died
a month after his return  to Tottenham. 
109
  On examination of the testicle, after its removal,
it was found  hard, white, very compact, tuberculat-
ed, and in a few spots very vascular.   The epididy-
mis was also enlarged.  We have, in the collection
of St. Thomas's Hospital, three or four preparations
of this disease, in which  the appearances of the tes-
tis are as above described.  The substance is white,
very hard, tuberculated, cartilaginous  matter in one
part; some ossific matter in others.
  The  disease does not increase, either in the part
or in the  abdomen,  to the same  magnitude as the
fungous disease.
  Disease of  the cord.—This disease  requires  the
operation for  its removal : but if the cord be affect-
ed, I have not known the operation succeed ; and,
indeed, there  is some danger to life in its  perform-
ance.
   Case.—In  visiting the wards of Guy's  Hospital,
I saw a man who  had a testicle very  hard and con-
siderably  enlarged,  and the cord of  at least  three
times  its  natural  size.  I said to the students, " It
will be of no use to  operate  in  this  case, for the
disease  has extended beyond the reach of the knife."
One of  the students,  who thought himself wiser than
the rest of the  world, told the man, if he would
place himself under his care, he would take a lodging
for him, and remove  the part.  The man consented,
and  this  young man removed the testicle, tracing
the cord, as I  was informed, very much towards the
abdomen.  Peritoneal inflammation succeeded, and
the man died in a few days, prematurely for the pa-
tient, usefully probably for the  rest of life to  this
foolish and presumptuous student.
  Constitutional treatment.—This disease will require
the same  constitutional  treatment  as  that which I
before described, after the operation  has been per-
formed, to prevent the return of the complaint. 
110
               LECTURE  XIX.

OF THE SIMPLE CHRONIC ENLARGEMENT  OF THE TESTIS.

   This is an extremely frequent  disease,  and  one
which has been mistaken for a malignant  complaint
of the part.
   Commencement of the disease.—This disease begins
in hardness  and swelling of the epididymis, at first
unattended with pain.   It gradually increases, with-
out pain, until the  testicle becomes involved in the
disease; the testis is quite  smooth; the epididymis
may be traced separately from the testis, the line of
separation being more distinct than in the natural
state.   The patient's  health  appears generally but
little  affected, and the part  is so indolent, that  the
patient handles it with a degree of roughness, which
surprises the surgeon.  Both testicles not unfrequent-
ly become affected at the same time ; and sometimes,
when the enlargment is subdued in the one, the oth-
er becomes diseased in a similar manner.   The sur-
face of the  testicles  and epididymis remain  quite
smooth, even under great increase of the part.
   Its further progress.—In the state which I  have
described the testicle remains  for weeks, and some-
times for months;  and  then under severe  catarrh
or violent exercise,  especially on  horseback,  it  be-
comes, very painful, with uneasiness of  the  loins and
redness of the scrotum, which will be relieved by
the means which are to be hereafter described;  but
soon the symptoms return, and at length a  suppura-
tive inflammation ensues, which usually happens at
the extremity of the  epididymis: a  sinus follows, 
Ill
which discharges seminal fluid, stiffening the  linen
as semen is wont to do.  From this sinus granulations
spring and produce  an exuberant growth, forming a
prominent granular swelling upon the scrotum.  This
still continues  for an  indefinite time, unless  some-
thing be done by surgery for its relief.

                    dissection.

  Before this disease was understood, I have seve-
ral times  known the testicle removed for it, and the
appearances upon dissection I have preserved in the
collection.
  Adhesive stage.—In the adhesive stage, an uniform
yellowish white adhesive matter loads the tissue of
the  part; the semeniferous  tubes remain,  but are
separated by the effusion which I have described.
  Suppurative stage.—In  the suppurative stage, upon
cutting  into the epididymis, and sometimes into the
body of the testicle itself, a  small abscess is  found,
containing pus, mixed with  adhesive or  fibrous mat-
ter;  and this  state of the testicle  will sometimes
render  its  removal necessary.   When it forms a
granular swelling, it is found, upon dissection, that a
small opening is  formed  in the covering of the epi-
didymis, through which the  granulations spring and
expand;  and sometimes the  testicle  itself forms the
granulation from the  abscess which it contains, and
which passes through  an  opening in the tunica albu-
ginea.  These abscesses will sometimes,  after dis-
charging  for months and  even for years, absorb the
testicle, and leave  the patient with  little more than
the tunica vaginalis and the tunica albuginea remain-
ing ;  and if both  testes  have  been affected,  impo-
tence is the result. 
112
      OF THE CAUSE OF THE SIMPLE CHRONIC DISEASE.

    Morbid state of the urethra.—This complaint  is
  often  depending for its production upon  a morbid
  state of the urethra, which produces a sympathetic
  influence upon the testicle.  Sometimes it  is simple
  irritation  only of the  urethra  which  produces it;
  sometimes a stricture in the membranous part; now
  and  then an  irritation in  the  prostate gland,  or in
  the prostatic  part of  the urethra.  But  still  it is
 wrong to view it  as having  merely a  local origin ;
 for there is, in most  of these cases, a state of consti-
 tution  which predisposes it, and without constitution-
 al  alterative means you will not succeed in curing it.
 I have often seen this disease  follow  syphilis; fre-
 quently observed it accompanied with an  eruption,
 which  many would conceive of a  syphilitic  charac-
 ter ; often known it  to follow  a mercurial  course in
 delicate persons,  who  have, during the  time,  been
 exposed to vicissitudes  of temperature, and to catch-
 ing cold from being frequently wet  in inclement
 weather.

  OF THE TREATMENT OF THIS CHRONIC INFLAMMATION.

   This complaint, for which the testicle is frequent-
 ly removed, under a  mistaken idea  of  its  malignant
 tendency, generally yields to the treatment  which I
 shall now advise you to adopt.
   When you are consulted respecting the complaint
in its adhesive  stage, you will  say to your  patient,
|* Now, if you choose to be cured, there is no difficulty
in effecting it;  but I  fear you  will  not submit."—
" Oh," he says, " I will  submit to any thing  to pre-
vent the loss of my testicle."   Well, the- plan then
is as follows : 
113
   Position.—1st.  Observe  the recumbent  posture
 for a month.   It is  not sitting with your legs raised
 which will suffice, but to  be absolutely recumbent is
 necessary.
   Medicine.—2d. Take two or  three grains  of  sub-
 murias hydrargyri and a  grain of opium night  and
 morning,'until the mouth  be  sore; and  then such a
 quantity as shall  preserve that tenderness  of the
 gums for a month.
   Local bleeding.—3d. Apply leeches twice  in the
 week, or let the patient stand before  his  surgeon
 and have the veins of the scrotum opened by a lan-
 cet.
   Applications.—4th. Apply upon the scrotum equal
 parts of camphorated mixture and vinegar.
   5th. About every fourth morning give an active
 dose of infusion of senna, with sulphate  of magnesia
 and tincture of senna.
   Period required for the cure.—In about three
 weeks, in this way, you will  reduce the size of the
 part; and then, if the urethra has been diseased and
 the complaint  be sympathetic, you may introduce
 daily a  silver sound, to  remove any obstruction in
 the  urethra, whilst the  patient is  still recumbent
 and living low;  when  the disease will, at the end of
 the month, or of five weeks, be cured.
   In the practice which  I have had an  opportunity
 of witnessing, it will  be readily supposed  I have seen
 a great  number of such  cases, and I can therefore
 speak with confidence of the  result of the above
 treatment; but  the  following is an  excellent exam-
 ple.
   Case.—An officer  of the British army, of conside-
 rable rank, some years ago, was seized with  inflam-
 mation in his testicle, for which he applied to a sur-
geon; who, after various attempts to reduce  it,  told
him that it was  a malignant disease, and that  it must
  VOL. II.               14 
114
be removed.   He submitted  to  the operation and
quickly  recovered.   Some months afterwards the
remaining testicle began to swell, and the symptoms
were so exactly similar to  those of the  former dis-
ease, that he became excessively alarmed, and plac-
ed himself under the care of Mr. Rose, who request-
ed a consultation with Sir Everard Home and myself.
We found  the testicle hard, swollen, and  but  little
painful : his general health had suffered from a warm
climate and exertionsdisproportioned to his strength.
He was put  upon the  plan  which I  have  recom-
mended above,  and in a very few weeks was  per-
fectly well.
   A fair  inference  may therefore  be drawn,  that
the testicle which  had  been removed  might  have
been saved.
   Many  testicles condemned  for  removal  I  have
thus known preserved.
   Sometimes  requires  removal.—When  the  disease
has proceeded so far as to produce an abscess in the
testicle, it will sometimes require to be removed.
   Case.—One of our students, who afterwards  be-
came a surgeon in the cavalry, had an inflammation
and chronic enlargement of the  testicle, which had
been repeatedly relieved by means  similar to  those
which I  have recommended: yet  each time he re-
turned to  exertion,  the inflammation  and swelling
were reproduced :  tired  by  repeated disappoint-
ments, and  unable  to  pursue his  profession as he
wished, he begged me  to  remove the  part, which  I
did : and upon examination of it, after the operation,
I found  a chronic abscess in its centre.
   Granular swelling.—When the abscess is followed
by a large swelling, produced by an exuberant growth
of granulations (a granular swelling,) the treatment
which is  to be pursued is to be as follows: 
115
   Treatment.—1st. Try pressure with adhesive plas-
ters ;  and if this does rtot succeed,
   Caustic.—2dly. Sprinkle the  surface  with  pow-
dered sulphate of copper, or nitrate of silver, which
gradually reduces it.   I  once knew arsenic  applied
freely upon the granulations, and it destroyed life.
   Removal.—3dly. It may be removed by excision.
An elliptical  incision  is made  into  the skin on each
side of  the  projecting  granulations,  and then  the
knife  is to  be carried horizontally under the root of
the swelling, where it projects from the opening in
the tunica  albuginea; and thus it is removed.   The
edges  of the skin are  then brought together by
suture, and healed.
   4thly. But when the  epididymis and testicle are
much involved  in the disease, and there is much loss
of substance in the  scrotum, it  is necessary  to re-
move the testicle.

             OF THE  IRRITABLE  TESTIS.

   Symptoms.—This disease is known by the follow-
ing symptoms:—the  patient has an uneasy sensation
in a part of  the  testicle ; it  is  tender  to pressure,
tender also in exercise, and unusually  sensitive at all
times.   The sensibility of the  part becomes occa-
sionally so  much increased, that  the slightest touch
is exquisitely  painful; pain is felt  in  the back  and
o-roin ; the motion of the part and slight pressure of
the clothes in  walking  produce so much  pain as to
almost forbid exercise, and the patient finds no com-
fort but  by reposing  continually  upon a sofa, or by
remaining in bed.  The testicle  is little swollen, and
the whole  of the  part is not equally tender.   The
spermatic cord sometimes  partakes of this exquisite
sensibility.   If the part be not supported, the pain
is scarcely tolerable.   The  patient is  obliged  to 
116
 place himself in bed upon the opposite side to the
 disease, or he does  not  rest.   He has  pain in the
 thigh on the same side,—the testis  appears full and
 loaded.   Motion  in  most cases  produces  not  only
 pain at the  time, but  additional uneasiness after-
 wards.  The stomach is  rendered extremely irrita-
 ble, and vomiting is sometimes produced.
   The  disease  frequently continues  many weeks,
 sometimes exists  for months,  and with  others en-
 dures for years.   When the patient thinks himself
 much better, a little  more exercise  than usual re-
 news all the symptoms.
   The  complaint  produces,  in  some  instances, so
 muoh distress  of mind, so high a degree  of bodily
 suffering, and so completely incapacitates the suffer-
 er  from amusement,  and  the pursuit of a profession
 or business, that he  seeks relief  from an operation
 which I was  thrice  compelled by  the patients to
 perform, rather than recommended it upon my  own
 judgment.
   The following  is a statement by a medical  man
 of the symptoms of the disease, which  rendered his
 life burthensome to him.

                     CASE I.

  " I think I can trace back the  origin of my com-
 plaint to the  Spring  of 1817, about eight or nine
 months  before I  married.   I  lived  too well :  got
 very corpulent and bloated,  and had  excessive ve-
 nereal excitement, which  I did not gratify,  and  felt
 the testicles and vessels of the cord ready to burst;
 but when I rose and  walked, the uneasy sensations
 subsided.
  " Soon after I married I began to feel the uneasi-
 ness in the  testicle I  have since suffered  from.  I
felt pain in coitu so great, as to lead  me  to go to 
117
London for advice.   The testis is  a little  fuller;
extremely  tender  to the  slightest  touch  of the
fingers: coitus always irritates it, so  that the swell-
ing and tenderness  increase from it:  the soreness is
felt in the upper and outer part of the testis,  and in
the vessels of the cord.   With regard to the nature
of the disease, I have been a long time convinced.it
is seated in the nerves of the spermatic cord ; the
pain is a benumbed sensation,—at  some times, a
pricking feel ;—at others,  such as  would  proceed
from  a compressed  or  irritated  nerve.  It is uni-
formly increased by whatever disturbs the position
of the testis, or presses upon  the ring,-or course of
the cord.   I can bear the  erect  position for a few
minutes, provided  the  part be  properly adjusted.
When I lie en the left side, the pain is of a dragging
kind,  and feels as if it extended from the region of
the ccecum; and when on the right it is  more sharp,
and feels  as if the  parts, which  are tender,  were
pressed upon  by those in the  neighbourhood:  I feel
most  easy  on  my back.   There is considerable ful-
ness on the  side of the  pubes,  which is always in-
creased, and extends higher in the direction  of  the
cord, when the  pain in the testis has been greater
than usual.
   " After  aperient  medicine  has produced  two or
three  motions, I usually  suffer  more pain for a day,
and  the passage of flatus through the  ccecum pro-
duces  the same effect.
   " The cord  appears, as far  as its tender state will
bear  examination, to be free  from organic change;
and  the testis, excepting that it is occasionally full,
seems unchanged in size or structure.
   "My general health  is good, and  every  other
function is natural :—yet I have now been confined
to a horizontal posture for a year.
   » It has always  happened, that however  severe 
118
 the pain has been on the side and right  limb, or re-
 gion, it has given way to cold applied to the abdo-
 minal ring; and comparative if not perfect case has
 been enjoyed for an hour afterwards.
   " The  means which I before  used, but  most in-
 effectually, as  to  my cure,  have been  leeches ; a
 solution of nitre, in a bladder, to the part; belladon-
 na and the cold hip bath ; sea bathing; regular  ape-
 rient medicines, and all  the  means which  the  best
 advice  in  this country could suggest.
   " I consider my symptoms might have originated
 in  an  injury I received  upon the cord,  some  time
 before  the symptoms began."

                      CASE  II.

   Master H. aged 14, has a teazing and  aching  pain
 in the  testis.   Exertion  brings on the  pain; leaning
 forward increases it.   He cannot walk one hundred
 yards but he has pain in  the groins, loins, thigh, and
 leg, to  the foot, on that side ;  the testicle is tender
 to the touch.  The recumbent posture relieves  him,
 unless he  has catarrh, and  then  he  has the  pain
 even in bed.

                    DISSECTION.

   I  have   removed  the  morbid part in three in-
 stances; and I thought,  in the  first case,  the centre
 of the epididymis was diminished, and that the dis-
ease might be produced by an accumulation of semen
behind it,  and that the  obstruction  might  produce
the pain ;   but I am inclined to  believe that the dis-
ease is in the nerve, as in the other two  cases there
was no  marked disorganization.
   It seems to me  to be  a species of tic douloureux,
supported  by  the  constant  functionat changes to 
119
 which the part is liable; for if it arose from organic
 change,  it would not, as it does, cease for a  consi-
 derable time, and then relapse.

        OF THE TREATMENT OF THIS DISEASE.

   Medicines.—The remedies I have seen most use-
 ful have been small doses of the  oxymurias  hydrar-
 gyri with  the compound decoction  of sarsaparilla,
 given  twice per diem, and continued for  a length of
 time.  The application of a belladonna plaster to
 the  part, and  opening a blister  at  the  groin,  and
 dressing it with ung: cetacei et opii.   A sea voyage
 to  a warm  climate, I  have  known improve  the
 patient, from the rest  and change of constitution it
 has  produced.   It will be right to try arsenic, which
 has considerable power over tic douloureux; to give
 Quinine, as bark relieves it;  also to try steel, as it
 has  been  recommended by  Mr.  Hutchinson,  of
 Southall, but at the same time to deplete the  part
 by leeches, and lessen the nervous irritation by  the
 application of  a solution of nitrate  of  potash and
 muriate of ammonia, in a bladder.   Bougies do  not
 relieve it; but  the ung: lyttee, used to  produce a
 slight discharge from the beginning of the urethra,
 I have known of service.
   The following are the three cases in which I have
 operated for the removal of the testis on account of
 this  affection.

                      CASE I.

   Mr.  G----contracted  a gonorrhoea at  Paris, in
October  1815, and  in consequence had inflammation
of the right  testicle, for  which he applied fomenta-
tions and took aperient  medicines: the testicle con-
tinued  swelled and painful until June 1816, when the 
120
employment  of strengthening  plasters  removed all
inconvenience; a slight degree  of pain returned at
intervals until June 1817, when he was again reliev-
ed by plasters, and thought  himself sufficiently well
to join his regiment.  The exercise, which his duty
obliged  him  to take, soon occasioned so much pain,
that during the winter of  1817 and spring of 1818,
he scarcely had a  moment's respite, but only  used
a blister, which he thought increased the  tender-
ness.  In May 1818 he  returned to England, and
bathed in the sea till September, at which time the
pain was nearly removed, but he was unable to wralk
or ride.   Since he  has  not employed  any remedy
but nine  weeks' sea-bathing at Brighton,  which pro-
duced no amelioration:  he was unable  to walk ten
yards without experiencing considerable pain;  the
only thing which  appeared  to relieve him was vio-
lent motion in a rough carriage.
  On account of the  continued pain,  confinement,
consequent depression of spirits, and  loss of health,
he  determined on having  the  testicle extracted,
which I removed on  the  1st of March 1819.   The
wound healed slowly, and one or two small abscesses
formed  in  the scrotum,  but he ultimately did ex-
tremely well.
CASE II.
  Captain P. had an irritable state of the left testis,
which commenced in March 1818.   The vein of the
spermatic cord felt  distended; the part was exqui-
sitely tender  to  the touch,  and exercise produced
pain, which  was intolerable  if the part was not sup-
ported :  he  could not rest on  the left side,  or bear
the slightest pressure on the testis ; he  had increas-
ed pain in  coitu, and  after it the part felt full and
loaded.   He was somewhat, but only  for a time, re- 
121*
lieved by the hot bath, or fomentations.   He tried
blistering at five  different times: applied two hun-
dred  leeches, at separate times, to the affected part:
employed also various lotions, opium, and belladonna,
with every medicine which seemed likely to be. use-
ful in  lessening  the irritability;  but all without be-
nefit.
   I removed the testicle for him in 1823 :  he quick-
ly recovered from the operation, and felt very grate-
ful for his restoration to society.

                     CASE III.

   This case is drawn up by  the  gentleman himself,
who came from  America to consult me ; he also saw
Mr. Abernethy  and  Mr.  Pearson.   Having  tried
every variety of medicine and local treatment with-
out advantage, and determined not to return to Ame-
rica with the disease, at his  request I removed the
part, and have since heard that he remains perfect-
ly well.  He says :
   " For several  years past my  left testicle has been
larger than my right;  at  times considerably so, es-
pecially when I  have   taken  cold.  Early  last sum-
mer I  began to  be uneasy about it, but neglected to
take advice.  In August I  lost two children  by the
yellowr fever, and in my anxiety I exposed  myself to
unusual fatigue ; and in a few days after their death,
the last week  in  August,  I had for the  first time
pain in the left  thigh and groin, also in the testicle,
which was  much enlarged.   I then applied to one
of our best  surgeons, who made an incision into it,
and let out a   large  quantity  of water; this was
about the 10th   of September : he then desired me
to suspend it, as  I do  now, and  to use a lotion "of the
extract of lead and opium.   In a few days after the
part again became painful, for which I applied tepid
   vol. ti.              15 
122
 poultices of bread and milk, and bathed it in warm
 Water.  The pain continued, and in about six weeks
 after,  the operation  was repeated; but very little
 water was drawn off:  no injection was  used.   For
 some time previous,  and  for about  six weeks after
 the  second incision, I took mercurial pills, two or
 three each day, and occasionally used mercurial fric-
 tion  on the thigh and testicle, keeping up a soreness
 in the mouth, but  not producing much salivation.
 With some intermissions this course  was continued
 for about four months: I  laid  in an  horizontal posi-
 tion, except occasionally for a few minutes at a  time,
 and drank only toast and water; lately I  have taken
 Madeira   and  water,  or  one or two glasses of Ma-
 deira, at  dinner.  In  December, a  blister was ap-
 plied to the scrotum, which  produced a  copious dis-
 charge.   I think  all   these  remedies gradually re-
 duced the size of the testicle ;  but the pain continu-
 ed;  sometimes a sharp shooting pain in the groin;
 but generally a heavy, dull, constant pain.
   " In March  I  procured some leeches from  New
 York, and applied seven ; bathing with tepid water,
 by Which I got  away  a considerable  quantity of
 blood, producing great  debility.  In  April I again
 applied three leeches; since which I used the lotion
 of lead and opium.
   " At present the part is about the same size as it
 has been for two months  past;  but the pain is con-
 stant, and I cannot stand for  ten minutes  without in-
 creasing  it considerably : there is great sensibility
 in the  part; the slightest touch is painful.
   " My general  health is as good as  it has been for
 years past; I am subject to headach, and other dys-
 peptic symptoms : a long residence in warm climates
 has injured my constitution."

/   . 
123
             OPERATION OF  CASTRATION.

   I shall conclude this Lecture with describing toyou
the operation of castration. The patient being placed
upon his back, upon a table of convenient height, with
his legs  hanging  over  its end ; and the hair of the
pubis being removed, the surgeon begins his incision
at the upper part  of  the  external abdominal ring
and extends  it to the bottom of the scrotum.  The
lower part of the scrotum  should be divided, or a
bag of matter afterwards forms in it.   The  next  in-
cision is made upon   the spermatic cord,  just below
the abdominal ring,  so as to lay it distinctly  bare,
and to enable the surgeon to raise  it.   In this second
incision the external  pudendal artery is divided, and
affords a bleeding,  which leads  the  surgeon to re-
quest it may be compressed by an  assistant, until the
testis be removed.   The next step of the operation
consists in raising the spermatic cord, and in passing
a  curved needle, armed  with a ligature, nearly
through its centre,  just  below the abdominal ring;
the ligature is then to be held by an assistant, which
prevents the retraction of the cord into the  ring, by
the contraction of the cremaster muscle.  The cord
is  then completely divided, and the surgeon drawing
by it the testicle  towards him,  separates the cellu-
lar tissue between it  and the  scrotum, and thus de-
taches it from the surrounding parts.
   Sometimes, from  inflammation, the testicle ad-
heres to the scrotum, in which case it is best to re-
move a portion of the latter, rather than to  make a
tedious  and  painful  dissection in separating these
parts.   When the testicle is removed,  the spermatic
artery is sought for in the anterior part of the cord,
and, when  found, is to be secured  by a ligature ;
next, an artery which accompanies the vas deferens, 
124
 is in like manner to be lied, taking care to exclude
 the vas deferens from the  ligature; after this, the
 thread which had been passed through the cord, to
 prevent its retraction, is withdrawn.  Any  vessels in
 the scrotum which bleed  must  be taken up.   The
 coagulated blood is then removed from the scrotum,
 and two sutures are put into it to bring the edges of
 the wound together ;  one just over  the end of the
 cord, and the; other midway between it and the bot-
 tom of the incision; lint is to be laid over the wound,
 and it is best at first not to apply any  plaster.*   The
 part  is to be supported  by a  handkerchief,  or T
 bandage.
   The ligatures  separate  in about  eight days, and
 in three weeks the wound  will probably be healed.
 The cruel  practice of tying the whole cord with a
 broad ligature is  now  properly abandoned  by every
 good  surgeon.

  * From the loose texture of the scrotum,  and from the large
 quantity of cellular tis«ue, the small vessels are  liable to escape
 the notice of the surgeon immediately after  the operation, by
 their retracting.   I always allow the patient to become  warm
 in bed before the dressing  is completed, at which  period the
 scrotum becomes relaxed,  and 1  have seen a free haemorrhage
 occur at this time, obliging the surgeon to remove the dressing,
 in order to secure the bleeding vessels.   If no further bleeding,
 however, takes place when the patient has become warm, the
 wound is dressed with  some mild  plaster,  and the parts well
supported.—T. 
125
               LECTURE  XX.

            ON DISEASES OF THE BREAST.

  The diseases of  this organ  have been  too much
considered as being of a  malignant nature;  and fe-
males, who have had the misfortune to have tumours
in their bosoms, have been often very unnecessarily
submitted  to an operation,  under  the idea of the
complaint being cancerous.  I  shall therefore  pro-
ceed  to state what 1 have been able to learn of the
various  diseases of this organ, to  discriminate the
malignant from  the more benign complaints, and to
point the  cases which  really  require removal, in dis-
tinction  from those in  which operations are entirely
unnecessary.

      OF  THE HYDATID OR ENCYSTED TUMOUR.

  Symptoms.—This disease begins  in  a swelling,
which is unattended with pain, and which  has the
character rather of a chronic inflammation, in a  part
of the breast, than as bearing a resemblance to a scir-
rhous tubecele;  for it  has  neither its mobility, its
excessive  hardness,  nor its general circumscribed or
distinct  limits, but it incorporates itself with  the sur-
rounding parts of the breast.
  The  skin over the mammary gland is undiscolour-
ed and the part is  scarcely tender to pressure.  The
o-eueral health is unaltered,  even when the swelling
becomes of the  most formidable magnitude.
  Becomes in part fluid.—As  it increases, a change
in the nature of the swelling is produced: at first it
was uniformly solid, but  is  afterwards distinctly di- 
126
 vided into a solid and a fluid part;  the latter fluctu-
 ating, so as at once to inform the surgeon of the ex-
 istence of a fluid.  If this part be punctured, a liquid,
 having the  usual character of serum, is discharged;
 the cyst sinks, but soon becomes again distended, and
 the swelling continues  to grow.  At  length the tu-
 mour acquires enormous magnitude, and some of the
 largest swellings in this organ are of the hydatid
 kind.   I have  twice seen swellings  not of this de-
 scription, rather larger than the hydatid ;  but gene-
 rally  the largest in  the breast are of this kind.
   One, which I removed, with Mr. Cline, from Lady
 Hewett, weighed nine  pounds.
   From Mrs.  King, at  Charing Cross, I removed
 one which weighed thirteen pounds;  but frequently
 they are removed when  still small,  under a supposi-
 tion that they are scirrhous tubercles.
   These  swellings  are  pendulous, and the  whole
 breast is very moveable  even  when large; they are
 generally unattended with pain,  although to  this
 rule there are exceptions, and the constitution is but
 little disordered.  The absorbent glands, in the most
 aggravated  form of this complaint, are undiseased,
 so that it does  not extend by absorption.
   Inflammation  of the  cysts.—Inflammation  some-
 times takes place in one of the cysts ;  and, when the
 cyst ulcerates,  serum mixed with  mucus, and occa-
 sionally with  a  little  matter, is  discharged;  the
 wound then heals, and the cavity seems obliterated;
 but the disease again ulcerates  in other parts,  and
 passes through  the same process.
   It is a complaint I have seen at  all ages after
 twenty, but more frequently in  advanced  age than
in youth. 
127
                    DISSECTION.

  Upon dissection, the breast is found to be consoli-
dated by the adhesive inflammation, so as to form a
very firm swelling  in  some parts,  but in others it
contains  cysts  distended  with serum.   The cvstf
vary in  size;  some of them contain mucus mixed
with  pus.   The  cysts which I  have seen  in  the
breasts  have been of three kinds.   First, The glo-
bular hydatid, like that which is  found in the liver,
contained within a vascular cyst.  A second  species,
composed of numerous membranes, which  may be
peeled from each other,  like the  concentric  lamellae
of the  crystalline  humour.   But  tumours  of  the
breast are  sometimes composed of simple bags,
which contain  and secrete the  serum,  or  watery
fluid, within them.

                     CASE I.

  Mi's. King,  of  Charing  Cross, aged 58,  had  an
enormous enlargement of  her left  breast;  she  dis-
covered it fourteen years ago, and supposed  it arose
from a blow.  When first  observed it was  as large
as a marble only, hard, and entirely unattended with
pain.
  It seemed to be buried in the breast, and  was  not
very moveable in the glandular structure.
  It gradually grew until  two years ago, when it
had acquired the size of a melon.   At that period it
seemed suddenly to grow faster than before ;  but was
still unattended with  pain,  and her general health
appeared to be good.
  Last Christmas it also acquired a very sudden in-
crease ;  but was  still free from  any painful sensa-
tions, excepting that sometimes, when she had a cold,
she felt a slight uneasiness  in the  part. 
128
   On the 30th of September  1822, I  was consult-
 ed;  the tumour then measured thirty-five inches in
 circumference, was  solid,  and felt  cartilaginous in
 some parts ;  but in  others was  soft and fluctuating,
 and one bag  evidently contained a  large quantity of
 fluid.   The  solid  tumour  was  placed above, the
 fluid occupied the lower part of the swelling.  Her
 general health was good, and the swelling was free
 from pain ;  but she  suffered  much from its  weight
 drawing down the  skin  and pectoral muscle, and
 putting the nerves exceedingly on the stretch.
   On the following day it  was removed, in the pre-
 sence of Mr. Key, surgeon of Guy's  Hospital, and
 Mr. Laviss, a practitioner in Westminster.
   The  large  vessels, divided in the operation,  were
 immediately secured, or pressed upon, so as  to pre-
 vent any considerable loss of blood.
   The  wound when dressed on the seventh day ap-
 peared  healthy ;  her constitution suffered but little,
 and  she recovered  without any untoward  circum-
 stance, and is now living at the same residence.
   Upon inspection, the greater part of the swelling
 appeared like boiled udder; within  which,  at va-
 rious parts, cysts  were contained, and  when  these
 were opened,  hydatids,  composed of numerous la-
 mellae, were found: serum was effused around them.

                     CASE  n.

   June  1818.—Lady Hewett, aged  60, tall  and of
strong constitution, dates  the origin of the swelling
in  her  breast from a blow she received, November
 1815, in  her  axilla,  by falling against  a  chair;  al-
though  she  had  previously felt  some  evanescent
pains in her  right bosom.   Nine  weeks  after  the
blow she felt uneasiness in  the  right breast, which
extended into the axilla.   In the beginning of  1816 
129
she discovered a swelling in her right breast, which
was about the size of a nutmeg, situated below the
nipple.   In May 1816 it had acquired  the size of a
melon, and she consulted  Dr.  Sharp, of Thrapston,
who ordered her what medicines he thought most
appropriate to her situation, and sent  her to Har-
rowgate;  but, as the swelling increased, she applied
leeches every day for two months, and afterwards
eVery other day, till September, without advantage.
   She then determined to try the  influence of pres-
sure, which she continued  several months,  by adhe-
sive plaster, and afterwards by an instrument, con-
trived for the purpose, which was worn during four
months, but without  any advantage, as  the swelling
still continued to increase.
   She therefore  determined  to leave  the  case to
nature, and she did so until November  1817, when
the swelling began to undergo a change.  It increas-
ed quickly, and became soft  at its upper  part, ap-
pearing inclined to  suppurate :—fomentations and
  oultices were applied, calomel  and opium  given,
  ut matter did not form.  This  treatment was con-
tinued  until the May  following, when she  discontin-
ued all the means.
   In June 1818 she made  up her mind  to  submit to
an operation, which I performed on the  10th day
of June 1818, in the  presence  of Mr. Cline, Mr.
Lowdell, and my nephew, Mr. Bransby Cooper.
   The swelling  was  of great size,  weighing nine
pounds.  It was in part solid, in some parts evident-
ly contained a fluid,  and over the  fluid part there
was a slight  blue  tint.   The  swelling was  verv
moveable, and reached down upon the upper part
of  the abdomen.   Lady  H.'s general health was
good.  The first steps of the operation consisted in
making a  puncture into the  tumour at  its  most pro-
minent part, and discharging  a  quantity  of  serum
   vol. h.              16
I 
130
from it, by which it  was at once  clear  the disease
was of the hydatid kind, and  the  magnitude of  the
swelling  was lessened.   An incision was  then  made
across the tumour, a little above its middle, and  the
flap of integument  being raised, the  upper part of
the swelling was detached from the  pectoral mus-
cle ; and with the handle of the knife the swelling
was further separated, and a flap of skin being  left
below to meet that at the upper part, the operatic*!
was thus concluded.   The  removal was  borne with
great fortitude.  Two arteries, of  considerable size,
required to  be secured.  The integuments  were
brought together by a single suture,  and by  adhe-
sive plaster.   On the  16th of June the wound was
first dressed, and on the 30th  Lady  H.  was quite
well.

                     CASE  III.

   The wife of Dr. W. aged  45,  twenty-six  years
ago, fell in getting  into  a  carriage, and  received a
blow upon  the breast,  which immediately  became
black and uneasy;  she applied  leeches upon it,  but
a small lump remained.  Three years ago the swell-
ing began to increase,  and, from  a rounded  form,
became oblong, but was free from  pain;  its increase
was  so gradual, that  little alteration  was produced
in twelve months.   At this time the veins  began to
enlarge and  the  skin to be discoloured;  yet still it
was  free from pain.  At the end of two years  she
applied to me, and I ordered leeches, which emptied
the veins, but did not  diminish the swelling,  for it
continued to increase, and several blue spots appear-
ed upon it;  but  it preserved a globular  form :  spi-
rituous lotions were  applied upon it to  check  its
growth by evaporation.        __-
  Two months  before the operation the  tumour 
131
underwent a sudden  increase,  and was supposed to
weigh about five lbs.  She was free from  pain dur-
ing the whole  progress of the disease ; her  spirits
were good; her activity undiminished, and  her con-
stitution was unaffected  until the last two months,
when she  said she  felt  nervous; and  head-aches,
which she  had always had occasionally, increased in
the progress of the  disease : the original lump was
for a time distinct  in the  tumour,  but at  length
blended itself with the general mass.
   In June  1818, in the presence  of Mr. Cline, I re-
moved this tumour,  by making two flaps,  as in the
last operation, and I  tied the arteries  which I divid-
ed as I proceeded.   Little  constitutional  irritation
followed, and in six weeks Mrs. W. was well.  The
appearances in this  breast were  similar to those in
Lady Hevvett's.

                     CASE IV.

   Mrs.  Styles, aged  28, had a tumour in the breast
which had existed three years, and which was some-
times  painful  from  changes  of  temperature,  and
sometimes from the  approach of  menstruation; but
the pain was inconsiderable.
   It began in  a swelling  of the  size of  a  filbert,
which  was hard  and moveable ; but it  gradually
became larger  until  it was about  two  inches  in  dia-
meter:  her menstruation and  bowels were* regular,
but rather inclined to costiveness ; her general health
was good.
   My nephew, Mr.  Bransby Cooper, removed  this
swelling, before me;  and  when he cut into  the tu-
mour, a bladder of water was opened.
   The cyst, in which the water was contained,  ap-
peared very vascular; it  was  then  removed : the
wound healed in  a fortnight;  but an  abscess after- 
132
wards formed  and discharged for six weeks, and
then  closed.  This  was  therefore  a  simple  cyst,
formed in the cellular membrane, containing a consi-
derable quantity of a serous secretion.
   We have, in the collection  at St.  Thomas's  Hos-
pital, a large globular hydatid, which Mr.  Cline in-
formed me was discharged from the  breast.
   It appears then, as I have stated,  that there are
three kinds of hydatid or encysted tumours, in the
breast.   One, in which the production is a globular
hydatid, like that which  is considered  to  be a dis-
tinct animal, and which is now and then met with in
different parts  of the human body; the  second  a
cyst composed of numerous lamellae  like the chrys-
tallinc humour;  and the  other, a bag containing se-
rum, and probably produced by an adhesive process
shutting the communication between the cells of the
cellular tissue, in which secretion proceeds.

                    DIAGNOSIS.

   The marks of distinction in this disease  are: 1st,
the health remaining perfect; 2dly,  the almost en-
tire absence of  pain, unless there  is  a suppurative
tendency in the cysts, when I  have  known the dis-
ease painful; 3dly, the swelling  being firm, smooth,
and not tender to  the  touch; 4thly, when  a  fluid
forms,  the  fluctuation  being very  distinct, and  a
slight bltfte tinge being observable when it approach-
es the skin ; 5thly, the fluid, when evacuated, having
the transparency of water, with a very slight yellow
tinge, and this is sometimes succeeded by a discharge
of mucus.

           TREATMENT OF  THIS  DISEASE.

   When the tumour  becomes of great magnitude, 
133
there is no other mode of relief but  by removing
it;  and, although the complaint be very formidable
in point of size, yet the  operation is  attended with
very little danger, and if the arteries  have become
large, the only care which is required  is to secure
them during the operation, as they are divided.
   When removed by operation, it does not return.—No
remote danger exists, for I  have never known  this
disease  return  after any  operation  in which the
swelling was clearly removed;  although I have (but
not in the breast)  when a small part of the swelling
remained.  But the disease does  not contaminate
the absorbent vessels or their glands,  but  is  to  be
considered as  entirely local.
  When a single cyst exists, the  swelling  does not
require removal.
  Case.—A young woman was sent into Guy's Hospi-
tal, many years ago, by Mr. Saumarez and Mr. Dixon,
who had a tumour in her breast,  which at  first felt
hard, and was about two and a half inches in diame-
ter.   Seeing her general health was perfectly good,
I applied a plaster, and did  no more; the swelling
underwent but  little change,  and  she quitted the
Hospital.   Many months after she  applied again for
admission, because the swelling was  much increased,
and I then ordered her into  the  operating theatre,
to remove it; but upon examining it with  great at-
tention I felt a  fluctuation,  and turning to the stu-
dents, I said,  " I shall put a lancet  into this  swell-
ing to ascertain its contents;" which I immediately
did, and serum only was discharged.  I introduced a
small piece of lint into the  orifice, brought  on an
adhesive inflammation, the sides of the cyst adhered,
and the patient did well, having  no return of the
complaint. 
134
           ON THE SCIRRHOUS  TUBERCLE.

  This disease is of extremely frequent occurrence.
  The symptoms with which  it is accompanied are
as follow :
  Symptoms.—The swelling is generally discovered
after it has acquired considerable magnitude, and  it
must have been  the growth of several  weeks.   It
is said to be discovered by accident:  but  if the pa-
tient distinctly traces her feelings she will have ob-
served some uneasy sensation, which led her to feel
the part.   Sometimes the attention  is first attract-
ed to the bosom by a drop of bloody serum having
stained the linen opposite the  nipple, it having flow-
ed from one of the lactiferous tubes.   Sometimes a
distinct and sharp pricking pain leads to  the  disco-
very of the swelling.
  Situation.—It  feels extremely hard.  It is evi-
dently seated in  the  gland  of  the breast.   It  is
moveable, but more so with the breast than in  itself.
It is usually distinctly circumscribed, so that the sur-
geon thinks he is able to decide upon its  limits, yet
it generally happens that portions of it  branch out
into the gland and connect it with parts of the breast
at a distance.
  Sometimes not tubercular.—In some  instances it is
rather a scirrhous inflammation in the breast than a
distinct tumour, which hardens and swells the bosom
throughout its whole extent.   In this state I have
seen it cross through the cellular tissue to the  other
breast,  and gradually extend in a similar  manner
through it.  At first the scirrhous  tubercle is not
painful, but subsequently becomes so; but then the
pain is occasional  only, occurring at distant intervals.
   Pain acute.—The pain is excessively severe, com-
monly as a stab in the  part;  sometimes a burning 
135
heat; now  a pricking  sensation ;  then a  sense  of
tearing, as if the  nerves of the  breast  were  torn
out, or the breast itself tearing off!   In other cases
the pain is more obscure, like the aching of rheuma-
tism.   It generally extends to  the shoulder on the
same side, and  often affects the nerves  of the arm.
  Intermittent pains.—The painful sensations in the
breast recur about  once in ten  days  or a  fortnight,
when the swelling begins to be  painful; but  more
frequently, as the disease advances; and I  believe
there is an occasional determination of blood to the
part, and that the disease increases,  particularly
wrhen this painful period  recurs.
  More severe  prior to menstruation.—Prior to men-
struation, (about four days,) the breast feels fuller,
heavier, and much more painful; and although, from
the last-mentioned  period it may have been tranquil,
it scarcely ever fails to  have  painful  sensations  at
the return of the menstruation; but  more just prior
to it, than at the exact moment;  for it is  relieved
so soon as the evacuation begins, and is always much
lessened after its cessation.
   Gradual increase of the disease.—The  swelling
gradually grows from the size  of a  marble, when it
is first observed, until it acquires a magnitude of two
or three inches in  diameter; for  it  rarely happens
that the true scirrhous  tubercle  increases to a  very
considerable bulk,  and this  circumstance  is one  of
its criteria.
  Retraction of the nipple.—The next change is a re-
traction of the nipple, and this occurs  from the lac-
tiferous tubes being drawn  out of  their course by
the swelling, and consequently  they draw in the nip-
ple,  in which they terminate  ; frequently  also the
nipple becomes red, inflamed,  excoriated, and some-
times ulcerated.
  Puckering of the  skin.—A change is also produced 
136
in the appearance of the skin, it is puckered so as to
resemble a cicatrix, and this arises from its adhesion
to the surface of  the tubercle.  Frequently the fol-
licles of the skin are filled with  black  sebaceous
matter around the nipple, in the  areola, and in the
skin on  the surface of the breast.
  Absorbents become affected.—The  cellular  mem-
brane becomes inflamed and hardened, and little tu-
bercles  form in the absorbent vessels under the in-
teguments.
  T%e glands in the axilla enlarge.—At  this  period,
or sometimes prior to it, the glands in the axilla be-
come enlarged, and many of these are often affected.
But if the disease be on the sternal side of the nip-
ple, the gland just above the clavicle at  the lower
part of the  neck, is felt  hardened and  increased ;
for then the irritation is extended by the  absorbents
through the  intercostal muscles to the internal mam-
mary absorbent vessels and glands.
  Extends to the clavicular glands.—When the glands
in the axilla have been many of them enlarged and
obstructed,  I have seen the scirrhous irritation pro-
ceed by the  absorbents from  the axilla to the back
of  the  shoulder, on  the scapula,  and  extend from
thence to the glands above  and behind the clavicle.
  Exists for years without destroying life.—Months
and sometimes years  roll on,  and the disease con-
tinues in  its  adhesive  stage,  and it even often de-
stroys  without further  change  occurring; but fre-
quently it  proceeds to  a suppurative inflammation:
then the skin appears of a  livid redness; the pain
becomes even more severe; a slight sense of fluctua-
tion, or rather of yielding, is  perceived in this part,
which  gradually ulcerates  and  discharges  only a
bloody serum; for true  pus  is not generated.   Pus
is attempted to  be  produced; but it is not formed 
137
 upon the truly malignant surfaces, but only upon the
 surrounding parts, if they  be  ulcerated.  I have,
 however,  sometimes seen  an approach to suppura-
 tion.
   Character of the sore.—The surface of the sore
 feels hard, like the original  tumour, and is remarka-
 bly  insensible to pressure: and  you therefore will
 observe the patient wipe it and handle it  with a de-
 gree of roughness and want of gentleness, which sur-
 prises those who are unaware of its little  sensibility.
 The granulations which spring from the sore are im-
 perfectly formed ;  in some  parts rising considerably,
 in others  scarcely any are produced :  they  differ
 from common healthy granulations in their hardness,
 in their insensibility,  and in their secretion;  which
 is, as I have stated, generally a bloody-coloured se-
 rum.
   The  ulcer frequently  bleeds.—Bleedings from the
 sore are frequent;  they occur spontaneously, and re-
 lieve the patient's sufferings;  and the  observation of
 this  may have led to the use of leeches in  the  treat-
 ment of the first stages  of  the disease :  they also
 arise from removing the adhering dressings, or from
 wiping  the  surface  of the  sore ;  and the flow  of
 blood does  not easily stop, as the vessels have little
 power of contraction ; pressure, however,  succeeds
 in checking the  haemorrhage.
   The edges of the  sore become everted, the ulce-
 ration gradually proceeds until a large ulcer is  form-
ed, and often a very deep excavation is produced, so
as to expose and even ulcerate the pectoral muscle.
 At this period, and often before ulceration has com-
menced, the patient complains of rheumatic feelings
in different  parts of the body, but particularly in the
loins and in the thighs;  but I have also known  other
 parts, as the spine, become painful : violent pain and
 tenderness  have been  felt in the  sternum and ribs,
   vol.  n            17 
138
and the patient describes the  pain  to  be  that  of
animals gnawing  the  parts.  I attended Lady M.
who, for many weeks  before her death, descnbed
herself to suffer daily the pains  of the rack, arising
from cancerous rheumatism.
   The appearances produced by this disease in the
bones, I shall presently describe.
   Great dyspnoea  is  also attendant upon this com-
plaint, and the  patient cannot  lie down in  bed, or
can only rest upon the diseased side ; she is  also fre-
quently teazed with a cough, unattended by expec-
toration.
   Frequently violent spasms are felt, which are re-
ferred to the  region of the stomach,  and they are
often attended with vomiting;  but,  I believe,  they
arise  from a tuberculated state  of the liver.  The
complexion is sallow, with  now and then  a slight
flush  upon the cheek.
   Extension of the disease.—After some  time the
arm,  upon the diseased side, begins to swell above
the elbow, then the fore arm enlarges; at length the
swelling extends to the axilla.   Its feel  is brawny;
it does not  pit so  easily  as common oedema; the
swelling seems  to arise from the loss of absorption
produced by the destruction of the texture of the
absorbent glands,  and from compression upon  the
veins of the axilla, from glandular enlargement. The
constitution becomes  excessively irritated   by  the
swelling, by the pain  which attends it, and by the
augmented disease in the breast, and thus gradually
the patient sinks under her sufferings.

OF THE DISSECTION OF PERSONS  DYING WITH SCIRRHOUS
               TUBERCLE, OR CANCER.

   The  tumour in the  breast  is a solid  mass,  ap-
proaching to the firmness of cartilage,  waved  upon 
139
 its surface, composed of fibrous  matter within,  and
 the lactiferous tubes  may  be seen  in white  lines,
 taking their course through it.*  If macerated for a
 time in the same water, the scirrhous matter softens
 and leaves the cellular texture, in which it has been
 deposited, with its  fibres  thickened and unnaturally
 strong.  Processes extend from the swelling into the
 surrounding parts of the breast, which must be care-
 fully felt for in the living subject, if an operation be
 performed.  The blood-vessels at the edge of the
 tumour are more numerous  than  in its substance, un-
 less it be ulcerated,  and then  around the  ulcerated
 part a great many are seen.
   It seldom happens,  when a tumour of this kind
 exists in the breast, that only  one is found, for there
 are generally  several smaller in different parts of
 the glandular structure.   The skin often adheres to
 the surface of the  swelling, and the absorbent ves-
 sels of the skin have  frequently little tubercles in
 their coats.
   If the swelling adheres  to the pectoral  muscle,
 scirrhous matter is deposited in the  direction of its
 fibres, and it is converted into a hard and white sub-
 stance ; the glands in the axilla are changed in their
 internal appearance  from the deposit of a scirrhous
 secretion  resembling that in the  breast,  but more
 vascular and more quickly ulcerating, and then they
 become spongy.   The  glands above the clavicle are
 in the same state ; and those  on  the left side, when
 enlarged, press  upon  the end of the thoracic duct,
 and disturb its  functions,  producing  excessive pain
 for some time after taking food.
   The glands behind the cartilage of  the ribs, when

  * It sometimes happens, that earthy matter is secreted into
the lactiferous tubes within the swelling; but this is by no means
a constant appearance. 
140
the disease is  placed upon  the sternal  side of the
nipple,  are  generally  diseased.   It  often  happens
that the axillary glands  upon the  opposite  side  to
the diseased breast are also enlarged and hardened.
   Of the lungs.—When the  chest is opened, the
lung on the diseased  side, and sometimes on both
sides, is inflamed, and partially adheres to the pleura
costalis.   Serum is found in the  cavity of the pleura,
on the diseased side, from which I have known death
produced  in  a  few days,  after an operation of re-
moving a scirrhous  -tubercle.   When the  finger is
passed over  the internal surface  of the pleura cos-
talis,"little scirrhous tubercles are felt upon it, and
the pleura on the  surface of  the  lungs  has similar,
but larger, scirrhous swellings.
   Of the liver.—The liver  lias  frequently scirrhous
tubercles  on it,  more especially when the disease in
the breast is seated on the  right side.
   Of the uterus.—The uterus is rarely free from dis-
ease ;  one, or sometimes several scirrhous tubercles
are formed  in it, and  this produces the pain in the
loins, of which the patient so  frequently complains.
   Of the ovaria.—I have  also  seen the ovaria en-
larged, hardened,  and tuberculated.
   Of the bones.—The  bones  have  frequently scirr-
hous deposits on the cancellated structure.
   We have the  sternum,  taken  from  Mrs.  Edge,
preserved  in the  collection  at St. Thomas's,  with
scirrhous secretion in it.  We  have the thigh bone
of the same lady,  which  broke merely  in her rising
from bed.  We have a fractured  thigh  bone  in the
collection, taken from another patient, which  broke
by her turning in  bed.
   We have also two most  curious  specimens of dis-
eased  spine, in which much of the bone has become
absorbed,  and scirrhous tubercles deposited  in the
spaces left  by absorption. 
141
  Age at which this disease  appears.—With respect
to the age at which the disease appears, I have fre-
quently seen  it at all  periods between thirty and
seventy years.   I do not  recollecX  more than  two
cases, in which the nature of the tumour was decid-
edly scirrhous, under thirty years.   I have seen one
case at ninety-three years, another case  at eighty-six,
and  have removed  one at seventy-three, ulcerated,
and  the patient did well.  It most frequently occurs
about fifty years  of  age.   In  ninety-seven  cases,
which I remarked, twelve were  of that age.
   Often confounded with chronic disease.—The tu-
mours which are found in women under thirty years
of age, and  which are usually called scirrhous, are
really only simple chronic enlargements, and are not
disposed to  malignant  action, and do not absolutely
require removal.
   Does not always shorten life.—When the disease
occurs in  very  old persons, it does not in  general
shorten life ; but the patient  lives as long with it as
 probably she would  have  done  if such tumour had
not existed,  and dies of some  other disease.   I saw
 a lady at  eighty-six,  who  consulted  me  upon  the
  Fropriety  of an operation for this disease, and whom
   advised  not  to  submit to it; and,  after several
 years, she died of another complaint.
    Occurring at the cessation of menstruation.—The
 disease is  supposed to occur more particularly at the
 cessation of menstruation,  and  which is  really the
 fact, for it is frequently sympathetic  with the ute-
 rus ;  but  still  the exceptions to this rule are very
 frequent.   The symptoms are augmented  by the
 approach  of menstruation,  and decline as the  period
 is passing.  The disease occurs more frequently in
 unmarried  women than in  others, and  in women
 who, being  married, have had no children, probably
 because the breast has not undergone  that  change
 for which nature had designed  it, in being the foun- 
142
 tain of nourishment to offspring; but yet pregnancy
 and nursing do not  prevent the  tendency to disease
 in some persons;  for I have known a woman die of
 the complaint w!i#~> had been pregnant  seventeen
 times, and had ten living children.
    If a tumour exists in the  breast  previous  to the
 cessation of menstruation, a malignant action will oc-
 cur in it at the period of its cessation, or soon after
 it.
   Many  persons  in a family affected.—There  are
 sometimes  several  persons in the same  family who
 will be affected with this disease.  A physician had
 three  relatives, sisters, the first of whom had a scir-
 rhous tubercle of  the  breast, of which she died.   A
 second had the disease, which  was removed by Mr.
 Lucas, sen.;  the  disease returned,  and  she  died.
 The third has applied  to me, from  a very painful
 swelling in the breast: they were unmarried. There-
 fore, in a family in which one  is affected, the  first
 dawn of complaint should be carefully watched, and
 the general health be well attended to in others.
   Progress of the disease sloiv.—The progress of this
 disease to its  termination is  always slow; but  in
 some more so than in others; and it is well that pa-
 tients,  who  must  fall  victims to the disease, should
 know  that  it often  remains stationary, and that I
 have seen it in one instance  seventeen  years;  one
 twenty-two .years;  in the last  case the  thigh  bone
 was broken  by a  very slight  accident; and, after
 several months, appeared to  be united, and  then
 again became  broken, in an effort to remove  her
 from bed.  As I was  examining the thigh bone, I
observed  her breast  ulcerated, and asked her how
long the disease had  existed, and she said  twenty-
two years.   The breast on the  left side was absorb-
ed, and a scirrhous swelling, with some enlargement,
existed over a large  portion of  the  skin, covering 
143
the pectoral muscle.  Dr. Babington informed me,
that he knew a lady, who had symptoms of the dis-
ease twenty-four years.
   Cause of scirrhus.—The  cause of this  disease is
supposed to be some  accidental blow, or the pres-
sure of a part of the dress;  but although a blow
may produce a swelling on the bosom, yet that swel-
ling will not be of a scirrhous  nature, unless some
defective state of the constitution disposes  to malig-
nant action.  If the constitution be good, the effects
of a blow are speedily dissipated ; but if the consti-
tution be faulty, the swelling grows  into a formida-
ble disease.  The complaint is, in part, constitution-
al, in part local.   It is constitutional  in so far as the
disposition  to  malignant  action is produced  by the
state of the habit.   It is local also, because the ac-
tion in the  part is peculiar, and the  result is a spe-
cific effusion different to that of common inflammation.
A wound, therefore, made  into the parts  will pro-
duce, on scirrhous disease, a cancerous ulcer; but a
wound made in removing the swelling heals like one
in any other part of the  body.   So with respect to
the  constitution, unless it be changed by a medical
treatment,  the disease will return as the disposition
to malignant  action which continues will reproduce
it.
   Influence  of the mind in predisposing to scirrhus.—
Anxiety of mind,  tending to the presence of slow fe-
ver, and suppressed secretions, are the  predisposing
causes of the  complaint.  A mother watching with
anxiety a near and dear relative in sickness; depriv-
ed of her natural rest, and inattentive to the devia-
tion  from  health in her own  person, is often after-
wards affected  with this  disease.  A  person,  the
prey of disappointment from reduced circumstances,
and struggling against poverty, when her  prospects
begin to brighten, finds a malignant tumour in her 
144
 breast; costive state of bowels, a dry skin, a paucity
 of other secretions  have  attended this anxious  state
 of mind, and laid the  foundation of that destruction
 which awaits her.

                     DISSECTION.

   In the examination of persons who have died  from
 this disease, besides the affection of the neighbour-
 ing glands, scirrhous tubercles are found in many oth-
 er parts of the body, but more  particularly in the
 thoracic and abdominal viscera.

                      CASE I.

   In addition to  the scirrhous  deposit in the  ster-
 num of Mrs.  Edge  (already  mentioned,) scirrhous
 tubercles were found in the following situations:
   In the integument covering each  breast;  in the
 glandular structure  of  the  breast itself, and in the
 neighbouring absorbent glands; also in the substance
 of the pectoral and  intercostal muscles.
   Thorax—On the  pleura of each side,  and on the
 pericardium, the cavities of which contained water;
 also  in the substance of each lung/
   Abdomen—In   the  liver,  pancreas,  mesenteric
 glands, and  uterus.

                      CASE  II.

   In  the dissection  of another patient, who  died
with an ulcerated  cancer  on the  right  breast, scirr-
hous  tubercles had  formed  in the direction of the
internal mammary artery on  each  side, but more
 particularly on the  right; also in the  intercostal
muscles.   The surface of each pleura,  and the  sub-
stance of each lung,  exhibited numerous  similar tu- 
145
mours.   The bronchial glands were also enlarged
from the same  cause.
   There seem  to  be  three  species of scirrhous  in-
flammation.
   Three species of scirrhus.—First,  That producing
a tubercle, which gradually grows to the size I have
described.
   Secondly, That  which gives origin to a number of
small scirrhous tubercles  in  several  parts  of the
breast, affecting both breasts, and producing similar
tubercles in various parts of the cellular membrane,
in the lungs, and in the liver.
   Thirdly,  A scirrhous inflammation of the breast,
which seems to involve the whole of  the glandular
structure, hardens the whole breast,  which becomes
attached firmly to  the  pectoral muscle, and to the
skin,  and often  extends over  to the opposite bosom.
VOL. II.
18 
146
                LECTURE XXI.

     OF THE TREATMENT OF SCIRRHOUS TUBERCLE.

   No specific  remedy having  been yet discovered
 for  this disease,  all  that  the  surgeon can do is, to
 employ the constitutional  treatment best calculated
 to keep the disease in check, by lessening inflamma-
 tory action.
   Constitutional remedies.—The  same attention  is
 required  to the due support of the secretions, .as in
 other complaints  of an inflammatory kind;  and the
 pilh hyd: subm: comp: in the quantity of from three
 to five grains  at  night, with compound infusion of
 gentian, soda, and rhubarb,  form an excellent medi-
 cine in that point  of view.
   Steel has  been recommended;  but  although it is
 useful in  another form of  disease of  the breast, in
 this  it often occasions  a feverish  heat; therefore it
 should not be employed unless in cases in which the
 uterine secretion  is defective,  and then the Plum-
 mer's pill at night, and the following draught twice
 per diem may  be  beneficial:

            R.   Vini  ferri 3j.
                Ammonia? carbonat: gr. vij.
                Aq: menth: virid: 3 j.
                Tinct: card: comp: 3ss.
           M. ft. Haustus bis die sumendus.

  Opiates.—Medicine  must  also be given  to  relieve
the severity of  suffering, and to subdue the  agoniz-
ing pains  with  which  the disease  is often accompa-
nied.   The tincture of opium, the liquor opii seda-
tivus, the  black drop, are  given  in  succession,  as 
147
 either form  is losing its effect,  combined with the
 camphor mixture, and a little of the spirilus aetheris
 comp. which is the best mode of administering them.
 A patient of mine in Guy's Hospital was much re-
 lieved by the stramonium, and this medicine  may be
 given in the following form:

           H.  Ext: stramonii gr. -|.
               Camph: gr. 2.
           M. ft. piiula bis terve die sumenda.

   Very small doses of belladonna sometimes succeed
 in diminishing the pain, and I have known bark also
 mitigate the severity of the symptoms.
   As no specific  has yet been  discovered  for this
 disease (for it would be  infamous quackery  to say,
 that any such remedy is known  for it) medical men,
 instead of going over again and  again  trials of the
 same means, should  endeavour  to discover, amidst
 the  numerous new articles  of medicine with which
 chemistry has of  late years furnished  them,  some
 remedy for this complaint.
   When  there is cough  attended with dyspnoea and
 pain  in  the side,  a  small quantity of blood, viz. six
 or eight ounces, should be taken from the arm, and
 then the blood is usually covered with an inflamma-
 tory coat.
   Effects of climate.—Climate has been supposed to
be likely to influence the progress of  this disease;
but  so tar as I have been able to learn,  it  has no
favourable effect.   A lady  consulted  me,  with  a
scirrhous tumour in her breast, which was removed:
soon  afterwards  her  husband's  mercantile  affairs
 obliged him to go to the Island of Trinidad, and the
wife accompanied  him.  She  suffered  greatly from
sea-sickness in her voyage, and it might have  been
expected  that  this  would  have  produced  some 
.448
change of action in the constitution.  From the ex-
treme  warmth  of  the  climate,  some  favourable
change  might have  been expected  to have arisen;
yet,  in a few months, the  disease returned  in  the
breast;  and,  finding that  it was making considerable
progress,  she determined to return  to England.   I
saw her soon after her return;  but the change from
a warm to a  cold climate had produced no more fa-
vourable change than her visit to the warm tempe-
rature of  Trinidad.  The glands in  the axilla were
enlarged; the breast was ulcerated; her lungs had
become affected; her  body was  emaciated;  and  it
was evident she had  but a short time to live.   I also
lately knew  an  English lady visit the south  of Eu-
rope, when  labouring under this disease, and there
she died of it.
   Vegetable diet.— It is supposed  that a  vegetable
diet, and food affording little nourishment is  condu-
cive  to recovery.   There  is no  greater  mistake.
Whatever weakens leads to an increase of the dis-
ease,  and to a more rapid termination of the exis-
tence.   Low living  renders  the person  irritable,
quickens the  pulse, and maizes the constitution feel
the disease more strongly.   Vegetable diet has not
the least  beneficial  influence over  this complaint.
Wine and fermented liquors, given so as to produce
a quicker pulse,  or heat of skin, are equally  impro-
per,  as  a feverish state is equally pernicious with
the nervous   irritability which low living  produces.
In short,  diet has  no specific influence,   and that
which  has agreed  best  with  the patient at other
times is  the most  appropriate under this disease.
Meat once per diem, and weak wine and water, as
a drink  at dinner, agrees best.   The other meals,
morning and  evening, to be as usual.
   Local  treatment.—The  local  treatment of  the
complaint consists  in subduing inflammatory  action; 
149
by perspiration;  by wearing oiled silk;  soap cerate,
or a poultice of bread and poppy water;  wearing a
piece of fur upon the part, or a portion of hareskin,
is found  to tranquillize the disease.
  Leeches.—As  the pain is occasionally severe, and
the disease  seems to grow by occasional determina-
tions  of  blood,  it  is right at  these times  to apply
leeches ;  four or  six of  them  may be used, but it is
wrong to weaken  the  patient  by their application;
and therefore great numbers of them, or  a frequent
repetition of their application, is wrong.  When the
pain  is excessively severe, it  is  right  to apply the
extract of belladonna with the soap cerate.

            Cerat. saponis  3j.
            Ext. belladonna 3j.
            01. lavendulae g". v.
                               M.

   Poultices.—If there be  a disposition to suppura-
tive inflammation in the tumour, it is right to use fo-
mentations and poultices.
   When the  part is ulcerated  and is granulating,
the  bismuth ointment  is a  good application;   as  it
also is to an appearance of erysipelatous inflamma-
tion on the surrounding skin.   The unguentum zinci
oxydi,  under similar circumstances, may be of ser-
vice.  Chalk and opium 1  have seen applied with
advantage.
   When the sore is excessively painful,  the follow-
ing  powder should be rubbed upon the parts  twice
in the day :

                Pulv. cinchonae gj.
                ---- opii 3j-
                               Misce.

   If the surface of the sore manifests a disposition
 to slough, it is right to  use a carrot poultice, or the
 nitric acid lotion. 
150
   When the arm swells, as it does on  the diseased
 side towards the close of the complaint, it is neces-
 sary  to  apply a roller from the hand  to the axilla,
 and to keep the arm from  the side, to allow of as
 much freedom as possible to circulation and absorp-
 tion,  which are impeded in the axilla, if  the  arm
 approximates the  side.

    OF THE OPERATION OF REMOVING A  SCIRRHOUS
                     TUBERCLE.

   Before  the  patient be submitted  to the opera-
 tion of having the  disease in the  breast  removed,
 she  will naturally inquire what danger it produces
 to life, and  what prospect it affords of preventing
 a return.  To the first  of these the  surgeon  may
 confidently answer, that the danger of the  operation
 is very slight;  for, in the immense number of cases
 in which I have  performed it, I have  lost  but  five
 patients : two of erysipelatous  fever  and inflamma-
 tion ; one from hydrothorax, which was found upon
 dissection to be connected with the exterior of the
 disease into the chest, affecting the lungs and pleura;
 one, a woman of great bulk, in whom the breast was
 very large ; and one from great age.
  To the second question,  the reply  is made with
 more difficulty.  A large proportion of cases return;
 but fewer than formerly,  if the patient, immediately
 after  recovering from the operation,  undergoes an
 alterative course of medicine.
  TTie only mode of relief.—It may  be truly said,  in
 the present state  of  our  knowledge,  the operation
furnishes the  only hope  of preventing the  disease
from  proving destructive,  with the  exception of
very  advanced age, in which it  makes  little inroad
on the constitution, and little progress in the  parts.
  Although the patient may not ultimately survive; 
151
yet it may be said, that in cases in which the disease
does  return, the patient is-generally preserved Irom
a most  painful  and  offensive  state by the operation
preventing ulceration.
   On these  accounts, I recommend  the  patient to
submit to it.   Hope is revived, and the only chance
for life  is given.
  Parts to be removed.—If the nipple be  drawn in,
it should be removed with the tumour: if any cords
or roots can be felt proceeding from it, they ought
to be removed ;  and  if the  skin adheres  to  the
tumour, or be in the  least inflamed on its surface, it
ought to be removed.
  It is not sufficient to  remove the tumour, but the
gland from the  nipple  to the tumour must be re-
moved :  and the  surrounding parts, to some extent,
must  be  taken away; for the disease does not  con-
sist in the tubercle only, but  there  are  roots  pro-
ceeding  from it into the  lobes  of the  breast in its
vicinity.   It will be sometimes necessary  to remove
the whole breast, where much is apparently  con-
taminated ;  for there  is more generally diseased
than  is  perceived, and it is best not to  leave  any
small portions of it, as tubercles reappear in them.
  Mode of operating.—The  operation  consists in
making two semicircular  incisions, nearly  perpendi-
cularly,  which  meet at  their  points; one  on the
axillary side  of  the  swelling,  and  the other on the
sternal:  the  portion of skin over the  disease should
be removed.   Each incision should   reach the  pec-
toralis muscle, which should  be distinctly  seen,  and
clearly exposed  in the  operation.  As the arteries
are divided, an assistant should  apply  his  finger
upon  them, until the whole of the parts to be extir-
pated have been removed.
  Removal of  axillary  glands.—If a gland  in  the
axilla be  enlarged, it should  be removed,  and  with 
152
 it all the  intervening cellular substance, as the ab-
 sorbent  vessels between the swelling and the gland
 are contaminated ; for it is wrong, after removing a
 swelling from the  breast, to make' a  separate in-
 cision to extirpate  a gland;  but it should be an
 extension  of  the  first  incision  from the  tumour to
 the gland.
   If several  glands in the axilla be enlarged, their
 removal does not succeed in  preventing  the return
 of the disease ;  some being still  seated beyond the
 reach of the knife.   I once  saw the  axillary vein
 opened in the operation of removing several of these
 glands ;  the gush of blood was  considerable,  but  it
 was evidently of the venous character ;  and a dossil
 of lint, placed in the axilla, stopped the  haemor-
 rhage, and the bleeding did not return.
   Vessels carefully secured.—So soon as  the  opera-
 tion is  performed,  the  divided vessels  are to be
 secured.  From faintness  and sickness the bleeding
 stops; but, as soon as action and warmth  return, the
 vessels  again bleed.  It  is therefore necessary to
 put a ligature upon each artery, for nothing is more
 annoying to a patient, or alarming  to her  friends,
 than after-haemorrhages :  the wound is  obliged to
 be opened  ; the patient becomes faint; the bleeding
 stops, and  the vessels concealed in coagula are diffi-
 cult to find.   Much  time,  pain, fatigue,  and alarm
 are saved  the patient, by attention  in securing  the
vessels at the conclusion of the operation.
 1  Use of a suture.—In  dressing  the  wound, put  a
suture through its centre, for it produces adaptation,
and  preserves it better than adhesive   plaster.   I
used to object to a suture, but experience has shewn
me  its utility.   The  emplastrum thuris compositum
and  emplastrum  saponis p. aeq.  is the  best  which
can be applied, being less  apt to produce  erysipelas
than the common adhesive plaster. 
                       153

  If erysipelas arise in the surrounding skin, apply
flour or starch to the surface.
  Arm  to be supported.—The arm should be sup-
ported  in a sling.   The ligatures  may  be drawn
away in seven.or eight days.
  In those cases in which there is a general scirrhous
inflammation of the breast, I  never now perform the
operation, because I  never knew  it succeed.  In
others, in which a number of tubercles form in the
breast, the whole mamma must be removed.
  After-treatment.—So soon  as  the patient  has  re-
covered from  the operation,  a medical  alterative
treatment should be pursued, to change the consti-
tution and prevent the  disposition to a relapse into
the former disease.

     ON  THE FUNGOUS OR MEDULLARY TUBERCLE.

   Differs from scirrhus.—This disease   differs  in
many respects from the  scirrhous tubercle.
   Occurs at all periods after puberty.—First, It occurs
at all periods of life after the  age of puberty, al-
though  still more  frequently  after  thirty years of
age,  than earlier.  One of  the worst cases I have
seen of the  complaint appeared at the age of twelve
years, and  destroyed life at  sixteen.   It began at
the  period  of the  evolution  of the  breast.   It was
removed by an operation  when  of large  size :  a
small tubercle reappeared, and it was also subjected
to operation;  but the disease  again grew,  and de-
stroyed  life.
   Difference of feel.—Secondly, this disease  is not so
 hard as the  true scirrhus, but has more the feeling
 of chronic inflammation at its early stages ; and as it
 increases it becomes  softer,  yields to the  impression
 of the  finger,  but immediately again fills  as  the
 pressure is  removed.   At this  period the skin is of
   vol.  n.         19 
154
the natural colour, and it so continues whilst the
tubercle  is in its adhesive stage ;  but,  after a few
months, the skin becomes livid, and then a distinct
fluctuation  may be  perceived from  a  fluid  being
found, which is contained  in  a cyst.  The veins  of
the surrounding skin  become extremely enlarged
and varicose, and  the surface assumes an inflamma-
tory appearance, of a darker  colour  than common
inflammation.   The cyst next ulcerates ;  or  if open-
ed, in either case,  discharges a fluid, which  has the
character of bile, composed of serum with red par-
ticles,  somewhat changed in their colour :  the fluid
leaves a yellowish  red stain upon  paper, and readily
coagulates,  as  serum  does,  by exposure  to heat.
The appearance of the fluid  differs so entirely from
that which is contained in the hydatid cyst, that any
one acquainted with  the two diseases readily distin-
guishes the one from the other by it.
   After the cyst has  been opened, a fungus  sprouts
forth,  which occasionally bleeds profusely,  but the
bleeding is easily stopped by pressure ; thef discharge
is excessive, wetting a handkerchief through in half an
hour, and of a faint  and  most sickening odour; the
edges become everted; a sloughing disposition mani-
fests itself in some parts of  the  tumour, and occa-
sionally in  the whole of the swelling;  and I have
known the entire disease slough away.  I remem-
ber, during my apprenticeship at this Hospital (St.
Thomas's,) Mr. Cline had  a case  in  which the  tu-
mour sloughed away, and  the wound healed, after
which the woman  was discharged from the Hospital
apparently cured; but I am not certain  if the com-
plaint did or did  not return.  In general, however,
the profuse discharge, the repeated losses of blood,
and the production of  similar disease in other parts
of the body, lead to  the  destruction  of life.  The
patieat falls a victim  to this complaint much sooner 
155
than to the  scirrhous tubercle, in the majority of
cases dying in a few months from the first discovery
of the disease.
  Less painful.—Thirdly, This disease  differs from
the true scirrhus in being much less painful; in  its
earlier stages it is altogether  free from  pain; and I
have known  it  acquire  great magnitude with little
diseased sensation : even in  its most formidable state
it is  seldom very sensitive.
  Glands not affected.—Fourthly, The glands in the
axilla are not generally inflamed in the same manner
as in true scirrhus,  by irritation or absorption; for I
have known  a person die of the disease without the
axillary glands being affected: but in some instances
they do participate  in  the disease.  The cervical
and  internal  mammary  glands are  also  rarely  af-
fected.
  Nipple not drawn in.—Fifthly, The nipple is not
generally drawn  in, nor is the skin puckered, having
the  appearance  of cicatrix, as in  true  scirrhus.
   Thus this disease may be distinguished from scirr-
hus  by aless circumscribed  and more diffused inflam-
mation; by  less hardness; by the formation  of a
cyst;  by the extreme  varicose state of the veins ;
by the fungus which sprouts from it after ulceration;
by   profuse  bleedings;  by  extensive sloughing;  by
less  pain ; by a quicker progress  to destruction ;  by
the  absence  of retraction of the nipple;  by the  want
of puckering of  the skin;  and by  the  glands being
less  affected in the course of  absorption.
   Health at first unaffected.—The  patient's constitu-
tion  at first  appears to suffer but little; but after a
time,  when the process of ulceration begins, she  be-
comes sallow and emaciated ; and from  the frequent
losses of blood has an extremely cadaverous appear-
ance. 
15fi
                    DISSECTION.

   Adhesive stages.—The  tumour,  in  its adhesive
 stage, appears  lobulated like an adipose swelling;
 but the substance, which is effused by the inflamma-
 tion is more compact, and varies in colour; in some
 parts assuming  the  character  of common adhesive
 matter, in others it is softer and mixed with red par-
 ticles of  blood.  In its next stage it forms a cyst,
 which contains the fluid that I have described; and
 from its interior it is that the fungous growth pro-
 ceeds, and this has the appearance, when cut through,
 of soft organized matter; in some  parts extremely
 vascular,  in others  of  the  semblance of coagulated
 blood;  other cysts are found containing bloody se-
 rum, and  a semifluid mass, looking like putrid brain,
 or sometimes  like cream  tinged by the  colouring
 particles of the  blood.
  Origin.—It adheres  to tendinous  structures more
 than others in its  commencement; for example, to
 the aponeurosis  of muscles, as  that of the pectoral.
 I have seen tumours of this kind arise from the del-
 toid aponeurosis, from the sheath of the femoral  ves-
 sels, and from the tunica sclerotica;  but still the cel-
 lular structure, in  each  part  of  the body, may be-
 come affected  by it.  In the dissection then of these
 cases we  meet  with the  glands in the axilla some-
 times slightly enlarged; and  next,  tumours, in vari-
 ous parts of the cellular tissue,  in  great  numbers;
 the lungs  I have seen loaded  with  them:  the liver
is generally tuberculated, and  I have seen one  kid-
ney affected.  The uterus  has soft  tumours on its
surface, and sometimes a  polypus growing from its
interior, which has been called by that able accou-
cheur, and excellent man, Mr. Clarke, the  cauliflower
excrescence, or polypus  uteri.   I have known almost 
157
every internal organ affected  by it, even the brain
itself.

          CAUSE OF THE FUNGOID DISEASE.

  Constitutional.—It is evident, in  a disease whicji
affects several different parts of the body, out of the
line of absorption, that  a constitutional cause must
exist to produce it : yet it has also a local malignant
action, so that a part  shall become diseased whilst
the surrounding parts still maintain  their  natural
functions.  Thus the disease is formed of a constitu-
tional disposition  to the complaint, with a local spe-
cific  action.   Upon   removing these tumours, the
surrounding  surfaces  generally heal rapidly, and
without any malignant action  being observed upon
the wounded part.  The incision,  in removing these
tumours,  must, however,  be  extended into the
healthy parts,  at  a considerable  distance from the
diseased ; for if there  be inflammation in the vicinity
of the tumour, the malignant action will recur in it.
I have known, in amputating a limb above the elbow,
for this disease in  the  elbow joint, the skin inflamed
between the elbow and shoulder, and the  stump as-
sumed the fungoid character.   Carefully, therefore,
avoid cutting near the diseased part,  or the com-
plaint will be certain to return.
  Predisposing causes.—The  predisposition to this
disease in the constitution is founded upon anxiety of
mind, and on those circumstances which have a ten-
dency  to destroy the regular and natural functions
pi the body.

                   TREATMENT.

  As the disease is founded in a constitutional change,
and in specific local action, the  objects in the treat- 
                       158

ment will be to correct the general  health and to
destroy the  local  and specific action.  The first is to
be attempted by  the  alterative  medicines already
recommended, viz.
                 Pil. hyd. subm  comp.
and  a bitter infusion with rhubarb and soda.
  But we are at  present entirely unacquainted with
any constitutional means, or local application, which
has influence over the disease when it has once been
manifested.
  Pressure.—Pressure  has been used to produce a
slough of the fungus,  and it  is  proper to give it a
trial;  but it is acting only upon  the effect, and will
not  prevent a fatal termination,  as the cause will
still  remain.  Aluminous applications are  useful in
preventing  the growth of the fungus, and the sul-
phate of iron has a  good  effect in the same point of
view ;  but  I know of nothing which has  a specific
action upon the sore.
  Its removal by operation.—It is  therefore necessary
to remove this disease  by operation ; and,  upon the
whole, it less frequently  returns than the scirrhous
tubercle, if  care be taken to extend the  operation
properly into the sound parts.
  The operation presents  none of those difficulties
which  have been described; for it has  been said
that the vessels  are large,  and  that  they bleed  so
profusely as to occasion dangerous haemorrhage.   It
is true, in the swelling  they are large: but the arte-
ries  of the surrounding parts are but little  augment-
ed,  and I have  never seen  any dangerous bleeding
from their division.   It is certain that the veins par-
ticularly, and the arteries of the part, if cut, bleed
freely; but they ought not to be divided in the ope-
ration, which should be extended  beyond  its limits:
they bleed  not  only from their  size, but  from the
difference in their structure, having little contractile
power. 
159
  After  the operation, as in scirrhus, the constitu-
tion will  require an alterative treatment, to prevent
the disposition to returning disease.

  OF THE SIMPLE  CHRONIC  TUMOUR OF THE BREAST.

  This disease is  not of a  malignant nature, nor does
it produce any dangerous consequences.   It attacks
the young and the apparently healthy, seldom begin-
ning after the age of thirty years;  and usually appear-
ing from the age of  puberty to that period.
  Appearance of the  swelling.—The character of
this swelling is as follows:—it  is  very superficial,
growing  rather upon  the  surface of the breast than
in its interior.  At first it feels like one of the mam-
mary lobes  being enlarged :  and then, as if several
were combined  in one swelling.   As it  increases it
becomes in some degree lost in the substance of the
breast.   It has not the hardness of the scirrhous tu-
bercle,  and it  is  not accompanied with  the loss of
health of the  fungoid disease.   It is an extremely
moveable swelling.   It is generally unaccompanied
with  pain,  either in  the part, or shoulder, or arm,
although I  have known exceptions  to this rule.   It
grows very  slowly and gradually, and does not gene-
rally acquire  a great  magnitude.   I removed one
which  had existed five years, which was not larger
than a walnut; and  I  nave  seen  one which,  after
fifteen years, still  remained but a small swelling.
  Sometimes acquires a large size.—In a patient sent
me to Guy's Hospital, by  Mr. Lukyn, of Feversham,
the swelling had  grown  to a great magnitude,  but
still felt  as  if composed of a simple enlargement of
the different lobes of the mammary gland.   I have
also seen one case, in  Guy's  Hospital, in which  the
disease became  excessively large,  and  it ulcerated
and destroyed life.  They will be sometimes painful 
160
at the period of menstruation :  there is nothing ma-
lignant in their nature,  and I  have never  known
them change their action into the scirrhous or fun-
gous disease, although under changes of the consti-
tution such  an event  would be possible.  The ab-
sorbent glands in the axilla are  unaffected.
   Diagnosis.—The diagnosis of this disease consists
in the youth of the patient;  in the  absence from
pain; in  the appearance of general health;  in the
slow growth of the swelling; in its superficial situa-
tion at first; in its extreme mobility;  in its feel be-
mg  that of the lobes of  the  breast  enlarged,  and
therefore it is  a conglomerate  tumour; the glands
in the axilla being free from disease.
   Dissection of the  tumour.—Upon dissection,  the
swelling  is  found  to  be composed  of a number of
lobes connected together by  a condensed cellular
tissue, and  which appear as enlargements  of the
lobes of the mammary gland.   These lobes are com-
posed of smaller, which hy maceration may be sepa-
rated.  The appearance  of the disease,  when cut
into, is that of sweet bread, that is lobulated in every
part, or composed of large lobes, which are divisible
into smaller.
   Cause.—The cause  of the disease is unknown.  I
have heard it frequently attributed, by the patient,
to the pressure of the bones in her stays,  or that of
some part of her dress.
   Treatment.—In  the  treatment of this disease little
is effected by medicine.   I generally  order  the em-
plast: ammon: c hydrargyro to be applied  to the
part, and give hydrarg: c cret&  with  soda and rhu-
barb, but the disease rarely disappears.  The great
gratification which the patient  receives in this case,
 is from the assurance  that  the complaint is not of a
 malignant nature.
   Removal by operation.—If the disease increases in 
161
 spite of an alterative treatment, and the patient be-
 comes anxious for its removal, there is very trifling
 risk from the operation,  for I have frequently per-
 formed it at my own house, and  the patients have
 returned  home  immediately  afterwards.   When,
 however, these swellings  grow to a very large size,
 the  vessels supplying them become extremely in-
 creased ;  and I remember seeing one removed from
 the left side, in which case the vessel that supplied
 the, tumour was  so large  as to afford a  gush of
 blood, which alarmed the surgeon, from the idea of
 their being some communication between the tumour
 and the interior of the chest.  When they are small,
 as they usually remain, it  is  right to secure each
 vessel which continues to bleed, however  slightly,
 or the wound will be obliged to be re-opened to se-
 cure it.

              OF THE ADIPOSE TUMOUR.

  In the breast  a fatty swelling is sometimes form-
 ed.  A Mrs. Smith, of Great Yarmouth, applied to
 me,  with  an enormous tumour in her  bosom.   As
 her general health was good, I advised  its removal.
 It weighed fourteen pounds  and ten ounces:  the
 gland of the breast was placed before it.  The  pre-
 paration is in the Museum at St. Thomas's Hospital,
 and she recovered very quickly.   The incision  for
 its removal  was thirty-two inches  in circumference.

            OF  THE IRRITABLE  TUMOUR.

  Occurring in  young persons.—This  disease gene-
 rally occurs in young women from the age of fifteen
 to thirty; the swelling  never acquires  magnitude,
and is distinguished  from  those which  I have de-
scribed by the- following circumstances :
  vol. jr.              20 
162
  Diagnosis.—A lobe of the breast is slightly swol-
len;  it is  extremely  tender  to  the touch, and, if
handled, the pain sometimes continues  for  several
hours.  The uneasiness is not seated in the swelling
only,  but extends  to the shoulder  and axilla, down
the arm to the  elbow, and  frequently to the wrist
and  fingers.   It  is  very much  increased prior to
menstruation,  is somewhat  relieved during  the  pe-
riod, and decreases after its  cessation.   The pain is
sometimes  so severe  as to destroy  rest; and even
the weight of the breast in bed is sometimes almost
intolerably painful.
  Produces vomiting.—When the pain is most severe,
the stomach sympathizes, and vomiting is produced.
The skin is undiscoloured, and  there is no external
mark of inflammation.   Sometimes only a small por-
tion of the  breast is  affected ; at others, the  greater
part of the bosom;  and  I  have known it affect  the
breast on each side.
  The  constitution is  highly irritable and sensitive,
the hair of the patient is usually light, the complex-
ion extremely delicate, and the temperament sangui-
neous.
  Continues for a long period.—I  have often known
this disease continue  for many months, sometimes for
years :  and once during twelve years.
  Not malignant.—It has not a  malignant tendency,
does not therefore produce any dangerous effect,  and
not  only does not  require an operation, but  such a
measure would be quite unjustifiable.
  Very frequently this disease  is  accompanied with
an amenorrhcea, or  with great paucity of menstrua-
tion, paleness of its colour, and  frequently it  is at-
tended  with profuse  fluor albus.
  Cause.—Its causes are irritability  of constitution,
generally a defect of uterine  secretion, and often its
immediate  exciting cause is a blow.
  Local treatment.—In the treatment, local irritabili- 
163
ty is to be diminished by the  application of the bel-
ladonna in extract, or opium  mixed with the cera-
tum cetacei;  the  extractum  conii ; or  the  recent
conium in a poultice is beneficial.  A plaster of soap
cerate, to produce perspiration, or the application of
hare skin,  or  some  other fur,  or the  oiled  silk  ap-
plied with the same view, are found to be useful.
   Leeches.—Leeches are sometimes employed when
the pain is excessive, and the  vessels  of the breast
are unusually full.   If too frequently used, they pro-
duce debility, and add to the  irritability of the sys-
tem.
   Constitutional treatment.—The constitutional treat-
ment consists  in diminishing constitutional irritability,
by restoring defective secretion, in giving tone to  the
system, and in acting particularly on the  uterine  se-
cretion.
   Medicines.—The usual medicines are small doses
of calomel and opium, combined with  a  mild aperi-
ent,  but  those  which  best  agree  are the  mistura
myrrhae c ferro, or the ferrum  ammoniatum; under
the continued use  of which  the disease gradually  dis-
appears.   Rhubarb and  soda,  or  these combined
with columba, I have also seen  very useful.
   Conium,  combined with  rhubarb, I have known
beneficial.

       OF  THE OSSIFIC TUMOUR  OF THE  BREAST.

   Case.—The following is  a case of this disease:—
Mary  Farmer, aged thirty-two,  had a swelling in  the
breast for fourteen years,  which had  been painful
during the latter seven.
   The pain was very  severe;  the  skin  over it  felt
hot,  and required  the constant application of evapo-
rating lotions to keep it cool.  The  tumour  was  ex- 
164
 cessively hard, and very painful before menstruation,
 but greatly relieved after it.
   Various applications, as  poultices,  fomentations,
 stimulating plasters, did not dispose it to suppurate;
 in  short, all  the means employed proved useless.
 When she consulted me, I thought, from the state of
 the health, the mobility of the  tumour, and its pe-
 culiar feel, that it was not cancerous ;  but still I re-
 commended its removal, to which she consented.
   Dissection.—Upon examination  of  the swelling,
 after the operation, it was found to be composed in
 part of cartilage and in part  of bone, the greater
 part of the former being ossified.

             OF  THE  LACTEAL  TUMOUR.

   Symptoms.—Some time after delivery, a woman
 applies to a surgeon with a fluctuating tumour  in the
 breast, of very considerable size, attended with pain-
 ful distention, but without discolouration.   The veins
 of the breast  are very large.   A  lancet being put
 into the swelling, milk is discharged in large quanti-
 ty,  sometimes to the  extent  of several ounces;
 which, after it has stood for some time, separates a
 cream upon its surface.
   Cause.—The cause  of this  complaint is the ob-
 struction of one of the lactiferous tubes near the nip-
 ple, or in it.
   Treatment.—Its treatment consists in leaving the
 opening made by the lancet  to discharge the milk
 which that part of the  breast secretes.   The  swel-
 ling then gradually subsides as the milk in the breast
 disappears.
  I, in one case,  saw great inflammation follow the
 opening;  but  still it is the only means of relief, un-
 less when the opening be made the child be weaned,
 and the secretion of milk be  arrested,  and  then the
continuance of the opening will be unnecessary. 
165
          BREASTS LARGE AND PENDULOUS.

   These glands sometimes  grow  to an  enormous
magnitude, about the age of twenty years, so as to
hang down upon the abdomen, not from relaxation
but from real increase.  I saw a case of this kind in
a young  woman, aged  twenty-three, which  began
three years prior to my seeing her; tender to the
touch, of a dark red colour.   She was often costive,
but regular in her menstruation.
   Dr. Babington and myself witnessed the following
case :
   Case.—Miss L. aged seventeen years,  of a light
complexion and delicate constitution, who is natu-
rally costive, has a remarkable enlargement of her
breast.  The left is twenty inches from its junction
with the chest above to  its  lower part, and its cir-
cumference measures twenty-three  inches.   The
nipple is flattened, the areola excessively expanded.
The breast feels as if every lobe of the mammary
gland was  increased to several times its usual mag-
nitude.
   Treatment.—The treatment consists in supporting
the breasts in  a suspensory bandage, in which each
breast is received, and this  is fixed over the shoul-
ders.
   The medicine best calculated to be useful is hyd:
e creta with rhubarb and soda.

                THE MILK ABSCESS.

   Treatment.—This abscess  requires the same gene-
ral treatment in its  adhesive, suppurative, and ulce-
rative stages, as we  have recommended for abscesses
of other parts.  In  general 1 leave them to  break
spontaneously ; but there are two exceptions to this. 
166
  First,  When the constitution and patient are suf-
fering severely and the  abscess  is slow to break, it
is right to assist nature with the lancet.
  And, secondly, when the abscess forms at the back
of the breast very  deeply, the  aid of an artificial
opening is required.
  Formation of sinuses.—When they ulcerate,  sinu-
ses, difficult to heal, are  sometimes produced ; and
the best treatment is to inject them with a solution
of sulphate of zinc, or a dilute sulphuric acid, and to
apply it constantly over the breast by linen. 
167
              LECTURE  XXII.

              ON  URINARY CALCULI.

   Where seated.—Urinary calculi are  found in the
kidney, in the ureter, in the bladder, and in the ure-
thra.
   Calculi in the  prostate, not  urinary.—The calculi
which arc met with in the prostate gland,  are not
urinary ;  they are formed in the ducts of that gland,
into which the urine does not gain access, and they
generally differ  from urinary  calculi in their com-
position.

       OF THE RENAL, OR KIDNEY CALCULUS.

   Symptoms.—The symptoms by which the presence
of a calculus in this organ is known are,  1st, pain in
the loin, in the situation  of the kidney,  which pain
extends  forwards towards the  navel  accompanied
with  a sense of numbness in  the bowels, and down-
wards to the spinous process of the  ilium.   The pain
is  of an obtuse kind, it often produces a sympathetic
effect on the stomach, and occasions vomiting.   The
loin is so tender, that the least  pressure on it occa-
sions  great  suffering to  the   patient.   The  act  of
stooping, when a stone exists in the kidney, produces
acute pain in the loins, and is sometimes followed by
a discharge of bloody urine.
   Case.—I knew a gentleman,  who, in  stooping on
his horse to  open a  gate, felt  severe pain in  the 
168
 loins; he immediately discharged  bloody urine, and
 afterwards felt  the symptoms (hereafter to  be de-
 scribed) of a stone passing from the kidney by the
 ureter.  He voided this stone by the urethra, four
 days subsequent to the  first  attack  of pain  in the
 loins.
   The presence of a stone in the kidney is some-
 times  manifested  by extreme irritability  of  the
 bladder.
   Case.—A chemist,  in the city, had  frequently con-
 sulted me  (when I lived there) for an irritable state
 of his bladder and urethra, for which I had recom-
 mended  various medicines, and  bougies had been
 passed;  but he  did not  experience any relief from
 their employment. After I left the  city, I was in-
 formed that he  was dead ;  and upon inspection of
 his body, no disease of the bladder or urethra  was
 found, but a  large  stone was discovered in the  kid-
 ney.
   Sometimes removed   by  ulceration.—Nature some-
 times succeeds in removing these  extraneous bodies
 by a process of  ulceration ; an opening being  formed
 in the loins, through which  a stone can be  felt, by
 passing a probe, and by which the calculus  is  ulti-
 mately discharged.
   Case.—A person came to  consult  me from the
 country with two openings, one above  and  one be-
 low the last  rib, through which  three calculi  had
 been  discharged.   Dr. Marcet analyzed these,  and
 found them to be composed of  the  ammoniaco-mag-
 nesian phosphate.
   Opening to be  dilated.—If the calculus cannot  rea-
 dily pass, from the small size of  the opening, the
 aperture should  be dilated  by sponge tent;  if  this
fails, a history may be  carefully used, as the  artery
and vein  are before the stone.
   A stone  in the kidney,  when very  large,  may, in 
169
some instances, be felt through the loins.   Mr. Cline
informed me, that  a patient consulted him who had
this disease,  in whom he could distinctly  feel  the
stone, by pressing firmly  on the loins;  the  patient's
general health would not at that time bear an ope-
ration, otherwise  Mr.  Cline  would  have  removed
the stone by incision.
   Upon dissection of  persons dying  with calculi in
the kidney, there are found;
   1st, Sometimes numerous small calculi, like grains
of sand, in the tubuli uriniferi.
   2dly, A stone, lodged in an infundibulum, or often
several, occupying different infundibula.
   3dly, A large  stone in the pelvis of the kidney,
connected by processes to others, seated in the in-
fundibula.
   Kidney  enlarged.---The   kidney  is  sometimes
scarcely altered in its size, at others it  becomes con-
siderably  enlarged.  If the stone interrupts the pas-
sage of the urine to the ureter, the glandular struc-
ture of the kidney becomes absorbed, the pelvis and
infundibula extremely  enlarged, and  these membra-
nous bags with the  capsule of the  kidney only re-
main.
   Ulcerates.—Sometimes  ulceration of  the kidney is
produced; it  enlarges, then wastes, and  gradually
becomes in a great degree absorbed ; matter is  dis-
charged with the urine ; high  constitutional irritation
succeeds, and if both kidneys  be  affected, the life of
the patient is destroyed.

                    TREATMENT.

   Medical.—The medical treatment  of stone in the
kidney consists  in giving the liquor potassae;  the
carbonate of potash, or soda;  not that  they dissolve
the stone, but they prevent the  formation of  uric
   vol 11.                21 
170
acid; the stone becomes encrusted with triple phos-
phate, which  is  a softer  substance, and, perhaps,
less irritating to the surfaces on which it rests ; these
medicines also deaden the  sensibility of  the  organ
itself.   If much  pain be felt in  the  loin, the  daily
exhibition of a purgative, occasional cupping, or the
application of a blister to  the loins,  will  be useful.
If there be a suppurative discharge,  an issue should
be made in  the lumbar region.

             OF STONE IN THE URETER.

  Symptoms.—The  presence of  a calculus in this
tube is shewn by pain being  felt  near the  spinous
process of the ilium,  and  in the  direction of the
psoas muscle, if pressure be made upon  it through
the  abdominal  muscles;  the pain  extends in  the
course of the anterior crural nerve, as the stone de-
scends over the lumbar nerves which form it; also
to the testicle, as the  stone  passes  the  spermatic
plexus;  and spasmodic contractions of the cremastic
muscle occur, as  it passes  under the spermatic ves-
sels.   The  patient is sick,  often vomits,  is covered
with a cold perspiration, and  is unusually pallid.
   Case.—The pain is sometimes  so  severe, that  a
gentleman,  who had several times suffered from this
disease,  informed me, that once, when a quarter of
a mile from his house, he was seized with this pain,
and fell on  the  ground, being unable to walk  until
his servants came to his assistance, and carried him
home.
   Pain  not constant.—The pain has remissions, and
the  patient is flattered with  the  hope of the  stone
having passed the ureter;  but, after a few minutes,
it returns with equal violence,  and  it  is  only after
repeated attacks that it escapes into the  bladder.
   Calculi in the ureter, I  have known destroy life
in the following instances : 
171
  Case.—Mr.  Cline  had removed a  stone from  a
boy in St. Thomas's  Hospital, by  the operation of
lithotomy ; the boy had recovered from the opera-
tion, when he was  seized with rigors,  great  pain in
the course of the  ureter, and vomiting;  a  swelling
formed just above the seat of the ccecum, in the
right  iliac region,  which gradually increased,  and
the boy's constitution quickly  gave way.  On exa-
mination  after his  death, the  pelvis of the kidney
and the ureter were  found  distended  with  matter;
and at the  end of the ureter, near  the bladder, a
stone  was discovered, which had prevented the es-
cape of  the urine  and of matter into the  bladder,
and thus occasioned death.   The preparation of the
diseased  parts is in  the  Museum  at  St. Thomas's
Hospital.
  Case—Mr.  Hallam,  of  Walworth, gave  me  a
preparation  of a stone, stopped in the ureter, which
was taken from  a patient  of  his, who  had  for  a
length of time discharged matter  from the  colon
per anum; nature had formed an  opening  for the
escape of the urine  and pus, in this case, first by
producing adhesion between the ureter  and  colon,
and then by making  a communication- between the
two by a subsequent ulcerative process.
  Case.—We have another curious  preparation of
a stone in the ureter, surrounded by an abscess, taken
from a patient who  came to my house  for advice.
She had  great pain in her loins, and  tenderness in
her abdomen, with so much fever as lead me to
suppose that she had but little time to live ; I advis-
ed ner to apply  to a  Mr. Smart, a surgeon, in my
neighbourhood in the city,  who  sent  to inform me,
a few days after, that she was dead, and that he had
permission to inspect the body.   Upon making an
incision into  the abdomen, there  issued a  strong uri-
nous smell, and a  watery fluid, mixed with matter. 
172
The  intestines were inflamed and  adherent;  the
bladder was small;  one kidney was much enlarged
and the other unaltered; the ureter of the enlarged
kidney  was greatly increased in size  and full of mat-
ter, it was completely closed  at  the lower  part by
a calculus, and had given way above, so as to allow
of the escape of the urine  and matter into the ab-
domen.
   A calculus may be discharged from the ureter by
ulceration through the muscles of the abdomen.
   Case.—Mr. Stone, of Mayfield, Sussex, gave me a
calculus, which  was discharged  from a  man who
worked as  a gardener.  An abscess formed near the
anterior superior spinous process of  the ilium, from
which this  calculus  and a  quantity of matter were
discharged.   The man recovered.

                    TREATMENT.

   Bleeding.—If the pain is very severe during  the
passage of  the  stone, the  patient should  be  bled
largely, to produce relaxation of the ureter, that it
may yield  to the pressure of  the stone and urine,
and he should be  put into the warm bath, to aid
such  relaxation.  Opium  and the  liquor  potassae
should be given,  to allay irritability; and the abdo-
men  should be fomented  and gently rubbed from
above downwards,  in  the  course of the  ureter, in
order to assist mechanically the  passage of the cal-
culus.

             OF STONE IN THE BLADDER.

   Symptoms.—The  symptoms change so soon as the
stone quits  the ureter and  enters the bladder; the
patient is  relieved  from the pain in the course of
the ureter, in the testis, and thigh, but suffers usu-
ally in the following manner: 
173
  Pain in  the urethra and at the frasnum.—1st.  He
experiences acute pain,  particularly opposite to  the
fraenum, but also along  the course of  the urethra;
this varies  in its degree,  more according  to the irri-
tability of the patient, than the form or roughness of
the calculus ; the pain is sometimes slight, but gene-
rally severe, and  is described by the  patient as a
cutting sensation ; or, sometimes,  as if boiling water
or lead  were passing through  the urethra.   Relief
is experienced  by pressing on the glans penis,  and
adult persons do  so;  children nip and draw the pre-
puce until  the latter  becomes excessively elongated;
they also, under severe suffering, after passing urine,
cross their legs, and  press upon the organs of gene-
ration with great force.
   The  adult, when voiding his urine, often rests his
head against the wall, bends his  knees, and relaxes
the muscles generally.
   Pain after the discharge of urine.—The  pain is
felt more after discharging the urine, when the blad-
der  contracts  around the  stone, than  before it is
voided.
   Frequently the faeces  pass at the same time with
the  urine, and  a prolapsus ani  is a common conse-
quence of  the excessive  action of the muscles of the
perineum and lower opening of the pelvis, more es-
pecially in children.  I   have seen  the abdominal
muscles  thrown  into violent  spasmodic actions for
some time after the discharge of  the urine, in some
of the worst cases of stone.
   Bladder irritable.—The  bladder is very irritable,
is capable  of retaining  but little urine, and becomes
diminished in size.
   Sudden stop to  the flow  of urine.—Often,  as  the
urine is discharging,  a sudden stop to its flow is  pro-
duced with violent pain, from a stone falling on  the
beginning of the urethra  and acting as a valve: as 
174
the force of the bladder's contraction  lessens,  the
stone recedes a little, and the urine again escapes.
Patients,  therefore, pass  their urine best in a re-
cumbent  posture, as the stone does  not then fall
upon the neck of the bladder.
   At first no change is produced  in the appearance
of the urine,  which can  direct the judgment;  but
when the disease  has existed  for some  time,  and
more especially from violent  exercise on horseback,
or in a rough carriage,  the  urine  becomes bloody.
A person having a  stone in  the bladder cannot ride
far on horseback without dismounting to pass his
urine; and is obliged to quit a carriage often for the
same reason.
   Discharge of mucus.—As  the disease increases
the  bladder becomes  more  irritable,  the urine is
loaded with mucus, and  sometimes  precipitates a
white sediment, composed of flakes of adhesive mat-
ter,  thrown out by the mucous membrane of  the
bladder,  when it  has become inflamed.  This state
is  often  attended with rigors, succeeded by heat,
and other symptoms of  intermittent fever, and mat-
ter is sometimes  discharged  with the urine.  The
mucous membrane of the bladder becomes ulcerated
when a stone has existed long; the patient loses his
health;  is incapable of getting sufficient rest; and
thus he is destroyed by the disease.
  A person labouring under  this complaint walks
with excessive care; he does not raise his feet  much
from the ground,  to prevent any shock to the  body,
which would create pain and occasion spasmodic ac-
tion of the bladder; he also lies down with  great
caution, as the sudden change of posture might alter
the position  of the stone and produce irritation. 
175
                    DISSECTION.

  Mucous coat.—In examining persons who die with a
stone in the bladder, the mucous membrane appears
loaded with blood, it is thickened, and highly villous.
Its muscular coat is much increased, and the capacity
of the  bladder lessened.   Numerous sacculi  are
sometimes  formed,  the mucous  membrane  being
forced between some of the muscular fibres,  and, in
these bags, stones are wholly or partially  received.
We have a preparation in the Museum shewing this
state of the bladder, with stones lodged in these sac-
culi.
   Ulceration of the mucous coat.—I have seen  ulce-
ration of the mucous membrane,  and we have an
example of stones ulcerating  the basis of  the  pros-
tate,  and making their way into the urethra.
  Bladder  contracted in part.—We have  also ano-
ther very curious specimen, in which the upper part
of the bladder  had  contracted around  the  stone,
whilst the lower part is in  the natural  state.
  A stone  is often found with an enlarged state of
the prostate gland;  and in  some cases is met  with in
a bag, formed directly behind the  prostate.
  Hour-glass contraction.—We have a preparation
shewing an  hour-glass contraction of the bladder, in
which one large stone is lodged in  the superior part,
and several in  the inferior;  and another, exhibiting
a stone in the bladder,  with a large fungus growing
from the prostate gland.
   Ureters.—The ureters are dilated, the kidneys en-
larged ; sometimes one is  enlarged and  the other
wasted from an ulcerative  process.
  Size of calculi.—The size of calculi  generally va-
ries  from a drachm  to  two ounces; but  the  weight
is not always proportioned to the size, but depends
upon the composition of the stone 
176
   The largest stone, which I have successfully ex-
 tracted, weighed near six ounces.  At the Norfolk
 and Norwich Hospital there is one of eight ounces.
 Mr. Mayo, of Winchester,  removed one, in fractur-
 ed portions,  of fifteen ounces.   I have  one in  my
 possession which I extracted, but not successfully,
 weighing sixteen ounces.   We have  a  model of a
 stone, given  to the collection  by Mr. Foster, which,
 I  understand,  was  twenty-five  ounces  in weight.
 One in Trinity College library, at Cambridge, weighs
 thirty-two ounces  and  seven drachms.  But  the
 largest stone which has been found  in the human
 body is that  given to the College of Surgeons by Sir
 James Earle, this weighed forty-four ounces.
   Pain not more severe from a large stone.—The seve-
 rity of the symptoms is often in an inverse ratio to
 the size of the stone; which, when it is very large, pro-
 duces  less pain,  because the urine dribbles away, or
 is  voided by very slight contraction of the bladder.
   Number of calculi.—The number of calculi is very
 various;  but in  the majority of  cases only one is
 found; two or more not unfrequently exist.  I have
 extracted nine in one case, thirty-seven  in another,
 and  the greatest number  I ever extracted  in  the
 operation was  one  hundred  and forty-two;  these
 were from Mr. Allis, of Worcester,  a patient  of
 Mr. Carden;  I have them now in my possession,
 many of them are about the size  of marbles.
   Removal of a number of stones not dangerous.—A
great number of stones does  not add much  to the
 patient's danger in  the operation; for it is not the
frequent introduction of the forceps into  the blad-
der, but  the violence which is  used in extracting the
stone or  stones which produces  mischief; thus the
removal  of one large stone is  more to be dreaded
than that of  many small.
   Stones rounded  or hollowed, when more  than one.—
 When m-M'o  than one calculous  exists, the first ex- 
177
traded is found smooth, and often hollowed by  the
friction of the others; so that the form of the first
shews the existence of a second or more.
  Form  of stones.—The form  of stone  varies  ex-
tremely ;  but when there is only  one, it is generally
oblong; when more than one, they are usually round-
ed and smooth; and when very large, they assume
the form of  the bladder.
  Surface of stones.—The surface of stones is some-
times smooth, as the uric acid calculus; a little irre-
gular when composed of triple phosphate; and very
rough if formed of the oxalate of lime : this latter
is called the mulberry  calculus.   But the severity
of the symptoms  does not always depend on  the
irregularity of  the surface of the stone, but  on  the
irritability of the bladder.
  Composed of lamellae.—Calculi  are generally com-
posed of concentric  lamella?, formed upon  a centre,
called the nucleus.   The colour of  the  different
layers varies  considerably, and  the  materials  of
which they  are composed are of very different  na-
ture : some calculi are brown, some are white.
  Nuclei.—The nucleus,  or  centre, is often some
extraneous body  introduced  into the  bladder, as a
portion of coagulated blood, a piece  of bougie, or
catheter.
  In the collection  at  St. Thomas's  Hospital  are
preparations  exhibiting various  foreign  bodies,  as
forming the nuclei to stones; as a portion of slate
pencil;  a needle, which had traversed a part of the
body previous  to its entering the  bladder;  also  a
piece of tobacco pipe, which had been  introduced
into the urethra by the patient,  to relieve some  im-
pediment to the passage of the  urine, it  broke and
passed  into  his bladder,  and was extracted some
time afterwards by Mr. Godwin, surgeon, at Derby,
  vol. u.              22 
178
 with a stone  formed around it.  Sometimes a small
 stone of uric acid forms in the kidney, and  descend-
 ing by the ureter into the bladder, it there  acquires
 an increase  from the  formation of  a calculous de-
 posit on it, of a different nature.

          COMPOSITION OF  URINARY CALCULI.

   My friend, Dr. Dowler, who has  paid  much at-
 tention to the analysis of these calculi, has favoured
 me with the following account:
   Urinary calculi of the  human body may  be  com-
 prehended under the following species.
   1.  Lithic acid, or uric acid calculus.
   2.  Lithate of ammonia.
   3.  Phosphate of lime, or bone earth.
   4.  Triple  phosphate, or phosphate of magnesia
 and ammonia.
   5.  Oxalate of lime, or  mulberry calculus.
   6.  Cystic oxide.
   Besides  these, other substances have  been men-
 tioned as forming  distinct  species of calculi, such as
 xanthic acid, carbonate of lime,  and the  fibrinous
 calculi; but they are of extremely  rare occurrence.
   The above calculi present the following chemical
 characters.
   1.* Lithic acid calculus.  Before the blowpipe  it
 blackens and  emits a  peculiar smell,  somewhat re-
sembling that of burnt feathers; it is soluble in the
caustic  fixed  alkaline  solutions by  the assistance of
heat, and is  again precipitated  from these by the
addition of an acid.  The nitric acid dissolves and
decomposes it with effervescence ;  if the  solution be
evaporated  to dryness, a new  acid, called  the pur-

  * I have omitted every character which is not essential to
fli« particular species.—D. 
179
puric, and ammonia are formed; these, uniting, pro-
duce a  purpurate  of ammonia, which is of a  pink
colour, and soluble in water.
   2.  Lithate  of ammonia.  By the  addition  of a
caustic  fixed  alkali, ammonia  will be disengaged.
The lithic acid may be  shewn by treatment  with
nitric acid, as  in the former instance.   When mixed
with  triple phosphate,  its presence  is ascertained
with difficulty.  4t is more soluble in water than the
lithic acid calculus, and is of a clay colour;  but its
characters have not as yet been sufficiently investi-
gated.                                          )
   3.  Phosphate  of lime.   Before the blowpipe, it
first blackens, then becomes white, and  afterwards
resists the action of heat.   If,  after being heated in
order to decompose the contained  animal matter, it
be  dissolved in very dilute nitric  acid,  the subse-
quent addition of  nitrate  of silver  will  produce  a
yellow  precipitate, which is a  phosphate of silver,
and of course  indicates  the presence  of  phosphoric
acid.  The lime may be detected by adding oxalate
of ammonia to the above nitric solution.
   4.  Triple  phosphate.   Before the blowpipe,  it
emits an ammoniacal smell, becomes reduced in size,
and  at  length melts  with difficulty.   The caustic
fixed alkalies  disengage ammonia.   It is very  solu-
ble in dilute  acids, and the subsequent addition of
ammonia  causes it to be precipitated in a crystalline
form.
   5. Oxalate  of  lime.   When  heated by the blow-
pipe it swells, its oxalic acid is decomposed, and the
lime is  left in the caustic state.   When digested
with  carbonate of  potash, a double  decomposition
follows; and  the  oxalate of potash,  thus formed,
presents its peculiar characters, which are indica-
tive of the presence of oxalic acid.
  6. Cystic oxide.  This  calculus  may  be  readily 
180
distinguished by its  external  appearance.  Before
the blowpipe it  emits a peculiar and foetid odour.  It
is soluble  in a solution of the neutral carbonates of
soda and potash ;  also in  those of the caustic alka-
lies, and most  of the acids.   Its  solution in  nitric
acid is precipitated by alcohol.
  The Xanthic  oxide, of which only one specimen
has  as yet  been  observed,  was so named  by Dr.
Marcet,  from the  circumstance of"'its producing a
peculiar yellow compound with nitric acid.
  Carbonate of lime is sometimes, but very rarely,
met with, forming small urinary calculi.   These ef-
fervesce  in dilute  muriatic acid, and a precipitate is
formed  by the  addition of oxalate of ammonia  to
the muriatic solution.
  The fibrinous calculus,  observed  by Dr. Marcet,
was probably formed from the fibrin of blood which
had  accidentally escaped  into the bladder: it pos-
sessed the usual  character of fibrin.
  Mr. Brande analyzed one hundred and fifty stones,
from the  collection of Mr. Hunter,  and the mate-
rials of which they were composed were as follow :
  Uric acid............16
  Uric acid plus, triple phosphate minus    .  .  45
  Uric acid minus, triple phosphate plus    .  .  66
  Triple  phosphate.........12
  Uric acid on phosphate nuclei.....5
  Oxalate of lime..........6
  In addition to these, Dr. Wollaston found one  of
the  cystic oxide; but  Dr. Marcet  met with this
stone in the kidney:  it is  not composed of lamella?,
like the other calculi. 
181
                   TREATMENT.

  Medical treatment.—With respect to the medical
treatment of calculi, I do not  believe in the power
of chemistry to dissolve a stone  in  the bladder,  if
it acquire any considerable magnitude.   The  medi-
cine^ given for this purpose, become so much chang-
ed in the'.r passage through the circulating and se-
creting system, that their chemical  influence is in  a
great measure destroyed.   They may alter the sur-
face of  a stone, so as to render it soft and  less irri-
tating ;  but  they do not  prevent a calculous  secre-
tion.
  Case.—Dr. Baillie and myself attended  a gentle-
man from Birmingham, who secreted a large quan-
tity of triple phosphate, which appeared  in white
crystals in his urine : we gave him the muriatic acid,
and the  secretion of the triple phosphate ceased,
but uric  acid was produced in equal abundance : he
had  then alkalies given to him, and the  triple phos-
phate reappeared ; he was at length, but not under
many months,  cured  by  attention  to his  diet  and
general health.
  Case.—I had a patient in Guy's Hospital with  a
stone in his  bladder,  in  whom various  experiments
were tried to dissolve the stone  by chemical men-
strua.  A catheter was introduced into the bladder,
and through it injections were thrown; thus an op-
portunity was given for a direct application of  the
menstruum  to "the stone.   After a  lapse of time, I
said to this  man, " Well, have  my medical friends
dissolved the stone f his answer was, " No, Sir, and
I have given up all the injections except opium, from
which I  receive considerable  relief."   The patient
died in the Hospital, and, on examination after death,
a stone  was found in his bladder. 
182
   Alkalies may lessen the sufferings.—But although a
 stone cannot be dissolved in the bladder, yet the ir-
 ritability of the latter may be so far diminished by
 alkaline remedies, as to enable the  patient to bear
 the disease with much less suffering.
   Case.—Admiral Douglas was the subject of stone ;
 I sounded him, and in the evening of that day a por-
 tion of the stone was discharged by the urethra, and
 I sent it to my friend Dr. Marcet for analysis,  who
 found it to be oxalate of lime ;  I therefore gave him
 acids, but he was not relieved by their use; he then
 took subcarbonate of soda  3ss.  four times in the day,
 in some water.  Some months afterwards  I was re-
 quested to meet Dr. Reynolds  and Sir  E.  Home in
 consultation upon the case of the Duke  of Portland;
 and when I  entered the room, Sir Everard said,
 " Cooper, how did you dissolve  the  stone in Admiral
 Douglas?" to which I answered, " I never dissolved a
 stone in my life."—" But," said Sir Everard, " he ex-
 presses himself well from some medicine you order-
 ed him."  I called in consequence on the Admiral at
 his hotel; when he said, " You  saw me in dreadful
 agony,  unable to  cross a  room; but  since I have
 taken the soda, 1 went from  Yarmouth, in Norfolk,
 to Portsmouth, by  land, and bore the journey well;
 and I could  now go  down  a country dance."   Yet
 the stone still  existed in his bladder; but  the soda
 had lessened  its sensibility, so as to enable him  to
bear the complaint without much suffering, and only
 a little inconvenience  from the stone, which still oc-
casionally stopped  the flow of urine.
  Magnesia and soda.—Magnesia  and soda  have
been  recommended  together;  but as  many stones
are magnesian, the use of the former medicine may
be improper.
  Diluents.—Great dilution  relieves the severity of
the symptoms,  and  more  specially  mucilaginous
drinks. 
183
  Stomachic medicines.—Medicines which assist the
digestive process are the  most appropriate to pre-
vent this disease, as it is  often the result of taking
food which is difficult of digestion; or of a weaken-
ed state of the stomach, which renders common food
indigestible.
  Disease returns.—After removing a stone from the
bladder, a medical treatment should be adopted, to
prevent a return of the disease.  The uric acid and
oxalate of lime  calculi  return less  frequently than
the triple phosphate, which are very often repro-
duced.
  Case.—I cut a Mr.  Miles  for the stone, and re-
moved a triple phosphate calculus;  in about twelve
months the disease returned, for I sounded him, and
found a stone.   Mr. Lyford, an excellent surgeon at
Winchester, extracted this  stone by the  usual ope-
ration ; yet, on examination of this gentleman's body
after his death,  which occurred  several months sub-
sequent to the second operation, several calculi were
found in his bladder.
  In another case, in which I extracted a triple phos-
phate  calculus, from a patient of Mr. Van Oven's, in
the city;  the disease returned, and I again perform-
ed  the operation,  and found  a large  coagulum of
blood in the bladder, surrounded by a triple phos-
phate  deposit. 
184
              LECTURE  XXIII.

         OF THE OPERATION OF LITHOTOMY.

   Previous inquiries.—Before performing  the ope-
ration for the stone, it is right to inquire carefully if
the  functions of  the  body are  well performed  in
other respects: if the digestion  be tolerably good,
and  the breathing and  circulation  be free.  For if
the liver be diseased ; if the chest be oppressed ; or
if the heart have an irregular  action, the  patient
does  not  in general  recover from the  operation.
Pain in the loins, vomiting, or the discharge of mat-
ter, indicating disease of the  kidneys,  also form  in-
superable objections to the operation.
   Case.—A patient came into Guy's Hospital to  be
cut for the stone; I sounded  him and found a calcu-
lus, but  he made water  almost immediately, and at
the  time  discharged  a considerable  quantity  of
matter.   I saw  that  he  was emaciated; he com-
plained  of pain in  his  loins, and  his stomach was
much disordered.  I therefore said, " I will not ope-
rate  upon this man, for  he would die from the ope-
ration."   In less  than a  month  he died, and I was
happy that I had not operated,  as  one kidney was
found wasted,  and the other at least twice  its natur-
al size, with its cavities  full of a purulent secretion.
   The success of one surgeon being greater than
that  of another chiefly depends upon his judgment
in this respect, viz. not   to operate when there  is
much functional or any organic disease.
   The age of the patient.—The  age of the  patient
does  not much influence  the result of  the  opera- 
185
tion, with the exception I shall  mention.   Old  age
is not to be a bar to it,  if,  so far as  the  stone  will
permit, the patient be active, and has no other com-
plaints.  I generally,  therefore, say to a patient, " If
the stone were removed, would you  be  capable of
taking exercise ? is your digestion  good ? is  your
breathing free V—If he answers, Yes, the operation
may be performed.
   Mr. Cline operated successfully upon a patient at
82 : Mr. Attenborough, of  Nottingham, at a  still
more advanced age.  1 operated  upon a gentleman
aged 76, who had been near sixty years in the island
of Jamaica:  I performed the operation in 1812, and
he  died about ten  years after,  having returned to
Jamaica and enjoyed  his health  there.
   Sixty a favourable  age.—About sixty years of age
is the  period at  which stone  is most  frequent in the
adult,  and then the operation is very successful.  In
the middle period of  life, fever is more violent from
the operation, and the patient  is often too much
loaded with adeps  to be submitted to it.   Fat per-
sons do not generally bear operations well, they have
little vital power;  they should  be reduced by diet
and medicine, and they must be accustomed to irri-
tation of the bladder, by the frequent  introduction
of  the sound ; but still  they have  more fever and
disposition to peritoneal inflammation, than at a later
period of life.
   The most favourable age.—The age at which there
is least danger  from the operation is from three to
twenty, for death is  then a very rare occurrence.
Under the age of  two years, children often become
convulsed and die from the operation, on account of
their excessive irritability.
   Average number of deaths.—The number of deaths
from the  operation,  taking all ages, is one to eight.
Fat persons at  all  periods,  but more  especially in
   vol. n.              23 
186
middle life, are  those who most frequently die.  A
surgeon sometimes proceeds to twenty or even thirty
cases with extraordinary success;  but then  he loses
several patients,  which still produces the average I
have experienced.
   Previous preparations.—A  short time prior to the
operation, in addition to the exhibition of purgatives,
&c. an enema  should be  administered, in order to
empty the large intestines, and particularly the rec-
tum, which, if distended with faeculent matter, would
be in great danger of being wounded.

                  OF  THE OPERATION.

   The table.—The table, on which the patient is to
be placed, should be two feet six inches high; it is
to be covered with  two blankets and  a sheet, and
several pillows are required to support the patient's
head  and back.
   Bandages.—Three  bandages  are required to se-
cure'the patient; of these, two are employed to con-
fine each  hand and foot of the same side together:
a loop, at one extremity, is first  passed around the
wrist, and the patient  then grasps the outer side of
the foot, about  its middle, having the bandage pass-
ing from the wrist between the two ; the bandage is
then passed under the foot, brought round on its in-
ner side over the instep, and  so round the wrist and
ancle ; after two or three turns around these parts,
it  should  be passed  over the hand and under the
fool, then to the wrist and  ancle  again, until the
wrhole is used.  The other bandage is to be placed
round the back part  of the neck, and each extremi-
ty being passed  under  the ham  of  the same  side
from within to without, they are to be  carried back
and tied behind the neck.   These bandages prevent
the patient from  making  any movements  likely to 
187
impede the operation, or occasion danger during its
performance.
  Instruments, 1st. The sound.—The instruments re-
quired are, 1st, a sound,  consisting of a solid portion
of steel, curved as the urethra, about  twelve inches
in length ; its thickness should be well proportioned
to the size of the urethra.
  State of the bladder when sounding.—Persons often
require to be sounded with  their bladder full, and
with it empty.   I have frequently found  a stone di-
rectly after the urine has been discharged, which I
could not perceive when there  was much  urine in
the bladder.  It is  right, therefore, to sound the
patient  first  with his bladder  full ;  and,  if the
stone  cannot  be  felt,  then  to  have  it emptied,
and sound again.  On this  account,  it is often use-
ful  to employ a silver  catheter, at first preventing
the escape  of the  urine, and afterwards  allowing
it  to  flow  through  the  instrument,  at the  same
time  continuing  to   sound.  When the  bladder is
empty, it  frequently  happens, however, that the
instrument is so confined that it cannot be moved
sufficiently to strike the stone.
  Position of the  patient.—The patient  should be
sounded  first in the recumbent position,  and if the
stone be  not then felt, in the erect; as the  calculus,
by  falling  upon  the  urethra  in  the  latter posture,
may be easily detected.
  Stone not always detected.—I have myself sounded
and not detected a stone at one time,  which I have
afterwards felt.   I have sounded and not discover-
ed a stone,  which another surgeon has  afterwards
perceived.  I  cut a  patient,  and  extracted thirty-
seven stones from his bladder, who had been sound-
ed and declared not to have a stone.
   Those who have  not had  experience in  this dis-
ease,  and have  not frequently  sounded patients af- 
                       188

flicted with it, sometimes  mistake the extremity of
the sacrum, or the os coccygis, for a stone.
   The staff.—The next instrument is the staff, which
is somewhat  similar to the sound, but rather more
curved, and having a groove on its convex part;  this
groove should be as large  as possible; 1st, because
it is more easily  cut into;  2dly,  because  the gorget
or knife passes more readily by it into the  bladder.
   How  to be  held.—When  performing the operation,
the staff is to be held by an assistant, perpendicular-
ly, or nearly  so; and its extremity should, if possible,
rest upon the stone ; its  groove  is to be slightly in-
clined to the  left side of the rapha of the perineum.
Nothing can  be more  unsafe  than to  incline  the
handle of the instrument towards the patient's abdo-
men, as it draws its point out of the  bladder into the
urethra ;  and when the gorget or knife are passed
on it towards the bladder, either is likely to slip be-
tween it and  the rectum.
   Position of the patient during the operation.—Be-
fore commencing the first incision, the surgeon should
see that the  patient be placed evenly upon the table,
so that one side be not higher than the  other; and
also that  the shoulders be sufficiently raised and  well
supported.
   The scalpel.—The  knife, for commencing the in-
cision in perinco, should have a considerable convex
cutting edge, as by it the  urethra is  more freely
opened.  The scrotum being  elevated, the incision
is begun opposite the under part of the arch of the
pubis,, and is  continued on the left side of the rapha,
along the perineum, as far as mid-way between the
tuberosity of the ischium and the anus.
   The first incision.—The first incision should divide
the skin,  &c. and expose the accelerator urinae; the
second should be carried between the left crus penis
and the bulb;  the latter  being pressed towards the 
189
right side by the fore finger of the  surgeon's left
hand.
   A part of the accelerator urinae is divided, and the
trans versus  perinei should be freely cut, as it forms
a great impediment to the extraction of the stone, if
undivided.
   Opening the urethra.—The next incision  should  be
made into the groove of the staff, by cutting into
the  membranous portion of the  urethra; for this
purpose  the knife must be  directed upwards, and
not  horizontally,  otherwise   the rectum is endan-
gered : the  opening  made to expose the  groove of
the  staff should be  an inch in length.
   A gorget, or a knife with  a probed extremity, is
next usually employed, to complete the opening into
the bladder.
   The gorget.—The  gorget  may be  considered as
the dividor  of the prostate gland, and  it also serves
as a director to the forceps.   It  was formerly used
with a blunt edge, so that it acted as a wedge : when
so formed and employed, the  scalpel should be car-
ried along the groove of the staff, so as to divide the
prostate gland laterally,  after the urethra has  been
opened, which allows the blunt gorget to enter the
bladder  with comparative facility.   The operation
performed with this instrument is attended with very
little bleeding, and has been  very successful in its
issue.
   Cutting gorget.—Hawkins had  one of the edges of
the blunt gorget made cutting.   Mr. Cline made the
greatest improvement upon the cutting gorget, in
having the  left side entirely  removed,  leaving only
the beak and its right blade, which had a sharp  an-
terior  edge: this instrument  enters  with ease.  It
should be introduced  horizontally, for  there is con-
siderable haeRiorrhage if it be introduced  obliquely,
as it then opens a plexus of vessels  surrounding the 
190
prostate, and which is continued to the  vesiculae se-
minales, and terminates in the internal iliac veins.
  Haemorrhage.—It  is quite contrary to my expe-
rience to say, that persons do  not  die of haemor-
rhage after this operation,  for  I have known many
instances of it; four in  particular, in  which  death
was the immediate consequence of bleeding, suffer-
ed to continue for  several  hours; and several I have
known die from gangrene  of the scrotum occurring
after severe haemorrhage.    The  patient should ne-
ver be left until the bleeding has ceased ; and, if  it
be very considerable, the  surgeon should place his
finger within the wound and compress the bleeding
vessel;  but  he should be careful not  to quit  his pa-
tient whilst  any haemorrhage remains.
  It is best  to use a small cutting gorget, as it les-
sens the danger of wounding blood vessels; and then,
if necessary, on account of the size of the stone,  to
dilate the wound,  do it with the blunt gorget.
  Mode of passing the gorget.—The  beak  of the
cutting gorget is passed into the groove of the staff,
where it has been previously opened at  the mem-
branous part, and the instrument is then pushed along
the groove into the bladder, so as to divide  the left
half of  the  prostate gland.   It  is necessary to press
the beak against the groove as  it glides along, and
occasionally to move it slightly backwards and for-
wards,  to   be  certain that  no  portion  of mem-
brane has got between the two: when the gorget en-
ters the bladder,  the urine flows out over its  supe-
rior concave surface.
   Size  of the gorget.—The  length of the  gorget
should be proportioned to the  size   of the  patient.
The breadth of its cutting part, when used for an
adult, should not  exceed   one inch; and  the blunt
gorget should be  used, if  the first  opening be  not
sufficiently free. 
191
  The gorget which I at first used  in my own ope-
rations was double, and  cut upon both  edges ; but
I thought it occasioned too much bleeding, and  di-
vided more  than  was absolutely necessary for the
removal of the stone.
  The knife.—The  knife is now frequently  substi-
tuted for  the  gorget,  and  that  which  I  for  some
time employed,  in various  cases, was straight and
narrow, with  a  probed  end.*   After  opening the
membranous part  of the  urethra, as  before, I  passed
this  knife along the  groove  of the staff into the
bladder.  In  the  young  this answers very well, and
also  in a thin  adult;  but in a  deep perineum, or en-
larged prostate  gland, I  prefer the gorget, as being
more definitive in  its cut.
   The forceps.—Forceps of various sizes are  also
required to lay hold of the stone, and those employ-
ed  must  depend  on  the bulk of the  patient: the
handles should  occupy  two-thirds,  and  the  blades
one-third  of the length.   I have tried many  others
of different proportions,  but think that which  I have
mentioned the best.  Some of  the  blades must be
flat, for small stones, or  fragments of stones; some
should  be curved, to remove calculi from   behind
the pubes or  prostate:  one pair should  be large, as
small forceps  will not retain a large stone in their
grasp, with sufficient firmness  to  extract  it.
   The  forceps must  be  passed along the  groove of
the gorget with great care, and  the gorget must be
well retained  during their passage.  I have seen  the
forceps pass between the bladder and rectum, from
the surgeon's  pulling back the gorget as  he  thrust
forwards  the forceps, which should never be done.

  * Mr. Thos. Blizard, who  was an excellent  and successful
operator, employed a knife of the same kind, excepting  that
the beak was at  an angle with the blade, instead of straight. 
192
The gorget must not be removed until  the surgeon
has thrust his finger forwards to feel that the groove
of the  staff has  been freely opened.   I  frequently,
if the perineum  be not very deep, remove the  gor-
get after it has entered the bladder ;  and introduce
the forceps by my finger, carried along the groove
of the staff.
  Mode of using  the forceps.—When  the forceps
have passed into the bladder,  the  gorget and staff
are to  be removed;  and  the surgeon,  before  open-
ing the forceps, should sound  with  them  for  the
stone.   When the situation of the calculus has been
thus ascertained, the blades of the  forceps are to
be separated and the stQne received between them;
and this must be done with great gentleness,  not
only to save the patient  pain,  but  to prevent  any
injury  to the internal surface of the bladder.
   When the stone is drawn down to  the opening in
the perineum, wait a little for the cessation of  mus-
cular action from the perineal muscles, and introduce
the finger by the side of the forceps, to feel if  any
obstruction exists, and  to press it out of the way of
the stone ; for the finger is the best  instrument for
this purpose.  It is right to  turn one  blade of the
forceps to the   pubes and the other  to the rectum,
as the stone cannot then injure  the urethra.  If the
extraction of the stone be violently  resisted, disen-
gage and remove  the forceps, then   introduce  the
finger  and feel  how the stone is placed, and, if ne-
cessary, turn its long axis  into the  direction of the
long axis of the  bladder.
   Having grasped the  stone with the  forceps, do
not be  hasty in extracting it, but be  gentle  in the
employment of your power,  depending upon  the
gradual rather  than the sudden exertion  of force.
The great danger, and the  most frequent cause  of
death, in my opinion, arises  from the surgeon's em- 
193
ploying excessive violence with the  forceps.   1st,
Bruising the bladder:  2dly,  Disengaging it from its
situation by tearing  down its natural adhesions; it
injures the peritoneum and brings  on peritoneal  in-
flammation : 3dly, It injures the prostate, sometimes
tears the urethra at the  membranous portion; and I
have known the rectum  lacerated  where it  had not
been injured by the incisions, which can only arise,
in the use of the knife, from ignorance or negligence.
  If the stone cannot  be  grasped with the  straight
forceps, a curved pair should be employed.
  The operation for  the stone  consists, therefore,
1st, in opening the membranous part of the urethra,
and  dividing the  transverse  perineal muscles on the
left side with the knife, and  exposing the groove of
the staff:  2dly, in dividing the left  half of the pros-
tate gland horizontally, and that portion of the blad-
der connected  with  it, by means of the  gorgetjfor
probed  knife :  3dly, in introducing the  forceps,  by
which the stone is seized and extracted.

OF THE  DIFFICULTIES AND DANGERS OF THE  OPERATION
                  FOR THE STONE.

  Stricture  in the urethra.—If the  urethra  be  the
subject  of stricture, do  not perform  the  operation
until it will  admit a large staff.  The strictures be-
ing removed,  the operation  is less difficult, and the
recovery  quicker  and more  certain.
  Enlarged prostate.—An enlarged prostate  gland
offers great difficulties to  the operator, and if the
stone be  of large size, the patient  will seldom reco-
ver, as the impediment to  extraction  is excessive,
and the violence obliged to be used such as  the pa-
tient can ill bear,  at the period of life at which such
disease  of the  prostate occurs.   It is, therefore, in
such cases,  a very fortunate  event when  the stone
  vol. ii.                24 
194
 breaks, as it is removed with less risk to the patient,
 although  it  renders the operation tedious.
   Lateral enlargement.—A lateral  enlargement  of
 the  prostate gland  produces less difficulty,  if  it be
 freely divided, than the enlargement of the middle
 lobe ;  and this gland should always be examined per
 anum in aged  persons, to prevent the  surgeon  being
 baffled by this disease,  and if he  finds it  enlarged
 laterally,  he must use a large  gorget, or else divide
 freely with  the knife.
   Middle enlargement.—If  it be an enlargement  of
 the  third lobe, the circumstance is  known by the
 passage of  the staff, which only enters the  bladder
 by its  handle  being  greatly depressed; also by the
 stone  being felt distinctly at one  time and not at an-
 other; and here let me observe, that when this
 happens in sounding,  I have  generally found  some
 difficulty in  the operation.   The curved forceps are
 proper to be used in this form of disease.
   Sac behind the  prostate:—The enlarged  prostate
 gland often  gives rise to another difficulty,  by occa-
 sioning a sac to be formed immediately behind it, in
 which the stone  is principally lodged, its extremity
 only projecting into the  bladder, so as to be felt by
 the forceps; in this case the curved  forceps are re-
 quired, and the finger must be passed  up the rectum,
 to raise the  stone from this situation,  and to bring it
 into  the axis of the bladder.
   Part of the prostate nearly  detached.—A  portion
 of the prostate is sometimes nearly separated in ex-
 tracting the stone, so as to be afterwards pendulous
into the bladder;  this occasions symptoms somewhat
similar to those of the stone to remain.   This hap-
pened  to Mr. Cline, who operated upon a gentleman
very  successfully as to  the  immediate result, but
who, after his recovery  from  the operation, found
all the symptoms of stone  return.  He lived a long 
                       195

time  after, and before his death  desired  that  his
body might be opened.   Mr.  Ramsden  inspected
the parts, and sent me the bladder, which is now in
the collection at St. Thomas's  Hospital, and a por-
tion of  the prostate gland hangs by a narrow neck
into the bladder;  this portion, by falling on the ure-
thra, produced the symptoms.
   Enlargement of the third lobe.—From the enlarge-
ment of the third  lobe of the prostate  gland, little
advantage  is, on the same account, derived from the
operation of lithotomy, as the patient still  experien-
ces all the  symptoms of  stone, excepting that the
urine is not usually bloody ;  but  even this circum-
stance 1 have known to happen.
   Contraction of the bladder.—I have seen a difficul-
ty arise in  performing this operation, from a partial
contraction  of  the bladder, by which the stone has
been  firmly embraced, so as to impede the  use  of
the forceps.  This arises  from the sudden  escape
of the urine which the bladder contained previous
to the operation.  The fundus of  the  bladder, and
half of  the organ near  to  it, embrace the  stone
closely, the forceps are passed into the anterior part
of the bladder and opened at its  cervix ;  but, in at-
tempting to seize  the stone, only one of its extrem-
ities is nipped by  the forceps, which slip from it im-
mediately the surgeon tries to extract the calculus;
this occurs several times, until the patient becomes
exhausted, when the contraction of the bladder sub-
sides, and then the stone is readily seized.  In such
a case, the  flat  forceps answer  best, gliding  most
easily over the stone.  If  the patient does not re-
tain his  urine for a long period before the operation,
this difficulty seldom occurs.
  Narrow  pelvis.—In persons who have  been the
subject  of rickets,  the pelvis is sometimes so narrow
as to render the performance of this operation ex- 
196
 cessively diificult.   I once saw Mr. Cline  operate in
 a case of this kind, and only his coolness and perse-
 verance could  have overcome the obstacles it pre-
 sented.  Tne subject was a child ; the tuberosities
 of the  ischia were very near each other, and when
 the forceps were  introduced  into the bladder, only
 the handles remained external to the wound ;  the
 extremity of the stone only could be caught hold of,
 and from this the  forceps  repeatedly slipped.  Mr.
 C. finding  that the  longest pair of  forceps, usually
 employed  for children, would not reach beyond the
 centre of the stone, and that it could not be held  by
 them, introduced a pair of forceps  made for an adult,
 and with these he succeeded in grasping the stone,
 but the opening of the pelvis was too small to admit
 of its being extracted whole ; he, however, after re-
 peated efforts, broke the calculus  with the  forceps,
 and removed it  by  fragments.   The child after-
 wards recovered.
   Large stone.—The stone is sometimes so large as
 to produce  great  difficulty in the  extraction.  The
 largest which I have successfully  removed has been
 between five and  six  ounces; but I remember to
 have seen one in the Norwich Hospital which weigh-
 ed eight ounces, and was extracted  without being
 broken.  If broken, a very large stone may  be suc-
 cessfully removed.  Mr.  Mayo, of Winchester,  in
 this way, extracted  one weighing  altogether fifteen
 ounces.   The largest which I have extracted whole
 was from  Mr.-----, of Fore  Street, in the city, a
relation of Mr. Field's, surgeon, in Wilderness Row;
it  weighed sixteen ounces;  I was  obliged to extend
the incision in perineo to the sacro sciatic ligaments,
and when I seized the stone  with the largest forceps,
 I found I could not extract it; I therefore endeavour-
ed to bore  a hole in  it with a gimlet, as I  held it be-
tween the  blades of the forceps,  but  scarcely made 
197
any  impression  upon it:  at last  I succeeded  in re-
moving it in the following manner:  Mr. David Ba-
bington, son of Dr. Babington, then  my apprentice
(a most amiable and  excellent young man, who en-
tirely fell a victim to  his professional zeal, and who,
if he had  lived, promised to  be one  of  the  highest
ornaments of his profession,)  assisted me.  I placed
a single blade, or crotchet, on the upper part  of the
stone, under the symphisis pubis, and then, whilst I
pulled the stone with the forceps through the open-
ing in perineo, Mr. BL pressed down the  stone by ele-
vating the handle of  the crotchet, and thus  brought
it below the line of the symphisis pubis, and thus it
was extracted.  The time occupied by the operation
was nearly an hour, and the patient  survived  only a
few  hours.
  Forceps with blades which  separate.—For extract-
ing very large calculi, a free  incision is required, and
the forceps must  be large  and  strong.  Mr. Cline
had some  made so that the  blades could be intro-
duced singly and joined together  afterwards ;  or one
blade could be used alone, as above described.
   Instrument  to break large  stones.—Forceps  have
been constructed with teeth, to break a large  stone;
and  Mr.  Earle  has  invented  a. perforator for the
same purpose : such an instrument, easily applied, is
in the highest degree desirable.
   Soft stones.—Soft  stones create a difficulty in the
operation, by  rendering it necessary to remove the
stone in fragments.   It is thought to be very desir-
able  afterwards to wash out the bladder by means
of a syringe, with a view to prevent the future form-
ation on any remaining  portion.  I believe it is bet-
ter to use the scoop, and to remove with it  all the
particles of stone which the  urine cannot carry  off,
as sand;  for injecting the bladder will not remove
fragments, and the after-flow of urine  through the
wound will remove sand. 
198
   Unnecessarily broken.—Stones are  often  broken
 which might be removed whole, if the surgeon were
 less violent, and more cautious.  The mode of pre-
 venting them from  breaking is, when the stone has
 been seized with the forceps, to put the thumb be-
 tween the handles, so as to prevent  them violently
 approximating, and to limit the degree of pressure.
   Number of stones.—A number of calculi  render
 the operation more tedious, but not so dangerous as
 one large stone.  It is not  the number of times that
 the  forceps  are  introduced, but the violence used
 with  them, which  endangers  the patient.   When
 there are several in the  bladder, care must be taken
 that none be left; and the surgeon must not  be con-
 tent with  examining by the forceps  only, but it is
 best to pass a sound into the bladder, either by the
 urethra or by the  wound,  to feel if any  remain ;  he
 should also pass his finger into the rectum  and raise
 the prostatic part of the bladder, so as to throw any
 stone lodged there into  the axis of the bladder ;  as
 it often happens that the prostate gland is enlarged
 when several stones  exist, and they are generally
 situated behind this enlargement.
   Calculi not always detected.—In the instances of
 the greatest number of calculi which I have  seen, it
 was  doubted for a length  of time  if any existed ;
 yet,  in  one case,  the urine had been  repeatedly
 drawn off, and in  the other the  patient had been
 several  times sounded, but a stone  could not be felt:
 —on examination, after the patient's  death, fifty-six
stones were found in the bladder.
   Form of the stone.—The  form of the stone  some-
times adds to the difficulty  of its  extraction ;  if  its
long axis  much exceeds its breadth, when  seized
by the  forceps in the centre it  will not  pass the
opening in the bladder, from its  extremities project-
ing on each side of the forceps : the surgeon, finding 
199
great resistance,  should withdraw the forceps,  and
passing his finger into  the bladder, he should turn
the stone, and place its long axis from the fundus to
the cervix, after which it can be easily extracted.
   Sacculi enclosing  stones.—-Sacculi  in the  bladder
sometimes enclose  stones so far, that only  the  end
projects into its natural cavity, and can be alone felt
by the forceps.   In my own practice I  have  met
with  only one decided case of this kind, which was
the following :
   Case.—A boy was admitted into  Guy's  Hospital,
in whose  bladder, by sounding, I found a stone ; but
the symptoms were less urgent than usual, and each
time  I sounded the stone was felt in the same  part
of the bladder.   This  led me to  examine per rec-
tum,  and  I then perceived a stone lodged and fixed
at the under part of the bladder over the  rectum,  1
therefore  made  an incision  between the bladder
and rectum in perineo, and,  directed by  my finger
in the rectum, I reached the stone  without Avound-
ing either the rectum  or  bladder; I then opened
the sac with the knife, and seizing the stone with  a
pair  of  dressing forceps, I extracted it.   The boy
for three  days only passed his urine by the wound,
and then it took its natural course,  and  the  wound
healed rapidly.
   Case.—In a case which I attended with Mr. James,
surgeon, at Croydon, he found, on inspection  of the
body after death, two calculi, having large extremi-
ties connected by  a narrow  stem,  one  extremity of
each was situated  in a sac, and the other  extremity
in the cavity of the bladder.
   As I have stated, a sacculus  behind an  enlarged
prostate gland is a frequent  occurrence, but the cal-
culi are  only occasionally falling into its cavity.
   Corpulency.—Corpulency  greatly increases the
danger  of the  operation, as well  as its  difficulty. 
200
The perineum is  often so  deep as to render it im-
possible to reach the bladder  with the finger; and,
if the stone be large, the impediments to its extrac-
tion are greatly augmented,  by the resistance afford-
ed by the perineum.
  Prolapsus ant.—When a child has been long sub-
ject to prolapsus ani, it often becomes troublesome
at the  time of the operation.  The anus should be
supported  by  an assistant  at  the time the surgeon
commences the  operation, or it protrudes whilst he
is making his  incision.   It may be observed, that in
cases in which the prolapsus happens after opening
the bladder, that if the instruments  be withdrawn,
they cannot again be introduced until the prolapsus
be returned.

  OF  THE  CAUSES OF DEATH  FROM THE OPERATION.

  The causes  of death from lithotomy which I have
witnessed are :
  Nervous irritability in children.—1st, Nervous irri-
tability occurring in very  young  persons : they are
generally pale  and almost comatose on the day after
the operation: on  the day following,  their eyes roll
quickly,  and  there is  excessive  restlessness; they
then become  extremely weak, are  convulsed,  and
expire.   To relieve this irritable  state,  calomel  and
opium are  the best remedies.
  Peritoneal inflammation.—2dly, Peritoneal inflam-
mation,  occurring  when much  violence  has  been
used in extracting the stone.
  The symptoms  are;  vomiting,  tenderness in the
region of the bladder, tension  of the  abdomen,  and
difficulty in procuring motions.
  The treatment  consists in administering calomel
purges, in applying fomentations, leeches, and blisters
to the abdomen; in bleeding from the arm, and the
use of the  warm bath. 
201
  In inspecting these  cases, I have seen  not  only
inflammation of the bladder  and peritoneum, but
extravasation of blood between the bladder,  pubes,
and abdominal  muscles,  shewing that  the bladder
had been drawn down  during'the extraction of the
stone.  The removal of a large stone, when the pro-
state gland is enlarged, kills in the same manner.
  Haemorrhage.—3dly, Haemorrhage.   This I have
seen repeatedly  destroy  life,  and it has  been with
no small degree  of surprise  that I have  heard it
denied it to be a cause of death.
  Case.—I  cut  a man  in  Guy's Hospital at one
o'clock  in the day; the operation was  soon  over,
and apparently under  the  happiest auspices; the
patient was put to bed, and I soon after quitted the
Hospital.   In the afternoon the  man became faint
and vomited several times.  At nine  o'clock in the
evening the sister of the ward, in turning down the
bed-clothes, found the lower  part of his body sur-
rounded  with blood, and the  man was extremely
faint.   Mr. Callaway, my apprentice,  was  sent for,
but the patient died in an hour.
  A surgeon should not quit his patient until the
bleeding caused by the operation has  ceased : the
patient should not be put to bed  whilst any haemor-
rhage continues; and when in bed he should be very
lightly covered for some time.
  I find that bleeding more frequently occurs when
the gorget  is passed obliquely, in the direction  of
the external wound, than when it is passed horizon-
tally.
  Gangrene of the scrotum.—4thly,* Gangrene of the
scrotum.  This I have seen several times, in persons
who have  been of intemperate habits,  or  in  those
extremely weakened by  age.
  vol. h.         25 
202
  Extravasation of urine.—5thly, Extravasation of
urine into the scrotum, producing great inflammation
and swelling, and leading to gangrene; it arises from
the incision being  made too high, so as to open the
cellular tissue of the scrotum.
  Scrotum to be supported.—After the operation of
lithotomy, the scrotum should be always supported
by  a bandage, to  prevent the  urine which flows
through the wound, from irritating it, and thus the
disposition to gangrene is lessened.
   Ulceration of the bladder.—6thly, An ulcerated
state  of the bladder, shewn by offensive urine, eva-
cuation of mucus and of pus,  mixed with blood, in
some, are sufficient to lead to a fatal issue in litho-
tomy.
  Diseased kidney.—7thly, Diseased kidneys,  whe-
ther inflamed, wasted, suppurating, ulcerated, or con-
taining stones; marked by pain in the loins, by puru-
lent discharge, and  by a disordered stomach.
   Visceral disease.—8thly,  Visceral disease,  as  a
morbid state  of the  liver;  dyspnoea  from some
chronic affection of the lungs;  palpitation  of the
heart; irregular or intermitting  pulse; which tend
to destroy the powers of restoration.

            OF  THE AFTER-TREATMENT.

   When  the operation is concluded the patient  is
unbound ; but the  legs should not  be  immediately
brought together if any bleeding continue,  as the
blood is apt to pass back into  the bladder, where it
coagulates; and  producing great urgency to make
water, the coagulum is forced out,  occasioning a re-
newal of the haemorrhage.
   To be kept dry.—No dressing is to be applied to 
203
 the wound,  but a folded sheet  or  napkin is  to be
 placed under the nates of the patient  in  bed,  and
 this should  be frequently examined,  to ascertain  if
 the urine be secreted and pass away: it should be
 changed for a dry one whenever it becomes wet.
   Opium.—Opium may be given, if  the  patient be
 very irritable; but  as  it is apt  to check  the action
 of the intestines it should not  be administered unless
 absolutely necessary.
   Diluents.—The patient should be allowed to take
 diluents freely at  first;  such  as  linseed tea, or bar-
 ley water with gum acacia in  it; and,  when the dan-
 ger of inflammation has passed, beef tea, broth, or
 gruel may be given.
   Saline medicines, with excess of alkali, are useful;
 if a tendency to fever or inflammation arises, purge
 the patient with castor oil, and foment the  abdomen;
 if it increase, give calomel and antimony,  and occa-
 sionally castor oil; if the pain in the abdomen be-
 come severe, bleed from tne arm of  the  adult,  and
 apply leeches to the abdomen of a child.
   Tying the legs together.—When the wound begins
 to granulate, and not before,  tie the legs  together;
 as much mischief arises from doing so,  soon after the
 operation; 1st,  in  bleeding, as already mentioned;
 2dly, it prevents the free escape of the urine;  it  is
 of no use until the wound be disposed to close.
  Position.—It  is  not   necessary  that  the patient
should rest on  his  back only; there is not any dan-
ger in his turning to the side, and great relief  is
often obtained by it.
  Passage of the urine.—The urine passes, in  some
cases, entirely by the urethra  in  the first few hours,
but this is not desirable;  the patient suffers less in
its discharge, and has less local irritation, if  it escapes 
204
easily by the wound.   In cases of enlarged prostate
gland,  it is proper  to introduce a flexihle catheter
bv the urethra, to permit  the  urine constantly  to
flow off.   When  the urine,  under  the common con-
sequences of the  operation,  takes its natural course,
the patient frequently  suffers from a rigor.
  Recovery.—Children  usually recover  from the
operation in about three weeks, and adults in about
a month ; sometimes both have the  wound  healed
within a  shorter period.
  Evils following the operation.—I have known two
evils arise  from  the operation; one,  a  loss  of the
power of the retention of urine, when the patient is
obliged to  wear a yoke, or jugum;  the other, an in-
terruption  to the passage of the semen, from  some
injury done to the veru montanum, where the united
ducts of  the vesiculae  seminales and vasa deferentia
terminate.
   Case.—A gentleman, I know, who has undergone
this operation,  has  pain in  coitu,  but does not pass
any semen, although he experiences the  orgasm.
   The patient's digestion and state of urine  require
to be attended to after the operation,  to prevent a
return of the disease.
   Mr. Key, surgeon of Guy's  Hospital,  performs the
operation  of lithotomy  in a different manner from
that usually adopted.  The points in which it differs
from that commonly  performed consist  in the em-
ployment  of a staff,  nearly straight, and a scalpel-
formed knife,  which  serves  both  for the external
incision  and  for  the division  of the prostate gland,
thus obviating the necessity for a change of instru-
ments.   The staff is  slightly curved for about an
inch  from its  extremity,  to enable  it  to pass more
easily over the prostate gland, and the knife  is about
twice the  length of a common scalpel.   The mode 
205
of performing  the operation is as follows: the pa-
tient being secured, and the staff introduced into the
bladder, an assistant is to hold the handle of the in-
strument inclined somewhat toward the operator, in
order  to  keep  its  extremity projecting some way
into  the  base  of  the bladder.  The staff  having
been fairly laid open by the usual free external in-
cision,  and  the point of  the  knife  being  steadily
pressed against the groove, the operator takes the
handle of the staff in his left hand, and lowers it  till
he feels his  hand checked by the ligament of  the
pubic  arch.  In this movement  of  the staff,  the
prostate is raised from the rectum, the ligament of
the arch acting the part of a fulcrum, and the staff
that of a  lever, by which the gut  is put out of dan-
ger of  being wounded.  The groove of the staff and
the edge of the knife are then  to be turned, by an
easy simultaneous movement of both  hands, in  the
direction most favourable for the free division of the
prostate, which will  be about an angle of 50° with
the horizon.  The knife is now  to be  carried gently
along the  groove through the prostate into the blad-
der, until  the gland is completely divided,  which the
operator easily ascertains, by the resistance afforded
to the  knife ceasing.
  In passing the  knife, to complete the section of
the prostate, its handle should be lowered to the
bottom of the  external incision,  by  which  a suffi-
ciently large  angle is formed between the knife and
staff', and thus an opening in the gland is made, large
enough to admit the  extraction  of a moderate sized
stone.   When  the stone is of unusual dimensions, or
the prostate increased in size, it will be advisable to
dilate the opening in  withdrawing  the knife, in  the
same manner as when the beaked knife is used : in
common cases  the  knife may be  withdrawn along 
206
 the groove  of the staff without the  necessity of di-
 lating.*


 OF THE HIGH  OPERATION, OR THAT  ABOVE THE PUBES.

   Not successful.—Attempts have been made to re-
 vive this operation, in  this country and  in  France;
 but in  England,  hitherto,  they have been  very un-
 successful.

   * As far as my own experience goes, 1 think the knife a much
 better instrument to divide the prostate with than the gorget;
 more violence is necessary to introduce the  latter, and the
 opening made by it  is  limited to the width of  the instrument:
 so that if a large stone be found  much force is required to ex-
 tract it, or the opening must be enlarged.  With the  knife, the
 surgeon may at once make a free incision through the prostate,
 which 1 consider a great advantage, as laceration or bruising of
 this part, by violence used in extracting  the stone, is the most
 frequent cause of subsequent inflammation.
  1 have always made use of a long slender knife, with a  prob-
 ed extremity, of the same form as that mentioned by Sir Ast-
 ley.   During the early part of my apprenticeship to  Sir A. C.
 he always used this  instrument;  and  the success of  his opera-
 tions, performed with it, was greater  than that  which attended
 the employment of  the gorget during the latter period of my
 time.
  The probed extremity prevents the danger of wounding the
 posterior  part of the bladder, supposing it  to  be in an empty
 and contracted state  at the time the knife be introduced, which
 might happen with an instrument having a sharp extremity.
  1 have had an opportunity of using  this knife in one case, in
 which great enlargement of the prostate existed ;  I did not find
 any difficulty in dividing the prostate; the operation was tedi-
 ous on account of the stone being soft, so that I was obliged to
extract it in pieces;  but the patient, who was 73 years of age,
perfectly recovered.
  Out of nine other cases,  in which  1 have  used the probed
knife, one only has  terminated fatally: most  of these patients
were young, and otherwise healthy.
  The blade of the  knife, which  1 used in the case of enlarged
prostate, was longer than that usually  employed.—T. 
207
   Preferable under peculiar  circumstances.—Those
who have witnessed the  general  safety and facility
in performing the lateral operation will never  make
use of the  high  operation, but  under peculiar cir-
cumstances; as when  the prostate gland  is  very
much enlarged, or when a stone of great size exists.
My opinion is,  that it  should be confined to a com-
bination of  these  two circumstances (viz. the large
stone and large prostate,) which  render the opera-
tion  in perineo very unsuccessful.   Those who wish
to be fully informed on this subject will  consult the
work of Mr. Carpue, who has taken great and very
laudable pains to explain this operation.

   OF REMOVING STONES FROM THE BLADDER BY  THE
             URETHRO-VESICAL FORCEPS.*

   Number of calculi.—When a great number of cal-
culi are found in  the bladder, there is generally an
enlargement of the prostate gland, and a  sacculus
formed in  the  bladder directly behind it.  In these
cases the bladder is rarely emptied completely of
its fluid  contents,  and calculi form from the  urine
retained in  the sac.
   Usually small.—Such stones do not  in general ac-
quire  the  magnitude of those  formed  under the
usual  circumstances; and  from  their number and
friction against  each  other,  their surfaces are gene-
rally smooth,  and their shape  rounded.   Fifty-six
such calculi were found in  the bladder of  Mr. Per-
kins, the brewer, who died from retention of  urine.
   Sometimes passed with the urine.—Persons who la-
bour under this form of the disease  sometimes pass
the smaller of the calculi whilst making water; but

   * These observations and cases have been already published
in the Medico-Chirurgical Transactions, vols. xi. and xii. 
208
 the larger still remain, producing retention of urine,
 and the operation of  lithotomy has often been  per-
 formed  for them ; but, as the  following cases will
 prove,  they may be extracted from the bladder by
 means which do not expose the patient to  any loss
 of blood, do  not occasion  the  slightest danger, or
 any very considerable degree of suffering.
   I am  fully aware  of the impossibility of extract-
 ing  large urinary calculi by  the  means which are
 here recommended ; yet I cannot  but feel  a hope
 that they  may be removed,  in the early  stages of
 the disease, by the following means, before they ac-
 quire a bulk too large  to pass by the urethra.
   In the infant also, it will be extremely difficult to
 contrive an  instrument of sufficient delicacy to be
 introduced  into the bladder  through the urethra,
 which shall possess such a degree of strength  as to
 enable it to grasp the stone firmly, and to extract it
 with safety.
   Instrument for extracting small  stones.—The  in-
 strument which I first  had made for the purpose of
 removing these calculi,  was merely a common  pair
 of forceps, made of  the size of a sound, and similar-
 ly curved;  but  Mr.  Weiss,  surgeons' instrument
 maker in the Strand,   shewed  me a  pair of bullet
 forceps,  which he thought would,  with a  little  al-
 teration, better answer the purpose I had in view.
 He removed two of the blades of these forceps  (for
 there were four,) and gave them  the  form of the
 instrument  which I had constructed; the blades of
 this instrument could be opened whilst in the blad-
der, by  means of  a stilette,  so as to grasp and con-
 fine  the stone ; it gave but little pain on its intro-
duction, but when opened to its greatest extent, and
stones were admitted  between  its blades,  their re-
 moval  was  painful, more particularly at the glans
 peuis, which  appears to be the  portion of the ure- 
209
thra furnishing the greatest resistance to their  re-
moval.
   I shall  now proceed to detail the  circumstances
of the first  case, as they have been related by the
patient himself.

      Case, as related by the Rev. Mr.  Bullen.

   The Rev. John  Bullen, of Barnwell,  near Cam-
bridge,  aged 64, of a spare habit of body and of a
sanguine temperament, having enjoyed  an uninter-
rupted  state of good  health, capable of partaking
largely of the amusement of hunting,  and living al-
ways with great moderation, was  attacked, in May
1818, with symptoms, of which he gives the follow-
ing account:
   " I was suddenly seized  with a  frequent  inclina-
tion to pass my water,  and an uneasy sensation along
the course  of the  urethra, which  continued  with
greater or less violence for  about a  fortnight, when
I was surprised by the appearance  of  a small round
white stone at the orifice of the passage.  The es-
cape of this small calculus, which was attended with
scarcely  any pain, failed to produce any beneficial
effect on my former symptoms, which  continued un-
abated,  both as to the degree  of irritation  and the
frequency of making water.  In this state I remain-
ed till  June following, during which month  several
similar calculi passed, to the number of about thirty,
producing no other inconvenience than a slight smart-
ing pain along  the  urethra.  At  the  end of June,
without any assignable cause, I was  suddenly reliev-
ed from this discharge of calculous matter, and from
every other symptom  but that of  a frequent desire
to void  my urine,  which latter  inconvenience occa-
sioned me no feelings of  anxiety or apprehension.
   " In the ensuing  winter,  I was seized with pains
   vol. n.              26 
210
across the back and loins; for which Mr. Brewster,
of Cambridge, supposing they proceeded from gra-
vel,  ordered  me  medicines, which he  considered
likely to alleviate  them, but without producing any
permanent good effect.
  " I was,  however, still enabled to pursue my fa-
vourite amusement  of  hunting, though  frequently
obliged to  dismount to make water;  at this  time
making no  alteration from my accustomed mode  of
living.
  " Without any material change I remained  until
the December of  1819, when I found the exercise
of riding was  becoming considerably more  painful,
and the inclination to pass my water more frequent,
attended with some degree of difficulty in its pas-
sage, and a change, from its usual  colour and clear-
ness,  to a  fluid  resembling chocolate.   For  these
symptoms several formulae of medicines having been
prescribed  without any material  benefit, I was in-
duced  to  consult  Mr.  Abbott, a most  respectable
surgeon at  Cambridge, who  ordered me medicines
highly beneficial in  their first effects;  the relief,
however, they afforded me,  was but of short  dura-
tion, for my symptoms  recurred with all  their  form-
er violence; and though the prescriptions  were re-
peatedly altered at Mr. Abbott's suggestion, no sen-
sible impression  could,  by the most judicious  treat-
ment, be made on  the disease.
  " My friend, Dr. Thackeray, of Cambridge,  was,
in the June following,  called in  consultation  with
Mr. Abbott; and both  agreeing that the symptoms
were  produced  by stone in  the bladder, the sound
was introduced to  ascertain  its  presence, but failed
to discover it.  My symptoms continuing unabated,
Mr. Abbott, a fortnight afterwards, still impressed
with the idea of stone, again sounded me;  but the
stones, for  the reasons  hereafter given, escaped de- 
211
 tection.   To relieve my frequent inclination to make
 water, and to mitigate the pain I experienced in its
 discharge, I was  recommended the use of an opiate
 glyster at bed-time, which afforded me considerable
 relief; but if the injection  were omitted but for a
 single night,  the  symptoms  returned  with all their
 former violence.
   " In this state of suffering I determined to consult
 Mr. Astley Cooper, and on the 17th of August went
 to town for that  purpose.  Mr. Cooper, suspecting
 from my  account that a stone was present  in  the
 bladder,  sounded me; but after searching for some
 minutes was unable to detect one; he then directed
 me to  discharge  the water from my bladder,  and
 the  sound being again  introduced was distinctly
 heard  to  strike upon a stone.  He then informed
 me that there was no hope of permanent relief but
 from the operation of Lithotomy; at the same time
 remarking that, as I  had not been sufficiently  reduc-
 ed by the irritation of the disease  to render  me a
 favourable subject for  the operation, it  would be
 better  for me to  return to Cambridge, and by pur-
 suing a certain plan of diet and regimen,  to reduce
 the high  health which I appeared  to possess.   He
 also prescribed alkaline medicine, for  the purpose
 of lessening irritation.   With  this advice I returned
 home,  where I remained  till October,  1820,  pursu-
 ing the use of the soda  and the  opiate injection.
 My sufferings  being alleviated only for the moment,
and seeing no probability of experiencing further
relief from  medicine;  on the  23d of October  I
came to London to submit myself to the  operation,
and the 30th was the day proposed for its perform-
ance.
  " On the day appointed, Mr. Cooper, his nephew
Mr. B. Cooper, and  Mr. Merriman, junr.  attended
at my  house.   Upon  sounding me, the instrument 
212
could be  distinctly heard,  by every person present
and even by myself, to strike  against a stone.  Mr.
Cooyer, however, was of opinion that the stone was
so small,  as to admit of extraction without cutting
into the bladder; and, therefore, determined not to
perform the operation,  but told  me  that he would
try less dangerous means to rid me of this complaint;
and happily under these circumstances the operation
was  deferred.
   " On  the 3d of November,  I called at Mr. Coop-
er's house, when  he passed a  full sized  bougie into
the bladder, for the purpose, as he  said, of dilating
the urethra, and thus giving the stone  an opportuni-
ty of passing with the flow  of urine.  This operation
was repeated on the 6th, 10th, and 13th of Novem-
ber; but on the 14th an inflammation took place in the
prostate gland, from the introduction of the bougies,
and put  a stop to the prosecution of this plan of treat-
ment. The effect of this inflammation was a retention
of urine, rendering it necessary for Mr. Cooper to draw
off my  water every twenty-four hours; at  which
time the calculus  could always be distinctly felt by
the catheter.  After the inflammation had subsided,
the power of making water  not having returned,
Mr. Cooper passed an elastic catheter into my blad-
der, and directed me to wear  it; teaching  me, at
the same time, how to withdraw it when it became
either painful or obstructed;  and, on several  occa-
sions, I  discovered small white stones in the opening
of the instrument similar to those which had passed
in 1818.  Mr. Cooper, upon  being acquainted with
this circumstance, expressed  a wish to remove the
instrument himself; when, upon withdrawing it,  a
stone was seen large enough to fill  the opening in
the side of the elastic catheter.   The passage  of
these calculi suggested to Mr. Cooper the possibili-
ty of inventing an instrument by which he might re- 
213
move those that remained in the bladder; and on
the 23d of November he brought with him some in-
struments contrived for the purpose ; one  of which
he directly employed, and was  so fortunate in  the
first trial as  to  remove  eight  calculi of small  size.
The operation was productive of  a very inconsider-
able degree of pain.
  " On the 28th, eight more were removed by the
same  means, of a larger size than the  former, two
being as big as horse-beans.  This operation was at-
tended with even less pain than the former.
  " On the 30th eleven  were extracted; three or
four being engaged each time  the instrument  was
withdrawn.   The  removal of these gave  me great
relief, for I was immediately enabled to pass a con-
siderable  quantity of urine  by my  natural efforts;
and previously to this, ever since the large bougie had
been  introduced, I had been unable to pass my wa-
ter without the aid of the catheter.
  " On the  8th  of December six stones  were re-
moved by the same means.
  " On the 13th, nine more were taken away.
  " On the 19th, three  more were extracted.
  " On the 23d, twelve more were removed ; thus
only allowing the  intermission of  a day or two for
the irritation to go  off.  The  operations were re-
peated until eighty-four calculi were, by these means,
extracted from my bladder;  when  Mr. Cooper pro-
nounced,  after  a most  careful  examination,  they
were all  removed.   My  health  has  been all  this
time  uninterruptedly good, with the exception of the
attack of retention of urine from  the  use of the
large bougie ; and I am now able to  discharge my
urine without the  use of the catheter,  and to walk
nearly as well as I ever did."
   The following case is, in  part, detailed from the
patient's  account  of his  symptoms;  and, in  part, 
214
 from the statement of Sir Gilbert Blane, who is the
 patient's  physician.

   Sir William Bellingham's Account of his Case.

   "Sir William B-----is in his 67th year; he  suf-
 fered much at times from  long  and severe attacks
 of gout, from about  his 35th to his 60th year; since
 which period the attacks have been much  less fre-
 quent, much mitigated, and  of short continuance.
 He thinks he first perceived red gravel  or sand to
 come from him occasionally, soon after a long fit of
 the gout  about* seven or eight years since, but did
 not suffer much inconvenience from it.  About four
 years since, he passed  pieces of gravel  at different
 times, and has continued occasionally to  do so ever
 since ;  sometimes larger than  a pea,  but  generally
 of an  oblong shape.   When  they occasioned any
 stoppage in the passage, he used a  hot bath at 94°
 and drank plentifully of some diluting drink, which,
 after a little time, relieved him.  In the summer of
 the year 1820, having had  occasion to use a great
 deal of walking exercise in London; for three or
four days he was much surprised on passing, first, a
considerable  quantity of very dark  stuff,  nearly like
coffee grounds ; and  afterwards  a considerable quan-
 tity of, what appeared  chiefly,  blood.  He did not
 experience any pain  of consequence with  this;  and
by the following day his urine was as clear as be-
fore.   Upon going into the country, he  found that
if he rode fast at  any time, it brought on the passing
of the dark stuff,.and afterwards, if persisted in, of
blood.   By degrees  he  gave  up riding,  and finally
ceased to ride abEut Christmas last; and  ('tiding the
 same effects to arise  in a slighter degiee  from walk-
 ing much, he has  very nearly given up that also, for
 the last  six  months.   Sir Astley  Cooper  and Sir 
215
Gilbert Blane attended him for these symptoms, in
June and July 1821, when  he left  London for Ire-
land ; whilst there, he continued  to  experience  the
same inconvenience as before, with  but little pain,
and the same on his return to London.  Early in June
last, he called on Sir Astley Cooper to say he was
going again to Ireland, and wished to  have some con-
versation with him, when Sir Astley  Cooper advised
his being sounded ;  which he  then was, and it  was
ascertained  that there was a stone.   As it appeared,
to Sir Astley Cooper, to be a small one, he proposed
trying  to extract it; and on the fourth trial, with in-
tervals of  a week  or  so  between them, a stone
weighing seventeen grains and a half was extracted
on the  18th of July.  About three weeks after, Sir
William, having some fears that there still remained
some stone  behind, again applied to Sir Astley Coop-
er, who upon sounding found that such was the case ;
and on  making at that time at his house an attempt
to extract, he brought it part of the way, but found
it too large to bring forward, and therefore returned
it; and, as  soon after as the parts'would permit, he
commenced enlarging the passage by bougies, which
he continued at intervals for nearly a fortnight,  and
then extracted a stone weighing fifty-four grains, on
the 28th of August  1822."
   Sir  William  B.  suffered pain in  making water;
swelling of  the  corpus spongiosum  at the  scrotum,
with considerable urethral  discharge, until Septem-
ber 23d, when the symptoms subsided, under the ap-
plication of fomentations and poultices.
   When the size  of the stone is observed, it  will
not excite surprise that I had considerable difficultyln
extracting the larger, which weighed fifty-four grains.
It was  in  that part of the  urethra  near the glans
that the chief impediment was found; and, if I had
thought proper to do so.  f could  have easily remov- 
216
ed it from thence by incision, but I preferred com-
pleting the extraction without occasioning a wound.
Yet I am now disposed to believe, that in a stone of
equal magnitude, it would be better to make a small
incision into the urethra,  anteriorly to the  scrotum,
than employ force  for the   extraction of the stone
through this narrower part of the urethra.   A. C.

                Mr. King's Case.

  Mr. William King,  aged  66, mariner,  residing at
Rochester, was  sent  to  me by Mr. Newsom,  sur-
geon, of Rochester, on account of his having symp-
toms of the stone.
  He came to London on the 29th of October 1822,
and on the 30th he visited  me.   I sounded  him, and
found that he had, as Mr.  Newsom supposed,  cal-
culi in the bladder.   I passed the  urethral forceps
into  the  bladder, and in a few minutes extracted
four calculi; and although I could still perceive  that
some remained in the bladder, I did not choose  to
risk  the  production  of any considerable degree  of
irritation; but advised him to come on November
1st, to have the operation repeated.
  On the 1st of November I extracted three cal-
culi ;  on the 4th, five  more ; on the 7th, twelve cal-
culi;  on  the  11th, two;  and  on  the  13th, three
more.  I  then examined  the bladder with  care, but
could not  perceive any more stones;  andx even be-
fore the  removal of the last, he  had  experienced
considerable diminution of the pain in making water,
and of the difficulty in passing it.
  It is delightful  to  hear the expressions  of grati-
tude which this patient  pours forth for the relief
which he has experienced from  these operations,
under which  he has suffered but a slight degree  of
pain, and has never  for a moment been  confined
from whatever exercise he was disposed to take. 
217
  Some years ago he passed red sand (uric  acid ;)
but for several months before he had  symptoms of
the stone, he had not perceived any.
   Case.—I have lately removed from a young per-
son (a patient of Mr. Rutherford, in Ratcliffe High-
way,) of the  name of Errington, a calculus of mode-
rate size, and enabled two others to  pass, by with-
drawing the  instrument in its dilated state, and thus
extended the urethra, in such a  degree, that the
stones passed in the afternoon of  the  same  day in
a copious discharge of the urine.
   I have heard that it has been  stated, that there
was no novelty either in  this idea  or in the  instru-
ment.   To this I  have only to observe, that  if the
idea had previously occurred  to  any individual, he
had so far buried it in his  bosom  that  I  had never
heard of it;  and, as to the instrument, I am quite
sure that Mr. Weiss consulted  no  musty volume for
its formation; for, so soon  as I  mentioned my wish,
that he should  construct a  pair of  forceps by divid-
ing a sound in  its middle,  and  giving it a  joint two
inches from its end, he, without quitting me, observ-
ed that he should make them to open, in the mode in
which he now  makes  them. Mr. Weiss has a strong
and ingenious mind, and  does not  use  petty artifices
to obtain employment or character.  But  let us for
a moment suppose (what I do  not  believe) that the
idea had occurred  to others, and the instrument had
been made centuries ago,  what are we  to say  of
the apathy of those bright ornaments  of  their pro-
fession, Cheselden, Pott, Hunter,  Cline, Home, Bli-
zard, &c. who,  if they had heard  of such  an  instru-
ment, had never employed it ?
  vol. ii.              27 
218
   OF BREAKING OR SAWING STONES IN THE BLADDER.

   An instrument for the purpose of breaking stones
in the  bladder  (called lithontripteur) has been in-
vented ;  and, during the last year, successfully em-
ployed in Paris, by Mons. Civiale.
   A description of the instrument, of the  mode of
using it, and an  account of  three cases in which  it
has succeeded, have been published from a Report
of the Royal  Academy of Sciences.
   The size and straight form of the lithontripteur
render it only  applicable to peculiar cases.   The
urethra must have acquired its full growth, and the
prostate  gland  must  be  in  a healthy state,  or the
instrument cannot be  employed with safety: even
then the urethra must, in most  cases, be  gradually
dilated by the  passage of bougies, before the  ope-
ration  can be  performed.   When  introduced  into
the bladder, the  lithrontripteur is not calculated to
seize a large stone,  as the claws or  holders do not
separate to a sufficient width to grasp it, which can-
not be  remedied unless the size of the instrument be
increased, or the springs weakened.
   The lithontripteur is therefore only adapted to the
case of an adult, having  a  sound state of urethra
and prostate, provided the calculus be also of a mo-
derate size.
   This instrument has not as  yet been successfully
employed in this country.
   Mr.  Weiss, whose name  I have already had oc-
casion to mention, has made an  instrument, which is
well calculated to break stones of small size,  and of
not very hard consistence: it is on the same plan as
the urethro-vesical forceps, but having strong springs.
He is  now  engaged in  perfecting   an  instrument,
which  will  divide a  stone into minute  pieces by
means of  a sawr. 
219
            OF CALCULI IN  THE URETHRA.

  They may be  best described in the three  situa-
tions in which  the  surgeon is called upon to aid
their passage, or to remove  them by operation; viz.
1st, in  the  membranous part of the urethra ; 2dly,
above  the scrotum ; 3dly, opposite the fraenum.
  In the membranous part.—If you are consulted on
account of  a stone  being arrested in its  progress at
the membranous portion of  the canal, you  find the
patient having the strongest desire to void his urine ;
but able  only to  pass a few drops,  with dreadful
agony.  You introduce a catheter into the membra-
nous part of the urethra,  and,  feeling a  stone grate
against its extremity, you should  immediately with-
draw it, and pass a bougie  as large  as the  passage
will admit;  when this touches  the stone it should
be left in, and the patient  should be directed to sit
in water as  hot as  he can bear it, and continue it as
long as he can:  at  the same time  he should take
opium with small doses of tartarized antimony.  In
half an hour, or  an hour,  withdraw  the bougie,
whilst the  patient  tries to  make water, when the
stone  will frequently follow the bougie, being forced
from him by the vis-a-tergo.  I have found this plan
to be  the most successful.
   Operation to  extract the  calculus.—If the  stone
permanently lodges  in the  membranous  portion of
the urethra, pass a catheter down to it, and intro-
duce a finger into  the  rectum, to  press upon the
canal  behind the  stone, so as to prevent any retro-
grade  movement  of it towards  the bladder; then
make  an incision in perineo upon the calculus, and
extract it with the  common dressing forceps.
   Stone behind the scrotum.—If the stone be placed
in the urethra  above  the scrotum, try to  press it
\ 
220
 forwards with the fingers, until it be brought before
 the  scrotum ; if this cannot be effected, it must be
 pushed back behind the scrotum, and there cut upon,
 if the use of the large  bougie, as in the former case,
 is not successful.
   Scrotum must not be opened.—Do not cut through
 the  scrotum to remove  a calculus until  all  other
 means have been tried ; and if it be at all necessary,
 which I  doubt, let the external opening be free, so
 as to allow of  a ready escape for the  urine, and
 thereby  prevent its  extravasation into  the  cellular
 tissue, which would  produce extensive inflammation
 and  suppuration.  A catheter should be introduced
 into  the  bladder after the operation, and left there,
 that the urine may flow through it during the time
 the  wound is healing.
   Stone near the glans.—If the stone be situated near
 the glans, the surgeon should  try to press it through
 the  meatus; but, if he  cannot accomplish this, He
 should introduce a common  probe, curved at its end,
 behind the stone, and draw  it forwards.
   Forceps cannot be introduced effectually, because
 they open  in the urethra  before  the stone, but can-
 not be passed over it.
   Meatus to be enlarged.—It is better to enlarge the
 meatus with a  lancet, to free the  passage of the
 stone, rather than risk the  laceration  of the  parts
 from violence.
   Preparations in the Museum at St. Thomas's Hos-
pital.—In the collection at  St. Thomas's Hospital I
 have two preparations,  shewing calculi which have
 ulcerated their way into the urethra.  One, a  stone
 of the form and size  of the little finger, and slightly
 curved, which I cut from a young  man who had a
 fistula in  perineo: with a  probe I felt the end  of a
calculus through the fistulous opening, and therefore
 made an  incision and extracted it;  its anterior extre- 
221
mity was in the membranous portion of the urethra,
its posterior in the bladder.   In the other prepara-
tion, the stones are seen partly in the prostatic part
of the urethra, passing there by ulceration.  I have
twice known a stone in the urethra destroy life by
occasioning an extravasation  of urine into the scro-
tum. 
222
             LECTURE  XXIV.

        OF CALCULI IN THE PROSTATE GLAND.

  I separate  these  from urinary  calculi, because
they are formed independent of  that secretion, and
they differ generally  in their  component  materials
from urinary calculi.
  Found in two situations.—I have  found them  in
two situations in the prostate :  1st, several calculi,
each seated in a separate small  duct; 2dly, nume-
rous calculi  placed together  in a cyst or bag in the
substance of the gland.
  Do not acquire a large size.—They rarely acquire
any considerable size;  the largest  I have seen not
being bigger than  a  pea,  and they  seldom are  so
large; but their numbers are sometimes very con-
siderable.
  Case.—I was called by Mr. George Vaux, to see
a Mr. Lewis, in  the  Old Jewry,  who had retention
of urine, and in whom there was difficulty in passing
the catheter.  As the instrument entered the  blad-
der through the prostate gland, it grated over a stone.
I passed my finger per rectum, and felt two or  three
calculi grating against each other, and I endeavour-
ed to  persuade him to  let me extract them, but he
would not consent.   He  died of diseased kidneys,
and I have his prostate gland, containing  the calcu-
li, in the collection at St. Thomas's  Hospital.
  Case.—The second case was that of General B—,
whom I cut for the stone in his bladder :  I removed 
223
many calculi, some of which were prostatic and some
urinary.   The  surgeon,  who had attended the  Ge-
neral previously, had observed that a bougie, which
he had introduced into the bladder, was marked by
the calculi.   The patient recovered.
  Case.—I operated  on  a  patient of  Mr. Forbes,
surgeon  at  Camberwell,  and  removed an immense
number of prostatic calculi.  These calculi had  pro-
duced not only painful feelings  in the perineum, but
a degree of irritation, which  kept the patient in con-
tinued mental  excitement, bordering upon insanity.
I introduced a staff into the bladder through the  ure-
thra, and opened the  perineum  as far as the pros-
tate, cutting into the urethra, as in the operation for
lithotomy;  I then made   an  incision  into the  left
lateral lobe, and extracted many calculi from a bag
formed in it.  The patient bore  the operation well,
but  did not perfectly recover;  a fistulous opening
remained,  and his symptoms  became as distressing
as before.   On  examining by  the  fistulous opening,
I could distinctly feel  more calculi, although I could
not discover them by introducing my finger per rec-
tum.  The   sufferings of the  patient  induced me,
about six months  after  the  first operation, to  per-
form a  second, which  I   accomplished by passing a
director into the fistulous opening, and  then enlarg-
ing this opening by a history: I extracted about half
as many  calculi as  in the first operation.   The pa-
tient soon recovered from the  effects of this second
operation, and the wound closed  entirely; but, after
a short time, his  sufferings became as  dreadful as
before, and, believing that he could not procure any
relief, he destroyed himself six  months after the
second  operation.
   The operation is not difficult, and is  certainly not
dangerous.   If  the calculi  are  in a  single cyst, a
single operation will produce complete relief; but if 
224
more than one cavity exist, other operations will be
required.
   These calculi are composed of phosphate of lime.

           OF CALCULUS IN THE FEMALE.

   Operation seldom  necessary.—Lithotomy  is much
less  frequently  required  in the female than in the
male, probably on account of the meatus readily per-
mitting the escape  of materials which would have
become the nuclei of stones in the  male,  be they
portions of gravel, of blood, inspissated mucus, or ex-
traneous bodies.
   Symptoms.—When the  female labours under  cal-
culus, her sufferings are more severe  even than.those
which the male experiences  from  this disease: at
first  the symptoms are of the same kind, as  urgency
to make  water, and  frequent  inclination to do so ;
sudden stoppage to  the flow  of the urine; pain at
the end of the urinary passage; and blood occasion-
ally  mixed  with the urine.  In  addition to  these
symptoms, as the irritability of the bladder increases,
the pain during micturition is excessive, and there is
agonizing suffering after the discharge of  the urine,
from a bearing down of the bladder, uterus,  and rec-
tum, with a sensation of  their being forced  through
the lower opening of the  pelvis.  The retention of
urine becomes imperfect,  and  the  person is always
wet, and smells offensively of urine.  The sufferings
of the patient  at  length render  her incapable of
moving from her bed.                          *
   The calculus is usually lodged in  the bladder, as
in the  male;  but I have  once seen a case in which
the stone was placed half in the urethra and half in
the vagina ;  the extremities of the stone were large,
and connected by a narrow  portion,  which  passed
througli  an ulcerated  opening in the under part of
the urethra. 
225
   Unnatural propensities in women.—Women  some-
times render  themselves the subjects  of lithotomy
from  perverse and unnatural propensities.  I have
known a female put a pebble into the meatus  urina-
rius.
   A lady in using a catheter for herself, broke it in
the bladder, and I extracted it  in the presence of
Mr. Ilott, of Bromley.
   I have known women introduce extraneous sub-
stances  into the vagina, to invite the operation for
the stone.
   Case.—A girl, about twenty years of age, came to
St. Thomas's  Hospital,  describing herself to  suffer
all the symptoms of the stone; she was placed upon
the operating  table, before all the students, and Mr.
Cline passed a sound to ascertain the presence of the
stone; he struck some  solid body, and a  person of
less caution might  have  immediately proceeded with
the operation; but he  said,  "I  feel  a solid  body,
which has not the hardness of stone;" he then ex-
amined  by the vagina, and drew from thence a por-
tion of  coal,  and  afterwards several other pieces:
she had no disease.
   Case.—I cut a woman in  Guy's Hospital for the
stone, and found a large piece of a brass nail in her
bladder, which is now in the collection at St. Tho-
mas's Hospital.
   Stone formed on an  extraneous  body.—In the fe-
male, a stone  will  form around an extraneous body,
as in the male, of  which the following is a curious
instance:—a woman was the subject of retention of
urine, and required the  frequent introduction of the
catheter : she was under   the care of Mr. Castle,
surgeon  at  Sittingbourne;  and one of  his  assistants
having passed  the catheter, allowed it to escape from
his fingers into the bladder, and there it  remained
for several months : she was then sent to Guv's Hos-
   vol. il              28 
226
pital, where I sounded her and felt the catheter.   I
opened the urethra freely with a knife, and passing
my finger into the bladder, found the catheter placed
transversely in it,  and on its centre a large calculus
with each end free from such accumulation.  I then
brought down one end of the catheter to the  mea-
tus, with my  finger, and thus removed it.   The cal-
culus deposit on the instrument weighed at least  an
ounce.
  Large stones may pass the urethra,—Very large
calculi can pass by the  meatus.   Mr. Giraud  gave
one of more  than  an ounce weight, which a woman
had  passed with her urine.
  Medical  treatment.—The same medical treatment
is proper in the female as has been recommended in
the male, to lessen the patient's sufferings.  It might
be thought that solvents could with  advantage  be
injected, but  the patients cannot bear them, and will
not submit  to their use, as they irritate excessively.
Opium  may  be injected, or  a suppository be intro-
duced ; but they only relieve for a very short pe-
riod.
   Calculi extracted  without cutting.—Stones of large
size  may be extracted from  the female without the
use of  cutting instruments.   Mr. Thomas has relat-
ed, in the Medico-Chirurgical Transactions, a case in
which  he dilated the meatus urinarius to extract an
extraneous  body from the bladder.  Guided  by this
circumstance, I removed a calculus, having,  by the
use of sponge tent, dilated the meatus;  and  in ano-
ther case, by the  dilating  forceps, I  took away a
portion of a catheter.
  Case.—Dr.  Nuttall  and  myself  attending  a case
together, he   objected to my mode of dilating the
meatus, and thought that forceps with blades open-
ing in  parallel instead of divergent lines would  be
better.   We  walked together to Mr. Weiss,  who. 
227
 with his usual  ingenuity, made a forceps  upon that
 principle.
   Unless a stone be extremely large,  it should be
 removed by dilatation of  the urethra, which may,
 by a speculum or  pair of forceps,  be opened suffi-
 ciently in a few minutes for  this purpose.   The ad-
 vantage  attending this mode of extracting a stone is,
 that  the passage  again  contracts, and the urine is
 afterwards retained.
   In the first case  in which I performed this opera-
 tion in Guy's Hospital, having used sponge tent,  the
 patient perfectly recovered in a very few  days.
   Mode of operating  with  the knife.—If the opera-
 tion for lithotomy be required in the female, it should
 be performed in the following manner:—the patient
 having been  bound in  the same position  as in  the
 operation on the male ; the sound  is to be introduced
 (and it may be sometimes necessary to use a curved
 male sound, which Mr.  Cline used  to  recommend,)
 in order  to detect the  calculus.
   The stone being found, a straight staff is to be in-
 troduced when the sound has been withdrawn; and
 this the  surgeon should hold  in his left hand, with
 the groove turned to the left branch of the ischium:
 the  beak of the straight history is then to  be passed
 along its groove into the bladder,  so as to divide the
 meatus and  urethra obliquely downwards  and out-
wards on  the  left side, between the vagina  and
branch of the ischium.   The finger  may then be
passed into the bladder,  to ascertain the situation of
the stone, after which the  forceps  are to be intro-
duced and the stone extracted.  The curved forceps
are sometimes necessary  on account of  the capacity
of the bladder, and the  usual position of the calcu-
lus,  which rests  behind the  neck of  the bladder,
over the posterior and upper  part of the vagina.
   Large stones difficult to  extract.-—A large stone is 
228
with difficulty extracted from the female, on account
of the  proximity of the meatus and pubes.
   Operation causes incontinence.—In all cases of this
operation which I have performed or witnessed, the
urine has not been afterwards retained; but I would
not deny that a patient might recover the retentive
power.
   As the loss of retention is a greater evil than I
can describe, producing excoriation, and a very offen-
sive state, I shall, in any future operation  of  lithoto-
my, try what may be effected by employing a suture
to bring the divided parts together.

       OF CALCULI IN THE SUBMAXILLARY DUCT.

   Produce inconvenience.—Stones forming in this duct
produce considerable inconvenience, and the cause of
the symptoms generally exists for  some time before
it  is discovered.
   Case.—When  I  was  living  with  Mr. Cline,  he
used frequently to say, " I have a spasm in my mylo-
hyoideus muscle," and it was usually at the  time of
eating  that  he made this  observation:  at length he
said, " I  have discovered the cause of the uneasiness
and spasm under my tongue, it arises from a stone in
the submaxillary duct," which he desired me to feel,
and which I removed from him in the manner I shall
presently describe.
   Case.—A medical man called upon me and said,
" I have  an  irritation and swelling under my tongue;
I  have taken great quantities  of blue pill; but as
my health is  becoming  impaired, and the  disease
continues, 1  am  advised  to  go to the coast."  On
putting my finger under his tongue, I felt  a calculus,
which  I immediately removed,  and in a week he was
well.
   Situation.—These calculi are generally situated in 
229
 the trunk of the duct, but sometimes in its branches
 within the substance of the gland.
   Size.—The largest I  have  seen was the size of an
 almond deprived of its shell; I have seen one fluted
 so as to allow of the passage of  the saliva through
 the depression.
   Composition.—They are composed of phosphate
 of lime.
   Operation to extract them.—The operation for their
 removal is to be performed as follows :—the cheek
 is drawn back by means of a blunt hook introduced
 at the angle  of the mouth;  the duct is pressed up-
 wards by the finger of an assistant, placed under the
 lower jaw: an incision is then made, with a pointed
 and curved history, upon the stone from under the
 tongue, within the mouth, so as to divide the lining
 membrane of the mouth and open the submaxillary
 duct; the stone being exposed is to be brought from
 its situation by means of a small hook which is to be
 passed under it.  If the stone be  deep seated in the
-substance of  the gland, a small pair of forceps are
 required to extract it. 
230
               LECTURE XXV.

        OPERATIONS FOR RETENTION  OF URINE.

   It is not my intention,  in  the present Lecture, to
 enter into a detailed description of the causes which
 give  rise  to the retention of urine; but merely here
 to state them generally,  and at a future time give a
 more particular account of each.
   Causes—The causes which  1 have known  pro-
 duce retention of urine in the male are :
   1.  A narrow orifice to the urethra.
   2.  A congenital obstruction in the urethra.
   3.  Permanent stricture.
   4.  Inflammatory stricture.
   5.  Spasmodic stricture.
   6.  Abscess or tumour  pressing upon the urethra.
   7.  Stone in the urethra.
   8.  An enlargement of the prostate gland.
   9.  Paralysis of the bladder.
   10. Chancres or other ulcers in the urethra, which
in healing close it.
   In the  female:
   1.  Polypus of the vagina.
   2.  Polypus of the uterus.
   3.  Ovarian enlargement.
  4.  Retroversion of the uterus.
  5.  Loss of power from uterine affection, a species
of hysteria.
   Consequences.—From whatever cause  the  reten-
tion  be produced, the bladder must be relieved of
its load, or the patient will die from inflammation or
gangrene, or  perish from irritation.
  An operation  necessary.—If therefore a catheter 
231
cannot be introduced; if relaxation by bleeding, the
warm bath, and antimony; if lulling the patient by
opium, do not succeed in giving a passage to the wa-
ter, an operation will be required to save the patient.
  Symptoms.—Besides the dreadful  pain and exces-
sive  irritation occasioned by the  distention of  the
bladder, retention of urine is marked by a frequent
urgency to make water, and swelling of the lower
 art of the abdomen, from the accumulation in the
 ladder ; this swelling reaches as high as the navel,
and on each side  to the lineae semilunares: the fluid
accumulation can be distinctly felt  through the ab-
dominal parietes.
  Operation.—The mode of relief which has been
usually resorted to has  been to puncture the blad-
der;  but, in the male, it is' not the operation which
I perform, nor do I recommend it  as a general prac-
tice ;  but as  it may be  occasionally required, I shall
describe the  different modes of puncture.
  Founded  on anatomical  knowledge.—The opera-
tions of puncturing the bladder are founded upon a
knowledge of the reflexion of the peritoneum, which
passes from the abdominal parietes above the  pubes
to the fundus of the bladder; and is continued to the
back of the bladder, near to the prostate gland, and
is then reflected to the  fore part of the rectum.
  Thus the cervix of the bladder and its fore part
above and behind the pubes,  also the posterior and
inferior part behind the prostate gland as far as the
entrance of  the ureters,  are  devoid of peritoneal
covering.

        OF THE  PUNCTURE ABOVE THE PUBES.

   When the bladder becomes excessively distended,
its fundus  rises  towards the umbilicus,  and carries
with it the peritoneum, so that a considerable space
I 
232
is left above the pubes uncovered by this membrane,
at which place a  trocar  may  be easily introduced,
without danger of wounding it.
   This space is covered  by the  linea alba, in the
centre, and at the sides by the pyramidales and recti
muscles, the bladder being attached beneath by cel-
lular tissue.
   Operation.—The operation requires the following
attentions.
   1st, The  patient is to be placed on a table,  in the
horizontal position, with his knees a little elevated.
   2dly, The hair  is to be removed from the pubes.
   3dly, An  incision,  one  inch in length, is  to  be
made through the integument immediately above the
pubes, in the direction of  the linea alba.
   4thly, A  trocar and canula, of  sufficient length,
are passed through the opening in the skin, and then
thrust through the linea  alba, cellular  tissue,  and
fore part of the bladder into its cavity.
   5thly, The direction  of the trocar  should  be to
the basis of the sacrum, that is, a little upwards, and
not directly  downwards in a perpendicular line, as it
may then pass between the  bladder and  pubes; and
even if the instrument enters the bladder, as the or-
gan contracts it slips from the canula.
   6thly, The trocar is to  be withdrawn to allow the
urine to escape through the canula.
   7thly, A  male  flexible catheter  is to be passed
through the canula,  cut to a proper length, so as to
remain in the bladder, and  it is to be secured so as
to prevent its escape.
   This operation is easy  of performance, requiring
little anatomical knowledge, and  has therefore usu-
ally had the preference given to it.
   After-treatment.—When the inflammation follow-
ing the operation has subsided, when all danger from
"Xtravasaticn  of, urine  into the cellular  membrane 
233
has ceased, and the patient recovers his health, it is
right to begin attempts  to re-establish the urethra
by the use of bougies, sounds, &c. and this may be
generally effected.
   Case.—I saw a man from Essex, below Maiden,
whose bladder  had  been successfully  punctured by
Dr. Hare, above the pubes, twelve months  before,
and who came to town to consult me, with a female
catheter still remaining in the bladder, in the same
opening at which the urine had been drawn off.  1,
after a time, succeeded in passing a catheter into his
bladder  through the urethra, the female catheter
was removed, and he returned into the country with
the wound above the pubes quite closed.
   Objection to  the operation.—An  objection to this
operation, formerly urged,  was,  that  the canula re-
maining  in  the bladder  produced  irritation : this is
obviated  by  the use of an  elastic gum catheter, in-
stead of the  metallic one.

    OF PUNCTURING THE  BLADDER BY THE RECTUM.

   Bladder forms a projection into the rectum.—When
the bladder is greatly distended, and has  not under-
gone any morbid change, it generally projects into
the rectum ;  so that if the finger be introduced into
the gut,  a fluctuating swelling is felt just beyond the
seat of the prostate  gland.
   When the prostate gland is enlarged, this part of
the  bladder  is more remote from the  anus  and less
accessible, although  still within reach.
   Part to be punctured.—Behind the prostate  gland
is a triangular space, bounded in the following man-
ner :—0n each side  by the vasa  deferentia and ve-
siculae seminales  meeting at the prostate ;  and the
peritoneum is the  boundary behind.   In the centre
of this space a trocar  and canula  may  be passed
   vol. h.         29 
234
through the fore part of the  rectum,  through the
cellular tissue  connecting it  to  the bladder,  and
through the coats of the latter into its cavity.
   If the centre of the space  be kept, there is no
danger  of wounding the vasa deferentia or vesiculae
seminales  if the bladder be distended.  The trocar
may be safely  introduced an  inch  behind the pro-
state without  risk of injuring  the  peritoneum, and
the vasa deferentia may be thus completely avoided,
whereas a puncture near the gland might endanger
them.
   Operation.—The  operation is  to be  thus per-
formed :
   1st,  The patient is to be placed on a high table,
so that  the surgeon can sit lower than the patient.
   2dly, The  finger is to be  passed per rectum to
the projecting portion  of the bladder  behind the
prostate.
   3dly, A trocar and canula, three inches long, arc
to be  passed upon the finger to the protruding part
of the bladder, and forced through the  fore  part of
the rectum and  posterior part of  the  bladder into
its cavity.   A curved trocar  has  been  advised and
employed, but it is quite unnecessary  if the silver
canula be  not suffered to remain.
   4thly,  The  trocar is  to  be  withdrawn, and  a
flexible gum catheter is to be passed through the
canula  into the bladder; the  canula is then to be
removed,  and the elastic catheter is to be confined
to a T bandage, or to a  tape passed between the
thighs.
  After-treatment.—When the patient has sufficient-
ly recovered from  the  inflammation which the dis-
ease and operation  have  produced, it will be  right
to begin with re-establishing the urethra.
1   This  operation is  easily  performed; but  it  is
decidedly   objectionable,  on  account of  the  urine 
235
being  liable to produce a  diseased  state  of the
rectum.
  Dr.  Cheston,  of  Gloucester, told me that he had
seen great disease of the intestine occasioned by it.
  I  was sent for to a patient  who had  undergone
this operation for a retention of urine from a disease
of the  prostate gland.  The bladder had been  punc-
tured just before my arrival, yet I easily passed a
catheter into his  bladder through  the urethra.  I
mention this to shew how little  the operation, was
required,  and that  the  enlarged gland did not pre-
vent the introduction of the catheter.

           OF THE  OPERATION IN  PERINEO.

  The neck  of the bladder  around the  prostate
gland is devoid  of  peritoneum;  and,  excepting the
posterior  surface,  where  the  vasa deferentia and
vesiculae seminales  are seated, there is no important
part which  can  be  injured by a puncture.
  Requires  anatomical  knowledge.—This  operation
requires more anatomical knowledge than  the two
which I have described; it is more difficult  to per-
form,  and much more care is required to preserve
the  opening  into  the  bladder;  yet,  to  a scientific
surgeon, even this presents but little difficulty.   Mr.
Cline  used always to advocate its performance.
   Operation.—The steps of the  operation are  as
follow:                           .      .        .
   1st,  An  incision is to be made  in perineo,  as  in
the  operation for  the  stone, and it is to be carried
to the bulb  of the urethra, where it is covered by
the  accelerator urinae.
   2dly,  The bulb is to be pressed by the finger  to
the  patient's  right side, and the incision is then car-
ried onwards between the bulb and left  crus of the
penis, as  far as  the prostate gland. 
236
  3dly, The surgeon is to pass his  finger into the
wound as far as the left side of the  prostate  gland,
so that it  may serve as a guide to  the canula and
trocar.
  4thly, The trocar and  canula  are to be  pushed
into  the cavity of the bladder, by the  left  side of
the gland.
  5thly, The trocar being withdrawn, the  canula
is left m the bladder to allow of the  escape of the
urine.
  bthly, Through the canula an elastic gum  ca-
theter  is  to be  passed  and  secured, as in the for-
mer case.
  Subsequent treatment.—When the patient  has  re-
covered sufficiently, the natural canal is  to be opened
by the  use of a sound or bougie ;  and in all cases of
considerable difficulty, when the urine  passes freely
by  the artificial  opening, a  caustic  may  be safely
employed.
  Other modes of relief.—Having described the dif-
ferent operations which are performed  for the relief
of a patient having  retention  of  urine, I shall now
proceed to point  out the practice  which I  have my-
self pursued in these cases.
  Most frequent causes of retention.—I must premise,
that 1 consider,  from the  experience I have had in
this  disease, that nine tenths of  the  difficulties  in
passing the urine  arises from strictures of the urethra,
or from enlargement  of  the prostate  gland : with
respect to  the latter, I have never yet seen a case in
which I could not pass a catheter, made  of proper
form and  size, although I do not wish to  be under-
stood to say, that there never can be  such a case ;
but  only,  that in the course of a very  extended  ex-
perience I have  never found an instance of it.   I
shall  say   more  upon  this subject when I speak of
the  diseases of the prostate gland;  but shall now 
237
return to describe the mode  of relieving retention
from diseases of the urethra.
  Preferable operation.—The  operation which I pre-
fer is, to open the urethra only, and not to puncture
the bladder, which  I hold, in the male, to be scarce-
ly ever necessary.
   Case.—One  night, when giving the surgical lec-
ture at St. Thomas's Hospital, a  dresser  of Mr.
Chandler's, then surgeon to the Hospital, came into
the Theatre to inform me that a patient was labour-
ing under retention of urine from the use of a caustic
bougie ; that the man was in great  pain,  and that a
catheter could  not be made to pass  the stricture.
1 said,  " I  will go with you into the ward after lec-
ture, and  do  what is necessary."  The  pupils  ac-
companied  me.  Upon examination of the man, I
found  that the stricture  was  seated in that  portion
of the urethra which was covered by the scrotum.
I tried to pass different  instruments, but  could  not
succeed.
   Reflecting  upon the  case, it appeared to me to
be exposing the patient  to  unnecessary pain  and
danger if  I punctured  his distended  bladder;  as,
when  I directed him to make attempts to discharge
his urine,  the  urethra swelled  excessively  behind
the stricture,  from  the  urine  passing as far as its
seat.  I therefore  determined  to make  an incision
into the  urethra  only,  which I immediately  did,
being  directed to the place by the  distention which
an-attempt to void  the  urine produced.   The ure-
thra was opened behind  the  scrotum, and the urine
readily discharged.   The patient rapidly recovered
without any bad symptom.
   I was also induced to act as I have described, by
the following case.   I was sent for  early one  morn-
ing to visit a patient with retention of  urine, who
had a cicatrix  at the extremity of the urethra, from 
238
a chancre ;  for some time the urine had passed in a
great degree by drops;  and when in  a stream, in
one  not  larger than a hair.   When I saw  him, the
urgency  to  make water was excessive, but  not  a
drop would pass, yet I found that it distended  the
urethra as far as opposite  to the situation  of the
fraenum.   I therefore immediately passed  a lancet
through the cicatrix in the usual seat of the meatus,
and so soon as I penetrated the glans the urine rush-
ed by the sides of the lancet.
  Case.—Mr. Robert Pugh, of Gracechurch Street,
sent to me to visit a patient of his who  had a reten-
tion  of urine from  stricture  in the  urethra, which
no instrument  would pass.  Upon  directing him to
try  to micturate, the urethra  could be  felt  to swell
behind the stricture, and I  passed a lancet into it
behind the  obstruction.  The urine directly flowed
through the opening.
  I  now never open  the  bladder, but merely do
as I  have above described;  and I am happy to say,
that  some of my surgical friends,  at our Hospitals,
have repeatedly adopted the same  plan, and suc-
cessfully.
  I sometimes introduce a female  catheter into the
urethra through the wound, to prevent extravasa-
tion  and  to permit  the easy  passage of the urine,
but this is not absolutely necessary.
  Objections  to the  operation.—This operation  has
been objected to, on the supposition that it requires
great anatomical knowledge, and is very difficult to
perform :—to the first  objection I will  say, that he
who is adverse to an operation  because it requires
anatomical  knowledge, should immediately give up
his  profession; for  if surgery be not founded upon
an accurate knowledge of anatomy, it will be better
for mankind that there should be no surgery, as dis-
ease will  proceed better with the natural  means of 
239
relief, than with the aid of those surgeons  who are
not anatomists.
  Difficulty obviated.—With respect to the  difficulty
of the operation, I would say to him who finds any,
pass a catheter or staff to the stricture, and, direct-
ed by its point in making the incision, carry it an
inch behind,  and  in a line  with the point of such
director, and the difficulty will vanish.
  The state  of  the urethra in stricture is very dif-
ferent to that which exists  with fistula in perineo:
in the former case it is large behind the obstruction,
in the latter it is contracted and very difficult to find.
   Little danger in this operation.—By the  mode I
have advised, the danger  of  retention  of urine  is
almost entirely dissipated, for opening of the urethra
will be  rarely followed by fatal effects.

      OF RETENTION  OF URINE IN THE FEMALE.

   Puncture rarely necessary.—The puncture of the
bladder is rarely required in the female; and when
it becomes  necessary,  the surgeon can hardly hesi-
tate in  his choice of  the mode he shall adopt.
   Different modes.—It might be performed through
the vagina, or it might be executed  by  the side  of
the meatus between it and the branch of the pubes
in some cases ; but the former would  probably cause
a fistulous orifice, by  which the  urine would con-
stantly  irritate  the vagina, and the latter would for
some causes of  retention be impracticable.
   Above the  pubes the  best.—The operation above
the pubes appears to be, in all  respects, preferable
to  any  other ; the steps of  it are  the same as those
in the male, and therefore there  is no necessity for
 my again describing  it. 
240
           OF  AMPUTATION OF THE  PENIS.

   When necessary.—This operation is  occasionally
 required for a  cancerous state of the part.
   Disease commences  in the prepuce.—The  disease,
 which renders the operation necessary, commences
 sometimes upon the prepuce  and  sometimes upon
 the glans.
   1.  When seated upon the prepuce, it begins on a
 pimple,  surrounded by a  hard base;  it ulcerates
 slowly and discharges  a bloody serum,  occasionally
 with  a  mixture of pus.   At  first, slight irritation
 only  attends it; and,  after a time, the patient ex-
 periences sharp  darting pains.  As the disease  ex-
 tends, a large portion of the prepuce  participates in
 it; and if it  be long suffered to proceed, a gland in
 one  or both  groins becomes affected.   A phymosis
 is gradually  produced, and a  division  of the  skin
 must  be  made, to ascertain the exact nature  and ex-
 tent of  the disease; and if the complaint  be decid-
 edly  cancerous,  it will be best   to  complete  the
 operation at once, by cutting away the whole of the
 affected prepuce by a circular incision,  and  then se-
 curing the divided  vessels.   When  the  bleeding has
 ceased, a poultice should be applied, with which  the
 wound heals  better than by any other dressing.
   Commencing  in the glans.—2dly, When the  dis-
 ease begins  upon the  glans penis,  it usually  makes
 its appearance  in the form of a wart, attended with
 considerable  irritation, and a discharge of  serous
 fluid.   The   wart  ulcerates,  and  the  surrounding
 parts  acquire a great  degree of hardness and swell-
 ing.   Other warts,  of a similar  nature, are  produc-
 ed, so that the ulcers  become numerous:  they also
 extend deeply,  and phymosis is occasioned  by  the
surrounding  tumefaction.   Great impediment arises 
241
to the passage of the urine, but at length  apertures
form from the urethra  through  the  skin of the
penis : the patient suffers from irritation of the raw
surfaces by the urine, and the disease is accompani-
ed  with  those lancinating and shooting  pains, which
usually attend cancerous affections.
   If the prepuce be slit up, the whole glans is found
swollen,  and excessively hard; and the penis, from
the  number  of  its  warty  excrescences,  and from
their eversion, has somewhat the  resemblance in its
appearance to the cauliflower.
  State of the corpus spongiosum.—The corpus spon-
giosum  and the urethra  are diseased nearer  to the
pubis than the glans, and the surgeon must examine
with care  the extent of the complaint in that direc-
tion.
  Hasmorrhage.—Free  haemorrhage from  the ulcer-
ated surfaces occasionally occurs, the  glands  in the
groin become  enlarged,  and  sometimes several  in
each groin; and when this happens all hope from
surgery has vanished.   The glands sometimes ulcer-
ate  and produce a  very  troublesome sore, with
everted  edges and irregular  surface, a serous dis-
charge, and sometimes free haemorrhages.
  Destruction of the penis.—The  penis  continues
ulcerating  until that  part which is naturally pendul-
ous  becomes  destroyed,  occasioning  retention of
urine, and  great  difficulty in its discharge  at other
times.   The urine passing in various directions ex-
coriates the scrotum, and leads to a most painful but
lingering termination of existence.
  Frequent  cause.—This  disease is often the  result
of a natural phymosis,  leading to  a confined and ir-
ritating   state  of  the   secretions  of the  glandulae
odoriferae; and, when  the constitution  becomes un-
healthy,  to the  production of unnatural actions in
the part.
  vol. n.               30 
242
   Medicine of no service.—As to the  treatment of
this disease, nothing is to be done by  medicine or
applications, but to  tranquillize the  parts and  to
keep them clean.
   Irritating applications prejudicial.—All  irritating
applications should be avoided.  Poultices, ointments
of bismuth, lead, chalk, opium,  zinc, may  be alter-
nately employed,  as  that  previously  used  loses  its
effect.
   Arsenic.—Arsenic I have tried in these cases, but
have never succeeded with it; on  the  contrary, it
has greatly irritated  and made  the sore more  ex-
tensive and the warts more numerous.
   Removal.—The only means by which  the effects
of this dreadful malady can be averted, consist in the
early removal of the diseased portions of the penis.
   It  is required, in doing this, that the surgeon pro-
ceed  somewhat beyond the exact  limits of the dis-
ease ; more especially must he  examine with  care
the  urethra and corpus spongiosum, in which the
complaint is usually most extensive.
   The operation is dreadfully  painful,  but it lasts
only for a moment.
   Operation.—Its steps are as follow :
   1st, Draw forward and elongate the penis as much
as is possible.
   2dly, Tie a piece of narrow  tape  tighly around
the penis at the pubes.
   3dly, Make a direct cut through the penis, be-
hind the disease, without any attention to preserving
the integuments to cover the corpora cavernosa and
corpus spongiosum ; for to do so is a great evil,  by
preventing a free escape of the urine.
   After-treatment.—4thly,  Tie a tape tightly around
the remaining part of the penis, and  make  pressure
upon it, and there  is no necessity for securing any
blood vessel. 
243
  When the bleeding has stopped, remove the tape
and apply lint upon the wound.
  In a few hours, the  necessity of micturating will
remove  the  dressings; and when  the. danger of
bleeding has ceased, a  poultice  should be applied as
the best means of exciting granulation and of healing
the sore.                                      .
  Introduction of bougie.—When the surface begins
to granulate, a  piece of bougie, two  inches long,  is
to be worn constantly  in the urethra,  to prevent its
contraction, otherwise it  gradually  closes  as the
wound heals, and produces retention of urine. 
244
             LECTUKE XXVI.

               OF FISTULA IN ANO.

  Definition.—This  is an  abscess  of the  cellular
membrane, near to  the rectum,  which produces an
aperture into the  rectum, or by the side of the anus.
  Difficult to heal.—If it be asked  why this abscess
is so much more  difficult to  heal  than  others, and
why it frequently requires an operation;  the answer
is, that from  its vicinity  to the  rectum,  it  is influ-
enced by the action of the  sphincter and levator ani;
and that these muscles have  a constant  tendency  to
prevent the union of the granulations and coalescence
of the sinus.   It therefore  rarely happens, but that
the surgeon is required to assist  nature in the resto-
ration of the parts  to a healthy state, by dividing
the sphincter, and thus destroying its influence upon
the sinus.
   Symptoms.—The  symptoms  of this disease are,
pain near the anus, with considerable  hardness, bear-
ing down, and tenesmus upon going to stool, and dif-
ficulty in the evacuation; throbbing and darting pain
in the rectum, and on the  diseased side of the nates.
A fluctuation is  perceived; and if the  case be left
to nature, the abscess breaks either into the rectum,
and the matter and blood are discharged  with the
faeces,  or  it breaks  externally near the anus, but
sometimes at a  distance from it, either in the peri-
neum or in  the nates.   The  matter which issues
from the abscess is  sometimes excessively putrid, ex- 
245
tricating a considerable quantity of air, and is highly
offensive.
  Discharge  of the matter.—The fistulous  orifice,
when it is formed into the rectum only, is the most
difficult of management, because the orifice is with
difficulty discerned.   When the abscess breaks both
externally and into  the rectum, it  is  most easy of
treatment; but it generally discharges itself only ex-
ternally ;  and a probe,  when introduced, passes to
the side of the  rectum,  sometimes to the external
surface of the intestine, at others from half an inch
to an inch from it,  so that  the original seat of the
matter is in  the cellular  tissue  surrounding the rec-
tum.
   Extensive  sinus.—I have  several times known a
sinus form on each side  of  the anus, and communi-
cate around the rectum, of which we have a prepa-
ration in the collection of St. Thomas's Hospital, so
that  the  rectum  has been considerably separated
from the surroundingyparts.  I examined a man who
died of a discharge from  a sinus  in the  groin, and
who had a fistula in ano ; and upon tracing the sinus
in the groin, it passed under Poupart's  ligament and
took the course of the vas deferens, and descended
into the fistula in ano.
   Small sinus.—Sometimes the sinus only just reaches
 the sphincter,  and is extremely  small, at first ap-
 pearing only as a suppuntion of one of the follicles
 of the anus.   Sometimes the  matter burrows four
 inches by the side  of the rectum.
    Caused  by a pile.—The  abscess has, in some in-
 stances, its origin in a suppurating pile.
    Origin sometimes local.—Fistula in ano is, in a few
 instances,  a local  disease, depending upon a change
 in the part itself;  but is  much  more frequently the
 result of distant visceral complaints, and of a broken
 state of the constitution. 
246
  How produced.—When confined to the  part,  it
arises  from obstinate costiveness and  the efforts to
discharge the faeces ; and the passage  of  an indura-
ted stool  produces inflammation of the muscles and
cellular tissue of the rectum.   But the  opposite state
to the above I have several times known produce it;
thus, in a severe diarrhoea, which  determining large
quantities of blood to the rectum, and  being accom-
panied with tenesmus, is followed by inflammation
and suppuration at the extremity of the rectum.
  But the  more common cause is disease  of the
liver,  which, preventing  the free return  of blood
from the intestines, leads to inflammation at  the anus,
and by influencing the secretions  for  the intestines,
occasions a similar effect.
  Diseased states of the lungs are also frequently giv-
ing rise to it, from the impediments they produce to
the free  return of blood, local  venous congestion is
produced: piles are  a common effect, and abscesses
at the anus frequently follow.
  Connected with phthisis.—Often, therefore, before
a person perishes from  phthisis, he has  a  fistula in
ano; and this is the  reason  fistula is considered as a
dangerous  disease;  althoughiin reality it is  not so,
but it is the consequence of more important diseases,
which destroy life.
  The surgeon often brings  discredit  upon  himself
by  operating  in these cases in the  last  stage  of
phthisis, when no operation ought to be performed,
and Avhen it is impossible the disease can be cured;
therefore that death, which  is the result of pulmo-
nary disease, is  falsely attributed to  the  fistula in
ano.
  Treatment medical.—The medical  treatment  of
this disease consists in restoring the secretions of the
liver and intestinal tube, by submurias  hydrargyri, or
pil: hyd: at night, and infos: o-kotia^ae comport urn. with 
247
soda and rhubarb, twice in the day ; and if there be
any  pulmonary  or  pectoral disease,  its  treatment
must  precede, and its cure be performed, before any
active local means of treatment be had recourse to.
The strength  of the patient  must also be restored
before any  operation be   performed,  or the wound
will not heal favourably.
  Local.—If a  patient applies with a tumour near
the anus,  threatening the production  of an abscess,
and the general health be tolerably good, its treat-
ment is to be as follows:—apply leeches to the part,
and let a  lotion of the acetate  of  lead be constantly
kept  upon  the surface.   Give to  the patient  the
confectio  ssnnae with sulphur,  as the most  gentle
aperient; all drastic  medicines exert  too much ac-
tion of the muscles  of the rectum, and determine
blood to the anus, so as to add to the irritation and
increase the disposition to suppuration.
   To be opened  early.—If the swelling increase and
become more painful,  apply fomentation and poul-
tice to the  part.   When a fluctuation can  be per-
ceived, put a  lancet into the  swelling, as  an early
opening prevents a large collection of matter, and I
have known the wound  immediately close  and  no
fresh accumulation follow.
   If it break by natural efforts, it is best to suffer it
to discharge and to fill by granulating, to make the
sinus as  small as possible before any operation  be
performed.
   The sinus very rarely  heals  entirely  by natural
processes, because, so soon as its sides adhere, they
are  pulled asunder by  the action of the sphincter
ani, and union is thus constantly prevented.
   Four states of fistula.—There  arc  four variations
of the fistula, as regards  the operation.
   Operation for the first.—The first is that in which
the abscess breaks  into  the rectum and near to the 
248
 anus; and  the operation consists in the following
 steps:  introduce a probe into the sinus, by the side
 of the anus, and carry it into the rectum, so as clear-
 ly to ascertain the course of the sinus, and to learn
 if any part of it extends above the opening into the
 rectum.  Then introduce the director, and pass the
 probe-pointed history of Mr. Pott through the sinus
 into the  rectum.  The finger  covered with oil is
 next to be introduced into the intestine, and is to be
 placed upon the extremity of the probe-pointed his-
 tory; then, if the sinus  be of  considerable length,
 the  finger and  knife are brought out together, so
 that the knife cuts the intestine  and sphincter  as it
 is withdrawn.  If any portion  of the  sinus  remain
 above the opening into the  rectum, it should be di-
 vided with the probe-pointed  scissors; one blade of
 which is passed into the extremity of the  sinus, and
 the other into the  rectum, and  then, by shutting
 them, the sinus  is divided.  If the opening into the
 intestine be situated only a  short distance  from the
 anus, the end of the history,  may be first brought
 out  at  the  anus  and the operation  completed by
 pushing the knife forwards.
   Second  state.—The second state  of the sinus  is
 that in  which the opening is only at  the anus; and
 when the probe is passed into it, it is felt at the ex-
 tremity of the sinus,  at some distance from the  rec-
 tum.
   Operation.—In this case, what I do is this:  I pass
 the  probe-pointed  history to the extremity of  the
sinus and  my finger  into the rectum.   I then, with
the extremity of the finger and the finger-nail, move
the rectum upon the blade of the knife near its pro-
bed extremity, and sometimes move the knife a little
 at the same time.   Thus I easily make the knife
divide  the intermediate parts, and  then  bring its
 probed point into the rectum, when the operation is 
249
concluded as in the first case.  I have known, in this in*
stance, the division made by the sharp-pointed curved
history;  but the objection to it  is,  that its  point
rarely takes the course of the sinus :  then a portion
is left undivided.
  Savigny,  an ingenious  instrument maker, made a
double history, with a pointed  and a. probed knife :
the one sliding by the side of  the other.  When it
was introduced the sharp-pointed  history was thrust
forward, and then retracted, and the probed history
succeeded it; but  the objection  to this  instrument
was,  that it was too large for its easy introduction
into the sinus, and it is really quite unnecessary.
  Third state.—The third state is, that where the
sinus enters  the rectum, and has no external opening.
It is required, if  the orifice cannot be felt by  intro-
ducing the  finger into the rectum, to wait until an
accidental inflammation leads to the capacity of feel-
ing a  swelling externally,  when  a  lancet should be
put into it from the side of the anus.   A probe be-
ing introduced, it passes into the suppurating cavity
communicating with the rectum.
  Operation.—In this case it will  be proper to per-
form  the operation which has been described for
the first  state  of fistula  when  there is  an opening
externally, and within the rectum.
  Fourth state.—The fourth and last state is, that in
which the sinus or sinuses extend from the anus into
the nates.
  Operation.—The  practice  I pursue  is,  then  to di-
vide the opening in  the nates  through the external
skin,  but leave that  near  the anus at first undivided,
and when I  have healed this part,  then operate upon
the other in the same manner  as in the  second kind
of fistula.
  vol. n.              31 
250
       OF TREATMENT AFTER THE OPERATION.

  Local.—When the fistula has been divided, put
dry lint into the wound, and compress  the part until
all bleeding has stopped.  On the following morning
apply a poultice, and in  two or three days the lint
will  separate. . Then  pass  a probe into the wound
often, to prevent the union  of the sides of the sinus
for five or six days from the operation, and continue
to poultice;  but after this  time, when granulations
arise, it is right to introduce lint into^the wound, and
prevent their inosculation, until the wound, gradually
granulating every where, the cavity becomes filled.
If lint be introduced  into the wound on the second,
or third, or following days from the operation, great
pain is given,  and much inflammation  is excited, so
that there is danger of fresh suppuration:  wait,
therefore, until  the  inflammation  has ceased, and
then introduce but a small quantity of lint, and with
great gentleness.
  Constitutional.—If the sore be very indolent/occa-
sionally purge the patient, and give  him the confec-
tio piperis, which produces  very healthy  granula-
tions, and apply to the wound lint dipped  in a solu-
tion of the sulphate of  copper, or spread with the
unguentum hydrargyri nitrico oxydi.

            OF  INJECTIONS FOR FISTULA.

  Of the cure by injection.—Although, as it will be
readily believed, I have seen a multitude of cases of
fistulae,  I have only known two cured by injection,
which were as follow.
  I  was attending,  with  Mr.  Pugh, surgeon, of
Gracechurch Street,  a  lady, in  Fenchurch  Street,
who had a fistula on each side of the anus.   I open-
ed one fistula, and cured it; but the  patient would 
251
not submit  to the operation upon  the other.  Mr.
Pugh and I  therefore agreed  that we  would  try
other means, and we injected  into the sinus with
oxymurias hydrargyri, the  liquor calcis gr. 1. ad 3j.
and the sinus healed.
   Case.—The second case was a gentleman from the
North, a friend of Lord Harewood, who had been
under the care of Mr. Hey, of Leeds, for a fistula
on the right  side of the  anus, and  who came to me
for advice.   The fistula was of great depth and dis-
tance from  the rectum  upon the  opposite side.  I
feared opening it, both from the delicate health of
the patient,  and the danger  of haemorrhage;  and
therefore threw into the sinus equal parts of  port
wine and water.  My nephew, Mr. Bransby Cooper,
finding it did not bring on sufficient inflammation, in-
jected port  wine,  undiluted, and thereupon inflam-
mation followed; adhesion  was  produced, and  the
case terminated without further alteration.

               OF SETON FOR FISTULA.

   Of the cure by seton.—Timid  persons prefer  this
mode of treatment to the knife, although  in the  one
case the irritation is long continued, and in  the other
the pain is only of a few minutes continuance.
   That it succeeds, in some instances, I have known;
for some of  my patients,  having submitted  to  this
remedy, returned to me well.
   My  objection to it is, that  the  irritation it pro-
duces is liable to occasion  other  abscesses, whilst
healing that for which it is employed.

             OF PILES  OR HEMORRHOIDS.

   Two states.—These are found in two states,  viz.
a varicose enlargement of a vein; or an excrescence
arising from its adhesion and organization. 
252
   The first is external or internal.
   Of the external—The symptoms  of  the first  are
 an external  swelling,  which feels round and  hard,
 which is  painful at the passage of the stools :  is hot
 and itches at other times.   It  sometimes bursts, and
 discharges blood  with the stools.   In  a few days it
 declines and disappears.   Sometimes it becomes in-
 flamed,  and very acutely painful;  and it  now  and
 then suppurates,  and  lays the foundation of fistula.
 If cut  into  before suppuration, a  large  and very
 solid clot of blood passes from it.
   Repeated returns  of this complaint engender an
 excrescence, which arises  from the swelling having
 undergone adhesion, and  becoming  organized, form-
 ing a cutaneous tumour which is very vascular.   The
 skin over it is  thin,—the  substance very  irritable,
 and  pains shoot from  it  into  the  rectum  to a con-
 siderable height from the anus.   I have  known a
 person confined to her bed from the excoriation and
 suffering  produced by such excrescences originating
 in external  piles.
   Internal.—The internal  piles are originally  en-
 larged veins:  they  produce pain about the sacrum,
 bleed frequently, and render the  passage of  the
 motions  difficult; and the stools are   often mixed
 with blood.
   At length many of  these become obliterated  by
 adhesion, and form very vascular pendulous tumours
in the entrance of the rectum.
   Occasion prolapsus ani.—They often  occasion pro-
 lapsus ani;  the patient feels as if there  was  more
 motion to discharge, and he forces  the  rectum until
 a part of it  becomes everted,  and the internal piles
 appear  externally, thus  producing  prolapsus ani.
 The  patient, after each  evacuation, is obliged  to
 return these with the finger;  the  evacuation is in
 consequence highly painful, tedious, and very  often
 the return of the part  is exceedingly difficult. 
253
   Profuse hemorrhage.—The  bleeding  from  the
piles thus everted is  often so profuse, that  the
weight of the  blood   exceeds that of  the  faeces.
The)  sometimes  vent  a considerable serous  dis-
charge.   When the number and  size  of  the  piles,
and  the degree  of prolapsus becomes great,  and
there is much difficulty in their return, inflammation
sometimes arises in them, and their return is render-
ed impracticable, without giving an unjustifiable de-
gree  of pain.  When  in this stcrte, in  addition to
other  sufferings, the urine  is  retained, the  faeces
pass with extreme  difficulty,  and there  is a free
sanious discharge  from the  part.   When thus in-
flammation is the  result of a  strangulation of the
piles from the pressure of the  anus, it is immediate-
ly relieved by the  return of the  parts ;  but  often
the inflammation precedes the descent, and then the
parts are too tender  to be returned.   It now and
then  happens that by this process  nature effects a
spontaneous cure of the disease ; the parts proceed
to gangrene,  and a slough of the piles is produced,
the  rectum ceases  to  prolapse, and at least  for a
great length  of time the patient is rid of  his  com-
plaint.
   Causes, sedentary habits.—The usual cause of piles
is a sedentary habit, which leads to  congestion of
blood in the vessels of the rectum.
  Diseased liver.—A diseased  state of the liver is
also a cause,  by preventing a free return of blood.
  Obesity.—Obesity occasions them, by the pressure
of the  omentum and  mesentery  upon  the mesen-
teric veins.
  Pectoral disease.—They,  like  fistula in ano, fre-
quently arise from pectoral complaints, which  affect
respiration and the freedom of circulation. 
254
   OF THE TREATMENT OF  PILES OR HEMORRHOIDS.

   Of the external.—If a patient applies with  an ex-
ternal  pile,  open his bowels  freely with confectio
sennae and sulphur.  Apply leeches to the parts, and
a lotion of acetate of lead.  If, when the inflammation
be subdued, the vein remains enlarged and hardened,
puncture it with a lancet,  and  discharge a large  and
very firm clot of blood which  it contains.
   If it suppurate, fomentation  and poultice will be
the best applications: and  when it bursts, if it shews
no  tendency  to  heal, it must be  opened  into the
rectum.
   Removing excrescences.—The excrescences  left by
external  piles are growths only of the skin, and they
may be freely removed when  they become trouble-
some.  Subdue the inflammation first, with  evapo-
rating lotions, and then  remove them by scissars, or
by the knife.  The former is  by far the most pain-
ful mode to the  patient, but most easily performed
by the surgeon.
  Do  not bleed.—These  excrescences  furnish no
bleeding  of any consequence.
   Mode  of removal.—I  generally pass a tenaculum
through  them, draw  them towards me, and cut them
off with a lancet.
   Treatment of internal piles.—The treatment of in-
ternal  piles is more difficult, and requires attention
to a number of circumstances.
   Medical.—First. The medical treatment demands
the exhibition of confectio sennae cum sulphure; the
bals: copaibae  is  also a good medicine,   if there be
hepatic congestion, gentle "doses of blue pill  should
be given, to restore  the biliary secretions; in gene-
ral,  however, mercury disagrees  in  piles:  Ward's
paste,  or confectio piperis of the London Pharmaco- 
255
pceia, is an admirable remedy, opening the  bowels
gently and contracting the dilated vessels; soda and
rhubarb I have  known  useful.   If  piles arise, as
they  sometimes do, from diarrhoea, the  confectio
opiata is the  best medicine.
  Local.—The local treatment, to prevent their in-
crease, is to inject cold  water into the rectum twice
per diem; a  dilute aluminous injection is also useful
combined with decoction of oak bark.
  Diet.—The  diet  must  be attended  to ; animal
food is better than vegetable, as occupying less bulk
to afford the same degree of sustenance, and conse-
quently presses less upon the returning  blood  ves-
sels.   Mutton  is the best butcher's meat.  White
fish is easy of  digestion.   All flatulent food should
be  avoided.   A  good  deal  of exercise  should be
taken;  and I have seen, in the incipient state of this
disease, horse exercise  of great benefit.
  Hasmorrhage.—When the  piles bleed,  the medi-
cine should be infusum rosae cum magnesiae sulphate;
cold water should be still injected.
   Prolapsus.—If prolapsus be  produced, it should
be  washed with a solution  of alum  and  oak bark,
and it should be returned by  a piece of linen dipped
in oil, or covered by ceratum cetacei.
   Inflammation.—When the piles  are inflamed and
a prolapsus  is produced, purge the patient once
freely; apply leeches;  foment and poultice the part,
and give opium as soon as the  purgative  medicine
has operated.  For two or three days let the bowels
be quiet: the  leeches, fomentations, and  poultices
being continued,  then purge again; for daily purging
adds to the inflammation and irritation.
   I have known the application of cold water to the
 prolapsus useful, also the acetate of lead lotion,  and
 the lotion mixed in a poultice,  agrees best upon the
 whole; although the  warmer  applications are the
 most congenial with the patients' feelings. 
256
   Puncture.—Spontaneous bleedings from the piles
 greatly relieve them; and  I have  therefore  some-
 times punctured them with  a lancet, with a view to
 the relief of the congestion of the vessels.
   However, all the  means which can be employed
 will not always prevent  their increase; nor when
 they are once suffered to  acquire considerable  mag-
 nitude,  and to produce  prolapsus ani,  can they be
 subdued by  any  medical or local treatment short
 of operation.
   Mode of examination.—To examine a patient pro-
 perly under these circumstances, and to enable you
 to form a correct judgment  of the necessity for, and
 the mode  of, operating,  it  is  necessary  that the
 patient should have an evacuation; and that, before
 the return of the prolapsus, the surgeon  should exa-
 mine the part.
   He will then observe  a portion  of the  rectum,
 forming the outer circle, and a number of round and
 dark-coloured projections, occupying the more cen-
 tral parts  of the  protruded mass.  The operation
 is then ascertained to be necessary or not, according
 to the degree of prolapsus and  the  number and size
 of the piles.
  Having determined that an operation  is required,
it is next to  be  considered  in  what manner it is to
be performed.
  Two modes of operation.—It may be  done by ex-
cision, or by ligature, or  it may  be effected  by a
combination of the two.
  Excision.—For excision, in the  early part  of my
surgical  career, I was a strong advocate;  for I found
it a less painful  operation than ligature, and it ap-
peared to me not dangerous; but as my  experience
increased, I was induced to change  my'opinion, and
to consider excision as not divested of danger.
  The three following cases arc proofs of this: the 
257
first, dying  of inflammation;  and the  second and
third from  haemorrhage.   I have  also  seen, in a
fourth case, extensive suppuration produced by ex-
cision.
   Case.—Mrs. O----,  the wife of a  respectable
medical man, came to London to have some  haemor-
rhoids  removed; and I advised their  excision,  ob-
serving, that her constitution  was of a feeble and
irritable kind.  I removed only one of three which
appeared.   In  three  days after  the  excision by
scissars, 1 found  her complaining  of great  pain in
her abdomen, from intestinal and peritoneal inflam-
mation :  she frequently vomited, and her abdomen
became tense.  The* symptoms were not relieved,
although motions were procured, and she died in a
week from the operation.  The internal surface of
the  intestine, and  the  peritoneum,  were inflamed
extensively.
   Case.—Mr. Esdaile came to London from Guern-
sey  or Jersey, in  order  to  have  a haemorrhoid
removed.   Mr. Leman  and I attended  him,  and I
removed a single pile by scissars.   On the following
day  he was exceedingly low, his pulse  small, so as
tobe scarcely perceptible.  On the  next he voided
a great quantity of blood from  his  intestines; and
on the day after he died,  falling a victim to  internal
bleeding, from the return of the divided  vessel with
the prolapsed intestine.
   Case.— The Earl of S----  applied  to  me  for
piles with prolapsus ani, and 1 removed  some of the
largest  with  scissars ;  the prolapsus  was  greatly
relieved; and for  more than twelve months after
he was little troubled, either  with haemorrhoids or
prolapsus.   About  two years afterwards he again
applied to me, for  a return of his complaint; and
seeing his  age,  and having examined  the  piles, I
thought before I operated, I would have a consulta-
   vol. n.          32 
258
tion, when  the operation  of excision was again re-
commended.  I removed with the scissars one of the
largest, and desired his lordship to keep the recum-
bent posture.   He laid down upon the bed  imme-
diately  after the pile  was  removed.  In about ten
minutes he said " I must relieve my bowels," and he
rose from  his  bed and  discharged into  the  close
stool what he thought to be faeces, but which proved
to  be  blood.   In twenty  minutes he had  the  same
sensation, and evacuated more blood than before, in
about  the  same lapse of time : he again  rose,  and
soon became very faint from the free haemorrhage.
I, therefore, opened  the  rectum with a speculum,
and saw an artery throwing out its blood with  free-
dom, I  therefore requested him to force  down the
intestine as much as he could, and raising the orifice
of the  bleeding vessel with a tenaculum, secured it
in a ligature, and  also compressed the artery with
a piece of sponge.   His lordship bled no  more.
On  the following day he was low, his  pulse  very
quick, and he had a shivering: on the next he  com-
plained  of pain in his abdomen; he  had sickness,
and tenderness upon pressure, and in four days he
died.   In the presence of  Mr. Wardrop I opened
his body, and found inflammation of the rectum, and
disease  of the glandulae  solitariae  of the intestine,
they being enlarged and hardened,  so that the  intes-
tine internally had a curious spotted appearance.
 He was not,  therefore, a healthy  or sound man in
other respects; and it is in such cases that unexpect-
ed symptoms arise after operation.
   Ligature.—-As a ligature  prevents the danger  of
 bleeding, it is best to use  it, although the process is
 more  tedious and painful.  The  pain which it pro-
 duces  may be  mitigated by not drawing the ligature
 too tight.   Draw down the pile with forceps, or a
 tenaculum, and tie a  piece  of waxed silk around  it, 
259
draw the knot  until the patient complains  severely,
then  tie a second, cut off" the ligature a little way
from  the knot,  and return the intestine and pile.
  Double ligature.—But  in  cases in which the pile
is very large, a safer and  less painful  plan may  be
adopted ; namely, to pass  a needle and ligature
through them, and to cut  ihem off beyond it.
  Operation.—The  mode of  operating  for  these
large haemorrhoids is  as  follows:  Draw down the
pile,  pass a needle, wilh a double ligature, through
its juncture  with  the intestine.   Cut  off the needle,
and the two ligatures will remain on the pile ; then
tie one above,  and the other below, and thus the
whole pile is included ; then cut off the  pile with a
lancet or scissars beyond  the ligature,  and  in the
evening or on the following day, the threads may be
removed, as all danger of bleeding  has ceased.
  By this operation haemorrhage is prevented, and
the pain is  exceedingly diminished, as the ligature
does not require  to be made very tight.
   The prolapsus ani generally soon ceases after the
complete removal of  the  piles ;  but if  it does not,
cold and astringent injections should be  employed,
and  the confectio piperis be given. 
2tH»
             LECTURE  XXVII.

             OF POLYPUS  OF  THE NOSE.

  Four kinds.—Polypi of the nose are of four kinds:
1st, The common pendulous polypus; 2d, The  hy-
datid polypus;  3d,  The  cancerous;  4th,  The  fun-
goid.

         OF THE COMMON PENDULOUS POLYPUS.

  Symptoms.—This disease is  marked in its com-
mencement by an occasional obstruction in the nose,
as if from catarrh; the obstruction being increased
in foggy and damp weather, and being greater early
in the  morning  and  late in  the  evening  than in the
middle of the day.
  Age.—Persons of all ages are subject to  the for-
mation of these polypi:  but it  is of more common
occurrence between the ages of forty and fifty than
at any other period.
  Appearance.—On looking into the nose, a jelly-like
appearance  is seen, which, upon directing, the pa-
tient to inhale through the nostrils, recedes, and upon
his  exhaling advances and re-appears; the  degree
of  motion,  however, necessarily  depends  on  the
magnitude of the  polypus compared  with  that of
the nostril.   The voice has a nasal sound, and there
is generally  some uneasiness felt  between the eye-
brows, in the situation of the frontal sinuses.
  Seat-—TN; poll pus grows  from that  portion of
the txhi.c .  . .1,. mc carane vvh.;;;; is situated upon
the same side with  the  turbinated bones.  I  have 
261
never yet  seen a polypus growing from that cover-
ing, the septum narium.   The  body of the polypus
is generally yellow, and is streaked with few vessels.
Its neck diminishes often to a very small stalk. Now
and then two or three  polypi  grow  from a  single
stalk.  When a polypus becomes very large, instead
of advancing to the nostril it recedes into the throat,
appearing behind the velum palati;  and sometimes
when it grows from the back of the nares, it makes
its first appearance in the throat.  It here becomes
of very considerable size, and at length would rea-
dily allow  a ligature  to be passed  around it;  but
this, as I shall presently  describe, is not  the best
mode of its removal.  When it appears in the throat,
1 have seen its  body divided into  a  number of  dif-
ferent  portions.
  In the collection at St. Thomas's  Hospital, their
great size  and  broken  surfaces are well  seen in
many preparations, as well as their origin  from  the
pituitary membrane.

                OF THEIR  REMOVAL.

  An operation necessary.—No other mode than an
operation will  succeed in  removing these excrescen-
ces.   I  have  repeatedly  tried the  application of
caustic;  but  it  only  acts upon  the surface,  and
the root grows  faster than that surface can be  de-
stroyed.   Aluminous  and  other astringent  applica-
tions render the breathing a little more free  at  the
moment, but produce no permanent  relief.
  Three modes.—Three modes have been proposed
for  their removal: 1st, by laceration;  2d,  by exci-
sion ; 3d, by ligature.
  1st. By laceration.— 1st, Laceration is  the  usual
mode.   For this purpose,  a surgeon should be pro-
vided with two pairs of forceps;  one pair slightly 
262
curved, terminating in a point hollowed at the end,
and that hollow containing pointed teeth, having an
aperture in each blade.  A second pair, formed like
common dressing forceps, only the blades longer and
more slender, having serrated  teeth,  received be-
tween each other like a serrated suture of  the skull.
These can be received into the smallest nostril, and
readily made to act in any part of it.
   Operation.—The operation is performed  as fol-
lows : the patient sits upon a chair opposite a strong
light, a probe is then  introduced into the nostril, and
the surgeon feels with it the exact situation of the
stalk of the polypus; then withdrawing the  probe, he
passes the forceps to  the stalk, and, enclosing it be-
tween the blades, with very gentle jerks,  he either
tears  through the stalk,  or draws away the  portion
of membrane from whence it grows : instead of re-
moving it by jerks, the  surgeon  may turn  the in-
strument upon its axis, and  thus  lacerate  the  stalk
of the polypus.   Now and then a thin  film of  bone
separates with  the pituitary membrane, which  only
more effectually secures  the  patient from  a return
of the disease.
   If more than one polypus exist  in  the  nostril, a
separate operation is required for each  ; and if they
exist upon each  side, the operation may be perform-
ed on the same day in each  nostril,  for there  is no
danger in this  operation.  I never knew but one
 Eerson die in  consequence of it;  he had previously
 ad some disease in the brain, a piece  of lint  was
placed in the nostril,  after the  operation,  and  this
gentleman died a few days after of inflammation of
the brain.  It is better not to introduce lint, or any
extraneous substance  likely to  produce  irritation,
immediately after the operation.
  No serious haemorrhage.—The haemorrhage which
results from  this operation  never amounts  to any
serious quantity. 
263
  As the disease is liable to return, when the in-
flammation succeeding the operation has subsided,
aluminous injections may be used, or  the liquor cal-
cis with oxym:  hydrarg: to lessen the disposition
to the return of the complaint.
  To remove them from the posterior nares, I  have
used curved forceps, introduced behind  the velum;
but they do not  answer so well as the mode I  have
next to describe.

           OF THEIR REMOVAL BY EXCISION.

  2d, By  excision.—#This operation  requires a pair
of scissars with probed extremities, made  straight,
with long and slender blades.
   Operation.—The patient being placed as in the
former operation,  the scissars are at first introduced
shut, in order  to  ascertain  the  attachment of the
polypus;  and being  then opened,  the stalk of the
polypus is cut  through ; then  the  surgeon, closing
the other  nostril,  directs the patient  to blow  forci-
bly through that  in  which the operation has  been
performed, when  the  polypus  is immediately  eject-
ed ; but if  the  polypus appear in the  pharynx, the
surgeon divides the stalk in the same  manner as be-
fore, and  then putting his finger behind the velum
palati, he  with it  draws the polypus  away through
the fauces.  In that way the largest  polypi are  to
 be removed ; and I  have never seen  either danger
 or difficulty arise  from its performance ; but, on the
 contrary, have  several times  succeeded  when the
 forceps by the nostrils had been employed in vain.
   Objection to  this mode.—It has  been  objected  to
 this mode of operating, that very  considerable hae-
 morrhage is produced  by it; but this can only arise
 from  a very indiscreet manner of performing it,  by
 repeatedly cutting the pituitary membrane, which
 could hardly happen with probed scissars 
264
   Hd, By ligature.—The  third  operation, namely,
 that  by ligature, is now  very generally abandoned
 by surgeons, on account of the difficulty of its appli-
 cation, and the necessarily imperfect removal of the
 disease.
   Disease resembling polypus.—There is  a  disease
 in  children very frequently  mistaken for polypus,
 by men who have  not had much experience  in sur-
 gery.  It is* an elongation  of the pituitary membrane
 of  the  nose,  from relaxed constitution,  and from
 effusion of serum into the  cellular tissue of the part;
 it is red and very  vascular.  It appears more upon
 the extremity of the superior turbinated  bone than
 upon  the  inferior;  but I  have seen  it upon both.
 It sometimes becomes chronic.   It requires  altera-
 tive medicine, and  the application of a solution  of
 alum, or of  sulphate of copper,  or nitrate of silver,
 I have more than once known this disease removed
 by forceps cruelly and unnecessarily.

               OF HYDATID POLYPUS.

  Occurring in young persons.—The nostrils of young
 persons sometimes become filled with growths which
 appear of the hydatid or encysted kind.   They re-
 semble wetted hladders hanging within the nose, are
 unattended with pain, but  produce the inconvenience
 of occasional obstruction.   When pressed  with for-
 ceps they burst, and discharge a  mucus, somewhat
resembling that secreted by the  sghneiderean mem-
brane : the  cyst only is  removed by the forceps.
 The nose may be repeatedly  cleared of them by in-
strument:-, but they are  always regenerated.  By
continued growth they enlarge the nostrils, and de-
form the face.
  Two modes of removal.   By alum.—1  have seen
 the:n  removed in two monies: 1st, By the  use of a 
265
strong solution of  alum introduced on lint,  and con-
stantly worn; 2dly, By the daily application of the
muriate of antimony used by a dossil of lint through
the medium of a canula.  The first is  the prefer-
able mode ; but I cannot decidedly speak  as  to its
preventing the return of the  disease : they are  de-
stroyed more  quickly  by the  muriate of antimony,
but with much more  suffering.

            OF THE CANCEROUS POLYPUS.

   Occurs in elderly persons.—This is a disease of age.
   Symptoms.—It  commences with  obstruction  in
breathing, but is, at first,  unattended with  pain; as
the disease increases, the sufferings are  very  acute,
and not confined to the diseased part, but extend to
the different  branches of the fifth  pair of nerves,
striking sometimes into the brain itself.
   Sloio growth.—Its  growth is slow, and it is some
time before it produces any discharge ; but at length
it ulcerates, and discharges a  bloody serum.
   Colour.—Its colour is purple ; its  feel is firm.  It
sometimes bleeds with great freedom.   It sloughs,
and in its progress it produces great alteration in the
form of the  face, which  it  disfigures  horribly.  It
extends into the sinuses, and  frequently affects the
lachrymal sac.
   It often alters the roof of the  mouth,  producing
absorption of portions of the superior maxillary and
palate bones.
   Destroys life gradually.—It is  a long  time in de-
stroying life ; the latter days of  the patient cannot
but excite pity in the most unfeeling bosom.   Medi-
cine and surgery do nothing for this disease ; except-
ing  opium,  belladonna, hemlock, and  hyoscyamus
are administered locally and  constitutionally to miti-
gate,  in  some degree, the  patient's tortures; and
   vol. n.                33 
266
the dose of  the former is at last increased  to keep
the patient in a constant  state of torpor.

             OF  THE FUNGOID POLYPUS.

  Occurs at  all ages.—The fungoid  polypus occurs
at all periods of life ;  but the best case which 1 can
give of this  disease is the following.
  Case.— A  young gentleman  came to  my house
with a large purple excrescence projecting from the
nostril, which completely obstructed the passage on
that side.  I made a  cast of this  disease, which is
now in the   collection at St.  Thomas's  Hospital.
There was a copious discharge of  sanious fluid  from
it;  but the  disease was little painful, and  the gene*
ral  health was, at first, but little affected.   I passed
a ligature around the root of the polypus as high as
I could reach, and it sloughed away without haemor-
rhage.  I was gratified with the result of this ope-
ration, as the patient appeared to be greatly reliev-
ed ; but some  time  afterwards  I heard that the
disease had  returned, and that  it had been again re-
moved.  It  again grew, and  ultimately destroyed
life.  The head was examined, and the disease  was.
found  to have grown  from a very small  surface of
the pituitary membrane.
  Extends.—In general the disease enters the  diffe-
rent sinuses, affects the lachrymal sac, and ductus ad
nasum; bleeds copiously, but has not the pain ac-
companying  cancerous disease.   The  patient  dies
from copious discharge, the frequent haemorrhages,
and at last from nervous irritation.

     OF POLYPUS  EXCRESCENCES IN THE PHARYNX.

  I have seen two cases  of this disease.
   Case.—One in  a Spanish gentleman, who  came 
267
through Paris, where he consulted various surgeons;
and on his arrival in London, asked my advice for  a
polypus excrescence  in  his pharynx, of the colour
of  the mucous membrane of this portion of the ali-
mentary tube, beginning from  the fold over the pa-
lato-pharyngeus, and hanging down  like a sausage
into the pharynx.   By great efforts he could-regur-
gitate it into his mouth.  I requested him to permit
me to pass a ligature around its  root, w hich I suc-
ceeded in doing, without much difficulty, and it se-
parated in eight days.
   Case.—I lately saw  a  second case, with my ne-
phew, Mr. B. Cooper : it was similar to the former
in appearance, but not quite so large, and grew more
from the root of the tongue.  I  removed it also by
ligature, and both these cases completely succeeded.

             POLYPUS OF THE  RECTUM.

   I have  several times seen the following disease.
   Case.—A lady sent for me to see her infant, who,
she observed, after a motion, had a substance like an
earth-worm  appear  at  the anus, of considerable
length,  and  of  a  red colour.   Upon examination,
after an evacuation, I saw at the anus a  red pro-
jection, and upon pulling it down, found it  to  be of
considerable  length, growing  about an  inch  to an
inch and a half from the  anus, attached to the interi-
or  of the rectum.   I drew it down, put  a thread
around it, and cut it off as near to its origin from the
rectum as I could, and it never returned.
   Case.—Sometime after, a child  was brought  to me
from Surrey, with  the same disease ; the substance
looked like a leech, and I cut  it off without putting
a thread around it.   Whilst at Lecture I was sent
for to attend the child on  account  of haemorrhage,
and I begged Mr. H. Cline to visit  the  patient for 
268
mc;  but he soon returned and  informed me, that
the bleeding had been of little consequence, and had
stopped spontaneously.  The child recovered.
   Case.—In a stone patient of Mr. Gaitskell's, upon
whom  I was operating,  the  child having  prolapsus
ani, I saw a small excrescence,  red and  pendulous,
growing upon the mucous membrane of the intestine,
which  I thought was the commencement  of one of
these diseases.
   Case.—I have only  twice seen this disease in the
adult;  once at the age of 23 years : I put a ligature
upon its root, and removed a portion beyond the li-
gature, having the external appearance of a common
earth-worm.
   Case.—An apothecary of Bristol, a friend of Mr.
Brickenden, surgeon, in  the Borough,  came  to me
some years ago with a polypus growing in  his rec-
tum, about  two inches from the anus, which  I re-
moved :  he had previously been subject  to dyspep-
tic symptoms, with great irritability of the rectum,
which  subsided after this operation, and  the use of
alterative medicines which were given him.

        OF  FUNGOID  POLYPUS OF  THE RECTUM.

   Case.—A gentleman  was brought  to me by Dr.
Hopkins, of Peterborough, who laboured under this
disease, the symptoms of which were a copious and
sanious discharge from the rectum :  very little pain;
but  upon  his  going  to stool, or even by efforts in
which  the  fasces were not discharged, a polypus was
protruded,  having a broken surface like a cauliflower,
large as an egg, and of  a dirty brown  colour, break-
ing readily, and bleeding where it broke.   The ge-
neral health had not materially suffered.   I put a li-
gature upon the neck of  this  polypus near  to the
mucous  membrane of  the intestine: it sloughed 
269
away in a few days, and for some time the gentle-
man appeared to be  well;  but having occasion many
months afterwards to go  through Peterborough,  I
was requested to see this  gentleman;  when I  found
the disease had returned, that the rectum had  ulcer-
ated,  and that his health was broken :  soon after he
fell a victim to the disease.
  In the present state of medical and surgical know-
ledge, this disease, iike the scirrho-strictured rectum,
will prove destructive.

               OF ENLARGED TONSILS.

   Of frequent occurrence.—Enlargement of this part
from  common angina is a frequent occurrence ; and
it is best relieved  by purging, by leeches applied to
the throat, or by a blister placed beneath the angle
of the lower jaw.
  Sometimes suppurate.—If the gland suppurate, the
pain is exceedingly severe ; the attempts to swallow
are agonizing, and the painful sensations extend along
the Eustachian tube to  the ear.   When  matter has
formed in the tonsil, it may be detected by applying
the finger to the surface of the gland in the fauces.
   Treatment.—Fomentations and  poultices assist its
progress most effectually;  and  I think,  upon  the
whole, that they do best when left to break sponta-
neously.   But when great difficulty of breathing at-
tends the presence of matter, it should be discharg-
ed  by puncture with a small  lancet, or with  the
knife used  to divide the cornea.  Some danger at-
tends the operation of opening  such abscesses,  and
circumspection is  required  to  prevent a wound of
the internal carotid artery.
   After  the matter  is  discharged, the case speedily
does well.
   Chronic  enlargement.—Sometimes  a chronic en- 
270
largement  of the  tonsils  occurs,  and  injures the
health by the difficulty of breathing it  produces, the
person  is obliged to sleep with the  mouth widely
opened, yet still  there is  much impediment to the
passage of the air, and consequently much stertorous
noise.
  Symptoms.—Children labouring under this disease
are often found during sleep in profuse perspiration,
especially about  the  head,  arising from  this exces-
sive dyspnoea.
  Treatment.—The treatment  of  this state consists
in applying powdered  alum to the surface of the
tonsil;  in using the sulphate of copper, in substance,
so as  to whiten the surface; or the nitrate of silver,
which produces  the same effect, and  from the em-
ployment of which I have  known  great advantage
derived; scarification I  have also seen of service.
  Removal sometimes required.—If the disease resists
these modes of treatment, it will be right to remove
the enlarged portion  of the gland, either by  ligature
or by excision.
  By ligatures.—A  ligature is employed  in  those
cases in which the tonsil  is pendulous,  and in which
the enlarged  part is connected to the throat by a
narrow neck.
   To apply a ligature,  an  iron is required, with a
small fixed  ring at its end, and a waxed  portion of
silk.
   Operation.—The  patient  sitting before the sur-
geon, and the thread being passed through  the ring
of  the  tonsil iron, an assistant  holds one end of  the
ligature against the cheek, and the surgeon retains the
other in his hand.  The iron is then  carried above,
behind, and then below the tonsil, and is, with the
end of  the ligature, brought out of the mouth; after
thus  nearly surrounding  the gland, a  single knot is
made, and one end of the thread  being again passed 
271
through  the ring of the tonsil iron, the knot  is by
means of it  made fast,  and a second  knot  is then
made, in the same manner.   The silk is left upon
the tonsil until it ulcerates through the gland, which
it does in about  a week.
  Another mode.—When the basis of the swelling is
large, a needle has been advised,.armed with a dou-
ble ligature, which is to be passed through  the base
of the gland: then each ligature is to be tied sepa-
rately, one before and  the other behind the tonsil,
and by this mode the ligatures  are prevented from
slipping; but their application is very difficult, and,
as far as I have seen, very imperfect.   Rather than
adopt it, I  advise the removal of a portion of the
gland by excision.
   By excision.—This  is to  be  done   by a pair of
curved scissors  with probed extremities, with which
there is  less  risk of  wounding  any important  part.
It  is best,  however,  to remove small  portions, and
to  proceed gradually, by repeating the operation as
occasion  requires; and to  touch  the  surface  with
nitrate of silver or sulphate  of copper.
    In these cases there is usually much general de-
bility, and it is right to give soda, steel, and rhubarb,
 and advise country  or sea air  with bathing, and a
 generous diet.

            OF ELONGATION OF THE UVULA.

    Sometimes of great length.—I  have seen this part
 grow to a considerable  length.   There is one in the
 collection at St. Thomas's Hospital,  which the boy
 could throw forwards between his incisores teeth.
    Symptoms.—By hanging  upon the  epiglottis,  it
 produces coughing, or  by irritating the pharynx it
 occasions sickness ;  and by  creating irritation of the
 glottis it produces an alteration  in the voice. 
272
   Cause.—It arises from  relaxation and over exer-
 tion of the voice in speaking.
   Treatment local.—Stimulating gargles, sulphate of
 copper in solution,  or directly applied  in substance,
 and alum, are  useful; but  sometimes the enlarge-
 ment becomes so distressing, as to occasion a neces-
 sity for its immediate removal.
   Operation.—The mode in which this is effected is
 as follows.  The end of the uvula  is seized  with a
 pair of polypus  forceps, and it  is  then drawn for-
 wards,  so  as to be put upon the .stretch,  and that
 portion which exceeds the  natural length of the part
 is removed by a pair of curved and probed scissars.
  No bleeding of any consequence follows ; and the
 only attention afterwards  required  is,  to avoid any
 unnecessary exposure to cold air.
  Not dangerous.—I have several  times had occasion
to perform this operation,  and have never seen any
ill effects arise from  it, but often  the greatest ad-
vantage produced. 
273
            LECTURE  XXV1IL

          PARACENTESIS  OF  THE ABDOMEN.

  Two kinds.—Dropsy  of  the abdomen  is of two
kinds : 1st, Peritoneal, or ascites;  2d, Encysted,  or
ovarian.

                    OF ASCITES.

  Symptoms.—The first symptom of this disease is
an unnatural sense of fulness in the  abdomen after
taking food, which renders  it necessary to  loosen the
clothes;  next, an increase of the lower part of the
abdomen, observable at all  times whilst the patient
is  in  the sitting posture.   When  the patient lies
down, the increase  in  the  abdomen is general, and
the  enlargement is accompanied  with an unusual
tension;  as  if  the abdomen were  inflated.  In the
sitting posture, a fluctuation can be  perceived in the
hypogastric and lower part of the umbilical regions,
by placing the fingers on one side and tapping  on
the other.   In the recumbent posture, the intestines
appear to undulate  in the cavity, having  more than
their usual  motion.   As the disease  increases, the
swelling extends from the lower to the upper part
of the abdomen, occupying  the whole cavity.
  Little  pain is felt, but considerable inconvenience
arises from  the distenion,  more  particularly  when
the patient  is in the recumbent position, on account
of the action of the diaphragm being impeded.   In
proportion as  the distension is greater, the fluctua-
tion  becomes distinct;  and  when  the tension is ex-
  VOL n.              34 
274
treme, the gentlest tap  on the  abdomen leads to a
perception of the  fluid.   The secretion of urine is
scanty.   The  enlargement of the abdomen  is fol-
lowed by swelling of the legs, either from the pres-
sure of  the  fluid upon the veins returning the blood
from  the lower extremities, or from the general de-
bility which  accompanies this disease.  1 have known,
when the  omentum  has  been  very  considerably
thickened, the perception  of  the fluctuation in the
abdomen to  be  indistinct;  and, under the  same cir-
cumstances,  in tapping,  the quantity  of fluid which
has escaped has been a portion only of that contained
in the cavity, part  being confined  behind the omen-
tum.
   Quantity  of fluid.—The  usual  quantity  of fluid
collected is  from twenty-eight to  thirty pints; but
when a  patient  has been tapped several times, the
abdomen  becomes much  more  enlarged,  and the
quantity is then from thirty to forty pints.   In young
persons  the  quantity is small; and the smallest quan-
tity I have known drawn  off by operation  was in a
medical student; it amounted only to six pints.
   Nature of the fluid.—The nature  of the fluid
secreted varies  but little in  ascites;   it is  much
more watery  than serum,  containing  relatively a
small proportion of albumen.  It has  generally a
watery  appearance, has a slight  yellow tinge, and
does not vary in its appearance and  consistence, as
the fluid of  other species  of dropsy.   If inflamma-
tion succeeds the performance of the first operation,
flakes of fibrin  or adhesive  matter are contained
in the fluid next discharged.
   Cause.—The cause  of dropsy, when it is  confined
to the abdomen, is most frequently a disease in the
liver, which  acts mechanically in producing  it.  The
pressure which  the diseased  organ  occasions upon
the vena  porta? interrupts the free  flow  of blood 
27,r)
through the vein, produces a congestion in the arte-
ries and veins of the alimentary canal, and of the or-
gans which are connected with it,  and consequently
leads to a greater effusion from the exhalent  extre-
mities of the arteries.  Diseases of particular abdo-
minal organs will, by the- irritation they excite upon
the  peritoneum, occasion  a greater determination to
its secreting surface.   Thus disease of the omentum,
or of the spleen, will produce this effect.
  I  have known diseased mesenteric glands produce
ascites ; and two children, who,  in my recollection,
have been tapped for this disease, have  recovered.
Taking large quantities of spirituous liquors tends to
produce this complaint, independently of the organ-
ic change it is likely to excite in  the liver;  its sti-
mulus leading to  a greater determination of blood to
the  vena porta? than  can readily circulate through
this  vessel, and consequently to effusion from the ex-
tremities of the arteries.
  But ascites is frequently the effect of disease in
the  chest, of water accumulated in the  cavities of
the  pleura, of water in the pericardium, or of some
organic change in the heart, interrupting the  action
of the source of the circulation :  the blood therefore
accumulating in the right side of the heart and in the
veins returning the blood  to  the  right auricle, leads
to the production of water in  the abdomen, and of a
general anasarcous state.
  It has been a question whether dropsy arises from
an increased secretion of  the blood-vessels, or from
an absolute diminished action of  the absorbent ves-
sels.  It is generally the  former  I have  no doubt,
for reasons which I have  already given, when speak-
ing of hydrocele. 
276
           OF  THE TREATMENT OF ASCITES.

   Medical.—The disposition to this disease may be
prevented, its  progress, when it has begun, may be
retarded, and  large  accumulations  of fluid may be
removed by medical treatment, and  by external ap-
plications.  If the disease  originate in  a complaint
of the liver, the  restoration of its secretions, and an
action upon the  alimentary canal by  mercury, com-
bined with other  purgative  remedies,  become the
best means of  preventing effusion.   If the complaint
originate from local disease in some of the other vis-
cera, as in the  spleen,  or  omentum,  the secretions
must be  increased in  a similar manner,  and blisters
should be applied, and for  some time continued, on
the abdomen.
   If water has already begun to form, the best me-
dicines, as far  as I know, are  the submurias hydrarg:
gr: jss. pulv: gambogiae gr: ss. scillae gr: iij. in the
form of a pill, taken every night : and  spir : aether:
nitric: 3ss.  to  3j. oxym: hydrarg: gr.  •£.  tinct: digital:
gutt. xv.  with  some camphor mixture, twice or three
times in the day.
   If water has already formed in considerable quan-
tity, and if the powers of  the constitution  are  suffi-
ciently strong  for its employment, the use  of elate-
rium becomes not  only justifiable  but desirable, as
being the most powerful and successful mode of pro-
moting the absorption  of the fluid  which  has  been
effused.  But  if the powers of the constitution have
been much enfeebled,  this remedy  becomes  dange-
rous from its severe effect.   Even  if the ascites be
accompanied  with  other  dropsical  symptoms, the
elaterium is still  the  remedy most  to be depended
upon, if the constitution will allow of its use.
   An operation necessary.—When medicines fail of 
277
their wonted and expected influence,  and the accu-
mulation is  so considerable as to impede breathing
by preventing the free  descent  of the diaphragm,
or when the patient finds it  difficult to assume the
recumbent posture, it becomes necessary to  remove
the  accumulation  by the operation  of paracentesis.
I have, however, known in a young person the ope-
ration performed for comparatively small collections
of  fluid,  when  the increase of the  collection had
ceased, and no disposition to its absorption had ma-
nifested itself.   It is  absolutely  necessary that the
fluctuation should  be extremely  distinct  before the
operation be  proposed; and in cases of diseased
liver, spleen, omentum, and mesentery, there is dan-
ger of the surgeon's  being deceived respecting the
disease.
  Result of an operation.—With regard to  the  re-
sult of the operation  for  ascites, when the  dropsy
arises from disease of the liver,  or  from organic al-
teration in the  chest, the  relief  is only temporary ;
but when it is the effect of constitutional disease, as
fever, or arises from functional  change only, under
these circumstances  the  operation of paracentesis is
frequently followed by a cure.   Even in diseased
liver, after the removal  of the water  by the use  of
the medicines which we  have already recommended,
I have known the patient ultimately recover.  Con-
siderable pressure upon  the abdomen after the ope-
ration, lessens the disposition to  the  return  of the
effusion.  Before  the  operation  of  paracentesis is
described,  I shall speak  of ovarian  or encysted
dropsy.

         OF OVARIAN OR ENCYSTED DROPSY.

  This is a bladder of water, formed within or upon
the ovarium. 
278
   Sy?nptoms.—The disease is, at first, discovered as
a swelling upon the brim of the pelvk from two to
three inches above Poupart's ligament, and is confin-
ed to one side of the pelvis.  It is unattended with
pain, and  the general health  remains  uninjured.
Under varied  positions of the body it moves, in some
degree, from side to side.    It is a very circumscrib-
ed swelling, and  has an elastic  feel;  it is often ac-
companied  in its  early stages  with an irritation to
make  water, and  now and then with a difficulty in
its discharge.
   Progress.—As it gradually increases  it rises from
the  lower part of the  abdomen to the upper, and
occupies more and more the centre of the abdomen;
at length it  extends over to the  opposite side from
that  in which it began: although it is generally larg-
est on the side in which it commenced; at first the
breathing is unaffected; but when the  size  of  the
swelling is very large, the action of the diaphragm
is greatly impeded by its pressure.
   Fluctuation.—The  fluctuation in this disease  is
much  less  distinct  than in ascites; but when it ac-
quires considerable size, it becomes  proportionally
more and more perceptible.  It depends, hoAvever,
upon the thinness of the cyst.   In ascites the fluid is
in direct contact with the  peritoneum, on the poste-
rior surface  of the abdominal parietes; but in ovari-
an dropsy a cyst sometimes of considerable thickness
intervenes between the water and the peritoneum.
   Solid enlargement.—The ovarium is subject to so-
lid enlargements of very considerable bulk ; and an
ignorant surgeon might plunge a trocar into such a
swelling, mistaking it for   ovarian dropsy, which a
little more attention to its want  of fluctuation might
have led him to discover.
   At first the water which is formed in the  encyst-
ed dropsy is contained, not in a single  bag,  but in 
279
several; the septa between which become gradually
absorbed^ and their number  consequently diminish-
ed ;  and this is  another reason for the  fluctuation
being  more  distinct as the disease  advances.  The
cyst  which is, at  first, of considerable  density,  be-
comes  thinned by a process of  absoption, leading to
a more distinct perception of the fluid.
  Nature of the fluid.—The fluid contained in an
ovarian cyst varies  much in appearance, it  being
sometimes  watery; sometimes serous, containing a
large quantity of albumen ; sometimes mucilaginous
and tenacious, so as to be ropy, but yet  coagulating
little under the influence of heat.
  Its colour.—The colour also varies;  sometimes be-
ing yellow  like  serum; sometimes it is brown  and
frothy; three times I have  seen it yellow like pus,
and containing similar globules.   One  case with Mr.
Simpson, surgeon, in Lime Street  Square, in which
a pail-full of this fluid was drawn off; a second in a
Miss Warner, of the  Kent Road; and  a third  in a
Mrs. R. of Chatham  Place, whom  I lately attended
with Dr. Key.
   Hydatids.—I have seen hydatids discharged with
the fluid.
   Quantity of fluid.—The quantity of fluid accumu-
lated  in this disease  is necessarily  varying, but  the
proportion  averages  from twenty-five to thirty-two
pints.   The greatest  increase of the  ovarium which
I have seen  is in the collection  of St.  Thomas's Hos-
pital, in  which  the accumulation  was  ninety-seven
pints.   The least which I have removed  has been
sixteen pints.
   Case.—The following is the  account upon a tomb-
stone near Dartford, Kent.   " Here lies the body Of
Ann Mumford, daughter of John Mumford, Esq., of
Sutton Place, in this parish.  Her death was occa-
sioned by a dropsy, for which,  in the  space of three 
280
 years and ten months  she was tapped one hundred
 and  fifty-five  times.  She died the  14th of May,
 1778, in the twenty-third year of her age, an exam-
 ple of patience, fortitude, and resignation."
   This  then is a proof of  extent of  the ^secretion,
 and of the necessity, in some cases for the repetition
 of the operation.
   Situation of the cyst.—In the collection of St. Thom-
 as's Hospital there is a preparation shewing the ori-
 gin of this disease; in one ovarium  bags are formed
 within its tunica albuginea; on  the other side, a cyst
 is produced externally to the ovarium, but pendulous
 from it; thus there are some cases of it internal and
 some external to the ovarium.
   Adhesion of the  cyst.—At first the bag does not
 adhere to the peritoneal lining of the abdomen; but
 as it becomes large, it gradually acquires such adhe-
 sion; and, upon dissection of these cases, the cyst is
 found to have united itself with the parietes of the
 abdomen, so as to leave no space between it and the
 peritoneum:  the intestines  and  omentum are  situat-
 ed behind it, under gie<t' accumulation.
   Burst  by accident.—The  ovarian cyst sometimes
 bursts by accident.
   Case.—Miss Warner, to  whose  case I have  al-
 ready alluded, was thrown  out of a one-horse chaise,
 and burst the ovarian cyst.  She soon afterwards
 began to make  large quantities of  water,  and the
 disease disappeared; but in seven years it returned,
 and she was obliged to be tapped.             v
   Case.—A lady  with  ovarian  dropsy, in getting
 from her bed, fell  against the corner of  the  night-
 chair, and ruptured the ovarian cyst, producing con-
siderable extravasation of blood  externally: her se-
cretion of urine became abundant, and her abdomen
much lessened; but the disease afterwards returned.
  Medical  treatment.—With respect to the medical 
281
treatment of ovarian dropsy, I fear a difference of
opinion with  many other medical  men, when I say,
that medicine has but little  influence over this com-
plaint.
  I have seen the most  gentle, as well as the most
drastic medicines given to promote the absorption of
the fluid, but without success ; and when we consid-
er the little vascularity of the cyst in which the wa-
ter is contained, and also how little influence  medi-
cine has over common hydrocele, we shall not be in-
clined to expose our patients to the trial of these
agents.
  Case.—Dr. Baillie and myself attended a lady  to-
gether, who could  only hiss her  answers  to our
questions ; and when we asked the cause, we learned
that for an ovarian dropsy, of which she afterwards
died, she had undergone  a course of mercury, which
had occasioned a sloughing  from the inside of her
cheeks, without relieving her dropsy : the  contrac-
tion of the cicatrices in the mouth had produced the
alteration in her voice.
  Diet.—With  regard  to diet, 1 tried in a case of
dropsy the following experiment.   1 lapped  a wo-
man in Spitalfields, and  I  ordered  her afterwards
not to drink, but merely  to suck an orange when she
was thirsty: with respect to her solid food I put her
under no restraint.   The next time  I tapped her, I
allowed her to take as much fluid as nature  prompt-
ed, but she filled faster with water in the former than
in the latter case ;  the  cause of  the difference ap-
peared to me  to consist  in the excitement of the
kidneys which the fluids occasioned.
  Pressure.—A considerable  effect  is produced in
retarding the progress  of  this disease,  by the pa-
tients wearing a  belt, which, by its pressure, pre-
vents the ready secretion  from the  exhalent  extre-
mities of the vessels into the interior of the bag.   I
  vol. it.              35 
282
therefore always lay my patients under the injunc-
tion to obtain and wear one.
  A patient  who is affected  with  this  disease has
the general  health  so  little deranged, as not to re-
quire any change in the  general  mode of living;
exercise  may be taken, and the same diet allowed
as under ordinary circumstances.

        OF THE OPERATION OF PARACENTESIS.

  Not to be performed early.—This operation ought
never to be performed early in the disease, but it
should be deferred until the accumulation  of water
by its pressure  upon the  diaphragm influences the
function of respiration.
  Reasons for delay.—If the quantity  of water  in
ascites be  but  small, much danger is to be appre-
hended of the trocar reaching  the  viscera; and in
the ovarian  dropsy  the operation  must not be per-
formed early, because  the adhesion of  the  ovarian
cyst to the peritoneum  on  the  fore  part of the
abdomen is not  yet produced.   The viscera, there-
fore, glide down between  the cyst and the parietes;
and I once saw, in a case of ovarian dropsy, the omen-
tum caught by  the canula, and a portion of it was
brought  through the  opening  in  withdrawing the
instrument, which  was  obliged to be returned by a
probe; inflammation succeeded, and the woman died.
This might have been avoided by further delay;
therefore the operation should not  be performed
until the  ovarium  ceases  to move easily from  side
to side.
  A second reason for delaying the operation  exists
in the  numerous cysts of  which the tumour is first
composed,  which afterwards break  into one; but
when the operation is performed early, the escape
of water is only from a single small cyst. 
28:$
  Before  performing the operation in the encysted
dropsy, as the fluctuation is much less distinct than
in ascites, the  greatest care is required to prevent
an error.
  I will here mention  two circumstances, in one of
which  my character  was exposed to  considerable
risk; of the other, I was informed by a medical man
who was invited to witness the operation.
  Case.—In  the  first  case, I was  desired to see a
lady who  I was told laboured under dropsy.  When
I entered the  room, I saw  a tall  delicate female
with an immense abdominal swelling, giving a distinct
sense   of  fluctuation.   I  requested the  physician
accoucheur whom I met, to  examine if the lady
was not with child ; he said,  he thought it was un-
necessary, a«: the fluctuation was very distinct, but
that he would do so, and let me  know  the  result in
a few days.   I heard no more  of  her for a week,
and then I learned that she had  been put to bed on
the morning  following  my visit.  I would not  have
performed the  operation of  paracentesis  for the
universe.
  Anecdote.—The circumstances which were told
me of  the other case were as follow;  A surgeon in
a country town called upon  another surgeon, and
said, " I am going to tap a woman to-morrow ; per-
haps your young  gentlemen  would  like to be pre-
sent."   As it was an operation  they had  never
witnessed, they  most  readily accepted the  invita-
tion ;  they were shewn  into a room in which the
patient was already prepared to undergo the opera-
tion, she sitting at one  end, with her abdomen bare.
The surgeon then,  taking  his  trocar and canula,
went to some distance, and walking up to the patient
with the  trocar  presented,  he  charged, as it were
with a bayonet, and plunged it  into the abdomen;
then withdrawing the trocar with an air of triumph, 
'2(14
it was with no small chagrin he found not a drop of
water escape;  but  however,  still  undismayed, he
withdrew the canula, and again renewing his attack,
he  a second time  introduced  the  trocar  into the
abdomen ; but was  equally unfortunate as before, in
finding  that no  water  followed.   Waiting a  few
moments, he  withdrew the  canula,  and  turning
round to the gentlemen, he said, " You may do her
up;" by  which  he  meant,  they might apply the
bandages; and he  added, " This,  gentlemen, is an
operation which you probably  never saw before,
and  which most likely  you may never see again.
This is  what wc call the operation of dry tapping."
  Before performing  this  operation,  the patient
should be placed upon an elevated seat with the ab-
domen bare, a sheet is to be doubled to about a foot
in breadth, and is to be passed around the body at the
upper  part  of  the  abdomen,  and  the  ends being
crossed  at the back, are to be held  by assistants ;
but  instead  of  doing this, I  frequently suffer  my
patient  to remain in the horizontal posture in bed,
turning  only to the  side ; by this plan,  that faintness
is prevented, which usually attends the escape  of
the water if the patient be in  the sitting position; a
pail  is required to catch the  water in the first  in-
stance,  and a  basin afterwards.   The necessary
instruments  are  a  trocar  and  canula, or  a lancet,
with a  canula shut  at its  end like a catheter, and
with holes  on  its  sides equal in  diameter to the
canal of the canula.
  A long trocar necessary in ovarian dropsy.—If it
be  ovarian  dropsy, and the  cyst  possess conside-
rable thickness, it is very desirable  that the surgeon
should be provided with a trocar and  canula  of  an
inch more than the usual length, as I once operated
upon a  patient of  Dr. de Vallangin, in whom I was
obliged  to employ a much longer trocar  and canula, 
285
being unable to reach the cavity of the cyst with
an instrument of the common length.
   The proper spot for the introduction of the trocar.—
The place at which the operation is performed was
changed  by Mr.  Cline from midway  between the
umbilicus and anterior superior  spinous process of
the ilium on the  left side to  one inch  below the
umbilicus ; and his  reason for this change was, that
in the spread of the abdominal  muscles from the
pressure  of the water, the epigastric artery is brought
into  a situation  of  risk  of  being wounded by the
trocar, a circumstance  which  did happen  to Mr.
Cline.  He  was  tapping a person in St. Thomas's
Hospital, and he  saw florid blood issue through the
canula ;  the quantity gradually  increased  as the
water flowed;  and as  the patient  was becoming
faint, he  withdrew the canula and closed  the wound,
but  the  bleeding continued into the abdomen, and
the man  died ; upon inspection, the epigastric artery
was  found wounded.
   Reflecting upon  this circumstance, he was led to
consider, that  an inch  below  the umbilicus in the
linea alba would  be the safest spot for the introduc-
tion  of the  trocar,  as no vessel would be there en-
dangered, and it  was only required that the bladder
should be previously emptied.  This part has been
therefore of late  years usually  selected for the ope-
ration.
   Danger of operating at the umbilicus.—Some have
recommended the  umbilicus, but the frequency of
hernia renders that spot unsafe.  An  inch above
the  umbilicus has  been also advised; but if there
be hernia, it is equally dangerous  with the umbilicus
itself; and  if the  umbilical vein remain unclosed,
there is  a danger of haemorrhage in performing the
operation at that part. 
286
   Beside the danger to the epigastric artery in the
operation performed at the part formerly selected,
there was danger of wounding  the  spleen when it
had become enlarged.
   Operation.—The surgeon should place himself on
a low stool by the side of the patient;  the sheet is
then tightly drawn by the assistant across the upper
part of the abdomen* by  which  its lower part is
rendered  prominent, and the point of the trocar is
placed an inch below the umbilicus,  and is passed
slowly and gently through the linea alba; the trocar
is  then withdrawn, and the canula being left in, the
water is allowed  to  escape through it.   If any in-
terruption to the  passage  of the fluid  by the pres-
sure of the omentum, or of the  mesentery on  the
end  of the  canula arise, a probe  should be gently
passed through the interior of the canula to remove
the obstruction.
   Canula left in the wound.—It has been recommend-
ed by Mr. Guy of Chichester, and  others, to leave
the canula in  the wound, occasionally to suffer  the
water to flow, and thus prevent its future accumula-
tion.
   Sometimes produces a cure.—A slight inflammation
of the peritoneum in these cases sometimes succeeds
the operation ; and by the change  of action thus ex-
cited in the  vessels, its disposition to a future secre-
tion is lessened, and in this  way a cure is produced.
   Pressure.—Immediately  after  the operation  has
been performed, a belt  is  to  be  tightly applied
around the abdomen, to prevent the  re-accumulation
of water by lessening  the determination of blood to
the parts.
   Operation rarely successful.—The result of the op-
eration  is generally unsuccessful  in  ascites, as  the
greater number of cases are  accompanied with  or-
ganic disease : the operation only acts upon  the  ef- 
287
feet, and not upon the cause, and the hope of per-
manent advantage  must be derived  from  medical
treatment, and not from surgical operation;  but the
removal of the water gives additional facility to the
operation of the medical means which are employ-
ed.
   With respect  to  the ovarian dropsy, the  opera-
tion is  the only means of relief;  but it generally fails
in producing a permanent cure.
   In ascites forming after fever, and after a course
of mercury, and in ascites unaccompanied by organic
disease, I have known the operation succeed in pro-
ducing a  permanent cure.   In ovarian dropsy, the
instances of permanent cure from operation  are  ex-
ceedingly rare.
   The case which I have given from the neighbour-
hood of Dartford shews the number of times this op-
eration may be repeated.
   In the very young and  in  the  very old, I have
known the operation succeed.
   Spontaneous cure of ovarian dropsy.—Of a  sponta-
neous cure of ovarian dropsy I have known  several
examples.
   Case.—The wife of a veterinary surgeon  had  an
opening  at  the umbilicus produced by ulceration,
through  which large quantities  of fluid were for a
length of time discharged ; but the opening ultimate-
ly closed, and the disease did not return.
   I have known the water discharged by the Fallo-
pian tube ; and  I attended a lady  in whom an ovari-
an cyst burst into  the  intestinal  canal; for several
years afterwards she was  subject to occasional  re-
turns of the disease, but ultimately recovered.
   I have known a person die from suppuration of an
ovarian cyst.
   Injection of the cyst.—The  injection of an  ovarian
cyst has  been  occasionally practised with  success; 
288
but it has also failed ;  so  that its  salutary influence
remains in doubt.
   Removal of the cyst.—The removal  of an ovarian
cyst from  the  abdomen might be performed in the
early stages of the disease by making an opening in-
to it, discharging its contents, and by dividing the
membranous bag from its natural adhesions.

           OF PARACENTESIS OF THE THORAX.

   When required.—This is  required for accumula-
tions of matter within  the cavities of the pleurae, or
matter  partially encysted in those  cavities.   With
respect to a collection of water in  the thorax, I have
only once known an operation performed for it, which
proved unsuccessful; the effusion of serum being on-
ly the effect  of some more formidable disease.

                   OF EMPYEMA.

   Causes.—Collections of pus in  the chest are the
result of inflammation of the pleura, or of the  peri-
cardium ;  but as the latter does not admit of relief,
I shall only describe the former.
   Symptoms.—The formation of matter in the cavi-
ty of the  pleura is preceded by the usual symptoms
of pleuritis—viz. pain  in  the side, cough, a hurried
breathing, and imperfect expansion of the thorax ;
these are  succeeded by rigors  and greater dispncea,
by a frequent,  small, and often irregular pulse ; and
if the disease be confined to one side, the patient can
only rest on  one side.   When the sides  of the tho-
rax are  accurately compared, the  diseased is  found
to be considerably larger  than  the  sound side ; the
upper part of the abdomen is also  much fuller on the 
289
side  affected; a tense and elastic swelling  may be
felt there, varying with the state of respiration.
  A swelling of the legs succeeds from the pressure
of the accumulated fluid affecting the free  circula-
tion  of the blood through the lungs, as well as alter-
ing the  position of the heart.
  Spontaneous cure.—Nature occasionally performs a
cure, in the following manner : The  intercostal mus-
cles  give way to  the  pressure of the matter, or an
ulcerative process is produced, by which the pus es-
capes to the outer side of the ribs under the integu-
ment, which at last also ulcerates, and thus the mat-
ter becomes discharged.
   Case.—I  was  sent for to Miss B—, in Chatham
Place, Blackfriars,  to meet her  medical  attendant,
Mr. Murley, on account of her being under the fol-
lowing  circumstances.  She  had great dyspnoea, se-
vere cough,  a quick  small pulse, great  emaciation,
and   hectic  flushes, succeeded  by rigors.   When I
examined her left side, I found a large swelling in
the  situation of the  spleen, and another, about the
size of a walnut, between the third and fourth ribs ;
when I pressed upon the tumour in the  situation of
the  spleen, that between the third and  fourth ribs
became enlarged, so that there was evidently a fluid
fluctuating between the two  swellings. Thus I found
that the  enlargement on the left side of the abdo-
men was occasioned by a descent of  the diaphragm
from accumulation of fluid in the chest, and I did not
hesitate to  advise  that  an opening should be  made
into the small and circumscribed swelling  between
the  ribs.
   This being done, an immense flow of matter im-
mediately succeeded  ; and when the swelling in the
region of the spleen was pressed the flow increased,
After a very long continued and  copious discharge.
   vol.  ii.              36 
290
       this  young  lady  recovered, and now enjoys good
       health.
          Case.—I attended a young lady in Seymour Street
       under  exactly similar circumstances, and she also re-
       covered from the  same  plan of treatment.   These
       abscesses would of  themselves  soon have burst, but
       I thought it better to save the constitution by aiding
       the efforts of nature.
          The  pus does not  always point externally.—It fre-
       quently happens, however, that the accumulation of
       pus in  the  thorax  is not accompanied by a partial
       swelling between the ribs, and under these  circum-
       stances the surgeon must be  guided in his judgment
       by the  symptoms I  have described.   In this case, it
       will  be required to make an  incision into the thorax
       without any  well marked circumstance  in the dis-
       ease, to  direct the situation of the opening.  The
       surgeon will  then consider in what place the wound
       will be the most dependant, so that the matter may
       readily escape.
         Operation.—As the patient should be in the  sit-
       ting  position at the time of the operation, the lower
       part  of the chest should be selected between the se-
       venth and eighth, or eighth  and  ninth ribs, and the
       opening should be  made rather posteriorly to the
       side  of the thorax, so as to completely avoid the dia-
       phragm.  The skin being drawn up an  inch, an in-
       cision is to be made through it upon the upper edge
       of the  rib; after which,  the  intercostal  muscles are
■H - -    carefully divided ; and a  straight canula  closed at its
*^V    end like a catheter,  but having holes  in  its sides, is
       then passed through the pleura, and the pus is al-
       lowed  to escape through it.   When the matter has
       been thus evacuated, the canula is removed, and the
       skin  being let go, the external and  internal wounds
       are no longer opposite to each other, and union is
       »ore readily* effected. 
291
  The reason for  making the incision upon the up-
per edge of the rib is to avoid the intercostal arte-
ry, which is placed in a groove in its lower margin.
  Sometimes succeeds.—This operation I have known
succeed, although it is generally  unsuccessful.
  Case.—A Mr. Bryant, in the city of London, had
this operation  performed upon him, by Sir B. Har-
wood, and he ultimately recovered.
  Spurious empyema.—Collections  of pus in the tho-
rax are  sometimes partial, and then the disease is
called spurious empyema.
  How produced.—An adhesion  forms between the
pulmonary and costal  portions of the pleura, between
which also matter becomes deposited, so that the
general cavity of the chest is excluded from  the ac-
cumulation.   This abscess  ulcerates the intercostal
muscles,  and  breaks  externally, after having been
the occasion of excessive pain, dyspnoea, and cough.
  Case.—A boy, who had  been  a  long time  at sea,
and who had been very much  the subject of sea-
scurvy, was sent to my house  by his mother, on ac-
count of  a large  accumulation  of matter upon the
left side of his thorax, a part of which passed to and
fro between the ribs, and projected very much if he
made a deep inspiration, or coughed.  Seeing him in
ill health, I was  fearful  of making an opening, but
advised him, on  account of his scurvy, to take bark
with sulphuric  acid;  under the improvement of his
general health which this treatment  effected, the
matter became entirely absorbed,  and the boy  per-
fectly recovered.
  Treatment.—The treatment of spurious empyema
is that of common abscess, viz. fomentations and poul-
tices; and the opening is to be left to nature  or per-
formed  by art, as the constitution  is able or  unable
to bear the process of ulceration. 
292
             LECTURE  XXIX.

                   OF HARE-LIP.

  Definition.—This is a congenital fissure in the up-
per lip, which resembles the form of the lip of the
hare.
  Many varieties.—But the deficiency of the lip and
palate is liable to great varieties.
  Simple fissure.—1st, It is  frequently a simple fis-
sure, extending from  the  edge of the lip  nearly to
the nostril.
  Entering the nostril.—2dly, It  is sometimes more
extensive, and is  accompanied with greater  separa-
tion, when it enters the nostril.
  Double fissure.—3dly, The defect occasionally ex-
ists on each side, and extends into both nostrils.
  Extending through  the bone.—4thly, The fissure is
not confined to the lip, but extends into the superior
maxillary bone, and sometimes along the whole of the
superior maxillary and palate bones, and through the
velum palati.
  Double fissure extending through the bone.—5thly,
A fissure is sometimes seen  opposite  each defect in
the  lip, which  extends through the maxillary  and
palate bones, leaving an insulated portion of  each of
these bones in the centre.
  Fissure only in the palate.—Cthly,  The defect in
the palate is in some  cases a circular opening, either
in the bone or in the velum  palati only.
   Cause.—As to  the  cause of this defect, it may be
remarked that such deficiencies are more frequently
observed in the median line  of the body than in any 
293
other parts.  The body is constituted in the greater
part of two halves rather than of one whole ;vthus
it  is obvious,  that the brain  and nervous system
of one side of the body is  distinct in its  functions
from the other side ;  as for example, in cases of pa-
ralysis the  nervous defect  is  confined often to one
half of the body.
   I have seen a child born with half its face ; its
arm and leg on one  side much larger than on the
other.
   With regard to the organs of sense, they are each
of them double.   In the organs of smell  and taste,
although less apparently double thantthose of sight,
hearing, or feeling, yet the function of one half of
the tongue and one half of the nose may be lost, and
the other half remain perfect.
   It is at the  median line that the'union of the two
halves of  the  body may be said to be  produced:
there it is  that the nerves unite, and the  blood-ves-
sels inosculate;  and from deficiency in that inoscu-
lation arise the  defects which are so  frequent  in
the central line of the body, viz. the defects  in the
lip and in the palate  ; a want of the sternum;  a de-
ficiency of the linea alba to a great extent; also  of
integument, pyramidal muscles, and fore part of the
bladder;  the  prepuce  imperfectly formed at the
fraenum;  an aperture in perineo in the  male giving
the appearance of the hermaphrodite.
   Exceptions.—The exception to this rule is in the
abdominal viscera, which  are supplied  by azygos
branches from  the aorta and  by nerves  from the
ganglia.
   Contrary effects.—On the other hand, the inoscu-
 lation in some instances is unusually free, producing
 a closure of the anus, or of the pudendum in the fe-
 male.
   Fissure in the lip easily cured.-—The congenital de* 
294
     feet in the lip may be readily repaired  by the pro-
     cess of adhesion, and this becomes desirable not on-
   ■  ly on account of the  disgusting  deformity which it
     produces,  but also from its influence  upon the nour-
-  J  .ishment of the child, its food returning  by the i'ii-
     natural aperture in the attempt to swallow it.   The
     edges of the fissure in the  lip are therefore  pared
     away, the  raw surfaces are  preserved in complete
 , -  contact, inflammation  arises, adhesive  matter is ef-
     fused, and vessels shooting into the adhesion produce
     a living union of the parts.
       Proper age for an operation.—It becomes a ques-
     tion of importance, at what period of life the opera-
     tion should be performed, whether immediately after
     birth, at from three to six months of infancy, or after
   ,  dentition is completed.
       It is undoubtedly true that  adhesion  is most sure
     to be lasting after the period of  dentition,  and that
     this operation, therefore,  scarcely ever  fails  when
     performed between  two years and  the adult age;
     on the contrary, during dentition it is attended with
     some danger, and sometimes the adhesion is destroy-
     ed  by the  violent efforts  of the child ; soon  after
     birth the operation often fails, and is attended with
     considerable danger.
       Of  the  proof  of  the danger during the period of
     dentition, I will mention the following case.  A child
     of a clergyman,  of  more than six  months of age,
     was sent to me from the country to be submitted to
     this operation.  I advised that it should not be per-
     formed, but the  answer was that the mother could
     not bear to see  the  child with this deformity.   I
     operated;  the child became  feverish, the  gums in-
     flamed, and an incisor  tooth  partially made its ap-
     pearance ; the child was attacked with  purging of
     the  most severe kind; and,  on the fifth day follow-
     ing the operation, it died. 
295
   Danger soon after birth.—The danger, however,
is much greater if the operation be performed soon
after birth; the nervous system is then  so  exceed-
ingly irritable, that convulsions are readily produced, '
and  the loss of a small quantity of blood occasions a
fatal influence.
   Case.—I was operating, at Great Yarmouth, upon
an infant with hare-lip in the presence of Dr. Gir-
dlestone, when he said, " Have you no fears of the
child's dying ?" to which I replied, " I never saw one
die from this  operation;" he  told me that  he had
witnessed an operation upon a child, which was soon
after seized with convulsions, and  of  those  convul-
sions it died.
   Case.—I was requested by Mr.  Price, surgeon, in  -
Tower Street, to  see a child,  born the  preceding
day  with hare-lip.  I performed the operation, the
infant lost but  little blood; on  the  following day,
when I called upon Mr. Price  to accompany him  to
visit the child, he  informed me that it was just dead,
and  that it  had lived  only twenty hours  after the
operation.
   Case.—An  infant was  brought  to  my house  in
Broad Street with hare-lip.   I operated  upon it up-
on a Monday, and desired that it might be brought
to me upon the Thursday; the mother called upon
the Thursday to inform me that the child was dead.
   Case.—During   the  year  1824 an  infant  was
brought to my house, with an hare-lip of the most
simple kind, and its parents were determined to have
the  operation  performed:  this was  done  upon a
Monday morning; on the Tuesday the father of the
child came to  my house,  and  said,  " Sir, my child
vomited very much last night,  and  is this morning in
a state of stupor."  I  directed  him to give the in-
fant  some calomel, and put it in the warm bath; I
called at the  house in the  evening, when I found
that the child was dead. 
296
   Thus the danger at the  infantile period  is consi-
derable, and the operation also often fails when the
life of the patient is  not endangered.   I operated,
in the presence  of Mr. Cline,  upon an  infant, the
daughter  of  the marshal of the King's Bench, but
the lip flew open when the ligatures were removed.
   Case.—I was requested to perform this operation
upon  a boy about twelve years of age, who had been
operated upon in his infancy by one of the first sur-
geons in the city of London, yet the union had been
so imperfect  that a second operation was demanded.
   Practical conclusions.—The conclusions, therefore,
as far as  my own experience  dictates,  are  these:
That prior to six months there is danger of a want
of union, and even of  the loss of  life ;  that from six
months to two years,  during the period of dentition,
the operation should not  be performed;  that,  after
dentition is completed, there is little risk of  failure
either as regards the  union of the lip, or the life  of
the child.
   Sometimes  an early operation beneficial.—Notwith-
standing I feel  it my duty to mention these adverse
circumstances, yet I have known the operation per-
formed, and have  performed it myself  in  infancy,
with  very complete success ; and in those cases in
which a fissure  has existed  in  the upper jaw, the
union of the upper  lip has, by its pressure upon the
bone, led  to  an approximation of the edges of the
fissure so as  to produce  considerable advantage  by
the early  operation.
   Two modes of operating.—The  operation  may be
performed with  a  simple interrupted  suture  ^or
with pins.  Mr. Cline, who had great  experience in
his profession, preferred, and in his lectures  recom-
mended, the  former.   The truth is, that it  may  be
very  successfully performed with either;  but the
interrupted  suture  is  the most  simple, and, as far 
297
as I  have seen, equally effectual; it has this great
advantage, that it prevents the  disturbance  to  the
adhesion, which the lip receives in  the removal of
the pins.
   Operation.—The steps of the  operation are as fol-
lows":  The child is to be  recumbent with its head
 f)laced over a pillow, the surgeon then  extends  the
 ip from the  nose, and if any adhesion  to  the gum
prevents its being extended, such adhesion must be
first divided ;  he next introduces a pointed and curv-
ed bistory, at the angle of the fissure, carries it down
to the red  edge of the lip,  and thus removes the sur-
face from one of the sides; the  removal of the  op-
posite surface is  effected from the angle of the fis-
sure  in the  same way.  A straight needle  armed
with a waxed silk is afterwards passed through each
side of the lip, at the juncture of the skin with  the
red part, and  about  the eighth of an inch from  the
raw surface ;  then another needle and ligature being
introduced through the integument, half way between
the first suture and the angle of the fissure, the edges
of the fissure are brought together by tying the por-
tions of silk,  the lower one should be secured first;
and when both  are tied, the ends of the silk are to
be cut off  above the knots, and  thus the operation
is concluded.   There is not any  necessity for apply-
ing adhesive  plaster;  and  the more  the part  is  ex-
posed to the  air, and  the  more dry it is kept,  the
better.   The coronary artery of the  lip bleeds free-
ly in the operation, but it  ought not to have a liga-
ture applied upon it,  as when the sutures are tight-
ened the orifices  of the  artery  become sufficiently
compressed to prevent haemorrhage.
   Removal of the sutures.—The general rule for  the
removal  of the sutures is on the fourth and fifth
days.  On the  fourth day take away the upper thread,
and upon the  fifth day  the  inferior one ;  but al-
  vol. n.         37 
298
though this is the general rule, yet if there be much
inflammation or tendency to suppurate about the su-
tures,  both should be removed on the fourth day.
  Afer-treatment.—After the removal of  the  su-
tures, it is  best not to apply any plaster unless  the
adhesion be incomplete at any part, and then avery
narrow and long strap may be carried  from  cheek
to cheek across the lip.
   Caution in giving food.—In giving the child food
after the operation, it should be done in such a man-
ner as  not to disturb or moisten  the lip.
  Mode of using pins.—If pins  are employed, they
are to  be introduced at  the  same part of the lip as
the sutures, and then the ligatures are to be twisted
over their e"|ids in the figure of  an x.   The pins
should be of silver  or gold with steel points, which
points  admi^of easy removal: great care is requir-
ed when taking away the silk and pins, that the ad-
hesions may not be disturbed ; this is to be done at
the same period after the operation, as  when su-
tures are used.
   Fissure in the bone.—A fissure in the bone accom-
panying that in the lip, makes no difference in the
mode of performing the operation, but renders  its
success more doubtful, from  the want of support by
bone  which the lip would otherwise  receive.   In
general also, in this case,  the fissure in the lip ex-
tends  into  the nostril, and  it requires great care on
the part of the surgeon to produce  a  union of the
upper  part of the fissure without deformity.

             OF THE  DOUBLE  HARE-LIP.

   Two fissures  in the Up.—If there  be a fissure  on
each side extending through the lip, without any im-
perfection  in the bone, the operation  is performed
in the  same manner as when the fissure is  confined 
299
to one side, but at successive and distant periods, so
as to  allow  time for  the complete  adhesion and
union of one side, before the second operation be at-
tempted.
   Extending through the bone.—A fissure in the bone
sometimes accompanies each fissure of the lip, and
then a projection of the  insulated portion of bone
occurs, in  some instances almost to the  extremity of
the nose.
   Operation.—The operation may be then perform-
ed  by removing,  or  not removing, the projecting
bone.  I  have successfully removed the projecting
portion of bone, uniting the lip at a future period ;
but there  was  this objection to the mode of relief,
that the upper lip did not  project as usual from the
want of that portion of the jaw and teeth,  and an
artificial jaw was required to form  a  support: it is
better, therefore, to  perform  the  operation upon
each fissure of the lip, by uniting the skin upon each
side, to that  which  remains  upon  the projecting
bone,  and to depend upon the  modelling  process of
growth for the gradual diminution of the projection;
the  operation being the same  as that which  is  ne-
cessary for  the simple fissure.   After the union of
the  lip, the  diminution of the  bony projection may
be assisted by gentle  pressure.

            DEFICIENCY OF THE PALATE.

   Inconvenience of.—When there is an  aperture  in
the  bony  palate, the person suffers a  twofold incon-
venience :  1st, In a nasal pronunciation ;  2dly, In the
passing of the food, particularly liquid, into the nose.
   Two modes of relief—If the opening  be confined
to the bony palate, there are  two  modes of  relief,
one  by the  patient's wearing an artificial palate, the
other  by  operation. 
300
  Artificial palates.—The most  simple of the artifi-
cial palates was made for me by Mr. Wiess in  the
Strand, which consisted  of  two plates of silver con-
nected together  in  the  centres by an axis,  so that
the one could be turned upon the other by means of
a key; thus when introduced, it could be easily fix-
ed.   Mr. Wiess shewed me one of the same form,
of elastic gum.  A plate of  silver, with two  springs
which passed  through its  centre, so  as to  expand
when pushed up, would  answer  the same purpose.
The common  contrivance is a piece of  silver, and a
sponge connected to it by  a  chain  or stem;  the
sponge being passed  into the nose through the aper-
ture in the palate, there expands by the moisture,
and fixes the silver plate against  the opening,  but the
animal fluids in the sponge soon become  putrescent,
and render the breath extremely offensive.
  A  portion  of membrane  from the  roof  of  the
mouth might be partially pared  off, and turned over
the opening, its circumference being placed  in con-
tact with the edges of the aperture so as to  produce
adhesion ; but of this operation I have not any ex-
perience.
  For a circular  deficiency in the  velum palati,  an
artificial palate of elastic gum will answer best.
  Operation for division of the soft palate.—An ope-
ration similar to that for hare-lip, has  been perform-
ed for a congenital  division of the soft palate.  Mr.
Cruickshank tried it and failed ; Mr. Roux of Paris,
and Mr. Alcock of London, have since been success-
ful.

                  CANCER  LABII.

  Its  commencement.—This disease wears two diffe-
rent appearances in its commencement.  It some-
times  assumes the character of a warty excrescence, 
301
at others, it is an ulcerated fissure in the  lip attend-
ed with surrounding hardness.
  At first begins in a wart.—When it is at first a wart
it is covered by  an incrustation, upon removing which
an  elevated and ulcerated surface  is  exposed with
surrounding hardness.  A fresh incrustation forms,
additional growth takes place in some parts, and ulce-
ration in  others, until at length  a considerable  pro-
jection is  produced.   When the  incrustation is  now
removed, the surface freely bleeds,  luxuriant granu-
lations appear in some parts and deep depression in
others.   It extends more upon  the red part  of  the
lip than upon the surrounding skin, though ultimate-
ly the latter becomes affected.   It is very little ten-
der to the touch, so that the patient handles it with
great freedom ; but  it is occasionally accompanied
with darting pains.
  At first begins as a fissure.—When it begins as  an
ulcerated fissure in the lip the  surrounding part is
hard, an incrustation is afterwards produced, and ul-
timately  the disease has very much  the  same  ap-
pearance as when it begins as a wart.  It gradually
ulcerates the  skin  towards  the chin, and although
beginning in a small spot at length involves the whole
lip.
   Character of the sore.—The  character  of the sore
is that of a cancerous ulcer, its edges  being everted,
and its surface hard; a gland under the jaw  next be-
comes affected between the symphisis and angle, and
sometimes the  glands  on  both sides: the  gland is
hard and at first not painful,  then the  surface  as-
sumes a livid appearance and  becomes occasionally
acutely painful; at  length it ulcerates, discharges a
bloody serum,  bleeds  frequently, the edges of the
ulcer are everted, the ulceration becomes extensive,
and the surface of  the sore very irregular; several
other  glands in the  neck become affected, difficulty 
302
of breathing and of deglutition ensue, and the patient
falls a victim to the disease after a long period of
suffering.
   Its cancerous characters.—Some persons deny that
the character of this sore is cancerous, but upon what
principle I cannot  understand, for it is unequal upon
its surface, it has irregular, callous,  and  everted ed-
ges, it is accompanied with lancinating pains,  it ex-
tends  its  influence to  the neighbouring absorbent
glands, and when a section is made of it after  its re-
moval its internal appearance is truly schirrhous.
   Rare in the upper lip.—I  have  seen  at least  two
hundred cases of this disease  in  the  under lip, and
have only witnessed one in the upper.   It is  a very
rare disease in  the female ; it is  a  complaint  of age
more than of youth, occurring most frequently from
fifty to seventy years.
   Supposed cause.—A great many of the  persons  in
whom I have seen this  disease have attributed it to
the custom of smoking, believing that  the  tobacco
pipe was instrumental in its production ;  but I have
frequently seen it in persons in whom it could  not be
attributed to that cause.  It seems to be much more
a local disease than cancer in most other  parts of
the body;  the general  health often  appearing ex-
tremely good.

                OF ITS  TREATMENT.

   Escharotics.—In the  early stages of this disease
the sore may be  destroyed  by  the application of
arsenic, which  occasions it to slough;  it might be
also destroyed  by  the  actual  cautery,  but  in  the
very earliest  stages it is most  prudent  and judicious
to remove it by the knife.
   Removal by the knife—The operation  should not
however be performed if a gland under  the jaw be 
303
enlarged, as the disease is then sure to return; but
if the gland be not diseased, the result of the ope-
ration  is  much more  successful than for scirrhous
tubercle in the breast.
  Medicine useless.—No local  applications short of
those that destroy the part, or any form  of internal
medicines, are found to be useful.
  Operation.—The  operation  is performed in the
following  manner: An  assistant puts a  finger  into
each angle of the mouth,  and stretches  the  under
lip to its utmost extent; the surgeon then makes an
incision on each side  of the disease, so  that  a tri-
angular portion of the lip is thus removed.
  Haemorrhage.—The coronary arteries bleed freely,
but do not require to be secured;  but  when the
inferior labial artery is formed on each  side,  by a
large  mental  branch,  I have  found it  necessary to
secure  that vessel  at the  inferior  angle  of the in-
cision.
  Sutures.—Three ligatures are  then required to
bring the edges of the wound together;  one at the
red edge of the lip, and  two  others at equal dis-
tances, in the remaining part of the wound.  These
are to  be passed  through the  lip by means  of a
straight  needle, as in  the operation for hare-lip.
Some  pressure is  afterwards required, to  assist in
the arrest  of the bleeding  from  the  coronary  arte-
ries ; the patient using a sponge for that purpose.
  Two-thirds at least  may  be thus removed, and
yet a  good lip  be afterwards formed.  The liga-
tures  are  to be removed  on the  fourth and  fifth
days, the  upper ligature being  left  to the  fifth day.
  It is a foily in this operation not  to encroach upon
the sound rather than upon the diseased part. 
304
        OP THE OPERATION FOR  TIC  DOULOUREUX.

    Nature of the morbid change  not  known.—Of the
 nature of that change in the nerve  which  produces
 this disease I have no  knowledge,  as 1 have never
 had an opportunity of dissecting a nerve  which had
 been affected with it.
    Appears to be an action under par.—To me  it has
 always appeared,  that  it  is  an  action  under  par,
 rather than an inflammatory action on  the nerve,
 and for this obvious reason, that the remedies found
 successful in it are those of a tonic kind:  large doses
 of  bark, the  free administration  of arsenic,  but
 above all, the remedy recommended by Mr.  Hutch-
 inson of large doses  of  steel, are the evidences  in
 support  of  this  opinion.—Opium,  belladonna,  and
 other narcotics, have only a temporary influence  in
 mitigating suffering.  As local  applications,  I  have
 known belladonna, and an ointment of the  subacetate
 of lead beneficial.
   Sometimes originates  in the brain.—But  this  dis-
 ease sometimes appears to  originate in the brain
 itself,  as  I  have  understood was the case  in my
 friend Dr. Pemberton, who suffered more from this
 disease than  any individual I  have ever  witnessed,
 and in whom a  portion  of bone  was  found  growing
 on the brain.*

  * In the  autumn of last year I was requested to attend a gen-
tleman from Lancashire, on account of his  suffering severely
from a constant pain on the right side of his  face, seated princi-
pally in the branches of the second and third divisions of the
fifth pair of cerebral nerves.   The complaint had existed for
several months previously, and  the pain was occasionally so
acute, that  his friends  thought he would  become  insane.  He
took, at separate periods, mercury, arsenic, steel, bark, sulphate
of quinine, opium, and various other narcotics, but without their
producing much mitigation of suffering.  The vinum colchici 
305
    Division of the nerve.—The operation  of dividing
 the  nerve  tor  this  disease is  sometimes  anxiously
 called for by the  patient, on account of his agonizing
 sufferings;  I have seen an  old weather-beaten cap-
 tain of a man  of war cry  like a  child under the
 painful influence of this disease ;  and a female once
 said to me, after the division of the nerve, "Sir, the
 operating  table  was a bed  of roses  in  comparison
 with the agony which the complaint had produced."
    The nerves commonly divided.—The nerves which
 I have  divided,  have  been  the   suborbitary,  the
 frontal  branches  of  the  ophthalmic, the mental
 nerve,  and  the  portio  dura of the seventh pair,
 which is perhaps  more frequently  the  seat of this
 disease than any other nerve in the body.
   Operation very simple.—The operation is extreme-
 ly simple, and is performed  in the following  manner
 upon  the  suborbitary  nerve.   The  ridge at the
 lower  part  of  the  orbit being felt,  the  foramen

 was the only medicine from which he experienced much relief,
 but it produced so great a derangement of the digestive organs
 (although taken in conjunction with other remedies,) that it
 could not be administered but at intervals.
  He died in the early part of February last, extremely ema-
 ciated,  and completely worn out, by the almost constant and
 severe suffering.  His mental faculties appeared perfect to with-
in a tew moments of his death, which took place on his making
 an effort to stand, when assisted out of his bed.  On examining
 his head after death, 1 found two  fungoid  tumours originating
from the dura mater; one situated on the right side of the sella
tursica, and connected with all the branches of the fifth pair of
nerves, but particularly the second and third ; the other was
 placed  over the cuneiform process of the  occipital bone, was
 of the size of half a large hen's egg, and was connected with the
 other tumour by a process of the same fungoid matter, which
 extended over the extremity of the petrous portion of the right
 temporal  bone.  The smaller  tumour  was  about the size of a
nut.  The pons varolii  and medulla oblongata, which were
 much displaced  by the  diseased  mass, appeared softer than
oatural, at the part immediately over the larger tumour.—T".
   vol.  n.           38 
306
through which  the  nerve passes is situated from a
quarter to half an inch  below the  centre  of that
ridge.   The point of a curved  history is then  pass-
ed into the cheek  three quarters of an inch below
the ridge of the orbit, and to the outer side of the
foramen, and is carried directly to the  bone ;  then
passing it upon the surface of the bone  under the
nerve, and little obliquely upward  towards the inner
canthus of the eye, the point of the knife is  brought
to the back of the skin at the distance of  an inch
from  where it entered; it is then kept  elevated
against the back of the  skin as it is withdrawn,  and
the  nerve  is thus freely divided  by an  opening
through the skin, not above half the size  of that
which is made in bleeding.
  Pressure  with the finger is for  a few  minutes
required, to stop the bleeding  from the suborbitary
artery.
  Division of the frontal branches.—The  operation
upon the frontal branches of the  ophthalmic is per-
formed in a similar manner; as these branches radi-
ate more at the upper part of the orbit, it is neces-
sary to make  the  division a little  more extensively
than in the former case.
  The eyebrow is drawn up,  and the  point of the
curved  bistoury introduced under it on to the ridge
of the orbit, to the outer side ; and  being  carried
inwards close to the  bone towards  the upper part
of the nose,  the point is elevated  to  the  skin,  and
withdrawn close to the  back of it, out of the open-
ing by which it  was introduced,  by which  all  the
branches are divided.
  Division of the mental nerve.—The operation upon
the mental nerve is different to the two former; the
foramen in the side of the lower jaw, through which
this nerve passes, is situated in a line drawn below
and between the two bicuspides; and  the  pain of 
307
the disease in the nerve is felt in the under lip,  and
the lower  part of the side of the face.
   In  this case, to divide the nerve, the under lip is
drawn from  the  gum, and the point of the curved
bistoury is  introduced through the skin of the mouth
close  to the jaw, on the fore part of the  foramen.
and is then carried  backwards close to the bone,
dividing the skin of the  mouth  and  the nerve as it
passes out  of the foramen, the incision  being about
three quarters of an inch in length; pressure is after-
wards required for a short  time over the foramen
to stop  the  haemorrhage from the artery which
accompanies the  nerve.
   Division of the portio dura,—I have only once di-
vided the portio dura of the seventh pair of nerves
for this  disease.  I laid bare  the branches  of  this
nerve anteriorly  to the parotid gland, carefully avoid-
ing it£ duct, and passing  a director under the nerves,
divided many of the branches,  paralyzing that  side
of the face, the  mouth being drawn over to the op-
posite side  ; a few days after the operation erysipe-
latous inflammation succeeded, with  a very high de-
gree of fever, of which this woman died.
   Operation seldom succeeds.—In  the  various opera-
tions which I  have performed for this  complaint, I
recollect but  two cases in which the operation com-
pletely succeeded.
   Affords  temporary  relief.—For  three  or  four
months,  the patient is relieved from suffering,  but
then the disease returns; and it is curious,  that it  is
reproduced whilst the  numbness of  the lip" conse-
quent upon the operation still  remains.   I  have di-
vided the nerve a second and a third time whilst the
numbness was remaining in the lip, produced by a
preceding operation.
   Removal of a portion of the  nerve.—It has been
said, that removing a portion of the nerve  prevents 
308
the pain from returning; but a person who had sub-
mitted  to this  operation informed me, that he had
caustic applied upon  the extremities of the divided
nerve, yet he  consulted me for the returning dis-
ease.
   With respect  to the operation for the  disease,
it ought to be  performed rather at the earnest de-
sire of  the patient than by recommendation of the
surgeon.

                 AURA  EP1LEPTICA.

   Case.—For this disease,  I have only once had oc-
casion to perform an operation.   The case was sent
to Guy's Hospital  by Mr. Masters, surgeon  at  Wat-
ford.   The man had  received a severe blow on his
thumb,  after which he had the  following symptoms,
which had lasted for several months : uneasiness  in
the parts;  pain extending up the arm in the course
of the radial nerve ;  also  to that side of the  neck,
accompanied, by  a  rotatory motion of the  arm  in-
wards ;  occasional loss of sense and volition,  so  as  to
occasion him to fall, but without any struggle ;  he
remained  insensible for  a few  minutes and  then re-
covered, excepting that the attack left some pain  in
his head.   As the man  had recourse  ineffectually  to
a great  variety of internal  remedies and to electri-
city, I recommended him to submit to  the  division
of the nerve, and making an incision  upon the  outer
side of the radius, opposite  to  the insertion of the
supinator radii  longus, 1 laid bare the nerve,  and put-
ting a director under  it, I removed a portion, which
measured, after its  removal, five eighths of  an  inch.
The man had some slight attacks of  the  complaint
afterwards, but on  his return  to Watford Mr.  Mas-*
ters informed me that he entirely recovered, 
309
               LECTURE XXX.

                  ON  AMPUTATION.

   Less frequent than formerly.—The removal of con-
 stituent  parts  of the  body becomes necessary from
 different  causes, but such operations are much less
 frequently  performed  at  present  than  they were
 thirty years ago.
   Improved treatment of compound fractures and dis-
 locations.—The  improved  treatment  of compound
 fractures  renders it rarely necessary to  amputate a
 limb for those  accidents.  A compound dislocation of
 a large joint, a few  years back, led the  surgeon  to
 condemn  the limb to  amputation,  but  it is now no
 longer generally  believed to require it.  There will,.
 however, be cases in which an operation will be oc-
 casionally required for one of these accidents.
   Of aneurisms and diseases of joints.—An aneurism
 in a limb, for which, forty years ago, amputation  of
 the limb  was  frequently performed, is now, by the
 simple operation  invented by Mr.  Hunter,  readily
 and effectually  cured.   The simple chronic and scro-
 fulous  enlargements of joints were formerly often
 deemed to  require the operation of amputation, but
 rest, external irritation,  alterative medicines, and a
 nutritious  diet, now generally do away with the ne-
 cessity of having recourse to so direful  an expedient.
  Of ulcers  and diseased bone.—Extensive ulceration
 of a limb is  now  much more frequently cured than
formerly.   The treatment of the diseases of bones 
310
 is much better understood, and  the result, although
 tedious, is rarely unsuccessful.
   Natural separation of parts.—In  gangrene, consid-
 erable portions of  the feet, or of other parts, will
 separate by the efforts of nature, often producing as
 perfect a cure  as  the surgeon is  able to effect by
 operation.
   Op4ration  sometimes necessary.—Amputation will
 still  be occasionally necessary for the accidents and
 diseases I have  mentioned:  for laceration of  limbs
 from machines;  for the effects  produced  by the
 bursting  of fire  arms; for some  cases  of gun-shot
 wounds ; for chronic and scrofulous complaints, and
 for malignant diseases of a cancerous or fungoid  na-
 ture ; also for deformities which are  either congeni-
 tal or the  result of organic change, and for exube-
 rant growlhs, as tumours.
   All that I wish  to advance upon the  subject  is,
 that although the necessity for this operation still
 exists, that the number of  amputations  thirty  years
 ago was much greater than of those of the  present
 day.
   Much less dangerous than formerly.—Amputation is
 not only much less frequent than formerly, but it is
 an operation of infinitely less danger.   The  exten-
 sive  surface  of wound left after the old operation,
 and filling the wound with  charpie or  flour, led  to
 the highest degree of constitutional irritation; whilst
now, the integument being brought over the wound-
ed  surfacej directly produces a  process of adhesion,
by which the  constitutional disturbance becomes les-
sened and the danger from the operation greatly di-
 minished.
   I shall now proceed to describe the various am-
putations which are required at different  parts of the
limbs.
   The common amputating  instruments are so well 
311
known, that I need not  enter into any particular de-
scription of them, but I  shall  mention those proper
to be used in each operation, when 1 give an account
of the mode of performing it.
  Application of the tourniquet.—Of the various tour-
niquets, I prefer that of Petit,  which  is generally
employed at the  Borough Hospitals.  In applying
this tourniquet, the pad should be placed immediate-
ly under the plate to which the screw is fixed, by
which the screw is made to act  more  effectually on
the  pad.   That  part  of  the limb upon which  the
tourniquet is to be placed should be first surrounded
by a piece of soft  linen  to  prevent  the tape, when
tightened, from cutting the integument.   In the thigh
it should be placed a little above the middle, where
the artery passes  nearest  to  the bone ; and in the
arm,  one-third of  the  length of the os humeri from
its head on the inner side the biceps.
  Artery compressed without the aid of a tourniquet.—
When amputation is required at the upper part of
the thigh,  the termination of the external iliac arte-
ry in  the femoral is to be compressed upon the edge
of the pubes, by an assistant, who  puts one  of  his
thumbs over the vessel,  and the  other  thumb upon
the first,  which is our usual mode.   If  the amputa-
tion  be performed high in the  arm, the  assistant is
either to press  the axillary artery  with his fingers
against the head of the  os humeri, or else  the sub-
clavian upon the first rib, by means of the ring of a
key or a pad, passed behind the  clavicle.

          OF AMPUTATION OF THE FINGERS.

   In  removing a portion of a finger at the second or
third joints, the operation is, I  think, best  perform-
ed in the  following manner:
   Instrument.—The only instrument required is a
common pointed scalpel. 
                       312

   Operation.—The finger being extended, the inte-
 gument is cut  through by a circular incision about
 half an inch  beyond the joint, and a lateral  incision
 is to be made on each side in the direction of the la-
 teral ligaments, extending from over the joint to the
 circular cut; the  portions of integument  are to be
 raised from  the flexor and extensor tendons  below
 and above as far as the joint, making two flaps;  af-
 ter  which the tendons and  one of the lateral liga-
 ments are to be divided, when the joint may be easi-
 ly dislocated, and  the  separation of the part readily
 completed.
   Vessels.—The vessels divided in this operation sel-
 dom require  the application of a ligature, the pres-
 sure from the  dressings  being usually sufficient to
 prevent any haemorrhage.
   Dressings.—The flaps of  the  integument  should
 be brought together, and kept so, by a narrow slip
 or two of adhesive plaster passed over the extremi-
 ty from the  dorsal to the palmar part,  and these
 strips should  be secured by a circular portion a little
 above  the stump.   The  hand and fore-arm  should
 be supported by a sling until the stump has healed.
   Another mode of operating.—The operation of am-
 putation may'be performed at either of these joints,
 by making a  single flap from  the  palmar  part.   In
 doing this the joint must be flexed, when the  scalpel
 is carried  through the  integument on the  dorsum of
 the joint, and through the joint  itself,  dividing  the
 ligaments  at one cut;  the  knife is then passed under
 the phalanx, which is to be amputated, and a flap of
sufficient extent is separated from the palmar side.
  Not always practicable.—This mode of amputating
is more expeditious than that first  described, but it
is  not  applicable  to those cases in which the  finger
is straight and the joint stiffened from disease, as the
knife cannot be  then  introduced into the  joint from 
313
the back part;  there is also much difficulty in sepa-
rating  the flap without including part of the flexor
tendons;  and, upon the whole, the union of the di-
vided parts is not so easily accomplished.
  Applicable to the toes.—These operations are equal-
ly applicable to the same joints of  the toes.
  Amputation of a whole finger.—When  it is  neces-
sary to remove the whole of a finger, I think it bet-
ter  to saw off the extremity of the metacarpal bone,
rather than to open the joint.   If the middle or ring
finger be thus  removed, less deformity results from
the operation, as the remaining fingers approximate
much more than when the extremity of the meta-
carpal bone is left; if the  fore or  little  fingers arc
amputated in this manner, an  ugly  projection is pre-
vented, which would not be of any utility if sulicred
to remain.  The wound  also  unites  more  readily,
than  that which  is  produced  by the  amputation
through  the joint.
  Instruments.—The instruments required  in  per-
forming  this operation are, a  common pointed  scal-
pel, and  a metacarpal saw ;* and my  metacarpal saw
moves upon its axis, so that it can  be made to cut in
any direction.
  Operation.—The finger to be amputated being ex-
tended and separated from the others, two incisions
are to be made through the integument, which meet
at an angle over the dorsum of the metacarpal  bone.
at a short  distance below the digital extremity, and
terminate  on each side of the first  phalanx at the
natural separation of the fingers ; two other incisions
of the same form and extent are to be made on the
palmar side, which arc to join the former  between
  * Iu amputating part of a metacarpal or metatarsal bone, I al-
ways use a chain saw, which 1 tind much more convenient than
the  common metacarpal saw, beina: employed with greater a
cility and cutting more rapidly.—T.
  vol. It.              39 
314
the fingers; the scalpel is then to be  passed  down
on each  side of the  extremity  of the  metacarpal
bone, so as to divide it completely from its  lateral
connexions, and the extensor and flexor tendons arc
also to be cut through at the point of the first incis-
ions; this being accomplished, the blade of the me-
tacarpal saw is  to be introduced between the bones,
and the  extremity to be removed is to be carefully
sawn off.
  Dressing.—The edges  of the wound  are to be
brought into contact, by binding the fingers on each
side of it together, when the hand and fore-arm arc
to be supported by a sling, as after the former ope-
ration.
  Operation of the fore or little finger.—In amputat-
ing either the fore or little finger, only two external
incisions are required, which should begin at a point
below the extremity of the  metacarpal bone, as in
the  other case, only  over the centre of that side
which is outermost, and extend one over the joint and
the  other under it in  an oblique direction, so as to
meet between the fingers;  two flaps are then to be
raised, so as to  expose the extremity of the meta-
carpal bone ; the separation of which  is to be com-
pleted as  before  described.   The edges of the
wound are to be brought into contact  by the appli-
cation of  adhesive  plaster, and  the  arm to be sup-
ported.
  Application of ligatures to the vessels.—If the ves-
sels which are divided in any of  these  amputations
afford a troublesome  haemorrhage, which cannot be
readily checked by pressure, it will be proper to se-
cure such vessels  by ligatures, before   the edges of
the wound are finally  approximated ; and after any
amputation, when a ligature has been applied upon
an artery, one of the ends of  the silk should be cut
off  a little beyond the knot  on the vessels, as it  is
• 
315
perfectly  useless,  and,  if allowed  to  remain, only
tends to increase irritation.
   Toes to be amputated at the joints.—When it be-
comes necessary to remove  any of  the  toes,  they
should be amputated at  the joint in preference to
separating the  extremity  of  the metatarsal  bone ;
because it is desirable to preserve the  width of the
foot  and support of the  body, which would be dimin-
ished by the removal of part  of the metatarsal bone.
   Operation nearly  the  same  as  before mentioned.—
The  operation  may be performed in the same way
as that last described for the removal of the fingers,
excepting that the incisions should not reach beyond
the joint,  which should be opened from  the side, as
in the amputations at the second and third joints.
   After-treatment.—After  any of these operations
upon the toes, the patient should  observe the recum-
bent posture, until union of the edges of the wound
has been  effected.
   Amputation through the metacarpus or metatarsus.—
Amputation should be performed through the meta-
carpal or  metatarsal  bones,  when all  the  finger or
toes are  so much  injured as to require  removal;
it is  much better than amputating  through the car-
pal or tarsal bones, as, in the hand, the patient after-
wards derives great advantage from the use of the
carpus, which is thus preserved ;  and, in the foot, the
insertions of the tibialis anticus, with those of the pe
roneus longus and brevis being uninjured, the remain-
ing part of the foot is much  more useful, than when
the  metatarsal bones are entirely removed  : in eith-
er case the wound  unites  sooner than when the ar-
ticulations are exposed.
   Portions of the hand removed.—In some cases, if
the injury or disease does not extend to all the meta-
carpal or  metatarsal bones, only such as are injured or
* 
316
diseased should be amputated.  Thus, in the hand,
the thumb with its metacarpal bone alone may be re-
moved, or all the fingers with their metacarpal bones
may be amputated, the thumb  being allowed to re-
main ;  the middle and ring fingers, the ring and lit-
tle fingers; or the middle, ring, and  little fingers with
their  matacarpal bones, may, in like manner, be se-
parated from  the others.
  Of  the foot.—In  the  foot, the  great toe  and  its
metatarsal bone may be amputated  from  the  others,
or the others  from it;  or the second and third, the
third and fourth, the fourth and fifth ;  or the third,
fourth, and fifth  may be  removed together  with
their metatarsal bones.
  Case.—In one instance I removed the  middle and
ring fingers with  their metacarpal   bones; approxi-
mating the  fore and  little  fingers,  which were not
injured, by bandage.   The patient  recovered quick-
ly, having  perfect  use of the remaining  portion of
the extremity.
  Case.—I also, in another patient, amputated the
thumb and the three  inner fingers with  their meta-
carpal  bones, leaving only the fore  finger, which was
infinitely more useful than any artificial  hook could
have been.
  Cases.—The metatarsal  bone of the great toe I
have several times had  occasion to remove; and Mr.
Key has amputated, the four smaller toes, with their
metatarsal bones, the two  outer cuneiform, and the
os cuboides, successfully; leaving the os calcis, astra-
galus, navicular and internal cuneiform bones  of the
tarsus, with the metatarsal  bone of the great toe
and the toe itself.*

  *  I have amputated through the metacarpal bones of the  fin-
gers, leaving only the thumb; and in another patient I removed
the three inner fingers, with half of the metacarpal bone of the
middle,  and the whole^" those of the ring and little fingers, to- 
317
      OF  AMPUTATION THROUGH THE CARPUS.

  Instruments.—The only instrument required is the
catling.
  Application of the tourniquet.—Before commencing
the operation, the tourniquet  should be  applied on
the upper arm.
  Operation.—The  patient being seated  in a chair,
the surgeon first makes  a circular incision through
the integument, just over the bases of the metacar-
pal bones, which should include more of the integu-
ment upon the  back of thejiand than towards the
palm; he then dissects the skin back  as far as the
styloid process of the radius ;  the integument is held
back by an assistant, whilst  the surgeon  takes hold
of the hand he is  about to remove ; and, feeling for
the extremity of the styloid process of the radius, he
passes the catling into the joint between the  radius
and  scaphoid bone,  by dividing the external lateral
ligament; and he completes the amputation by car-
rying the knife  through to the inner side of the car-
pal joint.
   Vessels.—It will be necessary before dressing the
stump to secure the ulna  and radial arteries by liga-
tures.
   Dressing.—The edges of the integument are to be
brought together over the extremity, and  retained
in contact by means of  straps  of adhesive plaster,*
passed from over the flexor to  over the  extensor
                         *
gether with the  unciform and orbicular bones of the carpus.
Both cases succeeded.—T.

  * I prefer the plaster I have before recommended, composed
of equal parts of the empl: thuris comp: and empl: saponis, to
the common adhesive plaster, on account of the tendency of the
latter to create irritation. 
318
muscles, and these  straps  are to be  confined  by a
circular piece, after which the arm is to be support-
ed in a  sling, or upon a pillow if the patient be con-
fined to bed.
  Amputation between  the  second  and third  row.—I
have known the hand  amputated between the first
and second  row of the carpal bones, but  1 think  it
objectionable on account  of the number of joinls
which are  exposed.

      OF AMPUTATION THROUGH THE  FORL>ARM.

  Instruments.—The necessary instruments are,  the
calling and  the saw.
  Position.—The patient is  to  be seated, and  the
tourniquet  applied as in the  former operation.*
  Operation.—The limb being extended, the surgeon
commences  the operation,  by making a circular  in-
cision througli the  integument sufficiently  high  to
avoid the  numerous  tendons  at the lower part of the
fore-arm; then he  separates the integument from
the subjacent parts, and  turns them back  to the ex-
tent of  about an inch and a  half; an assistant keeps
this supported whilst the surgeon cuts  through the
superficial muscles by another circular incision, and
allowing a short time for their retraction,  he  divides
the deep-seated layer, and exposes the  bones, from
which he  carefully separates the  muscles  and  inter-
osseous  ligament, by passing the catling between and
around  the  ulna and radius at the part on which  he
intends  to  apply  the saw..   The fore-arm is  then

  * If the integument of a limb be covered with  hair, the pa-
tient will be saved much suffering  by having that part, on which
the plaster will be applied, shaved, before the commencement
of the operation ;  otherwise when  the plaster is removed, these
hairs are  drawn out with it, rendering  the separation of the
dressing extremely painful.—T. 
319
held in such a position that the  surgeon  can easily
saw through  both bones at once,  in doing which he
should make  use  of the  whole of the cutting edge
of the instrument, and employ very  little pressure,
as the weight of  the saw itself  is almost sufficient.
If the ends of the bones have any sharp points pro-
jecting from them which will  sometimes  happen  if
they  have not  been cleanly  sawn  though,  these
points should be carefully taken off by the bone nip-
pers.
   Vessels.— After this amputation four vessels will
generally require to be secured;  viz. the  ulna, radi-
al, and two interosseal arteries.
  Dressing.—The wounds should be dressed as that
after  the amputation through the  carpus,  and  the
same  treatment adopted.
   Two flaps.—This amputation  may  be  performed
by  making two flaps, one formed  from the posterior,
and the. other  from the  anterior part of the fore-
arm.
  Danger of amputating low down.—I have seen two
cases in which inflammation and sloughing of  the
tendons have followed amputation performed through
the lower part of the  fore-arm a  little above  the
carpus ;  they both proved fatal.   It is better  there-
fore to avoid operating  at this part, as little advan-
tage is gained by leaving more of the bones, and the
risk is greatly increased.

      OF AMPUTATION THROUGH THE UPPER  ARM.

  Instruments.—The same instruments as used in the
last operation are all required.
  Position.—The tourniquet should be applied suffi-
ciently high to  allow of  ample space  for the per-
formance of the amputation  and the patient should
be seated in a  low chair.
0 
320
   Operation.—An assistant extends the arm, and the
 surgeon first drawing up the integument with his left
 hand so as to put it on the stretch,  divides  it by a
 circular cut with  the  catling about  one  inch and a
 half above the olecranon;  he then raises it from the
 parts beneath  to the extent of about two inches, ac-
 cording to the  size of the  limb, and turning it back,
 he, by another circular cut, carried close to the re-
 flected integument,  divides  the superficial muscles,
 and subsequently the deep-seated muscles down to
 the periostium, and  he finishes with the knife  by cut-
 ting through the periostium at the part  on which he
 is to apply the  saw.  The integument  and muscles
 being  carefully held back, the saw is applied  and
 the bone divided, when the amputation is completed.
   Vessels.—Three arteries will generally require the
 application  of  ligatures, viz. the brachial, profunda,
 and ramus amastomoticus.
   Dressing.—The edges of the integument are to be
 brought together by  the application  of adhesive
 plaster, and the patient being placed in  bed  on his
 back, the stump is to be  supported on  a pillow, so
 as to be rather higher than the shoulder.
   Application of a roller.—If the  skin  be  loose  or
 the muscles flabby, a roller should  be  put  around
 the limb to give support to these  parts, before  the
 patient  be placed in  bed.
   It may be necessary in  some cases to  amputate
 higher up than I have mentioned, but  the steps  of
 the operation will be otherwise  the same.

      OF AMPUTATION AT THE  SHOULDER  JOINT.

   Instruments.—The only  instrument required  is a
catling.
   Subclavian artery compressed.—The subclavian ar-
tery is  to be  compressed  upon  the first rib, from 
32 i
above the clavicle, by an  assistant.   The ring of a
common key covered with some soft linen is a con-
venient  instrument for this purpose.
  The patient should be seated on a  low chair, and
the arm, to  be removed, should be  elevated a  little
from the side by  an  assistant.
   Two modes of  operating.—The operation may  be
performed  by making a single  flap or two flaps; 1
prefer the former, but in  some cases, on account  of
disease extending so as to prevent the formation  of
a single flap, the  latter  mode should be adopted.
   Operation with a single flap.—In making the sin-
gle flap, the surgeon raises the deltoid muscle with
the fingers  and thumb of  his left hand,  and  intro-
ducing the catling through the integument, and under
the muscle  near to its insertion, he cuts upwards close
to os humeri as far as the under part of  the acromi-
on process; the  integument  and larger part of  the
deltoid  muscle  are thus raised, so as completely to
expose  the outer  part  of the shoulder joint;  the
arm being  then drawn  downwards, the  catling is
passed  into  the joint at the  anterior part, so as to
divide the tendon of the bicep3  muscle,  and  after-
wards is carried  round the head of the  bone  to  cut
through the capsular  ligament:  the separation of
the limb may be completed either  by passing  the
knife over  the head of the bone, and cutting down-
 wards to the axilla, or by placing  the  knife  in  the
 axilla and dividing upwards  to the joint; in either
 case  the amputation should be finished by one stroke
 of the catling.
   Vessels.—The axillary artery is to be  immediately
 secured by a ligature, and small branches from  the
 circumflex  arteries may be required  to  be tied.
   Operation with  two  flaps.— When two  flaps  are
 required, the first incision extends from just  below
 the point  of  the  acromion downwards, and  back-
   vol. h.               40  9 
322
 wards into the axilla, being curved a little forwards
 and  passing below the  insertion  of the  latissimus
 dorsi muscle ; the back flap is then raised, dividing
 at the same  time part of the deltoid, and the inser-
 tion  of  the latissimus dorsi; the  anterior  incision
 through the  integument is begun from  the same
 point as the  posterior,  but  carried downwards and
 forwards below the insertion of the pectoralis major,
 into the  axilla, so as to meet the  termination of the
 first incision; this flap is then  raised in part, to ex-
 pose the capsular ligament,  which  is to be divided,
 together with the tendon of the  biceps muscle as in
 the  former operation; after which, the head of the
 bone being dislocated, and the flaps being held back,
 the  catling is passed behind the  bone,  and the am-
 putation is completed by dividing the remaining por-
 tion of the interior flap  together with  the axillary
 vessels, nerves, &c.  The artery is to be secured as
 before mentioned.
  Dressing.—After either mode of amputating, the
 straps of adhesive  plaster,  employed to keep the
 edges of the  wound in contact, are best applied from
 before to behind, and should  be of sufficient length
 to keep a firm hold.
  Operation  successful.—In  every instance in which
 I have performed the amputation througli this joint,
 and every case in which  I have seen it done, the re-
covery of the patient has been speedy and perfect.

OF AMPUTATION  BETWEEN THE  TARSUS AND  METATAR-
                       SUS.

  Instruments.—As I  think  it best  to  saw  off that
part of  the internal cuneiform bone, which supports
the metatarsal bone of the great toe, a saw will  be
required, as  well as a strong catling.
  Position.—A tourniquet should  be applied  upon 
323
the thigh, and the patient should be placed upon  a
low table  in the recumbent  posture.
   Operation.—The leg  and foot  being  extended,
and fixed  by an assistant, the surgeon divides the in-
tegument across the dorsum of the foot, commenc-
ing at the base of the metatarsal bone of the great
toe, and terminating the incision about  half an inch
beyond that of the little toe ;  he then  makes a late-
ral incision  on each side, so  as to enable him easily
to dissect up  the flap of integument  as  far as the
joints of the four smaller metatarsal bones, and that
part of the internal cuneiform which is on a level
with these  articulations ; the extensor tendons being
next  divided,  the four small  metatarsal bones are
bent downwards,  and  their ligamentous  connexions
with the  tarsal bones cut through with the point  of
the catling, after which, the internal cuneiform bone
is sawn througli even with the other  tarsal bones :
the amputation is  completed by passing the catling
between  the separated bones, dividing the flexor ten-
dons, &c, and forming  a flap of about  equal size  to
the superior from the integument on the  sole of the
foot.
    Vessels.—The anterior tibial on  the dorsum  pedis,
and the two  plantar arteries of the  sole, will most
 probably require the application of ligatures.
    Dressing.—The integument is to be brought over
 the extremities of the  bones, and the edges of the
 wound kept in contact by straps of adhesive plaster,
 passed from the sole  to the dorsum;  the patient is
 to be placed  in bed, and the foot supported by a pil-
 low', until union has taken place.
    A single flap may be made.—Sometimes a single flap
 may be made from the dorsum, or sole of  the foot,
 but it does not unite so readily as  the double flap. 
324
        OF AMPUTATION THROUGH THE  TARSUS.

   Instrument.—A catling only is necessary in  per-
 forming this operation.
   Position.—The  tourniquet  must be applied, and
► the patient placed as in the former case.
   In this operation, the navicular bone is to be sepa-
 rated from the astragalus, and the os cudoides from
 the calcis.
   Operation.—The surgeon, having felt for the pro-
 jecting point of the navicular bone on the inner side
 of the foot, cuts through the integument about three
 quarters of an inch beyond it, straight across  the
 dorsum of the foot, and  having made two small  late-
 ral incisions, he dissects back the upper flap, and  di-
 vides the  extensor tendons over  the  articulations,
 which  he  then opens, first, by cutting  through  the
 lateral  ligaments on  the inner side, uniting the navi-
 cular bone to the  astragalus, then the  ligament  on
 the dorsum connecting  the same  bones,  and  after-
 wards  the ligaments between the os cuboides  and
 calcis,  above  and externally ; the knife being  then
 passed down between the articulations, the inferior
 ligaments with the flexor tendons and muscles in the
 sole are divided, and  the operation concluded  by
 making an inferior flap of  the integument equal to
 the superior.
    Vessels.—The same arteries require to be secur-
 ed  as  after the former operation, and  the dressing
 and after position of the patient are  to  be similar.
    Not a successful operation.—From  a  comparative
 result of this operation, with that of sawing through
 the  tarsal  bones, I  am certain  the  latter produces
 less irritation and danger than the former. 
325
      OF AMPUTATION OF THE LEG BELOW  KNEE.

   Various  modes of operating.—This operation may
be performed with a circular incision, and with  a
single or double flap.   I  prefer the  first, but cases
may present  themselves, in which it may be proper
to adopt either of the other modes.
   Instruments.—In  performing the operation with a
circular incision, a small amputating knife  is usually
employed in completing the first step; but a catling
is  necessary to  divide the soft parts between the ti-
bia and  fibula;  and this, if rather larger than usual,
does equally  well in the commencement.   A saw is
also required.
   Position.—The patient is to be placed in a recum-
bent position, on a table, and the tourniquet is to be
applied upon the thigh.
   Operation.—One assistant holds the leg, and sup-
ports it at a convenient height; another  assistant
grasps the leg just below the knee and keeps the in-
tegument stretched by drawing it towards the thigh,
when the surgeon commences  his  first incision over
the anterior  part of the tibia, about six inches below
the patella,  and carrying the knife round the limb,
he at one sweep divides the integument, terminating
the incision at the point from which he commenced;
he next separates the integument from the subjacent
parts to the  extent of two inches or more, and turns
it up, in which position it is retained by  an assistant,
whilst the surgeon cuts through the superficial mus-
cles,  close to the reflected integument; and having
allowred these to retract, he divides the  deep-seated
with the interosseous ligament and  the  periostium
by passing the catling between and around  the bones.
The knee being then turned inwards, the  saw is  ap-
plied first upon  the tibia, and  when this bone has 
326
been in part divided, the saw is made to act upon the
fibula also, so that the amputation is finished by saw-
ing through  the remaining portion of the  tibia and
the fibula together.

     OF AMPUTATION  WITH A SINGLE FLAP BELOW
                      KNEE.

   Maybe performed in two places.—This  operation
may  be performed as low  down as is possible with-
out interfering with  the  Tendo Achillis,  when the
patient is desirous of afterwards wearing an artificial
leg made of cork, instead of the common wooden
one;  otherwise the bone should be sawn  off  at the
same point,  as when the circular incision is made.
   Instruments.—A long catling and a  saw will be re-
quired.
   Operation.—The  position of the patient, and of the
limb, being as when the circular operation is perform-
ed, the surgeon feels for  the posterior edges  of the
tibia  and  fibula, over one  of which he  places the
thumb, and  over the other the fore finger of his left
hand, the palm resting upon the anterior part of the
limb; the extremity of the catling is then introduc-
ed immediately below one of these points, and stea-
dily  thrust through the calf  of the leg, until  it pro-
trudes just below the other point, when the blade is
carried downwards, so as to form a flap of sufficient
size, from the muscles and integument  posteriorly ;
the next step of the operation is, to  divide the inte-
gument anteriorly,  by making an incision  commenc-
ing at the place at  which the catling was thrust in,
passing over the  fore part of the leg, and terminat-
ing at the spot from which the catling was  pushed
out:  the amputation is completed after this, in. the
same manner as in  the common operation.
   Operation with a double flap.—A  double  flap  is 
327
sometimes made from the outer and inner sides of
the limb,  when the surgeon commences the opera-
tion by an incision on the outer part of the leg, reach-
ing from  the anterior edge of the tibia to the  back
of the calf; and having a semicircular form with the
convexity toward  the  maleolus  externus, he  then
dissects back the flap of integument, and afterwards
makes a corresponding flap on the inner side,  com-
mencing and terminating as the  former.  The flaps
being held back by an assistant, the  operation is fi-
nished in  the usual manner.
   Vessels.—After either of these amputations three
vessels will have to be secured,  viz.  the anterior ti-
bial, the  posterior tibial, and  sometimes  the pero-
neal.
   Dressing.—It is best in  either case  to place the
straps of adhesive plaster, when dressing  the stump,
from side to side, rather than from above to below,
as, by this, pressure  is avoided  upon  the  anterior
edge  of the tibia, which  might  otherwise  produce
much irritation and ulceration.
   After-position.—The patient should be  placed up-
on his back in bed, and the  thigh being flexed to-
wards the  abdomen, a pillow should be  put  under
the  ham,  and the stump be  allowed to  hang  over
it.  The limb should be inclined a little to the outer
side.
   Objections to a single flap.—The objections to the
operation with a single flap are, that the wound does
not unite so readily as that made by  a  circular inci-
sion ;  and  if after-haemorrhage  occurs, which  ren-
ders it necessary to open the stump, there is a great-
er difficulty in securing the bleeding vessels ; and in
debilitated persons, the disturbance of the adhesions
is  likely to produce a slough of the flap.  The  ante-
rior  edge  of  the  tibia  being also more exposed  i«
more likely to exfoliate, and the subsequent contrac-
tion of the flap makes the union tedious. 
328
  Sometimes necessary.—When, however, the integu-
ment upon the anterior part of the leg has been de-
stroyed, the formation of a single flap from the pos-
terior part becomes absolutely necessary.

          OF  AMPUTATION ABOVE THE KNEE.

  Instruments.—A large amputating knife and a saw
will be required.
  Position.—The patient is to be placed upon a ta-
ble on his back, and the tourniquet is to be  applied
high enough  upon the thigh to allow of ample room
for the  retraction of the integument and muscles.
   Operation.—One assistant supports  the  leg,  and
another draws up the integument on the upper part
of  the  thigh.  The surgeon first cuts  through  the
integument surrounding the limb about one inch  and
a half above the patella, to  avoid  the bursa of  the
rectus, beginning  on  the superior part  over the  rec-
tus, and passing  the knife round with  one sweep to
terminate at the  same point;  he then dissects up the
integument  for about  three inches, and this is kept
reflected by  an  assistant whilst the superficial mus-
cles are divided  by another circular cut close to it;
the assistant holding  the  integument  then draws it
upwards  to assist the r^Jraction of these muscles, af-
ter which the deep-seated muscles and the periosti-
um are cut through so  as to expose the bone, which
is lastly to be sawn through.
   Vessels.—The following vessels will require the
application of ligatures : the femoral branches of the
 profunda, and sometimes the sciatic.
   Dressing.—The integument is to be brought  over
 the end of the stump from side to side, and confined
 by straps of adhesive  plaster, after which, the pa-
 tient is to be placed upon his back in  bed, and a pil- 
329
 low should be put under the upper part of the thigh
 so as to elevate the stump.

          OF  AMPUTATION AT  THE HIP JOINT.

   Femoral artery to be secured first.—In this amputa-
 tion it is decidedly the safest plan to secure the fe-
 moral artery by a ligature at Poupart's ligament, as
 the first step of the operation.
   Mode of doing it.—An incision is begun two inches
 above the middle of Poupart's ligament and is  ex-
 tended two inches below it:  the femoral  artery is
 to be laid bare, and the ligature  introduced at  the
 centre of the incision is to be tied upon the denuded
 vessel opposite  Poupart's ligament, and above  the
 arteria profunda.
   Operation,—A long  catling is then used to make
 the inner incision through the integument  and  mus-
 cles.   This incision is to  be begun at the lower part
 of that which was made to expose the artery, and it
 is to be carried from thence on the inner side of  the
 thigh obliquely downwards, and  is then continued on
 the outer side of the thigh below the trochanter  ma-
 jor to the point at which it began; in this way a
larger portion of integument  is left to form a cover-
ing to the stump than would  be  produced  by a cir-
cular incision without obliquity.
   In  the same line a second incision  is to be made to
divide the muscles, but the edge of the knife is  to
be inclined obliquely upwards towards the joint,  and
the integument and muscles being drawn back, those
of the latter which are inserted into the trochanter
major should be cut through.
  A third incision is to be made to divide the psoas
and iliacus internus muscles and  the  forepart of  the
capsular ligament, when the knee being pushed back-
wards and outwards the head of the bone is dislocat-
  vol. ii.              41 
330
 ed as far  as  the ligaraentum teres will permit; this
 being divided, the head of the bone turns complete-
 ly out of the acetabulum forwards.
   A last  incision is made  by passing the knife  over
 the head of the  bone,  and behind it, so as to cut
 through the remaining muscles, &c.
   Not the quickest mode.—I am ready to acknowledge
 that this  is not the quickest mode of removing the
 limb;  but securing the artery in the  first instance
 prevents a patient, who is much reduced, from even-
 tually  sinking in consequence of the loss of a  very
 considerable  quantity  of blood.
   Vessels.—When  the limb has  been  removed,
 branches  of  the obturator, ischiatic, and gluteal ar-
 teries will required to be secured.   The sides of the
 wound are to be brought together,  and, if they easi-
 ly meet, by adhesive  plaster only; but if there be
 any difficulty  in  their  coalescence, it is  best to em-
 ploy a suture.
   The  same after-treatment is necessary as after
 other amputations.
   Preferable  to saw through the trochanter.—I am,
 however,  of opinion, that in every case in which the
 amputation can be performed by sawing through the
 thigh bone below the attachment of the capsular li-
 gament, that  it should be done in preference to open-
 ing the joint and  removing the head of the  bone
 from its socket.
   Case.—I have only once amputated at the hip-
joint, and  the patient  recovered, but only after ex-
 cessive suppuration from the acetabulum, sloughing
 of portions of the cartilage, and continuance of suf-
 fering and fever,  exposing  him to  great risk, which
would have been greatly lessened had it been  possi-
ble from the state of the bone to have sawn through
 the os femoris at the trochanter.
   Removal of the dressings.—*The removal of the 
331
dressing for the first time after an amputation must
depend in a great measure upon the feelings of the
patient as regards the stump, and  from the appear-
ance of the discharge.
  On the sixth or seventh  day.—If the patient does
not experience any unusual  pain in the stump, the
plasters should not  be  disturbed for six or seven
days, by which time the adhesion of  the edges of
the wound will have become sufficiently firm to pre-
vent any risk from the removing the dressings, pro-
vided it be done carefully.
  Part  cut away.—Should  the  patient experience
shooting  pain in the stump, and  have other  symp-
toms of suppurative  inflammation, some portion of
the plaster should be cut away from the lower part
of the wound, in order to allow of the escape of any
matter that may form, and a  light poultice  should
be applied.
  Plasters snipped.—When  a tightness is felt at any
part of the stump from the  pressure of the  plaster,
the surgeon should snip  some of  the  straps on the
side, which will generally relieve  the pressure.
  Mode of removing the vlastcr.—When the  stump
is dressed, the straps of plaster should  be taken off
one  by one, and care is required  not  to disturb the
ligatures ;  if union of  the wound  be not  complete,
some fresh straps  should be applied as the old ones
are  removed, by  which mode  separation  of the
edges of the wqund may be greatly  prevented.
   Sometimes  to be removed  early.—Should the first
dressings  become  much  loosened, or the  stump be
excessively painful, the  plasters  must be removed
earlier than I have mentioned.
   Separation of ligatures.—If the ligatures  do not
come away by the fourteenth day after the opera-
tion, the  surgeon  should gently  draw each  thread
when he  dresses the  wound, in  order to expedite
their separation.
/ 
 
       APPENDIX.
< 
 
ON THE
AREOLAR,  OR  MAMMILLARY  TUMOUR.


           By SIR ASTLEY COOPER, Bart.
  Age at which it occurs.—At the  age of seven years,  and
from that period until  puberty,  children are not unfre-
quently subject to the swelling behind the nipple, or
mammillae of the breast.  This swelling  occupies a circle
of an inch  or  more, involving  the  posterior part of the
nipple.
  Symptoms.—The child, feeling uneasiness in the part, is
led  to examine it with attention, and then finds a swelling,
which is generally tender to the touch,  and is sometimes,
though  not commonly,  acutely sensitive.  The skin over
it is undiscoloured;  it moves freely upon the pectoral
muscle ; but the nipple  moves with it.   I have seen it fre-
quently, both in boys and girls; but I think more frequent-
ly in the  male than in the  female.  It generally affects
only one breast; but sometimes, though rarely, it exists in
both.  It does not  appear to accompany a scrofulous dis-
position, but is found in irritable young persons.  The age
at which it has most frequently presented itself to my ob-
servation,  has  been from eight to  twelve years.
  Within  this period,  then, a surgeon  will be sometimes
called  upon to remedy a hard circular  sensitive  tumour
behind the nipple  and areola.  Its cause I shall presently
proceed to explain, when existing at this period of life.
  Not productive of serious mischief.—I have never  seen it
productive of any serious  disease.  Sometimes,  however,
it endures for several months, if attention be not paid to
the  means for  its removal.
  Treatment.—The best mode of treatment consists in the
application of the emplastrum ammoniaci cum hydrargyro. 
336
  and in giving small doses either  of the  hydrargyrus cum
  creta,  with rhubarb, or of the oxymurias hvdrargyri, with
  bark or sarsaparilla; under the influence of which remedies,
  it generally becomes  gradually absorbed in the space of
  from two to three  months.   It sometimes yields to evapo-
  rating  lotions.
    Disease in the adult.—The  same part  which  is affected
  posterior to the nipple, in earlier  periods  of life, becomes
  the  seat of more  serious disease in after age.   For the
  structure, which I am presently to describe, is liable, par-
  ticularly in the male, to be affected with the two malignant
 diseases to which the body is subject, namely to the schir-
  rous affection, or to the fungous.

           OF THE  SCH1RRUS OF THE MAMMILLA.

   Symptoms.—This disease begins with a circular swelling
 at the root of the nipple.   It is at first free from pain, but
 is  excessively hard, and is  somewhat irregular upon its
 surface.  It gradually  increases  in  size,  and  during its
 growth a shooting, darting, and occasionally a lancinating
 pain strikes through the swelling, and to the shoulder, in
 the course of the mammary nerves.
   Ulceration.—A slight ulceration next supervenes  upon
 the surface of the nipple,  which is succeeded by a yellow-
 ish brown  incrustation.   When  the  first incrustation is
 separated, it is succeeded by another, and a deeper ulcer-
 ation ensues, by which process the nipple of the breast is
 gradually removed, and the schirrous substance is exposed.
 Whilst  the ulceration is proceeding in the centre, the
 schirrus increases  in circumference,  until  it occupies  a
 considerable circle round the nipple, and as the bulk of
 the disease  augments, the pain with  which it is accompa-
 nied is likewise aggravated ;  yet the diseased part is only
 in a slight  degree  tender to the touch, and the patient is
 often seen to handle it in  an unfeeling manner.
  Bleeding.—The discharge from it, which had previously
 formed an incrustation, now increases and becomes fluid,
and the sore frequently bleeds.
   Glands affected.—The glands in the axilla become en-
larged and hardened, after a long continuance of the com-
plaint.  The patient's lungs become  diseased, and water
is effused into the cavitv of the chest.   I have seen several 
337
males, and one or two females die of tfois complaint;  and
I have given a view of the appearance which  the swelling
assumes on dissection.
  Removal necessary.—As  this disease is beyond  the con-
trol of medicine, for none  that I have ever known  recom-
mended, or seen employed, seems to have  the least influ-
ence in preventing its destructive effect, its removal must
necessarily be effected either by the knife or by the appli-
cation of arsenic.  The former mode  is vastly preferable
to the latter ;  it is upon the whole less painful in the exe-
cution,  and it is of more certain efficacy in completely re-
moving the disease.   Arsenic, on  the  contrary, often but
partially removes the complaint: and the irritation which
it excites extends the disease to the neighbouring absorb-
ent glands.  The absorption of the mineral, also, some-
times  produces  serious  effects  upon the   constitution.
When the disease is clearly and completely removed by
the knife, the  edges of the wound are brought together,
and they readily unite by adhesion.
  Treatment if an operation cannot be performed,—If the dis-
ease has been neglected, if extensive ulceration has ensued,
and the complaint has proceeded beyond the  relief which
is to be derived from  surgical operation,  the  applications
which I have seen most advantageous in tranquillizing the
sore, and improving its appearance, have been chalk  and
opium, in the proportion of an ounce  of the former to a
drachm of the latter; oxyde of zinc and opium in the same
proportions;  or oxide  of bismuth with opium.   These
means, however, only retard the progress  of the disease,
rendering the descent to the grave  a little more easy  and
a little less rapid, but they do not prevent the fatal termi-
nation of the complaint.

      OF  THK FUNGOUS  TUMOUR  OF THE MAMMILLA.

  Symptoms.—Of the fungous tumour  of this part I have
seen three different instances, each of which existed in the
male, and each was removed.
  The tumours began behind the  nipple, which adhered
firmly to their surfaces.   They were globular, and did not
possess the hardness of true schirrus, but felt at first more
like  simple chronic  tumours,  and grew less firm as they
increased.  They were  but slightly tender when pressed,
   vol. 11.          42 
333
 hiv] entirely free from pain.   They neither of them had ul-
 cerated.   After they had existed for several  months they
 began to increase rapidly, and this circumstance  excited
 alarm in the minds of the patients, so as to lead  them  to
 make application for surgical assistance.  The medicines
 which I advised, and the applications which I proposed,
 appearing to have no influence  in preventing the  progress
 of the disease,  I recommended  extirpation.   Two of the
 patients recovered without any returning disease ; the third,
 after a few months, sunk  under what was believed to be
 hepatic disorder.
   .More spongy than schirrous.—I have given  a plate of the
 appearance of one of these tumours ;  it is much more spon-
 gy than the true  schirrus.   The vessels which it  possesses
 are more numerous, and their diameters larger, more espe-
 cially of the veins.  It  not only adheres to the nipple, hut
 it proceeds from  its basis.  The vessels which supply it are
 of considerable size, and require to be carefully secured to
 prevent after-ha?morrhage.  In  neither of the cases had it
 contracted adhesion to the pectoral muscle ;  and there was
 therefore no difficulty in detaching it from the surrounding
 parts.

            ON THE  SEAT OF  THESE DISEASES.

   Having  thus described the diseases which  are placed at
 the basis of the nipple, I shall now proceed  to point  out
 the structure in which these complaints begin ; and which
 the plates connected with the work  will very clearly ex-
 plain.
   Discharge of fluid from the nipple of the  infant.—A child
 born at the full period of gestation, whether it be male or
 female, is found to have, issuing from its nipple, a fluid of
 milky appearance, which, when  alcohol is poured upon it,
 deposits  a solid, which has the  appearance of coagulated
 albumen.   This fluid the nurses are in the habit of press-
 ing out; as they  pretend that it is liable to excite inflam-
 mation if suffered to  remain.   Whether this be the case or
 not, or whether the inflammation which sometimes ensues
 be the result of pressure and friction which the nurses em-
ploy,  1 am not able to state ; but inflammation does some-
times  ensue, and require fomentation for its relief.
  Structure of the part.—Thirty-two years ago I first learn- 
339
 ed there was such a discharge from the nipple ; and was
 led to examine whence it proceeded ;  when, upon making
 a  section through the middle of the nipple towards the rib-,
 f found a circular  glandular structure, larger than a large
 pea, and  situated directly  behind the nipple.  It is of a
 red colour, from its extreme vascularity.  It con tains ducts
 vyhich open at the nipple ;  and from these may be pressed,
 first a milky fluid,  afterwards a  sebaceous matter.   The
 nipple over it is situated in a depression, and appears red
 and granular in many subjects.  The artery which supplies
 the gland is derived from the axillary  ; and the branches
 derived from, and  distributed to the gland are numerous.
 Veins return the blood in the  course of the arteries; and
 filaments of nerves  from the axillary plexus are distributed
 to it.
   Mode of exhibiting it.—All that is necessary  to do, in or-
 der to observe this structure, is to make an incision through
 the centre of the nipple.   In the foetal state, between the
 seventh and the  ninth month, this glandular substance is
 found, but of smaller size.   At the end of the first year, it
 is  still large and continues  so during  the second and the
 third year; and thenceforward it  seems to  lessen in  both
 male and female until the seventh and eighth year.   It is
 most  conspicuous  in fat  subjects, as it  is kept extended
 from the nipple by the adipose substance.
   Evolution of the nipple.—About the eighth year it begins
 to increase, hut  it varies as to time in different persons ;
 and as it grows towards the age of puberty the nipple be-
 comes evolved from it.  In the female, at  the age of pu-
 berty  two tumescences will appear ; the one a  small sphere
 directly  surrounding the nipple ;  which then  rather  sinks
 into this  little swelling;  and the other  a larger sphere
 which is composed of the mammary gland, or gland of the
 breast.   Thus there is a  mammillary  and  a mammary
 growth ;  a mammillary producing  the nipple, which is gra-
 dually envolved as the breast increases ; a mammary which
 is composed of the  lacteal gland,  the  lactiferous tubes  of
 which proceed  through the mammillary process.  In  the
male the mammillary gland forms the  nipple ; but instead
of tubes proceeding through it, ligamentous cords are seen
radiating from the point of the nipple through the mammil-
 lary substance.   These  ligamentous cords terminate in a
compact cellular texture at the basis  of the nipple ; and 
340
the cells thus produced become loaded with adeps, so ast<»
sustain and preserve the projection of the nipple.
   If, then, a section be made of the nipple of the male in
the adult subject through its centre, radiated  ligamentous
cords are found in its substance, and a strong network con-
taining fat at its basis.  In the plate this will be well seen
in a section of  the  nipple of Coombs, lately executed for
murder, whom I selected on account of his  age,  and be-
cause he was a healthy person.  I made a section  through
the nipple, and then threw it  into warm water to melt out
the fat which it contained,  and thus unloaded  the strong
network of cellular tissue at its basis.
   The evolution of the nipple is as follows :
   In both male and female infants a gland exists which is
the nidus of the future nipple, over which the skin  is puck-
ered into a small projection.    This glandular substance lies
concealed under the skin until near the age of puberty, and
then it gradually evolves, and becomes  everted  into  the
nipple of the adult.  In the  male, the tubes through which
the milk of the infant passes become ligamentous cords in
the nipple of the adult, and in the female the  similar tubes
become the lactiferous ducts of the nipple.  Thus it is that
the nidus of the adult  nipple is protected until the age of
puberty.
   Disease seated in this structure.—It is this structure, then,
of the male and female nipple, prior to the age of puberty,
at the time  when  evolution of the nipple is commenc-
ing,—which  produces the swelling to which young people
are subject,  from  the  age of  eight years to the  period of
puberty ; for, when the action is greater than  the evolution
requires, a hard inflammatory swelling is produced.
   It is in this structure that in future years the malignant
areola or mammillary  tumour forms.  Here the schirrous
tubercle commences, which  destroys  the nipple, and ulti-
mately extinguishes  the life of the patient.   It is in  this
structure that the fungous  swelling which the plate exhi-
bits is formed ;  and both of these are from the male.  The
female is less subject to the disease, because the mammil-
lary substance is principally absorbed, and lactiferous tubes
are formed in its stead. 
EXPLANATION OF  THE  PLATES,
                         PLATE I.

Fig. 1. A view of the nipple as it appears in the male' foetus.
Fig. 2. A section of the mammillary gland in the male child at
         birth.
Fig. 3. A posterior view of the  mammillary gland in the male
         child at birth.
Fig. 4. A section of the mammillary gland of a male two year*
         of age.

                        PLATE II.

Fig 5. Section of the mammillary gland of a female twelve years
         of age.
Fig 6. Section of the mammillary gland of a female four years
         of age.
Fig. 7. Section of the mammillary gland of a female at birth,
         with the vessels which proceed from the axilla.
Fig. 8. Section of the mammillary  gland  of a male five year?
         of age.
Fig. 9. Section of the mammillary structure of Coombs (lately
         executed at Maidstone.)
       The ligamentous  substance seen which remains after
         the  cessation of the  glandular structure.  Clusters 
342
          of cells in the cellular tissue, from which the fat has
          been separated by putting the section into warm wa-
          ter.

                         PLATE III.   '

  Three different views of a mammillary tumour, taken  from
a person of the name of Left,  aged 40  years, on  May 2(Jth,
1824.
  It commenced sixteen years before this period from a slight
blow, but did not become larger than a pea during eight years.
Four months before its removal  it became occasionally painful,
and increased considerably.
  It was seated in the right breast behind the nipple and are-
ola.
  From the kind of pain he described to  exist in  it, I advised
its removal.  Upon  cutting into  it  after the operation, 1 found
it to have more of the fungoid than the scirrhous character, and
was glad that I had removed it, as it appeared to me to be of a
malignant nature.
  1 did not see the patient afterwards.
Fig. 1. a. Integument,   b. The nipple,  c. The tumour
Fig. 2. a. Integument,   b. The tumour.
Fig. 3. a. The  tumour cut open.
  On  the 17th of November, 1824, I  removed  a  tumour from
the same situation for a hairdresser in the city.  Its size was
rather less than the former.

                       PLATE IV.

  The disease represented in this plate begins  in persons ad-
vanced in years, by a swelling behind the areola or nipple, J|nd
the latter becomes enlarged or drawn in.
  When it  ulcerates, the sore has a  cancerous aspect; but it is
rather more disposed to  slough than the cancer  of the female.
The edge  of the ulcer is ragged, the surrounding parts are 
343
hard, and the pain is of the lancinating kind, as in true cancer.
The  best  case  in illustration  is  to  be  found in  the Medical
Journal,  published by Mr. Elliott, now a  chemist in Fenchurch
Street.
  The disease extends to the absorbent glands in the axilla.
Fig. 4. An  anterior view of the nipple  of the male, in which
         the mammillary substance is affected with cancer ;  the
         nipple is enlarged, and the surrounding parts ulcerated.
         I  removed  it from a man between sixty and seventy
         years of age.
Fig. 5. An  internal view of the same disease, a section having
         been made through it to shew  the  scirrhous  deposit.
          It has very much the character of cancer in the fe-
          male  breast,   a. The  surrounding adeps.  b.  The
         scirrhous deposit.
END OF VOL.  II.
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